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from the origin of the median branch (C) are in general  
from the origin of the median branch (C) are in general  
longer and freer than those of the other group. The intermediate capillaries are short and the anastomoses frequent
longer and freer than those of the other group. The intermediate capillaries are short and the anastomoses frequent
In addition to the many connections between capillaries of
the same group, the three groups or lobules are intimately
connected with one another by numerous anastomoses. The
capillary connections between the median group and the
right group on one hand (Fig. 2) are of the same frequency,
although unlike those between the left group and the median
group on the other hand (Fig. 3). At one point there is an
anastomosis of all three groups (Fig. 2 d, d', Fig. 3 d, c, c', c").
The number and varied character of these connections show
the impossibility of dividing the capillaries of the glomerulus
completely into distinct groups.
r«:: ftC
Fig 6.
Through the divisions of the main branches of the glomerulus and their subsequent anastomoses, all the capillaries are
concentrated at two distinct levels (Fig. 2 F. G) in the median
plane opposite the afferent vessel. Though the formation of
the efferent vessel is clearly indicated at each level in the
sections, it cannot be said to actually originate until the
last capillary from the glomerulus has united with it (Fig.
3 L).
It is seen that the blood in passing from the afferent to the
efferent vessel has the choice of numerous paths of varying
lengths. The shortest path is that from the right lateral
branch of the afferent vessel just above the central point of
the glomerulus and in the median line (Fig. 3 D, c). Passing
outward from this point to the periphery of the glomerulus,
the paths become longer and more complex. The longest path
is that of the median branch and its subdivisions along the
inferior surface of the glomerulus. It is three times as long
as the shortest path (Figs. 2-3). Yet the shorter course is
zigzag and is composed of the smallest capillaries. As the
course between the afferent and efferent vessel becomes longer
and longer, the capillaries become straighter and larger, thus
correspondingly favoring the blood circulation through them.
The afferent vessel is larger than its branches, especially
just before the point of division ; the branches are larger than
their subdivisions. The efferent vessel is of the same size as
the main branches of the afferent vessel. The increased
diameter of the afferent vessel and its first branches is no
doubt due to the pressure in the artery when the glomerulus
was injected. Excluding this factor it is probable that the
diameter of the various vessels of the glomerulus is the same
from the afferent to the efferent vessel.
The very fine serial sections of the glomerulus not only
served as a basis for the reconstruction of the blood-vessels,
but also enabled me to study more carefully the relation of
Bowman's capsule to the glomerulus. Ludwig* has shown that
the basement membrane of the uriniferous tubules is elastic
and when treated with reagents is very likely to swell. Later
Mallf showed by digesting frozen sections of various organs
with pancreatin that the interstitial tissue and so-called basement membranes resolved themselves into fibrils, showing some
characteristics of yellow elastic tissue, some of white fibrous
tissue and some peculiar to themselves. This set of fibrils
(reticulum) is widely distributed and makes up the main
framework of the kidney. It is these fibrils of reticulum
which form the basement membrane of Bowman's capsule.
As the afferent vessel pierces Bowman's capsule, the reticulum fibrils forming it separate as shown in Figs. 4 and 5.
They are not reflected over the glomerulus, but, at the point
of separation, fibrils arise which penetrate the glomerulus
passing in all directions between its capillaries. The fibrils
are densest at the point these vessels penetrate the capsule and
gradually become less and less numerous as the periphery of
the glomerulus is approached. Up to the present I have not
determined the nature of these fibrils but on account of their
arrangement as well as the connection with them of Bowman's capsule, I do not hesitate to class them with the other
reticulum fibrils.
* Ludwig, Strieker's Handbuch, 1871, p. 495.
fMall, Abhandl. d. K. S. Ges. d. Wiss.,Bd. 17, 1891 ; also Riihle,
His's Arch., 1896, and Disse, Sitzungsber. d. Ges. z. Beford. d. ges.
Naturwiss. Marburg, 1898.
MEDICAL COMMISSION TO THE PHILIPPINES.
It is matter of general belief that scientists in the retirement of the laboratory pursue their abstruse investigations
oblivious of wars, revolutions, and the manifold variations in
the phases of international politics, and it is, perhaps, well on
the whole that there is some basis for the belief. But, as a
matter of fact, it will be found that the trend of scientific
research is, at times, enormously influenced by changes in the
outside world; for with these changes new problems arise
upon the solution of which depends the ultimate success of
national undertakings. No more striking example of such
influence could perhaps be adduced than the extraordinary
attention which is at present being paid to the study of the
causes, prevention and cure of diseases prevalent in the
tropics. While there have been, it is true, notable instances
of medical research prosecuted with brilliant results in
tropical fields in the past, it is only since Northern and Western nations have turned their faces resolutely towards the
South and the East— faces stern in the determination to hold
their own in the fierce international rivalry for conquest and
control of trade — that the importance of the medical problems
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
27
of the hotter regions of the earth has begun to be fully
appreciated, and that organized bauds of skilled investigators
have been seut iuto them to study the diseases to which a large
mass of their fellow countrymen will henceforth be exposed.
The earlier observations on the conditions aud diseases of
tropical countries we owe to missionaries and explorers, men
of roving instincts and venturesome habits, who partly in
self-defense, partly from desire to benefit other travelers or
the natives of the regions traveled through, observed the
sick and examined the methods of treatment in vogue
in those lands. All such studies were necessarily fragmentary
and of a desultory character, but no one with a knowledge of
the subject would speak of them disparagingly, for they
represent the beginnings of an important movement, and
have been, moreover, attended by valuable discoveries, some
of which have proved to be of the greatest benefit to humanity.
It is only necessary to mention the introduction of cinchona
bark into Europe in the 17th century by the Jesuits, who had
seen its beneficial effects in Peru, and to recall the immense
part played by its alkaloid, quinine, in the treatment of
malarial diseases to-day, to realize the significance of at least
one of these discoveries. Millions of lives have been saved,
and whole continents made accessible to civilization, for the
dangers of forest and morass have largely ceased to be prohibitive since the white man has learned to carry quinine in
his blood.
Later, white traders and white soldiers, the natural successors of missionary and explorer, on entering the tropical
regions took with them civil and military physicians, who by
virtue of their better medical and scientific training were able
to describe climatic conditions, investigate the symptomatology
of diseases, and study their causes, nature and treatment far
more accurately than their predecessors had done. Thanks to
their efforts we are already in possession of an analysis of the
more prevalent diseases peculiar to the tropics and of the
many facts of importance concerning etiology, pathology,
prophylaxis aud cure. Among the most fertile in results
has been the work done by Fayrer in India, and in Cochin
China by Calmette, on snake poison ; in Algiers by Laveran,
and in India by Koss, on the malarial infections ; in Bombay
by Vandyke Carter and Obermeier, on relapsing fever; in
China and other countries, by Manson, on filariasis; and in
the West Indies and South America, by Sternberg, Guiteras
and Sanarelli, on yellow fever.
During the last thirty years, however, remarkable advauces
have been made in pathological and especially in bacteriological technique. A large number of scientific investigators in
all civilized countries have been gradually overcoming
difficulties which had hitherto been insurmountable, but
which, by the new methods at their disposal could now be
satisfactorily attacked. The field of medicine has become so
wide and divided into so many departments that one man can
scarcely hope to cover all of them. Much as we have to
thank civil and military physicians in the past for the good
work they have done, we can scarcely ask in the future men
who have to devote a large share of their time to the treatment
of patients and to the performance of executive functions to
undertake the complicated researches necessary for the
isolation of the causative agent in obscure diseases. There
has to be a division of labor and the practical man must be
helped out by individuals who have been especially trained in
particular lines of work, and who can give all their time to
such work. Accordingly, of late, European governments and
educational institutions have been sending into tropical
regions men especially prepared and commissioned to investigate disease, and these men have been relieved of all duties
except those actually connected with their original research.
In this way, Koch and Gaft'ky went to Egypt and India, in
1883, to study Asiatic cholera, an expedition which resulted
in the discovery of the cause of the disease; and at Hong
Kong, in 1894, Yersin isolated the bacillus of bubonic plague.
That such special investigations of the causes of disease
justify the education of specialists and the expenditure of the
time and money required is fully evidenced by the practical
results which have followed. Cholera, now that the spirillum,
the growth and activity of which in human beings cause
the symptoms of the disease, is known aud its habits of life
and mode of dissemination have been studied, can in civilized
countries be absolutely controlled; the disease can no longer
gain a permanent foothold in a city in which modern
methods of sanitation are employed. Plague which swept
away whole populations at a breath in former times need
now scarcely be feared among Western nations; for even if
the hygienic precautions of the end of the century fail to
keep the disease out of the West, the method of preventive
inoculation which has been devised since the discovery of the
causative bacillus will protect those who avail themselves of
this prophylactic measure.
In the light of these facts the authorities of the medical
department of the Johns Hopkins University decided in
March of the present year to send two of their staff, Dr.
Simon Flexner and Dr. Lewellys F. Barker, to the Philippine
Islands, equipped with a complete outfit for the study of
disease by modern clinical and pathological methods. They
were instructed to study the diseases which prevail in the
islands "with the hope not only of making contributions to
the science of medicine, but also of being of service to the
American forces in those islands, to the natives of the country,
and to humanity at large." The expenses of the expedition
were defrayed through the generosity of a few friends of the
University. Two advanced medical students, Mr. Joseph
Marshall Flint, of Chicago and Mr. Frederick P. Gay, of
Boston, went as volunteers and at their own expense to assist
in the medical work at Manila. Mr. John W. Garrett, of
Baltimore, interested in the political relations of the archipelago, made a fifth member of the party.
The voyage out was made by way of Vancouver, Japan and
Hong Kong. Ten days were spent in Japan and the experience there proved of great value as an introduction to the
work in Manila, inasmuch as Japanese scientists have studied
and. indeed, with considerable success, several of the problems
which confront the investigator in the tropics. With
Doctors AoyoBia and Miura in Tokyo, several cases of kakke
were observed, a disease which in the Philippines and in
other countries, is more generally known under the name of
beri beri.
28
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 106.
The researches of the Japanese into the nature of
this malady are among tbe most interesting and important
extant. Dr. Aoyoma, who when investigating plague in
Hong Kong was himself attacked by the disease and for a
considerable period lay in a most precarious condition, showed
no ill effects of the ordeal passed through, but was as active
and enthusiastic as ever in the observation and treatment of
disease. In the laboratory of Dr. Kitasato, the celebrated
bacteriologist, of Tokyo, opportunity was afforded for looking
into the work done by Dr. Shiga, one of the assistants in
that laboratory, on the cause and treatment of dysentery. Dr.
Shiga, who has isolated a bacillus which he regards as the
cause of epidemic dysentery in Japan, has also, by inoculation
of tbe bacillus into animals, prepared a curative serum which
he believes will be of value in the treatment of human cases.
At Hong Kong, the members of the Commission, through
the courtesy of Dr. Lowson, had their first opportunity of
studying cases of bubonic plague, clinically in the wards of
the isolation hospital and pathologically in the dead-house.
The disease is constantly present there, though to a varying
degree, among the Chinese inhabitants, Europeans being
occasionally, though but rarely, attacked. A member of the
Commission, speaking of experience with plague, remarked
upon the curious mental phases passed through on encountering for the first time such a world-dreaded disease. During
the first visit to the morgue in which the dead bodies of
plague patients were kept, great care was taken to come into
no personal contact with the dead, and even draughts of air
leading from the vicinity of the cadavers were avoided. On
the second day, the swellings (or buboes) in the groin, axilla
or neck were palpated, but with some care; and on the third
day, they found themselves making post-mortem examinations
of the internal organs. Though Dr. Aoyoma developed the
disease as a result of his studies, and Dr. Miiller, of Vienna,
died from plague contracted while attending a nurse sick of
it, it is probable that pathologists, provided they take the
necessary precautions to avoid infection, have less to fear than
is ordinarily supposed. If one work much with the disease,
however, he would be very unwise did he not take advantage
of the protection afforded by Haffkine's preventive inoculation.
The members of the Commission arrived in Manila at the
beginning of May and at once, thanks to letters from
Surgeon-General Sternberg, and the courtesy of Colonel
Woodhull, the chief surgeon of the American forces in the
islands, were enabled to begin their work in the military
hospitals there. The majority of the American sick in
Manila are cared for in two large base hospitals known
respectively as the First and Second Reserve Hospitals. In the
former institution, with Major Crosby in control, are some
twelve hundred patients; while in the latter, under the management of Captain (now Major) Keefer, there are perhaps onefourth as many. Assoon as the patients are convalescent, those
who require further building up are sent to the pleasantly
situated Convalescent Hospital on Corregidor Island. This
hospital is situated on the shore snugly nestled beneath the
fort which fired on Admiral Dewey's ships as he entered
Manila Bay. In addition to the military institutions men
tioned, there are numerous "district" and "regimental"
hosjjitals in Manila, Cavite and other places whei^American
troops are stationed. It was a matter of pleasant surprise to
see how efficiently large military hospitals, seven or eight
thousand miles away from home, could be organized for medical and surgical work. Whatever criticisms may have been
made in America with regard to the administration of
military affairs, nothing but praise is to be recorded of the
medical services rendered by Colonel Woodhull and his staff
in the Philippine campaign.
On account of the especial facilities and material obtainable at the First Reserve Hospital, working headquarters were
established there, Lieutenant Strong generously sharing his
laboratory with the newcomers, and in every way possible,
lending his aid to the investigations undertaken. The time
at their disposal being limited, the members of the Commission
decided to choose, out of the many attractive problems which
immediately suggested themselves for investigation, certain
only which seemed to them of the greatest importance and
which could be most advantageously approached. It was
found that among the American soldiers in Manila the two
most fatal diseases in May and June were dysentery and
typhoid fever, while among the natives tuberculosis and beri
beri were common and destructive maladies. The dysenteries
and tropical diseases of the liver met with were made the
object of especial study, and one of the most important results
of the expedition was the isolation by Dr. Flexner, from the
dejecta of patients, of a bacillus which is almost certainly
the cause of the acute dysentery studied. The causative agent
in this disease once known, it is perhaps not too much to hope
that a preventive inoculation may be devised which will
render individuals going to the islands immune from attack.
Such a prophylactic measure if invented would be of incalculable value, since, according to an authoritative text book,
" In the tropics dysentery destroys more lives than cholera,
and it has been more fatal to armies than powder and shot."
Malarial fevers are frequently encountered, and in Manila the
parasites of the tertian and of the asstivo-autumnal variety
are easily demonstrable in the blood of patients suffering from
these types of the infection. The frequency and malignancy
of the cases vary with the locality and with the season of the
year. The deadly calentura perniciosa is much feared in
certain districts, and as soon as the country is settled this
form of malaria should be thoroughly studied. The forests
of the interior of Mindoro and the regions adjacent to the
Rio Agusan in Mindanao are localities of unusual interest in
this connection. The relation of mosquitoes to malaria, so
vital a question at the moment, is one well worthy of attack
in the Malayan archipelago. Not uninteresting too, in passing,
is the statement in certain of the Jesuitical records of
Mindanao that the natives of that island recognized as far
back as two centuries ago a relation between the intermittent
fevers and the prevalence of mosquitoes.
At Cavite, an outbreak of some two hundred cases of beri
beri among the Filipino prisoners yielded wide opportunity
for the study of this disease in its various clinical and pathological aspects. In the same town a large epidemic of what
was probably Dengue fever occurred.
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
29
The cases at the Spanish hospital of Sau Juan de Dios,
those at San Lazarus, the leprosy hospital, and those at the
city asylum, were made accessible to study through the kindness of Major Frank Bourns, of the Provost-Marshal's
department. There were still a few smallpox cases in the city,
though through the strenuous exertions of the officer mentioned, in the way of compulsory vaccination and the establishment of a carabao vaccine farm, this disease, which claimed
so many victims from among the American soldiers at the
beginning of the occupation, was practically stamped out of
Manila. Skin diseases are very prevalent among the natives,
and the affection known as dhobie itch (for the most part a form
of ringworm) attacked large numbers of American soldiers.
A considerable amout of pathological material was collected
by the members of the Commission especially from cases of
beri beri, leprosy and dysentery, and this was brought back to
America for farther study. An abundance of plague material
was similarily collected at Houg Kong. Bubonic plague does
not exist in Manila, and a careful search through the older
records would make it appear that it has never broken out in
the Philippines.
The climate, though trying, owing to the continuous heat
and moisture, is believed to be supportable if Americans will
take certain necessary precautions. As one genial Englishman
who has lived in Manila nineteen years, and who is now in
perfect health, put it, "it is not so much the climate as the
glass bottle which injures people out here." The visit of the
Commission to the islands was made in the hottest season of
the year, and at the beginning of July the onset of the rains
by increasing the moisture in the air added much to the discomfort. However, if one carefully chooses his diet, eschews
iced drinks, clothes himself rationally, avoids excesses both
physical and mental, keeps out of the sun during the hottest
time of the day, sleeps under mosquito-netting and does not
bathe in too cold water, he may live a fairly comfortable life
and will probably enjoy good health. Indeed, some Americans
have found themselves in better health in Manila than at
home, though this is the exception rather than the rule.
Diarrheal troubles are very frequent and are to be combated
by rest, a simple diet and, if necessary, by wearing a woolen
abdominal band. Much has been written about the drinking
of boiled water by the soldiers. Outside Manila this is certainly desirable, but any attempt to persuade soldiers on the
march to follow this custom will probably prove futile. The
Johns Hopkins party walked one afternoon from the Bag
Bag river to San Fernando, and before the end of the journey
found themselves drinking any water available, some of it certainly far from pure.
Early in July, Mr. Garrett left Manila for a trip through
Java, and a few days later the rest of the party returned to
Hong Kong, and began the homeward voyage which was
made by way of Suez and London. Two members of the
Commission spent three weeks in India, and there examined
as fully as possible in the time, the outbreaks of plague
which existed and the plague measures adopted by English
officers in the Indian Empire. In Bombay, Colonel Weir, and
in Poona, Major Keid and Major Windle accompanied them to
the scene of the outbreaks.
The excursion to Poona was most impressive. Traveling
upward for hours through the Western Ghats, the country
was so beautiful and the air so much cooler than at the sea
level, that one could scarcely believe that he was approaching,
in the plain, a little lower down on the other side, the peststricken city of Poona. On arrival at the railway station,
however, the first signs of distress were noticed. Train-loads of
people were fleeing from the place. A drive through the
town to the office of the chief plague authority showed how
rapidly it was being deserted. Many of the streets were
almost empty, shop doors and windows were closed and
barricaded, plague notices were pasted on the wall, a preternatural stillness was everywhere noticeable, the few people
encountered walking quietly along with heads bowed and faces
sorrowful. A visit was made to some houses whence plague
cases had just been reported with the native editor of the
principal Poona newspaper, this gentlemen having volunteered
his services as plague inspector. In a small hovel, scarcely
larger than a ship's cabin, one might find a patient surrounded
by several of his friends awaiting the arrival of the inspector.
The chances for contact contamination were manifold.
At the general plague hospital, there were some eight
hundred cases of the disease under the charge of Major
Windle. He was assisted by eight European nurses and a
number of native helpers. He complained that it was almost
impossible to retain natives as workmen ; even washermen and
grave-diggers could not be employed in sufficient numbers
owing to the fears and prejudices of the people. Cartloads of
the newly attacked were being brought into the hospital at its
entrance, while a body was carried out from the wards every
ten minutes to the morgue at the rear. Those who live in the
West can scarcely appreciate the enormous disadvantages
under which medical men fight plague in India. The people
are ignorant and superstitious, the rigid caste rules prevent
any successful application of modern hygienic measures, and
even the preventive inoculation cannot be utilized to any great
extent, owing to the fact that thus far the bacilli have been
grown in beef-broth, and the natives will not countenance
such a profanation of the sacred animal. Even in death, caste
rules have to be observed, and it was found at the morgue that
partitions had to be put up separating the low-caste Hindoos
from those of high caste, from the Mohammedans and from
the Parsees and Christians. The floor of the morgue presented
a melancholy sight; in one of the rooms no less than thirtytwo bodies lay upon the ground as closely packed as was
possible without actually piling the bodies upon one another.
Mohammedans are buried, and high-caste Hindoos are burned,
but the bodies sometimes accumulate so fast that they cannot
be disposed of by the usual methods. Major Windle stated
thai one day, a short time before, he had burned twenty-four
bodies in one heap. It is absolutely impossible in Poona to
employ occidental methods in the way of segregation or disinfection. The natives prefer to die rather than submit to rules
which are obnoxious to them. It is no uncommon sight to
see a widow, after uttering the death wail, beating her face and
breasts and throwing herself violent ly upon the body of her
dead husband, kissing his face and lips ; it is very strange that
no more than do contract the disease. One left Poona and
30
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 106.
Bombay thankful that in America no such unfavorable
religious and social conditions prevail.
Of the results which have been obtained by the Commission,
it is too early as yet to speak more than generally. The observations made in Manila have to be supplemented and controlled
by further microscopical and bacteriological studies upon the
material collected. It will be some months at least before a
full report can be looked for.
At present the observations concerning the causation of
dysentery, the differentiation of the fevers of the region, the
relative prevalence of typhoid fever and malaria, the studies of
the varieties of the malarial parasite there found, and the
investigations of beri beri, may be specified as among the more
important scientific results of the expedition. The influence
of the scientific spirit and methods, with the demonstration
of their practical utility, so beneficial in medical ceutres at
home and exerted at so early a period in the American regime
in the Philippines, can scarcely fail to be of significance in
the further development of medicine there.
It is probable that in the near future other expeditions will
be undertaken as only a beginning in the study of tropical
medicine has been made. England and Germany are alive to
the importance of such investigations. Major Ross has
recently been sent to East Africa to continue his studies upon
the part played by mosquitoes in the dissemination of malarial
parasites, and Dr. Wright is being sent by the English
government to establish a laboratory in the Malay peninsula
for the study of beri beri. Prof. Koch, of Berlin, has also
lately been sent on another expedition for the investigation of
the malarial fevers in the tropics. Schools of tropical
medicine are being established at various English and continental ports. The time seems ripe also for undertaking
instruction in tropical diseases in America. The establishment of investigating institutes, and of teaching departments
in such cities as San Francisco, New Orleans, Baltimore and
New York, would be an additional safeguard to the country,
since these are ports most likely to be infected. Moreover,
careful instruction as regards diseases peculiar to the tropics
and the special character assumed by other diseases when they
occur in the hotter regions of the earth would seem to be
essentials for those American physicians and surgeons who
comtemplate residence or practice in our tropical possessions.
Lewellys F. Barker.
AN APPARATUS TO AID THE INTRODUCTION OF A CATHETER OR BOUGIE.
By George Walker, M. D., Ohief of Clinic out-door Surgical Department, Johns Hopkins Hospital.
The accompanying cutis an apparatus which I have devised
to facilitate the passage of a filiform bougie, or catheter,
through a strictured urethra. The object of this instrument,
is to distend the canal, and in this way to enlarge the narrowed
portion, so that an instrument will pass through.
Fig. I (a) is a glass cylinder, the shape and size as seen in
the cut, with three openings; the first (J) is to communicate
with the urethra; the second (p) permits the entrance of oil
from cylinder (rri), Fig. Ill ; the third (d) is for the reception
of a rubber stopper carrying a catheter, or bougie; (/) is a
pure rubber stopper, through the center of which is passed a
glass tube (g) ; on the inner end of this is fitted a small ring
of rubber tubing (n). Through this glass tube a catheter (e)
is passed, and the rubber on the end is so fitted that it serves
to prevent an outward flow of oil.
Fig. II is a rubber stopper similar to the above, with a very
small opening through it, just large enough to admit easily
the passage of a filiform bougie (I) and small enough to
prevent the escape of oil or other fluid.
Fig. Ill (wi) is a cylindrical glass vessel for the reception of
oil ; it is to be hung on wall and is connected with Fig. I, by
a rubber tube (t) of varying lengths.
A rather stiff silk catheter should be used, as a soft-rubber
one has a tendency to bend in the glass cylinder. The free
end of the catheter is closed with a clamp or hard-rubber
stopper, so as to prevent the escape of oil.
When required for use the cylinder (d) is filled with oil by
slightly opening the pinch-cock (A) ; the end (b) is then introduced into the meatus and firmly held there by an assistant
so as to prevent the escape of oil between the glass and
urethra. The catheter, or bougie, is then passed into the
urethra as far as the strictured part; the stop-cock (A) is now
Tig. I
Ftg.JT,
opened, and the oil allowed to flow in and distend the urethra.
As this is being done the catheter, or bougie, is firmly pushed
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
31
inward, and as the walls are distended the stricture is slightly
opened, and the instrument allowed to slip through.
Fig. IV. — An Improved Urethral Irrigating Nozzle.
I do not say that by its use all urethra can be made permeable, but certainly filiforms can be thus introduced in a num
ber of cases which without it would be impossible, and
catheters passed through diseased portions that otherwise
would admit only filiform. Thanks are due Dr. Andrew
Stewart, of Washington, for some suggestions.
Fig. IV represents an irrigating nozzle showing an addition
to the ordinary straight nozzle in the form of a disc-shaped
flange attached to the body near the urethral end. The disc
serves to protect one's hands and other objects in the vicinity
from becoming soiled by the fluids which are ejected from the
meatus during irrigation. The straight nozzle which I have
used resembles in some particulars those of Valentine and
Young. The complete nozzle is made in one piece; it is
simple, cleanly, small and entirely efficacious.
SUMMARIES OR TITLES OF PAPERS BY MEMBERS OF THE HOSPITAL AND MEDICAL
SCHOOL STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN.
J. Whitridge Williams, M. D. The Frequency of Contracted
Pelves in the First Thousand Women Delivered in the
Obstetrical Department of the Johns Hopkins Hospital. —
Obstetrics, Vol. I, Nos. 5 and 6, 1899.
1. In our material, the frequency of contracted pelves (13.1 per
cent.) corresponds very closely with the general average of frequency observed in Germany.
2. This is due, in large part, to the presence of a large black
population in Baltimore, 469 out of our 1,000 cases being colored
women.
3. Contracted pelves are 2.77 times more frequent in black than
in white women, and occur in 19.83 per cent, of the former and
7.14 per cent, of the latter.
4. The statistics of Reynolds Crossen and myself indicate that
contracted pelves are observed in about 7 per cent, of the white
women of this country, or about once in every fourteenth case.
5. Contracted pelves, accordingly, occur in our white women
about as frequently as in many German clinics, notably, Rostock,
Breslau and Basel.
6. And occur quite as frequently as in Paris (Pinard and Budin)
and more frequently than in Vienna.
7. As every fourteenth white and every fifth colored woman
possesses a contracted pelvis, the necessity for routine pelvimetry
becomes apparent.
J. Whitridge Williams, M. D. A Case of Spondylolisthesis,
with Description of the Pelvis. — American Journal of Obstetrics, Vol. XL, pp. 145-171 ; also, Transactions of the American
Gynecological Society, Vol. XXIV, pp. 49-79.
In this article is described the pelvis obtained from a woman
dying after a symphyseotomy performed on account of a pelvis
contracted by spondylolisthesis. The smallest antero-posterior
diameter of the pelvis, extending from the lower margin of the
third lumbar vertebra, to the upper and posterior margin of the
symphysis pubis, was 6yi cm.
The article is accompanied by numerous illustrations, which
clearly illustrate the deformity, as well as its mode of production.
This is the first American case which has been described anatomically, though such cases have been observed clinically by Blake,
Lombard, Flint, Gibney and Lovett.
A full list of the literature on the subject accompanies the
article.
J. Whitridge Williams, M. D. Report of the Committee of the
American Gynecological Society, of which Dr. Williams was
Chairman, "On the Value of Antistreptococcic Serum in the
Treatment of Puerperal Infection." — American Journal of
Obstetrics, Vol. XL, pp. 289-314 ; and Transactions of the
American Gynaecological Society, Vol. XXIV, pp. 80-110.
I. A study of the literature shows that 352 cases of puerperal
infection have been treated by many observers, with a mortality
of 20.74 per cent.; where streptococci were positively demonstrated
the mortality was 33 per cent.
II. Marmorek's claim that his antistreptococcic serum will cure
streptococcic puerperal infection, does not appear to be substantiated by the results thus far reported.
III. Experimental work has cast grave doubts upon the
efficiency of antistreptococcic serum in clinical work, by showing
that a serum which is obtained from a given streptococcus may
protect an animal from that organism, but may be absolutely
inefficient against another streptococcus, and that the number of
serums which may be prepared is limited only by the number
of varieties of streptococci which may exist.
IV. Thus far the only definite result of Marmorek's work is the
development of a method by which we can increase the virulence
of certain streptococci to an almost inconceivable extent, so that
one hundred-billionth of a cubic centimeter of a culture will kill a
rabbit.
V. The personal experience of your committee has shown that
the mortality of streptococcus endometritis, if not interfered with,
is something less than 5 per cent., and that such cases tend to
recover if Nature's work is not undone by too energetic local
treatment.
VI. We unhesitatingly condemn curettage and total hysterectomy in streptococcus infections after a full-term delivery, and
attribute a large part of the excessive mortality in the literature
to the former operation.
VII. In puerperal infections a portion of the uterine lochia
should be removed by Di'ulerlein's tube for bacteriological examination, and an intra-uterine douche of four to five liters of sterile
salt solution given just afterward. If the infection be due to
streptococci, the uterus should not be touched again, and the
patient be given very large doses of strychnia and alcohol, if
necessary. If the infection be due to other organisms, repeated
douchings and even curettage may be advisable.
VIII. If the infection extends toward the peritoneal cavity,
32
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 106.
and in gravely septicemic cases, Pryor's method of isolating the
uterus by packing the pelvis with iodoform gauze may be of service.
IX. The experience of one of the members of the committee
with antistreptococcus serum has shown that it has no deleterious
effect upon the patient, and therefore may be tried if desired.
But we find nothing in the clinical or experimental literature or
in our own experience, to indicate that its employment will materially improve the general results in the treatment of streptococcus
puerperal infection.
Howard A. Kelly, M. D. A Curette for Cervical Cancer.—
American Journal of Obstetrics, Vol. XL, 1899, p. 829.
The author has devised a toothed curette for the removal
of redundant carcinomatous material in cases of cancer of the
cervix, which he considers much more satisfactory than any of
the dull or sharp scoops now in use.
The instrument consists of a stout handle 9i cm. long, a shank
114. cm., tapering to an ovoid bowl which is 4 cm. long, 17 mm.
wide, and 14 mm. deep. The essential feature of the curette is
the series of crenations, each 2 mm. in height and 2\ mm. wide at
the base, surmounting its blunt margin. These little teeth are
very effective in removing the diseased tissue. A smaller instrument, two-thirds the size of the one described, is also used.
W. H. Welch, M. D. Thrombosis and Embolism. — Albutt' s System
of Medicine, Vol. VII, 1899.
The Material Needs of Medical Education. — Journal of the
Alumni Association of the College of Physicians and Surge ni,
Vol.11, No. 4, 1900.
PROCEEDINGS OF SOCIETIES.
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
Tuesday, December 5, 1899.
Exhibition of Surgical Cases.— Dr. Mitchell.
We have to show three cases that have been treated in the
service of Dr. Halsted, during the last few months, all traumatic and all having been serious accidents.
Case I. — The first man, a miner, aged 28 years, was admitted
in August with the history of an injury received 32 hours previously, haying been crushed under a mass of falling coal.
He was unable to walk after the accident on account of pain,
though he had perfect motion of the limbs and could stand.
He had retention of urine and was catheterized by a physician
at the mines aud the bladder was later aspirated. The urine
obtained by catheterization contained a great deal of blood,
but the aspirated secretion was clear. He was operated upon
immediately after his entrance to the hospital.
On examination, the patient was unable to stand, the
bladder was much distended, reaching almost to the umbilicus;
the perineum was infiltrated with blood. A perineal incision
was made, opening a cavity beneath the symphysis pubis,
which was filled with blood clots and urine ; the bladder still
remained distended. A catheter passed through the meatus
entered this cavity in the perineum, thus locating one end of
the ruptured urethra. Suprapubic cystotomy was then
done and retrograde catheterization showed the proximal
end of the urethra, which had been ruptured just beneath the
symphysis pubis. The urine in the bladder was perfectly
clear. There was a fracture of the ascending and descending
ramus of the left pubic bone, and a separation of the symphysis
pubis. By attaching a piece of silk to a soft-rubber catheter,
we were able to pass it through the entire course of the
urethra. The urethra was not sutured because of the wide
separation. A Bloodgood suprapubic tube was fixed in the
bladder, and the perineal wound packed with gauze. The
patient did very well. The bladder could be irrigated through
the catheter and there was no trouble from infection. The
catheter was allowed to stay in until September, when it was
removed because blocked with salts, and a new one introduced.
This was finally removed, nearly two months after the
operation, but the urethra still opened in the perineum. On
October 23rd, the suprapubic tube was removed and the
wound allowed to close, and from that time he has been
voiding partly through the meatus and partly from the perineal wound, the latter having closed only within the last few
days. The urethra has been dilated from time to time and a
number 27 sound can be introduced with ease. He walks
without evidence of trouble. The pubis is evidently firmly
united.
Uase II. — This is a case of recovery after very great shock.
The man was admitted ten days ago, about 6.30 p. m., in very
bad condition and with the history of an injury to his right
arm a short time before. He was working in a guano factory
wheu his arm was caught in the machinery, and the forearm
and hand very badly crushed. The skin of the arm was torn
from the shoulder, down just as you would tear out the sleeve
of a coat. His pulse was 80 aud very weak, respiration 40,
temperature 97.5°, and he was crying with pain aud begging to
have the arm taken off. He was immediately put to bed, the
arm dressed with sterile gauze, the foot of the bed elevated
and he was infused with 600 cc. of salt solution in the breast,
and given i gr. morphia and a hot enema of coffee and salt
solution. Up to 10 o'clock he improved, his pulse had become
much stronger, he was quiet, his respiration slower and
altogether he seemed better. After that time he began to go
down again rapidly and there was considerable oozing from
the dressings. He was in very bad condition when put on the
table at 11 p. m., and though he was under ether only 10
minutes his condition became much worse during that time.
He was given strychnia hypodermically and salt solution
infusion during the operation. The foot of the table was
elevated and his legs tightly bandaged. The operation itself
lasted only 5 minutes. Dr. Bloodgood controlled the vessels by
digital pressure in the axilla and the arm was amputated just
below the shoulder. The vessels were quickly tied and the
wound packed with gauze. At the end of this brief period,
however, the radial pulse could not be felt, and the heartsounds were so weak that the second sound could not be
heard after the operation. The foot of his bed was kept
elevated, he was infused again with salt solution and given
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
33
hypodermics of strychnia and morphia with hot enemata of
coffee and salt solution. His condition remained very alarming during all that night, the pulse being rapid and weak.
the temperature rising to 103.6° and he became delirious,
attempting to bite and scratch the assistants. Towards
morning, however, he became quiet and from that time on
has made a rapid convalescence. The wound was inspected a
few days after the operation and everything was found clean
and in good shape. His blood-count has been somewhat
interesting. The night of the operation it was practically
normal, although there had been a great deal of hemorrhage —
red corpuscles 5,000,000, leucocytes 23,000, and hemoglobin
70 percent. Thirty-six hours later it showed reds 3,000,000,
leucocytes 12,000 and hemoglobin 50 per cent.
Case III. This case has been very interesting to us in connection with the question of nerve regeneration. He is a
German, 38 years of age, and was admitted on the 10th of
November with an injury of the inner and posterior part of
the left arm, having been in contact with a buzz-saw. He
was admitted in fairly good condition and kept quiet for two
hours before operation, when he was put on the table and the
arm cleaned very thoroughly. No anesthetic was used and
although the operation lasted two hours or more, no bad
effect was produced so far as we could see. There were three
main cuts with numerous lacerations extending from them.
The upper cut exposed the musculospiral and ulnar nerves
and divided the internal cutaneous. The second cut divided
the ulnar, made a large ojjening into the bone and divided the
musculospiral just where it winds around the bone, while the
third cut divided the median nerve just above the elbow,
without exposing the artery. The triceps muscle was extensively lacerated and the ulnar nerve was hanging in this mass
of lacerated muscle which was torn entirely from the bone at
one point. The biceps was also partially divided and there
was extensive laceration of the skin. We identified the peripheral portion of the nerves by pinching the ends slightly
and getting a corresponding contraction. The central portions
could be identified by pain when they were seized. A hasty
examination for anesthesia was made and it was thought to
be complete, but since then we find that we were mistaken.
Tbe nerves were sutured, the muscles brought together with
buried silver and catgut sutures, and the skin approximated
loosely over the wound. The man has made a perfect recovery
and everything has healed per primam except the portions
where there was no skin and these are covered by healthy
blood clot. At the first dressing we found complete anesthesia
of those portions supplied by the median, ulnar and musculospiral nerves. The only sensitive area was that supplied by
the external cutaneous and some filaments of the musculospiral that came off above the injury.
Discussion.
Db. Thomas. — Was there any difficulty in bringing the
ends of the nerves together ?
Dr. Mitchell. — They were very far apart at the time, but
we had no difficulty in approximating them and suturing
without tension.
Dr. Thomas.— It will be very interesting to watch his
recovery and note where regeneration first takes place, since
all the nerves were completely divided.
An Improved Stethoscope. Dr. Cabot. — I have with me
a stethoscope that I have used on about 40 cases adav for five
months and which pleases me so much that I thought it
worth while to bring it before you. It was invented by a
gentleman in Boston, not a physician, who had seen the
ordinary stethoscope and who thought he could make
an instrument that would combine the advantages of this
with those of the phoueudoscope. It consists of a simple
diaphragm of metal like that of the telephone connected
with the chamber into which the tube of the stethoscope
enters. It magnifies all sounds and it might be said to
bear the same relation to the ordinary stethoscope that the
high power of the microscope does to the low power. With
it you can, I think, also hear sounds deeper in the chest than
those heard with any other stethoscope. I have used it constantly for examination of the lungs and heart and find it
exceedingly valuable for both. It enables you to hear cardiac
murmurs, especially those of aortic regurgitation that can
not be heard in any other way and this seems to me to be a
point of great importance. The murmurs of mitral stenosis
are not always, however, heard as well as with the ordinary
stethoscope; that fact I can not account for.
A very obvious advantage of the instrument is that in
listening to cases of pneumonia of the posterior lobes where
the patient is very weak and you do not want to turn him, you
can slip this flat edge under the back and hear the sounds
with ease. I have known of an instance of a consultant being
called from New York to Boston in such a case and feeling
that he had not the right to turn the patient or raise him no
examination of the lungs was made for two days. With such
instrument as this such a delay could not occur.
I think also it is not an exaggeration to say that you can
hear as much of the heart-sounds through the clothes with
this instrument as you can with any other instrument next the
