Talk:The Johns Hopkins Medical Journal 6 (1895)

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL.

Vol. VI.- No. 46.

BALTIMORE, JANUARY, 1895.

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Contents

The Posture of the Head in Accidents when the Patient is , Proceedings of Societies :

under an Anesthetic. Bv H. A. H.^re, M. D., - - - 1 The Ho.spital Medical Society. - - 1-=^

The Visual Fielil as a Factor in General Diagnosis [Dr. de

A Contribution to the Study of Ansesthesia by Ether. By Prof. Schweinitz];— Catheterization of the Ureters in the Male

extraord. H. Dreser, -------- 7 ! [Dr. Brown].

I Notes on New Books, - - 16

Catheterization of the Ureters in the Male. By James Brown, | Books Received 17

M. D., 12 I Climatology and Public Health, ------- IS

THE POSTURE OF THE HEAD IN ACCIDENTS WHEN THE PATIENT IS UNDEli AN ANi:STHETir.

By H. a. Hare. M. D., Profrf:sor of Therapeutics in the Jefferson Medical College of Philadelphia. [Head before Ihe Johns Hopkins Hospital Medical Society, Notember \9th, 1894.]

Intlie presence of an accident from an anaesthetic tlie physician at once resorts to artificial respiration, after administering circulatory stimulants, and carries out his object by resorting to one of the several methods generally recommended for this purpose.

Be this method what it may, some studies which have been made with Dr. Edward Martin lead me to believe that it is of little value if the posture of the patient's head and neck is not correct, since the positions naturally assumed by the head of the patient at such times are generally capable of making all efforts at artificial respiration difficult or impossible.

As long ago as 1889, Howard, of London, published a very interesting paper on this topic which has since been widely quoted. While recognizing the value of his studies, my own have led me to reach somewhat different conclusions in regard to the posture of the head and its influence on the patulousness of the windpipe, and it is to these studies that I ask your attention. Howard's statements in regard to the role of the epiglottis in cases of arrested respiration in anaesthesia are as follows :

1. The epiglottis falls backward in apnuni and closes the glottis ; therefore the first thing in order and importance is the elevation of the epiglottis.

3. Traction upon the tongue, however, whatever the force employed, does not and cannot raise the epiglottis, as supposed.

3. The epiglottis can only be raised by extension of the head and neck. ,

The question which naturally arises first, is Howard correct in regarding the epiglottis as the cause of the obstruction? Personally, I believe he is wrong, because in tiit- great majority of cases the air passages are at once cleared of obstruction simply by drawing the tongue forward, a method resorted to by all of US, yet one which, as Howard iiimself states, and as we have proved, has absolutely no effect on the epiglottis unless the traction is applied well back on the dorsum of the tongue by a tenaculum. We riiay conclude, therefore, that the epiglottis is not the chief cause of the obstruction and that the tongue is more frequently at fault., but as any obstruction is undesirable, and as tiie epiglottis does sometimes certainly partially close the windpipe, what shall be done to govern its position ? Howard ftates that this may be accomplished solely by the posture of the head. The method which he recommends is as follows:

" Having, by bringing the patient to the edge of the table or bed, or by elevation of the chest, ]Movided that the head may swing quite free, with one hand under the chin and the other on the vertex, steadily but tirmly carry the head backward and downward; the neck will share the motion, which must be continued till the utmost possible extension of both head and neck is obtained. Sometimes a slight elevation and extejision of the chin will at once check stei'tororirregnlaritv

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of breathing ; but understand, the extension, which can in no case do harm, should always be rather more than appears necessary. It should never be forgotten, however, that the full effects of extension as above described can be secured with certainty only by making the extension complete as directed."

Once more the studies which I have made of this subject have convinced me that Howard's advice is not practically valuable. Although there can be no doubt that the changes described are produced, so fur as the position of the epiglottis is concerned, on the other hand such a position of the head and neck as he directs has the effect of strapping the soft palate over the dorsum of the tongue, thereby cutting off the entrance of air through the mouth and renders the nostrils the only path for its entrance. As the nasal cavities are in many jjersons obstructed by exostoses, hypertrophies or polyps, the nostrils do not afford a sufficiently certain entrance space for air, and removal of glottic closure by this posture nuiy cut off the air higher up.

If, on the other hand, the head is extended and simultaneously projected forward, both the tongue and epiglottis ai"e raised and the soft palate is so drawu as to permit of free breathing through the mouth as well as the nose. This is shown in the specimen which I now show you, in which the basilar process of the occipital bone is chipped away and the naso-pharynx exposed. •

Keturning to the question of the various modes of performing artificial respiration, such as Sylvester's or Marshall Hall's, let us see what accurate measurements of the volume of air pumped into the chest show as to their relative value. To determine this point the respiratory tract was connected with an ordinary gas meter, properly adjusted by means of a twoway, tube, through one valve of which the air entered readily, while it could only escape through, the meter. Curare was used to prevent voluntary breathing. When the Sylvester method was used the quantity of air passing out of the chest equalled 62; when that of Marshall Hall was employed the quantity was represented by 22. In another experiment the Sylvester method gave 18, while the Marshall Hall gave 8. It is evident, therefore, that the Sylvester is actually, as we have long believed it to be, by far the best method. In this connection it was found that in Sylvester's method it is vitally important to have an assistant grasp the feet and hold them motionless, since in this way the extension and upward traction of the arms above the head elevates and dilates the chest. This particularly is the case in children and persons of small weight, as the lower segment of the body readily follows the chest in its upward movement.

Very closely connected with the questions first considered is the condition of the res])iration, so far as its nervous control is concerned, in accidents from chloroform and in shock and cerebral concussion. The position of the medical profession is at present uncertain in regard to the dominant action of chloroform, chiefly because of the contradictory views expressed by special students of its powers, and the teaching of certain leading therapeutists and surgeons whose opinions are radically different. Further than this, many experimental investigations have seemed to reach quite different results and

have apparently left the subject more clouded than ever. Aside from the question, long since settled, that chloroform is the more dangerous auffisthetic in its immediate effects, we may without difficulty reconcile nearly all the contradictory results so far obtained if the individual researches are carefully studied, and as a result of such reconciliation reach the absolute conclusions so necessary in so important a subject. The conclusions are as follows, namely, that after its primary effect on the vaso-motor system, the dominant action of chloroform is certainly upon the respiratory centres in the medulla, and that this effect is the cause of death in most cases of chloroform accident. Not only does nearly all experimental work teach us this, but in a collective investigation made by me some time since as to the cause of death in man under chloroform, nearly every case reported was found to have suffered primarily from respiratory arrest. These statements are based first upon the report made by myself and my assistant. Dr. Thornton, to the Hyderabad government in India, and upon the confirmatory but entirely independent studies of Kandall and Cerna recently completed in Texas, in which these investigators took up the study to prove that our studies were erroneous and were forced to admit that death is due to respiratory failure.

Believing then that death is generally due to this cause when chloroform is given, it is incumbent upon the ana?sthetizer to watch the respirations, both because death creeps on in this way, and also because the rapidity and depth of breathing governs the dose of the drug, for the dose is not the amount poured on the inhaler but the amount taken in vapor into the chest. Lawrie's assertion that chloroform should be given only while the respirations are regular and withdrawn as soon as they are stormy is most wise.

AVhile I believe the respiratory action to be the dominant one in producing death as a rule, no one who has studied the effects of chloroform can deny that death may occur under its influence, in cases which are diseased, by its cardiac effect. Any shock may kill a case of cardiac disease, and it is natural therefore that any drug which possesses the peculiar influence of chloroform over the heart may be prone to cause death in this way.

In other words, supposing that the amount of depression from very full doses of chloroform equals 25 units, this amounts to little in the normal heart ; but if the heart be depressed 25 additional units by disease, the depression of 50 units may be fatal, particularly if to this 50 is added 25 units more of depression through fright and cardiac engorgement, through disordered respiration or struggling. That true depression of the heart-muscle may take place under chloroform seems to us most undoubted, as we think that the tracings in every research that we have "seen support this view. There is always a decrease in cardiac power manifested by the decrease in the force of the individual pulse-beat, and this passes away only if chloroform is removed early enough. AVe also agree with McWilliams that from the very first inhalation of cliloroforui there is a constant teiulency to cardiac dilatation.

Closely associated with influence of chloroform on the vital functions is its influence upon the blood-vessels, which, as

already stated, is its primary and dominant effect. This influence I believe to be very much more worthy of attention than is generally recognized. Every physiologist knows that the action of the heart and respiration is greatly influenced by vaso-motor relaxation. The gasping respiration of sudden faintness is probably due more to sudden vascular dilatation than to direct failure of the heart, and the exceedingly rapid pulse of shock is seen in conjianction with the relaxed bloodvessels so characteristic of this state. The integrity of the vaso-motor system is as necessary to life as the integrity of the heart, since it is under the government of this system that the cardiac mechanism is active and the vital interchanges take place throughout the body. Acting upon this belief I have found both in the laboratory and at the bedside that atropine enables more chloroform to be given without circulatory depression than can be used if no atropine is administered, and there is good reason to believe that the use of atropine by surgeons for the purpose of stimulating the respiratory function, or preventing cardiac inhibition by irritation of the vagus, in reality prevents dangerous symptoms chiefly by its vasomotor influence.

For some months I have been interested in studying tlie condition of the respiration in cases of traumatic shock, and it is surprising to note how death comes from failure of this function in distinction from failing circulation. Further than this, the employment of artificial respiration in these cases will often save life.

Very recently, in cerebral concussion, Hoi'sley has called attention to these facts and has practiced artificial respiration with good results in apparently hopeless cases.

Discussion.

Dr. Kelly. — We give chloroform frequently in the GyuiBcological Department, and, although in a very dangerous atmosphere, I also gave it in Philadelphia a great many times, before coming to Baltimore, but always in dread, because Dr. Wood of the University of Pennsylvania had said that any surgeon having a death from chloroform should be indicted for murder. The main reason why Philadelphia surgeons are afraid of chloroform is because they do not know how to give it. In abdominal surgery chloroform is better than ether, as it gives a quiet anissthosia, rapidly produced, and its after-effects ai'e not so disagreeable. My personal preference, save in cases of grave cardiac complications, as a dilated heart, or where there is failure in compensation, is always for chloroform. As I leave the choice of the anesthetic, however, to my anaisthetizers, I find that in a large majority of cases they select ether. I never ask an assistant to give chloroform who is averse to it, especially if he has not been accustomed to its administration. The man who administers chloroform should be afraid of his anaesthetic. He should watch his patient closely, and constant attention should be given to respiration, pulse and general appearance. Since the results of Dr. Hare's researches have been published, in which he proves that the respiration is the important factor and fails first before the heart, we pay more attention to the respiration than before.

Regarding nu'thods of resuscitation, I have found a nietiiod

of my own exceedingly satisfactory. I have treated about fifteen cases with uniform success by this method, which I believe to be the best for keeping up artificial respiration. I find too that I have been following the principle laid down by Dr. Hare — that of the extended and slightly flexed head. On the first indication of failing respiration the administration of the anaesthetic is instantly suspended, and the wound protected, if abdominal, a broad piece of gauze is laid over the intestines under the incision. An assistant steps upon the table and takes one of the patient's knees under each arm, and thus raises the body from the table until it rests upon the shoulders. The anaesthetizer in the meanwhile has brought the head to the edge of the table, where it hangs extended and slightly inclined forward. This position, shown in the accompanying cuts, is similar to that described by Dr. Hare and resembles that taken by the runner when he is breathing hard. The patient's clothing is pulled down under her armpits, completely baring the abdomen and chest. The operator, standing at the head, institutes respiratory movements as follows: inspiration by placing the open hands on each side of the chest posteriorly over the lower ribs, and drawing the chest well forwards and outwards, holding it thus for about two seconds (Fig. I); expiration, reversing the movement by replacing the hands on the front of the chest over the lower ribs and pushing backwards and inwards, at the same time compressing the chest (Fig. II). The success of the manceuvre will be demonstrated by the audible rush of air in and out of the chest.

The heart aud pulse should be constantly watched. As respiratory movements are continued, a little flickering pulsewave will be observed at the wrist, which shortly becomes faint and regular, and gradually increases in strength. From ten to thirty of these acts of induced respirations will usually suffice to excite voluntary respiratory movements, which begin with short, jerky, gasping breaths, becoming louder and then regular. The movements must then be timed to suit the natural efforts. As the depth of inspiration increases, the color slowly returns, the pupils contract, and the danger is past. In women with contracted, fusiform chests (tight lacers), this procedure is not available; in such cases respiration should be induced by direct autero-posterior compression of the chest by placing one hand on the lower third of sternum, aud the other on the back opposite the first, and alternately squeezing the chest and relaxing the pressure, when air will be audibly forced in and out, and the patient revived as by the previous method : it also fails in a rigid old chest.

The suggestion which Dr. Osier once made ooncerniug the use of external heat during the administration of an ana>st hotio in a prolonged or a severe operation is a very important one. Dr. Osier especially impressed me with this fact two years a^o on his return from London, where he had seen Horsley conduct his experiments in brain surgery on monkeys which were kept on a Avarm table during the operations. Horsley lays e5[x?cial stress on keeping up the body temperature, to prevent shook. Following this suggestion, I have recently had narrow hot water-bags made three feet long, which we keep in the operating room, aud in case the o}>eration is to be prolongetl, or the patient is feeble, we place one on either side of her

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 46.

body and an ordiiiarv water-bag at the feet. I am indebted to Dr. Hare for several important hints, especially concerning the use of atropine in cases of disturbed respiration. I cm also glad that he has placed the principle of the proper position of the head upon a scientific basis.

Dr. Osler. — With reference to the position which Ur. Kelly puts the patient into, I will mention the very interesting experiments made in Dr. Sanderson's laboratoi-y in Oxford by one of his assistants upon the influence of position on blood pressure. With a very carefully adjusted turn-table, the blood pressure was found to rise immediately as the lower extremities of the animal were raised.

Dr. Halsted. — I am pleased to hear what Dr. Hare has said, and I am sure that the position of the head which he advocates is the correct one. It is the position which we always use. We have learned to use it from experience. Dr. Hare said "Now you have got the position," when I was testing on the cadaver our position in order to see whether or not it opened the glottis. In pulling the jaw forward as we do it, one necessarily e.xteuds the head. In anesthetizing a patient we always catch the jaw close to the condyle and press it as strongly forward as possible, and so keep the glottis open. If this is properly done it will never be necessary to pull the tongue forward with an instrument. It is not, therefore, the extending of the head which opens the glottis. I^ we were to extend the head by pulling the ears we should not open the glottis. The extension of the head is simply incidental to the drawing forward of the jaw. I agree with Dr. Hare when he suggests that we might make use of atropiaoftener than we do. It is a drug upon which we can rely to increase arterial tension. But morphia is a vaso-motor depressant and lowers arterial tension ; hence I do not use it in conjunction with ether. I am afraid of chloroform and do not use it. In Germany, where they certainly ought to know how to give it, where they use it almost exclusively and write a great deal about the proper method of administering it — giving it drop by drop, a drop with each inspiration — they have had more deaths this year than ever before from chloroform, 1 to 1600 or 1700, according to Gurlt's statistics. For the last ten or twelve years Gurlt has, as you know, gathered statistics from the different German universities. The usual mortality is 1 to 2200 or 2300. This year from every university in Germany, almost without exception, the mortality from chloroform has been greater than for many years. That is very remarkable unless the manufacturers of chloroform are to blame. One death should be enough to deter a man from ever using it again. Dr. Lange took Dr. Kelly's attitude for a good many years, then he had a death on the table and said that he would never give chloroform again. It is perhaps possible to give morphia in so small a dose that it may for a few moments act as a vaso-motor stimulant and increase the arterial pressure, but in moderate and particularly in large doses it lowers arterial tension most pronouncedly. These statements are supported by the highest authorities,* and I take pleasure in calling Dr. Hare's attention to them.

Dr. Hare. — A characteristic symptom of the first stage of opium poisoning is a slow, full and strong pulse, and therefore the arterial pressure must be high.*

There are one or two points raised in the discussion that I would like to speak of.

I thoroughly agree with Dr. Kelly, although 1 am one of the much maligned Philadelphians in this instance, when he says that many persons don't know how to give chloroform in Philadelphia. In two of the cases in which I have seen accidents occur, the chloroform was given very much more as if it was ether than if it were chloroform ; and in the last case I saw, after the woman was once resuscitated, the resident physician two minutes later pulled the napkin over the patient's mouth and poured on about * ounce of chloroform so that her pulse was lost at the wrist and her breathing stopped a second time.

In regard to atropine, 1 think we do not use large enough doses of this drug. When I was a student a proper dose of atropine was 1-35U gr. and of strychnine 1-160. Now some surgeons give as much as i gr. of strychnia, and atropine in the dose of 1-100 to 1-50. Atropine is a better drug than we think it is, and does not get the credit it ought to have, simply because we do not give it in large enough doses. One onehundredth of a grain would be a very proper dose, and I have given myself, in cases in which I had reason to believe there was a condition of vaso-motor relaxation, very much larger doses, proportionately, than this. In a child of 8 months I have given 1-150 gr. of atropine twice in 8 minutes, and I believe that it saved the child's life.

This leads me to emphasize one other point which I am almost afraid to speak of, because I have emphasized it so often, particularly to the students of Jefferson College: I am confident that we let many cases die on account of vaso-motor relaxation. When you see the diagrams in the books on physiology, of the enormous areji of the vascular system when relaxed and the capacity of it as compared with the arteries and veins, and when you read of the influence of vaso-motor relaxation in producing tachycardia and cardiac exhaustion, then you can appreciate the importance of the vaso-motor system in maintaining life. In pneumonia, when you have a very feeble and very rapid heart, don't think that because the heart is rapid digitalis should be given. It is extraordinary the way the action of the heart will improve just as soon as you develop the normal resistance of the vascular system. The heart working agaiust a relaxed vascular system is in a worse condition than when working against a vascular spasm such as we have in chronic nephritis.

•C. Bl.sz : Ueber den arteriellen Druck bei MorphiumVergiftung. Deutache med. Wochenschr. 1879 and 1880. FicK : Ueber die Blutcirackschwankaiiijen im Herzventrikel bei

Morpbiniumnarcose. Verhandlungen des Cong, tiir innere Mfd. 1886.

BiNZ : Discussion of Fick'a paper. " We have learned to-day from Dr. Pick, by reason of his exceedingly precise methods of investigation, that morphia in doses which are not large weakens the lieart's systole, and therein lies a fresh proof of the old experience that morphia is a heart poison of such power that it may endanger tlie central organ of the circulation."

Harnack : Arzneimittellehre und Arzneiverordnungslehre, p. 650.

• Db. Halsted.— With the slowing of the pulse the fall in arterial pressure increases. Vid. Binz, Heubach, Fick and others.

January, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

Since Dr. Halsted has fired a shot at the therapeutist, I will hare to have a shot at the surgeons in return. Dr. Abel will agree with me when I state that morphia is not a vaso-motor depressant ; on the contrary, it is recognized as quite a powerful stimulant to the heart and vaso-motor system in ordinary doses.

The position I want to emphasize about the head under these circumstances is that it should be extended and craned forward in order to let the air pass in. One of the deaths I saw, which occurred in Dr. Goodell's jiractice, was due, I am confident, to respiratory failure. I tooii charge of the head and Dr. J. AVm. White used Sylvester's method of artificial respiration, and it was interesting to notice the difference in the respiratory sounds when the head was in the ordinary position and when it was pushed forward in the way I have described. The last point perhaps may have some relation to the question which Dr. Halsted has brought up in regard to why it is that in some years there are more deaths than in others. So far as I know, there have been no carefully carried out experiments in regard to the fatality of chloroform under varying conditions of the atmosphere. In Galveston there are very few deaths from chloroform. Lawrie has now had about 30,000 chloroform anesthesias without a death, and only a few accidents, not alarming. Perhaps it is that the condition of the temperature of the air — humidity and barometric pressure may have something to do with the quantity of chloroform which is taken into the chest, for it is not the quantity of chloroform that is put on the towel, but the quantity of chloroform which the patient takes into his lungs from the towel that is to be considered. This emphasizes still further Lawrie's statement that just as soon as the patient's respiration is getting stormy we must stop the administration, because if you do not do so you will not know how much chloroform the patient is getting.

Dr. Abel. — .The question is a matter of dosage. Small or therapeutic doses of morphine have no effect to speak of on blood pressure. It is a very different msitter when toxic doses have been taken. It is a notable fact that morphine has a more powerful action on the respiratory centre than on the vaso-motor centres.

I have listened with great pleasure to Dr. Hare's interesting paper. His report to Lieutenant-colonel Lawrie, of the Hyderabad commission, to which he has made reference in his remarks to-night, contains valuable confirmatory researches on the effect of chkiroform on the respiration and circulation, and all of us, I feel sure, will agree with him in his conclusions on these points.

The question has been raised to-night of the relative value of ether and chloroform. I was myself brought up under a chloroform regime, and when I first began to teach I put it rather more highly in the list of anaesthetics than I am inclined to do to-day. The Germans are now making a careful examination of the comparative merits of chloroform and ether. Many of their surgeons who have hitherto favored chloroform above ether are turning about and it would appear that chloroform is going to lose the day. Laboratory investigations are giving us fresh proofs of the greater safety of ether.

Chloroform has a remarkable affinity for some of the substances composing the nervous system. The brain and the medulla seem able to pack it away even when it is breathed in very dilute air solutions. Thus Kronecker and Gushing have found that the breathing of air containing only 0.34—0.42 per cent, by volume of chloroform will still lead to paralysis of the respiratory centre ; and Pohl, following out some early work of Schmiedeberg's, has shown that in the stage of complete anesthesia the brain contains about three times more chloroform than an equal weight of blood, blood containing 0.015 per cent, and brain substance 0.0418 per cent, chloroform. We have some information, therefore, as to the localization of chloroform in the body. Schmiedeberg long ago demonstrated that the serum of the blood contains very little chloroform during anesthesia, not more than would be dissolved in watei', and that the chloroform taken np and carried by the blood is bound to its red and white corpuscles. From experiments made by Pohl we know that it is the lecithine, cholesterine, fatty matters, and the protagon of the corpuscles of the blood and of the cells and fibres of the central nervous system to which the chloroform is tied. What proportion of chloroform is taken up by such viscera as the liver we do not yet know.

If so weak a solution as 0.5 percent, of air volume will still, after being breathed for some hours, cause cessation of breathing, that is rather against chloroform, even in the light of modern improvements in its administration. Paul Bert in 1884 proposed that only a "titrated" air solution, containing at the most no more than 4 per cent, of chloroform, should be used for anesthetic purposes. This method was employed for a time by a few practical anesthetists (Clover) and is said to have reduced the number of chloroform accidents. But for some reason or other, either because accidents still occurred or because the required apparatus was cumbersome, the method was given up.

The method of le melange ti/re is, however, being revived, only ether is being used instead of chloroform. Dr. Spenzer, an American chemist, working in Schmiedeberg's laboratory, has found that the inhalation of air containing 1.5 per cent, of ether by volume, for two hours, causes no anesthesia iu animals, the result being only a mildly hypnotic condition. If the air breathed contained 2.5 per cent, of ether by volume the anesthesia was also found to be entirely incomplete, the reflexes in this instance being exceedingly lively. AVhen the respired air continued 3.19-3^2 per cent, of ether, complete anesthesia was attained within 25 minutes, and could be kept up for hours without any respiratory disturbance whatever, and without danuvge to the heart. When 4.45 per cent, by volume of ether was employed, anesthesia w.ss complete within fifteen minutes, the breathing was slower but regular, the heart-beats a little more rapid and weaker than normally, but still of a regular rhythm. At G per cent, by volume of ether admixture the limit of safety was reached, for now cessation of the respiration occurred within S-10 minutes after allowing the ether to bo breathetl. Artificial respiration, however, always restoreil the animal, uo matter how often the experiment was repeated. Speuzer's experiments, ill which careful cheniic.il analyses of the respired air

6

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were made, thus substantiate Snow's results, gained many years ago (1858) by crude methods, that an air mixture containing about 3.5 per cent, by volume of ether will keep up an anaesthesia for many hours without endangering the respiration or circulation. We see, too, from Spenzer's experiments that even with ether there is but a narrow limit between safety and death.

This summer, in the pharmacological laboratory at Bonn, I saw an apparatus which allows us to give ether to human Ijeings according to this safer method of Je melange Hire with great success. The arrangement is such that the mixture can be made of air and ether in such proportions as you want it. It is then carried through valves that are so easily moved that there is no work of any consequence for the chest of the patient. I was told there that they had anesthetized patients by this method with great success. A further advanhige of this method is that air mixtures of ether that do not much exceed 4 per cent, are non-irritating to the mucous membrane of the respiratory tract. Ureser has made experiments on this point and has found that up to 5.4 per cent, by volume of ether vapor the mixtures were pronounced by his subjects to be easily borne.

The absence of knowledge as to toxic doses, that is, as to the amounts pro kg. of body weight from which no recovery is possible, is greatly to be regi-etted.

Unfortunately, too, we have, as far as I am aware,'no careful experiments as to the localization of ether in the organs of the body, and no equally exhaustive experiments as to its chemical fate in the organism as compared with chloroform.

One other point in the way of chloroform is the tendency to degeneration of the important viscera after its use. You cannot chloroform the healthiest and strongest bulldog, notably a toiigh species of animal, two successive times without his dying from the after-eifeets of the drug. Keep him deeply under ana3sthesia with chloroform for four hours, let him recover, and on the third day following repeat the experiment, keeping him again deeply under the influence of chloroform for four hours, put him away into his pen, he will regain consciousness as usual, but in the course of a few days death will ensue. Whether carefully wrapping up an animal in cotton wool would keep the animal alive after two such periods of heavy chloroforming I cannot yet say.

I have been much struck by the poisonous nature of chloroform in feeding experiments that 1 have undertaken for the purpose of studying changes in the metabolism of the liver. Repeated doses, even when not large, and single large doses (6-9 grams) according to the weight of the animal, soon

cause a profoundly cachectic condition, the animal's coat becomes shaggy, it loses weight and in the course of 6-14 days it dies, no matter how healthy it was before. Others have demonstrated that in such cases a marked fatty degeneration of many organs, notably of the liver, kidneys and heart, has been induced. Kast and Mester have come to the conclusion aftgr an examination of the urinary constituents, particularly of the so-called " neutral " sulphur compounds, that long-continued chloroform inhalation induces a profound disturbance in proteid metabolism, extending over several days. Of no little importance is the fact that it requires considerable time for the organism to get rid of chloroform, whether taken up from the lungs or from the digestive tract. This is demonstrated by the increased elimination of chlorides after chloroform anaesthesia, experiments on animals showing that the greater part of the chlorine of the retained chloroform is excreted in the form of chlorides, and that even on the fourth day after the administration of the chloroform the urine still contains an excess of chlorides.

One reason then why the Germans are turning about is that their studies have led them to believe that many of the deaths that occur very shortly after a prolonged administration of chloroform are due to the serious lesions of important organs induced by this drug. Virchow's Archiv and other journals and the inaugural dissertations of the last seven or eight years have had numerous contributions on this subject.

A recent contribution by Selbach from the laboratory of Prof. Binz, entitled "Are fatal after-effects to be feared as resulting from long-continued ether inhalations ?" reviews the literature on the untoward effects of chloroform, and describes a series of original experiments made with the view of determining the poisonous after-effects of prolonged etherization, and from these the author is led to infer that there is little or no danger of a fatal after-action following anajsthesia by ether in the case of human beings. Here too, then, on this important side of the question the advantage lies with ether.

Dr. Theobald. — Regarding the use of atropine preceding the administration of chloroform, I may say that for a number of years I have been in the habit of giving a hypodermic injection of 1 gr. morphine with yi^ of atropine previous to the use of chloroform, and the effect has been most satisfactory. Not only is the heart-depression in a great measure obviated, but the patient comes more quietly under the ana'sthetic, and the recovery from the anesthesia is slower and more satisfactory. The patient does not wake up suddenly with restlessness, but wakes up in a sleepy, good-natured state, and submits to the dressing with less objection.

THE JOHJsS lIOPKrN^S ITOSPITAIj REPORTS.

Volurae IV, No. 6 (Report in Surgery II), Now Ready.

Contents: The Results of Operations for the Cure of Cancer of the Breast, performed at the Johns Hopkins

Hospital from June, 1889, to January, 1894.

By WM. S. HAL8TED, M. D., Professor of Stmjcry, Johns Hopkins University, and Snrgcmi- in- Chief to the Johns Hopkins Hospital Price, $1.00. Address The Johns Hopkins Press, Baltimork, Md.

January, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

A CONTRIBUTION TO THE STUDY OF ANilSTHESIA BY ETHER.*

By Prof, extraord. H. Dresek, of tlie Pharmacological Laboratory at the University of Bonn.

Introductory Note by Prof. Abel.

Prof. Dreser has forwarded me the following jjaper in English for publication in this country. While his researches into the composition of the air in the closed masks described by him might appear to have less value for those that administer ether by the open method, yet a close reading of his exhaustive paper will prove of value to all anesthetists alike. That a deficiency of oxygen can so easily be induced in a closed mask, and that there is more danger on this score than from the accumulation of carbou dioxide, are points that are well worth establishing. It must also be of great interest to know that mixtures of air and ether containing more than 7 per cent, by volume of ether vapor cannot be inhaled without great irritation to the mucous membraues of the respiratory tract. Prof. Dreser has devised most ingenious appara'tus which makes it possible to autesthetize patients with mixtures of air and ether of known strength. In a trial experiment, recently made iu the gynajcological clinic of Prof. Fritsch,f at Bonn, a woman Was kept under the influence of ether during an hour and twenty-oue minutes, the time required for the performance of an operation for prolapse of the uterus, the anesthesia being entirely satisfactory to the oiJerators. Ana3sthesia was first induced with a mixture containing 6 per cent, of ether, the mixture was then increased to 8 per cent, of ether until profound aufesthesia was attained, and then lowered to 4 per cent., at which strength it was maintained throughout the entire operation. All this was accomplished without depriving the air in the mask of its oxygen and without allowing the exj)ired air to accumulate, the mask used containing two very simple and very mobile valves which separate the air to be inspired from that expired. It is "to be hoped that Prof. Dreser's method of administering ether in the form of titrated mixtures will be found so practicable that anesthetists will have no difficulty in employing it. The greater safety of such a method and its advantages iu lessening the untoward after-effects of anaesthesia are evident.

John J. Abel.

Even the healthiest person may by some accident, as a fracture, a dislocation or a wound, become a subject for the surgeon, who is then obliged to anesthetize him in order to come up to the motto of his profession, to cure tuto, cito et juctmde.

The anxious feelings which a patient who nuiy perchauce know something of these matters must have before the beginning of an operation, will be increased by his suspicions as to whether either Julliard's or Wauscher's mask may be quite fit to prevent auy accident occurring. This matter is therefore not only of scientific value, but also of a personal interest.

• Researches on the composition of the air in the masks of

Wanscher and of Jullianl during aniosthesia by ether.

■f-H. Dreser: Demonstratio eines Apparates fiir Herstellung dosirter .Votherihvrapf-Iiuflmischungen. Sitzungsb. li. Niederrhein. Gesellsch. f. Natar- u. lleilkundo zu Bonn.

Such were the suggestions that occurred to me on the occasions when I witnessed .surgical operations, and that induced me to make the analysis of the gas contained in the inner chamber of these masks.

I do not want to speak of the diverging assertions of clinical empiricism, but wish rather to furnish the precise data of analyses, in order that we may judge whether either method will prove efficacious and not dangerous.

Surgeons now try to substitute less dangerous agents, such as bromide of ethyl, ether, or pental, for chloroform, which is suspected of being a heart-poison. The vapors of these fluids, which are more volatile than chloroform, must accumulate in the air, to be inhaled in a far greater quantity than in the case of chloroform. Therefore the simple Esmarch mask used for chloroform is not efficient. The permeable cover of the Esmarch mask would bring about quite the contrary effect. The air exhaled by the patient being of a higher temperature than the surrounding atmosphere, a great quantity of ether w^ould escape into the room ; whereas the cooler atmosphere of the room, passing through the cover of the mask at the next inhalation, will carry too little ether into the patient's lungs.

For this reason the great basket-mask of Julliard has an impermeable cover of waxed taffeta, and the Wanscher mask has a bag of India rubber.

However, in spite of these differences, the principle which led to their construction is the same, viz. to have a pretty large fore-chamber close to the nose and mouth of the patient. The warm air exhaled must remain iu this chamber until the next inhalation, and by parting with it^ store of heat causes a more rapid evaporation of the narcotizing fluid. In Wauscher's mask, if it fits the patient's face well, the exhaled air will remain entirely in the India rubber bag ; in Julliard's mask it only partially remains. Thus the anesthetic vapors will reach the lungs of the patient iu sufficient quantity, jierhaps more even than is required.

The question now is, whether the air thus tarrying under the mask and bretithed again may not gradually be exhausted of its oxvgen and overloaded with carbonic acid; and in this event these two methods of applying anesthetics would hare to be considered dangerous.

Before giving the results of my analysis of the gas met with in the masks, and the physiological conclusions to be drawn from it. it is necessary to state the methods which I useil.

A. The Method Used ix Obtaining the Casks in the Masks and in Determining their VoLrMK.

A suuill quantity of the gi»s (about 100 cc) to lie analyzed was drawn from the inner chamber of the mask by means of glass tubes joined together with india rubber to a conduit, thus yielding without breaking to every movement of the patient. This conduit had been previously filled with concentrated salt water in order to prevent .is much :is jwssible auy absorption of the g;»ses. The end piece of the conduit, bent

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 46.

like a knee, was introdnced between the border of the mask and cue side of the nose. The estimation of the volume of the compounds was made according to Prof. Hempel's e.xpeditive method for the technical analysis of gas.* As the solubility of ether vapor in water is not inconsiderable, one must use concentrated salt water instead of ordinary water, or else the percentage of the ether vapors would fall short of that actually present, especially when the analysis is not done quickly.

I have tested in the following way the possibility of transferring ether containing air into Hempel's burette with sufficient accuracy by using concentrated salt solution as a separating fluid. Fifty cc. of air were measured into Hempel's burette and propelled into a vessel filled with salt solution saturated with ether. On shaking the air in this vessel, its volume was increased by the ether evaporating from this salt solution. In order to prove how much the volume in the shaking vessel might have diminished after carrying it back into Hempel's burette and measuring its new volume, the lower end of the shaking vessel was joined to a 100 cc. pipette by a rubber tube. After shaking, the pipette was filled with salt solution to its upper mark, placed on the same level as the fluid in the shaking vessel. Having again transferred the gas into Hempel's burette and noted its volume, the remainder of the 100 cc. salt solution in the pipette was weighed, and by means of the specific gravity of the salt solution the volume of air increased by the vapors of ether was calculated. The difference between the measured and the calculated values of the gas volume may be shown by the following table :

Read off.

Calculated

I

64.0 cc.

64.25 cc.

II

80.2

80.02

III

69.7

69.85

IV

86.8

86.97

V

62.4

62.35

VI

67.8

68.02

Hence it is clear that the difference is about 0.2 cc, when using salt solution as a separating fluid.

A few e.xplanatory words about the absorption of the narcotizing vapors in the analysis must be given. Hempel's experiments in 189i| proved that the vapors of carburetted hydrogen are readily absorbed by absolute alcohol. I made experiments proving the absorption of ether and bromide of ethyl by means of Plempel's "Aethylenpipette "J filled with absolute alcohol, using, however, the precaution of not letting the alcohol rise up to the caoutchouc of the connecting capillary tube. The gas to be analyzed was repeatedly propelled and carried back until two equal volumes were noted. Thus 1 have proved that any further absorption is impossible ; but the volume of the remaining gas was still too great, because it contained some alcohol vapors. These vapors are easily removed by tilting the closed burette and moistening its walls

• Gasanaly tische Methoden von Walther Hempel. 2te Aufl.

1890.

tVV. Hempel und G. M. Dennis : Ober die volumetrische Bestimmung <ler (lumpfurtniiieii Kolilenwassergtoffe. Ber. tl. deutscii. chem. Ges. zii Berlin, ISitl, p. 1162.

{ Hempel : Gasimalyt. Metlioden, p. 182.

with the separating fluid. The efficacy of this method can be tested by introducing 100 cc. of pure air into the alcohol pipette. The air carried back into the burette is increased by the alcohol vapors to somewhat more than 100 cc: after tilting, the original 100 cc. will be found again.

Test for the Analysis op Ethek and Bromide of Ethyl.

Kther.

Bromide of Ethyl.

I Air ij. 1 Increased ^"- by the vapors.

Air

free f rnm

vapors.

Air.

Air

Increased

by the

vapors.

Air

free from

vapors.

I

11 in

IV

V

VI

50.0 cc.

59.8 cc.

56.8

65.4

60.2

63.8

62.2

50.2 cc.

50.1

50.2

50.0

50.2

50.2

50.0 cc.

59.2 cc.

56.6

58.6

56.0

56.6

64.4

50.0 cc.

50.2

50.1

50.2

50.0

50.3 .

B. Observations on An^iisthesia by Bromide of Ethyl

BY MEANS OF WaNSCHEK'S MaSK.

The following 34 observations were made during shorter surgical observations. The Wanscher's mask used had a sponge near the metallic mouthpiece of the mask, upon which the liquid was poured. The free border of the mouthpiece was formed by an iudia rubber roll inflated with air in order to make it fit tightly to the patient's face. Nevertheless the mask did not always fit quite closely, because many a patient struggled vigorously at the very beginning. This may be one reason for the somewhat different percentages found in the proofs of air taken out of the mask.

No.

BrCjH,

vol. perot.

8.0

CO, per ct.

o,

per ct.

Remarks.

I

2.2

12.4

Proof taken after 1-1 i minutes.

II

8.2

3.0

10.6

" " " " "

III

4.2

12.0

7.1

" 3-4

IV

6.8

2.2

14.6

1-Ii "

V

4.0

2.2

16.2

" 30-40 seconds.

VI

6.2

3.3

13.0

VII

5.4

2.4

14.7

VIII

2.4

1.6

184

" '■ " 20 seconds.

IX

5.0

2.2

14.6

X

6.8

2.2

13.0

" " 55 seconds to 1 min.

XI

7.7

2.9

13.2

XII

4.0

2.2

16.4

" " " 30-40 seconds.

XIII

12.0

2.6

11.6

" " strugglingmucli.

XIV

4.0

3.2

13.4

" " " 2 minutes.

XV

7.2

3.8

10.6

" " " 1 minute, struggling.

XVI

9.6

2.9

11.8

" " " H-- minutes.

XVII

10.6

2.6

12.li

" • " " 35-45 seconds.

XVIIl

12.8

2.8

7.4

strugpling violently.

XIX

7.2

2.8

12.8

' 50-55 seconds.

XX

7.8

2.2

12.8

■* 55 seconds.

XXI

2.4

2.6

16.4

" " " 1 min. -1 min. 10 sees.

XXII

13.8

1.8

12.8

" " " 80 seconds.

XXIII

10.0

2.8

10.4

XXIV

14.6

1.9

13.1

" " " 1 minute.

The limits were 2.4-14.6 per cent, of bromide of ethyl, 2-3 per cent, of carbonic acid (with one single exception); the differences were mostly found in the percentages of oxygen, varying between 7.1-18.4 per cent. ; the average was 12-14 per cent. Oj. It was necessary to extend these

January, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

0. Inqutries to Healthy Persons without Narcotizing

THEM.

■ This furnished me with a much-wished-for opportunity to compare the feelings of conscious individuals breathing under the mask, concerning the percentage of the air met with in the inner chamber of it. The experiments were performed on men sitting perfectly quiet. The proofs of gas were taken after breathing half a minute, one minute, and two minutes. We had the following results:

After half

a minute.

Dr.

\. K.

St.

K.

H.

D.

CO™ per ct

Oj per ct.

CO3 per ct.

O2 per ct.

COo per ct.

O.J per c

5.8

13.6

5.3

13.9

5.0

15.4

5.6

13.8

5.5

14.3

6.2

13.6

G2

13.5

5.8

14.0

6.6

12.3

0.0

13.9

4.8

15.4

7.6

ll.S

5.4

14.2

5.4

14.4

6.0

14.2

5.6

14.0

5.6

14.6

6.3

12.9

After one minute.

7.2

9.7

6.5

12.5

6.6

11.6

6.4

10.6

5.6

13.6

6.8

10. G

6.2

11.2

6.2

12.6

6.2

12.6

6.9

10.1

6.2

128

6.6

11.8

7.0

9.8

6.8

11.2

7.6

9.8

7.0

9.8

6.6

After tivo

12.2 minutes.

7.4

10.6

6.2

9.6

7.8

8.8

6.4

10.4

7.2

6.4

7.8

9.4

6.8

10.6

7.6

6.0

7.7

7.1

7.0

8.8

7.8

5.0

8.8

5.8

8.2

6.0

7.0

8.0

8.0

6.6

7.8

7.4

6.0

10.8

8.2

6.4

7.0

9.5

The differences in these experiments are not quite so considerable as those met with in the narcosis by bromide of ethyl, yet they were greater than was expected. The reason was the different volume of the air extant in the India rubber bag, which varied according to the more or less deep folds of it.

In the experiments with bromide of ethyl, the air in the mask seemed to be especially impaired by loss of oxygen when the patients had been struggling. On that account I engaged a student to take exercise with dumb-bells in order to study the influence of muscular exertion on the composition of the air in the bag. The dumb-bells used weighed 12 kilos, the height to which they were lifted up being 1.25 meters; the work done with each lift was 15 kilogrammeters. There were 8-9 lifts in half a minute; the work done in this time was 120-135 kilogrammeters, and 240-270 kilogrammeters during one minute. When sitting perfectly quiet the following composition was found: .

After half a minute. After one minide.

COj =4.4 per cent. 0.j = 10.0 per cent. CO, =5.8 per cent. Oj = 13.4 per cent. 5.9 14.4 5.6 13.2

6.2 13.8 6.9 11.9

When working, was found:

After half a minute. After cue minute.

CO.j = 8.3 per cent. 0, = 10.0 per cent. CO, = 8.0 per cent, 0, = 9.4 per cent.

8.9 11.0

7.9 7.2 6.2 6.8

9.7 11.4 12.5 11.0

7.0 6.6 7.4 8.2

10.4 11.4 10.0

The results of all these experiments without narcotics show that the oxygen contained in the bag of the mask decreases so rapidly that after having breathed for half a minute in the mask, the light of a candle is extinguished in this air. I found that the percentage composition of air in which a candle had gone out was 16.2-15.4 per cent. 0; and .3.6—4.6 per cent. CO;. CI. Bernard* has obtained corresponding numbers, viz. 15.4 per cent. Oj and 2.3 per cent. CO:. After having breathed for one minute in AVanscher's mask, the partial pressure of oxygen had sunk to one-half of its pressure in the atmosphere — a linait when bad symptoms also began to appear in the well-known experiments of Paul Bert. After having breathed in the mask for two minutes only, 5-G per cent, of oxygen were several times met with. The consequence was that very disagreeable oppression of the heart and violent dyspncea were caused, so that the persons experimented upon were glad when the two minutes, the time of the experiment, were over. By comparing each single exjieriment we have evidence that it is not the percentage of carbonic acid, but only the diminished oxygen, which is the cause of this state of suffocation combined with cyanosis of the face or slight dizziness. In the last experiment on the inlluence of muscular activity with only 7.6 per cent. Oj, violent dyspnoea was especially complained of. It is therefore clear that a partially narcotized patient who struggles to get rid of this dangerous state will make his condition rapidly worse by his muscular straiuiug. By way of comparison with the various percentages found by nie, I quote CI. Bernard's experiments upon animals which died when the percentage of the air in the room had gone down to 3-5 jjer'cent. 0=; in these experiments the exhaled carbonic acid was absorbed. In similar experiments of W. Miiller the lethal limits were 1-5 per cent. ; Strogauow found 3-4 per cent. O-j ; Friedliinder and Ilerter 3.8-2.1 per cent. The explicit researches of these latter investigators show that the diminution of the oxygen to 12.7 per cent caused a little dyspna'a and a slight irritation of the vasomotor centers, producing only a small rise of the arterial blood pressure ; but when the air breathed had only 5.1 per cent. 0», the blood pressure rose 43 mm. of mercury above the normal. In these experiments on animals, air containing only 7.5 per cent, 0: called forth a decided dyspncea.

Now it may be clearly seen the Wauscher mask offers tjie unwelcome possibility that these states of deficiency of oxygen, already well known by experiments upon animals, will be reproduced in man in the course of a few ^1-2) minnt^s. Among the numerous recommendatious of the Wauscher mask at least some kind of information should have been given as to how often this mask should be replenished with air. The simple test with a burning candle, well known to any intelligent workman who intends going down into a well, shonid have warned the advocates of Wauschcr's mask.

1). On the Irritating Percentage op Ether Vapor. The recommendations of the Wauscher mask sjty little or nothing of the percentage of oxygen and carlwiiic acid, or of the perceutiige of ether vapors to bo met with jiu the mask.

• Li'^ons sur les sul>stAnces toxiques, p. 220.

10

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 46.

These conceutrations, which irritate the mucous membranes of the respirator}' organs, are most important for the lungs of the patients. The frequent catarrhal affections of the bronchi and lungs met with after ether narcosis are caused by too strong concentrations of the ether vapors. In order to state the percentage of ether vapors still respirable without molestation, we experimented upon ourselves by breathing proofs of several mixtures made by diluting ordinary air with var\iug projjortions of air saturated with ether vapor. Tiiese mixtures having been prepared in an India rubber bag, two or three persons breathed immediately one " proof," wrote down their sensations, i. e. whether they were " bearable," or caused some "irritation and cough," or "impossible to be breathed." Immediately afterwards a proof was taken out of the bag in order to determine the percentage of ether vapor. On the whole 18 experiments were made.

injury, so that they usually escape with slighter irritations of the bronchi.

The temperature of the air in the mask often amounting to 31° C. after having been breathed for one minute, favors the quicker evaporation of ether. Since none of the operators at Bonji make use of this model of Wanscher's mask for ether narcosis which I employed in the bromethyl narcosis and in my experiments upon healthy persons, I was obliged to perform a sort of artificial respiration by means of a bell-jar going up and down in warm water and propelling 500 cc. of the air into the mask to and fro. The border of the mask was closed l)y a caoutchouc membrane, a T tube of glass was put through the membrane, one branch of the T tube communicating with the bell-jar and the other with Hempel's burette. The temperature of the air varied in these experiments between 20° and .31° C. The percentage of ether vapors differed very much, as to the phase of respiration in which the gas proof was taken,

Ether vapor, per ct.

whether the bag containing the fluid ether was shaken or not. The following table shows the percentage met with :

I II

6.4

8.8

9.0 7.2 8.6 6.4 7.4 7.0 3.8 4.8 3.6 2.6 4.4 5.2 5.4 5.8 6.2

6.4

Two persons moderately irritated to cough ; the third

very little. None of the three could breathe in this mixture ;

cutting sensation in the throat. Same as II ; contraction of the glottis. Irritation and cough ; cannot be breathed over again. Irrespirable. , Moderately irritating; two persons, "bearable." Irritating, cough. Irritating.

Well bearable, easily respirable. Bearable. Without molestation.

Well bearable. Well respirable.

Causing only little sensation.

Without much molestation, but with moderate irritation.

Moderately irritating ; when breathed several times becomes molesting soon.

I

II

III

IV

V

VI

VII

VIII

IX

X

XI

XII

XIII

XIV

XV

XVI

XVII

XVIII

XIX XX

Temp.

Vol.

per ct. of

ether

vapora.

Remarks.

III

IV

V

VI

VII

VIII

IX

X

XI

XII

XIII

XIV

XV

XVl

XVII

XVIII

31.5°C

19.2

20.4

19.5

19.8

19.8

20.4

20.8

20.7

21.4

21.8 21.4 31.0 31.0 26.0 26.0 22.5

23.7

22.5 22.3

34.0 6.2 6.6 6.4 6.8 7.0 28.6 29.4 23.2 31.2

27.8 28.4 14.8 15.7

7.4 22.8

4.0

11.6

8.6 18.4

Strongly shaken. Without shaking.

Strongly shaken.

Moderately shaken.

Ether abundantly poured in, moderately

shaken. Moderately shaken.

Without shaking.

Shaken.

Without shaking ; taken at the end of exhalation.

Moderately shaken ; taken at the end of an inhalation.

Without shaking, at the end of exhalation.

Shaken ; taken at the end of inhalation.

Hence the percentage of ether vapors to be breathed in a conscious state by the patient should not exceed 7 per cent, as even this concentration causes some in-itation and cough. The reflex movement of cough is an unmistakable evidence that the vapors of the anagsthetic have reached the patient's lungs in too strong a concentration, and that in this way the lungs will be injured. When the patient by inhaling weaker concentrations of ether vapors has been made insensible, to such a degree at least as to show no more reflex action, this very state will favor the injurious effect of the stronger concentrations upon the lungs. As long as the patient is conscious, the reflex contraction of the glottis prevents the " irrespirable " gas or vapors from entering in the finest air passages. The physician Avho administers the narcotic should now take care that the lungs of the narcotized patient will not be injured. In order to obtain complete narcosis as soon as possible, it has been recommended to shake the fluid ether in the bag of the mask, whereby the concentration of ether vapors is increased to the maximum. Thus the physician himself produces these injurious concentrations instead of avoiding them. I believe that it is only by a shorter duration of such dangerous inhalations thai the patients are prevented from suffering greater

The results of this table show that the percentage of ether vapors differed exceedingly ; the minimum was 4 per cent., the maxima were 34 per cent, and 31 per cent.; the latter exceeded the limit of 7 per cent., which could still be endured more than four times. It is impossible to regulate the quantity of ether vapor for the patient in exact proportions, and the estimation can only be made by analysis. Hy the kindness of Professor Fritsch, who tried the newest model of ^Wanscher's mask, recommended by Grossnuiuu in som£ gynajcological operations, I had an opportunity to get 6 proofs of the air breathed by the patients. However, before proceeding I must mention that this newest model with its circular border placed on a straight place cannot fit the patient's face so well as the former mask, especially when it is very thin. This apparent defect proves to be salutary to the patient because it prohibits the danger of deficiency of oxygen. But even with that mask it is quite impossible to obtain a mixture of air and ether to be relied upon. Tlie following analyses show that even when

January, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

11

the ether is only moderately shaken, the percentage of ether vapors very easily exceeds the irritating concentration of 7 per cent.

Ether vapor. Per ct.

CO, Per ct.

Per ct.

I

II III

IV

V

VI

16.8

14 6 6.8 4.6

10.8 12.8

3.0 1.6 1.2 1.2 1.8 0.9

12.4 14.6 17.8 17.2 16.8 14.4

After 2 minutes, moderately shaken.

" 4 " lastly something shaken.

" i minute, without shaking. The mask rests upon the face very loosely. Ether in the mask moderately shaken. Moderately shaken.

In a former paper* I have published the results obtained with Julliard's mask on surgical patients at Tiibiugen. This mask was either wrapped in a dry towel only, or it remained uncovered. The composition then found was much more gratifying than that met with in Wanscher's mask. Lately I have had an opportunity to get some analyses in the case of patients that were being narcotized with Julliard's mask, the capacity of which \va.s something greater than that used on a former occasion ; besides in all these cases the mask was wrapped in a wet towel, which is not so porous as a dry one. The following analyses show the effect of such modifications, which at first might appear quite unimportant :

The application of a wet towel produces a much higher percentage of ether vapors, in maximo 16.4 percent.; however, this high percentage decreases soon after the ether has been poured in. But generally the percentage of ether vapors was shortly after this process still greater than 7 per cent., which is certainly too great for a conscious person as well as for further inhalation. After some struggling the narcosis was complete sooner than in the former manner. The average of carbonic was somewhat greater and that of o.xygen less than I had found in my former researches on Julliard's mask without any towel. Nevertheless, even if a wet towel was wrapped I'ound Julliard's mask and it had been lying for a long time (for instance 25 minutes) on the patient's face, the volumes of oxygen and carbonic acid are far less to be feared than those met with after one minute's breathing in the narcosis by bromide of ethyl with Wanscher's mask. The air in the latter

•Ueb. (1. Zusammensetzung des bi'i der .Velheinaikose gt'iitineten Luftgemenges. Beitr. z. klin. Chir., X., p. 412.

has been rapidly e.xhausted if the mask had been lying a longer time on the patient's face. In my later experiments with Julliard's mask the inner chamber was considerably larger than that of the model formerly used. The rapidity with which the air in the inner chamber of Julliard's mask is restored by the respiration of the jiatieut depend,s upon the ratio existing between the volume of each inhalation (ca. .500 cc.) and that which the prominent part of the patient's head allows to remain in the inner chamber.

In order to determine this volume, the mask put under water was emptied into a measuring cylinder. The mask formerly used contained 1400 cc, the new one 2100 cc. The volume of the patient's head, surrounded by the border of the two models of the mask, was about the same. It was fixed in the following way : The border of the mask was marked on the skin of the face with an aniline pencil; then the pei-son dipped her face up to the pencil-mark into a vessel previously filled with water up to its very brim; the displaced water caught in a salver gave the volume of the covered part of tlie head, amounting to 780 cc. Consequently the air remaining in the former mask was 1400 cc. — 780cc. :=620 cc; in the newer mask we had 2100 cc— 780 cc. = 1320 cc. Every inhalation will restore 500 cc. in the inner chamber of the masks ; in the former mask the patient has restored |-|A cc. = SO per cent, of the air by each breath ; in the mask used latterly he restored but y'j/ij oc =:37.8 per cent. The wet towel has the effect of increasing still these 1320 cc.

With one single exception the percentage of carbonic acid in the CiHs.Br narcoses was never great enough to cause it to remain in the system. We know from the researches of Mr. G. Strasbui-g, made by means of tlie :«rotonometer in the laboratory of Prof. Pfliiger, that the carbonic acid in the venous blood of the heart has a partial pressure on an average 5.4 per cent, of tlie atmospheric pressure. The partial pressure of carbonic acid in the arterial blood is equal to only 2.8 per cent, of the atmosphere. lu the experiments on narcotized patients the percentage of CO. met with was, as a rule, far below 5.4 per cent., which means that the discharge of carbonic acid from the blood into the air of the lungs is continually going on, although it is somewhat protraded in proportion with the diminished fall of partial pressure. In the experiments without narcotics the tension of carbonic acid frequently exceeds 5.4 per cent, after having been breathed for half a minute in Wanscher's mask : when working only for one minute even 8.9 per cent. CO: was found in one experiment. It is very likely that when the anjpsthetic vapors are breathed the exhalation of carbonic acid is somewhat diminished in comparison with the normal state.

When .lulliard's mask has no towel wrapped round, the percentage of carbonic acid was only 1.7-1.2 ju^r cent. One per cent, of carbonic acid is not at all dangerous, for the workmen digging the Gotthard tunnel could work hard in air containing 1 per cent, of carbonic acid for several hours without injurious consequences.

Some authors assume the narcosis with Julliard's mask to be a narcosis of ether mixed with carbonic acid which could not be exhaled when using that mask. It is very easy to refute such an assertion by simply comparing the few minutes

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[No. 46.

which are necessary' to produce ether narcosis, and the time which would be required for an individual to produce the quantity of carbonic acid necessary to narcotize himself. The data for this simple calculation we find in a treatise of W. Miiller,* published iu 1858 under the direction of Prof. C. Ludwig. These experiments showed that carbonic acid administered in a proper dose acts as a narcotic poison, and that it is able to kill an animal in a comparatively short time. In order to produce narcosis in an animal it is necessary that the quantity of 00: which its body is to absorb amounts to the third part, and to produce death to half of its own volume (0.5C7-0.5S4). To calculate the time necessary for such an auto-intoxication, we must consider that a person lying quietly on the operating table will not produce more than 5 cc. COi per kilogram of bodily weight in one minute. The volume of a kilo is about a liter := 1000 cc. ; a kilo of man must therefore produce and retain the third part of 1000 cc. ; the time required for producing these 333 cc. would be

• f3=:GG,5 minutes. During the few minutes in which an

ether narcosis is complete it is impossible to accumulate a quantity of carbonic acid of any consequence, especially when the greater part of this gas has been exhaled, at least when using JuUiard's mask.

In Friedliinder and Herter's experiments,f the partial pressure of carbonic acid had to amount to at least 25 per^cent. of

•Beitrage zur Theorie dcr Respiration. Sitzgsber. d. Wiener Akademie, 1858. XXXIII. Bd., p. 99.

tUeber die Wirkung Jer Kohlensuureauf den thierischen Organismus von C. Friedliinder u. E. Ilerter. Zeitschrift fiir pliysiolog. Chemie, II., 99.

atmosphere in order to produce in 1-2 hours a state of narcosis, but still quite insufficient for surgical purposes. The percentage of carbonic acid met with in my experiments, even on healthy persons, was never high enough to produce the slightest narcosis. On the contrary, according to the explanations of Prof. Jlicscher,* the lower percentages inhaled, as 3-12 per cent, of CO:, strengthen the breathing movements ; 10-12 per cent, cause decided dyspnoea with deep inhalations and active exhalations. Therefore the percentage of carbonic acid met with in the air of the masks cannot at all be looked upon as having a paralyzing or narcotizing effect.

By comparing the results of my former analysis with those given in the preceding pages it is obvious that among the methods of etherization used at present, the method of Julliard without any towel must as yet be considered the most favorable. The volume of air, which the covered part of the patient's head allows to remain iu the inner chamber, should not exceed 600 cc.

The desirable end to be attained in narcotizing is to prepare and keep well-known proportions of ether vapor and air well regulated and constant; this is as important in the administering of anesthetics as the prescribed doses of medicine taken internally. Just as the maximal dose of morphia and other strong acting drugs is fixed in the German pharmacopoeia, so should the vapors of the volatile poisons, such as our anaesthetics (chloroform, ether, bromide of ethyl, etc.), not exceed a maximum percentage when they are administered.

• Bemerkungen zur Lehre von den Athembewegungen. Archiv

fiir Anat. u. Physiologie, Physiolog. Abtheilg., 1885, p. 368.

CATHETERIZATION OF THE URETERS IN THE MALE.

By James Brown, M. D., Assistant in Geiiito- Urinary Surgery. [Read before the John* Iloplcins Medical Society, December 17, 1894.]

Catheterism of the ureters, which has for some time past been so frequently resorted to in the female to determine the limits of disease in the upper urinary tract, will doubtless in the near future be as frequently practised in the male, since we hope to show you to-night it can now be done as readily in the latter as in the former. Since the method employed by us involves the use of the Nitze-Leiter cystoscope, a few words respecting the construction of this instrument may not be out of place.

In 1887 two instruments, constructed upon the same principle, made their appearance almost at the same time — one by Nitze, made by Ilartwig of Berlin, and one from Leiter of Vienna; these two gentlemen, who had been associated in the construction of the platinum loop C3'stoscope of 1879, having quarreled and separated. We will first describe the Leiter instrument. This has the shape of a short beaked sound. Two forms are made: one, known as the anterior, for the examination of the anterior surface, vertex, neck and sides of the bladder; and one for the base and posterior surface, called the posterior cystoscope. They are alike in outward form, and

differ merely iu the position of the light and the window. Each is composed of three parts — beak, shaft, and ocular end. The beak, which contains the small incandescent lamp, consists of a hollow metal hood with a long oval aperture covered in by a solid piece of rock crystal. This opening for the exit of the rays of light is placed on the anterior or posterior surface of the beak according to the kind of instrument. The hood can easily be screwed off and on to allow of access to the little lamp. The terminals of the lamp fit into two sockets, and are brought by means of insulated surfaces iu direct communication with the battery. In the concavity of the elbow of the anterior instrument is placed a window prism, to refract the rays of light from the object looked at on to the end of the telescope. In the posterior instrument the window is at the convexity of the elbow, and is simply covered in by a plane glass window, as the object observed is in a direct line with the observer's eye. The shaft has two compartments ; one serves for the reception of the telescope tube, and one, a very small tube, contains the insulated wire for connecting the lamp with the battery, the circuit being completed by the wall of the

January, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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instrument. The telescope tube, which extends from the ocular end to the elbow, is removable and can be used with either instrument. The ocular end has an arrangement for connecting the battery wires — a switch or key for opening and shutting the circuit, and a small knob on its rim which serves to indicate the position of the beak, and thus enables us to know what part of the bladder we have under examination. The only notable difference between the Leiter and Nitze cystoscopes is in the arrangement of the beak. In the Nitze instrument the tip of the beak is in the form of a hollow silver cap which is provided with a small oval aperture for the exit of the rays of light. The aperture is only covered in with the thin glass of the lamp, which is firmly cemented into the cap. Nitze claims that, owing to the great resistance of these small lamps when properly made, the pane of rock crystal is superfluous and has the disadvantage of obstructing the rays of light as well as of compelling us to use a smaller lamp.

In December, 1888, Dr. Brenner of Vienna had Leiter to place along the under surface of the shaft of the posterior cystoscope a small cauula, whereby the fluid in the bladder could be changed without removing the cystoscope. This canula, which is 2 mm. in diameter and incorporated with the shaft of tiie instrument, terminates just below the window -at the vesical end, while externally it is prolonged with a curve downwards separately from the shaft for a distance of several cm. Dr. Brenner afterwards attempted by passing a catheter through this canula to catheterize the ureters. He was successful in one female case, but failed in the male.

Others, it seems, made similar attempts. Thus Mr. E. Hurry Fenwick, in his excellent book on "The Electric Illumination of the Bladder and Urethra," in speaking of this instrument, gives his opinion upon it as follows : " I have had Brenner's pattern, and I believe Mr. Harrison has also used it; it has been returned by both of us as unpractical. As regards its adaptability for catheterization of the ureters of the female I have nothing against it. The orifices of the ureters will be rarely found, however, so patulous or so well placed as to allow of such a proceeding being accomplished by means of this instrument."

Now it is this same instrument we employ and find little or no difficulty in catheterizing the ureters in the male or female. So far we have not a single failure to record.

Respectiug the mode of its performance this is very simple. With the bladder containing if possible from loO to 200, or even as much as 300 cc. of fluid (for the amount that will cause the ureteral orifices to present most favorably varies in different cases), we pass the anterior cystoscope and take a complete survey of the bladder. This done, we replace it with the Brenner instrument, which is passed with its stylet in. The ureteral orifices are searched for ; these being found, the stylet is removed, catheter inserted and passed nearly to the inner opening of the canula, ureteral orifice is again found and the catheter is passed into it. To prevent kinking of the catheter and to guard against exerting undue traction upon the ureteral orifice, the cystoscope must be kept in line with the catheter as long as the latter is within the uretei*. Not infrequently we have found it of great advantage to give the catheter a slight curve at its i\\>. Such a curve enables us, by rotating

the part of the catheter external to the bladder between the thumb and finger, to vary the direction of its tip in the bladder. If a small wire, to which has previously been given the desired curve slightly exaggerated, be passed into and left in the catheter when not in use, it will be found that the curve thus given the tip of the catheter will be retained when the wire is withdrawn. This is always done before introducing the catheter into the canula. Not infrequently this little manceuvre has enabled us to overcome the faulty presentation of the ureteral orifice of which Jlr. Fenwick speaks.

In considering the advisability of an operation upon one of the kidneys aud the kind of operation that had best be performed, if any, one would be largely influenced in his decision by the conclusion he arrived at respecting the second kidney. As one would not think of performing nejihrectomy in bilateral suppurati ve or tubercular disease, so one would not remove a kidney, even though the seat of a neoplasm, if he was convinced either that it was the ouly kidney or of the incapacity of its fellow to carry on the necessary renal function. It has been generally recognized by surgeons that the best possible way to determine the condition of the second kidney would be to collect its secretion unmixed with that of its diseased companion. While in the female, thanks to the efforts of Pawlik, Simon, Kelly and others, catheterization of the ureters is generally recognized as the only means of reaching this end with any degree of certainty; in the male, prior to the introduction of Brenner's modification of the Nitze-Leiter cystoscope, such a procedure had been so commonly regarded as impracticable that alulost no effort had been made in this direction. The various methods proposed for compressing one ureter and thereby obtaining the unmixed secretion of the opposite side have not been reliable in their results.

The brief histories of the following three cases serve to illustrate both the value of catheterization of the ureters as a diagnostic means and the class of cases to which it is applicable.

Case 1. — Mr. T. was a patient in this hospital under the care of Dr. Osier aud was referred to us last May for catheterization of the ureters. lie was 19 years old and gave a history of frequent and at times severe paroxysms of pain iu the right loin, dating back four years. The first attack followed two days after falling against a bar, striking upon his right side. It continued for two days and then disappeared, leaving him free for a month. He then had a second attack of a similar character. The pain was sometimes behind, sometimes iu front, but never radiated downwards. As time went on the attacks became more aud more frequent and occasionally were attended by nauseti and vomiting. The urine was noticed ou one or two occasions to be bloody. In 1892 he contracted syphilis and gonorrha?a. On Jlay 12, 1894, both ureters were Ciitheterized and from 3 to 4 cc. of urine collecteil from each. The specimen from the right side was cloudy and the microscope showed it to contain numerous polyuuolear leucocytes. That from the left was also cloudy, but it became perfectly clear on the addition of a minute quantity of acetic acid. Microscopically it was found to bealmost normal, containing merely a few reil and white blood-cells, doubtless attributable to the catheter. He was transferred from the medical to the surgical side, and on

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May 23d the right kidney was removed by Dr. Halsted. A stone was found occupying one of the infundibula. After recovering from the operation, the urine, except for the presence of a few threads in the first glass, the remnant of the attack of gonorrhoea, was found to be perfectly normal.

Case 2 was a gentleman from St. Louis, brought to me, September 19, 1894, by Dr. Black, of that city. Mr. S., married, aet. 62. His history is as follows : In 1873, after lifting a heavy weight, he was seized with a severe pain in the left renal region. It came on suddenlj', and after lasting a day or two it gradually disappeared. It was seated just below the false ribs and radiated downwards to the testicle, penis and thigh. It was accompanied by nausea, vomiting and diarrhoea and a frequent desire to micturate, the urine being bloody. A few weeks subsequently he had a second attack, but on this occasion the pain was suddenly relieved, a small flattened calculus the size of a large pea being soon afterwards discharged. Subsequently he had two other attacks, one in 1875 and one in 1886. From this time on up to six months ago he had suffered from a constant dull pain in the left renal region and numbness of the corresponding thigh. At times he would experience sharp cutting pains in the left loin, but these would last only a few minutes. Violent or sudden movements he instinctively avoided. Up to five weeks ago he had been almost entirely free from pain, and says that he felt better than he ever had since his first attack. All along his'genei'al health has been good, his weight averaging 171 pounds.

Slahia pneseni'. — Complexion sallow, well nourished; weight 171 pounds, height 5 feet 11 inches, micturition* normal, suffers from a constant dull pain in the left loin, together with a feeling of numbness along the outer part of the left thigh. Appetite is moderately good, tongue clean and moist and bowels' regular, heart and lungs normal, arteries soft and corneae clear. Neither kidney is palpable. Pressure over left kidney elicits j^ain more marked behind than in front. Pressure along the corresponding ureter is also painful, especially at the point where it crosses the brim of the pelvis. No jiain on pressure over corresponding points of the opposite side, nor in the hypogastrium. Both testicles were found hard and atrophied, and over each there was a depressed scar. Meatus small, 20 F., while a stricture was found 3 inches long in the pendulous urethra, commencing one-half inch from the orifice. The meatus being cut up to 29 F., and the stricture not admitting of the passage of the cystoscope, gradual dilatation of the stricture was advised to be practised until a 29 F. sound could be passed into the bladder. A specimen of uriue which the patient had just passed previous to visit was of normal color, acid reaction, specific gravity 1021, and slightly opaque, a small amount of yellowish sediment being deposited on standing. It contained no sugar, but was highly albuminous. The microscope showed the sediment to consist of pus and epithelial cells, the latter of various shapes, together with hyaline and granular casts. In the early part of November Dr. Black returned with his patient, stating that the stricture had readily yielded to the dilatation and a 29 F. sound could be easily introduced. On the 21stof November, with the patient under chloroform, after having made several fruitless attempts without general anaesthesia, both ureters were readily cathe

terized and several cc. of urine obtained, the catheter being passed several inches up the canal. These specimens, together with a specimen of the mixed urine, were submitted for examination to Dr. Lewellys F. Barker, at the Anatomical Laboratory, who kindly wrote out the following report:

Report on specimens of urine sent by Dr. Brown, November 21, 1894, Mr. S.

The mixed urine is of a pale straw color, turbid, and deposits on standing a whitish, flocculent but not abundant sediment ; contains a small amount of albumen, no sugar, no bile ; yields no diazoreaction of Ehrlich ; on microscopic examination there are a few hyaline and finely granular casts, a number of pus corpuscles with polymorphous nuclei, a few small mononuclear cells, numerous squamous epithelial cells, and also red blood corpuscles to be seen. The specific gravity is 1012. The reaction of the urine is acid.

The urine from the left ureter also contains a few granular and hyaline casts, red blood corpuscles, epithelial cells and many pus corpuscles. It contains a small quantity of albumen, but very much more than an equal quantity of the specimen of mixed urine from the bladder. Octahedra of calcium oxalate are visible.

The urine from the right ureter. This urine contains only a faint trace of albumen, much less even than the specimen of urine from the bladder, and very much less than the urine from the left ureter. Microscopically, a few granular and hyaline casts are present, also a few red blood corpuscles and flat and tailed epithelial cells. Only an occasional leucocyte can be made out.

In view of the results of this examination, showing clearly the presence of chronic nephritis on the right side, a condition admittedly rendering any operation extremely hazardous, together with the fact that the patient, though engaged in active business, suffered no severe pain while using ordinary care, a policy of nou-interference with the left kidney, which was evidently the seat of stone, was advised.

Case 3. — Mr. H., ajt. 30, was seen in consultation with Dr. N. R. Gorter, of this city, in regard to the advisability of catheterizing the ureters. The abdomen was the seat of an enormous tumor, the swelling, whose limits could be easily defined, extending from the margin of the ribs on the right side to within a fiuger's-breadth of Poupart's ligaments, two fingers'-breadth below umbilictis iu the median line, five fingers'-breadth to the left and two fingers'-breadth above the umbilicus in the median line. Its borders were smooth and rounded. Ou deep expiration a muffled tympanitic note could be elicited between liver and tumor; dullness just below the margin of the ribs. Behind, the dullness extended to the spine; the area of tumor dullness was not materially changed by position". There had been no history of a sudden diminution of the swelling with the discharge of a large quantity of urine. The patient first noticed the swelling two years ago, since which time it has been gradually increasing in size. The uriue, which was of an acid reaction, contained a considerable amount of pus. It had been examined for tubercule bacilli, but with negative results. The family history was unimportant. The patient's general condition was poor, his limbs wasted, skin sallow, appetite poor, intellect dull; over the swelling the subcutaneous veins were considerably dilated.

On November 19th both ureters were easily catheterized under chloroform and several cc. of urine collected from each. The following is Dr. Barker's report of the examination of these specimens :

January, 1895.]

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Specimen No. 1, from ike left ureter {Mi. H.)— The urine is of a pale straw color and shows a slight whitish sediment. It contains albumen, though in very small quantity. Microscopically, a few leucocytes with polymorphous nuclei, and a few squamous epithelial cells are found to be present in the sediment. The epithelial cells look fresh, and five or six of them are seen occasionally together.

Specimen No. 2, from the right ureter. — The urine is yellowish in

color, turbid, and yields considerable sediment on standing. It gives a copious precipitate of coagulated albumen on boiling, though not enough to render the urine solid. Still, there are many times as much albumen in this specimen as in specimen No. 1. On microscopic examination tlie sediment is found to consist largely of pus cells with polymorphous nuclei. There are also many small mononuclear cells, epithelial cells and red blood corpuscles present.

PROCEEDINGS OF SOCIETIES,

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of December 17, 1894.

Dr. J. J. Abel in the Chair.

The Visual Field as a Factor in General Diagnosis.— -Dr. l>e

SCHWEINITZ.

After a description of the normal visual field for form and color ; the different characteristics of the results of perimetric measurements obtained when the patient is standing, sitting, or reclining; the phenomena of adaptation of the retina and the changes which varying degrees of illumination produce in the field of vision; the area between the point upon the perimetric semicircle at which a color is recognized as such, and the point where the object is first seen coming in from the periphery (Hering's zone), and the extent of the color field according to the size, saturation and intensity of the test object. Dr. de Schweinitz divided his subject into :

1. The value of the visual field as a means of differentiating between organic and so-called functional affections of the nervous system, particularly hysteria.

In this connection particular attention was directed to the phenomena of reversal of the color lines; the possibilities of the hysteric visual field, according to the studies of Dr. de Schweinitz and Dr. .John K. Mitchell, being

(«) Simple contraction of the color fields with unaffected form fields.

(J) Contraction of both form and color fields, tlie green field being relatively more contracted than the others.

{(■) Partial or complete reversal of the normal sequence in which the colors are appreciated, most commonly that variety in which the red field is greatest in extent. Under these circumstances the color fields may be normal in size, sometimes evQii wider than normal, or there may be an associated contraction of all the color fields.

{d) Unusual obscurations of the visual field, for example, in the form of hemianopsia, or greater contraction of the fields on one side than on the other, the greater contraction usually being found on the same side with the anesthesia.*

The practical application of these facts was illustrated by the clinical histories of cases and an exhibition of characteristic maps of the visual-field-alterations.

The value of this method of examination was urged in the study of the implantation of hysteria on an organic lesion, c.^.

• Consult : A Further Study of Hysterical Cases and their Fields

of Vision. By John K. Mitchell, M. D., and G. E. de Schweinitz, M. D. Journal of Nervous and Mental Diseases, January, 1894.

spastic paraplegia of organic origin and hysteria, or of toxic hysteria, e.g. hysterical lead paralysis, and was especially commended in the differential diagnosis between true hysteria and so-called hysterical insular sclerosis.*

Finally, the diagnostic import of disturbance of the colorsense in the difficult distinction between certain types of neurasthenic and hysteric patients was pointed out.f

2. The value of the visual field in the localization of intracranial lesions, with special reference to hemianopsia, and the representation of certain retinal areas in the cerebral cortex.

Dr. de Schweinitz rapidly sketched the visual pathway from the peripheral percipient elements in the retina to the cortex of the occipital lobe, and described the results upon the visual field of lesions variously placed in its course, especially referring to the different varieties of hemianopsia and the value of the hemiopic pupillary inaction sign as a differential diagnostic point between lesions anterior and posterior to the primary optic centres.

Hemianopsia of the homonymous variety without pupillary defects, and the localizing value of this phenomenon associated with other symptoms, for example, aphasia, hemiplegia, hemianaisthesia, etc., was briefly discussed, the following features connected with hemianopsia being especially dwelt upon:

(1) Certain hemianopsias indicate that there is a correlation between the parts of the retina and the occipital lobe, and that the removal or destruction of certain portions of the occipital lobe result in loss of certain portions of the visual field.

(2) The probable existence of a centre for the macula lutea in the occipital lobe was described, and the description illustrated by a case of doable hemianopsia studied by the author in connection with Dr. Dunn, of West Chester, in which a small central portion of the field of vision surrounding the fixing point remained unaffected.

(3) It was pointed out that the facts just related and illustrated with diagrams indicated that a lesion of this macular centre would manifest itself in the form of a central scotoma, and the author urged a more careful examination of visual fields, and more thoughtful consideration of certain scotomas for which no real cause could be found in the optic nerve itself.

(4) The sense of sight being composed of color, form and light, it was pointed out how the evidence indicated that these

•Consult Buxzard : British Medical Journal, Octol>er 7, 1S93.

f Consult: Zur Kentniss der Augensymptome bei Neurosen, von L. v. Frankl-Hockwart and Alfred Topolanski. Beitragetur Augenheilknnde, XI. Heft 1S93 ; and Mitchell and de Scbweinits, U>c. fit.

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centres were situated in the cortex of the occipital lobe, or j)erhaps the posterior end of the occipito-teniporal convolution, and how a I'elative hemianopsia, that is one, for example, in which the light-sense was preserved, but either the form-sense or the color-sense was wanting, could ouly result from a cortical lesion.

The subject of hemiachromatopsia was illustrated by the description of two cases clinically observed, probably the result of disease of the occipital cortex affecting ouly the centre for color; although the case of Samelsohn was referred to, in which a glioma-sarcoma pressing upon the optic tract, optic thalamus and corpora quadrigemiua was associated with this symptom.

(5) The lecturer called attention to the fact that hemianopsia, although usually a direct symptom, may sometimes be an indirect sign of disease, as the result of what the Germans called fernwirkung, which Mr. Swauzy has translated into "distiint symptom."

(6) Finally, it was pointed out that hemianopsia may accurately localize a lesion within the cranium when that lesion is itself insignificant and unimportant, the main and essentiiil disease being quiescent. This point was illustrated by the description of a case of large tumor occupying the second and third temporal, and encroaching upon the fourth convolution, which gave no localizing sign of its presence, while a lesion in the cuneal region (a small cyst) was inferred from the study of the case, chiefly the visual phenomena, and laid bare by the surgeon's trephine.*

Catheterization of the Ureters in the Male.— Db. Brown. [See pa<;e 12.]

Dr. Welch. — I should like to have been able to discuss Dr. de Schweinitz's paper. I can only say that I have been fascinated by it. It will make a good many of us go home and read about this subject, and that is a sign of a good paper.

A word with reference to Dr. Brown's important communication. It is important as illustrating the practical value of the application of this procedure. I recall a case in New York in which I made an autopsy — a case in which a serious mistake was made which would have been avoided had this method of determining the presence or absence of the kidneys been used. The patient was a vigorous young German girl who had atresia of the vagina. An effort had been made to reach the uterus by cutting through this closed vagina. They opened the canal up to a certain distance and then abandoned the attempt. Then they found a mythical tumor on the left side. Various diagnoses were made as to the nature of that tumor. The prevailing opinion was that it was connected with the left ovary, and, indeed, that was tlic opinion of one of the most distinguisiied surgeons of New York. Dr. Lusk, who saw the case, made a correct diagnosis of movable kidney. The case was operated upon before the class at Bellevue Hospital and the kidney removed. Thert was nothing the matter witli the kidney other than that it was movable. The kidney was brought at once over to my laboratory. It was a very large.

•The case iB fully ilescribeil by Dr. H. (". Wood, under whose care the patient was, in the University Medical Magazine, Volume 1, page 383.

succulent kidney. I happened to have made an autopsy a few days before on a man who had only one kidney, and the appearance of the kidney was impressed upon my mind; the thick cortex and the beautiful markings of the ' cortex, the normal structure greatly exaggerated but perfectly healthy. This kidney looked so much like the one just mentioned that I surmised at once that it was the only kidney the patient had and suggested that, to the horror of the surgeon. The patient lived eleven or thirteen days, voiding no urine. For seven or eight days there were no symptoms to occasion alarm. During the last forty-eight hours urajmic symptoms manifested themselves and the patient died. The autopsy showed that the patient had but one kidney and that had been removed by the surgeon. The operator was very frank in bringing the case to the notice of the medical profession and published it in all its details in one of the medical journals in 1881 or 1882. He discussed at that time all the methods that his ingenuity could suggest as to the possibility of recognizing the presence of a second kidney. I do not know that he at that time even thought of the possibility of catheterizing the ureter. I remember that he discussed the advisability of jiressing on the ureter on one side and determining in that way whether the other was present. This is simply one case which shows that there is a practical use for this procedure.

NOTES ON NEW BOOKS.

Napoleone ; una Pagina Storico-Psicologica del Genio. By Dr. A.

Tkbaldi, Professor of Psychiatry, University of Padua. (Padova,

1895.)

In this liistorico-psychological study of Napoleon, Dr. Tebaldi has given the medical profession a most valuable and interesting contribution to Napoleonic literature. The material for the study has been mainly drawn from the previous works of Thiers, Taine, La Bourienne, Yung, Metternich, Levy, Baron de Meneval, Autommarchi, Lombroso, and the correspondence of Napoleon.

The point of view of the work is stated in the preface, and closely adhered to in the body of the te-\t : " It is not my purpose to pass judgment on the leader, the statesman or the legislator (for which indeed I feel myself incompetent), but I shall seek only the man, having as foundation for my study the examination of his physical development and inherited tendencies to bear out a psychological law."

The brochure is diviiled into five parts: Napoleon's Ancestry, Physical Development, Intellect, Personality, and Character, and each theme is treated lucidly and impartially. After these co^mes a reiumi: of the conclusions reached, which is in some measure the most interesting part of this instructive book.

In the chapter on Physical Development, the question as to Napoleon's being an epileptic is fully discussed, and the writer decides that " the physical examination of Napoleon shows him to be an undoubtedly neurotic individual, not improbably of an epileptic character, and with a constitution which rendered him liable to degenerative diseases, foreshadowing a brief course of life, owing to his hereditary predisposition to cancer."

The study on Intellect emphasizes strongly Napoleon's marvelous rapidity of conceptidu and execution, his absolutely independent judgment, his wonderful power of passing immediately from one difficult subject to another, and gives his own explanation of this ability, when, having compared his brain to a combination of little chests, he says, "When I leave one subject 1 close that box, to open another if anything else has to be considered." It mentions

January, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

17

his apparently endless endurance, his power of protracted concentration of thought, and while frankly admitting his ignorance of arts and sciences, adds : " In comparison with the warrior, it is true that the man of culture and the legislator dwindles, but it seems to me that some have tried to belittle him too much. It would be absurd to regard Napoleon as a litterateur or a scientist, but to my mind it is incorrect to think that his culture was unequal to the qualities of a great leader."

In treating of Napoleon's Personality full justice is done to his excellence as son and brother, to his frequent generosity to his personal enemies, to his correct views of law and order (for others), to his affection for Josephine ; while his impatience of personal restraint, his intense egotism, his absolutely elastic conscience, and his unapproachability as an equal, are frankly admitted.

The tracing by the writer of the change in his cliaracter from the First Consul, "pensive, polite, prudent in speech and serious in action "; to General, "enthusiastic, ardent, with ' La Pairie ' on his lips and love in his heart"; and then to Emperor, a man "grown stouter in body and stiffer in mind, cold, proud, preoccupied with ceremonies and etiquette," is excellent.

Some of the salient points in the study on Character are his firmness of will and promptness of action, which are shown to have involved him in troubles more than once when a subordinate officer. His intense capability for anger, of which Thiers says that the flashes thereof " when real lasted but a second, when feigned, as long as needful," and above all, his power to inspire his soldiers with such intense love for himself that as one man they were ready to do and dare whatever he ordered, are forcibly brought out. His alleged superstition is treated as a " pose " whereby he was enabled to mould more to his liking his subjects' opinions with regard to his own destiny.

The analysis of the entire subject throughout the brochure is keen and unprejudiced, the style markedly clear and direct, the author always going straight to the point, and the amount of information and compact reasoning he has succeeded in condensing into the one hundred and sixty pages of the work is unusual. G. H. S.

A Monograph on Diseases of the Breast. By W. Roger Williams. {John Bale & Sons, 87 Orcat Litchfield St., London. 1894.)

Mr. Williams, very wisely we think, begins his work on diseases of the breast with a short but clear and concise account of the ontogeny and phylogeny of the mammary gland. The history of the development of the gland in the human being and in the lower mammalia is not only interesting, but gives much aid in understanding tlie various congenital defects and anomalies in the gland. The second chapter on the morphology of the gland and its secretory functions is generally satisfactory. The author draws attention in this chapter to the common error of supposing that the gland is circular ; he points out that it really has a tricuspid form, and that in the ordinary operation for the removal of the breast, the apices of the cusps are nearly always left behind to orignate anew the disease.

The third and fourth chapters deal with mammary variations from defect, and with supernumerary mammary structures ; the account of these latter is especially full and clear. Chapter five deals with the various forms of mammary hypertrophy ; the subject is well classified and ably handled. The chapter on histology and neoplastic pathogeny is very satisfactory. One point is noticeable in reading this chapter, and this is that our knowledge of tlie nerve supply of the breast could be considerably extended.

Chapter seven is a statistical one, dealing with the varieties of mammary neoplasms and their relative frequency. The chapter brings out the interesting fact that whilst the relative liability of the female breast to malignant disease is above the average, its liability to non-malignant neoplasms is considerably below the average.

In the chapter on the parasitic theory of cancer wc are glad to see

that the author discountenances protozoa as a cause of the disease. Most of the prominent pathologists, we think, are now inclined to regai'd the so-called protozoa as the products of endogenous cell formation. The author states his belief in the non-contagiousness of cancer in this chapter, regarding the apparent cases as merely remarkable coincidences. Chapters eleven to seventeen are taken up with the study of mammary cancer, the term cancer being restricted to neoplasms of epithelial origin.

The chapters on the general morphology and general pathology of the disease are excellent.

The chapter on the operative treatment is not so satisfactory. While the author recommends a fairly radical operation, we cannot agree with him that the mere skinning off the fascia of the great pectoral muscle is sufficient in most cases. Whilst the well known researches of Heidenhain and others have shown that in most cases the progress of the disease is arrested for some time by the pectoral fascia, yet actual results have shown that entire removal of at least the sternal part of the pectoralis major has resulted more favorably to the patient.

In the chapter on the pathology of breast cancer we are glad to see that Mr. Williams has separated so sharply the intracanalicular fibroma, a non-malignant disease, from the tubular form of cancer, which is malignant ; the two are usually confounded.

In the chapter on cancer of the male breast one is struck with the fact that the disease is much more frequent than one would suppose from reading most text-books. According to the author, carcinoma occurs in the male breast once where it occurs in the female 99 times.

Chapters 17 to 23 take up sarcoma and non-malignant tumors. These chapters show the same care and systematic arrangement as those on cancer.

The closing chapters on mastitis, tubercle and syphilis of the breast are highly satisfactory.

Taking the work as a whole, one is impressed with the extremely systematic manner in which it has been arranged. The language is clear and forcible, and the references are profuse and culled from the best sources. The book is well printed upon good paper.

We would recommend Mr. Williams' work to any one who wishes to acquire a clear understanding of diseases of the breast without wasting unnecessary time on superfluous theories.

BOOKS RECEIVED.

A Manual of Organic Materia Medica and Pharmacogniyty . An introduction to the study of the vegetable kingdom and the vegetable and animal drugs, etc. By L. E. Sayre. With 543 illustrations. 1895. Svo, 555 pages. P. Blakiston, Son & Co., Philadelphia.

On Cfwrea and Choreiform Affettions. By William Osier, >I. D. Svo. 1894. 125 pages. P. Blakiston, Son & Co., Philadelphia.

Saint Thomas's Hospital Reports. Edited by Dr. T. D. Acland and Mr. B.Pitts. New Series, vol. xxii. Svo. 1«H. J. e<: A.Churchill, London.

Rcal-Encych>padit der gesammten Heilkunde. Medicinisch-Cbirnrgisches Ilandwdrterbuch fiir praktische .\ertze. By Prof. Dr. Albert Eulenberg. Third thoroughly revised edition. Vol. iv. Brenzcatechin — Cnicin. 1S94. Urban & Schwarrenberg, Vienna and Leipsic.

Tranmclions of thi Congre^ of American Physicians and Surgeons. Third Triennial Session held at Washington, D. C, May 29, SO, 31, June 1, 1894. Published by the Congress. New Haven, Conn.

Trataitx d' Kkcirothcrapii Oynecolngigtie. Archives semestrielles d'electrotherapie cynecologiqne. By G. Apostoli. 1S94. Societt' d'Editions Scientitiques, Paris.

Aiiatomt/ and Art. The .\nnual .\ddress read before the Philosophical Society of Washington, December 12, 1894. By Robert Fletcher, M. D. ISOo. Judd & Detweiler, Washington.

18

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 46.

On General Paralysis, with a critical digest. By W. Julius Mickle, iM.D., F. R. C. P. (LunJon), Grove Hall Asylum, London. Reprint from Brain. 1S94. Macmillan & Co., London.

Practical Suggestions respecting the Ventilation of Buildings. By John H. Kellogg, M. D. Reprinted from the 19th Annual Report of the Michigan State Board of Hfalth. 1891. Lansing, Mich.

The Relation of Static Disturbances of the Abdominal Viscera to Hie Displacements of the Pelvic Organs. By John H. Kellogg, M. D. Reprinted from the Proceedings of the International Periodica! Congress of Gynecology and Obstetrics. 1894. Modern Medicine Publishing Company, Battle Creek, Mich.

T/ie Pain Path at the Utica SVite Hospital. By \Vm. Paul Gerhard, C. E. 1894. Republished from the Engineering Record. Privately printed by the Author. New York.

Traumatic Paralysis of the Abducens Nerte. By Dr. 0. Purtscher, of Klangenfurt. Translated by Dr. Harry Friedenwald, of Baltimore. Reprinted from the Archives of Ophthalmology. 1894.

Traumatic Paralysis of the Abducens Nerve. By Dr. Harry Friedenwald, of Baltimore. Reprinted from the Archives of Ophthalmology. 1894.

The Effects of Various Metals on the Growth of Certain Bacteria. Read before the Association of American Physicians, May 30, 1894. By Meade Bolton, M. D., Johns Hopkins University. Reprinted from the International Medical Magazine for December, 1894.

Annali dell' latituto d'Igieni Sperimentale della R. Universitd di Roma. Edited by Prof. Angelo Celli. Vol. iv.. Fasciculi 2 and 3. 1894. Ermanus Loescher & Co., Rome.

Bulletino della Reale Accademia Medica di Roma. Edited by Prof. G. Colasanti and Prof. G. Sergi. 1894. Tipografia Innocenzo Artero Rome. '.

CLIMATOLOGY AXD PUBLIC HEALTH.

The following announcement is made by the U. S. Weather Bureau :

Washington, D. C, January 2, 1895.

The interest manifested by every class of people in the subject of climate and its influence on health and disease has determined the Honorable the Secretary of Agriculture, through the medium of the Weather Bureau, to umlertake the systematic investigation of the subject.

It is hoped to make the proposed investigation of interest and value to all, but especially to the meilical and sanitary professions, and to the large number of persons who seek, by visitation of health resorts and change of climate, either to restore liealth or prolong lives incurably affected or to ward off threatened disease.

The study of the climates of the country in connection with the indigenous diseases shoulil be of material service to every community, in showing to what degree local climatic peculiarities may favor or combat the development of the different diseases, and by 8U'_'gesting, in many instances, sui)plementary sanitary i)recautions ; also by indicating to what parts of the country invalids and healthseekers may be sent to find climatic surroundings best adapted to the alleviation or cure of their particular cases.

The hearty co-operation of the various boards of health, public sanitary authorities, sanitary associations and societies, and of physicians who may feel an interest in the work, is asked to achieve and perfect the aims of this investigation.

No compensation can be offered for this co-operation other than to send, free of cost, the puVilications of the Bureau bearing upon the climatology and its relation to health and disease, to all those who aid in the work.

Co-operation will consist in sending to this office reports of vital statistics from the various localities. That these reports may be of value, it is evident to all that they should be accurate and complete, anrl be rendered promptly anr! regularly. Blank forms of reports have been prepared so as to occasion as little trouble and labor as p iBsible on the part of the reporter, and will be furnished by the Bureau on application.

At the very beginning of the iovestigation it is not possible to

outline precisely the channels through which the results obtained will be made public, but it is hoped to publisli soon a periodical devoted to climatology and its relations to health and disease. The publication will probably resemble in size and general appearance the present Monthly Weather Review, the subject-matter being, of course, different. More detailed information will be furnished on application.

Mark W. Harrington, Chief of Bureau.

THE JOHNS HOPKINS HOSPITAL REPORTS.

VOLUME IV.

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL.

Vol. VI.- No. 47.

BALTIMORE, FEBRUARY, 1895.

+++

Contents

By

Gonorrhceal Pyelitis and Pyo-Ureter cured by Irrigation Howard A. Kelly, M. D.,

Primary Diphtheria of the Lips and Gums. By Simon Flex NER, M. D., and Herbert D. Pease, M. B.,

A New Apparatus for Applying Plaster Jackets, with a Brief Review of the Methods hitherto used. By R. Tunstall Taylor, M. D.,

TJretero-Cystostomy performed seven weeks after Vaginal Hysterectomy. By Howard A. Kelly, M. D., . - .

Two Successful Cataract Operations on a Dog. By Robert L. Randolph, M.D.,

- 22

28

Sigmoido-Proctostomy. By Howard A. Kelly, M. D.,

Proceedings of Societies :

The Hospital Medical Society,

Exhibition of Surgical Cases [Dr. Finney] ; — Acute Pancreatitis, Disseminated Fat Necrosis, Parapancreatic Abscess [Dr. Thayer]; — Myxocdema and Exophthalmic Goitre in Sisters [Dr. Oppeniieimer].

Notes on New Books,

Books Received,

PAGE.

- 30

32

GONORRHCEAL PYELITIS AND PYO-URETER CURED BY IRRIGATION.

By Howard A. Kelly, M. D. [Read before the Johns Hopkins Medical Society.]

In the case of which I shall give a detailed account, in tliis article, I have been able to realize one of tlie important benefits attainable by my new method of examining the female bladder and ureters (v. Johns Hopkins Hospital Bulletin, Nov. 1893, and Amer. Jour. Med. Sciences, Jan. 18'J4).

The patient came to me with an extensive accumulation of pus in the left ureter, extending up into the pelvis of the kidney. This was caused by a stricture of the vesical end of the ureter with a dilatation above it, associated with a gonorrhoea! infection.

I treated the stricture by dilating it with a series of ureteral catheters, increasing in diameter from 2 mm. up to 5 mm.

After drawing off the purulent fluid, the ureter and pelvis of the kidney were washed out w'ith medicated solutions. The calibre of the stricture was enlarged, reducing the quantity of the accumulation above it from 150 to 100 cc. The purulent character of the secretion was removed and all trace of gonococci disappeared.

My patient was sent to me by Dr. Stark, of Cincinnati, 0. She was a married woman, slight, somewhat haggard looking, thirty-one years of age. She had one child four years ago, without any special difticulty, her only jireguanoy in six years

of married life. The menses were regular and without pain. Headaches were rare ; the appetite was good and the bowels regular.

She was feeling depressed and had lost weight, and complained of a severe pain on urinating, persisting for alK>ut a half-hour afterwards. She had also a sense of pressure in the bladder, and was obliged to urinate every two to three hours. The trouble was especially distressing at night. She had no acute pain, but an aching in the limbs, and lower abdominal discomfort. The appearance of the urine as noticed by her varied greatly, being clear at times, and at other times containing much yellow sediment.

^ly examination showed that the vaginal outlet was torn back near the anus, but was well lifted up under the symphysis by an intact levator aui. The cervix was in the axis of the vagina somewhat low down, showing a slight tear, and the uterus was in retroflexion. There was no marked tenderness of the uterus, the left ovary was displaced downward .ind tender on pressure, but not adherent. On e-xamiuiiig the anterior wall of the vagina no special tenderness was developed on palpating the bladder.

The ureters were then palpated per ivffitiniii. and the left

20

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 47.

distinct!}' felt to be harder than normal and somewhat thickened, but without marived tenderness. The left ureter also showed a displacement towards the pelvic floor.

The bladder was examined under atmospheric dilatation with the patient in the knee-chest position, through the No. 10 speculum. There were abundant evidences of a patchy, mild grade of cystitis. The field opposite the ureter, the posterior pole, and its surrounding area were of a mottled red, injected appearance, the vessels being entirely obscured; this injection increased towards the vault, where no normal background appeared. The vault over an aresi 4x5 cm. was covered by fine grauules, averaging one or two to the square millimeter, most marked on the right side. The tips of each of these granules reflected the light and gave the surface a bright studded appearance. On the left side in places the surface presented a superficial worm-eaten appearance. On the right lateral wall 21 cm. behind the ureteral orifice was a ridge 2 mm. in height, extending downwards to the base of the bladder. Near the right ureteral orifice was an area of intense congestion presenting an cedematous appearance, surrounding the ureter, whose orifice could only be located by a little pallor in the form of a crescent.

Posterior to the right ureter was a superficial ulcer 2x3 mm., with a narrow red border and a yellow centre.

The left ureteral orifice was situated on a truncate cone about 6 mm. in diameter at its base and 2 mm. at thfe top. It was slightly edematous, and on the urethral side broken up by a number of irregular papillary eminences. The site of the ureteral orifice at the first examination was marked by a yellow spot of pus. On introducing a searcher into the opening of the orifice, a thin stream of pus escaped and ran down over the bladder wall.

Upon leaving the ureteral catheter in the left ureter for three minutes, 11 cc. of dark fluid escaped, followed by G cc of fluid containing pus. In the twenty-four hours following the examination the patient passed 700 cc. of urine.

During the whole time the patient was under treatment, lasting from the 1st of March to the 4th of August, 1894, T catheterized her left ureter about 120 times in all.' The first three weeks of her stay were passed in vain endeavors on my part to get the ureteral catheter well into the ureter. Three difficulties prevented this at first. In the first place the irregular papillary prominences on the left side in the neighborhood of the ureteral oi'ifices obscured it and made it impossible to locate it with certainty, after the first examiluition in which the pus was seen in it as stated; in the second place the location of the orifice was unusual, lying extremely displaced to the left; in the third place there was .1 spiral stricture of the intravesical portion of the ureter, and it was necessary for me to learn the twist of the stricture before I could pass the catheter at once at every sitting. I cannot say too much in praise of the tenacity and pluck of my patient throughout the first part of the treatment, which was very trying to me and more so to her, as I was entirely uncertain as to the ultimate outcome and could give no positive assurances.

