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As a conclusion to this study the cessation of ovulation will be ascribed to the gradual impairment of the vascular systems, through first, densification of the ovarian stroma and second, through the retroactive effect of imperfectly removed corpora lutea, which as an end result diminishes the blood-supply to the cortical area to such an extent that the growth of the primitive follicles is retarded and finally completely inhibited. These final retrogressive changes lead up to and constitute the menopause or climaterium.
As a conclusion to this study the cessation of ovulation will be ascribed to the gradual impairment of the vascular systems, through first, densification of the ovarian stroma and second, through the retroactive effect of imperfectly removed corpora lutea, which as an end result diminishes the blood-supply to the cortical area to such an extent that the growth of the primitive follicles is retarded and finally completely inhibited. These final retrogressive changes lead up to and constitute the menopause or climaterium.
OVARIAN CYSTS IN THE NEGRESS.
By Thomas E. Brown, M. D.
Comparatively little has been written concerning ovarian cysts in the negress, probably partly because that in most hospitals where extensive gynecological operations are performed the proportion of negro patients is very small, and partly because of the comparative rarity of this condition in negro women.
in fact, one frequently hears surgeons say: "The tumor before us presents all the features of an ovarian cyst, but inasmuch as the patient is a negress it is certainly not so, but a tumor of different origin (cystic myoma, etc.), as multilocular cysts are unknown in the negress."
That ovarian cysts are much rarer in negresses than in white women no one will deny, but as to the exact numerical relationship between the two few if any figures of importance are obtainable, and the object of this note is to give definitely and numerically this proportion as obtained by an analysis of ovarian cysts of various kinds operated upon at the Johns Hopkins Hospital.
In considering ovarian cysts the usual divisions have been made into (a) simple retention cysts, including Graafian follicle and corpus luteum cysts; (b) unilocular and multilocular ovarian cystomata, the two being considered together, as many regard the unilocular cysts as originally multilocular; (c) papillary cysts and (d) dermoid cysts of the ovary ; also for sake of completeness parovarian cysts and intral'gamentary cysts have been considered.
I shall discuss the frequency of ovarian cysts in the negress first (I) from a clinical and macroscopical standpoint, and second (II) from a microscopical and pathological standpoint, which is much more important.
An analysis is here given of the various kinds of ovarian cysts occurring in the white and the colored for a period of six years, from January 31st, 1892, until January 31st, 1898, the variety of cyst being determined by clinical observation and macroscopic appearance.
VARIETIES OF CYSTS.
Col. Wta. Col
589 17 I 7
I
ShB
~~ z
Unilocular
and multi
Papillary
locular
cysts.
cysts.
cysts.
c-e £*£
■j.
Wh.
Col.
Wb.
Col.
Wta.
Col.
Wh.
1 .>!.
88
3
53
2
14
4
3
It will thus be seen that out of 191 cysts, only 12 were in the negress, a proportion of 1 : 15, while the proportion of colored to white gynecological patients treated during the same period was 1 : 6.75 (589 : 3996), i. e. ovarian cysts were relatively 2.2 times as frequent in white as compared with colored women.
When we analyze the proportion in the different varieties of cysts, we arrive at some striking results.
In the case of the dermoid cysts, cysts due to the inclusion of some of the embryonic ectoderm in the ovarian tissue, we find that 7 of the 24 cases reported were in the negress, i. e. 1 : 2.5 (7 : 17), which would seem to indicate that the dermoid cysts are relatively more than twice as common in the negress as in the white woman (the proportion of white to colored gynecological patients being 1 : 6.75).
As regards simple retention cysts, the proportion of 3 to 88 (i. e. 1 : 29.3) is probably not a fair estimate, due to the fact that what to call a Graafian follicle cyst and what to call a dilated Graafian follicle depends largely upon the individual operator.
When we consider unilocular and multilocular cysts, however, we are struck at once by their remarkable infrequency in the negress, of the 55 cases mentioned only 2 being in that race, i. e. a proportion of 1 : 26.5.
This is of especial importance, because this form of cyst of the ovary grows to the largest size, and it is this variety of cyst which many surgeons declare never occurs in the negress.
Jax.-Feb.-March, 1899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
45
No cases were reported of papillary oysts of the ovary, parovarian or intraligamentary cysts in the negress.
Thus it will be seen that with the exception of dermoid cysts, ovarian cvsts are really much less common in the colored race, the results, however, being more or less indefinite, due to the fact that the diagnosis was made clinically and macroBCopically and not microscopically.
II.
An aualysis of ovarian cysts from the microscopical standpoint was made from all cases operated upon in the Hospital from the latter part of 1893 until October, 1898.
During that time there had been microscopically described and diagnosed in the Gynecological-Pathological Laboratory 244 ovarian and parovarian cysts, divided as follows: Dermoid cysts 32, Graafian follicle cysts GS, corpus luteuin cysts 16, unilocular and multilocular cysts 9-1, papillary cysts 10, and parovarian cysts 24.
(a) Dermoid cysts. Of the 32 dermoid cysts, G were in the colored, i. e. the proportion is 1 : 4.3, showing, as in the clinical study above, that these cysts are relatively more common in the negro race.
of Dermoid Cyst of the Ovary in the Colored.
d)S.
(-') J.
(3) I.
(4) S.
(5) V.
(6) C.
PATHOLOGICAL REPORT.
Dermoid cyst of right ovary, 7 cm.
in diameter
Dermoid cyst of ovary, 16 cm. in
diameter
Dermoid cyst of ovary, 7 cm. in
diameter
Dermoid cyst of ovary, 8 cm. in
diameter
Dermoid cyst of ovary, 4.5x3.5x3
cm
Dermoid cyst of right ovary, 2.5 cm. in diameter
REMARKS.
Myomatous uterus.
2 intraligamentary myomata.
Myomata uteri.
(J) Retention cysts. Of the 84 simple retention cysts (68 Graafian follicle cysts, 16 corpus luteum cysts), 7 were in the colored, a proportion of 1 : 11, showing that these cysts are relatively less common in the negress than in the white woman (as stated before, the proportion of colored to white gynecological patients being 1 : 6.75).
Casks ok Simple Retention Cysts in the Colored.
PATHOLOGICAL REPORT.
Double pyosalpinx.
(1) S. Right unilocular ovarian cyst, prob ably dilated Graafian follicle, intraligamentary, 9 cm. in diameter.
(2) C. Right corpus luteum cyst, 5 cm. in Epithelioma of cervix.
diameter. |B] W. Cyst of ovary from corpus luteum
i or Graafian follicle, «x4x4.5 cm. i4 \V. Corpus luteum cyst, unilocular, 5
| cm. in diameter
(5) B. Cyst of leftovary,5cm. in diameter '.
(probably of Graafian follicle).
(6) B. Graafian follicle cyst of rightovary,
4 cm. in diameter.
(7) T. Right Graafian follicle cyst, 4x3cm.
Double perisalpingitis and perioophoritis.
Myomata uteri.
Myomata uteri.
(c) Unilocular and multilocular cysts. Of the 91 uni locular and multilocular ovarian cysts, but 6 were in the colored, the proportion thus being but 1 : 14.7, showing that this form of cyst is relatively more than twice as common amongst white women.
It shows, however, that they are by no means so uncommon in the negress as popularly supposed.
Cases of Unilocular and Multilocular Ovarian Cysts in the Colored.
(1) G.— Color, black.
Pathological Report. — Multilocular ovarian cyst. Myoma uteri.
(2) H.— Color, black.
Examination. — Abdomen, especially right side, is distended by a firm elastic tumor mass reaching 9 cm. above the umbilicus, its longest axis being 23 cm. In left inguinal region is felt a hard, irregular mass, the size of a small hen egg.
Operation. — Cystectomy. Hystero-myo-salpingo-oijphorectomy.
The cyst was thin-walled, filled with bloody fluid ; it was developed fiom the outer pole of the right ovary and was entirely retroperitoneal. The uterus was myomatous, and there were many adhesions, especially about the cyst.
Pathological Report. — Multilocular cyst of right ovary 16 cm. in diameter, springing from the upper pole; the cyst wall is 1 mm. thick, the fluid is dark reddish-chocolate colored. Myomata uteri.
(3) I.— Color, black.
Examination. — Abdomen is much distended in its lower half, and a large mass of irregular outline can be palpated ; to the right it feels elastic ; to the left hard. The upper border of the mass reaches in the right parasternal line to within 11 cm. of the costal margin. Transversely it measures 29 cm.
Operation. — Cystectomy. Hystero-myo-salpingo-odphorectomy.
On the right side a multilocular ovarian cyst posterior to the uterus, filling the cul-de-sac and rising above the pelvic brim, with its walls intimately adherent to the intestines. Myomatous uterus, size of foetal head.
Pathological Report.— Ovarian cyst (either multi- or unilocular, probably the latter) ; fluid is clear, limpid and yellowish. Myomata uteri.
(4) C— Color, black.
Examination. — Abdomen is irregularly distended. On palpation a mass, divisible into two separate masses, can be made out, one occupying the lower portion of the abdomen, with irregular outline and nodular surface, the other reaching as high as the costal margin on the left, measuring 9x12^ cm. with smooth surface and elastic feel.
Operation. — Hystero-myomectomy. Cystectomy.
The cyst was punctured and the fluid withdrawn before the enucleation was started.
Pathological Report— \jeH,um\oca\a.r ovarian cyst, 7 cm. in diameter.
(5) F — Color, black.
Examination.— The body of the uterus is apparently of normal size and is pressed backwards by a large abdominal tumor, which is firm, elastic, tense, of smooth surface and gives a distinct wave of fluctuation. Corona of resonance is well marked.
Operation.— Cystectomy (left). Right salpingo oophorectomy.
The cyst-wall was punctured, the fluid obtained therefrom being of a muddy brown color. The cyst sprang from the left ovary and was adherent to the omentum. The right tube and broad ligament were plastered over the surface of the cyst. Right salpingitis. The uterus contained a lew myomatous nodules.
Pathological Report.— Large multilocular cyst of left ovary, li';l^ cm., containing 1800 c. cm. of dark brown tluic 1 containing much albumen.
46
(6) H.— Color, black.
Pathological Report. — Right multilocular ovarian cyst, 6 cm. in diameter, dense adhesions, cyst of left ovary 5 cm. in diameter, containing blood and debris.
Thus it will be seen that, although these cysts are less common in the negro race, nevertheless they do sometimes occur, and reach as large a size in some cases as the corresponding cysts in the white race, and thus the possibility of their being present should always be seriously considered when the physical examination points in that direction.
(d) Papillary cysts. No case of this kind was found in the negress in the cases analyzed.
(e) Parovarian cysts. Of the 24 parovarian cysts, only 1 was in the negress, showing the extreme rarity of this variety of cyst in this race.
(1) A. — Pathological Report. Right parovarian cyst. Myoma uteri. Left salpingitis.
Thus, of the 244 cases of ovarian and parovarian cysts, but 20 were in the colored race, i. e. the proportion is 1 : 11.2, showing that the relative frequency of these cysts is 1.66 times as great in the white as in the colored race.
If we exclude the parovarian cysts, of the remaining 220 true ovarian cysts 19 were in the negress, a proportion of 1 : 10.6, t. e. the relative frequency is 1.57 times as great in the white as in the colored race.
If we exclude the dermoid cysts, cysts which owe their origin to some defect in embryonic development, of the remaining 188 ovarian cysts (corpus luteum, Graafian follicle, multilocular, unilocular and papillary cysts), but 13 were in the colored, i. e. a proportion of 1 : 13.4, showing that these cysts are relatively exactly twice as frequent in white women as in colored.
Perhaps the thing that strikes one most in studying these cases is the extreme frequency with which the ovarian cysts in the colored are associated with other pathological conditions, especially with a myomatous condition of the uterus.
In 10 of the 20 cases reported, uterine myoma ta were also found. These were distributed as follows : In 3 of the 6 cases of dermoid cysts ; 2 of the 7 cases of Graafian follicle and corpus luteum cysts; 4 of the 6 cases of unilocular and multilocular cysts ; and in the 1 case of parovarian cyst reported.
In 3 of the 20 cases salpingitis, perisalpingitis or pyosalpinx was reported, i. e. evidences of inflammatory trouble, distributed as follows: In 2 of the 7 cases of corpus luteum and Graafian follicle cysts, and in the 1 case of parovarian cyst.
Thus, to summarize our results, while the simple retention cysts and the unilocular and multilocular ovarian cysts are 1 seen relatively much less frequently in the negress than in the white woman, they are present relatively much more frequently than is universally supposed; while from both a clinical and pathological study the dermoid ovarian cyst seems to be relatively more frequent in the negro race.
ON A HITHERTO UNDESCRIBED PEPT0NISING DIPLOCOCCUS CAUSING ACUTE
ULCERATIVE ENDOCARDITIS.
(PRELIMINARY REPORT.) By W. G. MacCallum, M. D., and T. W. Hastings, M. D.
(From the Pathological Laboratory of the Johns Hopkins University and Hospital.)
A. S., aged 37, was admitted to the service of Dr. Osier, September 14, 1898. Occupation and family history unimportant; personal history negative, excepting for an account of an indefinite febrile attack of three weeks' duration, in 1889, which was said to have been rheumatic fever.
Since July 4th, after contracting a severe cold, he had a fever which had been persistent until early in August, when it subsided but reappeared about the middle of the same month, and for this supposed relapse of typhoid fever the patient was sent to the hospital.
The signs of aortic valvular disease were noted on admission and the diagnosis of septicaemia and probable malignant endocarditis affecting the aortic valves was made after obtaining positive blood cultures on September 2 1 1 h.
The growth from the blood cultures was thought to be a short-chained streptococcus often occurring in pairs, but subsequently, on study of that obtained upon different media, it proved to be a definite diplococcus. On October 1st, three days before death, blood cultures wl-w taken a second time from the basilic vein with the same positive result.
The autopsy revealed an acute vegetative and ulcerative
aortic and mitral endocarditis. The aortic valves were bound together by exuberant branching vegetations which had undergone ulceration ; several of the mitral chorda? tendineaj were ruptured and the broken ends covered with vegetations. In the spleen and kidney there were septic infarctions in various stages of softening, the fresher ones being firm and white, the oldest forming large thin-walled cavities with almost diffluent conteuts. One such embolic abscess was found in the ileum. There was also a bronchopneumonia of the left lung.
Sections of the aortic valves showed the fibrinous vegetations to be loaded with masses of diplococci, and in those passing through the infarcts in the kidney plugs of similar cocci were found in the vessels at the edges of the infarcted area. From the heart's blood and the aortic vegetations, as well as the infarcts in the spleen and kidney and from the lung, pure cultures were obtained of the diplococcus which presented, in brief, the following morphological and biological characters :
Morphology. — A small somewhat elongated diplococcus occurring sometimes in chains of four, but generally in pairs,
Jaw.-Feb.-March, 1899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
47
which stained easily by methods of Gram and Weigert, No demon strable capsule.
Grmoths showed minute semi-translucent pin-point deep colonies and corresponding minute discrete translucent round superficial colonies. On slant agar the smear gave rise to a thin translucent growth made up of conglomerated colonies, the edge of which is slightly raised and crenated.
Glucose and ascitic fluid agar afforded a more profuse and rather less translucent growth, while on glycerine agar the growth was comparatively scanty. There was no gas formation in glucose agar.
Potato. — The growth was slow to appear; after two or three days it showed as a dry whitish or tawny layer.
Bouillon was rendered very slightly opalescent after fortyeight hours.
Litmus-milk was decolorized within four hours. Later (within forty-eight hours) the milk was coagulated and acidified. After this there was a rapid peptonization of the coagulant, the medium becoming transformed first into a turbid purplish fluid, or a turbid yellow fluid, overlaid by a layer of red, and later into a quite clear blood-red fluid. This reaction is very characteristic and absolutely constant.
Blood Serum. — The growth appeared in minute discrete dew-like colonies. Within forty-eight hours there appeared a depression on the surface of the medium corresponding with the line cf smear. Liquefaction of the medium occurred in course of time.
Gelatin was rather slowly but completely liquefied. Stab cultures took on the appearance of a wide funnel after about four days.
The sediment of organisms like the colonies on gelatin plates had a pale sulphur-yellow color.
The organism is quite hardy and may be recultivated from tubes several weeks old.
robiosis. — It is a facultative anaerobe, cultures in Buchnerjars growing with about the same profusion and rapidity as the aerobic controls. In au atmosphere of hydrogen the growth is rather less abundant.
Thermal Death Point. — The diplococcus is killed in five minutes by a temperature ranging between 60° and 65° C.
Pathogenicity. — Laboratory animals succumb to inoculation. White mice do not survive the intraperitoneal injection of suspension of the cultures. Death may take place as early as eight hours or be delayed for three or four days. The microorganism can be recovered from the blood aud organs gener The subcutaneous inoculations of mice also produce fatal effects after a longer period — two to four days. In the latter experiments no lesion was found at the point of inoculation and the organism was not recovered from am
Babbits appeared less susceptible. Of several experiments Ol.c rabbit which received 3 cc. of a suspension of the organism intravenously succumbed in 16 da}"S. At the at there was found an abscess at the site of inoculation, and from this as well as from the distended urinary bladder the organism was recovered.
One dog has thus far been inoculated after injury of the aortic valves by the passage of a probe into the heart through
the carotid (Rosenbach's operation), the culture being thrown into a vein. After five days the dog was killed and the autopsy revealed a fresh vegetative endocarditis, the tions springing from the edges of the perforation in the valve and from the point on the aortic wall where the intima was scraped off by the probe. There was also an extension of the vi getations onto the mitral valve; and at the point u line | he probe passed into the intraventricular septum an acute suppurative myocarditis hail formed. The organism was recovered in pure culture from the aortic vegetations and from the heart's blood and organs generally.
Experiments with the ferments and toxines are in progress and will be reported later.
This diplococcus which has been proven to be pathogenic for man and some of the lower animals seems not to have been met with before — at least, there is no record of such an organism to be found in the hacteriological literature available t" us. The chief peculiarities which distinguish it from the pyogenic cocci already described are:
(1) The mode of growth which resembles that of the micrococcus lanceolatus. the diplococcus intracellularis meningitidis and the streptococcus rather than that of the pyogenic staphylococci.
(2) The action on gelatin which resembles that of the staphylococci.
(3) Its activity in peptonizing milk and coagulated blood serum in which it differs from all the above-named pyogenic cocci.
In virtue of this last property and for the purpose of distinguishing it for the present, we propose the name Micrococcus zymogenes.
ALFREDO AXTUNES KAXTHACK.
Died at Cambridge, England, on the twenty-first of December, 1898, Alfredo Antunes Kanthack, M.A., M. D., F. R. C. P. (London), Fellow of King's College and Professor of Pathology in the University of Cambridge.
This announcement is a cruel blow to those who have had the good fortune to know and work with this brilliant man. Born in Brazil in 1863, the sou of the former British consul at Para, Kanthack received much of his early education in Germany. Studying in England at the University College in Liverpool and at London University, he obtained his I!. A. in 1884, his intermediate M. B. in L885, and B. Sc. in Pursuing his studies at St. Bartholomew's Eospital, he received
in 1887 the double qualificati f M. R. C. S. and L. I.'. 0. P.
In 1888 he obtained the F. R. C. S. as well as the M. B. and I'.. S. i London), with honors, receiving also the gold medal for obstetrics. The year 1889 Kanthack spent in work under Virchow in the pathological laboratory at Berlin, but he was compelled in lb90 to leave, in the midst of some important investigations, to serve as obstetrical assistant in St. Bartholomew's Hospital under Dr. Matthews Duncan.
In the sumn India as one of the com missioners appointed by the Royal College of Physicians, the
48
Royal College of Surgeons and the Executive Committee of the National Leprosy Fund to inquire into various points with regard to leprosy in India. A large share of the voluminous report of the commission was his work. Returning from India he became the John Lucas Walker student at Cambridge, but in 1892 he went to Liverpool with the intention of practising medicine. Here he held the post of medical tutor and demonstrator of bacteriology at the Royal Infirmary. Later, however, he went to London as director of the pathological laboratory, lecturer on pathology and bacteriology, and curator of the pathological museum at St. Bartholomew's Hospital. In 1896, during the illness of Professor Roy, he was appointed his deputy, and finally in the fall of 1897 he became professor of pathology at the University of Cambridge. In the same year he became an F. R. C. P., and was given the honorary degree of M. A. at Cambridge.
In his school days Kanthack had planned to devote his life to classical studies, and it was a disappointment to him at first to be compelled to turn to what he feared must be a more practical career; but from the beginning his energy and ability brought him enthusiasm and success. In the laboratory at Berlin he earned the admiration of all who knew him, and his early work in Virchow's Archiv on the pathology of the larynx* gained for him the recognition of many others. By no one was he more appreciated than by his great "Master" as he reverently called him, whose attitude toward his pupil was one of genuine affection.
The feeling of his contemporaries cannot be better shown than by quoting in full the cordial letter of Prof. Langerhans, written at the time of his application for the professorship of pathology at Cambridge :
"Herr Dr. med. Alf. A. Kanthack, zur Zeit in Cambridge, hatte vom Sommer 1889 bis August 1890 im Berliner pathologischen Iustitut einen Arbeitsplatz in demjenigen Arbeitssaal inne, welcher fur vorgeschrittene, selbststiindige wissenschaftliche Arbeiter bestimmt ist und fur welchen ich damals als zw r eiter Assistent von Rudolf Virchow meinem Chef gegenuber verantwortlich war. In dieser Eigenschaft bin ich damals taglich mit A. A. Kanthack zusammen thatig gewesen und besUitige ich hierdurch, dass sich Alf. A. Kanthack durch sein umfassendes Wissen, eiserne Energie, unermiidlichen Fleiss, durch seine grosse Wahrheitsliebe und strenge Selbstkritik und durch seine feinen, liebenswiirdigen und gewinnenden Umgangsformen die Achtung und Liebe aller, die mit ihm in Beruhrung kamen, gewonnen und dauernd erhalten hat."
Kanthack had published a considerable number of valuable scientific communications, a few of the more important of
Beitr;ige zu der Histologie der Stimmbiinder mit specieller
Beriicksichtigung des Vorkommens von Drilsen und Papillen. Arch. f. path. Anat, etc., Berl., 1889, cxvii, 531-544; Studien iiber die Histologie der Larynxschleimbaut— I. Die Schleimhaut des halbausgetragenen Foetus. Ibid., 1889, cxviii, 137-147; Zur Histologie der Stimmbiinder : Erwiderung auf den vorstehenden Artikel des Herrn Prof. B. Fraenkel. Ibid., 370-381 ; Studien uber die Histologie der Larynxschleimhaut. Ibid., 1890, cxix, 326; cxx, 273.
which were, perhaps, the researches referred to concerning the larynx, his studies upon snake poison,* his various communications with relation to leucocytosis, chemotaxis and immunity,! his studies on mycetoma,^ his Jackson Prize Essay on the bacillus of tetanus, and his further contributions to the same subject with Dr. Connell,§ and his admirable article upon the general pathology of infection in the first volume of Clifford Allbutt's System of Medicine. He also published in 1894, in association with Dr. Rolleston, a "Manual of Practical Morbid Anatomy, being a handbook for the post-mortem room," and in 1895 with Dr. Drysdale, a " Course of Elementary Practical Bacteriology, including Bacteriological Analysis and Chemistry."
He superintended the observations upon the Tsetse fly disease for the Royal Society, and one of his last publications related to this subject.||
Much of his work, however, through his modesty and generosity, remained unknown. Only his more intimate friends are aware of the fact that he was the first to succeed in cultivating the parasite of actinomycosis. Compelled in January, 1890, to leave Berlin in the midst of his experiments, he made all possible arrangements for the preservation of his cultures, but on his return, they had, unfortunately, " died out " and another observer had anticipated him with the discovery.
A large share of his energy was given to the help and instruction of others who will bear the warmest testimony to the true worth of their friend and teacher.
His uncompromising honesty, his hatred of anything superficial or incomplete, combined with an active, keen, discriminating mind, and it seemed, an almost unlimited power for work, were a source of admiration to all who knew him. His amazing energy and capability for work were, however, too much even for a fine athletic physique, and his friends had for some years before his death looked with anxiety upon the amount of labor which he crowded into the day.
To the writer Kanthack always seemed the most brilliant of
The Nature of Cobra Poison. Journ. Physiol., Camb., 1892,
xiii, 272-299. Report on Snake Venom in its Prophylactic Relations with Poisons of the Same and of Other Sorts. Rep. Med. Off. Local Gov., Bd. (1895-6), Loud., 1897, 235-266.
f Acute Leucocytosis Produced by Bacterial Products. Brit. Med. Journ., Lond., 1892, i, 13(11-1303; Immunity, Phagocytosis and Chemotaxis. Brit. Med. Journ., Lond., 1S92, ii, 985-9S9 ; (with Hardy) On the Characters and Behaviour of the Wandering (migrating) Cells of the Frog, especially in Relation to Microorganisms. Proc. Roy. Soc. Lond., 1892, Hi, 267-273, and Phil. Tr., Lond., 1895, clxxxviii, 279-318; (with Wesbrook) Report on Immunity Against Cholera : An experimental inquiry into the bearing on immunity of intracellular and metabolic bacterial products. Brit. Med. Journ., Lond., 1893, ii, 572-575 ; (with Hardy) The Morphology and Distribution of the Wandering Cells of Mammalia. Journ. Physiol., Camb., 1S94, xvii, 81-119.
\ Madura Disease (mycetoma) and Actinomycosis. Journ. Path, and Bact,, Edinb. and Lond., 1892, i, 140-162.
§TheFlagellaof the Tetanus Bacillus and Other Contributions to the Morphology of the Tetanus Bacillus. Journ. Path, and Bact., Edinb. and Lond., 1S96-7, iv, 452, and Trans. Path. Soc. Lond., 1896-'97, xlviii, 271-27'*.
|| Kanthack, A. A., H. E. Durham and W. F. H. Blandford : On Nagana or Tsetse Fly Disease. Proc. Roy. Soc, Vol. 64.
Jan.-Feb. -March. L899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
49
his contemporaries. His ideals were the highest ; and never was a man truer to his ideals. An exacting and searching critic of his friends, he was a severer critic of himself. This amounted sometimes to self-depreciation ; it was indeed, on such occasions, almost pathetic to note the apparent unconsciousness of his own superiority.
And with his high ideals he was ever full of practical suggestion. He never tired of urging the necessity of a more general introduction of accurate and scientific methods into medicine. His last public address* was an earnest appeal for more systematic and thorough clinical study in hospitals and schools.
His influence which was beginning to be generally felt in his own country was destined to have a far wider sphere. The loss of such a man is hardly greater to his university and to his friends than to the world at large.
Personally, Kanthack was the simplest and most lovable of men.
In 1895 he married Lucie, the daughter of F. Henstock, Esq., of Liverpool. W. S. T.
NOTES ON NEW BOOKS.
Operative Gynaecology. By Howard A. Kelly, A. B., M. D. ; Professor of Gynaecology and Obstetrics in Johns Hopkins University, Baltimore; Gynaecologist and Obstetrician to Johns Hopkins Hospital, Baltimore. 2 vols., 550 pages each, with 48 plates and 592 original illustrations. (D. Appleton, New York, 1898.)
This work is practically a series of clinical lectures, thoroughly and exquisitely illustrated by drawings from cases which have been under the author's care.
Volume Xo. I contains nineteen lectures upon the following topics :
1. Sepsis, asepsis, and antisepsis in hospitals.
2. Antisepsis and asepsis in private practice.
3. Bacteriology.
4. Topographical anatomy.
5. The gynaecological examination.
6. Gynaecological instruments and dressings.
7. Anaesthesia.
8. General principles involved in plastic operations.
9. Diseases of the external genitals.
10. Rupture of the recto- vaginal septum and relaxed vaginal outlet.
11. Operations on the vagina.
12. Affections of the urethra and bladder.
13. Affections of the ureters.
14. Operations upon the cervix of the uterus, including dilatation and curettage.
15. Prolapse of the uterus.
16. Vaginal hysterectomy.
17. Inversion of the uterus.
18. Vaginal extirpation of the submucous myomata and polypi.
19. The uterus as a retention cyst. The contents of Volume II are :
20. General principles and complications common to abdominal operations.
The Science and Art of Medicine. The Mid-sessional Address
delivered before the Abernethian Society on July 7, 1898. St. Bartholomew's Hospital Journal, August, 1898.
21. Care of wound and patient up to recovery.
22. Complications arising after abdominal operations.
23. Tubercular peritonitis.
24. Suspension of the uterus.
25 Conservative operations on the tubes and ovaries. l'i;. Simple salpingo-oGphorectomy and salpingo-oophorectomy for adherent tubes and ovaries.
27. Vaginal drainage and enucleation for pyosalpinx, ovarian abscess, tubo-ovarian abscess, and pelvic abscess.
28. Hysterectomy, with extirpation of ovaries and tubes, abdominal hystero-salpingo-oophorectomy.
29. Ovariotomy.
30. Abdominal hysterectomy for carcinoma and sarcoma of the uterus.
31. Myomectomy — hystero-myomectomy.
32. Operations during pregnancy.
33. Cesarean section.
34. Extra-uterine pregnancy.
35. The radical cure of hernia.
36. Intestinal complications.
37. The more remote results of abdominal operations.
38. On the conduct of autopsies, the making of protocols, and the preservation of tissues for microscopic examination in gynaecological practice.
Those who have been fortunate enough to see Dr. Kelly at home, will, while reading the work, easily imagine themselves in his operating room, listening to a brief history of the case to be operated upon ; a review of the anatomy of the parts ; a description of the operation to be done ; the reasons for selecting this special procedure; the difficulties and dangers to be met, and the best way to overcome them. The style throughout is conversational, clear, concise, clean-cut, and impresses one with the feeling that the writer is presenting a frank statement of his experience in the treatment of the different diseased conditions met with in abdominal surgery.
Few books have been more eagerly looked for ; few have so fully realized our expectations. The author in the opening paragraph of his preface says : " My aim in writing this book has been to place in the hands of many friends who have from time to time visited me, and followed my work, a convenient summary of the various gynaecological operations I have found best in my own practice. It is far from my purpose to present a digest of the literature of the subject, or even to describe all the important operations." The claims to originality are mainly connected with the operation for suspension of the uterus, the investigation of vesical and ureteral diseases, and with Kelly's modification of abdominal hysterectomy for fibroids. The chapters on sepsis and antisepsis, bacteriology, the conduct of autopsies, and preservation of tissues for microscopical examination, have been written with the assistance of acknowledged authorities in these several departments, and are deserving of more attention than is commonly given to chapters devoted to these subjects in surgical text-books.
However much we may desire to give special attention to individual chapters, the space at our disposal would preclude this, and we are compelled to speak of the work as a whole, and to present our impressions of it in a few sentences.
At first sight many will be inclined to think that the illustrations are the feature of the work, but those who have had any experience in abdominal surgery and its difficulties, and have read any considerable portion of the work carefully, will feel, that while the illustrations are all that illustrations could be, both from an artistic standpoint and because of their value in assisting the reader to follow the text, the great feature of the work is the careful selection of the best-known treatment for each disease described. Where, as in uterine fibroids, extra-uterine pregnancy, and pelvic abscess, the conditions in the different cases vary, the procedure best suited to those different conditions is indicated and clearly described. Wherever medical treatment is deemed of use, it is care
50
fully outlined. The old-time "applications," however, find no place in the work. Where no mention is made of medical treatment it is because nothing can be hoped for from this quarter, and no course of treatment is encouraged which is likely to end in disappointment.
Another feature, and a pleasing one, is the spirit of conservatism which everywhere pervades the book. We find, for example, that par-ovarian cysts are now enucleated without sacrifice of the ovary, contrary to the former practice. In ovarian disease, where the tube is not involved, it is allowed to remain, and in uterine fibroids, when consistent with safety, myomectomy, and not hysterectomy is advised. While the work is of great value to all interested in abdominal surgery, representing, as it does, the most advanced thought of the day, it ought to receive special welcome from those practitioners who live at some distance from hospital centres. Such men, if they study the principles of aseptic abdominal surgery as enunciated in the early chapters of the work, will not only be enabled to retain under their own care cases now referred to the city specialist, but will also be able to extend treatment which in the past, has only been possible in the larger centres, to those v ho on account of their limited means cannot avail themselves of he services of a specialist.
Dr. Kelly's original work on suspension of the uterus and affections of the bladder and ureters, places the profession und:r permanent obligation to him. In originating the operation of e ispension of the uterus he has added materially to our resources in the treatment of certain uterine displacements (decensus and retro-displacements). With this operation we have had some little experience, having done upwards of seventy cases with a single relapse, and without mortality. Two patients subsequently became pregnant and were delivered at term of living children, without special discomfort or complication ; two others are advanced four months in pregnancy, without development of any abnormal position of the uterus. If we restrict the operation of ventral fixation to those suffering from displacement and who have passed the menopaut •, and employ suspension in such as are liable to become pregna 't, the operation is likely to increase in favor, as a safe and reasonably certain method of securing relief from local discomforts, as well as from disorders referred to the stomach, spine and legs. Certainly in no class of cases have we met with greater gratitude, or seen more marked improvement in general health, than in those selected for this operation.
The easy use of the cystoscope and ureteral catheter requires a little experience and manipulative skill. To those who possess these requisites, Kelly's cystoscope and ureteral catheter will prove invaluable instruments, enabling them to recognize and relieve distressing conditions not generally diagnosed and therefore not corrected by the ordinary practitioner. Those who have maste' ed the use of these instruments, and this with a little perseverance is easily possible to all, will not long remain in doubt as to their value.
The work is an embodiment of modern ideas clearly and concisely presented in good order, and well represents the most advanced operative gynaecology of the day.
Lesslie M. Sweetxam.
books received.
Atlns of Legal Medicine. By Dr. E. von Hofmann. Authorized translation from the German. Edited by F. Peterson, M. D., assisted by A. 0. J. Kelley, M. D. 1898. 12mo. (Saunders' Medical Hand-Atlases.) W. B. Saunders, Philadelphia.
Index Catalogue of the Library of the Surgeon-General's Office, United States Army, Authors and Subjects. Second Series, Vol. III. C — Czygan. 1898. 4to. HOOpages. Government Printing Office, Washington, D. C.
A Pocket Medical Dictionary giving the Pronunciation and Definition of the Principal Words Used in Medicine and the Collateral Sciences, etc. By George M. Gould, A. M., M. D. A new edition entirely rewritten and enlarged, including over 21,000 words. 189S. 16mo. 530 pages. P. Blakiston's Son & Co., Philadelphia.
Twentieth Century Practice. An International Encyclopedia of Modern Medical Science by Leading Authorities of Europe and America. Edited by Thomas L. Stedman, M. D. In Twenty Volumes. Vol. XVII. Infectious Diseases and Malignant New Growths. 1898. 8vo. 715 pages. Wm. Wood & Co., New York.
Archives of Neurology and Psychopathology . Vol. I., Nos. 1-2, 1898. 8vo. 262 pages. State Hospital Press, TJtica, N. Y.
Diseases of the Eye. A Handbook of Ophthalmic Practice for Students and Practitioners. By G. E. de Schweinitz, A.M., M. D. Third Edition. 1899. 8vo. 696 pages. W. B. Saunders, Philadelphia.
A Manual of Physiology. With Practical Exercises. By G. N. Stewart, M. A.', D. Sc, M. D., Edin., D. P. H., Camb. Third Edition. 1898. 8vo. 848 pages. W. B. Saunders, Philadelphia.
A Text-Book of Mechano- Therapy. (Massage and Medical Gymnastics.) Especially Prepared for the Use of Medical Students and Trained Nurses. By A. V. Grafstrom, B. Sc, M. D. 12mo. 1899. 139 pages. W. B. Saunders, Philadelphia.
Saunders' Pocket Medical Formulary. By Wm. M. Powell, M. D. Fifth Edition. 1899. 16mo. 290 pages. W. B. Saunders, Phila.
The Treatment of Disease by Physical Methods. By Thomas Stretch Dowse, M.D.,Abd., F. R. C. P., Ed. 1898. 8vo. 412 pages. John Wright & Co., Bristol.
A Text-Book of Obstetrics. By Barton Cooke Hirst, M. D. 1898. 8vo. 846 pages. W. B. Saunders, Philadelphia.
Purity and Truth. Self and Sex Series. What a Young Ma n Ought to Enow. 1897. 16mo. 281 pages. The Vir Publishing Co., Phila
Translation of Lectures Delivered by Aurelio Bianchi, M. D., Parma On the Panendoscope and its Practical Application. With Transla tion of Special Articles by F. Regnault, M. D. and M. Anastasia des,M. D. Translated by A. G.Baker, A.M., M.D. 1898. 8vo 77 pages. G. P. Pilling & Son, Philadelphia.
Cleft Palate; Treatment of Simple Fractures by Operation; Diseases of Joints, etc. By W. Arbuthnot Lane, M. S. 1897. 12mo. 27S pages. The Medical Publishing Co., Limited, London.
Transactions of the American Gynecological Society. Vol. XXIII. 1898. 8vo. 491 pages. Wm. J. Dornan, Philadelphia.
THE JOHNS HOPKINS HOSPITAL BULLETIN.
The Hospital Bulletin contains announcements of courses of lectures, programmes of clinical and pathological study, details of hospital and dispensary practice, abstracts of papers read and other proceedings of the Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of the Hospital. It is issued monthly.
Volume X is now in progress.
The subscription price is $1.00 per year.
The set of ten volumes will be sold for $20.00.
BULLETIN
i<
v
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. X.-No. 97.]
BALTIMORE, APRIL, 1899.
[Price, 15 Cents.
COHTEISTTS.
An Analysis of the Cases of Tabes in the Johns Hopkins Hospital and Dispensary from its opening in May, 1889, to December 1, 1898. By H. M. Thomas, M. D., - - - - 51
On Typhoid Septicaemia, with the Report of Two Cases, one of which was a Typhoid Infection without Intestinal Lesions. By August Jerome Lartigau, M. D., - - 55
Cavities in the Brain Produced by the Bacillus Aerogenes Capsulatus. By Robert Reuling, M. D., and Arthur P. Herring, M. D., - - - - - - go
Acute Fibrino-purulent Cerebro-spinal Meningitis, Ependymitis, Abscesses of theCerebrum, Gas-Cysts of theCerebrum, Cerebro-spinal Exudation, and of the Liver, due to the
Bacillus Aerogenes Capsulatus. By W. T. Howard Jr M.D., - - - - _
Proceedings of Societies : Hospital Medical Society, ---- Resistance to Quinine of Certain Forms of Malaria [Dr. Cam ac] ;— A New Method of Staining Malarial Parasites [Dr. Futcher] ;— Laparotomy for Intestinal Perforation in Typhoid Fever [Dr. Thayer] ;— Presentation of Pathological Specimens [Drs. MacCallum and Harris.]
Notes on New Books,
Books Received,
AX ANALYSIS OF THE CASES OF TABES IN THE JOHNS HOPKINS HOSPITAL AND DISPENSARY FROM ITS OPENING IN MAY, 1889, TO DECEMBER 1, 1898.
By H. M. Thomas, M. D., Clinical Professor of Nervous Diseases, Johns Hopkins University, Neurologist to the Johns Hopkins
Hospital.
In the records of the Dispensary of the Johns Hopkins Hospital there are one hundred histories which have been classed as tabes. Of these I have excluded eight histories, either because the records are too incomplete, or because the diagnosis seems to have been a mistaken one. Twenty-seven cases have been treated in the wards of the Hospital, but unfortunately for the purposes of this paper, many of them were private patients in whose histories the records are often not complete.
Eight (8) of the patients were treated both in the wards of the Hospital and in the dispensary, and we therefore have for comparison the histories of 111 cases of tabes. That these histories are not all equally good, need not be said, and, indeed, nor a few of them leave much to be desired.*
After having read through some 130 histories, I feel that I
might with propriety make some observations upon the taking of histories, which, if followed, would be useful at least to the one Who has to tabulate them, but I shall not, only saying as I pass, that it is a subject which deserves more attention than is often given to it.
Kace.— White, 106; negroes, 5. Of the 106 white patients 70 were born in this country, 17 were Germans, 6 were Irish, and England, Scotland and France were each represented by 2; 6 patients were simply registered as white.
The small number of negroes is of particular interest, and deserves more detailed attention. We have, as I have just said, seen but five colored patients, in whom the diagnosis of tabes seemed in the least justifiable; that is to say, but 4.5 per cent, of our cases of tabes have any discoverable African blood in their veins, for it is to be remembered that in the eye of the law and of the statistician it takes but very little African blood to make a negro.
In the two years ending November 1, 1898, there were registered in the dispensary 35,796 new cases. Of these 3598 were negroes. This makes the negroes represent a little more than 10 per cent. (10.05 per cent.) of the new cases treated. In the cases of tabes, however, our percentage of negroes is only 4.5, which is less than half what it should be if the negroes were represented in their proper proportion. This difference, although interesting in itself, is hardly great enough to warrant
52
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 97.
much attention were it not for other considerations. I think I shall not be accused of exaggeration when I state that the great majority of physicians who are qualified to judge have come to the belief that syphilis is the chief, if not the only, cause of tabes.
We in the South know that syphilis is a very common disease among the negroes, but upon examining the records of the dispensary, I was surprised to discover how common it is. In the two years selected for comparison there were treated in the Genito-Urinary and Skin Departments 228 men who were suffering either from the primary syphilitic sore or the secondary skin eruptions. Sixty-three of these men were negroes, that is 27.63 per cent, of the whole number. When we compare this percentage with that which the negro men represent in the whole number of the men registered in the dispensary, during these years, is quite startling. There were registered 17,888 white males and 1223 colored males, i. e. 6.39 per cent, of colored males. Unfortunately there are included in this males of all ages, and so the comparison is not perfectly fair; but I believe the error is not great. We have then, during these two years, the negro males, representing 6.39 per cent, of all the males treated in the dispensary, but of the cases of syphilis seen in men during this time, the negroes make up 27.63 per cent.
If we determine the percentage which the cases of syphilis in white and black men, treated in the Skin and Genito-Urinary Departments during two years, bears to the whole number of males of each color admitted to the dispensary during that time, we find it is for the whites 0.91 per cent, while for the negroes it is 5.15 per cent. From this it would seem that in the men coming to this dispensary, the percentage of early syphilis is more than five and a half times greater in the negro race than it is in the white.
Sex.— Men, 92 white, 5 colored— 97; women, 11 white— 14. That is, the women represented about 12.6 per cent, of the whole number. In the dispensary the percentage of women suffering from tabes is smaller, being a little more than 9 per cent, (9.17 per cent.), whereas female patients represent a little more than 46 per cent, of all patients in the dispensary. In the cases of tabes treated in the wards of the Hospital, the percentage of women is distinctly larger than in the dispensary, reaching 25 per cent.
It is interesting to note that in the first 50 cases treated in the dispensary there was but one woman, and that she was the 50th case. On the other hand, in the wards, 3 out of the first 5 cases were women. This shows how very unreliable such statistics are unless a very large number of cases is considered.
Five of the patients were seen in the private wards of the Hospital and were from the higher strata of society. This is contrary to the usual statement that tabes affects women of the lower classes far more frequently than those who are more fortunately situated. Moebhis, out of 40 cases, found only one belonging to the upper classes.
This relative immunity that women appear to enjoy from tabes cannot be due altogether, I believe, to the fact that'fewer women suffer from syphilis than men. That syphilis is more common among men seems to be universally believed, and I have no doubt is true as a general proposition.
In certain classes of society, however, the difference, if it exists at all, cannot be great. As an illustration of this, the records of the Skin Department are instructive. During the two years preceding November, 1898, 130 men and 121 women were treated for the skin manifestations of syphilis, but during this time, more men were admitted to the dispensary in general, as well as to the skin clinics, so that if these figures indicated anything as to the liability of syphilis, it would seem that women are slightly more liable to the disease than men. We have as yet seen no case of tabes in a negro woman,* whereas syphilis is most common in them ; 42 of the 121 cases of skin syphilis in women were negresses, i.e. 34.87 per cent. The percentage of black females to the whole number of females in the dispensary is 14.23 per cent.
Age of Onset.
25-29 30-34 35-39 40-44 45-50 50 and over.
17 24 27 16 15
Total, 107
The time of onset of the disease showed nothing of very great interest. Most of the cases developed between 30 and 50. The youngest case was 25, and the oldest 66. The series includes 15 cases which developed after 50, and this is a larger number than would be expected. It may be doubted whether these senile cases should be included, but I do not see how we can do otherwise when the patients present the symptoms and signs that would have led to the diagnosis of tabes had they occurred at an earlier age.f
The onset of tabes is often very insidious and the early stages-may last for many years and it seems probable that some of these patients may have been unconscious or may have forgotten the first symptoms.
Duration of the Disease at the Time of Examination. — Cases, 104. This could be determined with more or less accuracy in 104 cases. Duration 1 year or less, 18 cases; between 1 and three years, 34 cases; between 3 and 5 years,
Since this analysis was mailewe have examined a colored woman in the Neurological Dispensary (No. 9525) who is suffering from
symptoms that indicate tabes ; irregular pains, numbness of the feet, difficulty in walking, loss of knee kicks, objective sensory disturbances on legs. The pupils were normal, and no history of syphilis could be obtained.
t Neurol. No. 2947. A man 70 years old, who gave the history of having had a venereal sore at 25, which was followed by a doubtful secondary skin eruption, came to the dispensary complaining that for the last 4 years he had had difficulty in walking in the dark. He had also had slight shooting pains and his feet felt numb. His pupils were of normal size. They reacted very slightly to light, the left better than the right. Both pupils reacted well during accommodation. His knee jerks were absent, his walk was stamping, the heel being brought down first, and he was unable to stand firmly with eyes closed. There was considerable anaesthesia of his legs.
April, 1899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
53
17 cases; between 5 and 10 years, 21 cases; between 10 and 20 years, 10 cases ; 30 years, 1 case.
Most of the cases (69) were seen during the first 5 years of the disease, but in 11 cases it had lasted 10 years or more, ouce even reaching 30 years.
Etiology. — Believing as we do that syphilis is the cause of the vast majority of cases of tabes, we have practically confined our attention to this factor.
Only men have been considered in the following table, and there are definite notes in 95 of the 97 cases.
Exposure to venereal contagion denied... 3 Exposure admitted but infection denied.. 7 Infection denied (exposure?) 7
Venereal infection denied . . 17 17.89per cent.
Gonorrhoea alone 18
Venereal sore denied 35 36.84 "
Gonorrhoea with chancre— indefinite. ...15 Gonorrhoea with syphilis 20
Gonorrhoea* 53 55.78 "
Chancre, syphilis 38
Syphilis with no history of chancre 2
Certain syphilis 40 42.1 "
Chancre indefinite 20
Possible syphilis 60 63.1 "
By certain syphilis is meant the definite history of a chancre which was believed to be syphilitic and was treated as such, or the history of a chancre which was followed by secondary manifestations, and in two instances, where skin eruptions were recognized as syphilitic, although there was no history of the primary sore. All other venereal sores have been tabulated as indefinite chancres.
In taking the histories, the supposition has been that in all cases of tabes syphilis lias preceded, and the burden of proof has been with the patient who denied its presence.
The results are: Certain syphilis, 42.1 per cent.; possible or probable syphilis, 63.1 per cent. These figures fall below those obtained by many of the later observers, but it is not due to lack of zeal.
Some time ago I analyzed the sexual histories of 1238 men who came to the Neurological Dispensary suffering from all sorts of troubles; in them I found certain syphilis in 10.9 per cent., and possible or probable syphilis in 21.4 per cent.
These percentages are much smaller than those found in tabes and the inference that syphilis bears an important relation to the development of tabes is plain, but I must resist the temptation of entering fully into the discussion of syphilis as the cause of tabes. It may not be, however, out of order to sum up what the cases studied here seem to show :
1. In a large proportion of cases of tabes, a history of syphilis can be obtained.
2. In a certain and not inconsiderable number of cases there h no history of a venereal sore or other syphilitic manifestations.
3. In negroes, tabes is relatively uncommon, whereas syphilis is much more common in them than in the white population.
Xote.— In some of the early cases the history in regard to
gonorrhoea was not particularly noted and for this reason the number given is probably too small.
1. The partial immunity of women is greater than can be satisfactorily accounted for by the relative infrequency of syphilis among them.
I do not take these conclusions as indicating that syphilis is not the most important cause of tabes; on the contrary, they seem to me to speak in favor of this belief. The fact that we were unable to elicit the history of syphilis in 36 per cent, of our cases does not of course prove that syphilis was not present in a large proportion of these cases.
Although tabes does not seem to be common in the negro, when it does occur, it has usually been preceded by syphilis. In four of our five cases there was the history of a venereal sore, and the same has been shown in the cases of tabes in women.*
That syphilis is not the only factor in this causation of tabes does seem to be shown. What the factors are that make white men so much more liable than black women to the development of tabes, I am sure I do not know; but of this 1 feel reasonably certain — that it is not due simply to the difference of primary syphilis among them. To say that it is due to a racial and sexual difference in the power of resistance of the nervous system, does little more than restate the facts.
Virchowf has lately raised his voice against the methods of study which have led to the all but universal belief that talus is always directly dependent upon preceding syphilis.
The time between the syphilitic infection and the first symptoms of tabes varies a good deal. This point was determined in 47 cases.
Tabes developed after the venereal sore in 47 cases. In the first 5 years, 6 times; in the second 5 years, 10 times ; in the third 5 years, 13 times; in the fourth 5 years, 10 times ; in the fifth 5 years, 4 times ; after 25 years, 4 times.
The shortest interval was 2 years, and the longest intervals were 26, 27, 30 and 42. It occurred about equally in the second, third and fourth five years.
As to the other causes of tabes, our histories show nothing important.
Initial Symptoms.— Either alone or associated, the following symptoms occurred as initial symptoms: Pain, 57 times ; ataxia, 24 times; numbness, extremities, 6 times; eye symptoms, 20 times ; nausea and vomiting (gastric crises), 4 times ; paralysis of bladder, 5 times; loss of sexual power, 1 time; paralytic attacks, 2 ti s; mental symptoms, 1 time; neurasthenia, 1 time.
Pain. — Pain was the first symptom in the majority of cases, occurring first or very early in the disease 57 times, li was unassociated 41 times and accompanied by other symptoms ID times.
Ataxia. — Difficulty in walking and ataxia were the firs! symptoms 15 times, and were associated with other symptoms 9 other times.
Eye symploms. — Double vision was the initial symptom 6 times. Dimness of vision occurred first alone 4 times. Double vision and dimness of vision wei A once, and
Kron. Deut. Zeitschr. f.Nervenheilk., XII— 1898, p. 303.
tabes dorsalis beim Weiblicben Geschlecht."
tCentralb. f. Xervenheilkunde in Psychiat., Nr. 105, 1898, p. 623.
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JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 97.
vision with other symptoms 7 times. Ptosis was the first symptom, associated with pain twice.
Numbness of extremities occurred alone 4 times, with pain twice.
Paralysis of the bladder occurred alone 4 times, with pain twice.
Subjective Sensory Symptoms — Pain. — In 71 cases pain was a prominent symptom. This was usually described as the characteristic lightning or shooting pain. In most cases it was severe, but in some it was mild. The pains were usually localized in the legs, but in three cases they were confined to the body, and in two to the arms, and in six others they were more or less general.
Girdle sense or pain, 27. — This symptom was noted as being present in 27 cases. Sense of numbness in the extremities, 45 Numbness of the feet was complained of 30 times, the patients often describing a feeling as if the floor were not solid or as if they were walking on some soft substance. There was numbness in both the hands and feet 12 times, and in the hands alone 3 times.
Crisis. — Gastric crises, 9. There were nine patients who gave the history of having had gastric crises. In two of the cases the nausea and vomiting were unaccompanied by painIn one of the cases very typical gastric crisis and Argyll-Robertson pupils were the only symptoms of tabes.
Laryngeal crises, 2. Two of our cases were subject to spasmodic cough ; one of them was a typical case of tabes, but in the. other the diagnosis was doubtful.
Eectal crisis, 1. One patient complained that early in his disease he had been subject to intense pain that began in the penis and ran to the rectum.*
Eye symptoms — Optic atrophy, 11. — Optic atrophy occurred in 11, possibly 12 cases. The twelfth case was one in which one optic nerve looked as if atrophy had begun. In the other cases it was double.
Eye muscle paralysis, 33. — Transient double vision was noted as having occurred in 20 cases, and in 13 other cases there was a noticeable weakness of one or more of the external muscles of the eyeballs. In one of these cases there was complete external ophthalmoplegia.
Ptosis was present in 7 cases, and in 1 there was nystagmus.
Pupils — Size. — The pupils were unequal in 30 cases. The left was larger than the right 18 times while the right was the larger 8 times. In four instances the history did not specify which was the larger.
There was contraction of the pupils in ten cases and they were noted as dilated twice.
Pupillary reflexes. — Argyll-Robertson pupils, 70. Both pupils immovable to light, reacted well during accommodation, 59. In one eye, 3. Reacted slightly to light, well to accommodation, 8.
The pupillary reflexes were said to be absent 8 times, and weak 3 times. They were found to be normal 21 times.
Ataxia. — Ataxia was present 91 times: in the legs alone, 78
Since this list was completed I have seen another case of tabes
that complained of the same symptom.
times; in the arms alone, 2 times; in both arms and legs, 11 times. There was no ataxia 8 times.*
Romberg's symptom, 82. — Present 82 times, marked 59 times, slight 23 times, absent 7 times, not noted 22 times.
Ataxia with optic nerve atrophy. — In the cases which showed atrophy of the optic nerve, ataxia was marked in 2 cases. It was slight in 8 cases and was absent in 1. In two of the cases Romberg's symptom was marked in spite of the patients being blind. It was very slightly marked in 4 cases, and was absent in 4 and not noted in 1.
Deep reflexes. — The knee jerks were absent 87 times; weak 6 times ; normal 4 times ; not noted 14 times.
Bladder. — The condition of the bladder was noted in 83 cases: Weakness, 35 times; paralyzed, 19 times; normal, 29 times.
Sexual power. — The sexual power .was inquired into in 75 cases: Power and desire lost, 38 cases (marked increase before the loss in 3 cases) ; power and desire weakened, 24 cases ; power lost, desire retained, 1 ; power and desire increased 1; normal, 10; sexual power present, intercourse without sensation, 1 case.
Objective sensory disturbances. — There are definite notes in this respect in 90 cases: Objective sensory disturbances were present in 78 cases; absent in 12 cases.
These were more often in the legs (40 times), but were also demonstrated in the arms and about the chest.
Definite areas of anaesthesia were marked out about the chest in several cases, but this was looked for and not found in more cases. The number of examinations, however, was not sufficient to make the definite proportions of any great value.
Muscular sense. — There were definite notes in 44 cases. In these it was disturbed 38 times, normal 6 times.
Trophic disturbances — Charcot's joints (Arthropathies). — These occur in a typical manner in 5 cases. There was suspicious enlargement of the joint in 3 cases.f In the 5 cases it occurred 3 times in the knee joints, 1 in the shoulder, and 1 in the elbow.
Perforating ulcer. — This occurred 5 times.
Mental Symptoms. — There were mental symptoms present in seven cases, and in one case there was a history of a previous attack of acute insanity, and in one epilepsy had been present from the 14th year up to the time of the onset of tabes, at 44. Since then there had been no fits.
In the 7 cases showing mental symptoms general paresis was suggested. In two of the cases this disease developed while the patients were under observation.
In eight (8) of the cases the ataxia developed quickly. At times
this followed an accident, but at other times there was no cause that could be determined. In most, if not all, of the cases, symptoms of tabes had been present for some time before the acute development of the ataxia.
t In one of these patients, who, since this was written, has returned to the dispensary after an absence of two years, and who had, at the time of his first examination, in 1897, a suspicious swelling of the last phalangeal joint of the left index finger, there has developed an undoubted tabetic arthropathy of the right thumb. This patient also had a healed perforating ulcer.
April, 1899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
55
ON TYPHOID SEPTICEMIA, WITH THE REPORT OF TWO CASES, ONE OF WHICH WAS A TYPHOID INFECTION WITHOUT INTESTINAL LESIONS.
By August Jerome Lahtigau, M. D., Assistant in Pathology and Bacteriology, Bender Hygienic Laboratory, Albany, New York.
Our knowledge of the various forms of typhoid infections has rapidly increased within the past few years, and more particularly that regarding the character of those atypical and more rare forms, the chief interest of which lies in the singularity of localization of the typhoid bacillus. The value of the contributions of recent years is largely the outcome of improved bacteriological technique and closer and more accurate study of the natural history, cultural behavior and experimental manifestations of the bacillus typhosus and the bacillus coli communis. Investigators have appreciated more and more the necessity of exact methods of differentiation between bacterial forms, and especially between more or less closely allied species, such as the bacillus of typhoid fever and the colon bacillus.
The absence of precise methods of differentiation between these two micro-organisms by the earlier workers in this field has, of necessity, thrown much discredit upon the conclusions and results of otherwise much good and brilliant work. The belief of the passage into, and existence of, the typhoid bacillus in the blood of the general circulation is by no means a new one, as shown by the writings of some of the early writers who worked upon typhoid fever. Eutimeyer, Almquist, Meisels, Xeuhaus, and others, claimed to have cultivated the bacillus from the general blood and that of the rose-spots during life, but their work, through the latter researches of Janowski, Staguitta, Grawitz, Fraenkel and Simmonds, and Sittman has not received acceptance. According to some observers the typhoid bacillus in almost every case at some time of the disipes into the general circulation from the more common foci of infection.
This view has received some support from the investigations of late years, demonstrating the great multiplicity of localization of Eberth's bacillus in the human economy: lesions of the bones, pulmonary implications, uterine infection, abscesses of various nature, etc., in all of which the organism has been found in pure culture. Wright and Semple' and Sanarelli 5 and other observers regard typhoid fever as primarily a blood infection, the two former writers basing their contention largely upon the fact that in the urine of almost every case suffering from typhoid fever they were able to find the specific organism. Kecent researches, however, show more and more conclusively that the typhoid bacillus is not, commonly, to be found in the blood of the general circulation. The explanation of this apparent discrepancy between the results of Sanarelli, am! Wright and Semple and other observers, who from their investigations have shown that the bacillus is only infrequently found in the general circulation, is to be found probably in the suggestive experiments of Wyssokowitsch 3 and the observations of Welch and Nuttal*. The first experimenter in some very interesting experiments upon rabbits was able to show that the organs in which typhoid bacilli are commonly found play a very important role in the removal of introduced bacteria from the blood. After injecting pure cultures of the typhoid bacillus into the blood the animals were sacrificed at
the end of eighteen hours, and bacteriological examination invariably failed to show bacilli in the blood of the general circulation, but always showed them in great numbers in the spleen. Welch and Xuttal in 1891, on the other hand, demonstrated the bactericidal properties of human blood serum for the typhoid bacillus, an observation since coufirmed by a host of investigators.
Instances of typhoid septicaemia diagnosticated during life by isolating the bacilli from the blood are very scanty in number. Bozzolo, 6 Guarnieri," and Silvestrini 7 have reported cases of this nature; Wiltschour 8 in the examinations of 35 cases found it once; Ettlinger 9 similarly succeeded in cultivating it from the blood during life, but a second culture in the same case from the vein of the forearm, the day before the patient's death, gave a doubtful result. Thiemich" 1 found it once in the blood taken during life from a vein of the forearm, and Stern" was likewise successful in two instances. P. Teissier 15 isolated the typhoid bacillus from the blood of a young man in the loth day of his disease; Kuhnau' 3 grew the organism from the blood of a pregnant woman during life in which the subsequent post-mortem findings confirmed the existence of a typhoid septicemia; more recently this writer" has published the reports of nine additional instances in which he found typhoid bacilli in the blood out of 11 cases of typhoid fever submitted to bacteriological examinations. E. Dates Block 15 has reported a very conclusive example of this kind in which the typhoid bacillus was discovered in the blood during life on two different occasions, at an interval of four days. This ease presents several interesting features, among others being the fact that a culture taken on the day before the patient's death contained the bacillus typhosus, whilst the bacteriological examination, post mortem, demonstrated its presence only in the spleen, liver, placenta, and kidneys, and the bacillus pyocyaneus in the heart's blood. In the recent Medical and Surgical Keports of the Presbyterian Hospital," Walter K. James aud George A. Tuttle report three cases in which they succeeded in isolating the bacilli from the blood during life.
The diagnosis on the autopsy table of general invasion by the bacillus typhosus is far less rare than its recognition during life, but it must not be supposed that as a post-mortem finding it is a frequent occurrence. The very early reports of this kind will not be considered in this paper, since their study was carried on at a time when the differences between the typhoid bacillus and the colon group were less appreciated than now. Karlinski," Vincent," Klein,"' Banti, 3 " WrigW and Stokes, 5 ' Flexner," Carter, 53 Chiari and Kraus, 5 ' aud finally Blumer" have contributed a fair number of instances in adults that showed the organism in the blood after death. Typhoid septicemia is an occurrence of comparatively greater frequency in the foetus born of a mother suffering from typhoid infection. The passage of the organism from mother to foetus has repeatedly received demonstration in the observations of