skin. You should not listen to the lungs through the clothes,
because the friction sounds of the clothes are so much like
those of the lungs.
There are certain things that you can not do with it. If the
patient has a very thin bony chest you do not get good effects,
and it is not always good for very superficial sounds. I
always carry the bell of the ordinary stethoscope to slip on
for such cases. I don't think I should want the instrument
alone without this arrangement, but I certainly should not
want ever to be without this instrument again. I feel sure
that any one who ever tries it will not give it up until something better is invented.
The Pulmonic Second Sound. Dr. Cabot.— About
one year ago, in reading Gibson's recent work on the
heart, I noticed some observations concerning the second
sound in health that disturbed me a great deal. I had always
been taught that in health the pulmonary second sound
was not so loud as the corresponding sound from the other
side. Dr. Sarah li. (,'reightou went over one thousand cases
34
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 106.
this summer in my clinic with reference to this point, throwing out all cases where there w r as anything wrong with the
heart. She showed that in each decade, there is a rising percentage of aortic and a diminishing percentage of pulmonic
accentuation as compared with the preceding decade. In
other words, unless these one thousand cases are very deceptive, the accentuation of the aortic sound is a matter of age,
the pulmonic sound being louder in the young and the aortic
in older persons.
One other point that has struck me in the last two years in
the examination of the normal chest is the presence in healthy
persons of fine rales at the base of each axilla. If you listen
in persons over 40 years of age, you will hear in a large proportion of cases these fine crepitant rales at the end of inspiration. They are heard over a very small area, frequently not
larger than half the size of your palm. The explanation of
this phenomenon is entirely dark to me. I thought it might
be due to the formation of pleural adhesions, but I find it in
connection with Litteu's phenomenon so frecpaently that I can
not see how that explanation can be accepted, so that I leave
the observation as a purely clinical oue without explanation.
BOOKS RECEIVED.
Transactions of the American Surgical Association. Volume the
seventeenth. Edited by De Forest Willard, A. M., M. D., Ph. D.
1899. 8vo. XLII+319 pages. Printed for the Association,
Philadelphia.
Transactions of the American Orthopedic Association. Thirteenth
session, held at New York, N. Y., May 31 and June 1 and 2, 1899.
Volume XII. 8vo. XXVIII+367 pages. 1899. Published by
the Association, Philadelphia.
King's College Hospital Reports; being the annual report of King's
College Hospital and the medical department of King's College.
Edited by Nestor Tirard, M. D., F. R. C. P., et al. Volume V.
(Oct. 1st, 1897-Sept. 30th, 1898). 1899. 8vo. XVII+270 pages.
Printed by Adlard and Son, London.
An Experimental Research into Surgical Shock. An Essay awarded
the Cartwright Prize for 1897. By George W. Crile, A.M., M.D.,
Ph. D. 1899. 8vo. 160 pages. J. B. Lippincott Co., Philadelphia.
The Serum Diagnosis of Disease. By Richard C. Cabot, M. D. 1899.
8vo. VII+154 pages. William Wood and Company, New York.
The Principles of Bacteriology. A practical manual for students and
physicians. By A. C. Abbott, M. D. Fifth edition, enlarged
and thoroughly revised. With 109 illustrations, of which 26 are
colored. 1899. 12mo. XI+590 pages. Lea Brothers and Co.,
Philadelphia and New York.
A Text-Book of Pharmacology and Therapeutics, or the Action of Drugs
in Health and Disease. By Arthur R. Cushny, M. A., M. D.,
Aberd. Illustrated with forty-seven engravings. 1899. 8vo.
730 pages. Lea Brothers and Co., Philadelphia and New York.
A Practical Treatise on Fractures and Dislocations. By Lewis A.
Stimson, B. A., M. D. With 326 illustrations and 20 plates in
monotint. 1899. 8vo. XIX+822 pages. Lea Brothers and Co.,
New York and Philadelphia.
Transactions of the American Gynecological Society. Volume XXIV.
1899. 8vo. XLVII+520 pases. Wm. J. Dornan, Printer, Phila.
Transactions of the Indiana Slate Medical Society, 1899. Fiftieth
annual session held in Indianapolis, Indiana, June first and
second, 1899. 8vo. 552 pages. Central Printing Company,
Indianapolis, Indiana.
Thirtieth Annual Report of the State Board of Health of Massachusetts,
1898. 8vo. XXXIX+878 pages. 1899. Wright and Potter
Printing Company, Boston.
VOLUME TO COMMEMORATE THE 25TH YEAR OF DR. WELCH
AS A TEACHER AND INVESTIGATOR.
It is customary in Germany for the pupils of a great teacher to
express their appreciation and gratitude by dedicating to him a
volume of their contributions to learning. The pupils of Dr. Wm.
H. Welch, of Baltimore, have decided to give expression to their
regard for him in a similar way and the publication of a volume
to mark his twenty-fifth year as a teacher and investigator is now
in progress.
During the past twenty-five years some seventy-five persons
have undertaken investigation under Dr. Welch's leadership, and
nearly half of these will contribute to the volume mentioned. The
edition will necessarily be limited by the number of subscribers.
An early announcement of the publication is made to give opportunity for subscription so that the committee can decide upon the
number of copies to be printed.
The volume will be royal octavo in size and will contain at least
five hundred pages of printed matter. It will, in addition, be
illustrated with many lithographic plates and text figures. The
price has been fixed at five dollars. The book will contain contributions to pathology and to correlated sciences agreeing in scope
with that of the leading scientific medical journals.
The Committee of publication consists of :
A. C. Abbott, University of Pennsylvania, Philadelphia, Pa.
L. F. Barker, Johns Hopkins University, Baltimore, Md.
Wm. T. Councilman, Harvard University, Boston, Mass.
Simon Flexner, University of Pennsylvania, Philadelphia, Pa.
W. S. Halsted, Johns Hopkins University, Baltimore, Md.
A. C. Herter, University and Bellevue Hospital Medical College,
New York.
Wyatt Johnston, McGill University, Montreal, Canada.
F. P. Mall, Johns Hopkins University, Baltimore, Md.
Walter Reed, Army Medical Museum, Washington, D. C.
Geo. M. Sternberg, Surgeon General's Office, Washington, D. C.
All communications and subscriptions should be addressed to
Dr. F. P. Mall (Secretary), Johns Hopkins University, Baltimore,
Md.
Baltimore, November 11, 1899.
MONOGRAPHS.
The following papers are reprinted from Vols. I, IV, V, VI and
VIII of the Reports, for those who desire to purchase in this form:
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and
Emmet Rixford, M. D. 1 volume of 164 pages and 41 fullpage plates. Price, bound in paper, $3.00.
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer,
M. D., and J. Hewetson, M. D. And A STUDY OF SOME
FATAL CASES OF MALARIA. By Lewellys F. Baker, M.
B. 1 volume of 280 pages. Price, in paper, $2.75.
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and
others. Extracted from Vols. IV and V of the Johns Hopkins
Hospital Reports. 1 volume of 481 pages. Price, bound in
paper, $3.00.
THE PATHOLOGY OF TOXA.LBUMIN INTOXICATIONS. By
Simon Flexner, M. D Volume of 150 pages with 4 full-page
lithographs. Price, bound in paper, $200.
THE RESULTS OF OPERATIONS FOR THE CURE OF INGUINAL HERNIA. By Joseph C. Bloodgood, M. D. Price,
in paper, $3.00.
Subscriptions for the above publications may be sent to
The Johns Hopkins Press, Baltimore, Md.
HOSPITAL PLANS.
Five essays relating to the construction, organization and
management of Hospitals, contributed by their authors for the use
of The Johns Hopkins Hospital.
These essays were written by Drs. John S. Billings, of the
U. S. Army, Norton Folsom, of Boston, Joseph Jones of New
Orleans, Caspar Morris, of Philadelphia, and Stephen Smith, of
New York. They were originally published in 1875. One volume
bound in cloth, price $5.00.
January, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
35
THE JOHNS HOPKINS MEDICAL SCHOOL.
FACULTY.
Danibl C. Oilman, LL. D., President.
William H. Welch, M. D., LL. U , Professor of Pathology.
Ira Kh.sisEN, M. D., Ph. D , LL. D.. Professor of Chemistry.
WILLIAM Oslbr, M. D., LL. D., F. R. C. P., Professor of the F
.Medicine, and Dean of the Medical Faculty.
Hknrv M. Hi'KD, M. H., LL. D., Professor of Psychiatry.
William S. Halsteo. M. D., Professor of Surgery.
Howaki> A. Kbllv, M. D., Professor of Gynecology.
Franklin P. Mall, M D.. Professor of Anatomy.
John J. Abel, M. D-, Professor of Pharmacology.
William H. Howell, Ph. D., M. D., Professor of Physiology.
Thomas B. Futchi
Joseph C. Bl
iples and Practice of
R, M. B., Ass
ioi>, M. V., A
:n, M. B., Assoi
N, Ph. D., Assc
.. _,Ph. L>., M. D., Assc
JohnG. Clark, M.L)., A
Ross
ASS. CUL
Willia.i K Bkooks, Ph. D., LL. D
J. Whiiruigb Williams, M. D., Pro'fes:
John- S. Killings, M. D., LL D., Lectu
Albxanubk C. Abbot., M. D., Lecturer
Chakles Wari
Rolbkt Flbtc
of Comparative Anatomy and Zobloev
of Obstetrics. B>
on the History and Literature of Medicine
Hygiene.
Ph. D., M. S . Lecturer on Medical Zoology.
, M li , M. R. C. S. (Eng.). Lecturer on Forensic Medu
I.RI
vs F. Bar
Wi
LLIAl
1 S. Tha'
lot
-. M
. T. Finn
(Ski
P. Drbvi
Wi
■ W. Rus
Ko
ISB 1
L. Rand.
. M. D., Clinical Professor of Pediatrics
:kbnzie, M U., Clinical Professor of Laryngology and Rhinology.
jbald, M. D . Clinical Professor of Ophthalmology and Otology.
HOMAS. M. D., Clinical Professor of Neurology.
Lord, M- D , Clinical Professor of Dermatology and Instructor in Anatomy.
ilchrist, M. R C. S., London, Clinical Professor of Dermatology.
rklby, M D., Clinical Professor of Psychiatry.
r, M. B , Associate Professor of Pathology.
, M D., Associate Professor of Medicine.
i\l. D., Associate Professor of Surgery.
Ph. D , Associate in Physiology.
l, M. Ii, Associate in Gynecology.
•H, M. D.. Associate in Ophthalmology and Otology.
:iatein Medicine,
iociate in Surgery,
ate in Gynecology.
iate in Pharmacology.
— jn Gynecology.
Charles R. Bardbbn, M. D., Associate in Anatomy.
Harvey W. Lushing, M. D., Associate in Surgery.
George W. Dobbin, M. D., Associate in Obstetrics.
Walter Jones, Ph. D., Associate in Physiological Chemistry and Toxicology
Frank R. Smith, M. D., Instructor in Medicine.
Hbnrv B. Jacobs. M. D., Instructor in Medicine.
Hugh H. Young, M. D , Instructor in Genito-Urinary Diseases
Otto G. Ramsav, M.D., Instructor in Gynecology.
Thomas McCrae, M. B., Instructor in Medicine
Albert C. Crawford, M. D., Assistant in Pharmacology
Sidney M. Cone. M. D., Assistant in Surgical Pathology.
Norman MacL. Harris, M. B., Assistant in Bacteriology.
Jesse W. Lazear, M. D., Assistant in Clinical Microscopy.
Stewart Paton, M. D., Assistant in Clinical Neurology.
Lee W
Hi
Percy M. D..
Louis P. H»>
Melv.n T. Si
Norman B. G
Ph. G..
eth Hukdon, M. D., Assis
O. Reik, M. D., Assistant
m G MacCallum, M. D.
hology.
n, M. D., Ass
GER, M. D., (
r, Ph. D., As.
, M. B.. Demi
ant in Gynecology.
n Ophthalmology and Otology.
Assistant in Pathology and Curator of the Mu
1 Clinical Microscopy.
GENERAL STATEMENT.
The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of iMedicine is
an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns
Hopkins Hospital. The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October
and ends the middle of June, with short recesses at Christmas and Easter. Men and women are admitted upon the same terms.
In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital
While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a
suitable preliminary education and upon thorough training in the medical sciences. The first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physiology Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. During the last two years the student is given abundant opportunity
for the personal study of cases of disease, his time being spent largely in the Hospital Wards and' Dispensary and in the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the
Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.
REQUIREMENTS FOR ADMISSION.
As candidates for the degree of Doctor of Medicine the school receives:
1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.
2. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading
knowledge of French and German; (b) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor
courses given in these subjects in this university.
The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises
and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in
each subject.
3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved
college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.
Applicants for admission will receive blanks to be filled out relating to their previous courses of study.
They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in
physics, chemistry and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a
degree in arts or science from an approved college or scientific school.
Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass at the
beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University
(2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in
this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that
only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.
Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.
ADMISSION TO ADVANCED STANDING.
Applicants for admission to advanced standing must furnish evidence (1) that the foregoing terms of admission as regards preliminary training have been fulfilled
(2) that courses equivalent In kind and amount to those given here, preceding that year of the course for admission to which application Is made have been satisfactorily 1
completed, and |3i must pass examinations at the beginning of the session in October In all the subjects that have been already puraued by the class to which admission
Is sought. Certificates of standing elsewhere cannot be accepted in place of these examinations.
SPECIAL COURSES FOR GRADUATES IN MEDICINE.
Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates In medicine. The attendance upon these courses has
steadily Increased with each succeeding year and indicates gratifying appreciatl >u of the special advantages here afforded, with the completed organization of the
Medical School, it was found ueceesary to give the courses Intended especially for physicians at a later period of the academic year than that hitherto seleoted It Is
however, believed that the period now chosen for this purpose is more convenient tor the majority of those desiring to take the courses than tho former one The special
cour.es of Instruction for graduates in medicine are now given annually during the months of May and June. During April there Is a preliminary course In Normal
■ — s are In Pathology. Bacteriology. Clinical Mlcl Medicine. Surgery, Gynecology. Dermatology. Diseases of Children Diseases of the
Nervous System, Genlto-Urlnary Diseases, Laryngology and Rhinology, and Ophthalne logy and Otology. T he instruction is Intended to meet tho requirements of practitioners of medicine, and Is almost wholly of a practical character. It Includes laboratory courses, demonstrations, bedside teaching, and clinical Instruction In the
wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several Instructors that they are prepared to profit by the opportunities here offered. The number of students who can be accommodated In some of the
practical- , . irUy limited. For these the places an ' i ng to the date of application.
During October a select number of physicians will be admitted to a special clas-» for the study of the important tropical diseases mot with In this region.
The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the
REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.
36
JOHNS HOPKINS I OSPITAL BULLETIN.
[No. 106.
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.
THE JOHNS HOPKINS HOSPITAL REPORTS.
Volume I. 423 pages, 99 plates.
Report In Pathology.
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
^ HeaUng of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. U.
a Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis
(Atrophy). By Henry J. Berkley, M. D. „.. ,. „„ „ „
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.
Mall, M. D.
Report in Dermatology.
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
T C Gilchrist, M. D., and Emmet Riiford, M. D.
A Case of BhXmycetic Dermatitis in Man; Comparisons of the Two Varieties of
P?otozoa7lnd the Blastomyces found in the preceding Case, with the so-called
Sites found in Various Lesions of the Skin etc.; Two Cases of Molluscurn
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhnng). By
T. C. Gilchrist, M. D.
Report In Pathology.
An Experimental Study of the Thyroid Gland of Dogs with especial consideration
of Hypertrophy of this Gland. By W. S. Halsted, M. D.
Volume II. 570 pages, with 28 plates and figures.
Report in Medicine.
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
Gallstones. By William Osler, M. D.
Some Remarks C n Anomalies of the Uvula. By John N. Mackenzie, M. D.
On Pyrodin. By H. A. Lafleur, M. D.
Cases of Postfebrile Insanity. By William Obler, M. D.
A^te Tuberculosis in an Infant of Four Months. By Harry Toulmin, M. D.
Rare Forms of Cardiac Thrombi. By William Osler. M. . D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.
Report in Medicine.
Tubercular Peritonitis. By William Osler, M. D.
A Case of Raynaud's Disease. By H. M. Thomas, M. D.
Acute Nephritis in Typhoid Fever. By William Osler, M. D.
Report in Gynecology.
The KSS X-o fXZoXZTU; «chV-1890. By Howard
The1ie^t L ;^he D Auto^i H Jfn E Tw R o C B ase i U D yin g in the Gynecological Wards without Operation ; Composite Temperature and Pulse Charts of Forty Cases of
Abdominal Section. By Howard A. Kelly, M. D.
ne Management of the Drainage Tube in Abdominal Section. By Hunter Robs,
TheGonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;
Ovarian Tumor; General Gynecological Operations from October 16, 1889, to
March 4, 1890. By Howard A. Kelly, M. D. n „_.„„
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howabd
A. Kelly, M. D., and Albert A. Ghriskby, M. D.
Lhrature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.
Carcinoma of the Cervix Uteri in the Negress. By J. W Williams, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D. „,„.„.
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
Howard A. Kelly, M. D.
Report in Snrgery, I.
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot
in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in Neurology, I.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.
Haematomyelia. By AU0U6T Hoch, M. D. ... , iV o_t i r, • ».
A Case of Cerebrospinal SyphiliB, with an unusual LeBion in the Spinal Cord. By
Henry M. Thomas, M. D.
Report in Pathology, I.
Amosbic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleob, M. D.
Volume III. 766 pages, with 69 plates and figures.
Report in Pathology.
Papillomatous Tumors of the Ovary. By J. Whitriooe Williams, M. D.
Tuberculosis of the Female Generative Organs. By J. Whitridoe Williams, M. D.
Report in Pathology.
Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Fleiner, M. D.
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.
A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
Report in Gynecology.
The Gynecological Operating Room; An External Direct Method of Measuring the
Conjugata Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele- Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
Flexure associated with Constipation a Source of Error in Gynecological Diag
nosis; Operation for the Suspension of the Retroflexed Uterus. By Howard A
Kelly, M. D. . . , . . .. ___ . _ -.
Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci.
By Mary Sherwood, M. D.
Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavely, M. p
Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. 1>.
Tabulated by A. L. Stavely, M. D.
The Employment of an Artiflcial Retroposition of the Uterus in covering Extensive
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.
Photography applied to Surgery. By A. S. Murray.
Traumatic Atresia of the Vagina with Haematokolpos and Haematometra. By Howard
A. Kelly, M. D.
Urinalysis in Gynecology. By W. W. Russell, M. D.
The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.
Resuscitation in Chloroform Asphyxia. By Howarr A. Kelly, M. D.
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.
Abdominal Operations performed in the Gynecological Department, from March 5.
1890, to December 17, 1892. By Howard A. Kelly, M. D.
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
May 4, 1892.
Volume IV. 504 pages, 33 charts and illustrations.
Report on Typhoid Fever.
By William Osler, M. D., with additional papers by W. S. Thayer, M. D., and J.
Hewetson, M. D.
Report in Neurology.
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of Mut mtuctdus; The Intrinsic NerveB of the Thyroid Gland of
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,
M. D.
Report in Surgery.
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to
January, 1894. By W. S. Halsted, M. D.
Report in Gynecology.
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.
Report in Pathology.
Deciduoma Malignum. By J. Whitribge Williams, M. D.
Volume V. 480 pages, with 32 charts and illustrations.
CONTENTS:
The Malarial Fevers of Baltimore. By W. S. Thayer. M. D., and J. Hewetson, M. D.
A Study of some Fatal Cases of Malaria. By Lewellys F. Barker, M. B.
Studies in Typhoid Fever.
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon
Fleiner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.
Volume VI. 414 pages, with 79 plates and figures.
Report in Neurology.
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.
Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the
Chromate of Silver Methods; Part i. — Alcohol Poisoning. — Experimental Lesions
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part II. — Serum
Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on
the Cortical Nerve Cell; Part III.— Ricin Poisoning.— Experimental Lesions Induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical
Nerve Cell produced by the Toxine of Experimental Rabies; Part V.— Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of
Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.
Report in Pathology.
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.
Cullen, M. B.
Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of
Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins. M. D.
Adeno-Myoma Uteri DirTusum Benignum. By Thomas S. Cullen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By
William D. Booker, M. D.
The Pathology of Toxalbumin Intoxications. By Simon Fleiner, M. D.
Volume VII. 537 pages with illustrations. (Now ready.)
I. A Critical Review of Seventeen Hundred Cases of Abdominal Section from the standpoint of Intraperitoneal Drainage. By .1. <■. (lark. M. 1>.
II. The Etiology and Structure of true Vaginal Cysts. By James Ernest Stokes, M. U.
III. A Review of the Pathology of Superficial Burns, with a Contribution to our Knowlr.lj the Pathological changes in the organs in cases of rapidly fatal burns. By
CUARLES RUSSELL RARDEEN, M. D.
IV. The Origin, Growth and Fate of the Corpus Lutemn. By .1. G. Clark, M. D.
V The Results of Operations for the Cure of Inguinal Hernia. By Joseph C. Blood,M.D.
Volume VIII. About 500 pages with illustrations. (In
press.)
Studies in Typhoid Fever.
By William Oslkr. M. I>.. with additional yaper!
M.D., I. P. Lyon. M. D„ L.P. Rambir
Mitchell. M.D.
Tltc price of a set bound hi cloth [Vols. I-1'II] of the Hospital Beports is
$35.00. Vols. I. II noil III ore not sold separately. Tin- price of
Vols. IV, V, VI noil VII is $3.00 end,.
Subscriptions for the above publications may be sent to
The Johns Hopkins Press, Balti;
Md.
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies
may be procured from Messrs. CUSH1NQ & CO. and the BALTIMORE NEWS COMPANY. Baltimore. Subscriptions, $1.00 a year, may be
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies will be sent by mail for fifteen cents each.
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. Xl.-No. 107.1
BALTIMORE, FEBRUARY, 1900.
[Price, 15 Cents.
C01TTEliJ"TS.
Report upon an Expedition Sent by the Johns Hopkins University to Investigate the Prevalent Diseases in the Philippines. By Simon Flexner, M. D., and Lewellys F.
Barker, M.B., - - - - 37
A Case of Multiple Gangrene in Malarial Fever. By William
Osler, M. D., ----- - 41
Benjamin Jesty : A Pre-Jennerian Vaccinator. By Thomas
McCrae, M. B., - 42
Haemophilia in the Negro- By Walter R. Steiner,
Summaries or Titles of Papers by Members of th
and Medical School Staff appearing Elsewh
Bulletin, ------------
Proceedings of Societies :
Hospital Medical Society,
Exhibition of Medical Cases [Dr. Futcher].|
Notes on New Books,
REPORT UPON AN EXPEDITION SENT BY THE JOHNS HOPKINS UNIVERSITY TO
INVESTIGATE THE PREVALENT DISEASES IN THE PHILIPPINES.
To President Gilman, Doctors Welch and Osler,
Philippine Committee of the Johns Hopkins University Medical School.
Gentlemen : — We have the honor to submit to you a brief
account of our work and movements in carrying out your commission to study the prevalent diseases in the Philippine Archipelago. Your commissioners, consisting of Dr. Simon Flexner
and Dr. L. F. Barker, to whom were voluntarily attached
Messrs. J. M. Flint and F. P. Gay, of the Medical School, the
latter having given their time and paid all their own expenses,
sailed from Vancouver on March 29th, 1899, and arrived in
Manila, May 4th, where they immediately established themselves for the purpose of the work mentioned. Owing to the
military situation it was found impracticable to visit other
ports in the Archipelago or to penetrate into the interior of the
Island of Luzon. The entire time of the commission, therefore,
was spent in the study of disease existing among the natives
and American troops in Manila and at Cavite.
Work in Japan and Hong-Kong.
As transport sailings were uncertain, and the passage out by
them slow, it was decided to save time and go by fast steamer,
the Canadian Pacific Railway giving special rates to the commission on tickets around the world.
The original plan of your commissioners was to proceed
directly to Manila by way of Hong-Kong, at which latter port
it was intended to stop only long enough to outfit for the tropics
and to catch the earliest steamer sailing for Manila. After
consideration of the probability that certain new kinds or
phases of disease, not occurring in temperate regions, might be
encountered in the Archipelago, and of the fact that the diseases of the Philippines would probably have much in common
with those of Japan, it was decided to spend one week in Japan,
where modern hospitals could be visited and advantage taken
of the results of the study of tropical disease by highly trained
and eminent Japanese physicians. The decision proved to be
valuable in many ways ; and we especially desire to express our
obligations to Professors Aoyama, Mitsukuri, Miura and
Kitasato, who showed us many courtesies. The opportunity
to see in the Japanese hospitals pure and mixed examples of
beri-beri assisted us greatly in our subsequent studies, as did
also the observations on dysentery made in the Institute for
Infectious Diseases at Tokio.
While outfitting at Hong-Kong we improved the opportunity
to study the bubonic plague, which was still prevailing at that
port. This study was made easy by tin.' generosity and courtesy
of the English Civil Physician, Dr. James Lowson, in charge
of the Plague Hospital and Mortuary. The study, begun in
this way, was extended when two months later we returned to
Hong-Kong, en route to America. At this time a considerable
exacerbation of the disease had taken place, and within a week
or ten days we saw several scores of cases and performed many
38
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 107
autopsies. The several forms of infection : inguinal, axillary,
tonsilar, cervical and pulmonary, were thus encountered.
Bacteriological examinations were made and tissues collected
for future study. Two of the party (Dr. Barker and Mr. Flint)
spent ou the return journey three weeks (at their own expense)
in India, where the great epidemics of plague there raging were
observed.
Arrival in Manila.
Immediately upon our arrival in Manila, quarters were sought
at the " Hotel de Oriente." Very insufficient accommodations
were secured for a limited time, as the sudden accession of
families of Army and Naval officers had strained the hotel to
its fullest capacity. Having been forewarned of the conditions
of living in Manila, we took the precaution to bring with us
from Hong-Kong a group of Chinese servants, intending to set
up housekeeping if practicable. After much difficulty a small
house was secured in San Miguel, where, by hiring parts of the
furnishings and buying what could not be rented, a temporary
establishment was secured.
Within a few hours after our arrival, the credentials and
private letters brought were presented to Colonel Woodhull,
Surgeon-in-Chief to the 8th Army Corps, and to General Otis.
Colonel Woodhull afforded us every opportunity to prosecute
our work in the military hospitals. Although no special introduction was in our possession, we quickly met Dr. Bournes,
chief health officer of Manila, who opened to us the hospitals
under his charge. Somewhat later we met Dr. Pearson, Chief
Naval Surgeon, who opened to us the Naval Hospital at Cavite.
Hospitals in Manila.
Civil Hospitals. These consist of a large hospital within
the walled city, San Juan de Dios. It has a capacity of from
250 to 300 beds, and accommodated, during our stay, both
natives and Europeans. The number of European patients
was small. When the military hospitals were much crowded
a certain number of wounded prisoners of war were accommodated. The hospital contained chiefly native medical cases of
both sexes. The San Lazaro or leper hospital, in the outskirts of Manila, contained from 80 to 100 lepers during our
stay. These had come from Luzon, almost exclusively from
Manila and its immediate surroundings. The two sexes are
provided for in separate, large and airy wards. One wing of
the building, having a private entrance, is devoted to native
prostitutes who apply regularly for examination, and are incarcerated here and treated medically when found to be suffering
from venereal disease.
Military Hospitals. These consisted, besides the regimental
hospitals which were virtually detention camps, of three
Eeserve Hospitals — the 1st, 2nd and 3rd Reserve Hospitals; a
convalescent hospital on Corregidor Island and the Hospital
Ship Relief, which was anchored in the bay. The First
Eeserve Hospital, under the control of Major Crosby, had been
originally the Spanish military hospital. It has been from
time to time, by the erection of tents over platforms raised a
foot or two from the ground, increased in capacity until in
July it contained 1200 or more beds. The Second Reserve
Hospital, under the control of Major Keefer, was a transformed
modern school- building, and because of its limited capacity
(250 beds), high ceilings and wide corridors it made a model
hospital. The Third Reserve Hospital had just been established towards the end of our visit, and was smaller than the
others and intended as a convalescent hospital. The hospital
at Corregidor is a temporary structure and intended for convalescents. It is especially well adapted for its purpose because
of the high and hilly character of the island and its complete
investment by the sea. The Relief was used as a hospital for
acute cases ; but some time before we left, the acute cases were
transferred to the Reserve Hospitals, and the Relief sailed for
San Francisco with invalided men.
The Reserve Hospitals accommodated especially American
sick and wounded ; but a ward in the First Reserve Hospital
was set aside for the Filipino wounded.
After the outbreak of beri-beri at Cavite, a hospital under
military control was established at San Roque in the remains
of the Spanish Marine Hospital which had been wrecked by
the insurgents.
Naval Hospital. A small hospital for sick seamen and
marines was established at Cavite. Through the courtesy of
Dr. Pearson this was open to us for clinical studies.
Clinical, Pathological and Bacteriological Laboratory.
Through the kindness of Colonel Woodhull and of Major
Crosby, the officer-in-chief of the First Reserve Hospital, a small
Filipino house, situated on the banks of the Pasig, was given
us in which to establish a laboratory. This was done on the
second floor of the house. The expense of putting up workingtables was kindly borne by the Medical Corps of the Army.
The laboratory equipment was set up in this building, and
within a very few days after our arrival work was begun. We
desire to speak of the co-operation of the Medical Staff of the
hospital who afforded us every opportunity to visit the wards,
and many of whom joined or assisted us in clinical and pathological work. We wish especially to acknowledge the co-operation and assistance of Lieut. Richard P. Strong, a graduate of
the Johns Hopkins University Medical School, who had on
our arrival already begun to do laboratory work and who gave
up much of his valuable time in furthering our interests. It
was found unnecessary to establish laboratories in the other
hospitals, in the first place, because all were connected with the
First Reserve by the Signal Service telegraphic system of
which we had free use; and next, because all the dead were
carried to the morgue in conjunction with the First Reserve
Hospital. We went or were frequently called to the other
hospitals to make clinical and bacteriological examinations.
With few exceptions, all the dead were subject to autopsy.
Post-mortem examinations were made at the Civil Hospitals
upon natives, and at the Military Hospital upon all that died.
Exceptions were made only in the cases of those dead from
gun-shot wounds, when, if pressed for time, necropsies were
sometimes omitted.
Prevailing Diseases.
The subject of the prevalent diseases may be considered as
they affect (1) the natives, and (2) Europeans and Americans,
especially the American garrison.
February, 1900.]
JOHNS HOPKINS HOSPITAL BULLETIN.
39
Diseases affecting Natives, (a) Skin Diseases. Of the skin
diseases prevailing among the natives, aside from small-pox
and other specific exanthemata, may be mentioned (1 )
of the scalp, which are very frequent; (2) dhobie itch; and
(3) an affection which resembles closely, and which is probably
identical with, Aleppo boil (Delhi boil, Biskra button, epidemisehe Beulenkrankheif). (b) Small-pox. This disease has been
so generally prevalent in Luzon that the natives have, to a
large extent, lost fear of it. All evidence points to the greatest
carelessness in preventing its spread during Spanish times.
Isolation of the sick and disinfection of the habitations seem
not to have been attempted; and vaccination, even among the
Spanish garrison, had not been carried out. Under these
circumstances it could be no surprise that after the American occupation the disease should appear and even become
epidemic. The epidemic which appeared early last year was
promptly met by Dr. Bournes, who caused the Spanish garrison
still in Manila, and natives and Chinese within the city to be
vaccinated. In order to insure satisfactory results he found
it necessary tore-establish a vaccine farm in which young caraiao
were used for the preparation of the virus. Under the influence of this measure and by the aid of isolation of the sick,
the disease had, in May, practically disappeared within the
military liues about Manila, (c) Leprosy. A definite focus
of this disease exists in Luzon. The cases, in the neighborhood of 100, which are confined in the San Lazaro Hospital,
came from Manila and the country immediately surrounding
that city. The disease affected both sexes, being more frequent
in adults, although also present in half-grown boys and girls.
The commonest forms were the tubercular and mutilating.
Autopsies were performed upon several cases that had died
during our stay, (d) Ttiberculosis. Accurate statistics of the
extent of the prevalence of this disease are difficult if not
impossible to obtain. That the disease is a common one is
indicated by several facts. It is frequently met with in the
native hospitals, where it may have been recognized duriug
life or is disclosed at autopsy. Many cases of supposed beriberi which we autopsied at San Juan de Dios proved to be
tuberculosis. It is possible that the two diseases had co existed, for we found such combinations freely recognized by
•Tapanese physicians in the hospitals in Japan. Tuberculosis
of the lungs was also found as a common complication in
leprous individuals that came to autopsy. Not very infrequent spectacles met with on the streets are much emaciated
and weak natives affected with suggestive coughs and free
expectoration. While it is not certain that these individuals
were examples of tuberculosis, there is strong probability that
this explanation of their condition is the correct one. (e)
il Diseases. Syphilis, by general agreement (statistics
not available), does not prevail unduly. Chancroids and gonorrhoea are, on the other hand, very common. The majority
of the prostitutes confined in the San Lazaro were victims of
these two diseases. A very common complication of the soft
sore, owing to lack of cleanliness, is swelling and suppuration
of the inguinal glands, (f) Beri-Beri. This disease is well
known among the natives. It would appear to be epidemic
and endemic in Luzon. It is, judging from cases met with in
San Juan de Dios Hospital and the statements of native phys
icians, constantly appearing in a sporadic form. During our
stay an epidemic appeared among the Filipino prisoners confined at Cavite. Some 200 cases developed in a few weeks ;
the mortality ranged from 20 to 30 per cent. The several
recognized forms of the disease— cedematous, paralytic, and
mixed — were encountered. Clinical and bacteriological studies
were made upon the living, and the dead were subjected to
autopsy and bacteriological examination. The difficulty of
getting to and fro between Manila and Cavite, on account of
the impossibility of land communication, made this part of our
work difficult and time-consuming. A considerable collection
of pathological material and other data has been made. This
material is now in process of study and arrangement.
Diseases affecting Americans. The chief causes of disability
among American land forces are the enteric diseases. These
are diarrhoea, dysentery, typhoid fever, and gastro-intestinal
catarrhs. Many of the diarrhoeas are merely preliminary to
the symptoms of dysentery. Other infectious fevers are relatively infrequent. A small number of cases of scarlet fever
and diphtheria only were encountered. The malarial fevers
prevailed but not seriously during the months of .May, June
and July, (a) Dysentery. This disease is responsible for the
greatest amount of invalidation and the highest mortality. It
appears in acute, sub-acute, and chronic forms. The chronic
form is sometimes attended by secondary abscess of the liver.
The acute form may end in 24, 48, or 72 hours. In it the
whole of the large intestine and usually the lower portion of
the ileum are involved. The mucous membrane of the gut is
swollen, congested and cedematous, in places hemorrhages
have taken place into the mucous membrane, and the submucosa is swollen and its blood-vessels greatly dilated. No
ulcers existed in such cases. Amoebae were absent or very
difficult to find in the fresh stools and in the intestinal contents immediately after death. In the sub. acute and chronic
forms ulcers are present in the mucosa; the coats of the
intestine are greatly thickened ; at times large sloughs of
mucous membrane, partly detached, occur, and t lie lesions are
confined to the large intestine. Amoebae are more commonly
present in these cases, but are variable as to actual occurrence and numbers. Large hepatic abscesses, usually single,
were encountered in a number of these cases. Amoebae were
variable in the contents of the abscesses. In one very large
abscess, occupying both right and left lobes of the liver, no
amoebae were seen, but a pure culture of the Staphylococcus
pyogenes citreus was obtained. The clinical studj of the cases
of dysentery with reference to amoebae was equally unsatisfactory. In cases with marked symptoms both in patients confined
to bed and those beginning to go about but still with persistently
loose bowels, these organisms were frequently missed : while
in instances ready to be discharged, they might, at certain
examinations, be found to be very abundant. In morphology,
the amoebae studied corresponded with the amoebae coli found
in Egypt and in this country. The bacteriological study of
cases of dysentery was carried out upon the fresh stools of acute
and chronic cases, and with the intestinal contents, mesenteric
glands, liver, etc., of can dyi i subjected to autopsy.
The intestinal flora was studied in its entirety by means
of plate cultures. Varieties of micro-organisms were separated.
40
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 107.
Many of these were well-known species or occurred normally
in the situations in which found. Tests with blood sera for
agglutination were made, and those organisms giving positive
reactions were separated for further study. Two groups of
bacilli were thus differentiated : (1) Having affinities with
the group of bacillus coli communis. The agglutination was
variable, being constant and sensitive with the blood-serum of
the same individual (host), and inconstant, and active in relatively strong solutions only, in serums from other individuals.
(2) Having affinities with the group of bacilli of which the
bacillus typhosus is the type. Agglutination was constant and
sensitive with blood-serum of host as well as the sera of other
individuals suffering from dysentery. Inactive with normal
serum and serum from cases of typhoid fever, malaria and beriberi. A bacillus belonging to the second group, which is still
under study, would seem to agree with the bacillus dysenteriae
isolated by Shiga from cases of endemic dysentery occurring
in Japan. It is regarded by us as an important factor in the
causation of the dysentery of the Philippine Islands. Experiments in immunization of animals and the production of vaccine are in progress, (b) Typhoid Fever. The total number
of cases of typhoid fever in the hospitals during May, June
and July was far below that of dysentery ; the number
of deaths also was less. It was, however, a frequent affection among Americans. The examination of the blood,
microscopically and with the Widal test, was of the
greatest help in diagnosis. The disease came to autopsy
presenting the classical intestinal lesions and also in
atypical forms. In the small number of autopsies made upon
those dead of this disease, several instances of slight intestinal
involvement or even entire escape were met with. These cases
would have remained very obscure or even undetermined
except for the Widal reaction and bacteriological examination.
In some instances the typhoid bacillus was found widely disseminated throughout the body, the autopsy being made immediately after death, (c) Malarial Fevers. A large proportion
of the cases were sent in from the field and outlying military
stations where examinations had to be hastily made, as instances
of " malaria " or " intermittent fever " turned out to be cases of
other diseases (typhoid fever, dysentery, etc.). A number of
true cases of malarial fever were, however, met with, and in
the blood of these the characteristic parasites, identical with
those occurring in other places in which studies of the blood
have been made, were found. No quartan parasites were met
with, but cases of quartan affection doubtless exist. Typical
infections with the " tertian " and "aestivo-antumnal " varieties of the parasite were encountered by us, and by microscopists among the Army physicians in the Reserve Hospitals
and on the Relief. One of the fatal cases of malaria was
complicated with acute lobar pneumonia. The cases of
" calentura perniciosa" which occur in Mindoro, Mindanao
and in certain parts of Luzon should be studied as soon as
these regions are accessible. The Archipelago is favorable
also for the study of the relation of mosquitoes and other
insects to malarial infection. Some of the malarial cases were
undoubtedly recidives, imported from Cuba or elsewhere. A
very small number of deaths were referable to malaria. Two
instances of acute malarial infection came to us for autopsy.
On the other hand, several instances of malarial pigmentations
of the organs, in persons dying from other diseases, were
encountered. Parasites in the latter cases were absent. These
men had, as a rule, been in Cuba or Porto Rico during the
Spanish war.
(d) Tuberculosis. A number of cases of pulmonary tuberculosis developed among the soldiers in the American troops.
A definite history of exposure to wet and various hardships
was elicitable iu many of these cases.
(e) Dengue. At Cavite there occurred a large outbreak
of an epidemic fever of short duration (a few days), known
locally as Cavite fever. Almost all who remained in Cavite
for any length of time were attacked. Second and third
attacks were common. Muscular pains were severe in some
cases and not in others. A slight exanthem was present in
many of the cases. Flushing of the face, restlessness and
general malaise accompanied the fever and rapid heart action.
Malarial parasites were not present in the blood, nor did the
serum from such cases agglutinate cultures of the typhoid
bacillus. The epidemic is regarded as one of Dengue.
(f) Tropical Ulcers. A number of the American soldiers
suffered from a form of indolent ulceration, locally known as
" tropical ulcer." These ulcers occurred singly sometimes,
but were more often multiple. They began as small pustules,
which gradually extended. They were most frequent among
those who had been compelled to make long marches through
swampy districts, and the patients themselves attributed the
ulceration to " poisoning " in the marshes.
(g) Wound Infection. Our experience with wound infections
was rather limited. The other problems undertaken, regarded
as more important as bearing on the general question of
disease and its causation in the Islands, left but little time
and opportunity to attack this interesting subject. Certain
observations of interest were made. Pyogenic infections due
to the common pus cocci occurred. In a small number of
gun-shot wounds causing compound fractures emphysematous
gaugrene occurred and the bacillus aerogenes capsulatus was
isolated. In oue instance of compound fracture of the tibia,
a spore-bearing bacillus was associated with the bacillus aerogenes capsulatus. It was found in cover-slip preparations
from the original wound and in the first set of cultures. It
could not be further transplanted and hence was not identified.
In two other cases was the bacillus aerogenes met with, one a
case of jDeritonitis following infection of the intestine from
an incarcerated hernia, and the other also a case of peritonitis
but secondary to perforation of a typhoid ulcer of the
intestine. The army surgeons were enthusiastic as to the
adequacy of the "First-Aid Package" in limiting the number of wound infections.
Clihatological and Hygienic Conditions.
The climate is that of continual summer. There is a wet
season (S. W. Monsoon) and a dry season (N. E. Monsoon).
The hottest period is at the end of the dry aud the beginning
of the wet season — precisely the period of our visit. The
climate from November to March is said to be delightful. In
the worst season of the year the climate is very trying, and
especial precautions are to be taken if Americans are to keep