After almost daily efforts for three weeks the stricture was finally cleared by an accidental turn of the hand ; this was

more readily repeated on two or three occasions subsequently, but not without discouraging failures, when the ureteral orifice was definitely located on the side of the pyramid in relation to certain papilhe and the direction of the stricture was ascertained so that the catheter could after this be passed with ease. After pushing the catheter through the stricture it entered about 8 cm.; a distinct sense of resistance was felt in attempting to withdraw it, due to the bite of the stricture, which was about 1} cm. long. So long as the point of the catheter went no further than the stricture no urine escaped, but i,is soon as the catheter cleared the stricture, pale urine began to pour out in a steady stream, continuing until 130 cc. was collected in three minutes. Sometimes the first urine drawn off would be of a reddish-brown color, followed by a whitish sediment, and at the last a thick, creamy fluid like pure pus.

The fact that so much urine escaped in so short a time proved conclusively that the case was one of extreme dilatation of the left urinary channels above the stricture, for the normal rate of secretion is but one cubic centimeter a minute for both ureters together, or one and a half in three minutes for one ureter. The discharge of 130 cc. would be twenty-nine times the normal amount, or at the rate of about twenty-two gallons a day for both sides together. Thus by a reduclio ad absurlum proving that the case was a dilated pyo-ureter and pyelitis.

After drawing off all the fluid, a piece of fine rubber tubing with a funnel at the end was connected with the catheter, and a saturated boric acid solution, two-thirds of the quantity of fluid taken out, was run into the ureter by gravity, by simply elevating the funnel filled with the fluid from 40-60 cm. above the level of the bladder. Care was taken to have the tubes full of fluid so as to inject no air. The patient during these manipulations was in the knee-breast position. She took no ana'Sthesia, as the treatment was not painful. After introducing the catheter into the ureter she raised her body on her hands so as to make it horizontal, to better dispose the fluid to run out. When the injection was given she again let her chest down to the table, and rose again when it was to flow out. I found that I could wash the urinary tract repeatedly with the same fluid if I desired it, by holding the funnel high when the fluid should run in, and by holding it an equal distance below the level of the table when all the fluid would well back into it again, often bringing too a considerable amount of shreddy white debris from the ureter.

After the first few treatments of this kind she began to experience relief from her pain and was much less frequently disturbed at night.

An examination of the urine made by Dr. Barker in the pathological laboratory of the Johns Hopkins Hospital states that it was of a straw color, neutral in' reaction, and contsiining an abundant muco-purulent, stringy, tenacious sediment. There was a small amount of albumen, but no sugar and no casts. The specific gravity was 1032. There were a great many polynuclear leucocytes, crowds of pus cells, and many diplococci, nearly all of which were within the protoplasm of the leucocytes. Octahedraof calcium oxalate were found, and a few cylindroids. There were no tubercle bacilli, and no other bacteria than diplococci, which were of the typical

February, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

21

appearance of gonococci, and much smaller than staphylococci or streptococci.

The bladder walls were treated by occasional applications of a five per cent, solution of nitrate of silver, applied directly to the affected ai-eas on absorbent cotton with an applicator, and by daily irrigations of a bichloride solution 1-150,000.

My first effort in the treatment of the case was to secure a continuous drainage of the ureter, avoiding all accumulation above the stricture, hoping by this plan to induce a contraction of the ureteral walls. To do this I made a short ureteral catheter 2 mm. in diameter and 5 cm. long, with a little shoulder about 2 cm. back of the inner end to keep it from slipping out of the ureter after introduction, and with a flange 6 mm. in diameter at the lower end to keep it from slipping altogether into the ureter. I placed this in the ureter by means of a searcher used as a mandarin to conduct it through the stricture. I found, however, that its presence gave so much pain and increased the irritation of the bladder, after being in place for twelve hours, that I was obliged to abandon its fui-ther use, although it acted well mechanically.

My next plan, which was successful in curing the case, was to have ureteral catheters made in four sizes, increasing from the smallest, 2 mm., to the largest, which was 5 mm. in diameter. The points of the catheters were blunt and straighter than the ureteral catheters ordinai'ily used, on one side almost on a line with the shaft.

In the course of two months the ureter was dilated sufficiently to permit the introduction of the largest catheter, from the end of which the accumulated urine would drop in a large free stream. With the catheters I began systematically to wash out the ureter and kidney with a bichloride of mercury solution 1-150,000, constantly increasing the strength until 1-16,000 was used. The treatment with the bichloride was interrupted several times for the injection of a one per cent, nitrate of silver solution, and once for a weak iodine solution. Towards the end while using the larger catheters I was obliged some six times to suspend the treatment for from two to three days on account of a chill followed by elevation of temperature from 102°-104° F. with a quickened pulse (120), headache, nausea and pain in the left inguinal region and legs. She was flushed and restless and suffered from sleeplessness at these times.

The result of ihe bichloride washings was a comjdete disappearance of pus cells, leucocytes and gonococci from the urine, aud the reduction of the size of the distended ureteral tract from one holding regularly from 140-150 cc. down to 90 or 100 cc. The bladder assumed a normal appearance and she became able to sleep through the niglit without rising once. She gained 20 pounds in weight and resumed the rosy appearance of perfect health, with a corresponding remarkable imjjrovemeut in spirits.

The treatments were discontinued August 8, 1894, and I saw her again in January, 1895, and then on two occasions catheterized the ureter, drawing off only 90 and 100 cc. of clear urine from the left ureter without a trace of pus or cocci. She has therefore recovered from the infection, but still has a stricture of the ureter of larger calibre with a lax distended ureter above it.

I made several attempts to empty the ureter by massage, with considerable success at first, but the procedure became so painful that it had to be stopped. Just before the massage the bladder was emptied by catheter, and immediately after treatment as much as 90 cc. of urine were secured.

I demonstrated the success of the massage and mapped out the exact positions in which* to make pressure, by placing a catheter in the ureter with the patient in the dorsal position, with a rubber tube attached to its outer end, a straight glass tube 50 cm. long attached at the other end of the rubber tubing filled at once with urine to the level of the ureter aud acted as a manometer. Respiratory movements were traced by its rhythmical ascent aud fall. On making pressure over the ureter through the abdominal wall the column ascended in the vertical glass, and by increasing the pressure could be forced out over the top. If the pressure was made to one side there was only a slight effect or none at all. By marking all the points of effective pressure on the skin and afterwards connecting the markings, the course of the ureter was accurately mapped out.

The following novel and important points are demonstrated by this case :

1. Stricture of the lower extremity of the ureter can be diagnosed without any operation, by using the cystoscope with the bladder dilated with air by posture.

2. Stricture of the ureter can be improved by gradual dilatation by a series of hollow bougies (catheters) and without a kolpo-ureterotomy. (See Kelly, Johns Hopkins Gynecological Report, No. 1.)

3. A stricture through which a No. 5 (5 mm. diam.) bougie is passed every day for several weeks will still hold back the urine if the walls of the ureter above have lost their contractility.

4. Pyo-ureterand hydro-ureter can be diagnosed by drawing off in a few minutes such a quantity of fluid as it is manifestly impossible for the kidney to secrete in that amount of time,

5. Pyo-ureter and pyelitis can be cured by washing out the ureter and pelvis without any preliminary cutting operation to disclose the ureteral orifice (as in kolpo-uretero-cystotomy, Bozemau).

6. \'ariations in pressure in the column of fluid in a distended ureter can be demonstrated by a manometer attached to the ureteral catheter.

7. In this way the course of the ureter can be mapped out

The Johns Hopkins Hospital Reports, Volume IV, No. 6 (Report in Surgery II), Now Ready.

Contents: The Uesilts of Operations for the Cure of Cancer of the Breast, performed at the Johns Hopkins

Hospital from June, 1889, to January, 1894.

Hv WiM. S. IIALSTICI), M. I)., Professor of Surgery, Johns Hopkitu UnUvrsilij, and Surgeon-in-Chief lo t/it Johns HoptiH* HoipUtd, Price, $1.00. . Address Thk Johks Hopkiss Pebss, Baltimork, Md.

22

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 47.

PRIMARY DIPHTHERIA OF THE LIPS AND GUMS.

By Simon Flexnek, M. D., Associate in Pathology, and Herbekt D. Pease, M. B., Fellow in Pathology. [From the Pathological Laboratory of the Johns Hopkins University and Hospital.}

The bacillus cliphtheri* has by the more receut studies of the subject been showu to be present sometimes in pathological processes which do not present the characteristic features of diphtheria. Among these may be mentioned follicular or lacunar tonsillitis, fibrinous rhinitis and otitis media.* It has also been found, although associated as a rule with other micro-organisms, in infected wounds of the surface in persons who were not themselves suffering from diphtheria and Avho had not been exposed to the dise'ase.f And in a comparatively few instances virulent forms of this organism have been found upon the mucous membrane of the healthy throat. J

The significance of those cases in which the bacillus diphtheriae is found in the body in the absence of the symptoms which usually accompany its presence, consists not so much in the danger threatening the host, as in the possibility of danger to other individuals, more susceptible perhaps, with whom such an ipfected person may come into contact. It is a growing belief that in just those cases in which the usual phenomena of diphtheria are wanting it is important to determine by bacteriological means the presence or absence of the Loeffler bacillus, for now, since attention has been directed'to these atypical forms of diphtheria, reports of cases in which from a slight and unsuspected diphtheritic infection instances of typical diphtheria have taken their origin are not uncommon. §

These considerations have led us to report two cases in which recently the bacillus diphtheria} has been isolated at autopsy from the membrane and exudate upon the gums and lips of two grown individuals. The appearances of the membrane in one and the exudate in the other case were in no way typical of diphtheria, and the cases obtain an additional interest from the fact that during life the patients presented no symptoms referable to the presence of the Loeffler bacillus. No other focus of diphtheria existed in the body as far as could be determined. The pharynx and larynx were both free from exudate or membrane, and thus while it must be assumed that in these cases the diphtheria bacilli often reached the mucous membrane of the pharynx, it must be admitted that arriving there they did no damage. The instances of laryngeal diphtheria in which the bacillus diphtherias can be found by cultures to be present upon the pharyngeal mucous membrane in the absence of any lesion in the latter situation are very well known.

The cases present, also, interesting examples of poly-infection with bacteria. That several different micro-organisms

•Koplik, New York Medical Journal, 1892; Councilman, American Journal of Medical Sciences, November, 1893 ; Flexner, American Journal of Medical Sciences, March, 1895.

fBrunner, Berliner klinische Wochenschrift, 1893, Nos. 22, 23 and 24.

t Loefller, Hoffmann, Fraenkel, Feer, and Park and Beebe.

SFelsenthal, Miinchener med. Wochenschrift, 1895, No. 3; Washbourn and Hop wood, British Medical Journal, Jan. 19, 1895.

may coexist in the body, each producing its effect, perhaps each a peculiar effect, is a fact not very infrequently demonstrable at autopsies upon human beings, and yet it is one not much emphasized in writings upon infection. The frequency and variety of terminal infections with bacteria in the course of chronic diseases, as determined h\ the bacteriological study of the autopsy material of this laboratory, have recently been described elsewhere.* The cases here reported are offered as additional examples of multiple and terminal infections.

Both of the cases are from the medical wards (Prof. Osier) of the hospital.

Case 1.— J. P., white, aged 67 years. He had been in the hospital on three separate occasions, the first being on the 17th of January, 1891. His symptoms at thattime pointed to arteriosclerosis and chronic nephritis. The second admission was on June 29th, 1891, at which time he was suffering from a double tei-tian malarial infection. The last admission was on October 17 of the same year. At this time he was suffering from dyspncEa and cedema of the legs. The urine was pale, its specific gravity never exceeded 1010, it was albuminous and always contained hyaline and granular casts. He incessantly scratched his legs, in consequence of which he developed a cellulitis of the left leg which was incised on January 17th, 1895. The subcutaneous tissue was found diffusely infiltrated, showing hei-eand there pus pockets. Posteriorly there was a large abscess extending from the popliteal space, which it involved, to the heel. The suppuration was intermuscular, the fasciiB being dissected up and disintegrating. Muscles and periosteum were not involved. From the cover-slips and cultures streptococci were obtained. He died on January 20th.

Autopsy, January 21st (Dr. Flexner). The anatomical diagnosis was as follows: Chronic diffuse nephritis (small red granular kidneys) ; arterio-sclerosis ; fibrous myocarditis ; globular thrombi in right auricular appendage; heart hypertrophy ; vegetative endocarditis (recent) ; sero-librinous pericarditis. Healed (?) tuberculosis of lungs; thrombosis of pulmonary artery without infarction ; congestion and cedema of lungs. Tubercular peritonitis. Cirrhosis of liver. Cellulitis of leg. Acute gastritis. Diphtheria of lips, grwis and teeth.

The following is the abbreviated protocol : Body 157 cm. long. Slightly built ; emaciated. Oedema of ankles and hands. Suppuration of tissues of the left leg. Oral cavity : The mucous membrane of the lips is congested. Where the lips come in contact with the teeth there is to be seen upon the surface a greyish, necrotic-looking membrane, which upon removal leaves a defect in the epithelial covering of the mucous membrane. The resulting ulcer is deep red in -color. The upper and lower lips are both affected, and the membrane is most marked over their central portions. The teeth are badly eroded, the crowns only retaining their enamel covering. The

• Welch : The Middletou Goldsmith Lecture, 1894.

Februaey, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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gums ai"e somewhat retracted, and covering the exposed portion of the teetli, and in part the gums, there is a membrane similar to that upon the lips. The mucous membrane of the tongue and pharynx is pale and free from membrane or exudate ; the larynx also is free. Peritoneal cavity : It contains no excess of fluid. The peritoneum covering the lower zone of the abdomen, and particularly the jjelvis, is covered with a large number of tubercles. These are either miliary or conglomerate in form ; and some of them are surrounded by a zone of dark pigment. Tubercles also exist in the mesentery. Intestines : Except for some pa'tches of congestion, nothing abnormal is to be seen. The mucous membrane is free from ulceration. Stomach: The mucous membrane is intensely congested and small ecchymoses and erosions are present within it. The surface is covered with sticky pus. Pericardium and Heart : The pericardial cavity contains 20 cc. of quite clear fluid, and both of its layers are covered with a fibi'inous exudation, easily removed, and exposing congested vessels and small points of hemorrhage. The heart is hypertrophied and dilated. Upon the free border of the mitral valve several translucent, fresh vegetations are visible. The muscle of the apex is converted into fibrous tissue, and at this point there is a globular dilatation. The segments of the aortic valve are not shortened, but they are diffusely thickened. At the insertion of the middle segment a calcified patch occurs, upon which a fresh translucent thrombus is situated. The coronary arteries are extensively atheromatous. Lungs : The left shows retracted scars and small calcified areas. The right is free from tuberculous lesions. Urinary bladder : It is contracted and almost empty. The mucous membrane just above the trigonum is diffusely hemorrhagic, while in other parts it is injected and contains small ecchymoses.

Bacteriological Examination. — The bacteriological study embraced first the phlegmon of the left leg, the acute pericarditis, the vegetations on the heart valves and the acute cystitis. In the first and last streptococci were found in large numbei's; in the other streptococci were also present, but in smaller numbers. The tubercles in the peritoneum were not examined for tubercle bacilli, but from their structure there can be no doubt that tubercle bacilli could have been demonstrated in them. The main interest, for the purposes of this paper, concerns the bacteriological study of the exudate upon the teeth, gums and lips, and the purulent material covering the mucous membrane of the stomach. The cover-slips made at the autopsy showed many bacteria in the membrane and exudate upon the lips. Among these were diplococci, small and large bacilli and chains of bacilli. Upon the blood-serum tube inoculated from the exudate a good growth was obtained in 24 hours. Cover-slips from this showed as the predominating organism a thin bacillus three or four times as long as broad, and which showed a tendency to grow in small clumps, the individuals being arranged side by side in nearly parallel lines, and also often placed at angles to one another. However, the size was quite variable, some individuals being five or six times as long as broad. A more striking characteristic was the variation in form, for slightly curved forms were to be seen, as well as forms with swollen ends or swellings elsewhere in their substance. This irresularitv was all the more

distinct in that these swellings often possessed the property of staining more intensely than the remainder of the rods. This irregularity of staining was well brought out in preparations treated with Stii'liug's gentian violet stain, and subsequently with a 1 : 1000 solution of acetic acid. But Loeffler's methylene blue solution also sufficed to show the differences in a striking manner. Besides this bacillus only a coccus grew upon the blood serum, the greater number of organisms transl)lanted from the membrane refusing to be cultivated upon this medium.

From the morphology of the bacilli alone it seemed probable that the organism was the bacillus diphthei'ia?, but to remove all doubt further tests were applied. The bacillus grown upon various media, namely, agar-agar, faintly alkaline bouillon, litmus bouillon and litmus milk, gave the following reactions. Upon agar-agar slants there was a faint growth along the line of the inoculation after 24 hours at 37° C. Later there was an increase in the width of the growth, but not in its thickness. It remained delicate and translucent. Single colonies upon agar-agar plates were not distinguishable from the colonies of a control culture. The ordinary bouillon and the litmus bouillon showed in 24 hours a faint cloudiness, which increased a little during the succeeding 24 hours and then remained stationary. A slight very finely granular sediment formed in the bottom of the tube, the bouillon, however, not having been rendered clear thereby. The first effect upon the litmus was to redden it slightly, and, comparing it with a typical culture of the bacillus diphtherife obtained from a case of faucial diphtheria, it was found that the two cultures produced the same amount of reddening in twenty-four hours ; nor was there any perceptible difference until the fourth day, when the culture from the throat, which was used as a control, showed a somewhat greater reddening than the other. The litmus milk pursued a similar course, except that in it the acid production went on more rapidly, the control culture again showing on the fourth day a more marked acid reaction.

A half-grown guinea-pig received subcutaneously on February 11, 1895, at 2 r. M., one cubic centimetre of a turbid suspension from an agar-agar culture several days old. A node corresponding with the seat of inoculation had formed liy the next day, but the animal did not appear to be ill. thi the 13th the node had increased in size, the animal was quiet, sat in one corner of the cage with its hair ruffled, aud showed a disinclination to move. It ate little. By the 14tb the node had further increased in size and had by this time become very hard. It was incised and the tissues were found to be infiltrated with a greyish-white firm fibrinous material. Cover-slips prepared from this material showed large numbers ^of the typical bacilli. After several days the animal seemed gradually to recover, it begjiu again to eat, an ulcer formed at the seat of inoculation, and after two weeks it is still alive, although much emaciated. The ulcer has not vet healed.

From the properties which this organism exhibited there can be no doubt that it is the bacillus diphtheriie, although not a form possessed of decided virulence.

The blood-serum culture from the stomach snive oulv two

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[No. 47.

organisms. The predominating one was a short bacillus with sharpened ends, tending to grow in chains; and the otlier agreed with the bacillus isolated from the membrane upon the mouth both in form and in cultural properties. Its virulence was not tested upon animals.

To summarize this case, it is seen to have been one of chronic nephritis associated with arterio-sclerosis, heart hypertrophy and cirrhosis of the liver, in which there was a triple infection : 1, old tubercular lesions in the lungs and tubercular peritonitis; 2, streptococcus cellulitis, pericarditis and endocarditis; 3, diphtheria of the gums, lips and stomach. It may be questioned whether the diphtheria bacillus is to be considered the cause of the acute gastritis, and it must be admitted that the data at hand do not permit of a conclusion upon this point. But that the bacillus diphtheria3 may cause actual diphtheritic processes in the stomach has been shown by the bacteriological study of some cases associated with faucial diphtheria; and the variety of inflammations in the throat with which this bacillus is associated makes it more probable still that it may give rise under exceptional circumstances to an acute gastritis such as was present in this case.

Case 2. — A. E., white, aged .36 years, was admitted to the medical wards, January 30, 1895. He complained of drojisy and dyspncea. On admission there was general oedema, which continued until death. Lungs: The patient had several attacks of brisk hiEmoptysis. The cough was severe; the expectoration blood-tinged. On the evening of February 1st he had a chill, and the temperature, which hitherto had been subnormal, now rose to 102° F., and ranged from 100°-103° until the 9th inst., when it fell to normal. During these 8 days the signs were: dulness and flat tympany over the right upper lobe, with tubular respiration and large crackling, resonant rales. Breathing tubular. When the temjjerature fell on the 9th it was regarded as the crisis. The upper lobe did not clear up, tubular respiration with fine crackling rales being still heard on the 12th. On the 11th the temperature again rose, and it pursued a fluctuating course, ranging from 105.G° to 99° for two days. On the 13th dulness was found ov.er the upper left front, and the vocal resonance was increased. A pure leucocytosis, reaching at its height 40,000, was present during the last days of life. T/ie urine contained albumin, red blood corpuscles, pus and epithelial cells and blood, waxy, hyaline, granular and epithelial casts in abundance. Death occurred on the 14th inst.

Autopsy, February 15th (Dr. Flexner). Anatomical Diagnosis: Lung tuberculosis with cavity formation; chronic interstitial pneumonia with tubercular bronchiectatic cavities. Acute lobar pneumonia. Chronic diffuse nephritis (large white kidneys). Tuberculosis of the bronchial, tracheal and mesenteric glands. Fatty degeneration of the heart. Diphtheria of lips.

An abstract of the protocol is as follows: Body 170 cm. long, strongly built and well nourished. There is cedema of the extremities and face. Lips: They are covered with a greyish-wliite exudate, which, upon the separation of the upper and lower lips, adheres principally to the lower one. This exudate can be easily removed with the finger, and there is uodefectof the epithelium visible beneath it. Lungs: The

upper lobe of the right lung is occupied by several cavities, the largest one being situated at the apex. The substance of the lung between the cavities is firm, pigmented and indurated. In the anterior portion there is a diffuse tuberculous infiltration, undergoing softening. Xumerous small bronchiectatic cavities with caseous walls are present in this portion of the lung. Miliary and conglomerate tubercles exist in the indurated tissue of this lobe. In the apex of the left lung are two depressed pigmented scars. The entire upper lobe is consolidated, granular, and grey in color. There is no evidence of resolution in this lobe. The lower lobe is congested and oedematous. Kidneys: Together they w-eigh 475 grams. The average dimensions are 12.5x7x4 cm. The cortex measures 9 mm. The two kidneys are alike. The capsule strips off easily ; the surface in general is pale, but shows a slight mottling with red. On section the striae are coarse, the surface is oedematous, the glomeruli are pale. The consistence of the organs is diminished. Pharynx: The mucous membrane is pale and free from exudation. Larynx : A few superficial losses of substance occur in the mucous membrane, being most numerous over the true vocal cords. Frozen sections of the kidneys show the epithelium of the labyrinthine tubules to be granular and fatty. The tubules in the pyramidal portion contain at times blood-coloring matter. An occasional cast is met with in the tubules. The interstitial tissue is increased in foci.

Bacteriological Examination. — From the lung cavity tubercle bacilli and many encapsulated diplococci were found in coverslips. From the consolidated lobe of the left lung the micrococcus lanceolatus was obtained. But of especial interest is the result of the study of the exudation upon the lips. Coverslip preparations made from the exudate showed a variety of bacteria, among which the bacillus diphtherife was not recognized. The blood-serum culture gave, however, after 24 hours at 37° C, a growth in which the predominating organisms were a bacillus which morphologically resembled the bacillus diphtherias and a streptococcus. Discrete colonies containing one or both of these organisms were present upon the first tube, the majority of the transplanted bacteria having refused in this as in the previous case to grow upon the blood serum.

'J'he bacilli were tested upon blood-serum, agar-agar, alkaline bouillon, litmus bouillon, litmus milk and potato, and compared with a known control culture. The bacilli from the exudate behaved in a characteristic manner in general, showing, however, one or two variations. In bouillon a slight sediment formed in the first 24 hours, which increased in the next 24 hours and then remained stationar}-, but a slight cloudiness persisted in the fluid. The baciHi were non-motile. On potato, after 24 hours at 37° C. there was no visible growth, but cover-slip preparations showed that there had been an increase of the organisms. At the end of the next 24 hours a slight greyish-white growth could be seen upon the potato. The litmus bouillon was rendered red in 48 hours in about an equal degree with the control culture. The litmus milk reaction was typical. Blood-serum to which an infusion of litmus had been added before coagulating the serum so as to obtain a blue medium, served excellently for demonstrating the acid-producing power of tlie organisms. There is a more rapid multiplication and more abundant growth of the bacilli

February, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

25

upon it and, in consequence, a greater acid formation. The first appearance of red is in the water of condensation which collects at the lower part of the tube between it and the culture medium; the red color gradually extends over the surface and also into the depth. The final effect is to produce a diffuse and intense reddening of the j^reviously blue culture medium, which shows especially well when viewed with reflected light.

A half-grown guinea-pig was inoculated subcutaneously with a solid culture, and at the site of inoculation there developed a well-marked local reaction in 2 days. The animal looked ill. At the time of writing (10 days after the inoculation) the animal still lives.

To summarize this case, it was one of chronic pulmonary phthisis and Bright's disease, the terminal event of which was an acute lobar pneumonia, to which was added in the last days of life an infection with the bacillus diphtheriae.

There can be but little doubt, we think, that in both of these cases the diphtheria developed during the last days of life, although in the first instance the reaction was much greater than in the last. As the first patient had been in the hospital for a number of weeks, it is probable that the infection originated in the hospital. In the same ward a nurse developed a typical case of diphtheria just about the time of his death, and may easily enough have been the source of infection, although a reverse order is not to be excluded. These cases remind one, moreover, of the small group of cases of latent diphtheria which Heubner* has just reported as occurring in children, in which the disease developed insidiously and was unsuspected until laryngeal stenosis suddenly developed, or the fact was revealed at autopsy. The affected children had been in hospitals suffering from some chronic disease.

• Berliner klin. Wochenschrift, December, 1894.

A NEW APPARATUS FOR APPLYING PLASTER JACKETS, AYITH A BRIEF REVIEW OF THE

METHODS HITHERTO USED.

By E, Tdnstall Tay'lor, M. D. [Read before the Johns Hopkins Medical Society.^

Having had charge for some months of the " Plaster Room " in the Children's Hospital, Boston, and repeatedly used the methods up to that time employed there, for the application of jilaster jackets, it became obvious to me that the resulting jackets were not in all cases, what one might wish for in the ti'eatment of Pott's disease.

These now familiar methods consisted of applying jackets in suspension of the patient, as originally advocated by Di". Sayre, but more commonly in the prone position on a hammock, as advised by Davy and modified by Brackett.

The objection to the first method was the fright and fatigue it caused in the patients, and that the finished jacket in a short time allowed more or less forward flexion of the spine, in that it was not applied with the spine well extended backwards.

Actual distraction of the vertebrae from each other by means of suspension, which was formerly supposed by some and now even urged as an advantage in treatment by many, is slight and even questionable.

It may not be amiss in this connection to quote Ur. Sayre's early views and Bradford and Lovett's rather recent expressions in regard to this subject.

In November, 1874, Dr. Sayre first applied a plaster jacket by means of suspension. In speaking of a case he had one year later in September, 187.5, in which he had made lead-tape tracings of the spine with the patient standing and then suspended, he says: "■ The change of position is seen ; thus proving with mathematical certainty the alteration that had taken idace in the compensating cicrvcs of the sinue, wil/iout, however, makinii any material change at the angle of the deformity ^

Bradford and Lovett say : " Suspending a healthy person by I lie head, obliterates the physiological curves (cervical and lumbar lordosis, dorsal kyphosis), and the spine becomes straight, so far as its formation will allow.

" The spine of a new-born child becomes straight by suspension, but in an adult the changes in the shape of the bones, the strength of the ligaments and the tension of the muscles prevent the spinal column from becoming perfectlj- straight.

" In suspension by the axilht or arms, the strain comes upon the latissimus dorsi, and though the superimposed weight, which would fall upon the lower part of the spinal column is removed, yet the curvatures in the upjier part of the spine are not made straight.

" In suspension in old caries of the spine, it is only the physiological curves which are obliterated; the sharp kyphosis i'^ held too firmly by injlammatorg adhesions to permit of correction. In earlier cases with movalle verlebrm the intra- vertebral pressure must he in a measttre diminished at the point of disease by suspension, but susjmision does not cause a disappearance of the sharp angular projections at the point ofdiseai:e, and in cases that present themselves for treatment the deformity cannot be corrected in that way."

These views I hold, and think I have seen clinically but little gained by suspension, in so-called distraction of the healthy from the diseased vertebra?, or in lessening the deformity in Pott's disease, the phvsiological curves being alone affected by it.

" The hammock method " of applying jackets offers certain advantages in lower-dorsal and lumbar disease, iu that it affords a comfortable position and a snugly fitting jacket. But in the upper and mid-dorsal caries, we have to resort to other means in order to get a close fitting jacket over the sternum, which does not touch the hammock at its upper part. This is obviated by cutting wedges outof the top of the jacket where it does not touch the chest, and approximating the edges thus made by adilitioual turns of the plaster bandages. Another means of gaining a like end is phiciug the

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[No. 47.

patient in such a position on the hammock that the hands just reach the upper cross-bs),r to which the hammock is attached, so that after the lower part of the jacket is finished, the upper part of the hammock may be cut through and the patient holding by his hands can sag down into a position of lordosis. In this position the jacket may be finished, though it entails a certain amount of fatigue to the patient. This, however, can be lessened by having straps or towels support the forehead and the thorax, where the jacket is already completed. By this method a nicely fitting jacket is obtained, but much time and care is required for perfecting it.

In very acute cases, however, it is well to resort to these methods of either suspension or recumbency, to lessen the pain incident to the superincumbent weight on the carious vertebrae.

With these methods before me, I had made the apparatus whicii I am about to describe. Its aims have been, first, to put the patient in as comfortable a position as possible, in which at the same time he can keep reasonably still ; and secondly, that the position shall be such as to elevate the ribs and cause a backward bending of the spine, producing a. certain degree of lordosis involving both the dorsal and lumbar I'cgions.

The object of this is, that the centre of gravity of the body may be thrown further backwards and the superincumbent weight be removed more or less from the diseased body or bodies of the vertebra;, to the healthy tramverse and articular procegses.

The first of the aims, a comfortable seat, is met by utilizing a stool, on which is fastened firmly a bicycle seat, taking up no space laterally. The feet are supported on stirrups, made adjustable by a sliding joint and pin. The sliding joint works on a rigid rod, which in turn can be moved through an anteroposterior arc, so that the legs can be put in any desired position, by means of a bolt which passes through the arc and rod.

The second aim, that of the production of lordosis, is met by having an upright, wJiich extends some distance above and behind the patient's head and has a ci"oss-bar on its top making a T. From this cross-bar descend rods on which are handles. These rods are made adjustable at the cross-bar for lolig or short arms, broad or narrow shoulders, by a double joint, by which they can be moved up or down and also sideways. The central upright is attached near the bottom of the stool behind, by a joint which allows motion in an autero-posterior direction, regulated by a set-pin and an arc which projects back from the seat.

Thus it will be seen, when the patient grasps the handles, his arms being stretched upwards, and the central upright is moved liiK^kwurd.-i, the pelvis being more or less fixed, the

result is the ribs are raised, the shoulders and spine are curved backwards. Then the jacket can be easily applied and carried higher up and closer over the sternum than is possible by other methods; an end which we wish to gain in all jackets for Pott's disease, thereby preventing as far as possible the forward bending of the spine.

Thus far the advantages presented by this apparatus seem to me to be, 1st, the jacket thus applied fixes the spine in the most advantageous position for lessening the tendency for the production of deformity. 2d, the rapidity and ease with which a jacket may be applied, as it requires, as a rule, no trimming at the crease of the groin in front nor in the axilla;, notwithstanding the fact it is carried high up on the sternum. 3d, it seems applicable to dorsal and lumbar caries, especially the former. In high dorsal caries these jackets should be supplemented by a head-support or jury-mast, as is done in jackets ajjplied by other methods for disease in this region. 4th, it seems a comfortable jacket to the patient, as the thorax is well supported, and the superincumbent weight is removed from the diseased vertebral bodies to the articular processes and hips.

I wish to especially emphasize the importance of the rigid supports, for the hands and feet in this apparatus, as swinging ones were tried and found unsatisfactory.

Certain precautions are necessary for the successful application of a jacket by this method: firstly, to avoid fatigue to the patient the arms need not be elevated after the handle-rods and uprights are adjusted until just as the plaster-roller is to be applied, which although but a question of a few minutes will be found a point worth noting clinically ; secondly, to insure a close-fitting jacket over the pelvis it is well to have the legs fully extended on the stirrups ; thirdly, to avoid breaking up adhesions that may have already formed in partly anchylosed spines, it is not advisable to carry the backward bending to a point where discomfort is produced, which should be our guide in fixing such cases. Finally, in many cases to apply a comfortable and successful jacket a forward projecting rod is fastened to the central upright, from which a head sling extension can be used to insure support and further steady the patient when restless, nervous or in pain.

In none of the methods now employed is the " dinner pad " found necessary or used.

In conclusion, I wish to express my thanks especially to Dr. Hall, interne on the staff of the Children's Hospital, Boston, for his suggestions to me in developing the plaster jacket stool, and to Drs. Bradford and Brackett, Lovett and Goldthwait, I feel very grateful for permitting and encouraging me in the use of the stool at their clinics.

URETERO-CYSTOSTOMY PERFORMED SEVEN WEEKS- AFTER VAGINAL HYSTERECTOMY.

By Howaed a. Kelly, M. D.

[Bead before the Johns Hopkins Medical Society.]

The patient brought before the Society this evening (Jan. 21, 1895) is deeply interesting on account of the novel conditions attending an operation for the relief of a uretero- vaginal fistula.

She entered the Hospital in August, 1894, with an extensive carcinoma of the cervix, for which Dr. Russell, resident gynecologist, performed vaginal hysterectomy. The disease had extended so far out into the broad ligaments that he was obliged to place the ligatures at a greater distance from the cervix than usual. She recovered rapidly from the hysterectomy, but retained as a sequel a ureteral fistula in the vault of the vagina near the middle of the cicatrix. From this there was the usual constant leakage of urine, although she regularly passed the urine accumulating in the bladder from the other kidney. From a simple vaginal inspection it was impossible to say whether the flow from the cicatrix came from the right side or the left. It clearly did not come from the bladder, for it remained unchanged by the injection of a sterilized solution of milk into that viscus.

To decide which was the severed ureter I placed the patient in the knee-breast position and introduced my No. 10 cystoscope, when the bladder filled with air and I was able to inspect the ureteral orifices. By introducing a searcher into the left ureteral orifice I found that this ureter was intact as far as the posterior wall of the pelvis. Upon introducing the searcher into the right ureteral orifice it could not be carried in more than two centimeters, on account of meeting an impassable obstruction. The urine was seen flowing from the left ureteral orifice while nothing escaped from the right side. The demonstration was thus complete that it was the right ureter which was injured and the left was intact.

Having cleared up the diagnosis in this way I proceeded to operate to relieve the condition, October, 1894, seven weeks after the original operation by Dr. Russell.

Operation : The patient was placed in the Trendelenberg position and an incision 12 cm. long made through abdominal walls loaded with fat. Every step throughout the operation was embarrassed by the obesity of the patient. After opening the abdomen, the large fat omentum and intestines were dislodged from the lower abdomen and pelvis with great difficulty, and held away by means of cotton gauze pads.

The end of the ureter could not be found on the pelvic floor on account of the rigidity and inflammation surrounding the line of scar tissue between the rectum and bladder. The right ovary and tube were also pinned down to this sear tissue by numerous vascular adhesions. The attempt to reach the ureter at this point was therefore abandoned and it was sought out at the pelvic brim, wliere it was readily found after lifting up the caput coli and incising the peritoneum and pushing aside the fat. It was then traced from the point of crossing the common iliac artery down to the pelvic floor, exposing the whole length of the pelvic portion by

splitting the peritoneum over its upper surface. The anterior portion of the ureter was involved in the inflammatory material surrounding the scar, which bled so freely that no attempt was made to dissect it out. Four centimeters of the length of the ureter lying directly posterior to the scar tissue were dissected out and the ureter lifted up from its bed and divided close to the scar, sacrificing as little as possible of its length.

I now found that although I had cut the ureter to the best advantage, I could not do more than merely bring it into contact with the bladder by pulling on it. It was of course evident that if I were to suture it to the bladder, exercising this degree of traction, it would pull out soon after the operation and I would have a uretero-abdominal instead of a uretero-vaginal fistula to deal with.

I was able to cope successfully with this formidable difficulty in the following manner: The bladder was dissected free from its attachments to the horizontal rami of the puliis on both sides, with scissors and fingers, and dropped down into the pelvis so as to extend it and carry it more into the back part of the pelvis, gaining at least 3 cm. in this way. By this means the ureter and the bladder were easily approximated without strain. I then made a small incision through the bladder wall, covered with fat at least a centimeter thick, at the point on the right nearest the ureteral end drawn straight across the pelvis. This incision passed through the peritoneum and was not more than 3 or 4 mm. in length and just large enough to receive the ureter snugly.

I then slit up the under surface of the ureter for about 4 mm., eularging the caliber of its orifice to avoid a stricture, and with a pair of long delicate forceps introduced through the urethra, the bladder, and through the incision, I caught the ureteral end and drew it into the bladder and held it there while it was being attached to the bladder wall by about six fine interrupted silk sutures passed through the muscular tissue of the bladder and peritoneal and muscular coats of the ureter on all sides, beginning with the under side.

The ureter thus dissected out of its bed. and attached to the bladder, was stretched like a lax cord from the posterior part of the pelvis to the bladder, which lay gibbous and flattened out on the pelvic floor.

The abdominal incision was closed down to its lower _' . where a narrow gauze drain was inserted for fear of 1 Care was taken in closing the incision not to di-.iw tog< uur the peritoneum underlying its lower end, to avoid raising the bladder and indirectly pulling upon the uret«r.

No leakage occurred and the drain was removed, and the wound heitled without suppuration. Her urinary difficulties were immediately and completely relieved with the perfect restoration of continence.

At a subsequent cystoscopic examination 1 discovered the abnormally placed ureteral orifice opening into the posterior

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hemisphere of the bladder into which it freely discharged its urine.

This case is one of especial interest for the following reasons :

I was able to determine on which side the injury had been sustained by my method of sounding the ureter in the kueebreast position with the bladder distended with air.

I was enabled in this instance, by a simple but delicate plastic procedure, to secure at once a perfect result without sacrificing any important structure.

It has heretofore been necessary in order to cure a similar trouble to extirpate the kidney of the affected side. It has not yet been the good fortune of any operator in this country to anastomose the ureter into the bladder at a date subsequent to that of the operation at which the injury was sustained.

About a year ago I was invited by my friend, Dr. Boldt of New York, to perform a similar operation for a similar condition. I found, however, upon opening the abdomen that the cellulitic inflammation, in the present case localized near the vaginal vault, in that instance extended up the ureter, encasing

it (periureteritis) and rendering it impossible to free any part of it without exciting a hemorrhage which would be beyond my power to control.

It is further important to note that the operations of uretero-ureteral anastomosis and uretero-cystostomy must not be looked upon as rivals in the same field. Where the ureter is cut far enough back from the bladder to permit an anastomosis of the upper into the lower end, the distance between the upper end and the bladder is too great to allow a ureterocystostomy to be considered. Where on the other hand the lU'eter is cvit near enough to the bladder to allow the upper end to be turned into the bladder, it will be found that the lower end is so short and so awkwardly placed that a ureteroureteral anastomosis is not to be thought of.

There is one class of case^ in which the procedure is elective, that is when the ureter has become lengthened and dilated by displacement upwards over a uterine myoma.

I would in this case elect to do a uretero-ureteral anastomosis if the ureter were dilated, or a uretero-cystostomy if it were of normal calibre.

TWO SUCCESSFUL CATARACT OPERATIONS ON A DOG.

Br Egbert L. Eakdolph, M. D. [Read before the Johns Hopkins Medical Society.]

It is generally known that cataract is not uncommon in the lower animals and especially in the dog and horse. In the horse cataract is apt to be the result of recurrent irido-choroiditis, and this latter affection as seen in the horse is remarkable for its tendency to relapses, appearing often periodically and representing the disease known as "moon-blindness." Cataract, then, in the horse is almost always inflammatory in its origin.

When cataract is found in the dog there is no such history of a coincident inflammation, but we find a conditiau that differs little from the same affection in man. With regard to the operation for cataract in the dog no special difficulties are presented as contrasted with the same operation in man, except that we are compelled to use a general anaesthetic in the former case, and this is a disadvantage. Cocain has undoubtedly lessened the gravity of cataract operations.

It is evident that the healing process in animals is surrounded with far greater dangers than is the case with human beings, and it is this no doubt that deters us from operating for cataract in the lower animals.

Early last Octoljer A. W. Clement, V. S., of this city, brought to my office a handsome pointer dog. The dog was perfectly blind and had been sent to Dr. Clement for relief. He was eighteen months old and in fine physical condition generally. His master said that he had been going blind for three months, and at the end of that time only light perception was left. On the street he would crouch at his master's feet at the sound of an api)roa('hing vehicle and could not be dragged away till the vehicle had pas.sed. When brought to my office and :illi)wcd to smell around the room he ran into the wall

and chairs at almost every turn. In being led one had to pull him along, as he was fearful of running into objects. On examination I found both eyes free from irritation. The pupils quickly responded to light. With the ophthalmoscope it could readily be seen that the lenses were opaque, and on using a mydriatic I found that they were uniformly and entirely opaque. The color presented by the cataract was more a milk-white than gray, not unlike what we see in the ordinary traumatic cataract when there has been extensive laceration of the anterior capsule and the whole lens has l)ecome immediately opaque. A similar appearance is presented by the so-called naphthalin cataract that I have produced in rabbits by feeding them on naphthalin in the manner described by Dor, Panas and others. Such cataracts belong to the variety known as soft cataract. I determined to perform discission, so the dog was first given a hypodermatic injection of morphia and then chloroformed. My instruments were boiled a half-hour before using them. Only two instruments are necessary, the needle and fixation forceps. The lids were held open by an assistant. At this time I operated on the right eye, and I may add that the pupil of the eye had been well dilated with atropia before the operation. The needle was passed into the cornea in the usual way and a crucial incision was made in the anterior capsule. Atropia was instilled and the dog was put into a small kennel and allowed to recover from the effects of the chloroform. The next day there was a large mass of cortical substance protruding into the anterior chamber. The recovery was absolutely uneventful and at no time were there symptoms of irritation. At the end of the first week Dr. Clement observed

February, 1895.]

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that the dog went about the stable-yard with greater freedom. He was confined to his kennel for two weeks and whenever let out into the yard he was closely watched by the stable-man. In three weeks there was a perfectly clear pupil, and only within the extreme ciliary margin of the pupil were there any remains of the capsule to be seen. During this time atropia was dropped in the ej'e three times a day. At the end of three weeks I made the following test : I arranged several chaii's in such a manner as to form a zig-zag path leading from one room through a narrow door into the adjoining room, and then went into the adjoining room and called to' the dog. He came along the path laid out for him without a pause. This he did several times without striking a chair. I then jilaced a chair in the doorway and called to him and he jumped over the chair to me without the slightest hesitation. That day I operated on the other eye and used cocain. The dog was exceedingly restless and had to be held down. This restlessness was not due to pain but to nervousness, but it was enough to convince me that a general anesthetic is indispensable. The operation was similar to the first one, and in five weeks there was to be seen only a small baud of capsule lying in the IDUjjillary area.

At this time it was impossible to detect anything wrong with the dog's vision. He moved about with freedom and rapidity, and ten days later his master, Mr. W. T. Wilson of this city, wrote me that he had taken the dog out on a hunt and had found him just as efficient as ever in so far as his hunting qualities were concerned, and that he jumped fences and ditches as readily as the other dogs in the field.

It seems then that the effect of the operation was to give the dog a vision that is practically perfect. At this time both Dr. Clement and I thought the case a unique one, and as far as I can learn it is unique in this country, but since then I have found quite a number of operations of a similar character reported in foreign journals. Among others, AVhite Cooper' in 1850 gives an interesting account of some successful operations for cataract performed on bears in the London Zoological Gardens. Discission was the operation employed. Brogniez" reports a case of successful cataract operation on a horse nine years old, and Chegoin^ operated successfully on an ass twenty-one years old.

As a general thing cataract in the lower animals appears in the earlier years of life, and when it occurs in tlie horse Crisp' thinks the cause is to be found in bad light and abundant exhalations of ammonia. Crisp is of the opinion that constitutional affections have little if anything to do in the causation of cataract in the lower animals, for usually the animals affected are well nourished and live for years. It will be remembered that the physical condition of my case was perfect so far as could be seen. Halteuhoff-' reports a case of cataract in a dog associated with diabetes, but on the other hand Professor Moeller," of the Veterinary School in Berlin, who has operated a number of times for cataract in dogs aud horses, has never found diabetes present, aiul this has also'beeii the experience of Professor R. Berlin.' 1 failed to test the urine in my case, but the general history of the dog' would exclude any such complication ; and I may add that in those cases of cataracts in rabbits produced by feeding ihem on

uaphthalin, frequent examinations of the urine failed to show the least evidence of sugar, though some of the clinical symptoms of these cases suggested diabetes, as for instance progressive emaciation, hurried breathing, and an excessive flow of urine.

In speaking of the causes, though, of cataract, in dogs more particularly, it is well to note the fact that accommodative strain, which may be a factor in bringing about cataract in man, can here be excluded; and inasmuch as good vision was obtained in the majority of the cases rejjorted, it is not likely that a disease of the retina or choroid had anything to do with the existence of the cataract. Another interesting fact in connection with this case is the rapidity with which the cataract develojied. Within three months after the vision began to fail the dog was blind. I was struck by the shortness of the time required for the absorption of the lenses. Ordinarily, even in very young children, it takes at least two months before absorption is complete, while in those who are older, a year or more with several discissions is the rule. In the first eye absorption was iDractically complete in three weeks, and in the fellow eye nearly all the lens substance had disappeared at the end of five weeks. One would be apt to think that so far as usefulness was concerned the dog would be worthless, but it will be remembered that this was not so.

I am sure that the absolute necessity of artificial help in the shape of glasses for cataract patients is much overrated. There are cases on record (quoted by White Cooper) where after the operation for cataract the jiatients were compelled, for the sake of experiment, to get along without glasses — in other words, to accommodate their eyes to the new refractive conditions, and after a few months they could get along quite comfortably, though of course unable to read. The vision of every animal (man included) is no doubt limited to the needs of the animal. It is not likely then that dogs are possessed of human visual acuteness, aud it is evident they do not re<iuire such vision. Certainly few, if anv", demands are ever made upon the accommodative apparatus of the dog's eye, so that the loss of the crystalline lens would be attended with comparatively little or no inconvenience, and the same may be said of the horse.

Possibly the good sight in these cases is to be accounted for by a reproduction of the lens fibres, aud in this connection I may refer to the experiments of Cocteau and Leroy d'Etiolles.' These observers found that in a certain length of time after the removal of the crystalline lens in rabbits, dogs and cats, that another lens was formed. It is a curious fact that in several of these experiments the capsule showed no cicatrice, but was perfectly clear, and cont;\ined a lens as voluminous and consistent as the lens that was extracted, and differing in no respect from the latter. Gunn' reports a case of traumatic cataract that had occurred in a child, where, after tlie absorption of the cataract, later on in life new lens fibres were demonstrable. By this time a reproduction of lens fibres may have taken place in my case, but we are not justified in attributing the good vision obtained to such a process, for sight improved ar the end of the first week, and the formation of new lens fibres would not likely have begun till the absorption of the old lens was complete.

30

JOHNS HOPKINS HOSPITAL BULLETIN.

[Ko. 47.

From investigations made in the London Zoological Gardens it has been found that cataract is common to nearly all of the lower animals, but it is a suggestive fact that cataract is most often seen in the two animals nearest man, the dog and horse. Neither e.\ti"action nor couching seems to be proper in operating on the lower animals. The impossibility of keeping the animal quiet, or of surrounding it with any of the usual safeguards, is an objection to extraction. AVhile JEoeller has had several successful cases of extraction, he states that his best results followed discission. As to couching, the danger of intraocular inflammation makes this operation quite as objectionable here as it is in the case of man. In my opinion discission is the only operation applicable to these cases. A general anesthetic is indispensable. A bandage should not be applied, as it attracts the dog's attention to his eye, and it will be rubbed or torn off and injury to the eye would result. It is imperative to use a sterile knife, for wecauuot here nullify the effects of infection by careful after-treatment, as we sometimes do in man. A small kennel is necessary, so that no temptation is offered to the dog to move about ; and finally a 1 per cent, solution of atropia should be dropped .in the eye three times daily during the first three weeks. As regards the auajsthetic to be used, my preference — from considerable experience — is in favor of ether, and I

have always been under the impression that it was particularly unsafe to administer chloroform to dogs. Dr. Clement tells me that he always gives chloroform and precedes the administration of it with a hypodermatic injection of morphia, and that he has never had any unfortunate results, a fact which he thinks is explained by the administration of the morphia.

Literature.

1. An account of operations for cataract on bears. By White

Cooper, F.R.C.S. Med. Times, New Series, Vol. I., pag. 621. London, 1850.

2. Extraction ilu cristailin chez le cheval, par A. J. Brogniez. An nates d'Oculist., ]843.

3. Operation de cataracte sur un ^ne, par Chegoin. Bull, de la Soc.

de Chirur. de Paris, 425.

4. Specimens of cataract and of opacities of the cornea in the lower

animals. Edwards Crisp, M. D. Trans. Path. Soc. London, Vol. XXII., 350.

5. Klinische Mittheilungen, von G. Haltenhofl. Zeitschr. fiir ver gleich. Augenheilk., 1885, p. 65.

6. Casuistische Mittheilungen iiber das Vorkommen und die opera tive Behandlungdes grauen Staaresbeim Hunde, von Prof. Dr. H. Moeller. Ibid., 1886, p. 138-146.

7. Beobachtungen uber Staar und Staaroperationen bei Thieren, von

Prof. Dr. R. Berlin. Ibid., 1887, 59-76.

8. Experiences relatives, a la reproduction du cristailin, par MM.

Cocteau et Leroy d'EtioUes. Journal de Phys. exper. et patholog.,Toni. VII., 30-44.

9. Trans. Oph. Soc. Unit. Kingdom, London, 1888, VII., 126.

SiaMOIDO-PROOTOSTOMY.

AN ANASTOMOSIS OF THE LUMEN OF THE SIGMOID FLEXURE THROUGH THE LATERAL WALL OF THE RECTUM AT THE PELVIC FLOOR, WITHOUT SUTURE.

By Ho^vard a. Kelly, M: D.

■ [Read before the Johns Hopkins Medical Society.]

1 was obliged on tlie 20th of October, 1 894, to perform a novel operation for the relief of an artificial sigmoid anus, consisting in the anastomosis of the sigmoid llexure into the lower part of the rectum on the pelvic floor, by ■means of traction sutures through the severed sigmoid, pulling it into a slit in the rectum, and bringing it out at the anus. By means of a pair of forceps laid across the anus grasping the sutures, the transplanted bowel was kept from retracting until a firm union had taken place between its outer surface and the edges of the incision. The entering bowel so snugly fitted the receiving bowel that no sutures were necessary to hold it in its new position. The patient recovered from the operation and has to-day, three and one half months later, normal bowel function.

The circumstances of the case were these: One of my friends, a skilful surgeon in the South, having a poor patient who could ill afford to leave home and pay traveling expenses and hospital charges, undertook to relieve her, giving gratuitous services. Her previous history had been one of pelvic imflammatory disease accompanied with severe suffering. She was 33 years old and had been married 3 years, without pregnancy. Her menstruation had been regular until two years ago, since which time it has Ijeen coming every 2 to 3 weeks, lasting 3 days and accompanied by niueli pain.

After placing her under an auresthetic and opening the abdomen he found the pelvis choked by extensive adhesions. He began the enucleation, but it became so difficult that only the right ovary and tube were found and removed. Among the matted structures in the pelvis a narrow rigid tubular structure resembling the left tube was found, extending from the brim of the pelvis down towards the pelvic floor. This was brought up and tied off. As soon as it was removed it was seen to be a section of a strictured rectum, 6 cm. long. The remaining structures Avere so densely matted together that their identity could not be established in spite of a persevering investigation.

The injury to the bowel could not be repaired by anastomosis on account of the wide lumen of the upper sigmoid portion, and the rigid contracted rectal portion which was continued in the form of a long stricture as far as the pelvic floor. He therefore concluded the operation by suturing both of the divided ends of the bowel into the lower end of the abdominal incision, the sigmoid at the extreme lower angle and fc^e rectum just above it. The incision 5 cm. long above this was closed, and the wound united and the patient recovei-ed witii two fistulas, the active discharging sigmoid listuln and the (Hiiescent rectal fistula.

Through my friend's courtesv she was sent to me two months

February, 1895.]

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after his operation, for further treatment at the Johns Hopkins Hosijital. At the examination I found an ojiening above the symphysis jiubis about 3 cm. long, at the bottom of which were two orifices, a hirger one below about 3 cm. in diameter, through which the index finger passed readily up over the left iliac fossa in the direction of the descending colon. This was manifestly the sigmoid anus. Immediately above it, separated by a narrow bridge of tissue, was a small orifice not quite a centimeter in diameter into which the index finger was pushed with difficulty. By continuing the examination bimauu Jly a long tight stricture of the rectum from the abdominal wall down to a point behind the cervix uteri was detected. I think that my effort to explore the strictured bowel at this time must have ruptured its coats through into the peritoneum on the right side, for her sufferings increased from that date, with a daily rise of the temperature and quickened pulse. I found also at the operation a week later an opening through the bowel into the peritoneum walled in by extensive adhesions of the small intestines associated with a wide-spread colon bacillus acute peritonitis, proved by cultures, involving the whole lower abdomen and extending up to the left renal fossa.

I began the operation by dissecting out the entire scar containing the sigmoid and rectal orifices, these were then separated, and each wrapped separately in gauze and laid aside. The incision was now lengthened and the enucleation of the inflamed pelvic structures begun.

It was necessary in the first place in order to reach the pelvic organs to detach numerous loops of adherent coils of small intestines bound together by a fresh exudate and bleeding freely ; in three places the external muscular coat was so torn as to require suturing. On completing the separation an opening was found in the strictured rectum below the promontory of the sacrum on the right about 2i cm. from the cut end and communicating with the peritoneal cavity.

The uterus and ovary and tube were so covered with dense fibrinous adhesions that it was impossible at first to tell where they lay, or to decide from appearances which tube and ovary had been removed in the first operation.

The uterus was finally discovered by cutting through the adhesions in the posterior part of the pelvis and letting out an encysted peritonitis of 120 cc, when the left tube was found and the position of the uterus traced by it ; its enucleation was then continued by carefully following its contour and stripping up the adhesions, digging it out of a bed of densely organized lymph. The ovarian vessels were then ligated. The uterus was amputated in its cervical portion just above the vaginal junction fifter ligating both uterine arteries, and the stump of the cervix closed by antero-posterior silk sutures. The pelvis cleaned out in this way presented the appearance of a rough excavation, without any nornuil peritoueum, from the extensive stripiiing up of the adhesions on all sides.

The pulse which was 100 at the beginning of the operation, began to weaken from the first, and towards the hitter part

it had become so rapid as to alarm the aniesthetizer, who repeatedly admonished me that the operation must be concluded quickly. Frequent hypodermics of strychnia were given without marked improvement.

The conditions at this stage in the operation were discouraging. I had before me in the first place a patient exhausted by an extensive peritonitis, who had just been subjected to a desperate pelvic operation, including suture of the intestines. I still had left a more formidable task in the establishment of a satisfactory anastomosis between the .amputated sigmoid and a rectum converted into a dense tubular stricture all the way to the pelvic floor.

I overcame these difficulties and concluded the operation in five minutes in the following manner: 3 cm. of the upper part of the strictured rectum were removed, severing it below the rupture; I then approximated the wedge-shaped flaps with silk sutures, closing its lumen. This rested on the right side opposite the second sacral vertebra. The end of the sigmoid was then caught with six long silk traction sutures passed through the peritoneal and muscular coats, entering about a half a centimeter from the edge of the incision, and emerging on the incision, without piercing the mucosa. The walls of the bowel were from 3 to 4 mm. thick and somewhat rigid, without the flaccidity of the normal sigmoid.

I now made an oblique incision into the rectum on the pelvic floor just above and behind the vagina close to the cervix, below the lower end of the stricture. This incision was made through the abdominal incision about 3 cm. loug, and directed from before backwards from left to right, the greater part lying to the left. With a pair of long artery forceps passed through the anus and ampulla and out through the incision into the pelvic cavity, the six traction sutures were caught in a bunch and pulled down and out of the anus, drawing the sigmoid into the rectal incision, which was held open with forceps to facilitate the entrance. The bowel was kept from slipping back into the pelvis by grasping the traction sutures in the heel of the bite of the forceps lying across the anus in the gluteal furrow. A rectal examination showed that about 1 cm. of the sigmoid projected into the rectum. The fit of bowel into bowel at the incision as seen from above was such a snug one that the liue of division between sigmoid and rectum could not be detected.

It was my iutention to fix the anastomosis by means of a few sutures uniting the sigmoid to the rectum, passed on the ^jelvic side, but I found this could not be carried out. as there was so little room between the bowel and the pelvic walls that I could not use either needle-holder or ueetUe.

The pelvis was washed out and a gauze pack inserted around the sigmoid and another up among the inflamed bowel and brought out at the lower angle of the incision, which was closed to this point. 8he made an excellent recovery and has since had normal bowel functiou. Since removing the pack there has been a cousbmtly decreasing purulent discharge from the lower angle of the wound ; at no time hjis she passed fecal nnitter in any other way than per auuui.

32

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 47.

PROCEEDINGS OF SOCIETIES

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of January 7, 1895. Dr. Abei- in the Chair.

Exhibition of Surgical Cases.— Dr. Finnet.

The first case I have to show to-night is one of very marked varicose veins of the leg. The internal saphenous and its branches were enlarged more than in any case I had previously seen. He was operated upon on December 29, 1894, the operation consisting of excision of the vein and its larger tributaries. He has done uninterruptedly well. There was no difficulty in the operation. The veins were very slightly adherent. An Esmarch bandage was first put on, which rendered the operation practically bloodless. We remove the first dressing to-night, and, as you see, the result is perfect. There is nothing especially interesting about the case except the enormous dilatation of the veins and the unusual length of the incision. I have here a photograph of the case before the operation, and also the specimen of veins removed, which I will pass around for your inspection. Only here and there were the vein walls thickened.

The patient's occupation was that of a fireman. He was on his feet a great deal and exposed to extremes of temperature, especially to heat. No family history of enlarged veins. His trouble began about ten or fifteen years ago. There was not much pain, but when he stood on his feet the veins dilated very much.

Various operations for the relief of this condition have been suggested from time to time, such as the ligation of the trunk of the vein about the apex of Scarpa's triangle below the saphenous- opening, multiple subcutaneous ligation, and excision of portions of the vein. None of these have been found so satisfactory as excising the whole varicose mass.

Case 2. My second case is one of more interest. He is a man fifty years of age; occupation, mason. His previous history throws no light whatever upon his present condition. T'here is a tuberculous taint in the family history ; no malignant disease. No venereal history. Has had measles, scarlet fever, varicella, rheumatism, typhoid fever and pneumonia; all pretty close together along about 1863. Has had hemorrhages from the lungs, but for two years past has had none, lias never had indigestion nor dyspepsia. Has no alcoholic history.

His present illness is as follows: In May, 1894, he had occasional attacks of great pain between his shoulder-blades, and at times on swallowing pieces of solid food would be regurgitated. If lie attempted to swallow these pieces forcibly he would vomit and choke. He became gradually worse until he was admitted to the hospital on Christmas day. He was then unable to swallow even liquids. When he attempted to swallow water it took him a long while to do so. Perhaps a little entered his stomach, but most of it regurgitated. He was failing in health and strength rapidly and weighed but 941 pounds. No history of traumatism nor of swallowing any irritating substance. An examination of his throat by Dr. Warlield revealed nothing.

Dr. Osier examined his lungs and found a few moist rales over the right apex posteriorly; otherwise normal.

When he entered the hospital he was in a very bad condition, having taken nothing for five days. We began giving him nutritive enemata, and his condition immediately improved very satisfactorily. After a while the rectum became somewhat irritated, and we thought it best to do a gastrostomy. This was done about ten days ago, December 29th. There have been from time to time various operations suggested ; all having in view the prevention of the escape of fluids by a valve-like opening. Of these the best was perhaps Witzel's, which consisted in taking two parallel folds of the stomach, sewing together their free edges over a glass tube, thus making a sinus about an inch or more in depth leading to the opening in the stomach. This has been practised with good success. Hahn's method consisted in making the opening through the eighth intercostal space, giving a bony margin to the fistula. The operation which we performed upon our patient is known as Frank's method. This consists in making an incision in the ordinary place along the edge of the left costal border and about an inch from it. A second incision is then made about one and one-half inches to the left of and parallel to the original incision, and the skin dissected free from the ribs beneath. Then a fold of the anterior wall of the stomach is lifted out of the wound and tucked under this flap of skin and brought out through the second incision; after fixing it there with sutures the original incision is closed up. Frank recommends doing the whole thing at one sitting, that is, drawing out the portion of stomach, suturing it to the edges of the second skin incision, and then opening at once. In tills case the patient's condition was so good during the operation and at the end of the operation that we decided to wait a day or two before making an opening. We did this and you can see the result. It is very satisfactory indeed. The patient now takes nourishment regularly through this opening. So far we have only given him fluids. There has not been the slightest leakage, so that the valve so far works admirably. We shall begin soon to give him solid food. He can masticate it, and through an apparatus it will be inserted into the stomach. (The patient was fed before the society with about 4 ounces of milk which was introduced through a funnel. There was no leakage.)

While the patient w as under ether we passed an oesophageal bougie. We were able to pass it only to the depth of 23 cm. from the incisor teeth. A No. 8 bougie would not pass beyond the pharynx. The stricture is a very tight one. I got no idea of tlie nature of it from the bougie.. Later when his condition improves we will begin attempts to dilate the stricture both from below and above. The most probable diagnosis is carcinoma.

Acute I'aniToatills, IHsscuiluatiMl Kat NetTosis. ranipaurretttic .Vbsccss. — Dii Til AVER.

Dr. Thayer showed a patient who liad suft'ered from acute pancreatitis with disseniiuutLd fat necrosis, followed by a parapancreatic abscess.

February, 1895.]

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33

The patient was 34 years of age, a piano-polisher, and had a somewhat alcoholic history. For a year and a half he had suffered from occasional attacks of severe cramp-like pain localized about in the median line, across the epigastrium and about the umbilicus. Two weeks before entrance into the hosjjital he was seized with severe pain associated with vomiting. The pain was continuous; there was fever and, at times, delirium. On entry a deeply seated mass was found in the median line just above the umbilicus. It could not be separated, distinctly, from the liver, which was palpable on the right, while to the left it reached about to the costal margin. It was tympanitic on percussion, and very tender on palpation. The mass was not distinctly fluctuating, but gave one the impression that it contained fluid.

The urine was free from albumen or sugar ; the blood showed a fairly well marked leucocytosis.

The diagnosis of acute pancreatitis, probably associated with disseminated fat necrosis, was made, and an operation was advised.

The operation by Dr. Finney revealed extensive disseminated fat necrosis in the omentum and subperitoneal fat, while underneath, in the lesser peritoneal cavity, there was a deep abscess, at the bottom of which the finger passed apparently into the pancreas. The abscess discharged thick creamy pus, showing numerous fatty acid crystals, bacteria, and masses of necrotic fat.

Cultures were unfortunately not made from the pus, as the opening was made unexpectedly several days after a preliminary operation. Cultures from the areas of fat necrosis made at the preliminary ojjeration were negative.

Cheniical examination of the areas of fat necrosis by Dr. Barker confirmed, entirely, the views of Langerhans, who demonstrated that the fat necroses consisted of a combination of lime with fatty acids.

Dr. Thayer then i-eviewed the main theories concerning the nature and cause of the fat necroses and their relation to acute pancreatitis. He mentioned the importance of an early diagnosis and operation in cases of this nature.

Dr. Finney. — A word with reference to the operation. When we opened the abdomen we came upon a mass of necrotic fatty tissue which evidently concealed pus beneath. We had to open the general abdominal cavity to get at this. I thought it better to pack off the abdominal cavity with iodoform gauze and get it closed off by adhesions before completing the operation ; this was why it was done in two stages. The mass was packed around with iodoform gauze, and five or six days afterwards when we thought the adliesions were sufficiently firm it was opened into. A good deal of pus was evacuated, together with masses of necrotic fat and what looked like pancreatic tissue.

Dr. Abel. — Dr. Abel said that it did not appear to him strange that calcium soaps were occasionally found in places far removed from the pancreas. As every one knows, the fats of our body are neutral fats and contain, under ordinary circumstances at least, only traces of free fatty .acids. If, now, we find salts of the fatty acids, such as the calcium soap that has been referred to, present in an area of fat necrosis, we must assume that some agent has split up the fats and that

the calcium salt was formed secondarily. Xow the ability to split up fats is met with in various parts of the body. Even the muscles, when removed from the body and kejit with antiseptic precautions, exercise a feeble fat-splitting power on neutral fats, phenol esters and acid anhydrides. The liver, however, has this ability in a marked degree and stands next to the pancreas in this respect. From the experiments of Nencki, Liidy, Salkowski and others we may fairly assume that neutral fats are constantly being split up in whatever tissues or organs they may be lodged. In the instance described by Dr. Thayer I think that all will admit that the accumulation of calcium soaps in the neighborhood of the pancreas is the result of the activity of the fat-splitting ferment of that organ.

Heeling of January 21, 1895.

Dr. Abel in the Chair.

Myxosdeiua and Exophthalmic Goitre in Sisters. — Db. Oppes HEIMER.

In the London Medical Society in 1893, Arthur Maude reported cases of myxoedema and exophthalmic goitre in the same family. Two sisters with these diseases were in Dr. Osier's wards, and Dr. Osier has kindly asked me to report them.

Ca$.e 1. Miss A., set. 19, admitted January 26, 189-t, complaining of goitre and great nervousness.

Family history is negative, excepting her sister (Mrs. B.).

Personal history is negative.

Present ilhiess began about three years ago after a severe fright. She became very nervous and has been easily excited ever since. The heart has been beating very rapidly, and for about eighteen mouths enlargement of the thyroid and exophthalmos have been noticed. The voice has been husky of late. The hands tremble, especially on excitement. The appetite is good; there is no nausea or vomiting; the bowels are regular. There is no cough or pain in the chest, but she has attacks of dyspnoea.

Status praesens: She is a fairly nourished, slightly built woman ; face is markedly flushed ; numerous areas of transient flushing. Lips and mucous membranes are of good color. Tongue clean, ^larked double exophthalmos ; no vou Graefe's sign. Thyroid gland is much enlarged, symmetrical. Pulse very rapid, ranging from 100 to I-IO. Liiugs and abdomen negative. Heart's apex in sixth space; very powerful and heaving impulse; the sounds are loud; first is booming, second both loud and clear. No murmurs. There is a fine tremor of the fingers. Urine negative : no sugar.

Patient was given the dried thyroid extract, five grains three times a day, during her stay at the hospital — fourteen days. She neither improved nor became worse, but lost two and a half pounds in weight She left the hospital ou February 9, 1894.

Her physician, Dr. Melvin, writes that she had to discontinue the thyroid because of the increase of nervousness. She has been taking tincture of belladonna min. xv t, i. d. for two mouths and has improved somewhat. In the last sis weeks she has been taking it verv irreirularlv. Ou Xovember 22.

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1894, the goitre was much smaller and the exophthalmos less marked. She is, however, very irritable, and does not obey orders.

Case 2. Mrs. B., sister of Miss A., tut. 37 — multipara.

Perso7ialhis(ory : Always healthy; never had rheumatism or chorea.

Present illness: Onset about three years ago, after nursing two children with measles while she was pregnant. Some three months after birth of the child, she noticed that about two days before the menstrual period the whole body would become more or less swollen, though never pitting ou pressure; this would disappear when the menstrual flow began. During the past year the menstrual periods have appeared at about six to eight weeks interval, and the swelling has always been more or less present, though worse at some times than others. The swelling never pits on pressure. Lately she has noticed that the skin has become dry and harsh and rough. She has also lost some hair lately. She always feels chilly. The appetite is good ; the bowels are constipated. She is very talkative.

Status praesens : A woman of medium height, but giving impression of being very large. The face has a heavy, dull look ; the cheeks and neck are very full, almost cedematous in appearance. The face is somewhat expressionless, and complexion has rather a doughy character. The supraclavicular spaces are markedly full, though there is no distinct pufEuess. The arms and legs are decidedly swollen, though not pitting anywhere, the skin having a resistant feel and being everywhere dry, and in places showing a scaling of epidermis. The finger-nails are thin and show marked longitudinal striations; edges are slightly everted and show irregularities. The hair is dry and coarse. The thyroid gland could not be felt; owing to the thickness of the neck the palpation was unsatisfactory. The abdominal and thoracic viscera negative.

The patient was given thyroid gr. v t. i. d., which in a week was reduced to gr. v b. d. She at once began to improve. She lost while in the hospital, 14 days, about 11.5 pounds, and in the first 25 days after leaving the hospital she lost almost as many pounds. Her pulse on admission was 60-70, and on discharge 80-100. She looked much brighte;- and felt better.

Her physician, Dr. Melvin, writes, Nov. 1894, that she has steadily improved ; she is now taking only three grains every other day. She is eight months pregnant, and it is interesting, tliat while in previous pregnancies she was very nauseated, this symptom is absent in the present one. The amount of the thyroid extract could not be decreased during pregnancy.

These cases are of especial interest in their bearing on the question of the pathogenesis of exophthalmic goitre. Although the disease has been well known for fifty years, and studied with especial care of late, there is still much difference of opinion as to its cause. As the symptomatology has become more and more complex the tlieories have varied.

Tlie classical triad has had many symptoms added, relating (liielly to the nervous system. It is diflicult to say which of these symptoms belong to the disease itself and which are hysterical. The tremor of .Marie and Charcot is considered a constant symptom. Paresis of almost every muscle has been seen. Charcot laid great stress on the paraparesis of the legs.

Paresis of the frontalis has recently been noted by Joffroy. The patient is requested to look down, and then, without raising the head, to look at the ceiling. A normal individual will wrinkle the forehead, but in exophthalmic goitre it remains smooth. This is not present in all cases, and is to be seen in some hysterical patients.

A peculiar oedema has been especially noted by Moebius and Maude. It does not necessarily occur in dependent portions, and resembles angioneurotic cedema. Non-pitting, hard, cedematous areas have also been seen. In a few cases (Sollier, Kowalewsky, von Jaksch) there has been true myxoedema associated with exophthalmic goitre.

To account for these symptoms there are at present only three well-supported theories : 1, that it is a pure neurosis; 2, that it is due to a central (medullary) lesion ; 3, that it is due to increased and, perhaps, perverted function of the thyroid gland.

The chief arguments in favor of the first theory are:

1. The frequent neuropathic family and personal history. Cases of exophthalmic goitre in the same family are not uncommon.

2. The onset with emotion.

3. The frequent association with chorea, hysteria and ejjilepsy.

4. The absence of any definite lesion.

5. The cases cured by some slight nasal operation. Against these may be urged that the meagre pathological

testimony may be due to lack of skill. The mortality is too high and the acute cases totally unlike a pure neurosis. The patient's statements as to the onset and its causes are always to be looked on with sus])icion.

The theory of a central lesion has been supported by Mendel, Hale White and others, Mendel's pupil, iiannheim, in his recent work sums up the arguments in its favor. He first premises that all the symptoms could be explained by bulbar lesions. Besides this, there are, pointing to the medulla —

1. The severe course of the disease and its combination with other spinal cord diseases.

2. Filehne's, Durdufi's and Bienfait's experiments, in which incision and stimulation of the corp. restiform. and tub. acustic. produced exophthalmos, tachycardia, and at times goitre.

3. The pathological evidence. Several observers have found more or less hemorrhage. Mendel found one restiform body smaller than the other, and atrophy of one solitary fasciculus.

In most autopsies, however, the central nervous system has been negative, and in Miiller's acute cases only slight, recent hemorrhages were seen.

Finally we have the thyroid theorj', led by Mobius in Germany, Joffroy in France, and Greenfield and Byrom Bramwell in England. The arguments for this may be stated as follows :

1. Morbid anatomy. In all autopsies some changes in the thyroid ghuul liave been observed, and, frequently, these have been in the direction of functional hyperplasia.

2. The action of the thyroid extract. The effects of overdosage in myxoedema were called attention to soon after the introduction of the thyroid treatment. The symptoms of

February, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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orer-dosage bear a striking resemblance to those of exophthalmic goitre.

3. The usual effects of thyroid adiiiiuistration in exophthalmic goitre is to increase the symptoms ; there are exceptions to this.

4. The most successful line of treatment so far is, that tending to diminish the bulk of the goitre. Out of G8 operations on record up to December, 1894, 18 completely recovered, in 26 there was more or less improvement, 9 showed no change. In 5 death was almost immediate (one of these cases was here), and in 4 death occurred within 24 hours. In 4 cases there was apparent cure, but the symptoms returned, and in 2 cases the operation was followed by tetany.

5. The striking contrast of the symptoms of exophthalmic goitre and myxoedema. This is well shown in the two cases whose histories are given above. This is the more striking as the cases occur in the same family, the only apparent bond being some affection of the thyroid gland.

6. Finally, the course of the disease is more like an acute intoxication. It is probable that the chief brunt of the intoxication falls on the central nervous system.

It would seem that some light might be thrown on the question by injecting animals with extract of the thyroid gland of exophthalmic goitre subjects. The disease has been observed" in animals.

NOTES ON NEW BOOKS.

BOOKS RECEIVED.

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL.

Vol. VI.- No. 48.

BALTIMORE, MARCH, 1895.

+++

Contents

Tumor developed from Aberrant Adrenal in the Kidney Thomas S. CnLLBN, M. B.,

The Bacteriology and Pathology of Diphtheria. By Simon Flkxnee, M. D., - - - - A Case of Chorea Minor occurring during an Attack of Maniacal Excitement in an Adult. By Henky J. Berkley, M. D.,

PAGE.

By - 37

39

Proceedings of Societies : The Hospital Medical Society,

Progressive Neural Muscular Atrophy [Dr. H. M. Thomas] ;

— Green Hair [Dr. Oppenheimer] ; — Brassfounder's Ague

[Dr. Oppenheimer] ; — Exhibition of Surgical Cases [Dr.

Platt].

Notes on New Books,

Books Received, -

TUMOR DEVELOPED FROM ABERRANT ADRENAL IN THE KIDNEY.

By Thos. S. Cullen, M. B., Assistant Resident Gynecologist, Tlie Johns Hopkins Hospital. [Read before the Johru Hopkins Medical Society.]

H. J., ffit. 49, German. Admitted iu the service of Dr. Kelly, October 10th, 1894. Her complaint ou entrance was pain in the lower part of the abdomen associated with swelling in the lower abdominal region. Her menses commenced at twelve and ceased six years ago. She has been married twentyeight years and has hud two children. Her family history is nuimportant. Twelve years ago she had malaria, and for several years she has complained of frequent micturition.

Her present trouble commenced in May, 1894, when she noticed a swelling in the lower part of the abdomen. This has gradually increased and has been associated with a moderate amount of discomfort rather than actual pain. The swelling seems to be located on the right side.

Status prcBsens. The patient is apparently well nourished, but slightly debilitated. Her appetite is poor, her tongue tlabby but clean, bowels regular. The urine has S. G. 1030, is amber colored, gives an acid reaction and contains a faint trace of albumen, and microscopically shows a few pus cells.

The abdominal measurements are as follows: Girth at umbilicus 100 cm., just above pubes 103 cm.; distance from pubes to umbilicus, 19.5 cm.; from ensiform cartilage to umbilicus, 19.5 cm.; from right superior spine to umbilicus, 23 cm.; from left ant. superior spine to umbilicus, 33 cm. To the left of the umbilicus there is slight flattening, to the right moderate

bulging, and (5 cm. to the right of the umbilicus a distinct tumor can be felt.

Operation, October 11th, by Dr. Kelly. Incision was made iu the median line under the supposition that the tumor was an ovarian cyst, as with the patient in the standing position it lay iu the right iliac fossa and crossed over the mediiui line just above the symphysis. Ou opening the abdomen the tumor was found to be retroperitoneal, and could not be reached on account of the excessive amount of fat. An oblique incision 12 cm. long was made midway between the lower border of the ribs and the crest of the ilium, aud commencing posteriorly at the quadratus lumborum. A soft tumor was exposed and punctured on the supposition that it contained fluid. From the point of puncture free bleeding occurred, but no fluid escaped. The incision was enlarged by cutting upward and inward toward the ensiform cartilage- In doing this the peritoneal cavity was opeueil. Considerable difliculty Avas experienced in enucleating the tumor from its bed of adipose tissue. The ureter as well as the large vessels at the hilum of the kidney were tied off by about eight stout ligatures. A small g-auze drain Wiis introiiuced into the jiosterior angle of the wound, the peritoneum closed by silk sutures, the muscle and skin by silkworm-gut. The stitches were removed ou October 19th. The patient made a good

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recovery and was discharged on November lOtb. The average temperature for the first ten days was 99.5°. Soon after the operation it dropped to 96°, but the same evening rose again.

Pathological Eeport.

The specimen consists of the right kidney, the lower half of which is of normal size, being 12 cm. long, G broad, and 5 in its antero-posterior diameter. It presents several fcetal lobulations. The upper half, however, is greatly enlarged and the seat of a neoplasm. This part has an oval contour, is 18x18 xl2 cm. in its various diameters, is covered with adipose tissue, and has a fibrous capsule which is directly continuous with the capsule of the kidney; thus it is apparent that the new growth has developed in the kidney. The tumor presents a yellowish mottling, and in the depth of the capsule numerous branching blood-vessels can be seen. On pressure it is yielding and elastic. On section the new growth presents a mottled appearance, the prevailing color being yellow. The consistence of the outer part of the growth is moderately firm, that of the central portion is soft, and evidently here and there is extensive necrosis with some hemorrhage. At one point the tumor extends into the pelvis in the form of a pyramidal growth, evidently corresponding iu shape and position to one of the renal pyramids (see Fig. 1). This tongue-like process of the tumor is 2.5 cm. long and 2 cm. broad, and projects free into the pelvis of the kidney, which it partially occludes. This projection shows no degeneration. The capsule of the tumor is directly continuous with the capsule of the kidney, and a layer of renal substance can be traced partly over the tumor beneath the capsule, indicating that the tumor has developed in the substance of the kidney (Fig. 1). Scattered throughout the capsule are numerous blood-vessels which appear as narrow slits. Extending inward from the capsule are trabeculaj which can be traced to the very centre of the tumor, where they are seen as delicate fibrils. The lower half of kidney shows no appai-ent change.

Histological Examination. The capsule of the tumor is composed of connective tissue very poor in nuclei (Fig. 2). The greater part of this tissue has undergone hyaline. degeneration. Scattered here and there throughout the capsule are slit-like or round spaces lined by one layer of cuboidal epithelium. These resemble identically kidney tubules which have been compressed, and they are undoubtedly renal in nature. In a few places single or double rows of tumor cells are seen scattered throughout the connective tissue. The capsule is richly supplied with blood-vessels, the walls of which are merely composed of one layer of endothelium. The ingrowths from the capsule are also connective tissue in origin. These, however, have undergone almost complete hyaline degeneration, and in places are necrotic and iiililtratcd by many red blood corpuscles.

The tumor proper is made up of polygonal cells, occurring chiefly in double rows, but sometimes in rows of three or four (Fig. 2). 1'he individual cells are sharply defined and vary considerably in size. Their protoplasm stains a light purple with ha;matoxylin, and with the oil immersion is seen to be made uj) of round globules, all of which are approximately the same size, and Ijetwecn which is a delicate granular material.

The nuclei of the cells are round, elongate oval, or irregularly oval. If the cell be small they are usually situated in the centre of the protoplasm ; where the cell is large they are pushed to one side. Between the double rows of cells are delicate capillaries which are separated from the cells by one layer of endothelium. Most of the capillaries are only wide enough to admit the passage of one red blood corpuscle at a time ; some of them, however, are dilated. Around a few capillaries are aggregations of lymphoid cells, associated with a small amount of new-formed connective tissue. On passing inward about 1 cm. from the capsule the tumor cells are seen to be necrotic. The capillaries are somewhat more resistant and can be traced a short distance further. The entire central portion of the tumor is necrotic. Specimens were stained for glycogen, but as the tissues were hardened in Miiller's fluid the results were negative.

The kidney tissue in the vicinity of the tumor is greatly altered. The glomeruli show marked increase of connective tissue cells in their capillary walls, some of them being almost obliterated. The lobules are much atrophied, their epithelium is almost flat, and their lumina are filled with hyaline casts. There is gretit increase of connective tissue between the tubules, and the blood-vessels are dilated. The farther away from the tumor the less the pathological change. In all parts of the kidney, however, there is considerable alteration. Sections from the lower half of the kidney, where little if any pressure was exerted, show thai the glomeruli are congested and enlarged, and that between the capsule and the glomerulus is a moderate amount of granular material. The convoluted tubules are dilated, their epithelium is somewhat granular, but their nuclei are well preserved. The collecting tubules are in some places dilated, the epithelium of these being flattened and pigmented. Their lumina contain hyaline casts. Scattered throughout the kidney is a moderate amount of connective tissue, which in many places has undergone hyaline degeneration. The capillaries between the collecting tubules are dilated.

Such tumors have frequently been described under the title, "StrTima suprareualis sarcomatodes aberrans," and have been dealt with at length by Horn, a student of Grawitz, also by Lubarsch* and others. They are usually multiple, are generally found in the upper half of the kidney, and vary from a cherry to a child's head in size. Most of them are yellow or yellowish red in appearance; some, however, are grayish. Each nodule is surrounded by a fibrous capsule and appears to be sharply defined. The large tumors show areas of softening in their centres. The adrenal gland may be intact or included in the tumor. Histologically the capsules of these tumors consist of connective tissue which may contain tumor elements. The tumor is made up of polygonal cells arranged in single or double rows. Some of these cells are cylindrical, and are so arranged that on cross section they present a glandlike appearance. The cells themselves have small, round, deeply staining nuclei which are surrounded by a large quantity of protoplasm. The protoplasm contains many fat

• Lubarsch : Virchow's Archiv, Bd. CXXXV, Heft 2, S. 149.

Makch, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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droplets of variable size, also small droplets of a homogeneous, highly refractive substance which gives the glycogen reaction. At times giant cells are found or nuclear figures may be made out in the tumor cells. The blood capillaries are very abundant and are only separated from the tumor elements by one layer of endothelium.

Some of the polynuclear leucocytes in the vessels may contain glycogen. The central portions of the tumor are frequently necrotic, and show numerous hemorrhages. From the histological appearances some have described these tumors as carciuomata, others as sarcomata, and they have not infrequently been thought to be endotheliomata, from their vascular arrangement. Microscopically the cells of these tumors resemble almost if not identically those of the adrenal gland. Grawitz accordingly concludes that these tumors arise from the adrenal elements. It is probable that in fcEtal life small portions of the adrenal gland become included in the kidney substance, and that in after-life they undergo development. Metastases are frequent, having occurred in twenty of the twenty-nine cases reported. These have been found in the inferior vena cava, having extended by continuity from the renal vein, in the capsule of the kidney, in the retro-peritoneal glands, lungs, pleura, thyroid glands, and also in the glands of the neck. The lungs and pleura are the parts most frequently invaded. The secondary growths are identical in character with the original tumor, their cells being similar in character and containing glycogenic granules. These tumors may occur at any age; the most frequent period is, however,

between forty and sixty. The symptoms are indefinite. The presence of a tumor in the renal region will, however, make one suspicious. In a certain number of cases blood is present in the urine, and in one case the urine contained tumor cells.

The present case is somewhat unusual, on account of the size of the tumor, also from the fact that it consists simply of one nodule. From the histological appearances it seems certain thai the tumor originnted from a portion of the adrenal gland tvhich had been included in the kidney substance. Whether the entire adrenal was included or not it is impossible to say. It was not found on the surface of the tumor, but may have been left in the abdominal cavity. In concluding, I wish to thank Prof. Welch for his assistance in the preparation of the pathological report, and Dr. Iloen for the excellent micro-photograph he has made.

Description of Plate.

Fig. 1. Three-fourths natural size. The upper half of the kidney is occupied by a tumor mass which is surrounded by a capsule. This capsule sends septa into tlii' tumor substance. The outer portions of the tumor are still firm. The centre is necrotic and is breaking down. The tuuior at its lower portion has grown into the pelvis of the kidney.

Fig 2. About 250 diameters. Is a section taken from Fig. 1 at point a. The left half is tumor substance, the right half a p'^rtion of the capsule. In the capsule a row of tumor cells can be seen. The capsule also contains elongate-oval deeply-staining areas ; these are cross sections of compressed kidney tubules.

THE BACTERIOLOGY AND PATHOLOGY OF DIPHTHERIA.

By Simon Flexner, M. D., Associate in Pathology, Johns Hopkins University.

The results of the researches of Loeffler published at the close of the year 1883 may be said to mark the beginning of the new era in the study of diphtheria, and whatever doubt surrounded his first publication regarding the relation to di])btheria of the micro-organism which now bears his name, has now been finally dissipated. The isolation of the Loeffler bacillus by workers in different parts of the world from the local lesions of the disease in many thousands of cases would seem to afford irrefutable evidence of the constancy of the relationship existing between the bacillus and the pathological process. Hence it is that attention has been directed to a consideration of other aspects of the subject than that of the presence or absence of the Loeiller bacillus in primary diphtheria.

The wide divergence of opinions regarding diphtheria which existed prior to the discovery of the bacillus diphtheria^ illustrates with what difficulty every advance in the study of a disease is accompanied so long as its ivtiological factor is still unknown. It had long boon a woll-ostalilishod fact that

• Being the substance of an address delivered on January S, 1895,

before the .Vlumni Association of the Jefferson Medical College, Philadelphia.

by a variety of agents, pseudo-membranes which offered more or less the appearances seen in diphtheria could be produced upon mucous surfaces in man and in animals; but it was at the same time recognized that none of these agents could reproduce the symptom-complex of diphtheria : and none of us arc likely to forget the almost interminable discussion which arose as to whether it was primarily a local or a constitutional disease. Nor did the study of its pathology give much assistance in the solution of this queitiou. and only after the specific micro-organism had been obtained in pure culture did it become possible, by a study of its proi)erties outside the body and of its occurrence under natural couditious in human beings, to establish a rational basis for a chissificatiou of the disease.

First of all, then, it is important to distinguish between the anatomical and the ivtiological significance of the term "diphtheria," and it will be found that a limitation of the term to a disease characterized by the pi-eseuce of the bacillus diphtherias in the jiffected portion of the Inidy will do much to eliminate the confusion of pathological conditions whicb, while anatomically resembling one another, are otherwise quite distinct.

The first question to which I would direct your atteutiou

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regards the proportion of cases of pseudo-membranous inflammations of the throat which are due to the LoeflBer bacillus. In the first series reported by Loeffler himself, a certain number of the cases examined did not yield the diphtheritic bacillus ; but of these, several were recognized as not having been cases of primary diphtheria. This failure to find the Loeflfler bacillus in all pseudo-membranous inflammations in the throat and air-passages has been confirmed by later investigators. Thus in a table prepared by Escherich, in 679 examinations collected from Paris, Berlin and New York, the bacillus diphtheriae was found in 427, or in 62 per cent, of all the cases. In a series studied by Morse of Boston, of 301 cases examined, the Loeifier bacillus was found in 217, i. e., it was present in 72 per cent, of the cases. Park and Beebe report that of 5611 cases examined, positive results were obtained in 3255 (58 per cent.). The bacillus was absent in 1540 cases (27 per cent.), while 816 cases were doubtful.. The doubtful cases represent those in which for some reason or another satisfactory cultures were not supplied. If these, then, be disregarded altogether — although it may not be entirely fair to do this — we find that out of 4795 cases of suspected diphtheria, 68 per cent, were instances of true diphtheria.

It is acknowledged that the pseudo-membranous anginje which are associated with the acute exanthemata are commonly not caused by the Loeffler bacillus, but are due ip most cases to the invasion of the streptococcus pyogenes. In a series of bacteriological examinations made by Booker in such cases, the bacillus diphtheriae was constantly absent; and Escherich, who studied fourteen cases of scarlet fever, states that the Loeffler bacillus is never present in the early days of the disease, but that in several of these cases they were found to be present later on, a fact which he attributes to the imperfect separation of diphtheria and scarlet fever patients in the Munich hospital, where his studies were carried on. He also found the Loeffler bacillus in certain cases of measles and whooping-cough, and he agrees with other investigators in holding that the acute exanthematous diseases predispose to infection with the bacillus diphtherise.

It had been observed by the older clinicians that during epidemics of diphtheria, pseudo-membranous inflammations of the throat in the course of typhoid fever were more frequent. Morse reports four cases of typhoid fever complicated with diphtheria; at least three of which developed diphtheria after admission to the hospital.

A purely local and perhaps non-contagious inflammation of the larynx has, by the bacteriological examination of a considerable number of cases of membranous croup, been shown to occur unassociated with diphtheria. These cases, however, are quite exceptional. Of 88 cases of membranous croup studied by Martin, 59, or 67 per cent., were of diphtheritic origin. The statistics of Park indicate that in New York fully 80 per cent, of the cases of the same disease are caused by the Loeffler bacillus. Of 229 of Park's cases, in 167 no membrane or exudate was found above the larynx. Welch and Abbott, Booker, Williams, Kolisko and Paltauf, C'oncietti and Fraenkel have reported cases of laryngeal diphtheria in which the pseudo-membrane was confined to the larynx and lower air-passages.

It is an undoubted fact that a case of so-called membranous laryngitis has not infrequently been the first of a series of cases of genuine faucial diphtheria.

Among the mosti impprtant results of the bacteriological study of the inflammations of the throat and air-passages has been the discovery that cases which present the features of a mild catarrhal angina or of a lacunar tonsillitis may be associated with the presence of the bacillus diphtheriiP, and that from these can arise other cases in which membrane is found on the fauces.

This class of cases has been studied by Escherich and Feei-, and especially by Koplik. Within the past few weeks I have seen two such instances in the practice of Dr. W. D. Booker, and from them obtained the Loeffler bacilli in cultures. The first was a girl of 16 years, who came to the surgical dispensary of the Johns Hopkins Hospital for enlarged glands of the neck. Upon examination she was found to have a lacunar tonsillitis. She suffered no inconvenience other than that resulting from the swollen glands. The plugs from the crypts of the tonsils contained the Loeffler bacillus. She made a rapid recovery.

The second was a child one and a half years of age whose tonsils were greatly swollen and almost meeting in the middle line of the throat. There was no visible membrane. Cultui'es from the throat showed the presence of the bacillus diphtherise. The local treatment recommended by Loeffler was used, and by the third day all symptoms of the disease had disappeared.

Heubner has just published a short series of cases, in which he calls attention to what he describes under the title of latent diphtheria. These were secondary to other diseases than scarlet fever and measles, and occurred in the young in the course of wasting affections, such as rickets, tuberculosis, etc., in hospital practice. The symptoms were fever, gastrointestinal disturbance, and slight bronchial and nasal catarrh. Heubner says that diphtheritic infection is not apt to be suspected in these cases until laryngeal stenosis suddenly develops, or the fact is revealed at autopsy by the finding of a false membrane in the pharjmx or larynx.

Eoux and Martin have found in the course of their inoculation experiments for the preparation of the anti-toxin, that animals which had been previously inoculated with other bacteria or their poisons, from which they had recovered, were more susceptible to the diphtheria toxin ; and, similarly, that pregnant animals or such as had just given birth to young exhibited a .similar diminution of resistance.

The mucous membrane of the nose affords a favorite resting-place for the Loeffler bacillus. In pharyngeal diphtheria these bacilli are commonly present in the nasal secretion, even in the absence of membrane in the nose. Primary diphtheria of the nasal mucous membrane sometimes occurs. Such cases have been reported by Stamm, Baginsky, Abbott, Ravenel, Czemetschka, Townsend and Park. Of the last two writers the membrane was confined to the nose in 4 and 9 cases respectively. Escherich has seen one case in which the infection of the nasal mucous membrane took place through the tear-duct in a case of diphtheritic conjunctivitis. Katz has just reported a case of faucial diphtheria which developed in

March, 1895.]

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a child exposed to infection from another child suffering from fibrinous rhinitis due to the Loeflfler bacillus.

Babes first cultivated the LoefEler bacillus from the pseudomembrane in diphtheritic conjunctivitis, and reproduced the disease by the inoculation of the organism upon the conjunctivas of rabbits. A number of cases of pseudo-membranous conjunctivitis have since been found to be associated with the bacillus diphtheriae, although it must be stated that not all are caused by this organism. In two cases which I examined for Dr. Pliram Woods the Loeffler bacillus was not found in the exudate, but streptococci were present in both. The results of Councilman's investigations would go to show that certain cases of otitis media are due to this bacillus.

The skin surfaces of the body would appear to be immune to the action of the Loeffler bacillus in the absence of any loss of continuity. Thus Wright cultivated the diphtheria bacillus from excoriated or ulcerated surfaces of the skin in 7 cases of diphtheria; and Park found this organism in wounds of the finger received by physicians while performing intubation. Cases of wound diphtheria associated with the Loeffler bacillus are reported by Brunner, Neisser, Treitel and Abel ; but it is probable that most cases of so-called wound diphtheria are caused by other micro-organisms. The relative insusceptibility of the external surfaces of the body to infection with the bacillus diphtherias is illustrated by the behavior of tracheotomy wounds, which only exceptionally become infected with this organism. Faltonek examined 953 tracheotomy wounds without succeeding in a single instance in isolating the Loeffler bacillus. Other observers have been more successful, but in these cases the possibility of the contamination of the wounded surfaces with the tracheal secretion cannot be excluded.

Having now passed in rapid review the situations of common localization of the Loeffler bacillus upon the surface and in the cavities of the body, I would ask your attention to its distribution within the viscera. At the time of Loeffler's first jjublication he expressed a belief that the bacillus diphtheria; was to be found only at the local site of the disease, and that it did not invade the tissues at all, or at least only exceptionally. He had cultivated it, however, in one case from the lungs ; and later Kolisko and Paltauf and Babes isolated in rare instances a few organisms fi'om the internal organs. The observations of Frosch, since confirmed by others, have shown that not uncommonly a few bacilli enter the circulation and may be cultivated from the internal organs at autojisy. They are not however only small in number, but their distribution is irregular, and it is necessary to transplant considerable quantities of material in order to grow them. Frosch cultivated the bacillus from the blood of the heart, the brain, pleural and pericardial exudates, pneumonic areas in the lungs, spleen, kidneys, bronchial and cervical lymph glands and liver. Booker has also obtained the organism from the internal organs. At the autopsy of a cliild of three years which had both pharyngeal and laryngeal diphtheria I obtained the bacillus diphtheriw in pure culture from the heart's blood, cervical lymph glands, liver, spleen, lungs and kidneys, but, contrary to Frosch's experience, they were present, in this case, in large numbers in the blood,

glands and spleen. In this as well as in a later instance I was able to cultivate the Loeffler bacillus from bronchopneumonic areas, and also to demonstrate them in sections from the bronchi and lung tissue. The predominating organism, however, was the micrococcus lanceolatus. Kutscher has just shown that the Loeffler bacillus exists at times in considerable numbers and may be the predominating organism in cases of broncho-pneumonia associated with diphtheria, and he inclines to the view that it is capable of causing both bronchitis and consolidation of the lung substance. Wright has found the bacillus diphtherije in the internal organs in cases of human diphtheria, and he has also cultivated them from the liver, spleen, heart's blood and kidneys in a small number of experimental guinea-pigs. Abbott and Ghriskey found that after inoculating cultures of diphtheria bacilli into the testicle of guinea-pigs, small nodules containing this organism sometimes appeared in the omentum ; and this bacillus has also been cultivated from the ecchymotic patches in the stomach and from the surface of the membrane in croupous gastritis. Of especial interest is the case reported by Howard, in which a bacillus in all respects resembling the bacillus diphtheriag, except that it did not possess pathogenic properties for guinea-pigs, was cultivated in large numbers from the heart-valves in a case of acute ulcerative endocarditis and from the infarctions in the spleen and kidneys.

Notwithstanding the results of later and more searching studies which have necessitated a modification of the earlier views regarding the relation of the Loeffler bacillus to diphtheria, and notwithstanding the fact that it is now known that the Loeffler bacillus can develop not only locally upon the affected mucous membrane, it must be considered as proven that only a few organisms penetrate into the body ; and there are undoubted instances in which the disease has pursued a typical, severe and even fatal course in which the bacilli have remained localized in the mucous membrane. Hence the local process is still to be regarded as the chief seat of the activity of bacillus diphtheria.

