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Wallace (D.) Note on the Nerve Supply of the Musculus sternalis. J. Anat. and Physiol., Lond., 1886-7, vol. xxi, p. 153.
Wallace (D.) Note on the Nerve Supply of the Musculus sternalis. J. Anat. and Physiol., Lond., 1886-7, vol. xxi, p. 153.
==ON THE PATHOLOGICAL CHANGES IN THE SPINAL CORD IN A CASE OF POTT'S DISEASE==
By Sylvan Rosenheim. {From the Anatomical Laboratory of the Johns Hopkins University.)
That scientific advances go hand in hand with improvements in the methods of research has nowhere been better demonstrated, perhaps, than in the study of the central nervous system. Early in this century much was accomplished by mere dissections and sectioning of the various parts of the nervous system, but the greatest strides have occurred since Weigert, in 1884, published his method of staining the myelin sheaths of the nerve fibres. Of the various methods employed to isolate the tracts in the spinal cord, that depending on the degeneration following severance of the connection between a nerve fibre and its trophic centre, namely, the cell-body from which it arises, has been one of the most important.
It is this method of study which has been utilized in the present case, in which the spinal cord was pressed upon by a tuberculous exudate. The methods of Weigert and Marchi have both been employed. It has been possible, by a combination of the two methods, to determine the extent of the degeneration following the compression, and to distinguish the more recent degenerations from those which occurred at an earlier date.
The case is also interesting in view of the light it throws upon some of the more recent problems in connection with the study of the spinal cord, especially
(1) The finer histological changes about the site of primary lesion, and
(2) The paths which descend in the dorsal funiculi. I wish to thank Dr. Barker for his aid in this study.
CLINICAL HISTORY.
The patient, H. H., a female, colored, jet. 15 years, entered Professor Osier's wards of the Johns Hopkins Hospital October 10, 1895, complaining of loss of power in the legs.
Family History. — Father and mother living and well. One of her brothers, who died at the age of 7 years, had contraction of the lower extremities, similar to that from which the patient suffers, one month before his death. Grandmother, on the paternal side, died of a " heavy cough " ; she was very emaciated before death. An aunt on the mother's side is a consumptive.
Personal History. — Patient has had no scrofulous breaking down. Menstruation not yet established. At the age of 6 years the patient was gradually attacked with loss of sensation in the feet, which was shortly afterwards followed by loss of power, and she was confined to her bed for three weeks, when she gradually regained power. She was able to run, walk and skip, and was in good health up to last February. Every winter she suffers from a cough, which lasts until the spring to return again the following winter. Thick white expectoration is associated with the cough.
Present Condition. — In February, 1895, the patient was attacked by influenza. She was ill until March 1st, when she was well enough to get up but found she had no power in the legs. Shortly after this the legs became flexed upon the thighs and the thighs upon the abdomen. This has been the condition for most of the time since, the muscles becoming relaxed only when the patient is asleep or very quiet. The
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bowels and bladder have been voluntarily controlled, micturition being frequent, about four times at niglit, five times during the day. The bowels are constipated, not moving sometimes for a week. About one month ago the movements of the bowels as well as micturition became involuntary. This lasted up to two weeks ago, when the involuntary condition ceased but the movements became frequent. Her mind has been clear all along. There has been no trouble with the eyesight, no pain in the head, and no pain in the back. The floor feels like a cushion. The upper extremities have at no time been afiected. There is no cough at present.
Physical Examination. — Bather thin but generally fairly well developed colored girl. Somewhat pale. Tongue covered with a white coat. Pupils equal. No nystagmus. Movements of the eyes normal. Chest is rather fiat; costal margin is prominent in right parasternal line. Over the upper right chest is a wound situated nearer sternum than axilla, measuring 5x2.5 cm. In the centre of this wound is a sinus in which a probe inserted passes upwards and inwards about 3 cm. to dead bone. Dead bone evidently in the sternum. Probe also passes behind sternum.
Lungs. — Front: Expansion very poor on both sides. Percussion fairly good. Breath sounds clear over right front. Slightly tubular in apex of right axilla. No rales are heard.
Back : Impaired resonance over both upper backs. At the left apex, breath sounds are somewhat tubular. At the base, percussion note is better, but everywhere expiration is somewhat blowing, particularly in left axilla. In this region vocal fremitus is absent, and breath sounds, as well as voice sounds, are distant.
Eight lateral decubitus: A distinct bulging can be seen in the left flank. It measures about 8x4 cm. On palpation it is distinctly fluctuating. Hypodermic needle inserted withdraws a thick, cloudy fluid which, on microscopic examination, is found to consist of broken down cells and granular debris.
There is no marked irregularity of the spine, and apparently no pain anywhere on firm pressure. No bed sores.
Heart. — Point of maximum impulse somewhat diffuse over fourth and fifth spaces from the sternum to nipple line. At the apex the sounds are clear. Soft systolic murmur in the second left space. Aortic area clear.
Abdomen. — Muscles held rigidly; spleen distinctly palpable.
Muscular Power and Sensation. — Muscular power in the arms good, flexors stronger than extensors. Reflexes present at elbow, but not so easily obtainable at wrist. Movements of the facial muscles fairly good. Legs are strongly flexed on thighs and thighs somewhat on abdomen. Almost constant clonus in muscles of left thigh. On attempting to straighten the legs, they are found quite spastic, and clonus is increased. Considerable wasting in the calf muscles, not so marked in the thighs. Patient cannot voluntarily flex the legs upon the thighs. When the legs are extended there is still slight clonus in left flank; not so much ir. the right.
Sensation markedly impaired. Sensations of heat and cold are almost entirely gone from the umbilicus down. Sensation of touch much impaired. There is a region of hyperaesthesia in the back, extending from a little above the ilia and stretching over the gluteal muscles.
The patient was operated on November 2, 1896. The lumbar abscess was incised and packed. The condition of the lower extremities did not improve. The patient gradually became weaker, and died February 13, 1897.
AUTOPSY.
The autopsy was made by Dr. Flexner February 14, 1897. The following notes have been extracted, by permission, from the protocol in the Pathological Laboratory :
Anatomical Diagnosis. — Ihiberculosis of the spine. Extradural exudate. Compression myelitis. Paraplegia. Tuberculosis of sternum. Intestinal tuberculosis. Paralysis of bladder. Pyo-cystitis, pyo-ureteritis, pyelitis, pyelo-nephritis, bronchitis. Lateral curvature of the spine to the left in lower part.
Muscles of feet and legs apparently very much atrophied. Thigh muscles also atrophied, the right more than the left.
On the right side, the pelvis is apparently thrown forward and rotated inward. Crest of the ilium is prominent, and right extremities are rotated inwards. The face shows no emaciation, contours rounded, lower jaw protuberant. The dura covering the brain is moderately adherent to the skullcap. The superior longitudinal and lateral sinuses contain recent clots. Pia and arachnoid are normal. No visible tuberculosis in the pia.
The spinal cord in two distinct situations is the seat of an extra-dural infiltration. The first begins about 2 cm. below the lower edge of the cervical enlargement and extends for a distance of about 5 cm. downwards; it is composed of dense caseous infiltration which averages 4-5 mm. in thickness. The second one begins above the lumbar region and extends over it and below it; it is thicker than the upper, but of the same nature. Both completely infiltrate the subdural areolar tissue.
The cord corresponding to the caseous infiltration is, in the cervico-thoracic region, distinctly softened. The roots of the spinal nerves (motor and sensory) pass through the exudate.
The exudate in the lumbar region has not compressed the spinal cord.
Heart. — Slight fatty degeneration in the intima of the aorta just above the valves.
Lungs. — Emphysematous and osdematous. Pus in bronchi.
Kidneys. — Capsule congested. Beneath the capsule and throughout the kidneys are white areas about the size of miliary tubercles. The kidney substance is soft and oedematous. On section, the cortex is greatly swollen. Striaj obliterated. Mucous membrane of the jielvis and ureters is congested, and shows ecchymoses.
Bladder. — Enormously distended ; contains thick pus. Walls thin.
Spleen. — Enlarged; substance soft on section. A few tubercles seen. Tubercles are occasionally met with in mesentery and omentum.
Intestines. — Swollen solitary follicles in the ileum with excavated centres. Ulcers near the valve, edges raised, surrounded by congested mucous membrane. Tubercles visible in the clear congested base.
Spine. — The bodies of the second, third and fourth thoracic vertebrae are eroded, softened, crumbly, and infiltrated with caseous pus. The transverse processes of the second and third
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lumbar vertebraB are similarly affected. The bodies of these vertebrje are only superficially diseased, however, and this affection is in the locality of the extra-dural exudate. Sternum eroded. Manubrium and gladiolus can be separated.
Muscles of the Back. — Along the spinal column the muscles are invaded by irregular sinuses and collections of pus-containing caseous material.
METHODS OF EXAMINATION.
The spinal cord was immediately put in a mixture of equal parts of formalin (5 per cent.) and Miiller's fluid. The brain, including the medulla, was put into 5 per cent, formalin.
Four slabs of tissue were taken from each segment of the spinal cord, two pieces across the entrance and exit of the nerve roots, and two pieces between the nerve roots, so that when, in the description, a certain segment is designated, a level between the nerve roots above and below the number of the segment mentioned is indicated. Of these four slabs, two pieces were used for Weigert's method and two for Marchi's method of staining, comparative information being thus obtained.
The degeneration of nerve fibres, as is well known, can be divided into two periods— that before and that after the absorption of the disintegrated myelin. The former corresponds to the breaking up of the myelin sheaths into fat droplets; these stain black in Marchi's fluid. The latter corresponds to the stage shown best by Weigert's method, in which there has been absorption of the myelin, and hyperplasia of the glia. Thus the method of Marchi shows those fibres which have only recently degenerated, while Weigert's method gives information regarding those that have been degenerated for some time. As will be seen later, the picture obtained by these two methods difiered considerably in parts. In general, the Weigert method revealed the greater alterations in this case, owing to the length of time which had elapsed since the beginning of the compression.
The roots of the spinal nerves on both sides, to as low a level as the twelfth thoracic inclusive (excepting the fourth cervical pair, which were accidentally lost), were likewise stained separately by the Weigert and Marchi methods.
For a more exact study of the pathological changes, especially in the softened region, additional stains were used — htematoxylin and eosin, hematoxylin and carmine, Upson's carmine. Van Gieson's stain, and Mallory's stain. Good results were also obtained by counter-staining Marchi specimens with Upson's carmine.
FINDINGS ABOUT THE REGION OF COMPRESSION.
As the protocol of the autopsy states there were two areas of extra-dural tuberculous exudate. The upper area alone led to compression of the cord.
The region of compression extends between the eighth cervical and the fourth thoracic nerves, thus involving about three segments of the spinal cord.
With low amplification (10 diameters), a section across the upper part of this region shows that the cord has been compressed dorso-ventrally, much more on the right than on the
left side. The outline of the gray matter is faintly preserved; the white funiculi contain many bands of sclerotic tissue, more marked in the dorsal funiculi. Many small holes in the tissue also occur here. About the middle of the site of compression the cord is much compressed laterally and broadened dorsoventrally. The gray matter is much distorted, the ventral horns being greatly shrunken ; the dorsal horns can be followed for only half their extent. The white matter shows much sclerotic tissue, the holes above mentioned and numerous dilated blood-vessels. In the region corresponding to the lower part of the lesion there is remarkable distortion of the spinal cord. In the ventral half a normal contour is approached, but the dorsal half narrows to a blunt point at the tip of the left dorsal horn. The ventral horns are much shrunken, the " dorsal horns are united for the ventral half of their extent; they then separate at an angle of about 60°, the right horn being much curved. The white matter abounds in sclerotic tissue and holes; the dorsal funiculi are destroyed in their ventral halves, their place being occupied by the united dorsal horns.
General Appearances at the Site of the Compressmi. . See Figs. XIII and XTV.
1. Although the disintegration of the white matter has been very extensive, numerous axis-cylinders staining deeply with acid fuchsin can be seen. The nerve fibres illustrate all stages of disintegration. Many are much swollen and of irregular shapes. Some are entirely devoid of myelin sheath. In other fibres the myelin sheath is still present, but the normal concentric rings are absent. In only a few fibres are the normal concentric rings preserved. Vacuoles are found in many of the nerve fibres. They occur in various parts of the myelin sheath, but are found especially just peripheral to the axis-cylinders.
The axones show various changes. Some are swollen and very irregular in shape. At times only part of the axiscylinder stains, giving rise to bizarre appearances. Some of the axis-cylinders refuse to take on the stain, and the nerve fibres are represented by homogeneous feebly staining masses. Many of the fibres have disappeared, leaving holes to represent them. In Marchi specimens, counter-stained in Upson's carmine, the disintegrated myelin is represented by smaller and larger black balls.
2. The neuroglia is much increased in amount (Fig. XIII). It helps to yield the intense red color seen in all the specimens stained in carmine. It occurs in fine and coarse bands in the lower part of the region of compression, giving rise to the reticl^]ated appearance of the white matter. It is also much proliferated in the gray matter in the middle region of the compression, the dorsal cornu having been converted into masses of sclerotic tissue. Here the ventral fissure is filled with dense connective tissue, and the sclerotic tissue in the white matter can be seen to radiate from this. Many neuroglia-uuclei are seen, some small and round, staining homogeneously with carmine, and surrounded by a small colorless area; others, larger, oval or irregular in shape and granular. Here and there, scattered in the network of neuroglia, are masses of ball-like material, which take on a slight pinkish color in specimens stained by Van Gieson's method. In some
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of these there is seen au irregularly shaped nuclear-like body, which takes on a faint pink stain.
3. The blood-vessels are numerous throughout the white and gray matter and in the fissures of the cord. They are much dilated and packed with blood corpuscles. Their walls stain intensely red in carmine, and around them are aggregations of cells with round and polymorphous nuclei. These vessels, with their thickened walls, give rise to the coarse bauds found at the upper part of the region of compression. There has been considerable hemorrhage at the lower part of the region of compression. Throughout the white matter are many extra vasated red blood corpuscles. They are massed in large heaps in the dorsal funiculi along the periphery and next to the broken up dorsal cornu. Scattered in the white and gray matter, are numerous polymorphous nuclear leucocytes. The blood-vessels at this level are much dilated and are full of corpuscles, most of them red.
4. The ganglion-cells show various changes in the region of compression. At about the level of the first thoracic and eighth cervical segments many of the cells are swollen, their protoplasm staining a homogeneous pink color in carmine. There is no trace of the normal tigroid masses, although these are well seen in sections from areas both above and below the compressed portion. The nucleus in some of the cells is displaced to the edge of the cell, being almost colorless, but containing a deeply staining nucleolus. The cell outlines are not sharp, and the protoplasmic processes are not seen. At the level of the second thoracic segment, only a few distorted ganglion-cells are to be seen. In Marchi specimens, counterstained in Upson's carmine, these stain a homogeneous pink color, and contain numerous small intense black granules. At the level of the third thoracic segment there are but a few indefinitely outlined cells devoid of Nissl bodies, but containing numerous black granules. At the level of the fourth thoracic segment the cells are again more numerous, but Nissl bodies are to be made out ouly in some, and in many the nucleus is displaced to the side of the cell.
5. There is a proliferation of the cells lining the central canal at the level of the first, second and third cervical nerves. The cells here are a couple of layers thick, in parts occluding the lumen of the tube. From the third to the sixth cervical segments, the lumen of the canal is patent and lined by a single layer of high columnar cells. From the sixth cervical segment down to the sacral cord there appears to -have been proliferation of these cells most extensive about the region of compression, being several layers thick there. The lumen is occluded from the first to the fifth thoracic segments. The cells in the proliferative area have lost their columnar appearance.
6. The holes, which have already been mentioned, ai"e found far above and below, but are much more numerous at the site of the compression. These holes have been described before by Krauss,* who attributes their occurrence, probably correctly, to the action of formalin on the tissues, which he thinks causes a contraction of the neuroglia. In this way, he says.
Krauss, \V. C. Formalin as a hardening agent fornerve tissues.
Trans. Am. Micr. Soc, 1895, Buffalo, 1896, vol. xvii, pp. 331-335.
using a 10 to 15 per cent, solution of formalin, the hardened cord has a honeycomb appearance. The fact that these holes are more numerous around the region of compression, in the present case, makes it evident that a softened condition of the cord aids a great deal in effecting this appearance. Some of these holes are empty, some are partly filled by the products of disintegration and absorption of the nerve tissue. The following types and variations of the contents of the holes may be mentioned.
In or about the centre of a hole is a round body containing a nucleus, which stains well in nuclear dyes, surrounded by clear, homogeneous, non-staining, small globules. They are seen in specimens stained by all the methods used. They are the familiar compound granular corpuscles. Variations of this type occur, the granules taking on in carmine and Van Gieson siiecimens a faint pink tinge, giving the protoplasm of the cell a homogeneous or somewhat reticulated appearance. Vacuolic areas occur in these. This variation may be due to dissolving out of the fat.
In sections prepared by all the methods (including Marchi specimens, counter-stained in carmine) there are seen in the holes, bodies, some the size and shape of axis-cylinders, others much larger and of irregular shapes, which stain homogeneously and deeply in carmine, eosin and acid fuchsin. They are the so-called corj)ora amylacea.
There are seen in Marchi and Weigert specimens in the holes, small black droplets and larger black balls.
With Van Gieson's stain some of the holes are seen to be filled with indistinct globules of various sizes, which take on a faint yellowish tinge. In Weigert specimens, counter-stained in Upson's carmine, these are seen more distinctly, and take on a blackish coloration.
The picture presented is that of a myelitis of some duration, showing in different parts of the lesion the forms of white and red softening. The most common of the microscopical appearances are well known ; these consist in the disintegration of the myelin into fat droplets, swelling of the axiscylinders, swelling and disintegration of the ganglion-cells, together with an inflammatory exudation and an infiltration with blood corpuscles. Some of the fat granule cells seen are characteristic. Corresponding with the long duration of the inflammation there has been an extensive proliferation of neuroglia, giving rise to interlacing fibrils and dense sclerotic tissue.
MICROSCOPIC EXAMINATION OF CERTAIN LEVELS ABOVE THE LESION.— ASCENDING DEGENERATION.
The appearance of a section at a given level varies with the method of preparation. In the following descriptions the method is indicated, and when the degeneration field at any one level varies according to different methods several sections will be described. The degenerated fibres are shown in specimens stained by Marchi's method, as black droplets of irregular contour, which on high magnification are seen to take the place of the myelin sheaths of the nerve fibres. The appearance varies according to the magnification used. Some degenerations are so clearly defined as to be readily studied with a magnification of 10 diameters ; in others the degenerated
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fibres are so few and scattered, as to require a higher magnification.
The degeneration field is indicated in the Weigert preparations by a lightening or lack of color. Where only a few scattered fibres have undergone degeneration, it is often impossible by Weigert's method to determine their absence.
First Thoracic Segment. — Upper part stained by Marchi's method and Upson's carmine.
The shape of the cord is tolerably well preserved here ; the gray matter is of normal configuration, but is not very sharply marked off from the white substance.
Dorsal funiculi: These show degeneration over the whole cross-section, but not completely. The degenerated fibres are more closely aggregated in the ventral half, but eveu here there is much intervening matter, partly of a fibrous nature, which stains deeply with carmine. A few axis-cylinders are seen on the periphery. Throughout are many dilated blood capillaries.
Lateral funiculi: In the regions of the fasciculus cerebrospinalis lateralis (lateral pyramidal tract) and the fasciculus cerebellospinalis (direct cerebellar tract) are seen scattered degenerated fibres. The zone thus occupied does not quite reach the lateral horn of the gray matter. Neuroglia tissue is found between the degenerated nerve fibres, and throughout, but more numerous towards the periphery, are large holes, some empty, some filled with material, as before described. But few axis-cylinders are found, staining a bright red color. Extending ventralward from the region of the fasciculus cerebellospinalis is a marginal strip, reaching the ventral median fissure, containing a few degenerated fibres, the number being more numerous in front.
Eighth Cervical Segment. — Weigert-Pal preparation. The shape of this section closely resembles that of the last.
Dorsal funiculi : Seen by the naked eye the dorsal funiculi appear much lightened throughout, excepting a narrow strip on the periphery stretching between the tips of the dorsal gray horns. Microscopically, the degeneration is confirmed. One sees numerous minute holes, probably representing degenerated dorsal root fibres, greatest in extent along the middle third of the septum. Throughout, however, are found numerous well-stained fibres, and along the periphery they all appear of a normal color.
Lateral funiculi : Here the lightened or degenerated area occupies the peripheral half of the column, extending from the tip of the dorsal gray horn to opposite the lateral gray horn. Many holes appear in this region. No lightening occurs in the fasciculus ventrolateralis superficialis (Gowers' tract).
The Marchi specimens show degenerated fibres in practically the same areas in the dorsal funiculi. In the lateral funiculi degenerated fibres are scattered in the peripheral half, being very scattered in the fasciculus ventrolateralis superficialis.
Seventh Cervical Segment,^ e,\gQYi-2&\ preparation. See Fig.
vin.
Dorsal funiculi: The degenerated area no longer occupies the whole breadth of the dorsal funiculi. A relatively large area of healthy fibres intervenes between it and the dorsal
gray horn. Considering both sides of the degeneration together, the lightened area has the shape of a tennis racquet, the end of which next the dorsal gray commissure is slightly expanded. As at the preceding level, the majority of the degenerated fibres occur along the ventral half of the septum.
Lateral funiculi : The lightened area, less intense than in the dorsal funiculi, extends from the tip of the dorsal gray horn to the emergence of the ventral roots. In its dorsal part it occupies the lateral third of the lateral column ; in the region of Gowers' tract it is slightly broader, occupying about half the breadth of the column. The lightening seems to consist in a feebleness rather than a lack of staining. Between Gowers' tract and the direct cerebellar tract is a band of fibres staining more deeply.
The Marchi specimen shows a similar distribution of the degenerated fibres in the dorsal funiculi, with a few scattered degenerated fibres in the lateral part of the fasciculus cuneatus (Burdachi). In the lateral funiculi, there are but scattered degenerated fibres in the lateral pyramidal tract, direct cerebellar tract, and Gowers' tract ; they are most numerous at the periphery of the cord.
Fifth Cervical Segment, Weigert preparation. See Fig.
vn.
Dorsal funiculi : The degenerated area occupies now a little more than the fasciculus gracilis. Considering both sides together it is bottle-shaped, the part resting next the dorsal gray commissure being slightly expanded. The lightening is more marked in the ventral half.
Lateral funiculi : The degenerated area extends from the tip of the dorsal horn to the exit of the ventral root. Next the dorsal horn, it occupies the peripheral third of the lateral column for a short distance ; it then narrows, and opposite the lateral gray horn it again expands, occupying half the breadth of the column.
Marchi specimens stained in carmine show a marked increase in neuroglia among the degenerated fibres in the dorsal fasciculi. Here also are seen many axis-cylinders staining intensely red. Burdach's fasciculus contains a few scattered degenerated fibres. In the lateral column the degenerated zone is about the same shape as in the Weigert specimen, the direct cerebellar being more affected. In the region of the fasciculus veutrolateralis superficialis (Gowersi), the degenerated fibres are more scattered.
Third Cervical Segment, Weigert preparation. See Fig. V.
Dorsal funiculi: The lightened area is restricted to the fasciculus gracilis (Golli), occupying the dorsal threefourths. Considering both sides together the area is triangular in shape with the base at the periphery. There is a small peripheral part next the dorsal median septum which is scarcely at all lightened.
The entering dorsal roots on both sides show lightening, more marked on the right side. There is also lightening of Lissauer's fasciculus.
Lateral funiculi: The degenerated zone extends from the tip of the dorsal gray horn to the ventral roots, occupying the peripheral half of the lateral column. It is much more intense in Gowers' tract. In the region of the fasciculus cerebellospinalis (direct cerebellar tract) the degeneration is
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more marked a little inwards from the periphery of the cord. Nest the periphery there is a band of almost normally staining fibres. Notwithstanding the degenerated fibres in the dorsal roots, the collaterals entering the gray matter appear to be of normal number and to be well stained.
The Marchi specimen (Fig. VI) shows iu addition to the triangular area in Goll's fasciculus scattered degenerated fibres in the fasciculus cuneatus, more numerous on the periphery.
In the lateral funiculi it is to be especially noted that more degenerated fibres are visible in the fasciculus cerebellospinalis (direct cerebellar tract) than farther ventralwards. The degeneration of this tract is better defined here than in the sections lower down.
Second Cervical Segment, Weigert preparation. See Fig. III.
In the dorsal funiculi the degeneration is the same as that described for the third cervical segment.
In the lateral funiculi the fasciculus cerebellospinalis and the fasciculus veutrolateralis superficialis are degenerated iu about the same region as seen at the third cervical segment; the band of more deeply staining fibres along the periphery next the fasciculus cerebellospinalis is very well marked. Besides these degenerations there appears to be a slight lightening in the lateral funiculi extending along the outside of the lateral gray horn. It is not very marked, and blends with the area of healthy fibres separating it from the fasciculus of Gowers.
The Marchi specimens (Fig. IV) at this level show blackened fibres in the entering dorsal roots.
First Cervical Segment, Weigert preparation. See Fig. I.
Dorsal funiculi: A surprising change has occurred in the shape of the degenerated field. Considered as before, the triangle has lengthened dorso-ventrally, the apex again reaching the dorsal gray commissure. The shape is not strictly triangular, as there is a slight concavity on each side next the fasiculus cuneatus (Burdachi). The dorsal half of the area is not as much lightened as the rest.
Many unstained fibres are seen in the dorsal roots on both sides. Lissauer's fasciculus also shows considerable lightening.
Lateral funiculi : Here the degenerated zones are separated a little ventral from the tip of the dorsal horn by a band of less lightened tissue. The dorsal portion embraces Lissauer's fasciculus, and is separated from the periphery by a narrow strip of almost normally staining white matter. The ventral part starts a little behind a line drawn across the lateral gray horns, and extends to the emergence of the ventral roots, occupying the lateral half of the column. There is also a slight lightening next the lateral gray horn.
The Marchi specimen (Fig. II) from this segment represents a little higher level, namely, at about the lowest part of the decussation of the pyramidal tract.
In the dorsal funiculi a few degenerated fibres are seen on the dorsal periphery of the fasciculus cuneatus.
The degeneration in the fasciculus cerebellospinalis is well marked, the shape of the area difEering slightly from that last described, being much thickened next the tip of the dor
sal gray horn. In the region of the fasciculus ventrolateralis superficialis there are but few scattered degenerated fibres.
MICROSCOPIC EXAMINATION OF CERTAIN LEVELS
BELOW THE LESION.— DESCENDING
DEGENERATION.
Fourth Thoracic Segmeiit, Marchi specimen. See Fig. IX.
The entire degeneration is so distinct that the individual degenerated fibres can be seen with a magnification of ten diameters.
Dorsal funiculi: The degeneration assumes a peculiar shape, which may be considered as a union of a septal degeneration and a degeneration of the comma of Schultze. The former begins at a point on the dorsal median septum and running ventralwards broadens out to join the comma tract. The latter is separated by a narrow interval from most of the dorsal horn, but touches the dorsal gray commissure and the nucleus dorsalis (Clark's column), where it is broadest. From here it tapers oif going dorsal wards, extending about three-fourths of the distance between the commissure and the periphery in the fasciculus cuneatus. The degeneration though intense is not complete.
Lateral funiculi: The fasciculus cerebrospinalis lateralis contains many degenerated fibres, and also many holes as described before. Some degenerated fibres appear on the periphery in the region of the fasciculus cerebellospinalis. Besides these, there is a small zone of scattered degeneration in the fasciculus lateralis proprius, next to the pyramidal tract.
The ventral funiculi contain scattered degenerated fibres. Numerous holes appear in the ventral and lateral funiculi, being more abundant along the periphery.
In the Weigert specimen, the degeneration occupies practically the same area. The comma zone is more lightened than the area of septal degeneration in the dorsal funiculi.
Fifth Thoracic Segment, Weigert preparation. Fig. X.
Dorsal Funiculi : There is a narrow degenerated strip in the fasciculus cuneatus, beginning near the gray matter constituting the nucleus dorsalis (Clarkii) and extending dorsalwards half the breadth of the fasciculus. The lightening is jjlainly visible, but not intense.
In the lateral funiculi, there is typical degeneration of the fasciculus cerebrospinalis lateralis (lateral pyramidal tract).
Marchi Specimen : No blackened fibres are seen in the dorsal funiculi. The pyramidal degeneration occupies the same area as that in the Weigert preparation. In the ventral funiculi, there are a few scattered fibres extending from the ventral median fissure to the emergence of the ventral roots, occupying the lateral half of the funiculus.
Sixth Thoracic Segment, Weigert specimen. See Fig. XI.
It is to be noted that the strips of degeneration in the dorsal funiculi are seen for the last time at this level.
From this point on the pyramidal tract degenerates in its well known form, being restricted at the beginning of the intumescentia lumbalis to the lateral two-thirds of the lateral funiculus. Here it is separated from the gray matter by a band of sound fibres.
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SUMMARY OF THE ASCENDING DEGENERATION.
1. Dorsal Funiculi. — Starting at the level of the first thoracic segment the degenerated area occupies the whole of the dorsal funiculi but is not complete. Some fibres particularly on the periphery are spared. Traveling up, the degenerated area is narrowed by the entering dorsal roots, so that at the level of the seventh cervical segment it assumes the shape of the tennis racquet before described ; at the level of the fifth cervical segment it is bottle-shaped, occupying now little more than the region of the fasciculus gracilis (Golli). It is to be noted in comparing the Weigert-Pal and Marchi specimens that the parts shown to be most sclerosed by the former method, namely, the ventral and medial parts, show by the latter a lessened number of blackened myelin sheaths ; whereas the blacker parts in the Weigert's specimens, the dorsal part, show some blackened sheaths. In general, the distribution of the degeneration, as shown by the two methods, is the same. At the level of the third cervical segment the degenerated area is triangular in shape, occupying the dorsal three-fourths of the fasciculus gracilis. At the first cervical segment the degenerated triangle has lengthened dorso-ventrally, again reaching the dorsal gray commissure. In the medulla, the fasciculus gracilis is much degenerated, and the degenerated fibres can be followed directly into the nucleus funiculi gracilis.
Besides this typical ascending degeneration, there is to be seen in the Marchi specimens, at the level of the first, second and third cervical segments, a narrow marginal degeneration in the fasciculus cuneatus. Farther down at the fourth and fifth cervical segments a few degenerated fibres are seen in this region. It is also to be noted that the dorsal roots at the level of the first, second and third cervical segments are partially degenerated.
3. Fascicuhis Gerehellospinalis (^Direct Cerebellar Tract). — The degeneration of this fasciculus corresponds to a definite area at the level of the eighth cervical segment. Below, the degenerated fibres of this fasciculus are mingled with those of the lateral pyramidal tract and of the fasciculus lateralis proprius. At the lower part of the eighth cervical segment it occupies the lateral half of the lateral column, extending as far forward as a point opposite the lateral gray horn. In ascending, the area of this degeneration, as seen in the Weigert preparations, remains narrow in its dorsal half, broadening out a little dorsal to the lateral gray horn, where it joins the fasciculus ventrolateralis superficialis (Gowersi.) (In the Marchi specimens the zone remains narrow until it reaches the lateral gray horn.)
The shape has completely changed at the level of the third cervical segment. For a short interval in front of the tip of the dorsal horn it is very narrow, it then broadens, atid is compact and well marked midway between the dorsal and lateral gray horns. At this level there is a zone of darker staining fibres nest to the periphery in the Weigert specimen, a little ventral to the tip of the dorsal gray horn. The Marchi specimen shows a well defined degeneration there. Ascending, the degeneration lessens very much in the Weigert specimens. At the first cervical segment, a sound band of fibres is interposed between the periphery and the degenerated area, as seen in the Weigert specimens. Here the degenerated area con
sists of a small part projecting from the tip of the dorsal horn, and separated from the periphery by the band of sound fibres mentioned. In the Marchi specimen at this level the relations are very different from those met with in the Weigert preparations; the degenerated area, which is very well defined, is very broad next the dorsal horn, and narrows to a point as it extends ventralwards. This latter shape is preserved at the lower part of the medulla, as seen in the Marchi specimens.
3. Fasciculus Ventrolateralis Stiperficialis {Gowersi). — The description of this fasciculus corresponds to the Weigert specimens, as the degeneration of this tract is not well marked in the specimens prepared by the method of Marchi. The degeneration is first plainly visible at the lower part of the seventh cervical segment, where it extends from the direct cerebellar tract to the emergence of the ventral root. It occupies here the peripheral half of the lateral funiculus, but is not very well marked at this level. Ascending it undergoes but slight change in shape. At the third cervical segment it becomes more intense, and is separated from the direct cerebellar tract by a band of darker color (less degenerated). This relation is seen also at the first cervical segment.
SUMMARY OF DESCENDING DEGENERATION.
1. Fasciculus Cereirospinalis Lateralis {Lateral Pyramidal Tract). — The degeneration in this tract begins at the fourth thoracic segment, where it is well marked, and is slightly removed from the neck of the dorsal horn. Descending it becomes smaller, the interval between it and the dorsal horn becoming widened. Corresponding to the change in shape of the cord in the lumbar region, it becomes narrowed from side to side and broadened dorso-ventrally. The degeneration continues down to the conus terminalis ; at the lower sacral region it can be plainly seen in the Weigert specimens, but it is no longer sharply outlined.
3. Fasciculus Ventralis Proprius and Fasciculus Lateralis Proprius { Ventrolateral Ground Bundles). — The degeneration in the ground bundles is most evident in the Marchi specimens. It begins at the level of the fourth thoracic segment, where it occujjies the entire ventral and part of the lateral funiculus. It rapidly diminishes in size, and has entirely disappeared at the level of the seventh thoracic segment.
3. Septal Degeneration. — This is an intense degeneration extending along the dorsal median septum from the dorsal gray commissure to near the periphery of the cord. It can be made out in Weigert specimens for but one segment below the lesion.
4. Comma of Schultze. — This is seen beautifully at the level of the fourth thoracic segment, one segment below the lesion. The head of the comma almost touches the doi'sal commissure, and joins on the other hand the septal degeneration before described. The head is more intensely degenerated than the tail end, which does not reach the periphery of the cord. At the level of the fifth thoracic segment, the degenerated areas occupy two small strips in the fasciculus cuneatus reaching to the gray matter. The tract is last seen as a similar less intense degeneration at the sixth thoracic segment.
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COMPARISON OF THIS CASE WITH OTHERS IN THE BIBLIOGRAPHY.
A feature of tbis case, very little described and figured in the literature, is the appearance of the holes left empty by the degenerated nerve fibres. The peculiar pictures seen are to be regarded, in general, as different stages in the disintegration of the nerve fibres. V. Babes* describes and figures some of these, namely, the hyaline masses occupying part of the holes. He says that the latter are probably derived from swollen axis-cylinders. The study of the present case confirms this view, as all stages between the degenerating fibres and the hyaline masses can be seen. He also pictures the holes, which are, in his cases, entirely filled with fat droplets.
E. A. Honien,"!" in Babes' Atlas, describes the process of the degeneration of the nerve fibres as it occurs experimentally in dogs. According to him, the first change to take place occurs about four days after the lesion, and consists of a swelling and granulation of the axis-cylinders. These lose their power of staining with the usual dyes, but stain strongly with acid fuchsin. This, according to Homen, harmonizes with the theory which assumes the cell to be the trophic centre, since the axis-cylinder is the first to suffer from the disconnection of the nerve fibre with it. This statement differs from that of Miiller. MiillerJ noted in a case of myelitis of tuberculous origin, that certain axis-cylinders colored deeply in specimens stained by Van Gieson's method ; he found further that the myelin sheaths, corresponding to these intensely staining axis-cylinders, are those which stain by Marchi's method. He takes this as evidence of the strong vitality of the axis-cylinders, and says that they can withstand destructive influences for a longer time than the myelin sheaths. In the present case, many deeply staining axis-cylinders were seen about the site of compression in sections stained by Van Gieson's method. In specimens stained both by Marchi's and Van Gieson's methods, some of the axis-cylinders in the degenerated fibres refuse to stain, and others stain but feebly.
The changes in the axis-cylinder are followed by a fragmentation of the myelin sheath, which begins in the part of the myelin immediately adjacent to the axis-cylinder and extends peripheralwards (Homen). This harmonizes with the fact that in the present case vacuolar areas were frequently found surrounding the axis-cylinder. In ten or twelve days the fibres first affected are, Homen declares, broken up into a granular mass. About this time, or a few days later, there begins to be a reaction on the part of the neuroglia, manifested by karyokinesis and proliferation of the neuroglia cells. About the twenty-first day, the corpora amy
Babes, V. Verschiedene Formen der Entartung und Entzundung des Riickenmarkes. Atlas d. path. Histol. d. Nervensyst.
Berl., 1896, Lfg. vi, S. 20-35.
t Hom^n, E. A. Die histologischen Veranderungen bei der (experimentellen) secundaren Degeneration des Riickenmarkes. Atlas (i. path. Histol d. Nervensyst. Berl., 1896, Lfg. vi, S. 5-19.
i Miiller, L. R. Ueber einen Fall von Tuberculose des oberen Lendenmarkes mit besonderer Beriicksichtigung der secundaren Degcnerationen. Deutsche Ztschr. f. Nervenh., Leipz., 1896-7, Bd. X, S. 273-291.
lacea first appear. About the same time a few leucocytes and compound granular cells are met with.
Dorsal Fvniculi. — This case confirms and adds to the history of secondary degenerations in this region. The ascending and descending degenerations concern fibres of both exogenous and endogenous origin. It has been long known that the fibres of exogenous origin after entering the dorsal funiculi bifurcate; the long ascending limbs of bifurcation are displaced so as to occupy a position more medial and dorsal as they pass up. Thus, a compression in the lower region of the cord causes an area of degeneration in the dorsal funiculi, which in ascending becomes gradually smaller in size, assuming in the cervical region a triangular shape with the base of the triangle at the periphery of the cord. The peripheral distribution of this and other long tracts led Flatau* to formulate the law "that the short fibres of the cord run in close relation to the gray matter, while the long fibres select a position nearer to the periphery of the cord."
What is exceptional in the present case is the fact that the apex of the triangular shaped degeneration does not reach the dorsal gray commissure at the level of the third cervical segment, whereas higher up in the region of the first cervical segment it has become lengthened dorso-ventrally, again reaching the dorsal gray commissure. In Schultze'sf cases, in two of which the lumbar cord was diseased, in one the cauda equina affected, and in the other there was a complete transverse lesion of the lower thoracic region, this dorso-ventral lengthening of the degenerated area was not seen. It is not pictured by Gombault and Philippe.J It is shown, however, in a case of Darkschewitch's,§ in which the cauda equina was jjressed upon by a pachymeningitis. In his case the dorsoventral lengthening was pictured high up in the cervical cord. The apex of the degenerated triangle in the fasciculus gracilis, in Spiller'sll case, in which the compression was exerted at the cervi co-thoracic junction of the cord, did not reach the dorsal gray commissure in a section taken just below the pyramidal decussation.
Concomitant with this dorso-ventral lengthening of the degenerated area, we find degenerated fibres in the dorsal roots of the first, second and third cervical nerves. The question naturally arises, is there any connection between these two facts. That this lengthening of the degenerated area is due to these degenerated dorsal root fibres is negatived both by the result of section of the cervical dorsal i-oots and
Flatau (E.) Das Gesetz der excentrischen Lagerung der langen
Babnen im Riickenmark. Ztschr. f. kiln. Med., Berl., 1897, Bd. xxxiii, S. 55-152.
tSchultze. Beitrag zur Lehre von der secundaren Degeneration im Riickenmarke des Menschen nebst Bemerkungen fiber die Anatomie der Tabes. Arch. f. Psychiat., Berl., 1883, Bd. xiv, S. 259-390.
^Gombault, A. et Philippe. Contribution a I'etude des l<!'8ion8 systematiaees dans les cordons blancs de la moelle ^piniere, Arch, de med. exper. et d'anat. path., Par., 1894, t. vi, H. 365-424.
§Darkschewit8ch, L. 0. Zur Frage von den secuiidiiren Veranderungen der weissen Substanz des Euckenmarks bei Erkrankung der Cauda equina. Neurol. Centralbl., Leipz., 1896, Bd. xv, S. 5-13.
JSpiHer, W. G. A microscopical study of the Spinal Cord in two cases of Pott's Disease. .Johns Hopkins Hoepital Bulletin, Bait., June, 1698.
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the study of human cases, iu which either the cervical roots were degenerated or there was a lesion of the upper thoracic or cervical cord; these results teach us that the ascending branches of the cervical dorsal roots remain throughout their entire course in the funiculus cuneatus. That the degenerated fibres are not longitudinal association paths seems untenable in light of the case reported by Mme. J. Dejerine and J. Sottas* of medullary syphilis of the cord, extending from the third to the eleventh thoracic roots. The authors found the fasciculus gracilis entirely degenerated, and they concluded from this and other cases that the fasciculus gracilis is composed entirely of ascending dorsal root fibres, and that it does not receive in its course any fibres of endogenous origin. The dorso-ventral lengthening of the degenerated area is readily understood, if the view that some fibres of the fasciculus gracilis end in the gray matter of the upper cervical region is correct.
Comma of SchuUze.-f — Our knowledge concerning the endogenous paths iu the cord is not so satisfactory. The path, linown as the comma of Schultze, had been seen as early as 1866 by Bouchard, and later by Striimpell, but it was first made the object of especial study by Schultze in 1883. Among several cases of degeneration in the spinal cord from compression, he found the comma shaped area in only one instance, extending as two parallel lines, two and one-half centimeters below the lesion.
The origin of the fibres in Schultze's comma is still a disputed point. Schultze assumed that they came from the dorsal roots, and the same view has been held by Bruns, Lenhossek,
Dejerine, J., et J. Sottas. Sur la distribution des fibres Endogcnea dans le cordon posterieur de la moelle et sur la constitution
du cordon de goll. Comp. rend. Soc. de biol., Par., 1895, 10 s., t. ii, pp. 405-469.
t The following bibliography dealing with the comma of Schultze has been consulted : —
Schultze. Beitrag zur Lehre von der secundiiren Degeneration im Elickenmarke des Menchen nebst Bemerkungen iiber die Anatomie des Tabes. Arch. f. Psychiat., Berl., 1883, Bd. xiv, S. 359-390.
Gombault et Philippe. Contribution a I'etude des lesions systematisees dans les cordons blancs de la moelle epiniere. Arch, de miSJ. exp6r. et d'anat path.. Par., 1894, t. vi, pp. 365-424.
Lenhossek, M. v. Der feinere Bau des Nervensystems im Lichte neuester Forschungen. Berl., 1893.
Hoche. A. Ueber Verlauf und Endingungsweise der Fasern des ovalen Hinterstrangsfeldes im Leudenmarke. Neurol. Centralbl., Leipz., 1896, Bd. xv, S. 154-156.
Also, XJeber secundiire Degeneration, speciell des Gowers' chen Biindels, nebst Bemerkungen tiber das Verhalten der Refiexe bei Compression des Ruckenmarkes. Arch. f. Psychiat., Berl., 1896, Bd. xxviii, S. 510-543.
Zappert, J. Beitriige zur absteigenden Hinterstrangsdegeneration. Neurol. Centralbl., Leipz,, 1898, Bd. xvii, S. 103107.
Midler, L. R. Ueber einen Fall von Tuberculose des oberen Lendenmarkes mit besonderer Beriicksichtigung der secundiiren Degeneration. Deutsche Ztsehr. f. Nervenh., Leipz., 1896-7, Bd. x, S. 273-291.
Campbell, A. W. On the Tracts in the Spinal Cord and their Degenerations. Brain, Lond., 1897, vol. xx, pp. 488-535.
Spiller, W. G. A Microscopical Study of the Spinal Cord.in two Cases of Pott's Disease. Johns Hopkins Hospital Bulletin, Bait., June, 1898.
Singer and others. Gombault and Philippe, Tooth, Marie and others maintain that they do not come from dorsal root fibres, as the comma is found degenerated in lesions of the cord itself. It is to be noted, however, that dorsal root fibres, that have already entered the cord, or their descending limbs of bifurcation, might be involved in a lesion of the cord itself.
That degeneration of the comma tract is, in this instance, not due to lesions of the dorsal roots outside the cord is proved by the present case, where all the root fibres are perfectly healthy for no less than eight segments above and for all the segments below the lesion. The fibres must arise then from the tracts in the ventral or lateral funiculi of the cord, from descending fibres of the dorsal roots which have already entered the cord, or from the cells of the cord. Now, as a matter of fact, no one has seen or imagined the least connection between the tracts in the lateral and ventral funiculi and the comma tract, or between the ventral roots and the comma path. Against the view that the bulk of the path is constituted of descending limbs of bifurcated dorsal root fibres is its long course, since, as shown by Hoche, degenerated fibres of the comma tract may be traced for ten segments below the site of the lesion, while it is generally believed that the descending branches of the dorsal root fibres run down but a short distance (von Lenhossek). The bulk of the path is then, in all probability, made up of fibres which arise in cells situated in the gray matter of the cord, a view which is made all the more probable by the close relation which has been proven to exist between this path and the gray matter.
Within the last year there has appeared an article by Zappert, iu which he supports the view that the path is composed of fibres partly of exogenous and partly of endogenous origin. He studied the cord of a luetic child which had died a few days after birth. There was inflammation of the pia mater in the cervical region, compressing the ventral and dorsal roots in this region and causing their degeneration. The cord itself was intact. Besides other degenerations, he found an intense degeneration of the comma of Schultze, reaching as far as the lower third of the thoracic cord. He therefore believes that the greater part of Schultze's comma is made up of fibres of exogenous origin.
