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explains the symptoms rather more satisfactorily than any other.
 
His practice is better than his precept in this respect, since he
 
places the disease where it probably belongs, among those of the
 
tliyroid gland. We are glad to notice that he insists upon the priority of the description by Graves. Of this, of course, there can
 
be no doubt, though Parry and others published individual cases.
 
Graves' clinical lecture in 1835 gave the first good description of
 
the affection.
 
  
Naturally in a new textbook one turns to certain of the diseases
+
http://www.archive.org/details/johnshopkinsmedi08john
about which there is still a good deal of difference of opinion. Appendicitis receives a very thorough and satisfactory treatment.
+
 
There is no work in English which gives so good an account of the
 
history of the affection. We are glad to see that Dr. Tyson does
 
not consider it necessary to speak of a typhlitis, stercoral or otherwise. It is satisfactory to see that the name even does not occur in
 
the index. lie describes catarrhal, ulcerative and interstitial forms
 
of appendicitis. The clinical description of the different varieties
 
is admirable. On the all-important matter of treatment the author
 
takes rather advanced ground, stating that "the diagnosis being
 
established, operative treatment should be recommended, except
 
in those cases where the disease is so far advanced as to make it
 
unlikely that the patient will be saved by operation." He thinks
 
that the operation after the first attack is safer than during the first
 
attack. On the much debated point of purgatives he leaves the
 
matter to the circumstances of the case and the good judgment of
 
the attendant, as the results may be either very happy or very mischievous. He believes that if there is doubt it is best not to purge.
 
  
The article on typhoid fever, with which the book opens, is in
+
BULLETIN  OF THE JOHNS HOPKINS HOSPITAL.  
every way worthy of the great importance of the subject. The
 
author is a strong believer in the use of the cold bath, and on the
 
question of treatment he everywhere displays sound judgment.  
 
  
We have said enough to indicate the importance of the work, its
+
Vol. VIII. - No. 70.  
thoroughness, and its reliability in all practical details. The publishers are to be congratulated on the appearance of the volume.  
 
It is one of the handsomest works issued of late years in this country,
 
and the type and paper are very much above the average. Altogether Tyson's Practice forms a very welcome addition to our textbooks, and we predict for it a most successful career.  
 
  
An American Text-book of Applied Therapeutics, for the use of
 
Practitioners and Students. Edited by J. C. Wilson, M. D.,
 
assisted by Augustcs A. Eshnek, M. D. Pp. 1-1326. {Philadelphia: W. B. Saunders, 1896.)
 
  
Since the main object of medical studies must always be the formulation of methods for the prevention and cure or alleviation of
 
disease, it necessarily results that laboratory researches and clinical
 
observations must ultimately be valued in proportion as they have
 
brought us nearer to the attainment of these aims — in other words,
 
according to the advances which have been derived from them in
 
the establishment of a rational system of therapeutics. The world
 
at large is apt to look at results rather than methods, and the
 
busy practitioner may justly demand that the previous studies and
 
experience of others should be presented to him in aconcrete form.
 
For these reasons the status of medicine at any particular period
 
will, to a great extent, be gauged by the therapeutic measures
 
which prevail at that time, and of which the textbooks dealing
 
with the subject are the exponents.
 
  
Graduates of twenty years ago will probably remember a time in
+
BALTIMORE, JANUARY, 1897.  
the first few years of their practice during which they were tempted to become adherents of the doctrines of therapeutic nihilism.
 
They had gone forth armed, they had been taught and for a time
 
had firmly believed, with agents with which they could infallibly
 
combat each and every untoward symptom. Is it to be wondered
 
at that many of them in a short time exchanged their early therapeutic optimism for a hopeless therapeutic pessimism? Could
 
they not justly reproach for this the faulty teaching which had
 
been accorded to them?
 
  
  
  
Medicine is still to a great extent an empirical art, but although
+
Contents
we can hardly hope that it will ever be numbered among the exact
 
sciences, there are signs which indicate that by slow degrees we are
 
attaining to a therapeusis which may always be at least rational.
 
  
The book before us shows a decided advance, not only because it
+
Presentation of Thorwaldsen's Statue of Christ to the Hospital, 1
registers real progress made in our knowledge of disease processes
 
and in our methods of treatment, but because it shows that the
 
difficult subject of therapeutics is now being attacked in a frank and
 
true scientific spirit. The writers have been chosen from among
 
men who have brought to bear upon the subjects allotted to them
 
not not only the results of a profound study of the existing literature, but also those which can be obtained only by a wide personal
 
experience. They are not mere compilers; they know whereof
 
they speak. If not all of them have added much that is new, they
 
have at least accepted the dicta of others only after a painstaking
 
proving of their statements. They have chosen the middle ground,  
 
and while confident that much can be accomplished by the use of
 
the various therapeutic measures which they recommend, they do
 
not by the employment of specious generalities attempt to conceal
 
those points upon which our present knowledge is still defective.
 
They hold a strong position midway between therapeutic optimism
 
and therapeutic nihilism. Above all and first of all they preach
 
the doctrine of prophylaxis.
 
  
In many of the articles a short account of the more prominent
+
The Bacilhis Proteus Zenker! in an Ovarian Abscess. By
manifestations of the disease underdiscussion will be found, which,
+
Hunter Robb, M. D., and Albert A. Ghriskey, M. D., - 4
although adding considerably to the bulk of the book, will assist
 
the reader materially in better appreciating the treatment recommended later. It is impossible to speak here in detail of all or of
 
any of the various contributions. In his article on tuberculosis,
 
Whittaker summarizes our present knowledge upon prophylaxis in
 
general, hygiene and climatology, and has ably marshaled all the
 
recent experience, upon which he formulates a treatment which, if
 
it contains little that is really new, is perhaps the best at hand. If
 
his conclusions as to the advantages to be obtained by the use of
 
tuberculin are not in accordance with those of other authors, his
 
results certainly deserve the most respectful consideration. Tyson's article upon the diseases of the kidney is brief but admirably
 
comprehensive. In speaking of typhoid fever, Wilson, after a
 
careful consideration of other methods, not only endorses the cold
 
bath treatment but repudiates the notion that it is cruel. This
 
latter view will certainly not be conceded by many even of the
 
most enthusiastic supporters of the procedure. Serum therapy
 
receives a full share of attention, and the subject has been treated,
 
by the writers upon the conditions for which it has been advised,
 
with a full appreciation of its importance. Whatever may be the
 
opinion with respect to Laveran's vie w as to the identity of the parasite for the different forms of malarial fever, the careful and precise
 
treatment which he lays down will not easily be improved upon.
 
  
Another point to be noted is the comparative simplicity of the
 
prescriptions which are given ; we are grateful for further evidence of the decline of polypharmacy. It would seem that we are
 
beginning to appreciate Huxham's advice, " The physician should
 
select a few (drugs) of the most effectual forhis useof each sortand
 
stick to them and not run into an immense farrago which some
 
are so fond of." Many of the illustrations are good, but not a few
 
are superfluous. As might be expected, the book lays no claim to
 
perfection. The student who looks to it for infallible remedies for
 
every disease will naturally be disappointed ; the man of more moderate demands will find in it much that will help him in his daily
 
work, and much that will stimulate him to the observation of disease processes and of the way in which they may best be met.
 
  
Frank R. Smith.
 
  
Die Fiirbetechnik desNervensystems. By Dr. B. Poll.^ck. {Pub
+
The Phrenology of Gall and Flechsig's Doctrine of Association Centres in the Cerebrum. By Lewellys F. Barker,  
lishcd by 8. Karger, Berlin, 1897.) Pp. 1-130.
 
  
This little book will be welcomed by neuro-histologists everywhere. It gives briefly the important steps in all the more impor
+
M. B., - - - - - 7
  
 +
Notes on New Books, ......... 14,
  
June, 1897.]
+
Books Received, 15
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
+
PRESENTATION OF THORWALDSEN'S STATUE OF CHRIST TO THE HOSPITAL  
  
  
  
135
+
Oa Wednesday afternoon, October 14, 1896, at 3 o'clock, there
 +
was uuveiled in the rotunda of the Administration Building
 +
of the Jolms Hojjkins Hospital, in the presence of the trustees
 +
and officers and a large audience of invited guests. Stein's
 +
reproduction of Thorwaldsen's statue of Christ, a gift from
 +
William Wallace Spence, of Baltimore. Mr. Spence, in presenting the statue, spoke as follows:
  
 +
"I have but a few words to say on this occasion; merely to
 +
state how it happens that this statue stands here.
  
 +
" On a visit to Copenhagen I saw the great work of Thorwaldsen, his ideal conception in marble, of ' Christ, the Divine
 +
Healer.' It impressed me more than did any statue I had
 +
ever seen, and I think this is the general experience of
 +
those who have the good fortune to see it. It was stated that
 +
Thorwaldsen himself said, ' I never was satisfied with any
 +
work of my own until I executed the Christ; now I am satisfied.' He felt that his genius had reached the zenith of its
 +
powers and that he could go no higher. Well might he be
 +
satisfied, for the grace, dignity and majesty of this figure have
 +
never been surpassed.
  
tant methods used in microscopic examination of the nervous
+
" Later on the thought came into my heart how eminently
system, including those of recent date. In the first section the  
+
appropriate it would be to have this ideal statue placed where
technique of cutting up the brain at autopsy is described, togetlier
+
it now stands, in the centre of this hall, under the lofty dome
with the methods for preserving the brain whole and forreproduc.
+
of this great hospital. To every weary sufferer entering these
ing plastically the specimens found at autopsy. In section two the
+
doors, the first object presented to him is this benign, gracious figure, looking down upon him with pitying eyes and outstretched arms, and as if it were saying to him, ' Come unto
general technique of hardening, staining, emliedding and section.
+
Me and I will give you rest' I thought it might help to comfort some sad and weai-y one, and lead his heart and thoughts
ing is discussed. The methods of making serial sections, including
+
up to the ever-living Divine Healer, who alone could give that
the recent method of Flatau for making serial longitudinal sections
 
of the whole spinal cord, are considered. We are glad to find mention made in section three of the work of Donaldson and others
 
concerning the alteration in weight of the brain and cord after
 
pri-servation in different hardening fluids. Too little attention has
 
been paid to such alterations in previous books on technique. Apparatus for drawing and photography are described in section four.
 
In the next section the methods of staining and impregnation are
 
taken up. The various ways of demonstrating nerve cells and their
 
axones and myelin sheaths are outlined. Golgi's method, Ehrlich's metliod and the new stains for neuroglia have been carefully
 
considered. Nissl's method is given, and also Held's modification of it. The differentiation with alum solution is simple, easy to  
 
manage, very inexpensive, and yields in the reviewer's experience
 
results fully as satisfactory as those afforded by the method with
 
anilin oil and alcohol. In the sixth section certain general points
 
to be borne in mind in the examination of normal and pathological
 
cases are emphasized. It is particularly gratifying to find epitomized at the end of this section the routine methods employed in
 
Waldeyer's laboratory for the study of the central and peripheral
 
nervous systems. A brief bibliography is appended as well as an
 
index. The book costs only two marks, and will probably find its
 
way into many laboratories, where it will prove a safe and convenient guide. L. F. B.
 
  
Arbeiten aus dem Institut fiir Anatomie und Physiologic des Centralnervensystems an der Wiener Universitiit. Herausgegeben
 
von Professor Dr. Heinrich Obeesteiner. Y. Heft, mit 5 Tafeln
 
und 46 Abbildungen im Texte. (Leipzig und Wien : Franz Deuticke, 1897.)
 
  
The most recent number of the fasciculi which are appearing at
 
intervals from Obersteiner's laboratory is fully up to the general
 
standard set by the preceding numbers. Itcontains seven articles,
 
one of which, on the innervation of the blood-vessels of the
 
brain, is by Obersteiner himself. In this article Obersteiner discusses the work of previous investigators and describes and pictures
 
a small artery of the pia mater stained with gold, in which he
 
brings the direct anatomical proof that the finer intra-cranial vessels, at least within the pia mater, possess their own nerves. He
 
refers briefly to the physiological and pathological significance of
 
such innervation.
 
  
Schlagenhaufer contributes an article on the course of the fibres
+
rest. With this feeling I asked permission of the trustees to
in the optic paths, in which is discussed also the tabetic atrophy of
+
present this statue to the hospital. It was cordially given,  
the optic nerve. He believes that there exists sometimes, at any
+
and at once I placed an order with Professor Stein, the eminent sculptor and Director of the Royal Academy of Art in  
rate, a compact uncrossed optic bundle which, however, forms only
+
Copenhagen, and there it stands. How well he has executed
a part of the uncrossed bundle, and probably corresponds to the
+
it you will judge.  
inferior (external) fibres. The direction of the course of this bundle
 
gives, he thinks, in all probability, the anatomical course of the
 
uncrossed bundle. The question of the total or partial crossing of
 
the optic nerves in man must, therefore, be regarded as decided in
 
favor of the latter through anatomical investigation. He thinks
 
that by means of a scheme constructed accordingly it is possible to
 
explain all the hemianopsias. As regards Gudden's commissure, he  
 
makes out that a part of the fibres stream into the ansa lenticularis
 
to become connected with both lenticular nuclei. Some of the
 
fibres run in the peduncle of the hypophysis. In front of Meynert's
 
commissure in the upper anterior part of the chiasm there is a
 
small system of fibres which remains intact when the optic nerves
 
and chiasm atrophy. He thinks it possible that the tabetic atrophy
 
of the optic nerves may be due to pressure at the foramen opticum.  
 