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Frascani", Janiszewski", Fremiti and Levy", Durck", Etienne 30 , Marfan 3 ' and probably earlier observers.
The question of the bacterial associations in this class of infections is an exceedingly interesting one, and especially the influence of secondary infections in modifying the relation of the patient to the typhoid bacillus. Vincent" in 1891 called attention to the importance of the streptococcus in typhoidal infections. This observer found in cases of typhoid fever brought to autopsy the streptococcus and typhoid bacillus associated in six out of thirty-one cases. The investigations of Flexner" similarly demonstrated the frequency with which the streptococcus is found as a complicating factor in this disease ; other observations of the same nature were made by Wright and Stokes", Netter", E. Fraenkel 36 , Karlinski 3 ', Carter 38 , and others.
The recently published case by Blumer 39 deserves special mention, not only as an instance of typhoid and streptococcus septicaemia, but also as a rare example of combined typhoid and streptococcus puerperal infection. The case was that of a married woman, 34 years of age, who was confined by a midwife. On the sixth day of the puerperium the patient, shortly after a hearty meal, was taken with dyspnoea and incoherency of speech. She rapidly became delirious and semi-comatose. The temperature was 100.8 F. The uterus was apparently normal. Patient died two days after the onset of her trouble. The postmortem examination showed the existence of typhoid fever: swelling and ulceration of Peyer's patches in the lower end of the ileum, acute spleen tumor and enlargement of mesenteric glands. The cultures from the heart's blood, liver, spleen, and uterine cavity, contained the streptococcus pyogenes and the bacillus of typhoid fever.
For the abstracts from the histories of the two following cases 1 am indebted to Drs. Henry Hun and Joseph D. Craig, of Albany, New York :
Case I. — Miss A., 20 years of age, came under observation October 19, 1897, complaining of gastric disturbances and fever. The past history is unimportant, except that three years before she had an attack of grippe, which was accompanied by very irregular and alarming heart action. On the 16th day of October, 1897, the patient was taken ill with nausea, and was actively sick at her stomach. The following day she still felt ill and a physician, who was called in, found a temperature of 102° F., together with a very decided degree of prostration. The patient brought under observation at this time did not show any tenderness or gurgling in the right iliac fossa and there had been no diarrhoea. From this time there was fever varying from 102° F. to 106.6° F. — the temperature at the time of her death. The spleen and liver became enlarged, later delirium supervened, vomiting persisted and cardiac weakness became prominent ; no diarrhoea at any time. Patient died October 25, 1897.
The autopsy was made on October 26th, 15 i hours after death.
The following notes are abstracted from the autopsy protocol : Exterior. — Body of a slender-built, moderately well-nourished girl. Rigor mortis well marked all over. Post-mortem lividity in the dependent parts. Pupils mid-wide and equal. Mucous membranes slightly cyanotic. Surfaces of body gen
erally pale, subcutaneous fat moderate in amount. Abdominal muscles of a homogeneous red-brown color. Peritoneal cavity dry, parietal layer smooth; visceral layer shows numerous areas over which there is congestion apparently corresponding to Peyer's patches. Omentum delicate, free from adhesions, completely covering the intestines. Appendix about 9 cm. long, has a distinct mesentery to within 1 cm. of its tip ; passes downward and inward across pelvic brim. The liver is visible two fingers' breadth below the costal margin in the mammary line. Spleen not visible. Both pleural cavities were dry; both lungs presented about the same appearance; the upper lobes were slightly congested; the lower and middle lobes on the right side and the lower lobe on the left were much congested, and on pressure a large quantity of dark blood could be expressed. A small quantity of mucus could be expressed from the medium-sized bronchi. Bronchial mucous membrane irregularly congested.
Heart. — Pericardium contains no excess of fluid. Pericardium is smooth. There are a few pin-point sub-pericardial hemorrhages. Heart contains fluid blood. The endocardium on the right side is smooth, the muscle shining through it has a somewhat mottled appearance in places. The tricuspid and pulmonary semilunar valves are normal. The length of the right ventricle is 6 cm.; the average thickness of the wall 4 mm. The pulmonary artery has a circumference of 5 cm. The endocardium of the left side of the heart is, in places, slightly thickened over the auricle. The ventricle is normal. Aortic and mitral valves are normal. Heart muscle is rather flabby and on section has a very cloudy, grayish-brown color, in places somewhat mottled in appearance. In both coronary arteries, which are patent, are small elevated areas of fatty atheroma. Spleen is much enlarged, measuring 17 x 20 x 5 cm. The capsule is smooth, tense; consistency of organ much softer than normal. On section the organ is of a chocolate-red color. The pulp is considerably increased in amount. The Malpighian bodies are plainly visible as pin- point, gray, circular areas. Liver is considerably increased in size, measures 23xl9x6£ cm. There seem to be a number of pinhead-sized hemorrhages beneath the capsule; consistency much softer than normal. On section the organ has the typical boiled appearance; the lobules are indistinct, the peripheries being quite yellow where they can be made out. Scattered throughout the organ is a number of pinhead-sized blood-red areas, apparently hemorrhages.
The adrenal glands appear normal.
Kidneys of about the same size, averaging 13x4£x3cm. fibrous capsule normal and strips off easily ; surface smooth; surface veins little dilated. On section cortex is swollen ; corfcex markings are somewhat indistinct; the glomeruli barely visible; the medulla congested. Pelvis appears normal.
Stomach and pancreas and female generative organs not examined.
Intestines.— Duodenum slightly bile-stained. Mucous membrane slightly congested ; jejunum shows similar changes, but with apparently no ulcerations. In the ileum, beginning 80 cm. above the iliocsecal valve, are a series of lesions affecting the solitary follicles and Peyer's patches. They are least marked in the upper portion of the ileum, where they consist in a great swelling of the lymphatic apparatus. The solitary follicles
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measure as much as one-half cm. in diameter. The most recent swollen patches are considerably elevated above the surface. Thej have a mottled appearance, the predominating color being pink, and the mottling being due to yellowish areas, presumably of necrosis, as in one or two places the surface has been broken and ulcers formed. In the lower portion of the ileum the swelling is much more extensive and the necrosis much more marked. The solitary follicles are often the size of a large pea, their inner surface being capped with an ulcerated area on which a yellow necrotic material is situated. The swollen Peyer's patches in the lower portion of the ileum show, scattered over their surface, numerous ulcerated areas, capped with this same yellowish necrotic material, varying in diameter from 4 mm. to considerably over a cm. The edges of all these ulcerated areas are, in places, distinctly hemorrhagic and. as a rule, the blood-vessels of the intestinal wall can be seen radiating from the edges of the lymphatic apparatus, tilled with blood. The lymphatic apparatus of appendix is markedly swollen, but no ulcerations are present. The upper portion of the colon is thickly dotted with swollen solitary follicles. These have an average diameter of about 7 mm., are considerably raised above the surface of the intestine, and show on their inner surface ulcerated areas capped by yellowish necrotic material similar to those seen in the small intestine. They differ from these latter from the fact that their bases are, as a rule, distinctly hemorrhagic, each nodule being surrounded by a distinct zone of submucous hemorrhage. The lower part of the colon is almost entirely free from such areas, but contains a number of discrete or confluent pin-head areas of hemorrhages.
Mesenteric Glands. — Particularly those behind lower portion of ileum are extremely swollen. They are soft in consistency and on section have a mottled appearance, the predominating color being a bright pink, the mottling being due to pin-point gray areas, which are scattered through them, perhaps the swollen follicular portions of the glands.
Anatomical Diagnosis. — Typhoid fever (beginning of second week), with typhoid septicaemia. Swelling of Peyer's patches and the solitary follicles with superficial necrosis and ulceration. Marked involvementof the solitary follicles in the upper portion of the colon. Great swelling of the mesenteric glands. Acute spleen tumor. Cloudy swelling of the heart muscle, liver and kidneys.
The microscopic examination of the heart, lungs, and kidneys adds particularly nothing to the macroscopic observations, except that the heart muscle showed the evidences of a moderate degree of fragmentatio myocardii. The following are the notes from the protocol regarding the microscopic appearances of the liver, spleen, mesenteric glands, and intestines:
Liver. — Capsule is everywhere normal in appearance. The connective tissue is not increased in amount. Liver cells are greatly swollen and extremely granular. Scattered throughout the liver substance are numerous, almost circular areas, presenting varying appearances, according to the stage of development. In some instances the areas show merely an extensive necrosis of the liver cells, many of them in such areas having lost their nuclei, this loss of nuclei giving rise to a light colored patch in the liver substance. .Many of the other areas show, besides this necrosis, an infiltration with
cells of varying characters. In some of them the necrotic area is infiltrated, for the most part, with small round cells of the lymphoid type. In others, large numbers of irregularly shaped epithelioid cells are present. No giant cells can be made out. The nodules resemble very markedly, in some instances, miliary tubercles, but there is not present a definite arrangement of the two varieties of cell, such as exists in tubercle; but, on the other hand, the two forms are evenly intermingled in the nodules. These nodules apparently bear no definite relation to any particular anatomical structure of the liver in most instances, although at least in one instance the necrotic area lies exactly around the central vein of the lobule. Besides areas of necrosis, there are found scattered through the organ a number of blue-staining areas, usually of much less extent than those occupied by the nodules. These areas have a granular appearance under the low power and which is more marked under the high power. It can be seen, at the edges particularly, that they are made up of individual rod-like structures resembling the typhoid bacilli. The blood-vessels of the liver show no particular change ; nor do the bile-vessels.
Spleen. — Capsule not thickened. Trabecular substance is normal in amount. The amount of blood present in the pulp is tremendously increased over the normal. Furthermore, it can be made out with the high power that in a great many instances the red-blood corpuscles are contained in large cells. Scattered throughout the organ are a numberof almost circular areas, in which it can be seen with the high power that considerable necrosis exists, as is shown by lack of nuclei and many of the spleen cells, and by the presence of nuclear fragments. These areas, as in the liver, are often infiltrated with lymphoid and epithelioid cells. There are also present in the spleen numerous blue-staining granular collections of bacteria similar to those seen in the liver. In some instances these collections of bacteria are in definite relation with necrotic areas, but this could very rarely be made out in the liver.
Mesenteric glands. — The amount of normal gland structure is very small. Almost the entire gland appears to be in a necrosed condition. In some areas the necrotic foci contain very large quantities of fragmented and destroyed nuclei. In other places very few of these are present. Among the necrotic areas are to be found, as in the liver and spleen, numerous epithelioid and lymphoid cells, some of these latter doubtless being cells which normally belong to the lymphoid glands. The areas of necrosis may possibly have been focal in origin, but in the section under observation they are so extensive that one coalesces with the other all over the gland. There are apparently no clumps of bacteria in this section under observation.
Intestines. — The lesions of the intestine vary. In all cases the superficial layer of the intestine seems to be necrotic to a certain extent, but this at any rate is doubtless due partly to post-mortem change. In the earliest stage of the disease to be made out in these sections, the lymphoid apparatus is 1 1 dously swollen, the cells present in the swollen area no longer being apparently lymphoid in character, but many epithelioid cells are also present. All through the swollen area there are evidences of necrosis in the form of numerous nuclear fragments. In the earlier stages the muscular coat of the intestine
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does not appear to be affected. The section which shows a more advanced stage of the disease shows that the progression consists mostly in the extension of the necrotic processes. In some instances the whole involved area is entirely necrotic, almost to the depth of the muscular coat, and there may be present beneath this necrotic material and between it and the muscular coat fibrin, in whose meshes are entangled polynuclear leucocytes and epithelioid cells. In this stage the muscular coat itself usually shows the presence of a few polynnclears and a large number of small round cells or epithelioid cells. Elsewhere in the swollen areas the necrosis is extensive, as in the mesenteric lymph glands. There is hardly an area in the section which has escaped it, In the later specimens the amount of cellular infiltration in the muscular coat is often very large, the muscle fibre being pushed widely apart by it, and in some places being distinctly necrotic over large areas. The infiltrating cells, under these circumstances, seem to be mainly small, round and epithelioid cells with an occasional polynuclear. Blue-staining collections of bacteria are seen in very large numbers in the deeper part of the necrotic areas in some of the sections.
Bacteriologic Report. — Coverslips from the mesenteric glands, spleen and bone marrow all show the presence of medium-sized, short, thick bacilli frequently occurring in clumps. Cultures were taken upon slant agar-agar from the heart's blood, spleen, lung, liver, mesenteric glands, kidney, and bone marrow.
The culture from the heart's blood, after 24 hours' incubation, contained four discrete pinhead-sized, gray-white, slightly elevated colonies. The morphologic appearances showed the presence of a bacillus of moderate length and thickness, apparently a pure growth. Culturally the organism behaved as follows:
Litmus milk. — No acidification or coagulation of the milk after six days' incubation in the thermostat at 37i° C.
Potato. — A moist, just perceptible growth along the line of inoculation.
Bouillon. — Diffuse cloudiness of the nutrient medium. Hanging drop preparations from young cultures show active motility.
Gelatin stab. — Whitish growth along the line of inoculation ; no liquefaction of the gelatin.
Dunham. — Diffuse cloudiness of the medium. No indol reaction. No gas formation in saccharose, glucose or lactose media.
Agar slant. — Moderate, moist, whitish elevated growth. This organism, with the serum of an undoubted case of typhoid fever, showed a very positive Widal reaction in dilutions, varying from 1 to 30 to 1 and 50.
Diagnosis. — Bacillus typhosus.
The cultures from the spleen, liver, mesenteric glands and bone marrow similarly contained a pure growth of a bacillus, morphologically and culturally, like the organism isolated from the heart's blood. The typhoid bacillus was also isolated from the kidney associated with the bacillus coli communis. From the lung the colon bacillus was isolated in association with the staphylococcus pyogenes albus.
Case II. — James K., aged 36, admitted into the Albany
Hospital, August 8, 1898, suffering from severe headache and pains in the arms and legs. The family history showed nothing of importance, and until the present sickness patient had always been quite well. Four days before admission he was taken ill with violent headache, fever, pains in limbs, and a slight chill. The following morning he went to his work, but felt so much worse that he went home and retired to his bed. The day before entering the Hospital he suffered from a nosebleed, and had another on his way to the Hospital.
The physical examination shortly after admission was quite negative, but the temperature was 102.2° F. Later on in the disease the liver became slightly, and the spleen very much, augmented in size. The bowels remained constipated from the beginning of the disease, and at no time did the patient complain of abdominal tenderness at any point. There was some vomiting on several occasions, but at no time was the gastric derangement very severe. Toward the end delirium came on. The temperature throughout the disease varied between 99.8° F. and 103°, until the day before his death when the temperature reached 105.2° F. Death August 25th, 1898.
The autopsy notes are as follows:
Body 175 cm. long, moderately well built, considerably emaciated. Rigor mortis in both extremities. Pupils wide and equal; mucous membrane pale; post-mortem lividity of dependent parts. Abdomen tense and very distended, apparently with gas. Walls discolored ; patches of greenish blue. Subcutaneous fat nearly absent. Muscles of thorax and abdomen pale and poorly developed.
Peritoneum. — Both layers smooth, glossy and free from injection. Omentum free from adhesions and contains a little fat; omental glands not enlarged. Intestines very distended with gas, particularly small intestines. Left lobe of liver visible below costal margin 5 cm. Stomach not apparent. Peritoneal cavity contains a small quantity of dark-colored, turbid fluid. Appendix measures 13.5 cm. in diameter, normal in appearance and free from adhesions; mesentery present throughout its entire length. Diaphragm fifth space on right side; sixth rib on left. Costal cartilages not ossified. Ketro-stern:il glands not enlarged. Both pleural cavities free from any excess of fluid.
Pericardium. — Both layers smooth ; cavity contains no excess of fluid.
Heart. — Contains red and chicken-fat post-mortem clots, and is distended with fluid blood; normal in size. The endocardium of the right heart shows post-mortem discolorations. Tricuspid valve normal ; also pulmonary and semilunar valves. The left heart shows areas of fatty atheroma in auricle; ventricle normal. Mitral leaflets very thick along their free edges. Aortic valves normal. Aorta just above valve shows areas of fatty atheroma. Coronary arteries patent; walls show large confluent patches of fatty atheroma. Heart muscle somewhat soft; on section, of a dark reddish-brown color (brown atrophy).
Left lung. — Bound down by old firm adhesions at the base and posteriorly. The pleura elsewhere is smooth. Lung crepitant; less so in normal than lower lobe. On section, the upper lobe is slightly congested; lower lobe markedly so and
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contains quantity of blood-stained serum, which readily escapes. Bronchial mucous membrane congested and covered moderate amount of mucus. One portion of the upper lobe contains a pea-sized, firm calcareous mass embedded in the lung substance proper.
Right lung. — Bound down by old firm adhesions laterally and posteriorly. Lobes very much increased in consistency, but still crepitant. On section, the three lobes generally present a similar appearance, and contain a large quantity of blood-stained serum, especially the lower lobe, from which it runs oft' in abundance. The three lobes are markedly congested. Bronchi and blood-vessels similar to other side. In several places are a number of nodules very firm, sharp, and circumscribed, varying from a small shot to large pea in size. On section, these nodules are calcareous.
Spleen. — Free from adhesions. The organ is very large, measuring 16x6x10 cm. Capsule not wrinkled, and smooth. Consistency much decreased. Trabecule not increased. Spleen pulp very much augmented. Malpighian bodies also very greatly augmented in size.
Liver. — Bound to the diaphragm and to the abdominal wall by adhesions. The organ is very much enlarged, measuring 26x20x8 cm. The capsule smooth. Consistency softer than normal. On section the organ is pale and cloudy (cloudy swelling).
Gall-bladder. — Distended with greenish-colored bile. Mucous membrane smooth and normal looking.
Left kidney. — Fatty capsule scanty. Fibrous capsule strips off fairly easily, occasionally tearing bits of kidney substance. The organ is somewhat enlarged. The surface is smooth ; veins somewhat prominent. On section the cortex is practically normal in amount; markings quite prominent ; glomeruli very distinct and congested. Medulla normal. Pelvis normal.
Pancreas, adrenals and left ureter are normal. Mesenteric glands not enlarged, or only very slightly so. Aorta shows occasional patches of fatty atheroma. Retro-peritoneal glands. — Enlarged, but not markedly so. The right adrenal gland occupies its normal anatomical position in relation to the surrounding viscera, but below it the kidney is absent. In its place is a small, somewhat (inn, inas.s of tissue 5 cm. long and 2 cm. in thickness, and which, on section, presents a very peculiar appearance, in no manner suggestive of renal tissue. The ureter of this side leads to this mass.
Bladder. — Contains a small quantity of light, turbid urine. The walls are not increased in thickness and the bladder is of normal size.
Intestines. — The small intestines show no injection of the mucous membrane nor are the solitary follicles swollen. In the small intestine Peyer's patches show no evidence of being swollen or of other implication. No evidence of ulceration or cicatrization. The mucous membrane of large int< ■ quite normal in appearance.
Anatomical Diagnosis. — Marked oedema and congestion ol both lungs; chronic adhesive pleuritis and healed (calcareous) tuberculosis of both lungs. Brown atrophy of heart, spleen tumor; cloudy swelling of liver and kidney; congenital
absence of right kidney ; slight swelling of mesenteric glands ; fatty atheroma of aorta ; coronary artery disease.
The microscopic examination of the heart shows some fragmentatio myocardii in addition to the macroscopic findings ; the lungs and kidneys microscopically show nothing very striking.
The following are some notes abstracted from the records of the microscopic examinations of the liver, spleen, and mesenteric glands:
Liver. — Capsule is normal in thickness. Connective tissue of the organ does not appear to be increased. The liver cells are swollen and rather indistinct. The nuclei are apparently, as a rule, well preserved. Scattered throughout the section in large numbers are circumscribed areas of focal change. In places as many as three of these can be seen under a low power. The appearance exhibited by these areas varies in different parts of the section. In some of them the process seems to be almost entirely necrotic in character, the liver cells in the area having lost their nuclei and taking rather an intense stain with the eosin. In these areas can be seen a few polynuclears and a number of small, round cells and cells of an epithelioid type. In other portions of the section the areas are extremely cellular and have the typical appearance of lymphoid nodules. In these instances the cells in such an area are either small or round cells, or rather long, irregular cells of an epithelioid type. There are no giant cells present, and the appearance of these nodules does not suggest tubercles. The nodules have apparently no connection with the vascular system of the organ. Besides these nodules, there can be seen occasionally in the liver substance patches of rather diffuse blue-staining material, which, under the high power, are seen to be composed of small rods, presumably bacteria. The hepatic vessels and the bile ducts are apparently normal. In one Held one of the bacterial patches described above is present in one of the areas of necrosis, but as a rule no such association exists.
Spleen. — The capsule is not increased in thickness. Trabecule appear normal in amount. The Malpighian bodies are rather large, but otherwise show no change. The pulp contains an excess of red-blood corpuscles, which are seal tired irregularly among the pulp cells. Some of these can be seen to be inside of large phagocytic cells. In a few places in the substance of the pulp there are sharply localized areas in n hicn the spleen substance has become necrotic. There are present in these areas a moderate number of cells ; a few of which are polynuclears, the rest either small, round cells or cells of an epithelioid type. The blood-vessels of the organ present about a normal appearance.
Mesenteric gland.". — Show extensive changes in the form of localized or diffuse areas of necrosis. These seem to be most marked in the central portions of the glands, but they are also present in the periphery. The necrotic areas stain sharply with the eosin, and contain large numbers of nuclear fragments, some polynuclear leucocytes, and a fair number of round cells and cells of an epithelioid type. In one or two places in the sections there are to be seen diffuse areas of bluestaining which, under the high power, are seen to be made up
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of masses of bacteria. These have no connection in any of the sections examined with the areas of necrosis.
Sections of the liver, spleen, kidney and mesenteric glands, stained by Flexner's methylene-blue method, showed masses of bacilli, resembling, morphologically, the typhoid bacillus.
Bacteriologic Examination. — Cultures were taken at the time of the autopsy from the heart's blood, lung, liver, gall-bladder, spleen, kidney and urine. From all of these, with the exception of the kidney and urine, one single organism was isolated which, morphologically, was a somewhat short, moderately thick bacillus which decolorized by Gram's method of staining. It grew upon media as follows :
Agar slant. — Abundant, moist, white, elevated growth.
Blood serum. — A growth very similar in appearance to that on agar.
Potato. — A moist, slight, almost invisible growth.
Bouillon. — A diffuse cloudiness. Hanging-drop preparations show a well-marked motility of the bacillus.
Dunham. — A diffuse cloudiness; no indol reaction could be obtained.
Litmus milk. — After several days it acidified milk, but failed to produce any coagulation.
Gelatin stab. — Moderate white growth along line of inoculation, but no liquefaction of the gelatin.
No gas formation in saccharose, lactose or glucose media.
Cover-glass preparations, stained by Pittfield's method, showed the flagella with a peritrical arrangement. Tested with known typhoid serum, the bacillus produced a typical Widal reaction in 12 minutes with a dilution of 1 to 10; in 42 minutes with a dilution of 1 to 100.
Diagnosis. — Bacillus typhosus.
The cultures from the kidney and urine contained the typhoid bacillus, but associated with an organism giving all the tests for the bacillus coli communis.
The possibility of the existence of typhoid fever without intestinal lesions was long since conceived by Louis 40 , who, himself in Observation 52 of his book, reported au instance that during life presented a typical clinical picture of typhoid fever. The patient died on the 55th day of his disease, and the necropsy showed absolutely no existence or evidence of recent implication of the intestinal canal. The belief of the occasional existence of typhoid fever without anatomic intestinal changes was entertained by a number of the earlier clinicians after Louis, but the clinical simulation of enteric fever by other maladies necessarily, in the absence of bacteriologic criteria, makes these reported cases less valuable as contributions to the study of this rare type of typhoid fever. The conclusive demonstration of this form, without intestinal lesions, dates since the discovery of the specific organism of etiologic importance, and more especially from the time when the differentiation of the typhoid bacillus from allied species became more firmly established. In addition to the reported cases of Banti", Karlinski,' 2 Guarnieri", Vaillard", Chantemesse' 6 , and Vincent", other instances carrying more conviction have been published by more recent writers.
DuCazal", in 1893, reported the case of a young man, 21 years of age, who had been ill for fifteen days before entering the Hospital. The clinical history suggested typhoid fever,
subsequently complicated by double pneumonia. At the autopsy the principal lesions were pneumonia of both lungs and acute spleen tumor. The intestines showed absolutely no evidence whatever of any anatomic alterations, but the cultures from the spleen contained bacilli, morphologically similar to, and on media behaving like, Eberth's bacillus. Kiihnau" some years later published an interesting observation of this kind. The patient was a pregnant woman, 32 years old, who developed typhoid fever with the subsequent development of erysipelas of the face. Bacteriologic examination of the blood during life showed typhoid bacilli, as already mentioned. The woman died, and the post-mortem examination showed enlargement and necrosis of mesenteric glands, abscesses of the kidneys and thrombosis of one of the ovarian veins. The intestines were free from any lesions whatever. The bacillus typhosus was cultivated from the kidneys, mesenteric glands and spleen.
The case of Pick" was that of a 23-year-old woman, who died in the fourth week of a typhoid fever. During life the Widal reaction was positive. The anatomic diagnosis of the autopsy was : Typhoid infiltration of the mesenteric lymph glauds, parenchymatous degeneration of organs, and left-sided lobular pneumonia. The spleen was not enlarged and the intestines were free from lesions. The serum test after death was positive in 1 to 10; cultures from the gall-bladder and mesenteric glands contained the typhoid organism ; that from the spleen was negative.
Meunier 60 , at the seance of the Societe Med. des Hop. de Paris of April 7th, 1897, reported an uncommon observation of typhoid infection in a boy, 8 years of age, suffering from acute miliary tuberculosis. Shortly after admission into the Hospital rose-spots appeared and the application of the Widal test gave a positive reaction. The lesions found at the necropsy were tubercular ulcers of the intestine. Typhoid bacilli were demonstrated in the cultures from the spleen, lungs and pleural exudate.
Beatty", about the same time, published a case of typhoid fever, commencing with nausea and pain in the back followed by jaundice. Death on the sixth day. The examination after death showed an enlarged spleen and mesenteric glands, but in the intestines there was au absence of lesions. The spleen contained typhoid bacilli.
Chiari and Kraus", in a very recent and valuable article, have discussed the subject very exhaustively and reported seven cases of atypical typhoid infection, in which there was an absence of anatomic lesions of the intestines. These observers classify enteric fever into four great anatomic divisions : The first include all those cases presenting the characteristic typhoid lesions; the second those anatomically atypical but, nevertheless, recognizable cases on the autopsy table ; the third comprising that class of cases characterized by an absence of anatomical lesions, making the diagnosis, anatomically, impossible, but in the organs of which typhoid bacilli are found ; and finally, the last group to include such cases as cannot be diagnosticated anatomically or bacteriologically, but which give positive serum reaction with the Widal test. Group III, of this classification, is of particular interest to us, inasmuch as the Case II, reported in our paper, belongs to this class. The
April, 1800.]
JOHNS HOPKINS HOSPITAL BULLETIN.
61
typhoid septicemias frequently fall under this heading. Of the five cases reported by Chiari and Kraus as belonging to this group, only three were based on the presence of the typhoid bacilli in one or more of the organs. The diagnosis of Cases XV and XVI is entirely based on a positive result of the serum test, no typhoid bacilli having been demonstrated in any organ. Although, with proper precautions and in sufficiently high dilutions, the specificity of the serum reaction is almost absolute, nevertheless certain errors must necessarily arise at times, and these become increasingly great as the dilution is made lower and lower. Chiari and Kraus used dilutions of 1 to 10 and 1 to 12, degrees of dilution particularly susceptible to fallacious results. In view of this, Cases XV and XVI lose much of their interest as examples of typhoid fever without intestinal lesions. These remarks likewise, in our opinion, apply with equal force to Case XVI II and all the cases of group IV, the diagnosis of all of which being based on the serum reaction with very low dilutions.
Flexner and Norman Harris (53) very recently have contributed a very carefully studied additional example of typhoid infectioii without intestinal lesions. The case was that of a man. G8 years of age, who suffered from shortness of breath, symptoms of pleuritis, and finally died two days after admission into the Hospital. The autopsy, performed one hour after death, showed thrombosis of pulmonary artery, gangrene of lung, perforation of pleura, pyo-pneumo-thorax, acute spleen tumor, parenchymatous degeneration of liver and kidneys. The mesenteric glands were not swollen, and the intestines showed nothing abnormal. The bacteriologic examination demonstrated the presence of typhoid bacilli in liver, spleen and lung.
Examples of typhoid fever, without intestinal implication, are not entirely limited to adults, but, on the contrary, the apparent small disposition to intestinal lesions of very young children suffering from this disease is one of considerable interest in this connection. Chanteinesse and Widal (54) called attention to the trivial character of the intestinal lesions in the young some years ago; and Brouardel and Thoinot (55) likewise mention this peculiarity, as does also Marfan (50). The publications of Etienne (57), Freund and Levy (58), and others, include cases of this character in which the intestinal lesions were at a minimum or totally absent.
Literature.
1. Lancet, 1895, Vol. II, p. 190.
2. Riv. d'igiene e sanita publica, 1893, Nr. 211. Annales de lTnstitut Pasteur XI, p. 221, L893.
3. Zeitschrift f. Hygiene, 1886.
4. Block, Bull. Johns Hopkins Hospital, 1897, p. 119.
5. Vchr. d. 10th Int. Cong., Berlin, Vol. II, 1890, p. 188.
6. Riv. gen. ital. di clin. med., 1892, p. 234.
7. Kiv. gen. ital. di clin. med., 1892, p. 330.
8. Rev. Centralb. f. Bak. and Parasitkde, 1890, S. 279.
'.'. Cited by Wurtz, Precis de Bacteriologic Clinique; Paris, 1895, p. 37.
10. Deutsch. Med. Woch , 1895, No. 34.
11. Centralb. f. Innere Med., 1890, No. 49, p. 1249.
12. Arch, de Med. Exp. et D'Anat. Path., Vol. VII, No. 5.
13. Berlin, klin. Woch., July 27, 1*96.
14. Zeitschrift f. Hyg. trad Infetsktn., Bd. XXV, 8. 492, 1897.
15. Bull. Johns Hopkins Hosp., 1897.
16. Medical and Surgical Reports of the Presbyterian Hospital
of New York City, 1898.
17. Wien. Med. Woch., 1891, Nos. 11 and 12.
18. Annales de l'lnstitut Pasteur, 1893; Le Mercredi Midi
cale, Fe.b. 17, 1892.
19. Baumgarten, No. 10, 1894.
20. Rif. Med., 1894, p. 674.
21. Boston Med. and Surg. Journal, March and April, 1895.
22. Journal of Pathology and Bacteriology, April, 1895; The
Johns Hopkins Hospital Reports, Vol. V.
23. Bull, of the Johns Hopkins Hospital, June, 1897.
24. Zeitschrift, f. Heilkuude, Heft V u. VI, p. 471.
25. American Journal of Obstetrics, etc., Jan., 1899.
26. Riv. gen. ital. di clin. med., 1892, p. 282.
27. Munch. Med. Woch., 1893, No. 38.
28. Berlin. Klin. Woch., 1895, p. 539.
29. Munch. Med. Woch., 1896, No. 36.
30. Gaz. Heb. de Med. et de Chir., Feb. 23, 1896.
31. Fievre Typhoi'de. Traite des Maladies de l'enfance; (I ran cher, Comby et Marfan, 1897.
32. Le Bulletin Medical, 1891, No. 91, p. 1049.
33. The Johns Hopkins Hospital Reports, Vol. V.
34. Boston Med. and Surg. Journal, March and April, 1895.
35. Quoted by Block.
36. Quoted by Block.
37. Cited by Vincent, Annales de lTnstitut Pasteur, 1893.
38. Loc. cit.
39. Op. cit.
40. Recherches anatomiques, pathologiques et therapeutiques
sur la fievre typhoi'de, 2d edition, p. 841.
41. Riforma Medica, Ottobre, 1887, p. 1448.
42. Wien. Med. Woch., 1891, No. 11, u. 12.
43. Riv. gen. ital. di clin. med., 1892, pp. 234-258.
44. Soc. des Hop. de Paris, March, 1890.
45. Soc. des Hop. de Paris, March, 1890.
46. Le Bulletin Medical, 1891, p. 1049.
47. Bull, et Memoires de la Societe des Hopitaux de Paris,
Tome X Troisieme, Serie 1893, p. 243.
48. Berlin. Klin. Woch., July 27, 1896.
49. Wiener Klin. Woch., 1897, Nr. 4, p. 84, Fall. II.
50. Bull, et Memories de la Soc. des Hop. de Paris, 1897.
51. Dublin Jour. Med. Sciences, Feb. 1, 1897.
.v.-. Zeitschrift f. Heilkunde, 1897, Heft V u. VI, p. 471.
53. The Johns Hopkins Bulletin, No. 81, Dec. 1897.
54. Soc. des Hop., Paris, March, 1890.
55. Traite de Medicine et de Therapentique, Brouardel, Gil bert et Girode, Tome 1, p. 756.
56. Traite des Maladies de l'enfance, Grancher, Comby et
Marfan, Fievre t.yphoide.
57. Loc. cit.
58. Loc. cit.
62
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 97.
CAVITIES IN THE BRAIN PRODUCED BY THE BACILLUS AEROGENES CAPSULATUS.
By Robert Reuling, M. D., Lecturer on Neurology, Baltimore Medical College, former Assistant Resident Johns Hopkins Hospital,
AND
Arthur P. Herring, M. D., Demonstrator of Pathology, and Prosector in Anatomy, Baltimore Medical College.
Reports of cases of subcutaneous and visceral invasion by gas-forming bacilli are multiplying rapidly. Chas. Norris' has given the most recent monograph on general infection by the bacillus aerogenes capsulatus. He reviews most of the recent literature and enters especially into bacteriological experimentation. The following case is of interest because the bacilli seemed to have had a predilection for the brain.
HISTORY OF CASE.
Mis. C. B. Age, 35. Colored. Admitted to the Surgical Ward of the Maryland General Hospital, suffering from shock caused by a gunshot wound of the abdomen. Prof. J. D. Blake was summoned and performed a laparotomy, suturing several perforations of the intestine. The bullet was not found. After applying the dressings the patient was put to bed and rallied from the operation very well. There was a slight rise of temperature the first day, but this soon subsided and it seemed as though an uneventful recovery would ensue. There was no pain or distention of the abdomen. Temperature and pulse normal, bowels constipated. On the third day a change in her condition was noticed. She seemed to be getting weaker without any appreciable cause. In a few hours after the change was noticed she quietly passed away. At the autopsy, which was performed 24 hours after death, the following condition was found: Body that of a strongly built and well-nourished negro woman. Rigor mortis marked. No crepitation of subcutaneous tissue. On opening the abdominal cavity the viscera appeared normal. The perforations were healing nicely; no indications of peritonitis. The bullet was found in left iliac muscle. On section of the various organs there were no appreciable signs of gas formation except in the uterus. Here a number of small spaces were seen. No gas could be detected, and on microscopical examination no bacilli were found. The heart and lungs were normal. The dura mater was found closely adherent to the calvarium. The brain was removed, surrounded by its meninges, and placed in a 4 per cent, solution of formalin to harden, before sectioning. The spinal cord was not removed. The external aspect of the brain was normal, the sulci and gyri being especially well marked. After the brain was thoroughly hardened (4 to 6 days), horizontal sections were made from the base upward, which revealed the following condition :
In the right hemisphere there existed a large cavity, involving the external capsule in its entirety, being five centimeters long, one centimeter broad and two centimeters deep, which appeared to be lined by a smooth glistening membrane. A small amount of bloody serum was found in it. Throughout the lenticular nucleus numerous small cavities were found, varying from one-half to one centimeter in extent. The anterior limb of the internal capsule, on a level with the middle commissure, contained several cavities,
also a small one in the optic thalamus. Another section made on a level with the velum interpositum showed the posterior limb of the internal capsule to be almost completely destroyed by two large cavities. None of these spaces communicated with the ventricles. The caudate nucleus was intact. In the external orbital convolution a large cavity existed, being three centimeters deep and one centimeter broad, apparently lined by a smooth membrane.
Left hemisphere was smaller than the right. The first section revealed a cavity in the anterior limb of the external capsule two centimeters long and one centimeter deep. In the posterior limb 3 to 6 small pits or depressions were seen. In the lenticular nucleus several large excavations. The fibres of the internal capsule on this side seemed to pass around the cavities. The caudate nucleus and optic thalamus were "normal. The cavities on this side were not as large nor as extensive as on the opposite side. The sulci and gyri were especially well marked, the former being very deep. No cortical or subcortical lesions were found. On section the cerebellum showed a few small subcortical cavities in the arbor vitae, superior surface. Otherwise, it was normal. After seeing this honeycombed appearance of the basal ganglia, the question immediately arose as to the cause. Was it congenital or acquired? Could the woman have lived in this condition without manifesting any symptoms of cerebral trouble? Could it be porencephalia? Was it produced by formaldehyde? These and numerous other surmises were uot answered until sections were made and examined microscopically.
We submitted several sections to Dr. Barker, who at once recognized the bacteria as the cause of the cavity formation.
On studying sections under the low power of the microscope, the edges of the cavities appear quite smooth, and the clean-cut appearance seen in the gross sections of this brain again shows itself. They are devoid of any membranous or epithelial lining. Indeed, some of these cavities are surrounded by comparatively normal tissue, the brain cells iu some instances forming the very edge. This is, however, an exception ; for surrounding most of them is an area of cell degeneration of variable thickness, which is easily recognized by the absence of nuclear staining; indeed, the absence of all cellular structure is frequently seen in this zone, so that a diffuse homogeneous staining with eosin divides this from the zone to be described next. On passing outwards, this advanced stage of degeneration is gradually superseded by one in which only a partial loss of nuclear staining is evident and staining of the individual cells appears. Lastly, this zone merges into normal brain tissue. As for the spaces themselves, they are usually quite empty, excepting for certain masses which take on a deep hematoxylin staining and under the low-power lens have a somewhat granular appearance; not infrequently these masses lie imbedded in the
Aprtl, 1899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
63
walls of the cavities; but what is especially striking, is that by far the majority of the capillaries iu the section are completely filled by them. When examined under a higher lens (No. 7 or oil immersion), it becomes evident that these darkly staining masses, just mentioned, represent aggregu bacilli, and, as far as we can judge from microscopical appearances alone, tbey are pure growths of a bacillus having the following morphology :
A fairly long, rather thick, bacillus, varying at times in either dimension, at times in both, with an average leno-th from 3 to ('. mm., and with the comparative thickness of the anthrax bacillus; its ends are slightly rounded; the organism occurs singly, in pairs and clumps, and in parts of these specimens as chains. It stains with the ordinary aniline dyes : also by Gram's method. No spores were found, but no special stain was used for their demonstration. The bacilli frequently lie free in the tissues at some distance from cavities, and their clumps are almost invariably surrounded by zones of cellular degeneration, such as have been described surrounding the cavities; similar cellular changes are frequently seen in the neighborhood of bacilli which lie within blood-vessels. Judging from these specimens it would seem that the veins and capillaries are especially active in carrying the organism, for those arteries with well-marked walls showed as a rule, with one or two exceptions, no bacilli in their lumina. As to the part played by the lymphatics in such a conveyance it is difficult to say; we believe they played a minor rule in this case. In none of the perivascular lymph spaces (space of His) could we find the organism.
In no portion of the specimen were there any changes pointing to an inflammatory reaction, the entire absence of small-cell infiltration being very striking.
There are no hemorrhages in the brain tissue, nor could we detect the presence of blood in the cavities.
The arteries throughout are normal, showing no evidence of sclerosis. Any attempt at repair was entirely wanting, there being no neuroglial hyperplasia nor formation of granulation tissue.
CONCLUSION.
We believe that the cell degenerations and cavity formation in this case are due to the presence of the bacilli described, and that they belong to the class of gas-forming bacteria, the gas formation being directly responsible for the presence of the cavities, and the cellular changes being due to the action of toxins.
In 1892 Welch and NuttalP reported in the July-Angusi number of the Johns Hopkins Bulletin their discovery of a gas-forming bacillus obtained from the emphysematous tissues and blood of a man dead of aneurism of the aorta, for which they proposed the name, bacillus aerogenes capsulatus. Gas bubbles were abundantly present in the in organs, notably in the myocardium, the liver, spleen ami kidneys. This gas burned with a pale-bluish, almost coli flame, a slight detonation being heard at the moment of ignition.
' pon microscopical examination of these organs, they found around masses of bacilli frequently, but nof alv disappearance of the nuclei and degenerative changes in
cardiac muscle cell, and the epithelial cells of the liver and kidney, especially iu the neighborhood of gas cavities, in the walls of which the bacilli were often densely accumulated. They describe the bacillus aerogenes capsulatus as follows: The bacillus is non-motile, straight or sometimes slightly curved, variable in size, but averaging about the thickness of the anthrax bacillus, and from 3 to G cm. in length, with adjacent ends slightly rounded or sometimes square cut; occurs singly, in pairs, in clumps, and sometimes in chains, and stains readily with the ordinary aniline dyes, and after using Gram's method, staining is either uniform' or with small unstained spots, less frequently with isolated deeply staining granules.
Capsules, although not constant, were frequently demonstrated, especially by Welch's method for staining capsules in specimens from the animal body and sometimes from agar cultures. No spores were found either in the animal body or in cultures.*
The bacillus grows upon all ordinary culture media under anaerobic conditions, at body temperature slowlv : at is to 80 0. no growth on surface of solid media under ordinary conditions. Gas is produced in all cultures containing fermentable material. Time and space will not permit us to describe the cultural characters more in detail, and those interested in this subject are referred to the original paper and also to that of Welch and Flexner in the Journal of Experimental Medicine, Vol. I. Thisorganism is non-pathogenic to rabbitseven when a pure culture is injected into the circulation.
If the animal is, however, killed immediately or soon after intravenous injection, after 4 to hours at 30 C., or about 18 hours at 18 or 20 C, there follows great gas formation in the blood-vessels and organs and the bacilli are found abundantly in these tissues.
Although we cannot prove in the absence of cultural growths of the organism found in this brain that the bacillus under consideration is identical with that described by Welch and Nuttall, there seems to be little doubt from the resem- ■ blance in morphology, staining characteristics and more especially in its reaction to Gram's method, and last but not least, in the changes which it produces in the tissues, that this organism is at least closely allied to the bacillus aerogenes capsulatus and probably identical. As animal experiments show this organism to be non-pathogenic, and clinical experience, with a single exception, (ends to show that general infection with this organism takes place immediately before or after death, practically tin' latter only,as far ascan be judged from the symptoms due to general gas formation in the body; and further, as there is no evidence in this case « hich points to a general infection b\ this organism, before the death of
the individual, we concluded that the chanj red post
mortem, the distribution of the organism most likely occurring in tin' preagonal period. The organism not infreqn produces localized emphysematous conditions only in the tissues, from which recovery usually takes place because it seems essential for the existence ami growth of this organism
•Since this publication Dunham lias found that this organism produces spores when grown on blood serum.
64
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 95
that the tissues must have been previously injured or that the blood-supply should be poor in oxygen. That an injury may be trivial and still favor its development seems quite clear from two cases reported by Fraenkel,' in which infection followed hypodermic injections, in one case after the injection of camphor, oil and ether under the skin, and in the other of a dilute solution in water of sulphuric acid and chloride of morphia. One of these cases pursued a rapidly fatal course, death occurring two days after the injection. Before the discovery of this organism the cause of death in such cases would very likely have been attributed to the entrance of air into a vein. Welch and Nuttall in thenoriginal paper expressed the belief that many of the deaths attributed to the entrance of air into the veins would prove to be cases of gas bacillus infection, and especially referred to cases occurring in obstetrical practice in which it was supposed that air had eutered the uterine cavity and had been absorbed by the uterine sinuses thus causing fatal air emboli. Perkins' reports such a case following an attempt at criminal abortion, and attributed the fatal outcome to air embolism. Dr. Dobbin, 6 of the Johns Hopkins Hospital, through the kindness of Dr. Perkins, had an opportunity of studying sections from the uterus in this case and found the characteristic lesions of gas bacilli infection, the bacilli corresponding in morphology and staining characters to the bacillus of Welch and Nuttall.
The " Schaumorgane " of the Germans are due to such infections and the elaborate article of Ernst on the "Schaumleber" is especially rich in the microscopical changes in the tissues. He describes the microscopical appearance of the " Schaumleber " as follows : " On making the usual single long transverse section through the liver, the two portions thus formed fell apart almost immediately, and while examining these gas bubbles I saw that they began to appear from the larger vessels soon in such numbers that hillocks of froth were formed on the surface of the section; these hillocks gradually coalesced. If these masses of froth were stripped away, hardly a few minutes passed before fresh ones had formed. This condition of re-formation of froth continued for a long time. The autopsy had been performed 3 hours after death and there were no evidences of decomposition."
In reviewing the literature on this subject one clearly sees that these infections with gas-forming bacteria are becoming more widely recognized, and the number of articles have increased every year since the appearance of those of Welch and Nuttall and that of Ernst. In fact, at present the changes due to these bacteria have been described in almost every organ, including, for instance, the liver, spleen, stomach, intestines, bladder, kidney, uterus, skeletal muscles, etc. Notwithstanding this, we have been unable to find any description of pathological changes attributed to these bacteria in the brain or spinal cord, which seems indeed strange if one considers the comparative frequency of these infections and that they are fairly well recognized by observers in general. One can hardly believe that the central nervous system should be spared from such changes in cases of general infection where almost all organs may show the presence of gas cavities. Of course that the liver, spleen, and perhaps the uterus may pre
dominate in showing the presence of these cavities when once the general circulation conveys the organism is not difficult to understand, for as the veins seem to be especially employed in such a conveyance it is no more than natural that organs which are abundantly supplied with large veins and therefore containing a large amount of the blood after death would contain a relatively greater number of the organism than an organ in whose parenchyma the veins were less abundant and the venous radicles of small calibre. The brain and cord can certainly be classed with those organs possessing a comparatively small amount of blood in their parenchyma after death; of course the membranes covering them must be excluded, for in these the veins being large, and containing a large amount of blood, in all probability an examination would, in the great majority of instances of general infection, reveal the presence of the organism. Of course the smaller venous radicles of the brain parenchyma would also contain a fair number of the organism, but these might be present in insufficient numbers to produce sufficient gases to give rise to appreciable microscopical lesions. We refer here, of course, more especially to cavity formation. The above is only a theory intended to cover the inference that probably in a great number of cases of gas bacillus infection showing gas cavities throughout the organs, the brain and spinal cord will in the great majority be spared. But in looking over the articles on this subject one can easily see why such changes in the central nervous system should have been overlooked and that in the report of cases coming to autopsy we have been unable to find, with one or two exceptions, any mention of a removal of the brain or cord, and it is more than likely that this was neglected, for had 'they been examined mention of this fact would undoubtedly have been made— this of course is a very evident reason for the non-recognition of similar changes as are described in this brain. Although this is, as far as we know, the first case in which cavity formation has been attributed in the brain to the presence of gas bacilli we do not claim that such changes have not been described before, but they have been explained by different etiological factors. Of such an instance we have found but two clear examples ; both the brains are described by the same observers, namely, by G. H. Savage and ^ . Hale White, in an article entitled " Causes of Holes in the Brain," appearing in the Transactions of the London Pathological Society, Vol. XXXIV, 1882. These brains the authors obtained from two general paralytics, and as the kidneys, liver, lungs, and heart muscles contained cysts, they very naturally describe the changes by the term of "Universal cystic degeneration." In reading this article one is struck with the admirably clear description of the pathological changes. The illustration of the brain presented herewith shows a picture almost identical with the one reported by us, so that we feel little hesitancy in ascribing the changes described by Savage and White to the bacillus aerogenes capsulatns or an allied organism. A short resume of the description of the brains and the changes in the other organs will not be out of place. " Taking first the kidney, sections appear to show that in
our cases the cystic change is due to dilatation of either
the Malpighian capsules or cortical tubules. And in the liver the cysts appear to be due to small vacuoles in the
Fie. 2. — Reproduction "f section of brain from Hale White and Savage's case of "General Cystic Degeneration." [Transactions of Pathological Society of London, Vol. XXXIV.]
Fig. 1. — Photograph showing cavities in the corpus striati
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Pis. 3.— Section showing edge of large gas cavity • l; s- Surrounding this is an area of cellular degeneration. (Ii srsion lens.)
April, 1899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
65
hepatic cells, which we have proved not to be fatty by their refusal to stain with osmic acid. The several vacuoles in the same cell, by increase in size, run together to form one that occupies nearly all the cell, which being so distended bursts. The vacuoles of adjacent cells thus coming together soon form
one large cyst By this process in parts of the liver the
cysts produced are so numerous that the whole organ has the appearance of a sponge; this is very well shown on holding
up one of the microscopic slides We do not think the
hepatic cysts have any true wall, but the appearance of one is often produced by the cyst in the course of its enlargement coming in contact with some fibrous tissue, which it stretches and pushes before it, so that at last it appears to have a thin lining membrane."
•• Lungs— The cavities are mostly circular and not connected with bronchial tubes ; they contain no lining membrane. They have a tendency to occur in groups, and seem to be situated indiscriminately among the air-cells, from which they are distinguished by their regular shape and containing no granular epithelial debris, but in many cases the cysts have in the interior a peculiar amorphous matter which takes the logwood stain with great brilliancy."
Before going any further we wish to call especial attention to the mention of this "amorphous matter" which takes on the logwood stain so deeply, which the authors describe in the cayity of the brain and in the vessels of the different organs ; this seems especially important as this "amorphous matter" which they describe is undoubtedly composed of masses of bacteria which the reader will remember often completely filled the vessels in the brain we describe and were so abundant in the walls of the cavities. Savage and White give only a short description of the appearances of the brain, but substitute for this a good illustration of the specimen. The description of the microscopical appearances of the brain cysts corresponds in all particulars to those found in the other organs. It would be useless for us to go into a minute comparison of the changes described in the case reported in this article and the other pathological conditions giving rise to cavity formation in the brain. One could hardly, after a careful consideration of such conditions as porencephalia which has been so admirably treated by Kundrat' to which the reader is referred— the condition known as Hut crible'—is now considered by most observers as of no pathological significance and the holes in this are extremely small, generally of pinpoint size and are frequently due to slight dilations of the \ u-chuw-Kobin lymph space, or by a shrinkage of the brain snbstance from the action of hardening fluids, causing a rather wide separation between vessels and parenchyma.
The holes produced in sclerotic processes found at times in the brain of general paralytics, and patients suffering from multiple sclerosis, could hardly take a form to resemble those Otaties produced by this organism, as the former would almost nee warily contain a lining membrane, and evidences of neuroglial hyperplasia in different localities would speak for the chromcity of the process.
Discussion. Dr. Welch— In connection with Drs. Herring and Hea
ling's contribution, it may be of interest to exhibit a microscopical section from a pig's liver which I examined to-day. I received the section from an eminent pathologist H ho was puzzled by the appearances. Two or three of the superficial lobules of the liver presented to the naked eye small, bleb-like spaces. The sections show a honeycombed appearance of the affected lobules, caused by an abundant development of bacilli identical, morphologically, with the B. aerogenes capsulatua. The gaseous spaces are sharply defined, and the appearances are indeed such as to be very puzzling, unless one is familiar with the blebs produced by the post-mortem development of our gas bacillus. The specimen is an example of emphysematous liver (Schaumleber), but is remarkable on account of the limited production of gas and the circumscribed arrangement of the holes, due in part to the large amount of connective tissue normally surrounding the hepatic lobules of the pig.
In the light of Drs. Herring and Reuling's observation, it is probable that certain cases reported in the literature as holes in the brain are really due to the post-mortem development of the gas bacillus.
Bibliography.
1. Journal American Medical Sciences, Feb. 1899. Vol
CXVII, No. 2.
2. Johns Hopkins Hospital Bull. Vol. Ill, No. 24.
3. See Article of Welch-Plexner. Journal of Experi mental Medicine, Vol. I, No. 1.
4. Boston Medical and Surgical Journal, Feb. 1897.
5. Johns Hopkins Hospital Bull. Vol. VIII, No. 71.
6. Virchows Archiv. Bd. CXXXIII, p. 308.
7. Die Porencephalic. Kundrat. Gratz. 1882.
8. Zur Pathologischen anatomic der Central organe des
Nervensystems Uber den Etat Crible (Oriesinger) Virchows Archiv. Bd. <;:i.
Report of five cases of infection by the Bacillus au-ogeues eapsulatus. Ed. K. Dunham. Johns Hopkins Hospital Bull. Vol. VIII, No. 73.
Eug. Fraenkel. Centralblatt fur Bakteriologie. I'.d. XIII. No. 1.
Malignant Emphysema. Dal ton. Amer. Journal Med. Sciences. Sept. 1897.
Wound infection with the Bacillus aerogenes eapsulatus. Medical News, Oct. 9, 1897.
Graham, Stewart and Baldwin. Columbus MedicalJournal, Aug. 1893.
THE JOHNS HOPKINS HOSPITAL BULLETIN.
The Hospital Bulletin contains announcements of courses of lectures, programmes of clinical anil pathological study, details of hospital and dispensary practice, abstracts of papers read and other proceedings of the Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of the Hospital. It is issued monthly.
V r olume X is now in progress.
The subscription price is $1.00 per year.
The set of ten volumes will be sold for $20.00.
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[No. 97.
ACUTE FIBRINO-PURULENT CEREBROSPINAL MENINGITIS, EPENDYMITIS, ABSCESSES OF
THE CEREBRUM, GAS-CYSTS OF THE CEREBRUM, CEREBROSPINAL EXUDATION,
AND OF THE LIVER, DUE TO THE BACILLUS AEROGENES CAPSULATUS.
By W. T. Howard, Jr., M. D., Professor of Pathology in the Western Reserve University, Pathologist to Lakeside Hospital,
Oleveland, Ohio.
(From the Pathological Laboratory of Lakeside Hospital.)
For the clinical history of the following case my thanks are due to Dr. Dudley P. Allen. H. E., male, white, aged 31 years, was admitted to Lakeside Hospital, service of Dr. Allen, March 22, 1898. His family history was without interest. The patient had had chicken-pox and scarlet fever, but denied syphilis.
In August, 1897, he contracted gonorrhoea, and shortly after this he noticed a painful swelling in the perineum. Six months later this ruptured, with the discharge of a considerable amount of pus. After this there was a permanent urinary fistula at this point. Three months after the occurrence of the first swelling another formed in the same region, and after the escape of pus healed and disappeared.
With the usual precautions under ether anaesthesia Dr. Allen curetted the fistulous tract which communicated with the urethra. After dilatation of the urethra a catheter was inserted and the wound allowed to heal.
A few days after the operation the patient became unconscious, developed symptoms of meningitis and died during the night of March the 29th, 1898. After the operation the temperature ranged between 99° and 104°, reaching 105° F. before death.
A few minutes after death the body was placed in a coldstorage chest kept constantly at 32° F.
The autopsy was begun ten hours after death. Anatomical Diagnosis. — Operation for cure of perineal fistula. Acute fibrino-purulent cerebro-spinal meningitis and ependymitis, with abscesses of the cerebrum, gas-cysts in the cerebrum, cerebro-spinal exudation and in the liver, septicasniia (?), due to the bacillus aerogenes capsulatus; fatty degeneration of the liver, heart and kidneys; cloudy swelling of the kidneys.
The body was 182 cm. long, the surface cold, rigor mortis was marked. There was no oedema and no emphysematous crackling of the subcutaneous tissues. The abdominal muscles were well developed. The peritoneum was smooth and glistening. The pelvic cavity contained a small amount of slightly blood-tinged fluid with a few gas bubbles. The abdomen was not distended.
The chest was well shaped. The pleural cavities and the pleurae were normal.
Both lungs were enormously congested and showed small areas of consolidation. On section a large amount of dark fluid-blood containing gas bubbles escaped. Gas bubbles escaped from the pulmonary vessels on pressure. The mucous membrane of the bronchi was deeply congested. The lungs were moderately pigmented. The bronchial glands were pigmented, but were free from tuberculosis. The mucous membrane of the trachea and larynx was congested.
The pericardium was negative. The heart was of ordinary size. The myocardium was pale. In the right auricle and auricular appendage and the right ventricle there were dark fluid-blood and loose clots, with a large number of large and small gas bubbles. The valves and coronary vessels were normal.
The liver was of ordinary size and its capsule smooth. On section a large amount of dark red blood containing large and small gas bubbles escaped from the hepatic and portal veins. The lobules were well marked ; the consistencies were not specially increased. Scattered throughout the organ there were a large number of small opaque areas the size of a pin's head. The bile-ducts and the gall-bladder were negative.
The spleen was four times the ordinary size. The capsule was not thickened. On section the organ was soft, dark red in color and markedly hypenemic. The Malpighian bodies and the trabecules were obscure. A large number of gas bubbles escaped on section.
The kidneys were of ordinary size. The capsules were readily removed. The surfaces were pale. The cortices were somewhat thicker than ordinary, and the glomeruli and veins were markedly congested. There were no gas bubbles to be found in the kidneys. The adrenals were negative.
The pancreas, oesophagus, stomach and small intestines were markedly congested. The colon and rectum showed nothing of interest. . The testicles were negative. The urethra was normal ; there was no stricture to be found. The perineal wound was healed, and no pus and no gas bubbles could be found. The right lobe of the prostate was larger than ordinary. No abscesses were found. The bladder was distended with urine. The mucous membrane was moderately congested; there were no ulcers. The pelvis was deep and narrow. Careful dissection failed to show any focus of suppuration. The pelvic veins, the inferior vena cava and the portal vein all contained large and small gas bubbles.