Revision as of 22:31, 20 February 2020


VOLUME XI


BALTIMORE

THE JOHNS HOPKINS PRESS

1900




Z§e §rU$enrv&(S Company


s <r\


BULLETI



OF


THE JOHNS HOPKINS HOSPITAL.


Vol. XL-No. 106.1


BALTIMORE, JANUARY, 1900.


[Price, 15 Cents.


COK-TEUTSI.


Contributions to the Surgery of the Bile Passages, especially

of the Common Bile-Duct. By W. S. Halsted, M. D., - - 1 Early Exploratory Operations in Tuberculosis of the Hip. By

Joseph C. Bloodgood, M. D., - jj

Gunshot Injuries by the Weapons of Reduced Calibre. By

L. A. LaGardb, U. 8. A., - - - - - . oq

A Reconstruction of a Glomerulus of the Human Kidney.

William B. Johnston, - - - -Medical Commission to the Philippines.

Barker, M. D.,


By

Ry Lewellys F.


An Apparatus to Aid the Introduction of a Catheter or Bougie. By George Walker, M. D.,

Summaries or Titles of Papers by Members of the Hospital and Medical School Staff appearing Elsewhere than in the Bulletin, ------ Proceedings of Societies :

Hospital Medical Society, - - Exhibition of Surgical Cases [Dr. Mitchell] ;— An Improved Stethoscope [Dr. Cabot] ;— The Pulmonic Second Sound [Dr. Cabot].

Books Received,


30


34


CONTRIBUTIONS TO THE SURGERY OF THE BILE PASSAGES, ESPECIALLY OF THE

COMMON BILE-DUCT.*

By W. S. H.lstkd, M. D., Baltimore, Surgeon-in-Chief to the Johns Hopkins Hospital, Professor of Surgery in the Johns

Hopkins University.


Just now I am very much impressed with the splendid results of operations for gall-stones in the common duct, for we have had of late a series of cases very desperately ill, and so transformed by their emaciation and discoloration, and so feeble in body and mind, that I could hardly picture to myself the various stages of metamorphosis toward convalescence. Every one has seen a patient whose life has been despaired of convalesce from acute disease ; they watched his rapid decline and expected an almost equally rapid recovery; but when the decline has covered a period of five or ten or perhaps twenty years the changes wrought are so great and apparently of such permanent character that the complete restoration to health is the more astonishing. The large cirrhotic liver, the dry slateyellow skin, the enfeebled intellect, the body emaciated to the last degree, seem at times almost to preclude all hopes of recovery to the practitioner who has not witnessed the changes so quickly brought about by nature as soon as the mechanical obstacles to recovery have been removed by the surgeon. What nature accomplishes without the surgeon's aid in her attempts to rid herself of the obstruction in the gall-passages and to

•Read at a Meeting of the Surgical Section of the Suffolk District Medical Society, May 3, 1899.


repair self-inflicted damage is marvelous ; but her methods are very crude and attended with much suffering and great danger, immediate and remote. I have, however, in mind at this moment two particularly creditable examples of nature's surgery.

In the first one the gall-passages were shortened to just the length of the two large stones which completely filled them. One occupied the gall-bladder, the other the pancreatic portion of the common duct; the duodenum was not only adherent to the gall-bladder, but served in place of its anterior wall, which had been destroyed; the stone in the gall-bladder, therefore, rested on the wall of the duodenum, which was pasted, so to speak, over the great hole in the front wall of the bladder. There was nothing that could be called cystic duct ; the choleductus was almost completely covered by the duodenum; the hepatic duct was much distended, admitting easily one finger. All signs of inflammation, except its results, had disappeared. The simplest conditions had been produced, and those most favorable to the expulsion of the stones in some subsequent attack ; gall-bladder and common duct were reduced to a short, wide, nearly straight tube, which bore a striking resemblance to an atheromatous aorta. The stone in the common duct was behind the duodenum and buried in its wall.


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 106.


The second patient had his first colic twenty-one years before admission to the hospital. He was never jaundiced. In the third attack, which began one month prior to operation, his temperature reached 106°. A physician aspirated pus from the distended gallbladder about twenty-four days after the onset of the third attack, or three or four days before we operated. The gall-bladder was opened in two acts. The fluid in the gall-bladder was almost clear and not bile-stained. Diagnosis : Stone in the cystic duct. Cover-slips showed few bacilli. Cultures yielded bacillus coli communis, pure. Patient applied for re-admission in eighteen months, because he had noticed a hard body just beneath the skin in the mouth of the sinus. By simply dilating the sinus I removed four large, very darkgreen, almost perfectly cylindrical stones, which were piled up upon each other in this sinus, forming a column 10 centimeters high. Nature would herself have extruded these stones which she had brought to the surface without causing the patient any discomfort.

Equally marvelous are the processes by which nature destroys all traces of her surgical handiwork. I have operated upon two cases in which perforation of the gall-passages and intestinal walls, and the expulsion of the stone, had undoubtedly occurred, but was unable in one of them to find any evidence of the perforation other than a few light and easily separable adhesions. Again, in a case of appendicitis, followed by gangrene of the greater part of the cecum and a wide preternatural anus, there were, within a year, only a few very light adhesions about a pinhole opening in the colon to tell the story. These facts are enough to make the ordinary operations for suspension of the spleen, liver, uterus, etc., seem ridiculous. Adhesions about an artificial opening fortunately never disappear. If innocent fistula? could be established, with the organs to be suspended, the problem might in a way be solved.

I wish to ask your attention to-night to a few of the unusual facts observed by us in our operations upon the bile-passages j particularly the common bile-duct. Almost every one of our common duct cases has presented us with a new fact or two which can hardly fail to interest the general practitioner, as well as those who concern themselves with the surgery of the bile-passages. To be as brief as possible, for the time is short, I will summarize at the outset some of the more noteworthy incidents observed by us in this department of surgery.

I. Dilatation of the first part of the duodenum caused by constricting adhesions ; as the result, perhaps, of tlie dilatation, an ulcer (" distention ulcer" — Kocher) on the confines of the pylorus ; the ulcer gave rise to a dissecting submucous abscess (chronic), rich in organisms because not reached by the most painstaking sterilization of the stomach. This abscess was punctured during the operation and a fatal peritonitis resulted (terminal infection), although, literally, only a drop or two escaped, and these were carefully wiped away.

II. Primary carcinoma of the duodenal papilla and diverticulum Vateri.

First operation. — Excision of portions of the duodenum (nearly its entire circumference), pancreas, common bile-duct and pancreatic duct in order to give the little growth, no larger than a pea, a wide berth ; circular suture of the duodenum and


transplantation of the stumps of the common duct and the pancreatic duct (Wirsung's) into the line of this suture.

Second operation. — Cholecystcysticoenterostomy by the writer's method* for intestinal lateral anastomosis.

III. Dynamic dilatation of the first portion of the duodenum and of the pyloric portion of the stomach, corresponding accurately to the limits of a sharply-circumscribed peritonitis; gall-stones in the gall-bladder; hydrops vesicas. Case full of interest for diagnostician. Beautiful instance of circumscribed dynamic dilatation caused by local inflammation ; no adhesions.

IV. Conditions suggesting hepaticocholecystostenterostomy (hepaticocholecystostcholecystenterostomy) as a possible operation ; common and cystic ducts reduced to fibrous cords ; dilated hepatic duct and gall-bladder. Remarkable toxic (?) renal colic resembling closely intestinal colic, associated with anuria ; colic and anuria entirely relieved by salt infusion.

V. Choledochotomy performed twice. The gall-bladder, which was shriveled at the first operation when two stones were probably in the common duct, was large and distended at the second operation when only one stone occupied the common duct (the ampulla). Hematemesis after the second operation.

VI. The densest adhesions that I have ever encountered in these operations, and probably the most difficult of my operations upon the bile passages. A small abscess in the midst of the adhesions; muscular coat of the duodenum converted into fibrous tissue; the exposed submucosa resembled gall-bladder so closely that the duodenum was aspirated and opened.

VII. Case illustrating the rapidity with which adhesions after perforation and extrusion of stone can be absorbed. Renal pains resembling intestinal colic (third observation of the kind within eighteen months). Tachycardia, believed to be due to toxemia of some kind (possibly benign embolism), suddenly disappeared during counting of pulse and while preparations were being made for subcutaneous infusion.

VIII. Discharge of pus and blood by mouth and rectum during severe gall-stone attack. Two years later, adhesions so extensive and so dense that the common duct was reached by a retroperitoneal route, over the right kidney. A stone in the ampulla had just ulcerated through the wall of the common duct and through its duodenal coverings.

Case I. — Duodenal stenosis from gall-stones ; dilatation of the stomach and of the pyloric end of the duodenum ; duodenal ulcer giving rise to a dissecting abscess. — J. S., age thirty-six, admitted February 5, 1899. Never had typhoid fever. Had malarial fever ten years ago with shaking chills. Never suffered from stomach trouble until present illness. Ever since he was eight years old has had sick headaches, lasting three to four hours, once a month ; these would be relieved by emptying his stomach. Has never been jaundiced nor had clay-colored stools. Present illness began very gradually. Three years ago, he noticed that his stomach would swell after eating and hardly regain its normal size before the next meal. Had more or less pain in the epigastrium, which was most marked about one hour after eating. No nausea or vomiting at first ; bowels regular. About the first of last October the pain became worse, and his sick headaches were more numerous and more severe. His vomiting now began. The vomiting was accompanied by colic, so severe as to double him up. Patient was obliged to stop


"Bulletin of the Johns Hopkins Hospital, No. 10, 1891.


January, 1900.]


JOHNS HOPKINS HOSPITAL BULLETIN.


work for two weeks. He then resumed work until Christmas, since which time he has been unable to work. Patient now vomits much more frequently. The vomiting is preceded by heartburn for about three hours and much pain in the epigastrium. Patient feels greatly relieved after the vomiting. For two weeks after Christmas he had eructations of gas ; none since then. Bowels usually constipated ; sometimes did not move for three weeks. He still suffers much from headache. His appetite is good, but he is afraid to eat. In October, 189S, patient weighed one hundred and forty-five pounds ; he now weighs one hundred and twentythree pounds, and is very weak. Neither stools nor vomitus have ever been blood-stained. Urine normal. Stools clay-colored. Patient not jaundiced.

On palpation of the abdomen no distinct tumor can be felt, but one detects an increased resistance just to the right of the umbilicus. The stomach's longest diameter is 31 cm.; its shortest diameter, 21 cm. The lowest limit of the stomach (tympanitic) is 3^ cm. below the umbilicus. Spleen not palpable. Heart and lungs normal. Glands nowhere enlarged. Pulse slow, feeble, 60 beats to the minute.

January 24th. Test breakfast (Ewald). Two hundred and sixty cc. removed one hour later ; green color ; acid. Total acidity, 5.9 cc. ; 0.1 normal NaOH. Free hydrochloric acid ; no lactic acid. No sarcinse nor Opper-Boas bacilli.

February 4th. Test breakfast. Sixty cc. removed. Total acidity, 20. No hydrochloric acid ; no lactic acid. A few Opper-Boas bacilli (?).

February 5th. Stomach tympanitic. Clapatage readily obtained. Stomach peristalsis quite marked at times. Gurgling felt over small intestines. Stomach washing with sterile salt solution, as preparation for operation, begun. Stomach holds about two liters. Cover-slip preparations show streptococci and staphylococci and numerous bacilli.

February 7th. Stomach washing continued. Cultures taken from the residual material. Cover-slips show only a few streptococci in short chains ; number much decreased since February 5th.

February 8th. Only a trace of free hydrochloric acid ; no lactic acid. Total acidity, 6.2 cc, 0.1 NaOH solution. Stomach peristalsis readily seen at times. Patient has been kept on sterile diet ever since his transfer to the surgical side. Has carbolic-acid gargle three times daily. Teeth cleansed three times daily with listerine and brush. Ingesta are boiled water, boiled milk, softboiled eggs, albumin. Micro-organisms seem to have entirely disappeared from the stomach, for the Petri plates are now sterile. Patient has shown great irregularity in amount of hydrochloric acid — at one time five per cent., at another zero.

February 9th. Operation.— Vertical incision through left rectus. This incision was made with the expectation of a possible gastroenterostomy. Stomach much dilated. In the region of the gallbladder is a mass of tissue tangled by dense adhesions. In this mass are gall-bladder and pylorus. The mass feels not unlike a new growth. Search for metastases negative, but a small, hard, dark tumor, the size of a pea, is discovered in the right lobe of the liver, near its edge, evidently an angiosarcoma. Pylorus separated from gall-bladder with the greatest difficulty. The separation had to be effected with the knife. It was impossible at first to determine accurately the relations of the gall-bladder, pylorus and duodenum to each other. In the course of the dissection a pinhole opening was made in what proved to be the duodenum. The surrounding parts had been well protected against such an accident. A drop of fluid escaped, and from these cultures were taken. The little hole was immediately sutured. The gall-bladder was next opened, and not until then could it be determined positively that the pinhole opening was not in the gall-bladder, the contents of duodenum and gall-bladder so closely resembled each other ; it was a thick, ropy, mucoid, colorless material. The gall-bladder was finally completely isolated. It was small and misshapen and


contained two or three hard mulberry-like gall-stones. The cystic duct contained no stones ami seemed to be very short and very fine. It was surrounded by numerous small vessels, two of which were tied. There was no bile in the freely opened gall-bladder, which was drained in the usual way with a rubber tube, a catgut purse-string suture sealing the bladder hermetically about the tube. Bismuth gauze was packed about the outside of the gallbladder. The peritoneum was closed with silk ; the muscles, fascia and skin with silver. Patient bore the operation very well. At G p. m , temperature 101°; respirations quiet and regular. Some distention of upper abdomen.

February 10th. Patient has been vomiting. Complains of pains in stomach and tightness across abdomen. Pulse 108 and feeble ; respirations 24 ; temperature 101°. Leucocytes at 12.30 p. m., 26,800 ; at 1.30 p. m., 34,000 ; 5.30 p. it., 36,000 ; 7 p. m., 37,800. At 6 p. m. patient drowsy, quiet ; respirations, 34 ; hands cold ; pulse barely perceptible. Cover-slips show no micro-organisms in the blood. Five hundred cc. salt solution infused under each breast. At 10 p. m. 1000 cc. salt solution infused under breasts. Pulse improved, 140 to minute ; low tension but regular rhythm. Respirations 36 ; expirations accompanied by short groans. Occasional hiccough ; no vomiting; no nausea ; no pain.

February 11th, 2.15 a. m. Patient died quietly.

Autopsy. — General peritonitis. Organisms, streptococcus pure. In the walls of the first portion of the duodenum, very near the pylorus, was an accumulation of thin mucopurulent fluid. This was held in bounds by a soft wall of granulations ; it was evidently an old abscess between mucosa and submucosa, which communicated with the lumen of the duodenum by a fine opening. A minute ulcer had perhaps been the starting point.

The first portion of the duodenum was distended, and the stomach was dilated ; the distention was due to the constriction produced by the adhesions, for which the gall-stones were responsible ; as a consequence, perhaps, of the distention and the resulting venous stasis, a minute duodenal ulcer ; and from the ulcer, the abscess, which was probably responsible for the fatal streptococcus peritonitis.

Of special interest in this case is: (1) the fact that carcinoma had been suspected — the duodenal stenosis, the dilatation of the stomach, the presence of Opper-Boas bacilli (?) justified the suspicion ; (2) the success which attended Dr. Cushing's efforts to sterilize the stomach ; the micro-organisms had apparently entirely disappeared from the stomach on the day preceding the operation, for the Petri plates, which from day to day showed fewer colonies, for that day were sterile; (3) the dissecting intramural abscess, starting probably from an ulcer which may have been due to thrombosis of a small artery, or to distention of the first part of the duodenum, or to vascular disturbances of some kind, infectious or mechanical. Although thrombosis of a small intestinal artery does not lead to infarction it may cause hemorrhages into the lumen of the intestine and slight intramural extravasations.*

Kocherf has demonstrated that in consequence of distention of the gut by retention of its contents and the resulting venous stasis, very considerable changes take place in the wall of the intestine. He writes as follows: "Arnd has proved that in strangulated hernias, when the circulation is greatly interfered with, micro-organisms make their way into the mucous mem


  • Archiv fur pathol. Anat. u. Physiol., 1875.

t Kocher : Mittheilungen aus den Grenzgebieten der Medizin und Chirurgie, Bd. iv, Heft 2, 1898.


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 106.


brane and can pass through the intestinal wall (diapedesis of the micro-organisms). On the other hand, Cassin* and Charrin f have shown how very important the normal epithelium of the intestine is as a protection to the intestinal wall against micro-organisms as well as ferments. The absence of this protection against ferments and bacteria leads to intoxication and infection. Finally, Beichel J has demonstrated that the considerable accumulation of fluid above the site of the obstruction is due in part to a hypersecretion of the mucous glands. Under the influence of the intestinal contents which, increased in amount and stagnating, are the more rapidly decomposing (the ofttimes considerable phenoluria and indicanuria is proof of the increased decomposition), the epithelium in the first place becomes destroyed because its nutrition is interfered with under the influence of the venous stasis. There result circumscribed necroses and hence ulcerations of mucous membrane, particularly in places where the venous stasis led to ecchymosis, and, finally, perforation of the serosa and peritonitis may occur. For the origin of these ulcers which, many times observed, have not been properly estimated in their relations to ileus, various explanations have been given. The most substantial explanation is the one which attributes them to the pressure of hard scybala, and it is not to be doubted that hardened fecal matter, just as foreign bodies — gall-stones, for example — can have pressure ulcers as a consequence. But the ulcers which we have pictured are certainly not dependent upon hard intestinal contents and the decubitus which they may mechanically bring about. They occur in jejunum and ileum as well as in colon by the filling up of these intestines with fluid or gas. The only factor which constantly accompanies these ulcers is overdistention of the intestine. Inasmuch as one can experimentally bring about a significant impairment of the circulation of the intestinal wall and its consequences, by overstretching of the gut, we hold to the proposition that the ulcers are best called distention-ulcers (Dehnungageschwure). Long ago I called attention to the fact that ulcers of just this kind could also in cases of strangulated hernia lead to a fatal peritonitis after constriction had been relieved, or a gangrenous loop of intestine had been resected and an entirely trustworthy suture had been made."

Case II. — Primary carcinoma of the duodenal papilla and diverticulum of the Vater, successfully removed by operation ; cyslico-enterostomy three months after the first operation. — Mrs. M. L., age sixty. Until August, 1897, patient was well. Her first symptom was itching of the skin, which came on suddenly and soon became severe. Patient says jaundice did not appear for nearly a month after the onset of the itching. Before the appearance of jaundice diarrhea set in, and there were six or seven stools a day which were watery and clay-colored. Patient has had no chills, no fever and no sweating. With the onset of the jaundice she noticed shortness of breath and an occasional swelling of the feet and legs. About the firstof January, 1898, she had persistent bleeding of the gums for three days, following the extraction of a tooth. At times the hemorrhage was profuse.


  • Mittheilungen aus Kliniken der Schweiz, Basel, 1898.

fFonctions protectrices de la muquese intestinale, Soc. de biologie, December, 1895. }Zur Pathologie der Ileus, Deutsche Zeitschrift fur Chirurgie.


Two months ago a tumor was noticed in the region of the gallbladder. This tumor does not seem to the patient to have increased in size and has never been tender. In March, 1897, she had several attacks of severe pain in the epigastrium. These attacks were not accompanied by vomiting or fever or sweating. A few weeks later she had a second but milder attack. The stools were light in color for two or three days at the beginning of these attacks, but patient recalls no change in the color of the urine or the skin at that time. The daughter of the patient states that these attacks of pain were very severe, and that her mother seemed very ill.

Examination February 14, 1898. — Patient somewhat emaciated, but fairly well-nourished. Mucous membranes pale. Heart and lungs normal. There is a distinct prominence on the right side, the highest point of which is midway between the umbilicus and anterior superior spine. The prominence descends markedly with inspiration. On palpation the prominent area proves to be pearshaped and distinctly fluctuating. The border of the liver, which reaches almost to the crest of the ileum, can be distinctly felt.

February 14, 1898. Operation. — Vertical incision through rectus muscle. A greatly dilated but not especially dense gall-bladder presented no adhesions. Liver projects five cm. below costal margin. Four silk sutures* placed in fundus of gall-bladder with French needles. Small aspirator introduced in center, between sutures; syringeful of clear fluid withdrawn. Gall-bladder opened ; contents evacuated. In the latter part of the fluid were many fine, sand-like, hard, greenish, round particles, suggesting miniature gall-stones. Common and cystic ducts were dilated to the size of one's thumb. A longitudinal opening two cm. long was made in the common duct. The same colorless fluid escaped from this incision. Duct explored with probe and finger. What seems to be a small, very hard stone is felt at site of ampulla. To determine the nature of this body, an incision was made through the wall of the duodenum. Noglandular metastases discoverable. Thestonelike body proved to be, as was feared, a carcinoma of the papilla.

Excision of the cancerous growth. — To give the growth a wide margin, a large piece of duodenum was excised, a wedge-shaped piece with the apex at the mesenteric border of the intestine. About three-quarters of an inch of the common duct and a shorter piece of the pancreatic duct were excised. The wound in the duodenum was closed in the usual way with mattress sutures. This was practically an end-to-end anastomosis of the duodenum. The common duct and pancreatic duct were transplanted into the duodenum along the line of suture. A linear incision into the common duet, which had been made for diagnostic purposes, was closed over a hammer. The gall-bladder was sutured to the peritoneum.

Abdominal wound closed in the usual way ; the peritoneum with a running silk suture, the muscles and fascia with buried silver sutures, and the skin with a continuous subcuticular silver suture. Bismuth gauze inserted to protect the suture of the intestine and common duct. Drainage tube surrounded by bismuth gauze, and gutta-percha tissue inserted into gall-bladder and held in place by a purse-string suture of catgut. Wound dressed with silver foil. Gutta-percha tissue placed between the raw edges of the skin and the gauze packing. Operation lasted three hours and ten minutes. Patient experienced apparently no shock from the operation.

February 16, 1898, first dressing. Profuse discharge of bile in dressing. Icterus less intense. Considerable abdominal distention, but no signs of peritonitis.


  • We find this a very useful procedure. The gall-bladder is manipulated by

these sutures and handling is thus avoided. These sutures are of additional service when it seems advisable to distend, subsequently, the gall-bladder with (iuid, and when it is desirable to close it temporarily during the operation.


January, 1900.]


JOHNS HOPKINS HOSPITAL BULLETIN.


February IS, 1898. Distention has almost completely disappeared. Tongue clean. Patient comfortable.

February 22nd. Discharge of bile into dressings still profuse. Stools becoming distinctly bile-stained. Icterus rapidly disappearing. Urine dark and gives bile reaction. Patient hungry.

February 27th. Skin sutures, tube from gall-bladder and the last of the bismuth gauze removed. Evacuations not bile-stained.

March 4th. Discharge of bile diminishing. Opening in gallbladder has been plugged for several days with bismuth gauze in order to determine, if possible, whether or not the transplanted common duct is patulous. Yesterday patient vomited 125 cc. of brownish fluid.

March 5th. Patient has had a large stool, quite dark in color. There is very little leakage from the opening into the gall-bladder, which is almost closed.

March 13th. Icterus continues undiminished. Stools are still slightly bile-stained. Abdomen somewhat distended. Active peristalsis is occasionally visible through the abdominal walls. Liver still readily palpable, the right lobe extending almost to the iliac crest. Appetite good ; tongue clean ; no indigestion.

March 27th. Attempts to plug the opening of the gall-bladder, with the hope of forcing bile into the intestine, not satisfactory, although there is some bile in the stools. Patient's general health good. Icterus has disappeared. Patient able to walk about, and is gaining strength rapidly.

April 5th. The conjunctivae are clear, but there remains still some evidence of bile pigment in the skin. No bile whatever in the stools, although the opening into the gall-bladder is almost closed ; it is barely large enough to admit a probe. Patient is beginning to have indigestion. The appetite as a rule, however, is good. The liver is diminished in size.

April 8th. Patient complains of colic and abdominal pain. Considerable abdominal distention. Dressings bile-stained. No nausea ; tongue is clear.

April 12th. Some nausea and vomiting. No distention of abdomen. Dressings very slightly bile-stained.

April loth. Abdomen soft and relaxed, but borborygmi heard by attendant and appreciated by patient. Little or no bile in dressings.

May 5th. Second operation: cholycyslduodenostomy, or eysticoduodenostomy. — Snture of fundus of gall-bladder. Complete closure of abdominal wound except for drainage. Incision alongside of old cicatrix, circumscribing fistula. Gall-bladder quite small, no larger than one's thumb. Liver about normal in size. Many fine adhesions about gall-bladder, which were easily separated. Gallbladder and ducts thoroughly exposed. The line of suture of common duct at previous operation was readily distinguishable by black-silk stitches, but it was almost impossible to find any trace of the duodenal suture. Common duct incised at site of old suture. Probe cannot be passed into the duodenum, but there is no positive evidence of the recurrence of the cancer. Unsuccessful attempts had been made before the operation to pass a probe from the gall-bladder through the common duct into the duodenum. Opening into the common duct closed in the usual way with mattress sutures over hammer. An anastomosis between duodenum and the gall-bladder or cystic duct was effected without much difficulty, although the parts to be sutured were very deeply situated and inaccessible. The duodenum was probably a little less freely movable than at the previous operation, and the gallbladder was so much reduced in size that we were compelled to pass some of the stitches into what seemed to be the cystic duct; in any event, the neck of the gall-bladder had to be used for the anastomosis. A bougie a boule, passed into the gall-bladder, was used as a darning ball to assist in the placing of the sutures. All the sutures were passed (none of them tied) before the openings into the neck of the gall-bladder and duodenum were made, the method employed being that which I described many years


ago for intestinal anastomosis. The opening in the fundus of the gall-bladder was closed with mattress sutures which inverted the wall. The abdominal wound was completely closed except for protective wicks which were passed through this line of suture into the gall-bladder. What seemed to be an enlarged gland was palpated during the operation but not removed ; it was forgotten. Patient suffered little or no shock from the operation.

May 6th, 4.30 p. m. Patient very restless, tossing about and occasionally vomiting. Ten p. m., has had occasional quiet naps and is more comfortable.

May 7th. Complains of pain in back and abdomen.

May 8th. Is very comfortable. Yellow stool, containing small particles of brown fecal matter.

May 9th. Large greenish-yellow stool.

May 11th. Patient has had daily, since last note, one or two greenish-yellow soft stools. She still complains of slight pain in abdomen.

May 12th. A large, quite well-formed greenish-brown stool. Considerable flatus expelled ; complains of gas in stomach. Slight nausea. Four p. it., vomited thick, mucus-like, chocolate-colored fluid containing milky curd.

May 29th. Patient complains of itching in the hands where the pruritus has always been the greatest when icterus was pronounced. No jaundice, however, is apparent.

June 8th. Slight chill, followed by rise of temperature to 39°. Trace of bile in the urine. Nausea, but no vomiting. No pain and scarcely any tenderness of the abdomen. Wound almost completely closed.

June 9th. Temperature normal ; patient feels well.

In the early autumn of 1898 this patient returned to the hospital too ill for operative interference, and in a few weeks died. During the summer I had corresponded with her, urging her to return to the hospital, for it was clear from her letters that the fistulous communication between the gall-bladder and the duodenum was not working well. At the autopsy it was found that the carcinoma had recurred in the head of the pancreas and duodenum closing the common duct and interfering with the perfect action of the cholecystenterostomy, or cystico-enterostomy. The anastomosis, as we had supposed, had been made between the dilated cystic duct and the duodenum ; the fistula was still perfectly pervious and should have acted nicely except for the interference, a little twisting or bending, created by the new growth.

