Talk:The Johns Hopkins Medical Journal 7 (1896)
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. VII.- Nos. 59-60.
BALTIMORE, FEBRUARY-MARCH, 1896.
+++
Contents
Hysteromyomectomy and Hystero-Salpingo-Oophorectomy by
Continuous Incision from left to right or from right to left.
By Howard A. Kelly, M.D., . 27
The Treatment of large Vesico-vaginal Fistuloj. By Hoavard
A. Kelly, M. D.,
Nephro-uretereetomy — Extirpation of the Kidney and Ureter
simultaneously. By Howard A. Kelly, M. D., Ten Cases of Cancer of the Uterus operated upon by a more
radical Method of performing Hysterectomy. By J. G.
Clark, M.D.,
Sub-acute and Chronic Cystitis treated by the Vesical Balloon.
By J. G. Clark, M. D.,
29
- 31
37
44
The Sterilization of Catgut by Cumol. and G. B. Miller, M. D.,
5y J. G. Clark, M.D.
Proceedings of Societies : Hospital Medical Society,
The Treatment of Pyo-ureteritis and Pyo-nephrosis by Ureteral and Renal Catheters [Dr. Kelly].
Hospital Historical Club, • Women in Medicine [Dr. Kelly].
Notes on New Books, Books Received,
46
50
52
HYSTEROMYOMECTOMY AND HYSTERO-SALPIXGO-OOPHORECTOMY BY CONTINUOUS INCISION FROM LEFT TO RIGHT OR FROM RIGHT TO LEFT.*
By Howard A. Kelly, M. D., Professor of Gynecology in the Johns Hopkins University.
The field for exsective operations is growing daily more limited, and my sympathy witli tliis conservative movement in gynecology is so strong that I am unwilling even to speak of the more radical methods to be dealt wdth in this jiaper without emphasizing the necessity of limiting them to extreme cases. I will tlierefore briefly review the recent conservative advances made before describing the radical plan of operating.
Eadical extirpative procedures Avill be avoided in a large number of myomatous uteri if the surgeon will carefully study out the relations of the body of the uterus and of the uterine cavity to the tumors ; he will then often find that the tumors are so disposed that he may enucleate them by one or more incisions, and save the utei-ine body intact. This may even be done with interstitial tumors as big as a man's head, and where the fundus is raised in the abdomen as high as the umbilicus. I have in one case taken out seven tumors by as many separate incisions. Cases so treated may be looked upon from a practical surgical standpoint as closely analogous to the long uterine wound closed in a Caesarean section.
- An address before Southern Surgical and Gynecological Association, Washington, D. C, November 12, 1S95.
The radical method will again be avoided in a liTi'ge number of the worst forms of inflammatory cases, those in which pus has formed, by my method of free incision in the vaginal fornix behind the cervix, followed by fi'ee drainage, without the removal of any organ. An abdominal incision may be required to guide the vaginal hand in breaking up all the pns pockets.
Hydrosalpinx and adhei'ent tubes and ovaries may be treated by breaking up the adhesions, and by splitting open the dorsum of the tube, and dilating its lumen. In such bad inflammatory cases the operator should let the patient definitely understand that she takes some chances as to recovery under this plan of treatment, and may later hare to submit after all to the radical operation.
The field left for the extirpation of uterus, tubes and ovaries, after making these important exceptions, is greatly limited. It includes hysteromyomectomy for uteri distorted by myomata, or enormous myomatous masses, where the question of conservation is as yet in abeyance. It also includes hystero-salpingo-oophorectomy for cancer aflfectiug both ovaries, and ovarian cystomata affecting both sides, and old inflammatory cases in which tubes and ovaries are bound down in such dense adhesions that rejuvenation is impossible.
28
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 59-60.
With these definltious I will now describe au operation which I practise at the Johns Hopkins Hospital, and which I have demonstrated in upwards of two hundred cases within the past two years. Visitors from the American Medical Association may remember some of my cases, operated on in the Hospital Amphitheatre, in May, 1895.
The great value of this operation is its rapidity, saving from 60 to 80 per cent, of the time consumed in the enucleation, and the method of dealing with certain serious complications.
The operation consists in the following steps :
1. Opening the abdomen.
2. Ligation of the ovarian vessels near the pelvic brim, either on the right or on the left side, clamping them towards the uterus, and cutting between.
3. Ligating the round ligament of the same side near the uterus, cutting it free, and connecting the two incisions, in order to open up the top of the broad ligament.
4. Incision through the vesico-uterine peritoneum from the severed round ligament across to its fellow, freeing the bladder, which is now pushed down with a sponge, so as to expose the supravaginal cervix.
5. Pulling the body of the uterus to the- opposite side to expose the uterine artery low down on the side opened up. The vaginal portion of the cervix is located with thumb and forefinger, and the uterine artery, seen or felt, is tied just where it leaves the uterus. It is not always necessary to tie the veins. '
6. The cervix is now cut completely across just above the vaginal vault, severing the body of the uterus from the cervical stump, which is left below to close the vault.
7. As the last fibres of the cervix are severed or pulled apart, while the body of the uterus is being drawn up and rolled out in the opposite direction, the other uterine artery .comes into view and is caught with artery forceps about an inch above the cervical stump.
8. Rolling the uterine body still farther out, the right round ligament is clamped, and cut off, and lastly the ovarian vessels are clamped at the pelvic brim, and the reniDval of the whole mass, consisting of uterus, tubes and ovaries, is completed.
9. Ligatures are now applied iu place of the forceps holding the uterine artery, round ligament, and ovarian vessels ; if the surgeon prefers, these may be tied as they are exposed without using forceps.
10. After the enucleation the operation is now finished in the usual way, a) by closing the cervical tissue over the cervical canal, and then, b) by drawing the peritoneum of the anterior part of the pelvis (vesical peritoneum and anterior layers of broad ligaments) over the entire wound area, and attaching it to the posterior peritoneum by a continuous' catgut suture.
The continuous transverse incision should always be started on the side where the ovarian vessels and the ovary and tube are most accessible. If the case is one of a fibroid uterus, and the tumors are developed under the pelvic peritoneum or iu the broad ligament of one side, this side should be opened up last, from below upwards, when the tumors can be rolled up and out with surprising facility.
Displaced ureters will not be injured, for on the side ou which the enucleation is started such a ureter is pushed down with the loose peritoneum as the uterus and tumors are pulled up and towards the opposite side; and on the other side, no matter how much the ureter is displaced out of the pelvis, as the tumors caught from below are rolled up and out, the ureter drops down with the peritoneum and cellular tissue to the pelvic floor, and the operator need not even see it be aware of its displacement, to avoid the risk of injuring it.
If the ureter is found to be displaced only on one side, the operation should begin on the opposite side.
To escape the danger of tying the ureter on the side ou which the uterine artery is caught after dividing the cervix, I am careful to put the forceps ou the artery well above the cervical stump and to tie there.
The abdominal incision is always closed without drainage, by using a continuous catgut suture for the peritoneum, interrupted silver wire sutures for the fascia, a buried continuous catgut suture for the subcutaneous fat, and the subcuticular catgut suture for the skin.
The important points accomplished by this method of operating are a) the great saving of time, and J) the simple way iu which certain serious complications are met.
ff) Time saved.— According to other methods of operatiug, half an hour or an hour, or even more, may be consumed in enucleating the tumors and in getting ready to close up the pelvic and abdominal wounds, while by this method the enucleation is often effected in three or four minutes, and in difficult cases iu from ten to fifteen mintites.
The experience of every surgeon will bear me out iu insisting upon the importance of saving time at this particular stage of the operation, that is, the stage of enucleation, which is most likely, when prolonged, to produce shock, and to be accompanied by excessive loss of blood.
Furthermore, when the enttcleation of the disease is completed, all important questions affecting the vital interests of the patient have been answered ; adhesions have been severed, important vessels controlled, iutestinal complications dealt with, and tumors developed in situations difficult of access have been removed. In other words, those factors in the case which often demand an alert judgment and the highest surgical skill have all beeu dealt with; the rest of the operation, closing the pelvic wound and the abdominal incision, follows a certain routine which may with safety be left in the hands of a well trained assistant.
b) Complications met.— I have insisted particularly upon the novel way in which serious complications are simplified by this plan of treatment, and I would refer chiefly to two kinds of complications :
First, fibroid tumors located under the peritoneum of the pelvic floor, and
Second, inflammatory masses situated behind the broad ligaments, with dense adhesions to the pelvic peritoneum, to the rectum, and often to the small intestines.
In the case of the sub-pelvic peritoneal fibroids, it is astonishing how difficult they are to get at from above, and how easily ou the other hand they roll out when handled from beneath by this procedure.
Showing line of incision through peritoneum from left to right, through left
broad ligament, round ligament, iitero-vesical peritoneum, right round ligament, and
ending with right broad ligament near the pelvic brim.
Ov ves
Fig. 2.
Left ovarian vessels tied, left round ligament tied, vesical peritoneum divided and pushed
down and left uterine vessels ligated. Cervix amputated and uterus pulled up and out, exposing
right uterine artery, which is clamped an inch above the cervical stump. The two following
steps are clamping the right round ligament and right ovarian vessels, when the mass is removed .
Hysterectomy Srun. Used instead of a knife for amputating the uterus at the cervix, curved blade enables the operator to work easily in a deep pelvis cupping out the stumi>.
February-March, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
29
I would say the same of the inflainmatory cases. Matted masses adherent in all directions which resist enucleation from above are often removed with ease when rolled up from I the pelvic floor from below. The adherent structures seem to be unrolled in a natural and easy way, in surprising contrast to the difficulties experienced, and the injuries inflicted, in gaining the slightest finger-hold in proceeding from above. To recapitulate: Abdominal hysterectomy by the continuous incision down through one broad ligament across cervix and up through the other broad ligament, is contrasted with hysterectomy by an incision down to the cervix through one broad ligament, and then down through the othei', followed by amputation of the cervix.
The special advantages offered by this method of operating are:
1. The saving of from CO to 80 per cent, of the time in the enucleating stage of operation.
2. The ease with which intraligamentary mvomata and myomata beneath the pelvic peritoneum may be enucleated.
3. The ease with which inflammatory masses posterior to the broad ligament may be enucleated by attacking them from below after dividing the cervix.
4. The control of a displaced ureter, on the side last opened up, keeping it out of the way of injury by the simple mechanism of the operation.
THE TREATMENT OF LARGE VESICO- VAGINAL FISTULA*
By Howard A. Kelly, M. D., Professor of Gt/nerologi/ in the Johns Hopkins Universify.
In the sixth decade of this century the treatment of vesicovaginal fistulae was for the first time put upon a scientific basis by the labors of A. J. Jobert, G. Simon, and J. M. Sims.
AVhile Jobert generally succeeded in closing the smaller fistula; by simply denuding the borders and ajjproximating the edges with sutures, he found that this plan did not succeed with those of larger calibre, where considerable tension was created by the approximation. In order to overcome this difficulty he devised a new plan of treatment {autophistie par glisseinent), which consisted in deep incisions through the vaginal walls so placed as to relieve the tension on the united edges of the wound.
A deep transverse incision made in the vault of the vagina in front of the cervix, extending even up to the vesico-uterine fold of peritoneum, has been knowu ever since as the incision of Jobert.-] Simon, who followed .lobert, did away with his plan of incising the vaginal walls by using two sets of sutures {Doppdnaht). Those introduced at a distance from the margins of the wound were used to relieve tension (sutures of detention), and those introduced close to the wound were approxinuition sutures simply (sutures of reunion).\ In addition to this, Simon devised specula to expose the fistula better, which have never been materially improved upon.
J. Marion Sims, working independently in the same line, devised his speculum for the exposure of the fistula with the patient in the left lateral position; he made a funnel-shaped denudation of its edges extending down to the vesical mucosa but not including it, and then united the wound with twisted silver wire sutures.§
- Proceedings of the Jolins Hopkins Hosiiitiil Medical Society,
.January 20, 1S96.
f See Comples-remlus de V Acad, des Sci.,\8h0. See also Traili des Jintulen, Paris, 1852.
- { See Ifeber die IleUuiig der Dlasenscheideiifistdn, Dr. G. Simon,
Giessen, 1854.
§ On the Treatment of V^esico-vaginal Fistula, by J. Marion Sims, Amer. Journ. Med. Scierices, 1852, vol. 23, p. 59.
I)i-. T. A. Emmet (The Principles and Practice of Gynecology/, Phila., 18791 and Dr. Nathan Bozeman ("The Gradual Preparatory Treatment of the Complications of Urinary and Faecal Fistulse in Women," N'eiu York Med. Jour., Oct. 1, 1887) both laid stress upon the urgent necessity of the careful preparatory treatment of cases of large fistula by dividing cicatricial bands and using pressure to promote their absorption before undertaking the operation.
In spite of the many successes attained in the treatment of vesico-vaginal fistulae by these methods, a certain percentage of cases still remained which could not be cured by any known plan of treatment, and it was even found necessary in some cases to resort to a comjolete closure of the vagina (colpocleisis).
The first active step taken w'itli a view of reaching these inoperable cases was that of A. Martin of Berlin, who covered the defect with large flaps dissected up from the contiguous vaginal walls (Zeitschrift f. Gyn. vnd Geb., Band XIX, p. 394).
L. von Dittel (Abilom. Blasensclieidenjislrl Operation, Wien. Med. Woch. 1893, No. 2.5) opened up a new avenue when he attempted to close a fistula through an abdominal incision : he cut the bladder loose from the uterus and the vagina, freed the fistula from all its attachments, sewed it up and dropped it, and then united the vesico-uterine peritoneum to the uterus and closed the abdominal incision.
A. Mackenrodt of Berlin (CentraMatt f. Gyn.. No. S, 1S94) has given us the following admirable plan for the successful treatment of these large fistulw (ut stip. p. 183); the fistula is exposed, the cervix and urethral prominence caught with tenaculum forceps, and the tissue made tense by traction in opposite directions. An incision is made through the vaginal walls in the median line across the fistula. Then with knife and forceps the margins of the fistula are split so as completely to detach the bladder from the vaginal walls ou all sides. The separation may be carried as far up as the vesicouterine peritoneum. The movable elastic bladder is now closed by denuding its edges and drawing theui together with fine silkworm-gut sutures Beneath these a second and even
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JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 59-60.
a third layer of sutures maj' be placed. After closing the bladder wound in this way, the vaginal wound is approximated as far as the tissues will permit, by denuding its margins, drawing the corpus uteri forwards, and passing sutures from side to side so as to bring the vaginal margins together and at the same time to hold the uterus lying upon them in anteflexion. If the margins will not come together they are sewed to the uterus on each side so as to form a (irni base in the place of the fistulous orifice.
W. A. Freuud {Eine neue Operation zur ScJiliei-sung gewisser Harnfistehi beim Weibe, Samm. Klin. Vort. N. ¥. No. 118, 1895) has succeeded in closing two large fistula' by utilizing the body of the inverted uterus brought through the posterior fornix into the vagina and sewed to the anterior vaginal wall. E. C. Dudley of Chicago performed a remarkable operation in closing a large intractable fistula by nuiking a semicircular denudation ou the inner surface of the bladder extending from one margin of the fistula around to the other. He then attached this denuded surface to the anterior part of the fistula and so obtained a closure. A portion of the posterior half of the bladder was thrown out of use, but the patient had good control over the newly formed organ.
In addition to these five plans, all aiming to reach the same difficult class of cases, I have one of my own to propose. It was carried out in the following manner : The patient, Mrs. Y., aged 4:0, 5-par., was operated upon, September 25, 1895. She had had a urinary fistula ever since her third labor, eight years ago, and five different attempts had been made by various surgeons to close it, all of them unsuccessful, and with the result of increasing the disability because of the sacrifice of important tissues at the base of the bladder, in fact the base of the bladder was entirely gone. I found the bladder everted through the fistula and filling the vagina with an angry red fungouS-likemass; on replacing this, the anterior vaginal wall was seen to be absent, and in its place there was an enormous fistulous opening in the base of the bladder.
The fistula measured 4x3 cm., and involved the anterior lip of the cervix, which was destroyed, as well as the entire neck of the bladder anteriorly (vesico-utero-urethro-vagiual^stula); in front the sharp contour of the cut-off urethra presented a marked contrast to the normal funnel-shaped neck of the bladder. Posteriorly to the right and left of the cervix the ureteral orifices opened ou the edges of the fistula. Two or more centimeters of each ureter had evidently been sacrificed in the operations. The vaginal walls forming the margins of the fistula were immovably fixed on all sides and contained numerous radiating bands of scar tissue. There was not the slightest chance of bringing such tissues together by any known method of denudation or suture, so I employed the following method, and covered the defect successfully. The steps of the operation were :
1. A crescentic incision separating the muscular and mucous coats of the bladder from the vagina, was made around the posterior two- thirds of the fistula, and the bladder detached from the supravaginal cervix all the way up to the peritoneum, and widely on both sides, by a blunt dissection. It was easy to avoid injuring the ureters sjjlinted by the catheters.
2. I next denuded a strip around the remaining anterior third of the fistula on its vaginal surface, carrying the denudation down to the mucosa of the bladder and the urethra.
3. Two flexible ureteral catheters 2 J mm. in diameter were passed through the urethra across the fistula, and one conducted into each ureter and pushed uji above the brim of the pelvis.
4. The part of the bladder freed from its attachments behind was now easily drawn forward and accurately applied to the immovable anterior third, to which it was united by interrupted fine silkworm-gut sutures. Each suture caught the under surface of the muscular coat of the bladder so as to turn the cut edge up towards the newly formed bladder. The ureteral orifices fixed on this edge were in this way turned into the bladder, and escaped transfixion or compression by the sutures through the presence of the catheters which made their jsositiou plain.
I left these ureteral catheters in situ three days, draining each kidney directly through its ureter and preventing any urine from entering the bladder to put a strain on the healing tissues. In the first forty-eight hours 900 cc. of urine escaped from the right ureter and 600 cc. from the left.
The wound healed perfectly except at the upper angle on the right, where a minute fistulous sinus 1 mm. in diameter remained, through which a little urine occasionally escaped.
When the patient left the ward she was able to hold 100 cc. of urine in the bladder and did not have to void it more than once in three hours. The raw surface on ths anterior vaginal wall was replaced by a firm contracting cicatrix. It is important to note the amount of control secured in spite of the destruction of the neck of the bladder.
My operation differs from that of Mackenrodt in that 1 do not detach the bladder on all sides and sew it together in the middle of the fistula. It differs also in that I do not in any case include any of the uterus. My plan is easier to apply where the destruction of tissue is so great as to include the upper part of the urethra. It also provides for a detachment of the bladder only in the posterior and postero-latcral portions where such detaclmient is most easily effected, and then brings the posterior bladder wall into accurate ajipositiou with the anterior vaginal wall.
My plan also differs radically from Dudley's, in that I make no denudation on the bladder mucosa, throwing out of use that part of the bladder lying below the line of denudation.
On the contrary, I utilize all the bladder tissue left by the fistula in freeing the posterior part and drawing it over the defect.
DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL
By JOHN 8. Billings, m. D.. I,L. D.
Contnlulng 56 largo quarto plaio8. iihotDtyiJos, and UlUographs, with views, plnns BUrt dotal! drawliics of all tlia bull.lliiBfl.nud tholr Interior arrangements— also wood-cutBoJ apparatus and flxturos; also 116 iiagos of lotter-prcss describing the plans followed lu ilie construction, and giving full details of heating-apparatus, ventilation, soworago and pluinblUK. Price, bound In cloth, $7.60.
HOSPITAL PLANS.
Five essays relating to the construction, organization and management of Hospitals, contributed by their authors for the uso ot The Johns Hopkins Hospital.
These essays wore written by DRS. JOHN S. BILLINOS. ot the U. S. Army. NoitTON FOLSOM ot Uoston. J03EPU JONES Of NOW Orleans, 0\sp\n Moiinis of Thlladelphltt, and Stkpuen Suith of New York. They wore originally published In 1K7S. Oue volume, bound iu clotb, price $5.00.
Fla. 1. The flstula shown in sagittal section, the bladder cut free from the uterus from a to x.
Via. 2. The fistula closed by drawing the bladder (a)
forwards to h.
The fistula seen from below, the ureteral orifices appear on the posterior margin. The knife is in the act of separnting tho bladder from the vagina in its posterior two-thirds.
Fig. -4. The bladder loosened as shown in Fie. 3, drawn forwards and attached to the vai;inal surface by interrupted sutures.
February-March, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
31
NEPHRO-URETERECTOMY-EXTIRPATION OF THE KIDNEY AND URETER SIMULTANEOUSLY.
By H. a. Kelly, M. D., Profesnor of Gynecology in the Johns Hopkins University.
I had under my care in 1892 and 1893 a case of tubercular kidney and tubercular ureteritis, which came to me through the courtesy of Prof. M. D. Maun, of Buffalo. I ojoerated ui)on the patient, Mai-ch 30, 1893, removing the left kidney with its ureter as far down as the pelvic floor, for au advanced renal and ureteral tuberculosis. The operation was described, with photographs, before the Surgical Section of the American Medical Association, at Milwaukee, in May, 1893, but the manuscript was lost and the paper was not published.
Case I. — The patient suffered from frequent spasms of the bladder of such intensity that she passed most of her time in a squatting posture in bed, screaming with pain, and from being a stout, hearty girl, she had become worn out and emaciated.
A vaginal examination showed the right ureter to be normal, while the left was large, thick, and rigid, apparently about 1 cm. in diameter, and so exquisitely sensitive that only the gentlest pressure could be made uj)on it. Its surface was also irregular and exhibited depressions at intervals. The enlarged ureter could also be located through the abdominal walls at the pelvic brim, and traced above this point by following a well-marked line of tenderness.
1 catheterized the ureters and obtained a few cc. of a clear brown acid urine from the right side, free from abnormal elements, but nothing escaped from the left side after waiting some ten minutes ; then upon manipulating the catheter a little, it was felt to pass through a resistant area in the posterior pelvis (ureteral stricture), and suddenly the urine began to flow so freely that in a few minutes about 90 cc. of jiale lemon-colored alkaline urine escaped, loaded with pus and containing tubercle bacilli.
Upon cystoscopic examination the bladder showed some scattered seed-like elevations in front of the left ureteral orifice.
1 determined to extirpate the left kidney with its ureter, and to this end made an incision in the left side 16 cm. long, outside of and parallel to the semilunar line. The muscles were divided, the peritoneum opened, and the viscera displaced to the right, and the posterior peritoneum cut through on the outer side of the colon, which was then further displaced to the right so as to expose the enlarged ureter lying on the psoas muscle. I then traced the ureter up to the kiduey, which was cystic; the kiduey was slowly enucleated from its bed; the surrounding fat contained a large amount of fibrous tissue and adhered densely to it, especially at the hilum, making the enucleation difficult. The renal vessels were linally tied with four fine silk ligatures aud the kidney completely detached. The large hard ureter was next freed from its cellular bed from above downwards to the pelvic brim; about the middle of its course in the abdomen the ovarian vessels were tied.
'I'he detachment of the ureter became more dillicull, after it was freed from the common iliac artery and vein ; at a point 4 cm. below the pelvic brim where the ureter turns forwards,
it was surrounded with such dense cellular tissue that I decided not to enucleate any farther, owing to the patient's weakened state ; so I tied the ureter on the floor and cut it off, leaving wedge-shaped flaps, and removed the kidney with the entire abdominal portion and one-half the pelvic portion of the ureter.
The mucosa of the lower end beyond the ligature was sterilized with the thermo-cautery and the flaps approximated with six fine silk sutures and dropped.
The abdomen was irrigated with normal salt solution ; then with the half hand in the abdomen as a guide, pushing out the thinnest dependent place in the left loin, an incision 3 cm. long was made by pushing a knife through, and a strip of gauze 14 cm. long was laid from the' brim of the pelvis down into the loin and brought out. It was not necessary to unite the peritoneal wound beside the colon, because the natural apposition was so good.
The long abdominal incision was then closed with interrupted silkworm-gut sutures. The gauze drain in the loin acted as a vent for some bloody serum, and was removed on the fifth day. When the sutures were removed the union was perfect and there was no suppuration at any point.
The urine, which had persistently contained pus, cleared up at once, aud the patient made an excellent recovery. On the eleventh of May I tried to remove the lower end of the ureter, left in the pelvis, by a vaginal incision, but found it impossible on account of the dense cicatricial tissue, which bled actively as soon as it was cut into.
Pathological Report. — The kidney was cystic and tubercular, and the ureter was converted into a large thick tubercular cord throughout.
The following report is from Dr. L. F. Barker, of the Johns Hopkins Hospital :
" The parts removed are the left kidney, with portion of the left ureter.
Weight of nuiss, 100 grams.
Surface of kidney is irregular, and there are several large protruding cysts, covered by the capsule.
The kidney measures 11x6x3.5 cm.
The largest of the cysts measures 4x5 cm.
The capsule of kiduey is thickened, and in places intimately adherent to the surface of kidney substance.
On section, about 65 cc. fluid escaped from the cysts. The fluid iu one of the cysts is white and flaky, and consists almost entirely of fatty debris. In another cyst the fluid resembles blood-stained urine. The cysts are found to communicate with the pelvis of kidney, and really correspond to the dilated calices.
The parenchyma of the kidney has been in a large part destroyed. In the central portion there is an area which has largely escaped, iu which the cortex has a depth of 7 mm., but elsewhere the substance of the organ is represented by layers of different thicknesses (averaging i mm.), spread out over the dilated calices. Even iu the less altered portion, the
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[Nos. 59-60.
frozen section shows that there are the same dilated tubules, the epithelium of which is somewhat flattened, besides occasional aggregations of rounded cells.
One or two glomeruli are seeu to have undergone fibroid transformation."
Ureter. The ureter presents two points of constriction, respectively 3 and 8 cm. (1} and 3} in.) from the kidney. The hilum of the kidney was lilled with dense adherent fat, preventing dissection of stricture without tearing it.
The ureter is much dilated, more at some points than at others, the calibre of its lumen varying from 1.7 to 3 cm. (J to IJ in.). Its wall is much thickened, measuring in places from 5 to 6 mm. The mucous membrane is of an opaque buff color, and at one spot, near the pelvis, there is a superficial area of calcification 5 mm. in diameter.
Frozen section of the ureter shows that the epithelium is entirely absent from the surface and that the mucous membrane is converted into a mass of diffuse tuberculous tissue, in which here and there definite tubercular nodules can be made out. The surface is not infrequently quite necrotic and the cells near it have undergone fatty degeneration. The muscular layer has been involved and there are many aggregations of small round and epithelioid cells there. In some places there is cell proliferation in the fibrous layer of the ureter. The connective tissue is from three to four times thicker than normal. '
I have heard from the i)atieut this year (Feb. 1896). She is stout and is in excellent health, and goes about everywhere, with but one of her old discomforts, frequency of micturition.
After the preceding operation, April 3, 1893, I secured a male cadaver for the purpose of determining the practicability of removing the entire ureter by an extra-peritoneal operation. I was able to do this easily through a long incision beginning in the loin back by the quadratus muscle and extended forwards and downwards, skirting the anterior superior spine and ending in the semilunar line. The kidney was freed and the peritoneum lifted up, and the entire ureter down to the bladder wall detached, without opening the peritoneum and without cutting a single large vessel. The accompanying drawing is from a photograph in my possession made at the time from the subject by Mr. A. 8. Murray.
Case II. — The next case to present itself in which the operation of nephro-ureterectomy seemed to be required was that of Miss P., age 23, a patient of Dr. B. W. 'i'aylor of Columbia, S. C. She began as a child to complain of constant pain and weakness in the back which often compelled her to lie down ; at nine years of age she was six weeks abed. She always suffered more or less from an inability to retain her urine, and this weakness became markedly worse after an attack of scarlet fever, when six years old. She received her first treatment when ten years of age, and has continued to need treatment year by year ever since that time. Micturition is frequent and not followed by relief. For four years past she has been obliged to go so frequently that she could pass but a few drops of pale urine at a time, accompanied by pain and strangury. For six years she has had an intermittent pain in the bladder, which within the past year changed to a
constant dull ache. A year ago for the first time she had an attack of spasmodic pain in the region of the left kidney, very severe, accompanied by vomiting, and followed by pain in the bladder. Since the first attack she has had many others, often with not more than a week's interval. During such attacks she was compelled to walk about, and Avhen confined to bed was obliged to lie with knees flexed upon the abdomen. Attacks were brought on by fatigue or exposure to cold, and lasted from one to three hours, each attack being followed by an increase in frequency of micturition, and in the amount of urine passed. Since the very first one she has had a constant pain and tenderness in the left groin above the crest of the ilium.
Repeated examinations of the urine showed that it was always acid, amber- colored, contained a marked amount of albumen, and deposited a heavy cloudy sediment. Pus cells were abundant, and hyaline and granular casts were found at almost every examination. Specific gravity varied from 1015 to 1020.
By palpation per vaginam the left ureter was found uniformly enlarged and extremely tender to pressure. It appeared to be transformed into a cord about three times the normal size. On the right side the ureter was normal and not sensitive. There was a distinct spot of tenderness at the pelvic brim about 3 cm. to the right of the promontory of the sacrum. The left kidney could not be palpated.
By cystoscopic examination the general surface of the bladder was found to be normal; the trigonum was injected, showing delicate leashes of vessels. The left ureteral orifice was deeply injected, surrounded by an area of granulations about 2 cm. in diameter, extremely sensitive to touch, and bleeding so readily that the ureteral orifice was at once obscured. It was impossible to introduce a catheter into the left side owing to the obstruction of the orifice by the granular masses. A ureteral catheter was introduced into the right (sound) side and normal urine obtained.
It was evident therefore from the examination showing the diseased state of the ureter, together with the history of the persistent pain localized on the left side, and the results of nine separate urinary examinations, that the disease was an infection of the left side, probably tubercular in character, although no positively recognizable tubercle bacilli were found in the urinary examinations.
In view of the manifest thickening of the ureter, shown by the vaginal examination, as well as the efflorescence of disease about the ureteral orifice in the bladder, I determined to extirpate the kidney with the entire length of the ureter, and, if the patient's condition would permit, to cut out an oval area in the bladder, resecting the localized disease there.
The operation was performed, December 18, 1895. Left nephro-ureterectomy for tuberculous kidney and ureter, by an extra-peritoneal abdominal incision.
Operation. — The left side of the nions was shaved, and the whole left side of the abdomen around to the backbone carefully cleansed and shaved. The patient lay on her right side with a pillow under the groin.
The incision commenced just iu front of the vertical muscles of the back at the costal margin, and was carried
February-March, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
33
down towards the middle of the crest of the ilium and then in a gentle curve around the anterior superior spine 2 cm. awa}' from it, and from this point in an oblique line down to the lower terminus of the left semilunar line, an inch above the symphysis pubis.
The posterior third of the incision was made first, and the renal vessels tied and the kidney and upper part of the ureter detached and brought out through it. The anterior two-thirds of the incision were then made in two successive cuts, after first closing the posterior part of the incision.
The first cut made was about 12 cm. long from the margin of the ribs by the quadratus muscle, down to a point just above the anterior su25erior spine, and extended into the peritoneum, through moderately fat abdominal walls and three thick layers of muscle, down to the subj)eritoneal fat. This was easily displaced and the peritoneum overlying the descending colon, which came into view, pushed inwards, while the fingers readily searched for and found the kidney in its normal position protected by the ribs. The surrounding fat was then slowly stripped off from the kidney on all sides, exciting a little bleeding from the capsule at one or two points where it adhered, and the kidney was gently drawn down and brought entirely out of the incision. The kidney mass consisted of two portions, a light-colored upper mass occupying about onethirtieth of its length, but swollen and divided by shallow sulci into several smaller masses, and a deeply congested lower twothirds which had some of the appearance of normal kidney substance. While holding the kidney, a small amount of fluid looking like blood and pus escaped through a minute opening in the lower part of the organ. The vessels were exposed by dissecting off the fat surrounding them with fingers and blunt instruments; they were unusually small in size, and of two arteries the larger was but li mm. in diameter. The vessels were clamped at a distance from the kidney, which was then cut free, and the vessels, tied one by one with fine silk, were allowed to drop back. The enucleated kidney was enclosed in a gauze bag and held in a towel to prevent contamination of the wound by any of its discharges. The dissection was then continued on down toward the pelvic brim by lifting up the colon and sigmoid, and freeing the ureter with the fingers. This was done most easily by using the fingers to separate the cellular tissue and at the same time jjulling the ureter with its attached kidney downwards. The upper part of the wound, with the exception of the upper angle which was left open 2i cm. for a gauze drain, was now closed by bringing all the muscular and fibrous layers together by means of three silver wire mattrass sutures and two interrupted sutures.
I then continued the incision on down about 3 cm. above Poupart's ligament and almost parallel to it, to terminate it in the mons at the lower end of the left semilunar line. The muscular walls below were quite thin and were soon cut through. At the lower angle of the wound the round ligament was exposed about 3 cm. from its extreme lower end, and 1 cm. below this the deep epigastric vessels also crossed the incision between the peritoneum and the fascia. These vessels were tied doubly and divided. The round ligament was not divided but pushed aside. The thin peritoneum separating the wound area from the small intestines w^as now pushed
aside gently and the external iliac artery exposed skirting the brim of the pelvis with the great psoas muscle above it and the crural nerves and iliacus muscle beyond. Below the artery the external iliac vein was exposed lying flat against the pelvic wall. The ureter was easily dissected out of its bed until the base of the broad ligament was reached, by simply pulling it forward with the fingers without tying a single vessel. The broad ligament formed a distinct obstacle to further exposure of the ureter, because the tissues at its base together with the uterine artery and veins completely covered in the ureter with a firm sharp band. The uterus could not be felt on the median side. By lifting up the broad ligament with a finger between the ureter and pelvic wall, a ligature was passed by means of a needle and carrier to the inside of the finger, while another was passed one centimeter further inside of this, and the uterine vessels cut between them. In passing the first suture I experienced a little difficulty in catching the curved needle and bringing it up in the narrow space between the pelvic wall on one side and the displaced peritoneum on the other, and as I caught the needle to bring it up, the point pricked the external iliac vein, with the result of an immediate oozing of venous blood, lasting a few minutes and ceasing spontaneously ; on account of this accident a second suture was passed from behind forwards, in the opposite direction. I was then able after dividing the base of the broad ligament to free the ureter up to its intra- vesical portion, which I recognized by the fact that any further efforts to strip it loose simply served to demonstrate its intimate connections with the bladder walls. At this juncture my assistant, Dr. Russell, put a finger into the vagina. When the end of his index finger rested at the vaginal vault, the tip of my finger in contact with the extreme end of the dissected portion of the ureter lay in contact with its second joint; in other words, I had dissected out the ureter 5 cm. below the vaginal vault.
During the latter part of the operation the patient was lying on her back with a long wound from the lower part of the ribs posteriorly extending down to the symphysis; the upper portion of the ivound was closed in its deeper parts, the lower portion remained entirely opened, and tne skin incision was not closed at any point. The kidney with its long ureter lay across the lower part of the abdomen to the right side, the ureter entering the wound at its lower angle. I now milked back any fluid in the ureter between two fingers, and clani]XHl the ureter 2 cm. from the bladder, and tied it half-way Wtween the clamp and the bladder with intermediate silk and then cut it off close to the clamp, after carefully surrounding the lower end with gauze to prevent any cont;iniiuation of the wound iu case a little pus should escape. The kidney with its ureter, 23 cm. long, were now taken away.
The lower end of the ureter distal to the ligature was nest sterilized with crude carbolic acid applied on cotton, and dropped to the pelvic floor about 5 cm. below the skin surface.
No ligatures were applied in this ureterectomy, at any jwint between the renal vessels and the uterine vessels. The abdominal walls were closed by silver wire for the muscles and catgut for the fat and skin. A small drain was put iu the lower end of the wound reaching down to the pelvic floor. The pulse
34
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[Nos. 59-60.
of the patient throughout the operation averaged about 136, and she showed marked cyanosis throughout. The recovery was smooth and uncomplicated.
Pathological Kepoet by Dr. Herndon.
The specimen consists of the right kidney and ureter. The kidney retains its usual shape, but is somewhat enlarged, being 13 cm. long, 6 broad, and 3.5 in its antero-posterior diameter. The upper half is somewhat flattened, dark red in color, except over one or two small pale areas, and is covered by numerous pin-point ecchymoses. On the anterior surface near its upper and outer margin is an oval depression 1.7x0.9 cm. This is surrounded by a zone of ecchyniosis, scattered throughout which are a few small yellow tubercles. The surface of the depressed portion is covered by similar tubercles. The lower 3 cm. of the kidney resembles the upper portion and presents a few small tubercles. The remaining portion of the organ is greatly altered in appearance. It consists of a wedge-shaped zone sharply differentiated from the surrounding tissue. Anteriorly it presents a lobulated surface, everywhere studded by minute yellow or translucent tubercles, which are either isolated or occur in small groups. Surrounding the tubercles are numerous pin-point ecchymoses. The corresponding portion of the kidney posteriorly presents a smooth whitish-yellow surface studded with small flattened tubercles.
This portion of the organ is soft and yielding. On section the altered portion of the organ is found to be occupied by four or five caseous abscesses containing thin milky fluid in which caseous material is suspended.
The walls of the abscesses average 2 mm. in thickness. The upper portion of the pelvis of the kidney is smooth and glistening. 'The remainder presents a few small white tubercles.
Histological Examination : The inner layers of the granulation tissue which form the walls of the abscesses are composed of typical tuberculous tissue, scattered throughout which are a few giant cells. The abscess cavity contains caseous detritus, some of which is clinging to the walls. The tissue in the vicinity of the tuberculous abscesses is greatly altered; some of the glomeruli are partially obliterated by newly-formed connective tissue, others have undergone complete fibrous transformation. The renal tubules where present have an intact epithelium. The connective tissue is markedly increased, and scattered here and there throughout it are numerous aggregations of small round cells, and frequently a tubercle is visible. The pelvis of the kidney is in part involved in the tuberculous process. Sections from the upper portions of the ureter show a slight desquamation of its epithelium and a moderate infiltration of the stroma beneath with polyuuclear leucocytes and lymphoid cells. Other portions of the ureter are practically normal. The tuberculous process seen in the kidney has not extended to the ureter. Tubercle bacilli can be demonstrated in the centre of the caseous areas found in the kidney.
Diagnosis : Tuberculosis of the kidney.
Case III.— :Mra. K. W., age 30; case of Dr. Wishart, of Leitersburg, Maryland ; married four yejirs, one child three
years ago after a hard instrumental labor. In thepuerperium she had chills and fever. She has never been quite well since the confinement, and for a year afterward she was a decided invalid. She had had a constant escape of urine since childbirth, resulting from an over-distended bladder. Her mother died of consumption.
As a child she was delicate; at eighteen years of age she had what was called "inflammation of the womb," and was quite ill for seven weeks, during which the lower abdomen was swollen and painful, and there was considerable fever. Her present trouble began ten months after childbirth, that is, two years ago, in October, 1893 ; the first symptoms were violent pain over the right kidne}', extending around to the front of the abdomen and down into the pelvis, accompanied by nausea and vomiting and chills and fever; the suffering was intense for about twenty-four hours. The attacks have recurred at intervals of about three weeks ever since. She has suffered from frequent and burning micturition, but has never passed any stone or blood in the urine. The urine was examined a year ago and found to contain pus. The attacks apparently had no counection with diets, drinks, or exercise. The burning micturition was noticed only just before and during the attacks. Her hands and feet swelled at times and she was puffy beneath the eyes. Her lips and mucous membranes are of a good color, and she is a large, stout woman, whose appetite and digestion are good.
The attacks of pain began under the right shoulder-blade and extended into the kidney, and w'ere violent from the very onset of the first attack. For the past year she has had them as often as three or four weekly, growing more intense. Pain is aching, cutting, piercing, like cutting into the flesh of the groin ; when it was most intense she would throw herself about aud lie on the floor screaming with agony; she would frequently break into cold sweats. She was never relieved until the doctor came and gave her morphine in large doses. When the attacks passed oft" she secreted large quantities of urine.
Tlie examination of the urine. — Amber color, opaque with sediment, acid reaction, marked trace of albumen.
Microscopical examination. — Ked blood corpuscles abundant; detritus; a few pus corpuscles.
The amount of urine passed varied from 600 to 800 cc. before operation. The vaginal examination showed that the right ureter was converted into a large thick cord, which appeared to be about 1 cm. in diameter and was exceedingly tender on pressure.
Under cystoscopic examination the bladder was found to be perfectly normal in all parts except for a red mammilated patch about the orifice of the right ureter. The left ureteral orifice and its surroundings were normal. A short ureteral catheter was laid in the left ureter and the urine secured showed pus cells, and a percentage of urea, 2.1 for the diseased side, and 2.6 on the opposite side, demonstrated to be sound. Tubercular bacilli were not found in the urine.
Operation. — The patient weighed about 225 pounds, and the fat on the abdominal walls was about 7 cm. thick, adding greatly to the diftieulty of the operation ; the ribs and the crest of the ilium lay so close together that I was obliged to
Febkuaky-March, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
35
make a horizontiil incision between them. The incision began in front of the posterior vertical muscles and extended 16 cm. across the abdomen in the umbilical line, reaching almost to the right semilunaris. Numerous bleeding vessels were clamped and tied with catgut. One large nerve with vessels accompanying it was divided between the transversalis and the peritoneum in the posterior part of the wound; this nerve was 2 mm. in diameter and ran down toward the crest of the ilium.
The peri-renal fat was freed on all sides of the kidney, completely detached, and brought out of the incision. By drawing it down over the lower lip of the incision the renal vessels were exposed, with the pelvis of the kidney lying beneath them.
An examination was now made to determine first, whether the kidney was diseased at all; second, whether a conservative operation could be done; and third, whether extirpation was necessary.
The capsule of the kidney became almost completely detached in the simple manipulation necessary to bring it out of the incision. The upper and lower portions of the organ looked like a normal kidney substance intensely congested. At the middle there was a zone 3 to 4 cm. wide where the kidney was greatly thickened, being perhaps 3 cm. thicker than at either end. This zone was of a pale color, slightly lobulated, and fluctuated on pressure, showing the presence of considerable fluid within. The peeling off of the capsule disclosed a markedly granular surface over an area about 2§ cm. in diameter on the anterior surface near the pelvis. A similar irregular depressed area with numerous white granules was also seen near the lower pole of the kidney, surrounded by tissue apparently healthy. The case was therefore one of tubercular nephritis, limited to the right side, as shown by the previous examination of the urine separated from that of the opposite side. The broad affected zone extending entirely through the central portion of the kidney rendered any conservative resection impossible. The renal vessels were therefore clamped in three artery forceps 1 cm. from the kidney, after freeing them from the surrounding fat. Each of the vessels was tied with a silk ligature cut short. The vein, which was 8 mm. in diameter, when flattened out slipped from the grasp of its ligature as it sank back into the abdomen, but the compression of the forceps checked a hemorrhage which would otherwise have been excessive. As it was there was a free oozing from both ends of the mouth of the large vein, but it was fortunately found and caught by the forceps again deep down in the abundant fat under the ribs, and another ligature placed about it, using a needle and carrier without drawing it up. Two other small actively bleeding vessels were also tied in the peri-renal fat.
The kidney and the entire ureter were now removed in the following numner. By pulling on the kidney and ureter, the latter was made tense and easily dissected out of its cellular bed, with the index and middle fingers pushing the peritoneum, the ascending colon, and the caput coli, to one side and stripping off the loose cellular tissue surrounding the ureter.
This dissection was carried down to the brim of the pelvis, and the common iliac artery could be felt with the tips of the fingers over its entire length, with the thumb resting on the
surface of the abdomen, the end of the thumb reaching the anterior superior spine.
I now freed the ureter down to its vaginal portion by introducing the entire hand into the cellular tissue, at first between the peritoneum and the abdominal wall, then under the peritoneum of the false pelvis, andfinally between the peritoneum and the walls of the true pelvis. This blunt dissection with the fingers was facilitated by pulling on the kidney and making theuretef tense. In this way I freed it and followed it forward to the broad ligament. At this point considerable resistance was felt, and the ureter appeared to the touch to pass through a hole with a sharp border in its upper part. Above this I distinctly felt the uterine artery pulsating.
At this point, about 6 cm. from the kidney, the ureter broke ; the lower end was at once caught in forceps and held, while by dint of pushing and working in my finger I succeeded in freeing about 2 cm. more of the ureter. Before doing this, however, I put a stout silk ligature over the abdominal end of the ureter, and by means of one hand in the pelvis and the other holding the long outside end of the ureter I succeeded in tying a tight knot about it, just behind the broad ligament, then with a long pair of scissors introduced through the abdominal incision and controlled by the hand introduced into the pelvis in the same way, the ureter was cut off onehalf centimeter above the ligature, after taking care to milk back any of its contents and to keep the upper end tight squeezed until it was removed.
The vagina was now thoroughly disinfected, and, with the patient still lying on her left side, I passed two fingers of my right hand up to the vaginal vault, and with my left hand. introduced into the pelvis through the abdominal incision, I brought both hands together with nothing but the vaginal tissue between them. I \w\\ made an opening in the vaginal vault and brought the end of the ureter through it and clamped it in a pair of forceps, until the abdominal wound was closed, when the vaginal end was removed also.
This opening was made in the following manner: I passed my entire left hand through the abdominal wound down into the pelvis and pressed the index and middle fingers against the right vaginal fornix, at the same time lifting up the uterine artery on the index finger so as to avoid any danger of cutting it ; the end of the ureter lay between these fingers. The index and middle fingers of the right hand were now introduced into the vagina (the patient was lying in the left lateral posture'* and pressed up against the fingers of the left hand in the abdomen, the palmar surfaces of both hands being turned upwards. The opening in the vault necessary to draw the end of the ureter into the vagina was now made by Pr. J. G. Clark, who introduced a pair of sharp-pointed scissors along my fingers up to the vaginal vault and pushed them through the thin septum, guided by my instructions; he then spread the blades of the scissors and withdrew them, in this way enlarging the hole iu the vault to about 2 cm. The opening was situated aWmt 2 cm. to the right of the cervix. The bleeding from this torn wound was venous and slight. With a pair of forceps pusheii through the vaginal opening, the ligature attached to the ureter was now caught, and the ureter drawn through into the vagina and held there while the abdominal wound was beins closed.
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[Nos. 59-60.
Closure of the abdominal i7icismi. — The whole wound-track was first irrigated with normal salt solution ; although the bleeding was slight a drain was put in on account of extensive separation of the cellular tissues, and the fear of the accumulation of the products of a serous weeping. The fascia and muscles were brought together by interrupted silver wire sutures, with a gauze drain in the middle, and the fat and skin were closed by buried and subcuticular catgut sutures.
The condition of the patient was excellent, and the pulse as quiet as if no operation had been performed at all; I therefore did not hesitate to put her at once in the lithotomy position and proceed with the extirpation of the remainder of the ureter per vaginam. The end of the ureter and the hole in the vault were exposed by using retractors and catching the right side of the cervix with a bullet forceps and drawing it strongly to the left side. By pulling on the forceps holding the ureter it was made tense, while I cut down through the vaginal wall, at first at the side between the anterior and the lateral walls, and then, curving the incision forwards under the base of the bladder to a point within one and a half cm. of the end of the ureter in the bladder. The ureter was so diseased that it broke off three cm. below the vault, and I had some difficulty in finding the short end in the tissue by the sense of touch and in grasping it with the forceps. There was a free venous oozing from the cut vagina below the vault. The ureter broke once more, and this time at its vesical extremity, and as I could not find the end again I closed the wound and stopped the bleeding by introducing about six catgut sutures, tied tightly ; the hole in the vault communicating with extensive cellular area above was left open for an inferior drain, Avhich was now inserted, pushing a piece of iodoform gauze well up into the cavity, and leaving its end hanging down in the vagina.
The recovery of this patient proceeded without a single unfavorable symptom and she has returned home.
Pathological Report by Dh. IIekndon.
The specimen consists of the left kidney and ureter.. The lower half of the kidney is 6.5 cm. long, 4 broad and 5 thick. It is for the most part of a dark red color, but on its anterior surface presents three pale, slightly elevated areas composed of aggregations of minute yellow tubercles. The remaining portion of the kidney presents a lobulated appearance, and is 6x4.5 cm. in its various diameters. This portion of the kidney is soft and yielding, and on section is found to consist of three or four large caseous abscesses containing thick, creamy, odorless fluid. The lower half of the organ is in most parts normal in appearance, but at one point contains a caseous nodule 1 cm. in diameter. The pelvis of the kidney is smooth and glistening. The ureter is 19 cm. in length. In the vicinity of the kidney it is 5 mm. in diameter, at its vesical end 9 mm. It is firm and somewhat rigid.
Hislolorjical exarmnalion : The walls of the abscesses are composed of typical tuberculous granulation tissue, lined by caseous detritus. The tissue in the vicinity of the tuberculous abscesses is greatly altered. Many of the glomeruli are completely hyaline, others are compressed by the greatly thickened capsule. The connective tissue is markedly increased,
and scattered here and there throughout it are young tuberculous nodules. The pelvis of the kidney has an intact surface epithelium slightly infiltrated with small round cells. The stroma beneath, however, shows marked small roundcelled infiltration. Sections from the upper and middle portions of the ureter are also slightly infiltrated by small round cells. The ureter in the vicinity of the bladder, although dilated, is little altered. The ureter throughout its course shows no trace of the tuberculous process. Tubercle bacilli were found in the wall of the caseous areas in the kidney. Diagnosis : Tuberculosis of the kidney.
The diagnoses were made in these cases by symptoms, by palpation, by insi)ection, and by the analyses of the separated urines.
The patients all presented a history of pain in the side, extending down the course of the ureter and accompanied by frequent painful micturition.
In the first case the renal symptoms were masked by the strangury in the bladder.
In the second case the intense jjain in the left side, and in the third case, in the right side, accompanied iu both cases by attacks of intense renal colic, pointed towards the chief focus of the disease.
By palpation in all cases the pelvic jjortion of the ureter was found to be enlarged and thickened, but only in the first case did it show any nodular enlargement. There was also in each case a point of tenderness at the place where the ureter crosses the pelvic brim. It was also shown by palpation that the ureter of the opposite side was normal.
By inspection the bladder was shown to be normal excepting around the orifice of the ureter on the diseased side, where there was a I'eddened granular mammilated appearance.
The separated urines showed that the abnormal constituents of the urine came entirely from the side indicated by this appearance in the bladder, and that the opposite side was sound.
Tubercular bacilli were found in the first case after a patient search ; in the second case bacilli, undoubtedly tubercular bacilli, were found which had some of the characteristics of the smegma bacillus. In the third case no bacilli were found and the diagnosis depended upon the history and the physical examination.
The only case I know of in which an entire ureter has been removed is one in which it was taken out piecemeal by two different operations, following the removal of the kidney. This operation is called a ureterectomy by Dr. Eeynier, the surgeon, and is not a nephro-ureterectomy as here described. The case was reported to the Surgical Society of Paris, February 15, 1893, and reported in La Semaine Medicalc, February 24, 1893, Vol. I, No. 8.
The patient was a man twenty years of age, from whom Dr. Keynier had removed the right kidney, April 27, 1892, for a uretero-pyelo-nephritis. At a later date he took out five inches of the ureter by enlarging the lumbar incision; in spite of this the man continued to suffer, and the effort was then made without success to reach the pelvic end of the ureter by a para-rectal incision. Luter he made a suprapubic
Fig. I. — Extra-Peritoneal Nephro-uketerectomy.
Cadaver with kidney detached and entire ureter separated down to its vesical extremity through the incipion shown in the cut, without opening the peritoneum at any point. April, 1893. (The cadaver used was male.)
Fig. II.— Diagram showinp positions of incisions for extra-peritoneal nephrouretoreotomy in Cases 2 and S.
The long incision was made in Miss P., and the short incision in Mrs. W.
Fig. hi. — Case 3. Mrs. W. Transverse incision. Kidney,
girdled by tuberculous zone, brought outside ; vessels exposed
in front and ureter behind.
Fia. IV.— Case 3. Mrs. \V. Renal vessels divided and ureter freed down to the brim of the pelvis. Tlie object of this picture is to show the ease with which the entire abdominal portion of the ureter can be palpated tlirnutili a horizontal incision, with only a part of the hand introduced.
Fui. v.— Opcuiiij; the vaginal vault to brinji the extremity nf the rijiht ureter through; the patient lies in the left semiprone posture, and the left hand is carried through the luml>ar incisiot\ behind the peritoneum down to the right vaginal fornix : the uterine artery is held up on the index linger. The right hand is introduced through the vagina to the vault. The assistant then pushes the scissors ihrouch the vault guided by the operator.
/ ^
Fig. VI. — Removal of the lower end of the ureter throiisih
the vagina. The ureter is pulled into the vagina througli the
puncture made in tlie vault by the scissors; this opening is
continued forwards in the direction of the dotted line, and
the entire ureter is removed.
Februart-Makch, 189G.
JOHNS HOPKINS HOSPITAL BULLETIN.
37
incision parallel to the inguinal canal, exposed and removed the lower end of the ureter five inches long, and the patient recovered completely.
In this way three different operations were done. It was not a nephro-ureterectomy such as I am describing here, in which a kidney with a large portion or all of its ureter is removed at one sitting.
The three cases whose histories I have given exhibit three different ways of removing the kidney with its ui'eter.
First, transperitoneal, that is, through an incision through the abdominal wall opening the peritoneal cavity; this incision involves the necessity of a second incision through the peritoneum, covering the posterior abdominal and pelvic walls, in order to get at the ureter.
Second, retroperitoneal, the extirpation of the kidney and ureter through a long abdominal incision beginning in the loin and extending downwards and forwards and ending somewhere in the neighborhood of the symphysis pubis. By this method the peritoneum is detached from its cellular connection with the abdominal and pelvic walls, lifted up, and the ureter exposed without opening the peritoneal cavity.
Third, retroperitoneal, by a short abdominal and a vaginal incision ; by this procedure the kidney is detached and the ureter freed from all its connections through a short incision
in the loin, as far forward as the base of the broad ligament. The rest of the ureter is then pulled through an opening made in the vault of the vagina, and removed down to its vesical end by continuing the vaginal incision forwards towards the neck of the bladder.
Two of my friends. Dr. Clinton Gushing, of San Francisco, and Dr. C. P. Noble, of Philadelphia, were present when I performed the second operation. Dr. Gushing suggested removing the ureter through the vagina, and Dr. Noble suggested removing the upper part of the ureter with the kidney through the incision in the abdominal wall, and at a later date taking out the pelvic end of the ureter. This was what I had tried to do in the lirst case, but I failed on account of the dense inflammatory tissue surrounding the lower end of the ureter.
I look upon the three cases as evolutionary in respect to the best mode of operating, and I would prefer in the future in all cases to operate by an incision in the side large enough to take out the kidney and easily admit a hand and fore-arm introduced for the purpose of detaching the ureter as far down as the vaginal vault. I would then tie the ureter at the lowest point, and remove all that portion with the kidney above the ligature. I would complete the operation by removing the vesical end of the ureter through the vagina, with the patient in the lithotomy position.
TEN CASES OF CANCER OF THE UTERUS OPERATED UPON BY A MORE RADICAL METHOD OF PERFORMINC HYSTERECTOMY.
By J. G. Clark, M. D., Resident Gipiecologist, The Johns Hopkins Hosjntah
Since my report of two cases of cancer of the uterus subjected to a more radical method of performing hysterectomy,* eight cases operated upon by Dr. Kelly and myself have been added to this number.
A review by Dr. Kussell of the clinical course of cases of cancer of the uterus operated upon by the vaginal and combined vaginal and abdominal methods, in the Johns Hopkins Hospital between October, 1889, and October, 1895, furnishes valuable data concerning the percentage of recurrence, the inherent tendency of cancer of the uterus to remain localized and not to become metastatic, and its certainty to recur if not widely excised.
The results of Dr. Russell's studies are in the main confirmatory of those of Winter and others, and are a most important and conclusive evidence of the necessity for a more radical operation than any heretofore proposed.
With regard to mortality and regionary recurrence, in 37 cases of cancer of the cervix, the results were as follows: 10 per cent, died from the immediate effects of the operation, 38 per cent, died with recurrence, 5 per cent, were not beard from, and 43.2 per cent, were still alive after a jieriod of one to live years.
In none of the fatal cases coukl a dislinct liistorv of metas
• See July-August Bulletin, 1S95.
tasis to other organs be elicited, but all died from local recnrI'ence.
This clinical observation is further substantiated by the records of ten autopsies on inoperable cases, made in the Pathological Department of the Johns Hopkins Hospital, which show metastases in only one case beyond the pelvic and retroperitoneal lymph glands.
In four cases there were carcinomatous deposits in the pelvic and retroperitoneal glands; and in five cases, notwithstanding the most extensive local involvement, there were no metiistases.
It is not my purpose at this time to go into the pathological aspects of this question, and these brief statements are only made to point to the necessity for a more radical oj>eratiou.
The systematic steps laid down in my first article remain practically unchanged, notwithstanding the introduction of certain modifications which have been found necessary for the most complete eradication of the disease in the course of the operations in the eight oa^es now reported.
The operation is not an easy one, and every detail should l>e worked out on the cadaver before it is attempted on tlie living subject.
It requires at least two hours and a half for completion, and on account of the close proximity to the great vessels in the pelvis, especially the external iliac veins and arteries, which must be preserved from injury during the course of the
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excision of the broad ligament, is tedious and involves the most painstaking care if the best results are to be obtained. If the operation is carried out properly in all of its details, especially those relative to the dissection of the uterine arteries and ureters, the Held of operation must be perfectly illuminated either by the brightest sunlight or a good electric light. The close anatomical relations of the bladder and rectum to the uterus necessarily preclude the possibility of any operation if the cancerous process has invaded either of these organs, but fortunately the tendency of this disease is to extend laterally into the broad ligaments before it invades the walls of either the bladder or rectum, and notwithstanding the rather extensive involvement of the broad ligaments, the operation promises good results if the cancer has not extended outside of its cervical limits anteriorly or posteriorly.
So far we have had no death from the immediate primary effect of the operation, and this result is attributable to the great care observed in immediately checking all bleeding, and preventing shock by keeping the patient warm during the operation, and injecting normal salt solution beneath the breast and into the rectum at its close.
Before referring to the eight additional cases operated upon by this method it is necessary to repeat the summarized steps of the operation as laid down in my original article, making a brief commentary upon the various steps, with especial r,eference to the modifications which have been added.
Summary of Steps.
1. Insert bougies under the local effects of cocaine, to save time and conserve the patient's vital powers for the operation.
2. Place patient in the Treudelenberg posture and make abdominal incision of sufficient length to insure free manual movements.
3. Ligate upper portion of broad ligament with ovarian artery; divide vesico-uterine peritoneum around to opposite side; push bladder off, and spread layers of ligament apart, exposing uterine artery.
4. Dissect uterine artery out for '2 i an. from uterus beyond its vaginal branch, and tie.
5. Dissect ureter free in the base of tlie broad ligament.
6. Ligate remainder of broad ligament close to iliac vessels and cut it away from its pelvic attachment.
7. Carry dissection well down below carcinomatous area, even though cervix alone seems to be involved.
8. Proceed on the opposite side in the same manner as on the first side.
9. Perforate vagina with sharp-pointed scissors, making strong traction on uterus with small vulsellum forceps so as to pull the vagina up and make its walls tense, then ligate in small segments (1 cm.), and cut each segment as it is tied.
10. Insert iodoformized gauze from above into raw space left by the hysterectomy ; draw vesical and rectal peritoneum over this with a continuous fine silk suture.
11. Irrigate pelvic cavity and close abdomen without drainage.
In the first case reported it was found impossible to insert the bougie into the ureters, and it became necessary to proceed with the operation without this valuable aid.
Cases occasionally occur iu which it is very difficult or impossible to insert the bougies or catheters, and it is well to know in what way to proceed safely with the radical operation in the face of this obstacle.
Under these circumstances the time consumed by the operation must of necessity be greater, as the most careful dissection is required to avoid ligating or cutting the ureters.
If, however, Stejjs 4 and 5, as above given, are carefully followed the ureters can be avoided safely, and a thorough operation can be performed.
In cases iu which the uterus has undergone senile changes, the uterine artery may be small and rather difficult to locate. To facilitate finding this vessel iu such cases, a little manffiuvre which was adopted in one case will be of great assistance.
After exposing the intraligamentary cellular tissue (Step 3), the leash of vessels which radiates from the common trunk of the uterine artery and enters the loose cellular tissue lateral to the uterus is included in one ligature, when the artery back of this- point at once becomes distended, turgid, and stands out quite pi'ominently.
The dissection is then carried down along the course of the vessel, with the handle of the scalpel (Fig. I). In this way there is little danger of injuring the vessel, and by coufining the dissection closely to the artery it is safely carried over the ureter, which appears as a glistening cord, to the internal iliac artery, where it is doubly ligated and cut.
By watching the ureter for a few seconds its identity is perfectly recognized by the characteristic rhythmical passage from above downward, of peculiar serpeutine waves, first noted by Dr. Kelly. The ureter is then barred through its course iu the broad ligament, and no fear need be entertained concerning the impairment of its nutrition by a close dissection, as it carries its own vessels. When the ureter is freed it can be lightly drawn out of the field of operation by a traction ligature while the operation is continued, or in some instances a more feasible plan is to push it out of harm's way against the pelvic wall.
The operations performed without the assistance of the bougies in the ureters can be made very thoroughly, but are infinitely more difficult, and are impossible in patients where the abdominal walls are thick and the pelvis deep.
There is the greatest comfort in having the danger of injuring the ureters completely eliminated from the operation by the presence of the bougies, which can be felt distinctly as solid bodies whenever it is necessary to determine the exact location of the ureters. The object of the careful dissection of the uterine artery (Step 4) is two-fold, first, to permit a complete excision of the broad ligament, and second, to render the operation bloodless.
It has been found expedient to modify Steps 6 and 7.
In order to exjjose most perfectly the lymphatic glands at the bifurcation of the external and internal iliac arteries it is necessary to ligate and cut the broad ligament as close to the pelvic brim as possible.
In some cases, especially w'here the peritoneum clings closely to the pelvic walls, or is more or less fixed by an inflammatory process, it is found necessary, as one of the final steps in the
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operation, to split the peritoneum higher up, at the point where the ureter passes over the brim of the pelvis, in order to gain free access to the glands. This modification will be referred to further on.
After cutting the broad ligament away from the brim of the pelvis close to tbe iliac vessels, the excision should be carried down towards the pelvic floor, great care being observed to dissect out all of the intraligamentary glandular and cellular tissue with it. Especial attention should be paid to the glands at the bifurcation of the iliac vessels, which may not be visible but can be palpated. These glands should be enucleated with the fingers, and the greatest care must be observed in this part of the operation, as one is in the most dangerous proximity to the external iliac artery and vein. Our usual plan is to leave these glands until the last part of the operation, when it will be found more convenient to remove them as shown in Fig. III. When the excision of the broad ligament has been carried down to a point on the pelvic wall corresponding to a transverse line passing through the vesical orifices of the ureters, it is suspended, and the excision of the base of the ligament, which lies in such close relation with the bladder, ureters and rectum, is completed later from below, upward.
After completing the operation on the opposite side in a similar manner (Step 8), the vaginal puncture should be made.
Especial attention is called to the method of excising the portion of the vagina and base of the broad ligaments which are removed with the uterus.
It is exceedingly important to excise a large cuff of vagina ; and to accomplish this with the greatest ease and thoroughness, an assistant should insert his finger into the vagina and definitely locate the margins of the cancer, and then withdrawing the finger at least 2 cm. below this point, make strong pressure upward against the anterior vaginal wall. With this assistance the operator is able to dissect down between the bladder and cervix and vagina, and perforate the vagina at the prominence made by the assistant's finger. In this way a wide area outside of the cancer can be excised.
The vagina is opened with pointed scissors, and the anterior wall is ligated in segments, and cut as far out as the ureters on either side (Fig. II). The ligatures must overlap so that a considerable area of tissue may thus be rendered necrotic and thrown off. This makes the extent of the operation wider than that represented by the excised tissue.
From this point on the operation must be continued with the greatest care. The thumb is inserted through the vaginal opening, if the left side is to be excised, and the index finger is carried behind the posterior layers of the broad ligament, acting as a guide to prevent inclusion of the ureter in the ligature and also to indicate the farthest limit for the excision. By constantly pushing the ureter upward against the bladder with the thumb one is able to continue the ligation and excision well out into the broad ligament beyond the vaginal wall and ureters and thus make the most radical operation possible. Fig. II.
The opposite broad ligament is excised from below in the same way when the uterus, broad ligaments and part of the vagina are removed en masse.
Before proceeding to Step 10, the pelvic walls in the region of the bifurcation of the iliac vessels are inspected, and if any glands are palpable they should be removed. AVe have found the following plan of the greatest advantage in this part of the operation. The gland which is usually most prominent is about the size of a large pea or bean and can be palpated distinctly in the crotch of the iliac vessels.
This is worked out from its bed, and when traction is made upon it, the lymph vessel leading upward is made taut and acts as a guide to the next gland. By this procedure we have been able to remove five glands in one chain. It is not possible to go above the pelvic brim, as the last accessible gland lies at this point; the next group of glands being situated higher up on the vena cava and renal vessels.
In operable cases of cancer the metastases rarely go beyond these glands, and frequently, even in very advanced cases, they are not involved.
A further study of the pathology of this subject may show that the removal of these glands will be of value only from the standpoint of prognosis. If the glands are not readily exposed, a grooved director can be inserted beneath the peritoneum along the course of the ureter, when it can be slit open as far as necessary to make the glands accessible and easily removed.
After enucleation of the glands and adjacent cellular tissue the operation is completed according to Steps 10 and 11.
The analogy between cancer of the breast with its glandular involvement and that of the uterus and its involvement of the broad ligament is apparent to all, and the remarkably good results obtained by the radical operation on the breast and axilla have no doubt turned the attention of many operators to the possibility of a more radical operation for cancer of the uterus.
As evidence of this tendency I find, since the publication of my first two cases, that Dr. Keis* of Chicago has worked out experimentally on animals and on cadavers an operation which has for its object the more complete removal of the diseased areas and the pelvic lymph glands.
The operation which Dr. Reis proposed is not described in detail, but I judge from his article that it is similar to the one employed in our ten cases.
Dr. Kumpf t of Berlin reports one case of cancer operated upon, as Reis states, according to his method.
Repobt of Cases.
Casr 3,} Gynecol. No. 3S23. R. P., admitted 9, 21, 95. aged M years, black.
Chief Complaint. Pains in back and constant bloody vaginal discharge.
Marital Iliitory. Married 23 years, ten children, oldest 22 years, youngest 2 years of age, labors natural, easy, usually in l>ed 2 weeks after labor.
Three miscarriages, no bad sequebv.
}feiistrual 7/Mfory. Flow appeared tirst in her thirteentli year.
•The Chicapo Medical Recorder, November, 1S95. f Tentralblatf fiir Gynecologie, No. 31, 1S95.
! Cases I and 2 reported in July-August number of The .Tohns Hopkins Hospital Uullbtin.
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always regular until within last year. Periods are irregular and flow profuse, bright red in color, fluid.
Family History. Good.
P(ut Ilittory. Healthy all her life.
Present Illness. In July, 1894, she ceased to menstruate, but felt very well, .\bout four months later, during sleep, there was an escape of watery fluid amounting to about one gallon. A slight discharge continued, accompanied by a feeling of weakness in her back, but no actual pain. After two months she had a severe hemorrhage, discharging large clots and fatty-looking material. This has continued, but not so profuse, up to the present time. She suffers occasionally from nausea. Abdomen not tender, locomotion slightly painful.
General Condition. Well nourished woman, mucous membranes an.-emic, tongue coated, appetite good, bowels regular, micturition at times painful.
Examination. Outlet relaxed. \ fungating friable mass about the size of a large orange fills the vault of the vagina. This mass breaks down on the slightest touch and gives rise to free l)leeding. The carcinomatous process involves the entire cervix and extends 1 cm. into the vagina. The broad ligaments are apparently not involved.
Diagnosis. Carcinoma of cervix and vagina.
Operation by Dr. Clark, Oct. 3, 1895. Removal of uterus, broad ligaments and part of vagina, with enucleation of pelvic lymph glands.
Catheters inserted into ureters without difficulty. Operation carried out in all of its details. Pelvic lymph glands, apparently enlarged, dissected out above the brim of the pelvis. A cufi of apparently healthy vagina 2 cm. in width removed with uterus.
Note. This case would have been considered a favorable one for vaginal hysterectomy by many operators, as the broad ligaments did not seem to be involved. The dissection of the uterine arteries, however, showed carcinomatous tissue in the broad ligaments. Pelvic lymph glands also appeared to be involved.
Case 4, Gynecol. No. 3888. M. C. D., admitted.lO, 17, 95, aged 48 years, white.
Chief Complaint. Bloody vaginal discharge.
Marital History. Married 32 years, eight children, labors not difficult, no ajiparent sequelse, youngest child 7 years old. Five miscarriages at various times between the births of her children, none since the birth of last child.
Menstrual Uislory. Began at 12 years, regular, flow free, lasting 4 to 5 days, painless. Became irregular 4 or 5 years ago, flow not appearing for 4 or 5 months at a time. Two years ago it began to appear more frequently and to last longer than earlier in her menstrual life. A year ago the flow became prolonged and copious, lasting two to three weeks, and frequently ending with a free hemorrhage. Since January, 1895, flow has been almost continuous.
Leucorrh(za. When free from bleeding she has a copious offensive yellowish discharge.
Family History. Negative.
Personal History. Hemorrhage from stomach and bowels 15 years ago.
Present Ailment. Constant backache for last year, and for the last few weeks she has had a dull aching sensation in her lower abdomen. History of hemorrhages {vid. sup.).
General Condition. Very aniemic, but patient says she does not feel debilitated. She is of very spare habit, but says this is her normal condition. Tongue clear, bowels constipated, appetite good.
Examination. Outlet relaxeil, vagina contains fetid bloody discharge. Cervix has been entirely excavated and in its place is a deep punched-out ulcerated pit, which extends upward to the cervico-fundal juncture, outward at least I'A cm. into the broad ligament, and downward as a ragged area for 2'/i cm. into vaginal wall.
The ureters seem to be surrounded by the carcinomatous process.
Diagnosis. Cancer of cervix and vagina involving the broad ligaments extensivel}'.
Operation, Oct. 18, 1895, by Dr. Clark. Removal of uterus, broad ligament and 3 cm. of vagina, along with enlarged lymph glands on pelvic walls.
Ureters catheterized before administration of ansesthetic without the slightest obstruction to the entrance of catheters, showing that they were not as extensively involved as at first appeared by the vaginal examination.
Operation much more satisfactory than had been anticipated, as it was found upon opening the abdomen that the carcinoma had involved the broad ligament quite extensively but had not reached the ureters. A very thorough dissection was made, and the carcinomatous tissue in the broad ligaments and vagina was apparently entirely removed. The pelvic lymph glands were not enlarged and appeared normal.
Unfortunately the cancer had extended so far anteriorly and posteriorly that the bladder and rectal walls were probably involved.
At the completion of the operation the patient's ymlse was 150, but under the influence of an enema of 1 liter of salt solution and the injection of a similar quantity under the breasts, it quickly dropped to 90 after she was returned to the ward.
10, 24. Vaginal gauze removed, no discharge. Patient has had incontinence of urine since the operation, although she voids almost a normal amount.
General Condition. Steadily improving. Symptoms in every way favorable. Temperature 101°, pulse 110.
11,10. Patient has made a rapid convalescence. Slight incontinence of urine, but much less than when previously noted.
11, 26. Patient discharge<l. Still has slight incontinence of urine. General condition excellent.
Vaginal wound perfectly healed. No apparent disease visible.
Bladder carefully examined and ureters catheterized to prove definitely that the incontinence did not come from a ureteral fistula. Both ureters found to be normal.
Incontinence probably due to a slight paralysis of the sphincter urethrm.
Feb. 24, 1896. Patient's husband reports to-day that his wife is apparently w'ell, has gained in flesh and strength, and is able to do all of her house work. Incontinence quickly passed away after she returned home.
Note. — This case represents the extreme limit of the operation for the radical removal of cancer of the uterus. Prognosis as to cure unfavorable, but as to relief of symptoms and prolongation of life good.
Case 5, Gynecol. No. 3923. E. J. C, admitted 10, 30, 95, aged 53 years, white.
Chief Complaint. Bloody vaginal discharge.
Marital History. Married twice, the first time 30 years ago, the second time 17 years ago. One child, 23 years of age, labor easy, no bad sequelie. One miscarriage in the second month 25 years ago.
Menstrual History. Began at 16 years, regular, flow free, lasting 4 to 5 days, without pain. Climacteric one year ago.
Leucorrhaa. For the last few months she has had a thick, yellowish, irritating and offensive discharge.
Family History. One sister dead of phthisis, grandfather had a cancer, otherwise history negative.
Personal Hintory. Healthy as an adult, except an attack of rheumatism four years ago.
Present Ailment. For the last four or five months has had a yellowish discharge, which has lately become blood-tinged. The latter has steadily increased, never amounting to a hemorrhage, but only a slight oozing, more marked after exertion. She has had no pain. Defecation at times painful.
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General Condition. Patient has lost flesh and strength in the last six months. Appetite fair, bowels regular.
Examination. Outlet normal (parous). Cervix excavated by ulcerative process, the normal outlines of the cervix being entirely obliterated, and in its place there is a deep pit which extends up to the cervico-fundal juncture, and out into vaginal walls. Bladder and rectum apparently not involved. Broad ligament slightly fixed and imlurated.
Diignosis. Cancer of cervix and vagina, extending out into broad ligaments.
Oiit. 31, 1895. Preliminary curettement without ether, all redundant tissue removed and vagina cleansed.
Nov. 2. Operation by Dr. Kelly. Removal of uterus, broad ligaments and part of vagina, also lymph glands at brim of pelvis.
Bougies inserted before operation. Details of operation carried out in full.
Patient lost no blood during operation, and was returned to ward with a pulse of 112. Saline injection under breasts and salt solution enema of one liter given. Incision closed with buried silver wire and subcutaneous catgut sutures.
Nov. 10. Vaginal gauze removed. Patient has had no nausea or vomiting following operation.
Nov. 11. The incision broke down and discharged a large amount of pua. General condition of patient very good.
Nov. 21. Incision perfectly healed without removal of silver sutures.
Dec. 3. Patient discharged to-day. Examination in the knee breast posture shows the vaginal vault almost completely healed. A small point of cleavage is still present, which is covered with granulation tissue. Imbricated sutures are seen well outside of the limit of granulation tissue.
So far as now demonstr.able the result is satisfactory. Patient has made an ideal recovery, with the exception of the suppuration of abdominal wound.
Case 6, Gyn. No. 3980. M. K., admitted 11, 4, 95, aged 44, white.
Chief Complaint. Constant vaginal discharge of yellowish or blooily matter.
Marital History. Married 29 years, five children, labors normal, three miscarriages, no bad sequela.
Menstrual History. Menstruation began at fifteen years, regular, not painful, duration usually four days, but for last two years a day has occasionally intervened during the menstrual flow when the discharge has ceased.
During the past year the flow has occurred at times every two weeks. Two months ago the flow was very copious, amounting as the patient thinks to a hemorrhage. Last period one month ago, of short duration and very scanty. Since last period constant hemorrhagic discharge. Menstruation previous to last two years has been copious, at times discharged in large clots.
Family History. Negative.
Personal History. Measles when a child. Has never been strong.
Present Condition. In June, 1895, patient first noticed that menstrual flow became more or less constant. It has continued without cessation up to the present time, and has increased rapidly in tlie last three weeks. Discharge is brownish, very fluid, ofTensive and irritating.
Oeneral Condition. Has lost about 20 pounds in past year. Appetite good, marked anrcmia, patient feels weak and languid, bowels constipated, micturition painless.
Examination. Outlet greatly relaxed. Filling fornix of vagina and projecting half way down into the vagina is a fungous mass about the size of a foetal head. The mass bleeds on the slightest touch, is very friable, and the odor from the discharge is very offensive. The carcinomatous process has destroyed the cervical portion of the uterus, but the vaginal walls seem to be but slightly involved. Vesical and rectal walls not encroached upon. Tlie broad ligaments are apparently involved as far out as the ureters.
Fundus uteri normal in size, freely movable and not adherent. Appendages normal.
Diagnosis. Cancer of cervix extending into broad ligaments.
Operation, Nov. 7, 1S95, by Dr. Clark. Rem.oval of uterus with broad ligaments and part of vagina.
Ureteral catheters introduced before ether was administered. The right ureter was cathcterized with great difficulty on account of an apparent constriction of its lumen, and during the cleansing of the vagina the catheter slipped out into the bladder, but with the aid of the catheter on the opposite side the operation was coml)leted without great difficulty.
Preliminary curettement of cervical mass attended with much hemorrhage, requiring a tight pack to control it while the abdomen was being opened and the uterine arteries ligated.
Uterine artery senile, requiring a ligature around its branches close to the uterus to make it stand out prominently.
On the right side the carcinomatous process had extended out farther than on the left.
Lymphatic glands in broad ligament not enlarged, and apparently not the seat of metastasis.
Pulse at completion of operation 108, no lilood lost during the hysterectomy.
On account of great anaemia and liability to shock, 1 liter of normal salt solution was injected beneath the mammary glands, and 1 liter of salt solution given by enema.
Abdomen closed with buried silver wire and subcutaneous catgut sutures.
Nov. 8. Patient has complained of no thirst, pulse 60, full and strong, rapid recovery from ether.
Nov. 13. Vaginal gauze removed without difficulty.
Nov. IG. Abdominal incision perfectly healed. General condition excellent.
Dec. 5. Patient discharged. Vaginal vault healed with the exception of one small area which looks suspicious.
Note. — On account of the'wide extension of the disease on the right side this case is considered unfavorable for permanent cure.
Case 7, Gynecol. No. 4031. A. A. L., admitted 12, 19, 95, aged 41 years, white.
Complaint. Backache and a constant irritating watery discharge.
Marital History. Married at 17 years of age, two children, oldest 21 years, j'oungest 19 years. Labors normal. One miecarriage IS years ago.
Menstrual History. Menstruated first at 13 years of age. Always regular until two years ago. Since that time irregular (see Pratnt Illness).
LeucorrliOM. Has had a slight discharge for several years ; for last six months this has iissumed a watery consistency and is slightly tinged with blood.
Family History. Good.
Past History. Always strong and healthy until present illness began.
Present Illness. Began with a hemorrhage about one and one half years ago while nursing a sick member of the family. This occurred at a regular period, and she gave but little thought to it. The next menstrual epoch was ushered in the same way, the tlow continuing more or less profuse for five weeks. Flow then appeared regularly until September. 1895, when she again had a profuse hemorrhage, which recurred November 4th and 2tith. Since the last date she has had irregular hemorrhages, with a watery, acrid discharge in the intervals.
Oeneral Condition. Patient has not lost an appreciable amount < •' flesh, but has grown weaker and j^aler. Bowels constipated, urination normal, appetite poor. Fairly well nourished, mucous membranes pale and anivmic.
Examination. Outlet relaxed. In the vaginal vault there is an ulcerated area 5x7 cm., its longest diameter transverse. The cervix uteri seems oulv slightlv if at all involved. The disease reaches
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within IJ cm. of tlie os uteri, which is slightly lacerated but not inflltrated. A small inunous polyp hangs from the cervix. The infected area has atypical carcinomatous appearance, the central portion is necrotic, white, and exhales a fetid odor. The margins are raised and are of a pinkish color, and there is a sharp line of <lemarcation between it and the surrounding mucous membrane. The entire ujiper third of the vagina and the upper part of the middle third are involved, and the disease extends over into the right lateral wall. Rectal examination shows no extension of the disease in that direction. Uterus and appendages normal.
Diagnosis. Carcinoma of vagina extending up into right vaginal fornix, and involving broad ligament.
Operation, Dec. 23, ISO.i, by Dr. Kolly. Removal of uterus, broad ligaments, infected portion of vagina, and accessible pelvic lymph glands.
Black rubber bougie inserted into ureters before the administration of ether.
In this case the u.sual steps of the operation were departed from, in that the carcinomatous area in the vagina was first outlined by an incision, and partly dissected up to the vaginal fornix, after which the abdominal incision was made and the operation comjileted in its usual way. It was attended by more bleeding than usual on account of the extreme vascularity of the vaginal walls.
The lymph glands on the right side were enlarged and distinctly palpable. A chain of five glands was dissected off from the bifurcation of the external and internal iliac vessels.
At the completion of the operation, while the ureter on the left side was being pushed to one side, the bougie suddenly broke close to the bl.adder with an audible snap. Dr. Kelly attempted to push the broken end down into the bladder and catch it with forceps introduced through the urethra, but this proved impossible. He then pushed it back to its former location, and splitting the ureter open longitudinally, withdrew it. The incision was neatly closed with one fine silk mattress suture, without occluding the ureter or diminishing its caliber. Since this accident, bard rubber bougies have been discarded and the English catheter suV>stituted.
At the completion of the operation the patient's pulse was 140 and weak, but it improved at once under the effects of the submammary injections and rectal enema of normal salt solution. Her pulse when she returned to the ward was 128. Incision closed with silver wire and subcutaneous catgut.
Dec. 24. Patient has had considerable pain and nausea. The question of occlusion of the ureter is certainly eliminated by the fact that she has passed twelve hundred cubic centimeters, or a normal amount of urine within the last 24 hours. •
Dec. 29. Patient has been exceedingly nervous and complains of great pain. Temjierature 100° F., pulse 90. No tenderness or tympanitis. Bowels liave moved very satisfactorily. Vaginal gauze removed, slightly blood-stained.
Dec. 30. Abdominal incision separated on account of the breaking of one of the silver wires. Cocaine was at once apjilied and the edges of the wound were brought together with penetrating silkworm-gut sutures.
Jan. 27th, 1896. Patient has made a steady recovery since the last note and is discharged to-day. The vaginal wound is not entirely healed, but appears perfectly healthy.
Case 8, Gynecol. No. 4056. G. H., admitted 1, 4, 90, aged 34 years, white.
Complaint. Bloody vaginal discharge.
Marital Jlistori/. Married 14 years, five children, all labors easy except fifth, which was very tedious. Last labor 3 years ago. Three miscarriages — first in the seventh month, second in the sixth month, and third in the fifth (twin pregnancy), occurring in .June, 189.5, 1 foitus macerated, the other living at birth.
yfenstriial llisUny. Menses began at 13 years, regular, painless, flow moderate, never clotted previous to July, 1895. Since then the discharge is always clotted and ollensive.
LeucorrluBa. None.
Family History. Negative.
Personal History. Always healthy up to July, 1895.
Present Ailment. In July, 1895, one month from the time of her last miscarriage, she began to have a discharge of clotted blood, which increased in frequency and amount until three months ago, when her physician excised part of the cervix. She was temporarily relieved, but flow again appeared and continued up to seven weeks ago, when the cervix was curetted, followed again by slight checking of the discharge.
The discharge is now thick, pinkish and offensive.
General Condition. Has lost considerable flesh. Is of spare habit, anremic, anxious expression, appetite good, bowels regular, micturition painless.
Examination, Jan. 8, 1896. Outlet moderately relaxed. Projecting from anterior and posterior lip of cervix is a fungating mass, about the size of an egg, which bleeds on touch.
It is almost entirely limited to the cervix, and only projects slightly into anterior and posterior vaginal walls. Fundus uteri slightly enlarged, movable, appendages normal. Broad ligaments do not seem to be involved.
Diagnosis. Cancer of cervix.
Operation, Jan. 8, by Dr. Clark. Removal of uterus, broad ligaments and a wide cuff of vagina, and pelvic lymph glands.
Bougies inserted under the influence of cocaine without difficulty before etherization.
This operation was uncomplicated, and so far as macroscopic appearances of the removed specimen, all of the disease was removed.
Submammary injections of salt solution and rectal enema of 1 liter of salt solution given. Pulse at completion of operation 140 and very weak. In two hours it had dropped to 90 and was full and strong.
Jan. 10. Patient reacted well from operation.
Jan. 10. Vaginal pack removed without difficulty. Patient ha.s been a victim of the morphia habit before she entered the hospital, and suffered greatly from the withdrawal of the drug after operation.
Feb. 8. Patient has made an uneventful recovery. She has increased in weight ; her expression is now good, color of skin and mucous membranes greatly improved. General condition excellent.
E.ramination shows the vaginal vault to be completely healed and there are no apparent remains of the cancer left.
Case 9, Gynecol. No. 4070. E. P., admitted Jan. 11, 1896, aged 43 years, white.
Complaint. Pain in the lower right abdomen and across kidneys. Almost constant bloody vaginal discharge.
Marital History. Married 20 years. No children and no mis. carriages.
Menstrual History. Began at 13 years, always regular, periods occurring every fourth week, not painful, amount moderate, lasting one to two days, bright red, not clotted. Last jieriod Jan. 1, 1896.
Leucorrhcea. For last 10 years, profuse yellowish-green, non-offensive, irritating discharge.
Family History. Negative.
Personal History. No illness since. maturity up to the beginning of this ailment.
Present Condition. First noticed pain in left lower abdomen two years ago, occurring suddenly as a sharp cutting jiain, which has gradually grown worse, and has often confined her to bed for three days to one week at a time. During attacks pain may be " sharp or dull thudding," does not radiate.
Patient lies on left side with left thigh flexed ui>on the abdomen. Nausea and vomiting are at times present, though not confined to attacks. Tenderness is more marked during attacks.
When walking she limps and inclines the body forward. Pain
Fig. I.— Method of dissecting uterine artery out to its origin. Ureter is seen passing immediately
beneath uterine artery.
I'm. II.— Uterine [artery douldy ligated and cut. Fore-finger posterior to broad ligament, thumb
uaiMtcd through vatrinal incision pushing ureter towards pelvic wall, thus permitting a wide excision
>f the broad lisxanient.
Fig. III.
RADICAL OPERATION FOR CANCER OF THE UTERUS.
ON THE LEFT SIDE THE METHOD OF SPLITTING THE PERITONEUM iS DEMONSTRATED. WHILE ON T-.E RIGHT THE PERITONEUM IS LAID OPEN, EXPOSING PELVIC LYMPH GLANDS AT THE BIFURCATION Or THE INTERNAL AND EXTERNAL ILIAC VESSELS; ALL THESE GROUPS OF LYMPH GLANDS ARE SELDOM ENLARGED IN ONE CASE. BOUGIES HAVE BEEN INSERTED IN THE URETERS. WHICH STAND OUT PROM INENTLY STUMPS OF LITlGiliTEB UTERINE ARTERIES ARE SEEN EXTERNAL TO THE URETERS,
February-March, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
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"across the kidneys" began two years ago, and has gradually increased until the present time, when it is a constant ache, which at times is increased to sharp, cutting pain. During these exacerbations of pain the vesical distress is increased, causing frequent voiding of small amounts of urine, which is accompanied and followed by pain and burning.
For past year micturition has been increased in frequency. Retention of urine is painful.
Bloody vaginal discharge began two years ago, at first at variable intervals, but for past year is constant. At first bright red, it varies at present between pink and dark red.
Two months ago she had a larger hemorrhage than usual, discharging a pint of clotted blood.
General Condition. Has lost flesh, fairly well nourished, color not good as formerly. Patient looks much older than the age given (43 years). Appetite good. Bowels constipated. Urine contains a moderate number of pus and epithelial cells.
Examination. Outlet intact, cervix excavated with jagged ulceration, leaving a shell-like margin. This ulcerative process is confined to cervix and has not invaded the vaginal walls.
The broad ligaments appear to be free. Fundus in retro-position freely movable.
Considerable pain on pressure in left ovarian region. Appendages normal.
Diagnosis. Cancer of cervix.
Operation, Jan. 15, by Dr. Kelly. Removal of uterus, broad ligaments, part of vagina and pelvic lymph glands.