The path is now recognized as a long path. Schultze, as mentioned, found it for only a short distance below the lesion. In tlie present case it was seen but for three segments below the lesion, probably because the AVeigert method is not delicate enough to demonstrate the sparsely scattered degenerated fibres lower down. Hoche, Bruce and Muir, and others, by means of Marchi's method, in cases of recent injury, have proven conclusively that the path extends for ten or more segments below the lesion; iu one case Hoche followed it down into the lumbar cord, although below, the fibres were very scattered.
The method used, and the fact that the authors did not follow the degeneration closely enough, led to the erroneous view of Gombault and Philippe, who tliought that the comma tract was connected with the oval field of Flechsig. They explained the change in position by saying that higher up the oval-field fibres are puslied aside, in a way analogous to the formation of the fasciculus gracilis.
Tlie fibres of Schultze's comma probably end, as pointed out by Hoche, in the gray matter of the dorsal horn, as they re
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JOHNS HOPKINS HOSPITAL BULLETIN.
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remain next to it for their entire course. He was able to trace fibres for a short distance into the gray matter, but they were soon lost owing probably to a change in direction.
The septal degeneration whicli runs but one segment below the lesion is rather unusual. Hoche figured it somewhat as seen in the present case. Spiller, in a case of compression of the cord at the level of the first thoracic segment, found a diffuse degeneration of the ventral portion of the dorsal funiculi, which extended 3i cm. below the place of compression. Miiller also described an intense degeneration of the ventral half of the dorsal funiculi, which extended for several segments below the compression, which was due to a solitary tubercle of the spinal cord, extending between the first and second lumbar nerves.
Fasciculus Cerebellospinalis. — Of the views relating to the origin of the axones of this path, that most generally accepted is that they arise from the nerve cells of the nucleus dorsalis. Tooth* however concludes from his experimental work done on monkeys, that in the cervical region and possibly also in the upper thoracic region, fibres from the dorsal roots of the spinal nerves enter largely into the composition of this tract. Tooth admits that lower down the fibres do not come by way of the dorsal roots. If this view of Tooth is correct, it will possibly explain the different pictures of this path, in the present case, given by the methods of Marchi and Weigert.
The nucleus dorsalis, which then, everyone admits gives rise to the bulk of this fasciculus, extends from the seventh cervical to the third lumbar segment of the spinal cord. The lowest limit of the transverse lesion in this case, being at the level of the third thoracic segment, one would expect an extensive involvement of this tract. The degeneration of this tract is found to occupy in its lower part, the usual area ascribed to it, but it is not very intense. The interesting point in connection with it is the variation in the picture given by the method of Marchi from that revealed by the method of Weigert.
Up to the third cervical segment, as seen by both methods, the degenerated area occupies its usual position, extending veutralwards from the tip of the dorsal gray horn and outside the region of the fasciculus cerebrospiualis lateralis. At the level of the third cervical segment the field degenerated becomes more evident in the Marchi specimens. It will be remembered that the third cervical dorsal roots on both sides are degenerated. The view of Tooth, that the cervical dorsal roots take j)art in the formation of this fasciculus, would explain this tract becoming more evident here. If Tooth be correct, however, it is curious that such a host of observations as those recorded, have been constantly negative as regards this point. On the other hand, in the Weigert specimen, the intensity of the degeneration remains the same, and there appears a band of sounder fibres which lies on the periphery of the cord next to the tip of the dorsal gray horn. The third cervical roots as seen in the Weigert specimen also contain degenerated fibres. At the level of the first cervical segment the area of degeneration is very faint in
Tooth. Quoted from A. W. Campbell, Brain, 1897, op. cit. p. 8.
the Weigert specimens, and is separated from the periphery of the cord by a bundle of sound fibres. On the other hand, in the specimens prepared by the method of Marchi, the degeneration is very well marked. It is readily seen with a magnification of ten diameters. The first and second cervical dorsal roots are found degenerated by both methods. The shape of the degeneration, also, is somewhat different at the level of the first cervical segment in the Marchi specimens. Next to the tip of the dorsal gray horn it is very broad, occupying the peripheral third of the lateral column. In passing ventralwards it diminishes in breadth.
The shape of this tract as seen in the Marchi specimens corresponds "to that in the new edition of Quain* in a case of hemi-section at the level of the twelfth thoracic nerve. Hoche'sf pictures of this tract at the level of the first cervical segment do not correspond with that seen in the present case. His cases were instances of compression myelitis at the level of the first thoracic and between the fourth and fifth thoracic segments. He represents the fasciculus cerebellospinalis as starting in a point at the tip of the dorsal gray horn and increasing in width on going veutralwards to join Gowers' tract. In his cases the cord was examined from four to six weeks after the onset of compression.
Fasciculus Ventrolateral is Siqierficialis (Gowersi). — This tract is not so well understood as is the direct cerebellar. Its origin is not definitely known. Schiifer in Qnain's Anatomy states that it probably comes from cells in the dorsal horn in the lumbar region. CampbellJ believes that the axones probably arise from cells in the gray matter of the lumbar cord, possibly in the middle cell-column" of Wakleyer. Lenhossek§ says it arises partly from cells in the ventral horns and partly from cells in the middle zone of the gray matter.
One would therefore expect in this case to find considerable degeneration of this tract. This is not especially indicated in either the Weigert or Marchi specimens. In the latter only scattered degenerated fibres are found in the tract as far up as it was traced. The Weigert method revealed more alterations, and with it the degeneration seemed to be more intense at the higher levels of the cord. It was not, as mentioned by Schiifer, most intense immediately adjacent to the fascicuhts cerebrospiualis lateralis (lateral pyramidal tract), but a little ventral to this, opposite the gray horn. This appearance conies out best at the first cervical segment, where a sounder band of fibres is interposed between the degenerated Gowers' tract and the direct cerebellar tract.
The position of Gowers' tract in the figures of Hoche agrees fairly well with the present case as far as the first cervical seg
Quain (J.) The Elements of Anatomy. Edited by E. A. Schafer
and G. D. Thane. 10 ed. The Spinal Cord and Brain, 1893.
t Hoche, A. Ueber secundiire Degeneration, speciell des Gowerschen Biindels, nebst Bemerkungen iiber das Verhalten der Reflexe bei Compression des Riickenmarkes. Arch. f. Psychiat., Berl., 1896, Bd. xxviii, S. 510-543.
j Campbell, A. W. On the Tracts in the Spinal Cord and their Degenerations. Brain, Lond., 1897, vol. xx, pp. 488-535.
I Lenhoss^k, M. v. Der feinere Bau des Nervensystems im Licbte neuester Forschungen, Berl., 1893.
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meiit, the diflerence of methods being taken into consideration. Farther up the degeneration cannot be followed in the Weigert preparations, nor is it indicated in the Marchi specimens. It is generally conceded that the bnlk of Gowers' tract is ascending, so the fact that the degeneration of the direct cerebellar comes out well, and that of Gowers poorly or not at all, by Marchi's method, would seem to indicate that Gowers' tract degenerated sooner in this case than the direct cerebellar.
Rajjidity of Degeneration. — It may be worth while here to say a word concerning the results given by the Weigert and Marchi methods. ScliatTer* noted certain differences between the results of the two methods in a case of transverse lesion of the spinal cord. He employed both the Marchi -and Weigert methods, and obtained results which diflered from previous observations. He concluded from his work that after a transverse lesion of the cord, the fasciculus gracilis degenerates most quickly, the fasciculus cerebrospinalis lateralis next, while the descending degeneration in the dorsal funiculi, the ascending degeneration of the fasciculus cuneatus, the fasciculus ventrolateralis superficialis and the fasciculus cerebellospinalis follows later.
Whether all of SchafTer's conclusions are true or not remains to be seen, but the case here recorded lends support to some of his statements. The fasciculus gracilis is the most sclerosed of all the tracts, as is beautifully revealed by Weigert's method. Homenf states that after section of the spinal cord in dogs, the first degenerative changes are seen three or four days after the operation in the dorsal funiculi above the place of operation. The fiisciculus cerebrospinalis lateralis shows on the whole slightly more degeneration by Weigert's method than either the fasciculus cerebellospinalis or the fasciculus ventrolateralis superficialis, although the latter shows well marked degeneration at the highest levels of the cord. The Marchi method which reveals degeneration in actual progress, shows least of all in Gowers' tract throughout its entire course. The degenerated field in the dorsal funiculi corresponds in area to that in the Weigert specimens, but is of less intensity. An interesting point with regard to the fasciculus cerebellospinalis is the fact that different fields of degeneration are revealed by the two methods at the highest levels of the cord. Concerning the descending degeneration, the most striking feature is that the degeneration in the dorsal funiculi extends but one segment below the lesion. In the lateral pyramidal tracts, the black dots representing degenerated fibres, can be followed as far down as the lumbar cord, but here they are only sparsely scattered. The degeneration is however well marked at this level in the Weigert preparations.
The fact that the oval field of Flechsig (the descending septo-marginal tract of Bruce and MuirJ) was not indicated
SchafEer, Karl. Beitrag zur Histologie der secundiiren Degeneration. Arch. f. mikr. Anat., Bonn, 1894, Bd. xliii, S. 2.52-266.
t HoQU-n, E. A. Atlas d. path.Histol. d. Nervengyst., Berl.,1896, Lfg. vi, S. 5-19.
X Bruce, A. and Muir R. On a Descending Degeneration in the Posterior Columns in the Lumbo-sacral Region of the Spinal Cord. Brain, Lond., 1896, vol. xix, pp. 333-345.
by the Marchi specimen would go to indicate that this tract also degenerates rapidly. In fact, the recent cases of Hoche, Bruce and Muir, and Scarpatetti,* in which this tract and the comma of Schultze were thoroughly degenerated, were instances in which death ensued within a month or two after the onset of compression. Thus the individual fibres were caught in the first period of degeneration by the Marchi method, whereas they would not have been shown by other methods. By the Weigert method, these paths in the dorsal funiculi are shown only where the fibres are massed together and there has been considerable sclerosis, as found by Gombault and Philippe, who thus discovered their median triangle. In the present case there was some lightening of these areas in the Weigert preparations.
LEGENDS FOR FIGURES.
The lettering for the tracts is the same throughout. Each of the drawings of the spinal cord represents a magnification of five diameters.
F. ca. I. — Fasciculus cerebrospinalis lateralis (lateral pyramidal tract).
F. vl. O. — Fasciculus ventrolateralis superficialis (Gowersi). F. els. — Fasciculus cerebellospinalis. F. c. — " cuneatus (Burdachi). F.g.— " gracilis (GoUi). F.L. — Lissauer's fasciculus. F. ». — Septal fasciculus.
Comma. — Schultze's comma fasciculus. F. p. ^ — Fasciculus proprius lateralis.
Fig. I. Level of the first cervical segment. Weigert-Pal preparation.
The degeneration of the tracts is indicated in this and the other Weigert preparations by a lightening in color.
Fig. II. Level of the first cervical segment. Marchi specimen.
Fig. III. Level of the second cervical segment. Weigert-Pal specimen.
Fig. IV. Level of the second cervical segment. Marchi specimen.
Fig. V. Level of the third cervical segment. Weigert-Pal specimen.
Fig VI. Level of the third cervical segment. Marchi specimen.
Fig. VII. Level of the fifth cervical segment. Weigert-Pal specimen.
Fig. VIII. Level of the seventh cervical segment. Weigert-Pal specimen.
FiQ. IX. Level of the fourth thoracic segment. Weigert-Pal specimen.
Fig. X. Level of the fifth thoracic segment. Weigert-Pal specimen.
FiQ. XI. Level of the sixth thoracic segment. Weigert-Pal preparation.
Fig. XII. Lumbar region of the cord. Weigert-Pal specimen.
Fig. XIII. Specimen from the region of compression. Stained by Van Gieson's method. Leitz objective yV (oil immersion), eye piece 3.
JV^. — Swollen irregular shaped nerve fibres, containing swollen deeply staining axones.
N.' — Nerve fibres containing vacuolic areas.
Scarpatetti, J. von. Befund von Compression und Tuberkel im
Ruckenmark. Jahrb. f. Psychiat., Leipz. u. Wien, 1896-7, Bd. xv, S. 310-329.
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September-October, 1898.]
JOHNS HOPKINS HOSPITAL BULLETIN.
251
(?. — Neuroglia, greatly increased in amount.
O.' Nuclei of neuroglia cells.
M. — Masses of globular material imbedded in the neuroglia, staining a pinkish color.
il.— Empty hole.
H/ — Hole containing a disintegrating nerve fibre.
H." — Holes containing masses of more or less globular appearance, staining a pinkish color. They are probably modified compound granular corpuscles.
H.'" — Holes containing material taking on a yellowish and pinkish coloration. Probably broken down nerve fibres.
C. — Compound granular corpuscle.
Fig. XIV. From various parts of the region of compression. Leitz objective x'j (oil immersion), eye piece 3.
1 and 2. Corpora amylacea — Van Gieson's stains.
3 and 4. Eighth cervical segment. Two large irregular holes, containing cells, the nuclei of which stain a deep red color. The protoplasm contains vacuoles, and in parts looks as if it were made up of small globules. These are probably modified compound granular corpuscles Upson's carmine.
5. Second thoracic segment. Hole containing one of the cor
pora amylacea, which are very numerous at this level. It stains a pink color. Marchi's fluid and Upson's carmine.
6. Same section as 5. Shows several degenerating fibres. In one the axone stains a faint pink color ; in another the axone is barely outlined. Numerous black globules of myelin are seen. The rest of the myelin has a faint yellowish color.
7. A nerve fibre is shown here, with a vacuolar area around the axis-cylinder.
8. Marchi specimen counter-stained in Upson's carmine. Hole containing a degenerating nerve fibre. Tlie axone stains a fairly good pink color. The myelin sheath is represented partly by black granules, partly by a yellowish staining mass.
9. Haematoxylin and eosin. Hole containing three compound granular corpuscles. The nuclei stain black and are granular.
10. Eighth cervical segment. Van Gieson's stain. Swollen ganglion-cell. The protoplasm stains a homogeneous pink color. The nucleus is almost colorless ; the nucleolus stains a deep pink color.
11. Weigert-Pal specimen counter-stained in Upson's carmine. Large hole containing several large black masses, surrounded by ball-like masses, which are outlined by darkly staining rings.
THE TREATMENT OF OTOMYCOSIS BY THE INSUFFLATION OF BORACIC ACID AND OXIDE OF ZINC*
By Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology, Johns HojMns University.
Seventeen years ago, in an article published in the American Journal of Otology,! I called attention to the value of a powder containing equal parts of boracic acid and oxide of zinc in the treatment of otomycosis aspergillina. In this article objection was urged to the use of alcohol, the agent most commonly employed for the destruction of aural fungi, on the ground that it not infrequently causes considerable pain when instilled into the auditory canal and tends to aggravate the inflammation of the canal walls and tympanic membrane usually present in otomycosis. A distinct gain, it was pointed out, would be made if a renredy could be found which would effectually destroy the parasite and at the same time exert a beneficial influence upon the inflammation excited by its presence; and such a remedy, it was claimed, had been found in the boracic acid and oxide of zinc powder.
Experiments were described which showed the specific action of boracic acid in destroying aspergillus and other fungi, and the drying effect of the oxide of zinc was held to render more effectual the germicidal action of the acid. At the same time, there was abundant evidence to show that the combination of the two, used as suggested (by insufflation), was one of the most efficacious remedies that we possess in overcoming diffuse inflammation of the external ear.
Although in the interval that has elapsed since the publication of this paper, I have used this remedy in all the cases of otomycosis that I have met with, and have never known it fail to destroy effectually the parasite — a single application often accomplishing this result, and more than two applications being seldom needed — I should not feel warranted in bringing the subject again to the attention of otologists but
Read before the American Otological Society, July 18, If
fVol. Ill, No. 2, p. 119.
I
for the fact that the majority of them, to judge by the textbooks, still seem to adhere to the practice, which, I think, should long since have become obsolete, of treating these cases by alcohol instillations.*
That alcohol is a suitable agent to pour into a diffusely inflamed and painful auditory canal will hardly be maintained by any one; while its relative inefficiency in destroying aspergillus seems to be shown by the statement of Politzer, that the instillations should be kept up for "a year" to prevent a return of the growth,! and that of Hovell, who says they should be repeated " two or three times a day " until the parasite is gotten rid of, and continued at intervals of a week for " several mouths " in order to guard against a relapse.J As opposed to this, we have the one, two or, at most, three applications of the zinc and boracic acid powder, at intervals of 2-1 or 48 hours, immediately and effectually eradicating the parasite, and at the same time, almost invariably, greatly benefiting the attendant inflammation.
The addition of bichloride of mercury or boracic acid to alcohol, as has been recommended, probably increases its parasiticidal effect, but certainly does not lessen its irritant action. Boracic acid and iodoform, mentioned among other agents by Gleason, ought to be efficacious, but, for the sake of our patients and their friends, iodoform should not be used if a less objectionable remedy will accomplish the same purpose. Chinoline salicylate and boracic acid, 1 part to 8 or 1 to 16, recommended by C. H. Burnett,§ is highly extolled by Eobert Barclay.ll I cannot speak of the value of this remedy from
•Compare Politzer, Dencb, McBride, Hovell, Gleason. f Diseases of the Ear, p. 187. t Diseases of the Ear and Naso-pharynx, p. 195. § Medical & Surg. Reporter, Phila., Vol. LXI, p. 539. 1 Burnett's System of Diseases of the Ear, Nose and Throat.
252
JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 90-91.
personal experience, but I am prepared to believe that it must yield favorable results from the large proportion of boracic acid which it contains.
The boracic acid and oxide of zinc powder is open to the single objection that it is a somewhat insoluble comjioiind, but this is not a serious objection, especially if it be blown into the ear, as it should be, only in sufficient quantity to cover lightly the walls of the meatus aud the tympanic membrane. The parasite destroyed and the inflammation subdued, the removal of that portion of the powder which may have adhered to the membrane and canal walls may be safely left to nature, which, through the outgrowth of the epidermis, will accomplish this completely within the course of a few weeks.
A brief description of a single typical case, recently under observation, will suffice to illustrate the action of this remedy and the manner of its employment.
Mr. X, of Baltimore, consulted me in the latter part of May last, because of an uncomfortable " full feeling," attended by slight pain, in the left ear. The history of the case indicated that there had been a slight dermatitis in each auditory canal for a considerable time. The symptoms complained of in the left ear were found to be due to the presence of aspergillus nigricans, which had excited a well-marked diffuse inflammation of the deeper portion of the canal walls and the tympanic membrane.
By the aid of the syringe, probe and forceps the aspergillus was removed as completely as possible aud the meatus was freed of a considerable quantity of exfoliated epithelium. The ear was then dried and the boracic acid and zinc powder blown in lightly. On the following day, although the unpleasant symptoms were entirely relieved, the treatment was repeated as a matter of precaution. This completed the cure, which a lapse of three weeks has shown to be radical.
BOOKS RECEIVED.
Atlas and Abstract of the Diseases of the Larynx. By Dr. L. Griinwald, of Munich. Authorized Translation from the German. Edited by Charles P. Grayson, M. D. 1898. 12mo. With 107 Colored Figures on 44 Plates. 103 pages. W. B. Saunders, Philadelphia.
On Cardiac Failure and its Treatment, with Especial Reference to the Use of Baths and Exercises. By Alexander Morison, M. D., F. E. C. P 1897. 8vo, 256 pages. The Rebman Publishing Co., London.
Hay Fever and its Successful Treatment. By W. C. Hollopeter, A. M.,M. D. 1898. 12mo, 137 pages. P. Blakiston's Son & Co., Philailelphia.
A Report on Vaccination and its Results, Based on the Evidence Taken by the Royal Commission during the Tears 1889-1897. Vol. I. The Text of the Commission Report. 1898. 8vo, 493 pages. New Sydenham Society, London.
A Text-Book upon the Pathogenic Bacteria. For students of medicine, and physicians. By Joseph McFarland, M. D. Second edition, revised and enlarged. 1898. 8vo, 497 pp. W. B. Saunders, Phila.
An American Text-Book of the Diseases of Children. By American teachers. Edited by Louis Starr, M. D., assisted by T. S. Westcott, M. D. Second edition, revised. 1898. 4to, 1244 pp. W. B. Saunders, Philadelphia.
The Diseases of the Stomach. By William W. Van Valzah, A. M., M. D., and J. Douglas Nisbet, A. B., M. D. 1898. 8vo, 674 pp. W. B. Saunders, Philadelphia.
Twelfth Annual Report of the State Board of Health of the State of Ohio, for the year ending October SI, IS07. 8vo, 308 pp. 1898. The Laning Printing Co., Norwalk, Ohio.
Preliminary Report of an Investigation of Rivers and Deep Oround Waters of Ohio, as Sources of Public Water Supplies. By the State Board of Health. 1897-98. 8vo, 259 pp. J. B. Savage Press, Cleveland.
Second Catalogue of the Library of the Peabody Institute of the City of Baltimore, including the additions made since 1882. Part III, E-G. 1898. 4to, 2006 pp. Baltimore.
An American Text-Book of Gynecology, Medical and Surgical, for practitioners and students. By H. T. Byford, M. D., etal. Edited by J. M. Baldy, M. D. Second edition, revised. 1898. 4to, 718pp. W. B. Saunders, Philadelphia.
A Text-Book of Materia Medica, Therapeutics and Pharmacology. By G. F. Butler, Ph. G., M. D. Second edition, revised. 1898. 8vo, 860 pp. W. B. Saunders, Philadelphia.
King's College Hospital Reports; being the annual report of King's College and the medical department of King's College. Edited by N. Tirard, M. D., F. R. C. P., et al. Vol. IV. {Oct. 1st, 1896-Sept. .30th, 1897). 1898. 8vo, 358 pp. Adlard and Son, London.
The Office Treatment of Hemorrhoids, Fistula, etc., without operation. By Charles B. Kelsey, A. M., M. D. 1898. 12mo, 68 pp. E. R. Pelton, New York.
Twentieth Century Practice. An International encyclopedia of modern medical science by leading authorities of Europe and America. Ed. by Thos. L. Stedman, M. D. Vol. XV. Infectious Diseases. 1898. 8vo, 658 pp. Wm. Wood & Co., New York.
The Principles and Practice of Medicine. By William Osier, M. D. Third Edition. 1898. 8vo, 1181 pp. D. Appleton & Co., New York.
The Mineral Waters and Health Resorts of Europe. Treatment of chronic diseases by spas and climates with hints as to the simultaneous employment of various physical and dietetic methods. Being a revised and enlarged edition of "The spas and mineral waters of Europe." By H. Weber, M. D., F. R. C. P., and F. P. Weber, M. D., F. R. 0. P. 1898. 8vo, 524 pp. Smith, Elder & Co., London.
A Clinical Text-Book of Medical Diagnosis for Physicians and Students. By Oswald Vierordt, M. D. Authorized translation with additions by F. H. Stuart, A. M., M. D. Fourth American edition, from the fifth German, revised and enlarged. 1898. 8vo, 603 pp. W. B. Saunders, Philadelphia.
WALTER S. DAVIS, M. D.
At a meeting held at 4.30 o'clock Wednesday afternoon, on the twenty-eighth of September, in the office of the superintendent of Johns Hopkins Hospital, presided over by Dr. H. M. Hurd, the following resolutions were adopted :
Whereas, we have lost our beloved comrade and fellow-worker, W.\LTER S. Davis ;
Be it Resolved, That we, the Medical Faculty of the Johns Hopkins University and the stafif of the Johns Hopkins Hospital do express to his family our most heartfelt sympathy in their great bereavement.
His enthusiasm in the profession was unbounded and always a stimulus to his co-workers ; but we shall remember him particularly for his sterling character, his ever cheerful disposition, and his fidelity as a friend, aud,
Be it further Resolved, That a copy of these resolutions be conveyed to his family and published in the Bulletin of the Johns Hopkins Hospital. THOMAS S. CULLEN,
JAMES F. MITCHELL, GUY L. HUNNER.
Committee.
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may be procured from Messrs. CITSITINO & CO. and the BALTIMORE NEWS COMPANY. Baltimore. Subscriptions, §1.00 a year, may b» addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies will be sent by mail for fifUen cenU each.
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. IX.- No. 92.]
BALTIMORE, NOVEMBER, 1898.
GOIsTTEIsTTS.
The Diajnosis of the Condition of each Kidney by Inoculation of the Separated Sediments into Guinea-pigs in Suspected Renal Tuberculosis. By Edward Reynolds, M. D., - - - 253
Laparotomy for Intestinal Perforation in Typhoid Fever. By Harvey W. Gushing, M. D., 257
Spontaneous Hsemorrhagic Septicsemia in a Guinei-pig, caused by a Bacillus. By George H. VVbaver, M. D., - - - - -270
Antitoxic Relation between Bee Poison and Honey (?). By G. H. Stover, M.D., ------- 271
Proceedings of Societies :
The Hospital Medical Society,
Broadbent's Sign [Dr. Camac] ; — Aortic Aneurysm [Dr. Brown] ; — Discussion of Mr. MacCallum's Paper on Pathology of Heart Muscle [Dr. Flkxner] ; — Epidemic Cerebrospinal Meningitis — Exhibition of Specimens [Dr. Livingood].
Notes on New Books,
274
Books Received, ----------------- 275
THE DIAGNOSIS OF THE CONDITION OF EACH KIDNEY BY INOCULATION OF THE SEPARATED SEDIMENTS INTO GUINEA-PIGS IN SUSPECTED RENAL TUBERCULOSIS.
By Edward Reynolds, M.D., Boston, Mass.
The direct inspection of tlie air-distended bladder which we owe to Kelly, with its sequelae of easy exploration of the ureters, has already led to great advances towards an accurate knowledge of the urinary diseases of women, and at the present moment, when so much is opening up before us, any new step towards exactness of diagnosis seems worth reporting.
Little is yet known of the natural history of renal tuberculosis; indeed, it is for comparatively few years that we have known that tuberculosis can be primary in the kidney, and the great mass of the profession has not yet realized that this disease is often localized for many years in one kidney before invading the rest of the urinary tract; but in the last three years we have been accumulating a considerable amount of clinical evidence in support of these views, namely, that though renal tuberculosis does in the end kill when untreated, it is often nevertheless so strictly localized in one kidney that the patient may be restored to perfect health after this is removed by nephrectomy. Among the many cases of this nature which we now have may be cited a remarkable one by Vineburg* and three by Kelly. f I am myself able to add three unpublished cases, two of my own and one very remarkable
•Medical Record, Feb. 6th, 1898.
f Johns Hopkins Hospital Bulletin, Feb.-Mar., 1896.
case which I saw in consultation after a nephrectomy by another surgeon. Those who have ever seen how these patients are transformed in nutrition and general health, by the removal of the offending kidney, will be slow to listen to arguments against the ojjeration for cases in which the disease is unilateral, but it is of course justifiable only in such cases, and our success must therefore rest on our power of diagnosing the disease while it is limited to one kidney, and thus confining the operation to cases which are capable of cure by nephrectomy. For this purpose we must not only be able to establish the diagnosis of renal tuberculosis, in advance of the constitutional breakdown of the patient, but must also be able to satisfy ourselves with some positiveness of the health of the other kidney; and striking testimony to the advances which have been made in this subject during the last few years is to be obtained by inspection of the most recent text-books on medical diagnosis. Thus one, which shall be nameless, in the course of three pages devoted to renal tuberculosis, gives under diagnosis only these three clues: the presence in the sediment of the urine of little, yellow, cheesy masses of degenerated tuberculous material ; the presence of pus and other signs of chronic pyelitis from no assignable cause other than tubercle, and, lastly, the presence of tuberculosis in other organs. Even the latest edition of Osier, in which the section on this subject
254
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 92.
has been considerably rewritten and evidently brought up to date, may be summarized as saying that there is but little chance of making a diagnosis unless we are put upon the track by finding tuberculosis in other organs, though this acute writer does mention the special methods of examination employed by gynecologists and the hope for the future which they afford.
It is apparent that these medical descriptions refer to what we from a surgical standpoint should call advanced disease. Our surgical specialty has already led us to the possibility of establishing the diagnosis at a very much earlier stage than this.
Though such a diagnosis can be made only by physical examination, a suspicion of tubercular or other renal disease will often be excited by the symptomatology, and this must therefore be briefly reviewed. The early symptoms of the disease will vary greatly both in character and in intensity in different cases, and from time to time in the same case, but will consist typically of pain and tenderness over the abdomen on the affected side, frequency of urination, and sometimes hematuria. These symptoms are, however, equally characteristic of simple pyelitis, renal calculus and new growth in the pelvis of the kidney. There are, indeed, no differences of kind in the symptomatology of these diseases in their early stages, though there are differences in the degree in which the several symptoms are likely to be present.
All these diseases are characterized by dull pains over the kidney and along the course of the ureter on the affected side. The pain is often bearing-down in character, and therefore a uterine origin is usually assigned to it; is usually increased by standing ; and is always more or less associated with frequency of micturition, occurring at night as well as in the day-time. Ill all of them the call to micturate is a very urgent one; the pain on micturition is usually leferred to the meatus ; and all are liable to more or less tenesmus at the end of micturition. In all the pain may be increased by jarring or jolting (as in driving over rough roads).
This whole group of symptoms is, however, in reality symptomatic of the amount of inflammation present, and therefore varies with this subsidiary feature of the case. They are often though not always more marked in renal stone than in tlie other diseases.
All the diseases enumerated may be accompanied by hematuria, but this is rare in simple pyelitis ; it is more likely to be profuse in tuberculosis or a new growth than in stone.
In all, the patients are almost equally liable to attacks of mild renal colic, due usually to inflammatory obstruction in the ureter. They differ from the pains excited by the passage of a calculus in being less severe and not followed by the appearance of the stone. These attacks are perhaps less common in new growths than in the other diseases under consideration. Not infrequently, at intervals in the course of these chronic renal diseases (and especially in tuberculosis and simple pyelitis), the inflammatory symptoms will be found to be most marked on the sound side. This is probably because each exacerbation of the disease in the affected side leads to an increased elimination of toxic materials from the functionally more active kidney; and this excites a transitory and some
what acute inflammation in the mucous membrane of the urinary apparatus on the sound side.
This transposition of symptoms I have seen so frequently (I may say almost constantly) that I am sure it must always be guarded against. The side on which the patient tells us that the symptoms were first noticed is usually the diseased side.
The inquiry into the history should be followed by palpation, both abdominal and bimanual. In all these lesions we find, on palpation, a tenderness which may extend from top to bottom of the urinary tract on the affected, and even on both sides, but which is usually most marked at one or more of three points: namely, over the kidney; at the spot where the ureter crosses the brim of the pelvis, in which ease it is often limited to a spot the size of the finger-tip, midway between the umbilicus and the anterior superior spine of the ilium (McBurney's point or its fellow); and, finally, over the vesical end of the ureter at the side of the cervix, which examination may even detect an enlargement or induration of the ureter. These tender points are again symptomatic of the amount of inflammation present, and therefore usually vary with the amount of pain.
A study of the history and the results of the gynecological examination usually enables us, then, to suspect, and sometimes permits us to postulate, a diagnosis of some renal disease of a surgical nature, but it does not enable us to say what, nor always on which side it is. The special examination now steps in and the real diagnosis begins here.
If a visual examination of the bladder shows that the vesical mucous membrane is substantially normal except in the interureteral region, and that a strongly localized inflammation is present there, the source of that inflammation is probably to be found in the passage of a vicious urine from one or the other ureter. If one ureteral orifice is abnormal in appearance, this probably marks the diseased side. The next and most important step is the catheterization of the ureters and a microscopical and chemical examination of the urine secreted by each kidney. But here the results must be interpreted with the greatest care, as recent advances have made it certain that most of our past opinions on the results of urinalysis must be revised in the light of the new knowledge. This is especially true of renal tuberculosis; the large amounts of degenerated pus and bits of necrotic material which are commonly described as characteristic of the disease being, in fact, found only in locally advanced cases, while the urinary signs of early tuberculosis are usually limited to the detection of pus and the bacilli by the microscope.
In the more advanced of the class of cases which are still quite operable we are indeed almost sure to find more or less degenerated pus, but the amount of it varies greatly from time to time, and is not infrequently insignificant. The detection of tubercle bacilli in the sediment of the urine is of some positive value (it is absolute if its confusion with the smegma bacillus is sufficiently carefully excluded; and it should therefore be absolute in the sediment of the urine obtained by ureteral catheterization). Its absence is of no diagnostic value whatever; e.g. I have had a highly trained expert uuike repeated negative reports on the urine from a
November, 1898.'
JOHNS HOPKINS HOSPITAL BULLETIN.
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bladder in which tubercular ulcerations were actually visible aud in which a subsequent report was jaositive.
It is probable that the discharge of the bacilli with the urine is not uniform, and no man can exjiect to search a sediment so thoroughly as to detect the bacillus with certainty if only a few are present; but it is held that if a fresh sediment is injected into the peritoneum of a guinea-pig, the presence of only one or two bacilli will be enough to cause infection in this very sensitive animal. The generally accepted opinion that this is the most delicate test for tuberculosis known, and the great surgical importance of using the most delicate test possible for the determination of the condition of each kidney separately in suspected renal tuberculosis, has then been my reason for injecting the sediments obtained from the kidneys by ureteral catheterization into separate guinea-pigs in each of three cases of suspected renal tuerculosis.
If this test is to be of real surgical value two points must be determined with regard to it: 1. Will it give us positive evidence in the early stages of the disease? 2. How absolute is the negative evidence obtained by the negative results from the other kidney in the same case? But neither of these questions can be answered by anything but an extended experience.
One case was positive as regards one kidney only, both the others were wholly negative, though each woman showed evidence of surgical disease in one of her kidneys. I have put off the publication of this report for several mouths in the hope of reporting the ultimate results in the equally important negative cases, but as both patients are still deferring operation* I am publishing the one positive result in the hope of inducing others to try this very delicate test, and also because the individual case is of itself of much interest from the slight development of the disease in the kidney which was removed, and from the very satisfactory improvement in the patient's condition since operation, which certainly so far supports the negative result obtained from the examination of her remaining kidney.
On March 31, 1898, I saw, with Dr. Percy C. Proctor, of Gloucester, Mass., Mrs. P., thirty-one years old, ten years married, multipara, of tuberculous family history, but with good personal history until the beginning of the present illness.
Eight years ago, after suffering for some months from backache and bearing-down pain, she suddenly began to pass bloody urine, which gradually returned to the normal after a duration of some weeks. Though partially relieved of her backache after the attack, she has been a semi-invalid ever since. Four years later, in October of 1894, she had a second, similar attack, and on the 17th of February, 1898, a third attack, the haematuria beginning with equally little warning. The pain has always been relieved during the attacks, but has always returned after their cessation, and has never been affected by the act of urination. During these attacks she has passed urine about every half hour daring the day, but only
While the paper was in press both negative cases came to
operation, and both proved to have non-tubercular disease. Both will be published in detail later.
once or not at all during the night. In the intervals between the attacks she has had no frequency or other abnormalities of urination, (. e. the symptomatology was indistinctive.
On palpation no tenderness could be detected. On examination under ether her genital organs were essentially normal, and a careful visual inspection of the bladder showed no abnormality whatsoever, except that a stream of thin blood trickled steadily downward from the right ureteral orifice, while from the left spouted intermittently a normal looking urine.
The ureters were catheterized and the specimens were submitted to Dr. J. B. Ogdeu, Assistant in Chemistry in the Harvard Medical School, whose reports of the examination of the urine and of the inoculations which he made at my request are here appended:
"On March 22, 1898, two specimens of urine from the right and left ureters — case Mrs. P. — were submitted to me by Dr. Edw. Reynokls, for examination.
Urine from Right Ureter. — Amount received 10 cc; color, bloody ; reaction, alkaline ; specific gravity could not be taken as quantity of uriue was not sufficient ; urea, 1.01 percent.; albumin, between i and i of 1 per cent. The sediment, which was abundant, con-' sisted chiefly of normal blood. After the blood had been destroyed by means of distilled water, which had been acidulated with acetic acid numerous leucocytes, a few small round and caudate cells (probably ureteral) and rarely a brown granular cast were found. No crystalline elements detected.
Urine from Left Ureter. — Amount received 3cc.; color, pale, slightly turbid ; reaction, acid ; specific gravity could not be taken; urea, 0.95 per cent.; albumin, a trace. The sediment contained frequent normal and abnormal blood globules ami few leucocytes, many medium and small round cells, and numerous small caudate cells as from the ureter. An occasional granular and brown granular cast, and uric acid crystal.
The clinical examination of these specimens did not reveal much toward deciding as to the most probable cause of the clinical symptoms. The uric acid crystals suggested a possible cause of the trouble, but as it was several hours after the urines had been collected before a microscopical examination could be made, they were probably secondary (formed and deposited after the collection of the urine).
The considerable quantity of normal blood in the urine from the right ureter was apparently of traumatic origin, and was the probable cause of the alkalinity of the urine. The presence of numerous leucocytes in the sediment led to the question: Are there more leucocytes than can be accounted for by the amount of blood present? This I was unable to fully decide, although they appeared to be present in somewhat larger numbers than would be expected in that quantity of blood.
The tubular disturbance shown by the presence of casts, although slight, appeared to be more marked in the left kidney than in the right.
Since the question of a tuberculosis of the urinary tract had been raised as a possible cause of the symptoms in this case, it was considered advisable to make as thorough and complete an examination of the urine for tubercle bacilli as was possible, and at the same time, if a tuberculosis existed, to determine wbether one or both kidneys were diseased. Accordingly the sediments of both specimens were washed twice, by decantation, with distilled water, in order to free them fiom albumin and other soluble urinary constituents, a centrifuge being used to settle tbe sediments after each addition of water. Each sediment was then divided into two portions ; one portion was injected into a guinea-pig, and the other was reserved for microscopical examination for tubercle bacilli.
256
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[No. 92.
The injections into the guinea-pigs were made as follows : The barrel and needleof asmall Koch syringe were thoroughly sterilized by dry heat; the abdominal wall of a guinea-pig was thoroughly cleansed and then i cc. of the sediment of the urine from the right ureter was injected into the abdominal cavity. The barrel and needle of the syringe were cleansed and again sterilized. The abdominal wall of another guinea-pig was cleansed, after which ice. of the sediment of the urine from the left ureter was injected into the abdominal cavity.
The pigs, following the injections, showed only slight disturbance, from which they recovered in a few days, and were apparently quite well for the eight weeks they were under observation. An examination of the- pigs between the fifth and sixth weeks showed that the one which had been inoculated with the sediment of the urine from the rigtit kidney had, in both groins, enlarged glands, wliich were hard and quite nodular. The one injected with the sediment of the urine from the left kidney showed no enlarged glands and was apparently in a healthy condition. Both animals were then placed under the care of Dr. W. F. Whitney.
On the same day that the inoculations were made the portion of sediment which had been reservo'l for microscopiral examination was centrifugalized, and the sediment placed on cover-glasses was carefully dried, stained and examined. No tubercle bacilli could be found in the limited number of preparations at hand. The - amount of sediment furnished by these small specimens was originally comparatively slight, and since some of the sediment had been used for the inoculation experiments, too little remained for as thorough a. microscopical examination as is often necessary for the detection of tubercle bacilli in the urine."
The patient was kept absolutely in bed on a non-stimulating diet, but the hsematuria continued until the latter part of April, when the bleeding ceased and the pain in the backreturned. As I thought it advisable to give her some weeks in which to regain condition, the pigs were left undisturbed till some weeks later, when I received the following letters from Dr. W. F. Whitney, curator of the Warren Anatomical Museum and Pathologist to the Massachusetts General Hospital. .
"May 2G, 189-;. The guinea-pig inoculated with the urine from the right kidney of Mrs. P. was killed to day, and showed cheesy abscesses in the glands of both groins, in the pus from which a few scattered tubercle bacilli were found. There were also characteristic miliary cheesy nodules in the spleen, as well as a few scattered areas in the liver. Tlie condition is perfectly characteristic of inoculated tuberculosis."
June 13, 1898. The guinea-pig inoculated with the urine from the left kidney of Mrs. P. on March 22, 1898, was killed June 9, 1898, and found to be perfectly normal."
As I always think it a pity to disturb the ureter of the sound side by catheterization immediately before an operation, in renal cases, I made no further ureteral examination, but the urine secreted in 24 hours was now collected and submitted to Dr. Ogden, whose report upon it follows :
"On June lOth an examination of the twenty-four hour urine showed the following :— Twenty-four hour quantity, 1150 cc; color, pale, turbid; reaction, acid; sp. gr., 1013; urea, 1.13 per cent, or 12.99 grammes in 24 hours; albumin, a slight trace ; bile and sugar absent. The sediment consisted chiefly of pus which was free and in clumps. Considerable squamous and scaly epithelium and a few blood globules; a few small round cells. An occasional hyaline and granular cast with renal cells and little blood adherent.
The greater part of the pus seemed to come from the same source as the squamous and scaly epithelium, in other words, probably from the vagina. I could not be certain that some of the pus did not come from the bladder or from the diseased kidney. There was still evidence of a tubular disturbance (shown by the casts) which had more the appearance of a mild renal congestion than any primary disease of the kidneys.
The sediment of this twenty-four hour urine was thoroughly examined for tubercle bacilli, but with a negative result."
June 24th I removed the right kidney by lumbar nephrectomy. The kidney was brought to the surface with great ease and rapidity and was so wholly normal in appearance that nothing but the absolute certainty which I thought myself to possess of its diseased condition would have induced me to remove it. The ureter was thoroughly normal in appearance, was cut some two inches below the kidney, closed in by catgut sutures, and dropped into the wound. On splitting the kidney after its removal the tubercular disease was at once evident, in the shape of numerous miliary tubercles on the mucous membrane of the pelvis.
The very beaittiful painting which is here reproduced was made for me by Miss Florence Byrnes, artist to the Harvard Medical School.
Dr. Whitney kindly examined the kidney, and his report and the letter which he sent me are inserted below:
"The kidney was of normal size. The capsule stripped off easily, showing the surface marked by numerous small, superficial cicatricial depressions. The cortical part was slightly narrow and pale. In the papillary region were a few scattered minute opaque dots, and the pelvis was quite thickly covered with them, and markedly injected. Microscopic examination : The epithelium of the cortical tubules was low and irregular, and the cicatricial depressions were marked by a round-cell infiltration and disappearance of the tubules at that point. The opaque dots were composed of small round and epithelioid cells with an occasional giant cell. The centres were cheesy degenerated. The diagnosis is a miliary tuberculosis of the pelvis and kidney."
Makblehead, Mass., August 13, 1898. Dear Dr. Reynolds: — I enclose the report of the kidney which you desired. The case is certainly favorable, as the local lesions are comparatively slight, and it is interesting that, with so little ulceration and loss of substance, a positive result should have been obtained from the inoculation with the urine.
Yours sincerely,
W. F. Whitney.
The patient's convaleseucefrom the operation was rapid and satisfactory. She passed from thirty to forty ounces of urine uninterruptedly and never had a bad symptom. 1 have not seen her since, but a letter from Dr. Proctor, dated October 10, 1898, informs me that she is now passing forty ounces of normal urine with no evidence of renal irritation in the sediment. She has gained in flesh and color and is greatly improved in general condition.
The negative results of two examinations of the sediment for tuberculosis, made by an expert at widely separate times, and the positive result of the inoculation of a guinea-pig by one of these same sediments, with the confirmation of this positive result by inspection of the kidney in question, and the improvement of the patient's health after the operation, form certainly a picture of considerable clinical interest, more
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especially, as this is, so far as I am aware, the first case in which this test has been used for the esamiiiatioa of each kiduey separately.
As so little is known of frequency of unilateral and primary renal tuberculosis I had hoped that an examination of the records of a large number of autopsies, performed upon subjects who died from other diseases than tuberculosis, might yield something of interest, and accordingly requested Dr. John T. Bottoinley to examine the pathological records of the Boston City Hospital for some years past. He looked over 3300 reports which were consecutive except for the omission of deaths from tubercular disease in other organs of the body, but found only two cases of primary renal tuberculosis, both unilateral, one of which died from fracture of the spine, the other of uremia.
His abstracts of the cases are as follows:
Case I. Surg. Eec. C, Vol. 23, Page 248. Male, 48 years. No venereal diseases, case of scalp wound, alcoholism, and fractured spine.
Autopsy Eec, Vol. 16, Page 56. Autopsy showed that right
kidney was about normal size ; upper third replaced by several sacs, each corresponding to a pyramid and its accompanying cortex ; each sac had a thin, firm capsule which was filled with opaque, white, cheesy or putty-like material, a little gritty to the touch. In one of the lower pyramids was a similar sac ; no evidence of any inflammation ; microscopic examination negative ; pelvis and ureter normal. Bladder and ai>pendage8 were normal except a few small calcified nodules in prostate.
Anatomical diagnosis. Stenosis of aortic valve. Chronic passive congestion of spleen and kidneys. Chronic tuberculosis of right kidney. Fracture of spine.
Case II. Med. Rec, Vol. 175, Page 249. Female, 45 years, married. Always well till three months before ; all symptoms pointed to disease of the kidney.
Autopsy Rec, Vol. 3, Page 125. Autopsy. No truly normal tissue remained of left kidney. The entire wall was composed of abscesses of varying sizes, containing a thick almost cheesy pus. Peri-nephritic fat adherent to the wall, also to diaphragm ; nothing important in other organs.
[The second case could probably have been saved by nephrectomy had the diagnosis been made a few months before. She, however, entered the hospital in the year 1880 and in a dying condition.]
LAPAROTOMY FOR INTESTINAL PERFORATION IN TYPHOID FEVER.
A RFPORT OF FOUR CASES, WITH A DISCUSSION OF THE DIAGNOSTIC SIGNS OF PERFORATION. By Harvey W. Gushing, M. D., Resident Surgeon, The Johns Hojjhins Ebspifal
The present communication is based upon four recent cases of laparotomy foi- perforating typhoid ulcer, in one of which the abdominal ca\ ity was opened on three successive occasions with recovery.
The fact that surgical intervention offers practically the only hope in tlieso cases seems to be studiously overlooked, if we are to judge by the paucity of occasions in which laparotomy has been performed for this condition.