  
 +
"A few years ago, at the formal opening of the Hospital,
 +
President Gilman expressed the hope that some day it might
 +
stand there. To-day his hope is realized. And now, Mr.
 +
President, I beg to present this statue to the Johns Hopkins
 +
Hospital."
  
 +
The statue was then unveiled by little Emily Riggs, an
 +
infant great-granddaughter of Mr. Spence.
  
F. Rezek describes and pictures a primary polymorphous sarcoma
+
Mr. W. T. Dixon, the President, in behalf of the Board of
of the brain.
+
Trustees of the Hospital, accepted the gift in the following
 +
words :
  
Pfiegler and Pilcz contribute along article entitled "Beitriige zur
+
" Mr. Spence — It gives me very great pleasure to accept, in
Lehre von der Mikrocephalie." They describe twelve cases of their
+
behalf of the Board of Trustees of the Johns Hopkins Hospital,
own, with consideration of no less than 365 bibliographic references.  
+
your generous gift, this beautiful and impressive statue, and to
 +
assure you of our appreciation of your motives and munificence.  
  
An interesting study of the histology of the ganglion cells of the  
+
"These grateful feelings of the trustees, I am confident, will
horse in normal conditions and after arsenic poisoning is given by  
+
be cordially shared by all the workers in every department of  
H. Dexler. Two beautiful plates accompany his article. The same
+
the Hospital, by our many friends throughout the country, as
writer publishes also a short note on the course of the fibres in the  
+
well as by the sick and suffering who may come under our
optic chiasm of the horse.  
+
care.  
  
Julius Zappert, in an article on degenerations in the spinal cord
+
" You have most appropriately placed this ' Divine Healer '
and medulla oblongata in the child, embodies the results of his
+
just where it can be seen by all who may enter the doors of
studies on the spinal cord and medulla of children who have died
+
the Hospital, thus affording them the opportunity to derive
during the first three years of life. He has used Marchi's method
+
comfort, courage and hope from its contemplation. And not
and describes his findings with especial reference to the changes in
+
only are the outstretched hands of this Christus Consolator
the various nerve roots. L. F. B.
 
  
  
  
BOOKS RECEIVED.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
  
  
  
Tuberculosis. By William Osier, M. D. 8vo. 1897. Reprinted
+
[No. 70.  
from " Loomis' System of the Practice of Medicine," New York
 
and Philadelphia, I, pp. 731-848.  
 
  
Diseases of the Ear, Nose and Throat and their Accessory Camties. A
 
condensed text-book. By Seth Scott Bishop, M. D., LL. D. 1897.
 
8vo, -196 pp. The F. A. Davis Co., Philadelphia, New York,
 
Chicago.
 
  
Annual Report of the Trustees of the State Hospital for the Insane, at
 
Warren, Pennsylvania, for the year ending No-oember 30, 1896, to the
 
Board of Commissioners of Public Charities. 1897. 120 pp. Herald
 
Printing and Publishing Co., Erie, Pa.
 
  
Medical and Surgical Report of the Presbyterian Hospital in the City of  
+
held out to this company, this community and the people of  
New York. Edited by A. J. McCosh, M. D., and W. B. James, M. D.
+
this age, but they will remain extended to tens of thousands
Vol. II, Jan., 1897. 8vo, 272 pp. Trow Directory Printing and
+
of the generations yet to come.  
Bookbinding Co., New York.  
 
  
Ouy's Hospital Reports. Edited by E. C. Perry, M. A., M. D., and  
+
" There are grave responsibilities and many discouragements
W. H. A. Jacobson, M. A., M. Ch. Vol. LI, being Vol. XXXVI
+
in maintaining and conducting a hospital, especially a hospital
of the third series. 1895. 8vo, 272 pp. J. & A. Churchill,  
+
with the high aims and beneficent purposes of the one you
London.  
+
are honoring to-day, and we cannot too earnestly assure you
 +
that such evidences of interest in our efforts to comfort the  
 +
sick, relieve the suffering and advance knowledge, as come
 +
with your gift, are most encouraging and insj)iring to us all."
  
Guy's Hospital Reports. Edited by E. C. Perry, M. A., M.D. , and
+
The following hymn by Whittier was sung by a male
W. H. A. Jacobson, M. A., M.Ch. Vol. LII, being Vol. XXXVII
+
quartet :
of the .third series. 8vo. 1896. 230 pp. J. & A. Churchill,
 
London.
 
  
Lectures on Pharmacology for Practitioners and Students. By Dr. C.
+
" So stood of old the holy Christ
Binz. Translated from the second German edition by Peter AV.
+
Amidst the suffering throng ;
Latham, M. A., M.D. Vol. II, 1897. 451 pp. 8vo. New Sydenham Society, London.  
+
With whom his lightest touch sufficed
 +
To make the weakest strong.  
  
A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in Photolithochromes from Models in the Museum of the St. Louis Hospital,
+
That healing gift he lends to them
Paris. With explanatory woodcuts and text. By E. Besnier,
 
A. Founier, et al. Edited and annotated by J. J. Pringle, M.B.,
 
F. R. C. P. Fol. 1897. Part IX. W. B. Saunders, Philadelphia.
 
  
Transactions of the Indiana State Medical Society, 1895. Forty-sixth
+
Who use it in his name ;
annual session held in Indianapolis, Ind., June 6th and 7th, 1895.
+
The power that filled his garments' hem
Svo, 534 pp. Carlon & Hollenbeck, Indianapolis.
 
  
Hysteria and Certain Allied Conditions. By George J. Preston, M. D.
+
Is evermore the same.  
1897. Svo, 298 pp. P. Blakiston, Son & Co., Philadelphia.  
 
  
DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL
+
For lo ! in human hearts unseen
  
Bv JOHN s. Billings, m. D., ll. D.
+
The Healer dwelleth still,  
 +
And they who make his temples clean
  
Contaiulng 56 large quarto plates, phototypes, and litliographa, with views,
+
The best subserve his will.  
plans and detail drawings of all the buildings , and their Interior arrangements—
 
also wood-cuts of apparatus and fixtures; also 116 pages of letter-press describing
 
the plans followed In the construction, and giving full details of heating-apparatus,
 
ventilation, sewerage and plumbing. Price, bound in cloth, $7.60.  
 
  
 +
That Good Physician liveth yet
  
 +
Thy friend and guide to be ;
 +
The Healer by Gennesaret
  
136
+
Shall walk tlie rounds with thee."
  
 +
President Gilman of the Johns Hopkins University, upon a
 +
special invitation from the trustees of the Hospital, afterwards
 +
made the following address:
  
 +
We are assembled in the presence of one of the best works
 +
of modern Christian sculpture, — a transcendent theme, treated
 +
by an illustrious artist, in his noblest manner; a work, too,
 +
that has stood the test of more than seventy-five years without
 +
a word of censorious criticism. Canova saw it in Rome, while
 +
it was modeling by the artist, and praised it. The people of
 +
Copenhagen determined to have it. It was reproduced at
 +
Potsdam (Berlin) in front of the Church of Peace, near which
 +
the Emperor Frederic lies buried. A copy, in plaster, surrounded by the twelve apostles, from the same artist, was
 +
brought to New Yoi-k at least forty years ago and exhibited
 +
in what was known as the Crystal Palace or the World's Fair.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
But we have here, not the original cast in clay, nor a plaster
 +
reproduction, nor one in galvano-plastic ; but we have a
 +
marble like that which Thorwaldsen himself touched with
 +
his chisel. The pose, the drapery, the figure, the outstretched
 +
arms, the head, the face, are reproduced for us with exactness
 +
by a living artist of Copenhagen.  
  
 +
We are greatly indebted to that honored citizen of Baltimore who has brought here a work which from so many
 +
points of view delights and inspires us.
  
 +
This is not the first time that a hospital has been decorated
 +
by a great work of art. If I remember rightly, Benjamin
 +
West painted the picture of " Christ Healing the Sick," for the
 +
Pennsylvania Hospital in Philadelphia; and, if I am not mistaken, in St. Luke's Hospital, New York, there is still a
  
rXo. 75.
 
  
  
 +
famous picture by Daniel Huntington, "The Dream of
 +
Mercy," based upon an incident in Buuyan's Pilgrim's
 +
Progress.
  
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.  
+
Nor is this the first gift that this hospital has received. Its
 +
munificent endowment by Johns Hopkins has been strengthened by fuuds provided for the foundation of a school of medicine and surgery, which supplements the work of the Hospital.
 +
And minor gifts have come in. Not long ago we had a very
 +
small but noteworthy present, a likeness of Florence Nightingale. At another time a friend gave us models and pictures
 +
of various public institutions throughout the country. Again,
 +
one who loves medical biography and history has hung upon
 +
these walls a fine collection of the portraits of illustrious physicians and surgeons who in many countries and in many
 +
generations have adorned their profession. Eecently a large
 +
gift has enabled the trustees to provide better facilities for the
 +
instruction of those who are here engaged in preparing themselves for the profession of medicine or for nursing. And now
 +
we have this work of art which, perhaps, appeals to more of
 +
us than any of the other gifts, unless it be that touching
 +
memento of a departed child, the "White Eose Fund," which
 +
enables the Superintendent every year to distribute flowers to,
 +
and to provide for the entertainment of those who are convalescing in the Children's Ward.  
  
 +
Baltimore is fortunate in many ways in the gifts that are
 +
coming to it. We seem to have reached a period in the history
 +
of this city when its citizens are ready to adorn and decorate
 +
the place of their residence. Mr. Spence has presented a noble
 +
statue of William Wallace that stands in Druid Hill Park.
 +
Around the Washington Jlonument are the works of Barye, of
 +
Dubois, and of Story, and also the grand figure of Chief
 +
Justice Taney, perhaps the best portrait statue, with one or
 +
two exceptions, that has ever been produced in this country,
 +
the work of our own Rinehart. But pleasant as these tokens
 +
are, I must not dwell upon them, but must rather speak of the
 +
circumstances under which this work of Thorwaldsen was
 +
produced, and tell you some things regarding the sculptor.
  
 +
The city of Copeijhagen, at the entrance to the " Sound," is
 +
not a very large place; I should say not more than one-half or
 +
two-thirds the size of Baltimore (if size is measured by population) ; but it has a port, a university, a citadel, a harbor,
 +
and an academy of fine arts, the latter holding high rank
 +
among the academies of Europe. The city suffered greatly
 +
by the bombardment of 1807 during the Napoleonic wars, and
 +
it was not till some twelve or thirteen years afterward that
 +
an historic edifice, which had thus been destroyed, was reconstructed. This was the old church which bears the name of
 +
the " Frue Kirke." The sound would be more familiar to us if
 +
I called it Notre Dame, or the Church of Our Lady. Denmark,
 +
as you know, is a Protestant country, and this is a Lutheran
 +
church. I have heard it called a Presbyterian church, and I
 +
do not know that Mr. Spence will object to that. While in
 +
the process of reconstruction, the commissioners had a conference with Thorwaldsen, a native of Copenhagen, and arrangements were made by which he should model a statue of Christ.
 +
It was also agreed that the approach to the altar from the
 +
main portal should be lined with statues of the apostles, beginning with Peter and Paul. This arrangement was carried
  
THE JOHNS HOPKINS HOSPITAL REPORTS.
 
Volume I. 423 pages, 99 plates.
 
  
Report In Pathology.
 
  
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
+
January, 1897.]
  
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
 
  
Vena Portae and its Influence upon the Circulation. By P. P. Mall, M. D.
 
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis
 
  
(Atrophy). By Henry J. Berklet, M. D.
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.  
 
  
Mall, M. D.
 
  
Report in Dermatology.
 
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
 
  
T. C. Gilchrist, M. D., and Emmet Rixford, M. D.
+
out by the artist, then liviug in Home; and such is the origin
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of
+
of the Christus Consolator upon which we are loolviug.
  
Protozoa, and the Blastomyces found in the preceding Cases, with the so-called
+
Not far away from this church stands the Thorwaldsen
 +
Museum, constructed by the people of Copenhagen for the
 +
reception of the casts of all or nearly all the works that Thorwaldsen made. This museum was subsequently endowed by
 +
him with a very considerable sum of money, and now constitutes his monument. In the interior court his body lies
 +
buried.
  
Parasites found in Various Lesions of the Skin, etc. ; Two Cases of Molluscum
+
Now perhaps you would like me to tell you regarding the
 +
artist himself. Perhaps I may mention two or three things that
 +
will connect him with this country. Those of us who have
 +
watched the ships coming in and going out of a great harbor,
 +
as I did in my boyhood in New York, remember how common
 +
it was to see ships with carved beaks, often quite well wrought.
 +
Now Thorwaldsen commenced his sculpture by carving beaks
 +
for great ships. It is not unlikely that in some such place as
 +
the Naval Museum in Brooklyn some of those images which
 +
Thorwaldsen and his father carved are still preserved.
  
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
+
When Thorwaldsen was beginning to acquire a reputation,
 +
about the year 1807, the United States Consul at Leghorn
 +
negotiated with him to model a statue of Liberty to be placed
 +
in Washington. Whether it was for the summit of the capitol
 +
or to stand upon the ground, I do not know, but the life of
 +
Thorwaldsen records the fact that negotiations weut forward for
 +
the statue, and also that a proposal was made to him to make
 +
a monument t6 commemorate the American victories over the
 +
pirates of Tripoli and Tunis.  
  