Ureters catheterized before administration of ether. Details of operation carried out as usual. A very thorough dissection of intraligamentary and pelvic cellular tissue with the lymphatic glands and vessels. Cancer was found to run out closely to the ureters, and appeared to involve the bladder at these points. The muscular coat of bladder was slightly lacerated, bnt not more so than in former operations. At the completion of the operation the patient was in a very good condition, considering the extensive operation to which she had been subjected.
The usual submammary injection of 1000 cc. of salt solution and a rectal enema of 1000 cc. of salt solution were given.
Incision closed with buried silver wire and catgut.
Jan. 19. Patient has reacted well from the operation. Pack removed and found covered with a slight bloody discharge.
Jan. 22. For the last few days patient has complained of incontinence of urine, with burning pain on micturition. Temperature 99° F. and pulse 90. Patient weak and drowsy.
Jan. 27. Line of incision perfectly healed. Condition otherwise almost same as noted above. Vesical irrigations bring away considerable amount of pus and flaky matter.
Feb. 1. Incontinence continues the same, vulv;e excoriated and red. External genitals bathed with boric acid solution and covered with zinc o.\ide ointment. Patient's general condition wor.se.
Feb. 7. Patient very weak and drowsy, expression listless, complete incontinence of urine.
Feb. 10. Patient is now suffering intense pain in bladder and rectum. Condition growing worse rapidly.
Feb. 12. Patient died suddenly this morning.
Autopsy, Feb. 13, by Dr. Flexner.
Anatomical Diagnosis. Operation wound for extirpation of uterus and broad ligament; sloughing cystitis anil pericystitic infiltration (purulent;. Rupture into rectum. Purulent proctitis. Ascending pyelo-nephritis.
Surface. Body 1-16 cm. long, slightly built, greatlj' emaciated, abdomen scaphoid, no subcutaneous redema.
Mucous membranes of conjunctiva jiale.
In midline of body from umbilicus to symphysis, linear scar 14 cm. long, completely healed.
Omentum. The omentum is adherent to under surface of incision by delicate fibrous adhesions; with this exception, the omentum is free ; it contains a small amount of fat.
Peritoneum. Peritoneal cavity does not contain any excess of fiuid. Intestines free from adhe.sions, serosa delicate, perhaps a little granular, especially on the jejunum.
Mesenteric glands not enlarged, but through mesentery appear congested. Delicate adhesions between one of the lower loops of the ileum and the stump of the ovarian vessels on the right side.
Appendix. Normal.
Sigmoid flexure. The sigmoid flexure projects to the right side and is bound by very light adhesions to the peritoneum over the iliac muscles, by firmer adhesions to the bladder. On breaking these adhesions to the bladder this is noticed to be much discolored, of a greenish and in places almost black hue, which extends to the peritoneum covering the sigmoid flexure.
The seat of operation is apparently in perfect condition, the peritoneum is firmly united, and the catgut suture joining the vesical and rectal reflections of the peritoneum is not yet absorbed.
Heart. Normal.
Lungs. Normal.
Spleen. Small, but appears normal.
Left kidney. Free from adhesions. Is not markedly dilated. Cajisule is adherent ; in some places corresponding to the adherent areas the surface is granular.
The cortex generally has a slight pinkish tint in which there are many white elevated nodules, varying in size from a miliary tubercle to lines and dots of sand. On section these agree with linear lines of varying width extending upwards from pelvis.
Pelvis dilated, mucous membrane thickened and congested and shows numerous ecchymoses.
Pelvis contains greenish thick [lus.
Ureter dilated to size of a large quill, mucous membrane much congested, thickened and contains small ecchymo.«es.
Right kidney. Somewhat larger than left, cai^sule firmly adherent. Pelvis not dilated, but mucous membrane thickened, ecchymotic and very hypera^mic. Kidney a mass of small and confluent abscesses; on section of these, pus escapes only occasionalh". It seems to be a diffuse interstitial infiltration rather than localized abscess- formation.
Bladder. Bladder is fixed to pelvic wall and cannot be removed without more or less tearing of its substance. On both lateral walls the soft tissues are necrotic, pigmented, and gangrenous in appearance, as deep as the bony structures. A considerable amount of semi-fluid pus escapes on exerting the slightest pressure on the tissues about the bladder on either side ; there is more, however, on the left than right. The bladder itself has thickened walls; its mucous membrane is a pultaceous pigmented purulent mass. There are some mineral concretions in the dark pus which covers the surface.
Left ureter is evidently occluded at its point of entrance into the bladder, but is certainly not included in a ligature.
Intestines. The jejunum is pale and moderately distended. The ileum is contracted. The large intestine is normal. Mncons membrane of the rectum covered with pus, and in its middle third there is an opening communicating with pericystic abscess and bladder.
Pancreas. Pal e an d fi r m .
Stomaci. The mucous membrane is pale.
Duodenum. A few small congested patches.
Oesophagus. Normal.
Lircr. Smtill, free from .adhesions. On section somewhat mottled. Central veins very distinct. Weight 960 grams.
Oall bladder. Moderately distended with thick dark bile.
Glands. All of the glands in the abdominal cavity, so far as they could be found, were dissected out and examined maeroscopically.
The retroperitoneal, above the pelvic brim .is well as those in the abdominal cavity, especially the glands lying uiKin the external iliac vessels and between these vessels and the psoas muscle, were removed. In no case were they found to contain met&stases, nor were they perceptibly enlarged.
The absence of metastasis refers to the examination by the
44
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[Nos. 59-60.
unaided eye. It will be necessary to make sections to exclude metastasis with certainty. Microscopic Examinalion. Lymph glamis normal.
Case 10, Gynecol. No. 4143. M. E., admitted 2, 11, 9(), aged 33 years, white.
Chief Complaint. Bloody vaginal discharge.
Marital History. Married 17 years, seven children, labors usually long and tedious, especially the first and sixth, non-instrumental. Twin births at one labor.
Attended in confinements by a midwife. Laceration of perineum during first labor. Last labor 3 years ago. One miscarriage in December 1895, no ill effects.
Menstrual Ilistory. Flow began at 14 years, regular every fourth week up to 3 years ago. For past three years periods have been exceedingly irregular, varying from one to two months apart. During last six months she is unable to difllerentiate the menstrual flow from an almost constant hemorrliage which she has had.
Leueorrh(&i. During the last six months she has bad a profuse, yellowish, non-irritating, offensive discharge, wlien the bloody discharge was not present.
Family History. Negative.
Personal History. Since maturity no definite illness, but patient has never felt perfectly well.
Present Condition. Fiist noticed bloody vaginal discharge about six months ago, at whicli time it was very scanty, but has continued almost constantly since that time. At times the flow is very profuse, coming in gushes wliich vary in amount from } to 1 pint.
General Condition. Has lost gome flesh, but is still a very stout woman, weighing about 190 pounds. She is very aniemic, appetite good, bowels constipated, micturition normal.
E.vaminalion. Outlet considerably relaxed, cervix occupied by a fungating mass which is about the size of a base-ball, and pirojeots half-way down into vagina. This mass springs from the posterior lip of the cervix and has apparently not spread beyond this point. The tissue is very friable and breads down under the lightest touch. Uterus movable, not adherent. Appendages normal. Broad ligaments do not seem to be involved. The abdominal walls are very thick, and hang pendulous in a large fold.
Diagnosis. Cancer of cervix.
Operation, 2, 13, 96, by Dr. Clark. Removal of uterus, broad ligaments, a cuff 3 cm. in width of vagina, and the pelvic lymph glands.
Catheters inserted into ureters without difficulty before etherization. In this case the operation would have been impossible without the catheters in the ureters, as the abdominal walls were thick, 8 cm. (3 in.), and the pelvis was very deep, which rendered the operation exceedingly difficult.
The entire web-like structure of lymphatics with numerous glands were removed from the lateral pelvic walls, and the vagina was widely excised around the margin of the cancer. The operation required three hours to complete it. The patient's pulse was 146 when she left the table, but under the influence of the salt enemata and injection beneath the breasts, quickly dropped to 110, and the patient recovered rapidly from the ansesthesia without the slightest sign of shock.
SUB-ACUTE AND CHRONIC CYSTITIS TREATED BY THE VESICAL BALLOON/
By J. G. Clark, M. D., Resident Gynecologist, the Johns Hopkins Hospital.
The most frequent cause of cystitis is catheterization of the bhxdder without proper observance of aseptic details, in postoperative and obstetrical cases.
The highly concentrated urine excreted for the first few days after surgical operations, especially after the more serious abdominal sections, gives rise to needless irritability of the bladder and renders frequent catheterization necessary.
A series of observations made by Dr. Russell on the urinary excretion for the first five days subsequent to coeliotomy shows a great diminution in the normal amount of fluids with an increase in the solids of the urine. If, in addition to this chemical irritant, infectious matter is introduced into the bladder by the catheter, the most favorable conditions are present for the production of a serious inflammation. The rigid technique in catheterization insisted upon by modern surgeons fortunately renders this complication comparatively rare, and the chronic forms of cystitis as a rule date the onset of the attack to a specific infection or a badly conducted puerperium.
The acute forms of cystitis usually yield to treatment, if taken in hand at once, by mild vesical irrigations and diuretics, as it is only necessary to eliminate the cause of irritation, which is readily reached by these means, to cause a subsidence in the inflammation.
The method of treatment which I am about to describe is not advised in these simple acute cases; but in the sub-acute
•Read before the Johns Hopkins Hospital Medical Society.
or chronic cases it finds its field of usefulness. The unsatisfactory results of treatment of these obstinate ailments by the usual therapeutic remedies are universally acknowledged by all physicians and surgeons.
The late Professor Goodell, of the University of Pennsylvania, in his remarks preceding the details of treatment of chronic cystitis, usually spoke of the extreme persistence of the inflammation and the diflBculty of curing it, a statement fully confirmed by the large number of remedies which he afterwards suggested for its treatment.
The one symptom common to all forms of cystitis is frequent and painful micturition, due to the expulsive efforts of an inflamed bladder, excited either by a slight distension of the bladder or by the presence of irritant salts in the urine.
If the acute inflammation is not soon relieved the bladder remains contracted, the mucous membrane becomes congested and thickened, new connective tissue is formed in the vesical walls, the rugffi are much more prominent than normal, and the intervening sulci conceal septic matter which cannot be reached by irrigation, as the moment the fluid begins to distend the bladder such acute pain is produced that the bladder contracts with great force and prevents it even coming in contact with the deeper parts, much less washing away or rendering innocuous the concealed pus. As evidence of this, one can see almost immediately after the most thorough vesical irrigation with a two-way catheter, small quantities of urine voided, highly charged with pus, desquamated epithelium and other degeneration ^jroducts.
February-March, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
45
Tt is to overcome this difficulty in reaching the source of infection that the vesical balloon is especially valuable.
At one of Dr. Kelly's clinics given during the meeting of the American Medical Association, in May, 1895, I exhibited an improvised apparatus, made by attaching a toy balloon to an English catheter, and demonstrated its method of application. Since then special balloons have been made which have proved in every way satisfactory.
By means of this apparatus the bladder is distended, the ruga; smoothed out and all of the inflamed and infected areas are brought in contact with the vesical balloon, which is employed as the carrier of therapeutic remedies.
Rubber balloons have been introduced into tlie bladder and inflated preceding the repair of vesical fistula?, to facilitate the operation, but so far as I am able to glean from medical literature, this is the first employment of such an apparatus for the treatment of cystitis.
The Vesical Balloon.
The apparatus consists of a small balloon made of thin rubber, 6 cm. in diameter when collapsed, connected with a thicker rubber tube 26 cm. in length, with a small cut-off valve or clip to retain the air when the bag is inflated. These balloons can be distended to about the size of a well-filled normal bladder.
We have employed the usual surgical aspirator as the most convenient means for inflating the balloon, but the small rubber bulbs connected with nasal atomizers, or a cheap airpump like the bicycle-pnmp, would probably be equally satisfactory.
The balloons are made of delicate rubber tissue, and if not carefully preserved are soon destroyed. They should be washed in warm water immediately after use, and then slightly inflated and allowed to dry thoroughly, in order to prevent the walls of the collapsed balloon from adhering together.
When the apparatus was in its experimental stage we used the oleaginous ointments, which were quickly found to decompose the rubber, and at the suggestion of Mr. Waltz, pharmacist to the Johns Hopkins Hospital, gelatine was tried, which at once proved an ideal vehicle for the various medicaments.
Gelatine possesses the advantages of melting at the body temperature and not injuring the rubber, and when brought in contact with the mucous membrane of the bladder is quickly absorbed.
Up to the present time we have found a ten per cent, ichthyol gelatine very satisfactory. In addition to this we have had made up a bismuth, zinc, salicylic acid and bichloride gelatine, but so far have had no occasion to use them.
Method of Ai'i>lying the Vesical Balloon.
Before usiTig the balloon it should be boiled and placed in a boric acid solution or in sterilized water. The capacity of the balloon should always be accurately determined previous to its use, by inflating it to the size desired, and counting the number of cylinders or bulbs of air required to fill it.
By observing this precaution there is no danger of overdistending the bladder, as the exact degree of distension is determined by the number of cylinders of air introduced.
The external urethral orifice and surrounding parts are cleansed with soap and water and bichloride solution (1 to 1000) by the nurse, after which the bladder is catheterized and the patient placed in the knee-breast posture, carefully protected by a sheet.
The patient should lie with chest flat on the table, her arms hanging over the sides, in order to make the bladder distend perfectly when the speculum is introduced.
A small pledget of cotton rolled on an applicator is saturated with a twenty-per cent, solution of cocaine and inserted into the nrethra and allowed to remain for .3 minutes, when a No. 10 vesical speculum can be introduced without giving the patient much pain. Frequently the patient complains of no discomfort whatever until the end of the speculum impinges upon the inflamed mucous membrane of the bladder wall.
Before the jiatient is placed in position, the gelatine, which has been previously sterilized, is immersed in a water bath and melted. For ordinary use in private practice or in a limited hospital service it is not necessar}' to have the elaborate apparatus here figured (Fig. Ill), but a small metallic ointment box is sufficient for all practical purposes.
The temperature of the water bath should be only sufficient to reduce the gelatine to the consistency of cold olive oil, as in this state it will adhere better to the balloon, which can be more easily rolled into the form of a suppositorv.
Before preparing the balloon for introduction into the bladder the hands should be disinfected. The bag is rolled between the thumb and forefingers in the same wav as a hand-made cigarette. Into the concavity which naturally forms when the balloon is completely collapsed the gelatine is poured to overflowing, and the balloon slowly rolled, more gelatine being added until it assumes the form of a suppository well covered with the semi-fluid gelatine. It is now clasped with a long, slender crane's bill forceps. Fig. II, and inserted through the speculum into the bladder and released.
As the distension progresses the patient suffers considerable pain and an urgent desire to void her urine. By forewarning her of these attendant symptoms she will be able to withstand the pain, and the inflation can be carried up to the desired degree in 3 to 5 minutes.
The pain in chronic cystitis is usually severe during the first two or three applications, but the patient as a rule experiences so much relief subsequently that she is willing to persevere in the treatment.
A rectal suppository of 1 grain of opium, introduced immediately after the trciitment, is of great service in alleviatinothe subsequent suffering. Having inflated the bag up to the required size, the clip on the rubber tube is closed, aud the patient then assumes the dorsal or lateral postura
Our rule is to leave the balloon in place for 1,3 or 20 minutes, beyond which time it does not appear safe, as the ureters are blocked while it is in place. In removing the balloon the clip is opened, when all but a small amount of air esc^ipes; the rest is then aspirated with the air-pump, when the collapsed rubber bag is easily pulled out through the urethra.
We have treated at least ten cases with success by this apparatus. A history of cue case, of a severe type of chronic
46
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 59-60.
cystitis of 13 months standing, well represents the efficiency of the vesical balloon.
Case of Chronic Cystitis.
M. ,1., admitted 10, 21, 95, colored, aged 35 years, married 10 years, no children, no miscarriage.
Complaint. — Frequent and painful micturition. Hematuria.
Menstrual History. — Menses appeared first at 16 years, always irregular, sometimes not occurring for two months. When she was about 27 years old she had a continuous fever for about one year, after this she only had a slight discbarge every three months.
For the last 7 or 8 years the menstrual How has ceased and there is no history of vicarious menstruation. She has suffered no inconvenience on this account, and says she is perfectly well with the exception of her present complaint.
FainiUj Ilistori/. — Mother living and well, two sisters died of phthisis.
Personal Ilistori/. — Patient has always been " delicate," but has never had any prolonged spell of illness.
Present Ailment. — About thirteen months ago she began to have slight pain on urination, which grew rapidly worse, notwithstanding the remedies given by her physician. For the last five months blood has frequently appeared in the urine.
The frequency of urination is much greater at night, when she is often compelled to get up 8 to 10 times. She does not think the pain is increased by exertion, but says one week ago when coming to the hospital she had agonizing pain and several blood clots were passed.
There is a constant dull pain over the bladder, which becomes sharp and cutting during micturition. About the time the patient began to experience painful urination she noticed a yellowish vaginal discharge, which was j»robably of gonorrheal origin.
Present Condition. — Patient says she has lost considerable llesh since illness began. Defecation painful when bowels are constipated. Frequent and painful urination. When the paroxysms come on the patient has an expression, of intense pain.
Examination of Bladder. — Urethra congested and reddened. The vesical trigone is intensely reddened, the rugaj stand out prominently, and over the surface of the bladder are fiakes of pus and small blood clots. The area of intensest inflammation is in the inter-ureteric area and gradually shades off towards the fundus of the bladder.
In the areas of greatest inflammation the mucous membrane is of an angry red color and bleeds when touched lightly with the ureteral searcher. The capillaries are indistinguishable in the inflamed areas, and a careful search of the bladder fails to reveal the ureteral orifices. In the less congested areas above the trigone the capillaries are prominent, and at various points small, intensely red clumps or congeries of minute vessels are seen.
The anterior wall of the bladder in isolated places appears normal.
Treatment. — Application of ten per cent, ichthyol gelatine by means of vesical balloon. Patient experienced great pain at the time of application.
10, 22. Patient greatly relieved two hours after treatment, and still feels much better than before the treatment.
10,23. Balloon again applied, still very painful; bladder appears less congested and the ureteral orifices are faintly visible. Marked improvement in symptoms; urination much less painful. Patient got up only three times last night. A colored drawing of the bladder by Mr. Brodel as it now appears is shown in Fig. IV.
11, 10. The bladder has been treated every third day since the last note was made, and now appears almost entirely well. The patient no longer experiences any pain between the treatments and thinks she is entirely well. Advised to remain one week longer.
11,19. Patient discharged to-day. The mucous membrane has assumed a perfectly healthy hue, except a slightly increased reddening around the ureteral orifices. No treatment since the last note. The pain is entirely relieved, and the patient got up but once last night to urinate. A second colored drawing made by Mr. Brodel, Fig. IV, shows the present condition of the bladder.
THE STERILIZATION OF CATGUT BY CUMOL.*
By J. G. Clark, M. D., Resident Gynecologist, and G. B. Miller, M. D., Assistant Resident Gynecologist,
The Johns Hopkins Hospital.
Since the introduction of catgut as a practical suture and ligature material by Lister, many articles have been written for and against its use, and numerous methods of sterilization have been proposed. That many of these methods are unreliable is shown by the outbreaks of infection which have been traced either by direct bacteriological investigation or by the strongest circumstantial evidence to the catgut used in the cases.
Koch first called attention to the fact that commercial catgut as it is usually received from the manufacturer is rarely infected with pyogenic organisms, which accounts in a groat measure for the absence of infection following the use of catgut prepared by the most questionable methods. • Read before the Johns Hopkins Hospital Medical Society.
This observation has been largely lost sight of in the discussion of this subject, and many surgeons claim to obtain the most satisfactory results from the enijiloyment of catgut which is open to the gravest objections when considered from the bacteriological standard. At least three serious outbreaks of infection in surgical cases have been attributed to catgut. The first occurred in 1879 in the service of Zweifel, which was certainly traced by Koch to the suture material by a careful bacteriological study.
The urgent protest of Zweifel against the use of the Lister method of sterilization by carbolized oil caused many surgeons to abandon catgut.
Kocher, in 1881, after a very superficial study of the
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Februaby-March, 189G.]
JOHNS HOPKINS HOSPITAL BULLETIN.
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germicidal power of juniper oil, introduced it as a sterilizing medium. Later, a large nimiber of cases in his hospital service became infected, and Kocher, feeling that he had such strong evidence against the catgut employed in the cases, published an article against its use in any form, entitled "Fort mit dem Catgut!" (Away with catgut!).
In January, 1893, a very serious reign of infection occurred in the gynecological wards of the Johns Hopkins Hospital which Dr. Kelly believed to be due to catgut prepared by boiling in alcohol under pressure. Unfortunately the whole of the suspected catgut was used up in the last infected case, and consequently bacteriological proof similar to that obtained in Zweifel's cases was wanting. Dr. Kelly was so firmly convinced, however, of its role as an infecting agent that he, like Kocher, discarded all catgut, and for the two following years used silk entirely as a suture material.
Many chemical methods of sterilization have been proposed, but all are open to the objections of either failing to render the catgut innocuous, or impairing its tensile strength, or so impregnating the catgut with irritant chemicals that it acts as a local irritant when introduced into living tissue. The most perfect means of sterilization for surgical purposes is unquestionably heat. Until 1888, when Benckisser and Reverdin brought out independently of each other similar methods of sterilization by dry heat, it was considered impossible to raise any form of animal ligature to a temperature sufficient to render it sterile without making it brittle.
Eeverdin demonstrated that it was uot the oil as previously supposed, but the hygroscopic water in catgut, which caused it to become brittle when heated. If this is driven off by dry heat at a temperature of 70° C. it can be carried safely up to a temperature of 150° 0. without impairing its integrity.
Reverdin and Benckisser both made careful bacteriological studies of these methods and found them to be efficient. The complicated apparatus, consisting of a hot-air oven and a thermo-regulator, however, prevented their general adoption.
The observations of these two investigators stimulated others in the right direction and caused them to look for a li([uid of a sufficiently high boiling-point to sterilize catgut. Brunuer found that the boiling-point of xylol was 136° to 140° C, and at once adopted it as a sterilizing medium.
This at last seemed to be the perfect method, but Kronig found spores occasionally present in catgut which were more resistant than the anthrax spores with which Brunuer had experimented, requiring a greater temiierature for their destructiou than that attained by the boiling xylol. After a further search Kronig found that llie boiling point of eumol, a hydrocarbon compound, ranged between 168° and 178° C, and substituted it for xylol.
After a careful review of Kronig's article,* Dr. Kelly decided to return to the use of catgut.
Kronig's method is as follows :
1. Roll the catgut in rings.
2. Dry it in a hot-air oven or over sand-bat li fen- two liours at 70° C.
•Ceatralblatt fiir Gyuacologie, Juli 7, 1894.
3. Heat it in cumol to a temperature (105° C.) a little short of the boiling point, for one hour.
4. Transfer it to petroleum benzene for permanent preservation, or, if desirable, leave it in the benzene for three hours and transfer it to sterile Petri dishes.
A bacteriological study of this method by the writers shows that sterilization of catgut by the cumol is perfect, but that the transference from boiling cumol to benzene is open to serious objections.
Bacteriological Study.
The catgut used in the culture experiments was of the largest size (No. 3) used in the Gynecological Department of the hospital. Pieces were cut deeply in many places and immersed in bouillon cultures of the following bacteria: staphylococcus pyogenes aureus, streptococcus pyogenes, bacillus coli communis, bacillus anthracis, bacillus capsulatus (Welch), and bacillus subtilis. The cultures were, with one or two exceptions, 24 hours old at the time of the immersion of the catgut, a few being 4 days old. At the end of 4 to 5 days the pieces of catgut were taken out of the cultures of bouillon, which had been kept in the incubator in the meanwhile. These pieces were then dried in the hot-air oven at a temperature of 80° C. for one hour, and subjected to the cumol sterilization. After boiling for one hour in the cumol they were removed without abstracting the cumol remaining in them. They were placed upon agar either in Petri dishes or tubes, and these placed in the incubator. In every case the culture media upon which they had been placed remained sterile. Pieces of the infected catgut which had been dried but uot sterilized were in like manner placed upon agar, as a control. In every instance these gave a growth of the micro-organisms with which they had been infected. In the experiments the staphylococcus pyogenes aureus, bacillus coli communis, bacillus anthracis, and bacillus subtilis were used each four times, the bacillus capsulatus once, and the streptococcus pyogenes once. The latter died either in the bouillon or in the drying process. The staphylococcus pyogenes aureus and bacillus coli communis were used on account of their common occurrence iu cases of infection, and the bacillus anthracis and bacillus subtilis on account of the great resistance of their spores to the usual methods of sterilization.
Four experiments were made with the infected catgut to test the germicidal properties of benzene. The catgut was placed in the benzene and allowed to remain 24 hours, then removed and the benzene evaporated at room temjierature. Iu each case the agar upon which this catgut had been placed showed a luxuriant growth of the micro-organism with which the catgut had been infected. The same micro-org-auisms were used here as in the other experiments except the streptococcus pyogeues and the bacillus capsulatus. A culture was made directly from the commercial benzene and two colonies grew upon the agar. Cover-glasses of those showed a large straight bacillus whose properties were uot determiued.
Modified Cumol Method. From the above investigation we found that it was necessary to modify the method of Kronig so :»s to do away with the
48
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[Nos. 59-60.
use of benzene, as it is not a germicide and cannot be rendered sterile by heat without great danger. The following method was therefore ado])ted :
1. Cut the catgut into the desired lengths and roll 12 strands in a figure of eight form so that it may be slipped into a large test tube.
2. Bring the catgut gradually uj) to a temperature of 8U° ('., and hold it at this point one hour.
3. Place the catgut in cuniol, which must not be above a temperature of 100° C, raise it to 105° C. and hold it at this point for one hour.
4. Pour off the cumol and either allow the heat of the sandbath to dry the catgut or transfer it to a hot-air oven, at a temperature of 100° C, for two hours.
5. Transfer the rings with sterile forceps to test tubes jireviously sterilized as in the laboi-atory.
in making the catgut up into rolls it is only necessary to tie the ends in the isthmus of the figure of eight to hold them securely in proper shape.
If convenient it is better to use the hot-air oven for the drying process, but this is not absolutely essential, as a sand-bath can be improvised, as suggested by Kronig, to serve this jnirpose.
A beaker glass of at least a half-liter capacity is imbedded three-fourths of its height in a tin or agate-ware vessel of sufficient capacity to permit three-fourths of an inch of sand to be packed about the sides and beneath the glass.
In drying or boiling, the catgut should not come in contact with the bottom or sides of the vessel, but should be suspended on slender wire supports or placed upon cotton loosely packed in the bottom.
During the drying process the beaker glass is covered with a sheet of pasteboard, through which a centigrade thermometer is thrust so that the mercury bulb may be suspended about midway in the vessel. In this way the temperature can be regulated perfectly.
A Bunsen burner is placed under the sand-bath and the temperature in the beaker glass is slowly brought up to 80° C, where it is held for one hour, to dry the catgut. A higher temperature than 100° C, before the catgut is thoroughly dry, renders it brittle ; this step in the method must be carried out most carefully.
When the drying jjrocess is completed the cumol is poured into the beaker glass and brought up to a temperature of 165° C, a little short of the boiling-point, with two Bunsen burners. A copper wire netting should be placed over the beaker glass to prevent the ignition of the cumol. This temperature is more than sufficient to kill all micro-organisms, and it is not necessary to allow the cumol to boil, which causes unnecessary evaporation (Kronig). The catgut is left for one hour at this temperature, when the cumol is poured off for subsequent use.
Cumol, which is of a clear limpid or slightly yellowish apitearance when procured from the chemist, is changed to a brownish color by boiling.
The catgut is allowed to remain in the sand-bath until the excess of cumol is driven off and it appears entirely free from any oily matter. A period of one to two hours is usually sufficient to dry it thoroughly.
From the sand-bath or hot-air oven it is transferred with sterile forceps to sterile test tubes, such as are used for culture media, in which it is preserved from contamination until ready for use. Small quantities should be placed in each tube, to obviate the necessity of opening them too frequently.
In conclusion, it is well to bear in mind that while cumol is not explosive it is very inflammable, and great care should be observed in lifting the wire screen from the beaker glass to prevent drops of the cumol from falling in the flame or on the heated piece of metal on which the sand-bath rests, as it will take fire, flare up and ignite the fluid in the beaker glass. Such an accident has occurred three times in our experience.
PROCEEDINGS OF SOCIETIES,
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
The 'I'rcatmcut of I'yo-iirctoritis and Pyonephrosis by Ureteral and Kcnal Catheters.— Dr. H. A. Kelly.
I want to give this evening a brief resume of some important work going on in the gynfecological department during the past year, namely, the treatment of pyo-uretcritis and pyonephrosis by the renal catheter. In the first place, a word or two as to diagnosis ; by means of my cystoscopic apparatus, shown to this society in October, 1893, and the renal catheters first used in April, 1893, I have been able, in all cases with great facility and sometimes in a few minutes, to trace to its source the pus found in the urine of women.
Judging by the number of cases I have met with, pyuria in women appears to be common, and as a rule its source is utterly unknown to the practitioner in charge.
I have found pue in all parts of the urinary tract, from the external urethral orifice up to the kidney. In one case there
was an abscess in one of Skene's tubules at the orifice ; in two other cases a suburethral abscess discharged into the urethra and filled the vesical speculum with pus as it was drawn out.
In another instance a contracted pelvic abscess opened into the bladder through the right broad ligament; by my cystoscope I could see the opening and run in a sound, and by pressure cause pus to ooze out.
In other cases I have been able to locate the affection in the urinary tract alove the bladder by getting separated urines from both sides, and examining it bacteriologically and microscopically; a careful examination of the urea will determine the working coefficient of each kidney, a valuable point in the judgment as to the safety of operating.
I want to dwell now more particularly on the treatment of ureteral and renal pyuria by the renal catheter. There are two ways of treating accumulations of pus in the kidney by the renal catheter: «) by evacuation : b) by washing out.
a) The treatment actually begins with the first evacuation
Februaey-March, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
49
when the pus is drawn off by the catheter, and may be continued either by leaving tlie catlieter in the kidney for several hours (as in one of the first cases, where it was left in from 12.30 p. m. till late in the same evening), or for several days (from Wednesday morning until Sunday evening, in a case now in the house). By leaving the catheter in for a length of time I have been able to evacuate and drain an abscess, and then by introducing the catheter at intervals of one to five days I can keep it well drained. In several patients I have introduced it as often as once daily, in one woman over 120 times in all.
b) Washing out the kidney. In each case the kidney has been washed out after evacuating the pus, by a syringe connected to the catheter. I first used simple gravity for this purpose, by connecting the catheter with a funnel by means of a rubber tube. As the funnel was held high or lower, the fluid ran in or out (v. Johns Hopkins Hospital Bulletin, February, 1895).
I have used solutions of 1-150,000 bichloride of mercury and gradually increasing to 1-2500 and in one case even to 1-1000. In some instances I have used boric acid, and in one nitrate of silver. I find that the occasional use of the bichloride solution with the regular use of boric acid solutions gives good results.
Sometimes it only seems necessary to let the pus out to start an improvement. A case in point was that of Miss D., sent to me by Dr. Norment of Baltimore. She had an abscess in the pelvis of the kidney, and another just below the pelvis in the ureter. The lower pocket contained 45 cc. of pus. I evacuated these in my office, and she improved so much that she returned to work and abandoned further treatment.
The washing out may be repeated at intervals of 1 to 4 days, according to the condition of the patient and the way she stands it. This little procedure does not call for anaisthesia. The quantity injected is usually not more than two-thirds that of the fluid withdrawn. In one instance, in using the forcebottle of the aspirator, a quantity was accidentally forced in larger than that which came out, and ihe patient at once had a severe renal colic. Three women had ureteral chills and fever in the course of the treatment, with nausea" and general malaise; there were two or three chills, and a sharp rise in temperature, highest on the second day, gradually subsiding and disappearing by the fourth or fifth day; the initial chill was more marked than the subsequent ones. The temperature went as high as 104 in one case and 103 in another, but no harm resulted, and treatment was continued.
The progress towards recovery is often as follows : After from five to ten catheterizations, the thick creamy pus begins to become watery and of low specific gravity, containing a small amount of urea (0.3 to 0.7 percent.). Finally the pus disappears, leaving a hydronephrosis of lesser volume than the original pyonephrosis, and later the hydronephrosis too disappears and the condition becomes normal. I will now briefly cite a few of my cases : Case 1. Mrs. B had been in the Hospital about a year before for a suspensory operation. At that time she complained of frequent micturition. The urine was e.xamined and the bladder inspected and found nornuU. She returned a year later, suff'ering extreme pain in the right loin, with high temperature, and wretchedly depressed. I put her in the
knee-breast position, passed a catheter up the ureter into the kidney, but nothing came, as the pus was too thick to flow. I left the catheter in and sent her to the ward, where Doctor Clark attached the aspirator and drew out 280 cc. of thick, greenish pus, of fetid odor. Her kidney was then regularly washed out with bichloride and boric acid solutions, and the urine became clear. One time by mistake a 1-1000 solution was used; she suff'ered a good deal of pain, but made more improvement than after any previous treatment. She was finally discharged perfectly well after about 12 washings, with clear urine and without pain.
Case 2. Mrs. S. was brought here on a stretcher about four months ago, apparently in the last stages of illness and not far from death. I introduced the renal catheter, made suction on the end, and drew down a large amount of pus, and then washed her kidney out. The bladder specimen, examined at the time of admission, was reddish in color ; thick white precipitate; acid ; contained a trace of albumen.
Microscopic examination showed the entire field filled with pus cells. No tubercle bacilli found. Urea, one-half normal. Specimen of urine from right ureter, pale lemon color, with lower layer of gray thick sediment and an upper layer of sediment. Quantity too small for chemical examination. Field filled with pus cells. One hyaline cast. Amount of urea, one-fourth the amount of the mixed urine. Urine from left ureter: slight amount of albumen present; few leucocytes; few epithelial cells. Urea three times as much as from the diseased side. She has been washed out regularly, and the kidney, on entrance larger than a child's head, is now quite small ; there is no more pus in the urine and she is well. She has gained 15 pounds.
Case 3, Mrs. S., a gonorrhceal stricture low down in the ureter, has been reported in the Bulletin (February, 1895) and will, therefore, not be reported in detail. Washed out over 120 times, with the result that from containing 150 cc. of pus, the kidney and ureter now contain 90-100 cc. of clear urine. I could not relieve the stricture entirely, and she still has a hydro-ureter.
Case 4, Jliss S., was washed out over 100 times. Instead of getting better she got gradually worse. One day on applying suction to the end of the catheter I brought out a couple of black granules which proved to be masses of uric acid. I concluded upon this find that the inefliciency of the washing was due to a mechanical cause, a stoue in the kidney, so I cut down and removed a small stone as big ;is the end of my thumb.
Case 5 was sent to me from Chicago for diagnosis (v. Med. A'ews, Nov. 30, 1895). I was able to settle it by drawing out pus and urine through the catheter by suction, together with a number of little black specks and some granular debris ; but the smaller specks were apparently of calculus. On withdrawing the catheter, a little calculus, black and niammillated on one side and buft'-colored and jagged on the other, Wiis found in its eye. The microscope showed that this was broken ofl' from a larger stone. The end of the catheter also, instead of being smooth and round, was hammered down and angular and the side scraped otf. This patient has not been ojierated on, but there can be no doubt about the correctness of the diagnosis.
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[Nos. 59-60.
Case 6, Miss F., is still in ward H under treatment.
The renal catheters used vary in diameter from 1 J to 3 mm., the average size used being 2-2J mm. in diameter. If the pus will not flow tlirough the catheter, suction will sometimes bring it.
A valuable plan wliere suction will not succeed is to inject some boric acid solution, say 15 or 20 cc, and then manipulate the kidney and mix tlie solution with the pus, and then let it run out with the diluted pus. In the case treated in this way last Wednesday 1 brought down a large beaker two-thirds full of pus so thick and curdy that you would have supposed it impossible to get it through the ureteral catheter used.
If you doubt whetlier the catheter actually readied the pelvis of the kidney, I have the following way of demonstrating that it actually was there. These catheters are pliable and easily molded by warmth, and after it has been some time in the kidney and ureter, on laying it on a cold surface as soon as it comes out it takes distinct curves and shows both the point at which it crossed tiie pelvic brim and the curve at the end where it impinged on the upper part of the pelvis of the kidney and bent over. One catheter taken out of a big abscess in this way gave a good idea of its size and form.
Bactekiological Report of these Cases by Dr. G. B Miller, Gynecological resident.
Case 1.— Cultures made (March 30, 1895, and May — , 1895) from the pus obtained from the catheterized ureter, gave the micro-organism described more fully in Case 6. The length of the bacillus varied even more here than in that case, it being frequently 20-30 times the thickness. The pus was not examined microscopically at the time of its catheterization.
Case 2. — Numerous cover-glasses were stained for the bacillus tuberculosis at dififerent times, and proved negative. No cultures were made.
Case 3. — The pus from the catheterized urine was repeatedly examined by Drs. Barker and Stokes. Tlie former found "many diplococci, and these nearly altogether within the protoplasm of the leucocytes; a few within the squamous epithelial cells, and very few outside the cells." He believes "that if gonorrhoea can be diagnosed from pus that this is a case." Dr. Stokes found the same micro-organisms. No other bacteria were found.
Case 4. — The urine drawn from the right ureter was examined by Dr. I'arker, who found that the pus when stained showed many bacilli within the protoplasm of the polynuclear leucocytes, also many bacilli in the urine, some being in chains.
Case 5. — No bacteria were reported as being found in the catheterized urine.
Case 6. — The pus from thi' catheterized ureter (Nov. 12, 1895) showed, when stained, a large coccus occurring singly and in pairs. These were not seen within the pus cells. Cultures from the pus upon glycerine agar proved negative.
Numerous cover-glasses of tiie pus from the bladder were stained (Oct. 28, 1895) for the bacillus tuberculosis, but proved negative. The same i)us stained by the ordinary methods showed bacteria in large quantities. Two forms of microorganisms were made out: one, a coarse bacillus, straight or very slightly curved, with rounded ends; the other, a coccus
occurring in pairs and in short chains, and seen occasionally within the pus cells.
Cultures made from the bladder (Feb. 16, 1895) gave a white waxy growth on agar and glycerine agar raised above the surface and with irregular edges. The organisms did not produce gas with glucose agar, did not liquefy gelatine, but grew in a similar way as upon agar, coagulated and reddened litmus milk, and grew upon potato as a delicate, white, beaded growth. In form, the micro-organism was a coarse, slightly curved bacillus with rounded euds and 5-6 times as long as thick.
Note. — In Cases 1 and 6 the micro-organism does not correspond to any known pathogenie bacillus; whether it was the cause of the suppuration or was introduced into the bladder from the outside is not known, but it is probable that the latter was the case. The extension also from the bladder to the diseased kidney in Case 1 was possible.
HOSPITAL HISTORICAL CLUB.
Meeting of January 13, 1896. IVomen iu Medicine.— Dr. Kelly.
Dr. Kelly spoke to the Society about Dr. Elizabeth Blackwell's recent book. Pioneer Work in Opening the Medical Profession to Women.
Dr. Blackwell is an Englishwoman, born in Bristol, England, in 1821. Her father was an active member of the Indepemlent Church, and upon his removal to the United States in 1833 he became the friend of William Lloyd Garrison and entered zealously into the anti-slavery struggle. Three of his nine children have achieved distinction. Dr. Emily IJlackwcll was associated with her sister iu the practice of surgery in New York, and Henry B. Blackwell, husband of Lucy Stone, has long been known for his untiring efforts in behalf of the enfranchisement of women.
The Blackwell family settled first in New York, but afterwards removed to Cincinnati, and it is here in the W^est, in the early forties, that Elizabeth Blackwell's struggles to obtain a medical education began. Her father had died insolvent, and the three elder daughters had to support the family by keeping a boarding-school for girls, so that in 18-15, when the idea of becoming a physician first took shape in Miss Blackwell's mind, she was twenty-four years old and had yet to earn the money to pay for her medical tuition. She did this by teaching in the South, first iu a forlorn Kentucky town and later in the Carolinas.
In 1847 she iiad saved enough money to begin, and went to Philadelphia, then the chief seat of medical learning in America, where her application for admission was refused in turn 1)y the four medical colleges of that time. Her interviews with the various professors bring out some curious details which well illustrate the muddle of mind with which many intelligent men approach a subject so novel and so revolutionary as advanced education for women. Dr. Warrington, a well-known (Quaker physician, and Dr. Pancoast, professor of surgery in the Jefferson Medical College, then the largest medical school in I'hila(k'l])hia, both approved of a woman's
February-March, 189G.]
JOHNS HOPKINS HOSPITAL BULLETIN.
51
studying medicine, but they saw no better way for her to enter the medical classes than to disguise herself as a man. Trousseau gave Dr. Blackwell the same advice when she wanted to attend lectures at the Ecole de Medecine in Paris.
The dean of one of the smaller schools, thinking of his pocketbook, frankly replied to the application, " You cannot expect us to furnish you with a stick to break our heads with." Professional rivalry is undoubtedly a serious obstacle to women in medicine, and keener for various reasons than the natural rivalry of man to man, but it is entertaining to read of a professor in a medical school who felt so sure of the rapid practical success of a woman physician that he actually proposed to enter into partnership with Dr. Blackwell, on condition of sharing profits over $5000 on her first year's practice. Miss Blackwell's application for admission having been refused by the medical schools of both Philadelphia and New York, she procured a list of all the smaller schools in the Northern States, and quite at a venture applied to a round dozen of the best of them at once. The application was accepted by the medical college of Geneva, New York, and Dr. Blackwell was graduated from that institution in 1849, at the top of her class.
An interesting letter in Appendix I, from Dr. Stephen Smith, of New York, explains that the action of the Geneva Medical College in admitting Miss Blackwell was not originally meant to be serious. The faculty did not intend to admit her, but wished to escape direct responsibility by referring the question to the medical class, with the understanding that if a single student objected, outt)f a total of 150, the application would be refused.
" But," says Dr. Smith, " the whole affair assumed the most ludicrous aspect to the class, and the announcement was received with the most uproarious demonstrations of favor. A meeting was called for the evening, which was attended by every member. The resolution apjDroving the admission of the lady was sustained by a number of the most extravagant speeches, which were enthusiastically cheered. The vote was finally taken, with what seemed to be one uiuinimous yell, 'Yea!' When the negative vote was called, a single voice was heard uttering a timid 'No.' The scene that followed passes description. A general rush was made for the corner of the room which emitted the voice, and the recalcitrant member was only too glad to acknowledge his error and record his vote in the affirmative. The faculty received the decision of the class with evident disfavor, and returned au answer admitting the lady student. Two weeks or more elapsed, and as the lady student did not appear, the incident of her application was quite forgotten and the class continued in its riotous career. One morning, all unexpectedlj', a lady entered the lecture-room with the professor; she was quite small of stature, plainly dressed, appeared diffident and retiring, but had a firm and determined expression of face. Her entrance into that Bedlam of confusion acted like nuxgic upon every student. Kacii hurriedly sought his seat and the most absolute silence prevailed. For the first time a lecture was given without the slightest interruption, and every word could be heard as distinctly as it would if there had been but a single person in the room. The sudden transformation of the class
from a band of lawless desperadoes to gentlemen, by the mere presence of a lady, proved to be permanent in its effects. A more orderly class of medical students was never seen than this, and it continued to be to the close of the term."
After graduation, Dr. Blackwell pursued her studies for several years in Europe,
" Now up, now down, like Vjucket in a well,"
in her experiences with medical authorities. At St. Thomas's Hospital, London, the surgeon to whom she was introduced thought it very indelicate for a lady to want to study in a hospital, and he simply acknowledged her letter of introduction by a line to one of his nurses, requesting that Dr. Blackwell would not visit any of the men's wards. At St. Bartholomew's Hospital it was the other half of hnnnmity that was excluded from a woman's knowledge; through the courtes}' of Sir James Paget she was made welcome to all the wards, " except the department for female diseases " I
Dr. Blackwell's account of her life as a mgc-femme in the Maternite, Paris, is one of the most interesting chapters of the book. La Maternite was a great state institution, which received young women from every department of France to be trained as midwives. It occupied the old convent of Port Royal, and the discipline was monastic in its simplicity, regularity, and seclusion. The French authorities refused absolutely to make the slightest modification of their rules in favor of a foreigner and a graduate in medicine, and Dr. Blackwell was obliged to enter the Maternite upon the same conditions as the young ignorant French girls. The picture she gives us of the daily life of these French girls is charming. From seven to eight every morning, iladame Charrier, the (lide-sagc-femtm, gave a stormy hour of instruction ; later, after attending to the mothers and little ones in the wards, there came a second lecture from Dr. Dubois, " a little, bald, grey-haired man, with a clear, gentle voice and a very benevolent face."' At 12 o'clock came dinner, followed by the sending up of a "prayer rocket," when the young girls crowded out of the hall, amidst laughing and bustle, each carrying off for breakfast a loaf of bread under her arm and odd little pots of 'eatables in her hands. A pretty custom was class instruction in the old wood of Port Royal, preparatory lessons which the older (7(r<\< gsivc to the younger ones, seated on the grass under the shade of some fine tree. At night a favorite amusement in the dor/oir was "to promenade the bedsteads": the bedsteads were of iron on rollers so easily movable that an impulse given to the first bed would set a whole row going. Or perhaps a bedstead would be sent violently down the middle of the room, rolling over the old brick lloor of the monks with a tremendous noise, and " accompanied by a regular Babel of laughter, shoutiug, and jokes of every description."
In the midst of all this the practical work of obstetrics went on, and these gay. ignorant girls were trainetl as midwives of every degree of efficiency and inetlicieucy. Eliz;ilH?th Blackwell's presence among them was the old system and the new side by side, A sad accident to Pr, Blackwell iu the Maternite completely changed lier medical ambition. We read on page 157, " 1 still mean to be at uo very distant day the fiirst lady surgeon in the world," and a little further ou the
brave woman says simply that she had to abandon her intention of making surgery a specialty. She lost the sight of one
eye at La Maternite, from an infection accidentally incurred
while syringing the eye of a baby suffering from purulent
ophthalmia.
In 18r>l, Dr. Blackwell established herself in New York, and began to practise under conditions that would have overcome a less courageous spirit. She had no medical countenance whatever, society was distrustful of the innovation, and patients came very slowly. Occasionally she received iusoleut letters, and unprincipled men spoke to her on the streets when she was called out after nightfall. She took a little orphan girl to live with her, to relieve the loneliness of her life, and an incident in connection with this child shows how severely Dr. Blackwell was let alone by the medical profession of New York. The little girl, who was accustomed to call her "Doctor," happened to be present one day during the visit of a friendly physician. After he was gone the child said, with a puzzled look on her face, " Doctor, how very odd it is to hear a man called *' doctor ' !"
A passing note records gratefully that Dr. Sims was one of the first physicians to be cordial. He was at the time enlisting support for the foundation of the Woman's Hospital in New York. Dr. Blackwell writes: "He seems to be in favor of women studying medicine. I think I shall help him in any way I can." After a hard struggle for seven years, 'Dr. Blackwell, who had meanwhile been joined by her sister. Dr. Emily Blackwell, succeeded in establishing the New York Infirmary and College for Women, occupying the chair of hygiene in the college, while Dr. Emily Blackwell became chief surgeon to the infirmary. Dr. Blackwell returned to England in 1869, where she accepted the professorship of gynecology in the London School of Medicine for Women, established by Dr. Elizabeth Garrett Anderson.
It has been a long and useful life, and Di-. Blackwell's modest account of it forms a striking chapter in the history of medicine. She herself dates the end of her pioneer work in 1869, when successful medical colleges for women were in operation in Boston, New York, and Philadelphia, and when some of the older medical colleges for men had opened their doors to women. Just what advances have been made since 1849, when Dr. Blackwell was the only wonum in the United States with a medical degree, may be seen by a reference to the Keport of the Bureau of Education for 1893. It states that the total enrollment of students in all the medical colleges of the country, for 1892-3, was 28,900, of whom 1302 were women. This would give one woman physician for every twenty-two men. In Eussia, which we are wont to think of as a semi-civilized community, the figures are one in twenty-eight. The advancement of women in medicine as in other lines of study and activity during the last twenty-five years has been enormous. No other movement forwards can compare with it in rapidity and force. It is simply another world to live in.
Dr. Blackwell's varied experiences have brought her in contact with many distinguished men and women, and she gives us pleasant glimpses as we read of some of them — Lamartine, Lady Byron, Florence Nightingale, Francis Newman, Charles
Kingsley, and others. A letter from Lady Byron, very obscurely expressed, on the niagnetoscope, suggests the radical incompatibility of mind between the poet and his wife.
A good story of George Jacob Holyoake is worth recording. At the Bristol Social Science Congress, in 1869, Herman Bicknell gave a " breakfast of all the religions." Holyoake coming in late from a meeting of Bristol workingmen, was greeted by his host with, " Now, Holyoake, pray let us have your famous demonstration of the non-existence of God." Mr. Holyoake thought for some minutes in profound silence, and then burst out, " Upon my word, Bicknell, I have really quite forgotten it."
NOTES ON NEW BOOKS.
BOOKS RECEIVED.
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. Vll.-No. 61.
BALTIMORE, APRIL, 1896.
+++
Contents
Ulcerative Endocarditis due to the Gonococcus ; Gonorrhoea!
Septicsemia. By Wm. Sydney Thayer, M. D., and George
Blbmer, M. D.,
A New Apparatus for immediate and permanent drainage of
the Urinary Bladder after Suprapubic Cystostomy. By Jos.
C. Bloodgood, 51. D.,
The Bacillus Aerogenes Capsulatus in a Case of Suppurative
Pyelitis. By Herbert U. Williams, M. D., - . - The Checking of Operative Bleeding by Torsion. By Edward
Martin, M. D.,
PAGE.
Proceedings of Societies : Hospital Medical Society, --------72
Exhibition of a Case of Hemiplegia with Motor Aphasia, occurring in a Patient convalescing from Typhoid Fever. [Dr. Blumer];— Some Points regarding the Pathology of Malaria [Dr. Barker]; — Pleuro-peritoneal Tuberculosis [Dr. Osler] ; — Intubation of the Duodenum [Dr. J. C. Hemmeter].
Notes on New Books, 80
Books Received, S3
ULCERATIVE ENDOCARDITIS DUE TO THE GONOCOCCUS; GONORRHCEAL SEPTICiiMIA.
By William Sydney Thayer, M. D., Associate in Medicine in the Johns Hopkins University;
Resident Physician to the Johns Hopkins Hospital,
AND Geokge Blumer, M. D., Assistant in Pathology in the Johns Hopkins University.
Clinical observations of cardiac complications of gonorrhoea are not new. Since the note of Brandes (Arch. Gen. de Med., Par., 1854, XCIV^, 357), a considerable number of cases of so-called " gonorrhoeal " endo- and pericarditis have been reported. Lacassagne (Arch. Gen. de Med., 1873, CXXIX, 15), after discussing the literature and reporting a case of his own where an acute pericarditis occurred in the course of a gonorrhoea, concludes that: 1. Gonorrhoea may be complicated by inflammation of any serous membrane; 3. the particular localization of the process, in such cases, is determined by the predisposition of the individual ; 3. the cardiac complications are very rare; 4. the myocardium, perhaps, the endocardium, sometimes, but particularly the pericardium, are attacked.
In the majority of the cases in literature where the direct association of endo- or pericarditis with gouorrhoja has been made out clinically, an arthritis has also existed. Morel (Des complications cardiaqucs de la blennorrhagie, Thi^se, Par., 1878, No. 269), however, in his conclusions, asserts that "rheumatism is not a necessary intermediary between the specific lesions and those of the serous membranes, though the
• Vid. Arch, de Med. Exper., Paris, Nov., 1S95.
coexistence of these two lesions is the usual condition. A particularly interesting case of this nature, endo- and pericarditis appearing on the fifth day after the beginning of the urethral discharge, without coexisting arthritis, has recently been reported by Prevost (Arch. Med. Beiges, 1895, 5).
With the recognition, however, of the fact that endo- and pericarditis are occixsional complications of gonorrhoea, the true nature of these processes and their relation to the primary lesion is far from being settled.
Since Neisser's description of the gonococcus, and more particularly since the demonstration of satisfactory methods of culture by Bumm, in 1885 (Der Micro-orgauismus der Gouorrhoischen Schleimhauterkrankungen (Gonococcus Xeisser), Wiesbaden, 1885), and Wertheim, in 1892 (Die Ascendirende Gonorrhoe beim Weibe, Leipzig, 1893), the various complications and sequels of gonorrha?a have been studied more intelligently and with greater care.
To the more common complications of gonorrhcea, conjunctivitis, cystitis, metritis, salpingitis, epididymitis, arthritis and periarthritis, the occurrence of numerous other complications has of recent years been recorded — peritonitis (particularly in the female), pleurisy, local foci of suppura
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tion, myocarditis, indeed general pyjemia, various cutaneous affections, iritis, neuritis, meningitis, meningo-myelitis, albuminuria, etc. But in these complications, as in the cases of the cardiac affections, the same question has existed with regard to the nature of the process.
Wertheim (Z. c.) showed clearly that in the female direct infection {per contitutum) of the uterus, tube, ovary and peritoneum might occur. The power of the gouococcus to cause suppuration is now undoubted. The ophthalmia is also clearly an infection by direct transmission of the virus. But if the entrance of the gonococci into the tubes and ovaries can be traced per contmuum, and into the eyes by direct transmission, the same cannot be said of the iritis, which has been observed without a coincident conjunctivitis, nor of the commonly observed arthritis, nor of the various processes which have been observed in the nervous system. Indeed there are relatively few of the numerous complications above-mentioned which we can clearly trace to an extension per continmim, or, however much we may suspect it, to a direct transmission of the infective agent. Even in epididymitis, where until recently the extension per continuum has been generally accepted, the entire freedom from disease of the tracts connecting the urethra and epididymis has compelled us to seek another explanation.
Are these secondary processes truly gonorrha?al ? ' If so, what is their relation to the primary lesion ?
As Finger (Arch. f. Derm. u. Syph., Wien u. Leipzig, 1894, X5VIII) well says, there are various possibilities in this connection :
" (ff) The complication is produced by the gouococcus alone —purely gonorrhceal.
(b) The disease of the mucosa furnishes the opening through which the pyogenic cocci enter and give rise to the complication — mixed infection.
(c) The gouococcus produces the complication into which, however, the pus cocci enter later; both exist together until the gouococcus, dying, is succeeded by the pyogenic coccus — secondary infection.
(d) The complication is essentially not of a microbic nature; it is produced by the products of the growth of the gouococcus in the urethra and absorbed — of toxic nature."
That secondary infections may exist in gonorrhcsa has been clearly proven, and this fact has led certain observers to the extreme view that this was true in all instances — that the gonococcus was unable of itself to produce these secondary inilammatory processes. Later observations with improved methods have shown that this idea is erroneous.
In the arthritis, which is so common a complication of gonorrhoea, Petrone, in 1883 (Riv. Clinica, 1883, 94), found microscopically what he believed to be gonococci in an affected joint. This observation was followed by a number of others. The evidence, however, was suggestive, not positive, the identification depending only on the form of the bacteria. Deutschman, in 1890 (Graefe's Arciiiv f. Ophth., XXX\"I, Abth. I, 109), went a step farther. In two cases of arthritis secondary to ophthalmia neonatorum he found, microscopically, the characteristic biscuit-shaped diplococci, which lay chiefly in the bodies of pus cells. These cocci became decolor
ized whe7i heated according to Gram's method, while cultures
taken on the ordinary media proved negative.
Lindemann (Beitriige z. Augenheilkunde, 1892, I, H. V, 30) obtained, likewise, from a joint involved after ophthalmia neonatorum the characteristic diplococci, becoming decolorized on staining by Gram's method. He also believes that he succeeded in cultivating them (after Wertheim), though there were contaminations.
Hock (Wien. Klin. Woch. 1893, No. 41, 12th Oct., 736) finally succeeded in obtaining the gouococcus microscopically and in pure culture from a knee-joint in an infant with gonorrhceal ophthalmia. Neisser, in 1894 (Deutsch. Med. Woch. 1894, XX, 484) obtained gonococci microscopically and in pure culture from the aukle-joint and a finger-joint in an adult. And finally Bordone-L^ffreduzzi (Proc. XI Internat. Med. Congr. and Deutsch. Med. Woch. 1894, XX, 484) not only obtained the organism in pure culture from an affected ankle-joint, but reproduced a typical gonorrhcea by inoculation from the second generation of these cultures, into the urethra of a healthy man who had never before suffered from urethritis. These cases go to show that in many instances the secondary processes in the joints are pure gonorrhceal infections, the gonococci reaching the joints, doubtless, through the circulation.
A case recently reported by Finger (/. c.) is of much interest. Prom an arthritis of the left knee-joint following on ophthalmia neonatorum he obtained gouococci micioscopically and in pure culture during life. The child developed extensive phlegmon in the neck and mediastinum and died. At autopsy gonococci alone were found in an area of perichondritis about the cartilage of a rib ; gonococci and streptococci in the kneejoint {where, during life, gonococci alone were found), and in the periarticular abscess of the left thigh ; streptococci alone in the articulation of the left jaw and in the phlegmons of the neck and mediastinum. lu patches of pneumonia pneumococci and streptococci were found. This case is particularly interesting in showing the possibility and manner of developmeut of secondary mixed infections.
From a suppurative tendo-vaginitis {m. tibialis anticus) secondary to a gonorrhcea, Jacobi and Goldman n (Beitrag z. Klin. Chirurgie, 1894, XII, 827) obtained, in microscopical specimens of the pus, characteristic gonococci, decolorizing by Gram's method, while cultures on ordinary media proved negative; while more recently Bloodgood and Flexner obtained the organism in pure culture from a similar tendo-vaginitis (unpublished observation). Lang and Paltauf (Arch. f. Derm. u. Syph. 1893, 330) obtained the gouococcus in pure culture from an abscess on the finger coming on during an acute gonorrhcea. No connection could be made out between the abscess and the joint or the tendon sheath. Mazza (cf. Bordone-Uffreduzzi, I. c.) obtained the organism in pure culture from a suppurative pleurisy complicating a gonorrhcea. In this case there existed also an eudo- and pericarditis. Wertheim (Deutsch. Med. Woch., Vereins Beil. No. 17, 1895, p. 118) has recently, in a case of cystitis, excised a piece of the mucous membrane of the bladder, where he found not only all the epithelial cells filled with gonococci, but also the subepithelial connective tissue, where capillaries entirely filled with
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masses of gonococci were to be found. The patient had, at the same time, gonorrhoeal joint affections. Krakow (Gaz. Lekarska, 1894, p. 633) reports a case of puerperal sepsis complicated with joint suppuration, and gonorrhoeal ophthalmia and pemphigus bullosus in the new-born. Both in the vagina and in the pus from the joints gonococci were found. Finger (Z. c.) is then apparently justified in his conclusions: "25. By entrance into the blood current, distributed by this, the gonococcus may be the cause of the most varied articular, periarticular, perichondritic metastases ..." and " 36. Entering into the connective tissue, the gonococci may succeed in causing a genuine suppuration."
The proof, however, that many of these secondary suppurative processes are genuine gonorrhceal metastases is not enough to justify the assumption that all are of the same nature. The fever and constitutional symptoms, the albuminuria so commonly jjresent, all point to a general intoxication, while the unsuccessful efforts to demonstrate bacteria in the lesions of the nervous system suggest strongly that these changes may be due to a soluble toxine. We must, probably, recognize in gonorrhoea a general disease, one which from a local starting point may cause severe general symptoms, fever, chills, albuminuria, while in other instances grave secondary local lesions may follow. In some instances, conjunctivitis, ei)ididymitis, metritis, salpingitis, arthritis, synovitis, pleurisy, local suppurative processes, it has been definitely shown that the gonococcus itself may be the exciting cause, the coccus reaching the affected areas doubtless through the blood current; in other instances, neuritis, myelitis, cutaneous manifestations, iritis, the negative results of microscopical and cultural researches suggest that the local lesion may be due to a toxine alone.
As to the nature of the cardiac complications of gouorrhoia, little that is iu any way positive has been contributed until a recent date. Martin (Be v. Mud. de la Suisse Romnade, 1873, 3, 308) reported a case of gonorrhcea, suppurative prostatitis, cystitis, ulcerative endocarditis, myocardial abscesses and metastatic abscesses in the kidneys. In the thrombi on the valves and in the suppurative foci he found, microscopically, two varieties of bacteria, one of which resembled, strongly, Neisser's gonococcus.
Gluzinski reported a case of ulcerative endocarditis with what morphologically resembled gonococci on the valves.
His (Deutsch. Med. Woch. XXIX, 1893, 993) found in the thrombi on a valve in a fatal case of ulcerative endocarditis following goiiorrhiea, organisms resembling gonococci which decolorized when treated by (i ram's method. Unfortunately, the heart had been hardened in Miiller's lluid, so that the value of this test is doubtful.
Councilman (Tr. Assoc. Anier. Phys. 1893, VllI, 165) reported a case of gonorrhtea, suppurative prostatitis, arthritis, pericarditis with suppurative foci in the heart-muscle. He found the characteristic biscuit-shaped diplococci iu the urethra, knee-joints, pericardium, and in the abscesses iu the heart-muscle. These organisms decolorized entirely when treated according to Oram's method.
Winterberg (Festschr. z. 35 Jiihr. Jub. d. Vereins Deutsch. Aerztezu ISan Francisco, 1891, 8°, -10) found gonococci on the
valves in a case of ulcerative endocarditis following gonorrhcea complicated with arthritis; they decolorized on treatment according to Gram.
These cases are certainly suggestive, especially the latter two, where the identification of the organism was more satisfactory. But the absence of culture experiments renders the results inconclusive.
Leyden's (Zeitschr. fur Klin, iled., 1893) case goes a step farther. The case was one of ulcerative endocarditis following gonorrhoea, epididymitis, arthritis. Cultures on ordinary media, taken from a vein during life and from the left ventricle after death, were negative. On microscopical examination, however, after death, typical gonococci were found in the thrombus on the valve. These showed all the morphological and tinctorial characteristics of gonococci: 1. They were biscuit-shaped dij^lococci, never arranged in masses like staphylococci ; 3. A good number of the diplococci lay in the characteristic manner within cells; 3. They lost their color when treated by Gram's method; 4. They were easily decolorized when treated with alcohol and oil of lavender.
The evidence hei'e that the organisms jiresent were gonococci is strong, and the absence of growths on culture experiments on ordinary media, from the blood during life and the left ventricle after death, forms certainly suggestive evidence that the gonococci were present in pure culture. The definite proof, howevei', of the existence of a gonorrheal septicemia as well as of an ulcerative endocarditis due to the gonococcus alone is, we believe, furnished in the following case:
Case. L. S., widow, 34 years of age, entered the Johns Hopkins Hospital on April 25, 1S95, complaining of weakness, cough and vague general pains.
Faintly History. — Father died of sunstroke. Mother is living and well. Is an only child. Her husband died of pulmonary tuberculosis.
Personal History.— Says that she had none of the ordinary diseases of childhood. No history of chorea, pneumonia, malarial or typhoid fever. Catamenia began at the age of 14 ; have always been regular. Was married at 24; has had five children ; two miscarriages. Three months ago suffered from "rheumatism"'; the pains were chiefly in the fingers, wrists, knees and shoulders; they were apparently not severe ; would last only a few hours in one place, disappearing to return in another joint. She asserts that the joints were not swollen at the time ; was in bed ten days. Has been short of breath on exertion for three or four years. No history of oedema of the feet or legs.
Present Illness. — The patient dates her present illness to the time of the rheumatism, three months ago. Since this time she has never been strong. Three days ago she became worse, feeling very weak and tired ; at this time she noticed a patch of herpes upon her lower lip. Since this time she has felt weak and exhausted ; vague pains in the back and limbs, drowsiness, thirst, anorexia ; no epistasis or diarrhica. Gave up her work two days ago. Yesterday morning had a distinct chill.
On entrance, April 2oth, the patient was a rather sparely nourished woman ; face flushed ; lii>s and mucous membranes a trifle cyanotic ; pulse 132, of small volume, regular in force and rhythm ; respiration 30 ; temperature 102.2°. Lungs : clear throuchout. Heart: the point of maximum impulse in the fourth and fifth spaces; sounds best heard just inside the nipple line in the fourth space. The first sound was loud and rough, preceded by a presystolic murmur and followed by a blowing systolic murmur which was transmitted into the axilla. Hepatic dulness at fifth rib in the
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mammillary line ; border palpable about 3 cm. below the costal margin. Spleen, not dialinctly palpable. Abdomen, negative ; no rose spots.
The blood showed no malarial parasites, but a slight leucocytosis, 12,000 leucocytes per cu. mm.
26, 4, 95. Urine.— Reddish amber, acid, 1015, distinct trace of albumen, no sugar, abundant white flocculent sediment; microscopically, numerous pus and large epithelial cells; no casts seen. Distinct diazo-reaction.
At the morning visit the following note (Dr. Thayer) was made : "The patient passed a good night; the fever has diminished this morning. The thorax is symmetrical ; costal angle narrow ; expansion of the two sides equal. Auscultation and percussion clear throughout. Heart: point of maximum impulse is in the fifth space about in the mammillary line, 9Jcm. from the median line ; impulse strong and preceded aitparently by a slight thrill. Relative dulness begins at the third rib, does not pass the left sternal border ; passes oblicpiely out to the point of maximum impulse. The first sound is flap|)ing and valvular and is preceded by a short vibratory murmur, presystolic in time, which disappears above the fourth rib ; it is followed by a loud blowing systolic murmur which is lost as one reaches the mid-a.\illa, and is but feebly heard at the base. The second pulmonicsound is accentuated. Along the left sternal border the sounds have a peculiar sticky quality. The pharynx, uvula and fauces are injected. The spleen is easily i)al])able ; dulness above begins at the fifth rib."
27,4, 95. {/rt«e.— Practically the same as on last note. Diazoreaction present.
29, 4, 95. "The patient has had daily exacerbations of temperature, coming on at irregular intervals ; yesterday there were two, one associated with a sharp chill. Today the skin is moist ; pupils dilated ; pulse rapid. The heart's action is tumultuous. There is a distinct presystolic thrill to be felt at the point of maximum impulse. The systolic murmur is perhaps a little louder than on the first note. The right kidney is easily palpable, as is also the left, which can be easily felt below the spleen."
30, 4, 95. Urine. — Catheterized specimen ; deep reddish amber, acid, 1014, trace of albumen, sediment white and flocculent; epithelial cells, no pus cells, no casts seen, no diazo.
30, 5, 95. This morning the skin is hotand dry ; pulse twenty-six to the quarter, regular. The point of maximum impulse is in the fifth space, very sharply defined and preceded by a thrill. The presystolic murmur is not as intense as it has been, but thp valvular flapping first sound is very intense and is followed by a slight but well-marked systolic whiff. The second pulmonic is accentuated."
Urine. — Same as on former notes. Diazo-reaction present.
4, 5, 95. " The spleen is very large, reaching more than six centimeters below the costal margin. Heart's action rapid, sounds much the same. Vaginal examination negative."
7, 6, 95. " This morning the patient is quiet ; skin cold and moist ; night-gown wet. Pulse regular, 29 to the quarter, volume small, tension rather low. There is visible pulsation in the fourth and fifth sjiaces just about the nipple. The jioint of maximum impulse is in the fifth space, eleven cm. from the median line. There is a slight presystolic thrill. Relative dulness begins at the third rib, does not pass the left sternal margin. At the point of maximum impulse is heard a short slight presystolic murmur, foUowetl by a snapping valvular first sound and a loud blowing systolic murmur which is heard throughout the axilla. The presystolic murmur is heard only just about the i>oint of maximum impulse ; it is lost as one passes toward the base. The second pulmonic sound is sharply accentuated, while the second aortic is feeble. At the base the eyatolic murmur is not to be heard, but above the fourth rib there is a slight, sticky, grating sound heard after the first sound, very suggestive of a i)ericardial rub. This is particularly marked in the third loft space close to the sternum. There is ai)parently a faint diastolic murmur heard along the left border of the sternum."
8, 5, 95. Examination of the blood negative for malarial organisms. Leucocytes 17,500 per cu. mm
9, 5, 95. Prins.— Normal, acid, 1008, trace of albumen, abundant sediment of pus and vaginal epithelium.
11, 5, 95. "The iiatient is much emaciated and very sallow. Tongue quite antemic. The temperature yesterday was lower than it has been for several days, reaching only once 102°. The skin this morning is very hot and dry. Lungs: clear in fronts and axillio ; backs clear, excepting for a few fine moist riles at the bases. Heart : point of maximum impulse 13 cm. from the median line. Relative cardiac dulness reaches to the right sternal margin, beginning above at the third rib. The first sound at the point of maximum impulse is intensely sharp and valvular. The systolic murmur is short and scarcely to be heard in the mid-axilla, while the presystolic rolling murmur is well marked and echoing ; it disappears, however, inside of the mammillary line and above the fourth rib. The second pulmonic sound is intensely accentuated. The first sound is reduplicated over the mid-sternum. The heart's action is very rapid, and the soft diastolic murmur, of which there was a suspicion at the last note, is not to be heard."
The patient began on the 7th to suffer from a slight diarrhoea, which increased steadily in severity ; on the llth there were eight movements. These consisted of a greenish watery fluid with small curds of milk : microscopically, granular debris, trijile phosphate crystals, great numbers of bacteria. The fever and diarrhoea continued and the jiatient grew rapidly worse.
14, 5, 95. The patient is much emaciated, dull, apathetic. The pulse at the time of the visit is slow, but of small volume and very low tension. The anaemia has become very marked. Heart sounds same as on last note." Blood Count. — Red corpuscles, 1,840,000, Colorless " 14,000,
Hasmoglobin, 22 per cent.
Dried specimens stained with the Ehrlich triple stain show a moderate poikilocytosis ; considerable difference in the size of the corpuscles ; very few nucleated red corpuscles ; marked leucocytosis. A differential count of 500 leucocytes showed :
Small mononuclear, 2.8 per cent.
Large mononuclear, 2.4 "
Transition forms, 0.4 "
Polynuclear leucocytes, 94.2 "
Eosinophils, 0.2 "
Urine. — Specimen obtained by catheter ; clear, normal, 1009, acid, trace of albumen; sediment abundant, white; considerable numbers of pus cells, occasional casts with pus adherent ; no tubercle bacilli ; faint diazo-reaction.
16,5,95. "This morning the patient is very dull, feeble and apathetic. The diarrhoea grows steadily worse. Over the trunk and arms, and to a less extent over the thighs and legs, are a number of small pin-head petechial spots. The pulse, which has heretofore been regular at the time of the visit, is to-day bigeminal, the first of the two beats being the stronger ; it is of small volume, very soft. Heart : point of maximum impulse is in the sixth space 15 cm. from the median line. Relative dulness begins at the second space and extends several cm. to the right of the sternum. To the left it passes obliquely outward to the point of maximum impulse. The heart's action, which was at first regularly bigeminal, becomes rapid and irregular after slight exertion, returning to the bigeminal rhythm again on rest. At the point of outermost impulse the first sound is sna]>i)ing and resonant; it is followed by a systolic blowing murmur, which is heard throughout the axilla, and is preceded at the point of maximum impulse by a slight echoing sound which hardly deserves to be called a presystolic murmur. In the fourth and fifth spaces, however, just inside the mammillary line a thrill is to be felt and a i)re8ystolic murmur is well heard. A slight presystolic tremble may sometimes be heard in the mid-axilla. The second pulmonic is accentuated ; the second aortic is feeble. Along
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the left border of the sternum there is a slight soft diastolic murmur. In the lower right chest, in front and behind, are numerous fine moist rdles ; elsewhere the respiration is clear."
Urine. — Specimen obtained by catheter ; slightly smoky, acid, 1011, marked trace of albumen ; sediment considerable ; much pus ; no casts seen ; red blood corpuscles ; diazo-reaction absent.
The patient failed rapidly and died about an hour and a half after the last note was made, at 11.20 a. m.
Autopsy, by Dr. Flexner, two hours after death.
(Abstract.) Anatomical diagnosis: Acute ulcerative endocarditis caused by the gonococcus. General infection with gonococci. Subacute tumor of the spleen; infarction of the spleen. Infarction of lungs. Gumma of lung. Subacute nephritis. Chronic passive congestion of the viscera. Gonococci in the vagina and uterus.
Externally. — Body 1G3 cm. long ; well nourished ; still warm ; no rigor mortis. Slight livor mortis of the dependent parts. Small petechia; in the skin of the trunk and thighs.
Internally . — Subcutaneous fat moderate in amount. Muscles dark red in color. Peritoneum : no excess of fluid ; both layers smooth. Pericardium, : in the pericardial cavity, about 30 cc. of clear strawcolored fluid. Both layers of the pericardium smooth, with the exception of a few old fibrous patches over the right auricle.
Heart. — All the cavities of the heart, but especially the right auricle, are distended and contain fluid blood. The endocanlium of the right side of the heart is smooth. The tricuspid valve is a little thickened along its free border, but it is not retracted. The pulmonary and aortic valves appear normal. To the mitral valve, affecting especially the aortic segment, thrombus masses are attached. Springing from the auricular surface of the valve, the ventricular surface being comparatively smooth, there are red granulations, and to the aortic segment a pedunculated mass is attached. This mass measures 3x2 centimeters and projects into the auricle. The vegetations are for the most part easily removed ; some are, however, more resistant. Where they were removed the surface of the valve was found eroded, the actual loss of substance being great enough to leave a distinct depression. The large thrombus is variegated, pink and grey in color, and is of different consistency in different parts. While quite soft in its interior it had not undergone puriform softening. Its surface is granular. It is firmly attached to the heart valve, which at the point of attachment appears to be thickened. The cardiac muscle is pale, softer than normal, and a little mottled. Coronary arteries delicate. The heart weighs 350 grams. Dimensions : length of left ventricle 8 cm. ; length of right ventricle 8 cm. ; thickness of left ventricle 13 mm. ; of right ventricle 4 mm. Aorta above valves measures 6.5 cm. Foramen ovale admits the tip of the little finger.
Lungs. — Old adhesions over right apex. On section, the lung has a salmon color ; its consistency is quite firm. In the lower left lobe is an hemorraghic infarction measuring 1.5 cm. in diameter at the pleura. Several broncho-pneumonic areas are also present. In the lower portion of this lobe there is a grey, homogeneous and quite firm mass 1.5 cm. in diameter, sharply circumscribed and embedded in the lung substance.
Spleen. — Weight 780 grams. Dimengions 22x13x8 cm. The surface, excepting for a few flakes of fibrin at its upper end, is smooth. On the outer surface there is an infarction 2.5 cm. in diameter, over wliich the fibrin is present. The spleen is moderately firm in consistency; pulp abundant; malpighian bodies prominent.
Kidneys.— Combined weight 380 grams. Capsule slightly adherent, surface somewhat mottled by congestion and small ccehy nioses. Cortex swollen and pale, stri;c indistinct. Glomeruli diflioult to see. A few hemorrhages into the mucous membrane of the pelvis.
Liver. — Weight 2030 grams ; cloudy swelling.
Stomach, intestines, bladder, rectum, pancreas, adrenm show nothing remarkable.
Brain. — Not examined.
Uterus. — Not enlarged ; mucous membraae smooth ; covered by a thin opaque exudate. Vagina covered by a thin opaque exudate.
Frozen sections. — Heart's muscle shows extensive fatty degeneration.
Kidney: much swelling of the epithelium of the convoluted tubules. The glomeruli contain fat in small droplets. No fat on the tubular epithelium. There are small accumulations of round cells in the cortex between the tubules and in the neighborhood of the glomeruli.
Liver: moderate chronic passive congestion.
Microscopical examination of lui/rdened specimens. — The cardiac valves show a condition of subacute endocarditis. The process consists in the infiltration of the valve substance with cells of various character and arrangement. The process is most acute at the surface of the valves and gradually becomes less acute as the depths are reached. On the surface, where the more acute process exists, the tissues are infiltrated with large numbers of polymorphonuclear leucocytes and a few small round cells. These leucocytes occur as a rule in masses, the nuclei being in places intact, in other places very extensively fragmented, the remnants of the nuclei staining poorly and the tissue between them consisting of a granular, fibrinouslooking material. From the base of this acute process there is a gradual shading off into a subacute one, the leucocytes decreasing in number and their place being taken at first by small round and spindle cells, deeper down by spindle celli only, so that at the base of the valve there is a well-formed but cellular connective tissue.
In places scattered through the area-s of inflammation there are seen large cells filled with fine darkly staining granules. These at flrst sight might be taken for cells containing bacteria, but they are evidently "mastzellen." The surface of the valve is covered by a blood clot in which the corpuscular elements are still very distinct ; there is evidently an increase of the polymorphonuclear elements in the blood forming this clot. Capping the clot in many places is a layer of fine granular material presenting the appearance, offered at times in thrombi, of blood platelets. This material stains well in the cosin used as a counter-stain for the h;ematoxylin, and also retains at times the aniline colors used for demonstrating the bacteria. Diplococci are found scattered through the sections in small numbers, much smaller than would be expected from the appearances shown by the cover-slip from the valve. Their small number is evidently due to the facility with which they are decolorizetl, but a small portion of those present probably taking the stain.
These diplococci are usually oval and appear often to lie end to end, though in places pairs are seen with a well-marked biscuit arrangement. The diplococci are found in greatest number in the more acute areas, more especially in those areas where the fragmentation of the nuclei is most marked. .\t times the organisms lie outside of the cells, but at times they may be distinctly made out to be within polymorphonuclear leucocytes. One or two diplococci were seen in the blood clot, lying on the surface of the valves; they seemed to be free in the blood and not in leucocytes.
The lung shows a condition of chronic interstitial pneumonia. The pleura is moderately thickened, and in places markedly so, large bands of connective tissue running from the surface into the depths of the lung substjince. All through the lung the walls of the alveoli are much thickened, partly from engorgement of the vessels, but more particularly by an extensive formation of new connective tissue in the alveolar walls.
Many of the alveoli are somewhat dilat«d and empty ; many contain a slight exudate of granular material, flat epithelial cells, a few polymorphonuck-ar leucocytes, and a few large cells containing dark-brown pigmentC'staubjellen"). The blood-vessels of the lung contain much blood, and there is a non-oocluding thrombus in one of the larger branches of the pulmonary artery. Here and there through the lung substance an atypical growth of epithelium is seen.
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The bronclii appear normal ; they are free from exudate. The nodule which was situated in the lower lobe of the right lung consists of three zones : an outer zone composed of dense fibrous tissae, forming a capsule for the mass ; a peripheral zone immediately beneath this, containing long epithelioid cells and a few round cells ; and a central zone consisting of tissue which has undergone coagulation necrosis, containing fragments of many nuclei. A few large giant cells are seen in the peripheral zone of this area, as well as in that of a second much smaller area which is adjacent and which resembles the first in every respect. These areas are evidently gummata.
The spleen pulp contains much more blood than normal, tlie individual corpuscles being usually well preserved, causing partly, no doubt, the increased size of the organ. The polymorphonuclear leucocytes in the blood are evidently much incre.ised in number, and there is also an increase in the small round cells of the pulp. The malpighian bodies show the greatest changes ; they are uniformly enlarged, this enlargement being due to an increase in the number of the small round cells normally composing them. A lesion which is less uniform, but which is commonly found — in one section at least six were present — consists of small accumulations of cells in the substance of the malpighian bodies. These cells differ from the normal spleen elements in their larger size and more distinctly epithelioid form ; they compose the larger part of these areas, which are distinctly focal in character ; they are several times as large as the lymphoid cells, contain distinctly vesicular and usually oval nuclei, and are supplied with a relatively large amount of i)rotoplasm. As well as these cells there are present in the foci a relatively increased number of polymorphonuclear leucocytes and a few nuclear fragments. In size, but not in structure, they resemble miliary tubercles. In the latter respect they are very like the focal lesions of diphtheria described by Oertel, etc.
In these areas a few very large cells with a good deal of protoplasm and very large vesicular budding nuclei, similar to the nuclei of bone-marrow cells, are seen.
The wedge-shaped area observed in the spleen macroscopically is seen to consist of two zones : an outer one consisting almost entirely of blood corpuscles, and an inner in which besides these elements a certain amount of necrotic spleen tissue is also to be seen. The arteries in the neighborhood of this infarction seem clear. One or two of the veins in the neighborhood, however, are seen to contain fairly fresh thrombi. In one place, in the immediate neighborhood of the infarction, a small area of , necrosed spleen substance containing fragmented nuclei and a few polymorphonuclear leucocytes was observed.
The kidney shows a chronic interstitial nephritis of moderate grade, and evidences of a fresh process in the glomeruli. The capsule is not present in the sections. The subcortical layer is decreased and in places absent, the glomeruli here lying immediately beneath the surface. There is a moderate amount of connective tissue scattered through the kidney substance, more particularly in the cortex. There, at times, it assumes the form of a wedge shaped mass of connective tissue, the base outwards, dipping down into the kidney substance. The greater increase in connective tissue is around the glomeruli, affecting the capsule of Bowman and ailjacent tissues. The connective tissue just described is of the fibrous variety, but besides this there are a number of collections of small round cells of the lymphoid type, occurring mostly in the deeiier layers of the cortex and usually having no connection with the glomeruli. Besides these changes there is a diffuse increase in the intertubular connective tissue. The glomeruli appear much more cellular than normal, and this is seen to be due to collections of cells within the capillaries, many of which on cross-section are entirely filled with cells. These cells are of two varieties : (1) oval cells of an epithelioi<l type with large vesicular nuclei and a moderate amount of protoplasm, and (2) polymorphonuclear leucocytes. In places the polymorphonuclear leucocytes
have escaped from the capillaries and are seen in the capsular space and in the tubes themselves at quite a distance from the glomeruli. The tubular epithelium is in places swollen and granular, the free edges of the cells ragged, while the lumina of the tubules contain much finely granular material. One or two hyaline casts were seen in the medulla.
Gonococci could not be demonstrated in any of the organs.
Bacteriological Examination,. — In the cover-slip from the vegetations on the mitral valve there are numerous polymorphonuclear and a few large and small mononuclear leucocytes, besides a quantity of finely granular material. Between the cellular elements there are a very large number of bacteria, consisting of small oval cocci, occurring in pairs, side by side, and very often having a distinct biscuit shape, the opposing sides being concave. At times liseudo-chains of three or four elements are seen, and in a few instances the organisms have a tetrad arrangement. The polymorphonuclear leucocytes, almost without exception, contain diplococci ; there may be only one or two pairs in the protoplasm, or the whole cell body may be replaced by a mass of diplococci. In quite a number of cases not only the protoplasm but also the nucleus has been invaded, and several pair.s of cocci may be seen lying in the nucleus surrounded by a clear non-staining zone. No bacteria were seen in either the large or small mononuclear leucocytes.
These cocci presented the morphological features of gonococci. Cover-glass specimens stained with gentian violet, which readily stained the cocci, and then treated with Lugol's solution and alcohol (Gram's method), become completely decolorized ; not an organism retains the stain.
Cover-glass specimens from the vagina and uterus show similar diplococci, decolorizing when treated by Gram's method.
Cover-slips from the infarction in the spleen a:e negative.
Cultures.— {1) During life :
4, 5,95. Cultures from the blood were made by Si ttman's method. The blood was drawn from the median basilic vein by a syringe which had been boiled for twenty minutes. The arm had been previously thoroughly scrubbed with soap and water and wrapped with a towel wet with a solution of bichloride of mercury, tVitbAbout 2 cc. of blood was thoroughly mixed with a tube of agaragar and plated. No growth resulted.
7, 5, 95. Cultures were taken again in the same manner. The mixture in the plates was at least one-third blood. After fortyeight hours in the thermostat the plates were crowded with white pin-head colonies. Cover-slips from these colonies showed a small oval diplococcus, at times biscuit-shaped, the elements lying side by side. Transplantations were made into agar-agar, gelatine, potato, litmus milk and bouillon. No growths resulted.
12, 5, 95. Cultures were again taken by the same method with the same result — an apparently pure culture of the same coccus. Similar colonies were found in the plates, and the same negative results were noted on attempts at transplantation.
(2) At the autopsy :
Cultures on agar-agar and bullock's blood serum from all sources — heart's blood, valves, liver, spleen, lungs, kidney — were wholly negative. But little of the heart's blood was transplanted. The laboratory was at this time out of the media necessary to grow the gonococcus.
The extraordinary resemblance of the organisms found in the vegetations on the mitral valve to the gonococcus and its characteristic reactions to staining reagents recalled immediately the negative results obtained on attempts to transplant the growths obtained during life. On re-examining these plates the colonies were found to consist of organisms exactly resembling those found in the thrombi on the valves. They showed the same staining reactions, decolorizing immediately when heated by Gram's method. Considering the large quantity of blood used, it may readily be seen that the medium was not materially different from that advised by VVertheim. The growths on this medium were abun
April, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
63
dant, while transplantations on to ordinary media were without result.
Transplantations were again made, May 17th, on human serum and urine, bullock's serum, agar-agar and urine, foetus extract (Flexner) and agar, but the organism refused to grow. These media tested with living gonococci proved suitable. The conclusion is that by the sixth day the organism had died out.
Animal Experiment. — A mouse was inoculated into the root of the tail with a piece of the large thrombus the size of a hemp-seed. The result was negative.
These results, we believe, justify us iu assuming tLat the organism present in j)ure culture in the circulating blood and on the affected valves was the gonococcus of Neisser.
(a) Its form and arrangement were characteristic.
{i) AVhile present free, the cocci were frequently found crowded iu the protoplasm of leucocytes iu the thrombus on the valve.
(js) It refused to grow upon the ordinary media.
{d) It grew readily upon a mixture of human blood aiul agar-agar (one-third blood).
(e) It decolorized when heated by (i ram's method.
The question of the point of entry arises, of course, immediately. Nothing definite was known of the manner of life of the patient before entry. The fact that cover-slips from the vagina and the interior of the uterus showed similar dijjlococci, decolorizing ou treatment according to the method of Gram, leaves little doubt that the infection took place through the ordinary channels.
Note. — Since the writing of the above, two j)ublications have appeared treating of cases of the same nature. In the first instance (Dauber und Borst, Deutsch. Arch, fiir klin. Med., Bd. 56, II. V and VI, 1896), cultures were obtained from the affected valve on blood serum agar, while transplantations and attempts to grow the organisms on the ordinary culture media failed. Though the nu)rphology of the organisms was characteristic, while they decolorized when treated by Gram's method, yet owing to certain irregularities in tlie gross appearance of the colonies, the authors hesitate to assume that they wei'e gonococci.
This conclusion is (properly, we believe) disputed by Michaelis (Zeitsch. fiir klin. Med. XXIX, H. V and VI, 18'JG, p. 556), who reports a characteristic case. The diplococci on the affected valves showed all morphological and tinctorial characteristics of gonococci, while cultures taken upon the ordinary media were negative.
One of the authors with Dr. liazear has had occasion to observe, within the last month, a second typical case of ulcerative endocarditis associated with gonorrha>a where the gonococci were obtained from the circulating blood three times in pure culture, while at tlie autopsy (Dr. Flexner) growths were obtained upon hunuin blood serum agar from the affected valves, from the heart's blood and from the pericardium (jiericarditis). The ease will be reported in full shortly.
PosTSCKii'T. — The attention of the authors has just been called to a review (by C. Fraenkel in the Ilygienische Rundschau, 1896, No. 6) of a jirevious report of this case.
The reviewer states that " because during life, a gonor
rhceal affection was not discovered in the patient despite
careful examination, (while) moreover, cultures of the microorganism which was found were not made on human blood
serum or Wertheim's serum agar, the case cannot be considered
as an entirely unassailable (eiuwandsfreie) observation." We
confess that we cannot see the justice of these objections. It
is a well known fact among all gyniL-cologists that gonorrhceal affections in the female may easily exist without being
recognized by ordinary methods of examination during life.