The result in this case is not encouraging, for it was my opinion at the time of the operation that the case could not have been more favorable. But I did in this case what I never do if it can be avoided, namely, cut well down to or perhaps a little way into the new growth for the sake of diagnosis. It is furthermore a rule in myelinic that pieces shall not be excised from new growths in vivo for diagnostic purposes ; we must learn to make the diagnosis in other ways. In the case of a very small breast tumor it is occasionally impossible to make the diagnosis before operation. I have sometimes approached the tumor with the knife very cautiously, and could tell before I reached the growth, from the findings in the outlying tissues, whether we had a malignant tumor to deal with or not. I shall have more to say about this at another time, but I feel that one cannot condemn too strongly the universal practice of exploring tumors with the knife or with the harpoon or even with the needle. After investigating the subject superficially, I have the impression that amputations for the truly malignant


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 106.


sarcomata have comparatively seldom been successful when preliminary exploration has been done. If I find it necessary to make an incision into a sarcoma of an extremity, I first apply an Esmarch bandage, and if the tumor is a malignant growth, the bandage is not removed until the growth has been removed. So, too, in cysts of the breast; we should not aspirate them, because (1) they may be malignant and the aspiration harmful, and (2) if maliguant, the aspiration does not tell us so. This is the first and I believe the only instance in which an operation for primary carcinoma of the duodenal papilla has been done ; moreover, I know of no other case of excision of a portion of the common duct. Heidenhain* (Worms) demonstrated last year at the twenty-seventh Congress of German Surgeons, a shriveled gall-bladder which he had removed for a small cancer of its wall ; after extracting six calculi from the bladder, a little button-like prominence on its wall caught his eye. The microscopical examination showed little or no thickening of the mucous membrane, but unmistakable alveoli in the muscular wall of the gall-bladder; furthermore, some of the lymph-vessels were plugged with cancer cells. In three months the patient succumbed to livercancer which had attained great dimensions, although at the time of the operation the liver was apparently perfectly normal. At the same session Hollander! (Berlin) reported an extirpation of the gall-bladder and cystic duct and resection of a portion of the liver for cancer, which per continuitatem involved the liver. The result he could not give, for he had performed the operation only three weeks before. There can be little doubt as to the ultimate result of Hollander's operation, although, having operated only three weeks previous to his report, he could not give it.

Case III. — Dynamic or paralytic dilatation of first portion of duodenum and of the pyloric end of the stomach correspondiyig accurately to the limits of a sharply circumscribed peritonitis. Oall-stones in gallbladder and cystic duct. Obstruction of cystic duct and hydrops vesical. — Mrs. S. G. M., age forty six. Admitted January 31, 1899. Never had typhoid fever. Headaches at intervals all her life, sometimes very severe and lasting several days; especially severe during menstruation. Digestion has been bad for sixteen years. After meals a heavy feeling in epigastrium followed by fullness and a feeling of suffocation. Belching of gas common; occasionally would regurgitate a mouthful or two of food. Rarely vomited ; never any blood in vomitus. Bowels generally constipated. Micturition frequent, occasionally twenty times a day ; generally several times at night. Menses regular. Average weight, one hundred and fifteen pounds. Has lost in weight of late. Present illness, patient states, began December 31, 1898, although she was much run down before that time. This attack came on gradually. Some distention of stomach, and in the afternoon some pain which became severe at night. The pain was in the epigastrium — a colicky pain — which, as she expressed it "went through the abdomen." Morphia exhibited. Next morning patient felt easier. Morphia continued for next two days. Pain relieved but not entirely subdued. Stools after this were very black, like tar. Physician found something in the stools which he thought might possibly be a gall-stone. Since this attack patient has never been well ; constantly in bed. Great deal of soreness through abdomen, and at times attacks of colic. These


  • Heidenhain : Verhandl. d. deutsch. Ges. f.Chirurgie, 1898, p. 126.

t Hollander, I. c. p. 131.


attacks usually came on in the evening without known cause. Much belching of gas. Bowels regular. Stools not clay-colored. No jaundice. Patient's daughter states that for many years her mother has had attacks of abdominal pain, for which the doctor gave morphia hypodermically. There were intervals of several months between the attacks.

Examination. — On palpation no tenderness except beneath the right costal margin. Here there is to be felt a rounded mass resembling a distended gall-bladder. Right rectus muscle very hard. The mass which is to be felt at the outer edge of this muscle seems lobulated.

January 29th. Attack of what patient calls "colic." She ia nervous and distressed, and complains of abdominal pain. Swallows air and belches it up again.

January 31st. Transferred to surgical side. On inspection a distended piece of gut between umbilicus and tumor, extending obliquely from the left and above to the right and below, probably six or eight inches in length. Peristalsis is to be observed at intervals ; it is not very active, but at times is quite constant. A tumor suggesting gall-bladder projects from the lower border of the liver. It seems to be nodular, or rather has a nodule on it at its upper part. This tumor descends with respiration, and is somewhat tender. The edge of the liver can be felt on each side of the tumor.

February 3d. Operation. — Vertical incision through right rectus muscle. No fluid in abdomen. Gall-bladder distended to size shown in diagram on blackboard. Its walls were thickened and white. The first portion of the duodenum and the pyloric end of the stomach were distinctly distended. Corresponding accurately to the distended portion of the bowel was a slight peritonitis, scarcely more than an injection of the serosa, and an exudate, only enough to cause very fresh adhesions between the duodenum and the gall-bladder. We should hardly call them adhesions ; the duodenum seemed rather to be lightly glued to the gall-bladder just as it might be an hour or two after an operation.

I was extremely interested to find that the vascular injection seemed to correspond accurately to the limits of the dilatation (almost ileus at times). The adhesions, if we choose to call them such, were so fresh that they were separated by very slight pressure of the finger. The general abdomen being walled off by gauze packing, the gall-bladder was opened. Its contents were colorless and in consistency like the white of an egg. Cover-slips were negative. First, one large gall-stone was found with a facet at each end. Then a second stone was detected with a probe in the cystic duct, but it could not be dislodged. Cysticotomy was performed and the stone removed in fragments. The previous attempts to dislodge it had evidently broken up the stone. Incision in cystic duct closed by mattress sutures. Gall-bladder treated in the usual way, namely, hermetically sealed about a rubber tube and protected by bismuth gauze, from the general peritoneal cavity. Abdominal wound closed in the usual way.

At first no bile escaped by the tube, but on the 10th of February, bile was abundant in the dressings.

March 2d. Wound has completely healed. Patient discharged eured.

Various diagnoses had been made in this case : (a) distended gall-bladder with adhesions ; (b) cancer of bile-ducts and liver, involving secondarily the colon; (c) carcinoma of the colon, involving secondarily the gall-bladder and gall-ducts. The distended intestine I watched with much interest several times. It seemed to me too small for colon : and no mass could be felt in the distal side of the distended gut to explain the distention. Peritonitis is undoubtedly the most common cause of paralytic ileus, and I have repeatedly observed in appendicitis that dilatation of the cecum and of the ileum may


Jaxuart, 1900.]


JOHNS HOPKINS HOSPITAL BULLETIN.


be caused by a very slight, perhaps merely a toxic peritonitis, but I have never before noticed such a sharp line of demarcation between the inflamed and noninflamed portion of the intestine. The dilatation corresponded accurately to the vascular injection. This was the more striking because two portions of intestine so very different were involved. That the comparatively thin wall of the duodenum should be more or less affected by inflammation of its serosa is to be expected, but that such a thick-walled gut as the pylorus and the pyloric end of the stomach should be paralyzed by such a very slight inflammation of the serosa was surprising.

Case IV. — Conditions suggesting hepaticocholecystostcholecysienterostomy as a possible operation. Common and cystic ducts reduced to fibrous cords, dilated hepatic duct and gall-bladder. Renal colic

stimulating intestinal colic; relieved by salt infusion. — Mr. ,

age sixty, had been suffering from gall-stones for several years, but not until be became persistently icteric and very ill was the first operation performed. The operator, a distinguished surgeon, found most difficult conditions confronting him. The entire common duct was impervious and reduced to a librous cord ; the cystic duct, greatly narrowed, was probably impervious ; the gall-bladder and hepatic ducts were dilated. The surgeon, very skillfully, I am told, attempted to construct a new common duct over a tube or catheter from the tissue which he had at his disposal. Just what these available tissues were I do not quite understand. For about five weeks, and until this tube was removed and the surgeon went away on his vacation, the patient was fairly comfortable and seemed to be gaining a little. Then he developed high daily fever and occasional chills, and became jaundiced again. I saw the patient in consultation with Dr. Gardner, of Providence, about one week, I believe, after the fever and the symptoms of obstruction had manifested themselves. The gall-bladder could not be felt. There was perhaps a little more muscle resistance on the right side over the region of the bile-ducts than on the left side, also perhaps the suggestion, rather indefinite, of a little induration such as might be caused by fresh adhesions. It occurred to me that in case the gall-bladder and hepatic ducts were still both dilated one might establish a fistulous communication between them, making an hepaticocholecystostomy and then, immediately, a cholecystenterostomy ; in all an hepaticocholecystostenterostomy. In any event, we thought that an operation for the relief of the symptoms was imperative. Accordingly a vertical incision through the inner margin of the right rectus muscle was made, avoiding the fistulous tract which remained after the withdrawal of the tube over which the new common duct had been constructed. I worked for two hours trying to identify and to separate the parts concerned in this operation. The gall-bladder, the ducts and the duodenum were glued tightly together and to the under surface of the liver. The gall-bladder which was finally extricated from the tangle was very small, contracted and empty ; the cystic duct was a fibrous cord. When bile was at last reached the patient was in such bad condition that the operation had to be discontinued. The parts in the neighborhood of the common and hepatic ducts were so firmly matted together that neither the latter nor the remains of the former had been demonstrated when it was necessary to bring the operation to a flose.

The patient rallied satisfactorily from the immediate effects of the operation ; but twelve or fourteen hours thereafter complained of very severe abdominal pain, which, as he indicated the location of it, ?eemed to be in the region of the colon and passing from right to left. The pain, though perhaps constant, became excessive during the paroxysms. It was never referred by the patient to his back or sides, nor did it radiate to the testicles or groin or crest or ilium. The abdomen was perfectly flat, and peristalsis could


not be observed. Nevertheless, large high enemata of hot water were given, but without appreciable relief- The urine was scanty and very dark and contained albumin and casts and a few bloodcells. Dr. Gardner promptly attributed the pains to the kidney, and related a somewhat similar case. Believing his interpretation of the pains to be correct and recognizing the fact that something must be done quickly for the relief of the kidneys, I transfused about 750 cc. under the breasts. The pulse, which was alarmingly rapid before the transfusion, dropped 40 beats within thirty minutes, and 20 beats within five minutes, and the colicky abdominal pains disappeared. Within twenty-four hours the infusion was repeated with similar results. The kidneys responded promptly to both infusions.

I report this case because (1) it suggested a new operation, hepaticocholecystostcholecystenterostomy, or hepaticocholecystosteuterostomy ; (2) it was the first of three cases of colic which I have seen associated with scanty high-colored urine ; and (3) it was, so far as I know, the first instance of subcutaneous infusion of salt solution for the relief of toxic renal colic. Soon after this Dr. Young, by salt infusions, undoubtedly saved the life of one of my patients whom I had operated upon for appendicitis, and who was suffering from perhaps the most furiously rapid toxemia that I have ever known of. This case has been reported by Dr. Young in the Maryland Medical Journal. The resemblance to intestinal colic is so great that it would undoubtedly be mistaken for it even by experienced practitioners of medicine. This was a valuable lesson for me, for since then I have twice recognized as renal colic this pain, which had been regarded as intestinal colic and treated with high injections. Our list of desperate cases of toxemia treated advantageously with infusions of salt solution is assuming large proportions.

Case V .—Choledochotomy performed twice within four and onehalf months. The gall-bladder, small and contracted at the first operation, when two stones were in the common duct, was large and distended when only one stone occupied the common duct (the ampulla). — Mrs. M. P. E., age fifty-eight, admitted May 3, 1897. October, 1892, patient began to have moderately severe attacks of pain in the region of the gall-bladder. The attacks would come ou suddenly and last several hours unless relieved by anodynes. The pain, milder at first, would gradually increase until it became very severe ; it commenced in the epigastrium and extended into the right hypochrondrium. During the winter of 1892-1893 the attacks occurred every two or three days. Occasionally there would be an interval of two or three weeks. During the remainder of 1893 and all of 1894, the attacks persisted at longer or shorter intervals, the pain always beginning in the epigastrium and radiating to the back. Sometimes during a severe attack there would be slight vomiting. Morphia generally gave relief. Patient says that the attacks were not accompanied by tenderness nor tumefaction. In the attacks observed by me there was always tenderness and, after the first operation, distention of the gall-bladder. In the spring of 1895, she went to Hot Springs, Va., where she remained several months. After this she had no pain for fifteen months, but did not seem to gain or improve in health. In September, 1896, in Italy, the pain returned. The attacks recurred with great regularity for seven or eight weeks. Most of them were attended by nausea and some by vomiting. She became jaundiced for the first time in December, 1896, and has remained more or less icteric until admission. Just after the paroxysms the icteric is deeper. For the past five months she had remained in bed most of the time. She vomits frequently, is seldom free from nausea. The bowels


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[No. 106.


have not been markedly constipated ; appetite is poor ; headaches occasional but not severe. Prior to this illness, however, she suffered very much from headaches. At no time has she had chills or sweating.

Examination. — Patient is quite deeply jaundiced ; her color is a dark slate-yellow ; tongue heavily coated ; body much emaciated ; expression rather dull, eyes lusterless. Heart not enlarged ; no adventitious sounds. Lungs negative. Urine dark, almost coffeecolored, trace of albumin, much bile-stained sediment. A few bilestained casts and epithelial cells. Red blood-corpuscles, 4,220,000 ; white, 6,000.

May 4, 1897. First operation. — Longitudinal incision through right rectus muscle ; resection of cartilages of eighth, ninth and tenth ribs, because the common bile-duct was very inaccessible. Choledochotomy ; removal of one small mulberry calculus. Exploration of duct fails to detect a second stone. Suture of duct wound. Gall-bladder atrophied and not opened. Bismuth gauze packing to suture in duct. Peritoneum sutured with fine silk, muscles and fascia with silver wire, and skin with a buried suture of catgut. Little or no shock from the operation.

On opening the abdomen the tissues were bile-stained. There was no fluid in the peritoneal cavity. The outer surface of the contracted gall-bladder was covered with new connective tissue in which were little masses of fat. The omentum was loosely adherent to the gall-bladder. The cystic and common ducts were easily isolated after division of three of the costal cartilages. No stones could be felt in the bladder or cystic duct. The stone found in the common duct could be moved quite freely up and down in this duct, but could be forced into the cystic duct, the common duct, about 1J cm. in diameter, being uniformly dilated. Bile flowed from it when opened. It was carefully explored with the fingers but not with an instrument. The gall-bladder was not opened. Two mattress sutures closed the opening in the duct, one preliminary suture being taken before the duct was opened. The sutures were passed without difficulty, the wall of the duct being about 3 mm. in thickness. No leakage occurred after the stitches were tied. The calculus, without facets, was spherical, about 1.6 cm. in diameter, and had a granular surface like a mulberry calculus.

May loth. Patient has recovered uneventfully from the operation. She is easily nauseated, however, and has very little desire for food. The stools have about the color of dark coffee and the skin has become lightened perceptibly. She complains, however, of an aching pain in the back, not relieved by posture.

May 24th. Patient has no inclination to eat; takes almost nothing by mouth. Nutritive enemata, which have been administered uninterruptedly since the operation, are still well borne. About every two days there is quite a definite attack of pain in the umbilical region and back, ushered in by nausea. Vomiting usually follows in a few hours and the distress is relieved.

May 29th. Condition little changed. Patient is fairly comfortable except for the attacks. Takes a little more food. Stools semi-solid and still quite dark. Urine has trace of bile.

June 13th. No bile in urine. Vomitus contains considerable hydrochloric acid.

June 26th. Appetite and digestion have steadily improved. Nausea less constant, often absent. Patient constipated, requires enemata; stools normal as to color.

July 4th. Much more comfortable. Nausea has disappeared ; color greatly improved, but the attacks of pain continue, although they are less frequent.

July 13th. Slight chill at 5.30 p. m., accompanied by pain in the back and head. Temperature reached 103° at 7.30 p. m.; fell to 99.2° at 5 a. m. Examination of blood for malaria, negative.

July 25th. Patient has lost one and one-half pounds in weight in the past week. The right lobe of the liver is enlarging. The spleen is palpable. Patient is having short attacks of fever accompanied by slight chills ; headache and yawning usually associated


with them. The attacks of pain continue ; they are still controlled by very small doses of morphia, one-sixtieth to one-fortieth of a grain. She sits up out of bed most of the time.

July 27th. The pain in the back has of late been accompanied by a slight rise of temperature, 99.2° to 105.5°. The urine contains no bile. The stools consist of light and dark portions sharply separated. Patient is gaining quite rapidy in weight.

August 5tb. Stools clay-colored. Temperature reached 102° last night during an attack of pain. Skin is becoming icteric ; urine contains bile ; slight pruritus. Patient's weight has increased five pounds in ten days. From August 8th to 12th no bile in urine.

Sept. 12th. The attacks of pain and the pyrexia continue. Patient is decidedly icteric after some of the more severe attacks. What we have feared ever since the operation we are now quite certain of, namely, that there is still a stone in the common duct, probably in Vater's diverticulum. The liver is considerably enlarged, but the gall-bladder has not been definitely made out.

September 13th. Second Operation. — Vertical incision near linea alba. Adhesions from previous operation separated without much difficulty. Liver much enlarged ; gall-bladder and common duct distended with bile. The wall of the common duct was much thicker; the wall of the gall-bladder, on the other hand, was probably thinner than at the previous operation. A small stone was palpated deep down behind the duodenum, presumably in the ampulla. The line of the old suture in the ductus choledochus could not be very definitely made out, but a short yellowish-white streak, evidently cicatricial tissue, corresponded, I thought, to the site of the original slit in the duct. A fine suture was placed in the common duct to serve as a handle for the subsequent manipulations. The duct was opened, and about 60 cc. of clear greenish bile escaped. A gauze plug was inserted into the proximal end of the slit to prevent the stone from slipping into the hepatic duct. Interrupted sutures were taken over a hammer of the proper size. The dislodgment of the stone was somewhat difficult. It was a little smaller than the first stone, but otherwise repeated the original exactly. The gall-bladder was opened, sewed to the peritoneum, and drained in the usual way ; a rubber tube surrounded first by gauze and then by protective being held in place by a purse-string suture of catgut. Wicks of bismuth gauze protected the line of suture in the common duct. The operation was attended with very little shock and the patient reacted very well.

Sept. 20th. There has been more or less nausea ever since the operation. Patient objects decidedly to stomach washing. Bile is draining actively from the tube. There has been little or no nausea to-day, but patient is weak and much depressed. The removal of a piece of gauze from the gall-bladder gives patient the first sensation of "heartburn," which she has had since the operation ; it lasted several hours.

Sept. 22d. Patient is thin and emaciated and alarmingly weak ; speaking is a great exertion to her. Temperature subnormal. There are no wound complications, nor any signs of peritoneal irritation or obstruction. Alimentation is almost exclusively rectal ; 6 p. m. vomited 1000 cc of fluid thick with "coffee grounds." Patient very restless. Examination of vomitus: No bile; bloodcorpuscles abundant; altered blood pigment; free hydrochloric acid ; no lactic acid.

Sept. 23d. Patient has vomited several times during the day ; in all about 2000 cm. of the same dark coffee ground vomitus. The pulse is very feeble.

Sept. 24th, 8 a. if. Pulse barely susceptible early this morning ; rallied a little after exhibition of salt solution per rectum. Still vomiting large amounts of same fluid, though nothing is being administered by mouth. 12 m. Patient is very low but still conscious. Infusions of salt solution were given under breast and in buttocks. 5.15 p. m. One drachm of one per cent, solution cocaine given by mouth. 5.30 p. m. Patient vomited 360 cc. of same dark fluid. Cocaine given again. No vomiting since second dose.


January, 1900.]


JOHNS HOPKINS HOSPITAL BULLETIN.


Sept. 25th, 1 a. m. Patient responds a little to the saline infusions. She is moaning and restless. Her nose and extremities are cold. She sleeps in short naps, with her eyes open and eyeballs rolled up. Complains greatly of thirst. Champagne and albumin retained and apparently relished.

Sept. 28th. Infusion again soon after midnight. Involuntary stools and small amount of dark vomitus. Is somewhat flighty at times. Pulse is thready, irregular, and cannot be accurately counted. She is sighing and seems almost moribund. Too weak to recognize surroundings or members of the family. About noon to-day I saw the patient for the first time since the third day after the operation, having returned to town as rapidly as possible in response to a telegram sent forty-eight hours ago. Dr. Cushing, house surgeon, who had attended her constantly, day and night, met me at the door of the hospital with the words, " no hope, she is dying. We went to her room ; she was cold and almost unconscious ; her eyes were open, the eyeballs rolled up ; the lower jaw had dopped. She had had more involuntary movements and could retain no nourishment. Her pulse was littre better than a flutter and could not be counted. In less than forty-five minutes I returned to the patient and found her pulse 120, and fairly regular in force and rhythm. I doubted my senses when I counted it. She was moreover not so cold, her eyes were not staring, and her lower jaw was raised. A miracle ! From that moment her convalescence was uninterrupted. She slept an hour, and on waking looked better than she had in two or three days. For twenty-four hours she was so weak that she could barely move her arms. She remembers nothing that transpired on the 23d, 24th and 25th of September.

In eight weeks, on November 22d, this patient left the hospital, not only able to walk but to take a long journey on the railroad. In one period of seven days she gained nine pounds. Her liver was rapidly diminishing in size.

In April, 1898, I had the pleasure of seeing this patient again. Her color was natural, her digestion excellent, her weight above normal and her strength steadily increasing. Her liver did not extend below the costal margin.

I have seen many cases regarded as hopeless recover, but never a being so near death as this have I known to escape it. I have speculated much as to the possible explanation of the very sudden change in her favor, but it would lead us beyond the limits of this paper to discuss the matter. In toxemias I have noted almost instantaneous drops in the pulse rate. Twice within a month I have observed a fall of 30 beats to the minute follow in less than thirty seconds the opening of an abscess. The abscesses were large and very acute ; one was a suppurating laparotomy wound and the other was a circumscribed abscess in the peritoneal cavity. The very instant that the abscesses were opened the change in the pulse was noted. A few months ago we were preparing to infuse with salt solution a patient upon whom I had operated for gall-stones and whose condition gave me not a little anxiety. His respirations were about 40 per minute and his pulse between 130 and 140. The physical signs indicated not very clearly some consolidation of the lower lobe of the right lung. While the instruments were being sterilized for the infusion, and while Dr. Cushing, the house surgeon, was counting the pulse, it fell to less than 100.

Was the hemorrhage from the stomach in the case of Mrs. R. (Case V) due simply to the prolonged vomiting; or to interference with the circulation of the portal vein (liver cirrhosis, pressure of packing) ; or to thrombosisof a small arterial branch:


or to a retrograde embolism (Recklinghausen,* von Eiselsbergt) or malposition of the pylorus or duodenum? It could hardly have been due to sepsis for there were no signs of infection. As long ago as 186?, Billroth J remarked that in septic cases we might have duodenal ulcers and fatal hemorrhages therefrom. He showed in his experiments upon animals that sepsis might cause intestinal hemorrhage, although, in his experience, it seldom did so in man; if, however, there existed an obstruction to the circulation, such as liver cirrhosis causes, little hemorrhages in the stomach plus the action of the gastric juices might lead to the formation of ulcers. The nausea began almost immediately after the operation. Whatever was the cause of this almost continuous nausea and frequent vomiting was also, probably, at least the remote cause of the hemorrhage. Von Eiselsberg has just reported seven cases of stomach and duodenal hemorrhage following operations upon the abdomen. Hematemesis occurred in six of his cases, and never later than the second, usually on the first day. The hemorrhages were demonstrated in three cases post mortem.

In my case the vomiting of" coffee grounds " was not observed until the tenth day. This patient was so carefully watched that I am quite sure that if hematemesis had occurred earlier it would not have been overlooked. In seeking for a common cause for the stomach and duodenal hemorrhages, Von Eiselsberg excludes vomiting because in two cases there was no vomiting, and in two, hematemesis occurred only a single time; he also excludes sepsis because in four of the cases there was no infection, and reaches the conclusion that " If the behavior of the wound is to be regarded as the cause of the hematemesis, then it must be assumed that in the cases which healed by first intention a retrograde embolism from a non-infected thrombus had taken place."

I wish that there was time to discuss this feature of the case more fully, but I must pass on to the consideration of another fact which this remarkable case developed. There were at the first operation almost certainly two stones in the common duct, one in the ampulla, the other more or less freely movable in the duct, although it fitted it quite snugly; but the gallbladder was small and contracted and not opened, and the liver was little if at all enlarged; the color of the skin was a light slate-yellow or ash-yellow — not the darker bronze-yellow of complete obstruction. At the second operation, however, when there was only one stone in the common duct, the gall-bladder was distended with bile and quite large, and the liver was greatly enlarged, its right lobe almost reaching the crest of the ilium. The patient's color and symptoms indicated that the stone in the ampulla did not at all times obstruct the duct completely. It sounds almost paradoxical to say that the removal of a stone should increase the obstruction, or that the one stone plugged the duct more completely than the two. I believe that a stone in the diverticulum, particularly a small


  • Die Storungen des Blutkreislaufes.

t Die Verhandlungen der duutschen Gesellschaft fur Chirurgie, 1899.

t Ueber Duodenalgeschwurebei Septicaemia. Wiener med. Wochenschr., 1867.


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[No. 106.


one, is more likely to block the duct effectually and to lead to distention of the gall-bladder than a stone, however large it may be, elsewhere in the common duct. A stone in the middle of the duct may at first occlude it completely, but the duct wall soon becomes infiltrated and thickened, it loses its elasticity, and, when distended with bile, stretches. The stone no longer plugs the duct tightly and bile trickles by into the intestine even when a second stone occupies the diverticulum, but when the proximal stone is removed, the bile instead of trickling up to the distal stone is probably jetted against it with sufficient force to hold it as a ball-valve. Furthermore, dilatation should not occur so readily in the portion of the common duct protected by the duodenal wall as in the free portion. In 1885 I operated upon a patient whose common duct contained a stone larger than the largest pecan-nut; at times one half of this stone projected into the duodenum, the other half occupied the duct; a flange had been cut on the calculus by the cicatricial ring, which engaged it and prevented it from slipping into the intestine; and yet this patient was so very slightly jaundiced that a stone in the common duct had not been suspected.

Cask VI. Miss M. H., age thirty. Transferred to surgical from medical side, January 27, 1896. Indigestion for eight years. For past four years the " gastric distress " has been very great. Patient describes a "gnawing sensation" in the epigastrium. Colicky pains radiated throughout thorax, but were at times very severe " in the back." Two years ago she had typhoid fever. For the past six months she has had frequent definite sharp gall-stone attacks with nausea, and four times with vomiting. Never blood in the vomitus. No chills, fever nor jaundice. Patient is a confirmed invalid. She suffers from headache and occasionally from vertigo.

Examination. — Abdomen flat. On deep inspiration spheroidal tumor is to be seen just below the costal margin on the right side. This tumor can also be felt. It moves with the enlarged liver, ascending and descending with the respirations. Last September patient first began to have attacks of pain in right hypogastrium, and accompanied by nausea and sometimes by vomiting. Spleen not palpable. The severe pain suffered by patient could be relieved by drawing up the knees. This pain radiated to the right shoulder-blade.

January 28, 1896. Operation. — Cholecystostomy. Vertical incision through the right rectus muscle. Elongated right lobe of liver. Very dense fibrous adhesions between the gall-bladder and duodenum. These adhesions were divided with great difficulty, and finally what appeared to be gall-bladder presented. It was aspirated, and a thick greenish fluid withdrawn. It was consequently opened with some confidence, but proved to be duodenum. It was sutured again at once, the suturing being very difficult because the muscular coat had been separated from the submucous coat during the dissection of the adhesions. The muscular coat, owing to the chronic inflammation which had existed for so many years, had become sufficiently fibrous to resemble cicatricial tissue, and consequently was unintentionally stripped from the submucosa. When the submucosa presented, it did so in the form of a little knob-like bladder, this coat resembling almost precisely the wall of the gall-bladder. The gall-bladder was finally found, deeply imbedded in adhesions, almost four cm. to the right of its usual position and far under the enlarged liver. It was opened, and one large oval stone, two cm. by one cm., removed. In the course of the operation a small abscess was discovered in the midst of the adhesions. Patient's recovery was considerably retarded by digestion disturbances, which finally disappeared completely


April, 1899. Patient says that she is in robust health and wishes to become a masseuse.

Cask VII. The history of this case cannot be published at present.

Case VIII. Discharge of pus and blood by mouth and rectum during severe gall-stone attack. Tteo years later adhesions so extensive and so dense that the common duct was reached by a retroperitoneal route, over the right kidney. — Mrs. M., age thirty-five. Admitted March, 1895. No typhoid fever. First attack of gall-stones, six years ago, began with sharp attack of pain in the right side of the abdomen. Two years ago miscarriage at seventh month ; was ill in bed thereafter four months. While in bed patient had great pain in region of gall-bladder, with high fever, for ten weeks; was continually blistered over liver. Eight weeks after the abortion she felt suddenly something "give way" ; this giving way was followed by great relief, and by horribly offensive discharge of pus and blood from the rectum and mouth. These discharges were irritating, gave her a very sore throat and mouth. She spat blood and matter for two or three weeks, and the stools during this time were very offensive. She has had pain and tenderness constantly, with occasionally severe attacks since that time ; has been jaundiced more or less ever since, but more markedly so since last July. On admission, body jaundiced and greatly emaciated; tenderness over the entire abdomen, especially in the region of the gall-bladder. Liver, in deep inspirations, extends two fingers' breadth below costal margin, and has a fairly sharp edge. Spleen palpable; stools acholic.

March 19, 1895. — Operation. Liver small, barely reaches costal margin ; its high position complicated the operation. Colon adherent to liver by rather loose bands ; gall-bladder exposed when these were divided. It was high up under the liver and no larger than the tip of the little finger; it was not opened. Adhesions were so dense over the common duct that the peritoneum was opened over the right kidney, and the common duct approached from behind under the peritoneum. A stone being felt, the common duct was the more readily exposed ; the stone was extracted through a hole made by ulceration. This hole proved to be at the junction of the duct and the duodenum, and was shut off from the peritoneal cavity by very delicate adhesions. The intestinal part of the opening was closed completely, the duct part as well as possible. The sutures were passed with great difficulty. The opening in the duct could not be completely closed, the tissues being necrotic, and bile escaped through it even after the sutures were drawn tight. Probing of the duct was carefully done. No other stones were found.

October, 1895. Six months after operation, patient is very well, She weighs one hundred pounds.

April, 1S99. Examined in my private office : patient still enjoys perfect health ; she now weighs one hundred and ninety pounds. Patient states that she has recently given birth to a healthy child.

I report the case of this woman because (1) she was so very ill when operated upon; (2) it is one of the two cases in which intestinal perforation had undoubtedly occurred prior to operation ; (3) the common duct was approached in a new way, namely, from behind the peritoneum ; (4) the stone, in the ampulla, had ulcerated through the walls of the ductus choledochus and the duodenum, and would perhaps soon have been extruded ; (5) the increase in the weight of the patient seemed phenomenal ; it was almost doubled within the year following the operation.

What the result to the patient would have been if this stone had ulcerated its way out of the common duct is quite certain, and yet I have several times found stones imbedded in adhe


January, 1900.]


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sious outside of the bile passages; they were usually close to the gall-bladder. Once I discovered a stone in the wall of a thick-walled gall-bladder; it was completely buried and was causing no disturbance, and was detected in the process of sewing in the drainage tube. This is, I believe, the only case in which I have not divided all of the adhesions encountered. If no contraindication exists, such as necessity for abbreviating


the operation, we should separate the adhesions if possible. The chance of meeting fistulous openings between bile passages and the intestine I regard as an indication for thorough exploration rather than a contraindication to it. Not infrequently adhesions alone are responsible for the symptoms which persist after the calculi have been removed by the surgeon or have escaped in other ways.


EARLY EXPLORATORY OPERATIONS IN TUBERCULOSIS OF THE HIP.

A PRELIMINARY REPORT.

(From the Clinic of Prof. Halsted, The Johns Hopkins Hospital).

By Joseph 0. Bloodgood, M. D., Associate in Surgery.


I wish to report a case of early operation in tuberculosis of the hip, and am sorry the patient is not here to demonstrate the very happy result.

Case I. — Tuberculosis of left hip, of seven weeks' duration. Operation: Capsule distended; tubercular synovitis; small tubercular focus in the neck of the femur. Result, January, 1899 (13 months), perfect. No restriction of motion.

M.K. Surg. No. 8380. Male, set. 42 years, butcher by trade, was first admitted to the hospital October 6, 1893, 5 years ago, suffering from tubercular arthritis of the left shoulder joint. The disease of the soft parts and bone was extensive ; for this reason excision was performed at once. Although 3 cm. of the shaft of the humerus were removed, the functional use of the arm is an excellent one.

It is of interest to note the possible etiology of the arthritis of the shoulder. This man had always been in excellent health. He could remember no cases of tuberculosis in his family. Eight months ago, he cut his left wrist with a dirty butcher-knife. The wound healed in about one week. One month later he noticed pain in the left shoulder, which was followed by a slight stiffness. The condition was treated for rheumatism. Five weeks ago he noticed a swelling of the upper third of the arm to the inner (medial) side of the biceps muscle.

The patient was readmitted November 30, 1898 (5 years later), complaining of pain and stiffness of the left hip joint. The following are the important facts in the history:

About seven weeks before admission, without any recollection of a traumatism, he experienced, when getting out of bed one morning, pain in the left hip. This pain has been increasing, and is now and then referred to the knee. During the last two weeks the joint has become almost immovable. He baa been able to walk some, although it gives him a good deal of pain. He limped into the hospital.

Examination. — When the patient lies flat on his back with both legs extended, the anterior superior iliac spines appear to be on a level. There is very slight apparent shortening of the


  • Read before the Johns Hopkins Hospital Medical Society. May

8th, 1899.


left leg. This, however, is due to real shortening between the trochanter and external malleolus. There is no shortening between the iliac spine and great trochanter. The hip is fixed at about 25°. There is no apparent abduction or adduction. Any attempt at motion at the hip joint gives pain, and with each motion the pelvis moves with the limb. There is no swelling about the hip joint except on the anterior surface of the thigh. This swelling is situated below the outer twothirds of Poupart's ligament, to the outer side of the vessels and extends downwards a distance of about 4 cm. It is most prominent 2 cm. within the line of the tensor vaginas femoris and 2 cm. below the iliac spine. The swelling is not very painful and on palpation seems to fluctuate. When the patient is quiet in bed and does not attempt to move the limb he suffers no pain. The leg is only painful when he attempts to walk or when some one attemps to bend it at the hip joint. The examination of the lungs was negative. The general health of the patient appears to be excellent. The patient remained under observation from November 30th to December 8th. On December 2nd, following an injection of 2 milligrams of tuberculin, the temperature rose to 100.5°. On December 4th, following 4 milligrams of tuberculin, the temperature rose to 100°. With these two exceptions, a two-hour chart shows a registration of rectal temperature between 98.5° and 99.5°. Following the injections of tuberculin the patient complained of no discomfort whatever. The only fact to be noted was that shown in the slight fever. The leucocyte count before operation was 4,000.

The arthritis was considered to be, without much doubt, tubercular, and the swelling on the anterior surface of the thigh to be due to distention of the capsule of the hip joint which had not yet ruptured.