Head.— The scalp was of ordinary thickness and moderately congested. The skull was normal. The vessels of the dura-mater were moderately congested. The sinuses contained dark fluid-blood with large and small gas bubbles.
Brain.— The vessels of the surface of the brain were very much congested. The pia-arachnoid over the cerebral hemispheres showed a number of small opaque areas of fibrinous exudation. The structures at the base of the brain, including the nerves, were bathed in a thick yellow pus. The piaarachnoid over the inferior surface of the cerebrum, a large portion of the cerebellum, the pons and the medulla were covered with a thick fibrino-purulent exudation.
On section of the left cerebral hemisphere just above the
April, 1899.]
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Sylvian fissure, involving the intra-parietal fissure, and the ascending parietal and the supra-marginal convolutions, there was an abscess with soft, necrotic walls. This abscess varied from 0.5 to 2 cm. in diameter. Near this abscess at one side there were a number of smooth-walled cavities measuring from 1 to 5 mm. in diameter.
On the inner side, this abscess extended deep into the tissue. Occupying the anterior half of the left superior temperosphenoidal convolution there was an irregular abscess with soft necrotic walls. The abscess cavity was filled with a semi-fluid necrotic material. This abscess varied from 0.5 to 1.5 cm. in diameter. Both of these abscesses extended inwards and communicated with the left lateral ventricle. Nearly the whole of the surface of this ventricle was covered with a thick layer of pus and the wall over a large surface was necrotic. The lenticular nucleus of the left side contained a number of small smooth-walled gas-cysts or cavities varying from 1 to 5 mm. in diameter. In the internal capsule there were several similar gas-cysts. The right lateral ventricle, the right cerebral hemisphere, the cerebellum and the pons and medulla showed nothing abnormal on section.
Spinal Cord. — The dura mater was moderately hyperemia The vessels of the pia-arachnoid were bypersemic and contained small gas bubbles. In the membranes there were gas-cysts from 1 to 3 mm. in diameter. The cord was of ordinary consistence and appeared normal.
Bacteriological Examination. — Coverslip preparations made from the lungs, heart, vena? cavse, portal vein, pelvic veins, liver, the cerebral and spinal exudations, and the brain abscesses, showed in great numbers and in pure culture a large stout bacillus often in pairs, threes and fours end to end, and usually with capsules. Careful study of the meningeal exudate failed to demonstrate the presence of any other bacteria. Half a cubic centimeter of this pus was injected into the ear-vein of a rabbit. The animal was killed a few minutes later and put in the incubator. After five hours the animal was enormously swollen, its subcutaneous tissues being emphysematous. At the autopsy gas was found in the heart and blood-vessels and in all the organs. Oapsulated bacilli similar to those injected were found in pure culture in the various organs.
At the autopsy plate and slant cultures were made on glucose agar and upon slanted coagulated blood serum from the brain abscesses, the meningeal exudate, the heart's blood, and from the liver, lungs, spleen, kidneys and portal vein, were grown both aerobically and anaerobically (Novy's jars).
The aerobic cultures were sterile after three days in the incubator. All the anaerobic cultures showed, after 24 hours in the incubator, numbers of grayish-white colonies, which after a few days were from "-i to 3 millimeters in diameter. In gelatine cultures slow liquefaction of the medium occurred. Milk was coagulated in forty-eight hours. There was slight visible growth with gas formation on potato. Sugar bouillon was rendered diffusely cloudy. The organism was non-motile. In blood serum-cultures spores were found.
The bacillus produced gas in media containing fermentable substances. Cultures of this bacillus were pathogenic for guinea-pigs and pigeons. Rabbits killed after intravenous
inoculation and kept in a warm place always showed marked emphysematous swelling with typical " Sohaumorgane." This bacillus stained well with the aniline stains and by Gram's staining method.
From the brain abscess and the meningeal exudate, then, as well as from the various organs there was obtained in pure culture a bacillus identical with the bacillus aerogenes capsulatus (Welch).
Microscopical Examination of the Ohgans.
The brain and spinal cord were hardened in 10$ formalin, and portions of the other organs were hardened in Zenker's fluid and in 95$ alcohol.
Central Nervous System. — Sections made from the cerebral and cerebellar cortex, from the pons and medulla and from the spinal cord, and from the brain abscesses were stained in hematoxylin and eosin, in eosin and methylene-blue, in thionin, and m carmine .followed by Weigert's fibrin stain. A study of the meningeal changes showed marked dilatation of the blood-vessels. Many of the small arteries were filled with both polymorphous and mononuclear leucocytes. In some vessels the endothelium was partially or totally desquamated and the sub-endothelial tissue infiltrated with cells, and well marked thrombosis was found in some arteries. In some vessels both polymorphous and mononuclear leucocytes could be seen in the media and adventitia. In some places there was proliferation of the cells of the adventitia with the formation of large round or spindle-shaped cells. Only a few bacilli were seen in the vessels, but in places numbers were found in the adventitia. The exudation varied very much in thickness, being thickest at the base of the brain over the cerebellum, the pons and the medulla. The most numerous cells were polymorphous nuclear neutrophils. Besides these there were many mononuclear cells of varying size and answering to the description of plasma cells. In addition to these in some places large round or oval mononuclear cells of the connectivetissue type were seen. Here and there a few red-blood cells were found. In some places the exudation was rich in fibrin, while in others this was scanty.
In many places on the cerebral and cerebellar cortex, proceeding along the course of the vessels in the sulci, there was a marked infiltration with polymorphous nuclear leucocytes and plasma cells. The exudation was, in general, rich in fibrin. The blood-vessels were dilated, and many of the arteries showed the same changes described in the meningeal vessels. In these areas bacilli were always found. In some of these broad bands of cellular infiltration in the cerebellum gas-cysts of varying size containing bacilli were seen.
Sections of the cord made at differenl levels showed wellmarked meningitis. The exudation was most marked in the cervical and upper dorsal regions, and was in every way similar to that described in the cerebral meninges. At various places, especially, however, in the exudation over the medulla and the cervical cord, there were a number of gas-cysts. The gas-cysts of the spinal meninges varied from twenty," to four to five mm. in diameter. The cysts of the pons and medulla did not exceed one hundred /« in diameter. These cysts were round or oval in outline and contained, both in their cavities
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and along their margins, a number of large bacilli. The exudate in the neighborhood of the cysts was usually compressed.
Brain. — Sections made through the abscesses in the supramarginal and ascending parietal convolutions and including the infra-parietal tissue, and through the abscess of the superior tempero-sphenoidal convolution showed large central areas of necrotic material. This material was homogeneous and hyaline in appearance and stained diffusely with eosin. Here and there a few nuclei could be made out. Nuclear fragments were numerous in some places. In this material myriads of bacilli were found. The bacilli occurred singly and in small and large groups. About the necrotic area there was always a deep zone of dense cellular infiltration. The most numerous cells were polymorphous nuclear leucocytes. Lymphocytes and plasma cells were found in great numbers. Many of the cells resembling plasma cells contained two nuclei and were evidently proliferating. In some places cells with kidney-shaped nuclei were seen. This zone of cellular infiltration varied from one to three or four mm. in thickness. Bacilli in small and large groups, sometimes in huge clumps, could always be found in this zone. Infrequently bacilli were found in leucocytes. The blood-vessels near this zone were dilated. In many of the arteries among the redblood cells many polymorphous nuclear and large mononuclear cells were seen. In some vessels thrombi were found. In these the intima cells were often desquamated and leucocytes were seen in the media. Well-marked cellular infiltration was found about many of the arteries. Bacilli were but rarely seen inside the vessels. Near the zone of cellular infiltration a varying number of bacilli were sometimes noticed. In rare instances in this region small spaces (gas-cysts), varying from ten to thirty ;j. in diameter and containing bacilli, were found.
In sections including the wall of the left lateral ventricle no trace of the ependyma remained. The ventricular surface of the sections was covered with a thick layer of hyaline material staining diffusely with eosin. This hyaline, homogeneous layer varied in thickness, and was similar in appearance to the necrotic material of the abscesses of the cortex. This layer contained myriads of bacilli and often nuclear fragments, with an occasional polymorphous nuclear leucocyte. Beneath this layer there was a thick zone of cellular infiltration in every way similar to that described in the abscesses. Many bacilli were seen among the cells in this zone. The underlying tissue showed areas of infiltration with cells about the blood-vessels, many of which contained thrombi. With the exception of the gas-cysts and the inflammatory lesions above described, no special changes were made out in the white or gray matter of the brain or cord.
Sections of the gas-cysts or cavities in the internal capsule and in the lenticular nucleus showed simply separation and compression- of the tissues due to the pressure exerted by the gas. None of the cysts appeared to be dilated blood-vessels. Large numbers of bacilli were always found along the walls of the cysts. In some places large clumps or colonies were to be seen. There was no inflammatory reaction about the cysts.
Four varieties of gas-cysts could be recognized in the central nervous system in this case. (1) Cysts developed in
the meningeal exudation on the surface of the cerebrum, cerebellum, pons, medulla and spinal cord. These cysts varied from twenty // to from two to five mm. in diameter. (2) Small cysts, never exceeding fifty ,u in diameter, occurring in the inflammatory exudation following the course of the arteries in the cerebellum. (3) Small cysts from ten to twenty ii. in diameter, occurring near the abscesses in the parietal lobes. (4) Cysts varying from 0.5 to 1.5 mm. in diameter found in the superior tempero-sphenoidal lobe, in the lenticular nucleus and internal capsule on the left side.
Lungs. — Sections of the lungs showed slight chronic interstitial pneumonia and emphysema. There was marked congestion of the air vesicles about some of the small bronchi. No bacilli were seen in the alveoli or in the blood-vessels, though some of the latter contained many leucocytes.
Liver. — The liver showed extensive fatty degeneration, best marked in the liver cells at the periphery of the lobules. The interlobular fibrous tissue was increased, and in many places was infiltrated with cells resembling lymphocytes and plasma cells. Nuclear figures were occasionally seen in the latter cells. The veins and capillaries were congested and in many bacilli were seen. In a number of sections there were areas varying from 0.5 to 1 mm. in diameter, in which the nuclei of the liver cells did not stain. The cytoplasm was swollen and more granular than ordinarily. Many cells contained fat drops. Many of the liver cells, especially in the centre of the areas, were shrunken to one-half their normal size. In these areas the endothelial cells of the capillary walls did not stain. Occasionally leucocytes still retaining their staining properties were seen. Long stout bacilli were always found, sometimes in small, but usually in great, numbers. Small gas-cysts containing bacilli were occasionally seen. The necrotic areas bore no special relation to the central veins, the portal veins or the bile-ducts. The latter were normal. The liver tissue in general was well preserved and stained well with the usual dyes.
Spleen. — The spleen showed marked congestion, but no : areas of cell destruction and no gas-cysts.
Kidneys. — The kidneys showed cloudy swelling of the ! epithelium of the convoluted tubules, congestion of the glomerular and intralobular capillaries, and of the veins. No bacilli and no gas cavities were found. The heart showed nothing of interest.
The bacilli noted in the sections of the various organs were identical. They were most numerous in the brain abscesses and in the meningeal exudation. The bacilli varied considerably in size. They were sometimes two ,u long, but the most common forms were from four to six ;i in length. A few bacilli were seven /* long. Some of the bacilli had square ends, but usually the ends were rounded. They often occurred in pairs, threes and fours, end to end. Not infrequently they were bent or curved, and some were wavy in outline. The bacilli stained well and uniformly with hematoxylin, thiouin, methylene-blue and by Weigert's method. The last method gave the most clear-cut pictures. With this stain the outlines of the bacilli were often somewhat irregular, due to irregular swelling or contraction of their protoplasm. Slightly clubbed forms were sometimes seen. No stained capsules
Apbil, 1899.]
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were found in the tissues, but occasionally ill-defined masses resembling empty capsules were seen. Careful search of the affected tissues failed to disclose the presence of any other bacteria.
In this case it is evident that the tissue necrosis, the inflammatory lesions and the gas-cysts were due to infection by the bacillus aerogenes capsulatus. The pyogenic properties of t his bacillus are now well known.
In my opinion the presence of the bacilli in such great numbers in the nervous system and their relative paucitj in the blood-vessels and other organs precludes the idea thai thej were post-mortem invaders. When an unusual organism is found in association with inflammatory lesions it is no longer thought necessary to assume that the pyogenic cocci have caused the lesions and died out before the case came to bacteriological examination, thus reducing an organism found
in large numbers and in pure culture to the level of an accidental and innocuous invader. The complete revolution of our views concerning the pyogenic properties of the typhoid
bacillus is an illustration in point. The formation of gascysts in the brain, the cerebro spinal exudation, and in the liver is probably to be regarded as a post-mortem change. The perineal wound must be regarded as the portal of entry for the bacilli. A search of the literature fails to disclose a case of abscess of the brain with cerebro- spinal meningitis due to the bacillus aerogenes capsulatus. 1 have found this bacillus in the blood-vessels of the brain in several cases without inflammatory lesions. Through the courtesy of Dr. Reuling, I have examined a section through a gas-cyst of the brain of the case he reports in this number of the Bulletin. In every respect it agrees in appearance with gas-cysts of the internal capsule and lenticular nucleus of my case,
PROCEEDINGS OF SOCIETIES
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
Resistance to (Juinine of Certain Forms of Malaria.— Dr. Camac
The value of the following temperature records is both diagnostic and therapeutic. Where the aid of the microscope is not to be had the temperature chart may be all the physician has to guide him in both diagnosis and treatment. It is with the object of drawing conclusion on these two heads that the present malarial temperature charts are exhibited. In each of the following cases the malarial parasite was, of course, found and its type determined, so that the conclusions are reliable as referring to malaria only.
Case I. — J. B. Type jEstivo-Autumnal. Blood Examination by Dr. Hamburger. Sept. 30 (day of admission), intracellular hyaline amoeboid ring-sbaped bodies ; one crescent. Oct. 1, a crescent ; organisms scarce ; hyaline intracellular body. Oct. 2, 10 a. m., quinine gr. x ; 12 m., quinine gr. v q, 4h.; p. m., one intracellular hyaline body. Oct. 3, No organisms.
Temperature. — Daily paroxysm ; not reaching normal during the intervals ; temp, normal on Oct. 4.
Treatment. — "0 grains of quinine required to control fever. Time required, 3 days.
Case II. — R. B. (colored). Type iEsnvo-AuTUMNAL. Blood examination by Dr. Pancoast. Sept. 24 (day of admission), 7 p.m., one ring-shaped body. Sept. 25, 10 a. m., ring-shaped amoeboid body. 12 m. quin. gr. x ; 4 p. m., quin. gr. v. q. 4 h.
Temperature. — Daily parox.; slight drops, not reaching the normal (WidaPs agglutination negative); temp, normal 27th.
Treatment. — 9-3 grs. required to control fever — 3 days.
Case III. — JI. .1. Type JCstivo-Autdmnal? Blood examination by Dr. Pancoast. Sept. 27 (day of admission), one ring-shaped body ; 10 p. m., quinine gr. x ; 12 m., quinine gr. vq. ! h.
Temperature. — Daily paroxysms ; not reaching normal during intervals. 2 p. m., 27th, temp. 104.2; fever apparently controlled by quin. ; parox. only delayed. 10 p. m., 29th, temp. 101.8. 10 p. m., 30th, temp, normal.
Treatment. — 105 grs. required to control fever; time required, 3 days. Especially instructive case as blood examination was not conclusive.
Case IV. — P. C. Type Double Tertian. Blood examination by Dr. Runner. Numerous organisms. 2 sets, 1st full grown in very pale corps ; fine, actively motile pigment ; 2d, half-grown intracellular pigment, motile ; corps somewhat enlarged.
Temperature.— Parox. 27th, from 2 p. m. to 3 p. m. Parox. 28th, 2 p. m. Quin. gr. xx, 2p.m.; quin. gr. v, 6 p. m. q. 4 h.
Treatment. — 50 grains controlled fever, inclusive of time when parox. should have occurred. Time required, y 2 day.
Case V. — J. S. Type Double Tertian. Blood examination bg Dr. Banner. Two sets of organisms : 1st group, Sept. 13, parox. 2 p. m.; 2d group, Sept. 14, parox. 6 p. m.; 1st group, Sept. 15, parox. 2p.m.; 2d group, Sept. 16, parox. 4 p. m.
Treatment. — Sept. 16, 4 p. m., subcutaneous inject, quin.gr. xviii. Sept. 17, parox. of 1st set delayed to 6 p. m.; also modified Sept. 15, 104.8 ; Sept. 17, 102.6. Sept. 17, 6 p. m., intravenous inject, gr. vii ss. Sept. 17, abortive rise at 10 p. m. Sept. 18, fever controlled. Fever controlled by 25'i gis. Time required, 2 days.
Case VI. — J. B. Type Double Quartan. Blood examination by Dr. dishing. Two sets of quartan parasites. Case developed on surgical side. Further blood examination made by Dr. Thayer. Oct. 26, 10 p. m., paroxysms complete ; quin. grs. v, 2 and 4 p. m. Oct. 28, 2 a. m., paroxysms complete. Oct. 29, 12 noon, quin. grs. v q. 4h. Oct. 30, slight parox. Oct. 31, slight parox.
Treatment. — 30 grs. greatly modified parox. of two group ; 76 grs. controlled fever.
There are to be observed in these six cases several striking features: 1st, The marked resistance to quinine of the sestivoautumnal type. 2d, The tendency of the sestivo-aulumnal not to reach normal during the intervals. 3d, No form resisting the quinine beyond :'. days.
The most effectual time to exhibit quinine has been fully investigated by Golgi ; Marchiafava and Bignami, and Case VI of the present series demonstrates well Golgi's observations. He finds that quinine administered in quartan fever, 4 or 5 hours (even in small doses) before segmentation reailily kills the young form=, but has no influence upon the adult forms, the following paroxysn a occurring uninterruptedly. The tertian, however, is readily influenced by the administration of quinine just before the paroxysms (Case IV), the following paroxysms being prevented or delayed. From the teachings of Marchiafava and Bignami the following may be concluded for tertian and quartan fever ;
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[No. 97.
Fall dose at crisis :
Full dose 6 hours before crisis :
1. Parox. prevented.
2. Aborted.
3. Delayed 6-24 hours.
1. Delayed.
2. Aborted.
3. Pseudocrisis.
By watching the chart and observing first its character uninfluenced by quinine, then its character after the administration of quinine, and noting at the same time when the quinine was administered with reference to the paroxysm, the diagnosis not only of malaria but of its type may sometimes be made. Fever which shows no signs of breaking three days after the administration of full doses of quinine every four hours is other than malaria; if it yields earlier than the third day, on moderate doses, it is likely to be of the tertian or quartan type, whether double or single. The tendency of the aestivo-autumnal fever to resist quinine has led the Italian observers to speak of the gradual destruction of the parasite as one of "fractional sterilization," and this tendency would induce the careful physician to prolong his quinine for a greater period in dealing with this form. Here, however, we may take as a guide the lact that the aestivoautumnal fever often fails to touch normal during the intervals between paroxysms, whereas the tertian and quartan more commonly do. To those cases therefore who bear quinine badly it may be discontinued earlier and with greater safety in the tertian and quartan than in the sestivo-autumnal.
It may, however, with profit, be repeated, and repeated emphatically, that fever which does not show signs of breaking within three days, when propierly met by quinine, is other than malarial, and quinine is being given not only to no advantage, but in many cases with harmful effects.
We have, therefore, in the proper observation of the temperature chart, both a diagnostic and therapeutic guide, though we have not the aid of the microscope.
It may be interesting in this connection to mention a recent conversation with Dr. John T. Metcalfe, one of Louis' students, who remembers the pre-quinine days. I think it was about 1820 that quinine was separated by Pelletier, prior to which Peruvian bark was used exclusively. The preparation known as Peruvian paste was so thick that it could be just swallowed. A tablespoonful was taken at a dose, and frequently vomiting was so severe as to require the use of opium. A 3-ounce bottle of quinine was brought to Natchez, Miss., and was sold for $90.
A New Method of Staining Malarial Parasites.— Dr. Fitciier.
As Dr. Lazear and myself, during the past winter, came across a convenient method of staining malarial parasites in dry specimens, I thought it might be of interest to report it to the society. We do not claim originality, either for the method of fixing, or the method of staining, the organisms, but, so far as the combining of the two methods is concerned, we think it has not been done before. It is a very quick process and very- serviceable in cases where one is called out to see a suspicious case and has not a microscope at hand with which to examine the fresh blood.
The dried-blood specimens, made in the usual way described by Ehrlich, are then fixed in a i per cent, solution of formalin in 95 per cent, alcohol. It is important that the formalin
solution should be made up fresh each time it is used. We have found satisfactory results by adding four or five drops of a ten per cent, aqueous solution of formalin to 10 cc. of 95 per cent, alcohol just before using. This method was first described by Benarioin the Deutsche Medicinische Wochenschr., No. 27, 1891. He used a 1 percent, solution of formalin in 90 per cent, alcohol, however. He stated that not only was the haemoglobin of the red cells well preserved, but the granules and nuclei of the leucocytes were well fixed and took the stain particularly well. The cells were especially well stained with eosin and hematoxylin. The specimens are fixed in this solution for only one minute, washed in water, blotted and then stained in the special mixture.
As to the staining agent, our attention was first drawn to the use of thionin by Dr. W. G. McCallum, who referred us to an article by E. Marchoux, in the Annales del'Institut Pasteur, Vol. ii, p. 610, 1897, in which the author gives a report on the malarial fevers of Senegal, and in which he describes his method of using thionin in staining the parasites. The author considered it especially serviceable for staining malarial organisms, but instead of formalin he used the ordinary alcohol and ether fixing method and, so far as we know, the use of formalin and this stain have not been combined before. He makes a saturated solution of thionin in 50 per cent, alcohol, of which 20 cc. are added to 100 cc. of a 2 per cent, carbolic acid solution. This solution can be kept in stock and used as required. It is perhaps better to keep the stain for some time before using as it improves with age. Thionin phenate is formed, which is believed to be the active staining agent. Only 10 to 15 seconds are required for staining.
The malarial parasites come out very distinctly as reddishviolet bodies with this stain, and it is especially serviceable in staining the ring-shaped bodies of the ffistivo-autumnal infection. These are very hard to distinguish in fresh specimens and usually do not stain satisfactorily with eosin and methylene-blue. Any one who has stained specimens in this way knows how he has regretted, on examining them two or three months later, to find that they have faded. With the thionin stain the parasites retain the color much better than they do when stained with methylene-blue.
The method of fixing and staining malarial parasites is then as follows :
Make the ordinary smear preparation, fix in the formalin solution for one minute, wash in water, thoroughly dry, stain with the thionin solution for from ten to fifteen seconds; ten will probably give the most satisfactory results. Wash off the excess of stain, blot, mount in balsam and the specimen is ready to be examined. The whole operation does not last more than two minutes from the time you begin to fix until it is ready for examination, whereas with the old method of fixing with alcohol and ether, one usually has to wait two hours to get satisfactory results, and even theu it is often found, if eosin aud methylene-blue have been used, that the haemoglobin of the red cells has not been properly fixed and the cells show peculiar vacuolic areas. With the formalin fixing and thionin staining the protoplasm of the reds is well fixed and practically unstained, and the parasites stand out
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distinctly as reddish-violet bodies in the substance of the red cell. The ring-shaped bodies of the aastivo-autumnal variety come out much better than with any other agenl in use.
We also used the thionin stain to try and bring out the flagellated processes in the aestivo-autumnal infection. Probably one of the most convenient methods for obtaining permanent preparations of the flagella is that described by Sakharov, in which an ordinary specimen on the slide is made and at the same time several specimens of blood are taken on coverslips, leaving the latter in contact with each other m a moist chamber and watching the ordinary preparation under the microscope until flagellation begins, when the coverslips in the moist chamber are taken out and drawn apart and dried. One will then most likely catch the organisms in the flagellating stage.. We have fixed some of these by heat and then stained with thionin, and have obtained some good specimens showing the flagellate processes coming off from the body of the parasite. At this time we had not been using the formalin fixing, but there is no reason why it should not be substituted for the heat.
This method of fixing and staining is not to supersede the examination of the specimen of fresh blood, always the most satisfactory method, but only where staining is the only resource and rapid results are desired. We have placed under the microscope on the table specimens of the three types of malarial organism staiued by this method.
Dr. Flexner.— There is a method, you will remember, which was worked out by Dr. Mallory for staining the amoeba coh. The specimen is stained in thionin and placed in a weak solution of oxalic acid to remove the coloring matter from all other cells except the amoeba. I also had the opportunity of stinking recently some specimens of amoebic dysentery stained by Dr. Harris of Philadelphia, witli toluidin blue and the organisms are as easily made out as when stained with thionin. I do not know whether these methods would succeed with the malarial parasite, but they might be tried.
Dr. Lazear.— During the summer I tried the toluidin blue for the malarial parasite. It is fully as good as methvlene-blue, but does not stain so deeply as the thionin.
Dr. Thayer.— It appears to me that the method of staining advised by Dr. Futcher is one which is of very considerable oractical value. It is often impossible for the busy practitioner to examine the fresh specimen of blood, and most of the other methods of preparation are rather delicate proceedings, at least if one wishes to obtain really good specimens. A thoroughly satisfactory method which can be carried out almost inside of two minutes is a great advance.
T should like to emphasize particularly its value in staining the aestivo-autumnal parasites. The hyaline bodies take up all dyes very feebly, and it is often extremely difficult for the unskilled eye to distinguish them. By Dr. Futcher's method )f staining with thionin, however, a perfectly satisfa specimen may instantly be obtained. I know of no method which brings out the testivo-autumnal parasite so well.
Laparotomy for Intestinal Perforation In Typhoid Fever
[See Bulletin for November Discussion, 1898. |
Dr. Thayer.— I had the good fortune to observe the first
case which Dr. Cushing has mentioned throughout the greater
part of its course. I happened to walk into the ward on the
night upon which the second operation was done and found
the boy in a condition of profound collapse. This 1km ■,
on very suddenly, Dr. Cushing having seen the child bul a short time before. When 1 saw him he had been vomiting; the skin was cool; there was profuse sweating; the temperature had fallen several degrees: there was abdominal tenderness; the pulse was feeble and rapid : the face was drawn ; the cheeks and eyes sunken. There could scarcely have been a more typical picture of acute peritonitis. And" vet, when the abdomen was opened, there was not only no peritonitis, but there was not enough disturbance to suggest the existence of obstruction to any one present. Such a picture is an excellent demonstration of the difficulties which may stand in the way of a correct diagnosis in these cases.
What Dr. Cushing has said of the leucocytes is, it semis to me, of considerable importance. I have no doubt that it is quite true that in an individual with distinct evidences of perforative peritonitis a normal or subnormal number of leucocytes is a very bad prognostic sign. I remember one or two instances of general streptococcus septicemia where the leucocytes were normal or subnormal in number; one case in particular where there were but 3000 leucocytes to the cubic millimeter. As long ago as 1892, Werigo showed that after inoculating animals with cultures of pyogenic bacteria there occurs primarily a reduction in the number of leucocytes to the cubic millimeter. In the milder cases this initial' fall is followed by a subsequent leucocytosis. In the particularly malignant and rapidly fatal cases, however, no subsequent rise in the number of leucocytes occurs. The same condition has been noted experimentally by various other observers. And I am inclined to believe that, as in pneumonia, so in other malignant general infections, a subnormal number of leucocytes may be regarded as a bad symptom, and it is not at all impossible that in Case III the fall in the number of leucocytes following the direct evidence of perforation may well havi been associated with the sudden onset of what proved to be a rapidly fatal streptococcic infection, the previou leucocytosis having been due to the moderate local peritonitis about deep ulcers.
Monday, December L9, 1898.
Presentation of Pathological Specimens.— Drs. MacCalmjm
and Harris.
Dr. MaoCallum presented lultiple
metastases from a sarcoma primary in the pelvis. The patient was a young man, aged '.'I, who had complained of chills and obstinate constipation with greal pain on defecation. There was also severe pain in knee, hip and back, and recently considerable loss in weight and strength. Physical examination revealed signs of consolidation at left api tumor mas Q g laterally out of the pelvis in the
inguinal regions: and per rectum a large smooth ma.-., filling the pelvis over which the mucosa of the re< turn could be
72
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 97.
moved. There were also several subcutaneous nodules. After a very painful illness the patient developed a pleurisy and died without any great elevation of temperature.
At the autopsy the most extensive tumor growth was found in the pelvis. The pelvis was completely choked by the new growth which projected over its brim and formed the nodules palpated during life. The mass lay between the bladder and intestine, projecting into the bladder and forming a large ridge across its posterior wall. The prostate retained almost its normal appearance, the median lobe being apparently unchanged. Rectal mucosa was not involved. This large tumor was directly continuous with the chain of retroperitoneal glands which were densely matted together and surrounded the recto-vesical cul-de-sac. Sections showed that the tumor — an alveolar large round-cell sarcoma with giant ce ll s — had invaded the bladder from without, as remains of epithelium exist over the intra-vesical projection. The prostate was almost completely replaced by the tumor mass, and the seminal vesicles pushed far back towards the rectum. Metastases occurred in the testes, liver, epicardium, lungs and mesentery, as well as the subcutaneous tissues. The lymphatic glands, with the exception of the immediately adjacent retroperitoneal glands, were very slightly involved.
In the lung, in addition to a mass at the hilum, the metastases were chiefly in the form of flat, button-like nodules on the pleural surface, and on cutting up the arteries which run to these nodules, the arterial walls were seen to be infiltrated with tumor cells so as to form a thick cord-like structure with relatively narrow lumen— a few of these arteries were actually plugged with masses of tumor cells, evidently indicating the channel of metastasis. The possibility, perhaps, cannot be excluded that the perivascular involvements in the neighborhood of the subpleural nodules are merely extensions iu the lymphatics of the vessels from the tumor masses which themselves may have arisen from an infection of the pleura — an idea supported by the extensive involvement of the costal pleura.
The very similar cases of Audree and Zenker (both reported in Virchow's Archiv) were referred to.
Dr. Harris. — The greater interest of this case, no doubt, lies in the pathological statement that Dr. MacCallum has presented, but the bacteriological findings will, I think, prove by no means unworthy of consideration.
The bacteriological analysis of the autopsy was as follows : The streptococcus pyogenes was isolated iu pure culture from the liver, the spleen and a sarcomatous nodule on the abdominal wall ; associated with this organism was the bacillus proteus vulgaris in a culture obtained from the lung.
Subsequently, additional interest was added to the case by the accidental infection with the streptococcus of Dr. dishing and Miss Eeed. In the former, the symptoms of beginning trouble appeared within six hours at the site of a small prick in one finger; within twelve hours the axillary glands and lymphatics of the limb were swollen and tender. The symptoms of infection becoming more pronounced, surgical aid was required, and, with excision of the infected area, recovery
soon set in. From the excised portion of the finger the streptococcus pyogenes was obtained in pure culture.
In the latter case of infection the trouble was entirely local in character, being confined to the tissues at the root of a finger-nail. Redness, pain, swelling and pus formation were the cardinal symptoms. The finger received surgical treatment and slowly healed by granulation. Coverslips from pus showed streptococcus. In consideration of these two ca'ses of accidental infection it was thought advisable to continue the bacteriological study of the organism, and tests were made to determine its virulency upon mice. The first mouse received subcutaneously 0.3 cc. of a bouillon culture. It was found dead next morning, and had probably died within twelve hours— rather a rapid result. The animal was autopsied, but all that was found was a subcutaneous cedema with possibly a small focus of necrosis. The inguinal glands were swollen, but not hemorrhagic. The axillary glands were in the same condition, and all the vessels leading to them were tremendously engorged. The lumbar and mesenteric glands were increased in size. The spleen was greatly swollen, dark-red and soft; the liver was also enlarged and friable; the kidneys in the same state, but pale instead of dark. Cultures from the organs of the mouse were negative, the organism being recovered only from the site of inoculation.
From that organism the second mouse was inoculated, using only one small loopful from the agar culture and administered beneath the skin. This mouse died in sixty-five hours, and the same appearances were found on autopsy of this animal. In addition the lungs showed numerous broncho-pneumonic patches. From these and from the heart's blood the organism was obtained in abundance.
From a liver culture of this mouse a third mouse was given the same quantity, and it died in less than sixty hours.
Upon the grounds of susceptibility to infection with the streptococcus pyogenes we are at once struck by the fact that the human being is very much more prone to this infection than mice, for, in a large number of cases occurring in the human subject, the isolated organism fails to kill a mouse inoculated with it. I can call to mind several occasions where I injected rabbits and mice with streptococcus obtained from cases of puerperal septicaemia, and had entirely negative results. Therefore, upon the high degree of virulence exhibited by this streptococcus, is the bacteriological side of the case presented.
NOTES ON NEW BOOKS.
Twenty-ninth Annual Report of the Massachusetts State Board of Health. {Boston : "W right & Potter Printing Co., 1898.) The Massachusetts State Board of Health Report for 1897 contains the records of work done by the Board during the year set forth in the lucid style so long characteristic of preceding issues. A general report, including a joint report upon the restoration of Green Harbor, is followed by a section relating to water-supply and sewerage. This section contains a report to the legislature, advice to cities and towns regarding their respective water-supplies ami sewerage systems, records of chemical and microscopical work done in the examination of water-supplies and rivers, water-supply statistics and a complete account of the work at the Lawrence Experiment Station on sewage purification and the filtration of
April, 1800.]
JOHNS HOPKINS HOSPITAL BULLETIN.
73
water. The sewage purification of cities and towns in Massachusetts ia finally discussed.
Section 3 consists of a report on food and drug inspection and the analytical examination for adulterations, etc.
Sections 4, 5, 6 and 7 describe the work and results of the State Bacteriological Laboratory, including diagnostic examinations and the making of antitoxin.
Statistical summaries of disease and mortality follow, and a review of the sanitary statistics of the various towns of the commonwealth completes the report.
There is, perhaps, no publication in this country in which statistics are more carefully worked out, or made to yield more definite information, than those collected by the Massachusetts State Board of Health, largely due to the fact that its well-known secretary is one of the most careful and patient statisticians in this country.
From this report, we gather that infectious diseases in Massachusetts have steadily decreased during the last forty years, with the exception of a slight rise in 1S96. An outbreak of small-pox, limited to about eighteen cases, occurred in Boston and neighboring municipalities during the first half of the year. In this connection, and in view of the recent retrograde changes in the vaccination laws of England, it is interesting to note that during the ten years (18S8-1 897) the death-rate in Massachusetts amongst vaccinated small-pox patients was 6.3 per cent., and amongst unvaccinated small-pox patients 25.5 per cent., about four times greater. We may note here that in Massachusetts, also, the vaccination laws suffered, in 1894, an unnecessary amendment, still in force, allowing any regular physician to certify to the unfitness of a child for vaccination, so exempting the child from the legal restrictions otherwise imposed. The granting of such exemptions should certainly be left to the discretion of boards of health.
Typhoid fever showed a reduction of about twelve per cent. Careful consideration of the mortality lists of the different Massachusetts towns confirms once more the rule that a continued high Jeath-rate from this disease in any one community points to the probable pollution of the water-supply of that community and calls for careful investigation. The number of diphtheria cases steadily decreased during the years 1894, 1895 and 1896. The fatality of cases diminished in a much greater ratio due probably to improved treatment and greater sanitary precautions. It can be definitely established that the fatality of epidemics, as well as their extent, is generally lessened by rigid supervision and painstaking care.
The epidemic of cerebro-spinal meningitis, which occurred early in this year (1897), has been exhaustively treated in the monograph of Councilman, Mallory and "Wright, to whom the investigation of the epidemic was entrusted by the State Board of Health. This monograph is abstracted in the report. It is interesting to compare with this epidemic of the year 1897 in Boston, the similar epidemic in Chicago during the year 1898, an account of which has been recently issued by the Chicago Health Department.
The food and drug inspection and examination upset some of the popular notions regarding the supposed extensive adulteration of foods. The adulterations in most cases are usually of a nature commercially fraudulent rather than physiologically harmful. It is curious to note that the production of pure butter is provided for by the maintenance of no less than four separate sets of o while on the other hand, the laws supposed to control the sale of poisons allow the unlimited sale of proprietary medicines containing violent irritating poisons or narcotics, a defect certainly requiring correction.
In most of the large cities of the State, bacteriological laboratories have been established for the diagnosis of diphtheria, tuberculosis, malaria, etc. The bacteriological laboratory of the State Board, in addition to the production of diphtheria and tetanus antitoxin, undertakes diagnostic work for those communities unprovided with a local laboratory. The use of formaldehyde as a gaseous disinfectant has become quite general throughout the State.
A large part of the report deals, as usual, with the analysis of the public water-supplies of the State, and also of rivers not now used for water-supply but receiving sewage from communities on their banks, a very provident proceeding; also with the investigations of the Lawrence Experiment Station on the filtration of water and disposal of sewage. In January, 1897, the laboratory for water analysis was transferred from the rooms of the Institute of Technology to the State House. Both this laboratory and that of the Experiment Station at Lawrence are now under the charge of Mr. H. W. Clarke. The chemical and microscopical methods developed in these laboratories continue in use. The bacteriological work is restricted to the usual efficiency tests of the filters and examination of Merrimac river water at the Experiment Station. No record of bacteriological work on the other public water-supplies is given. Owing to the distance which many of the samples of water must travel to reach the laboratory, and to the difficulty and expense of providing cold storage in transit for them, we think it probable that the additional information which may be obtained by bacteriological analysis of the water-supplies of the whole State is likely always to be restricted to qualitative work, omitting the quantitative as impracticable. Nevertheless, so many interesting and valuable chemical and biological determinations embracing not only the mere analytical results, but also the methods of analysis themselves, have come from the laboratories of the State Board in the past, that one is tempted to hope the near future may see quantitative bacteriological methods employed, for a time at least, on all the water-supplies of Massachusetts, if only to demonstrate their practicability or impracticability, in such work as the Board undertakes for the public. We think that the value of such bacteriological work is considerable and its practicability has been already amply demonstrated, certainly where the laboratory can be reached within a few hours of the collection of samples. The Lawrence experiments this year (1897) have been devoted to a continuation of the experiments of last year (1896) on the purification of tannery, papermill and wool-scouring establishments, on the filtration of highly polluted waters, and on the removal of iron from the waters of certain parts of the State.
Under food and drug inspection, and in addition to the ordinary routine work, the foil used for wrapping various preparations, the metal stoppers of liquid preparations, etc., have been examined for lead with interesting results. In certain countries, the inspections of these wrappers and stoppers as well as of culinary utensils, beer faucets, etc., is controlled by law. The refractometer, principally, is used in the detection of adulteration of such fats as butter, lard, olive oil, etc. A large percentage of cheap jellies were found to contain no trace of the raspberry, strawberry, etc., which the label proclaimed as present.
The report of the bacteriological laboratory of the Board at the Bussey Institute, under the charge of Dr. Theobald Smith, contains a number of tables illustrative of the results of the use of antitoxin, classification of the bacteriological diagnoses made and of the examinations for the malarial organisms.
Under the Health of Towns, an epitome of the reports -of the various boards of health of the State is given. The action of the Lowell authorities in attaching a " poison " label to all the faucets in the mill fed with canal water shows that they at least are troubled with few doubts on the dangers of polluted water-supplies.
In conclusion, we may congratulate the State Board of Health, through its president, Dr. Walcott, on the continued excellence of its Annual Report as exemplified in this issue. It mustbe confessed that we miss the detailed accounts of methods of water analysis, their applications and limitations, which have made certain of the previous reports indispensable adjuncts to chemical, biological and bacteriological laboratories throughout this country. No oni tution has contributed more to these subjects in the past ; certainly no one of these subjects is yet exhausted. We believe that much of the information liearin;; on these points is ftill practically unknown in many sections of the country. Nor can we do other
74
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 97.
wise than regret that the able pen of Dr. Smith has not yielded to this report some account of the routine methods in his department. Changes in technique, however slight, are often of considerable value, and in any case, the repeated publication of even an unchanging routine, wearisome as it may seem, gradually tends to bring about a greater uniformity in method as new laboratories are established and the latest and most successful methods are considered for adoption. To the sanitarian and statistician, in general, the present volume will prove fully as interesting as its predecessors, but the student, the analyst aud the ubiquitous "laboratory man" will certainly turn back, with some disappointment, to the reports of 90-96.
To the general public, the explanations accompanying some of the statistical tables of this report and the brief summaries of the conclusions to be deduced from the tables are most valuable. "We can only wish that this method of making clear to "the laity" the meaning of the endless succession of figures in which statisticians delight was more extended in this report and more generally followed in others of a similar nature. H. W. H.
A Primer of Psychology and Mental Disease. For use in Training Schools for Attendants and Nurses, and for Medical Classes. By C. B. Burr, M. D., Medical Director of Oak Grove Hospital, &c. Second Edition. Thoroughly Revised. {The F. A. Davis Co., Philadelphia, New York, Chicago, 1898.) The appearance of a second edition of Dr. Burr's Prime* of Psychology is, in itself, evidence that it has met a want and, considering that there are other more or less similar works to compete with it in its rather limited circle of patronage, is an indication of its worth. The present edition, in addition to the general revision, has had added an address given before the Training School class of the Eastern Michigan Asylum, in 1895, a valedictory address on the occasion of his leaving that institution.
If one is to offer any criticism of the work it would be on some minor point, such, as for example, the statement that in mania there is no tendency to suicide. Maniacs do sometimes commit impulsive suicide, and like most other insane are to be considered as rather uncertain in their conduct and needing watching. This and possibly one or two other similar statements should be less absolute, and in a future edition iheir modification is suggested. As a treatise for the instruction of hospital attendants we can heartily recommend this book.
Archives of the Roentgen Ray. Edited by W. S. Hedley, M. D.,
and Sidney Rowland, M. A. Vol. II, No. 4; Vol. Ill, No. 1.
{W. B. Saunders, Philadelphia, 1898.)
These two issues of this now well-known publication appear to be fully equal to their predecessors, and to contain the usual number of scientific communications. Most of them are of a rather technical character, relating to the physical characteristics of the X-Rays and their management, as would be naturally expected, but one or two are of medical interest. One of these is the preliminary notes of Drs. Wolfenden and Ross on the influence of the Roentgen Rays upon the growth and activity of bacteria and micro-organisms, in which they were found to have a very marked stimulating influence on the bacillus prodigiosus. The authors are continuing their research on the pathogenic bacilli especially, and it will be an important gain if they can give us some authoritative data on their behavior under the action of the rays.
The same issue reproduces from the British Medical Journal an abstract of the papers and discussions on the uses of the Roentgen Rays in the diagnosis of tuberculosis at the late congress on this disease at Paris last summer. Their value, in this particular direction, seems fairly settled, or at least highly probable, when they are utilized by experienced operators.
On Cardiac Failure and its Treatment. With special reference to the use of baths and exercises. By Alexander Morison, M. D., Edin., M. R. C. P., Ed. {London: The Rebman Publishing Co., Ltd., 1897).
This work is a scientific monograph on cardiac weakness, a condition that is sometimes too little recognized, though, unfortunately frequent enough and often of serious importance, even without actual irreparable organic disease affecting the mechanical action of the heart. Whether it be the nervous system that is at fault, or the muscular tissue has iost its tone, or the heart is embarrassed by the mal-cooperation of other important organs or tissues, the general result is alike in all, a cardiac failure, varying only in degree in any particular case. The recognition and treatment of each and all of these factors is an important question, and serves to indicate how complete in this, as in other affections, the investigation of the disorder should be from the very beginning of the treatment.
The book appears to give within its compass reliable and thorough monographs of its subject, and the latter portion on the treatment of these conditions will be doubtless found valuable and suggestive. The remarks upon and descriptions of the gymnastic and nydrotherapeutic methods ought to be particularly useful as comparatively new in our literature, and the author has supplemented his own skilled observations and opinions with an appendix by Dr. Groedel, of Bad-Nauheim, who has also had the revision of the chapters on these special subjects.
KOOKS RECEIVED.
Arcfiives of the Roentgen Ray. Edited by Thomas Moore, F. R. C. S., and Ernest Payne, M. A. (Cantab). Vol. Ill, No. 2, November, 1898. 4to. The Rebman Publishing Co., London. W. B. Saunders, Philadelphia.
Annual and Analytical Cyclopedia of Practical Medicine. By Charles E. de M. Sajous, M. D., and one hundred associate editors, etc. Volume 11.1899. 4to, 607 pages. The F. A. Davis Co., Publishers, Philadelphia, New York and Chicago.
The American Year-booh of Medicine and Surgery. Collected and arranged with critical editorial comments by S. W. Abbott, M. D., J. J. Abel, M. D., et al. Under the general editorial charge of George M. Gould, M. D. 1899. 4to, 1102 pages. W. B. Saunders, Philadelphia.
Saint T?iomas' Hospital Reports. New series. Edited by Dr. Hector Mackenzie and Mr. G. H. Makins. Vol. XXVI. 1898. 490 and 170 pages. J. & A. Churchill, London.
3000 Questions on Medical Subjects Arranged for Self '- Examination. Second edition. 32°. 1899. 189 pages. P. Blakiston's Son & Co., Philadelphia.
An American Text-book on Diseases of the Eye, Ear, Nose and Throat. Edited bv G. E. de Schweinitz, A. M., M. D., and B. Alex. Randall, M. A., M. D., Ph. D. 1899. 4to, 1251 pages. W. B. Saunders, Philadelphia.
Saint Bartholomew's Hospital Reports. Edited by N. Moore, M. D., and D'Arcy Power, F. R. C. S. Vol. 34. 1S99. Svo, 396 and 258 pages. Smith, Elder & Co., London.
Thirty-fourth Annual Report of the Trustees of the Boston City Hospital, with report of the Superintendent, February 1, 1897, to January 31. 1898, inclusive. 1898. 8vo, 215 pages. Municipal Printing Office, Boston.
Transactions of the Medical Society of the State of North Carolina, Forty-fifth aimual meeting held at Charlotte, N. C, May 3, 4 and 5, 189S. Svo., 173 and 50 pages. Carolina Publishing Co.. Winston, N. C.
Transactions of the American Ophthalmological Society. Thirtyfourth annual meeting, New London, Conn. 1898. Svo, 471 pages. Published by the Society, Hartford.
Transactions of the College of Physicians of Philadelphia. Third series. Volume the twentieth. 1898. 8vo, 227 pages. Printed for the College. Philadelphia.
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. Subssriptions, $1.00 a year, may be i sent by miilfor fifteen' cents each.
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. X.-No. 98.1
BALTIMORE, MAY, 1899.
[Price, 15 Cents.
COl^TEHTS.
Acute Diffuse Gonococcus Peritonitis. By Harvey W. Cushing M. D., ■ .
A Case of Atrophy of the Optic Nerves following Hemorrhage from the Stomach, with a Consideration of the Causes of Post-Hemorrhagic Blindness. Bv Samuel Theobald, M. D., - . - '.
Lichen Scrofulosorum in a Negro. By T. Caspar Gilchrist M.R.C. S., L. S. A., A New Instrument for Measuring Heterophoria and the Combining Power of the Eyes. By Frederick Herman Vbrhoepf, Ph.B., --...--.
PAGE.
On the Solution of Mercury in the Body. By Arthur Smith Chittenden, 92
Proceedings of Societies :
Hospital Medical Society, 95
Exhibition of Medical Cases [Dr. Futcher] ; — Aneurism of Aorta, Compressing and Rupturing into Left Bronchus [Dr. Flexner] ;— Multiple Metastases from Pelvic Sarcoma [Dr. Flexner].
Notes on New Books,
Books Received, --------.-.-..
08 102
ACUTE DIFFUSE GONOCOCCUS PERITONITIS.
By Harvey W. ('ushixc;. M. D. '<> Surgical Clinic of Dr. Ilalsted, The Johns Hopkins Hospital.)
Owing to the influence of Bumm's original assertion, that gonorrhoea] processes remain limited to surfaces lined by mucous membrane, it had until comparatively recent times, been generally doubted that the gonococcus of Neisser, without ■me association of the more common pyogenic organisms, was capable of inducing an acute general peritonitis. It is howw recognized that structures other than those of an epithelial character are liable to invasion by the gonococcus and. indeed, parts covered by endothelium seem particularly attack by this organism. Thus the joints, plura, periand endocardium are liable to gonococcal infection, and - :i these affections are metastatic in character, and occur fcnng the course of a general gonococcus septicaemia, they nevertheless suffice to prove the untenableness of Bumm's original statement. Nevertheless surgeons have clung to the belief in the immunity of the peritoneum to gonococcal infection, and it has generally been granted that gonorrhceal processes in women are checked in the neighborhood of the abdominal ostiaof the tubes, where by continuity of extension, a peritonitis otherwise might readily be induced. We must for the p continue to believe that such an inhibition of the growth
organisms does usually occur when the serosa is reached, bul whether under unusual circumstances a general peritonitis may not follow, by implantation of gonocoeci from the tubes
upon the peritoneum, has hitherto I n regarded as extremely
improbable. The usual conception is concisely expressed in a recent paragraph by Frederick Treves,* as follow.-:
"Peritonitis lias been met with in association with gonorrhoea, but inasmuch as the gonococcus cannoi survive in the •• ity ii is doubtful whether peritonitis due to the
gonococcus alone has any existence It is very probable
that a mixed infection is the cause of the pyosalpinx often met with in gonorrhoea. That pyosalpinx may lead to acute peritonitis is undoubted, but it has not been demonstrated tch a complication is due to the action of the gonococcus alone; it is probably the outcome of a mixed infection. . . ."'
Even among those Ee\i >i 3, who have d
attention from an experimental as well as a clinical standpoint to the possibility of this complication of gonorrhea in
Fred'k Treves, Allbutt's System of Medicine. Vol. II]
1897.
76
JOHNS HOPKINS HOSPITAL BULLETIN.
[Xo. 98.
women, the subject remains one of debate for the want of one link in the chain of evidence, which it is hoped that this communication will establish.
The recent observation at the Johns Hopkins Hospital of two cases of diffuse peritonitis, clue to pure gonococcal infectiou, which it is the design to report, has led to the following brief historical review of the literature dealing with the question outlined in the preceding paragraph.
Bumm,* in 1889, published the following statement in which the principles laid down by most subsequent writers can be seen reflected. "Ab es eine gonorrhoische Entziindung des Peritoneum giebtistmir immer sehr Zweifelhaft gewesen. Die Mikroben der Gonorrhoe vermogen nur auf Schleimhauten pathogene Wirkungen zu entfalteu, gehen aber in Serosen Hohlen zu Grande. Reiner gonorrhoischer Eiter, der sich aus geplatzten Tubensacken in's Peritoneum ergiesst, wirkt in der Kegel nun als aseptischer Fremdkbrper. Es wird abgekapselt, etc." He goes on to say that only a mixed gonococcal infection can be followed by a septic peritonitis.
At the meeting of the German Gynaecological Society, held in Bonn, in 1891, Bummf further emphasized his views. He believed that gonorrhoeal infections ran a course as a superficial mucous membrane affection merely and never penetrated the deeper connective tissue in which the gonococcus would perish : that the organism of Neisser had nothing to do with septic processes, which occurred only through the medium of mixed infections : that the gonorrhoea] process, usually localized in the urethra and cervix, under certain influences, primarily that of menstruation, but also during the puerperium, and from coition and instrumentation, might extend to the endometrium of the body and tubes. Beyond these parts, however, he believed the process did not pass, being limited by the endothelial peritoneal surface.
At this same meeting WertheimJ presented the results of some clinical and experimental investigations which question the assertion as to the immunity of the peritoneum in Bumm's sense, and which remain to-day the most important contribution to this subject.
His observations, which are directly in opposition to those of Bumm, demonstrated conclusively that at all events a circumscribed pure gonococcal peritonitis could be produced experimentally in animals and was possible in human beings.
Bumm, E. Zur Aetiologie der septisehen Peritonitis. Miinchener
med. Wochenschr., Bd. XXXVI, No. 42, p. 715, 1889.
tBumin. Ueber die Bedeutung der gonorrhoischen Infection fur die Entstehung schwerer Genitalaffectionen bei der Frau. Verhandlungen der deutschen Gesellschaft fur Gyniikologie, IV. Kongress, 1891, p., 359.
Ref. Centralbl. f. Gyniikologie, Bd. XV, p. 448, 1891. Ref. Journal of Obstetrics, Vol. XXIV, p. 1265, Nov., 1S91.
tWertheim, Ernest. Zur Lehre "von der Gonorrhoe. Verhandlungen der deutschen Gesellschaft fiir Gyniikologie, IV. Kongress, 1891, p. 346.
Die ascendirende Gonorrhoe beim Weibe. Bakteriologische und klinische studien zur Biologie des Gonococcus Neisser. Archiv fiir Gyniikologie, Bd. XLII, p. 1, 1892.
Ref. Journal of Obstetrics, Vol. XXIV, p. 1379, Nov., 1891.
Ref. Centralbl. f. Bakteriologie, Bd. XII, p. 105, 1892.
In a carefully conducted series of experiments he found that the inoculation into the abdominal cavity of certain animals of a pure culture of gonococci, which organisms he had cultivated successfully upon human blood-serum agar, would produce a localized peritonitis, provided that there was introduced at the same time a non- absorbable material. For his purposes nutrient agar sufficed. He found, however, that even in white mice and guinea-pigs, the most susceptible of the lower animals, the process remained localized, was evanescent and never fatal. The acute circumscribed seropurulent reaction consisted of a deposit of pus cells and gonococci in great abundance on the hyperaemic serosa of the bowel. Nor was this all, for in sections the gut showed the gonococci penetrating deeply under the serosa and between the muscle bundles in ever-increasing intensity for about seventy-two hours, after which the multiplication of the organisms would cease and they would become more difficult of cultivation. The control animals would invariably recover. In his entire series of laparotomized animals no instance of mixed infection was encountered, and he recovered the introduced organisms in pure culture, and afterwards conclusively demonstrated their nature by the production of a specific anterior urethritis in man.
He further demonstrated that in a considerable percentage of cases of chronic salpingitis, which, from the absence of any growth upon ordinary media had previously been supposed to be sterile, a pure culture of gonococci could be obtained upon his blood-serum agar. Similarly from two cases of ovarian abscess he isolated pure cultures of these organisms.*
By his experimental and pathologic studies, therefore, Wertheim showed that the gonococcus was capable of multiplication upon the peritoneal serosa and in the tissues, and of inducing an acute localized, though evanescent, peritonitis. Similar occurrences in the human peritoneum and the possibility of a diffuse peritonitis of similar nature remained undemonstrated.
Wertheim! in a subsequent report published a case in which, during a laparotomy for salpingitis, he found an extensive acute pelvic peritonitis. In the exudate he demonstrated gonococci and succeeded in cultivating them on his bloodseruni agar. The abdominal ends of the tubes were open and discharging pus. The fimbria? were free from adhesions. Had the process been left to itself it would have gone on to organization of the exudate and the formation of extensive pelvic adhesions, the usual sequel of these conditions. The author believes this to be the first assured case of acute gonococcal infection of the peritoneum in a human being.
Since Wertheim's communications occasional contributions
The frequent demonstration by other observers since Wertheim,
of gonococci in the pus of ovarian abscesses, when the organisms are no longer demonstrable in the chronic peritonitis about the append dages, is most naturally explained on the supposition that the bloodclot of a ruptured follicle offers a more favorable culture medium for their maintenance than does the peritoneal serosa.
tWertheim, Ernest. Ein Beitrag zur Lehre von der Gonokokkenperitonitis. Centralblatt fiir Gyniikologie, Bd XVI, p. 385. 1S92.
Ref. Centralbl, f. Bakteriol. und Parasiten, Bd. XII, p. 108, 1892.
Man. 1899.]
JOHXS HOPKINS HOSPITAL BULLETIN.
to the subject have been made by various writers, all of rather negative value.
Menge,* at the Tenth International Congress in Berlin in 1891, reported the results of examination of twenty-six cases of purulent salpingitis. He found micro-organisms on eighi occasions and gonococci on three, but, like Bumm, he Failed to demonstrate the latter in inflammatory processes of the peritoneum. Menge, however, unlike Bumm, does not commit himself, but leaves the problem unsolved as to whether the acute and chronic pelvic peritonitides, which we find accompanying purulent gonorrheal salpingitis, are due to a specific gonococcal infection, or to the chemical irritation of the overflowing secretion, or are the product of a definite mixed infection.
Zweifel,-f in his discussion of Menge's paper, gave the conclusions drawn from a great number of personal observations, namely, that the formerly denied sequence of infection of the abdominal cavity with gonococci stood in contradiction to clinical experience. He believed in the existence of a gonococcal peritonitis, and that the organisms can be found only in the very acute cases, such as, for example, do not last louger than a week. He acknowledged, however, that definite proof to support this statement had not yet been brought forward.
Similarly Charrier,| in Pozzi's clinic was not able to cite a definite instance of such acute gonococcal peritoneal inflammation, although he believed in its existence. He considers it a short-lived process and one complicated, as a rule, by ;onCOmitant infection with other pyogenic cocci.
Menge reported a case to the Gesellschaft fur Ceburtshiilfe in Leipzig, in 1893,§ in which, following the correction, under anaesthesia, of a retroflexed uterus associated with a small pyosalpinx, a general peritonitis supervened. Zweifel operated and found a double pyosalpinx with beginning general peritonitis. The pus from the tubes showed a few gonococci on culture. Xone, however, could be demonstrated on coverslip preparations. The abdominal contents were negative culturally, nor could any organisms be found on stained preparations. The patient recovered and Menge believed that the peritonitis was attributable less to the micro-organisms than to ptomains present in the pus. He believed that they were dealing with a purely chemical peritonitis.
The principle which Bumm had laid dowu, namely, that peritoneal infection after gonorrhoea was more apt to occur after menstruation, parturition, &c, soon became emphasized by the reports of cases in the literature tending to disprove the common belief that the infection to involve the general cavity must be a mixed one. The observations alluded to did this,
77
. Menge, K. Ueber die gonorrhoische Erkrankung der Tuben
und des Bauchfells. Zeitschr. fur Geburtschulfe und Gynakologie, Bl. XXI, 1, p. 119, 1891. Ref. Centralbl. f. Gynakologie, Bd. p 711, p. 457, 1893.
fZweifel. Verhandlungen des X. Internat. Medic. Congresses, Berlin. 1S90. Bd. Ill Abeth. 8. Gynakologie, p. 176, 1891.
it'harrier, P. De la po'ritonite blennorrhagique chez la femme. Th.'se .le Paris, 1892.
S Menge. Ueber Laparotomie bei geborstener Pyosalpinx.
Centralblatt fur Gynakologie, Bd. XVII, p. 457, 1893.
however, more because of negative findings of the pyogenic group than by any positive demonstration of the existence of the gonocoeeus alone.