On a recent visit to the military hospital at Fort McPhersou, the writer was told that of thirty autopsies held upon fatal cases of typhoid which had occurred there, perforation was found to have been the cause of death in six instances, one being of the appendicular variety. This would attribute to perforation aloi.e 30 per cent, of the fatalities, a percentage which corresponds with that of Hare of Brisbane, and is almost twice that of Murchison (11.38 per cent.), and three times the figures given by ]ir. Fitz (6.58 per cent, in 4680 cases). In none of these cases had operative intervention been advised, nor do I know of a single instance of operation for the relief of typhoid perforation on any of the possible 2000 cases which have died from typhoid in the field hospitals and elsewhere during the late war.
H the recent statistics of Gesselewitsch and Wanach (Centralblatt f iir die ( rreuzgcbieten der Medizin und Chirurgie, Bd. I, No. 6, p. 382, IS'.IS) are to be relied upon, namely, that lO per cent, of the entire number of fatalities in typhoid are due to perforative peritonitis, we may credit 200 of these deaths to this cause alone. According to the statistics from Fort McPherson and those of Hare, 400, or double the number, would be accounted for in this way.
In a recent communication Dr. Nicholas Seun writes: "Strange as it may seem, having seen hundreds of cases of typhoid fever during the war, I was called upon only once to operate for perforation. In that instance the patient was moribund, and I refused to operate. I have reason to believe that this complication was frequently overlooked."
We have four widely different but quite characteristic histories to report:
In Case I an early diagnosis and immediate operation, before peritonitis set in, led to recovery.
In Case II general purulent peritonitis with three perforations was present, and it should be considered that the relief of the general peritonitis, and not typhoid perforation which had taken place many hours before, was the objective point of operation.
In Case III what may be considered as pre-perforative symptoms of peritonitis were present and were neglected. Perforation subsequently occurred with, unfortunately, a virulent streptococcus infection, which proved fatal despite early laparotomy.
Case IV illustrates one of the strange attacks which closely simulate perforation. No lesion was found at the operation, and the exploration had no appreciable effect upon the subsequent course of the fever.
Case I. Surgical No. 8009. Typhoid perforation at end of second week. Laparotomy. Suture of perforation. Drainage. Fcecal fistula after 3 days from second perforation. Spontaneous closure of fistula. Seven days later symptoms of perforation. Laparotomy, No perforation found. Obstruction over
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looked. Two days later laparotomy for acute mtestinal ohstruction with closure of second perforation. Recovery.
Herbert H., aged 9, was brought into the medical wards of the Hospital on the 8th of August with the history of having been ill since the first of the month with "pain in his head and stomach." His mother and one brother were also in the hospital, and one brother had just died of "typhoid" at home. On entrance, the temperature was 104.2°, the pulse rapid, the spleen enlarged and the general appearance typhoidal. There was some tenderness noted in the lower right quadrant of the abdomen. There was no Widal reaction obtainable at this time, nor had there been in the case of his brother and mother, who had had a very mild type of fever. The patient was put on the usual bath treatment. August 9th, leucocytes 8400.
Dr. Thayer's note on August 11th says: "Abdomen is a little full. Patient does not flinch on pressure."
There is no further note of unusual interest. The boy was dull, and seemed to be having a rather severe attack. He complained much of pain in his abdomen on being given his tubs.
On the morning of August 13th (five days after admission) the patient was found to be complaining of abdominal pain. He had vomited twice and his pulse rate had increased. The leucocytes were 9600.
He was seen, in consultation with Dr. Thayer, at 1 P. M. At this time his respirations were 34 ; his pulse 165, rather thready and of poor quality ; temperature 105°. He was crying out and complaining of general colicky abdominal pain. He was very restless ; his expression pinched ; his color quite cyanotic, with lips blue and extremities blue and cold. The abdomen was quite soft and there was no muscle spasm. There was considerable general tenderness, which seemed more marked on the right side. Pressure per rectum in the recto-vesical cul-de-sac seemed to cause especial pain, but no more marked on one side than the other. There was some apparent increase of dulness in the flanks, but no shifting dulness. There was no obliteration of liver dulness. The leucocytes were 16,000. The patient was immediately transferred to the operating-room.
Before the administration of anaesthesia the temperature was 105° (there had been no fall up to this time) and the pulse 170.
Operation /.—August 13th, 1898, 1.30 P. M., four hours after first symptoms, under primary chloroform ansestliesia.
Median laparotomy. Partial evisceration. Clostire of perforation. Toilet of peritoneum with salt solution irrigation. Drainage.
An incision was made in the median line below the umbilicus. On opening the peritoneal cavity a considerable amount (perhaps 200 cc.) of sero-purulent fluid escaped, coming chiefly from the pelvis. Cultures were taken from this fluid and it was also immediately examined in cover-slip preparations. It contained a great number of polymorphonuclear leucocytes, but no micro-organisms could be found. The serosa of the intestine was everywhere greatly congested, but evidently the greatest reaction was in the right iliac fossa, where the loops of the ileum were especially injected and covered with a slight fibrinous deposit. The general cavity to the left was walled off with gauze and the loops of the ileum drawn from the wound. The last foot of the small intestine showed several greatly thinned areas corresponding to Peyer's patches. In the centre of one of these areas, the surroundings of which were quite bluish in color, was a small perforation about two millimetres in diameter, from which fluid fasces were flowing. It was about 25 cm. from the caecum and situated in the free
surface of the bowel. A few centimetres beyond this were two more patches, which seemed very thin and practically covered by little more than serosa. A few fine, filmy adhesions held the omentum to this part of the bowel.
The perforation was closed by a circular suture of fine silk taken about the edge of the thinned area, which was fortunately small, measuring about one centimetre in diameter. A similar inversion of the two thin neighboring patches would have been attempted, but the patient's condition at this time demanded immediate attention and the idea was abandoned. His pulse was almost imperceptible and his respirations were very shallow. Hypodermic injections of strychnia were given and an infusion of a litre of salt solution in the pectoral region. The exposed coils of intestine were irrigated and the abdominal cavity was flushed out with salt solution. A strip of bismuth gauze was left in for drainage, leading down to the site of the suture, and another to the two thinned Peyer's patches. The omentum was pulled down over the gauze. The abdominal wound was then partly closed. The operation lasted but twenty minutes from the beginning of ansesthesia till the final closure.
The cultures taken from the fluid found free in the peritoneal cavity remained sterile. No cultures were taken from the material flowing from the perforation.
The patient rallied well from the operation, and in eight hours the pulse had fallen to 112, and the temperature to normal. There was no vomiting, and he slept most of the time for the next twenty-four hours, taking liquid nourishment (albumen water) well, during his waking intervals. Three hundred cubic centimetres of salt solution were given per rectum every four hours for thirst. On the following day the temperature again became elevated ; the day after the leucocytosis disappeared, and for the following ten days the clinical picture was that of an ordinary typhoid in the third week. A faecal fistula developed on the second day, discharging typical peasoup faeces. It was impossible to tell, at that time, whether this discharge came from the broken down suture or from one of the neighboring thinned Peyer's patches, to which the drain led. (It was subsequently proved to come from the latter.)
The boy complained a good deal of abdominal pain at times, and of pain on micturition, but there was no abdominal rigidity or other symptoms of peritoneal inflammation. He was given regular ice sponges, after which he would sleep for long intervals. The fscal fistula ceased to discharge after a few days. There was considerable diarrhcea at this time (cf. Clinical chart).
August ISlh. (6 days after opei-afion I.) A positive AVidal reaction was obtained by Dr. Schenck for the first time (in ten minutes in a dilution of 1 to 40). Cultures from the rectum, taken through a high rectal tube, showed only the bacillus coli communis. The patient had a pinched look and was very peevish. The pulse was weak and dicrotic. A crop of rose spots was present on the abdomen.
August 25th. {\^ days after operation I.) On the evening of this date, after a very good day, the patient became suddenly much worse and vomited several times. At 9 P. M., when seen in consultation with Dr. Thayer, he was quite
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collapsed and very restless. His abdomen was slightly distended. He was hiccoughing and complaining of abdominal pain. He looked pinched and the extremities were cold and sweating. His leucocytes were only 4000.
A definite diagnosis of perforation was made and steps taken for immediate operation. An hour later the temperature had fallen four degrees to 98.6°, and the leucocytes had increased to 13,000.
Operation II, August 25, 1898, 10.30 P. M.; two hours aftei first symptoms ; under chloroform anaesthesia. Median laparotomy. No cause for symptoms demonstrable. Closure tvifh drainage.
The abdomen was opened beside the first incision, avoiding the site of the fistula. There was no free fluid. The bowels were not injected except to a slight degree in a few places, corresponding to some of Peyer's patches. No evidence whatever of a perforation could be found. There were no adhesions except about the loop of ileum which led to the old sinus and which was surrounded by quite firm omental adhesions. These were not broken up. There was no particular distension of one coil more than another. (There was nothing to suggest the thought of obstruction, and I must confess it did not occur to me. I supposed that I had overlooked a perforation somewhere, but the patient's condition precluded further search.) The wound was closed, with a small drain leading to the omental adhesions.
The operation lasted thirty-five minutes from the beginning of ausesthetizatiou. Cultures taken from the site of the adhesions remained sterile.
The patient's condition did not seem to be materially affected by the operation. The collapse, with cold sweating extremities, the sudden onset of abdominal symptoms, with hiccough, vomiting and pain, the drop of temperature without signs of hfemorrliage and the rapid rise in the leucocytes made operative intervention imperative.
During the following twenty-four hours the condition became progressively worse. All attempts at feeding were followed by immediate vomiting, and euemata were but partially retained. The patient had voided no urine for 18 hours. The lips were parched ; the tongue dry and coated. By the early morning of August 37th (30 hours after operation II) the distension had become more pronounced, and on close inspection, with a candle placed beside the exposed abdomen, a slight visible peristalsis was to be made out, which first demonstrated that obstruction, and not peritonitis, (despite the leucocytosis at this time of 20,000) was responsible for the symptoms, and it was learned that the irrigations, preceding the enemata, since the time of collapse, had not been stained with faecal matter as had previously been the rule.
The child's condition, however, seemed to forbid operative intervention. He was vomiting without effort, restless and in collapse more pronounced than at any time previous. The radial pulse could not be counted. He was given small doses of morphia and strychnia and hot compresses over his abdomen, which quieted him considerably, and four hours later an operation was determined upon.
Operation III, August 37th, 8.30 A. M. (34 hours after operation II), under chloroform ansesthesia.
Median laparotomy. Acute intestinal obstruction due to adhesions about a second perforation. Obstruction relieved. Perforation sutured. Closure with drainage.
The recent wound was re-opened. There was no sign whatever of peritonitis. The small intestine, which was greatly distended, was turned out of the abdomen together with that loop of ileum and its surrounding omentum, which had become adherent to the anterior parietes, as a consequence of the drainage at the first operation. In this omental mass was an acute kink of the bowel, about ten centimetres proximal from the old suture, the distal part of the bowel and the colon beyond being completely collapsed. The original suture was intact. At the exact situation of the kink, and covered by the omentum which caused the obstruction, was a second perforation, apparently corresponding to the thin Peyer's patch seen at the first operation.
On freeing the obstructing omentum, gas and faeces in great amount escaped from this perforation, greatly diminishing the distension. The perforation was about 1 cm. in diameter, with rounded edges, showing everted mucous membrane, so that evidently the whole floor of the ulcer had given way. It was closed easily by a single purse-string suture of fine silk. The bowels after irrigation with salt solution were replaced. A small drain of bismuth gauze was inserted down to the wad of omentum, from which cultures had previously been taken. (In these cultures Dr. Clopton found an abundant growth of the bacillus coli communis, of proteus vulgaris, bacillus lactis aerogenes and an organism culturally closely akin to the bacillus typhosus.) The abdominal wound was partially closed.
The operation lasted twenty-five minutes from the beginning of auajsthetization. The patient's pulse could not be counted. He was given 500 cc. of salt solution in each pectoral region and also per rectum.
Throughout the day the child's condition remained most serious. Distension was pronounced with active, visible and painful peristaltic cramps. He was given small doses of morphia, and large hot bichloride fomentations, for which he seemed very grateful, were at short intervals placed over the whole abdomen. He vomited only twice after returning to the ward, and soon began to retain his nourishment. Twelve hours after the operation, flatus first began to pass from the lower bowel. On the following day, though considerable meteorism remained, the bowels moved three times, and considerable diarrhoea persisted for the four or five succeeding days. As the clinical chart shows, the patient, though greatly emaciated and very feeble, returned to his typical typhoidal condition which ran its course in the next ten days.
Convalescence was very tedious. The child had a series of superficial indolent staphylococcus albus abscesses over the back and shoulders which had to be opened, and a protracted bloody mucous diarrhoea set in which kept him thin and weak. The abdominal incision broke down after the third opei'ation, and was slow in healing. He has, however, made a complete recovery.
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In Case I, therefore, we have what is most unusual, a child with early perforation. The symptoms at onset were typical, and the condition was readily diagnosed. The early vomiting was a great help, while the prostration, abdominal pain, tenderness and the leucocytosis made the picture complete before the onset of peritonitis.
The history of preceding abdominal pain for some days before the actual occurrence of perforation is interesting and, in the light of the subsequent cases, important, in that it most probably was associated with a slight local peritonitis due to the near approach of an ulcer to the general peritoneal surface. From what will be said later it seems possible that clinical symptoms arising from this condition are not uncommon and that they may be utilized in foretelling a perforation, or at all events in putting the attendant on his guard so that the patient may be kept more than ordinarily quiet and tubs omitted, especially if they are disagreeable and resisted.
Among other points of unusual interest is the fact that so prompt intervention was rendered possible, owing to the discernment of Dr. MacCallum, who had charge of the ward, and that the perforation was closed before there was any evidence of peritoneal infection, the cultures from the free fluid remaining sterile.
The subsequent perforation of a neighboring ulcer showed that it would have been desirable at the first operation to have turned in by a suture those patches which seemed thin, and threatened perforation, as was done by Sifton* in his case with recovery, and also by W. Hill.f In view of the fact, however, that there were several of these areas, and that it did not seem justifiable to further prolong the operation, a strip of gauze was placed leading to the two worst looking patches. Whether the trauma of the gauze was itself responsible for the subsequent perforation, or, whether by forming adhesions, it saved the general cavity from the escape of intestinal contents through a perforation, which would have occurred in any case, must remain undetermined.
The leucocytosis which at the first operation afforded an apparently certain indication was completely misleading at the second. Here, although in two separate counts the leucocytes were 20,000 there was found no inflammatory reaction to account for the increase. I do not know whether obstruction is usually associated with leucocytosis or notj
Sifton, H. A.: Chicago Clinical Review, Vol. IV, p. 368, 1894-5.
t Reported by Keen: Surgical Complications and Sequela of Typhoid Fever, 1898, p. 238, Case 40.
t In a condition of obstruction at the hepatic flexure, following a recent operation for acute appendicitis the patient had a leucocytosis of 44,000 without peritonitis, whereas during the acute stage of his appendicitis tlie leucocytes had been only 23,000. A differential diagnosis between peritonitis and obstruction is most difHcult. Bogart's case was similar to this one, an obstruction simulating general peritonitis. Damner Harrison (Brit. Med. Jour., Oct. 20, 1894, p. 8C5) operated on a typhoid case for perforation, and found an obstruction. Barbe {Etude clinique sur certaines formes des perforations de I'intestin grcle : Importance du diagnostic precoce. These de Paris, 1895) calls attention to similar cases. No record of the number of leucocytes is given by these writers. The high degree of leucocytosis, such as was present in the writer's two
It is also noteworthy that the perforation was not associated with an early drop in temperature, contrary to the supposed rule, whereas one of the first symptoms of the obstruction was a fall of four degrees. The importance of immediate intervention was evidenced at the first operation. Practically the same symptoms appeared twelve days later without perforation. As was found subsequently these symptoms were due to an acute obstruction, and at the second operation, which was performed immediately after the onset of symptoms, the real condition was overlooked because at this early period distension of the proximal bowel which would naturally have suggested obstruction had not yet taken place. The question of justifiability of such an immediate intervention on the first symptoms of perforation will be considered later, as well as the difficulty of distinguishing between acute obstruction and perforation in their early stages.
It was learned from this case that a median incision was a bad one as the lesions occur in the right iliac fossa almost as naturally as do appendicular ones. It is also apparent that the mere performance of laparotomy in the course of typhoid fever, provided it is made before the occurrence of septic extravasation, is in itself attended with little more risk than a similar procedure in febrile states, the only apparent drawback to it being the necessary omission of any bath treatment during the subsequent progress of the fever.
I have found in the literature only one instance in which more than one laparotomy has been performed in an attempt to combat intestinal perforation and its sequels. In Bogart's* interesting case a perforation in the ileum, which was closed by the tip of the appendix, occurred in a third attack of fever. Death resulted three days later from obstruction at the hepatic flexure of the colon, an operation for the relief of which was abandoned. Of this case Keen| says : '• I can scarcely think that we would ever be justified in re-opening the abdomen in such a case. Possibly a very exceptional case might justify such a procedure, but a typhoid patient rarely escapes with his life even after one operation and could not be expected to survive a second. The same remark would apply to any new perforation which might occur. Such cases must unfortunately be left to their fate ; but if the surgeon has been careful to search for and suture any impending perforation he has done much to prevent such a disaster."
Dr. Keen's last remark holds true, but it is hard to agree with the statement that a patient should be left to his fate, no matter how desperate the condition, provided surgical intervention offers any chance of relief, forlorn though it may be. The great vitality of some of these patients is illustrated as well by this case as by the remarkable one of Dr. Finney's in which after two relapses, an otitis media, a pleurisy, and phlebitis subsequent to the operation, there was eventually a complete recover}'.
cases, may possibly be of some diagnostic value in differentiating between these conditions, though in a manner entirely opposed to the usual interpretation.
Bogart, J. Bion : Laparotomy for Perforating Typhoid Ulcer of
the Ileum, etc. Annals of Surgery, Vol. 1, 1896, p. 596.
f Keen, W. W.: Surgical Complications and Sequelae of Typhoid Fever, p. 232, 1898.
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Case II. General Ko. 33,970. — Typhoid perforafmi in the fifth iveelc. Laparotomy under cocaine ancesthesia. General peritonitis. Suture of three 2^erf orations in ileum. Deatli four hours after operation.
September 3, 1898. William N., aged 18, was brought to the medical wards of the hospital with the history of a febrile attack of three weeks' duration. The patient's mother and sister died at home during his stay in the hospital of " malignant typhoid."
The patient was dull and stupid, and presented a typical typhoidal appearance. The medical note on the abdomen at entrance is as follows: "Abdomen. Peculiarly mottled, especially in inguinal regions, a bluish discoloration, taches bleuiUres. Walls somewhat tense ; grooves obliterated ; everywhere tympanitic. Slighttenderness across upper abdomen in umbilical and epigastric regions. Spleen enlarged, edge readily palpable. Liver. Relative dulness at upper border of 6th rib; absolute in 6th space and extending to costal margin ; towards left extending 3 cm. below xyphoid ; edge palpable."
Sept. 5th. The abdomen was noted by Dr. McCrae as being natural.
Sept. 10th. The patient has well-marked diarrhoea with colicky pains.
Sept. 11th. Widal reaction positive in dilution of 1 to 100.
Sept. 12th. Dr. McCrae. "Patient has been complaining of abdominal pain. Abdomen is slightly distended, tense. Rose spots present. Liver dulness present. No abdominal tenderness on palpation. Leucocytes 7500 at 10 A. M." 4 P. M. Patient vomited twice in early afternoon after nourishment. Leucocytes 8400 at 8 P. M.
Sept. 13th. "Patient has been very ill for 48 hours. Eyes are sunken. He has somewhat the look of collapse. Abdomen is somewhat full with respiratory movements present. The walls are very tense and tender on palpation. Liver dulness absent in mammary line, present in mid-axillary line."
The patient vomited after nourishment at 10 and 12 o'clock last night.
The leucocj'tes on this date were as follows :
Leucocytes at 9 A. M. 6000
" " 10 " 7200
" 11 " 8800
"12.15 P.M. 6400
" "1.30 " 6000 operation performed.
" " 2 00 " 70C0
At 1 P. M. a note by Dr. Thayer is as follows : Patient lying on back. Tongue beefy, eyes sunken and wide open. Respirations shortand shallow. Patienthasaperitoniticfacies. Green vomitus in sputum cup. Pulse small, 152. Abdomen tense, full and tympanitic. AVith patient on his back there is no hepatic flatness in the mammary line and none till one almost reaches the axillary line. There is dulnebs in either flank which disappears when the patient lies on the opposite side. Frequent vomiting during the examination. There is a well-marked friction throughout the right axilla which is heard all the way down to the costal margin. With patient lying on his left side there is no hepatic flatness anywhere.
The patient was immediately taken to the operating-room.
Operation at 1.30 P. M. under cocaine anaesthesia. Closure of three perforations in ileum. Irrigation and drainage for general septic peritonitis.
A linear infiltration of the skin with Schleich's solution was made in the right linea semilunaris. On opening the abdominal cavity there was an e.xplosion of gas followed by the escape of a large amount of stinking material looking like pea-soup stools. The bowels were of a dark bluish color, dis
tended, covered by a thick plastic lymph and everywhere bathed in the foecal extravasation.
The CEecum was located, and the first loop of ileum when drawn out showed three large ragged holes about IJ cm. in diameter and with fine bridges across them made by threads of submucosa.* They were closed with Halsted mattress sutures. The appendix and colon were free from perforations. The patient was given a few whiffs of chloroform ; the bowels were turned out, and the abdominal cavity cleaned as thoroughly as possible and irrigated with salt solution. Drainage was left in to the bottom of the pelvis and to the site of the suture.
The operation lasted 20 minutes.
Needless to say his condition was desperate with a pulse of 160 and respiration 60.
The patient rallied somewhat after the operation under stimulants and salt infusion, but remained in a state of euthanasia, often seen in severe septic infections, and died four hours later. Unfortunately no post-mortem examination could be made.
The cover-slip preparations taken from the general cavity at operation showed a great diversity of organisms, some cocci, but mostly bacilli of various shapes and sizes, and a great number of pus cells. No streptococci were seen. Nothing was grown out on culture but the bacillus coli communis.
This case well illustrates the practical hopelessness of operation when perforation, at its onset, has been overlooked, and the operation delayed until the stereotyped symptoms of extensive extravasation, such as obliteration of liver dulness and evidences of shifting free fluid, have appeared. It is such cases as this which render the operative statistics for perforation so uniformly bad. Abbe'sf case, however, makes recovery seem never impossible after operation.
The complete absence of abdominal tenderness and of leucocytosis unfortunately was misleading, but the preceding diarrhoea, abdominal pain and vomiting under ordinary circumstances would have led to early exploration had it not been for the fact that so many of the house cases this fall have complained of adominal pain and tenderness associated with diarrhoea. This point will be referred to later.
The importance of making cover-slip preparations as well as immediate plate cultures from the abdominal contents in cases of peritonitis is well shown by the fact that the bacillus coli communis overgrew all other organisms in what the cover-slips had shown to be a polyinfection. Careful investigations, such as those of FlexuerJ, show what a variety of organisms may be present. Undoubtedly the colon bacillus being more in evidence is frequently held resj)onsible for peritoneal infection due to more virulent but culturally less vigorous organisms. In one of Flexner's cases (Case IV) there was obtained from the peritoneal cavity the bacillus typhi abdominalis, bacillus coli communis, proteus vulgaris,
•Such as are shown in Keen, op. cit., Plate V, Fig. I.
t Abbe, Robert : Perforating Typhoid Ulcer. Peritonitis. Operation. Recovery. Medical Record, Vol. XLVII, p. 1, January 5, 1895.
JFlexner, Simon : Certain Forms of Infection in Typhoid Fever. Johns Hopkins Hopital Reports, \'ol. V, 1895.
k
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staphylococcus aureus and the streptococcus pyogenes. I know of no other case in which the bacillus typhosus has been obtained in culture from a general peritonitis following perforation. The organism in our Case I, though akin to it, was not positively identified. Korte* isolated the bacillus from a general peritonitis which originated however from a ruptured suppurating mesenteric gland. Klein also is said to have obtained it, but from a localized peritonitis.
Case III. Surgical No. 8131. — Typhoid perforation at end of fourth week after prolonged abdominal symptoms. General streptococcus per itotiitis. Laparotomy. Suture of perforation. Death after eight hours.
Sept. 5, 1898, Peter B., colored, aged 31, was admitted to the medical wards complaining of having had " pain in his head and stomach and general weaknpsB" since August 23rd. He had had some diarrhoea and abdominal pain during this time, but had not taken to his bed.
The note on the abdomen at entrance is as follows : "Abdomen looks natural ; no distension ; costal and iliac grooves are well marked ; respiratory movements are present. Some tenderness on palpation, especially in right inguinal and iliac region. Liver dulness begins at the sixth rib and extends to costal margin. Spleen is just palpable." Blood count. Red corpuscles 4,820,000. White corpuscles 5,600.
The Widal reaction was positive in dilution of 1 to 100. The patient was very ill and delirious at times, and on the night after admission jumped ten feet out of the ward window without, however, injuring himself. A slight leucocytosis was found a few days after admission which, coupled with his abdominal pain, occasioned suspicion, and he was watched very closely.
On several occasions the writer saw him in consultation with Dr. McCrae, but the complete absence of objective abdominal symptoms and the fact that there were several patients in the wards with similar subjective symptoms made us hesitate about operative intervention. For ten days he pursued a usual typhoid course, though the leucocytosis at one time reaching 15,200 persisted (cf. Clinical chart) and abdominal pain was constantly complained of. There was no diarrhoea. He was given the usual bath treatment.
Dr.McCrae's note the morning of the 17th inst. states : "General condition good. There is no delirium. Tongue is still coated. Patient frequently lies with knees drawn up. He states that he has very slight abdominal pain this morning. Abdomen is flat, soft on gentle palpation. Patient complains of severe pain when pressure is applied. Muscles at times are rigid, at others soft.
I am inclined to believe that his perforation took place the following night coincident with the drop in temperature (cf. Clinical chart). His pulse at midnight was recorded at 120 and his respirations at 36. By a strange misfortune during rounds the next day at noon he seemed very much better. His pulse was 76 and respirations 22, possibly as a result of the recent tub, and there seemed to be no change in his abdominal condition.
He was quite delirious during the day. There was no nausea or vomiting His leucocytosis had disappeared. At midnight of this day Dr. McCrae found him in considerable pain, lying on his back with his knees drawn up. He was dull and answered questions slowly and unintelligently. Respirations 44. Pulse 120. There was some vomitus on the floor beside the patient's bed. This was the first vomiting that had been noted.
Respiratory movements were absent from the abdomen. There
Korte, W.: Erfahrungen fiber die chirurgische Behandlung der
allgemeinen, eitrigen Bauchfellentziindung. Verhandlungen der deutsch. Gesellschaft fur Chirurgie, 21ter Congress, p. 164, 1892.
was no fulness but general tenderness on palpation, especially in the right iliac fossa. There was distinct dulness, which was movable, in the right flank. The liver dulness began at the 7th interspace and extended to the costal margin. His leucocytes were 4300.
September 19th. Operation at 1 A. M. Ether anmsthesia. Laparotomy. General peritonitis. Suture of perforation in ileum. Irrigation. Gauze drainage.
The incision was made through the right rectus sheath, and the muscle drawn toward the median line. On opening the abdominal cavity bubbles of gas and sero-purulent fluid escaped. Cover-slips from this fluid were immediately examined and found to be full of streptococci with an abundance of other pleomorphic organisms.
The ileum was quite distended. For about two feet from the Cfficum, as it was withdrawn, it appeared injected and pretty extensively covered with a delicate, fibrino-plastic lymph which could be readily peeled off in sheets. This pellicle was in many places glistening and quite transparent. There were no adhesions. About 10 cm. above the caecum in the centre of a dark bluish area measuring about li cm. in diameter was a small perforation which was partially occluded by a pouting nubbin of red mucous membrane and from which there seemed to be escaping very little of the intestinal contents at this time. The perforation and thin patch were turned in with Halsted sutures. There was not a great amount of extravasation or free fluid present, certainly not enough to have given shifting dulness.
The eventrated bowel was irrigated and the fibrin wiped off with wet salt sponges. The general cavity was wiped dry with salt sponges. Drainage was inserted to the bottom of the pelvis and to the site of suture and a neighboring thin Peyer's patch.
The patient stood the operation, which lasted 30 minutes, fairly well. There was no vomiting during or after the anesthesia.
Death supervened 8 hours after the operation. The temperature remained high. There was no vomiting and nourishment was taken frequently. Nutritive and stimulant enemata were given and retained. The clinical picture was one of acute general toxaemia, such as streptococcus infection sometimes produces.
From the peritoneal fluid at operation Dr. Clopton obtained in cultures an abundant growth of the streptococcus pyogenes, the bacillus coli communis, the bac. lactis aerogeues and a yeast fungus.
Autopsy. Eleven hours after death. Dr. Nichols.
Anatomical diagnosis. Typhoid fever. Perforation. General fibriuo-purulent peritonitis. Operation. Healing ulcers in ileum, caecum and appendix. Slight ileo-colitis. Suppurating peritoneal gland. Acute splenic tumor. Cloudy swelling of kidneys, etc., etc.
The protocol need not be given here in full. The lesions in the organs were typical of typhoid infection. The peritoneal surfaces were quite generally involved in an inflammatory process with thin adhesions and without the production of much fibrin or pus. The free fluid had a sero-purulent character. There was a second threatening perforation a short
"ExWv"'S «\"'^
I
PUOTOGUAl'II OF THE ILKIM I'l' C'aM; 111.
November, 1898.]
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distance above the ileo-csecal valve. The mesenteric glands were all swollen, soft, and one showed an area of suppuration the size of a pea. There were two or three small round healing ulcers in the csecum and appendix. The following description is taken directly from the protocol :
The Ileum presents a remarkable appearance. The very edge of the ileo-cEecal valve has preserved its mucous membrane. Above this the mucous membrane has been completely destroyed over a large surface by single, confluent, often suspicious looking ulcers. One has reached the size of 7 cm. in length by 4 cm. in breadth. (This is well shown in the photograph.) The central part of this has a small clot adherent to it, and corresponds to a hajniorrhagic area on the serosa, looking like an imminent perforation situated 4 cm. above the ileo-cajcal valve. These ulcers have the same general characteristics, their edges are raised, seem opaque, congested and partly hismorrhagic. Their base is clean and apparently extends down to the transverse musculature. It is of bright red color, and transverse striae can be plainly seen. About the edges and often running in small strands across the base is a pink, delicate, new growth of epithelium. The general direction of these ulcers is longitudinal. This extensively ulcerated area does not extend much further than 11 cm. from the valve. Fourteen centimetres above the valve is a similar ulcer, puckered and inverted by the silk sutures where the perforation had occurred. This ulcer was not larger than a five-cent piece.
There are about five small, similar ulcers at various distances apart above this. The whole mucous surface is somewhat congested and there, are .small sub-mucous ecchymoses. Peyer's patches and the solitary follicles are not swollen to any appreciable extent.
Bacteriological Report — Dr. Harris. — Cultures from the abdominal cavity gave the streptococcus pyogenes. From the spleen and gall-bladder was obtained an actively motile bacillus, which decolorized by Gram, and in cultural characteristics corresponded to the bacillus typhosus. From the liver, kidney and peritoneal gland an organism was obtained which was identified as the bacillus coli communis. Also from the pelvic exudate, lung and peritoneal gland was obtained a bacillus corresponding to the bacillus lactis aerogenes.
This case would appear to be of special importance in that it exemplifies the existence of a definite recognizable condition spoken of above as the pre-perforative stage of ulceration. It seems not unnatural to suppose that, owing to the extreme degree of ulceration of the ileum or possibly of the appendix, some inflammation of the serosa, limited by adhesions, may have taken place. This would account for the abdominal pain, tenderness and leucocytosis of several days duration and the disappearance of the latter after perforation had actually occurred. Doubtless it would have been better to have operated early, and have sutured or drained from any suspicious patch.
These preliminary abdominal symptoms undoubtedly somewhat disguised those of perforation with extravasation when it subsequently actually occurred, and the abdomen unfortu
nately was not opened until after evidences of general peritonitis had begun to appear.
How often a streptococcus peritonitis has been the cause of death in the fatal operative cases cannot be told, and it is a matter of regret that bacteriological reports showing the variety of peritonitis present in these cases are not more often noted. Keen* says : " There is but a single instance, so far as I know, of a bacteriological examination of the contents of the peritoneum in typhoid perforation." Undoubtedly peritonitides of this nature are very fatal, and the abundance of long streptococcus chains, found in cover-slip preparations during the operation, gave immediately a bad prognosis to what seemed otherwise a favorable case.
The extent of peritonitis macroscopically was one such as is not infrequently recovered from in those more fortunate cases in which streptococci are not the paramount infective agent. As Durham f has emphasized, " the more virulent the infection the less marked are the local signs of peritonitis."
A streptococcus infection in typhoid is undoubtedly a very severe complication and Vincent J believes that it carries with it an extremely grave prognosis. Doubtless, considering its frequency in autopsy records of perforation, it has been present in many of the fatal cases which have succumbed after operation. Eeports by Flexner,§ Fraenkelll and others show how frequently streptococci are obtained from the peritoneal exudate at post-mortem examinations after typhoid perforations. Tavel and LanzT[ in their extensive report on peritonitis, recognize the frequency and importance of streptococcus infections, but they seem to have encountered no cases of typhoid perforation at the surgical clinic in Bern, nor has Korte** in his recent paper added any to his two previously published cases.
It is strange with the degree of ulceration found and the abundance of streptococci present, that there was no diarrhoea in this case. The steady drop in the leucocytes, after the perforation and with the onset of general peritonitis, is a most interesting feature and recalls the condition in Case II, where with the purulent peritonitis no leucocytosis was presen t, though it will be observed that no count was made in the latter case at the time of probable perforation or just before it. It is quite well recognized that in appendicitis the leucocytosis, which may be high (30,000 to 30,000) before, drops after perforation, and
•Op. cit.,p. 220.
f Durham : On the Clinical Bearing of Some Experiments on Peritoneal Infections. Med. Chir. Trans., London, Vol. LXXX, p. 191, 1897.
^Vincent, M. H.: Etude sur les resultats de 1' association du streptocoque et du bacille typhique. Annales de 1' Institute Pasteur, Vol. VII, p. 141, 1893.
^ Flexner, Simon : Certain Forms of Infection in Typhoid Fever, .lohns Hopkins Hospital Reports, Vol. V, 1895.
II Fraenkel, Euj!. : Zur Aetiologie der Peritonitis. Miinchener med. Wochenschrift, Bd. XXXVII, s. 23, 1890.
H Tavel, E. und Otto Lanz : Ueber die Aetiologie der Peritonitis. Mitteilungen aus Kliniken und medicinischen Instituten der Schweiz, 1898.
Korte, W.: Weiterer Bericbt iiber die chirurgische Behandlung
der diffusen eiterigen Bauchfellentzundung. Mitteilungen aus den Grenzgebieten der Medizin und der Chirurgie, Bd. II, 1897, p. 145.
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with the onset of general peritonitis often disappears completely.
I am inclined to believe that in these suspicious cases the tubs should be discontinued. The late appearance of vomiting and its single occurrence shows the unreliability of this symptom for the diagnosis of perforation.
Case IV. Surgical No. 8154. — Typhoid fever in foiirlli week during relapse. Supposed perforation. Exploratory lajxirotomy negative. Recovery.
Maggie P., aged 15, was admitted to the medical wards, August 8, 1898, in the first week of typhoid fever. The fever pursued a typical course (cf. Clinical chart) without abdominal symptoms, with no leucocytosis and with a positive Widal reaction. A moderately severe phlebitis of the left leg appeared unassociated with leucocytosis on the 33rd day. There was considerable swelling of the leg, and tenderness over the femoral vessels. The temperature reached 10i°, but in a few days dropped to normal, and remained down twelve days. The patient was up in a wheel-chair, and without symptoms.
On September 22nd (the 52nd day after onset) a relapse of the fever came on abruptly, the temperature rising suddenly to 103° and on the following day to 105°. There was some nausea and vomiting, without abdominal tenderness or pain, but associated with a leucocytosis of 16,000. This condition persisted for the succeeding 48 hours, and therightiliacfossa was noted as being slightly resistant. Some tenderness was noticed in the right calf.
On September 24th, the child began to complain of abdominal pain. She was seen in the evening in consultation with Dr. McCrae, but there were no objective abdominal symptoms at that time. The condition was much as on the preceding day. There was some tenderness in both calves on pressure.
September 25th, 1.30 A.M., the child awolfe crying out with a sudden sharp pain in the abdomen " unlike anything she had previously had." Some nausea and slight vomiting followed. Leucocytosis 11,000. Two hours later, 3.30 A. M., the patient was again seen by the writer. She was complaining of colicky pain in the abdomen. Her thighs were kept flexed. There was some slight distension present. The liver dulness did not reach the costal margin by a finger's breadth. The walls were somewhat tense, and with moderately deep pressure in the right iliac region muscle spasm was elicited and the patient would cry out with pain. The chief rigidity, however, was above the level of the umbilicus. Her leucocytes had dropped to 8200. She vomited about 20 cc. of nourishment given her just before.
Operation September 25th, 6 A. M., four and one-half hours after the first appearance of symptoms.
Exploratory laparotomy. Negative findings. Closure loithout drainage.
An incision was made in the right iliac region. There was no free fluid in the general cavity ; no injection of the peritoneum. The appeudi.x, ileum and ascending colon appeared normal and without adhesions. The Peyer's patches in the ileum were swollen and hard, being felt like buttons through the bowel. The gall-bladder was not distended or inflamed. The pelvic viscera were negative. No thrombi could be palpated in the internal iliac veins. There were no suppurating glands felt in the mesentery. The abdominal wound was closed. The operation lasted only fifteen minutes.
The patient showed no ill effects from the operation. There was no subsequent nausea or vomiting; her leucocytosis dis
appeared, and she passed through an uneventful relapse of fever (cf. Clinical chart).
In the light of our previous experience with Cases II and III and with such symptoms as sudden acute abdominal pain, nausea and vomiting with increasing distension, some rigidity and tenderness and leucocytosis (especially a falling leucocytosis), the writer did not dare take the responsibility of withholding operative intervention even though there was some doubt as to the diagnosis. The possibility of an extension of the phlebitis to the internal iliac veins, thus causing some abdominal pain and tenderness, was thought of, but with the preceding phlebitis of September 23nd there had been no leucocytosis, pain or vomiting. The fact that the chief rigidity was above the level of the umbilicus suggested a gall-bladder complication, which in itself would have demanded exploration. The general appearance of the child was not that of collapse following perforation. There was no marked change in pulse, temperature or respiration with the above-mentioned symptoms. Nevertheless, I believed much less responsibility to be associated with an exploratory laparotomy than with running the risk of neglecting a i)erforation until signs of peritonitis should occur.
The precise cause of the patient's symitoms remains undecided. She was a very nervous child, ai:d there had been some children with acute abdominal affections in the ward during her previous period of convalescence.
Similar cases have been reported. Herrington andBowlby* report an operation on a young girl convalescing from typhoid who had even more marked symptoms of perforation with collapse than those related above. There is no mention of a leucocyte count. A laparotomy revealed no peritoneal lesion. Convalescence was uninterrupted.
General Considerations on Operation for Typhoid Perforation. — In recent years several tables have appeared in which are included all of the supposed authentic cases of operation for this particular complication in typhoid, notably those of Finney, Keen and Monad and Vanverts.
Statistics, however, always misleading, are especially so when they concern a question involving so many considerations as are included under the one head of " Results of Operation for Typhoid Perforation."
In the first place two distinct varieties of perforation may be recognized in which the operative prognosis is widely different. In one, the appendicular form, the process takes place in a quiet corner of the abdomen usually remaining localized, owing to the formation of adhesions, for perhaps a long time. In these cases some pre-existing chronic appendicular trouble may predispose toward perforation in the same way as does an ulcer of typhoidal origin in this situation. The condition, then, is practically one of acute perforative appendicitis occurring in the course of typhoid, and has the same prognosis and surgical features as similar conditions unassociated with
Herrington, W. C, and Bowlby, A. A. : Typhoid Fever Convalescence; Symptoms of Perforation, Laparotomy ; no Lesion found;
Recovery. Med. Chir. Transactions, London, Vol. LXXX, 1897, p. 127.
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typhoid which give a certain percentage of recovery in uuoperated cases.
In the other variety the perforation almost always occurs in the freely moving bowel, usually in the lower foot of the ileum.
I believe that Dr. Fitz* first clea'-ly distinguished between these two varieties of perforation in typhoid, emphasizing the fact that many cases would be called appendicitis which, when occurring during typhoid fever, are classed as perforations. Undoubtedly the appendicular cases are much more common thau has been ordinarily supposed. Fitz finds, however, only 3 per cent, in 167 cases. Of the 20 cases of perforation in the pathological records of the Johns Hopkins Hospital there have been 3 appendicular perforations which, grouped with a single case out of the nine of which I am personally cognizant, makes 9.6 per cent, which have occurred in the appendix.
To further quote from Dr. Fitz's paper : " The probability of its occurrence (perforative appendicitis) furnishes the best solution to the prognosis of intestinal perforation in the latter disease (typhoid fever). Most cases of recovery from symptoms of perforation of the bowel iu typhoid fever are those in which an attack of appendicitis is most closely simulated, while the fatal cases of perforation of the bowel in typhoid fever are, in the great majority of instances, those in which other parts of the bowel than the appendix are the seat of of perforation."
It is of course important to recognize the fact that either of these conditions may be present, but a differential diagnosis can hardly be made, and were such possible, operative interference is as surely indicated as in any acute apj)endicitis. The prognosis in the appendicular varieties, for the reasons given above, is naturally more favorable, but in all cases the earlier surgical intervention is sought the better for the patient. This applies especially to the variety in which the perforation is in the free bowel. Here, also, adhesions presumably form as the nicer approaches the serosa, but inasmuch as they are attached to a movable part of the bowel they cannot be relied upon to hold, and extravasation usually soon takes place. It is with perforation of the ileum that we are chiefly concerned, and in looking for information upon this subject we are hampered because we find commingled iu the statistician's tables, two very different and widely separate conditions, one, the results of operation for typhoid perforation, the other, the results of operation for general peritonitis following typhoid perforation.
The mortality following operation for general septic peritonitis, due to extravasation of intestinal contents, is necessarily high. Could these cases be excluded from the tables we should find that operative interference in typhoid perforation is associated with a moderately low mortality.
A consideration of our cases, and of some heretofore reported, emphasizes the necessity of early operation upon the first symptoms of perforation, or possibly upon recognizable pre-perforative symptoms, without waiting for the usual signs of peritonitis. It is far better to operate early, needlessly if it so
• Fitz, R. H. : latestinal Perforation in Typhoid Fever : Its Progress and Treatment. Trans, of the Assoc, of Am. Phys., Vol. VI, p. 20n, 1891.
eventuate, rather than to wait until symptoms of peritonitis appear and actually demonstrate a perforation by its dread and practically inoperable sequel of general septic infection of the peritoneal cavity.
Any abdominal symptoms occurring in the course of the fever are as urgent indications for a surgical consultation as is the appearance of pain and tenderness in the right iliac fossa under all occasions, and only when this is fully realized will the mortality of these cases approach the low percentage reached in operations for acute perforative appendicitis or perforating gunshot wounds of the abdomen. Delay in these two latter conditions is no longer thought of, and equally prompt intervention ou the first abdominal symptoms in the course of typhoid, without waiting for actual evidence of peritonitis, will similarly reduce its high death-rate. It is hard to understand Dr. Keen's advocating delay until symptoms of shock have passed away and his preference of the second twelve hours for operating, when one appreciates that extravasation, perhaps of virulent organisms, is with all probability continually taking place while we are waiting.
There are of course certain cases, of which Dr. Osier* makes mention, in which perforation gives rise to no signs whatever as the patients are desperately ill and the local features are masked by the severity of the toxtemia. The diagnosis is usually made at such times on the autopsy table. Hospital cases, however, are usually carefully watched and some symptoms almost invariably should give warning of the complication, if not before, certainly at the time of perforation.
The figures, however, as they are given, including cases of all descriptions, even those condemned before they reach the operating room, present a comparatively low mortality.