The study of the properties of this bacillus as it exists' outside the human body and the results derived from the inoculation of susceptible animals would indicate that the effects which it produces upon the body are due to a soluble poison, a toxin, proceeding from its growth and multiplication. By means of this toxin, separated from the living bacilli, all the constitutional effects of diphtheria can be induced. For the pi'oduction of the false membrane the presence of the bacillus itself is necessary.

The growth and multiplication of the bacilli in the false membrane in the pharynx, larynx and nose are associated with the formation of this toxin, which, entering the body, causes the symptom-complex of the disesise, Sidney Martin has extracted from the pseudo-membrane an albumose which possesses the poisonous properties of the toxin.

We owe especially to Koux and Yersiu and Briegcr .and Fraenkel our knowledge of the nature and proiKTties of this toxin. According to their researches it belongs to a class of substances of albuminous nature, jwssessing iwisonous properties, for which the n.ame tox-albumens hiis been proposed. Tp to the present time the tox-allMun.n of diphtheria has not

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been obtained in a pure form, but in its impure state it is found to possess extraordinary potency. Susceptible animals (rabbits, guinea-pigs, kittens) inoculated with it exhibit all the symptoms of diphtheria, not excepting the post-diphtheritic paralysis.

The study of the action of this bacillus upon animals has shown a material difference in the virulence exhibited by cultures derived from different colonies, those obtained from a single case showing at times wide variations in virulence. The guinea-pig being the animal most susceptible to its influence, is generally employed for testing these variations.

No less striking are the differences in the potency of the toxin produced by the bacillus, and it has been found that there exists a direct relation between the virulence of the organism and the intensity of the poison which it is capable of yielding.

It cannot be said that any such relation between the virulence of the organism and the severity of the symptoms has been shown to exist for human beings. Indeed, contrary to the results arrived at by Roux and Yersin — which seemed to indicate that a progressive diminution in the virulence of the bacilli corresponding with the mildness of the attack took place, and that the same thing happened during convalescence from a severe attack— Escherich, Tobiesen, and especially Wright, have shown that no such diminution of virulence occurs. Fully as virulent organisms may be found in' cases which are mild from a clinical standpoint as in those of severer grade.

The question of individual jiredisposition or of resistance to the invasion of the bacillus diphtherias and to the effects of its toxic products has therefore to be considered in this as in the case of other infectious diseases. What the physical basis for this' distinction really is we are probably still far from having discovered. A few of the conditions which favor or 'nhibit infection in human beings and in animals seem clear. Hence it is that the results of the recent studies of Wasserman and Abel upon the action of the blood-serum of healthy liuman beings upon animals previously inoculated with the LoefHer bacillus are suggestive, as they indicate that the serum of certain individuals contains some protecting substance, the power possessed by the serum of adults being greater than that of children.

It is quite established that the bacillus diphtheria; may possess all grades of virulence down to complete absence of pathogeiiic power, and some confusion has arisen by the introduction of the term "pseudo-diphtheritic" bacillus to denominate an organism which, while it resembles the true bacillus diphtheria-, is devoid of virulence for guinea-pigs. This bacillus was first isolated by Hoffmann, who regarded it as identical with Loeffler's bacillus. Roux and Yersin advanced the view that this so-called "pseudo-diphtheritic" bacillus represents an attenuated form of the true bacillus diphtheria, and the work of Abbott, Park, Koplik and I^scherich lends support to this position. On the other hand, it is suggested that the name "p8eudo-dii)htheritic " should be reserved to thsignate bacilli which, though resembling the true diphtheritic bacillus, show certain cultural differences and are devoid of pathogenic effect for guinea-pigs. Such a pseudo-diph

theritic bacillus has been found in a few cases of genuine diphtheria associated with the true bacillus diphtheriiB.

It must be confessed that our knowledge of the relation of the Loeffler bacillus to diphtheria and associated pathological processes has been much extended in the past few years. Thus this organism has been found in a large proportion of all cases of pseudo-membranous inflammation of the throat, and is the probable causative agent in all cases of true diphtheria. Those pseudo-membranous angina; in Avhich the Loeffler bacillus is not found are characterized in themselves and distinguished from cases of true diphtheria by the mildness of their course, their slightly contagious character and their low mortality; in Park statistics, excluding those associated with scarlet fever, the death-rate was 1.7 per cent.

That virulent diphtheria bacilli may be present upon the mucous membrane of the pharynx without giving rise to a false membrane is proven by those cases of pure laryngeal diphtheria from which the bacilli have been cultivated from the pharynx. Loeffler found in the throat of a healthy child a bacillus which was identical with the true bacillus diphtheriiB; later Hoffmann, Fraenkel and Feer found it under similar circumstances. In 330 healthy persons examined by Park and Beebe, who gave no history of contact with diphtheria, they found the non-virulent organisms in 24, virulent bacilli in 8, and pseudo-diphtheritic bacilli in 27. The examinations included for the most part children. Of the 8 cases in which virulent bacilli were found 5 were children in an .asylum where from time to time true diphtheria occurred. Of the remaining three, one was from a house where a supposed case of croup had existed three weeks before. Two of the 8 children developed diphtheria some days later; the other six remained healthy. Loeffler recently examined the throats of 60 school children and found diphtheria bacilli in four. Of these two subsequently developed diphtheria, one a slight inflammation of the throat, the fourth remaining well.

The study by Park of the throats of persons exposed to diphtheria has shown that in 50 per cent, virulent liOeffler's bacilli are present. Of these 40 per cent, developed later the lesions of the disease. Park states that in the families from which his statistics covering this point were obtained the conditions for the transmission of the disease were most favorable. On the other hand, in families where the patient suffering from diphtheria had been well isolated, the bacilli were found in less than 10 per cent, of the healthy children.

Considered in the light of our present knowledge of the common existence of pathogenic micro-organisms, such as streptococci, staphylococci and pneumococci, in the mouths of healthy persons without necessarily doing harm there, these facts of the occasional occurrence of virulent diphtheria bacilli in the throats of healthy persons are less surprising. Doubtless it is necessary that a certain susceptibility to their action — a predisposition, if you prefer, must exist before their peculiar effects can be exerted. I beg to recall in this place the experimental results obtained from healthy human blood-serum as bearing upon this point. However, the figures furnished by Park and Loeffler would indicate that the presence of the bacillus diphtheria; in the throat is far more significant even for the individual himself, to leave out of

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ooiisideration for a moment those with whom he may come in contact, than are the other pathogenic organisms mentioned.

The bacteriological study of convalescent cases shows that virulent bacilli may persist for a time after the disappearance of the false membrane. They are not uncommonly present after 2 to 3 weeks, and in a few instances they have been found after a much longer period. In a case reported by Park, and one also by Abel, they were still demonstrable on the 56th and 65th day respectively after the membrane had entirely gone.

The severity of the case has no influence upon the duration of the presence of the bacilli; the occurrence of nasal diphtheria as a complication seems to favor this persistence. Tezenas found in 13 cases complicated with nasal diphtheria that for a long time after the membrane had disappeared a serous exudation from the nose continued. In ten of these cases LoeiBer bacilli were demonstrable so long as the secretion persisted, although they had long ceased to be present in the throat. Hence where cultui'es cannot be made it is recommended to continue the isolation of the patients for at least three weeks after the disappearance of the membrane.

It is probable that the bacillus diphtherire is capable of increasing only witfiin the body of infected persons or in the seat of inoculation of susceptible animals. The bacilli are, however, able to remain alive and in a condition capable of causing infection for a considerable time when oiitside the body. Conditions which promote the drying of the organism and exposure to strong light are unfavorable for the preservation of its vitality. The individual Loeffler bacilli quickly die when allowed to become air dry. But in bits of mucus or membrane, particularly if protected from the light and preserved in a damjj place, they may remain alive for a long time — upon old cultures from 5 to 15 months; in bits of membrane from 4 to 17 weeks. They have been cultivated from tableware and toys ; from soiled linen which had been in contact with the sick; from the shoes and hair of nurses, and from the broom used to sweep the floor of a diphtheria ward. In view of these facts it is unnecessary to point out the importance of thorough disinfection and of the rigorous care that should be observed in disposing of the excreta of the sick.

The association of other micro-organisms with the bacillus diphtheriiE in the false membrane is by no means uncommon, although cases of pure diphtheritic pseudo-membranous inflammations are said to exist. The organisms usually associated with the Loeifier bacillus are the pyogenic cocci, strepto-, staphylo- and diplococci. Their presence is now known to be of great clinical and pathological significance, especially if they enter the deeper tissues, as they are wont to do. While the bacillus diphtheria? is found only exceptionally in the adjacent lymph glands and internal organs, there exists a group of cases of poly-infection, especially with streptococci, in which the latter enter the circulation and invade the organs. Since the introduction of the anti-toxin treatment of diphtheria this class of cases has attracted especial attention. 'I'hese cases had been recognized and studied by a number of investigators, and in this country especially by Councilman and his associates. iJroneho-pnoumonias, suppurations

of lymph glands and septic forms of diphtheria are attributed to these associated bacteria, particularly to the streptococcus. Koux and Yersin first pointed out the importance of this poly-infection, and subsequently Schreider, Mya, Barbier and Martin confirmed their observittions. Funk, Koux and Martin and Bernheim have recently made careful experimental studies on this subject. The latter employed only organisms which had been associated in the diphtheritic membrane, and he found that the virulence of the Loeffler bacillus is increased both by being grown with the streptococcus or in the filtrate obtained from streptococcus cultures. A limited number of experiments with staphylococci did not show a similar increase in the virulence of the bacillus diphtheriae, a result confirmatory of Mya's earlier experiments. On the other hand, in human beings, according to Morse's statistics, cases of polyinfection with staphylococci run a more unfavorable course than those with streptococci. Welch has criticized his conclusions and shown the improbability of their correctness.

The natural variation in vii'ulence of the bacillus diphtheriae led first unintentionally, and later purposely, to the rendering of animals immune to subsequent inoculation to the Loeffler bacillus. But it was soon observed that this method of securing immunity was capricious and unreliable. The use of cultures of bacilli attenuated by chemical agents, the injection of tissue fluids into another of an animal dead of a previous inoculation of the bacilli, the employment of sterilized bouillon cultures and of cultures grown in infusions of cellular organs, such as the thymus gland, while attended with success in some cases, were found to be precarious methods of securing immunity, and not at all adapted to large animals. The use of a virus obtained from bouillon cultures several weeks old by filtration has been successfully employed by Behring, Ehrlich and Wasserman, Koux and others, to render even large animals such as the horse immune to large doses of diphtheria cultures. And one of the surprising and significant facts which has resulted from the study of the changes induced in the body fluids of the immune animal consists in the discovery that they contain a substance which is capable of rendering other animals, and even human beings, immune from diphtheria and also of curing the disease after its development.

This anti-toxin obtained from the blood of immune animals, though antidotal to the poison of the bacillus diphtheriaj, exerts no power over the poison produced by the bacteria associated with the Loeffler bacillus in the pseudo-membrane, and thus it becomes clear why cases of poly-infection are less influenced by the anti-toxin treatment than those of pure diphtheria.

It is but a confirmation of an intuitive belief to find that in the blood of human beings well of diphtheria there exists a body smiilar to that found in immune animals. The e.\perimentsof Klemenciwiczand Escherich proveil the correctness of this supposition, and Abel has just furnished a large series of observations with confirmatory results. In animals a certain time elapses after the inoculation of the toxin before the antitoxin appe;irs, and it is only after repeattni doses at intervals that a high grade of anti-toxic power is developed in the bloodserum. In human beings the blood taken on the 5th or Gtb

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dav after infection shows no protective action ; the protecting power appears from the 8th to the 11th day, and it persists a variable time. Sometimes it fails to appear at all. After .some months it may be still present, though in a diminished degree, or it may have entirely disappeared. The longest periods of its persistence yet observed are 150 and 200 days.

These facts bear out the experience of physicians who have noted that diphtheria is not one of those diseases one attack of which affords protection to subsequent infection. Perhaps the individual differences observed are to be explained by the variation in the amount of healing and protecting substiinces formed in any case.

In cases of genuine diphtheria the Loeffler bacilli are found in large numbers in the pseudo-membrane, there being less in the deeper than in the older and more superficial parts. A lesion of the surface provides a condition favorable to their settlement and increase, a fact also borne out by experiments on susceptible animals. Where no previous defect exists it is j)robable that the toxin itself can cause a superficial lesion. The tonsils, which are the starting-points of many cases of diphtheria, afford an excellent nidus for the bacilli, on account of the incompleteness of their epithelial covering, even in health. The depth and extent of the necrosis of the mucous membrane vary in different cases; and the character of the pseudo-membrane is affected by the nature of the underlying structures ; in the pharynx it is firmer and less easily separable than in the larynx and trachea, where a distinct basement membrane is found in the mucosa.

The earlier workers in the field of experimental diphtheria failed to find in the internal organs the lesions which had been described by Oertel in the tissues of human beings dead of diphtheria. These lesions consist of foci of cell-death characterized by extensive destruction and fragmentation of cell nuclei. In such areas of necrosis fibrin may be deposited.

Dr. Welch and I confirmed and extended these results of Oertel by experiments upon guinea-pigs, kittens and rabbits. Subcutaneous inoculation of cultures of the organism or of the filtrate in a bouillon culture 4 or 5 weeks old, produces, besides the local lesion peculiar to each, foci of cell-death in the adjacent lymph glands and in the lymph glands throughout the body ; in the spleen, liver, lungs, heart muscle and intestinal mucosa. The kidneys show degenerative changes. When the dose is small and the animal lives several weeks the paralysis which belongs to the disease may develop. This phenomenon, first observed in animals by Koux and Yersin, was noticed among our animals. Interesting changes have been described in the peripheral nerves under these conditions by Sidney Martin. In some cases he observed defects in the myeline sheaths, which stained poorly in osmic acid, while in certain severe cases the sheaths had entirely disappeared. The axis cylinders were either intact or had undergone granular degeneration, and the continuity of some of the fibres had become broken. At times the muscles supplied by these nerves showed signs of fatty degeneration. These changes agree with those found by Gombault, Meyer, Leyden and Arnheim in human beings who had suffered from diphtheritic paralysis.

Albuminuria is a not infrequent complication of the disease, and casts may appear in the urine. In some cases the urine may be much diminished in amount, but ursemia is unusual ; and hydrops, which seldom occurs, is, when present, of a mild grade. The heart is not uncommonly involved, and the lesions described are either parenchymatous degeneration, in the severer grades, associated with fatty degeneration, or interstitial myocarditis. The lymphatic glands of the neck become swollen, but show a slight tendency only to suppuration. Various complications due to the invasion of secondary micro-organisms occur.

A CASE OF CHOREA MINOR OCCURRING DURING AN ATTACK OF MANIACAL

EXCITEMENT IN AN ADULT.

By Henry J. Berkley, M. D.

[Read before the Johns Hopkins Medical Society.]

Mary H., set. 47 years, was admitted to the City Insane Asylum on August 27, 1894, with subacute mania and general chorea, the musculation affecting the entire body.

The maniacal attack, which was preceded by a prodromal period of several weeks, began about the nuddle of -Tuly, and according to the report of the physician in attendance, was unaccompanied by fever, but, on the other hand, the circulation was very defective, the extremities being cold and bluish. In the third week after the beginning of the mental excitement slight jactitations of the facial and arm muscles were noticed. These muscular movements increased in severity, until the chorea was as severe as an ordinary case of St. Vitus dance in childhood.

On admission the patient was considerably excited, inco

herent, talked in a rambling, silly manner, and had general choreic movements that were especially well marked in the upper extremities and in the facial muscles. There were, however, movements of almost all the other muscles. The hands and arms were moved in an irregular, purposeless way, the time of the contractions not differing in any manner from an ordinary case of chorea minor. There was no tremor about the facial or small muscles of the hands. The gait did not l)etray any incoordination, but the finer tests could not be applied on account of the mental condition. Articulation was not interfered with.

The physical examination showed a very anaemic woman, without bodily deformity or visceral disease. The heart's action was weak, rapid, ninety-six beats to the minute, but

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there was no murmur. There was no elevation of temperature. The tongue was furred, the vegetative functions disordered. Menstruation had entirely ceased for several years.

The irides were slow to react to light or accommodation. The deep reflexes were subnormal, the superficial a little slow. The urine contained neither sugar nor alVjumen.

During the month of September the choreic movements gradually diminished in intensity, though no medicine was given to influence them, and by the middle of October had almost ceased, only an occasional incoordinate movement of the facial, arm or neck muscles betraying the presence of clonic spasm.

On October 17, the patient was again thoroughly examined. The mental excitement had almost abated, and the woman was considerably demented. She would occasionally answer a direct question by some irrelevant monosyllable, usually the word "why" to all interrogations. The physical condition had improved considerably, the eye irregularities and the deep reflexes had returned to the normal. There was no heart lesion, both the first and second sounds being clear. The pulse was rapid, ninety-six to the minute, there was no irregularity.

December 28. — ^The physical condition of the patient is still improving, while the mental remains stationary or is slightly worse. The mental reduction is very considerable; she is untidy, tears her clothes and soils her room. Will occasionally aTiswer a question, though never to the point. The pulse now stands at one hundred and four beats a minute. The irregular muscular movements have entirely ceased for a number of weeks, having endured in all a little more than three months.

The family history offers but a single point of interest, namely, that two of the woman's three children (both girls) had chorea in childhood, from which they made a perfect

recovery. The third child, a son, is not bright, and the whole family seem to be below the average in intelligence.

The family deny that there have been cases of insanity among its members, also, positively, that the mother ever had a previous attack of either chorea or insanity, a statement that is corroborated by an elder sister of the patient. On the other hand, they state that she has always been healthy until the past June, at which date the first symptoms of the mental disorder were noticed.

The family are in poor circumstances, and it is more than probable that insufficient and improper food played a large part in the causation of the mental trouble.

Whether the chorea had as its genesis an infection beginning during the first weeks of the maniacal excitement is problematical ; certainly there was no coexisting rheumatism or other febrile disease at the time.

The case reverses many of our accepted ideas of the mental condition in chorea minor, and in this respect appears to be unique. Occasionally in chorea we find pronounced disturbances of the faculties of memory and attention, as well as other imj)ortant mental faculties, iind rarely acute melancholia may be present, or the patient may become in some degree demented, but in all forms of chorea, including chorea insaniens, the choreic movements always precede the mental disturbance, and never follow in its course. Again, primary chorea in a woman of forty-seven years running the course of an ordinary attack of St. Vitus dance, and tending eventually to a full recovery in the course of twelve to fourteen weeks, is practically unknown ; such cases as do occur in this decade of life ordinarily inclining toward a chronic progressive type^ and are not properly to be classed among the Sydenham choreas.

PROCEEDINGS OF SOCIETIES.

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of Janu<trij 21, 1895. Dr. Abel in the Chair. Progressive Neural Muscular Atrophy.— Dh. H. M. Thomas.

The two cases which I bring before you to-night illustrate a very interesting and rare form of muscular atrophy. One of the patients is at present in the hospital, and the other, his sister, kindly comes, so that we can have the opportunity of seeing them together. They both complain of weakness in the feet and hands, and besides this, as you see, the brother is suffering from another troublesome affection.

The family history of these cases is of interest. The brother says that their father's uncle on his mother's side and the son of this uncle also suffered with trouble in the hands and liad difficulty in walking. Another first cousin of the patient's father, his mother's sister's child, also suffered from what was thought to be the same trouble. As far as they know, the patients here now are the only members of the family affected in the present generation.

The history of the patient is as follows: K. II., a^t. 3G.

Dispensary Xo. 80,927, applied to the dispensary for relief from the spasmodic movements about the neck and face. So far as he knows he was well as a young child and learned to walk at the proper time. He thinks that he was able to play as well as other children, but remembers that he never could learn to skate. When he was eleven years old he had some sort of skin affection of the chest for which he was salivated, and to this date he ascribes the beginning of the trouble iu hrs legs. He was at that time unable to walk for a week. He had scarlet fever when ho was about thirteen years old. followed immediately bj' typhoid fever, after which he had dropsy. Following this illness he had some difficulty in speaking plainly, which has gradually become worse. At first the weakness in his legs gave him very little trouble and he was inconvenienced only when he ran. He taught schix>l from the time he was seventeen until he was twenty-one, when he had to give it up on account of his difficulty in speaking. When he was abont nineteen the weakness iu his ankles b.id progressed so far that they would turn under lun» and csmse him a great deal of pain. After giving up his school he learned to telegraph and w;is employed iu this occupation up

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to three years ago ; although he never was a rapid operator nor did he write a very good hand He himself noticed nothing particularly wrong with his hands until his attention was called to them here in the hospital. The weakness in his legs increased very gradually, and the deformity which is now present developed equally slowly. He has never complained of any sensory symptoms.

The spasmodic movements about his head and neck are difficult to bring into relation with the muscular atrophy, and perhaps it would be better to consider them as a separate affection. They began ten or twelve years ago, when he was about twenty-five years old. At that time he noticed a slight twitching in the muscles of the right side of the neck, coming on every afternoon and lasting about an hour. The twitching at first was slight and did not cause any movement of the head; it gradually increased and became more constant, until after a time he was never free from it, and the muscular contraction became so great as to cause movernents of the head. At first he had some slight voluntary control of these movements. He was opei'ated on twice in Chicago, the nerve having been once stretched and once cut. He derived no benefit from these operations and the disease gradually involved other muscles, spreading to the other side of the neck, and four or five years ago to the muscles of the face. At times he has slight tremors of the muscles of his arms and hands. Any excitement increases the movements; they, however, entirely cease during sleep.

As you see, the patient's head is usually held bent towards the left shoulder, with the chin up, and is in constant motion, the chin often being depressed and twisted until it touches the left shoulder. Occasionally the head is turned to the right. From time to time the muscles of the face are all thrown into tetanjc contraction. Any effort to speak exaggerates these facial contortions. The platysmae also are involved in the spasm. Every now and then the contractions cause slight movements of the shoulders and arms.

The patient speaks in a peculiar muffled voice, and often seems compelled to make a great effort to overcome some spasm of the muscles of articulation. Some words are, however, brought out in a clear, distinct tone.

We are inclined to think that this distressing spasmodic affection of the muscles is an example of torticollis involving many more muscles than is usual. This is in itself a most interesting condition, but this evening I wish to call particular attention to the case in respect to the muscular atrophy. You will notice that both feet are deformed, the left rather more than the right, but both in the .same manner (Fig. 1). The heels are somewhat drawn up, the soles of the feet are opposed, the arches of the feet are exaggerated, and the feet are very thick through the instep. The toes are dorsally flexed. On the outer edge of each foot there are large hard calluses, due to the position of the feet in walking. There is very little evident atrophy about the legs or feet. The thighs, fifteen cm. above the patellae, measure fifty-three cm. The largest circumference of tile calves is thirty-four cm. All the muscles moving the Inp-joints and the knee-joints are very strong. In flexing the ankles, the tibialis anticus seems to be the only muscle acting. An endeavor to make passive extension brings about exagger

ation of the deformity. The peronei seem to be completely paralysed. The extensors are strong. The movements of the toes are very limited, but they can still be moved feebly.

No disturbance of sensation could be demonstrated. The knee-jerks and the reflexes from the Achilles tendons are abolished. The skin reflexes, plantar, cremasteric and abdominal, are active. In the calf muscles on both sides can be noticed wave-like muscular contractions, which are somewhat coarser than what are usually called fibrillary contractions.

The patient walks with a clumsy shuffling gait on the outer edge of the feet with the toes turned in.

If you examine the arms you will notice that the muscles of the neck and shoulder, arms and fore-arms are well developed, but that there is a marked atrophy in the small muscles of the hands. This is especially evident in the space between the thumbs and forefingers (Fig. 3), and on the ball of the thumbs. The muscles about the shoulders and elbows are strong, and also the muscles moving the wrist show no marked weakness. Adduction and abduction of the fingers are very weak, as are also the movements of the thumb. No fibrillary contractions are noticed in the arms; no reflexes are obtained from the tendons of the triceps muscles, and we have been unable to demonstrate any change in sense perception.

The electrical examination in the muscles of the arms and legs revealed a remarkable condition. The small muscles of the hands could not be made to respond to either the faradic or galvanic currents, nor could I, with any strength of current that the patient could stand, cause a contraction in any of the flexor muscles of the ankles except the tibialis anticus muscles. And in general the nerves and muscles of the arms and legs responded, if at all, only to extremely strong currents; thus — the uluar nerve above the elbow showed a slight K. CI. C. to a current of 8 M. A.; the musculo-spiral to 10 M. A. During the examination it was noticed that the muscles of the forearm were the seat of slight irregular spasmodic contractions. The muscles of the arms and legs in general responded normally to mechanical irritation.

The history of the sister is as follows:

Mrs. K., mt 28, Dispensary No. 87,679, thinks she was a strong little girl, had measles, but can remember no other illness. Has been married eight years; has never been pregnant.

When about twelve years old her feet began to get a little weak, although at this time she paid very little attention to them. At times her ankles would turn under her and she was unable to learn to dance, or to take part in games that required much running. Her ankles gradually became weaker, and when she was eighteen years old she was advised to put on braces ; this she did, and wore them for three years, but finding that they did not help her she discontinued their use. Her feet have very slowly grown worse, the right foot being worse than the left, and she has noticed that she has very little power over the right great-toe.

For the last five or six months the patient has had numb and tingling sensations in her hands, and when they get in the least cold she is unable to perform any of the finer movements with them, such as getting coins out of her purse, or a key out of her pocket and unlocking the door. She has not

Makch, 1895.]

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noticed any other weakness about her hands nor any atrophy. She has occasional twitchings about the eyelids, but no other jerkings in the muscles.

Her general health is good.

Upou examination I think it is evident that her legs below the knee are smaller than they should be ; she flexes the ankles fairly well, but in resisting my eiforts to extend them, the toes are turned in, the inner border of the foot is drawn up, and the foot assumes a position quite similar to that of her brother's. The tibialis anticus is the only muscle of this group that is at all strong, and in short the same muscles are involved as in her brother, although in a less degree. The knee-jerks are present, but are somewhat subnormal.

In her hands, as you see, there is undoubtedly beginning atrophy of the small muscles, and their resemblance to her brother's is evident.

No fibrillary contractions have been noticed anywhere, and we have been unable to demonstrate any sensory changes.

The electrical examination revealed the same condition as that described in the case of her brother, and it is quite startling to apply very strong currents to muscles which act well voluntarily and receive no response.

I think there can be no doubt that these patients are suffering from the same disease, and it seems probable, although of course not certain, that the other members of the family mentioned in the history were similarly affected.

We have here a disease occurring in a family, characterized by a slowly progressing weakness and atrophy of certain muscles, beginning at about the time of puberty, in the muscles of the legs and feet, especially the peroneal group ; accompanying this weakness there has slowly developed a deformity of the feet, equino-varus ; years after the onset, the small muscles of the hands have become involved, so slowly that it was not noticed by either patient.

Associated with this change in the muscles there is a very remarkable electrical condition. The muscles most involved cannot be made to contract by any current that can be used. In most of the other nerves and muscles of the body there is a very great decrease iu their electrical excitability.

So far the symptoms are parallel in the two cases, but the sister complains of distinct subjective sensory disturbances, from which the brother is apparently entirely free. No fibrillary contractions or similar phenomena were detected in the sister's muscles, whereas in the muscles of the brother's calves thei'e are coarse fibrillary contractions, and a peculiar um-est in the muscles of the fore-arm, not to speak of the intense torticollis, which is his most distressing complaint, but which we are at present unable to associate witli the disease under discussion. It is, however, quite possible that a more extended examination of the sister might reveal some fibrillary contraction. In the brother the deep reflexes are abolished, and althougii present "n tlie sister, are distinctly less active than is usual.

These cases are good examples of that form of progressive muscular atrophy which seoms to occupy an intermediary position between the spinal forms on one side and the group collected together under the name of muscuhir dystrophies on the other. It is known bv several names, and there is still a

good deal of discussion about its pathology. Cases belonging to this class were described as early as 1856 by Eulenbnrg. Eichorst also described similar cases in 1873, and Osier in 1880 described a most interesting family, the Farr family of Vermont, in which many members were affected by an unusual foi-m of muscular atrophy. Hammond in 1881, Ormerod in 1884, and Schultze in 1884 each recorded cases. Charcot and Marie (Eevue de Medecine, 1886, p. 96) collected a number of cases, recognized them as a peculiar form of muscular atrophy and gave a very clear clinical picture, so that this form of muscular atrophy is known in France as the Charcot-Marie type.

Tooth (Brain, 1887), in England, quite independently describes the disease under the name of muscular a/ropJiy of the peroneal type. He was followed by Herringham (Brain, 1888). Hoffman (Arch. f. Psych, etc., 1889, p. 660), in a long and thorough article, reviews the subject and suggests the name progressive neurotic muscular atrophy, as indicating his belief that the pathological basis for the disease was a slowly progressive degeneration of the peripheral nerves. Sachs of New York (Brain, 1890) wrote of the disease as the peroneal form or leg type of progressive muscular atrophy- He considered it a form of the spinal atrophies beginning in the legs. Hoffman's second article appeared in the first volume of the Deut. Zeitschrift f. Nervenheilkunde, in which he thinks it better to call the disease progressive neural, instead of neurotic, muscular atrophy. Bernhardt (Virchow's Arch., Bd. 133, 1893) proposes as a name for the trouble progressive spinal ncuritic viusrular atrophy, as he thinks that the spinal cord as well as the peripheral nerves are involved. Ferrier is of the same opinion (Brit. Jfed. Jour., 1893) and he suggests the name myelo-nmropathic amyotrophy.

The authors agree well as regards the clinical picture. It occurs either as a hereditary or a family affection. It often begins in childhood, causing great deformity of the feet. The muscles first affected are usually the small muscles of the feet and the peroneal group. The progress is very slow, and usually after several years the small muscles of the hands become affected before the muscles of the thigh show any weakness. In fact in certjiiu cases the disease may begin in the hands (Hoffman). The disease may not begin until puberty or adult life. It is often accompanied by both subjective and objective sensory disturbances. The deep reflexes may be normal, diminished, or abolished. Fibrillary contractions and muscular twitchings are often present. Very generally there are marked changes in the electrical excitability of the nerves and muscles, consisting either iu a loss or a very great decrease of the excitability, and this can often be demonstrated not only in the atrophic muscles, but also in nerves and muscles tliat are performing their fuuctious quite normally. Bernhardt h;is described the case of a memWr of a family in which this disciise occurred, who only complaiueti of becoming tired very easily and in whom he demonstrated this reuuirkable electrical condition and was from this able to nuike the diivgnosis.

In regard to the pathology, not a great deal is known. Hoffman refers to two old cases, one by Virchow and one by Friedreich, iu which was found a marked degeueratiou in the

peripheral nerves as well as some slight degeneration in the colunuis of Gall, and he refers to the record of a case by Diibreuilh (Kev. de Med., 1890) in which was found old tlegeneration of the nerves, most intense at the periphery, decreasing towards the spinal cord, and just observable in the anterior cervical and lumbar roots. There was also a slight increase of the neuroglia of the columns of Gall, and the pyramidal fibres were somewhat more deeply colored than usual. The gray matter of the spinal cord was normal. There were well marked degenerations in the muscles.

Hoffman does not consider that these observations determine whether the disease is primarily in the spinal cord or the peripheral nerves, but thinks that especial emphasis should be laid upon the lesions of the nerves as distinguishing these cases from the ordinary spinal form of progressive muscular atrophy, and I think we cannot go far wrong in following him in calling these cases progressive neural muscular atrophy.

Dr. Oslek. — This disease is of great interest on account of its rarity. There have been very few observed in this country; I think Dr. Sachs has reported the only one. The Farr family, which came under my observation some years ago, had 13 members affected in two generations. I had a letter the other day from the son of my old patient, Wesley Farr, and he states that none of the members of his generation or in his family or in his cousins' have been affected. Many of them now are men and women past the adult period. He mentions that if the disease is beginning in him at all it is beginning with a "yanking" in his eyelids. It is rather remarkable in that group that in all the members affected it began late in life, all over 40, which has raised some doubt as to whether that family actually belongs to this type of the progressive muscular atrophies. These are the only cases we have ever had at this hospital.

Meeting of February 4, 1895.

(ireeii Hair.— Du. OrrENUEiMER.

Dr. Oppenheimer presented a specimen of green hair.^ The hair was from a patient, aged 58, a coppersmith, who came to the medical Dispensary in July, 1891. He had been a workman in copper works for four yea'rs, exposed to very fine copper oxide dust. He was not very clejiuly in his habits. Since half a year or so he had had vague stomach symptoms; nausea, occasional vomiting, some distress, but no actual pain after eating ; no colic. No pulmonary symptoms were complained of, and the examination of the chest and abdomen was negative. There was no line on the gums. He did not return after the first visit, but it was ascertained that he died two years later with a severe cough.

The chief point of interest was the hair. Like the specimen presented, it was a pale but quite distinct green. This was more true of the hair on the head and of the moustaches, l>ut all over the body, in the axillaj, over the pubes and shins there was the same coloration. Copper was easily demonstrated chemically. Microscopically the hair was uniformly colored, no crystals being seen anywhere. The color was less marked towards the root of the hair. Boiling in water did not remove the color, but ammonia did so at once.

Greenish hair with men in copper works and in copper mines is not unknown. As far back as 1654 Bartholin noted its occurrence. Several observers since then have remarked on it, Kobert, in his " Intoxications Krankheiten," and Ilirt, in his "Krankheiten der Arbeiter," both mentioning it. Petri in 1881 reported a case in which the root of the hair was free and crystals were to be seen.

On questioning at the copper works, it was found that the patient was an exception, the majority of men being free. They state, however, that it is only by scrupulous cleanliness that they avoid the coloration. They must wash their hair daily in a solution of soda, as ordinary water is ineffectual. The part first apt to be affected is the moustache, and next the head; though, if the latter is protected by a thick cap, it will be free. The color appears a few days after starting work, and is more apt to come in summer time, when they sweat freely. Then the underwear has a greenish tinge, wherever it has been thoroughly wet with sweat. They seldom have any gastro-intestinal disturbance, but a severe, distressing cough is not uncommon, and occasionally ends fatally.

Brassfounder's Ague. — Dr. Oppenheimer.

Dr. Oppenheimer also presented a case of " Brassfounder's ague." The patient came into Dr. Osier's wards first on October 9, 1894, complaining of colic and general weakness. He had been a workman in a large bell-foundry in the city for 4 years, employed in a room where the metal is melted. He was regarded as a case of lead poisoning ; the colic, extensor weakness and a blue line on the gums pointed to this. He had also mitral stenosis. He left the wards October 15, 1894, and was again admitted on January 18, 1895, for dyspnoea, and other symptoms, due to lack of compensation. He gave the following history as regards his chills :

He is employed in the room where the metal is melted. For this, old copper, zinc and brass are melted in a vat ; white fumes arise, and are inhaled, giving rise to a feeling of fulness and distress in the chest, and coughing. Later new copper is added, but this does not give rise to any fumes. He begins work at 7 A. M., and all melting is over by 4 P. M. If he is to have a chill, when he gets into the open air he feels tired and has pains all over, especially in the joints. About 6-7 P. M. he has a severe shake, lasting 1-3 hours; he takes a whiskey punch, goes to bed and sweats profusely ; then he falls asleep. The next morning he feels exhausted and tired, enough so at times to keep him from work.

The following circumstances increase the probability of a chill:

1. Absence from work for some time previous.

2. Damp, cloudy weather.

3. Poor ventilation; thus the chills are more frequent in winter than in summer.

Out of 38 workers in his department, all have had chills. On a bad day nearly all will have a paroxysm. There are seldom less than two or three laid off, and occasionally all have been absent. There seems to be no difference in susceptibility.

According to Hirt, these chills were first called attention to in 1844 by Blaudet. Green how reported several cases in

March, 1895.]

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1862, and his conclusions were practically tlie same as the patient's. Hirt had two paroxysms after inhaling the fumes. His description is as follows: "A few hours after inhaling the fumes there is a peculiar, uneasy sensation through the whole body, a feeling of prostration and weakness. This is combined with drawing pains in the back, and soon one is obliged to stop his work. Musciilar pains appear next, at times in the upi^er, usually in the lower limbs ; these may become very intense. With all this the pulse is quiet and the respiration not hurried. Soon after going to bed a general shivering appears, which usually increases to a well defined chill, lasting fifteen to twenty minutes. The pulse becomes rapid, as high as 130 to the minute. Coughing, which at first is unimportant, not more than a mere tickling in the throat, becomes severe and distressing, giving rise to soreness in the chest. Frontal headache sets in and is intensified with each paroxysm of coughing, making the condition almost unbearable. However, the height of the paroxysm is soon reached (in three to six hours), and the stadium decrement! begins with a profuse sweat. The symptoms abate and the patient falls into a deep sleep, from which he awakes with a quiet pulse and respiration, no cough, and only a slight headache, and some weakness to remind him of the paroxysm."

The description tallies very well with the patient's except that the after-effects were severer with the patient.

The white fumes, arising from the vats, precipitate as a powder. Dr. Aldrich has kindly examined this, and finds it contains zinc oxide and carbonate, but no arsenic.

Exhibition of Surgical Cases. — Dk. Platt.

Case 1. This boy, '11 years of age, came to us some seven weeks ago. He was run over by a heavy express wagon and fractured his right thigh. He was neglected by his parents or physician, or all together, for 15 days, and when he entered the Garrett Hospital the thigh was bent at a right angle at the point of fracture. I bring him before you to show what an excellent result can be gotten in a boy ; a much better result than could be obtained in an adult. The injured extremity is only one-half cm. shorter than the other, which is quite within the normal limits of variation.

Case 2. This boy of 11 years is a case of congenital hypertrophy of the foot. I have never before seen a case where the foot alone and not the leg was involved. Sometimes we have hypertrophy of the toes or fingers, but hypertrophy of the foot is very uncommon. The mother is said to have had a severe cellulitis of the foot during pregnancy. An interesting fact in this connection is that every three or four months the patient has what appears to be an inflammation in the foot. One might think it was a case of beginning acromegaly, but I do not believe it is anything but a pure congenital hypertrophy of the foot. The patient can walk and run and has no tenderness, limitation of motion, or indication of a local disease in the foot or ankle.

Case 3. This little girl, about 8 years of age, has a congenital amputation of the forearm just below the elbow. She has two teat-like rudimentary fingers. The extreme upper end of the radius is of full size, while the ulna is rudimentary and can scarcely be felt. The rudimeut^iry forearm

is quite useful, enabling her to wash dishes and perform other household duties.

Case 4. This boy, 6 years of age, had a testicle incarcerated between the internal and external rings, both rings being tightly closed. The testicle was frequently bruised and painful. The people at one of the hernia institutes were anxious to inject him for the cure of a supposed hernia. The boy came into the Garrett Hospital, where I operated upon him. I exposed the testicle, and after stripping the cord np to the internal ring and making slow traction, succeeded in lengthening it sufficiently to reach the upper part of the scrotum ; then by dilating the external ring from below it was made large enough to get the testicle through. The testicle was stitched to the bottom of the inverted scrotum and pulled down. It is now in the upper part of the scrotal pouch.

Case 5. This was a case of complete epispadias. The boy had only a trough out of which the urine dribbled day and night. I have performed upon him the five classical operations of Thiersch, which have spread over a long period of time. The result is very good. There Avas at first absolutely no closed urethra. He has now a complete urethra (with two small lateral openings, which will be closed later), through which he passes his water, and has very good power of control over his urine.

NOTES ON NEW BOOKS.

BOOKS RECEIVED.

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL.

Vol. VI.- No. 49

BALTIMORE, APRIL, 1895.

+++

Contents

The Writings of Mauriceau. By Hunter Robb, M. D., - - 51 The Psychologic Development of Medicine. By J. H. McCorMicK, M. D., 58

Peritonitis caused by the Invasion of the Micrococcus Lanceolatus from th£ Intestine. By Simon Flkxner, M. D., - - 64

A Rapid Method of making Permanent Specimens from Frozen Sections by the Use of Formalin. By Thos. S. Cullen, M. B., 67

The Condition of the Gemmules or Lateral Buds of the Cortical

Neurodendron in some Forms of Insanity. By Hexky J.

Berkley, M. D., 68

Proceedings of Societies :

The Hospital Medical Society, 69

Exhibition of Specimens : Cases of Tuberculosis [Dr. Flkxner] ; — An Ideal Result following Double Tenotomy in a Case of Convergent Strabismus [Dr. Theobald]. Notes on New Books, "2

THE A^niTiisras OF m:^tjiiicea.u.

By Hunter Robb, M. D., Professor of Gynwcology, Wester7i Reserve University, Cleveland, Ohio. [Read before the Johns Hojtkinit Hospital Historical Society, April 8, 1895.]

FraiK;ois Mauriceau, Master of Arts, an ancient provost and guard of the company of sworn Master Surgeons of the City of Paris (for these are the titles which follow his name on the first page of his principal work), was born in the year 1637 and died in 1709. The accounts which we have of his life are very meagre, and it is qirite possible that had he not lived at a time when the number of illustrious names added to the history of medicine was very small, he would have been almost unknown to posterity. Levret, however, says that Mauriceau " drew from the cradle" the art of midwifery.

In any case, when considering the principal Avorks on midwifery and on the diseases of women which appeared during the 17th and 18th centuries, it would seem that his writings could hardly be passed over in silence.

Besides his 283 aphorisms, to some of which I shall refer later, he wrote a work on midwifery which passed through many editions. The title as it appears in an English translation by one Hugh Chamberlen, is as follows: "The Accomplisht Midwife, treating of the diseases of women with child and in child-bearing, and also the best directions how to help them in natural and unnatural labor, with fit remedies for the several indispositions of newly born babes, illustrated with divers fair figures and very correctly graven in copper. A work nuuh more perfect than any yet extant in English,

being very necessary for all teeming women, as also for physicians."

The edition which I have been reading was published in 1682, but the book appeared first in au incomplete form, as the author himself tells us, in 1668. It is dedicated with a great many stereotyped polite phrases to Antoine Daquin. who was the chief physician of Louis XIV. After the dedication ■we have the usual page of epigrams, one to the envious critic, another to the jealous ignoramus, both of which are by the author. The third, written by Dulaurens, is in praise of "Fran9ois Mauriceau, the writer of a most useful book on child-birth."

In the preface the reader is recommended to approach the study of the work in a teachable spirit, for the author says, "As purgatives though excellent in themselves will not profit a body that has not been prepared for them, so books canuot instruct those who are not ready to receive instruction." He then goes on to compare the authors who had written on this subject before his time to geographers who have never set-n the countries which they describe, and adduces his sixteen years practical experience as a proof that he knows of what he writes.

Possibly as a sort of bribe to his readers, he promises that in the last part he will reveal all the most profound secrets of the art, and while humblv acknowledging that there mav be

52

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 49.

6ome chaff among the wheat, he thinks that those who look for it will find in the book a sufficiency of good grain to reward them for their labors.

The work is divided into three books, which are preceded by an anatomical treatise on the female generative organs.

The first book treats of the different diseases of pregnant women from the time of conception to that of labor; the second book deals with labor itself ; the third is devoted to a consideration of the puerperal state, and to the diseases of newly-born infants.

Perhaps the most striking thing about his anatomy is the mistake (which he persists in emphasizing more than once) iu calling the ovarian ligaments " the true ejaculatory vessels which go from the testicles to the uterus." The Fallopian tubes also appear in his figures, but he takes pains to describe them as " the vessels which many esteem to be the only true ejaculatory vessels described by Fallopius under the name of tubes, or trumpets."

To the ovaries he ascribes functions analogous to those of the testicles iu the male, but he says that they are formed differently, being made up of vesicles " which some moderns concede to be eggs without shells, which, after being fructified by coitus, some days later fall into the uterus."

He especially criticises the views of Graaf and his followers for saying that the human female possesses ova, and adds, "This sentiment ought not to be followed by other wise men for the reasons as well known to them as to me."

He incidentally mentions ovarian cysts and believes them to be due to some congenital malformation of the ovaries.

As I said just now, he believes that the ovarian ligaments are the real vasa deferentia because they go straight from the ovary to the uterus. The fact that they are solid tubes and not canals does not seem to have caused him any difficulty, since he argues that this will not at all prevent the sperm from trickling through. Believing as he did most thoroughly that the female contributes semen as well as the male, and being utterly opposed to the idea of the existence of ova, he could not see how the fluid could pass from the ovaries to the fallopian tubes, "seeing that the two are not connected."

He divides the uterus into four parts, the body, the internal opening, by which he meant the external os, the neck of the uterus or vagina, and the external orifice or vulva.

He corrects the measurements of Galen and other anatomists, and says that the length of the uterus from the vulva is not four but eight inches. He condemns Bartholini for saying that the uterus during pregnancy becomes thicker as well as longer, and quotes Galen and Vesalius to show that the pregnant uterus develops at the expense of the thickness of the walls, just as happens when the bladder expands as jt fills with urine.

He did not understand that during pregnancy there is an actual increase in the number of muscular fibres in the uterus. He says that if an ewe be opened in the last days of pregnancy the fcetus can be seen through the transparent walls of the uterus.

In aphorism xxiv Mauriceau states that the vessels in the uterus develop in size during preguanc)'. " If this be 80," says Boivin, "and if the calibre of the vessels is aug

mented, why should the walls of the uterus become thinner ? As a matter of fact the uterus loses little or nothing in thickness ; this is a phenomenon of pregnancy which is most astonishing and admirable. It is true that the uterus can become tliin at certain portions, especially those which are in contact with a prominent angle of the pelvis. Many causes may give rise to rupture of the uterus, and the viscus is not always distended in proportion to the size of the child."

Believing that the menstrual fluid was meant to nourish the child, he thought that blood came from pregnant women, whenever the supply to the uterus was more than was required to nourish the foetus. He accounts in this way for the exceptional instances of menstruation during pregnancy.

He held that the uterus was supplied to a very great extent by the sixth pair of cranial nerves, which also went to the stomach, and thus finds an explanation for the various gastric disturbances occurring iu pregnancy.

He bases the signs of virginity on the disposition of the four caruucula?, and says that " the membrane w hich some describe as lying within and across the vagina, and call the hymen," is pathological. He ridicules the idea that it is always possible to tell for certain as to the virginity of a woman, and quotes in support of his position certain verses from Proverbs, chapter xxx, interpreting them perhaps correctly, but upon this point I must plead ignorance.

He had evidently dissected animals, since he describes the uterus of some as containing several different cavities. Aphorism XX says "the uterus of a woman possesses only one cavity, and is different from that of most other animals, in which this organ possesses several small cells." Boivin's footnote is as follows : " Several cases of double uterus in women have been reported ; I saw at an autopsy of a newly-born female infant a double uterus; each uterus possessed an orifice corresponding to a separate vagina ; these two vaginse ran together and terminated in separate orifices at the inferior commissure of the vulva ; the same infant had several supernumerary fingers and toes."

The semen of a woman he holds to be an extract of the purest arterial blood elaborated in the ovary and containing a quintessence of all the parts of the body. He is highly indignant with those who deem the semen an excrement, when in reality it is the " master fluid of the body."

On generation he says, "Sperm from the male and female is necessary for generation, and both secretions must be prolific, that is, they must contain the idea and form of all parts of the body."

Aphorism Ixiv says, "Sterility is usually due to some imperfection in the woman ; for thirty sterile women one sees only one sterile male."

In speaking of sterility he lays much stress upon atresia as a cause of this condition, and recommends operation if constitutional measures are not successful.

He considers birth-marks to be due to some malformation in the blood-vessels, and ridicules the idea that the so-called strawberry marks are caused by drinking red wine during pregnancy, since "it is well known," he says, "that such things are seen in countries where nothing but white wine is taken."

April, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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He mentions an interesting case of a pregnant woman who nursed a child who had smallpox and afterwards bore an infant who bad also the marks of smallpox. He fails to explain this phenomenon satisfactorily, but does not believe that it was simply due to mental emotion on the part of the mother.

Speaking of the signs of conception, he considers a slight pain in the region of the navel as of importance, and thinks that it is caused by tension upon the urachus.

The flattening of the abdomen in the first few weeks of pregnancy he attributes to the loss of flesh at this time.

He maintains that dropsy, although it may be mistaken for pi'egnancy, does not necessarily exclude the latter condition, and quotes the case of a woman who had di'opsy for nine years and yet bore four children during this time. He speaks of the "incomparable science "of Democritus, who, judging only from the expression of the face, on one day saluted a girl as virgin and on the next day as woman, not knowing that in the interval she had been seduced; but later on he modifies this expression and says that it was probably more of a lucky hit on the part of Democritus than a scientific diagnosis.

He questions the statement of Hippocrates that while the male child is fully formed at the end of thirty days, in the case of a female child forty-two days are necessary, and thinks that both sexes receive a perfect form within the same jjeriod of time.

In aphorism Ixxviii he says that "the whole body of the foetus is formed from the first day of conception, and is then not larger than a millet seed ; the remaining time of pregnancy serves only to give it the necessary growth."

He does not agree with Aristotle, who says "that the heart is formed first, but I'ather with Hippocrates, who says that no starting-point can be distinguished in the foetus any more than in a circle which has no beginning."

He criticises Tertullian, who thought that the soul was evolved from certain essences in the semen, and, like a good churchman, believes that "the soul comes from without, and is fixed in the body of the child after it is fully formed."

The question of extra-uterine pregnancy gives him another opportunity for inveighing against Graaf and Fallopius. He gives an account of a case which was reported by a surgeon named Vassal. He claims to have made a drawing of the fresh specimen, asserting that the one usually accepted was made a month later, when the parts were much decomposed and mutilated by handling. According to his account the case was strictly speaking not one of extra-uterine pregnancy, but the fcetus had developed in a part of the uterus which had bulged out at the side, forming a kind of hernia. The l)icture which he gives would seem to favor his view if we could be quite sure that the round ligament was in the position in which he represents it to be (Fig. II).

Naturally on the subject of tubal pregnancy we should feel more inclined to take the views of men who knew which were the real tubes, and as we have said, on tliis point Mauriceau was not only mistaken, but has taken great pains to make it (|uite clear to us that he was in error.

In aphorism xxi he refers to this again. "The generation of the infant can very well hike place near one of the corners

of the uterus where the ejaculatory vas deferens called the tuba joins it, but it is impossible that generation should take place in the vessel itself." Boivin's note is as follows : " Proofs are not wanting that pregnancy has taken place both in the tube referred to by Mauriceau and in the ovary, and that the infant has developed there."

He gives various signs for diagnosing the sex of the foetus in utero, but concludes that it is impossible to make a certain diagnosis. On this point he refers to several old superstitions, such as the one which taught that if conception takes place with the waxing of the moon a male child is engendered, whereas from a conception when the moon is waning a female child is to be expected.

He thinks that we can be more certain as to the number of children which a woman will probably bear at one time. Although he says that four is generally the limit, he reports many instances in which more were born at one birth, and until the number reaches fifteen he seems to think that such records are just within the bounds of possibility. But when he arrives at the history of a certain dame Marguerite, Countess of Holland, " who in the year 1276 was brought to bed of three hundred and sixty-five infants at one and the same time, who all received baptism and died on the same day together with their mother," he confesses, and not without reason, that we have reached the domain of fable.

He defines superfcetation as a "reiterated conception," and holds that this, as a rule, is impossible, " because after the first conception the mouth of the uterus is closed entirely and will not receive the semen of the male ; yet exceptions may occur after the sixth day, but not before, since the first conception is not complete until after this period of time has passed ; then, however, if the woman during coitus be intensdy excited the cervix may open and the semen again enter the uterus."

He holds that twins as a rule are not instances of superfcetation, since they are born about the same time, and must therefore have been conceived about the same time.

The fifteenth aphorism is curious. "One sometimes sees weak and infirm women produce fairly healthy children, because the infant has in itself a peculiar principle of life which often purifies the nourishment which it receives from the mother, just as we see that the graft rectifies and renders milder the austerity of the sap of the wild tree on which it is grafted."

For the production of moles he holds the corruption of the sperm either of the male or female to be responsible, but he says that those occurring in unmarried women are not genuine moles.

In spesikiug of the so-called gaseous moles he seoms to think that they are instances of physometra. For the diflferential diagnosis he gives us numerous points. {1) a mole has no active movement but is strictly passive: {2} ou feeling the abdomen when the uterus contains a mole it will be found harder but more tender, and increases in size rapidly; (3^ a mole being a dead weight is more trouble to c^irry than a living fo?tus : (4) the bladder is more involved, but the breasts are not so much tumefied and do not contain much, if any. milk ; (h) scirrhous growths and the menstrual blood are quite different from moles; (<i) when a mole is oist out Wfore the

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second or third mouth it is called a false germ; these false germs are membranous, while moles are fleshy ; (7) the movemeut of a mole is only like that of a dend weight in the abdomen ; (8) a mole does not come from the uterus at term, although it is possible for a pregnant woman to have at the same time a mole in the uterus.

Aphorism Ixvii says "the generation of a false germ in a woman previously sterile is generally a sign that she will be fruitful." Boivin adds, "the false germ or mole being the result of a degenerated conception, nothing is more certain than that the woman is apt to conceive."

His rules for the care of pregnant women are principally hygienic, although some of us might be inclined to think it rather severe that the pregnant woman should not be allowed to take a bath.

In aphorism xiii he expresses an opinion which has often been disputed, but with which, with certain modifications, the best authorities now agree: "Cinchona can be given with as much safety for the cure of fever to pregnant women as to other persons."

In aphorism viii he says that any serious operation like that belonging to a stone in the bladder and other serious conditions should never be performed upon a pregnant woman. To this statement Boivin makes an exception. "A stone in the bladder, if voluminous, could on the one hand interfere with the progress of tlie head and irritate and tear the bladder, and on the other hand might occasion inflammation of the uterus and cause the woman intense pain. It is better therefore to extract the stone before labor comes on."

He gives an interesting story of a tremor in the hands of an infant whose mother received a fright during her pregnancy : the baby was born prematurely and had a peculiar tremor of the hands, but otherwise was perfectly healthy ; he grew up, and in due time he married ; when signing the marriage contract some of the bystanders noticed that his hands shook very much, and not knowing of his infirmity they conjectured that "he felt nervous lest he should be making an unfortunate bargain."

He starts out by saying that the pregnant woman should not be bled, but modifies this statement in subsequent chapters, although he makes a great point of the fact that contrary U) the prevailing opinion it is much safer to bleed in the earlier months of pregnancy than when it is far advanced.

The vomiting during pregnancy he looks upon in most cases as reflex in origin, and recommends only simple remedies unless it persists for a long time, when he thinks that it must be caused by morbid material adhering to the coats of the stomach, which should be removed by laxatives after the wonuin has been bled.

lie deprecates the use of strong purgatives for fear of abortion. In speaking of vesical disturbances he seems to recognize the frequency of pseudo-incontinence, since after trying simple remedies he employs the catheter. Were it not that he looks upon the menstrual fluid as a source of nourishment for the fcetus, and consequently explains hemorrhages from the uterus and other parts of the body as being due to the fact that more blood is brought to the parts than the fcetus needs for its nutrition, bis renuirks on the subject of varicose veins

and hemorrhoids, which he attributes generally to stasis in the veins caused by obstruction, are excellent.

He distinguishes three kinds of diarrhoea, (1) lienteric flux, (3) diarrhoeic flux, (3) dysenteric flux, and says that any severe attack may induce an abortion.

He recognizes severe hemorrhage as a sign of impending abortion, but notes that in some cases the menstrual flow appears during pregnancy without any bad results. He thinks that when it appears in the first months it is usually caused by some false germ of which the uterus is trying to rid itself, but that when it appears in the later months it is probably due to partial separation of the placeuia.

Unless the bleeding is excessive he would leave nature to take its course, but if there are signs of convulsions or syncope he insists that labor must be brought on artificially, " otherwise the woman will breathe out her last breath together with the blood."

He tells us a sad story of the death of his own sister, which he says "is still so vivid that the. ink with which I write it to make it known in order that the recital may profit the public, seems to be blood."

He then cites several cases in which, by turning and immediate delivery, the lives of several patients who were having severe hemorrhages were saved.

He holds that dropsy of the uterus occurs in general abdominal ascites by the passage of the water through the porous substance of the membranes of the uterus, and that water is engendered in the uterus itself when it is debilitated by cold, violent labor, or by suppression of the discharges. To differentiate such a dropsical condition from pregnancy, he tells us that in the former the breasts will not be swollen and will contain no milk ; no foetal movements will be remarked at the proper time; the abdomen is generally distended: the color of the face will usually be bad ; " these dropsies occur principally in sterile women, although it is possible for pregnancy to be accompanied by dropsy." He says, " When such women lose a quantity of water from the uterus it must not be mistaken for amniotic fluid, since the membranes will be found later to be unruptured."

He seems to use the term inflammation in the case of parturient women as synonymous with erysipelas; in fact he substitutes the word " inflammation " for erysipelas when quoting one of the aphorisms of Hippocrates.

It seems to have been a popular notion that a pregnant woman suffering from syphilis could not be treated for the disease until after the child was born. To thi? idea Mauriceau was strongly opposed, and quotes instances to prove that such cures had been effected, and that the only indication in such cases was not to carry the treatment beyond a mild salivation.

In speaking of the premature discharge of the fretus from the uterus he makes four divisions: (1) etlluxion, that is, the discharge of the contents of the uterus within six days after fruitful coitus, when the sperm had attained no consisteuce; (2) expulsion of the false germ up to the second month ; (3) abortion, a discharge of the perfectly formed fffitus up to the beginning of the seventh month ; (4) premature labor. "AVhenever the foetus is expelled after the beginning of the seventh month it is a labor."

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Amoug the othei' causes of abortion he puts the various acute diseases.

In the second book he treats of normal and abnormal labor. Four conditions are mentioned as requisite to make a normal labor : (1) the birth must be at term ; (3) it must occur without any particular difficulty; (3) the infant must be born alive ; (4) the presentation must be favorable.

With respect to a normal presentation as described by Mauriceau, Boivin says " the head does not take this situation, that is, with the face looking downwards, except in the case of a third occipital presentation or at the end of the first stage of labor; but in the time of Mauriceau and for some time afterwards the mechanism of normal labor was still unknown, so that a presentation of the head was considered bad in which the face was not downwards."

He corrects the erroneous opinion held by Hippocrates that an infant born at eight months was likely to be more feeble than one born at seven months. This opinion was founded upon the idea that it was necessary for the infant to make efforts in order to be born, and that these efforts were first made at the end of the seventh month, so that if the infant did not succeed in escaping from the uterus he was necessarily enfeebled by his futile efforts.

Mauriceau explains that the uterus is the active and the fcetus merely the passive agent in the act of labor. In support of his views he i-efers to a book written by one Bouaventure, which he says is larger than the Bible and is entirely devoted to the proof of this one point.

The figures in his table of statistics, of which there are three, given to show the duration of the natural pregnancy, vary a great deal. According to these, gestation may last for eleven months and six days. He does not attempt to answer the medico-legal question as to how late a child may be born after the death of its father and still be considered legitimate.

In aphorism Ixxxvi he says "pregnancy rarely goes beyond the tenth month; scarcely one out of a thousand of children born at the end of seven months survive; but half of those born at the end of eight months do well, if carefully nursed."

Aphorism Ixxxiiisays: " Some pregnant women feel fcetal movements after the end of the first month; many others do not feel them before the end of six weeks or two months; others again, only after four months." To this extraordinary statement Boivin objects that the sniallness and the consistence that the embryo possesses at the end of a month and the quantity of water by which it is surrounded would render its movements imperceptible to the mother, and even at a later period she could very well confound the movements of the intestines with those of the infant.

lie devotes a great deal of space to discussing the question whether the pubic bones separate during the act of labor, and throws discredit on the case of the celebrated Ambroise Pare, who at an autopsy upon a woman who was hung a short time after labor had found the bones separated to the extent of a finger's breadth.

In proof of his position he says: "If such a separation did fake phue tlio woman could not stand up immediately after

labor," and incidentally we learn that his hospital patient* were made to walk from the lying-in room to their bedrooms immediately after delivery.

The difficulty experienced by elderly women in their first labor he rightly attributes not so much to the want of yielding of the pubic joint, but rather to the ossification of the joints between the sacrum and the coccyx.

He distinguishes between false and true labor pains, and mentions the dilatation of the os and the bulging of the membranes as a sign of approaching labor.

He understood the nature and dangers of cases of placenta prfflvia. He holds that those who would make three membranes, the chorion, the amnion, and the allantois, are mistaken, since there are in reality only two, and these are really separated only with difficulty, the allantois being never seen in the human fcetus.

He regards the idea that an infant born in a caul is lucky as a mere superstition, except from the fact that the labor must necessarily have been an easy one.

It had been held by many authors that the waters were composed of the urine coming from the bladder by the urachus ; but this Mauriceau says cannot be, since the nrachus in the foetus is not pervious. He quotes a noted anatomist named Gayant as a supporter of his own view. He holds that the waters are necessarily an exudation from the membranes, since they occur also in the case of false germs.

He evidently understood the uses of the amniotic fluid and denies that it serves as a nourishment of the child, as also the statement of Hippocrates that the infant sucks by the mouth its nourishment from the uterus. In support of this he quotes Aristotle, and shows besides that the waters have no nutritious qualities.

He gives a very good figure showing the placenta and umbilical vessels of the fostus (Fig. III). He understood, apparently, that the blood from the vessels of the mother did not pass directly to those of the foetus, and says that any severe indisposition on the part of the pregnant woman can give rise to pathological appearances in the placenta. That the knots in the cord signified the number of children to be born hereafter he declares to be a simple superstition.

In three figures he presents the different natural situations of the infant in the uterus when labor is to be normal. "The infant changes his position in the uterus during pregnancy. Towards the end of the seventh or eighth month the head, which heretofore has been above, t-akes up its position below, the fietus having made a sort of a somersault. This perhaps accounts for the idea of some authors that the fcetus attempts to leave the uterus at the end of the seventh mouth."

He is opposed to the idea that women approaching their term should take much exercise, and more especially coudenius the advice of Liebaut that they should go driving or ride a saddle-horse at a brisk trot, considering that such exercises, even when they do not cause miscarriage, are productive of malpositions.

He adds that baths are dangerous, not ouly ou account of their too great humidity but also ou account of the excitement whicli they cause and which may lead the mouth of the womb to open.

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His directions for the conduct of a normal labor are on the whole excellent except those relating to the delivery of the placenta. They are about as follows: "AVhen the symptoms of labor appear the rectum and bladder should be emptied. In strong women blood-letting may be practiced. An internal examination should be made from time to time in order to follow the dilatation of the os, and the genitals should be anointed with some emollient oil. Too many examinations should not be made. The woman should not be allowed to lie down too long in the first stage. Vomiting is not a dangerous symptom. The membranes should not be ruptured too soon. Many midwives, for fear of displaying ignorance, will not send for a surgeon sufficiently soon, and prejudice the poor women against them, calling them butchers and executioners."

"The woman should be allowed to choose her own posture for the second stage of labor. A feather-bed should not be used, and arrangements should be made to prevent the soiling of the bed-linen. Pressure on the abdomen should not be employed, though the os may be gently dilated by means of the fingers. No violence should be used in pulling upon the head, and direct traction should not be made, but rather a rocking motion from side to side."

"After the child has been born it is necessai-y to first see that there does not remain a second fa?tus in the uterus. Even before tying or cutting the cord the placenta must be delivered. To do this, the midwife, taking two or three loops of the cord around the two fingers of her left hand and advancing the right hand near the vulva, makes gentle traction on the cord. Too strong traction must not be employed for fear of breaking the cord, in which case there may be a dangerous hemorrhage. Meantime the woman should be told to blow hard into one of her closed fists, or should put her finger down her throat in order to excite vomiting. A competent nurse may at the same time press lightly with the flat of her hand on the abdomen, employing friction. If these measures do not succeed, the hand must be introduced into the uterus and the placenta seized and taken away. Care should be taken not to leave any part of the placenta^ any clots of blood or any false germs in the uterus. In the case of twins the placenta of the first should not be delivered before the second is born." The false germs would of course be remnants of the placenta, although Mauriceau says particularly that he has seen false germs discharged after the placenta has been delivered entire.

It is possible that he had often seen rupture of the cord following this method, since he devotes a chapter to the method of manual separation of the placenta after the cord had been broken.

He advises against the use of powerful drugs by the mouth to assist the expulsion of the placenta, and prefers extraction by the hand. He recognizes the necessity of bringing away all the membranes.

Besides normal labor he recognized three grades, (1) laborious or tedious labor, (2) difficult labor which is accompanied by certain complications, (3) abnormal labor, which is due to some malposition of the foetus.

Of the last named he makes four main divisions, (1) when the ant4irior part of the body presents, (2) when the posterior

part of the body presents, (3) when the lateral part of the body presents, (4) foot presentations.

He devotes a good deal of space to the description of the physical and moral character of the good obstetrician.

In speaking of the question as to whether the foetus in utero is still alive, he says that all the signs must be taken into consideration together, since each by itself is equivocal; the most trustworthy, however, being the recognition of (1) movements, (2) pulsation in the umbilical vessels or in the radial artery.

He is unwilling to allow the use of the hook by the midwife. He seems to have understood very well the operation of internal turning. Boivin says that his ideas on the subject were not original but had been described by Louyse Bourgeois. The forceps was unknown in Mauriceau's time.

In convulsions which are not easily controlled he recommends the induction of labor, and digresses to tell a story in which the operation was indicated but was performed too late to be of any service to the woman because the two priests who were present spent a whole day in discussing the question as to whether or no the baptism of the foetus in utero was sanctioned by the church.

"Some authors," he says, "in foot presentations recommend turning on the head, but can tell us of no easy way of effecting this." He uses the hook in the extraction of the dead foetus, and recommends if necessary the reduction in size of the head or body by means of a curved knife.

He devotes a whole chapter to the condemnation of Caesarean section on the living woman, and says that it is always fatal. He explains away cases of reported success by saying that they exist only in the imagination of the authors.

Caesarean section on the dead woman he considers not only lawful but necessary, and prefers to make a median and not the lateral incision recommended by many other authors.

Boivin, remarking on the aphorism which forbids Caesarean section on the living woman, says "this operation has rarely been successful ; nevertheless, since it has succeeded sometimes, one should try this method of saving the mother and infant when no more certain means present themselves."

In Book iii he speaks of the care of the parturient woman and of the new-born babe. He forbids all tight bandaging and nauseating medicines, but allows a comfortable bandage and a light but nutritious diet. He warns us not to allow the woman to partake of the various delicacies which are usually prepared for the collation at the baptism of the infant.

He considers it a superstition that the wearing of the husband's shirt will ))roduce the drying up of the milk. About post-partum hemorrhage, beyond recommending perfect rest (unless it be due to the presence of faces in the Ijowel, in which case euemata should be given) he has not much to say.

He gives pictures of pessaries to support the prolapsed uterus after it has been put back into position. He himself preferred the ring pessary. He recognizes the error of Kousset, who would have us introduce the pessary into the cavity of the uterus itself, and adds: "This absurdity of Kousset, which he backs up with ridiculous arguments as if it was an interesting fact, would lead us to believe that he allowed himself to be deceived in the majority of fabulous stories which he puts down in the same book respecting Csesarean section."

(Clururcicii),

iViPansl' 16,

Mori U 1-7 OcloW. I

Tibs'

No. 2. Extra-utenne Pregnancy.

April, 1895.]

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He speaks of prolapse of the rectum as sometimes occurring during labor.

He recommends the suturing of ruptures of the perineum at once, but speaks also of a later operation when it is necessary to freshen up the cicatricial tissues by means of the scissors or bistoury.

After-pains, he thinks, are due togas in the intestines or to the presence of some foreign body, it may be a kind of false germ, a portion of the placenta, or clots of blood remaining in the uterus, or finally, by the sudden suppression of the lochia or by the overstretching of the ligaments.

Boivin notes that in speaking of the suppression of the lochia as placing a woman's life in danger, Mauriceau has mistaken the effect for the cause.

He recommends a good warm bouillon instead of the nauseating oil which was usually given in such cases. " Some midwives, under these conditions, give the woman a few drops of blood taken from the placenta; this is a mere superstition."

He also recommends hot fomentations and, above all, the removal of the foreign body if any be present in the uterus.

He seems to understand the nature of the lochia and gives a more or less correct account of the reasons for the change in color which occurs. He says that those who believe that the lochia consists of the milk of the breasts are ignorant of their anatomy, " since they should know that there is no channel which connects the mammifi directly with the uterus, unless indeed they suppose that it comes thi-ough the mammary vein which is supposed to unite with the epigastric vein, whereas as a matter of fact the epigastric vein does not connect with the uterus at all."

He understood that after the detachment of the placenta there was left a wound in the uterus which must have time to heal.

The sudden suppression of the lochia he says is very prejudicial to the woman. He seems to think, however, that it is often followed, and not rather preceded, by an inflammation of the uterus. He prefers bleeding from the arm to bleeding from the foot on these occasions.

He believes that scirrhus causes trouble by blocking uj) the uterus and preventing the passage of the normal excretions. He adds that a scirrhus can turn into a cancer and then become very painful.

" Cancer of the uterus is incurable because it cannot be

taken away like a cancer of the breast. Cancer of the vulva can be cured by salivation, but when the growths are once in the uterus the treatment is of no avail." He probably mistook venereal for carcinomatous ulcers.

He understood that bad cow's milk was provocative of disease. He describes single and multiple abscess of the mammary glands, and gives pictures of nipple shields and general instruction about the nature and treatment of sore and retracted nipples. He condemns the custom of pressing back the blood from the cord into the infant's belly, since the blood, far from enriching that of the infant, is more liable to produce suffocation, since it is not vivified. He advises the placing of a compress over the fontanelle for several months.

His remarks upon the nursing of infants are excellent, except that he insists more than once that a mother should not be allowed to nurse her child for the first five or six days after birth.

He treats of the various diseases of young children in a very sensible way, and the chapters on indigestion, aphthae, teething, chafing, and the venereal diseases are excellent and show the soundest common sense and good practice.

He had the right ideas about the occurrence of syphilis in infants, whether congenital or acquired, although we must differ with him when he says that a syphilitic woman should not be allowed to suckle her own child who is already syphilitic, but that a new nurse should be obtained, "although she is very apt to acquire the disease from the infant." This doctrine would seem very much in contradiction of that which he promulgated before, namely, that a woman's life is of more importance than that of a young child ; and if her life, why not her health ?

He closes with a chapter on the rules to be observed in selecting a wet nurse. Throughout the whole book he shows an intelligent conservatism. He shows that he must have possessed the power of observation and was not afraid to act when occasion demanded it.

A criticism of his aphorisms is also found in Levret"s works.

From his writings we may picture to ourselves an honest, upright man, who, if not particularly brilliant, could safely be entrusted with the care of difficult cases, and who never allowed his common sense to be obscured by the various superstitions which prevailed in his time, by the greed for gain, or by the gratification of his personal vanitv.

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[No. 49.

THE PSYCHOLOGIC DEVELOPMENT OF MEDICINE.

By J. II. ^IcCoRMicK, M. D., Washinglon, D. 0. [Abstract of paper read before (he Johns Hopkins Hospital Historical Club, April Sth, 1S95.]

[A preliminary discussion of tlie independent evolution of culture concepts and the acquisition of a culture status by primitive peoples through mental evolution rather than by contact with other peoples, is omitted as of anthropological rather than medical interest.]

In the development or evolution of medicine, four stages are traversed — Imputation; Personification; Reificatiou; and Scientific Explanation. By imputation is meant attributing to things powers and properties they do not possess. Pei'sonificatiou is when these attributes are deified or personified. Reification is the designation of that stage in which these attributes are reified or made real ; while in the last an attempt is made to give the true or scientific explanation. In proportion as the degree of culture advances we find medicine ascending from the lower to the higher of these stages, so that culture development is but a history of the healing art from empiricism based upon imputation, to scientific or rational medicine.

Among all primitive people everything is symbolic; their words and thoughts are expressed in symbols, and the unknown is expressed in terms of the known by this means; symbolism pervades everything everywhere. Since all practice is based originally upon some preconceived theory, and is the practical application of such theory, the history of medicine is the evolution of the mental conception of the cause of disease and of the action of the various agencies which govern or modify it.

How do primitive people formulate their theories? By observing nature in all of her protean forms and infinite variety. They are close students of nature and of natural phenomena, but are unable to see beneath the surface and, beholding that which is far beyond them, attribute it to some supernatural, some divine being who shifts the spenes and causes the changes of day and night to follow one after another.

Thus unknown forces and phenomena are ascribed to more powerful beings than themselves, having powers and attributes similar to their own but in a magnified degree. The mysterious movements of nature are operated and controlled by these supernatural personages, and hence are attributed to causes which do not exist. This is imputation.

To illustrate: the North American Indian believes the breath to be the spirit or soul, and this is how he arrives at such a conclusion.

On a cold frosty day the warm breath as it leaves the mouth is condensed by the cold air, forming a slightly visible cloud, and he observes that all living animals, both man and beast, emit this cloud, and that tvhen dead this phenomenon does not occur, therefore he reasons this must be the spirit of life, and its absence denotes death. Again, he hears the thunder, and attempts to find in the living objects around something like it. He perceives that the growl of the bear somewhat resembles the noise of the thunder, therefore a great bear must have

made the thunder, and what he hears is this animal growling in the heavens. When the breath is blown upon the hand a slight force or pressure is felt, and as a result, when the winds begin to blow it is but the bear-god sending forth his breath; if gentle, it is a life-giving, beneficent breath; if strong or forceful, it is an angry, death-dealing, destructive breath, showing that the sky-bear is filled with rage. The clouds are but the prototype of the breath of man, only being so much greater they must have come from the bear-god, who can render himself invisible.

This is imputation, in that he attributes to the bear the power of thundering and causing winds; conversely, when he hears the thunder he reasons that the bear causes it.

In time he notes that when it thunders a storm is about to break, cold, wind and rain follow, and the hunter becomes wet and cold, and from consequent fatigue and exposure takes cold ; chills and fever, rheumatism and other diseases follow. This is the bear disease — for did not the bear cause it? For some I'eason, it may be, he has angered the wind-god or the raingod, and thus their displeasure is visited upon him. To propitiate by prayers, gifts, sacrifices and the performance of ritualistic ceremonies is his chief hope of relief.

We will now consider the evolution of medicine as it has actually existed from the beginning to the present time, taking the four stages in order of their occuri-euce. It must be remembered, however, that while one particular stage predominated at any given time, even at first some degree of all was present, just the same as now.

Imputation.

Let us first endeavor to ascertain what was early man's conception of disease; for upon such conception depended his method of treatment; and in passing, attention is called to the fact that the same ideas, fundamentally, are found in every quarter of the globe, thus giving positive evidence in support of the statements and assertions made in the proposition which it is the province of this paper to demonstrate.

"Man," says Tylor, "as yet in a low intellectual condition, having come to associate in thought those things which he found by experience to be connected in fact, proceeded erroneously to invert this action, and to conclude that association in thought must involve similar connection in reality."

There are certain physiological functions, such as digestion and elimination of excretions, upon which the body depends for its existence, and when these are disturbed they give rise to pain or discomfort; and not knowing that such a departure from his normal condition is due to perversion of function, early man connects it with some mysterious power, a malevolent spirit.

After he has witnessed death and has recovered from the shock occasioned thereby, he seeks to find a reason for this sudden loss of energy and animation, and the failure to respond

April, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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to the demands made upon the one who was recently full of life and vigor.

Thus disease and death were caused by auger of offended external spirit, by supernatural powers of a human enemy, or by displeasure of the dead.

In India, Africa, China, the Pacific Isles and among the North American Indians, no natural death was recognized, but poison or witchcraft was the means by which all were removed.

The most powerful cause was the anger of the offended spirit. It has been already shown that the conception of the spirit or god is the natural sequence of the observation of natural phenomena; this idea is universal and forms one of the strongest proofs in support of the proposition to be demonstrated.

The septenary system of the Hindoo philosophy, so well described by Khys-Davids, has its exact counterpart in the religious scheme of the North American aborigines. The vast collection of swastica made by Prof. Thos. Wilson shows the universality of this idea of the cross based upon the cardinal points of the compass, and is the result of a psychologic process.

The sun rises in the east and sets in the west. In front was the north, behind the south, above the sky, beneath the earth, and the centre around which all revolved was the abode of man. Can you not recognize the analogy to the ancient conception of astronomy in this?

If an east wind blew, the sickness was caused by the god of the east wind ; if a man was sunstruck, the god of the south was enraged ; if from the west or north, a like god was the cause. Propitiations and sacrifices followed as a logical result and were based upon their various beliefs relative thereto. The old method of punishment, found everywhere, of quartering the body had its origin in the oiferings to the gods of the four ends of the world, and from this came the method of crucifixion, in vogue in many parts of the world.

In Lien-chow, province of Kway-oi, if a man strikes his foot against a stone and then falls sick, his family know it was a demon and offer wine, rice, fruit, incense and worship. Eecovery follows.

Supernaiural Power of Human Enemies. — Witchcraft, sorcery, practice of magic, voodooism and kindred practices are the imputed means by which an enemy inflicts disease upon his unwary victim.

Witches and wizards have exercised their uncanny and occult powers from time immemorial — a belief surviving among the negroes of our own (Southern States, to say nothing of the Indians. In New England even, the practice of charging persons with being witches existed not much more than two centuries ago, and need not be here discussed.

I knew an old negro suffering from vertigo who declared it to have been caused by a witch, and an old woman with a large goitre.which she claimed was due to the poisoning of a spring from which she drank. She thought the poison was placed in the spring by an old witch and was only toxic to her, because any one else could drink with impunity.

Displeasure of the dead was a fruitful source of disease. Ghosts, spooks, wraiths and unlaid spirits came back and,

invested with power from the spirit-world, worked mischief upon those whom they thought had injured them in life. The mythology and folklore of every country and every age have teemed with legends of all these agencies.

Personificatiox.

The transition from the stage just described to Personification is so gradual that no line of demarcation can be drawn. In the former the various natural phenomena were given as the cause of disease; in this, these agencies are deified or demonized.

"Sickness may be caused by invisible spirits inflicting invisible wounds with invisible spears, or entering men's bodies and driving them raving mad." Tylor, in his Primitive Culture, says: "As in normal condition, the man's soul inhabiting his body is held to give it life, to think, speak and act through it, so an adaptation of the self-same principle explains almost all conditions of body or mind by considering the new symptoms as due to the operation of a second soullike being, a strange spirit." "The possessed man, tossed and shaken in fever as though some live creature were tearing and twisting him within, rationally finds a spiritual cause for his suffering and a name for it which it can declare when it speaks in its own voice and character through his organs of speech" (Vol. II, pp. 113-116).

This is widespread, for we find in China, Australia and North America, stones possessed by demons; and it is this spirit of evil and mischief, not the stone, which inflicts the injury. Among the Dyaks of Borneo, and in Cambodia, illness is due to the tormenting demon, while in Australia smallpox is caused by a black deformed demon. Woutan of Scandinavian mythology both causes severe illness and pestilence as well as cures them.

Assyrians and New Zealanders both believed in a demon for each part of the body.

In Ceylon the demon of disease was the son of a powerful king, whose wife, proving faithless to him, was ordered cut in twain, one part to be thrown to the dogs and one part to be hung in a tree. Before execution the queen said, " If this charge be false, may the child in my womb be born this instant a demon, and may that demon destroy the whole city and its unjust king." Nevertheless she was executed, but the severed parts immediately united and the child was born, and it went to feed upon the carcasses in the graveyard, and after a time brought disease upon the city.

The Israelites believed disease and death to be due to a destroying angel.

•• Disease is still represented as evil influence to be exorcised. In the popular minds diseiise walks the earth as a devouring fiend and has a personality about it as of old. Our very phrases 'stricken with disease,' 'visitations and seizures,' are survivals of the conceptions of primitive times."

Among the Kosicrucians, disease was provoked by a spirit imprisoned in crystal. The natives of southwest Australia venerate pieces of crystal called "Teyl," which no sorcerer is allowed to touch, as it would cause the spirit to depart. Capt. Gray notices the accordance of this word in sound and signification with the " Baetyli," so celebrateil in P.igan

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antiquity, mentioned by Burder in his Oriental Customs. These stones were rounded and were supposed to be animated, by means of an incantation, by a portion of the deity. Magicians were supposed to be possessed with a power given them from the gods; in Syria the Witch of Endor (1100 B. C.) claimed to hold conferences with the dead.

In Hellas Ulysses visited the spirit-world, and men were turned into swine (400 B. C).

In the consideration of the foregoing subdivisions, no treatment of disease in detiiil has been given, because the method of both was by imputation, and the consideration of special cases, as illustrations and corroborative testimony, will be more striking and better followed when the two are combined.

All treatment fell under three heads, dynamic or empiric, thaumaturgic or magical, and theurgic or by divine agency, and sometimes one method alone was used, but more frequently all three were combined in a single case. Usually they believed the efficacy of the drug to be due to some magic rite or formula which had to be performed or recited before the material was ready for use, and this principle did not exist at all in the ageucy to be employed, or was at least latent and the ceremony was necessary to implant it or render it active.

This is well shown by the customs of the Cherokees in gathering herbs for medicinal use. " The shaman goes provided with a number of white and red beads, and approaches the plant from a certain direction, going round it from' right to left one or four times, reciting certain prayers the while. He then pulls up the plant by the roots and drops one of the beads into the hole and covers it up with the loose earth. In one of the formulas for hunting the ginseng the hunter addresses the mountain as the 'great man ' and assures it that he comes only to take a small piece of flesh (the ginseng) from its side, so that it seems probable that the bead is intended as a compensation to the earth for the plant thus torn from her bosom. In some cases the doctor must pass by the first three plants met until he comes to the fourth, which he takes and may then return for the others. The bark is alwajs taken from the east side of the tree, and when the root or branch is used it must also be one which runs out toward the east, the' reason given being that these have imbibed more medical potency from the rays of the sun.

When the roots, herbs and barks which enter into the prescription have been thus gathered, the doctor ties them up into a convenient package, which he takes to a running stream and casts into the water with appropriate prayers. Should the package float, as it generally does, he accepts the fact as an omen that his treatment will be successful. On the other hand, should it sink he concludes that some part of the preceding ceremony has been improperly carried out and at once sets about procuring a new package, going over the whole performance from the beginning.

Herb-gathering by moonlight, so important a feature in European folk-medicine, seems to be no part of the Cherokee ceremonial. There are ll.\ed regulations in regard to the preparing of the decoction, the care of the medicine during the continuance of the treatment, and the disposal of what remains after the treatment is at an end. Pretenders endeavor to impose upon the ignorance of their fellows by posing as

doctors, although knowing next to nothing of the prayers and ceremonies without which there can be no virtue in the application."

Among the Chinese panax quinquefolia or ginseng is given to ward off or remove fatigue, invigorate the feeble, restore exhausted animal power, to make the old young — in short, to render man immortal. It is found in the mountains of Shantung and Leotung, but now most of it is imported from this country.

Its very name, ginseng, signifies the wonder of the world or the dose for immortality, and directions for gathering are upon the first two days of the 2d, ith and 8th moons, when the stars are said to be propitious.

An investigation will prove the common belief that the aborigines were well versed in botanic medicine to be erroneous, as most of the plants used had no medicinal virtue and were used because of their supposed resemblance to some part or organ of the body, or again because the priest or physician had a dream to get this certain plant, and so it became fixed in the primitive materia medica. As before stated, none of these remedies were effective until some mysterious process had been performed and certain ceremonies were executed which had for their office the transference of power from the tutelary god to the plant. However, some remedies were used which were of great value, although all were subjected to the same ritualistic forms before using; yet a striking example of the union of both may be shown.

Since the days of Lister we have prided ourselves upon the excellence of our sui-gery as compai-ed with that prior to the advent of antiseptics, yet centuries ago antisepsis was practiced upon the then undiscovered continent of America. A wound is inflicted upon the body of a warrior in battle or from accident upon the chase, and several days elapse before the wounded mau is brought to his camp to be treated. The loss of blood, fever, accumulation of foreign matter at the seat of injury, have resulted in the formation of pus, and possibly sloughing has already taken place; the shaman and his assistants are summoned and the treatment begins. Beside a clear running brook a red willow grows, its roots bathed by the flowing stream. In a large cauldron the fresh roots of the willow are placed and covered with water from the stream and allowed to boil, and while it is boiling the shaman tells us that the spirit of the arrow has entered the wound which is decayed and dead. He believes that when an animal dies worms have entered and killed it, and because he sees them crawling in the putrifyiug mass he concludes that the worm has entered the wound of the patient and the flesh is dead.

The breath, which is white, is the spirit of the soul, and the blood, which is red, is the spirit of the body, and they both exist at the same time, as he well knows that when the white soul, the breath, ceases to come from the mouth, then the red soul, the blood, ceases to flow from the wound, and one cannot be without the other. So he takes the water, which is also white, and which also gives life, and the roots of the red willow which is watered by the stream, and is therefore a part of it and cannot exist without it (due to his observing that willows grow in wet and marshy places or along the banks of a stream), and the two make a red liquid by boiling, which resembles

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blood and typifies the red soul. After jjrayers and sacrifices, etc., to the gods, the boiling liquid, now cool, is placed in the mouth of the shaman, and by blowing either directly from his mouth or by use of a reed he thoroughly cleanses the wound aud blows into it the souls, white and red, and after di-essing it to prevent the spirits from coming out before they have found their lodging place, the patient is allowed to rest. Thus he places or gives back the spirits which had departed, and he uses unknowingly an antiseptic solution, the active principle of which is salicylic acid.

The celestial bodies were supposed to have a great influence over disease, and the moon is in nearly all languages feminine, because of its coincidental relation to the functional activities of women, many of the diseases of women being ascribed to its baneful influence, and to avoid or relieve such maladies certain forms and rites are necessary.

Astrology accounts for many of the mysteries both of the cause and cure of disease. The collection of herbs at certain phases of the moon, and the planting of cereals or other crops must be upon the full of the moon, else, so they say, the fruit will tui"n to flower and the roots will shrivel and dry up. Moon-lore is too well known to enter upon at this point, although many examples bear directly upon the question at issue.

In the system of materia medica of the Chinese each organ had its specific remedy ; thus, in a work written centuries ago, of which the following is a literal translation, this scheme was laid down:

"Of all roots that are produced, the upper half of what grows in the earth is known to possess the property of ascending the system, while the lower half has that of descending ; as to the power of the branches, they medicinally extend to the limits of the body.

The peel or bark has influence over the flesh and skin ; the pith and substance of the tree within the trunk operate upon the viscera; that which possesses light properties ascends and enters the region of the heart and lungs, that which is heavy descends and enters the region of the liver and kidneys; that which is hollow promotes perspiration, that which is solid internally attacks the internal parts of the system; that which is hot, but decayed, enters the breath, that which is mollifying enters the blood-vessels. Thus the upper and lowei", the internal and external parts of a medicinal plant have each their corresponding effects on the huuuin system."

For example, if you have a disease of the pleura or lungs you should take the bifurcated root of the mandrake, because it looks like a man, cut out the part which corresponds to the thorax and apply in a poultice to the chest.

For this reason fox's bones and otter's livers were given in consumption, and hart's and rhinoceros's horns, tiger's and elephant's bones were excellent in extreme weakness to strengthen and fatten the body, and a dose of tiger's bones was thought to impart courage.

In nearly every country the idea prevails that decayed teeth are due to the presence of a worm, which, as Gushing will show in an article to be shortly published, arises from their observance of worms in decaying animal and vegetable matter.

The Indian believes rheumatism to be due to a worm in the limb of the afflicted individual, or sometimes to the spirit of slain animals, usually the deer, thirsting for vengeance on the hunter.

This latter theory is clearly shown in stories told of poisoned arrows. It is well known that early man had no knowledge of toxicology as such, but seeing persons or animals die from the effects of certain agents, thought death to be due to a spirit going into the man. When a man died from the bite of a rattlesnake it was believed to be the spirit of the rattlesnake entering the body which produced this result. Accordingly, if one wished to destroy his enemies he induced the spirit of the serpent to act for him by the following process : A snake was killed and the arrows or other weapons were placed in the blood in a circle, and by prayers and incantations the spirit went into the missile and could be transmitted to the body of the victim.

The treatment of rheumatism illustrates the three methods. Among the Pueblo Indians a patient crippled, drawn up and twisted by this disease is given a decoction of the young shoot.-? of the fern, because Avhen young and tender they are curled up like the sick one, and as they grow they unfold and become straight, and therefore they cause the partaker to unfold and become straight. But this is not all : the fern is straight, but it cannot bend forward and backward except it be broken, and it alone would cause the sufferer to remain forever straight, unable to bend. To remedy this the measuring-worm is given mixed with the fern, as he not only has the power to straighten himself from his curled-up position, but he can resume it again at his pleasure.

The thaumaturgic or magical method is fertile in its resources, but only one is necessary, the wearing of magic charms, amulets, and cords or girdles. The use of iron crosses, rings and cords survives to-day, and a common practice among the negroes is to tie knots in a cord equal to the number of letters in the name.

The following formula and explanation for the treatment of rheumatism among the Cherokees is so interesting aud illustrative of many points already noted that it will be given at some length. In the prayer reference is made to the "Great Ada'wehi," which is a term used to denote one supposed to have supernatural powers, and is applied alike to human beings and to the spirits invoked in the formulas.

Formula for Treatini; the Crippler (Rhei-matism).

Listen ! ha ! in the sun land you repose, O red dog. O now you have swiftly drawn near to liearken. O great .^ii:i wOhl, you now ne^'er fail in anything. O appear and draw near running, for your prey never escapes. You are now come to move the intruder. Ha ! You have settled a very small part of it far off there at the end of tlie earth.

Listen! ha! In tlie frigid land you repose, blue dog. O now you have swifily drawn near to hearken. O great Ad:l wOhl, you never U\i\ in anything. O appear, etc. [Like al>ove.]

Listen ! ha ! In tlie darkening land yon rcjuise, O black dog, etc.

Listen ! On AVa hala you repose. O white dog, etc.

Listen ! On Wa hala you repose, O white terrapin. O great Adii wi?hl, you never fail in anything. Ha ! It is for you to loosen its hold on the bone. Relief is accomplished.

(Prescription.) Lay a terrapin shell upon (the spot) and keep it there while the five kinds (of spirits) listen. On finishing, then blow once. Repeat four times, beginning each time from the start. On finishing the fourth time then blow four times. Have two white beads lying in the shell together with a little of the medicine. Don't interfere with it, but have a good deal boiling in another vessel — a bowl will do very well— and rub it on warm while treating by applying the hands. And this is the medicine : What is called yi'na-Utse'staC bear's bed," the Aspiiliumacrostichoides or Christmas fern) ; and the other is called K;"i'ga-Asgfi"'tagi ("crow's shin," the Adianthum pedatum or Maidenhair fern) ; and the other is the common EgiVli (another fern) ; and the other is the little soft (leaved) EgiVli (Osmunda einnamonea or cinnamon fern), which grows in the rocks and resembles Yanii-Utese sta and is a small and soft (leaved) Egil'li. Another has brown roots and another has black roots. The roots of all should be (used).

Begin doctoring early in the morning; let the second (application) be while the sun is still near the horizon ; the third when it has risen to a considerable height (10 a. m.) ; the fourth when it is above at noon. This is sufficient. (The doctor) must not eat, and the patient also must be fasting.

Explanation. — The disease, figuratively called the intruder (iilsgeta), is regarded as a living being, and the verbs used in .^peaking of it show that it is considered to be long, like a snake or fish. It is bronght by the deer chief and put into the body, generally the limbs, of the hunter, who at once begins to suffer intense pain. It can be driven out oilly by some more powerful animal spirit which is the natural enemy of the deer, usually the dog or the wolf. These animal gods live up above beyond the seventh heaven and are the great jirototypes of which the earthly animals are only diminutive copies. They are commonly located at the four cardiiuil points, each of which has a peculiar formulistic name and a special tfolor which applies to everything in the same connection. Thus the east, north, west and south are respectively the sun land, the frigid land, the darkening land, and Wa'hahV, while their respective mythological colors are red, lilue, black, and white. Wa'hala is said to be a mountain far to the south. The white or red spirits are generally invoked for peace, health and other blessings, the reel alone for the success of an undertaking, the blue spirits to defeat the schemes of an enemy or bring down troubles upon him, and the black to compass his death. The white and red spirits are regarded as the most powerful, and one of these two is generally called upon to accomplish the final result.

In this case the doctor first invokes the red dog in the sun laud, calling him a great adawehi to whom nothing is impossible and who never fails to accomplish his purpose. He is addressed as if out of sight in the distance, and is implored to appear running swiftly to the help of the sick man. Then the supplication changes to an assertion, and the doctor declares that the red dog has already arrived to take the disease and has borne away a small part of it to the uttermost ends of the earth. In the second, third and fourth pai'agraphs, the blue dog of the frigid land, the black dog of the darkening land, and the white dog of Wahala are successively invoked in the same ternjs, and each bears away a portion of the disease and disposes of it in the same way. Finally, in the fifth paragraph the white terrapin of Wahala is invoked. He bears oS the

remainder of the disease, and the doctor declares that relief is accomplished.

The connection of the terrapin in this formula is not evident, beyond the fact that he is regarded as having great influence in disease ; and iu this case the beads and a portion of the medicine are kept in a terrapin shell placed upon the diseased part while the prayer is being recited. The beads are white, symbolic of relief.

The blowing is also a part of the treatment, the doctor either holding the medicine in his mouth and blowing it upon the patient, or, as seems to be the case here, applying the medicine by rubbing, and blowing his breath upon the spot afterwards. In some the simple blowing of the breath constitutes the whole treatment.

The medicine consists of a warm decoction of the roots of four varieties of fern, rubbed on with the hand. The awkward description of the species shows how limited is the Indian's power of botanic classification.

The application is repeated four times during the same morning, beginning just at daybreak and ending at noon. Four is the sacred number running through every detail of these formulas, there being commonly four spirits invoked in four paragraphs, four blowings, with four final blows, four herbs in the decoction, four applications and frequently fourday tabu. In this case no tabu is specified beyond the fact that both doctor and patient must be fasting. The tabu generally extends to salt or lye, hot food, etc., while in rheumatism some doctors forbid the patient to eat the foot or leg of any animal, the reason given being that the limbs are generally the seat of the disease. For a similar reason the patient is also forbidden to eat or even touch a squirrel, a buffalo, a cat or any animal which humps itself. In the same way a scrofulous patient must not eat turkey, as that bird seems to have a scrofulous eruption on its head, while ball-players must abstain from eating frogs, because the bones of that animal are brittle and easily broken.

Reification.

There comes a time in the civilization of every nation when medicine and religion are divorced. For one or another reason, usually peculiar to each individual community, there is a breaking away from the ecclesiastical power which holds all knowledge within its jealous embrace, and the people learn to investigate for themselves. The old superstitions and beliefs of supernatural powers in man give way before the evidence to the contrary in the physical world. This is the time when men go to the other extreme and say everything was created for a purpose, and they gather together a vast collection of half truths, due to erroneous and imperfect methods of investigation, and necessarily place a wrong construction upon them.

This accounts for the impetus given to the study of medicine in Europe in the middle ages ; but we find centuries later that a thousand years before the Christian era, in China, almost the same ideas existed, just as the indei)i'ndeut discovery of printing and art of making gunpowder.

They believed that the body was com])osed of water, fire, wood, metal and earth, the five elements of which everything was composed, fcjo long as the eciuilibrium was nuiintained

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between them the person enjoyed health; as soon as one predominated, sickness ensued. To discover and then counteract that which predominated was the treatment. Inflammation was due to excess of fire. Distortion of eye and mouth was due to the excess of wood over metal which contracted the muscles. Under such circumstances, earth discharged its nature, its power relaxed in the interstices, the eyes became hollow and muscles contorted.

Their knowledge of anatomy was slight and superficial. Eeverence for the dead forbidding dissection, until a much later period, their only knowledge was derived from animals, and curious enough, this same respect gave them a knowledge of osteology, as the bones were often arranged and preserved with scrupulous care by relatives and friends. The great viscera of chest and abdomen were known, but their relative positions were not. The heart was supposed to lie on the right side and the liver on the left. The circulation of the blood was known, but they were ignoi'ant of the part played by the lungs in its purification.

"Throughout the human body a vivifying ethereal fluid was transfused, which was called Ke and resembled the ether of nature. According to the best ancient authors, water entered the body through the mouth. Beside the natural way of evacuation, it was either absorbed during cold weather by the Ke, or in hot weather it came out as perspiration; when grief oppressed the mind it appeared in shape of tears or was given out as saliva."

When the Ke was vitiated its ejection was obstructed, it accumulated and dropsy resulted, and a cure was effected by evacuation of water.

Their imperfect knowledge of the circulation gave rise to one of their most singular notions, the doctrine of the pulse.

The native physicians now say that owing to their delicacy of touch they can distinguish no less than 24 different kinds of pulse, and declare that for every part of the body there is a pulse peculiar to that particular locality. In the arm there are 3, the inch, the bar and the cubit ; the liver has its pulse located in the right wrist, while the left governs the heart, and by examining the pulse in the various parts of the body they can tell disease and its cure; also whether a woman will give offspring and whether it will be male or female. Among the Turks and other Mohammedan people a similar doctrine is fouiul.

The nose is the part of embryo which is first formed, hence in literature the nose ancestor was the desigiuition of the original founder of a family.