Examination of the vaginal secretion was not made in our
case durimi life, but after death, in both vagina and uterus,
characteristic organisms were found, diplococci of characteristic biscuit shape existing frequently within leucocytes,
decolorizing when treated according to (Jram's method.
Furthermore, it would appear that the reviewer had failed to
take into account the constitution of the medium upon which
successful cultures were twice obtained during life. This
medium consisted, as is stated above, of an intimate mixture
of the blood drawn immediately from the median basilic vein
with about a double quantity of melted agar, the mixture
being immediately plated. Upon such a medium, practically
that of Wertheim, the organisms were successfully cultivated.
In the second case which has been mentioned above and will
be reported later, cultures of the organism were obtained iu
the same manner during life, and, after death, upon human
blood serum agar, while attempts to cultivate the organism
Tipon all other media were without result. It may be added
that the second case which occurred in a man was coincident
with a gouorrba-a recognized during life.
W. S. T. AND G. B.
THE JOHNS HOPKINS HOSPITAL BULLETIN,
Volume VII.
The BULLETIN lit Itie Johns Hopkins Hospital ontored upon lis serculh volume. January 1, 1896. It coulaius original communlcatlous relating to medical, surgical and gynocologioal topics, roporis of dispensary practice, reports from tlie pathological, anatomical, physlologico-cheralcal, pharmacological and cUnlcal laboratories, abstractii of papers read before, and of discussions iu Ihe Tarlous societiea connociod with the Hospital, reports of lectures and other matters of general interest Iu the work of the JohusHopkius Hospital and the Johns Hopkins Medical School.
Nino numbers will be Issued annually. The subscription price Is $1.00 per year. Volume VI, bound In cloth, $1.00.
NOTICE.
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Letters of inquiry can be sent, which will receive prompt answer, or personal interviews may be held.
Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indigent patients a uniform rate of fo.OO per week has been established. The Superintendent hits authority to mollify these terms to meet the necessity of urgent cases.
The Hospital is designed for cases of acute disease. Cases of chronic disease are not admitted except lemiKirarilv. Priv.<»te ptitients can be received irrespective of residence. The rates in the private wards are governed by the locality of rooms and range from 120.00 to $35.00 per week. The extras are laundry expenses, massage, the services of an exclusive nurse, the services of a throat, eye, ear and skin or nervous s|>ecialist, and surgical fees. Wherever room exists in the private wanls and the cxmdition of the patient does not forbid it, comjxanions can be accommodated at the rate of $15.00 per week.
One week's boani is payable when a patient is admitted.
64
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 61.
A NEW APPARATUS FOR IMMEDIATE AND PERMANENT DRAINAGE OF THE URINARY BLADDER
AFTER SUPRAPUBIC CYSTOSTOMY.
By Jos. C. Bloodgood, M. D., Resident Surgeon, Johns Hopkins Hospital; Assistant in Surgery,
Johns Hopkins Medical School.
(Read before the Johns Hopkins Hospital Medical Society, November 4th, 1895.)
The term cystostomy is used beciiuse a permanent opeuing is made into the bladder through the abdominal wall. By immediate drainage I mean that the tube is introduced at the operation and allowed to remain one or two weeks, at the end of which time it is removed and the sinus allowed to close — or iu those cases in which the opening must be kept open, the apparatus for permanent drainage is introduced. In both cases the apparatus, to be described, consists of a tube attached to a rubber bag reservoir, the tubes only differing for immediate and permanent drainage.
Until cue and one-half years ago the few cases of suprapubic cystostomy in which, for some reason, the sinus had been kept open, the patients have worn a hard rubber tube provided with a stopper, which was removed at frequent intervals to allow the bladder to empty itself. In all these cases there has been constant leakage, wetting both day and night clothes, and making it almost impossible for the patient to I'eep dry or free from the odor of urine. In those cases in which the bladder became irritable when distended, the stopper could not be used. The condition has been one of such discomfort to patients that surgeons only in very urgent cases resort to this method of drainage. The apparatus which I am about to describe provides such perfect drainage and the patients are so comfortable that I feel confident it will encourage the more frequent use of suprapubic cystostomy.
It has been perhaps because we have had few such cases that a better apparatus has not been improvised before. We were stimulated to improve our methods by the necessity of a case, that of a young and active business man, in which it was necessary to keep the bladder open for the local treatment of an early tuberculosis, and at the same time it was quite imperative that he should be able to continue his business with some comfort, and especially to be free from the odor of urine and the frequent change of dressings. With the intelligent co-operation of this patient this new apparatus was devised. He has worn the tube and bag for one and one-half years and has been able to conduct his business as usual. (1 see him at the theatre now and then.) Since this first case five others have been provided with the apparatus. All are able to keep dry and free from the odor of urine, and to continue cheir ordinary life with comfort.
Encouraged by the success of the apparatus as permanent drainage in these cases, it occurred to me that it could be used with equal satisfaction for immediate drainage after operation. I devised and had made such an apparatus some four months before the opportunity offered itself for its use.
In July, 1895, suprapubic cystostomy was performed and this method of immediate drainage introduced. The patient, a man aged 63 years and quite feeble, was suffering from acute purulent cystitis. The prostate was only moderately enlarged.
There was dribbling of urine with retention. Catheterization was re(|uired to prevent over-distension. Catheterizatiou followed by copious irrigation gave no relief and the manipulation was very painful. His daily temperature rose frequently to 103° and never fell beloAV 101°; his pulse ranged belween 110 and 1.30. The patient's relief after the operation was immediate and permanent; the tube was not removed for two weeks, since which time he has worn the apparatus for permanent drainage.
During the two weeks iu which the apparatus for immediate drainage was used no urine leaked into the wound. The bag was emptied every three or fours hours, and twice daily the bladder was irrigated without a catheter through the tube into the bag. The patient after the third day was allowed to sit up in bed, and on the seventh day to get up in a chair.
Previous to this case the following method of drainage had been employed. A short rubber tube was introduced into the bladder and the suprapubic wound packed with gauze about the tube. The urine was collected in large pads of gauze placed on the abdomen. The care of these patients required a great deal of time ; it was almost impossible to keep them dry. The drainage tube and gauze had to be changed on the fifth day, frequently sooner, and the re-introduction was painful. The gauze packing always became saturated with urine.
Description of the Aitaratus.
The rubber bag reservoir for both immediate and permanent drainage (see Fig. I) is 18x12 cm. in diameter, and holds about 350 cc. of urine. Patients usually empty the bag when about 250 cc. collects — every four or five hours. Sealed to the upper and central portion of the bag is a thicker piece of rubber with a small opening in its center, into which the head of the tube is inserted. The ends of the abdominal belt are also fastened to the center piece. The abdominal belt cari-ies the entire weight of the bag (see photograph), so that there is no dragging on the tube. Two rubber tubes lead from the bag, the lower one being used to draw off the urine, and the upper to wash out the bag. Both are provided with stoppers.
After operation it is not necessary ta change the position of the patient to empty the bag, and when the patient is up and dressed the bag can be emptied with no more than the usual unfastening of the clothes.
A longer tube could be attached to this shorter one and carried into a vessel beneath the bed, so that there would be continuous drainage. After operation there would be some danger of this tube being dragged upon, thus disturbing the suprapubic tube in the bladder. One of the six patients using this apparatus for permanent drainage employs this method
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April, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
65
at night, and is relieved of the call to empty the bag every four or five hours.
The tube used for immediate drainage after operation (B'ig. II) is made of hard rubber and consists of three pieces: A, shaped like a bolt, is 2 cm. long. Its head is 1.8 cm. in diameter and 3 mm. in thickness. The top of the head is grooved (A') to allow free drainage into the bag. The head of the bolt is inserted into the hole of the bag, the elasticity of the rubber making a snug fit. (S), the second piece, which is saucer shaped, is screwed on the bolt, so that the rubber bag is held very tightly between the head of the bolt and this piece, and leakage is prevented. The straight portion (C) of the tnbe is 10 to 15 cm. long and 1.5 cm. in diameter; 1.5 cm. from the bladder end is a shoulder (D) 5 mm. in width, pierced with four holes. This tube is first fixed into the bladder and then the bag armed with the bolt and second jiiece is screwed into the end of the tube.
The me/hod of fiec.uring the tube in the Madder. — After opening the bladder, four silk sutures are passed through the wall, not including the mucous membrane, the inner piece of each suture being passed through the corresponding hole in the shoulder of the tube. The tube is inserted into the bladder and the sutures tied. The shoulder rests on the bladder wall, making a very snug fit, allowing no leakage (Fig. III). Gauze is packed down to the bladder about the tube, filling the suprapubic wound. The sutures are long and are carried out of the wound with the gauze. The object of the gauze is to absorb any leakage which during the first few days might take place. It may not be necessary, yet it is a safeguard against auy infection by extravasated urine, and aids in holding the tube in place.
The abdominal wound is partly closed and gauze pads are placed about the projecting portion of the tube and held in place by a binder. On this cushion rests the bag reservoir — Fig. IV.
November 30th, Dr. Ilalsted kindly allowed me to use this apparatus on a second case. The drainage has been perfect (now two days). I have carefully examined all the gauze and find there is no leakage. There has been no pain or discomfort.
The tube for permanent drainage is not provided with a shoulder. It should be long enough to extend into the bladder at least 1 cm. The bladder end should be slightly bulbous. The tube should be curved or straight according to the direction of the sinus; as a rule slightly curved. The second piece rests on the abdominal wall. It is smooth and produces no irritation. The abdominal belt holds the weight of the bag. The photograph shows the apparatus in position in a very fat man weighing 250 pounds. This patient has had a suprapubic sinus for three years, the urethra being closed by a very large prostate gland. He has had exj)erieuce with both methods. This new apparatus he has worn eight months, and he tells me that he has been able to keeji dry and free from the odor of urine ever since.
January, 1896. Since the note of November 30th, Dr. Ilalsted has used the apparatus for immediate drainage in two eases; and these two cases, with the one operated on
November 30, are now wearing the apparatus for permanent drainage. Two of the operations were for stone in the bladder, and are wearing the apparatus until the cystitis improves sufificiently to allow the sinus to close; the third operation was for carcinoma of the bladder.
lu the last two cases a purse-string suture has been placed in the wall of the bladder about the tube in addition to the four sutures described.
In the first case (November 30) leakage took place on the sixth day, one suture having pulled out, but the sinus was already lined by fissure granulation, so that the tube for permanent drainage could be introduced, and in a few days the sinus contracted about the tube and no leakage took place. In the second and third cases, in which the additional pursestring suture was used, leakage did not take place until the eighth day, the suture having pulled out; the tube for i)ermauent drainage was then introduced, and in a few days no leakage took place.
Judging from these cases, we can feel certain that the apparatus for immediate drainage will work perfectly for eight days, and no doubt in some cases longer; at this time, no leakage having taken place, the sinus leading into the bladder will be lined by firm granulations, the bladder will be fixed by adhesion, and the wound will be in an excellent condition for the introduction of the tube for permanent drainage. For two or three days, until the sinus contracts about the new tube, some little leakage will take place, but most of the urine will be collected in the rubber bag. The apparatus for permanent drainage should be changed morning and evening, and carefully cleaned. The bladder should be irrigated at the same time. As a rule, the bladder can be irrigated by introducing a glass nozzle 1 or 2 cm. into the urethra, the irrigation flowing out the suprapubic sinus. It is also a good plan to have the patient provide himself with two rubber bags, one for day and one for night use, so that each bag will be dry part of the time — the rubber will last longer.
The problem for immediate drainage after suprapubic cystostomy seems to be solved by this apparatus, for it provides perfect drainage, allowing no leakage, with a tube which can be removed without pain or difficulty, after which the wound will be in an excellent condition for the tube used for permanent drainage, which in turn leaves a sinus which will quickly close as soon as the introduction of the tube is discontinued.
In the last few weeks I have heard from most of the cases wearing the permanent apparatus, none of Avhom have any complaint.
In three cases of cholecystostomy, in which we did not wish the sinus to close, and from which the discharge w:is sufficient to annoy the patient by soaking the clothes, this same apparatus is worn with perfect comfort and no leakage.
HOSPITAL PLANS.
Five essays rolnting to tho coustnicUon, org»iit»»ilon and mnn.isomeDt of Hospitals, oonlrlbutea by their authors for tho use of The Johns Hopkins Hospital.
Tlieso essays wore written by BBS. JOHX S. Billings, of the r. S. Army, Sobton FoLSOM ot Boston, JosETH JONKS Of Now Orle.ius. Caspar Morris of Phllodelphla, and Stephks Smith of New Tork. They were originally published In ISTS. Ono Tolunie, bonnj In cloth, price (.VOO.
66
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 61.
THE BACILLUS AEROGENES CAPSULATUS IN A CASE OF SUPPURATIVE PYELITIS.
By Herueut U. Williams, M. J)., Laboratory of Pallioloyij, University of Buffalo.
The iucreasiug interest which the peculiar bacillus that is to be reported iu this paper has receutly awakened leads me to report a case of suppurative pyelitis in which this organism occurred, although not in pure culture.
During a short stay in Baltimore, at which time I was engaged in study in the Bacteriological Laboratory of the .Johns Hopkins University, I was enabled, through the courtesy of Professor AVelch, to study the gas bacillus, which had been first described by him in 1891. On my return to Buffalo I made an autopsy upon the body of a large man, 47 years of age, who had been dead 31 hours, and whose organs presented the peculiar appearances described by Welch and Nuttall, and which have generally been spoken of under the name of " schaumorgaue." It is necessary to state that the autopsy took place iu a private house, that the cadaver had not been placed on ice, but that the weather had been cold. A brief account of the autopsy record is as follows :
The subcutaneous fat was very abundant. The peritoneal cavity presented no extraordinary appearances. The lungs were bound to the chest wall by firm adhesions, and upon section they were dark in color and bloody fiuid exuded from their cut surfaces. They were free from consolidation. The pericardium was obliterated, and beneath the epicardium over the left ventricle small hemorrhages existed. The heart was enlarged and of a spongy texture. The mitral valve showed slight thickening along its free edge ; the other valves were delicate. The aorta was moderately atheromatous. The spleen was large and dark in color. The liver was not enlarged, but its capsule was irregularly thickened. Upon the section of this organ it was observed to be pervaded with small cavities up to 1 mm. in diameter, which gave to it a distinctly spongy appearance, and from which frothy fluid tinged with blood coloring matter escaped. The left kidney was enlarged. The capsule stripped off with ease, and upon incision into this kidney the fact was disclosed that the pelvis and calyces were dilated and filled with pus. Gas bubbles were not noted in this material. The right kidney was also enlai'ged and softened. As the urine had not been examined for many weeks, neither the physician iu attendance nor the patient had suspected the condition found in the urinary tract.
The condition of the organs, particularly that of the liver, at once suggested the probability of the presence of some gasforming micro-organism. The organs were removed to the laboratory and immediately examined bacteriologieally. Cover-slip preparations were made from the parenchyma of the liver and the heart, as well as from the pus of the left kidney. In addition, dextrose-litmus agar tubes were inoculated from the same sources. The pus from the kidney exhibited in the stained smear preparations large, broad bacilli, the ends of which were for the most part rounded, and which could be seen at times to be surrounded with capsules. A small number of smaller and thinner bacilli, as well as oval coccus-shaped bodies, were also seen. The large bacilli which were the predominating organisms occurred as a rule singly.
The same micro-organisms iu about the same proportion were found upon the cover-slip preparations jirepared from the substance of the liver and the heart. The cultures were grown by Buchner's method at 36 degrees C. in the thermostat, and a rapid development with abundant gas formation took place. These showed upon microscojjical examination a mixture of the several forms of bacteria already described, the oval cocci appearing now iu the form of short chains.
Experiments on animals were undertaken about six weeks later, at which time a suspension derived from the culture made from the liver was inoculated into the ear vein of a rabbit. The animal was killed at the end of five minutes and kept in a warm place for %i hours, at the end of which time it was greatly swollen. Gas was not demonstrated in the peritoneal cavity, although the right heart was blown up and gas bubbles were found in the blood-vessels and in the subcutaneous tissues. Cover-slip preparations showed the same large bacillus as had been present in the culture used for inoculation, and cultures from the viscera gave the same organism. About 1 cc. of the blood serum from the pleural cavity of this animal which contained the bacilli in considerable numbers, was injected into the muscles of the breast of a pigeon. At the end of five hours crejiitation was present over the jjoint of injection. The animal died on the third day. As the bacilli were not recovered from the seat of inoculation, the interpretation of this experiment is not clear.*
This bacillus agrees both morphologically and in its pathogenic effects with the organism originally described by Welch and Nuttall, and subsequently by Frankel and others. The occurrence of the bacillus aerogenes capsulatus as a widely dift'used organism in nature is proven by the large series of cases iu human beings which have been reported recently by
- Note by Dr. Flexnkr. — During a visit to Buffalo I was presented, through the kindness of Dr. Williams, with one of the
original culture tubes prepared from the liver of this case. On returning to Baltimore I found that the organism, now some eight or ten weeks after the autopsy, was still alive, and I was able to complete the experiments left incomplete in Dr. Williams' study. The original culture still contained, along with the gas bacillus, both the thin bacilli and the stieptococci which were present at the time of the autopsy. Their separation was effected by the inoculation of rabbits which were killed soon afterwards, and tlie preparation of cultures from the heart's blood of such a case. The bacilli obtained were short and thick, presenting rounded extremities ; were single or combined into short chains and frequently capsulated. They grew readily at the temperature of the thermostat and produced abundant gas in sugar culture media. They furthermore were non-motile and slowly liquefied gelatine. They could he easily stained with Gram's method. Inoculated into pigeons and guinea-])igs, the characteristic lesions were produced, the animals succumbing in 24 to 48 hours. At the autopsy gas phlegmons had formed at the site of the inoculation ; the tissues were dissected up extensively and were necrotic, and the bacilli were found in very large numliers in the local lesions. Gas formation in the tissues was detected us early as two hours following the inoculation, and it was present at the autopsy.
April, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
67
Welch and Flexuer.* That this micro-organism can enter the body by way of tlie genito-urinary tract is made probable by this case, as well as by some others in the litcratnre. lu a recent report by Goebel of the case of a man 24 years of age, in whom at autopsy, in addition to a papilloma of the bladder, abscesses of the prostate gland and seminal vesicles and consecutive suppurative pyelo-nephritis existed, this micro-organism was obtained from the substance of the liver and heart in which many gas vesicles were contained. Associated with this bacillus were streptococci and the bacillus coli communis. It is not stated in this report whether or not the gas bacilli were present in the abscess formations. In a second case, this one being a man G(j years old in whom the prostate was enlarged, there was found at autopsy beneath the mucous membrane of the bladder, numerous gas bubbles, the largest of which measured 4 mm. in extent, from which a pure culture of the gas bacillus was obtained.
Among the cases reported by Welch and Flexner there are two of infection of the genital tract in which this microorganism was found. The first occurred in a man G5 years of age who suffered from hypertrophy of the middle lobe of the prostate gland, cystitis, pyo-ureter and double pyelo-nephritis associated with multiple miliary abscesses in the kidney. The autopsy was conducted 14 hours after death. The pelvis of the left kidney was greatly dilated and contained a thick, greenish, somewhat blood-tinged pus and bubbles of gas. The mucous membrane of the pelvis showed a greenish discoloration, and gas bubbles were present in its substance. In the substance of the kidney as well as in the mucous membrane of the pelvis small abscesses occurred. The left ureter was dilated to the size of the index finger, and its mucous membrane presented a similar appearance to that of the pelvis of the kidney. The right kidney, excepting for the fact that it was even more enlarged than the left, presented the same appearance as the former. The bladder was dilated, its walls greatly thickened, the mucous membrane mottled and greenish in color. The enlarged middle lobe of the prostate projected into the bladder and offered an obstacle to the jjassage of the urine. It was as large as a horse-chestnut. Bacteriological examination of the kidney and bladder gave as the j)redominating organism a very coarse bacillus which agreed in morphology with bacillus aerogenes capsulatus, a smaller number of thinner, finer bacilli, and a few cocci. Cover-slips from the abscesses showed cocci only, which proved to be the staphylococcus pyogenes aureus. From the bladder and kidney, the gas bacillus, the bacillus coli communis and the streptococcus pyogenes were obtained. The second case was a man of 35 who had suffered from stricture of the urethra and cystitis. Perineal section had been performed. At the autopsy, which was made one hour after death, besides a chronic cystitis there were found double pyo-nephrosis and pyo-ureter associated with multiple miliary abscesses of the kidney. Both of the kidneys presented about the same appearances. On the surface there were many discrete and contlueut abscesses. The pelves were much dilated and filled with thick, greenish-yellow pus. The mucous membrane itself was con
•Tlu" ,Toiirii;il of Exiierimental Moiliciiie, \'ol. 1, No. 1, page 5.
gested and granular. Both ureters were greatly dilated and contained cloudy urine and Hakes of purulent material. The bladder was contracted, its walls thickened, its mucous membrane congested and granular. The bacteriological examination of the kidney abscesses, the contents of the ureter, the bladder, and of the seat of the operation in the perineum, all showed the presence of the gas bacillus, the bacillus coli communis, streptococci and the staphylococcus aureus. In this last instance, although gas was not observed in the purulent contents either of the kidney or of the ureters, the short time which had elapsed between the death of the patient and the autopsy is to be remarked in view of the presence of the gas bacillus in the tissues. The part played by it in causing the lesions described cannot be determined in view of the other well known pathogenic species which were associated with it This small group of cases is of interest, it is considered, in connection with the question as to the existence of this organism in external nature and the various modes in which it may invade the animal body. It cannot be excluded, as has been pointed out by Welch and Flexner, that as it is often present in the intestinal canal, the gas bacillus was not brought to the kidney by the circulating blood, just as in other instances the colon group of organisms is transmitted to these parts. The finding of this particular organism in the external wound in the case of the periueal section would, however, indicate that it may have entered from without. It is not urged for the case which I have reported that the entire series of phenomena described are to be regarded as ante-mortem in their development, the length of time (31 hours) which had elapsed between the death of the individual and the autopsy examination and the fact that the body had not been kept on ice nuiking it possible that the invasion had taken place postmortem. It must be considered, in all. events, that the rich development of the organisms in the viscera with the production of the appearance of "schaumorgane" was a post-mortem phenomenon, even though it be admitted that the kidney invasion had taken place during life.
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68
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 61.
THE CHECKING OF OPERATIVE BLEEDING BY TORSION.*
By Edward Maktin, M. D., Clinical Professor of Genito-Uri')iary Surgery, University of Pennsylvania.
In selecting the topic of my paper to-night it was not my intention to attempt a systematic consideration of the various means of controlling hemorrhage during operation, but rather to bring up for discussion one or two methods which, though not popular, have seemed to be serviceable under suitable circumstances; indeed, distinctly better than the procedures more commonly adopted. J particularly allude to manual pressure, proximal ligation, and torsion. But before taking up this my proper subject it may not be amiss to consider the effect which modern methods have exerted on operative and post-operative hemorrhage.
Within a few years, not more than ten, nearly every major operation was accompanied by such severe primary hemorrhage that marked systemic effects were produced — consecutive bleeding, that occurring within a few hours coincident with systemic reaction, was frequently observed — and secondary bleeding, occurring about the fifth or sixth day, was a common and often fatal complication. The abundant and continued bleeding during operation was due to the fact that forcipressure as it is now employed was not generally adopted, the vessels being seized and immediately ligated as j-apidly as possible. Moreover, the use of the Esmarch bandage and tube was popular, and later many surgeons had faith in copious irrigations with hot or cold fluids, or failed to appreciate the effect of a slow bleeding continued through a long operation.
The frequent reactionary bleeding was practically a sequel of the severe pi-imary hemorrhages, the patient being so depressed that comparatively large branches failed to bleed and were not secured. The increased blood pressure incident to reaction naturally led to hemorrhage into the wound. The secondary hemorrhage was, of course, due to infection. At the present day both consecutive and secondary hemorrhage are extremely rare, and save in exceptional cases but little blood is lost even in prolonged operations on vascular parts. The primary bleeding is avoided by proximal pressure where this is applicable, either instrumental or digital, the Esmarch tube when its use is indicated being applied with just sufficient pressure, and being kept in place for as brief a time as possible, the vessels are seized in forceps sufficientlv strong to break the inner coat as soon as they are divided, or even before this if they are observed, the wound is kept dry, and if the operation is likely to be prolonged, attention is given to even the smallest vascular branches which by a slow, long-continued oozing might cause serious loss of blood. The effects of this slow but continued bleeding are well shown in bone operations — the removal of extensive sequestra, for instance. Such operations are generally followed by pronounced shock, due, not to the bone trauma, but to loss of blood, often not appreciated by the surgeon because it is so readily dried from the bone cavity by the assistant that it
•Read before the .Tolins Hopkins Hospital :\Iedical Society, Xov. 16th, 1895.
makes little show provided the sponge is used rapidly and skilfully.
The crushing of the divided vessels by the forceps, the use of finer ligature material, the application of the ligature with greater care, more consistent effort being made to secure the artery, freed from the surrounding tissues, the avoidance of shock and the more careful application of dressings, all tend to prevent recurrent bleeding. I have seen but two instances of consecutive bleeding in the last eight years ; one patient was suffering from splenic leukemia, the other from profound cholemia. Capillary bleeding was controlled only by pressure, recurring with its original severity for many days whenever the pressure was removed. I have seen but four cases of secondary hemorrhage in the same time, one a gunshot wound of the femoral artery and vein, in which I had employed lateral closure in the last-named vessel with the idea of lessening the danger of gangrene ; the other three (seen within the last four months), cases of external perineal urethrotomy, bleeding occurring in one instance two weeks after the original operation. In all these cases the wounds were apparently clean. In the three urethral cases permanent catheters had been worn. Since the cause of secondary hemorrhage is commonly septic infection, the reason why this once ever-threatening complication of operations is no longer of importance in considering the question of prognosis is readily understood.
Considering uow the bleeding which occurs during an operation, the first measures adojited by the surgeon are those designed to prevent the loss of blood immediately incident to the division of such vessels as lie in the line of incision required for the proposed operation. The preventive means usually employed is jjroximal pressure, applied by the rubber baud, which under certain circumstances, as in shoulder or hip-joint amputations, must be kept from slipping by long transfixion pins or by bandage loops drawn upon by assistants. This method is efficient, is simple, requires no especial skill in its application, and is usually followed by no bad results. I believe that under certain circumstances manual pressure is equally efficient and is safer and simpler. In amputations and other major o])erations involving the extremities of infants and children under twelve, the grasp of the hand is usually sufficient to check bleeding, nor need this grasp be very firm. The hand, or two hands, of an assistant encircle the limb a convenient distance above the seat of operation, and firmly close upon it until the distal pulsation disappears. The am])utation or excision is then conducted in the ordinary manner, and the vessels which can be found are seized. By a momentary relaxation of the grasp, arterial branches which are still patulous can be made to bleed for a moment and thus can be recognized and secured. It can readily be seen that by this method the tissues are not bruised, the effect of severe and continued pressure on the vaso-niotors is wanting, and relaxation and tension may be made almost instantaneously, so that the minimal amount of blood is lost. In even the muscular adult this method of controlling hemorrhage is
April, 189G.]
JOHNS HOPKINS HOSPITAL BULLETIN.
69
applicable to operations upon the foot or the hand. In the emaciated adult — and such an one belongs to the class whom we particularly wish to protect from all unnecessary trauma — amputations of the thigh or upper arm may be thus successfully and bloodlessly accomplished. By manual pressure somewhat differently applied as required by the different conformation of the parts, the free bleeding which occurs in operations requiring division of the scalp readily may be controlled. In this case the ulnar edge of the hand is pressed firmly to the side of the incision from which the vascular supply is derived, and is made to press and retract as strongly as possible. Should a flap be raised, drawing this back sharply upon its pedicle will angle the vessels of supply sufficiently to check bleeding.
Digital pressure as a means of preventing hemostasis is particularly applicable to the common carotid artery and the abdominal aorta. Both these vessels are large, supply parts which are exceedingly vascular and which are subject to affections requiring extensive and difficult operations. The carotid is readily found and can be efficiently occluded by backward pressure against the transverse process of the sixth cervical vertebra. Pressure on one or both of these vessels would be indicated in certain operations upon vascular growths involving the bones or cavities of the face or cranium. In thin subjects the abdominal aorta can be distinctly outlined and can be efficiently compressed through the abdominal parietes, or through an abdominal incision the fingers could be applied directly to the artery. Such a procedure would be of great service in operation upon large malignant growths, such, for instance, as those which involve the pelvic bones. Digital pressure applied to the peripheral vessels often efficiently supplants the tourniquet. Thus I have been enabled to operate successfully on a large dissecting aneurism of the upper third of the femoral artery, employing as a preventive hemostatic only the thumb of an assistant placed on the artery as it passes over the brim of the pelvis.
Preliminary ligation is a method of hemostasis requiring an operation in itself, thus lengthening and complicating the necessary surgical intervention, yet successfully employed ami strongly recommended under proper conditions by the few surgeons who advocate this measure. I have no personal experience with this method. It would seem serviceable, and many times has been satisfactorily employed in excision of tlie superior maxilla, the external carotid being secured, excision of malignanb degenerations of the tongue, the lingual being tied, excision of the arm and scapula for sarcoma, the subclavian being secured, and amputation at the hip-joint, the femoral being secured. In all these cases the vessel of supply is readily and quickly secured, and the application of a ligature to it would very slightly lengthen the time of operation.
Though checking of hemorrhage by means of torsion seems to have been known to Galen, Amussat (Archive Generale de Medecine, tome XX, p. (108, 18"i!)) deserves the credit of having proposed, practiced and popularized this procedure. He observed that there is little or no bleeding when limbs are wrenched off or when vessels are torn. He experimented on animals, tearing, rupturing and contusing the blood-vessels, but without satisfactorily checking hemorrhage. By chance
he happened on one occasion to twist an artery which he had just cut, and observed that the spirals thus formed had no tendency to become effaced and that the flow of blood was checked. Repeated experiments conviiiced him that the method was safe and applicable in surgery. His experiments were performed upon dogs and horses. The femoral, carotid, internal iliac, thoracic and abdominal aorta were twisted in the following manner : the divided artery was seized in a pair of forceps, drawn out for half an inch, separated from the surrounding connective tissue by a second pair of forceps, and seized by the latter or by the fingers to prevent the twists from extending too far. The distal force2is was then twisted until the artery lying between the grasp of the two instruments was entirely broken through. The results of operations upon the dog were not entirely satisfactory, since the blood-vessels of this animal are extremely retractile and the blood readily coagulates. The horse was therefore considered a better animal for experimentation. In every case hemorrhage was satisfactorily checked.
Thierry (de la Torsion des Arteres, Paris, 1829), in an elaborate paper on this subject, held that any form of forceps might be employed, provided they had a catch which held them closed, and provided their width was equal to the diameter of the artery to be twisted. He objected to separation of the artery from surrounding parts and drawing of it out from the wound, holding that the twists wonld extend too far, thus rendering them less permanent. He twisted small arteries four times, the ones of medium size six times, the large ones ten times. He did not fix the arteries before twisting them either with the forceps or fingers, nor did he consider it necessary to twist to the point of breaking the inner coats of the vessel, holding that the spirals of the twist were permanent and sufficient to arrest bleeding.
In criticising this method Petit called attention to the fact that the twists do extend far beyond the limits of the wound, that the nervous and cellular attachments of the vessel are torn, that there is a greatly increased amount of inflammation, and that the attachments of small vessels coming off from the artery which is twisted may be readily ruptured. Indeed Petit states he has seen this done in experiments on animals.
Schrilder (translated by Petit, de la Torsion des Arteres, Paris, 183-1), from cadaveric examination, found that if the artery be exposed for a few lines of extent, seized, drawn out and twisted, the twists do not extend beyond the surface of the wound, this being prevented by the adhesion of the artery to the surrounding parts. The fibrous coats form a valve wliich so completely closes the vessel that its resistance cannot be overcome by pressure of liquid driven in with great force. In the centre of this external valve there is elevated a little projection exhibiting spiral markings formed bv the debris of the broken fibrous tissue, A few lines alwve the position of this external valve the middle and internal coats are broken and torn circularly. They roll upon themselves, closing the artery lumen, the out«r coatings of the middle tunics becoming apposed. The valve thus formed much resembles the semilunar valves of the .lorhi, since pressure within the vessel tends to close them more tightly. At the same time there is produced a clot within the vessel, though
lO
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. (;i
this is not always formed. The effects of torsiou are thus sumiuarized : the inuer and middle coats of the artery are torn circularly and become approximated, forming a valve. The outer fibrous coat forms a second valve which firmly closes the opening of the arteries.
Torsion as a means of checking hemorrhage became extremely popular at this period ; it was introduced into England and Germany. The best known surgeons and students of the day practiced the method and wrote upon it. Among these may be mentioned Fricke 1830, Robertson 1830, Kush 1830, Froriep 1831, Buet 1831, Bedor 1831, .Jobert 1831, r^eclerc 1831, Detorres 1831, Delpech 1831, Foucoude 1832, Ott 1831, Lorch 1832, Textor 1832, Velpeau 1832, Clot Bey 1833, Fricke 1833, Von Griife 1833, Brockmiiller 1833, Schroder 1834, Costello 1834, Dupuytren 1834, Lisfranc 1834, Boycr 183.o, Manec 1830, ISanson 1830, Ungar 183G, Dietrich 1830, Grofe 1837.
There was a singular absence of ,id verse criticism. There was, of course, a difference of opinion as to the technique, as to whether the best results were obtained by twisting the free vessel or seizing it above in a second pair of forceps, as to whether the vessel should be twisted through completely or only partly thi-ough. But on the merits of torsion by whatever method carried out there was a general agreement, it being generally conceded that twisting, though more troublesome than ligature at the time of operation, greatly lessened the dangers of secondary hemorrhage and afforded a better opportunity for healing by fii-st intention. And here occurred a singular thing and one difficult to explain — torsion, having been thus brilliantly heralded and successfully employed in luindreds of cases, was gradually abandoned by the active surgeon. Few references are found to it in literature after 1838, the most- notable of these perhaps being communications from Blandin 1841, Deviennc 1843, Lauer 1844, and Houish 1801. The method was practically abandoned when Syme in 1868, by a brief publication in the Lancet advocating its use, again revived interest in it. Bryant, and about the same time Humphrey, experimented on dogs, horses and human cadavera, and gave the method clinical trial in hospital cases, thus repeating the experience of Amussat and his contemporaries, and arriving at practically the same conclusions.
The method again became popular for a time and was well represented in the literature of the day, some fifteen or twenty j)apers being contributed to the subject in the next few years. Again the method was generally commended, though Ogston (Lancet, April 17,1869), as the result of a few experiments in the human cadavera, holds that vessels secured by torsion are liable to secondary hemorrhage, especially when the arterial tension is increased upon reaction from shock. lie states that his experiments show it is a dangerous hemostatic, since while some of the twisted vessels withstood a tremendous pressure of mercury, others yielded as soon as the fluid metal was poured in with a pressure of less than two inches. lie holds, however, thai torsion is suitable for small vessels, and that the surgeon should make a judicious choice of both torsion and ligation in his operations.
Humphrey (Brit. Med. Journ., Vol. I, 1869) so clearly describes the effect of tAvisting upon vessels, and reaches
results from his experiments so similar to mine, that I in part give the tenor of his communication. When the artery is seized and twisted the inner coat breaks usually just above the grip of the forceps, since here the twisting is the most marked, and this break takes place before the outer coat begins to give way. In continuing the twisting the fibres of the outer coat also give way, leaving a pointed end composed of the torn shreds of this coat firmly compressed together, sealing the vessel and holding in contact the lacerated edges of the inner coat. The twisting has another effect, that is, after the inner coat is ruptured the subsequent twisting detaches it from the outer coat and turns it upward, forming a valve or inverted funnel. Experiments with mercury to determine the resistance offered by torsion against the escape of fluid show that a well-twisted human carotid or femoral generally supports a column of from 12 to 20 inches of mercury, but sometimes when the torsion is performed in precisely the same manner in the same vessels the metal escapes under a lower pressure. It is not possible to be sure of so twisting a large artery as to enable it to bear a column of more than a few inches. In the innominate, common iliac, and especially the aorta, the results are less satisfactory. The mercury first distends the vessel just above the twist and to some extent by its pressure untwists it; it then traverses the funnel-shaped aperture of the inner coat and passes to the twisted outer coat, comparatively slight pressure sometimes sufficing to carry it thus far; the further escape entirely depends upon the outer coat, the mercury either breaking through or causing a gradual untwisting. Humphrey found that the artery bears a higher column of mercury when its end has been quite twisted off than when this has been only partially done. The results of twisting with two forceps were not so satisfactory. The rotation of the artery upon its axis takes part for some distance above the part seized by the twisting forceps when the arteries are seized. Usually the coats immediately beneath the forceps give way, and the artery above unfurling itself, tends to complete the twisting and tearing of the coats nearer to the forceps. The vessel may give way higher up and undergo complete torsion at one or more places. With a ligature a well-tied artery bears a column of 30 inches or more of mercury, an unnecessary resistance, since about six inches of mercury represents the blood pressure.
For several months at the time of writing his paper he checked hemorrhage entirely by twisting, thus treating the femoral and other large arteries. He has never yet known an artery bleed in the human subject after he was sure that it had been really twisted. He has always twisted the end of the artery quite off, requiring 10 or 12 rotations, and continues twisting until the severance is quite complete, also being extremely careful not to make any traction upon the vessel while this twisting is going on. He holds that in amputations and other operations, all vessels, even up to the size of the femoral artery, as a general rule may and should be secured by torsion, that healing of wounds may be thus expedited, and that in the greater number of o])erations ligature may be superseded by torsion.
Bryant's experiments and clinical trials proved the full
April, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
71
reliability of torsion. He differed from Humphrey, however, in holding that the artery should not be twisted off, but in the case of large vessels rotation should be continued only until the sense of resistance was overcome. In his Practice of Surgery he states that in Guy's Hospital up to 1874 there were 200 consecutive amputations of the thigh, arm and forearm in which all the arteries had been twisted. One hundred and ten of them had been of the femoral artery, and that there was not a case of secondary hemorrhage. Indeed, since torsion has been generally practised in the hospitals they have learned no longer to expect this complication. In amputations where hemostasis was accomplished by ligature, 7 per cent, of the fatal cases, or 1^ ])er cent, of the whole number, were lost by secondary hemorrhage.
In 1870 Tillaux (Bull, et Memoire de la Soci^to de Chir., torn. II, p. 2.31) resuscitated torsion in France. Since this year he states he has exclusively employed this method in both minor and major operations in the service of three active hospitals, and in not a single case was there primary or secondary hemorrhage. The twists never pass higher than half to four-fifths of an inch above the point of seizure. The sheath prever.ts the extension of the twist. In the case of the large arteries it is always thick and resistant and completely immobilizes the vessel.
Hill had good results in 70 operations. His conclusions are: Torsion is applicable to arteries of all calibres, and especially suitable to large arteries. A single forceps is necessary ; the artery should be seized in the bite of the forceps. Twisting must be carried to complete detachment of the portion seized. Folding in of the inner tunics is useless. Inllamed and atheromatous arteries are efficiently treated by torsion. Primary healing is encouraged by this method, primary bleeding is checked as readily by torsion as by ligature. The dangers of secondary hemorrhage are much less after torsion than after ligature.
M'Donnell (Medical Press and Circular, I87fi, T, p. IT).'}) writes as though torsion were becoming an established pra(;tice. He quotes Mr. CoUes' words: " In Steeveus Hospital my colleagues and I have seldom resorted to any other means of arresting hemorrhage, even from the largest vessels, and we have never had reason to regi-et the adoption of the practice."
Finally Murdoch (American Pi-actitiouer and News, Vol. X, p. 126) states that since 1S72 ho has used torsion for the arrest of hemorrhage after all operations, to almost the entire exclusion of all other methods. The femoral has been twisted over a hundred times, the anterior and posterior tibial over three hundred times, the brachial eighty-one times, the axillary and popliteal each eighteen times, without a single case of secondary hemorrhage. Tlie method employed has been that of free torsion. The vessel was seized in a pair of forceps which will liold the end of the artery firmly, and with serrations sufficiently blunt to prevent cutting of the part seized by the blade. It was then drawn out, as in the application of a ligature, and three or four sharp rotations of the forceps were made. In large arteries such as the femoral the rotations were repeated until the sense of resistance ceased. The end should not be twisted oif. This method was also resorted to in all other surgical operations, such iis ampu
tations of the female breast, the removal of tumors, the excision of joints, etc. In the thousands of cases to which torsion
was applied there was not a single instance of secondary
hemorrhage which should be fairly, attributed to this method
of controlling bleeding. Murdoch states that the advantages
of torsion are the great facility with which it is applied, the
great security which it affords against secondary bleeding, and
the more rapid healing incident to the absence of any irritating
or foreign body. In i-egard to the greater facility with which
torsion is ajiplied, he states that any one skilled in both methods
will readily concede the advantages of this claim. 'No assistance is required; but three or four turns of the forceps are
needed, requiring far less time than the application of a
thread; the delay incident to the slipping or breaking of the
ligature is entirely obviated. The greater safety of the method
is abundantly proven by the figures which be quotes, and the
favorable oifect on healing is a self-evident proposition.
As to my personal experience with torsion I have performed many experiments with animals, have twisted the arteries in the cadaver, and have employed this method of arresting hemorrhage in perhaps the majority of operations which I have performed in the last six years. The results of my experimental research were practically the same as those announced by Amussat, Bryant, Humphrey and Tillaux, or with slight differences which have an unimportant bearing on the object of my communication to-night.
As to the comparative merits of limited torsion, that conducted by two pair of forceps, one seizing the artery transversely above and limiting the extent of the twist, or free torsion, but a single pair of forceps being used, of complete torsion, the end of the vessel being twisted off, or incomplete torsion, the end of the vessel seized in the forceps being allowed to remain, it seems fairly clear that the best results are obtained by free incomplete torsion, this method being the simplest, and according to experimental research best withstanding hydraulic pressure. It is also clear that by all the various methods of torsion hemostasis may be safely accomplished, and that in the pre-antiseptic period this method practically did away with secondary hemorrhage. The re;ison for its neglect by surgeons during this period is hard to understand. Because the method required separation of the arterv from surrounding tissues it was more troublesome and timeconsuming, since ligature cm nia^sevtos extremely popular, but little effort being made to free arteries before applying the thread It is also probable that the method did not lessen mortality, indeed Bryant stiites as much ; the re;isou in this case being probably because an amputation, for instance, with twenty ligatures hanging from it was better drained than one in which no ligatures were nsed: hence the sepsis was more likely to renuiin local in the former case.
At the present day, when the ideal ligature material is vet to be discovered, and when the necessity for drainjige rarelv exists, torsion should play an active role in our treatment. Under ordinary circumstances and in healthy wounds it is safe, is time-saving, and loaves the wound free of foreign Kxlies.
Experience in thousands of c.ises has shown that there is no danger of consecutive. bleeding, the hemorrhijgo occurring at once or not at all.
72
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 61.
It is applicable to atheromatous vessels, since in these the outer coat, the efficient bar to bleeding, is still strong. Clinically I have found the ligature easier of application in deopseated wounds where the vessel could not be clearly isolated, in inflammatory tissue where the vessels were adherent and often brittle, in securing veins close to their origin from a large trunk, as in the Halsted operation for carcinoma of the breast, and in the checking of bleeding from two or three small points lying close together. Under other circumstances and in the ordinary operations by means of forcipressure alone, and in the case of small arteries and veins, the vessels being seized direct and not through a thick mass of intervening tissue, or if the vessel bleeds on removal of the foi'ceps by the further application of torsion, but few ligations will be required. The failure of torsion is in the case of small vessels often due to seizing of the vessel transversely. As the forceps is twisted the artery is wound around its beak and is finally ruptured, retracting beyond easy reach and bleeding more freely than before, or the artery is not grasped at all, a mass of the neighboring tissue being seized and twisted ofE, or the artery is seized in the midst of a mass of connective tissue but slips from the grip of the forceps as the twisting is continued, perhaps bleeding into the small sac made by the matting together of the connective tissue. When the method is rightly applied the bleeding is at once arrested ; wheue it is difficult of application the ligature should be used.
Indeed in this method and others which I have advocated to-night, it has not been my purpose to urge torsion to the exclusion of others more commonly employed, but rather to call attention to some useful aids to the practising surgeon, holding that best results are obtained by altering methods
to suit varied conditions, rather than in subjecting all conditions to one method of procedure.
Discussion.
Dk. Kelly. — This question of torsion does not touch the gynecologist so closely as it does the general surgeon, because the abdomen would be the last place, in spite of the best statistics presented, where we would dare trust solely to the twisting of a large artery. Bleeding from an external wound can be seen at once and readily controlled, but in abdominal surgery the trouble would be quite serious by the time the abdomen was opened.
I have listened, however, with much pleasure to Dr. Martin's paper, for in the great revolution surgery has undergone recently we have fixed our attention too closely upon certain principles, and in the process of reconstruction have relegated many useful things to the surgical waste-basket. We might well go carefully over old methods and operations and readjust and utilize them mutatis mutandis.
Dr. Platt. — I have used torsion with the smaller vessels, but when I have cut down upon the larger vessels I have invariably tied them, being afraid to run the slightest risk. In the matter of plastic surgery, torsion is the best method, for if you put a ligature close under the skin it is pretty sure to suppurate out and leave a little fistula.
Dk. Kelly. — I would add that we now have a perfect method of sterilizing catgut, with cumol boiling at 155° centigrade, and we can use the gut with perfect freedom, without fear of after-trouble. We are therefore almost as well off as if we used torsion ; we simply add a little absorbable animal substance which disappears in a few days when it has done its work.
PROCEEDINGS OF SOCIETIES,
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
Meeti?ig of Novemljcr 4, 1895.
Dk. Flkxner in the Chair.
Exhibition of a case of Hemiplegia witli Motor Apliasia, occurrin); in a Patient convalescinij from Typlioid Fever.— Dk. Blumkk.
The case which I exhibit to-night illustrates one of the rare complications of typhoid fever, viz., hemiplegia with motor aphasia. The little girl was brought to the dispensary because of a paralysis of one side. The family history is negative and there is nothing of importance in her personal history. We saw her for the first time on the 23d of last August. Seventeen weeks before that she had an attack of typhoid fever, typical and somewhat prolonged. The attack began with malaise and a feeling of weakness; then there Wiis a continuous fever for ten weeks, with constant headache, diarrhoea, pain in the abdoftien, and mental dullness. Her brother had an attack at the same time. About one week after she had begun to eat solid food she was suddenly seized with violent convulsions. This attack occurred about eight o'clock in the morning while she was at breakfast. She was immediately put to
Ited. The convulsions were confined almost entirely to the right side as far as the extremities were concerned. The movements were also quite marked in the head, but I have been unable to find out definitely from her mother whether they were confined to the right side of the face or not. These movements were violent from eight o'clock in the morning till four o'clock in the afternoon. At four o'clock the movements of the head and face almost ceased, but the movements in the arm and leg continued with greater or less intensity for two days. During that time the child seemed unable to speak and did not seem to understand anything. About five weeks after the onset of these convulsions she began to recover the use of both limbs on the right side, which up to then had been paralyzed, and some power of speech. At first she did not recognize any of her family, or, rather, probably recognized them but miscalled them, calling her father " mother," and so on. At the time she was brought to the dispensary she was able to walk, although she dragged the right foot a little. The arm had not recovered like the foot. There was no evidence of facial paralysis at that time and no hemianopsia. She apparently at that time had a pure motor aphasia. She understood perfectly all that was said to her, would do any
April, 1896.]
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thing she was asked to do, but when an object was held up to her, while apparently recognizing it, would often call it by the wrong name. Some few things she would name correctly. Since she has been in the Hospital she has been improving steadily as far as speech is concerned and now names most objects correctly. There has also been some slight improvement in the walking. In the arm there has been no apparent improvement. The arm is generally held at right angles, as you observe it ; it is a rigid paralysis. She is unable to move her elbow and can hardly move her fingers. She shows no signs of facial paralysis ; the tongue is protruded straight, and there is apparently no abnormality about the muscles around the angles of the mouth.
We have here a complete right-sided hemiplegia originally with motor aphasia. The question is, what was the lesion which produced it? The lesion evidently implicated the motor areas in the cortex and also the area presiding over motor speech, that is to say it implicated the ascending frontal and ascending j^arietal convolutions, and also the posterior portion of the third left frontal convolution. Was the lesion a hemorrhage, was it a thrombosis or an embolus? The age of the child is rather against the lesion being a hemorrhage, as is also the fact that the irritative lesion lasted such a long time. In case of a hemorrhage of such an extent, in all probability destruction of the tissue would have taken place at a much earlier period and the irritative lesions would have ceased. As for an embolus, there never was any source of origin for an embolus, there being no heart lesion at all. Of course the child had gone through a very long period of illness, and in such illnesses there is always a chance for the formation of thrombi in the auricular appendages, and the dislodgment of these thrombi with subsequent emboli and softening. It is impossible, of course, to make an absolute diagnosis between thrombosis and embolism in this case. We have been led to make the diagnosis of thrombosis by the similarity of this case to another case which occurred in this hospital earlier in the year. In that case the patient was seized with convulsions, which were not, however, one-sided as in the child's case, but which terminated fatally in a short time. At the autopsy, extensive thrombosis of the greater number of the branches of the middle cerebral artery was found. In the present case the first three branches of the middle cerebral — the inferior frontal, the ascending frontal and the ascending parietal — were probably involved. We have two arterial trunks to be considered. Sometimes the inferior frontal and ascending frontal branches arise from a single trunk ; sometimes the ascending frontal and ascending parietal branches arise from a single trunk; and it is possible that all three might arise from a single trunk. In the latter event we would have to take into consideration only a single thrombus in the common trunk. We can, however, assnme that there was a partial thrombosis of the middle cerebral, the thrombus covering the origin of these three branches and cutting off the blood supply. Tlie fact that the signs of irritation existed so long before the actual paralysis would rather point to softening than to primary destruction by hemorrhage.
These cases are apparently j)retty rare. I have been able to find l)ut six or seven cases in the literature at mv eonimanJ,
some with convulsions and some without. There was one case reported by Doctor Gee in 1878 which was almost identical with this. He was inclined to think it was due to embolus? although there was no heart lesion to account for it. He thought it might have originated in one of the auricular appendages.
Dr. Thayer. — I had the good fortune to observe two quite similar cases while interne in the Massachusetts General Hospital, in the service of Dr. G. (i. Tarbell, with whose kind permission these notes are communicated :
Oase 1. — J. McD., aged 21, single, a currier, was admitted to the Massachusetts General Hospital on the 6th of October, 1888. His family history was good ; previous history negative. He had complained for two weeks of headache and "sore bones." Four days before entry he gave up work and went to bed. Physical examination showed a large, well-formed man; well nourished; face flushed; conjunctivas injected; lips and mucous membranes of good color; tongue moist, thick yellow coat. The abdomen was rather depressed ; moderate tympanitic gurgling in the ilio-caecal region ; slight tenderness in the epigastrium ; a few rose spots on abdomen and back. The area of splenic dullness was enlarged : spleen easily felt.
Urine normal ; acid ; 1020 ; albumen, trace ; sediment slight; hyaline and finely granular casts. 7, 10, 88. — "Stupid and apathetic ; numerous rose spots." 9, 10, 88. — Xo change. 11, 10, 88.— "To-day has been particularly stupid, puts tongue out only when spoken to sharply. Swallows milk when it is poured into his mouth, but cannot be made to suck it through a tube. Pulse rather small, somewhat dicrotic." 12, 10, 88 (10th day). — "At about 1 A. M. the ward tender noticed that the patient was unable to move the right leg and arm. At 12.15 A. il. the patient was seen in bed, on his back, face flushed, eyes half closed, pupils rblled upwards, equal, respond to light. Conjunctiva^ injected ; wrinkles on the left side of the mouth slightly more marked than on the right- Patient is very stupid, will not protrude the tongue when asked to. When asked questions, several times made a noise as if trying to answer, but seemed unable to speak. Fnable to move right baud, arm, or leg. The arm or leg can be placed in any position without movement. When asked sharply to move the arm he pulls it with the left hand. Cutaneous reflexes present on the left side, absent on the right Marked ankleclonus on the right side; bicipital reflex increased ou the right. Patellar and tricipital reflexes not markedlv increased on the right. Pulse 80, regular, of moderately good strength." 13,10,88. — "This morning the condition of the patient is about the same. In the sputa-cup is about an ounce of a viscid, finely aerated mucous and blood-stained expectoration ; a purulent matter. Some of the blood in streaks, some rather intimately mixed and dark in color." 14, 10, 88. — " Yesterday afternoon and to-day the patient seems to be brighter: smiles when spoken to; tried to siwik, but is unable to articulate words." 18, 10, S8. — On this date the temperature, which had been gi-adually falling, reached the normal }K<int, and the following note was made : " The patient is decidetlly brighter; when spoken to he seems to understand what is said, but shakes his head, indicating that he cannot sjieak, Caiinot protrude tongue, but opens his mouth better: the drawing of
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the mouth to the left side has grown much more marked. On more careful examination it seems much more doubtful whether he understands the remarks made to him. He looks brighter, but on a more careful examination he appears to shake and nod his head, usually nodding without regard to the question asked." (It maybe said that the nurses who were constantly about him were convinced that he understood perfectly what was said.) 20, 10, 88. — "Temperature normal. From the 2.5th to the 7th of November patient had slight rises of temperature and cough with the blood-stained expectoration and evidences of a consolidation at the left base. On the 30th of October he was able to protrude his tongue.'" 13, 11, 88. — " Improving; bright and cheerful ; cannot talk ; makes a meaningless noise to attract one's attention ; cannot copy any noise or word." 27, 11, 88. — "There is still moderate dulness through the left side, with somewhat modified respiration and medium and coarse rales on inspiration." 3, 12, 88. — " Can turn over in bed." 6, 1, 89. — " Can pull himself up in bed and stand alone." 10, 12, 89. — " Can say a fewwords indistinctly ; can write his name with his left hand." 11,1,89. — "He desires to go home; can walk fairly well, though cannot go up and down stairs. Can understand what is said to him apparently perfectly well ; reads the paper, can say but a few words. As far as can be seen, understands the use of articles shown him but cannot name them. Can move right arm from the shoulder, but can move muscles of forearm but little; is bright and cheerful, but sometimes cries when he fails to do something which he attempts."
Case 2. — J. P., 10 years of age, school girl, was admitted to the Massachusetts General Hospital on the 21st of November, 1888, with characteristic symptoms of typhoid fever of five days duration. The urine was free from albumen. Rose spots were noted for the first time on the 25th of November. On the 9th of December, the twenty-third day of the disease, it was noted that the patient was " dull, in a typhoidal condition ; defecation and micturition involuntary." 10,12,88. — " Yesterday afternoon the nurse noticed that the child did not answer questions and lay persistently on the right side. This morning cannot speak; a])parently understands questions; tongue protruded straight when asked; no facial paralysis; motion and sensation m legs good; right arm and hand are moved slowly and with difficulty ; grasp of right hand decidedly weaker than left; rellexes apparently not exaggerated." 13, 12, 88. — "To-day made a few sounds; nurse thought she said 'milk.'" 16, 12, 88. — "Has said several words this morning; calls 'nurse'; cries out; smiles when spoken to, evidently understands what is said; uses right hand and arm almost as well as left." 20, 12, 88. — "Talks a good deal; says, 'yes, yes,' and 'no, no' to herself." 27, 12, 88. — " Talks more and expresses herself fairly well." 4, 1, 89. — "The temperature was normal to-day for the first time." 18, 1, 89. — The patient had been up and about, but while she talked and understood what was said, she appeared decidedly weak-minded and irritable; very dull; it is noted that she "still seems stupid and weak-minded." 23, 1, 89. — "lias been doing perfectly well; walking about; hungry all the time; mentally still stupid and below par. Two days ago insisted that one of the patients had stolen her clothes and
that she had been sent for to come home. Mother came for child to-day and she was discharged."
Thus, in each of these instances, during the height of an uncomplicated typhoid fever (10th and 2-ith days), in young and robust individuals, there appeared suddenly a right-sided hemiplegia with complete motor aphasia. In neither case were there convulsions.
I had not seen another instance of this nature until the case of my unfortunate colleague, to which Dr. Blumer has referred. The lesion in each of the Boston cases was probably a thrombosis; there were none of the ordinary sources for an embolus; the heart was in good condition in each case. Artei-ial thromboses, though rare, do occur in other regions, while venous thromboses are, of course, common.
Meeting of January 20th. Dr. Flexnee i7i the Chair.
BOOKS RECEIAED.
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. VII.- Nos. 62-63.
BALTIMORE, MAY-JUNE, 1896.
+++
Contents
The Anatomical Course and Laboratory of the Johns Hopkins University. By Franklin P. Mall, 85
An Outline of the Course in Normal Histology and Microscopic Anatomy. By Lewellys F. Barker, M. B., and Charles K. Eardeen, 100
The Photographic Boom and Apparatus in the Anatomical
PAGE.
Laboratory of the Johns Hopkins University. By A. G.
Hoen, M. D., 109
Adeno-Myoma of the Round Ligament. By Thumas S. Cul LEN, M. B., 112
A List of Scientific Medical Journals in Public and Private
Libraries of Baltimore, compiled by Miss E. S. Thibs - - 111
THE ANATOMICAL COURSE AND LABORATORY OF THE JOHNS HOPKINS UNIVERSITY
By Fkanklin P. Mall, Professor of Anatomy, Johns Hopkins University.
Three years have now passed since the teaching of anatomy was begun at the Johns Hopkins University. A number of radical changes were introduced into the course, and during the first year a new anatomical laboratory was constructed. The methods of teaching, as well as the laboratory, I believe to be a success and therefore make the following publication.
The literature on the construction of anatomical laboratories is extremely brief. Descriptions of some of the European iustitutions have been published in detail, and T have found that by llis* the most valuable. He describes a carefully planned building accurately, giving aims and ideals as well as difllculties to be overcome. In America we cannot boast of the multitude of buildings erected especially for the teaching of anatomy and investigation in this subject. This lack is to be the more regretted because we have nuuiy problems peculiar to this country. Our students and our climate arc both unlike those in Europe, and yet in our many medical colleges the most fundamental branch in medical science is treated in a very sliaineful way. The dissecting room is as a rule poor, while the laboratory facilities for microscopical study are usually wanting altogether. A few of our leading institutions are marked exceptions to the above statement.
The object of the laboratory is to teach students, to train investigators, and to investigate. Although the first mentioned requires the greater portion of the instructor's time, its importance is by no moans as groat as the second and
'His, Zeit. f. .\natomie, Bd. II, 187
third. A subject like anatomy, tsmght for many centuries, has recently been made a new science through the studies in embryology and histology. The studies in embryology have gradually become more and more comparative in nature, and in turn have influenced to a very great extent our conceptions of comparative anatomy. The great influence of histology is not yet fully felt outside of the study of the higher animals, but its importance has been shown over and over again in the branches fundamental to medicine.
The laboratory method of instruction has become vcrj firmly established in many of our colleges in their undergraduate courses, but in medicine the results are yet taught to a great extent by means of lectures. Our problem is the study of the structure and the development of the parts of the human body, utilizing all the methotls at onr disposal to instill these facts into the student's mind. The aim is to make the course one continuous problem for each student to investigate, aiding each one with good material, and tejvching him how to study, wherever necessary.
The instructor soon leiirns the value of investigation, even in the dissecting room, and with this ideal constantly in vie»% he soon imparts a portion of it to his students. When anatomy is studied in this way, the student must indeetl be stupid not to discover the many defects as well as errors in some of onr favorite English text-books.
No subject has been taught more carefully nor in greater detail than anatomy. It hiis l>een taught by the greatest minds, and has been presented by means of printing and
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[Nos. 62-63.
cugraving ever since these arts have been invented. Yet in looking over the history of men like Vesalius and John Hunter, one is struck with the fact tluit they taught it from the human body. They had their battles to light and even to risk their lives to procure human bodies for dissection. They had to antagonize the prejudice against dissection at that time, as nuiny of us in America must to-day.
But with all the good examples shown us by our great predecessors, the tendency has been to teach more and more by means of lectures ; and although dissection has grown very popular, it is usually done very poorly and sometimes not at all. In Europe the lecture courses have, in many universities, become gigantic in extent, and the only thing which can stop any of them is a total lack of students.
I have asked many professors, even of anatomy, where they had learned their anatomy, and in nearly all cases tlie reply was " in the dissecting room."' They all admitted that in addition to demonstrations, lectures were of little use to students, and some believed them worse than useless. The zoologists and botanists have long ago learned the absurdity of the lecture method of teaching, but the anatomist patiently keeps up this slow and stupid method of instruction. It is stupid because no anatomist would use this same method if he were to learn instead of to teach. ,
We know very well that the burden of responsibility is removed, to a great extent, if the instructor goes over the whole subject carefully once a year. He then can tell his student to go to the dissecting room to see for himself, li the student does not attend the lectures, the professor carries no responsibility, no matter how uninteresting or uninstructive they may be. Yet the beauty of the courses of lectures is that the professor carries no responsibility if the student does not know his anatomy.
I believe that there is but one way to learn any subject, and that is through study. The very name shident tells what the person so named should be doing; and with a natural science, dealing with a most complex object,- extending through the three dimensions of space, any other method besides studying the object itself is practically useless.
Lectures with demonstrations arc certainly valuable — more valuable than the lectures with text-books alone. Yet analyzing the object itself is infinitely more valuable than to watch the results exposed by another. Wrestling with the part which is being studied, handling it and viewing it from all sides, and tabulating and classifying the parts worked out, give us the greatest reward. All this may be accomplished by practical laboratory work. If we can make the student work thoughtfully and carefully, a great result is achieved. It makes of him an artist, an actor, an expert, not a dilettant. He is upon the stage, not in the audience.
If, now, all the energy which is expended in conducting extensive lectures is employed in managing a dissecting room, we will find to our astonishment that this ideal can be reached in a certain number of cases. It is not difficult to keep account of the many details of the work, for there are many people in business who easily manage much greater accounts with precision. So this difficulty must be placed aside as one easily overcome. In our laboratory we can tell, though asked
at almost any time, what any of the 70 students have done during the year. Also we can give the complete history of any of the subjects dissected. For instance, in Subject No. 70 the first lumbar nerve arose in such-and-such a way and was distributed through the branches to certain regions. It was dissected by Mr. Smith during a certain month. There were in this subject 34 vertebra? ; it was white; a male, about 50 years old ; was embalmed with carbolic acid and had been in cold storage for 15 months, etc. Mr. Smith's dissection was excellent, good, indifferent, or bad; his knowledge of the subject was also excellent, good, indifferent, or bad; he dissected certain parts poorly, others well, and so on. These records are all kept by the various instructors and are finally recorded upon cards, each representing the part dissected. This method is cari'ied through for osteology, histology, neurology, and embryology, and finally, when the student appears for examination, we have his complete record before us.
In arranging the course on anatomy at this University, very great stress was laid upon the microscopical work. Although this course is conducted separately and independently of that in gross anatomy, they are, however, adjusted to each other in every respect. Much of the advance in modern anatomy is due to the microscope, and we believe that if an anatomical course is robbed of this sub-dejjartment it loses its most important support.
In many of the medical institutions of this country, histology is not in charge of the department of anatomy, and often is not represented at all, or at best by too brief a course.
In Europe, histology is often an independent department (as in Austria), or it is frequently subordinate to physiology. There is no harm whatever in giving a histological course in departments other than anatomy, but anatomy must not be robbed of its privilege of conducting such a course. Histology has found its home principally in Germany, and in that country every anatomical institute has associated with it histology.* Waldeyer says that anatomical instruction and research should be carried on as far as possible with the naked eye and then continued with the microscope.f This has been our ideal in the planning of our course and in the construction of our laboratory. When a course is conducted in this way it requires much space, extensive apparatus and a large number of instructors. In Leipzig much space is saved in utilizing the same room for both courses: anatomy in the winter and histology in the summer. J This gives an abundance of room for microscopical work, for in all cases more space is required for the course in gross anatomy than for histology. In the Leipzig laboratory a special room containing a floor space of 1 14 square metres had been constructed for histology, but it was found to be too small, and the course had to be transferred to the large dissecting room, which contains 210 square metres floor space. In Berlin 300 students must be accommodated, and two parallel courses are given in a room containing 153 square
- Seo AVakleyer in Die Deutschen ITniversitiiten (Report to the
University Exhibit at Chicago, 1893), Berlin, 1893, Bd. II.
f WaUleyer, AVic soil Man Analumie lehreii und lelirnen, Berlin, 1884.
X His, ZeitBchriftfur Anatomic und Entwicklungsgeschichte, 1877.
Mat-June, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
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metres of floor space.* But WiiUleyer deplores the fact that they are cramped iu space, which is a very serious difficulty.
Our histological laboratory has an area of 150 square metres, and is intended to accommodate 50, or at the highest 00 students. If necessary other rooms may be used for the same purpose, which will enable us to instruct a much greater number iu histology. Each student is supplied with a working place and locker, containing in addition to Leitz microscope II with Abbe condenser, a suitable dissecting microscope. All the necessary reagents are obtained in the labora
projection of specimens are employed whenever necessary.
In a general way we dissect as far as possible in the dissecting
room, and continue with the microscope in the histological
laboratory.
During the first year a practical course was given iu the embryology of the chick, but it was found unnecessary to continue this with many of the students, as most of them have had an extensive course on embryology before they begin the study of medicine. However, embryology is alluded to frequently in our courses in practical anatomy and histology.
Fio. 13.
JI/^, Macerating room. LW, Light well. CI, Closets. E, Elevators. BB, lUeaching balcony. The doited rectangle as well as the S(iuare over the stairs mark the light wells in the central portion of the building.
tory. The course extends through 15 hours each week, from October 1 to March 15, but most students do some work during odd hours, as the laboratory is open all day.
The aim, throughout the course, is to begin with the fresh tissues, and to end ultimately with nuiny of the complex methods in demonstrating the structure of difficult organs, like the brain. Suitable charts, models, dissections as well as
- Die AnstaUen und Kinrichtungen des olloiitlichen (iesiindhoitswoseusin i'reussen, 1890.
and each organ is also presented from the staudi>oiut of histogenesis.
Our laboratory has been desigued especially to curry out our ideals, and during it^ coustructiou we have coustautly kept before us the following poiuts:
Light.
Heat and ventilation.
Biisemeut planned to manage heat and for the reception of anatomical mat,erial.
Cold storage and embalming rooms.
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 62-63.
First Iloor, lecture room, etc.
Second Iloor for histology, which was planned in connection with the work ou anatomy.
Photography, dark room for reconstruction, chart-making, etc.
Reseai'ch and preparation room. I'rivate rooms.
Third floor to contain a multitude of dissecting rooms, each complete in itself.
A study room.
Models displayed in the rooms when needed.
Suitable lockers and rooms for the use of students.
shaft, in which are placed the stairs and the elevator (see Fig. 13). This gives an abundance of light for the stairs and the ujiper floors, but we did not trust to this light alone for the illumination of the halls. There are about as many windows as jjossible in the building. They are wide, and reach nearly to the ceiling, thus giving ample side light for each room. The large rooms ou the north side receive light from all three sides, thus making it possible to work with the microscope in any })art of the room. Over each door entering the hall there are large transom windows, which aid in the illumination of the halls. Ou the first floor the hall is illuminated with a special
Third Fi_ookFL:ah
i. J. ->. « 6. y.
Fio. 10.
DR, Dissecting room. SB, Study room. C, Cases. L, Lockers. E, Elevators. The (lotted rectangles around DR indicate tlie e.xtent of the light wells. The lighter partitions indicate tliat the walls are fhin and
can be removed easily.
An abundance of storerooms. Storeroom for combustibles.
Animal house and aquaria.
Bone room.
Light. — The great majority of laboratories are very poorly lighted, and this is a very serious defect. In many of the American medical colleges the dissecting room is on the top floor, with an additional skylight. This is a most superior method of illumination, and we have adoj)tc-d it not only in this laboratory but also in the pathological.
First and foremost in the building is a great central light
window, thus giving all of the halls throughou' the building splendid light.
Each room on the third floor has, in addition to this abundance of side light, a large skylight (see Figs. 10 and 13). The rooms are protected from the cold by a special layer of glass on the level with the ceiling. These light shafts communicate with the attic floor by means of windows, which give additional light to this floor, and give an entrance to this shaft from the iuside of the building to clean the skylights.
May-June, 1896.]
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The balcony on the fourth floor connects with the fire esciijies as well as with the roof, so it is possible to go to any portion of the building as well as through the ventilating shafts without constructing any scaffolding or breaking any of the walls.
Heat and Ventilation. — The heating and ventilating systems of the building are very perfect. Cold air, obtained through the windows of the basement, is heated by means of steam
The ventilating system is by means of two large central shafts, which grow larger and larger as the top of the building is reached, to make room for the additional air entering the shafts from the upper lloors. In the center of the north shaft is the smokestack, and in the other the steam exhaust from the engine. In addition to these pipes there is a steam coil in each shaft which aids to heat the air in the shaft,
CB.
Basement Flt^w.
«o fj
» 3. * .f. 6. 7. «
Fig. 1.
tank, .ite
A Driveway, /i^, Refrigerating apparatus. C, Condenser. £^ «£- C, Engine and compressor. /', Pump. i?. Brine tan iJfl, Refrigerating room. S, Shelves. A7i', Emlialming room. j1/^/J, Machine room, i?/', Hoiler pit. T, Toilet Pr, Privs toilet. K, Elevator. CI, Closet. JT, Janitor's toilet. JR, Storage room. I', Cbemical vault. CB, Coal bins.
The figures 1, 2 and 3 in the boxes communicating with the hot-air shafts indicate that the shafts communicate with the first, second and third floors respectively.
coils and then allowed to pass to the rooms through shafts in the outside walls. The Arabic figures in the Basement Plan indicate the tkiors with which the shafts communicate, 1, to the first floor, and so on. Kach room in the building has its own hot-air shaft, and in no case does one shaft go to two stories. There is an abundance of heat, which can be cut olT from the room or from the basement, as will be described further on (see Fig. 1).
making a constant upward current of air (see various (Jnuind Plans).
In all cases the communication with the shaft is near the Hoor of the room and on the side of the room opposite the entrance of warm air. The ventilating registers of the larger rooms near the sh;ift enter it directly, while those soine\yliat distant pass up the partition walls and communicate with the shaft immediately below the rooi (see Fig. 13).
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[Nos. 62-63.
During two years" experience we have never had gases or odors to enter the shaft and to come out again on the floor above or below, as the suction force of the shaft is suflicleut to carry everything entering it to the outside of the building.
The macerating room as well as all of the closets have their own special ventilating shafts communicating with the roof, as the laws of Maryland prevent their being connected with the main shaft.
The elaboration of the building was made by Jlr. Archer,* and that of the heating system by Mr. Xewton of the firm of Bartlett, Ilayward & Co.f I am under obligations to Mr. Archer for the interest he has taken in our problem, as well as the willingness he has shown in adopting plans to overcome our dilllculties.
The Bdfscmoit. — The basement is partly above ground on the south, and wholly above ground on the north side. Its plan is shown in Fig. 1. On the north side there is a drive, D, through (he whole building, which facilitates the handling of bulky apparatus as well as the reception of anatomical material. This drive is one of the most jiractical arrangements of the whole building. Very close to the drive is a sub-basement containing the boilers, BF. Communicating with the boiler pit is an arched vault, C£, extending below the sidewalk, which can be filled with fuel from the street. A hall extends through the basement, and from this the elevator, £, communicates with all the floors above. In addition to this there are the embalming room £R, the engine room EA, storage rooms JR and CL, cold storage vault RE, chemical vault V, machine shops MR, and toilet rooms T. The dark parts of the basement and the vaults are illuminated with electric light.
The whole system of heating, as well as the hot and cold water pipes and drainage, are all exposed in the basement. Nothing is buried and out of reach. A certain number of windows are utilized to obtain the air from the outside, by boxing them off with a large second window. This space communicates by means of large shafts with the sheet-iron boxes containing the steam coils. From these boxes the hot air passes through the hot air shafts to the various floors above, as indicated by the figures 1, 2 and 3. Each room is heated with its own shaft, and each shaft has its own hot air box. The circulation of hot air can be regulated from the room above as from the hot air shaft below. Moreover, the steam for any shaft or set of shafts can be cut off by closing the valve of the steam pipe passing to the respective hot air boxes
Tliere are two boilers, either or both of which may be run iit high or low pressure without interfering with the heating apparatus. Whenever it is necessary to operate the engine it is necessary to run at least one boiler at high pressure. The capacity of the boilers and engine is sufficiently large to operate any machinery we may need in future.
The garbage of the building is all crenuited in the basement.
- Mr. George Archer, Central Savings Rank Building, I'.altimore, Mtl.
t Bartlett, Ilayward & Co., Kaltimore, Md.
77ie Preservation of Anatomiral Material.— The supply of anatomical material for dissection and the laws regulating it in Maryland are such that it influences materially the plan of our course in anatomy. Not only is the material scarce, but our most abundant supply is obtained during the summer months when the weather is extremely warm. These facts compel us to resort to rigid methods in its preservation as well as in its dissection.
We have tried a great variety of methods to embalm bodies and find none more excellent than the carbolic acid mixtures. Even the formaldehyde solutions appear to be inferior to it. I prefer to use enough carbolic acid to coagulate all of the muscles, as this destroys the odors completely, and then the parts will not decompose while they are being dissected. This is accomplished with about one kilogram of the pure acid diluted sufficiently with alcohol and glycerin. It is well to mix them in thirds, or in the ratio of one of acid to two of glycerin and two of alcohol. Simply injecting this fluid into a large artery with a syringe by no means sends the fluid to all parts of the body in every case. It is necessary to inject it gradually under a constant pressure. In our laboratory we have a constant pressure apparatus in the embalming room, which can be regulated with ease up to two atmospheres (Fig. 2). About 5 to 7 lbs. to the inch pressure are usually sufficient to distend all the arteries of the body thoroughly. With this pressure about 4 to 6 quarts of the fluid is gradually forced into the femoral artery. A double cannula is em]doyed, injecting both the peripheral and central ends at the same time. It is easy to tell by the appearance of the skin when the body is well injected. The coagulation in the skin about the neck and arms usually appears first, then the face, and finally that of the leg opposite the one in which the femoral has been cut. These marks indicate that the deeper parts have been well injected.
The body is now allowed to remain in the room for from 12 to 24 hours, when the second injection is made to color the arteries. I have never fully understood why the Europeans have had such difficulty in filling the arteries to their satisfaction for the dissection room. I find plaster of Paris colored with red lead eminently satisfactory ; it is easily handled and never flows from a cut vessel. We inject a very fluid plaster colored with red lead under a high pressure (about 10 lb. to the square inch). Two quarts of this fluid will flow into the arteries in the course of a minute or two, and then it is immediately allowed to flow out. This procedure distends all of the small arteries and leaves practically no plaster in the large vessels, for the plaster remains in the small arteries but flows out again from the large ones.
Subjects treated in the above-mentioned manner can be kept for a long time in almost any fluid, and also in an ordinary ice-box (40° F.). I have kept them in the latter for over a year, but there is a tendency for the feet and hands to mould. These are not perfect methods, aiul when they are employed they have a marked tendency to make the dissecting-room disagreeable and dirty.
When well embalmed subjects are placed in cold storage (l)elow 32° F.) they may be preserved indefinitely. Yet, siuiply freezing the subject does not accomplish the object
The upright tank is connected with the water main, from which it is filled, thus giving a large quantity
of compressed air. This is used to drive the embalming fluid into the arteries.
Fio. 3. Fi,.\sii-LiunT Photoquai'ii ok the KBrKioKK.^Tisc; .\rr.\R.vTis in the B.vsk.mknt.
The vault is on the left, as indicated in the sectional view. Fie. 4.
May-June, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
91
perfectly. We are iu the habit of believing that cold air is dry aud will prevent evaporation, but even at a very low temperature (20° F.) there is a marked evaporation. Our vault is cooled from above, and the slight difference of temperature between the floor and ceiling of the vault is sufficient to dry completely the fingers and toes of the subject in the course of six months. This moisture, which leaves the floor of the vault, forms into large icicles about the steel pipes immediately below the ceiling of the room.
I have often been struck with the remarkable property of the epidermis to prevent the drying of the skin, even after it has been in a warm room for several months. This property can be increased to a very great extent by oiling the skin, a method we employ altogether to prevent our subjects from drying while the dissection is taking place. Vaselin is much superior to oil, and after many trials we use it exclusively to keep the skin soft and moist, both in the cold storage and in the dissecting room.
After the body has been embalmed it is smeared over with a large quantity of crude and cheap vaselin, and then wrapped with the continuous roll of water-closet paper. A second coating of vaselin iu places over the paper covering the feet and hands and then the whole body is wrapped in muslin. This mummy-like body is now frozen aud preserved in the cold storage. I have now kept subjects treated iu this way for two years in the cold storage, and when placed upon the dissecting table they have all the appearance of fresh bodies. The wraps are not removed from the legs and arms until they arc about to be dissected; they prevent the skin from drying before it is removed.
My experience, therefore, shows that subjects may be preserved perfectly and in the natural condition for years with carbolic acid, vaselin, and freezing.*
The Freezing Ap^Jaratus and Vault. — In applying cold storage in our laboratory it was necessary to adjust it to the heating apparatus of the building. The boilers for heating Ibe building are 60 horse-power strong and are employed during the daytime of the winter only. It was necessary that they be high-pressure boilers, while the heating apparatus of the building requires low-pressure steam. If this could not be the case it would be necessary to add au additional boiler, calling for, in all probability, an additional fireman with additional expense for coal during the winter. This difficulty was overcome by the introduction of a reducing valve between the boilers aud the heating system, which reduced the steam pressure to about one atmosphere for the heating, leaving high pressure iu the boilers for the engine. The exhaust steam from the engine is allowed to escajie into the heating apparatus, and thus performs an additional work in heating the building after it comes from the engine. An automatic pump forces the condensed steam back into the boilers.
The entriueer is in llie ImildiuLr durinii' the daytime only, so
- Tlie iliJTerent vnethdil.s I'lnployoii in tlie viuions nu'iliojil colleges
in America for the preservation of aniitoniioiil material have liecn imlilishoil recently by a eommitico appointcil liy the .Vssociation of American Anatomists, Science, Vol. '^, IWKi.
we desired to construct our apparatus in such a manner as to accomplish the work for the whole twenty-four hours by operating the engine during the daytime only. If this were not the case it would cause a considerable extra expense to run the machine all night. This obstacle w'e overcame most successfully. In fact our ice machine and vault can do all the work we desire of it by working but a few days per week.
Then the apparatus must be relatively inexpensive. Before decidiug upon the machine we purchased, \ve communicated with a number of firms, and believe that we have procured the cheapest as well as the best. Our machine and vault were constructed by the Remington Machine Company of Wilmington, Dehnvare, and cost considerably less than .$4000. The cost of operating the machine in addition to our ordinary expense of heating the building has been less than $100 per year. The capacity of the vault is about 200 subjects, but can be enlarged sufficiently to supply all demands.
We purchased a two-ton machine, i. e. a machine whose refrigerating capacity in 24 hours is equivalent to 2 tons of ice; a photograph of it is shown in Fig. 3. This machine much more than fulfills our requirements, and may ultimately be used to cool a number of working rooms iu the summer. Yet it is very desirable in the construction of any apparatus to have an excess of force at hand. Of the two systems employed for refrigerating a room we selected the indirect. In the direct method the compressed anhydrous ammonia is permitted to escape into coils of pipe suspended in the room through which the heat is absorbed. In the indirect method the coils of ammonia pipes are immersed in brine which is first cooled, and this cold brine is iu turn pumped through a system of pipes suspended from the ceiling of the room (see Fig. 4).
In our apparatus the ammonia expands into a long coil immersed in 5 tons of strong calcium chloride solution, B. The operation of the engine, E, first cools this brine, which is now forced by an additional pump, P, through the pipes, b, along the ceiling of the vault, as the figure shows. The tank of calcium chloride brine is placed within the vault, and then when the nuichine is not running this great quantity of brine absorbs the heat which gradually enters through the insulated walls.
The vault is well constructed with a number of layers of boards, air spaces and mineral wool, as the diagram shows. Each layer of board is covered with one or two layers of paper ; the outermost layer is tarred. The door is insulated in the same way and is over a foot thick. The interior is illuminated with electric light. There are thermometers on the outside wliich read the temperature of the brine as well as that of the air of the vault.
We found that in the beginning it was necessary to operate the machine for 36 hours continuously to reduce the temperature of the vault to 32° F. After this au additional run of the machine for S hours reduced the temperature of the vault to 20° F. During this time the brine was circulating constantly througii tlie tubes suspended from the ceiling of the vault. The temperature of the brine at this tijue had fallen to 0° v., and we have never atteniptetl to reduce it lower. With the vault at 20° F. and the brine at 0° the machine may
remain quiet for a whole week, at the end of which the tem})erature in the vault is 33° and that of the brine 25°. When the
temperature of the vault has risen to 32° it is desirable to
cool it again, because opening the vault fre(iuently causes
thawing, thus making the room very sloppy.
I have now taken the temperature of the vault, brine and
outside room twice a day during a whole year, with the time
the engine was running. The above table is a portion of this
record.
The chart is not as complete as might be desired, for the brine temperature is not given for the time in which the machine is not running. This was not easily done, for it was necessary to start the engine to obtain the temperature of the brine. Our method of managing the apparatus is not to open the vault very much while the engine is not running. When the vault is opened frequently during the day its temperature rises rapidly and necessitates starting the machine. The temperature records of December 2d and 3d are accounted for by the frequent opening of the vault.
After we are accustomed to a cold-storage plant for the preservation of anatomical material it is difficult to understand how we ever got along without it, as difficult as it is to get along without a microtome. It makes us commander of the situation for all times of the year.
In our anatomical course we employ extensively pigs' hearts and lungs, sheeps' heads and other material obtained from the slaughter-house. These materials are frozen and kept ou hand constantly. The same applies to preservation of dissections during the holidays when students cannot attend to them. More important than either of these is the preservation of large dissections used in teaching. It dispenses wholly with the large alcohol vats. The large dissections are wrapped in vaselined cloths and simply labeled. It is as easy to manage such dissections as it is to care for a large model. Furthermore, the vault may be considered a large freezing microtome for cutting cadavers, or even for cutting serial sections on an ordinary microtome. And last, but not least, we preserve cadavers not suitable for dissection, as well as carciisses of animals until we are prepared to make skeletons of them.
Before we decided to adopt cold storage we obUiined manv valuable hints fi-oui Professor Huntington of Columbia College, New York, who luid emidoyed a machine similar to ours for a greater length of time. I am under many obligations to him for valuable recommendations. Yet our apparatus can be improved in a number of ways, the most important of which I Ijelievc to be the construction of two vaults, one within the other ; the inner vault to be surrounded completely with the cold brine and to be used for freezing the bodies ; the other vault to be used for preserving purposes, and to be kept at 32° F. or slightly below. In this case the engine could be used to cool the brine about the inner vault whenever necessary. Moreover, the outer vault should be surrounded with a brick or stone wall, as the expausiou and shrinkage of woixl are too great. This expansion is very marked and causes destruction of the insulation, and tinally of the whole vault, I should also cover the lloor with zinc or some metal and have it drained. It is necessary to clean the vault about once a year and the extensive thawing is very injurious to the floor.
Groinitl Floor. — The lirst lloor is occupied temporarily I'V the rharmacological Pepartment, It contains a large room ultimately intended for microscopical work, but at present used as a lecture roi>m. There is also a combustion room, a library, a chemical laboratory, au experimental room, and a private
94
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 62-63.
room. Tbrougli the kindness of Professor Abel the experimental room is used by the advanced workers in anatomy. It is fitted up with the necessary apparatus for registering blood pressure, for artificial respiration, and so on. The motor-power is obtained from the engine in the basement.
Hisfolor/iral Lnborafori/.— The histological laboratory is constructed with light on three sides in order to have the maximum working space. The main side faces north (Fig. 6). In all there are 15 windows in the room, giving window space for 30 students. The east end of tlie room is shown in Fio-. 7.
room, which is practically the interior of a microscope, and are shown what they are expected to study.
It is the aim of this course to illustrate the general anatomy, as is often the case in systematic lectures, with demonstrations and specimens. During the first half of the course fresh specimens are studied almost altogether, and throughout the course frozen sections are given the class with each organ.
We have a great abundance of pigs' embryos, which can be obtained by the hundred every day. These are used a great deal in studying the histogenesis of the organs.
Fu). f). LEG, Lecture room. CL, Cliemical laboratory. PL, Private lalwratory. EL, Experimental laboratory. L, Library. CR, combustion room. CI, Closet. U, Hood. C, Cases. Ta, Tables. S, Shelves. D, Desk. JH, Klevator.
The full capacity of the room is 50 or 60, the additional students to be jilaced in the middle of the room. Each student is furnished with the necessary outfit and a Lcitz microscope. Stand II, with Abbe condenser. Students are permitted to take the microscope from the building, as each one is personally responsible for everything placed in his charge. Each student has also a dissecting microscope.
The lectures are given in the laboratory with necessary charts, models, and gross as well as microscopic specimens to elucidate the subject. AVhenever necessary, as in the case of the medulla oblongata, they are all taken into the photographic
In addition to the systematic course given there is an optional course in technique. The class is divided into groups of ten, and each group takes up a class of tissues like the alimentary canal, and so on. The course is not the same from year to year, and this variation proves to be most instructive to the students. They enter the course with enthusiasm and profit a great deal by it. They aid materially also in the preparation of the specimens for the class. Although this course is optional, practically all the students take it.
Throughout the course students are encouraged to read a few special nionograjihs. They soon grow beyond the text
I'lc;. ,. Ill^l.rl.ijiiH AL Lai.uJIAT' iK', ,,.N 1 11 1 .--(■.(■■NK 1 (■"lii
Fic. S. South End ok thk PitErARATios Room on the Skcosd Floor.
The apparatus ami reagents wliieli are used in common for all kinds of histological preparation are in
this room.
Mat-June, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
95
books, and by this reading gain a much better idea of the scope of histology. We find that with the research method of teaching we can lead the student much further into the subject than without it. Students do better work when you expect much of them than when you expect little.*
Preparation Room. — The jirej^aration room is located conveniently about the center of the building, and is used for all the work of the advanced students, and for the preparation of the specimens for the histological course (Fig. 6, PR, Fig. 8). It is fitted up with the necessary apjjaratus for the work
embalming room, this room contains the apparatus of Ludwig for fine injections made by Petzold.* The hood, arranged with hot and cold water and well ventilated, is intended primaril)' for the making of corrosion specimens; it also contains the automatic water still Vjy Stoelting.f There is also an incubator and a large parafllin oven, both made by Keen & Ilagerty.J The glassware of this room as well as all the jars of the building are after the same pattern, and have been made by Jalineke & Hofmana.§ The jars are all ground flat on top, and are either fitted with Hat lids with a knob or,
2 < — (^ «^
Seicohd TlookFlt^km,
/%/.
z. 3. *■. <f. <s. y a
Fig. fl.
UL, Ilistologioixl laboratory. PR, Preparation room. /'/., Private laboratory. DR, Dark room. .1, Light room. A', Projecting room. LD, Women's dressing room. T, Toilet. //, Hood. (', Cases. ^, Shelves. Ta, Table. A', Elevator. CI, Closet.
— a set of Griibler's sta'insf and other reagents; ordinary microtomes of ThomaJ and Schan/.e ;§ the Minot microtome by Zinnnermann,|| and the CO: freezing microtome of Hauscii and Lomb.^l In addition to the large injecting apparatus in the
•The details of this course arc given by Barker aiiil H:irileen, Johns Hopkins Hospital Bulletin, Baltimore, No. (i2. t Dr. (t. (iriiblor & Co., l?ayerische Str. li)>, Leipzig, (iermany. X U. .Tung, Landhans Str. 12, Heicielborg, Germany. ^5^1. Solianzc, Brnder Sir. ^\?<, Leipzig, (Iermany. II E. Zimmormann, l-'milieii Str. 21, l.i'ipzig, Gormany. t Bauscli & Loinb Optical Co., Rochester, New York.
as in the case of the large jars, with ground plate glass. Along the wall there are a nunilnM" of lockers for advanceil students* microscopes, etc.