Westf all's statistics (1898) given by Keenf are the most recent, and show 19.36 per cent, of recoveries in 83 collected cases. Those of FinueyJ (1897) include forty-five fairly authentic cases, with eleven recoveries, making his statistics somewhat better with 26.22 per cent, of recoveries. Monad and Vanverts§ consider the mortality to be much greater, namely 88 per cent., contrasted with a supposed 95 per cent, of deaths in unoperated perforations. With this small margin, however, they strongly recommend operation.
It is probable that the last figures morenearly represent the truth, as there are presumably many cases lost from tardy operations, which are never reported, and in the more favorable statistics given above there are doubtless some cases included which are of questionable typhoid origin.
Only in recent years has it become possible by bacteriological examination and by the serum reaction to conclusively demonstrate the nature of certain fevers. The writer recently operated on a perforated appendix associated with a general fibrino-purulent peritonitis due to a colon infection in a patient who subsequently had for three weeks a typical typhoid
Osier : Practice of Medicine, 3d edition, 1898, p. 26.
•f Surgical ComplicationsandSequelsof Typhoid Fever, 1893, p. 234.
I Finney, J. M.T.: The Surgical Treatment of PerforatingTyphoid Ulcer. The Annals of Surgery, March, 1897.
gMonad, Ch. et J. Vanverts : Du traitement chirurgical des p^ritonites par perforation dans la lievre typhoide. Revue de Chirurgie. T. XVII, 1897, p 169.
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chart and a general typhoidal appearance without leucocytosis, and with no abdominal symptoms. This would undoubtably in former years have been considered an ajipendicular typhoid perforation. Only after persistent negative results with the Widal reaction could we believe the case to be nou-typhoidal.*
Another case, which would certainly have been considered a perforation in an ambulatory typhoid had not careful microscopical and bactei'iological study been made of the tissues, is as follows :
The patient, Fred. H., aged 26, having been discharged from the work-house the day previously, entered the hospital January 25, 1897, after 12 hours of acute abdominal distress. He had all the symptoms of general peritonitis, and at operation a single perforation was found in the ileum the size of a five-cent piece and about ten inches above the ileo-csecal valve. He died 6 hours later, and the necropsy revealed an acute splenic tumor, parenchymatous degeneration of the liver and kidneys, but no other intestinal lesions characteristic of typhoid. There were no focal necroses in the liver, and the bacillus typhosus was nowhere obtained in cultures.
This case of perforation of the ileum, evidently not typhoid, presents such similarity to the notable one of Miculicz, which is usually admitted to have been of typhoid origin, that I cannot but believe the latter also was due to a perforation not resulting from typhoid fever, though its exact nature must remain uncertain. Doubtless many others of the tabulated perforation cases would likewise be discarded as " not typhoid " could they be scrutinized in the light of more recent and positive methods of diagnosis.
Diagnosis. — The question of early diagnosis of typhoid perforation is unfortunately but little touched upon in the recent monographs upon the subject, which give little more than a stereotyped picture of pain, collapse, vomiting and abdominal tenderness, a symptom complex which is enough of course in ordinary cases to assure one of the condition. We have seen illustrated by the above cases, however, that this picture is but rarely complete, and the difficulties in the way of the recognition of perforation are frequently so great that it may be overlooked entirely. Two of them also show that other conditions may give the characteristics typical of perforation when this complication has not occurred.
The complete symptomatology is usually given as follows. During the course of the fever, usually in the third week of a severe attack, most often in male adults there appears, with sudden onset, abdominal pain usually in the right side, associated with more or less tenderness and rigidity. Vomiting follows with more or less irregularity. The onset may be associated with a chill and pyrexia, or with cold extremities, collapse and a drop in temperature often of several degrees. The pulse becomes small and wiry. Leucocytosis is supposed to make its appearance, and soon more or less abdominal distension sets in with increase of vomiting, shifting dulness in the flanks, obliteration of liver dulness, a gradual return of i)yrexia if there has been a fall, with rapid feeble pulse, restlessness and
Thi8 case subsequently came to autopsy and a tuberculous
enteritis was found. The appendicular perforation was probably through a tuberculous ulcer.
thirst, all indicative of general peritonitis, with death supervening in 24 to 48 hours.
Of these symptoms, especially those associated with the onset, a few remarks will be made.
Abdominal pain and tenderness. — It is a well -recognized fact that the character of the symptoms in typhoid fever seems to vary in different years within considerable limits. An unusually large number of the cases which have been treated in our medical wards this fall have had abdominal pain and tenderness which have frequently been associated with diarrhoea. This has been so pronounced a feature that several cases have been seen in surgical consultation for symptoms which have subsequently disappeared. A sudden acute onset of increased abdominal pain is an all important symptom which unfortunately may be absent, or owing to a patient's stupor be overlooked. Any complaint of pain, however, of less abrupt onset, associated with tenderness, must arouse the greatest suspicion on the part of the attendant. I cannot but believe that the condition which has been spoken of above as a pre-perforative stage of ulceration often exists. A little localized inflammation of the serosa, with or without the passage of microorganisms and leading to a slight adhesive peritonitis, usually of omentum, can give rise to these symptoms and produce an associated slight leucocytosis. This is precisely analogous to what occurs in the pre-perforative stage of appendicitis which, however, is of less urgent nature because in the case of the appendix which is fixed and does not move about freely in the general cavity, as do the coils of ileum, the adhesions are less likely to be dislocated and a general peritonitis, which would result from this separation, is avoided. This is as true of appendicular perforations in typhoid as of those occurring at other times. I believe that this pre-perforative stage may be frequently recognized as in Case III reported above. Doubtless m some of the successful cases of operation for perforative peritonitis such a pre-perforative stage has been met with. This was notably so in Dr. J. B. Murphy's case,* where no perforation was found, but merely a local inflammatory reaction about one threatening ulcer. Several of the other successful cases illustrate a preextravasation stage where adliesions had reinforced the serosa before it gave way entirely and had temporarily prevented extravasation. Among such cases may be mentioned Watsou's,t Bogart'sJ and our first case at the third operation.
Under rare conditions when the adhesions are firm, which, for the reasons mentioned above, is more likely to occur when the appendix is the seat of threatened perforation, the base of the ulcer may completely penetrate the bowel and yet the general cavity be protected. A local abscess may result, or the adhesions may floor the ulcer and subsequent healing take place over them so that recovery follows withoitt operative intervention.
This is the usual explanation of recovery following symptoms of perforation, in cases which have not been subjected to operaration. In the case of Buhl,§ qtroted by Fitz, at an autopsy
•Westcott's table, Case No. 41. Keen.
t Watson : Boston Med. and Surg. Journ., Vol. CXXXIV, 1896.
t Bogart : Op. cit.
I Zeitschr. f. rat. Med., 1857, N. F. VIII, S. 12.
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following death from haemorrhage, a pre-existing perforation was found to have been closed by omentum. This was twentythree days after the occurrence of symptoms of perforation. Dr. Hare* of Brisbane, says : "At present it is an open question whether the treatment should be medical or surgical ; whether indeed laparotomy is justifiable." He reports an interesting case in which symptoms of perforation had occurred. The patient subsequently died, some time later, with dysenteric symptoms, and the ileum was found surrounded by adhesions, which were especially dense at the point corresponding to a supposed perforation. I do not think, however, that this case is at all conclusive. A threatened perforation with perhaps the escape of some organisms through an intact serosa, which Dr. Welch has proved to be possible, would have accounted for the localized peritonitis. Had the perforation been complete, doubtless the adhesions would not have long sufficed to confine the extravasation. In his second case of supposed recovery after perforation an operation, had it been offered in the first hours of symptoms, would with greater probability have insured success. Mr. Gairdner'sf interesting cases also would show that a fatal peritonitis without an absolutely complete perforation may take place. He reports five such instances.
The protection by adhesions in this way is too precarious a thing to be relied upon, and that they should hold for any length of time is something which can never be anticipated. The recognition of this pre-perforative stage I would emphasize as all important.^
This is the period in which, if possible, an operation should be performed, and as it may endure but a short time, the opportunity should be immediately seized. Such a condition existed in Bogart's case§ in which he found a perforation of the ileum closed and the ulcer floored by the adherent tip of the appendix. He speaks of the presence of sero-puruleut fluid in the general cavity which doubtless was free from organisms as it was in our Case I, which was operated upon before extravasation of intestinal contents had taken place. An opportunity of operating in this stage was unhappily neglected in Case III.
An analogous pre-perforative stage was recognizable in the following case, one of dysentery, upon which the writer recently operated, though too late. The patient had been in the medical wards for some days with a severe amoebic dysentery. He developed considerable abdominal pain, tenderness and leucocytosis, with some rigidity of the parietes. Several
» The Cold Bath Treatment of Typhoid Fever, 1898, p. 178.
tGairdner: Peritonitis in Enteric Fever. The Glasgow Med. Journal, Vol. XLVI, p. 114, Feby., 1897.
t Under "pre-perforative stage" let it be understood that the whole period is included between the first involvement of the serosa with the customary formation of adhesions at that point, until these adhesions, which may for a time constitute the floor of the ulcer after the serosa has given way, have themselves become broken down and general extravasation has taken place. This period as in perforating appendicitis may last a longer or shorter time and is associated with pain and tenderness and a possible rise in leucocytosis owing to the localized peritonitis. i Bogart, J. Bion : loc. cit.
days later, while having a rectal irrigation, sudden evidence of perforation and extravasation occurred with acute paiu and collapse. At the operation, three hours later, bis abdomen was full of fifices, which were pouring from a large opening in the sigmoid flexure. The autopsy revealed an extraordinary degree of ulceration of the colon with a complete loss of substance in the bowel in several places, but all of these ulcerated areas, except the one found at the operation, were completely floored by protecting omental adhesions.
As iu the three typhoid cases reported above, here too was a distinctly recognizable pre-perforation or pre-extravasation stage of intestinal ulceration which demanded operative relief before final signs of perforation with extravasation had rendered the chances of giving it most desperate.
Undoubtedly, signs exist which are often considered trivial, but which may aid us iu anticipating a final perforation by indicating early laparotomy.
Temperature and Pulse. — A prouounced drop in temperature is a not infrequent symptom, associated with the onset of the perforation. It must, however, be clearly distinguished from the great fall in surface temperature, which is often pronounced and gives rise to the cold and clammy extremities so characteristic of the collapse of onset. This latter condition, however, may be associated with a rise of central temperature. In some of the cases cited by Fitz this collapse was the only symptom indicative of perforation.
The suilden fall of the central temperature, wheu it occurs, is such a pronounced feature that more importance has been ascribed to it than it deserves. Dieulafoy* considered it au almost infallible sign. He says : " La perforation intestinale, au cours de la fievre typhoide se traduit dans la tres grande majorite des cas, par uue chute hru^ve de la temperature." He thinks the appendicular attacks occurring in the course of the fever show, ou the coutrar}', a rise in temperature, and may thus be distinguished. Lerebonllet.t however, takes exception to this statement in a thorough discussion, and believes it to be exceptional. Gesselewitsch and WanachJ also emphatically assert that many cases are accompanied by a rise in temperature. One can merely state that when present it is a characteristic symptom, but that it may be absent. It also, of course, frequently occurs in other conditions such as haemorrhage, and our Case I further illustrates its unreliability as there was no drop with the perforation, but a prouounced fall with the obstruction and after each operation. It may possibly be a means of distinguishing, as Dieulafoy suggested, between a perforation with extravasation into the free cavity and one protected by adhesions giving merely a local inflammatory reaction.
•Dieulafoy: De rintervention chirurgicale dans les peritonites de la fievre typhoide. Bull, de I'Academie de Medicine. Oct. 27, 1896.
tLereboullet : Sur le diagnostic et le traitement des perforations intestinales dans la fiuvre typhoide. Bull, de I'Acad. de M^d. Nov. 3, 1896.
t Gesselewitsch and Wanach : Die Perforations Peritonitis beim Abdominal Typhus und ihre operative Behandlung. Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie, Bd. I, H. 1 und 2, 1898.
268
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 92.
The disparity between pulse and temperature may be a marked feature, the former being small and rapid during the drop in temperature. The respiration likewise is apt to be more rapid and shallow with less marked abdominal movements.
Of symtoms other than those associated with a threalening perforation or with its immediate occurrence little need be said. A cliill sometimes occurs, but more often with the circumscribed and appendicular varieties, when, too, the temperature is more apt to rise. Vomiting is an important symptom when present, but its frequent absence makes it an unreliable one. The acoustic phenomenon of Levaschoff, a sound caused by the passage of gas through the perlbration with each descent of the diaphragm, has not been generally confirmed. Later signs, such as siiifting dulness from free fluid, distension, obliteration of liver dulness and other indications of abundant extravasation of gas and faeces, such as were present in Case II, make the diagnosis of a long standing perforation as easy as its prognosis is unfavorable. Even many of these stereotyped indications of general peritonitis may be misleading. In Case III shifting dulness was a marked feature, and yet but little free fluid was present. Similarly a distended colon may cause partial obliteration of liver dulness, but even with perforation and extravasation too small an amount of gas may escape to produce it.
Leucocytosis. — Of great interest and of great diagnostic importance in these cases would seem to be the presence or absence of leucocytosis.
The final interpretation, however, to be given to this symptom is far from being made. Dr. Finney says: " Of all the socalled diagnostic signs of perforating typhoid ulcer most reliance is to be placed upon the development of an attack of severe, continued abdominal pain, coupled with nausea and vomiting, and at the same time a marked increase in the number of white blood corpuscles." We have seen, however, in some of our cases a fall and not an increase in leucocytes, which must receive consideration.
The fact that " there is not only no increase in the proportion of colorless corpuscles during the fever, but that on the contrary there is rather a tendency toward a diminution in number at the height of the disease," was emphasized by Thayer* in 1892. The occurrence of leucocytosis therefore is quite properly in most cases supposed to be coincident with the presence of some septic complication other than the surface ulcerations of the intestinal tract. Cabotf is inclined to the belief that in all the cases in which leucocytosis exists constantly, some complication really is present though it may be unrecognized. He cites two cases with a leucocytosis of 2i,000 and 18,000 respectively, occurring at the time of perforation. He further states: "It occasionally happens in very exhausted patients that complications fail to produce any leucocytosis, the patient (as in some cases of pneumonia or purulent peritonitis) being unable to react against the infection " (p. 170). This statement, I think, needs some qualification.
Thayer, W. S.: Two cases of Post Typhoid Anaemia. With
Remarks on the Value of Examinations of the Blood in Typhoid Fever. Johns Hopkins Hospital Reports, Vol. IV, No. 1, p. 88.
tCabot, R. C: Clinical Examination of the Blood, p. ](!8, 1897.
Using the cases above reported, in all of which careful leucocyte counts were made, we are confronted by quite a diflerent picture. In Case II the complete absence of leucocytosis was the unfortunate cause of a deferred operation. I doubt not, however, that a leucocytosis, which subsequently disappeared, was present at the onset of the peritonitis.
In Case I there was an early and recognized leucocytosis appearing, however, before any signs of general peritonitis had developed; and in the peritoneal fluid comparatively few white cells were present and no micro-organisms.
In Case III, a preceding leucocytosis associated with abdominal pain and tenderness, which, as has been stated, was probably indicative of a mild local peritonitis about the extensively ulcerated bowel, was completely wiped out concomitant with the occurrence of general peritonitis and the appearance of great numbers of leucocytes in the extravasated peritoneal fluid.
In the case of dysenteric perforation, mentioned above, the leucocytosis had previously been constantly high. A few days before the perforation it was 47,000. At the time of perforation it was 41,000. An hour later it had fallen to 30,000 and at the time of operation it was 27,000, a drop of 20,000 in three hours. At the operation the lower bowel was matted together with adherent omentum, this local inflammatory j^rocess doubtless being the cause of the preceding leucocytosis. The general cavity was full of fajcal and purulent fluid, in which were great numbers of polymorphonuclear leucocytes, eosinophiles and mononuclears in about the proportions found in the blood. Many of these cells were crowded with organisms and disintegrating. There is but one natural conclusion to be made from this sudden diminution of the number of white cells in the peripheral circulation coupled with their appearance in the peritoneal exudate.
Similarly in appendicitis the writer has frequently seen, after a high percentage of leucocytes present during the acute stage, a drop in their number occurring in association with the onset of peritonitis, as characteristic as that which occurs with the subsidence of the acute attack and recovery.
In Cabot's table XXI of counts made in general peritonitis, there are 4 without leucocytosis, the numbers varying between 4600 and 6000. Of those with leucocytosis, as well as in his cited dysenteric case with 24,000 leucocytes there is no recognition of a possible fall in number such as occurred in the cases cited above after the onset of general peritonitis.
Cabot* says : "A steadily increasing leucocytosis is always a bad sign and should never be disregarded even when other bad symptoms are absent." I would add that a decreasing leucocytosis may be a much worse sign, and should never be disregarded. This is especially of importance in those typhoid cases in which the "other bad symptoms" are diflBcult to estimate on account of the dull condition of the patient.
From these data on leucocytosis the following conclusions may be drawn :
1. The appearance of leucocytosis in the course of typhoid fever points toward some inflammatory complications in its early stage.
<0p. cit., p. 197.
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JOHNS HOPKINS HOSPITAL BULLETIN.
269
2. If this complication be a peritonitis and remain localized, associated possibly with a pre-perforative stage of ulceration (cf. Case III) or with a circumscribed slowly-forming peritonitis after perforation, it may be and usually is signalized by an increase of leucocytes in the peripheral circulation.
3. If, however, a general septic peritonitis follow, the leucocytosis may be but transitory and overlooked, as it disapijears concomitantly with the great outpouring of leucocytes into the general cavity.
The various forms of operative procedure advocated in these cases it is not the object of this paper to discuss. They are fully set forth in the recent monographs on the subject by Finney, Gesselewitsch, McOosh, Keen, and Farrar Cobb.* CONCLUSIONS.
The diagnosis of intestinal perforation in typhoid fever may present many difiBculties. No abdominal symptoms either subjective or objective occurring in the course of the fever should be regarded as trivial, and a sudden change of any sort in the patient's condition should lead first of all to the suspicion of this most serious comiJlication. A distinction should be drawn between the two varieties of perforation, the appendicular and those occurring in the free bowel, as their symptoms, course and prognosis vary considerably. Many cases, however, even those of perforation from the free bowel, present what may be recognized as a pre-perforative stage which in some cases calls for a laparotomy in anticipation of a complete perforation with extravasation. The presence of leucocytosis is not an infallible sign of perforation as it may disappear with the onset of general peritonitis. It is most valuable in this anticipatory stage.
When the diagnosis is made operation is indicated, whatever the condition of the patient. As Abbe's case esemplities, no case may be too late. A precocious exploration from an error in diagnosis is not followed by untoward consequences such as must invariably be expected after a neglected and tardy one.
Our present knowledge amply corroborates the statement of Miculicz made at Madgeburg in 1884: "If suspicious of a perforation one should not wait for an exact diagnosis and for peritonitis to reach a pronounced degree, but on the contrary one should immediately proceed to an exploratory operation, which in any case is free from danger."
Discussion". Dr. Finney. — There are a number of points in Dr. Cushing's most interesting paper to which I should like to call attention. Some of the points he has made are new, and I think a distinct addition to our knowledge of the subject. This is a subject in which I have been, personally, very much interested and have recently had occasion to go over the literature of the operation pretty thoroughly. I have myself operated upon four cases with one recovery; the other three were practically moribund at the time of operation. They were forlorn hopes, but as Dr. Abbey's case recovered, and since we have nothing to lose by operating in such cases, we may occasionally gain something. Next to Dr. Cushing's case, which must take the palm for having recovered under the greatest difBculties, I think my
Farrar Cobb: Septic Peritonitis and its Surgical Treatment.
Boston Medical and Surgical Journal, Sept. 8, 1898.
case a good second. Dr. Cushing's patient had three successive laparotomies, and subsequently recovered. My case had but one operation, but he had almost every complication that a typhoid patient can have.
In regard to the question of leucocytosis, we expressed the hope a year or two ago (the suggestion being first made by Dr. Thayer) for much of diagnostic value in the blood count of these doubtful cases. It has been of some value, but just how much remains to be seen. Dr. Cushing mentions the fact that in one case the increased number of leircocytes suggested perforation, and in another the rapid decrease in leucocytes was suggestive, if not of perforation, at least of a critical condition of the patient. The question of the value then of the blood count and its diagnostic significance remains to be determined.
In Dr. Cushing's third case I find the only one, in about a hundred which I have collected, occurring in a negro, and he died.
The question of a pre-perforative stage, as Dr. Cushing has called it, is very interesting and important if it can be really diiferentiated. It is a point which will be further investigated with a great deal of interest. As to statistics, it depends entirely upon how many doubtful cases one admits into one's series. In our previous report we found 36.3 per cent, of recoveries. Then Dr. Keene's very exhaustive work appeared in which he reduced the percentage to 19.6 per cent., but since then there have been a number of cases that will, I am glad to say, bring up the percentage somewhat. I have not a complete history of some of these cases as yet, but I think it will average between 30 per cent, and 35 per cent. The distinction which Dr. Cushing has drawn between operating for the relief of a perforating typhoid ulcer, and a general septic peritonitis following such a perforation, is a very good one.
After all, early operation is the main point in this as in many other operations. If we can get these cases early enough we shall have a much larger percentage of cures, and there, as Dr. Osier has suggested, the physician and surgeon must work together and try in every way to increase our diagnostic ability. So far as the technique of the operation is concerned, I believe there is not much to be gained, and we have reached the point in dealing with these cases where we haven't much to hope for in that direction, but must turn in the direction of an earlier diagnosis for any marked improvement in our statistics.
Dr. Osler. — I think Dr. Cushing is to be congratulated upon his excellent results. Certainly to save one case in three of perforation is much more than we can do on the medical side, for they all die with us, except a few cases of appendical perforation.
Dr. Cushing has pointed to the difficulty of diagnosis, and I do not know of any more difficult problem than to determine in some cases the existence of perforative peritonitis. The local symptoms may predominate, and I would ask whether in the case of the young girl the general symptoms of collapse, change in countenance, pulse, etc., were present or not?
There are many other points in connection with this question that I would like to discuss, but the programme is a long one and there will probably be other speakers. I would, however, refer to one point mentioned, the great importance, when the autumnal crop of typhoid cases is in hospital, that the house surgeon and house physicians should often make rounds together.
270
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 92.
SPONTANEOUS HilMORRHAGIC SEPTICMIA IN A GUINEA-PIG, CAUSED BY A BACILLUS.
By George H. Weaver, M. D., Chicago.
(From the Pathological Laboratory of Ruih Medical College.)
Tlie bacillus here described was obtained from a large female guinea-pig, which died suddenly without apparent cause in the animal room attached to the pathological laboratory of Rush Medical College.
Upon examining the body, the condition of the uterus first attracted attention. The right cornu was swollen to a diameter of 1 to 1.5 cm. for 5 cm. of its length. The covering of peritoneum exhibited marked vascular injection, but no exudate. The opposite cornu was of the normal size and appearance of the unimpregnated uterus. On opening the uterus from in front the cavity was found empty. The mucous membrane of the right cornu presented numerous scattered hiemorrhagic areas, which became confluent in front. On the posterior surface, about midway between the bifurcation and apex of the horn, was an area 1^x2 mm. in diameter, slightly elevated, firm, and of a dirty blackish-brown color.
The spleen was enlarged and soft ; the kidneys and liver pale. The heart was distended with blood. The lower lobe of one lung was firm, airless, and of a dark red color. In the opposite lung was a smaller area of firm consistence, of a deep red color, slighily depressed below the surface. On section the solidified portions were yellowish in color, and airless.
Cultures upon agar-agar, from the uterine wall, spleen, kidneys, heart-blood, and pneumonic area gave an abundant growth of the bacillus to be described below. Portions of the organs, hardened in alcohol, and stained with haematoxylin and eosin, and with Loeffler's methylene-blue, were examined with the following results:
Uterus. — The mucous tissue is largely destroyed in the right cornu at the site of the necrotic area. The superficial layer consists of necrotic cells, some with fragmented nuclei, some containing blood-pigment. In some places are areas of hjemorrhage with wellpreserved blood-cells, the infiltrated tissue staining poorly. The tissues beneath the serosa are much swollen, and the capillaries here much dilated. The muscular coat is much thickened from enlargement of the fibres and separation of them by fluid exudate. There is no round cell infiltration in any part of the organ. Sections stained with methylene-blue show abundant bacilli, corresponding to those obtained in cultures, in the necrotic uterine lining. They have penetrated but a short distance into the tissues and are not found in the deeper layers of the mucosa, nor in the muscular or serous layers.
Lungs- — The lesions in the lungs are those of a bremorrhagic pneumonia. The exudate is in part made up of small round cells (multinuclear). In other parts it is almost entirely ha;morrhagic, containing few or no leucocytes. In these latter areas the blood is, for the most part, well preserved, and some round cells contain pigment. When stained with methylene-blue and eosin, numerous bacilli are found in the ha;morrbagic areas. In places they are so numerous as to be easily recognized in mass with the low power. In the areas where the exudate consists of small round cells, few bacilli are to be found.
Liver. — Extensive fatty degeneration of the liver cells extends throughout the lobules.
Kidney —The epithelium of the convoluted tubules is swollen and cloudy. The glomeruli are distended with blood, in some escaped blood being seen free in the capsules. There are a few small areas of haemorrhage in the cortex.
-Sptecn.— There is a hyperplasia of the cells, and many large cells containing pigment.
DESCRIPTION OF ORGANISM.
Cultural Peculiarities. — In gelatine plates at room temperature, after 48 hours, the deep colonies appear to the naked eye as pin-point sized, white growths, and with a No. 3 Leitz objective, as round or slightly oval, pale yellowish, with an even outline and finely granular. After the same length of time the superficial colonies appear to the naked eye as about 1 mm. in diameter, glistening white, slightly elevated, with even or finely serrated edges. With the No. 3 Leitz objective they are translucent, with finely serrated edges, and uniformly and finely granular.
On agar-agar after 48 hours at 37° C. the superficial colonies were quite characteristic. The colony consisted of three zones. The centre was transparent or translucent white. About this was a zone of opaque white, while a third peripheral zone was transparent like the centre. The edges were finely irregular, and the colonies about y\ inch in diameter.
The growth upon an agar-agar slant was abundant, white and porcelain-like.
On gelatine there was a fine granular growth along the line of puncture, and at the surface a fine growth which did not spread over the surface, nor become elevated.
On Loeffler's blood-serum mixture there was an abundant creamy, white growth, with gas production in the water of condensation. In glucose-agar there was abundant gas production. Bouillon was rendered diffusely cloudy. On potato there was a yellowish-white growth, elevated aud with an irregular surface, which after a few days tended to extend over the surface beyond the site of inoculation.
Litmus-milk was turned faintly pink in 24 hours at 37° C, and in a week had lost some color, but there was no coagulation. There is no odor to the cultures, and no production oi indol or phenol.
The growth is not so luxuriant when oxygen is excluded. Growth is rapid at a temperature of 37° C, less so at 20° C. Slow growth occurs at as low as 7° C.
Morphology and Staining Projiertieg. — The bacilli from cultures upon agar-agar, and blood serum, are non-motile. They stain readily with the aniline dyes. With carbol-fuchsin there is often a nxore intense staining at the poles, which is not present in specimens stained with Loeffler's methyleneblue. The bacilli are short, two to four times as long as thick, with rounded ends. They resemble the bacilli of chickencholera. They occur singly, often in pairs, but never in long strings. They are decolorized by Gram's method. No spore formation was observed.
Effects upon Animals. — Guinea-pigs and mice (house and white) died in from 15 to 36 hours after subcutaneous inoculations. The fatal dose of a 24-hour bouillon ctilture, at 37° C, was 0.5 cc. in guinea-pigs, and from 15 to 45 drops in mice. In guinea-pigs, at the autopsy, there was found a reddish,
November, 1898.]
JOHNS HOPKINS HOSPITAL BULLETIN.
271
gelatinous exudate extending into the tissues to some distance from the point of inoculation. The adjacent lymph glands were swollen and very red. The serous cavities usually contained a blood-stained fluid exudate. The viscera of the abdomen and thorax did not show much macroscopic change except a swelling of the spleen, and perhaps an increased amount of blood in the lungs. Cultures from the blood in the heart, the various viscera, and serous cavities, always showed large numbers of bacilli everywhere. Sections of the various organs after hardening in alcohol allowed the bacilli to be demonstrated in the smaller vessels and capillaries. The tissue changes were not marked. There was fatty degeneration of the liver cells ; distention of the capillaries in the glomerular loop in the kidney, with haemorrhage into the capsule; areas of haemorrhage in the spleen, and areas of haemorrhagic pneumonia.
In mice there was at times some (Edematous infiltration at the point of inoculation, but usually none. The internal organs were macroscopically little changed, except an enlargement of the spleen and a reddish mottling of the lungs. Smear preparations and cultures showed the bacilli to be present in all the organs and in the blood in the heart. In
sections stained with Loeffler's methylene-blue the smaller vessels and capillaries of the various organs contained numerous bacilli. The tissue changes consisted in an increased amount of blood in the spleen, and fine areas of haemorrhagic pneumonia in the lungs. In the pneumonic areas the bacilli were numerous.
Rabbits are almost entirely immune. After subcutaneous inoculations a local reaction occurs, but recovery follows. One young rabbit died after an injection of a very large quantity, probably from intoxication rather than from infection.
White rats and pigeons were entirely refractory.
This bacillus is an example of the bacteria classified by Hueppe as the cause of true haemorrhagic septicaemia. They are usually short bacilli, which appear as diplococci because of the deeper end-staining. They do not spread over the surface of the gelatine, and usually do not grow on potato. They cause a true septicaemia, and invading the general vascular system cause a haemorrhagic diathesis. A sharp line cannot be drawn between these and bacteria, which also cause multiple necrosis by growth in certain small areas.
This organism resembles some of those already described, but varies in its effects upon animals, and in other vital properties.
ANTITOXIC RELATION BETWEEN BEE POISON AND HONEY (?).
By G. H. Stover, M. D., Denver, Colo.
Miss M., aged 35, single, consulted me on September 9, 1895, on account of the rather unusual swelling of her right cheek following a bee-sting received some days before; the whole right side of the face was considerably swollen and she felt some constitutional symptoms.
After treatment for five days she recovered, and on her final visit made the interesting statement that, while in the past
she had never been able to eat honey, indeed, was nauseated by the smell of it, even, since being stung she had developed a craving for it, and found that she could eat it with complete satisfaction and with no ill results.
Will some of the immunization experimenters throw light on this occurrence?
PROCEEDINGS OF SOCIETIES,
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
Broadbent's Sign.— Dr. Camac.
It is with regret that I announce that the patient with adherent pericardium, who exhibited very strikingly the Broadbent Sign, is unable to be here to-night. As the phenomenon has been demonstrated to this Society at a former meeting I trust it will not be amiss to have reference to the sign without showing the case.
Broadbent* describes this sign of adherent pericardium as follows : ". . . Marked systolic retraction of some of the lower ribs on the lateral or posterior aspect of the thorax may sometimes be seen. This phenomenon is best seen when the patient is sitting up in a good light and the movements of the chest are carefully observed from a short distance off, first from the
•Adherent Pericardium. R. C. P.
John F. H. Broadbent, M. D., M.
front and then from the lateral aspect. When a pulsatile movement is seen over the lowest part of the left side of the chest posteriorly, it may at first sight appear to be expansile. On a more careful scrutiny it will be found that there is a tug on the false ribs during the cardiac systole and a sharp rebound during diastole, which can be felt as well as seen when the hand is laid flat upon the chest-wall at the spot ; it is more marked when a deej) insjiiration is made ; it may be seen occasionally, not only on the left side, but also on the right, especially if the patient leans over to the left. Here, it is not possible that the heart can be directly fixed to the chest-wall at the points of retraction by pericardial adhesions, as the lung tissue intervenes ; but the explanation seems to be the following: The heart is, by means of the pericardium, adherent not only to the central tendon of the diaphragm but probably also to a large area of the fleshy or muscular portion of the diaphragm, and, it may be, to the anterior thoracic wall as well ; as it contracts it drags upwards and inwards the less resistant
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fleshy part of the diaphragm towards the central tendon or anterior chest-wall ; hence the points of attachment of the digitations of the diaphragm to the lower ribs and costal cartilages are dragged inwards and downwards. It will always be found in such cases that the retracted positions of the chestwall correspond to the floating ribs or costal cartilages of the lower ribs at the points of attachment of the diaphragm. (Systolic recession of the left subcostal angle and epigastrium does not necessarily imply the presence of pericardial adhesions.)"
"The above is a most important diagnostic sign of adherent pericardium wAm^rfsem^, and is quite distinct from recession of the lower ribs in inspiration."
Twice in the course of the description Broadbent infers that this is not a constant sign of adherent pericardium. He says at the beginning of the description that the sign " may sometimes be seen," and again at the conclusion that it is a most important sign " when present." It is to the explanation of this inconstancy that one's attention is drawn.
I have been unable to find in any work upon anatomy an accurate description as to the extent of pericardial attachment to the diaphragm. The general arrangement of the pericardium would suggest a hammock in which the heart is slung, attached above to the cervical fascia and below to the diaphragm, the diaphragmatic attachment involving largely the central tendon.
McClellan* gives the following description : The pericardium " is intimately adherent to the middle leaflet of the tendon about the opening for the inferior vena cava, and more loosely connected to the m\\&c\\\&r part on the left side ". . . . "These connections " (together with those of the deep cervical fascia already mentioned) "of the pericardium are of great interest, for if the entire diaphragm descends in respiration it must draw with it the heart sac, and therefore exert more or less strain upon the vessels at the base of the heart. The author inclines to the belief that the central portion or tendon of the diajohragin does not descetid, although the lateral muscular portions do. On one occasion, after the excision of the sixth, seventh and eighth ribs on the right side, he was able to examine the upper surface of the diaphragm during the forced efforts of inspiration under ether, and on another, after the evacuation of the contents of an enormous abscess, involving the left lobe of the liver, he could easily introduce his hand into the abscess cavity and detect the lateral upheavitig of the diaphragm and the rapid pulsation of the heart. In the latter case, during the straining of the patient in the act of vomiting, it was observed that the diaphragm descended and ascended with spasmodic contractions, Itit only upon the sides, there being apparently little if any change in the relations of its central tendon."
These observations would lead to the conclusion that the action of the diaphragm is like that of a flying bird, the central tendon being the motionless body, while the muscular portions would suggest the flapping wings.
Here, too, would seem to be the explanation of why, in extensively adherent pericardia, this sign may be absent. For
Regional Anatomy. Vol. I, pp. 272-273, George McClellan,
M. D.
if the pericarditis have involved that portion of the pericardium
attached to the muscular diaphragm, which is constantly engaged in respiratory acts and attached to the false ribs, the tug on these ribs will be more pronounced than had it involved that portion attached to the central tendon, which is stationary and not engaged in respiratory acts. This explanation is further borne out by Broadbent's observation that the sign "is more marked when deep inspiration is made," the diaphragm being thus I'endered more tense and consequently better suited to allow the heart to tug upon the ribs.
May we then say that those cases of adherent pericardium, in which Broadbent's Sign is absent, are such as have the least extent of involvement of that portion of the pericardium attached to the muscular diaphragm ?
While this may appear anatomically correct it can only be conclusively proven by careful measurement of the diaphragmatic attachment of the pericardium in both healthy and adherent pericardia.
Aortic Aneurysm. — Dr. Brown.
This case came to the hospital about a month ago complaining of pain in both sides of the back, especially the left, and the epigastrium. He came from healthy stock that did not indulge in alcohol to any extent, but his own personal history was different, as he had indulged largely in alcohol and had been exposed many times to venereal disease though he denied lues. He had been a hard worker. The present attack commenced nine months ago with a definite pain in the lower part of the back, at first rather slight and not enough to prevent the performance of his usual duties. Later it increased and at last became so intense that work was impossible; by this time the pain had radiated to the right side occasionally. He had no marked cough and very few other symptoms except the pain, but that was so great that sleep was difficult and it was necessary to maintain firm pressure to secure relief. He obtained this by standing up and pressing the epigastrium or the lumbar region against the edge of the table.
When he came into the hosi^ital the physical examination showed a systolic and a diastolic murmur with marked pulsation in the left side of the chest which lifted up the sternum and was well marked in the axillary line. There was no point of expansile pulsation in this area. In examination of this area no tumor was seen, bttt one of the examiners described a tumor felt by ballottement, though all others were unable to feel it. Over the pulsating area both sounds of the heart were heard, but there was no diastolic shock. An examination of the arteries showed very marked sclerosis, and pulsation of the abdominal aorta was obtained with diflBculty. The pain has lessened markedly since he came into the hospital.
Perhaps it will be of interest in connection with this case to say something of the etiology of the trouble. When we consider the etiology of aneurysm we have mainly to discuss the question of arterio-sclerosis. In this there are many factors, one of the most important being that of heredity. In this case that point applies but very slightly. Next comes the diffusion of certain poisons throughout the system, among which the most important are alcohol, and the poisons of gout, rheumatism and
November, 1898.]
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syphilis. Exactly how these poisons act it is impossible to say definitely, but probably some at least act upon the adventitia of the arteries, and cause changes there which are finally compensated by hyperplasia of the intima. We simply have to take the etiology of arterio-sclerosis to work out the anatomical etiology of aneurysm. Given a man with weak arteries, and let him live a quiet life with little strain, he probably will not develop an aneurysm, but allow that man to do very hard work in which the strain upon the arterial system is very great and you have a great possibility of producing the disease.
In the question of diagnosis of aneurysm of the aorta there are various signs and symptoms according to the different portions affected. The aneurysms of the aorta may be divided into those of the ascending thoracic branch, of the arch, of the descending thoracic branch and of the abdominal aorta. In the first we have more signs than in any of the others. There is very marked pulsation, sometimes a tumor, though often few pressure symptoms, while, in the case of the transverse arch, the pressure symptoms are more marked, but the physical signs are less so. As we go into the descending portion of the thoracic aorta we may have more of the pressure symptoms, while as we proceed to the lower thoracic and upper portion of the abdominal aorta the symptoms become less because the chances of pressure are diminished. An aneurysm can be simulated by so many other conditions in the abdomen that Dr. Osier has said in his work that without the discovery of an expansile tumor, which can be grasped, a definite diagnosis cannot be made in many cases.
As regards the treatment, it is indeed multiform. Diet of a very dry character with rest in bed is given with the hope of diminishing the pulsation and increasing the formation of fibrinous elements in the blood. Various operative treatments, such as wiring of the sac and electrolysis, have been performed with the object of coagulating the fluid contents of the sac, with slight success, however, in most cases.
We attempted to clear up the diagnosis in this case by means of an X-ray photograph, but it was not much of a success. In looking up the subject of the application of X-ray photography to aneurysmal cases, however, I find that many have given it up, as better results are secured by use of the fluoroscope, carefully watching for a pulsating tumor. Whether the pulsating tumor will be shown by the fluoroscope in this case it is difficult to say, as fluoroscopic and radiographic work in the chest and abdomen are very difficult, but the signs and symptoms in this case are strongly in favor of its being a case of aneurysm, probably of the lower portion of the thoracic aorta.
Discussion of Mr. MacCallnin's Paper on Patliology of Heart
Muscle. — [See Bulletin for Aug., p. UU.]
Dr. Flexner: Mr. MacCallum's acquaintance with the embryology and histogenesis of the heart muscle made the pathology of the same muscle a peculiarly suitable subject of study. One must admire the technical method whicli resolves the muscle fibres into structures almost as complex as organs. Of much interest is the part played by these elementary constituents in the pathology of the fibre. In addition to the demonstration of the minuter changes in the fibres, the light shed on the nature of fragmentation of the heart muscle —
whether due to irregularities in contraction or degeneration — is considerable. The necessary conclusion from these studies is that there is at least one form of fragmentation which cannot be regarded as agonal in origin — the one preceded by what Mr. MacCulluii denominates sarcolytic degeneration. Whether in the light of this study we are to agree with the French writers who woitld make of this condition a disease |)cr se is another question and one still to be answered.
The study of fibrous myocarditis must interest those who pay attention to histogenesis. The facts elicited are, to say the least, unexpected, and an explanation of the order of the degeneration does not seem apparent.
Epidemic Cerebro-Spinal Meningitis— Exhibition of Speci nifrns. — Dr. Livingood.
The present case is of interest as being one of several cases of epidemic spinal meningitis occurring in Baltimore which has come to autopsy. Some of you here present witnessed the autopsy. I do not think it necessary to go into minute details of the lesions generally met with in epidemic meningitis, as they have just been given in detail in Councilman, Mallory and Wright's monograph, which is accessible to you. I shall therefore confine my remarks to the case under consideration.
The patient was a boy aged 13 years. He was moderately well nourished ; there was no external eruption; the skullcap was of average thickness; the external (hard) meninges were injected ; the vessels of the cortical pia were also injected, but there was no excess of fluid or any exudate in the cortical moderated. The exudate covered the basal portion of the brain, and existed in the form of a thick, adherent, creamy membrane, extending over pons, medulla and throughout the spinal canal. The ventricles were dilated, especially the lateral ventricles, and in the most dependent parts contained a turbid fluid. The walls of the ventricles were softened and somewhat macerated. The only other organs of interest besides the brain are the lungs. The right lung was free from adhesions ; no pleurisy. The lower lobe was deeply congested, and contained four or five small areas of consolidation each the size of a marble. On section these were coarsely granular and variegated, pale or red, in cidor. The upper lobe contained about its midportion and near the pleura a consolidated focus the size of an orange. The pleura was congested over it and covered with a fibrinous membrane. The contained bronchi were dilated and contained purulent contents. On section it also was coarsely granular and variegated in appearance.
The bacteriological examination consisted in the study of cover-slips from the exudate in brain and cord and the consolidated foci in the lungs, and the examination of cultures from these several sources. The films made from the meningeal exudate showed only doubtful organisms; those made from the lungs showed many bacteria, chiefly within cells, which were in the form of diplococci, in many ways resembling the gonococcus, except for the absence of the buscuit-like flattening. In other cells the forms resembled more the lanceolate coccus. Tested by Gram's method most of the cocci gave up the dye ; only those presenting lancet shapes seemed to retain it.
The cultures were interesting. Lumbar puncture made during life gave a positive result in that films and cultures
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[No. 92.
showed diplococci agreeing with the meningococcus intracelluliiris of Weicliselbaum and Jaeger. At tiie autopsy cultures from tlie heart's blood, lungs, (consolidation) spleen, kidney, liver, brain and spinal meninges were made. Positive results were obtained only from the lung and meningeal exudate. The plate from the exudate over the medulla contained very few colonies of the meningococcus. The organisms isolated from the lung proved to be the micrococcus lanceolatus.
The meningococcus as obtained from the exudate presented the usual characteristics as given by Weicliselbaum, Jaeger and Councilman, and did not retain the dye when treated by Gram's method. The culture from the lung failed in so far as the meningococcus was concerned, which was believed to be present there from the study of 81ms, and which was shown by Councilman to be capable of setting up pneumonic conditions. As the subject of the nature and classification of these organisms has so recently been reviewed in the Bulletin (J. H. H. Bulletin No. 83), I shall not take up your time in restating the present views concerning them.
XOTES ON NEW BOOKS.
The Psych'ology of Suggestion. By Boris Sidis, M. A., Ph.D., Associate in Psychology at the Pathological Institute of the New York State Hospitals. With an Introduction by Prof. William James, of Harvard University. {D. Appleion & Co., New York, 1898)