Plato and Proclus had faith in the pentad or five (.">) principles of nature, the 5 planets known to them presided over the five viscera, the 5 elements, 5 colors and 5 senses.

Mars was hot and dry ; medicine bitter, red in color, affected the heart, (ireen medicine came from wood and operated on the liver. Red medicine came from fire and operated on the heart. Yellow medicine came from earth and ojierated on the stomach. White medicine came from metal and operated on the lungs. Black medicine came from water and operated on the kidneys.

The pentad and duad were the mysterious numbers of the Chinese as well as of nuiuy other nations. The //<'«</ and yin

or male and female energies in nature, the active and passive agents, form an important part in every department of Chinese learning, for they believe every phenomenon can be explained by these obscure and awful principles.

Yang, or male principle, is hot, cold, warm, or cooling; yin, or female energy, is sour, sweet, acid, or salt. The blood is of two kinds, yang or arterial and yin or venous; the first is strong, the latter is slight ; the yang circulates throughout the body, while yin nourishes the soul and most of the bones and sinews.

Galen and Paracelsus, while retaining many of the beliefs noted in imputation, started on the long journey toward truth and reached the stage of reification, and their investigations and teachings left their impress for many generations.

They believed the brain to be a cold, inert gland whose function was to secrete a phlegm. The heart sent forth animal spirits, and the body was composed of four fluids, bile, blood, atrabile and phlegm.

Galen explained functional acts by forces or faculties ; for example, food is conveyed to the stomach by an attractive faculty, is kept there by a retentive faculty, until it is converted into chyme by an alterative faculty, made to pass into the duodenum by an expulsive faculty, to be taken up by the veins and carried to the liver, where it was converted into blood by a blood-making faculty.

The four systems of Asellius became widespread in their influence, the chemical, iatro-mechanical, spiritual, and vital. There were five crises in the chemical : ens ausirale, or influence of the stars ; etis veneni, or poisonous principles of food and drugs; ens naturale, or force which directs the microcosm ; ens spinUiale, or spiritual principle, whose action is seen in sympathy and antipathy; en^ Dei, the spirit of God, which sends disease as a chastisement.

An analogous doctrine is found in the five principles of the Hindus, the elements of earth, air, fire, water and ether, from which the ancient philosophers of Greece derived their doctrine of the elements.

It must be borne in mind that the spirits referred to in this connection are not the same as were mentioned under the first two subdivisions, but are regarded as a physical or tangible force.

Although much of the imputed in medicines remained, yet it had a different signification. While the lights of a fox in wine (the fox being long-winded) or bear's gall in water were of great virtue in iisthma, and wine in which the feet of a yellow hen have washed was a sure cure for jaundice, the remedies were regarded as having something of definite action, of a physiological or chemical nature, the exact character of which was not definitely understood.

Empiricism was in the heyday of its success: everything was used that could be used, and the extent and variety were simply appalling. Wolfs liver steeped in wine for cough, cow's blood in vinegar for spitting of blood, burnt deer's horn for fluxes. Phrenitis wjjs curetl by attaching a sheep's lights while yet warm to the patient's neck,

Disetises of the air were treated with wormwood, rue, ants, earthworms steeped in vinegjxr and eel's blood boiled in wine. Moss from the skulls of animals and the powdered

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thigh-bone of noted criminals were in high repute. The following prescription of Paracelsus, known as Paracelsus plaster, would be a boon to dermatologists in curing malignant growths, but unfortunately its method of preparation | has become one of the lost arts:

1} Take a quintessence of all of the gums in the world i lb.

Magistery of the magnet 1 oz.

Elements of the fire of amber (that is, the electrical fluid). 1 lb.

And of such great strength was it that it was known to have pulled rocks of some size from their bed in the soil.

'•There remains in the people a belief in the efficacy of drugs as drugs — a belief that for every bane there must be an antidote, so for every disease there must be a curative leaf or root."

From this step to the last an imperceptible change takes place; a gradual accumulation of indubitable facts brings us to that stage where all is demonstrated, all is logical, all is final, as far as it is possible to_ carry human inriuiry, and the questioner is stilled, for all his queries are answered, or if not answered, he is satisfied that he is iu the right path and by diligent pursuit will eventually reach the goal. This is the fourth or scientific stage.

Scientific Explanation. AVhat need be said further upon this point? Its history is our own history, its work is what we have and are doing, its aim, scope and outlines are well defined. We have but to correct the errors of the past and demonstrate things as they are.

PERITONITIS CAUSED BY THE INVASION OF THE MICROCOCCUS LANCEOLATUS

FROM THE INTESTINE.*

By Simon Flexner, M. D., Associate in Pathology. [From the Pdthological Laboratory of the Johns Hopkins University and Hospital.]

The conditions which underlie the causation of acute peritonitis have been the subject of so many studies during the past few years that many of those favoring or inliibiti'ng its development are now well known. The experimental investigations of G. Wegner, Grawitz, Ilalsted, Barbacci, Tavel and others have conclusively shown that the healthy peritoneum possesses the power not ouly of rapidly absorbing or otherwise disposing of sterile fluids and solids, but also of disposing of a large uumber of saprophytic and pathogenic bacteria when these are introduced in such a manner as to avoid greatly injuring the tissues themselves. In order that pathogenic tjacteria, introduced directly into the peritoneal cavity, may cause a peritonitis, general or circumscribed, evanescent or fatal, the normal conditions of the peritoneum must in some way be modified so as to afford an opportunity for the development of the bacteria. Measures which vitiate the vitality of the endothelial lining of the cavity, or which remove the organisms from the destructive action of the fluids and cells of the peritoneum, accomplish, as a rule, this result. Thus it is found that certain sterile soluble toxic substances, whether derived from the growth of bacteria or from the intestinal contents, permit, when introduced along with pathogenic bacteria, the growth of the latter; and this is doubtless, in part at least, due to the injurious effects which the toxic agent exerts upon the covering endothelial cells. Solid foreign bodies, which are themselves not capable of setting up inflammatory changes, atford,when introduced along with the micro-organisms, a nidus suitable to their increase; and bits of strangulated tissue, as for example the omeutum, do likewise; and both of these doubtless act by affording a place of settlement for the bacteria removed from the action of the liviug cells and fluids, permitting them to manufacture one of their

• Reail before tlu- Medical and ('hiriirj;i(.-al Faculty of Maryland,

April li-i, 1895.

chief weapons of offence, their toxines, and thus to provoke an acute peritonitis.

These two sets of conditions illustrate what commonly happens in the occurrence of peritonitis in human beings, in whom, it is to be assumed, the factors are not radically different from those in our experimental animals. And upon analysis it is found that most cases of peritonitis can be brought into one or the other of these categories.

The most frequent cause of peritonitis is perforation of the intestine, an accident which permits the ingress of the intestinal contents into the abdominal cavity, these contents carrying both the necessary foreign substances and the infecting micro-organisms. Lesions of the intestinal wall of a non-perforating character permit, as has been shown by Dr. Welch for the bacillus coli communis, not infrequently the escape of . this organism into the peritoneum and elsewhere in the body. The alterations in the intestinal wall need not for this purpose be of a severe grade ; congested areas and small hemorrhages in the mucosa often suffice. Not all, however, of these escaped organisms produce a peritonitis; indeed, in the majority of instances peritonitis does not develop. Netterhas found that in most cases of fatal acute lobar pneumonia, coverslip preparations made from the glossy and uninjured serous coat of the abdominal cavity will show the presence there of the micrococcus lanceolatus, an observation which I have in several instances been able to conflrm. It must be clear tlien that in human beings, as in experimental animals, some other condition than the mere presence of pathogenic micro-organisms in the abdominal cavity is necessary in order that peritonitis may be produced.

I conceive that if it is possible, iu view of a lesion of the intestine, for micro-organisms to penetrate beyond the cavity of the intestines, to enter the mucosa itself and later to invade the deeper structures and finally appear in the peritoneal cavity, that the way is also opened for the escape of soluble sub

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stances into this cavity from the interior of the intestine, these substances being in part the jjroducts of the growth of the bacteria there pi'esent and in part of the chemical changes taking place in the ingesta. That these soluble products may in themselves, independently of bacteria, cause inflammation is shown by the existence of a fibrinous exudate upon the serous coat of the intestines enclosed in hernial sacs without bacteria (chemical peritonitis) ; and conversely, the presence of bacteria in the hernial fluid does not necessarily involve the development of peritonitis.

The existence of chronic inflammatory changes such as thickenings of the peritoneal coat and adhesions between neighboring viscera, are certainly not inconsistent with the assumption, in these parts, of an abnormal or lessened vital resistance.

Thei-efore it would seem as if these two conditions, namely, the opportunity for the escape from the interior of the intestine of soluble chemical substances into the abdominal cavity, and the pre-existence of chronic inflammatory changes, might become important factors in the development of peritonitis, the presence of the infecting micro-organism being assumed. And the recognition of their predisposing effect might serve to bring into better harmony the observed facts in human pathology with the results of experimental investigation. The following cases are offered as illustrating the effect of these two factors.

Another factor of great moment in the development of acute inflammations of serous surfaces is the alteration of the fluids and cells of the body which takes place in the course of chronic heart, liver and kidney disease. This topic, however, has no especial bearing upon this paper and will be dismissed here. In the light of these considerations it becomes clearer why the colon bacillus, the micrococcus lanceolatus, and perhaps still other pathogenic bacterial species may be sometimes present in the peritoneal cavity without doing harm there, although the study of. the aetiology of peritonitis has shown that both of these organisms may be involved in its development. In passing, however, it may be stated that the bacillus coli communis is perhaps not so often concerned alone in the causation of peritonitis as has been supposed, but it is oftener associated with other micro-organisms, particularly streptococci and pneumococci.

The micrococcus lanceolatus has been found as the only organism present in acute peritonitis by Barbacci, Weichselbaum, A. Fraeukel, Sevestre, Courtois-Suffit, Netter, Uaillard, and Wright anil IStokes. To their reports I now wish to add two cases.

The first case was a mulatto child, 3 J years of age, who was admitted into the medical service (Dr. Osier) of the hospital on Nov. 6th and died on Nov. 12th, 1892. At the time of admission the child had been ill for one week. At the first examination the abdomen was found to be distended and tympanitic, and there was evidence of some fluid. The urine was turbid, specilic gravity 1010, it contained much albumen and hyaline and epithelial casts.

The autopsy was made six hours after death. Anatomical diagnosis: Chronic diphtheritic dyseutei-y, acute exacerbation; fibrino-purulent peritonitis; broncho-pneumonia; acute

nephritis ; general anasarca. General infection of the body with the micrococcus lanceolatus.

Only that part of the protocol relating to the intestines and abdominal cavity is given. The solitary follicles of the jejunum were enlarged, and the patches of Peyer in this situation less so. In the ileum the Peyer's patches were more distinctly swollen, and areas in which the mucosa was hyperasmic were here present. In the region of the ileo-ca:'cal valve the intestine was much congested, and small deposits of fibrin were to be seen. The large intestine was thickened, and in the mucosa were many pigmented, slate-colored spots and small ulcerations. A small amount of a white, opaque exudate, very adherent, was applied in this region to the surface of the mucosa. This exudate did not make at any place a continuous layer, but was composed of separate dots hardly exceeding each the size of a pin's head. The peritoneal cavity contained a considerable amount (several thousand cubic centimeters) of a very thin, opaque and milky fluid in which small flocculi floated. The serous coat of the cavity and of the intestines was hyperaemic and covered with a layer of fibrin mixed with pus cells.

This exudate examined microscopically showed enormous numbers of a capsulated coccus, occurring chiefly in pairs, which was proven to be the micrococcus lanceolatus. The number of pus cells in the fluid was not very large, so that the turbidity of the fluid seemed in part due to the large number of micro-organisms present. The same organism was cultivated from the spleen, liver and kidneys. It was found in sections stained, with Weigert"s fibrin stain, to be present in the lumen of the intestine.

The second case was a colored woman, 10 years of age, who w^as admitted to the gynecological ward (Dr. Kelly) on March 10th last. At this time she complained of great abdominal pain and dyspncea. She dated her present illness one week prior to admission ; the onset was with a chill, the abdominal pain appearing some days later. Upon admission the abdomen was only slightly distended in its lower zone, but it was excessively tender. On percussion there was tympany over the entire abdomen. The second day after admission the distension had incrciised and the tenderness became more pronounced. Temperatui'e fluctuated between 101° and 102.5° F.; pulse quick. The vaginal examination showed the presence in Douglas' cul-de-sac of a mass the size of an enlarged fundus uteri. An exploratory incision was made by Pr. Clark on March 12th. The much distended intestines immediately extruded themselves through the opening. They were hypenemic and covered with a thick layer of fibrin and pus. The peritoneal cavity was flooded with sterilized salt solution, the pelvis packed with gauze (a ruptured pvosalpins was suspected) and the incision in part closed. Death occurred on March 14th at 1.30 P. M.

Autopsy, March 14th, at 4 P. M. Anatomical diagnosis : Diphtheritic entero-colitis. Acute fibriuo-puruleut peritonitis; extension into the pleural canities. Chronic pelvic peritonitis ; hydrosalpinx. Acute spleen tumor. Pareucbymatous degeneration of viscera.

An abstract of the protocol is as follows : Body well nourished; in the median line of the bodv, begiuuing 10 cm. below

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the umbilicus, there is a linear incision, closed in its upper part with sutures, the lower part being packed with iodoform gauze. The edges of the incision are covered with a sticky, blood-stained, not distinctly purulent exudate which lightly agglutinates the edges. The parietal peritoneum is bound by light, recent fibrinous adhesions to the congested and distended intestinal loops over the lower zone of the abdomen. The omentum is spread out and covers the upper half of the cavity, and it is free from old adhesions. Both of its surfaces are covered with an opaque exudate. The intestines generally present small subserous ecchymoses, and they are covered by a fibrinous exudate, becoming much thicker at the edges of contact of the loops. The fibrin is thickest over the loops of the intestine which occupy the pelvis.

The uterus is bound by old adhesions to the bladder in front and the rectum behind. The left Fallopian tube is involved in dense adhesions ; it is dilated and bent upon itself. The ovary is also enclosed in adhesions, and it occupies the recess formed by the bending of the elongated tube. In its entire length this tube measures 15 cm. It is smallest at the uterine extremity (size of little finger) and largest at the fimbriated end (size of thumb). The fimbriated extremity is hidden in the adhesions. The contents of this tube are clear and watery. On the right side there is a dense mass of adhesions in which is enclosed a cavity lined with smooth walls, the contents of which are slightly turbid fluid. At one extremity of this there is a pedunculated hydatid the size of a pea. The former represents the remains of the ovary. The right tube is less enlarged and it is buried in adhesions; it contains clear and thin contents. The cavity of the uterus is normal in size; the mucous membrane is velvety.

There is no pneumonia; the pleura is, however, covered at the base of the lungs, on each side, with a tolerably thick layer of fibrin. A similar layer also covers the diaphragm, but not completely. This exudate in the pleura was produced by the extension of the infiammatory focus through the diaphragm.

The jejunum is distended; in its upper portion it is less congested than the remainder of the intestine. The upper part of the ileum, which is distended throughout, shows only a slight congestion of the mucous membrane; but as the intestine is descended the congestion increases, although even here it is not uniformly present. Beginning 75 cm. above the ileocsecal valve, the mucous membrane of the intestine is diffusely congested, it is swollen and presents small hemorrhagic points. In this situation the surfaces of the valvula3 conniventcs are covered with a heavy yellow fibrinous exudate, the intervening mucosa being covered with a lighter granular exudate. This area extends for a distance of 45 cm., leaving a stretch of intestine of 30 cm. above the valve free. The cajcum is greatly congested, it presents foci of necrosis and exudation which are stained with bile. In the ascending colon the follicles are enlarged for a distance of 20 cm., and the mucous membrane about them is swollen and ecchymotic. A fibrinous exudate is also present here.

The bacteriological exaniinuLion of the exudate in the periUnieal cavity at the time of the exploratory incision showed one species only of micro-organisms, namely, a capsulated dip

lococcus. The same organism was isolated from the abdominal cavity and from the exudate in the pleura at the autopsy. No other species could be found, and this one was proven to be tlie micrococcus lanceolatus. Cultures were also made upon agar-agar from the fibrinous exudation in the intestine. A diplococcus similar to the one found in the peritoneum was isolated.

Animal experiments. — A mouse was inoculated into the root of the tail, at the time of the autopsy, with a small (juantity of the exudate from the pleura. It died on the 3d day. Locally there was an wdema which contained many typical capsulated diplococci. In addition there were an acute fibrinous pleuritis and pericarditis, in both of which the same species of organism was contained. A second mouse was inoculated subcutaneously with a small amount of the growth upon an agar-agar culture, derived from a single colony from the plates made from the exudate in the intestine. It died in 2i days. From the local process and the peritoneum of this animal many capsulated diplococci were obtained.

The study of the hardened tissues taken from both the large and small intestine showed the diphtheritic process to consist of a necrosis of the epithelial layer and the subjacent glands in the mucosa, upon which and in which a pseudo-membrane containing fibrin, leucocytes, detritus and bacteria was deposited. The leucocytic infiltrations extended into the depth, often filling the gland himina, appearing between the glands, in and beneath the muscularis mucosse, and in a variable amount being present in the the submucosa. The capillary blood-vessels in the mucosa were invariably hyaline and thrombosed in the areas of necrosis with pseudo-membrane formation, but sometimes in other places as well. Actual hemorrhages had taken place here and there into the mucous membrane. The submucosa showed a varying picture. In the congested and pseudo-membranous areas generally it was swollen. At times this swelling was an cedema in which only a few emigrated cells were visible; at other times much fibrin was present in it, with at the same time either few or many emigrated cells. The muscular coat was quite free from infiltration with fluid or cells. Sections stained with Weigert's fibrin stain brought out the bacteria in addition to the fibrin. As a matter of fact, although with the hematoxylin and eosine staining much fibrin was found to be present, yet by the former method some unsuspected areas came to view, and notably the material occluding many of the capillaries in the mucosa took on a vivid blue stain. In the false membrane many bacteria were found, and among these diplococci were easily distinguished. Corresponding with the situations of the false membrane, the bacteria could be traced into the glandular laj'er, both inside and between the glands, and they reached nearly but not quite to the muscularis mucosa?. However, in other situations in which no pseudo-membrane was present bacteria had passed into the substance of the glandular layer. In the deeper parts only two species could be distinguished, a diplococcus and a short bacillus, the latter often staining irregularly. The former predominated. Bacteria were not found to pass through the muscularis mucosa;, they were not found in the submucosa among the cellular infiltration, nor in the cedematous and fibrinous portions. Diplococci were only

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very exceptionally found in spaces (lymphatics ?) in the subserous coat, less often in the intermuscular fibrous fasciculi. There was no evidence therefore of a continuous growth through the intestinal coats. There was evidence, however, of a transportation by the lymph current. Upon the peritoneal surface great numbers of the characteristic diplococci were found.

The especial interest in these cases concerns first the nature of the micro-organisms causing the acute peritonitis; second, tlie demonstration of their invasion from the intestine in the absence of perforation, and third, the part believed to have been played in the one by a chronic dysenteric process, and in the other a chronic peritonitis, in rendering the peritoneum susceptible to the action of the introduced micrococcus lanceolatus.

A RAPID METHOD OF MAKING PERMANENT SPECIMENS FROM FROZEN SECTIONS

BY THE USE OF FORMALIN.

By Thos. S. Cullen, M. B.

Any one who has hardened tissues in formalin will be impressed with the rapidity of its action, with the firm consistence of the tissue, and with the absence of the contraction of the specimen so often seen when alcohol is used as the hardening medium. Microscopical examination of a specimen hardened in formalin, as we all know, shows almost perfect preservation of the cellular structure. Eecently it occurred to me that formalin might be used in the prej)aration of frozen sections.

One of the greatest difficulties experienced in rendering frozen sections permanent lies in the fact that when passed through alcohol the section frequently not only contracts but contracts irregularly, distorting the specimen ; further, such specimens will often stain imperfectly. The use of formalin will obviate these difficulties, allowing one to make an excellent permanent specimen from the frozen section. My method is as follows : The tissue to be examined is frozen with carbonic acid or ether and then cut; the sections are then placed in 5 per cent, watery solution of formalin for 3 to to 5 minutes, or longer if desired; in 50 per cent, alcohol 3 minutes, and in absolute alcohol ] minute. The tissue is now thoroughly hardened and can be treated as an ordinary celloidin section, being stained and mounted in the usual way. On examining this mounted section one might readily take it for a well preserved alcoholic specimen. Supposing we stain with hsematoxylin and eosin, tlie entire process is as follows:

a. Place the frozen section in 5 per cent. aq. sol. formalin for 3 to 5 minutes.

h. Leave in 50 per cent, aicoliol 3 minutes.

c. In absolute alcohol 1 minute.

d. Wash out in water.

e. Stain in hiBmatoxylin for 2 minutes. /. Decolorize in acid alcohol.

g. Rinse in water.

h. Stain with eosin.

i. Transfer to Of) per cent, alcohol.

y. Pass through absolute alcohol, then through either creasote or oil of cloves, and mount in Canada balsam.

The blood is lost in frozen sections. To overcome this Prof. Welch suggested that the specimen be first fixed in formalin and then frozen. I tried this and "found that we were able

to preserve the blood, but that it did not stain very distinctly. For convenience this second procedure will be called method II. The essential factor is the same in each case. The latter process, however, requires at least two hours. A small piece of the tissue is thrown into 10 per cent, solution formalin for two or three hours. It is then put on the freezing microtome and thin sections can be readily made. The sections are stained in the usual way. The detailed procedure of method II is as follows:

a. A piece of tissue lx.5x.'Ai cm. is placed in 10 per cent aq. sol. formalin for 2 hours.

b. Frozen sections are made.

f. Left in 50 per cent alcohol 3 minutes.

d. In absolute alcohol 1 minute.

e. The sections are now run through water and stained in haematoxylin for 2 minutes.

/. Decolorized in acid alcohol.

g. Rinsed in water. h. Stained in eosin.

('. Transferred to 95 per cent, alcohol.

j. Passed through absolute alcohol, then either through creasote or oil of cloves, and mounted in Canada plug balsam.

For ordinary use method I is all that is required. Given a piece of tumor from the operating room, it is possible to give as definite a report in 15 minutes as one would be able to give after examining the alcoholic or Miiller's fluid specimens at the expiration of two weeks. Method II is of especial value in the examination of uterine scrapings. Instead of putring them in the 95 per cent, alcohol in the operating room, they may be immediately dropped into 10 per cent. aq. sol. formalin. By the time the pathologist receives them, which is at least two hours afterwards, they are firm enough to bo frozen without difficulty, and permanent sections can l>e immediately made. The second method is to be recommended for all delicate tissues. In employing these methods one must remember, as for example in epithelioma, that some of the cell-nests will drop out, tliere not being anything to hold them in sifu. as there is when celloidin is used. We have, however, hardened and stained epithelioma of the cervix by this method without the slightest difficultv.

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THE CONDITION OF THE GEMMDLES OE LATERAL BUDS OF THE CORTICAL NEURODENDRON

IN SOME FORMS OF INSANITY.

A PRELIMINARY NOTE. By Henkt J. Berkley, M. D.

In the early years of the chromate of silver methods, the protoplasmic extensions of the nerve cells were considered to be of comparatively little importance in comparison with the cell body and axis-cylinder process. Golgi thought their function to be principally nutritive, and that they had junctures with the vascular glia and blood-vessels, while Nansen went to the limit of denying to them the property of nervous function, relegating it entirely to the axis-cylinder.

The discovery that the axis-cylinder was occasionally an offshoot of one of the protoplasmic processes at some distance from the cellular body was a powerful factor in producing an alteration in these views, and to-day the cell branches are regarded as an essential portion of the nervotis apparatus, having an almost equal significance in the production of the nervous impulses with the cell body ; hence the now universal adoption of the name neurodendron, or neurodendrite, for the branches.

AYith the neitrodendron, the lateral buds, or gemmula;, have gradually acquired more and more significance. Kolliker in 1891 looked upon them as artifacts, while in various recent reviews of the nerve cell they are disregarded entirely, or their presence is simply mentioned, for they are considered to be of no import in the economy of the nerve cell. More recently, however, Leuhossek testifies to their constant presence in silver preparations, and has actually demonstrated them in fine Nissl preparations. Cajal and Retzius also admit their universal presence on the dendrites of the pyramidal cells of the cerebrum and the Purkiuje cells of the cerebellum. None of the writers who mention them at all advance a theory as to their nature, beyond that they are possibly chromophile particles attached to the sides of the dendrons, nor do they attact much significance or importance to them.

Another point in regard to the gemmules is that they are supposed to be much more prominent in early than in adult life; an idea which, in view of recent developments in the histology of the nerve cell, seems to be disproved. The probable truth of the matter lies in the circumstance that the earlier chrome-silver methods only stained the buds very imperfectly, or in a manner not sufficiently striking to direct much attention to them, the rounded knob at the free extremity commonly being more definitely stained than the stem.

However, recent methods of obtaining silver impregnations have brought them out more and more clearly, until now they form an important portion of the picture of nearly all of the cortical cells.

I have recently observed, by means of a new and seemingly constant method of silver staining in a number of slides from cases of chronic alcoholism, and from demented subjects, a distinct alteration in these gemmulre that foreshadows the discovery of a class of pathological lesions of the brain cells which we have hitherto not been able to see by any mode of nerve-cell staining in possession of the pathologist. The cases from which we have drawn are still few in number, nine in . all, from the cerebra of seven alcoholics and two dements; but the changes have been always present; and more important, in the brains of several rabbits which had been subjected to the ingestion of considerable quantities of alcohol, the differences between the dendrons of the control and those from the alcoholic brains were most striking, for not only were lesions present, but they were invariably constant. It is true that these changes form only a portion of the lesions of the nerve cell, but being the most prominent they at once attract attention.

Briefly, in both alcoholics and dements they consist in a diminution of the lateral buds, proceeding in well advanced cases to a total disappearance of the short side processes. Not only does this change affect the larger pyramidal cells, but also the smaller angular and irregular ones, and eventually ends in a lessening in size of the protoplasm of the dendron, besides the stripping of the buds from its sides.

It would seem that by the use of this new method of staining — the phospho-moljbdate of silver in free nitrate of silver — which offers a constancy and fineness of detail before unattainable in pathological preparations, that we have almost passed the borderland of the uncertainty of mental disease, and will be able to relegate, in the fullness of time, all decided mental changes to the same definite category in which we are now able to place the formerly obscure diseases of the nervous system, whose lesions are now more or less thoroughly understood, and place psychiatry upon the same footing as many of its sister branches of medicine that rest upon a secure pathological basis.

REPORT IK GYIS^ECOLOGY, III.

By T. S. CuLLEN, M.B.

I. Hydrosalpinx, its Surgical and Pathological Aspects, with a report of twenty-seven cases. II. Post-operative Septic Peritonitis. Numerous plates.

REPORT IN DERMATOLOGY, I (in press).

Containing Protozoic Dermatitis, MolluBCum Fibrosum, L'rticaria, etc. By T. ('. Gilciikist, M. E. C. t^. Wsny Illustraticns.

Apbil, 1895.]

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PROCEEDINGS OF SOCIETIES.

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of January 31, 1895.

Dr. Abel in the chair.

Exhibition of Specimens: Cases of Tuberculosis.— Db. Flex NER.

1. Primary tuberculosis of tlie serous membranes involving the pleura and peritoneum. Tuberculosis of the mediastinal, pericardial, tracheal, bronchial, peritoneal and retropei-itoneal lymphatic glands. Perforation of an adherent bronchial gland into the bronchus. Extension of tuberculosis from the peri-pancreatic tissue into the pancreas. Tuberculosis of the intercostal muscles. Healing infarction of lung.

The patient was a colored man, 35 years old, who dated his last illness from October 3, 1894. He was admitted into the medical wards of the hospital, October 13, 1894; he died December 6tli at 2 A. M. At the meeting at which the specimens from this case were exhibited. Dr. Osier made the following remarks upon them: "On admission the patient had high fever, but nothing was to be discovered locally except the involvement of the pleura. A slight effusion into the left pleural cavity occurred, and the aspirated fluid, which was clear, gave negative results in cultures. Subsequently the case changed very much in character. Instead of a continuous fever it became extremely irregular and intermittent, and for nearly ten days there was intermittent pyrexia. For 8 to 10 hours out of the 24 the temperature not only fell to normal, but subnormal, indeed down to 97° or even 96°. Two or three weeks after his entrance into the hospital he began for the first time to have abdominal trouble. No especial tenderness was present, but the abdomen became large, and distinct areas of induration made their appearance. One of these lay ti-ansversely across the upper portion of the abdomen, and this we thought was the thickened omentum. Taking the pleurisy and involvement of the peritoneum into consideration, we thought the diagnosis of tuberculosis tolerably certain in spite of the absence of any local indications of tuberculosis. The patient had no cough, and no expectoration came from the lungs. He had a small amount of mucoid expectoration, which was carefully examined and found negative. The day before his death, as I was dictating a note upon his case, my attention was attracted to a nummular mass of sputum in the basin at his bedside. It was so unlike anything that had been previously seen that I asked the nurse if it had come from this patient. She said it had. It was at once examined and found full of tubercle bacilli. The patient had no involvement of the lungs, and, as the autopsy showed, the bacilli came- from a softened lymphatic gland which had perforated into one of the bronchi."

The main features of this case are as follows: 2'he left lung and pleural cavity. — The left lung is bound in places by firm adhesions to the costal wall. The two layers of the pleura are much thickened and contain large and small tubercles. The two layers are not everywhere in contact, and where they are separated, stringy masses of fibrin run from one

surface to the other. A small amount of iluid occupies these spaces. The pleura covering the diaphragm is also much thickened, and to this the lung is firmly attached. On section, the lung is dai'k in color, it is not entirely airless, and it is entirely free from tuberculous infiltration. The vessels and bronchi are free. The larynx and trachea are free from ulceration. There are adhesions between the right bronchus just below the bifurcation and a packet of enlarged and tuberculous lymph glands. In this bronchus, 2 cm. below the bifurcation, affecting the division going to the lower lobe, there is a perforation due to the softening of one of the adherent glands. The surface of the bronchial mucous membrane corresponding to this is covered with necrotic material easily removed, and the bloodvessels of the adjacent mucous membrane are congested.

The right lung and pleura are free from tuberculous infiltration; but in the lower lobe of this lung there is a consolidated area as large as a hazel-nut, of a brownish-red color centrally, and a paler peripheral portion, which proved to be an infarction partly decolorized and undergoing organization.

Intercostal muscles. — Beneath the fascia covering the intercostal muscles are small tubercles and several larger caseous areas. The largest equalled a pea in size. The masses are imbedded in the muscle substance, as shown by the microscopical examination.

Peritoneal cavity. — The abdominal wall is bound by firm adhesions to the omentum, and the omentum in turn to the visceral layer of the peritoneum. The omentum extends over the entire front part of the cavity of the abdomen, descending to the superior surface of the bladder and extending well into the lateral regions of the cavity. The omentum is much thickened, the thickening being greatest over the site of the transverse colon. This thickening is due to the development of discrete tubercles and diffuse tuberculous tissue within its substance. The peritonea] covering of the intestines contains many discrete tuberculous masses, yellow in color and opaque, resembling those in the omentum. The intestines are matted together by these as well as by a stringy, yellow fibrinous exudate. The parietal peritoneum is covered with similar tubercles, and the vesico-rectal fossa also. All the viscera are surrounded by a tissue containing tubercles and tuberculous tissue, and thus firmly bound to adjacent structures. The under surface of the diaphragm is studded with tubercles and firmly united to the liver.

The pancreas is involved in a firm mass of adhesions, and in the region of the duodenum its substance for a distance of 3x3 cm. is invaded by a tuberculous growth. This mass is of an opaque, yellowish color. Fpon microscopical examination it is composed of caseous material, and in the edge next the pancreas discrete tubercles are visible in the granulation tissue there present. The gland acini are very indistinctly visible in the caseous area, and they are fast disappearing from the advancing edge of tuberculosis.

2. Phthisis pulmonalis with the formation of large trabeculated cavities. Tuberculous bronchiectatic cavities. Tuberculosis of epididymes, testicles, seminal vesicles, prostate gland, bladder and kidney. Adhesion between the left semi

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nal vesicle, prostate and urethra, perforation of the urethra. Tuberculosis of liver, spleen and adrenal glands.

The patient, a colored man, was admitted into the medical wards of the hospital (Prof. Osier), December 14, 1894. The present illness was dated from July, 1894. The physical examination indicated a large cavity in the left apex, and also a cavity on the right side. Behind the right testicle an enlargement, apparently connected with the epididymis, was felt. The sputum contained many tubercle bacilli.

Lungs. — The upper lobes of both lungs contain large trabecnlated and communicating ulcerative tuberculous cavities. In the left lung there are several bronchiectatic cavities as well.

Adrenal glands. — The left is much enlarged ; its dimensions are 8x3.5x1 cm. It is surrounded by adhesions. On section it is found to be converted into a fii'm caseous mass. The right adrenal measures 4x3x1 cm., it is also involved in adhesions, and on section shows a similar tuberculous transformation.

Scrotum, epididymes, testicles, seminal vesicles, prostate gland, urethra. Madder and kidneys. — On the left side of the scrotum there is a small fluctuating mass the size of a walnut which is not distinctly connected with the testicle. The skin over this swelling is congested and glazed. On section this proves to be an abscess cavity containing caseous pus. The epididymes are much enlarged and tuberculous, and on the left side there are adhesions between the epididymis and the sci'otal tissues corresponding to this abscess. In the testes are scattered grey and firm tubercles. The seminal vesicles are enlarged and tuberculous. On section of the left one it is found to be converted into a thickened and indurated mass containing a central cavity filled with softened caseous material. The walls of this cavity are almost of cartilaginous hardness. Between the enlarged vesicle and the prostate gland an adhesion had taken place, and the softening of this part of the wall of the vesicle has extended into the prostate and through it to the urethra. Thus a perforation of the urethra 2 mm. in diameter, which is situated in the prostatic portion to the left of the verumontanum, had taken place. This perforation communicated with the cavity of the vesicle. The right seminal vesicle is converted into a caseous mass which has just begun to soften. The mucous membrane of the bladder is, in general, pale. Just above the neck of the bladder the mucous membrane is cedematous, and this edematous condition extends to the lower angle of the trigonum. In the mucous membrane corresponding with this oedema are small, elevated, opaque nodules of the size and general appearance of miliary tubercles. Descending, these nodules become more numerous and a little larger in the mucous membrane of the prostatic portion of the urethra, and here there is considerable congestion of the mucous membrane. The kidneys are swollen, the capsule is removed with difficulty, and minute hemorrhages are evident in the substance of the organs. Each kidney presents a tuberculous nodule as large as a walnut, which is located for the most part in the pyramidal portion, but extends into the cortical part as well.

Notwithstanding the tuberculosis of both adrenal glands, there were no symptoms or other indication of Addison's disease in this case.

An Ideal Result following Double Tenotomy in a Case of Convergent Strabismus. — Dr. Theobald.

This case is of interest for several reasons. In the first place the squint was of very high degree ; in the second place it had existed some 33 or 34 years; and thirdly, the result obtained was exceptional.

Before describing the case it will be well to say a few words as to the difficulties which beset us in obtaining good results in squint operations. No operation for squint is perfectly successful unless it restores binocular vision. The restoration of binocular vision would be a very easy matter in almost all cases but for one thing — after an eye has squinted for some time it almost invariably becomes more or less amblyopic. As the squint develops it is, at first, intermittent; the eye squints in, from time to time, during accommodation perhaps, and at other times is straight. With each turning in of the eye there occurs double vision. This double vision produces so much annoyance that the brain at once begins to shutout the vision of the squinting eye, and as a result of this a marked amblyopia soon develops in this eye. It is this amblyopia which often makes it a difficult matter to bring about binocx;lar fixation after tenotomy. We very often find, after an eye has been squinting for some time, that its fixation is eccentric; in other words, if we close the non-squinting eye and direct the patient's attention to some object, he will not look directly at the object, for the vision of the macula region is not so good as that of some eccentric portion of the retina, and hence he prefers to direct this eccentric portion of the retina towards the object he is regarding. I have seen cases where, after a tenotomy, the muscular balance was almost perfect, and yet the eye which previously had squinted seemed to have no disposition whatever to follow the movements and to fix with the other e3'e, the whole tendency to binocular vision seemingly having been destroyed, the eye squinting sometimes in a little and and again out a little whilst the other eye was fixing a given object.

This question of the amblyopia of squinting eyes is one that has attracted a great deal of attention in recent years. Donders and Von Graefe, and the authorities of their time, accepted the view to which I have just referred — that the amblyopia is produced by the squint; that when the eye begins to squint there is so much confusion from the double vision that the brain shuts out the vision from this eye, and that in time amblyopia is produced as the result of this. This was the view generally accepted until a comparatively short time ago, when Schweigger and Alfred Graefe advanced a different view. They held that instead of the squint being the cause of the amblyopia, the amblyopia Avas the chief cause of the squint; that the amblyopia was congenital, and that the amblyopic eye having little capacity to fix with the other eye, was prone to become strabismic. This view is the one which at the present time probably receives the most general acceptation. It has not commended itself to my judgment, however, and in 1886 I wrote a paper, published in the transactions of the American Ophthalmological Society, bearing upon this question — whether the amblyopia was dependent upon the squint or whether the squint was dependent upon the amblyopia. A significant point which I laid sti'ess upon at that

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time is this: the exact location of the amblyopic area in the retina of the squinting eye. When an eye first begins to squint there are two images in it whicb are especially troublesome. One is the image of the object which the individual is regarding with the non-squinting eye, and which of course is formed upon an eccentric portion of the retina of the squinting eye ; the other is the image which happens to fall upon the macula region of the squinting eye. The former is the image which causes the individual to " see double"; the latter is especially annoying because it overlies and is mentally confused with the image of the object which is being regarded by the properly-directed eye. These are the two images which must be suppressed if the individual is to enjoy even tolerable visual comfort. For this reason there are two portions of the retina of the squinting eye, supposing the amblyopia to be the result of the squint, where we should expect the amblyopia to be most marked. These two portions are the macular region of the squinting eye, because there the individual must get rid of the object which is seen confused with the object he is looking at ; and the other is that portion of the retina in the squinting eye which receives the image of the object which in the properly directed eye is formed upon the macula. In convergent squint the part of the retina in question lies to -the nasal side of the macula, while in divergent squint it lies to the temporal side. Now this is exactly what we find to be the case in squinting amblyopic eyes. The macular region is found to be highly amblyopic, and in convergent squint the inner portion, and in divergent squint the outer portion of the retina. This to my mind is almost conclusive evidence in favor of the view that the amblyopia is really produced by the squint.

Since my paper was read in 1886, several very interesting cases have come forward bearing upon the question at issue. One is a case reported by Dr. Roosa. Schweigger makes the point that no case has ever been reported where a person has been known to have had normal vision in an eye which has afterward squinted and become amblyopic. It would seem that there should be dozens of such cases. Such is not the fact, however. The reason is that concomitant squint almost always develops in early childhood, usually before the age of five years, and, as may be supposed, the occasion and the opportunity to test the vision before this age rarely presents itself; furthermore, it is almost impossible to test the visual acuteness with any degree of satisfaction at so early an age. Dr. Roosa has reported, however, in his recently published work upon eye diseases (p. 549) a case of this character. A girl seven years of age was brought to his office and was found to have practically normal vision in both eyes. Ultimately she developed a squint, and later on was brought back again, and the squinting eye was then found to be decidedly amblyopic.

A still more interesting case was reported by Dr. W. B. Johnson, of Paterson, N. J., to the American Ophtlialmological Society. Here the reverse happened — an individual who had been extremely amblyopic in a squinting eye regained normal vision in it. The significance of this case is, that if the amblyopia had been congenital the vision would certainly not have been regained in the way it was. The facts in this case were these : A man, 19 years of age, liad s<[uinted in liis left eye since three

years of age. The other eye was good. In the squinting eye he could only count fingers at six inches. He visited Dr. Johnson just before the accident about to be related occurred, and his vision was tested with the result stated. A few days afterward he received an injury in the normally directed eye, from a piece of steel or iron, and the eye had to be enucleated. This left him only with the previovisly squinting and highly amblyopic eye. The case was carefully watched and studied by Dr. Johnson. The day after the enucleation of the injured eye the patient expressed himself as seeing better already with the squinting eye. Seven days after the accident the vision had increased from counting fingers at six inches to |^. Thirteen days afterward, with a +1.75 glass, he was able to read .Jaeger Xo. 9. Eighteen days after the accident he had full normal vision, and this condition lasted when he was last examined three years afterwards. This case was regarded by members of the Ophthalmological Society as having an important bearing upon the question of the origin of amblyopia in squinting eyes. The amblyopia in this instance was certainly acquired, because, if congenital, vision would not have been restored as it was. These two cases have especially interested me because they so strongly sustain the view which I argued in favor of a few years since.

The case I wish to speak of was that of a man 37 years of age. His right eye squinted strongly inward. His strabismus was due to a fall and had existed -3.3 or 34 years. The origin of the squint is significant. Where a squint develops as the result of a fall it is almost necessarily a paralytic one and manifests itself quickly. It does not go through the usual stages of a slowly developing concomitant squint, as previously described. In paralytic squint good vision is more likely to be retained in the squinting eye than in concomitant squint, for as the squint is usually of high grade and forms quickly, it is not so essential that the amblyopia should be developed in order to rid the individual of the annoyance of double vision. This patient had normal vision in his left eye and 1^ vision in the squinting eye. He consulted me in September, 1894, but did not consent to have his eye operated upon till March of the present year. I did a very free tenotomy of the right internal rectus. I not only cut the tendon proper, but also divided very freely Tenon's capsule. After this operation there was still a considerable residual squint left Three days afterward I did a free tenotomy of the internal rectus muscle of the opposite eye. After free division of the tendon and free section of Tenon's capsule there was still a slight residual squint, so I introduced a conjunctival stitch and attached it to a plaster strip on the temple. The first operation was done ]^Iarch Sth, the second March 11th. On Marcli 12th, after the removal of the stitch, I found he had binocular vision, and here came the especially interesting feature of the case. Usually in making our tests of the lateral balance of the muscles we find that in distant vision, a four or five degree prism, base up or down, will produce a degree of vertical diplopia which the eyes cannot overcome. This man's eyes were so intent upon maintaining binocular vision that it was necessary, even the very day after the second tenotomy, to use a vertical prism of seven to eight degrees in order to keep the images apart. With a prism of four or five degrees the eyes

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would blend the two images at ouce. The lateral muscles were tested in this way, and there was found to be an insuflficiencv of the external recti muscles varying from 1" to nothing. On March loth I found it necessary in the vertical diplopia test for distance, to use a nine degree prism to prevent the eyes from merging the two images, and iu the near test it was necessary to use one of eleven degrees. There was lateral orthophoria, both in the distance and in the near, and no hyperphoria. When the eyes of this individual were once put iu such a position that binocular vision was possible, they seemed to be much more intent upon maintaining it than normal eyes usually are, although they had been squinting for 33 or 34 years and during all this time had never known what it was to work harmoniously. This very unusual feature of the case is what seemed to make it worth reporting.

NOTES ON NEW BOOKS.

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL.

Vol. Vl.-Nos. 50-51.

BALTIMORE, MAY-JUNE, 1895.

+++

Contents

Medical Lore in the older English Dramatists and Poets (exclusive of Shakespeare). By Robert Fletcher, M. D., - - 73

Tetany in Pregnancy. By H. M. Thomas, M. D., - - - 85

A Death from Chloroform. Impossibility of Inducing Artificial Respiration on Account of Rigid Thorax and Adherent Abdominal Viscera. By J. G. Clark, M. D., - - - - 89

A Quick Method of Filtering Blood Serum. By Given Campbell, M. D., and A. D. Ghiselin, M. D., 91

PAOS.

Proceedings of Societies :

The Hospital Medical Society,

A Case of Pharyngomycosis Leptothrica [Dr. BarkebJ ; — A Case of Anthrax in a Human Being [Dr. Flexxer].

Notes on New Books,

Books Received,

Obituary,

93

MEDICAL LORE IN THE OLDER ENGLISH DRAMATISTS AND POETS (EXCLUSIVE OF

SHAKESPEARE).

By Robert Fletcher, M. D. [Read before the IIMorical Club of the Johns Hopkins Hospital, May 13, 1895.]

Upon hearing the title of this paper it may, perhaps, excite your surprise that Shakespeare should be specifically excluded from the list of authors, since his plays abound in allusions to medical matters. But everything relating to the special lines of knowledge of that uuequaled writer has been so thoroughly investigated, every allusion to medicine, law, religion, folk-lore, flowers, birds or animals, has been so worked into essay or book, that tliere is nothing which could now be said that would not seem trite or stale. There is half a column of references to the literature treating of medicine in Shakespeare in the Index Catalogue of the National Jledical Library, and still there comes from time to time some jounuil from the Far West — an Oklahoma Medical Clarion, perchance — with the familiar title in its table of contents of " Shakespeare's medical knowledge," or " Remarks on Hamlet's madness from a psychological standpoint."

In the course of a somewhat miscellaneous reading, aside from professional studies, it has been my custom through many years to copy passages relating to medical subjects, and it is from the rather opulent collection which has been thus formed that I have selected some readings for to-night, which I trust may be found novel and entertaining and possessed of some interest from a historical point of view. It is difficult to put such disjointed material into any workmanlike shape, and you will kindly make allowance for the species of mosaic work submitted to you. It would be an easy matter to tiike

an author's works, or a single play, and read out all the medical allusions to be found therein, but I have thought it better to select certain subjects to be illustrated by quotations. The first subject will be the condition of medicine generally in what is termed the Elizabethan period, and the estimation in which its practitioners were held by the people: next, early references to the venereal disease and it5 treatment, and lastly, some miscellaneous curiosities of therapeutics and the like. I shall not trouble you with extracts relating to materia medica merely; they are very numerous, and one division of the subject, which I may term the Witches' Pharmacopoeia, and which is extremely curious, would alone occupy the canonical hour of your evening.

It is perhaps not an unfair test of the popular repute in which a profession is held to observe how its members figure in the novels and plays of the period. Certainly in the works of the great novelists of our own time the doctor appears in a most admirable light. He may be eccentric, but is always benevolent^ and sometimes skillful beyond the power of attainment of any living physician. Judged by this st.indard. the average doctor of the sixteenth century was a comi>ouud of ignorance and knavery, with an occasional d:»sh of jvdautry. In all the literature of the period in question I c^uiuot call to mind a decided instance to the contrary, if he lie not a charlatan or a pedant he is merely a lay-figure in a doctor's gown a!id cap. like tlie physician in Macbeth.

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In 1629 there was published iu London a curious volume entitled: " Micro-cosmogruphie, or a piece of the world discovered in essays and characters." It was an anonymous i)roduction, but the author was Dr. John Earle, afterward Bishop of Salisbury. Among his "characters" he has a physician and surgeon, and it must be admitted that they are not models of ethical conduct. Of the physician he says :

" His practice is some businesse at bed-sides, and his speculation an Uriuall. Hee is distinguisht from an Empericke by a round velvet cap, and Doctors gowne, yet no man takes degrees more superfluously, for he is Doctor howsoever. He is sworue to Galen and Hypocrates, as University men to their statutes, though they never saw them, and his discourse is all Aphorisms, though his reading be onely Alexis of Piemont, or the Regiment of Health. The best cure he ha's done is upon his own purse, which from a leane sickliness he hath made lusty, and in flesh. His learning consists much in reckoning up the hard names of diseases, and the superscriptions of Gallypots in his Apothecaries Shoppe, which are rank't in his shelves and the Doctors memory. He is indeed only languag'd in diseases, and speakes Greeke many times when he knows not. If he have beeue but a by-stander at some desperate recovery, he is slandered with it, though he be guiltelesse; and this breeds his reputation, and that his Practice ; for his skill is meerly opinion. Of all odors he likes best the smell of Urine, and holds Vespatians rule, that no gaine is unsavoi'y. If you send this once to him, you must resolve to be sick howsoever, for he will never leave examining your Water till hee have shakt it into a disease. Then follows a writ to his drugger in a strange tongue, which hee understands though he cannot conster. If he see you himselfe, his presence is the worst visitation ; for if he cannot heale your sickness, he will bee sufe to helpe it. Hee translates his Apothecaries Shop into your Chamber, and the very Windowes and benches must take Phisicke."

As a rule, the physician of those times was a more flourishing man than the surgeon. There are proverbial expressions which indicate the general prosperity of the former. In a play by George Chapman, All Fools, 1605, III, 1, there is such an instance :

Heaven, lieaven, I see tliese politicians

(Out of blind fortune's hands) are our most fools.

'Tis she that gives the lustre to their wits,

Still ploilding at traditional devices ;

But take 'era out of them to present actions,

A man may grope and tickle 'em like a trout,

And take 'em from their close dear holes as fat

As a physician.

Of the surgeon he says :

"A Surgeon is one that has some business about liis Building or little house of man, whereof Nature is as it were the Tyler, and hee the Playsterer. It is ofter out of reparations than an old Parsonage, and then he is set on worke to patch it againe. Hee deales most with broken Commodities, as a broken Head, or a mangled face, and his gaines are very ill got, for he lives by the hurts of the Common-wealth, llu differs from a I'hysitian as a sore do's from a disease, or the sicke from those that are not whole, the one distempers you

within, and the other blisters you without. He complaines of the decay of Valour in these dales, and sighes for that slashing Age of Sword and Buckler; and thinkes the Law against Duels was made meerly to wound his Vocation. Hee had beene long since undone, if the charitie of the Stewes had not relieved him, from whom he ha's his Tribute as duely as the Pope, or a wind-fall sometimes from a Taverue, if a quart Pot hit right. The rareness of his custome mak[e]s him pittilesse when it comes : and he holds a Patient longer than our Courts a Cause. Hee tells you what danger you had beene in if he had staide but a minute longer, and though it be but a prickt finger, hee makes of it much matter."

Beaumont and Fletcher frequently introduce medical consultations in their plays, and "a physician" or "a surgeon" is nearly always to be found in the persons of the drama. It must be admitted, however, that those great writers had no admiration for the medical men of their time. They represent them either as pretenders or pedants, and they are held up to ridicule accordingly. In the play of Monsieur Thomas, 1639, II, 1, Francesco is taken with a fainting tit, and is cared for at first by his friends. One of them, Valentine, says:

Come, lead him in ; he shall to bed ; a vomit, I'll have a vomit for him. Alice. A purge first ;

And if he breath'd a vein — Val. No, no, no bleeding ; A clyster will cool all.

In scene 4 the same patient is the subject of a consultation :

Enter three physicians wilh an urinal. First Phys. A pleurisy I see it. Sec. Phys. I rather hold it For tremor cordis. Third Phys. Do you mark the freces?

'Tis a most pestilent contagious fever ; A surfeit, a plaguy surfeit ; he must bleed. First Phys. By no means. Third Phys. I say, bleed. First Phys. I say 'tis dangerous,

The person being spent so much beforehand, And nature drawn so low ; clysters, cool clysters. -See. Phys. Now, with your favours, I should think a vomit, For take away the cause, the efTect must follow ; The stomach's foul and furr'd, the pot's unphlegm'd yet. Third Phys. No, no, we'll rectify that part by mild means; Nature so sunk must find no violence.

The third doctor, who proposes bleeding, objects to the emetic as a violent remedy. The expression that " the pof s unphlegm'd yet" would appear to mean that no phlegm appearing in the pot, it was to be supposed still in the stomach.

In the next act, Francesco, whose sole complaint is hapless love, is discovered in bed, the three physicians, reinforced by an apothecary, endeavoring to apply their remedies.

First Phys. Clap on the cataplasm. Francesco. Good gentlemen — <9<!c Phys. And see those broths there

Ready within this hour. — Pray keep your arms in. The air is raw, and miuiaters much evil.

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Fran. Pray, leave me ; I beseech ye, leave me, gentlemen ; I have no other sickness but your presence ; Convey your cataplasms to those that need 'em, Your vomits, and your clysters. Third Phys. Pray, be rul'd. Sir.

First Phys. Bring in the lettice-cap. — You must be shav'd. Sir, And then how suddenly we'll make you sleep.

The commentators have discussed in their ponderous manner the meaning of the " lettice-cap " in the foregoing passage. They suggest a lettice or lattice cap, one of open work, which is absurd ; there was a fur, too, called letice, hut this would not cool the heated head. Thei'e is no doubt that lettuce leaves were applied to the shaven head as an appropriate remedy; the hypnotic effect of the plant was much vaunted in those times. Its use, as well as that of its active principle, lactucarium, has gone by, but in country places in England a like treatment is still employed, and plantain leaves or a cabbage leaf with the morning dew on it is thought to be cooling to the head of a delirious person.

There is a play by Middleton, A Fair Quarrel, 1613, IV, a, in which a surgeon is introduced, whose obstinate pedantry is amusingly contrasted with the impatient anger of the patient's sister. The Colonel lies wounded on his bed. His sister begins the interview :

Col.'s Sist. Come hither, honest surgeon, and deal faithfully with a distressed virgin ; what hope is there ?

Surgeon. Hope? chilis was scap'd miraculously, lady.

Col.'s Sist. What's that, sir ?

Surg. Cava vena ; I care but little for his wound i' th' lesophag, not thus much, trust me ; but when they come to diaphragma once, the small intestines, or the spinal medul, or i' tli' roots of the emunctories of the noble parts, then straight I fear a syncope ; the flanks retiring towards the back, the urine bloody, the excrements purulent, and the dolour pricking or pungent.

Col.'s Sist. . Alas, I'm ne'er the better for this answer.

Surg. Now I must tell you his principal dolour lies i' th' region of the liver, and there's both inflammation and tumefaction feared ; marry, I make him a quadrangular plumation, where I used sanguis draconis, by my faith, with powders incarnative, which I tempered with oil of hypericon, and other liquors munditicative.

Col.'s Sist. Pox a' your mundies frigatives ! I would they were all fired !

Surg. But I purpose, lady, to make another experiment at next dressing with a sarcotic medicament made of iris of Florence ; thus, mastic, calaphena, opoponax, sarcocolla —

Col.'s Sist. Sarco-halter ! what comfort is i' this to a poor gentlewoman? Pray tell me in plain terms what you think of him?

Surg. Marry, in plain terms I do not know what to say to him ; the wound, I can assure you, inclines to paralism, and I find his body cacochymic ; being then in fear of fever and inflammation, I nourish him altogether with viands refrigerative, and give for potion the juice of savicola dissolved with water cerefolium ; I conld do no more, lady, if his best ginglymus were dissevered. — [Exit.

It seems the wound required to be twice cauterized; the Surgeon says. Act V, 1 :

Marry, I must tell you the wound was fain to be twice corroded ; 'twas a i)lain gastrolophe, and a deep one ; but I closed the lips on't with bandages and sutures, which is a kind conjunction of the parts separated against the course of nature.

Most of the terms used by this learned Theban are readily understood, but one or two require a passing word. What is

meant by "chilis" I cannot tell; the word is probably corrupt. The hypericon is St. .Tohn's wort, a vulnerary famous even to this day. I do not know what calaphena is unless it be a misprint for sagaijenum. The dressing for the wound was to consist of orris root, gum mastic, calaphena, opopona.x and sarcocolla; three highly aromatic gum-resins held together by isinglass as a vehicle; surely this was a good antiseptic application, though somewhat difficult to clean oflf. What savicola is I do not know, but the cerefolium is the chaerophylluni or chervil.

Francis Beaumont, in his elegy on the death of the Countess of Rutland (tlie daughter of Sir Philip Sydney), indulges in a furious tirade against her physicians ; after exclaiming against their venality and ignorance, he gives this explanation of why they failed to save the countess, though they might cure common persons:

And I will show

The hidden reason why you did not know

The way to cure her : you believ'd her blood

Ran in such courses as you understood

By lectures : you believ'd her arteries

Grew as they do in your anatomies,

Forgetting that the State allows you none

But only whores and thieves to practise on ;

And every passage 'bout them I am sure

You understand, and only such can cure ;

Which is the cause that both yourselves and wives

Are noted for enjoying so long lives.

But noble blood treads in too strange a path

For your ill-got experience, and hath

Another way of cure. If you had seen

Penelope dissected, or the Queen

Of Sheba, then you might have found a way

To have preserv'd her from that fatal day.

.\s 'tis, )'0u have but made her sooner blest,

By sending her to Heaven, where let her rest ;

I will not hurt the peace which she should have.

By longer looking in the quiet grave.

You will notice the reference to the provision made for dissection, "anatomies," as the poet terms them, by supplying the bodies of those dying iu prison.

In the following spirited passage the ingratitude experienced by the Surgeon and the Soldier when the danger is past is well described:

What wise man,

That, with judicious eyes, looks on a soldier,

But must confess that fortune's swing is more

O'er that profession, than all kinds else

Of life pursued by man ? They, in a state,

Are but as surgeons to wounded men,

E'en desperate in their hopes. While pain and anguish

Make them blaspheme and call in vain for death.

Their wives and children kiss the surgeon's knees.

Promise him mount:\ins, if his saving hand

Restore the tortur'd wretch to former strength ;

But when prim death, by .Esculapius' art,

Is frighted from the house, and health appears

In sanguine colors on the sick man's face.

All is forgot ; and, a.«king his reward.

He's paid with curses, often receives wounds

From him whose wounds he cured : so soldiers.

Though of more worth and use, meet the same fate.

As it is too apparent. I have obserr'd

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When horrid Mars, the touch of whose rough hand

With palsies shakes a kingdom, hath put on

His dreadful helmet, and with terror fills

The place where he, like an unwelcome guest.

Resolves to revel, how the lords of her, like

The tradesman, merchant, and litigious pleader,

And such like scarabs bred in the dung of peace,

In hope of their protection, humbly offer

Their daughters to their beds, heirs to their service,

Ami wash with tears their sweat, their dust, their scars ;

But when those clouds of war that menaced

A bloody deluge to the affrighted state.

Are, by their breath, dispersed, and overblown,

And famine, blood, and death, Bellona's pages,

Whipt from the quiet continent to Thrace ;

Soldiers, that, like the foolish hedge-sparrow.

To their own ruin, hatch this cuckoo, peace.

Are straight thought burthensome ; since want of means.

Growing from want of action, breeds contempt ;

And that, the worst of ills, falls to their lot.

Their service, with the danger, soon forgot.

— Massinger, The Picture, 1630, II, 2.

An older writer has tersely described the ingratitude of the recovered patient, in an epigram in Tiniothie Kendall's Flowers of Epigrams, 1577 :

Of Phisitions. Three faces the Phisition hath

first as an Angell he When he is sought : next when he helpes

a God he semes to be. And last of all, when he hath made

the sicke deseased well, And asks his guerdon, then be semes an ougly Fiend of Hell.

Here is a scene from a play of the famous George Chapman. He was dramatist, poet, scholar, and his fine though rugged translation of Homer holds its own to this day with all other versions. The play is All Fools, 1605.

Dariotto has received a slight wound in the head in a chance encounter, when enter Page with Francis Pock the surgeon ; Valerio says :

What tbinkest thou of this gentleman's wound, Pock; canst thou cure it. Pock ?

Pock. The incision is not deep, nor the orifice exorbitant ; the pericranion is not dislocated. I warrant his life for forty crowns, without perishing of any joint.

Dariotto. 'Faith, Pock, 'tis a joint I would be loth to lose for the best joint of mutton in Italy.

(Note. This is a free allusion. A mutton, or laced mutton, was a common term for a buona roba or lady of pleasure )

Rinaldo. Would such a scratch as this hazard a man's head ?

Pock. Ay, by 'r lady. Sir : I have known some have lost their heads from a less matter, I can tell you ; therefore. Sir, you must keep good diet ; if you please to come home to my house till you l)e perfectly cured, I shall have the more care on you.

Valerio. That 's your only course to have it well quickly.

Pock. By what time would he have it well, Sir?

Dariotto. A very necessary question ; canst thou limit the time?

Pock. Oh, Sir, cures are like causes in law, which may be lengthened or shortened at the direction of lawyer ; he can either keep it green with replications or rejoinders, or sometimes skin it fair a th' outside for fashion's sake ; but so he may be sure 'twill break out

again by a writ of error, and then has he his suit new to begin ; but I will covenant with you, that by such a time I'll make your head as sound as a bell ; I will bring it to suppuration, after I will make it coagulate and grow to a perfect cicatrice, and all within these ten days, so you keep a good diet. Dariotto. Well, come, Pock, we '11 talk further on 't within.

A surgeon of rather more firmness is found in Beaumont and Fletcher's play of The Chances, 1631,111,2. Antonio, who has received several wounds, is a most unruly patient, demanding wine, decrying the food provided for him, and abusing his surgeon, who, he says, has so dressed his wounds that he looks like the figure of the signs of the zodiac in the almanacks ; one of his friends remonstrates with him:

Fy, Antonio,

You must be governed. Antonio. He has given me a damned glyster

Only of sand and snow-water, gentlemen,

Has almost scowred ray guts out. Surgeon. I have given you that. Sir,

Is fittest for your state. Antonio. And here he feeds me

With rotten ends of rooks, and drowned chickens.

Stewed pericraniums and pia-maters ;

And when I go to bed (by Heaven 'tis true, gentlemen).

He rolls me up in lints with labels at 'em,

That I am just the man 1' th' almanack.

My head and face is Aries' place.

This ungovernable patient insists on having music and song while he is " opened," as he terms it, that is, has his wounds dressed. He enquires of the surgeon how long he will take to cure him, who replies "forty days"; on which Antonio exclaims :

I have a dog shall lick me whole in twenty.

Good man-mender. Stop me up with parsley, like stuffed beef. And let me walk abroad.

Amongst the more or less occult mysteries of medicine the weapon-salve offered a tempting bait to the credulous and a ready profit to the quack doctor who furnished it. Henry Glapthorne, a dramatist almost forgotten, wrote a play in 1635 in which Doctor Artlesse and his man Urinall are important personages. Urinall, who is a ready-witted knave, has met with a young Dutchman named Sconce, who is au.xious to figure among the swaggering blades of the town, but being rather lacking in courage, he has purchased a bos of the famous salve from the aforesaid Urinall. The scene th us begins :

Sconce. But you are certaine Urinall this oyntement is Orthodoxall ; may I without error in my faith believe this same the weapon salve Authenticall?

Urin. Yes, and infallibly the creame of weapon salves, the simples which doe concurre to th' composition of it, speake it most sublime stuffe ; tis the rich Antidote that scorns the Steele, and liids the iron be in peace with men, or rust: Aureliui Bombatiua Paracelsus, was the first inventer of this admirable Unguent.

Sconce. He was my Country-man, and held an Errant Conjurer.

Urin. The Devil he was as soone : an excellent Naturallist, & that was all ujjon my knowledge, Mr. Sconce ; and tis thought my master comes very neare him in the secrets concerning bodies Physicall, as Herbes, Roots, Plants vegetable and radicall, out of

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whose quintessence, mixt with some hidden causes, he does extract this famous weapon salve, of which you are now master.

Uriuall continues to regale the ears of Master Sconce with wonderful stories of the cures effected by anointing the weapon which had inflicted the wound, and ends with a most convincing incident. A great explosion of gunpowder had taken place on some celebration and threescore persons were blown up, yet, says Urinall :

Thirty of their lives my Master saved.

Sconce. Rarer, and rarer yet : But how, good Urinall ?

Urinall. He dressed the smoake of the powder as it flew up, Sir, and it healed them perfectly.

Later on Sconce has occasion to use the famous remedy after receiving a slight wound in the arm, and a pleasant discussion takes place in which he and his friend Fortresse, with Doctor Artlesse and a gentleman named Freewit, took part. Freewit begins:

I have seen experience of this weapon salve, and by its

Most mysterious working knowne some men hurt, past the

Helpe of surgery recover'd. . . . Yet I cannot

With my laborious industry invent

A reason why it should doe this, and therefore

Transcending naturall causes, I conclude

The use unlawful!.

Doct. But pray sir, why should it be unlawfull?

Free. Cause Conscience and religion disallow In the recovery of our impair'd healths. The assistance of a medicine made by charms, Or subtle spells of witchcraft.

Doct. Conceive you this to be compounded so? Free. He prove it, mas' tr Doctor.

Yet to avoide a tedious argument, Since our contention 's only for discourse. And to instruct my knowledge, pray tell me, Athrme you not that this same salve will cure At any distance (as if the person hurt Should be at Yorke) the weapon, dres'd at London, On which his blood is. Doct. All this is granted 'twill.

Free. Out of your words, sir. He prove it Diabolicall, no cause Naturall begets the most contemn'd effect. Without a passage through the meanes ; the (ire Cannot produce another fire until It be apply'd to subject apt to take Its flaming forme, nor can a naturall cause, Worke at incompetent space : how then can this Neither consign' d to th' matter upon which Its operation is to cause effect. Nay at so farre a distance, worke so great And admirable a cure beyond the reach And law of nature ; yet by you maintain'd, A Naturall lawful agent, what dull sence can credit it?

Doct. Sir, you speake reason, I must confesse, but every cause Workes not the same way ; we distinguish thus : Some by a Physicall and reall touch Produce : So Carvers hewing the rough Marble, Frame a well polish'd statue : but there is A virtuall contact too; which other causes

Imploy in acting their more rare effects.

So the bright Sun does in the solid earth.

By the infusive vertue of his raies.

Convert the sordid substance of the mould

To Mines of Mettall, and the piercing ayre

By cold reflexion so ingenders Ice ;

And yet you cannot say the chilly hand

Of ayre, or quickning fingers of the Sunne,

Really touch the water or the earth.

The Load-stone so by operative forte,

Causes the Iron which has felt his touch.

To attract another Iron ; nay, the Needle

Of the ship guiding compasse, to respect

The cold Pole Articke ; just so the salve workes,

Certain hidden causes convey its powerfull

Vertue to the wound from the annointed

Weapon, and reduce it to welcome soundnesse.

Free. This, Mr. Doctor, is

A weake evasion, and your purities Have small affinity ;

But that this. This weapon salve, a compound, should affect More than the purest bodies can, by wayes More wonderfull than they doe, as apply'd Unto a sword a body voyd of life, Yet it must give life, or at least preserve it.

■Doct. You mistake, it does not,

Tis the blood sticking to the sword atchieves The cure : there is a reall sympathy Twixt it, and that which has the juyce of life, Moystens the body wounded.

Free. You may as well

Report a reall sympathy betweene The nimble soule in its swift flight to heaven, And the cold carkasse it has lately left. As a loath'd habitation ; blood, when like The sap of Trees, which weepes upon the Axe Whose cruell edge does from the aged Trunke Dissever the green Branches from the Veines, Ravish'd, forgoes his native heate, and has No more relation to the rest, than some Desertlesse servant, whom the Lord casta off, Has to his vertuous fellowes.

Among other somewhat unusual medical treatment, the inspiring courage in a cold-blooded youth by appropriate diet and training is thus told of in Love's Cure, III, v. Xd'i'i :

Piorato. Then for ten days did I diet him

Only with burnt pork, sir, and gammons of bacon :

A pill of caviary now and then

Which breeds choler adast, you know — Bobadillo. 'Tis true. Piorato. And to purge phlegmatic humours and cold crudities.

In all that time he drank me aquafiyrti*,

And nothing else but — BobadiUo. Agua-fit^, signior,

For aqua-fortis poisons. Piorato. Aqua-fortis,

I say again ; what's one man's poison, signior,

Is another's meat or drink. BobadiUo. Your patience, Sir ;

By your good patience, h'ad a huge coKl stomach.

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Piorato. I fir'd it, and gave bim then three sweats, In the Artillery Yard, three drilling days ; And now he'll shoot a gun, and draw a sword. And fight, with any man in Christendom. BobadiUo. A receipt for a coward ! I'll be bold, Sir, To write your good prescription. Piorato. Sir, hereafter

You shall, and underneath put probatum.

In introducing the subject of the venereal disease as next in order for illustration, it is right to say a few words as to the value of such illustrations for critical or historical purposes. It must be borne in mind that satirical writers or dramatic j)oets would be naturally prone to treat the matter from a ludicrous point of view. An element of the comic seems to be an essential part of familiar descriptions of the consequences of engaging in the wars of Venus, and we should not, therefore, accept without some caution the canons of treatment laid down in the plays. Nevertheless, there are so many allusions to the " wood," as it was termed, meaning guaiacum, to the swejiting process known as " the tub," to special forms of diet, as well as to manifestations of the ravages of the disease, that altogether it forms a very curious illustration of the popular belief as to the widespread nature of the poison and its approjsriate treatment. Heusler, referring to the lack of any description of disease of the genital organs, produced by coitus, in such writers as Horace, j\{artial, or Juvenal, makes use of the curious argument that in his time neither amorous nor serious poets were accustomed to allude to such an awkward subject, and yet the disease existed. Certainly Martial cannot be supposed to have been restrained from saying what he pleased by any motives of delicacy, and considering the minuteness with which he details the physical effects of pederasty, it is a fair argument that had he known of any contagious disease of the genital organs proper, the result of coition, he would have lavished his wit upon so tempting a subject in endless epigrams. But of the existence of a very general knowledge of venereal disease in the sixteenth and seventeenth centuries in England, the following 'inotations will leave no doubt.

It is not, of course, my intention to enter into the vexed question of the first appearance of syphilis. Whether it can be identified in classic, oriental, or bible writings — whether it originated at the siege of Naples, or was brought from the West Indies by the Spanish discoverers — all of this has been debated vehemently, and it is perhaps a still unsettled question. I must, however, remind you of certain dates. The year 1493, during which the siege of Naples was progressing and Charles VII arrived to take command, has been usually taken to be the year in which the disease became virulent and epidemic. In 1494 it was spoken of as morbus -gallicus, and as early as 1508 guaiacum was being used as a remedy for it.

The earliest allusion to the scourge which I have met with in general literature is in an old Scottish poem called KowlTs Cursing. It forms part of the Bannatyne JISS. dating from 1492 to 1503, and is published in Sibbald's "Chronicle of Scottish poetry from the thirteenth century to the union of the Crowns," Ediub., 1802, 4 vols. The passage in (juestion is at p. 331 of Vol. I :

Now cursit and wareit be thair werd

Quhyll thay be levand on this erd ; Hunger, sturt, and tribulation. And never to be witliout vexation. . . . The paneful gravel and the gutt, The gulsoch that thay nevir be but, The stranyolis, and the grit glengor, The bairschott lippis them before.

In plain English it is as follows:

Now cursed and accursed be their fate.

While they be living on this earth ;

Hunger, strife, and tribulation

And never to be without vexation. . . .

The painful gravel and the gout,

The jaundice that they never be without,

The strangury and the great glengor.

The gulsoch is the jaundice ; in Low Dutch it is still called gheelsucht, or yellow disease. Stranyolis is from Strang, old Scotch for urine which has been retained until it is strung or malodorous. The term which concerns us is the great glengor. Jamieson in his Scottish Dictionary defines it under various spellings, as hies venerea, derives it from old French ^orre, a sow, and gives the doubtful suggestion that it might have been glandgore. How the word sow came to be applied in this connection I cannot explain. You will doubtless remember a similar etymology for the Greek word indicating the especially faulty organ.

In the French and English dictionary of Randle Cotgrave, first published in 1611, is the following definition under Gorre, f. a sow (also the French pockes. Norm.) ; also bravery, gallantness, gorgeousness, etc. Femmes d, la grande gorre. Huffing or flaunting wenches ; costlie or stately dames.

This is not the only instance of the application of the name of an animal to the venereal disease. I shall shortly have to speak of the " Winchester goose," and in the camjjaign of the British army in the Peninsula in the Napoleon wars the name of " the black lion" was given to an extremely destructive form of syphilitic ulceration.

It is not surprising that the vindictive Scotchman should have included the " grand-gorre " among his curses, and the unsavory objurgation, in the shape of ' pox take you,' or 'pox on it,' survived to quite recent times. The word did not always mean the venereal disease. Thus Dr. Donne w'rites to his sister: "At my return from Kent I found I'egge had the poxe ; I humbly thank God it hath not disfigured her." The prefix of great, the great-pox, in contradistinction to the smallpox was common enough, and iu France la grande verolle and la petite verolle were in like contrast. You will remember the mot of Louis XIV when it was announced in the circle that an actress famous for her amours had just died of the smallpox. " It was very modest of her," said the king.

The nomenclature of the venereal disease is very extensive. I shall only touch upon those names referred to in the poets. In a play by Nash, Pierce Pennilesse, 1592, is this passage: " But cucullus lion facit monarhiini — 'tis not their newe bonnets will keepe tliem from the old boan-ache." This most appropriate name is employed also by Shakespeare. Words or allusions indicating its French origin are endless, and its Italian source is not forgotten. Florio in his Worlde of

Wordes, 1598, has the verb infrancMosare, to infect or to be infected with the French poxe; to frenchifie. And on the other hand, the Frenchman Motteux, in his translation of Eabelais, whicli is a jierfect treasury of quaint old English, makes Friar John say: "He looks as if he had been struck over the nose with a Naples cowl-staff." It is amusing to observe how these compliments are reciprocated. In a translation of the Colloquies of Erasmus, by Sir Roger L'Estrange, is this passage: " C. Your chin, too, looks as it were stuck with rubies. S. That's a small matter. 0. Some blow with a French faggot-stick (as they say). 8. Right, it was my third clap, and it had like to have been my last."

There is a name for syphilis of which I have met with but one instance, namely, the marbles. I jiresume it to have arisen from the chain of enlarged glands in the groin characteristic of the disease. In the Harleian Miscellanies is a play entitled A Quip for an Upstart Courtier, 1592, and in it one says to the doctor : " Neither doe I frequent whorehouses to catch the marbles, and so to prove your patient."

" The scab " was a very common appellation, often used vituperatively, as in some lines of that most charming lyric poet, Robert Ilerrick. It refers to one of his books and is addressed

To THE SowRE Reader.

If thou dislik'st the piece thou light'st on first, Thinke that, of all that I have writ, the worst. But if thou read'st my Viooke unto the end, And still dost this and that verse reprehend, perverse man ! If all disgustful! be, The extreme scabbe take thee and thine, for me.

Again, in The Sea Voyage, by Beaumont and Fletcher :

Is thy skin whole ? Art thou not purl'd with scabs? No ancient monnments of Madam Venus?

And in The Dutch Courtezan by Marston :

Is a great lord a foole, you must say he is weake. Is a gallant pocky, you must say he has the court-skab.

One of the oddest and oldest terms in the copious nomenclature of the venereal disease is the Winchester goose. There is no doubt as to its origin. In the early days of Loudon the Bankside was a continuous row of brothels near the river, which were under the jurisdiction of the Bishoj) of Winchester, and the victim who suffered the usual consequences of a visit to this tainted locality was called a Winchester goose. In course of time the term was applied to the disease itself, and the allusions to it in the old writers are very frequent. John Taylor, the Water Poet, who was intimately ac(]uainted with all river-side customs and phrases, calls it

A groyne bumpe, or a goose from Winchuster,

and the Nouienclator, one of the earliest English dictionaries, published in 1585, defines it as " a sore in the grino or yard, which if it come by letcherie, it is called a Winchester goose, or a botch." In Ben Jonson's Underwoods is this passage :

And this a sparkle of that fire let loose That was rak'd up in the Wincestrian Goose, Bred on the Bank in times of popery When Venus there maintaiu'd the mystery.

Shakespeare has more than one allusion to the goose of Win Chester. In an early manuscript entitled The Pennyless Parliament, i^reserved in the TIarleian Miscellany, it is spoken of as the pigeon, and a satirical advice follows for the means of avoiding it : " Those that play fast and loose with women's apron-strings may chance make a journey for a Winchester ])igeon ; for prevention thereof, drink every morning a draught of noli me tangere, and by that means thou shalt be sure to escape the physician's purgatory." In Webster's play of Westward hoe! 1G07, Act III, Scene .3, there is an elaborate account of the origin of the term Winchester goose, but it is too lengthy for present quotation.

There are many and even copious allusions in the dramatists and poets to the treatment of syphilis by two methods : the one by sweating in the tub, and the other by guaiacum administered in decoction, the two methods being combined, or the latter following the former.

The earliest i-epresentation of the famous tub is, I believe, in the works of Ambrose Pare, page 598 of the edition of 1575. It is rather a cask than a tub. The patient was seated inside on a perforated stool beneath which hot bricks or stones were placed. Through a small trapdoor in the side of the tub a mixture of vinegar and brandy was thrown upon the heated bricks and the steam was confined by a sheet fastened round the patient's neck. In England the common tub used for salting meat, ' powdei'ing ' it, as the term then was, seems to have been employed. The humorous allusions to this double use are frequent. In Measure for Measure, the clown, speaking of Mistress Overdone, the bawd, says: "Troth, Sir, she hath eaten up all her beef, and she is herself in the tub." The writer of an article in the .January number of Harper's Magazine, on Shakesperean phrases in use in the United States, is much puzzled by this phrase of "in the tub," being evidently unaware of its meaning. He suggests that the expression of " in the soup " has like application. In Timon of Athens, IV, 3, is this passage:

bring down rose-cheeked youth To the tub-fast and the diet.

Sometimes an oven, or a hole in the ground, was used for the sweating, and in every case a strict diet was enforced. Dry food, and above all "burnt" or overdone mutton, cut by choice from the rack or neck, was alone to be had. The ([uotations will give all this in full. The first is from Beaumont and Fletcher's play of The Knight of the Burning Pestle, 1G13, III, 5. It is, I think, intended partly as a burlesque ou the style of Spenser's Faerie Queeue. A knight and lady are imprisoned in a cave where they are tortured by a giant. The knight had carried off his "lady dear" from bet friends in Turnbull Street, a locality like the Baukside, notorious for houses of prostitution. He begins :

I am an errant-knight that followed arms

With spear and shield ; and in my tender years

I stricken was with Cupid's liery shaft.

And fell in love with this my lady dear.

And stole her from her friends in TunibuU-Street ;

And bore her up and down from town to town,

Where we did eat and drink and music hear :

Till at the length at this unhappy town

We did arrive and coming to this cave.

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This beast us caught, ami put us in a tub

Where we tliis two months sweat, and should have done

Anotlier month if you had not reliev'd us.

Woman. This bread and water hath our diet been, Together witli a rib cut from a neck Of burned mutton ; hard hatli been our fare ; Release us from this ugly giant's snare.

Man. This hath been all the food we have receiv'd ; But only twice a day, for novelty, He gave a spoonful of this hearty broth To each of us through this same slender quill.

{Pulls out a syringe.)

lu the corned}' of Ilouest Man's Fortune, by the same authors, 1613, V, 3, there is this reproach to a libertine :

All women that on earth do dwell, thou lovest, Yet none that understand love thee again. But those that love the spital. Get thee home. Poor painted butterfly ! Thy summer's past ; Go, sweat, and eat dry mutton.

8o of a similar gallant in Middleton's Michaelmas Term, 1607, I, 1 :

He'll be laid shortly ;

Let him gorge venison for a time, our doctors

Will bring him to dry mutton.

The loss of hair from syphilitic disease did not escajjc the observation of the satiric poets, and the allusions to l^rench crowns and nightcaps are endless. There is a poem called " A fig for Momus," published in 1595. I have uot seen it, but (juote from Beloe, who says it is the oldest satire in the language.

Last day I chaunst in crossing of the street. With Difiilus the innkeeper to meet. He wore a silken nightcap on his head, And looked as if he had been lately dead ; I askt him how he far'd ; not well, quoth he. An ague this two months hath troubled me. I let him passe, and laught to hear his skuce. For I knew well he had the pox by Luce, And wore his night-cappe ribbin'd at the ears, Because of late he swet away his heares.

In Your Five Gallants, Middleton, 1608, I, 1: " He's in his third sweat by this time, sipping of the doctor's bottle, or picking the ninth part of a rack of mutton dryroasted, with a leash of nightcaps ou his head like the pope's triple crown, and as many pillows crushed to his back."

George Farquhar, the dramatist, in one of his poems speaks more hopefully to one who has been in the " powdering tub."

You will revive, the pox expire. Then rise like phuinix from the fire. The metal's stronger that's once soldered, And beef keeps sweeter once 'tis powdered.

Many of my quotations speak of a " Cornelius tub," or Cornelius's tub. How the name came to be applied, or who Cornelius was, I have been unable to discover. Sometimes it is " Cornelius's dry-fat," but a dry-fat, or dry-vat, is an oldfashioned name for a bo.x or cask.

In Armin's Nest of Ninnies, 1608, one says of the students: " And when they should study in private with Diogenes in his cell, they are with Cornelius in liis tub."

It was natural that the old story of Diogenes and his tub should present an opportunity for the gibe of the satirist. In Cotgrave's English Treasury of AVit and Language, 1655, p. 221, is this epigram :

As for Diogenes, that fasted much,

And took his habitation in a tub,

To make the world believe he loved a strict

And severe life, he took the dyet, sir, and in

That very tub sweat for the French disease.

And some unlearn'd apothecary since

Mistaking 's name, call'd it Cornelius tub.

How early the system of treating syphilis by sweating was introduced cannot, I suppose, be settled, but Rabelais has a characteristic reference to it, book II, chapter 2, which contains also a satisfactory explanation of how the sea was made and came to be salt. I quote Motteux's translation, which in this instance is exact:

"The earth at that time was so exceedingly heated that it fell into an enormous sweat, yea, such an one that made it sweat out the sea, which is therefore salt, because all sweat is salt; and this you cannot but confess to be true if you will taste of your own, or of those that have the pox when they are put into a sweating ; it is all one to me." This was written before 1532.

There is a curious example in connection with the diet of how an old system may put on a new birth. In 1817 a Frenchman named Gandy wrote a thesis in which he highly lauded the treatment of syphilis by the dry method, namely, dry food and but little of it. The treatise attracted but little notice, but about thirty years later this method of treatment was tried at the Hotel-Dieu of iMarseilles with some success. It was called the Arabic method, as the secret of it had been communicated, so it was said, to the hospital surgeons by an Arab. The diet consisted exclusively of dry biscuits, nuts, dried almonds, figs and raisins. A tisan made from sarsaparilla, China root and cloves was freely given, and a mercurial j)ill was administered thrice daily. The latest account of this treatment was written in 1860. Two hundred years before, the famous Mrs. Aphra Behn wrote what she termed "A letter to a brother of the pen in tribulation," and you will see how closely the descriptions agree as to the diet. The word tabernacler was, applied to street preachers of the time, such as the notorious Orator Henley, who were accustomed to preach from a cask or tub :

Poor Damon ! art thou caught? Is'tevenso? Art thou become a Tabernader too? When sure thou dost not mean to preach or pray, Unless it be the clean contrary way ; This holy time * I little thought thy sin Deserv'd a tub to do its penance in. 0, how you'll for th' Egyptian fiesh-pots wish, When you're half famish'd with your lenten dish, Your almonds, currants, biscuits, hard and dry, Food that will soul and body mortify ; Damned penitential drink, that will infuse Dull principles into thy grateful muse.

There is yet another j)owerful method of sweating which

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would have greatly pleased the late Doctor Hewsoii, the euthusiastic advocate of the dry-earth treatment. It is from D'Avenahfs play of The Wits, 1636, Act IV, Scene 1 :

Though I endured the diet and the flux,

Lay seven days buried up to the lips like a

Diseas'd sad Indian, in warm sand, whilst his

Afflicted female wipes his salt foam off

With her own hair, feeds him with buds of guacum

For his sallad, and pulp of salsa for

His bread ; I say all this endur'd, would not

Concern my face.* Nothing can decline that.

Salsa was probably sassafras, the Spanish name for which was salsafras.

I shall conclude these illustrations of the history of syphilis with one capital scene from The Picture, by Massinger, 1630, Act IV, Scene 2. Ubaldo and Ricardo are both in love with Sophia, who first listens to Ubaldo's account of his rival.

Sophia. How ! is he not wholesome ?

Ubaldo. Wholesome ! I'll tell you for your own good ; he is A spittle of diseases, and, indeed, More loathsome and infectious ; the tub is His weekly hath ; he hath not drank this seven years, Before he came to your house, but composition Of sassafras and guaicum ; and dry mutton His daily potion ; name wbat scratch soever Can be got by women, and the surgeons will resolve you, At this time, or that, Ricardo had it.

Sophia. Bless me from him !

Ubaldo. 'Tis a good prayer, lady.

It being a degree unto the pox.

Only to mention bim ; if my tongue burn not, hang me,

When I but name Ricardo.

After Ubaldo has been dismissed by Sophia, who is entertaining both him and his friend, Ricardo, with illusive hopes, Ricardo is introduced, and proceeds to traduce his friend, as follows :

Ricardo. He did not touch your lips? Sophia. Yes, I assure you.

There was no danger in it?

Ricardo. No ! eat presently

These lozenges of forty crowns an ounce, Or you are undone. Sophia. What is the virtue of them 7

Ricardo. They are preservatives against stinking breath Rising from rotten lungs. Sophia. If so, your carriage

Of sucli dear antidotes, in my opinion, May render yours suspected.

Ricardo. Fie ! no ; I use them

When I talk with him, I should be poisoned else.

But I'll be free with you ; he was once a creature,

It may be of God's making, but long since

He is turn'd to a druggist's shop ; the sjiring and fall

Hold all the year with him ; that he lives he owes

To art, not nature ; she lias ^ivcn him o'er.

He moves like the fairy king, on screws and wheels.

Made by his doctor's recipes, and yet still

They are out of joint, and every day repairing.

• Mako mo look concerned.

He's acquainted With the green-water, and the spitting pill 's Familiar to him ; in a frosty morning You may thrust him in a pottle-pot ; his bones Rattle in his skin, like beans toss'd in a bladder. If he but hear a coach, the fomentation. The friction with fumigation, cannot save him From the chine-evil. In a word, he is Not one disease, but all ; yet, being my friend, I will forbear his character, for I would not Wrong him in your opinion.

Distinct allusions to gonorrhcea are, as might be supposed, comparatively infrequent in the older dramatists, though common enough in the plays of the 18th century. How early syringes were employed in the treatment of the disease I do not know, but in most of the instances in which they are named in the drama, " birding pills " are also spoken of, and the "green-water" is frequently alluded to. The term "bird" was a familiar one in those days to denote the venal fair who bestowed her favors, with theirnot infrequent penalties, upon all comers. The expressions "to go a birding," " birding pills " and " birding syringes," which are often used, have obvious meanings. What the "birding-pill" contained I cannot say, but it was probably composed of Chio turpentine; the "spitting-pill" of course consisted of mercury in some form, generally the old-fashioned blue pill. The "greeuwater " has a rather interesting history. It was a decoction made from the herb clary, the Salvia sclarea. The various ])lants of the sage family have mostly disappeared from pharmacopoeias, but they are still used in household medicine. Captain .John (J. Bourke, 3d Cavalry, in a recent article on the Folk-foods of the Rio Grande Valley, tells how he once arrived at a convent, hot, thirsty, and exhausted, after a long ride, and was refused the cold water which he demanded. The good priest said that it was only Americans who would drink cold water when heated, and sent for some "cbie" seeda and steeped them in water which became speedily mucilaginous. This was administered to him in small quantities, and he declares that its effect in removing his thirst and fever and restoring his voice was surprising. He did not know what plant the seeds came from. Now chia is the name given to the seeds of more than one species of wild sjjge, and it is a jwpular remedy in the form of a tea in the Stiit^s on the Mexican border. The "green-water" of the poet was made from the heads of the clary plant, and doubtless contained some mucilage from the seeds. As a demulcent it would rank with the barley water and flaxseed tea which are still ordere<l as diet drinks for the unlucky victims of "birding."

In the following passage from The Chances, 1031, III, 1, Don John has offended Dame Gilliiui, his old nurse, who retorts upon him thus :

OUlian. Well, Don John,

There will be times again when, "Oh, good mother, What 's good for a carnosity in the bladder? Oh, the green water, mother 1 " Don John. Doting take you !

Do you remember that ? OilU'an. "Clary, sweet mother, clary 1 " Fr«<i. Are vou satisfied ?

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Oilltan. " I'll never whore again ; never give petticoats

And waistcoats at five pounds a piece ! Good mother ! Quickly, mother ! " Now mock on, Son.

Later on Dame Gillian says of her hopeful charge:

He 's ne'er without a noise of syringes In 's pocket (those proclaim him), birding-pills, Waters to cool his conscience, in small vials, With thousand such sufficient emblems.— [Ill, 4.

The term '■ caruosity of the bladder" is significant of the supposed pathology of gouorrhcea.

Sage is also recommended as a spring medicine :

Now butter with a leaf of sage, to purge the blood ; Fly Venus and phlebotomy, for they are neither good."

— Knight of the Burning Pestle, III, 4.

There is an amusing passage in a play by Shadwell, The Virtuoso, 1G7C, which in a coarse way exhibits the manners of the time at the theatres. Speaking of certain young bloods, one says :

" Such as come drunk and screaming into a play house, and stand upon the benches, and toss their full perriwigs and empty heads, and with their shrill unbroken pipes cry, Damme, this is a damn'd play. Prythee lei's to a whore, Jack. Then says another with great gallantry, pulling out his box of pills, Damme, Tom, lam not in a condition ; here's my turpentine for my third clap ; when you would think he was-not old enough to be able to get one." — I, 1.

We complain somewhat in our own day of theatre ill manners, but such an exhibition of insolent debauchery as that just quoted seems almost incredible. That it was not uncommon, even at a later period, is shown by a passage in the play of The English Friar, by John Crowne, 1690, Act I, Scene 1, where I.,ord Stately says :

"Ay, there's a folly reigns among us ; your young fellows now are proud of having no manners, no sense, no learning, no religion, no good nature; and boast of being fops and sots and pox'd in order to be admired."

Closing the references to the venereal disease with this (]U0tation, I shall occupy a few moments more of your time Vitli some passages illustrating what I have termed miscellaneous medical subjects.

The domestic treatment for hysteria, or a fit of the mother, as they termed it, was not lacking in potency. In The Magnetic Lady, by Ben Jonson, 1632, V, 1, Item says:

What had she then ? Needlci. Only a fit of the mother ;

They burnt old shoes, goose-feathers, asafoetida, A few liorn-shavings, with a bone or two, And she is well again about the house.

Here is a forcible application of the frequent term of " good surgery" as applied to the body politic. It is from The Muse's Looking (Jlass, a play by Randolph, 1638 :

The land wants such As dare with rigour execute her laws ; Her festerVl members must be lanc'd and tented. He 'b a bad surgeon that for \>\iy spares The part corrupted till the gangrene spreads And all the body perish. He that 'a merciful Unto the bad, is cruel to the good.

The pillory must cure the ear's diseases ; The stocks the foot's offences ; let the back Bear her own sin, and her rank blood purge forth By the phlebotomy of a whipping-post.

Clysters are more often mentioned in French than in English plays. In a comedy published in Paris in 1683, termed Le Mercitre galant, there is a droll name given to the apothecary. This functionary, as we know, was accustomed to carry his immense syringe duly charged and resting on an appropriate tray, with ostentatious publicity to the patient's residence. Kneeling at the bedside while the patient discreetly presented what an old writer terms " his back face," the compound, consisting mainly of starch and castor oil, was administered. In the play referred to, Oronte says (I give it in English): " Who is this man? Has he any calling ?" M. Michaud, the man in question, replies: "Between ourselves, Sir, my grandfather was a kneeling musketeer " {mousquftaire a gtnoux). " What sort of a charge was that ?" says the other. " Why," replies Michaud, " it is what the vulgar in their common language call an apothecary."

Florio in his Italian dictionary, 1578, referring to the well known story in Pliny's Natural History that the ibis gives himself a clyster and voids himself upwards, adds the embellishment that the bird uses salt water from preference, and that Hipjjocrates from watching his proceeding first learned how to give clysters.

A curious precaution seems to have been taken by certain careful fine ladies, previous to attending a long ceremony. The usher says :

Make all things perfect; would you have these ladies They that come here to see the show, these beauties That have been labouring to set off their sweetness. And wash'd. and curl'd, perfumed, and taken glisters For fear a flaw of wind might overtake 'em. Lose these and all their expectations? — Madams, the best way is the upper lodgings ; There you may see at ease.

— Humorous Lieutenant, I, 1.

The learned Porson was credited with the authorship of a bit of humor in mock Greek, familiar to us all in our student days, in which the proportion between the secretion of tears and of urine was nicely adjusted, an excess of the former diminishing the supply of the latter. There is a medical application of the same fancy in The Scornful Lady, of Beaumont and Fletcher, 1616, III, 3. An angry lover says:

But if I come,

From this door till I see her will I think How to rail vilely at her ; how to vex her, And make her cry so much that the physician. If she falls sick upon it, shall want urine To find the cause by, and she, remediless, Die in her heresy.

In that capital piece of fun, " Father Tom and the Pope," the priest, after many potations, is obliged to ask for a certain utensil which he denominates a " looking-glass." The term is not uncommon in the old plays, though its origin was not evident. A passage in one of Webster's plays, The Thracian Wonder, 1661, IV, 2, seems to offer an explanation :

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Antonio.- A looking-glass, I say.

Claudia. You shall, sir, presently ; there's one stands under my bed.

Antonio. Why, that's a Jordan, fool.

Olaudio. So much the better, Father ; 'tis but making water in 't, and then you may behold your sweet phisnomy in the clear streams of the river Jordan.

There is, however, a different meaning given to it in a curious work written by a surgeon, namely Festivous Notes to Don Quixote, by Edmund Gayton, 1054, p. 236: "The men running to the close-stooles, the women to the looking or leaking-glasses."

The etymology of Jordan is also uncertain. In old French, jar means urine, and in Armorican, dourdcn, and in analogous Welch dur dyn, have the same signification.

There is, I believe, still to be seen in the apothecaries' shops what is known as sal prmiella, or alum-nitre, as it was sometimes called. It consists of nitrate of potassium chiefly, and was used as a remedy for a sore throat, small fragments of it being allowed to dissolve slowly in the mouth. In the following passage from The Duchess of Malfy, 1623, it is alluded to, coupled with a sneer at the loud-praying Puritans. It occurs in the fourth act of that very powerful tragedy, when amongst other tortures inflicted on the unhappy duchess whose death has been determined upon, a "Masque of madmen" is introduced. One of them says : " Shall my 'pothecary outgo me because I am a cuckold ? I have found out his roguery; he makes alum of his wife's urine, and sells it to Puritans that have sore throats with overstraining."

The allusions in the older writers to "casting the urine," uroscopy, as it is now the fashion to call it, and to the impudent rogueries of the quacks who flourished by it, are too numerous to be taken up on this occasion. In like manner I must pass by the amusing tricks and impostures of the quacksalvers and mountebanks who figure so constantly in the plays of the seventeenth century. I cannot resist, however, giving one example of the latter which I am sure you will enjoy. It is from the play of The Widow, by Ben Jonson and others, circa 1616, IV, 2. Latrocinio, the quack, happily named, is receiving his dupes and says :

You with the rupture there, hernia in scrotum,

Pray let me see you space this morning ; walk, sir,

I'll take your distance straight ; 'twas F. O., yesterday ;

Ah, sirrah, here's a simple alteration !

Sccunilo gradu, ye F. U. already ;

Here's a most happy change. Be of good comfort, sir ;

Your knees are come within three inches now

Of one another ; by to-morrow noon

I'll make 'em kiss and jostle.

Here, too, are some therapeutic and hygienic maxims for summer. This extract is from Summer's I^ast AVill and Testament, by Nash, 1593. Orion, ruler of the dog-days, says :

While dog-days last the harvest safely thrives ;

The eun l)urns hot to linish up fruit's growth.

There is no blood-letting to make men weak.

Physicians in their Cataposia

r. little Elinctoria

Masticatorum and Cataplasmata ;

Their gargarisms, clysters and pitch'd cloths,

Their perfumes, syrups, and their triacles

Refrain to poison the sick patients.

And dare not mitiister till I be out,

Then none will bathe, and so are fewer drown'd.

All lust is perilsome, therefore less us'd.

Cataposia used to mean boluses, but strictly is anything to be swallowed. Elinctoria were medicines to be licked up.

The dog has been credited with an instinctive knowledge of physic and surgery, and his tongue, with which he licks his own wounds, is popularly supposed to have powerful curative virtue. The following verse is from Flowers of Epigrammes, by Timothy Kendall, 1577:

Fower properties praiseworthy sure,

are in the dog to note : He keepes the house, he feares the thefe

by barking with his throte. He plays well the Phisition,

with licking tongue he cures ; Unto his master still he stickes,

and faithful fast endures.

In a play just quoted. Summer's Last Will and Testament, there is a longer account :

That dogs physicians are, thus I infer.

They are ne'er sick but they know their disease.

And find out means to ease them of their grief ;

Special good surgeons to cure dangerous wounds,

For stricken with a stake into the flesh

This policy they use to get it out :

They trail one of their feet upon the ground,

And gnaw the flesh about where the wound is.

Till it be clean drawn out ; and then, because

Ulcers and sores kept foul are hardly cured.

They lick and purify [them] with their tongue,

And well observe Hippocrates' old rule.

The only medicine for the foot is rest ;

For if they have the least hurt in their feet,

They bear them up and look they be not stirr'd.

When humours rise they eat a sovereign herb.

Whereby what clogs their stomach they cast up ;

And as some writers of experience tell.

They were the first invented vomiting.