T. C. Gilchrist, M. D.  
+
I have come upon another incident perhaps more curious.  
 +
You know that when a man becomes famous all the world
 +
begins to ask " Who was his grandfather ? " and to trace his
 +
heredity as far as possible. As soon as this Danish sculptor
 +
became famous, people found out that he was descended from
 +
an old Icelandic sculptor. But they did not stop there ; they
 +
thought they found that he was a desceudant of Thor Finn.
 +
Thor Finn is the name of one of the Norsemen who is said to
 +
have crossed the Atlantic, not far from the year A. D. 1000, and
 +
is said to have skirted along the New England coast and to have
 +
established himself iu the southern part of that peninsula. A
 +
son was born to Thor Finn in what is now Rhode Island (so at
 +
least it is said), and to that man they have traced the genealogy of Thor-wald-sen, and thus they claim that Thorwaldseu is descended from the first person born of European
 +
descent in the new world.  
  
Report In Pathology.
+
The enterprising secretary of the Rhode Island Historical
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration
+
Society took occasion to address a letter to Thorwaldsen congratulating him not only on his honors but on his origin, and
 +
Thorwaldsen replied, with a fine touch of courteous humor,
 +
"Let us admire those savants, for if it were uot for them, we
 +
should not know where we came from or whither we are
 +
going."
  
of Hypertrophy of this Gland. By W. S. Halsted, M. D.  
+
It is just one hundred years this very month, and I may
 +
say this very week, since Thorwaldsen, iu a note dated October
 +
16, 1796, states that he is on his way from his northern home,
 +
like the Norsemen of old, to establish himself in the south.  
 +
He was a passenger upon a government frigate which stopped
 +
leisurely at one point and then another, so that his journey
 +
grew tiresome. At last he abandoned the man-of-war and
  
  
  
Volume II. 570 pages, with 28 plates and figures.  
+
found other conveyances to carry him from Malta to Palermo,
 +
to Naples, and so on to Rome. There he went to work.  
  
Report in Medicine.  
+
But how could this boy maintain himself in Rome ? It was
 +
by the aid of a scholarship provided for him by the Royal
 +
Academy of Copenhagen. He had not been a very bright boy
 +
in his ordinary school instruction. His teacher could uot
 +
make anything out of him, and the pastor who was engaged
 +
in giving him lessons for confirmation shook his head many a
 +
time at the dulness of the artist. One day in the course of
 +
these lessons he said, "Thorwaldsen, was that your brother
 +
that took the j)rize iu the Academy of Fine Arts the other
 +
day':"' " No," said the young sculptor, "it was I." "You!"
 +
said the teacher; "Mr. Thorwaldsen [with the emphasis on
 +
the title], go up to the front seat." It is not a bad thing for
 +
those of us engaged in instruction to remember that sometimes boys who are dull at books, who do uot like to receive
 +
knowledge through the printed page, may yet have talents that
 +
are worth developing. This should never be forgotten.  
  
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with  
+
Now I want to remind you that scholarships just like that
 +
which enabled Thorwaldsen to go forward, have been established within a short time in Baltimore. Rinehart, as you
 +
know, left a considerable sum of money, which was carefully
 +
invested by Mr. Newcomer and Mr. Walters, until it reached
 +
the sum of $100,000, and it was then given to the Peabody
 +
Institute. This very week the Maryland Institute, by the aid
 +
of that fund, has instituted a school of sculpture, to bear the
 +
name of Rinehart, and besides this, Rinehart scholarships
 +
have been bestowed upon two young men, selected with great
 +
care by distinguished artists, and they are now engaged iu the
 +
prosecution of their art-studies, one in Paris and the other in
 +
Rome. I think it is not unreasonable to hope and believe that
 +
as the years roll by we shall hear something proceeding from
 +
these influences worthy to stand beside the Danish artist
 +
whom we this day commemorate, worthy likewise of Rinehart's
 +
bounty.
  
Gallstones. By William Osler, M. D.
+
At Rome, Thorwaldsen instantly came under the modern
Some Remarks on Anomalies of the Uvula. By JoHX N. Mackenzie, M. D.
+
influences of that day. Wiuckelmann, the well-known critic,  
On Pyrodin. By H. A. Lafleor, M. D.
+
had already called attention to the great value of the Greek
Cases of Post-febrile Insanity. By William Obler, M. D.
+
art iu distinction from that of the Renaissance, and sculptors
Acute Tuberculosis in an Infant of Four Months. By Hahrt Toclmin, M. D.  
+
began to work iu the Hellenic spirit. You get an illustration
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
+
of this movement in the Flaxman designs, as produced
Notes on Endocarditis in Phthisis. By William Osler, M. D.  
+
in England. You get another illustration in the work of
 +
Oanova, and you get an especially good illustration in the early
 +
work of Thorwaldsen.  
  
Report in Medicine.  
+
A great many illustrious people came to Rome. An amusing story is told of Sir Walter Scott. He was very desirous of
Tubercular Peritonitis. By William Osler, JI. D.
+
meeting and talking with Thorwaldsen, and they were introduced to one another; but Thorwaldsen could not speak a
A Case of Raynaud's Disease. By H. M. Thomas, M. D.  
+
word of English, and Sir AValter was not at his ease in French.  
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  
+
All that any one could hear was "plaisir," "plaisir," "connaissance," and similar nouns, expressing gratification that
 +
they had met.  
  
Report in Gynecology.
+
The sculptor soon came into church circles. He was a particular friend of Cardinal Consalvi, and made his monument.  
The Gynecological Operating Room. By Howard A. Kelly, M. D.  
+
It was through his influence, undoubtedly, that Thorwaldsen
The Laparotomies performed from October 16, 1889, to March S, 1890. By Howard
+
was selected to make for the Church of St. Peter the famous
 +
monument of Pius the Seventh. Some one objected that a Protestant had been selected. The Pope inquired, " Is not he the
  
A. Kelly, M. D., and Hunter Robb, M. D,
 
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of
 
  
Abdominal Section. By Howard A. Kelly, M. D.
 
The Management of the Drainage Tube in Abdominal Section. By HnuTER Robb,
 
  
M. D.
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
The GonococcuB in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Pentoneum;
 
  
Ovarian Tumor; General Gynecological Operations from October 15, 1889, to
 
  
March 4, 1890. By Howard A. Kelly, M. D.
 
Report of the Urinary Examination of Ninety-one GjTiecological Cases. By Howabd
 
  
A. Kelly, M. D., and Albert A. Ghriskey, M. D.
+
[No. 70.  
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (3hecking
 
  
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.
 
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.
 
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
 
Myxo-Sarcoma of the Oitoris. By Hunter Robb, M. D.
 
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
 
  
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
 
  
Howard A. Kelly, M. D.  
+
best artist in Eome?" "Undoubtedly," was the answer.  
 +
"Then let him hold the place."
  
Report in Surgery, I.  
+
Thorwaldsen after a time went home, and, as I have said,
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot
+
received the commission for a statue of Christ. He returned to
 +
liome, and with his helpers, it took him eight or nine years to  
 +
complete the group of Christ and the Apostles.
  
in the Management of Dead Spaces. By W. S. Halsted, M. D.
+
You must be familiar with many of the works which he
Report in Neurology, 1.  
+
produced meanwhile. The little medallions of Night and Day
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
+
which hang in so many parlors were his. Almost every one
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.  
+
who goes to Eurojie knows the Sleeping Lion of Lucerne and
Haematomyelia. By Adqdst Hoch, M. D.
+
the statue of Lord Byron at Cambridge. He made many
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By
+
portrait busts. He worked long on mythological subjects, till
 +
finally " he turned from Jove and Mars to nobler themes."
  
Henry M. Thomas, M. D.  
+
The story goes that he made six models of the Christ before
 +
he was satisfied with the one which is here reproduced. At
 +
first he thought of giving to the figure an iiplifted hand, in
 +
the attitude of benediction. Afterwards he uplifted both arms
 +
as if in prayer. The artist was standing before his statue one
 +
day, when he said to a friend, " I am not satisfied with that."
 +
His friend replied, " What was your motive in giving that
 +
posture; what were you thinking about?" Thorwaldsen
 +
paused, and in a moment turned down the arms to the position
 +
in which you now see them, and then said, " I am satisfied now."
 +
 
 +
It is worth while for me to add that between five and six
 +
hundred works by this artist have been catalogued — a large
 +
part of which may be seen (in the cast, if not in the original)
 +
at the Thorwaldsen Museum in Copenhagen.  
  
Report in Pathology, I.  
+
Now, ladies and gentlemen, it is not for me to draw the
Amffibic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleub, M. D.
+
lesson of the statue. I suppose (to use a phrase of Coleridge) that this statue "will find each one" of us in his own
 +
mood. To some it will be a reminiscence of travel, — of a
 +
delightful day in Copenhagen. To others it will be a work
 +
that is famous in the history of modern art. To many of the
 +
anxious and suffering it will be suggestive of hope and faith
 +
and love. To each, according to the inward eye that he brings
 +
to bear upon it, will the lesson be given. I do not propose to
 +
read a homily ; but I may remind you that throughout modern literature and art this figure appears. From the Divine
 +
Comedy of Dante to the Paradise Lost of Milton, in the
 +
Saul of Browning and Tennyson's Crossing the Bar, one name
  
  
  
Volume III. 766 pages, with 69 plates and figures.  
+
is repeated. So it is in painting, from Eaphael and Leonardo to
 +
those gifted men who are now decorating the churches in this
 +
country with the illustrations of the life of Christ. So it is
 +
in sculpture, fi'om Michael Angelo to St. Gaudens. So it is in
 +
religious meditation, from Thomas a Kempis to Phillips
 +
Brooks. Everywhere there is one Jiote prevalent, one name
 +
pre-eminent. Whatever else the founder of Christianity may
 +
have been, we cannot read the narratives of his life without a
 +
certainty that he was the Great Physician. W'hatever else
 +
may be found in this statue, however we may look at it, we
 +
must be mindful that it represents to us one who lived and
 +
walked upon this earth, and wrought more cures and more
 +
wonderful cures than any physician or surgeon that had ever
 +
lived. Thorwaldsen, better than any artist that I know,
 +
has produced this thought in marble. Li " Ecce Homo "
 +
attention is called to a fact which you will allow me to repeat
 +
— that the founder of Christianity was not only the Great
 +
Healer, but when he first organized his followers into a definite society, for the purpose of bearing glad tidings throughout
 +
the world, he sent them on their mission as physicians. " Go,"
 +
he said, "and heal the sick "; and the narratives of the Evangelists and of the Book of the Acts bring out most clearly
 +
this distinctive character. Among its other lessons we shall
 +
remember that this " House of Mercy," this " Hotel-Dieu," is
 +
pervaded by the spirit which appeared upon the earth almost
 +
nineteen hundred years ago.  
  
Report in Pathology.  
+
In the presence of Mr. Spence it will not do for me to
 +
recount the many good deeds which he has done for the city,
 +
the many great services, political, financial, mercantile, philanthropic, educational and religious, which he has rendered to
 +
Baltimore ; but I must be allowed to say that twice when the
 +
finances of the Johns Hopkins University have been in a critical condition, he has been the one citizen to come forward and
 +
by his example to inspire the liberality of others. He was
 +
kind enough to tell you that I had on a " wishing cap," or
 +
words to that effect, seven years ago. I am going to put on
 +
my "wishing cap" now, and I am going "to wish" that as long
 +
as Baltimore lives and flourishes it may have the presence and
 +
influence and co-operation of such men as William Wallace
 +
Spence.  
  
Papillomatous Tumors of the Ovary. By J. Whitridqe Williams, M. D.
 
  
Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D.
 
Report in Pathology.
 
  
Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Flexner, M. D.  
+
THE BACILLUS PROTEUS ZENKERl IN AN OVARIAN ABSCESS.  
  
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.  
+
By Hunter Robb, M. D., Professor of Gynecology, Western Reserve University, Cleveland, 0., and Albekt A. Ghriskey, M. D.,
  
A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.  
+
former Assistant Gytiecologist to the Johns Hopkins Hosjntal.  
  
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.
 
  
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
 
  
Report In Gynecology.  
+
Mrs. T. G. was admitted to the gynecological ward of the
 +
Johns Hopkins Hospital, August 8, 1891, with the following
 +
history :
  
The Gynecological Operating Room; An External Direct Method of Measuring the
+
The patient was a Bohemian, 36 years of age, and had been
Co'njugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
+
married seven years. She had had three children, and said
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofle.xed Uterus. By Howard A
+
that she had never miscarried. The oldest child is six and the  
Kelly, M. D.  
+
second four years old; the third child, born in Jan., 1890,
 +
died of " summer complaint " at the age of six months. Her
 +
labors had been easy ; she remained in bed for two days after
 +
each, being attended only by a midwife. PIcr menses first
 +
appeared at 16 years of age. They were irregular, lasting usu
  
Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci,
 
By Mary Sherwood, M. D.
 
  
Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavelt, M. D.  
+
ally seven days, and were often profuse and painful; since
 +
marriage her menses have been regular, lasting five or six days,
 +
being profuse but not painful. In May, 1890, she ceased to
 +
menstruate for two months, but in July her menses reappeared
 +
and lasted six days. At this time they were profuse and
 +
accompanied with a great deal of backache and pain in both
 +
ovarian regions. She had never had leucorrhiva; she suffered
 +
from constipation. There was no urinary difficulty. The
 +
patient remained well until April, 1891, when a hemorrhage
 +
from the vagina occurred suddenly and continued for six days.  
 +
Two hours after the hemorrhage ceased she passed foul
  
  
 +
January, 1897.]
  