Dr. Sidis, after devoting a chapter to the discussion of the meaning of the term "suggestion," all previous definitions of which he finds unsatisfactory, submits the following :
" By suggestion is meant the intrusion into the mind of an idea ; met with more or less opposition by the person ; accepted uncritically at List; and realized unrefiectively, almost automatically."
Thus, if I ask a friend to lend me five dollars, it is a suggestion only in case he is reluctant to do so, and, nevertheless, finally gives me the money without thinking of his prospects of reimbursement. If he lends it to me willingly, or with the expectation of getting it back, or if he declines to let me have it at all, it is not a suggestion. This seems like a pretty arbitrary limitation, and it would be easy to show, by citations, that Dr. Sidis, in practice, dispenses with every one of the limitations wliich he imposes on the intruding idea.
It does not follow, because a writer fails in the definition of his subject that he may not have something of interest to say about it. Dr. Sidis has made many interesting observations, and presents the facts in regard to hypnotism and allied conditions, with which, naturally, the book is largely occupied, clearly and temperately. But, as might perhaps be expected from such a beginning, his inferences are not always warranted by the facts on which they are based.
The book is divided into three parts, the first treating of suggestibility, normal and abnormal, the second of t'le self, or personality, the third of the relations of suggestion to social phenomena.
In the first part the author undertakes to determine the laws of normal and abnormal suggestibility. The former he concludes to be as follows :
"Normal sugiestibility varies as indirect suggestion, and inversely as direct suggestion."
In ordinary language, this means that if you want a normal person to do something, the surest way to do it is to conceal your
wishes from him, while insinuating the idea of the action into his mind. So stated, it is evident at once tliat It is not a universal or even a general law. Dr. Sidis must be mure unfortunate than most people in his acquaintances if their knowledge that he would like them to do so and so would not be some inducement to them to do it even uncritically and somewliat against their inclinations.
The law of abnormal suggestibility he formulates as follows :
"Abnormal suggestibility varies as direct suggestion, and inversely as indirect suggestion."
That is, in dealing with an abnormally suggestible person, the more explicit and imphatic the commands are made, the more likely they are to be executed. Dr. Sidis evidently has the hypnotic condition in mind, but it is l>y no means true that persons in this state are always insusceptible to indirect suggestion. As Dr. Sidis himself points out, the fallacy in the accounts given by Bernheim, Charcot and others of the various stages of the hypnotic state is due to the fact that the symptoms had been indirectly and unconsciously suggested to the patients by the operator. But hypnotism is not the only condition of abnormal suggestibility. In " negativism," or "contrariness," the patients may be led to do anything desired by telling them to do just the opposite.
The fact is, that in a normal condition, every suggestion, direct or indirect, tends to be carried out, but, on the other hand, it is apt to suggest, indirectly, conflicting ideas, which may inhibit it. In the hypnotic state, on the contrary, the conflicting considerations would seem to be largely or completely in abeyance.
In the second part, on " The Self," Dr. Sidis considers the nature of personality and the relations of what he calls the subconscious subwaking or secondary self, as manifested in such conditions as hypnotism, double consciousness and hysteria, to the primary or waking self. This is much the most interesting portion of the work. Theaccount of thecaseof Rev. Thomas C. Hanna, who suffered complete loss of memory as the result of an accident, and of the means and steps by which the lost connection was recovered, is of remarkable interest, and the more detailed account which is promised will be most welcome to all readers of the book who are students of such sulijects.
Perhaps the most original contribution of facts to be found in the book is the account of experiments tending to show that some degree of the abnormal acuteness of the senses which is a wellknown phenomenon in many cases of hypnotism and hysteria is subconsciously present, to a certain extent in the normal condition. Thus, the author found that when words, letters or figures were shown at such a distance that they appeared as a mere confused blur, if the subjects of the experiments were required to guess what was shown them, their guesses were correct in a much larger proportion of cases than could be accounted for by chance. If his results in this direction are confirmed by subsequent investigators, they would seem to constitute a distinct advance in this department of psychology.
Although the tendency of the book is to show the subconscious presence, in normal conditions, of mental phenomena which are usually thought of as peculiar to abnormal states. Dr. Sidis doesnot seem fully to appreciate the fact that there is really no sharp distinction between our conscious and subconscious selves, but that they are constantly passing into and out of each other. AVithout attempting to criticise his discussion of the essential nature of personality, it may be said that our conception of our own personality in any given case is made up of our present sensations and feelings and our memories of the past. Only a small portion of all our experiences occupy our attention at any given moment ; many can be readily called up ; many more are lo.st beyond the possibility of recollection. We have entirely forgotten how we first learned to walk and to talk, for instance, although the knowledge then gained still abides with us. In the states of abnormal consciousness which the author has in minil, great blocks of the knowledge which is ordinarily at our command may be, for the time being, as much out of
NOVEIIBEE, 1898.]
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reach as tne rerollection of the events of infancy. And just as we accept the account of others as to the events of times which have passed from memory, and incorporate them in our conception of our personality, so the hypnotic subject may accept the statements of the operator as to who and what he is, and govern himself accordingly.
As a physical basis for tlie phenomena of association and dissociation of states of consciousness, the author assumes the truth of the theory of contractility of the neuron. However convinced he may personally be of its correctness, it is hardly fair to his nonprofessional readers to give no liint of the fact that it is, thus far, a mere hypothesis, without, as far as at present appears, even the possibility of experimental verification, and open to very grave theoretical objections.
In the chapter on "Subconsciousness and Insanity," Dr. Sidis brings out clearly the analogy between posthypnotic suggestion and morbid impulses and imperative conception. Paranoia is much less satisfactorily treated.
In the third part of the book, treating of the psychology of crowds and mobs, and of crazes" of various sorts, the mistake is made of confounding quite distinct phenomena. The influence exerted on susceptible persons by the presence of a multitude filled with a common emotion may very probably be, in some respects, analogous to the hypnotic condition, but there would, doubtless, have been a stampede for the Klondike if every one of those who went had supposed he had private and exclusive information of the riches to be gained there.
On the whole, the book, while containing much of interest, is valuable rather for its facts than its reasonings.
The Disea.'es of the Stomach. By William W. Van Valzah, A. M., M. D., and J. Douglas Nisbet, A. B., M. D. Illustrated. {Philadelphia: W. B. Saunden, 189S.)
The stomach is a very important viscus, notwithstanding the fact that recent surgical successes have shown that under certain special conditions it can be dispensed with in the economy. Its importance is sufficiently in evidence when valuable text-books on its ailments follow each other with the rapidity which they have within the last two or three years. The present volume, while not supplanting the valuable treatises that have preceded it, has merits of its own, and is apparently well suited for a textbook on its subject.
The authors' plan of their work is a simple one, giving first the general methods of diagnosis and the general medications, then following this successively by sections on the dynamic affections of the stomach, including under this head all the symptomatic disorders that present, so far as known, no characteristic pathological anatomy, on the anatomical diseases which are, on the other hand, thus characterized, and finally ending with a section on the vicous circles of the stomach," on the action of gastric disorders in producing or in being produced by disease elsewhere. This classification may be open to some criticism, hut, on the whole, it seems fairly well adapted to afford a general view of the morbid conditions in which the stomach plays a chief or principal part. It is not esi)ecially original in its contents, and will hardly displace the recently published and excellent work of Hemmeter as a favorite with the American physician, hut, as already said, it has its merits, and is well worthy of being an addition to any medical library.
Public Health Reports. (Formerly abstract of Sanitary Reports.) Issued by the Supervising Surgeon-General of the Marine Hospital Service. Vol. XII, Nos. 1-53. (Washington: Government Printing Office, 1898.)
This volume contains the reports of sanitary inspectors. United States consuls, and others on health conditions in foreign parts, translations from foreign languages of papers on special epidemics.
and statistics of municipal health authorities here and abroad, of commissioners of emigration, etc., etc.; altogether a vast amount of valuable information upon sanitary matters. The woik is a very useful one for reference in regard to these subjects, and the series of three volumes must form a very valuable record of sanitary statistics throughout the world, while the monthly publication of the parts that compose them is a useful current record.
The Archives of the Roentgen Rays. (Formerly Archives of Skiagraphy.) The only journal in which the transactions of the Roentgen Society of London are officially reported. Edited by W. S. Hedley, M. D., and Sidney Rowland, M. A. (London: The Eebtnan Publishing Co., 1898.)
The title of this journal sufficiently indicates its nature and scope. It is elegantly printed and illustrated, and should be well received by those who use the Roentgen rays in physical or medical rt-search. The only thing one can say against it is, that with the widening range of utility of Roentgen's discovery in surgery and medicine, a less expensive journal issued more frequently would be still more welcome to the medical profession. .4n actinoscopic adjunct is becoming almost essential to a surgeon's outfit, or at least such must be available to him, and there is every reason to believe that new utilities will be found, as time passes, for this method.
BOOKS RECEIVED.
Tenth Report of the State Board of Health of the State of Maine for the Two Tears Ending Dee. Zl, 1897. 395 pages. Svo. 1898. Kennebec Journal Print, Augusta.
Practical Urinalysis and Urinary Diagnosis. A manual for the use of physicians, surgeons, and students. By Charles \V. Purdy, M.D , LL. D. Fourth revised edition. Svo. 1898. 3(55 pages. The F.A. Davis Co., Phila.
Essentials of Materia Medica, Therapeutics and Prescription Writing. Arranged in the form of questions and answers. Prepared especially for Students of Medicine. (Saunders' Question-Compends, No. 7.) By Henry Morris, M.D. ]2mo. 1898. 288 pages. W. B. Saunders, Phila.
A Primer of Psychology and Mental Disease. For use in trainingschools, for attendants and nurses and in medical classes. By C. B. Burr, M. D. Second edition, thoroughly revised. l"mo. 1898. 116 pages. The F. A. Davis Co., Phila.
The Care of the Baby. A manual for mothers and nurses, containing practical directionsfor the management of infancy and childhood in health and in disease. By J. P. Crozer Griffith, M. D. Second edition, reviseil. Svo. 1898. 404 pages. W. B. Saunders, Phila.
Transactions of thf Association of American Physicians. Thirteenth Session. Held at Washington, D. C, May 3, 4 and .5, 1^98. Vol. XIII. 1898. Svo, 484 pp. Printed for the Association. Phila.
Operative Gynecology. By Howard A. Kelly, A. B., M. D. Vol. II. 1893. 4to, 5.57 pp. D. Appleton & Co., New York.
Lehrbuch der AUgemeinen Pathologic und der pathologischen Anatomie. Von Dr. E. Ziegler. Zwei Biinde. Neunte neu bearbeitete Auflage. ZweiterBand. Specielle pathologische Anatomic. 1898. Svo, 1024 pp. Gustav Fisclier, Jena.
The Pocket Formulary for the Treatment of Disease in Children. By Ludwig Freyberger, M. U., Vienna. IB mo. 1898. 208 pages. The Rahman Publishing Co., Limited, London.
Trarisactions of the Michigan State Medical Society for the Tear 189S. Volume XXII. Svo. 189S. 450 pages. Published by the Society, Grand Rapids.
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[No. 92.
THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1898-1899.
PACULTY.
Wii
iiBL C. Oilman, LL. D., President.
LiAM H. Welch, M. D., LL. D., Dean and Professor of Pathology. Remsen, M. D., Ph. D , LL. D.. Professor of Chemistry. ,Li*M OsLER, M. D., LL. D., F. R. C. P., Professor of the Medi.
iple
nd Pr
of
Henry M. Hurd, M. D., LL. D., Professor of Psychiatry.
William S. Halsteii. M. D., Professor of Surgery.
HowAK.) A. Kbllv, M. D., Professor of Gynecology and Obstetrics.
Fkanklin p. Mall, M D.. Professor of Anatomy.
lOHN J. Abel, M. D., Professor orPharmacology.
William H. Howell, Ph. D., M. D., Professor of Phy>iology.
WiLLiAU K. BuO'.KS, Ph. D., LL D., Professor of Comparative Anatomy and Zoology.
John S. Hillings, M. D., LL. D., Lecturer on. the History and Literaiure of Medicine.
Alexanuek C. Abboti, M. D., Leciurer on Hygiene.
Chables Waruell SriLES, Ph. U , M. S . Leciurer on Medical Zoology.
RoiiKRT Fletcher, M. D., M. R. C. S.. Eng., Lecturer on Forensic Medicine.
William D. Booker, M. D.,Clinic.iI Profes-or of Diseases of Children.
loHN N. Mackpnzie, M, D., Clinical Professor of Laryngology and Rhinology.
Samuel I'heobalu, M. D., Clinical Professor of Ophthalmology and Otology.
Hbkrv M. Thomas. M. D., Clinical Professor of Uiseases of the Nervous System.
Simon Flhxn»r. M. D , Associate Prosessor of Paihology
J. Wh
I Wi
1 F. Ba
AMS, M. D., Associate Professor of Obstel !R, M. B , Associate Professor of Anatomy. R, M. D., Associate Professor of Medicine. , M. D., Associate Professor of Surgery. , Ph. D., Associate in Physiology.
William W. Russell, M. D., Associate in Gynecology.
Hrnrv J. Berkley, M. D., Associate in Neuro-Pathology.
J. Williams Lord, M. D, Clinical Professor of Dermali^logy and Instructor in A;
T. Caspar (mlchkist, M. R C. S., Clinical Professor of Dermatology.
Robert L. Ranuolph, M. D., Associate in Ophihalmology and Otology.
Thomas B. Futchrr, M. B , Associate in Medicine.
Joseph C Bloougooi., M. D., Associate in Surgery.
Thomas S. Cullen, M. R., Associate in Gynecology.
Ross G. Harrison, Ph. D., Associate in Anatomy.
Reid Hunt, Ph. U., M. D., Associate in Pharmacology.
Frank R. Smith, M. D., Instructor in Medicine.
Oeorgh W. Dobbin, M. D., Assistant in Obstetrics.
Waltpr Jonrs, Ph. D. , Assistant in Physiological Chemistry and Toxicology.
Sydney M. Cone, M. D . Assistant in Surgical Pathology.
Harvey W. Cushing, M. D., Assistant in Surgery.
Henry Barton Jacbs. M. D.. Instructor in Medicine.
High H. ¥ ung, M. D , Instructor in Genito-Urinary Diseases.
Charles R. Bardeen, M D., Assistant in Anatomy.
Stewart Paton, M. D., Assi-tant in Nervous Diseases.
Norman McL. Harris, M. B., Assistant in Bacteriology.
Albert C. Crawford, M. D., Assistant in Pharmacology.
J. W. Lazear, M. D , Assistant in Clinical Microscopy.
Henry O. Rkik, M. D , Assistant in Ophthalmology and Otology.
Elizabeth Hubdon, M D., Assistant in Gynecology.
Wali BR S. Davis, M. D., Assistant in Clinical Microscopy.
J. L. Walz, Ph. G., Assistant in Pharmacy.
GENERAL STATEMENT.
Tlie Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close afBliation with the Johns Hopkins Hospital.
The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.
Men and women are admitted upon the same terms.
In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. The first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physioiogy, Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. During the last two years the student is given abundant opportunity for the personal study of cases of disease, his time being spent largely in the Hospital Wards and Dispensary and in the Clinical Laboratories. Especially advantageous for thorough clinical trainiug are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.
REQUIREMENTS FOR ADMISSION.
As candidates for the degree of Doctor of Medicine the school receives :
1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.
2. Graduates of approved colleges or scientific schools who can furnish evidence : {a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.
The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.
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 French, German, Latin, physics, chemistry, and biology above indicated.
Applicants for admission will receive blanks to be filled out relating to their previous courses of study.
They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.
Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory trainiug as specified above. It is expected that only in very rare instances will applicants .who do not possess a degree in arts or science be able to meet these requirements for admission.
Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.
ADMISSION TO ADVANCED STANDING. Applicants tor admission to advanced standlug must furnish evidence 11) that the foregoing terms of admission as regards preliminary training have been tulfllled, (2) that courses equivalent In kind and amount to those given here, preceding that year of the course for admission to which application Is made, have beeii satisfactorily completed, and i:J) must pass examinations at the beginning of the session in October in all tlie subjects that have been already pursued by the class to which admission is sought. Certiflcates of standing elsewhere cannot be accepted in place of these esaraiualions.
SPECIAL COURSES FOR GRADUATES IN MEDICINE.
Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afforded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine are now given annually during the months of May and June. During April there is a pi-eliminary course in Normal Histology. These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory coursee, demonstrations, bedside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here offered. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application.
The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the
REGIST RAR OF THE JOHNS HOPKINS MEDICAL SCHOOL. BALTIMORE.
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may be procured from Messrs. CUSHINO & CO. and the BALTIMORE NEWS COMPANY. Baltimore. Subscriptions, Sl.OO a year, may be addressed to the publishers, TEE JOHNS HOPKINS PRESS, BALTIMORE ; tingle copies will be sent by mail for fifteen cenU each.
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. IX.- No. 93.
BALTIMORE. DECEMBER, 1898.
GOlSTTElSrTS.
PAGE
Medicine in the Nineteenth Century. By T. Clifford Allbutt, M. D., ----- _-----.-- 277
On Refractory Subcutaneous Abscesses caused by a Fungus Possibly Related to the Sporotricha. By B. R. Schenck, M. D., ----..____.--. 286
CE lematous Changes in tlie Epithelium of the Cornea in a Case of Uveitis following Gonorrhojal Ophthalmia. By Edwaed Stieren, M. D., ---------------- 290
PAGE.
Proceedings of Societies :
The Hospital Medical Society, 292
Primary Focal Htematomyelia from Traumatism [Dr. Peakce Bailey] ; — Two Cases of Pylorectomy [Dr. Finneyj ; — The Non-Medical Treatment of Epilepsy [Dr. Hurd].
Notes on New Books, ----- 297
Index to Volume IX, - - - - - 299
MEDICINE IN THE NINETEENTH CENTURY.
By T. Clifford Allbutt, M. D., Regius Professor of Physic, Cambridge University.
{Delivered before the Johns Hopkins University, Oct. 17, 1898.)
Were we asked to describe in a phrase the tendency which distinguishes our age it might be replied that it is the study of origins. In the later thirteenth and early fourteenth centuries, for example, men's minds were fixed for the most part on the validity of dialectic, were bent rather upon securing mental surefootedness and sharp and true weapons of thought than upon the verification of premises. For instance, Albertus Magnus, with the utmost fairness, marshalled from the writings of his adversaries thirty arguments in ftivor of the doctrine of the oneness of the soul ; so that on the death of the individual his share is merged again in the whole, and loses whatsoever personality it may seem for a time to have assumed ; on the other hand for the doctrine of the persistence of individual souls after death he found thirty -sis valid reasons; thus the essential multiplicity of the soul was proved. Again Raymond Martini found eighteen reasons for the eternity of the world, and eighteen against it; the doctrine hung anxiously in the balance until he discovered seven other reasons which fortified it ; he scrupulously admitted indeed that the last seven were not altogether apodeictic, but " with the reinforcement of faith " they suiBced to sustain it. Thus again for these disputants Aristotle and Galen were not so much chosen as received as guides, and their scriptures accepted as bibles. Now althougli it is not fair to press this character as a conspicuous feature of
the greatest minds of the latter half of the thirteenth century, for Thomas of Aquino, for example, regarded Aristotle as a pagan sage to be treated with no more than resj)ect, and it is still less true of Roger Bacon, the greatest of them all ; still it was the fashion of that time to look rather to agility and sureness of logical fence than to genesis and verification. To one of our own time who turns to their pages, or of John Henry Newman in our own time, the quickness and subtility of their arguments, the keenness and variety of the language which they elaborated by incessant exercise in such dialectic, make a most interesting study. Therein indeed the reader may find cause to regret that in modern times we have too often allowed these instruments of close and strong logic to fall into rust and neglect, though in our own time again we shall not thus speak of our greatest minds ; to confine ourselves to our own race, argument more sure and penetrating than that of Newton, of Faraday, or of Darwin, for example, is not to be found in any century. Still the common mind of our time is set rather towards the investigation of premises — of origins; we look less to the closeness of our web of arguments, and take less heed to every logical stitch than our forerunners, who took their causes for granted and thought only how to fight for them. Yet although we may escape too cheaply in respect of logical processes on one way, we must travel at least as warily, namely, on the
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method of experiment. Generally speaking, facts are now preferred to arguments, and as facts so far from being the fixed and flinty tilings they are supposed to be, are shifty and protean, we require from those prospectors who proclaim the discovery of facts a minute demonstration of their methods, and we do not allow any agility in verbal fence to put us off this prime demand. Show us your clews, take us over the tracks you say you liave surveyed, bring us into the ambush of nature which you think you have discovered ; for howsoever finely you may talk about them we shall not believe you until we in our turn have followed you on the path. This at any rate is the attitude of those who pursue the exact sciences, and it is with the sciences, whether of experiment or observation, that not weonly but also our fathers of the thirteenth and fourteenth centuries were concerned.
It may be urged that surely these sciences are the labor of our times, not of earlier times when sages spent their time in sophistry ! Yet such an assertion is scarcely justified. Sucli is the essential kinship of man in all ages that by whatsoever names he calls them, or by whatsoever methods he pursues them, his search is after the ends of science; I mean his argumentative search, for I am not at present speaking of artistic creation. When we turn to the speculations whether of the Greeks, or, after them, of Western nations, we find that they concerned themselves with the same subjects as those of the modern thinker; they argued of cosmogonies, of the elements of nature, of ethics, of law, of the virtues latent in natural objects, and so forth. The antagonism between the conceptions of creation and of development is not, as too often we think, a division of our own time only ; in cruder forms, but still in full distinction, these opposing theories were familiar to philosophers of the fourth century before Christ as well as of the thirteenth century after Christ. The explanations given in such days as those differed widely from ours, but they were explanations, and were discredited only because they turned out to explain too little. Even to-day the experimental method can only be applied to the exact sciences; to the moral sciences and to medicine, for example, dialectic must still be largely applicable. In the study of medicine the experimental method has but a narrow field ; observation takes a higher place in its pursuit, but dialectic has also no inconsiderable part, and we shall do wrong if we allow instruments fashioned under other conceptions of method to fall from our hands under the attraction of the richer results of the modern methods of the exact sciences. While ethics and politics must largely depend on dialectic and mechanics, let us say but little on it — though mathematics is indeed in itself a sublimated dialectic; medicine, occupying a middle position, must keep both weapons furbished. For instance, a true conception of causation is largely a matter of dialectic, and however ingenious our experiment and observation we cannot afford to be ignorant of the laws of causation and of thought, and of the language in which these abstract ideas are to be expressed. For this language, I repeat, we are indebted to our forefathers of the thirteenth and fourteenth centuries as well as to Hume and to Mill. I have hinted that we are too prone to think, indeed to vociferate, that a fact is a fact, forgetting that inference is of the essence of every proposition ; inference sticks to fact as closely as shadow to substance.
A statement of the plainest facte implies a cement of inference, and he who has learnt to handle ideas will thus far have a great advantage in every research. Looseness in words and lack of lucid and orderly expression of ideas in the records of modern medicine is lamented by Dr. Da Costa in his address to the Association of American Physicians and Surgeons, May 4, 1897, and in a recent leading article the London Times laments the same defects in English lawyers of the day and urges the need of a more formal education in this great accomplishment. Those who decry dialectic decry also what they are pleased to call " theory." That such and such a teacher is too " theoretical " is a stone thrown in many a classroom, and often no doubt it hits the mark. It is true that to pursue philosophy as a study in itself has been a source of mischief or of bewilderment in many schools, as in Germany and in Scotland. Nevertheless we are now beginning to find that long practice in theoretical, that is in abstract, thought has giveu both Germans and Scotchmen a strength in dealing with modern and more fertile problems which Englishmen at any rate somewhat jealously and somewhat impotently admire. In England we are apt to retort that we are saved by our adhesion to the inductive method. If such an one — and now I may pass beyond my own land — be asked what he means by induction it turns out that he means, or thinks he means, a mosaic of concrete observations. Not only does he fail to realize that even these are bound together, as I have said, by a cement of inference, but perceiving, as he unconsciously must, that such short links do not carry him far in explaining things, he takes refuge in assertions which indeed are broad enough but have taken on appearance of solidity from their established currency. Mrs. Gruudy is not unknown even in the sphere of abstract propositions; use and convention may make the hollowest surmises respectable and their acceptance comfortable. It is by no means true that the ordinary man hates abstract propositions; he loves many of them, as for instance that the weather depends on the phases of the moon; that most bodily discomforts arise from disorders of the liver, and so forth. There is no proposition, however wide and abstract, which he will not swallow with avidity if it be brought from the pages of an old almanac ; nay, easy as knowledge outgrows such outworn opinions he will yet strive to extract some truth from their arid sources — to prove that there is "'something in them after all." What the ordinary man hates is not the abstract proposition but the making of abstract propositions. He inherits any ready-made theory gladly, but he resents being called upon to make one himself, or even to adapt his mind to such novelties; he has never been practised in this gymnastic and it jades him. He dislikes it as we dislike any unaccustomed exercise, as we love an old coat or an old pair of shoes.
I need not occupy your time, gentlemen, by pointing out that the inductive method consists of two jjrocesses at least — in observation and imagination; in imagining again and again from a short series of facts the probable course of a longer series ; and then in testing the truth of all or any such notions until the right one is hit off. Such surmising requires an alert imaginative or theorizing faculty. To pursue the study of philosophy for itself alone has only a gymnastic value, and leads, as I have said, to routine and sterility; but I repeat
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also that past exercise iu this faculty, barren as it seemed for awhile, turns out, when carried into more fertile fields of research, to have given to such students a suppleness and sureuess of argument which we may well envy. The AngloSaxon brain contains, as its literature has shown, the sanest and strongest imagination of any in the world; but thus far in the world's history it has been rather a pioneering brain, a fighting brain, whether with man or Nature; and immediate material results have been prized to the disadvantage of the more prophetic powers. The Anglo-Saxon has fought rather for bread to-day than for cake to-morrow ; nevertheless, the future will be for those who can combine the practical spirit with a mind exercised in the arms of theoretical and dialectical precision.
What we have learned, then, is that speculation in former times has been valuable as exercise rather than as achievement; that, although the deductive side of our method of thought is better adapted to exposition, the inductive bias is for most men the safer way in research. In the words of Klebs (Allgem. Pathologic, vol. i, p. 4), we must learn not that the construction of hypotheses is bad, but that "Diese Hy pothesenbildung nicht das Spielzeug einer weitschweifenden Phantasie sein soil, sondern das Werkzeug ernster wissenschaftlicher Arbeit."
Among the lessons of this kind which we have painfully learned during the last two thousand years two stand out perhaps as the chief; these are, first, the barrenness of all conceptions based upon causal entities; secondly, the constraining need of verification. First, concerning causal entities, there has been a tendency of late to bring back into physiology the notion of "vitalism" or "vital force," and to scoff at those who would apply the word " mechanical " to the processes of life. It may well be that the connotations of the word mechanical embarrass us in the use of it to signify the complex phenomena of life ; on the other hand, we are on safe ground so long as we endeavor from the simpler phenomena of physics to rise continuously to conceptions of the more complex phenomena of life ; at any rate, we must not desert this track so far as it goes, and within these limits there is plenty to discover. But, under whatsoever name, to import an occult principle as a cause is to return to the most sterile rhetoric of the middle ages. Unable to shake themselves wholly free from the personification of natural objects, a personification which had gradually been removed from the objects themselves to their supposed causes, the ancients assumed such a principle to govern the movements of the celestial bodies ; and even to this day we are apt to speak of force as something or entity acting on matter. That physical forces acting as simple molecules can account for the complex phenomena of life no one wishes to assert; no one will assert that they can account for the phenomena of chemistry in which the molecules, though less complex than the living, are far more complex than those studied in physics. But if we are to assume a vital principle in the animal cell assimilating food, then what need is there of a study of any other forces ? The fact is, we are too impatient to await the unravelling of the manifold composition of forces in a highly compound niolecnle, an investigation which is only possible by long and un
wearied series of experiment. No one attributes the virtues of chemical molecules to " chemism " ; nor the vastly more complex functions of societies to a principle of socialism. Products differ from factors as sugar differs from a mixture of carbon, hydrogen and oxygen, and as an organism differs from the unrelated activities of an aggregate of nucleated cells. The phenomena of life are wholly conditioned by the peculiar complexity of its molecule, and with the size and complexity of the molecule the synthesis of forces increases in a multiple ratio.
We may speak, then, of a molecule as a highly elaborate construction of matter, or we may regard it as a highly elaborate system of forces, and this view of life, which brings its phenomena into line with the subject-matter of other sciences, is one, at least, of the achievements of our own time which we shall do well to preserve.
Another conception which now rules our thoughts far more profoundly than ever before in the history of mankind is that of law in the course of Nature. Far indeed from a new idea — for that Nature works by fixed laws, first conceived by the sages of Ionia, had penetrated the minds of thinkers of the fifth century before Christ, and moulded the thoughts of Hippocrates. This great conception, by means of which alone a knowledge of Nature and an empire over her become possible, was afterwards obscured for many centuries ; it was left, indeed, for our own day to grasp the idea in its full meaning. The lonians were not free from a tendency to personify these laws, and even to-day we may hear the Laws of Nature spoken of as agencies by which Nature is compelled, rather than as our formulas for invariable sequences. Yet it is no exaggeration to say that, even in its ontological form, a true conception of natural law was a greater achievement of the mind and more important in the advance of knowledge than the doctrine of the conservation of energy or the conception of evolution — ideas which we are wont to regard, and rightly to regard, as consummate achievements of modern philosophic theory. Again, the perception that activity of thought can only be true and just in the best sense when it is in vital and incessant connection with the activities of the phenomena on which it is engaged, is an invaluable quality of modern thought.
An accomplished Oxford tutor, lately taken from us, said of another department of knowledge : " One always comes back to the feeling that the truth in the ultimate problems is not got by thinking (in the ordinary sense), but by living." What Nettleship experienced in the study of ultimate problems is no less true of proximate problems.
It was for lack of this touch of nature that the older universities of Europe fell out of line with life. Whether for the analysis or for the harmony of knowledge, we cannot keep before us the quality, depth, complexity and manifold interaction of natural processes without incessant converse with them in their flow. We cannot retain a conception, nay, not even an apprehension, of the infinite vastness and variety of the work of the eternal loom by taking thought alone, by discussing them as if we were gods. Our minds can only be edified with Nature's bricks; beside her work the worlds we build out of our own heads are but doll's houses. Philosophy,
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as a mere literature, ends, as I have said, in conjectural systematizing, in speculation upon speculation, in a visionary gymnastic. Oxford scorned the " base and mechanical pursuits " of Boyle, and the wiseacres who so spoke of that great man are dead and forgotten. Medicine in Germany was almost grotesque until the day of Rokitansky and Miiller. Moreover, ideas thus engendered are not only hollow and arid, but they have all the rigidity and inertia of inanimate things; they become as shells which happily may be sloughed off but never have part in new development, and meanwhile are strangling the very germs of it. Ardent enquirers in touch with nature are thwarted or extinguished, and Nature, indifferent as ever to man's self -sufficient conceits, goes her own way like a wild dam eating up her own offspring. Not only ai'e notions engendered without the seed of Nature contrary to the truth ; they are also antagonistic to the discovery of the truth. As Dr. Daremberg says, " Les idees sont plus entetees que les faits." Is it not one of the marks of our own age that man is not only now freed fi'om the bondage of authority, not only is he now free of the kingdom of pure thought, but he is also brought into touch with Nature ; now Nature is to be his inspiration, not his destruction.
Even in my young days the first chapter of Genesis was generally held in its literal meaning as a string of aifirmative propositions ; and for many previous generations the advance of true conceptions of biology had been continually thwarted thereby. In medicine as well as in natural history we are dependent on true biological conceptions, for without them we are apt to lie content with empiricism.
Again, with evolution has arisen a living conception of progress ; mankind, no longer dreaming about a golden age in the past, is set with its face to the future ; the golden age is in the future, not in the past, and the happiness of the human race is to be won by reading the secrets of natural law, and by strenuous effort. Yet this dream of a lapsed golden age, like all such myths, held some truth in it; a truth which, in the revolution of the standpoint from past to present and future, fell into neglect. The study of the past is now returning in a new spirit, in that stiody of origins which, as I have said, is a feature of our generation ; and the neglected lesson that we cannot afford to foi-get the travail of any age is seen in a new light. Tradition is recognized as the mould into which our activities have run as an embodiment of human experience; and we are learning the humble lesson that modern man is perhaps no greater in faculty than his forefathers ; that if we have entered into new and more fertile fields it is by means of our inheritance rather than by means of greater faculties. If the average modern man be as highly endowed as the greater ancients some few of them, such as Archimedes or Aristotle for example, were perhaps richer in mental gifts than the greatest of modern men. If this be so it will appear that tradition is a larger part of progress than we are disposed to admit. If the transmission of acquired faculties by inheritance be not altogether disproved, it is proved at any rate that such inheritance is a much smaller factor in progress than we had assumed. It seems certain indeed that its sphere is at best a very small one ; and that we stand at the apex of the pyramid not by virtue of better building but because we were born
with the pyramid below us. To cohtemii or to subvert the ideas of our fathers is then to cut the ground from below our own feet ; to destroy that accumulation of the results of former labors which in commerce we call capital, and which in things of the mind we call tradition. There is no evidence that we are greater even by virtue of a more highly organized brain ; there is no evidence that we are a new and more gifted variety of man ; we are greater because we are born richer in circumstance, richer in the gifts and endowments whether handed down to us in material shapes or as learning from past ages. If in certain ages of the world tradition has held too large a j)lace in the admiration of men, and has laid too heavy a hand on freedom and originality of thought, we may yet appreciate the due value of tradition in our own advance, and our duty to our descendants in preserving for them all that seems good in our own time, while our minds play freely nevertheless, and are not smothered by its weight. For as Plato says in the Ion: "There is a stone which Euripides calls a magnet, but which is commonly known as the stone of Ileraclea. This stone not only attracts iron rings, but also imparts to them a similar power of attracting other rings ; and sometimes you may see a number of pieces of iron and rings suspended from one another so as to form a long chain, and all of them derive their power of suspension from the original stone. In like manner the Muse first of all inspires men herself ; and from these inspired persons a chain of other persons is suspended, who take the inspiration." May we not accept this beautiful figure which Plato imagines of poetry to signify all tradition by which man is enriched and advanced. " Through all these," he says, " the God sways the souls of men in any direction which he pleases, and makes one man hang down from another." It is in our great seats of learning, such as this in which I am now speaking, that men forge and hand down to their children the cosmos of inherited experience in which we dwell and about which we breathe an atmosphere which forms and inspires without our being conscious of its presence. If we may counsel that our minds shall come to Nature "disencumbered, clear and plastic," this counsel has regard to the accidents of mental occupation, not to the edification which began in the cradle and ends only as the faculties of assimilation in each of us are outworn. You will thus be prepared to know that our great ancestors among the ancients, however vast their mental endowments, could not have built up true doctrines. The empirical method is the necessary porch of entrance into science ; and there can be no true generalizations till facts have accumulated in quantity sufficient for the foundation of them.
To Hippocrates little was possible beyond superficial clinical observation ; anatomy and pathology were slowly to be built up by harassed and painful men in many a broken century to come. But Hippocrates, thus confined to clinical observation, could describe such general movements as fever calculate, and the phases of disease in time — as acute and chronic, as subject to crises, and so on ; and again, on this chemical basis he formed the great conception of diathetic diseases, so that thenceforth many diseases were no longer regarded as isolated events, but as terms in series. Wliile we admire the breadth of these conceptions we admire also the genius which all attain to them when
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DO other kind of enquiry was then open ; for it was not until the time of the school of Alexandria that anatomy and pathology could be said even to begin. Nosological detail, as we daily study it, was out of his reach. The method of experiment was not even formulated, though Littre has reminded us that Hippocrates made the profound observation that no study of the brain could have led us to foresee that wine would produce so peculiar a disturbance of its functions. It was left to Galen to bring empiricism, clinical observation, normal and morbid anatomy, and even experimental methods together in one coordinate study, soon however to be eclipsed in the darkness of the middle ages. Even to this day physicians have not assimilated the lesson that disease is not an entity but a particular state of the body and has no more of a separate or objective existence than, let us say, the constellations of the Great Bear or Charles's Wain.
I need not at this day remind you that progress in any one science depends on what may be called the accident of jjrogress in ancillary sciences and arts. I have always thought it a remarkable instance in this sense that the stupendous advance of modern surgery waited upon two main conditions, namely, on the discovery of anaesthetics and on those researches of Pasteur which laid the foundation of modern bacteriology. When 1 was a boy surgeons operating upon the quick were pitted one against the other like runners on time. He was the best surgeon, both for patient and onlooker,who broke the three-minutes record in an amputation or a lithotomy. What place could there be in record-breaking operations for the fiddle-faddle of antiseptic precautions":' The obvious boon of immunity from pain, precious as it was, when we look beyond the individual, was less than the boon of time. With anesthetics ended slapdash surgery; anaesthesia gave time for the' theories of Pasteur and Lister to be adopted to practice. It is within the memories of some of us how the great performing surgeons scoffed at Lister's first essays — happily this great man has lived himself to see his own splendid vindication. How the improvement of the microscope lifted physiology and pathology into new realms of discovery is a familiar story, but one perhaps not fully comprehended by those who have not learned how the want of this instrument arrested the work of Harvey in his labors on the problem of generation, as well as on the circulation of the blood ; or, on the other hand, how its use by forwarding the work of Bichat founded modern physiology afresh; how by the microscopic discovery of the human egg the mystery of generation was unveiled by v. Baer in lS'i7; how by forwarding the work of Schleiden and Schwann the realm of the cellular pathology was opened out, afterwards to be cultivated so successfully by Virchow.
Illuminated by such cross-lights new fields of clinical medicine, which on the old method of Hippocratic observation Sydenham had carried perhaps to its extreme limits, stood revealed by the labors of the great French school of Laenuec and Magendie, of Louis, Andral, Cruveilhier, Trousseau and Charcot. Laennec gives me the impression of being one of the greatest physicians in history ; one who deserves to stand by the side of Hippocrates and Galen, Harvey and Sydenham. But without the advances of pathology Laennec's work could not have been done; it was a revelation of the morbid anatomy of the internal organs during the life of the patient.
It were too long a task for us now to turn to other fields to note how the discoveries of the great chemists of the last two generations threw light upon pathogeny ; how those of the biologists gave a new meaning to the study of human morphology. You know already how natural knowledge advancing from many quarters was extended, and especially in the realm of medicine which we are now contemplating. Each great branch of natural knowledge has its own Hinterland which it surveys for the common good. Nor shall we forget that a like activity in other departments of human intellectual enterprise has enlarged the conceptions of physicians even where the facts stood aloof from their ordinary conversation. As Locke and Hume told for medicine in the eighteenth century, if indirectly yet none the less enormously, so in our own century Lyell, Darwin, Spencer and others, by profoundly modifying the whole attitude of our minds towards Nature, have given to physicians a new standpoint from which to survey their particular world.
It would now seem that even in medicine the experimental method, which seemed forbidden to her, is making its way after all. If pathology never can become a science of direct experiment in the sense that physiology is so, it makes use of it as a second line of advance. If we cannot produce a pneumonia we can study the results of cutting a nerve. In physiology the number of variables is embarrassing, yet in medicine it is far greater. No two cases of a disease are alike — temperament, race, season, circumstances, all variables, conspire to modify cases and inferences.- It will always, indeed, be impossible in any branch of the biological sciences to isolate conditions and to repeat them as in chemistry and physics. Yet, as I have said, an approximation to such means is manifested in the bacteriological laboratory where pure cultures are separated, their toxines tested in proportion to body weight, antitoxins calculated, and immunities predicted.
It would seem to be, in the study of immunities, that the physician will first attain the reward of scientific research in prediction. A science which cannot predict quantitatively is in an inchoate stage. Multiplication of corpuscles, like the increase of cell growths in a hypertrophied heart or kidney, is but a case of compensation — a measure of resistance to disturbance.
Whether we regard it from the static or the dynamic point of view, the conception of the vis medicatrix nature gains newer force every day. Our blood and other corpuscles are microbes, their serums are factors in natural processes, and are regarded as healthy or unhealthy as they happen to be convenient or inconvenient at the moment of observation. Glands, such as the liver and kidney, are aggregations of microbes specialized for particular functions, and generate juices which are factors of nutrition, and not only of negative, but, as we have learned so well in respect of the thyroid, of positive influence in the balance of its manifold processes.
From experiment and observation we find that this reserve energy of the body in its various parts is enormous. How large is the view of the province of therapeutics thus presented to us we may see in the rapid advance of what I may call physiological remedies. As hygiene is to the state of health, so is physiological medicine to that of disease. By
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physiological medicine I mean the use of the ordinary functions of the body in counteraction of contingent or inherent perils.
It is a common but I think a shallow reproach to modern medicine, that, with all the advance of our knowledge of pathology, therapeutics stands where it did in the time of our fathers, or has even fallen back, in so far as a certain sceptical distrust of empirical remedies has discouraged the continued use of remedies which the wisdom of our fathers had discovered by practice and observation. It is said that we will not use the most respectable of traditional remedies unless we have some notion of its mode of operation. It is possible that the invaluable work which a scientific scepticism has done for us, not in therapeutics only, has been attended by some destructive effects which are to be regretted. I think, however, it would be diflficult to bring forward many instances of the kind in our own case ; while, on the other hand, the pruning and clarifying which our practice has undergoue far outweigh any such temporary disablements. The truth is that the cry itself is a shallow one. I will not stay to assert that modern surgery, the brilliant progress of which is in all our mouths, is progress in therapeutics, the division between surgery and medicine being a division of convenience, a division to which a mere practical and temporary usefulness only is to be attributed. Are we to forget, for instance, how the prognosis of peritonitis, of obstruction of the bowels, of pleuritic effusions, of encephalic tumors, of perityphlitis, of pelvic diseases, of ovarian ascites, and so forth — a prognosis in troops of cases turned from sadness to hope — is not to be called progress in therapeutics because not infrequently the method is carried out by the skill of another hand ? It might as well be asserted that the modern scheme of feeding in fevers, because it is carried out by trained nurses, is no therapeutical progress. Nor will I admit, even in the sphere of drug therapeutics, that our progress is contemptible.
When we regard the additions nuide to our hypnotics, the discovery of the value of the nitrites, of the bromides, of arsenic in pernicious anemia, of the salicylates, of the antipyretic, hypnotic and antalgesic group, of the antiseptic treatment of diseases of the skin, of the antitoxic treatment of diphtheria, of the thyroid treatment of myxcedema; when, again, we realize the greater precision of our use of the older empirical i-emedies, as of digitalis, in the preciser administration of remedies in syj^hilis, in the injection of alcohol and ether, of apomorphiue, of ergotine of strychnine, of hyoscine, of cyanide of mercury ; when, once again, we think how much more accurately we discriminate our means in the treatment of phthisis, of dyspepsia, of fevers, of palsies, central or peripheral, we may confidently take encouragement and meet those adversaries in the gate who say that therapeutics has made no considerable progress. At the same time, we may well take to heart the lesson which such criticism may teach us. While we have learned that empirical knowledge, although a power against ignorance, is of less avail against the more ordered and living knowledge of a maturer science, on the other hand, for this very reason, we are now, perhaps, apt to despise unduly the traditional remedies which rest their claims to usefulness more on empirical than on reason