Veit,*in L893, reported five cases in which the sym of acute diffuse peritonitis had occurred in women in childbed, who had become infected in two instances shortly before the confinement and in three during the puerperium. In these eases after a stormy period of a fVw days the threatening symptoms disappeared, leaving a condition .if chronic gonorrhoea] pyosalpinx. Veil declared that the peculiar anatomical condition present in the puerperal state occasioned the rapid onset of the peritonitis and offers the suggestion that possibly the lochia affords a good culture medium for gonococci, a view which BrSsef holds because of the observation that one often finds during the child-bed period, the gonococci in great abundance in old infected eases which previously were in such a quiescent state that few, if any, organisms could be demonstrated in the discharges.
Penrose^ reports a somewhat similar case of a colored woman who, four weeks after her confinement, contracted an acute gonorrhoea, which was followed in six days by symptoms of acute peritonitis. A laparotomy was performed disclosing general peritoneal involvement with a recent double salpingitis. Both tubes were removed. Unfortunately the value of this case was lost by the failure to investigate the bacteriology of the peritonitis and the uncertainty of the pathological report on the tissues which had been removed.
Chaput,§ also cites a case in a girl of seventeen, in whom a general peritonitis followed a double pyosalpinx. The abdominal openings of the tube were patent, and pus could be squeezed from them. The patient died of -paralysis of the intestine." Chaput considered the ease an example of general gonococcal peritonitis.
Korte|| also, in his second report on peritonitis, describes a case (No. 20) in which a general peritonitis, sudden and with great collapse, followed the rupture of a pyosalpinx. The patient recovered after the laparotomy which disclosed a pronounced degree of peritonitis in the exudate of which a few intracellular diplococci were found. Unfortunate!) thej could not with surety be demonstrated to be gonococci.
In 1896, Brosel reported two cases of non-puerperal peritonitis for which he held the gonococcus alone responsible. As in Menge's case, referred to above, the cause of the peritonitis on oue occasion was the rupture during manipulation of a small gonorrhoea! pyosalpinx. Signs of collapse and
Veit, J. Frisebe Gonorrboe bei Frauen. Dermatologisebe Zeitschrift. Bund. I, p. 165, 1893.
t Brose, P. Ueber die diffuse gonorrhoische Peritonitis. Berliner klin. Wochenschr., Bd. XXXIII. p. 779, Aug. 31, 1896.
t Penrose, Chas. B. Acute Peritonitis from Gonorrhoea. Medical News, Vol. LVII, p. 16, July 5, l
i Chaput. Peritonite blennorrhagique, etc. Bulletins de laSociete Anatomiquede Paris. Annee tie p, 9, 246, IS94.
|| Kbrte, W. Weitere Bericht iiber die chirurgische Behandlung der diffusen Eiterigen Bauchfellentzundung. Mitteilungen aus den Grenzgebieten der Medizin und der Chirurgie, Bd. II, p. 167, 1897.
' Brose, P. Loc. cit.
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general peritonitis followed. In the light of Wertheim's and Veit's observations, Brose, although urged to intervene, withheld operation, and after four days the symptoms subsided. His second case was one of a spontaneous rupture of a gonorrhoea! tube. Here also extreme symptoms, not only of pelvic, but of a generalized inflammation with profuse vomiting, extreme meteorism and collapse so marked that the ease looked hopeless, followed. Again operation was withheld, and by the sixth day all symptoms had subsided. Brose naturally believed that these peritonitides, differing so greatly in their course and prognosis from the ordinary streptococcus and staphylococcus invasions, represented a distinct form of peritoneal infection. Their symptoms, such as great pain, general tenderness, vomiting, meteorism, singultus, high temperature, small and frequent pulse, are the same as those of general peritonitis from any cause. Their prognosis is however widely different, as complete recovery, except for the chronic condition left in and about the appendages, is the usual outcome, lie acknowledges, however, that as no ease has been confirmed by section, the pathologic anatomy and the bacteriology of " gonorrhceal peritonitis" are only matters of conjecture.
During the discussion* which followed Brose's report, the apparent verdict was "not proven." Diihrssen believed that he had seen two cases similar to those reported, and he had treated them also in an expectant manner. He regarded the fresh cases, where only endo-salpingitis existed, as the most dangerous for the production of general peritonitis, for in them the abdominal ostia are not closed. A previous pyosalpinx with adhesions naturally renders its occurrence less likely. Bagiusky, at this time reported a fatal case in a child following a vulvo-vagiuitis of gonorrhceal origin. Unfortunately no note was made on the bacteriological findings of the peritoneum at autopsy. Kiefer expressed doubt as to the extent of the process in Brose's cases, believing that a local peritonitis might have given similar symptoms. He truly said, " Einen wirklich einwandfreien Fall von diffuser gonorrhoischer Peritonitis giebt es bis jetzt nicht."
Bland Sutton! later in the same year briefly reported a case which almost filled the requirements demanded by Kiefer. It was that of a young girl presenting acute abdominal symptoms supposed to be of appendicular origin. On opening the abdominal cavity he found pus leaking from the ostia of the tubes, which were as large as the thumb, and a general peritonitis of a peculiar form with free purulent fluid described as " gummy." This fluid contained " myriads of micrococci and an abundance of gonococci." The patient was found subsequently to have had a vaginal discharge for three months.
The infection here was regarded as a mixed one, though the variety of micrococci" was not given. Bland Sutton's report is brief, and no note is made concerning any relation to catamenia or other setiological factor in the spread of the infection.
If this case is to be regarded as one of general gonococcal
Berliner klin. Wochenschr., Bd. XXXIII, p. 261, Mar. 23, 1896.
tSutton, J. Bland. Some interesting pelvic cases. Brit. Med. Journ., Vol. II, p. 1309, Oct. 31, 1896.
peritonitis, it and Wertheim's (1. c.) are the only two which I have been able to discover in a careful search of the literature which carry any convincing proofs of such an origin.
It is hoped that the two following cases, in which the condition was unsuspected and the diagnosis not made until the gonococci were demonstrated in the abdominal cavity, are sufficiently conclusive to establish beyond question the existence of a diffuse pure gonococcus peritonitis.
Case I. — Surg. No. 7719. — Acute Abdominal Symptoms during Menstruation and following Qonorrho «. Laparotomy. General Peritonitis. Recovery.
Mollie C, a maid, aged 25 years, was admitted to Dr. Osier's service May 20, 1898, complaining of abdominal pain.
Her history given on admission was without note. There was nothing to call attention to any pelvic disturbance. She denied the possibility of gonorrhoea] infection, and a cursory pelvic examination was negative. Catamenia had always been regular.
The patient stated that four days previously her usual mensirual period had begun. Two days later after an exposure to cold, having fallen asleep in a draught while drying her hair, the flow partially ceased. The same day she began to have some sharp colicky pains in the abdomen and back, but kept at work until the day before admission, when the pain became more severe and quite constant. She remained in bed. Her bowels were constipated. She had some pain in the abdomen during evacuation of the bladder. The next day she was admitted to the medical wards from the dispensary by Dr. Frank R. Smith.
On admission the patient was very much excited and restless, and the history and examination were equally unsatisfactory. The temperature was 100.5°; pulse 110, of good quality; respiration not accelerated. A leucocytosis of 19,000 was present. She was flushed and had a thickly coated tongue. She lay with her knees drawn up.
The abdomen was symmetrical, somewhat full in the umbilical region. Liver dullness extended from the sixth rib to the costal margin. Neither liver nor spleen were palpable. There was no dullness in the flanks; no rose-spots. The only areas of tenderness which the patient acknowledged were in the upper zone of the abdomen. Some muscle spasm was elicited on palpation there. There was no rigidity. Rectal and vaginal examinations were negative (though the patient subsequently said they gave her great pain).
The following day the symptoms became more pronounced. General abdominal tenderness was more marked; the temperature rose to 102.8°, the leucocytes to 22,000. She was transferred to the surgical side for exploration.
Operation May 21,1898, ether anaesthesia.
Median exploratory laparotomy. General peritonitis. Acute double salpingitis. Gonococci demonstrated. Salpingectomy. Peritoneal toilette. Drainage.
An incision was made through the inner border of the right rectus muscle. On opening the peritoneal cavity no free fluid, but a deeply injected serosa quite universally covered with a deposit of yellow fibrin, was found. The appendix was immediately sought for. It was deeply injected and covered with flakes of" lymph," but there was no evidence of perforation, adhesions or anything identifying it as the source of trouble. Cultures and coverslip preparations were made from the surface of the appendix, and a flake of fibrin was removed for examination. While the coverslips were being examined a systematic examination of the abdominal viscera was made.
May, 1899.]
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The serosa of the uterine appendages and pelvis presented uo evidences of an older process than that covering the appendix and right iliac fossa. The incision was enlarged and the small. bowel evertrated while the region of the stomach, liver and gall-bladder were explored. No perforations could be found. There was the same injection and deposit of lymph everywhere. The under surface of the liver was covered quite uniformly with a thick deposit. The coverslip examination meanwhile was reported as showing a deeply staining biscuitshaped coccus, for the most part intracellular, occurring in pairs and not decolorizing by Gram's method. This led to a further examination of the Fallopian tubes. Like the rest of the exposed viscera, they were deeply congested and quite abundantly covered with lymph ; they were somewhat swollen, but not markedly so. There were no adhesions of any note about them, and the fimbriae were free. Both appendages presented the same appearance. On gently squeezing the tube and stripping it toward the free end a thick drop of purulent material could be made to appear much like that seen at the external meatus in gonorrhceal urethritis in the male. An abundance of organisms with the morphology of gonococci were demonstrated in the pus.
Both tubes were removed. The abdominal cavity was thoroughly irrigated with salt solution, and much of the lymph willed away with salt sponges. The abdominal wound was partly closed, and two drains of gauze wrapped in rubber protective were left leading to the stumps of the tubes.
The patient was quite ill for two days after the operation; restless, with dry tongue, meteorism, vomiting and general appearance of peritoneal infection. She subsequently made a complete recovery. The protective wicks were withdrawn on the fourth day and the wound closed immediately. Doubtless the drainage was unnecessary.
There was a little irregular bloody discharge from the vagina, with some leucorrhcea for a few days. No organisms could be positively identified as gonococci in the urethral or vaginal secretions.
After the operation this additional note was obtained from Hie patient. She had been exposed to infection for fivi or more, and for two years bad had some menstrual irregularity, the flow at times being replaced by leucorrhcea. For some months she had had quite a profuse leucorrhcea and considerable burning pain with micturition. She had been expo re-infection a few days before her menstrual period.
BACTERIOLOGICAL REPORT BY DR. nUGII H. VOl
Peritoneum — Smears and cultures were made from the large
flakes of fibrin which were adherent to the intestines: very little
flu ill pus present. The smears showed pus cells and fibrin without
Cultures made on agar slants are negative after several
days in the thermostat.
Cultures on ascitic-lluid agar (inoculated with pus and fibrin w.iich had been on an agar-slant for twenty hours) show no growth after many days in the thermostat.
Fallopian tube; surface burned; tube incised with sterile knife. Smears from pus show leucocytes and epithelial cells, and numerous bacteria resembling morphologically the gonococcus. Most of them are inclosed within leucocytes in numbers varying from two to sixteen, typical biscuit-shaped, grouped generally in
pairs, sometimes in tetrads. No other bacteria present. After Gram's stain all are discolorized.
Diagnosis, gonococcus.
Cultures were unfortunately not taken from the tubes.
Note.— The negative result of inoculations of large amounts of fibrin and pus from the peritoneal cavity upon ordinary agar slants practically excludes the possibility of the presence of the ordinary organisms of peritonitis.
The absence of growth on ascitic-lluid agar signifies nothing, as the medium was inoculated from the surface of an agar-slant twenty hours old. While the positive cultural evidence of the presence of the gonococcus in this case would have been desirable, the certain identification of the organism in the tube and the absence of growth on the ordinary media makes the diagnosis of gonococcus infection convincing.
The demonstration in this case of gonococci on coverslip preparations from the peritoneum made and examined during the operation showed that the peritonitis was not simply of a chemical nature, as the negative cultural findings upon the ordinary media inoculated in the operating room might otherwise have led us to believe. The routine immediate examination of the flora of the exudate in cases of peritonitis often is of the greatest service to the operator, and may give a distinct clue to the prognoses and proper treatment of the case. Had no such examination been made in this instance possibly the source of the infection might not have been recognized, and not improbably the peritonitis have been regarded as a chemical one, as Menge believed it to have been in his case. Negative bacterial results have characterized nearly all of the observations previously mentioned in this report, except the experimental ones of Wertheim. Whether "chemical" peritonitis, so-called, has any actual existence remains a question of doubt. Tavel and Lanz* recognize such a condition, while Flexnerf has never failed to find organisms in his L06 cases of peritonitis examined after death. The pathologist doubtless may be less likely to encounter these rather benign cases than the surgeon, but it is possible that some of the " chemical "cases described by surgeons may be, afterall, of bacteriologic origin, though difficult to recognize, as was the one here reported.
Cask [[.—Surgical No. 7760. — Acute abdominal symptoms during menstruation simulating appendicitis. Laparotomy. General peritonitis. Recovery.
.M. B., a factory girl, aged IS, was admitted lo Dr. Osier's service May 30, 1898, complaining of pain in the right side of tin- abdomen, with persistent nausea and vomiting. The meagre history relative to her condition which could be obtained at entrance was as
follows: Six days previously she was awakened in the mi ig
with abdominal pains so severe that she could not gel up. Up to this time she had been perfectly well. Her bowels were constipated for some days after this onset, and she had been constantly
nauseated with frequent spells of prolonged vomiting, which had increased of late. She bad been hiccoughing some. All disturbance with micturition and menstruation was positively denied at this time. Her pain had been , stant and always in the right
♦Tavel. E., and Otto Lanz. Deber die Aetiologie der Peritonitis.
Mittheilungen alls kliniken und medicinisrhen [nstituten der
Schweiz, f Reihe, f Heft., [893.
f Flexner, Simon. The Etiology and the Classification of Peritonitis. Philadelphia Medical Journal, Nov. 12, 1898.
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[No. 98.
iliac fossa. She had had no chill and was unaware of any pyrexia. Her general appearance was that of collapse, with peritonitis.
She was seen by Dr. Halsted in consultation with Dr. Thayer, and a provisional diagnosis was made of general peritonitis presumably of appendicular origin.
She was immediately taken to the operating room, where the following note was made before anesthetization: "The patient is a young woman with flushed cheeks, a thickly-coated tongue and a general appearance of acute toxoemia. Her respirations are costal in type, somewhat accelerated— thirty-four to the minute. Pulse is 100, rather small, but regular and fairly good quality. Temperature is 98.6°. Her extremities are cold, but not clammy as from collapse. There is a leucocytosis of 26,000.
Abdomen. — There is no distention. On the left side there is no rigidity or muscle spasm and no apparent tenderness. Tenderness on the right side is marked, but protective spasm is not a prominent feature. There is a definite point of tenderness two or three centimetres to the right of the umbilicus on a line to the anterior spine. Percussion note has about the same quality over the whole abdomen, with no dullness in the flanks."
The patient insisted that her chief tenderness was in the epigastric region. A vaginal examination which had been made in the ward previously was reported as negative, except for an absent hymen and slight vaginitis.
Operation May 30, 1898, 2 P. M. Ether anesthesia. Exploratory laparotomy. Oeneral peritonitis. Oonococci demonstrated in exudate. Double salpingectomy . Irrigation and drainage All incision was made over the site of the appendix. On opening the peritoneal cavity the whole serosa was found greatly injected and quite uniformly covered with a layer of fibrin. There was no free fluid; no pus. The appendix was found to be deeply congested and covered with " lymph," but in no respect differing from the appearance of the rest of the bowel. The distribution of the exudate was so uniform that (as in Case I) there was nothing to draw attention to any particular organ in searching for the origin of the peritonitis."
The under surface of the liver, the spleen, stomach and pelvic viscera, all were deeply injected and more or less thickly covered with exudate. This seemed especially abundant on the under surface of the liver, from which it could be peeled off in large flakes, leaving a raw surface exposed.
The tubes were examined early in the search, as the peculiar character of the peritonitis resembled so closely that seen in Case I. They were, like the appendix, congested and covered with lymph, but the fimbriae were free and there was no evidence that the pelvic peritonitis antedated that in the upper portion of the abdomen. Only after a careful examination of the gall-bladder, stomach, mesenteric glands and bowel were the tubes re-examined when, with some difficulty, it was found that a purulent drop could be brought to the abdominal ostium.
Coverslip preparations were immediately made from this pus, and a biscuit-shaped diplococcus decolorizing by Oram's method was demonstrated in moderate numbers. Cultures were made on various media from this material and from different parts of the abdominal cavity, and a sheet of fibrin about three centimetres in diameter was stripped from the under surface of the liver for future study, and by chance was dropped in a bouillon tube.
Both tubes were removed, the pelvis was carefully wiped out with saline sponges, the intestines irrigated and much of
the thick fibrin sponged off. The abdominal wound was partly closed, leaving a small drain leading into the pelvis.
The patient made a satisfactory and complete recovery.
An attempt, made subsequent to the operation, to demonstrate gonococci in the vaginal discharge was unsuccessful. The following important feature of the history was obtained after the operation. She had been frequently exposed to infection for a year and had had considerable leucorrhcea for six months, with some burning and cutting pain during micturition. Several days before her last menstrual period she was re-exposed after a long interval of freedom, and had a return of abundant discharge. Menstruation began as usual, but ceased after three days with the onset of the abdominal pain and vomiting, leucorrhcea and ardor. The patient to protect herself had referred her pain to the epigastric region, and denied any tenderness on pelvic examination.
The appendicular tenderness is an interesting feature. Possibly the great congestion of the organ may have been responsible for the tenderness on pressure near McBumy'a point.
RACTERIOLOGICAI, NOTES BY DR. YOUNG.
May 30, 1898 — A. coverslip preparation from the purulent contents of the right tube shows many pus cells and a considerable number of diplococci, with typical morphology of the gonococcus, mostly intracellular. Some cells contain a number of cocci, ODe showing as many as twenty-five. All completely decolorized by Gram's method.
Diagnosis, gonococcus.
Smear from peritoneal cavity (poor preparation; stains badly) shows four typical gonococci, all intracellular; too few to decolorize.
Cultures: 1. Bouillon culture from pus from peritoneal cavity shows no growth after three days in thermostat.
2. Another bouillon tube, into which a large mass of fibrin stripped from the under surface of the liver was dropped, shows slight cloudiness in the bouillon at the bottom of the tube (around the fibrin) after three days in the thermostat. Coverslips made from this show numerous, fairly large diplococci, biscuit-shaped and otherwise typical, morphologically, of the gonococcus. Numerous coverslip preparations were made, and all show diplococci in great numbers and nothing else. All decolorize by Gram's method.
Cultures from this bouillon and also from the fibrin show no growth on ordinary agar after many days in the thermostat.
3. A hydrocele rluid-agar tube was inoculated with a small mass of fibrin which was removed from Douglas' pouch. After twentyfour hours in the thermostat five small, transparent, pin-point colonies were seen on the surface of the medium adjacent to the fibrin. At the end of forty-eight hours they are as large as a small pin-head and semi-translucent in appearance.
Slide-smear preparations show diplococci, morphologically the same as gonococci in pairs and tetrads. All are completely decolorized by Gram.
Transfers on agar from colonies on the hydrocele-agar show no growth after many days in the thermostat.
Diagnosis, gonococcus.
Note. — The growth of the gonococcus in ordinary bouillon into which a large mass of fibrin had been dropped is interesting. As is well known, the gonococcus grows well in Marmorek's human serum bouillon (composed of one-third human blood-serum and two-third bouillon) and it seems probable that the fibrin in this instance added the chemical ingredients which sufficed to convert the ordinary bouillon into a fluid resembling this mixture.
The growth was very abundant, and the typical morphology,
May, 1899.]
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decolonization by Gram, and negative growth on agar made the diagnosis of gonococcus positive.
The fact that this culture was taken from just beneath the liver is also conclusive evidence that the gonococcus infection was general throughout the peritoneal cavity.
The similarity of these eases is very striking. In both there was a diffuse involvement of the general peritoneal cavity occurring during menstruation and following a recent exposure to infection associated with the exacerbation of a preexisting leucorrhcea. Apparently the uterus and tubes at such a time are less able to resist invasion, and an acute gonorrheal process may the more rapidly ascend from the cervix through the patent abdominal ostia to the serosa. In both cases the onset of abdominal symptoms was sudden with pain and vomiting, but without the shock and collapse seen in perforative peritonitis. In neither case was abdominal tenderness a marked feature, nor was there any distention from paralysis of the bowel as would have been expected with such a pronounced degree of peritonitis under ordinary circumstances. No information was gained by pelvic examination, as both patients concealed the nature and seat of the trouble. The examination of the appendages, however, under more favorable circumstances would have been negative, as the tubes were patent and there had been no accumulation in the lumen. Leucocytosis was pronounced in each case.
The character of the peritonitis in both was the same; a dry fibrinous peritonitis having, as Brose has said, a distinct individuality. There was practically no pus or serous exudate. In the pelvis there was no evidence that the process had been of longer duration there than elsewhere. The whole serosa was uniformly injected and the deposit of fibrin on the liver and spleen was so thick that it could be stripped away, showing that there was an extensive dissemination of the infections agent, whether the gonococcus itself or some chemical product of its growth. The fibrinous pseudo-membrane, however, was not essentially of the adhesive kind. Adhesions even in places where the " lymph " was thickest were not a pronounced feature.
From our knowledge of the self limitation of the gonococcal peritonitides and fromBrose's clinical observations, it seems probable that both of these cases might have recovered without operative intervention, but probably with a following chronic pyosalpinx which would subsequently have demanded operation.
Microscopical sections of the tubes showed, especially in Case I, an advanced degree of endo-salpingitis with leucocytes and broken-down epithelial debris in the lumen, and great congestion of the sub-epithelial tissues, which contained many leucocytes with greatly fragmented neuclei. The tubes in Case 1 1 showed a much less marked catarrh ; one of them i- deed (left), being only slightly abnormal. This case, however, showed possibly the most advanced peritonitis and the more severe symptoms. Attempts to demonstrate the organisms in the stained sections were unsuccessful. /
The gonococcus has made a place for itself as one of the most important pathogenic bacteria. Few organisms, not even
the bacillus typhosus, rival it in the number of suppurative sequela' which may follow a primary infection. Its occurrence in the conjunctiva, and in the iris, the joints, bursa? and tender sheaths; its occasional demonstration, as I be cause of endo- and pericarditis, pleuritis and phlebitis, and the recent observations of cases of pure septicaemia* with its cultivation from the blood shows that its possibilities for metastatic complications are as numerous as are those arising from the spread of infection by direct continuity of surfaces. A general peritoneal involvement by direct extension of an unmixed gonorrhoea! process, though long considered among these possibilities has heretofore remained nnproven. It adds another variety to the peritonitides of mono-infection which are rare except when of hematogenous origin.
Conclusions.
1. The gonococcus is capable of causing a specific infectious disease, namel}', gonorrhoea and at the same time other and less specific pathological conditions.
2. There is experimental proof that in certain small animals the gonococcus can set up acute alterations in the peritoneum homologous with the acute septic serositides in man, but differing from these in their tendency to rapid and spontaneous healing.
3. Hitherto there has been wanting conclusive proof that in the peritoni tides attendant upon gonorrhoea occurring in women, the gonococcus was solely or chiefly concerned. The inflammations had been variously regarded as mixed infectious and chemical inflammations.
4. The cases reported in this paper bring for the first time convincing evidence of the existence of a diffuse, general intlammation of the abdominal cavity caused by the gonococcus.
5. It has been recognized that extension of the gonorrhoea! infection from the genital organs to the peritoneum may occur in the puerperal state; a similar sequel is shown to be possible during menstruation.
6. Such ascending forms of gonorrhoea doubtless under ordinary circumstances remain localized in the pelvis, and rarely demand surgical investigation in the acute stage.
7. A general involvement of the peritoneum such as occurred in the two cases given, must either be rare or unrecognized, and may depend upon some especially receptive condition of the serosa or virulence of the organism.
8. The peritoneum is not more immune than are the peri- or endocardium to gonococcal infection, and being more exposed, suffers more commonly in females, although the relatively benign course of the disease makes it a rare condition to come to the attention of the surgeon in the acute
Colombini, P. Bakteriologische und experimentelle Untersuchungen uber einen merkwurdigen Fall von allgemeiner gonorrhoischer Infection. Central!)!, f. Bakteriologie, u. s. v., Bd.
XXIV, No. 25, p. 955, Dec. 30, 1898.
Thayer and Lazear. A second case of gonorrha?al Bepticcemia and ulcerative endocarditis, &c. The Journal of Experimental Medicine, Vol. IV, No. 1, pp. 81, 1899.
82
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 98.
A CASE OF ATROPHY OF THE OPTIC NERVES FOLLOWING HEMORRHAGE FROM THE
STOMACH, WITH A CONSIDERATION OF THE CAUSES OF
POSTHEMORRHAGIC BLINDNESS.
By Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology, Johns Hopkins University.
Loss of vision as a consequence of hemorrhage from the stomach is an occurrence of sufficient rarity to warrant the reporting of every well-authenticated case of this character. In a paper upon "Amaurosis and Amblyopia after Hsematemesis," by Dr. Ed. Pergens, of Brussels, in the January number of the Annales D'Oculistique for 1896, the author, after a seemingly exhaustive search of the literature of the subject, has been able to bring together data of but 64 published cases, two of these being newly reported cases of his own.
The unanimity with which the text-books upon diseases of the eye mention excessive hemorrhage, and especially hemorrhage from the stomach, as one of the causes of optic neuritis, would seem to indicate that cases of this character are of not infrequent occurrence — a conclusion scarcely warranted. 1 am inclined to believe, by the facts.*
Briefly reported, the case which has recently come under my observation is as follows:
A. B., set. 57, formerly a lumberman of West Virginia, and more recently a restaurant keeper in one of the small towns of that State, was first seen December 5, 1898. He gave a history of serious disturbance of the stomach of twenty years' duration, the most prominent symptom being frequently repeated attacks of vomiting. On the 6th of May (1898) he had, for the first time, a hemorrhage from the stomach. It was of severe character, and was followed, at intervals of forty-eight hours, by two other equally severe hemorrhages. The loss of blood was so great that his life was despaired of, and he was confined to bed for six weeks. For part of this time (two or three weeks), according to his account, he was in a semi-conscious state — was aware of the presence of people about him and could hear their voices, but could not speak to them or express his wauts.
On the day of the second hemorrhage his sight, which had previously been good, became greatly impaired, and his belief is that during the two succeeding weeks he was "entirely blind." At tin.- end of this period his vision began to improve, and he was able to see people moving about the room. This improvement in vision continued, so that by the last of June or first of July he could see well enough to walk upon the without guidance; and this amount of vision he retained until about the middle of November, when his sight began again to decline. The decline from this date was pretty rapid, so that when I saw him he had to be led about like one entirely blind. He admitted that he had been a pretty constant smoker, but denied having been a hard drinker, and also denied having had syphilis.
I have been able to find in the Catalogue of the Surgeon General's Library, under the title " Inflammation of the Optic Nerve,"
but a single reference to optic neuritis following hemorrhage.
The condition of his stomach was carefully investigated by Dr. Osier and Dr. Thayer, who found a nodular mass near, and partially occluding, the pyloric orifice, which they regarded as the result of a chronic ulcerative process, the indications pointing to a more recent development of a malignant growth in the old cicatricial tissue.
The examination of the eyes gave results as follows : Pupils semi-dilated, somewhat oval in shape and entirely unresponsive to light. The ophthalmoscope showed advanced atrophy of both optic nerves, with some cupping, and marked contraction of the retinal arteries. The optic discs had a woolly appearance, their outlines were irregular and ill-defined, and in each eye there were pigment changes in the retina, not only about the margin of the disc but at points some distance from it and especially in the macula region, indicating that the atrophy of the nerves had been preceded by an inflammatory process which had involved the retina as well as the optic nerves. Upon testing his vision, I found that with each eye he was able to count fingers at about 12", but only in a very limited part of the field, which in each eye was slightly to the temporal side of the central fixation point.
After an interval of eight days, he having meantime been under treatment in the Johns Hopkins Hospital, he thought his sight somewhat better, and I found that he could then distinguish with each eye Snellen C. at about 10". An attempt was made at this time to take his visual fields; but this was very difficult and the result unsatisfactory because of his macula blindness and consequent inability to maintain central fixation. The result obtained in the right eye is shown in the accompanying diagram; the attempt as to the left eye was abandoned. Although there seemed but little probability thai his sight could be improved by any plan of treatment, he was placed upon small doses of hydrarg. biniodid. with potassium iodid. and increasing doses of strychnias sulphas.
Although, as has been said, the text-books, almost without exception, speak of loss of sight following severe hemorrhage from the stomach, usually ascribing this result to optic neuritis, they have but little to say as to the way in which the loss of blood induces such disturbances in the visual apparatus.
The theory, advocated by Samelsohn* and others, that the optic neuritis is not due to the loss of blood, but that it and the diseased condition of the stomach which induces the haunatemesis are both dependent upon a central lesion, probably in the optic thalamus, does not seem to be tenable; for we know that other severe hemorrhages, as well as those from the stomach, are followed by loss of sight. Thus Fries| states that while 35J per cent, of the reported cases of amblyopia from loss of
Graefe's Arch., Vol. XXI, 1, p. 150.
t Klinische Monatsblatter f. Augenheilkunde, 1S7S.
N.
83
, less marked contraction of the reins, specially about the disc and the tnacu la, at the macula, and occasionally, hemorire grounds for believing that many of past have been regarded as embolism of lie retina were, in fact, cases of thront i picture, let us consider, more in detail, ndings described in Pergens' paper and agree. In the twenty earlier examinastated, are the more instructive, we find ■ conditions:
i ■
5
-ially arteries 2
2
very thin ; 1
is dilated 3
i mention of contracted arteries 13
11
1
white 1
vas isclnemia of the disc 15
7
with cherry-colored macula 2
ixudates, etc., in retina 3
ere characteristic changes in theretina 12 r upon optic disc 8
least, three instances the typical piclu recirculation — the case in which the and the two cases in which there was with the red spot at the macula — and is safe to say, 1 think, that the condiiccounted for more satisfactorily upon any other.
ire two cases in which the retinal vesimial (vision being recovered in each) ; es were slightly enlarged and tortuous o; one in which the veins were dilated present in each eye; and one in which "arrested circulation," all the retinal 1 in size. In the three last-mentioned mm nt to interference with the venous ,u with the arterial. This might be jurrence of a hemorrhage into the irve, as suggested by Samelsohn, or by i in I retinal vein, all hough it cannot be
■istic signs of this latter c lition were
ise cases. In this connection, however, it n a case id' marked impairment of vision ine hi observed by Dr. Harry
more, in which the ophthalmoscope ie typical picture of thrombosis of the
1. Art. centr. Re tin re. Inaug. Dies., Zurich,
82 JOI
A CASE OF ATROPHY OF STOMACH,
Clinical Pre
Loss of vision as a consequence of stomach is an occurrence of sufficient reporting of every well-authenticated ( In a paper upon "Amaurosis and Anil mesis," by Dr. Ed. Pergens, of Brussels ber of the Annales D'Oculistique for li seemingly exhaustive search of the lib has been able to bring together data of 1 two of these being newly reported cases
The unanimity with which the text-1 the eye mention excessive hemorrhage, rhage from the stomach, as one of the c would seem to indicate that cases of tb infrequent occurrence — a conclusion sc inclined to believe, by the facts.*
Briefly reported, the case which has my observation is as follows :
A. B., ast. 57, formerly a lumberman more recently a restaurant keeper in on that State, was first seen December 5, 1 of serious disturbance of the stomach tion, the most prominent symptom bei attacks of vomiting. On the 6th of J the first time, a hemorrhage from th severe character, and was followed, at i hours, by two other equally severe hem blood was so great that his life was de confined to bed for sis weeks. For pa: three weeks), according to his account, scious state — was aware of the presenc and could hear their voices, but cou or express his wants.
On the day of the second hemorrhag previously been good, became greatly i. is that during the two succeeding wi blind." At the end of this period his v and he was able to see people moving ; improvement in vision continued, so th or first of July he could see well eno streets without guidance; and this retained until about the middle of Nov began again to decline. The decline fr rapid, so that when I saw him he had t entirely blind, lie admitted that he h stant smoker, but denied having been also denied having had syphilis.
I have been able to find in the Catalog
eral's Library, under the title " Inflamma but a single reference to optic neuritis foil
May. 1809.]
JOHNS HOPKINS HOSPITAL BULLETIN.
83
blood were due to hemorrhage from the stomach and intestines, "25 per cent, were due to uterine hemorrhage, 25 per cent. to abstraction of blood, 7^ per cent, to epistaxis, cent, to bleeding of wounds, and 1 per cent, each to haemoptysis and hemorrhage from the urethra.
The theory of Westhoff and Ziegler that the loss of vision is caused by a primary fatty degeneration of the optic nerve induced by ischsemia; as well as that of Hoffman, who attributes the amblyopia and the subsequent atrophy of the optic nerve to a retro-bulbar neuritis, seems to receive but little -upport from the evidence afforded by the ophthalmoscope in the majority of the reported cases.
In the paper of Pergens, already referred to, a brief abstract is given of each one of the sixty-four cases of amaurosis and amblyopia following hamiatemesis which he was able to find upon record. In a considerable number of them no ophthalmoscopic examination was made; in forty-three instances the ophthalmoscopic findings are given, but the time at which the examination was made varies greatly in different cases.
If we decide, arbitrarily, to regard all the ophthalmoscopic examinations made within three weeks of the onset of the eye symptoms as early, and all after this jjeriod as late examinations, it will be found that 20 of the 43 cases belong in the Erst category and 23 in the second. The early examinations are, of course, the more instructive. Now, after a careful consideration of the findings in these earlier examinations, it seems to me that, while a very few of them might, perhaps, be cited as supporting the theory of primary fatty degeneration of the optic nerve of Westhoff and Ziegler, the great majority of them point strongly to an obstruction of the blood current in the central retinal artery as the cause of the subsequent intra-ocular manifestations; and, in view of the well-recognized tendency to the formation of thrombi in post-hemorrbagic anaemia, it seems highly probable, if this theory is Correct, that the obstruction was of thrombotic origin. This jeems the more probable because there is, I believe, a reason why the disposition to thrombosis after loss of blood should manifest itself especially in the retinal vessels.
The occurrence of thrombi after excessive hemorrhage is to be explained by the reduction of blood pressure and the consequent slowing of the blood current, the alteration in the condition of the blood itself (especially the multiplication of the platelets), and, probably, also by changes (consequent upon anaemia) in the vessel walls. Now in the retinal circulation, beside all these general conditions, we have, in the intra ocular tension, a special condition tending further to obstruct the enfeebled blood current. Here then, it would seem, at the point where the central retinal artery pierces the lamina cribrosa and becomes subject to the intra-ocular pressure, the
' >'< conditions for the development of a thrombu ■ere we have the especial point of constriction or obstruction behind which, when other conditions are favorable, a thrombus is prone to develop. The intra-ocular pressure, doubtless, impedes the bloodstream in the retinal veins also, but probably not to the same degree as in the arteries.
The ophthalmoscopic picture in thrombosis of the central retinal artery is much the same as is found in embolism of the artery, namely, paleness of the optic disc, marked contraction
of the retinal arteries, less marked contraction of the veins, opacity of t he retina, especially aboul the discand the macula, a cherry-colored spot, at the macula, and occasionally, hemorrhages; indeed there are grounds for believing that many of the cases which in the past have been regarded as embolism of the central artery of the retina were, in fact, cases of thrombosis.*
Having in mind this picture, let us consider, more in detail, the ophthalmoscopic findings described in Pergens' paper and see in how far the two agree. In the twent] earlier examinations, which, as before stated, are the more instructive, we find recorded the following conditions:
Cases.
Arteries contracted 5
Vessels contracted, especially arteries 2
Vessels contracted 2
Arteries filiform, veins very thin 1
Arteries contracted, veins dilated 3
Total in which there is mention of contracted arteries 13
Optic disc, pale 11
Optic disc, greenish-gray 1
Optic disc, clouded 2
Optic disc, clouded and white 1
Total in which there was ischsemia of the disc 15
Cloudiness of the retina 7
" " with cherry-colored macula 2
White plaques, miliary exudates, etc., in retina 3
Total in which there were characteristic changes in the retina 12 Hemorrhages in retina or upon optic disc 8
Here we have in, at least, three instances the typical picture of obstructed arterial circulation — the case in which the arteries were filiform, and the two cases in which there was clouding of the retina with the red spot at the macula— and in all of the others it is safe to say, I think, that the conditions present may be accounted for more satisfactorily upon this theory than upon any other.
Besides these there are two cases in which the retinal vessels are described as normal (vision being recovered in each) ; one in which the arteries were slightly enlarged and tortuous and the veins greatly so; one in which the veins were dilated and hemorrhages were present in each eye; and one in which there was a picture of "arrested circulation," all the retinal vessels being increased in size. In tie- three last-mentioned cases the indications point to interference with the venous circulation rather than with the arterial. This might be explained by the occurrence of a hemorrhage into the sheath of the optic nerve, as suggested by Samelsohn, or by thrombosis of the' central retinal vein, although it cannot be said that the characteristic signs of this latter condition were present in any one of these cases. In this connection, however, il is of interest to mention a case of marked impairment of vision following a severe uterine hemorrhage, observed by Dr. Harry Friedenwald, of Baltimore, in which the ophthalmoscope showed in each eye the typical picture of thrombosis of the
Kern. Zur Embolied. Art. centr. Keticse. Iraug. Dits., Zurich
1892.
84
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. OS
central retinal vein. The vision of one eye was. regained, but that of the other was permanently lost.
As to the evidence afforded by the ophthalmoscope in the twenty-three cases described by Pergens in which only a late examination was made, it cannot be claimed that it throws much light upon the question under consideration; for the atrophied nerves and contracted arteries usually mentioned as present might have been due to other conditions as well as to thrombosis of the central artery, and this is equally true of t he case which I have reported.
The character of the visual field in my case, as well as that in several of the small number of cases in Pergens' paper, in which the field is described (vision having been retained only in a circumscribed area in the temporal field) is significant, and seems to point to the partial preservation of the retina in the neighborhood of the papilla by means of the cilio-retinal arteries.
Of the whole number of cases collected by Pergens, autopsies were made in but four. In one of these a thrombosis of the splenic artery was found, but no mention is made of the condition of the eye. In a case reported by Hirschberg* there was complete atrophy of the optic nerve of one eye, and atrophy of a limited portion of the optic nerve of the othereye. In the affected portion of the nerve there were numerous bloodvessels with thickened walls but no thrombosis and no signs of hemorrhage in the optic nerve sheath. The death of the individual, it should be stated, did not occur until three years after the loss of vision.
In an autopsy by Ziegleiyf twenty days after the attack which led to loss of vision, no macroscojiic changes in the optic nerves or their sheaths were found ; but the microscope showed fatty degeneration of the nerves and their iutra-ocular expansion.
The only other autopsy was one made by Eaehlmanu.J All the arteries presented constricted lumina from a fibrous endarteritis. The veins also had undergone slight constriction, in
two places being almost totally obliterated. There was oedema of the retina, especially in the neighborhood of the disc. In the choroid the endarteritis was pronounced and there was hyaline degeneration. Here, too, it will be seen, we have mention of vascular changes, the thrombosis of the splenic artery in the first-mentioned case being, at least, suggestive, and the condition of the retinal vessels and of the retina itself in Kaehlmann's case being especially significant.
The fact that both eyes are so frequently involved in blindness dependent upon acute anaemia* seems, at first sight, to make against the theory that the loss of vision is due to thrombosis of the central retinal artery, since it implies the occurrence nearly simultaneously, at different points, of two thrombi; but, if the iutra-ocular tension plays as important a role in the etiology of these cases as I believe it does, this objection loses much of its force.
Conclusions.
1. That the weight of evidence afforded by the ophthalmoscope points to thrombosis of the central retinal artery as the usual cause of the blindness which occurs iu post-hemorrhagic anaemia.
2. That the resistance offered to the already enfeebled blood current in the central retinal artery by the intra-ocular tension is an important etiological factor in determining this result.
3. That, in exceptional instances, the ophthalmoscope indicates that the thrombosis occurs not in the artery but in the central retinal vein.
4. That, in other exceptional instances, it may be that the loss of sight and the ophthalmoscopic changes which accompany it are the result of a hemorrhagic or serous effusion into the optic nerve or its sheath (Samelsohn). And here, again, the obstruction and damming back of the blood current in the central retinal artery by the intra-ocular tension, probably, have much to do with bringing about this result.
LICHEN SCROFULOSORUM IN A NEGRO.
By T. Caspar Gilchrist, M. R. C. S., L. S. A.,
Clinical Professor of Dermatology in the Johns Hopkins University. (From the Pathological Laboratory of the Johns Hopkins University and Hospital.)
This case is of interest not only on account of its great rarity in this country, only four cases having been previously reported, but also because it is the first recorded instance in the negro. In the four cases already reported, one of which occurred in Canada, no microscopical examination was made.
While attending a number of negro children in an orphan asylum for tinea tonsurans, one young girl, eleven years of age, was brought to me with some lesions on the back and thighs which the attendant thought were ringworm patches
Zeitschr. f. klin. Med., Vol. IV.
t Ziegler und Nauwerck's Beitr. z. path. Anat., Vol. II.
% Fortschr. d. Mediz., 1889, p. 92S.
and which had been noticed a few days previously. The patient appeared to be a healthy, well-nourished girl ; she was not anaemic, did not complain of anything, had a good appetite but was rather quiet iu her manner. The tongue was clean. On examination there were found on the upper portion of the back a number of round and oval patches varying from about 10 to 20 mm. in diameter. A few similar patches were found on the extensor surfaces of both thighs, about the left groin, on the anterior surface of the right thigh and in the
Whether one or both eyes were affected is stated in fifty-seve n
of the cases collected by Pergens. Of these, both eyes were involved forty-nine times ; one eye only eight times.
May. 1899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
pubic region. The patches all consisted of groups of small. conical, slightly scaly and therefore whitish firm papules each papule being about 0.5 mm. in diameter, raised and presenting a flattened summit which was covered with a somewhat adherent but uot profuse whitish scale, on removal of which a bleeding surface was exposed. The papules presented in every patch exactly the same character and were always discrete and of the same size. There was a slight red areola surrounding the base of the papules. The most recent patch presented a group of seven rather closely aggregated conical papules which were uot scaly. The oldest groups which were in the groin were much larger and the central portion appeared to be clearing up, although on close examination one could still detect the remains of slightly scaling papules which were much Battened. Many of the lesions were pierced by lanugo hairs and were therefore situated around hair follicles. Two patches ou the left groin were becoming confluent and thus formed an irregularly shaped area.
This case was not diagnosed absolutely at first, and numerous scales were examined in the usual way for the ringworm fungus lint no evidence of any mycelium or spores could be found. The patient was seen every other day and numerous new lesions were observed developing, especially on the back as well as on the abdomen, forearms, and arms. Five weeks after the first appearance of the eruption a typical phlyctenular conjunctivitis of the right eye developed. The diagnosis was confirmed by Dr. Theobald. The distribution of the lesions at tills time was as follows: A few scattered patches on the extensor surfaces of the forearms and arms; 4 patches on the right side of the chest; 5 scattered areas ou the abdomen between the umbilicus and pubes ; nearly 60 groups distributed over the whole back ; a few extensive patches on the es surfaces of both thighs and numerous areas in both groins. The head, neck, hands, legs and feet were all clear.
Patches which were only two days old were seen to consist of from four to seven, conical but flattened, firm, non-scaly papules, some arranged around, others between the hair follicles. Many of the lesions presented the appearance of a keratosis pilaris. The papules always appeared in the same way, gradually developing whitish, but not profuse, adherent
m removal of which a bleeding surface was ex] The patches were gradually increased in size by the addition of new papules around the periphery while the older central lesion gradually flattened but remained seal)'. The I then assumed a circular or oval-shaped aspect with a cli up center. The long axis of the patches in the lumbar ■•'as transverse to the body. When two adjoining pa approached one another the intervening papules showed a
. to gradually disappear, but over the region of the
right scapula there was a large irregular area of papules which was made up of 10 groups, none of which had cleared up in the center. A whitish collarette extended up the hairs in "f the papules in the lumbar region. Xo vesicles or pustules were observed clinically during the course of the A few solitary papules could be i attered
over the back. All varieties of the lesions are well shown in the photograph (Fig. I) especially if a hand magnifier I There were no subjective symptoms.
A probable diagnosis of lichen scrofulosorum was made al first which was confirmed by the extension of the lesions, their uniform character and the appearance of atypical phlyctenular conjunctivitis. Numerous enlarged lymphatii glands were also present hut as they occur of ten in health] negroes, this symptom was not regarded as important.
Tin' patient is the fifth of eighi children (live girls and three boys), all living and in good health with the exception of oue girl who died of " consumption." The father and mother are living and in good health. There is no tuberculosis in any form in the family now living.
Under the internal administration of hypophosphites and cod liver oil the cutaneous and eye troubles both rapidly disappeared. The sections all presented two striking features :
(1) semiglobular-looking masses situated in the homy layer and in the majority of instances around the hair follicles, and
(2) marked pathological changes in the upper portion of the corium beneath these papular masses and also around I be hair follicles, especially the deepest portion. The latter was characterized by its tubercular structure. One could followin the sections the formation of these clinical papules. Fig. II explains their genesis. The blood-vessels in the upper portion of the corium and papillaj were dilated and many polynuclear leucocytes had wandered out into the tissue and into the epidermis up to the horny layer where these cells became disintegrated; numerous lymphoid cells were found in the same situation, undergoing the same processes. Thus a mass of detritus and an apparent firm ground substance is deposited in the horny layer. This ground substance takes up the eosiu stain very readily while the cells take up the hematoxylin. There are also a few degenerated epithelial cells in the mass of detritus. The stratum lucidum and stratum granulosum have disappeared. Xo apparent fluid exudation accompanies this emigration of cells through the rete, and the epidermal cells are but little swollen, nor an- the interepithelial spaces much widened. Large numbers of pigment granules are also scattered throughout the papular lesion.
In Fig. Ill is represented a section of the whole patch excised showing three papules, (/') all of which are well marked. One shows its relation to a hair follicle (P); from the second it is evident that the section has just passed outside of the follicular opening as e\ idenced by i he pr< • the lower portion of the follicle ( // | ; while the conned the third with a hair follicle is seen iii another Bection. The more pronounced papules show that they arc made up of the same materials which have already been described, with the exception thai there is a larger amount of pigment in the lesions. Directly in contact with the hair (£T) there is awellmarked hyperkeratosis encircled by the papular lesions. This hyperkeratosis extends nearly half way down fo I be bailfollicle. The- middle papule exhibits completely the nature of the lesion just outside of the hair; it consists of a firm substance imbedded in which are i numbers of
degenerated polynuclear leucocytes, lymphoid cells, many epithelial cells and masses of pigment granules. The m layer beneath consists of two layers oi i jh which are
emigrating hundreds of wandering cells. There i- -one
86
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 98.
widening of the interepithelial spaces, but no marked oedema. The corium, especially directly beneath the papules and around the hair follicles shows marked changes. In the first region there is a fairly well defined area consisting of the papilla' and upper portion of the corium, in which are massed large numbers of lymphoid cells, numerous polynuclear leucocytes and some plasma cells with dilated blood-vessels.
(Fig. in, c.)
Around the hair follicles in the lower portion are masses of chiefly round mononuclear cells, some plasmacells and epithelioid cells and a few mast cells. In four sections typical tubercles were observed in this situation (Fig. Ill, G), with giant cells forming the center surrounded by numerous epithelioid cells and mononuclear round cells at the periphery. The hair follicles themselves are unaffected. The blood-vessels (V) throughout the corium are dilated, are surrounded by numerous mononuclear round cells, a few plasma cells and numbers of polynuclear leucocytes. Two unaffected sebaceous glands were seen in one of the sections. The sweat ducts and sweat glands were normal, although a duct was seen passing close to the lesion. The blood-vessels accompanying the sweat duct were dilated and surrounded by additional cells as were other vessels. No tubercle bacilli were found in any of the sections stained for this purpose.
Hebra first described the disease and named it lichen scrofulosornrn to characterize its clinical features. He declared that it was always acccompanied by other symptoms of scrofula. The disease had been previously described as lichen simplex by Erasmus Wilson, and as lichen circumscriptus by Cazenave. Jacobi in 1891 drew attention to the tubercular nature of the lesions, which he thought to be a perifollicular tuberculosis of the skin. Although he demonstrated a single tubercle bacillus in one of his sections, an inoculation into guinea pigs gave negative results. Later (1896) he demonstrated the presence of tubercle bacilli in a typical case and obtained positive results in a rabbit. In 1892 Sack decided, after a careful histological examination, that the disease was a miliary tuberculosis of the skin, the nodules showing a central caseation, then giant cells, epithelioid cells and small round cells. He suggested "tuberculosis lichenoides cutis" as a more applicable title. Later observers have apparently demonstrated the tuberculous nature of the affection especially of the severer forms. Thus Jadassohn found in 19 cases 14 associated with tuberculosis, and only one case in which no such disease was present. He was of the opinion that the disease was non-bacillary, but that it was a disease of tuberculous persons. Of 16 cases treated with tuberculin 14 reacted typically, but although inoculations were made into guinea-pigs from nine of the cases, negative results followed. Kaposi believes that there is nothing to prove that lichen scrofulosorum is a manifestation of tuberculosis, although he asserts that tuberculosis is always present. In Tilbury Fox's six cases he noted the presence of tuberculous symptoms in the patients. Pellizarri succeeded in producing tuberculosis in a guinea-pig after the inoculation from one case.
Haushalter (1898) inoculated 4 guinea-pigs from 2 cases and they became infected with tuberculosis, one of the cases had an otitis media, the other a tuberculous lymph gland as
well as enlargement of other cervical glands. Some German dermatologists, e. g. Kromayer, Kaposi and Lukasiewicz, are opposed to the tubercular origin of this disease on account of the absence of caseation, the mildness of the affection and the rapid recovery. Only a very few cases have been recorded in France, and in those examined histologically no tubercle bacilli were ever demonstrated, although the subjects were tuberculous. It was believed, therefore, by the French dermatologists, Ilallopeau, Brocq and Bureau that the lesions of lichen scrofulosorum were uot due to direct infection but rather to the toxin of tuberculosis. Hallopeau reported one case which was associated with lupus. The lichen eruption was scattered chiefly over the trunk, but one group of papules was situated directly around the lupus nodule which had a scar in the center. In Lefebre's case no bacilli were found in the sections, and the animal inoculation was negative. In both the cases recorded by Morris and Crocker tuberculous glands were present, but in Walker's case tuberculosis in any form was absent, neither was there any tuberculous history.
With reference to the American reports, only two cases have been exhibited at the meetings of Societies, and of these only clinical histories have been given. In all the cases recorded, the histological findings always show a likeness to those in tuberculosis, but in most instances after diligent search no bacilli have been found nor was the disease reproduced in guinea-pigs after inoculation. The inoculations, however, which have resulted successfully have demonstrated its tuberculous nature in those cases. My own case is a comparatively mild one and the presence of bacilli could not be demonstrated. Clinically it presents all the typical features of a lichen scrofulosorum as originally described by Hebra with the exception of the color, which would naturally differ in a negro's skin. Tilbury Fox called attention to the fact that instead of always appearing in groups, the papules may occur singly.
Sack in his desertions and drawings shows that the papule is formed by the miliary tubercle being deposited directly beneath the epidermis and by some slight hyperkeratosis of the horny layer.
In my case the papules consist of distinct lesions involving the horny layer, and form, as it were, a dry pustule. . It was neither clinically nor histologically a pustule, since it appeared to be made up of a homogeneous ground substance with masses of nuclear detritus and numerous pigment granules. There was no special hyperkeratosis. The tubercular nature of the disease was far from being pronounced histologically in the present case and the tubercles were situated around the lower portion of the hair follicle.
It is strange that a tubercular cutaneous eruption which yielded so readily to cod-liver oil should arise in a well-fed, healthy child with good hygienic surroundings and without previous history of tuberculosis. Clinically the case suggests the adoption of Hebra's title of lichen scrofulosorum or Unua's folliculitis scrofulosorum rather than tuberculosis follicularis. Since successful inoculations, however, have been made in at least three cases, then the latter title would be more correct.
<F*-{cAjvjJ
Fig. II. — Shows a commencing papule (A) which is formed between the horny layer (JJ) and the mucous layers (M\. Numerous polynuclear lencocytes (/'i and lymphoid cells are emigrating through the epidermis to the horny layer. Two papillae \ B) are Blled with wandering cells and dilated vessels.
Fig. I. — Photograph of a ease of lichen scrofulosorum in anegro girl. The lesion can be best seen by using a hand magnifier as a small scaly papular eruption.
2 m
, x r *
• •■■< '...■• '-■'■■ ■ :"
Fig. [II.— Sliows thi '■ ■ p )i ""' ' > i //i; in thi tWl , the i s pening. //. //. are hail Colli of lymphoid, plasma and conn " leucocytes; I V, dilated bloodvessels; <?, is a tnbereli , . >t the hsir follicle IT; P.isfat; S D, collection of cells around
M\v, 1390.]
JOHNS HOPKINS HOSPITAL BULLETIN.
87
Bibliography.
Bronson: Archives of Dermatology, Vol. r, p. 137.
exhibited before the New York Dermatologies! Society, April. 1874.
Crocker, H. R.: Transact. Clin. Soc. of London, XII, p. 195, 1879.
Fox, T.: Ibid., p. 190.
Gottheil, W. : Journ. of Cu tan. and Genito-Urinarv Dis., IV. 18S6.
Hallopeau: Monatsch. fur prakt. Dermat., XXIII, p. 354, 1896.
Hallopeau and Bureau: Annales de Dermat. et de Syph., VII. p. 10S4 and 1264, 189G.
Haushalter: Ibid., IX, p. 455, 1898.
Hebra: On Skin Diseases, Sydenham Society Translation, 1868.
Jacobi: Deutsch. Dermat. Gesell. Verhandl., 2-3 Congress,
1890-'91, and Annales de Dermat. et de Syph., VII, p. 1112, 1896.
Jndassohn : Annales de Dermat. et de Syph., VII, p. 1111, 1S96.
Kaposi : Ibid.
Lefebre, II.: These de Dermat., Paris. L897-'98, Abst. Annales de Dermat. et de Syph., IX, p. 1045, 1898.
Morris, M.: Brit. Journ. of Dermal., X, p. 333, L898.
Pellizarri, C. : Annales de Dermat. et de Syph., VII, p. 1111, 1896.
Rieketts, B. M.: Cincin. Lancet and Clinic, XV, L885.
Sack: Monatsch. fur prakt. Dermal.. XIV, p. 137, L892.
Shepherd, F. J.: Canad. Medic, and Surgio. Journal, Montreal, IX, p. 283, 1880-'81.
Walker, N.: Scottish Medic, ami Surg. Journal, Is98.
Text-Books: E. Wilson, Cazenave, Unna, Duhring, Crocker, Hyde, Twentieth Century Practice of Medicine, Vol. V.
A NEW INSTRUMENT FOR MEASURING HETER0PH0RIA AND THE COMBINING POWER OF
THE EYES.*
By Frederick Herman Verhoeff, Ph. B., Student of Medicine, Johns Hopkins University.
This evening I wish to describe a new instrument that I have recently devised for the estimation of certain functional disturbances in the extrinsic muscles of the eyes. The Instrument is equally useful for testing both the heterophoria Bind the combining power of the eyes, but as one of its main features is that of a phorometer, I shall speak of it as a reflecting phorometer.
The instrument consists essentially of four mirrors, two for each eye, arranged one above the other and mounted in a rectangular frame so as to rotate on axes. The axes of the two upper mirrors are in the same line and are parallel to the horizon and perpendicular to the direction of sight. The axi of the lower mirrors are parallel to each other and lie in planes perpendicular to the horizon, and parallel to the direction of sight. The distance between the two lower axes jc 6.25 cm.- This distance may be greatly varied without . any material effect on the accuracy of the instrument, but the distance given was chosen as the most convenient one and closely approximates the average distance between the eyes.
The lower mirrors are made as large as possible without their interfering with one another. The upper mirroi
me size as the lower except perhaps a little longer. A good size for the lower mirrors is 3 cm. s 5.5 cm., and for lieupper mirrors 4 cm. x 6 cm. In this model the s es of the upper mirrors are 5 cm. ahove the middle points of the axes of the lower mirrors, but this distance is unnecessarily
•Read before the Johns Hopkins Hospital Medical Society, Iannary 23, and before the Maryland < iphthalmological and Otological Society, January 26, L899.
The axes of the lower mirrors are at an angle of 45 degrees to the perpendicular, but I think it would be better to reduce this angle as much as possible. The ideal way would 1"- to have the axes perpendicular, but this is impossible since the lower mirrors would shut oft' the view from the upper ones. One of the upper mirrors is permanently set at an angle of 43 degrees to the perpendicular, while the other is freely movable about its axis, and to its outer end is attached a lever, 15 cm. in length, which is arranged to move along a scale and mark oft' the amount of rotation of the lever. Since I he angle through which a mirror rotates is half the angular deflection produced in a ray striking it, the scale must be made so that one-half a degree of rotation of the mirror corresponds to one degree on the scale. The scale must be still furl her changed if it is desired to have it register prism-degrees.
To each of the lower mirrors a lever is firmly attached perpendicular to the axis at its middle point. These levers are each 8 cm. Ion"/, and at a point on each, 6J cm. from the mirror, a small hole is drilled about the size of a cambric needle. Below this another, larger hole is dialled into which a key is fitted similar to those used on violins for tuning purposes. To a partition, placed midway between these levers, is attached another lever 1 I cm. in length and pivoted at a point :! J cm. directly behind a line joining the two levers