Gynecological Operations not involving Cceliotomy. By Howard A. Kelly, M. D.
 
Tabulated by A. L. Stavely, M. D.
 
  
The Employment of an Artificial Retroposition of the Uterus in covering Extensive
 
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.
 
  
Photography applied to Surgery. By A. S. Murray.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
  
Traumatic Atresia of the Vagina with Hsmatokolpos and Bxmatometra. By Howard
 
A. Kelly, M. D.
 
  
Urinalysis in Gynecology. By W. W. Russell, M. D.
 
  
The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.  
+
smelling black clots of blood and experienced labor-like pains.
 +
During May, June and July she was free from these laborlike pains, but complained during these months of weakness,
 +
of occasional chills and fever, of pains in the lower zone of the
 +
abdomen, and backache. On admission to the hospital she was
 +
too weak to walk. The slightest touch over the region of the
 +
left ovary provoked intense pain. The temperature on admission was normal ; the jiatient weighed 123 pounds.  
  
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.
+
At the examination made August 8, 1891, under chloroform
 +
narcosis, the following note was made :
  
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.
+
Vaginal outlet moderately relaxed; vagina bathed with
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.  
+
bloody fluid ; cervix small, bilaterally lacerated, pointing upwards; uterus anteflexed, sagging in the pelvis, enlarged, soft
 +
and movable. Right broad ligament thickened. Fallopian
 +
tube and ovary not definitely palpated.  
  
Abdominal Operations performed in the Gynecological Department, from March 5,  
+
On the left side a fluctuating tumor is outlined, about the
1890, to December 17, 1892. By Howard A. Kelly, M. D.  
+
size of an orange, adherent to the uterus.  
  
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
+
Diagnosis. Abscess of the left ovary. Treatment advised,  
May 4, 1892.  
+
coeliotomy.  
  
 +
Urinary analj/sis. A voided specimen examined on August
 +
9th was turbid, straw-colored, specific gravity 1.020, reaction
 +
acid. On standing it deposited a heavy bloody and mucous
 +
sediment. On boiling, albumen was found to be present. A
 +
large number of red blood corpuscles were revealed by the
 +
microscopical examination, as well as numerous epithelial cells
 +
both large and small.
  
 +
A catheterized sj3ecimen was cloudy, amber-colored, specific
 +
gravity 1.035, reaction acid. Albumen as in voided specimen;
 +
mucous sediment not so deeply stained with blood. The
 +
microscopical examination gave much the same results as those
 +
shown by the previous specimen.
  
Volume IV. 504 pages, 33 charts and illustrations.  
+
Operation August 12, 1891, under chloroform narcosis.  
  
Report on Typhoid Fever.  
+
Incision 7 cm. long through thin abdominal walls. On
 +
exploration of the pelvis, the mass previously palpated on the
 +
left side was brought into view. It was bound down to the
 +
broad ligament, uterus and pelvic walls by dense connective
 +
tissue adhesions. The tumor mass was successfully enucleated, but during its delivery a small rupture occurred at the
 +
point at which it was adherent to the fimbriated extremity of
 +
the Fallopian tube, and a small quantity of purulent fluid,
 +
having a strong foetid odor, escaped. A ligature was immediately tied about the rent, thus preventing the escape of more
 +
fluid. The remaining portion of the Fallopian tube, although
 +
not adherent, was enlarged and thickened. The tumor mass
 +
was transfixed and ligated below the round ligament, after
 +
which it was excised and the pedicle cauterized.  
  
By William Osler, M. D., with additional papers by W. S. Thayer, M. D., and J.  
+
The Fallopian tube and ovary of the right side being bound
Hewetson, M. D.  
+
down by only a few adhesions, were enucleated without difficulty. The fimbriated extremity of the tube was occluded,  
 +
enlarged and thickened. The ovary appeared inflamed, but
 +
was not enlarged. The tube and ovary were removed by transfixion and the pedicle was cauterized. The jjelvic cavity was
 +
irrigated with three litres of a sterilized salt solution at a
 +
temperature of 112° F. and sponged dry.  
  
Report in Neurology.
+
A drainage tube was inserted in the lower angle of the  
Dementia Paralj-tica in the Negro Race; Studies in the Histology of the Liver; The
+
wound and the usual dressings applied. Time of operation,  
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the  
+
40 minutes.  
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of .Whs- musculu^; The Intrinsic Nerves of the ThjToid <31and of
 
the Dog; The Nerve Elements of the Pituitarj' Gland. By Henry J. Berkley,  
 
M. D.  
 
  
Report in Surgery.
+
The specimens removed consist of the tube and ovary of the  
The Results of Operations for the Cure of Cancer of the Breast, from Jime, 1889, to
 
January, 1894. By W. S. Halsted, M. D.
 
  
Report in Gynecology.
 
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
 
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.
 
Report in Pathology.
 
Deciduoma Malignura. By J. Whitridqe Williams, M. D.
 
  
  
 +
right side, which are covered with villamentous adhesions, and
 +
the tube and ovary of the left side, which are encapsulated in
 +
connective tissue-like adhesions.
  
Volume V. 480 pages, with 32 charts and illustrations.  
+
VIII-13-91. First dressing. The gauze plug in the drainage tube is thoroughly saturated with a dark bloody discharge,  
 +
and streaked with a fluid resembling pus. Tube cleansed with  
 +
20 pledgets of cotton, the last three pledgets being but faintly
 +
stained. The discharge had a decided odor of decomposition.  
  
CONTENTS:
+
The cotton immediately over the drainage tube was slightly
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D.. and J. Hewetson, M. D.
+
moistened with the same character of secretion as that seen
A Study of some Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  
+
upon the plug and upon the cotton pledgets.  
  
Studies in Typhoid Feyer.
+
Abdomen flat, no distension, general condition good, usual
By William Osler, M. D., n-ith additional papers by G. Bluher, M. D., Simok
+
cultures taken.  
Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.  
 
  
 +
VIII-14-91. Second dressing. Slight amount of fluid on
 +
cotton over the drainage tube ; plug in tube moistened by a
 +
clear fluid holding a clot of blood at the lower end. On the
 +
gauze plug there are white opaque points of lymph, corresponding in position to the perforation in the drainage
 +
tube. The fluid has the same odor of decomposition. Tube
 +
cleansed with twelve pledgets of cotton, which when withdrawn were stained with a serum-like fluid, the two last being
 +
hardly soiled at all. Drainage tube removed and a plug of
 +
iodoformized gauze inserted down the track of the tube.
 +
Abdomen flat, general condition good ; usual cultures taken.
  
 +
VIII-15-91. Third dressing. Gauze removed from the
 +
tube track; moistened; not as much odor. Track of tube
 +
cleansed with peroxide of hydrogen. Abdomen flat, general
 +
condition good. Gauze reapplied to wound, but not down
 +
the track ; abdomen sensitive. Gauze impregnated with permanganate of potassium and oxalic acid applied over the
 +
protective dressing and track of the tube.
  
Volume VI. About 500 pages, many illustrations.  
+
VIII-19-91. Fourth dressing. Stitches removed. Line of
 +
union good; some suppuration about the track of the tube.
 +
General condition good.  
  
Report in Neurology.  
+
VIII-26-91. Fifth dressing. Small amount of creamy
 +
fluid escaped from the track of the tube. Line of incision
 +
in good apposition and well united.  
  
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical
+
Analysis of temperature cliart. — The temperature was taken
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.  
+
for ten days after the operation by the mouth, rectu m and vagina.
 +
The highest point registered was that on the fourth day, when
 +
it was 102° F. by the rectum, 101.8° F. by the vagina, and
 +
101.2° F. by the mouth. After this it was never above 101° F.
 +
and on the 9th day registered 100.5° F.  
  
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the  
+
Bacteriological examination. — The following cultures were
Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions
+
made from the left Fallopian tube and abscess cavity: Two
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. E.xperimental
+
sets of Esmarch's roll plates on agar-agar, one smear and one
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol) ; Part II. — Serum
+
stab culture in the same medium ; a blood-serum tube (bullock's
Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on  
+
blood) and a litmus milk tube. From the right Fallopian
the Cortical Nerve Cell; Part HI. — Ricin Poisoning. — Experimental Lesions Induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic
+
tube, which was distended by a muco-purulent, rather viscid
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical
+
looking fluid, we only made gelatine Esmarch's roll jilates.  
Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of
 
Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.  
 
  
Report in Pathology.  
+
Microscopical examination. — Cover-slips stained with gentian violet show numerous polynuclear leucocytes, with compound granular bodies, and a few cells with large round
 +
nuclei resembling epithelial cells. Many bacilli were observed;
 +
they were rather faintly stained, and were seen only occasionally within the leucocytes. These bacteria were stained
 +
best with carbolic gentian violet.  
  
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.
+
Numerous rod-shaped bacilli were found in the preparation
Cullen, M. B.
 
  
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of
 
Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. WiLKlNS, M. D.
 
  
Adeno-Myoma Uteri Diffusum Benignmn. By Thomas S. CJullen, M. B.
 
  
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. Bj
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
William D. Booker, M. D.  
 
  
The Pathology of Toxalbumin Intoxications. By Simon Flbxnieb, M. D.
 
  
TJie price of n set hound in cloth [Vols. I-1'I'\ of the Hospital JSepoi-ts is
 
$30.00. Vols. I, II and III are not sold separately. The price of
 
Vols. IV, V and VI is $5.00 each.
 
  
 +
[No. 70.
  
  
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.
 
The following papers are reprinted from Vols. I, IV and V of the Reports, for thoee
 
who desire to purchase in this form:
 
STUDIES IN DERMATOLOGY. By T. C. GiLCHRiST, M. D., and Emmet Koeord,
 
  
M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,
+
from the Fallopian tube on the right side. Though less
 +
intensely stained, they resemble tubercle bacilli somewhat
 +
morphologically. They are, however, completely decolorized
 +
when treated after the method of staining for the latter organisms. It is to be noted that the organisms were very numerous in the specimen from the point at which the cultures
 +
were made.
  
J3.00.  
+
After 48 hours in the thermostat all tubes were sterile,
THE MALARIAL FEVERS OF B.-ILTIMORE. By W. S. ThaTER, M. D., and J.  
+
except the blood serum slants, which showed an opaque, very
 +
faintly granular growth, apparently due to closely set colonies.  
 +
Only the growths from the two inoculations from the abscess
 +
contents were considered reliable for study. Inoculations were
 +
made from these on the agar-agar, blood serum, potato and  
 +
gelatine. Examined microscopically they proved to be pure
 +
cultures of a bacillus.  
  
Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARH.  
+
All these tubes showed growth after 24 hours on agar; very
 +
faintly after 48 hours on gelatine, on account of the lower
 +
temperature, but more distinctly on the latter on succeeding
 +
days. The appearance of the colonies in gelatine corresponded
 +
to that presented by the bacillus proteus, a fact suggested by
 +
Dr. Booker and confirmed by Dr. Welch. These colonies
 +
showed the typical twisted wandering offshoots (schwiirmende
 +
Colonien) characteristic of the proteus group. The gelatine
 +
was not liquefied.  
  
By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.75.  
+
Cultures from the Dramage Tube. — First dressing 24 hours
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted
+
after operation. Roll plate, agar-agar, Esmarch's tubes. The
 +
colonies on the tubes from the gauze plug were composed of
 +
the skin-coccus. Microscopical examination of stained coverglass preparations from the secretion showed a few diplococci,  
 +
and numerous bacilli identical with those found in the abscess
 +
cavity. The coccus grew on potato and in bouillon with the
 +
characters of the streptococcus pyogenes albus, but liquefied
 +
gelatine, though less rapidly than this organism.  
  
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481
+
The inoculation of a guinea-pig subcutaneously in the flank
 +
with the serum-like secretion from the gauze plug was without result.  
  
pages. Price, bound in paper, $3.00.  
+
Further inoculations from the drainage tube on bullock
Subscriptions for the above publications may be sent to
+
serum were not made, as the supply of culture medium was
 +
exhausted.  
  
The Johns Hopkins Press, Baltimore, Md.  
+
The case is of unusual interest on account of the results of
 +
the bacteriological examination. The bacillus proteus vulgaris (variety Zenkeri ?) was found in cultures from the
 +
abscess cavity in the left ovary, and on cover-slips in the right
 +
Fallopian tube. In all our previous examinations of abscess
 +
cavities, cysts and Fallopian tubes, we have never met with
 +
another instance in which it was present.  
  
 +
Macroscopical and microscopical de.fcripfion of specimens from
 +
the Pathological Laboratory of the Johns Ho})kins Hospital, by
 +
Dr. .T. Whitridge Williams.
  
 +
Appendages on loth sides. Left side: Tube 6 by 0.7 by
 +
1 cm. Fimbriated end thickened and adherent to ovary, but
 +
not occluded ; some portions are still bound down to the
 +
ovary, but at other places the adhesions have evidently been
 +
torn loose during the operation. On section it is seen that the
 +
mucosa is much thickened and resembles a pyogenic membrane. The characteristic folding has disappeared. Scattered
 +
through it here and there are areas which appear decidedly
 +
caseous.
  
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed hy THE FRJEDENWALD CO., Baltimore. Single copies
 
may he procured from Messrs. CVSHINO & CO. and the BALTIMORE NEWS COMPACT, Baltimore. Subscriptions, $1.00 o year, may he
 
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies will be sent by mail for fifteen cents each.
 