Operation. — December 8, 1898. Anaesthetic, ether. When the patient was fully narcotized, it was demonstrated that with the exception of flexion there was but little restriction of motion in the hip joint. An incision was made in the anterior surface of the thigh, beginning at the anterior iliac spine, and the capsule of the hip joint was exposed by separating the tensor vaginaa femoris on the outer side from the rectus muscle on the medial side. As soon as the muscles were sepanih sd a tense swelling was found, which upon its surface was smooth


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and white in color. Upon its outer surface there was no exudate, nor was it adherent by connective tissue to any of the surrounding structures. When incised, it was found to be from 3 to 4 mm. in thickness, of firm white tissue, and proved to be the distended capsule of the joint. The cavity contained a large amount of viscid serous fluid containing numerous flakes of lymph and some necrotic material. The inner surface of the capsule of the joint presented the ordinary picture of tubercular synovitis. Here and there one saw cedematous hemorrhagic granulation tissue, in which were areas of yellow necrotic tissue, which could be easily scraped from its fibrous base. Between these areas of granulation tissue were smooth areas paler in color. On retracting the muscles more widely and enlarging the opening in the capsule, the head and neck of the femur were easily exposed. The examining finger at once found a small cavity on the inferior and slightly anterior surface of the neck, near its junction with the head of the bone, which about admitted the index finger (Fig. 1 «). One could also see the cavity, and in its



Case I. Fig. 1. bone removed.


Focus of tubercular osteomyelitis, b. Area of


center was a small area of yellow necrotic tissue. The bone lining the cavity was slightly hemorrhagic, but when cut with the ehisel was found not to be very soft. About 3 to 4 mm. of bone about the cavity were removed with the chisel (Fig. 1 b.) Beyond this, the cancellous bone appeared to be normal. The head of the femur was easily seen. The cartilage was not eroded. The cartilage lining the cotyloid cavity could be seen only at the rim about the head. It also appeared to be normal. The trochanter and shaft of the femur were exposed. The periosteum was not thickened. The entire surface of the capsule of


the joint was curetted. The bone cavity in the neck, and the surface of the synovial membrane after curetting were swabbed with pure carbolic. The wound was then thoroughly irrigated with 1 to 1000 bichloride, followed with salt solution. After mixing iodoform powder with the blood clot, the wound was closed, leaving a small drain extending into the capsule but not into the cavity in the bone. The entire limb and pelvis were fixed in a fully extended and slightly abducted position in plaster.

Notes after Operation. — The patient was perfectly comfortable and at no time during the convalescence experienced pain in the wound. The night after operation the temperature rose to 103.2°, falling to normal in the morning. On the second evening it rose to 104°; on the third to 103°; and on the fourth to 102°, falling to normal each morning. With this rise of temperature there was very little change in the pulse. The leucocyte count varied from 2700 to 4000. Nothing was found to explain the fever. Culture and coverslips from the serum in the wound were sterile. From December 12th to January 28th the temperature chart records no fever. The drain was removed on the sixteenth day. For four weeks the sinus communicating with the joint was irrigated daily with 1 to 1000 bichloride and injected with an emulsion of iodoformized oil. The wound at no time showed any evidence of infection and was completely closed at the end of five weeks. The patient was kept in bed in extension for six weeks, and then allowed to get up in plaster.

Note, August 14, 1899. The patient returns to the hospital walking without crutches or cane. It is eight months since the operation and six months since the plaster cast was removed. For five months the patient has been able to return to his work as a butcher. He has had no further pain. The wound is healed solidly. Careful measurements show no difference in the length of the bone or between the anterior iliac spine and trochanter, except the one noted before operation of 1 cm. shortening between the trochanter and external malleolus. Motions in the left hip joint are possible in every direction, and are but very little restricted in each (see Figs. 2, 3, 4). Forced motions are painless. Previous to operation the left leg was flexed to 25 degrees ; it now can be fully extended without change in the pelvis.

Examination. — January 10, 1900. The patient's condition is the same as that noted in August. The result so far appears to be a perfect one, not only with every evidence of an eradication of the disease, but with complete function of the joint. (See Case IX for operation in the right hip.)

Case II. — Tuberculosis of right hip, of seven years' duration. Operation: Firm fibrous ankylosis; no evidence of bone or joint tuberculosis; incapsulated extra-articular tubercular abscess. Result, Jan. 1900, 9 months, excellent.

Surg. No. 3540. There is at present (May, 1899) in the wards, a young girl who was admitted to the hospital November, 1, 1894. At that time she was suffering with tuberculosis of the right hip, the onset of which had been two years previous, when she was eleven years of age; that is, seven years ago.

Examination. — November 5, 1894, under ether. No apparent shortening. The right (affected) limb is flexed to 45 degrees,


JOHNS HOPKINS HOSPITAL BULLETIN. JANUARY, 1900.



Fig. 2. — Result lu Case I, eight months after operation.



Fig. 3. — Limit of abduction, Case I


Fig. 4.— Limit of flexion, Cum- I


January, 1900.]


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slightly abducted and slightly rotated out. Apparently do real shortening between anterior iliac spine and trochanter or trochanter and external malleolus. The measured shortening between anterior iliac spine and internal malleolus 1 cm. (due to abduction).

Examination. — April 25, 1895, after seven months. The flexion is less 20 degrees. Apparent shortening 1 cm., due to tilting up of the pelvis. Measured shortening between iliac spine and external malleolus 2.5 cm. Keal shortening between iliac spine and trochanter perhaps 1 cm. Patient is very fat, and these measurements are difficult to make. The leg is still slightly abducted. Kotation out less.

Examination. — December 8, 1896, after two years. Apparent shortening 3 cm. Keal shortening between anterior iliac spine and trochanter 1 to 1.5 cm.; between trochanter and external malleolus 2.5 cm. (about equally distributed between thigh and leg). These measurements demonstrate that within the last two years, under the best orthopedic treatment, a centimeter of real shortening has taken place, and there has been a lack of growth in the shaft of the femur of 2.5 cm.

Examination. — April, 1898. Very little if any change.

From November, 1894, up to the present time, a period of almost five years, she has been under treatment. After her first admission to the hospital she remained in the wards for two years. The treatment consisted of iodoform injections, and later of fixation in plaster. During this time her general health has remained about the same. There has been little or no loss of flesh, no fever, and no evidence of tuberculosis elsewhere. On December 6, 1896, she was given tuberculin, which was followed by no evidence of reaction. Four weeks later an abscess formed below the great trochanter. It was opened, and healed rapidly. In October, 1897, there was slight reaction to tuberculin. About four weeks ago she returned to the hospital for inspection. She was still using crutches, and suffered a good deal of pain in the hip, not only during the day when she was sitting in a chair or walking on her crutches, but also at night. This pain was generally relieved by extension.

Operation. — April 20, 1899. Ether. Under the anaesthetic it was found that the hip joint was almost completely fixed in a flexed and very slightly abducted position, with no rotation. An incision similar to that employed in the first case was made. On dividing the fascia lata about 5 cm. below the anterior iliac spine, a small cavity (2 cm. in diameter) was opened. In the center of the cavity was a mass of yellow necrotic material and a little clear serous fluid. The wall of the cavity was of smooth white fibrous tissue. No granulation tissue could be found. This cavity corresponded in position to the abscess which formed and healed a year and a half ago. It was completely excised and no communication between it and the bone or joint could be demonstrated. (A very small healed sinus, however, might have been overlooked). On exposing the joint, the head and neck and trochanter of the femur were covered with dense connective tissue. This was excised, exposing the periosteum over the trochanter and upper part of the shaft. The periosteum was slightly thickened, and on stripping it back the bone was a little rough. The outer layers of the bone of the shaft and trochanter were very thin, also that of the neck. The anterior surface of the neck, troch


anter and shaft was removed with a chisel (Fig. 5 a). The cancellous bone was very softand hemorrhagic; the marrow was also fatty and very hemorrhagic. The head of the bone and t he acetabular cavity were covered with scar tissue, in which no granulation tissue could be found. Over a small portion of the head of the bone which was exposed there was normal cartilage. No disease of the pelvic bones about the acetabular cavity could be demonstrated. About the acetabular cavity there was a narrow ridge of new bone (Fig. 5 c). The wound was thoroughly irrigated, and the small bone cavity made during the exploration was allowed to fill with blood clot mixed with iodoform, and the wound closed without drainage.



Case II. Fig. 5. — a. Area of outer table removed to expose neck, epiphysial line and head. 6. Gouge groove to explore acetabulum through head. c. New bone about rim of acetabulum.

At the operation, although the junction of the neck and the shaft was exposed, it was difficult to tell whether the angle between the neck and the shaft were more or less than normal. The neck, however appeared to be shorter than normal. Following the operation, the patient had no discomfort and the wound healed perfectly. She was discharged September 15, 1899, wearing a splint and using crutches. This supporting apparatus was used because I feared that following the removal of the bone, the neck of the femur might possibly have been weakened, and that to allow the patient to walk without some support might be followed by bending of the neck with its resultant deformity. While in the hospital, especially after the patient was up and about on crutches, the pain complained of before operation was not present.

Examination. — January 19, 1900. The patient has no pain. She walks much better but still uses the crutches and wears


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the splint. No change in measurement. Advised to discontinue crutches and later the splint.

I have reported these cases to the Society to illustrate the happy result, in the first case, after an early operation. Here, seven weeks after the beginning of the disease, we found a greatly distended capsule filled with necrotic material and lined by tubercular granulation tissue and a tubercular focus in the neck of the femur. Following the partial removal of the disease of the soft parts and the apparent complete removal of the disease of the bone, we have every evidence of the complete cure of the disease, and three months after operation the patient is able to resume his occupation as a butcher, and the functional use of the joint is almost perfect.

In the second case, after seven years of conscientious orthopedic treatment, the patient is practically in the same condition. The exploratory operation, however, demonstrated that the disease was to all appearances cured. In this latter case an earlier exploratory operation, if it had demonstrated the same condition, would have relieved the patient of a number of years of enforced rest, or, if the disease had been present, would have allowed its earlier eradication.

ADDITIONAL CASES.

Note, January, 1900. — Since the above report was made, twelve cases of tuberculosis of the hip have been subjected to operation. Nine are here reported — three cases of very recent date not being included in this report. In all, the immediate results have been very encouraging.

Case III. — Tuberculosis of left hip, of 15 months' duration. No relief of symptoms after two and a half months' treatment with extension in bed. Operation: Distention of capside ; erosion of head and neck ; no bone foci found ; immediate relief of symptoms. Residt January 1 , 1899, six months, excellent G. L. H. Surgical No. 8874. Male, at. 10. Was admitted April 19, 1899, complaining of pain in the left leg. His father died of tuberculosis of lungs, and one brother had been operated upon in this hospital for genu varum. About fifteen months ago this patient complained of pain in the left hip. The pain was intermittent, but had not prevented him from going to school or playing about ; now and then he would limp ; for different periods he would be free from pain and limping ; no history of trauma. About six weeks ago, after a well interval, he complained of sudden pain in the left hip and began to limp. The pain in a day increased so rapidly that he went to bed, being unable to walk, and that night, for the first time, cried out from pain. Being more comfortable the next day he was taken to a hospital where he remained a few days, and left with a brace. Yesterday, twenty-four hours before admission, he fell on the brace and had passed a very uncomfortable night.

Examination. — The left hip was so tender that any attempt at motion produced much pain, and an examination was made with difficulty. There was flexion (40°), abduction (45°), but no aversion. From April 20th to May 12th (22 days) the patient was placed in extension, and was more comfortable. Measurements made on the last day showed apparent shortening of .5 cm., due to slight adduction, but no real shortening. The hip was still very tender and fixed. April 29, reaction to tuberculin. From May 28th to July 2nd, although the patient was in extension, night cries increased and he was uncomfortable. From July 2nd it was noticed that there was a fullness in Scarpa's triangle. The hip was still very painful and fixed in a position of flexion and adduction. For this reason an operation was decided upon.


July 3, 1899. Operation (Dr. Cushing): Ether ; anterior incision. The joint capsule was distended and thickened ; no evidence of rupture. On incising the capsule, about an ounce of seropurulent fluid escaped. A part of the cartilage over the head was roughened and slightly elevated from the bone. The joint cavity was full of tubercular granulation tissue. In places one could see that the cartilage of the acetabulum was eroded and lifted from its base. A portion of the anterior surface of the head and neck was chiseled away, showing the epiphysial line. No focus of disease in the bone was found. The area of most marked erosion of the cartilage, and the erosion of the bone at the edge of the epiphysis, as shown in (Fig. 6, a. a. a.) were chiseled away. After disinfection



Case III. Fig. 6. — a. a. a. Areas of superficial erosion, b. Areas removed.

of the joint and bone cavity, dry iodoform was dusted in the wound, which was closed without drainage. The operation lasted one hour and five minutes.

For a few days previous to operation the pulse ranged between 90 and 100, and for three days after operation it ranged between 120 and 150 ; the temperature rose to 102°. By the seventh day pulse and temperature had reached normal. The patient was comfortable.

On August 2nd (thirty days after), a small sinus opened in the wound, discharging a clear, serous fluid, which completely healed on August 29th. Measurements made on August 30th showed a lengthening of 1 cm. and no real shortening. The flexion had disappeared, and there was a slight tendency to outward rotation. Motion in the joint was much less restricted. On August 31st, two months after the operation, the patient was fitted with a brace. On September 6th he left the hospital wearing a brace.

In this case the usual orthopedic treatment of extension and rest in bed had been given a fair trial, but did not relieve the symptoms. At the operation, tension was relieved by incision and drainage of the distended capsule, after which the patient was much more comfortable. The incision of the capsule also allowed


January, 1900.]


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correction of the flexion, and a short time after the operation all movements of the hip joint were freer and without pain.

Case IV. — Tuberculosis of left hip, of <>ne year's duration. Operation : Distended eapsuie, with purulent material ; synovial membrane convt rted into granulation tissue; sliglit erosion of head and neck and acetabulum ; wound closed ; healing per primam. Result, January, 1899, six months, excellent.

Surgical No. 9234. W. C, colored boy, aet. 2 years. Admitted July 26, 1899. One year ago the child complained of pain and tenderness in the left hip, and in a few days began to limp. The parents noticed that the leg became shorter ; the pain was worse at night, and there were night cries. The child continued to walk a little.

Examination. — The general condition was good; no evidence of rickets. The left leg was flexed to 70 degrees at the hip and 45 degrees at the knee, and adducted. Motions at the hip are restricted in all directions, but not at the knee. It was difficult to make accurate measurements, but there appeared to be no real shortening.

August 2nd (six days after admission). Operation (Dr. Mitchell): Ether: anterior incision. The capsule of the joint was thickened and ccdematous. On incising the capsule, an ounce of thin, brownish, purulent and necrotic material escaped. The synovial tissue seemed to be converted into granulation tissue. There was noticed a slight erosion on the anterior and superior surfaces of the neck at its junction with the head ; round ligaments, intact ; the rim of the acetabular cavity was covered with grayish granulation tissue ; both of these areas, as well as the capsule of the joint, were curetted. The wound was irrigated with salt solution, dusted with dry iodoform powder, and closed without drainage. The full time of the operation was fifty-five minutes.

Pulse previous to the operation was 120; during the operation, 140. The chart registers an average pulse of 120 previous to operation and one rise of temperature to 103°, which, however, followed tuberculin given on the 27th of July. Following the operation the highest temperature was 101.5°, the evening of the first day, and the pulse rose to 180, but fell that evening to' 130; up to November 27th. when patient was discharged, the average pulse was from 110 to 120. With the exception of a slight rise of temperature to 102° on October 2nd, there was no fever after August 4th, 48 hours after operation. The patient left the hospital on November 27th in plaster. The wound healed per primam.

Case V. — Tuberndosis of left hip. Subgluteal extraarticular abscess. Operation : Incision of abscess and arthrotomy ; tubercular synovitis ; erosion of head and neck ; posterior perforation of capsule. Result, January 1, 1899, two months, improved.

J. W. G.. colored boy, set. 2 years. Admitted November 9, 1899. The parents not being with the child it was impossible to get a history.

Examination. — The child is placed flat on his back. The left anterior iliac spine (the affected side) is a little lower than the right. There is a marked lumbar lordosis unless the left hip is flexed to a position of 90 degrees ; motion at the hip joint in this position is possible in all directions, but only to a few degrees. The knee is flexed to an angle of 90 degrees. Extension is only possible to a few degrees ; no rotation of thigh. If the right leg is placed in a similar flexed position at the knee and hip, there is an apparent shortening of about 1 cm., but no real shortening of the left leg. Between the anterior iliac spine and trochanter on the outer surface of the left thigh and beneath the gluteal muscles there is a fluctuating swelling.

Operation.— November 11, 1899. Ether. Under complete narcosis the leg can be veiy slightly flexed and extended. This restriction almost completely disappeared after the abscess was incised. The abscess was situated beneath the gluteal muscles and fascia


lata and contained thick, gelatinous, purulent material, with shreds of necrotic tissue, and was found to communicate with the hip joint through a small opening in the posterior wall of the capsule. The joint capsule, which was not distended, was opened through the usual anterior incision. The synovial membrane was covered with tubercular granulation tissue. On account of the youth of the child, a large incision was not made, so that the head, neck and acetabular cavity were not seen, but with the index finger erosions were felt on the anterior surface of the head and neck, which were curetted Theabscessaud thecapsuleof the joint were also curetted, swabbed with pure carbolic, irrigated with salt solution and filled with emulsion of iodoform and oil. The operation took fifty-five minutes. Very little ether was given. The condition of the patient at the end of operation was excellent.

January 15, 1900. The child is still in extension, which has reduced the flexion of both knee and hip from 90 to 35 degrees. There are no night cries. The patient appears to be perfectly comfortable. The wound is now a superficial granulating area.

Case VI. Tubercidosis of left hip, of seven months' 1 duration. No relief of symptoms after one month's treatment with extension. Operation: Tense distended capsule ; no bone focus of disease; slight erosion of the head, with loosening q) articular cartilage ; round ligaments separated ; wound closed ; healing per primam. In six weeks the wound reopened. Second operation. Result. January, 1899. after two months, excellent. Wound closed.

Surgical No. 9117. G. B.. aet. 4A years; admitted June 26, 1899. One and one-half years ago the boy fell on the ice and bruised his left hip. An area of ecchymosis over the hip remained some days. Following the injury, however, there was no special pain complained of and no limp. Eleven months later (that is, 7 months ago), the parents noticed that the child began to limp, and complain of pain, first in the calf of the leg, later in the ankle, then in the knee. About two months later the parents noticed that the affected leg was shorter and the boy walked on his toes. In about a month he began to have night cries. For the past two weeks the boy has been unable to walk on account of pain.

Examination —The left leg is flexed at the knee and thigh, with marked adduction ; no rotation ; very little motion at the hip joint. The patient was placed in extension from June 26th to July 24th. He cried a good deal at night, when asleep or awake. All attempts to overcome the flexion by extension were unsuccessful. Manipulation of the hip joint continued to be painful ; for this reason operation was decided upon.

Operation.— July 24,1899 (Dr. Cushing) : Ether: anterior incision. After separating the muscles a very tense distended capsule was exposed ; it was incised, and about an ounce of flocculent, yellow, serous fluid was evacuated. The joint, head and neck of the bone were thoroughly exposed. The round ligament seemed to be destroyed. When the thigh was flexed, one got a good view of the acetabular cavity. The lining cartilage seemed smooth. The cartilage over the head of the bone appeared to be loose. The head epiphysial line was exposed by chiseling. No focus of disease was seen. The wound was irrigated with salt solution, dusted with dry iodoform powder, and closed without drainage.

Dr. Cushing noticed that under an anaesthetic the leg could not be fully extended. As soon as the capsule was incised and the tension was relieved, full extension was possible. Time of operation about fifty-five minutes ; pulse before operation, 120 ; during operation about 140. As in the previous cases in children there was a slight tachycardia after the operation for five days, and some fever for three days. The wound healed per primam.

It was noticed on August 5th, 11 days after operation, that the leg was but slightly flexed, very little adducted, but there was slight outward rotation. On the 14th of August there was no flexion. At this time he was sent into the country in a brace.

On September 6, 1899, about a month later, he was readmitted


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[No. 106.


to the hospital, not in as good condition as when he left. He had night cries and some pain. Twenty days after admission a sinus formed in the wound which discharged tubercular pus.

From September 28th to November 4th he was placed in extension. November 3d, measurements: Apparent shortening of 1 cm., and real shortening from trochanter to anterior iliac spine of about 1 cm. No abduction or adduction or flexion, but marked outward rotation. The hip is pretty firmly fixed in this position except that it can be slightly rotated in.

Operation, November 4, 1899 (Bloodgood) : Ether. It was found that the sinus of the previous operation passed through the rectus muscle into the joint. At this second operation the joint was exposed by an incision which separated the tensor vaginas femoris and gluteus medius on the outer side and the sartorius and rectus on the medial side. The sinus and cavity corresponding to the capsule of the joint were lined with tubercular granulation tissue. It was found that the head and neck of the bone were intact. A few pieces of partly separated cartilage were removed from the head of the femur. The outer surface of the neck was rough, soft and hemorrhagic. On extending the femur and pushing it upwards, the head of the bone moved a little in each direction. Under ether there was very little restriction of motion at the hip joint. The soft parts and bone surface were curetted, the exposed surfaces were swabbed with pure carbolic, the wound irrigated with salt solution, dusted with dry iodoform powder, and closed with a piece of protective drain into the joint cavity- No loss of blood ; no shock. Time of operation was about sixty minutes. Average pulse about 140.

Following the operation there was a slight tachycardia for a few days, but no rise of temperature. The operation in this case was a secondary one and of less extent than others. The patient was put up in plaster and later in extension, and was much more comfort able than previous to operation. The wound was irrigated, and at frequent intervals swabbed with pure carbolic and filled with emulsion of oil.

Note. — December 9, 1899, 35 days after operation. Measurements between iliac spine and trochanter and iliac spine and malleoli are about equal. Position of leg after removal of extension is as follows : The left (affected) anterior iliac spine is elevated 1 cm., the left leg is rotated out perhaps a little more than the right (this outward rotation is much less than previous to operation). The apparent shortening (1 cm.) corresponds to the elevation of the iliac spine. There is no flexion. The motions of the hip joint are about 10 degrees in flexion and extension ; adduction to a few degrees ; no restriction of outward rotation ; a marked restriction of inward rotation and abduction. Although the hip is pretty well fixed, the position could not be a better one- Attempts at motion are not painful. The wound has healed.

December 15, 1899. The patient is in the hospital, and is walking about on crutches, in a brace.

Case VII. Tuberculosis of left hip, of one year's duration. Subgluteal, extra-articular abscess and abscess beneath the adductor muscles. These abscesses developed during orthopedic treatment. Operation: Incision of subgluteal abscess; anterior arthrotomy of joint; anterior and posterior perforation of joint ; abscess beneath adductors drained through joint ; tubercular focus in neck. Result, January, 1899. two months, improved.

Surgical No. 8201. Boy, set. 8 years. Admitted October 6, 1898, one year ago. The arthritis of the left hip had been present one year, following traumatism. The limb was in a position of flexion (28 degrees) and adduction (21 degrees), with slight internal rotation. Apparent shortening, 4 cm. ; real shortening (anterior iliac spine to trochanter), 1 cm. Muscle spasm was marked. There was no evidence of abscess. The patient was placed in bed in an extension apparatus, which at once relieved the pain. He was discharged February 28, 1899 (five months), wearing a splint, and


appeared to be in excellent health. This patient was readmitted October 1, 1899, not because he was suffering any pain or discomfort, but in answer to a letter inquiring as to his present condition. He was still wearing the splint and walking with crutches. When the splint was removed and the patient placed in bed, and the anterior iliac spines fixed to the same horizontal plane, the left affected leg was so adducted that it crossed its fellow on a level with the patella. There was a large abscess behind the great trochanter in the gluteal region, and a slight fullness beneath the adductor muscles. The patient was observed in the hospital from October 1st to October 28th. There was no fever. He suffered no pain except when the apparatus was removed or when forced motions were attempted at the hip.

Operation.— October 29, 1899. Ether. The gluteal abscess was incised. It was situated between the gluteus minimus and medius and extended down to the middle third of the leg beneath the fascia lata. Passing the index finger, one could feel the capsule of the joint on its posterior surface. In this position a probe found communication with the joint cavity.

The usual exploratory incision on the anterior surface of the thigh was then made. The capsule of the joint when exposed was slightly distended, but on i:s outer surface there was no exudate and no adhesions. When incised, it was slightly thickened, and the joint cavity contained a moderate amount of seropurulent material filled with cheesy necrotic masses. The head and neck of the bone were easily felt and seen, and on the anterior and slightly inferior surface of the neck, near its junction with the head, a small tubercular bone focus was found. (Similar to Case I, Fig. 1.) This was removed with a chisel. The head of the bone seemed firmly in place in the joint cavity, and there was very little restriction of motion. The rim of cartilage which could be seen was not eroded. By pressure over the thigh in the adductor region, a great amount of tubercular pus was expressed into the joint cavity, and the finger and probe demonstrated a second opening in the capsule of the joint leading to a large abscess cavity on the lateral surface of the thigh, beneath the adductor muscles. This opening was enlarged and the cavity curetted out. The patient had a comfortable convalescence. January, 1900. Extension has corrected to some extent the adduction and flexion. The patient walks well in his brace. The wounds are almost healed. The marked adduction will need further operative treatment.

Case VIII. — Tuberculosis of right hip; orthopedic treatment for 12 months, during which time an iliac abscess, from perforation of the acetabulum, developed. Operation : Incision of abscess and arthrotomy of joint ; tubercular synovitis ; slight erosions of head and neck, with partial separation of the articular cartilage of head and acetabulum. Residt, January 1899, two months, excellent.

Surgical No. 8086. R. H., ast. 4. First admitted September 7th, 1898, with the following history : About five months ago it was noticed that the child limped; at the same time the parents noticed that the right ankle was swollen. Six weeks later the child wakened at night, crj-ing from pain in the hip ; next day was unable to walk ; this pain and inability to walk disappeared in a few days, the night cries and pain at night continuing. About eight weeks ago a slight trauma was received by the right knee; The knee became swollen and was put up in plaster by a physician. Night cries continued. The hip became more stiff.

Examination. The child walked into the hospital. The limb is flexed; slightly adducted; no rotation of foot; apparent shortening of about 1 cm; no real shortening between anterior iliac spine and trochanter; no fullness in Scarpa's triangle; adduction is impossible, and there is about 10 degrees of abduction. Patient was placed in extension September 2oth. 18 days later, he was discharged from the hospital, wearing a brace and using crutches, with a high shoe on the left foot. March 29, 1899, 7i months, patient was readmitted.


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Examination. Perfectly comfortable. Night cries have ceased. Examination reveals no muscle spasm. There is no flexion, abduction or adduction. Apparent shortening is \i cm. There is very little motion at the hip. No real shortening between trochanter and anterior iliac spine. May 6th, 37 days, discharged, wearing a splint and using high crutches and high shoe. On October 27, 1899, tive months latter, he was readmitted, not because of any pain or discomfort, but on account of swelling which had been noted for two weeks over the outer third of Poupart's ligament. Measurements : No apparent shortening; no real shortening. Leg is in a straight position, slightly rotated out. Flexion is possible to 30 degrees; abduction to 10 degrees, but adduction is impossible. There is only slight muscle spasm, associated with attempts at motion. On account of the abscess an operation was decided upon.

Operation.— November 4, 1899. Ether. Usual anterior incision, which also opened into the abscess. The abscess cavity was between the skin and fascia of the muscle. From it a sinus led below Poupart's ligament, passing between the sartorius and tensor vaginse femoris. then into the iliac fossa, anterior to the sheath of the iliac muscle. After curetting this abscess cavity the joint capsule was exposed by separating the rectus from the tensor vaginse femoris. No infiltration of the tissues outside the capsule. By pressure over the capsule a purulent material was expressed from the sinus, but on opening the capsule of the joint a direct communication could not be found. The cartilage of the head of the femur was soft and separated easily : it was removed by catching it with a clamp. The base consisted of soft hemorrhagic bone, the gross picture of tuberculosis. The anterior surface of the head and neck was chiseled. There was no evidence of disease in the neck, which seemed to be confined to the head of the bone, especially beneath the cartilage. The round ligaments had been torn and that portion of the acetabular cavity which was exposed showed evidence of disease. The cartilage was soft, and some could be pulled away, leaving a base of soft hemorrhagic bone. No attempt was made to find out the direct communication between the joint and the iliac abscess, as it would have required too much destruction of bone. The abscess cavity was traced into the pelvis between the iliac and the psoas muscle. The wounds were swabbed out with pure carbolic, irrigated with salt solution and dusted with dry iodoform. A protective drain was left into the abscess cavity and into the joint. Time of operation was about one hour and thirty-five minutes. Patient was in excellent condition.

Following the operation there was the usual tachycardia pulse of 130 to 160 for about ten hours ; no rise in temperature ; no pain or discomfort.

Examination. — December 1, 1899, twenty-seven days since operation. There is no apparent shortening. The anterior iliac spines are about even. Both legs are straight ; no outward rotation ; no real shortening ; position of the leg is perfect. Flexion, extension, abduction and adduction and outward rotation are possible only to a few degrees. Inward rotation from a position of outward rotation is possible to a greater extent than outward rotation. Attempts at motion give no pain.

Wound healed except a small granulating area and a sinus communicating with the abscess cavity. Patient is ordered brace, high shoe and crutches.

January, 1900. No change.

Case IX. Tuberculosis of right hip. Slight symptoms four months; very acute symptoms three days. Operation at once. Capsule distended, very tense; synovial membrane hyperemic; on chiseling outer table of neck, a definite bone focus found in the neck near epiphysial line. January 1, i900, six weeks, excellent result.

Surgical No. 9699. N. K.. set. 40. Admitted November 32, 1899. In July (four months ago) patient began to have pain in the right hip, and he stopped work and rested for about two weeks. Was comfortable when he kept quiet. Returning to work, he was free


from pain for a couple of weeks, but since that time he has found that he has to rest quite frequently during the day when these attacks of pain come on. He is a butcher by trade and has to stand a good deal. Three days before admission, while at work, he was seized suddenly with severe pain, so intense that he went home to bed, and sent for a physician who gave him morphia, but this did not relieve the pain. He was brought to the hospital on a stretcher in the ambulance.

The right leg was fixed in a position of flexion of about 45 degrees. Any attempt at motion was intensely painful. Extension was at once applied in this flexed position, which in a few hours relieved the patient of the pain. Next morning he was more comfortable. On examination there was a distinct fullness in Scarpa's triangle. The history and the present condition were similar to the attack in the left hip joint (Case I). There is no apparent or real shortening. The result in the left hip is a perfect one. The patient was in extension with complete relief of symptoms from November 22nd to November 27th, but any attempt at motion gave him pain. Chart records a temperature between 99° and 101° ; pulse of 70 to 80.



Case IX. Fig. 7. — a. Tubercular osteomyelitic focus, b. Area of outer table chiseled to expose aud remove a and 6. c. Area of softened cancellous bone.

Operation.— November 27, 1899. Cocaine and chloroform. The usual anterior incision was made without difficulty under cocaine, but it was found that the retraction of the muscles necessary to expose the hip joint was so painful that chloroform was given. As soon as the patient was under the anaesthetic it was still found that complete extension was impossible. The capsule of the joint was distended. On incision a fluid spurted out. demonstrating the great tension. It was a seropurulent fluid filled with coagulated lymph. On examining the capsule carefully, it was found that the synovial membrane was intensely injected and hyperemic. There was no evidence of granulation tissue. The head of the bone was easily seen in the acetabular cavity, and the cartilage, both on the head and acetabular rim, seemed normal and was not sepa


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[No. 106.


rated. No disease could be seen at the head or neck or trochanter of the femur. The bone of the anterior surface of the neck, between head and trochanter, was chiseled ( Fig. 76) , and in the epiphysial line, between the head and neck, on the anterior and inferior surface, a small focus (about 5 mm. in diameter) of definitely tuberculous bone was found (Fig. 7 a). Surrounding this and extending into the head and neck, the bone was soft and hemorrhagic (Fig. 7c.) The tuberculous area and this softer cancellous bone were removed with the curette. The appearance of the bone lining the cavity was normal except perhaps slightly hemorrhagic but firm. The bone cavity and joint capsule were swabbed out with pure carbolic, irrigated with salt solution, and the bone cavity allowed to fill with blood mixed with iodoform. The wound was closed with a small drain extending into the capsule but not into the bone cavity. Operation required two hours and ten minutes. There was no shock, and the condition of the patient at the end of the operation was excellent.

Examination.— December 16, 1899. Wound is healed with the exception of a small sinus which was filled with iodoform and organized blood clot. Patient has had absolutely no discomfort since operation, and for about seven days has moved his right hip in every direction, and we find on examination to day that one is able to flex, abductaud adduct, rotate in and rotate the hip outwards to quite a marked degree, but not completely. These motions are without pain. January 12, 1900. The patient is up on crutches ; the wound is healed except a small superficial area. Passive and active motions with hip are but slightly restricted and give no pain.

For some years before this report, which I made to the Society in May, 1899, I had given a good deal of consideration to the subject of tuberculosis of the joints, and especially of the hip, and had been forced to the conclusion that there was much room for improvement upon the usual orthopedic treatment. I had in mind early exploratory operations in which the surgeon might be fortunate to find the focus of the disease in the bone at a period when its complete excision ; or, if the tubercular osteomyelitis were more extensive, a partial excision might be done without interfering with the continuity of the bone or function of the joint. From early experiences, especially in the knee, arthrotomy with irrigations with antiseptics and injections of large quantities of iodoform seems to have been the best procedure for treatment of the tuberculosis of the synovial membrane.

The majority of surgeons now follow the more conservative and orthopedic treatment. In the past many, and at present, without doubt, some, surgeons resort to operation, even early in the disease, but as a rule such operations have been accompanied with excision of at least the head of the femur and frequently more, of the neck and trochanter.

My first object in the early operation for tuberculosis of the hip was to avoid a complete removal of the head or of an amount of bone sufficient to interfere with the continuity of the upper end of the femur, or function of the joint, to excise the diseased bone only in small areas by a gouge and curette, trusting to antiseptic irrigation, and especially to the healing process, to check the further extension of the tubercular processes, and to encourage healing of the tissues already diseased, both of bone and soft parts. Every surgeon must have observed, especially in excisions of the knee, that tuberculous bone has frequently been left behind, but that the disease has been cured. Change of circulation, due to the operative interference, and the scar tissue of the healing process, both seem to exert a curative influence on the tubercular tissues.


The more frequently one operates, and the earlier in the disease, the more frequently he may be fortunate in finding single focus, of tubercular osteomyelitis which can be completely excised without injury to the continuity of the bone or function of the joint as in Cases I and IX. As our experience grows, I trust we will find that early operations check the disease with more certainty and in a greater number of cases than the usual orthopedic treatment. I trust also we will find that it shortens the period of treatment.

In five of these cases the joint capsule was greatly distended. It would seem beyond question that arthrotomy and irrigation in such cases are the only reasonable treatment. The symptoms due to tension are relieved, and both the infiltrated and uninfiltrated tissues, relieved of this pressure, are better able to take care of the tubercular process. In addition, the arthrotomy allows a thorough local disinfection of the surfaces of the capsule and bone, and with the aid of a small gouge one is able to explore the trochanter and neck and head of the femur without endangering the continuity of the bone. In this early exploration, any focus of bone can be completely or partly excised according to its extent. Loose articular cartilage, both on the head of the femur and on the acetabulum, can be removed and the diseased bone beneath subjected to local disinfection.

From these observations it would seem that in many cases of tuberculosis of the hip, synovitis with effusion is present early in the disease ; in a number of cases the capsule ruptures and extra-articular abscesses form. An anterior arthrotomy, if performed before rupture takes place, would effectually prevent this complication.

In three of our Cases, Nos. V, VII and VIII, extra-articular abscesses were preseut at the operation. The joint capsule in these three cases was not distended but perforation and communication with the abscess cavity were found in each case. In addition to the incision of the abscess, the joint was opened by the usual anterior incision and drained. In Case VII there were two abscesses; the one beneath the adductor muscles, on the inner lateral surface of the thigh was drained through the joint capsule. Microscopic examination of the wall of abscesses from tuberculous bone, demonstrates, especially early in the disease, that the wall of such " cold " abscesses is composed of ordinary granulation tissue. We seldom find evidence of tuberculosis. Clinical observations demonstrate that extensive excisions of the abscess wall are not necessary. The most important point in the treatment is the removal of the source of infection in the bone. For this reason in operations for tuberculosis of the hip in which extra-articular abscesses are present, I believe it is better in every case to simply incise the abscess, curetting and thoroughly disinfecting in addition, if you wish, but most important of all in every case to explore the joint and search for the focus of tubercular osteomyelitis. We however, will have to wait before forming definite conclusions, and compare the immediate and ultimate results in these cases with those in which the extra-articular abscesses have simply been incised. Kecent observations, however, have impressed me with the value of early exploratory arthrotomies in tuberculosis of the hip, not only for a confirmation of the diagnosis early iu the disease, but for treatment.