able grounds. For in the use and practice of all methods we must remember that medicine is an art, that it is something more than an applied science.
Our art has always been, and probably long must be, in advance of scientific direction and explanation. Moreover, as in all arts, more than knowledge is needed, namely, common sense, rapid and firm decision, and resourcefulness — faculties by no means resting upon intellectual conceptions, but on a certain virility of character not to be got from books. It is no uncommon experience to see physicians of high intellectual subtlety, of great learning and of a pretty wit, lose themselves in the practice and even in the exposition of their profession, because in them the critical faculty exceeds the practical. Indiscriminate doubt, however valuable an attitude of mind in the laboratory, is mischievous in the field of action, where a keen determination to make the best of imperfect instruments, to use any accredited means rather than none should be the dominating impulses — impulses which enlist also on the side of the physician the hope and animal si^irits of the patient ; for, after all, the practice of medicine contains no small element of " suggestion." Furthermore, the fastidious spirit, which I have endeavored to indicate, is, on the whole, opposed to progress, as, even in thought, it lends itself too readily to irresolution, and irresolution is the quick way to indolence. On the other hand, I need not warn you that practice without continual scientific re-edification soon degenerates into stereotyped and sterile routine.
Once more, when we are twitted with the discovery of manifold new diseases, without the discovery of any means of dealing with them, we may reply that not only are we discovering the course and ends of these destructions, not only are we discriminating between this series of symptoms of dissolution and that, but we are engaged, as I will remind you again, in the study of origins. We are no longer satisfied to contemplate the wreckage of disease, but we are earnestly hunting out the processes in which such and such deviations from health took their being.
The study of origins, then, is not only the new method of modern criticism, of modern history, of modern anthropology, of our reading of the evolution of the universe itself from elements which even themselves are falling under the same analytic inquiry, but the study of origins is leading to a revolution in our conception of therapeutics, as of all these other studies ; a revolution which as yet we have not fully understood. This revolutionary conception is that death is not to be driven away by the apothecary, not by auy cunning compilation of drugs, but is to be prevented by the subtler strategy which consists in knowing all the moves of the game. Few and simple are the diseases which can be expelled by leechcraft, as we expel a worm. The medicine of the future will consist in setting our wits to nature, in recognizing that when evils have befallen us there is no counsel, and that in the simple beginnings of things are the time and place to detect where stealthy nature, atom by atom, builds and unbuilds, feeds us or poisons us. To disentangle the clue we shall not pull at it anyhow ; we shall anxiously seek the beginning of it, thence to unravel its windings.
There is an old saw that Nature takes as much trouble to
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make a beggar as a king. She does not make diseases to sit so loosely that they can be expelled by violence or bound by a charm Much of curative medicine, in the vulgar sense, will thus be swallowed up in preventive medicine. We shall not wait till we are half dead before we take in hand our disorders; abnormal processes, not their results only, will be our fruitful study.
Another feature of modern therapeutics is the use of Nature against herself. We learn, as I have said, to play the game; we are not content to sleep at our posts till we must fight desperately, against a checkmate, but we keep in touch with the enemy all through, and use the same means. Thus, by the side of preventive medicine, we learn that hygiene, in its largest sense, is also to be our guide. Instead of trusting to prescriptions for alleged specifics, which have no little kinship with magic and antidotes, we ally ourselves with Nature's own forces. For example, if we cannot prevent infantile palsy, which soon, perhaps, we may do, we shall attempt its cure, not by idle drugs, but by strengthening the physiological factors of life ; by the use of massage, electricity, warmth, and so forth. As we further discover the physiological factors of life, we learn to supplement the failing juices of a gland from other sources in the economy; by learning the distribution of heat in the body, we find that fever can be controlled by conductions of heat by cold baths and otherwise ; by a better knowledge of the mechanics of the circulation, we arm ourselves with means for regulating its currents by baths and gymnastics and the like. Even iu the sphere of drugs themselves we are, year by year, deposing this drug and that from the place of specifics, as in the case of quinine, and putting them iu the ranks of preventive agents, and, with respect to others, we are carrying our study of origins into their qualities, as well as into the healthy or morbid processes over which they have power. Tlie relation of atomic weight to physiological effect, the experiments by which, on slight substitution of one molecule for another, we convert compounds from cne kind into another and widely diverse kind, from convulsants, for example, into narcotic or paralyzing agents, we throw light not only on their own properties but also on the secret processes of the animal body itself. I will not stay to illustrate in the same way the parallels between the members of different series, nor the advances, of late the least active, by the way, of physiological chemistry, and of chemotaxis, and of the study of the behavior of serums and the like within the more comprehensible range of the test tube. Such considerations impress us again and again with the importance of the union of practical and laboratory or theoretical work iu the same jiersou and in the same schools. No scientific observer who has not made medicine more or less a practical study can be as well equipjied as otherwise he would be to investigate such subjects as these.
The modern hospital must be the modern laboratory of medicine. As in the sixteenth century the great laboratories of anatomy sprang into existence, in the seventeenth the laboratories of physics, in the nineteenth the chemical (Liebig), the physiological (Ludwig), the chemico-physiological (Hoppe-Seyler), the pathological (Virchow), the hygienic (Fettenkofer), so the clinical laboratories initiated but
the other day in Germany by v. Ziemsseu, Curschmann, and in the United States by Pepper, are the factories out of which the new medicine is to come— the medicine which, penetrating into the intimate processes of Nature, learns to turn Nature to her own correction. The clinical laboratory is to be the sceue of the study of the origins of disease.
What are the aids and dangers of "specialism" in these advances? Against this tendency iu modern studies and practice an outcry has been raised which, if a little unintelligent in its way of expression, has not been without justification. In advancing civilization the ajj plications of thought, as well as those of labor, must be divided and strbdivided. The activities of the mind are at least as multiform as those of the traveler in the world, and it is impossible for all explorers to follow each other over all ways. As pioneers increase in number and in adventure the more are they divided from each other, the more diflScult is it for each to make himself master, even by report, of the work of all. This general law is as true for medical inquiry and for medical practice as for electricians or naval engineers. Not only so, but we may say that, in the sciences, men are not traveling over one world only, but over many. If within each world of mathematics, physics, chemistry, and so forth, explorers separate and travel out of sight of each other, what shall be said of the remoteness of explorers in these several worlds ? Yet these several worlds of the sciences are not as Mars to us, but as the various kingdoms of the earth. What goes on in each is of the utmost importance to all, and as civilization advances becomes not of less importance, but of more and more. Herein lies the justification of what I have called the outcry against specialism. The protestants have perceived this inter-relation of all knowledge, and they have foi'eseen both the narrowness of spirit and the lameness of practice which must come of such a disintegration of parts of such an isolation of efforts. Nay, they may not improperly conceive that a less amount of knowledge, duly systematized, may be of more value in affairs and in philosophy than more knowledge in scattered parcels. If the outcry has been somewhat unintelligent, this has been not iu the perception of the kind of injury to learning. This is to be credited to them as a virtue. But in the want of perception that some division of labor is inevitable, the protestants have seemed to care less for the advance than for the system of learning, and, indeed, to have set practice in some antagonism to learning.
We shall henceforth perceive, I trust, that this new movement comes from the deeps ; that it is not by withstanding the very conditions of modern progress that we shall secure its balance, its concert and its sanity. Happily, evolution will be found still to consist not in differentiation only, but also in integration. As labor is divided, an organization of knowledge must proceed step by step with the division. Specialism will have its disadvantages, as all exclusive aspects of things have them. In practice, specialism will have its charlatanry, as omniscience has had it. It is only by the increase of discernment and education in society at large that the genuine and humble children of Nature will be known, and it is by progress in its best sense that such discernment and education are to be extended. 1 do not hesitate to say that even within
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my own lifetime these qualities in the relation of society towards onr profession have not only increased, but have waxed abundantly, and thus is a medium formed in which the remoteness and alienation of specialized workers finds a corrective. The worker in all subjects, even in the larger operations of ordinary trade, learns that he, too, must think of the whole as well as of parts and details. Even money cannot everywhere be broken up into small change; commerce can no longer be a piecemeal affair. In the tradesman, indeed, is engendered a mind in favor of breadth of view, and even in the man in the street is begotten a hazy notion that there cannot be, as in ancient Egypt, a physician for every part of the body. There is no mean in Nature but Nature makes that mean ; if these qualities of intellectual concert, of scientific formation of mind, of breadth and sagacity are needed, they will be found, and the way to them will be found also. Indeed, such conceptions of education are gaining apace on the general mind, though their full bearing is not yet understood. It is this very breadth of mind which is aimed at by educational reformers, by those who prize education before mere acquisition, who assert that, with the greater complexity and definiteness of knowledge, associations of workers and certain harmonies in their results must be brought about.
Those, then, who resent the specialization of science, as of other fields of human work, although they are wrong in their way of opposition, have hold, nevertheless, of an important truth, and they agree with the Thracian King Zamolxis, who was also a god. Zamolxis observed that "as you ougiit not to attempt to cure the body without the head, or the head without the body, so neither ought you to attempt to cure the body without the soul, and this,"' he said, "is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they are ignorant of the whole, which ought to be studied also, for the part can never be well unless the whole be well." (Cliarmides.) Although then we cannot hope that every physician shall be a man of science, we may secure that he shall have the scientific habit of mind, for thus, as we have seen, he will be habituated to lay out his knowledge systematically, to trace phenomena to their sources, and to see his own facts in their due relation to other facts. This is the philosophic temper which cannot be learned from books and rarely without tradition and converse with gifted men.
Some disciples are more apt to receive this grace than others ; some men, many learned specialists, are incapable of wise scientific judgment; no examination can test it; no memory can secure it; it is in part a product of time, which accepts what is good and i ejects that which is transitory. It is to be assimilated from organs of knowledge, such as universities, and not from mere polytechnic institutions. It is the highest reward of the teaching from a living source, for, as Professor Butcher says, "the test of life is to impart life."
Too many students pass through their schools without an awakening of their minds. They believe their superficial knowledge to be exhaustive, and they become the mouthpieces of ready-made opinions.
I should be an ill bird were I to say anything to-day in depreciation of the value of lectures, of my own wares. In bygone times I have said much in depreciation of tliem, urg
ing that they are survivals of a time when books were scarce and dear, and when knowledge was looked upon as spoonmeat. I have helped forward the cry that the laboratory must be the future living source of knowledge and of inspiration. While men were blind to this new truth it was necessary to urge it to the hindrance of other needs which men were not likely to forget. Now that the battle is won, and the laboratory is everywhere with us, we may turn again to consider what there is in older methods which we would not willingly lose. In lectures we may still find the virtues which flow from living converse with thoughtful men who have been over the field of our studies before us, who can show us how their minds worked, how they systematized their knowledge, how they came to see it in the light of other researches, how they inspired it with human interest. For such ends as this we must have no mere retail dealer in knowledge for our lecturer. In all universities it .is now recognized that, except for tutorial work, the lecturer to beginners must be the leader in his faculty. He it is who can give the true first set to the thoughts of young men who are entering into the subject of their lives ; older men and advanced work may well be undertaken by demonstrators.
Thus far I have considered specialism and breadth in respect of the education in our profession, but a larger problem lies before us, namely, that wider culture which lies beyond the confines of all professions. One of the difiicult conditions of our own generation is the urgent pressure on young men and boys by reformers and anxious parents who desire, not unreasonably, to mold their sons into money-making machines at as early a date as possible. When I took my degree at Cambridge our course was, in the first place, to take an arts' degree, at that time only to be had in the arts. Thereafter came the natural-science studies, with their tripos, and after that again the clinical studies proper to our professional life. This course occupied us up to the age of twenty-five, at least, and in some respects it was a far better education than we now bestow. Now, from the first hour of the medical student's arrival in Cambridge he is too often turned at once into the narrower channel of his special calling, and he even tries to pick up a precarious instruction in clinical work while he is ostensibly at work on the preliminary sciences. Nay, such is the pressure of the times, parents and teachers are getting impatient even with this rate of speed, and are insisting that even at school time is wasted in classical and other broader studies which might be utilized for science, and that men should come up to the university ready to "specialize" farther still. Among other strong arguments in favor of this reform is this : That whoso means to practice surgery should acquire manual dexterity, and that this advantage cannot be acquired by the ordinary man unless he begin to educate his plastic fingers in early youth. This argument I will dismiss in a word by saying that, in my opinion, every man should be educated in a handicraft or mechanical art of some kind during his early youth. The importance of this element of education is curiously forgotten even by such a mechanical race as the English and American. So much for surgery; the boy who has learned to use a lathe or to make a chest of drawers will have fingers apt enough for surgery.
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There is, moreover, another means of education most useful in early life, namely, that of measurement. At every national school youths of both sexes should learn to measure accurately to thousandths of an inch and to hundredths of a grain ; thus the eye is taught with the hand, and, what is of more importance, the mind is trained to know what accuracy means. These occupations, invaluable in training of character and skill as they are, would add nothing to the burden on a growing brain.
Of the sciences, those of memory and observation only should have a place. The mind of youth is in a stage when the imagination, rather than abstract thought, should be cultivated. To collect natural objects, and thus to be drawn into the haunts of animals, into the habitations of plants, and to see the structure of the earth, excites and enlarges the imagination and strengthens the memory at a time when these faculties are ripe for culture. I have never happened to meet a young man, educated in abstract science at school, who seemed to me to have used his time to the best advantage. If, for the present, it has led to success in the narrowest sense, I think we are entering even now into a generation when success must be based on a larger education than this — on an education in letters and in the humanities, as well as in the laws of the material universe. Rousseau well said we should not teach children the sciences, but give them the taste for science.
We are apt to forget that even in these days of science, advancing by leaps and bounds, that still the greater part of man's life is spent in the expression of his thoughts and in converse with mankind. He should, therefore, have learned to handle the ideas which concern himself and his fellows, not only in their material conflict with Nature, but also in those higher spheres of history, ethics, politics and social aspiration for which alone man can be said properly to live. If we regard the mastery of modern man over Nature in any other light than as clearing for us a larger base for a reconstruction of societies which shall be more wise, more humane, more beautiful in spirit than in the past, there would be nothing but sadness in the contemplation of modern life, with its "gay afflictions, golden toil." No doubt we must rebuild our material home, but we ourselves also must be born again. (Newman).
The uses of learning Latin and Greek lie in this — that in these studies, more than in any others, the ideas which concern man in his highest endowments of mental, spiritual and social life are manifest, and not only so, but are manifested in languages the most virile and beautiful the world has known. Latin and Greek are called dead languages. If so, the Hermes of Praxiteles and the Venus of Milo are corpses. Latin and Greek contain in perfection of form not modern science, but that for which modern science exists — the best that man has lived and thought. It would be a narrow pedagogy which should assert that strong and penetrating thought, and noble and chastened imagination are to be found only in Latin and Greek ; we may be thankful, indeed, that the English language is or has been as noble an instrument, and enshrines at least as fine a literature. Yet it has been said long before our time
that to know one literature only is to wander in the sphere of letters without a scale of relative dimensions — to lose the faculty of comparison for lack of standards of comparison. To learn to speak a language like a parrot is but to train a mechanical memory. Latin and Greek, however, although they contain the finest records of human thought and action, are, as I have said, not the only shrines of letters, and the noble literatures of France, Germany or Italy may take the place of either of them, and carry the additional advantage of common usefulness.
But do not let us forget that our calling derives its honor not from its power of repairing the carnal body ; were this its only title to respect it would take a low place in the hierarchy of professions. Those professions which deal with the ends which alone make life worth preserving — such as that of the law of religion, philosophy and of the fine arts — would in such case regard our occupation but as a higher kind of farriery. The glory of our profession, from the hour when Hippocrates, in that oath wherewith like a trumpet, the notes of which reverberate still through the ages, summoned us to take our place in the forefront of the fight, has been that we are concerned not only for mankind, but for men. The ideal side of a physician's life is that he brings healing or solace to his human fellow. The Greek philosopher, like the modern socialist, would sacrifice man to the State ; the priest would sacrifice man to the Church; the scientific evolutionist would sacrifice man to the race. Yet, while all these elements of cooperation and of aspiration work together for good, we thankfully see that, after all, the tendency of civil evolution, as of Christian ethics, is to use society as a means for man himself, as a means to purify and to elevate the individual soul. The physician, then, is more than a naturalist; he is the minister not only of humanity at large but of man himself. Thus it is that the humblest of us, and he who labors in the darkest and most thankless parts of our cities, is never a drudge; in the sight of the angels he is illustrious by the light of his service to men and women. The man of science can tell us delightful things about birds, flowers and wild life, for all life is various and touching; he can tell us queer and uncomfortable things about our insides, amazingly useful things about steam and electricity, but at bottom, when the marvel is over or the material gain is won, all this grows stale. Ideas concerning the harmony of the spheres, concerning cosmic evolution, concerning the inhabitants of Mars, are prodigious; they may uplift iis sometimes with a sense of the greatness of man's inheritance, but alone they are cold and unsatisfying. The child of his age feels that a sonnet of Wordsworth, a flash of Browning's lamp into man's heart, an idyll of Tennyson give us thoughts worth more than all the billions of whirling stones in the universe. In strengthening and cherishing this inner life of his brother and sister, happily, the physician has many fellows, but the physician alone among them all holds sacred the lamp of the personal life for its own individual sake; he alone forgets Church, State, nay, even the human race itself, in his tender care for the suffering man and for the suffering woman who come to him for help.
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ON REFRACTORY SUBCUTANEOUS ABSCESSES CAUSED BY A FUNGUS POSSIBLY RELATED
TO THE SPOROTRICHA.
By B. K. Schenck, M. D.
On November 30, 1896, A. W. presented himself at the surgical cliuic of the Johns Hopkins Hospital with an infection of the right hand and arm of an unusual nature. The primary point of infection was on the index finger, whence it extended up the radial side of the arm, following the lymph channels, and givingrise to several circumscribed indurations, which were in part broken down and ulcerated.
One of these indurated areas was incised, and deep in the tissues a thimble full of gelatinous, puriform material was found. A culture from this fluid was made on gelatin. At the end of four days there was a growth of the staphylococcus epidermidis albus, besides which several other distinct, white colonies, raised from the surface of the medium appeared. Cultures made on agar from the latter colonies showed after three days in the thermostat, an abundant growth of an organism, not resembling the bacteria and evidently present in pure culture.
On December 7, under aseptic precavitions, an indurated area just above the elbow was incised, a,nd a small piece of tissue removed for microscopical examination. Two cultures were taken on slant agar from the puriform contents of this nodule. In three days both tubes showed a growth in pure culture of the peculiar organism previously obtained.
On December 14, Dr. Finney made the following note : " Ulcerated area, size of finger nail, over dorsal surface of second joint of index finger — right hand. Edges much undermined. Sero-purulent, gelatinous discharge on surface. A second, similar ulceration between second and third metacarpal-phalangeal joints. An indurated line, 1 to 1.5 cm. in diameter, follows along dorsum of hand and forearm, with here and there ulceration.
On the arm there are two indurated points, which have been excised, the highest one being in the middle of the arm. At the junction of the upper and middle thirds of the forearm there is an indurated spot, the size of a bean, situated to the outer side of the main line.
Epitrochlear gland not involved. Axillary glands palpable, but not especially enlarged."
Dr. Finney then removed with aseptic precautions a second, larger piece of tissue for microscopical examination.
The patient gave the following history : Age 36. Marked family history of tuberculosis. Patient has suffered from phthisis for jiast twelve years.
During the latter part of August, 1896 (3 months before visit to the Johns Hopkins Hospital Dispensary), while working at the iron worker's trade in St. Lonis, the patientscratched the index finger of right hand, on a nail, while reaching into a red lead keg. Shortly after this a small abscess formed which was opened with a pin. A slight amount of watery fluid escai>ed, which patient thinks did not look like pus. In about three weeks the ulcer between the second and third metacarpal-phalangeal joints appeared. This was treated at the St. Mary's Dispensary (St. Louis). The inflammation traveled up the arm, and in about seven weeks after the
From the Pathological Laboratory, Johns Hopkins University and Hospital.)
infection seven similar abscesses had formed. These were opened, and a watery discharge escaped. About this time a " waxen kernel," size of a walnut, appeared in the axilla. It was not especially tender and disai>peared in two days. While in St. Louis the arm was bandaged daily with bichloride and carbolic dressings. The patient thinks that he had no fever, and says the pain was very moderate. Being unable to work he returned to his home in Baltimore late in November.
Physical examination on entrance showed evidences of advanced tuberculosis of the lungs, and the sputum contained numerous tubercle bacilli.
The infection involving the hand and arm proved very refractory to treatment, the last lesion, at point of primary infection, not granulating until late in February, 1897.
The organism which was assumed to be in etiological relationship to the above-described lesions was obtained in three cultures from two different foci of the disease: Once from one of the lesions in the forearm, admixed with the skin coccus, and twice from one of the lesions in the arm, in pure culture.
Cultural Characteristics. — Cultures were made on all our common media, including plain, glycerine and sugar agars, plain and sugar bouillon, plain and acid gelatin, milk and potato. With the exception of the milk all the cultures developed luxuriantly.
Agar. — At 37° C. the growth is first apparent at the end of 48 hours, when the tract of the needle is marked by a faint line, slightly opaque, which under a low magnifying power is seen to be made up of minute colonies, with feathery outline, resembling somewhat minute snowflakes. At the end of 73 hours, the line of inoculation is sharply marked by an opaque, white, moist growth, having well-defined edges, raised from the surface of the media. Here and there at the periphery are isolated colonies. As the age of the culture increases — about five days — the growth extends very much in thickness and but little peripherally. The surface is corrugated, the edges lobulated and sharply defined (Plate I, Fig. b).
In cultures of ten days and older the growth is very thick ; the surface is rough, corrugated, and stained a dark brown color, the shade at the periphery being deeper than in the centre. The medium also becomes stained.
Colonies of three days appear to the naked eye as round, raised, ntoist dots, 0.5 to 1 mm. in diameter. Under the low power they appear to be made up of a feltwork of minute fibrilla3, dense in the centre, lighter at the periphery, with a feathery outline." Scattered through this meshwork are many minute dots, consisting of the couidia.
Colonies of ten days are characteristic. They are round, sharply circumscribed, and elevated from the surface of the medium. The surface of the colony is brownish, and marked
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by radiating lines proceeding from centre to periphery, evidently caused by the drying and shrinking of the growth (Plate r, Fig. a).
By a comparison of the development on glucose, lactose and saccharose agars, little difference is to be made out during the first two weeks. lu cultures older than 14 days, however, the growth continues longer and becomes heavier on glucose than on plain agar, and in all the sugar media there is more discoloration both of the growth and of the substratum.
Gelatin. — The growth in stab cultures develops slowly. It is much more abundant in the upper part and spreads laterally over the surface, while the development in the depth is feeble, being scarcely perceptible in the lower third. At the end of six days there is slight liquefaction of the medium. The organism grows somewhat more luxuriantly in acid gelatin, and the liquefaction is greater.
Bouillon. — -Growth in bouillon is fairly abundant in three days, and appears as little, cottony tufts which settle to the bottom of the tube, leaving the supernatant fluid perfectly clear. As growth proceeds, it tends to spread up the side of the tube. The reaction of the bouillon is not altered.
Polnto. — At the end of 48 hours the growth is abundant. It is elevated, the surface is moist and the edges lobulated. After several days the surface of the growth becomes rough and wrinkled, the edges discolored and the potato darkened.
Milk. — There is no change produced in the tint of litmus milk at the end of seven days, and no coagulation takes place. The organism does not seem to thrive in this medium, film preparations showing only very small numbers.
Fermentation Tests. — Stab cultures in glucose, lactose and saccharose agars show no gas bubbles. Glucose, lactose and saccharose media, made from sugar-free bouillon, prepared according to the method of Theobald Smith, placed in fermentation tubes, give an abundant growth in the aerobic bulb, the anaerobic tube remaining clear. There is no gas formation.
Relation to Oxygen. — No growth develojis in culture placed in the Buchner jar.
Vitality. — Growth which has remained on potato for eleven months again develojjs when placed in sterile bouillon. Agar cultures retain their vitality for at least nine months. To test the resistance to low temperatures, portions of growth from bouillon were placed in sterile water and allowed to remain in cold storage, at a temperature of 28° F., for ten weeks, after which they proved to be alive. In these cases actual congelation did not take place. When frozen for this length of time, however, they lose their vitality.
The vitality of cultures is destroyed by exposure to a temperature of 60° C. for five minutes.
The optimum temperature for development is between 20° and 37° C.
Morphology and Development. — For many of the points relating to the morphology and development of the organism, I am indebted to Dr. Erwin F. Smith, of the United States Department of Agriculture, Washington, who has given much time to the working out of the more difficult and obscure points pertaining to its life history and classification.
I take this opportunity of acknowledging the great value of his help and advice, and of expressing my appreciation of his kindness.
Cover-glass preparations made in the ordinary way, from agar and bouillon cultures, show two forms : (!) a thread-like, branching form, or mycelium, and (2) oval, spore-like forms, or conidia. In an unstained specimen the mycelium is seen to be made up of a doubly contoured thread, branching irregularly, but not very profusely, and never dichotomously. The protoplasm appears granular. The diameter of the threads presents considerable differences, with an average of 1.5 to 2 microns. The conidia are elliptical or ovate, many of the latter forms being distinctly ajjiculate. They are also doubly contoured and granular. The spores from the solid media are rounder and smaller than those developing in bouillon. They vary in length from .3 to 5 microns.
The organism stains well in all the basic dyes, and is not decolorized by the Gram method. Stained preparations show marked irregularities in the coloring, especially of the mycelium. The conidia frequently show a small unstained area near the smaller pole of the spore.
In smears made from agar or bouillon it is not possible to determine the relation which the conidia bear to the mycelium. Occasionally, however, one or two spores are seemingly attached by the smaller end to the side or end of the mycelium. This relation can be much more clearly brought out by observing their development in hanging-drop cultures, the description of which I quote from Dr. Smith's report of April 13th. The drawings are also reproduced from Dr. Smith's sketches. "When a little of the bouillon containing the colorless, elliptical or cylindrical conidia was inoculated into hanging drops of alkaline beef broth, and set away under a moist bell jar for forty-eight hours, there was an abundant growth of the fungus, the spore-bearing branches of which, being undisturbed, retained their spores in the normal condition, and the appearance of the fungus under such conditions is shown in the sketches (Figs. 1 to 3). Here from three to six or more spores were to be found, quite commonly clustered at the tips of the spore-bearing branches. Naturally, if the fungus had been disturbed by shaking or lifting out into a drop of water, most of these spores would have been readily washed away, leaving only one or two, that is, leaving such appearances as are shown on the drawings made directly from the bouillon cultures" (Figs. 4 and 5).
The life history of the organism was studied from bouillon cultures and from hanging drops. The conidia germinate by sending out one or more straight, unbranched germ tubes, sometimes from the end, again from the side. These germ tubes give off spores of the same character, the attachment being either terminal or lateral, by means of short pedicles or sterigmata (Figs. 6 and 7i. Other seemingly similar spores push out into the branched mycelial forms, which in turn produce a new generation of conidia.
The existing classification of the fungi is a purely artificial one and is incomplete in many particulars. On this account it is often very difficult to determine where an organism is to be classed. Dr. Smith has kindly gone over the points in
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regard to the classification of this organism, and his conclusions are as follows :
" It is a couidial fructification only, and on this account it is impossible to give more than a guess as to its position in the natural system of classification. To determine this the perfect spore form would have to be obtained. It can only be put into a form genus, in other words, into some artificial system of classification, until the natural one is known. It seems to me that it might be classified in either of these genera, according to the system given in Saccardo's Sylloge Fungorum, which is the commonly accepted standard of the artificial classification.
(1) \t\s wot wwWke i\\e Botrytisbassiaiia, the muscardine, or calicino disease of silk-worms, and might therefore be regarded as a Botrytis. Against this classification, however, it is the fact that the spore-bearing branches are not erect, which is a rather trilling distinction. It might also be classed as (2) Sporotrichum, but inasmuch as it becomes dusky when it is old it might also be classed as (3) Trichospormm. Saccai-do separated out the dusky forms of Sporotrichum into a separate genus under this name. The mere difference in color, as we know from cultures of many fungi, is often a vei-y trifling matter, the early stages of a fungus often being white and the later stages dusky or even brown. On this ground I think that his distinction is of no value, and I think that we may throw out the genus Trichosporium altogether. As regards the other two, my own judgmeut would be that it fits best into Sporotrichum. In his Sylloge Fungorum Saccardo describes more than one hundred species of Sporotrichu?n, but most of them are described very imperfectly, and I cannot identify this fungus as belonging to any one of them."
The tissues removed for microscopical examination present the characteristics of a chronic abscess, consisting of inflammatory and cicatricial tissues. On the inside is a layer of necrotic material, nest a zone of leucocytes, and outside newlyformed connective tissue, in which are several minute secondary abscesses.
Numerous sections stained by theWeigert and Gram methods failed to reveal any micro-organisms whatever. Sections stained for the tubercle bacillus by the carbol-fuchsin method were also negative.
Animal Experiments. — 4 dogs, 6 guinea-pigs, 1 rabbit, 1 wild mouse and 3 white mice were employed. The results were as follows :
Dog I. The external jugular vein was opened, and 1 cc. of a suspension in salt solution of the orgauism was introduced. The dog remained well, and was killed on the 30th day. Nothing unusual was made out at the autopsy. All cultures were negative. The microscopical examination of the organs revealed nothing abnormal.
Dog II. Inoculated subcutaneously on the abdomen with 2 cc. of a 36-hour plain bouillon culture. On the next day there was an induration at the point of inoculation, followed in 24 hours by the formation of a tumor about 3 cm. in diameter, which on palpation gave evidences of fluctuation and tenderness. This remained practically unaltered for ten days, and then gradually became smaller and firmer to the touch.
The dog remained apparently well, but was killed on the 28th day. Nothing was made out in the internal organs, and cultures from these were all negative. The tissues around the point of inoculation were excised and found to consist of firm scar tissue, in the centre of which was a small cavity containing a few drops of a gelatinous fluid. Agar tubes, inoculated with several loops scraped from the walls of the cavity, showed on one six colonies and on the other eight colonies of the organism. Bouillon cultures were also positive. However, no organisms could be demonstrated in cover-slips.
Microscopical sections through the wall of the cavity showed advanced cicatricial tissue. Numerous sections, stained according to the Gram and Weigert methods, failed to reveal the organism.
Dog III. Inoculated subcutaneously over the abdomen in a manner similar to Dog II. A second series of injections was made over the thigh in order to ascertain whether or not enlargement of the inguinal lymphatic glands would follow. Induration developed at the jioints inoculated, followed in two days by fluctuation and tenderness, the process increasing until the end of the first week, when the tumors became firmer and smaller. At no time were the inguinal glands palpable. Dog killed on the 21st day. The internal organs appeared normal ; cultures from them remained sterile. Microscopical examination of the organs negative. At the local lesions nodules of fibrous tissue, containing small cavities similar to those in Dog II, were found. These little pockets contained a scanty amount of gelatinous material.
Smears from the cavities were negative.
Cultures from both lesions were positive, the organisms being rather few in number. They were, however, more abixndant than in cultures from Dog II.
Microscopical examination of the fibrous tissue revealed the same condition as already mentioned and micro-organisms could not be demonstrated.
Dog IV. Inoculated subcutaneously in a similar manner, the induration and swelling took place as before, and on the fourth day, when the process seemed to have reached its height, the lesion was excised. The nodule was larger and less firm than the preceding ones, the cavity was greater and was completely filled by a thick, yellowish-red, gelatinous material, smears from which showed fibrin and red-blood corpuscles in small amounts, large numbers of polymorphonuclear leucocytes and a few objects similar in size and shape to the couidia characteristic of the organism introduced. None of these bodies were seen in leucocytes, all being extracellular.
Cultures from the walls of the cavity showed a very abundant characteristic growth of the organism.
Microscopical examination of the excised tissue shows the lesiou to be a focus of inflammation. The walls are made up of the subcutaneous areolar tissue, forming a loose mesh work, the spaces of which are filled with coagulated albuminous material and leucocytes. The pus cells also infiltrate the connective-tissue stroma. At the edges of the cavity the connective tissue is denser and the infiltration of the leucocytes more marked. The cavity is lined by a mass of coagulated serum and necrotic pus cells. In specimens stained with hannatoxylin and eosin, it is not possible to make out the organisms ; but sections
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stained by the Weigei't method reveal them in hiri;e iiumljei-^, situated principally between the inner layer of cell detritus and the adjoining zone of infiltrated connectis-e tissue which forms the wall of the cavity. For the most part they are associated in clumps of from six to thirty elements, but many occur singly and in groups of two or three. They occur mainly close to the edge of the cavity, but now and then may be situated singly or in clumps in the connective tissue stroma.
The organisms are of irregular shapes and sizes. In form they are round, oval and club-shaped, the last predominating. Tlie smallest round forms are from one to two microns in diameter, while the long, club-shaped forms vary from two to four microns in length. These club forms are of irregular diameter, swollen at one end and tapering at the other; the staining is slightly irregular, there being often a small area near the centre taking the stain less intensely. The oval antl round appearing forms correspond in size to the varying diameter of the club forms, and give one the impression of being cross-sections of the latter. These organisms are frequently seen within the bodies of both leucocytes and large connectivetissue cells. Many, however, are extracellular (Plate II, Figs. 1, 2, 3).
In the dog then, the inoculation of fluid cultures, either intravenously or subcutaneously, produces no evident constitutional symptoms and no internal pathological changes. When introduced subcutaneously there is a local lesion at the point of inoculation, consisting of a circumscribed inflammation and abscess formation. When allowed to remain for from three to four weeks absorption of the contents of the abscess takes place, and a mass of scar tissue containing a small cavity alone remains. In the cavity organisms are present probably in very small numbers as is shown by the failure of cover-slip preparations and the small number of colonies developing in cultures.
If, however, the nodule is excised at the height of the process, signs of active inflammation are obtained — an exudation of serum and white-blood corpuscles having taken place, as well as an inflltration of the adjacent connective tissue with leucocytes. The micro-organisms are abundantly present, being seen in cover-slips, and developing luxuriantly upon cultures, while sections from the lesions stained by the Weigert method reveal them in large numbers.
Rabbit. — One rabbit was inoculated intravenously with 1 cc. of a 36-hour plain bouillon culture. The animal developed no evident symptoms and remained apparently well for five months.
Giiinea-pigs. — Six guinea-pigs were inoculated without result. In three the organisms were introduced subcutaneously. No induration followed at the point of inoculation. In three the inoculation was into the peritoneal cavity. No appreciable symptoms resulted. Five of these six animals died at periods ranging from six days to seven weeks after the inoculations, but in none was anything to be seen at autopsy, and all cultures from the organs were negative. At the time of these experiments numerous guinea-pigs kept at the pathological laboratory died of some unknown cause, and apparently the death of these animals was not due in any way to the organisms introduced.
J//(r. — While Mouse I. Inoculated subcutaneously with 0.3 cc. of a suspension made in sterile bouillon, from agar growth. On the second day the mouse appeared ill, sat in the corner of the cage, refused to eat and scarcely moved when the cage was shaken. Death took place on the sixth day. At the point of inoculation there was an area 0.5 cm. in diameter, raised, soft, and gelatinous in consistency, and paler than the surrounding tissues. This involved the subcutaneous tissue and muscle. On section the intestines were hemorrhagic and the spleen enlarged. The other organs appeared normal.
8mear preparations from the point of inoculation showed abundant oval and long forms of the micro-organisms, the latter varying from two to four microns in length. These stain irregularly, having usually a more or less clear area at one end. The same forms were present in smears from the lungs and liver, but in much smaller numbers. Those from the peritoneal cavity, spleen and heart's blood were negative.
Cultures from the local lesion, lung and liver showed the micro-organism in pure culture. The culture from the spleen was contaminated, while those from the kidney and heart's blood remained sterile.
Microscojnml examination of the tissues. — Point of inoculation. The subcutaneous connective tissue is infiltrated with large numbers of the organisms situated in clumps, some around the blood-vessels, and others having no apparent relation to the blood-supply. The leucocytes are fairly abundant, and often contain several organisms within their protoplasm. Numerous larger phagocytic cells appear. Deeper down in the tissues the organisms are very abundant, and lie in large masses between the muscle bundles. The organisms do not invade the muscle, and there is no apparent increase in the muscle nuclei. Sections stained in haamatoxylin and eosin show hyaline degeneration of the muscle fibres.
Liver. — In the liver many organisms appear in the larger blood-vessels and capillaries. Throughout the organ are minute focal necroses and degenerated liver cells, the organisms being in the capillaries of the diseased area and occasionally within the necrosed liver cells, and in leucocytes. The organisms have the same characteristics as those above described.
Sections of the lung and spleen appear normal except for the presence of the organisms in small numbers both within and without cells. They appear for the most part in small clumps containing numerous elements, but also occur here and there singly.
No pathological changes were made out in the kidney sections and no organisms could be demonstrated.
Lymphatic glands. — The lymphatic structures throughout the body showed the most striking and characteristic appearances. The organisms were readily demonstrable in the peribronchial, perinephritic and peritoneal glands, which contained immense numbers of them. They presented the same characteristics as before, and occurred for the most part outside of and between the lymj^hatic cells, although at times they are seen within the cells (Plate II, Fig. 4).
White Jlouse II. Inoculated in a manner similar to Mouse I. Death occurred on the 10th day. The autopsy revealed
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the same soft, semi-caseous area at the point of iuoculatiou and a similar htemorrhagic condition of the intestines.
The microscopical findings were the same as in the previous experiment.
Mouse III. A wild mouse was inoculated with 0.3 cc. of a 36-hour bouillon culture. Animal appeared to be unaffected until the fourth week, when it became less active and refused to eat. Died on the 38th day. Around the point of inoculation there was a very extensive indui-ation, the tissues being hard, shrunken and dry. This sclerosed condition involved the whole posterior third of the back extending down the thighs and to the root of the tail. Internally the intestines were adherent and the testicles involved in the cicatrix.
Cover-slips and cultures were negative.
Microscopical examination of the tissues removed from the local lesion showed exceedingly dense scar tissue. No organisms were demonstrated. Examination of the organs was negative.
SUMMARY.
The condition in the human subject reported here seems sufficiently unusual to warrant publication.
It is further of interest in view of the evidence given, which would indicate that the skin abscesses and indurated lymphatic glands were due to infection with a micro-organism, differing markedly from the bacteria, but agreeing with certain of the fungi.
The cultural characteristics of the organism are similar to those of many fungi and yeasts, and the imperfect life history which could be determined renders it not improbable that it may belong to the genus sporolricha. But for the present the exact classification of the parasite must be left undecided.
The experiments upon the dog and the mice prove the pathogenicity of the organism, and indicate that, under dif
ferent circumstances, it may remain local in its development and effects (dog), or it may invade the internal organs and produce a sort of pya?mia (mouse).
The etiology and pathology of many fungoid affections in man and animals receive a new interest in the light of the more recent studies of the pathogenic yeasts and their possilile relation to tumor formations. It may be mentioned that the pathological conditions met with did not in any instance suggest any otiier than a simple inflammatory jjrocess.
I take pleasure in acknowledging my indebtedness to Dr. Flexner for advice and assistance in the course of the study recorded here.
EXPLANATION OF FIGURES. Plate I.
Fig. a. Colonies of 10 days. Glucose agar. From lung of white mouse I.
Fig. b. Growth on glucose agar. 3 days. Photograph by Dr. J. F. Mitchell.
Fig. c. Cover-glass preparation from glucose agar. X 1000. Photograph by A. H. Eggers.
Figs. 1 and 2. Growth in hanging drop of bouillon. 60 hours.
Fig. 3. Same. 4 days. Reproduced from camera sketches by Dr. E. F. Smith.
Figs. 4 and 5. Cover-glass preparations from bouillon.
Fig. 6. Swollen and germinating conidia, from hanging drop of bouillon. 30 hours.
Fig. 7. Germ tubes with conidia attached, from hanging drop of bouillon. 3 days.
Plate II.
Figs. 1, 2 and 3. Sections of wall of abscess in subcutaneous tissue dog. Leitz obj. i ^Fig. 1), i (Fig. 2), and J. (Fig. 3).
Fig. 4. Peribronchial lymph glands of white mouse. Carmine and Weigert's stain. Leitz obj. J inch.
(EDEMATOUS CHANGES IN THE EPITHELIUM OF THE CORNEA IN A CASE OF UVEITIS FOLLOWING GONORRHCEAL OPHTHALMIA.
Edward Stieren, M. D , Pittsburgh, Penna.
Oedema of the corneal epithelium with various changes and distortions of the epithelial cells due to pressure of fluid in the intercellular spaces, has been observed by many workers in the pathology of the eye, and has been described and depicted more or less thoroughly since Arlt's' original observations in 1855. He described the oedematovts changes taking place in the cornete of eyesafl'ected with choroiditis accompanied by increased intraocular tension.
Fuchs,'*' Fridenberg," Hirnbacher and Czermak,' Klebs" and other observers have seen these changes occurring in glaucomatous and staphyloniatous eyes.
Some experimental work has been done; Leber, Gutmann, and others have produced artificial oedema in the corneal epithelium. Leber" succeeded by injecting oil of turpentine under the anterior epithelium in producing, without any roughening of the surface, a corneal opacity which closely resembled
the haze of glaucoma. On microscopical examination he found numerous vacuoles in difi'erent layers of the epithelium with a pronottnced dilatation of the intercellular spaces. More recently, Gutmann^ by injections of a solution of asphalt in chloroform, demonstrated a communication between the lymph space.'! of the corneal matrix and the finer system of channels in the anterior epithelium, and produced a condition similar to that found by Leber.*
The corneal oedema of glaucomatous eyes (causing haziness and the appearance of rainbow colors around a flame at night)