In a passage which has been read you will remember that the irascible Antonio tells his surgeon who has decided that it will require forty days to heal his patient's wounds : I have a dog shall lick me whole in twenty. There is a story which Ricord delighted to toll as to his travels in Spain. He employed a farrier who also doctored horses, to attend to his team. The man refused any recompense on the ground that he could not accept a fee from a brother physician. In the Musarum Deliciw, published in 1636, is this epigram :

A Farrier Physitiak. A neate Physitiun for a Farrier sends, To dress his horses, promising amends ; No (quoth the Farrier), amends is made. For nothing do we take of our own trade.

An example of the prevailing belief in sympathetic remedies is to be found in the use of fox's lungs as a restonit.ive in certain disorders of the respiration. Heynard is noted for his speed and endurance and conset^ueut long-wiudeduess. His

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odor seems to have been also thought efficacious. In The White Devil, by John Webster, 1612, IV, 2, is this:

Thou hast stain'd the spotless honour of my house Antl frightenVl thence noble Bociety ; Like those which sick o' th' palsy and retain Ill-scenting foxes 'bout them, are still shunM By those of choicer nostrils.

Again in The Devil's Law-case, by the same writer, 1623, 111,3:

This is the man that is your learned counsel,

A fellow that will trowl it off with tongue.

He never goes without restorative powder

Of the lungs of fox in 's pocket, and Malaga raisins

To make him long-winded.

Falstafif carried sugar candy for the same purpose.

In a play by Brome, The English Moor, 1659, I, 3, is this :

Melieent. Where be my bride-maids?

Tetty. They wait in your chamber.

Buzzard. The ilevil a maid 's i' this but my fellow Madge the kitching maid, and Malkin the cat ; a hatchelor but myself and an old fox that my master has kept a prentiship to palliate his palsie.

Epitaphs abound in medical allusions but are foreign to the present subject, but I am tempted to quote one because of its neat description of two consecutive amputations for gajigrene. It is, I suppose, still to be seen in Banbury Churchyard in England, and tells of a young man " who died by a mortificatiou which seized in his toe (his toe and leg both being cut off before he died)."

Ah ! cruel Death, to make three meals of one. To taste, and eat, and eat till all was gone. But know, thou Tyrant, w" th' last trump shall cull, He '11 find his feet to stand, when thou shall fall.

I'he lugubrious drawings of the' Dance of Death, which were so popular about the period of the Eenaissauce, could be well illustrated by passages from the English poets. The skeleton, and especially the skull, offered many temptations for moralizing. In The Revenger's Tragedy, by TOurneur, lOO.S, V'indici takes up the skull of a former mistress of his prince and says with bitter irony :

Here's an eye Able to tempt a great man — to serve God. A pretty laughing lip that has forgot how to dissemble. Melhinks this mouth should make a swearer tremble, A drunkard clasp bis teeth and not undo 'em To suffer wet damnation to run through 'em.

The term grip, which has become so familiar, was an oldtime name for Death, expressive of the suddenness with which

he seized his prey. Here is an e.xample of its iTse from a poem by Barnabe Googe, 1563 :

So death our foe

consumeth all to nought ; Envying these

with dart doth us oppress ; And that which is

the greatest grief of all. The greedy Grip

doth no estate respect. But when he comes,

he makes them down to fall.

In Quentin Durward, Sir Walter Scott, who was deeply read in the old poets, makes Le Balafre observe, in explanation of the dying wish of the Boar of Ardennes whom the former had slain : " lien have queer fancies when old Small-back is gripping them."

I shall close this rather desultory paper with an extract from the author from whom I have just quoted, Barnabe Googe. It describes in a fanciful but impressive way the contest between "Death our foe," and the rich man who is sailing at his ease on the sea of pleasure. The latter is well delineated, and his devotion to sensual enjoyments forcibly portrayed. Then begins the catastrophe:

But in the midst of all his mirth,

while he suspecteth least. His happy chance begins to change

and eke his fleeting feast. For Death (that old devouring wolf),

whom good men nothing fear, Comes sailing fast in galley black,

and, when he spies him near. Doth board him straight, and grap)>les fast,

and then begins the fight. In Riot leaps as captain chief,

and from the mainmast right He downward comes, and Surfeit then

assaileth by and by ; Then vile Diseases forward shoves

with pain and grief thereby. Life stands aloft and fighteth hard,

but Pleasure, all aghast, Doth leave his oar, and out he flies —

then Death approach eth fast. And gives the charge so sore that needs

must Life begin to fly. Then farewell all ; the wretched man

with carrion corse doth lye, Whom Death himself flings overboard

amid the seas of sin. The place where late he sweetly swam,

now lies he drowned in.

THE JOHNS HOPKINS HOSPITAL REPORTS, Vol. IV, Nos. 7-8, REPORT

By THOMAS S. CULLEN, M.B.

I. Hydrosalpinx, its Surgical and Pathological Aspects, with a report of twenty-seven cases. II. Post-operative Septic Peritonitis.

III. Tuberculosis of the Endometrium. Numerous plates. Price, fl.OO.

GYNECOLOGY, III.

Address The Johns Hopkins Press, Baltimore, Md.

May-Jtjne, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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TETA.NY iisr PREa:N^A.jSrCY.

By H. M. Thomas, M. D., Assistant in Seuroloyij. [Read before the Johns Hopkins Hospital Medical Society, May 20, 1895.]

The occurrence of tetany is so rare in this 'country that I thought it might not be without interest to some members of the Society to have their attention called to the history of a case which I believe to be an extremely good example of this disease. The fact that in this instance the disease stood in close relation to several pregnancies makes it somewhat more remarkable, for although the association is well recognized, it is by no means common.

The important points in the history of the case, which I had the opportunity of examining in the Johns Hopkins Hospital, are as follows :

Mrs. L. P., £et. 33. There was nothing iu her family history of importance, and from her own account the patient seems to have been strong as a young girl. 8he may have had convulsions as an infant, but certainly not after her first year. There is no history of any sort of hysterical attacks. She was married at 18, and her first child was born nineteen months afterwards. She was well during this pregnancy. Her second child was born two years after the first. During the last two months of this pregnancy she began to suffer with stiffness and aching of her hands. Just before her confinement she was better, and continued so for nine days after; then the cramps returned, and she rarely passed a day without having several attacks, each lasting for a few minutes. As she expresses it, " her hands would close and at times her feet would draw." These attacks lasted until September, when she was free from them for two months, but after she was exposed to cold they came on again with great severity and were accompanied by intense pain. At one time the spasms in the muscles of her hands and arms did not I'elax for a week. She weaned the baby, and being exposed to cold at her second menstrual period, she had another very severe attack.

Directly after this her third pregnancy set iu, and she became entirely free from cramps for five months, but was subject to them again during the next three months, and was again free from them during the last month. Shortly after labor she contracted pneumonia and was ill for three mouths.

Her fourth pregnancy began when the third child was three months old. She had no cramps until the middle of the fifth month, when they recurred as in the former pregnancies. She was much better just before labor, but during labor had a very severe attack for a few hours. On the ninth day after labor she had another attack, and thou became free from them.

The fifth pregnancy began when the baby was five months old. Attacks of cramp came on as usual at five months and were somewhat more intense. The last mouth of pregnancy was free, but as before she had an attack on the ninth day after labor, and was then again free until she began to menstruate, nine months later. After this she had an attack with each period.

The sixth pregnancy set iu in Noveinbcr. ISST. and was a

repetition of the preceding pregnancies, except that the cramps were somewhat worse. She began to menstruate again in February, 1889, and the cramps returned and recurred around each period until warm weather in June, when she became entirely well and continued so until December, when she was again subject to them during the winter. She was free from them during the summer of 1890, and again affected during the winter. In the next summer, that of 1891, she was much better, but not absolutely without symptoms.

Her seventh pregnancy began in September, 1891. As in the former pregnancies she had no cramps during the first five months, although it was winter, but the attacks when they came on were extremely severe. She was free for six weeks before confinement, had no attack on the ninth day, and none until February, 1893, when she began to have slight intimations of them. Menstruation reappeared in May, and with it an attack of cramp. In June she had a severe attack, iu July a very slight one, and was then free from them until winter. During December, January and February they were severe. She came to the Johns Hopkins Hospital in March, 1894, and while there had no attacks.

The description which the patient gives of these attacks is very graphic and characteristic. They begin with a tired, aching sensation iu her hands, which is soon followed by the fingers becoming stiff and drawing shut, the feet also becoming stiff and drawn. In a severe attack the pain is intense, and the fingers are so tightly closed that the nails cut through the skin, the arms being stiff and held close to the chest and the hands blue and swollen. At times the spasm spreads to many other muscles ; the whole body becomes stiff, and the face and eyes are drawn, and even the muscles of the larnys are affected, stopping respiration for a moment or two and Ciiusing her to feel as if she were going to strangle. The patient has never lost consciousness iu an attack.

The duration of the attack varies very greatly, from a few minutes to several hours, or even days, and she has never found anything that seemed to shorten theui, although the pain can be controlled to a certain extent by repeated doses of morphia.

The examination of the patient on several different occasions yielded as the most important points the following:

She appeared to be a bright, intelligent woman, and had a wonderfully clear recollection of the history of her case. There was nothing about her that suggested hysteria. Her eyes were normal: there was no paralysis anywhere: sensation was apparently normal, and I was unable to demonstrate any hyperexcitability.

On sevei'al occasions fibrillary coutractious were noticed in the muscles about her eyes, but we never had an opportunity of observing a spontaneous attack of spasms of the muscles.

We were always able to pi-oduce a sharp contraction in the facial muscles by tapping the nerve root or its several branches,

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and, on one or two occasions, even stroking the skin over the nerve would produce the effect.

Continued steady pressure over any one of the nerves in the anus would cause a tonic spasm in the muscles supplied by it. This was much harder to demonstrate in her legs, and indeed we were only able to produce an incomplete spasm. Continued pressure on the facial nerve produced no spasm.

The nerves all responded to a much weaker faradic current than is the case in a normal individual.

There was a marked increase in the excitability of the nerves to the galvanic current, the K. CI. C. occurriug to such a small current that the galvanometer would only just indicate it. The anode opening, tetanus could be obtained in response to a weak current, usually between one and two M. A.

The most interesting electrical condition was discovered more or less by accident. It was noticed that when a comparatively strong current (two M. A.) was allowed to pass through a nerve, and when the stimulating pole was the cathode, the muscles were thrown into tetanus, which did not subside until the current was broken. The cathode was then placed over the nerve and the current was very gradually increased from nothing; when the current was still very weak, often indeed before the galvanometer indicated the passage of any current, one could notice fibrillary contractions in the muscles, and as the current was increased the contractions became more marked and the muscles began to be tetanized. This tetanus continued to increase until all the muscles supplied by the nerve were thrown into a strong, steady spasm, wliich passed off suddenly if the current was broken, or gradually, if it was gradually decreased. If the anode were substituted for the cathode, no such occurrence took place; on the contrary, several times when fibrillary contractions were already present they became much less marked as the current was inereiised. The current could be increased to five or even seven M. A. without causing tetanus.

This contraction, which, as far as I know, has been noticed but once before (by v. Bechterew, Neurol. Centralb., 1893, p. 755 ; Deutsch. Zeitsch. f. Nervenheil., vi, p. 457, 1895), is probably due to the production of cathelectrotonus in the nerve, and may be called cathelectro tonic tetanus (C. Elt. Te.). It could be demonstrated in all the nerves, and offered a most excellent opportunity for study of the muscular distribution of the different nerves.

'J'here was but one exception to the general rule, and that was in the left ulnar nerve above the elbow, where the anode as well as the cathode produced the Elt. Te. There was also here, as would be expected. An. C. Te.

I did not demonstrate any increased sensory excitaljility to either current, but the tests were not made as carefully as they should have been.

We always found the deep reflexes exaggerated, but more so on some days than on others, and indeed the ease with which the objective symptoms could be brought out varied a good deal from day to day. Her menstrual period came on just before leaving the hospital, and the second night she liad a alight attack of cramps in her hand; on the following day all the signs liefore noted were much exaggerated.

After going to her home in Virginia she suffered a good deal of pain. I last heard from her in the fall ; at that time she had begun to have her usual premonitory symptoms, and felt sure that she was going to have a return of the spasms during the winter.

I think this case is an unusually good example of this disease. Tetany, aud I may perhaps be permitted to bring some of the more important features to your especial attention.

The disease had lasted twelve years, and bore a most interesting relation to the six pregnancies through which she had passed during this time. She was always perfectly well dur- j ing the first half of pregnancy, but had then daily attacks of tetany, which became more violent and alarming with each succeeding pregnancy. For three or four weeks before confinement she had no attacks, and only once during labor did she have the spasms, but on the ninth day after confinement she had always had a severe attack, except in the case of her last confinement. While nursing her babies she was free (with one exception, that of the second child), but when menstruation reappeared she was subject to tetany at each period during the cold weather, but was free from them during the summer. In April, 1894, when she was comparatively well, there was no difficulty iu demonstrating Trousseau's symptom, the facial phenomenon, aud a very great increase iu the electrical excitability of the nerves.

•Trousseau aud all subsequent writers have mentioned pregnancy as a predisposing cause of tetany, but in point of fact there have not been many cases reported in which the relation was noticed.

In 1887 Meinert of Dresden (Arch, fiir Gyniikologie, Vol. XXX, p. 444) published an article upon the subject, in which he abstracted all the cases he had been able to find in the literature. He collected in all nine cases, only four of which were at all typical, and in only one of the four was there an examination of the nervous system. This is Weiss's interesting case, which I shall have to refer to again. Meinert himself reports a good case, that of a woman who had attacks of tetany duriug two of her six pregnancies. Trousseau's symptom was demonstrated.

Hoffman (Deut. Arch. f. klin. Med., 1888) records a case in which there was tetany shortly after confinement, then attacks during cold weather, freedom for a year, then another attack after confinement, immunity for six years, until she again became pregnant, when the attacks reappeared. She had no more attacks after confinement until she contracted typhoid fever, when they returned, stopping on her recovery.

Herman (Lancet, April, 1890) reports a case of tetany in pregnancy, with nephritis and cancer of the pylorus. Iu this case the spasms occurred four days before labor. They had been preceded by continued vomiting. The attacks stopped after confinement. Trousseau's symptom could not be produced. Facial phenomenon and elec. excitability were not tested for. Death occurred from cancer of the stomach several weeks after coulinement.

Dakin (Trans. Obs. Soc. of London, 1891), under the title "Tetany iu I'regnaucy," records a case of a wonum whoiu the fourth month of pregnancy began to vomit incessantly aud tlieii liad continuous sj)asms in the muscles of her hands

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and arms, aud finally in those of her face. She died on the third day. No objective examination was made. He refers to Meinert's aud Herman's articles and tabulates the cases.

Frankl Hochwart, in his monograph "Die Tetanie" (Berlin, 1891), says that he was able to find the report of fifteen cases of tetany which occurred during pregnancy. He gives no abstracts.

Julius Neumann, in March, 1894, read before the Obstetric and Gynaecological Society of Vienna a paper on the occurrence of tetany during pregnancy, a preliminary abstract of which is published in the Centralblt. f. Gynilk. 1894, p. 489. The paper has just appeared in the Ai'ch. f. Gyniik., Vol. xlviii, 1895. He gave the history of two cases. The first was that of a woman who had been pregnant eleven times. The first four pregnancies were normal. In the fifth pregnancy, and in all subsequent pregnancies, except in two in which there was a miscarriage at the third month, she had attacks of tetany, from the time of the first fcetal movement until delivery. She was observed in the last pregnancy, and it was then noticed that the uterine contractions occurred synchronously with the cramps in the extremities. After confinement the attacks became much less severe and disappeared in the second week. Trousseau's symptom and the facial phenomenon were demonstrated.

The second case was that of a woman who had been pregnant seven times. She had attacks of cramps in the last part of her first pregnancy, and when she was nursing her third child, but had no more cramps until the seventh pregnancy, in which she was observed. For two months before entering the hospital she had had light cramps in her hands, which had ■ become very intense at the onset of labor, and on admission the spasm was so severe that she was entirely helpless. The cramps became very much better after delivery, but recurved with great intensity when the uterus was emptied of some retained clots. The attacks were frequent while the patient was nursing her child, but ceased entirely when she weaned the child at six weeks. Trousseau's symptom, the facial phenomenon and increased electrical excitability of the nerve were observed. Neumann saw the patient eight months later when she was again four months pregnant. At that time the facial phenomenon was easily produced and Trousseau's symptom was present.

Richard Brown (Centralbl. f. Gyniik. 1894), at the same meeting, rej)orted two cases, in the first of which cramps came on during confinement, and here too they occurred with each labor pain, and stopped when the woman was delivered. The second case was associated with osteomalacia and persisted after confinement.

Gottstein's case, which I shall refer to later, completes the list. All the writers have been struck with the rarity of the occurrence, but there can be no doubt that at times pregnancy does predispose to tetany, and it is interesting to notice that the attacks occur almost always in the last half of pregnancy; indeed, during the first three or four months there seems usually to be some condition unfavorable to the occurrence of such attacks, for in certain cases which are subject to tetany they completely disappear with the onset of pregnancy, to reappear at the fiuirtli or liflh nunitli. \Vh:it eii-ininistanee it

is in connection with pregnancy that predisposes to tetany we are entirely unable to say, for we have as yet not much light on the whole subject of the causation of this remarkable disease. Certain facts have been determined, however, which seem to point out the direction which we must follow in the investigation. Quite a number of cases of tetany have been i recorded in connection with disturbances of the stomach and iutestines, and certain observers have isolated toxic substances from the urine in these cases, and they believe that it is the action of these poisonous substances upon the nervous system, more particularly upon the spinal cord, that produces the disease.

In those cases of tetany which occur in epidemics, and those cases which sometimes follow the ordinary acute infectious diseases, the thought naturally occurs that the condition is brought about by the action of the soluble toxic agents produced by the different specific micro-organisms, for the study of multiple neuritis has taught us how sensitive the nervous system may be to such substances.

Certain poisons, such as chloroform and alcohol, may produce tetany, and finally the occurrence of typical tetany after the total extirpation of the thyroid gland is of the very I greatest importance. This condition follows the operation iu about 221 per cent, of the cases, i. e. in IMllroth's clinic 12 times in 53 cases (v. Eiselsberg). That this is due in some way to the loss of the gland itself is shown by the fact that not a single case occurred after 115 operations in which only part n of the gland was removed, and also by experimental work on animals. The function of the thyroid gland is just now one of the most interesting problems in physiology, and although there is much to be determined, it has been demonstrated that it plays an important role in the metabolism of the body. It is believed to do this either by changing harmful substances into harmless ones, or by secreting some substance that is important for the economy. Perhaps it acts iu both of these ways. At any rate it seems that when the function of the thyroid gland is abolished, either by disease or by operation, the blood is changed in such a way that it tends to act injuriously upon the nervous system. Therefore we are to look for the cause of tetany following the extirpation of the thyroid gland as depending essentially upon the same kind of condition as that which we saw was the probable cause of tetany occurring under the other circumstances mentioned, i'. «. the action of some poisonous substance on the central nervous system.

The only other predisposing causes of tetany which Fnuikl , Hochwart gives are in connection with child-bearing, i. <•, pregnane}', labor and lactation. Does it not seem probable that under these conditions we may have such an altered state of metabolism that at times there may be present in the circulation substances which tend to act injuriously on the central nervous system and cause, among other nervous disturbances, tetany ?

The circumstances which combine to cause totauv during pregnancy must be extremely rare ; the fact that there are not more than twenty cases recorded sutlicieutly proves this.

In looking for a possible explanation, certain facts seemed interesting in this connection. Several years ago l>r. Wui. S.

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Halsted did a great deal of experimental work ou the thyroid gluuds of dogs. The work has not yet been published, but Dr. Halsted has kindly given me permission to refer to certain experiments which bear particularly upon the subject under consideration.

He found that dogs always died with symptoms of tetany when both thyroid glands were removed, but that he could keep them alive for an indefinite time without symptoms, and with only a very small fraction of the original gland tissue present, if he took away the gland piecemeal in several operations.

Two of his dogs which were undergoing this procedure, and

ere apparently in perfect health, became pregnant. The first dog had lost the left thyroid glaud four months previously. For two days before she gave birth to her pups she had convulsions, and behaved just as did the dogs whose thyroids had been completely extirpated. She had no more convulsions after the pups were born, and bore without symptoms two other operations, reducing the gland tissue to one-fourth of the right ihyroid. She finally died with symptoms of tetany after what was left of the thyroid had been removed.

The left thyroid of the second dog had been removed in two operations, and one-third of the right three mouths before she became pregnant. The day before the pups were born she had tremor of the tongue and general clonic and tonic convulsions, that is, she showed the symptoms which follow total extirpation of the glands. She was perfectly well the next day, and remained so even after Dr. Halsted by subsequent operations had reduced her to only one-ninth of the right glaud. She died with symptoms of tetany when this last bit was removed.

These experiments seem to show that the mutilated thyroids in these dogs were, as far as could be determined, quite sufficient for all ordinary circumstances, but that pregnancy, or to speak more accurately, labor, introduced conditions which re(iuired additional work from them, which they were unable to perform.

May there not have been in the cases which have been observed in women some abnormality of the thyroid gland, and may it not have been the combination of this condition with that of pregnancy which led to the production of tetany':' A few of the cases lend a certain amount of support to this view.

In Weiss's case a goitre was removed entire from a woman four months pregnant; immediately after the operation the spasms of tetany came ou ; she was one of the four cases in

Billroth's clinic of operative tetany that did not end fatally but passed into the chronic stage.

In Neumann's first case there was a goitre which had been present since the time of her first confinement, and he thinks I that this may have had something to do with the production of the disease.

Gottstein's most interesting case, which has just been reported in the Deutsche Zeitschrift f iir Nervenheilkunde, March loth, 1895, is important in this connection. A woman of 34 years who had had attacks of tetany in her right side since she was twelve years old, became very much better before her marriage, having gone without any attacks for more than a year. She married at 28, became pregnant in five months, and at the fourth month began to have severe attacks of tetany, which increased in severity until she was confined, when they completely stopped. They reappeared in eight weeks. Two years afterwards she had an abortion, during which she had a very severe attack. She was then better for a time, but the attacks returned and were present every day until she was seen in 1892. Upon examination she showed the typical symptoms I of tetany, and as the most careful examination was unable to I reveal an evidence of the presence of the thyroid gland, the ! diagnosis was made of tetany due to atrophy of the gland.

Mikulicz made two attempts to transplant the thyroid gland of another patient into her abdominal wall. The glands were absorbed, and it was noticed that during the process the patient was very much better, but afterwards returned to her previous condition. In March, 1894, they began to treat her with thyroid extract, and a very marked improvement was at once noticed. Her attacks were reduced from 20 to .30 during a night to 5 or 6, and she was in every other way much better. Certainly a most remarkable result.

I am fully aware that the facts are few, and may perhaps be better explained in some other way, but they seem to me to be best brought into accord with our present knowledge, by the hypothesis that the occurrence of tetany during pregnancy i depends primarily upon some abnormality in the function of | the thyroid gland, and that it is the unusual demands made upon this organ in the later mouths of pregnancy which make this such a favorable time for the occurrence of the attacks.

I am inclined to entertain the opinion that it is probable that tetany occurring under other conditions will in most cases be found to be due to an iusullicieucy, absolute or rela-1 tive, in the action of the thyroid gland or like structures. If' this be true it may serve to explain why the disease occurs so frequently in certain localities and is so rare in other places.

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A DEATH FROM OHLOROFORM. IMPOSSIBILITY OF INDUCING ARTIFICIAL RESPIRATION ON ACCOUNT OF RIGID THORAX AND ADHERENT ABDOMINAL VISCERA.

By J. G. Clark, M. D., Resideiit Gynecologist.

The case which I report is of especial interest, as all of the conditions required for the proper administration of chloroform were fulfilled, and when the first danger-signal was observed, the auajsthetic was withdrawn and the most energetic and prolonged resuscitation measures were employed without the slightest reaction either in the cai'diac or i-espiratory functions.

In the discussion of Dr. Hare's paper before this Society,* Dr. Kelly, in describing his method of resuscitation, laid especial stress upon the fact that in patients with contracted and fusiform chests or with pigeon-breasted chests, or in aged women, this method would probably be of no avail in establishing respiratory movements.

This case fully supports his statement as demonstrated clinically and by the autopsy, although at the time of Dr. Kelly's report no case of chloroform asphyxia had come under his observation which had failed to react when this method was employed.

The patient was admitted twice to the gynecological wards, first, April 18, 1894, when she was operated upon for a multilocular ovarian cyst, and again, January 1, 1895, when she returned on account of a stitch-hole sinus and persistent vesical iri'itability.

Her history, as given at the time of her first admission, is as follows :

B. B., colored, aged 47 years, married.

Present Complaint. — Swelling of abdomen and pain in right leg.

Marital History. — Married 37 years; 1 child, born about 2fJ years ago, died when 18 months of age. Labor normal. IS'o miscarriages.

Menstruation began at 14 years, flow moderate, lasting three to four days, regulai', not painful. For last year irregular. Symptoms are those of approaching climacteric.

Family History. — Negative.

Personal History. — Since childhood patient has been strong and healthy up to present illness. Has done much hard manual work.

Present Illness. — One year ago the patient noticed a slight enlargement of her abdomen, but as it was not accompanied by pain or discomfort, she gave it but little thought. The swelling increased slowly but steadily until February, 1894, when it was quite marked. At this time the right leg began to swell ; four weeks later the left leg also became cedenuitous. At present both legs are greatly swollen from the toes up to Poupart's ligaments, and deep indentations can be made with the finger-tips. She complains of slight dyspncea when lying in the recumbent posture.

General Condition. — A rather emaciated woman of about 45 years, skin brown, mucous membrane somewhat pale,

• The Johns Hopkins Hospital Bulletin, No. ■(('>, January, 1895.

arcus senilis well marked, small cataract of right eye. Arteries hard and ajipear to be atheromatous. Abdomen greatly distended by a fluctuant tumor, smooth in outline and presenting a small boss on the left side. Tumor somewhat larger on right than on left side. Appetite poor, tongue pale and flabby. Bowels constipated. Pain just before and after urination. Walking not painful, but difficult, on account of general weakness. Complains of palpitation of heart and general debility. Within the last 3-ear she has lost many pounds in weight.

Examination of C/«es/. — Thorax long, contracted at waist, sternum prominent, pigeon-breasted. Costal respiratory movements limited. Heart and lungs normal.

Examination of Abdomen. — Abdomen greatly distended, particularly on whole of right side, veins prominent, skin of natural hue, liuea albicantes well marked. Greatest circumference of abdomen below umbilicus 9G cm.

Percussion shows a tympanitic area extending from ensiforni cartilage to 3 cm. above umbilicus, laterally to nipple lines. Below umbilicus, percussion note flat. Wave of fluctuation distinct over dull area. Whole of lower abdomen from the above named tympanitic area to pubes is filled with a cystic mass ; in left lower zone a nodular mass can be easily mapped out.

Per Vaginam. — Outlet relaxed, left vault of vagina filled with a fluctuant immovable mass directly continuous with mass in abdomen. Left vaginal vault along with cervix drawn up into pelvis and not palpable.

Diagnosis: Cystoma ovarii multilocularis.

Treatment. — Cystectomy.

Operation : 4, 23, 1894. Patient was nervous and very much frightened at the thought of taking ether, consequently chloroform was first administered until the secondary stage of anaesthesia was entered, when ether was substituted. When placed upon the operating table her pulse was 120 and regular. No change in the pulse or respiration w;is noted in changing from chloroform to ether.

Incision 17 cm. long through thin abdominal wall, cystic mass exposed, densely adherent to abdominal pariet<?s.

Peritoneum not recognized on account of it.s intimat* adhesion to tumor. Cyst evacuated with trocar of G litres of dark brownish fluid. Many daughter cysts evacuateil by rupturing their walls with the fingers. Enucleation of cvst wall from its bed of adhesions excessively difficult on account of its intimate adhesions to abdominal walls and intestines. Hemorrhage very free. Cyst seemed to spring from right side, but tubes and ovaries were so incorporated with it by dense adhesions as to render it^ differentiation impossible.

The ovarian and uterine arteries were tied to check hemorrliage, and the mass with the uterus wjis removed. lu enucleating the cyst wall from the floor of the pelvis, a part of its wall was left behind. A louaritudinal fear 3 cm. in

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length in the rectum occurred during the enucleation; this was immediately sutured with five silk ligatures.

Peritoneal cavity washed out with salt solution, and five pieces of gauze introduced to check the extensive oozing over the adherent areas. The operation was extremely diflicult, attended with profuse hemorrhage, and required one hour and forty-five minutes to complete it. Notwithstanding these adverse conditions the patient was removed from the table with a pulse of 128, only an increase of eight beats over that noted before the anaesthesia was begun. The progress of the ana'sthesia was even and quiet, and at no time caused the slightest alarm.

Seven days from the time of operation the great redema noted on her admission had entirely disappeared. The patient made a good recovery, and was discharged eight weeks from the date of operation with the following note : Abdomen soft, no tenderness, incision perfectly healed, general condition good.

It is the custom in the gynecological department, in all cases where patients are nauseated by ether, or have a strong aversion to it on account of the disagreeable sensations produced in its earlier administration, or where the arteries are sclerotic, to administer chloroform in beginning the anaesthesia, and this is often continued throughout the operation, depending upon the preference of the anaesthetizer. The employment of chloroform was doubly indicated in this case, as the arteries were sclerotic and the patient had a marked antipathy for ether.

The above detailed history of the patient's condition, her operation, and the progress of the anaesthesia, is of especial value, as it furnishes a standard for comparison with the notes made on her case previous to her second anassthetization, eight mouths later, during w'hich she died. The case is also of interest from the pathological aspect, as the small portion of cyst wall left adherent to the rectum at the time of her operation proliferated rapidly and formed the large multilocular cyst noted in the autopsy report.

The next note on the case was made Jan. 2, 1895, at the time of the patient's readmission to the hospital eight mouths after her operation, as follows: Patient returns to-day complaining of considerable pain at a point on the anterior abdominal wall 4 cm. to the left of the umbilicus, probably from its situation the seat of one of the sutures. This has been discharging for the last six months. The pain is not at all severe, the principal annoyance being the discbarge, which up to a few days ago has been quite profuse. She also complains of great vesical distress, which has been especially marked for the last three weeks, often causing her to urinate as often as every half-hour. General condition about the same as noted in the first history. No cedema of extremities, tongue clean and of a good color, pulse full and regular, arteries sclerotic. Patient thinks she has lost weight since her operation.

Physical examination : Abdomen large and flabby, incision of former operation completely healed. A small sinus 4 cm. to left of umbilicus admits probe 1 cm.

Vaginal examination shows an immovable ovoid mass behind and above syniphysis which does not diminish in size on catheterizing the bladder.

On account of the pain caused by the examination and the ill-defined nature of the tumor, it was deemed best by Dr. Kelly to administer an anaesthetic. Chloroform was again chosen for the same reasons as those noted at the time of her operation.

The first stage of anaesthesia was quiet and passed without any perceptil)le change either in the pulse or respiration ; following this the patient became rigid, and as this condition was very persistent, the auajsthetizer very properly brought the Esmarch inhaler closer, but at no time was it nearer than two inches from the face. The patient still remained rigid, and as her respirations began to grow quite shallow it was considered best by the auffistlietizer to change to ether. He turned from the patient long enough to get the ether cone which was at his side, and on turning back he was unable to find the temporal pulse, and at once felt for the radial pulse, which was also imjierceptible. Kespiration by this time had also ceased. No time was lost in proceeding at once to artificial resuscitation. Dr. Stokes quickly got upon the table and lifted the patient by the knees until she rested on her shoulders, another assistant extended the head by pulling and lifting forward on the condyles of the lower jaw, while Dr. Kelly iustituted respiratory movements by placing the open hands on each side of the chest posteriorly over the lower ribs and drawing the chest well forward and outwards, holding it thus for about two seconds, and then reversing the movement by replacing the hands on the front of the chest over the lower ribs and pushing backwards and inw'ards, at the same time compressing the chest. The success of this manoeuvre is demonstrated by an audible rush of air in and out of the chest, but in this case there was not the slightest respiratory effect produced, and after a thorough test it was abandoned. During this time a nurse administered hypodermics of strychnine and atropine. Dr. Kelly has pointed out this class of cases as the ones which do not respond to this method.

He says : " In women with contracted, fusiform chests (tight lacers) this procedure is not available ; respiratory movements should be induced in these cases by direct autero-posterior compression of the chest by placing one hand on the lower third of the sternum and the other on the back opposite the first and alternately squeezing the chest and relaxing the pressure." For this reason the antero-posterior compression was quickly resorted to as soon as the first method j)roved ineffectual. Notwithstanding the most energetic efforts, there was not the slightest effect produced, and at no time after the pulse first disappeared was it again felt. The failure of pulse and respiration occurred coincidentlj-, although the respiratory function was apparently impaired first. Taking in connection with this clinical observation the fact that the heart, as shown by autopsy, was practically uornuil while the respiratory apparatus was greatly impaired, it appears certain that this was a case in which the failure in the respiratory functiou was the primary cause of death.

In the light of the autopsy it appears that uo method would have been of value in this case, as in addition to a rigid pigeonbreasted thorax and an adherent left lung, the abdominal viscera were completely matted together and adherent to the anterior abdominal wall and the diaphragm, thus practically

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immobiliziug or splinting the diaphragm and rendering its movements and also the abdominal walls impossible by any artiflcial means.

The autopsy was made by Dr. Flexner, and I append the notes from the protocol.

Anatomical Diagnosis. — -Lymphatic leukaemia, old operation wound; multilocular cyst of ovary (chloroform death); hydronephrosis and chronic diffuse nephritis; gall stones.

Body IGO cm. long, well developed, mucous membranes pale. Pupils dihited and equal. Abdominal scar 10 cm. from former operation, beginning 5 cm. below umbilicus and extending to 4 cm. of pubes. To the left of the umbilicus is a bloody scab, on the removal of which a small opening is seen in the skin. Probe, however, only passes through the skin.

On cutting through the abdominal walls, the viscera arc found to he firmly adherent to jiarietal jjeritoneum, so that the abdominal organs, especially the bladder, are separated tuith great difficulty.

The large and small intestines, omentum, and stomach are matted together by fitrn adhesions, which, however, can be more easily separated than those binding organs to abdominal vmlls. Liver is very firmly adherent to diaphi'agm. On separating the loops of small intestine from each other, in the hypogastric region a large cyst of a greenish brown color with exceedingly tense walls is seen. The mass is slightly lobulated, there being three large ones, the right one appearing to be made up of a number of smaller ones. The peritoneum covering the mass was united to the surrounding loops of intestines by adhesions. The tumor was firmly adherent to the bladder in front and the rectum behind.

The right ureter is seen lying on the jiosterior abdominal wall and is very much dilated; lower down it becomes lost in the adhesions between the tumor and rectum. The tumor completely fills the pelvic cavity, the walls of which are so adherent that the fingers cannot be passed around it without first breaking up the adhesions. The lower half of the appendix vermiformis is adherent to the tumor.

Lungs. — Lungs voluminous and do not collapse on removal

of sternum. Left lung is free from adhesions, but the pleural cavity contains about 50 cc. of yellowish serum.

The right lung is hound to the parietal pleura throughout its entire extent by firm adhesions, which are not readily broken down.

Spleen. — AV'eight 480 grams; measurements 17x12x5 cm. On section spleen presents a mottled appearance, consisting of numerous pearly white, almost opaque nodules varying in size from a millet seed to a hemp seed which are scattered through the pulp.

Heart. — Weight 340 grams; left ventricle wall 2 cm., right ventricle wall 5 cm. in thickness. Eight and left side of heart contain fluid blood. Aortic and pulmonary valves normal. Tricuspid valves normal. Mitral valves very slightly thickened, otherwise normal. Consistence of heart muscle normal. Walls of coronary artery contain patches of fatty degeneration of the intima, more mai'ked about the orifices of the branches. No embolus or thrombus ; vessel clear of obstruction.

Liver. — Capsule covered with remains of adhesions, but not especially thickened. On section liver substance is found to be homogeneous and cloudy, of firm consistence and reddish color.

Gall-bladder contains ten dark black faceted stones. Common bile duct is patent.

Right Kidney. — Weight 110 grams, size 10.5x5x2.25 cm., very firm, excessively pale. Capsules strip off readily, but in some areas are firmly adherent and bring away masses of the cortex when removed. Pelvis and calices much dilated, as is also the right ureter. Cortex greyish white, except in small spots on the surface where there are a feV irregular congested areas.

Left Kidney. — Weight 200 grams, 12x65x45, normal.

Pancreas normal.

Bladder greatly distended and adherent, otherwise normal.

Aorta: numerous patches of fatty degeneration throughout its whole extent, and especially marked about it^ orifices.

Trachea free, 7imcous membrane slightly congested.

Oesophagus and larynx normal.

A QUICK METHOD OF FILTERING BLOOD SERUM.

By Given Camphell, M. D., axd A. D. Ghiseux, M. I). [Read before the Johns Hopkins Hospital Medical Society, May 20, 1S95.]

Scrum-thcrajiy is now well established as a means of treating disease, and while writers may differ as to the amount that can be accomplished by its use, all agree that we have in it a most useful means of combating infectious diseases.

One of the arguments urged against its use is that in injecting the blood serum of an aninuil into a human being there is danger of communicating to the patient any disease, such as glanders, from which the animal may be suffering. Again, the senmi cannot be sterilized by heat, aud to prevent putrefactive bacteria from entering it, the strictest antiseptic precautious must be observed while the serum is being collected.

In view of these facts the writers desire to present to the

Society a method of preparing blood serum which has Iveu used successfully in my private laboratory for over a year.

All of the authorities on bacteriology agree that blood serum cannot be practicably sterilized by filtration ; the chief reason given being that albuminous liquids will not pass through a Chamberland bougie, or that if they do finally filter it will be found tbat in doing so their composition is changed, only part of the albumen of the liquid psissiug through, so that serum thus filtered will not coagulate by heat.

Another objection urged is the difficulty experienced in preventing recoutamiuation of the filt<;red liquid when the liltration is done by negative pressure, as is usually the case.

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The reason for this is obvious. When filtration is accomplished by negative pressure a vacuum is formed in the flask for collecting the filtrate, and also, of course, in the interior of the bougie and in the connecting tubing: the unopposed pressure of the atmosphere (15 pounds to the inch) is the force which drives the li<[uid through the bougie.

Now the tendency of the air is to get in to fill this vacuum, and if there is the slightest break in any of the connections air will leak through to where the filtrate is and will carry bacteria with it.

The first of the objections, namely, that the serum is altered, is answered by the fact that while serum filters with difficulty and is altered in its composition when a low pressure is used to force it through the bougie, it filters very rapidly and passes through unaltered when, as in this method, a pressure of over 150 pounds is used in its filtration.

As to the second objection, it need only be said that in the present method a positive, not a negative pressure is used, and in place of the air being sucked into the filtrate, the tendency is rather to force air out through any faulty connection, because some air of course must be displaced when the filtrate enters the collecting flask.

The method here described was first thought of in August, 1893. Before going farther it may be said that no originality is claimed for this idea. The device is merely the expansion of an idea furnished by a very similar apparatus that appeared in the Army Exhibit at the World's Fair in Chicago. But the difference in price and practicability is much in favor of the modification. The apparatus just mentioned was for filtering liquids through a Chamberland bougie in which the pressure was obtained by the iffee of carbon dioxide gas. As to whether this apparatus had ever been employed for filtering blood serum the writers cannot say, but no report of the apparatus nor of its being so used can be found.

The very considerable expense of the apparatus just mentioned led the writers to devise a filter which answers every purpose and which can be readily procured and for a very moderate price.

A brief description of the device will be given here; and the exact measurements of the one in use by the writers will Le given in a woodcut.

The filter proper is on the principle of a single-bougie waterfilter, sufficiently strengthened to allow the safe use of a high pressure, and so arranged that a sterile flask may be attached to the bougie in such a manner that the filtrate undergoes no risk of contamination.

To the filter is connected a drum filled with li(|uefied carbon dioxide such as is used in charging soda water, and can be obtained of any dealer in soda water supplies. The drum must suitable for this purpose is sold by the Saint Louis Carbonic Acid Gas Company, of St. Louis.* It consists of an iron cylinder four feet long by four inches in diameter and contains ten pounds of the lifiuefied gas.

In the upper end of this cylinder is fixed a safety valve and also a valve by which the pressure can be turned on. To this

•Similar drums containing carbon dioxide under pressure are supplied by other manufacturers in several large cities.

valve is attached a very thick-walled rubber hose which has fixed in it a pressure gauge registering three hundred pounds. The hose with gauge and suitable connections for connecting the drum to the filter is furnished with the drum.

The method of using the filter is as follows: A rubberstoppered flask having two tubes passing through the stopper is the vessel used for collecting the filtrate. One tube is short and has its upper end enlarged and loosely packed with cotton. To the outer end of the long tube is attached a piece of the best black all-rubber hose about two feet long, divided in the middle and the two pieces joined by a glass nozzle. On this piece of hose are two of ilohr's pinchcocks.

FlQ. II.

The other end of this hose is passed through the hole in the lower cap and gasket {A, Fig. I), and then through one of the rubber stoppers that are used to fix a bougie into a Pasteur

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water filter. The hose is then slipped over the open end of the bougie, and the stopper just mentioned is slipped up along the hose and over the end of the bougie, with the hose of course intervening {B, Pig. I).

The apparatus thus connected as shown in Fig. I is now put into the steam sterilizer and sterilized for three quarters of an hour.

It is then removed and the bougie introduced into the shell {M, Fig. Ill), its stopper {S, Fig. Ill) carefully adjusted and the lower cap {L, Fig. Ill) screwed tight. Serum is now poured in the upper opening of the shell, and the upper cap ( V, Fig. Ill) screwed on.

This serum is collected in the ordinary way except that mere culinary cleanliness, if this term be allowed, is used in place of the aseptic precautions that are so tedious and unsatisfactory in the old method.

The drum is now connected to the filter as seen in Fig. II. The valve {X, Fig. II) is now very gradually turned and the gauge observed, when it will be found to indicate an increasing pressure. When the pressure rises to the desired degree the valve is closed. The best pressure for filtering blood serum is 200 lbs., but much over this should not be used for fear of crushing the bougie.

When filtration is complete the drum is disconnected, the pinohcocks are closed on the rubber tube, one at each end of

the glass nozzle (as shown in Fig. I), and the tube is cut off (at 0, Fig. II). The cut extremity is enveloped in sterile cotton. The collecting flask may now be sealed (at D, Fig. I) and the serum preserved indefinitely. When it is desired to withdraw any of the serum for use the following precautions are employed : The sealed tube D is opened, leaving the cotton in place, and the end of the rubber tube which has remained over the lower end of the glass nozzle is slipped off. The hose being still full of serum acts as a syphon, so that when the pinchcock is opened the serum readily flows from the flask. By syphoning from the middle of the filtrate, any deposit of cholesterin that may have formed will be avoided. In filling test tubes in this way contamination is practically unknown.

Serum thus prepared is perfectly clear, coagulates at exactly the same temperature as unfiltered serum, nor does such filtration have any appreciable effect on any toxin or antitoxin that may be present.

To give an idea of the advantage of this method it need only be said that 1000 cc. of such serum can be filtei'ed in five minutes.

The writers desire to express their thanks to Dr. H. H. Born of St. Louis for the very excellent photographs that illustrate the paper.

St. Lotris, Mo.

PROCEEDINGS OF SOCIETIES,

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY. Meeting of March 15, 1895. Dr. Abel in the Chair. A Case of Pharyngomycosis Leptothrica. — Dr. Barker.

I wish to bring before you this evening a specimen of a rather rare pharyngeal disease, namely pharyngomycosis leptothrica, sections of which are exhibited under the microscopes'. The piece of tissue from which these microscopical sections were prepared was sent me by Dr. Campbell of Chicago, who made a provisional diagnosis from the clinical appearances of the case.

This affection was first described by A. Fraenkel in 1878. He had noticed in the throats of a number of persons a membrane looking somewhat like that of diphtheria, but which produced no symptoms in the patient. He observed that the portions of the pharynx most likely to be attacked were the lateral walls, although sometimes thcposterior wall and sometimes the tonsils and root of the tongue were affected. The clinical symptoms consisted solely, as a rule, of rawness or dryness with a sensation of tickling. The patient often discovered the disease himself by looking into his throat. In some cases there were manifestations of hypochondriasis and hysteria, and the attendant worry over the condition had impaired the general health of such persons. Indeed, owing to the emaciation which resulted from the anxiety of the patient, one case was taken to be tubei'culous pharyngitis. The study of Fraenkel showed this disease to be due to the

leptothrix buccalis which is present in the membrane in very large numbers. Many attempts have been made to cultivate the leptothrix, and some experimenters have stated that they have been successful. The disease has, however, not been reproduced by inoculation.

The diagnosis, even without the microscopical examination, is tolerably simple when one has once seen a case. The disease is most likely to be confused with lacunar tonsillitis; but this latter affection sets in acutely with a febrile paroxysm ; and, moreover, the membrane does not resemble that of pharyngomycosis. It can also be readily distinguished from diphtheria both by the appearance of the membrane and by its clinical course. In pharyngomycosis there is no marked inflammatory reaction about the membrane, and when inflammation does occur it is supposed to be due to complications. When the disaise attacks the tonsils the membrane may be mistaken for those tonsillar plugs so often seen clinically, but it can be differentiated from the latter by the difficulty or impossibility of removing the leptothrix membrane. Only a superficial examination could lead one to mistake thrush for this disease.

The treatment is not very satisfactory; the condition often persists for a long time ; the prognosis is, however, good. All thus far agree that repeated cauterization is the l>est treatment.

Under the microscope what one finds is the following: The leptothrix occurs sometimes in quite long threads, the threads being composed of individiuil members which stain unequally. The leptothrix is formed in the crypts and on the surface of the tonsil, and seems to cause an increase of the superficial

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epithelium. It is stated that it may invade the tonsil itself. In the specimen which I have examined I have not been able to make out the leptothrix in the substance of the tonsil. Looking into the crypt in a section through the middle of the plug one sees a central core made up of squamous epithelial cells ; and going off at right angles from the sides of this core are the bundles of leptothrix threads. One of the best ways to demonstrate the organism in sections is to treat the latter with Lugol's solution for three or four minutes, washing out •the excess with water and finally mounting the specimen in glycerine. One can then easily pick out the bluish-black leptothrix masses owing to the starch reaction. On the surface the leptothrix is mixed with loose epithelial cells. There is an increase in the number of lymphoid cells on the surface and in the crypts of the tonsils. But as the tonsil is always throwing out such cells, this is to be regarded as only an increase in the normal process of. lymph-cell transudation on the part of the tonsil.

A Case of Anthrax in a Unman Being.— Dr. Flexnek.

Dr. Flexner. — I shall say a few words only regarding this case and then ask you to look at the specimens which have been placed under the microscopes for your inspection, as it is to be reported in full very soon by Drs. Bloomer and Young.

This case presents the usual features of that form of anthrax infections in human beings known as malignant anthrax oedemas. The oedema was of that peculiar gelatinous type often seen in some of the experimental infections in animals. It extended beneath the clavicles and affected the mediastinal tissues. This fluid contained large numbers of the anthrax bacilli. The bacilli were cultivated from the heart's blood and organs, thus denoting an anthrax septica3mia. Interesting localizations of the bacilli were found (1) in the stomach and intestines, producing areas of focal inflammation associated with necrosis and hemorrhage in which myriads of bacilli were contained; (2) in the peritoneum, causing an acute fibrino-purulent peritonitis, and (3) in vegetations upon the heart valves, producing an acute vegetative endoparditis.

NOTES ON NEW BOOKS.

BOOKS RECEIVED.

PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.

THE JOHNS HOPKINS HOSPITAL REPORTS.

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL.

Vol. Vl.-Nos. 52-53.

BALTIMORE, JULY-AUGUST, 1895.

+++

Contents

The Treatment of Diphtheria by Antitoxin. By AVilliam H. Welch, M. D., 97

A more Radical Method of Performing Hysterectomy for Cancer of the Uterus. By J. G. Claek, M. D., 120

Notes on New Books, 125

THE TREATMENT OF DIPHTHERIA BY ANTITOXIN.*

By William H. Welch, M. D., FaiJwlogisl to the Johns Hopkirn- Hospital and Professor of Pathology, Johns Hoj}kins University.

I shall endeavor in this paper, after a brief historical introduction, to present some of the more imjjortant general considerations bearing npon the treatment of diphtheria by antitoxic serum, together with statistics of results already reported, with the expectation that those who are to follow in this discussion before the Association will be able to offer the results of personal experience in the application of the new remedy.

In July, 1889, Babes and Lepp, in an article entitled " Kecherches sur la Vaccination Autirabiques,"| published results of experiments undertaken to solve the question " whether the fluids and cells of animals which have been rendered by vaccination immune have not become vaccines and capable of protecting also other organisms." The results of these experiments showed that the blood of dogs thoroughly vaccinated against rabies, when injected into susceptible animals, -conferred a certain amount of protection against the effects of subsequent inoculation with the rabid virus, and appeared capable of preventing the development of rabies

• This paper is based upon the address at the opening of the discussion on this subject before the Association of American Physicians at the meeting hehl in Wasliington, D. C, May 31, 1895. I

have endeavored to bring the paper up to the date of sending it to the printer (July, 1895).

■|- Babis and Lepp, Annales de I'lnstitut Pasteur, July, 18S9. Kichet and Hericourt are sometimes quoted as the first experimenters to show that the blood of animals is capable of conferring protection upon susceptible animals, but their work has no reference to modern serum therapy, as their experiments were made with the blood of dogs which liad not previously been vaccinated or treated in anv wav.

even when the injection of the immune blood was made immediately after the reception of the virus. The authors coneluded that "one must admit the possibility of vaccinating with the fluids and cells of animals whicii have been rendered refractory to the disease."

The first publication clearly demonstrating the principles of serum therapy was made by Behriug and Kitasato on December 4, 1890, in an article in the Deutsche medicinische Wochenschrift entitled "Ueber das Zustaudekommen der Diphtherie-Immunitiit und der Tetanus - Immuuitiit bei Thiereu." Although in this article the immunizing and curative property of the blood and blood serum of artificially immunized animals was demonstrated only for tetanus, the application of the same principle to diphtheria was indicated in the same article and in a second paper by Behring iu the following number of the same journal.

The first public announcement of the demonstration of the power of the blood serum of animals artificially immuuizeil against diphtheria to protect and cure susceptible animals inoculated with the diphtheria bacillus or its poison, was made by Behring in the report of experiments made by himself and Wernicke, and communicated to the Seventh International Congress of Hygiene and Demography held iu London iu August, 1891. There followed in lS!t3 the article by Behriug and Wernicke,* in which these experiments were fully

• Behrinc und Wernicke : Deber Immunisirung und Heilang von Versuchsthieren bei der Diphtheric. Zeitschrift fur Hygiene, Bd. XII.

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described and which sets forth the fundameutal principles underlying serum therapy of diphtheria.

The first trial of immune serum in the treatment of human diphtheria was made in von Bergmann's clinic in Berlin in the autumn of 1891. This trial, together with those made in 1802 by Henoch in Berlin, by Ileubner in Leipzig, and in the Institute for Infectious Diseases in Berlin, were of a tentative nature and made Avith weak serum and insufficient doses.

It was not until early in 1893 that Behriug succeeded in obtaining anti-diphtheric serum equaling the strength of even his so-called normal serum, of which sixty times the strength is that of the weakest Bchring's serum at present in use. In April, 1893, Behring referred to 30 cases treated with this normal serum. Of these cases, 11 treated in the Institute for Infectious Diseases were reported in detail by Kossel.

From this period on Behring and Ebrlich succeeded in obtaining healing serum of greater and greater strength, until in August, 189-3, Ehrlich and Wassermann obtained from goats healing sernm twenty to sixty times the strength of Behring's normal serum. At the Eleventh International Medical Congress held in Rome (March 29 to April 5, 189-1) Heubuer reported the results of his expei'ience with the serum treatment of human diphtheria. His observations, however, were made on cases treated with much weaker antitoxin than is now recognized as suitable.

In April, 1894, Ehrlich, Kossel and Wassermann reported briefly the results of serum treatment of 220 cases in six Berlin hospitals, the inception of the treatment in these cases dating from June, 1893, but the great majority of the cases occurring after December, 1893. These cases, with additional ones making a total of 233 cases with a mortality of 23 per cent., were reported more fully in an article by Kossel in the Zeitschrift fiir Hygiene in July, 189i. The era of serum treatment of human diphtheria by approximately sufficient doses of antitoxin really begins with this publication of Ehrlich, Kossel and Wassermann in April, 1894, although even in this series of cases, according to later statements of Ehrlich and Kossel, a large number of the cases were treated with quantities of antitoxin which we now consider to be insufficient.

In an address before the Berlin Medical Society on June 27, 1894, Katz reported the results of antitoxin treatment dating from March 14, 1894, with Aronsou's serum from horses on 128 cases of diphtheria in Baginsky's service. In the discussion on this address four weeks later Bagiusky completed the series of cases up to 163 with a mortality of 12.9 per cent., and Aronson stated that similarly favorable results had been obtained by Ganghofner in Pr.igue and Escherich in Graz.

In 1893 and the first half of 1894 various articles appeared concerning the preparation of antitoxin, the best methods of estimating its strength, the proper immunizing and therapeutic doses, and similar questions. Since August 1, 1894, Behring's serum prepared at Ilijchst has been for sale.

It is evident from this brief historical summary that the general principles of serum therapy of diphtheria were fully established and its application to human beings in active operation before Roux delivered his memorable address on the subject at the Eighth International Congress of Il3-giene and Demography held in Budapest, September 1-9, 1894, three

years after Behring's original communication to the preceding Congress in London. Roux, however, presented the subject with such clearness am^ force, and with such an array of convincing and carefully analyzed statistical evidence, that the attention of the great body of physicians throughout the world, who bad paid little heed to the previous work, was arrested, and the question of the healing power of diphtheria antitoxin became and has continued to be the foremost medical question of the day. From September, 1894, onward the supply of antitoxin from various sources (not all of equally trustworthy character) has become more and more accessible to physicians, and each succeeding month has given birth to a large number of articles on the serum therapy of diphtheria from various parts of the world.

L'nless one denies absolutely the causal relation of the Loffler bacillus to diphtheria, it must be admitted that the treatment of this disease by antitoxin rests upon a sound experimental basis. The only notable opponent of the view that the LOffler bacillus is the cause of diphtheria is Hanseman. His arguments, which have been well answered by C. Fraenkel, are equally applicable to the acceptance of the etiological relations of the cholera bacillus, the tubercle bacillus and many other specific bacteria of infectious diseases. It is not probable that any one here sides with Hanseman in this matter, so that it is unnecessary to rehearse the arguments, which in my judgment are conclusive, that the Loffler bacillus is the cause of diphtheria.

The laboratory does not furuish any more impressive experiments than those which demonstrate the power of antitoxic serum to prevent and to cure the disease caused in animals by inoculation with the diphtheria bacillus or its poison. The serum arrests the spread of the local process and abates the symptoms of general toxfeniia. These experiments prove beyond question that this healing serum possesses properties which are directly and powerfully antagonistic to the toxic action of the diphtheria bacillus, and there is no good reason to doubt that under similar circumstances this antagonistic power, so readily and surely and uniformly demonstrable in the case of lower animals, will manifest itself also in human beings. The only question, and that of course an important one, in this connection is: To what extent the conditions in the treatment of experimental diphtheria by antitoxin are or can be made similar to those in the therapeutic application of the same agent to human diphtheria ?

Although it is true that the lower aninuils are not susceptible, or only very exceptionally susceptible, to natural infection with the Loffler bacillus, still there is in my opinion identity in essential points, anatomical, clinical and etiological, between experimental diphtheria and uncomplicated human diphtheria. The assertion sometimes made that spreading pseudo-membranous inflammations resembling those of diphtheria cannot be produced experimentally in auimals by inoculation with the Loffler bacillus is an error, a> 1 have repeatedly had opportunity to demonstrate by intratracheal inoculations of kittens and rabbits. It is rarely in our power to reproduce experimentally in one species of animal the exact counterpart of a disease caused in another by natural modes of infection,

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but in the case of diiihtheria the resemblance is closer than in most of our attempts to reproduce such diseases by inoculation of their specific germs.

But even if the anatomical and clinical characters of experimental diphtheria are believed by some to differ more widely than I think they do from those of human diphtheria, there remains as the most important point, regarding the matter here under discussion, the conclusive demonstration that in uncomplicated human diphtheria no less than in experimental diphtheria the local inflammation at the site of infection is caused by the growth of the Loffler bacillus, and the lesions of internal parts and the systemic symptoms are due to the absorption of a toxic substance or of substances formed by this bacillus. It would be ditKcult to understand why an agent with the specific property of neutralizing in the bodies of animals the effects of these toxic substances should be unable to neutralize in human beings similar effects of the same toxic substances, provided this agent can be administered in the proper dose and at the right time.

Dosage and timely administration are factors of prime importance in determining the efficacy of antitoxic treatment. It is our inability to conform to the demands of these factors which has rendered thus far the treatment of tetanus in human beings by antitoxin disappointing. The tetanus antitoxin can be produced by methods similar to those employed in making the diplitheria antitoxin, and of a power expressed in inimnnizing units greater than that of the diphtheria antitoxin. No less striking than in diphtheria are the laboratory experiments in the prevention and cure of artificial tetanus by administration of the tetanus antitoxin, but in this case the dose of antitoxin required to check the disease increases so enormously with increase in the size of the animal, on the one hand, and with the lapse of time after reception of the virus on the other hand, that we meet herein most serious obstacles to the successful application of this agent in the treatment of human tetanus.

It has been shown experimentally by Behring, Boer, lioux and others that as regards both of these points the conditions are far more favorable for the treatment of diphtheria by its antitoxin than in the case of tetanus. In an animal, at a certain time after reception of the tetanus poison, the theoretically efficacious dose of the tetanus antitoxin may be a million-fold greater than that required for sinqde immunization, a quantity too large to administer; whereas the effective dose of the diphtheria antitoxin at relatively the same period may be increased only eight or ten-fold. Doubtless the great advantage which we have in the treatment of human diphtheria by antitoxin as contrasted with tetanus is that we are able to recognize and treat the former disease before the production and absorption of a serious quantity of poison.

Only clinical experience can determine what practical difficulties there nuiy be in tlir way of the successful employment of antitoxic serum in tlie treatnuMit of human diphtheria, but there is no doubt in my mind that the results derived from experiments nn animals justify, nay, demand, the most careful aiul thorough trial of the new method of treatment upon human beings.

We have no certain kiiowledire as to the nature of the sub

stances called antitoxins nor as to their mode of action. This is not, however, an argument against their therapeutic employment, for we have no positive knowledge as to the mode of action of many of our therapeutic agents. There are two prominent theories as to the mode of action of the diphtheria antitoxin. The one may be called the chemical and the other the vital theory. The chemical theory is that the antitoxin directly neutralizes in a chemical sense the toxins. This seemed to be the natural intei'pretatiou of the fact that the injection into susceptible animals of a mixture in suitable proportion of the antitoxin and the toxin is harmless, but Buchner and Koux have shown that this earlier view is incorrect, and that by selecting animals of greater susceptibility or by increasing the natural susceptibility of an animal, the presence of active toxin in the mixture can still be demonstrated. The experimental evidence, therefore, is in favor of the other theory, viz. that the antitoxin acts through the agency of the living bod}', and probably in the sense that it renders the cells tolerant of the toxin.

The results of the treatment of human diphtheria with antitoxin S23eak also in favor of this vital theory.

If, as seems probable, the curative effects of the healing serum are brought about through the agency of the living cells of the body, we can understand why these effects will not follow the introduction of the serum with the certainty and precision of a chemical reaction. The cells must be in a condition to respond in the proper way to the introduction of the antitoxic serum. For one reason or another this responsive power may be in abeyance. It may be weakened by intense or prolonged action of the diphtheria poisons, or by other previous or coexistent disease, or by inherent weakness, or there may even be some individual idiosyncrasy which hinders the customary response of the cells to the antitoxin. Clinical experience shows that cases of diphtheria inherently refractory to timely treatnieut with antitoxic serum are most exceptional, if indeed they occur at all.

There is some evidence in favor of the view that while antitoxin may exert its protective action upon certain groups of cells, other cells, as for example the nerve cells, may, either by their nature or on account of such influences as I have mentioned, not be equally protected against the toxin. There is also the possibility that antitoxin may neutralize the effects of certain toxins and not of others present in diphthcriiu

Antitoxic serum exerts no bactericidal effect upon the dijilitheria bacillus, although, when administered in projvr quantity, sufficiently early in the disease, it anvsts the spread of the local inflammation which is caused by the bacillus. Virulent bacilli may persist in the throat days and even weeks after recovery following injection of antitoxin.

One of the most important characters of antitoxin is that it requires a definite quantity of tiiis substance to neutralize the effects of a definite quantity of toxin. In animals the curative dose of antitoxin stands in a definite quantitative relation to the size and susceptibility of the individual ami to the amount and intensity of the poison in the system. We have no precise nu^thodof det<>rmining how much and how viruknt the poison may be in a given Citse of human diphtheria nor lunv susceptible to the toxin the patient may be. The dosage

of iinlito.xii), therefore, in human diphtheria is empirical, the main factors determining it being the age of the patient, the assumed duration of the disease up to the time of administering tlie remedy, and tlie apparent severity of the disease. As tlie healing serum is expensive and is capable of inducing unpleasant symptoms, it is desirable not to give an excessive quantity. Under these circumstances it may readily happen that an iusufficieut dose is given and that the administration must be repeated. The general rules regarding the dosage of antitoxin are sufliciently well known not to require mention here, and I speak of this matter only to indicate that because a patient may have received a dose or even two or more doses of antitoxin, this furnishes no absolute guarantee that a quantity of antitoxin adequate to neutralize the effects of the toxin has been given. AVe now know that in the early period following introduction of the treatment entirely insufficient doses were given.

Both experiments on animals and clinical exjierience demonstrate that the earlier antitoxic serum is administered after the inception of the disease, the better are the chances of recovery. It is usually impossible to rescue the lives of guinea-pigs by means of antitoxin if the treatment is delayed longer than forty-eight hours after inoculation with an amount of diphtheria 2>oison fatal to these animals in four or Ave days, although the duration of life may be considerably prolonged. In human beings the conditions are different, but, as will appear from the statistics to be presented, tlie evidence is conclusive that the superiority of serum treatment over all other methods is most strikingly manifested in the results of the cases in which the antitoxin is given not later than the third day of the disease. Although in many cases the treatment is beneficial when the antitoxin is administered in larger-doses at a later period of the disease, the importance of beginning the treatment at the earliest possible date, without waiting to determine by cultures whether or not the LofHer bacillus is present, cannot be too strongly enijihasized.

It is of course often impossible to meet this demand for early treatment, as cases of diphtheria are frequently not seen or recognized by the physician, particularly in hospital jiractice, until after several days' duration of the disease and when grave symptoms have already developed. It is, moreover, in many cases difficult or impossible to determine how long the disease has existed when it is first seen by the jihysician.

The fact that the benefits of antitoxin treatment become more and more doubtful the further the disease has progressed and the graver the lesions and symptoms, renders more difficult the collection and analysis of absolutely convincing statistics in favor of the treatment. The accusation is sure to l)e brouglit that many of the cases which have responded promptly to early treatment, and these for reasons which have been stated will form a large contingent of the successful cases, were mild cases which would have recovered e(|uaily by other methods of treatment. This objection can be fully met only by large series of statistics collected from many ejiidemics, at different times and in various localities.

The bacteriological study of human diphtheria has disclosed several points important to bear in mind in determining the value of antitoxic treatment. Tlie Jjotller bacillus has been

found in healthy throats, although only very exceptionally unless the jierson has been exposed to dijihtheria. This same bacillus may cause all grades of inflammation of the throat, from a mild erythematous angina to the gravest pseudo-membranous inflammations. There has resulted a conflict, not yet settled, between the clinical and the bacteriological diagnosis of diphtheria. As regards these diversities of effect, however, the conditions pertaining to the diphtheria bacillus are in no way different from those relating to many other pathogenic bacteria, as for example the pneumococcus, the streptococcus, the cholera bacillus, and even the tubercle bacillus, all of which may be found on healthy mucous membranes and njay exert their pathogenic activity with all degrees of intensity. Inconvenient as these facts may be, they must be recognized, and they require a readjustment of previously adopted boundary lines of diagnosis. It would, of course, be absurd to say that a person who harbors in his healthy throat Lijffler bacilli has diphtheria, just as it would be equally ridiculous to consider a person infected w^ith the pneumococcus or the streptococcus when these latter bacteria are present under similar conditions, but it is no less absurd to limit the application of the term "diphtheria" only to those higher degrees of pathogenic action of the Loffler bacillus characterized by spreading jjseudo-membranous iuHammatious and general toxa3mia.

But while the boundaries of the domain of diphtheria have (bus been widened by the inclusion of cases not presenting the ordinary clinical characteristics of diphtheria, in another direction they have been restricted by the exclusion of some cases which on clinical grounds would be diagnosed as diphtheria but which by bacteriological examination are proven to be caused by other bacteria than the Loffler bacillus.

The statement is sometimes made that twenty-five to thirty per cent., or even a larger percentage of the clinical tliphtherias are not genuine diphtheria in the bacteriological sense, but this statement is (juite misleading. These figures are based upon the bacteriological examination of large numbers of cases in which there was simply more or less suspicion of diphtheria. They do not relate generally to a large number of cases presenting unmistakable anatomical and clinical characteristics of diphtheria. They are derived from the routine examinations for Boards of Health and children's hospitals of susjiected cases of diphtheria. When one considers that in some cases of diphtheria repeated, painstaking examination, microscopical and cultural, by a skilled bacteriologist, is recpiired for the detection of the diphtheria bacillus, it is evident that less reliance is to be placed upon these statistics en grus than upon many snniller series reported by bacteriological experts. Of the statistics of the latter character there are many which show that in "the scries of cases examined (including in each series from a dozen to over three hundred cases) from ninety to one hundred per cent, of the clinical dii)ht herias are due to the Loffler bacillus. Our experience in Baltimore has been that not over five per cent, of the cases which the clinician would confidently diagnose as diphtlieria are false dijjhtheria or dii)htheroid. These latter figures relate, of course, to i)riniary dijihtheria and not to the pseudo-membranous anginas complicating scarlet fever and

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other infectious diseases, a large proiwrtion of which are not referable to the Loffler bacillus.

I shall consider subsequently in this article the influence which the control of the clinical diagnosis of diphtheria by bacteriological examination is likely to have ujion fatality statistics of this disease.

There is an important difference between experimental diphtheria and many cases of human diphtheria, a difference of great significance in determining the scope of efficiency of treatment by antitoxic serum. Our experimental diphtheria is a pui"e, uncomplicated infection in which only the diphtheria bacillus and its toxins are concerned. On the other hand, in many cases of human diphtheria there are complications and mixed infections due to other micro-organisms against which, when duly developed, the diphtheria antitoxin is powerless. The most common and dangerous complicating micro-organism is the streptococcus pyogenes. Bacteriological examinations of fatal cases of diphtheria demonstrate in a lai'ge proportion of cases the invasion and pathogenic effects of this most common of all secondary invaders. The confidence with which some observers, particularly of the French school, classify their cases of diphtheria into pure and mixed infections, on the sole basis of the bacteriological examination of the exudate in the throat, does not seem to me justifiable. The complete microscopical and cultural examination of this exudate will in practically all cases reveal the presence of other bacteria, and usually of streptococci, besides the Loifler bacillus. But as these other bacteria are common or regular inhabitants of the healthy throat, their mere presence in this situation is not conclusive evidence that they are engaged in pathogenic action. The abundance of these other bacteria may afford some indication as to their role, but of greater importance is their demonstration in situations where they are not normally present.

Eeiche,* in 42 autopsies on cases of diphtheria in which the Loffler bacillus had been demonstrated during life, made cultures from the kidney and spleen. In 64.3 per cent, of these cases streptococci and staphylococci were found in the kidney or spleen, and in 45.2 per cent, streptococci were found alone. These cocci must have reached these organs through the circuhiting Idood. Tie found streptococci in the kidney in one case wiiich died on the second day of the disease, and positive results were obtained also on the third and fourth day. These results are evidently of much significance in indicating the frequency and the earliness of invasion of complicating micro-organisms in diphtheria and the resulting obstacles to uniformly favorable results of antitoxin treatment.

But the chief evidence in favor of mixed infection must bo sought during life, in the character of the lesions and symptoms, although these may be misleading. There is also evidence that tlie failure of a case of diphtheria to respond in the usual way to the timely injeelion of a sullicient dose of antitoxic serum is an indication of complications and mixed infection.

The opinion is entertained by Uoux, Martin and other

• Reiche: Centiiillilatt f. iiineio Mc.licin, lS!t5, No.

P'rench writers that broncho-pneumonia, one of the most common and serious complications of diphtheria, is due to a large extent to local unhygienic conditions which can be guarded against. Thus they attribute the frequent occurrence of broncho-pneumonia in some groups of their cases to the infection of the hospital wards with the bacteria causing pneumonia, and claim that by improved sanitary conditions this complication may be to a large extent eliminated. Further investigations are needed to determine to what extent this view as to the causation of broncho-pneumonia is justified, but it can scarcely be doubted that this complication is often the result of invasion of the lower air passages and the lungs by bacteria which are regularly present in the throat, and whose activity is likely to be manifested in this way in many cases of diphtheria, independently of the local sanitary conditions.

Without doubt the remedial role of diphtheria antitoxin is materially restricted by its inability to combat developed streptococcus sepsis, broucho-pneumonia and other complications referable to secondary infection, or to stop impending suffocation by immediate removal of mechanical obstacles in the form of false membranes in the air passages, but the antitoxic serum is the most powerful agent which we possess to prevent the development of these complications and secondary infections. The timely administration of the healing serum, by antagonizing the effects of the Loffler bacillus, antagonizes in large part the causes of the increased susceptibility to secondary infections and thus greatly lessens the frequency of their occurrence.

In considering the obstacles in the way of cure of diphtheria by antitoxin, the self-evident fact should not be forgotten that this remedy cannot restore cell life which has already been seriously damaged by the action of the diphtheria bacillus or its poison. The researches of Oertel upon human diphtheria, and those of Flexner and myself upon experimental dijjhtheria, demonstrate that the toxins of the diphtheria bacillus are most powerful poisoners of cells, the internal lesions of pure diphtheria being especially characterized by widely distributed areas of cell death. We have no way of gauging accurately at any given period of the disejise the extent of the damage already inflicted upon the cells of the body. If the nerve cells or their axis cylinders have already been so damaged that paralysis must follow, or the cardiac nerve' cells or muscular fibres have been similarly injured, or the renal epithelium so affected that degeneration and nei>hritis ensue, the administration of antitoxin cannot restore tliese cells which are already on the way to degeneration and death.

This irretrievable damage to cell life may l»e present for a considerable time before we are able to recognize its effects. P. Meyer detected pathological changes in the peripheral nerves as early as the third day after the onset of diphtheria and before paralysis was manifest, Tlie occurrence of paralyses, including cardiac paralysis, after antitoxin has been administered even thus early in the disease, cannot therefore necessarily be attributed to failure of this agent to neutralize toxin developed after its injection.

Having now considered tlie experimental b:isis and the

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theories of action of antitoxic treatment, the imiiortauce of early adniiuistratiou and suflicient dosage, and certain etiological and patiiological cliaracters of human diphtheria to be borne in mind in estimating the scope of the treatment, let us turn to the examination of the evidence wliich has hitherto been published concerning tiie efficacy of the antitoxic treatment of human diphtheria. This evidence is of Iwo kinds, first, the general impressions of clinicians who liave had opportunity to observe the effects of antitoxin administered in a number of cases of diphtheria, 'and second, the fatality statistics of cases treated with antitoxin.

Unquestionably great value attaches to the impressions and conclusions of careful clinical observers as to the merits of therapeutic agents. Baginsky has said that naked figures are so little the expression of the endless variations of clinical observation, of all those fortunate and unfortunate accidental circumstances which pertain to the constitution and nutrition of the patient, and of the complications and difficulties whicli may bring danger in a mild attack, or lead to a successful issue an apparently severe attack, that to the clinical observer such figures appear of little value in comparison with the treasure-house of his accumulated exjierience. And it is to his experience of many years in the same hospital and on similar clinical material that Baginsky rejjcatedly recurs in his monograph "Die Serum-therapie der Diphtheric," in support of his favorable conclusions as to the healing power of antitoxin, and this in spite of the fact that liis statistical results, leading to the same conclusions, are based upon a larger number of cases than those of any other single observer yet published, and are among the most convincing of the statistical reports. In explaining why at the end of ten months' trial of antitoxin he has determined to commit himself to a definite judgment in its favor, he says : "The reasons for this are to be found in the continual re])etition of improvement and recovery of severe cases which previous experience indicates would have terminated fatally; and furthermore, in the outcome of an involuntary experiment with interruption of the use of the serum for a period on account of failure in its supply. .During this period the mortality of our patients immediately rose again to its former height." "The improvement in the general condition of the patients imparts to our diphtheria wards an entirely different character from the former one. That this is not duo to any change in the character of the clinical material, to milder forms of the disease, was unfortunately demonstrated by the observations in the months of August and September, when, as by a single blow, we were transjHjrted back to the old times, to the same melancholy picture of children deeply prostrated and often in vain struggle with death." In August and September the supply of antitoxin failed.

'I'lii' j)ul)lished testimony of those who have had the largest oj)portunity to study the therapeutic effects of antitoxin is overwhelniingly in its favor. In no less favorable terms than those of Baginsky are expressed the opinions of such ol)servers of high rejiutation and extended experience as lleubner, von Widerhofer, von lianke, (langhofiier, Escherich, Bokai and the physicians of the Hopital des Enfants Malades and Hupitjil Trousseau in I'aris. These observers have reported

already in detail over 2300 cases of diphtheria treated with antitoxin.

Many of those w'ho have reported smaller series of cases, and a few who have reported as many as a hundred cases, have expressed themselves with much caution or have not ventured any final judgment, although in most of these reports the results appeared to be favorable to the new treatment. An example of this conservative position is that of Vierordt, who says that a final decision as to the value of antitoxic serum is not to be expected in the immediate future, as such decision retjuires a long series of observations in different epidemics and on varied clinical material.

Antitoxic serum is a new and strange remedy, but the effects whicli follow its injection in individual cases are not new and strange. Nothing happens which the physician may not have occasionally seen to happen in cases treated in the ordinary way. In severe as well as in mild cases of diphtheria he may have seen an apparently jirogressive local process quickly arrested and the general symptoms promptly abated. But why should anything new and strange happen after the administration of antitoxin? Cure by antitoxin is cure by nature's own remedial agent. That which is new and strange is the frequency with which in case after case the timely injection of antitoxin promptly arrests the local inilammation and checks the constitutional disturbance.

liecovery following treatment by antitoxin is such a natural kind of recovery that in any given case the jihysician may readily have the feeling that the same thing might have happened without the use of the remedy. We can, therefore, understand why it should be those with the largest experience in the treatment of diphtheria by antitoxin who are most decided in expressing their opinion as to its beneficial effects. The very fact that the mode of cure is such a natural one and unattended by peculiar phenomena is an obstacle to drawing positive conclusious from a small number of observations, even if these appear to be most favorable.

That there should be wide diversity in the percentage of cures in reports of different observers is of course to be expected when we consider the varied character of the cases treated and the importance of early administration of antitoxin. It may happen that a series of cases is made up so largely of advanced and complicated diphtherias at the time when the antitoxic treatment is begun, that the beneficial effects of the treatment are not apparent. It is on the whole remarkable that there should have been so few reports in which the fatality has not been materially diminished during the period of administration of antitoxin.

Tliere are only very few writers who on the basis of personal experience (and this in no instance a large one) have expressed an opinion unfavorable to antitoxin. Kohts may be mentioned as one who on the basis of 47 cases treated with serum, with 29.1 per cent, deaths among the tracheotomized and 7.G per cent, among the noii-tracheotoniized, finds such apparently favorable results no better than by other methods of treatment.

So far then as the testimony of physicians based upon their clinical exi)urience is concerned, this, as I have already said, is overwhelmingly in favor of the antitoxic treatment, wherever

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their experience in its employment has been a large one. Those with less experience are often even more enthusiastic, but many of these, iu view of their limited experience, are wisely conservative and a few are hostile to the new treatment.

But general clinical impressions, convincing as they may be to the individual receiving them, may not be equally convincing to others. They do not furnish any strict scientific proof of the value of a therajjeutic agent. Tf antitoxin really exerts any specific curative action in diphtheria this must be apparent iu the figures of fatality statistics of this disease, and it is only by such statistics, much as they may be decried by some, and difficult as it may be to guard them from errors of interpretation, that a strictly scientific demonstration of the eflBcacy of antitoxin in the treatment of diphtheria can be brought.

The possible fallacies of interpretation belonging to fatality statistics in general apply iu no small measure to those of diphtheria. The case mortality from diphtheria varies within wide limits according to the more or less severe character of . the prevailing epidemic, according to the season of the year, according to the age, according to the method of treatment, in cities and in country districts, etc. Statistics of case mortality from hospital practice will differ widely from those from private practice, and each of these will differ from the general case mortality returns from cities. Nor does each of these three classes of statistics represent a uniform material. The material of one hospital may consist very largely of cases of diphtheria admitted in an advanced stage of the disease, or of laryngeal cases sent for operation, while that of another hospital may contain a much larger proportion of cases admitted in early stages of the disease. In general the fatality of diphtheria in hospital practice is higher than that of private practice, as would be expected from the later stage of the disease in which the patients generally enter the hospital; but to this rule there are many exceptions. In some hospitals the patients are all children, in others there may be a considerable proportion of adults with diphtheria. In private practice among the poor, patients may be first seen by the physician frequently in as advanced stages of the disease as in hospitals, and the conditions for successful treatment, and particularly for intubation or tracheotomy, are less favorable for this class of private patients than for hospital patients.

Still other reasons might be given for the lack of uniformity of diphtheria statistics from different sources, but enough has been said to show that as regards the question whicii interests us here, each report of a series of cases treated with antitoxin requires its own special consideration and analysis and is not comparable with reports from other sources relating to a different class of cases.

The larger the number of cases embraced iu the statistical tables, the greater becomes the mutual compensation of such differences as those mentioned, and therefore the more trustworthy are the conclusions derived from tlie statistics; but in collecting the statistics of the general fatality of diphtheria treated with antitoxin it has seemed to me important, for tlie reasons which have been mentioned, that the tables should contain for eacli report, as far as possible, statements of the total number of cases treated with antitoxin, of the num

ber and percentage of deaths, of the previous or simultaneous fatality, and of the class of cases, whether in hospital or in private practice. I have also analyzed the oases so far as practicable according to the ages of the patients and according to the day of the disease on which antitoxin treatment was begun. It has seemed to me of especial interest to consider the fatality in operated and not operated cases. There are of course many other points of view which it would have been interesting to consider in the statistical study of the cases reported, but it has seemed to me that the analysis already indicated should suffice to determine the main question at issue, namely, the specific curative power of antitoxin, as well as certain other questions.

It is scarcely ten months since antitoxin has been used by more than a very few favored physicians, and it is a much shorter time since its use has become at all general. In this comparatively short time there have, however, been published more or less definite reports of the results of the treatment in at least 15,000 cases. I have collected 82 reports from SO different sources containing 7166 cases. These are presented in Table I. This collection of cases is by no means complete, as I have consulted only the more readily accessible journals, but it is believed to include all of the more important reports. I have not included any reports of single cases, as these are often to illustrate some special point, nor any reports of series of cases less than ten. Indeed only four reports with less than 12 cases in the group have been included in the tables. Xor have I made use of such merely general published statements without detail as that there have been treated in France up to the end of December 2700 cases with a mortality of 16 per cent., in Austria outside of Vienna 950 cases with a mortality of 15.7 per cent., in Croatia and Slavonia 428 case-s with a mortality of 10.8 per cent., in Berlin hospitals 1500 cases with a reduction in fatality of one-half, etc.

Eulenberg has recently (July 15, 1 895) made a provisional report concerning the collective investigation inaugurated by the Deutsche mediciuische AVocheuschrift by sending out cards to be filled out by physicians reganling their results in the treatment of diphtheria with and without serum. Up to the date of the report the cards returned embraced 10,240 cases of diphtheria, of which 5790 were treated with serum and 4450 without serum. The tot;il fat^ility of the former group was 9.5 per cent., that of the latter group 14.7 percent. No further details of this investigatiou have as yet been published, and these cases are not included in my tables.

I have entirely avoided the duplication of cases, so far as I can determine,* There has been no selection whatever of cases. All of the reports of the characters described which came to my notice are included, although many of the early

•This duplication of cases appears in several of the published statistics, especially of the Berlin statistics. Thus the cases reported by Schubert, Voswinckel. Canon anil Weibpen appear in the report of Ehrlicli, Kossol aiul Wassermann. and partly in the reports of Korte, Ponnenburg and H.shn, sometimes twice repeated. Most of these cases are included without duplication, in my table, althoofih they were treated with insutTicient doses to a large extent. The cases attributed to Virchow. Aronson and Katz in some statistics are included in those of Baginsky.

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Berlin cases (contained in statistics of Korte, Sonnenburg and Ilahn in my tiibles) and some of the others were treated with entirely insufficient doses of antitoxin, and some observers have purposely selected, especially at the time when little serum was to be had, only severe cases for treatment. Kohts' 47 cases could not be inserted, as in the report which I have seen he does not give the number of deaths.

The reports are of unequal value. Some present full and precise details of each case or of the group of cases, with statements as to previous or simultaneous fatality in the same class of cases in the same locality, whereas others are meagre and unsatisfactory.

Some reports are based upon the bacteriological control of the clinical diagnosis, others upon the clinical diagnosis uncontrolled by bacteriological examination. In general the statistics from the larger hospitals relate to cases in which the Liiffler bacillus was demonstrated, whereas many of the reports from private practice are without bacteriological examination. A few, notably Leichtenstern and Wendelstadt, purposely base their observations upon cases in which the diagnosis is purely clinical without bacteriological control.

I shall take this o^iportunity to consider the influence which the recjuirement of the bacteriologist, that the clinical diagnosis of diphtheria should be controlled by a bacteriological examination in testing the efficacy of antitoxin treatment, is calculated to have upon the characters of statistics intended to show the value of the treatment. It is a favorite criticism of these statistics that the bacteriological, as distinguished from the purely clinical, diagnosis of diphtheria will operate in favor of a low fatality in antitoxin statistics, and that therefore it is unfair to compare these statistics, with those which are based upon the uncontrolled clinical diagnosis of diphtheria. Some of the critics would have us believe that the antitoxin statistics on the one hand contain a large proportion of cases of mild inflammation of the throat with Loffler bacilli, but which no clinician would recognize as diphtheria, and on the other hand exclude a large proportion of fatal pseudo-membranous inflammations of the throat and air passages which clinically would be regarded as diphtheria.

In most of the statistical reports from hospitals on antitoxin treatment the statement is expressly made, and it is apparent from the description of the cases, that they do not represent anything else than the usual run of cases of diphtheria as they have regularly for years past presented themselves at the same hospitals. The mild diphtheric sore throats without clinical evidences of ordinary diphtheria are not likely in any large number to be recognized at all as diphtheria, and still less likely to find their way into general hospitals, from which most of the statistics are derived. Where, as in the statistics of Baginsky and others, sufficient detail concerning each case is reported to enable the reader to form an intelligent estimate of the character and severity of the case, it is evident that affections without the customary anafomical and clinical characters of diphtheria do not enter into the statistics.

It is erroneous to say that the antitoxin statistics are not based upon the clinical diagnosis of diphtheria. The diagnosis is clinical, but with subsequent bacteriological control.

The cases are admitted to the hospital with the clinical diagnosis of diphtheria, and the healing serum is or should be at once administered without waiting for the result of the cultures from the throat. Soltmaun has been justly criticised for delaying the injection of antitoxin until after the bacteriological examination was completed.

The assumption that non-membranous anginas and tonsillitis containing Loffler bacilli figure to any appreciable extent in these statistics is without warrant of facts.

There are treated of course together with severe cases many mild cases with small patches of membrane on the tonsils or in the throat, but such cases are clinically diphtheria, or certainly ought to be suspected of diphtheria by the clinician. It is important that such cases, w'hen caused by the Loffler bacillus, especially in young children, should be treated by antitoxin, for not a few such cases when untreated develop into severe cases, sometimes suddenly into laryngeal diphtheria. Kurth, for example, relates a case in which a twin brother of a child ill with diphtheria was found to present small membranous patches on the tonsils which during two weeks of observation would at times disappear and which did not apparently make the child ill. Loffler bacilli were demonstrated, but the parents would not consent to the injection of serum. At the end of fourteen days, laryngeal diphtheria suddenly developed. The injection of antitoxin was followed by recovery in four days. This is simply a type of not a few cases which are regarded as suddenly developed laryngeal diphtheria.

If, as is doubtless true, in some hospitals a larger number of cases are now received for serum treatment in earlier stages of diphtheria than formerly, this is not because the bacteriological diagnosis has supplanted the clinical, but because the importance of early inception of serum treatment has been justly emphasized. The recognition of mild and very mild cases of diphtheria is not a discovery of the bacteriologist, but has long been known to physicians, nor is it a peculiarity of the fatality statistics of cases treated by antitoxin that such mild cases are included in the statistics. They appear equally in previous fatality statistics of diphtheria. Mosler, for example, reports 313 cases of diphtheria with a fatality of 14.5 per cent, treated during a year in the Greifswald clinic before the introduction of serum, and there are numerous other statistics showing that mild cases often preponderate in previous fatality statistics of diphtheria. Nor is the comparison in all of the reports with statistics in which the diagnosis is without bacteriological control. In several reports the comparison is with the results of cases in which the Loffler bacillus was demonstrated, but which were not treated with serum.

As regards the exclusion from antitoxin statistics of cases presenting the clinical characters of diphtheria without the Loffler bacillus, it is evident, from what has previously been said, that, with thorough bacteriological tests, this can affect only a very small number of cases of unmistakable primary clinical diphtheria. Of the cases concerning which the clinician is in doubt, a considerable proportion are not diphtheria by bacteriological examination, w hich alone can decide the question. Although some of the non-diphtheric, pseudomembranous cases are very grave affections, their general

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fatality is much lower than that of genuine diphtheria. The exclusion from the fatality statistics of diplitheria of tlie pseudo-membranous cases without Loffler bacilli is, therefore, the exclusion of a generally milder class of cases, as has been repeatedly demonstrated, and the result is to assign a higher and not a lower fatality to the remaining cases. A few examples taken from reports in Table I will suffice to demonstrate this. Fi'om the statistics of Roux, Martin and Chaillou 138 pseudo-membranous cases treated with serum were thrown out because they were proven subsequently to be devoid of Loffler bacilli. The fatality of these cases was only 8.5 per cent., whereas in the 300 remaining cases which contained Loffler bacilli and were injected with serum the fatality was 36 per cent. In Sevestre and Meslay's statistics 39 cases without Loffler bacilli, but treated with serum, gave a fatality of 3.4 per cent, as opposed to a fatality of 10 per cent, in the treated cases containing Loffler bacilli. A similar difference appears in other reports. The serum has no curative influence on pseudo-membranous inflammations not caused by the Loffler bacillus.

In the best reported statistics information is afforded as to these various points, and the reader can learn the ratio of apparently mild cases and the number and results of the diphtheroid cases.

Although only those statistics which are based upon the thorough bacteriological examination of the cases treated can lay claim to entire accuracy, the benefits of antitoxic treatment are clearly apparent in reports based upon the uncontrolled clinical diagnosis of diphtheria. Of course in ordinary general practice it is not to be expected that the diagnosis will rest upon a bacteriological examination, but it should be understood that in the absence of such examination there must be occasional instances of apparent failure of antitoxin which would be found explicable had a bacteriological examination been made.

In many reports the percentage of deaths in the cases treated with antitoxin is corrected by excluding cases evidently hopeless on admission or dying within twenty-four hours after commencement of the treatment. These corrected percentages are usually very materially lower than the rates based on all of the deaths. For example, if the cases dying within twentyfour hours after injection of antitoxin be excluded, the percentage of deaths in Roux, Martin and Chaillou's cases becomes 31.5 instead of 36 ; in Baginsky's 13.5 instead of 15. (i ; in von Widerhofer's 14.3 instead of 33.7; in Vierordt's 14.6 instead of 35 ; in Lebreton and Magdelaine's 10.8 instead of 13; in Moizard and Perregaux's 11.3 instead of 14.7; in Sevestre and Meslay's 6.6 instead of 10 ; in Bokai's 18.3 instead of 35.5, etc. I have, however, not used these reduced percentages, although in many instances it might with propriety have been done. The statistics in my tables, therefore, do not give in many instances as favorable percentages for antitoxin as may justly be claimed, but on the other hand they are more properly comparable with the previous or simultaneous fatality rates from diphtheria, these being based upon the total number of deaths in all of the cases treated. I have aimed to avoid the accusation of selection of cases or of unfair manipulation of the figures.

In the majority of the reports the cases treated are all or nearly all of the cases of diphtheria which were admitted to the hospital or came under observation during the period of treatment, but in some it is expressly stated that in consequence of the cost and the scarcity of the healing serum mild cases and evidently hopeless cases did not receive the serum. There is no evidence of selection of mild cases in order to obtain results favorable to antitoxin.

The percentages in the column headed " Previous Fatality" are those given by the writers for diphtheria not treated with antitoxin. In some instances they relate to the average fatality for a series of preceding years, in some to the minimum and the maximum fatality for several years, in some to the simultaneous fatality or the fatality during a period of interruption in the supply of serum. In all instances they are the case mortality rates of diphtheria in the hospital or locality from which the cases treated with antitoxin are derived. The arrangement of the reports is only in part chronological. Following the references to the articles, it is stated, so far as could be ascertained, whether the cases were in hospital or in private practice.

It appears from Table 1* that of 7166 patients with diphtheria treated with antitoxin 1339 or 17.3 per cent. died. Among these cases are included many treated during the early period after the first introduction of the treatment, with entirely insufficient doses. There arc also included a large number of cases dying from complicating diseases not referable to diphtheria, or dying within twenty-four hours after beginning the treatment, cases which cannot properly be regarded as indicating failure of the serum treatment. The great bulk of the statistics come from children's hospitals. Under these circumstances, indeed from any point of view, the fatality derived from Table I of cases treated with antitoxin is very low.

There is, however, no standard of comparison for the fatality in this entire group of cases. It cannot be compared with fatality statistics from hospitals nor with those from private practice. The table contains at least five or six times as many cases from hospital practice as from private practice. The ratio of deaths to all cases, therefore, is greater than could be expected from the returns of all cases similarly treated in cities, but even in comparison with municipjil fatality statistics of diphtheria during the prevalence of mild tvpes of the disease, the percentage of de;»ths is very low. This strikingly low fatality in itself speaks strongly in favor of the efficacy of the serum treatment.

In 46 reports contained in the txible the previous or simul

• The report of Fiirth concerning the results of serum treatment

in the medical an.l surgical clinics at Freiburg was publisheii too late to be included in my t.iMes. 100 cases were treated wilh a fatality of 12 per cent. During the five preceding years the fatality from ordinary treatment fluctuatei^ between SI and 49 i>er cent., averaging 39 per cent. The same average existevl during the seven months of the year corresponding to the period during which antitoxin was used. There was laryngeal involvement in 43 cases and tracheotomy was performed in SI with 11 deaths (35.4 yer cent.). In previous years tr.icheotomy wsjs required in 46.2 per cent, of the cases, with a mortality of 70.4 per cent. (Abstract in the Medical News, .\ugust 17, lSd5.)

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TABLE I.— FATALITY OF CASES OF DIPHTHERIA TREATED WITH ANTITOXIN. Number of Cases Treated with Antitoxin, the Ndmber and Percentage of Deaths, and the Previous Fatality, in 82 Reports.

Pbevious Fatality.

References.

1. Rouz, Hartln and Cbaillou.

2. Kossel.

3. KOrte.

i. Sonnenburg.

6. Hahn.

6. Daginsky.

7. Heubner.

8. V. Widerhofer.

9. V. Kiinke. lU. Stintzing.

11. Itauclifuss.

12. V. .Merinir.

13. V. Noordcn.

14. StIirOder. l.S. Vierordt.

16. Kumpf.

17. Lebreton and Magdelaine. 1*1. Le Geudre.

19. Moizard and Perregaux. 20 Sevestrc and Meslay. 21. Ganghofner, 1'3. Soltman.

23. Bokai.

24. Escherich. 25- Guandiiiger.

26. Monti.

27. Heim.

28. Unteiliolzner.

29. BSurnler.

30. IJOiger.

31. Hilbert.

32. Hager.

33. Moeller.

34. Kuntzen.

35. Schmidt. SB. Seiz.

37. Charon.

38. Washbourn, Goodall and Card.

39. Scitz.

40. Pavlik.

41. Handler.

42. Herri nghatn.

43. Caiger.

44. Hali:

45. Tirard and Willcocks.

46. Uutrer.

47. Epidemic in Trieste. Cases in

private practice.

48. Cases in buspital.

49. Bliimenfeld.

50. Wjtthaucr.

51. Dreyfus.

52. Simon. 63. Malvoz. 54. Gougenlieim.

5.5. Itapmund.

58. Schttller. 67. GrOnfeld.

58. Schucwen.

59. Heidcnhain.

60. Kiscl.

61. Welland.

62. V. Muralt.

83. Blattner.

84. Gerloczy.

65. D'Espine.

66. Mya.

67. V. Engel.

68. Fischer.

69. Biggs— Cases in the city treated

by sanitary inspectors.

70. Casi'Sin Wilfard-Parker Hosp'l.

71. Lennox llrownc.

72. Codd and Whitehouse.

73. WInktIeld.

74. Horowitz.

75. SIgel.

76. Howard.

77. Van Nes.

78. Loichtcnstcrnand WendelBtadt 7». Kiirth. <*>■ TImmor.

81. Cases treated in Cartagena.

82. Mason.

78 (26 per cent.)

13(11.1 percent.) 40 (33.1 per cent.) 18 (16.8 per cent.)

49 (24 per cent.) 83 (15.6 per cent.)

27 (13 per cent.)

71 (23.7 per cent.) Ill (19.7 per cent.)

12 (20.1 percent.) 34 134 per cent.)

4 i5 per cent.) 19 (23 per cent.) 8 (12.7 per cent.) IB (23 per cent.) 2 (8 per cent.) 31 (12 per cent.) 3 (17.6 per cent.)

34 (14.7 per cent.) 15 (10 percent.)

14 (13.7 percent.)

13 14.6 per cent.) 42 (24 per cent. )

5 (9.5 per cent.)

11 (40.7 per cent.)

1 (4 percent.) 8 (22 per cent.)

8 (25.8 per cent.)

2 (7.7 per cent.)

2 (8.66 per cent.)

1 (4 per cent.)

27 (35.5 per cent.)

3 (12 per cent.)

3 i2l.4 percent.)

1 (3.6 per cent.)

4 (30.8 per cent )

14(19.4 percent.)

2 (5.7 per cent.) 1 (7.7 per cent )

5 (1.5.8 per cent)

3 (16.7 per cent )

8 (26.8 per cent.) 3 127 3 per cent.)

1 { 10 per cent.) 37 113.5 per cent.)

5(6.5 percent.) 40 (22.2 per cent.)

2 (4 per cent.) 5 (14 per cent.)

15 (19.3 per cent.)

2 (12.5 per cent.) 1 (7 per cant.)

12 (9.5 per cent.)

7 (7 per cent.)

1 (3.1 per cent.)

1 (8.3 per cent.)

3 12.6 per cent.)

9 (7.9 per cent.)

2 (3.4 per cent.)

9 (23.8 per cent.) 15 (27 3 per cent.)

8 (10 per cent.)

2 (11.8 percent.)

10 (25.5 per cent.)

35 (15.5 per cent.)

40 (15.69 per cent.) 45 (27.4 per cent.)

2 (4.4 per cent.)

4 (36.4 per cent.) 4 (18.2 percent.) I (4.8 percent.) 12(12 percent.)

3 (7.5 per cent.)

12 (23 ner cent.) 25 '20.3 per cent.) 10 (10.3 percent.) 8(19.4 percent.) 21 (13.5 percent.) 81 (26.4 per cent.)

50 per cent.

53-61 percent.

45.1 per cent. 27.8 per cent

During period of interruption of serum treatment.

41 per cent.

4J per cent.

48-52 per cent.

50 per cent. 42.2-56 per cent.

25 per cent.

55 per cent.

30 per cent.

45 per cent. 30-37 per cent. 41-87 per cent. 13-28 percent.

50 per cent. 50-60 per cent.

.50-60 per cent.

50-80 per cent.

43.6-78.2 per cent.

27.2 per cent. 53.5-67.5 per cent.

36-45.5 per cent.

.52.5 per cent. 66.7 per cent.

30.6 per cent. i6-41.8 per cent.

30 per cent.

31.25 percent.

38 percent.

43.8-62.6 per cent. 50per cent.