and extending from I be needle hol< ne to 1 be similar bole
on the other. Three centimeters from the pivol of this middle lever a small bole is bored and a thread is then run through this hole by means of a needle and then continued through the holes of the other two levers. The thread connected with the keys on these levers and wound np until it is 3.1 cm. in length on each side. It must be firmly fastened
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[No. 98.
in the hole of the middle lever so that it will not slip. The thread is then made tense by means of rubber bands or helical springs attached to the levers and then to the sides of the frame. The object of the middle lever is to produce equal though opposite angular displacements in the two laterally moving levers.
A diagrammatic representation of the arrangement of the mirrors and levers is shown in Figs. ] and 2. In Fig. 1, the two upper and the two lower mirrors are parallel and hence both scales register zero. In Fig. 2, one upper mirror is rotated to estimate hyperphoria or right sursumduction and the middle lever is depressed, tilting the two lower mirrors towards each other, to estimate exophoria or abduction.
A double level is fastened to the top of the instrument and the latter, resting upon a suitable stand (I have been using a camera tripod), is leveled and pointed at a small circular spot, distant twenty feet or more. To find the zero point for lateral displacement, one sights over one of the lower mirrors and then through this mirror and ascertains whether the image is in line with the object. If not, the middle lever should be moved up or down until this condition is obtained and then zero marked on the scale provided for the purpose. One must then sight over the other mirror in a similar manner, the adjustment being made this time however by the key attached to the lever of this mirror. A one-half decree prism is now held, base in, before one of the mirrors and the image as seen through both prism and mirror is put in line, by means of the middle lever, with the object as seen over them. One degree must now be marked upon the scale since there is a lateral displacement of one-half degree produced on
each side. Similarly a scale of degrees for both esophoria and exophoria is obtained. To obtain the zero point for the upper mirrors, the middle lever is pulled clown until both images can be seen with one eye and they are then placed on a level by means of the lever attached to one of the upper mirrors. Another method is to put the middle lever at zero and then view a horizontal line with one eye, moving the lever attached to the upper mirror until the line is apparently continuous. By the use of prisms an empirical scale may be obtained by this method.
After the zero point for the lateral displacement is once obtained, it is an easy matter to readjust the instrument if the threads should break or stretch. All that is necessary is to place the middle lever at the zero mark and then turn the keys attached to the levers of the lower mirrors until the object is in line with the images seen through the mirrors.
It is important both in graduating and in using the instrument to have the object at the same height as the instrument and also directly in front of the latter.
At the back of the instrument there is a door with two horizontal windows cut in it so as to correspond to the level of the eyes and their distauce apart. On a pivot on the inside of the door is a shutter so arranged that when worked by means of a string it alternately closes one window and opens the other, one being always closed while the other is open. It would be very advantageous to have this shutter worked by some sort of clock-work arrangement.
To use the instrument, the patient is directed to sit down behind it, place his eyes on a level with the windows, and look through them at the circular spot, which, as has been said, should be at a distance of about twenty feet. The levers are then placed at zero on both dials and the shutter is moved to and fro at a moderate rate of speed. The patient is now asked to state whether the object seems to move or not. If not, his muscle balance is perfect. If he sees the object apparently moving obliquely, the outside level", that is the lever attached to the upper mirror, is moved until the patient .says the movement is horizontal and then the middle lever is adjusted until there is practically no movement. The outside lever will then register the amount of hyperphoria while the middle lever registers the amount of exophoria or esophoria, according as it is below or above the zero point.
If now it is desired to measure the relative adduction, abduction, or sursumduction of the eyes, that is the combining power of the eyes, the door at the back of the instrument is opened and the patient directed to look through the mirrors with both eyes. He will then see the object single, aud without effort, since his heterophoria has been corrected by the previous adjustments. The middle lever is now depressed until the patient, by the greatest effort that he can make, is just able to fuse the images. The dial will then register the number of degrees of abduction. Similarly the amount of adduction and of right and left sursumduction may be obtained.
In addition to the test with the shutter, the amount of heterophoria may be estimated by this instrument in a manner similar to that adopted when prisms are used. To do this all that is necessary is to produce vertical or lateral dip
May. 1899.]
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lopia by the levers, and then move the proper lever until the images are in line. It is well to use this test as a confirmation
of the shutter test.
The diagram, Fig. 3, is intended to illustrate in as simple a manner as possible the construction involved in locating the position of the image for each eye. The relations of object and mirrors to each other are exaggerated in order that the construction lines may be more plainly seen. The mirrors are in their primary positions, so that a line drawn perpendicular to the axes of the upper and lower mirrors will be perpendicular to the plane of the lower mirror. is the object, M and J/' the mirrors. From <>, a line A is so drawn that it is perpendicular to and bisected by the prolongation of M. Similarly from A the line A /is drawn perpendicular to and bisected by the prolongation of J/' at K. All the rays from striking M will be reflected in lines Airected from .-1 and these rays will be reflected from M', in lines directed from /. Therefore an eye directed towards the mirror J/', will see the image of at I. The actual path taken by a ray of light from is indicated by the line B P E. The locus of A, as M is rotated on its axis, A', is evidently the circumference of a circle whose radius is R. The locus of /during this rotation is the circumference of a circle with the same radius but whose center is at 0, R C being drawn perpendicular to, and being bisected by, the prolongation of M'.
When M' is rotated on its axis, which lies in the plane of the construction, ic is evident that / will move along the circumference of a circle perpendicular to the prolongation of M and whose center is K. This circle being at an augle to the line of sight, /will apparently take an elliptical path.
From this it will be seen that when the middle lever is moved the image pertaining to each lower mirror moves in the circumference of a circle tilted at an angle of 45 degrees to the perpendicular and whose center is at the foot of the
perpendicular drawn from theobject to the axis of the mirror. Since the projection of a circle is an ellipse, the image of each mirror will apparently move in an elliptical course, and will thus not only move laterally, but also upwards to a slighi extent. This, of course, would seriously interfere with th< accuracy of the instrument if each lower mirror were rotated independently, but by the arrangement previously described, both mirrors are made to move equally though in opposite directions and hence the images when viewed with both eves maintain their horizontally.
If the test object is a perpendicular line its image will generate the surface of a cone and thus when projected the two images, as they are carried apart, will make increasing angles with each other. In this way a certain amount of rotation of the eyes on their principal axes could be measured, and with this model about eight actual degrees of such rotation can be determined. This method is entirely distinct from that just to be described.
The rotation of the eye on its principal axis is spoken of as torsion. Where this rotation remains constant I would sug gest that the term torsional strabismus or squint be used. Where the eye has simply a tendency to rotate, the term cyclophoria has been suggested. These conditions may be accurately determined by the following arrangement: Two equal circular disks each having two perpendicular lines drawn through its center are placed one above the other so that one of the perpendicular lines in the upper disk is continuous with one of the lines in the lower. The upper disk is so made as to rotate upon its center when desired and degrees should be marked off upon the background to which it is attached. The lower disk should have its semi-circumference plainly marked off in degrees. The instrument is then pointed at the two disks and the hyperphoria lever so manipulated that the images of the two are exactly Bupe) "imposed. The patient's esophoria or exophoria should be corrected by prisms.
To measure the amount of torsion the eyes are capable of undergoing, that is. the torsional combining power of the eyes, the upper disk is rotated until the lower or upper lines are beginning to be seen double and the number of degrees read off. To test the torsional squint, the upper disk is rotated until only two lines are seen ami the number of degrees read off. To test the cyclophoria it is best to rotate tin' upper disk a definite number of degrees and then have the patient read off the number on the lower disk as he sees it. the difference between the patient's reading and the number of degrees the upper disk has been rotated will lie tin- number of degrees of cyclophoria.
From a few experiments made upon myself and others, I am inclined to believe that normal eyes have little or no torsional combining power. In the few cases I have examined I have not found the slightest evidence of cyclophoria in tin otherwise normal eye. Considering tin- disinclination normal eye to undergo torsion, it seems to me that if cyclo phoria were present to any extent it would soon lead to torsional squint and produce amblyopia in one of tie
A certain amount of angnlar displacement of the vertical lines may be produced without diplopia resulting, but this is
90
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[No. 98.
not overcome by rotation of the eye, however, as diplopia is almost immediately produced by the equal angular displacement of the horizontal lines. The phenomenon must be due, I think, to a psychical compensation, if I may be permitted to use such an expression.
The reason this psychical compensation is so much greater for the perpendicular lines than for the horizontal is due, I think, to the fact that in viewing perspectives, the eyes have a stimulus to fuse non-corresponding points that are displaced laterally, while there is no call upon them to fuse perpendicular displacements, the eyes being always upon the same plane with regard to each other.
In this connection I quote the following from G. T. Stevens*: " It is an interesting as well as an important practical fact, and one to which little attention has been given, that horizontal lines cannot be held in union while being rotated from the horizontal direction to au extent nearly equal to that in which vertical lines can beheld in union. If vertical lines can be held in union with a rotation of 20 degrees or more, horizontal lines become double with a total rotation for both tubes of from 6 to 8 degrees. Indeed, it requires some practice to hold the lines in union with a rotation of each tube either out or in to the extent of 3 degrees."
Stevens made his observations by means of an instrument which he calls the Clinoscope. This instrument enables him to superimpose various figures. The observation just quoted was made by superimposing two straight lines only. Stevens believes the phenomenon is due to differences in torsion, for he says: "A very considerable latitude is permitted in respect to the position of the vertical lines and the torsional act may overcome an important normal deviation." My experiments, however, lead me to believe that what Stevens has been studying is not the amount of torsion, but the variations in the psychical compensation for the different meridians of the eye. I have found that the greatest angle of separation of the lines at which they may still be fused, depends to a certain extent upon their length or what is just the same thing, upon the distance at which they are observed ; the greater the distance, the greater the angular displacement allowed. This could not be the case if the phenomenon were due to torsion. On the other hand, if due to a psychical compensation for noncorresponding points, the increase in the angle with the increase in the distance would be expected, since the extremities of the lines would have to be placed farther apart in order for the extremities of their retinal images to be the same distance apart as before the increase in distance.
Another observation that I have made seems to prove conclusive! v that it is not by undergoing torsion that the eyes combine lines which are placed at an angle to each other. This observation was made by having the upper part of the vertical line on one disk separate from its lower part so that it could be put at an angle to the latter. If the upper part is rotated it will be seen that the line is no longer continuous, but consists of two radii of the disk placed at an angle. This line is readily fused with the vertical line on the other disk even when its two parts are at an angle of more than 10
degrees. It is inconceivable that such a line could be combined with a straight line by a process of torsion, since at least one of the eyes would have to rotate in two opposite directions at one time, but the assumption of the existence of a psychical compensation explains the phenomenon here just as satisfactorily as when both verticals are straight lines.
F.c4
In Fig. 1 the upper disk, A, has been rotated 8 degrees, while the lower disk, B, is in the primary position. C represents the appearance presented to the eyes when A and B are superimposed. In Fig 5 the upper and lower parts of the vertical on A have each been placed at an angle of 5 degrees to the perpendicular, and are thus at an angle of 10 degrees to each other. The horizontal line remains perpendicular to the lower part of the vertical line and hence has been rotated 5 degrees. C shows the appearance when A and B are superimposed. It will be noticed that the angle between the two parts of the displaced vertical line on C, is less than the corresponding angle on A.
F,c 5
Archives of Ophthalmology, Vol. XXVI, pg. 201.
In the proper use of the reflecting phorometer the shape of the object to be viewed is of very great importance. As mentioned above, when the images are displaced lateralis they are also inclined towards or away from each other and consequently it would be impossible to combine them if the object were a line, unless the eye underwent torsion. This, I find, it refuses to do, and it is necessary to adopt a plan to overcome the difficulty. Practically I have found that the images of a small circular spot about 3} cm. in diameter are readily combined. As a matter of fact, the images of the round spot when lateral separation is produced are converted into ellipses whose axes are inclined to one another, just as in the case of the straight line, but there does not seem to be
May. 1309.]
JOHNS HOPKINS HOSPITAL BULLETIN.
enough difference in the images to interfere with perfect fusion. Theoretically a sphere should be employed as the object, for no matter how rotated its projection would bra circle. If used, however, it must be evenly illuminated otherwise the shading would defeat the purpose in view. Lighted caudles, of course, cannot be employed. The best arrangement is, either a small white circular spot on a black background of good size, or a lamp with a round window.
The number of degrees the hyperphoria lever moves is almost exactly half the number of degrees of the vertical displacement of the images. It is not exactly half, however, because the circumference which measures the angle made by the moving image, has for a center a poiut a little in front of ih.' eve. (Fig. 3, C). But at a distance of 20 feet this error is not appreciable, and even if it were the dial could be graduated empirically. The closer the mirrors are together and the nearer the eye is held to them the less is the error. For the near point, however, the error becomes considerable, and if it is desired to test hyperphoria for the near point a special scale is necessary.
Ju a theoretically more perfect instrument, it would be necessary to have both the lateral and vertical movements produced by the lower mirrors. This would entail, however, a more complicated mechanism, and I think it is hardly demanded. In this model only one of the upper mirrors is moved. It would be better, however, to have them so arranged that they would move equally but in opposite directions. This is so, because if the lower mirrors be tilted for a high degree of lateral displacement, the moving of one upper mirror would produce a movement of the image along an oblique line instead of a vertical one and hence diminish or increase the reading. This error is very slight, however, and diminishes directly with the amount of lateral displacement.
The center of the curve along which the lateral movement of each image is made, is, for practical purposes, at the intersection of the line of sight with the axis of the lower mirror. Since the eye is a short distance behind this point, the lateral movement for near objects is perceptibly less than that registered by the instrument. It is thus necessary to make a scale for the near point and on this model I have done so, taking as the near point an object whose image is 30 cm. from the eye. The method of obtaining the scale must be modified from that adopted for the 20 ft. scale, since the image is about as far back of the real object as the distance between the upper and lower mirrors. The difficulty is overcome by laving an upright line at this distance behind the object and in making the scale the image is adjusted with regard to this line and not with regard to the object.
The range of this model is from 10 degrees of exophoria to 15 degrees of esophoria. If additional range is required all that is necessary is to add prisms to the cells at the back provided for the purpose. Thus if a 5-degree prism, ba frere added before each eye, the range obtained would be from degrees to 25 degrees esophoria, and if base in, from 5 degrees esophoria to 20 degrees exophoria.
There may be some objections raised to the use "f I be thread in this instrument. I must admit that it does seem rather reckless to have the accuracy of the instrument hanf
91
thread, as it were, but the little likelihood of the thread being broken and the ease with which a new thread can be inserted and the instrument readjusted, I think fully warrant its use. Other mechanisms could be devised for the purpose, but 1 think they would not increase (he accuracy of the instrument to any extent.
The advantages of the instrument are obvious. Even without the use of the shutter mechanism it has the same advantage that Stevens' phorometer has over the ordinary prism test. This lies in the evenness and rapidity with which the reading may be obtained. In Stevens' phorometer, it is necessary to separate the images primarily at a distance equal to the limit of the instrument, that is about 10 degrees, and they are farthest apart when the heterophoria is least, and therefore most difficult to estimate. I think this is a decided disadvantage, for one image is on the fovea while the other is on a less sensitive portion of the retina, and it is consequently not only more difficult for the patient to estimate their relative positions, but he is likely to overlook or suppn image entirely. In the reflecting phorometer, on the other hand, the images need be separated only so far as to produce constant diplopia.
Moreover, such difficulties are entirely overcome by the use of the shutter previously described. By means of this it is possible to locate the images upon corresponding points, in fact upon the foveas of both eyes. The very slightest heterophoria is thus detected at once, the image apparently moving in one direction or another, and when the apparent movement is overcome by moving the levers, not only the esophoria or exophoria is indicated on the scale, but the amount of hyperphoria as well. I have not tested the instrument with cases of amblyopia, but it is extremely likely that it will prove of the greatest value in just such cases, since the patient is seeing with only one eye at a time and hence has little tendency to suppress either image.
In testing the strength, or really the combining power, of the eye muscles, the instrument has very decided advantages. Ordinarily in testing the combining power of the muscles, first one prism and then another is placed before the patient's eyes until a strength is reached which the patient cannot overcome and diplopia is produced. The objection to this method is that the patient is tired out by having to overcome prisms so many successive times, and one can never be sure that he is not suppressing one image. With this instrument, however, separation of the images is gradually, though quickly, produced by the proper lever, and when the patient says the images are slipping apart the result is read off on the scale. This occupies no more time that ii hikes I.. read ii.
Another very important use to which the instrument can be put is to give gymnastic exercise to the eye muscles. By moving the lever, the patient himself can do this, not by jerks as with prisms, but smoothly, and 1 find that if is possible for the eye muscles to abduct, adduct, or snrsumduci to ;i greater extent than with prisms and that it is not so fatiguing to the eyes. By the use of this instrument I have no doubt that ezerciseof the muscles of the eyes will produce mon factory results than have hitherto been generally claimed for it.
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[No. 98.
I wish to express my great obligations to Mr. R. F. Rand for the very careful drawings he has made for me, and to Dr. James Bordley, Jr., for looking over the literature. So far as he has gone, Dr. Bordley has found no mention of any instrument at all similar to this one.
During a discussion following the reading of the above paper before the Maryland Ophthalmological and Otological .Society, my attention was called by Dr. Hiram Woods to an article by Dr. Alexander Duane in the New York Medical Journal for August 3rd, 1889. In this article Dr. Duane describes a test for the insufficiencies of the ocular muscles that he calls the parallax test. The principle of this test, I find, is undoubtedly the same as that involved in the shutter test as described by me. " It consists of shifting the screen from one eye to the other and making the patient observe if the image moves, aud if so, in what direction." Dr. Duane measures the amount of insufficiency by determining the prism required to overcome the movement in any one direction, and he claims that the test is an extremely delicate one, especially for hyperphoria. Dr. Duane evidently shifted the screen by hand, and it seems to me that if lie obtained such excellent results in this rough way, the test, used in connection with
the reflecting phorometer in the way I have described, should prove of still more value.
I have given personal instructions regarding points necessary to the manufacture of the instruments to E. B. Meyrowitz, of New York, from whom in future they can be obtained.
Discussion.
Dr. Theobald. — I think Mr. Verhoeff has devised an instrument that is going to be of distinct value aud one having decided practical merits. The shutter device, so far as I know, is entirely novel and very ingenious, and accomplishes exactly what is aimed at. The instrument combines with the qualities of the Stevens' phorometer the power to determine the ability of the muscles to fuse images; in other words, it gives the strength of the muscles in overcoming diplopia. At the same time it is simjde and not likely to get out of order. I at first made the criticism that if one of its strings should be broken it would be difficult to get the instrument gauged again, but Mr. Verhoeff promptly threw it out of gear and in a few moments had it rearranged, showing that objection was not well founded.
I congratulate him upon having done such an excellent piece of work, and I think the oculists will consider it an instrument of great practical value.
ON THE SOLUTION OF MERCURY IN THE BODY.
By Arthur Smith Chittendex.
{From the Pharmacological Laboratory of Johns Hopkins University.)
The apparently ready absorption of metallic mercury and its subsequent elimination in a soluble form has led numerous investigators to inquire into the action of the body juices upon the apparently insoluble metal.
That inunctions of finely divided mercury or the inhalation of the vapor can give rise to marked symptoms of mercurial poisoning has long been a matter of common knowledge. That this fact involves somewhere and somehow a solution of the metal is obvious; and the determination of the place aud nature of this solution has held the attention of mauy investigators.
For some time it was supposed that the blood exercised an oxidizing influence on the metal; and although this belief obtains substantially today among pharmacologists, yet the experiments which first led to this vie\, have long been considered fallacious. For purposes of investigation the method of introducing mercury into the blood usually consisted in anointing either abraded or vesicated surfaces with quantities of mercurial ointment : animals were also compelled to inhale mercurial vapor. As a result of these experiments, soluble mercury was found in the blood, urine, and feces, and apparently, also in the form of metallic globules, in the depth of the epithelium and in the dejecta.
Oberbeck* in a series of painstaking experiments found, upon
! Oberbeek, Mercur. u. Syphilis. Berlin, 1801.
making microscopic sections of the area treated with mercurial ointment, that the corium was infiltrated with minute globules of the metal. After a similar inunction of vesicated surfaces, Zuelzer* found the ducts of sebaceous glands as well as the sheaths of the hair follicles filled with the metallic globules.
In a paper some years previous to the foregoiug, Hoffmannf obtained precisely opposite results in a series of similar experiments. It remained for llindlleischj to repeat these investigations and to determine the reason of the discrepancy in results.
After anointing an unabraded surface and cutting sections as described, he found that if he sectioned with the blade passing through the deeper tissues first and out through the skin, no globules of metal appeared in the corium and deeper structures; whereas, if he reversed the block and cut through the skin first, the mercury droplets could be made out in the depths of the tissue. In other words, the metal was carried iuto the tissues mechanically in sectioning.
In the experiments in which inunction on abraded surfaces was practiced and in which the insoluble metal was found in the internal organs, the lymphatic spaces and the capillaries werq
Wein. Medicinal Halle, 1864.
f Hoffmann, Inaug. Diss. Wurzburg, 1854.
X Rindfleisch, Arch. f. Dermat. u. Syph., 1870.
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doubtless opened and the metal was picked up U the circulation.
The appearance of metallic globules in the faeces of dogs which have been anointed with mercurial ointmenl may also be explained by the fact that unless the ears alone be treated, it is almost impossible to prevent the animal from licking off and swallowing the mercury.
According to Hermann.* generally speaking, metallic mercury cannot as such pass through the intact epithelium in any part of the body. This is true of the respiratory epithelium as well as of any other. In cases where the mercurial vapor is inhaled, the metal is found condensed upon the surface of the epithelium, no globules passing beneath the surface unless they enter by some break in its continuity. Still other investigators, such as Hoffmann, Rohrig, Barensprung, Neumann and Fleischer concur in this opinion.
If. then, in inhalation and inunction experiments insoluble mercury does not pass through the intact skin to be acted upon by the circulating fluids of the body, but does appear in soluble form in the blood and dejecta, what are the factors effecting solution ? They may be found in two situations : in the secretions on the surface and in the menstruum of the ointment. That the secretions of the skin contain materials which will effect the solution of mercury has been sufficiently proven. Lewald has shown that by treating mercury with ammonium bntyrate, a component of the secretion of the skin, solution follows; moreover, the sebaceous secretion contains various other agents capable of acting in this way.
When mercury is precipitated on the respiratory epithelium in inhalation experiments. Hermannf says that, aside from the oxidation processes which might be effected by the air in passing oyer these surfaces, we must suppose some supplementary oxidation as a result of the activities of the tissue juices. • borne out by the researches of Eindtleischt wherein he finds, after introducing blue ointment into the conjunctival sac and suturing the eyelids, that, although inflammation has occurred and pus has formed, subsequent section of the glycerine fails to reveal any metallic globules. The questionable methods of experimentation and the wide discrepancy in the results of investigation lead Schmiedeberg§ to cast serious doubt upou the power of the blood to oxidize mercury.
The possibility that the various investigators refermay have unwittingly introduced soluble mercury and therefore obtained positive results is apparent, and it was with this eontingency in mind that Fiirbringer|| devised a method calculated to eliminate experimental errors.
Having rubbed up definite amounts of mercury with gum arable and glycerine, he obtained a dark -gray emulsion from which the larger globules separated out on standing; the remaining globules were exceedingly fine and remained
•Hermann, Toxikologie, Berlin, IS74. Also Harnack, Arzm mittellehre. Leipzig, 1883. tLoc. cit. Also Harnack, loc. cit. tLoc. cit.
gSchmiedeberg, Arzneimittellebre, Leipzig, 1895. II Furbringer, Virch. Arch., 1880, B-1. 62.
Pension. In the supernatant liquid Furbringer found only rery minute amounts of mercury; this emulsion he injected ■ nto the femora] veins of dogs. After a definite time, varying from twelve hours to seven .lays, he drew off and immediately
defibrinated the blood. Eaving allowed bhe bl I to stand
until the corpuscles had settled to the bottom,, the serum was decanted off and the organic matter destroyed by oxidation with IK'l and KC10.;the resulting solution was then submitted to electrolysis and positive evidence obtained in a number of experiments of the presence of soluble mercury.
In five experiments in which the animals were killed respectively, one, two, three, five and six days after injections, the chemical manipulations afforded plain evidence of Hie pres
enceof mercury in the lor f mercuric iodide rings. In
four experiments no mercuric iodide whatever could be detected, and in three further instances the presence of mercury was questionable, as if could not be asserted positively that mercuric iodide was obtained.
Ffirbringer's work is open to criticism in two particulars. In the first place, it is possible that a soluble compound is formed when mercury is rubbed in a mortar with solutions of gum arabic. Here, certainly, we have an exposure of finely divided mercury to oxygen, organic substances and to salts of potassium, calcium and magnesium. That it is possible for a soluble compound to be formed under these circumstances, Furbringer admits; for, when his emulsions were allowed to stand for a long time in loosely stoppered vessels, a soluble mercurial compound, presumably mercurous mucate, was obtained. This possibility is further strengthened by the experiments of many investigators which show that when mercury is shaken with fluids containing salts and proteids a small amount of a soluble mercurial salt is formed.
A second criticism is that, oxidation of blood serum with HC1 and KCIO. will make soluble any metallic mercury which may be in suspension in the serum.
In justice to Furbringer it must, however, be stated that he attempted by means of control experiments to show that he had not introduced soluble mercury into his animals and that the operation of defibrinating lie- blood and the subsequent chemical manipulations could not account for the mercury found in those of his experiments which yielded positive results.
Bearing in mind the criticism made upon previous in gations of this character, it. is the objecl of this paper to present a method which shall, in so far as may be, eliminate questionable details of experimental ion.
I have chosen the urine an. I faeces as the objects of investigation because tbej seemed to present, theleasl possibilities of error; in so doing, the dangers of oxidation and contamination of the mercury by salts and fatty acids of are avoided.
Method or Preparing \m> Injecting the Mercury.
An alcoholic solution of mercuric chloride was treated with stannous chloride until all the mercury was precipitated in a finely divided form; Ibis was tillered ami washed with hot water until the lilt rat.' gave no precipitate with silver chloride. The residue on 1 1. .. r was then suspended in a physi
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ological salt solution ; when examined under the microscope this suspension showed the presence of globules of mercury which were smaller than a red-blood corpuscle.
Having dissected out the femoral artery and clamped it centrally, about 5 com. of this suspension, containing approximately 0.25 g. of metallic mercury, was injected peripherally into the artery of each of four dogs.
The needle was withdrawn and in each case the clamp removed and the wound closed by deep and subcutaneous sutures. By thus deeply burying the artery the possibility of hemorrhage or of the animal licking up mercury was obviated. The urine and fasces of these animals were collected for a period of six weeks after the injection and analyzed for mercury.
jIethod of Detecting the Mercury in the Urine
AND FiECES.
For the method of detecting and determining the mercury in the urine and faeces I am indebted to Wiuternitz* I constructed a system of three upright glass tubes each of which connected with a common T-tube and contained a roll of pure copper gauze 20 cm. in length. The urine was collected from time to time, filtered, acidulated to 1 per cent, with HC'l and passed over the copper rolls through the uppermost arm of the T-tnbes.
Karh day's urine passed through this system six times and the collecting was continued for six weeks. The rolls of copper gauze were then withdrawn from the tubing, washed with water, alcohol and ether and submitted to a high temperature in the combustion furnace for one hour.
In glowing the copper rolls, a bayonet tube was used which contained beyond the rolls of gauze a layer of copper oxide and a spiral of silver wire separated by suitable asbestos plugs. In the straight end of the tube which projected from the furnace a small bulb was blown and in this were placed leaves of gold foil.
During the heating a stream of dry carbon dioxide was passed continuously through the tube from the bayonet extremity; at the end of an hour a large number of minute globules of mercury could be clearly seen on the sides of the tube as it projected from the furnace and in the bulb ; also an amalgam had formed upon the gold foil. These globules could be rolled together into larger ones and gave red crystals of mercuric iodide when subjected to vapors of iodine.
To determine the mercury in the collected feces, these were extracted for several days with water, the nitrate acidulated and passed over another series of copper rolls ; the heating of the rolls was then carried out as in the urinary determination but failed to reveal any mercury in the form of visible globules. When, however, the tube and bulb were subjected to iodine vapor, plain evidence of a ring of mercuric iodide was obtained. The amount of soluble mercury present in the feces was very minute as compared with that in the urine. This is hardly contrary to what might be expected, since secretion of mercury in the bile is slowf and the reabsorption in the intestine is
Winternitz, Arch. f. Exp. Path. u. Pharm., Bd. 25, p. 225.
fLewin, Toxikologie II Auf., 1897, p. 110.
rapid.* Furthermore, my method would not detect the mercury present in the feces in the form of a sulphide. The total amount of mercury injected into the four animals was approximately one gramme; the amount recovered from the urine was estimated to be about 20 mg. That the amount recovered should be small is borne out by the researches of Lewinf who finds that after inunctions with blue ointment, mercury continues to appear in the urine for eight months.
The finely divided mercury used in these experiments was freshly prepared for each animal in order to eliminate any possibility of oxidation on standing.
That finely divided mercury could have been excreted as such by the epithelium of the urinary tubules would hardly seem probable inasmuch as repeated microscopical examination failed to reveal the presence of any globules either in the lumen or in the epithelial cells themselves.
Ftirbringer speaks of the formation of thrombi during his experiments at the point where the cannula was introduced into the vein ; other observers have mentioned emboli in the lungs. By injecting into the femoral artery it was sought to have the emboli form peripheral wards. Having killed one of the animals used in the experiments, I examined microscopic sections of the pavv of the leg injected and failed to find any emboli. When Prof. W. H. Welch examined sections of the lymph glands which were submitted to him he made the following interesting observation: Scattered among the lymphoid cells were numerous large multinuclear megakaryocytes, a condition resulting from parenchymatous^ embolism of the bone marrow ; these cells are subsequently expelled into the circulation from which they are filtered out by the lymphoid tissue.
The appearance of these cells in the lungs has also been observed in animals in which embolism of the bones had been produced.
Just how the solution of mercury by the body juices is effected and what part is played by the albuminous constituents, we cannot say, but that solution is effected and the mercury eliminated as an albuminate§ seems to be true.
Van der Does|| finds that after shaking dilute egg albumen with finely-divided silver and then filtering, the filtrate is no longer coagulable by heat; the albumen thus treated will not decompose when exposed to air, and that silver has gone into solution. Albumen treated in this manner with mercury does not give a similar result.
Real encylopudie des gesammten Heilkunde, Bd. XVI, p. 317.
t Lewin, loc. cit.
J Lubarsch, Fortschr. d. Med., 1893, II, p. 805. Maximow, Virch. Arch., 1898, CLI., p. 297.
§ Real encylopadie der Gesammten Heilkunde, loc. cit.
|j Hoppe-Seyler's Zeitschrift f. Physiol. Chemie, XXIV, p. 351.
THE JOHNS HOPKINS HOSPITAL BULLETIN.
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JOHNS HOPKINS HOSPITAL BULLETIN.
95
PROCEEDINGS OF SOCIETIES
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY. Monday, January 9, 1899. Exhibition of Medical Cases.— Dr. Fi rcHER.
During the fall of 1898, Lancereaux, of Paris, published a now method of treating aneurisms. He published the first communication, in connection with Paulesco, about the October and the method is as follows:
He injects into the subcutaneous tissue of the thigh 250 cc. of a -J per cent, solution of gelatin in normal salt solution. Of course, it is thoroughly sterilized and injections are made with aseptic precautions. The injections should always be made at a considerable distance from the aneurism, and he considers the most satisfactory place to be the subcutaneous tissue of the thigh. The interval between injections should be from two to fifteen days, He states that about 20 injections are necessary to produce a cure, and from a considerable series of cases in which he has adopted this treatment quite a large percentage are reported as cured. He finds, however, that ordinary diffuse dilatations of the arch of the aorta are not relieved by the treatment, but that the most satisfactory cases are the saccular dilatations of the aorta, or of any of the other vessels.
Hachard, also, used this method of treatment, but recommends that a weaker solution than the 2 per cent, be used. He found that after the injections were given a great deal of pain was complained of for several hours at the seat of injection, so he recommends the use of a 1 per cent, solution, which apparently causes no pain. He reported two cases in which death occurred; one was a case of pulmonary tuberculosis, in which he believed the haemoptysis was due to minute aneurisms ou the small vessels crossing the pulmonary excavations. This patient died rather suddenly during the treatment. The second case was one under the care of Dr. Barth, and, in this instance, the patient after the sixth injection had a sudden attack of dyspnoea, suffocation, and died in a few minutes. An autopsy showed definite clotting in the aneurisms] sac; there was a layer of fibrin about 4 cm. thick all over the wall of the sac, but the clots had extended into all the vessels, excepting the left subclavian, springing from the arch of the aorta, completely occluding them, and causing sudden death.
The beneficial effect of the treatment is supposed to be
due to increased coagulability of t lie blood ritonea)
injections have been made in the rabbi* by I. am
he believed that the coagulability of the blood was always
d. However, the adoption of this mode of treatment
of aneurism has led to a great deal o n before the
■ of Medicine, in Paris, and variou claim
that the coagulability of the blood is not increased. Laborde
ch'ims that it is not, and says that gelatin is not absorbed when
injected into the peritoneal cavity, and that he has found the
same amount of gelatin several hours after injection, as was
originally given. He states that possibly eventually it may be
1, and if so, it is because it undergoes peptonization.
Laborde recommends that the gelatin injections be mad
the sac itself. Camus and Gley have performed experiments
and found that there is no increase in the coagulability of the blood after infcra-peritoneal injections of gelatin in rabbits— that is, there is uo diminution in the time required for coagulation to take place.
We have now tried the treatment in four cases of aneurism in the medical wards of the Johns Hopkins Hospital.
The first was that of J. B., who was admitted about two months ago, with a definite saccular aneurism of the arch of the aorta about the junction of the transverse and descending portions of the arch, at least that is where we believed it to be during life. He had received six injections— two of the 2 per cent, solution, and four of the 1 per cent., because it was found that the first gave considerable pain. This pain was very intense and most severe about six hours after the injection. The patient appeared to be doing fairly well, when he was suddenly seized with an attack of dyspnoea, coughing and profuse hemorrhage, and died. At the autopsy there was found a general dilatation of the arch of the aorta with a localized saccular dilatation about the junction of the transverse and descending portion of the arch. At the point of pressure of the sac on the left bronchus there had been a perforation causing hemorrhage and death. There was no deposition of fibrin on the sac wall. The second case in which the treatment was adopted was a patient, U. C, with aneurism of the descending portion of the thoracic aorta. He has now had 28 injections, more than the number supposed to be required to produce a cure. There was definite pulsation visible and palpable over the lower part of the thorax with a definite diastolic and systolic murmur in the back. There was intense pain at the seat of pulsation previous to the adoption of this treatment. Since the treatment was begun he has had very marked diminution in the amount of pain, and the pulsation is appreciably diminished. During the time of treatment he has gained 19 pounds in weight. It is the most satisfactory case we have had, so far, out of the four. The third case is that of 0. G., who has a saccular abdominal aneurism. He has now had 16 injections, with little or no evident improvement. He still has a great deal of pain.
The fourth case, C. L., has had 2 1 injections for a rather diffuse dilatation of the arch of the aorta. In this case, and in that of U. 0. and 0. (i., there has been a marked increase in
the coagulability of the bl 1 after each injection— that is, the
time of coagulation was distinctly diminished. (Exhibiting cases.)
An in!' mlilion that has followed the injections in
Case IV is the occurrence of localized tumors at, the seal of infection in the abdominal wall. Tim injections were made here because we thought there might be less pain than that which followed injections in the thigh. Tim pain wa however, much diminished. The day following the injection a nodule the size of a hickory-nut frequently developed, occasionally accompanied with an elevation of temperature. These nodules persist lor eighl or (en days and then gradually disappear.
In the second case the coagulation time averaged about three minutes for the first ten injections and a! came
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much delayed, for a short period, requiring 17 minutes for coagulation to take place. What the explanation of this is I cannot say, for it has again come down to Ave minutes.
THE SCHOTT TREATMENT OF HEART DISEASE.
About two years ago Dr. Camac read a paper before this society describing fully this method of treatment. Last summer I had the opportunity, through the courtesy of Dr. Theodore Schott, of seeing the method as used at Bad Nauheim. The treatment consists of two factors: the giving of thermal saline and carbon dioxide baths and the use of carefully regulated muscular exercises. The constituents of the saline bath consist largely of sodium and calcium chloride and the temperature is about 93 degrees F. After a series of these baths the patient is given a series of the carbon dioxide baths. The effect of the bath treatment is believed to be due to a stimulation of the peripheral circulation, thus increasing the amount of blood in the skin and subcutaneous tissue and in this way relieving the heart.
The exercises are believed to have practically the same effect; the patients usually get the baths in the morning and the exercises in the afternoon. The baths are given first for about six minutes and the time gradually increased until the patients are allowed to remain in the bath for about eighteen minutes.
I saw a patient given his first bath. It was a case of myocarditis in which the heart was very large, much dilated and its action extremely weak. Before putting him in the bath the area of cardiac dullness was carefully mapped out on a piece of transparent paper, and after the bath the cardiac dullness was again percussed out, the first diagram was placed over the second by means of definitely located points and any change in the area of cardiac dullness was thus noted. It was remarkable in this case to see the change ; there was fully a finger's breadth difference in the extent of dullness before and after the bath.
At first the diminution after the bath is not permanent, but eventually a gradual gain is made and a widely dilated heart may diminish to practically its normal size.
Efforts have been made to devise a means of giving these Schott baths in hospitals and other institutions, and Theodore Schott has given formulas according to which the various baths can be prepared and carbon dioxide generated. The usual method of preparing the latter has been to use hydrochloric acid and sodium bicarbonate. During the past year a firm in New York known as The Triton Company have devised a means of dispensing with the use of hydrochloric acid and recommend a simpler way of generating the gas. They have prepared boxes containing a package of sodium bicarbonate and cakes of sodium bi-sulphate, the gas being generated by the action of these two salts upon each other. In addition to the bicarbonate of soda five pounds of salt and varying quantities of calcium chloride should be first added to forty gallons of water in the bath. The sodium bicarbonate is then put into the water and the cakes of sodium bi-sulphate, of which there are eight, are placed about the patient as follows: Two beneath the shoulders, two at each side of the body, and
two under the knees. In two or three minutes there is a rapid generation of the gas and the patient may then be placed in the bath, where he remains a variable tim -, according to the stage of the treatment.
This patient with myocarditis has received the treatment here. He has had no rheumatism; has not been a heavy smoker, but a rather hard drinker, and it was found on physical examination that he had a much dilated heart, the point of maximum impulse being in the sixth interspace 12 cm. from the mid-sternal line, just before the first saline bath was given. His heart's action was very weak, the pulse very feeble and many of the beats not recorded at the radial pulse. Dr. Hastings was kind enough to make these charts, on which the red lines indicate the area of relative cardiac dullness before the bath, and the dotted lines that after the bath. The greatest width of relative cardiac dullness before the first bath was 12 cm., and after the bath 9 cm. With each succeeding bath the area of dullness gradually diminished and this chart represents the present area of relative cardiac dullness, which you see is markedly diminished. The apex beat is now in the 5th interspace 7.5 cm. outside the median line and the greatest breadth of relative cardiac dullness is only 7 cm. His condition is much improved and he goes about the wards with very little dyspnoea.
Dr. Welch. — Referring to the first cases, I should like to ask whether in the gelatin treatment for aneurism any attention has been paid to factors other than the coagulation time, particularly as to whether there is any increase in the number of platelets in the blood or any diminution in the red-blood corpuscles ? I speak of this because the coagula in aneurism are not ordinary clots as they form outside of the body, but are genuine thrombi which consist in their inception of platelets, and it is difficult to bring the occurrence of these thrombi in the body into any definite relationship with the rapidity of coagulation of the blood. Many diseases like lobar pneumonia and acute rheumatism in which there is increased fibrin content are not so frequently associated with peripheral thrombi as are typhoid fever and certain anaemic and cachectic conditions in which the fibrin content is low. We cannot bring the appearance of coagulation in the living vessels into direct parallelism with the coagulability of the blood as ordinarily understood. There are indications suggesting a connection of these thrombi with the number of platelets in the blood. In chlorosis, for instance, the number of platelets is increased and peripheral thrombosis is a well-recognized complication,whereas in pernicious anaemia the number of platelets is diminished and thrombosis rarely, if ever, occurs. In haemophilia there is sometimes total absence of platelets. There is much for the view that the number of platelets is an index of lowered resistance of red corpuscles. If, therefore, there is any evidence that the gelatin treatment favors the production of thrombi in aneurisms, it seems to me that some light may be thrown upon the explanation of this occurrence by the study not only of coagulation time and fibrin content, but also of the possible influence of the gelatine injections upon the resistance and number of the red copuscles and the number of platelets.
May, 1809.]
JOHNS HOPKINS HOSPITAL BULLETIN.
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Aneurism of Aorta, Compressing and Rapturing Into Lefl Bronchus. — Dr. Flkxnf.r.
Anatomical Diagnosis: Aneurism of the aorta, rupture into the left bronchus, haemoptysis; aspiration of blood into the lungs; compression of left bronchus; slight bronchiectasis, ami carnificatiou of the lung; acute splenic tumor; slight chronic nephritis.
The pericardial sac does not contain an excess of fluid; both layers of the serous membrane are smooth. There projects into the summit of the sac a roundish tumor springing from the aorta, which is intimately united with the pulmonary artery. The heart was opened in situ. It was found that springing from the left lateral wall of the ascending portion of the aortic arch is a saccular aneurism projecting toward the left side. The projection into the pericardial sac is found to be due to an extension from this aneurism. The dilatation of the aorta begins 5* cm. above the attachment of the aortic valves and, as will be seen, includes portions of the ascending, transverse and descending aorta. An opening which is approximately circular and measures 6i cm. is situated on the left lateral side of the artery. This opening can be divided approximately into three segments ; the first third springs from the ascending, the second from the transverse portion and the third, which is the shortest, from the descending portion of the arch. The depth of the sac is approximately 4 cm. The sac, as stated, extends to the left and pushes aside the upper lobe of the left lung to reach the pleural surface with which it is firmly united. Finally it comes to impinge on the left bronchus, and it has also grown together with the fibrous wall of this structure. The oesophagus also is pressed upon by that portion of the sac which has come to lie next it.
The entire main bronchus, from the bifurcation of the trachea to the first division in the hilus of the lung, is pressed upon by the sac of the aneurism. As a result the walls of the former are distinctly thinned and there is a marked lateral compression of the tube. The bronchus has been perforated just below bifurcation of the trachea at a point coinciding with the intercartilaginous tissue between the second and third rings. The mucous membrane covering the second ring is eroded, while that over the third is swollen and defective superficially. The membrane between the third and fourth rings is much attenuated and appears to be covered by nearly intact mucous membrane only. There are two small ruptures to be made out in this membrane, which might readily have iroduced in the removal of the lungs and bronchi. The mucous membrane of the bronchus where it is freed from the recently coagulated blood which covers the surface is pale. The left lung is bound to the chest wall and to the pericardium and aneurism by old adhesions; the apex only is crepitant. The bronchi upon section show a moderate dilatation of the medium-sized tubes, while the lung substance is congested, dense and more or less airless, the consistence being inci In this carnified and congested tissue there are sea whitish or grayish points, and from the surface a cloudy Quid can be expressed. Certain areas of tin- lungs present a grayish and slightly coal-pigmented aspect and are semi-translucent. The right lung is voluminous. There tire moderate pleural adhesions, the anterior and superior half being bound to the
pericardium. Where free from adhesions to the chest walls and pleura it shows blotches of haemorrhage, and upon section there are present deep red areas corresponding to points of blood aspiration. The medium-sized bronchi are plugged with recent clots of blood. The trachea and larynx, except for the staining of mucosa, are free from coagula of blood.
The aorta is the seat of marked arteriosclerosis with slight, calcification. The sclerosis does not begin immediately above the valves in that it leaves the first part of the aorta (dear for a distance of 5 cm.; the most marked sclerosis is in the transverse arch. The sclerosis is less marked again in the thoracic aorta and abdominal aorta where relatively few sclerotic patches occur. The sac of the aneurism is almost, entirely free from clots ; the coats of the artery are shown to be present everywhere, the inner coat presenting an irregular corrugated appearance. Fatty patches, a few elevated fibrous nodules and a number of calcified areas measuring several millimetres in diameter — these last showing a slaty pigmentation- — occur in the sac of the aneurism. These slaty and calcified areas are, on section, found to agree with underlying and closely adherent, nearly black lymphatic glands. The coagula upon the wall consist merely of a recent granular deposit, not exceeding a millimetre in thickness and imperfectly covering the inner surface.
Bacteriological examination showed the lung, liver and kidneys to contain the bacillus lactis aerogenes. The lung and liver, spleen and kidneys gave the micrococcus lanceolatus. 0.3 cc. of a culture of the micrococcus injected into a mouse produced death from general septicaemia.
Miss Reed has kindly examined the sections from the case, the chief interest of which centres in the spleen and the lefl, lung. The spleen shows in its substance, especially in the neighborhood of the capsule over the ventral surface, a number of haemorrhages, some small and others larger, although the largest does not exceed 1 or 2 mm. in diameter. In a broad way two kinds of haemorrhages may be distinguished, although the line of demarcation is not absolutely sharp. The larger ones consist of red-blood corpuscles chiefly, with probably a due proportion only, of white corpuscles; the smaller, infiltrating areas which may not certainly be haemorrhages, but localized congested areas, show a less perfect preservation of the haemoglobin and the number of leucocytes with irregular nuclei considerably increased. Among the leucocytes in these latter situations are cells, the protoplasm of which reacts in a manner peculiar to haemoglobin, which contain single nuclei or nuclei undergoing fragmentation. Similar cells to these are found distributed throughoul the pulp of tie spleen and are probably relatively as numerous as in the congested or haemorrhagic areas jusl mentioned. £ lined by the Biondi Heidenhain method seem to prove what those stained in methylene-blue and eosin indicated, l hat these cells are normoblasts. The contents of some of the larger branches of the splenic vein are red co shaped nuclei; the latter were not improbably endothelial cells,
derived from the ve 'tern. Small thrombi consist
ing of platelets and of leucocytes an- ale > found in dilated veins containing in addition red corpuscles and endothelial cells presumably desquamated. The mixture of leucocyl
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JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 98
platelets form small islands within the lumen of the vessel. Capillary thrombi in the region of the small haemorrhages were not discovered. In sections stained by Weigert's fibrin method this element occurs in foci in the splenic pulp. Finally, a fairly large number of cells containing red corpuscles are present in the pulp.
The description of the lung is limited to the left lung. The bronchi are moderately dilated and contain mucus, fragments of red corpuscles, and more or less modified desquamated cells. The blood-vessels in the wall are swollen and the wall is infiltrated throughout with round cells, some of which present exquisitely reticulated nuclei, placed somewhat eccentrically, and resembling plasma cells. This infiltration is not limited to the wall of the bronchus but involves the connective tissue which includes in the same sheath the vein and the artery. The artery shows a new growth of tissue in the intima, which is young and cellular and not annular, but is developed especially on the side of the vessel next the bronchus. The irregular distribution of the new tissue in the intima is shown in a section which includes a branch of the artery, for the new tissue is developed almost exclusively on the side of the vessel, next to the bronchus and is very little present in the point of origin of the new branches. In the lung the new growth of tissue is in the pleura — in the interlobular and perivascular tissues especially. The alveolar walls, it is true, do show an increase in the immediate neighborhood of the perivascular infiltration, but at distances from this there is only a filling up of the alveoli with desquamated epithelial cells, serum, a lew leucocytes and a minimal amount of fibrin. The greatest amount of fibrin is in the immediate vicinity of the largest and most infiltrated bronchus. Not a few of the desquamated epithelial cells contain blood-pigment, or coal-pigment, or red-blood corpuscles. In sections stained in alkaline methyl ene-blue and eosin there were short chains of cocci to lie made out. Thrombi are want ing in the vessels in this organ.
The type of liver cirrhosis is syphilitic. Sections through the coarse librous band in this organ showed adense sclerotic tissue containing numerous islands of liver substance and a moderate number of newly formed bile ducts. Some blood-pigment and partial obliteration of the smaller-sized arteries throughan annular growth of connective tissue in the intima are also present. Gummata as such are not present in any of the sections examined. The kidney showed a marked degree of parenchymatous degeneration and a small amount of new connective tissue. The heart muscle exhibited a marked degree of fragmentation and segmentation of the myocardium. The type of fragmentation is that regarded by .Mi-. MacCallum as being preceded by degeneration (sarcolytic) of the affected fibres.
.Multiple .Metastases from Tel vie Sarcoma.— [See Bulletin for
April, 1899.]
Da. Flexnee.— The case reported by Drs. MacOallum and Harris is interesting from several standpoints. The distribution of the metastases exhibits two modes of dissemination of tumor cells: (I) Blood-vascular and (2) lymph-vascular. The nodules in the lungs undoubtedly owe their development to the first-mentioned mode. This is rendered probable not only by the relations of the primary and secondary tumors,
but also from the fact that Dr. MacCallum succeeded in tracing the growth along the walls of the blood-vessels to the nodules situated especially in the pleura, and also found groups of tumor cells in blood-vessels in the lungs. The testicular growth is conceivably of blood-vascular origin, the tumor cells having passed through the lungs and gained access to the general circulation. I am, however, disposed to regard the invasion of the testes as having taken place through the lymphatics, from the pelvic growth, by means of retrograde transport — a phenomenon not so very infrequently met with under similar circumstances.
As Dr. Harris pointed out, the streptococcus in this instance was highly pathogenic, not only for human beings but also for mice, an observation that has interested us greatly, in that our experience has been that growths of streptococci from human autopsies do not usually exhibit striking pathogenicity for these small animals. The streptococcus infection in this case was doubtless an example of terminal infection. We have now encountered a number of instances of terminal bacterial infection in malignant tumors.
NOTES ON NEW BOOKS.
The American Year Book of Medicine and Surgery. Edited by George M. Gould, M. D. [W. B. Saunders, Philadelphia, 18994
The standard of previous years has been kept up in this work. It contains 1032 pages of text and 70 pages of a complete index. In the preface Dr. Gould refers to the omission of the name of Dr. William Pepper from the list of contributors. His place has been taken by Dr. Stengel and Dr. Edsall. The editor draws attention to the increasing difficulty of the yearly task of selecting what articles shall be noted. In this connection the hope may again be expressed, that it might be possible to give the titles of the most important articles not referred to in the text. If space allowed this, it would be an addition to the value of the book. The extracts are well made and evidently combine a maximum of information in a minimum of space. Altogether Dr. Gould and his staff of editors are to lie congratulated on the Year Book for 1898.
Annual and Analytical Cyclopaedia of Practical Medicine, l.y Charles E. de M. Sa.ious, M. D., and one hundred associate editors. Volume II. (The F. A. Davis Co., Publishers; PhitadS
phia. )
The second volume of this valuable cyclopaedia covers the subjects from " Bromide of Ethyl to Diphtheria." It contains 60J pages of useful reading matter. The object of the editor has been not only to facilitate the labor of the practicing physician and to assist investigators and authors in their researches, but also to render clear, through contributions from men possessing special knowledge or unusual experience in a particular line, diseases which, owing to their complexity, are not generally understood. The high standard of work commenced in the first volume is here maintained. The second volume contains among others, excellent articles on " Cerehral Hemorrhage," by Dr. William Browning; '• Cirrhosis of the Liver," by Professor Adami ; " ( holera," by Professor Rubino ; "Cholelithiasis," by Professor Graham ;"D:abetes," by Professor Lepine ; and "Diphtheria," by Drs. Northrup and Bovaird. The editor 6tates in the preface, in reply to numerous inquiries, that he himself wrote the unsigned article on "Animal Extracts," which appeared in the first volume.
If AT, L899.]
JOHNS HOPKINS HOSPITAL BULLETIN.
99
Manual of Physiology, with Practical Exercises. Third Edition, By G. X. Stewart. Ph. I)., Professor Physiology, V Reserve University. (Philadelphia: II". B. Saunders, 1898.)
The rapid appearance of successive editions of this conveniently sized manual is sufficient evidence of a continued demand among medical students for text-books of smaller compass than the wellknown stan lard works.
The present author, unwilling to meel this demand with a more or less elementary account of the subject, succeeds in crowding into his hooks all its details and gains the desired reduction in size l'v conciseness and brevity of treatment. The hook is accordingly replete with facts, and extremely suggestive to one who possesses a previous knowledge of the subject. But as the high degree of condensation is necessarily attended with a corresponding loss in clearness and intelligibility, it is at least questionable whether it is really suited to the needs of medical students.
The practical exercises which, at first glance, enhance the value of the hook, occupy about one hundred pages out of a total of 8omewhatover eight hundred. But the conviction grows on one th.it the author might have utilized this space more profitably to the leader as well as himself, if it had been expended upon a fuller and more lucid exposition of the general text. The frequent en ss references from text to exercises in itself seems an acknowledgment on the part of the author of the insufficiency of the former. After all, the exercises claim no special merit as far as the choice of experiments is concerned ; quite a number of excellent laboratory manuals, such as Stirling's or Brodie's, amply provide for the students' needs in this direction, while their grouping under the several chapters with reference to the systematic course, to which the author calls attention in the preface, will hardly be expected to secure a similar arrangement in practice. That the latter is advantageous an 1 desirable for many reasons goes without saying, but its actual attainment depends on more things than the position of the exercises in a manual.