In the center of the room are two large preparation tables, drained to a central sink, with hot and cold water .and pis. These are extremely useful for all kind of work, irom Itoil
•N. Petitold, Bayerische Sir. 13, Leipzig, Germany.
fC. U. StoiUing Mfg. Co., l^.-^ South Clinton St., Chicago, III.
t Keen A llagcrty, Baltimore, Mil.
§.Iahneke & llofraann, Fraueuwald in Thiir., Germany.
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JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 62-63.
ing of reagents, or making wax plates, to distilling alcohol. This room is among the most active in the building, and takes the place among the advanced students which the dissecting room does among the beginners. It is tlie general shoj) of the laboratory.
While there has been a great agitation in Europe for a Siudienzhnmer, I believe that the great need is just such a room as I have described for advanced students. We have also a study room, but it loses much of its force, because all the dissecting rooms are study rooms. Yet Ave have one room where the student can make shorter dissections and study preparations.
Pholography. — Optical apparatus in connection with ])hotography is such an essential to morphological research that before our laboratory was designed we purchased the large Zeiss outfit, with modifications similar to those I have had made for the University of Chicago four years ago. This apparatus had designed for it rooms as shown in Fig. 6, A, the idea being to enter the "camera" for all kinds of work.
AVe have, however, made a number of alterations in the electric light as well as in the screen for the reception of the picture projected. Dr. Hoen has had adjusted to the Zeiss apparatus a lamp of 4000 candle power, for alternating current, which is most satisfactory in every respect.* We have a set of lenses which enables us to enlarge any picture from one diameter to two thousand, and a movable screen aids us to obtain a given number of diameters easily, which is necessary for reconstruction work.
Our jihotographic lenses have been made by Zeiss, and tliey are interchangeable from the ordinary camera to the Zeiss camera, as well as to the lens holder on the large Zeiss projecting apparatus. This last arrangement enables us to use these lenses for the pi-ojeetion of histological sections as well as for lantern slides.
This room is perfectly dark, thus permitting us to expose a negative or a bromide by simply attaching it to a screen as described by Ilis.| The screen we employ is movable and very simple in its construction. It is more fully- described by Dr. Hoen. By opening the blinds daylight is admitted into both projecting and developing rooms. We thus have complete command of the light, enabling us to use the rooms for a variety of purposes.
Private Rooma. — The rooms marked P, L, and A, on the second floor, :i8 well as three rooms on the south side of the third floor, are used as private rooms for advanced students at present. The arrangement of one of these is shown in Fig. 9. The fact that the furniture and cases are only loosely attached to the rooms enables us to rearrange the whole laboratory from time to time as circumstances demand.
Disaccling Rooms. — The traditional large dissecting room has been abandoned altogether. As a substitute for it we have nine small rooms, the largest one to hold eight or ten dissecting tables, while the smallest room holds but one table. The upper floor was at first constructed as two large and two small
- Hoen, The I'liotographic Room of the Anatom. Lab., Jolins
Hopkins Hospital Bulletin, Nos. G2-03.
tllis, Mikroiihotoj;raj)hiselie8 Apparat. il. I.eipziger Anatoniie, Leipzig, 18!i2.
rooms, and after the building was finished the additional rooms were made by inserting thin partition walls, as shown in Fig. 10. This arrangement facilitates enlarging the rooms at any time if necessary.
The criticism has frequently been made that it is difficult to discipline the students if an instructor is not always present. Our experience proves that this is not the case, as the students remain quiet and orderly witliout the presence of the instructor. They know that their only opportunity of learning anatomy is in the dissecting room, and generally utilize it. The universal opinion of the students is in favor of small rooms, and most of them prefer the rooms with but one table. The same order is insisted upon for the dissecting room as for the lecture room, and all are agreed that it is for the best. I allow the students to arrange their own dissecting classes, and always favor the good students by placing them in a room by themselves whenever possible. No smoking or loafing is permitted, and this again favors the work of the student.
Each room is fitted up with tables, chairs, book racks, hot and cold water, a sink, model cases, and a blackboard. In fact each is a study room by itself. Fig. 11 shows a corner of one of the smaller rooms. The floors are of Georgia pine, and are saturated with paraffin once a week, and are usually kept very clean. As soon as they become slightly soiled they are scrubbed with lye and saturated with paraffin again. Each room has a skylight, which, with the addition of the great number of windows, gives a most excellent light in all parts of the room.
The subjects come into the room vaselined and wrapped as described. The extremities are kept wrajiped with the vaseline until the skin is removed, and when the body is cut the muscles are kept from drying by means of moist, but not wet, cloths. An excessive moisture favors decomposition and also soils the floor.
The course in practical anatomy begins immediately after the completion of the brief course on osteology. At the beginning of the session each student is loaned a skeleton for the year and also assigned a place in the histological laboratory. The latter entitles him to an outfit and the use of a Leitz microscope. Stand II, with an Abbe condenser, eyepieces I and III and objectives 3 and 7. During the second year a ^ oil immersion is added to the microscope. He thus has the use of a good microscope throughout his student time at this University.
During October the beginners are requested to arrange themselves into groups of twos or fours to aid the instructor in making up the dissecting classe's. The first subjects are dissected by six students, the two on .the head being second year students and working on alternate forenoons. The beginners start on the abdomen and chest. The weekly task placed before each student during the winter is about as follows. It must be remembered, however, that after the dissection is fairly well started each student works for himself and by liiniself.
Ill the following chart Class No. Ill is composed wliolly of second-year students. First-year students, wlio begin with Class No. I, usually dissect the whole body in 22 to 2G weeks.
Fig. 9. A Private Lajmratory us the SEoixn Floor.
Fill. II. IxsiDK View ok D.n'k ok the Disskctino Rooms ox the TniBP Floor.
May-Juke, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
97
APPROXI!\rATE ARKANlJBMENT OF THE COURSES IN (iROSS ANATOMY AND IX HIST(JL0GY.
20 TO 30 Hours per Week.
Osteology.
Spinal column
Upper extremity . . Lower extremity . .
Head
Head
Head
Class I. Abdominal walls . .
Lumbar plexus and thigb Back and gluteal region . .
Class II. Chest walls
Axilla.
Perineum (pelvis cut) .
Thigh
Leg and foot
Remove muscles . . . .
Front of arm
Back
Body divided.
Back of arm
Remove muscles .
Class IIL Superficial neck. . . .
Class II.
Class I.
Deep neck
Face
Sympathetics and heart
Back of neck.
Arm removed. Temporal and frontal region. . . Muscles of mastication & nerves
Tongue and larynx
Base of skull
Eye
Class I or II,
or
Special Dissection.
15 Hours pee Week.
HiSTOLOCY.
Vegetable cell and fibers
/ Animal cells, egg and germ \ layers.
Cartilage and muscle
Neuron
Blood
Blood-vessels, lympli and lym
pliatics
Bone
Connective tissue fibrils
Muscle
Alimentary canal
Alimentary canal
Urinary organs
Reproductive organs
Skin and nose
Eye and ear
Spinal cord
>iedulla oblongata
Medulla oblongata
Brain
Brain
About one-half of the lirst-ye;ir stiuleuts do not dissect the head until the second year.
All of the students have had one year each of jihysics, chemistry and biology before coming to us. Most of them have had a course in practical embryology. The course in embryology at this University is given during the spring of the year.
John Hunter has expressed himself that the otily way to learn anatomy was by dissection and dissection and dissection. We believe firmly in this method and add to it concentration. If any one desires to know tlie very essence of an investigator's spirit let him read the introduction of v. Bear's Embryology.* The feelings of a scholar are expressed on every page. His association with his instructors meant so very much to him. Later, in his autobiography,! he rehearses the early period of his life and says: " Often during my life then,J as well as later,§ have I doubted the wisdom of our university courses. It seemed to me that the whole system was wrong in that it compels us to take a number of courses for 45 minutes at a time in order to convert our information into a heterogeneous mass. Would it not be better if we could study one subject after the other, so that we could busy ourselves with one, or at the highest two, subjects continuously for several weeks?" He continues this thought furthcr,and finally states that whenever we wish to do anything thoroughly we do one thing at a time.
As a student I demanded the privilege of studying one subject at a time and was often envied by my fellow-students.
- v. Bear, Entwicklungsgeschichto der 'riiivre, Ki'migsberg, 1S2S.
fv- Boar, Nachrichten iiber I.rbm und Si-hriftcn, St. Petersburg, 186(1. 1:1815. § 18GG.
The privilege I then demanded I now gladly give my students and am extremely well gratified with the result Continuous individual instruction is not ea^y and takes much time, yet I believe that I can carry the plan through with a much greater number of students than I now have.
At present we devote 23 continuous weeks to gross anatomy and histology exclusively during the first year, and about the same time to the dissecting room duriug the second year. In later years the students may continue to dissect, and if they are especially desirous of studying a number of parts at the same time they are employed :is student demonstrators.
Our dissecting room is open every day from Monday morning until .Saturday evening, and with a class of 70 we have an average attendance of 30 students during all this time.
Each student keeps a complete record of all the nerves he dissects, and when he lias finished the parts he is examined ou what he has dissected before the muscles are removed. I keep on file a card for each dissection which ultiniat*.'ly receives all the notes the instructors have made of the ijuality of his work. This gives us a permanent record of all the work which is done by the student in our labiirator)'.
With all this precaution we still have poor students. First and foremost we are careful to admit only those students who have had a good training,* and then when they come to us
• From the Announcement of tho Johns Hopkins Medical School, for 18!V>-9G :
As candidates for the degree of Doctor of Medicine the school receives :
1. Those who have satisfactorily complete<l the Chemical-Biological course which le.ids to the A. B. degree in this university.
2. txraduates of approved colle.ires or scientitic schools who can furnish evidence : ((i> That they have a good reading knowledge of French and German ; (h) That they have such knowledge of
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[Nos. 63-63.
we give them an opportunity to work. Some, however, are not bright, and a few others are not inclined to work. They, of course, do not acconiplisli much, and I shouki feel inclined to hold our method of instructing them in anatomy responsible for it were it not that they do equally poor work in other departments where the lecture method is employed.
Study Room. — In recent years there has been an agitation in favor of teaching anatomy by means of a study room. This method is practiced in many universities by placing the objects used to illustrate a lecture at the disposal of the student after the hour; he can then take the specimen in his hand and see for himself. A few students utilize this opportunity, but it is only of much value to advanced students.
If now all these specimens and models are placed togetlier in one room which is at the disposal of the student, we have the study room as arranged by Rauber* in the University of Dorpat, or by Kollmannf in the University of Bale. Similar
physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.
Tlie phrase "a minor course," as employed in this university, means a course tliat requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory ; in chemistry and biology four class-room exercises and five hours a week in the luboratory in each subject are required.
.Many inquiries have heen received regarding the character and amount of the requisite training indicated by the term "Minor Course" in these sciences. In explanation, it may be stated, with respect to Biology, that the candidate should have followed for at least a year a laboratory course in the structure, life liistory, and vital activities of selected types of animal and vegetable life. In the Chemical-Biological course for undergraduates in this university the laboratory work in biology at present includes the study of such -types as amoeba, hiematococcus, yeast, penicillium, bacteria, mushroom, hydra, vorticella, a fern, a flowering plant, the earthworm, lob.ster, anodon ; the gross and minute anatomy of the frog, the development of its eggs, the structure, formation, and metamorphoses of the tadpole ; the study and drawing of the bones of the human skeleton ; the comparison of some parts of related vertebrate skeletons ; dissection of a mammal ; the field and laboratory study of some few flowering plants. The laboratory work is the more important i)art, the lectures and other exercises subsidiary. It is, of course, not to be understood that this curriculum of biological work must be rigidly followed. Equivalent work will be accepted.
The candidate should have followed a course in general Chemistry for at least a year. This course should include laboratory work, about five hours a week through the year, and lectures and class-room work covering the outlines of inorganic chemistry and the elements of organic chemistry. A good knowledge of the subject as presented in Kemsen's " Introduction to the Study of Chemistry" may be regarded as the minimum requirement. A fuller knowledge of Chemistry is, of course, desirable.
In Physics, the candidate should have followed a collegiate course for at least one year. This should include four hours a week of class-room work and at least three hours a week of quantitative work in the laboratory. Special attention should be given to theoretical mechanics and to the mechanical and electrical experiments.
3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of I'rench, TJerman, physics, chemistry, and biology above indicated.
•Rauber, ICntwicklung von Studiensiile, Leipzig, 1895.
t KoUmann, Archives des sciences physiques et naturelles, t. 28, 1892, and Verhandl. d. anatom. (iesellschaft, 1895.
methods of instruction are employed in the Austrian ixniversities, and I have observed their use in Professor Toldt's laboratory in Vienna. Professor Drasch of Graz also informs me that they were used extensively while he was a student. We are all familiar with the excellent exhibitions of anatomical specimens in the English laboratories and museums and appreciate fully their importance as recently emphasized by Prof. Keillor.*
A whole series of papers has been written during the last 20 years about the teaching of anatomy, and the universal opinion is in favor of teaching and studying at the same time;t to study the object from every standpoint. There has been a marked revulsion against simply giving the students the results of anatomy — the favorite method in America today. The references just given will be very instructive to the advanced students of anatomy and I recommend that they be read freely.
In the early part of this century RudolphiJ wrote an essay on the various methods of learning anatomy and gives an extensive literature on the subject. "Yet," he says, "it is wholly indispensable for those who wish to study anatomy to make their own dissections, for the best preparations made by others, the best plates, etc., cannot take the j^lace of specimens made by the students. It is altogether a different thing to have dissected the vessels and nerves for one's self and to have observed their relations, than to have simply seen the finished preparation in which the parts are more or less distorted." In this way Eudolphi continues in the most interesting manner.
In our laboratory we have set aside a large room as a study room, but find that there is no special demand for it as long as the students can make their own dissections. As soon as they have begun work it is easy to make them find most of the fine nerves as well as the sympathetics, and after the part is fully dissected it is taken to pieces systematically (and this is the review); then the ligaments are studied. We have made a study room of all of our dissecting rooms, and our Studieiizinwier remains as a room for special and briefer dissections. It is fitted up with coarse vises for holding sheeps' heads and useful things of that kind. When students desire to study the peritoneal cavity of a lower animal, to dissect or macerate hearts, or to dissect sheejjs' eyes, this room is used. Here they also study finished dissections and models which are at all times at their disposal. Throughout the dissecting rooms there are large cases in which are exposed many of the models and preparations of Ziegler,§ Steger,|| Benninghoven
• Keiller, New York Medical .Tournal, 1891.
■filis, AulTassung der organischen Natur, Leipzig, 1870; His, Aufgabe u. Zielpunkte der Wiss. Anat., Leipzig, 1872 ; Turner, Address at the Opening of the new Anatomical Department at the University of Kdinburgh, 1880; Hertwig, Der anatoniische Unterricht, .Tena, 1881 ; Schiefferdecker, Der Anatomische Unterricht, Deutsche Med. Wochenschrift, 1882; Kolliker, Die Aufgaben der Anatom. Institute, Wiirzburg, 1884 ; AValdeyer, Wie soil !\Ian Anatomie lehren un<l lehrnen, Berlin, 1884.
tUudolphi, Ueber Anatomie, Berlin, 1828.
JZiegler, Freiburg in Baden, Cermany.
llSteger, Thalstr. 21!, Leipzig, Germany.
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and Messing,* Anzoux,t 1"ranioiKl,| as well as the wire models of Abbe and Edinger.
The finer preparations of bones are employed to elucidate the course in osteology, and there is an abundance of loose bones at the disposal of the instructors. In addition to excellent mounted skeletons we have complete skeletons, which are loaned to the students for the whole year. If there is any breakage or loss of bones the student must pay for a new skeleton. The method of placing good specimens and instruments at the disposal of students works admirably when the responsibility of keejiiug them in good order rests upon the student. Whenever the student wishes to study the attachment of muscles or anything of that kind, a mounted skeleton is placed at his disposal in the study room.
The plan of the third floor shows the arrangement of the
women are in a special room on the second lioor. This room is also fitted np with a table, a few chairs, washstiinds with hot and cold water, and closets. The closets for the men are in the basemetit and the third floor, while in addition to these there is a private closet for each floor.
Store-rooms. — One of the most important adjuncts to a laboratory is an abundance of store room. There is on each floor a large hall room for the use of the janitor's utensils, laundry, and so on ; each is well ventilated. In addition to the cold storage we have two rooms in the basement in which to keep alcohol specimens during the summer and at other times when they are not in use. The whole fourth floor is one large store room communicating with the elevator (Fig. 1.3). A glance at the plan will show the arrangement. The central hall is illuminated by all the skylights of the building, thus
TloorFlah.
H.— (>
Fig. 14. The Animal House.
model and specimen cases. The models are well displayed and can be taken out easily to demonstrate any point as it may arise.
Lockers. — There are a number of hat and cloak hooks in the halls of the first and second lloors, where students can lay off their wraps easily before going into the histological laboratory or the lecture room. On the third lloor there are a number of lockers for men, with latches, but the padlocks must be supplied by the students if they desire to lock them. In the autumn the lockers are assigned to the students, who nuiy retain them for one complete year, thus giving them a place to lock up their things during the summer. The lockers for the
• Benninghoven and Messiii;;, Porotheenstr. 38, Herlin, Gerniiuiy. \ Au/.oux, Hue de Vauniard oti, Paris, France. ITiamoiul, Ivue de I'lOcole de Modeoine 0, Paris, France.
making it a very agreeable room to work in. In addition to this there are twelve large store rooms used for all kinds of bulky ware necessary in an anatomical laboratory. Special rooms are set aside for glassware and others for chemicals. As we still import most of our equipment, it is necessary to lay in a stock for the whole year and to have an abundance of storing space. The alcohol and other very inflammable substances are stored in an underground vault outside of the building, which communicates with the basement. This enables us to procure a suflicieut supply, duty-free, to last for a year. Under no conditions could we keep a large quantity of inflammable material on hand without such a vault, for it would be impossible to place an iusurance upon the building.
Animal Houfe. — One of the most diflioult problems in the construction of a laboratory is the care of live animals. A
100
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miml)er of methods are employed, audit matters little whether the animals are kept in the basement or the attic, they are a nuisance and hard to care for. When either of the above arrangements is made it is impossible to make any alterations in the room from time to time as circumstances demand. The simplest and easiest method is to construct a special animal house. Our animal house is completely separated from the building, and has its own yard in which the animals can run about. The liouse (as Fig. 14 shows) is divided into four rooms, each of which is ventilated by itself. There are hot and cold water in the large rooms, and all the iloors are asphalted and drained. The rooms are heated by steam from the boilers in the main building. In addition one of the rooms has a large coal stove for heat during the night in cold weather. AV'e can thus give animals every comfort and cleanliness, and find that under these conditions dogs are not very noisy. The house is practically a hospital for operated animals, monkeys as well as dogs.
A space has been set aside in the basement for aquaria, but they are yet to be constructed.
Maceraliiuj Rooms. — A large room on the fourth tloor is fitted up especially as a macerating room. It has a sjiecial
ventilating Hue, a store room adjoining for clean bones, and a large balcony for bleaching and drying purposes (Fig. 13, BB). The room has hot and cold water as well as a special steam connection with the boilers in the basement. The skeletons which come from the dissecting rooms are placed in sacks and numbered, which in nearly all cases completes the record of each subject. The bones from the subjects embalmed with carbolic acid are cleaned with lime or 1 per cent acetic acid. In either case we must boil them; and this is easily done with steam. In addition to these skeletons we obtain subjects too far advanced in decomposition to embalm, and they are first frozen and then cleaned as soon as time will permit, often a year after the subject is obtained. All of the bones cleaned are preserved until summer, when the fat is extracted from them. Our extractor was made by Lentz,* and it is set up in the animal house for additional security in a room containing the alcohol stills. The water-bath of the apparatus is heated with live steam, which is easily controlled and is more satisfactory as well as safer than the gas flame. The apparatus can be started and may run for days without any special attention.
- E. A. Lentz, SpanJauerstrasse 30 and 37, Berlin, Germany.
AN OUTLINE OF THE COURSE IN NORMAL HISTOLOGY AND MICROSCOPIC ANATOMY.
By Lewellys F. Barker, M. B., and Chauleh R. Bardeen.
The problem of reducing to a minimum the amount of energy expended in the routine work of teaching is one which necessarily interests every working histologist. While we would deprecate the adoption of a fixed, rigid programme to be followed year after year, we believe that in a subject like normal histology, where many of the methods employed are constant, a careful list of the work actually done and of the methods actually used during one or two years will be of considerable service as a basis for the organization of the course in ensuing years. The programme which we present here is almost exactly that which has been followed during the past year in the Johns Hopkins Medical School. It is by no means intended to represent an ideal course in histology ; on the contrary, it has very obvious defects, some of which we hope soon to be able to remove. It is simply a course which has been given, adapted to certain conditions, and one to be modified from time to time with changing conditions and as further experience of our own and others shall indicate.
In framing a course in histology for the regular students of this school there were certain points which demaiuled particular consideration. In the first place, the class of students might fairly be expected to differ from that of the average medical school. Every student, in order to gain admission, must have a college degree or its e(|uivalent, must possess a good reading knowledge of French and (iernuin, and in addition give evidence of having studied biology, chemistry and physics, including practical laboratory work in these subjects during at least one year. It might be safely assumed that the average student in such a school, as a result of his previous scientific training and experience, would be able to do more
and better work in normal histology and microscoj)ic anatomy, than has before been expected of medical students, and our experience thus far justifies such an assumption. One difficulty which speedily became obvious, however, was the unequal preparation of the different students for microscopic study on entering the school. Whereas some of the students had worked extensively with the microscope, an occasional one having had more than a year's instruction in practical histology, others in their work in practical biology had done little normal histology or none at all. In organizing a course, the needs of all the students had to be considered, and arrangements were made by means of which the experienced found work difficult enough for them, and the untrained were given tasks which were not beyond them. It is probable that this inequality as regards preliminary attainments in microscopic work will grow less with the years, since the students admitted at the beginning of the school have had no opportunity of directing their preliminary education to suit the requirements of admission. But there must always be greater individual differences, probably, among the class of students entering such a school, than in the medical school requiring no college degree before admission, inasmuch as, other things being equal, specialization and individuality increase ^OTri\/w.%?6 with age and educational advantages.
In deciding as to the plan to be ailopted in the course we have been much infinenced, too, by the fact that our students are students of medicine. Thus it will be noticed that in the selection of tissues, those from the human body make up a large part of the material used; and when animal tissues are employed, special care has been taken to point out how they
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differ from the human. Moreover, in deciding what to exclude from the course — for this we think as imjiortant as the matter included — thought was given to the bearing of the Sfiecinieus on the practical work in medicine which was to follow, and stress was laid ujjou those portions of human histology whicli previous experience has taught us are of the most importance in the appreciation and interpretation of the ])atliological alterations in disease. While in the future all detail will, we must believe, be found to be of importance to the pathologist, in the present status of pathological histology a knowledge of certain details is of much greater value than that of others; and for the student entering medicine, a judicious selection of what shall be given and what shall be left out should be made by some one who has had a more or less wide training in pathological histology.
The time is now past, we believe, when an instructor in l)athology should be compelled to devote the time intended for the study of diseased tissues to instruction in normal histology and microscopic anatomy. It is true that every student has his knowledge of normal structures widened and more firmly rooted by good courses in pathological histology, but he should not meet with normal ap])earances in these courses for the Orst time.
Further bearing in mind the life-work I'oi- which the student is preparing himself, Ave have not, in this course, always chosen the method which would show the finest structural details of the tissues. While the most delicate methods have been introduced in jjlaces, we have endeavored to familiarize the students with a large number of different modes of preiniration, and to helji them to understand the varying ajjpearances of one and the same tissue under different methods of preliminary treatment. A piece of spleen hardened in Miiller's Uuid is quite unlike a portion of the same organ hardened in alcohol or in Flemming's mixture, and the appearances of such tissue in stained section differ still more from those to be seen in a frozen section of the fresh spleen. The student who has been brought up entirely on "giltedged" histological methods will find himself sadly at a loss in battling with the "rough aiul ready " world in which the pathologist has to live.
Nor could we leave out of account, in framing the course, the fact that in the studies of the subsequent three years, various portions of the body are again submitted to extended microscopic investigation. Thus in the second year in the department of pathology, a j)rcponderance of attention is paid to the structui'e of certain of the organs; in the third year in the department of medicine, the blood of patients is submitted to very accurate color-analyses, and in the course in obstetrics the histology of the female genital organs is again thoroughly reviewed. In surgical pathology, microscopic work is also done, and in the planning of the courses in neurology, dermatology, gyn;i)cology, ophthalmology, etc., i)rovisiou will doubtless be made for microscopic work.
The course beginning October first extends to March fifteenth. Three full half-days are devoted to regular class work, and additional time throughout the week is available for special work in technique, recitations and drawing. Between March lifteeutli and .luue tirst considerable time
is available for review, and for extra work for those students who have had difficulty in keej)ing i)a<;e with the course while in progress.
The teaching, consisting in the main of practical work in the laboratory under the direct guidance of a corps of demonstrators, is su])plemented by a series of GO lectures witli demonstrations, explanations of charts and models and darkroom projections.
After some introductory work on the cell in general, and a review of the blastodermic layers, the student begins his histology with the study of the morphological units in the body, that is to say, with the study of general histology, and pro(X'eds to the study of the architecture of the organs (microscopic anatomy) only after he has had considerable experience in isolation and dissociation by means of teasing, tearing, dissecting, macerating, corroding and digesting the elementary tissues. It has seemed to us that this system has marked advantages over that in which histological studies are begun with the study of organs. The student who tries to study organs when he cannot recognize almost at a glance epithelium, smooth muscle, striped muscle, cartilage cells, nerve cells, nerve fibres and the like, is comjiarable to the student in chemistry who attempts to understand and memorize the reactions of complex organic compounds without having been taught the significance of an alcobol-, an aldehyde-, an amine- or amide-groui). Familiarity with units is, we are convinced, the only key to a proper understanding of the tissues. And thus in the study of organs the student is stimulated to search for morphological units of a liigher order — for examjjle, vascular or secretory units — a task which can often be lightened by the study of developing tissues where such units may generally be seen in simpler forms.
From the first the student is advised to pass as gradually as possible from the naked eye appearances to the relations as seen under high powers of the microscope. Thus after the naked eye study in the course, and the color, odor, consistence, etc., have been noted, pieces of the tissue are examined with the aid of the dissecting microscope (8-20 diameters), first in bulk and afterwards dissociated ; only then does the examination with higher powers of the microscope begiu, at first with low powers and finally with high powers, in some instances with oil-immersion lenses.
During the early part of the course very few microtome sections are permitted, and, throughout, the importance of methods other than those of mere sectioning is esjKMjially emphasized. The student goes to the animal body or to the cadaver in the dissecting room, set>s the genenil relations of the tissues there, procures for himself the specimen, and thus is taught how and where material for study is to be obtained.
In addition to the regular class work, to each student is assigned the task of the complete preparation of some tissue or set of tissues, involving the processes of taxing, hardening, embedding (in celloidin and paraflin) and sectioning. Some members of the class find the time to do more of this sort of work than others, and as all of it is done under the direct supervision of an instructor, the technical esjHTieuce gained should be subsctiuently helpful.
It will be noted in the tables that liberal use has been made of embryouic tissues. Starting out with tlie blastodermic layers, the student from the lirst is taught to lead all tissues, as far as possible, back to their early embryonic origiu, and through the whole course no small measure of the attention of the student is directed to the histogenetic relations, at different stages, of the tissue or organ under consideration.
While the morphological facts are necessarily the first objects in the course, still the physiological bearings are not entirely lost sight of, and we have had no hesitancy now and then in calling the attention of the students to a physiological, chemical, or even clinical relation when we have thought it important that it should be especially associated in the mind with a certain morphological peculiarity. Thus, while any marked "overlapping" of courses is avoided, the attempt is made to impress upon the student the fact that histology, instead of being divorced from a number of kindred subjects, stands in the most intimate, almost inseparable, connection with them.
The student is encouraged at all times to make careful objective drawings of what he sees.
Text-books in English, German and French are used in the course, and in addition each student is required to read original articles in the literature and to make a careful abstract of at least one scientific article. In this way he gains the habit of going to the sources for his information, is impressed with tlie limitations of histological knowledge, sues the lines along vvliich origiiuil research is moving, and learns the origin of text-books.
It will be observed in perusing the list, that whereas none of the important organs have been omitted, certain parts of the body have been studied in more detail than others. This we think unavoidable, but we have arranged the subjects so that especial attention should be given to those parts of the body in which at present most advance is being made. Thus the sense organs and nervous system, it will be seen, have been examined in considerable detail, and as far as possible the students are made conversant with the newer ideas coucerniug the minute anatomy and histogenesis of the peripheral antl central portions of the nervous system. Preceding this portion of the work, six half-days, in addition to the time allotted to the subject in the course, are given to the student for the study of the gross anatomy of the central nervous system. A series of sections at various levels of the spinal cord and brain are then carefully studied and drawn, and finally several days are devoted to the study of tracts, thus bringing the student's knowledge together in a more or less orderly fashion. Our experience, though brief, has confirmed us in our belief that the histology and microscopic anatomy of the nervous system are properly, for the present at least, included in this course. Much has been demanded of the students, but within certain limits, students, we think, do more thorough work when much is expected of them.
In choosing the methods mentioned in the following list we have been influenced in a given instance sometimes by one factor, sometimes by another. When the method suggested seems at first less desirable than certain others which are in vogue aTid which could have been selected, it should not be taken for granted that the other method has not been thought
of. It may be that the method in question has been chosen to suit a certain particular condition in the course. Still we know only too well that there are many ways in which the list can be improved, and not a few errors which would be better eliminated. We shall be particularly grateful for corrections or suggestions from those who take an interest in the subject. It is an especial pleasure in closing to acknowledge our indebtedness to Professor Mall for helpful counsel and manifold suggestion.
The method here used for designating the main steps employed in ])reparing the various tissues for histological study was devised as a convenient means of brielly indicating the necessary technique when planning out the work of the course. The writing out in full of the technique used for each tissue was found to take too much time and to be needlessly cumbersome. Word-abbreviation was too apt to be confusing, and thus a completely artificial system seemed on the whole to be the best.* The various technical processes employed in histological study were roughly arranged in eleven -odd groups: fresh examination, dissociation, demlctjicalion, fixation, hardening, microscopic jireparation, stuiniwj, clearing, fastening, mounting, and special, and each of these groups was designated by a particular letter of the alphabet. Thus, for example, , all the methods used for staining are grouped under " G." The various methods in each group are further designated by numbers, thus c. g. staining with borax-carmine is indicated by "G."; furthermore, since certain of the technical steps are carried out by the instructors and certain of them by the students, the group representing the particular process is written (or printed) as a " capital " when representing work done by the instructor, as a " small letter " when it is done by the student. An example will make this clear: In indicating the methods used in preparing the cardiac end of a dog's stomach for microscopic examination, the following signs are used: "Dis; Ea ; Fs; gi, u; ks," which being interpreted means that the tissue was (1) fixed in Zenker's fluid ; (2) hardened in graded alcohols; (3) embedded and sectioned in celloidin by the instructor; and by the student (4) stained in hannatoxyliu and eosin ; and (5) mounted in balsam. Only the more important steps, or those to which especial attention is to be called, are indicated, thus the clearing agent most often used in the daily routine of the classroom, carbol-xylol, "Hi," is seldom put down among the steps of the technique.
With this explanation it is hoped that the following tables and the programme will be clearly self-explanatory. The technical methods used are, in the main, those commonly given by the various books on technique, though many of them have been taken from the literature, and a number have been slightly modified to suit our own needs or preferences.
EXPLANATION OF ABBREVIATIONS EMPLOYED. A.— ^Iethodsof Preservation or Examination in Natural Statk. (1) Fresh tissues.
•The method for a similar purpose used by Benda in the " Histologischcr Hand-Atlas" of Benda and Guentber (Leipzig, 1895) suggested the method here employed .
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(2) Tissues in normal fluids.
(3) Tissues in physiological salt solution.
(4) Tissues in aqueous humor.
(5) Tissues in blood serum.
(6) Tissues in iodized serum.
(7) Tissues in Farrant's medium.
(S) Tissues in 1 per cent, sugar solution.
B. — Methods op Dissociation, Maceuation, Cokuosion ok Altkua TION.
(1) 0.25 per cent. ac. acetic.
(2) 30 per cent. j)otassic hydrate.
(3) 33i per cent. alcohol (Ranvier's alcohol).
(4) 0.1 per cent, osmic acid.
(5) Cone. ac. hydrochloric.
(6) Cone. ac. nitric.
(7) Muller's fluid.
(S) 0.1 per cent, potass, bichromat.
(9) 0.5 per cent. ac. chromic. (10) 0.5 per cent, ammon. chroniat. (I I) Digestion with pancreatin and sod. bicarb.
(12) Digestion with pepsin and ac. hydrochlor.
(13) Iodized serum.
(14) Water.
(15) 20 per cent. ac. acetic. (U>) Cone. ac. suljihuric.
(17) liUgol's solution.
(18) Sat. sol. tannic acid.
(10) 0.05 per cent. ac. chromic.
C. — Methods of Decalcification.
(1) 3 to 5 per cent. ac. nitric.
(2) 2 per cent. ac. chromic. (:i) Ac. acetic glaciale.
(4) Muller's fluid.
(5) Per cent. ac. picric. (()) Per cent, liydrochlor.
(7) V. Elmer's fluid.
(8) l'hloroglucin-|- ac. nitric (llaut;).
D. — Method.s of Fi.vation.
(1) Heat on cojipcr bar at 120° C.
(2) Boiling water.
(3) Steam.
(4) Absolute alcohol.
(5) Flemming's solution.
(0) Hermann's solution.
(7) Fol's solution.
(8) Osmic acid vapor.
(9) 1 per cent, osmic acid.
(10) 10 per cent. ac. nitric.
(11) Sat. sol. hydrarg. perchlor. in 0.75 per cent. NaCI solution.
(12) 5 per cent, formaldehyde.
(13) Zenker's fluid.
(14) Bethe's fluid.
(15) Kleinenberg's solution.
(16) Ecpial parts abs. alcohol and ether.
E. — Methods pok Hardknino* sometimes used for Fixing, etc.
(1) (iraded alcohols 33J per cent., 50 per cent., 70 per cent., 80
per cent., 90 per cent., 95 ))er cent., absolute.
(2) Graded alcohols SO, 95, absolute. (:')) 95 |)er cent, alcohol.
(4) Muller's fluid.
(5) Miiller's lluid 3 pts. + alcohol (95 per cent.) 1 pt. (G) Erlicki's fluid.
(7) 1 per cent. ac. chromic.
(8) 5 per cent, formaldehyde.
(9) Cox's solution.
(10) Cajal's osmo-bichromic solution (rapid Golgi method).
(11) 2 pts. Miiller's fluid + I |)t. 1 per cent. ac. o.smic {Marchi).
(12) Weigert's mordant for neuroglia.
(13) Distension and drying.
F. — IMethods of Preparation for Micuoscopic E.xamination.
(1) Transfer simply to slide.
(2) Spread out thin on glide.
(3) Semi-desiccation method.
(4) Teasing.
(5) Strip off in layers.
• The line between ll.vliiK ami liai-deninR lluids miiat of necesisity bo an avti lluial one. Wo have dosiitnatoii as fl.\iiiK lluids those commonly allowed to aot foi' twoiity-four hours or les.>< on the tissues ; as hardeuini; fluids those used a longer time thuii this.
(6) Free-hand section.
(7) Section with Valentine's knife.
(8) Frozen section.
(9) Celloidin section.
(10) Paraffin section.
(11) Dissection.
(12) Elder-pith section.
(13) Grinding and polishing.
(14) (luUen's formaline method.
G.— Methods op Staining and Impregnation.
(1) Borax carmine.
(2) Alum cochineal.
(3) Indigo-carmine.
(4) Picro-carmine.
(5) Upson's carmine.
(6) Van Gieson's lluid.
(7) Delafield's hiematoxylin. (S) Bohmer's hematoxylin.
(9) Heidenhain's h;r;raatoxylin.
(10) Weigert's myelin stain.
(11) Weigert-Pal myelin stain.
(12) Ehriich's acid hiematoxylin.
(13) Eosin.
(14) Acid fuchsin.
(15) Acid picric.
(16) Safranin.
(17) Methylene blue. (IS) Aqueous mai;enta.
(19) Dahlia.
(20) Methyl violet.
(21) F,hrlich's triple stain.
(22) Weigert's librin stain.
(23) Weigert's neuroglia stain.
(24) Mall's reticulum stain.
(25) Boiled gold chloride methods.
(26) Lowit's gold method.
(27) Golgi's gold method.
(2S) Lemon juice gold method.
(29) 0.75 per cent, argent, nitrat.
(30) Silver nitrate -|- ammon. hydrat.
(31) Lavdowsky's modification of Ehriich's methylene blue
method.
(32) Nissl's methylene blue and soap solution.
(33) Thionin.
(34) Gcrlach's gold chloride solution.
(35) Benda's iron ha;matoxylin.
(36) Aniline blue.
H. — Methods of (^i.earinq.
(1) (Jarbol-xylol (ac. carbol. pur. itls. 1 + xylol 3).
(2) Xylol.
(3) (^reasot.
(4) 01. caryophyll.
(5) Ol. bergamot. (()) Ol. origanum.
(7) 01. cajeput.
(8) Acid glycerine.
(9) Glycerine.
I. — Methods of Fastening Sections ti> Slide.
(1) Mayer's albumen.
(2) Gul land's water "method.
(3) Schallibaum's collodion method.
(4) Clove oil collodion method.
(5) Obrepgia's collodion-paraffin method.
K. — Methods of Mounting.
(1) Glycerine pur.
(2) Glycerine 20-f-.ac. arsenios. trace + water SO.
(3) Farrant's medium.
(4) Sat. .sol. pota.ss. acetat.
(5) Xylol b.alsam.
(6) Dammar.
(7) Beiizolcolophonium.
(8) Physiological salt solution.
(9) Glycerine and alcohol with or without acid. L. — Other Methods of Preparation.
(1) Injection with aqueous Berlin bine.
(2) Injection with carmine gelatine.
(3) Injection with Berlin blue gelatine. (41 Injection with cinnabar gelatine.
(5) Injection with methylene blue (intra vitam).
(6) Feeding with madder.
(7) Artificial cedema.
Subject.
Special Features Illustrated.
Animal.
Methods
Employed.
Mesencephalon, Di
Section through inferior colliculi corp. quad.
Human.
E„,,; F.j;G„;H,;Ki.
encephalon and
Section through superior colliculi corp. quad, includ
nerves directly
ing tegmentum, suVjst. nigra, cerebral peduncles,
connected with
corpora raamillaria, optic tract, i)ulvinar and cor
them.
pora geniculata.
Human.
E,^.,;F,,;G„;Tf,;K,,
Diencephalon, Te
Ten coronal sections for macro.scopic study through
lencephalon and
hardened half hrain, respectively, 30, 46 55 (;:;
Human.
E.; F„.
nerves directly
GO, 75, 80,02, 107 and l:i7 mm. behind frontal pole!
connected with
Horizontal section for microscopic study including
them.
parts between wall of third ventricle and cortex
of island of Reil.
Coronal section for microscopic study through thala
Human.
E. , ,;F,;G„; H,; K,.
mus and hypothalamus, including nucleus hyjio
Human.
E,,,;F,;G„;H,;k5.
thalamica (Luysi),
Sections of cortex for microscopic .study :
Human.
rE,,,,;F,;G„;H,;K,,
(1) ITpper part of gyrus centralis anterior.
E.,;F,;G,;H,;K,.
CJ) Middle third of gyrus temporalis superior.
(:'.) ( :uneus adjacent to calcarine fi.ssure.
(4) <Tyrus fornicatus.
-!
(5) Ammon's horn and nucleus amygdahx'.
((!) Substantia perforata anterior.
(7) Gyrus frontalis inferior (pars opercularis).
(8) Gyrus angularis.
L
Finer structure of cortical substance.
Human.
E,; G.„j; F,; h,; k^
Lobus olfactorius.
Transv. section.
Human.
E,; F,; G,,; H,; K5.
Transv. section. Rabbit. |
E,; G.,g; F,; h,; k,.
THE PHOTOGRAPHIC ROOM AND APPARATUS IN THE ANATOMICAL LABORATORY OF THE JOHNS HOPKINS UNIVERSITY.
By a. (!. lIoEN, M. D.
The sco])c of photo-micrography can convcjiicntly he divided into photo-micrography (1) with high powers, (3) with medium powers, and (3) with low powers.
(1) Photo-micrography with high amplification ((iOO lo 1200 diameters) is employed chielly for the delineation of pathological material, snch as micro-organisms, free and in sections of tissues, malarial and leukemic blood, etc., as well as for the demonstration of some of the minuter iiistological changes which occur in the cells, such as karyokinesis; the demonstration of nerve termiuations in the tissues, as well as for the finer histological structures in general.
(3) Photo-micrography with medium am])lification (150 to 400 diameters) is applied to tissue work, whore it is desirable to differentiate structural elements in pathological as well as in normal histological material, micro-urinary deposits, ami the study of vital movements (amteboid) of certain cells by serial exposures. Under this heading it is perhaps well to enter our criticism in reference to the illustrations as fouml in the various tc.xt-books on normal histology. Beautifully as the majority of them are executed, we cannot help but point out their deficieucy in properly conveying to the student's mind the correct appearance of the microscopic image or field. It has become a fixed fact in the minds of instructors that teaching histology from drawings and diagrams is by no means altogether satisfactory. Most of the diagrams are selected from exceptionally line or lucky specimens, and many of them are composite pictures, taken from different slides, the salient points of one being blended with those of others, thus nuiking perfect pictures which have a tendency to puzzle tiu^ student, because he cannot verify thorn from liis sections. 'Pile diagrams are iuloiided to ohicidalo (ho subject, and if
they are accompanied with photographs they aid markedly in giving the student the proper impression of the subject at hand, nothing more or loss ; whilst on the other hand a drawing, no matter how carefully and conscientiously conducted, has constantly mixed with it a certain element, individualism, personal equation, if one chooses, which cannot be eliminated or ruled out. Furthermore the draughtsman never thinks of portraying the imperfections, bubltles of air, dust, cotton libers, etc., which are likely to be present, even in the best preparations. The very perfection of his drawing is misleading and incorrect.
With a view to eliminating these difficulties, we have made in connection with the histological course, a series of well executed photo-microgra]>hs, taken from the best specimens as prepared and stained by the students themselves. From these photographs lantern slides have been made for projection on a screen. For lower powers than 150 diameters, the specimen itself is utilized for projection by a system of lenses to be described further on.
(3) Photo-micrographs with low powers (from 1 to 100 diameters) applied for the purposes of studying various tissues with reference to their anatomical relations and for injected specimens of whole organs. Also extremely useful in embryologioal research, in which it hjis been found of great service as a time-saver to give correct outlines for reooustructions. The above uses of photo-micrograjihy have Ikh;u kept in mind in purchasing and elaborating the apjMinitus in the Anatomical Laboratory. Primarily the apparatus was intended for soientilic investigation, but in the course of time it was found extremely useful for teaching .as well. We shall describe our apjiarafus under ihe following heading:
The Rooms. — lu coustriicting the rooms we were guided by the idea that the operator should worl< witliiu tlie camera, so we made the main room perfectly dark. This communicates with a room for illumiuatiug purposes on one hand and with a second dark room for developing on the other hand. Of these three rooms, the larger one contains the tables carrying the condensers, microscope, camera and projecting apparatus, whilst the smallest, well lighted one contains the electric arc light and tables for ordinary microscopic observation. The second dark room contains the necessary chemicals for developing plates and conducting such other manipulations as appertain to ))hotography. It is supplied with hot and cold water and is lighted by incandescent lamps, one of which is hooded with black velvet over a frame of asbestos and the lower end is covered by three thicknesses of deep ruby glass. The accompanying figure shows the floor plan of these rooms with some of the apparatus in place. The walls and ceiling of the large room are painted a dull or flat black from which no reflection can take place. The windows are protected against the admission of light by Venetian blinds on the outside, an adjustable l)lack cloth one on the inside, and over these, sliding paneled wooden blinds. The inside blinds are also painted black, and are provided with screw clamps for taking up warps in the Avood and to ensure perfect contact of their surfaces. •
The table bearing the condensers, light filter and microscope is so placed tliat it directly faces the aperture in the partition, througii which the light from the electric arc lamp is projected l)y the paraboloid reflector to be mentioned further on. The table bearing the camera is so placed that it forms a continuation of the first; both tables are brought into the same plane l)y means of set-screws.
The tables and camera were made by Zeiss, but we fouiul it necessary to add these set-screws to adjust thon to a given plane easily. On the north wall, directly opposite the opening in the partition, a plaster of J'aris screen has been made, which is perfectly smooth to ensure a good reflecting surface. This screen is emjiloyed to receive the projected i'mage, with low powers, for demonstrating histological specimens themselves to the classes. In addition to this it was found necessary to have a smaller movable screen constructed, which is also adjustable vertically, its use being to adjust tlie apparatus easily to any given number of diameters in making diagrams and reconstructions.
lUnmination. — Sunlight is perhaps the one source of illumination that every photo-micrographer has tried some time in the course of his work, and has been glad to abandon for any new illumiuant which would give him practically the same actinic power. There are, however, so many drawbacks to it that it is necessary to observe the time of the year, the day, the hour antl the condition of the atmosjjhere as factors which determine the power of his light, not to say anything of the many disai)pointing days when it does not shine at all. In our laboratory sunlight has been entirely superseded by the electric arc light, with whi(di we are ca])able of accomplishing everything desired. The lamp used is the ingenious invention of Ooerper, of Eiirenfeld, (iermany, and luanufactured in America by the Ilelios Electric Light Co. of Pennsyl
vania.* The lamp we employ is calculated to be of 4000
caudle power, and is run by an alternating current of 30
amperes, and is in no respect dangerous to life. The construction is extremely simple. A glance at Fig. 4 shows the carbon
holders balanced by means of a chain over a pulley in the
lamp mechanism. As a result of this arrangement with the
alternating current, the combustion of the carbons is compensated for by the descent of the upper and the ascent of the lower
carbon in exactly the same ratio, and the arc is thus fixed
practically at one point, and remains there from the time the
current is turned on until the carbons are consumed. We
found it necessary to substitute for the upper porcelain
reflector one made in the form of a paraboloid, which completely encloses both carbon points. Our reflector is made of
one piece of copper, lined on the inside with a thick coating of
white lime, and our experience with it convinces us that it has
very markedly increased the power of the light. In order to
easily adjust the lamp in the optical axis of our jihoto-micrographic apparatus, we adopted the j^lan of mounting it on a
mechanical stage, made much after the pattern of that
employed on the better class of microscopes. This frame is
attached to the wall in an upright position, thus giving both
vertical and lateral movements, and we find that it works
admirably, and is capable of adjusting the lamp to the fraction of an inch. These alterations and modifications were
made by Messrs. Murrill & Keizer of Baltimore, to whom we
are very much iiulebted for advice and suggestions in reference to the same. In attaching the parabolic reflector to the
lamp, the carbon points were made to pass through two openings in it in order to keep them in place. Experience showed
us, however, that there was considerable vibration of the two
points in spite of this, which we overcame by attachiug a guard
to the side of the lamp, to steady the upright rod of the lower
carbon point. This guard is adjustable with a screw, as the
figui'e shows. With these adjustments we succeeded in attaining a source of light which is not continually moving up and
down, as in the case of the lamp furnished by Zeiss. The
heat generated by this lamp is considerable, and it was found
necessary to 2)rotect the mechanical stage and the surrounding
woodwork by asbestos sheeting.
Apparatus and Accessories. — The apparatus consists of a Zeiss stand T' for photo-micrography with 2, 2.5, 4, 8, 10, 35, and 70 mm. lenses and Nos. 2 and 4 projection oculars. In addition to these lenses, there are also the following photograjdiic lenses which can be used for photographing with low powers as well as for ordinary lantern projection :
Anastigmat 1 : 6.3, focus 43 millimeters.
1: 7.2, " 96 "
1: 7.2, " 1-48 "
1:12.5, " 260 "
1:18, " 632 With these lenses it is possible to photograph objects from one diameter upwards, and this is very necessary, for it is often desired to obtain a specific enlargement of a specimen, as in reconstruction work.
In addition to these lenses there is a complete projection fable
'McKay-Howard Electric Construction Co., Baltimore, Md.
with its appendages, as well as the large camera. For delicate work there is a spectral illuniinating apparatus after Hartnack.
The anastigmat lenses are all interchangeable, and the large ones are fitted with a prism to photogi-aph at right angles to I lie object, as is often necessary in photographing objects under lluids. The sub-stage of the condenser of the microscope is Ihat constructed after the formula of Prof. Abbe, is achromatic and supplied with two iris diaphragms, by which the access and egress of light may be regulated to the requirements of the amplitication to be used, or in other words, they ])ermit the use of the entire aperture of the condenser or only fractional portions thereof, as the case may be. It is fitted with two adjusting screws, by which means the condenser may be accurately centered for the objective in use, and an even and uniform illumination of the field secured.
As two tables or stands are supplied with this apparatus, one bearing the condensers, light filter and sole plate for the microscope, and the other the camera, we found that it was impossible to bring both tables to an exact level with each other or to retain thena there, in consequence of which it was also impossible to establish a perfect optical line between the former and the latter. We found an adequate remedy for this by having set-screws put into each one of the iron pedestals of the tables; these screws rest in small metallic discs, which are simply laid on the lloor in their proper position. This imjtrovemeiit of the Zeiss table has been found very serviceable in leveling the tables from time to time.
Method)^ of Ilhimination for High and Medium Powers. — 1st Method: In order to illustrate this it is necessary to refer to Pig. 1. The star rejiresents the arc light, the rays of which are received uj)OU the plano-convex lens x, which is so placed that the arc is in its principal focus, thus rendering all rays jiassing through it, parallel. In their further course through the bi-convex lens xx the rays are brought to a focus, whicli is made to coincide, by adjusting this lens on tlie sliding bar, with the principal focus of tlie lower lens of the Abl)e condenser in the microscope {M). The lower lens of the Ablie cond(!nser renders the rays parallel, while its second lens converges them and brings them to a focus in the plane of the object, giving there a small but very bright image of the source of illumination.
2d Method: This consists in the use of a plano-convex lens of much shorter focus than the one supplied witli the outfit. It was made for us by Messrs. Bausch & Lamb of Kochester, N. Y., and is mounted in a metal frame whi(di is fastened to the wall, and by means of set-screws permits of perpendicular as well as lateral movements. The collar is also movable in the optical axis, so that the distance between the collecting lens and the light can be regulated with ease. The lens is four inches in diameter and its principal focal distance is five inches. Its adjustment for accurately focusing the lani)> is accomplished by nieans of the set-screw, which is moved liack and forth unfil a bright beam of light, not greater in diameter than the lens itself, is projected on llie screen. Fig. 4 of tiie lamp shows the lens as having been pushed through the o]iening in the partition by means of the set-screw and in position for focusing the lamp.
In order to accuratelv center the .Abbe condenser for the
objective system we have adopted the following plan : The condenser is racked down far enough to enable us to unscrew its top cap which carries the small, nearly hemispherical and the upper achromatic i)lano-convex lenses of the system. This discloses the iris dia])hragm situated immediately below it, the aperture of which is now reduced to its smallest diameter by the regulating lever of this part of the coudeuser. The resulting small opening is now carefully brought into the focus of a weak objective (10 mm.) and a low eyepiece {No. 4), and by means of the centering screws attached to the condenser, lateral and vertical movements are imparted to the latter until the opening in the diaphragm occupies a central position in the visual Held of the microscope. We may state here that all of our objectives are carefully centered to the optical axis by Zeiss' "slidiiig objective changer."
To center the source of illumination to the optical axis the following w.as found to lie the speediest and most certain method in our hands: 'J"he lenses of the guide-bar as well as those of the microscope, including the Abbe condenser and eyepiece, are removed; a pin-hole diaphragm is now placed in an eyepiece (freed of its lenses), which is slip])ed into the tube of the microscojie. I'y looking through the pin-hole oi)eniug in the blank eyepiece, the carbon points of the electric arc light (without current) can now be brought into view by means of the adjusting screws on the meclianical stage bearing the lamjjs, to occupy a position corresponding to the oj>euing in the diaphragm in the cj'epiece. Once so adjusted the lamp has a tendency to remain in this jwsition, reijuiring periiaps one adjustment in the course of six hours use.
The lenses for rendering the liglit parallel and condensing it are now j)laced upon the guide-bar and so adjusted that a sharp and bright image of the burning carbons is jirojeeted exactly in the center of the lower iris diaphragm of the Abbe condenser, wiiich is closed to its utmost for this pnrjiose.
For very iiigh powers (immersion systems) the wliole aperture of the Abbe condenser is utilized by opening the iris diaphragms to their fullest extent: for medium powers alwut one lialf of this a]>erture is suflicient. We found in i>ractice tiiat the illumination of the object wiiich gave the most clear and sliarp picture visually also answered the best pnrjwses for photography. To secure the best illumination, the condensing lens XX is moved back and forth upon the guide-bar until the projected image of the microscopic field upon the ground glass of the camera is brightest and most evenly illuminated, thus fixing the position for the lens xjr. for the focus of this lens and of the lower lens of the Abbe condenser .are now coincident.
Lifffif Filler. — We have confined ourselves exclusively to the bichromate of potash and sulphate of copper solution as recommended by Neuhaus in his admirable work on Photomicrography (p. (i4, 1890). It is made ;is follows:
Sulphate of copper. 175 grams. Bichromate of potash. 17 grams. Sulphuric acid. 2 cc. Wafer, from 500 to I0(H> cc.
The more concentrated solution is applicable to s}>ecimens stained very lightly with the various blues (^ba>matoxylou,
112
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 62-63.
anilines, etc.) or for the reds, particularly safranin pre])arations. Eosiu is a decidedly disturbing element in photomicrography, and unless it is very cautiously and lightly used, as a counter-stain to other dyes, produces au indetinable haze or indistinctness upon the plate which mars an otherwise good negative very much. As practically no heat rays permeate this solution, it answers the jnirpose of a heat filter thoroughly. The position of the light filter is of little moment, jjrovided that the rays of light which pass through it are the only ones which reach the Abbe condenser.
Focusing. — With a camera length of 55 to 60 cm. we have rarely found it necessary to have recourse to any special focusing appliance; the fine adjustment is within reach of the hand, while watching the appearance of the image on the ground glass. The focusiug glass we employ is an ordinary hand lens, with which most of our work requiring from 150 to 400 diameters is accomplished.
The plate for intercepting the image is made of finely ground glass, such as Zeiss sujiplies with his outfit. For bacterial work a plane glass screen is used in connection with • Zeiss' focusing lens, which is adjustable to the eye of the operator.
When the long camera is emjdoyed we use the focusing rod and Ilooke's key as furnished with the Zeiss outfit.
Plates. — After using the plates of a number of manufacturers, we have selected tliose made by the "Cramer Dry I'hite Company " of St. Louis, ilo., as those which give us uniformly the best results.
They are ortliochromatic in the widest sense, are very uniform, and the instantaneous or extra rapid plates made by this comi)any are sensitive to an exquisite degree.* For bacterial work we use the latter (1000 to 1200 diameters), preferring the " medium " plates for histological purposes (150 to 400 diameters).
•From two to five seconds exposure is sufficient to impress these plates, even unJer such great clispersion of liglit as takes i^lace, for instance, with tlie 2 mm. immersion system of 1.10 N. A. The .advantages of this short exposure are obvious.
The development of these plates is accomplished as advised by, and after the formula of the manufacturers (in their circular), by a combination of hydroquinone and eikonogen. Care is necessary in manipulating these plates in the dark room with reference to the light used, which must be of a deep ruby red and feeble, otherwise they will fog. It is safer to develop the plates away from the light, using the latter only occasionally to watch the progress of the development.
Determination of Amplification and Means of Measurement. — AV'ith the Zeiss system of objectives and projection oculars, we have adopted the plan as advocated by him in his "Special Catalogue," (p. 3(>), and also noted in Neuhaus' work before referred to (p. 73).
As Zeiss has adopted a nomenclature for his objectives and oculars by designating them by their focal distances, it is an easy matter to arrive at the magnifying power of any one combination of objective and projection ocular by having recourse to the following formula:
jT X P=:x — in that L represents the camera length, the
focal distance of the objective, and P that of the ])rojection ocular.
If therefore an objective of 3 mm. focal distance and the projection ocular No. 4 be used in combination witii a camera length of 550 mm., we shall have:
linear.
550 _ 1100
3 mm. X 4 _ — y
In this calculation the reckoning must be made from the shoulder of the ocular to the ground glass or screen. In those instances where it is necessary to be extremely accurate in the measurements, the stage micrometer ruled in lOths and lOOths of a millimeter is made use of. Eeprodnctiou =:x.
Yet for accurate work it is always necessary to control by projecting a millimeter scale. These we have had ruled in square millimeters, in stjuare tenths and hundredths. For careful rccoustruction work this is very necessary, as a projected rule shows easily any irregularity in the amplification at the periphery of the field.
ADENO-MYOMA OF- THE ROUND LIGAMENT.
By Thomas S. Cdi.len, M. B. (Tor.), Instructor Assistant Resident Gynecologist to
Isolated cases of adeno-myomata of the uterus have been from time to time reported, and recently our interest in these cases has been awakened by the excellent work of v. Recklinghausen, " Die Adeuomyome und Cystadeuome der Uterus und Tnbenwandung," and within the last few months we have had two cases in the Johns IIo])kins Hospital.
While adeno-myomata of the uterus are not so rare, sinular tumors of the round ligament have ajiparently never been reported.
Leojjold described a cystic myoma of the U. ligament. The writer, after carefully examining the tumor microscopically, came to the conclusion that the cyst cavities were dilated lyni])h spaces.
in Gijneiologii in the Johns Hopkins University, the Johns Hopkins Hospital.
Aschenborn, in a patient with phthisis, found a tumor the size of a walnut lying in the inguinal canal and springing from the Iv. ligament. It was a thick-Avalled cyst, and contained clear transparent fluid. The microscopic appearances were not described.
Coulson had a case closely resembling that of Aschenborn. Roustan describes a case observed by Duplay. Situated over the external ring was a tumor twice the size of a num's fist. This on section resembled a cystic testicle. Microscopically the solid portions consisted of non-striped muscle, adipose and connective tissue. Some of the cyst-like spaces were traversed by trabecula'. None of the cavities presented any epithelial liinng. The liinior was a myoma undergoing degeneration.
ADENO-MYOMA OF THE ROUND LIGAMENT.
^¥Y/'J
Fig. 1.
NATURAL SIZE. LONGITUDINAL SECTION OF THE TISSUE REMOVED. THE UPPER PORTION IS SKIN. THE GREATER PART OF THE SPECIMEN CONSISTS OF LOBULES OF FAT. THE ROUND OR OVAL DARK AREAS IN THE FAT ARE HEMORRHAGES. SITUATED IN THE ADIPOSE TISSUE IS THE TUMOR, WHICH CONSISTS OF MUSCLE BUNDLES. SCATTERED HERE AND THERE THROUGHOUT THE MUSCLE ARE ROUND OR IRREGULAR DARK SPACES. THESE REPRESENT THE DILATED GLAND CAVITIES. RUNNING INTO THE MYOMA FROM ALL SIDES ARE STRANDS OF CONNECTIVE TISSUE.
^^^^^
^C?-.^,
i^JMi^SldK
rh/:\
Fig. 2.
SIXTEEN TIMES ENLARGEMENT OF A PORTION OF THE ADENO-MYOMA. THE SPECIMEN CONSISTS CHIEFLY OF NON-STRIPED MUSCLE FIBRES. IN THE RIGHT LOWER CORNER ARE MASSES OF FAT CELLS. NEAR THE LEFT LOWER CORNER ARE SEVERAL FAT CELLS. IN THE VICINITY OF THE LEFT UPPER CORNER IS A PSEUDO-GLOMERULUS. THIS IS COMPOSED OF STROMA, SCATTERED THROUGHOUT WHICH ARE CROSS SECTIONS OF SEVERAL GLANDS. THE SURFACE OF THE GLOMERULUS IS COVERED BY ONE LAYER OF CYLINDRICAL EPITHELIUM. ITS CAPSULE IS COMPOSED OF ONE LAYER OF CELLS WHICH IN PLACES ARE CUBOIDAL OR ALMOST FLAT. THE CELLS OF THE CAPSULE HAVE PRACTICALLY NO UNDERLYING STROMA BUT LIE DIRECTLY ON THE MUSCLE FIBRES. THE SPACE BETWEEN THE PSEUDO-GLOMERULUS AND THE CAPSULE IS, ON TRACING IT TO THE RIGHT, SEEN TO BE CONTINUOUS WITH A GLAND CAVITY, AND IS NOTHING MORE THAN A DILATED PORTION OF THE GLAND. ABOVE AND TO THE RIGHT OF THE PSEUDO-GLOMERULUS ARE CROSS SECTIONS OF TWO GLANDS. BELOW IT ARE SEVERAL LONGITUDINAL SECTIONS OF GLANDS. ONE SHOWS DICHOTOMOUS BRANCHING. ALL OF THE GLANDS ARE SURROUNDED BY STROMA, WHICH SEPARATES THEM FROM THE MUSCLE.
May-June, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
113
The above are the reported cases which at first siglit might bear some semblance to the case I report.
Clinical History.
L. N., xt. 97, admitted in the service of Dr. Kelly, Oct. ISth, 1895.
The patient has been married 13 years; had one instrumental labor 7 years ago. Her menses commenced at 14, and were regular until the birth of the child, since which time they have occurred every 3 weeks, have been very copious, and liave lasted from 4 to 5 days. The latter part of each period has been accompanied by a good deal of pain, which persists for several days after the flow ceases. Last menstrual period two weeks before admission.
Family Ilistury. — Her father died of paralysis; one aunt and her grandmother died of carcinoma.
Prenent Trouble. — About 8 years ago the patient noticed a slight swelling in the right inguinal region. This has gradually enlarged, especially duriug the last 2 years. She has experienced severe cutting pain in the nodule. The pain radiated to her back, and was most severe after exertion or at the menstrual jjcriod. The patient is debilitated; her apjjetite is moderate; bowels regular. She has a thick white or yellowish leucorrheal discharge. This is uou-irritative, and is not offensive.
Vaginal examination is negative.
The mass occupies the u]iper part of the right labium. It is irregularly ovoid, and is firmly fixed in the deep tissue; it is, however, movable to the extent of 1 cm.
Operation by Dr. Kelly, Od. 19, 1895. — An oval incision was made over the site of the nodule. The mass was freed laterally and posteriorly. Above, it was closely connected Avith a baud of tissue 1 cm. broad. This proved to be the right round ligament. The round ligament was traced upward to the internal ring. Midway between the external aud internal ring it contained a nodule 1 x.C cm. in diameter. The round ligament was pulled down, clamped and cut off at the intermil ring. Several enlarged lymph glaiuls were then dissected out. The pillars of the ring were brought together by silver wire sutures. The round ligament was sutured into the canal. The canal throughout its entire extent was closed by mattress sutures of silver wire. The incision was then closed with catgut. The patient was discharged on Nov. 3d.
Anatomical Appearances.
Pathological No. 928. The specimen consists of a piece of tissue 7 X 4 X 3.5 cm. One surface of this is covered by nornuil skin, the underlying tissue is composed of fat, embedded in which is an exceedingly firm nodule 3.5 x 3 x 2 cuu, Fig. 1. This nodule on section is composed of interlacing bundles of fibres which form a dense network. Scattered throughout the nodule are many small irregular, pale, translucent, homogeneous areas. On examining the specimen after hardening iu Miiller's fluid, some of the homogeneous areas are found to contain round, oval or irregular spaces. Accompanying the specimen are several lymph glands, one of which is 1 X .8 cm.
Histological Examination.
The uodule is to a great extent composed of non-striped muscle fibres which wind in aud out in all directions, but do not show any concentric arrangement. In many places the muscle fibres are swollen, and the cell protoplasm contains large (piantities of yellowish-brown granular pigment. At several points the muscle has undergone hyaline degeneration. This is especially noticeable around blood-vessels. The blood supply is abundant. Scattered here and there throughout the muscle substance are small islands of adipose tissue. Traversing the uodule in all directions are glands, Fig. 2. Some of these are small and round on cross section, others are cut lengthwise. These glands are surrounded by stroma similar to that of the uterine mucosa. It would be impossible to distinguish some of these from uterine glands. A few of the glands present slight dichotonious branching. Some of the glands contain round masses of protoplasm, scattered throughout which are several nuclei. These giant cells api)ear to be cross sections of tufts of epithelium.
In many places the glands present a j)eculiar arrangement and correspond to v. li'ecklinghausen's pseudo-glomeruli. These pseudo-glomeruli consist of stroma resembling that of the uterine mucosa. They contain numerous ca|)illaries and may have one or more glands situated iu their depth. In some places there is hemorrhage into their stroma. The pseudo-glomeruli are half-moon shaped, cone-shaped or irregular in contour. They are covered by one layer of cylindrical ciliated epithelium. What corresponds to Bowman's capsule consists of a layer of cells resting directly upon the muscle fibres. The cells of the capsule opposite the convexity of the glomerulus are almost flat ; on passing off laterally they are seen to be cuboidal or cylindrical. The cells of the so-called capsule are directly continuous with those of the pseudoglomerulus. The space between the capsule and the glomerulus may be empty ; many, however, contain desrjuamated epithelial cells, some of which are vacuolated aud contain brown granular pigment. Numerous spaces contjiin red blood corpuscles. On tracing one of the spaces latenilly it is found to be directly continuous with the lumen of a gland. The cajisule forms one wall of the gland aud the pseudo-glomerulus the other, Fig. 2. In otJier words, the space between the capsule and the so-called glomerulus is nothing more than a dilatation of the gland cavity. In numerous places the glaiul epithelium on one side is found to be cylindriail, on the other side cuboidal or almost flat, Ou examining this more closely it is found that where the epithelium is separated from the muscle by a moderat<> amount of stroma it is cylindrical, but that where the epithelium rests directly upon the muscle it is invariably cuboidal or flat,
A few small glands are seen lying directly between muscle bundles. Extending into the myomatous growth from the periphery are numerous bands of connective tissue. The adiliose tissue surrounding the myoma shows considerable hemorrhage. The skin covering the surface of the sj>ecimen is nornuil. The lymph glands, apart from being somewhat swollen, are normal.
Unfortunately we were not able to obtain the smaller
114
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[Nos. 62-63.
nodule of the rouiul ligameut for examiuation, and cannot say whether it was an adeuo-mjoma or uot.
From a clinical stantlpoiiit the excessive 2'ain iu the nodule at the meustrual jjcriod is siguilicant. It leads to the belief that there was some definite sym2>athetic relation between the uterus and the nodule iu the round ligament.
l>oth V. Ivecklinghauseu and I considered adeno-myomata of the uterus uon-maliguant, and the fact that the uodule iu this case existed for eight years aud increased very slowly, aud at the operation showed no evidence of malignancy, strengthens our belief that tliese tumors are benign.
The only case in the literature that throws any liglit ou this case is the one reported by A. Martin. A patient, ii;t. 70, consulted him about a rapidly growing tumor. He opened the abdomen aud removed 12 litres of chocolate-colored lluid from the tumor which jiresented at the incision. This growth sprang from the left U. ligament, being connected with it by a pedicle. I'ommorsky, who nuide the microscopical examination, found that the cyst conkiining the chocolate-colored lluid had very thin walls and that its inner surface was in places covered by clots. The pedicle of the tumor contained several small cysts which were filled with clear Uuid anil whicli communicated with one another. One of these cysts was lined by low cylindrical ciliated epithelium. Slartin says that in this case the structure aud contents corresponded to those of tumors arising from the parovarium.
Origin of the Glands.
The glandular elements in our case correspond very closely to those found by v. Recklinghausen in adeno-myomata of the uterus. In those cases he was able to trace a marked resemblance between the tumor glands and remains of the Wolflian Ijody, aud came to the conclusion that the glands were derived from this source. While admitting the probability of the glands in our case being due to remains of the Wolflian body, we cannot, from their striking resemblance to those of the uterine mucosa, aud from the fact that their stroma resembles that of the mucosa, refrain from suggesting the possibility that they may be due to an abnormal embryonic dejjosit of a portion of JI tiller's duct.
Literature.
Aschenborn : Cystis ligamenti uteri rotuudi in canuli iiij;uinali dextro. Arch. f. Kliu. Chir., Berl., 1880, XXV, 178.
Coulson : A cystic tumor of the round ligament in a woman. Lancet, Lond., 1.S59, II, IK!.
Cullen : Adeno-myoma uteri diffusum benij^uura. Johns Hopkins Hospital Reports, Vol. VI (in press).
Leopold : Beitrag zur Lehrc von di u kystischen Unterleibsgeschwulsten. Arch. f. Gynaek., Berl., 1880, XVI, S. 403.
Martin, A. : Zur Patliologie des Ligamentum rotuudum. Zeitschr. f. Gob. u. Gyn., ISOl, Bd. XXII, S. 444.
liecklinghausen : Hie Adenomyomo und Cystadenome der Uterus uml Tubenwanilung. Berlin, 18U().
Ivoiistan : Tuuieurs du ligameut rond. Montpel. Mrd., 1884, 2. s. II, JUl-121.
A LIST OF SCIENTIFIC MEDICAL JOURNALS IN PUBLIC AND PRIVATE LIBRARIES
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BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. VII.- No. 64.]
BALTIMORE, JULY, 1896.
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Contents
The Presence of an Oidium in the Tissues of a Case of PseudoLupus Vulgaris. By T. C. Gilchrist, M. R. C. iS., L.S. A., and William Royal Stokes, M. P., .....
On Movements of the Eyelids associated with Movements of the Jaws and with Lateral Movements of the Eyeballs. By Harry Friedenwald, A. B., M. D.,
The Abortive Treatment of Acute Suppurative Adenitis of the Groin by Pressure Bandage. By A. Bradley Gaither, A.M.,M. D.,
Two Rare Cases of Diseases of the Skin. By T. C. Gilchrist, M. R. C. S., L. S. A.,
129
Proceedings of Societies :
Hospital Medical Society, 143
A Clinical and Experimental Study of the so-called Oystershucker's Keratitis [Dr. Randolph]; — E.xperimental Lesions produced by the Action of Ricin on the Cortical Nerve Cell [Dr. Berkley] : — Cardiac Hypertrophy [Dr. Blumer] ; — Exhibition of Surgical Cases [Dr. Platt].
Correspondence: A Case of Hemiplegia occurring with Typhoid Fever. W. H. Haynes, M.D., Brooklyn, N. Y., - - I-W
Books Received, - - - -H6
THE PRESENCE OF AN OIDIUM IN THE TISSUES OF A CASE OF PSEUDO-LUPUS VULGARIS.*
(PRELIMINAKV h'EPORT.)
By T. C. Gilchrist, M. R. C. S., L. S. A., Associate in Dermatology, Johns Hopkins University and Hospital, AND William Royal Stokes, M. D., Baclerioloyist to the Board of Health of Baltimore.
{From the Pathological Laboratory of tlie Joltns Uopkiiit University and Hospital.']
In November, 1894, Otto Basse reported an extraordinary rase to wliicli he gave later the title of " Saccharomycosis llominis." Tlie case was that of a woman thirty-one years III' age, who suffered from a localiaed subperiosteal inflammation of the left tibia. This abscess opened spontaneously, and numerous doubly contoured, very refractive, roundish and ovoid bodies were found, situated both intracellular and e.Ktracellular in the pus and abscess wall, which were found by culture and by inoculation experiments in animals to be blastomycetes. Later the patient developed superlicial ulcers on the face, subperiosteal swellings over the right ulna and the left sixth rib near the axillary line. Busse obtained pure cultures of blastomycetes from the ulnar swelling and also growths from the bottom of the ulcers. The case ended fatally, and the autopsy revealed purulent lesions in the kidneys, spleen and lungs, in all of which similar organisms were present in large number.
' Read before the Johns Hopkins Hospital Jledical Society.
Busse found that these bodies grew on all ordinary media. and he carried out successful inoculation experiments in animals through three generations, thereby producing pathogenic lesions. Tn mice the inoculation of pure cultures caused death. The organisms were also found to produce fermentation in saccharine solutions, and were thus classeii under the saccharomyces.
In Ma)', 1894, six mouths previous to the publication of Busse's first jirticle, one of ns (Gilchrist) exhibited and described before the American Dermatological Asswiation. at Washington, U. C* microscopical sections from a case which had been under l>r. Duhring's care in Phil.-idelphia. Or. Duhring described the Ciise .is a typical chronic scrofnlo derma of the back of a man's hand. A jwrtiou was excised and was kindly sent to Gilchrist. In this tissue there were found large numbers of bodies which were round, donblv
• Reference in Duhring's Text-lKiok on Cutaneous Medicine, Vol. I., p. 167.
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[No. 64.
contoured and refractive, and after the unstained sections were treated with licjuor potassa? they appeared very distinct as against the blurred appearance of the tissue. The tissue consisted of very hypertrophied epidermis, throughout which were scattered numerous miliary abscesses, each one of which contained from one to nine of these bodies. The bodies varied from 10//-16/Jt in diameter and contained a vacuole. Numerous budding forms were observed and the mode of development was found to be only by gemmation. They were seen to be both intracellular and extracellular, and were also scattered throughout the corium. In thin section the ordinary hsematoxylin and eosin stain revealed their jiresence. No opportunity was afforded for making cultures or inoculation experiments, as the case was operated iipon before the tissue was examined. The opinion was expressed by Gilchrist before the society that these organisms should be classed as belonging more to plant than to animal life. It was not until Busse's report appeared that these organisms were positively identified as blastomycetes.
Since 1894 a number of observers have been working on the pathogenesis of the yeast fungi, and particularly the blastomycetes. Both Sanfelice in Italy and Rabiuowitch now in Philadelphia have done extensive and valuable experimental work on animals, and their results have been extretaely interesting. Maffucci and Sirleo, Fermi and Aruch, and Tokishigi have found similar organisms causing pathogenic lesions in animals.
From a case of sarcoma of the mesenteric glands in a man, Corselli and Frisco obtained pure cultures of blastomycetes with which successful inoculation experiments were carried out in animals. Curtis, in France, also found a yeast fungus present in myxomatous tumors in the right groin and loin of a man, and he obtained pure cultui'es and also produced successful inoculation experiments. Charrin and Ostrowsky have described a case of a submaxillary abscess in a man where large numbers of the oidium albicans were found present in the pus. Finally, Eoncali in a case of adenocarcinoma of the ovaries with metastases in the omentum found numerous bodies which showed an appearance like Sanfelice's blastomycetes, but no mention is made of cultures or inoculation experiments.
Through the courtesy of Dr. Ilalsted we are enabled to report a very interesting case of a cutaneous disease in a num. The patient is thirty-three years of age, married, about 5 feet 9 inches in height, and of slender but wiry build, lie is one of thirteen children, twelve of whom are still living and in good health; one child died when five months old from whooping cough.
About eleven and a half years ago, three months before marriage, on July 4, 188.5, the present eruption began at the back of the left ear, just behind the mastoid process, as a "pimple" which was about as large as a "grain of wheat," but it was roundish in shape and only slightly raised. The eruption began to spread in a linear direction towards the lobe of the ear, and very slowly, so that during the succeeding four or five years the length of the patch was only 1* to 2 inches. As the disease extended the oldest portion gradually healed spontaneously, so that a white, slightly hypertro])hic scar was produced.
The healing process was always only partial and took years for its accomplishment. The linear scar which is now distinctly visible is about I2 inches long by \-\ inch broad. After four or five years the disease, which continued to spread very slowly forwards, reached the cheek, and then began to extend upwards and downwards, so that in seven years after the commencement of the eruption it had only reached the external canthus of the left eye, after which it continued to travel along both eyelids. The tendency to heal as it went along was still a characteristic feature of the disease, but the scar was now more atrophic, whitish and thin, particularly over the cheek. Besides extending to the eye, the disease also spread gradually down the left cheek until it reached the left side of the chin. In about nine years the nose was reached by the growing edge, then the bridge was soon crossed and the right eyelids and eyebrows became involved. After this the patient noticed that the growth now began to be much more rapid, especially on the forehead and down the right cheek.
About one month after the first lesion was observed there appeared on the back of the right hand, over the middle of the third phalanx, another " pimple " which soon became pustular and opened spontaneously. This lesion also began to spread slowly, but peripherally, and assumed the same characters as that on the face ; it took about four years for it to spread over the whole posterior surface of the hand from the knuckles to the wrist and from the thumb to the inner margin of the hand. The eruption was treated with caustic by the family physician and this brought about its cure.
Another secondary lesion occurred six months after the first on the right side of the scrotum at the upper portion, and this again was characterized as a "pimple" which followed the same course as the others, except that it contained only a little pus, but the characteristic creeping propensities were shown till it reached about the size of a silver dollar. This scrotal lesion grew slowly for a year, when it healed spontaneously. No external applications were used.
Still a fourth lesion appeared in the same manner and at about the same time as the scrotal eruption, on the anterior surface of the left thigh and just above the internal condyle. This lesion also spread jieripherally for about a year until it reached a patch 3 inches by 4 inch in size, when it also healed spontaneously without treatment and left a slightly raised scar. On the back of the neck, just above the 7th cervical spine, a fifth lesion made its appearance a little later than the one on the thigh, and this continued to grow for two years, when it also healed spontaneously.
The patient says none of the lesions were at all painful.
Present rondilion. — On the face the diseased -portion presents a distinct line of demarcation. The upper border, as shown in the crude sketch of the patient, extends from the middle of the right eyebrow directly upwards, and then extends across the forehead to the left side, where it curves down again to a point just outside the external canthus of the left eye. This border consists of a comparatively thin (i inch wide), inflammatory, red ulceration which is superficial and covered with a scanty scab. Along the right eyebrow the characters of the lesion present a somewhat different aspect, viz. a firm papil
July, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
131
lomatous appearance. These papillomatous growths can be separated, and sometimes a minute quantity of pus cau be squeezed out from between them. Thin scabs were found partially covering these lesions.
The right border of the facial jiatch extends from the right
eyebrow horizontally outwards to a point within an inch of
the ear, then it extends downwards and forwards towards the
right angle of the mouth, and stops abruptly within half an
inch of this point. The border of the patch then turns
slightly upwards and inwards towards the ala of the nose.
This right border is nearly an inch broad, and presents,
especially towards the lower angle, a pronounced papillomatous character which is dry and scabby, and where it has
encroached on the region of the beard it is pierced by hairs.
The largest papillfe, which are all closely aggregated together,
are about the size of a large pin-head, and sometimes a small
quantity of pus can again be squeezed out from between the
papillae. The other portion of this border is covered with a
thin scab, ou removal of which a superficial ulcerative patch
is exposed.
The continuation of the lower border extends across the nose within an inch of the tip as a superficial ulcerative edge.
From the left ala the lesion extends downwards to the left angle of the mouth, and from there it extends still further down to the border of the jaw, along which it continues upwards to the point of its first commencement. This margin also is about one inch broad, and again at the lower angle, i". e. between the mouth and the border of the jaw, the papillomatous character is well marked and pierced by numerous hairs. These enlarged papillre are raised nearly } incli above the level of the normal skin.
The margin along the lower jaw is much narrower and superficially ulcerated.
The whole area enclosed by this irregular border consists of one continuous atrophic scar which is whiter than normal skin and thinner. The eyelids of both eyes are practically destroyed so that the patient cannot cover the eyeballs. Round the left eye the patch presents a raw, red, moist, easily bleeding surface, which extends for one inch downwards from the lower border of the eye. The right eyelids present similar appearances except that the lower patch is not so extensive. The tears from the eyes arc conliuuiilly ruuuiug
over these patches, particularly on the left side. The patient says that the disease is not even now particularly painful.
On the back of the right hand is au atrophic thin whitish scar which extends over the whole surface of the dorsum. The scar on the right side of the scrotum is about the size of a silver dollar, is reddish and somewhat contracted, whereas the scar on the left thigh is smooth, thin, very white and not contracted. The lesion which was situated on the back of the neck has left a hypertrophic scar which presents a distinctly keloidal appearance.
There are no enlarged glands. The patient has no cough ; the bow^els are regular, tongue fairly clean, and he says that he has always enjoyed good health. There is no history of syphilis, although the patient's wife had a i months miscarriage, but no children. The wife's courses are very irregular. No tuberculous history in the family could be obtained.
In making a diagnosis of this disease the first impression was that of lupus vulgaris, but on closer examination some peculiar features were seen which, with the history, did not confirm this diagnosis. The appearance did not simulate that of lupus papillomatosus, neither were any lupus nodules found in any portion of the lesion. Tuberculosis cutis, and particnlarly tuberculosis verrucosa cutis (Riehl and Paltauf), was then thought of, and clinically various points of resemblance presented themselves between this latter disease and our case. Tuberculosis verrucosa cutis begins as a papule which later becomes pustular, and after forming a scab, which falls oflf, a papillomatous growth is produced. This disease spreads very slowly peripherally, and on lateral pressure a little pus can be squeezed out from between the papillae ; but the hands, forearms and feet are the only regions of the body where this disease has been found. The history of the lesion in our case and the fact that it healed spontaneously in three situations on the body is almost sufficient clinically to exclude tuberculosis of the skin in any form. Scrofuloderma was also thought of. but was excluded on the grounds that there were no enlarged glands and the entire absence of auy other signs of this affection. In order to make a diagnosis of our cjise. two portions were excised, oue from the right eyebrow and one from the right border of the patch on the face, for microscopical examination. One portion was dropped into 5 per cent formalin solution, and the other into 95 per cent alcohol.
Pathological Histology. — Unstained sections treated with ordinary liquor potassa? showed the presence of numbers of curious bodies which were doubly contoured and very refractive, whereas the tissue assumed a blurred appearance.
The stained specimens showetl an hypertrophy of the epidermis, throughout which numerous variously sizeil well defined miliary abscesses were scattered. The epidermis was elsewhere considerably infiltrated with polyuudear leucocytes, and irregular masses of detritus were situated on the epidermis in places. Large collections of granulation cells were massed in the corinm. and a few miliary abscesses were also observed in the upper portion of this region. A fair amount of inflammatory material was also distributed throughont the coriuni, and in a number of sections there was some evidence of the formation of tnbercule-like nodules in the deeper portion of the corinm. Situated in all the miliary
132
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 64.
abscesses, and also among the granulation cells in the corium, were numbers of doubly contoured, refractive, round and ovoid bodies, varying in size from 10,'/-20/'. in diameter. Many of these forms presented buds of various sizes, and sometimes a vacuole was discernible, but this was not constant. The bodies were usually found singly, but they were sometimes arranged in groups. They were more numerous in the miliary abscesses than elsewhere. The contents of the bodies consisted of granular protoplasm which took up the ordinary stains. One of us (Gilchrist) who first observed these curious forms thought that they simulated very closely the blastomycetes which were found in the case already described by him, and therefore cultures and inoculation experiments were then carried out. In all the sections only a few giant cells were found, and it was only occasionally that one of the bodies was seen enclosed in a giant cell. The sections from the papillomatous growth did not differ materially from those already described, except that the papillae were much hypertrophied, and sometimes a miliary abscess opened on the surface between the papilla^, which would explain the origin of the pus when pressure was made on them. Although numerous sections were stained for tubercle bacilli, yet none could be found.
Cultures. After sterilizing the surface of the' papillomatous lesions, careful cultures were taken in two places from the pus which was squeezed out. Other cultures were taken from beneath the scabs, and also after excising a portion of the surface of the lesion.
The organism grew in pure culture from both of the tubes inoculated with the pus from two separate places, but those from the tissues contained a profuse growth of the pus organisms, and in only one instance a single large colony of the parasite developed.
The cocci from the tissues were not further noticed, as they were not present in the pus and could have no causal relation to the chronic jirocess.
The morphology was first studied from portions of young colonies, and these fresh specimens were seen to consist of large refractive, oval or round bodies, showing a double contoured membrane suggesting an episporiuni and an endosporium, and containing numerous refractive granules resembling fat drops. These bodies often showed evidence of increase by budding, and at times the formation of short hypha?. They possessed an average diameter of from 10/J!-16,a, and closely resembled the bodies observed in the tissues. At times the granules within the protoplasm showed Hrownian movements. They stained with the ordinary aniline dyes, the deeply staining membrane being separated from a central" mass resembling a granular nucleus by a more lightly staining hyaline zone.
The development of this organism was observed by means of hanging drop cultures made from bits of colonies, and is as follows : From the round or oval bodies there occurs a growth of numerous long branching threads of mycelium, at first clear, but later containing numerous fine granules or larger round refractive bodies. At various points along the sides of these hyphse numerous small knob-like projections of the limiting membrane occur, which gradually enlarge and at last
form large round cells or conidia. These either remain attached by means of narrow stems or sterigmata, or become free, and then greatly resemble the cells observed in the tissues and young colonies. These latter cells also frequently give evidence of increase by budding, and this is of interest in relation to the budding forms in the tissues. The growth in cultures is attended by the formation of envelope-shaped and dumbbell-shaped crystals of oxalate of lime.
The cultures grow most favorably on glycerin-agar and potato and are rather slow in developing. At the end of about 1 days numerous grayish-white colonies appear on the surface, which later become pure opaque white and develop numerous fine prickles, so that they resemble minute chestnut burrs. On potato this process continues until the growth becomes confluent and resembles a portion of the skin of a white rat stretchedover the surface of the medium. A prominent characteristic of the growth is its firm adherence to the substratum, rendering it impossible to detach individual colonies without removing portions of the surrounding agar. Colonies also develop favorably on plain nutrient gelatine, 20 per cent beer-wort gelatine, plain agar, and 5 per cent beerwort agar, bouillon, fluid beer wort, Dunham's solution, and milk : none of these fluids show any perceptible change, and no indol is formed. No alcoholic fermentation or the formation of any gas was observed after several weeks' growth in glucose, lactose and saccharose bouillon in the fermentation tube, (lelatine is not liquefied.
The animal inoculations with fresh bits of tissue consisted in the subcutaneous inoculation of one white mouse and one guinea-pig. The mouse died in 34 hours of a pneumococcus septicemia. The guinea-pig has survived the inoculation for several months and shows no perceptible change. One guineapig inoculated with tissue in the peritoneal cavity by Dr. Flexner was killed at the end of 2 months, but showed no evidence of any disease except a few gray necrotic areas in the liver. The cultures were negative.
These inoculations are therefore only of negative importance, as enabling us in connection with the facts mentioned to rule out tuberculosis. Numerous attempts were also made to reproduce lesions in the skin of a dog from pure colonies by scarification and subcutaneous pockets, but with negative results.
A pure culture teased in salt solution was injected by Dr. Flexner into the external jugular vein of a dog under antiseptic precautions. During the space of about two months the animal seemed to become somewhat emaciated, but remained otherwise well. At the end of this time the dog was killed, and at the autopsy both lungs presented a striking picture. Projecting from the entire pleural surfaces there area large number of generally discrete, pea-sized or larger,, firm, light-yellow nodules. On section these extend for the distance of from i to 2 cm. into the lung substance, and are yellow in color, but are clotted here and there with lighter, grayish yellow, softer, halfpin-head sized areas. These nodules are regular and round, and their circumferences are sharply marked out from the surrounding normal lung tissue. On section of both lungs, numerous similar bodies are scattered throughout the entire substance, but no cavities or large caseous areas were noticed.
July, 1896.J
JOHNS HOPKINS HOSPITAL BULLETIN.