  
  
 +
The ovary is converted into a pus sac 5.5 cm. in diameter.
 +
The greater part of its exterior is smooth, though signs of
 +
several dense adhesions are observed. On the surface are a
 +
few dilated follicles. The abscess wall varies from 0.5 to 1
 +
cm. in thickness, its interior being lined by a characteristic
 +
pyogenic membrane 2 to 3 mm. thick. Externally it is glistening and presents many circular elevations, 1 to 5 mm. in
 +
diameter, which are raised only a few mm. above the general
 +
surface. These are found to be movable and to represent tags
 +
of tissue. On section, the pyogenic membrane is readily divided into two layers; the one nearer to the pus cavity being
 +
opaque, thicker, of a yellow color, and having a tuberculous
 +
aspect (?) ; the other, lying next the ovarian stroma, is lighter
 +
in color, more translucent, and considerably thinner than the
 +
inner coating.
  
BULLETIN
+
Cover-slips from the pus show many thick bacilli, but no
 +
tubercle bacilli.
 +
 
 +
Right side : Tube 5 by 0.4 by 1.2 cm. ; fimbriated end
 +
occluded ; many adhesions. Ovary 3 by 3 by 1.5 cm. Many
 +
adhesions on surface. On section, the ovary is succulent and
 +
contains an oldish corpus luteum and a small corpus luteum
 +
cyst, 5 mm. in diameter, with white opaque walls 1 mm. thick
 +
and with a glistening interior. There are also several follicles with hemorrhagic contents.
  
 +
Microscopical examination. The left tube presents a marked
 +
purulent salpingitis, the folds of its mucosa being infiltrated with leucocytes and round cells. In places the epithelium is swollen and breaking down, and in others has
 +
entirely disappeared, affording a picture which beautifully
 +
illustrates the liquefaction of tissue.
  
 +
There is also a marked endarteritis.
  
OF
+
Sections through the wall of the ovarian abscess show that
 +
the jDortion adjacent to the cavity contains many newly formed
 +
blood-vessels; it is filled with leucocytes and most beautiful
 +
fibroblasts, which are rapidly proliferating, nuclear figures and
 +
cell division being well seen.
  
 +
In this portion the connective tissue bands are hardly visible.
 +
As we recede from the abscess cavity we find fewer leucocytes,
 +
more fibroblasts and connective tissue, until we gradually
 +
approach characteristic ovarian tissue.
  
 +
The bacillus corresponds morphologically to the bacillus
 +
proteus Zenkeri, and stains well with methylene blue, and does
 +
not entirely decolorize with the Gram or Weigert stain. It
 +
may be observed in the abscess walls as a bacillus of varying
 +
lengths and in forms simulating cocci. The fibroblasts are
 +
strikingly like the large cells of the corpus luteum.
  
THE JOHNS HOPKINS HOSPITAL.  
+
In a contribution to the subject of the proteus vulgaris in
 +
abscesses, Hauser', besides the report of his own case, gives a
 +
resume of the instances previously reported by other writers.
 +
Ilauser's case is that of an adult W'ho had a series of abscesses
 +
in the hand, following an injury from one of the autopsy
 +
instruments. The pus, which was of an ichorous and stinking
 +
character, contained both the streptococcus and proteus. The
 +
suppuration was regarded as induced by the streptococci, and
 +
the peculiar character of the contents of the abscesses was
 +
attributed to the presence of the proteus.  
  
 +
Beck'' reports several cases of puerperal endometritis in
 +
which the proteus vulgaris was found, and one case of puru
  
  
Vol. VIII -No. 76.]  
+
January, 1897.]  
  
  
  
BALTIMORE. JULY, 1897.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
  
  
  
IPrice, (5 Cents.  
+
lent peritonitis, following total extirpation of the uterus for
 +
carcinoma, in which the presence of the same organism was
 +
demonstrated.  
  
 +
Finally, Dilderlein' reports that in the lochia of puerperal
 +
women he has often found bacilli which cause a rapid liquefaction of gelatine; but from his brief description one is not
 +
able to say whether or not he was dealing with the proteus.
  
 +
It seems fair to assume that our patient had a puerperal
 +
endometritis following the abortion which occurred last April,
 +
and that the infection subsequently involved the Fallopian
 +
tube and ovary.
  
coisrT:E]isrTS.  
+
The proteus Zenkeri, which he classifies among the anaerobes of putrefaction, is described by Hauser' as follows: The
 +
organisms 0.4 in bi'eadth, and of an average length of 1.65;
 +
in some instances the forms are rounder, at other times longer.
 +
After inoculation on gelatine, a layer which towards the periphery becomes thinner and has the appearance of the steps of
 +
stairs, is formed around the point of inoculation, and from
 +
the margin of this layer numerous threads and rods begin to
 +
pass out; after 24 hours we find large numbers of moving
 +
islands, composed of rods and threads presenting exactly the
 +
same appearance as in the case of proteus mirabilis. The
 +
deposit becomes gradually thicker and opaque, but no lique
  
  
 +
faction of the gelatine occurs except sometimes quite at the
 +
surface. The formation of spirilla is seldom observed. Cultures in gelatine and blood serum do not show any marked
 +
odor; meat infusion, on the other hand, is decomposed by the
 +
organism with the production of a strong smell. In its other
 +
effects the proteus Zenkeri resembles the proteus mirabilis
 +
and the proteus vulgaris, and as Hauser' has pointed out,
 +
there is probably only one species of proteus, the vulgaris, of
 +
which the other forms are to be regarded as simple physiological variations.
  
PAGE
+
Literature.
  
Studies on the Lesions induced by the Action of certain Poisons on the Cortical Nerve Cell. Study VII : Poisoning
+
1. Hauser: Ueber das Vorkommen von Proteus vulgaris
with Preparations of the Thyroid Gland. By Henry J
+
bei einem jauchig-phlegmonosen Eiterung. Munchener medicinische Wocheuschrift No. 7, 16 Februar, 1S92, p. 103.  
Berkley, M.D.,  
 
Five Successful Cases of General Suppurative Peritonitis treat
 
ed hy a New Method. By J. M. T. Finney, M. D.,
 
  
An Experimental Study of the Treatment of Perforative Peri'
+
2. Beck : Die Faulnisbachterieu der menschlichen Leiche.
 +
Baumgarten: Arbeiten auf dem Gebiete der pathologischen
 +
Anatomie und Bacteriologie aus dem pathologisch-anatomischen Institute zu Tiibingen, Bd. I, S. 155, 1889.
  
 +
3. Doderlein : Untersuchung iiber das Vorkommen von
 +
Spaltpilzen in den Lochien, etc. Archiv f. Gyuilkologie,
 +
1887, Bd. 31, S. 439.
  
 +
4. Fliigge: Die Microorganismen, 188G, p. 310.
  
137
 
  
  
 +
THE PHRENOLOGY OF GALL AND FLECHSIG'S DOCTRINE OF ASSOCIATION CENTRES
  
141
+
IN THE CEREBRUM.
  
 +
Br Lewellts F. Barker, JI. B., Associate Professor of Anatomy in the Johns ffopki7is University and
 +
Assistant Resident Pathologist to the Johns Hopkins Hospital.
  
 +
[Remarks made before the Clinical Society of Maryland, November 20, 1896.]
  
PAGE.
 
  
By Arthur
 
  
 +
In the history of medicine the 18th century stands out
 +
prominently as a period in which flourished a whole host of
 +
so-called medical systems and theories. The animismus of
 +
Stahl and the nerve-ether theory of Hoffman had been displaced by the system of Boerhaave ; the last, in turn, being
 +
gradually supplanted by the doctrine of irritability advanced
 +
by Albrecht von Haller, who had formulated a new theory
 +
based upon his experiments in physiology. William Cullen,
 +
again, combining Hoffman's system with the doctrine of irritability of Haller, sought the cause for all pathological processes in the nervous system. Each individual attempted to
 +
subordinate the most varied phenomena met with in disease to
 +
his own particular principle, and as yet the newer studies in
 +
anatomy and physiology were not wide-reaching enough in
 +
their influence to prevent the development of the most diverse
 +
and contradictory medical theories. The " excitation theory "
 +
introduced by John Brown met with an enthusiastic reception
 +
not only in England but also on the Continent, although it
 +
was gradually undermined by the vigorous opposition of
 +
Stieglitz and of Hufeland. It was only toward the end of the
 +
18th century and the beginning of the 19th that the investigations in the field of natural science began to affect medical
 +
ideas to any very considerable degree. The natural philosophy of Schelling, which was accepted widely by physicians,
 +
especially in Germany, benefited medicine very little, if at all.
  
  
tonitis in Dogs by a New Method of Operation
 
  
W. Elting and Wm. J. Calvert, ......  
+
Indeed, the statement has been made that the general tendency of the time to favor Schelling's philosophy did more than
 +
anything else, except the curiosity of the public, to spread the
 +
three false doctrines, animal magnetism, phrenology, and homCEopathy. Animal magnetism, fathered by the shrewd Anton
 +
Mesmer, had a brilliant career until the French commission
 +
with Franklin at its head successfully demolished it. Homceopathy, founded by Christian Friedr. Samuel Hahnemann,
 +
which attempted to subordinate the whole of the healing art
 +
to an arbitrary dictum, Siinilia similibus curantur, still has
 +
many adherents, especially in America. Phrenology or cranioscopy, connected closely with the name of Franz Josef Gall,
 +
has now but few disciples, and an avowal of belief in phrenological doctrines is usually received, even by the layman, with
 +
a suppressed smile.  
  
Squamous Epithelioma and Epithelial Hyperplasia in Sinuses
+
Gall was born at Tiefenbrunu, in Germany, in 1758. The
and Bone following Osteomyelitis. By S. M. Cone, M. D., ■
+
history of his life affords entertaining reading. He studied
 +
medicine in Strassburg and Vienna, and practiced his profession
 +
in the latter city, where he became very well known. He tells us
 +
in his books how at a very early age he noticed among his playmates the existence of definite relations between the external
 +
appearance of the head and face and certain mental characteristics. His lectures delivered in Vienna, in which his
 +
phrenological doctrines were chiefly set forth, were very popular and largely attended until 1802. when at the instance of
  
On the Blood-Pressure-Raising Constituent of the Sui)rarenal
 
Capsule. By John J. Abel, M. D., and Albert C. Crawford,
 
M. D.,
 
  
Notes on New Books,
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
151
 
  
158
+
[No. 70.
  
  
  
STUDIES ON THE LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE
+
the ecclesiastical authorities he was commanded by the Austrian government to discontinue "his public teaching. On
 +
leaving Vienna he went to Paris, where he gathered around
 +
him many supporters and continued to lecture, investigate
 +
and publish. He died at Montrouge, near Paris, in 1828.
  
CORTICAL NERVE CELL
+
It has been thought by many that Gall's statement concerning his early observations of his schoolfellows was made
 +
late in his life with the object of bolstering up his claims to
 +
originality. Macal lister, in his excellent and comprehensive
 +
article on Phrenology in the Encyclopedia Britannica, points
 +
out that Prochaska, of Vienna, who had published a work on
 +
the nervous system in 1784, is really to be looked upon as the
 +
father of phrenology, inasmuch as in his volume are to be
 +
found the germs of the views propounded by Gall in the same
 +
city a few years later. Prochaska in turn was preceded, at any
 +
rate as far as the idea of connecting the anatomical diversities
 +
of the brain with intellectual peculiarities is concerned, by
 +
Metzger, who 20 years before had proposed the inauguration
 +
of a series of observations bearing upon this point. Moreover,
 +
the doctrines of localization of function in the brain are of
 +
still older date, though it must be admitted that very little
 +
positive knowledge upon this point existed before the beginning of the 19th century.
  
STUDY vn.  
+
After leaving Vienna, Gall attached to himself Spurzheim,
 +
who seems to have been for some time an enthusiastic pupil,
 +
and, along with his preceptor, to have made many investigations upon the structure of the brain and the shape of the
 +
skull. Spurzheim rendered great service to the phrenological
 +
doctrines in England and America, where he lectured to large
 +
audiences and attracted many pupils, the most important one
 +
in America being perhaps George Combe. Gall and Spurzheim did not, however, remain throughout life in harmony.
 +
They separated in 1813, in the subsequent years, each preaching his own doctrine and disparaging to a certain extent, at
 +
least, the philosophical views of the other.  
  
POISONING WITH PREPARATIONS OF THE THYROID GLAND.
+
The doctrines of the phrenologists maybe briefly summed
By Henry J. Berkley, M. D., Associite in Neuro-Patholoyii, The Johns Hopkins Universily.  
+
up as follows : They believed that the brain, as a whole, is
 +
the organ of the mind, and that it is made up of multiple
 +
organs, each mental capacity displayed by an individual depending upon the development of its corresponding organ in
 +
the brain. The form of the skull was thought to depend
 +
upon its relations to the brain within it, though Gall in  
 +
one of his publications vigorously opposes the appellation
 +
" cranioscopy " as descriptive of his doctrines, stating that he
 +
had always maintained that his work was directed toward the
 +
anatomy and physiology of the brain, the contributions concerning the relations of the form of the skull to the morphology of the brain being merely an appendage of the bulk
 +
of his studies.  
  