The book otherwise possesses many admirable features. We need only mention the superior character of all that pertains to its mechanical make-up, the number and variety of its illustrations, and the extent to which the most recent advances in physiology have been appropriated and used throughout the volume. We are a littie surprised to find in so crowded a book a long paragraph on the Care of the teeth, a sort of error in perspective which also crops out occasionally in passages in which a relatively unimportant point is spread over a number of pages, out of all proportion to its value and significance. The discussion of the " Kate of bloodflow" covers about nine pages while the "origin of urea" is disposed of in three pages. In thechapteron nutrition wealso note the omission of Drechsel's theory of the formation of urea and the scanty treatment given to the inorganic compounds, some of which like Ca have lately acquired so much significance in the genera! economy of the body. A few minor errors, like the formula for uric acid on page 136, the reference to Fig. 143 on page 519, and the incorrect account of the Holmholtz arrangement of the induction coil should have been corrected in a revised edition.
G. P. D.
The Peritoneum. By Byron Robinson, B. S., M. D. Part I : Hisand Physiology. 4°. Numberof pages 405 (not including a bibliography of 103 pages). 247 illustrations. {Chicago: The W. T. Keener Co., H97.)
itiis volume is the first of what the author evidently intends to be a series of books dealing completely with the subject of the teum. He tells us that it " is the outcome of a half dozen years of personal labor in 2xperiments in the peritoneum, in the study of its anatomy and in microscopical research. The I others have been consulted and credited." Indeed, so ready is the author to give credit to those who have aided him, he has
often, we fear, ascribed to other investigators much that they would not claim as their own.
Dr. Robinson has been anxious to follow the example of the illustrious John Hunter, by distinguishing himself in scientific Studies Of value to medicine. He has pul his whole soul into the work. It is dedicated to his wife and professional associate, Dr.
Lucy Waite. Each chapter is he itations from general
literature which have appealed to the author as particularly lit. Wordsworth and Dryden, Gibbon and Froude, Lord Bacon and Emerson have all served to inspire the author in his work. The chapter on the blood-vessels, for instance, is headed by a quotation from Tennyson's Brook :
" Men may come and men may go, bul I go on forever."
i In the title-page the following is quoted from Schiller :
" To COntro a subject, to he its master, to concentrate upon ii all thai is absolutely necessary, demands, in truth, the powers of a giant, and is more difficult than one would think."
Eager to discover the secrets of the structure of the peritoneum. Dr. Robinson has been led into attempting the mastery of many subjects necessary for this work, histology, histological technique, physiology, pathology, comparative anatomy and the history of medicine. The result has been moat remarkable, as the extracts given below will show 7 .
The book is divided into chapters. "Owing to an attempt to make each chapter as complete as possible," says the author in the preface, " repetitions have been to a certain extent unavoidable." Indeed, the author has been so desirous of expressing in every paragraph andsentencethe totality of his knowledgeof the subject, that repetition might be found on every page were Dr. Robinson capable of expressing his ideas so accurately that they would appear to be quite the same when they are the second time transcribed. The titles are the only clues as to the specific nature of the various ediapters.
The absolute disregard of logical order displayed by the author is the most remarkable thing about the book. This is indicated in the extracts quoted, but to he fully enjoyed must be sought in the original.
" Diligence and accuracy are the only merits which an historical writer may ascribe to himself."— Gibbon, heads the historical sketch with which the book opens. In the first paragraph the time of Erasistratus is given as from 340-280 B. C; in the second paragraph that of Galen is given as 131-201 to 210 A. I). Then the author goes on to say, " Galen must have been in the possession of the writings of Erasistratus. for he noted the fact in regard to the lacteals of kids 150 years after the death of Erasistratus." Further on in the book the following account is given of the origin of the cell doctrine and of its application to the study of the peritoneum. It will not seem strange to state that the organ known as the peritoneum is composed of simple cells, when one recognizes the penetrating power of the microscope and t lie vigorous and far reaching invest i gations of the nineteenth century " (p. 20). After a conn discussion of the work on the cell of Schleiden, Schwann, Midler and Johannes Miller, to each of the last two of whom is given in different parts of the same paragraph the credit of popularizing Schwann's works (Johannes Mueller is evidently meant), the author goes on to say : " U this period of the world appeared the immortal Bichat, whom the French claim founded histology, by employing the discoveries of Schleiden in the plant cells and those of Schwann in the animal cell ll will, perhaps, be
remembered that Bichat died in [802, two years before tin- birth of Schleiden, ami eight years birth of Schwann.
What has confuse. 1 the historian is the fact that I'.icbat called the peritoneum a "cellular membrane," meaning, thereby, one containing areolar connective tissue, which, at his time, was commonly called cellular tissue. For any understanding of oui modern cell concepts, the use of the microscope is necessary.
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[No. 98.
Bichat, owing to the imperfections which existed in the instrument while he lived, put little faith in the value of the microscope as a means of tissue study. Considering the work done of recent years in cytology, it is not uninteresting to read the concluding remarks of Dr. Robinson on this subject : " Finally, the last break in traditional thought was made by the celebrated Brecke, who stated that a nucleus was not necessary to any cell. We now have the final definition of a cell— that is, a mass of protoplasm" (p. 27). Briicke is here probably referred to. Briicke is celebrated for having been the first to suggest definitely ('61) the modern conception of ultra-cellular units ranking between the molecule and the cell.
"The peritoneal membrane," he tells us, "is not dissimilartothe skin, being of about equal area"(p. 14). In the discussion of the various elements composing the peritoneum, he tells us " Perhaps the most typical specimen to observe a connective tissue corpuscle is in the blood-vessel wall of the broad ligament of a gestating turtle." Among elements not before described, is the " elastic tissue cell." "The elastic cell is what gives to the peritoneum its peculiar quality of adaptation to environments. The elastic cell must belong to a certain extent to the endothelia, for which they are capable of extension and contraction to a wide degree. The elastic fibre, composed, of course, of cells, is produced, according to Ranvier, by fusion of small globules. The elastic cell is very abundant ; it is associated with the genital organs and endows them with the wonderful power of changing their conditions and of returning to normal without loss of integrity" (p. 31-32).
Here we have a most curious example of the confusion of ideas of form and function, so characteristic of the author. He has evidently fused an idea of the elasticity of the endothelial cells, and an idea of the existence in the peritoneum of elastic fibres into the vague conception of elastic cells.
We have not space at our disposal to quote here at greater length the author's original descriptions of his anatomical findings.
As to the physiology, "especially will we be surprised to know that the peritoneum of the dead animal will absorb, for many hours after death, exactly similar to that of the living" (p. 35). "The physiology of the peritoneum must be looked for in the inter-endothelial space by its dilatation and contraction. The cover-plates are, perhaps, not engaged much in physiology (sic). The hard, indurated metamorphized protoplasm of the cover-plate aids chiefly in a mechanical way to facilitate motion, when aided by the visceral fluid secreted through the inter-endothelial space. However, the cover-plate doubtless plays a role in osmosis. " The forces which are said to induce peritoneal absorption of fluids may be enumerated as follows: (a) Vital cell forces; (b) stomata ; (c) imbibition ; (d) filtration ; («) intra-abdominal mechanical pressure ; [f) osmosis " (p. 394). " Through ages of evolutionary processes of iufective invasion, the pelvic, appendicular and gall-bladder region (the region of the large intestine) has acquired a physiology which resists the infectious germs in the common regions of peritonitis" (p. 399).
Although the object of the present volume is to deal mainly with the normal histology and physiology of the peritoneum, the author does not hesitate to refer to his extensive clinical and pathological experience when this may aid in making clear his thought. " The peritoneal surface is equal in area to the skin, and when injured by traumatic processes or attacked by disease, shows similar effects, as profound shock, significant vascular disturbances and depressions. A square foot of peritoneum being inflamed shows similar disturbances as the inflammation of a square foot of skin. In the peritoneum the inflammation is not so apt to be circumscribed or limited as it is in the skin, and hence the more danger of sepsis. Sepsis may pass through the peritoneum and leave it, as a bullet leaves a gun-barrel, uninjured" (pp. 256-257). " When foreign bodies (microbes or colored granules) enter the peritoneum the leucocytes swarm out (a) to digest the invader, (6) to surround or imprison the microbe or (c) to sterilize the germ" (p. 289).
Of equal value are the author's researches in the comparative anatomy of the peritoneum. "In this work we have examined the peritoneum of man, horse, dog, sheep, cat, cow, pig, hen, woodpecker, sbypoke, frog, turtle, rabbit, crawfish, dove, guineapig, rat, fish, and embryos of man and some other animals. The material has been ample, but it would have been desirable to examine the peritoneum of monkeys and other animals only obtainable by living in proximity to a menagerie, where one could examine systematically the various genera and species and note the differences. However, material has been sufficient to induce me to believe that the peritoneum of vertebrates is constructed so much alike that it is equally well to select two animals, as the rabbit and the frog (cheap and conveniently obtainable), and carefully interpret the phenomena of structures and function of their peritoneum. The endothelia of the fish are like those of mammals. The crawfish has relatively small-sized endothelia, and they are very compact " (p. 34). " This work has proved that the structure of the peritoneum of vertebrates and mammals is quite similar " (p. 23). "The turtle (amphibia, sic) is one of the best animals to show vast interstitial subperitoneal spaces " (p. 395).
Many of the illustrations taken from the literature, especially those from Kolossow's articles, are well reproduced. The great number of the drawings, made by the author himself, serve to adorn the text. The bibliography is as complete a one as money can buy.
Taking the book as a whole, it reminds us more strongly of the remarkable Syllabus of Ephraim Cutter on Clinical Morphologies, than any other book that we have seen, though -the latter has the additional merit of better order and of much greater condensation. It may be remembered that Cutter names among other things in a long list of objects to be looked for when examining the sputum, the "lumina of blood-vessels," and apologizes for not adding to the list the difficult "morphology of the air." B.
The American Pocket Medical Dictionary. Edited by W. A. Newman Dorland, A. M., M. D. Containing the Pronunciation and Definition of over 26,000 of the terms used in medicine and the kindred sciences, along with over 60 extensive tables. (Philadelphia : W. B. Saunders, 1898.)
This is a handy little volume that, upon examination, seems to fairly fulfill the promise of its title, and to contain a vast amount of information in a very small space. It must be, of necessity, incomplete ; but it is somewhat surprising that it contains so many of the rarer terms used in medicine as it does.
The principal criticism suggested, and this seems a little ungracious when so much is given in so small a compass, is that it might well have contained a few more of the modern synonyms of the nervous system, proposed by Dr. Wilder, than we find in it. These terms have already been employed in medical literature and are likely to be employed again, and their inclusion would have added to the value of the book.
The work is of rather convenient size, and is attractively gotten up.
Hay Fever and its Successful Treatment. By W. C. Hallopeter, A. M., M. D. (Philadelphia ; P. Blakiston, Son & Co., 1898.)
About two-thirds of this little volume is taken up with the history of hay fever, or, what amounts to the same thing, the discussion of its exciting and predisposing causes. Then come descriptions of the symptoms and theories of its pathology, etc., and about ten pages at the end of the work are devoted to the treatment. The author pins his faith upon a systematic course of daily atomizing, and swabbing the nasal and post-nasal mucosa with antiseptic solutions (Dobell's solution, well diluted, is recommended), with such general tonic measures and attention to the diet, habits, etc., as appear indicated in each individual case. Any existing
May.
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abnormal condition of the nasal passages is, of course, to be looked for and remedied if possible. In old cases, when the nerve habi1 of this disease has become established, he advises this treatment for several weeks before the expected onset of the attack, but does not apparently give the duration of the treatment, and i; assumed that in some cases, at least, he would continue it through the whole hay fever period. It is to be inferred that by this method also, and indeed he expressly so states in his remarks on prognosis, he succeeds in time in breaking up the tendency and curing the patients in the majority of cases.
The book is clearly written and can be read comfortably at a sitting. A bibliography is appended that seems fairly full as regards recent American contributions.
Diseases of the Eye. A Hand-book of Ophthalmic Practice, for Students and Practitioners. By G. E. de Schwbinitz, A. M., M. P., Professor of Ophthalmology in the Jefferson Medical College ; Professor of Diseases of the Eye in the Philadelphia Polyclinic ; Ophthalmic Surgeon to the Philadelphia Hospital; Ophthalmologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases. 'With 255 illustrations and two chromo-lithographic plates. Third edition; thoroughly revised. (Philadelphia: W.B. Saunders. 925 Walnut St., 1S»9.)
The fact that the publishers have found it necessary in so short a time to issue another edition of the work of this gifted ophthalmologist is strong evidence that the fruits of his labors are speaking positively and that the " Hand-book " has won its success by supplying, probably more fully than any other American text-book on this subject, the wants of students and practitioners.
The author is to be congratulated upon such a substantial tribute to the value of what he has done for ophthalmology in this country.
The first edition of Dr. de Sehweinitz's book was wide favorably criticised, and it is unnecessary here to review 7 at length a third edition. We note that paragraphs on the follow! I jects have been added to this edition : Favus of the Eyelids, Blepharo-chalasis, Koch- Weeks' Bacillus Conjunctivitis (Acute contagious Conjunctivitis), Pneumococcus Conjunctivitis, Diplo-bacillus Conjunctivitis (subacute Conjunctivitis), Parinaud's Conjunctivitis, Pneumococcus Infection of the Cornea, Mixed (Staphylococi, Streptococci) Infection of the Cornea, Schizomycetal Infection of the Cornea, Oyster Shucker's Keratitis, Fugacious Periodic Episcleritis, Roentgen Rays for detecting foreign bodies in the Vitreous. Retinitis Striata, Hereditary Optic-nerve Atrophy, Eucain and Holocain. While it is evident that the author is no advocate of the so-called mechanical theory of the origin of pannus (page 249), we think that he might have expressed his own views more positively with reference to this interesting process. The belief is gaining ground that pannus is the corneal manifestation of trachoma,— in other words, that it is an invasion of the cornea by the trachomatous process. The fact that the region of the upper lid is the seat of the intensest manifestations of trachoma is, we think, sufficient reason for the usual location of pannus, not because the granules are more marked in this region, but because the specific bacteria are probably there in greater numbers and purity than anywhere else in the conjunctiva, consequently the upper part of the cornea is peculiarly exposed to infection.
W hat the author says about the use of eserine in corneal ulcers (page 278i should be remembered, and we are in accord with him in thinking that atropine in such cases is the better drug,— indeed further than this, it has always seemed to us that eserine o of its use in glaucoma, deserves a very insignificant place in ocular therapeutics, and that so far as its use in corneal ulcers is concerne .', the condition of irritation is far more apt to be heightened than ameliorated.
The author quotes Nettleship (page 308) as saying that episcleritis is more common in men than in women. We have found just the reverse, and so also have Meyer and Stellwag. It would be
interesting to know what the author's own experience has this connection.
It is not uncommon to hear students complaining of t number of remedies and methods of treatment laid down in the text-books out of which a choice must be made. We think that the most effective and, in many respects, the safest teacher of ophthalmology to whom we have ever listened was one who was in the habit of delivering his opinions as axioms, who used \ drugs, and who rarely spent much time upon the rehearsal of other men's theories and suggestions. There is probably no Bcii rich in discarded theories and so hampered with worthless suggestions as medicine, and the text-book which banishes such material from its pages will be apt to leave the most lasting impression upon its readers.
The book which Dr. de Schweinitz has given us, we are gratified to see, bears throughout the mark of personal experience and is unusually free— except when essential— of "what others think." The chapters on diseases of the conjunctiva and iris (Chapters VI and IX) which are supremely important for students and practitioners are admirable, and did the limits of a review permit we might multiply examples of valuable observations and advice. We cannot close without calling attention to the accuracy and suggestiveness of the many illustrations (235), and to prophesy for tins third edition of Dr. de Sehweinitz's book no diminished measure of success. r, l R.
The Care of the Baby. A Manual for Mothersand Nurses. By J. P. Crozer Griffith, M. D. ( W. B: Saunders, Philad, !
Although a manual for mothers and nurses, and not distinctly a work for the use of the practicing physician or one interested in the purely scientific side of the subject, the present volume contains so much excellent material, and is so admirably compiled, that it can be read with great advantage by any one who is interested in the care and proper bringing up of young children.
The book is written for the layman, or, rather for the lay woman, and for that reason the author has made use of a style an i writing which can be easily understood by her, and has avoided the many technical words and phrases which are so characteristic of the usual literature on this subject. This popular style, we think, will not only be of advantage to those for whom the book is especially designed, but has made the text such attractive reading that it is difficult to see how any one can take up the bookbecoming interested in its contents.
The entire subject of the "Care of the Baby" has bei thoroughly taken up, and the author begins with a consideration of some points of importance to be observed by the mother and nurse during the latter part of pregnancy and labor. This is followed by chapters on the baby's growth, the baby's feeding the baby, exercise and training, the baby's nn i rooms, and, finally, the sick baby.
There are so many excellent points throughout the entire volume that, in so short a review, it is almost impossible to give a just criticism. The section on feeding the baby is particularly good, and we are glad to see that the author has taken sui as to the duty of every mother to nurse her own child; and also that, in the consideration of the subject of artificial feeding, be has followed largely the rules laid down by llotch, of Boston. the sections on exercise and training, and the baby's inn rooms the mother will find many valuable bints on the proper hygienic management, care, and moral training of her offspring, the importance of which cannot be possibly overestin
The chapter on the sick baby has been er the
following headings: I. The features of disease. M. The management of sick children, and III. The disorders of chili lirst of these divisions, that on the features of disease has, we think, the disadvantage of not being complete enough to be of value to the physician and probably too full and technical for the
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[No. 98.
mother, whose mind may be filled with so many apparent symptoms that she will be made very miserable by the slightest indisposition on the part of her child. It contrasts markedly with the section on the management of sick children, which deserves nothing but the highest commendation. Under the third section, on the disorders of childhood, a brief account is given of all diseases peculiar to that period of life, and especial stress laid on their nursing and management. The work is completed by a good appendix containing accurate directions and receipts for making various articles of diet and medicines and for giving baths, hot and cold packs, spongings, etc.
Dr. Griffith has avoided criticism by making the statement in his preface that "the chapter on the sick baby is not intended to supplant the physician, but is designed especially for mothers in emergency, where medical aid cannot be quickly obtained "; and in emphasizing the importance of this statement we feel that we are not doing wrong in recommending the book most highly to mothers, nurses, and physicians.
A Text-Book of Obstetrics. By Barton Cooke Hirst, M. D., Professor of Obstetrics in the University of Pennsylvania. (Philadelphia: W. B. Saunders, 925 Walnut St., 1898.) Professor Hirst is so very well known both as a practical obstetrician and a teacher of obstetrics that the title of this volume alone should be more than enough to assure its getting into the hands of the majority of specialists, general practitioners, and students of obstetrics throughout the country. The work is an admirable one in every sense of the word, concisely but comprehensively written, in a style which makes its reading more a matter of entertainment than the perusal of numerous dry facts and dogmatic statements, which is unfortunately so characteristic of many other books on this same subject. Frequent reference in the text has been made to the work of others, both in this country and abroad ; but a laudable effort evidently has been made to avoid mentioning the long lists of names and the tedious recapitulation of literary productions, which, in the opinion of the author, only tend to confuse and to complicate matters for the student. Hence, only the epoch-making articles have been referred to.
The illustrations of the book are, for the most part, excellent, and although some of them cannot be said to come strictly into the category of art, yet they have the advantage of bringing out the points which the author wants them to show. Exceptions to this might be made, however, in the case of a few reproduced photomicrographs, which occur in the section on the placenta. Photomicrographs may be scientifically accurate from the purely optical standpoint, but it is so very rare that one sees the reproduction of one of these pictures showing what is claimed for it, that it is with considerable regret that we see them, however few, in a publication possessing so many other advantages.
The author has divided his subject into the following sections : Pregnancy, Physiology and Management of Labor, and the Puerperium, the Mechanism of Labor, the Pathology of Labor, Pathology of the Puerperium, Obstetric Operations and the Newborn Child.
The section on pregnancy is, in the main, excellent, and offers no points for criticism, except that possibly enough stress has not been put upon the development of the fcetal appendages; we do not mean by this that there should be anything like a full treatise on human embryology in this place ; but the development of the placenta with its relation to the decidua and uterine wall is so important a subject that we think a little more space might have been allotted to it. The diseases of the fcetal appendages, placenta, membranes, decidua, etc., are considered immediately after the question of their development. This is a new departure, for these subjects are, in the majority of text-books, given a section to
themselves, and put later in the volume. Their consideration, however, at this time and place may have distinct advantages, for, clinically, many of these conditions cannot be recognized until after labor, and when put under a separate heading, as is usually done, the student may get the idea that they are desperate diseases to be treated per se.
Too much credit cannot be given to the masterly manner in which the author has presented the subjects of the management of normal labor and the puerperal state, but it is difficult to see whv these subjects should have been taken up before the mechanism of labor has been considered.
The treatise on pelvic contraction and deformity, and labor when complicated by such conditions, is an excellent one in every possible sense of the word. This section appeared a few years ago in the first edition of the American Text-Book of Obstetrics, and to those who are familiar with this work it needs no recommendation.
We are somewhat surprised that the author has not mentioned the importance of a bacteriological diagnosis, by means of the uterine culture, in puerperal infection, nor can we agree with him in thinking that in many cases the repeated, frequent douching of an infected uterus to be of value, for in our experience such cases are by no means the rule. He also advises the routine use of the curette ; and strong (1-2000) bichloride intra-uterine douches ;upon this point we must also confess that we are skeptical. In our opinion the treatment of puerperal infection and the determination as to whether we shall use the curette and douche are directly dependent upon the nature of the infection as indicated by the bacteriological findings in the uterine lochia. Except the above, the section on puerperal infection is good.
Operative obstetrics and the section on the care of the new-born child are both well worked up, though that on the new-born child is short and more might have been said on the subject of infant feeding.
BOOKS RECEIVED.
Nervous and Mental Diseases. By A. Church, M. D., and F. Peterson, M. D. 1S99. 8°. 813 pages. W. B. Saunders, Philadelphia.
On Fractures and Dislocations. By Professor Dr. H. Helferich. Translated from the third edition (1897) by J. Hutchinson, Jun.,
F. R. C. S. 1898. 8°. 162 pages. The New Sydenham Society, London.
The Pathology and Treatment of Sexual Impotence. By Victor
G. Vecki, M. D. From the author's second German edition, revised and rewritten. 1899.. 8°. 291 pages. W. B. Saunders. Philadelphia.
Transactions of the American Pediatric Society. Tenth session, held in Cincinnati, June 1, 2 and 3, 1898. With an index of Vols. I to X. Edited by F. M. Crandall, M. D. Volume X. 189S. 8°. 226 + xii pages. Reprinted from The Archives of Pediatrics.
American Pocket Medical Dictionary. Edited by "W. A. N. Dorland, A. M., M. D. 1S98. 16°. 518 pages. W. B. Saunders, Philadelphia.
Proceedings of the American Medico-Psychological Association at the Fifty-fourth Annual Meeting, held in St. Louis, May 10-13, 1898. Svo. 417 pages. Published by American Medico-Psychological Association.
Annual Addresses of the President of the Medical Society of the District of Columbia. Delivered 1894-95-96-97-98. By Samuel C. Busey, M. D., LL. D. 1899. Svo. 178 pages. Washington, D. C.
The British Ouiana Medical Annual. Tenth year of issue. Edited by W. S. Barnes, M. D., and J. F. S. Fowler, M. B. 1S98. Svo. 52+ xxxiii pages. Baldwin & Co., Georgetown, Demerara.
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may be procured from Messrs. CUSH1NO & CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, SI. 00 a year, maybe addressed to the publishers, THE. JOHNS HOPKINS PIIE**, BALTIMORE ; single copies icill be sent by mail for fifteen cents each.
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL
Vol. X.-No. 99.]
BALTIMORE, JUNE, 1899.
[Price, 15 Cents.
CON"TElTTa.
The Duties and the Dangers of Organization in the Nursing
Profession. By George M. Gould, M. D., 103
A Pin in the Vermiform Appendix. By James F. Mitchell,
M. D., - 10S
The Presence of Typhoid Bacill i in the Urinesof Typhoid Fever
Patients. By Norman B. Gwyn, M. B., 109
A Case of General Infection by the Diplococcus Intracellulars
of Weichselbaum. By N. B. Gwyn, M. B., 112
Correspondence : A Pin in the Appendix Vermiformis. By
D. C. Moriarta, M. D., 113
Proceedings of Societies :
Hospital Medical Society, • - 113
A Demonstration of Intestinal Anastomosis by Means of a New Forceps [Dr. Laplace] ;— A New Operation for Vesicovaginal Fistula [Dr. Kelly] ;— Primary Cancer of the Appendix [Dr. Hurdon] ;— A New Use for Renal Catheters [Dr. Kelly].
Notes on New Books, no
Books Received, - 120
THE DUTIES AND THE DANGERS OF ORGANIZATION IN THE NURSING PROFESSION.
By George M. Gould, M. D., of Philadelphia.
\\ hen I received the kind and honoring invitation of your committee to speak to you to-day I chanced to be chatting with a friend; I read the letter to him and asked him what I should do. His answer was a description of his personal efforts in behalf of nurses and their calling, efforts extending "ver many years, and most unselfishly carried on. The general effect was not encouraging to me. My friend could not see how he had done any good to others while he had sadly wasted his own time and life, to find at last that he had aroused only suspicion and had ended in resultlessness. When I came to ponder the matter I thought I bad found the solution of my friend's pessimism in the fact of the needs, difficulties, and dangers of organization, and that in the swift historic uprising of your large body, these needs, difficulties and dangers musl at first necessarily end in much confusion and disap ment. All human institutions reach a condition of equilibrium through manifold trials, and the trials should not deter us from adding our personal influence as one factor thai . it is true, that may not have influence in determining or hastening progress. If our contribution is in
An address to the Graduating Class of the Johns Hopkins
Hospital School for Nurses, delivered June 2, 1899.
must remember that in science a negative experiment is always of value. We must learn the " No thoroughfares" of life for the first time and before signs have been put op across them, by actually running against them and thus experimentally proving that there can be no advance in that direction. Moreover, some later Baron Ilaussmann of progress may be able to crash the Boulevard of Science straight through the obstruction thai we, in our impotence, deemed insuperable.
I shall say but a passing word as to the need of organization, — and that consists only in the emphasis of its inevitableness.
^ on find yourselves in a a what chaotic condition to-day so
far as pertains either to social, national, international, or professional organizations. But in these times of a th kinds of "combines" and concentralizations, there is no escaping the evolutional fatality of union. I use the word ••fatality" advisedly because I would at least hint by it my feeling thai there are cruelties and dangers of many kinds almost inevitablj connected w i t F 1 any verj thorough organization, — not enough to make us refuse to join, hut surely enough to make us cautious. Majo tyrants and
democracies are as tyrant other type of govern The very forces of cohesion which compel lit to bind themselves to solidarity and unity of purpose have an
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[No. 99.
inherently fatal tendency to crush out the independence of the units and to reduce effort to a huge and ungovernable mechanicalism in which freedom is sacrificed to the attainment of object, and method is scorned for result. Up to now you illustrate none of this, and my warnings may seem very much like foolish croaking. I learn, indeed that your class is an instance of the good of organization, and with all my heart I congratulate you on the fact that the educational ideal has been uppermost, in your three years of work, and that you have not been bribed and whipped to do an atrocious amount of slavish work for the benefit of some heartless institution, which pays you in a sheepskin, the significance of which lies in the knowledge fought for despite jaded bodies and minds. But the point of my croaking is that you compare the lots of many of your sisters in other training schools which demand so many hours a day of toil that the educational aspect is lost sight of, aud is impossible for the weary ones. There you see the evil of organization.
In a calling like yours and, I may add, like mine— that of the nurse and the physician — the need of organization is most evident, and yet there is a strange waywardness, an unaccountable shyness which preserves freedom and individualism by an aloofness that serves at least as an excellent "governor" of the machine, and which keeps it from self-sacrifice to ultramechanicalism. For many years, in season and out of season, I have been pleading for a unitized medical profession and the dire consequences of our disorganization have never been more frightful than to-day. But none would be more prompt than I to delimit sharply the range of action of medical organizations, should they seek to tyrannize over the righteous freedom of the individual member.
In your calling and condition the duties and dangers of organization are greater than in almost any other. Among several reasons for this there is one that 1 trust you will pardon me for alluding to. I may do this the more freely because I have a hundred times urged the greatest liberality toward and encouragement of the desires of women for a wise equality of opportunity with men. But no such generosity ueed blind as to the fact that by nature woman in her uses of social power and organization is a "born tyrant." In the purely personal relation she is grace divine, but whenever put in authority over others, and especially over other women, she usually manages to make herself as hateful and as well hated as human ingenuity will permit. It is, of course, not always so, and thank God for the blessed exceptions! In organizations of women, women must necessarily be officers, and of course majorities must rule. It strikes me therefore in selecting the officials of whatever organizations you may form, you should use your best endeavors effectually to squelch politicians and tyrants and to reward those who show das Ewig-Weibliche, the graciousness of justice, and the justice of graciousness, in the exercise of authority and power. In governing, for Heaven's sake do not learn of us men only our faults while you assiduously forget both our virtue of justice and yours of love. The hardest duty you will have to learn is thai of kindness and justice to minorities. Politically, the most tyrannous of human beings and the most enslaved is the American. Can you not manage it so in your treatment
of those who do not vote with the majority, that you do not march over their rights with the ruthlessness which is fast reducing the terms Democracy and Republicanism to hideous jeer- words of inverted significance?
The roots of institutions and of organizations too frequently spring from the richly manured depths of selfishness. The commercial doctor is despicable enough; do not add the commercial nurse to the terrible burdens under which humanity must stagger !
If the spirit of trades-unionism gets control of your societies and organizations, I hope they will quickly be blown to utter smithereens. The very essence of your life, the heart of your work lies in the personal relation, the wooing back to health and life of bodies and minds hurt in the world's financial warfare. Send metal, even gold, instead of blood, into your hearts, and you may have very perfect corrosion-images of the cardiac structure for the laboratories of the future nursopathologist, but you will then be deservedly dead while the pathologist will be lecturing learnedly upon your fatal disease I beg that you will keep the financial relations to your patients utterly out of the reach of your laws and by-laws and resolutions. This is absolutely a personal matter to be governed by your character, your ability, your whim and fancy, and by your patients' condition in life; I hope you will withdraw from any society that in the least attempts to govern you in this matter. Money you must have to live by, as must all of us. Nursing is your trade ; it must give you the means necessary for carrying on your trade; but if you wash dishes for money alone they will be dirty dishes when they leave your hands. When your work is an art and when it is with the material called life, the rule holds all the more strenuously; the great God of Life will not allow you to have a master above Him !
This brings us logically to a thought concerning the relation of the nurse to the family of her patient. There is oue pretty effective answer to the impertinence of some families which would look upon the nurse solely from the employer's point of view. If you let such upstarts see that the financial motive is the dominant one in your mind and in your organizations, your answer to the one impertinence is only by another: I'm a? good as you! But the killing reply to all false pride is the acted one: I am in truth better than you,-£ that is, I will prove to you that I am more unselfish than you. To those who would positively or negatively treat you as a kind of servant paid for by your demanded wage, you may, as does the true physician, teach a nobler way, both by word and action, that while the laborer is indeed worthy of his hire, the hire is not by any means the worth of the laborer.
Not the least of the dangers to which as an organization your guild will be subject is another kind of subserviency — to the physician and to his profession. To steer clear of the Soy 11 a of a too smart independence and the Chary bdis of a too decided servantship will task the tact of the best of you. In all matters pertaining to therapeutics, of course you must be unflinchingly loyal and eveu obedient to the medical man's orders. And yet you have your own individuality, and. as an organization, yours should be an entity subject to your own corporate ideals and conditions. There, has been much criticism of a tendency, for the existence of which 1 cannot
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JOHNS HOPKINS HOSPITAL BULLETIN.
vouch, for the nurse to supplant the physician. Many nurses are doubtless wiser than many physicians, bul tragedy awaits that nurse who is conscious of the fact, at hast if she even whisper it to the person in her mirror!
I suspect the nurse's greater danger lies in the loves and hates of partisanship. "Her favorite doctor" is liked
her too much, and the one she does nol ia>,. half so bad as she thinks. It may be that she needs herself of all such likes and dislikes and tix herattentio the impersonal aims and needs of her calling. 1 have heard of chief nurses who turned hospitals topsy-turvy and transformed training schools into hothouses of evil and cliqueism by assigning hated nurses to detested physicians, or by worts ing her girls to death, and other such petty savageries. It is Bad,— but possibly the world will be better when you all become head nurses and superintendents !
The business conduct of your organizations will need careful looking after. To be effective, charity itself must become a business. Some wise unwise mot-maker has said that charity is the basest of human passions. Doctors are proverbially bad business men, (though I do not believe they are quite so pitiable as they are represented) but surely despite all their native shrewdness in buying and selling, women will probably commit grievous business errors in conducting their orgai isations. A lawyer-like prudence is demanded nowadays to guide any great movement right. The friend of whom I spoke tells me that a most excellent scheme of an insurai ce or beneficial organization for the benefit of nurses went all to smash after great efforts and partial successes because of — but that is another story ! Would it be rank heresy to suggest a cool, legal, male brain as an adviser even to the wisi best of women? Surely the lied Cross Society has demonstrated with appallingly glaring colors the need of such a head. When an organization handles millions of dollars without accounting for a cent, it is high time that san< and women should pinch themselves to see if they are really awake or not. You need to make every training school in America demand a free three-years' educational course with hours a day devoted to practical work; you need a great journal devoted to your interests and your progress : you imething corresponding to an insurance company adapted to your peculiar conditions ;you need a post-graduate school for superintendents; you need a systematization ol business, how to hud work, how to supply country towi farms with trained nurses, where to secure special training, aad how to find the people wanting that kind of specially trained nurse, etc.; you need nurses' houses or homes, where you can meet each other, and have something like a when you are off duty: you need special loan-libraries; you need laws to protect your calling from the scandal o corrupt, who, for purposes of gain and immorality, don the the nurse: you need a rigid ordering of your relations with the city, the State, and the National Government, and particularly with the military departments; you need an ional and even an international organization, and tor all these and other things you need wise and clear bi raids to govern and to guide you, and to mold you one of the great agencies for alleviating sociologic ill and for
105
bringing about a more lowly civilization than we have .-.. far dreamed id'.
And. with it all. will you bate quackery more than vou do th.' devil himself? Already i he quacks, those pathogenic microbes of the profession of medicine, those verminous para >!' poverty and ignorance, are quoting Trained Nurse So-and so as endorsing such and such a concoction or cot traption for the magical cure of all disease. I bese by all that is holy and of good report, thai you renounce this wickedness! When the official head of a representative American nursing organization officially sprawls over and through the advertising iper as a
limitless endorser of "Greene's Nervura" and of "Electropoise," i1 behooveth yoa to haul up sharp and see that your skirts do nol draggle even in the shallowesl of these filthj puddles!
I wish I could say something of use, and that might encourage you to add your influence in pro\ iding an effi ctive and systematized service of trained nurses f or |)„. | ,,;,,. ,i States Army. Whether in peace or in war i except perhaps in the front during actual battle) the army needs you. The lack of such an organization with its resultant terrible morbidity and mortality among the sick soldiers during the late Cuban skirmish was demonstrated beyond all doubt. The Nurses Associated Alumnae of the United States and I al their second annual meeting in New York about a month ago, took up this important matter, and are earnestly trying to secure the passage of a bill by ( longress to bring aboul I he desired object. In this way only can the' business he ■ atized, the wasted efforts of competing organizations neutralized, and as Oarlyle would say. the work get itself done.* Another good that would follow the establishing id' such systematization would be the disappearing forever and ever, world without end. amen, of the advertising self Beekers, the quack doctors posing as philanthropists, and the silly mob of the eharity-beerazed senr s about with
their incapacities and fatuities like the myriads of Blue-Bottle Plies of The four Little Children, I in a wise
geographic book actually written before the Hispano-American W'ar.i
Women in; 1 d into three classes, the flood for somethings, tie- Good-for-nothings, ami the Unspeakables. There is nothing which fashion h; class. In its heart it likes the third class far more. With
In our imperialism-craze you must suffer for the sins of your
rulers, and must prepare yourselves to meet tin di mand for nurses in tropical countries where in the name of liberty we are shooting down those win. ask for Liberty. The English Colonial
'(■m was formed in 1896 to provide specially trained for England's colonies in all parts of the worl.l. The Lancet makes the wise sui^eBtion to try to train up a school of native Here is a great work for you also.
t "And on the signal being given all the I'.lue-Bottle Flies buzzing at once in a sumptuous and sonorous manner, tbi lions ami mi,' OUnde echoing nil ovej the waters ami
resound he tumultuous top of the transitory titmice,
upon the intervening ami verdant mountains wit. a serene ami sickly suavity only known to the truly virtuous."
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the sharp X-ray eyes of moralized intelligence, look through the walls and roofs of a vast number of modem homes and you will find doless daughters whom their parents are trying to get rid of, and doless wives who, money alone excepted, are trying to get rid of their husbands.
When servant-girls marry, the first thing they demand is a servant-girl. Shop-girls — I beg pardon, I mean Salesladies — must not work after marriage, they must ape the vices of the second class of ladies who scorn their too perfect flatterers. Lazy, cunning, pretty, empty-headed, and empty-hearted, the young ladies of the foolish ill-to-do well-to-do, while nursing their hysterics, and their flaccid muscles, manage to twist ever tighter the silken bands whereby, sitting at the center of the commercial economic slaveries of civilization, they draw into their laps the stolen products of human industry and cruelty, avid to get the most and give the least. But even here are awakening, thank Heaven, an increasing number of women who, like Bore's monk, are looking about them with horror and alarm, and are determining that their lives at least shall not sink into the degradation of spiderhood. Yours is the splendid proving that there are at least ten thousand American women unsatisfied with araneal ethics.
In other reactions from spiderliness we have many sad morbidities, the "New Woman" being not the very least. Perhaps the "New Nurse" is to be another if she is not wise and wary. Institutional medical charity justifies all the bitterness wrapped in the jibe that "charity is the basest of human passions." If it is incapable of turning all the milk of human kindness to bonnyclabber and even to mitey cheese, if it cannot at one stroke and directly pauperize the patient, curse the giver, and debauch the medical profession, it labors hard to do it by indirection ; then if all plans fail, trust some advertising medical college for getting hold of several hundred nurses and making them help the Professors to attain notoriety, students, consultations and iniquitous state appropriations! Organization and Institutionalization may be good things for you, but not unless you are somewhat wiser than serpents and more shy of nets than are many doves.
The most powerful antidote for the evils of malorganization or over-organization, and for the dangers that beset your future career, I believe will be found iu the very nature of your calling and in the goodness of the human heart, which rarely fails to respond sympathetically to the cry for help by the suffering.
And this work of yours is so good, and will only remain so good, if you refuse to allow any institution, or rules, or organizations to come between you and your patient. Your calling is of the best and most truly evolutional (not revolutional) because it continues the kind of occupation and by the same methods you have inherited from Mother Eve, — personal work by personal methods. The giving of love, care, helpfulness, sympathy, nurturing, nursing, — what else has woman done in the world? What better thing could any being do? The female man-imitators are doomed! Is evolution a word, a philosophy, a thinker's game of thought, or is it the most actual (if facts and the most inescapable of biologic laws? There can be no rejection of the law of heredity. The habits of a million ancestors are commands which we seek to break
only at our infinite peril. The fact, of course, is that each of our personalities is the last link of the biologic chain which binds us to the infinite number of our ancestral organisms, and God, if you please, has yet some control of the cosmic process! He will hardly permit the last link to cut itself from the past and set up as an independent existence. The ghosts of all history unite in and direct each individuality. Strength and effectiveness consist in obedience to their orders.
There is one way in which organization can help you, if you, as you must, use it as a tool and not allow it to use you as one. This consists in making it a means whereby you come to your patient. The hospitals have half turned you into servants, — they at least are well supplied with nurses, so we may leave them out of the count. Then the rich have you at command; for we are all the slaves of the plutocrats. Upon them then we may waste no thought or sympathy. The poor, ('. e. the very poor of the cities, can also command you, through the hospitals. But there are far more needy, more numerous, more worthy classes to whom neither you nor your societies, I fear, have hardly given a thought. Among these are the farmers and the people of small villages. These constitute the great majority of the good people of the United States, and they do indeed need your advice, skill, knowledge, and help, quite as much as do any city-folk. Ignorance and disease await you there fully as much as they do in crowded places. It seems to me that one of your primal duties of organization is to secure a machinery of distribution whereby you and your knowledge of hygiene, the knowledge par excellence of the trained nurse, shall be brought to the country and to the village. Genuine missionaries you must be to carry the gospel of nursing to your far-away over-worked and untrained sisters of a million country and village homes, and to the sick ones there.
The reckless poor and the reckless rich of the cities, as we have seen, are well nursed and provided for; they are your masters. But let it no longer be said that " none but a pauper or a millionaire can enjoy the luxury of a nurse." You have yet to organize a machinery to reach the wants of the great and more deserving middle classes. To this class let us add another that still more acutely touches our sympathies, — the proud and self-respecting poor of the cities, who, no worse off financially than the spongers, have as yet not been bribed, corrupted, and herded in the hospitals and almshouses by the professional philanthropists and the selfish charity-mongers. It seems to me that your most pressing duty is to these two sets of people. The clerk, the prudent workman, the little shopkeeper, the working woman, etc., with incomes of from three hundred to one thousand dollars a year — these cannot afford to pay you twenty dollars a week for your services. And if this is so, those with still smaller incomes can afford to pay you but a small percentage of this amount. And for that matter, is your conscientious, skilled, and devoted help for seven days and nights, not really worth far more than twenty dollars? Ilemember too that your profession is fast rilling and like every other, filling to overflowing. Give, then, in advance and in chosen cases, before pitiless competition forces the wage-limit down. But that is a deplorable argument; so let us return to the more gracious, eterually-to
June, 1809.]
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107
be-repeated, eternally forgotten, Noblesse oblige! Wage-pride id a nurse or a physician is the devil in the pulpit; it is Croker and Quay throned and lording it as statesmen. In
this matter I beg and beseech you to think of the duty and the blessing of grace, and the gift of yourselves. Most other giving than self is, in the last analysis, but a fraud and a delusion. Whether you will or will not, you are. if nol copartner of the medical profession, at least a chief assistant ; and the tradition and the practice of the members of that profession is to give on the average at least one-third of their lives to the needy and suffering, without thought of compensation in money. Verily, verily, I say unto you that you must go and do likewise ! If you wish us to love and honor you, that is the surest way to command our honor and love. " By what means? Quickly comes the answer: First, by individually meeting the need of the needy with your service, or a part of it, at a price or at no price, corresponding to the ability to pay ; Secondly, by means of the Visiting, or District, or Instructive Nursing Society. If there is no such society where you live, then establish such a society! Start it with a membership of one ; get others to join ; plan it out, work it out, with the help you can and will find if you do really wish to find it. If the established society works badly, if it is the outcome of dilettantism and unbusiness-like sentimentalism, set to work to put it in better order. All things are possible to the resolved woman !
The Instructive District Nursing Associations of Chicago and of Boston, seem to be models. These and similar have recognized the profound need of teaching the members of the families among which they go how to become good nurses; how by example and precept to care for each other and for themselves, and in a hundred ways to brighten and purify their lives. A nurse is not a good nurse unless she is a good teacher and inspirer of others to emulate her skill, neatness, and unselfishness. In district nursing one has a greater variety of cases, more out-of-door exercise, greater freedom Saturdays and Sundays, etc. One also, I think, does more good and leaves more lasting impressions. There is a commingling of pathos and fun that is altogether blessed, and seeing more life, one's own character is broadened and sweetened. In the choice and method of carrying on an occupation, the purer the purpose and the more earnest the emotion, the closer must one come to actual life. All desire to get away from the blood and muscle and heart-thro of actuality, ends in resultlessness, ennui, md even in doWnight sin. Keep your finger on the pulse of life if you would know how the heart of life is beating. But all who can, must be made to pay for the work and for the teaching. charity is very pleasant but it is very iniquitous. Nay, more, all charity is a curse unless it seeks to do away with the need of charity. You must not let your noble calling degrad vHous relief-doling. i s aristocratic flummery and class-prejudice beginning to imong you ? I hear whispers of the fact, and in some of the literature I have glanced over, especially in that emanating from England, it crops out in amusing innocence. I have found there such recurring expressions as " Nurses of nigh birth," " of lower birth," etc. I'am treadingon dangerous
ground perhaps, inn I trusl that there is sufficienl American ismin you to scorn such long-eared nonsense. Neither in your speech nor in your hearts let such expressions and distinctions arise. If in the sisterhood of nations our country has any function it is surely to show the unchns! ianit \ .' 1 1,,untruth, and the unscience of such prides and such lack oprides. The only professional or scientific significance of such terms I can imagine is the obstetric one:— the high-birthers must have entered the world after the maimer of Caesar! The common fashion of the low-birthers seems preferable! But I hear that the high-birthers make the best nurses, ate better for the instructive and district nursing societies to employ, that they are better received in poor families, that they are not so "stuck up " as regards what is call,.,! menial work, etc. Let every low-birther make it her chiefesl point of pride to disprove this !
Let me read a few sentences from the history of the .Mayflower people by oue of them. They surely were low-birt hers if there ever were any such :
" But that which was most sadd & lamentable was, that in 2. or 3. moneths time halfe of their company dyed, espetialy in .Ian ■ ,V February, being y" depth of winter, and wanting houses & other comforts; being infected with y" scurvie & other diseases, whirl, this long vioage & their inacomoilate condition bad brought upon them ; so as ther dyed some times 2. or 3. of a day, in y" foresaid time ; that of 100. & odd persons, scarce 50. remained. And of these in y<= time of most distres, ther was but 6. or 7. sound persons, who, t'o their great comendations be it spoken, spared no pains,' night nor day, but with abundance of toyle and hazard of their owne health, fetched them woode, made them fires, drest them meat, made their beads, washed their lothsome cloaths, cloathed A uncloathed them ; in a word, did all y bomly & necessarie olliees for them w cL dainty & quesie stomacks cannot endure to hear named; and all this willingly & cherfully, without any giudgingin y e least, shewing herein their true love unto their friends& bretheren. A rare example & worthy to be remembered. Tow of these 7. were M r William Brewster, ther reverend Elder, & Myles Standish, ther Captein & military comander, unto whom my selfe, & many others. were much beholden in our low & sicke condition. And yet the Lord so upheld these persons, as in this generall calamity they were not at all infected either with sicknes, or lamnes. And what I have said of these, I may say of may others who dyed in this generall vissitation, Mothers yet livirig, that whilst they had health, yea, or any strength continuing, they were not wanting to any that had need of them. And I doute not but their recompence is with y" Lord."— The Bradford History of the Plymouth Plantation.
"Servants of the poor" is another term used by orators to graduating nurses and by writers of mock heroics. Itisquite highfalutin— and quite silly ! I trust you will not go to your life-work a victim of any phrase-maker's tricks. Sour firs! duty, like that of all of us, is to see facts; your Becond, is to know facts; your third, is to make facts. If you musi dub yourself with any other titles and think of yourself as anything less or more than a nurse— quite a noble and ennobling name, I think— is not the word friend enough ? A se
you must not he. a patronized or a patronizer 5 [are not be.
Friendship is what is needed by the patientand by his family. The friend maj teach and hi Ip : be
must always sympathize with and love.
You may gather that 1 have a more vivid feeling of the
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[No. 99.
dangers than I have of the benefits of organization, and I shall not very emphatically deny the charge. The shame and infamy of anti-Dreyfus France, the degradation of American politics, the cruelty and selfishness of monopolies, our pension demagogery, such things are ever before our > to warn us against giving up our freedom and our honor to any organization. The hardest of all problems you will have to solve will be to secure the good things that are obtainable only through organization and at the same time to avoid the evils so generally the consequences of organization.
It is only by means of money that one can get that which is worth more than money, and that which money cannot buy. Just so it is only by means of organization that you can obtain that which organization alone cannot give. This means, of course, that you must use the power derived from organization as a mere instrument. There is nothing more harmless, neutral and unorganized than water — the oceans of it that cover so much of the earth. There is nothing more symmetric and beautiful than a snow crystal; but transmute an ocean into a polar ice-cap, and death is its command, even to the wandering splinter of it called an iceberg. Let love ami ethics fail for a day to use, fill and thrill your organizations, and the devil will surely seize upon them and make them serve his purposes.
In the polar regions of our earth the cold is so intense and continuous that ice and snow are always forming and it is
impossible to say what would be the disastrous consequences as regards the temperature, climate and vegetation, even the life of the entire globe, were it not for the existence of one great countervailing fact: Up from the great oceans of the equatorial and temperate regions softly creep the massive currents of warmer water, until approaching the poles, they dip deeply downward beneath the arctic ice-cap, and spreading through these freezing ocean abysses, they bring the melting messages from the far-away sun, from summer days and smiling climes. Your work in life seems wonderfully like all this. However lethal and frightful our civilization, it shines with such splendid and alluring auroras that into it with reckless fatalism press the infatuated discoverers and travelers from lands where labor wearies and deadens, and where love is becoming the legend of idle singers of empty days. Over this white waste of frigid expanse deepen the glaciers of selfishness, and glitter the ice and snow of luxury and of greed. Among the influences that prevent this palsying congelation of death from crawling and crunching through the whole wide world, comes Love! And what love is purer and more vivifying than that of you workers, what more heartening than that which gives itself to win back to health, to hope, and to life, those who have been broken by disease and worn by suffering ? Yours the privilege, cosmic and yet personal, of throbbing beneath and through the bitter chill of an icing civilization the softening warmth of divine beueficence and love!
A PIN IN THE VERMIFORM APPENDIX.
By James F. Mitchell, M. IK, Assistant Resident Surgeon. The John? Hopkins Hospital.
In the Johns Hopkins Hospital Bulletin, Xos. 94, 95, 90, January, February, March, 1899, was published a collection of thirty-five cases in which pins had been found present in the vermiform appendix, or had been the cause of attacks of appendicitis.
Since this publication a most striking case has appeared in the service of Dr. Halsted, and in connection with the subject seems worthy of record.
History.— \X. 0. R. (Surg. No. S898), a colored boy. aged seven years, was admitted to the surgical wards April 20. 1 399, complaining of "cramps in the stomach."
Since he was two years of age he has offered from repeated attacks, with abdominal symptoms referable to the right iliac region and accompanied by pain, tenderness and vomiting. These have recurred at intervals of a few months for the past ars, the duration of the attacks varying from a few days to one or two weeks. The intervals have never been completely free from local symptoms.
No history of the ingestion of a foreign body could be obtained from the' parents.
On April 22 (four days before admission) he complained of feeling badly, and of a feeling of tightness in the abdomen followed in a short time as usual by cramps and vomiting; no chill ; not much apparent fever. Since onset there have
been paroxysms of pain about the navel, the attacks lasting three or four minutes and being so severe as to cause him " to be doubled up." Abdominal tenderness has been marked ; bowels constipiated, one movement yesterday, after medicine ; no pain on micturition, but increased frequency.
Examination on admission (Dr. dishing). " Well developed colored child with slightly pinched fades ; lying mi back with knees drawn up. Pulse compressible, rather poor quality. Tongue has a diffuse, thin, white coating. Respiration costal in type ; abdominal movements slight. Abdomen slightly and symmetrically distended. Child protects right iliac region with hands. Dulness over whole of right iliac region. No dulness in left Hank. Abdominal spasm and rigidity limited to right iliac fossa render palpation difficult. There seems, however, to be a mass in the right iliac fossa. Temperature 103.2°. Leucocytes 11,000.*' He was prepared for immediate operation.
Operation under chloroform anaesthesia (Dr. dishing!.
Laparotomy for appt ndicular abscess. Evani/dion of abscess. Appendectomy. Pathological anastomosis of tip of appendix with ileum, through which a pin passed, producing a perforation in opposite wail of ileum. Closure of two appendicular communications. Drainage.
Under anaesthesia the tumor was found to occupy the
Situation of Absc
Head of pin appendix
Pin pe rforatin g Jle u m
From a sketch at the time oi operation bj Dr. Cashing. Showing the relations of the pin to the appendix, ileum and caecum.
The appendix and pii "'- lhr i ,ln ' " "' ,r ' 1 with faecal matter.
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L09
whole right iliac region from median line to level of umbilicus. Incision was made over the tumor through outer border of rectus muscle, and subsequently enlarged, dividing the epigastric vessels. Theabdominal wall was oedematous. The tumor mass was covered by a layer of infiltrated omentum, which was adherent to anterior parietes. Adhesions were freed and walling-off gauze placed about the mass at po approach to the free cavity.
The tumor mass was attacked and an a itaining
about 15 cc. of bad smelling fiocculent pus evacuated, t loverBlips showed some bacilli, no streptococci.
The appendix was sought for and finally freed from the side of the tumor mass. Xo perforation could be made out in the appendix. The abscess was situated at some distance from it lying between caecum and ileum. The appendicular serosa was not markedly injected. The appendix was found to have a double communication with the bowel : one at its base and another about 5 cm. from its tip, where it anastomosed with the ileum by a free communication opposite to the mesentery.
In the appendix opposite to this communication a hard. round body, the size of a hat-pin head, could be felt, and running from this through the passage into the ileum extended the shaft of a pin, the point of which reached the abscess some distance away.
The rueso-appendix was tied off and the appendix amputated at its base, the stump being inverted into the caecum. The communication with the ileum near the tip was treated in the same way, the opening into the ileum, which was by mucous membrane, being closed by three mattress, Halsted sutures which had been placed before the division.
I lie seal of operation was drained with iodoform gaii
the abdominal wound partly I
The patient took the anaesthetic well and had no bad Symptoms referable to it.
The operation was performed inth andthechild
seemed in good condition at its close, although the pulse was rapid — 134. During the evening be was comfortable and apparently doing well. Frequent salt-solution enemata were
given to relieve thirst. At midnighl he was seen 03 lb-. Baer, the ward surgeon. The pulse was then 116 andof fairvolnme and the patient complained only of slight pain.
At six o'clock next morning the nurse noted no change in his condition ; pulse slower. Happening to pass his bed a few minutes later she noticed his eyes rolled up and glassy, and was unable to rouse him. Attempts to resuscitate him were unavailing and he died at (5.45 a. m.
Autopsy (Dr. MacCallum) showed localized peritonitis, about caecum; broncho-pneumonia of slight extent; great enlargement of thymus; small hemorrhages about thymus and mediastinal tissues: moderate glandular hyperplasia.
No definite assignable cause of death.
Bacteriology. — Bacillus coli communis and an unidentified
bacillus were obtained from the appendix. (Dr. Clopton) cultures from the heart, spleen and thymus gland were sterile. Pneumococcus was gotten from the lungs, and from the kidney ami liver bacillus coli communis. Cultures from the kidney, liver and peritoneal cavity gave an unidentified bacillus, probably proteus Zenkeri.
THE PRESENCE OF TYPHOID BACILLI IX THE URINES OF TYPHOID FEVER PATIENTS.
By Norman B. Gwyx, M. 1'... Assistant Resident Physician Johns Hopkins Hospital.