L33
The bi'ouchial glands are enlarged, firm and light yellow on section. Nothing else of interest was noted. Bits of the lung nodules and bronchial glands were teased and examined fresh, and in both cases there were found very numerous, round, highly refractive bodies, with double contoured membrane and clear protoplasm. These bodies entirely resemble the original bodies found in the pus and in young cultures. Fresh sections of the lung hardened in 10 per cent formalin and then stained according to Flexner's method, show that these nodyles consist of central large areas of coagulation necrosis, containing an occasional giant cell and much fat, and surrounded by a zone of large epithelioid and lymphoid cells, forming lesions of the general nature of pseudotubercles. The bodies mentioned above are seen as light blue round bodies, scattered for the most part throughout the necrotic areas. From the study of these bodies in fresh sections it is quite evident that there has been an extraordinary increase of them within the lung tissues.
From the lung nodules and bronchial glands pure growths of the same organisms were obtained on human blood serum, agar agar, and beer-wort agar. On this latter it was interesting to note that practically no mycelium was formed, but the colonies were whitish, dome shaped, smooth and shiny.
Further inoculations were made from the lung nodules of the dog into the peritoneal cavity of a guinea-pig, and also from pure cultures from the nodules into the subcutaneous tissue of the neck of a horse. In about one month's time an abscess of the epididymis of the guinea-pig developed, and the pus contained numerous organisms similar to those inoculated. In about the same time a local abscess developed in the neck of the horse at the point of inoculation, and a large number of the organisms were found, but no pus cocci. Cultures from the abscess contents showed a pure growth of the oidium.
It is interesting to note that these organisms jjroduced lesions in animals similar to the cutaneous lesions in the patient, i. e. the production of miliary abscesses and the formation of tubercle-like nodules. A number of other animals have been inoculated, but the results from these experiments will be reported later.
The development of mycelium and distal and lateral cells
or conidia, and the failure of the organism to cause alcoholic fermentation, have led us to classify the parasite as an oidium, a subdivision of the class of true fungi, and separated from the blastomycetes or yeast fungi. The entire absence of mycelium in the tissues would at first sight suggest that the organism in the tissues and that in the cultures are not identical. Brefeld, however, in his study of ustilago, a species of fungus causing the blight in many of our cereals, has pointed out that the spores alone are to be found at the seat of disease, and that a somewhat complicated cycle of development takes place elsewhere in nature, ending in the introduction of spores into other plants. This is true of many of the fungi.
Tokishigi has also studied an organism greatly resembling the one found in our case, which occurs in the nodular abscesses of a disease affecting many horses in .Japan. Although he was unable to demonstrate any mycelium in the pus or tissues, he observed the growth of a well marked thallus in his cultures. These facts taken in connection with the occurrence of pure cultures of a fungus from the pus obtained from the cutaneous lesion on the patient in two instances, and the successful inoculations in animals (guineapigs, dogs and a horse), show that the organisms in the tissues and eultui-es are the same. We think that our organism differs from the numerous blastomycetes described by the authors cited above, in that it forms mvcelium and does not ferment sugar.
In conclusion, therefore, we are of the opinion that this extensive cutaneous disease is caused by the presence and growth in the tissues of a species of oidium. Whether the organisms found in the case already recorded by one of ns (Gilchrist) are the same as those found in this case will remain in doubt, although the similarity of the two organisms in the tissues is, to say the least, very striking. As far as we know this is the only example in literature of a pure cutaneous disease which has been shown to be caused by a species of oidium; and it is the third example where lesions of the human skin have been produced by organisms allied to the yeast fungi, Busse's case and Gilchrist's being the other two.
We take this opportunity of expressing our thanks to Professors AVelch and Flexner for their advice and help in our investigations.
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JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 64.
ON MOVEMENTS OF THE EYELIDS ASSOCIATED AVITH MOVEMENTS OF THE JAWS AND WITH LATERAL MOVEMENTS OF THE EYEBALLS;^=
By Harry Friedenwald, A. B., M. D.
At a recent meeting of this Society (October 7, 1895), Dr. Thomas presented a patient with unilateral congenital ptosis. In the course of his remarks he described certain associated movements occasionally seen in cases of ptosis, though the patient presented did not definitely show this peculiarity. In a conversation Avith Dr. Thomas I mentioned a number of cases which had come under my observation, some of the patients being under treatment at the present time, and at Dr. Thomas's kind invitation I have the honor to present a few to you this evening.
Quite a number of associated movements of the upper lids have been described ; these vary greatly. In some, as in the cases referred to by Dr. Thomas, there was ptosis, but in others the same peculiar association of movement existed without ptosis. The lid movements occurred in some in association with opening and closing or with lateral movements of the jaws, in others they were associated with lateral movements of the eyeballs.
A. I shall first present a case of the former variety.|
C. D., female, aged 9, has normal eyes excepting, slight hypermetropia. The movements of the eyeball are perfectly normal in every direction. There is no ptosis of either eye, but the right palpebral fissure appears on very careful examination to be a trifle smaller than the left, the difference being about 1 mm.
She was first brought to me by her mother, who complained that when the child ate, the right eye assumed a peculiar and repulsive appearance. This had been noticed since she was an infant. Giving her something to chew, especially when she is looking down, demonstrates the peculiar association of movement. It is seen that the right uj)per eyelid is drawn forcibly upwards only in lateral movement of the jaw and, what is most curious, only when the jaw is moved toward the same side as that of the eye. During protracted lateral movements the lid is spasmodically raised and soon assumes a condition of continuous contraction. These peculiar movements become less marked when the patient's gaze is directed forward, and are not at all visible when she looks upward.^ Two similar cases have been reported (Gunn, Schapringer) ; in both there was ptosis, and lateral movement of the jaw produced elevation of the lid, but in both this was associated with a movement of the jaw toward the side opposite the eye; in other words, the levator palpeljrae superioris was excited into action
•Read before the Jolins Hopkins Hospital Medical Society.
tThe variety has been carefully studied by Dr. M. Bernhardt in the " Beitrag zur Lehre von den eigeiithuemlichen Mitbewegungen des paretisclien oberen Lides bei einaeitiger angeborener Lidsenkung," Neurol. Centralb., 1894, p. 325. He lias collected all the published cases aud discusses the various explanations that have been given. We shall therefore refrain from entering upon a discussion of the subject in this paper and limit ourselves to the report of two new cases, one of which is quite unique.
XSee Sinclair, Ophthalmic Review, Oct.. 1895, p. 308.
by muscular effort of the pterygoid of the same side. The same relation existed in all those cases in which the eyelid was retracted both by opening the mouth aud by lateral movements of the jaw. The case presented is unique in showing association of the levator with the pterygoid of /he opposite dd». (Demonstration of case.)
The second case which I wish to present is Miss R. S., aged 20 ; she was treated for slight error of refraction which produced asthenopia; there is slight drooping of the right eyelid.
^\'hen she eats, the right eye becomes widely dilated, 2 mm. at least of the sclerotic being thus exposed above the cornea. The lid is elevated only during lateral movements of the jaw, but I have not been able to determine whether it is the movement toward the same side or the opposite. Besides these defects there is slight crossed diplopia in the left portion of the field of fixation, with several degrees of vertical displacement, the image of the right eye being higher. She is positive in stating that the peculiar movements of her lid came on not earlier than six years ago. Unlike the other cases that have been described, this was not congenital. (Demonstration of case.)
B. We may next direct our attention to the association of movement of the lids with lateral movements of the eyeballs.
The published cases belonging to this category are as follows :
Case I.*— F. W. Browning (Trans. Oph. Soc, 1890, p. 187), male, aged 46. When he looked outwards, either to the right or to the left, the upper lid of the same side drooped, while the other was slightly elevated. The lid movement was more marked on the left side. When he converged strongly, both upper eyelids were simultaneously raised above the horizontal — the left most so. As he followed the descending finger, the eyelids followed the globes down to the horizontal, but there remained stationary. All extreme movements of the eye produced coarse nystagmus.
Cases II and III,* Dr. Sidney Philips (Trans. Oph. Soc, 1887, p. 306). Condition present in two brothers, aged 7 and 3 years. When the eyes were directed outwards, to the right or to the left, the upper eyelid of the other side drooped, that of the same side " remained raised."
Case IV,* Pfliiger (XX. Congress of Heidelberg, S. 202). Female, aged 18. AVhen looking to the left the palpebral aperture was wide open ; looking straight forward produced a slight drooping of the right upper eyelid, while looking to the right brought on complete ptosis of the right eyelid. The patient could not overcome this ptosis voluntarily. Looking up (aud to the right) did not alter the position of the eyelid. Strong movement to the left produced extreme opening of the palpebral aperture, which was maintained if the eye was likewise directed downwards.
The first to systematically study these cases was Fuchs
•Abstracted by Sinclair, Ophthalmic Review, Oct., 1895.
July, 1896.
JOHNS HOPKINS HOSPITAL BULLETIN.
135
(Deutschmanu, Beitriige zur Augenheilk., Vol. II, p. 13). He published eight cases. lu three of these the lid was raised wheu the eye was abducted (Cases V, VI and VII).
Case V, male, 39 years ; ocular movements normal. On looking directly forward no difference is noticeable in the palpebral opening on both sides, but when the right eye is adducted the eyelid droops. The affection was probably congenital.
Case VI, male, 4.5, syphilitic. Eight eye : slight ptosis and paresis of the internal rectus, pupil dilated, and the accommodation paralyzed. This condition disappeared under treatment with potassium iodide, but at the same time the like affections appeared in the left eye. It was then that the left upper eyelid showed the associated movements under consideration — it was raised in abduction of the eye, but drooped in adduction. A year afterwards the ptosis had entirely disappeared, aad likewise the associated movement. There was absolute paralysis of convergence (though the lateral movements were normal), the pupils were unequal and stationary, and there was paralysis of the accommodation.
Case VII, female, set. 30. Paresis of the external recti muscles, especially of the right, and slight ptosis of both upper eyelids, slightest on the left side. (The ptosis on the left side soon disappeared.) In looking to the right, the eyelids remain in the same position, but in looking to the left the eyelids fall 2 mm. In convergence or when the eyes are raised or lowered there are no peculiar movements of the eyelids. In this case there was relaxation of the right lid in adduction, and of the left in abduction.
In five of Fuchs's cases the upper lid was raised during adduction of the eyeball.
Cases VIII, IX, X, XI, XII. — His five patients were all adults. In one only was the affection congenital. All had ocular paralyses (probably nuclear) ; three had paralysis of all the muscles supplied by one oculo-motor nerve, one of the superior rectus and levator palpebral, one of the superior and internal rectus with slight paresis of the inferior rectus. In three of the cases the contraction of the pai'etic upper lid was so great during adduction of the eye that it rose higher than on the healthy side. Two of the cases showed contraction of the pupil during adduction, and in one there were interesting rhythmic associated movements of the lid and pupil. To these cases we must add the last one of Fuchs's mentioned under the former head of associated movements, in which the right lid relaxed in adduction, while the left relaxed in abduction.
These cases belong to the same class as those of Browning and Ptliiger described above. They are the only ones that have hitherto been published. I shall add one to the list. (See Case XXIV.)
In 1893 we described two cases (Archives of Ophthalmology, Vol. XXII, p. 349), similar to cases of \', \' 1 :uul \]| (of Fuchs).
Case XIII, Miss S. W., a;t. 11. The right eye appeared normal, but the left was smaller and lay deeper in the orbit. It was found that the movements of the left eye toward the nose were somewhat restricted, but that there was almost complete paralysis of the e.\ternal rectus muscle. When the attempt is made to look to the left, the left upper lid is raised
so much that the palpebral fissure is as large as on the right side. If the eyes are turned to the right, the left palpebral fissure becomes very narrow. This patient had binocular vision when the eyes were directed forwards.
Case XIV, B. C, set. 17, female, white. There was complete paralysis of the left external rectus with very slight convergent strabismus when looking directly forward. There was probably binocular vision. When the eyes are moved to the right or wheu the eyes are converged, the left palpebral fissure is much smaller than on the right side. On moving the eyes to the left (the left eye does not move beyond the median line), the left palpebral fissure becomes so wide that about 1 mm. of sclerotica is exposed above the cornea.
Sinclair (in the Ophthalmic Keview for October, 1895) describes five cases in all respects similar to Fuchs's and my own (Cases V, VI, VII, XIII, XIV). These he has overlooked, stating that no cases similar to his own are on record.
His cases XV to XIX are all children ; four are girls. In all of them the left eye is affected. The external rectus is jiaralyzed in all the cases; the internal is weak in three.
To these I wish to add the following, the first of which is here presented to you :
Case XX, A. V., female, aged 10. The patient h:is slight enophthalmus of the right eye and a rather high degree of hypermetropia, but otherwise the eyeballs are normal. In direct vision the palpebral fissures are about ecjual. The lateral movements of the right eye are very defective. Adduction is considerably impaired, the eyeball turning but slightly inwards, and moving in an upward direction when attempts at adduction are made. At the same time the enophthalmus is markedly increased. Movements inward and downward are not at all impaired. There is complete paralysis of abduction, the right eye not moving beyond the median line. There is no diplopia, and in direct vision it was shown that the patient had binocular vision.* This, together with the history furnished by the mother, proves that the condition was 'congenital.
The associated movements to be described are as follows :
The right palpebral fissure measures (i mm., the left S mm. when she looks towards her left; attempting to look toward her right, her right palpebral fissure becomes 10 mm., the left remaining about the same. The difference becomes still more marked when the lateral movements are made in a plane below the horizontal : looking toward her left the right eye almost closes, the palpebral fissure mejisuriug 3 to 3 mm. : looking toward the right widens the fissure to 8 to 9 mm. (Demonstration of case.)
A similar csise is Xo. XXI. iliss E. V., agetl 30, had a paralytic stroke wheu she was five years old. Up to that time her eyes were normal, afterwards her eyed were crossed: no diplopia. Paralysis of the external rectus of the left eye. Wheu looking to her right, left palpebral fissure l>ecomes smaller than the right; on looking in the opposite direction. the relative size of the palpebral fissure becomes in versed.
Case XXII is very interesting in other respects:
• Tests wore made with the stereoscope and by means of Lippincott'a method. Toward either side there was no binocular vision.
136
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 6-1.
H. F., aged 19, complained that he was forced to move his head from side to side in reading. V. RE. is perfect ; L. E. amblyopic. There was comphle congenital paralysis of abduction and adduction of both eyes. Movement upwards and downwards perfectly normal. In attempting to look toward the right the left lid drooped somewhat, bnt was opened widely when looking in the opposite direction.
Case XXIII. Mrs. M. B., aged 59, fell when 18 months old and injured left eye. The left eye appears to be deeper than the right eye. There are several scars about the orbital region. The left palpebral fissure is 2 mm. smaller than the right in direct vision. Looking toward the right, both eyes move properly, bnt the left palpebral fissure becomes much smaller. Looking toward the left, we find complete paralysis of the left external rectus, and the left fissure becomes much larger than the right. There is no drooping in accommodation.
It is very curious that in almost all these cases it is the left eye that is affected. It is likewise remarkable that the great majority are females.
The next case is one in which the eyelid droops with abduction, and is raised in adduction, as in cases VIII, IX, X, XI, XII (of Fuchs).
Case XXIV. J. F., aged 35, has cerebral syphilis. The patient suffered a severe apoplectic attack four years after the secondary signs occurred. There was paralysis of the left leg and arm, and later the right leg and arm and the right eye were paralyzed. The right eyelid drooped and a high degree of divergence set in (ocular-motor paralysis). His condition gradually improved. When examined (September 6, 1894) we found in the right eye paralysis of the internal rectus (not complete, eye can be brought into median line by great effort), complete paralysis of the upward and downward movements. Movements outward normal. The left eye showed paresis of the internal superior and inferior recti; external rectus normal. There is no movement downward and outward in either eye, which would indicate paralysis also of the superior obli(iue. The levators are almost normal. When the patient looks to the right, the right upper eyelid droops, making the right palpebral fissure smaller than the left. When looking to the left, the right palpebral fissure becomes widely dilated, so that a part of the sclera is exposed above the cornea, while the left eyelid droops so far as to reach the upper margin of tlie pupil. Pupils are of medium size, do no react alike, the left seems to react slightly to acconmiodative impulses. Vision of neither eye greatly impaired (6/12, (J/9 without glasses).
From this list we see that there are eight cases (I, I\', VIII, IX, X, XI, XII, XXIV) in which the upper eyelid is raised in attempts at adduction and droops in abduction, and that there are on the other hand fifteen in which the opposite conditions prevail.
Iq one case (VII) there was relaxation of tlie right lid in adduction and of the left in abduction.
Taking the first set of cases into consideration, wo find that six of the eigiit cases are males; that in five the condition was acquired, and in three it was congenital ; in one there was uo paralysis of the ocular muscles, in four the ocular-motor nerve was completely paralyzed ; in one the superior and the
levator ; and in one there was double oculo-motor paralysis ; and in one both superior recti were affected.
In the last named case all external movements produced nystagmus.
In two of the cases the pupil contracted during adduction, and in one there were rhythmic movements of the lid and pupil.
In the second group of fifteen cases (in which the lid is raised in abduction and droops in adduction) six were males and nine females.
The condition was congenital in twelve, in two it was acquired in infancy; in the remaining case it was acquired after oculo-motor paralysis, and disappeared in a year. There was no paralysis in four cases; the external rectus was paralyzed in ten cases, and in four of these the internal was also paretic. In one case (Case XXII) both external and internal recti were paralyzed. The affection was limited to one eye, excepting in one case in which both eyes were affected.
In seven cases there was enophthalmus. In one of the cases there is a note that the drooping of the lid also occurred when the eyes were converged (Case XIV); while in another (Case XXIII) the adduction in convergence did not produce droojiing, while adduction in lateral movements did.
In eleven cases the left eye was affected, in two the right eye, and in three both eyes. Finally there was one case (Case VIIj which belongs to both classes. In this both external recti were affected, and there was slight ptosis.
It is evident that while the oculo-motor nerve is the one paralyzed in the first class of cases, it is the abducens which is chiefly affected in the second class.
No satisfactory explanation of these conditions has been given. It is probable that when acquired after paralysis they belong to the same category as those associated movements observed in hemiplegia. For the larger number, the congenital cases, we may assume the existence of abnormal relations of the cerebral nuclei and association fibres, but this is only restating the question.
C. The following cases are of interest as showing the closer association between the superior rectus and the levator than between the two levators.
Mrs. E. H., aged 44. Ten years before examination paralysis of left leg and arm, and later of the right leg. At the same time paralysis of the right eye. At the time of examination the patient was able to walk, but dragged the right leg. There was diabetis insipidus. The right eye showed complete paralysis of superior and inferior movements ; there was slight ptosis of the left upper lid. Looking forward, the left fissure is 2 to 3 mm. narrower than right. Looking down, the left eye does not follow the movement of the right, hit remains looking directly forward and the eyelid remains open.
R. W., male, aged 21, colored. Left convergent strabismus since childhood of very high degree. Movements of this eye arc peculiar; they are limited to an upward and inward movement. When the patient looks down with the right eye the left eye looks forward and slightly inward, and the upper lid remains raised, even when the right eye looks downward to that degree that it is almost closed.
Neither of these patients has any difficulty in opening or closing the eyelids.
July, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
137
THE ABORTIVE TREATMENT OF ACUTE SUPPURATIVE ADENITIS OF THE GROLN BY
PRESSURE BANDAGE.*
By a. Bradley Uaither, A. M., M. D.
The frequency with which the complication of acute suppurative adenitis of the groiu is present in cases of urethritis and chancroid, and the very unsatisfactory results of treatment instituted to check the process, should make any procedure which holds out even a fair chance of success, most welcome. When used for abortive treatmei)t, applications of iodine, mercurial ointment, belladonna ointment, etc., have given practically no results, while injections of solutions of bichloride of mercury or carbolic acid are painful and liable to set up a great deal of inflammation. There is also the risk of infecting the bubo, the contents of which are always absolutely free from germs. In the hands of some operators gratifying results have been obtained from injections, but as a rule they have been discarded as unsatisfactory. In fact, all the abortive methods having been found wanting, it has become more and more popular with surgeons to abandon such treatment altogether, and to endeavor to bring the condition to an operative stage as soon as possible.
Dr. Lydston advocates " the early and complete extirpation of all bubos." He claims that " when suppuration has begun in the glands, and this suppuration begins early, even as soon as the third day, the inflammation extends to the peri-glandular tissue; and then the case becomes long and obstinate, from the continued suppuration."
Dr. Edward Martin says that " in the treatment of bubo the best results in the long run would be obtained by immediate incision of the glands as soon as they become markedly inflamed, and closure of the resulting wound by suture. It is a good rule to attempt the abortion of a bubo not longer than three days. If no good results follow in this time, suppuration will almost certainly occur."
Such had been my opinion before using the pressure baudage abortive treatment, but on account of the results obtained from a series of cases, I would now advise putting on a pressure bandage, regardless of the age of the bubo, if suppuration has not advanced to such a degree as to bring the case practically to the operative stage.
The bandage is applied as follows: A piece of cotton as large as the list is folded in on itself again and again until it has the shape of the bubo, and when placed on it does not completely cover it. This is carefully adjusted, aiul a wad of tightly compressed cotton as large as a cocoanut placed over it. Small pieces of cotton are also used on the inner and outer surfaces of the thigh, to prevent chafing. A very tight spica bandage is tlien put on.
The amount of pain experienced by the patients varied greatly. In some cases tlie j)ressnre did not seem to increase it at all. In fact, the relief of pain has been, in most cases, remarkable.
One mau with a large bubo in each groin had suffered a
•Read before the Johns Hopkins Hospital Mi\lical Society.
great deal and had been unable to work for three weeks previous to a])plying for treatment. Two days after the double bandage had been applied he returned to his work, that of a laborer, and continued the same without interruption while the bubos were being aborted. In almost every variety of treatment for bubo, the point insisted on is rest in the dorsal decubitus position. While wearing the pressure bandage this is by no means imperative, though it is to be preferred. If the bandage remained in position 24: hours, even if the gland went on to suppuration, the pain would be diminished.
In the series of cases reported here, which were treated in the genito-urinary clinic of the Johns Hopkins Hospital Dispensary, the bandage was used regardless of the condition of the bubo or the apparent hopelessness of success.
Eighteen cases were treated, four of which were practically in the operative stage when the bandage was applied, and three of the four showed no improvement.
In two cases the men were unable to keep the bandage on more than a few hours, saying that the pain, already great, became unbearable.
Of the remaining twelve cases, the bubo was aborted in nine, including two which seemed to be so far advanced as to leave no chance of success. The earlier the bandage was applied the better was the termination, and if treatment was begun before any sign of suppuration could be made out, a satisfactory result w;is obtained in more than 85 per cent of the cases.
In estimating this percentage it must be held in mind that in a certain proportion of cases a bubo will subside while we are doing our best to hasten suppuration. I recall the case of a man who had a bubo in each groin, one of which had reached the operative stjige, while the other was not quit* so far advanced. In order that both might be incised at the same time, he was advised to apply a poultice and come back in three days. He kept poultices continually ou each bubo, and on his return it was found that suppuration was being checked on both sides, and eventually he recovered without operative interference. The notes on four of the cases treated are iis follows :
Case I.— F. R., white, age 26, October 30, 1S95. Patient has had discharge from urotlira three weeks. Has had two attacks of urethritis. Now has no pain on micturition, or incre:vsc in frequency. Dischargn is thin and serous. There is a barrel-shaped induration exteudini: 2 centimeters along the frenum. Smear preparation ma'ie and no organism found. Examination with endoscope reveals ulcer in fossa navicularis, eitending from 1 centimeter from meatus almost to meatus. Ulceration is most marked on upper right side of urethra, but extends completely around same. Treatment : Irrigations of bichloride of mercury jvjos November 7, 181*5. Condition same.
November 13. Has intlammatory bubo in right groin, duration 4 ilays. Size of hen's egg. Skin covering swelling bright red. No sign of suppuration. Very painful. Patient can hardly walk. Treatment : Pressure bandage.
138
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 64.
November 18. Bubo much improved. Redness and swelling less. Gland is hard and almost painless. Continue bandage.
December 2. Gland is smaller, liard and painless. Stop bandage. On December 16 a macular eruption appeared on hands and wrists, later over abdomen, and patient is now under treatment for syphilis, with no further trouble from bubo.
Case II.— W. L. W., age 45, white, November 21, 1895. Patient has had discharge from urethra 15 days. First attack. Pain on micturition during first five days; none at present. No increase in frequency of micturition. Glands in left groin slightly enlarged. No pain. Treatment: Lafayette mixture.
November 27. Patient returns with inflammatory bubo, left side. The glands are matted together. Slight redness and tenderness. No suppuration. Treatment : Pressure bandage. The bandage was renewed from time to time, and on January 7, 1896, the glands were hard, painless, and gradually being absorbed.
Case III.— A. P., colored, age 24, December 27, 1895. Patient hag had bubo, left side, 3 weeks. Says it was preceded by two small discharging sores on either side of the frenum, which can still be seen, but have almost healed. There is a large inflammatory bubo in left groin ; glands are matted together and show evidences of suppuration over one small area. Skin covering swelling is adherent and glistening. Treatment: Pressure bandage.
January 2, 1896. Bubo smaller and harder. No further sign of suppuration. Continue bandage.
January 7. Slight evidence of bubo. Swelling in groin not jiainful. Stop bandage.
Case IV.— C. B., white, age 18, November 16, 18^5. Has had discharge from urethra '•'> weeks. First attack. Some pain on micturition and increase in frequency. Discharge profuse and purulent. Treatment: Injection bichloride of mercury -^uluo- Has inflammatory bubo, left si<le, size horse-chestnut. Skin covering swelling red. Considerable pain on pressure. No evidence of suppuration. Treatment : Pressure bandage.
November 21. The glandular enlargement in left groin has alifiost disappeared. No evidence of suppuration. Continue bandage.
November 27. No sign of inflammation about inguinal glands, which are now slightly enlarged. No pain. Stop bandage.
The patient continued under treatment for urethritis until December 24, without any sign of a return of the bubo.
Ill several instances the tightness of the bandage caused cedema of the penis by interference with the circulation, which readily subsided when the pressure was relieved. In a case of double bubo, when the bandage was left off for one day on account of oedema, there was in that time marked evidence of a return of suppuration, which had apparently been checked.
The bandages were renewed in from four to eight days, and the patients were able to continue work without inconvenience. If the abortive treatment did not prove successful, the bubos were much larger than they would probably have been had they not been kept under pressure.
In one case, in which the bubo was incised under ether after the pressure bandage had been worn 8 days, the glands were found hard, matted together, and without suppuration at the top, but at the very bottom some pus was discovered. It seemed that the suppurative firocess had been checked from above downward and had almost stopped. It is probable that had the bandage been persisted in a few days longer there would have been no necessity for an operation and absorption would have taken place.
It can be said in favor of the pressure bandage treatment for acute suppurative adenitis of the groin :
1. It is safe.
2. Pain is, as a rule, diminished after 24 hours.
3. It does not prevent the patient from pursuing his usual occupation.
4. It gives a high percentage of successful cases. 2012 St. Paul Street.
TWO RARE CASES OF DISEASES OF THE SKIN.
By T. C. Gilchrist, M. E. C. S: L. S. A. [Exhibited before the Johns Hopkins Medical Society.]
I. — Lymphangioma Circumscriptum.
The first case is that of a young girl, 13i years of age, who came to us in our dispensary clinic about three months ago. The family history did not reveal anything bearing on the disease.
The following liistory of the present lesion was obtained from the mother; when the patient was only eighteen months old, a small patch of eruption was first noticed on the outer side of the left thigh just below the left great trochanter, and the eruption consisted of a group of thick clear " blisters " (so the mother says), some of which were very dark colored (hemorrhagic). Neither pain nor swelling accompanied the eruption. The patch at first was about the size of the palm of the hand, but as time went on it increased very slowly in size, until the patient was eight years of age, when she met with an accident (a full on the affected side) which resulted in an injury to the cutaneous lesion and the deeper tissues.
Suppuration followed, and a large abscess resulted which included not only the patch but a portion of the thigh below. After suffering locally and constitutionally for some time, the patient was brought to the hospital for surgical treatment and was operated upon. On looking up the report of the case, it was found that an incision 7 inches long had been made over the abscess, which was cleaned out and an elliptoidal jjortion of skin was removed, and the resulting wound was sewed up. A note was made about the thickened skin, but no mention of vesicles or any particuliir cutaneous lesiou was re])orted. The girl left the hospital cured of the abscess si.x weeks later. Previous to the accident the patient's health had always been good. The mother now says that, after the operation, where some of the original patch of eruption had not been removed, the "blisters " increased rapidly in number and extent, especially over the region of the scar and surrounding area. This second rapidly appearing lesion presented the same characteristics which distinguished the original patch.
FIG. I
-■■•y^-:... -■-•-- — ■^--•^- . ;:.
';^,;^:; ;{f
t||^; : ; )f.
'"'^W^-'PWM)
'^'^^^^i^^
no, 2
\\
&
^^ \j-'
rcv-«'
nG.3
K 7 ^
FIG ..—LYMPHANGIOMA CIRCUMSCRIPTUM. A section of vesicle. L— Lymphatic dilated C— Capillaries. V-Bloodvessels. G — Sebaceous gland S — Sweat gland.
FIG. 2.-URT1CARIA PIGMENTOSA. Section of nodule from arm of a child (.6 months old). A-Arrectores pili muscle. F— Part of hair follicle. S— Sweat duct and glands. ii » ii
FIG. 3.-URTICARIA PIGMENTOSA. ,— Mastzell in normal skin. 2-Mastzellen in centre of growth 3, 6 ^^ 7-Mastzei en showing deeper stained and larger granules. 4-Varieties of fatty infiltrated mastzellen. 5-Mastzellen with two nuclei. A — Small portion of larger drawing magnified.
CORRESPONDENCE.
BOOKS RECEIVED.
+++++++++
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. VII.- No. 65.
BALTIMORE, AUGUST, 1896.
+++
Contents
The Witches' Pharmacopoeia. By Robert Fletcher, M. D., - 147
Farther Observations upon the Treatment of Malignant Tumors with tlie Toxins of Erysipelas and Bacillus Prodigiosus,
with a Report of 160 Cases. By Wm. B. Coley, M. D., - - 1.^)7
The Psychical Nerve Cell in Health and Disease. By Henry
J. Berkley, M. D.,
162
The Frequency of Contracted Pelves in Baltimore. By .1. Whitridge Williams, M. D., ------- 164
Special Courses for Graduates in Medicine. Change of Date, - 168 Notes on New Books, -- 168
THE WITCHES' PHARMACOPCEIA.
By Egbert Fletcher, M. D.
The subject of this evening's paper is extraordinarily copious, and long-descended in its history. A belief in witchcraft characterized the earliest periods of which we have any record; it prevails among all savages or semi-civilized peoples at the present time, and is by no means extinct in otherwise intelligent communities. The cowardly fear and the resulting cruelties which have sprung from this strange superstition are too well known to need comment. In Merry England and in religious New England, men and women, old and young, the ministers of the Gospel, the clown and the philosopher, have perished at the stake or on the gallows, victims to this hideous delusion. A striking feature in the history of witchcraft is the fact that by far the greater number of its votaries were women, mostly old women. It is hard to find any explanation of this condition. King James I., in his Demonologia, ungallantly accounts for it by saying: " For as that sex is frailer than man is, so is it easier to be entrapped in these grosse snares of the Divell, as was over well proved to be true by the serpent's deceiving Eve in the beginning, which makes him (he homlier with that sexe sensine."
The personal appearance of the typical witch was not attractive, llarsnet, in a work published in 1003, says a witch is "an old weather-beaten crone, having lier chin and knees meeting for age, walking like a bow, leaning on a staff, hollow
- Read before the Historical Club of the Johns Hopkins Hospital,
Aiiril 13, 1896.
eyed, untoothed, furrowed, having her limbs trembling with palsy, going mumbling in the streets; one that hath forgotten her paternoster, yet hath a shrewd tongue to call a drab a drab." (Declaration of Popish Imposture, 1.36.)
If she ventured out in the daylight she was pursued with obloquy. In Gay's fable of The Old Woman and her Cats, the poor creature exclaims :
Crowds of boys Worry me with eternal noise ; Straws laid across my path retard ; The horse-shoe's nailed (the threshold's guard), The stunted broom the wenches hide, For fear that I should up and ride. They stick with pins my bleeding seat, And bid me show my secret teat.
Your genuine witch was believed to be incapable of shedding tears, and if through torture she could be made to weep, her power had departed :"id she became a helpless victim to justice. King James sa\o: "They cauuot even shed tears, though women in general are like the crocodile, ready to weep upon every light occasion."
Old age was not always a necessary adjunct to witchcraft. Some of the famous witches of chissical times, such as Canidi.% Erichthoi", and Circe, were beautiful women. The first was a famous hetaira and was once the mistress of Hor.ioe.
Accounts are given in history and legend of wiairds who practised their diabolical art. but they seem to have labored for more important purposes than their female rivals. In old
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chronicles, in popular story, and above all in the drama, it is the witch who figures as the minister of evil, and it is with her and her marvelous storehouse of materials we have to do to-night.
It is a mistake to suppose that these materials consisted only of offensive or grotesque substances — of " eye of newt and toe of frog." If the time permitted it would not be difficult to show that certain legendary qualities attached to them have come down from classic and pre-classic days. This will to some extent appear as we progress in the enquiry, for the literature of witchcraft is very ancient, and it will be found that the same ingredients have been made use of through many ages to produce the like results. Astrology lent its aid, and plants which were under certain planetary influence, especially those belonging to the moon, acquired more potency in consequence. Old Culpepper, in his British Herbal, gives a list of over 500 plants with the planets which govern them. The doctrine of signatures too had its influence in the selection of ingredients for malevolent as well as for healing purposes, and if liver-wort or eye-bright were powerful for good, the lurid flowers and leaves of aconite, hemlock, henbane, and belladonna were manifestly suited for diabolic charms.
The term pharmacopceia made use of in the title of this paper, must be understood in its most comprehensive sense. It comprises substances from the vegetable and atiimal kingdoms, and the products of the atmosphere must be included.
In addition to its materia medica, witchcraft has its especial pharmacology. Not only must the materials be procured with certain magical forms and precautions, many of which are of Druidical origin, but the commixture must be made under spell and incantation. There are two divisions of the phar macopoeia of witches, of distinctly opposite qualities — one, and the most numerous, comprising noxious ingredients, and the other consisting of the ordinary healing remedies of popular medicine. The woman who made use of the latter was known as a " white witch." She removed warts, cured fits, counteracted the spells laid upon cattle, and was looked upon as a generally beneficent sort of neighbor. The grey witch was one who, as occasion required, practised either the kindly or the malevolent arts, and the black witch was one who dealt in the latter exclusively. A mere list of the materials employed by the malevolent witch would be wearisome, and it will be more interesting and convenient to select from the rich stores of the drama and of poetry some passages which refer to witches and their baleful arts. Some comments elucidatory of the qualities and the folklore history of the ingredients employed, will, I trust, be not uninteresting.
The play most familiar to us all in which witches play a tragic part is, of course, Macbeth. Thomas Middleton, a contemporary of Shakespeare, was the author of a drama called The Witch which is wonderfully rich in this particular lore. A comedy by Thomas Heywood, entitled The Late Lancashire Witches, was published in 1634. Another comedy entitled The Lancashire Witches, and Teague O'Divelly the Irish Priest, written by Thomas Shadwell, was first performed at the Duke's Theatre in 1682. The two latter plays were reprinted in 1853 by Mr. James Orchard-Halliwell, the celebrated Shakespearean scholar, only 80 copies being printed. This
work is now extremely scarce. From these plays and from collateral writings my illustrations will be drawn.
It is proper to say that in neither of these dramas has the author devised the proceedings he describes from his own imagination, so far as the materials and methods employed are concerned. These have been borrowed largely, and in some instances literally, from Reginald Scot's Discoverie of Witchcraft, published in 1584. He, in his turn, had delved with wonderful diligence in fields of all kinds from classic days to his own, and this confirms what I have already stated as to the great antiquity of the folklore of witchcraft.
The famous incantation scene when the witches are expecting the approach of Macbeth, and have filled their cauldron with the most powerful ingredients of their art, is curious as exhibiting almost exclusively substances of animal origin. The only exceptions are " root of hemlock digg'd i' the dark," and " slips of yew silver'd in the moon's eclipse." Familiar as it is, it must be repeated in full for the sake of some comments upon the composition of the " hell-broth."
IHrst Witch. Round about the caldron go ;
In the poison'd entrails throw, —
Toad, that under the cold stone
Days and nights hast thirty-one
Swelter'd venom sleeping got,
Boil thou first i' the charmed pot. All. Double, double toil and trouble ;
Fire burn, and, caldron, bubble. Second Witch. Fillet of a fenny snake.
In the caldron boil and bake ;
Eye of newt, and toe of frog,
Wool of bat, anil tongue of dog.
Adder's fork, and blind-worm's sting,
Lizard's leg, and howlet's wing, —
For a charm of powerful trouble,
Like a hell-broth boil ami bubble. All. Double, double toil and trouble;
Fire burn, and, caldron, bubble. Third Witch. Scale of dragon ; tooth of wolf ;
Witches' mummy ; maw and gulf
Of the ravin'd saltsea shark ;
Root of hemlock digg'd i' the dark ;
Liver of blaspheming Jew ;
Gall of goat ; and slips of yew
Silver'd in the moon's eclipse ;
Nose of Turk, and Tartar's lips ;
Finger of birth-strangled babe
Ditch-deliver'd by a drabMake the gruel thick and slab ;
Add thereto a tiger's chaudron,
For the ingredients of our caldron. All. Double, double toil and trouble ;
Fire burn, and, caldron, bubble. Sec. Witch. Cool it with a baboon's blood,
Then the charm is firm and good.
The commentators have expressed some conjectures as to what the "poisoned entrails" were, but there is, I think, no doubt that the term applied to the entire ingredients of the cauldron. The toad figures constantly in necromantic charms, and its venom, if it have any, is supposed to reside in the glands of the skin. The blind-worm is the slow-worm, which is spoken of in Timon as the "eyeless venom'd worm." As a matter of fact it is a harmless reptile. Mummy was formerly
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oue of the articles of the pharmacopceias, and its virtue was doubtless due to the aromatics with which it was endued. Sir Thomas Browne, in his Urn-burial, says of it: "The Egyptian mummies which Oambyses or time hath spared, avarice now consumeth. Mummie is become merchandise. Mizraim cures wounds, and Pharaoh is sold for balsams." The " gulf of the ravin'd salt-sea shark " is the stomach of that voracious fish. " Nose of Turk and Tartar's lips " seem to have no obvious qualifications, but it would be hard to find two lines of as concentrated expression as those which follow —
Finger of birth-strangled babe Ditch-delivered by a drab.
The " tiger's chaudron " means the entrails of the animal. The tiger is of great importance in Chinese medicine; for an attack of hydrophobia the skull, teeth and toes of the animal are ground up and given in wine.
This wonderful collection of " poisoned entrails " was to be cooled with a baboon's blood. The baboon, or btibian of the Dutch, was a large and dangerous ape, described by travelers of those times as found in great flocks near the Cape of Good Hope. Monstrous stories were told of it by contemporary writers.
When in reply to Macbeth's demand for further prognostications of his fate, more charms became needful, the first witch says :
Pour in sow's blood, that liath eaten
Her nine farrow ; grease that's sweaten
From the murderer's gibbet throw
Into the flame.
In illustration of the first of these ingi-edieuts, Stevens quotes from Holinshed's History of Scotland, 1577, a law of Kenneth II. which provided that, " if a sowe eate her pigges let her be stoned to death and buried."
The fat or grease that drops from the body of the murderer hung in chains was one of the ingredients in the preparation of the " hand of glory," and it was also believed that where it fell the baleful mandrake sprang. Human fat was long believed to be a remedy for rheumatism and sprains. A Gernum druggist once told me that it is still asked for, but that harmless goose-grease stiffened with spermaceti is the succedaneum, and when served from an antique jar with a mysterious inscription upon it, it gives great satisfaction.
Another and very important use of human fat was to anoint the body of a witch and thus enable her to soar through the air. This will be spokeu of in more detail further on. In Middleton's play of The Witch, Hecate says to one of her followers :
There, take this unbaptised brat ;
Oiving the dead body of a child. Boil it well ; preserve the fat ; You know 'tis precious to transfer Our 'nointed ilesli into the air, In moonlight nights.
This play of Middlutou's was discovered in manuscript in the last century. It contains incantation scenes very similar to those in Macbeth, and it has been a matter of debate with the commentators whether Shakespeare copied his witch scenes from Middleton, or Middleton copied from Shakespeare,
There is no question of the superiority of the latter in the strength and sublimity of the passages, but it may become necessary for the followers of Mr. Ignatius Donnelly to insist that Lord Bacon also wrote Middleton's plays.
In The Witch, Hecate recounts the materials of her charms, which belong to the vegetable materia medica. Stadlin, her acolyte, says :
Where be the magical herbs? Hecate. They're down his throat ;
His mouth cramm'd full, his ears and nostrils stuff'd ;
I thrust in eleoselinum lately,
Aconitum, frondes populeas, and soot —
You may see that, he looks so black i' the mouth —
Then slum, acorum vulgare too,
Pentaphyllon, the blood of a fiitter-mouse,
Solanum somnificum et oleum.
These magical ingredients were crammed into the mouth and nostrils of the unbaptised babe before boiling him for his fat. The entire formula is taken almost literally from Reginald Scot's Discoverie of Witchcraft, and he obtained it from one of the curious works of John Baptista Porta, the Neapolitan, who wrote about everything that savored of superstition.
In the foregoing passage eleoselinum is the Apium petroselinum, or parsley. Slum is the winter-parsnip ; acorum is calamus, which in the doctrine of signatures belongs to the stomach. Pentaphyllon is the Greek name for the cinquefoil, or Potentilla reptans, its five leaves representing the five senses. The fiitter-mouse, or flicker-mouse, is the bat. The populeas frondes are the leaf-buds of the poplar, till lately used as an ointment. The poplar was also a funeral tree. In another scene of the same play Hecate asks of her son Firestone : Dear and sweet boy ! what herbs hast thou?
Firestone. I have some marmartin and mandragon.
Hecate. Marraaritin and manilragora, thou wouldst say.
Firestone. Here's panax too, I thank thee — my pan aches I'm sure, With kneeling down to cut 'em.
Hecate. And selago. Hedge-hyssop too ; how near he goes my cuttings ! Are they all cropt by moonlight ?
Firestone. Every blade of 'em. Or I'm a moon-calf, mother.
Hecate. Hie thee home with 'em ; Look well to the house to-night ; I'm for aloft.
Selago was a plant of much renown. It was probably the Club-moss, or Lycopodium selago. and was held in great repute by the Druids, who termed it Golden herb, or Cloth of Gold. It had to be gathered by a naked maiden on a moonlight night under a cloudless sky. When she touched the plant with her foot it was taken up with many precautions, and it conferred on the possessor the }X)wer of understanding the language of birds and beasts. There is a curious old print representing the damsel touching the plant with her foot while two Druid priestesses watch the proceeding. They are standing under an oak tree, and one of them holds a branch of mistletoe in her htuid. The print has been reproduced by Mr. Folkard in his Plant-Lore. The hedge-hyssop is the Gratiola.
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There is much folklore connected with parsley. The Greeks bestowed a crown of dried parsley on the victor at the Isthmian games. They strewed it also on the bodies of the dead. A despairing lover cries :
" Garlands that o'er thy iloor I hung.
Hang withered now and crumbling fast; Whilst parsley on thy fair form flung, Now tells my heart that all is past."
Its ominous association with death no doubt accounted for its presence in necromantic compounds. It was also an emblem of generation, and the belief survives in the nurse's story to the children that the newly arrived infant was dug out of the parsley-bed. Of the mandragou or mandrake much will have to be said presently.
To return to Middleton's play. In the fifth act a Duchess, " on fell thoughts intent," enters the abode of Hecate, and finds the queen of witches before a caldron. This dialogue ensues :
Sec. What death is't you desire for Almachildes?
Dueh. A sudden and a subtle.
Jlee. Then I've fitted you. Here lie the gifts of both, sudden and subtle ; His picture made in wax, and gently molten By a blue fire kindled with dead men's eyes. Will waste him by degrees.
Sue. In what time, prithee?
Sec. Perhaps in a moon's progress. •
Due. What, a month? Out upon pictures, if they be so tedious ! Give me things with some life.
Hec. Then seek no farther.
Due. This must be done with speed, dispatch'd this night, If it may possible.
nee. I have it for you : Here's that will do't; stay but perfection's time, And that not five hours hence.
After further colloquy the Duchess leaves and Hecate proceeds to concoct her fatal mixture.
Hec. Give me some lizard's brain ; quickly, Firestone. Where's grannam Stadlin, and all the rest o' th' sisters? Fire. All at hand, forsooth.
Enter Stadlin, Hoppo, and the witches. Ilec. Give me marmaritin, some bear-breech ; when? Fire. Here's bear-breech and lizard's brain, forsooth. Hec. Into the vessel ; And fetch three ounces of the red-hair'd girl I killed last midnight.
Fire. Whereabouts, sweet mother? Hec. Hip, hip or flank. Where's the acopus? Fire. You shall have acopus, forsooth. Hec. Stir, stir about, whilst I begin the charm. Black spirits and white, red spirits and gray, Mingle, mingle, mingle, you that mingle may ! Round, around, around about, about ! All ill come running in, all good keep out 1 First Witch. Here's the blood of a bat. Hec. Put in that, O, put in that 1 See. Witch. Here's libbard's-bane. Hec. Put in again I
Firet Witch. The juice of toad, the oil of adder. Sec. Witch. Those will make the younker madder. Hec. Put in— there's all— and rid the stench. Fire. Nay, here's three ounces of the red-haired wench. Ohoritt. Round, around, etc.
Of the ingredients made use of for this potion intended to be fatal to the Duchess's husband or lover, the bear-breech deserves some notice. It is the Acanthus mollis, much employed for decorative purposes by the Greeks and Komans. £ts leaves form the principal adornment of the capital of the Corinthian pillar. The story of its origin is too well known to need repeating. The oil of adder is probably not a product of the snake, but is the " greene oyle " obtained by boiling the Adder's tongue, or Ophioglossum vulgatum, in olive oil. The herb was in great favor with witches. The libbard's-bane or leopard's bane, often called wolf's-bane, is the Aconite. In Ben Jonson's Masque of Queens is this verse :
I ha' been plucking, plants among. Hemlock, henbane, adder's-tongue, Night-shade, moonwort, libbard's-bane.
It is suggested by the commentators that the poison which the Apothecary sold to Romeo was Aconite. The latter demanded a poison so swift with action —
That the life-weary taker may fall dead.
And that the trunk may be discharged of breath
As violently as hasty powder fired
Doth hurry from the fatal cannon's mouth.
This is possibly confirmed by a passage in the second part of Henry IV. :
Though it do work as strong
As Aconitum or rash gunpowder.
It is a classic legend that Aconite sprung originally from the foam dropped from the mouth of Cerberus, the tripleheaded dog of hell. The hood-shaped flower from which its name of monks-hood was derived, was in Scandinavian folklore known as " Thor's hat." Ben Jonson in his play of Sejanus (Act III.) describes a homoeopathic use of Aconite:
I have heard that Aconite Being timely taken hath a healing might Against the scorpion's stroke ; the proofe we'll give That while two poisons wrastle, we may live.
Henbane, the Hyoscyamus, was another plant of ill omen. Plutarch tells us that it was woven into a chaplet for the dead. Juno's horses were fed upon it, according to Homer, and it still holds a place in the veterinary pharmacopceia as a remedy for certain equine disorders. It is supposed to be the " insane root " which Banquo speaks of :
Have we eaten of the insane root That takes the reason prisoner?
Old Bartholomasus says of it: "Henbane is called iusaua, mad, for the use thereof is perilous, for if it be eate or dronke, it breedeth madness, or slow lykenesse of death."
The yew-tree, from its sombre foliage and its constant presence in churchyards, had an evil repute. Shakespeare calls it "the double fatal yew," from the poisonous qualities of its leaves and from its wood being employed to furnish bows, the instruments of death. It was famous for the latter purpose. Browne writes of it as —
The warlike yeugh, by which more than the lance The strong-armed English spirits conquered France.
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It was much used by the witches in their charms. Hecate announces to the aerial spirit :
With new fallen dew From churchyard yew I will but 'noint, And then I'll mount.
It has been thought that the "juice of cursed hebenon," which caused the death of Hamlet's father, was the juice of yew leaves. In Marlowe's Jew of Malta it is called " juice of hebon." Eben, hiben, were Norse names of the yew.
Hemlock, the Couium maculatum, is supposed to be the fatal poison administered to Socrates, Phocion and other Greeks condemned to death by the Areopagitica. It is a constant ingredient of the witches' charms.
The Deadly Nightshade, the Atropia belladonna, is a powerful poison also much used by witches. Those who partook of it were seized with madness, during which they prophesied and saw visions. Possibly the dilatation of the pupils, the well known effect of atropine, accounted for this latter belief. The Solanum dulcamara, the common nightshade, had poisonous berries, but the root and stems were employed in medicine, though their use is, I suppose, now obsolete.
Among the ingredients employed by Hecate there are two which the commentators have given up in despair of their identification, namely, acopus and marmaritin. Nevertheless, both of them are mentioned by Pliny in his Natural Hi«tory. Acopus, or acopos, he describes as " a stone like nitre in appearance, porous and starred with drops of gold. Gently boiled with oil and applied as an unguent it relieves lassitude, if we choose to believe it," he discreetly adds. Marmaritis he says is the plant Aglaophotis, which owes its name to the admiration in which its beauteous tints are held by man. "It is found growing among the marble quarries of Arabia on the side of Persia, a circumstance which has given it the additional name of Marmaritis" (from marmor, marble). "By means of this plant," he continues, quoting from Democritus, " the Magi can summon the deities into their presence when they please." It is interesting to observe a bit of Magian lore coming from ancient Persia preserved in the charm of a witch in the 17th century. The plant has not been identified, though it has been with some reason supposed to be the Peony. This handsome flowering plant was held in great esteem by the ancient Greeks. Its name Pajonia was derived from Pajan, the first physician who attended upon the divinities upon Olympus. According to Homer he healed the wounds of Ares and Hades. The name Preon was also applied to Apollo, and a pasan was a song which celebrated his healing power. Pffiouia, or the healing goddess, was also one of the names of Minerva.
The unhappy old women who were suspected of being witches were subjected to many well known ordeals to make them confess their diabolic powers. Even in very recent times there are accounts of ignorant rustics tying the thumbs and toes of a supposed witch together iind throwing her into a pond, where if she floated she was a witch, and if she sank, as was most likely, she usually died from the ill usage. It is gratifying to know that Matthew Hopkins, the notorious witch-finder, met his death in this manner at the hands of
some country fellows who believed him to be a wizard. Hudibras refers to the miscreant's fate in these lines:
" Who after proved himself a witch, And made a rod for his own breech."
Hopkins' method was to probe all parts of the woman's body with pins or needles until he found the " witch spot," which was insensible to pain. There is still to be seen in the courthouse of Salem, Massachusetts, a bottle of pins which had been used in this manner during the witch-hunting which led to the execution of twenty-two persons on Gallows-Hill in that city in 1692. In Shadwell's play of The Lancashire Witches, Sir Jeffery, a justice of the peace, says :
" Now, you Shocklehead, and you Clod, lay hold o' th' witch quickly. Now you shall see my skill ; wee'l search her ; I warrant she has biggs or teats a handful long about her parts that shall be namelese; then wee'l have her watched eight and forty hours, and prickt with needles, to keep her from sleeping, and make her confess ; gad, shee'l confess anything in the world then ; and if not, after all, wee'l tye her thumbs and great toes together and fling her into your great pond."
The " biggs or teats " — bigg is an old English name for a cow's teat — refer to a curious belief. Every witch was supposed to have in some unseen part of her body a teat with which she nourished her own particular imp or familiar. There is no reference to it in ancient writers ; it seems to have been a happy discovery of the English witch-finders.
In a scene of the same play the witches are relating to their master the Devil, who is in the form of a black goat, their several achievements. Mother Demdike says :
To a mother's bed I softly crept, And while the unchristen'd brat yet slept, I suckt the breath and a blood of that, And stole another's flesh and fat, Which I will boyle before it stink.
The use made of the fat of an unbaptised child has been already mentioned, but there is something to be said as to the sucking its breath. A cat, especially a black cat, was the familiar companion of the witch, and she was supposed to sometimes assume its form and suck a sleeping child's breath till she destroyed it. The common belief that a cat may perform this injurious act not improbably had its origin in the superstition that the creature was a witch iu disguise.
Among the functions of witches, the preparation of philters, or love cups, which were to procure the affections of youth or maiden, played an important part It must be said that the ingredients of these charms were obscenely nasty, and most of them may well be omitted from notice. In the same scene of the play just quoted. Mother Spencer says:
To make up love-cups, I have sought A wolf's tayle-hair and yard ; I've got The green frog's bones, whose flesh was t«'en From thence by ants : then a cat's brain ; The bunch of Hesh from .i bl.-jck fole's head, Just as his dam was brought to be<l, Before she lickt it.
The bunch of flesh upon the newborn foal's head is the Hippomaues, concerning which some wondrous beliefs were held.
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It was of black color, the size of a fig, and if it was removed artificially instead of being licked off by the mother-mare, she refused to allow the foal to suck. Virgil, Ovid, and other classical authors speak of it as a famous aphrodisiac and much employed in the preparation of love philters. Thus there is another instance of the antiquity of the witches' materials. Cuvier says that tlie hippomanes is a concretion sometimes found in the liquor amnii of the mare, and is eaten by her just as the placenta is eaten by many animals after parturition.
Further on, one of the persons of the play says : " Fennel is very good in your house against spirits and witches ; and alicium, and the herb mullein, and longwort, and moly, too, is very good."
Fennel was given to the victors in the Isthmian games, and on account of its pleasant odor and graceful tendrils it is used even now as a decoration for the table. It was hung on doorways to keep away evil influence. Mullein, the Verbascum thapsus, from its woolly fibres was readily inflammable, and its stalks dipped in suet made a candle which was known as hig- or high-candle, and by corruption, hag-caudle. The ancient Romans called the plant Candelaria, and used it as a torch at funerals. In Italy it is still called Light of the Lord.
Alicium has not been identified.
Longwort is the Pulmonaria or lungwort, sometimes known as the Jerusalem cowslip. From its spotted leaves it was, under the doctrine of signatures, held to be a remedy for diseased lungs.
Much has been written about the herb Moly, which is the last named in this passage. It was first mentioned by Homer as the remedy given by Hermes to Ulysses to enable the latter to withstand the enchantments of Circe. It has been thought to be a species of Allium or garlic. It is worth noting that most of the preservatives against evil influences were strong aromatics.
In the same scene Mother Demdike and her excellent sisters give us some further insight.into their pharmacopoeia:
Demd. Oyntment for flying here I have,
Of children's fat stoln from the grave, The juice of smallage and nightshade, Of poplar-leaves and aconite made ; With these
The aromatick reed I boyl, With water-parsnip and cinquefoil, With store of soot, and add to that The reeking blood of many a bat. Mother Dickiiiion. From the sea's slimy owse a weed I fetched to open locks at need. With coats tukt up, and with my liair All flowing loosely in the air. With naked feet I went among The poisonous plants, there adders-tongue, AVitli aconite and martagoii, Henbane, hemlock, moon-wort too, Wild fig-tree that o'er tombs do's grow, The deadly nightshade, Cyprus, yew, And libbard's-bane, and venomous dew, I gathered for my charms. Mother Ilargrave. And I
Dug up a mandrake, which did cry ;
Three circles I made, and the wind was good,
And looking to the west I stood.
Most of these plants have already been commented upon. Smallage is our familiar celery, which has appropriately fallen from a witch's ingredient into a preposterous quack remedy of the present day. What kind of weed it was " from the sea's slimy owse " which would open locks, I cannot tell. It was a part of the ceremonial to go with naked feet and hair unbound when gathering magic herbs.
The Martagon is the Jloonwort, the Botrychium lunaria. If placed in a key-hole it had the power of opening the lock. This fabulous quality is described by Pliny in his account of the plant. It is perhaps the same as the Spriugwort, famous in German legend for its use in opening treasure-chests. The legends connected with the fig-tree are very ancient and numerous. Lender its boughs Adam concealed himself after tasting the forbidden fruit. Each blossom was inhabited by an evil spirit. In this particular instance it was a fig-tree that had grown over a tomb.
All of the herbs mentioned in the foregoing passage are described as magical herbs by Porta, Paracelsus and Agrippa.
A characteristic bit of malice on the part of the witches is described further on in the play of The Late Lancashire Witches, by Heywood and Brome, 1624. Joan has been preparing a dinner for some guests, when she breaks in upon them with this mournful story :
Joan. O husband, O guests, O sonne, gentlemen, such a change in a kitchen was never heard of ; all the meat is flown out o' the chimney-top, I thinke, and nothing instead of it but snakes, batts, frogs, beetles, hornets and bumble bees ; all the sallets are turned to Jewes ears, mushromes, and puckfists ; and all the custards into cowsheards.
The salads provided for this unlucky feast were all turned into fungi of various evil characters. The Jews' ears is the Auricula Judse, a fungus resembling the human ear, which grows upon the elder, on which tree Judas was said to have hanged himself. The puckfist is the common puff-ball. Cowsheards, or cowshards, is cow-dung.
In a beautiful fragmentary play of Ben Jonson's, The Sad Shepherd, a similar scene is described. The hunting has been successful and the venison is laid before the fire, when a malignant witch, Maud, enters and utters this curse :
Maud. The spit stand still, no broches turn
Before the fire, but let it burn
Both sides and haunches, till the whole
Converted be into one coal. Clarion. What devil's paternoster mumbles she? Aiken. Stay, you will hear more of her witchery. Maud. The swilland dropsy enter in
The lazy cuke and swell his skin ;
And the old mort-mal on his shin
Now prick and itch withouten blin. Clarion. Speak out, hag, we may hear your devil's matins. Maud. The pain we call St. Anton's fire.
The gout, or what we can desire
To cramp a cuke in every limb,
Before they dine, yet seize on him.
The "swilland dropsy " is the watery dropsy. The "mortmal " is a term used by Chaucer, and means an ulcer ; so " the old mort-mal on his shin " is a chronic ulcer of the leg, which was to prick and itch withouten blin — that is, without
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ceasing — an appropriate torment for the cook, whose function required him to stand almost continually. What disease was meant by St. Anthony's fire has been much debated. It is most probable that it was ergotism, the Kriebelkrankheit of the Germans, a dry gangrene of the extremities, the effect of the continued use of rye-flour containing ergot. " Saint Anton fire thee ! " was a common form of malediction.
It is an ancient belief that witches had power over the moon and could cause its light to change or disappear under the influence of their spells. Prospero describes Caliban's mother, " the foul witch Sycorax," as one " so strong that could control the moon." Centuries before Shakespeare's time the same belief prevailed, for Aristophanes introduces it in his comedy of The Clouds. Strepsiades tells Socrates that he has a plan to do away with paying of interest, for, says he :
If I were to buy a Thessalian witch, and draw down the moon by night, then 8hut her up in a round helmet-case like a mirror, and keep watching her —
Soc. What goo<l would that do you then ?
Strep. What? If the moon were not to rise any more anywhere, I should not pay the interest Soc. Because why?
Strep. Because the money is lent by the month.
The time of the full moon was especially favorable for gathering herbs for use in spells. In The Merchant of Venice, Jessica, sitting with the amorous Lorenzo in the brilliant light of the full moon, says :
On such a night Medea gathered the enchanted herbs That did renew old Jason.
The belief in astrology, as prevalent in classic as in recent times, had much to do with the witches' materia medica. The signs of the zodiac, with their fantastic relations to the human body, are still regarded with belief in their importance. A story is told of a well-to-do farmer who was ordered a purgative but who would not swallow it because he had looked in the almanac and seen that the sign for the mouth was in bowels, and he thought the two together would be too much for him.
Of all plants possessing necromantic endowments, the mandrake is the most famous. In our present pharmacopoeias the name is appropriated to the harmless Podophyllum, but the old herbals term it the Atropa mandragora, its first name being derived from Atropos, one of the dreaded Parca;. There are numerous allusions to it in the classic writers, and a well known one in Genesis, chapter sxx. The lad Reuben brings home mandrakes to his mother Leah. The barren Kachel begged them of the latter, and even gave up her husband Jacob for the night to her more fruitful rival, trusting doubtless to the supposed power of the root to cure sterility. There were said to be two forms of the mandrake, the male plant, which had a pleasant perfume, and the female, of which the leaves were large and had a rank odor. Cruden in his Concordance suggests that Reuben would naturally bring home to his mother only the sweet smelling plants of the harvest field, and the only other reference to the mandrake in the Bible is in Canticles vii. 13, where it is said, "The numdrake
gives a smell, and at our gates are all manner of pleasant fruits."
The account given of the mandragora by Pliny is interesting from a far-away hint at an ansesthetic. " It is given," he says, "before incisions or punctures are made in the body, in order to ensure insensibility to pain. Indeed, for this last purpose the odor of it is quite sufficient to induce sleep." It has been thought that the mandrake was identical with the Eryngium, a root which had a fancied i-esemblance to the genitals, and which Pliny says had been administered to Sappho and was the cause of her passionate love for Phaon.
Joannes Wierus, in his De presagiis djemonum, Basel, 1563, states that Josephus describes a root called in the Hebrew, Baaras, which in the evening emits sparks of light. Like the mandrake, its extraction from the earth is attended with swift death to the person attempting it. To avoid this danger, a young dog which was kept without food for twenty-four hours was fastened to the root with a string, and upon meat being placed in advance of him he naturally rushed towards it, drawing out the root thereby. If the sun shone on the root the dog died suddenly, and was buried with secret ceremonies. A favorite habitat for the mandrake was the earth at the foot of a gibbet, the fat which dropped from the murderer's body encouraging its growth ; when drawn from the ground it emitted shrieks like the cries of a human being, and death or madness fell upon the rash experimenter. It was partly a plant and partly an evil spirit, and it may be well supposed that with all these qualities it was a choice ingredient for the witches' potions.
There is preserved at Vienna, so Dr. Danberry relates, a manuscript copy of the work on Materia ^ledica of the Greek physician Dioscorides, who lived in the first or second century. It contains a curious drawing representing the goddess Discovery presenting to the author a nnindrake freshly plucked from the earth. The root has an entirely human appearance, and the dog which had been employed to extract it is lying dead on the ground. The manuscript is of the fifth century.
The English romance-writer, William Harrison Ainsworth, who was deeply read in witch-lore, has embodied these beliefs regarding the mandrake in a spirited ballad, part of which may be quoted :
At the foot of the gibbet the mandrake springs,
Just where the creaking carcase swings :
Some have thought it engendered
From the fat that drops from the bones of the dead :
Some have thought it a human thing.
But this is a vain imagining.
And whether the mandrake be create
Flesh with the flower incorporate.
I know not ; yet, if from the earth 'tis rent.
Shrieks and groans from the root are sent : . . .
Whoso gathereth the mandrake shall surely die ;
Blood for blood is his destiny.
Some who have plucketl it have dieil with groans
Like to the mandrake's expiring moans :
Some have died raving, and some beside
With penitent prayers— but iiU have dieil. Jesu ! save us by night and by day From the terrible death of mandragora !
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Certain portious of the human body played an important part in the charms prepared by witches, such as the hair, the nails, blood, saliva, etc. Most of these entered into the composition of philters or love potions. If a love-sick maid could administer, in a cake or bread, cuttings from the hair or nails of the desired youth mixed with similar portions from her own person, he was certain to become madly in love with her. Among many tribes of North American Indians it is a custom still prevailing to bury the parings of the nails and portions cut from their hair, lest they should be employed for hurtful purposes. Dalyell, in his " Darker Superstitions of Scotland," relates that a young woman was indicted by the judicatories of Leipzig in 1633 for administering an amatory charm of bread compounded with hair and nails to a man whom it sickened (p. 219). 'L'he most important use of the human body was in the preparation of the unguent with which the witch anointed her body to enable her to fly through the air on her forbidden errands. Allusion has been made to this in some of the passages already quoted. John Wier, whose work is a perfect treasury of witch-lore, says that the proper method was to boil an unbaptised child in a caldron. The thick part of the concoction was made into an unguent, and the thinner part was bottled. " Whoso drank of the latter became immediately a companion of the order, a great clerk and master." Jerome Cardan gives a formula in which the fat of a chiUl is mixed with parsley, aconite, ciuquefoil, belladonna and soot. Probably the earliest specific account given of the use of such an ointment is to be found in The Golden Ass of Apuleius, written in the second century. Lucius, the hero, by the connivance of the waiting-maid, watches his hostess, a famous witch, while performing her necromantic rites in the privacy of her chamber at midnight. She anoints her body with an unguent, whereupon feathers and wings spring out, and thus transformed into a bird she flies out of the window. Lucius, determined to try the experiment upon himself, persuades the maid to bring him the ointment. She unintentionally fetches a different jar, and poor Lucius, to his horror, finds himself transformed into an ass. His adventures after being thus transmogrified form the subject of this celebrated romance.
Toward the end of the 16th century there flourished in Scotland a notable wizard named Doctor Fian, who was a schoolmaster. He became enamored of a young lady of great beauty, whose brother was one of his pupils. Failing to ingratiate himself with the sister, he resorted to "conjuring, witchcraft and sorcerie." The rest of the story shall be told as it is related in Pitcairn's Criminal Trials of Scotland, I, 213. So, "calling the said scholler to him demanded if he did lie with his sister, who answered he did : By means whereof he thought to obtain his purpose; and therefore secretly promised, to teach him without stripes, so he would obtain for him three haires from his sisters privities, at such times as he should spie best occasion for it, which the youth promised faithfully to perform, and vowed speedily to put it in practise, taking a piece of conjured paper of his master to lay them in, when he had gotten them : and thereupon the boy practised nightly to obtain his masters purpose, especially when his sister was asleep. But God, who knoweth the secrets of all
harts, and revealeth all wicked and ungodly practises would not suffer the intents of this divelish Doctor to come to that purpose which he supposed it woulde ; and therefore to declare that hee was heavily offended with his wicked intent, did so work by the gentlewomans owne meanes, that in the end the same was discovered and brought to light : for shee being one night a sleepe, and her brother in bed with her, sodainly cried outt to her mother, declaring that her brother wolde not suffer her to sleepe: Whereupon her mother having a quicke capacitie, did vehemently suspect Doctor Fians intention, by reason she was a witch of herself ; and therefore, presently arose, and was very inquisitive of the boy to understand his intent: and the better to know the same did beate him with sundrie stripes, whereby he discovered the truth unto her. The mother, therefore, being well practised in witchcraft, did thinke it most convenient to meete with the Doctor in his own arte: and thereupon took the paper from the boy, wherein hee should have put the same haires, and went to a yong heyfer which never had borne calfe, nor gone unto the bull, and with a paire of sheeres clipped off three haires from the udder of the cow, and wrapt them in the same paper, which shee again delivered to the boy: then willing him to give the same to his sayde master, which hee immediately did. The school maister, so soone as he had received them, thinking them indeed to be the maids haii-es, went straight and wrought his arte upon them. But the Doctor had no sooner done his intent to them, but presently the hayfer cow, whose haires they were indeede, came unto the door of the church wherein the school maister was, into the which the hayfer went, and made towards the school maister, leaping and dauncing upon him, and following him forth of the church, and to what place soever he went ; to the great admiration of all the townes men of Saltpans, and many others who did beholde the same. The report whereof made all men imagine he did worke it by the Devill, without whome it coulde never have been sufficiently effected : and thereupon the name of the saide Doctor Fian (who was but a young man) began to growe common among the people of Scotland, that he was secretly nominated for a notable conjurer."
There were other charges brought against the wizard at his trial beside the foregoing one, and the result was that the luckless doctor was burned at the stake in Edinburgh in January, 1591.
A cognate subject of investigation to that which we have been pursuing is the preservation against the power of witchcraft. It would lead us too far afield for the present occasion, and a very brief notice must suffice. English county folklore abounds in spells which had a protecting power, and plants under especial planetary influences were largely employed. They were purposely cultivated in domestic gardens, and many of the most beautiful flowering plants which have spread throughout England, and are to be found also in our own land, were brought from Palestine and Syria, and were first found in the extensive gardens of the monasteries. Among them were the wall-flower, the scarlet anemone or blood-drops of Christ, the blooming almond-tree, one of the symbols of the Virgin, and the marigold. These with many others found their place in art and are to be seen in illumin
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ated breviaries and in paintings, and were in high repute as preservatives from evil spells.
One of the most famous of these preservatives was the St. John's wort, or Hypericum. An old distich tells us that —
Trefoil, vervain, John's wort, dill, Hinder witches of their will.
Baldur, the White God of the Norse Valhalla, was replaced in Christian days by St. John the Baptist. He was called the White Saint John in some old German and Gallic calendars. There are many relics of sun-worship still practised in Europe on St. John's day. Flowers with large sun -like discs were sacred to Baldur, and later to St. John the Baptist, and it was thus that the Hypericum obtained its name of St. John's wort and was believed to have especial power in repelling evil influences. From its handsome yellow flowers it obtained the name of the Rose of Sharon Boiled in wine or ale it was a popular remedy for spitting or vomiting of blood. In Norway red spots on the plant are called St. John's blood, and are supposed to make their appearance on the day of his beheading, August 29th.
The Ash tree, and particularly the Rowan, or mountain ash, had a like celebrity, and sprigs of the latter were sewn in the dresses of children to protect them from ill. Rustics in Scotland still take with them a branch of Rowan tree when going a-milking, to prevent witches from drying up the cows.
The Vervain, or Verbena, was also a sacred herb. It was gathered with certain observances, and this verse was repeated during the process :
Hail to thee, Holy Herb !
Growing on the ground ; On the Mount of Olivet
First wert thou found. Thou art good for many an ill,
And healest many a wound ; In the name of sweet Jesu
I lift thee from the ground.
Other protecting plants were the Cyclamen, Pimpernel, Angelica, Bracken, Fern, Rue, Broom, Maiden-hair, Agrimony and Ground-ivy. Yellow or green flowers growing in hedgerows are especially repugnant to witches.
The Ash tree has a use in medicine which I fear is forgotten ill these days. In the curious early Welsh book of treatment known as The Physicians of Middvai, written early in the 13th century, is a remedy for " Ulceration of the P'ars," j)robably our otorrhoea. " Take the seed of the Ash, otherwise called the Ashen-keys, and boil briskly in the water of the sick man ; foment the ear therewith, and put some therein on black wool." It is prudently added, " By God's help it will cure it." Black wool is an ingredient in many charms.
T'he English Folk -Lore Society recently published a reprint of a cutting from an old newspaper, without date, which describes the medical treatment of a woman who had been bewitched. It is a veritable curiosity in therapeutics, but it is to be thought that nowa-days we should call the affliction luidcria, and not bewitchment.
They then gave to the said Magdalen Ilolyday the follow
ing medicines : — Imprimis, a decoction — ex f nga Daemonium
(St. John's wort) — of Southernwood, Mugwort, Vervain, of
which they formed a drink according to Heuftius' Medical
Epistles, lib. xii., sec. iv., also following Variola, a physician
of great experience at the Court of the Emperor. They also
anointed the part with the following embrocation: — Dog's
grease well mixed, four ounces ; bear's fat, two ounces ; eight
ounces of capon's grease; four and twenty slips of mistletoe,
cut in pieces and powdered small with gum of Venice turpentine, put close into a phial, and exposed for nine days to the
sun till it formed into a green balsam, with which the said
parts were daily anointed for the space of three weeks, during
which time, instead of amendment, the poor patient got daily
worse, and vomited, not without constant shrieks or grumbling, the following substances: — Paring of nails, bits of
spoons, pieces of brass (triangular), crooked pins, bodkins,
lumps of red hair, egg-shells broken, parchment shavings, a
hen's bone of the leg, one thousand two hundred worms,
pieces of glass, bones like the great teeth of a horse, a luminous matter, sal petri (not thoroughly prepared), till at length
relief was found, when well nigh given up, when she brought
up with violent retching, a whole roio of pins stuck on blew
paper! After that, these sons of ^sculapius joyfully perceived that their potent drugs had wrought the designed cure
— they gave her comfort, that she had subdued her bitter foe,
nor up to the present time has she been afflicted in any way;
but having married an honest poor man, though well to do in
the world, being steward to Sir John Heveuingham, she has
borne him four healthy children. . . . Whether this punishment was inflicted by the said old woman an emissary of
Satan, or whether it was meant wholesomely to rebuke her for
frequenting wakes, may-dances, and Candlemas fairs, and such
like pastimes, still to me remains in much doubt. 'Non possum solvere uodum.'
P. S. — I hear the physicians followed up their first medicine with castory, and rad. ostrutii and sem. dauci, on Forestius' his recommendation."
The radix ostrutii was, I suspect, the root of Imperatoria ostruthium, or Masterwort It is regarded as a powerful stimulant and emmenagogue, and such was its reputation that it was termed rcmedium divinum. Tlie semitui danri must be a misprint for seniina dauri, the seeds of the carrot, which were held to be diuretic and aromatic. Forestius's work, published in 1589, is a collection of curious cases with still more curious treatment.
The Elder-tree has been mentioned in some of the previous passages, and there were many strange superstitious connected with it. The '-fox-headed Judiis." as an old writer termed him, alluding to the color of his hair, was believed to have hanged himself upon an Elder tree, and that entirely credible writer, Sir John Maundeville. declares that he saw the veritable tree while in the Holy Land. There is a curious bit of folklore relating to the Elder, well known no doubt to the witches, who rode on broomsticks in their uight journeys. Coles, in his Art of Sinipling." U)5(>, says:
" It hath been credibly reported to uie from several hands;, that if a mau take an Elder stick, and cut it on both sides, so that he preserve the joynt, and put it in his pocket when he
156
rides a journey, he shall uever gall." Eichard Fleckno, in his Diarium, 1658, also tells us:
How Alder-stick in pocket carried
By horseman who on highway feared [fared],
His breech should nere be gall'd or wearied,
Although he rid on trotting horse,
Or cow, or cowl-stafE, which was worse.
It had, he said, such vertuous force,
Whose vertue oft from Judas came,
(Who hang'd himself upon the same,
For which, in sooth, he was to blame)
Or 't had some other magick force
To harden breech, or soften horse,
I leave 't to th' learned to discourse.
In The Athenian Oracle, once edited by Samuel Wesley, brother of the famous John Wesley, is a confirmatory story. "A friend of mine," says the relater, "being lately upon the road a horseback, was extremely incommoded by loss of leather; which coming to the knowledge of one of his fellow travelers, he over-persuaded him to put two Elder sticks into his pocket, which not only eased him of his pain, but secured the remaining portion of postefiours not yet excoriated, throughout the rest of his journey."
It is much to be desired that this very valuable information should be made known to the members of the Hunt and to young cavalrymen going into the field.
In conclusion, it may be said as worthy of observation that the witches in Middleton's play, as well as those who figure in the other dramas from which quotations have been given, are of a somewhat vulgar type. Their purposes are purely malicious. Their names even are appropriate to their character. They are spoken of as Mother Bombey, Mother Demdike, Mother Sawyer, and the like. In Macbeth they are simply the " three weird sisters." The only one named is their queen, Hecate. They appear suddenly on the heath of Forres, in thunder and lightning, and after their fell work is done they vanish to aerial music. Their purpose, though malignant in the extreme, is of a lofty kind. They inspire Macbeth with ambitious hopes which lead him to the murdef of the "gracious Duncan," and after a career of bloody tyranny end in his own destruction. There is in this the leading feature of the Grecian tragedy, that of irresistible fate. This is Shakespeare's method of handling the subject. The ordinary witch dreads the constable and the justice, but, as Charles Lamb observes, it would be "a hardy sheriff with the power of a county at his back, that would lay hands on the weird sisters."
In the play of The Witch of Edmonton, written conjointly by Kowley, Decker and Ford, there is a strong passage which,
I think, must have been written by Ford. The witch has lost her familiar imp, who had been sent to perform some diabolic work, and she invokes his return thus :
Not see me in three days? I'm lost without my Tomalin ; prithee come ; Revenge to me is sweeter far than life ; Thou art my raven, on whose coal-black wings Revenge comes flying to me ; O, my best love, I am on fire (e"en in the midst of ice) Raking my blood up, till my shrunk knees feel Thy curl'd head leaning on them. Come then, my darling. If in the air thou hoverest, fall upon me In some dark cloud ; and as I oft have seen Dragons and serpents in the elements, Appear thou now to me. Art thou i' the sea? Muster up all the monsters from the deep. And be the ugliest of them : so that my bulch* Show his swarth cheek to me, let earth cleave, And break from hell, I care not: could I run Like a swift powder-mine beneath the world. Up would I blow it, all to find out thee. Though I lay ruin'd in it. — Not yet come?
The raven, alluded to in this passage, from his solemn hoarse voice and sable plumage, has been at all times regarded as a bird of ill omen. His croak announced approaching death. Marlowe, in his Jew of Malta, describes him as —
The sad presaging raven, that tolls The sick man's passport in her hollow beak ; And in the shadow of the silent night Doth shake contagion from her sable wings.
Lady Macbeth, sure of herself in the intended tragedy, exclaims :
The raven himself is hoarse That croaks the fatal entrance of Duncan Under my battlements.
In the Koran (Sura V, 30-35, Sale) the raven is connected with the murder of Abel. Cain did not know how to conceal the body of his slaughtered brother, but, says the text, "God sent a raven, which scratched the earth to show him how he should hide the shame of his brother. And he said, 'Woe is me! am I unable to be like this raven, that I may hide my brother's shame ? ' "
The feathers of the bird had their appropriate uses, and Caliban in bis curse exclaims:
As wicked dew as e'er my mother brush'd With raven's feather from unwholesome fen. Drop on you both.
•Bulch, bulchin, an urchin, a hobgoblin.
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157
FURTHER OBSERVATIONS UPON THE TREATMENT OF MALIGNANT TUMORS WITH THE TOXINS OF ERYSIPELAS AND BACILLUS PRODIGIOSUS, WITH A REPORT OF 160 CASES.*
By Wm. B. Coley, M. D., Attending Surgeon to the New York Cancer Hospital, Assistant Surgeon to the Hospital for Ruptured and Crippled.
Abstract.
The cases reported extend over a period of upwards of four years, and they embrace nearly every variety of sarcoma and carcinoma. In practically all the cases the diagnosis was confirmed by microscopic examination made by the most competent pathologists. In addition, the majority of the tumors had been pronounced inoperable by leading surgeons, and in many cases still further evidence of malignancy was furnished by a history of repeated recurrence after ojierauion.
It would seem possible from this large series of cases to arrive at some scientific opinion as to the value or vvorthlessness of the toxins in malignant tumors. The fact was emphasized that this method of treatment had been advocated only in ■ inoperable cases which were entirely hopeless, not only from a surgical standpoint but also as regards any other hitherto known method of treatment. The author expressed the desirability of having these results subjected to the severest criticism. If they were able to stand this they would be of the greatest importance, not only as bearing upon the future treatment of malignant tumors, but also as throwing some light upon the unsolved problems of the etiology and pathology of such tumors.
An attempt was made to show that the method of treatment rested upon a rational basis, namely, the considerable number of cases of undoubtedly malignant tumors that had been permanently cured by attacks of accidental erysipelas. The writer's own observations covered the whole field from the accidental erysipelas to the mixed toxins. He was led to take up this line of investigation from having observed a small, round-celled sarcoma of the neck, five times recurrent, and given up as hopeless, cured by an attack of accidental erysipelas, patient having been found alive and well seven years afterward. His first series of ten cases were treated with repeated injections of living bouillon cultures, with the view of producing erysipelas. The unmistakable improvement that followed the repeated injections, even when no erysipelas was produced, especially in sarcoma, suggested that a portion, if not all of the beneficial influence was due to the toxins instead of the living germ, and this led to experiments with the toxins alone.
The first experiments were conducted with bouillon cultures that had been subjected to 100° C. and were used without filtration. The reactions followitig the injections of this solution were similar in character to those obtained from injections of the living germ, although less severe. In order to increase the virulence of the cultures, the writer made use of the fact demonstrated by Roger, that the bacillus prodigiosus, a non-pathogenic organism, had the power of intensifying the
•Paper read at theineetingof the Johns Hopkins Medical Society,
April 6, ISPli.
virulence of the streptococcus of erysipelas. The toxic products of the two germs were prepared separately and mixed at the time of using.
This mixture produced a much more severe reaction than when the erysipelas was used alone, and the beneficial influence upon the tumor was likewise more marked. Later on, at the suggestion of Mr. B. H. Buxton, the two germs were grown together in the same bouillon, the erysipelas being grown alone for 10 days and the bacillus prodigiosus added and the two allowed to grow together for another week or 10 days, at the end of which time they were passed through a Kitasato filter. This appeared to be a still greater improvement in technique.
A still further change was made with a view of utilizing whatever of value might exist in the insoluble products remaining in the dead germs ; the cultures were heated in a temperature sufficient to render them sterile, which was found to be 58-60° 0. for One hour. By the addition of a little thymol the fluid could be kept indefinitely in glass stoppered bottler. This preparation was much stronger than those before described, and experience proved it to be much superior to the others in its action upon the sarcoma. An analysis of the cases treated showed that -18 were round-celled sarcoma, 13 spindle-celled, 7 melanotic, 2 chondro-sarcoma, 3 mixed celled, 14 sarcoma, special type not known. Total number of ca^es of sarcoma 93 ; carcinoma and epithelioma 62 cases ; sarcoma or carcinoma 10; tubercular 2; fibro-angioma 1; mycosis fungoides 1 ; goitre 2 ; keloid 1. Of the cases of sarcoma, nearly one-half showed more or less improvement; the variety that showed the greatest improvement was the spindle-celled ; that which showed the least, the melanotic. A'est in order of benefit was the mixed celled — round and spindle; then round-celled, Avhile osteo-sarcoma closely approached the melanotic in showing but little change. In a series of 9 cases of melanotic sarcoma, no improvement was noticed in 6, very slight in 3. Most of the cases of osteo-sarcoma failed to respond to the treatment, many showed slight improvement, and one case, a very large osteo-chondro-sarcoma of the ilium, apparently disappeared and the patient remained well for nearly a year, when a recurrence occurred. One case of roundcelled sarcoma of the neck of very rapid growth showed very marked decrease during the first week's treatment, after which time it continued to grow iu spite of large doses of the toxins.
Keimkt of Successful Cases.
The cases most worthy of especial note were the following: Case I. — A twice recurrent inoperable sarcoma of the neck
with large secondary sarcoma of the tonsil.
Last operation performed by Dr. Wm. T. Bull. March, '91.
The tumor was so extensive that only a portion could be
158
removed; the general condition of the patient, May 4, 1891, was so bad that he was expected to live but a short time. He could swallow no solid food, and liquids with difficulty. He was treated from May -1 until October 8, 1891, with repeated local injections of living cultures of streptococcus of erysipelas ; decided improvement followed the injections, and whenever they were discontinued for a short time the growth increased in size. On October 8 a severe attack of erysipelas was produced by using a new and more virulent culture. During this attack the tumor of the neck nearly disappeared, the tumor of the tonsil decreased in size; general condition of the patient rapidly improved and he had soon regained his usual health and strength. He has had no treatment since. He was last seen in September, 1895, four years later, at which time the tumor of the tonsil, though still present, had greatly shrunken in size ; there was a small mass at the site of the old scar in the neck, apparently made up of cicatricial and fibrous tissue.
Microscopic Report.
[Copy from Records, N. Y. H. Laboratory.] PpEC. No. 1870.— Report of Microscopical Examination.
Operation, a piece of tumor about the size of an orange was removeil, but a portion yet remains, being too deeply seated for extirpation.
^Microscopically the tumor is composed of fibrous tissue and spindle cells, the fibrous tissues predominating in places and in others the spindle cells.
There are many areas of cells resembling mucous cells, and not to be differentiated from myxomata ; vascular supply abundant and vessel walls formed by tumor tissue.
Diagnosis, " myxo-sarcoma."
Farquhar Ferguson, M. D.,
Pat/iologist to the New York Hospital.
Case II. — Large recurrent sarcoma of the back and groin ; entire disappearance of both tumors; patient in perfect health, without recurrence four years after the beginning of the treatment, and more than three years after the cessation of the treatment.
Patient male, aged 40; sarcoma of the back and lower lumbar region 7x4 inches, with a secondary tumor the size of a goose-egg in the groin. The groin tumor was removed by operation, January, 1892; it rapidly recurred. Patient was examined by Dr. Wm. T. Bull and several other surgeons, who all regarded the case as inoperable. Diagnosis of sarcoma was made and confirmed by Dr. Farquhar Ferguson's (pathologist to the New York Hospital) examination of a portion removed under cocaine.
Treatment by repeated daily injections of living bouillon cultures of erysipelas was begun in April, 1893. At the end of two weeks a severe attack of erysipelas was produced. At the end of three weeks both tumors had entirely disappeared. Recurrence followed in July, and the tumors, both in the back and the groin, grew more rapidly than before. The injections were resumed, and between October, 1892, and January, 1893, the patient had four additional attacks of erysipelas; they were milder in character, and the effect upon the tumor was less striking.
In January, 1893, the tumor in the back was removed, but that in the groin left undisturbed. At the end of three weeks there was an apparent recurrence in the back, and the injections with the mixed toxins of erysipelas and bacillus prodigiosus were then begun. Both tumors quickly disappeared. Treatment was discontinued in March, 1893; patient has been in perfect health, free from recurrence since.
Pathological Report.
[Copy from Records, N. T. H. Laboratory.] The tumor is a Barcoma, in which the cells are round, oval, and spindle, in which everywhere there is seen a stroma of fibrous tissue, apparently the remains of the subcutaneous tissue which has not been completely destroyed during the development of the tumor. Yellow elastic fibres are quite abundant throughout the tumor, but the vascular supply is not very abundant. Farquhar Ferguson, 'SI. D.,
Patltologist to the New York Hospital.
Case III. — Large inoperable sarcoma of the abdominal wall and pelvis; entire disappearance of the tumor; no recurrence three years after.
The patient, a boy of 16 years of age, had a tumor 7x5 in. in extent, involving apparently the entire thickness of the abdominal wall, attached to the pelvis, and judging from the symptoms and position, evidently involving the wall of the bladder. A portion of the tumor was removed, and pronounced spindle-celled sarcoma, by Dr. H. T. Brooks, pathologist of the Post-Graduate Hospital. The case was regarded as inoperable by Prof. L. Bolton Bangs and referred to Dr. Coley for treatment with the toxins. Patient was admitted to the N. Y. C. H., Jan., 1893, treated for three months with the mixed filtered toxins. At the end of that time the tumor had nearly disappeared, and the remainder was gradually absorbed after the injections were discontinued; there was no breaking-down of the tumor tissue ; patient has been in perfect health up to the present time, more than three years after cessation of treatment.
PatJiologisfs Report.
Spindle-celled sarcoma.
H. T. Brooks, M. D., Pathologist to the Poat-Oraduate Hospital.
Case IV. — Large inoperable sarcoma of the abdominal wall; entire disappearance; no recurrence 2 J years afterward. The patient a woman, 28 years of age.
Exploratory operation had been performed in August, 1893, by Dr. Maurice II. Richardson, of the Massachusetts General Hospital. The tumor was too large to be removed; a portion was excised for microscopic examination. The diagnosis made by Dr. AV. F. Whitney, pathologist to the hospital, was fibrosarcoma. The patient was sent to Dr. Coley by Dr. Kichardson for the erysipelas treatment. The injections with the mixed toxins were begun in October, 1893, and continued for 10 weeks; the tumor entirely disappeared. The patient is still in perfect health, with no trace of recurrence.
Pathologist's Report.
August 31, 1893. The specimen from the tumor of the abdominal wall (Mrs. L.) was a small, dense, ill-deSued, whitish, fibrous-tooking mass, which
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on microscopic examination was found to be made up of large numbers of small cells with a tendency to form fibres. This latter condition was more marked in some places than others. The diagnosis is fibro-sarcoma. W. F. Whitney, M. D.,
PathohmUt Ui the Massachusetts General Hospital, Curator Warren Museum, Barvard Med. School.