Bizzozero, in his excellent article, first demonstrated the presence of a series of intercellular spaces or clefts forming a system of
minute channels for transporting nutritive fluids to the individual cells and containing a small amount of viscid cement substance. Pfluger'^ and Grubor'" have also described the nutrition of the corneal epithelium through these channels.
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Sections from local lesion. — Dos;
Peribrouchial lynijih arlands. — Mouse.
Pl.^te II.— To face p. 2'.K).
Decembee, 1898.]
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is due to the increase in intra-ocular pressure, the tension of the tunics being suddenly or gradiially raised, while the centrifugal flow of fluids is impeded or entirely shut off, resulting in an accuinnlation of fluid in these intercellular space'. These are now transformed from mere channels into dilated lacuna;. This at least seems the most plausible theory, although Fuchs' thinks it possible that the oedema can be caused by pressure osmosis, the aqueous humor being forced by the intra-ocular pressure through Desceniet's membrane (esi)ecially as this is often broken down in inflammatory glaucoma) into the corneal substance proper and thence through the lymph channels in the nerve sheaths and of the corneal matrix into the epithelial interce hilar spaces.
In the case I wish to describe there is j)resent an oedema causing marked changes in the epithelium which cannot be ascribed to increased intra-ocular pressure, since this was never present. Before entering into the microscopical appearance of the sections, a clinical history of the case is of decided inijjortance, and is as follows :
John A., se[. 35 years. American ; occujiation, commission merchant, was first seen in June, 1894, confined to bed with gonorrhce.il rheumatism and gonorrhceal ophthalmia of both eyes. 'J"he right eye was the worse of tiie two, the central part of the cornea at this time breaking down in an ulcer; the ulcerative process went on to perforation, allowing the aqxieous humor to escape and the iris to come in contact with the cornea, when the ulcer finally healed over and left a central opacity, adherent to the iris and about 4 mm. in diameter. The treatment consisted in the application of 2 per cent sol. argenti nitratis, atropin, cold compresses to eyes continually, with the internal administration of salicylates. The disease in the left eye ran the usual course and made a good recovery without any corneal involvement. The patient was seen from time to time after this, and in March, 1896, he made his appearance with the right eye painful, and the left eye a little sensitive to light; insjtection showed considerable ciliary injection of the right eye, the globe was tt-nder to touch; an ophthalmoscopic examination was impossible on account of the adherent iris and corneal opacity. Enucleation was advised as sympathetic ophthalmia was feared, the inflammation extendiug, without doubt, along the entire uveal tract. The eye was removed shortly afterwards, that is about two years after the contraction of gonorrhceal ophthalmia.
MICROSCOPICAL EXAMINATION.
Sections through the limbus, cornea, iris and ciliary body show evidence of a marked inflamnuition involving all these structures. In addition to the changes in the corneal epithelium, which will be described below, the corneal matrix shows marked sclerotic changes, and numerous large blood-vessels coursing through it. The iris shows an acute inflammation as well as sclerosis, but in the sections examined it is nowhere adherent to the cornea. Between the iris and cornea there is considerable inflammatory exudate. The ciliary body shows marked sclerotic changes. The inflammatory processes, chronic and acute, are much more marked in one side of the eye than in the other.
The epithelial layer of the cornea is markedly thickened, the thickening being most pronounced at the limbus on the less
involved side. For a distance of about 4 mm. from this point towards the other side the epithelium tapers down gradually and almost uniformly to the thickness of normal corneal epithelium. Although there is a slight hyperplasia present in all this area, the cells are larger than normal and there exists a certain dimness of outline in the individual cells, while their nuclei are swollen.
Beyond this point the cells begin to lose their characteristic appearance. At first this is most marked in the basement eel Is ; their approximation is not so jterfect, the intercellular spaces are dilated, the length of the cell is increased ; the nucleus is pushed towards the top of the cell, while its base retains its normal attachment to Bowman's membrane. Here the more superficial layers are not much disturbed, except that the cells and their nuclei are slightly enlarged and the cell outline is not so sharply defined.
As we proceed across the field the above changes in the basement row become more exaggerated ; the cells are drawn out longer and become narrower, while the position they formerly occupied is encroached upon by the dilating intercellular spaces. Their protoplasm stains lighter than normal. The more superficial cells are pushed forward. These changes become more marked toward the left (the more involved) side of the section, apparently due to persistent pressure of fluid. Round and oval vacuoles occupy in places the former sites of cells, now broken down. In some instances they contain broken down cell debris and degenerating nuclei.
These spaces occur for the most part in the basal layers ("Fusszellen " of Rollet and Lott), but are also present in the more superficial ones, a most interesting factor, however, being the manner in which the most superficial layer of cells remains intact under these circumstances. In several instances a vaciiole extends from Bowman's membrane below to this supeificial layer above, and this latter appears to be reinforced by a mass of broken down cell substance forced against its posterior border. Polymorphonuclear leucocytes appear in considerable numbers in the intercellular spaces in the more affected regions of the epithelium. When these spaces or vacuoles are not present the basal row of cells has the appearance of a uniform row of " palisades,"* while the cells above tliem and lying horizontally appear as rows of " arcades."*
Fuchs* observed that in glaucomatous eyes the vacuoles were most numerous at the points of nerve channel entrance into the basal row of cells. This cannot be demonstrated in the present case.
In the substan/ia cornea propria evidences of a most active inflammation are present. Round-cell infiltration is nuuked, with the formation of new blood-vessels in every field. Descemei's membrane for the greater part is intact though most of the cells are flatter than normal. Where it has broken down the sites are marked by the presence of numerous polymorphonuclear leucocytes.
The anterior chamber is filled with the coagulated remains of a thick fluid inflammatory exudate, dotted with mononuclear and polymorphonuclear leucocytes. The iris is gfnerally infiltrated with round cells and polymorphonuclear leucocytes.
Apt terms need by Klebs.
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and in nn-iii tlieie are vast accuniulatioiis cf llit-iii. 'i'lie bloodvessels are enlarged. The tissue elements are considerably broken down and contain ninch free pigment.
As we approach the ciliary attachment of the iris the round cells become more numerous and there is much thickening, due to new fibrous tissue. Schlemni's canal is much reduced in calibre by an inflammatory deposit on its interior, and surrounding it are numerous mononuclear and polymorphonuclear leucocytes. Between the fibres of the ciliary muscle and of the corneal matrix in this region there are deposits of fibrous tissue. These secondary inflammatory alterations are much more marked on the side in which the cedeiiui of tlie cornea is found. To these altei'ations the oedema is probably due.
It seems not improbable that the lymph spaces conducting from the cornea into Schlemm's canal have been occluded either by the sclerotic changes in the tissues, by the accumulation of inflammatory exudate, or by mechanical pressuie.
At any rate the absorption of corneal fluids has been checked in this region. A stasis in this locality would cause accumulation of fluid in the intercellular spaces of the epithelium.
In addition to the occlusion of the channels of absorption it is not improbable that another factor in causing the oedemti has been the severe acute inflammation attacking the cornea and neighboi'ing structures, and thus tending to cause an increased outflow of fluid from the blood-vessels. There is nothing to indicate, however, that the intra-ocular tension was at any time much increased.
In conclusion, I wish to express my gratitude to Dr. C. R. Bardeen for his timely assistance in preparing this article, and to Ur. R. L. Randoli)h for his careful review of the same. To Dr. Heckel of Pittsburgh, I am indebted for the clinical history of the case and for the specimen from which the sections were prepared.
DESCRIPTION OF PLATE.
Fig. 1. Zeiss, ocular 4, objective AA, 65 diameters.
Alcohol fixation, celloidin section, hfematoxylin and eosin stain. The section passes througli the cornea, sclera and iris near the corneal margin. In the corneal epithelium, represented at the right above, may be seen the a-ilematous spaces described in the text. The many blood-vessels passing through the substantia propria show the severe alteration which the
main body of the curiiea has undergone. The ai.terior chamber is filled with an inflammatory exudate. Inflammatory changes in the iris are obvious.
Fig. 2. Zeiss, ocular 4, objective DD, 370 diameters.
Alcohol fixation, celloidin section, stained with Bende's iron hiematoxylin and with congo red. A vertical section passing through the corneal e])ithelium, from a region slightly nearer the centre of the cornea than that shown in Fig. 1. The marked alterations in the epithelial cells, described at some length in the text, are here clearly shown. A few leucocytes appear among the epithelial cells.
BIBLIOGRAPH'y.
I. Arlt: Die Krankheiten des Auges. Prague, 18.55. 3. Archiv fur mikr. Anat., Vol. XXXII.
3. Birnbacher and Czermak: Beitritge znr pathologischen Anatomie und Pathogenese des Glaucoms. v. Graefe's Archiv, XXXII, II.
4. Bizzozero: Ueber den Bau geschichteter Plattenepithelien. Moleschott's Untersuchungen, XI.
5. Pick : Diseases of the Eye.
6. Fridenberg: The formation of Vacuoles in Corneal Epithelium. New York Eye and Ear Infirmary Reports, Vol. VI.
7. Fuchs : Lehrbuch der Augenheilkunde.
8. Fuchs: Ueber glaucomatose llornhauttriibung. v. Graefe's Archiv, XXVII, III.
9. Genersich: Zur Lehre von den Saftkaniilchen in der Cornea. Wiener medicin. Jahrbiicher, 1871.
10. Gruber: v. Graefe's Archiv, XL, IV.
II. Graefe und Saemisch : Ilandbuch der ges. Augenheilkunde, IV.
13. Klebs: Ueber odenialose Verilnderungen des vorderen Hornhautepithels. Ziegler's Beitriige, Vol. XVII.
13. Leber: Ueber die intercellularen Liicken des vorderen Hornhautepithels iin normalen und pathol. Zustande v. Graefe's Archiv, XXIV, L
14. Pfliiger : Zur Erniihrung der Cornea. Klin. Monatsbl. fiir Augenheilkunde, Mar., 1882.
15. Schweigger: Lehrbuch der Augenheilkunde. Berlin, 1885.
16. Smith: Glaucoma, etc. System of Dis. of the Eye. Norris and Oliver, Vol. III.
17. Weichselb.ium : Grundriss der pathologischen Histologie. Wien, 1893.
PROCEEDINGS OF SOCIETIES,
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY. Meeting of November 7, 1898.
I'riinary Focal Hieuiatomyella from Traumatism. — Dr.
Pearck Bailby, New York.
The definition was self-explanatory with the exception of the word primary, which was used by the author as indicating that the hremorrhage was the result of force exerted directly upon the spinal cord without the intervention of a fracture or dislocation of the spine. Primary traumatic hajmatoniyelia is thus differentiated from the haemorrhages which complicate crushes of the cord brought about by compression. After a brief historical introduction, and after expressing the belief
that this affection was more frequent than is generally recognized, the questions of causation, pathological anatomy, symptoms, diagnosis and prognosis were severally considered. With the exception of pistol-shot wounds, sudden flexions and extensions of the neck were the best established causes. The author believed the lesion was produced by an actual stretching of the cord, with resulting laceration of blood-vessels and to a certain extent of centrally situated nerve fibres; he rejected the explanation proposed by Thorbun that a momentary displacement of a vertebra was the immediate causative agent. The pathological anatomy of the condition consists in a focal ha?morrhage confined chiefly to the gray matter always in the cervical or upper thoracic region ; the blood sometimes burrows for considerable distances up and down the cord. The extravasa
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tion on its absorption leaves a cavity which may remain patent or be filled up by new tissue. Secondary degenerations are usually not pronounced. The symptoms are in general those of other spinal cord traumatisms, though usually less severe and less numerous; but the motor and sensory symptoms have distinguishing characters. The distribution of the motor symptoms depends upon the extent and situation of the clot. Tiiere may thus be spinal hemiplegia, or monoplegia, or (probably) brachial diplegia, or paralysis of the legs, or paralysis of b3th arms and legs. The paralysis at first, unless the lesion is very small, is flaccid in all its characters; later it assumes the central neurone type in the legs with places in the arms of peripheral neurone type. The sensory symptoms consist, in addition to pain in the neck, of a dissociated anesthesia, that is, anesthesia for temperature or for pain or for both, with perfect preservation of tactile sensibility. A case was reported in which this peculiar clinical condition was absolutely distinct, biit in which, as shown by subsequent microscopical examination, the blood had exceeded to a certain extent the confines of the central gray niatter of the cord. The sensory anomalies of primary focal haamatomyelia from traumatism are usually transitory, unless the case is exceptionally severe. In reported cases the analgesia has disappeared before the thermoansesthesia.
In the anther's cases thermoanaesthesia was the only sensory anomaly present.
Diagnosis depends chiefly upon this dissociated anajsthesia ; light is further thrown upon it by the transitory paralysis of most muscles and by the general rapid improvement of the patient.
The prognosis is better than for any other form of injury to the cervical region of the spinal cord. Several cases were cited from literature to show how rapid recovery may be. Two personally observed cases were also reported. In one, after complete paralysis of arms and legs, with loss of power of the sphincters, resulting from a diving accident, the patient could use his hands, and walk unassisted up four pairs of stairs, in less than two months; in the other, a man who, as the result of a fall of thirty feet, was completely paralyzed in the legs, with retention of urine, was able to go to work (night-watchman) in two months.
The treatment is the same as for other varieties of spinal cord injuries, except that any operative measures are strongly contraindicated.
Dr. Pkeston. — I have been very much interested in Dr. Bailey's clear presentation of this subject. It is an extremely suggestive paper. As he was reading the paper I could not help wishing I had had this particular knowledge many years ago. It has been my fortune or misfortune to see quite a large number of these cases of spinal injury, for the City Hospital is located in the centre of our city, and many cases of sudden injury are brought in there.
One of the most puzzling questions connected with these cases is that referring to the advisability of surgical interference. I have been always of the opinion that where we can be sure that there is direct injury to the column there should be prompt interference. I can recall now, however, a certain
number of cases in which I advocated opei'ation and where the after results proved that it would have been better not to have opened the column. Again I can recall cases that I am sure would have been benefited by an operation. We had no definite symptoms to decide the question as to whether there was simply this focal injury or whether we had an injury which involved the bones and portions of the spinal cord, particularly the white columns. The hopes that were raised a dozen years ago by surgical exploration of the brain have not been borne out. We have had to limit the sphere of surgical interference, but I think neurologists are now looking strongly to some sort of surgical interference in injuries of the spinal cord. I think, perhajis, there may be some slight predisposing cause here in Baltimore to haamorrhagic myelitis. At any rate we see a large number of such cases. Dr. Osier has just whispered the suggestion that it is due to the smooth pavements of Baltimore.
We can now, after what Dr. Bailey has told us, differentiate clearly between cases of focal hasmatomyelia and cases in which the cord has been injured. The loss of pain and temperature sense and the preservation of tactile sensibility are two valuable points in the diagnosis. He has also given the neurologists help in enabling them to give a favorable prognosis in these cases, which is a boon to men practicing upon a class of cases where few die and none get well.
Dr. Barker. — I am grateful to have had the opportunity of listening to a paper so rich in personally studied matter and first-hand experience.
The difference in the etiology of spinal haemorrhages and of cerebral hemorrhages is obvious from what Dr. Bailey has said. While nearly all spinal haamorrhages are due to trauma, relatively few cerebral hemorrhages are thus produced, the majority of the latter being dependent upon chronic arterial disease. A spinal hemorrhage due to vascular disease is one of the rarest of pathological findings.
If I understood Dr. Bailey correctly he referred in one part of his paper to the possibility of occurrence of an anesthetic area in which no painful sensations resulted on the application of heat, though pain could be elicited by ordinary methods of stimulation. 1 have been convinced myself in the study of sensations that "heat-pain " is due to the stimulation of jjain nerves and not to the stimulation of " temperature nerves," i. e. the warm points or cold points. In areas on the circumscribed area of elective sensory paralysis on my own left arm where pain sensations are the only ones which can be elicited by any method of stimulation, a test-tube heated above a certain temperature, after a certain latent period, will always cause pain not preceded or accompanied by any temperature sensation. The studies of von Frey demonstrate conclusively the existence of points in the skin which when stimulated give rise to painful sensations, but not to thermal or tactile sensations. In the case I have studied all the warm-points, cold-points and pressure- or tactile-points in certain areas are thrown out of function and the pain-points alone yield a response. Ice and heat applied to these areas cause painful sensations, but no feeling of cold or warmth. One interesting feature of the heatpain and cold-pain as studied upon surfaces supplied only with
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pain nerves is tlie latent period of the pain. When one carefully applies a piece of ice or a hot test-tube to such an area he has no sensation at all at first ; only after the lapse of some seconds does any sensation result. There is first disagreeableness which soon goes over into distinct pain. Ordinarily when a hot test-tube is applied to normal skin the part is jerked away quickly. This is due to the fact that there is such violent stimulation of the heat-points that we are warned that if we do not remove the arm pain will result. We say that it hurts, but as a matter of fact we are not hurt but only warned that we shall feel pain unless the heat be removed. The same is the case in applying a piece of ice. If the ice remains in contact long enough we have " cold-pain," but the first effect on normal skin is a violent stimulation of the cold-points with a startling sensation of cold. I have wondered if heat-pain and cold pain are ever really absent in areas where pain-sensations can be elicited by the application of ordinarily painful stimuli, such as pricking with a needle. I am of the opinion that the prolonged contact of ice or hot water would give rise always in such cases to the sensation of pain. May it not be that the existence of heat-pain and cold-pain is often overlooked in cases in which the cold-points and warm-points are thrown out of function. Many, of course, still hold that heat-j)ain and cold-pain are due to over stimulation of temperati;re nerves and not due to the stimulation of specific pain nerve, but this view is irreconcilable with our present physiological and pathological knowledge.
I would add a few words with reference to the relation of hEematomyelia to syringomyelia and central glioma. Since the investigations of Minor, early in this decade, the attention of all neuro-pathologists has been directed towards this dissociation of sensation or elective sensory paralysis in cases of central hsematoniyelia. As Dr. Bailey has said there can be but little doubt in most cases with regard to diflerential diagnosis, for the symptoms follow so directly upon the trauma that one can scarcely make a mistake. The pathology of these cases, however, is somewhat more puzzling than their clinical history. A number of cases have been studied in which in addition to haemorrhage, or the signs of old hfemorrhage, cavity formation with gliosis (or gliomatosis) in the periphery of the cavities has been observed. Some pathologists assert that after haematomyelia not only may partial obliteration of the hajmorrhagic cavities by glia tissue occur, but tliese cavities may become lined later by glia cells and thus give lise to syringomyelia or even be the starting point of a central gliomatosis. Minor goes so far as to suggest that such cavities secondary to hemorrhage may possibly at once or later become connected with the canalis centralis, receive an ependymal lining from this and so give rise to the appearance of a malformation of the cord. One cannot help being somewhat skeptical with regard to such a point. It is certainly not to be forgotten that in so-called gliomata in which the main constituents are cells of the ependymal type multiple cavities are frequently found, and there seems to be a special tendency to haemorrhage in such cases. In a case of this kind where such multiple cavities exist with surrounding gliosis or ependymal tumor formation a slight trauma might produce a hffimorrhage, and the symptoms would be those of hsematoniyelia. Clinically this might
present the typical picture of primary haematomyelia, but pathologically it would have to be considered as hEematomyelia secondary to the new growth.
I would also like to ask Dr. Bailey if he has, in his experience, met with any case of bilateral gummata giving rise to dissociation of sensation of the syringomyelic type.
Dr. Bailey. — Replying to an inquiry from Dr. Osier I would say that I think undoubtedly many of the cases once called concussion of the spine were cases of intra spinal haemorrhage.
In regard to Dr. Barker's inquiries I have never personally seen analgesia in these cases except for thermal stimuli, but I did not examine to see whether after a certain time of application of heat the patient complained of pain. We held the water on for a few seconds only.
As to the ependymal lining of the gliosis that occurs after cavity formation I have only had the opportunity of seeing one case in which I could trace the whole process. The man was an active man and healthy in every other way. In his case there was a large growth in the central part of the spinal cord, but it was in no way connected with the central canal. The central canal is the part of the gray matter that seems to escape most frequently in haematomyelia, and in the case to which I made reference this canal was normal and there were no ependymal cells lining the cavity.
As to bilateral gummata, I have no doubt they could give rise to dissociated ana3sthesia as many other processes do, such as pachymeningitis.
In the cases I have examined the knee-jerk has been absent for two or three weeks, but entirely returned at the end of two months. As to the cause of the absence of knee-jerk I am sure I do not know.
Two Cases of Pylorectomy.— Dr. Finney.
The first case is that of a man about 50 years of age who presented himself at the Hospital on July 15, '98, complaining of distension of the stomach, daily vomiting, and constipation. His family history was negative. For about one year he had noticed a pain in the stomach, accompanied by a full feeling, and had lost weight, falling from 126 pounds to 95 pounds in the course of the year. He began to vomit after eating his meals, and has vomited twice daily about a quart, more or less, of light brown, sour material. He says that he has vomited materifil which he had eaten the day before, or even two days previously. The day before entering the hospital he vomited a little bright red blood.
On examination he appeared rather emaciated, had a temperature of 99.4°, pulse of 62, with a volume full and firm, pupils equal, skin moist and mucous membranes of good color. There was considerable arteriosclerosis. His heart sounds were regular, and there was no murmur. His abdomen was soft and not distended. Waves of peristalsis were seen moving from left to right. To the right and just above the umbilicus a hard mass could be felt, about the size of one's thumb, which moved up and down with respiration. Examination of the contents of the stomach showed no free hydrochloric acid, and microscopically no tumor cells.
The diagnosis of carcinoma of the pylorus was made, and an
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operation advised. He was operated upon July 20th. The stomach was irrigated daily, for a day or two beforehand, and rectal feeding only, for 24 hours previously. A small incision was made under cocaine anesthesia, as I had promised him I would make an exploratory incision first, to find out what the trouble really was before giving him a general anaesthetic. Under cocaine then, I made an incision about 4 inches long in the median line, exposed the tumor so that I could see and feel distinctly its outlines, also an enlargement of some of the mesenteric glands, and thus confirmed our previous diagnosis. Ether was then administered and the operation proceeded with. The median incision was enlarged, and also a lateral one was made through the right rectus. We found a hard, scirrhous mass about the pylorus, which was a little larger than it had appeared through the abdominal wall. This was removed without any particular difficulty except that the duodenum was very adherent to the head of the pancreas, and we had some difficulty in arresting hjemorrhage after its separation. By dividing through the duodenum the growth was removed with a portion, perhaps one-third, of the stomach, which I have here. Several enlarged mesenteric glands were also removed. The stomach was sutured in the usual manner, grafting the duodenum into the stomach after partially closing the cut end. There was no difficulty in doing this. I used the mattress suture of Dr. Halsted, and closed the abdomen without drainage. He made an uninterrupted recovery.
The patient is present to-night, having kindly come from Pennsylvania to attend this meeting. He has gained 30 pounds in weight since July 15th. You may be interested in seeing the man and examining the condition of the wound at present (exhibiting the patient). You will see that the scar is very firm, and there is no weakening of the abdominal walls due to the section of the rectus.
Case II. Case II is that of a man 56 years of age who came to the Hospital on October 12, '98, and was operated upon in the clinic. His family history is also negative. About 4 months ago pain began in the epigastric region, starting first in the left hypochondrium, beginning about one-half hour before meals, and relieved after eating. He never suffered with it directly after eating. It was not much worse when he came to the Hospital than at the time he first noticed it, and now it passed over the whole upper portion of the abdomen. There had been some nausea and vomiting, with rapidly increasing weakness for the past few months. He had lost in weight he thought about fifteen pounds. He looked as if he had lost more than that, as he was rather emaciated. Nothing was made out on physical examination except that in the abdomen to the right of the median line, in the upper umbilical region, there was a slight tumefaction. On turning to the right in the recumbent position this mass moved to the right about 1 cm., and when turning to the left it moved to the left 3 cm. Here is a drawing showing the location of the mass and the relative position before and after dilatation of the stomach..
Analysis of the stomach contents showed no free hydrochloric acid, and a faint trace of lactic acid. This case was also diagnosed as cancer of the stomach, probably of the pyloric end, and involving a portion of the stomach. He was
operated upon October 21st under ether. Incision was made in the median line, the stomach was delivered and packed about with gauze. The adhesions were not so marked as in the other case, although the omentum bothered us considerably by being adherent below, and the larger portion of it had to be ligated and divided. Some glands felt to be enlarged, below the stomach in the omental fold, were removed, I think about four in all. There was no particular difficulty about the operation, the same procedure being employed here as in the other case, with this exception, in the second operation I removed much more of the stomach, taking out at least twothirds, and sutured the duodenum to what was left of the stomach. The growth in this case extended much more along the lesser curvature of the stomach than along the greater, so that I took out an additional V-shaped piece here, and thus facilitated the subsequent suture very much. The procedure is an old one, having been suggested first by Billroth. After suturing the cut edges where the V-shaped piece had been removed, the opening in the stomach was found to match the lumen of the duodenum exactly, and I then had a simple circular suture of the intestine, and made use, in performing it, of the dilatable rubber bags of Dr. Halsted.
The first case made an uninterrupted recovery. He complained of nothing after the operation save hunger, and so bitterly did he complain of this that we gave him some milk thirty hours after tiie operation. The second was one of those unfortunate cases that happen now and then, in which the operation was a great success, but the patient died. The operation was very satisfactory, the enlarged glands we had felt were removed without difficulty, and, as it proved subsequently at autopsy, all the enlarged glands were removed. The case did well surgically, there were no symptoms of peritonitis and no pain, but he rapidly developed a typical pneumonia in the right lung, which extended to the left, and on the fifth day he died. The autopsy showed an extensive double lobar pneumonia.
Cover-slips from the abdomen wei-e negative. There was not a single adhesion between the abdominal wound and the site of operation, and the peritoneal cavity was perfectly dry. It was unfortunate that this man should have developed a pneumonia, as apparently all the growth had been removed.
Dr. CuSHiNG. — One of the most striking features of Dr. Finney's report lies in the closure of the abdominal wound without drainage after a long operation necessarily associated with more or less soiling of the peritoneal cavity. Of course the peritoneum will take care of a certain number of microorganisms provided no nou-absorbable material such as a bit of necrotic tissue or faecal matter is left behind. In these operations high up in the intestinal tract, however, another most important and encouraging factor must be taken into consideration, namely, the organisms or better, lack of organisms, which the peritoneum has to take care of. In Dr. Finney's first case unfortunately no cultures were taken from either diiodenum or stomach. In the last case in which the healing was so perfect and clean, cultures taken from the duodenum at the time of operation remained sterile and cover-slip ])reparations were negative. It is astonishing to consider that the duode
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nil in should be free from micro-organisms especially in a case of this sort where there has existed a condition of chronic disease. My attention was first attracted to this subject a year ago after operating upon a case of perforating gunshot wound of the abdomen in which, though twenty-seven hours after the accident, but a slight degree of peritonitis was present. There were four perforations present in the upper part of the jejunum. On looking over the cases of gunshot wound with intestinal jjerforation which had previously been operated upon in the hospital, I found, strangely enough, that the only ones which had recovered were those of jejunal perforations. Since that time we have been observing very carefully indeed the bacteriology of all cases in which the upper part of the alimentary canal is opened on the oj)erating table and have found the duodenum sterile on several occasions. This I think is an all-important prognostic feature of these cases, and I do not know that it has ever been emphasized before. In conjunction with Dr. Livingood I spent several weeks last spring upon some experimental work with animals which gave us very much the same results as we had observed clinically. It apparently is possible in some instances to render the greater part of the intestinal tract surgically clean before operation, that is, free from pathogenic micro-organisms. I hope soon to publish the results of our observations.
Dr. Cone. — As Dr. Flexner is not here to speak of the pathology of Dr. Finney's cases I might say a word. Most of us have been over the pathology of the last case. It showed only in a few areas the invasive character of the epithelium, but the glands were typically invaded with adeno-carcinoma. The gross appearance of the specimen from the second case was that of scirrhus carcinoma involving nearly the entire circumference of the stomach, showing no ulceration, but the mucosa had been worn off. Frozen sections showed masses of spindle cells and round cells which made us think of sarcoma although it is one of the rarest tumors of the stomach. There were tumors of very few epithelial cells in teased sections.
These tumors of the stomach may be classified as follows : medullary, scirrhus, colloid and diifuse carcinoma. The last case was most interesting because it shows how the stomach may be invaded by a growth that cannot be determined microscopically from an examination of the tumor itself, but one must go further and look at the glands which show typical adeno-carcinoma.
Dr. Finney.— I would like to say a word as to the anesthetic used in these cases. In the last case the patient impressed us as being a poor subject for a long, depressing operation. The operation varies in length from one to three hours, depending upon the difficulties with which one meets, and the rapidity of the operator. A patient who is under an anaesthetic for two hours must of necessity be affected to some extent. It has been proven, first by Dr. Halsted in his breast operations for cancer, that haemorrhage is the prime factor in shock in most cases. That rule holds good in most instances except in opei-ations in the peritoneal cavity. In the latter instance the element of time certainly plays an important jiart, and so if we have a long, depressing operation upon a
patient who has lost many pounds in weight, we have a patient already pulled down, and in a condition to stand very poorly any marked strain. The question of choosing an anaesthetic then becomes a very serious one. If one could do these operations satisfactorily under cocaine it would be a great gain, but when it comes to an operation of this sort where you have to handle the stomach so much, and do so much violence to the solar plexus, so to speak, you must use a general anaBSthetic. I debated in my own mind the relative advantages and disadvantages of chloroform and ether, and decided in favor of the latter. I believe that the ether played a very important part in the production of this patient's pneumonia. We need a new anesthetic for cases of this sort. Neither ether nor chloroform is an ideal aussthetic, particularly for cases of this kind.
The Non-Medical Treatment of Epilepsy. — Dr. Hukd.
Within a few years past a new departure has been made in the treatment of epilepsy. The former treatment by medicine alone has been unsatisfactory, and remedy after remedy has been used and discarded. Surgical operations also have been performed, in some instances with good results, but in a great majority of instances with little benefit.
In epilepsy we do not deal with the epileptic paroxysm alone but with a complexus of symptoms, among which the epileptic convulsion may be regarded as the last of a series of morbid processes.
The majority of epileptics possess an extremely weak nervous system, perhaps inherited, and the individual patient is always unduly susceptible to disturbing influences. It has been known for a long time that the causes of epilepsy varied. In many instances epilepsy has been thought to be due wholly to disturbances of digestion, but it is now pretty evident that we have to deal with a more serious trouble. It is not primary digestion alone but often secondary digestion which is at fault. There is some defect in metabolism as a result of which the system becomes poisoned. The neurotic organization to which I have referred being unduly responsive to the. action of this poison is overwhelmed by it and we have an epileptic paroxysm. It was formerly thought that if some remedy could be found to control the paroxysm, epilepsy was cured, but now we know that remedies which merely control the paroxysm do very little to cure tlie disease. It is like tying the hands of a maniac to cure his excitement. The general eftect of the bromides and of similar remedies has not been to prevent the generation of the poison in the system, but merely to restrain its manifestation in an epileptic attack. Such restraint may be effective for a time, but finally the poison becomes so overwhelming that a paroxysm can no longer be restrained, and a furious convulsion follows which probably equals in force the sum of the minor paroxysms which had been prevented by the remedy. It has been found by experience that the condition of such a patient is worse than if he had more frequent but milder convulsions.
It has been found in institutions for the insane that the effect of large doses of bromide upon insane epileptics lias been to deaden their sensibilities, to increase their growing dementia and to render them more furious and dangerous ; and the
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majority of physicians who have to deal with this class of patients long ago concluded that it was unwise to attempt to cure these patients by remedies which were given to check convulsive seizures.
Recent observations have indicated the character of the poisonous substances which enter the circulation and produce the epileptic seizure. They are probably leueomaines, but their exact relations to the disease have not been fully worked out and much remains to be done to determine the means of preventing the formation of these poisons in the system. There has however grown out of these investigations a system of providing for epileptics which promises much for the future. In this system it is not intended to substitute hygienic and moral influences for medical treatment or to decry medical treatment, but rather to relinquish the idea of depending upon drugs alone in the treatment of epilepsy.
Within the past few years provision has been made in many States for the care of epileptics in large colonies. The epileptic is not a pleasant member of the home circle whether he is sane or insane, and he seldom does well if treated at home in the family, being difficult to control and unable to co-operate in curative measures. In New York, Ohio and to some extent in other States institutions for their special treatment have been started. In the msjority of instances this treatment consists in giving the epileptic the largest possible amount of open-air life and in controlling his diet so that the amount of nitrogenous food may be carefully regulated. It is equally essential that the growing epileptic shall have something to do. It has been fouud that patients fed upon drugs with nothing to do have frequent epileptic seizures, while, if kept employed in the open air the seizures are less frequent. An attempt is now made to give them useful labor every day under medical control with the theory that a physician should in every case prescribe the kind and amount of labor and the time of day it should be performed. Many epileptic patients are prone to seizures immediately after meals, especially if allowed to fall asleep. It is necessary therefore in all matters which relate to the labor of the patient that the medical man shall say when and how the patient shall exercise.
As the result of such treatment patients who have been subject to daily or weekly seizures often without any medicine, go a month, sometimes a year, or longer without a convulsion.
From our present knowledge the best treatment for an epileptic is an open-air life, carefully selected food and a judicious amount of labor.
NOTES ON NEW BOOKS.
Atlas of Legal Medicine. By Dr. E. vohHofmann. Translated by
Frederick Peterson, M. D., and Aloysius O. J. Kelly, M. D.
56 plates in colors and 193 illusirations in black. (TT. B. Saunders,
Philadelphia, 1898.)
The previous volumes of the present series of Atlases have been reviewed in these pages as they have appeared. The series is a very valuable one, and well illustrates the importance of colored drawings in representing natural objects in the domain of medicine. To pathologists, and especially to coroners' physicians, the present volume will be found of service. It is manifestly quite
impossible to do more than draw attention to the salient features of the work, for to do it justice in a review a record of the various medico-legal conditions described would be necessary. The object of the Atlas is to show the appearances met with in organs and the body in general in case of death from violence or unexplained causes, which come under the jurisdiction of coroners or their physicians. As in this country we do not have a specially trained set of legal physicians, the opportunity to become familiar with many of the objects treated of in the volume is open to few ; and therefore as a work of reference in doubtful instances, or as affording an opportunity to siudy the effects of poisons, etc., upon the organs, the Atlas will fulfil a useful purpose.
Annual and Analytical Cyclopaedia of Practical Medicine. By Charles E. de M. Sajous, M. D., and one hundred As.sociate Editors. Volume I. {The F. A. Davis Co., Publishers, Philadelphia, 1898.)
The Annual of the Universal Medical Sciences comes to us now in a new form, that of an Analytical Cyclopaedia of Medicine. The change is explained by the editor, aiid would seem to better fit it for the use of the practitioner of medicine to whom the original "Annual " often failed to give the desire<l information. The general appearance of the pages is somewhat novel, as tlie newer literature upon etiology, treatment, etc., is interpolated at irregular intervals in the general text, occupying a smaller sized type. Thus each subject is treated in a complete fashion as in any modern textbook, and may be read as such by confining the attention to the large type only, while the recent additions to the subject may be obtained in the course of this reading, or separately by consulting the matter in small type. It is expected that the entire domain of medical subjects will be embraced in six volumes. The present volume covers the subjects from "Abdominal Injuiies to Bright's Disease." The list of associate editors embraces some of the best known names in this land and foreign countries.
The Methodist Episcopal Hospital Reports, Vol. I, 1887-1897.
Edited by Lewis Stephen Pilciier, M. D., and Glentworth
Reeve Butler, M. D., (New York: Published by the Hospital,
1898.)
This handsome volume contains a history of the Hospital from its beginning, together with the usual scientific medical reports from the officers of its medical staff. Thelongestof these contributions are those on the several diseases of the female genital organs and on operative methods, by Dr. L.S. Pilcher, on the injuries of the cranium and spine and on appendicitis, by Dr. George R. Fowler, on fracture by Dr. J. P. Mathews ; and there are besides a number of minor reports, all of interest and value. It appears that from the first the surgical side of the Hospital has received the largest patronage — over two-thirds of the total number of patients suffering from diseases requiring surgical relief ; hence the predominance of surgical papers in this volume. The medical side is, however, also well represented by valuable reports by Drs. Butler, Mathews, Shaw and others.
The volume is beautifully printed, and the illustrations are especially good, and even the half-tones are intelligible and useful, which is not always the case in works of this kind. In these as well as in other respects the authorities of the Methodist Episcopal Hospital have set a high standard for their future reports.
The Anatomy and Functions of the Muscles of the Hand and of tlie Extensor Tendons of the Thumb. By J. Francis Walsh, M. D. Essay awarded the Boylston Prize for 1897, Department of Anatomy and Physiology, by the Boylston Medical Committee, Boston, Mass. (Philadelphia: Charles H. Welch, 1897.) The merits of this careful and thorough study of the anatomy of
the human hand are directly evidenced by the fact that it is the
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Boylston Prize Essay of last year. It is a thorough critical study of the gross anatomy of a very important region which can hardly fail to have some practical bearing on some of the surgical questions tiiat may from time to time arise on the musculature of the hand. The theoretical value of such studies is of course beyond question.
Medical and Surgical Reports of the Boston City Hospital. Ninth Series. Edited by Charles F. Folsom, M. D., W. T. Counx-ilman, M. D , and Herbert L. Burrell, M. D. (Boston : Published by the Trustees, 1898.)
About half this volume is taken up with the discussion of diphtheria in some of its aspects, and the papers are of decided value and interest. In Dr. Jenks' study of the nervous system in this disease, tlie microscopic examinations were largely confined to the pneumogastric nerve, though the spinal cord was also examined in some cases and the brain in one or two. It is to be desired that a more thorough investigation of the higher nerve centres should be made in this disease than seems to have been done so far.
The other papers in this volume, are all apparently meritorious, as might be assumed from the names of the editors. Those on formaldehyde as a disinfectant, and on the anaesthetics used in the eye, are among the longest and are of considerable practical interest.
Ill the surgical abstract accounts are given of several cases of foreign bodies in the digestive tract, tliat are of interest in connection with some occasional hospital experiences, and as showing how such bodies are liable to behave under certain conditions. In one case a plate with three false teeth was passed safely in the natuial way; in another a similar plate and teeth lodged in an enlargement of the oesophagus, and was only detected there by the dangerous hemorrage it produced. In still another case a fish bone ulcerated through the peritoneum, causing an extensive abscess between it and the abdominal wall.
The volume is a worthy addition to a valuable series.
Epidemic Cerebro-Spinal Meningitis and its Relations to Other Forms of Meningitis. A Report of the State Board of Health of Massacliusetts. {Boston: Wright & Potter Printing Co., State Printers, 1898.)
This report, by Professor Councilman and Doctors Mallory and Wright, will take rank with the best scientific literature and become an authority upon this disease. It gives a historical sketch of the disorder, and full reports of over one hundred cases; its bacteriology, symptoms and complications; its diagnosis and relations to other forms of meningeal affections. Altogether, the report is one of the best monographs of its kind and compass on a single disease.
The relations of cerebro-spinal meningitis to mental disorders are only very briefly touched upon. Considering the fact that meningitis figures amongst the alleged causes of insanity so frequently, this is a little noteworthy here ; the more so since the authors elsewhere express the opinion that "all infections of the meninges other than by the diplococcus intracellularis are fatal." There are many who will hardly accept this conclusion, but those who do can not avoid admitting that cerebro-spinal meningitis, due to the infection of the diplococcus intracellularis, is one of the more potent and frequent causes of insanity.
The report has a lengthy bibliography attached, but it "contains some omissions," to use a Hibernicism, some of which, it would appear, might have been included, the references certainly being noteworthy enough to have been included in the literature. As, however, the list given only contains those works and articles mentioned in the text, and is not represented to be a complete bibliography of the more important memoirs on the subject, this
hardly calls for criticism. The report itself will most certainly be often quoted in the future and take a most honorable position in the literature of its special theme.
Doctor and Patient: Hints to Both. By Dr. Robert Gaesunq, Vienna. Translated, with the permission of the author, by A. S. Levetds, with a preface by D. J. Leech, M. D., F. R C. P., etc. (Bristol: J. Wright & Co., 1898.)
This is a work of a class that has had several representatives in this country, but it has a special value as showing low nearly alike the professional conditions are in all countries. The Vienna professor might have written his book for an English-speaking public in the first place, and hit nowhere amiss. The fact is, the doctor and patient stand in the same relations to each other over the whole civilized world, and the same ethical queatiot s, troubles and trials exist in one place as well as in another. Here we have in our cities the dispensary evil, and in our country generally too large a freedom of medical education and practice, whidi are only partly peculiar to us; in the older countries also we hear of the overcrowding of the profession, and the medical proletariat spoken of by Dr. v. Ziemssen in a recent address is an evil in Germany as well as here. There they have, moreover, the socialistic unions, cheapening medical practice, as in England. The "Battle of the Clubs" is an apparently perennial question for discussion in the medical journals. Another custom of medical practice which is generally reckoned with us as hardly commendable or profitable to the physician appears, judging from this little work, to be common enough in Austria as to be accepted as perfectly normal, viz. the regular season contract with patients and their families. If tliis is the usual or even common practice it is rather to our European confreres' disadvantage.
The ethical tone of the work is, as might be expected, the very best, and it is one that will be profitable for occasional reference by the old practitioner as well as valuable to the beginner in the medical profession.
A Text-book upon the Pathogenic Bacteria for Students of Medicine and Physicians. By Joseph McFarland, M. D. Second Edition. 1898. 497 pages. 8vo. (W. A. Saunders, Philadelphia.)
We had occasion to review the first edition of this work in August, 1896. In this edition parts have been rewritten and new chapters have been added, which have much enhanced the value of the work. In the light of our present knowledge the omission of cerebro-spinal meningitis under the section on acute inflammatory processes is much to be regretted. In the chapters dealing with general technique, the author at times recommends measures which are now somewhat obsolete, and some proce<lure8 are faultily described. We do not think that the majority of bacteriologists would coincide in Dr. McFarland's remarks concerning the action of light upon bacterial growth, and to many they would seem quite erroneous upon the whole. Contrary to the statement in the book we have invariably found the house-mouse highly susceptible to anthrax ; also the growth of staphylococcus pyogenes aureus is by no means most typical upon nutrient agar-agar, but upon potato, when grown at room temperature. The statement regarding the streptococcus pyogenes and the diplococcus )>neumonije having no growth upon potato, we believe to be exceptionally the case and not the rule. The author's view that the pseudo-diphtheria bacillus is but an attenuated variety of the true bacillus diphtheriae is now considered untenable. Several of these errors were pointed out in a review of the first edition. Until they are corrected the book cannot be entitled to the praise it otherwise might readily command. Tlie arrangement of the book as a whole is good, and the matter of its various sulijects is commemlably planned and dealt with, while its photograjdiic reproductions and general make-up are of a high order of excellence. N. ^IacL. H.