It has been frequently shown that typhoid bacilli may be presentin the urine of typhoid fever patients and convalescents and that the danger of infection from this source was to be considered ; up to the present time, however, we have completely overlooked this question, and systematic disinfection of the urine has never been perfectly, if at all, carried out. It the presence of these bacteria in the urine were but an occasional happening and associated always, as in somecasi 3, with urinary disturbances marked enough to attract attention and arouse suspicion, no great danger of infection need be feared, but their occurrence in 20 to 30 per cent, of all cases, often in urines presenting slight if any alteration, ma evident that in the spread of typhoid fever the urine plays a far greater part than has heretofore been suspected. Bouchard,
. seems to have been the first to describe this cot his investigations showing bacilli in 50 per cent, of faulty differentiation of the typhoid from colon bacilli may have given this high percentage.
Hueppe, Seitz, Konjajeff, Karlinski, Neumann, Borges, de la Faille give varying results in describing the same condition. Hueppe fiuding bacilli but once in eighteen cases,
Karlinski in twenty-one of forty-four. Blumer, in this hospital, investigating pyuria in typhoid fever found typhoid bacilli twice in sixty cases. Wright, of Netley, obtained typhoid bacilli in the urines of six of sevi n casi 3. P.esson in six of thirty-two. Neumann noted that the bacilli were usually in pure culture and were often so abundant as to render fresh urine turbid, the urine remaining, however, acid in reaction: the evident danger of infection is emphasized by this writer and others.
More recent work has been done by Petmschky, HortonSmith, and Richardson. Petruschky, though obtaining bacilli but three times in fiftj eases, dwells upon the number and persistence of the organisms, calculating 1 bat in one case 170 million of bacilli were present in one cubic centimetre of the urine; persistence ofthe bacilli for three months after convalesces 1 n one case.
Smith found bacilli in three of sevei 1 id confirming
Neumann'- adds that it is often possible b
the organisms in the freshly-voided urine.
Richardson's investigations are perhaps the most important. In two series of thirty-eight and ail I - of typhoid
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fever, bacilli were obtained from the urine in nine and fourteen instances ; the time of appearance, the persistence and disappearance of the bacilli, the coincident condition of the urine, and therapeutical resources for removing the organisms are fully discussed.
The results obtained by the above observers may be thus briefly tabulated:
1. In quite a high percentage, perhaps from twenty to thirty per cent, of all cases of typhoid fever, typhoid bacilli may be present in the urine.
2. When present they are usually in pure culture, often so numerous as to make the freshly- voided urine turbid and may then be detected by a coverslip examination.
3. Appearing generally in the second and third week of illness, the organisms may persist for months or years, probably multiplying in the bladder, the urine being apparently a suitable medium for their growth.
4. Though often showing evidences of cystitis, and marked renal involvement, the urine containing bacilli has usually only the characteristics of an ordinary febrile urine ; the presence of bacilli has no prognostic importance, and their disappearance or persistence without having induced local change is the rule.
5. Lastly, as shown by Richardson, irrigation of the bladder with bichloride of mercury, and the internal administration of urotropin, a compound of ammonia and formaldehyde, seem to be safe methods of removing the bacilli; thirty or sixty grains of the latter quickly' removing all bacilli in six cases.
In discussing the conditions under which bacilli may he present in the urine, it must be mentioned that an association of bacterium with the typhoid roseola was early noted and has been mentioned by most observers. Konjajeff held thatbacteriuria indicated always the presence of the lymphoid nodules in the kidneys; according to Borges some impairment of the renal tissue was always necessary to allow passage of bacteria ; Wright sees in the bacteriuria and roseola clear evidence that typhoid fever is a general infection; Blumer thought that occasionally the bacilli came to the bladder through the anterior rectal wall; Futterer's work showing the almost immediate appearance in the gall-bladder and urine of organisms injected into the portal and jugular veins, together with the fact that many urines containing bacilli show no evidences of renal changes, may be taken as indicating that the typhoid bacilli may appear in urine as a simple excretion from the blood. That typhoid bacilli are present in the blood in practically the same per cent, as in the urine is seen from the work of Kiihnau and others.
Siuce Blumer's investigations in 1895, no bacteriological examinations of typhoid urines have been followed in this hospital. The occurrence of several cases of cystitis in the typhoid cases, and the outbreak of a small house epidemic of typhoid fever drew our attention thereto ; although in the first case examined aspiration of the bladder was resorted to, it was found that cleansing the meatus and anterior urethra with 1-50000 bichloride sufficed to give pure cultures in almost every case, the standard tests for differentiating the typhoid bacillus were employed; if on examination of the fresh speci
men no organisms were to be seen, as much as five to ten cubic centimetres of urine were plated out.
In most of our cases pyuria and signs of bladder irritation were present, the development of which led to the bacteriological examination ; in others the urinary condition aroused no suspicion.
Case I, for the report of which I am indebted to Dr. dishing, was at once the most remarkable and interesting, presenting a chronic cystitis of four years' duration, following shortly after an attack of typhoid fever. Pure cultures of typhoid bacilli were obtained on aspiration of the bladder; the patient left the hospital much relieved by bichloride irrigations. Unfortunately we have not been able to follow the further history of this case. Houston reports a somewhat similar case of three years' duration.
Case II showed the development of an acute cystitis at the end of a relapse six weeks from the onset of his illness ; typhoid bacilli in large numbers were obtained in pure culture from the urine; the pyuria and symptoms cleared up on irrigation (bichloride of mercury 1-50000) and at present, three months after discharge, urine is quite clear and, on culture, negative.
In Case III, an outside case ; marked pyuria in the third week together with the fact that the patient had never given a Widal reaction induced the physician to have cultures taken from the urine ; the examination of the fresh urine showed myriads of motile bacilli, proving on culture to be typhoid ; the urinary condition improved on bichloride irrigation, and three mouths later the urine was clear and showed no bacilli on culture.
Case IV developed pyuria in the fifth week of his illness. Numerous bacilli were present in the fresh urine; the urinary condition cleared up on bichloride irrigation; patient could not be followed after his discharge.
In Case V, the development of a cystitis three mouths after an attack of typhoid fever; typhoid bacilli were presentin abundance in the fresh urine; the condition improved on irrigation and an examination three months later showed the urine clear and no bacilli.
The three next cases we could follow more closely, and could also watch the effect of urotropin on the bacteriuria.
In the first of these a severe nephritis and cystitis had developed in the third week of illness ; the freshly-drawn urine was turbid from presence of pus and innumerable bacilli ; it could be calculated in this case that 500 million typhoid bacilli were excreted in each cubic centimetre of urine.
Urotropin grs. x three times daily was begun and in two days no bacteria were to be seen in the urine, ten colonies of typhoid bacilli however growing on culture from one cubic centimetre ; the nephritis and cystitis improved and after 5 days no bacilli could be cultivated ; cultures remained negative for two weeks and the urine was now free from all traces of nephritis or cystitis. At this time however although patient was still taking urotropin, and after six hundred and thirty grains had been administered, typhoid bacilli reappeared in considerable numbers.
In the second of these three cases pyuria and signs of cystitis developed in the third week of illness, numerous bacilli were to be seen in the turbid fresh urine, which bacilli, though the
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patient had never given a Widal reaction, proved to be (\ phoid organisms: after SO grs. of urotropin grs. v three times daily the bacilli disappeared and pyuria improved, but in spite of the fact that urotropin was continued, both bacilli and pus reappeared on the eleventh day of treatment, or after 165 grs. of urotropin had been given. Treatment was continued, and in six days more bacilli disappeared entirely, and have never reappeared. In this patient it was calculated that 3 million typhoid bacilli per cub. centimetre were being excreted at the time of first examination.
The last of our cases, one of typhoid septicaemia, running an irregular course with intermittent fever and chills, and one in which the Widal reaction was at first uncertain, had nothing in the urine to attract attention, there being but a trace of albumin and slight turbidity. The turbidity was found to be due to innumerable typhoid organisms. TTrotropin grs. x three times daily reduced the number of organisms to one hundred per cub. centimetre in four days. The patient died on following day still showing few bacilli in the bladder. Typhoid bacilli were found everywhere throughout the body at autopsy and in the blood before death ; till the appearance of a marked Widal reaction the urinary condition in this case gave the only reliable indication of the nature of the illness, and it seems reasonable to suggest that in cases where the Widal reaction is delayed a bacteriological examination of the urine should be made, especially since it has been repeatedly shown that with the presence of the typhoid bacillus in the blood, the serum reaction may be long delayed or feeble. This absence of the Widal reaction with presence of bacilli in the urine was noted in two of the foregoing cases. As most of our cases were selected for examination on account of their urinary condition we cannot use them to figure percentages of results. In a later series of seven cases positive results were obtained in the three final cases above recorded, or in 42 per cent, of cases.
We were not able to determine at what time the bacilli appeared in the urine, their persistence for four years in one case and three months in another being seen. In the latter case the urine showed nothing suspicious till the development of cystitis at the end of three months ; this patient during convalescence probably excreted millions of bacilli daily, and might have continued so to do had his urine not come under observation; estimating, as in one of our cases, 500 million bacilli per cubic centimetre of urine, a daily amount of 1000 JC. of urine would contain 500,000 million organisms. According to Petruschky's calculation, such a urine if .1 in ten cubic metres of water or sewage would give 50,000 colouies of bacilli per cubic centimetre of the water. In most of our cases there was pyuria; albumin was present twice in large amount, usually however, only in traces, with albumin generally a few hyaline and granular casts: in one case the urine showed no pus and neither albumin nor casts; complete repair of the affected bladder or kidneys, as far as could be seen from the urine, was the rule, the cystitis of four duration had been untreated and had become very chronic.
The observation of Neumann that in typhoid fever cloudy, freshly-drawn urine acid in reaction could usually be sus
111
pected, was frequently confirmed, the possibility of detecting the bacilli in the fresh specimen as emphasized by Smith, being shown in all but one ease. For the removal of the bacilli, bichloride irrigations (1-50(100) were completely effective in threeof five cases which could be followed; 165 grains of urotropin removed the bacilli in one case; in another reap pearance of the bacilli during its administration was ^^n :,, a third there was immediate reduction of the number ol organisms, the death of the patient preventing further observation.
The infected urine could be readily rendered sterile in half an hour by the addition of an equal volume of 1-10 carbolic acid.
Since typhoid bacilli are present so frequently and in such abundance in the urine, unless a systematic bacteriological examination can be made, all typhoid urines should be disinfected before being thrown out; great care should also he exercised in the handling and routine examination: careful centrifugalization of urine is usually possible and in the absence of cultural tests should be insisted upon ; detection by this means of bacilli in fresh urines, should suggesl the applicable anti-bacterial treatment and proper disinfection of the urine.
Bibliography.
1. Bouchard : Rev. de Med., I, 1881.
2. Hueppe: Fortschrt., der Med., IV, 1886.
3. Seitz: Munich, 1886.
4. Konjajeff: Central, fur Bakt., VI, 1889.
5. Karlinski: Prag. med. Woch., XV, 1890.
6. Neumann : Berlin klin. Woch., 1SS8, 1890.
7. Borges: Wurzbiirg, 1894.
8. Baart de la Faille : Utrecht, 1895.
9. Blunier: Johns Hopkins Hosp. Reports, V, 1895.
10. Wright: Lancet, 1895, II, 196.
11. Besson : Rev. de Med., X VII, L897, 405.
12. Smith: Trans, of Med. & Surg. Soc, London, 1897.
13. Petruschky: Central, fur Bakt., 1898, XXVIII.
11. Richardson: Journal of Experimental Medicine, L898, III, 1899. 15. Houston : Brit. Med. Journal, Jan. 14, 1899.
Discussion.
De. Harris.— We are greatly indebted to Dr. (iwyn for this painstaking work in regard to the very important question of the elimination of typhoid bacilli through the urine. If is remarkable that as long as the organism has been known to be so very ubiquitous more examinations have nol been made heretofore of the urine The necessity for examinations of the urine as a matter of routine in all cases should be stronglj brought forward. I would like to ask Dr. (iwyn some questions regarding bis methods of procedure. Were dilu (ions mad.-, or were plates made straight from the urine: and secondly, was any attempt made to exclude the so-called pseudo-organisms? In some of our analyses we have met with an organism that gave the reaction of the typhoid bai illu in all culture media, except in gelatine which it slowly liquefied, and even there it would he from ten bo fourteen days before
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it would show this difference from the typhoid bacillus. With the dry blood method it always gave a pseudo-reaction, thai is, au imperfect clumping, which in a hasty examination might be mistaken for the action of the typhoid bacillus. I would also like to ask if he has tested the Hiss media, which is said to far surpass Eisner's in respect to efficiency.
As regards the lurking of the organism in the bladder for so many years is it not possible that the patient may be reinfected and a nephritis or cystitis set up by the second invasion without any of the usual symptoms of typhoid? Rearing upon my question there was a case I believe in the hospital last summer in Dr. Young's service where he credited the patient with carrying the organism for seven years, lie isolated the organism and permitted me to go over the work and it was evident that he had obtained the bacillus typhosus ; but he had great doubts as to whether the patient did reallj suffer with cystitis all the years after the primary infection.
As regards the finding of the organism in the urine 1 would like to know^ whether it has been isolated at any time in the absence of albuminuria, cystitis, or symptoms of nephritis. There are cases on record in which the urine has been reported as completely free from evideuces of bladder or renal involvement: practically always, however, slight traces of albumin are found with few casts. These are matters I
think that would make the routine examination of the urine very necessarv. The disease may be spread, especially in country families, through the friends attending the patients and then going about ordinary household duties, neglecting the disinfection of urine and faeces of the patients, and of their own hands.
Dk. (iwvx. — I would say that in many of these cases a dilution was not necessary. As to the tests for differentiating the typhoid bacillus the usual tests, the growth in ordinary media, the motility of the organism, the non-production of indol and especially the serum test, were always used. We have not used Hiss's media this year, but I have used it before with satisfaction. In many cases the urine will show quite large amounts of albumin with casts and pus; evidences of acute nephritis and cystitis. In the majority of cases a mere trace of albumin with few casts and little or no pus will be found. Cases are reported in which the urine has shown absolutely no evidence of changes, either in the kidneys or bladder. All of our eases have shown at least a trace of albumin.
The first case 1 referred to is, 1 think, that which was under Dr. Young's care.
A CASE OF GENERAL INFECTION BY THE DIPLOCOCCUS INTRACELLULARIS OF
WEICHSELBAUM.
By N. B. Gwyn. M. B., Assistant Resident Physician, Johns Hopkins Hospital Baltimore.
The diplococcus intracellularis meningitidis, now recognized as the causative agent of cerebrospinal fever, while found in the meningeal lesions, has not as yet been demonstrated in I he general circulation, nor have we known it to play the pail of a general infective agent. During the past few months there have been admitted to Professor Osier's wards a series of 11 cases of cerebrospinal fever, and in one of these the specific organism has been demonstrated not only in the meningeal lesions, but in the blood and in the inflamed joints. The history of the case is as follows :
Jacob B., aged 24, native of the city, was admitted November 4, 1898, supposed to be suffering from typhoid fever. The patient was a packing-clerk in a manufactory, and had always been strong and veil. There was no history of contact with any cases of meningitis. On Nov. 1, after two or three days of slight indisposition, the patient was seized with severe pain in the back of the neck ; subsequently be had a chill with nausea, vomiting, and fever. On Nov. 2 he was very much worse. He had become delirious and was feverish. He had diarrhoea, and friends noticed that there were "drawing" movements of the hands. There was no retraction of the neck nor any stiffness of the muscles. On Nov. 4 he was seen at home by Dr. Hastings. The temperature was 100.8°; he was delirious ; the limbs were very rigid ; the spleen was palpable, large, and firm. He was ordered to be sent at once to the hospital. The condition on admission was as follows :
He was a well-nourished man ; the cheeks were flushed, the pupils dilated, equal, reacting to light and on accommodation. He was unconscious and could not be roused. The tongue was coated ;
the throat was clear. The rigidity of the muscles of the neck and back was marked, and the body could be lifted with the hand placed under the occiput. The respirations were quick and jerky and there was impaired resonance in the right axilla. The pulse was 140, temperature 100.2°, respirations 44. There were swelling and redness of both elbows, the right wrist, the right knee, and several of the smaller joints of the hands.
On Nov. 5 he remained in much the same condition, with marked rigidity of the neck and of the abdomen. Purpuric spots developed about the feet. The defective resonance over the right lower lobe of the lung increased, and was present also in the left infrascapular region. The affected joints were more swollen and red. Slight external strabismus had developed. A reddish purple mottling of the skin of the body and extremities was noted. The urine contained a large amount of albumin with hyaline and granular casts and red blood corpuscles. The patient gradually failed and died at 10.40 on the morning of the 6th, the temperature having gradually risen to 105.5° before death. The leucocytes increased from 17,000 per cubic mil. on admission, to 37, C00.
Lumbar puncture was performed on November 5, and cultures were taken from the blood and from the swollen and inflamed right knee joint. By the lumbar puncture a rather characteristic sei-opurulent exudate was obtained. In it the characteristic hemispherical diplococcus was found, both in the leucocytes and lying free, isolated, and in small clumps. Numerous large swollen forms were also seen, all of these readily decolorized by Gram's stain. Cultures from the meningeal exudate were made by inoculating the surfaces of Loeffler's blood-serum and glycerin-agar tubes with a large quantity, as much as one-half cc. After 18 hours in the thermostat at 37°C, the blood-serum and glycerin-agar tubes
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showed a characteristic growth — small, isolated colonies from J to 1-J mm. in diameter, on the Loeffler's hlood-serum, raise viscid and white, on the glycerin-agar, rather translucent, the colonies, as seen hy the microscope, heing (inely granular with regular horders. Morphologically the organisms showed typical biscuit-shaped or hemispherically-shaped cocci, arranged as diplococci, staining well with gentian violet, better with methylene blue, and decolorizing readily by the Gram stain.
From the knee joint about 3 cc. of thick, yellow stringy pus was obtained. Hemispherical diplococci, both intracellular and extracellular, were found in it, corresponding in morphology to those found in the meningeal exudate. Of the plates taken from the knee-fluid the blood-serum agar showed numerous small colonies about i mm. in diameter, the agar plates showing also nine or ten smaller ones. The organisms were identical in form and staining reaction with those from the meningeal exudate.
The Blood. 10 cc. were taken. On the blood-serum agar plates three minute but well-marked colonies grew. They presented the typical hemispherical cocci easily decolorized by Gram's stain. In a tube of undiluted blood at the upper end of the clot which had formed, there was a faint, greyish patch, in which were diplococci similarly arranged and of similar staining reaction. In all of the cultures there were found occasional, deeply staining, large, swollen diplococci, and others again which remained pale among the neighboring well-stained organisms.
Further cultures from the knee and blood gave typical growths on Loeffler's serum. The cultural peculiarities of the organisms from the three sources were identical and are as follows : on agar, faint growth of isolated, small colonies ; in litmus-milk, no change noted, no coagulation, no acidification ; growth was proved by reinoculation from the litmus-milk tubes. In bouillon, a slight cloudiness with a stringy precipitate. On potato (slightly acid) there was no visible growth, though the organisms could be demonstrated
on coverslip. In gelatin and glucose-agar there was a very slight, disconnected growth, with no evolution of gas in the latter, doi liquefaction of the former.
Transplants from the undiluted blood tube gave no further growth.
In all the protocols the characteristic diplococcus, decolorizing by Gram, could be demonstrated. The feebleness of the growth of the organism was shown by the number of inoculated tubes which remained sterile, and in the fact that after 48 hours on a culture-medium reinoculation frequently gave negative results. The morphological and cultural qualities show that the organism from the three sources was identical, and was the diplococcus intratellularis meningitidis or meningococcus.
This is believed to be the first instance recorded in which general infection or septicemia has been demonstrated in this disease. In the report on epidemic cerebrospinal meningitis Councilman, Wright, and Mallory make the statement that " so far as can be learned from cultures of blood, liver, spleen, and kidneys, at the post-mortem, septicemia is never produced. The organisms may have been present and not grown out on cultures. They are never found except in connection with the lesions of the disease."
The autopsy on this case showed the organisms only in the characteristic lesions in the brain and cord. No serum-reaction could be demonstrated. Of special interest is the fact of the separation of the organism from the inflamed joints, which throws light upon the cause of the arthritis, not infrequently associated with the acute infections, and particularly with cerebrospinal fever.
CORRESPONDENCE.
A PIN IN THE APPENDIX VERMIFORMIS.
May, 1, 1899. Editor of the Johns Hopkins Bulletin, Baltimore.
Dear Sir. — In your issue of January, February and March, there is an article by Dr. Mitchell on foreign bodies in tbe vermiform appendix with special reference to pointed bodies. I was not aware that these cases were so rare.
I reported such a case to the New York State Medical Journal, Oct. 24, 1896. In this instance the appendix had ulcerated and perforated; nature had taken care of the condi
tion with adhesions. After the appendix was removed we found a pin in the appendix, head down, with the point caught iu the wall. Upon inquiry later the little fellow said he had swallowed a pin about a year previous while playing witli his brother, who tried to take it away from him, and he swallowed it to avoid his brother getting it.
Yours very truly,
D. U. MORIARTA.
511 Broadway, Saratoga Springs, N. V.
PROCEEDINGS OF SOCIETIES.
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY. Monday, February 6, 1899.
A Demonstration of Intestinal Anastomosis by Means of a New Forceps. — Dr. Ernest Laplace.
Mr. President, Ladies and Gentlemen. — Allow me, if you please, the privilege of expressing my great appreciation of the honor conferred upon me iu being allowed to appear before tin; Medical Society of the Johns Hopkins University. It is a compliment, perhaps the greatest one that a member of our
profession can have at present, because of the credit which the Johns Hopkins University has brought to the profession of medicine in America. This is only appreciated by those who have traveled over this country and abroad and learned of I hi standing of your members. Therefore when I realize that I am with yuti fco-nighl 1 find it impossible to express my true feelings and I can only hope that you will think me sincerely thankful for the privilege of being here.
The object of this demon ,-i i : , is to show an instrument
that has for its purpose the facilitating of the operation of
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anastomosis. Without entering into a consideration of the operations done heretofore for this purpose, all of which have their advantages and, of course, some disadvantages. I believe it is agreed among surgeons that the ideal operation is that performed by means of sutures, that operation by which the ends of the gut are sutured together, and it matters little whether we use a continuous, a Lembert or other suture. The suture operation is the operation of to-day, and I believe is destined to be the operation of the future. Any apparatus, any instrument, any contrivance that can facilitate the accomplishment of this operation is, I believe, something to be studied and if it possesses any merit, something to be adopted in such cases as require rapidity. We know that rapidity in operating will diminish the amount of shock, and may, perhaps, remove the last straw that would have broken the camel's back.
Now I have been trying for sometime to devise these simple forceps which consist only of two ordinary haemostatic forceps, bent or curved at the end into a semicircle so that placing the two together they form a complete ring or circle. Then I have a little clasp here which holds them together. ISlow these two rings are to subserve the same purpose that the -Murphy button or the Halsted rubber bags do, or that ,m\ other support within the gut can accomplish and in addition, no matter what stitch you use, these rings can be removed just before the last stitch is placed, without any difficulty.
1 shall now demonstrate the manner of operating on the intestines which we have here. Inasmuch as we have to deal with intestines of different caliber we have devised live different sizes of the forceps as seen here. The smallest is for work on the gall-bladder, and it makes a quick way of operating.
I have here a stomach and a bit of intestine and my purpose shall be to unite the gut to the stomach. Putting them side by side in this way, I take the knife, and, depending upon the size of forceps I wish to use, I make the incision. Here I shall make a large one and use the large caliber forceps. Making the incision directly into the stomach and then one into the gut I have here the two openings, into one of which I introduce one blade of the forceps, and into the other the Becond blade ami they are ready to clasp. Now when this is done the operation is practically over. All I have to do is to put the stitches in.
Now as I go around the gut towards the end of the area to be sutured I reach that part of the operation which is ordinarily difficult to perform. Here, however, my assistant will simply turn the forceps over, reverse the whole thing for me and, as he brings the unsutured portion of the gut before me, what has heretofore been so difficult, is now the easiest part of the operation. Now I have sutured it all around, except where the handle of the instrument projects through the wound and I want to remove it. I first remove the clamp, which allows the two halves of the forceps to fall apart ami then, drawing out one half, not straight, but describing a semicircle, it is easily removed and the other half can be made to follow in the same way. Now all I have to do, is to put in one more stitch and the operation is finished. I shall now make an opening in the stomach, however, and show you that the gut is perfectly patulous.
Now let us do an end to end anastomosis. Wishing to unite the two ends of the gut you first measure for the size of the forceps needed and to make sure that the mesenteric surfaces will meet, you begin by placing the four fixation sutures at the four cardinal points. Now I can introduce the forceps anywhere between these stitches. Dr. Gushing very properly asked me to-day, " What would you do if you had to anastomose guts of different caliber?" The answer to that is that I should invaginate the two ends, and for that purpose I have devised this little instrument for catching the gut at its border, dipping it down into the bowel, stitching it nearly all the way around, and then withdrawing the forceps.
Now gentlemen, this I believe meets all the possible indications for operation upon the intestines. I first presented this method at the last meeting of the American Medical Association in Denver, last June, and on the same day it was published in the Philadelphia Medical Journal. I have since then demonstrated it in Philadelphia and other places. At one of these demonstrations I invited a gentleman in Philadelphia to see the operation, and at its close he told me that he could simplify these forceps, and within 24 hours he exhibited the forceps he had made. His description of them was published last Saturday in the Philadelphia Medical Journal. I wish therefore, in justice to this instrument, to say a few words, not in criticism of his forceps, but simply to show how they were developed. It is natural to suppose that in getting up an instrument of this kind it did not jump into existence all of a sudden ; it had to grow, as it were. The idea was to have a ring that would be removable and it was natural to think first of a ring such as he devised instead of one like this, and in fact, the very first forceps I made had exactly the shape of that published by this gentleman last week ; it was i round and 1 open. He has no claim to originality except that the forceps are simpler than mine. You can easily see that when I remove one-half of these forceps at a time I have to describe a semicircle, and if either branch of the forceps were more than a semicircle I should have to make the turn something more than a semicircle to remove it. In other words, to divide a ring into the two smallest possible portions I must divide it in half, for if one portion be smaller than a half, the other must be larger. This gentleman published his claim 24 hours after he first thought of the idea and he therefore had no opportunity to test it, and he does not know what I learned by experience. I claim therefore that while his may be simpler it does not meet all the requirements of the case and I have given mine the shape you see because it seems to be the simplest possible instrument that will meet every possible emergency. I have in my possession the first forceps I used for this purpose more titan a year and a half ago, which are like those published Saturday, and which I discarded because it was not the required thing.
Dr. Halsted. — I should think that for a lateral anastomosis it promises all that Dr. Laplace claims for it and we shall certainly give it a trial very soon. It is quicker, much quicker, I should say, than the method we employ; I cannot say how many minutes, because, of course, one cannot deter
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mine thai point bj work upon alcoholic specimens. I should think it would be of great assistance especially EorchoL enterostomies. It is possible, of course, to do this op without an instrument, but it is a very difficult one.
I was interested in Dr. Laplace's reply to Dr. Cushing's question as to what he would do in an end to end anastomosis if the guts were of different sizes. If I understood him he would really do a lateral anastomosis, or reduce them to the same caliber. The fact is that iu surgery one very often, perhaps usually, when doing end to end anastomoses, has to deal with intestines of different sizes. I think we have had three or four within the last year where the intestines were of different size and it is a question still,! suppose, as to whether it is not advisable, if possible,— if it is not preferable I mean, l» do an end to end anastomosis rather than a lateral anastomosis, because we do not. as you know, have as good ultimate results in the latter as in the former.
Dr. Laplace.— I believe that in such a ease as Dr. Halsted speaks of, if the gut is distended and thin it can be puckered up in the manner I have hinted at. thai is, having Blade the four cardinal sutures, if the guts do not invert, all you have to do is to insert a temporary suture, pucker the large gut and theu continue as you would with the Murphy button.
A New Operation for Vesicovaginal Fistula.— Dr. Kelly.
I wish to present two interesting eases which I have had during the past year, in which I have been obliged to resort to new procedures in operating upon vesico-vaginal fistulse. You all know very well that the history of the vesico-vaginal fistula; instituted an important era in the history of si at large ; in fact, I imagine the enthusiasm over the work of Jobertof France. Sims of this country, and Simon of Germany, was due to the fact that men recognized that it was the replacing of older surgery by newer and more accurate work. .Now when Sims closed vesico-vaginal fistula' and succeeded as no one had succeeded before, and as Dr. Emmett sui 1 even better afterwards, better perhaps, than any one ever will again, I think men felt that the chapter on this subject had been closed. The truth was, it had only been opened, for the operation was applicable only to the simple cases and it was necessary to devise new operations for the more difficull A\e know that even these operators did not succeed in a large percentage of cases, for in many they were obliged to n
\ the vagina and turning the current of the urine into the rectum.
The great difficulty in handling certain cases of \ vaginal fistulae is due to two facts: in the first place. 1 tula may be a very large one, and in the second place there may be such an amount of scar tissue surrounding the fistula that its resistance prevents bringing together the parts. In cases of large fistula' with entire loss of the base of thi der and with scar tissue in the vagina, the old method of Operating was to open through Douglas' cul-de-sac, turn the uterus so that its fundus was brought out at the vulva, the bladder to the posterior wall of the uterus so thai it was made to do the work of the base of the bladder, finally making
a hole in the fundus through which tin- woman emit,] menstruate. The mosl important recenl finding has been the recognition of the fact thai the Madder tissue itseli often seriously involved in the sear tissue, and that thi der can be drawn .low u and sutured to itself so as to cl< fistula. This is a very important factor in the treatment of certain of these cases thai cannot be treated in the classical way.
A case came' to me from New York this fall, upon which an abdominal hysterectomy had been performed for fibroids. There was a large fistulous opening into the bladder, from the vault of the vagina. It wa< to the peritoneum,
high up in a virginal vagina, had been operated upon several limes and there was an abundance of scar tissue. The edges of the fistula were of such character that I could have no hope of bringing them together and securing union. I opened the abdomen, my intention being to expose the pelvic lion,. dissect the bladder away and sew it up. The patient had a. very large ventral hernia and, unfortunately for the facilityof the operation, was very fat. I opened the abdomen, started on my plan, but in attempting to separate the bladder ii to tear and tore so widely that I saw at once a successful operation as planned would be impossible. I then cut through the top of the bladder to see if I could get at it from the inside, and then freshen and bring the edges together. 1 could not do this and therefore split right, down through the opening tc draw- the parts together, but I found that this procedure could not be carried out satisfactorily and so I followed this jdan wdiich succeeded. The bladder was widely opened, in fact split, in half; 1 found the bladder in front id' the fistula fairly movable and I continued the denudation directly down, starting with the bladder walls above and then, passing some catgut sutures, bringing the wounds together. I had thrown out of use a little of the bladder at the sides of tin- fistula. I then put a drain through the vagina, up into the peritoneum and closed up the hernia., which was an extensive one. The patient made an immediate and perfeci recovery.
It is a new thing to have gone, by means of a suprapubic incision, through the mucosa of the bladder, draw the fistula out and closed it by diminishing the capacity of the bladder.
Case 2. A doctor wrote me from Virginia thai he had a case of vesico-vaginal fistula and wanted to know what was the best way to operate upon it. 1 replied that the besl waj was to send it, up here, as he had had no experience in operating upon such cases. The fistula could not he gotten at from below:! therefore opened the abdomen, separated the bladder, freed the fistula on both side- and brought the edges together with catgut. Theresull was a perfeci recovery.
Dr. Halsted.— In the firsi case, Dr. Kelly, did the portion of the bladde lined the fistula ?
Dr. Keu.y.— No.
Dr. Halsted. -U hal I it ?
Dr. Kelly. — It lay up in the peritoneal cavity pro by a drain.
Dr. Halsted.— Does she still bavea little fistula ?
Dk. Kelly. — .No. it is all closed up.
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Primary (aucer of the Appendix.— Dr. Hurdon.
Dr. Hurdon presented a case of primary cancer of the vermiform appendix.
Dk. Kelly. — This subject is a large one and it would require a volume to go into it completely and do it justice, so that here one can only outline a few of its important relations. I have been paying close attention to the relation of appendical disease to pelvic diseases for a long time, and the records of our department will show the exact condition of the vermiform appendix in every case in which the abdomen has been opened for about 2 years past.
We meet with appendical disease in a great variety of relationships. We may have cancerous disease of the appendix as in this case, where there was an adeno-carcinoma, which showed no relationship to the pelvic disease; then, again, we meet with cases in which the disease is dependent upon the condition of the pelvic organs. I had within 48 hours, last weekfive cases in which I had to remove the appendix.
Where the disease depends upon the pelvic organs, the appendix becomes adherent to the diseased organ, as a uterine fibroid, or an ovarian tumor; these cases we see quite frequently. Then again we meet with a class of cases iu which the appendical disease has followed an operation ; these are more rare, but quite interesting. After a clean operation, as the enucleation of a diseased tube or ovary, the patient within a few months or a year complains of a pain in the right side, etc. The abdomen is opened and the appendix is found adherent to the seat of the former orjeratiou. I have had such a case within the past ten days, where the appendix was pulled out long, and was adherent to the old wound.
It is important to bear this in mind and always inspect the appendix whenever a laparotomy is performed.
This case emphasizes another important fact, that is, how to treat these cases by operation. I believe in the removal of all abnormal appendices, but I do not believe in taking advantage of the opportunity to remove a normal appendix.
Monday, February 20, 1899. New use for Renal Catheters.— Dr. Kelly.
I have a brief but important communication to make regarding the further extension of the use of renal catheters.
It did seem a few months ago that certain discoveries were going to limit the use of them. Dr. Neumann, of Guben found that without catheterizing the ureter he could separate urines and retain them separated in th i bladder, obtaining them later from the bladder by means of tubes. This was done by using an instrument of this kind (drawing) which he calls a urine separator. It is a tube with a solid septum running down the centre and projecting beyond the end of the glass tube ; the form of the catheter is retained by means of a wire cage. Urine running in this side will run down and discharge at the oute'r end, and the same for the other side. If we put this instrument into the female urethra and bladder, press it up against the symphysis and then with the index finger in the vagina, push the floor of the bladder against the instrument, we have the floor of the bladder separated into two loculi so that the urine coming out of the right ureter
runs down on one side, and that from the left on the other, thus giving us a simple method without using the catheter.
This was published in October in the Deutsche medicinische Wochenschrift and not long after Dr. Harris, of Chicago, was able to use a small staff so as to form two little pockets in which the urine was accumulated and was drawn off by the catheter.
These methods did look at first as if they would very much limit the field of the catheter, but a new and very important use for the catheter has recently arisen.
We all know that some of the most obscure cases with which we have to deal are those in which there is vague but distressing pain in the side, especially the right, and one may long be in doubt as to whether the pain is renal, hepatic, intestinal or hysterical. By means of this catheter, I have been able to include or exclude the kidney. When the upper end of the catheter presses upon the pelvis of the kidney the patieut will sometimes tell us that we are touchiug the very point where she had the pain. Further than that, I have been able to produce an attack of artificial renal colic by injecting solution of boracic acid into the kidney through the catheter. Again, a patient who has been suffering from renal colic will often have afterwards an attack of genuine renal colic following the treatment. I have had two cases recently that are interesting in this connection. In one there was a tumor below the ribs on the right side. Some five or six consultants gathered together to determine what it was, some thinking it to be a tumor of the gall-bladder. I injected fluid and the patient at once complained of pain in the back quite as severe as a genuine attack of renal colic, so we were satisfied that the kidney was in its normal position.
In the other case which occurred not long ago, the condition was so exactly like a large floating kidney that I unhesitatingly made that diagnosis, nevertheless I passed in the catheter first and produced an attack of colic. The patient would not locate the colic in the lump we felt in front but insisted that it was in the back. We then made a median incision to examine the opposite kidney. Instead of cutting posteriorly I cut in the median line and found by the hand that the left kidney was normal, but on examining the other side I found an eularged gall-bladder in front of the kidney. The induction of the renal colic and location of the pain by the patient thus gave us our correct diagnosis.
There are then, several valuable uses for ureteral aud renal catheters in the future, especially to diagnose the cause of pain, particularly in the right side.
Every surgeon must think at once of the chances of introducing infection into the higher urinary tract, and I am extremely careful about introducing catheters in a case where there is much infection.
I have never seen an infection conveyed from the lower into the higher urinary tract by catheterization of the ureters.
NOTES ON NEW BOOKS.
An American Text-Book of the Diseases of Children. By American Teachers. Edited by Louis Starr, M. D., assisted by Thompson S. Westcott, M. D. Second edition, revised. (Philadelphia : W. B. Saunders, 1898.)
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The second edition of this work is in many respects an improvement on its predecessor. In any work, by so many authors, a certain overlapping of material and variety of opinion on important subjects is to be expected, and compared with similar works by a single author, must seem lacking in uniformity. Under the competent editorial direction of the present volume, however, this defect has been as far as possible eliminated. The entire subjectmatter has been revised, many articles rewritten, and some new ones introduced.
Among the latter are " Modified Milk and Percentage Milk Mixtures," *' Litha?mia," and a section on " Orthopaedics."
The first of these is brief but sufficiently practical for a working knowledge of the important subject.
" Lithaemia " is well discussed by Dr. B. K. Rachford. The author, however, speaks with a certainty of the role of the alloxuric bodies hardly warranted by our present imperfect knowledge of the pathology of the so-called uric acid diathesis.
In a short section of twenty-seven pages, Dr. J. E. Moore has condensed much of real use to the general practitioner on the subject of orthopaedics. The article is well illustrated and is a decided addition to the volume.
The articles rewritten are "Typhoid Fever," "Rubella," "Chicken Pox," " Tuberculous Meningitis," "Hydrocephalus" and " Scurvy."
Those on "Infant Feeding," "Measles," "Diphtheria" and "Cretinism" have been thoroughly modernized.
In the treatment of diphtheria one expects more emphatic mention of the antitoxin and less of the use of such almost extinct measures as swabbing with hydrogen peroxide, calomel fumigations and the various solvents mentioned.
The articles on hereditary syphilis and diseases of the new-born are very good.
In the light of recent investigation more mention might be made in the articles on cerebrospinal meningitis of the bacillus intracellularis of Weichselbaum. On the whole, however, the book very well fulfills the purpose for which it was compiled — a textbook for students carefully condensed with few omissions, and a reference book sufficiently practical for the general practitioner. The mechanical construction is excellent, and the numerous illustrations instructive. R. A. TJ.
Text-Book of Materia Medica, Therapeutics and Pharmacology. By G. F. Butler. Second edition. (Philadelphia: W. B. Saunders, 189S.)
A review of this book was published in the Bulletin about two years ago. The changes in this edition seem to be very slight, the only notable additions being a table of the " untoward action of drugs" which brings a large amount of very useful information into a small compass and a form convenient for reference.
Annual and Analytical Cyclopaedia of Practical Medicine. By Charles E. de M. Sajous, M. D., and one hundred associate editors assisted by corresponding editors, collaborators and correspondents, Vol. II. (The F. A. Davis Co., Philadelphia, 1898.)
Volume II of the Annual and Analytical Cyclopaedia of Practical Medicine contains some valuable articles on therapeutics; not only are the latest papers and cases cited, but a systematic account of the preparations of the drugs and their physiological action is given ; special emphasis, however, is laid upon the untoward action of the drugs and their use in therapeutics. All the most important drugs between bromide of ethyl and digitalis are discussed in this volume, and in most cases with considerable fullness. Thus 22 pages are given to chloroform and 17 to digitalis. Under chloral the various new combinations of this drug with other hypnotics are described and their relative merits discussed. Under bromine and its preparations consider
able attention is given to bromism and a word of warning raised against the reckless use of these remedies in epilepsy.
Some of the other drugs discussed in this volume are cinchona, caffeine, colchicum, the preparations of copper, curare (which seems to be yielding good results in certain diseases), cubeb, etc. In some cases (notably in the article on digitalis) there is a tendency on the part of the editor to quote freely from the ordinary text-books on the subject rather than from original papers, but on the whole perhaps the most recent views of physicians as to the value and methods of administering the drugs which are discussed in this volume are nowhere better expressed than here.
Essentials of Materia Medica, Therapeutics and Prescription AVriting. By Henry Morris. (Philadelphia: W. B. Saunders, 1898.)
This useful little book has now reached its fifth edition. The general plan is the same as in former editions, the chief alterations being the omission of certain parts and the introduction of some of the newer remedies. Welcome additions are the introduction of the metrical, as well as of the apothecaries' system of weights and measures, and a very carefully prepared index. It seems to us that this little work has more value than some of the numerous manuals which though more pretentious are neither fuller nor more accurate.
Saunders' Pocket Medical Formulary. By W. M. Powell. Fifth edition. (Philadelphia, 1899.)
This book contains over seventeen hundred prescriptions arranged alphabetically according to the diseases to be treated ; these formulae are taken from a great variety of sources — textbooks and manuals of therapeutics, medicine, surgery, obstetrics, the various specialties, from original papers, and not a few from various hospitals. The book also contains tables of doses, incompatibles, antidotes, gargles, inhalations, a " surgical remembrancer," a diet table, obstetrical tables, etc., all arranged in such a way as to make consultation of it as easy as possible. It is remarkable how much information the author has succeeded in getting into so small a book.
The Anatomy of the Central Nervous System of Man and of Vertebrates in General. By Ludwig Edinger. Translated from the Fifth German edition by Winfield S.Hall, Philo Leon Holland and Edward P. Carlton. 445 pages. 25S engravings. (F. A. Davis & Co., Publishers, 1899.)
Great productive activity has characterized of recent years the study of the anatomy of the nervous system. Even the investigator devoting his whole time to the subject finds it almost impossible to keep thoroughly acquainted with the results of others in the same field, and any text-book grows old so fast that revised editions of it appearing only a few years apart, have to be so much rewritten as to seem like new books.
The two authors who have been most successful in seizing from the great mass of ideas and facts annually brought forth materials wherewith to build clear and definite representations of modern neurological conceptions are Van Gehuchten of Louvain, and Kdinger of Frankfort. The former writes mainly from the point of view of outline schemes based upon the neuron concept. Edinger, on the other hand, while utilizing both the neuron doctrine and outline schemes, is concerned rather with the form relations of the anatomical mechanisms of the nervous system. His illustrations have, many of them, the rare merit of suggesting real structures and the third dimension. He has been especially interested in comparative studies. In the preface to the second edition, 'pinted in the fifth, he writes as follows :
" There must be a number of mechanisms which are present in all vertebrates: those which make possible the simplest expressions of the activity of the central nervous system. It is only
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necessary to find that animal or that stage of development in any animal in which this mechanism appears in so simple a form that it may he completely understood. Once any one has anywhere perfectly established the relation of such a mechanism, e. g. a nerve hundle or a cellular structure, he is ahle usually to find it again, even where, through adventitious matter, it is made more or less obscure. The discovery of such fundamental features of brainstructure appears to be the next and most important task of brain morphology. Once we know them it will be easier to understand the complicated mechanisms with which the more highly organized brain performs its function."
The suggestiveness of this point of view, together with a clear and attractive style have rendered Edinger's book deservedly popular. Successive editions have rapidly followed one another, the first, quite a small volume, appearing in 1885, the fifth, greatly enlarged, in 1896. . The book is now divided into three parts.
Part I is introductory. In forty pages a clear, interesting and concise description of the fundamental ideas accepted by most modern neurologists, is given.
Part II gives a review of the embryology and the comparative anatomy of the vertebrate brain. Something over 100 pages are given up to this subject. It is especially attractive because of the author's personal researches in this line.
Part III treats of the structures found in the mammalian, especially in the human brain. To this nearly two-thirds of the book is devoted. Text and illustrations serve to make this intricate subject uncommonly clear.
The translation is for the most part fairly satisfactory. The illustrations have been well reproduced. The book should meet with the welcome reception it so richly deserves. B.
The Pocket Formulary for the Treatment of Disease in Children. By Ludwig Freyberger, M. D., Vienna. M. K. C. P., London. M. R. S. C, England. (Rebman Publishing Co., London, 1S98.)
As is stated in the preface the object of this little book is to give the busy practitioner and senior student of medicine, in a concise and handy form, all of the information which may be required as regards the treatment of diseases of children by drugs.
The greater part of the work is taken up by a list of remedies, arranged in alphabetical order, which are best suited to the treatment of children's diseases, and each drug accurately but briefly described as to its properties, source and dose. The scheme which has been adopted in the discussion of the various remedies is as follows: Properties, under which are mentioned the source, ingredients, methods of preparation, etc.; Use, whether internally or externally, and for what ; Therapeutic dose, in both English and French (metric) system ; Incompatibilities, Correction of Taste, followed by one or more formula which, in the author's opinion, are the most suitable modes of administration of that particular drug. The Appendix contains formula? for sprays, gargles, hypodermic injections, enemata, and suppositories, and the Therapeutic index, which completes the volume, contains an alphabetical list of the diseases of infancy and early childhood, together with the special remedies, which are indicated in each affection.
The book is of a convenient size and of suitable binding to be carried in the pocket, and cannot fail to fulfill the mission for which its author has put it before the profession.
A Text-Book of Mechano-Therapy : by Axel V. Grafsteom, B. Sc. M. D. (Philadelphia: W. B. Saunders, 1899.)
This little book is designed for the use of medical students and trained nurses. There is a strong need for a concise presentation of this subject. In part, it is well supplied here. The book throughout is dignified in tone. Its average merit is more than fair, but its execution is unequal, and many details are open to criticism.
The work treats of both Medical Gymnastics and Massage. A synopsis of the Swedish movement system constitutes the first division. The classification here is especially to be commended, and stands in contrast with much of the discursive and sometimes bewildering literature of this subject. The movements are graphically described, and with or without practical demonstration will serve as a competent guide or reference book to the student. It is to be regretted that in the second division of the book, which relates to Massage, the nomenclature which has become classic through use in the best schools and by the best writers, has been abandoned. Further, while it is of course impossible to master the detail of technique from text-books only, the chapter which treats of it will be little help to the novice. The illustrations of a patient's position while undergoing a kneading of the abdomen is, indeed, distinctly incorrect. At most it can be said that there is furnished here a working basis solely for teachers. The chapter on General Massage is negative, and falls short of the requirements of teachers or scholars. There should be outlined, as was shown to be possible in the Swedish movement system, a definite and recognized system of massage — like that of Dr. S. Weir Mitchell, or of the Swedish or the German school. This outline should include directions as to the position of the patient and of operator; and something of the action of the hand and of its relation to the presented surface.
The concluding chapters, which treat of the application of mechano-therapy to the treatment of disease, aside possibly from the omission of some practical suggestions, are exceptionally thorough, although necessarily and intentionally condensed.
It is interesting to find here included, among the applications of mechano-therapy, the treatment of hernia by taxis, and the kneading of the uterus after labor to maintain contraction — all legitimate forms of massage and very properly so considered.
Foundations of Zoology. By William Keith Brooks. A course of lectures delivered at Columbia University, on the Principles of Science as illustrated by Zoology. (New York: Published for the Columbia University Press by The Mac M Ulan Co., 1899.)
The theme of most of the thirteen lectures is the nature of life which, rather than the physical basis of life, is held to be the foundation of zoology. Huxley's statement that protoplasm is the physical basis of life, leaves out of account the essential idea of fitness as an attribute of such a basis, and the nature and origin of this fitness form the subject of a large part of the discussion.
The author in approving Spencer's definition of life — the continual adjustment of internal to external relations — elaborates it by considering in more detail the nature and effect of external relations or environment, all of which he includes in the term " nurture." " Life is response to the established order of nature." In nature each stimulus which may call forth a response is a sign with a significance, and life is the use of the ability to read and act on these signs— to read the language of the environment.
From this he passes on to show that the nature of the response depends on what, in the experience of the ancestry was found beneficial, and here he develops in an interesting way a reconciliation between the opposing ideas that the development of the complicated nature of an organism with its ability to respond to stimuli is due on the one hand to the inherent potency of the germ, or on the other to response at each stage of its embryological development to external stimuli, by the idea that were we to know exhaustively the nature of the germ, we might see that the responses made to the external stimuli were no more than, from the nature of the germ, we might expect. From all this it is plain that the beneficial result of interpretation and response to stimuli depends on whether the stimuli or signs have the same significance as they had in the time of the ancestors.
These ideas are based on the essential conception that those
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animals which do not respond to stimuli properly, in the end die out, and the ability to respond is continued from one general i< n to another, not by the inheritance of the results of individual adaptation, but by the inheritance of the adaptive mechanism, which is in the end the object of the selective process. Do we exaggerate the importance of the adaptive mechanism when we say that we acquire no nurture except that which our nature provides for? Life is, perhaps in each invidual case, an acquired art. and the adaptive mechanism the inherited thing, and the basis of our expectation of what the organism will do under certain stimuli. In other words, except for the guiding influence of the adaptive mechanism, the influence of nurture will be fortuitous in its effects.
It seems to appear from this that as physical modification is, in the end, dependent on the function demanded for the existence of the species, the adaptation must occur in the active relation to environment, i. e. the response to stimuli, and this response depends on the adaptive mechanism which is inherited and competent as long as the environment is essentially that for which in the ancestors the adaptive mechanism was prepared by selection. As soon as this environment changes selection must again intervene and modify the adaptive mechanism.
The views of the Lamarckians are discussed with no great forbearance, and their absurdity especially brought into relief by the idea that " the probability that haphazard effects of nurture will be injurious is prodigious — even if they are inherited, they will probably not chance to be beneficial independently of selection— the chances' are, therefore, against adaptive modification by the direct action of the environment."
The effects of nurture are to be distinguished from those of ancestry, and here there is introduced an interesting conception of the genealogical tree ; for while most writers speak of a geometrical progression in the increase of ancestors, as we go further and further back, Prof. Brooks shows that these diverging lines, after a little, essentially converge, and that if we go back far enough the plan of ancestry of an individual is rather like a long thread with frayed edges, and from this he deduces the origin of a species from a very few individuals — perhaps one, whence the origin of genera from individuals, and of the metazoan from one protozoan. He pictures the development of the individuals of the bottom fauna from the pelagic in the ancient ocean — their growth in size and powers, so that they subsisted on their ancestors, and traces the peopling of the earth from these. Even to-day the existence of animal life in the sea is still ultimately dependent on the most minute pelagic creatures, which form their food. He gives a most vivid account of the tropical marine fauna, impressing on us the extraordinary absence of vegetable life in those depths, and the 98 of competition in the bottom fauna as compared with the pelagic — the larva; of animals living on the bottom become pelagic in the deeper part of the ocean, because otherwise they would be devoured by their parent's neighbors.
The author goes on to the discussion of the argument from contrivance in creation as opposed to the evolution of beings— the consideration of the teleological explanation of creation. As to the 'eternal paradox about necessity and freedom he, as an humble zoologist, who almitshis accountability, is quite content to leave to Milton's fiends the discussion of ' Fixed fate, free will, foreknowledge absolute.' "
\s to the manner of the creation he attempts a reconciliation of the views of Darwin, Gray and Huxley in the wider teleology of Huxley. He does not wholly agree with Huxley in considering that the argument of Paley that the contrivances of human artificers prove nature a contrivance and the work of an artiti received its death blow in natural selection, but thinks that Paley's argument is rendered inconclusive.
The lectures are concluded with a consideration of the work of Agassiz and that of Berkeley. Agassiz's idea of tin? wider teleology—that " it is not because we find contrivances in nature but
because the order of nature is one consistent and harmonious whole that beholds it to be intended " — was, of course, pre-Dai winian. He considers all the data of natural science as a language in which the creator tells us the story of the creation, and Berkeley too, finds in the signs to which in life we Irani to respond, as stimuli, the parts of a language which we come unconsciously to read and know — in which the creator reveals to us the intentions of the creation.
The book is interesting in its breadth of conception and clearness of style. While in the main a criticism of the theories expressed by previous writers many of the the-, s are based on the profound knowledge of biology of the writer himself, and we cannot but think as we follow his convincing reasoning, that we have be'ore us the latest addition to American classics in scientific literature. \V. G. M.
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 Hermann Weber, M. D., F. R. C. P., and F. Parker Weber, M. D , F. 11. C. P. With a map. {London : Smith, Elder & Co., 1S98).
The title of this enlarged and revised edition of a well known work, states in a general way its scope and purpose. It is. however, more than a mere description of the various European sanatoria ; it includes a general account of the therapeutic uses of water that, in itself, will be found a valuable guide to the many who wish to utilize this agency. The usefulness of health resorts, as the authors claim, is not overstated, and all the accessories to the water cure are fairly stated and valued; it would be a very excellent thing had we some work of this kind on American health resorts.
Two new chapters have been added, besides the general revision ; one on sanatoria other than hydropathic ones, and one on the different diseases in relation to the selection of mineral waters, climatic and other cures, etc. The latter is quite lengthy and full ; the former hardly as much so as it might well have been made, or as the subject deserved. Considering the importance attributed to it at the present time, the space given to sanatoria for consumptives, (only about four pages), is not by any means as much as could well have been devoted to it. There is already quite a growing literature of the subject, and it seems likely to have a larger share of professional and other attention in the near future.
The bibliography at the end of the book, though not exhaustive. is quite lengthy, and will be found useful for reference.
Atlas of Syphilis and the Venereal Diseases, including a brief Treatise on the Pathology and Treatment. By Prof. Dr. Franz Macbk. English translation from the German. Edited by L.
|i. Seventy-one colored plates. Cloth, $3.50
(Philadelphia : W, H. 8ai
This admirable little volume deserves a wide circulation. The full page colored plates, from original water colors, an- remarkably well-executed for a work of such popular price. The wioi) testations of syphilis are taken up in order of their development, and together present a vivid pictorial representation of the disease.
The lesions of chancroid, bubo, condylon re given much less space, but are well shown. The appended treatise, while necessarily brief, is only fairly well done, and the meth treatment are not such as would find favor in this country. To treat syphilis solely by inunctions which are disi I
as soon as a disappearance of the symptoms Occurs, and only resumed in their reappearance, seem- to us irrational, as well as dirty, and tedious. Since the author omits tLe protoidid from