 +
It is not my purpose in this brief communication to
 +
describe the whole list of faculties and the portion of the
 +
brain assigned to each by Gall, Spurzheim and others;
 +
phrenological diagrams are familiar to all of us, and, moreover, 'an account of the views of the various adherents
 +
and modifiers of the system is to be found in almost any
 +
encyclopedia. A glance at the loose manner in which some
 +
of the so-called organs of the mind were localized in the
 +
brain by bumps upon the skull will suffice to show the
  
  
The favorable side of the administration of the thyroid
 
extracts is shown in the very numerous articles in current
 
medical literature published both in this country and in
 
Europe. Comparatively few of these papers treat of other
 
than the bare clinical results from the most auspicious standpoint, and it is quite safe to say, after a review of some of
 
them, that the results would have been as brilliant had no
 
medicament been administered.
 
  
It is nevertheless true that the extract, when administered
+
unscientific nature of the whole system. Whereas Gall believed that there were only some 26 or 27 organs of the  
to either man or the lower animals, will occasion very grave
+
brain, with some of his followers the number was increased
symptoms of a toxasmic nature, symptoms that involve the  
+
considerably. Fowler, for example, describing as many as 43
cerebral, the vaso-motor and digestive functions, and perhaps
+
different faculties. Spurzheim divided the different capacities
also the normal action of those ductless glands that throw into
+
of the human mind into (1) the feelings, including the propensities and sentiments, and (2) the intellechial families,  
the circulation a potent though unknown substance ; and  
+
including the perceptive and reflective activities. As examples
when this administration is pushed even to a moderate degree
+
of the propensities may be mentioned concentrativeness, amativeness, philoprogenitiveness, combativeness and acquisitiveness ; of the lower sentiments, self-esteem, vanity and cautiousness may be mentioned; and of the higher sentiments,
death is almost invariably the result, either through the  
+
benevolence, veneration and firmness. Among the perceptive
advent of convulsions, or extensive loss of weight with indications of profound poisoning of the central nervous system,  
+
faculties he included the appreciation of form, size, weight,
shown by the change in the heart's action and in the respiratory movements.  
+
color, locality, number, order, time and language; while the
 +
power to study causality and the ability to compare one thing
 +
with another were described as reflective faculties. Having
 +
gained an idea as to the localization of a certain faculty, Gall and
 +
his friends would examine the heads of their acquaintances and
 +
the casts of the skulls of persons who had possessed the particular mental characteristic under examination, and would
 +
seek for a distinctive feature corresponding to this particular
 +
trait. The following examples are excerpted from Macallister's article. Amfitiveness was located by Gall in the lower
 +
part of the posterior surface of the head because he found this  
 +
area to be hot in an hysterical widow. He referred the faculty
 +
to the underlying cerebellum. It is amusing to learn that the
 +
adherents of phrenology explained the presence of a rudimentary cerebellum in the girl Labrosse, who had during life
 +
exhibited very marked amative tendencies, by assuming its
 +
obliteration from over-use. Destructiveness was located above
 +
the external auditory meatus, inasmuch as this is the widest
 +
part of the skulls in carnivorous animals. A marked prominence had been found in this situation on the head of a
 +
student, "so fond of torturing animals that he afterwards
 +
became a surgeon," and it was also well developed in the head
 +
of an apothecary who subsequently became an executioner.
 +
Acquixitivcness, located upon the upper edge of the anterior
 +
half of the squamous suture, was attributed to"this region
 +
because Gall had noticed it to be prominent among the pickpockets of his acquaintance. The bump of con.''(riictireiiess
 +
was easily found, since it was large on the head of a milliner
 +
of very good taste and upon a skull said to have been that of
 +
Eaphael. iSi If -esteem was located over the obelion because
 +
Gall found this region prominent in a beggar who had excused
 +
his poverty on account of his pride. The lore of approbation
 +
was supposed to be situated outside the obelion, inasmuch as
 +
this part of the head was especially protuberant in a lunatic
 +
who thought herself the queen of France. Cau/ioumess was
 +
assigned its proper situation from the observation of the large
 +
size of the parietal eminences in an ecclesiastic of hesitating
 +
disposition. Veneration, located in the middle line at the
 +
bregma, was determined by Gall after visiting churches, where
 +
he found that those who prayed with the greatest fervor had
 +
distinct prominences in this region. The bump of ideality
 +
was found especially developed in the busts of poets, and was
 +
said to be the part touched by the hand when comjiosing
 +
poetry. Since the frontal eminence was prominent in llabe
  
A medicament having these qualities cannot, therefore, be
 
administered with impunity to every sane or insane patient,
 
  
 +
January, 1897.]
  
  
and it was therefore directly for the purpose of ascertaining
 
the toxicity of one of the best known varieties of the thyroid
 
extract that the following series of experiments was undertaken.
 
  
The first portion of the investigation was made upon eight
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
patients at the City Asylum, who, with one exception (No. 1),
 
had either passed or were about to pass the limit of time in
 
which recovery could be confidently expected. To these
 
patients the thyroid tablets, each pill representing five grains
 
of the fresh sheep's gland, were administered, the dosage beginning always with a single pill daily for a period of three days,
 
then, after a certain tolerance had been established the dosage
 
was increased to two tablets daily, and, unless the symptoms
 
induced became grave, the number of pills was increased to
 
three daily, the length of continuance depending upon the
 
results.  
 
  
Loss of weight always attended the administration of the
 
tablets, as did disturbances of the circulation in the form of
 
tachycardia and enfeeblement of the cardiac action. Digestive disturbances and slight pyrexia were present in more than
 
half the cases. A peculiar odorous sweating was noticed with
 
two patients, and increase of the cutaneous transpiration in
 
  
  
 +
lais and Swift, it was believed to be the organ of the sense of
 +
the ludicrous. The capacity for recognizing faces was supposed to depend upon the width of the interval between the
 +
eyes, inasmuch as Gall found in a squinting girl a good
 +
memory for faces. The murderer Thurtell, who had a large
 +
organ of benevolence, is said by devotees to phrenology to have
 +
been in reality generous, since it was discovered that he once
 +
gave half a guinea to a friend. Many other laughable instances
 +
might be given of these crude methods of localization and of
 +
the futile attempts of the adherents of the doctrine to bolster
 +
up their tumbling edifices.
  
138
+
It is easy to understand how a shrewd man like Gall, — and
 +
any one who reads his books will be very ready to grant his
 +
shrewdness and intelligence, — developing with great rapidity
 +
a system full of interest for the public and stimulating their
 +
curiosity by providing them with an infallible clue to the
 +
determination of character and fitness for occupation in life,
 +
should have attained wide-spread and lucrative popularity.
 +
He soon made large amounts of money, lived in state, and
 +
numbered among his personal friends some of the first names
 +
in France. Nor was he a charlatan pure and simple; he undoubtedly had a brilliant mind, and made elaborate and careful
 +
studies of the brain and skull which resulted in discoveries
 +
of permanent value concerning the anatomy and physiology
 +
of the brain. No better proof of this statement can be obtained than by perusing the volumes which I place before you,
 +
kindly loaned by the Provost of the Peabody Library. This
 +
atlas, with its well-executed copper- plates, in particular, shows
 +
the care with which much of his work must have been done.
 +
The edition, including the atlas, sold in Paris at 1000 francs.
  
 +
It is curious how nearly a man starting with false premises
 +
may often approach to actual conditions. 'I'he newer investigations bearing upon the architecture of the brain have thrown
 +
much unexpected light upon the origin of the phenomena of
 +
the mind; the significance of the brain for the psychic phenomena has been established upon the basis of exact scientific
 +
investigations, and we are now justified perhaps in speaking in
 +
a certain sense of a " new phrenology." It may be interesting
 +
to refer briefly to the series of investigations which have led
 +
up to our present knowledge upon this subject.
  
 +
In so far as his doctrine maintained that the convolutions
 +
represented the most important substratum of the mental
 +
activity, and that the single convolutions of the cerebral cortex
 +
are not of equal significance for intellectual life, Gall most
 +
certainly approached the modern theory of cerebral localization. The investigations of Flourens led him to very different
 +
conclusions, and in 1812 he published his well-known " Examen de la Phrenologie," which was thought to have demolished
 +
the phrenological doctrines. It was Flourens' idea that every
 +
portion of the substance of the cerebral cortex had precisely
 +
the same significance. He believed that the removal of any
 +
given mass of the grey matter affected all the mental functions
 +
in exactly the same way, so that visual or olfactory perceptions would not be diminished in different proportions, no
 +
matter what area was extirpated. The facts which have been
 +
discovered by pathologists and clinicians concerning aphasia
 +
were, however, in entire opposition to these ideas of Flourens.
 +
Gall and Bouillaud had recognized that circumscribed lesions
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
in the cerebrum, especially in the frontal region, could give
 +
rise to definite disturbances in speech. Later, Marc Dax
 +
pointed out that aphasia occurred practically only when the
 +
left half of the cerebrum was diseased, and in 1863 Broca
 +
established the fact that in right-handed people the third left
 +
frontal convolution is the portion of the grey matter of the
 +
cerebral cortex which is important for articular speech. Subsequent studies upon aphasia have shown that there are several dift'erent kinds of the affection, only one variety of which
 +
depends upon disease of Broca's convolution, i. e. the one in
 +
which the capacity to speak out the word which the individual has in his consciousness is lost; the inability to understand
 +
spoken words, and the incapacity to call into consciousness the
 +
names of objects which are visible to the individual, being
 +
associated with disease of other parts. These facts alone
 +
prove that different regions of the brain are of different significance for the intellectual functions.
  
[No. 76.  
+
In addition to the studies on aphasia there have been
 +
recorded a whole series of pathological lesions which clinically were associated with definite disturbances of sensation ;
 +
thus, lesions of the occipital cortex have a tendency to affect
 +
visual sensations; lesions of certain portions of the temporal
 +
cortex interfere with hearing; the sense of smell has been
 +
shown to be connected with the under surface of the cerebrum, and the sense of touch with the upper frontal and
 +
anterior parietal regions. Physiologists by means of experiments upon animals have added most satisfactory support to
 +
these clinical and pathological observations.  
  
 +
In 1870 Fritsch and Hitzig reported the results of their
 +
investigations concerning galvanic excitation of the surface of
 +
the brain of animals, in which it was shown that stimulation
 +
of definite regions calls forth movements of certain only of
 +
the parts of the body. Three years later Ferrier used faradic
 +
stimulation of the cortex and was able to elicit quite complicated movements of different parts of the body, movements
 +
which seemed to be purposeful, inasmuch as they correspond
 +
to those employed by the animal when utilizing its sense
 +
organs, that is to say, movements such as are employed in
 +
listening, touching, looking at, or smelling external objects.
 +
Munk proved fiirther that by the removal of certain convolutions it was possible to produce in animals disturbances of
 +
sensory activity quite analogous to those which had been
 +
observed in the clinical and pathological study of diseased
 +
human beings.
  
 +
The studies of Goltz upon dogs supply an exceedingly interesting link in the chain of experimentation. This investigator
 +
demonstrated the possibility of keeping a dog alive for a
 +
considerable length of time in the entire absence of a cerebral
 +
cortex, and in this way was able to ascertain what faculties
 +
the animal possesses when only the lower parts of the brain
 +
are functioning uncontrolled by the cerebrum. He found
 +
that an animal without a cerebrum still possesses a very complex nerve life, a fact which is not so very surprising when
 +
one recollects the observations of comparative afiatomy.
 +
While the dog of Goltz's experiment appeared to be devoid of
 +
memory and judgment and incapable of finding out for himself among the objects outside of the body those necessary for
 +
the satisfaction of his needs, he showed himself to be by no
  
all. Irritability and a greater or less degree of mental and
 
motor excitement were remarked in all cases, no matter how
 
depressed or demented they had been previous to the administrations. Two jjatients became frenzied, and of these one
 
died before the excitement had subsided, the immediate cause
 
of the exitus being an acute disseminated tuberculosis. A
 
peculiar gelatinous feel to the integument of the forehead and
 
cheeks, precisely similar to that in myxcedema, combined
 
with puflBness of the skin about the malar prominences, was
 
very noticeable in those cases in which the administration of
 
the extract was continued for any length of time. Urinary
 
examinations were made several times before the commencement of the administration of the thyroid, and several times
 
during its administration, but only for the purpose of noting
 
the presence or absence of albumen and sugar. In the
 
abstracts this analysis is mentioned only when there is evidence of the presence of these abnormal constituents.
 
  
Abstracts of Histories of Insane Patients Treated
 
WITH Thyroid Extract.
 
  
I. Adolescent insanity. Martha H., set. 17. Sister insane.
+
10
Admitted with melancholic symptoms accompanied by considerable mental confusion. Occasionally had to be fed with
+
 
stomach tube. Could not speak, and it was imjoossible to
+
 
determine what delusions were present. After being several
+
 
weeks in the Asylum she partly recovered, and then relapsed,
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
and there appeared to be considerable mental reduction after
+
 
the lapse of several months. Then began to brighten, and take
 
more interest in her surroundings, also to gain flesh. The
 
thyroid gland was, apparently, small on palpation. Weight at
 
beginning of the thyroid administration 115 pounds. A single
 
thyroid tablet was administered for ten consecutive days, at
 
the end of which time there was slight febrile reaction, with
 
a pulse ranging from 100 to 110 (normal 78). The mental
 
change was very slight, patient exhibiting some irritability,
 
but nothing more. The weight is now 109 pounds.
 
  
On the fourteenth day, the thyroid being continued, the first
 
signs of improvement were noticed. Patient became brighter,
 
ate food without compulsion, and on the twentieth day volunteered to do work about the ward and conversed rationally.
 