' 21.1 per cent. 20-30 percent.

25-45 per cent. 33 percent. 34 per cent.

86 per cent. 10.7 per cent. 40-50 percent.

36-48 per cent. 30.1) per cent.

46-63 per cent.

Annales de I'lnstitut Pasteur, Sept., 1894. (Cases In QSpital des Enfaotfi Malades ) .

Deutsche Med. Wochenschrift, 1894, p. 948. (Hospital.)

Berliner Klin. Wochensclinft, )6!I4, p. U«a. (Hospital)

Deutsche Med. Wochenschrift, 1894, p. 930. (Hospital.)

Ibid. 1895, Vereins-Beilage, p. 2. (Hospital ) DieSerumtherapie derDjphtherf (Hospital.)

Von Dr. Adolf Uaginsky, Berlin, 1895. April 2, 1895.

Reported at 13ter Congress fiir Innere Medicin, Miinchei Munchener -Med. Wochenschrift, April 9, 1895. (Hospital.) Ibid. (Hospital.) Ibid. (Hospital.) Ibid. (H(j.spital.) Ibid. (Hospital.) Ibid.

Ibid. (Hospital.) Ibid. (Hosi)ital.)

Deutsche Med. Wochenschrift, 1895, p. 169. (Hospital.) Miinchener Med. Wochenschrift, Nov. 20, 1894. (Hospital.) I.c liollctin .MiMlical, 1895, No. 10. (HOpital des Enfants-Malades.) linK. It .M.'iiioires de la Soc. MM. des HOpitaux de Paris, Dec. 20, 1894

Hr.pital Tiousseau.) Jour, ik' .M(idecine et de Chirurgie, Dec. 15, 1894. (HSpital Trousseau.) Le Bulk>tin Medical, 1895, No. 18. (Hopital Trousseau.) Prager Med. Wochenschrift, 1895, Nos. 1. 3 and 3. (Hospital.) Deutsche Med. Wochenschrift, 1895. No. 4. (Hospital.) Il>i.1. 180S. No. 15, and Wiener Med. Presse. 1895, No. 13. (Hospital.) Alwtnut ill Miinchener Med. Wochenschrift, 1895, No. 7. (Hospital.) Wiciur Kdii. Wochenschrift, 1895, No. 1. Wicn. r .Mi'.i. Wochenschrift, 1895, Nos. 4 and 5. (Hospital.) Ibid. I«i5, Nil. 4. (Hospital.) Ibid. (Hospital.)

Munchener Med. Wochenschrift. 1894, p. 1083. (Hospital.) Deutsche Med. Wochenschrift, 1894, No. 48 (Hospital.) Iliiil.lWit. Voreins-Beilage, p. 142. (Hospital.)

nnere Medicin, 1894, No. 48. (Private practice.)

(11ms, .ita(.)

M. .). Wochenschrift, 1894 No. 49. (Hospital.) I). Ills. )m M. 1. Wochenschiift, 1894. No. 53. (Private practice.) TlH i;,|M 111. \|,,ii:i|shcfte, Dec, 1894. (Private practice.) ,\nii il' ~ '(. (1 Sue. Kovale des Sciences M^dicaleset Naturellesde Ilruxelles,

T 111, |i. ;;:;;' 1S94). (Hospital.) Hilt. Mi-.l. .l.,ur., Dec. 33, 1894. (Hospital.)

Alist. Ill Jiuiuhcner Med. Wochenschrilt. 1895, No. 12. (Hospital.) Wirner Med. Presse, 1895. Nos. 1 and 5. (Private practice.) Ibid. No. fi. (Private practice.) Brit. Med. .Toiirn., Dec. 23, 181)4. (Hospital.) Ibid. Dec. 39. 1894. (Hospital.) Ibid. Jan. 19, 1895. (Hospital) The Lancet, Jan. 19, 1895. (Hospital.) Cases treated in four London hospitals, British Med. Jour., Feb. 3, 1895.

Das Oesterreichische Sanitiitswesen, Jan. 3, 1895.

Wiener Klin. Wochenschrift, 1895, No. 3. (Private practice.)

Therapeut. Monatshefte. Feb., 1895.

Lyon MMical. Feb. 3, 1895. (Hospital.)

La Mfidecinc Modrrne, Feb 6, 1895. (Private practice.)

Le Scalpel, Fel). 17, 189.5.

Annales des Maladies de I'Oreille, du Larynx et du Pharynx, 1895, No. 5. Abst. in the Medical News. June 1.5, 1895. (Hospital.)

Zeifschrift f. Medizinal-lieamte, Feb. 15, 18115. (Collective investigation of use of antitoxin in private practice in district of Minden.)

All^-( ni. Med. i-intral-Zeitung, 1895, No. 88. (Private practice.)

Abst. Sclinii.lt's Jahrbflch. mm, Bd. 246, p. 37. (Hospital.)

B. iliTHT Klin. Wochenschrift, 1895, No. 10. (Private practice.)

Ibid. (Private practice.)

Deut.«ehe Med. Wochenschrift, 1695, No. 10. (Hospital and private practice)

Ibid (From private practice of six physicians in Baden.)

(^orrespondenzbl. f. Schweizer-Aerzte, 1895, No 5. (Hospital.)

Abst. in Miinchener Med. Wochenschrift, Mar. 5, 1895. (Hospital.)

Abst. Ibid. (Hospital.)

Riv. Mi'd. lie la Suisse Homande, April 20, 1895. (40 cases in hospital.)

Wiener Mi-d Illiitter. 1895. p. 760. I Hospital.)

Prager Med. Wochenschrift, 189,5.

New York Medical Becord, April 8, 1895. (Hospital, consultation and private practice.)

Ibid. April 20, 1895.

Le Bulletin M6d leal, 1895, No. 21. (Hospital.) British Med. Jour., May 18. 1895. (Hospital ) Ibid. Mav 11, l.sfti. (Hospital.)

Abst. in Miinchener Med. Wochenschrift, May 7, 1895. (Hospital.) Ibid. Mav 21. 1895 labstract). (Hospital.) The Medical News, June 1, 1895. iPrlvate practice.) Deutsche Med. Wochenschrift, June fi. 1895. (Hospital.)" Miinchener Med. Wochenschrift, June 11, 1895. (Hospital.) Deutsche Med. Wochen.schrift. July 11, 1895. (35 cases-hospital.) Abst. In Deutsche Medizinal-Zeitung. June 10, 1895. (Hospital.) Abst. in British Med. Jour., July 6, 1895.

Ueported to Assoc, of American Physicians, May 81, 1896. Abst. in the Medical News, June 15, 1895. (Hospital.)

Total (82 Reports).

123B (17.3 per cent.)

J^^ f"-fi'^*^V of ^^'^^ coMi of diphtheria treated with antitoxin wai 17.3 per cent. The previous or simultaneout fatality of cases not treated with antitoxin IS stated m AfS reports. TheM mnlnin 5100 i-ases treated with antitoxin with 1008 dealhu. a fatality of 18. G per cent. Estimating the k^ oo-uJ t. '" "'*""' ""^' "'"'"* """ *""* "/'*" preriniia or simuUaneo'ia fatality for each t/mup Uakinq the hneest figures {liven), there would have own -_,U deaths or 42.1 per cent. There was, therefore, an apparent reduction of case mortality by the use of antitoxi'n'of bo^S per cent.

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taueous percentage of deaths from diphtheria uot treated with antitoxin is given for the same hospital or locality in which were the cases treated with antitoxin. These reports contain 5406 cases of diphtheria treated withantitoxiu, with 1008 deaths or 18.6 per cent. If we calculate the number of deaths in each series of these cases upon the basis of the previous fatality, selecting the lowest percentages given, we have 2279 deaths or 42.1 per cent. There is, therefore, on this estimate by the use of antitoxin an apparent reduction in the number of deaths of 55.8 per cent.

There must be a much greater difference between the characters of the cases composing the two groups compared than appears from the statements of the writers and the details of the cases described, if this striking reduction in fatality is not due to the serum treatment.

If we separate the hospital cases from those in private practice we obtain from 61 reports of Table I 5777 cases of diphtheria treated with antitoxin in hospitals. These furnished 1081 deaths, giving a percentage of 18.7. Although this is not an unheard of fatality of diphthei-ia in hospitals, it is most exceptional, and I am not aware that anything approaching it has been observed in hospitals receiving large numbers of cases of diphtheria in children. The fourth column in Table I gives the percentages observed in many such hospitals.

There are 41 reports which give for the same hospital the previous percentage of deaths from diphthei'ia not treated with antitoxin. These fui-nish 4899 cases treated with antitoxin, with 944 deaths or 19.3 per cent. If we calculate the number of deaths which would have occurred among these cases had the percentages of previous fatality obtained, selecting the lowest percentages given, there would have been 21 HO deaths or 43.5 per cent. The apparent diminution in the number of deaths as the result of serum treatment is according to this estimate 55.6 per cent. If we had selected only the larger and most carefully analyzed and satisfactory statistics from the principal hospitals, in large part children's hospitals, there would have been in over 3000 cases an apparent reduction in fatality of 60 per cent.

There may occur considerable differences in the annual fatality from diphtheria in a hospital during a series of years, but such differences between the minimum and the maximum fatality as that just noted between the actual and the estimated fatality are most exceptional. In the Friedrichshain hospital in Berlin there has been observed a difference of 28 per cent, in the annual fatality from diphtheria. The largest difference observed in the surgical clinic in Berlin during ten years was that between 43.2 per cent, in 1888 and 58.5 per cent, in 1890.* In the report of the Metropolitan Asylums J?oard"j" in London, where the case mortality from diphtheria in hospitals is generally much lower than on the Continent, the fatality in 1889 was 40.7 per cent.; in 1890, 33.5 per cent; in 1891, 30.6 per cent; in 1892, 29.3 per cent.; in 1893, 30.4 per cent This apparent reduction in fatality since 1889 in large part disappears if only patients under 15 years of age are

•v. Hirsch. Arcliiv f. klin. C'luruijiic, BJ. 49, Hft. 4. t British Medical Journal, Dec. 22, 1894.

considered, the corresponding percentages for these being respectively 40.7, 41.6, 36.9, 35.6, and 37.

The natural interpretation of our statistics showing in over 7000 ca.ses, of which at least five-sixths are from hospital practice, treated with antitoxin an extraordinarily low percentage of deaths for this class of cases, and showing an apparent reduction in fatality of from 50 to CO per cent, by the use of antitoxin, is that antitoxin exerts a specific curative ]iower over diphtheria.

What are the objections which may be and have been urged against this natural interpretation of the statistical evidence? In the first place it has been claimed that these observations have been made during the prevalence of unusually mild diphtheria. In some places the prevailing type of the disease seems to have been mild, but the great majority of the observers quoted in the table consider that the prevailing diphtheria in their localities has been of average severity, and they cite in many instances the simultaneous fatality of cases not treated with antitoxin as proof that the disease is not of peculiarly mild type, indeed in several places it seems to have been of more than average severity. During the period in which Roux treated with antitoxin 300 cases in the Hopital des Enfants-Malades with a fatality of 26 per cent, the fatality in the Ilopital Trousseau, also in Paris, and receiviDg a similar class of cases, was 60 per cent.

But even if it be admitted for the sake of argument that the prevailing type of diphtheria during the past year has been mild, it is to be considered that the influence of this milder tyi)e upon the cases received in many hospitals appears chiefly in the reduction of their number, and far less in a change in the character of the cases admitted. This is the statement of von Kanke, of Bokai and of several other physicians in charge of diphtheria wards. They say that so far as their hospitals are concerned, as a rule, severe and advanced cases are sent there by physicians in the city, often for operation to relieve laryngeal stenosis, and that when the epidemic is mild in character they receive fewer cases, but not many milder cases. Doubtless these conditions will not hold for all hospitals, particularly not for such as are intended for the compulsory isolation of all cases of diphtheria which Ciinuot be properly isolated at their homes, but they are probably sipplicable in large part to most of the hospitals from which come the reports now under consideration.

So far as I can judge, no proof has been brought forward iu support of the opinion that the low percentage of fatality of diphtheria treated with antitoxin can be referred iu any large measure to the prevalence of an unusually mild type of the disease, although iu a few scattered groups of casei. particularly some of the smaller series iu my table, this may lie in part the explanation.

1 am inclined to attach decidedly more weight to a second criticism of antitoxin statistics which has been m.ide, namely, that iu hospitals where the serum treatment has been carrie<i out a proportionately larger number of crises are received now than formerly iu the earlier stages of diphtheria. The advocates of the treatment have properly insisted uix»n the importmce of early injection of the serum, and. especially during the time when the serum w:js uot to iiny extent iu the

108

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 52-53.

hands of general practitioners, it wonld be natural to suppose that physicians would send their patients and parents take their children to such hospitals as soon as possible after recognition of the disease. Inasmuch as with any approved method of treatment of diphtheria the results are better the earlier it is begun, it is evident that statistics based on the former experience with the treatment of diphtheria in hospitals would not be altogether comparable with the antitoxin statistics from the same hospitals.

It is, however, very difficult to say how luuch allowauce is to be made for this criticism. There has been wide-spread skepticism among physicians and the general public as to the value of the treatment. Thus Rapmund, in his efforts to establish in the disti-ict of linden a collective investigation of serum therapy in diphtheria, found the physicians so skeptical that of 194 practitioners only 20 would use it at all, and only two employed it extensively. There are also statements as to the unwillingness of parents to have it tried on their children. Many of the reports state that during the period of serum treatment cases were not received in any earlier stages of the disease than formerly; in a few of the reports, as for example in that of Kunt/.en from Oschersleben, it is said that physicians were induced to send their patients early in the disease. In Berlin and some other cities there has been a marked increase in the number of patients with diphtheria admitted to hospitals since the introduction of the antitoxin treatment, and this has been without a corresponding increase in the total number of cases in the cities. Heubner in his recent address at the Congress of Internal Medicine in Munich admits that lighter cases of diphtheria go to the hospital now, but that this is not enough to explain the great difference in fatality. There are undoubtedly considerable differences in different hospitals as to the proportion of cases admitted in early stages of diphtheria, but in many of the hospitals where the benefits of antitoxin have been most apparent as contrasted with the previous results it is expressly stated that the number of mild cases admitted is no greater than formerly.

If we make all due allowance for this possible increase in the proportion of early cases treated in hospitals, and certainly some allowance must be nuide, this factor is still altogether inadequate to explain the great reduction in fatality of diphtheria treated with antitoxin. This will also be apparent later when we consider the results of treatment according to the day of the disease on which it is begun.

A third criticism, namely, that the bacteriological control of the diagnosis of diphtheria operates in favor of a low mortality in antitoxin statistics, has already been fully discussed.

It is manifestly improper to compare the average fatality of thousands of cases treated in hospitals with antitoxin with exceptionally favorable results at certain periods in a few hospitals in a comparatively snuill numlier of cases without serum treatment, and still more improper, as has even been done, to make such comparison with the most favorable percentages which one can find reported from private practice or in municipal mortality statistics. Surely some consideration must be given to the previous and simultaneous results

obtained from cases without serum treatment in the same hospitals from which the cases reported are derived.

We have now considered the principal objections which have been made to the natural interpretation of statistics showing an apparently great reduction in the fatality of diphtheria by the use of antitoxin. I believe that it has been shown that even if all possible allowance be made for such assumptions as those considered, they are still wholly inadequate to accouut for an apparent reduction in the deaths from diphtheria by antitoxic treatment of 50 to 60 per cent, in nearly 5000 cases collected from hospitals in Germany, France, Austria, Italy, England and America, and reported by forty different physicians, most of whom are of high reputation and large experience. These statistics seem to me to establish beyond all reasonable doubt the conclusion that antitoxin is a specific curative agent for diphtheria.

It has been contended that the only absolutely convincing proof of the curative efficacy of antitoxin is the demonstratiou of a marked reduction in the total number of deaths from diphtheria in a city or town in proportion to all of the cases. Municipal mortality and morbidity statistics are necessarily far less accurate than hospital statistics, and for reasons which have been stated, the prevalence of a mild type of diphtheria will have greater influence upon municipal mortality statistics for diphtheria than upon hospital statistics. It is to be expected that when sufficient time has elapsed and the employment of antitoxin in the treatment of diphtheria has become sufficiently general, the reduction in fatality by •its use will be apparent in general fatality statistics. At present we have little infornuition upon this point. The mere statement of the total number of deaths, without knowledge of the morbidity and of the prevailing type of disease, is of course not decisive for either side of the question, but so far as it goes it is interesting to learn that in Boston during the antitoxin period (.January 1 to May 1, 1895) the total fatality from diphtheria was 14 per cent., as compared with a fatality of 31 per cent, during the corresponding period of previous years (Mason), and that in Cartagena, Spain, during four months of employment of antitoxin, the total number of deaths was only one quarter the average number for the same period of time during the preceding ten years.

The only antitoxin statistics which I can find based upon such material as composes municipal fatality statistics are those of Risel and of Kurtli.

Ilisel reports the results in all of the cases treated by antitoxin during two months in the city of Halle. They are derived from the practice of thirty physicians among the poor and the rich, in the houses of tlie patients and in hospitals, and include mild and severe cases as they presented themselves. Of the 89 patients treated in their homes, almost without exception children not over 7 years of age, 6 died, giving a fatality of (i.7 per cent. 19 of these had laryngeal diphtheria, of whom 4 died. Of the 25 patients treated in hospitals, 3 died, a fatality of 12 per cent. 15 of these had laryngeal involvement, of whom 3 died. The total fatality was 7.9 per cent. No data are given for comparison with the previous or simultaneous fatality of cases not treated with serum. In only a few cases, and these in hospitals,

July-August, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

109

was the cliuical diagnosis confirmed by 1)acteriological examination.

Kurth reports tlie results of serum treatment in the practice of sixty physicians in Bremen and a few outlying villages from October 8, 1891, to January 31, 1895. A circular letter was sent from the Bacteriological Institute to every physician in the city, and ajipareutly general co-operation on the part of the physicians and the public officials was secured. In 97 cases treated with serum the diagnosis of diphtheria w'as established, in the great majority of cases by demonstration of the Loffler bacillus controlling the previous clinical diagnosis. The total case mortality was 10.3 per cent. The fatality of the 64 cases treated in the city (hospital and private practice) was 7.8 per cent. ; that of 33 cases derived from the surrounding country district was 15.2 per cent. ; that of 35 cases treated in the city hospitals was 14.3 per cent. Laryngeal diphtheria occurred in 66 per cent, of the cases in country districts and only in 36 per cent, of the cases in the city. This and the generally less favorable results in country practice are attributed by Kurth not to greater severity of the epidemic in the former, but to the custom in the country of not calling the physician until the symptoms are urgent, and to the greater distance which the physicians have to travel. If the bacteriological control of the diagnosis be disregarded, that is, if all the cases diagnosed clinically as diphtheria and treated with serum be considered, the fatality was 9.4 per cent., another illustration that bacteriological control of the clinical diagnosis results in higher, not as some have claimed in lower, percentage of deaths. Of the 50 cases of clinical diphtheria, all of the cases being included which did not show Loffler bacilli, the fatality was only 6 per cent. During the serum period there occurred 25 cases of diphtheria not treated with antitoxin, with a fatality of 24 per cent. During the same period of the year in which the serum-treated cases occurred, there were during the j)receding year 148 cases of diphtheria with a fatality of 32 per cent. It must be conceded that these interesting reports of Eisel and of Kurth speak strongly in favor of the possibility of bringing about a great reduction in the general fatality from diphtheria in cities by treatment with antitoxin. As a larger proportion of the cases in private practice can be treated in early stages of the disease than in the hospitals, this reduction should be greater than that already shown by hospital statistics.

A most convincing demonstration of the healing power of antitoxin is furnished by the experience of Baginsl<y during an involuntary pause in the serum treatment caused by failure in the supply of serum. Between March 15, 1894, and March 15, 1895, there were treated in Baginsky's service by antitoxin 525 children with a fatality of 15.6 per cent. During the period of forced interruption of the serum treatment, this period being chiefly the months of August and September, 126 children were treated without antitoxin, with a fatality of 48.4 per cent. There was absolutely no selection of cases in either group. In his comments upon this experience Baginsky says: " It is all the more remarkable, as the ratio of mortality of those treated with the serum both before and after the period of interruption varied within very small percentage ligures. If one will permit figures to speak at all,

there has scarcely been made on human beings a more demonstrative test of the curative power of a therapeutic agent. It was an experiment forced upon us, but it proved to us how terrible was the form of disease which we were treating, and how numerous would have been the victims without the use of the healing serum."

A similar experience has been reported by several other writers. Thus Korte noted a rise in fatality from 33.1 per cent, during the serum period to 53.8 during the period of failure in the supply of serum. Ganghofner, under similar conditions, a rise from 12.7 per cent, to 53.2 per cent. ; Heim, from 22 per cent, to 65.6 per cent., and during the epidemic in Trieste the fatality rose from 18.7 per cent, to 50 per cent. when the serum failed. All of these highly significant observations were made on cases occurring in the same epidemic, the period of enforced interruption of the serum treatment being preceded and followed by the periods of serum treatment.

"We have considered thus far mainly the hospital statistics. These are for manifest reasons more numerous, larger and more carefully analyzed than those from private practice. It is, however, in private practice, especially among those classes who are in the habit of calling the physician early in the disease, that the best results from serum treatment are to be expected, for here there is more frequent opportunity for timely treatment. A glance at Table I will show that in general the fatality of diphtheria treated w^th serum in private practice is much lower than in hospitals.

If we summarize the 18 reports from private practice in Table I we have 663 cases of this class treated with antitoxin, and among these are 46 deaths, giving a fatality percentage of only 6.9. This would indicate that the serum treameut may reduce the fatality from diphtheria in private practice to nearly one-third that under the same treatment in hospitals. Some of the reports of the results of serum treatment in private practice furnish, indeed, most remarkable evidence of the efficacy of this treatment.

Most of the reports attempt some sort of classification of the cases treated with antitoxin. The simplest and most common, although not the most valuable, is the division according to degrees of apparent severity, expressed by such epithets as mild, moderate, severe, very severe. Such a classification is, of course, only of limited value, as even the mildest case of diphtheria may unexpectedly assume a malignant character. If, as we believe to be proven, antitoxin iujecteti in time arrests the local process and the constitutional disturbance, then many of the cases which appear under the head of mild cases in antitoxin statistics would under other methods of treatment have become severe cases and would be so recortled. Indeed, with the early administration of antitoxin there should be comparatively few severe cases.

The classification of diphtheria adopted by Eoux into angina and croup, with and without miorobic association, has been followed by some of his successors. So far as this classification is actually based upon a correct separation of pure diphtheria from diphtheria with mixed infection, it is of the utmost importance in determining the relative value of antitoxin in the treatment of these two divisions of diphtheria.

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 52-53.

I have already expressed the opinion, however, that the bacteriological examination of the exudate and secretions in the throat is not decisive in determining the presence or absence of mixed infection. Still Konx's analysis of his cases on this basis indicated clearly that the serum was far more efficacious in diphtheric anginas and croup which yielded pure cultures of the Liffler bacillus than in those which gave, in addition to the Loffler bacillus, cultures of other pathogenic bacteria. In presenting these results the epithet "pure" applied to angina or croup is to be understood to signify that only the Loffler bacillus was found in the cultures, and the epithet "associated" to signify that this bacillus was found in cultural association with the coccus of Brisou, staphylococci or streptococci, most commonly the lust. The " corrected " percentages are those obtained after subtracting deaths occurring within twenty-four hours after admission.

Of the 300 cases treated with serum with a total fatality of 26 per cent, reported by Roux, Martin and Chaillou, there were 120 pure anginas, fatality 7.5 per cent, (corrected 1.7 per cent.); 49 associated anginas, fatality 24.2 per cent, (corrected 17.7 per cent.) ; of not operated croup, 4 pure, fatality 0, 6 associated, fatality 16.6 per cent. ; of operated croup, 49 pure, fatality 30.9 per cent, (corrected 24.4 per cent.), and 72 associated, fatality 56.9 per cent, (corrected 43.1 per cent.).

Of Moizard and Perregaux's 231 cases, total fatality 14.7 per cent., there were 44 pure anginas, fatality 4.5 per cpnt.; 42 associated anginas, fatality 14.3 per cent.; 94 pure croup, fatality 18.5 per cent; 51 associated croup, fatality 17.6 per cent. No correction is made in these percentages.

Of Sevestre and Meslay's 150 eases, total fatality 10 per cent, there were 29 pure anginas, fatality 3.4 per cent; 24 associated anginas, fatality 12.5 per cent (corrected 8.3 per cent); 67 pure croup, fatality 8.9 per cent (corrected 7.5 per cent.); 30'associated croup, fatality 16.6 per cent (corrected 6.6 per cent).

It will be observed that in the last two reports the excess in fatality in the "associated" diphtherias is much less striking than in Roux's statistics, and in some cases disappears altogether. This I am inclined to attribute to failure o/ the method employed to indicate properly the division into pure and mixed infections, for the testimony is unanimous that the serum is of far less benefit in mixed diphtheria than in uncomplicated diphtheria, the most common and dangerous complicating micro-organism being the streptococcus pyogenes.

Most noteworthy has been the improvement in the results of serum therapy of diphtheria in the Paris hospitals since Roux's original communication to the Congress in Budapest in September, 1894. The fatality has descended from IJoux's origiiuil percentage of 26, in the later reports to 14.7, 12 and 10 per cent, and according to a recent statement of Moizard and Bouchard (July, 1895), it at present oscillates between 8 and 14 per cent These are the best results which have hitherto been reported from any hospital for any large number of cases, and they are certainly most significant As Moizard and Bouchard in their recent communication say, "This result can no longer be attributed to fortunate series of cases, a,s was claimed at the beginning by adversaries of the method. Thousands of patients have been treated, and it can now be

said that the controversy is closed." This striking descent from Roux's first fignres is not, however, attributed by the writers wholly to improvements in the methods of serum therapy. As Roux pointed out in his first paper, the hygienic conditions in the two Paris hospitals from which these statistics come were very bad. These conditions have since then been greatly improved, and this reform has been especially manifest in the reduction of the deaths from bronchopneumonia.

A most important classification of diphtheria for estimating the curative value of antitoxic serum is that into cases without and with laryngeal stenosis, and especially when such degrees of stenosis are considered as require operative interference by tracheotomy or intubation. I have therefore prepared the following table (Table II) which gives the results of antitoxin treatment in operated and not operated cases of diphtheria. This of course is not equivalent to a division into anginas and croup, as many cases of croup are included in the non-operated cases, but I have desired to submit the new method of treatment to the most severe test. No one can claim that laryngeal diphtheria requiring intubation or tracheotomy is anything but a severe disease. If the benefits of antitoxin are unmistakably manifested in these operated cases of croup, then the test is an experimentum cruris and puts an end to the objections of those who assert that the apparently favorable results of serum therapy in diphtheria are attributable mainly to the large proportion of mild cases treated.

The same reports with a few additional oi>es, for which references are given, have been used for Table II as for Table I, but many of the reports in Table I were not available for this table, as the writers did not always present their results in a form which fitted into the classification adopted. The table gives for each report the total number and fatality of cases treated, as in Table I, the number and fatality of cases not operated on (including cases of cropp), the number and fatality of cases operated on, " T " signifying tracheotomy, "I" intubation, "I and T" signifying intubation followed by ti'acheotomy, and, so far as reported, the previous or simultaneous percentage of fatality from operation in cases not treated with antitoxin. In the final column are pertinent statements concerning cases in the series. Some reports are inserted which do not give the number of cases under the dilferent headings. These, of course, cannot be used in the summary giving the totals.

Of the 4294 cases in Table II, 27.2 per cent re<|uired tracheotomy or intubation. Thei-e were, however, many more cases of laryngeal diphtheria in this group than the ratio of operative cases would indicate, for it is the testimony of the great majority of the observers that the stenotic symptoms of laryngo-tracheal diphtheria are relieved without the necessity of operation in a much larger proportion of the cases treated with antitoxin than by any other method of treatment As is well knoW'U, recovery without intubation or tracheotomy from descending laryngo-tracheal diphtheria, especially in children, is exceptional under all other methods of treatment, and the greater relative frequeucy with which such recovery occurs under serum treatment is a strong proof of the efficacy of antitoxin.

.Is;

1

Deducting those which died in less than 24 hours after admission to the hospital, there remain 107 trachcotomies with 4.' deaths (39.2 percent.).

In all of the fatal operations it was necessary to perform tracheotomy within 12 hours after admission

Of 8 tracheotomized cases under 3 years of age, 5 died (63.5 per eent.l. The previous fatality for tracheotomy under 2 years was 90.7 per cent.

The fatality of 38 per cent, in the table is that of 47 tracheotomies performed during ihe period iu which thesupply of antitoxin temporarily was exhausted and could not be at once replaced.

During two months in which the supply of serum failed the general fatality rose to 48.4 per cent, and that from triftheotomy and intubation to 62.3 per cent. The fatality at once fell upon re-iiitroductiou of the antitoxin treatment.

22 cases of laryngeal diphtheria (croup) recovered without operation 21 cases of croup recovered without operatiou.

22 cases of laryngeal diphtheria (croup) reco^'ered without operation 21 cases of croup recovered without opcratiou.

Deducting 8 cases in a hopeless condition on admission, there was only one death among the noo-traeheotomized cases, a death rate of only 2 7 per cent.

Of the intubated cases 7 died in les-q than 21 hours after admission. Deducting these, the fatality from Intubation was only 18.1 per cent.

Deducting 15 deaths in less than 24 hours after admission, the total fatality is reduced to 9.7 per cent. These cases are those treated iu the Iinpital Trousseau in Paris from the middle of Sept. to Dec. 25, 1894.

12 laryngeal diphtherias recovered without operation. During period in which the supply of serum failed the general fatality rose to 53.2 per cent, and that of operated cases to 68.9 per cent.

In 14 cases presenting symptoms of moderate laryngeal stenosis upon admission, these symptoms disappeared after injection of antitoxin without operation.

During period when supply of serum failed the ^neral fatality rose to 65.6 per cent. Heim treated altogether 48 cases in two groups, but of his 2d group of 21 cases 13 were still under treatment at date of report and these are not included in mv table.

313 cases of diphtheria treated In the same hospital (Greifswald) from Oct., 1893, to Sept., 1694, gave a fatality of only 14.5 per cent.

In 13 previous series of tracheotomies in each group the

average of deaths numbered SV. The 7 unoperated cases were mild.

During a period of exhaustion of the supply of serum the general fatality rose to 50 per cent. These data are from abstracts in the British Med. Jour., Feb. 2. 1895. and the Deutsche Mod. Wocbenschrift, 1894, No. 5:;. The general serum fatality is variously given as 187 per cent.. 20.3 per cent, and 22 per cent.

Only one adult in this scries.

Collection of cases treated in private practice by several physicians in Minden.

After intubation (U cases) no death,

after intubation and tracheotomy 1 death,

after tracheotomy 1 death.

10 cases of croup rt'covercd without operation.

The fatality of 42 unoperated cases not treated with

antitoxin was 33.4 per eent., that of 20 tracheotomizcd

cases not so treated was 85 per cent.

3 of the 4 deaths were from croup.

Of Kossel's 44 cases of laryngeal dii^litheria treated with antitoxin, 31 (47.7 per cent.) recovered without operation ; of von Widerhofer's 130 stenotic cases treated with serum 22 (16.9 per cent.) recovered without operation ; of von Ranke's 63 cases, 21 (33.3 per cent.); of Vierordt's 24 cases, 9 (37.5 per cent.); of Ganghofner's 56 cases, 12 (21.4 per cent.); of Bokai's 63 cases, 14 (22.2 per cent.); of d'Espine's 21 cases, 10 (47.6 per cent.). Von Ranke says that before the use of serum at most 5 per cent, of his cases of laryngeal stenosis escaped operation, whereas now 33 per cent, escape. Of Ganghofner's stenotic cases formerly 12 per cent, escaped operation, whereas now 21 per cent, escape. The experience of Heubner and many others is similar.

In this respect, as in so many others, the results in the Paris hospitals have been most favorable. Of Moizard and Perregaux's 145 cases of croup, 90 (63.1 per cent.) recovered without intubation or tracheotomy. Roux, Martin and Chaillou say, " Of 169 children, admitted to the service for diphtheric angina, 56 presented laryngeal symptoms ; 31 had hoarse voice, and in 25 the voice was so far extinguished and the dyspnoea (tirage) so marked that one might believe that the latter patients should be operated on. Under the influence of the serum (and in these cases one should not fear to make an injection every twelve hours), the dyspnoea diminished, then occurred only paroxysmally, the child coughed up false membranes, and at the end of two or three days the respiration became normal, to the great astonishment of the interns and personnel of the pavilion who, with their large experience of children affected with croup, indeed thought that operation could not be avoided. To-day in the presence of a child with dyspnoea it is not necessary to press for operation. One can inject the serum and wait as long as possible. Since the introduction of the serum the number of tracheotomies in the pavilion has diminished."

Out of his large experience Baginsky exjjresses himself in these vigorous words : " Here again the observation of the individual cases of laryngeal stenosis, and more especially of those which do not come to the point of operation, speak to me more forcibly than the statistical figures. The surprising regression of the laryngo-stenotic respiratory phenomena, the freedom of breathing, the disappearance of the hoarse voice and the croupy cough, the euphoria of the children, the change in their general condition so that two days after the injection they are sitting up in bed, playing and contented and observant of their surroundings ; all of these things produce in him who has had before his eyes for years the hopeless picture of continually progressing laryngeal stenosis, in very truth ineffaceable impressions."

Experience based upon such a large number of oases and careful clinical observation must be regarded as representing the norm. That there may be deviations from tliis norm, even in a fair number of eases, seems to be illustrated by the experience of Leichtenstern and Wendelstadt, who in 123 cases of diphtheria, with 37 tracheotomies, were not able to note any material reduction in the proportion of cases requiring tracheotomy as compared with former series of cases. Their observations were uncontrolled by bacteriological diagnoses.

Another point to be considered in this connection is of capital importance as an indication of the value of serum treatment. Cases which are free from symptoms of laryngeal involvement at the time of injection of the serum do not develop such symptoms later, or do so only very exceptionally, unless evidences of such involvement appear within twentyfour hours after the injection.

Regarding neither this nor any other point is there entire unanimity of opinion in the various reports, nor is such to be expected from observers of limited numbers of cases with unequal distribution in the various groups of mild cases, of early cases, of anginas, of croup, of pure diphtheria, of septic diphtheria, etc., to say nothing of the absence in some reports of any bacteriological control of the diagnosis and of treatment by insufficient doses or inferior quality of serum. I am only surprised that the conflicting statements are not more numerous. But there are not many points concerning which there are so few diffei'ences of statement as concerning the efficacy of antitoxin in preventing descent of the diphtheritic process to the larynx and the trachea. Over and again one can read in the reports such statements as that in all of the patients who entered without laryngeal diphtheria, the larynx remained free, or that unless the symptoms of stenosis appeared within the first twenty-four hours after injection of the serum, they were not observed at all or onlr most exceptionally. Among the many vouchers for these statements may be cited Kossel, Roux, Baginsky, von AViderhofer, Heubner, von Ranke, Vierordt, Ganghofner, Escherich, Bokai, Van Nes, Kurth.

It is this power of antitoxin to check the spreiid of the diphtheritic process from the tonsils and pharynx into the larynx, and from the larynx into the bronchi, which has impressed many observers in favor of the new treatment more forcibly than any other feature of their experience with its action. Thus Vierordt observed that of 24 children with diphtheria who were admitted with unaffected larvns and treated with antitoxin, only one developed temporarily a hoarse cough on the third day. In all of the others the larynx remained free. Of 23 patients who were admitted with unaffected larynx not long before the introduction of the serum treatment, nine afterward developed croup. This is doubtless a somewhat unusual experience as regards the large proportion of cases of croup developing under previous methods of treatment.

It follows from what has been said that the ratio of oj>erative cases in antitoxin statistics will in general be smaller than in statistics of Ciises of the same character treated by other methods. On the one hand there will be fewer larvugeal stenoses developing after commencement of the treatment, and on the other hand a larger numlHT of recoveries from laryngeal diphtlieria without the necessity of o|KTation,

The following figures serve to illustrate this jwint. In the service from which the cases report<Hl by Roux were derived. tracheotomy was performed before the serum jwriod in 50 per cent, of the cases of diphtheria, after the introduction of serum in 40 per cent. The later Paris reports give a much greater reduction in the ratio of tracheotomies. In Bjiginsky's service 43.9 per cent, of the cases were o}->erate<l on Wfore the use

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of serum, and 18.1 per cent, after its introduction ; in von Ranke's service the corresponding figures are 57 per cent, before and 43.5 per cent, after; in Bokai's 65.6 per cent, before and 40.8 per cent, after. As already mentioned, Leichtenstern's figures, 32 per cent, before and 30 per cent, after serum, are exceptional.

It is furthermore to be considered that in view of the power of antitoxin to abate beginning and moderate symptoms of stenosis, operation will be delayed rather than hastened, and, when performed, the indications for it will generally be undent. For manifest reasons, most of the operations will fall within a period not remote from the time of injection of the serum. Of the 121 tracheotomies in the report of lloux, Martin and Chaillou, 102 were performed either before the first injection of antitoxin or within 12 hours afterward; 14 between the 12th and the 36th hour after inception of the serum treatment, and only 5 later than 36 hours after the injection of the serum. Of the 23 tracheotomies with 12 deaths reported by Kossel, the operation was performed within the first twelve hours in all of the fatal cases, and of the 11 successful cases it was performed in 9 on the day of admission to the hospital, in 1 on the second day and in 1 on the following day. Kossel refers the increase in the stenotic symptoms after injection of the serum in the two last cases to the separation of the false membranes, a point to which others have also called attention as an effect of antitoxin and which is to be borne in mind in cases of croup treated by antitoxin.

Turning now to the results of tracheotomy and intubation in cases treated with antitoxin, we find in Table II that in 11 reports there were 648 tracheotomies with 258 deaths, a fatality of 39.8 per cent., and 342 intubations with 99 deaths, a fatality of 28.9 per cent., and 26 intubations followed by tracheotomy with 14 deaths, a fatality of 53.8 per cent. These are not unheard of fatalities from these operations, but they are so low as to indicate decidedly remedial action of antitoxin.

The percentage of fatality from tracheotomy in diphtheria given by Monti from a total of 12,730 cases up to 1887 is 73.3. The percentage given by \^ Ilirsch in 1054 tracheotomies in diphtheria, in von Bergmann's clinic in Berlin during the last ten years and seven months (up to July 31, 1894), is 68.7, the fatality during the first four years of this period being 70.5 per cent, and during the last four years 03.8 per cent. The fatality during the first year of life was 98.8 per cent. and sank for each year to the ninth, when it was 41.7, and after the tenth year it rose again.

More proper, however, than comparison with these latter percentages is comparison with the percentages of fatality in the same hospital or place from which the respective groups of cases are reported. It will be observed that with one exception in the table the percentage of deaths following operation in cases treated by antitoxin is lower, and generally very much lower, than the previous or simultaneous fatality. Kraske's exceptional series is of so few cases (only 5 with and 12 without serum) as to be without any significance. The lowest fatality thus far reported in a series is 3 deaths in 31 truchcolouiii'.s with serum treatment, or a fatality of only 9.67

per cent. This is reported by Schroeder from the hospital in Altona.

If for each group of cases we estimate the number of deaths which would have occurred in the tracheotomized cases treated with serum on the assumption that the previous or simultaneous fatality in cases not treated with serum had obtained, we obtain the following result : The actual percentage of deaths in 510 tracheotomized cases treated with serum was 42.5. The percentage of fatality in these cases estimated on the basis of previous or simultaneous fatality in the same hospitals would be 64.5. There was therefore an apparent reduction in-fatality by the serum treatment of 34.1 per cent. This difference between actual and estimated fatality is greater than is observed in any ordinary experience of variations in fatality during a series of years in the same hospital from tracheotomy in diphtheria.

I confess to some surprise that the analysis of the tracheotomized cases treated by serum should have yielded results so strikingly favorable to antitoxin treatment. When one considers that the benefits of serum treatment are most strikingly apparent when the treatment is begun early in the disease and become more and more doubtful after the third day, it would not have been a convincing argument against the treatment if these benefits were not conspicuously manifest in cases of diphtheria requiring tracheotomy, for, as has been explained, the great majority of these tracheotomized cases are already the subject of advanced laryngeal stenosis when the antitoxin is first injected. There are, however, not a few cases which begin apparently as laryngeal diphtheria {croup d'emblee), or ill which the involvement of the larynx occurs within twentyfour or forty-eight hours after the onset of the attack. That careful observation would reveal in many of these apparently primary or early laryngeal diphtherias a latent or slightly manifested diphtheric angina I believe to be true.

It is interesting to note that in several reports the benefit of serum treatment has been much more evident in the operated cases than in those not operated on, although this is not the rule. Indeed Leichtenstern and Wendelstadt find in their series of 123 cases that the difference in favor of the serum in tlifir non-operated cases was so small as to be without significance, whereas there was a difference in favor of the serum of 20.8 per cent, in their tracheotomized cases with and without serum treatment. They attribute, therefore, the entire benefit of the serum in their experience to its action in tracheotomized cases. Their experience, however, is exceptional, although in a measure approached by that of Ganghofuer and of Van Nes. On the other hand, in Vierordt's experience the entire benefit of antitoxin seemed to be in the non-operated cases. As has been repeatedly explained, such diversities of experience with limited numbers of cases is to be expected, and the norm can be established only by observations of large numbers of cases in different places and at different times. This norm is that both operated and not o]>erated cases are benefited by antitoxin, and that the difference in each class between serum fatality and fatality from other methods of treatment is a large one.

The fatality of intubated cases in 'J'able II, treated with antitoxin, is 28.9 per cent., which is 10.9 per cent, less than the

July-August, 1895.]

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113

fatality of traclieotomized cases. Before the introduction of the serum treatment a collective investigation was set ou foot by the German Gesellschaft fiir Kiuderheilkuude to determine tJie average fatality following intubation. In 1893 von Kanke reported to the Society that 1445 cases of diphtheria with laryngeal stenosis treated by intubation gave a fatality of 63.5 per cent. This i-esnlt was interpreted in favor of intubation as opposed to tracheotomy. There is a difference of .33.6 per cent, between this percentage and that obtained from our 342 intubated cases treated with antitoxin. This difference is so great that, after making all possible allowance for differences in the series of cases entering into the two groups of statistics, it seems impossible to explain it otherwise than as a powerful additional support of the arguments already presented in support of the claims of antitoxin. Here certainly the objection that the cases treated by antitoxin were light ones cannot be made.

Table II enables us to compare the fatality of 250 intubated cases treated with antitoxin with the fatality estimated ou the assumption that the previous or simultaneous fatality from intubation in the same hospital had obtained in the several groups. By this calculation we find the actual fatality to be 31.6 per cent., and the estimated fatality 62.4 per cent. In other woi'ds, thei'e was an apparent reduction in the fatality of intubated cases of 49.5 per cent, as the result of the serum treatment.

However distrustful one may be of statistical evidence in therapeutics — and previous experience justifies much distrust — I fail to see on what credible assumption this striking reduction of fatality can be explained otherwise than as demonstrative of the specific curative power of antitoxin in diphtheria.

Lamentable for the victims but adapted to convince the skeptical were the experiences of Baginsky and Ganghofner during the periods of failure in the supply of serum. During the euforced two months' interruption of the serum treatment (August and iSeptember) in Baginsky's service there were 116 cases of laryngo-steuosis with a fatality of 62.2 per cent., as opposed to a fatality of 37.8 per cent, in the serum periods which preceded and followed the pause. The percentage of operations rose to 55.2 as opposed to 18.1 per cent, during the periods of serum treatment, and this without any change in the general character of the cases admitted. During the serum periods there were more intubations than tracheotomies, whereas during the pause there were 45 tracheotomies and 19 intubations, 13 of the latter requiring secondary tracheotomy. In (ianghofner's service the fatality of the operated cases rose from 13.6 per cent, to 68.9 per cent, during the interruption in the supply of serum.

'i'here remain two points to be touched upon before dismissing the laryngeal stenoses. These are the substitution of intubation for tracheotomy in a larger and larger proportion of the laryngeal diphtherias reipiiring operative interference and treated by the serum, and the shortening of the period during which the tube or the tracheal canula is required to be kept in the air passage.

An agent which would arrest the progressive descent of the diphtheritic process from the larynx into the bronchi and

hasten the disappearance of the obstructive exudate is just what was needed to make intubation the ideal operation for the relief of the great majority of cases of croup requiring operative interference. Such an agent we now possess in antitoxin for a large group of cases, and we arc not surprised, therefore, to find that the employment of intubation, as a substitute for tracheotomy, has been greatly extended by the introduction of serum therapy.

Several writers give figures showing that serum therapy materially hastens the time when extubation or removal of the tracheal canula is permissible, but I have not attempted to collect these figures.

Of the 3127 not operated cases, including as already stated many cases of croup, 350 died, giving a fatality of 11.2 per cent. In V. Hirsch's statistics of diphtheria from von Bergmann's clinic for ten years the average fatality of not operated cases (1004j was 26 per cent, varying only from 25.9 per cent. during the first four years of the period to 27.3 per cent, during the last four years. There is, however, no general standard of fatality for cases of diphtheria not operated on. The variations are within very wide limits, as might be expected. Only a comparatively small number of the reports give separately the previous or simultaneous fatality of non-operated cases not treated with serum. I find in the reports the following data ou this point. In Roux, Martin and Chaillou's report the previous fatality of non-operated cases averaged 83.9 per cent., the minimum being 32.1 per cent., and the maximum 47.3 per cent., as opposed to 12.8 per cent, under the serum treatment; in Baginsky's report the corresponding figures are 31.6 per cent, versus 10.9 per cent.; in Bokai's 34.5 per cent. versus 14 per cent.; iu Ganghofner's 15.8 per cent, (the lowest in a series of years) versus 12 per cent.; in ^'au Nes 33 per cent., the average of ten years, with a minimum of 16 per cent, and a maximum of 41 per cent, versus 13.3 per cent; in Leichtenstern and Wendelstadt's 15 per cent, versus 10.4 per cent.

Age is a factor of such prime importance iu the prognosis of diphtheria that I have prepared the following UMe (Table 111), in which the cases treated with serum collected from twenty-five reports are classified according to age. Unfortunately there is very little uniformity of system iu the different reports in giving the results according to the ages of the patients, many of the reports simply stating the number of adults or the maximum age of the children or the uumber of cases under a certain age or the uumber between arbitrarily selected limits of age, etc., so that many of the reports were not used for the following bible. In each space iu the table the upper number is the total uumber of the cases iK'lougiug to the heading, aud the lower uumber is the uuuil)er of deaths among these cases.

The most frequently quoted percentages of fatality in diphtheria according to the ;ige are those of Herz, aud are as follows :

Under 1 year SO per cent.

1-3 years 45 "

3-5 " 40 "

5-10 " IT "

Over 10 years 17

As the cases in the preceding table were not classified according to the ages bj a uniform plan in the different reports they cannot all be summarized in a single table, but the chief results can be presented as follows:

14 Reports.

Total.

0-3 yrs.

3-4 yrs.

4-6 yrs.

C-8yrs.

8-10 yrs.

10-12 yrs.

13-15 yrs.

' ' ndetermined.

Cases

Deaths

Percentages

1234

215 17.4

187

60

33.1

337

70

31.4

297 176

48 19

16.3 10.8

114

8

i 0.63

32

5

1.6

21 4.1

(H) (0) (0)

In the following table the cases under 4 years are from 20 reports containing 1630 cases (fatality 17.0^) and those over 4 are from 17 reports containing 1451 cases (fatality 17.4^).

Cases

Deaths

Porcentag:es

0-2 years.

Over 15 years.

The following table gives the results for each year up to

5 and over 5 years.

18 Reports.

Total.

Under 1 year.

1-2 years.

3-3 years.

3-4 years.

4-5 years.

Over 5 years.

Undetermined.

Cases

Deaths

Percentages

983 179 18.3

34

10

47.1

112 37 33

118

36

30.6

116 17

14.7

140

31

23.1

452 42 9.3

1 (10) (0) (0)

The table furthermore shows under one year 35 eases with 16 deaths or ib.1% ; under 2 years 291 cases with 97 deatlis, or 33.3^ ; under 3 years 304 cases with 93 deaths or 30.6^, and under 4 years 692 cases with 122 deaths or 17.6^ {each of these four groups of cases being from a total number of cases in the first group of lOSO cases, in the second group of 1914 cases, in the third group of 1140 cases and in the fourth group of 1S65 ea»e», the average fatality for the whole number of cases being 17.3^.)

The percentages of fatality in V. Hirsch's statistics of 2658 cases from the surgical clinic in Berlin for 10 years and 7 months (ending July 31, 1894), according to age are:

Under 1 year 88.3 per cent.

1-2 years .". 82.5 "

3-4 " 63.9 "

4-5 " 56.0 "

5-6 " 46.9 "

6-7 " ; 43.7 "

7-8 " 36.1 "

8-9 " 28.1 "

9-10 " : 31.1 "

10-11 " 31.3 « 

11-12" 20.9 "

12-13 " 18.5 "

13-14 " 16.7 "

14-15 " 15.

15-16 " 13.5 "

Adults (72 cases) 11.1 '■

Baginsky gives the following percentages from his service in the Kaiser- und Kaiserin-Friedrich Childreir s Hospital in Berlin as the mean of the four years 1890 to 1893 inclusive:

Under 3 years 60.2 percent.

2-4 years 51.3 "

4-6 " 38.

6-8 " 28.9 "

S-10 " 24.5 « 

10-12 " 38.8 "

12-14 " 18.5 "

Baginsky's results in Table III may be compared with this last list of percentages, otherwise I do not consider that these

statistics of Herz, Ilirsch and Baginsky furnish any certain standard of comparison for the percentages of fatality derived from Table III. I have cited them, however, in the absence of any such standard to show in a general way that these latter percentages indicate a low fatality according to age. The contrast between a fatality percentage of 33.3 for ca^es of diphtheria under two years of age treated with serum, and that of 60 to over 80 for cases of the same age not so treated is a striking one, even if a large allowance be made for differences in the characters of the cases in the two groups.

We come now to the consideration of the influence upon the fatality of the length of the interval between the onset of diphtheria and the first injection of antitoxin. In experiments upon animals this factor is decisive in determining the resultIt is the factor which Behring from the first has put in the foreground. His claim is that no death will occur from diphtheria if antitoxin is injected in suflicient dose at the beginning of the disease, and that the fatality will fall under 5 per cent, if the treatment in proper manner is begun before the third day of the disease.

Of course the only significance of this great emphasis upon the importance of early treatment is as an expression of the fact that cure is rendered more ditticult the larger the number of the diphtlieria bacilli, the greater the amount and intensity of their toxins, the greater the damage already inflicted by the bacilli and their toxins, and the more serious the complications and secondary infections. There is. however, no absolute parity between the length of time the disease h:»s lasted before beginning treatment and the increase of these d.ingers. One ease may become desperate within forty-eight hours after the onset, and another may present no grave symptoms after a week's duration. The virulence, tli.> nmnli.r and the

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microbic associations of the infecting bacilli, and especially the local and general susceptibilities of the patient, are factors no less important than the single factor of time in inlhiencing the issue.

The individual peculiarities of each case must be considered. If all is judged according to one simple uniform standard — antitoxin cures the case or it does not cure the case — and it must be confessed this is all which seems to be in the minds of many, then the practitioner will not come to any clear conception of the wonderful powers of the healing serum. The sins of some observers in this matter seem incredible. They lump together indiscriminately all of their cases, including those complicated with measles, scarlet fever, tuberculosis and other diseases, the mixed infections, the anginas, the croups, the advanced and the early cases, the true and the false diphtherias, the infants and the adults, and throw tlien\ into the scale to be weighed for or against antitoxin. An unsuccessful case is put down to the discredit of antitoxin without reference to its peculiarities. On the basis of experience in treating a dozen cases, the writer boldly attacks results established by the careful observation of hundreds of cases. It is true we need these brute figures for comparison with former fatality statistics of diphtheria, and they have served to demonstrate the curative efficacy of antitoxin, but reports of personal experience with the serum treatment should at least contain the data for an intelligent analysis' of the cases treated. Such an analysis is requisite in order to reveal the full scope and capabilities of the new treatment. We have ali-eady seen that the study of the cases with reference to laryngeal involvement has brought to light evidence in favor of the serum treatment more convincing than that derived from the gross statistics of all cases treated, and evidence of a kind which meets many of the objections which have been urged against the interpretation of the gross statistics as demonstrative of the efficacy of antitoxin. We shall now see that the analysis of the cases according to the day of the disease on which the serum treatment is begun almost, if not completely, substantiates Behring's original claims, astounding as they seemed to be.

There is, of course, in many cases considerable uncertainty as to the exact duration of the disease at the time when the patient is first seen by the physician. The statements of parents or of those in charge of the children are often the only evidence on this point which can be obtained. Satisfactory information will be particularly difficult to obtain in the class of patients in the diphtheria wards of hospitals, these patients being chiefly the children of laborers. We are also to consider that a diphtheric affection of the throat may exist without such manifest disturbance as to attract even intelligent observation, or it may be mistaken for a simple sore throat. A tabulation of cases of diphtheria according to the day of beginning treatment will be, therefore, only of relative value, but we cau fairly assume that the duration of the disease will very rarely, if ever, be shorter, but often longer, than that stated.

In the excellent reports on antitoxin treatment from the Paris hospitals, the cases are not analyzed according to the day of beginning treatment, as Koux, whose scheme of classili

cation has been followed by most other French writers, stated in his original article that it was practically impossible to obtain trustworthy statements on this point from parents of the children. Most of the reports, therefore, which enter into Table IV are from German and English sources.

The statements as to the day of the disease are entirely from information obtained from parents and others, and are not estimates on the part of the physician, although in several instances the reporter says that the condition of the patient plainly indicated a longer duration of the disease than that assigned by the parents and put down in the report. It will be observed that not all of the reports in the table fit into any one system of classification, and therefore not all can be summarized in a single table. In each space the higher number is the total number of cases belonging to the heading, and the lower is the corresponding number of deaths.

As is well known, the fatality from diphtheria by any approved method of treatment is smaller the earlier in the disease the treatment is begun. This is clearly shown in the following table from the statistics of Y. Ilirsch of the cases treated in the surgical clinic in Berlin for ten years preceding August, 1894, and of course before the employment of antitoxin. The results are according to the day of the disease on which treatment was begun.

First Day.

Secoiid Day.

Third Day.

Fourth Day.

Cases, . . . Deaths, . . . Percentages, .

241

44

18.3

405

92

22.7

333 124 38.1

416 223 53.6

Fifth Day.

Sixth Day.

Seventh Day.

Eighth Day.

Cases, . . . Deaths, . . . Percentages, .

203

136

67

525 219 67.4

- 506 367 72.5

239 191 81.6

The preceding table is not intended to serve as a standard of comparison for my tables giving the results of cases treated by antitoxin, as the classes of cases in the two groups are not comparable.

Philip* has reported from Baginsky's service the results of treatment, before the use of antitoxin, begun in the earliest stages of diphtheria, the patients being brothers and sisters of children with diphtheria who were examined for Loffier bacilli, 80 that opportunity was given for recognition of the disease at its onset. The fatality was 10.5 per cent, lower in these cases recognized and treated early than in the others. The fatality of the cases treated by Baginsky with serum during the first three days of the disease was 32.2 per cent, lower than the preceding average fatality of cases not treated with serum. Plainly some more potent healing factor than merely that of early treatment was present. The only difference in the methods of treatment of the two groups of cases was the use of antitoxin in the one and its absence in the other.

•Philip: Arch. t. Kinderheilk., Bd. XVI.

July-August, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

117

TABLE IV.

FATALITY ACCORDING TO THE DAY OF DISEASE UPON WHICH ANTITOXIN IS INJECTED.

(la each space the higher number is the total number of cases treated on the corresponding day, and the lower number is that of the deaths.)

REPORTER.

Total number of Cases Treated.

1st Day.

2nd 3rd Day. Day.

4th Day.

5th Day.

6th Day.

After 6th Day.

Undetermined.

REMARKS.

Koseel

117 13 (11.1 per ct.)

14

30 1

29

9 1

11 2

6 3

12 5

6 1

Fatality for first three days was 1 4 per cent.

KOrte

121 40 (33-1 per ct.)

Of 37 severe and moderately severe cases injected during the first three days 8 died (21.6 per cent). The results following injection begun after the third day were less favorable.

Baginsky

625 83 (15.-6 per ct.)

111 3

134 14

92 13

62 12

39

14

13 4

29 12

55 11

All of the three fatal cases of the tirst day were far advanced on admission, therefore the statements of the parents as to the date of beginning of the disease were probably erroneous (liaginsky). Fatality for fii^st three days was 8.9 per cent. •

V. Mering

74 4 (5 per ct.)

Treatment begun on 1st or 2nd day in nearly all cases.

V. Noorden

81 19 (23 per ct.)

Treatment begun on the 3rd or later day in nearly all

cases.

Schroeder

63

8 (12.7 per ct.)

1st & 2nd Day. 23 1

3rd & 4th Day.

27 3

After 4th Day. 13

4

Vierordt

65 8 (14.6 per ct.)

3

14

2

17 2

9

7 1114 3 1 1 1

Kumpf

26 2 (8 per ct.)

18

1

3 1

After 3rd Day. 5

i cases were still under treatment at date of the report.

Ganghofner

110

14 (12.7 per ct.)

3

30

2

35 3

18

i

9 3

2

13

2

Heim

27 6 (22 per ct.)

9

2

1

7 1

3

1

1

5 3

BOrger

30 2 (6.6 per ct.)

3

13

9

3 1

1

1

1

Hager

25 1 (4 per ct.)

14 1

5

4

1

1

Private practice. The single fatal case died of complications after cessation of the diphtheria.

Kuntzen

25 3 (12 per ct.)

3

6

7 1

2

2

1 1

1

Schmidt

14 3 (21.4 per ct.)

The three fatal cases were not treated until after the disease had lasted for 8 to 14 days. Private practice.

Seitz

35 2 (5.7 per ct.)

10

12

9

After 4th Day.

The two deaths were in infants lH years and 13 months old with advanced laryngeal diphtheria on day of admission, presumably therefore treated after 2nd or 3rd day, although this is not stated.

Hall

11 3(27.3 per ct.)

2

4

4 2

1 1

Epidemic in Trieste Hospital cases

105 27 (25.7 per ct.)

6

30 6

29 9

20 5

11 4

7 3

2 1

Epidemic in Trieste Cases in private prartice

72 5 (6.9 per ct.)

14

27 2

18 1

8 2

2

1

11 2

Witthauer

36 5 (14 per ct.)

4

8 2

4 1

6

3

Blumenfeld

50 2 (4 per ct.)

1st & 2nd Day. 40

3rd & 4th Day

8

1

2

1

3

Of the 2 fatal cases, in one the treatment began on the 4th and in the other on the 5th day. Private practice.

Uapmund

100 7 (7 per ct.)

39 1 34

15 1 5

3

1

The deaths are given for the 1st and 2nd, the 3rd and «h and the 5th, 6th and after 6th day respectively.

2

3

2

Scbaewen

15

6

3

1

Ot the 5 undetermined cases the statement is that they had been ill several days before the injection.

Kisel

114

9 (7.9 per ct.)

78 4

21 4

4

4 5 1

- 89 of these cases were treat«d at their homes, and S in 1 1 hospital. They were mostly children.

V. Muralt

58 2 (3.4 per ct.)

11

18

17

After 3rd Day | 1

12 1 1

Uodd and Whitehouse

11

4(36.4 per ct.)

1

2

5 2

1

1 1

Winkfleld

22

4(18.2 per ct.)

8 2

7 1

4 1

1

m the 2 fatal cases in which it i? -; .n •■ ■ was made on the 2nd day, in one tbire >• sion advanced larynuial and nasal cV: glandular swellings, and in the othi i branes in the throat, nasal discharge . swellings.

Howard

40 3(7.5 per ot.)

24

2

1 "

Private practice.

Van Nes

62 12 (23 per ct.)

a

1

13 1

10

1

'■

7

No details given of fatal > day of the disease, but it tlo'n of the day was vti;. patients ichildren of lal>. i . ,

Kurth

97 10 (10.3 per ot.)

12

36 2

16 1

19 3

5

1

a 1

Ot thc2fat.ll cases in which it > began on the ind day. one was and died 18 hours afterward: tlv after disappearance ot the loc-.-ii .iiptitinria wnn albuminuria and broncho-pncunionia.

The following table is the sumvMrt/ of the 19 reports of the preceding table in ichieh the nwnber of <A« eatts vHh th^ rettUl* corrttpondimg to rA«  disease on loJiich antitoxin treatment toas begun is gicenfor each day up to and after the 6th day.

19 Reports.

Total. Isi Day.

2nd Day.

8rd Day.

4th Day. 6th Day.

168 116 32 84 19 29.3

6th Day. "^'rtatTf" | Cndctermlned.

Cases

Deaths

Percentages

1489 x'^ 212 1 5 14.2 2.2

45ii

. m

S.l

311

42

13.5

44 101 («»

IS » OS)

34.1 3S.: (1T.8I

118

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 42-53.

Including teith the preceding 19 reports those of Schroeder, Bliimenfeld and liapmund, we hare the following table tohich gives the results of antitorin treatment begun on the \tt and '2nd, on the Zrd and ith, and after the ith day.

22 Reports.

Total.

1st and 2n(l Day.

3rd and 4th Day.

After 4th Day.

Undetermined.

Cases

Deaths

Percentages

1702 229 13.5

814 45 5.5

534

81

15.2

286

91

31.8

(681 (12) (17.6)

It may alio be computtd from the table that of 1729 cases of diphtheria teith a fatality of 14. 9;^, 1115 cases treated with antitoxin during the first three days of the disease yielded a fatality of 8.5^, whereas 54G cases in which antilonn was first injected after ilie third day of the disease yielded a fatality of 27.8%. 0/232 cases in which treatment was begun on the first day 5 (2.15^) died; of 492 cases in which treatment was begun on the second day, 38 (7.7;i) died; o/331 eases in which treatment was begun on the third day, 43 (13^) died.

Kohts, an opponeut of the serum, treatment, at the recent Congress for Internal Medicine in Munich, claims for his method of local treatment no deaths among cases treated on the first day of the disease. For later days his results are much higher than those in the serum statistics. The percentages of deaths according to the day of beginning his treatment, as given by Kohts, without a statement of the number of cases treated, are as follows: 1st day, 0; 2nd day, 20 per cent.; 3rd day, 47 per cent.; 4th day, 55 per cent.

Table IV shows that out of 233 cases in which it is alleged that antitoxin was injected on the first day of the disease, 5 died. As a matter of fact, however, the assumed duration of the disease in each of these fatal cases is doubtful, as it rests solely on the statements of parents or those who cared for the children, and is aj)parently contradicted in at least the three cases concerning which any details are given by the condition of the patient on admission. Baginsky's three cases (\os. 311, 479 and 511 of his tables) when admitted were far advanced in the disease, with extensive membranous exudates, cyanosis and very bad general condition. Hager's case may more readily be accepted, as it occurred in private practice, but here the patient died after disappearance of the diphtheria from complications, whether or not referable to the diphtheria is not stated.

Of the fifth fatal case reported by Van Nes no details are given in such form that the case can be identified from^his description, but he himself places little reliance upon the alleged duration of the disease in the class of patients admitted to the hospital, these being the children of laborers.

I am not aware of the report of any fatal case of diphtheria properly treated Vjy antitoxin within the first 24 hours after the beginning of the disease, in which the duration was positively determined, still as I have not read every article which has been published on the subject it is possible that such a case may have been reported. There are, however, many such cases of prompt recovery reportecl as that quoted from Hall in Table IV.

It is noteworthy that the percentage of deaths in SN cases in which treatment was begun before the third day of the disease is only 5.5. If the doubtful deaths attributed to the first day be excluded, the percentage actually falls a trifle short of 5. If we furthermore make allowance for the fact that the assigned duration of the disease can scarcely be shorter, but may readily be longer than the actual duration, then our tabulation of 1702 cases of diphtheria according to the day of beginning treatment verifies Behring's original pre

diction. I do not, however, consider that it is justifiable from so small a number of cases and from material of the kind composing our table to draw any definite conclusions as to the exact percentages of deaths according to the date of beginning treatment.

According to the table the percentage of deaths in cases in which the serum treatment is begun on the 3rd and 4th days of the disease is nearly three times greater than that in cases treated on the 1st and 2nd day, and the percentage after the 3rd day is 3} times greater than that of cases treated~within the first three days.

We are of course not to infer from these results that antitoxin may not be beneficial when administered after the 3rd or 4th day of the disease. There are cases which are still mild after this duration, but which subsequently become serious, and even in desperate cases antitoxin holds out some hope of cure.

It is apparent that the largest proportion of cures by antitoxin are to be expected from private practice among those who call the physician in at an early stage of the disease. While a similar statement may be made concerning any other suitable method of treatment, it is not, I believe, true in the same measure as for the serum treatment.

The main purpose of this article has been the study of the evidence thus far published concerning the curative power of antitoxin in diphtheria. I do not propose to consider the practical points relating to the employment of antitoxin, nor to consider in detail the specific effects of injection of the healing serum. There has been much diversity of opinion as to these effects, and I shall present briefly the principal points which seem to me to be established.

Most writers approve of the continuance of such measures of local and general treatment as have hitherto been found to be useful, but recommend the avoidance of all irritating and caustic local applications.

The injection of the serum may be followed in a few hours by local pain, swelling and redness, but there is no danger of abscess formation if the serum is uncontaminated and proper antiseptic precautions are taken. In over 3000 injections Martin observed the formation of an abscess only three times.

In twenty-four to forty-eight hours after the injection the general condition of the patient is remarkably improved in the great majority of those patients who are in a condition to be benefited at all by antitoxin. This general improvement is accompanied by a fall of temperature, which may be a critical fall, especially if the disease is not far advanced;

July-August, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

119

ofteu it is a fall by lysis. hJoiiie hold that there may be a temporary rise of temperature as an immediate effect of the injection. Accompanying the fall of temperature is improvement of the pulse as to frecjueucy and tension, but the heart's action may for some time, even into the period of convalescence, remain weak.

In the favorable cases the local diphtheritic process is arrested, ixsually within the first twenty-four hours after the injection. Membrane may appear upon spots previously inflamed and invaded by the bacilli, but otherwise there is no extension of the membrane in the majority of the cases which are benefited. The area covered by membrane becomes sharply demarcated and the swelling of adjacent mucous membrane disappears. The membrane may disappear by rapid separation or by gradual softening. Sometimes it persists for several days after disappearance of all other local disturbance. Large membranous casts are coughed up from the larynx, trachea and bronchi under the serum treatment more frequently than under former methods. The rapid separation of the membrane in the lower air passages may cause sudden increase of stenotic symptoms. Nasal discharge is lessened. The swelling of the glands in the neck and the surrounding CEdema disappear, so far as these are not referable to secondary infections.

The most uncertainty prevails as to the influence of antitoxin in preventing the three most important complications or sequelte of diphtheria, nephritis, heart failure and paralysis. The weight of evidence is that genuine nephritis is far less common in cases treated by antitoxin sufficiently early than under other methods of treatment, but it is questionable whether albuminuria is less common, although it is considered to be by Kossel, Roux and others. If there is an albuminuria in any way directly referable to the injection of the serum, and this is by no means established, it is simple albuminuria with perhaps a few narrow hyaline casts but without evidence of any serious damage to the kidney. Peptonuria, it is claimed by Hecker, is an effect of the serum, but it is without clinical significance. Albuminuria is such an extremely common symptom of diphtheria that it must be very difficult to determine that it can be referred to the serum in any case.

Many writers emphasize especially the favorable influence of antitoxin upon the heart, but there are some who have observed that with decided improvement in all other symptoms the force of the heart may still remain weak and occasion anxiety. Baginsky's experience is that the minor disturbances of the cardiac action are not less frequent in cases treated with serum, they appear to be even more fre([uent as a larger number of cases survive, but that actual death from heart failure is far less common in the serum cases than in others.

I'ost-diphtheric paralyses may occur in cases treated with serum as early as the second or third day of the disease. Whether they occur in cases treated within the first twentyfour hours is not certain. According to some, paralysis is even more common in the serum cases than under former methods of treatment. This is doubtful, but if true, it may be attributed to the survival of a larger proportion of cases.

It is apparent from what has been said that antitoxin is most strikingly beneficial in progressive fibrinous diphtheria and especially in the prevention and cure of laryngeal diphtheria. In septic diphtheria the serum treatment is of little avail.

Antitoxic serum may produce unpleasant effects, but these do not involve danger to the patient. They are in all probability referable to the serum as such and not to the healing, so-called antitoxic, substance contained in the serum. The most common undesired effect is some form of exanthem, usually erythema and urticaria, sometimes an eruption like measles or scarlatinal rash. The same exanthems have been observed by Bertin after the injection of ordinary serum of the horse, and by Richardiere after injection of Marmorek's anti-streptococcus serum.

The serum from some horses is more likely to cause these exanthems than that from others, and there may beindividnal idiosyncrasies favoring their occurrence. Some writers report the occurrence of an exanthem in not more than five per cent, of their cases, others have observed them in over fifty per cent, of the cases treated with serum. They may be localized in the neighborhood of the seat of injection or extend from that over the greater part of the body, or make their first appearance at a distance from the point of injection. Often without noticeable fever they may be accompanied by considerable elevation of temperature and by pain and swelling in the joints. A rarer but more severe form of serum exanthem resembles erythema multiforme, and when this is accompanied, as it may be, by high fever, and severe pain in the bones and joints with swelling of the joints, the condition of the patient may really seem serious, but these patients recover. Some have attributed a petechial eruption to injection of the serum, but this may occur in diphtheria without serum treatment.

These occasional untoward effects of the healing serum are annoying, but, being unattended with danger to life and without serious consequences, they do not contraindicate the use of the serum.

There have been a few cases reported in which the writers, without any satisfactory evidence whatever, have referred the death of the patient to the use of the serum. The essential harmlessness of the serum has been demonstrated by over a hundred thousand injections,* and if future investigations should show that through some idiosyncrasy on the part of the patient death ever is attributable to the injection of the serum, this would probably count for about as much as the rare deaths from the use of ether or chloroform.

I shall leave untouched the question of the immuuiiing properties of antitoxin.

The principal conclusion which I would draw from this paper is that our study of the results of the treatment of over 7000 cases of diphtheria by antitoxin demonstrates beyond all reason:!-' .'"'i" that anti-diphtheric serum is a sj>ecific ciira

• Tlus v\ I'll 1.1 ^^.■^■m to be at least a moilerate estimate, as writing

November 20, 1S94, Beliring says that there had been t>p to that (late certainly over 40,000 injections (Das neue Diphtheriemittel, von Dr. Behrinp, Berlin, 1S94, p. 25).

120

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 52-53.

tive agent for diphtheria, surpassing in its eflBcacy all other known methods of treatment for this disease. It is the duty of the physician to use it.

The later reports show in general a decided improvement in the results of the treatment over the earlier ones, and there is every reason to believe that the results of the second year's employment of the new treatment will make a much more favorable showing than those of the first year. We shall come to a clearer understanding of the mode of action of the healing serum. Improvements in the methods of preparation and preservation of the serum, and possibly the separation of the healing substance, at least from other ingredients which produce the undesired effects, may be expected.

The discovery of the healing serum is entirely the result of laboratory work. It is an outcome of the studies of immunity. In no sense was the discovery an accidental one. Every step leading to it can be traced, and every step was taken with a definite purpose and to solve a definite problem.

These studies and the resulting discoveries mark an epoch in the history of medicine. It should be forcibly brought home to those whose philozoic sentiments outweigh sentiments of true philanthropy, that these discoveries which have led to the saving of untold thousands of human lives have been gained by the sacrifice of the lives of thousands of animals, and by no possibility could have been made without experimentation upon animals.

A MORE RADICAL METHOD OF PERFORMING HYSTERECTOMY FOR CANCER

OF THE UTERUS.

By J. G. Clark, M. D., Resident Gynecologist.

The onset of carcinoma of the uterus is so insidious, and its early stage gives rise to so few disagreeable subjective symptoms, that finally, when the patient is forced by repeated hemorrhages, which usually first alarm her, to consult a ghysician, the disease has passed beyond the possibility of a radical operation for its cure.

The route of upward extension is almost invariably by the broad ligaments; and on account of the close attachment of the lower portion of the ligament to the cervix, the progress is rapid through the intraligamentary lymphatics, and if not checked in the early stage is soon beyond the limits of any operation.

The downward growth on the vaginal walls and the metastasis from this point is often so very extensive that it also cannot be removed by the usual methods.

A casual review of the literature of the operative treatment of carcinoma is sufficient to convince one of the inadequacy of any method of treatment; but as the operative method is the only one which offers any chance of cure or benefit at present, it should be emploj'ed in all cases where the disease has not passed beyond the palliative effect of hysterectomy.

If the broad ligaments are densely infiltrated and the cervix deeply excavated, any form of radical operation is out of the question, as there is no possibility of even alleviating the symptoms.

If on the other hand the cervix is extensively ulcerated and the broad ligaments only slightly involved, the prognosis is favorable at least for the euthanasic effect of hysterectomy, and in a certain proportion of cases the disease can be removed completely even by the ordinary methods of hysterectomy.

During the last six months the clinical courses of three inoperable cases admitted to the gynecological wards of the .Johns Hopkins Ilosjjital have been closely followed, and in reviewing the histories of these cases in conjunction with the autopsy notes, we are more than ever convinced that any measure which offers the slightest prospect of mitigating the

agonizing pain and relieving the symptoms caused by pressure of the growth upon the rectum and ureters should urgently be advised.

Death in cases which are not operated upon is usually caused by obstruction of the ureters (uremia), i)eritonitis, or toxaemia from septic absorption.

The involvement of the ureters is usually late, but many weeks before this complication arises the sacral plexus may be pressed upon in one or both sides of the pelvis by the cai'cinomatous masses wedged into the inferior strait, and the patient suffer the most agonizing sacral and sciatic pain.

One of the three cases just referred to was of this type. The patient was admitted to the hospital six months before her death, and throughout the remaining days of her life was not free from pain a single hour, even under the influence of large doses of morphine.

The autopsy revealed a dense board-like infiltration of the broad ligaments which extended out to the jielvic wall, involving the sacral plexus at its points of egress from the sacrum. In this case had the uterus and broad ligaments been totally extirpated, e.veu six months before the patient was admitted, the i)rogress of the disease would jirobably not have been arrested, but she would have been sjiared the frightful agony of the last six months of her life by the relief of the pressure on the nerves. The left ureter in this case was completely blocked, and in addition to the pressure pains which she suffered there was present a partial uraimic toxaemia for three months before death which caused constant -nausea and considerable vomiting.

The second patient, a nuilado woman, was admitted three mouths before death with a deep crater-like excavation of the cervix and dense induration of the broad ligaments. She suffered intense pain, which was only j>artial]y controlled by morphine, and at last died of peritonitis from perforation of the lateral wall of the uterus into the peritoneal cavity. Iler abdomen became intensely tynipauitic, and for five days before death her temjierature ran as high as 105° to 107° F.

July-August, 1895.]

JOHNS HOPKINS HOSPITAL BULLETIN.

121

In the third case death resulted from urtemiu, both ureters being blocked, and in addition there was a ])yelone])hrosis and ureteritis on one side. For 73 hours before death there was total suppression of urine. In these cases we have exemplified the three usual terminations of carcinoma which are not subjected to operation: (1) asthcmia and uraemia from toxic absorption ; (3) peritonitis from perforation of the uterus, and (3) ura3mia, and pyelouephrosis from septic infection. These three cases also give us a vivid composite picture of the frightful suffering which these unfortunate women experienced.

The offensive discharge from the necrotic tissue is another excessively disagreeable symptom which invariably appears as soon as the ulcerative process is well under way, and can only be stopped by a complete removal of the carcinomatous tissue. This is of itself a justifiable indication for operation, as the discharge is always checked for some time, and frequently does not reapj>ear even though the disease continues to extend.

It is Dr. Kelly's rule to advise hysterectomy in all cases which have not passed beyond the limit of the palliative effect of the operation, even though there is no jiossibility of a cure, simply for the relief of the inevitable sym])toms which must arise if the uterus is not removed.

For the radical cure of cancer of the uterus the same surgical rule obtains as in cancer of other regions, viz. total extirpation of the primary focus and as extensive areas of adjacent tissue as possible to insure the complete eradication of the disease.

It cannot be gainsaid that it is better to have a local recurrence and ultimate death from metastasis following the removal of the uterus, with a decided amelioration of the usual distressing symptoms, than to have these symptoms increasing in their severity until death without operation.

The faults common to all methods of removing the uterus are (1) the broad ligaments are cut too close to the uterus, and (2) too small portions of the vagina are removed. (Fig. III.)

In at least 95 per cent, of cases where there is upward extension of the disease it is through the lymjjhatics of the broad ligaments. The local recurrence which we so often see on the margins of the vaginal incision also demonstrates very clearly the fact that usually too little of the vagina is removed.

In carcinoma of the fundus the extension is invariably through the broad ligaments, and any operation which removes a considerable portion of these structures offers the greatest hope of a permanent cure.

The usual methods of performing hysterectomy have been extremely unsatisfactory to every gynecologist, for the reason that only a small jiortion of the broad ligaments is removed and the remainder usually conceals nests of e])ithelial cells which fall outside the limit of the knife. The same may be said of the vagina. The results of the pathological examination of the uteri removed by hysterectomy in the Johns Hopkins Hospital not only definitely sustain this clinical observation, but also point strongly to the necessity of a more radical method than yet projiosed.

Of the last 30 cases, the specimens have been submitted to a most careful pathological examination, which has shown

that in 15 cases the carcinomatous process had passed beyond the limit of operation ; in one case the result was doubtful, and in only four cases could it be definitely said that all of the disease had been comj)letely removed.*

No stronger argument than this can be advanced for a more radical operation.

In at least five instances where the extension had occurred along either one or both broad ligaments, the carcinoma could not have passed more than a few millimeters beyond the limit of operation, as the epithelial cells were very sparse and were only barely perceptible in the margins of the incision.

In other cases there was no involvement of the broad ligament, but too little of the vaginal wall had been excised.

In comjjaring Fig. Ill of a uterus removed by vaginal hysterectomy and Fig. IV of the specimen from Case II which was removed by the method which I shall describe, it will be seen that none of the broad ligament or the vaginal wall is removed with the former, while with the latter there is a large portion of the broad ligaments and a considerable cuff of vagina.

The great danger of cutting or ligating the ureters in the past (Fig. 11) has prevented a wide excision of the broad ligaments, but now that Dr. Kelly has entirely removed this danger by introducing bougies into the ureters in all operations where they may be involved, we can turn our attention with greater conlidence to the more extensive extirpation of the tissues adjacent to the uterus.

The value of this procedure has been freiiueutly demonstrated in Dr. Kelly's clinic, and if generally adopted will no doubt save many lives which are lost from cutting or tying the ureters.

After laying a plan before Dr. Kelly for the more complete extirpation of the uterus, the broad ligaments and a portion of the vagina, and receiving his cordial endorsement and encouragement, I was granted the opportunity in April, 1S95, to put into effect the principles embodied in the proposed operation. There are three essential steps in this operation which differ from those now employed: 1st, the introduction of the bougies; 3d, the ligation of the upper portions of the broad ligaments, including the round ligaments and ovarian arteries, cutting them close to the jielvic walls, opening the two layers and dissecting the uterine artery out to its origin and ligating before excising any tissue, and 3d, the excision of a much larger jiortion of the vagina than usual.

•In a forthcoming article by Dr. IJussell upon the clinical course of cases subsequent to hysterectomy for carcinoma in the Johns Hopkins Hospital, it will appear that there is a greater percentage of permanent cures than the pathological examination of these 20 cases would seem to indicate. From the openinf: of the hospital in 1SS9 to August ISiM, 4S hysterectomies were performed ; of this number 41 were vaginal, 4 abdominal and 3 combined vaginal and abdominal. The results of these operations are as follows : 5 died from the primary effect of the oi>eration, 17 died subsequently from extension of the disease, t> have not been heard from, and 20 <ir are living and 3 dead, there are 4S per cent of these cases still living, certainly a very gratifying result, as it has now been nearly a year since the last of this series of cases was operated upon.

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By carefully ligating the artery in this way, and introducing the bougies, we eliminate the dangers of iieniorrhage and of injury to the ureters, and are enabled to extirpate the uterus, its broad ligaments, and the upper portion of the' vagina en masse.

The value of excising the carcinomatous tissue in one }iiece is dwelt upon with much stress by Dr. Ilalsted in the description of his operation for cancer of the breast, by means of which he has reduced the ratio of local recurrence from 50 to 20 per cent.* The same rule must hold good here.

He says " the suspected tissue should be removed in one l>iece: (1) lest the wound become infected by the division of tissue invaded by the disease or of lymphatic vessels containing cancer cells, and (2) because shreds or pieces of cancerous tissue might readily be overlooked in a ])iecemeal extirpation."

The j)rincipal reason for the careful dissection and exposure of the uterine artery is that one can tie it well out in its course and then, by making traction on the uterus towards the opposite side from which we are cutting, the broad ligament can be cut away close to its pelvic attachment. Figs. I and IV.

If one attempts to ligate the artery in the tissues any distance from the uterus without first dissecting it out, there is great danger of including carcinomatous tissue within the ligature and thus defeating the object of the operation.

Another reason for first ligating the artery as far ou't as possible is that there is no possibility of removing any more tissue after the broad ligament is once divided, as that portion attached to the pelvic wall at once retracts, carrying with it the artery and any carcinomatous tissue which may lie beyond the ligatures. This is the essential principle in the o])eration which is now proposed, and if followed will unquestionably give better results than where the broad ligament is ligated with one or two ligatures en masse and cut away close to the uterus.

While the introduction of the bougies is highly essential to this operation, it can be performed, but with much less facility, by following the course inirsued on one side in Case I.

The bougie was not introduced in the right ureter for reasons stated further on, and when the enucleation was begun it was found necessary to dissect out the ureter in its course and draw it to one side with a loose traction ligature, after which the operation was completed with as much ease as on the side where the bougie was introduced.

This necessarily requires more time, and consequently it shoiild be the invariable rule to lay bougies in both ureters, as the operation must be done with the most painstaking care if it is to be of any more value than the methods now pursued.

The details of the operation will be given in the description of the cases, and in the remarks following dase I defective points in the Icrhniqtie are noted which are corrected in Case II.

Case I. — Mrs. .L I'., mulatto, aged -18 year.s, adinilird A|iril 24, 180.5.

•The Johns Hopkins Ho.s|iital Reports, Vol. IV, No. (1.

Complainl — Hemorrhage from uterus and offensive vaginal discharge.

Marital Ilistorii — Married 25 years ; 12 children ; no miscarriages. All labors normal except the last in November, 1894; child still-born. Menses began when she was 14 years of age ; flow always regular and painless, lasting one and a half days. Since the birth of her la.-^t child she has had almost constant hemorrhage.

Leworr/(/B« for many years ; up to six months ago the disclnirge was odorless, but at that time became very ])rofuse and offensive.

Fam ill/ Histo rij — Negati ve.

Personal History — Patient has always been a very healthy woman.

Present Ailtnent — In August, 181)4, when patient was about six months ])regnant, the leucorrhffial discharge above noted became very offensive and irritating, and she began to grow weak and lose flesh. November 16th, 1895, she gave birth to a still-born child, and about one month later had a copious hemorrhage from the vagina, which has continued more or less up to the time of her admission to the hospital. She has at no time suffered the slightest pain, and barring the weakness and general debility, which is more apparent to her friends than herself, feels very well. Urination normal, bowels costive, no pain during defecation. Patient is auEEmic and has lost considerable flesh. Appetite poor, sleeps moderately well.

Examination — Abdominal walls lax and flabby, numerous liuea albicantes. Vaginal outlet much relaxed; beginning on the vaginal wall 2* cm. from the cervix there is a fungatiug mass which almost fills the vagina and completely involves the cervix. The broad ligaments are slightly involved close to the uterus. The fundus uteri is slightly enlarged and freely movable. Api)eiidages normal.

Diagnosis — Cancer of upper portion of vagina and cervix.

Operation, April 2G, 1895 — Urethra anaesthetized with cocaine, and ureteral bougie inserted into the left ureter through a No. 8 vesical speculum. The patient being very nervous, and as the right broad ligament seemed quite free, it was deemed best to proceed at once with the general anaesthetic, only a slight attempt having been made to lay a bougie in this side, which was not successful. An incision 15 cm. in length in the median line exposed the pelvic organs, which were found as described in the examination. The bougie in the left ureter could be felt as a solid cord running up along the side of the cervix and then curving gently outward in company with the iliac vessels and up over the brim of the pelvis. At the base of the broad ligament it lay at least IJ to 2 em. outside of the indurated area, and could easily be disjjlaced 1 cm. further out towards the pelvic wall, thus throwing it entirely out of the carcinomatous process.

'i'he operation was begun by tying the upper portion of the Itft broad ligament, including the ovarian artery, as closely Ik the pelvic wall as possible, clanqiing the uterine side and cutting between.

I laving divided the round and the upj)er portion of the broad lii^aiuents, and se]»arated the two layers of the latter, the vesical peritoneum was sni]i])ed with (he scissors, following the crease where it is reflected onto the uterus, around the anterior

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face of the uterus to the opposite broad ligament. By spreading the layers of the broad ligament apart, with a stalk sponge tlie uterine artery was exposed in the intraligameutary cellular tissue, it appearing somewhat tortuous, aud near the uterus imbedded in carcinomatous tissue. A careful dissection was now begun, au assistant in the meantime making strong traction with a small vulsellum forceps caught in the fundus, thus enlarging the normal space between (he uterus and pelvic wall and making the artery taut.

The artery was bared for 2i cm. from the uterus, the dissection being carried well down towards the internal iliac artery, which could be seen pulsating close to the point of ligation. A small blunt-pointed curved aneurism needle proved of great service in carrying the ligature. As the vessel ■walls seemed somewhat atheromatous, a second ligatui-e was placed for double security. This step in the operation was rather difficult on account of the close proximity to the large vessels, which were in danger of injury. During this dissection the ureter was constantly under touch, thus eliminating all possibility of injuring it.

The ureter was next dissected out of its bed and ])ushed toward the pelvic wall ; aud the broad ligament and the intraligamentary tissue ligated on the pelvic side close to the internal iliac vessels, with imbricated ligatures, each including 1 cm. of tissue.

Having reached the vaginal vault, the dissection was carried down along the lateral aud anterior vaginal walls with the fingers, by means of which the walls were pushed away from their attachments. There had not been the slightest loss of blood up to this point.

The upper portion of the opposite broad ligament was now ligated on the pelvic side aud clamped on the uterine side and cut. The two layers were then separated with a stalk sponge, the uterine artery dissected out aud doubly ligated. At this point careful palpation showed the broad ligament to be more extensively involved than the preliminary examination had indicated, and in order to remove as much as possible it became necessary to know the exact position of the ureter lest it inadvertently be ligated or cut.

With the other ureter as a comparative landmark, this ureter was easily located in the broad ligament and dissected out. A loose traction ligature was then thrown around it, and while the dissection was being carried down back of (he vaginal Avails, was drawn out of the way by an assistant. The broad ligament was ligated close to the pelvic wall as on the op])osite side and cut. At this point it became evident that the carcinomatous process had not only penetraled (he pos(erior vaginal wall, but had involved I lie anterior reetal wall to a considerable extent.

On account of the close relation of the recial and vaginal walls which were bound (ogedier by (he inllamnuitory process, an assistant was direc(ed to insert his index-finger into (be rectum while a\i attempt was made to separate the two walls. This could not be acconii)lished satisfactorily. The rectouterine rellection of jieritoneuni had been previously snipped aiul pushed oif in the same manner as the vesico-uterine rellection. ]5y making strong u]iward traction on the uterus, the vagina was also drawn mnvard and made t|uito tense. By

light percussion, a procedure suggested by Dr. Kelly to be emi^loyed in all cases of hysterectomy for accurately distinguishing the cervico-vaginal juncture, the point for amputation can be located accurately. An opening was made in the anterior vaginal wall with the sharp-pointed scissors, aud from this ])oint the vagina wa^ encircled by an incision made with Dr. Kelly's special hysterectomy spud, which proved of great value here in cutting so deep in the pelvis. Unfortunately a small area of carcinomatous tissue on the rectum could not be removed. With this exception the enucleation seemed to be very thorough. Considerable bleeding from the vaginal walls, which required several ligatures to control it, followed the amputation of the vagina. Before completing the operation another attempt was made to clear the rectal wall of the carcinomatous tissue by a careful dissection, but proved impossible. One or two large strips of iodoformized gauze were packed down into the space occupied by the cervix aud upper portion of the vagina, after w^hich the pelvic cavity was closed by whipping together the recto-uterine and vesicouterine reflections of peritoneum by a continuous suture, beginning at the stump of oue ovarian artery and running aci'oss to the opposite stump, thus effectually closing off the peritoneal cavity, which was then irrigated with 1 litre of normal salt solution (Fig. Y). The abdominal wound was closed with buried silver wire and subcutaneous catgut.

The vaginal gauze was removed in five days. Patient discharged in 24 days. Examination at (his time as follows: Vaginal vault smooth and vaulted, small line of cleavage felt where the vaginal walls haA'e united. No sign of local recurrence of the disease.

The pathological examination had by this time been made l)y Dr. Gullen, who confirmed the clinical observation that all of the carcinoma had not been removed, consequently the j)atient was requesled to return in one month for examination. June 20 — Patient examined to-day, and on the anterior rectal wall there is a minute area which is unquestionably carcinonuiious. The patient is perfectly comfortable, has gained five pounds, the hemorrhages have not appe;ired and she believes she is jierfectly well. The pelvis appears to be free, and by rectum there is no trace of induration on either side.

Jieinarks. — AVliile the dissection of the ureter in which no bougie was introduced was satisfac(orily aoconii)lisheil, it was much slower (liau on the opposite side, and in contrast much more diflicult. The bleeding from the vaginal walls following the excision of the uterus should be obviated by first jierforating with sharp scissors the vagina ;uitoriorly well below the carcinomatous area and then ligatiug the vaginal wall in snuvU segments and cutting, thus controlling all hemorrhage as the operation proceeds (vid. Case II).

With the exce]>(ion of the one point on the rectum which could not be removed, the operation was very Siitisfaclory. As far as (he ((uestion of complete cure is concerned, unfortunately for the patient this is quite as serious as though a much larger area was left.

Case 11. — Jlrs. E. Y., In-rman housewife, agetl 57 years. admitted dune 4th, IS'.'o.

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Gomphint — Excessive loss of blood from uterus.

Maritul Hhlorij — Married twice, one child and one miscarriage during first marriage, labors easy and not followed by any untoward symptoms. JIarried 23 years to second husband, during which time she has borne three children and had ten miscarriages. Nothing out of the normal course of events occurred in any of the labors, and no pain or discomfort followed the miscarriages. She was attended in all of her confinements by a German midwife. Menopause occurred in her 47th year, up to that time menses ill ways regular and normal since they first appeared in her I'.Uli year.

Fain ily History — Xegati ve.

Persomil Histori/ — Patient has always been very strong and healthy since childhood.

Present Ailment — One year ago she began to have a slight leucorrha?al discharge, which continued for six months, when it became blood-tinged ; since then it has grown more profuse and hemorrhagic until the present, when it is almost pure blood.

About Eiister, 1895, she had a severe hemorrhage, losing about one pint of blood.

General Condition — Slight an;eniia, no cachexia, very slight pain in lower part of pelvis, no loss of flesh. Appetite good, bowels regular, no urinary complaint. Heart and lungs normal.

Examination — Vaginal outlet relaxed, faint scar tissue in posterior vaginal wall. Projecting into vagina from cervix there is a fungating mass 2.5x5 cm., which is very fi-ialile and bleeds freely during the examination.

The cancerous process seems to be circumscribed and extends only slightly onto the vaginal walls. Fundus uteri small, senile, freely movable, not involved by the carcinoma. Broad ligaments very slightly involved. Ovaries not detected, probably senile.

Diagnosis — Cancer of cervix.

Operation, JuneCi, 1895 — Urethra anaesthetized with cocaine and patient ))laced in knee-breast posture. After an inffectual search for the ureteral orifices it was considered best to place the patient in the elevated dorsal posture, when t,liey were quickly located and bougies inserted into both.

Especial care was observed in this case as in the preceding to disinfect thoroughly the vagina. The broad ligaments were tied oflf and the dissection of the artery niade in the same way as in the preceding operation.

After freeing the vaginal walls for 2* cm. below the cervix, the vagina was i)erf orated anteriorly, but instead of at once completing the am])utation, a small segment of the vaginal wall was ligated and cut and then another, and so on around the entire circumference, so that by the time the uterus with the upper portion of the vagina had been removed all bleeditig was checked.

The oi)eratioii was coni)ileted by j)acking gauze into the ui)])er part of the vagiiui and closing tlie j)eriloneum over this, nuiking the seat of ojieration entirely extra-jieritoneal. This o]ieralioM rei|uired two hours for its coni])]elioii, the dissection

of the xiterine arteries requiring more time than any other step. It was practically bloodless and there was no variation in the patient's pulse from the beginning to the end.

The subsequent notes on the case are as follows :

June 1th — Patient recovered from ether by the time she reached the ward; at that time her pulse was 92, full and strong. She has passed a comfortable night. Temperature 99 J° r. ; pulse 100 this morning.

JuJie dth — Bowels moved thoroughly from the effects of fractional doses of calomel and an enema. Feels well ; no tenderness or distension in abdomen.

Jrine MUh —Cxiiuze pack removed from vagina; no odor; slightly blood-stained.

June ISth — Temperature normal ; abdominal wound inspected; subcutaneous catgut absorbed, union perfect, line of incision represented by only a faint hair-line.

July 5/A— Patient discharged, feeling perfectly well. Highest temperature on fourth day 100° F. ; pulse 112. The vaginal vault is entirely closed in, is perfectly smooth and dome-like. The line of union between its walls is represented by a small, almost imperceptible cicatrix. No induration in the lateral pelvic walls. Prognosis as to radical cure good.

August MUh — Patient returns to-day by appointment ; again examined and same condition found as just noted.

In conclusion, the steps of this operation may be summarized as follows :

1. Insert bougies under the local effects of cocaine, thus saving time and conserving the patient's vital powers for the operation.

2. Make abdominal incision of suflicient length to insure free manual movements.

3. Ligate upper portion of broad ligament with ovarian artery; divide vesico-uteriue peritoneum around to opposite side; push bladder off, and spread layers of ligament apart, exposing uterine artery.

4. Dissert uterine artery out for 3j cm. from uterus beyond its vaginal branch and tic.

5. Dissect ureter free in the base of the broad ligament.

(5. Ligate remainder of broad ligament close to iliac vessels and cut it away from its pelvic attachment.

7. Carry dissection well down below carcinomatous area, even though cervix alone seems to be involved.

8. Proceed on the oj)posite side in the same manner as on the first side.

9. Perforate vagina with sharp-j)ointed scissors, making strong traction on uterus with small vulsellum forceps so as to pull the vagina up and make its walls tense, then ligate in small segments (1 cm.), and cut each segment as it is tied.

10. Insert iodoformized gauze from .above into raw space left by the hysterectomy; draw vesical and rectal j)erituneum over this with a continuous fine silk suture.

11. Irrigate i)elvic cavity and close abdomen without drainage.

July 15, 18!)5.

FIG. I. In this plate the pc-ritoncum of one side of the pelvis is dissected oflf. showing the intimate anatomical relation of the bladder. uterus, uterine artery and ureter. Bougies are inserted into the ureters making them stand out as rigid tubes. The close relations of uterine artery and ureter and the ureter and cervical portion of uterus are well demonstrated, showing the imp<.ssibilitv of a wide e.xcision of the broad ligaments without the introduction of the bougies into the ureters.

NOTES ON NKW BOOKS.

PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.

THE JOHNS HOPKINS HOSPITAL REPORTS.

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL.

Vol. Vl.-Nos. 54-55.

BALTIMORE, SEPTEMBER-OCTOBER, 1895.

+++

Contents

A Case of Anthrax Septicsemia in a Human Being associated with Acute. Anthrax Endocarditis and Peritonitis. By George Blumer, M.D., 127

A Study of Subcutaneous Fibroid Nodules. By T. B. FutCHER, M. B., 133

Cases of Amoebic Dysentery. By Cunningham Wilson, M. D., 142

Proceedings of Societies :

The Hospital Medical Society,

143

Hyperpyrexia in Typhoid Fever [Dr. Oslek] ; — Abscess of the Liver, perforating the Lung [Dr Osleb]; — Pyarthrosis [Dr. Finney]; — Specimen of Stomacli removed after Francke's Operation for Gastrostomy [Dr. Finney] ; — Schede's Operation for Varicose Veins of the Leg [Dr. Finney].

Notes on New Books,

146

Books Received, .--- 146

A CASE OF ANTHRAX SEPTICEMIA IN A HUMAN BEING ASSOCIATED WITH ACUTE ANTHRAX ENDOCARDITIS AND PERITONITIS.