Case V. — Spindle-celled sarcoma of the leg. Popliteal region. Three times recurrrent. Disappearance. Recurrence in gluteal region after one and a half years.
The patient, a girl, 15 years of age, had undergone three operations by Dr. Wm. T. Bull, for spindle-celled sarcoma starting in the metatarsal bone. In January, 1894, a tumor the size of a child's head was removed from the popliteal region. The one in the stump, the size of a hen's egg, was left to test the value of the toxins. Complete removal of the tumor in the popliteal region was impossible. The toxins were administered at the N. Y. H., under Dr. Bull's direction, for about 2 months ; treatment was continued at the N. Y. Cancer Hospital by Dr. Coley. The indurated mass in the calf slowly disappeared ; tumor in the stump also disappeared.
Patient remained well for li years. At the end of that time there was a recurrence in the gluteal region. The toxins were again administered ; the tumor diminished in size, and in February, 1896, was removed.
Pathological Report.
Tumor the size of a child's head, measuring 9x7x4| centimeters, is partly surrounded by a smooth capsule, but presents many freshly incised surfaces ; whitish in color ; very firm ; of little vascularity, and presenting the appearance of fibrosarcoma.
Microscopic examination of the tumor shows the typical structure of a fibro-sarcoma, with sarcoma elements predominating ; vascular supply fairly predominant. F. Ferguson, M. D.,
Pathologist, New York Hospital.
Case VI. — Extensive spindle-celled sarcoma of the scapula and chest-wall ; entire disappearance of the tumor under three months' treatment ; patient at present in perfect health ; no trace of recurrence 33 months later.
The patient, a girl, aged 16 years, was admitted to the " incurable ward " of the New York Cancer Hospital on June 20, 1894. The tumor apparently started in the region of the left scapula, 4 months before, and extended to the vertebral line behind, and in front to the edge of the sternum; it was fixed to the chest-wall, measured 13 inches behind, 7 inches in front. The left arm was bound down by the new growth so that it could not be raised to a horizontal position ; the skin was normal ; there were no general or local signs of inflammation. A portion of the tumor was removed for microscopic examination and a diagnosis of typical spindle-celled sarcoma was made by Dr. II. T. Brooks, pathologist to the Post-Crraduate Hospital. The patient was treated for three months with daily injections of the mixed unliltered toxins; improvement was ininiediate and the tumor very rapidly disappeared by absorption. Patient remains in jiorfect health at the present time.
Pathologisfs Report.
Typical spindle celled .sarcoma.
H. T. Brooks, M. D. Pathologist to the Po.ti-Oradttate Hospital.
Case VII. — Intra-abdominal round-celled sarcoma of mesentery and omentum; disappearance; patient well, without evidence of recurrence 1} years later.
The patient, female, aged 23 years, was operated upon by Dr. Willy Meyer at the German Hospital, in August, 1894. A small tumor involving the mesentery, omentum, large and small intestine, was found and removal considered impossible. Portion was excised for examination and pronounced bj- Dr. Schwytzer, the pathologist of the German Hospital, " roundcelled sarcoma." Patient was referred to Dr. Coley for treatment with the toxins. Injections were given in the gluteal region and abdominal wall for about six months, with occasional intervals. In February, 1896, an attempt was made to close the sinus in the abdominal wall which had persisted since Dr. Meyer's operation. The sinus was found to lead into the gall bladder and several impacted gall-stones were removed ; careful exploration of the abdomen failed to reveal the presence of any tumor. Patient perfectly well, August 7, 1896.
Case VIII. — Epithelioma of the chin, lower jaw and floor of mouth; entire disappearance; patient perfectly well two years later.
The patient, a woman 34 years of age, was admitted to the Methodist Episcopal Hospital in May, 1894. A rapidly growing tumor was found, involving lower jaw, floor of mouth and soft part of the chin, extending over an area about the size of a silver half-dollar, presenting the appearance of a typical epitheliomatous ulcer. The patient was regarded as inoperable by Dr. Geo. R. Fowler ; a portion of the growth was excised and diagnosed as epithelioma, by Dr. Wm. X. Belcher, pathologist to the hospital. The patient was treated at the N. Y. C. H. from June, 1894, till September, 1894, with the mixed unfiltered toxins. There is no trace of the tumor to be found at present and the woman is in perfect health (July, 1896).
Pathologist's Report.
Jlaterial from chin and lower jaw, May 20, 1S94. Sections were not entirely satisfactory, but from gross appearance of the materials and those revealed by the microscope the diagnosis of epithelioma is offered. W. X. Belcher, M. D.
Case IX. — Enormous osteo-chondro-sarcoma of the ilinm; tumor disappeared; patient regained his usual health and remained well for seven mouths, at which time a recurrence occurred. The tumor has resisted further treatment: the patient, although alive, is in a hopeless condition.*
Case X— Spindle-celled sarcoma of the hand, 6 times recurrent; remained well for one year, then recurred.
Case XL — Very large, twice recurrent angio-sarconia of the breast; treated for six months with the erysipelas and prodigiosus serum; marked reduction in size, making the tumor easily removable; excision, September, 1S95 : no recurrence, February 8, 1896.
The patient, a woman aged 59 years, was admitted to the N. Y. C. H. on January 20, 1895 ; had a very large recurrent tumor in the region of the left breast, extending from the sternum to the niid-axillarv line; the tumor was fixed to the
•Patient died, July, 1S96.
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chest-wall, and entirely inoperable; patient was extremely weak. She improved slowly under the local injections of the erysipelas serum, and in September the tumor had become so much reduced that it was easily excised.
Microscopical Report.
I have examined a large number of sections from different parts of the tumor of breast of No. 207, and altbough there is considerable diversity in detail of the new growth in different parts, I think that the structures are all referable to the type of angio-sarcoma, which accordingly is the anatomical diagnosis.
T. MiTCHBLL PrUDDEN, M. D.
Case XII. — Large inoperable round-celled sarcoma of the iliac fossa; treatment was begun in June, 1893 ; tumor almost entirely disappeared ; patient was in good health, August, 189-4, after which time he was lost sight of.
Case XIII. — Probable sarcoma of the sacrum ; disappearance of tumor ; complete restoration to health.
The patient, male, 38 years of age, began to lose flesh and strength in February, 1895. Later had severe pains in lower portion of the spine and sacrum, shooting down the legs. April 1, began to get lame in the right leg; soon after in the left; all of the symptoms progressively increased, and on the 2d of May his weight had fallen from 175 to 134 pounds. He was admitted to Dr. Kinnicutt's service at St. Luke's Hospital ; rectal examination showed a tumor, hard in consistence, attached to the anterior portion of the sacrum, the lower portion of which only could be reached with a finger. Clinical diagnosis of Dr. Kinnicutt and the others who saw the patient in consultation was inoperable sarcoma. No microscopic examination was made. A two to three weeks' trial with the erysipelas toxins was advised by Dr. Coley. The improvement was almost immediate ; injections were made into the buttocks; treatment was repeated daily, and at the end of one week the excruciating pain had almost entirely subsided, the lameness improved rapidly, and at the end of six weeks the patient had gained 28 pounds and was able to resume his work. Examination, March 8, 1896, showed the patient to be in perfect physical health; his lameness had disappeared; no trace of a tumor could be detected on rectal examination ; his weight at that time was 175 pounds.
Several other cases in which very marked improvement had followed the use of the toxins were reported.
Attention was further called to nine successful cases in the hands of other surgeons who had used this method. The most important of these were the following:
Case 1. — A large spindle-celled sarcoma involving almost the entire palate and pharynx. — This case, it was stated, had already been reported in the New York Medical Kecord, November 17, 1894, but its value was greatly enhanced by the fact that there had been no recurrence two years afterwards.
Case 2. — Extensive inoperable intra-abdominal sarcoma, reported by Dr. Herman Mynter of Buffalo, in the New York Medical Kecord, February 9, 1895. In this case the tumor disappeared, and up to April, 1896, there had been no recurrence.
Cases 3-6.— Drs. L. L. McArthur and John E. Owen of Cliicago had had three successful cases, although sufficient length of time had not elapsed to determine whether or not
they could be classed as cured. All of the cases were recurrent, and in two amputation of the leg had been advised ; in a third, amputation of the arm.*
Case 7. — Czerny of Heidelberg, who has used the method in four cases of sarcoma and in four of carcinoma, has reported one case of rapidly growing, inoperable, round-celled sarcoma of the parotid which nearly disappeared under the influence of 18 injections. The case has been more recently referred to as cured, by Glueckmann.
Case 8. — Dr. Judson C. Smith, of the Post-Graduate Medical School, had a case of small round-celled sarcoma of the neck, the size of an orange, disappear entirely under eight weeks' treatment with the mixed toxins. Microscopic examination was made. Patient gained 25 pounds in weight, remained well for a number of months, at the end of which time a recurrence took place.
Cases 9-10. — Two other successful cases were briefly reported, both of which were confirmed. by microscopic examination ; both cases were recent, and therefore could not be classed as permanent cures.
The writer stated that he did not expect the profession at large to accept without question and criticism such remarkable results as he had reported, and for that reason he had related with some detail the successful cases in the hands of other surgeons who had employed this method. He was of opinion that a series of xtpwards of 20 successful cases of inoperable sarcoma (four of which had remained well upwards of 2i years), the diagnoses of which had been established beyond question according to accepted methods of diagnosis, ought to be sufficient to demonstrate the real and positive advance that had been made in a field which, up to this time, had been regarded as absolutely hopeless. He did not doubt that there were those who would still remain skeptical about the value of the toxins in spite of the evidence presented. Such persons must either fail to see any logical connection between the accidental erysipelas and the toxins, or they must go even farther and deny that there are any authentic cases of malignant tumors that were cured by accidental erysipelas. The only explanation they can have to offer for the results which cannot be questioned is, that in all the successful cases there must have been an error of diagnosis.
Such an explanation might be entitled to some consideration were a single case only involved, but those who would seriously propose it as a satisfactory explanation in view of the results in more than 20 cases, could not claim to be guided by scientific principles. The writer stated that he had carefully examined the literature of the subject of spontaneous disappearance of tumors supposed to be malignant, but had failed to find a single instance in which the diagnosis had been confirmed by the microscope. It would apjiear remarkable that these cases should be the first on record with a clinically and micro.scopically confirmed diagnosis to disappear spontaneously, and it would seem more remarkable still that this disappearance should be coincident with the beginning of the treatment with the toxins.
- In two of these cases there was a suspicion of recurrence in
April, 18%.
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Furthermore, it would be clearly unfair to rule out these cases on the ground of error in diagnosis, without ruling out the cases of cure following operation, for the same reason.
The writer then briefly referred to the various theories that had been offered in explanation of the action of the toxins. He still adhered to his opinion, expressed in his earlier paper, published iu December, 1893, that the micro-parasitic origin of malignant tumors furnished the only rational explanation of this action. His conclusions were, 1) that the mixed toxins of erysipelas and bacillus prodigiosus exercise an antagonistic and specific influence upon malignant tumors, which influence in a certain proportion of cases may be curative. 2) That the influence of the toxins is very slight in most cases of carcinoma, including epithelioma, most marked iu sarcoma, but that it varies greatly with the different types, the spindlecelled form being by far the most responsive to the treatment. 3) That the action of the toxins is not merely local in character, but systemic. 4) That the toxins should be reserved for use in clearly inoperable cases of sarcoma, or in cases after primary operation, to prevent recurrence.
Discussion.
Dr. Welch.— I have been very much impressed by this personal statement from Dr. Coley, and I see no way of gainsaying the evidence which he has brought forward, that there is something specifically and genuinely curative in his method of treatment. A single undoubted cure of a demonstrated cancer or sarcoma by this treatment would be enough to establish the fact that the treatment exerts some specific curative effect, for the spontaneous disappearance of undoubted malignant growths of this character is almost unknown. Dr. Coley has, however, presented to us positive proof of the cure, not of one only, but of several cases of malignant tumor by his method. Although I suppose that in any given case the chances of cure by this method are at present not great, still the demonstration that cure is possible gives every encouragement for perseverance in this line of investigation and work, and for efforts to perfect the method of treatment.
It is interesting to learn that the most strikingly beneficial results have been obtained in the treatment of spindle-celled sarcomata. There are certain kinds of sarcomata which some pathologists are inclined to rank rather among the infectious tumors than among the genuine tumors, iu the sense in which these terms are used by Cohnheim ; but it is rather certain sarconuxta of the lymphoid type than the fusiform-celled sarcomata which are thus believed to be possibly outside of the class of genuine tumors, according to Cohnheim's classification.
As Dr. Coley suggests that the variations in his results may depend in part upon variations in the virulence of his cultures, and as it is well known that streptococci vary notably in virulence, I would like to ask if he has as yet utilized the methods of Marmorek iu order to obtaiu cultures of uniformly high degrees of virulence. Dr. Livingood in my laboratory has confirmed the results of Marmorek and succeeded repeatedly by his method in transforming streptococci of low virulence into those of very exalted virulence.
It seems to me that it would be practicable and most inter
esting, and possibly demonstrative of the specific effects of the
treatment, if Dr. Coley, in carrying out his researches, would
occasionally cut out small bits of tissue from the tumor and
by their examination endeavor to determine the details of the
process of cure.
It does not seem to me absolutely necessary to adopt the hypothesis of the parasitic causation of these malignant growths in order to explain their disappearance under this treatment. It is conceivable that the peculiar biological properties of the tumor cells — and peculiar they unquestionably are — may render them particularly susceptible to the toxic substances injected. The evidence that the curious bodies often seen in malignant tumors are genuine parasites is, in my opinion, far from conclusive at the present time.
Dr. Finney. — I have had the opportunity of observing the action of both the erysipelas organism and the toxin in a number of cases, both in hospital and private practice. One point which Dr. Coley has not mentioned to-night, but which he has referred to previously, 1 will speak of, because I think it of great value. It is the influence of the treatment on cases which may not finally result in a cure. The first case in which I used the erysipelas occurred about the time Dr. Cole\' began to make his observations in New York. It was a case of a woman with inoperable carcinoma of both breasts. Against my will, but at the urgent request of herself and her husband, I inoculated with a pure culture of the erysipelas streptococcus. She had at the time a very distressing and severe cough, with intense pain, evidently from involvement of the pleura. She had also evidences of internal metastases. After the first reaction from the erysipelas the pain almost entirely disappeared, and did not reappear with severity while the patient lived. She had been almost constantly under the influence of morphia up to the time of the inoculation, and after that time she had only a little codein from time to time to relieve her cough, which persisted after the pain had disappeared. I observed a similar action in another case. I think this patient lived three months after the inoculation. She gradually wasted away, more from inanition resulting from the internal metastases.
I had one case of inoperable carcinoma of both brejjsts, in which it was impossible to produce any reaction from the erysipelas. I injected it under the skin. I scarified and dressed the wounds in pure cultures in large amounts iu very virulent erysipelas without getting the slightest reaction. Of course there was no result from this case.
I would like to ask Dr. Coley whether he has ever observed any cumulative effect of the toxins? In one or two Ciises it seemed as if that had happened. After a number of injections with gradually increasing doses, without any reaction, a sudden tremendous explosion would take place which slowly subsided, and then for a varying length of time there would be no reaction, even with larger doses than were used previously.
I have observed no cases up to the present time where there has been a cure. But unfortunately, all the cases in which I have used it, except one under treatment at the present time, have been either carcinoma or Civses of sarcoma that were beyond hope from any source.
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Dr. CoLEY. — I have been very much interested in the discussion and I think I have gained as much from it as any one. I was particularly interested in the remarks of Dr. Welch. I did not mean to make quite so strong a statement in regard to the parasitic theory ; I should have said that that was the way it appeared to me.
I have used the streptococcus from all sources, but the streptococcus from a virulent case of erysipelas seems to have a better effect than a streptococcus from an abscess.
I have used Marmorek's method somewhat. Mr. Buxton has repeatedly passed the cultures through rabbits, and he had been doing it for some time before Marmorek's paper came out. That is the way, I believe, in which improvement in technique is to come, along the lines which Marmorek has shown us, in increasing the virulence of the cultures.
I will say, in answer to Dr. Bloodgood's question regarding metastases, that the patient with sarcoma of the back and groin was a case of marked metastases, the tumor being the size of a goose egg and also recurrent in the groin. That case has remained well over three years since the cessation of treatment.
A case which I published a year ago, treated by Dr. Rumgold of San Francisco, was one in which a round-celled sarcoma reappeared eight times in the breast. It disappeared under the mixed toxins, but the patient died a few weeks later. Autopsy showed very extensive metastatic deposits in the internal organs. In this case the external growth had been cured, but the internal growths were too far gone to be influenced.
About removing specimens during the course of the treatment, as suggested by Dr. Welch, I will say that I have done
that in a considerable number of cases. In many of these cases a marked fatty degeneration and necrosis of the malignant cells were clearly visible under the microscope. I shall try to show these changes in micro-photographs of the sections.
In regard to intra-orbital sarcomata, I have not had an opportunity of treating such cases before removal of the eye. I have had four or five cases of recurrent tumors in the orbit after the eye had been enucleated. The effects were very slight, if any. They were all melanotic or round-celled sarcomata.
As to the safety of the treatment, I think that if the cases are selected with some judgment the injections can be used with almost perfect safety. I have had three cases in which I am sure death was hastened by the use of toxins. In one case I ought not to have used the treatment. There was an enormous sarcoma of the scapula and chest wall. The patient was so much emaciated that he could not have lived more than a couple of weeks, but with two very minute doses of the weaker solution of the toxins he lived only three days.
The differences obtained by the same doses at different times is best explained, I think, not by cumulative action, because that is not clearly proven, but by the fact that the reaction is greatly increased when the injection is made into a more vascular part. A patient can stand perhaps five to ten times as much injected subcutaneously remote from the tumor as he can injected into a vascular tumor. Sometimes we inject into a part that is more vascular than others, and to this is to be attributed the difference in reaction. I always caution any one to begin with the minimum dose and increase it very gradually. One half a minim of the unfiltered mixed toxins is suflBcient for the initial dose.
THE PSYCHICAL NERVE CELL IN HEALTH AND DISEASE.*
By Henky J. Berkley, M. D.
The cortex of the brain of all mammals contains a large variety of different forms of nerve cells. Among these, and perhaps three-quarters of the whole number, are certain cells of peculiar form and character which are not present in other parts of the nervous system, and probably subserve as the substratum of the mental functions, and accordingly they have been named the pst/chi'cal nerve cells.
Of these cells there are two varieties — a small and a large form — only differing anatomically in their size, the other characteristics being equal. The small cells occupy the region of the cortex comparatively close to the surface of the brain, the others are more deeply situated.
The body of the cells is of pyramidal or conical form. Out of the superior portion departs what is known — from its early origin — as the primordial process, which at some distance from the cellular body branches and rebranches until it assumes the outspreading appearance of a tree. Out of the basal portion of these cells also proceed extensions, which correspond
•Read at the Niiiety-eij:hth Annual Meeting of the Medico-chirurgical Faculty of the State of Maryland, April 28, 1896.
to the roots of the tree, and may be either few or many in number.
The uppermost branches of the psychical cells reach high up into the outer lamina of the cortex, where they come into contiguity with the endings of the very numerous nerve fibres that arise from the medullated masses at the foot of the convolutions, or have their source Avithin the cortical layers and ascend toward the brain surface.
So far, except in shape, the psychical cells do not differ from other nerve cells in the brain-rind, but if we look a little closer at the branches of the neurons, we will find that they are thickly studded with short lateral projections, the majority of these having the form of a round-headed pin with the sharp point set into the protoplasmic substance of the stems. These peculiar lateral projections, or gemmulse, are present to some extent on other cortical cells, but have not the full development they possess with the psychical, and accordingly it is reasonable to suppose they have peculiar attributes differing from other cells.
Let us consider for a moment their probable function. Surrounding the branches or dendrites of the cells is a maze of
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innumerable fine nerve fibres, and from these filaments are given off at frequent intervals, which, after branching and rebranching a number of times, end in little bulbs that constitute the intracortical end-apparatus of the nerve fibres. Now these little bulbar endings come into very close approximation with the globular ending of the gemmules, and it is exceedingly probable that the nervous forces passing from cell to cell, or the external impressions conveyed centralwards from the peripheral organs to the nerve centres, overleap the slight barrier between the ending of the nerve fibre and the bulbous ending of the gemmule, and through the medium of the latter are continued on toward the cell body, where, acting as a temporary irritant, they excite the cells to action, and a thought or motor impulse is engendered.
Besides the protoplasmic processes, another even more important portion of the psychical cell has its origin in the basal region. The axon, or axis cylinder, invariably departs from this end, usually in the form of a thin cone which gradually attenuates until it becomes the axis cylinder. On its way toward the white medullated matter the axon gives off a number of side branches or collaterals. These invariably return toward the surface of the brain, and after a number of subdivisions, end in the bulbar apparatus before described, and serve the purpose of connecting one cortical psychical neuron with a large number of others situated in its immediate neighborhood.
Thus it is found that the cortical neurons not only receive impressions from more distant sources, intrinsic or extrinsic to the brain, but that one cell receiving the dynamic force may communicate it to dozens of other cells, and that a considerable excitation of numerous neurons may result from what was in the first place an excitation of inconsiderable moment, for in fact the whole mass of cells in the cortex of the brain are so intricately united one with another by the complicated arrangement of fibres and collaterals that the brain-rind may be considered as an unit, at least such is the present idea derived from a study of its minute anatomy by the silver methods now in vogue.
We have seen the form and connections of the psychical cell in health, let us turn for a moment and see its deportment under certain pathological conditions.
I have studied during the past few months the effects of the action of certain poisons upon the cortical cell, notably the effects of alcohol, of the poison derived from the castor-oil bean, riciii; and for the toxins of bacterial source that developed in experimental hydrophobia. All possess the quality of destroying the protoplasm of the nerve cell and annulling its functions, some with extreme rapidity, some more slowly. All act upon the living substance of the cell in a similar numner, the process being one of a peculiar type of parenchymatous degeneration.
In the earliest stages of the degenerative process, or where the amount of the poison circulating through the blood-channels is but snuill in amount, we find the changes confined to the fine free extremities of the dendrons, principally in the outermost layer of the cortex, where the branches of the psychical cells have their endings. On these fine branches, in tlie jdace of the smooth rounded contours of the stems, one finds they
have acquired a number of knots or tumefactions in their course, and over the site of these swellings the round-headed gemmules are beginning to show signs of disease. They no longer assume the full black staining from the silver, but appear light-colored, and besides are, owing to the swelling of the stems, pushed further apart than is natural.
A stage further in the process shows an increase in the number of the tumefactions. 'J'hey also extend further downward on the stems. The gemmules are now beginning to drop off from the branches, are being taken up by the lymphatics, and rapidly disappear. Soon the finer branches begin to atrophy and disintegrate, they dwindle and drop off from the thicker stems, or are reduced greatly in length, and the portions remaining are thickly set with swellings of smaller or larger size, from which the gemmules have almost entirely disappeared.
As the irritation of the protoplasm of the nerve cell continues, the destruction becomes more and more intense, the long apical and basal branches are reduced to knotted stumps, scarcely retaining anything of their former aspect ; eventually the remaining portions of the neuron, now reduced to the corpus and axon, become involved in the retrogressive process; the body also begins to break up, but as it is extremely resistant to the effects of the toxin, it is a long time before actual disintegration takes place and it is removed by the lymph currents.
The axis cylinder seems to be the most resistant portion of the cell to the destructive influences of irritant poisons; long after the other portions of the neuron have attained a considerable degree of degeneration, it retains its fine rounded thread unswollen, and apparently uninfluenced by the morbid process going on in the other members. The collaterals and terminal apparatus retain their normal form until the destruction of the cell has been completed. The only disease in which there is an exception to the rule of the contiuuance of the axon is in hydrophobia, where a few cylinders may now and then be seen to have spindle-like thickenings in their course.
Synchronous with the degeneration of the protoplasmic twigs of the neuron, interesting changes take place in the nucleus. The nucleolus, as well as the coarser molecular particles contained in the nuclear ring, sw^ell and form rounded or irregular corpuscular bodies that occupy a large portion of the circle. The nuclejir substance also shoivs altered properties, it absorbs more of the aniline dye, and no longer shows the usual disposition of the molecular particles found in health. Even in the second st^ige of the degeneration, when the cellular branches are tumefied and thegenimul* aredjing, the cells are practically incapable of functioning, for their connection with other neighboring or more distant neurons is already broken, and they C!»n no longer receive the nervous impressions transmitted from other elements, and any impulses originating within their corpora must be perverted ones, and more likely to be the source of irregular muscular contractions than of perfectly coordinated movements: iu fact we do find these very incoordinate motions iu many crises of severe poisoning with toxins, especially those of bacterial source.
In the tumefactions of the dendrites of the nerve bodies and loss of the !;emmul!i\ the connectinsr link between the
164
terminal fibre apparatus and nerve cell is broken, and one can readily see in the loss of the anatomical relations an explanation of the numerous dementias and mental obtundities that follow a not inconsiderable proportion of cases of infectious fevers.
The pathology of a number of chronic insanities seems to depend largely on the condition of the protoplasmic branches of the nerve cells and of their adherent gemmules. In vari
ous forms of dementia there is a distinct diminution in the
numbers of these little ajjpeudages to the neuron, together
with reduction of the calibre of the stems. In some cases of
idiocy I have found a pronounced lack of development of the
gemmules, and accordingly deficiency in the number of points
on which external impressions may be received by the central
cell, hence the mental slowness and obtundity.
THE FREQUENCY OF CONTRACTED PELVES IN BALTIMORE;^
By J. Whitridge Williams, Associate Professor of Obstetrics, Johns Hopkins University.
Five years ago 1 wrote a short article, entitled Pelvimetry for the General Practitioner," in which I endeavored to show that pelvic mensuration was grossly neglected in this country and that our obstetrics suffered severely in consequence.
At the present time, I am glad to say, far more attention is being paid to it, and students generally are taught that it should constitute an important part in the examination of the pregnant and parturient woman.
In the article referred to, after discussing various aspects of the subject and urging that pelvimetry be made an integral part of the first obstetric examination, I stated : "Any one, who will regularly pursue this course, will be amazed to find how many moderately contracted pelves do exist, and will then be able to explain, in a rational way, many difficult cases of transverse or other presentations, which previously he merely turned or delivered by forceps or cranioclast, and whose abnormal presentation or mechanism he ascribed to some freak of nature rather than to a rational and sufficient cause."
Since the opening of the Out-door Obstetrical Department of the Johns Hopkins Hospital, a little more than a year ago, external and internal mensuration of the pelvis has been made an integral part of the examination of every pregnant or parturient woman who applies for aid, and the results have amply substantiated the prediction just quoted.
Up to March 15, 1896, we have collected the measurements of one hundred women, nearly all of whom were examined several times during the course of pregnancy, while a few were examined only at the time of labor. It is to the results of these observations that I desire to direct your attention.
I might say, in passing, that all the women were examined by Dr. Geo. W. Dobbin, the Assistant Resident Obstetrician of the Hospital, but in almost every case mentioned in this article the examination was also controlled by me, so that there is no reason to attribute any of the cases to faulty pelvimetry.
The study of pelvic contraction is of comparatively recent date. Until the sixteenth century, absolutely nothing was known concerning it ; it being supposed that the pelvic bones separated during labor, and that any obstacle to the birth of the child was due to resistance offered by the soft parts.
As the first accurate description of the pelvis was given by Vesalius (1514-1564), any idea as to abnormal j)elves was impossible before that period. And it was not until after his
•Read before the Medical and Cliirurgical Faculty of Maryland, May, 1896.
death that one of his pupils, Julius Caesar Arantius' (15301589), described the first recognized case of contracted pelvis. The teachings of Arantius, however, exerted but little influence, and the earlier uncertainty concerning the normal anatomy of the pelvis continued for many years, and naturally the doctrine of contracted pelvis remained undeveloped.
It appears from a careful perusal of the works of the great Mauriceau" that he recognized contracted pelves in only two cases ; one of them being the case upon which Hugh Chamberlen attempted to illustrate the advantages of the forceps invented by his uncle, and so ignominiously failed.
It was not until the first part of the eighteenth century that the doctrine of contracted pelvis began to exert any influence upon obstetrical practice, when Heinrich van Deveuter,' in his " New Light for Midwives," described the flat and generally contracted pelves, and demonstrated their effect upon the course of labor. iSiuce then the doctrine of contracted pelvis has never been lost sight of, and nearly all the greatest names in obstetrics are associated with its rise and development.
The great Smellie" played an important part in this regard, and his teachings exerted great influence. It is only necessary to recall the fact that he originated the method of manual mensuration of the diagonal conjugate, and the estimation from it of the length of the conjugata vera, to appreciate the extent of his services.
Baudelocque," in the latter part of the same century, devoted a great deal of attention to the subject, and it is to him that we are indebted for the first pelvimeter and our knowledge of tlie importance of the external pelvic measurements.
.Stein" was the German who played an important part in developing the subject, and in impressing its importance upon liis fellow-countrymen.
Since the introduction of pelvimetry and more accurate knowledge concerning pelvic deformity by Deventer, de la Motte, Smellie, Baudelocque, Stein and others, its importance has steadily increased, and the methods of pelvimetry and our knowledge of contracted pelvis have gradually improved.
To mention in detail the progress in this line would be almost equivalent to writing the history of obstetrics for the past one hundred and fifty years, and we shall therefore only refer to the work of Michealis'" and Litzmann,"'"' " and then turn from the historical side of the subject. For it is to these two men that we are indebted for perfecting our knowledge upon these lines and making possible the brilliant operative results, of which we are so justly proud.
August, 1896.
JOHNS HOPKINS HOSPITA.L BULLETIN.
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Micliealis was professor of obstetrics in Kiel from 1843 to 1850, and during those seven years accurately measured the pelvis in one thousand consecutive cases, and found that 72 of them were contracted to 8.75 cm. (3.5 inches) or less in the conjugata vera. This was the first accurate statistical knowledge on the subject, and his results are as valuable to-day as when his book, " Das enge Becken," first appeared in 1851.
Litzmann" succeeded Michealis at Kiel and continued the same line of work and soon collected another thousand cases with accurate pelvic measurements, which with Michealis' cases form the basis of our knowledge concerning the frequency of contracted pelvis.
Up to the time of Michealis, the conception as to what constituted a contracted pelvis varied greatly. Many authors considered a pelvis contracted only when it offered an absolute bony obstacle to labor ; while others considered the slightest deviation from the normal standard sufficient to justify the employment of the term. Michealis'" was the first to suggest a rational terminology, and stated that we should designate as contracted not only those pelves which directly interfere with the birth of the child by direct mechanical obstruction, but any pelvis which is contracted sufficiently to alter the normal mechanism of labor; all pelves having a conjugata vera of 8.75 cm. (3.5 inches) or less being designated as contracted.
And Litzmann" stated : " According to my conception, we must consider the border-line, from which contraction of the pelvis from an obstetrical standpoint begins, as such a degree of shortening of one or more diameters, as under ordinary circumstances (medium size and resistance of child) will exert a direct mechanical, but not necessarily retarding influence upon the course of labor."
He placed the border-line at 9.5 cm. (3.8 inches) for flattened and 10 cm. (4 inches) for generally contracted pelves, and accordingly found that 14 per cent, of his cases were contracted. Had the same limits been placed upon Michealis' cases he would have observed 13.1 per cent, of contracted pelves in his series, instead of 7.2 per cent., as he stated.
The limits suggested by Litzmann have been generally adopted, and we usually designate as contracted, flat pelves having a conjugata vera of less than 9.5 cm. (3.8 inches), while in generally contracted pelves the limit is placed at 10 cm. (4 inches).
Since the appearance of the statistics of these two observers, many of the German obstetricians have studied their cases iu the same manner; and we shall now adduce some of their statistics to illustrate the frequency of contracted pelvis in Germany and its variations in the various clinics. Thus:
Leopold,' in Dresden, 1892-93 (Franke) in 2512 cases, found 24.3 per cent, contracted pelves.
Schwartz," in Giittingen, 1862-05, in 463 cases, found 22 per cent, contracted pelves.
Schwartz, in Marburg, 1859-62, in 5()1 cases, found 20.3 per cent, contracted pelves.
Weidenmiiller," in Marburg, 1885-95, in 3214 cases, found 18.1 per cent, contracted pelves.
Fischl," in Prag, 1882, in cases, found 16 per cent, contracted pelves.
Miiller," in Berne, 1880, in 1177 cases, found 16 per cent, contracted pelves.
Litzmann," in Kiel, 1850-57, in 1000 cases, found 14.9 per cent, contracted pelves.
Michealis," in Kiel, 1843-50, in 1000 cases, found 13.1 per cent, contracted pelves.
Kottgen,'" iu Bonn, 1895, in 2000 cases, found 13.45 per cent, contracted pelves.
Pfund," in Munich (Winckel), 1885, in 1199 cases, found 9.5 per cent, contracted pelves.
Schatz," in Rostock, 1895, in — — cases, found 9 per cent, contracted pelves.
Gonner," in Basel, 1882, in cases, found 7.9 per cent
contracted pelves.
It accordingly appears that from 8 to 24 per cent, of all the women entering the German-clinics present more or less pelvic contraction. In other words, every twelfth to every fourth woman has a contracted pelvis.
It is possible that Leopold's' figures may be somewhat too high, as they are based in great part upon external measurements alone, and accordingly are not of as great value, as if based upon the results of both external and internal mensuration.
Winckel" states that it is safe to say that from 10 to 15 per cent, of the women in Germany present some pelvic contraction, but that only about 5 per cent, are sufficiently contracted to give rise to difficult labors ; while Schauta considers that we may assume that every seventh woman will present more or less contraction.
I have been unable to find accurate French statistics to compare with the German, but note that Pinard," in a recent article on symphysiotomy, states that he observed 107 contracted pelves in his clinic during the year 1895, and as he has a material of about 2000 cases a year, this would correspond to a frequency of about 5 per cent. Out of these 107 cases he performed twenty symphysiotomies, which clearly shows that many of them were seriously contracted.
The statistics just adduced give some idea as to the frequency of contracted pelves in Germany and France, and it now remains to consider their frequency in this country.
It is generally believed that contracted pelves are of very rare occurrence in this country, and a casual review of the American text-books would serve to confirm this belief.
Dewees,' in his Compendious System of Midwifery, stated that in all his experience he is doubtful if he had met with three cases of contracted pelvis; and this statement concerning their frequency h;is been very generally !»ccepted and handed down to the present time.
Lusk," iu the latest edition of his work, states that ail varieties of pelvic deformity may be observed among our foreign-born population, but considers that contracted pelves exist but rarely in our native-born women.
This appears to be the general opinion, and iu a discussion before the New York Obstetrical Society, Frnitnight* stated that he had observed only 2 contracted pelves in 1000 labor cases.
All the evidence which has beeu adduced in support of the rarity of pelvic deformity iu this country has been of a very
166
general character, and I am acquainted with only one author, Reynolds,-" who has attempted to study the question from a statistical standpoint. In 1890 he read a paper befoie the American Gynaecological Society'" on this subject, and stated that he had observed only 30 contracted pelves in 2227 labor cases which had come under his control in Boston. This would represent a frequency of 1.34 per cent.
He designated as contracted all pelves having a conjugata vera of 8.75 cm. (3.5 in.) or less, when flattened, or 10 cm. (4 ins.) when generally contracted, and stated that they nearly all occurred in foreign-born women, only three or four of the cases occurring in native-born Americans.
From his own confession, it appears that he only measured the pelvis when some obstacle to labor arose which required operative interference, and it is evident that a large proportion of cases thereby escaped observation, as it is well known that the great majority of women with contracted pelves have spontaneous, if slow, labors.
I agree entirely with Winckel," who says "the publication of Reynolds unfortunately fails to prove anything, because only those cases were measured in which operative interference was necessary. It therefore cannot be claimed that his material was thoroughly worked up," etc. And " so long as it is not demonstrated that rachitis, for example, occurs far more rarely on that side of the ocean than with us, so long as thousands and thousands of pelvic measurements are not adduced, so long will all such statements rest upon a very uncertain foundation."
It is evident that Winckel" has struck the keynote, and not until we are in a position to present series of pelvic measurements from thousands of consecutive labor cases shall we be able to prove or disprove the general statements of the text-books.
There is, however, absolutely no doubt to my mind that they occur far more frequently than is generally supposed.
How many of the men here present have not performed craniotomy after fruitless attempts at forceps or version ? How many cases of vesico- vaginal fistula have yoii observed ? No doubt, the vast majority of such cases were due to contracted pelvis.
According to the statistics of Zinke," 213 symphysiotomies were performed throughout the world between 1892 and 1894, and of these, 24, or 11 per cent, were done in the United States. All these operations were rendered necessary by pelvic contraction. And does it not appear strange, if they are of so infrequent occurrence as is generally stated, that we should have performed one-ninth of the symphysiotomies of the world ; while the European countries, with their large preponderance of contracted pelves, should have to divide the other eight-ninths among themselves ?
It is readily understood, in the absence of routine pelvimetry, how a very large proportion of the moderate degrees of pelvic contraction are overlooked, when we consider the relation which the German statistics show to exist between the number of operative and spontaneous labors occurring in these cases. Thus, Michealis" showed that 71 per cent, of his cases ended spontaneously, Leopold' 69.5 per cent., Gonner" 54 per cent., and Pinard" 72 per cent. In other words, from
one-half to three-fourths of the moderate degrees of pelvic contraction would pass unnoticed, if the pelvis were not measured, unless the obstetrician observed his cases far more accurately than is usually the case.
An article on the frequency of contracted pelvis is hardly the place to point out the effect of the pelvic deformity upon the presentation and position of the child, upon the mechanism of labor or its duration, or i;pou the prognosis for the mother or child, and we shall, accordingly, pass over this part of the subject, and simply state that a careful examination of the pelvis would reveal in many instances the cause of many abnormal presentations and of many a tedious and difficult spontaneous labor, not to speak of the operative cases.
We now turn from the work of others to our own observations. The routine examination of the pelvis in one hundred consecutive cases has shown us that fifteen of them were abnormal.
In our one hundred cases, we have found one-half as many contracted pelves as did Reynolds" in 2227 cases. This is certainly a remarkable showing ; and, while I wish it distinctly understood that I consider that we are dealing with too small a number of cases to be justified in basing statistical conclusions upon them, at the same time it serves to prove that Reynolds has overlooked a large number of cases by the omission of routine pelvimetry, ana that contracted pelves are far more frequent with us than is generally supposed, and the reason that they are not discovered more frequently is that they are not looked for.
I have designated as contracted only those pelves which presented an oblique conjugata of 11 cm. (4.4 in.) or less, and which correspond to a conjugata vera estimated at 9 cm. or less (3.6 in.) — in other words, only pelves whose conjugata vera is shortened 2 cm. (0.8 in.) or more. In two instances I have depai-ted from this rule and have considered as contracted one pelvis having a conjugata vera of 9.75 em. (3.9 in.), and another of 9.5 cm. (3.8 in.), for the reason that they both gave rise to difficult labors, necessitating in the one case a difficult breech extraction, and in the other the application of high forceps.
When we analyze our cases according to the variety of deformity presented, we find that we have to deal with :
four rachitic flat pelves,
four simple flat pelves,
five generally contracted pelves,
one coxalgic oblique pelvis,
one transversely contracted pelvis of a male type.
It is usually stated by most American authors that the great majority of contracted pelves, which are observed in hospital practice, occur in foreign-born womeii, while only a small proportion are observed in the native-born.
When we consider our material from this point of view, we find that seven cases occurred in negresses and eight cases in white women.
Of the eight white women, four were native-born, two were German, one Hohemian and one Irish. These figures certainly do not bear out this statement, as they clearly show that eleven of our fifteen cases occurred in native-born Americans.
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JOHNS HOPKINS HOSPITAL BULLETIN.
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It is also of interest to consider how the several varieties of deformity are divided among the various nationalities.
We find that our seven blacks presented three generally contracted pelves, two rachitic and two simple flat pelves.
Of our four native-born whites, two presented simple flat pelves, one a flat rachitic and one a coxalgic oblique pelvis.
One of the two Germans presented a generally contracted pelvis, and the other a transversely contracted pelvis which conformed to the male type.
The Bohemian had a generally contracted, and the Irish woman a flat rachitic pelvis.
No doubt, to most of you, the data just adduced possess only a purely scientific interest, and we shall therefore turn to the more practical consideration of the effect of the contracted pelvis upon the course of labor.
Two of the pelves considered in this paper belong to women who have not yet been confined, but it may be of interest to consider the history of their past labors. The first case is a colored secundigravida, with a generally contracted pelvis, whose previous labor was very slow and was terminated by the forceps delivery of a dead child. And the other case is a German who has had two children. She has a transversely contracted pelvis of the male type, very deep, with a very high symphysis pubis, lateral contraction of the pelvic outlet, the distance between the ischial tuberosities being about 8 cm., and the conjugata vera 8.5 cm. (3.4 in.), both her previous labors having been terminated by craniotomy.
It is apparent that the pelvic contraction in these two cases is quite marked, and played an important part in the production of the fcetal mortality in the previous labors.
Of the thirteen cases which have already been delivered, seven were delivered spontaneously, while six necessitated operative interference.
Five of the seven spontaneous cases were delivered at full term of live children. The sixth spontaneous case was a syphilitic colored primipara, with a flat rachitic pelvis, conjugata vera 8 cm. (3.2 in.), who was delivered at the eighth month of a macerated syphilitic foetus ; while the seventh case resulted in an abortion at the sixth month. This was an Irish woman, pregnant for the third time. Both her previous labors had resulted in dead children after tedious forceps opei-ations, the last delivery resulting in a complete perineal tear and a large vesico-vaginal fistula, which were repaired at the Johns Hopkins Hospital. This case was spontaneous only because of the abortion, and the probabilities are, had she gone on to full term, that she would have required a symphysiotomy.
The six cases whicdi re(iuircd operative interference were delivered as follows :
four by high forceps,
one by craniotomy on dead child, and
one by a difficult breech extraction.
No one can hear these somewhat dry statistical statements without being convinced of the very important part i>hiyed by the pelvic deformity in the cases before us.
It is evident that the defornuty alone, or the abnormalities in the mechanism of labor produced by it, were the direct cause of the various operative jirocodures which we have just men
tioned, or of the foetal mortality in the previous labors of the
women who have not yet been confined.
Who, after hearing these results, can say that the study of moderate degrees of pelvic contraction is not worthy of far more consideration and investigation than are accorded them by most of us?
I believe that I have made it evident that pelvic contraction is of far more frequent occurrence than is generally believed, and that it is the cause, directly or indirectly, of a large proportion of the obstetrical operations which we are called upon to perform.
Does it not then behoove us to be on the lookout for it, and prepared to recognize it before the onset of labor, so that we may be prepared in advance for the eventual forceps or version, and in rare cases for the more serious operations of symphysiotomy and Caesarian section ?
This necessitates the careful and routine examination of every pregnant woman before the onset of labor, when we should map out the presentation and position of the foetus and carefully study the form and size of the pelvis.
It is not until this is done that we are doing anything like our full duty by our patients, and if I have succeeded in imi^ressing the importance of the systematic examination of pregnant women, including pelvimetry, upon a single man here, I shall feel amply repaid for the preparation of this paper.
Dohrn' stated some years ago, "that the physician who does not measure the pelvis is comparable to one who diagnoses heart and lung troubles without the aid of auscultation and percussion "; and I can only indorse his statement. At the same time I do not wish to be understood as advocating pelvimetry as the summum bomim of obstetrics. I have just shown you its importance, but unfortunately its practical teachings are not absolute.
The birth of the child is dependent not only on the size of the pelvis, which we can determine with reasonable accuracy, but also upon the size of the child's head, its compressibility and adaptability, and the character of the labor pains, which unfortunately we can only approximate, but never determine absolutely in the concrete case.
Therefore, in moderate degrees of pelvic contraction, pelvimetry does not give all the information we desire. And with pelves of the same size, we sometimes find that one patient is delivered spontaneously, while with the next we are obliged to resort to operative interference.
These considerations, however, do not absolve us from the necessity of pelvic mensuration ; they only teach ns its limitations and enable us to comprehend the more fully the many factors which should be considered by the conscientious accoucheur.
Literature.
1. Arantius: He humauo fretu liber. Eiusdem anatomicarum observationum liber, etc. Venet. loST.
2. Baudelocque: L'art des accouchenieuts. Xouvelle ed. 1789.
3. Dcventer: Neues Hebammeulicht, III. Auf. Jena, 172S.
4. Heweos: A Compendious System of Midwifery. 1S24.
168
5. Dohrn: Ueber Beckenmessung. V'olkmaim's Sammhmg klin. Vortriige, Nr. 11.
6. Fischl: Ueber Frequeuz uiid Prognose der Geburt beim engen Becken. AUg. Wiener med. Zeitiing, 1883, Nr. 42.
7. Franke: Enges Becken uud spontaue Geburt. Leopold's Arbeiten, II, 29-47, 1895.
8. Fruitnight: Discussion to paper by Von Ramdobr — The difference in treatment in hospital and private practice of dystocia due to contracted pelvis. Am. Jour. Obst. XXIII, 180, 1890.
9. Gonner : Zur Statistik des engen Beckens. Zeit. f. Geb. u. Gyn. VII, 314, 1882.
10. Kottgen : Zur Statistik des engeu Beckens. D. I. Bonn, 1895.
11. Litzmann: Die Formen des Beckens, 18(31.
12. Die Geburt bei engen Becken, 1884.
13. Ueber die Erkenntuiss des engen Beckens an der
Lebenden. Volkmann's Sammlung klin. Vortriige, Nr. 20, 1871.
14. Lusk : The Science and Art of Midwifery. 4th ed. 1895.
15. Mauriceau : Traite des maladies des femmes grosses. II ed. Paris, 1675.
10. Michealis: Das enge Becken, 1851.
17. Muller: Zur Frequenz und Aetiologie des allgemeinen verengten Beckens. Arch. f. Gyn. XVt, 155, 1880.
18. Pfuud: Aerztl. Intelligenzblatt, XXXII, 247, 1885.
19. Pinard: De la symphyseotomie a la clinique Baudelocque pendant I'annee 1895. Annales de Gyu. et d'Obst. XLV, 1, 1896.
20. Reynolds : The frequency of contracted pelves. Trans. Am. Gyn. Society, 1890.
21. Schatz: Ueber das enge Becken in Norddeutschland. Cent. f. Gyn. 1895, 1057.
22. Schauta: Die Beckeuanonialien. Miiller's Handbuch der Geb., Bd. II, 1889.
23. Schwartz : Die Haufigkeit des engen Beckens. Monats. f. Geburtskunde, XXVI, 437, 1865.
24. Smellie: Treatise on the Theory and Practice of Midwifery. 8th ed. 1774, and Collection of cases.
25. Stein: Beschreibungdes kleinen und einfachen Beckenmesser, etc. Kleine Werke zur practischen Geb. Marburg, 1798, p. 135.
26. Wiedenmiiller: Zur Statistik des engen Beckens. D. I. Marburg, 189.5.
27. Williams: Pelvimetry for the General Practitioner. Medical News, March 21, 1891.
28. Winckel: Lehrbuch der Geburtshiilfe, II. Auf. 1893.
29. Zinke: Syn)physiotoniy versus Embryotomy upon the Living Fetus. Ohio Medical Journal, April, May and June, 1895.
HOSPITAL PLANS.
Flvo eeaayn relating to the construcllon, organization nnd management of HoS' pItaU), contributed by their authors for the use ot The Johns Hopkins Hospital
Those essays were written by DBS. John 8. Billings, of the U. 8. Army, Noii TOM FuLSOu ot Boston, Joseph Jones ot New Orleans, Oahpab Monnis ot Fhlladel phla, and STEPHEN SMITH of New York. They were originally published In 1876 Due volume, bound la cloth, price $5.00.
SPECIAL COURSES FOR GRADUATES IN MEDICINE GIVEN BY THE
JOHNS HOPKINS UNIVERSITY AND HOSPITAL.
CHANGE OF DATE.
With the completion of the organization of the Johns Hopkins Medical School, it has been found necessary to give the courses intended especially for jjhysicicms hereafter during the months of May and June, instead of at an earlier period of the academic year as heretofore. This new arrangement applies to the academic year beginning October, 1896. The courses of instruction for the undergraduates who are candidates for the degree of Doctor of Medicine are open only to these undergraduates. Physicians, not candidates for a degree, are admitted only to the special courses which begin May 1, 1897, and which continue for two months. Those who have had the requisite training and desire to undertake advanced and research work in the various laboratories, may be admitted at any time during the academic year, at the discretion of those in charge of these laboratories.
It is believed that the new arrangement as to the time of holding the graduate courses will prove to be more convenient than the former one to the majority of those desiring to take the courses.
These courses are intended especially to meet the requirements of practitioners of medicine. They include laboratory courses in pathology, bacteriology and clinical microscopy, and practical instruction in the hospital and in the dispensary in medicine, surgery, gynecology and the various special departments of practical medicine and surgery.
The detailed statements concerning these courses, the fees and all other necessary information, will be found in the published Announcement of the Special Courses for Graduates in Medicine, which will be sent upon application to the Johns Hopkins Medical School, Baltimore.
NOTES ON NEW BOOKS.
Text-Book of General Pathology and Pathological Anatomy. By Richard Thoma, Professor of General Pathology and Pathological Anatomy in the University of Dorpat. Translated by Alexander Bruce, M. A., M.D., F. R.C. P. E., F.R.C.S. E. ; Lecturer on Pathology, Surgeons' Hall, Edinburgh, etc. Volume I, with ■loCi Illustrations. (London: Adam and Charles Black, 1896.)
This translation of Thoma's Lehrbuch der allgemeinen pathologischen Anatomie, which .tppeared in the original in 1804, is a welcome addition to the rather meagre list of pathological textbooks in the English language. This first volume treats of general pathological anatomy and general pathology, the part relating to special pathological anatomy not having yet appeared in German.
Section I of the book is devoted to general etiology and is taken up mainly with the description of pathogenic micro-organisms and entozoa. Upon the whole this section is less satisfactory than the remaining parts of the book, as indeed is now-a-days usually the case in text-books on General Pathology. The student cannot dispense with works devoted especially to the description of pathogenic micro-organisms and other parasites.
The heading of Section II is "Elementary Forms of Disease." This section is occupied with the consideration of " Disturbances of the Circulation of the Blood " and the " Disturbances of Tissue Nutrition. " The treatment of the subject of the circulatory disturbances constitutes the most original and valuable part of the work. It is especially in this field of pathology that Thoma has labored for many years with brilliant succe.ss, during the period both of his assistantship to Prof. Arnold in Heidelberg and of his professorship in Dorpat. His presentation of the subject of the general and local disturbances of the circulation is an admirably
Fu;. 12. Northwest Corner of the Stcdy Koom on the Third Floor.
The case shown contains the wax models made by Ziegler. The main part of the room is devoted to the study of models and tinished dissections.
August, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
169
clear and important contribution, and can be confidently recommended to students of pathology as worthy of careful reading. It is based throughout upon a large amount of original investigation, characterized, as is so much of Thoma's original work, by ingenious experimentation and by the effort to attain mathematical accuracy and to find mechanical explanations of pathological phenomena. Thoma's highly important researches on angio sclerosis are considered in this section only in part. It is much to be desired that the volume to be devoted to special pathological anatomy may appear before long, for this will contain doubtless a compendious and authoritative presentation of his studies on angio-sclerosis, now widely scattered and difficult for the ordinary reader to grasp in their entirety.
The third and final section of the book is entitled " Combined Forms of Disease," and is devoted mainly to tumors. The concluding chapter on General Diseases contains a condensed and inadequate consideration of the general pathology of fever. In the first chapter of this final section Thoma presents his well-known views advocating the abandonment of the term " inflammation." All of circulatory and exudative phenomena of inflammation arc treated in this work, not under the general heading of inflammation, but under the " Local Circulatory Disturbances," being resolved into their components, such as Hypersemia, Stasis, Diapedesis, Emigration, Exudation. So far as inflammation is to be considered as a circulatory disturbance characterized Ijy exudation, it is entirely practicable to treat it in the manner ad opted by Thoma, although not without loss of comprehensiveness and of perspective. But inflammation cannot be resolved wholly into a circulatory disturbance with exudation, and it is interesting to consider how the author of a textbook on pathology who proposes to discard the word " inflammation" would attempt to deal with the entire group of phenomena, including regressive and progressive changes of tissue, which are usually embraced under the conception of inflammation. Thoma himself, after setting forth his various objections to the perpetuation of the word inflammation, evidently finds it impracticable to get along without it. Besides the simple circulatory disturbances and the simple nutritive disturljances and tumors, there remain what Thoma describes as "combined pathological conditions of the organs which have been almost without exception described as inflammations." These conditions must be described as a whole, and some name is needed to designate tlie group of elementary pathological changes which are comprised in " these combined pathological conditions." We have no name, and Thoma suggests none other than inflammation for these " combined pathological conditions," nor is a better one likely to be found and to gain currency.
The work of the translator is in general good. Occasionally, however, the sense of the original has been lost, as on page 351 where the translation reads "deficiency of albumen and the pronounced watery condition of the blood cannot be regarded as the cause of the oedema, if this change also diminishes the amount of albumen in the fluid of ccdemas which are due to other causes." This apparently incomjirehensible statement becomes clear when it is founil that the author said, " although this change diminishes the amount of albumen," etc. And in the sentence following the preceding one, the sense of the original is not accurately preserved in the translation which reads, "The so-called hydriemic oedema ajipears as the result of disease of the capillary walls which increases their permeability, and is itself associated with angiosclerosis." The last part of the sentence is in the original, "in Beziehung steht zu der Angiosklerose." These failures to present the exact sense of the original hapjien to occur in particularly important and italicized sentences giving Thoma's conclusions as to the cause of so-called hydriemic ledema.
The publishers' work deserves only commendation. The clear typography, the reproductions of tlie usually excellent figures and the general appearance of the book are admirable. W. II. AV.
Atlas of Nerve Cells. By M. Allen Starr, M. D., Ph. D., with the co-operation of Oliver S Strong, A. M., Ph D., and Edward Leaming, M.D., F. R. P. S. Pp. 1-78, with fifty-three plates and thirteen diagrams. {New York and London: PublUhed for the Columbia Univ. Press, by MacmiUan & Co., 1896.)
The atlas consists of a series of artotype reproductions of photographs made by Dr. Leaming from tissues stained (in the main by Golgi's method) and sectioned by Dr. Strong, together with a descriptive text by Dr Allen Starr, in which many of the essential facts which are at present known concerning the distribution and interrelations of the neurons within the central nervous systems have been included.
In the introductory note upon the Golgi method, Dr. Strong describes in some detail the various modifications which he has employed, referring especially to (1) a "lithium bichromate method " by means of which he gets quickly results equal to those obtainable by the long method, and (2), a formaline-bichromate method which is even more certain, and which he has found of especial value in the study of the adult brain.
The photographictechnique is discussed in asection by Dr. Leaming, in which there will be found some notes of interest to those engaged in photomicrography regarding (1) a modification of the tropffijlin screen, and (2) a method of obviating difTraction spectra and halation.
Dr. Starr states in the beginning that he has " not attempted to write an exhaustive account of nerve histology, but rather to present a brief review of the essential facts which can be demonstrated by the aid of the Golgi stain, and to show how these facts aid in the knowledge of nervous action."
As regards the structure of the spinal cord, cerebellum, and cerebral cortex, the researches of Golgi, Cajal, van Gehuchttn, His, Retzius, v. Kolliker, v. Lenbossek, Berkeley and others have been freely used, and a clear epitome is given. The medulla and pons have not been extensively treated. It is pleasing to note that the relations of the superior colliculi of the corpora quadrigemina to the optic nerves, and of the inferior colliculi to the cochlear nerves, have been emphasized. We should have been glad to find the central relations of the cochlear and vestibular nerves dealt with rather more in detail, now that this has been rendered possible through the brilliant researches of Held of Leipzig.
Concerning the nuclei in the thalamus and their connections, the results of von Monakow's work (publisheil at length in the Archiv f. Psychiatrie) have been briefly abstracted and incorporated. Dr. Starr further describes in connection with the thalamus (p. 53) certain cells which are especially characteristic of the median and lateral nuclei, to which he gives the name "stellate cells of the thalamus." He speaks too of some cells hitherto undescribed, which he believes to be peculiar to the ventral nucleus of the thalamus (vide PI. xxviii). The text includes also notes on some original studies of the nucleus caudatus and nucleus lentiformis.
In view of the recent work of FlechsigCcf. Neurol. Centralbl., 1S96, No. 1), Fig. 12, p To, is perhaps open to objection, but all must feel grateful to find reproduced in the atlas the beautiful plates of the cortex taken from the "Stmlien" of the late celebrated Swedish investigator, Hammarberg. Hisstudies of the cellular structure of the cerebral cortex are by far the most exact which up to the present time have been unilertaken. although they are not so widely known and appreciated .is they deserve to be.
The press-work has been excellently done, and the reproductions of the photographs are superb. The plates are remarkably even in character ; that showing the spinal ganglion in the chick and those illustrating Purkinje cells are particularly be.'iutiful.
It is the intention of the author at some future lime to issne another volume, in which there will be illustrated the peripheral nerves and their endings, together with the organs of sense.
L. F. B.
170
Text-Book upon the Pathogenic Bacteria. By Joseph McFarland, M. D. ( W. B. Saunders, Philadelphia, 1896.)
Dr. McFarland's boolc opens with an introiluctory chapter which discusses principally the controversies which were waged upon the subject of spontaneous generation, and ends with a list of the principal pathogenic organisms discovered from 1879 to the present time.
Chapters one and two deal with the morphology and biology of bacteria, the classification of Cohn is cited as the most scientific one, and the various points bearing on the growth and development of bacteria are fully discussed. In chapter one it is twice stated that the bacillus coli communis is a non-motile organism, a statement we think which is hardly borne out by the work of recent investigators, particularly that of Theobald Smith. In chapter two the statement that most species of bacteria are not affected in their growth by the presence or absence of light is contrary to the teachings of most bacteriologists.
Chapter three deals with immunity and susceptibility ; it covers this difficult ground as well as could be expected in such a short space.
Chapters four to nine deal with technique, the proceedings recommended being similar to those ordinarily in use in all laboratories. The examination of water, soil, and air is taken up in a Ijrief manner in the three following chapters.
The second partof the book deals with specific diseases and their bacterial causes. It opens with a chapter on suppuration, in which the ordinary pus producing organisms are described. We cannot agree with the statement that the staphylococcus jjyogenes aureus shows its most characteristic growth upon agar, as oftentimes the color is almost entirely lacking on this medium, whilst on the other hand the growth on potato rarely fails to show pigment from the very outset. The statement that the streptococcus does not grow on potato is evidently meant to imply that it has no visible growth. The statement tliat the bacillus pyocyaneus is probably "aharmle.ss saprophyte" does not accord with the work of Gessard, Chasrin and others who have implicated this organism in a definite form of intestinal infection, the so-called " maladie pyocyanique."
The chapters on tuberculosis, leprosy and the other chronic infectious diseases are short and concise.
The chapter on diphtheria is a fairly satisfactory review of the subject, though most bacteriologists probably regard the pseudodiphtheria bacillus as a separate organism, and not as an attenuated diplitheria bacillus, as the author states it to be. '
Tetanus, rabies and symptomatic anthrax are treated of briefly and satisfactorily; it is to be noticed in the chapter on the lastnamed subject tliat tlie proteus vulgaris is spoken of as a harmless saprophyte, an opinion quite commonly held, but whicli isdisproved by the association of this organism with Weil's disease, pleurisy, peritonitis, etc.
Typhoid fever is satisfactorily treated of, though the statement that tlip typhoid l)acillus slightly .-icidifies litmus milk is toosweeping, as the acidification is in many instances followed by a marked alkalinization.
The cholera group is taken up satisfactorily in chapters six and seven.
In the chapter on pneumonia the statement is twice made that the diplococcus pneumoniae will not grow on potato, when, as a matter of fact, it does grow on this medium, though the growth is often invisible. The stati-mcnl that tlie diplococcus pneumonitc, which is normally present in the mouth in a certain percentage of cases, can be drawn into the bronchioles by a deep inspiration is a rather startling one. In the first place, currents of air do not detach bacteria from moist surfaces, and in the second, the inspired air does not reach the terminal bronchioles.
The remainder of the book takes up bubonic plague, measles, influenza, and a number of the infectious diseases of animals.
Barring the minor mistakes mentioned above, the book is fairly satisfactory ; there are occasional typographical errors, and in places the author's language is a little obscure.
The plates are good. G. B.
UeVjer die Wirkung der Theebestandtheile auf kbrperliche und geistige Arbeit. By August Hoch und Emil Kraepelin. Kraepelin's Pyscholog. Arbeiten, Band I, Heft 2 and 3, pages 378-488.
The results of this research are among the most interesting of recent psycho-pharmacological contributions. The investigators have undertaken an exact study of the action of the two main constituents of tea, the caflein and the ethereal oils, paying particular attention to the effects of these substances, (1) on muscular work, and (2) on the association processes concerned in adding. To determine the former, the ergograph was used, and no small part of the problem consisted in so modifying this instrument as to make it accurate enough for the research. A large number of curves showing muscle-fatigue with and without the action of the substances under examination, were obtained from the individuals submitting themselves to experiment, every precaution being taken to eliminate error from irregularities in work, rest, sleep, the taking of food, etc. The experiments were made upon Drs. Hoch, .Tost, Hibbard and Reis ; the majority of them in Kraepelin's laboratory in Heidelberg, a part of them in the laboratory of the McLean Hospital in Massachusetts.
The experiments made upon Dr. Hoch showed that caffein distinctly increased the capacity for muscular work, the ergograph curve proving that this increase affected mainly the amplitude of the individual movements rather than the number of them. The tea oil, on the contrary, lessened the capacity for muscular work, but made distinctly easier the associative processes concerned in adding. The results of the experiments on Drs. Hibbard and Reis agreed in the main with those obtained with Dr. Hoch ; the experiments made upon Dr. Jost differed considerably, in that larger doses of caffein were required, and besides the effects appeared later and lasted very much longer, a personal difference perhaps not so very surprising considering what is already known of the action of alcohol upon different individuals.
The mode of action of the caffein and of the oils is discussed at some length and most entertainingly. The details must be sought in the original article, but it may be interesting to state that the authors conclude that the caffein acts immediately upon the muscular tissue, permitting the increase in the amplitude of the individual movements without materially altering their number ; while the tea-oil acts upon the motor centers in the nervous system, rendering difficult the setting free of motor impulses, and so affecting the number rather than the amplitude of the movements. While the caffein in tea is known to render the course of ordinary associations somewhat easier, the experiments of Hoch and Kraepelin have led them to conclude that the associative processes are also distinctly facilitated through the action of the ethereal oils, and they stale that the euphoria of the tea ilrinker may depend in laige part upon the action of these ethereal oils upon his nerve centers.
The presence in the same crude drug of two chemical substances possessing almost diametrically opposite effects is by no means unique: a number of similar instances in pharmacology will be immediately recalled.
It is easy to see that the results of the research, aside from their high scientific value, have also an eminently jiractical hearing; since the quality and psychic effect of a given sample of tea will depend largely upon the relative proportions of the caffein and the ethereal oils which it contains, the qualitative determination of these may afford a new field of activity to the commercial chemist.
L F. B.
Th« Johnt Hopkint Hntjritnl BuUetim are istued monthly. They are printed by THE FlilEDENWALD CO., Baltimore. Single copies may be procured f mm Mes»r». CUSIIINO dk CO. and the BALTIMOHK NEWS CoMBANY', Baltimore. Subscriptions, fl.Od a year, may be addreued to the publishers, THE JOHNS HOPKINS PBESS, BALTIMORE ; single copies will be sent by mail for fifteen cents each.
I
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. VII.- Nos. 66-67.1
BALTIMORE, SEPTEMBER-OCTOBER, 1896.
+++
Contents
A Case of Combined Protozoan and Bacterial Infection. By Simon- Flexner, M. D., 171
Notes on Two Cases of Ureteral Abnormality. By Geoegk Blomer, M. D., 174
Tumors in the Mouse. By L. E. Livingood, M. D., - - - 177
The Anatomical Changes in Two Cases of Retinal Detachment. By Robert L. Randolph, M. D., 179
The Bubonic Plague. By Simon Flexner, M. D., - - -LSI
P.IGK.
Absolute Alcohol as a Disinfectant for Instruments. A Bacteriological Study. By Robert L. Randolph, M. D., - - 185 Proceedings of Societies :
Hospital Medical Society, 188
Generalized ^Melanotic Sarcoma [Dr. Blumer] ;— Specimen of Adenocarcinoma of Pancreas [Dr. Blumer].
Xotes on New Books, 190
Special Courses for Graduates in Medicine. Change of Date, - 192
A CASE OF COMBINED PROTOZOAN AND BACTERIAL INFECTION.
AMCEBIC DYSENTERY, MALARIA, AND MICROCOCCUS LANCEOLATT'S. ACUTE FIBRINOPURULENT PERITONITIS
By Simon Flexner, M. D., Associate Professor of Pathology, Johns Hopkitis University; Resident Pathologist, Johns Hopkins Hospital.
[From the Pathological Laboratory of the Johns Hopkins Unirersity and Hospital.]
The recent literature upon malariiil infectious in luunau beings contains a few instances of associated protozoan and of mixed protozoan and bacterial infectious. Among the associated protozoan infections may be included cases of multiple malarial infections, in which an individual may be infected at the same time with different groups or generations of the same organisms, or of organisms of different types, and the rare co-existence of malarial and other protozoan infections, such as amoebic dysentery.* The instances of mixed protozoan and bacterial infection are more numerous and embrace the combination of pneumonia (lobar and lobular) and malaria, bronchitis and nuilaria, and the rarer one of typhoid fever and malaria. Respecting the cases of concurrent pneumonia and malaria, it may be said that the same bacteria as are concerned with the causation of uncomplicated cases of this disease are found in the lungs in the mixed infections. Barker has described a case of associated erysipelas
- Cf. Thayer and llewetson : The Malarial Fevers of Baltimore.
Johns Hopkins Hospital Reports, 1S1I5, vol. V. Barker : A Study of Some Fatal Cases of Malaria, idem, alludes to a case of combined malaria and amcebic dysentery occurring in the hospital.
and tertian malaria in which an invasion of the blood with streptococci existed, both micro-organisms appearing there and in the internal organs in large numbers.
The present case obtains its interest in part from the unusual character of the infection, and in part from the extent, character and consequences of the intestinal lesions. Dr. Thaver has kindly supplied the following notes of the clinical history :
The patient, A. .T., was a Pole about 29 years of age, from whom a satisfactory history could not be obtained. He had been living in a malarious district since March of the past vear (1895), but he had been quite well until three weeks prior to his entrance, which was on October 31st. His illness be^u with diarrhcea, which rapidly assumed a severe character, the movements containing much blood and mucus. During these three weeks he stated that he had several times esj>erienced slight chilly sensations and also felt feverish. On entrance to the hospital he was very an;vmic, extremelv sallow : had a palpable spleen, slight fever and severe dysentery, the movements showing much blood and mucus. The dejections contained many motile ama>b.<e having the chanicteristic appearances of the amivba coli. The blood examinations showed hyaline bodies and crescentic and ovoid pigmented forms of
172
JOHNS HOPKI.NS HOSPITAL BULLETIN.
[Xos. 66-67.
the malarial parasite. Under the administration of fiv'i grain doses of quinine every three hoiars the tenijierature fell. The diarrhoea was treated with irrigations of quinine (xtto) lupeated twice dailj', but without apparent effect. The patient continued to lose blood per rectum and died on the 2nd of November.
The autopsy was performed 7 hours post mortem. Body of a moderately strongly built, much emaciated man. The surface presented a distinctly sallow hue. The mucous membranes of the mouth and conjunctivae were extremely pale. The abdomen was moderately distended; the subcutaneous fat almost absent; the muscles dark-brownish red in color.
The peritoneal cavity. The omentum was well spread out, covering the intestines, but it presented an opaque appearance and was covered with a sticky exudate. The loops of the moderately distended small intestine were glued together by a similar sticky exudate. The serous membrane itself was iu places vividly injected. In the fossse small accumulations of fluid containing flakes of fibrin were encountered. The omentum was adherent along its lower border to the much enlarged and inflamed appendix vermiformis. The appendix lay anterior to the ctecum and between it and the anterior abdominal wall; it was provided with a mesentery which reached within 3 cm. of its tip, and at the termination of this the appendix was bent sharply upon itself, giving rise to a right angle. The distal 3 cm. of appendix was th^least dilated part; the remainder had the thickness of the index finger and presented in addition three bulbous enlargements, which on section were found to correspond to areas of necrotic tissue. The whole was embedded in a sticky, opaque exudate.
Intestines. The large intestines were greatly distended. The sigmoid flexure was of rigid consistence and pi-ojected beyond the pelvic brim. Within this portion for a distance of 2x5 cm. the serous coat was infiltrated with blood and presented a necrotic appearance. On opening the large intestine the entire mucous membrane was found in a frayed and sloughing condition, opaque, everywhere infiltrated with gelatinous pus, and evidently necrotic. The necrosis seemed to extend far beyond the mucous coat and to involve the deeper layers. The walls, as a whole, were much thickened. In many places coagula of blood were discovered. Amid this general necrosis and sloughing more cii'cumscribed ulcerations existed, some of which seemed to reach to the peritoneal coat. These in particular were surrounded by thickened and purulent margins, and at times they definitely undermined the adjacent tissues. The ulcerations and sloughing extended from tiie rectum to the caecum, involving the whole of the latter, penetrating into the appendix, but ending abruptly with the ileoCiecal valve. The small intestine was entirely free from ulceration, and it showed throughout nearly its whole extent, although most prominently upon the crests of the valvulaj conniventes, a slaty pigmentation. The duodenum was more pigmented than other parts of the small intestine.
The spleeii was enlarged, weighed 380 grams, its capsule was wrinkled, and on section it presented a bluish black color. In consistence it was almost diffluent. The Malpighiau bodies appeared enlarged, the pulp increased.
The liver weighed 2100 grams, its color was dark and slaty.
Small greyish white nodules could be seen on section, which varied in size from a pin point to a hemp seed. The larger ones could easily be made out to be abscesses, the contents of which were opaque, gelatinous and pus-like. The wall of the yaU Madder was thickened and infiltrated with a similar exudate to that covering the peritoneum. The mucous membrane was, however, intact. The remainder of the organs exhibited no remarkable lesions.
Microscopical examination of the fresh specimen. Attention was first directed to the study of the exudates for amcebffi, and for this purpose pus («) from the peritoneal cavity, (5) from the intestinal contents, {c) from the liver abscesses, was employed. The most painstaking search failed to reveal amrebas in the pus from the peritoneal cavity, while on the other hand many typical living and moving amcebEB were discovered in the pus from the ulcers in the large intestine and the intestinal contents, and a smaller number in the contents of the liver abscesses. '
The exclusion of amcebfe from the peritoneal exudate led next to the staining of cover-slips for bacteria. By the use of ordinary staining agents (gentian violet, methylene blue) myriads of capsulated diplococci resembling the micrococcus lanceolatus were revealed. The contents of the liver abscesses, stained iu the same manner, failed to show any bacteria whatever. The microscopical examination of the abscess contents indicated that fewer pus cells and more necrotic and disintegrating liver cells composed these than in ordinary abscesses, thus recalling the fact pointed out by Councilman and Lafleur* in their monograph on amcebic dysentery, that true suppuration is not caused by the amreba dysenteria?.
The source of the bacteria found iu the peritoneal exudate, and which evidently were the cause of the acute peritonitis, was sought in the intestinal contents, where, as is well known, they are not infrequently contained, and from which source, as we have previously pointed out,t they may invade the peritoneum and set up a fatal peritonitis. The condition of the appendix vermiformis, which arrested attention from its swollen and necrotic appearance, was believed to have led to the escape of the micro-organisms in question. Upon closer examination it was found that corresponding with the dilatations previously described, the entire wall was in a necrotic condition. The ulcerations themselves reached deeply into the inner coats, but did not penetrate all the coats. The lumen of the swollen appendix was filled with yellow, gelatinous pus quite resembling that found in the peritoneal cavity itself. Cover-slip preparations showed many encapsulated diplococci, besides several kinds of bacilli. The former much predominated in numbers.
Malarial bodies were not numerous in smear preparations from the organs, although pigment was abundant. However, a few undoubted ovoid bodies were found in the smears from the spleen and bone marrow.
Cultures. Petri's plates were made from the blood in the heart, the exudates and all the organs, upon agar-agar. Those from the heart's blood, spleen, lunys, and liver abscesses showed
Mohns Hopkins Hospital Reports, vol. II, 1801, p. 395. Johns Hopkins Hospital Bulletin, 1895, No. 49, p. 64.
September-October, 1896.] JOHNS HOPKINS HOSPITAL BULLETIN.
173
no growth after haviug been kept at the temperature of the thermostat for 48 hours.
Peritoneum. The plate was crowded with colonies, apparently of two kinds, which, owing to the large numbers, ])i'obably did not reach full development. The larger colonies consisted of bacilli which were identified and shown to be the bacillus coli communis. The smaller colonies (predominating) were made up of oval diplococci which were shown (cultures and animal experiments) to be the micrococcus lanceolatus. The plate made from the Mle contained 7, from the liver 30 colonies of the bacillus coli communis. The jjlate from the kidney was crowded with colonies of the colon bacillus, among which a few smaller colonies of diplococci were found, these being the micrococcus lanceolatus.
Histological examination. The microscopical examination of the hardened tissues was confirmatory only of the features of the case as already described. Nothing new was discovered. As regards the malarial pigmentation, the dark pigment was found especially in the liver and spleen (bone-marrow not studied), and in these organs in the usual situations The parasites themselves were very difficult of demonstration. The lesions in the large intestine caused by the invasion of the amojbaj were perhaps the most interesting. The necrosis, it was found, extended into, but for the most part not through the innermost muscular tunic, but it was surprising to what extent the mucous membrane might be dissected away from the submucosa without losing its vitality. Not a small part of the frayed appearance presented by the large intestine was produced by this partial dissection of the mucous coat. The bases of the ulcers proper were formed for the most jiart by the circular muscle, which was itself infiltrated with inflammatory products, cells, serum, fibrin. The inflammatory infiltration extended into the depths of the tissue, often to the serous coat, and spread laterally for a great distance. It seems probable that the ulcers in the appendix originally were caused by amcebffi, and that subsequently the extension of the necrosis to the serous surface was the work of the micrococcus lanceolatus.
Aniojbaj apparently were abundant. Hut just here it is pro2)er to state that in the hardened tissues it would be easy to be led into error in regard to the significance of many of the anueba-like cells present. From a study of the transitions of connective-tissue cells and their progeny in the chronically inllamed parts, it is quite certain that many of the bodies resembling anuebiB are swollen and degenerated (fatty or vacuolated) tissue cells. These, too, often lay in definite spaces, and they were found in the submucosa and muscle and within small
veins. Without the proof supplied by the examination of the intestinal contents during life and at the autopsy, one must have remained in doubt as to the presence of amcebae among these elements.
The kidneys showed a moderate degree of parenchymatous degeneration. In addition to this, emboli of liver cells were detected in branches of the renal vein. Similar emboli were discovered in the central veins of the liver lobules notinfrequently. Lubarsch* has reviewed the literature upon the subject of " l)arenchymcell emboli." It appears that liver cell emboli are either of traumatic or of infectious (or due to intoxication) origin. There is no definite relation between the extent of the injury and the occurrence of such emboli. The transported liver cells, besides being found in the veins of the liver, occur in the heart, pulmonary arteries and branches of the renal and hepatic arteries. Among the infectious diseases liver cell emboli are found very often in eclampsia and chorea. In eclampsia they are found in the arteries of the lungs and brain and in the renal veins ; in chorea in the hepatic artery and branches of the portal vein (patent foramen ovale). Where hemorrhage, necrosis and softening exist, liver cell emboli are encountered. Thus they have been found in scarlet fever, in softening of hepatic gummata and in liver abscess. The transported liver cells have been followed from the hepatic veins into the coronary, renal and other arteries. Their occurrence in veins — renal and cerebral — is attributed to retrograde embolism, for which a high degree of venous stasis, such as occurs in eclampsia, has been assumed. Evidence of such stagnation is wanting in our case. On the other hand the disintegration of liver tissue, such as has been found in other cases, is supplied by the abscess formation and circumscribed necrosis in the liver. Lubarsch stiites that the conveyed liver cells may persist from 3 weeks to 2 J months, but evidences of jjroliferation have never been observed.
Kemarks by Dr. Barker: The case is an interesting one on account of the curious combination of infectious. In studying the fatal cases of malaria from Professor Osier's wards my attention was called to the fact that bacterial infections were often concurrent with malarial infections. In one instance a double protozoa infection had been noted, and since that study was made several such double protozoan infections have been observed in the hospital. This c;ise is the first one in which we have to deal with a double protozoan infection associated with a bacterial infection.
> Fortechritte der Me.iizin, Baii.l XI. 1893.
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JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 66-67.
NOTES ON TWO CASES OF URETERAL ABNORMALITY.
By Geoege Blumer, M. D., Assistant in Pathology, Johns Hopkins University. [From the Pathological Laboratory of the Johns Hopkins University and Hospital.]
The following two cases of ureteral anomaly, which have recently come under observation, seem uncommon enough to merit description. Through the kindness of Ur. Kelly we are enabled to supplement the descriptions by plates.
The clinical histories of the cases have no special bearing upon the pathological findings, with the exception of the fact that in case No. 1 an attack of acute cystitis had occurred some five years before death ; the notes are therefore confined to the pathological aspects of the cases.
Case 1. — Anatomical Diagnosis. Diphtheritic inflammation of the bladder, left ureter, and left renal pelvis ; suppurative nephritis and perinephritis of the left kidney; hydro-ureter and hydro-nephrosis of the right kidney : miliary abscesses iu the right kidney ; prolapse of the ureteral and bladder mucous membrane into the bladder cavity; localized fibrinous peritonitis; acute bronchitis; fatty degeneration and cloudy swelling of the liver; slight general arterio-sclerosis.
The following is the abstract from the autopsy protocol referring to the ureters and bladder : ,
The right ureter is dilated to the size of a lead pencil, and contains j)ale, cloudy urine. The walls are thin. The mucous membrane is congested. There is nowhere any constriction until the bladder is reached.
The left ureter is dilated to about the size of the normal ileum, its walls are markedly thickened, and it contains a thick greenish black purulent material with an offensive odor. The mucous membrane has a dirty, sloughy appearance and a green-black color, its surface shows numerous irregularities in the form of patches of grayish white false membrane formation, the membrane being firmly attached to the subjacent tissue.
The bladder is somewhat enlarged and contains turbid, foulsmelling urine. Its walls are greatly thickened, measuring as much as three centimeters in their thickest part. The mucous membrane is corrugated and of a greenish black color, and shows numerous areas of densely adherent grayish false membrane similar to those seen in the ureter. Projecting into the bladder from a point where the left ureteral orifice is normally present is a pyramidal sac, tense and fluctuating, and evidently containing fluid. This sac hangs free in the cavity of the bladder and reaches from its place of origin nearly to the internal urethral orifice. It is about eight centimeters in length, has a narrow neck, measuring three centimeters in diameter where it joins the bladder wall, and gradually expands as it passes out from this point, reaching its greatest diameter of nine centimeters a short distance from its free end. On its inner side, about its middle, a minute opening can be made out. This opening is circular and just about large enough to admit a pin point ; it is situated in the center of a small area of dense fibrous tissue, and is evidently the lower opening of the left ureter. On opening the sac it is found to contain a thick greenish black purulent material
similar to that already seen iu the left ureter, and the index finger can be passed directly from the sac into the dilated ureter. Both the internal and external surfaces of the sac are covered with mucous membrane which shows patches of false membrane formation similar to those seen in the ureter and bladder. The sac wall appears to be of the same thickness throughout.
From the normal site of the right lower ureteral orifice there projects a similar but much smaller sac three centimeters in length ; it is not nearly so tense as the one ou the other side. On the inner side of this second sac is an opening the size of a pin's head, from which urine escapes ; there is apparently no cicatricial tissue about this opening. The sac communicates freely with the left ureter. The prostate gland is slightly enlarged, but not sufficiently so to offer any obstruction to the outflow of urine.
The urethra is free from obstruction throughout its entire course. A microscopical examination of the sac wall shows that between the two layers of mucous membrane lies connective tissue containing many bundles of unstriped muscle fiber.
Remarks. This peculiar prolapse of the mucous membrane of the lower end of the ureter and that of the adjacent part of the bladder is not of common occurrence, although we find some similar cases on record.
All of these cases seem to come under two main categories :
1. Those cases iu which there is distinct evidence that the condition is due to congenital deformity.
2. Those cases in which the process has apparently resulted from some acquired abnormality of the genito-urinary tract. By far the larger number of cases present distinct evidence of congenital malformation ; in fact, out of the thirteen cases which we have been able to collect, ten were evidently of congenital origin, death occurring in five of these in the early years of childhood.
All of these five cases occurred in female children, and in four of them, those of Davies-Colley, Caille, Beach, and (Jcerdts, there was not only a i>rolapse into the bladder, but the prolapsed sac actually passed through the urethra and appeared externally.
In the congenital cases proving fatal at a later date, the deformity was in some instances less severe than in the cases ending fatally in early life; in other instances the deformity was just as great in the late as in the early cases, the previous escape of the individual perhaps being due to the fact that he had escaped genito-urinary infection, which seemed to have been the cause of death in the majority of the cases which succumbed early in life. The deformity iu these congenital cases consisted in most instances of a partial or complete closure of the lower ureteral orifice. In one case another form of deformity is cited, viz. a ureter having a long portion of its course iu the bladder wall, and for this reason sub
'^5^ ■ A-/ i
CASE I
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The Frle.lciiWHl.1 Co., Krii;r«vcr« hii.I PrlnUri.
The KrkclonwaM Co., Ensr.i>er» •■■■I Primers.
September-October, 189G.]
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jected to an abnormal amount of pressuru from the bladder musculature.
Accompanying the deformity which was the actual cause of the condition, were often other evidences of congenital malformation. In several instances abnormalities of the kidney pelvis or double ureters were present, and one case is cited in which a deformity of the uterus was noted.
Of the cases in which there was no apparent congenital cause for the condition — and to this class we consider our case belong." — we could find but two examples, one reported by T. Smith, the other by Hutinel.
Smith's case, judging from his description and from an excellent plate which illustrates his article, was almost exactly similar to our own. In his case, however, urinary calculi were present on the right side in the jirola]>sed pouch, and on the left in the renal pelvis.
lu Hutinel's case, which occurred in an old man, the subject of cystitis, the pouching only involved the left ureter. At the time of death the lower orifice of the left ureter was not blocked, as the pouch communicated with the bladder by a pouch the size of a three-franc piece, but there was evidence of a foi'uier blocking in a much atrophied kidney on the affected side. Unfortunately Hutinel does not state whether the abnormally large opening which existed between the sac and the bladder was apparently due to simple dilatation or to an ulcerative process.
Judging from the fact that in our case the abnormally small ureteral opening was contained in an area of cicatricial tissue, and from the history that the patient gave of a previous attack of acute cystitis, we are inclined to think that the blocking of the lower ureteral opening was due to an old intiammatory jirocess with a subsequent formation of new tissue, which, in contracting, narrowed the ureteral orifice. It would seem likely that in the cases of Smith and Hutinel the same process might have taken place, as both patients showed evidence of old inilammatory disease of the genitourinary tract.
As far as the mechanism of the pouching is concerned the cases can again be divided into two classes, those in which there is a uniform dilatation from the pelvis of the kidney down to the end of the sac, and those in which the pelvis of the kidney and the main portion of the ureter are not dilated, the sacculation occurring only at the extreme lower end of the ureter.
In the former class of cases, to wliicdi ours belongs, the pouching can be exj)lained by a theory, the essence of which was advanced by Smith in reporting his case. He suggests I hat the prolapse in these cases is due to the disproportion between the capacity of the ureter and kitlney pelvis on the one hand, and the size of the lower ureteral orifice on the other. When, either from an extreme hydro-uephrosis or from an abnornuil narrowing of the lower ureteral orifice, the urine is no longer able to escape from this orifice as fast as it is secreted, the distended ureter and kitlney pelvis are compressed by the action of the abdominal muscles, particularly (luring urination and defecation, and a considerable downward pressure is brought to bear on the lower ureteral oritico. This liiially results in the ju'olapse of its mucous membrane, and as
the mucous membrane of the bladder is directly continuous with that of the ureter, it is of course pushed downward at the same time, the result being a pouch covered on both sides by mucous membrane, and directly continuous with the dilated ureter and kidney pelvis.
In the cases in which no hydro-nephrosis or hydro-ureter exists — and most of the congenital cases are of this kind — we must seek for some further abnormality in connection with the lower end of the ureter.
According to Bostrom, this abnormality consists in the manner in which the ureter passes through the bladder wall.
In the normal condition, this author states, the ureters pass obliquely through the bladder wall, and their lower openings lie partly in the bladder musculature, the contraction of the muscle counteracting the downward jiressure of the urine and hindering dilatation of the portion of the ureter lying within the musculature.
In the cases in which sacculation takes place the ureter is stated to pass straight through the bladder wall and to end just beneath the mucous membrane, in those cases where the ending is blind. From this it results, according to Bostrom, that the area of ureter surrounded by muscle is much smaller than normal, the resistance to the downward pressure of the urine is insufficient, and a prolapse of the mucous membrane of the ureter and bladder results. That the portion of the bladder wall which surrounds the ureter is not included in the prolapsed tissue is proved, Bostrom thinks, by the absence of muscular tissue from the wall of the sac.
Burckhard, in his paper, modifies somewhat Bostri'm's theory, holding that the primary cause of the abnormality lies not so much in the abnormal position of the ureter as in the congenital lack of musculature in the bladder wall. He also states that the dilated portion of the ureter does not originate, as Bostrom believes, in the portion just beneath the mucous membrane of the bladder, but on the contrary begins in the portion which lies within the bladder wall, the proof of this lying in the fact that rn his case he was able to demonstrate unstriped muscle fiber in the wall of the sac. The absence of muscle fiber in the sac wall in Bostrom's case he explains on the grounds of disappearance from pressure atrophy.
Case 2. — Anatomical Diagnosis. Sloughing carcinoma of the uterus involving the vagina and bladder: involvement of both ureters in adhesions: hydro-nephrosis and hydro-ureter: kinking of the right ureter from the ptissjige of the right ovarian vein over the dilated ureter; arterio-selerosis ; heart hypertrophy; recent vegetative endocarditis; emphysema of the lungs; diverticuhe of the intestine.
The following is the abstract from the autopsy protocol (Pr. Klexner) referring to the ureter:
The ureter on the right side is greatly dilated. The greatest dilatation is in the upper third, next the hilum of the kidney. At its entrance into the kidney there is a pyriform bulgiug of the ureter, the walls of which are so attenuates! at this point as to permit of the slightly turbid but almi^t colorless contents being seen through them. The ureter just next to the hilum. and corresponding with the smaller part of the pyriform enlargement, h;»s the size of a thumb. At a distance
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of five centimeters from the hilum of the kidney a sharp beud occurs in the ureter, which is much constricted at this point by the passage over it of the ovarian vein, the walls of which are here thickened, but the lumen not entirely occluded. It is owing to the pressure from this vein that the upper part of the ureter is so much more dilated than the lower part, which will be described later. The pressure from above has caused the pushing downward of the upper portion of the dilated ureter, thus partly covering over the lower portion and causing an S-shaped bend or curve.
The lower portion of the ureter has a length of ten to twelve ceutimeters, and at the uterine end is embedded in firm adhesions. The dilatation of this part is somewhat less than that of the upper portion, and on an average it is about the size of the inde.\ finger. The lower part of the ui'eter contains the same faintly turbid fluid contained in the upper part. A j)robe cannot be passed from the slit up ureter into the bladder, even with the use of a moderate amount of force.