The thyroid extract was discontinued on the twenty-second
 
day, and patient was discharged one week later, six months
 
after her admission, and did not relapse.
 
  
II. Melancholia folloioed hij deep dementia. Olivia P., ist.
+
[No. 70.  
37. Education fair. No heredity. Married. Nutrition
 
poor. Thyroid fairly well developed. Weight 100 pounds.  
 
Oil admission refused to speak, and would not take food.  
 
  
Patient was deeply demented, and quiet for several months
 
before the thyroid treatment was begun. She lost flesh very
 
rapidly, and on the eleventh day of the treatment showed
 
pronounced mental and motor excitement. Slight febrile
 
reaction, accompanied by a pulse rate of 120 beats. On
 
the twelfth day she passed into a state of frenzy, the motor
 
excitement being more pronounced than the mental symptoms. The thyroid extract was now discontinued, but the
 
excitement kept up, despite numerous attempts, with narcotics, baths, and systematic exercise, to allay it, for seven
 
weeks, at the end of which time she died with the clinical
 
  
  
 +
means an involuntary machine. Goltz states that he could
 +
stand upright, could run, could be set in motion by external
 +
stimuli of various kinds, that he could show evidences of
 +
emotion, becoming angry and biting and howling under provocation. When hungry the whole body entered into lively
 +
motion, and after food had been taken the animal again became
 +
restful and showed evident signs of satisfaction. As Flechsig
 +
points out, these experiments do not permit any conclusion
 +
regarding the condition of consciousness after the loss of the
 +
cerebrum, but they do show distinctly the power and the
 +
independence of the bodily instincts, and teach us that no
 +
small part of the acts concerned in these can be set free
 +
simply through bodily influences, entirely independent of the
 +
higher mental faculties.
  
evidences of acute miliary tuberculosis. An autopsy was not  
+
The studies of His and Flechsig, which have done so much
permitted.  
+
in recent years to give us an insight into the finer organization
 +
of the nervous system, have been especially devoted to the
 +
development of the nervous system. It is to the work of
 +
Flechsig to which I wish on this occasion to especially direct
 +
your attention.* His method of outlining tracts by the observation of successive periods of myelinization is not new. His
 +
larger work, published many yeai'S ago and entitled "Die
 +
Leitungsbahnen iniGehirn und Riickenmark," is based almost
 +
entirely upon studies made after this fashion. The tracts
 +
which function first, receive their myelin sheaths before the
 +
others, and a tolerably definite idea of the physiological
 +
capacities of a develojiing animal at a given moment, up to a
 +
certain period at least, can be gained by ascertaining the number of tracts which have already been medullated. Thus the
 +
spinal cord, medulla, pons and corpora quadrigemina are
 +
almost entirely medullated at a time when the parts higher up
 +
show very little or no myelin. Even in the new-born child,
 +
Flechsig has shown that the cerebrum is almost entirely
 +
unripe, inasmuch as extremely few of the myriads of nerve
 +
fibres which it contains are at this period medullated. Man,
 +
therefore, at the beginning of his earthly experience, resembles
 +
very closely the dog of Goltz's experiments; he is practically
 +
a being without a cerebrum, and yet, as in Goltz's dog, even
 +
with the drawing of the first breath, the bodily instincts in
 +
the child demand satisfaction. The new-born infant, with
 +
satisfied impulses and unaffected by external stimuli of a
 +
disagreeable nature, shows no evidence of consciousness. H
 +
it become hungry or be exposed to cold, or if painful stimuli
 +
be applied to it, active movements of the body result.  
  
III. Beginning dementia. Frank G., aet. 20, well educated,
+
Flechsig has shown, in his study of the embryonal cerebrum,  
was admitted to the asylum suffering from an attack of acute
+
that it is the sensory paths which first become medullated.  
mania. There he improved, but was taken out too soon,  
 
relapsed, was readmitted, and then gradually demented.
 
Thyroid of normal size. Is good tempered. Weight at beginning of thyroid administration 125 pounds. On the seventh
 
day of the treatment became quite irritable and impatient.
 
By the fifteenth day he was so quarrelsome that it was necessary to restrain him. During these 15 days he lost five
 
pounds, and there was considerable tachycardia and sweating.
 
The myxoedematous symptoms were not so pronounced as in
 
some of the other cases. The administration of the extract
 
now being discontinued, he regained weight, became more
 
quiet, and after the lapse of several weeks he was sent to his
 
friends somewhat improved.  
 
  
IV. Dementia. John B., fet. 31, admitted as a case of acute
+
*I have thought it best at this time to present, in as clear and
mania, and after a period of four months gradually demented,  
+
brief a manner as possible and without discussion, the main tenets
became quiet, and not at all irritable. Thyroid gland normal.  
+
of Flechsig with regard to the structure and function of the brain.  
Treatment was now begun, and within a week there was
+
While in such a short communication it is impossible to do justice
j^ronounced febrile reaction, with tachycardia and sweating.  
+
to so broad a subject, it is to be hoped that it may be possible to
There is a marked difference in the asjject of the face, which
+
show at least the trend of his views. The anatomical basis for his
now appears puffed and rounded, in contrast to the former
+
studies is given at some length in the voluminous notes appended
rather emaciated appearance. The facial expression also
+
to his "Gehirn und S'eele " (Leipzig, Veit. Co., 189(>). An idea of
became anxious, but there was no pronounced excitement.  
+
some of the criticisms which may be made of his doctrines can be
The treatment was continued thr»c weeks longer, without
+
gained by a perusal of the discussion of the address delivered by
producing other change than an increase of the myxcedematons characteristics, and was then discontinued. From a  
+
Flechsig at the Versammlung deutscher Naturforscher und Aerzte,
mental standjwint, the course of the patient's disease was
+
Frankfurt, September, lS9()(cf. Centralbl. f. Nervenheilkunde und
now rapidly downward, and he became absolutely demented
+
Psychiatric, October, ISOO).  
and degraded.  
 
  
V. Chronic vielancholia. Marcus Z., set. 30, Russian Jew,
 
admitted to the asylum with alternating melancholia and
 
mania. Thyroid normal. Much emaciated from chronic
 
diarrhcea. Refused food at first. Has been quiet for some
 
months, suffering from well marked delusions of persecution.
 
Under enforced feeding became well nourished, but not less
 
melancholic. Six months after admission treatment with
 
thyroid extract begun. One tablet for ten days, two for four
 
days, and three daily for two weeks longer. On the 11th
 
day became much excited, complaining that his countrymen
 
wished to kill him. There was slight febrile reaction and
 
increase in the pulse rate to 120 (normal 75). The cheeks
 
soon began to assume a marked puflBness, and on palpation
 
had a jelly-like feel. No other phenomena were noticed,
 
except that at the end of the month's treatment he had lost
 
eight pounds, which he rapidly regained after it was discontinued. Then he also became quiet, and at the date of writing
 
still remains an inmate of the institution, retaining his oldtime delusions.
 
  
VI. Dementia following puerperal melancholia. Katie S.,
 
ret, 35, was admitted in 1893, four weeks after confinement.
 
Recovered in about six weeks, was taken home, and there
 
relapsed and became permanently demented. Is untidy, mischievous, but never excited. Pulse rate normally 85 to 90.
 
Thyroid normal. Was placed on thyroid extract, one pill,
 
then two pills ilaily. lu second week marked febrile reaction.
 
  
 +
Gradually the individual fibres of one sensory path after
 +
another, beginning with that concerned in the sense of smell
 +
and ending with that by which are carried auditory impulses,
 +
passing from the sense organs of the body toward the cerebral
 +
cortex, gain their myelin sheaths. Each sensory path includes
 +
a very large number of nerve fibres containing the axones of
 +
neurones whose cell bodies are situated lower down. Following the different sensory paths to their cortical termination, it
 +
is easy to show in these early stages, in which very little of
 +
the brain is medullated, that the individual sensory paths
 +
terminate in tolerably sharply circumscribed cortical regions,
 +
for the most part widely removed from one another, being
 +
separated by masses of cortical sitbstauce which remain for a
 +
considerable period entirely unripe. Indeed, the cortical
 +
terminations of the individual sense paths correspond entirely
 +
to those regions of the surface of the brain which pathological
 +
observation has shown to stand in relation to the different
 +
qualities of sensation. It is the destruction of these internal
 +
sense organs which results in cortical blindness, cortical deafness, etc.
  
 +
After these sensory paths in the child's brain have become
 +
medullated, new paths begin to develop from the points where
 +
the sense fibres terminate — paths which go in the opposite
 +
direction. These fibres as they become medullated can be
 +
traced passing downwards to the medulla and the spinal cord,
 +
to the nuclei of origin of the motor nerves, and connecting in
 +
this way the sensory regions on the surface of the cerebrum
 +
with the motor apparatus. The area of the cortex concerned
 +
in the sense of touch has an especially well developed bundle
 +
of these motor fibres, the fasciculus cerebro-spinalis or so-called
 +
pyramidal tract, which consists of more than 100,000 fibres on
 +
each side, an arrangement which permits the carrying out of
 +
very delicate movements, especially of the parts of the body
 +
concerned in the sense of touch. Connections between the
 +
cortical sensory areas and the lower centres which appear to be
 +
concerned more directly with the bodily instincts, have already
 +
been made out. It is clear, therefore, that bodily instincts
 +
and external sense impressions may reciprocally influence one
 +
another. According to Flechsig, the sense of smell is moat
 +
intimately connected, the sense of hearing least associated
 +
with the centres concerned in the exercise of the lower
 +
instincts, a fact which, if confirmed, might account for the
 +
more ideal character of auditory impressions.
  
July, 1897.]
+
In the diagram before you, the localization of these various
 +
sense areas in the brain, according to the newest investigations
 +
of Flechsig, has been pictured. It will be seen that they are
 +
very sharply circumscribed, although at the peripheries of
 +
the areas the fibres do not terminate so close together as in the
 +
central parts. The large region, the sonifesthetic area, occupying the whole domain between the fossa sylvii up to the
 +
corpus callosum, including the gyri centrales and the feet of
 +
the frontal convolutions, together with the lobulus paracentralis and the middle third of the gyrus fornicatus,
 +
represents the cortical field in which terminate on either side
 +
those of the 200,000 fibres of the medial lemniscus which
 +
do not stop at the basal ganglia. These fibres, together with
 +
those relaid in the thalamus, it is believed, carry to the
 +
cortex the impulses which are concerned in the projection
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
Gyru.cm,.r..l,{J»«;r;;p,S<,m»»>.l,.tlo.,„.  
  
  
  
139
+
Corpus cAllonnn
  
 +
Porulx louguti,
 +
 +
(Septum pellucW,
  
  
pulse 120 to 1.30, very weak. There is considerable sweating.
 
Facial puffiaess well marked. Has become very irritable,
 
restless, aud difficalt to control. Thyroid extract discontinued after three weeks' administration, after which she gradually returned to her usual condition.
 
  
Vn. Deep dementia foIJoioing confimonal mclnnrlioliu.
 
ilaggie E., set. 2.5, was admitted in December, 1893. Thyroid
 
normal. When treatment with the thyroid extract was commenced was untidy and deeply demented. On the tenth day
 
there was slight febrile reaction accompanied by slight motor
 
excitement. These symptoms abated in the course of a few
 
days, though the administration of the thyroid extract was
 
continued, and, after three weeks, no improvement having
 
been noticed, it was discontinued.
 
  
VIII. Imbecility with recurrent mania, followed by apparent
+
"^ti^^i^r^^^j^
dementia. C. B., aet. 21, admitted with second attack of
 
excitement in December, 1895, and within a few weeks became
 
apparently deeply demented. Thyroid gland very small.
 
Administration of the extract was begun, and after a few
 
days there was febrile reaction, considerable sweating, and a
 
myxcedeniatous appearance of the integument of the face.
 
The pulse rate altered from 72 to 110, and the patient lost
 
weight rapidly. There were also considerable motor and
 
mental excitement, with the febrile symptoms, all of which
 
gi'adualiy abated, though the treatment was faithfully kept
 
up for a considerably longer time. The patient has had
 
several lucid intervals during the fall of 1896, but now seems
 
completely demented.
 
  
The above experiment upon eight human subjects points
 
out conclusively that the administration of even the very best
 
and purest of the commercial desiccated thyroid tablets is not
 
unattended by danger to the health and life of the patient,
 
and that at times the administration of very limited amounts
 
of the gland may be followed by symptoms not only difficult
 
to control, but of very marked influence upon the future
 
mental powers of the subject.*
 
  
These results obtained, we then decided to further pursue
 
our experiments upon the lower animals, to determine the
 
amount necessary per kilo of weight to cause death, the immediate cause of the dissolution, and the lesions, both macroscopic and microscopic, present at death, especially those pertaining to the cerebrum.
 
  
Through the kindness of Dr. Crawford of the Pharmacological Laboratory, who undertook the ordering of the administration to the animals, we obtained material from five mice
+
^^^
and three guinea-pigs, to which the same desiccated sheep's
 
thyroid tablets used in the first part of the investigation had
 
been fed; also the cerebrum from one guinea-pig to which
 
had been administered thyroid extract, and the cerebrum of a
 
dog from which the thyroid had been extirpated about one
 
year previous to its death, but in which, at the autopsy, supernumerary thyroids were discovered, though the animal during
 
life had exhibited minor symptoms of a cachexia.
 