By George Blumer, M. D., Assistant in Pathology, and Hugh II. Young, M. D. (From the Pathological Laboratory of the Johns Hopkins University and Hospital.)

k

The following case of the (Edematous form of aiitlirax seems worthy of being recorded, on account of the rarity of this form of the disease iu this country, and also because of certain other interesting features of the case, namely, acute peritonitis and endocarditis due to the bacillus anthracis. The case has already been briefly referred to by Dr. Flexuer in the Johns Hopkins Hospital Bulletin for May-June, 1895.

C. B., aged 59, a native of Germany, and a laborer in a hair factory, came to the Johns Hopkins Hospital Dispensary on Saturday, May 11, 1895, complaining of the swelling of the lids of the riglit eye. His history was as follows :

Family History. Ilis father and one brother died of some lung trouble, the exact nature of which he does not know: one brother died of cancer of the liver. The family history is otherwise negative.

Past History. He had the usual exanthems as a child. Denies venereal history, and gives no history of secondary lues. Drinks one glass of beer daily. Does not use tobacco. Had typhoid as a young man, but since that time has always been strong and healthy. He has worked in a luiir factory for thirteen years.

Present History. Two days ago, while working with South American hair, he scratched his right eye with his hand, as it was itching. The next morning he noticed that the eyelids were slightly swollen, and itchy, and by this morning they were so swollen that he came to the dispensary.

At the time of the visit the swelling was confined to the lids of the right eye, and was fairly sharply localized: it was (Edematous in character, and quite boggy, the overlying skin appearing almost of a natural color. Two small incisions were made, one into each lid. and a small quantity of rather thin, whitish fluid, resembling diluted milk, was evacuated. Cultures upon agar-agar were made at this time, and two days later the tube inoculated showed a pure growth of an organism which resembled the bacillus .anthracis. aud which upon inoculation killed a mouse iu "24 hours. Further to5tfi proved it to be the anthrax bacillus.

The patient Avas admitted to the hospital on May 13, four days from the onset of the disease. The physician who attended him at his home, from Saturday until his admission on Monday, stated that his temperature had been subnormal during the entire period. On admission the patient com

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plained of nothing but slight pain beneath the right side of the jaw ; otherwise he felt perfectly comfortable. He had no headache or malaise. His mind was perfectly clear. The following note was made at this time:

Patient is in bed on his back. Temperature F. 102°. Pulse 133 per minute, regular, volume fair, tension not increased. Kespirations 16 per minute, easy. Tongue has a slight white coat. The mucous membranes are of a fair color, not cyanosed.

Both eyes are closed by oedema. On the left side the swelling is not nearly so marked as on the right, the lids being distended by a modei-ately lirm, watery cedema.

The lids of the right eye are much swollen, hard, and tense, and the overlying skin is occupied by several vesicles, varying in size from a pea to a bean, and filled with clear, yellowish serum.

The eyes themselves appear uniuvolved.

Over the whole of the right side of the face and neck, and extending ujo onto the scalp, is a marked cedema of varying consistency; immediately around the right eye it is very hard, and covered by tense shiny skin; over the forehead, neck and remainder of the face, as well as over the implicated scalp, it is much less firm and can be easily pitted by pressure.

The oedema extends across to the left side of the forehead, and occupies the neck as low down as the clavicle. On the inside of the mouth, the right cheek is mai'ked with the imprints of the teeth, and has a yellow -gray sloughy appearance.

The thorax is rather barrel-shaped, but expands well and equally.

The lungs are hyper-resonant throughout on percussion; on auscultation the breath-sounds are clear, but expiration is 1 prolonged.

The point of maximum cardiac impulse is neither visible nor palpable. The heart-sounds are best heard in the fifth intercostal space 3 cm. within the mammillary line. The souuds are rather distant, but apparently clear. Tile area of relative cardiac dullness is almost obliterated by lung tympany.

The border of the liver is indistinctly felt just below the costal margin.

The spleen cannot be palpated.

The abdomen is natural in a])pearance, but is universally tender to the touch.

The shins are clean. There is no oedema.

The glands on the right side of the neck are moderately enlarged, and tender. Their consistency cannot well be made out, on account of the overlying oedema.

The glands elsewhere are not enlarged.

May 14, 10 a. m. The patient is much worse this morning. He has had several involuntary passages of urine and fu'ces during the night. The mind is quite clear, and he an.swers questions rationally. He complains a good deal of cramp-like pains in the abdomen. The pains are situated in the umbilical region, and are sharp and constant, with occasional acute exacerbations, during which he has a desire to defecate. The abdomen is extremely sensitive to pressure this morning. The spleen cannot be palpated. The pulse at

the wrist is almost imperceptible and practically uncountable.

The heart-sounds are extremely distant and feeble.

The temperature has been subnormal since 4 a. m. this morning and is now F. 97°.

The right eye is somewhat more swollen than it was yesterday, and the oedema now occupies the whole of the scalp, and has spread down the right side of the chest to the level of the pectoral fold; it also occupies all the tissues overlying the upper part of the sternum.

The patient gradually sank, and died quietly at 4 p. m. on the 14th.

Before death the adema had spread further over the left cheek, and had also extended somewhat further down the chest. The patient became very cyanotic before death. There was no respiratory distress at-any time. His mind was perfectly clear to within fifteen minutes of his death.

On the morning of the 24th he had three loose watery stools, of a grayish color, and apparently containing no blood.

The urine was passed involuntarily and could not be examined.

Autops)', May 15th, 18 hours after death, the body in the meanwhile having been preserved on ice. Body 174 cm. long, moderately well nourished, strongly built. Rigor mortis in both extremities. The right eyelids are redematous, closing the eye ; they are congested and glazed, and the epidermis is peeling off. The whole right side of the face, below the eye, is oedematous, and the oedema extends over the head and neck. The left eye and left side of the face are less swollen. The oedema is well marked anteriorly over the neck and clavicles, and can be followed well down on the chest. On incising the skin, above the clavicles, much clear serum-like fluid escapes. The oedema extends beyond the median line to the left, and is immediately evident after incision, extending to the sternum. Subcutaueous fat is moderate in amount.

Peritoneum. The peritoneal cavity contains turbid fluid; at least 2000 cc. of such fluid is present in the cavity. The serosa is- injected, its reflection lost, the vessels very hyperaemic. Smaller and larger ecchymoses are seen beneath the serous membrane. In the smaller omentum, in the region of the pancreas, a large ecchymosis is seen.

In several situations along the small intestine the serosa is very hyperaemic, or even hemorrhagic, over areas as large as a silver (juarter, and at these places the walls of the intestine are bulged outwards. The tissues about the kidneys and pancreas are translucent in appearance and very (edematous.

Mediastinum. On removing the sternum the mediastinal tissues are swollen, cedematous, and contain gas bubbles. The cedema of the mediastinal tissues can be traced downwards from the neck, passing in with the cellular tissue below the clavicle. Large gas bubbles or spaces occupy this tissue.

Lungi^. Both lungs lie free in the pleural cavities. They are both em])hyseniatous, particularly in the upper lobes, and along the anterior borders, which almost meet in the middle line of the body, anteriorly.

The heart is nearly covered by lung.

On incision the two lungs present similar ajipearances. They mx> cedematous and very hyperasmic, the cedema and

September-October, 1895.]

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hyperajinia being particularly noticeable in tlie lower lobes. There is no actual consolidation.

Pericardium and heart. On incising the pericardium there is an escape of gas. No excess of fluid in the pericardial cavity. Both layers smooth and pale.

The heart is not enlarged; its cavities appear normal. The valves show no chronic change; the auriculo- ventricular orifices not perceptibly abnormal. Along the free edge of the mitral valve, and less along the aortic segment, are several small elevations, appearing to be quite recent vegetations, covered by small red clots. The aorta is quite smooth. The heart's flesh fi'iable and pale.

Liver. The capsule is free from adhesions. Surface smooth. On section, dark in color, quite cloudy ; consistency perhaps diminished.

Spleen. Free from adhesions ; well up under the costal margin ; moderately large ; only moderately soft ; red in color ; pulp abundant.

Kidneys. Both alike. Capsule strips off easily. The organs are swollen, the surface almost uniformly congested, the congestion being still evident on section. Stria? are coarse. Glomeruli visible and red. Ureters noi-mal.

Adrenals and pancreas appear normal.

Stomach. In the pyloric region there is in the mucous membrane a lai'ge, deeply congested area, measuring 8x6 cm. in extent. It is not clear that there is a false membrane over it, but some grayish-yellow material adheres to the surface.

Intestines. The duodenum is congested uniformly. Beginning in the jejunum, which is less congested, there occur at intervals small, elevated, deeply congested, or hemorrhagic foci. These are quite circumscribed, although the mucous membrane about them is congested. They average 2 mm. in width and project I mm. above the surface of the intestine ; they do not seem to correspond with the lymphatic follicles. The serosa over them is often the deeply congested, bulgedout portion already described ; this is, however, not exclusively the case. These foci are quite numerous in the jejunum, at least 15 being present in this part of the gut alone. At times, two or three were close together, though, as a rule, they were more separated. In the ileum they were also seen, in this situation perhaps a little more separated, but in all as many were present as in the jejunum. In connection with one of these areas in the ileum, what appeared to be a false membrane occurred. If a membrane, it was thin, and easily scraped away. Several of the nodules showed superficial ulceration. There was uo relation detected to the lymphatic apparatus, and the nodes were less numerous near the ileo-cajcal valve. The large intestine shows no such localized foci, only a diffuse congestion.

Mesiyit eric glands were swollen, congested, hemorrhagic, and softened.

Brain and cord not examined.

Bladder contained a small amount of turbid urine: the mucous membrane appears uornuil.

BaCTERIOLOGICA L E KAMI X ATION.

Cultures were made, at the time of the first visit to the dispensary, from the incision made into the upper lid. Cover

slips and cultures were made during life, from the serous fluid from one of the vesicles over the right eye, and also from the blood.

The cover-slips from both the vesicle and the blood showed large bacilli, occurring usually in chains, and morphologically resembling the bacillus anthracis.

The cultures taken on the first visit, and also those from the vesicles and _ blood, all showed large numbers of graywhite colonies.

Transplantations were made from these colonies, upon agaragar, gelatine, bouillon, potato, and litmus milk, the resulting growths resembling in every particular the growth of bacillus anthracis ; and cover-slips showing large bacilli similar to those obtained from the vesicle and blood.

A mouse inoculated subcutaneously with an oese of the original culture died 34 hours later with local oedema and swollen spleen, and the organism was found in abundance in its heart's blood and other organs. At the time of the autopsy coverslips were made from the peritoneal fluid, hearfs blood, cedematous fluid in the neck, spleen, kidneys and lungs. Typical anthrax bacilli were present in all these preparations, in the peritoneal fluid associated with pus cells.

Cultures from the heart's blood, spleen, peritoneum, liver, kidney and lung, all showed a pure culture of the bacillus anthracis.

Cover-slips and cultures from the urine were negative. At the time of the autoi)sy three mice were inoculated subcutiineously :

1. With one oese of blood from the heart.

2. With 2 oeses of urine (the surface of the bladder having first been sterilized).

3. With a small piece of tissue scraped from one of the intestinal nodules.

All three animals died within a short time of one another, about 24 hours later. Autopsies showed local cedema and swelling of the spleen, and cover-slips from the site of inoculation, and from the spleen, showed typical anthrax bacilli.

Histological Examixatiox.

Sections were made from the heart valve (including one of the fresh vegetations), from the lung, liver, kidney, spleen. stomach and intestine.

Heart valve. The valve itself appears to be normal, with the exception of an adherent triangular mass attached to one surface of it. This mass represents one of the small fresh vegetations. It is attached by its base, its apex lying free, the principal points of attachment being at the two angles. At its point of attachment the vegetation consists almost entirely of fibrin ; the body of the mass contains, beside fibrin, granular material, red blood corpuscles, many polynnelear leucocytes, and a few cells of an epithelioid type. The jwlynuclears and epithelioid cells are not equally distributed throughout the mass, but in certain places form closely packed aggregations of cells.

The valve itself appears to be free from anthrax bacilli, these being limited to the vegetation. Here they are extremely numerous, much more so than in the blood, and are distributed throughout the mass, being jH?rhaps a little more

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numerous in the cellular masses described above than elsewhere. The bacilli occur at times singly, but are generally in groups or long chains.

Lung. The lungs show a moderate degree of chronic interstitial pneumonia, with compensatory emphysema, and some congestion.

The anthrax bacilli are more numerous here than in any other organ ; they occur in the blood-vessels of the alveolar walls in large numbers. Xone are to be seen in the alveoli themselves.

Liver. The liver shows some thickening of the capsule and a well marked interlobular cirrhosis. In places there is a marked increase in bile pigment in the cells. A few localized areas of extensive fatty degeneration, with fragmentation of nuclei are seen scattered through the organ.

The bacilli are not very numerous in the liver ; when seen, they are in small groups between the cells, evidently in the blood-vessels.

Kidney. The surface of the kidney is covered by a slight exudate very similar to that obtained from the peritoneum. It consists mainly of red blood cells, but a few poly- and mononuclear elements are also present.

The organ shows here and there thinning and adhesion of the capsule with localized conuective tissue formation. A few fibroid glomeruli are seen. The kidney cells are well pi^served, as a rule, but in places, especially in the convoluted tubules, are swollen and granular.

The anthrax bacilli are present in moderate numbers; a few are seen in the exudate on the surface, and they are scattered throughout the organ, being most numerous in the glomerular vessels.

Spleen. The chief change in the spleen seems to lie in the accumulation of blood within its tissues ; the amount of blood is very large, and is evidently largely responsible for the swelling of the organ. The number of polynuclear leucocytes in the organ is very evidently increased.

The bacilli are found throughout the organ, most abundantly in the Malpighiau corpuscles; they appear to lie in the blood spaces.

Stomach. The changes here are rather sharply localized in the area situated in the pylorus, the gross appearance of which has been described. There is some slight necrosis of the outer layers of the mucosa all through the section, and a much more marked necrosis in the region of the local lesion.

The lesion consists in a sharply localized infiltration of the mucosa with anthrax bacilli. The bacilli forming this mass evidently originally came by means of the blood current, as deep in the mucosa two blood-vessels are seen, both of which show distinct breaks of continuity, with hemorrhage into the surrounding tissue. The mass of bacteria stretches continuously from these vessels, through the mucosa, to the mucous surface of the stomach, and consists of myriads of closely interwoven bacilli. The mass is not of even width from the surface to the depths, but spreads out widely in two places, one immediately beneath the mucous surface, and the other midway between the surface and the muscularis mucosa, thus forming two spreading masses connected witli each other and

with the ruptured vessels by comparatively thin pedicles of bacteria.

The mucous membrane surrounding this mass is very necrotic, though there is but little reaction, only a few polynuclears being seen about the focus.

Intestines. In the diseased areas, described macroscopically, the intestinal wall is much thickened.

The surface epithelium in these areas is almost entirely destroyed, and in many instances the villi have also disappeared, their bases remaining on the level of the openings of the follicles of Lieberkiihn. The denuded surface thus left is ragged, but is practically free from exudate of any description. The villi which remain show two distinct processes. A certain number of them show a markedly more cellular conuective tissue than normal, the increase in cells being of the lymphoid variety, and perhaps being only apparent, as the tissue is much compressed from the dilatation of the central vessels.

Certain others of the villi show a necrotic appearance, their cellular elements being greatly reduced in number, the nuclei of the cells which remain staining poorly, and the mass of the affected villus having a hyaline appearance and staining sharply with the eosin. This necrotic process on the surface of the intestine is not confined to the mucosa immediately over the diseased foci, but is found on the surface of the intestine elsewhere.

The muscularis mucosa is seen as an indistinct line, the indistinctness being due to its infiltration by cells, most of them polynuclear leucocytes, which spread apart its fibres, and render its distinction from the submucosa difficult.

In jilaces it is pushed up towards the mucous surface, by the much dilated blood-vessels of the submucosa; in places it is pushed down towards the submucosa by the dilated vessels in the mucous coat.

in the submucous coat the most marked changes are seen, these changes being responsible for most of the increase in thickness of the intestinal wall.

The blood-vessels are intensely dilated and full of blood, in which it is easy to see that an excess of polynuclear leucocytes exists. In places there has been actual rupture of the vessel-wall, with extravasation of blood into the surrounding tissues.

Surrounding the blood-vessels, and filling up the entire area between the muscularis mucosoe and the internal muscular coat, is a dense cellular mass, thickest at the centre of the diseased area, and gradually shading off at the periphery into approximately normal tissue. The return to normal is more rapid towards the jieritoneal tium towards the mucous surface.

The mass consists almost exclusively of leucocytes with polyform nuclei, as a rule, densely packed, but, in places, separated by masses of granular or fibrillar fibrin.

Towards the mucous surface of the intestine the cellular infiltration practically stops at the muscularis mucosa, this structure containing only a moderate number of leucocytes, and but a very few being found in the mucosa.

Passing towards the serous surface of the intestine, we find that the polynuclears have passed between the fibres of the

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131

circular muscular coat, in places spreading these fibres widely apart by their accumulation, and have penetrated into and through the longitudinal coat, appearing in large numbers on the serous surface of the intestine.

The longitudinal coat contains, in places, large numbers of the pus cells.

Here and there, throughout the cellular mass in the submucous coat, are small areas of necrosis with nuclear fragmentation.

The cell infiltration in the submucous coat is, as a rule, diffuse, but in places it appears as small circumscribed nodules. These nodules, under the low power, strongly resemble the normal lymphoid follicles of the intestine, the resemblance being made more striking by their situation in the submucous coat, and pushing up to, though not into the mucous coat. Under the high power, however, they are found to be made up of polynuclear leucocytes.

The nodules then are small, round or oval areas of cells situated about in the normal position of the lymphoid follicles, but having no relation whatever to these follicles, as their structure proves, and being in fact focal inflammatory lesions.

The collections of ganglion cells, both in the submucous coat, and between this coat and the internal muscular layer, are widely separated by the wandering in of polynuclear leucocytes between the cells.

The lymphatic vessels just beneath the muscularis mucosa are in places widely dilated, and crowded with bacilli.

In places on the peritoneal surface is an exudate composed of many red blood cells, a good many polynuclear leucocytes, a few mononuclear leucocytes, and fibrin.

The anthrax bacilli are found in all portions of the intestinal wall, though in greatest number in the submucosa.

The necrotic areas on the surface of the mucosa show very large numbers of bacteria ; in the majority of instances, however, these do not appear to be anthrax bacilli, but a much shorter bacillus, though an occasional long bacillus resembling anthrax is seen.

In places, however, on the necrotic surface, masses of practically nothing else but anthrax bacilli arc seen.

In the deeper parts of the mucosa, both the anthrax and shorter bacilli are seen, the anthrax bacilli being more numerous near the surface.

In the submucosa the bacilli are numerous; they are scattered throughout the inflammatory areas in small groups, and are found in large numbers in certain regions, viz. :

1. In or immediately beneath the muscularis mucosa in the form of a baud of bacilli, closely woven, of about the normal thickness of the muscularis mucosa. Those immediately beneath the muscularis mucosa are evidently at times in the dilated lymphatics described above.

2. Along the borders of the blood-vessels of the submucosa, liaving a similar band-like formation, and being most numerous along the border of the vessel nearest to the mucosa.

3. At the junction of the longitudinal and circular muscular coats, in the form of a loose network.

The bacilli are found scattered through the cinular muscular coat in fair numbers, often in quite large masses between

the muscle fibres, and in these instances in the same areas where the polynuclears are abundant. The longitudinal muscular coat and the peritoneal exudate show a few bacilli,

usually singly or in twos and threes.

Remarks. Clinically the case presents no very striking features. The cedematous form of anthrax is certainly rare in this countrv, but numerous cases have been reported elsewhere. That the infection took the a?dematous form was probably due to its location, most cases of this variety occurring about the eyelids, presumably on account of the thinness of the skin and the loose character of the cellular tissue in this region.

Debrou' reported a very similar case in 186.5, though in his case the intestinal lesions were not so far advanced as in ours, and there was no endocarditis present.

The occurrence of clinical symptoms, pointing to peritonitis and intestinal lesions, is worthy of note, as in a number of cases with extensive intestinal involvement no local svmptoms at all were present.

Mahomed' and Haase' report such cases, whilst Verneuil* and Houel, on the other hand, report cases similar to ours, with well marked abdominal symptoms.

The presence of abdominal symptoms may be of value in pointing out beginning intestinal involvement, as in a recent and interesting case reported by Schiitte,* in which there were independent infections of the skin and intestinal tract at quite long intervals.

Schiitte's case also illustrates the differences between primary and metastatic anthrax.

The patient was a butcher's apprentice, who assisted in killing a cow affected with anthrax.

Five days later there appeared on the upper lid of the right eye a carbuncle, the patient not complaining of abdominal symptoms until fourteen days afterwards.

At this time he had pain in the abdomen, constipation having preceded the pain for several days.

Death occurred on the 16th day after infection. Already at this time the malignant pustule had begun to disappear. but there was an extensive cedema over the face and neck, as well as of the mucous membrane at the entrance to the epiglottis. Moreover there was a typical anthrax -mycosis int«stinalis," with hemorrhagic lymphadenitis of the mesenteric and retro-peritoneal lymph glands.

Although the spleen was not ineonsiderablv eularsred. anthrax bacilli could not be found, either in it or in the osdematous skin of the neck, neither could thev be found in the neighborhood of the pustule, which was opened four hours post mortem : but streptococci and staphylococci were cultivated from the bloody fluid.

From the mesenteric lymph glands, iu addition to colon bacilli, and streptococci, anthrax bacilli showiu? jrreat virulence for mice were cultivated. These latter were found in large numbers iu the pathological lesions iu the stomach and intestines, where they occurred especially thickly, and at the inner margin of the necrotic tissues, becoming progressively fewer as the deeper layers were reached. They were never found iu the blood-vessels, though in these

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there were mauy streptococci, these being especially uumerous in the spleen.

In this case we have to deal with a primary carbuncle of the skin, and also a primary intestinal infection. From the latter situation the lymph glands became infected through the lymphatics. Upon these lirst infections there was added later a general streptococcus infection through the blood current. How did the intestinal infection occur?

It could uot have occurred at the same time as the skin infection, inasmuch as fourteen days elapsed between the two. It could then only have occurred either in consequence of the scratching of the itching pustule by the patient himself (in which pustule, during life, anthrax bacilli had been demonstrated), the bacilli having thus been carried to the mouth ; or the original blood had become dried on his hands or some other part, and the spores had been carried by himself into the intestinal canal.

Our case evidently differed entirely from this, the intestinal affection being secondary to the local one, and taking place through the blood current; the clinical symptoms show that the intestinal lesions occurred within a day or two of the original lesion, and the pathological findings leave no doubt as to the part played by the blood-vessels.

The case is interesting from a pathological point of view on account of the endocarditis, the peritonitis, and the intestinal lesions.

Endocarditis due to the bacillus anthracis ajipears to be rare; we have only been able to find two cases reported, both of them by Eppinger.'

Our case differs from both of Eppinger's, in that we found a perfectly fresh endocarditis on a previously normal valve, whilst in both of his cases, though there was a fresh endocarditis, there was also evidence of old valvular disease, the latter of course probably not due to the anthrax bacillus. The fresh vegetations in Eppinger's cases, and ours, were, judging from his description, of similar formation, though apparently the anthrax bacilli were present in much smaller ijumbers in his cases.

In one of his cases the evidence goes to show that the endocardial infection was not conveyed, at any race not entirely, by the heart's blood, but took place by means of infective emboli, occluding the newly formed vessels in the chronically diseased valve. As Eppinger points out, this process could not occur in a normal valve, which is free from blood-vessels.

and was only possible on account of the pathological vascularization brought about by the old endocarditis.

Actual peritonitis due to the anthrax bacillus would also seem to be rare.

In the cases of Mahomed," Houel, and Waldeyer," the peritoneal cavity contained large quantities of fluid of a serous character, but in none of these cases was fibrin present, though in Waldeyer's case the visceral peritoneum was injected and slightly cloudy. In none of the cases were the microscopical characters of the fluid ascertained.

In Krumbolz's' case fluid was also present, and though its microscopical characters are not mentioned, the anthrax bacillus was found in it, both in cover-slip and culture. It is quite possible that cultures and cover-slips would have shown the bacillus in all these cases, for in our case the fluid did not at all resemble pus, nor the ordinary serous peritoneal exudate, whilst the description of the fluid in the cases above mentioned would lead us to believe that it was probably similar in character. The intestinal lesions found in our case correspond very accurately, as far as the gross appearances are concerned, with those described by v. Recklinghausen,'" v. Wahl," Baumgarten" and others. We have been unable to find any minute microscopical description of these lesions, though in general characteristics the lesions seem to have corresponded fairly well with ours.

Literature.

1. Debrou : .\rchives Gen^rales de M^decine, October, 1865.

2. Mahomed : Transactions of the Pathological Society, London,

18S2-3.

3. Haase : Thesis, Wurzburg, 1894.

4. Verneuil : Gazette Hebdomadaire de Medecine et de Chirurgie,

May 29, 1857.

5. Houel : Gazette des Ilopitaux, Paris, 1850. 3 S. Vol. II, 485.

6. Schiitte : Dissertation, Gottingen, 1895 ; Abstract in Bericlit

iiber die aus dem Pathologischen Institut der Universitiit GiJttingen in Etatsjahr 1891-5 veroSentlichen wifisenschaftliclien Aibeiten.

7. Eppinger : Die Hadernkrankheit, Jena, 1894.

8. Waldeyer: Virchow's Archiv, Bd. 52, 1871.

9. Krunibolz: Beitriige zur Path. Anatoiuie iind zur allgemeinen

Pathologic, 1894, XVI, 240.

10. Von Recklinghausen : Virchow's Archiv, Bd. 30, 1804.

11. Von Wahl : Virchow's Archiv, Bd. 21, 1861.

12. Baumgarten : Lehrbuch der Pathologischen Mykologie, Vol.

II, 1890.

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133

A STUDY OF SUBCUTANEOUS FIBROID NODULES.

By T. B. Futcher, M. B.

During the last two years several patients have been admitted to the Johns Hopkins Hospital, in Professor Osier's service, in whom this interesting complication has been observed. Considering the comparative infrequency of the condition and the meagreness of the literature on the subject in the medical journals of this country, it seemed appropriate that these cases, together with a number derived from other sources, should be reported. Before doing so, however, a short review of the literature will be given.

Although our knowledge of subcutaneous fibroid nodules is for the most part recent, yet they had been observed at least as early as the latter part of the last century, when Sauvages * described them, though he did not note their association with rheumatism, the merit of which is ascribed by Jaccoud to Froriep. Froriep's observation was made in 1843, but there has been some doubt expressed as to whether or not what he described was the true subcutaneous fibroid nodule of rheumatism. Hillier^'f described them in 1868, whilst in 1871 Jaccoud" gave a very accurate and concise account of the nodules in his TraiU de Pathologie interne. Meynet," of Lyons, reported a case in 1875, one year after Barlow and Warner" observed the first case of their series. It is to the last mentioned writers that we are indebted for a good deal of our information concerning the subcutaneous nodules. They reported a series of 37 cases before the International Medical Congress held iu London in 1881, and were the first to systematically study the nodules and draw definite conclusions from their observations. Since the report of their series, quite a number of cases have appeared in the literature, most of them, however, in British and French journals. In looking up the literature of the subject one would be led to suppose that subcutaneous fibroid nodules are a rare occurrence in this country, judging from the comparative infrequency with which cases have been reported iu the medical journals. Dr. Osler^" is of the opinion that rheumatism occurs much less frequently in Philadelphia and Baltimore than in London, and that subcutaneous fibroid nodules as a complication of rheumatism are a "great rarity" in these two cities. The first case reported in this country, so far as can be ascertained, was from Dr. Osier's clinic at the University Hospital, Philadelphia, by J. K. Mitchell'* in December, 1888.

Cheadle'" attributes the fact that the nodules are so often overlooked and so seldom described, to three reasons: (1) because they are rarely seen in adults, and that it is from adults that we take our ideas of rheumatism as a disease ; (2) that they are not known of or looked for by the physician ; (3) that they often escape notice by their smallness.

The nodules usually vary in size from a hcmpscod to a walnut. They are situated generally in the subcutaneous tissue, and as a rule are quite freely movable. Not infrequently

• Davaine is the authority for this statement (Ref. 21). f See literature at the eiul of the article.

they may be attached by their deep surface to the deep fascia, the sheaths of tendons and muscles, and occasionally to the periosteum. Sir Dyce Duckworth-* is of the opinion that there are several different varieties of the nodules, and our observations would lead us to conclude that there are at least two distinct forms: (1) those which are comparatively small, extremely firm, distinctly rounded, and easily movable beneath the skin ; (2) those which often grow larger, are softer in consistency, somewhat flattened and lobulated, and to which the skin occasionally is slightly adherent. The first class comprises the larger number of cases, and to it belongs the typical subcutaneous fibroid nodule. Those belonging to the second type appear to be of a fibro-lipomatous character, and seem to be less frequently associated with endocardial complications than do those of the first type. In certain cases both forms will be found associated in the same patient, as in cases V and VI of the jjresent article.

Angel Money "^^ claims that the subcutaneous tissue is not alone the only situation where rheumatic fibroid nodules are to be found. He holds that the heart muscle may be the seat of nodular masses similar in appearance and structure to those found in the subcutaneous tissue. He speaks of " nodular pericarditis" and "pericardial nodules," and considers the two conditions to be distinct. In an autopsy on a woman aged 20, the whole pericardial sac was found obliterated by fairly recent adhesions, and nothing nodular about the pericarditis could be detected. Three definitely sub-pericardial nodules were found, however, each about the size of a hempseed. Angel Money holds that they are the "true homologues of subcutaneous nodules and ought to be called subpericardial nodules."

The subcutaneous nodules may be found either in the neighborhood of joints, or, as is quite commonly the case, over the fleshy bellies of the muscles. The fingers, dorsal surfaces of the hands and feet, the vicinity of the olecranon and condyles of the humerus, the margins of the jiatella and neighborhood of the malleoli are the most common situations. Other less common situations are the superior curved line of the occipital bone, the temporal ridge and forehead, the vertebral and scapular sj)ines, crest of the ilium and the fibrous structures of the intercostals. The skin over the nodules is usually freely movable and natural in color, although in certain instances it has been found somewhat thickened and reddened, and adherent to them as iu Middletou's" case. When such a condition exists, it is supposed that friction has set up a cert^iin amount of inflammation in the skin, resulting iu its becoming adherent to the nodules. Karely is there any pain complained of, but in some cases the nodules have been the seat of pain in damp weather, and their presence has also been associated with slight itching, as in the last mentioned case. At times slight pain is complained of during the growth and disappearance of the nodules, as iu Case VI.

It would appear that instead of the nodules occurring as

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[Nos. 54-55.

distiuct localized swellings, there may be a diffuse thickeniug of the subcutaneous tissue as in liershman's case/* which was reported as "A Case of Progressive Enlargement of the Hands." As a proof that such a condition may possibly exist, this same patient had typical subcutaneous nodules about both elbows and over one patella, sections of one of these showing the general characteristics of the nodules, and there was in addition a distinct history of repeated attacks of rheumatism.

The nodules occur most frequently in children and young adults. Dr. Osier" has found them oftener in adults. In Barlow and Warner's series of 37 cases, 17 of whom were boys and 10 were girls, all the patients were under 19 years of age. Without being able to state positively, it would appear from the cases which have been reported, that females are affected oftener than males. The duration of the nodules varies very much. The shortest duration from the eruption to the disappearance of a single nodule in Barlow and Warner's cases was 3 days, and the longest 5 mouths. Sir Dyce Duckworth" reported two cases, in which in one instance the nodules lasted 18 months, and in the other 30 mouths. There may be only a single crop of the nodules, or, as is more commonly the case, a succession of crops, some nodules diminishing while others are increasing in size. They very rarely appear about joints that are acutely inflamed. Usually they make their appearance after the acute symptoms have subsided and the temperature has become normal. The onset of the nodules is not accompanied by a fresh rise in temperature.

Tn examining a patient for the presence of subcutaneous fibroid nodules, it is always necessary to make a very close examination of the body. If the nodules are quite small the patient himself will in all likelihood be ignorant of their presence, owing to the fact that in the majority of cases their growth is not associated with pain. An inspection of the body is therefore not sufficient ; the neighborhood of the joints and the skin over the bellies of the muscles should be carefully palpated, as the nodules may be so small that their presence nuiy be revealed only by this means.

Fereol and Davaiue" have reported a number of cases of rheumatism, in which the skin and subcutaneous tissue presented small thickenings, which were due, not to a definite formation of fibrous tissue, but apparently to a localized cedema. These nodules rarely lasted longer than three days, and in many instances disappeared within 24 to 36 hours after their appearance. On account of their rapid onset and disappearance, and their association with rheumatism, they have been called by Fereol " uodosites cutanOes c'j)henii'res chez les arthritiques." Some writers consider them to be quite distinct from the ordinary subcutaneous fibroid nodule, whilst others consider them allied, differing only in degree of development.

A number of very interesting cases have been reported in which subcutaneous fibroid nodules have been found associated with severe attacks of migraine. A case reported by J. Ilobbs", of Bordeaux, is particularly interesting in this connection. The patient, a fenuile, had for twelve years suffered from severe attacks of migraine, which were almost invariably associated with the onset of the menstrual periods, and on

repeated occasions accompanied by the appearance of a subcutaneous nodule over the left frontal region. Upon the cessation of the menstrual flow the migraine and nodule disappeared. During one of the attacks the patient had quite an extensive crop of nodules over the forehead and scalp and about the right elbow. There was a distinct family history of rheumatism, and the patient's hands showed marked changes from chronic rheumatism. Davaine"' reported three cases in which the onset of migraine was in each instance associated with the appearance of subcutaneous nodules over the frontal region. This condition is interesting as it seems to afford proof to the theory that migraine is sometimes rheumatic in origin, and the presence of the nodules would give a clue to the true cause of the migraine in cases where there was no apparent joint involvement.

Several instances have been recorded where subcutaneous nodules have been found in cases of osteo-arthritis. Newton Pitt"' has reported several such cases, and states that the nodules have the same histological structure as those of rheumatism, although differing from them clinically in the following points : (1) they occur in adults ; (3) they are much more chronic and last for years ; (3) they are at times extremely painful and tender, the pain returning from time to time; (4) they are usually unassociated with any cardiac lesion ; (5) they may vary in size from a small shot up to one inch in diameter, but they are generally larger than those of rheumatism. Payne"^ and Mahomed" have both observed the nodules in osteo-arthritis, the latter stating that they are not identical with those of rheumatism.

As regards the gross appearance of the nodules, Cheadle"^' says that " when they are exposed by dissection, they appear as oval, semi-transparent, fibrous bodies, like boiled sago grains." The accounts of microscopical examinations vary considerably, but agree in a general way in that the nodules appear to be made up essentially of fibrous tissue in various stages of development. The examination made by Barlow and Wanier showed the nodules to be made up of a fibrous network, with caudate, spindle-shaped and nucleated cells and a large number of blood-vessels. They suggested that the appearance presented many of the characteristics of organizing granulation tissue. In a number of instances where microscopical examinations were made, the blood-vessels have been found markedly increased in number, and special stress has been laid on the changes in the blood-vessels themselves. In Middleton's case already mentioned, the nodules were made up largely of connective tissue in various stages of development. Hlood-vessels were almost entirely absent from the centre of the nodules, but at their periphery the arteries were abnormally numerous, and in many instances their coats were thickened by an infiltration of cells, the tunica intima being frecjuently particularly affected. The middle coat was also considerably thickened and dissected by a collection of cells. Groups of these cells frequently extended to a considerable distance from the vessels, and in many instances they mapped out the course of the minute vessels in the papillae of the skin. Middleton thought, on account of the marked changes in the blood-vessels, that the nodules might possibly be vascular in origin, as if produced by some irritant carried

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in the blood. Cavafy" found a marked proliferation of the endothelial cells in many of the blood-vessels in addition to the changes in the vessel-wall noted above. The vascular changes are not always a feature, however. In .7. K. Mitchell's'^' case the histological examination made by Dr. Osier showed "a dense fibrous stroma, with cells chiefly ovoid, the ends prolonged into fibrils. There was no such arrangement of round-celled elements, as in granulation tissue, which Barlow found in his specimens. The extreme toughness of the nodules indicates that they have undergone conversion into fibrous tissue. In teased specimens there were places in which the fibres were closely set together, as in embryonic connective tissue, but in the larger part very few cells could be seen among the wavy bundles of fibres."

The microscopical examination of the nodules from Case I of the present article (the full account of which will be given with the report of the case) showed several interesting features which, so far as can be ascertained, have not been previously noted. Briefly stated, these consisted of a definite hyaline degenerative change in the fibrous tissue in many places, whilst in other situations areas of calcareous degeneration were to be made out. The sections also showed the presence of giant cells and minute hemorrhages.

One of the most interesting features in regard to the nodules is that they disappear without leaving any apparent indication of their previous existence or situation. This seems remarkable, as definitely formed fibrous tissue, when once present, is not supposed to undergo absorption and disappearance. The same nodules may at various times undergo a diminution and increase in size. On account of the marked vascularity of the nodules this would be readily explained by a vaso-motor influence causing contraction or dilatation of the vessels.

Barlow and Warner stated that the nodules were in their nature probably homologous with the inflammatory exudations which form the vegetations on the cardiac valves. F. D. Drewitt"- has suggested that they might be related in their origin as well as in their nature. In the case of the cardiac vegetations, they generally occur on the free margins of the cardiac valves, where they are constantly subjected to the friction of the blood current, and when the valves become inflamed, to friction on each other as well. Likewise, the nodules are most commonly found over the most prominent part of the joints, where they are most liable to be subjected to injury and friction. Dr. Drewitt brought forward further proof of his theory that friction may be a factor in the production of the nodules, or at least in determining the position where the nodules occur. He stated that if the nodules make their appearance in a patient with rheumatism, who is kept constantly in bed on his back, they will occur in greatest numbers over the occiput and the spinous processes of the vertebra;, situations in which, under ordinary circumstances, they rarely occur.

Subcutaneous fibroid nodules are considered by such authorities as Barlow and Warner and Cheadle as a positive indication of the existence of a rheunuitic taint in the individual in whom they may be found. It would appear that rheumatic cases with endocardial complications seem to be most liable

to this interesting complication. This is borne out by the fact that in the majority of the eases which have been reported endocarditis has been present. A synopsis of Barlow and Warner's series of cases shows how grave the cases are in which the nodules occur. Of the 27 cases there was a distinct history of arthritis in 19, whilst 6 others had definite joint pains. In every case there was evidence of endocarditis, either mild or severe; pericarditis was present in 8 cases; in 10 there were definite choreiform movements, and 8 out of the 27 cases proved fatal. Cheadle holds that the presence of the nodules in a case of rheumatism is of very grave import, especially when they occur associated with definite signs of endocarditis, as he has found in his experience that the heart complication is "persistent, uncontrollable and marches almost infallibly to a fatal end "' and is practically equivalent to signing the patient's death-warrant. He also maintains that the gravity of the case is in direct proportion to the number and size of the nodules. Other observers have noted the progressive character of the heart lesion in cases of rheumatism associated with subcutaneous nodules.

Edge'" is of the opinion that cases in which the nodules occur without any associated endocarditis appear to be more common in adults than in children.

In some instances it has been noted that the heart murmur has diminished in intensity with the disappearance of the nodules. Whether or not this is of any practical importance is doubtful, as the intensity of the murmur bears no definite relationship to the gravity of the heart lesion.

C. H. Brown'- reported a case which was particularly interesting, in that it was the first case reported in this country in which thei'e was an association of rheumatism, chorea, endocarditis and subcutaneous fibroid nodules. Case II showed a similar combination, and as far as can be ascertained these are the only two such cases that have been reported in this country. Brown is of the opinion that cases of rheumatism which are associated with chorea are specially liable to the occurrence of subcutaneous fibroid nodules.

Fibroid nodules are rarely an accompaniment of acute rheumatism. They occur most commonly after the acute symptoms have subsided and their presence indicates that the rheumatism is very likely to run a chronic course, so that one should be guarded in his statements to the patient or his friends as to whether or not recovery will be rapid and complete.

Just as the nodules have been shown to be of some value from a prognostic standpoint, so in certiiin cases they may aid us in establishing a relationship between rheumatism and certain morbid conditions found in a patient. For instance, they were of great importance in arriving at the cause of the neuritis in Case VII. Xot infrequently the nodules occur in patients without there being any evidence or history of paiu or swelling of the joints. If we are to believe the statement of Barlow. Warner and Cheadle that the presence of the nodules is an absolute indication of a rheumatic taint, then their occurrence in cases of chorea and endocarditis without any joint involvement would prove the connecting link l)etween these diseases and rheumatism.

There are several conditions which might be mistaken for the subcutaneous nodules of rheumatism:

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1. Traumatic painful subcutaneous nodules. In this case there would likely be a history of traumatism; the nodules would be limited to possibly one or two in number and would be painful.

2. In the case of the ephemeral nodosites of Feruol, the true skin itself is involved; the nodules are not so hard and librous and disappear very suddenly.

3. Erythema nodosum might possibly be mistaken for the rheumatic nodules. In this condition the skin between the knee and ankle is usually the part involved. The thickening is in the true skin. The nodes are larger in diameter than the tibroid nodules usually are, the skin over the affected area is usually reddened and undergoes a series of changes in color. The affected areas in erythema nodosum are painful and tender to the touch.

i. Subcutaneous syphilitic gummata might at first present a somewhat striking resemblance, but in this condition the skin would soon become adherent to the mass, and the whole would present the characters of an inflammatory tumor. A possible history of lues and other evidences of syphilis would put one on his guard.

.5. In cases where tophi are deep-seated about the joints, as they not infrequently are, there might be some difficulty in diagnosis. Where such are present, there would most likely be others present in the ears, showing the deposition of iirate of soda. The history of the case would also give a clue to the true condition.

(i. Urticarial wheals show a slight resemblance, but would be distinguished by the skin itself being involved, and the areas presenting a whitish centre surrounded by a reddish halo. Pruritus would be marked, and there would in all probability be a history of gastric disturbance.

7. Heberden's nodosites might be mistaken for the nodules. The former are limited to the sides of the distal phalanges, are hard aud firmly united to the phalangeal bones of which they form a part.

8. A number of cases of subcutaneous nodules associated with syphilis have been reported. These do not appeal" to be gummatous in character, and present a striking resemblance to fibroid nodules of rheumatism. Careful inquiry should be made for a syphilitic history in all cases where nodules are present without any apparent joint complication. Cases of fibroid nodules in syphilis have been reported by Lailler,*' Dr. Stephen Mackenzie," Sir Dyce Duckworth,^^ and Dr. Kingston Fowler.'^'

9. The fibroid nodules of osteo-arthritis are very similar to those of rheumatism, but Dr. Newton Pitt claims to be able to distinguish them by the points already given.

10. Certain benign growths, as lipomata and fibromata, might be mistaken for fibroid nodules. The lipomata are larger, softer and more lobulated than the nodules, and are situated most commonly over the back and shoulder-blades. More difficulty would be found with the fibromata, as the fibroid nodules are really of a fibromatous nature.

The nodules seem to have a life history of their own and appear to be uninfluenced by any special treatment. One should treat the disease of which they are only a symptom.

Case I. — No history of rheumatism ; enormous hypertrophy and dilatation of the heart ; adherent pericardium; chronic proliferative peritonitis with ascites; subcutaneous fibroid nodules ; no endocarditis.

Louisa R., aged (on a<lmission) 13, an occupant of Ward G, with the exception of a few months at a time, from May 14, 1891, to December 8, 1894.

Father and mother are living and well ; no rheumatism in the family.

The patient has had measles, scarlet fever, and whooping-cough ; she has never had rheumatism or chorea. The mother is positive that there never has been any swelling or tenderness of the joints. Some time before admission to the hospital she had for a time pains in the muscles of the right arm.

Her illness began in the summer of 1891 with swelling of the feet and shortness of breath.

In the three years and a half during which she was under observation she had all the signs of enormous dilatation and hypertrophy of the heart ; there was a loud, rough apex systolic murmur, and we regarded the case as one of extreme mitral insufficiency from disease of the valve, with secondary great enlargement of the right heart. She had a pulsating liver, which gradually shrank. The recurring ascites was attributed to proliferative peritonitis and perihepatitis, and it was thought probable that she had adherent pericardium.

She never at any time bad swelling of the joints ; for the past eighteen months she had extreme and persistent cyanosis of the arms and legs.

About two years before her death we noticed for the first time the presence of subcutaneous fibroid nodules. They were most numerous about the elbows and along the margin of the ulnae. A few were also noticed about the wrists and over the ankles. The majority of them were small and shottj', though one or two about the elbows were larger and broader. They never were at any time painful ; a majority of them were very persistent, but one or two of these about the elbow disappeared.

This case is of a good deal of interest, as the presence of the subcutaneous fibroid nodules, even in the absence of a rheumatic history, rather tended to corroborate our view that she had disease of the mitral valve segments.

The autopsy showed colossal enlargement of the heart, which occupied nearlj' the whole of the front of the chest. The pericardium was adherent, particularly over the right chambers. The cardiac orifices were enormously dilated, but the valves themselves, beyond a trivial thickening, were not involved.

On microscopical examination the nodules are seen to be made up essentially of fibrous tissue in various stages of development. The older portions consist of a rather dense fibrous connective tissue in which the fibres are arranged in bundles running parallel to each other. Other portions are composed largely of cellular elements, which under a high power are seen to consist of small round cells, fibroblasts and polynuclear leucocytes. In these situations blood-vessels are quite numerous, so that to a certain e.xtent there is a resemblance to granulation tissue, as Barlow and Warner noted in their specimens. Several giant cells were present in the younger portions of the nodules, twenty-six nuclei being counted in one of these. The transition from the young portions to the well developed fibrous tissue is quite gradual.

Some of the sections show a very interesting feature in the occurrence of a definite hyaline degeneration of the fibrous tissue in certain situations. Where this degenerative change is most marked, the fibrous tissue appears to be arranged in bundles with a concentric distribution of the fibres, so that when the bundles are cut transversely they appear to be made up of a series of concentric rings. Til is hyaline degeneration also occurs, though to a less marked degree, in situations where there is not this special arrangement of the fibres. A further interesting feature is the occurrence of a distinct calcified change in these areas of hyaline degeneration at certain points. Portions of the fibrous tissue which have

undergone hyaline change show quite marked cellular infiltration, which, however, is almost entirely absent in the areas of calcification. The calcareous deposit appears to take place between the layers of fibres which have undergone hyaline change.

The vascularity of the nodules is quite a striking feature. The blood-vessels are most numerous at the periphery of the nodules, the central portions being comparatively free, excepting in the areas of cellular infiltration where minute blood-vessels are present. Some of the larger vessels show an infiltration of small round cells into their walls, these, in certain instances, extending some distance into the surrounding tissue. Many of the bloodvessels contained an excess of polynuclear leucocytes, which in some cases almost fill the vessel ; other vessels are occluded with plugs of fibrin. In one or two instances there is a distinct proliferation of the endothelial cells, the lumen of the vessel being almost filled with the proliferated and desquamated cells.

Minute hemorrhages into the connective tissue are seen in several situations.

The nodules are for the most part quite circumscribed, although cellular infiltration into the surrounding connective tissue does occur to a greater or less extent.

Case II. — Rheumatism, chorea, endocarditis and subcutaneous fibroid nodules.

F. F., male, set. 16, was admitted to the Johns Hopkins Hospital in Dr. Osier's service, June 29, 1894, complaining of pains in the wrist joints and nervousness.

The family history was unimportant; no history of rheumatism in any member of the family.

The patient had measles, chicken-pox, mumps and diphtheria when a child. There was no history of his having had scarlet fever. From childhood up to the onset of the illness for which the patient was admitted to the hospital he ha<l always had good health. Used tobacco and stimulants moderately ; denied having had gonorrhoea or syphilis.

The patient's illness began 10 weeks previous to admission to the hospital with sudden swelling of the right ankle-joint, which was also very tender to the touch. Skin over the joint was reddened. During the first week of the illness almost all the large joints became affected, the ankles, wrists, left tempero-maxillary joint, knees and hips being involved in the order named. All these joints were swollen and painful, so that during the second week he was unable to move in bed. Improved gradually during the third week, andat the end of the fourth week patient was able to get up. Since then patient had several relapses, having had to go to bed for one week.

Five days previous to admission, patient began to have involuntary movements of the arms, legs and tongue, which, however, were not so severe as to prevent his getting about. Two days previous to admission, however, the movements of the arms became very violent and uncontrollable, and those of his tongue interfered very much with his talking. Deglutition was not interfered with. There were sliglit spasmodic movements of the facial muscles, but the patient could not say how long they bad been present.

No symptoms specially referable to the heart were complained of.

An examination of the patient on admission, showed but slight evidences of rheumatism, all tlie joints being moved quite freely without causing much pain. Complained of slight pain in the metacarpo-phalangeal and phalangeal joints of both iiands, which were slightly tender on palpation.

The backs of both hands showed numerous subcutaneous fibroid nodules, particularly in the neighborhood of the metacarpo-phalangeal joints, about each one of which there were from four to five nodules. The nodules were present also about the phalangeal juints, but in smaller numbers. The wrists were free, but there wore several nodules about the elbow-joints, chiefiy over the olecranon processes and condyles. No nodules were to be found on any other part of the body. The nodules varied in size from a pin's head to a split pea, the skin being freely movable over them and not red

dened. Those over the metacarpo-phalangeal joints were best seen by tightly closing the hands.

The patient exhibited slight, but definite choreiform movements in the arms and hands, with occasional twitchings of the leg and facial muscles.

The lungs were clear throughout on percussion and auscultation.

Thepointof maximum cardiac impulse was bestseen in the fourth space in mammillary line. No thrill was to be made out. Relative cardiac dulness began at the third rib ; extended transversely from the left sternal margin to a point 2 cm. outside the nipple line. At the point of maximum cardiac impulse there was a rough systolic murmur to be heard, this being also well heard along the left border of the sternum.

The examination of the urine showed it to be practically normal, although at a subsequent examination a faint trace of albumen and a few granular casts were found.

The general condition of the patient while in the hospital improved markedly. The examination of the patient on August 15th, the day on which the patient left the hospital, showed thattbe choreic movements had practically ceased and the joints had entirely cleared up. An occasional nodule could still be made out on the backs of the hands and there was one still to be seen over the right elbow.

The examination of the heart showed that it had undergone a definite change. The point of maximum impulse was now in the fourth space 2 cm. outside the mammillary line. Relative dulness began at the second rib. The first sound at the apex was sharp and snapping, and was followed by a slight systolic whiff, traceable into the axilla. There was now a short presystolic murmur audible at the apex. A slight, soft systolic murmur was to be heard over the base of the heart and a systolic puff over the vessels of the neck.

The thyroid gland was distinctly enlarged, the right side being a trifle the largar. Eyes were not particularly prominent. The usual range of the pulse was between 108 and 128.

The highest temperature at any time during his stay in the hospital was 101°, and it had been normal for 3 days previous to his discharge.

The treatment was rest withol. gaultheriae and liquor arsenicalis in increasing doses. Patient was taking 20 minims of Fowler's solution 3 times a day previous to his leaving the hospital.

The above case is interesting in that it shows the very unusual association of rheumatism, chorea, endocarditis and subcutaneous fibroid nodules in the same patient. It was also interesting on account of its showing that the cardiac changes were progressive, the heart increasing definitely in size and tlie murmurs changing in character. An effort has been made to try and find ont the patient's present condition, but we were umible to get any information with regard to him. So far as can be ascertained, the only other similar case reported in this country was that of C. II. Brown. Mackay reported a similar c;ise in the Lancet, the patient making an excellent recovery.

Case III. — Rheumatism, aneurysmal dilatation of tht aorta, and subcutaneous fibroid nodules.

P. H. D , colored, male, ret. -19. was admitted to the Johns Hopkins Hospital, in Dr. Osier's service, November 22, 189-1. complaining of pain in the left side and shortness of breath.

The family history was unimportant ; no hereditary disease in the family.

There was no history obtainable of the patient baring had any of the diseases of childhood. Had small-pox when 29, and facial erysipelas when he was 30 years of age. There was no history whatever of rheumatism previous to three years before admission, when patient began to complain of severe pain in the fore part of

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the left foot, which was excessively tender and considerably swollen. Confined to bed two weeks. No other joint involvement. Had gonorrluea when 39 ; no history of the initial lesion or any secondary symptoms of syphilis obtainable.

Eight years ago, five years i)revious to the " rheumatic " attack, patient noticed in front of his right knee a small lump which felt like a shot under the skin. Four or five months later a similar lump appeared over the front of the left knee, and subsequently one appeared over the right and left elbows in the order named. The nodules made their appearance without any apparent cause. They felt to the patient like "bird-shot" beneath the skin, were always freely movable, and at no time painful. Their size had gradually increased until one year previous to admission, since when they had remained stationary. Patient never knew them to diminish in size and increase again. He had never seen similar lumps on any other part of the body.

The symptoms of which the patient complained, on admission to the hospital, began three weeks previously, with pain of a constant aching character in the lower part of the left side of the chest. Occasionally the pain was sharp and shot up towards the left shoulder, but never down the arm. It was worse on exertion and deep breathing. Patient had had dyspncea for four or live days, and occasional attacks of palpitation and vertigo. No histor of oedema of the feet. Appetite good ; bowels regular.

An examination of the patient, on admission, showed him to be a well formed, well developed man. There was marked pulsation of the carotids and suhclavians, and that of the radials was visible. Radial pulse was 76 to minute, regular in force and rhythm, good volume, and somewhat collapsing in character, though not typically so.

On the left elbow there were two large, subcutaneous, movable, lobulated nodules, the larger, 3x4 cm., being situated just behind the internal condyle, the smaller, 2.5x2.5 cm., just below the tip of the olecranon. On the right elbow, just below the tip of the olecranon, there was a still larger nodule, measuring 4x5 cm., and just by the side of this a smaller one, not larger than a split pea. On both knees, just below the patella, were similar nodules, the one on the left side being 3x3 cm., that on the right being a trifle larger and consisting of an agglomeration of smaller ones. These nodules were all moderately firm. They had never been painful and were not tender on palpation.

Lungs were clear throughout on f)ercus8ion and auscultation.

The examination of the heart showed rather interesting changes. The point of maximum cardiac impulse was in the fifth space, 1 cm. outside the mammillary and 11 cm. from the midslernal line. Kclative dulness began at the fourth rib, extended transversely from the left sternal margin obliquely outwards to the point of maximum impulse. At the point of maximum impulse the first sound was dull, preceded by a very faint rumble, and followed by a slight systolic murmur, which was lost 4 cm. outside the point of maximum impulse. Second sound quite sharp. Immediately inside and above the point of maximum impul.se the first sound was preceded by a distinct presystolic rolling sound, which was heard over a very small area. Passing inwards and upwards from this point the sounds were represented by a double murmur, a systolic and a diastolic, the latter being best heard along the left border of the sternum and in the aortic area. In the second right interspace the sounds were quite loud, the first being represented by a harsh systolic murmur, the second by a well marked, somewhat accentuated second sound, followed by a slight murmur.

The further physical examination of the patient revealed nothing of importance, with the excejition of a symmetrical enlargement of the parotid glands.

On December 23 it was noted that the radial pulse had become distinctly collapsing in character.

On January 24, 18!)5, there was notice<l for the first time a pronounced throbbing over the second costal cartilage and interspace on the right side close to the sternum. This was both visible and

palpable. Percussion note was slightly dull over this area. The double murmur was still audible as on admission. Tracheal tugging was just to be made out.

An examination of the patient on February 8, 1S95, revealed a striking difference in the volume of the two radial pulses, the right being much smaller than the left. There was no inequality of the pupils. The pulsation above noted had extended upwards, and on this date there was a distinct lifting of the inner end of the right clavicle and the sterno-clavicular articulation with each heart beat. This pulsation was most marked in the recumbent posture, almost disappearing when the patient sat upright. It seemed to be less marked over the second right cartilage and interspace where it was first noted. No thrill was to be made out over the pulsation, but a distinct thrill was to be felt over the vessels of the neck. .

About two weeks later, February 26, the patient became very hoarse and cough was very distressing. Large quantities of ropy, tenacious sputum were expectorated. Microscopical examination of the sputum on this and subsequent occasions failed to show the presence of tubercle bacilli. For the first time it was noted that there was an inequality of the pupils, the right being larger than the left. Patient had been passing a diminished amount of urine, which contained a distinct trace of albumen and numerous hyaline and finely granular casts. The lifting of the right clavicle did not seem so marked as on previous examinations. The double murmur was to be heard as before.

From this date on the patient's general condition seemed to be gradually getting worse. He suffered intensely from severe attacks of dyspncea and palpitation of the heart. A laryngoscopic examination by Dr. Warfield on March 8th showed a complete paralysis of the left aryteno-epiglottidean fold, although the cords did not seem to be affected. The attacks of dyspncea and palpitation gradually became more severe, and face became swollen, particularly on the right side.

The subcutaneous nodules were much the same as on admission, being possibly a trifle smaller. There had been no appearance of any fresh nodules on any part of the body. Patient did not have any evidences of arthritis while in the hospital.

On March 14 the patient became unconscious and died at 9.30 p. m.

Postmortem . Only the most important parts of the post-mortem examination will be given. The heart and aorta showed very interesting changes. The heart was both bypertrophied and dilated ; both ventricles were involved, particularly the left. Left ventiicle averaged 19 mm. in thickness and was 9 cm. in length. Average thickness of right ventricle was 4 mm., the length being 9 cm. Mitral orifice measured 10 cm. in circumference, and the mitral valve appeared quite normal. Tricuspid orifice measured 12.5 cm. in circumference ; valves were normal. Pulmonary valves were normal. Both auricular apjiendages contained recent thrombi. The aortic valves were thickened and retracted at their margins. The aorta measured 8 cm. in circumference just above the valve. There was a diffuse dilatation of the ascending and transverse portions of the arch of the aorta. The circumference of the aorta, at the origin of the innominate, was 10 cm. At the beginning of the thoracic aorta there was a farther dilatation which extended for a distance of 17 cm. It extended backwards and to the left, was spindle-shaped and involved all the coats. The central part of the dilatation was covered « ith light, adherent, laminated fibrin. This dilatation measured 12 cm. in circumference at the beginning, 13 cm. at the widest part, and 8 5 cm. at its inferior extremity. It was adherent to the fourth and fifth dorsal vertebra", the bodies of which were eroded by pressure. The aorta was the seat of extensive nodular endarteritis. There were adhesions between the pericardial sac and the aorta.

Both lungs were partially bound down by old adhesions.

Kidneys showed marked chronic diffuse nephritis.

The left pneumogastric and recurrent laryngeal nerve were pressed on by a calcified pigmented gland.

Unfortunately no specimens of the nodules were obtained at the

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autopsy, so that a report of the microscopical examination of tliese cannot be given.

The above case is interesting on account of the long duration of the nodules — 8 years, and from the fact that they appeared 5 years before the patient had had an attack of rheumatism. The heart and aortic changes were interesting, as the aneurysmal dilatation practically took jjlace while the patient was under observation in the hospital wards.

Case IV. — Rheumatism and subcutaneous fiOroid nodules without endocarditis.

J. B. T., male, let. 28, a hospital employee, was admitted to the Johns Hopkins Hospital, Dr. Osier's service, June 24, 1895, complaining of pains throughout the body, vomiting, diarrhoea and sore throat.

Father was living at 68 years of age and had always been subject to attacks of rheumatism from childhood up. After a rheumatic attack when 20 years old he had numerous nodules appear beneath the skin of the arms and legs, some of which the patient states have persisted- up to the present time. According to the patient's statement, these nodules would increase in size during an attack of rheumatism and diminish again afterwards. Could not say whether his father had crops to appear and disappear. Most of the nodules were the size of hazel-nuts but were never painful. Patient's paternal grandfather was disabled for 22 years as the result of repeated rheumatic attacks. A paternal aunt was subject to rheumatism, and a second died of apoplexy.

Patient hail had measles, chicken-pox and mumps. When 14 years old he had a severe attack of pain in the lumbar region of the vertebral column, and also in the muscles on each side and over the shoulder-blades. Was confined to the house for 2 weeks, and had to be propped up in a chair. It was 6 to 8 months before he was able to get about properly, and since then he has never been able to do much stooping without causing pain in the back. About the time of this attack the patient notic,ed a lump about the size of a hazel-nut on the dorsal surface of the right forearm about 3 inches above the wrist joint, and a similar one on the palmar surface of the left forearm about the same distance from the wrist. These have persisted up to the present time, never having entirely disappeared. During an attack of pain in the joints, the nodules would become larger and harder and afterwards diminish in size again. Since the attack of pain in the back when 14, patient has had repeated attacks of pain in nearly all the larger joints of the body, which, however, have never been swollen. Has had nodules appear and disappear during these attacks. Two years ago patient had a severe attack of pain in the left ankle, which prevented him from working for;! or4 months. Joint was not swollen. During this attack the patient noticed several nodules appear on the front ami outer aspect of the left thigh, and two between the crest of the ilium and the left costal margin. Three of tliese on the thigh and the two last mentioned ones have persisted to the present time. Several mild attacks of pain in the joints have occurred since two years ago, and several nodules have appeared and disappeared since then.

Had an attack of dysentery when 19, which lasted one year ; malaria when 18; pneumonia 3 years ago. No history obtainable of gonorrhoea or syphilis. Never had chorea or palpitation of the heart.

The symptoms of which the patient complained on admission began Ave days previously with pains in the elbow, shoulder, knee and ankle-joints, and pain in the back. Pain wrs severe, and he had a stabbing pain beneath the right shoulder-blade. Soon after the joint pains began his throat became slightly sore. Those symptoms continued up to the time of admission, previous to which for 24 hours he had had nausea, vomiting and diarrhoja, which he attributed to an indiscretion in diet.

The patient was a large framed, healthy-looking man. Pulse was 100 to the minute, regular, good volume; vessel wall not thick

ened. Throat was slightly reddened, but tonsils were not swollen. Joints were all slightly painful, but not swollen. The following were the situations of the nodules :

Right arm : 1 on the outer side of the arm 8 cm. above the external condyle, 2 on the anterior aspect of the forearm over the flexor muscles, and 2 on the posterior surface over the extensors. These varied in size from 1 to 2 cm. in diameter, were strictly subcutaneous and movable, moderately firm, somewhat flattened and not tender.

Left arm : 1 nodule, 1x1.5 cm., about 4 cm. above the wrist on anterior surface of forearm. It was subcutaneous, movable on the deep structures, rather firm and flattened. This was in all probability the one which had been present since the onset of the rheumatism when patient was 14.

Left thigh : I'here were 4 nodules on the outer and anterior aspect of the middle third of the thigh, all of which measured 2x2 cm., and one of which was rather tender on pali)ation.

•Ibout midway between the iliac crest and the left costal margin there were two separate nodules, which were rather deep and measured 3x3 cm. They were rather deep-seated and somewhat tender. Skin was less freely movable over them than i i the other instances.

Lungs were a trifle hyper-resonant on percussion. Few tine, moist rales heard in right axillary region.

The point of maximum cardiac impulse was neither visible nor palpable. Heart-sounds best heard in 4th space, 3 cm. inside the mammillary line. The relative dulness did not begin until the 4th rib was reached. The heart-sounds were clear at apex and base. and of normal intensity. No murmurs were to be made out.

Physical examination was otherwise also negative.

The long standing of the nodules, some having lasted 15 years and others 2 years, the occurrence of nodules in the patient's father, and the absence of any cardiac lesion, makes the case an interesting one.

Case V. — Rheumatic history, subcutaneous fibroid noduks and doubtful carcinoma of the stomach.

Mr. U., set. 57 years, was admitted to the Johns Hopkins Hospital, June 21, 1895, complaining of general weakness and nausea.

There was a distinct history of tuberculosis in the family, his father and two sisters having died of it. No history of rheumatism or malignant disease in the family.

When a child the patient had measles, whooping-cough and mumps. Gave a doubtful history of his having had typhoid at the age of 27. After this attack of fever he had diarrha'a each spring for 6 or 7 successive years. Had gonorrhcca when 21. but there was no history of lues obtainable. He had had frequency of micturition at night for 3 or 4 years. Two years previous to admission he had a mild attack of rheumatism in the ankles. There was no history of chronic stomach trouble. Used tobacco and alcohol in moderation.

The illness for which the patient c^me to the hospital began four months previously with severe pains in the shoulders, arms and, to a less extent, in the knees. The joints were apparently not swollen. During the attack he liad severe nausea and vomiting, which was not specially associated with the taking of food. He did not vomit any blood. His appetite was poor and nausea was constant, being increased by the sight of food. Flatulence was a prominent symptom. Had not had any pain in the epigastrium. Wm gradually losing flesh.

The patient was not aware of the presence of any lumps beneath the skin.

He was rather pale and somewhat emaciated.

In the parasternal line, about 5 cm. below the costal margin, a small nodular thickening, detinitely situated in the abdominal wall, was to be felt on palpation. The mass w.is somewhat lobulated and rather soft. On the exterior surfaces of the forearms several similar ones of a tibro-liix>matous character were to be seen

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and felt. They were freely movable and the skin was not adherent to them. Along the outer margin of the right tibialis anticus tendon there was a very hard subcutaneous fibroid nodule, and another occupied a corresponding position on the left foot.

The heart and lungs were clear throughout.

An Ewald's test-breakfast was given on two occasions, the contents of the stomach when removed showing an absence of free hydrochloric acid on each occasion. There was no reaction for lactic acid, however.

After inflation of the stomach the lower margin did not pass a point 4 cm. above the umbilicus. A slight sense of induration was to be felt in the left parasternal line, which was not to be made out when the stomach was empty.

The patient lost considerably in weight while lie remained in the hospital.

lu the above case we have the two forms of the uodules present iii the same patient, the soft, flat, comparatively large fibro-lipomatous form, and the small, round, very firm variety.

Case VI. — Rheumatiim, subcutaneous fibroid nodules, with cardiac hypertrophy.

The following case was shown by Dr. Toulmin (now of Philadelphia), at the Hospital Medical Society when he was a resident medical officer in the medical service. The case was not reported, and I am indebted to Dr. Toulmin and Dr. Hobach for finding the address of the patient and permitting me to examine him.

Mr. G., set. 55, was seen at his own house.

There was nothing of importance in the family hi.story. The patient had whooping-cough and mumps when a child. When 22 years of age he had his first attack of rheumatism ; both ankles and right hip joint were affected, being very painful, but not swollen. He was laid up for two months, but did not have any subcutaneous nodules at that time. From then until eight years ago he had several mild attacks of rheumatism. Patient had not complained of any heart symptoms up to this time. Eight years ago he had a right-sided hemiplegia, speech being affected, which lasted three- months. Does not remember whether he had any joint involvement at that time or not. It was during this illness that the patient first noticed the presence of lumps beneath the skin on various parts of the body. His physician counted as many as 140 at this time. Quite a number of these occurred over the epigastrium, and the patient states that the one which is still to be seen and felt in this region first appeared at that time. Some of the lumps were as large as walnuts, were all freely movable, and were painful when they were growing or diminishing in size. Other situations where the nodules appeared at that time were : one on the left under eyelid ; several painful ones on the scalp and on the back of the neck at the junction of the cervical and dorsal regions ; others were present on the anterior surfaces of the arms, forearms, thighs ami legs. The patient states that in all the last mentioned situations the nodules varied in size between a pea and a hazel-nut, most of them disappearing within 24 hours, and none lasting longer than three days.

Since eight years ago the patient has had repeated crops of no<iule8, at no time being perfectly free from them.

In October, 1S02, he had a second attack of right-siiled hemiplegia which laid him up eleven weeks. Again he had a profuse crop of noduUs. The right ankle joint was swollen and painful, and he suffered from dyspnoea and slight precordial pain. Since then he has not had any further joint trouble, and has always been able to attend to his work.

The patient was a healthy looking, fairly well nourished man. Pulse was 92 to min., regular, pood volume, vessel wall a trifle thickened. Subcutaneous nodules were present in the following situations: one beneath the costal margin in the left hypochondrial region, 3x3 cm., soft, somewhat lobulated and rather sensitive on palpation. This was of a Bbro-lipomatous nature.

Right arm: One in front of internal condyle .5 x 1 cm.; five on the anterior surface of forearm, varying in size from a bean to a hazelnut.

Left arm : One about the size of a hazel-nut above the external condyle on the outer side of the arm ; four on the ulnar side of the forearm, also varying in size between a bean and a hazel-nut. All the above were rather flat and not extremely hard.

Right leg : Two over the extensor tendons on the dorsum of the foot, and one apparently in the skin about 4 cm. above the ankle. These were in size between a pea and a bean.

Left leg : One about the size of a bean on the inner surface of the tibia about 11 cm. above the ankle. It was very hard, round, quite movable, subcutaneous, and extremely sensitive to the touch. Excepting for the tenderness it presented all the characters of a subcutaneous fibroid nodule. The patient had been forced for years to wear boots, owing to the pain in the nodules produced by wearing laced shoes.

The Lungs. Hyper-resonant on percussion, but otherwise were clear.

T?ie Heart. The point of maximum cardiac impulse was in the sixth space, 1 cm. inside the mammillary line. The relative cardiac dulness began at the third rib and extended from the left sternal margin obliquely outwards to the point of maximum impulse. The first sound at the apex was distinctly prolonged and softened, but there was no definite murmur to be made out. Passing upwards along the left border of the sternum, a very faint systolic murmur was to be heard, the murmur being of maximum intensity over the pulmonary area. Both aortic sounds were quite clear.

This, like the preceding case, shows the association of the two varieties of subcutaneous nodules in the same patient.

Case VII. — Rheumatic neuritis with subcutaneous nodules.

I am indebted to Dr. Osier for the notes of the following interesting case :

Mr. H.,aged 60, seen with Dr. Lockwood, July 1, 1895, complaining of pains in the arms and legs.

Patient is a tall, spare man, who has always enjoyed good health with the exception of dyspepsia, to which he lias been subject at intervals for many years. He has taken very good care of himself, is a moderate drinker, and has an excellent family history ; no gout ; no rheumatism.

Early in March of this year he began to feel pain in the right leg, chiefly about the ankle and instep. It was as though he had a band about these places. The pain was sharp, but never very acute. He has felt at times a little numbness and tingling, and on several occasions there was a little redness of the skin about the ankle. Shortly afterwards the left leg became affected in the same way and the pain in the ankle was sharp. In it he had one day very sharp, stabbing pains down the back of the leg. He describes here, too, the same feelings as if there was a band about the ankle. Patient still experiences this sensation at times. There was no swelling, no special numbness, no enlargement of the joints. It was confined altoeetber to the legs. It did not incapacitate him in any way, but it was a source of a good deal of annoyance and distress. About two months ago the arms began to be affected. Ill-defined iiains from the shoulder, without anything to be seen or localized, but with a good deal of tenderness, particularly of the muscles, when Jie laid the arm on anything. He does not seem to have had any paraesthesiae. The muscular power of the arms has been perfectly good. The chief distress really has been in soreness on pressure ; thus, yesterday there was so much distress in the arms that to get relief he had to sit with them stretched out on jiillows. Early in the attack he noticed the presence of certain nodules on the legs and arms which would appear and disappear. Most of these have now gone except the ones which I describe below.

On the skin, one-third from the elbow of the right arm just along the margin of the ulna, there is a small subcutaneous fibroid

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nodale, very superflcial and very distinct. There have been others which have disappeared. There is no thickening of the ulnar nerve ; there are no trophic changes, no trace of sensitiveness in the muscles themselves, though there is much pain when the arm is resting in a certain position. The blood-vessels are not specially thickened. There is no soreness along the musculo-spiral nerve, no actual soreness on pressure on the muscles. On several occasions there has been a little redness. One of these small nodules was on the edge cf the left tibia, but has disappeared entirely. There is no atrophy of the muscles in the arms or legs ; a little tenderness along some of the cords of the brachial. Knee-jerks are present; perhaps a little plus. Pupils are of medium size, react well to light. No swellin.' of the joints ; no toplii in the ears ; he never ha had gout.

July 8, 1895.— He has not been so well. Has had much soreness, particularly in the arms and about the left wrist, where there has been subcutaneous redness and swelling. There was also tenderness. There is now on the extensor surface of the left arm midway between the elbow and wrist, a raised red region about 3x2 inches. The redness looks fading, but it is distinctly puflfy. It was a patch similar to this, but horizontal, which was on both ankles at the early period of the disease.

The subcutaneous fibroid nodule on the right arm has disappeared. There is one now on the inner surface of the left knee. This feels like a small shotty body beneath the skin. It was a little sensitive. There is another small nodule just on the inner surface of the patella.

The instep is distinctly swollen and red, and it is tender ^ustoutside the outer malleolus. There is a little superficial redness also just above the outer malleolus.

After the shooting pains which he had at first on the outer side of the left foot, there was some numbness. It feels a little numb to-day.

This was nncloubtedly a case of rheumatic neuritis. Had it not been for the presence of the subcutaneous nodules it would have been almost impossible to say that the condition was rheumatic, owing to the very indefinite nature of the joint symptoms. Their occurrence, however, shows somewhat conclusively that the neuritis was rheumatic in origin.

Case VIII. — Subcuianeous fibroid nodules in a case of arthritis deformans.

Mr. C, ajt. — , was admitted to the Johns Hopkins Hospital on September 12, 189.5, complaining of enlargement and deformity of the wrist, finger, knee and ankle juints, with pain in these situations.

A satisfactory history could not be obtained from the patient. There had been a history of gout in the family for several generations back.

The patient had his first attack of joint trouble 24 years ago. It commenced in the great toe joint.

The following note was dictated by Professor Osier :

Mucous membranes pale, face flushed, otherwise the patient looks well nourished.

The hands show very characteristic lesions of arthritis deformans.

Right hand : The right wrist is almost completely ankylosed ; there is thickening about the bases of the metacarpal bones, and the knuckles are large. The interossei muscles are wasted. There is fair mobility of the metacarpal joints. The fingers have a strong ulnar deflection. There is ankylosis of the 1st and middle nietacarpo-phahingeul joints, of the first interphalangeal joint of the index, middle anil little fiuL'ers, and of the distal joint of the ring and little fingers. No Heberden's nodes.

The fingers are thin, and the skin a little rough and somewhat discolored over tho joints. About the knuckles of the middle

finger, chiefly on the extensor tendon as it passes over the joint, are 4 or 5 subcutaneous fibroid nodules. One flat yellowish-looking nodule exists on the extensor tendon passing over the knuckle of the ring finger. The extensor muscles of the forearm are a little atrophied.

Left hand : Ankylosis of the wrist much less marked, as also is the ulnar deflection. Ankylosis not so marked in the fingers. In the little finger Heberden's nodes are extremely well developed, and the juints are ankylosed. Nodes are well developed in the index finger. Flat subcutaneous nodules are present on the extensor tendon of the middle finger. Radial thickening on both sides.

The knees are very much enlarged, particularly the right, which is very much rounded ; outlines of the patella are lost. Probably some exudation into the bursa. Patella not movable. Much less thickening about left knee ; patella movable.

There is very slight flexion in the knees, much more in the left than right.

The ankle joints are uniformly enlarged ; very slight mobility ; obtuse thickness over the tarsus.

No tophi in the ears.

Heart. — Apex beat neither visible nor palpable. Loud, rough systolic murmur at the apex, transmitted towards the axilla. At the base there is a soft systolic, not loud or rough. Second sound audible and not accentuated.

Case IX Chronic vegetative endocarditis tcith subcutaneous fibroid

nodules.

Dr. Osier has kindly given me the full notes of the following interesting case, which was seen in consultation with Dr. J. K. Mitchell, June 7, 1893. Only abstracts from the history will be given.

Martha S , aged 29, a native of Providence, R. I.

When 12 years of age patient had scarlet fever and rheumatism, evidently a severe attack, in which the doctors stated that her heart was affected. She gradually got better, but a year or two subsequently she had a second light attack.

About a year ago she began to have pains in the fingers, and some of the spots to be hereafter described appeared. Last summer she was at her home in Providence not at all well, having occasional attacks of pain in the feet and in the joints, with chilly feelings. About October she began to have more definite fever, preceded by marked chilly sensations, and she has been ill with occasional fever ever since, the temperature rising to 102° to 104°, sometimes with a definite chill. For the past month the temperature range has been from 97° to IOi°. The joints, and particularly the ankles at times, have been red, swollen and painful.

To-day the only complaint she has is of pain in the right ankle, which is a little swollen, and just in front of the inner malleolus, reddened. There is no enlargement of the smaller joints.

The apex beat of the heart is forcible, outside the normal position. There is no thrill. On auscultation there is a loud systolic murmur, rough in quality, propagated beyond the axilla. The sounds at the aortic cartilage are clear, and the pulmonary second is very much accentuated.

There is no enlargement of the spleen or liver.

One of the most remarkable features about the case istheappearance of painful spots in and beneath the skin. These are apparentl}- of three different characters: (a) reddened, elevated sjxits in various parts, resembling closely urticaria, and these appear and disappear. There were only two on the skin at the time of my visit ; (*) local spots of soreness in the skin from two to three lines in diameter, not elevated, usually as Dr. 3. K. Mitchell describes them. " pale pink, not elevated, not hard, exquisitely tender, and painful even without being touched"; (c) definite firm sulvutaneous nodules which have appeared and disappeared, and which are very sensitive to the touch. At the occasion of uiy visit only one of these was present beneath the skin about the eighth rib on the right side. It felt the size of a small pea, was movable and she winced on the slightest pressure.

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The diagnosis was maJe of a chronic vegetative endocarditiswith intermittent fever.

Literature.

1. Ballin, L. : 4to, Lyon, 18S5.

L>. Bar, Louis: Par., 1890, 1 pL 4to, No. 271, 64 pp.

3. Barhiw and Warner : Trans. Internal. Med. Cong., London, 1881.

4. Bertoye: Lyon Med., 1887, LIV, pp. 179-184.

5. Besnier : Diet, encyclop. sc. m^d. (.■Vrt. Rhumat.), 1876, p. 504.

6. Birchard, A. D. : Cincinnati Lancet Clinic, 1890, N. S., XXIV, 684-G89.

7. Bourcy, P. : France medical de 1882, No. 5.

8. Bourcy, P. : Bull. Soc. Clin, de Par. (1881), 18S2, V, 287-291.

9. Brissaud : Revue de medecine, Par., 1885, V, 241-252.

10. Brocq and Troisier : Revue de medecine, 1881, p. 297.

11. Brocq : Journal de medecine de Paris, 1884, p. 466.

12. Brown, C. H. : Journal of Mental and Nervous Diseases, August, 1893.

13. Cavafy : Brit. Med. Journ., March 31st, 1883.

14. Cayley, W. : Clin. Soc. Trans., 1894.

15. Chauffard : Gaz. d. hop. de Toulouse, 1894, VIII, 225. 1(>. Cheadle, W. B. : Lancet, 1889, p. 871.

17. Cliodorowski: Th(>se, Paris, 1882.

18. Chuffard : The.se, Paris, 1886.

19. Coutts, J. A. : Illust. Med. News, Lond., 1889, III, 267-271.

20. Coutts, J. A. : Lancet, London, 1890, II, 873.

21. Davaine, J. A. : 4to, Paris, 1879.

22. Drewitt, F. D. : Brit. Med. Jour., March 31st, 1883.

23. Duckworth, Sir Dyce : Lancet, Dec, 1882, p. 943.

24. Duckwortli, Sir Dyce : Lancet, May 5, 1883, p. 778.

25. Duckworth, Sir Dyce : Pract., Lond., 1892, XLVIII, pp. 161-165.

26. Duckworth, Sir Dyce: Clin. Trans., Vol. XVI, p. 190.

27. Edge, A. M. : Brit. Med. Jour., 1884, Vol. I, 818.

28. Edge, A. M. : Brit. Med. Jour., 1885, Vol. I, p. 737.

29. Edge, A. M. : Brit. Med. Jour., Jan. 21st, 1893.

30. Edwards, W. A. : Univ. Med. Mag., Jan., 1890.

31. Eve : Br'it. Med. Jour., March 3l8t, 1883.

32. Fereol : These, Paris, 1879, 8vo.

33. Fowler, J. K. . (a) Trans. Clin. Soc, Lond., 1884, XVII, 65-67 ;

(b) Brit. Med. Jour., 1884, Vol. I, p. 167 ;

(c) Lancet, 1884, Vol. I, p. 115.

34. Fritz, C. : Union medical, Paris, 1884, 3 8., XXXVII, p. 69 ;

Bull, et mem. soc. m6d. d. hop. de Par., 1883-4, "2 s., XX, 227-229.

35. Gilly : -Marseille medical, 8th Sept.. 1887, p. 518.

36. Guyot : Bull, et Mem. d. hup. de Par., 1886, 3 s.. Ill, 68-72.

37. Hadden, W. B. : Clin. Soc. Trans., Vol. XXIII, 1890.

38. Hershman, C. F. : Internal. Med. Mag., Oct., 1894.

39. 40. 41. 42. 43. 44. 45. 46. 47.

48. 49. 50. 51. 52. .53. 54.

Hillier: Diseases of Children, 1868.

Hirschsprung: Jahrbuch fUr Kinderheilkunde, 1881, 16 B. HoVjbs, J. : Archives cliniqne de Bordeaux, No. 8, p 380. Honnorat, J. : Lyon medical, 1885, XLVIII, p. .561-563. Hutchinson, Mr.': Brit. Med. Jour., March 31st, 1883. Jaccoud : Traitr de pathologic interne, 1871, t. II, p. 546. Jordan, F. A. : Brit. Med. Jour., 1885, Vol. I, p. 889. Lailler: Bull, et mem. soc. d'hOjp. de Paris, 1886, 3 s.. Ill, p. 68. Lindmann, J. : Deutsche med. Wchnschr., Leipz., 1888, XIV, 519-524.

Loysel De La Billardiere, A.': These, Paris, 1889, No. 296. Mackenzie, Stephen: Brit. Med. Jour., March 31st, 1883. Mackenzie, Stephen : Clin. Trans , Vol. XVI, p. 188. Mackay, E. : Lancet, Jan. 20th, 1894. Mahomed, G. : Brit. Med. Jour., 1882, II, 827. Mahomed, G. : Brit. Med. Jour., March 3Ist, 1883. Meusnier: Congrcs de Blois, 1884. Meynet, M. : Lyon medical, 1875.

Middleton, G. S. : Glasg. Path, and Clin. Soc, 1886-91-92, III, 26.

Middleton, G. S. : Am. Jour. Med. Sc, Oct., 1887, Vol. 94, p. 433.

Mitchell, J. K. : Univ. Med. Mag., Vol. I, 1888-9, p. 161. Money, Angel : Brit. Med. Jour., March 31st, 1883. Money, Angel : Lancet, 1891, I, 510.

Nepven : Compt. rend. soc. de biol., Paris, 1890, 9 s., II, 328-331. Osier: On Chorea, 1894.

Parker, R. A. : Brit. Med. Jour., March Slst, 1883. Payne : Brit. Med. Jour., March 31st, 1883. Phillips, S. : Clin. Soc Trans., 1894. Pitt, G. N. : Clin. Soc. Trans., 1894.

Porter, F. E. : Bost. Med. and Surg. Jour , June 30th, 1886. Prior, J. : Miinchen. med. Wchnsch., 1887, XXXIV, .525-528. Rehn, H. : Verhandl. d.Cong. f. innere Med. Wiesb., 1885, IV, 296-298.

Rehn : Traits des maladies de I'enfance de Gerhardt. Reis, Max : " Ueber den rheumatismus nodosus," Bonn, 1890, C. Georgi, 37 p., 8vo.

Riembault: Loire med., St. Etienne, 1884, III, 148-1-52. Troisier and Brocq : Revue de medecine, 1881, I, p. 297. Troisier, E. : Progres myd., Paris, 1883, XI, 947-966. Troisier, E. : ProgrCs mod., Paris, 1884, XII, 3-5. Troisier, E. : Bull, et mem. soc. med. d. hop. de Paris (1883), 1884, 2 8., XX, pt. 2, 45-67.

Troisier, E. : Union mid., Paris, 1884, 3 s., XXXVII, 385, 393.

Wainer and Barlow : Trans. Internat. Med- Cong., Lond., 1881.

, West, S. : St. Barth. Hospl. Reports, Lond., 1886, XXII, 213 215. , Widal, F. : Gazette hebdomadaire, 1883, p. 825 et suiv.

CASES OF AMCEBIC DYSENTERY.

By Cunningham Wilson, M. I)., Birmingham, Alabama.

The following case.s of amndiic dysentery, occurring in my private practice, lack, in careful study, the hospital reports of 8uch cases. Two of them, however (cases 3 and 3), are of more than usual interest ou account of finding the amoebaj while examining the patients for other conditions. The first three cases falling into my hands at such short intervals of time led me to believe that this form of dysentery will be found to make up a large proportion of this disease in this climate. During 181(4, however, only one case came to my

notice, but in some suspicious cases I was unable to use the rectal tube to get the contents of the bowels.

The amcebn? did not differ iu any way, as far as I was able to see, from descriptions given by Councilman and Lafieur and from those I saw from a patient in Dr. Osier's clinic at Johns Hopkins Hospital. There were no symptoms of abscess of the liver in any of the cases.

Case 1. June 1, 1893. I saw for the first time B., white, male, aged forty-nine, married, of very large frame and

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extremely emaciated. Has always lived in the South. About two years ago began to have frequent actions from bowels, consisting largely of mucus and blood. This condition has kept up with more or less severity since ; at the time of my visit was having from one to twenty stools daily. Microscojjic examination of a portion of the stool just passed showed numerous actively moving amcebce. Frequent examinations of the discharges during the next three weeks always showed the ama3bse. At this time he left the city. His condition with rectal injections, milk diet and other remedies improved very little.

Case 2. S., white, male, aged 30; locomotive engineer. In 1890 had an attack of dysentery which lasted him two weeks. Since then has had several similar attacks of less severity. August 15, 1893, came to me complaining of internal hemorrhoids, otherwise feeling well. Examination of rectum with speculum revealed two or three small hemorrhoids and higher up two superficial ulcers. Removing the speculum, a quantity of bloody mucus adhered to it. Placing a small portion of this under the microscope, active amcebag were found. On more careful inquiry it was found that he had beeii having frequent, small and painless bloody discharges from the bowels which he had taken as symptoms of hemorrhoids. He was advised to use rectal injections of quinine solution. A few days later he was attacked with a violent dysentery which confined him to his bed for three weeks. The amoebs were abundant in the dysenteric discharges. Ice-water injections with suppositories of iodoform and opium seemed to give him most relief. During the following winter he had another attack, but has remained well since.

Case 3. W., white, aged twenty-eight, single; telegraph operator. Was born in Ohio; has lived in Alabama three years. His first sickness was a rectal abscess two years ago, which resulted in an anal fistula. During the past year has

had several attacks of diarrhcea with considerable cramping in lower bowels. September 3, 1893, came to me to have an operation for cure of fistula. Examination showed a superficial fistula. On removing the speculum there was adhering to it a quantity of blood and mucus similar to what I had seen in Case 2. Microscopic examination showed numerous active amoebfe. Three days later he was attacked with a moderately severe dysentery which kept up for a week. The amffiba; were constantly found during the attack. His strength was considerably reduced and he remained in poor health until October 1, when he took a vacation East and soon regained his health, which has remained good since. Treatment during attack was cold water injections with iodoform and opium suppositories.

Case 4. P., white, male, Russian. Was seen a few hours before death, September 15, 1894. No history could be obtained. He was having frequent involuntary actions of mucus and blood from bowels. An autopsy was held four hours after death. Nothing of consequence was found in thorax except sclerotic changes in blood-vessels. In the abdomen the entire big gut was prominent, very much thickened and adherent to neighboring structures. The omentum had engrafted itself to the transverse and descending colon, at many points, preventing perforations. The gut was easily torn, tearing by its own weight when lifted. The mucous surface was an area of necrosis, indented with deep ragged ulcers, many of them just ready to break through. Examination of contents of the ulcers showed numerous active amceba?. Sections of the intestinal wall showed, in a marked degree, the hyaline degeneration described by Councilman and Lafleur (Johns Hopkins Hospital Reports, Vol. II), of muscular fibre as well as of the plastic material thrown around the intestine. Sections of the liver showed advanced cirrhosis. Chronic interstitial changes had taken place in the kidneys.

PROCEEDINGS OF SOCIETIES,

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

MeeUng of October 7, 1895.

NOTES ON NEW BOOKS.

BOOKS RECEIVED.

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL.

Vol. Vl.-Nos. 56-57.

BALTIMORE, NOVEMBER-DECEMBER, 1895.

+++

Contents

147

150

Bacillus Pyogenes Filiformis (nov. spec). By Simon FlexNER, M. D.,

A Clinical and Experimental Study of the so-called Oyster Schucker's Keratitis. By Robert L. Randolph, M.D.,

The Clinical Course of forty-seven Cases of Carcinoma of the Uterus subsequent to Hysterectomy. By W. W. Russell, M.D., 154

Notes on Some Cases of Angina treated with Behring's Antitoxine. By George Blujier, M. D., 158

Proceedings of Societies :

Hospital Medical Society,

Pyarthrosis — Discussion [Dr. Halsted] ; — A Case of Congenital Ptosis [Dr. Thomas] ; — Remarks [Dr. Barker].

Notes on New Books, --.

Books Received,

Notice, ------ Index to Volume VI, _ . .

167 168 168 168

BACILLUS PYOGENES FILIFORMIS (NOV. SPEC.).*

By Simon Flexnek, M. I)., Resident Pathologist, The Johns Flopkiiis Hospital ; Associate Professor of Pathology,

Johns Hopkins University.

[From the Puthologieal Laboratory of the Johns Hopkins University and Hospital.]

(Preliminary Communication.)

During the past winter a large healthy female rabhitof the stock of the laboratory gave birth to a litter of young, and about the fifth day following parturition, although it had not appeared ill, was found dead in its cage. Following the rule of the laboratory, which is to make autopsies upon all animals which die, this one was e-\amiued in the usual way. It is necessary to state that the young of this animal were found dead before the death of the mother occurred.

The animal bore its litter on March 13th or 14th, and was found dead on the morning of the 18th. The autopsy was performed in the afternoon of the 18th.

Tile body was well nourished ; there was no evidence of death from violence, the mammary glands were still large, and upon section a lactiferous fluid escaped from their cut surfaces. There was no excess of fluid in the peritoneal cavity, the layers of the serosa appearing normal except as is about to be mentioned.

The condition of the uterus especially arrested attention

• Read before the .Johns Hopkins Hospital Medical Society,

November 4, 1895.

upon the examination of the abdominal viscera. It was several times larger than the normal, although much smaller than the uterus of the rabbit at term, and presented a series of dilatations and contractions which, except for their irregular distribution, might have been mistaken for a pregnancy. This condition was, however, hardly to be considered under the circumstances, and indeed upon inspection the dilated pouches appeared thin and semi-trauslncent. and gave the impression of being quite empty. The serosa over the dilatations was injected ; the vessels of larger size being very prominent and turgidly filled with blood, the intervening tissue presenting a rosy hue. Both coruua of the uterus were similarly affected. Nothing abnormal was observed in connection with the ovaries. On opening the uterus after its removal with the vagina attached, the pallor of the mucous membrane contrasted with the injection of the serous coat. This pallor of the mucosa was of a peculiar opaque quality and unlike the appearance of the velvety membrjiue itself. On gently stroking the mucosa with a knife a thick, opaque material could be removed, which appeared to be only lightly adherent to the surface of the membrane. It was to the pres

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ence of this material that the peculiar opacity was due, and the exudate extended from the vagina throughout the entire estentof the uterus. In the dilatations before mentioned the mucous membrane was of extreme tenuity, and here, as might have been expected, the layer of opaque exudate was thinner than elsewhere. The impression was given that the dilatations were brought about by accumulations of a gas. After the removal of the exudate the underlying mucosa was found to be congested. The other organs of the peritoneal cavity apparently were normal.

The pleural cavities contained fluid which was not in large amount and of a transparent hajmoglobin-red color. The serosa itself was covered with a thick shaggy layer of a fibrin-like material. Both the parietal and visceral layers were covered with this material, which was very thick over the region of the diaphragm. The lungs were in part voluminous, in part collapsed, the expanded portions being of a firm consistence and apparently consolidated. The bronchi contained fibrinous plugs.

The pericardial sac contained a small amount of fluid between layers of a shaggy appearance, due to the presence of a fibrinous-looking exudate similar to that found covering the pleune. It was, however, thinner here than there.

The lymph glands of the body showed no especial enlargement and the other viscera no gross pathological changes.

BdderiologicaJ Examination. Cover-slips made fi;om the exudate in the vagina and uterus showed a surprisingly large number of organisms which were strikingly pleomorphic. These organisms form for the most part thread-like structures ; not a few, however, are much smaller. They vary from bits only a little larger than cocci to thread-like forms as long as the longest anthrax chains. At first sight there would appear to be several kinds of bacilli present ; but the appearance, in both large and small forms, of a striking irregularity of staining makes this improbable. Very few of the bacilli stain regularly, for the most part brightly staining spots appearing between unstained areas. An outer membrane always stains, enclosing the stained dots in a colorless ground. A closer study reveals the stained particles to occur w-ith much regularity, that is, they are about equidistant in the longer forms, where they arc best studied, and in general they are of the same size. The threads are not as a rule straight, but present delicate sinuous and wavy outlines. The short forms are straight with rounded ends. Among these organisms a large number of pus cells and a few larger cells with single vesicular nuclei were scattered. Although many pus cells were present in the exudate, yet from the appearance of the cover-slips no inconsiderable portion of it must have been furnished by the bacilli.

Cover-slips made from the pericardial and pleural exudates, as well as from the consolidated portions of the lungs, showed the same organisms. While they were very numerous in the cover-slips from these situations, they were not as abundant as in the uterus.

Aerobic cultures were made upon various media, Loeflfler's blood serum, sugar-agar, sugar-bouillon, plain agar and bouillon, the agar, urine and serum mixture; anaerobic cultures were made in plain and sugar-agar and bouillon as

well as upon blood serum in Buchner's jars and an atmosphere of hydrogen. All these kept in the thermostat for several days at 37° C. showed no growth whatever.

Fearing that it would not be possible to cultivate the organism upon the usual media, the pleural cavity of a second rabbit was inoculated by breaking up a speck of the pleural exudate from the first one in bouillon and injecting the suspension with a sterilized syringe, after making a small skin incision, into this cavity. This inoculation was positive in its results.

Subsequent experiments were conducted as in the previous one by transplanting small bits of the fibrinous material from the inflamed parts of previous animals, or of the fluid which was also present in the pleural cavities in the other animals. In this way the series was kept continuous and the bacilli alive.

Considerable variations were observed according as the inoculations were made into the pleural cavity, the peritoneal cavity, the subcutaneous tissues, beneath the dura mater, or directly into the circulation.

The inoculations were positive in all cases except a few in which they were made subcutaneously. The death of the animal occurred soonest when inoculation was made beneath the dura mater. A small portion of the skull was trephined, under the usual antiseptic precautious, and a drop of the jjleural fluid or a speck of the fibrinous exudate was introduced beneath this membrane, care being taken not to injure the brain. These animals, which quickly recovered from the effects of the operation, died on an average about twelvehours after the inoculation. The usual appearances were as follows: The external layer of the dura, excepting at the point of puncture, appeared quite normal; the internal layer was injected. Corresponding with the point of puncture, but smaller, a grayish-white area was visible, this being most marked in the case of the introduction of a bit of the fibrin, and doubtless consisted in part of the introduced exudate. The pia was distinctly reddened, the vessels being more prominent than normal, and the meshes of the pia contained a thin but otherwise distinctly turbid fluid. There were no pathological changes to be observed in the cortex of the brain, nor were any found in the ventricles.

Cover-slip preparations made from the point of inoculation showed, besides pus cells, a very large number of the typical bacilli. Similar preparations from the meninges at a distance from the point of inoculation also showed bacilli, but they were fewer in number, and among them more or less leucocytes with amphophilic granulations and polymorphous nuclei were scattered.

The pleural inoculations were followed by death, as before stated, in every instance, the death of the animal occurring upon the third or fourth day. The appearances presented at autopsy were for the most part an exact reproduction of those observed in the animal wliicli had succumbed to the natural disease. Upon the side of inoculation a thick grayishyellow shaggy membrane covered the pleural surfaces, being at times four or five millimeters in thickness. The pleural cavity contained several cubic centimeters of a clear haemoglobin-colored fluid besides, the lung for the most part being compressed. At times smaller or larger areas of lobular pneu

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monia would be present; and as a rule the inflammation was not limited to the serous membrane of the side of inoculation, but extended into the opposite pleural cavity and into the pericardial sac. However, in these situations the process was as a rule less intense, the solid exudate being less considerable, and in the case of the opposite pleural cavity sometimes entirely wanting. The superficial vessels, however, were injected and the serous surfaces of the affected membrane covered with a slimy material. In addition to this, the opposite i^leural cavity always contained a pink serum similar to that described upon the side of inoculation.

The study of the exudate upon the side of inoculation, as well as the fluid contained in the opposite pleural cavity and in the pericardium, showed the same organisms as had been introduced. They were most numerous upon the side of inoculation and in the solid portion of the exudate. So far as could be determined by the use of cover-slip preparations, they were absent from the blood and distant viscera.