Revision as of 14:51, 16 February 2020

DEVELOPMENT OF THE INTERNAL MAMMARY AND DEEP EPIGASTRIC ARTERIES IN MAN

Mall FP. Development of the internal mammary and deep epigastric arteries in man. (1898) Johns Hopkins Hospital Bulletin 9: 232.

By Franklin P. Mall.

(From the Anatomical Laboratory of the Johns Hopkins University .)


The great importance of the fact that the main arteries of the vertebrates arise directly from the aortic arches has been shown repeatedly in ontogenetic and phylogenetic studies. Furthermore, it gives us a scientific basis for the explanation of the numerous variations which may occur while this simple system of arteries is being transformed into the complex system as found, for instance, in man.

While the modification of the aortic arches is taking place, certain arteries become larger, others disappear, while in others tlie direction of the circulation is reversed. The laws governing these changes have been discussed extensively by Thoma in his numerous communications. It is the law of use and disuse expressed in this instance by rapidity. For a given vessel at a given time in its development there is a certain rapidity of circulation through it at which it ceases to grow. If the rapidity of the circulation is increased the vessel becomes larger ; if it is diminished the vessel becomes smaller ; if the circulation comes to a standstill the vessel disappears altogether. This law is constantly at work throughout development in the grown animal and in all pathological changes. It does not appear to govern the firstgrowth of the capillaries but itgoverns the growth of the vessels after the circulation in them is once started.

Any one who has studied the growth of the blood-vessels extensively in living animals as well as in fixed preparations is well aware of the fact that blood-vessels are constantly being formed and destroyed. This process is so extensive that at almost any stage of the development of an animal we may safely say that more blood-vessels have disappeared than are present at that time.

With the above ideas clearly in view, I have studied the extension of the blood-vessels into the body- walls of the embryo to see whether or not some secondary system, regular like the aortic arches, appears to be subsequently converted into the


main arteries of the body- walls and the extremities. That the vertebral artery is formed by the union of a number of branches from the descending aorta has been shown by His,* by Froriepf and by Hochstetter.J These branches are the segmental arteries from the aorta while it is still in the branchial region. The aorta soon shifts away from the branchial region with the bending of the head and the development of the neck. While this is taking place the segmental arteries unite at their distal ends to form the vertebral artery while the communicating branches are gradually broken off as shown in Fig. 1, V, from a human embryo of the fourth week. This process continues down to the seventh cervical segmental artery, where it ceases. At this point the subclavian artery arises, Fig. 1, S, as shown by Hochstetter. From now on for a few segments the process is very diflBcult to follow, but further on throughout the thoracic region of the embryo the process is simple. This is easily accounted for by the perfect segmental arrangement of this portion of the body throughout its development.

There are, however, two other sets of segmental arteries in the thoracic region of the body which appear before this set is formed and gives rise to the arteries of the body-walls. The first set is already well developed in embryos at the end of the second week.§ They arise from the aorta and pass immediately to the umbilical vesicle, there to break up into a plexus which is collected by the omphalo-niesenteric veins. Soon these arteries disappear and the omphalo-mesenteric artery takes their place. These vessels are of course on the mesial side of the ccelom.


Hi8(W.) Anat. mensch. Embryonen. III. Zuf Geschiehte der Organe, Leipz., 1885.

fFroriep (A.) Arch. f. Anat. u. Physiol., Anat. Ablh., Leipz., 1SS6, S. 69-1.50.

t Hochstetter (F.) Morphol. Jahrb., Leipz., Bd. xvi, 1890.

? Mall (F. P.) J. Morphol., Bost., Vol. xii, 1896-7, Fig. 16.


September-October, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


233


Before this first system has disappeared, and before the permanent intercostal vessels have appeared the second set of segmental arteries arises from the descending aorta, passes on the lateral side of the ccelom into the menibrana reuniens, as is indicated to us by a figure given by von Kiilliker,* as well as by the description of His.f Von Kiilliker pictures a cow's embryo with the whole membrana reuniens filled with a minute plexus of veins which radiate from the myotomes towards the umbilical cord, while His describes this same region in the human embryo as filled with branches of the umbilical vein which empty into the sinus reuniens above, and into the umbilical vein below. According to His's description they arise when the communication between the umbilical veins and the sinus reuniens is severed. Although the picture given by von Kiilliker does not correspond with His's description it does not contradict it, nor is it peculiar to the cow's embryo. I have in my collection a well-preserved human embryo (No. LXXVI), in which the membrana reuniens is filled with a plexus of veins much like



Fig. 1. — Arterial system of a humau embryo four weeks old (No. II). Enlarged 10 times. F, vertebral artery; P, pulmonary artery ; C, creliac axis; S, subclavian artery ; 4, fourth dorsal seijmeutal artery.

that in the cow's embryo. The specimen was taken from the uterus seven hours after the death of the woman, and without opening, the ovum was hardened in absolute alcohol. All the vessels down to the capillaries are filled with blood, thus making it an excellent specimen for the study of the blood-Tessels. It represents a stage somewhat more advanced than the one pictured by von Kiilliker, as the plexus of veins does not cover the whole membrana reuniens. The ventral wall over the heart near the liver contains no vessels, while the membrana reuniens covering the upper end of the heart is filled with a plexus of vessels which communicate with the capillaries of the mandibular arch. ., There is an extensive plexus through the arm and lateral body walls which extends through the menibrana


von Kolliker (A.) Grundrisa der Eutwicklungsgeschichte des MenschenundderhiJherenThiere. 8°. Leipzig, 1880. S.103, Fig. 85.

fHisCW.) Anatomie menschlicher Embryonen. Ill, Zur Geschichte der Organe. Leipzig, 1885, 8°. S. 206, also Fig. 130,


reuniens covering the liver, and finally encircles the cord and communicates with the umbilical veins.

The specimen just described is about 22 days old and, although I have six other good embryos between 14 and 28 days old, I find no such plexus in the membrana reuniens, although in all but one of them (14 days) the arm shows a rich plexus of capillaries filled with blood. In stages older than four weeks I find no blood-vessels in the membrana reuniens with the exception of that portion encircling the cord, where there is a rich network of veins. Although I have a number of excellent specimens of five or six weeks, the membrana reuniens over the heart and liver contains no blood-vessels until it is invaded by the ventral plate, which is accompanied by the development of the intercostal vessels. In pigs' embryos this extensive membrane is also free from veins, with the exception of the zone encircling the cord, which again has a venous plexus more marked, however, than in the human embryo.

It appears, then, that during the third week of development, while the umbilical veins still empty into the sinus reuniens, an extensive plexus is formed throughout the greater extent of the membrana reuniens, which receives blood from the aorta on its dorsal side, and empties it into the umbilical vein on its ventral side. As the umbilical vein changes its position to enter the liver, this circulation through the membrana reuniens is broken up as the much earlier circulation through the umbilical vesicle was broken up.

The earliest collecting vein for the descending aorta is the omphalo-mesenteric vein ; next, it is the umbilical vein, and finally, when the abdominal walls are comjileted, it is the cardinal. This in turn is partly converted into the vena cava inferior.

The permanent arterial system is already well outlined in embryo II (Fig. 1). The aortic arches and segmental arteries are sufficiently well marked to permit one to number them. The vertebral artery is in process of development, it being formed by a union of a number of segmental arteries, as shown by His, by Froriep, and by Hochstetter. The seventh cervical segmental artery gives rise to the subclavian artery. The lower cervical, all the dorsal and lumbar segmental arteries, are concerned in the development of the thoracic and abdominal walls. Fig. 1 illustrates the extent of the arteries. It shows a simple arrangement from the vertebral to the hypogastric artery. The lower lumbar arteries are not shown. A section of this embryo is given in Fig. 2. It shows the relation of a segmental artery to the myotome. The segmental arteries supply primarily the spinal cord and ganglia by two groups of branches, one near the middle line and one more lateral. A more ventral group of segmental arteries supplies the Wolffian body. The blood from all these groups of arteries is collected by the cardinal veins.

The lateral group gives rise to the intercostal arteries by first supplying the myotome, and, as this grows into the membrana reuniens by a process of budding, the vascular loop follows it. In so doing the loop is first on the dorsal side of the sympathetic and finally on its lateral side, thus making the sympathetic cord cross the intercostal arteries and veins on their ventral side, as is the case in the adult.

No sooner has the vascular loop extended to the lateral side of the sympathetic cord than it begins to anastomose with


234


JOHNS HOPKINS HOSPITAL BULLETIN.


fNos. 90-91.


neighboring segmental loops, as single vessels near the subclavian and hypogastric arteries, and as a plexus midway between these two. Tliis gives us at tliis early period a complete lateral anastomosis from the subclavian artery to the femoral, as Fig. 3 shows. It remains only for this system to shift around towards the median line with the muscle, nerves and ribs to form the condition of things as found in the adult.



Fig. 2. — Section through a human embryo lour weeks old (No. II). Enlarged 55 times. 4, aorta ; FW, foramen of Winslow ; MB, membrana reuniens; L, liver; R, heart.

Fig. 3 shows that the upper and lower segmental arteries of the series do not correspond at this early time with the same in the adult. Above, the superior intercostal is missing, while below, there is only a small fourth lumbar artery present, and it arises from the middle sacral. Iliolumbar and circumflexiliac arteries are altogether wanting, and I should judge from the relation of the arteries in this embryo, that the arch formed by the iliolumbar and circumflex-iliac is of secondary origin and has nothing to do with the segmental arteries. That they form anastomoses with the lower lumbar arteries in the adult can be explained in other ways.

The hypogastric artery is present long before the segmental arteries are formed near its junction with the aorta, and on this account we can no more call the trunk of the common iliac artery segmental than we can apply the same term to the


descending aorta. We can only locate its origin in the neighborhood of the fourth lumbar artery.

Hochstetter has settled definitely that the subclavian is a branch from the seventh cervical segmental artery.* Between the seventh cervical and the third dorsal we have three segmental arteries. In Fig. 1 the segmental arteries in this region are all simple with the exception of the seventh, which sends a large branch into the arm. From this stage to the one pictured in Fig. 3 there is a jiimp, but in it we see the intermediate stage between Fig. 1 and the adult.



Fig. 3. — Arterial system of a human embryo six weeks old (No XLIII). Enlarged 5 times.

All of the arteries below the vertebral are destined to pass behind the sympathetic, and it is excluded only on account of its direction. In Fig. 3 the eighth cervical segmental passes on the ventral side of the nerve, which shows conclusively that it must either be a new artery or a secondary connection between the eighth segmental and the subclavian. Since the first and second intercostal arteries pass behind the sympathetic in this embryo and in front of it in the adult, we must accept Hochstetter's opinion that the superior intercostal is formed by secondary connections between the upper intercostals and the subclavian. If the old connection remains, it forms the arteria aberrans.

I stated above that the sympathetic lies in front of the subclavian, while in the adult it lies in a great part behind it. Hochstetter explains this change of position by a wandering of the trunk of the artery through the group of embryonic nerve cells. In earlyembryos the sympathetic system resembles a group of sprouts from the segmental nerves which cross the segmental arteries, and the sympathetic cord is of secondary formation. This cord grows very rapidly during the fifth and sixth weeks, to form a great mass of cells extending from the vagus gang


Hochstetter numbers the segmental arteries to correspond with the vertebrK above them. Throughout I number the arteries with their .accompanying nerves. He states that the subclavian arises from the sixth segmental, this being the same artery that I call the seventh cervical segmental.


September-October, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


235


lion to the adrenals, connecting all of the branches with the segmental nerves to make of them rami conmiunicantes. This all goes on hand in hand with the descent of the heart into the thorax. At the same time the arm is rotating towards the ventral median line, and drags with it the subclavian artery. In so doing the subclavian is dragged into the sympathetic cord in its earliest stage, thus allowing the greater portion of the cord to be developed on its dorsal side. The portion of the sympathetic which from the first lies on the ventral side of the subclavian becomes the ansa subclavia.

The descent of the heart into the thorax on the inside with the descent of the arm over the clavicle on the outside of the body causes great tension on the upper intercostal arteries, and favors the new formation of blood-vessels in a more direct line. This is the reason why the main branch of the superior intercostal is a secondary and direct artery from the subclavian.

The simple diagram, Fig. 4, shows the origin of the main ai'teries of the trunk from the aortic arches and segmental arteries. This compared with Figs. 1 and 3 will explain itself. In the diagram the vessels which remain are black ; those which disappear, outlined; and those new formed, striated.

Resume : — While the aortic arches are forming, the arteries arising from the descending aorta pass on the mesial side of the coelom to the umbilical vesicle, and the blood passing through them is collected by the omphalo-mesenteric veins. Soon the segmental arteries arise, unite and shift backwards in the head region to form the vertebral artery. In the trunk they also unite within the lateral body-wall to form the internal mammary and deep epigastric arteries. Thisanastomosing arch, lying immediately below the tips of the ribs and the rectus abdominis muscle, wanders with them to the ventral middle line, the commrinicating branches forming the intercostal arteries. The whole course of the anastomoses between the tips of the segmental arteries takes on in its wandering the shape of the letter


Z (Fig. 4), the upper angle marking the origin of the subclavian. With the rotation and descent of the arm the subclavian is dragged partly through the sympathetic cord ; the origin of the superior intercostal is shifted, by the formation of a new anastomosis, from the dorsal to the ventral side of the sympathetic cord.



Fifi. 4. — Diagram to show the development of the arteries of the trunk from the aortic arches and segmental arteries. The arteries which remain are black; those which degenerate are outlined; those newly formed are striated. /. C, internal carotid; E. C, external carotid; J?. A., bulbus aortae ; P., pulmonary artery; A. D., descending aorta; v., vertebral; S., subclavian; F., femoral; C, umbilical; 7, seventh cervical; 3 and 12, third and twelfth dorsal.

The first vein collecting the blood from the abdominal aorta is the omphalo-mesenteric ; next the umbilical, and finally, the cardinal assumes this function.


TWO INSTANCES IN WHICH THE MUSCULUS STERNALIS EXISTED. WITH OTHER ANOMALIES

Henry A. Christian.


ONE ASSOCIATED


(From the Anatomical Laboratory of the Johns Hopkins University.)


During the past winter, two specimens of the musculus sternalis were found in the dissecting rooms of the Anatomical Laboratory of the Johns Hopkins University, and at the suggestion of Dr. Mall I make the following report of them. Both specimens occurred double in well developed white, male cadavers.

That the simple report of such anomalies can have little value in itself, is fully recognized ; but by recording such cases material will be accumulated, from which in the future generalizations can be drawn and perhaps some light thrown on the origin of such muscles as well as of the general body musculature. Realizing this I report the following two cases, which have perhaps an additional interest in that each represents a distinct form of this anomaly and one is further associated with a series of variations confined to the regions from which the sternalis arises.

Specimen I. — The M. sternalis is well developed on both right and left sides. Unfortunately, however, an incomplete autopsy has partially mutilated the muscle of the right side, thus somewhat obscuring its true relations. However, as seen, the two muscles appear symmetrical and about equally developed. As shown in (Fig. 1) these supernumerary muscles have their origin in part by tendinous fibres arising from the lower two-thirds of the manubrium sterni medial to the origin of the M. pectoralis major, in part by fibres continuous with the tendinous attachment of the sternal portion of the M. sternocleido-mastoideus. The larger number of the fibres arising from the tendon of the M. sterno-cleido-mastoideus cross to the tendon of the M. sternalis of the opposite side, those from the right side passing ventral to those from the left, while a part are continuous with the tendon of the same side. The tendon thus formed continues to the second intercostal space, where the muscle fasciculi begin and soon spread out into a fiat thin muscle about three centimeters in breadth. This muscle, slightly increasing in breadth, continues down to the fifth intercostal space, where it ends by an insertion into the fascia covering the M. rectus abdominis, a little below its point of origin. In its course the M. sternalis lies over the sternal origin of the M. pectoralis major and receives its nerve supply from a branch (anterior cutaneous) of the III intercostal nerve, which perforates the M. pectoralis major and becomes lost in the substance of the M. sternalis.

Specimen II. — On the right side the muscle arises from the tendon of the M. steruo-cleido-mastoideus and the thick fascia over the sternum (Fig. 2), extending as low down as the second rib. In addition a fasciculus arises from the second rib. This smaller fasciculus joins the main muscle on its lateral side in the region of the fourth rib. The main tendon becomes muscular at the third rib, from which place it continues down to be inserted into the fifth rib about three cm. from the sternum. In the third intercostal space this muscle receives a very minute filament from the anterior perforating cutaneous branch of the intercostal nerve, and also a larger twig from the outer cord of the brachial plexus. This latter nerve may be traced for 6 cm. running on the M. pectoralis major. It then pierces the M. pectoralis major over the third rib to continue upward between the M. pectoralis major and M. pectoralis minor to the upper border of the latter, where after passing beneath the acromial branch of the acromio-thoracic artery, it ends by joining the outer cord of the brachial plexus.

On the left side a much smaller fasciculus arises from the fascia over the first intersjiace. This soon becomes muscular, spreading out into a very thin muscle, which is inserted into the fifth rib. The nerve supplying this muscle can be traced to the anterior thoracic nerve, having a very similar course to that of the nerve supplying the muscle of the right side.

The musculus sternalis was noted by Cabrolius in 160i, and first accurately described by Du Puy in 1736. From the time of Du Puy down to the present, literature furnishes descriptions of about 175 well authenticated cases — a number apparently sufficient to enable us to safely generalize.* Unfortunately, however, none of these early descriptions note the


•The following will show the relative frequency of occurrence of this anomaly :

Wood 7 examples in 175 cadavers.

Turner 21 " " 650 "

Gruber 5 " " 95 "

Macalister 21 " "350 "

Le Double... 33 " " 722

Christian 2 " " 70 "

Total 89 " " 2062

About i\ per cent.


innervation. Although Hallet (1848) reported a case receiving its nerve supply from the III, IV and V intercostal nerves, and Malbranc (1876) by electrical stimulation on living subjects found a M. sternalis supplied from the intercostals, and another from the anterior thoracic, Cunningham was the first to fully recognize the value of the nerve supply in studying the origin of this muscle. This view is fully supported by recent studies in comparative myology as well as by the study of the development of the skeletal muscles. This information being recent the earlier writers make no mention of the nerve supply, and their reports are, from our present point of view, of scarcely more than historical interest, showing only the various forms that may occur. Since it appears that " all of the muscles arising from a myotome are always innervated by branches of the nerve which originally belonged to it" (Mall), it is evident that the origin of a muscle variation can only be studied to advantage when its nerve supply is given. Keviewing the literature from this standpoint I find that in but eighteen instances the nerve supply of the M. sternalis is given. To these I add two, making twenty in all, as shown in the accompanying table.

Can we infer anything as to the origin of this anomaly from these twenty specimens tabulated below ? That there have been many views as to the origin of this muscle, is shown by the various names (M. sternalis, M. presternalis, II. episternalis, M. sternalis brutorum, M. rectus thoracicus, M. rectus thoracis, M. rectus sternalis, M. accessorius ad rectum) which from time to time have been applied to it. The main hypotheses which have been advanced regarding the origin of this muscle are as follows :

(a) It is an upward extension of the M. rectus abdominis.

(b) It is a downward extension of the M. sterno-cleidomastoideus.

(c) It is a remnant of a panniculus carnosus and to be associated with the platysma myoides in man.

(d) It is an aberrant portion of the M. pectoralis major.

In 1876 Bardeleben concluded from the standpoint of morphology that not one but several different muscles had been described under the name of M. sternalis, and that of 130 cases, which he tabulated, 7 per cent, were varieties of the M. rectus abdominis, 31 per cent, of M. pectoralis major, 55 per cent, of M. sterno-cleido-mastoideus and 6 per cent, skin muscles.

Of the earlier cases reported, it is possible that some may have been genuine cuticular muscles, but that a muscle, which we would now class as M. sternalis, could have such an origin is not possible since it lies in a plane deeper than the platysma myoides, the representative of this class in man. Further to be an aberrant portion of this cuticular muscle, it should be innervated from above the brachial plexus, a condition which we have not as yet found to exist. That it is not a strictly downward extension of the M. sterno-cleidomastoideus, though the majority of the muscles are connected by their tendons of origin with the M. Sterno-cleido-mastoideus, we conclude from the fact that it does not have a similar nerve supply.


TABLE GIVING THE ORIGIN, INSERTION AND INNERVATION OF THE MUSCULUS STERNALIS

Observer.


side.


Fick,


R.


A. A. VI


S. 601.



2. Fick.


3. Fick.


4. Bardeleben,

A. A. IIIS. 324.

5. Bardeleben.


6. Bardeleben.

7. Bardeleben.

8. Bardeleben.

9. Bardeleben.

10. Bardeleben.

11. Bardeleben.

12. Shepherd,

Jour. Anat. and Phys. XIX-p.311.

13. Shepherd.


14. Shepherd.


20.


Wallace, Jour. Anat. and Phy. XXI-p. 153.

Christian, Specimen I.


Christian. Sj)ecimen 11.


R.


(R.


\ R.


\ R. ( L.


(?) L.


(L. I ! R.


15. Shepherd.


L.


16. Shepherd.


(L.



i R.

\


17. Shepherd.


(R.


(R. 1 L.


u.


Origin. Tendons of steruo-mastoid on both sides and upper digitations of pectoralis major on both sides.

Digitations of pectoralis major by means of two horizontal tendons to right and left at upper edge III rib.

Tendon left sterno-mastoid, few fibres from tendon right sternomastoid, manubrium sterni and upper digitations of pectoralis major of both sides.

Manubrium sterni and upper digitations of pectoralis major of both sides.


Tendon sterno-mastoid.


Right tendon sterno-mastoid. Both tendons of sterno-mastoid.

Right tendon sterno mastoid.

Manubrium sterni. Manubrium sterni.

Fascia of pectoralis major at II rib and left sterno-mastoid.

Right sterno-mastoid and some fibres from left pect. major.

Manubrium sterni.

Manubrium sterni.

Both sterno-mastoids and right pectoralis major.


Sterno-mastoid.

Sterno-mastoid and sternum opposite II and III rib.


Sternum opp. II rib.

Sterno-mastoid and right pector.

Pect. major over manubrium

sterni. Pect. major over manubrium

sterni.

Manubrium sterni. Manubrium sterni.


Right tendon sterno-mastoid and few fibres from left pectoralis •major.


Manubrium sterni and both tendons of sterno-mastoid.

Manubrium sterni and both tendons of sterno-mastoid.

Tendon of sterno-mastoid, fascia over manubrium sterni and a small fasciculus from II rib.


Fascia over I interspace.


iQsertlon. Rectus sheath at VI and VII ribs, digitations of ext. oblique arising from V rib and from fascia over sternum at level V rib.

Rectus sheath at VI and VII ribs and fascia of lowest digitations of pectoralis major.


Rectus sheath at V and VI ribs and fascia of pectoralis major and fasciculi to III, IV and V


Rectus sheath at VI rib, and a deeper layer to V rib and intercostal membrane between V and VI ribs.

Rectus sheath at VI rib and two thin fasciculi to left pectoralis major.

Rectus sheath at VI rib. Rectus sheath at VI rib.

Rectus sheath at VI rib.

Rectus sheath. Rectus sheath.

Rectus sheath at V rib.


Rectus sheath.

Rectus sheath.

Rectus sheath.

IV costal cartilage, border of sternum opposite V and VI ribs and aponeurosis of ext. oblique.

Ill costal cartilage and border of sternum.

Fasciculus into lower segment pectoralis fasciacontinuing with fibres of pector., lovcer end of sternum and ensiform cart.

Aponeurosis of ext. oblique.

III costal cartilage.

IV costal cartilage and fasciculus into fascia over pectoral is major.

A slip to fasc. over pect. maj. and a second to same lower down.

Pectoralis major and sternum opposite IV costal cartilage.

One fasc. to III cost, cart., a second to lower sternum and third to fasc. over pect. major.

Ill, IV, V and VI costal cartilages and border of sternum.


Rectus sheath at V rib. Rectus sheath at V rib.

V costal cartilage.


V' costal cartilage.


Remarks. Intra vitam contracted with sterno-mastoid inraisinghead.


Motion with sterno mastoid observed.


Nerve Supply. Ill and IV intercos.


IV intercos.


II, III and IV intercos.


Ill and IV intercos.


II and III intercos.

II and III intercosII and III intercos.

II intercos.

II intercos.

II intercos.

III intercos.

Ill intercos.

Ill and IV intercos.

Ill (?) intercos.

Int ant. thoracic. Anenceph.

Ant. thor. (?) Ant. thor. (?)

Int. ant. thor. and III intercos.

Int. ant. thor.

Int. ant. thor.

Int. ant. thor.

Int. ant. thor. Int. ant. thor.

Ext. ant. thor.

Ill intercos. Ill intercos.


Branch from Brachial plexus and a small twig from intercos.

Ant. thoracic.


Between the two remaining hypotheses there has been much discussion. Bardeleben advanced the theory that it belonged to the same plane of muscles as the M. rectus abdominis and M. sterno-cleido-mastoideus, and Testut the theory that it represents a connecting link between the M. obliquus abdominis externus and M. sterno-cleido-mastoideus, a condition normally found in the snake. However, Le Double claims that this latter condition does not hold and that the muscle found in the snake is represented in man by a deeper layer. It is probable that there is no exact analogue of this muscle in the lower animals. In some animals, as the Armadillo, beaver and Echidna the M. sterno-cleido-mastoideus extends down on the sternum (Turner) bxit not so far as the VI rib, and there is no connection with the M. rectus abdominis, which lies in a deeper plane. In all cyano-morphous primates (Keith) a M. supracostalis anterior occurs which is a digitation of the M. rectus abdominis arising from the I rib, but this lies beneath the M. pectoralis major. However there can be no doubt that Bardeleben was justified in his conclusion that a close relationship exists between the M. sternalis and the M. rectus abdominis since he and others have reported undoubted cases where the M. sternalis received its nerve supply from the intercostal nerves in a manner similar to the M. rectus abdominis.

This view of Bardeleben was generally accepted until P. S. Abraham reported some cases in anencephalic monsters, receiving nerves from the brachial plexus through the anterior thoracic branches. Soon after this Cunningham reported similar cases from adult cadavers. Such a nerve supply suggested a close relationship with the M. pectoralis major and from the fact of the long course of the nerve through and over the M. pectoralis major and from the recurrent course of many of the lower anterior cutaneous branches of the intercostal nerves perforating the fascia beneath the M. sternalis to run around the inner border of this muscle, it was concluded that it is an aberrant portion of the M. pectoralis major which had rotated inward and downward to this present position. This conclusion seems to be fully in accord with the facts and to be justided by the nerve supply which we regard as the link between present position and the myotome from which it arose. That this muscle is really often innervated from the brachial plexus is further shown by the contraction of the M. sternalis when the brachial plexus is electrically stimulated.


Here then we have two views as to the origin of this muscle, conflicting but both apparently well justified. Can these views be in any way harmonized ? From the twenty cases tabulated above it is readily seen that these muscles divide naturally into two classes, one with a fixed insertion into the middle ribs or margin of the sternum and supplied by nerves from the brachial plexus, the other with a less fixed insertion into the sheath of the rectus and a nerve supply from the perforating branches of the intercostal nerves, the origin of the two classes being very similar. From this we conclude that in the musculus Sternalis we have a muscle functionally always the same — probably antagonistic to the triangularis sterni— but that we have included under one term two distinct muscles, one closely related to the M. rectus abdominis, and the other an aberrant portion of the M. pectoralis major, the former supplied from the intercostal nerves and arising in the embryo from thoracic myotomes, the latter supplied from the brachial plexus and arising from cervical myotomes. Therefore, from the standpoint of innervation and development we agree with the results obtained by Bardeleben that the name M. sternalis has been used as a general term and that it should be reserved for those presternal muscles associated with the M. pectoralis major, while the name M. rectus thoracis should be applied to those related to the M. rectus abdominis.


The cadaver from which specimen No. 1 was taken showed a number of additional muscle anomalies in the region of the course of travel which must have been followed by M. sternalis in its development. When one sees a marked anomaly he should look for and will frequently find associated variations. These may indicate the forces at work to produce variation, and for this reason I enumerate those which accompanied Specimen I.

Mnsadus deido-hrjoideus. — A M. cleido-hyoideus (Fig. 3) is found on the left side, occurring with no variations in the M. sterno-hyoideus, M. sterno-thyroideus or M. omo-hyoideus. It occurs as a thin narrow ribbon of muscle fibres more delicate than the M. omo-hyoideus. It arises from the body of the hyoid bone just above and overlapping the external third of the M. sterno-hyoideus and internal half of the M. omo-hyoideus. From this origin it passes downward and slightly outward to be inserted into the clavicle just posterior to the clavicular insertion of the M. sterno-cleido-mastoideus. Just before reaching the clavicle the muscle spreads out fan-like to be inserted by an aponeurosis about twice the breadth of the muscle and extending along the clavicle from a little internal to the middle point of the insertion of the M. sterno-cleidomastoideus to a point about one cm. external to its insertion.

Quite frequently the M. omo-hyoideus gives off a slip to be inserted into the clavicle and consequently this muscle may be regarded as an aberrant portion of the M. omo-hyoideus here entirely split off except at its very origin. Its nerve supply is apparently the same as that of the M. omo-hyoideus, a fact supporting this view of its histogenesis.

M. sterno-thyroideus. — On the left side the M. sterno-thyroideus is normal as to its size and attachment. The muscle of the right side is fully twice as broad as that of the left and somewhat thicker. Its origin from the sternum is normal. Its insertion is by three heads, each more or less distinct. Of these the inner is inserted as usual on the inferior surface of the oblique ridge of the thyroid cartilage and represents in size and insertion almost the normal muscle. The middle head continues up closely associated with the outer border of the M. thyro-hyoideus, which latter is somewhat narrower than the one of the opposite side. Most of the fibres of this head are inserted into the anterior inferior and middle border of the hyoid bone, while a few are inserted into the middle jiart of the superior border of the thyroid cartilage. The outer head consists of a distinct ribbon of fibres running up to be inserted into the deep cervical fascia and sheath of the carotid artery intimately blending with these structures. The main part of the muscle is supplied by a branch from the hypoglossal loop, while the middle and outer heads receive fibrils from a branch of the hypoglossal nerve given off above that to the M. thyro-hyoideus.


Fig. 1.— Sketch sliowiu!;- the nttiiclinient of tlie M. steniali: in Spefimei] No. I.


Fig. 2. — The attachment of the M. sternalis in- Specimen No. II.



Fig. 3.— The neck of Specimcu I, to tlie .M. cleido-hyoiilens to the clavicle.



Fig. 4. — The axilla of Specimen No. I, to show the slip from the M. latissimus di>rsi to thi' pcctoralis nn)jor.


Arising on the right side from the tendinous portion of the M. digastricus, where it is held down to the hyoid bone by a strong loop of fiiscia, is found a small muscle about one cm. wide, nearly cylindrical in shape and running downward and outward around the larynx for about 6 cm. to be inserted into the fascia about the cornicula laryngis (cartilage of Santorini). Its nerve supply consists of a fine fibril arising from the hypoglossal nerve.

M. trapezius. — The M. trapezius of the right side gives off a fasciculus about 5 cm. wide and 1.5 cm. thick which is inserted into the clavicle at the inner part of its middle third just external to the origin of the clavicular portion of the M. sternocleido-mastoideiis. This fasciculus extends upward to join the anterior border of the main portion of the M. trapezius about 10 cm. from its insertion into the occipital bone. No special distinct nerve supply could be found for this fasciculus.

M. latissimus dorsi. — On eacli side of the subject the M. latissimus dorsi (Fig. 4) possesses an accessory tendon of insertion. The larger normal tendon passes as usual beneath the axillary artery and brachial nerves while the accessory tendon passes over, thus forming an arch for the nerves and vessels. The regular head is inserted into the bicipital groove of the humerus while the accessory one is inserted along with the tendon of insertion of the sternal portion of the M. pectoralis major into the anterior bicipital ridge. The tendinous fibres of this latter are intimately associated with the pectoral tendon for about 2 cm. and then separating pass down as a rounded tendon to join the muscle fasciculi which come off from the main muscle about 6 cm. from its humeral insertion. The accessory head thus formed is about one-fifth the size of the other tendon, which is normal and 7.5 cm. in length.

The two heads form a triangle with the long and short heads of the M. biceps and M. coraco-brachialis as a base. Through this pass the axillary artery and vein, the median, musculo-spiral, ulnar, internal cutaneous and lesser internal cutaneous nerves. So far there is almost perfect symmetry in these structures on the two sides of the cadaver, but the nerve supply to each head is apparently different, though the ultimate origin of the individual nerve fibres from the cord may possibly be quite the same.

The accessory head of the M. latissimus dorsi of the left side is supplied and apparently solely supplied by a rather small nerve entering the muscle substance. This can be traced up to the lower border of the M. pectoralis minor, there to join a nerve which is unmistakably the internal anterior thoracic, since it supplies the M. pectoralis minor sending some of its fibres through this muscle to supply the M. pectoralis major. On this side of the body the internal anterior thoracic nerve arises by two divisions and probably receives fibres from the VII and VIII cervical nerves.

On the right side, at first sight, the accessory head would seem to receive its nervous supply from the II and III intercostal nerves, since two stout branches from these sources enter the muscle substance. However, on closer examination, these appear to pass through the muscle substance without giving off any fibres to the muscle and to end further on as cutaneous nerves. As no other definite nerve fibre could be traced to this head, it must be supplied by a fibre from the middle or long subscapular nerve, running up in the muscle substance from the main muscle body. If this be the case these fibres would ultimately have about the same source in the cord as those supplying the accessory head on the left side as may be seen by comparing the diagrams of the two plexuses.* On the right side the long subscapular nerve arises from the posterior cord of the plexus just after this cord receives a branch from the inner cord. Thus this long subscapular nerve probably consists of fibres from the VII and VIII cervical nerves, the same nerves as those supplying fibres to the accessory head of the M. latissimus dorsi of the left side through the branch from the internal anterior thoracic nerve.

On neither side does the M. latissimus dorsi receive a slip from the tip of the angle of the scapula.

M. extensor carjii radialis accessorms. — This muscle occurs only in the right arm. Its origin is from the radial side of the M. extensor carpi radialis longior by a slip separating about 4 cm. from the origin of this muscle. About 5 cm. above the annular ligament this slip becomes muscular. Just above the ligament it passes under the tendon of the M. extensor carpi radialis longior to be inserted with the M. extensor carpi radialis brevior into the base of the metacarpal bone of the middle finger. It is innervated by a branch of the musculocutaneous nerve.

M. extensor digiti tcrtii. — Occurs only in left hand. Its origin is from the posterior shaft of the ulna below the origin of M. extensor indicis. Its tendon passes down with that of the M. extensor indicis through the same compartment in the annular ligament, and is inserted finally into the tendon of the M. extensor communis digitorum belonging to the middle finger and on its ulnar side. Its nerve supply is from the posterior interosseous branch of the musculo-spiral nerve.

Scapula. — On either side of the body, the tip of the acromial process is separate from the scapula, being connected to the spine of the scapula by a firm ligamentous band of connective tissue surrounding the proximal ends of bone lying in juxtaposition. The ends of the bones are covered with cartilage, and all are so firmly bound together that very little motion is possible.

All of these eight variations, in addition to the M. sternalis, are along the course the diaphragm takes in its excursion, during development, from the neck to its permanent location. It is to be noted that all this takes place before the embryo is four weeks old, and that at this time the muscles are just beginning to be formed from the myotomes.

Aug. 22, 1898.

Literature

Bardeleben (K.) Der Musculus sternalis. Ztschr. f. Anat. u. Entwicklungsgesch., Leipz., Bd. i, 1875-6, S. 424-458.

Bardeleben (K.) Die morphologische Bedeutungdes Musculus sternalis. Anat. Anz., Jena, Bd. iii, 1888, S. 324-333.

Baker (F.) Some Unusual Muscular Anomalies. Med. Kec, N. Y., vol. xxxii, 1887, pp. 809-811.


Anatom. Laboratory, Johns Hopkins Univ. Nerve Records of Subject 94.

Cuyer (E.) Anomalies osseiises et musculaires. Bull. Soc. d'aiithrop. de Par., 4. s., t. i, 1890, pp. 557-570.

Cunningham (D. J.) The Musculus Sternalis. J. Anat. and Physiol., Lond., 1883-4, vol. xviii, pp. 208-210; also ibid, 1887-88, vol. xxii, pp. 391-407.

Fick (R.) Drei Falle von Musculus sternalis. Anat. Anz., Jena, 1891, Bd. vi, S. 601-606.

Gegenbaur (C.) Lehrbuch der Anatomic des Menschen, — Aufl., 8°, Leipzig, 1895, Bd. i., S. 390.

Jung (A.) Eine noch nicht beschriebene Anomalie des Musculus omohyoideus. Anat. Anz., Jena, 1872, Bd. vii, S. 582584.

Keith (A.) Notes on Supracostalis anterior. J. Anat. and Physiol., Lond., 1893-94, vol. xxviii, p. 333.

Lambert (0.) Considerations nouvelles a propos d'un nouveau cas de muscle presternal. Bull. Soc. d'anthrop. de Par., 1894, 4. s., t. V, pp. 237-241.

Le Double (A.) Sur trente-trois muscles presteruaux. Bull. Soc. d'anthrop. de Par., 4. s., t. i, 1890, pp. 533-554.

Michel (M.) Two Cervical Muscle Anomalies in the Negro. Med. Rec, N. Y., 1892, vol. xli, p. 125.

Mall FP. Development of the ventral abdominal walls in man. (1898) Jour. Morph. 14: 347-366.

Mall (F. P.) Development of the Ventral Abdominal Walls in Man. J. Morphol., Bost, vol siv, 1898, pp. 347-366.

Perrin (J. B.) Notes on Some Variations of the Pectoralis Major, with its Associate Muscles seen during seasons 1868-9, 1869-70. J. Anat. and Physiol., Lond., 1870-71, vol. v, pp. 233-240.

Quain (J.) The Elements of Anatomy. 10th ed.

Shepherd (F. J.) The Musculus sternalis and its Occurrence in (Human) anencephalous Monsters. J. Anat. and Physiol., Lond., 1884-5, vol. xix, pp. 311-319.

Schultz (J.) Zwei Musculi sternales. Anat. Anz., Jena, 1888, Bd. iii, S. 228-234.

Testnt (L.) Les anomalies musciilaires chezrhomme espliqu^es par I'anatomie comparee; leur importance en anthropologie. 8°. Paris, 1884.

Turner (W.) On the Musculus sternalis. J. Anat. and Physiol., Lond., 1866-7, vol. i, pp. 246-253.

Walsh (J. J.) A Sternalis Muscle. Univ. Med. Mag., Phila., 1897-8, vol. X, p. 231.

Wood (J.) On Human Muscular Variations and their Relation to Comparative Anatomy. J. Anat. and Physiol., Lond., 1866-7, vol i, pp. 44-59.

Wallace (D.) Note on the Nerve Supply of the Musculus sternalis. J. Anat. and Physiol., Lond., 1886-7, vol. xxi, p. 153.

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