Remarks. In this case the hydro-ureter and hydro-nephrosis were evidently due in the first case to the inclusion of the lower end of the ureter in adhesions. The peculiar kinking, which was the interesting feature of the case, was due to the [uissage across the dilated ureter of what appeared to be the right ovarian vein, though instead of emptying into the inferior vena cava, as would normally be the case, it terminated in the right renal vein. As the vein was not in any way bound down, its mere tautness was evidently sufficient to cause compression of the dilated ureter.
We have been unable to find an account of a similar case.
Literature.
Beach : Transactions of the Pathological Society, Loudon, 1873-4, vol. XXV, p. 185.
Bostrom : Beitriige zur pathologischen Anatomic der Nieren. Freiburg and Tubingen, 1884.
Burckhard: Uentralblatt fiir allgemeine Pathologic und pathologische Anatomic, Bd. VII, No. 4, p. 129.
Caille: American Journal of the Medical Sciences, vol. 95 N. S., p. 481.
Davies-Colley : Lancet, London, March 15, 1879.
Geerdts : cited by Schwartz.
Hutinel: Bulletin de la Societc d'Anatomie de Paris, 1873, vol. XLVIII, p. 695.
V. Lechler-Neelsen : cited by Schwartz.
Schwartz: Beitriige zur klinischen C'hirurgie, Bd. XV^, lift. 1, 1895.
Tange : Virchow's Archiv, Bd. 118, 1889, p. 414.
Discussion.
Dr. Kelly. — Prolapse of the ureter has been observed in women out through the bladder and even projecting from the external urethral orifice.
I had a case of colon bacillus infection about a year ago in which the urine taken directly from the kidney was examined a number of times. After washing out the kidney a great many times, and finding that I could not clear up the pus in the urine, as I had done in other cases, I concluded that
there must be some mechanical cause to keep up the disturbance, and I cut down and removed a stone.
The condition on the right ride of this case is a very important one. Cases of hydro-nephrosis of lesser degree, 10-15 cc. or more, have been attracting my attention more and more. In all of them we find a diminished amount of urea in the urine, for the kidney has been somewhat impaired in its functions. It is important to be able to recognize the condition ; it cannot be palpated through the abdominal walls, but can be made out by introducing my renal catheters in women. These cases must be handled carefully because of the increased liability of infection. If one side is hydro-nephrotic and the other side has suppurated, then we must proceed with unusual caution in any surgical interference. In a recent case the urinary analysis showed a percentage of urea on the sound side of 2.6 per cent, and only 0.3 per cent, on the hydro-nephrotic side.
Dr. Flexner. — We have had very scant opportunity in the pathological laboratory to make bacteriological examinations of cases of wound diphtheria, the case reported by Dr. Blumer being the second one in several years. The previous case, upon which I performed the autopsy, was associated also with the geuito-urinai-y apparatus and followed the operation of perineal section for stricture of the urethra. Previously there had been cystitis, pyo-ureter and pyo-nephrosis. The diphtheritic process extended from the external wound through the bladder and ureters into the pelves of the kidneys, which were more or less completely involved. The micro-organism which was separated from the local inflammations was the staphylococcus pyogenes aureus.
Of course these cases are examples of diphtheritis, and not of diphtheria, and in the great majority of cases of so-called "wound diphtheria" the pyogenic cocci, and not the bacillus diphtheria?, are the causative agents. Examples of wound diphtheria caused by the diphtheria bacillus have been reported, these having usually occurred in persons suffering from faucal diphtheria. Brunuer has, however, fouud the bacillus diphtherise in cases in which no history of faucal diphtheria could be obtained.
NOTICE.
All inquiries concerning the admission of free, part pay, or private patients to the Johne Hopkins Hospital slioulil be aiidressed to Dr. Henry M. Hurd, tlie Superintendent, at the Hospital.
Letters of inquiry can be sent, wliich will receive prompt answer, or pergonal interviews may be held.
Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indigent patients a uniform rate of $5.00 per week has been established. The Superintendent lias authority to modify these terms to meet the necessity of urgent cases.
The Hospital is designed for cases of acute disease. Cases of chronic disease are not admitted except temporarily. Private patients can be received irrespective of residence. The rates in the private wards are governed by the locality of rooms and range from 120.00 to $35.00 per week. The extras are laundry expenses, massage, the services of an exclusive nurse, the services of a throat, eye, ear ami skin or nervous specialist, and surgical fees. Wlierever room exists in the private wards and the condition of the patient does not forbid it, companions can be accommodated at the rate of $15.00 per week.
One week's board is payable when a patient is admitted .
September-October, 1896.]
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TUMORS IN THE MOUSE.
By L. E. LiviNGOOD, M. D., Fellow in rathology, Johns HopkuDi University.
The necessity of broadening our knowledge of pathology as well as deepening it, has forced itself vei-y emphatically before workers in this subject in recent years."-" Especially is the study of morbid conditions occurring in animals used commonly in experimentation, of interest and importance, lying as they do in closest relation with our studies of the human conditions.
It has thus occurred to Dr. Welch, to whom my heartiest thanks are due for his happy instigation, that a more minute study of a series of tumors found growing spontaneously in mice in captivity would prove an interesting problem.
The many attempts at inoculating and grafting tumors, for the most part carcinomata, into animals, especially the more or less successful attempts recently made by Moran,' Boinet,' Mayet' and othei's,"'" have interested me to study the possible homology and analogy of these tumors to those found in human beings, and the discoveries of possible parasites, to a search in the field of etiology.
Tumors in certain domestic animals were noted and more or less carefully described by the ancients. Hixzard in the XVIII century was the first to call attention to their frequency in carnivora. After 1825 we find various tumors in animals described by Trousseau, Leblanc,' Semmer" and others. Cadiot" (1894), in reviewing the carcinomata in dogs and horses, asserts that all animals will probably be found susceptible to carcinomata, which he claims to be the most frequent form.
Moran describes a tumor appearing spontaneously in a mouse, lying in the subcutaneous tissue but not attached to the skin. He describes it superficially as of tubular-gland type.
No. 1, of the series which I ask leave to bring before you to-night and of which Fig. 1 is a partial picture, was fouud in the right lung of a white mouse dying of experimental bacterial infection. It projected from the upper surface of the middle lobe as a small white boss about 5 mm. in diameter, slightly friable and apparently softer in the center. The lung tissue about it was congested. No other growths were noted.
Microscopically the boss presents the appearance of an adeno-carcinoma. At one point it may be seen arising from within a bronchus, growing as a papilloma within and, at one point, breaking through its walls and dispersing in the surrounding tissue. The greater part of the tumor is made up of infiltrating fingers of epithelial cells. The cells are of irregular columnar or polygonal type with oval vesicular nuclei. They are often arranged in single rows lining a long cul-do-sac, or they project into the surrounding tissue in solid masses. There is nowhere distinct basement membrane nor transverse section of a duct or tubule. The connective tissue stroma is very scanty, the infiltrating fingers alone seeming to restrain one another and causing, by mutual pressure, irregular growth. About the periphery and less markedly in the midst of the tumor there are areas in which the tumor has undergone disintegration, shown by fragmentation of nuclei and breaking down of cells.
The alvoolar cells and connective tissue cells about the
tumor have proliferated, giving the lung a carnified appearance.
No. 2 was removed during life under surgical precautions, from the neck and shoulders of a white mouse.
An alcoholic specimen of the tumor shows a small firm lobulated mass, partly encapsulated, about the size of a chestnut; the surfiice is irregular ; the interspaces are filled with coagula. On section, however, the tumor presents a rather uniform white color and firm consistence. To this tumor is attached a small one of less uniform structure and color.
Macroscopically the appearance is that of sarcoma, but microscopically it is that of a true gland. It is divided into lobules by thick bands of connective tissue extending in from the dense fibrous capsule. These connective tissue elements show signs of proliferation.
The tumor is tubo-racemose in type. The tubules and acini are lined usually with a single layer of cuboidal or columnar epithelium, resting on a basement membrane. Frequently the luniina of the tubules are filled with cells forming solid epithelial cords, in which the cells are compressed and distorted. Again the lumina are wide and free. No ducts are apparent. The cells are throughout of the same charactei", although immediately under the capsule in some places they are flattened and compressed, looking like deeply staining fibrous tissue cells.
At one point the tumor elements have worked their war between the fibers of the capsule, at which point the capsule is hamiorrhagic. The smaller lobe is a lymphatic gland which has not been invaded, although firmly adherent to the capsule of the tumor at the point of infiltration. Its blood-vessels are much congested.
On the opposite side of this gland is a small nodule of normal glandular structure.
Several months after removal of this tumor there was a recurrence at the seat of operation (Fig. 2), and iissociatetl with this, on the death of the mouse, was found a metast^Jtic deposit in the lung. This tumor was of the same type :is the original one, an adeno-carcinoma, presenting three distinct appearances as shown in Fig. 2 : 1) normal gland structure, iu which the acini are frequently filled with cells ; 2) more truly carcinomatous growth, in which the gland type is lost through the proliferation of the cells, although the clumps of cells still remain hemmed in by the basement meuibrane; 3) a dilat<id condition of the alveoli, leading to thinning of the walls.
No. 3 is a tumor projecting from the inner side of foreleg of a white mouse ; with this w:is a metjistatic dejiosit iu the lung.
The tumor in alcohol represent-s a rather uniform lobuKited growth about the size of a hickory nut, consisting of two hemispheres, lying immediately beneath the skin, to which, however, it is not adherent. It is distinctly circumscribed. Through the skiu its nodular surface may be felt. On section it presents a uniform, firm vellowish surface; m:jgni
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fied it shows a dense fibrous capsule euclosing the elements of a true carcinoma, consisting of long solid epithelial cords and culs-de-sac and, likewise, elements of more glandular appearance, in which acini are sometimes lined with a single, sometimes with a double layer of cubical epithelium. The epithelial elements are in certain areas separated by considerable young connective tissue and have atrophied. Certain areas l)resent marked necrosis of epithelial cells, the luminaof some tubes being tilled with necrotic elements.
The connective tissue stroma, which is quite abundant, is in places estremely vascular, and in others its cells are widely separated, giving it a myxomatous appearance.
There are several lung metastases. Fig. 3 shows a small one arising apparently within a lymph space.
No. 4. A tumor occurring in the axilla of a grey mouse, is about the size of a hickory nut, hard, nodular, appearing immediately beneath the skin, to which in places it is firmly adherent. It is of firm consistence and yellow color (alcoholic specimen). On cross section it differs from the other tumors in being more irregular in color and consistency. There are several dark, softer areas on its surface.
Microscopically the tumor is made up in part of irregular gland structure with a single layer of cubical cells lining the alveoli, but for the most part is composed of cords of polyhedral epithelium. It may be seen projecting up' into the corium of the skin, but at no point is it in communication with the epidermal tissue. Certain areas are necrotic. In some places what appear to have been gland acini are now dilated spaces lined by a single layer of flattened cuboidal cells and containing a granular material, remnant of disintegrated cells. The connective tissue stroma shows signs of proliferation. In this, as in all the preceding tumors, karyokinetic figures were found in abundance in the tumor cells.
The 5th tumor (Fig. 4) represents one of several nodules, small, measuring 4 mm. in diameter, of granular appearance, projecting from the skin on the fore- and hind-leg of a wild mouse. These tumors were excised and sections show them to be pure adenomata of the sebaceous glands. Sofaie of the gland acini appear normal, being filled with their j^eculiar opaque, coarsely granular epithelial cells w^th small round nuclei. The acini are limited by a distinct membrane. The cells lying next to it are small and compressed ; as one approaches the center of the acinus they become larger and show the appearance of their peculiar degeneration, the nuclei becoming obscure and the protoplasm swollen. Some of the acini are distinctly cystic, partly filled with fine granular material derived from the degenerating cells. The dilated ducts may readily be traced at times through the hair follicles to the perii)hery. The epithelium of the hair follicles does not seem to have j)rol if crated. Among the gland cells no distinct karyokinetic figures are to be made out.
Heneath the tumor the subcutaneous tissue has normal appearance, limiting all growth further downwards. The small glands found in almost continuous succession throw light on the presence of the one in tumor No. 3.
The type of these tumors is, in general, with exception of the last, adeno-carcinoma, some showing an almost pure carcinomatous appearance. And in this connection it is
interesting to note that the macroscopic appearance is almost invariably that of sarcoma; a nodular surface, well circumscribed by fibrous capsule, uniform firm structure, which might naturally, as Cadiot holds, have led the older writers to place sarcoma as the most common tumor in animals. From this series carcinoma should certainly have that place. The elements making up the tumor and method of their growth differ in no way from those of growths occurring in human beings. Two of them give metastases which preserve the original type of structure and cells. One gives further evidence of its malignant nature by recurrence three months after removal. The last occurred as multiple tumors. The rate of growth of none was noted, except the recurrence of tumor No. 2, which was very rapid.
The position and character of all of them are suggestive of their point of origin. Three occur primarily about the neck and breast of the animals. All of these are superficial, lying immediately beneath but still not involving the skin. Their elements are not those of epidermal epithelium, but are distinctly glandular, and suggest at once as their point of origin the mammary gland. The origin of the last is obvious.
The occurrence of the primary tumor in the lung is interesting when we consider the rarity of that occurrence in man.
The capsule we must look upon either as a thickening of the original gland capsule or a proliferation and condensation of the connective tissue about the growing mass.
I may say in closing that in none of them, with the ordinary methods of staining, have I discovered anything which resembled the " coccidia " found by Buffer and Walker," which they wish to associate with the etiology of the condition, nor the blastomyces of Busse' and Sanfelice.'
Kefbrences.
1. Morau : Comptes-rendus, Societe m6d. et biol., Paris, 1891, 8. iii, 289.
2. Boinet : Comptes-rendus, Societe de biologie, Paris, 1894, 10 s., p. 475.
3. Mayet: Provence Medicale, 1894, viii, 553.
4. Trousseau and Leblanc : J. univ. et hebd.de m6d.etcbir. prac, Paris, 18:-.2, vi.
5. Cadiot: Presse Medicale, Paris, 1894, 219-222.
6. Semmer: Oesterr. Vierteljahrsch. f. wissensch. Veteriniirk., Vienna, 187.3.
7. Kuffer and Walker : Journal of Patliology, Vol. I, No. 3.
8. Busse: Contralblatt f. Bakteriologie, Bd. xvi, p. 175.
9. Sanfelice : Zeitsch. f. Hygiene, Berlin, Vol. 21, Pt. 1, 1895.
10. Burke : Veterinarian, London, 1890, Ixiii.
11. Hanau : Archiv f. klin. Chirurgie, Berlin, 1889, xxxix, p. 678.
12. Hyvert: Montpellier, 1872.
13. Parke : Med. News, Febr. 1896 et seg.
14. Ustariz : Anales de cienc. med., Madrid, 1877.
THE MALARIAL FEVERS OF BALTIMORE.
An Annlysis of 6i6 cases of Malarial Fever, with Special Reference to the
Relations existing between different Types of Haematozoa
and different Types of Fever.
By Wii-liam Sidney Thayer, M. D., and John Hewetson, M. D.,
AssisUtjitR in the Meaiatt Clinic of The Johnit Jiopkinn I]oftf}itat. 218 pnK<'x, quarto, witli plntes mid charts. Trice SS.OO, Postage paid.
IKoriniriif part of The Jolms Hnplntis Hmpil nl neportu. Vol. V, 1895.] Orders should bo addressed to The Johns HorKiNS Pkess, Baltimore, Md.
CASE I,
a. — Atrophic degeneration of the retina in its anterior part. Disappearance of all the retinal layers as far back as the Internal Granular Layer. Muller's Fibres are wavy in their course and appear swollen.
b. — Remains of the Internal Granular, External Molecular, and External Granular Layers.
c. — Several layers of albuminous transudate.
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Fibrillary Degeneration of the Vitreous Body,
Tk« FrledeuwjUd Oo., £osT«Tcr« auiI Printer!.
September-October, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
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THE ANATOMICAL CHANGES IN TWO CASES OF RETINAL DETACHMENT.
By Robert L. Random'H, M. D.
I have selected the following cases as being fairly typical of che two principal conditions leading to detachment of the retina. Case I was a spontaneous detachment due to fibrillary degeneration of the vitreous, and Case II was where a small round cell sarcoma had pushed the retina away from the choroid.
Case I. — The detached retina as it sprung from the papilla
oked like a funnel having a neck about one-fifth of an inch long, and which at this distance from the papilla commenced to assume the funnel-like shape. The retina was detached below all the way around to the ora serrata. Above and at a point one-sixteenth of an inch posterior to the ciliary muscle it was lying in position. From this point it turned backwards, and then passed directly down to a point which lay in the pole of the lens, and fi'om here it took a coui'se forward ■nid then upward, and finally lost itself in the ora serrata.
jat part of the funnel which had an upward direction was thrown into numerous and intricate folds and enclosed in its meshes a mass of vitreous body, while that part which passed below was composed of the entire thickness of the retina, which appeared quite normal. The peculiarity of this portion was the absence of folds. The inner surface of the retina at the widest part of the funnel was covered with a thick mass of vitreous body, and the angle which was formed by the ciliary body in front and by the retina behind as it fell backwards and downwards from the ora serrata, was filled with coagulated material and fine fibrilke, which latter passed forward and served to form numerous bridges across it. The ciliary processes were covered posteriorly with several layers of the vitreous flbrillae. The zonula was not distinguishable as such, it no doubt being merged into the fibrillaa. That portion of the vitreous space lying between the retina and choroid was empty. No doubt we had a iluid here during life. ^\.i some points anteriorly could be seen what are described by Nordenson as the choroidal tufts, " chorioidalzotten," which appeared like little bridges uniting the retina and choroid. There was nothing worthy of note about the choroid, and the same could be said of the ciliary body, iris and lens. There was a good deal of material in the anterior chamber which was probably the transudate coagulated by the hardening process.
Microscopic changes. — The changes in the retina were very noticeable, and particularly in the anterior part of the eye. The anterior portion of the detached retina was the seat of the most marked degenerative changes, the retina itself resembling closely a reticulated tissue in which there was hardly a trace of the several layers. Posteriorly it was easy to recognize the various layers, but they gradually disappeared towards the ora serrata, and the only evidence of a layer was a single row of granules which marked the course of Ihe external granular layer.
- Read in the Section of Oplitlialmology at the Atlanta Meetiiigof
the American Moiiical Aasiioiation, May, ISlUi.
The layer of rods and cones was intact in several places, but this condition was generally found in the posterior half of the eye. At those points where the retina was thrown into very intricate folds this layer was more apt to be wanting, but even in this situation it was sometimes present. In those situations where the layer of rods and cones was absent, its place was filled with a mass of albuminous drops which were arranged in layers one on top of the other. On the inner surface of the retina one could see the meshes of the vitreous fibrillae, which appeared to be exercising traction on the surrounding retina. This layer of fibrillEe was tolerably rich in nuclei.
In one place the retina had curved around so as to form a loop; on one side of this loop all the layers of the retina were to be seen, with the exception of the ganglion cell layer. The layer of rods and cones could be plainly seen as well as the external limiting membrane. On the opposite side of this loop the only layers which were present were the external granular layer and the external molecular layer, the latter to a very limited extent. The inner layers in this situation had been pulled out of all shape by the vitreous fibrillar. The external granular layer presented generally a very irregular borderline, appearing at points as papilla;-like projections due, I think, to the folding of the retina. The nerve fibre layer was not easily recognizable, and the layer which occupied its normal position, and which to a large extent was the nerve fibre layer, was the seat of numerous nuclei. The radiating libres of Miiller showed generally a wavy course. The line of demarcation between the nerve fibre layer and the ganglion cell layer was difficult to make out. This was no doubt to be attributed to the traction exerted upon the nerve fibre layer by the fibrillte, and also to the very irregular course followed by the radiating fibres. As a rule the ganglion cells had dropped out of the section, and it was impossible to identify this layer.
An examination of the neck of the detachment, or, as I have called it, the neck of the funnel, showed no remains of the vitreous body. This neck appeared to be a mass of connective tissue, in which it was impossible to distinguish any of the layers of the retinji, though it seemed to be made up largely of the granular layers. At the papilla there was no semblance of the retinal structure. There was, too, at this latter point a notable absence of blood-vessels. Upon the neck of the detachment, on all sides, several layers of albuminous drops rested. The fibrilla? were for the most part devoid of nuclei. They often looked as though they came directly out of the retina and made their way into the vitreous Iwdy, or sis though they were prolongations of the radiating fibres, so intimate wjvs their connection.
Choroid. — On the inner surface there were several layers of albuminous transudate resting on the pigmentary layer of the retina, which had remained behind. :is it usually does in such cases. Increivscd nucleation Wiis everywhere present throughout the choroid, and further than the iH>ints just mentioned there wjis nothing noteworthy in this jwrt of the eye.
180
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 6(5-67.
The vitreous body was wanting entirely in the posterior portion of the eye. Just behind the lens it seemed to be transformed into a granular debris devoid of fibrillar, while in other portions it was composed apparently of nothing but the librillEB which have been described. The lens, iris and ciliary muscle were normal.
The chief points, then, about the pathological anatomy of this case were: 1. The widespread atrophic degeneration of the retinal layers, and especially of the layer of rods and cones. As a general thing the granular layers were the only layers that were preserved. 2. Swelling of Muller's fibres. 3. The presence of albuminous drops in various localities, and especially between the choroid and retina, and along the neck of the detachment; and finally the transformation of the vitreous body into fibrilla3. I may say in connection with this case that I am indebted to Dr. Mary E. Hennessy, of New York, for the specimen, who unfortunately was unable to furnish me with the history.
Case II. — The second case was that of a boy, aged seven years, who came to the Johns Hopkins Hospital early this spring. His parents had taken him to an oculist several months before ; at that time his eye was not thought to be in a serious condition. He had been complaining for the last three weeks of severe pain in his right eye, and his parents had noticed a whitish yellow reflex from this eye. This reflex was very noticeable when he came to the hospital. The tension of the eye was decidedly elevated and the conjunctiva injected. Vision was completely gone. I advised enucleation and the eye was removed the following day. The macroscopic condition was as follows: The tumor involved almost the entire nasal half of the retina, filling up that side of the vitreous space both above and below. It extended back and seemed to proceed from the nasal side of the optic nerve, and advancing into the vitreous, stopped at a point about a quarter of an inch posterior to the lens. Over the area occupied by the tumor there was no trace of the retina to be seen. On its free side the growth was quite nodular, and one of the nodules projected across to the temporal side of the eycand almost reached the retina on that side. The retina in the temporal half of the eye was completely detached.
Microscopic changes. — The tumor was scant in intercellular substance and was made up of small round cells. Bloodvessels were tolerably numerous and they were usually filled with red blood corpuscles. Large areas of the growth failed to take on the hematoxylin stain, but stained with eosin. These were evidently necrotic areas. Hemorrhages were not infrequently seen. Wherever the tumor was present the retina was indistinguishable, the tumor having grown into it. Tlie tumor cells were found in the ojitic nerve as far back as a quarter of an inch from the papilla. The vitreous body had been crowded over to the temfftral side of the eye and had been transformed into the characteristic fibrillaj, which were evidently exerting traction upon the retinal folds. These fibrillae had pulled the retina into intricate folds in the anterior portion of the eye, and just behind the lens the traction was enough to pall the retina backwards far enough to leave only a short narrow bridge separating the latter from the growth. The layer of rods and cones was nowhere visible,
and just as in the first case, the ganglion cells in the ganglion cell layer had dropped out of the section. The internal and external granular layers were clearly definable, say from the equator around to the ora serrata. The retina posterior to the equator was very much thickened and broken down, failing to stain. At one point only, and for a very short distance, the external limiting membrane could be seen. The fibres of jMiiller were somewhat swollen and had a very wavy course, a course which moi'e or less disturbed the position of the retinal layers.
The choroid nearly everywhere had been attacked by the growth, that is to say, large and small heaps of the sarcoma cells were present in this coat, and generally they were resting under the pigmentary layer, this condition extending around as far as the ciliary region on the nasal side, and on the temporal side a short distance from the paj)illa. There were no albuminous drops.
The principal changes in this case were the conversion of the vitreous body into fibrillaj and the atrophic degeneration of the anterior portion of the retina.
It would seem, then, that fibrillary degeneration of the vitreous body is to be found in both classes of cases. In the case of spontaneous detachment it was evident that the fibrillae were largely concerned in pulling the retina away from its normal position, and from the arrangement of the retinal folds shrinkage or contraction from within must have been going on. In this case, as will be seen from the drawing, there was a considerable exudate consisting of layers of albuminous drops resting on the membrana limitans externa, which exudate no doubt played a part in separating the retina and choroid. These two conditions would explain the detachment in the first case and similar ones. In the second case the presence of the sarcoma was sufficient to lift the retina from its position, though even here it was evident at a glance that the retiiia was subject to a force from within which helped to pull it still further away from the choroid. I failed to discover a rent in the retina in either case.
In conclusion I may say that the most striking anatomical change in these two cases was the fibrillary degeneration of the vitreous body, a condition which, I think, is found to a more or less extent in every case of retinal detachment, and which no doubt is the chief element in the pathogenesis of the disease.
THE JOHNS HOPKINS HOSPITAL BULLFTIN,
Volume VII.
The BULLF.TIN of tho .lohna Hopkins Hospltnl entoreil upon Ita eeventh volume, January 1, 18%. It coutaluu original communications relating to medical, surgical and gynpcologtcal topics, reports of dispensary practice, reports from the patliologlcal. anatomical, physlologlco-chomlcal, pharmacological and clinical laboratories, abstracts ot papers road before, and of discussions In the various societies connected with the Hospital, reports of lectures and other mattora of eoi>ernl liUorost In the work ot the Johns Hopkins Hospital and the Johns Hopkins Medical School.
Nine uumbors will be Issued annually. The subscription price Is $1.00 per year. Volume VI, bound In cloth, $1.00.
September-October, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
181
THE BUBONIC PLAGUE.
[The substance of a report made to t!ie Journal Club of the Johns Hopkins Hospital by Simon Fi.exner, M. D.]
In October of 1894 <an abstract of a report to the .Journal Club of the Hospital, upon the subject of the bacillus of the plague, appeared in the Hospital Bulletin. The account there given of the micro-organism which had but a short time before been isolated from a number of cases of the black plague by Drs. Yersin and Katisato, and which was believed to be the cause of this devastating pest, was drawn from the reports of these investigators published at that time. The expedition sent by the Japanese government, at the head of which was Dr. Katisato, contained Dr. Aoyoma, whose mission it was to study the clinical and pathological features of the disease. Dr. Aoyoma became himself infected with the disease a short time after the beginning of his studies at Hong-kong, and although he recovered, the report of his studies has only recently appeared.* As was to be expected, these relate more jiarticularly to the symptouuitology and the pathological anatomy of the disease, although account is taken of the epidemiology and to a less extent of the bacteriology and of the mode of infection. In order that the first report given in the Bulletin may be in a manner complete, it is considered desirable to append an absti'act of Dr. Aoyoma's recent report.
In May of 1894 the Japanese consul in Ilong-koug announced to the Japanese government that the plague had appeared in Canton. Immediately following, a quarantine first of nine days and later of seven was set upon incoming ships, and Dr. Katisato, with his assistant Ishigami, and Dr. Aoyoma with his assistant Miyamoto and medical student Kinoshita, were sent to Hong-kong, where they arrived on the 12th of June. Through the kindness of Dr. Lowson they were permitted to arrange for their work in one of the rooms of the Kennedy Town Hospital, where on the 14th they had established themselves ready for work. Unfortunately Aoyoma and Ishigami became ill with the pest on the 28tli of June, owing to which the studies which are here to be given were limited to fifteen days of active service. In this time 19 autopsies were held and 4.5 clinical cases studied, the latter more or less completely. In addition to these the opportunity of seeing a largL' number of cases in the Chinese hospitals had been embraced.
Respecting the situation of Hong-kong and the condition of the soil, its inhabitants and houses, the following may be stated: Hong-kong is one of the widest of the islands situated in the (Uilf of Canton stream, and lies 142 km. southeast of the city of Canton, and 02 km. east of Macao, and is separated by a small body of water, which is used as a harbor, from the mainland. The island is mountainous, from two to five miles in length, and consists of granitic rock. Respecting the climate it may be stated that it is tropical, and the warmest months of the year are from March to November. The winter is also warm, and snow is not known in that locality.
- Mittheilungen aus den ^lediciniscben Facultat der KaiserlichJapauiscben Universitat, Band III, No. II, Tokio, 1895.
Victoria, which is the principal town, extends from east to west along the north coast, between the sea and the mountainous background, and follows the latter, as it is built in part upon the mountain side. In the most easterly part we meet the barracks, villas, factories and the European shops. The westerly and middle parts, which are lower, are the Chinese ijuarters. The portion of the town which was most affected is known as Taiping-chan, which lies in the middle of the city. As regards the streets themselves, excepting that they are narrow, they are the equals of the best European streets. The houses, which are usually two stories in height and built after the European fashion, number about 7900, of which 6600 belong to the Chinese population.
The number of inhabitants of Hong-kong is difficult to ascertain and probably reaches the neighborhood of 2.50,000. The rej)ort obtained from the water-supply bureau gave 163,949, of whom 151,974 were Chinese. The overcrowding of the houses of the Chinese workmen has greatly increased during the past ten years. It is stated that in the ten years from ISSl to 1891 the number of inhabitants of the city increased 41 per cent., while the houses increiised only 13 ,^j per cent. The densest population is found in Taiping-chan, where it would appear that in a house area of 0.173 acre 3740 Chinese live. The streets of this part are very narrow, the houses are two-storied, the windows small and few in number. The houses, which are long in form, are separated by partitions into two parts, each of which is further subdivided into a number of large rooms. In the earlier times one of these rooms housed a single family, but at the present, owing to overcrowding, these rooms have been divided by subpartitions into an upper and a lower compartment, and these compartments further by upright partitions, so that several rooms have been const ructed out of the original ones, in each of which a family now lives. The average size of the main room is 26x14 feet by 10 feet high, and coutiviuseight partitions averaging 7x6 feet by 7 feet high, over which a sort of loft is often built to increase the accommodation, and in a room of this description from 16 to 25 people live.
The canalization is constructed so that one system of pipes receives the washings from the rains and the other the sewage from the kitchens, etc. The first works jierfectly, whereas the other is for the most part in a very bad condidion. so that stagnations frequently occur and the sewage is dammed back upon the houses.
The city itself is provided with an excellent water supply, which in certjiin times is even subjectetl to tiltnition. The clothing of the Chinese is hygienically to be recommended. The only difliculty to be pointed out is, that although well conceived for the purpose, it is never under any circumstances subjected to washing, which fact is equally true of their bedding. The personal habits of both the men and the women are almost beyond belief in their crudeness and neglect. Cleanliness on their part, or anything approaching it, is aD absolutelv unknown art.
182
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 66-67.
As regards the cause of the plague, it may be said that Katisato discovered bacilli in the blood and iu the lymphatic glands which differed somewhat in their morphological characters but which agreed in their cultural projierties. According to Katisato, the bacillus which appears in the blood resembles the organism of chicken cholera, possesses a capsule, the middle portion staining very faintly ; while the bacillus obtained from the lymphatic glands is somewhat longer, has rounded ends, and stains more uniformly than the other. The bacillus obtained by Yersin is stated to have rounded ends, to be easily stained with the aniline dyes, and to be decolorized with Gram's method. The ends again stain more uniformly than the middle part. According to Katisato, the organism would at times stain by (Iram's method, and at others not. Aoyoma, however, observed that those contained within the lymph glands were decolorized, and those iu the blood stained by this method. The number of organisms contained within the blood is usually not large, and may be so small that it is necessary to prepare a large number of cover-slip preparations in order to find sufficient for a diagnosis. On the other hand, they are found abundantly iu the affected lymphatic glands.
The study of the tissues has shown that in the lymph glands a variety of bacteria may be met with. As a constant and predominating species the lymph gland bacillus of Katisato is found, although in rare cases micrococci predominate. Careful observation, however, shows within these masses greater or less numbers of the pest bacilli, the streptococci occupying the blood-vessels rather than the gland substance. The pest bacilli in the tissues stained less intensely in alkaline methylene blue solution than the streptococci, and the staphylococci least of all. It is stated that while the streptococci retain the Gram stain, the bacilli and the staphylococci do not. It is suggested by Aoyoma that the foi-ms described by Katisato as occurring iu the blood and retaining the Gram stain may have been pairs of cocci and not bacilli at all. He regards the association of the bacilli and cocci as of great importance, inasmuch as in the greater number of instances the affected glands suppurate, while a very small fraction do not; Hence it is considered that the suppuration is caused not by the plague bacilli which are always present, but through the action of pus-producing bacteria which entered along with the former or later than these ; and Aoyoma has further found that in suppurating glands the plague bacilli are either much diminished in numbers or have entirely disappeared.
It may be recalled that in the first reports of Katisato and of Yersin they stated that the bacilli might enter the body first through the respiratory tract, second the digestive tract and third, excoriations of the surface. Aoyoma, on the other hand, e.vpresses the opinion that in the great majority of cases, if not in all, the entrance is through external wounds. He points out that physicians and nurses who are in attendance upon infected individuals and spend much time in the places in which the sick are kept, rarely become infected with the disease. In this epidemic, of all such persons who were in attendance upon the sick, only three Japanese physicians and one Chinese physician became infected, the nurses having entirely escaped. During the prevalence of the epidemic 300 English soldiers volunteered to cleanse and disinfect the
Chinese pest-houses. Of these only ten became affected with the disease. Thus it would appear as though an actual pest atmosphere did not exist and that the infection did not take place through the inspired air. Moreover, Aoyoma did not observe that the tracheal or bronchial glands were in a condition of intense inflammation, which he presumes would have been the case had the bacilli invaded through the air passages.
Respecting the question whether the organisms are taken into the body through the drinking water or with the food, it may be said that the Chinese do not drink unboiled water, and never under any circumstances eat uncooked foods. That portion of the town (Taiping-chan) which was most infected, and iu which the hygienic conditions were the worst, received its drinking water from the general supply. It is true that Katisato was able to cause infection in mice by introducing the bacilli into their stomachs through glass tubes, but it is stated by Aoyoma that Katisato does not any longer regard these experiments as being certain proof of infection through the alimentary tract. It is noteworthy that at autopsy the lymphatic apparatus of the stomach and intestines and the mesenteric lymph glands were never found greatly inflamed, and the last contained very small numbers of the bacilli only, or iu certain cases none at all. Hence it is stated that all physicians who observed this outbreak of the pest were forced to the idea that the bacilli entered chiefly through external wounds.
In the great majority of cases the deep inguinal and the axillary glands, and in a small number of cases the superficial inguinal glands, of one side were first affected and afterwards other glauds became involved. This fact is explicable only upon the assumption that the organism entered through small defects of the skin which were present either on the feet or the hands; and as the working class of Chinese usually go barefoot, such small defects can easily be imagined to exist. Further, as is known, the lymphatic vessels of the feet run to the deeper and lower inguinal glands, thus exposing these first in the great majority of cases. The superficial inguinal glands receive the lymphatics of the penis and the skin over the lower portion of the abdomen, and these are but seldom primarily affected. Of the nine Japanese whom Aoyoma observed, two women showed affection of the axillary glands, one of the submaxillary glands, whereas in the other no glandular affection could be detected, uotwithstaudiug the fact that the bacilli were found in the blood. Of the Japanese men, four showed swelling of the axillary glands, and one only of the inguinal glands. This is interesting when it is considered that the Japanese do not go barefoot. It may also be mentioned that among the Chinese the women show affection of the axillary rather than of the inguinal glands.
The wounds through which the infectious agent enters show, as a rule, no reaction. Notable exceptions to this statement are his own case, in which a lymphangitis was present, and that of his assistant, Nakahara, who succumbed to the disease and in whom lymphangitis was also observed, iu both cases beginning in the hand and extending towards the axilla. As regards the manner of diffusion of the bacilli, nothing new has been offered in this report. The period of incubation of the disease is given at from two to seven days ; and as regards
September-Octobek, 1896.]
JOHNS HOPKINS HOSPITAL BULLETIN.
183
the age and the sex of those affected, it may be said that the greater number of cases occur in young males.
The following table gives the relative proportion of men, women and children affected :
Men 02.40 per cent.
Women 19.2:3
Boys 8.93
Girls 9.45
It is worth noting that Aoyonia himself did not observe a single case in newly-born children or sucklings, although an English physician, Dr. Lowson, claims to have seen five or six cases among the latter.
The mortality in Hong-kong from the beginning of the disease until the 2nd of Sej^tember is given as follows :
Number Affected. Number Died.
Europeans 11 2
Japanese 10 6
Manilanese 31 1
Urasinese 3 3
Indians 13 10
Portuguese 18 12
Malayanese 3 3
West Indians 1 1
Chinese 2fil9 2447
Symptomatology. The symptoms of the disease during the last plague were not, as was stated by most authors, protean, but they were quite simple. The disease began for the most part without prodromata, with a chill, or even in the first instances with pain and swelling of the glands and with succeeding chill and fever. Prodromata when present were usually short aud varied in duration from a few hours to two or three days, or perhaps somewhat longer. The symptoms in the prodromal stage are prostration, headache, nausea, vomiting, loss of appetite, vertigo, aud only rarely pains in the lumbar region or in the back. In the cases of the affection of the more intelligent population, even before the outbreak of the fever, slight swelling and pain were noted in the glands; whereas in the more obtuse Chinese these slighter phenomena were not noticed.
The temperature rises quickly to 39° or 40° C. or even higher, and renuiins high during the progress of the disease. Delirium sets \i\ early, for the most part after the second day, aud continues day and night, altiiough in the lighter cases it may be absent during the day. On the other hand, severe cases occur in which from the beginning until death supervenes the functions of the brain are intact. The pulse is usually of good volume, as a rule is dicrotic and varies in frequency from 90 to 120 per minute. The spleen is palpable usually after the second or third day. It rarely can be felt more than a few cm. below the costal nuirgius. The liver also is usually enlarged and palpable.
The urine is in most instances of dark color, cloudy, contains albumen, and does not, as a rule, give the dia/o reaction. A few casts, citiior hyaline or granular, and white corpuscles are usually present. Very rarely the urine contains blood.
After the first or second day the glaudular affection becomes
more marked, and those glands first involved may reach the size of an egg. The pain increases with the growth in size, although in some cases it may be absent excepting upon pressure. The glandular affection is characteristic, inasmuch as it begins in one group and then involves in succession others, as for example first the inguinal, then the axillary, then those of the neck, and finally the submaxillary glands. The glands of the neck, of the elbow and the knee are seldom primarily affected. Only very rarely do several sets of glands become enlarged at once. Very soon after the swelling of the glands the periglandular tissues become involved and then later the skin. In the milder cases, suppuration may not occur and the swelling gradually diminish and finally disappear. On the other hand, suppuration may occur even in glands but little enlarged.
The temperature rises rapidly to 39 or 40 degrees, and in rare cases to 41J degrees. In other instances the rise is more gradual. After remaining continuous for three or four days, there may be a critical fall, or the decrease may be gradual. In severe cases which recover the fever lasts from one to three weeks, and towards the end 2)resents an irregular and remittent type. In not a few cases after the temperature has returned to the normal at the end of the first or the beginning of the second week there is a relapse, the fever now assuming a remittent character. The remittent fevers are suppurative; the fever is very rarely from the beginning remittent and irregular.
Actual hemorrhages into the skin were observed but once by Aoyoma, although congested areas are not infrequent. These latter areas disappear upon pressure and are believed to be caused by the bites of mosquitoes. Respecting the question of the appearance of an exanthematous eruption, it is stated that a rapidly disappearing erythema may occur. Symptoms referable to the brain, with the exception of the ilelirium, were very rarely observed. Fibrillary twitchiugs occurred before dejith, and iictual convulsions were seen in very rare instances. In only one case was opisthotonus observed.
In the Foitdroyante cases death may occur before any considerable glandular swelliug can be made out; in the severest cases taking place on the second day. As a rule, death occurs from the second to the eighth day, and on an average on the fourth day. As suppuration of the glands rarely occurs before the tenth day it was not observed in these more rapid cases. When dejith takes place late in the course of the disease it may be due to a secondary pya>mic infection. The suppuration of the glands may continue for months, so tliat the convalescence of the patient is rendered very slow and tedious. When suppuration does not occur the glands gradually become snuiUer, although the enlargement may not entirely disappear for two or three months.
Complications are stalled to be quite frequent. Of those, nephritis occurs quite commonly in the severer cases. It develops iis early as the thinl or fourth day of the disease, is accompanied with the appearance of a moderate amount of albumen in the dark red urine, and microscopically hyaline aud granular exists, jis well as white aud reii blood corpuscles, are found. iKdema w;is rarely seen, aud when present, of light
184
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. e6-G7.
grade, aud anuria was never observed. The blood which is present in the urine is not derived from parenchymatous hemorrhages, but from small extravasations into the mucous membrane of the pelvis of the kidney and the bladder. Abscess formation in addition to the lymph glands was observed in the liver, lungs and other organs in the later stages of the disease. Icterus of a light grade, and presumably of catarrhal origin, was often present; in one case it reached a very high degree, and at the autopsy it was found that the common duct had been pressed upon by a group of enlarged lymphatic glands. Serous pleuritis occurred but seldom, and seemed when present to be associated with the enlargement of the axillary glands. Pneumonia was seen in a single instance only, but bronchitis was much more common. Rarer complications are periostitis, lymphangitis, furunculosis of the skin, phlegmons which have their origin in the suppurating glands, carbuncle, singultus, and bloody stools.
Respecting the question as to whether cases of the pest without glandular affection ever exist, it may be said that in three cases which came to autopsy and which were proven to have died of the plague, enlargement of the glands was not made out during life.
The blood presented a dark red color, aud the estimation of the corpuscles showed that the red corpuscles were only inconsiderably or not at all diminished, while the white w^-e always increased. The number of white corpuscles per cubic mm. varied from 20,000 to 200,000; a control count of normal blood in a Chinese gave 10,000 white corpuscles to the cubic mm. The increase in white blood corpuscles is in the poly morpho-nuclear neutrophilic variety. Eosinophilic cells were very rarely seen. It is stated that the blood platelets were increased in number.
During the short time that Aoyoma carried on his studies he made autopsies upon 19 cadavers. The following is in brief the result of his studies of these cases: There is not infreijuently a post-mortem rise of temperature; in one case the temperature taken four hours after death in the rectum, with a thermometer which registered 43 degrees, could not be estimated because the mercury was driven to the top of the capillary tube. Post-mortem muscular contractions also occurred in a similar manner to those observed in cholera. The affection of the lymph glands in various regions of the body has already been referred to, and it remains to say that in no case did he find evidence of a primary affection of the pleural or peritoneal lymphatic glands. No matter in which part of the body the glands are primarily affected, the entire lymphatic apparatus of the body shows at least some swelling, and perhaps congestion as well. With the exception of minute ecchymoses nothing abnormal was observed in the heart. The lungs and the pleura were not the seat of iuUammatory changes, although in the latter, in certain of the cases of 23rimary axillary affection, an increased amount of fluid existed in the pleural cavity. The spleen was enlarged, and sometimes consideral)ly so. The kidneys showed the lesions of cloudy swelling, and often were congested. Small hemorrhages occurred in the mucous membrane of the pelvis. The liver was enlarged and hypera;mic and the seat of parenchymatous degeneration. The stomach and intestines showed more or less injection of the
mucous membrane and increase of the mucous section. The pia arachnoid was as a rule hyperajmic and very cedematous. Purulent inflammations were never present in this situation. In few cases a moderate number of small hemorrhages were observed in these membranes. The fluid within the ventricles ^Yils moderately, never greatly increased. The substance of the brain showed a moderate oedema and numerous hemorrhagic points. In one instance an extravasation of blood the size of a bean was found in the medulla oblongata, aud in another one of the same size occurred in the pons. The pia arachnoid of the spinal cord was hyperEemic and cedematous. Lesions were not found in the cord itself.
The increase in size of the lymphatic glands depends upon several factors, namely, hypersemia, exudation, hemorrhage, hyperplasia of the gland cells, and great development of bacteria. The bacilli which are present are found in the earlier stages in the lymph spaces about the follicles, and later they are found within the follicles, the lymph sinuses and the medullary cords. The cells of the affected gland undergo various degenerative changes and may become necrotic. They lose their nuclei in the latter case, and a variable amount of nuclear detritus is present among the degenerated and necrotic cells. The hemorrhages are not limited to the gland itself, bu t may be found, as well as greater or less oedema, in the periglandular tissues. The usual fate of the enlarged glands is to suppurate, although in certain cases the swelling may disappear without suppuration and the glands return to normal ; while in still others a fibroid induration may result. The suppuration is either of the nature of simple abscess formation, or preceding this there may be a necrosis of the gland substance; in certain cases the suppuration does not remain limited to the glands, but extends into the periglandular tissue. Sections of the lymph glands showed a variety of bacteria. It is stated that in the primary localization various bacteria may be associated. Among these can be distinguished the pest bacilli and cocci, and among the latter both streptococcus and staphylococcus forms may be discovered. Aoyoma considers the association of these organisms as very important in determining the suppuration or non-suppuration of the affected glands. The spleen usually shows the presence of large numbers of bacilli, and among these more i-arely micrococci. The pest bacilli were also, though not constantly, found in the intei-stitial substance of the kidneys and in the glomerular capillaries. They were also present in the inter- and intra-acinous tissues of the liver. The mesenteric glands sometimes contained the bacilli in small numbers ; it is not stated whether or not they were found in the structures of the central nervous system.
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BV JOHN S. lilLLINGS, M. D., LL. D.
Coiilalnlng 60 largo quarto plates, phototypes, and lUlicigrapUs, with views, plau» aud detail drawings ot all the buildings, and their Interior urrangemouU— also wooilcuts ot apparatus and fixtures; also IIG pages ot lettor-jjress describing Uio plans tollowed In tho construcUon, and giving full details of heatlug-apparatus, ventilation, sewerage and plumbing. Price, bound In cloth, (7.50.
September-October, 1896.] JOHNS HOPKINS HQSPITAL BULLETIN.
185
ABSOLUTE ALCOHOL AS A DISINFECTANT FOR INSTRUMENTS. A BACTERIOLOGICAL
STUDY.*
By Kobert L. Eandolph, M. D.
For the past eight years I have employed absolute alcohol as a disinfectaut for all cutting instruments used in operations upon the eye, and recently I instituted a series of bacteriological experiments to test the value of this agent as a practical disinfectant. The cataract opei'atiou demands a keener knife, probably, than any operation in surgery, and the peculiar objections to heat for sterilizing cutting instruments led me to adopt the use of absolute alcohol as the best substitute for heat. I have satisfied myself again and again that not only does moist heat, but even dry heat dulls the edge of instruments, and this I understand has been the experience of many surgeons. In making this contribution to our knowledge of alcohol, it is not with the idea that I am introducing a new disinfectant, for I am well aware that there are not a few ophthalmologists who use it as an agent for sterilizing instruments. No matter though how well satisfied we may be with aseptic measures, we cannot understand why they are satisfactory, or, in other words, how much they contribute to our success, until these measures have been subjected to bacteriological tests, and, as far as I know, no exhaustive series of tests of absolute alcoliol as a disinfectant for instruments has been made.
The experiments of Koch go to show that alcohol possesses inferior germicidal qualities, in so far as its action upon the spores of the anthrax bacillus is concerned, the spores retaining their vitality after a submersion of one hundred and ten days in alcohol. This power of resisting the action of germicides exists in a marked degree in the case of the spore-producing organisms, as is shown among others by the works of (jlobigf and of Reinicke.| It is evident that in the case of the spores of the anthrax bacillus at least, absolute alcohol is practically useless as a germicide, but the negative results of Koch should not be taken as an evidence that absolute alcohol has no value whatever as a disinfectant. This is true only in so far as one organism is concerned, and that, too, an organism which, as far as we know, surpasses nearly all other bacteria in its vitality. It does not seem practical, then, to take Koch's results as a criterion for the germicidal value of absolute alcohol.
My experiments were undertaken at first to control, as it were, and to throw some light, from a bacteriologi(!al point of view, ujjon the method which I employ for sterilizing instruments in operations on the eye. These experiments were not intended to demonstrate theeffect of alcohol upon any special organism, but to ascertain the value of this agent as a disinfectant for every-day conditions in eye surgery. The question arises, why not determine the effect of absolute alcohol upon some
•Read before the thirty-secoiul annual meotini: of tlu» American 0|>litlialniolot;ical Society, Now Lonilon, Conn., .Inly, 1>>!W.
f Ueber cinen KartolTelbacillus rait, unyewohnlich wiilerstandsfahigen Sporen. Zeitschr. f. Hygiene, Bd. Ill, 18SS. S. o2l!.
I Hacteriologiache Untersucluinpen iiber die Desinfeotion der lliinile. Arcliiv fiir Oynaekologie, I5il. 4!), S. f)ir>-i>5S.
one or more of the commonly met with pathogenic organisms, for instance the so-called pus organisms, and be guided in my conclusions by results reached in this manner? We know for certain that the pyogenic bacteria are concerned in the production of many serious affections of the eye and its appendages, and that in those cases of sloughing cornea following the operation for cataract, to say nothing of panophthalmitis, one or more varieties of pyogenic cocci have been often found present in the affected tissues. No doubt many a staphylococcus and streptococcus infection has been conveyed to the eye by the instruments. There are practical reasons, though, for not approaching the subject from this point of view. The line between pathogenic and non-pathogenic organisms is not sharply drawn. Organisms which ten years ago were regarded as harmless, have been since shown to possess, under certain conditions, distinct and intense patliogenic properties. Take for instance the bacillus coli communis, the bacillus prodigiosus and the aspergillus f umigatus. Any one of these bacteria I have found, when introduced into the eye, will call forth the most intense inflammation. The investigations of de Schweinitz, Haab, I'oplawska, and of myself, go to show that other than the so-called pyogenic cocci are met with which are capable of producing the most intense panophthalmitis. However valuable observations conducted on these lines might be, they would not tell us whether alcohol protects us from a host of other bacteria which under certain circumstances are just iis pathogenic as the staphylococci or streptococci. These were my main reasons for not selecting a special organism to t«st the efficacy of absolute alcohol as a germicide.
Fiirbringer* first called attention to the value of alcohol iis a disinfectant for the hands. Ilis work has been gone over by Reiuicke (loc. cit.), who ha5 added a long series of most exhaustive experiments bearing upon this question of hand disinfection, and he agrees with Fiirbringer in attributing valuable qualities to alcohol as a disinfecUint for the hands. Keinicke employed in his experiments permanganate of potjisb and oxalic acid, sublimate soap, carbolic acid, lysol and trikresol, and compared the results obtained with these agents with the results obtained by disinfecting the hands with alcohol, and his conclusions were as follows: After first w;ishing the hands for five minutes in hot water, using soap and a nail brush, then following this by scrubbing them from 3 to 5 minutes with 90 per cent alcohol, he found them almost always absolutely free of germs. He sjiys finally that the quickest disinfection that can be relietl upon is scrubbing the hands for five minutes in alcohol. His results were coufirmetl in the main by Krouig,t AhlfeldJ and !Schaefer,§ though these
• Untersucliungen iind Vorschriften vilier die Desinfection der Hiinde des .\er7.te8 nebst Bemerkungen uberden liakJeriolog. Cbarakter des Nagelsclunnties. Wiesbaden, l!>SS.
tCVntralblalt fiir Gyn.-ikologio. l."^!^.
I Mon-itssobrifl fur GebnrUhulfe iind Gyn.^kologie, 1S<>5, Heft 3.
gTliorapeuliscbe Monatshefle, .Tuli IStVi.
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observers differed iu some points as to the exact action of alcohol.
Reinicke thinks that the alcohol in taking up the fat takes up the bacteria which are on the hands, and thus the bacteria can readily be washed away (abgespiilt).
Kronig is of the opinion that alcohol, from its dehydrating and astringent power, changes the skin so that the bacteria are held fast in the shriveled epidermis, and iu this manner that they are rendered inactive.
Ahlfeld, however, believes in the germicidal power of alcohol and submits this test: Thirteen people were made to wasii one of their hands for three minutes in hot water, using soap and a brush, at the same time the finger-nails were trimmed and cleaned. The hands were then rinsed in sterile water. Ahlfeld then removed some 0/ the dirt beneath the finger-nails with a small sjjlinter of wood, and dropped the latter into bonillon. Another finger-nail was treated in the same manner, and the piece of wood was dropped into asmalJ glass containing I ccm. of alcohol. The piece of wood was always small enough to be completely covered by the alcohol. The same individuals were then required to repeat the cleansing process with the other hand, but instead of using soap and water, the hand was scrubbed for one minute in alcohol, and inoculations were made from the finger-nails in the same manner as in the first series. The results were as follows : In those cases where tl^e cultures were made from finger-nails which had been washed in soap and water, colonies were present in every instance but two ; while in those cases where the alcohol was employed as the cleansing agent, the tubes remained sterile. In the twelve cases where the infected particle of wood was allowed to remain in the J ccm. of alcohol for two days after evaporating the alcohol and filling the vessels with bouillon, the latter were found to be sterile after a certain length of time. These tests certainly indicate that alcohol possesses germicidal power.
Schill and Fischer* found that when tuberculous sputum was mixed witli alcohol in the proportion of five parts of the latter to one of the former, the bacilli were rendered inactive, as was' shown by inoculation experiments. Yei>sint found that pure cultures of the tubercle bacilli were destroyed by five minutes exposure to the action of absolute alcohol.
1 might add that Green of Birmingham, England, has recently repeated the experiments of Reinicke and failed to confirm them, but his experiments are very few in number and his work is not yet completed. His communication appeared in the Deutsche med. Wochenschrift for June 4th.
As I remarked before, I have been unable to find any experiments bearing upon the efficacy of alcohol as a disinfectant for instruments.
The scheme followed by me in these experiments was as follows: A porcelain-lined tray ten inches long, two inches deep and five inches wide was first sterilized by dry heat. The instruments were then taken from the case and laid in the tray. Sfiuibb's absolute (98-99^=!^ per cent.) alcohol was poured on the instruments till they were completely covered, and then the tray was covered with a sterilized top. The instru
- Mittheilungen aus ilem K. Gesundheitsamte, Bd. II, 1884.
t Ann. de I'lnatitut Pasteur, t. II, 1888, p. 60.
ments were allowed to remain iu from a period ranging from fifteen to forty minutes. Only once, though, did they remain in the extreme limit; this was in the first series, tvhere a great many instruments were sterilized at one time, and necessarily the last instruments taken from the alcohol had been immersed for a much longer period, namely, forty minutes. Agar tubes were used for the inoculating medium. Each instrument was taken from the alcohol with a pair of long forceps (which had been sterilized by holding them in a flame), and after being plunged once in sterilized water it was then pushed down into the agar. I may say here that each tube was stabbed at least three times, and the majority of tubes were stabbed five or six times, so that every portion of the instrument which would be likely to come in contact with the eye iu an operation was rubbed against the culture medium. The instrument remained in contact with the agar from 20-30 seconds, which is longer than the knife remains in contact with the eye in the operation for cataract. The tubes were then placed in the thermostat at the temperature of the human body and allowed to remain for at least three days.
Fresh alcohol was of course used at every sterilization of the instruments. J have divided these experiments into three series. The first series consisted in the inoculation of one hundred tubes with eye instruments which had been sterilized in the way described. The following instruments were sterilized :
Graefe's cataract knives 7
Fixation forceps 6
Iris forceps 4
Iris knives 4
Lereich's forceps 1
Desmarre's pincette 1
Canaliculus knives 5
Scalpels and bistouries used in lid operations 12
Strabismus hooks 6
Lid retractors 4
Foreign body needles 4
Iridotomy scissors 2
Discission needles 4
Cystotomes 4
Scoops 2
Hooks for tearing capsule 3
Beer's cataract knives 6
And to these seventy-five instruments were added tweuty11 ve nails. These nails were three and one-half inches long and one-eighth of an inch thick. It may be said that the nails had been lying for nearly a year in an open box about twenty feet from where all the autopsies of the Johns Hopkins Hospital are made, and it is almost certain that they were in consequence infected, and doubtless many of them with pathogenic bacteria.
Out of one hundred tubes inoculated in this manner there were five infections. It matters little as to the nature of these infections, for, as I have said before, the probabilities are that almost any if not all bacteria when introduced into the eyeball will cause inflammation, so that I did not concern myself
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as to the properties of the bacteria found in tlie five infected tubes further than tliat tliree of the growths loolied as though they were air bacteria, from the fact that tliey were more or less colored, and cover-slips showed that they were very gross. One of the organisms somewhat I'esembled the staphylococcus albus, but I am of the opinion that it was too large.
I confess that I was surprised at the result, for I thought that I would get more air infectious, and also that the bacteria present on the nails at least would withstand the action of the alcohol.
Another more crucial test was then made: Seventy-five other nails were taken from the same box, and, as iu the first instance, they were sterilized by allowing them to remain from fifteeu to thirty minutes in absolute alcohol. Instead, though, of simply stabbing the agar, the nails were pushed into the agar as far as they would go aud allowed to remain there. The tubes were then placed in the thermostat for three days. Nine infections resulted, or, in other words, nine tubes had growths in them. Five of these growths were almost certainly the result of infections which occurred after the nails had left the alcohol ; two of these five were mold.
It is proper to say that all these experiments were made in the Pathological Institute, and furthermore iu two rooms adjoining the autopsy am2;)hitheatre. The conditions, then, for obtaining sterile tubes, or rather the conditions for testing the disinfectant properties of alcohol, were not favorable. It is not improbable that had these experiments been made in a room freer from chances of accidental infection from the air, that I would almost surely have gotten a greater number of sterile tubes. As it was, the results were surprising, especially in the case of the nails, aud for reasons stated above.
I have often heard the remark made that eye instruments, from the manner iu which they are kept, are not so ajit as are other instruments to be unclean. This is probably so, but it is no excuse for relaxing antiseptic precautions iiieye ojjerations. In order to ascertain how many instruments in a given number were clean, that is to say bacteriologically clean, I made the following test with fifty instruments taken at random from my own case of instruments and from the hospital case. Some of the instruments had been used the day before and others not for a week previously. After use the instruments are nsiuilly dipped iu warm water and then wiped with a soft linen rag and returned to the case. lustruments which had been treated in this way were taken, as I have said, at random from the case and plunged several times into agar tubes. Fifty experiments were made in this series, and in sixteen cases the tubes remained sterile. It is certainly surprising that sonuuiy sterile tubes followed these inoculations, and while this series shows that the measures we adopt for cleaning our instruments immediately after an operation possess decided advantages, it also goes to show that the majority of instruments, even when treated with our usual care, are infected. I nuido no examination of the infected tubes.
Thinking that a fitting conclusion to this work would be to ascertain the effect of absolute alcohol upon the pyogenic bacteria, I nuide the following experiments, fifty in number. Fifty eye instruments were first sterilized by iieat and then iufected with a jjure culture of the staphylococcus albus in the
following manner: A platinum loop was passed into the tube containing the growth of the staphylococcus albus, and gently drawn across the latter and withdrawn, aud rubbed over that jnirt of the instrument which is brought into contact with the eye. The instruments were then placed in a tray (which had been sterilized by heat) and one-half a pint of absolute alcohol was poured over them. Twenty minutes were allowed to elapse and each instrument was taken out with sterilized forceps, and that part which had been infected was plunged several times into an agar tube. The results were as follows: Forty-three tubes contained pure cultures of the staphylococcus albus. As to the seven tubes: one was sterile, one was infected with a large micrococcus, one contained a mold, another the bacillus subtilis, and the other three tubes contained bacilli, which were characterized by their very large size and by the luxuriance of their growth, and probably were air bacteria.
These results, to say the least, would seem contradictory when compared with the results of the experiments recorded in the first part of this paper, experiments which pointed to the undoubted value of alcohol as a disinfecting agent. We must consider this fact, though, iu this connection, that when we infect an instrument with an organism in pure culture the infection is exceptionally, and I might say unnaturally, viruuleut, or in other words, that no instrument which has been infected accidentally by exposure to the various conditions surrounding us in every-day life could be so septic as the instrument infected artificially or infected iu the manner described in the last series of experiments. The organisms are present iu far greater numbers aud they exist in their purity. Such a condition is practically never met with. The chance infection which happens to everything which is exposed for any length of time to the air is of the mildest character, even when the organisms are pathogenic, as compared to the infection with au organism in pure culture.
It is not unlikely that in the first and second series of experiments some of the instruments were infected with pyogenic bacteria, but these bacteria were present iu too small numbers and under conditions too uufavorable to withstand the action of alcohol.
It is evident that the alcohol iu the first and second series was ade(puite for disinfecting purposes, but it is equally true that alcohol is totally inade(iuate for disinfecting instruments which have been infected with the staphylococcus albus in pure culture, aud this might coutraiudicate our relying upon absolute alcohol for disiufcctiug instruments which had been used iu an operation when the pyogenic organisms are present in great numbers — as for instance, in panophthalmitis.
COKCLUSIONS.
1st. That iu a given number of eye iustrumeuts, by far the majority are infected by exposure to the air.
2nd. That absolute alcohol would seem a valuable disiufectaut for instruments infected under the conditions which ordinarily surround us iu every-day life. This (.H>nclusiou seems warranted by the results obtained iu the first and second series of exi>eriments. Attention may be called to the fact, too, that in the second series the nails were all without
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a doubt iufected, and it might be said that they had been exposed to conditions which, to say the least, were extraordinarily favorable for infection, so that this series, I think, is strongly suggestive that alcohol possesses disinfectant properties of no little value.
3rd. That the septic character of instruments infected with
a pure culture of staphylococcus albus is not altered by exposure for twenty minutes to the action of absolute alcohol.
I may add that the alcohol employed in these experiments was Squibb's absolute alcohol, which is supposed to have a strength varying from 98i to 99y\ per cent. This is the grade of alcohol which I use in operations.
PROCEEDINGS OF SOCIETIES,
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
Meeting of February 3, 1896. Dr. Flkxner in the chair. Uenonilizcd Melanotic Sarcoma.— Dr. Blumer.
Ur. Hloodgooi). — As I remember the clinical history of the patient from whom the specimens came, it was as follows: An old lady, some 70 years of age, presented herself to the dispensary last August, with a pedunculated tumor in the right axilla. The tumor was perhaps 3 or 4 cm. in diameter and its pedicle perhaps 2 cm. long, but not larger in diameter than the finger. It seemed to be a characteristic benign tumor. There were no palpable glands in any part of the body and no pigmentation in any part of the skin, although she had had a pigmented pedunculated wart in this region of her body for a great many years. The growth was removed by Dr. Nassau under cocaine. She came back in two months with enlarged glands in her right axilla and three darkly pigmented bodies on the skin near the scar of the primary operation. These glands were excised and they proved to be metastases from a melanotic sarcoma. Later the suj)raclavicular glands enlarged and were removed, and also showed metastases within two weeks. After the removal of these glands in the neck and axilla metastases appeared in the skin all over the body. This has been the second observation that we have made in the hospital of the sudden appearance of these nodules. The interesting features of the case were the benign apjjearance of the primary tumor, with no evidence of its infiltration through the pedicle into the axilla, and the sudden appearance of the metastases.
Dr. Blumek. — The autopsy was made over 48 hours after the patient's death, so that the body was not perfectly fresh. There were, however, no marked signs of decomposition. The site of the operation in the upper part of the chest was fairly clejir, but in the axilla extending to and involving the right breast was a solid mass of new growth which in spots showed pigmentation. This mass was about the size of a fist. The surface of the body, particularly of the chest and abdomen, was covered with small nodules, varying in size from that of a pea to that of a large bean. Some of them were attached to the skin, others were not. Some were pigmented, some were not. None of them were very darkly pigmented, the pigmented ones being rather light brown in color. There were very few metastases in the skin over the back and extremities ; none, if 1 remember correctly, on the arms and legs. On cutting into the abdominal muscles they were also found to con
tain small metastases, some pigmented, others non-pigmented.
The muscles of the back likewise contained a large number of
pigmented metastases. The peritoneal cavity contained a
moderate quantity of fluid, and both layers of the peritoneum
were studded with tumor metastases varying in size from a
miliary tubercle to a large bean. The most marked metastases in the peritoneum were in the dependent parts, particularly in the pelvis, over the bladder and around the appendix.
It seemed almost certain in this instiince that these were
metastases due to transplantation, that tumor cells had been
free in the peritoneal cavity and had gravitated to the lowest
part and become affixed there. The parietal layer of the pericardium contained no metastases, nor did the heart muscle
itself. In the visceral layer of the pericardium were two or
three pigmented metastases not larger than a pea. On the
surface of both lungs just beneath the pleurae were quite a
large number of metastases, most of them small, and the substance of the lungs also contained similar ones. In all these
situations the metastases varied both in size and color. The
liver contained but a single metastasis, which was only found
after prolonged search. The adrenals both contained small
metastases, as did also the kidneys and spleen. Thei-e were
no metastases in the bladder beyond those on the peritoneal
surface. The uterus was also free as far as we could make
out. In the right ovary was a nodule about the size of a pea.
The intestines showed numerous metastases on the peritoneal
surface, particularly along the mesenteric attachment, and a
few metastases were present in the mucous membrane of the
rectum, and in the mucosa here and there throughout the
intestines. There were one or two small nodules in the pancreas. The thyroid gland was normal on the left side, but
the right lobe was considerably enlarged and hemorrhagic.
Outside the hemorrhagic area, which occupied the center, was
quite a large area of tumor metastasis presenting the same
character as the metastases elsewhere. The periosteum of one
of the ribs, the 7th or 8th on the right side, and the pericranium in the right parietal region both contained suniU
metastases. The one in the pericranium penetrated some distance into the parietal bone, but did not pass into the cranial
cavity. The dura was entirely-free, but there were numerous
metastases in the pia-arachnoid, most of them of small size.
The brain showed a considerable number of metastases. They looked very much like snnill cysts with dark contents in the brain substance, but on cutting into them they were found to be pigmented metastases, and here the pigment showed up much better than in other parts of the body. A great many of the metastases were situated in the cortex. There were also
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numerous metastases throughout the brain substance. There was one moderately large one iu the right crus of the cerebrum and one of similar size in the right lobe of the cerebellum, and several scattered around and through the gray ganglia at the base.
The bacteriological examination simply developed the fact that the patient had a general staphylococcus infection, which was probably the immediate cause of death.
There are several points of interest in this case. Ju the first place the distribution of the metastases was of interest. The places iu which metastases are rare and in which they occurred in this case are in the genital organs (right ovary), in the pancreas and in the thyroid gland. A most curious clinical feature is that notwithstanding the extensive involvement of the brain there were absolutely no signs of brain involvement during life. It was noted after death that the right pupil was much larger than the other.
An interesting feature of this class of tumors concerns the melanin which causes the coloration of the tumors, and the origin of this melanin. Does it come from the blood directly, or is it a product of cell activity ? As far as I know there is nothing to prove that it comes from the blood. Iron has never, with jiossibly one exception, been found in the pigment, although this does not absolutely exclude a blood oi'igin, as in malaria we know that the pigment, which does not contain iron, comes from the blood. It seems probable, however, that the pigment in these cases comes from some secretory activity of the cells themselves.
Another point of interest in these cases is the changes sometimes found in the urine — the so-called " melanuria." In the urine, sometimes immediately after voiding, sometimes not until later, there appears a dark pigment. Such urine is found to contain a substance called melanin, but it is not the melanin that gives the dark color to the urine, but some other substance excreted at the same time. The melanin has been isolated, but when tested does not give the reaction. The substance found in the urine is not present solely in melanuria, but also in cases where there is an excess of indol.
Specimon of Adeno-Carcinoma of Pancreas.— Dr. Blumku.
This case came into the medical side with a diagnosis of brain tumor. The man had several symptoms of tumor of the brain, some inco-ordination and double choked disk, but no definite paralysis. On careful examination he was found to have a definite abdominal tumor in the median line suggesting an enlargement of the retroperitoneal glands. I do not know that a fiat-footed diagnosis was made during life, but it was suggested that it was perhaps a primary tumor of tlie pancreas. The autopsy was made 2-1: hours after the death of the patient. He was much emaciated and jaundiced. There were no metastases to be made out externally. On opening the abdomen the liver was found much enlarged, and there was a very large mass occupying the median line iu front of the spinal column, and a large mass in the left fiank. The parietal peritoneum was free from metastases. The visceral peritoneum showed a few metastases over tlie intestines, and one rather interesting metastasis over the appendix vermiforniis. This metastasis over the appendix had a cir
cumference about that of a dime and had completely obliterated the cavity of the appendix. It had evidently grown iu
from the peritoneal side and pushed the walla of the appendix
together, as the sections demonstrate.
The pericardium in this case showed metastases from a direct extension from the bronchial glands. The heart muscle was the seat of one metastasis, in the left ventricle. There were a large number of metastases on the pleurae and in the substance of the lungs. The bronchial glands on the right side had grown directly into the right bronchus, and there were numerous tumor nodules projecting into this.
The liver weighed some ten or twelve pounds. It contained a very large number of metastases which were distinctly umbilicated and had all the characteristics of carcinoma metastases. The common bile duct was entirely obliterated, being included in the large mass which lay in front of the vertebral column. The gall bladder was very much dilated and extended a hand's breadth below the margin of the liver. The right adrenal gland was entirely replaced by a mass of tumor substance not very much larger than the normal adrenal. In the 2)lace of the left adrenal there was a tumor mass about the size of a fcBtal head at term, and no sign of adrenal substance. This mass had grown directly into the left kidney, in which, beside this growth, there were a number of metastases about the size of a pea. There were similar small metastases in the right kidney. The spleen was free from metastases, as were the other organs, with the exception of the lymph glands and the cerebellum. The periimncreatic glands were very much enlarged and formed a mass the size of a cocoauut, which lay in front of the vertebral column. No trace of the pancreas could be found; it had been entirely replaced by the tumor mass. No trace of it could be found microscopically.
The meninges showed no metastases, nor did the cerebrum, but springing from the dura lining the right posterior fossa of the skull and compressing the right lobe of the cerebellum, there was a tumor about the size of a pigeon's egg. This did not directly compress anything beyond the cerebellum. This, of course, accounted for the cerebral symptoms which the man had during life
It seems to me that the most interesting point iu this c-ase is the fact that both the pancreas and the adrenals were entirely thrown out of function without definite symptoms resulting therefrom. The man, as far jis had lieen made out, had certainly had no symptoms of Addison's disease during life, and the urine had been free from sug:ir. Of course there have been a number of c;ises of Addison's disease reported in which there was absolutely no dise;kse of the adrenals, aud, again, there have been Ciises of total destruction of the adrenals in which there were no symptoms of Addison's disease. There iuive likewise been ctises of entire replacing of the pancreas with new growth without any diabetic symptoms. The ipiestiou arises whether or not the tumor cells arising from tli < different organs can take on any of the functions of the ■ . ■■ from which they grow, whether they can keejMip theso-ram-ii internal secretion of the orgtins which is necess;iry for the preservation of health. The microscopical apiv?arance of the tumor suggests that it came from the jiaiicroas. It is an adeuo-carciuoma. Acconliug to the present uuderstAndiug of
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metastasis, the cells of the tumor occurring in the adrenal should have taken on the character of pancreatic cells and not of adrenal cells, in which case the internal secretion of the adrenals would have been entirely lacking. The question whether in such a case the cells in the pancreatic tumor and in the adrenal tumor secrete the substance normal to the cells of each of these organs is one which needs further investigation.
Discussion.
Dr. Flexnek. — The example of generalized melanotic sarcoma presented by Dr. Blumer has many points of interest. I wish to add a word regarding the pigments of these growths. It is at least probable that this pigment has the same origin as that present normally in the skin, hair, choroid coats of the eye and substantia nigra of the brain. Until the chemical nature of the normal pigments is more fully investigated and the melanin of this class of sarcomata obtained in a purer state than has been hitherto done, it will not be possible to state definitely what their relation is. We are comparatively well informed concerning the origin of certain of the pathological pigments, and indeed, although less fully, of their chemical conqwsition. We find in given cases no difBculty in referring certain pathological pigments to the bile and others to the blood. Among those derived from the blood are at least several quite well characterized kinds which iU'e yielded by the coloring matters of the red blood corpuscle — ha?matoidin, a definite chemical body hwinafiiscin, less well defined, being devoid of iron ; and hasmosiderin, a chemical complex which contains iron in a readily demonstrable form. The dark pigment found in the blood, organs and parasites themselves in malaria and to which the name " melanin " is also applied, differs chemically, according to Carbone, from the pigment of melanotic sarcomata.
The ])igment in these tumors is deposited in smaller part witliin the tumor cells than in the interstitial framework of the growths. Where the (piautity of coloring matter within the tumor cells becomes considerable the cells tend to degenerate, and thus it happens that areas occur which -apparently consist of pigment only. The color of the latter varies considerably, and in certain tumors or in some metastases of otherwise dark tumors it is of a light brown or almost yellow color. So far as we are informed at present the ])igment is produced — antochthonously, if you please, by the tumor. However, other views have prevailed at different times. Schmidt has drawn attention to the circumstances that a small portion of the pigment in nearly all melanotic sarcomata gives the reaction for iron, that the pigment is present in the connective tissue septa as well as in the tumor cells, that, further, at times there is considerable pigmentation of organs at a distance from the tumors, and he has used these facts to support the idea that tlie jjigment may be formed elsewhere, and after partial loss of the iron reaction be transported to ajid deposited within the tumor. He thinks that he has found additional support in the observations of Wagner of the existence of masses of pigment in the heart and kidneys independent of tumor formation in cases of melanotic sarcoma of the skin associated with numerous actual metastases, and of Oppeuheimer, who noted iu melanotic skin sarcoma dis
coloration and pigmentation of the skin, mucous membranes,
serous membranes and adipose tissues. A more probable
exjilanation of the iron-containing pigment is that it is
derived directly from the transformation of the htemoglobiu
of the red blood corpuscles, as actual hemorrhages are not
uncommon in these tumors.
The chemical analyses of the dark pigment (melanin) have yielded results somewhat at variance with one another. Iron has been detected in it (Eiselt, Nencki-Oppenheimer, Morner, Dressier) by some and missed by others (Virchow, Berdez, Nencki). Hence the question of a direct blood origin of the pigment is more or less still a disputed one. An interesting observation has been made by Berdez and Nencki and by Morner, who found in melanin a large percentage of sulphur, in some instances exceeding 10 per cent. Even this observation has been variously interpreted as proving and as disproving on the one hand origin from the blood, and on the other autochthonous formation. Finally Joos has conceived that the sarcoma cells produce the pigment from the colorless albuminous bodies of the blood plasma. The conclusions which have been arrived at by Abel and Davis (The Journal of Experimental Medicine, 1896, Vol. I., No. 3) in their painstaking study of the pigment of the negro's skin and hair are as follows: The pigment isolated from the containing granules contains only the merest trace of iron — so little, in fact, that it must be considered when entirely pure as free of iron. They further conclude, from the results of their work, that the jjigment is not a derivative of hajmoglobin, but probably is ultimately derived from the proteids of the parenchymatous juices.
NOTES ON NEW BOOKS.
Ueber (lie Beziehiinuen der Lcucocyten zur Bacterieiden Wiikuiig (le•^ Blutes. By Maktin Hahn, Assistant at the Hygienic Institute at Munich. Munich, lb95, Olilenbourg, pp. 1-42.
In this monogra|>h of Dr. Hahn's presented to the K. LudwigMaximilian University, pro venia legendi, a series of investigations are reported reganling tlie relations of the leucocytes to the bactericidal action of the blood. The article opens with a discussion of previous work on the same subject. The objections made by Metscbnikoff to the views advanced by tlaukin and Kantliack are considered, and the researches of Denys and Havet, and of Vaughan and McClintock, arc referred to. Halm's work follows <lirectly ui)on some exiierinients previously made by Bucbner. He injecte<l Aleuro7uUbrei mio tin; pleural cavity of rabbits and obtained from them afterl'4 hours, blood serum and defibrinated blood, as well as the pleural exudate. The latter was frozen and quantitative bactericidal experiments made with it. He found like Schuster that the exudate rich in leucocytes far exceeds the serum in bactericidal activity, due to the increased amount of labile bodies present iu it, bodies which jirobably have their origin in the leucocytes. He made further experiments with isolated leucocytes, jiroving that the addition of a salt-solution extract of leucocytes to ordinary blood serum deiinitely increases its bactericidal powers. An interesting exception lo this rule was the fact that cholera bacteria appear to resist markedly the action of leucocyte lluid obtained by means of Aleumnatbrci. This the investigator attributes to two causes : (I) the presence of small amounts of aleuronatbrei diminishes the bactericidal power of the serum, and (2) the
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191
serum after the destruction of the alexines is not favoraVjle for the development of comma bacilli.
Further experiments were made with histon blood with the object of determining whether the bactericidal activities depend upon decomposition products or upon actual secreting products of the leucocytes. In histon blood, in contradistinction to defibrinated and coagulated blood, the leucocytes are preserved in good condition, and it was found that in it or its plasma the same bactericidal activity was developed as is characteristic of the defibrinated blood or serum of the same animal. Phagocytosis was excluded inasmuch as the plasma, freed from cells, was just as active as the blood containing leucocytes. Hahn concludes, therefore, that the bactericidal activity of the serum does not depend upon products resulting from the destruction of the leucocytes, but much more upon substances representing actual secretions of these cells. The article closes with some interesting considerations upon the relation of the substances under consideration to natural immunity and to therapy, and some emphasis is laid upon the possibility of increasing them artificially within the body. Those interested in this field of investigation will be well repaid by a perusal of the original article. L. F. B.
DIABETES MELLITUS.*
BULLETIN
THE JOHNS HOPKINS HOSPITAL.
Vol. VII.- Nos. 68-69.
BALTIMORE, NOVEMBER-DECEMBER, 1896.
+++
Contents
Alveolar Sarcoma of the Cerebellum. Clinical Report. By
Henry M. Thomas, M. D. — Remarks on Anatomical Relations of the Cochlear and Vestibular Nerves. By L. F.
Barker, M. B. — Pathological Report. By Simon Flexner,
M. D., - - - - - - 193
John Bell, Surgeon. By Walteh B. Platt, M. D., - - -198
Concerning Neurological Nomenclature. By Lewellys F. Barker, MB.,- - - - - - - - - - 200
A Complete Duplication of the Left Ureter from the Kidney to the Bladder. By Otto Ramsay, M. D., - - - - -201
Notes on Congenital Motor Defects of the Eyeballs (Congenital Paralysis of the Ocular Muscles). By Harry FriedESWALD, A.B., M.D., 202
Malarial Infection as a Source of Error in Snrgical Diagnosis.
By W. W. Russell, M. D., - 204
The Agglutinative Action of the Blood Serum of Patients
Suffering from Typhoid Fever. By E. Bates Block, M. D., 206 Proceedings of Societies: Hospital Medical Society, -------. 208
Case of Addison's Disease— Death during Treatment with the Suprarenal Extract [Dr. Osler] ; — Treatment of Ectopic Pregnancy by Vaginal Puncture [Dr. Kelly].
Notes on New Books, 211
Books Received, 212
Index to Volume VII, --------- 212
ALVEOLAR SARCOMA OF THE CEREBELLUM.
CLINICAL KEI'ORT. By Henry M. Thomas, M. D., Neurologist to the Johns Ilopkins Hospital and Clinical Profetior of Nervous Diteate*, John* Hopkint rnitertilg.
REMARKS ON ANATOMICAL RELATIONS OF THE COCHLEAR AND VESTIBULAR NERVES. By L. F. Barker, M. B., Assistant Resident Pathologist, The Johns Hopkins Hospital, and Associate Professor of Anatomy ,John« Hopkini UnipertU]/.
PATHOLOGICAL REPORT. By Simon Fle.xnkr, M. D., Ilesidsnt Pathologist, The Johns Hopkins Hospital, and Associate Professor of Pathology, John* Hopkin* UnirfrtHy.
The patient whose liistory I wish to bring before you this evening, I saw through the courtesy of Dr. Iliram Woods, who referred her to nie on October 17, 180.">. Iler history in brief is as follows :
Miss Bhuik, xt. 30, school-teacher. She complained of difficulty in walking, of deafness and difficulty in seeing.
Eamily history: fatiier died of Bright's disease, one brother lias epilepsy, eight brothers and sisters died in infancy.
Personal history: patient is the youngest of 13 children. She was always a delicate child, although she suffered from no especial illness. She played very little with other childreu, as she easily became tired. During iier school life she had several nervous breakdowMis, and when IS was thought by a prominent physician of this city to have delicate lungs. Miss Blank has been engaged in teaching for nine years, but has lost more or less time every year. At different times during this period
her voice has failed her for ten days or two weeks, but not, however, during the last three years. She has fainted several times. Three years ago she began to complain of very severe headache, which was brought on by any excitement, especially laughing. The pain was very severe, but lasted only a few moments; if it had lasted longer she thought she would have become unconscious. These attacks of pain recurred nearly every day until August, 1805, when Dr. Woods gsive her glasses, from which she derived some relief. Jliss Blank stated that she had at times momentary losses of vision. esj>ecially of the left eye, but sometimes of lK>th. She thought that this depended upon whether she was worried or excileil. For about a year the patient has had some difficulty iu walking; at times she staggered and walked :is if she were drunk. I>jist June, if she walked even a block, the exertion cansetl a severe headache.
At the time of her first visit to me she said that she walked much better than she did six mouths before. Sliecomjilained at times of tremor in the legs.
Other than the headache, she has suffered from no i)ain, but has had a sensation of tingling in the feet and of numbness in her nose and mouth. Since January, 1895, she has become more or less deaf. She has not complained of double vision, but for a week or two previous there has been noticed a slight jerking of the ej'eballs.
She complained of some difficulty in passing her urine, but of no lack of control.
Latei", at other times, I learned from her mother and sister that thei-e had been a gradual change in ^ Msposition ; they had noticed ♦^^■•' " " i.xoibthan a year. She had become fretful and unreasonable and hard to get on with.
The examination, at her first visit, gave the following result: patient speaks usually in rather a slow manner, but at times rapidly and loud. The speech is not scanning and her articulation is distinct.
Eyes: there is a well-marked rotary nystagmus, which is increased in looking towards the left. Muscular movements of eyes are normal except that lateral movements seem to tire her ; she is unable to hold her eyes either to the right or left for any length of time. Pujjils are round and equal, and they react to light and during accommodation. They dilate equally in a dim light. The fields of vision are slightly contracted; colors are seen in the normal order.
Vision practically normal.
Ophthalmoscopic examination shows a well-marked ueuroretinitis in both eyes.
During the examination the patient on several occasions complained that she had become blind; this blindness lasted for one or two moments. She was quite deaf in her left ear, being unable to hear a watch on contact. In the right ear she heard fairly well. Objectively, sensation was undisturbed in face. The facial muscles, those of the tongue and the muscles of mastication all acted normally. Muscular strength of arms was good and there was no tremor. She wi'ote fairly well, although she says that at times her writing is very poor and that her hands often shake. Deep reflexes are active. In standing there is a tendency to sway, and if the eyes be closed she staggers and if not steadied would fall to the left. Her walk is unsteady and tumbling, somewhat like that of a drunken man.
The muscular strength of legs is good, no noticeable tremor; the deep reflexes are active.
These symptoms suggested strongly the presence of a brain tumor, and that was the diagnosis, although the possibility was entertained that the case might be one of multiple sclerosis combined with hysterical symptoms.
She came to see me, October 18th, complaining of a very severe headache. On October 25th, while walking and feeling as well as usual, she fell on the street. She went home and went to bed, and after that time she never was able to walk at all. AVhen she got up she would sway, and it seemed to be impossible for her either to stand or to walk. Soon after going to bed she complained of very intense headaches, sometimes darting down the back of the neck and behind the
ears. These headaches were controlled fairly well by hot applications and a capsule containing 5 grains of phenacetin and i of a grain of codeia, repeated when necessary. The hearing in her right ear gradually became less and less acute, and this loss of hearing was accompauied by very annoying ringing in the ear. In the early part of December she became quite deaf, being unable to hear any sound, either by bone conduction or in any other way. Dr. Woods examined her again and determined that the deafness was due to some disturbance in the nervous mechanism. Pier vision seemed to be not quite so acute, although she could still read. At this time Dr. Woods noticed a beginning atrophy of the optic nerves. There was no paralysis of the eye muscles, but it seemed to be very difficult for her to move her eyes up or down, or in or out. She would not look to one side or the other for any length of time. There was no ptosis. The nystagmus varied from day to day. After she became deaf, all communication was carried on by means of writing. As she became blind we had to write in larger and larger characters, and finally vision left her entirely. After this the only communication was by signs ; she would ask questions that could be answered by "yes" or "no," and we would press one or the other hand in answer to the questions. Pain became less toward the last. She had two or three attacks of vomiting, and in the last two weeks had several slight convulsions, and on one or two occasions she complained of a sensation as if she were falling out of bed. A little more than two weeks before she died she developed a complete right facial paralysis. She never knew that her face was paralyzed, and I did not make an examination by electricity, but I am confident from the character of the paralysis that it was peripheral. She had a little fever every now and then and her pulse got a little more rapid. She finally died quietly, being perfectly conscious up to within half a minute before her death, when she spoke and tried to give her attendants some directions.
After she went to bed there was no doubt that the patient suffered from a tumor of the brain. Dr. Osier saw her shortly afterward, and he confirmed the diagnosis of brain tumor. There was very little to assist in localization at this time. The patient had a jjeculiar unsteadiness while standing, suggesting cerebellar trouble, and she had deafness in one ear, the other ear not having become markedly deaf. As that ear began to get deafer and deafer, remembering some of the later investigations as to the association of the posterior pair of the corpora quadrigemina with the central tract from the auditory nerve, and considering also the facts brought out by Nothnagel in his well-known article on diagnosis of tumors of this region, I believed that the growth involved the corpora quadrigemina, and when the patient became quite deaf I felt still more confident that that was the case. When the right facial paralysis developed it was not easy to explain it, but I thought that it might be a pressure symptom.
Ever since Nothnagel in 1889 called attention to the symptoms which tumors of corpora quadrigemina produced, a great deal of interest has centred around such growths. The localizing characteristic of tumors in such a position he stated as being an uncertain swaying gait, especially when it occurs as the first symptom combined with an ophthalmoplegia affecting
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both eyes but not quite symmetrically. He says nothing about the loss of hearing in such cases.
In the Archiv filr Psychkitrie for 1894 there are three articles following each other on tumors of the corpora quadrigeniina. It is interesting to note the different points of view taken by these authors. The first article is by Bruns, of Hannover, in which he endeavors to establish the points in diagnosis between tumors of the corpora quadrigemina and those of the cerebellum. He had a case of each in which the symptoms were very similar, in fact they both presented the combination of symptoms which Nothnagel had considered as characteristic of tumors of the corpora quadrigemina.
Bruns concludes that this complex of symptoms is not to be relied upon in making a local diagnosis between the cerebellum and the corpora quadrigemina, but he thinks, however, that the order in which the symptoms occur and their relative prominence may give some indication. Thus, if the ophthalmoplegia is prominent and the first symptom, and the sixth pair of cranial nerves be not involved, and the ataxia develop later, the corpora quadrigemina are implicated; whereas, if the ataxia occurs first and is jirominent, and the ophthalmoplegia includes the sixth nerve, the tumor is more (irobably in the cerebellum. He does not mention loss of hearing as a localizing symptom.
The second article is by Ilberg, in which he rejiorts a case of gumma in the corpora quadrigemina. The case is reported fully, but he makes no general remarks.
The third, and for our purpose the most important article, is by Ernst Weiuland; he reports a case and considers the relation of the posteria corpora quadrigemina to disturbances of hearing. Including his case, he was able to collect nineteen cases of tumors of the corpora quadrigemina, in nine of which there were disturbances in hearing, and he thinks that if the examinations had been made more thoroughly there would have been fewer negative cases. Weiuland concludes that nerve deafness is an important focal symptom, especially if taken in connection with cerebella ataxia and ophthalmoplegia. When the deafness is unilateral the growth is on the opposite side.