The inoculation of the fluid from one of these pleural cavities into the peritoneum did not always succeed in causing the death of the animal. The periods of incubation in these cases, even when the inoculations were successful, were longer than in the previous ones, the animals affected often not dying in less than a week. The results of the peritoneal inoculations were to produce either a general sero-flbrinous peritonitis or a circumscribed fibrinous peritonitis. In several instances where the inoculations were made into the pleural cavity, an extension through the diaphragm with the productions of a localized pseudo-membranous inflammation over the liver was observed. The exudate in all these cases showed large numbers of typical bacilli upon microscopical examination.

In several instances the subcutaneous inoculation of the pleural fluid was successful. Larger and smaller areas of tissue were converted into a rigid fibrinous material in which bacilli were found in large numbers.

Perhaps the most interesting, certainly the most widespread, effects were obtained by the intravenous inoculation of the pleural fluid. The results were uniformly fatal, the animals all succumbing in from two to four days after inoculation. At autopsy abscesses were present in the viscera. These were generally miliary in size, although at times they were larger and spreading. Preferences were exhibited in reference to their localization, certain organs being entirely spared. The abscesses were never absent from the brain and heart muscle. They appeared occasionally in the liver, more rarely still in the voluntary muscles, never in the kidneys or the lungs.

The effects of the intravenous inoculations with respect to the points of localization of the bacilli were in part dcter

THE JOHNS HOPKINS HOSPITAL BULLETIN,

Volume VII.

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Nine numbers will be Issued annually. The subscription price is $1.00 per year. Volume VI, bound lu cloth, $1.00.

mined by the local conditions; for example, the inoculation into non-pregnant female animals was not followed by the reappearance of the micro-organisms in any of the structures of the genital tract, whereas in the case of pregnant animals the inoculations were followed by the re-localization of the organisms and the inflammatory process in the pregnant uterus.

The appearances first described in the uterus of the animal dead of the natural disease indicated that an accumulation of gas had occurred in this structure. This appearance was again observed in the experimental disease in this situation, and also in several instances in which the inoculations were made into the subcutaneous tissue and in the pleural cavity, in the last instance the gas bubbles appearing in the inflamed mediastinal tissues.

Culthmtion Experiments. From time to time in the course of the transference of this organism from animal to animal, attempts were made to cultivate it. The repeated use of ordinary media in aerobic and anaerobic cultures failed as in the first instance. The use of more concentrated media, as for example five per cent, peptone in solid and fluid forms, also was without success. An attempt was now made to cultivate the organism upon the organs of a healthy rabbit, which were removed with all precautions and transferred to sterile test tubes. Only occasionally did one of these tubes show contamination. Those which were uncontaminated and had shown no growth for several days were inoculated with material from the experimental animals. For the first time a growth was obtained, not, however, upon all the organs. The growth was fairly vigorous upon the lungs, the heart aud the uterus, and perhaps upon the kidney ; no growth occurred either upon the spleen or liver. Transplantations from these growths were successful only to the extent of one or two subsequent generations. The best results were obtained by cultivating the organisms upon several one-third to one-half grown fcetuses obtained from the rabbit, upon which medium transplantations were successful through a series of six of these objects. The inoculations of animals from the sixth generation of the bacilli obtained in this way, either into the pleural cavity or into the circulation, were followed by positive results indistinguisiiable from those obtained by the use of the pleural fluid before mentioned.

Further facts concerning the morphology aud biology of this organism, such as the question of spore formation, thermal death point, the effect of drying, the length of vitality outside the body, as well as the pathological histology of the lesions caused by it, will be given when the full details of this study are published.

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[Nos. 56-57.

A CLINICAL AND EXPERIMENTAL STUDY OF THE SO-CALLED OYSTER SHUCKER'S KERATITIS.

By Kobert 1.. ItAsuoi.PH, ^1. 1).

The extent of the injury inducing the so-called oyster shucker's keratitis does not explain the violent reaction that follows. This fact seems to have impressed every ophthalmologist who has been brought into frequent contact with the disease. Cinders and small particles of steel or sand, when they lodge on the cornea, often remain in situation for several days without causing apparent infiltration of the surrounding tissue, and not infrequently does one meet with a case where a cinder has been imbedded in the cornea a considerable length of time without giving rise to anything but unpleasant subjective symptoms. The most common foreign bodies removed from the cornea are the filings or chippiugs of iron or copper, or particles of emery, sand and cinders. It is rare that we see an area of infiltration about the foreign body, and when this latter condition exists it usually means that the foreign substance was infected with pathogenic bacteria, or by its continued presence and consequent irritation has brought about conditions favoring the invasion and growth of microorganisms. When we consider the remarkable resources of the eye for nullifying the effects of pathogenic bacteria we may safely say that a foreign body of the nature just mentioned, when it lodges in the cornea, will as a general rule give rise to an appreciable keratitis only after it has remained in situation for a number of days.

What is known as oyster shucker's keratitis is distinctly a traumatic affection, due to an injury from a particle of the oyster shell. The disease is chiefly remarkable for the rapidity with which an area of infiltration appears at the site of the wound, in marked contrast to the history of wounds by other kinds of foreign bodies of the same size and in tlie same location.

The existing evidence indicates that oyster shucker's keratitis is found more frequently in ^klaryland than in any other part of this country. Dr. Jas. A. Spalding, of Portland, Me., writes me that the affection is practically unknown in that part of the United States, and the same Ciui be said of the disease in Charleston, S. C, from information kindly furnished me by Dr. Kollock of that city. The reports of the New York and Philadelphia eye hospitals contain now and tlien a few cases, but Baltimore seems to carry off the palm. In New Orleans the disease as such appears to be unknown. The reports of the eye hospitals in Baltimore contain the records of several hundred cases during the past few years.f The frequency of the disease in Maryland may be explained by the fact that the oyster industry is a more extensive one in that state than it is anywhere else in the world. Cases of the disease do occur no doubt in New Orleans and Portland, Me., 80 that probably latitude has nothing to do with determining

•Read before the thirty-firat annual meeting of the American Ophthalmological Society, in New Lonilon, Conn., July 17 and 18, 1895.

f I have been informed by one of tlie staff of the Presbyterian Eye an<l Ear Hospital that during the past three months twentyfour cases have been treated at that hospital.

its existence, nor is there any reason for supposing that the keratitis is to be traced to some organic or inorganic property peculiar to the oyster shell of the Chesapeake Bay.

Baltimore is the greatest oyster market in this country, and, according to Ingersoll ("The Oyster Industry," by Ernest Ingersoll, Tenth Census of the United States, Washington, 1881), there are at least six thousand shuckers in Maryland, and most of these are found in the shucking houses of Baltimore. In many of the northern cities, as for instance in Portland, Boston and New York, oysters are received in great quantities that have been shucked in Baltimore, so that oyster shucking in those cities evidently does not exist as a trade to the extent that it does in Baltimore. The magnitude, then, of the oyster industry in this city may be said to account for the frequency of oyster shucker's keratitis.

In a large number of the cases reported here the oyster shuckers had been plying their trade for many years and had been struck for the first time. In two cases the men had shucked for eighteen years without being struck, and it is surprising to note the fact that in none of the sixty-five cases reported M'ere there any novices (new hands). It will be seen then that it is possible to shuck oysters for many years and still to escape injury from a particle of shell, and that the great majority of oyster shuckers escape altogether. Hence we cannot regard the disease as a very common one. It is more than probable that long familiarity with the work breeds contempt of its dangers, and this may explain why in neariy all cases it is the veteran who is wounded and not the recruit. It is very much the same kind of danger that surrounds the mechanic at the emery-wheel. Possibly the danger is a little greater in the case of the oyster shucker. Considering then the number of oyster shuckers in jMaryland and the quantity of work done, it may be said that the disease is of exceptional occurrence.

Causes : As I have said, the disease is distinctly of traumatic origin ; that is, a minute particle of the oyster shell is violently chipped off by the hammer* that is used in the shucking process, and it flies into the eye. The particle is generally too small and too light to penetrate toany distance into the cornea. Large pieces, however, are sometimes detached and are driven through the entire thickness of the cornea, and when such a thing happens loss of the eye usually results. This occurrence is happily rare. I'nlike other foreign bodies that lodge in the cornea, the particle of shell can seldom be detected. Thfs I think is due to the fact that in the rapid infiltration that takes place the particle of shell is thrown off. It is no

•The use of the hammer to break off the edge of the shell before introducing the knife-blade constitutes the chief element of danger in oyster shucking as practiced here in Maryland. In other sections, as for instance in the far South and down East, the shucker dispenses with the hammer and sticks in the point of the knife at once in order to pry open the shell. This no doubt explains why the disease is seldom seen in the portions of the country just mentioned.

November-Decejiber, 1895.] JOHNS HOPKINS HOSPITAL BULLETIN.

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uncommon thing to see a particle of steel that is surrounded by a necrotic area drop out at the slightest touch, and sometimes we meet with these small points of infiltration where no foreign body can be detected, it evidently having been dislodged or thrown off in the suppurative process. In two or three instances I have succeeded in removing from the centre of one of these areas of infiltration a small jjarticle of what was undoubtedly a piece of shell. My friend, Dr. B. W. Goldsborough, who lives in Cambridge, Md., one of the smaller oyster shucking centres, tells me that he has more than once removed small particles of shell from these infiltrated areas. No doubt in many cases the piece of shell simply strikes and wounds the cornea without lodging in it. The superficial nature of the injury readily explains why the particle of shell would be apt to drop out as soon as infiltration began.

Symptoms: The photophobia in oyster shucker's keratitis is marked. The patient tells us that he has a defined sensation of having been struck in the eye. This sensation is not usually followed by pain until some hours later. Frequently the exposure to artificial light, as for instance the lighting of the gas or lamp the evening of the same day, will mark the time when the unpleasant symptoms begin. From now on the pain is usually intense, and the clinical symptoms resemble those of phlyctenular keratitis somewhat intensified.

In an article which appeared in the Virginia 3Iedii:al Montlihi about fifteen years ago* — which article, by the way, is the only publication known to me on this subject — the writer states that the position of the ulcer is a constant one, that it is always found in one place, and this is the centre of tlie cornea. The most exposed part of the cornea is the point that is usually struck, and as this part represents an area through which the visual line is passing at the time, and as the visual line always passes through the cornea somewhere near the centre, the location of the wound will be here, and for no other reason, though this explanation does not seem to have occurred to the writer of the article referred to, other reasons being given by that writer for the location of tlie keratitis. It may be added that this location of the ulcer is not an invariable one, for I have frequently noticed a peripheral situation.

There is usually more or less circumcorneal liypern'mia. The ulcer is very white, whiter than otiier corneal ulcers. 1 have never seen such an ulcer with blood-vessels running to it, and its size no doubt is dependent more or less upon the size of the particle of shell. The ulcer is sharply circumscribed as to its borders, which, instead of fading off gradually into the adjacent tissue, will be seen to lie adjacent to perfectly transparent cornea. Such an ulcer suggests more strongly a chemical than a parasitic origin. The ulcer does not show the same tendency to spread as do other corneal ulcers, and when the keratitis assumes a diffuse character it is probably an evidence that bacteria have invaded the tissue at this point. Such complications do occur. I have seen such an ulcer remain absolutely localized for two or tliree weeks withoiit any apparent deiiarture from its origiiuil liorders. On

• Oyater Sluicker'a Coineitis, by W. J. Minowell, M. D., Va.

Med. Month., Vol. V, page 883.

this account the prognosis is favorable, though this is largely governed by the size and depth of the wound. A perforating wound of the cornea or a wound involving a large area is usually followed by loss of the eye, and this is especially true when the former condition is present.

Treatment : The yellow salve has proved useless in our hands. The galvauo-cautery was used in a certain number of cases, but it did not seem to exercise any specific influence for good, and the same can be said of eserine. A compress bandage and a mild sublimate solution {f^^ used every four hours, together with an occasional drop of a solution of atropia — 1 per cent. — have given the best results. To this treatment the keratitis responds promptly, and in a week or ten days the subjective phenomena have been so ameliorated that the sliucker can resume work. The opacity can be detected by oblique illumination and is permanent. In several cases where the shuckers had been struck more than once, I found the old nebula?.

The striking point in these cases is the rapidity with which an area of infiltration makes its appearance at the site of the injury. These areas range in size from a pin's head to twice these dimensions, and even larger. The condition differs so entirely from what we are accustomed to see from injuries caused by other kinds of minute foreign bodies that it has occurred to me that the oyster shucker's keratitis might be due to some specific micro-organism. With this idea in view, I made microscopical examinations and inoculations on culture media, using chiefly nutrient agar, from sixty-five cases of oyster shucker's keratitis, of which the following fifteen cases may be taken as a fair sample of wliat the bacteriological examinations disclosed. In making inoculations a sterilized dropper and cocain solution were used for anassthetizing the cornea. The point of the platinum needle was well forced into the necrosed tissue, and in nearly all cases small particles of the wall of the ulcer were brought away and carried into the agar tube. In every case Esmarch tubes Avere uuule. which were promptly placed in the thermostat.

F. II., struck in left eye three clays ago. Central ulcer. Pain anil photophobia intense. There was nothing definite in the coverslips, and after twenty-four hours there was no growth on the agar.

J. R., struck in right eye with particle of shell yesterday. Large ulcer and marked area of infiltration. Eye very painful. Inoculations into three agar tubes. Two cover slips were made, and one stained with methylene blue and the other with gentian violet. In both cover-slips small micrococci were to be seen, occurring as diplococci. In tube A there was a diffuse growth, and at some jioints the colonies looked round and fiat, and an examination of several of the colonies showed the same organism, a short bacillus. There was no growth in tube B (inoculated from J). In a third tube where the inoculation was made directly from the ulcer there was an abundant growth of what was evidently an impurity.

J. H .struck in left eye three weeks ago. At the present time there ia a violent ker.ito-iritis ; the pupil being contracted and pus in anterior chamber. Two ulcers on the cornea. Cover slips from the ulcer showed nothing. In lube -•! there was a round, large and slightly iritlescent colony with reddish centre and yellow halo, which was the only colony in this tube. This turned out to be an enormous micrococcus. In tube B the agar was dotted with a fine growth, the colonies being very numerous and revealing under

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the microscope bacilli : :..:. l varieties. The inoculations

were made into both tubes directly from the ulcer.

P. S. , large ulcer in centre of left cornea from an injury received yesterday. Cover-slips showed nothing definite. In tube A there was a vigorous growth of several varieties of bacteria. In tube i> (inoculated from A) there were two kinds of bacilli, one staining very deeply and having rounded ends, and the other bacillus being more slender and having sharply cutends. Both these bacilli were present in tube A. Tube 6^ contained nothing.

A. G., struck in left eye yesterday. Small central ulcer. Coverslips negative. In tube A after twenty-four hours there was a small round white colony that turned out to be the staphylococcus pyogenes albus. There was no growth in tubes B and C (representing the first and second dilutions of tube A).

W. H. W., struck in left eye yesterday. Minute ulcer on the nasal side of the centre of the cornea. Cover-slipsshowed nothing. Tubes A and B contained numbers of small white colonies scattered over the surface of the agar, and examination showed them to be bacteria of various kinds and shapes. {B was inoculated from -4.) Tube C was inoculated direct from the eye and contained two colonies of a long slender bacillus.

R. L., left eye, small central ulcer. Was struck yesterday. Cover-slips vague. Tube B inoculated from A contained a bacillus and large micrococcus. Tube C contained nothing.

T. W., struck yesterday. Central ulcer. Pain intense. Struck for the first time, though he has shucked oysters for fifteen years. Cover-slips and cultures negative.

C. L., struck in right eye yesterday. Large ulcer somewhat below the equator of the cornea. The staphylococcus aureus was found in this case. .

G. ,T., struck in left eye six days ago. Small ulcer on periphery of the cornea. On the second day tube A was found to be dotted with small white colonies which turned out to be a short bacillus. This bacillus was also found in tube B. Nothing grew in tube C.

G. B., struck two days ago, and pain did not come on till he went home that evening and faced the lighted lamps in his house. The staphylococcus aureus and two varieties of bacilli were found in the agar, one a short heavy bacillus and the other a short slender bacillus.

J. B., struck three days ago in the left eye. Small central ulcer. .Small colonies of two kinds of bacteria in tube i) (inoculated from A). One of these was the staphylococcus aureus and the other \ias a large bacillus.

A. S., struck in right eye three days ago. Small ulcer nearly central. Struck in same eye a year ago. Has been shucking for eighteen years. Cover-slips vague, but in tube C there grew the staphylococcus albus and a bacillus. Three tubes made, tube C being second dilution of tube A.

F. R., struck three days ago in the left eye. Central ulcer. There was nothing on the cover-slips, and in l)oth tubes A and B there was a large stumpy bacillus. B was inoculated from -1.

W. J., struck in right eye yesterday. Large central ulcer. One of the cover-slips showed a large micrococcus that also was found in tube B. This tube was inoculated from A.

In eleven cases out of the si.xty-five there was absolutely no growth on the agar. This is not surprising when we consider the very small surface or area from which the inoculations were made. I took particular care never to touch any part of the cornea but the ulcer, and as this always occupies a very prominent position on the cornea it is likely that most bacteria would be swept off into the conjunctival sac by the constant movements of the lids. In thirty-nine cases the bacteria were of various kinds, and there were no two cases presenting the same bacteriological conditions. As a rule bacilli were the predominating organisms, and usually they were

large and coarse. In three of the fifteen cases given in full I found the same bacillus, about the size of the bacillus subtills, possibly somewhat shorter. I made a suspension of this organism in sterilized water and injected a few drops into the cornea and conjunctiva of a rabbit's eye, but scarcely any reaction followed. In several of the cases where there appeared to be some similarity between the organisms 1 tried the effect of injecting a suspension of the organism into the cornea, but always with negative results. In five cases the staphylococcus pyogenes aureus or albus w'as found. The injection of a suspension of this organism into the cornea was followed by suppuration, a thing, of course, to be expected. Inasmuch as the pyogenic staphylococci are found in several other external diseases of the eye, and even in the normal conjunctival culde-sac, to say nothing of their association with inflammation in other parts of the body, and moreover the fact that they were found in only five cases out of sixty-five, we are justified in the conclusion that the pus organisms had nothing specifically to do w'ith the inflammation in those cases where they were discovered.

Were oyster sbucker's keratitis a parasitic disease, certainly its specific organism, if recognizable by our present means of investigation, would have been found in several of the cases; but, as I have said, in only three cases did I find the same organism present, and the experiments with this organism seemed to show that it was possessed of slight, if any, pathogenic properties. It may be added that being once struck did not produce immunity, as there were several shnckers among the sixty-five who had been wounded twice in the same eye.

Is the disease of chemical origin? is there an)' chemical substance in the juice or shell that produces this immediate and intense reaction in the human cornea? To test this hyj)othesis I obtained about an ounce of the oyster juice, to which I added about a teaspoonful of the chippiugs from the shell and then passed this mixture through a Pasteur filter. I always made the oyster shucker open the oyster into a vessel so that I could obtain the juice fresh. This fluid after being filtered was injected from a sterilized hypodermic syringe into the cornea and conjunctiva of a rabbit's eye. Fifteen experiments of this character were made and the result in every case was negative, a fact that goes to show that in so far as the rabbit's cornea is concerned the juice of the oyster manifests no pathogenic effect when injected into that part of the eye.* In the first case I obtained a beautiful kerato-iritis in one eye, and in the other eye an ulcer not unlike the ulcer produced by the oyster shell. On examining the filtrate I found that it contained two varieties of bacteria — in other words, that it was infected. The injection, though, of these bacteria (both were bacilli) into the cornea of the rabbit was in no instance followed by a keratitis, so that the iullammation in the first case must have been due to some organism not found in the oyster. In the other fourteen cases I obtained a filtrate free from micro-organisms, and this filtrate was shown to possess no pathogenic properties when injected into the cornea of a rabbit.

• It may be well to state that in only one or two series of experiments did I use the same filtrate. Fresh juice was obtained and filtered for every experiment.

November-December, 1895.] JOHNS HOPKINS HOSPITAL BULLETIN.

153

The bacteriological study of these cases would seem to indicate that the so-called oyster shucker's keratitis is uot of parasitic origin. A number of experiments with the oyster juice after the latter has been freed of its living organisms goes to show that the juice of the oyster probably has nothing to do with the causation of the keratitis seen among oyster shuckers, and furthermore that the injection of this juice, even as much as a syringeful, under the skin of a rabbit was in no case followed by inflammation. Nor when the unfiltered juice was injected into the cornea was it followed by any irritating effect. It remained to be seen whether there was any chemical ingredient in the shell capable of calling forth this inflammation.

Several fresh oysters were procured and the edges were chipped off and ground up fine. The edge of the shell was selected, as it is this part that is chipped off by the shucker. These particles were then sterilized in a test tube. The heat did not seem to alter the size of the particles. The reaction of this substance was decidedly alkaline. I made a very small wound in the cornea of a rabbit with a cataract knife and rubbed in gently with a platinum needle a few particles of the powder. This experiment was performed eighteen times and in every case I succeeded in getting a well defined ulcer. The ulcer was accompanied with little or no circumcorneal injection, and its edges were sharply cut and separated from the healthy cornea. These ex])eriments show beyond a doubt that there is something in the oyster shell that wlien introduced into the cornea will produce keratitis.

It is difficult to imitate successfully all the conditions connected with a foreign body in the cornea. In the first place, the size of the foreign body is problematical, and the most difficult thing to imitate is the manner and force with which it strikes the cornea. I thought that it would be possible to approach this latter condition by using what the boys call a blow-gun or spit-blower. It was seldom that I succeeded in blowing the particles of shell with force sufficient to drive them into the cornea. Twelve experiments of the following character were performed. One long blower was loaded with cinders from a locomotive smoke-box, and another blower was loaded with particles of oyster shells. Both the cinders and shells were sterilized. At a distance of six inches from the cornea the load was blown into the latter. In a few cases a cinder remained sticking in the cornea, but in only one case did a particle of shell stick ; the particles of shell were too fine to be blown with force sufficient to make them lodge on the cornea. It was noticeable, though, that the reaction was more or less intense in the eye into which the shells had been blown, while there was practically no reaction in the eyes into which the cinders had been blown. In the case of the eyes where the shell was used, redness of the conjunctiva and increased secretion were seen, while in the other class of cases the conjunctiva renuiined normal. 'I'he reason that 1 failed to get an ulcer was that I never succeeded in wounding the cornea to any extent.

It could hardly be expected that the reaction in the case of a rabbit's cornea would be as intense as that following similar injuries in man. I have always been impressed with the promptness with which injuries to the ej'es of dogs and rab

bits heal. Injuries that, in the case of human beings, necessitate long and careful treatment, get well readily in rabbits and dogs. Spontaneous affections of the rabbit's conjunctiva are comparatively rare. This is not the case to the same extent with dogs, which, like man, are not infrequently seen with eye affections. The tissues, too, of a rabbit's eye are certainly more resistant to infected wounds than those of man. This fact I have demonstrated elsewhere again and again. It is not likely then that we would get a keratitis in a rabbit that resembled exactly what we are accustomed to see in the oyster shucker. The keratitis in the shucker would be more intense in its clinical history, simj)ly because it is the human cornea that is affected; this intensity being due perhaps to the frequent presence in the conjunctival sac of pathogenic bacteria, and to the feebler resisting powers of the tissues.

It is reasonable to suppose then that any agent that will produce an ulcer in a rabbit's cornea will certainly have the same effect on the human cornea. It has been shown that, with the exception of the pus organisms, none of the organisms found in the sixty-five cases of oystgr shucker's keratitis produced keratitis when injected into the cornea, that is to say, there was no apparent infiltration of the cornea at the point of injection ; and this, added to the fact that no one organism was found constantly present, inclines one to the opinion that the disease is probably not of bacterial origin — this in the light of our present bacteriological knowledge. It has been shown that the oyster shell contains an inorganic material that does produce keratitis when introduced into the corneal tissue.

The analysis of Chatin and iluntz* shows that the shell of the oyster contains considerably over 90 per cent, of calcium carbonate. The analyses show that carbonic acid held in combination wdth calcium and magnesium is present to the extent of 44 to 48 per cent., and that calcium oxide varies from 49 to 53.7 per cent., and magnesium oxide from 0.4 to 0.5 per cent. The tables further show that sulphates, phosphates, silicates, fluorides, bromides and iodides are present, the sulphates forming about IJ per cent., the phosphates ^'^ per cent, and less, the silicates 3 to 3 per cent, and more, the fluorides a few hundredths of 1 per cent, the bromides and iodides some thousandths only of 1 per cent. The bases corresponding are calcium, magnesium, iron and manganese. Organic matter is present to the extent of ] per cent., and remains in the form of a thin membrane or network when the mineral matters are dissolved out of the shell with the help of acids. It will be seen then that the carbonate of lime forms nearly all of the oyster shell.

I obtained some pure carbonate of lime ^^uot the chalk such as is furnished by the druggist), and after making a sterilized wound of the cornea, powdered some of the lime that had been previously sterilized, between the lips of the wound, and in every iust^mce I succeeded in getting an appreciable keratitis. This experiment was repeated with pcf^itive results a number of times. It would seem then that the carbonate of lime is iu itself sufficiently irritating to call forth au iufiammation of the cornea under certain conditions.

•Analyse des cociuilles d'Huitres. par MM. .\. Chatin et A. Miintz, Comptes Rendus, t. CXX, 53.

154

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 56-57.

In this cuMiiL'Liiuii it is interesting to note the fact that on the Eastern Shore of ilaryland, in the hitter part of September and during October, when the winds are very high and the roads dusty, a form of ophthalmia is very common, which is attributed to the fine particles of oyster shell dust that fill the air and get into the eyes of those who drive along the roads. The roads in that section are for the most part shell roads. The ophthalmia is characterized by great redness of the conjunctiva and profuse secretion. Not infrequently both eyes are affected, and it is a very painful affection. I am indebted to Dr. B. W. Goldsborough of Cambridge for information on the subject of this interesting eye disease, which he tells me is often seen in his section of the country at certain seasons. This certainly shows that the oyster shell possesses irritating qualities. Accounts are contradictory as to the irritating effect of the dust on a well-known shell road in the vicinity of Baltimore.

It has been suggested that the mud which covers the oyster probably flies into the eye and causes the trouble. Any one who has visited an oyster shucking establishment will be struck at once with the appearance of the shuckers. Their hats, faces and the upper portions of the body are peppered with fine particles of mud, and I have been told over and over again that the mud frequently flies into the eyes, but other than a little temporary burning no inconvenience follows. The face is often the seat of hundreds of little poinds where a drop of mud has struck and hardened. I am sure that were the injury inflicted in this manner we would meet with the disease far oftener, in fact oyster shuckers keratitis would be a very common affection, but it has been shown that the disease is of exceptional occurrence.

As to any other ingredient of the oyster shell playing a role in the production of the keratitis I am unable to give any evidence at this time. Positive evidence exists to show that the carbonate of lime possesses properties irritating enough to produce keratitis in the cornea of rabbits and dogs, a keratitis of a sluggish character. And though no typical picture of oyster shucker's keratitis was obtained in these animals, it is highly probable that the peculiar asjfect of the disease as seen in man is due to conditions belonging to the human eye alone, conditions which help to intensify the process. It is more than likely that some one or more of the other chemical ingredients of the shell may play a part in the etiology of the keratitis. From the analysis of Chatin and

Muntz it is evident that the oyster shell contains ingredients besides the carbonate of lime which might be irritating to the cornea and conjunctiva.

Conclusions.

1. Oyster shucker's keratitis may be defined as a traumatic keratitis where the injury is produced by a particle of the oyster shell.

3. The disease is chiefly remarkable for the rapidity with which the cornea undergoes necrosis at the site of the injury, this area of necrosis being usually very small, owing no doubt to the small size of the foreign body. Small foreign bodies of copper, steel and sand usually produce no appreciable keratitis; and even when they lodge in the cornea, commonly reqnire several days to cause a noticeable inflammation. On the other hand, the oyster shucker presents a marked infiltration of the cornea at the point of injury within twenty-four hours after the accident.

3. This decided reaction on the part of the cornea makes the injury a peculiarly dangerous one when a large area is wounded, or when entrance has been made into the anterior chamber, such conditions in my experience being invariably followed by loss of the eye through panophthalmitis. How often do we see the cornea injured in the same degree by other kinds of foreign bodies and still the vision not entirely destroyed.

4. Bacteriological investigations failed to discover any specific organism, nor did any of the organisms obtained from cases of oyster shucker's keratitis manifest any pathogenic properties when introduced into the corneae of rabbits, with the exception of the pyogenic cocci. It is not likely then that the disease is of parasitic origin.

5. The carbonate of lime, of which the oyster shell is almost entirely composed, was found to possess qualities irritating enough to call forth a keratitis when introduced into the cornea of a rabbit, and it is more than probable that several other chemical ingredients of the shell w-ould be more or less irritating to the cornea.

6. It is certain that bacteria always play apart in traumatic keratitis, but it is evident that in this variety of traumatic keratitis the cornea is rendered especially susceptible to the effects of micro-organisms, by the irritating chemical ingredients of the oyster shell, notably the carbonate of lime.

THE CLINICAL COURSE OF FORTY-SEVEN CASES OF CARCINOMA OF THE UTERUS

SUBSEQUENT TO HYSTERECTOMY.

By W. W. EussELL, M. D., Associate in Gynecology. {Read before the Johns llopkins Medical Society, Noremher 4, 1895.)

The doubts which have existed as to the ultimate value of complete extirpation of the uterus for carcinomatous growths can be set aside with certainty. From the statistical reports of many operators we are now justified in claiming the possibility of cure in a certain number of cases by removal of the uterus, or a relief from distressing symptoms for months and even years. We obtain then by snch a procedure either a cure or a palliative effect, very often anticijiating a cure where we obtain only cessation for a variable period of the local discharges, hemorrhages and pain.

It is connnonly accepted that these patients live usually not over two years after the appearance of the first local signs.

If we are able theu to free tliem from this terrible affliction for a louger time than this, even though recurrence does result in the end, are we not justified iu the jirocedure? The indication for operation is to obtain a cure, although ultimately there may be only temporary relief.

Our results clearly illustrate this fact, as sixteen of the twenty-one cases still living have passed the limit of two years and are enjoying good health — a period of exemption well worth the trial.

The following forty-seven cases of hysterectomy for carcinoma of the uterus include all those operated upon by Dr. Kelly and myself since the opening of the Gynecological wards in October, 1889, and in Dr. Kelly's private practice up to October, 189.5, thus giving a time limit of from one to five years.

Many of these cases we have seen personally within the past three months, and where they lived at a distance we have obtained our information by writing to the local consultant or to the patients themselves.

Vaginal hysterectomy has been employed iu forty cases, abdominal in four, and the combined operation in three cases.

Grouping them all under one head the results are as follows :

Death from primary effect of operation 5 = 10 per cent.

Patients still living 21 = -ll "

Patients died with recurrence IG = 34 "

Patients not heard from 4=8 "

Died from heart lesion. 1= 2 "

Three of the deaths immediately following the oi^eration were due to peritonitis and two to ligation of the ureters.

Kecurreuce and death took place in the sixteen cases within eighteen months, but the prognosis in eight of these at the time of operation was unfavorable.

One patient of the twenty-one still living was operated upon nearly five years ago for extensive disease springing from the cervix. She presented herself in perfect health about every six months for examination, but we were never able to find any return of the trouble locally. About sixteen months ago there appeared in the left side of the neck above the clavicle a nodule, to which she called our attention. Since then other glands in this region, on the ojiposite side of the neck and in the axillaa, have become similarly affected, some of which have broken down and discharged externally. She is at present in a critical condition. As her home is at a considerable distance, we are compelled to accept this as a metastatic manifestation.

Two cases died within four months after the uterus was removed. One had at time of operation such extensive infiltration on either side of the cervix that the case was considered hopeless. The uterus in the second case was found during the operation converted into a friable carcinomatous mass adherent in every direction to the bowels, so that complete enucleation was impossible.

Carcinoma of the breast developed and was removed in two cases several months after the uterus was extirpated. One of these died of a pre-existing heart lesion without any evidence of a local return, and the other is at present also free from

any pelvic trouble, but the carcinoma has again appeared in the breast.

The Fallopian tube prolapsed iu three cases in which it had not been removed, and during the healing of the vaginal incision was caught so that it protruded into the vagina, greatly reddened and swollen. These upon examination made us suspicious that there had been a return of the disease, but the microscope proved their true character. Two of these patients are still in good health ; the third died from a recurrence.

Another patient returned a year after operation with a note from her physician telling me that he had discovered a mass in the vaginal vault which he believed to be of a malignant character. There had been associated with it a profuse vaginal discharge, and occasionally some bleeding. This mass proved to be a large silk ligature which had been left on the broad ligament and had become imbedded in the granulation tissue. Since the removal of the ligature the patient has been absolutely well.

The most interesting of these cases is a patient who presented herself three mouths after vaginal hysterectomy for carcinoma of the cervix, with a fungus-like growth arising in the vaginal vault along the scar resulting from the operation. Dr. Kelly dissected the mass carefully out and thoroughly cauterized the surrounding area. This took place two and a half years ago, and the patient at present continues to be in excellent health.

Local return occurred in all the cases terminating fatallv, but in none could we elicit any history of metastatic growths in other parts of the body, the single exception being the one case above cited where the patient is still living.

Pneumonia was the cause of death in one instance thirteen mouths after the operation ; here there was an extensive malignant ulcerated area in the vaginal vault, which had appeared a few mouths after she left our care.

Adeno-carcinoma, body of the uterus 9 cases.

Carcinoma, cervix 38 "

KesuUs of hysterectomy for carcinoma of the body:

Patients still living 7 = 77 per cent,

•' died recurrence, operation incomplete 1 = 11

" died primary effect of operation 1 = 11

No. cases still living, 5 yrs. elapsed 1

'^ 3 " •• •• 2

" " 2 " " . . 2

" 1 " " 2

The uterus was removed by supravaginal amputation in three cases. An ordinary vaginal hysterectomy was performed in the remaining six. Kecurrcnce has taken place therefore only in the case where the operation was not completed.

In some of the cases the growth had penetrated the w.nlls of the uterus so that it could be seen just beneath the peritoneal covering, and yet no evidence of involvement of the lymphatics or the parametrium could l>e detected. The three cases in which the cervix was left have proved as satisfactory ivs those iu which the whole uterus was removed.

156

JOHNS HOPKINS HOSPITAL BULLETIN.

[Nos. 56-57.

Kesults in hysterectomy for carcinoma of the cervix :

Patients died from primary effect of the

operation 4 = 10 per cent.

Patients still living 14 = 3G "

Patients died with recurrence 15 = 38 "

Patients not heard from 4 = 10 "

Operations over 4 years ago and patients still living 3

3 " " " 4

" 2 " " " 4

" 1 " " " 3

The uterus was removed in four cases by the combined method. One of these died a few days after the operation from ligation of the ureter, and another in which the disease was associated with pregnancy died several months after operation with a recurrence in the vagina. The remaining two are reported as free from any suspicious signs.

Vaginal hysterectomy was employed in thirty-four cases, three of which died from the operation, and fourteen afterwards from the original disease.

The four cases not accounted for up to the present time were considered at the time of operation favorable for cure. Two of them I have since seen, one two years after operation and the other one year, and both at that time showed no evidence of ulceration or induration by vaginal examination.

The fourteen women who are still living do not giv6 symptoms pointing to metastasis or local recurrence, except the one mentioned with the nodules in the neck and axilla. This single case proves that even after a lapse of four years we are not justified in claiming a cure. We cannot definitely at present fix a period of years through which a patient must live in order to pass the danger limit. Fritsch, Schauta, Hofmeier, Leopold and Boldt have followed their cases from

five to seven years after the removal of the uterus, and even as late as seven years there continues to be a fall in the percent, of cures.

Olshausen, Schauta and Fritsch report over 47 per cent, without recurrence after a lapse of two years. It is a striking fact that in our cases thus far, all recurrences but one have taken place within eighteen months.*

We have not attempted to show the relationship of the different forms of carcinoma to their tendency to recurrence, but the form of disease has undoubtedly a great infiuence upon the ultimate results. This point is clearly demonstrated by our experience, as in not a single one of the seven cases in which the uterus was completely removed for adeno-carcinoma of the body has a recurrence been noted; while in the thirty-eight cases where the cervix was diseased, fifteen have died with a return of the trouble.f

Metastases were found only once beyond the pelvic and retroperitoneal glands, in ten autopsies performed in the pathological laboratory upon patients in whom carcinoma of the uterus was present. This was an adeno-carcinoma of the body of the uterus, and a few nodules were found in the liver. In four others there were carcinomatous deposits in the pelvic and retroperitoneal glands.

This, in conjunction with the fact that by far the greater majority die subsequent to hysterectomy with a continuation of the growth in the vagina and parametrium, proves the possibility of complete eradication.

• Statistics obtained from Winter, Berliner klin. Wochenselirift,

1891, No. 33, and Ztsch. f. Geburtsh. u. Gyn., Vol. XXIV, p. 135 ; also Boldt, American Jour. Obstet., Vol. 26, p. 517.

fKinkenburg (.Ztsch. f. Geburtsh. u. Gyn., Vol. 23) and Hofmeier (same journal. Vol. 32) have made similar observations.

St.vtistics of Forty-seven Cases of Cakcinoma.

Name.

Seat of Disease. | Operation.

Date of Operation.

Date of Death.

Remote Resllts.

Mrs. L.

Cervix. Fungating mass iiiin.- \ lu'iiial hystcreAomy. upper portion of vagina.

11-31-89

8-30-91

Local return.

E. C.

Body.

\ affinal bystuiectomy. Uterus ruptvired dui'ing removal.

1-2-^

Patient continues to be in excellent health.

C.G.

Cervix. Previous operation, high amputation.

Vaginal hjsteicctuiny. First use of ureteral catheter.

6-18-90

Patient last examined 10-3-93. No sign of return.

D. J. B.

Body.

Vaginal hysterectomy. Bladder opened. '

8-38-90

Five days after operation.

Death, peritonitis.

Mrs. H.

Cervix. Extensive lateral in 111tratlon.

Vaginal hysterectomy.

3-38-91

Fire mouths after operation.

Local return in vaginal vault.

M. W.

Cervix. Fungating mass in vagina.

Vaginal hysterectomy.

4-4-i)l

Last examination 10-3-95. No evidence of return.

J. B.

Portlo vag. Disease extends I cm. on vaginal walls.

Vaginal bysterectotny.

5-4-91

Discharging gland.s in neck and axilUe. No local return, )<-15-y5.

E. C.

Cervix. Disease circumscribed.

Vaginal hysterectomy.

7-1-91

Last seen S-9-93. In perfect condition.

M. A. B.

Cervix. Fungating mass in vagina. F.xtenVivc lateral involvement

Vaginal hysterectomy.

11-9-91

9-5-93

Local return in few months.

Dr. Miller's Patient.

Cervi

Vaginal hysterectomy.

4-23-91

Excellent health. No evidence of return, 9-11-95.

Mrs. W.

Cervi.x. I,:itiriu iinoivuuieut. Myoma at fundus.

Vaginal hysterectomy.

13-23-91

1-1-93

Local return.

K. K.

Cervix. Exlcusivc lateral inllltratlon.

Vaginal and abdominal.

1-30-93

Died from operation. Ligation of ureters.

Mrs. M.

Cervix.

Vaginal hysterectomy. Cauterization of left pedicle on account of inBltrated area. Prognosis bad.

,.8-18-92

Patient in excellent health. No local return, 9-1.5-95.

November-December, 1895.] JOHNS HOPKINS HOSPITAL BULLETIN.

157

Name.

Seat of Disease.

Operation.

Date of Operation.

Date of Death.

Remote Resclts.

Miss B.

Body.

Incomplete vaginal hysterectomy on account of extensive disease and inflltration of fundus.

'^-33-93

About three months after operation.

Disease had brolien through uterine wall and spread out on intestines.

Mrs. G.

Cervix.

Vaginal hysterectomy.

8-3-92

9-38-92. Portion of tube in incision removed with cautery. 9-1-95, patient in L'ood li'-iilth.

F. C.

Cervix. Two nodules found in uterus entirely separate from cervix.

Vaginal hysterectomy. Bladder perforated and afterwards closed with good result. Bad prognosis.

11-37-93

10-18-93

13-12-(iri ised. Loca;

C. T.

Cervix. Complicated by 4 months' pregnancy.

Vaginal and abdominal.

11-10-9J

.5-1-94

Patient died in Hospital. Local return with perforation of bladder and rectum.

R. A.

Body. Associated with myoma.

Supra-vaginal amputation. Cervical canal cauterized.

11-38-93

Patient In good health, 9-13-95.

Z M.S.

Cervix. Fungating mass in vagina.

Vaginal hysterectomy.

12-17-93

5-13-93. Ulcerated area in vaginal vault dissected out and cauterized. — 9-31-9.1. No sign of local return.

A. E.

Cervix. Fungating mass iilliug vagina. Invasion of vaginal mucosa.

Vaginal hysterectomy.

6-25-93

Unable to find patient.

Mrs. D.

Cervix.

Vaginal hysterectomy.

3-6-93

Patient continues in good health,

10-1-95.

Mrs. C.

Cervix.

Vaginal hysterectomy.

4-13-93

Unable to obtain information regarding patient.

Mrs. G.

Cervix.

Vaginal hysterectomy. Impossible to remove all disease laterally.

4-18-93

7-1-93

Local return.

E. B.

Body.

Vaginal hysterectomy. Uterus ruptured in removing.

5-10-93

Breast removed for cancer about one year after hysterectomy. 10-1-95, no return in vagina, but patient under treatment for some recurrence in breast.

Mrs. S.

Cervix.

Vaginal hysterectomy.

8-30-93

Died one year later.

Local return.

8. L.

Cervix. Vagina fllied with fungating mass, and inflltration for a cm. about cervix.

Vaginal hysterectomy. Bladder perforated. Transfusion of salt solution in radial artery.

10-10-93

8-15-94

Local return.

P. H.

Cervix. Circumscribed nodule.

Vaginal hysterectomy.

11-8-93

Last heard from S-20-95. Donblful return in cicatrix.

L. W.

Body. Associated with myoma.

Supra- vaginal amputation.

2-1.5-93

Continues in excellent health, 10-5-95.

C.8.

Cervix.

Vaginal hysterectomy.

11-25-93

Died from operation. Peritonitis.

M. F. W.

Portio vaginalis. Disseminated nodules in vaginal mucosa.

Vaginal hysterectomy. Whole upper third of vaginal mucosa removed.

11-25-93

2-1-95

Death from pneumonia. Local retam.

M. G.

Body.

Vaginal hysterectomy.

12-1-93

Continues to be in excellent health, S.17-95.

M. D.

Cervix. Lateral intiltration so far advanced that a bad prognosis given.

Vaginal hysterectomy. Bougie in ureter.

12-11-93

1 No evidence of local return. Patient in ' excellent health, 9-13-95.

A. R.

Cervix. Post, lip only involved.

Vaginal hysterectomy.

1-31-94

Sent by physician (or examination on account of suspicions nodule in scar, which proved to be silk liirature imbedded in granulation tissue. No evidence of return of disease, 9-13-95.

L W.

Cervix. Fungating mass filling upper portion of vagina. Mucosa of vagina not diseased.

Vaginal hysterectomy. Bougie passed into ureter.

2-15-94

About nine months after operation.

Local return.

N. C. J.

Cervix. Uterus torn olf above internal OS. Lateral infiltration. Bad prognosis.

Vaginal hysterectomy.

3-17-94

6-8-94

Local return.

E. O.

Cervix. Lips entirely disappeared. Disease far advanced laterally.

Vaginal hysterectomy. Uterus ruptured during removal.

3-3-94

11-5-94

Local return.

8. B. H.

Cervix. Nodules fell beneath vaginal mucosa. Prognosis bad.

Vaginal hysterectomy. Bougie in ureter. Pus cavity beside uterus in abdomen.

8-5-94

Five months after operation.

Local return. Death sudden.

M. E.

Cervix. Vagina and parametrium involved. Bad prognosis.

Vaginal hysterectomy. Nodule in broad lig. dissected out.

8-5-94

Eight months after j Local return, operation. [

M. 11.

Cervix.

Vaginal hysterectomy.

8-7-94

Died from operation.

Death due to pcrltooitis.

M. Q.

Cervix.

Vaginal hysterectomy.

8-21-94

Died from oueratlon.

Death due to peritonitis.

B. Z.

Portio vaginalis. Disease had encroached upon vaginal walls 3 cm.

Vaginal hysterectomy. Ureter cut.

8-23-94

Ureter dissected out and sutured into incision in l>ladder. S-1.5-S6. no sign of return. No urinary diflicalty.

M. P.

Body.

Abdominal hysterectomy.

7-35-94

Perfect health when last soon, 8-18-85.

A. R.

Cervix. I'.iniliiiu .1 oiuiation, vaginal and

ib.l..iiiinal.

8-8-94

No local induration or ulceration. Good hoallh, ^16-a5.

8. A.

Cervix. Converted into shell.

Cumbimil operation, vaginal and abdominal.

0-5-94

Doctor write* that p,itient Is in good condition, with no sign of recurrence of disease, l(V-lC>-lVi.

K. A.

Body.

Supra-vaginal amputation. Cervix cMipiu'd out.

6-30-94

No evidence of recurrence, 9-13-»5.

B.C.

Cervix. Vaginal livstcrectomy. Tube caught in vairinal incision.

3-17-94

Patient in good health and vitbont symptoms pointing to return. 9-1 i-a5.

Carcinoma of breast removed about one Tear after the vaginal hysterectomy. I'aliont died of hc,»rt lesion.

Mrs. W.

Cervix.

Vaginal hysterectomy.

11-15-91 Died about eighteen months affcr op1 eration.

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[Nos. 56-57.

NOTES ON SOME OASES OF ANGINA TREATED WITH BEIIRING'S ANTITOXINE.

By George Blumkk, :M. D., Assidant in Pathology, The Johns Ifnph'vs Hospital

The following cases of siugina, either due to the bacillus diphtheriae, or simulating true diphtheria and due to other organisms, have been observed iu the hospital since the intro•ductiou of the antitoxiue treatment.

Some of the cases are of interest as relating to the eilect of the autitoxine on diphtheria; others were not treated by antitoxiue, but present some special point of interest bearing more or less upon diphtheritic or diphtheroid inflammations.

In the cases treated by autitoxine, the preparation prepared under the direction of Behring was exclusively used, the various strengths being indicated according to the severity of the case and regardless of the age of the patient.

The autitoxine was usually injected into the cellular tissue of the back, though occasionally into the musculature of the thigh, the injection being done with a syringe previously sterilized by boiling, the skin of the part to be injected having been prepared by the methods usual before operative procedures.

The cases, which number eighteen, may be grouped under the following heads:

MEMBK.-VNOUS ANGINA DUE TO THE BACILLUS DiPHTHERIAE.

Case 1.— Female, aged 11, white. Admitted to the hospital December 31, 1894, complaining of sore throat.

JJi«/oij/.— The family histor.v is negative. The patient had measles, whooping cough and typhoid fever as a young child.

The present illness began four nights ago, the patient waking up in the middle of the night with an attack of nausea, followed by vomiting and headache. The throat did not feel sore until the following night, and she then noticed pain on swallowing. .-Vt first the soreness was confined to one side, but later both sides became involved.

On admission the general condition was good. There was great swelling of both tonsils, the glands almost meeting in the median lino. The inner surface of each tonsil was lined by a purulent membrane, whicli, on removal, loft a bleeding surface.

January 1. The membrane has extended to the uvula, and soft palate. There is slight glandular swelling on the left side.

.January 2. The child looks rather pale and is dull and apathetic. Bohring's Antitoxine No. 3 was injected into the snl)outaneous tissue of the back.

.Tanuary 3. The child is much brighter, states that s!ie feels better, and voluntarily asks for food. Tlio swelling of the tonsils has diminished, though the uvula is still covered by membrane. The tense oedema of the tonsils and adjacent parts observed yesterday has disappeared.

January 4. The membrane has almost disappeared.

The temperature on admission was 101.5° F., and ranged between this point and 103° F. up to the time of the Inoculation, when it wjis 103° F. Following the inoculation it sank gradually; the morning following It was 100.5° F., but after this never passed above 100° F., the convalescence being uninterrupted.

The pulse was noted to be a little feeble the day on which the inoculation was made; the following morning it was much improved. About six days after the inoculation the patient began to have attacks of urticaria, coming and going over a period of a week. The eruption was not confined to tlie region of the original Injection, but occurred in various parts of tlie body.

BacteriiiUnjical Examination.— Cn\cr-s\\\>a from the throat did not show definite diphtheria bacilli.

Cultures after 24 hours sliowed almost a inire ciilturo of the bacillus diphtheriae.

A guinea-pig inoculated with a 24-hour buuillon culture died 14 days later with characteristic lesions, diphtheria bacilli being obtained from the seat of inoculation.

Case 2.— Female, aged 35, white. Admitted to the hospital January 7, 1S95, complaining of sore throat.

Histonj.—Hev father died of some disease of the liver, her mother of heart disease. No other diseases in the family.

.\s a child she had the usual exanthems. Slie liad an attack of diphtheria at 9 and another at 29, the latter being a severe attack. She has had four attacks of tonsillitis in the last three years.

The present illness began with a feeling of malaise three days ago; the following day she had chilly feelings and pain in the limbs and back. The throat was not noted to be sore till yesterday.

On admission the general condition was good. There was a general reddening of the throat and a large patch of grayishwhite membrane over the left tonsil, which was detached with difficulty and left a bleeding surface.

Behring's Antitoxine No. 1 was injected into the muscles of the back.

January 8. The membrane on the left tonsil remains the same. There is a small patch on the right tonsil which was not noticed yesterday.

January 10. The membrane has completel.v disappeared.

The temperature on admission was 100.5° F. At the time of the inoculation, two hoiu's later, it was 101.5° F., and had risen two hours later to 102° F. The following morning it had fallen to 100° F., but rose again slightly, reaching 100.5° F. at 4 P. M.; from this time on it fell, reaching normal in four hours and never again rising above that point. The pulse was good at all times. No skin eruption was observed.

liactcrinlogical Eraminatinn. — Cover-slips from the throat showed typical diphtheria bacilli. Cultures on blood serum showed many colonies of the bacillus diphtheriae and a few of the streptococcus pyogenes.

An animal inoculated with a 24-hour bouillon culture failed to react either locally or constitutionally.

The organism isolated was certainly not the pseudo-diphtheria bacillus. It acidified litmus bouillon, and grown side by side with a culture of the pseudo-bacillus, could easily be distinguished. The patient was discharged seven days after the disappearance of the membrane, the bacilli still being present in the throat.

Februaiy 17. The patient again comes under observation after a five weeks' holiday. The throat is quite clear. She states tliat during her absence, and about three weeks after the cess;ition of the first attack, she had a second fairly severe attack of sore throat, which was diagnosed tonsillitis by the attending ph.vsician, but without a bacteriological examination.

Cultures were again from the throat, and diphtheria bacilli and streptococci found to be present.

The patient was kept under observation, and three d&ys later cultures were again taken. tl)o patient having used at frequent intervals for the preceding 24 hours a bicliloride spray and a solution of h.vdrogen peroxide as a gargle. Large numbers of diphtheria bacilli were still present.

Two days later a tliird set of i-ultures were made, the patient in the meanwhile liaviug had Lii(Uor"s toluol solution vigorously applied to botli tonsils five or six times. The diphtheria bacilli were still prtksent, though in smaller numbers.

These organisms, like those isolated in the first attack, were harnih'ss for animals, so the patient was allowed to return to her wiu-k. Three weeks later she was again admitted to the ward with a history of having been taken with sore throat. fever and malaise four days previously. She had been attended

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159

for a time by her own physician, and creosote had been applied locally. On admission there was a glossy white membrane over each tonsil, very tenacious in character. The patient was practically convalescent at this time. The membrane gradually disappeared and had entirely goue seven days froiA admission. There was no fever.

In the interval between the first and last attacks, and in the last attacli, the diphtheria bacillus could always be obtained from the throat. It was on several occasions inoculated into animals and never produced either local or general reaction.

The organisms finally disappeared from the throat three days after the disappearance of the membrane caused by the last attack, or three months and three days from the beginning of the first attack.

Case 3.— Female, aged 8, white. Admitted to the hospital February 1, 1895, complaining of sore throat.

History.— The family history is negative. She has had the usual exanthems and has been treated for some chronic throat disease since August last.

The present illness began five days ago with a shaking chill lasting about half an hour. She felt well the next day until evening, when she had some fever. She complained of sore throat from the first.

On admission the general condition was good. The right tonsil was swollen and covered by a large patch of yellowish-gray membrane; the left tonsil also swollen and shows a smaller patch of membrane; the uvula free.

Behring's Antitoxine No. 2 was injected into the subciitaneuus tissue of the back.

February 2. The membrane is still i)resent, but looks swollen and has a shining translucent appearance.

February 3. The edges of the membrane are curling up. There is a fine pink papular eruption over the face and back, not itchy.

February 5. All the membrane has gone but a small patch over the right tonsil. The eruption has disappeared.

February 8. The child complains of itching of the back. There are ten to twelve urticarial wheals about the seat of inoculation.

February 9. The urticaria has disappeared.

The temperature on admission was 101° F., but had fallen to 99° F. when the inoculation was made; it never again passed 99.3° F. The pulse was always satisfactory.

Back'rioloyical Examination. — Cover-slips from the membrane showed a fair number of typical diphtheria bacilli. Cultures showed the same organism in an almost pure state.

A guinea-pig inoculated with a 21-hour bouillon culture died 76 hours later, the autopsy showing the typical lesions of experimental diphtheria, and the organism being recovered from the seat of inoculation.

The organism disappeared from the throat five days after the disappearance of the membrane.

Case 4.— Female, aged 30, white. Admitted to the hospital February 5, 1895, complaining of sore throat.

Hi.story. — The family history is unimportant. The ijatient h;iil the usual exanthems as a child. She has had two attacks of appendicitis, the last one two years ago. She had right-sideil pleurisy 20 mouths ago. Since the age of 15 she has had nine or ten attacks of tonsillitis, none of them very severe.

The present illness began two days ago witli chilly feelings, which lasted for twenty-four hours. Last night she began to have frontal headache, which persisted up to a short time ago; all day yesterday she had pains through the limbs. The throat felt a little sore from the first.

On admission the general condition was good. The fauces and tonsils were slightly ccmgested, the tonsils quite swollen, especially the right, which was almost covered with a patch of yellowish-gray adherent membrane; a smaller patch was present on the left tonsil.

Behring's Antitoxine No. .T was injected into the subcutaneotis tissue of tlie back. In the afternoon some pain at the seat of Inoculation was complained of.

February (>. The patient fools much better. There is still some pain at the seat of inoculation. The throat Is less swollen,

though the patch on the left tonsil is somewhat increased in size.

February 7. The throat is almost clear; what membrane remains is swollen and pearly looking.

February 8. The membrane has entirely gone.

The temperature on admission at 2 I'. M. was 102° F.; at (! P. II., about two hours after the inoculation, it had risen to 1(12.5° F.; it then fell, reaching 99° F. at 8 the following morning. At 12 noon on the Oth the temperature was 100° F.; it then fell gradually, reaching normal at midnight and never ag.iin going higher than 99.6° F.

The pulse ranged from 76 to 106; it was always strong.

No skin eruption was noted.

liactcrioloyical Examlruition. — Cover-slips from the membrane showed typical diphtheria bacilli. Cultures showed the same organism associated with the staphylococcus aureus and a few St roptococei.

A guinea-pig inoculated with a 24-hour bouillon ciUture showed marked local tumefaction, but did not die.

The diphtheria bacillus disappeared from the throat 22 days after the disappearance of the membrane.

Case 5.— Male, aged 26, white. Admitted to the hospital March 6, 189.5, complaining of sore throat.

History.— Aside from a history of tuberculosis in two sLsters the family history was negative. The patient had the usual exanthems as a child, and malaria and typhoid as an adult. He has been subject to attacks of .sore throat ever since childhood. some of these attacks having been severe enough to confine him to bed.

The present illness began three days ago with dryness and. later on, soreness of the throat. No cliill or fever. He has beadache and pains through the limbs.

On admission the general condition was excellent Both the tonsils were swollen and reddened, and the middle part of each was covered by a thick yellowish membrane, which, on being detached, did not cause bleeding. The neck glands were a trifle enlarged and tender.

Behring's Antitoxine No. 2 was injected into the sulwutaneous tissue of the back.

The membrane gradually disappeared and was entirely gone three days after admission.

The temperature on admission was 99.5° F.. and never again pas.sed above 99° F. The pulse was always strong.

No skin eruiition was noted.

rtncteriological E .ramiMition.— Coyer-slips from the tliroat showed a few typical diplitheria bacilli. Cultures gave an almost pure growth of the same organism.

.\ guinea-pig inoculated with a 24-hour bouillon culture died 48 hours later, the autopsy showin,g typical lesions of exiierimontal diphtheria, and the bacillus being recovered from tie seat of iuocidation

Tlie organism dis.appeared from the throat three days after tlie disappearance of the membrane.

Case 6.— Male, aged 24. white. Admitted to the hospital March 10. 1S95. complaining of sore throat.

History. — The family history is negative. The patient had the ustial exanthems as a child, and la grippe and dengue as an adult. lie has always been subject to attacks of tonsillitis.

The present illness began two days ago with soreness in the region of the left tonsil and chilly sensations. The attack l>eg:in in tlie morning, and b.v evening a small patch of membrane was noticed on the left tonsil. On removing the membrane a bleeding surface was exposed.

C~>u admission the general condition was good. The tonsils were swollen, and over each was a blackish eschar caused by the use of I.ollior's toluol solution; beneath the eschar a gray membrane could be made out. The glands lu the neck were slightl.v enlarged.

Behring's Antitoxine No. 3 was injected into the sulK'Utaneous tissue of the back.

Two days after the inoculation the membrane bad entirely disappeared, though the tonsils still looked a little rod.

The temperature on admission was 104.S» F.: the next morn

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[Nos. 50-57.

ing it had fallen to 99.5° F., and did not rise alx)ve 100.5° F. all that day. The following day it began to rise at 8 A. M., reaching 103.5° F. at noon, after which it fell gradually, being 99.5° F. at S the ne.xt morning and never again passing the normal. The pulse was always good.

No skin eruption was noted.

Baclcrioloijical Examination.— CoYcr-sUps from the throat showed a fair number of typical diphtheria bacilli. Cultures showed an almost pure growth of the same organism.

A guinea-pig Inoculated with a 24-hour bouillon culture showed a marked local reaction, but did not die.

The bacilli were still present thirteen days after the membrane disappeared, though not virulent

Case 7.— Male, aged 5, white. Admitted to the hospital .Tune 13. 1895.

Hts^rj/.— Could not be obtained.

On admission it was noted that the child was small and iUnourished. The skin was pale. Tlie mucous membranes not cyanotic. The respiration was loud but not stridulous. 'Ihere was a constant purulent discharge from the nostrils, and much muco-pus dribbled from the mouth. Membrane could be made out on the soft palate, but examination of the tonsils and pharynx was not satisfactory. The temperature was 105° F. on admission.

Behring's Antitoxine No. 2 was injected into the muscles of the right thigh. The child was practically moribund on admission and died suddenly eight hours later.

Bacteriological Examination.— CoviM-sUps showed the diphtheria bacillus and cocci in groups or chains. From the cultures the diphtheria bacillus and the streptococcus were isolated.

An autopsy was not permitted.

Case 8.— Female, aged 29 months, white. Admitted to the hospital with dyspnoea August 12, 1895.

His^o/v/.— Family history negative. The patient had measles five weeks ago. She has had a discharge from the right ear for seventeen months.

The present illness began three days ago with cough. The child, however, ran about and played as usual up to last night. This morning about 4 A. M. she woke up with a severe attack of dyspnoea, which has gradually increased.

On admission the child was dull and apathetic. The mucous membranes and finger-tips were slightly cyanotic. There was marked obstruction to inspiration. Both tonsils were swollen and covered with a grayish exudate. Tliere was no exudate on the posterior pharyngeal wall. Temperature 100.5° F.

Behring's Antitoxine No. 3 was injected into the subcutaneous tissue of the back.

The dyspnoea became rapidly worse about three hours after admission, and the patient died during an attempt at' tracheotomy.

liriclrriolof/ical Exami)wtion.—CoysT-s\\ps from the membrane showed many typical diphtheria bacilli. Cultures showed the same organism. An autopsy was not permitted.

Case 9.— Male, aged 2 years and 10 months, white. Admitted September 8, 1895, complaining of sore throat.

History.— The family history was negative. The child has had no previous illness.

The pres(!nt illness began tive days before admission with anorexia. Two days later the child complained of i)ain on swallowing. This morning a membrane was discovered in his throat by his physif'ian and he was brought to the hospital.

On admission the general condition was good. Both tonsils were swollen and covered with patches of grayish-yellow exudate extending on each side Into the uvula. The pharynx is clean. The glands of the neck are not enlarged.

Behring's Antitoxine No. 2 was injected into the subcutaneous tissue of the back.

Seittember !). The membrane seems to have spread slightly. The child Is bright.

September 10. The child Is better; the membrane has ceased spreading.

September 11. The membrane has largely disappeared.

September 13. The throat is entirely clear.

The temperature on admission at 8 P. M. was 100.4° F. At 2 A. M., four hours after the inoculation, it reached 101.8° F.; it then fell gradually, reaching normal 24 hours later and never again jmssing 90.2° F. The pulse was always strong.

Nil skin eruption was noted.

Baclii-Uihtijiciil Bd;omin«<w».— Cover-slips from the throat showed suggestive bacilli, but no typical ones. Streptococci were present in fair numbers. Cultures showed the diphtheria bacillus and the streptococcus.

A guinea-pig inoculated with a 24-hour bouillon culture of the bacillus died 48 hours later with the lesions of experimental diphtheria, the organism being recovered from the seat of inoculation.

Case 10.— Male, aged 2, white. Admitted to the hospital September 20, 1895, with dilBculty in breathing.

Hixtorii. — A satisfactoiy history cannot be obtained, as the mother speaks only Bohemian.

From the mother's account the child lias only been ill twentyfour hours, its only symptoms being irritability and loss of appetite.

On admission the child looked ill. The breathing was rai)id and slightly obstructed. The voice was, however, clear. Over the tonsils and the neighboring parts of the soft palate a thick white membrane was seen.

Behring's Antitoxine No. 2 was injected into the buttock.

The breathing was somewhat more obstructed in the evening and the voice a trifle brassy.

September 22. The membrane has entirely disappeared. The child looks perfectly well.

The temperature remained steadily up about 102° F. until the 23d. when it fell gradually, reaching 99.4° F. at 10 P. M. and not rising again.

Bactcrisloijical Examination. — Cover-slips from the membrane showed a fair number of diphtheria bacilli. The cultures showed an almost pure culture of liaeillus diphtheriae.

Case 11. — Male, aged 7, white. Admitted to the hositital November 4, 1895, complaining of sore throat.

Bifttory. — The family history is unimportant except that he lost one sister from croup. He has had measles but no othei' illness. The present illness began four days ago with pain in the throat, which was increased by swallowing. The pain was at its worst two days ago, and he felt weak at that time. The pain and the weakness are the only symptoms complained of.

On admission the general condition was good. Both tonsils were swollen and showed numerous areas of membrane formation with rather a iiatchy arrangement. There was also a patch of membrane on the soft palate to the right of the uvula. The breathing was somewhat harsh, but there was no great dyspnoea.

Behring's Antitoxine No. 2 was injected into the muscles of the- left thigh.

November 6. The patient is quite comfortable; he has no pain on swallowing.

November 7. Only a small patch of membrane remains.

November 8. The membrane has quite gone.

The temperature on admission was 100° F., and sank following the inoculation to 98.8° V. It was up to 100° F. at noon on the Gth, and then fell gradually, never again reaching above 99.5° F.

Bavtcrioloiiical Bir'«Hniio<iow.— Cover-slips showed a good many typical diphtheria bacilli. Cultures showed the same organism, almost a pure growth.

The cases recorded in this group arc of that class which from a clinical standpoint alone would be regarded as diphtheria, /. e. they are characterized by definite membrane formation. Aside from the question of the influence of the autito.\ine on the progress of the disease they present no special points of interest, with the exception of Case 2. This case is of interest from several points of view : 1. As showing the duration of antitoxine iinmunization and of natural immunization.

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2. As showing the possibility of auto-infection.

3. As demonstrating that the diphtheria bacillus can exist for long periods in the throat.

4. As demonstrating the resistance of the diphtheria bacillus to chemical agents.

That the immunity conferred by the antitoxine (passive immunity) does not protect over as long a period as natural immunity (active immunity) has long been known as far as animals are concerned. Cases showing the duration of this artificial immunity in man are not, however, common. Henach has reported a case in which a recurrence of the disease occurred from 35 to 30 days after the use of the antitoxine, and Wolff-Lewin reports a case where a child who had apj)arently recovered perfectly after the use of antitoxine develojjed symjjtoms of a fresh attack ten days from the beginning of the first one. In our case the patient was immunized on January 7th and contracted a second attack of what was presumably diphtheria about three weeks later; it is true that the patient was not under observation during this second attack, but cultures made only a week later showed the diphtheria bacillus to be present in the throat. During this second attack no antitoxine was used, and yet a third attack occurred thirty-seven days after the beginning of the second. In this case, theu, the period over which active immunity lasted would seem to be about thirty-seven days, whilst that over which passive (antitoxine) immunity lasted was only twenty-one days.

It seems highly probable that auto-infection occurs in most cases of croujjous pneumonia and in many of streptococcus throat; it is also known that virulent diphtheria bacilli are occasionally found in the throats of healthy people. This case would seem to prove definitely that auto-infection does occur in diphtheria, as it was shown that the diphtheria bacilli were constantly present in the throat between the second and third attacks, the throat all this time pi'esenting a perfectly normal appearance. It is only fair to conclude that when the immunity was worn out the individual became infected by the bacilli then present.

Although the patient was not under constant observation from January 7th, when the first attack began, until April 10th, when the diphtheria bacilli finally disappeared from the throat, yet cultures were made frequently enough to warrant the assumption that the bacilli were continuously present over the period between the dates specified. In an observation recorded in the British ^ledical Journal of which Sevestre speaks, the bacilli were obtained from the throat seven months after the disappearance of the membrane; but in this case the cultures were few and far between. The question of the survival of the diphtheria bacilli after the disappearance of the membrane is an important one from a prophylactic point of view, for we must admit the possibility if not the probability of individuals such as our patient transmitting the disease to others. Such a possibility once being estublislied, the isolation of diphtheria cases would not be subject to any fixed law, but would depend on the demonstration of the presence or absence of the bacillus in the throat.

The fact that the bacilli in this case were only in part destroyed by the repeated action of Loffler's toluol solution is

an interesting one, especially as the solution was acting on a throat devoid of membrane. The fact that the bacillus appears so resistant should not, however, deter us from the use of such chemical agents, as clinical experience has amply proved

their value.

Diphtheria Simulating Follicular Toxsillitis.

Case 12.— Female, aged 23, white. Admitted to the hospital .January 17, 1895, complaining of sore throat.

History.— The family history was uuimportaut. The ijatient had the usual exanthems as a child; slio has not been subject to sore throat. The present illness began four days ago with backache, headache, sore throat and pains in the limbs. There was slight pain ou swallowing.

On admission the general condition was good. Both the tonsils were swollen and on both sides covered with numerous yellowish i)atehes, apparently plugging the follicles. No definite areas of membrane were to be made out.

Behriug's Antitoxine No. 2 was injected into the subcutaneous tissue of the back.

.January 18. This morning a small patch of membr-iue about the size of a split pea was noticed on the soft palate; it was quite adherent.

January 19. The membrane is disappearing.

.January 21. The membrane has entirely gone.

The temperature on admission was 100.2° F., and about the same at the time tlie inoculation was made; the following morning it was 99° F., and never passed above this point subsequently. The pulse w^as always strong. There was some itching about the scat of inoculation three days after its performance, but no skin eruption was noticed.

Bacteriological Examination.— Coyer-sWps from the throat showed suspicious bacilli, but nothing definite. Cultures showed the diphtheria bacillus in practically pure culture.

A guinea-pig inoculated with a 24-hour bouillon culture showed marked local i-eaction, but did not die.

This case corresponds to those described by Koplik as acute lacunar diphtheria of the tonsils. It illustrates the necessity, not yet fully appreciated, of a bacteriological diagnosis ju all cases of throat inflammation. It is just such cases as this which would be clinically regarded as a non-infectious tonsillitis, which may give rise to serious epidemics of diphtheria.

Diphtheria Without Membkaxe.

Case 13.— Female, aged 35, white. The patient has been in the hospital for fifteen mouths with progressive muscular atrophy. Ou February 17, 1S95, she complaiued of sore throat. The throat was examined aud found to be a little swollen and reddened, but there were no signs of membnine. On the ISth the throat was again examined and showed the same appearances. Cultures were made at this time aud showed, the following day, many colonies of typical diphtheria Kicilli.

The patient was transferred to the isolation ward .January 19. Her throat then was a little swollen and reddened, but there Avere no signs of memJirane. There was no dyspnoea, no running at the nose. The general condition was excellent. The throat rom;uned reddened and swollen over a period of eight days, the swelling subsitliug duriug this period and the redness decreasing.

The treatment consisted of a bichloride spray locally, and whiskey as a stimulant.

The temperature, which was 100.2 F. on the night of January 17, rose to 101.5° F. l>y noon of the next day. and remained up fill G P. M.; it then gradually fell, reaching normal ou the lOtli and never passing 90.5° F. substMiuently.

BactiTiologinil A'.r(iminur bouillon culture showed a well-marked local reaction, but did not die.

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This case again illustrates the necessity of a bacteriological diagnosis in all suspected throat cases ; cliuically, no feature was present in tliis case to indicate diphtheria.

Multiple Infection with Bacillus Diphtheriae.

Case 14.— Male, aged 4. white. Aduiilted to the hospital March 29, 1S95, on account of fevei- nnd a disohaiiic from tho right ear.

Histori/.—'rhc family history is imitiipurtant. Tlio patient was in the hospital the June previous with malarial fevor. but recovered completely. The present illness began three days ago with pain in tho head. At this time the ehild was noticed to hold his hand constantly to the side of his head. The morning following the onset of the pain he seemed better, but it was noticed that there was a discharge from the right oar, which has eontinued since. His nose has been discharging for a month or two; he has never complained of sore throat.

March 31. On admission to the isolation ward the child looked rather pale and stupid. There was a thick, creamy, odorless discharge from the right ear which was very profuse. From both nostrils there was a thick muco-purulent discharge. There was no sign of memijrane in the nose. The tonsils and pharynx were reddened, but showed no signs of meml)raue. The neck glands were enlarged, hard and tender to the touch. There was a small area of dullness at the base of the left lung over which the breathing was feeble. On tho radial side of the right thumb there was an e.xcoriated area at the root of the nail. This area was covered by a whitish-yellow membrane, which, on being stripped off, left a raw, non-bleeding surface.

Behring's Antitoxine No. 2 was injected into the subcutaneous tissue of the back. >

.\pril 2. The child seems about the same. The ear is still discharging profusely; the nose less so than formerly. A slight nuMubi-ane has reformed over the wound in the right thumb. The throat is perfectly clear. In the afternoon the ehild did not look quite so well.

April 3. The child looks better this morning. About midday the left ear was noticed to be discharging; the patient had not complained of any pain in the ear region. There is still a slight menjbrane f)ver the right thumb.

April 4. The left thumb is excoriated at its base; there is no membrane over the excoriation.

The ehild was taken home against advice this afternoon.

The temperature on admission to the liospital was 104° 1'. It sank in the evening to 101° F., and from March 30 to the time of admis.sion to the isolating ward varied between normal and 101° F. .■Vt the time of the injection of the antitoxine tlje temperature was 100.8° F.; it sank gradually over the next fortyeight hours, the highest point reached after the inoculation being 101° P. at 8 V. .M. on the day following. The pulse was always fah'ly strong.

No reaction about the seat of inoculation and no skin eruption was noted.

Hactcrioloniail nxaminatimi.— Cover-slips from the discharge from the right ear showed the predominating organism to be a bacillus morphologically resembling the diphtheria bacillus; a good many cocci in chains were also present. Cultures showed many typical diphtheria bacilli and a fair number of streptococci.

A guinea-jiig inoculated with a 24-hour bouillon culture showed very marked local reaction and was very ill for two or three days, bnt eventnally recovered.

(Jultures from the nasal cavity, the tonsils and the pharynx all showed the bacillus diphtheriae associated with the streptoioccus pyogenes; in the tub(!s from the nasal cavity a few colonies of the staphylococcus aureus were also present.

Cultures from the right thumb showed the dlplitheri;i l)acillus with the streptococcus pyogenes and the staphylococcus aureus. Cultures from the left thumb showed the diphtheria bacillus and the streptococcus pyogenes.

The organisms were still present when the child was removed from the hospital.

The two main points of interest in this case are the double otitis media and the occurrence of wound diphtheria.

It is possible that many cases of otitis media in which the diphtheria bacillus is concerned are overlooked, the reported cases not being very numerous. Councilman has reported cases in this country, and Kossel and Kutscher in Germany. In Kossel's cases the diphtheria bacillus could not be isolated from the throat, though membrane was present, a fact which Kossel explains by the overgrowth of the diphtheria bacillus in this locality by other organisms. Most of these cases of otitis media have not been pure diphtheria infections, so that it is often impossible to say whether we are dealing with a primary mixed infection, or whether the diphtheria bacillus was the original causal factor and other organisms afterwards crept in.

Cases of wound diphtheria would also seem to be uncommon, that is if the term wound diphtheria be limited to the infection of woitnds with the Klebs-Loffler bacillus.

Abel has reported a case in which the diphtheria bacillus alone was present in the membrane, proving conclusively that this organism is capable of membrane formation per ,se, a fact which had been disputed by many writers.

It is interesting to note in our case, that while the diphthei'ia bacillus was obtained from the wound on each thumb, membrane was only present over the wound of the right thumb.

Angina Caused by the Pseudo-Diphtheria Bacillus.

Case 15.— Female, aged 22, white. The patient had been in tlie hospital for some weeks with chlorosis. On the evening of .January 31, 1895, she complained of slight sore throat, and examination showed a reddened and swollen condition of the tonsils, with a small patch of membrane (?) on the left side. The next morning the membrane could not be seen and the patient felt perfectly well.

The temperature had risen sharply on the evening of the 31st to 100.5° F., but was normal by 8 A. M. the next morning, and no further elevation occurred.

Bactcriolixjical Examination. — Cover-slips showed apparently characteristic diphtheria bacilli. The cultures were overlooked until the second morning after they wore taken, when the meditmi was seen to be thickly studded with white colonies resembling diphtheria colonies. On cover-slips the organism much resembled llie diphtheria bacillus; it was, however, shorter and thicker, and the individual organisms showed a strong tendency to lie in rows parallel to one another. Culturally, the organism also resembled the diphtheria bacillus, but was a much more profuse grower and alkalinized litmus milk.

.V guinea-pig inoculated with a 24-hour bouillon cultm-e showed neither local nor general reaction.

Tho organism could not be recovered from the throat eighteen days after the attack.

The organism isolated in this case corresponds in all its characteristics to that first described by Hofman and subsef|ueutly by Loffler aiul others. Koplik has described cases in which this organism was found, but not associated with membrane. The membrane in our case seems rather doubtful, as the examination at which the membrane was seen was made by candle light, and on the following morning no membrane was to l)e made out.

Mejibiianous Angina simulating Diphtheria hut due to Oro.vnisms other than the Klehs-Lopfler Bacillus. Case IG.— Male, aged 32, white. Admitted to the hospital

.lauuary 24, 1895, complaining of sore throat.

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History. — The family history was unimportant. Th(> putiont had tlie usual exanthems as a cl)ilfl and thiiilvs he liad diphtheria at three years of age.

The present illness began two days ago with severe headache and a violent shaking chill la.sting about twenty minutes and followed by fever. The following day he felt better, but woke, up on the morning of the third day with fever again. The throat has only been slightly sore.

On admission the general condition was good. Both tonsils were swollen and congested and covered with a thick grayyellow membrane, which was quite densely attached. The uvula and soft palate were not invaded.

Behring's Antitoxine No. ?, was injected into the subcutaneous tissue of the back.

.Tanuni-y 2.5. The patient feels nnu-li In-ttcr. 'I^lio membrane lias iiartly disappeared.

.Tanuary 26. The membrane has entirely disappeared.

The temperature on admission was 100° F.; it had risen to 102° F. two hours later, and then fell rapidly, reaching normal in twelve hours. The pulse was always strong.

Bactcriolor/ical £j"rt/«.in«/io;(.— Cover-slips were negative for diphtheria bacilli.

In cultures the predominating organism was a sliort, slim bacillus which grew well on all media, producing a bright green pigment. The organism corresponded in all its culture reactions with the bacillus pyoeyaneus.

Case 17.— Female, aged 41, white. The patient had been in the hospital for several months with acromegaly. She was admitted to the isolating ward January 2.5, 1895.

History. — The evening before admission the temperature rose and she complained of sore throat. The following morning, wlien the patient was seen, she was quite short of lireath and sitting up in bed. Examination of the throat showed both tonsils to be much swollen and reddened. Over the left tonsil was a large grayish-yellow patch the size of- a quarter, which had the appearance of false membrane. By 7..30 in the evening several spots of exudate were seen on both tonsils and the case presented more the appearance seen in follicular tonsillitis.

Behring's Antitoxine No. 3 was injected into the subcutaneous tissue of the back.

January 2G. The throat looks a little better. The patches still remain, but the swelling has subsided somewhat.

January 27. The patches are fewer in number.

January 28. The exudate has almost gone. The patient complains of a little pain and stiffness in the neck and back.

The temperature on admission was 102° F. By the following morning it had fallen to 100° F., but rose again in the evening to 102° F. A similar exacerbation occurred the following day, after which the temperature gradually fell to normal. The pulse was strong all through the course of the illness.

No skin eruption was noted.

Bacteriological Examination. — Cover-slips showed no diphtheria bacilli; a variety of organisms were present, no one apparently predominating.

Cultures showed an almost pure culture of the streptococcvis pyogenes.

Case 18.— Male, aged 31, white. Admitted to tlie hospital March 11, 1895, complaining of sore throat.

History. — The family history was uninijiortant. The patient had the usual exanthems as a cliild; he has not been subject to sore throats.

The present illness began three days ago with soreness of one, and later, of both sides of the throat. He had headache and general aching all over. No chill or chiil.y sensations.

On admission the general condition was good. Tlio throat was congested, and tlie .tonsils were much swollen, almost meeting in the middle line. On the inner side of each tonsil there was a sloughy-l(x>kiug yellow-gray membrane. The neck glands were enlarged and tender.

Behring's Antitoxine No. 2 was iiijccli'd into llic sulicutaiicous tissue of the back.

In the evening of tlie day of admission the throat was so swollen that the patient had ditticulty in swallowing even liquids.

March 12. The swelling Is decreasing; the patient feels better.

Mai'cli It. The swelling is much less.

Marcli 19. The membrane has entirely disappeared.

The temperature on adraissioil was lO.'J.o' F.; bj- 8 A. M. the next morning it was down to 101° F.. but by 8 P. M. was up to 104° F. : it fell in the night, but rose the next afternoon to 102.5° F., after which it gradually .sank to normal.

No skin eruption was noted.

Bacti rioliiiiiral Exiiminatiori.—CoYer-sVips from the membrane showed numerous cocci in chains, but no diphtheria bacilli.

Cultures gave a practically pure growth of streptococcus pyogenes.

These cases again show the necessity of bacteriological examination in all inflammatory throat affections.

Case 16 is interesting from a bacteriological point of view, for, so far as we have been able to make out, a membranous angina due to the bacillus pyoeyaneus has not been described hitherto. This organism, though usually comparatively harmless, has been described as a factor in various diseased conditions, usually in association with other organs; in our case it was apparently in pnre culture, but this may be due to the fact that it had overgrown the organisms with which it was associated. The comparatively frequent presence of the pyoeyaneus in chronic otitis media would lead one to suspect that it may not be an infrequent inhabitant of the nasal or buccal cavities.

The Effect of the Axtitoxixe Treatmext.

Of the eighteen cases above recorded, si.xteen received the antitoxine treatment, three of these cases being non-diphtheritic.

While this of course is too small a number of cases on which to base any statistical conclusions, several facts in connection with the treatment seem worthy of attention.

Two of the cases died, but both of these were moribund on admission, one dying three and the other eight hours after admission, so that the antitoxine was given no chance.

The other thirteen diphtheria cases were most of them mild, in fact none were very severe, but both on the general condition and on the temperature the antitoxine seemed to have a marked effect. It was almost invariably noticed that the day following the injection the patient was much brigiiter, and in the case of children the return of the appetite was the most marked indication of improvement.

Ill looking over the cases it will be noted that in those due to the bacillus diphtheriae the autitoxiue.as a rule, causeda reduction of the temperature to the normal inside of twenty-four hours ; in one or two of the cases there was a slight rise in the temperature eighteen to twenty hours after the inoculation, but in only one case was no effect on the temperature noted. The last two cases afford excellent examples of the effect of the antitoxine on non-diphtheritic cases : both were early cases, so that a spontaneous fall of temperature can be e.xcluded, and in both the temperature was not influenced in the slightest degree by the antitoxine.

Skin eruptions following the antitoxine injections were noted in several of our cases: they have been noted by varions observers since the inauguration of the treatment, but not enough stress has been laid on the fact that these eruptions are iu all probability due to the serum ;x'r sf, and not to the antitoxic agents contained therein. TUe deleterious effects of the serum of one species of animal when injected into a

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member of anotliui . , , i .: ue too well known to be repeated here, but it is interesting to know that Sevestre, by injecting horse-serum in twenty-centimetre doses into children with non-diphtheritic sore throats, was able to produce urticaria and other forms of skin eruption similar to those observed after the use of the autitosine.

The skin eruptions were the only bad effects, if one could so call them, which were observed after the use of the antitoxine. No other appreciable symptoms plainly due to the injection could be observed, nor did the examination of the urine give evidence of any such.

PROCEEDINGS OF SOCIETIES,

THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of October 1, 1895.

Pjartlirosis— Discussion onDr. Finney's paper. (See September-October Bulletin, page 144.)

Dr. Halsted. — In these cases of knee-joint irrigation we do not hope to do more than to greatly inhibit the activity of the micro-organisms — to assist the tissues to destroy the microorganisms. It is rarely necessary to do more than incise an acute abscess ; the tissues do the rest. And yet we know that the tissues about the abscess have been invaded by the pyogenic micro-organisms. In irrigation of the knee-joint we do not expect to reach the micro-organisms outside of the joint.

In the last case reported by Dr. Finney — the one with triple infection — I do not feel at all sure that we could not'have taken care of the joint itself. We amputated because in a few days we found the tissues in the thigh almost up to the hip-joint invaded by the organisms to a shocking extent, with lesions characteristic of the air-producing bacillus.

That solutions of bichloride of mercury are more efficacious than salt solutions in destroying and inhibiting pyogenic organisms outside of the body we have sufficient proof. There is also abundant clinical, if not wholly conclusive experimental evidence that the same is true in the tissue spaces, in joints, etc.

The irrigation of the urethra in the treatment of gonorrbcea furnishes a good clinical example of the benefits to be derived from solutions of corros. sub. Here, too, the specific micro-organisms have been demonstrated in the tissues outside of the urethra.

I speak from a great deal of experience, from daily observations for five years in the Roosevelt Hospital Dispensary, New York. In this work I was very ably assisted by Drs. Itichard Hall and Frank Hartley of New York. The salt -olutions are worse than ineffectual in the treatment of gonorihcta. With them we never succeeded in aborting a case of gonorrhoni, either in private or dispensary practice, but we constantly induced a cystitis and ejjididyniitis. With the bichloride irrigation, not a single case of cystitis or epididymitis occurred in these five years. I think that we have had tlie same exi)erience in the dispensary here. Doctor Brown told me less than a year ago that he had never produced cystitis or ejjididymitis with bichloride irrigation. In private jn-actice it is very common, indeed it is the rule, to abort a gonorrhcea within a week or ten days with bichloride irrigation. Previous to the use of this irrigation I used to dread to have a case of gonorrhcea come to my office; after its

introduction 1 was glad to see them. The treatment became so pojnilar that certain specialists in New York said that they would never use it because it was ruining their practice. Men after a few visits were cured. Nor would they return when a fresh urethritis was contracted. 'Furthermore, they taught their friends h'ow to treat themselves. It would be too much of a digression to give the details of this treatment at this time. But I must ask your permission to say that everything depends upon the intelligent use of the method. The strength of the solution is determined by the use of the microscope and by the tolerance of the particular urethra. The strength to be used varies from 1-200,000 to 1-25,000. A tolerance of the stronger solutions has, usually, to be acquired. ftleu with red hair have, as a rule, sensitive urethras.

The gonococci disappear jiromptly from the ui-ethral discharge after irrigation with solutions of corrosive sublimate, but are uninfluenced, apparently, by irrigation with the salt solution.

A t'ase of Congenital Ptosis.— Dr. Thomas.

The patient, B. L., dispensary No. B 587, whom I wish to show to you to-night, is a boy fourteen years old. He applied at the dispensary a few days ago complaining that he was unable to open his left eye. No similar case had ever occurred in the family so far as was known. The patient was the eighth child and the only son. His birth was natural but difficult. It was noticed soon after birth that he did not open his left eye, and this condition has remained unchanged ever since. In other resj^ects the boy has developed normally.

In looking at him you notice that while his right eye is widely opened, his left eye is nearly closed by the drooping upper lid. The skin of the forehead on the left side is drawn into deep furrows, as if he were trying to lift the eyelid by a strong action of the occipito-frontalis muscle. If the left eye be covered by the hand the forehead becomes smooth. When asked to look up, the patient opens his right eye wider, rolls the eyeball upward and contracts the occipito-frontalis on that side. On the left side the eyeball remains stationary, and the only noticeable change is a still greater contraction of the occipito-frontalis muscle ; if, however, the left eye bo passively opened, the eyeball is moved upward to some extent, but not so far as on the right side. In looking down, the eyes move normally, but the left upjier lid does not follow the movement as does the right.

The lateral movements of the eyes are normal in extent, but there is a curious disassociation ; they appear to move independently of each other. His pupils are equal, moderately

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coatracted ; they react to light and during accommodation. Ophthalmoscopic examination shows the fundus to be normal. The facial muscles and those of mastication act normally.

In this case we have a congenital defect, consisting of a paralysis of the left levator palpebrse superioris, paresis of the superior rectus, and an associated over-action of the occipito frontalis on the same side, forming the common picture of congenital ptosis. The disassociation of the ocular movements is also of interest.

Congenital ptosis is, in our experience, not a common affection, this being the first case which I have had an opportunity of studying. The cause of the trouble is believed to be some abnormality in the nucleus of the third nerve, from which the muscles involved receive their motor nerve fibres. As far as I know, but a single careful anatomical examination of such a case has been made. I refer to the case of Prof. Siemerling, reported in the Archiv f. Psych, u. Nervenkrank.,Y6\. XXIII, p. 764, 189;'. The patient died from general paralysis, but during life he showed no ocular symptoms referable to that disease except the Argyle-Robertson pupils. The congenital ptosis was of the left eye. Siemerling discovered a lesion in the dorsal and ventral parts of the principal group of cells in the nucleus of the third nerve, and what seemed remarkable, the lesion was bilateral, although the left upper lid was alone affected. The nucleus of the third nerve is a complicated structure. It is, however, impossible to go into this question to-night, as I want to call your attention to some other interesting points in connection with congenital ptosis.

In 1883 Ml-. Marcus Gunn exhibited a case before the Ophthalmological Society of London, which showed remarkable associated movements of the paralysed eyelid. When the patient opened his mouth or moved his jaw towards the right, the paralysed left ujjper lid was raised. This case created a great deal of attention, and a committee including Dr. Gowers, Dr. Stephen McKenzie and others was appointed to examine the patient. They confirmed Mr. Gunn's observation and expressed the opinion that in that case the levator palpebrfe "is innervated both from the nucleus of the third nerve and from the external pterygoid portion of the nucleus of the fifth nerve."

Since the publication of this case, a number of cases have been reported, and in May, 1894, Bernhardt {Neurol. CentralblL, Vol. XIII, p. 325) was able to collect twenty-four cases, eighteen of which he used for comparison. In nearly all of those the associated movement of the paralyzed lid occurred, either when the mouth was opened or the jaw moved away from the side on which the ptosis was present, i. e. during the action of muscles supplied by the fifth nerve. In two remarkable cases the fallen lid was raised when the other eye was voluntarily closed, an associated movement between a muscle supplied by the facial nerve on one side and one supplied by the third nerve of the opposite side.

The extent of the associated movement apparently varies in the different cases. The most striking report that I have seen was published in the Arrliiivs of OpJt/kiilmologi/, Vol. XXII, p. 65, 1893, by Dr. A. A. llubbell, in which there are three excellent photographs, illustrating this associated movement. In this case the paralyzed upper lid was raised quite

as much if not more than the normal one when the mouth was opened.

As you see, when the patient whom I have here to-night "opens his mouth wide, or moves the lower jaw strongly towards the right, there is no very evident raising of the left upper lid. If, however, careful measurements are made, it is found that the visual aperture widens two or three mm. The widening is greater when the patient looks down during the movement of the jaws. Voluntary closure of the right eye produces no effect on the left. It is not at all certain that this slight widening of the aperture is due to a contracture of the levator palpebrae and not to other mechanical causes.

The explanation of these associated movements is not clear. Most observers agree with the English committee in the belief that it is due to the third nerve's receiving axis cylinder processes from cells situated in the fifth nucleus. We know that fibres running in motor nerves may arise from cells quite widely separated in the central nervous system. You will see from the diagrams of the nuclei of the motor cranial nerves, which I have placed on the blackboard, the relative positions of the third and fifth nuclei. The third nucleus is under the aqueduct of Sylvius; the principal motor nucleus of the fifth is about the middle of the upper half of the fourth ventricle. The descending root of the fifth extends quite to the level of the third nucleus. There is some doubt as to whether this root should be considered sensory or motor. It is not difficult to believe that nerve cells might send their axis cylinder processes from either the motor nucleus, or from the nucleus from which the descending root arises, to leave the brain by the third nerve. If such a condition underlies the associated movements which occur in congenital ptosis, the question suggests itself whether the condition is a normal one, or whether it only occurs in connection with the abnormality of the third nucleus upon which the ptosis depends. In two cases in which the ptosis was acquired as one of the symptoms of ophthalmoplegia externa due to nuclear disease. Dr. Ilughlings Jackson was unable to demonstrate any associated movements of the paralysed lids, and in the case before you I have not been able to convince either you or myself that there is any actual contraction of the paralysed levator muscle. These cases, so far as they go, would seem to indicate that this connection is not always present. I know of no anatomical investigations that bear on the subject.

Dr. Jackson, in the article referred to above {Lancet, Jan, 6, 1894), suggests another interesting question in connection with cases of congenital ptosis, /. c. whether Muller"s muscle is also paralysed. You may remember that the eyelid contains, besides the levator palpebral smooth muscular fibres, the so-called iliiller's muscle, which help to elevate the lid. This muscle receives its nervous supply from the cervical sympathetic. These nerve fibres leave the spinal cord by the upper four or five dorsal roots. The nerve cells from which they arise have not been localized, but it is believed that they are situated somewhere near the third nucleus. Since we believe that congenital ptosis is due to some central legion, it is important to know whether Midler's muscle is paralysed. Dr. Jackson suggests a method by which this may be determined. It was pointed out by Jessop i^Proctcd. of Royal Soc.,

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Vol. XXXVIII, p. 432, 1885) that if a solution of cocaine be dropped into the eye the pupil dilutes and the visual aperture widens. He demonstrated by experiments that this was due to a stimulation of the endings of the sympathetic nerve, causing contraction of the dilator muscles of the iris and of Jliiller's muscle in the lid. Dr. Jackson urges the importance of applying this test in nervous diseases wherever the sympathetic may be involved, and points out the desirability of testing a ease of congenital ptosis in this manner.

We dropped into both eyes of this patient three or four drops of a four per cent, solution of cocaine. At the end of half an hour both pupils were dilated and the visual apertures of both eyes had widened about two mm. It would appear from this that the cocaine acted equally on the two sides and gave no evidence of paralysis of Miiller's muscle.

Note. — The patient has been examined on several occasions since he was shown to the Society. The observations differ but little from those recorded, but it may be of interest to give the last note of the examination under cocaine.

December 9, 1895. 10.50 a. m., visual aperture, R. eye opened normal, 12.5 mm.

L. eye opened normally, 5 mm. Eye wide open, 5 nun. Pupils equal, about 5 mm. in diameter. One minim of an 8-per cent, solution of cocaine was put into each eye.

11.40 a.m., visual aperture. E. eye opened normajly, 11 mm. Wide open, 15 mm.

L. eye opened normally, 7.5 nun. Eye wide open, 8 nun., and with mouth open, 9 nun. I'ujiils e(iua], diameters about 9 mm.— H. JI. T.

Dr. L. F. Barker. — The case which Dr. Thomas has shown is of more than ordinary interest. As to the connections of the nervus trigeminus and its motor and sensory nuclei with the nucleus nervi oculomotorii, there is little that can be said to have been definitely established. This much is certain, that fibres run from the gray matter connected with the sensory portion of the fifth nerve (t. e. the substantia gelatinosa near the spinal tract of the 5th and the so-called sensory nucleus of the 5th) into the fasciculus longitudinalis medialis, and the intimate relations of the latter bundle to the oculomotorius nuclei have been very definitely proven. Whether or not the motor nuclei of the trigeminus (nucleus princeps and nuclei minores [radicis descendeiitis]) are directly connected with the nuceus n. oculomotorii, does not as yet seem clear. A large amount of work has been done with regard to the various groups of ganglion cells of which the nucleus of the oculomotorius nerve is made up, but up to the present the cells which have to do with individual muscles have not been satisfactorily localized. Neurologists have recently been inspired with new hope as regards this point through the introduction of a new method of investigation. In June of last year Nissl of Frankfurt-am-llain, in an address in Baden-Haden {Ccntrnlblt. fur Nvrnmheilk. u. Psyihiatrie, 1894, Bd. XVII, pp. 337-344), described a procedure which, although of relatively narrow api)lication, has the advantage of establishing exactly the location and relations of many of the nerve cells in the gray masses. For example.

he states that the method will determine for each individual eye-muscle the localization of its corresponding nerve cells in the central nuclei, a result to which the most careful investigators with the use of other methods (c. g. v. Gudden's or llarchi's) have hitherto been iniable to attain.

In an adult or half-grown animal a solution of continuity of the fibre connecting a nerve cell with a peripheral part, be it muscle fibre or epithelial surface, leads to retrogressive changes in the body of the nerve cell. These alterations, though somewhat different in nerve cells of different types, are very characteristic and easily recognizable, Nissl claims, after some experience. Very soon, too, changes occur in the neuroglia cells which are in the neighborhood of the affected neurons. The changes in the cells are recognizable in alcohol tissues sectioned and stained according to the latest directions of Nissl, and his staining reaction has to be looked upon as one of the most delicate we possess for the study of degenerations of the body of the nerve cell. In order to apply the method to the eye muscles, one would either extirimte a given nuiscle or cut the nerve supplying it, and subsequently (the lesions in the rabbit are most characteristic between the 8th and the 15th day) kill the animal and study serial sections of the nucleus of the third nerve. As Nissl points out, the very delicacy of the reaction necessitates the greatest caution in its application. Operations must be done asepticalh', one must be absolute master of the technique and must be familiar with the appearances of the various cell-forms in the normal condition, otherwise the investigator will be led into serious error. Nissl suggests that his method be called "Die Methode der primiiren Reizung." Should this method prove to be as useful as it promises, and already confirmatory work has been done by other investigators, we can hope for a speedy settlement of the much vexed questions regarding the cells of the eye-muscle nuclei. Now that the importance of the gray matter in the anterior corpora quadrigemina as a governing centre for the various movements of the eye muscles is generally recognized, and the connections of the axons of the cells situated there by means of collaterals with the various eye-muscle nuclei have been definitely established, the possibility of an exact localization of the cells in the nuclei concerned directly with the individual muscles comes opjiortunely.

Another point in connection with the case Dr. Thomas has just reported seems to me worthy of remark.

In the formation of an associated movement there has been a marked dissociation of muscular contractions ordinarily assocuited. Dr. Thomas has spoken of the dissociation of movements of the muscles of the two eyes. Usually in contracting the frontalis muscle the fibres on both sides of the forehead are contracted at once. This -boy possesses in an extraordinary degree the power of unilateral contraction of the frontalis ; indeed, when his eyes are open the left frontalis is continually forcibly contracted, while the muscle on the right side is at rest. This is by no means surprising, for we know of many so-called associated movements which, tlirough training and education, can be dissociated, as for example the isolation of finger movements observable in an accomplished pianist.

NOTES ON NEW BOOKS.

BOOKS RECEIVED.

INDEX TO VOLUME VI OF THE JOHNS HOPKINS HOSPITAL BULLETIN.