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In all the joints, especially the hip and knee, the synovial sac can be thoroughly disinfected and filled with iodoform, and with a small chisel the more common positions for the tubercular focus can be explored. To open and irrigate a normal joint, even with 1 : 1000 bichloride of mercury solution, is not followed by any restriction of motion, and Case I demonstrates that the hip joint can be drained for six weeks and yet almost complete restoration of the function result. Anterior arthrotomy of the hip is a simple operation and its dangers should be confined almost entirely to the danger of the anaesthetic. However, it must always be borne in mind that a virulent pyogenic infection of the wound at the operation or later would be a serious complication, and if we found that this occurred with any degree of frequency, it would most certainly detract from the results, even in comparison with the orthopedic treatment. More extended experience will be necessary before we can judge of the risk of infection. (There has been no iufection in our series of 12 cases.)

The anterior incision in cases of tuberculosis of the hip is not a new procedure. Mr. Barker (Manual of Surgical Operations, 1887) describes it as R. W. Parker's operation. More recently, in Treves' System of Surgery, Mr. Barker again gives this incision first place, and in addition states that Professor Hueter, of Greifswald, described asimilar method independently but at about the same date of Mr. Parker's. (Transactions of Clinical Society of London, 1880, page 105.) Bradford and Lovett (Orthopedic Surgery, second edition, 1899) describe the anterior incision for the excision of the joint, but prefer the posterior incision. As far as I am able to find in the more recent authorities, the suggestions made and the methods followed in these cases are sufficiently original to justify their publication.

To repeat, the chief object in the early operation for tuberculosis of the hip is to take the disease in its early stage, to relieve the tension of the distended capsule, to check and cure the tubercular synovitis by disinfection and drainage, to explore the bone with the hope of finding the tubercular osteomyelitis, in which case it can be partially or completely excised ; trusting also to disinfection, drainage and the healing process to check and later cure the disease of the bone without injury to its continuity. The acetabular cavity can be explored, as shown in (Fig. 55) by chiseling through the head ; more extensive operations on the acetabulum, however, could not be performed without removal or temporary dislocation of the head. It is too early to judge of the results, except in Case I, in which the patient has now a perfectly functional joint one year after operation.

In operations for tuberculosis of the joints, one must always bear in mind the possibility of disseminating the tubercle bacilli. In operations on joints where the Esmarch can be used, this danger may not be as great as in operations on the hip and shoulder. It will require, however, a number of years and careful observation to get at data for this study. The method of operation is clearly described in the details of the history of the nine cases reported. The most important anatomical point is to bear in mind the deep external circumflex vessels. Sometimes it is not necessary to divide these, but if it is found that more room is required, these vessels should


be carefully ligated. The joint can be exposed easily without dividing the muscle by separating the tensor vagina' femoris and the glutei muscles on the outer side and the sartorius and rectus to the inner (medial) side. I believe it is a better plan to lengthen the incision rather than to make a cross cut of the muscles. The separation of the muscle leaves a cleaner and a less ragged wound, and perhaps detracts much from the danger, not only of pyogenic infection but of tubercular dissemination. Through this wound, by separating the muscles, one can clearly see the capsule of the joint and the trochanter and upper portion of the shaft of the femur. On dividing the capsule, one can explore with great ease the neck and head of the femur. In these operations the head has not been dislocated from the acetabular cavity, but if one found the round ligaments destroyed, with extensive disease of the head and acetabular cavity, the head of the bone could easily be temporarily displaced to allow a better treatment of the head itself and the acetabular cavity, after which it could be replaced. This course was followed in a recent case by Professor Halsted.

Discussion.

Dk. Halsted. — To indicate what we may hope for as a final result in certain cases of hip-joint disease, even when a considerable portion of the head of the femur has been removed, and in support of what Dr. Bloodgood has said, I will refer very briefly to a case which I intend very soon to report in full with other interesting hip-joint cases. The patient, a boy, thirteen years old on admission, had an acute osteomyelitis in 1895, at the age of eleven, which involved the entire diaphysis of the right femur. Eleven months he spent in bed, and for seven months could not lie on the affected side. After walking about with a cane and without much pain for more than a month he had to take to his bed again for about a week during a second acute attack of pain in the same bone. Two or three months later two abscesses appeared, one behind the knee and one internal to the trochanter. The boy was thenceforth for nearly a year quite comfortable and considered himself sufficiently well, until the 1st of November, 1897, when he was hit in the right groin by a wagon-pole. He suffered greatly from this blow, and the following morning could not flex his . thigh. Two weeks later, November 19, 1897, he was brought to us by his physician, who stated that for several days he had been having very high fever with daily intermissions. The boy was emaciated; his expression anxious and indicative of suffering. He lay on his back; the right thigh was abducted, rotated outwards and slightly flexed ; the groove in the right groin was obliterated and there was an appreciable fullness over the head and neck of the femur. Pressure over the joint and all attempts to move the head of the femur caused pain. About the level of the top of the trochanter of the right femur, but internal and anterior to it, was a sinus from which pus escaped. Behind the inner hamstring tendons was the orifice of a second sinus discharging more pus than the other. The femur was much enlarged, and the soft parts of the thigh were swollen. An involucrum had evidently replaced the entire diaphysis. A probe in the popliteal sinus touched rough bone. The measurements, which developed a fact or two of interest, I will give at another time.


20


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 106.


1st Operation. Nov. 2J,, 1S97.— Excision of One-Half (Anterior) of the Head, Neck and Upper Portion of Trochanter of the Eight Femuk by Frontal Section. There was a small abscess containing only a few drachms of pus just below and in front of the capsule of the hip joint, which communicated with this joint. The wall of the abscess was carefully excised. Having made the frontal section of the trochanter, neck and head of femur, the extent of the disease in these parts could be accurately determined. The upper end of the soft sequestrum was cut off. The disease had involved the neck and head and had finally, perhaps just after the blow from the pole, infected the hip joint. By some oversight no drawing was made of the lesions in the head, neck and trochanter. Nowhere were there signs of active bone disease; there was a little sequestrum near the top of the trochanter, and a little, very slender bit of sequestrated bone in the neck; the shape of the head and of the neck was not altered by the disease; the head of the bone had lost some of its cartilage, and granulations were growing from the denuded parts. The infection of the joint was probably recent, and it could be demonstrated how this might have taken place. It was not contemplated at the outset to do more at the first operation than to relieve the trouble about the hip joint, for the patient's condition contraindicated an extensive operation. The patient recovered promptly from this and from two subsequent operations upon the middle and lower thigh. As you may see in the photographs, the boy can extend his thigh perfectly, and can flex it to nearly a right angle. He walks without a cane and says that he finds the right thigh as useful as the left. The operated thigh is from 1 to 1.5 cm. longer than the other; and there are 2 cm. of apparent


lengthening on the right or operated side. This apparent lengthening is due in part to abduction and will undoubtedly disappear.

This case sheds a new light upon the surgery of the hipjoint, proving as it does that not only a useful but functionally an almost perfect joint may be obtained even when onehalf of the head and neck of the femur have been removed by, approximately, a frontal section. We may, therefore, attack tuberculous cases in the early stages in some such conservative way, taking a fine and very thin slice from the anterior surface of the neck or head, or trochanter, or from all, and having located the disease, excise only as much as may be necessary. The acetabulum can be explored in a similar manner. If the disease is operated upon early it would probably rarely if ever be necessary to remove the whole head of the femur ; and we may find that having removed a part of the disease the remainder, as in tuberculous peritonitis, may take care of itself the better for having been interfered with aud assisted.

The hip joint, a simple ball and socket joint, promises more for these conservative operations than any other joint ; large surfaces covered with cartilage do not lend themselves so readily to the formation of strong adhesions and ankylosis as the less simple joints; of all the joints the knee is perhaps the least suitable for conservative surgery. With its ligaments and reduplication of synovial membrane, with its fibro-cartilages and numerous recesses and pockets it furnishes conditions well suited to the propagation of the tubercle bacillus ; and when the crucial and lateral ligaments have been much weakened by the disease, an ankylosed joint is usually more serviceable and more comfortable than one in which motion has been secured.


GUNSHOT INJURIES BY THE WEAPONS OF REDUCED CALIBRE.*

By L. A. LaGarde, Surgeon, U. S. A.


My first acquaintance with the military weapons of reduced calibre dates from a time wheu I was pursuing studies with firearms in this institution. I am, therefore, very happy to return here to-night to talk of guns and missiles with you. .

In considering the effects of the modern arm, experimenters have generally studied it by comparison with the older weapon. I hold in my hand the Springfield rifle, calibre 45, which was used by our foot troops from 1874 to 1892. It is a single loader and in expert hands it is capable of delivering 20 shots per minute.

Its projectile has a velocity of translation of 1301 f. s., a Telocity of rotation on its long axis of 800 turns per second, and a maximum effective range of almost 2000 yards. It is made of lead hardened with antimony, cylindro-conoidal in shape, weighing 500 grains, and is propelled by 70 grains of black powder.

I will now exhibit our present service rifle — the KragJorgensen — adopted in 1892 for use by the foot troops. It is


♦Read before the Johns Hopkins Hospital Medical Society, Nov. 10, 1899.


a typical example of the reduced-calibre weapons at present in use by all the powers. It is provided with a magazine which holds five cartridges. In expert hands it is capable of delivering as many as 40 shots per minute. Its projectile weighs 220 grains, 30 calibre, composed of a nucleus of lead, enclosed iu a hard steel mantle. Its velocity of translation is 2000 f. s., the velocity of rotation 2400 turns per minute; whilst it possesses a maximum effective ran^e of 4000 yards, propelled by 37 grains of smokeless powder.

In some experiments which I conducted iu 1892 at Frankford Arseual, under the orders of the Secretary of War, my efforts were especially directed to the difference in destructive effects between the missile of the 45 calibre weapon, and that of a missile so similar to the Krag-Jorgensen bullet, that for all practical purposes they may be regarded alike.

We fired the two bullets altogether one hundred and ten times, into ten cadavers. Our aim was to traverse similar parts of the body or parts offering about the same resistance, with first one and then the other bullet at all the ranges — from 100 to 2000 yards. The ranges were not actual ; they were simulated by reducing the charge of powder so that the projectile was


January, 1900.]


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21


given the remaining velocity which was common to it for any given range.

Impart. — The first thing to attract our attention at the outset of our experiment was the difference in the amount of shock imparted to a member when hit first with one and then with the other bullet. The shock was estimated by the oscillation of a limb when suspended. As might have been expected, the greater sectional area and greater weight, of the 15-calibre projectile, caused greater shock than that noted by the smaller and lighter bullet on impact with a resistant bone. Indeed, the difference was so marked that it often happened that the presence of a fracture from the latter was only noticeable upon close inspection, whereas it was invariably predicated by the motion imparted to the member when traversed by the larger bullet. The shock from either bullet as judged by the motion to the limb, was nil when soft parts alone were hit.

The minimum amount of shock from the smaller calibre bullet has been the cause of much concern among military men. The English in the Soudan, and in the Ashanti campaign were so doubtful of the efficacy of this small calibre missile to arrest the impetus of savage tribes that they resorted to the practice of making their missile explosive by filing the nose through the steel casing enough to expose the lead core. This is the famous Dum-Dum bullet which takes its name from the place of its manufacture in India. When the lead is exposed, as stated, the projectile disintegrates on impact with a resistant structure. The fragments of the steel mantle and lead core, acting as individual missiles add greatly to the destructive effects in the foyer of fracture.

Explosive Effects. — Our observations with the old and new rifles were next directed to explosive effects. We noticed these so called explosive effects with the new weapon up to 350 yards, whilst they were seldom exhibited with the old arm beyond 200 yards. Explosive effects in gunshot wounds are peculiar to rifle projectiles impressed with high velocities. Within the zone of explosive effects they are common in the experience of the military surgeon, whereas they are seldom witnessed by the civil surgeon whose experience is almost entirely confined to wounds by pistols, whose projectiles are possessed of comparatively low velocities.

In speaking of explosive effects, one should not confound the term explosive effects with explosive action. The latter term should be restricted to those wounds caused by an explosive bullet — that is, a projectile that explodes on impact. Such a projectile is hollow, charged with explosive materials which ignite when the bullet strikes against a hard substance, like bone. The bullet is thus torn asunder, causing usually an extensive lacerated wound. On the other hand the projectiles possessed of superior velocities do not explode on impact. They are solid, and at most, seldom become altered in shape. Indeed, those of the small calibre, enclosed in a mantle of the hardest steel, do not even deform when they collide with the most resistant parts of the human body; and yet they are proverbial for their explosive effects in the proximal ranges.

Explosive effects are well exhibited by firing the projectile of the old and new arm into tin cans at close range. For the


purpose of comparison, if the experiment is done by firing into tins when empty, and into another set of tins of similar capacity filled with water, the empty cans will exhibit no alteration in shape. The orifice of entrance and exit of the bullet will correspond in size to the sectional area of the projectile; on the other hand the tins that were filled with water will show great alteration in shape. The sides of the vessels will exhibit a bulging as if some interior force had exerted an outward pressure in all directions. The orifice of entrance will usually correspond to the calibre of the projectile, whilst the orifice of exit will be marked by a large irregular opening with everted edges.

If the exjieriments are continued upon a cadaver at close range, impact with a resistant bone will present certain characteristic features: The wound of entrance in the skin will correspond in size to the diameter of the bullet; the wound of exit will be marked by a bursting forth of the skin. "The track leading to the bone is conical in shape, the base of the core corresponds to the wound of exit in the skin, and the apex of the core corresponds to the seat of fracture. The bone is finely comminuted. A close inspection shows that the bony particles have been driven into the tissues at right angles to the bullet track ; it is not uncommon to find bony sand in the wound of entrance."

Five theories have been advanced to explain these explosive effects.

1. Hydraulic Pressure.

2. Compressed air, or the projectile air.

3. Rotation of the bullet.

4. Deformation of the bullet.

5. Heating of the bullet.

1. Hydraulic Pressure. — The term " hydraulic theory " has been employed by many writers to explain the highly destructive effects often found in gunshot wounds at the proximal ranges. It is based on the principle of Pascal. This principle is only applicable to a closed vessel tilled with liquid. In accordance with this principle if a certain pressure is made upon a given area of the imprisoned liquid a similar pressure will be exerted within on like areas of the vessel walls.

The experiments of Coler, Stephenson and others have effectually disproved this so-called hydraulic theory. They have shown that the highly destructive effects noted by firing into sealed vessels filled with liquid were to be noted in the same way when the vessels were unsealed. Ordinary tin buckets filled with water whether the tops were in place or not sustained the same amount of destruction.

2. Compressed air, or projectile air. — This is called the projectile air of Melsens, because it is he who recently revived this theory of projectile air in explanation of the destruction in wounds that so often suggest explosive action. Boys lias succeeded in making exact photographs of bullets in transit. He caused the bullet to cross an electric circuit. At the moment of contact with the circuit the bullet and the immediate vicinity of its trajectory are illumined by a spark which serves to throw the image upon a photographic plate. A study of the views thus obtained distinctly shows a pad of compressed air in front of the projectile. Melsens believed


22


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[No. 106.


that this cushion of air entered the tissues at the moment the skin was penetrated or before, and that the destruction of tissues was to be accounted for by the explosion which occurred when the compressed air again regained its normal volume. The tissues fail to show any evidence of air having been forced into them, such as one might infer from the presence of emphysema, and altogether it may be said that the theory of projectile air has but little to recommend it to consideration.

3. Rotation of the bullet. — The rotation of a rifle bullet is imparted to it by the twist in the barrel. The longer the bullet the sharper must the twist be. The old Springfield 45-calibre bullet, which was but two calibres in length, and which revolved 800 turns per minute at the muzzle described one complete turn in 22 inches, because the twist in the barrel corresponded to one complete turn in 22 inches. In the present rifle the twist is sharper, viz., 1 turn in about 10 inches, and the rate of revolution is estimated at 2400 turus per minute. It is generally admitted by ballisticians that the velocity of rotation is well maintained, — that it does not diminish with the velocity of translation. Taking for granted that the projectile makes a complete turn in ten inches, we must admit that the rotation of the bullet can have but a minimum amount of effect to disjday in traversing a thigh bone which may be but one inch in diameter, because in traversing it the ball is making only T \ of a turn.

4. Defortri'ition. — The fact that the old leaden bullet became deformed when colliding with a resistant bone, especially at short range, added greatly to the amount of destructive effects. Deformation can find no plea as a cause of destructive effect in all cases since the steel-clad bullet that does not deform is proverbial for the creation of explosive effects.

5. Heating. Heating of the bullet by the act of ignition to explain explosive effects found adherents long ago, and it was not until recent years that this erroneous notion was set aside. It is not necessary to explain to an audience like this in the very institution where the significance of heat imparted to missiles was forever determined. We ware able to show in 1892 that the heat on a bullet caused by the ignition of the powder is not sufficient to destroy the ordinary septic germs. The experiments were conducted with missiles from lowvelocity rifles and the weapons of reduced calibre with the same result. To speak briefly we can truthfully say that the heat of a missile cuts no figure in gunshot wounds.*

The true cause of explosive effects is the superior energy possessed by the bullet at the moment of impact. The bone, and even the soft parts, receive a large amount of this energy and move "outwards in lines radiating from the long axis of the bullet-track with such a degree of force that they act as secondary missiles on the neighboring tissues and cause still further smashing and pulping of the tissues. Even fluid particles participate in this secondary action but it is all the more marked when fragments of bone are driven apart in this manner." (Stephenson.)

Soft Parts. — Our next experiment at Frankford with the


♦Proceedings Pan American Congress for 1893, Vol. 1. N. Y., Med. Record, Vol. 47, No. 25.


small-diameter bullet demonstrated that the wound of entrance was usually round, the size corresponding to the diameter of the bullet; the edges of the wound were at times clear cut, but more often they were rolled in and often blackened like the wound of entrance of the old leaden bullets. This, as you know, once gave rise to the idea that the edges of the wound were discolored by burning ; but thanks to the assistance of Professors Welch and Councilman, as already stated, this idea was refuted for all time in the laboratory of this institution.

The wound of exit of the small-calibre bullet was generally larger than the wound of entrance, and beyond the zone of explosive effects especially it was generally round, marked at times by a mere slit; again it was star-shaped, T-shaped, semicircular, &c; the edges were generally turned out.

Diaphyses of long bones. — Our next observations at Frankford Arsenal referred to the effects of the small-calibre bullet upon the compact substance of long bones. Here I may state that the destructive effects of the old and new bullet up to 350 yards were alike, and severe. Beyond 350 yards the lesion in the bony tissue changed perceptibly with the smaller bullet, the comminution was less, the fissures were larger, and the spiculae of bone were not so often detached. The general tendency with the little bullet between 500 and 1500 yards was to inflict a wound approaching a perforation, although a clear-cut perforation in the diaphysis itself was seldom seen. At 2000 yards the small bullet showed a tendency to again shatter the bone.

Effects upon the epiphysial ends of long bones. — Clear-cut perforations were generally observed when the small bullet traversed the spongy ends of bones. This was especially true after the zone of explosive effects and even within this zone — 350 yards — complete perforations with little or no Assuring were often seen.

Actual Conditions. — Of the wounds noticed in Cuba during the Santiago campaign I may add that they partook the general characters of the wounds that I have described as exrjerimental wounds. The wounds of the soft parts healed immediately, without an exception to my knowledge, under antiseptic dressings. The wounds of joints, including the knee, elbow, shoulder and hip were immobilized, dressed antiseptically, and they all did well. The wounds of the skull, including brain substance almost invariably suppurated, owing no doubt to the amount of dirt introduced from the scalp with the bullet.

Wounds of the lungs. — Those that survived 24 hours generally did well. In the majority of instances it was difficult to restrain the men after two or three days.

The wounds of the abdomen were generally fatal. Four or five men recovered with gunshot wounds that appeared outwardly to have perforated the intestines, but no actual proof of such perforation was obtainable. I was told that three laparotomies for gunshot injury of the abdomen were done at one of the field hospitals. The patients all died in a few hours after operation. For mauy reasons laparotomy for gunshot wound in the abdomen on the field was not considered safe or practicable. Upon the whole, the gunshot injuries by the Mauser, the reduced-calibre rifle of the Spaniards, were in keeping with those humane effects so confidently predicted by


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23


experimenters generally. The wounds of soft parts healed without suppuration. The lesions of bone that formerly caused such a high mortality in the statistics of wars were most successfully treated by antiseptic dressings and the proper use of immobilizing materials. Comminution, and Assuring were noticed in the diaphyses. It was, however, seldom necessary to cut down for the purpose of removing spiculse of boue, as the displacement of fragments did not require this amount of interference. The clean-cut perforations of the epiphyses, without fracture, rendered joint injuries the most favorable of all bone lesions for rapid healing, with little or no loss of function. This was especially true of gunshots of the knee.

The difference between the gunshot wounds of civil and military hospitals will be more marked in the future. The civil surgeon will continue to treat pistol-shots in which the balls often lodge. Some lesions from this source often show complete separation of fragments, which necessitates cutting down. The joint lesions are often severe, necessitating the opening of the joint, under antiseptic precautions, turning out blood clots, removing fragments, etc. Such precautions are necessary to insure against sepsis. On the other hand, it may be said that the action of the steel-clad bullets from the present military weapons and the use of antiseptics have so modified the results in the gunshot wounds of warfare that the burden of the military surgeon and the sufferings of the patient, immediate and remote, will be very much lessened.

Discussion.

Exhibition of Radiographs showing Results of SmallCalibre injuries. — Dr. W. C. Borden, U. S. A. — During the late war I was stationed at Key West with an X-ray machine, and from a study of the wounded soldiers I have arrived at some general conclusions relative to the effects of the small-calibre bullets on the human body, more particularly upon the bones. Dr. LaGarde has gone over the consideration of the theoretical effects of the bullets and these pictures will show the clinical effects as demonstrated by the Roentgen ray.

It seems to me that there are four main elements that influence the effect upon bone tissue — (1) the velocity of the bullet — (2) the part of the bone struck — (3) the angle of incidence and (4) the form of the bullet. Clinically, there is one thing above all others that affects the course of the case, and that is the presence or absence of sepsis in the wound.

When the bullet is traveling at extremely high velocity the explosive effects are produced whether the bullet strikes the bone, I mean now the shaft of the bone, at any angle or in any part. For instance, if it strikes the bone perpendicularly, it will produce a bad fracture, and it will do this equally if it merely grazes the bone. When the bullet strikes the bone laterally, merely grazing the periosteum at a high velocity, it produces a fracture that may be termed a fracture by contact. Here is an illustration (showing radiograph) ; the bullet passed across the front of the forearm, just grazing the radius, and yet, as you see, it shattered the bone completely; and here is an example showing a similar effect upon the hand at short


range. In this case the whole distal end of one of the metacarpal bones has been blown completely out, and yet the wound of exit was very little larger than the wound of entrance; the range was five hundred yards.

So much for the effect upon the human body when the velocity of the bullet is at its greatest. Now, the angle of incidence seems to me to have a marked influence. When the bullet strikes the bone in the median line with perpendicular impact, it shatters the bone as badly as if it were within the explosive range. Here is an illustration of a fractured thigh, in which the bullet went straight through, striking the femur with a median impact, and you see how badly the femur is shattered. In a little over a year after the injury I radiographed this same case; the wound had healed readily without any suppuration, and though there is a tremendous callous formed about the fracture, the position and function of the limb are almost perfect. Now as to tangential impact, when the bullet strikes the bone at an angle the fracture and Assuring are not so great, no matter what the range may be, provided it is outside the explosive zone. In this case (showing radiograph) the bullet struck the outer side of the radius, tore off a piece of bone and made a straight fracture.

Now as to the form of the bullet. Dr. LaGarde has spoken only of the bullet as it strikes after passing through the air; but in war it may ricochet, strike some object, become deformed and then strike the body. In these cases the effect of the bullet is decidedly different from that of the plain undeformed bullet. In this case (showing radiograph), for instance, the bullet struck some object before it hit the man, and the whole end of it became flattened so that it was practically like a Dum-Dum bullet. The velocity was low, for the bullet lodged in the tissues and yet because of its extreme deformity when it struck the bone it shattered it immensely. Here is an injury of the same class showing two bullets in the same limb. Both bullets were deformed and the shattering was very great. Here is a photograph of several Mauser bullets removed after X-ray examinations of the patient. All but one of them are deformed.

Here is a rather interesting radiograph showing the passing of a Mauser bullet through a phalanx. The bullet is so small and travels with such velocity that it may pass through a finger and not tear it off as would a larger bullet. Relative to this case I would say that gunshot injuries of the hand always cause some permanent loss of function. This is due to injury to the soft parts; and in regard to injury to the soft parts by the small-calibre bullet I would say that we have had a great many cases where, though the bones were markedly shattered, if the soft parts were not much torn there was not much loss of function ; but if the soft parts were greatly disturbed, the resulting cicatrizing tissues caused considerable disturbance of function.

The injury produced by these bullets to the ends of long bones is quite different from that of the shafts. In the shaft the Assuring and comminution are always greater than in the extremities. Whatever the theory of explosive effect may be it is certainly true that the dense tissue of the shaft transmits the shock more than the softer tissues and causes greater solution of continuity.


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JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 106.


Concerning the humane effect of these bullets I should say that where they do not kill outright they are certainly much more humane than the old bullets were. I saw some cases, — one I remember in particular — where the bullet passed through


the abdomen, directly through the liver, and yet the patient was up and ran away from the hospital eleven days after receiving the injury.


A RECONSTRUCTION OF A GLOMERULUS OF THE HUMAN KIDNEY.

By William B. Johnston.

(From the Anatomical Laboratory of the Johns Hopkins University, Baltimore.) WITH SIX FIGURES.


Since the appearance of Carl Ludwig's article upon the Kidney in 1872,* in which he devotes but a few words to the structure of the glomerulus, and in which are reproduced a few drawings of the glomeruli of mammalian kidneys, other investigators have been inclined to pass over this part of the vascular mechanism of the kidney, mentioning only its afferent and efferent vessels. The difficulty of seeing anything but the exterior of a glomerulus has, of course, always obscured its intimate structure. For these reasons it has appeared advisable to make a more careful study of the arrangement of the blood-vessels of the glomerulus by means of the method of reconstruction.

The requirements for such a reconstruction are a perfect set of serial sections through a well injected glomerulus, the sections being thin enough to pass at least twice through any of its vessels which may be struck parallel to the plane of cutting, as well as a conception of the outward form of the glomerulus previous to cutting.

Preliminary injections of the dog's kidney with a variety of substances brought out the advantages of a supersaturated aqueous solution of Berlin blue over other injection masses, and the advisability of selecting and cutting a single glomerulus. Adult human kidneys from the autopsy table were usually abnormal and always failed to be well injected. In order, therefore, to obtain a good injection of a normal glomerulus, the kidney of a child three months old, dead but a few hours, was injected in situ through the abdominal aorta until the Berlin blue appeared in the renal vein. The difficulty of obtaining a faultless series of very thin sections was greater than that of selecting and cutting out a well-iujected glomerulus from clear bits of this kidney, though very many seemingly perfect glomeruli proved to be but partially injected. A chosen glomerulus from the child's kidney was imbedded in paraffin in the usual way and cut into serial sections 3 /x thick. The 3-1 sections through this glomerulus were then stained in Upson's carmine and mounted in balsam. Drawings of each of these sections enlarged 1333 diameters, the greatest convenient enlargement, were made with a camera lucida (Figs. 4, 5, 6) and the corrected drawings transferred with carbon paper to wax plates 4 mm. thick, i. e. 1333 times as thick as the original sections.


•Handbuch der Lehre von den Geweben des Menschen und tier Thiere. S. Strieker, Vol. 1.


Before beginning the reconstruction, that part of each plate representing the glomerulus proper was cut out, the line of iucision following the outer borders of the external vessels, leaving Bowman's capsule in the outer shell. The remaining wax shells thus obtained were carefully piled in order, and a plaster-of-Paris cast made of the cavity. The solid cast roughly indicated the external form of the enlarged glomerulus. As a further guide to the reconstruction, the sections of the blood-vessels appearing in each plate were cut out with the exception of wax bridges connecting them. The internal relation of these sections in wax representing the blood-vessels was thus preserved, which aided materially in piling and blending the individual sections.


XV



Fig. 1. — Was model of the glomerulus, enlarged 444 diameters, seen in profile from the left side. A F afferent vessel ; E Fefferent vessel.

From the model thus made it appears that the afferent vessel of the glomerulus, after entering the capsule of Bowman, immediately divides into five diverging branches, which with their subdivisions and with the efferent vessel form an almost spherical tuft of blood-vessels. For the sake of description we may assume that the glomerulus is suspended from its afferent vessel. The efferent vessel originates, roughly speaking, from a loop of capillaries which projects in the equatorial plane from the side of the glomerulus opposite the efferent vessel, but to the right of the median line (Fig. 2 E. V.). From this point the course of the efferent vessel is upward, inward, and to the left, grooving the superior surface of the glomerulus and dividing it into two unequal parts. This vessel leaves the glomerulus a little superior and


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25


anterior to the point where the afferent vessel divides and in a direction opposite to that of the efferent vessel. (Fig. 1.)



Fig. 2. — Wax model of the glomerulus, same enlargement and same view as in Fig. 1. The left lateral group of capillaries is separated from the median group and turned back, exposing the interior of the glomerulus, a. A short section of a capillary of the median group is removed to show the course of the deeper-lying capillaries.

Externally the upper half of the glomerulus is seen to be composed of freely anastomosing capillaries, somewhat more pronounced on the left than on the right side. The capillaries of the lower half, except on the posterior surface, are loDger and more direct. The projecting loop of capillaries mentioned above, the course taken by the efferent vessel within the glomerulus, and the tendency of many of the external capillaries to turn towards the right side, give the glomerulus the appearance of being twisted to the right. Except on the superior surface where the left half is a little above the right, the spherical form is well preserved. Lobulation where it appears at all is superficial. (Fig. 1.)



Fig. 3 — Diagram of the wax model seen from the left side. Enlarged 444 times. The right lateral group of capillaries is turned back from the main group. The group E F is a connecting loop turned over to expose deeper capillaries. The lines marked Figs. 4, 5 and 6 indicate that Figs. 4, 5 and •', are taken from those planes, representing sections 7, 17 and 30 respectively of the original series.

The capillaries of the glomerulus can be roughly divided into a right, a left and a median group, corresponding to a right branch (Fig. 3 A), a left branch (Fig. 2 B) and a median branch (Figs. 2-3 C) of the afferent vessel. Two additional branches, a right lateral branch (Fig. 3 D) and a


left lateral brauch (Fig. 2 E ), take part in the fornmtiou of the lateral group of the corresponding side and of the median group. All rive branches arise from the afferent vessel at the same time though at different angles. The distances between their points of origin are not the same. According to Ludwig, the glomerulus is composed of from 4 to 8 groups of bloodvessels.

Each main brauch from the efferent vessel subdivides almost immediately. Each of the two lateral branches (D and E) has three subdivisions which are soon lost in the three main groups. They have in general the same arrangement.




Fig 4.

In the upper half of the left group (Figs. 1-2) there is a complex network of anastomosing capillaries. In the right group (Fig. 3), which is smaller than the left group and lies at a lower level, the course of the capillaries is more direct.



Fig. 5.

FlOS. 4, r> and fl. — Camera tracings of sections 7, 17, and 30, showing the capillaries, reticulum nuclei and Bowman's capsule. Enlarged 444 diameters.

The capillaries of the median group nearest to and farthest from the origin of the median branch (C) are in general longer and freer than those of the other group. The intermediate capillaries are short and the anastomoses frequent


In addition to the many connections between capillaries of the same group, the three groups or lobules are intimately connected with one another by numerous anastomoses. The capillary connections between the median group and the right group on one hand (Fig. 2) are of the same frequency, although unlike those between the left group and the median group on the other hand (Fig. 3). At one point there is an anastomosis of all three groups (Fig. 2 d, d', Fig. 3 d, c, c', c"). The number and varied character of these connections show the impossibility of dividing the capillaries of the glomerulus completely into distinct groups.



r«:: ftC


Fig 6.

Through the divisions of the main branches of the glomerulus and their subsequent anastomoses, all the capillaries are concentrated at two distinct levels (Fig. 2 F. G) in the median plane opposite the afferent vessel. Though the formation of the efferent vessel is clearly indicated at each level in the sections, it cannot be said to actually originate until the last capillary from the glomerulus has united with it (Fig. 3 L).

It is seen that the blood in passing from the afferent to the efferent vessel has the choice of numerous paths of varying lengths. The shortest path is that from the right lateral branch of the afferent vessel just above the central point of the glomerulus and in the median line (Fig. 3 D, c). Passing outward from this point to the periphery of the glomerulus, the paths become longer and more complex. The longest path is that of the median branch and its subdivisions along the inferior surface of the glomerulus. It is three times as long as the shortest path (Figs. 2-3). Yet the shorter course is


zigzag and is composed of the smallest capillaries. As the course between the afferent and efferent vessel becomes longer and longer, the capillaries become straighter and larger, thus correspondingly favoring the blood circulation through them.

The afferent vessel is larger than its branches, especially just before the point of division ; the branches are larger than their subdivisions. The efferent vessel is of the same size as the main branches of the afferent vessel. The increased diameter of the afferent vessel and its first branches is no doubt due to the pressure in the artery when the glomerulus was injected. Excluding this factor it is probable that the diameter of the various vessels of the glomerulus is the same from the afferent to the efferent vessel.

The very fine serial sections of the glomerulus not only served as a basis for the reconstruction of the blood-vessels, but also enabled me to study more carefully the relation of Bowman's capsule to the glomerulus. Ludwig* has shown that the basement membrane of the uriniferous tubules is elastic and when treated with reagents is very likely to swell. Later Mallf showed by digesting frozen sections of various organs with pancreatin that the interstitial tissue and so-called basement membranes resolved themselves into fibrils, showing some characteristics of yellow elastic tissue, some of white fibrous tissue and some peculiar to themselves. This set of fibrils (reticulum) is widely distributed and makes up the main framework of the kidney. It is these fibrils of reticulum which form the basement membrane of Bowman's capsule.

As the afferent vessel pierces Bowman's capsule, the reticulum fibrils forming it separate as shown in Figs. 4 and 5. They are not reflected over the glomerulus, but, at the point of separation, fibrils arise which penetrate the glomerulus passing in all directions between its capillaries. The fibrils are densest at the point these vessels penetrate the capsule and gradually become less and less numerous as the periphery of the glomerulus is approached. Up to the present I have not determined the nature of these fibrils but on account of their arrangement as well as the connection with them of Bowman's capsule, I do not hesitate to class them with the other reticulum fibrils.


  • Ludwig, Strieker's Handbuch, 1871, p. 495.

fMall, Abhandl. d. K. S. Ges. d. Wiss.,Bd. 17, 1891 ; also Riihle, His's Arch., 1896, and Disse, Sitzungsber. d. Ges. z. Beford. d. ges. Naturwiss. Marburg, 1898.


MEDICAL COMMISSION TO THE PHILIPPINES.


It is matter of general belief that scientists in the retirement of the laboratory pursue their abstruse investigations oblivious of wars, revolutions, and the manifold variations in the phases of international politics, and it is, perhaps, well on the whole that there is some basis for the belief. But, as a matter of fact, it will be found that the trend of scientific research is, at times, enormously influenced by changes in the outside world; for with these changes new problems arise upon the solution of which depends the ultimate success of national undertakings. No more striking example of such


influence could perhaps be adduced than the extraordinary attention which is at present being paid to the study of the causes, prevention and cure of diseases prevalent in the tropics. While there have been, it is true, notable instances of medical research prosecuted with brilliant results in tropical fields in the past, it is only since Northern and Western nations have turned their faces resolutely towards the South and the East— faces stern in the determination to hold their own in the fierce international rivalry for conquest and control of trade — that the importance of the medical problems


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of the hotter regions of the earth has begun to be fully appreciated, and that organized bauds of skilled investigators have been seut iuto them to study the diseases to which a large mass of their fellow countrymen will henceforth be exposed.