Gowers also states that double nerve deafness should suggest disease of the corpora quadrigemina. In Bruns' case no note is made in regard to the hearing, although it is stated that the left tympanic membrane was defective. The case was of a boy two and a half years old. In Ilberg's case there was marked deafness on the right side, which he explains by slight infiltration of round cells in the right auditory nerve. The tumor, however, was in the left posteria corpora quadrigemina, and so agrees very well with Weinland's proposition. Dr. Barker has kindly consented to give you the result of the latest investigation in regard to the central course of the eighth nerve, and Dr. Flexuer will demonstrate the tumor which was found in the case which I luive reported.
=REMAKKS on the ANATOMIC Variations OF THE Cochlear and Vestibular Nerves
Dr. L. F. Barker. — Our newer knowledge of the anatomy of the rhombencephalon and mesencephalon, and of the origin and course of certain of the nerves connected with these,
throws so much light upon the functions of these parts and yields so many data from which conclusions may be safely drawn in clinical cases, that a few remarks concerning certain of the points with particular reference to the cochlear and vestibular nerves, may not be out of place in connection with this interesting report which Dr. Thomas has just made.
The nerve formerly called the eighth cranial, acoustic, or auditory nerve, has, since the investigations of Duval, Bechterew and Forel, been known to consist, in reality, of two nerves which are anatomically separable and functionally, almost, if not entirely, independent, the Nerviis cochlew and A'errus vestibuli. Both these nerves, as far as we at present know, carry only centripetal impulses, and the bipolar cell-bodies of the neurones of which they are made up are situated entirely (with possibly a few exceptions) outside the main body of the central nervous system, in ganglia which embryologically correspond to the ganglia on the posterior roots of the spinal nerves. The ganglion for the N. cochlea is the ganglion spirale; that for the N. vestibuli is the ganglion vestibulare.
The Cochlear Nerve. — The dendrites,* or, if preferred, distal axones, of the cell bodies in the ganglion spirale grow out to the organ of Corti and end there free among the cells of that organ, one bundle of them corresponding to the nervus saccularis going to the saccule. The impulses beginning in these processes pass through the cells in the spiral ganglion, are then transmitted by their axouos which run in the cochlear nerve to the junctiou of the medulla with the pons. At the point where the X. cochlear arrives in the central nervous system, its constituent fibres enter into relation with certain definite masses of grey matter, in which are situated the cell bodies and dendrites of large numbers of sensory neurones of the second order.
Through the work of Flechsig and his pupils, and particularly through the researches of the brilliant young Leipzig investigator, Ilaus Held, we have, of late, been made tolerably well acquainted with the exact relations of the peripheral neurones of the acoustic path to those situated in the grey matter inside the central nervous system. The two most important groups of the sensory neurones of the second order belonging to the cochlear nerve are (1) the nucleus N. cochlearis dorsalis (nucl. tuberenli acustici) and (2) the nucleus N. cochlearis ventralis. The fibres of the cochlear nerve entering the latter nucleus, in part end there, in part give off collaterals and go on further directly into the trapezoid body, coming into relation with the superior olivary nucleus and the nucleus of the trapezoid body of one or both sides. The fibres may end in these nuclei, or some of them may, as is shown in this diagram, constructed according to Hold's description, pass on through the lateral lemniscus to masses of grey matter situated higher up in the central nervous system. Similarly those axones of the cochlear nerve reiiching the dorsal nucleus of this nerve, may eud in it by free branching among its cells or their dendrites, or may juiss on by it
- The fibres of the cochle.ir and vestibular nerves peripheral to
the ganglia, like those of nearly all peripheral sensory neurones, are nioilullatod and histoloirically inilistinjrnishable from axones, though ombryologioally and pliysiologicAlly they may |>erhaps be looked upon as dendrites.
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[Nos. 68-69.
into the s/ri(B meduUnrcK, those bundles of medullated fibres which make up the transverse white bands visible on the floor of the fourth ventricle about its middle, spoken of sometimes in the text-books as the strice acufsticcB. The constituent fibres of the striaj medullares decussate for the most part in the middle line and dip down into the depth to become involved in the superior olivary complex, the impulses they bring finding their further course forwards, in all probability, along the fibres of the lateral lemniscus.
The axones from the cell bodies situated in the ventral cochlear nucleus go to make up a large part of the trapezoid body (corpus trapezoideum) on each side. Many of the axones of the neurones situated in the dorsal cochlear nucleus also dip down mesial to the corpus restiforme, and come into relation with the superior olivary nucleus and lateral lemniscus of the same or of the opposite side. The fibres of the lateral lemiirscns run forward through the pons and reach the level of the inferior colliculi of the corpora quadrigemina, in which many of the fibres terminate by free endings; some of the fibres of the lateral lemniscus run also into the grey matter of the superior colliculi to terminate among the dendrites of the nerve cells situated there. A large number of fibres pass beyond the corpora quadrigemiua in a bundle lying along with the brachium quadrigeminum inferius, mesial and ventral to the pulvinar, and dorsally and laterally as regards the red nucleus of the tegmentum; this bundle (the direct acoustic cortical path of Flechsig and Held) becomes joined by a bundle from the medial geniculate body and passes directly through the internal capsule to a definite cortical area in the temporal lobe. This area, which corresponds to Flechsig's Horsphare, is represented mainly by the gyri temporales transversi, especially by the anterior, and so is largely hidden in the wall of the fossa Sylvii, reaching the external surface of the hemisphere only at that part of the gyrus temporalis superior which is in contact with the gyri transversi, /. e. its middle third.
In the lateral lemniscus in addition to the fibres passing from below upward, there are numerous axones which pass from above downward, belonging to neurones in the various grey nodules of its path, so that the grey masses of the corpora quadrigemina, the nucleus of the lateral lemniscus, the superior olivary nuclei of the two sides, the nuclei of the trapezoid bodies together with the primary nuclei of termination of the cochlear nerve, are provided with conducting paths as shown in the diagram, going in both directions, so that the manifold interchange of impulses among these nuclei is fully provided for.
One point of especial interest is the absence of any direct connection of the cochlear nerve with the cerebellum, this nerve being quite different from the vestibular nerve in this respect, as I shall point out in a few moments. The demonstration of the important connection of the auditory path with the inferior colliculi of the corpora quadrigemiua, we owe to Flechsig, who further asserts that the fibres of the brachium quad, inferius pass to the auditory centre in the temporal lobe chiefly by way of the medial geniculate body.
The cochlear nerve becomes connected with the superior colliculi of the corpora quadrigemiua in at least two ways :
(1) through fibres which pass from the lateral lemniscus directly into the superior colliculi, and (2) through fibres which pass from the superior olivary complex through the fasciculus longitudinalis medialis (posterior longitudinal bundle) to the nuclei of the oculomotorius nerve.
The superior olives are connected with the nucleus N. facialis and with the nuclus N. abducentis. An anatomical substratum for the acoustic eye reflex can thus be easily constructed, inasmuch as the superior colliculi of the corpora quadrigemina have to be looked upon as the centres directly in control of the movements of the eye muscles.
The development of the superior olivary nucleus in the animal series appears to stand in a more or less direct relation to the acuteness of the hearing of the animal. It is small in man, and Flechsig in his lectures amusingly remarks, "Wir spitzen auch die Ohren nicht." It is stated that animals which have no cochlea also lack trapezoid body, lateral lemniscus and the inferior colliculi of the corpora quadrigemina.
The Vestibular Nerve. — The distal processes of the neurones, the cell bodies of which are situated in the ganglion vestibulare, pass to the ampulla of the semicircular canals and to theutricle. The central processes or axones, which are thicker than those of the cochlear nerve, unite to form a thick bundle which runs along with the cochlear nerve, but is, even macroscopically, as a rule, distinguishable from it. On entering the central nervous system the vestibular nerve passes mesially as regards the corpus restiforme, though laterally as regards the tractus spinalis nervi trigemini, and probably comes into relation with the nucleus nervi cochlearis ventralis only through collaterals given off in passing. There are four distinct nuclei of termination (or of reception) of the vestibular nerve, three of them corresponding to the grey matter in the floor of the fourth ventricle known as the area acnstica. Of these three masses of grey matter the upper one is known as the nucleus N. vestibularis superior (Flechsig, Bechterew), often spoken of in the German text-books as the main nucleus (Hauptkern). The lower nucleus is called the nucleus N. vestibularis medialis (Schwalbe), the " hintere acusticus Kern " of the Germans, while the large-celled nucleus of Deiter's, situated laterally and between the two, is known as the nucleus N. vestibularis lateralis. In addition to these three nuclei of reception a fourth has to be considered, namely the mass of grey matter adjacent to the bundle of fibres of the vestibular nerve known as its descending root (ascending root of Roller); this nucleus is called the nucleus N. vestibularis spinalis.
In these four nuclei are situated the cell bodies and dendrites of sensory neurones of the second order belonging to the vestibular paths. Impulses can arrive in these nuclei besides from the vestibular nerve from numerous other sources; thus for example the nucleus N. vestib. lateralis receives numerous axones from the nucleus fastigii of the other side of the cerebellum. The large axones from a portion of the cells in Deiter's nucleus pass down into the anterior and lateral columns of the spinal cord, so that it is not impossible, as has been suggested, that Deiter's nucleus may represent a way station between the cerebellum and the cord and perhaps, througli the anterior horn cells, the muscles.
The axones of the sensory neurones of the second order in
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these vestibular nuclei pass iu large part to the medial lemniscus of the opposite side and to the cerebellum; some of them enter the fasciculus longitudinalis medialis. Those which go to the cerebellum may be divided, according to Held, into two groups: (a) a bundle passing from the nucleus N. vest, superior, ending in the central grey masses of the cerebellum ; and (b) bundles of fibres passing from the nucleus N. vest, medialis along with the corpus restiforme into the cerebellum. The contrast between the relations of the vestibular nerve and those of the cochlear nerve to the cerebellum is thus seen to be striking. Flechsig believes that the axones from the vestibular nuclei which enter the fasciculis longitudinalis medialis pass forward to come into relation with the eye-muscle nuclei, possibly through the superior colliculi of the corjjora quadrigemina. It is his opinion that the impulses passing along these fibres may have to do with the maintenance of the eyes in certain positions. Professor Osier has just referred to the fact that in diseases of the semicircular canals or of the vestibular nerves there may be an accompanying nystagmus, and we now have the promise, at least, of the anatomical explanation of this symptom.
It is generally conceded that the impulses coming from the semicircular canals play an important role as regards the position and equilibrium of the head, and the connections of the vestibular nerve with the cerebellum are of especial interest in this regard.
In the case before us a remarkable symptom-complex has been presented. According to Dr. Thomas and Dr. AVoods, the patient has suffered from headaches, giddiness, deafness, disturbances of equilibrium, disturbances of vision, interference with the movements of the eye muscles, including nystagmus, vomiting, convulsive seizures, right-sided facial paralysis, with all which there has been complete retention of consciousness. In connection with the more recent knowledge of the structure of the rhombencephalon and mesencephalon, such a group of symptoms is of very great significance, and I shall be extremely interested in learning the results of the pathological examination which Dr. Flexner has made.
Pathological Report by Dk. Flexner.
I was invited by Dr. Thomas and Dr. Woods to perforin the autop.sy in this case. Tlie subject was a well nourished young woman. The examination was limited to the brain, as consent was not obtained for a complete autopsy.
The soft tissues of the scalp were lax and the skull-cap was of moderate thickness. The dura mater was entirely free from adhesion to the calvarium. The superior longitudinal sinus contained Iluid, dark blood. Internally the dura mater adhered to a tumor mass which projected on the left side into the inferior fossa of the skull. The tumor measured Gx^x-i cm. and was attached to the median side of the left lateral cerebellar hemisphere, its growth being directed forwards. The firmest attachment of the tumor was to the dura forming the internal periosteum of the skull in the floor of the inferior fossa, and when separated from this, the latter presented a shaggy and torn appearance.
The tumor had exerted pressure hiteraliy upon the left corpora ([uadrigeniina, the rigiit being but little if at all involved
in the compression. There was no growth directly into these parts. The tumor had also flattened the left half of the pons almost to the median line. The left crus cerebri was pressed upon, particularly on its superior surface, and the left superior peduncle of the cerebellum partially flattened. The middle and right lobes of the cerebellum were free from the tumor and the effects of direct pressure.
Upon section of the tumor and left cerebellar hemisphere, the former was seen to extend throughout the entire thickness of the cerebellum and to be continuous both with the cortical and medullary portions. In external appearance the tumor was not so unlike the cerebellum, being distinctly lobulated. It had a strikingly opaque yellow color, and in consistence was firmer than the cerebellum itself, being somewhat moveable independently of the latter.
The central portion which made up the greater part of the tumor was mottled red and grey, while the cortex alone exhibited the yellow color already referred to. Within the tolerably soft tumor, firmer nodules the size each of a bean existed. These were most numerous nearer the cerebellar connection than elsewhere.
The tumor growth extended beneath the dura where it covered the petrous portion of the temporal bone. The bone itself was, however, quite smooth.
The seventh and eighth nerves on the left side were pressed upon and much flattened. Those of the right side appeared small and atrophied. All the ventricles of the brain were dilated and contained an excess of clear fluid.
Under the microscope the tumor varied less in its diflfereut parts than might have been supposed from the variations iu its gross appearances. The softer parts were (Edematous, and the elements composing the tumor more or less widely separated by fluid. The tumor itself was very cellular, the connective tissue framework being rather scantily developed. A few thick bands existed in the denser part of the growth, to which, indeed, these may have owed iu part their greater consistency, and within these calcareous concretions of small size were occasionally found. The chief cells of the tumor were of an epithelioid type, the form being for the most part an elongated oval. These cells were gathered into groups, often iu whorls, separated by thinner and thicker strands of even more elongated cells with nuclei of the same general character as those in the enveloped cells. The amount of intercellular substance between the enveloping cells might belittle or much, and in any case it was homogeneous and not fibrillated; or it might be absent altogether. Thus it happened that quite distinct alveoli came to be formed, and rarely the cells occupying an alveolus were flat and scale like and closely approximated. Smaller cells of the lymphoid type also existed, forming independent round or irregular groups, but more often giving rise in the neighborhood of vessels to elongated masses. Blood-vessels were in certain situations quite abundant, but they were not distributed with auy regularity through the tissue. In some places the tumor was not remarkably vascular. It should be said that painstaking search for processes such as are found associatetl with the colls in gliomata failed to reveal anv such. From this description the diagnosis of alveolar sarcoma seems justified. The tumor is believed to have
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spruug from the cerebellum, although no other evidence for this belief than its position and attachments are at hand.
Dr. Thomas. — It is seen from the report of autopsy that the tumor involves the left lobe of the cerebellum, pressing upon the corpora quadrigemiua, but not involving them by actual ingrowth, and that the auditory nerve of that side is in very close connection with it. This relation may account for the early deafness in the left ear, although it is difficult to understand how the facial nerve on that side could have escaped. We are forced to believe, unless a careful microscopical examination shows some central changes, that the deafness in the right ear and the paralysis of the right side
of the face were distant pressure symptoms, a very unsatisfactory explanation.
The diagnosis of tumor of the corpora quadrigemiua was based on the combination of double nerve deafness, the cerebella ataxia, and the weakness of the eye muscles, although there was no actual paralysis. The absence of ophthalmoplegia was explained by the supposition that the tumor was in the posterior rather than the anterior corpora quadrigemiua. I believe that under similar circumstances the same diagnosis would be justified, although the possibility which is ever present when a local diagnosis has been made, of the disease being somewhere else, would be still more prominent.
JOHN BELL, SURGEON.
By Walter B. Platt, M. D. {Read before Ihe Johns Hopkins Hotpital Historical Club, May 11, 1896.)
One of the best men of his profession of the latter part of the eighteenth and the early part of this century was the man who signed himself John Bell, Surgeon. He was an eminent teacher without a university, a surgeon for years without a hospital, and a teacher with enthusiastic pupils in a school made mostly by his own efforts.
Had he followed the example of many notable Scotch surgeons of to-day and gone to London, where he had plenty of admirers, he would have leceived more honor than others of his townsmen who remained in Edinburgh and succeeded in gaining the attention of those who, with singular blindness, passed him by.
Bell, the second son of the Kev. William Bell, was born in Edinburgh on the 12th of May, 176.3, and received his education principally at the High School of his native city. His early liking for medical studies was very evident, and as soon as possible he entered as a pupil of Alexander W.ood, a wellknown surgeon.
He became a Fellow of the Royal College of Surgeons of Edinburgh, and in 1780 was Lecturer on Anatomy and Surgery. He then made a large number of dissections and founded a museum, an "extra-university enterprise." His brilliant success was a direct result of his zeal and activity as a teacher. Charles Bell, his younger brother, assisted him in his work for several years, and later edited his great work on Surgery. Bell's "Anatomy of the Human Body," a portion of which I have the pleasure of shoAving you to-night, passed through many editions and was translated into German. A rapid improvement in the surgery of arteries followed hisAVork on anatomy, in which these were particularly described.
In his " Nature of Wounds" he gave a clear exposition of the advantages of securing first intention union, something just then comiug to be regarded as desirable, as distinguished from the recent practice of dilating and separating the edges of a wound by means of tents and all manner of substances to prevent rapid healing.
For twenty years he was the leading surgeon of Edinburgh, during which time he had a long controversy with Dr. Jas.
Gregory, the Professor of Medicine in the university of that city. The result was most unfortunate for Bell. Although he only replied when attacked, his defense was so violent as to cause a reaction against himself. It ended in the limitation of the number of attending surgeons to the Infirmary to six, of whom Bell was not one. Gregory at this time was severely censured by the College of Physicians for violation of the truth.
In his " Letters to the Medical Profession " Bell makes a long and labored criticism of Gregory and others of his opponents (as was the fashion of that day, and until within thirty years not uncommon in our own country), in which italics and large cajjitals were freely employed. If the quotations from Jas. Gregory are correct, they certainly show him up in a bad light, as a disagreeable and undesirable person. As a specimen, upou his appointment to the position of Censor to the College of Physicians, Gregory says: "Since they will have me for a censor, they shall have me for a censor; I can assure them with perfect truth I would rather act as a whipper-in to a herd of swine pursued by a legion of devils, than a Censor to a College of Physicians, or to any society of men who needed such censorious admonition as at present it is my duty to give them."
In another part of the book Bell dwells upon the importance of much dissection in order to properly qualify a surgeon, and scoffs at those who try to make a surgeon by experience alone, and without a previous thorough anatomical training.
" To ally Anatomy more closely with Surgery, to connect the art more intimately with the science from which it flows, seemed to me a task as 3'et imperfectly accomplished, and yet of the very highest importance. The study of Pathology contributes not only to make the surgeon intrepid, bold and skilful, but to keep alive those sentiments which give a peculiar value to his best and most sacred duties. The continual reference of every symptom and suffering to certain i>hysical changes going on within the body, begets a lively sensibility for the feelings of the patient while he lives, or to his fate while his life is in dan<rer."
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He speaks of the horrors of a surgical ojieration by an unskilful surgeon and with poor assistants, a situation much worse than to-day, when an anaesthetic allows more time for clumsy helpers to do their part. Some members of the profession seem to have understood the art of advertising almost as well as men of our time who cannot wait for the wellearned reputation of good work. Bell scores a brother surgeon, Benjamin Bell, who for some months advertised a mild cure for stricture as opposed to the use of caustic. This was well contrived by writing a book on the subject and advertising the work in the public prints, a thin device to secure private practice often used in our day.
.John Bell speaks in terms of well deserved contempt of the effort to teach surgery or anatomy to a class most of whom are one hundred feet away from the demonstrator, instead of compelling each one to work out his own salvation by careful work on the cadaver. Surgical anatomy as we understand it, was not systematically taught before the time of Bell.
While Bell spent some of his valuable time in personal attacks on such members of his profession as he deemed worthy of satire and exposure, there is little doubt that in the main i t was richly deserved. Those were pre-emiueu tly days of personality and vituperation, and Bell in his philippic against Gregory says, " I neither mistook my bird nor missed my shot." The latter, as we have seen, tried (and with success) to exclude Bell, the leading surgeon of Edinburgh, from the Infirmary.
In at least one way his exclusion from the Infirmary proved a blessing to the profession, for Bell soon set about writing his " Principles of Surgery," in three volumes, a most remarkable and interesting work. Men of that day did not disdain to say a good thing now and then in the course of their strictly surgical teaching. His work is a monument of learning, representing pretty well the best surgical ideas up to his time, as well as his own, original and acquired. In editing: a subsequent edition of the work, his brother Charles speaks of the correctness and importance of the principles taught by his brother, as well as of his admirable qualifications for teaching. To give an extract:
"Experience is observation founded upon previous kiunvledge . . . The present mode of teaching anatomy tends little to excite this spirit of observation. He will have little sympathy with the ])ains or sufferings of his patient who does not reason on what is going on within the body, who does not watch incessantly the symptoms indicating change, whether toward health or disease; and feel more fears and anxieties than his patient can imagine, and see dangers of which his friends cannot be conscious. Such reasoning repealled from day to day is truly experience."
David Williams, in a memorial to the College of Surgeons against the Managers of the Edinburgh Inlirmary, referring to the proposed limitations of the number of attending surgeons to six, whereas there were formerly a much larger number, says, "A surgical case is very different from a medical one. Surgery depends more upon particular facts, and medicine more upon general reasonings. Any surgeon therefore can observe a matter of fact that falls under his notice, but it is not every iihysician who is ca}iable of entering into a long
process of reasoning on a difficult case." Again he makes an observation which will apply very well to a number of hospitals in our own day : " Upon a deliberate consideration of this case it is apprehended that there is another party whose interests have been entirely overlooked, that is the public."
This appears to have been the case in the exclusion of Bell from the Infirmary, for, hospital or no hospital, heenjo3-edtbe confidence of the public to the extent that he was the leading surgeon of Edinburgh for twenty years.
In the preliminary discourse to his Principles of Surgery, in speaking of the education and duties of a surgeon. Bell writes: "Such is the natural horror at blood, and the vacillations and difficulties of the surgeon himself when anything so daring as a dangerous operation is to be done; and such are the increasing and anxious inquiries of friends, that operations, though the least part of our profession, strike a deeper interest into the public mind than the daily cures we perform. Operations usurp an importance in surgical education which they should not naturally have. Operations have come at last to represent as it were the whole science, and a surgeon, far from being valued according to his sense, abilities and general knowledge, is esteemed excellent only in proportion as he operates with skill." lie concludes: "Respect yourselves, deserve well of your country, and all those who are around you will be sensible that you are deserving ; refrain from complaints, which will but harden your enemies and disgust your friends."
Like many another good man. Bell was one of those who could give excellent advice to others which he was unable to apply to his own case.
Hell's Surgery contixins a vast amount of interesting information to any student of the history of medicine. He refers to the abuse of tents to prevent primary union of wounds, and we may as Avell notice that the old surgeons, without any knowledge of the true principles of aseptic or antiseptic surgery, did look upon primary union as a thing to be desired, and achieved it in a certain proportion of cases. He refers again to the sympathetic cure of wounds, so-called, by practicing upon a bloody towel, a stiiin, or upon a weapon. All this might of course be done at a distance as well as on the spot by the charlatan who advocated this sort of thing. He says further that one of the chief of medical schisms arose about the time of Paracelsus upon the question, "Whether it was necessary that the moss should grow absolutely in the skull of a thief who had hung on the gallows, and whether the ointment while compounding was to be stirred with a murderer's knife."
.V more practical matter from our standpoint was the treatment of apoplectic attacks, which was apparently considered to be the province of a surgeon. After reviewing the condition in which we find the patient, in a most graphic way, he says: "Raise your patient into a sitting posture; have him supported behind; let his legs hang over the side of the bed; bleed from a large orifice in one or both jugulars: expose him, especially if the weather be sultry, to a stream of cool air by opening the windows and the door of the chamber: sprinkle his face with cold water." " Bleed him while his pulse rises or until his face change, and if the stertorous breathin?
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relax, if the pulse become frequent and soft, if he swallow more freely, if his groans seem less oppressed, if he raises his eyelids at last and appears to know his friends, if he begins to shudder as if feeling the cold, and to move his limbs, you are going to save your patient."
In a historical sketch by Strothers, upon the Edinburgh Anatomical School, we are told, referring to Bell, "Among numerous students was a young man, remarkable for his keen eye, intelligent countenance, and small stature. It struck this youth that although the professor then in the chair was an excellent teacher of anatomy, the application of anatomy to surgery was quite neglected."
He seems never to have recovered from his exclusion from the university, and although his private practice was extensive it did not atone for the loss of a public position. "Bell was not only the reformer of surgery in Edinburgh, but the father of it." "A bold and dexterous operator, he combined all the qualities of a great surgeon to an extraordinary degree." "He was master alike of the head, hand, tongue aud pen." That he was a grateful and warm-hearted man, the dedication of his "Anatomy of the Human Body" to Rutherford witnesses. In this he says :
"To Daniel Rutherford, Professor of Medicine and Physician to the Royal Infirmary, Edinburgh. Sir, — In presenting this book of plates to one who is so well able as you are to judge of their defects, I ought to add some value to the offering by declaring the motives of it. It is a mark of gratitude for the friendly care with which, in company with my worthy master, you watched over me during a long and dangerous illness. Perhaps there can be no higher compliment betwixt medical men than this confidence in time of sickness, and surely if I may judge by my own feelings, nothing can be more grateful than the remembrance of
kindnesses bestowed at such a time. — May your skill be long useful to your fellow-citizens, and may it be always valued as I value it. I am. Sir, with respect,
Your friend and humble servant,
John Bell."
He married later in life than most of our profession, since he was no less than forty-two years of age when he wedded the daughter of a retired physician.
In 1816 he was thrown from his horse, and in consequence of disability he went to Italy the year following, where he engaged in the study of art in its various aspects. The results appeared in his "Observations on Italy," edited by his friend. Bishop Standford. Mrs. Bell, in writing a preface to this work after her husband's death, says: "With warm affection aud sanguine temper he looked forward with hope that his labor and reputation would one day bring independence, and meanwhile he would give his last guinea to any one who required it. Judging others by himself, he was too confiding in friendship, too careless in matters of business; consequently in the one he was exposed to disappointment, aud from the other involved in difficulties and embarrassments which tinged the color of his whole life." John Bell died of dropsy, in Rome, April 15, 1820.
In regard to the impression he made upon those about him, one of his biographers says : " He was impetuous and energetic, and in controversial writings almost violent. He was one of those men who, without achieving great success, leave behind them an abiding impression, aud stamp their character in the institutions and thought of the age in which they live. In person he was below the middle height, of good figure, active looking, and dressed with excellent taste. Keen and penetrating eyes gave effectiveness to his regular features, so that his expression was of a highly intellectual type."
CONCERNING NEUROLOGICAL NOMENCLATURE.
By Lewellys F. Barker, M. B., Associate Professor of Anatomy; Assistant Resident Pathologist.
The nervous system, as is well known, was formerly described as being made up of nerve cells and nerve fibres. Each peripheral nerve fibre of the cerebro-spinal system consists of an axis cylinder around which is a fatty sheath, and outside this again is another sheath, the neurilemma. Bundles made up of great numbers of these nerve fibres held together by firm fibi'ous tissue run through the tissues of the body and are known as "nerves." The term "nerve," as originally employed, had reference to the firm, sinewy or tendinous character (Latin ncrvus, Greek vcufim) of these bundles, a quality dependent in reality on the fibrous connective tissue of the bundle rather than upon the really functioning irritable structures within it. The terms " nerve " and " nervous " are now connected in thought rather with the functionally irritable structures.
The relations of the nerve cells to the nerve fibres remained for a long time unknown. The nerve cells occurring in groups within the nerve centres were known to possess branched pro
cesses, the so-called protoplasmic processes or dendrites. Later
on it was shown that the axis cylinder of every nerve fibre is
always a process — an integral part, therefore — of a nerve cell,
though this process is very different in form and probably in
function from the other processes (dendrites). It has then
been demonstrated that the whole nervous system is made Tip
of units, each unit consisting as a rule of a nucleated cell
body with its dendrites, together with one or more axis cylinder processes with side-branches (side-fibrils, and collaterals
or paraxones) and end-ramifications. Each of these units
inclusive of all its processes is in reality a single cell of the
body, quite analogous to a single liver cell, or a single muscle
cell, and a very suitable name for the unit would be " nervecell " were it not for the fact that this term has been used for
decades to indicate only a portion of the unit as mentioned
above (viz. all except the axis cylinder) aud in many minds
would call forth this erroneous idea. It remained, therefore,
to find a satisfactory name for the whole nerve unit. Waldeyer
Fig. f.— Double ureter on the left side with double renal pelvis. Abnormal position of the right kidney.
Hydro-ureter on both sides.
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of Berlin suggested that from the Greek 6 ■^zopd/v a new German word be coined, dcr Neuron (pi. die Neurotieii),a,rid the introduction of this term has been of significant influence in making the ideas involved in what is now generally called the neurone-conception of the nervous system generally known and appreciated. The term has been in Germany almost universally adopted by morphologists, histologists, physiologists and clinicians notwithstanding the objection offered by V. KoUiker that the term 6 -jzuiiw-j in reality indicates " einen Sammelpunkt vieler Neuren oder Nerveii." He has suggested that the word Neurodindrcn or Neurodendridien be used instead. Van Gehuchten has adopted Waldeyer's word, spelling it in French "le neurone," and French writers generally employ it. The leading investigators in Spain and Italy have also adopted the same term ; so that even if it were etymologically somewhat objectionable, its use has become so general and cosmopolitan that it seems as though we must also employ it in English. Baker's suggestion that we use the term ncure is a very good one, but the term of Waldeyer has already become too prevalent to be easily supplanted. The question arises, how is Waldeyer's term to be anglicized? Would it be justifiable to bring it into English through the French and to spell it neurone, pronounced neurone, or could it be brought into English directly from the Greek and be so spelled and pronounced? It is especially desirable that this spelling and pronunciation be permissible, owing to the fact that a few writers, among others Schaefer and Donaldson, have
employed another word, neuron (Gk. to -ytuoDy), to mean the axis cylinder process, a nomenclature which is obviously etymological ly faulty and which in my opinion is not likely to become generally popular owing (1) to the existence of a better term for the axis cylinder, viz. axone or neuraxone (Greek alai^), already current; and (2) to the likelihood of its confusion with the word introduced by Waldeyer for the whole nerve unit, a word now in almost universal use in other countries.
For the sake of avoidance of confusion in the bibliography a speedy agreement concerning the nomenclature is certainly highly desirable. I have submitted the question, very much as outlined above, to Prof. B. L. Gildersleeve of the .Johns Hopkins University, with a request for aid, which has been courteously and promptly given. Prof. Gildersleeve ftrites me that V. Kolliker's objection to >;y//(u> will not hold, for it would apply equally well to -afiOz-^w.>, which means "the house of the virgin." He adds, "While the spelling neurone is not pleasing, still for that matter the spellings anode and catlwde are just as objectionable, since after the analogy of tnelfwd they should be spelled aiwd and cathod, and under the circumstances neurone seems to be inevitable." It is a matter of congratulation, I think, that neurologists may thus use the term in English with the sanction of a recognized authority in Greek. If medical and scientific writers will co-operate, we may finally hope to bring about the establishment and maintenance of a uniform international nomenclature.
A COMPLETE DUPLICATION OF THE LEFT URETER FROM THE KIDNEY TO THE BLADDER.
By Otto Ramsay, M. D., Baltimore, Md.
The following case, coming to the autopsy table from the gynecological ward of the Johns Hopkins Hospital, is of interest from a rare abnormality of the ureter which it illustrates, being a duplication of the left ureter throughout its entire extent, beginning at the kidney with a double pelvis, and ending in separate ureteral orifices at the bladder.
The patient from whom the specimens were obtained was a woman of 45 years of age. She had been admitted to the gynecological ward suffering with a carcinoma of the cervix uteri, which on examination was found too far advanced for operative help. Death followed soon after her admission, the result of exhaustion. There were no signs of ur;vmia, the patient passing a moderate amount of urine daily. As no bladder examination had been made before death, there was no suspicion of the condition found at the autopsy.
I cite here only the anatomical diagnosis, and the condition of the kidneys, ureters, bladder and urethra, the remaining l)ortions of the autopsy report being of no interest to us in this connection.
Autopsy No. 813, June 23, 189(3.
Anatomical Diagnosis. — Sloughing carcinoma of the uterus, perforation into the rectum. Involvement of the ureters, llydroureter and slight hydronephrosis. Double ureter on the left side, with double kidney pelvis and two bladder oi'ifices.
Extension of the tumor to the surrounding tissues and infection of the lymphatic glands. Chronic nephritis. Subacute pericarditis. Obliterating pleurisy. Peritoneal cyst attached to the appendix vermiformis.
Condition of the Urinary Organs. — Both kidneys about the same in general appearance ; the left is somewhat larger than the right, with its upper extremity 5 cm. above the upper extremity of the right kidney. The ureters are dilated and contain quite clear fluid.
The right ureter is about the size of the index finger ; the pelvis of the corresponding kidney is dilated, the calices being deepened, but relatively these parts are dilated less than the ureter.
The whole kidney is very pale, the cortex being uniform in tint; the glomeruli pale, though visible. The pyramids are not quite so pale as the cortex.
On the left side the ureter is double. Beginning at the hilum of the kidney by separate pelves. IxHweeu which there is no communication, the two ureters from here run side by side, bound closely together, but entirely separate, to the bladder, where they enter at distinct orifices 1.5 cm. apart. They are dilated throughout their whole extent from the poiut where they are involved in the growth at the cervix uteri to the kidney. Each is about the size of the little fingex, and
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contains quite clear contents. They show marked contraction where they pass through the growth extending from the cervix, but a probe can only with some diflBculty be forced into each ureter from its appropriate orifice.
The mucous membrane of the bladder is beset with fine hemorrhagic points. At the orifice of the single right ureter there is a teat-like projection into the cavity of the bladder, at the summit of which the ureteral orifice is found. This projecting portion of the mucous membrane is firm in consistence and is probably due to a direct extension of the new growth. The bladder is moderately distended with turbid urine. The urethra is congested, but shows no sign of the extension of the new growth,
The accompanying drawings illustrate well the condition.
Fig. 1 shows the two dilated ureters on the left side, from their origin, to the spot where they are compressed by the new growth, also the markedly dilated right ureter. Fig. 2 shows the bladder with the two ureteral orifices and the teat-like projection at the site of the right ureteral orifice.
The condition of complete reduplication has been described by Weigert, Debierre and others, but I found no reference similar to the condition here pictured. In a case reported by Heller (Deutsch. Arch, fiir klin. Med , Bd. V, Heft 2) there was a hydroureter and hydronephrosis of one portion of a double ureter and double pelvis, the dilated ureter ending as a closed sac in the wall of the bladder; a similar case is also reported by Weigert (Virch. Arch. No. 70, p. 490).
NOTES ON CONGENITAL MOTOR DEFECTS OF THE EYEBALLS (CONGENITAL PARALYSIS
OF THE OCULAR MUSCLES).
REPORT OF A CASE OF BILATERAL PARALYSIS OF THE EXTERNAL AND PARESIS OF THE INTERNAL RECTI MUSCLES.
By Harry Friedenwald, A. B., M. D.
Paralysis of the ocular muscles is a subject, of great interest to the neurologist and to the ophthalmologist. The slightest degrees of impairment make themselves very apparent and are readily measured. Affections of the different nerves are separated without difficulty, and the situation of the lesion can often be deduced with exceeding nicety.
For these reasons the paralyses of the ocular muscles have been, carefully studied, and various classes of central and peripheral origin have been separated. There is a class of cases which is congenital. Those that have been published were collected recently by Kunu (Deutschmann's Beitraege zur Augenheilkunde. Vol. II, p. 711), and number about seventy-five. They include single paralyses and combined paralyses of all the extrinsic ocular muscles, monolateral and bilateral.
There has been some discussion as to whether these congenital cases form a separate type or belong to the same class as those occurring in youthful persons and young adults, and recognized as acute nuclear paralysis, or what Wernicke terms polio-encephalitis superior. Moebius has taken the latter view (Ueber iufantilen Kernschwund; Muench. Med. Wochenschrift, Vol. XX.VIX, 1892, No. 2-4).
Kunn, on the other hand, seeks to establish these cases as a separate class, due not to atrophy of the nuclei, but to the non-development or defective development in the embryo of one or more parts of the motor chain from the cortical centres to the muscles themselves. It was with a view of bringing this question before you that I present a case and these notes to you.
Among the cases which I had the pleasure of demonstrating heret last winter there was one of congenital paralysis of the right external rectus muscle, with some iniiiainnent of adduc
•Read before the .Tolins Hopkins Hosnital Meiiical Society,
November 2, 1896.
f See Johns Hopkins Hospital DuUetin, No. 04, July, 1896.
tion of the same eye. The usual result of acquired paralysis, namely contracture of the antagonist, M'as missing. There was also slight enophthalmus.
At the same time I reported two cases very similar to the above. In both of these there was absolute inability to move the left eye outwards beyond the median line. In one there was likewise enophthalmus, with some interference with adduction. In neither of these cases was there contracture of the antagonist muscle. In none of the three cases was there diplopia. In direct vision, all had binocular vision. All of these cases showed the peculiar movements of the eyelids associated with lateral movements of the eyeballs, which was the subject of the paper.
Monocular paralysis of the external recti is the most common form of congenital paralysis.
At the same time I reported the case of bilateral paralysis of the external I'eeti. I have since then been able to study this case much more thoroughly, and shall present him to you.
H. F., aged 19, complained that he was forced to move bis head from side to side in reading, and that his left eye was weak. There was no astlieiiopia, but his eyes became red after reading. At the first examination I could not make out any lateral movement in either eye, a request to look toward either side being followed by a corresponding movement of the head, the eyes remaining stationary. It was for this reason that I was induced to regard the case as one of paralysis of both abduction and adduction of both eyes.
The patient has been examined a number of times since then. Under atropia, a slight degree of hypermetropic astigmatism was found in the R. E. (0.5 Dc Ax 70°). The left eye is amblyopic, V 6/60, which cannot be improved with glasses. There is no movement outwards in either eye. But after numerous trials tlie right eye tested at the perimeter couhi with difficulty be aiiducted to about 45°, and monocularly even to 60°, but it could be held there only a few moments. At the same time the right palpebral fissure became smaller, the left larger than usual. As to the left eye, repented and very great eft'orte did not succeed in adduction ex
' /
A^'
Fig. 2.— Two perfect ureteral orifices on the left side. Teat-like mass on
the right side with the right ureteral orifice at its summit.
The Frimleiiwiild Co.. Engravpra and Prlilten
November-December, 189(3.] JOHNS HOPKINS HOSPITAL BULLETIN.
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ceeding 30° or 35°, and then only for an instant. This likewise resulted in associated movements just the contrary of those described above.
Tested with a red glass before the right eye, there was homonymous diplopia toward either side, but not in the primary position.
With the phorometer there were about 4° of left hyperphoriaand 4° of esophoria. His eyes do not appear to be directed perfectly parallel in distant vision.
Examinations of binocular vision resulted in his being able to fuse simple pictures in the stereoscope after a few minutes trial. This, however, is known to be an unsatisfactory test. Tested according to the Lippincott method, binocular vision, or more definitely binocular perspective vision, was shown to be present when the patient looked directly forwards, but not when the object was held on either side. Tested by the most delicate method— Herring's Fallversuch— the patient answered correctly only in abouthalf the trials. This appears to be attributable to the very defective vision of the left eye.
We should therefore conclude that while binocular vision is not perfect, it is present to a certain degree, and probably as great as the relative defect of vision in the left eye would permit of.
The convergence of the eyes has been examined a number of times and is very defective. But the patient appears to converge to within the reading distance. The convergence is mainly due to contraction of the right internal rectus.
Other defects were sought for. Facial paralysis, which existed in some of the reported cases, is not present. There is no mental defect, and the only other peculiarity is great hesitancy in speech. The affection is undoubtedly congenital and was observed very early. (Demonstration.)
In this case let me call your attention to the defective action of both internal recti mnscles. This has been commonly observed in cases of bilateral paralysis of the external recti. It is just the contrary of what is expected, namely, contracture. What is still more important is that in many of these cases convergent action of the interni was perfect even though the lateral action was entirely wanting or very defective and difficult.
This is, as Kunn has pointed out, a mark of difference separating cases of congenital paralysis from all acquired cases.
There has beeu much difference of opinion concerning tlie significance of the defective action of the interni iu these cases of complete paralysis of both externi. Graefe thoiiglit that the initiative of hiteral movement hiy iu the e.xterui, and these being paralyzed, the interni failed to act. Kunn and Simon (Entstchinig derKoordinirten Augenbewegungen, Zeitschr. f. Psychologie, Band XII, p. 102) regard the inability of the interni to perform lateral movements as the result of disuse, no attempts being made by the patient to look toward either side on account of the diplopia that would ensue.
Inasmuch as there was some defect iu adduction in two of my three monocular eases, I am inclined to regard this, at times certainly, as a parlial congenital paralgsis of these muscles. When convergence is good, and lateral movement is very defective, we may accept Kunn's explanation. This has given rise to some difficulty in explaining why the iuternus of the fellow eye is not affected in unilateral paralysis of the abduceus, for here, too, movements toward the side'of the paralyzed muscle produce diplopia. The difference appears to me to lie iu the fact that in these cases there is considerable play for the muscles iu all movements between extreme lateral deviation (toward the side opposite to that of the paralyzed muscle) and the median line.
An important characteristic of congenital paralysis lies iu
the existence of binocular vision, which was found in all the monocular and binocular cases that I have seen and in many of those reported. There is also absence of diplopia.
Kunn explains the varying positions in which the eyes have beeu found — parallelism, convergence or divergence— as those naturally assumed by the eyeball iu the orbit; and that these vary need not be a matter of surprise, since the different primary positions of otherwise normal eyes are found to vary greatly. The absence of contracture has beeu noted iu most of the cases published and is to be considered as a mark of cougenital paralysis.
Concerning secondary deviation (of the normal eye when the affected one is used for fixation) which is almost universally present in acquired paralysis (excepting iu very rare cases when the paralysis has existed for many years), we may state that this sign, as Graefe long ago discovered, is always absent iu the congenital cases. This is explained by Kunn as due to the fact that no association between the paralyzed muscle and its fellow has ever existed. If, therefore, attempts are made to call the paralyzed muscle into activity there is no impulse sent to the fellow muscle.
Many cases of congenital paralysis of the ocular muscles have had associated with them other congenital defects, such as facial paralysis, unequal development of the two sides of the face, mental disturbances, etc., etc.
Heredity has been a conspicuous factor in cases of congenital paralysis.
Considering the peculiarities of congenital paralysis, Kunn asserts that these cases form a definite class, and he ascribes them, not to fretal disease or to atrophy of the centres, but to arrested development. He calls attention to the cases iu which absence or presence of the muscles has beeu demonstrated in congenital paralysis, and to one (Beruhardt's) iu which the centre was found normal. Ilis conclusion is that either of these portions or any others in the motor chain may suffer arrest of development. He therefore discards the term unclear paralysis and substitutes congenital motor defects of the eyeballs" (augeborene Beweglichkeitsdefecte der Augen), a term which I think should be adopted until the nature of these cases is more dofiniti'ly dctiTniin^d.
]S O T ICE.
All inquiries concerning the admission of free, part pav, or private patients to the Johns Hopkins Hospital should be addressed to Dr. Ilenrv M. Hurd, the Superintendent, at the Hospital.
Letters of inquiry can be sent, which will receive prompt answer, or personal interviews may be held.
Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indicent natients a uniform rate of fo.lX> per week h.-ui been established. The Superintendent h;is authority to moilifv these terms to meet the necessity of urgent CAses.
The Hospital is designed for csises of acute disease. Cases of chronic disease are not admitted except tenn>orarilv. Private patients can be received irrespective of residence. The rates in the private wards are governed bv the localitv of rooms and r«nge from |2t\tX1 to f35.0ll per week. iMie extras are laundrv exi^enscs, massage, the services of an exclusive nurse, the services of a throat, eye, ear and skin or nervous specialist, and surgical fees. Wherever room exists in the private wanis and the condition of the patient does not forbid it, companions can lie accommodated at the rate of f 15.(X> per week.
One week's board is payable when a patient is admitted.
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MALARIAL INFECTION AS A SOURCE OF ERROR IN SURGICAL DIAGNOSIS.
By W. W. Russell, M. IX, Associate in Oynecoloyy.
The discovery of the ha;matozo:i of malaria and the subsequent establishment of their relation to malaria as the definite cause of the disease, has almost excluded the possibility of its being offered as a cause for irregular fevers attending surgical affections. Yet with this definite knowledge of the cause of malaria, we still find in the current literature cases cited with atypical elevations of temperature associated with surgical troubles which are ascribed to malarial influences. Such assertions are inexcusable when a -positive diagnosis can be obtained by an examination of the blood. This neglect has led to appalling mistakes, of which an example came to my knowledge a few years ago. A patient presented herself to a surgeon complaining of pain in the lower abdomen, pelvis and back, with chills and fever. Upon examination a mild pelvic peritonitis was found. She was advised to have the tubes and ovaries removed, and submitted to the operation. The jsatient had a severe chill the next day, followed by a rise of temperature to 107° and collapse. The blood was then examined and found teeming with malarial organisms. The patient eventually recovered, but nevertheless the oj^erator was 'iiegligent in not excluding by systematic study of the case the possibility of malarial infection, before performing what proved to be an unnecessary mutilating operation.
My experience during the August and September service in the Gynecological Wards of the Johns Hopkins Hospital was interesting from the number and variety of cases in which malarial organisms were found. The possibility of malaria being superimposed ujiou various sui'gical affections was strikingly shown, as well as the dangerous conclusion which might be reached without the positive proof of the presence of the organism in the blood. The experience teaches further that in malarial districts malaria must be always suspected in fevers following operations without an assignable cause.
Some writers have suggested that temperature and pulse charts are valueless during post-operative convalescence. The danger of such teaching is well demonstrated by the following cases, in which the first suggestion as to the true character of the trouble was found on the daily charts.
Case No. 1. Mrs. D. G., age 33. Patient complains of loss of control of bowel. .The personal history is negative until 1893, when she had an attack of typhoid fever. This was followed by an abscess around the rectum, and a recto-perineal fistula, which was ojiened by her consulting physician; since then there has been complete incontinence of the bowel. She has been operated upon twice within the last year for restoration of the sphincter ani without success. She suflFers almost constantly from diarrhoja, but the stools do not contain blood or mucus. General health is excellent.
Operation Sept. 9, 1896. The ends of the retracted sphincter, which were separated two-thirds the circumference of the bowel, were dissected out of scar tissue and brought together by silk-worm gut sutures passed deep into the tissue.
Sept. 18. Sutures removed. The sphincter well contracted and apparently holds firmly, but some separation of skin
surfaces. There has been no escape of flatus or feces since the operation, and the patient is able to control her bowels for an indefinite period.
Sept. 23. The patient's convalescence has been uninterrupted, the temperature ranging from 98° to 100.4°. This morning a severe chill occurred, and the temperature rose to 103.8°, the pulse during this time not reaching over 84 beats per minute. By 5 P. M. the temperature had fallen to the normal line, and continued so until 10 A. M., September 25, when there was a chill and a similar rise of temperature to 103.6°. The blood at this time was examined and found to contain numerous malarial organisms of the tertian type. Quinine in doses of five grains every five hours was given, and thereafter three grains four times a day uniil the fifth day following the last chill. After the patient had taken the quinine there was no chill or rise of temperature, and the organisms completely disappeared from the blood.
The patient was discharged from the hosj^ital October 2d, in excellent health, the result of the operation perfect.
The initial chill did not occur until fourteen days after the operation, but during this period there had been a slight daily rise of temperature not reaching above 100°. The wound broke down but slightly. The first suspicion was naturally directed to the seat of operation, but as the condition there did not seem to waiTant interference, it was thought advisable to await developments. The chill on the second day suggested at once the blood examination, with the happy result given in the case.
Case No. 2. L. G., age 27. Patient's personal history negative until four days before admission. She was three months pregnant, and had attempted to introduce into the uterus an instrument to produce abortion, but her doctor says that she had introduced it into the bladder instead of the womb. Since then she has had constant pressing pain in the region of the bladder and lower right side, with fever. For four days micturition has been exceedingly painful, and she has noticed that the urine is bloody. There is a great deal of tenderness in the region of the bladder, and the bearing-down pains have grown steadily worse. On examination the patient was determined to be in the third month of pregnancy. The bladder was inspected in the knee-breast position with a 9J vesical speculum. The entire mucosa was found to be of a deep fiery-red color, bleeding on the slightest touch, and quantities of free blood poured out through the speculum. The foreign body could not be made out on account of the hemorrhage. The urethra was greatly dilated, and easily admitted the little finger. On palpation of the bladder, by passing the finger through the urethra the foreign bodies could be easily felt, but were too large to be extracted. An incision was then made into the base of the bladder and a disintegrated sea-tangle tent was removed. A permanent fistula was established by suturing the mucous membrane of the bladder to that of the vagina.
The patient's temperature from the time of oi)ei'ation to the
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thirteeuth day had ranged from 9S° to 101.3°, at which time there was a decided chill followed by a rise of temperature to 102°, the pulse reaching 13G beats per minute. By five o'clock the temperature had subsided to normal. A similar rise occurred on the second day following, reaching 104.8°. The blood examination revealed numerous malarial organisms of the tertian type. The patient was not given quinine until the third chill, which occurred on the second day following, when the temperature rose to 106.8°; the same quantity was then administered as in the preceding case, with a similar result. The cystitis having cleared up on the twenty-ninth day after the operation, the fistula was closed in the ordinary way and the patient was discharged ten days later in excellent condition.
The acute inflammation of the bladder suggested at first thought an ascending pyelitis as the cause of the chill, but again the temperature chart and the examination of the blood definitely settled the diagnosis.
Case No. 3. A. G., age 33. Patient was operated upon by Dr. Kelly in the hospital in October, 1895, for chronic inflammatory disease of the right tube and ovary and liiBmatoma of the left ovary. She returned complaining of chills and fever of about one week's duration, and a discharge from the abdominal incision. Since the operation the menses have been irregular, appearing at intervals of four to eight weeks. No leucorrhoea.
Present condition. Patient says she has been greatly benefited by the operation and has gained about forty pounds. She had not suffered any pain until the past month, when she began to have some of a shooting character in lower right side and back. They were not constant, but at times very severe. At present there is no abdominal tenderness, but there is a slight discharge from the incision. One week ago she was taken with chills and fever, which have recurred daily up to the present time. During this period the abdominal pain has not been more marked than previously. Micturition negative, the bowels constipated.
The patient's temperature on admission was elevated. The physical examination did not reveal the cause of the fever. A small sinus in the lower angle of the abdominal incision leading down to a buried silver wire suture explained the discharge of which the patient complained. By a vaginal examination the uterus was found movable and not enlarged. A sensitive induration extended from the right cornu out to the pelvic wall. On the left side of the uterus there was no evidence of disease.
The day after admission a morning chill occurred, followed by a rapid rise of temperature, which subsided during the afternoon. As the condition suggested malaria, a blood examination was advised, and several tertian organisms were discovered. Quinine was immediately ordered, with complete disappearence of all symptoms in a few days. The silver wire suture was withdrawn, followed by spontaneous closure of the sinus.
The patient's previous history and operation at once gave ground for assigning a local pelvic trouble as the source of the infection. This seemed to be coiilirmed by the condition found by digital exaniinalioii, and operative procedure was
almost decided upon when the subsequent chill put us upon the right clue.
Case No. 4. Mrs. M. J. T., age 49, colored. Married. Has had five children and three miscarriages. The youngest child fourteen years old. First labor was a breech presentation, and in all the others the placenta had to be extracted. Miscarriages all occurred before the birth of the last child.
Menstrual history: she has always been regular until six weeks ago, when the flow lasted for two weeks. The usual duration is one week, and the flow very profuse. Last regular menstruation two months before admission. She has had a free leucorrha'al discharge for the last two weeks, which has become offensive.
Familji hidorij negative.
Personal history : she had rheumatism in legs during past year, typhoid fever twenty-five years ago. There is a history of chills and fever for a number of \'ears. The present trouble began fifteen years ago, when she first noticed a slight swelling of the abdomen, which has been growing slowly and steadily larger. During the past two weeks she has suffered with severe bearing-down pains in the lower abdomen. She has had considerable palpitation of the heart. The week before admission claims to have had chills and fever every other day.
General condition : appetite poor; she sleeps fairly well; is a well nourished woman, but has not been able to do any work for the past two weeks on account of the pain.
Examination : heart and lungs negative. Skin and mncous membranes pale. Abdomen distended by a mass extending from symphysis pubes to umbilicus, which has a symmetrical outline, has a smooth surface, is non-fluctuating, softish, and decidedly sensitive.
Vaginal examination : the cervix is low in the pelvis, nearly flush with the introitus, the os is dilated to about 4 cm. iu diameter; the lips are soft, but do not break down ou examination. The canal is occupied by a soft boggy mass which protrudes from theos. The tumor in the abdomen is directly continuous with the cervix.
Diagnosis: submucous myoma.
Operation Sept. 5, 1S96. Ilysteromyomectomy after Dr. Kelly's method of continuous incision from left to right. No difficulty encountered. A gauze drain was introduced through the dilated cervix into the pelvis. The abdomen closed with buried catgut and silver wire sutures. The patient's tenii>erature from the time of admission to operation ranged from 98.0° to 101.6°, this was believed to be due to the absorption of toxiues from the necrotic surface of the myoma.
Sept. 10. The cervical drain was removed, temperature at the time being 10"J°. An offensive discharge became apjvirent after the removal of the drain.
Sept. 13. Abdomen exceedingly tender. The tongue is raw and sore.
Sejit. 13. Abdomen still more sensitive. The temperature is slightly lower since removal of the pack. The tongue is decidedly worse, and the vaginal discharge continues profuse and foul.
Sept. 14. Abdominal tenderness less niarkedaud mon? localized about the incision. Ou examination, the iucisiou was
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found widely separated throughout its leugth, with a free discharge of pus. The Tagiual discharge continues as before. Temperature 103.4°.
Sept. 15. Patient not improved. The vaginal discharge continues. Tongue decidedly cleaner. The abdominal incision is still dischai-ging freely. Complains for the first time of swelling and pains in thighs and feet, especially of the right leg. On examination the right leg was found swollen and sensitive to touch. At 4.20 temperature suddenly went up to 105°, followed by great exhaustion and signs of collapse. Patient responded to stimulants, and in a few hours was much more comfortable.
Sept. 16. The discharge from the incision still continues free. The right leg very badly swollen and exceedingly sensitive. Vaginal discharge less and tongue much better.
Sept. 17. Tongue practically well, and other symptoms greatly improved.
Sept. 19. Patient improved until 4 P. M., when temperature rose to 104.2° attended with delirium. No induration could be felt about stem of cervix or in pelvis.
Sept. 24. Patient's blood examined and the tertian organism discovered. Patient was put upon quinine, but it made no impression upon the temperature.
Sept. 27. The incision nearly healed, and the vaginal discharge has become less and more healthy in appearance. Temperature still ranges from 100.2° to 103°.
Oct. 15. The temperature since operation has not fallen to normal, the highest point being 105.8°, but this morning at eight o'clock it dropped to 98.6°.
Nov. 4. Patient discharged to-day. Temperature since last note has never reached higher than 100°, and for the past week has been practically normal. The abdomen is perfectly healed. The vaginal discharge is healthy, and the pelvis is free from inflammatory induration.
The coincident malarial and wound infection made this case most puzzling, and if the other cases had not aroused our suspicions, it is doubtful whether the organism would have been searched for. While the administration of quinine did not at once control the temperature, it at least disposed of one cause of it.
THE AGGLUTINATIVE ACTION OF THE BLOOD SERUM OF PATIENTS SUFFERING FROM TYPHOID
FEVER.
By E. Bates Block, M. D., Assistant Resident Phi/sicia7i, The Johns Hopkins Hospital.
Perhaps the most suggestive result of the study of the artificial })roduction of immunity in animals, since the introduction of the serum-therapy, has been the application of the principles expounded by Pfeifier to the diagnosis of typhoid fever.
It will be recalled that this author, by the use of the blood serum of animals rendered immune from the cholera vibrio, was able to show that the bacterial protoplasm of the Tarious comma bacilli, more or less nearly resembling t)ie cholera organism, were distinct from each other and were each one entirely specific. He found that the cholera organisms, when mixed with the blood serum of an immunized animal and introduced into the peritoneal cavity of a guinea-pig, quickly lost their motility and very soon underwent disintegration.
This effect, which was so striking and invariable when the micro-organism and the blood serum of an animal immunized from it were employed, failed to be exhibited when, with the same serum, other, though nearly related, micro-organisms were subjected to the same treatment. Thus it became possible, at a time when the specificity of the vibrio of Asiatic cholera was more or less unsettled, to prove by this reaction its entire independence, and to separate it from forms nearly approaching it in morphology and presenting many of its cultural characteristics.
The application of the same principle to the difl'erentiation of the bacillus of typhoid fever from the colon group of microorganisms was successfully made by Pfeiffer, and later by Lajffler, Dunbar, and others. The credit, however, of modifying the test so as to utilize specific bacteria for the detection of the presence of definite immunizing substances in the body fluids.
should be given to Gruber and Durham, Widal, and Griinbaum. The particular phenomenon which promises to be so useful in assisting in the diagnosis of typhoid fever consists in a clumping, or agglutination, of the typhoid organisms when brought into contact, outside the body, with the body fluids containing the immunizing substances. This reaction, first noted by Bordet, and more fully studied by Gruber, and his pupils Durham and Griinbaum, occurs when the bacteria are mixed with blood serum containing a sufficient quantity of the specific immunizing substance.
The method employed by Widal is to obtain a syringe of blood from a vein of the forearm of a patient suffering from typhoid fever, the serum being allowed to separate from tlie clot. He then makes a dilution of from ten to twelve parts of bouillon to one part of serum, inoculates this with typhoid bacilli, and places it in the thermostat at 37°, until the next day, when the upper part of the fluid appears clear and a white precipitate is seen at the bottom. Tlie control tube is more cloudy and no precipitate forms.
This test-tube reaction was first noticed by Charriu and Roger in working with the bacillus pyocyaneus in animals immunized ngainst that organism.
The method advised by Griinbaum, in the Lancet o[ iha 19th of September, 1896, seems to be the most satisfactory, and with slight modifications is the one which we have adopted here. His method is as follows : A drop of blood is taken in a U-shaped capillary tube from the ear or finger and eentrifugalized; the tube is then broken off at the junction of the serum and the corpuscles, and the former blown out xipon a glass slide or into a watch-glass. The necessary quantity is then
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sucked up to the first mark on a straight capillary tube which has another mark corresponding to sixteen times the volume indicated by the first mark. Bouillon is then sucked up with the serum until the second mark is reached. The fluid is then blown out into a watch-glass, thoroughly mixed, and again sucked up, the process being repeated several times to insure thorough mixing of the bouillon and serum. The emulsion of typhoid bacilli is prepared by taking a platinum loopful of a culture not more than twenty -four hours old, grown on rather dry agar, and carefully rubbing it up with a drop of the bouillon against the side of a test-tube containing one ccm. of bouillon, and subsequently mixing it with the whole amount. A drop of the serum-mixture and a drop of the typhoid emulsion are then thoroughly mixed on a cover-slip and examined as a hanging drop. A control cover-slip should be made from the typhoid emulsion alone in order to be sure that there are no, or very few, pre-existing clumps. If the serum-emulsion-niixture be looked at immediately after mixing, the bacteria will be seen free in the field and actively motile. Gradually, however, if the case be one of typhoid fever, they will be seen to stick together, and tlie clumps become larger and larger by the addition of other bacilli, until, in half an hour, if the reaction be marked, all, or nearly all, of the bacteria are in clumps or agglutinated, and have completely lost their motility. The only modification which we have made is to take the blood from a vein of the forearm ; this affords a larger quantity of serum and permits of several different tests being made from the same serum. This seems by far the most satisfactory method for several reasons: (1) Normal serum, if not diluted suflBciently, causes a slight clumping of the bacilli, and in some cases it is quite as marked as inveryearly cases of typhoid fever, although in the absence of typhoid fever the motility is not destroyed. (3) The clumping is only relative, and without time limitations as well as a deflnite degree of dilution the results cannot be considered constant. (3) This method is much cleaner than the dried blood method (vide infra), and the amount of dilution can be more accurately controlled. (4) The reaction may be more quickly determined than by the test-tube method. According to Griinbaum the reaction may be present on one day and not on another, so that several examinations should be made. By this method he obtained a marked reaction in eight cases of enteric fever, and a negative result in thirtytwo other cases, with the exception of a case of jaundice, in which there was a marked reaction. So that the negative result does not exclude the presence of typhoid fever; while a positive result, if marked, is in favor of the diagnosis of typhoid fever.
In twenty cases of typhoid fever tested in Professor Osier's wards, in conjunction with Dr. C. N. B. Camac, with a dilution of 16: 1, and the time limited to one-half hour, the reaction was complete or marked in eleven cases. The earliest reaction observed was on the 10th day; the latest on the lOGth day: in the others the test was made between the -tlst and the G9th day, except in one case in which it occurred on the 00th day. All of these cases had had very severe attacks, and two of them had relapses.
In six cases the reaction was partial. Tiiey rangixl between the 16th and 67th davs, onlv two of tliem boin"- later than the
38th day. In all of these cases the illness was of moderate severity, although one case had a relapse.
In three cases the reaction was slight; these were all mild cases, and were tested on the 8th, 24th and 60th days of illness. One of these cases had a relapse. The only diseases other than typhoid fever in which we have obtained clumping of typhoid bacilli are diabetes and malaria. In one case of diabetic coma a partial reaction was obtained, and in one case of pernicious comatose malaria it was very marked, although the motility of the organisms was not completely destroyed in either of these cases, nor did either of them give a history, or show evidence of the existence, of typhoid fever.
At present we are unable to say definitely to what property of the serum agglutination is due, although many theories have been brought forward to explain it.
Besides in the serum, agglutination has been observed in milk, urine, pus, blister-fluid and tears. We believe that we have obtained it from the stools in two cases.
It is not given by cedematous fluid, aqueous humor, saliva, gastric juice, and bile free from blood.
Among the diseases in which it has been demonstrated are cholera, pyocyanean infections, typhoid fever, tetanus, pneumococcus infections, diphtheria, and so forth, but each with its own specific serum.
In one case of typhoid fever the blood taken at autopsy yielded only a partial reaction.
In a case with perforation, successful operation and subsequent relapse, the reaction on the 106th day was very marked within 5 minutes, though the patient at the time was convalescent.
According to Widal and Sicard, the clumping is less marked as the activity of the fever lessens, disappearing altogether about the 41st day. In the few cases that we have tested here this did not seem to be the case.
In most of the foregoing tests cultures of typhoid bacilli from three different sources were used. The cases that reacted at all, reacted most markedly with one of them alone; with the other two cultures agglutination was much less marked. This is fully in accordance with the fact that the more virulent the culture the more marked is the reaction, although the virulence of this particular culture had not been established. Also, as was pointed out by Pfeitl'er, if the animal be rendered immune by a very virulent culture, the agglutinative action is remarkably increased.
There remains one more method which, if it can be made more accurate, will be eiisy, and of practical value as an aid to diagnosis. Widal first noted that dried serum, even dried blood, if moistened with sterile water or with serum, would produce the reaction. Wyatt Johnston of Montreal has tried this method verv thoroughly, and the following is taken from his article. A drop of blood is obtained from the ear or finger on a sterile ghvss slide or piece of paper, allowed to dry, and is then moistened with a drop of sterile water. The water is mixed with the serum of the drop of bUxnl; .in oese of this is then abided to an oese of typhoid emulsion, and examined ;is a hanging drop. By this method in some cases he obtained the reaction as late as four weeks after taking the blood.
lie seems to have been successful in everv case tested.
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The results which have been obtained liere by this method are so far uncertain, and do not sliow the regularity of action so prominent in the former method.
In the 17 cases of typhoid fever tested in Professor Osier's wards, the reaction witJi dried blood was marked in 9 cases; of these, 6 were severe attacks and 3 had been mild.
In three cases the reaction was partial ; two of these were severe, and one was of moderate severity.
In two mild cases, one on the 3d, the other on the 17th day of illness, the reaction was doubtful.
In three cases the reaction was slight ; of these, one was a mild case and one severe. The third case at the beginning of relapse showed no agglutination, but nine days later it was slight. The relapse was of moderate severity.
I wish to express my thanks to Professor Osier for the opportunity of studying the cases included in the report.
PROCEEDINGS OF SOCIETIES.
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
Meeting of October 19, 1896.
Dr. Thayer in the chair.
Case of Addison's Disease— Death during: Treatment with the Suprarenal Extract.— Dr. Osler.
Maggie S., aged 21, applied at the Medical Dispensary of the Johns Hopkius Hospital, May 15, 1896, complaining of weakness and discoloration of the skin. A day or two subsequently she was seen by Dr. Thayer, who suspected Addison's disease and asked me to see her. The condition seemed very suggestive, and I admitted her to Ward G on June l&th. The following is the account as obtained by Dr. Block :
The family history was good, though one grandfather died of consumption of the throat, and one uncle had consumption. She has four sisters and two brothers, all well.
As a child she had eczema very badly, which again appeared after an interval of twelve years, affecting only the ears. She had diphtheria and scarlet fever, and three years ago influenza. She has had what she calls slight rheumatic trouble in the left knee for four or five years. For the past four winters she has had cough, with a small amount of sputum, never any night sweats. The cough always ceased in the spring. She has often had cramps in the stomach,, particularly when she caught cold. Her menstrual function has been regular. In the dispensary history it is stated that a year ago last winter some of the glands were swollen, and the mother said she had scrofula.
Her present illness she thinks dates from about a year ago, when she began to have headaches in the frontal region, which have troubled her on and off until about eight weeks ago. At this time she had a chill, the only one she has ever had, and following it she was so prostrated and weak that she was in bed for nearly three weeks. At this time she often had the cramps in the lower abdomen. Two months after the headaches began, that is in August, 1895, she first noticed a change in the color of the skin, appearing about the face, and particularly the nose, which became very yellow and then dark brown. The upper lip was next affected in the same way, and gradually the whole face, which assumed a yellow color with dark brown blotches. The process came on very gradually and soon affected the surface of the body and the skin of the external genitalia. Accompanying this pigmentation and the headaches she had weakness, which gradually became more and more nuirked. She tired easily on walking.
often got suddenly dizzy, everything became black before her, and she would have to catch hold of the nearest object to prevent falling. She states that these sudden weak feelings would come on also when she was sitting still. She had lost in weight in two years ago from 115, to 96 pounds. A symptom, too, of which she complained a good deal was itching of the skin.
She was a bright, intelligent looking girl, not much emaciated. She had no fever, and for the eleven days she was in hospital the temperature did not rise above 99.5°, and the early morning temperature was often 97°. There was no annemia. The blood count on admission was 4,500,000 red per cubic millimetre, and on the 25th it was above 5,000,000. There was no leucocytosis, and the differential count gave polynuclear leucocytes, 33 per cent.; small mononuclear, 45 per cent.; large mononuclear, 12 per cent.; transitional, 2 per cent.; eosinophiles, 4 per cent.
The condition of her skin was as follows: The scalp had a shining yellow color ; the hair was dry and very coarse. The face had a yellow, dull, dark color, with blackish brown splotches, situated just above both eyebrows, across middle half of nose, and involving the whole of upper lip. The eyelids and the inner canthi of the eyes were also very dark. The face showed from fifteen to twenty very small, almost black pigmented areas, some of which resembled moles. The neck had similar small areas.
The abdomen, chest, back, legs and arms had a similar dark yellow brown color. The areolte of the nipples were large and deeply pigmented. Below and to the left of the umbilicus there was a bean-sized browu-black area. Both flanks were almost black in color. Nearly opposite the first lumbar vertebra on the back was a bean-sized mole, deeply pigmented. The gluteal grooves were almost black. The skin of the legs was brownish, and around the knees deeply pigmented. The lower parts of the legs were not so dark colored. The backs of both hands were deeply colored, especially the joints and about the roots of the nails. The hands and feet were cold and moist. On the inner side of left wrist were two deeply pigmented scars. Over the whole body were pin-head sized whitish areas which gave somewhat the appearance of cutis anserina, but not raised. No large leucodermic patches were present. There were a few patches of pigmentation on the buccal mucous membrane.
The lungs were negative; she had no cough aud no expectoration. The heart sounds were rather weak aud not well heard. There was a venous hum in tiie ri^ht side of the
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neck. The pulse raugecl from 76 to 96 and was regular. There was no enlargement of the liver or of the spleen, and there was uo dilatation of the stomach. The examination of the lower abdomen was negative. There was uo enlargement of the external glands. The urine was acid, amber colored, specific gravity 1015.
On June 22nd the adrenal glycerin extract was begun. It was made in the following manner. Fifty-four perfectly fresh pig's adrenals were finely chopped up and thoroughly mashed with pestle and mortar. They weighed 114 grammes. To this 114 cc. of pure glycerine was added, and 114 cc. of aqua chloroformi. This was allowed to macerate after thorough mixing for twenty-four hours. It was then strained several times through towels and twice through filter paper, the latter in a refrigerator. The last filtrate was a rather cloudy, reddish, thick fluid with a meat-like odor. About 200 cc. remained after filtering, so that 3.7 cc. represented one gland. The patient was started on j ss t. i. d. =z2 cc, or one-half a gland.
On the day following the administration she complained of cramps in the lower part of the abdomen and slight headache, symptoms which she said she had frequently had on previous occasions.
On the 25th she had hiccough very badly for fifteen minutes. This, too, she states that she has had at intervals for the past year. There had been no inci'ease in the pulse, no change in the temperature. Her appetite and digestion were good, and the blood count had risen above normal.
On the 29th she was not so well. She vomited for the first time. The extract was then stopped. She began to have diarrhoea, and felt very giddy and faint.
On the 30th the vomiting persisted, and she had attacks of weakness in which she became short of breath. The cramps in the abdomen had ceased, however, and she felt better. There was no increased rapidity of the heart's action.
July 1st. At 2.45 this morning she became very noisy, screaming and calling out, and the pulse was very weak. The temperature was 97.5°. She became quiet again, but did not seem quite rational. At eight o'clock she lay with her eyes half closed, breathing rapidly and noisily. The pulse at the wrist could not be felt. Slie would not protrude her tongue, and when aroused she became very restless and tossed herself about, throwing off the clothes. The pupils were of medium size and reacted to light. The heart impulse could not be felt ; the sounds were very feeble, and the pulse was 128 to the minute. At times the respirations became extremely feeble, almost sighing. A few minutes after this note was made the patient died suddenly.
The autojisy by Dr. Flexner showed the following condition : Both suprarenal glands were the seat of extensive caseous disease, chieily in the form of nodules which were partially calcified. There was no trace of nornuil gland tissue remaining. The caseous process extended beyond the limits of the gland into the adjacent lymph glands, which, though little enlarged, were also involved. The abdominal lymph glands and those of the anterior mediastinum were somewhat swollen. There was no involvement of the solar plexus or of the splanchnic nerves. Peyer's patches in the ileum were a little swollen, and the solitary follicles in the large intestine
were somewhat enlarged. The left lung showed a thin, wedge-shaped, triangular area near the base, with caseous nodules, some as large as a pea. At the right apex there was some thickening and retraction of the pleura covering an old caseous, partially calcified nodule, and the pleura on this side was obliterated. There were no other tuberculous foci in the body. The heart looked normal.
Remarks. — Of course the first question which suggests itself is whether the toxic symptoms, of which this patient died, were due to the suprarenal extract. Addison's disease may prove fatal either by a gradual asthenia, the result of the vomiting and diarrhoea; by sudden syncope, which may occur at any stage of the disease ; by extension, local or general, of the tuberculous process, and lastly by a sort of toxaemia, in which the patient for several days may have nervous symptoms, such as this patient presented. In a paper pubished in the International Medical Magazine for February of this year, in which I have reported six cases of the disease. Case \^, a patient of Dr. JIullin's, at Hamilton, for forty-eight hours before death had the following group of symptoms : a slight convulsion, which was followed by a dazed condition in which he did not seem to appreciate what was said, great feebleness and rapidity of the pulse, sighing respirations, cold hands and feet, and subsequently much restlessness, pulling at the bed-clothes, and tossing about from side to side. The symptoms were very much the same as those presented by this patient, and I do not think that we can hold the extract responsible. The doses were not excessive. I had hoped to show you the case of Addison's disease which we had under treatment last year and which was shown to this society on several occasions. lie has not been regularly under treatment, but Dr. Futcher reports that he is still alive, though v;eak and failing.
Treatment of Ectopic I'rciriiaucy by Vairinal Puncture.—
I)u. Kki.lv.
I have an interesting and important subject to bring before you to-night, a novel method of treatment of estra-utcriue pregnancy, briefly discussed before this Society at the meeting, October 23, 1893"(see Hulletiu, Nov.. 1S93, p. 109).
Previous to October 23, 1882, it had been my habit, whenever extra-uterine pregnancy was recognized, whether ruptured or unruptured, to extirpate the sac and theclots, through an abdominal incision, at the earliest possible moment, but I had a patient who was too weak for this plan of treatment, and I determined to try a vaginal puncture. I therefore punctured the vaginal vault with scissors, cleaned out the clots, and drained, and the patient got well. In another case, after I had opened the abdomen I found the intestinal adhesions so intimate with the s;ic and so well wallet! off that I determined to make a vaginal puncture. With my finger introduced within the abdominal incision to guard against any encroachment upon the abdominal cavity, I made a free opening into the vaginal vault, through which the wound was drained, and the patient recoveretl. I have now the records of ten cases treated in this way, all of which have done well ; there has been no mortality, and no marked suppuration in the process of recovery. Couvaleicence has beeu
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[Nos. 68-69.
rapid and smooth, and it is especially satisfactory, in that the patient has simply been relieved of the abnormal products without losing any of her normal pelvic structures.
The Operation. 1 do not consider it necessary any more to make the abdominal incision. After an accurate diagnosis of the case, outlining the sac and its relations by abdominal and rectal palpation, and after careful vaginal palpation, to determine the proximity of the sac to the upper vaginal wall, a point is located behind the cervix in the vaginal fornix close to the sac, and a pair of sharp scissors is plunged upward in the direction of the axis of the pelvis. The scissors are then opened and some of the fluid blood usually trickles out at once. Larger scissors are then introduced, if need be, and the opening widened by withdrawing them with blades open. It is important to have a large opening, both for the purpose of getting two fingers in to clean out the sac and for good drainage afterAvard. The torn edges of the wound never bleed excessively. The sac must be delicately cleaned out, and everything be brought away down to the shell of the sac and surrounding adhesions. In one of these cases I brought out a well-defined Fallopian tube cast, due to hemorrhage in the tube. The cleaning out is followed by irrigation, after which the sac is plugged with gauze, which is left in for several days, and sometimes longer, and then the wound is washed out daily until it closes. I know of no instances of more than moderate suppuration following this plan of treatment.
The rt/)r('on' objections to this procedure are several. In the first place, the question arises, would you treat an unruptured tubal pregnancy in this way ? I have never seen but two early unruptured tubal pregnancies, and it is improbable that an unruptured tubal pregnancy at au early stage would be diagnosed at all. It is then practically a question which we do not have to answer. As to the possibility of hemorrhage, the tube having ruptured, the villi become degenerated, and sudden hemorrhage from these surfaces is the great danger to which these patients are liable. But practical experience from these ten cases shows that the occui'rence of hemorrhage is not au imminent danger. In nine cases there was no hemorrhage of any moment after cleaning out the sac. In one case, however, a very important exception, there was an active hemorrhage which I was unable to stop, so I opened the abdomen, extirpated the sac and so checked the hemorrhage, and the patient recovered. For this reason any one who undertakes the vagiiuil puncture must be prepared to make an abdominal section.
One would think that such cases would be particulai'ly prone to suppurate. You expose an area which contains debris not under the control of the tissues of the body, and so peculiarly liable to become septic, if any favorable opportunity is offered; but under the plan of treatment I have detailed, active suppuration has not occurred.
There is one other danger, and one of these cases vividly illustrates it. In some cases the walls of the sac are quite thin, and may readily rupture up towards the abdominal cavity. This did not occur in any of my cases, but something akin to it did. The douche nozzle in one of the earliest cases was thrust through the sac into the abdominal cavity several days after the operation, and a couple of quarts of boric acid solu
tion was forced into the peritoneal cavity. I had to open the
abdomen one night above the symphysis, to wash out the boric
acid solution. The patient made an excellent recovery in
spite of the fact that over a litre of the solution was in the
abdomen for some time.
The plan I have outlined not only marks au important deviation in the treatment of extra-uterine pregnancy, but it also will serve as an index of the line of progress that is being made in general in the domain of gynecology. I uniformly treat all pelvic suppuration cases in the same way where I have good reason to think that I can get at the pus and establish good drainage. The present method of treating these cases is to take out the uterus by the vagina. I have insisted all along that I can get just as good drainage without taking out the uterus. The subject has therefore a broader bearing than the aspect in which I have presented it before the society to-night.
Dr. L. F. Barker. — One objection that might have been raised a year or two ago to the operation Dr. Kelly advises, has recently apparently been made less weighty, that is, the danger of sepsis from bacteria in the vagina. It has been shown by Menge, of Professor Zweifel's clinic in Leipzig, for non-pregnant, and by Kronig of the same institution for pregnant women, that the vagina is nearly always aseptic, that is, free from bacteria that can do harm to the tissues. Doderlein had asserted that the vaginal secretions of women could be divided into two classes, those in which pathogenic bacteria were present and those in which they were absent. It has been shown by Menge and Kronig that within a few hours after the introduction of any body from the outside, even though it be not aseptic, the vagina becomes practically free from pathogenic bacteria. Even if bacteria be introduced experimentally in pure cultures, the vagina is capable of freeing itself in a few hours of streptococci, staphylococci and other pyogenic forms. Menge and Kronig found that the normal inhabitants of the vagina, both cocci and bacilli, are for the most part anaerobic and non-pathogenic. Kronig in his experiments first introduced artificially into the vagina the bacillus pyocyaneus in order to see the effect of the vaginal secretions upon it. Having found that in a few hours all the bacilli were destroyed, he afterward introduced virulent streptococci and staphylococci, and they were just as rapidly and surely destroyed. The vaginal secretion therefore appears to possess active bactericidal powers.
These investigators have further pointed out that irrigation of the vagina before the introduction of the bacteria materially lessens the bactericidal powers of the secretions. Thus for example, irrigations with lysol or sublimate, or the thorough scrubbing of the vagina, previous to the introduction of the outside bacteria, enabled the bacteria to survive for a long time in the vagina, whereas if the irrigation and icrubbing were omitted the bacteria introduced were rapidly killed. They concluded that in cases of operation in the vagina or through the vagina, irrigation should not be employed, and that the most important point to be observed is to omit any examination with fingers that are not aseptic, or the introduction of anything which could carry with it pathogenic bacteria into the vagina, including the prohibition naturally of coitus for some hours preceding the operation. It is better.
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JOHNS HOPKINS HOSPITAL BULLETIN.
211
they think, to trust to the natural bactericidal i)owers of the vaginal secretions under all circumstances, even under pathological conditions, than to attempt to sterilize the vagina by ordinary irrigating methods. I think the results of these investigations are very important in connection with the operation which Dr. Kelly has spoken of to-night, and may in part account for the successful results and the absence of suppuration in his cases. (Of. review of articles by Kronig and Meuge, J. H. H. Bulletin, Vol. VII, Nos. 59-60.)
Dr. Kelly. — A very good contrast, and one which answers Dr. Halsted's question, is that between this class of cases and the suppurating sacs that we open; in the latter, although carefully cleansed, there is a continuous weeping of pus during the healing process. The two classes of cases are different in their clinical characteristics.
I am very glad that Dr. Barker has called attention to these important results from Professor Zweifel's clinic; they are not sufficiently well known in this country. It is interesting to note that Menge's work has superseded that of Doderleiu.
NOTES ON NEW BOOKS.
Manual of Midwifery for the Use of Students and Practitioners. By W. E. FoTHERGiLL, M. A., B. Sc, M. B., C. M., etc. With double colored plate and 69 illustrations in the text. 12mo, pp. 484. {New York and London: The Macmillan Company, 1896.) This is an admirable little book, clearly and concisely written and systematically arranged. The illustrations, when not diagrammatic, have generally been made from frozen sections, and are a genuine assistance to the student. The account given of menstruation, ovulation and conception is fresh and in accord with modern views. Ectopic gestation is also fully and satisfactorily considered, and the chapter in which it is described is a model of clear and accurate statement. The chapters on labor, the use of the forceps, the induction of premature labor, symphysiotomy,' etc., are also to be commended. As might reasonably be anticijiated, there is a degree of local coloring in the book which is j)ardonable when the position of Edinburgh in medical teaching is considered.
Twentieth Century Practice of Medicine. Volume V. Dise.ases of
the Skin. Edited by Thomas L. Stedman, M. D. (New York :
Wm. Wood & Co., 1896.)
The contributors to this volume on dermatology consist of some of the most competent experts both in this country and in Europe, and the results are, speaking generally, excellent. Of course, as one would expect, some articles are particularly good, especially from a practical standpoint; others again make excellent monographs, but their lengtliy and almost useless discussions are to be deplored. A weak point of this volume, as well as of many other modern standard works on cutaneous diseases, is the meagre and often untrustworthy descriptions of the pathology of the affections described. We have already a largo number of excellent works on dermatology, and although some considerable advance has recently been made in dermato-pathology, we see little of it in the newer works. Again, the pathology of dermatology is almost entirely ignored by pathologists, and yet in cutaneous diseases we have the best field for exi)erimental research.
The iirst article, by 0. W. -VUen, on the "Anatomy of the Skin and its Appendages," is short and contains a good rosumt^ of our present knowledge of the physiology and anatomy of the skin.
On page 7 Allen says that " It is at the level of the granular cells that fluid exudations into the epidermis eflCect a separation of the
layers when bullse form or vesiculation occurs." This is not correct according to the more recent work on this subject, for vesicles may begin to form (1) between the horny and the granular layers, (2) in the centre of the rete JIalpighii, (3) in the deeper layers of the epidermis, and (4) beneath the epidermis.
We do not find any description of the various sense points of the skin, which we think ought now to be given in a modern textbook.
" Parasitic Diseases," by L. D. Bulkley, is excellent and is the most practical article in tlie whole book. He has made a new departure in that he has added a third class, viz., " Diseases caused by micro-organisms of uncertain nature," the other two classes being "Diseases caused by (]) animal and ('.;) vegetable parasites." Under vegetable parasites also he has included myringomycosis, vaginomycosis and labiomycosis. Another ought to have been added, although only two cases have thus far been recorded, viz., diseases due to the invasion of blastomycetes or organisms allied to the yeast fungi. Bulkley makes the statement that tinea versicolor is very uncommon in this country and forms only one per cent in the statistics of the American Dermatological Association, whereas in Baltimore we consider it quite a common disease. His statement is probably due to the fact that patients with this cutaneous affection do not apply to the dermatologist for treatment because subjective symptoms are practically absent.
" Erythematous Affections," by H. H. Whitehonse, is fairly good, but the pathology is not at all clear, and in some instances cannot be accepted. His descriptions of bullous and pustular affections are much better.
The article by J. X.Hyde, on "Eczema and Dermatitis," is thorough, well written and very practical. It will prove to be of great value to students and practitioners. Under dermatitis calorica he says that in the vesicular stage, " when examined in section, it is clear that the blebs are histologically identic;d with those seen in herpes zoster, pemphigus and other affections characterized by the formation of bulla;." This most sweeping statement certainly cannot be accepted. The character of the vesicle of herjies zoster is quite distinct from all the other affections mentioned, and it may be added that almost all the vesicular and bullous affections exhibit some, if only slight differences both as to location and contents.
As we might expect, Crocker's articles on " Squamous Affections " and " Phlegmonous and Ulcerative Affections" are all that maybe desired.
The " Papular Affections," by L. Brocq, is an article which, as a monograph, cannot be too highly praised, but for a test-book is too long and almost wearisome.
A. V. Harlingen has written two sections, one on "Diseases of the Sebaceous Glands," and the other on " Diseases of the Sweat Glands." They are both good, complete, and deserve much credit.
" Diseases of the Hair and Nails" is a well written section by D. W. Montgomery, and is a good resume of the subject.
The article on " Benign Neoplasms," by John T. Bowen, is very good, especially the pathology.
Xeroderma Pigmentosum, or Kaposi's disease, written by its author, is such an extremely rare affection in this country that it hardly warrants the detailed description which is here given.
The last and longest article is on " Dermatoneuroses" by H. Leloir. These excellent descriptions, like Brocq's, are too lengthy and discursive for a test-book and could have been condenseil with benefit. He emphasizes the fact that dermatologists shonld "admit the existence of intimate relatiors between diseases of the skin and those of the nervons system, for they demonstrate tliat the nervous system is only a differential ectoderm, and that the skin may be considered schematically as a peripheral and terminal expansion of the nervons system."
The whole volume is well bound, the type is particnlarly clear, but the illustrations are to be severely criticised, not on acconnt of their quality, but ou account of their quantity and distribuUon.
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JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. G8-69.
There are sixty-six illustrations in all, of which fifty accompany the first two articles, viz., on An.atomy of the Skin, etc., aud on Parasites, whereas the remaining .sixteen illustrate rare diseases, e. g. xeroderma pigmentosum is accompanied by eleven drawings. It would have been far preferable to have illustra,ted the descriptions of the commoner diseases, as has already been done in two or three of the later text-books on dermatology.
Judging the volume as a whole, we feel safe in recommending this new text-book to students who wish to enter this special branch of medicine at all thoroughly, and to practitioners for the excellent practical advice which will be found contained in it.
T. C. G.
A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in photolithochromes from models in the Museum of the Saint-Louis Hospital, Paris, with explanatory woodcuts and texts by Ernest Besnier, A. Fournier, Tenneson, Hallopeau, Du Castel, Henri Feulard, Leon Jacquet, of the Saint-Louis Hospital. Edited and annotated by J. J. Pringle, London. (F. O. Rebman, Publisher, London, and W. B. Saunders, Philadelphia.) Part I. Price S3. This number constitutes the iirst publication of a series of twelve parts. To those who have had the advantage of seeing and studying the wonderful Baretta models in the Saint Louis Hospital at Paris, the photo-lithochromes of this pictorial atlas will remind them very vividly of those reproductions. Accompanying the colored plates are descriptions by the distinguished experts of the Saint-Louis Hospital, so that anew illustrated text-book on cutaneous affections will thus be published. Part I contains four plates which, together with the text, constitutes twenty-eight quarto volumes, paper bound. Plate I represents a pronounced case of Lupus vulgaris on the central portion of the face. Although this may be a faithful reproduction of Baretta's model, it does not represent lupus vulgaris as we are in the habit of seeing it, which is accounted for by the fact that the disease has existed for some lentith of time. The smaller nodules do not exhibit that " apple-jelly " color which we see in the early lupus nodules. The description is by E. Besnier, and a good, clear, practical account of this disease is the result. Plate II represents the posterior surface of the forearm and hand of a case of dermatitis herpetiformis (Duhring), and cannot be too highly praised ; the bulte, filled with pus, appear to stand out from the plate. This effect of three dimensions is enhanced by placing the illustration against the window-pane and viewing it by transparent, light. This
plate ranks as the best photolithochrome which we have ever seen. Plate III shows a syphilitic chancre of the vulva, and is also an excellent reproduction. Plate lY represents the thigh, anterior surface, of a case of purpura hjemorrhagica. The case must have been a very severe one, and the effect again is enhanced by transparent light. Woodcuts are added in the text to explain the separate lesions.
The editors and publishers cannot be too highly praised for the beautiful and excellent manner in which these illustrations have been executed. T C G
BOOKS RECEIVED.