Latest revision as of 11:06, 22 February 2020

Origin, Development And Degeneration Of The Blood vessels Of The Ovary

Clark JG. Origin, development and degeneration of the blood vessels of the ovary. (1899) Johns Hopkins Med. J 10:

Clark JG. The origin, growth and fate of the corpus luteum as observed in the ovary of the pig and man. (1899) Johns Hopkins Hospital Reports, 7:

(From the Anatomical and Qynascological Laboratories of the Johns Hopkins University.)

Preliminary Statement.

Anatomical and physiological study of the vascular system of the ovary and its influence upon the success^ e stales and accompanying phenomena occurring in the evolution of the graafian follicle. also a consideration of the relationship of the corpus luteum to the conservation and to the final cessation of ovulation.

By J. G. Clark, M. D., Late Resident Gynecologist in the Johns Hopkins Hospital, Associate in Gynecology in the Johns

Hopkins University.

Presented before the Johns Hopkins Medical Society, December 19, 1898.


In February, 1896, at the suggestion of Prof. Mall, I began the study of the ovarian circulation, with a view of determining the normal distribution of the arteries and veins of the ovary and their relationship to-each other. At first sight the solution of this question did not appear to present greater difficulties than those encountered in the ordinary course of any research. A study of the sections of a few injected adult ovaries, however, at once demonstrated the futility of attempting to draw any conclusion from this source, for the close crowding

together of the parallel vessels of the medullary portion, and the markedly irregular course of those in the cortex or folliclebearing zone, rendered impossible any accurate observations concerning the relative number and distribution of the veins and arteries, and the exact course followed by each system.

With a view, therefore, of securing ovaries possessing a simpler scheme, a study was made of the lower animals, such as the dog, rabbit, guinea-pig, sheep and pig, but with unsatisfactory results, and only after the injection of the generative organs of a monkey was a suggestive clue secured. Beyond this point, however, it was difficult to proceed, and only after the injection of a very large series of ovaries from individuals, ranging in age from a six-months fetus to a woman many years beyond the menopause, were final conclusions reached.

In the search for this normal scheme through an extensive number of serial sections, various questions directly dependent upon the circulation have presented themselves for solution, which have widened the scope of this work until it has developed into a composite anatomical and physiological research.

Thus the various vital phenomena have been considered which transpire within the follicle from its embryological origin aud progressive growth to the time of its disappearance, either through an obliterative process or through its rupture, organization as a corpus luteum and final retrogression as a corpus fibrosum. In this connection theories have been suggested as to the cause of ovulation, the synchronism of ovulation and menstruation, the mechanism of the rupture of the mature follicle and the final cessation of ovulation, which have been based upon observations made in the study of a very large number of sections.

Soon after beginning this work I was struck not only with the difficulty of arriving at a definite knowledge of the scheme, but also of determining the age at which this scheme may be taken as a standard for comparison.

This is certainly not possible after active ovulation is established for the constant changes in the vascular system induced through the maturation, rupture and organization of the follicle, introduce an element of variability into the circulation of this organ which, so far as I know, occurs in noother.

Failing to reach any satisfactory starting point in the adult, the ovary of a girl approaching puberty was next studied, but with little less success, for it was found that almost as constant variations occur in the follicular circulation before as after the inauguration of ovulation. In the hope of finally reaching a period in the life of the female individual, at which a definite standard for comparison might be found, numerous specimens from children of various ages were injected and closely studied. Finally the ovary of a six-months fetus was obtained, which furnished a definite clew as to the arrangement of the vessels, but as the follicular apparatus was still in process of development a new-born child in which the tunica albuginea was well formed was selected as the standard. Even here the solution of the question was not easy, for in order to trace the ramifications of the vessels from the point of their entrance into the ovary to their ultimate termini the study of the serial sections of many ovaries was necessary.


To briefly summarize the chief points in this investigation I have considered them under a skeleton outline, the main headings of which will conform in general to the arrangement in my forthcoming paper.

In this preliminary statement it is impossible to more than hint at the points which will, in the final publication, be developed through schematic demonstrations and many drawings from injected specimens, and for the same reason references to the numerous researches which have been made upon many of the subjects considered in this report must be omitted.

Embryological Considerations.

The primitive circulation of the Wolffian body will be dwelt, upon, and an explanation of the origin of the spermatic vessels as an independent system from that of the former will be offered. As is well known among embryologists the Wolffian and Miillerian ducts are well formed and the germinal eminence is of considerable size before visible signs of the differentiation of sex become manifest. Up to this point the embryo is said to be of the hermaphroditic or indifferent type.

In retracing the steps of development from the well-formed embryo back to this period some very interesting points concerning the differentiation of sex have been secured. The radical differences existing between the vascular system of the testicle and ovary have furnished a valuable sign for determining the gender of very young embryos, before the external differential marks are established.

The fact to which attention will be directed especially is that the testicular circulation is peripheral, the main artery of which courses over the dorsal .aspect of the organ, giving off in its course rib-like branches which in turn send penetrating brauches into the gland. Between the arteries are situated the collecting veins which unite at the base of the testicle to form the spermatic plexus.

In the ovary this scheme is exactly reversed, the arteries with their accompanying veins entering the center of the organ where they branch tree-like and terminate as a fine capillary anastomosis in the tunica albuginea.

Upon the peculiarities of each circulation the differential signs of sex are based — a visible dorsal vessel always indicating a male; an alabastic-like non-vascular white cortex a female embryo.

In microscopic sections the presence of large peripheral vessels also indicates the male, whereas large central vessels indicate the female sex.

The significance of the vascular arrangements in the testicle and ovary will also be discussed from the physiological standpoint, and to the radical differences existing between them will be ascribed the persistence of the testicular function in the male to old age, and the comparatively early abrogation of ovulation in the female. In the testicle the production of sperma is a more or less fixed and constant function like that of the pancreas, the parotid and other secreting glands, consequently the circulation is not subject to variations and is only interrupted through disease or through senile changes, whereas in the ovary there is a constant variation in the circulation incident to the obliteration or disappearance of follicles and the compensatory production of connective tissue which sooner or


42

later begins to limit the peripheral circulation, and this in turn leads though secondary influences to a final cessation of ovulation.

Incidentally. I may remark that these wide differences in the circulation lead me to the conclusion that the origins of the ovary and testicle are not as generally believed the same, but are totally different, and that the expressions " asexual period," " hermaphroditic stage of the embryo," etc., merely serve to mask our inability to select the differential features of the sexes back of this point.

In view of the fact that the common progenitor of the ovary and testicle is the Wolffian body and that the atrophy or degeneration of the latter is coincident with the active growtli of the former, an endeavor has been made to discover the explanation of this apparent paradox. According to my observations upon this point, it lies in the fact that the vascular system of the sexual glands originates entirely independently of that of the Wolffian body, consequently the synchronous development and degeneration of the two sets of organs is j>ossible.

Having traced the development of the circulation in the ovary and testicle from the so-called asexual period to the point where they have formed systems diametrically opposite in their distribution and ultimate arrangement, the further consideration of the testicle will be dropped and the study of the ovary along the line of its development and progression to its ultimate history will be pursued.

Development of the Graafian Follicle.

My study leads me to reject the Valeutine-Pfluger theory concerning the origin of the follicle and to accept, with some reservation, the general scheme of development as suggested by Waldeyer. So far a3 the genesis of the "egg nests" and their ultimate subdivision into follicles are concerned, I am in accord with the latter investigator, but as to the origin of the so-called follicle epithelium or membrana granulosa, I feel that the evidence in my hands is sufficient to put me at variance with Wahleyer's conception and to incline me towards that of Foulis, who believes that the, germinal epithelium only forms ova and that the lining membrane of the follicle is derived from the connective tissue stroma.

The Ovarian Circulation of the New-13orn Child.

With the completion of the fibrous covering of the ovary (tunica albugiuea) shortly after birth, the vascular system becomes fully developed, and this period, therefore, may be said to represent the typical scheme, for up to this point there has been no derangement of its central or peripheral branches, which will occur later through the progressive development and degeneration of follicles.

The secondary branches of the circulatory tree occupy a comparatively small medullary area, its tertiary branches being given directly off. into the follicle-bearing zone. The follicles are, as as rule, still in their primitive state, only a few of the many thousands as yet showing progressive development.

Even at this early period, however, isolated follicles undergoing progressive and retrogressive changes may be noted. These changes, as I shall hope to show, are closely analogous


to if not identical with those occurring in the ovaries of older children, and in women after ovulation is inaugurated.

The arrangement of the circulation as established at this early age is shown in the following schematic way:


Vasa auastomotica superfieialia


Kami corticalcs ;

Rami folliculares ' Vasa auastomotica follicularia


Venae ovaricae propriae


Arteria ovarica propria


Arteria ovarica



Arteriae parallelae ovarii


Venae ovaricae


As will be seen from this sketch each follicle is provided with a vascular wreath, which is formed by the terminal twigs of the main cortical branches.

The development of this wreath and its final obliteration, along with the disappearance of the corpus luteum, does not affect the general scheme, for it merely represents one small terminal system, the destruction of which, so far as its effect upon the general system is concerned, is like the lopping off of an ultimate twig of the branch of a large tree.

For this reason the changes in the ovarian circulation incident to the progressive development and degeneration of the follicles, even in early womanhood, are local and not general. It is only in the later periods of the ovulating life of the female that the latter effect is noted. Beyond the follicular zone the terminal vessels break up into capillaries which form a fine parallel running anastomosis in the tunica albuginea, which hitherto has not been described.

The extensive anastomosis throughout the ovary renders easy the shifting of the circulation from one set of vessels to another, consequently the destruction of the function of the ovary is almost an impossibility before its final cessation through natural causes.

In the same way the persistence of the function in even tiny bits of the ovary, which are occasionally left after an ovariotomy, may be explained.

In order to conform to the new method of classification, recently decided upon by anatomists, a system of nomenclature has been adopted which is based upon the regional distribution of the vessels.


Jan.-Feb.-March, 1899.]


JOHNS HOPKINS HOSPITAL BULLETIN.


43


Classification of Vessels:


English. Ovarian artery.

" veins.

Extra ovarian or liilus branch ' of artery.

Extra ov., or lulus branches of

veins.

Medullary branches.

Cortical branches. Peripheral anastomosis.

Follicular branches.

" anastomosis.

Uteroovarian anastomosis.


Latin. Arteria ovarica.

Vena? ovarica? or Vv. ovaricse.

Arteria ovarica propria or Aa. ovaricse propria (Ramus I, II, III, IV, V).

Vena- ovarica? propria?.

Rami meiiullares or arteria; parallela? ovarii.

Rami corticales.

Vasa capillaria anastomotica superficialia.

Rami folliculares.

Vasa anastomotica follicularia.

Arteria anastomotica uterina.


In order to follow the progressive changes in the ovary from birth tii the climacteric, specimens from my collection representing the following ages have been selected : child of 2 years, girls of 9 and 12 years, and of 14 years, just after the establishment of ovulation, young woman of 24 years, middle-aged woman of 35 years, woman approaching the menopause at 42 years, and finally an old woman of 66 years, long after the menopause.

In these specimens an endeavor has been made to follow not only the changes incident to the circulatory system, but also the other progressive histological transformations.

The comparison of this ascending series has suggested certain hypotheses concerning the physiology of the ovary, which I trust have been strongly sustained, if not confirmed, by the specimens in hand.

The Ovary of a Child of Two Years.

In the six-months foetus the main branches of the ovarian artery correspond in the general form of their distribution to the fasciculi of a widely spread folding-fan, the divisions between the arteries being filled with primitive follicles.

As the ovary grows in age the vessels with the connective tissue septa?, which form these divisions, change from a gently curved to a perpendicular course, the branches occupying the medullary portion being crowded into parallel lines (arterise parallels ovarii).

In the two year old child, through the development and retrogression of numerous follicles from birth up to this time, the medullary area comprises a much larger portion of the than that noted in the new-born.

As there is no increase in the number of follicles after birth t'je obliteration of each primitive or partially develop naturally decreases the total original number, which results in an increase in the medullary portion of the ovary at the expense of the follicle-bearing or cortical zone.

The law of development in the follicle is from within outward, that is the primitive follicles lying nearest the central circulatory tree arc the first to undergo development.


In the young child the developing follicles instead of moving towards the periphery, as occurs in the girl approaching puberty or in the adult, tend to maintain their primitive position, their enlargement being simply centripetal without any attempt at mobilization.

Having reached a certain stage in their development, a retrogressive change following the degeneration of the ovum is inaugurated; and the original Bite, occupied by the follicle, is replaced by a very minute addition of connective tissue to the stroma of the organ, which naturally builds up through successive accumulations the central area.

Follicles in various stages of development and retrogression are noted in all ages after birth, and according to my observations the same principle involved in the Obliteration of the unruptured follicles before puberty governs the organization of the corpus luteum after ovulation is inaugurated.

Briefly stated the changes consist in an increase in the vascular wreath around the primitive follicle and a coincident or dependent hyperplasia of the membrana propria and an accumulation of liquor folliculi.

What determines the cessation of these progressive changes and the beginning of the retrogressive or obliterative process remains unexplained. The fact remains, however, that with the degeneration of the ovum the liquor folliculi is absorbed and the cavity is filled in with large embryonic connective tissue cells arising from the theca interna.

Through the gradual diminution in the blood supplied by the follicular wreath the excess of connective tissue undergoes hyaline changes and absorption until finally only a mere trace of the new-growth remains.

In this way the size of the ovary is maintained within reasonable bounds. Were each mature or large follicle to be replaced by permanent connective tissue, the ovary would very early in life assume the proportions of a new-growth, which sooner or later would constitute fibromata of no mean dimensions.

Progressive Changes in the Ovary.

In the progressive growth of the ovary the obliterative changes just referred to continue until the follicle-hearing area, reduced by many thousands in its numbers of primitive follicles, becomes a narrow zone compared with its width in the new-born child.

The crowding together in more or less parallel lines of the secondary and tertiary branches of the ovarian vessels is, to return to our antilogy, simulated by the partial closure of the fasciculi of the fan. The increase in the internal resistance through the building np of a denser medullary centre and the closer crowding together of the parallel vessels sooner or later breaks the equilibrium of forces and consequently the follicles no longer maintain their primitive position while enlarging but undergo mobilization towards the tunica albuginea, that being the direction of least resistance.

The actual rupture of the follicle, according to my opinion, is due to the influx of blood during the menstrual cycle into the medullary blood-vessels, which ba a double action, first to push the mature follicle rapidly towards the surface, and


u


JOHNS HOPKINS HOSPITAL BULLETIN


[Nos. 94-95-96,


second, through the increased pressure, to close the parallel running anastomosis in the tunica albuginea, and thus permit a physiological necrosis and rupture of the follicle.

Concerning the question of ovulation and menstruation I shall endeavor to offer further evidence to prove that the rule of synchronism is the normal, and that deviations from this rule are probably due to modifications in the life habit incident to changes in environment and to departures from primitive methods of living and from primitive laws governing sexual congress.

A brief paragraph will be devoted to the processes through which the mature but unruptured follicles undergo obliteration. I shall assume that this is not a pathological condition, but is merely Nature's method of getting rid of a functionless


cavity. The organization of the vascular system of the corpus luteum, followed by its retrogressive changes and final disappearance, will be considered, and I shall take the position that little or nothing of the follicular vascular system remains when the resorption of the corpora fibrosa is complete.

As a conclusion to this study the cessation of ovulation will be ascribed to the gradual impairment of the vascular systems, through first, densification of the ovarian stroma and second, through the retroactive effect of imperfectly removed corpora lutea, which as an end result diminishes the blood-supply to the cortical area to such an extent that the growth of the primitive follicles is retarded and finally completely inhibited. These final retrogressive changes lead up to and constitute the menopause or climaterium.

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