The earlier observations on the conditions aud diseases of tropical countries we owe to missionaries and explorers, men of roving instincts and venturesome habits, who partly in self-defense, partly from desire to benefit other travelers or the natives of the regions traveled through, observed the sick and examined the methods of treatment in vogue in those lands. All such studies were necessarily fragmentary and of a desultory character, but no one with a knowledge of the subject would speak of them disparagingly, for they represent the beginnings of an important movement, and have been, moreover, attended by valuable discoveries, some of which have proved to be of the greatest benefit to humanity. It is only necessary to mention the introduction of cinchona bark into Europe in the 17th century by the Jesuits, who had seen its beneficial effects in Peru, and to recall the immense part played by its alkaloid, quinine, in the treatment of malarial diseases to-day, to realize the significance of at least one of these discoveries. Millions of lives have been saved, and whole continents made accessible to civilization, for the dangers of forest and morass have largely ceased to be prohibitive since the white man has learned to carry quinine in his blood.

Later, white traders and white soldiers, the natural successors of missionary and explorer, on entering the tropical regions took with them civil and military physicians, who by virtue of their better medical and scientific training were able to describe climatic conditions, investigate the symptomatology of diseases, and study their causes, nature and treatment far more accurately than their predecessors had done. Thanks to their efforts we are already in possession of an analysis of the more prevalent diseases peculiar to the tropics and of the many facts of importance concerning etiology, pathology, prophylaxis aud cure. Among the most fertile in results has been the work done by Fayrer in India, and in Cochin China by Calmette, on snake poison ; in Algiers by Laveran, and in India by Koss, on the malarial infections ; in Bombay by Vandyke Carter and Obermeier, on relapsing fever; in China and other countries, by Manson, on filariasis; and in the West Indies and South America, by Sternberg, Guiteras and Sanarelli, on yellow fever.

During the last thirty years, however, remarkable advauces have been made in pathological and especially in bacteriological technique. A large number of scientific investigators in all civilized countries have been gradually overcoming difficulties which had hitherto been insurmountable, but which, by the new methods at their disposal could now be satisfactorily attacked. The field of medicine has become so wide and divided into so many departments that one man can scarcely hope to cover all of them. Much as we have to thank civil and military physicians in the past for the good work they have done, we can scarcely ask in the future men who have to devote a large share of their time to the treatment of patients and to the performance of executive functions to undertake the complicated researches necessary for the


isolation of the causative agent in obscure diseases. There has to be a division of labor and the practical man must be helped out by individuals who have been especially trained in particular lines of work, and who can give all their time to such work. Accordingly, of late, European governments and educational institutions have been sending into tropical regions men especially prepared and commissioned to investigate disease, and these men have been relieved of all duties except those actually connected with their original research. In this way, Koch and Gaft'ky went to Egypt and India, in 1883, to study Asiatic cholera, an expedition which resulted in the discovery of the cause of the disease; and at Hong Kong, in 1894, Yersin isolated the bacillus of bubonic plague. That such special investigations of the causes of disease justify the education of specialists and the expenditure of the time and money required is fully evidenced by the practical results which have followed. Cholera, now that the spirillum, the growth and activity of which in human beings cause the symptoms of the disease, is known aud its habits of life and mode of dissemination have been studied, can in civilized countries be absolutely controlled; the disease can no longer gain a permanent foothold in a city in which modern methods of sanitation are employed. Plague which swept away whole populations at a breath in former times need now scarcely be feared among Western nations; for even if the hygienic precautions of the end of the century fail to keep the disease out of the West, the method of preventive inoculation which has been devised since the discovery of the causative bacillus will protect those who avail themselves of this prophylactic measure.

In the light of these facts the authorities of the medical department of the Johns Hopkins University decided in March of the present year to send two of their staff, Dr. Simon Flexner and Dr. Lewellys F. Barker, to the Philippine Islands, equipped with a complete outfit for the study of disease by modern clinical and pathological methods. They were instructed to study the diseases which prevail in the islands "with the hope not only of making contributions to the science of medicine, but also of being of service to the American forces in those islands, to the natives of the country, and to humanity at large." The expenses of the expedition were defrayed through the generosity of a few friends of the University. Two advanced medical students, Mr. Joseph Marshall Flint, of Chicago and Mr. Frederick P. Gay, of Boston, went as volunteers and at their own expense to assist in the medical work at Manila. Mr. John W. Garrett, of Baltimore, interested in the political relations of the archipelago, made a fifth member of the party.

The voyage out was made by way of Vancouver, Japan and Hong Kong. Ten days were spent in Japan and the experience there proved of great value as an introduction to the work in Manila, inasmuch as Japanese scientists have studied and. indeed, with considerable success, several of the problems which confront the investigator in the tropics. With Doctors AoyoBia and Miura in Tokyo, several cases of kakke were observed, a disease which in the Philippines and in other countries, is more generally known under the name of beri beri.


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[No. 106.


The researches of the Japanese into the nature of this malady are among tbe most interesting and important extant. Dr. Aoyoma, who when investigating plague in Hong Kong was himself attacked by the disease and for a considerable period lay in a most precarious condition, showed no ill effects of the ordeal passed through, but was as active and enthusiastic as ever in the observation and treatment of disease. In the laboratory of Dr. Kitasato, the celebrated bacteriologist, of Tokyo, opportunity was afforded for looking into the work done by Dr. Shiga, one of the assistants in that laboratory, on the cause and treatment of dysentery. Dr. Shiga, who has isolated a bacillus which he regards as the cause of epidemic dysentery in Japan, has also, by inoculation of tbe bacillus into animals, prepared a curative serum which he believes will be of value in the treatment of human cases.

At Hong Kong, the members of the Commission, through the courtesy of Dr. Lowson, had their first opportunity of studying cases of bubonic plague, clinically in the wards of the isolation hospital and pathologically in the dead-house. The disease is constantly present there, though to a varying degree, among the Chinese inhabitants, Europeans being occasionally, though but rarely, attacked. A member of the Commission, speaking of experience with plague, remarked upon the curious mental phases passed through on encountering for the first time such a world-dreaded disease. During the first visit to the morgue in which the dead bodies of plague patients were kept, great care was taken to come into no personal contact with the dead, and even draughts of air leading from the vicinity of the cadavers were avoided. On the second day, the swellings (or buboes) in the groin, axilla or neck were palpated, but with some care; and on the third day, they found themselves making post-mortem examinations of the internal organs. Though Dr. Aoyoma developed the disease as a result of his studies, and Dr. Miiller, of Vienna, died from plague contracted while attending a nurse sick of it, it is probable that pathologists, provided they take the necessary precautions to avoid infection, have less to fear than is ordinarily supposed. If one work much with the disease, however, he would be very unwise did he not take advantage of the protection afforded by Haffkine's preventive inoculation.

The members of the Commission arrived in Manila at the beginning of May and at once, thanks to letters from Surgeon-General Sternberg, and the courtesy of Colonel Woodhull, the chief surgeon of the American forces in the islands, were enabled to begin their work in the military hospitals there. The majority of the American sick in Manila are cared for in two large base hospitals known respectively as the First and Second Reserve Hospitals. In the former institution, with Major Crosby in control, are some twelve hundred patients; while in the latter, under the management of Captain (now Major) Keefer, there are perhaps onefourth as many. Assoon as the patients are convalescent, those who require further building up are sent to the pleasantly situated Convalescent Hospital on Corregidor Island. This hospital is situated on the shore snugly nestled beneath the fort which fired on Admiral Dewey's ships as he entered Manila Bay. In addition to the military institutions men


tioned, there are numerous "district" and "regimental" hosjjitals in Manila, Cavite and other places whei^American troops are stationed. It was a matter of pleasant surprise to see how efficiently large military hospitals, seven or eight thousand miles away from home, could be organized for medical and surgical work. Whatever criticisms may have been made in America with regard to the administration of military affairs, nothing but praise is to be recorded of the medical services rendered by Colonel Woodhull and his staff in the Philippine campaign.

On account of the especial facilities and material obtainable at the First Reserve Hospital, working headquarters were established there, Lieutenant Strong generously sharing his laboratory with the newcomers, and in every way possible, lending his aid to the investigations undertaken. The time at their disposal being limited, the members of the Commission decided to choose, out of the many attractive problems which immediately suggested themselves for investigation, certain only which seemed to them of the greatest importance and which could be most advantageously approached. It was found that among the American soldiers in Manila the two most fatal diseases in May and June were dysentery and typhoid fever, while among the natives tuberculosis and beri beri were common and destructive maladies. The dysenteries and tropical diseases of the liver met with were made the object of especial study, and one of the most important results of the expedition was the isolation by Dr. Flexner, from the dejecta of patients, of a bacillus which is almost certainly the cause of the acute dysentery studied. The causative agent in this disease once known, it is perhaps not too much to hope that a preventive inoculation may be devised which will render individuals going to the islands immune from attack. Such a prophylactic measure if invented would be of incalculable value, since, according to an authoritative text book, " In the tropics dysentery destroys more lives than cholera, and it has been more fatal to armies than powder and shot." Malarial fevers are frequently encountered, and in Manila the parasites of the tertian and of the asstivo-autumnal variety are easily demonstrable in the blood of patients suffering from these types of the infection. The frequency and malignancy of the cases vary with the locality and with the season of the year. The deadly calentura perniciosa is much feared in certain districts, and as soon as the country is settled this form of malaria should be thoroughly studied. The forests of the interior of Mindoro and the regions adjacent to the Rio Agusan in Mindanao are localities of unusual interest in this connection. The relation of mosquitoes to malaria, so vital a question at the moment, is one well worthy of attack in the Malayan archipelago. Not uninteresting too, in passing, is the statement in certain of the Jesuitical records of Mindanao that the natives of that island recognized as far back as two centuries ago a relation between the intermittent fevers and the prevalence of mosquitoes.

At Cavite, an outbreak of some two hundred cases of beri beri among the Filipino prisoners yielded wide opportunity for the study of this disease in its various clinical and pathological aspects. In the same town a large epidemic of what was probably Dengue fever occurred.


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The cases at the Spanish hospital of Sau Juan de Dios, those at San Lazarus, the leprosy hospital, and those at the city asylum, were made accessible to study through the kindness of Major Frank Bourns, of the Provost-Marshal's department. There were still a few smallpox cases in the city, though through the strenuous exertions of the officer mentioned, in the way of compulsory vaccination and the establishment of a carabao vaccine farm, this disease, which claimed so many victims from among the American soldiers at the beginning of the occupation, was practically stamped out of Manila. Skin diseases are very prevalent among the natives, and the affection known as dhobie itch (for the most part a form of ringworm) attacked large numbers of American soldiers.

A considerable amout of pathological material was collected by the members of the Commission especially from cases of beri beri, leprosy and dysentery, and this was brought back to America for farther study. An abundance of plague material was similarily collected at Houg Kong. Bubonic plague does not exist in Manila, and a careful search through the older records would make it appear that it has never broken out in the Philippines.

The climate, though trying, owing to the continuous heat and moisture, is believed to be supportable if Americans will take certain necessary precautions. As one genial Englishman who has lived in Manila nineteen years, and who is now in perfect health, put it, "it is not so much the climate as the glass bottle which injures people out here." The visit of the Commission to the islands was made in the hottest season of the year, and at the beginning of July the onset of the rains by increasing the moisture in the air added much to the discomfort. However, if one carefully chooses his diet, eschews iced drinks, clothes himself rationally, avoids excesses both physical and mental, keeps out of the sun during the hottest time of the day, sleeps under mosquito-netting and does not bathe in too cold water, he may live a fairly comfortable life and will probably enjoy good health. Indeed, some Americans have found themselves in better health in Manila than at home, though this is the exception rather than the rule. Diarrheal troubles are very frequent and are to be combated by rest, a simple diet and, if necessary, by wearing a woolen abdominal band. Much has been written about the drinking of boiled water by the soldiers. Outside Manila this is certainly desirable, but any attempt to persuade soldiers on the march to follow this custom will probably prove futile. The Johns Hopkins party walked one afternoon from the Bag Bag river to San Fernando, and before the end of the journey found themselves drinking any water available, some of it certainly far from pure.

Early in July, Mr. Garrett left Manila for a trip through Java, and a few days later the rest of the party returned to Hong Kong, and began the homeward voyage which was made by way of Suez and London. Two members of the Commission spent three weeks in India, and there examined as fully as possible in the time, the outbreaks of plague which existed and the plague measures adopted by English officers in the Indian Empire. In Bombay, Colonel Weir, and in Poona, Major Keid and Major Windle accompanied them to the scene of the outbreaks.


The excursion to Poona was most impressive. Traveling upward for hours through the Western Ghats, the country

was so beautiful and the air so much cooler than at the sea level, that one could scarcely believe that he was approaching, in the plain, a little lower down on the other side, the peststricken city of Poona. On arrival at the railway station, however, the first signs of distress were noticed. Train-loads of people were fleeing from the place. A drive through the town to the office of the chief plague authority showed how rapidly it was being deserted. Many of the streets were almost empty, shop doors and windows were closed and barricaded, plague notices were pasted on the wall, a preternatural stillness was everywhere noticeable, the few people encountered walking quietly along with heads bowed and faces sorrowful. A visit was made to some houses whence plague cases had just been reported with the native editor of the principal Poona newspaper, this gentlemen having volunteered his services as plague inspector. In a small hovel, scarcely larger than a ship's cabin, one might find a patient surrounded by several of his friends awaiting the arrival of the inspector. The chances for contact contamination were manifold.

At the general plague hospital, there were some eight hundred cases of the disease under the charge of Major Windle. He was assisted by eight European nurses and a number of native helpers. He complained that it was almost impossible to retain natives as workmen ; even washermen and grave-diggers could not be employed in sufficient numbers owing to the fears and prejudices of the people. Cartloads of the newly attacked were being brought into the hospital at its entrance, while a body was carried out from the wards every ten minutes to the morgue at the rear. Those who live in the West can scarcely appreciate the enormous disadvantages under which medical men fight plague in India. The people are ignorant and superstitious, the rigid caste rules prevent any successful application of modern hygienic measures, and even the preventive inoculation cannot be utilized to any great extent, owing to the fact that thus far the bacilli have been grown in beef-broth, and the natives will not countenance such a profanation of the sacred animal. Even in death, caste rules have to be observed, and it was found at the morgue that partitions had to be put up separating the low-caste Hindoos from those of high caste, from the Mohammedans and from the Parsees and Christians. The floor of the morgue presented a melancholy sight; in one of the rooms no less than thirtytwo bodies lay upon the ground as closely packed as was possible without actually piling the bodies upon one another. Mohammedans are buried, and high-caste Hindoos are burned, but the bodies sometimes accumulate so fast that they cannot be disposed of by the usual methods. Major Windle stated thai one day, a short time before, he had burned twenty-four bodies in one heap. It is absolutely impossible in Poona to employ occidental methods in the way of segregation or disinfection. The natives prefer to die rather than submit to rules which are obnoxious to them. It is no uncommon sight to see a widow, after uttering the death wail, beating her face and breasts and throwing herself violent ly upon the body of her dead husband, kissing his face and lips ; it is very strange that no more than do contract the disease. One left Poona and


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[No. 106.


Bombay thankful that in America no such unfavorable religious and social conditions prevail.

Of the results which have been obtained by the Commission, it is too early as yet to speak more than generally. The observations made in Manila have to be supplemented and controlled by further microscopical and bacteriological studies upon the material collected. It will be some months at least before a full report can be looked for.

At present the observations concerning the causation of dysentery, the differentiation of the fevers of the region, the relative prevalence of typhoid fever and malaria, the studies of the varieties of the malarial parasite there found, and the investigations of beri beri, may be specified as among the more important scientific results of the expedition. The influence of the scientific spirit and methods, with the demonstration of their practical utility, so beneficial in medical ceutres at home and exerted at so early a period in the American regime in the Philippines, can scarcely fail to be of significance in the further development of medicine there.

It is probable that in the near future other expeditions will be undertaken as only a beginning in the study of tropical medicine has been made. England and Germany are alive to


the importance of such investigations. Major Ross has recently been sent to East Africa to continue his studies upon the part played by mosquitoes in the dissemination of malarial parasites, and Dr. Wright is being sent by the English government to establish a laboratory in the Malay peninsula for the study of beri beri. Prof. Koch, of Berlin, has also lately been sent on another expedition for the investigation of the malarial fevers in the tropics. Schools of tropical medicine are being established at various English and continental ports. The time seems ripe also for undertaking instruction in tropical diseases in America. The establishment of investigating institutes, and of teaching departments in such cities as San Francisco, New Orleans, Baltimore and New York, would be an additional safeguard to the country, since these are ports most likely to be infected. Moreover, careful instruction as regards diseases peculiar to the tropics and the special character assumed by other diseases when they occur in the hotter regions of the earth would seem to be essentials for those American physicians and surgeons who comtemplate residence or practice in our tropical possessions.

Lewellys F. Barker.


AN APPARATUS TO AID THE INTRODUCTION OF A CATHETER OR BOUGIE.

By George Walker, M. D., Ohief of Clinic out-door Surgical Department, Johns Hopkins Hospital.


The accompanying cutis an apparatus which I have devised to facilitate the passage of a filiform bougie, or catheter, through a strictured urethra. The object of this instrument, is to distend the canal, and in this way to enlarge the narrowed portion, so that an instrument will pass through.

Fig. I (a) is a glass cylinder, the shape and size as seen in the cut, with three openings; the first (J) is to communicate with the urethra; the second (p) permits the entrance of oil from cylinder (rri), Fig. Ill ; the third (d) is for the reception of a rubber stopper carrying a catheter, or bougie; (/) is a pure rubber stopper, through the center of which is passed a glass tube (g) ; on the inner end of this is fitted a small ring of rubber tubing (n). Through this glass tube a catheter (e) is passed, and the rubber on the end is so fitted that it serves to prevent an outward flow of oil.

Fig. II is a rubber stopper similar to the above, with a very small opening through it, just large enough to admit easily the passage of a filiform bougie (I) and small enough to prevent the escape of oil or other fluid.

Fig. Ill (wi) is a cylindrical glass vessel for the reception of oil ; it is to be hung on wall and is connected with Fig. I, by a rubber tube (t) of varying lengths.

A rather stiff silk catheter should be used, as a soft-rubber one has a tendency to bend in the glass cylinder. The free end of the catheter is closed with a clamp or hard-rubber stopper, so as to prevent the escape of oil.

When required for use the cylinder (d) is filled with oil by slightly opening the pinch-cock (A) ; the end (b) is then introduced into the meatus and firmly held there by an assistant so as to prevent the escape of oil between the glass and


urethra. The catheter, or bougie, is then passed into the urethra as far as the strictured part; the stop-cock (A) is now



Tig. I


Ftg.JT,


opened, and the oil allowed to flow in and distend the urethra. As this is being done the catheter, or bougie, is firmly pushed


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31


inward, and as the walls are distended the stricture is slightly opened, and the instrument allowed to slip through.



Fig. IV. — An Improved Urethral Irrigating Nozzle.

I do not say that by its use all urethra can be made permeable, but certainly filiforms can be thus introduced in a num


ber of cases which without it would be impossible, and catheters passed through diseased portions that otherwise would admit only filiform. Thanks are due Dr. Andrew Stewart, of Washington, for some suggestions.

Fig. IV represents an irrigating nozzle showing an addition to the ordinary straight nozzle in the form of a disc-shaped flange attached to the body near the urethral end. The disc serves to protect one's hands and other objects in the vicinity from becoming soiled by the fluids which are ejected from the meatus during irrigation. The straight nozzle which I have used resembles in some particulars those of Valentine and Young. The complete nozzle is made in one piece; it is simple, cleanly, small and entirely efficacious.


SUMMARIES OR TITLES OF PAPERS BY MEMBERS OF THE HOSPITAL AND MEDICAL SCHOOL STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN.


J. Whitridge Williams, M. D. The Frequency of Contracted Pelves in the First Thousand Women Delivered in the Obstetrical Department of the Johns Hopkins Hospital. — Obstetrics, Vol. I, Nos. 5 and 6, 1899.

1. In our material, the frequency of contracted pelves (13.1 per cent.) corresponds very closely with the general average of frequency observed in Germany.

2. This is due, in large part, to the presence of a large black population in Baltimore, 469 out of our 1,000 cases being colored women.

3. Contracted pelves are 2.77 times more frequent in black than in white women, and occur in 19.83 per cent, of the former and 7.14 per cent, of the latter.

4. The statistics of Reynolds Crossen and myself indicate that contracted pelves are observed in about 7 per cent, of the white women of this country, or about once in every fourteenth case.

5. Contracted pelves, accordingly, occur in our white women about as frequently as in many German clinics, notably, Rostock, Breslau and Basel.

6. And occur quite as frequently as in Paris (Pinard and Budin) and more frequently than in Vienna.

7. As every fourteenth white and every fifth colored woman possesses a contracted pelvis, the necessity for routine pelvimetry becomes apparent.

J. Whitridge Williams, M. D. A Case of Spondylolisthesis, with Description of the Pelvis. — American Journal of Obstetrics, Vol. XL, pp. 145-171 ; also, Transactions of the American Gynecological Society, Vol. XXIV, pp. 49-79.

In this article is described the pelvis obtained from a woman dying after a symphyseotomy performed on account of a pelvis contracted by spondylolisthesis. The smallest antero-posterior diameter of the pelvis, extending from the lower margin of the third lumbar vertebra, to the upper and posterior margin of the symphysis pubis, was 6yi cm.

The article is accompanied by numerous illustrations, which clearly illustrate the deformity, as well as its mode of production. This is the first American case which has been described anatomically, though such cases have been observed clinically by Blake, Lombard, Flint, Gibney and Lovett.

A full list of the literature on the subject accompanies the article.


J. Whitridge Williams, M. D. Report of the Committee of the American Gynecological Society, of which Dr. Williams was Chairman, "On the Value of Antistreptococcic Serum in the Treatment of Puerperal Infection." — American Journal of Obstetrics, Vol. XL, pp. 289-314 ; and Transactions of the American Gynaecological Society, Vol. XXIV, pp. 80-110.

I. A study of the literature shows that 352 cases of puerperal infection have been treated by many observers, with a mortality of 20.74 per cent.; where streptococci were positively demonstrated the mortality was 33 per cent.

II. Marmorek's claim that his antistreptococcic serum will cure streptococcic puerperal infection, does not appear to be substantiated by the results thus far reported.

III. Experimental work has cast grave doubts upon the efficiency of antistreptococcic serum in clinical work, by showing that a serum which is obtained from a given streptococcus may protect an animal from that organism, but may be absolutely inefficient against another streptococcus, and that the number of serums which may be prepared is limited only by the number of varieties of streptococci which may exist.

IV. Thus far the only definite result of Marmorek's work is the development of a method by which we can increase the virulence of certain streptococci to an almost inconceivable extent, so that one hundred-billionth of a cubic centimeter of a culture will kill a rabbit.

V. The personal experience of your committee has shown that the mortality of streptococcus endometritis, if not interfered with, is something less than 5 per cent., and that such cases tend to recover if Nature's work is not undone by too energetic local treatment.

VI. We unhesitatingly condemn curettage and total hysterectomy in streptococcus infections after a full-term delivery, and attribute a large part of the excessive mortality in the literature to the former operation.

VII. In puerperal infections a portion of the uterine lochia should be removed by Di'ulerlein's tube for bacteriological examination, and an intra-uterine douche of four to five liters of sterile salt solution given just afterward. If the infection be due to streptococci, the uterus should not be touched again, and the patient be given very large doses of strychnia and alcohol, if necessary. If the infection be due to other organisms, repeated douchings and even curettage may be advisable.

VIII. If the infection extends toward the peritoneal cavity,


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[No. 106.


and in gravely septicemic cases, Pryor's method of isolating the uterus by packing the pelvis with iodoform gauze may be of service. IX. The experience of one of the members of the committee with antistreptococcus serum has shown that it has no deleterious effect upon the patient, and therefore may be tried if desired. But we find nothing in the clinical or experimental literature or in our own experience, to indicate that its employment will materially improve the general results in the treatment of streptococcus puerperal infection.

Howard A. Kelly, M. D. A Curette for Cervical Cancer.— American Journal of Obstetrics, Vol. XL, 1899, p. 829.

The author has devised a toothed curette for the removal of redundant carcinomatous material in cases of cancer of the


cervix, which he considers much more satisfactory than any of the dull or sharp scoops now in use.

The instrument consists of a stout handle 9i cm. long, a shank 114. cm., tapering to an ovoid bowl which is 4 cm. long, 17 mm. wide, and 14 mm. deep. The essential feature of the curette is the series of crenations, each 2 mm. in height and 2\ mm. wide at the base, surmounting its blunt margin. These little teeth are very effective in removing the diseased tissue. A smaller instrument, two-thirds the size of the one described, is also used.

W. H. Welch, M. D. Thrombosis and Embolism. — Albutt' s System

of Medicine, Vol. VII, 1899. The Material Needs of Medical Education. — Journal of the

Alumni Association of the College of Physicians and Surge ni,

Vol.11, No. 4, 1900.


PROCEEDINGS OF SOCIETIES.


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY. Tuesday, December 5, 1899. Exhibition of Surgical Cases.— Dr. Mitchell.

We have to show three cases that have been treated in the service of Dr. Halsted, during the last few months, all traumatic and all having been serious accidents.

Case I. — The first man, a miner, aged 28 years, was admitted in August with the history of an injury received 32 hours previously, haying been crushed under a mass of falling coal. He was unable to walk after the accident on account of pain, though he had perfect motion of the limbs and could stand. He had retention of urine and was catheterized by a physician at the mines aud the bladder was later aspirated. The urine obtained by catheterization contained a great deal of blood, but the aspirated secretion was clear. He was operated upon immediately after his entrance to the hospital.

On examination, the patient was unable to stand, the bladder was much distended, reaching almost to the umbilicus; the perineum was infiltrated with blood. A perineal incision was made, opening a cavity beneath the symphysis pubis, which was filled with blood clots and urine ; the bladder still remained distended. A catheter passed through the meatus entered this cavity in the perineum, thus locating one end of the ruptured urethra. Suprapubic cystotomy was then done and retrograde catheterization showed the proximal end of the urethra, which had been ruptured just beneath the symphysis pubis. The urine in the bladder was perfectly clear. There was a fracture of the ascending and descending ramus of the left pubic bone, and a separation of the symphysis pubis. By attaching a piece of silk to a soft-rubber catheter, we were able to pass it through the entire course of the urethra. The urethra was not sutured because of the wide separation. A Bloodgood suprapubic tube was fixed in the bladder, and the perineal wound packed with gauze. The patient did very well. The bladder could be irrigated through the catheter and there was no trouble from infection. The catheter was allowed to stay in until September, when it was removed because blocked with salts, and a new one introduced. This was finally removed, nearly two months after the


operation, but the urethra still opened in the perineum. On October 23rd, the suprapubic tube was removed and the wound allowed to close, and from that time he has been voiding partly through the meatus and partly from the perineal wound, the latter having closed only within the last few days. The urethra has been dilated from time to time and a number 27 sound can be introduced with ease. He walks without evidence of trouble. The pubis is evidently firmly united.

Uase II. — This is a case of recovery after very great shock. The man was admitted ten days ago, about 6.30 p. m., in very bad condition and with the history of an injury to his right arm a short time before. He was working in a guano factory wheu his arm was caught in the machinery, and the forearm and hand very badly crushed. The skin of the arm was torn from the shoulder, down just as you would tear out the sleeve of a coat. His pulse was 80 aud very weak, respiration 40, temperature 97.5°, and he was crying with pain aud begging to have the arm taken off. He was immediately put to bed, the arm dressed with sterile gauze, the foot of the bed elevated and he was infused with 600 cc. of salt solution in the breast, and given i gr. morphia and a hot enema of coffee and salt solution. Up to 10 o'clock he improved, his pulse had become much stronger, he was quiet, his respiration slower and altogether he seemed better. After that time he began to go down again rapidly and there was considerable oozing from the dressings. He was in very bad condition when put on the table at 11 p. m., and though he was under ether only 10 minutes his condition became much worse during that time. He was given strychnia hypodermically and salt solution infusion during the operation. The foot of the table was elevated and his legs tightly bandaged. The operation itself lasted only 5 minutes. Dr. Bloodgood controlled the vessels by digital pressure in the axilla and the arm was amputated just below the shoulder. The vessels were quickly tied and the wound packed with gauze. At the end of this brief period, however, the radial pulse could not be felt, and the heartsounds were so weak that the second sound could not be heard after the operation. The foot of his bed was kept elevated, he was infused again with salt solution and given


January, 1900.]


JOHNS HOPKINS HOSPITAL BULLETIN.


33


hypodermics of strychnia and morphia with hot enemata of coffee and salt solution. His condition remained very alarming during all that night, the pulse being rapid and weak. the temperature rising to 103.6° and he became delirious, attempting to bite and scratch the assistants. Towards morning, however, he became quiet and from that time on has made a rapid convalescence. The wound was inspected a few days after the operation and everything was found clean and in good shape. His blood-count has been somewhat interesting. The night of the operation it was practically normal, although there had been a great deal of hemorrhage — red corpuscles 5,000,000, leucocytes 23,000, and hemoglobin 70 percent. Thirty-six hours later it showed reds 3,000,000, leucocytes 12,000 and hemoglobin 50 per cent.

Case III. This case has been very interesting to us in connection with the question of nerve regeneration. He is a German, 38 years of age, and was admitted on the 10th of November with an injury of the inner and posterior part of the left arm, having been in contact with a buzz-saw. He was admitted in fairly good condition and kept quiet for two hours before operation, when he was put on the table and the arm cleaned very thoroughly. No anesthetic was used and although the operation lasted two hours or more, no bad effect was produced so far as we could see. There were three main cuts with numerous lacerations extending from them. The upper cut exposed the musculospiral and ulnar nerves and divided the internal cutaneous. The second cut divided the ulnar, made a large ojjening into the bone and divided the musculospiral just where it winds around the bone, while the third cut divided the median nerve just above the elbow, without exposing the artery. The triceps muscle was extensively lacerated and the ulnar nerve was hanging in this mass of lacerated muscle which was torn entirely from the bone at one point. The biceps was also partially divided and there was extensive laceration of the skin. We identified the peripheral portion of the nerves by pinching the ends slightly and getting a corresponding contraction. The central portions could be identified by pain when they were seized. A hasty examination for anesthesia was made and it was thought to be complete, but since then we find that we were mistaken. Tbe nerves were sutured, the muscles brought together with buried silver and catgut sutures, and the skin approximated loosely over the wound. The man has made a perfect recovery and everything has healed per primam except the portions where there was no skin and these are covered by healthy blood clot. At the first dressing we found complete anesthesia of those portions supplied by the median, ulnar and musculospiral nerves. The only sensitive area was that supplied by the external cutaneous and some filaments of the musculospiral that came off above the injury.

Discussion.

Db. Thomas. — Was there any difficulty in bringing the ends of the nerves together ?

Dr. Mitchell. — They were very far apart at the time, but we had no difficulty in approximating them and suturing without tension.


Dr. Thomas.— It will be very interesting to watch his recovery and note where regeneration first takes place, since all the nerves were completely divided.

An Improved Stethoscope. Dr. Cabot. — I have with me a stethoscope that I have used on about 40 cases adav for five months and which pleases me so much that I thought it worth while to bring it before you. It was invented by a gentleman in Boston, not a physician, who had seen the ordinary stethoscope and who thought he could make an instrument that would combine the advantages of this with those of the phoueudoscope. It consists of a simple diaphragm of metal like that of the telephone connected with the chamber into which the tube of the stethoscope enters. It magnifies all sounds and it might be said to bear the same relation to the ordinary stethoscope that the high power of the microscope does to the low power. With it you can, I think, also hear sounds deeper in the chest than those heard with any other stethoscope. I have used it constantly for examination of the lungs and heart and find it exceedingly valuable for both. It enables you to hear cardiac murmurs, especially those of aortic regurgitation that can not be heard in any other way and this seems to me to be a point of great importance. The murmurs of mitral stenosis are not always, however, heard as well as with the ordinary stethoscope; that fact I can not account for.

A very obvious advantage of the instrument is that in listening to cases of pneumonia of the posterior lobes where the patient is very weak and you do not want to turn him, you can slip this flat edge under the back and hear the sounds with ease. I have known of an instance of a consultant being called from New York to Boston in such a case and feeling that he had not the right to turn the patient or raise him no examination of the lungs was made for two days. With such instrument as this such a delay could not occur.

I think also it is not an exaggeration to say that you can hear as much of the heart-sounds through the clothes with this instrument as you can with any other instrument next the skin. You should not listen to the lungs through the clothes, because the friction sounds of the clothes are so much like those of the lungs.

There are certain things that you can not do with it. If the patient has a very thin bony chest you do not get good effects, and it is not always good for very superficial sounds. I always carry the bell of the ordinary stethoscope to slip on for such cases. I don't think I should want the instrument alone without this arrangement, but I certainly should not want ever to be without this instrument again. I feel sure that any one who ever tries it will not give it up until something better is invented.

The Pulmonic Second Sound. Dr. Cabot.— About one year ago, in reading Gibson's recent work on the heart, I noticed some observations concerning the second sound in health that disturbed me a great deal. I had always been taught that in health the pulmonary second sound was not so loud as the corresponding sound from the other side. Dr. Sarah li. (,'reightou went over one thousand cases


34


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 106.


this summer in my clinic with reference to this point, throwing out all cases where there w r as anything wrong with the heart. She showed that in each decade, there is a rising percentage of aortic and a diminishing percentage of pulmonic accentuation as compared with the preceding decade. In other words, unless these one thousand cases are very deceptive, the accentuation of the aortic sound is a matter of age, the pulmonic sound being louder in the young and the aortic in older persons.

One other point that has struck me in the last two years in the examination of the normal chest is the presence in healthy persons of fine rales at the base of each axilla. If you listen in persons over 40 years of age, you will hear in a large proportion of cases these fine crepitant rales at the end of inspiration. They are heard over a very small area, frequently not larger than half the size of your palm. The explanation of this phenomenon is entirely dark to me. I thought it might be due to the formation of pleural adhesions, but I find it in connection with Litteu's phenomenon so frecpaently that I can not see how that explanation can be accepted, so that I leave the observation as a purely clinical oue without explanation.


BOOKS RECEIVED.

Transactions of the American Surgical Association. Volume the

seventeenth. Edited by De Forest Willard, A. M., M. D., Ph. D.

1899. 8vo. XLII+319 pages. Printed for the Association,

Philadelphia. Transactions of the American Orthopedic Association. Thirteenth

session, held at New York, N. Y., May 31 and June 1 and 2, 1899.

Volume XII. 8vo. XXVIII+367 pages. 1899. Published by

the Association, Philadelphia. King's College Hospital Reports; being the annual report of King's

College Hospital and the medical department of King's College.

Edited by Nestor Tirard, M. D., F. R. C. P., et al. Volume V.

(Oct. 1st, 1897-Sept. 30th, 1898). 1899. 8vo. XVII+270 pages.

Printed by Adlard and Son, London. An Experimental Research into Surgical Shock. An Essay awarded

the Cartwright Prize for 1897. By George W. Crile, A.M., M.D.,

Ph. D. 1899. 8vo. 160 pages. J. B. Lippincott Co., Philadelphia. The Serum Diagnosis of Disease. By Richard C. Cabot, M. D. 1899.

8vo. VII+154 pages. William Wood and Company, New York. The Principles of Bacteriology. A practical manual for students and

physicians. By A. C. Abbott, M. D. Fifth edition, enlarged

and thoroughly revised. With 109 illustrations, of which 26 are

colored. 1899. 12mo. XI+590 pages. Lea Brothers and Co.,

Philadelphia and New York. A Text-Book of Pharmacology and Therapeutics, or the Action of Drugs

in Health and Disease. By Arthur R. Cushny, M. A., M. D.,

Aberd. Illustrated with forty-seven engravings. 1899. 8vo.

730 pages. Lea Brothers and Co., Philadelphia and New York. A Practical Treatise on Fractures and Dislocations. By Lewis A.

Stimson, B. A., M. D. With 326 illustrations and 20 plates in

monotint. 1899. 8vo. XIX+822 pages. Lea Brothers and Co.,

New York and Philadelphia. Transactions of the American Gynecological Society. Volume XXIV.

1899. 8vo. XLVII+520 pases. Wm. J. Dornan, Printer, Phila. Transactions of the Indiana Slate Medical Society, 1899. Fiftieth

annual session held in Indianapolis, Indiana, June first and

second, 1899. 8vo. 552 pages. Central Printing Company,

Indianapolis, Indiana. Thirtieth Annual Report of the State Board of Health of Massachusetts,

1898. 8vo. XXXIX+878 pages. 1899. Wright and Potter

Printing Company, Boston.


VOLUME TO COMMEMORATE THE 25TH YEAR OF DR. WELCH AS A TEACHER AND INVESTIGATOR.

It is customary in Germany for the pupils of a great teacher to express their appreciation and gratitude by dedicating to him a volume of their contributions to learning. The pupils of Dr. Wm. H. Welch, of Baltimore, have decided to give expression to their regard for him in a similar way and the publication of a volume to mark his twenty-fifth year as a teacher and investigator is now in progress.

During the past twenty-five years some seventy-five persons have undertaken investigation under Dr. Welch's leadership, and nearly half of these will contribute to the volume mentioned. The edition will necessarily be limited by the number of subscribers. An early announcement of the publication is made to give opportunity for subscription so that the committee can decide upon the number of copies to be printed.

The volume will be royal octavo in size and will contain at least five hundred pages of printed matter. It will, in addition, be illustrated with many lithographic plates and text figures. The price has been fixed at five dollars. The book will contain contributions to pathology and to correlated sciences agreeing in scope with that of the leading scientific medical journals.

The Committee of publication consists of :

A. C. Abbott, University of Pennsylvania, Philadelphia, Pa.

L. F. Barker, Johns Hopkins University, Baltimore, Md.

Wm. T. Councilman, Harvard University, Boston, Mass.

Simon Flexner, University of Pennsylvania, Philadelphia, Pa.

W. S. Halsted, Johns Hopkins University, Baltimore, Md.

A. C. Herter, University and Bellevue Hospital Medical College, New York.

Wyatt Johnston, McGill University, Montreal, Canada.

F. P. Mall, Johns Hopkins University, Baltimore, Md.

Walter Reed, Army Medical Museum, Washington, D. C.

Geo. M. Sternberg, Surgeon General's Office, Washington, D. C.

All communications and subscriptions should be addressed to Dr. F. P. Mall (Secretary), Johns Hopkins University, Baltimore, Md.

Baltimore, November 11, 1899.

MONOGRAPHS.

The following papers are reprinted from Vols. I, IV, V, VI and VIII of the Reports, for those who desire to purchase in this form:

STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixford, M. D. 1 volume of 164 pages and 41 fullpage plates. Price, bound in paper, $3.00.

THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J. Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA. By Lewellys F. Baker, M. B. 1 volume of 280 pages. Price, in paper, $2.75.

STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481 pages. Price, bound in paper, $3.00.

THE PATHOLOGY OF TOXA.LBUMIN INTOXICATIONS. By Simon Flexner, M. D Volume of 150 pages with 4 full-page lithographs. Price, bound in paper, $200.

THE RESULTS OF OPERATIONS FOR THE CURE OF INGUINAL HERNIA. By Joseph C. Bloodgood, M. D. Price, in paper, $3.00.

Subscriptions for the above publications may be sent to

The Johns Hopkins Press, Baltimore, Md.

HOSPITAL PLANS.

Five essays relating to the construction, organization and management of Hospitals, contributed by their authors for the use of The Johns Hopkins Hospital.

These essays were written by Drs. John S. Billings, of the U. S. Army, Norton Folsom, of Boston, Joseph Jones of New Orleans, Caspar Morris, of Philadelphia, and Stephen Smith, of New York. They were originally published in 1875. One volume bound in cloth, price $5.00.


January, 1900.]


JOHNS HOPKINS HOSPITAL BULLETIN.


35


THE JOHNS HOPKINS MEDICAL SCHOOL.


FACULTY.


Danibl C. Oilman, LL. D., President.

William H. Welch, M. D., LL. U , Professor of Pathology. Ira Kh.sisEN, M. D., Ph. D , LL. D.. Professor of Chemistry. WILLIAM Oslbr, M. D., LL. D., F. R. C. P., Professor of the F

.Medicine, and Dean of the Medical Faculty. Hknrv M. Hi'KD, M. H., LL. D., Professor of Psychiatry. William S. Halsteo. M. D., Professor of Surgery. Howaki> A. Kbllv, M. D., Professor of Gynecology. Franklin P. Mall, M D.. Professor of Anatomy. John J. Abel, M. D-, Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.


Thomas B. Futchi Joseph C. Bl


iples and Practice of


R, M. B., Ass

ioi>, M. V., A

n, M. B., Assoi

N, Ph. D., Assc

.. _,Ph. L>., M. D., Assc JohnG. Clark, M.L)., A


Ross


ASS. CUL


Willia.i K Bkooks, Ph. D., LL. D J. Whiiruigb Williams, M. D., Pro'fes: John- S. Killings, M. D., LL D., Lectu Albxanubk C. Abbot., M. D., Lecturer Chakles Wari Rolbkt Flbtc


of Comparative Anatomy and Zobloev of Obstetrics. B>

on the History and Literature of Medicine Hygiene. Ph. D., M. S . Lecturer on Medical Zoology. , M li , M. R. C. S. (Eng.). Lecturer on Forensic Medu


I.RI



vs F. Bar


Wi


LLIAl


1 S. Tha'


lot


-. M


. T. Finn


(Ski



P. Drbvi


Wi



■ W. Rus


Ko


ISB 1


L. Rand.


. M. D., Clinical Professor of Pediatrics

kbnzie, M U., Clinical Professor of Laryngology and Rhinology.

jbald, M. D . Clinical Professor of Ophthalmology and Otology. HOMAS. M. D., Clinical Professor of Neurology.

Lord, M- D , Clinical Professor of Dermatology and Instructor in Anatomy. ilchrist, M. R C. S., London, Clinical Professor of Dermatology. rklby, M D., Clinical Professor of Psychiatry.

r, M. B , Associate Professor of Pathology.

, M D., Associate Professor of Medicine.

i\l. D., Associate Professor of Surgery.

Ph. D , Associate in Physiology.

l, M. Ii, Associate in Gynecology.

•H, M. D.. Associate in Ophthalmology and Otology.


iatein Medicine,

iociate in Surgery, ate in Gynecology.

iate in Pharmacology. — jn Gynecology. Charles R. Bardbbn, M. D., Associate in Anatomy. Harvey W. Lushing, M. D., Associate in Surgery. George W. Dobbin, M. D., Associate in Obstetrics.

Walter Jones, Ph. D., Associate in Physiological Chemistry and Toxicology Frank R. Smith, M. D., Instructor in Medicine. Hbnrv B. Jacobs. M. D., Instructor in Medicine. Hugh H. Young, M. D , Instructor in Genito-Urinary Diseases Otto G. Ramsav, M.D., Instructor in Gynecology. Thomas McCrae, M. B., Instructor in Medicine Albert C. Crawford, M. D., Assistant in Pharmacology Sidney M. Cone. M. D., Assistant in Surgical Pathology. Norman MacL. Harris, M. B., Assistant in Bacteriology. Jesse W. Lazear, M. D., Assistant in Clinical Microscopy. Stewart Paton, M. D., Assistant in Clinical Neurology.


Lee W


Hi


Percy M. D..

Louis P. H»> Melv.n T. Si Norman B. G


Ph. G.. eth Hukdon, M. D., Assis O. Reik, M. D., Assistant m G MacCallum, M. D. hology.


n, M. D., Ass

GER, M. D., (

r, Ph. D., As. , M. B.. Demi


ant in Gynecology.

n Ophthalmology and Otology.

Assistant in Pathology and Curator of the Mu


1 Clinical Microscopy.


GENERAL STATEMENT.


The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of iMedicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns Hopkins Hospital. The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter. Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. The first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physiology Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. During the last two years the student is given abundant opportunity for the personal study of cases of disease, his time being spent largely in the Hospital Wards and' Dispensary and in the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives:

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

2. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German; (b) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.

3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING.

Applicants for admission to advanced standing must furnish evidence (1) that the foregoing terms of admission as regards preliminary training have been fulfilled (2) that courses equivalent In kind and amount to those given here, preceding that year of the course for admission to which application Is made have been satisfactorily 1 completed, and |3i must pass examinations at the beginning of the session in October In all the subjects that have been already puraued by the class to which admission Is sought. Certificates of standing elsewhere cannot be accepted in place of these examinations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates In medicine. The attendance upon these courses has steadily Increased with each succeeding year and indicates gratifying appreciatl >u of the special advantages here afforded, with the completed organization of the Medical School, it was found ueceesary to give the courses Intended especially for physicians at a later period of the academic year than that hitherto seleoted It Is however, believed that the period now chosen for this purpose is more convenient tor the majority of those desiring to take the courses than tho former one The special cour.es of Instruction for graduates in medicine are now given annually during the months of May and June. During April there Is a preliminary course In Normal ■ — s are In Pathology. Bacteriology. Clinical Mlcl Medicine. Surgery, Gynecology. Dermatology. Diseases of Children Diseases of the

Nervous System, Genlto-Urlnary Diseases, Laryngology and Rhinology, and Ophthalne logy and Otology. T he instruction is Intended to meet tho requirements of practitioners of medicine, and Is almost wholly of a practical character. It Includes laboratory courses, demonstrations, bedside teaching, and clinical Instruction In the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several Instructors that they are prepared to profit by the opportunities here offered. The number of students who can be accommodated In some of the practical- , . irUy limited. For these the places an ' i ng to the date of application.

During October a select number of physicians will be admitted to a special clas-» for the study of the important tropical diseases mot with In this region. The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.


36


JOHNS HOPKINS I OSPITAL BULLETIN.


[No. 106.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


THE JOHNS HOPKINS HOSPITAL REPORTS. Volume I. 423 pages, 99 plates.

Report In Pathology.

The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction; ^ HeaUng of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. U. a Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis

(Atrophy). By Henry J. Berkley, M. D. „.. ,. „„ „ „

Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

Mall, M. D.

Report in Dermatology. Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By

T C Gilchrist, M. D., and Emmet Riiford, M. D. A Case of BhXmycetic Dermatitis in Man; Comparisons of the Two Varieties of

P?otozoa7lnd the Blastomyces found in the preceding Case, with the so-called

Sites found in Various Lesions of the Skin etc.; Two Cases of Molluscurn

Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhnng). By

T. C. Gilchrist, M. D.

Report In Pathology. An Experimental Study of the Thyroid Gland of Dogs with especial consideration

of Hypertrophy of this Gland. By W. S. Halsted, M. D.

Volume II. 570 pages, with 28 plates and figures.

Report in Medicine.

On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with

Gallstones. By William Osler, M. D. Some Remarks C n Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleur, M. D. Cases of Postfebrile Insanity. By William Obler, M. D. A^te Tuberculosis in an Infant of Four Months. By Harry Toulmin, M. D. Rare Forms of Cardiac Thrombi. By William Osler. M. . D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

Report in Medicine. Tubercular Peritonitis. By William Osler, M. D. A Case of Raynaud's Disease. By H. M. Thomas, M. D. Acute Nephritis in Typhoid Fever. By William Osler, M. D. Report in Gynecology.

The KSS X-o fXZoXZTU; «chV-1890. By Howard The1ie^t L ;^he D Auto^i H Jfn E Tw R o C B ase i U D yin g in the Gynecological Wards without Operation ; Composite Temperature and Pulse Charts of Forty Cases of Abdominal Section. By Howard A. Kelly, M. D. ne Management of the Drainage Tube in Abdominal Section. By Hunter Robs,

TheGonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

Ovarian Tumor; General Gynecological Operations from October 16, 1889, to

March 4, 1890. By Howard A. Kelly, M. D. n „_.„„

Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howabd

A. Kelly, M. D., and Albert A. Ghriskby, M. D. Lhrature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking

Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D. Carcinoma of the Cervix Uteri in the Negress. By J. W Williams, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.

Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D. „,„.„.

Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment

of Ureteral Stricture; Record of Deaths following Gynecological Operations. By

Howard A. Kelly, M. D.

Report in Snrgery, I. The Treatment of Wounds with Especial Reference to the Value of the Blood Clot

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Neurology, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.

Haematomyelia. By AU0U6T Hoch, M. D. ... , iV o_t i r, • ».

A Case of Cerebrospinal SyphiliB, with an unusual LeBion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report in Pathology, I. Amosbic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleob, M. D.

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

Report in Pathology.

Papillomatous Tumors of the Ovary. By J. Whitriooe Williams, M. D.

Tuberculosis of the Female Generative Organs. By J. Whitridoe Williams, M. D. Report in Pathology.

Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Fleiner, M. D.

The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.

A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.

Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.

Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.

Report in Gynecology.

The Gynecological Operating Room; An External Direct Method of Measuring the Conjugata Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele- Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid Flexure associated with Constipation a Source of Error in Gynecological Diag nosis; Operation for the Suspension of the Retroflexed Uterus. By Howard A Kelly, M. D. . . , . . .. ___ . _ -.

Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci. By Mary Sherwood, M. D.

Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavely, M. p

Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. 1>. Tabulated by A. L. Stavely, M. D.


The Employment of an Artiflcial Retroposition of the Uterus in covering Extensive Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.

Photography applied to Surgery. By A. S. Murray.

Traumatic Atresia of the Vagina with Haematokolpos and Haematometra. By Howard A. Kelly, M. D.

Urinalysis in Gynecology. By W. W. Russell, M. D.

The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.

Resuscitation in Chloroform Asphyxia. By Howarr A. Kelly, M. D.

One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age. By Howard A. Kelly, M. D., and Mary Sherwood, M. D.

Abdominal Operations performed in the Gynecological Department, from March 5. 1890, to December 17, 1892. By Howard A. Kelly, M. D.

Record of Deaths occurring in the Gynecological Department from June 6, 1890, to May 4, 1892.

Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

By William Osler, M. D., with additional papers by W. S. Thayer, M. D., and J. Hewetson, M. D.

Report in Neurology. Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of Mut mtuctdus; The Intrinsic NerveB of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley, M. D.

Report in Surgery. The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to January, 1894. By W. S. Halsted, M. D.

Report in Gynecology. Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Cullen, M. B. Report in Pathology. Deciduoma Malignum. By J. Whitribge Williams, M. D.


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

CONTENTS: The Malarial Fevers of Baltimore. By W. S. Thayer. M. D., and J. Hewetson, M. D. A Study of some Fatal Cases of Malaria. By Lewellys F. Barker, M. B.

Studies in Typhoid Fever. By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon Fleiner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.


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

Report in Neurology.

Studies on the Lesions produced by the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.

Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part i. — Alcohol Poisoning. — Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part II. — Serum Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part III.— Ricin Poisoning.— Experimental Lesions Induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical Nerve Cell produced by the Toxine of Experimental Rabies; Part V.— Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Pathology.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S. Cullen, M. B.

Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins. M. D.

Adeno-Myoma Uteri DirTusum Benignum. By Thomas S. Cullen, M. B.

A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By William D. Booker, M. D.

The Pathology of Toxalbumin Intoxications. By Simon Fleiner, M. D.

Volume VII. 537 pages with illustrations. (Now ready.)

I. A Critical Review of Seventeen Hundred Cases of Abdominal Section from the standpoint of Intraperitoneal Drainage. By .1. <■. (lark. M. 1>. II. The Etiology and Structure of true Vaginal Cysts. By James Ernest Stokes, M. U. III. A Review of the Pathology of Superficial Burns, with a Contribution to our Knowlr.lj the Pathological changes in the organs in cases of rapidly fatal burns. By

CUARLES RUSSELL RARDEEN, M. D.

IV. The Origin, Growth and Fate of the Corpus Lutemn. By .1. G. Clark, M. D. V The Results of Operations for the Cure of Inguinal Hernia. By Joseph C. Blood,M.D.

Volume VIII. About 500 pages with illustrations. (In

press.)

Studies in Typhoid Fever.

By William Oslkr. M. I>.. with additional yaper! M.D., I. P. Lyon. M. D„ L.P. Rambir Mitchell. M.D.

Tltc price of a set bound hi cloth [Vols. I-1'II] of the Hospital Beports is $35.00. Vols. I. II noil III ore not sold separately. Tin- price of Vols. IV, V, VI noil VII is $3.00 end,.

Subscriptions for the above publications may be sent to


The Johns Hopkins Press, Balti;


Md.


The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may be procured from Messrs. CUSH1NQ & CO. and the BALTIMORE NEWS COMPANY. Baltimore. Subscriptions, $1.00 a year, may be addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies will be sent by mail for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Xl.-No. 107.1


BALTIMORE, FEBRUARY, 1900.


[Price, 15 Cents.


C01TTEliJ"TS.


Report upon an Expedition Sent by the Johns Hopkins University to Investigate the Prevalent Diseases in the Philippines. By Simon Flexner, M. D., and Lewellys F. Barker, M.B., - - - - 37

A Case of Multiple Gangrene in Malarial Fever. By William Osler, M. D., ----- - 41

Benjamin Jesty : A Pre-Jennerian Vaccinator. By Thomas McCrae, M. B., - 42


Haemophilia in the Negro- By Walter R. Steiner,

Summaries or Titles of Papers by Members of th

and Medical School Staff appearing Elsewh

Bulletin, ------------ Proceedings of Societies :

Hospital Medical Society,

Exhibition of Medical Cases [Dr. Futcher].|

Notes on New Books,



REPORT UPON AN EXPEDITION SENT BY THE JOHNS HOPKINS UNIVERSITY TO INVESTIGATE THE PREVALENT DISEASES IN THE PHILIPPINES.


To President Gilman, Doctors Welch and Osler,

Philippine Committee of the Johns Hopkins University Medical School.

Gentlemen : — We have the honor to submit to you a brief account of our work and movements in carrying out your commission to study the prevalent diseases in the Philippine Archipelago. Your commissioners, consisting of Dr. Simon Flexner and Dr. L. F. Barker, to whom were voluntarily attached Messrs. J. M. Flint and F. P. Gay, of the Medical School, the latter having given their time and paid all their own expenses, sailed from Vancouver on March 29th, 1899, and arrived in Manila, May 4th, where they immediately established themselves for the purpose of the work mentioned. Owing to the military situation it was found impracticable to visit other ports in the Archipelago or to penetrate into the interior of the Island of Luzon. The entire time of the commission, therefore, was spent in the study of disease existing among the natives and American troops in Manila and at Cavite.

Work in Japan and Hong-Kong.

As transport sailings were uncertain, and the passage out by them slow, it was decided to save time and go by fast steamer, the Canadian Pacific Railway giving special rates to the commission on tickets around the world.

The original plan of your commissioners was to proceed directly to Manila by way of Hong-Kong, at which latter port


it was intended to stop only long enough to outfit for the tropics and to catch the earliest steamer sailing for Manila. After consideration of the probability that certain new kinds or phases of disease, not occurring in temperate regions, might be encountered in the Archipelago, and of the fact that the diseases of the Philippines would probably have much in common with those of Japan, it was decided to spend one week in Japan, where modern hospitals could be visited and advantage taken of the results of the study of tropical disease by highly trained and eminent Japanese physicians. The decision proved to be valuable in many ways ; and we especially desire to express our obligations to Professors Aoyama, Mitsukuri, Miura and Kitasato, who showed us many courtesies. The opportunity to see in the Japanese hospitals pure and mixed examples of beri-beri assisted us greatly in our subsequent studies, as did also the observations on dysentery made in the Institute for Infectious Diseases at Tokio.

While outfitting at Hong-Kong we improved the opportunity to study the bubonic plague, which was still prevailing at that port. This study was made easy by tin.' generosity and courtesy of the English Civil Physician, Dr. James Lowson, in charge of the Plague Hospital and Mortuary. The study, begun in this way, was extended when two months later we returned to Hong-Kong, en route to America. At this time a considerable exacerbation of the disease had taken place, and within a week or ten days we saw several scores of cases and performed many


38


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 107


autopsies. The several forms of infection : inguinal, axillary, tonsilar, cervical and pulmonary, were thus encountered. Bacteriological examinations were made and tissues collected for future study. Two of the party (Dr. Barker and Mr. Flint) spent ou the return journey three weeks (at their own expense) in India, where the great epidemics of plague there raging were observed.

Arrival in Manila.

Immediately upon our arrival in Manila, quarters were sought at the " Hotel de Oriente." Very insufficient accommodations were secured for a limited time, as the sudden accession of families of Army and Naval officers had strained the hotel to its fullest capacity. Having been forewarned of the conditions of living in Manila, we took the precaution to bring with us from Hong-Kong a group of Chinese servants, intending to set up housekeeping if practicable. After much difficulty a small house was secured in San Miguel, where, by hiring parts of the furnishings and buying what could not be rented, a temporary establishment was secured.

Within a few hours after our arrival, the credentials and private letters brought were presented to Colonel Woodhull, Surgeon-in-Chief to the 8th Army Corps, and to General Otis. Colonel Woodhull afforded us every opportunity to prosecute our work in the military hospitals. Although no special introduction was in our possession, we quickly met Dr. Bournes, chief health officer of Manila, who opened to us the hospitals under his charge. Somewhat later we met Dr. Pearson, Chief Naval Surgeon, who opened to us the Naval Hospital at Cavite.

Hospitals in Manila.

Civil Hospitals. These consist of a large hospital within the walled city, San Juan de Dios. It has a capacity of from 250 to 300 beds, and accommodated, during our stay, both natives and Europeans. The number of European patients was small. When the military hospitals were much crowded a certain number of wounded prisoners of war were accommodated. The hospital contained chiefly native medical cases of both sexes. The San Lazaro or leper hospital, in the outskirts of Manila, contained from 80 to 100 lepers during our stay. These had come from Luzon, almost exclusively from Manila and its immediate surroundings. The two sexes are provided for in separate, large and airy wards. One wing of the building, having a private entrance, is devoted to native prostitutes who apply regularly for examination, and are incarcerated here and treated medically when found to be suffering from venereal disease.

Military Hospitals. These consisted, besides the regimental hospitals which were virtually detention camps, of three Eeserve Hospitals — the 1st, 2nd and 3rd Reserve Hospitals; a convalescent hospital on Corregidor Island and the Hospital Ship Relief, which was anchored in the bay. The First Eeserve Hospital, under the control of Major Crosby, had been originally the Spanish military hospital. It has been from time to time, by the erection of tents over platforms raised a foot or two from the ground, increased in capacity until in July it contained 1200 or more beds. The Second Reserve Hospital, under the control of Major Keefer, was a transformed


modern school- building, and because of its limited capacity (250 beds), high ceilings and wide corridors it made a model hospital. The Third Reserve Hospital had just been established towards the end of our visit, and was smaller than the others and intended as a convalescent hospital. The hospital at Corregidor is a temporary structure and intended for convalescents. It is especially well adapted for its purpose because of the high and hilly character of the island and its complete investment by the sea. The Relief was used as a hospital for acute cases ; but some time before we left, the acute cases were transferred to the Reserve Hospitals, and the Relief sailed for San Francisco with invalided men.

The Reserve Hospitals accommodated especially American sick and wounded ; but a ward in the First Reserve Hospital was set aside for the Filipino wounded.

After the outbreak of beri-beri at Cavite, a hospital under military control was established at San Roque in the remains of the Spanish Marine Hospital which had been wrecked by the insurgents.

Naval Hospital. A small hospital for sick seamen and marines was established at Cavite. Through the courtesy of Dr. Pearson this was open to us for clinical studies.

Clinical, Pathological and Bacteriological Laboratory. Through the kindness of Colonel Woodhull and of Major Crosby, the officer-in-chief of the First Reserve Hospital, a small Filipino house, situated on the banks of the Pasig, was given us in which to establish a laboratory. This was done on the second floor of the house. The expense of putting up workingtables was kindly borne by the Medical Corps of the Army. The laboratory equipment was set up in this building, and within a very few days after our arrival work was begun. We desire to speak of the co-operation of the Medical Staff of the hospital who afforded us every opportunity to visit the wards, and many of whom joined or assisted us in clinical and pathological work. We wish especially to acknowledge the co-operation and assistance of Lieut. Richard P. Strong, a graduate of the Johns Hopkins University Medical School, who had on our arrival already begun to do laboratory work and who gave up much of his valuable time in furthering our interests. It was found unnecessary to establish laboratories in the other hospitals, in the first place, because all were connected with the First Reserve by the Signal Service telegraphic system of which we had free use; and next, because all the dead were carried to the morgue in conjunction with the First Reserve Hospital. We went or were frequently called to the other hospitals to make clinical and bacteriological examinations.

With few exceptions, all the dead were subject to autopsy. Post-mortem examinations were made at the Civil Hospitals upon natives, and at the Military Hospital upon all that died. Exceptions were made only in the cases of those dead from gun-shot wounds, when, if pressed for time, necropsies were sometimes omitted.

Prevailing Diseases.

The subject of the prevalent diseases may be considered as they affect (1) the natives, and (2) Europeans and Americans, especially the American garrison.


February, 1900.]


JOHNS HOPKINS HOSPITAL BULLETIN.


39


Diseases affecting Natives, (a) Skin Diseases. Of the skin diseases prevailing among the natives, aside from small-pox and other specific exanthemata, may be mentioned (1 ) of the scalp, which are very frequent; (2) dhobie itch; and (3) an affection which resembles closely, and which is probably identical with, Aleppo boil (Delhi boil, Biskra button, epidemisehe Beulenkrankheif). (b) Small-pox. This disease has been so generally prevalent in Luzon that the natives have, to a large extent, lost fear of it. All evidence points to the greatest carelessness in preventing its spread during Spanish times. Isolation of the sick and disinfection of the habitations seem not to have been attempted; and vaccination, even among the Spanish garrison, had not been carried out. Under these circumstances it could be no surprise that after the American occupation the disease should appear and even become epidemic. The epidemic which appeared early last year was promptly met by Dr. Bournes, who caused the Spanish garrison still in Manila, and natives and Chinese within the city to be vaccinated. In order to insure satisfactory results he found it necessary tore-establish a vaccine farm in which young caraiao were used for the preparation of the virus. Under the influence of this measure and by the aid of isolation of the sick, the disease had, in May, practically disappeared within the military liues about Manila, (c) Leprosy. A definite focus of this disease exists in Luzon. The cases, in the neighborhood of 100, which are confined in the San Lazaro Hospital, came from Manila and the country immediately surrounding that city. The disease affected both sexes, being more frequent in adults, although also present in half-grown boys and girls. The commonest forms were the tubercular and mutilating. Autopsies were performed upon several cases that had died during our stay, (d) Ttiberculosis. Accurate statistics of the extent of the prevalence of this disease are difficult if not impossible to obtain. That the disease is a common one is indicated by several facts. It is frequently met with in the native hospitals, where it may have been recognized duriug life or is disclosed at autopsy. Many cases of supposed beriberi which we autopsied at San Juan de Dios proved to be tuberculosis. It is possible that the two diseases had co existed, for we found such combinations freely recognized by •Tapanese physicians in the hospitals in Japan. Tuberculosis of the lungs was also found as a common complication in leprous individuals that came to autopsy. Not very infrequent spectacles met with on the streets are much emaciated and weak natives affected with suggestive coughs and free expectoration. While it is not certain that these individuals were examples of tuberculosis, there is strong probability that this explanation of their condition is the correct one. (e) il Diseases. Syphilis, by general agreement (statistics not available), does not prevail unduly. Chancroids and gonorrhoea are, on the other hand, very common. The majority of the prostitutes confined in the San Lazaro were victims of these two diseases. A very common complication of the soft sore, owing to lack of cleanliness, is swelling and suppuration of the inguinal glands, (f) Beri-Beri. This disease is well known among the natives. It would appear to be epidemic and endemic in Luzon. It is, judging from cases met with in San Juan de Dios Hospital and the statements of native phys


icians, constantly appearing in a sporadic form. During our stay an epidemic appeared among the Filipino prisoners confined at Cavite. Some 200 cases developed in a few weeks ; the mortality ranged from 20 to 30 per cent. The several recognized forms of the disease— cedematous, paralytic, and mixed — were encountered. Clinical and bacteriological studies were made upon the living, and the dead were subjected to autopsy and bacteriological examination. The difficulty of getting to and fro between Manila and Cavite, on account of the impossibility of land communication, made this part of our work difficult and time-consuming. A considerable collection of pathological material and other data has been made. This material is now in process of study and arrangement.

Diseases affecting Americans. The chief causes of disability among American land forces are the enteric diseases. These are diarrhoea, dysentery, typhoid fever, and gastro-intestinal catarrhs. Many of the diarrhoeas are merely preliminary to the symptoms of dysentery. Other infectious fevers are relatively infrequent. A small number of cases of scarlet fever and diphtheria only were encountered. The malarial fevers prevailed but not seriously during the months of .May, June and July, (a) Dysentery. This disease is responsible for the greatest amount of invalidation and the highest mortality. It appears in acute, sub-acute, and chronic forms. The chronic form is sometimes attended by secondary abscess of the liver. The acute form may end in 24, 48, or 72 hours. In it the whole of the large intestine and usually the lower portion of the ileum are involved. The mucous membrane of the gut is swollen, congested and cedematous, in places hemorrhages have taken place into the mucous membrane, and the submucosa is swollen and its blood-vessels greatly dilated. No ulcers existed in such cases. Amoebae were absent or very difficult to find in the fresh stools and in the intestinal contents immediately after death. In the sub. acute and chronic forms ulcers are present in the mucosa; the coats of the intestine are greatly thickened ; at times large sloughs of mucous membrane, partly detached, occur, and t lie lesions are confined to the large intestine. Amoebae are more commonly present in these cases, but are variable as to actual occurrence and numbers. Large hepatic abscesses, usually single, were encountered in a number of these cases. Amoebae were variable in the contents of the abscesses. In one very large abscess, occupying both right and left lobes of the liver, no amoebae were seen, but a pure culture of the Staphylococcus pyogenes citreus was obtained. The clinical studj of the cases of dysentery with reference to amoebae was equally unsatisfactory. In cases with marked symptoms both in patients confined to bed and those beginning to go about but still with persistently loose bowels, these organisms were frequently missed : while in instances ready to be discharged, they might, at certain examinations, be found to be very abundant. In morphology, the amoebae studied corresponded with the amoebae coli found in Egypt and in this country. The bacteriological study of cases of dysentery was carried out upon the fresh stools of acute and chronic cases, and with the intestinal contents, mesenteric

glands, liver, etc., of can dyi i subjected to autopsy.

The intestinal flora was studied in its entirety by means of plate cultures. Varieties of micro-organisms were separated.


40


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 107.


Many of these were well-known species or occurred normally in the situations in which found. Tests with blood sera for agglutination were made, and those organisms giving positive reactions were separated for further study. Two groups of bacilli were thus differentiated : (1) Having affinities with the group of bacillus coli communis. The agglutination was variable, being constant and sensitive with the blood-serum of the same individual (host), and inconstant, and active in relatively strong solutions only, in serums from other individuals. (2) Having affinities with the group of bacilli of which the bacillus typhosus is the type. Agglutination was constant and sensitive with blood-serum of host as well as the sera of other individuals suffering from dysentery. Inactive with normal serum and serum from cases of typhoid fever, malaria and beriberi. A bacillus belonging to the second group, which is still under study, would seem to agree with the bacillus dysenteriae isolated by Shiga from cases of endemic dysentery occurring in Japan. It is regarded by us as an important factor in the causation of the dysentery of the Philippine Islands. Experiments in immunization of animals and the production of vaccine are in progress, (b) Typhoid Fever. The total number of cases of typhoid fever in the hospitals during May, June and July was far below that of dysentery ; the number of deaths also was less. It was, however, a frequent affection among Americans. The examination of the blood, microscopically and with the Widal test, was of the greatest help in diagnosis. The disease came to autopsy presenting the classical intestinal lesions and also in atypical forms. In the small number of autopsies made upon those dead of this disease, several instances of slight intestinal involvement or even entire escape were met with. These cases would have remained very obscure or even undetermined except for the Widal reaction and bacteriological examination. In some instances the typhoid bacillus was found widely disseminated throughout the body, the autopsy being made immediately after death, (c) Malarial Fevers. A large proportion of the cases were sent in from the field and outlying military stations where examinations had to be hastily made, as instances of " malaria " or " intermittent fever " turned out to be cases of other diseases (typhoid fever, dysentery, etc.). A number of true cases of malarial fever were, however, met with, and in the blood of these the characteristic parasites, identical with those occurring in other places in which studies of the blood have been made, were found. No quartan parasites were met with, but cases of quartan affection doubtless exist. Typical infections with the " tertian " and "aestivo-antumnal " varieties of the parasite were encountered by us, and by microscopists among the Army physicians in the Reserve Hospitals and on the Relief. One of the fatal cases of malaria was complicated with acute lobar pneumonia. The cases of " calentura perniciosa" which occur in Mindoro, Mindanao and in certain parts of Luzon should be studied as soon as these regions are accessible. The Archipelago is favorable also for the study of the relation of mosquitoes and other insects to malarial infection. Some of the malarial cases were undoubtedly recidives, imported from Cuba or elsewhere. A very small number of deaths were referable to malaria. Two instances of acute malarial infection came to us for autopsy.


On the other hand, several instances of malarial pigmentations of the organs, in persons dying from other diseases, were encountered. Parasites in the latter cases were absent. These men had, as a rule, been in Cuba or Porto Rico during the Spanish war.

(d) Tuberculosis. A number of cases of pulmonary tuberculosis developed among the soldiers in the American troops. A definite history of exposure to wet and various hardships was elicitable iu many of these cases.

(e) Dengue. At Cavite there occurred a large outbreak of an epidemic fever of short duration (a few days), known locally as Cavite fever. Almost all who remained in Cavite for any length of time were attacked. Second and third attacks were common. Muscular pains were severe in some cases and not in others. A slight exanthem was present in many of the cases. Flushing of the face, restlessness and general malaise accompanied the fever and rapid heart action. Malarial parasites were not present in the blood, nor did the serum from such cases agglutinate cultures of the typhoid bacillus. The epidemic is regarded as one of Dengue.

(f) Tropical Ulcers. A number of the American soldiers suffered from a form of indolent ulceration, locally known as " tropical ulcer." These ulcers occurred singly sometimes, but were more often multiple. They began as small pustules, which gradually extended. They were most frequent among those who had been compelled to make long marches through swampy districts, and the patients themselves attributed the ulceration to " poisoning " in the marshes.

(g) Wound Infection. Our experience with wound infections was rather limited. The other problems undertaken, regarded as more important as bearing on the general question of disease and its causation in the Islands, left but little time and opportunity to attack this interesting subject. Certain observations of interest were made. Pyogenic infections due to the common pus cocci occurred. In a small number of gun-shot wounds causing compound fractures emphysematous gaugrene occurred and the bacillus aerogenes capsulatus was isolated. In oue instance of compound fracture of the tibia, a spore-bearing bacillus was associated with the bacillus aerogenes capsulatus. It was found in cover-slip preparations from the original wound and in the first set of cultures. It could not be further transplanted and hence was not identified. In two other cases was the bacillus aerogenes met with, one a case of jDeritonitis following infection of the intestine from an incarcerated hernia, and the other also a case of peritonitis but secondary to perforation of a typhoid ulcer of the intestine. The army surgeons were enthusiastic as to the adequacy of the "First-Aid Package" in limiting the number of wound infections.

Clihatological and Hygienic Conditions. The climate is that of continual summer. There is a wet season (S. W. Monsoon) and a dry season (N. E. Monsoon). The hottest period is at the end of the dry aud the beginning of the wet season — precisely the period of our visit. The climate from November to March is said to be delightful. In the worst season of the year the climate is very trying, and especial precautions are to be taken if Americans are to keep

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