  
A portion of the material for microscopic examination was
 
  
*I do not take into consideration the possible presence of putrefactive products in the tablets, as they were perfectly free from all
 
evidences of decomposition.
 
  
 +
Oolliculiia superior (corp. quad.)
 +
. Hnin nucleus of tliaUmua.
  
  
hardened in Muller's fluid for after-treatment according to
 
the silver-phospho-molybdate formula, and another portion in
 
alcohol, for staining with the anilines, hematoxylin, aud more
 
particularly to examine into the lesions of the blood-vessels,
 
both in the abdominal viscera and cerebrum.
 
  
The five mice were first fed with the tablets. All of them
 
ate the pills readily to obtain the sugar coating them. For a
 
few days there was no appreciable effect. Then they grew
 
dull, the cheeks became puffy, there was trembling and increase
 
of the frequency of the respiratory movements, and death
 
rather suddenly.
 
  
Abstract of the Histories of the Thyroid Mice.  
+
Fig-. 6.  
  
No. I. Administration of the tablets commenced Aug. 22, '96.
 
One pill 32nd; three, 24th. Animal remains bright and eats
 
other food ; 2.5th, two tablets. On 26th, it seems frightened
 
and the face appears swollen ; on the 37th instant, it is still
 
trembling very greatly, and no pill was given. On the 28th,
 
it is very much brighter and the trembling has almost ceased.
 
On the 29th, is bright, and feeding of the thyroid was again
 
begun. Sept. 1st, three pills were fed, the animal eating
 
nearly the whole quantity. The 2nd instant, the face is
 
again swollen, and on the 3rd, refused to eat a portion of the
 
tablets, and has become quite dull. On the 4th and .5th
 
instant, the animal continued dull, trembling, aud looks weak
 
and sick. On the 7th, the eyes are very bright, and there
 
is slight emaciation. Five pills were given, but not all were
 
eaten. On the 8th, only two pills were taken ; there is much
 
trembling. Died during the night of the 9th instant, having
 
eaten a portion of the tablets left in the cage.
 
  
The autopsy showed congestion of all the viscera, but without hemorrhage. The brain was soft.
 
  
No. II. On the 33nd August, cue pill administered, on the
+
Soraae»tUetic
23rd aud 24th, the same quantity, but little not being eaten.
 
On the 35th, two pills were eaten, the animal still remaining
 
bright. On the 36th, two tablets were eaten, and the face
 
shows signs of swelling. On the 27th, the testes have become
 
swollen, in addition to the face, but the appetite is still
 
retained. On the 38th, the eyes are partly closed, and on the
 
29th, the animal is trembling, the legs are dragged, but it still
 
takes care of its coat.
 
  
September 1st, the animal is dull, the face much swollen.
 
Three pills were eaten. On the 3rd, is much brighter, sleeps
 
well, but has not taken all the pills during the last two days.
 
On the 5th instant, will hardly touch the sugar-coated tablet.
 
On the 7th, the face is markedly swollen, the animal is dull,
 
the hair less sleek, and the eyes almost closed. Kespi ration
 
134 per minute. Died in convulsions at 2.30 1*. M.
 
  
The autopsy was performed immediately. Besides some
 
unimportant congestion of the abdominal viscera there were
 
no ascertainable lesions.
 
  
No. III. Commenced feeding on 33ud August, but no symptoms were noticed uutil the 36th, when the face became
 
slightly swollen and the animal declined to eat the pill. On
 
the 28th, there is slight trembling. On the 30th, the trembling continues. On Sept. 3nd and 3rd, took daily three pills.
 
On the 5th, is dull, tottering, very weak. On the 7th
 
instant, the hair is rough, and it seems weak, hut eats the pills
 
  
 +
Gynm hippocampi.
  
  
140
 
  
 +
Fig. +.
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
  
[No. 76.
 
  
 +
LEGENDS.
  
 +
Fig. 1. Sagittal section through brain of a child one month old stained by the
 +
Weigert-Pal method. lAfter FUchsig.)
  
well. On the 8th, is trembling very much, but eats the pills.
+
a. Taenia thalaini optici iretiex path tor the transference of olfactory
Died during night.
 
  
Autopsy showed congestion of the abdominal viscera.  
+
impressions to the centres governing the movements of the
Brain rather soft.  
+
head ?).
 +
 
 +
b. White matter of septum pellucidum (in part running between the
 +
 
 +
olfactory area and the gyrus hippocampi).
 +
 
 +
c. Corpus callosum corresponding to the somiesthetic area.
 +
D. Superior I
 +
 
 +
h. Inferior jcolliculus of corpora cjuadrigemina, cut near the middle
 +
line : here very few meduUated fibres are present; sections lateral
 +
to this show many,
 +
r. Red nucleus of the tegmentum ; below this is seen the decussatio
 +
brachii conjunctiva
 +
(In this and succeeding plates I have translated Flechsig's terms as tar as possible into the nomenclature of the Anatomical Society. For his sense-centres and
 +
association-centres English terms which seemed most suitable have been employed
 +
For the suggestion of the name " soma-sthetic area" as a translation of the German
 +
KorperfuhUplKire I am indebted to Prof. B. L. Gildersleeve.— L. F. B.)
 +
 
 +
Fio. 2. Horizontal section through the brain of a child aged 3 months. (AHer
 +
Flechstg.) \ j'-'»
 +
 
 +
II. Tractus opticus.
 +
 
 +
H. Association system (cross-section) in the g. hippocampi, connecting
 +
the olfactory cortex of the uncus with Ammon's horn, going
 +
over into the alveus.
 +
M. Nucleus amygdalae.  
 +
P. Pyramidal tract in cross-section.
 +
p'. Temporal cerebro-pontal path.
 +
p'. Frontal cerebro-pontal path.
 +
The decussation of the nervus trochlearis is shown. The projection fibres of the
 +
olfactory sense area and of the g. hippocampi are completely medullated. At the
 +
tip of the frontal lobe and at the junction of the superior and middle temporal gyri
 +
myelin is as yet entirely absent. In many other parts (darker in tint) corresponding
 +
to the advanced age, association fibres are already medullated.  
  
No. IV. Feeding commenced on August 'Z2nd, but does not
+
Fio. 3. Horizontal section from the brain of a child a little over a week old.  
eat the tablet well, hardly averaging J of a pill daily. On
+
{After Flcchxig.)
the 26th, the animal is bright, but the face is slightly swollen.
 
On the 29th, refused to eat pill, but remaiued dull until
 
September 3nd, and thereafter refused to eat pill at all. On
 
the 12th instant, had apparently fully recovered.  
 
  
No. V. Administration commenced on the 22nd August,
+
C. Nucleus oaudatus.  
and the dried gland was all eaten. On the 26th instant, the
+
P. Putamen of the nucleus lenticularis.  
face is swollen. On the 28th, there is much trembling, but
+
gp. Globus pallidus of the nucleus lenticularis.  
three pills were eaten. On the 29th, would not eat pill, but
+
The optic radiation is well medullated ; the auditory path is not yet medullated
on Sept. 1st ate four pills. On the 5th instant, is trembling
+
as far as the cortex.  
considerably, but ate two pills. On 8th instant, was bright,
 
though trembling. On morning of 9th instant, found dead in
 
cage. The autopsy showed the usual congestion.  
 
  
Abstract op the Histories of the Thyroid
+
Fig. 4. Sagittal section through the brain of a child said to have died in the  
Ctuinea-Pigs.  
+
fifth month of life. (The child was probably some months older.) (After Fleclmii.)
 +
All parts of the white substance medullated, only in places still mixed with
 +
non-medullated fibres.  
  
No. I. Fed with thyroid extract, 20 mg. daily, from Oct.
+
C, P. (IP, as in Fig. 3.  
21st until Oct. 30th, on which day it died. Weight at beginning of experiment, 620 grammes. The animal became dull and
+
T. Thalamus (lateral nucleus).  
gradually emaciated. Weight at autopsy, 380 grammes. All
+
II. External geniculate body.  
intei-nal organs very much congested. The animal received a
 
total of 180 mg. of extract.  
 
  
No. II. Pig fed on the same desiccated thyroid as in the  
+
X. Substantia iiinominata Rei! (gray substance between the n. lenticularis and the n. amygdalse).  
former experiments. Weight, 810 grammes. On Oct. 21st, one
+
M. Nucleus amygdalir.  
and a half pills administered; on 22nd, four pills; on the
 
23rd, the same quantity. The respiration had now reached
 
144 per minute. On the 24th, 2.5th and 26th, four tablets were
 
fed daily, and during the night of the 26th, the animal died.
 
At the autopsy the abdominal organs were found to be
 
much congested. Weight, 620 grammes (loss 190 grammes).  
 
This animal received about seven grammes of the dried thyroid
 
gland, or less than one per cent. (.864j of its bodily weight to
 
produce a lethal effect.  
 
  
No. III. Fed on desiccated thyroid tablets. Weight, 580
+
x—y. Projection fibres of the anterior upper and inner part of the  
grammes. Oct. 21st, one pill ; on 22ud, three tablets ; on the
+
somiEsthetic area (KOrperfiihlsphiire); these run from the  
23rd instant, four; on the 24th, 25th and 26th, the same; on
+
internal capsule (between P and C) forwards and bend around
the 27th instant, six pills; on the 28th, four tablets; on the  
+
at an acute angle at x to pass upwards and inwards.  
29th, five ; on the 30th, five. The animal had been for several
+
V. Lateral ventricle.  
days very dull and had rapidly emaciated. The exitus took
 
place on the morning of the 30th instant. At the autopsy the
 
viscera were found to be much congested. The weight was 320
 
grammes. Loss of weight during the nine days of the experiment, 260 grammes. The animal received more than 2 per
 
cent, of its weight in the dried gland to produce dissolution.  
 
  
No. I\". The same thyroid preparation fed. Weight at
+
Fig. .5. External view of right cerebral hemisphere, showing sense-centres and
beginning of the administration, 610 grammes. On Oct. 22ud,
+
association-centres. (After Fle.chxig.) The more closely dotted areas show the regions
two tablets were fed to the animal ; on the 23rd, three ; on
+
in which the majority of the sensory projection fibres terminate. The large areas
the 4th, four pills; on the 26th, six pills; on the 27th, four
+
between the dotted areas represent the association centres.  
pills ; on the 28th, five pills. The pig has become very dull
 
and does not take care of its fur. Died Oct. 30th. At the
 
autopsy the animal weighed 370 grammes (loss, 240 grammes)
 
and the viscera were much congested. This animal received
 
1.30 per cent, of its bodily weight of the gland to cause death.  
 
  
 +
Fio. 6. Internal view of left cerebral hemisphere. (After FUchHg.)
  
 +
1. Corpus mammillare.
  
No. V. Thyroid dog (Dr. Abel). Thyroid gland extirpated
+
2. Median section of optic chiasm.  
i)i loto in Oct. 1895 ; died one year later, after showing profound emaciation and a dermatitis suggestive of myxoedema.
 
At the autopsy several parathyroid bodies the size of a small
 
pea were discovered. This animal was fed for several mouths
 
on thyroids and thyroid extracts, seemingly without benefit.
 
The autopsy showed no demonstrable lesions.  
 
  
The guinea-pig series may be looked upon as an example of
+
3. Cross-section of anterior commissure.  
the acute type of poisoning by the administration of thyroid
 
gland, while the mice are of a more chronic order. It is
 
impossible to estimate the exact percentage necessary to produce lethal results with the mice, for the reason that these
 
small animals always left some crumbs of the tablets on the
 
floor of their cages which it was not practicable to collect.  
 
The guinea-pigs on the other hand were fed with the entire
 
pill without loss, and but in one case was less than about one
 
per cent, of desiccated gland found to produce lethal results,
 
the administration being distributed over five days.  
 
  
The microscopic examination of the cerebra of the eight
+
4. Superior colliculus of corpora i|uadrigemina.  
mice and guinea pigs showed, both with the silver phospliomolybdate, and aniline and hematoxylin stains, an absolutely
+
.5, Corpus callosum (cross-section).  
normal condition of the nerve elements and neuroglia ; none
 
of the varicose and atrophied dendrites, with loss of the gemmulffi, of the former studies being discovered. The corpora
 
retain their angularity and sharp outlines, and the axons
 
with their appendages, the collaterals, retaining their natural
 
appearances. The sections stained with anilines and hematoxylin showed the normal appearances of the nucleus and
 
nucleolus, and not even in the tunics of the blood-vessels,
 
where pathological changes were most carefully sought for,
 
could any demonstrable lesion be discovered.  
 
  
The nearest approach to any pathological condition found
+
6 Fornix.
was in the cerebrum of the dog that had had its thyroid gland  
+
 
extirpated a number of months before death, though even
+
7. Septum pellucidum.
here the lesions were confined to a very few tumefied dendrites,
+
z. Pineal gland.
a condition that was most probably caused by the long continued state of mal-nutrition into which the animal had fallen.  
+
H.S. Tegmentum.
 +
T. Basis pedunculi.  
  
More particular attention was paid to the examination of
 
the liver than to the other organs of the abdominal cavity,
 
but here again we failed to find more than a turgescence of
 
the blood-vessels, the liver cells retaining their natural characteristics.
 
  
It is obvious from these results that the death of the various
 
animals was induced by an entirely different kind of intoxication than that causing the lesions of the nerve elements in
 
riciu and alcohol tox£emias, and it is therefore a poison that
 
does not induce degenerative alterations in the sheaths of the
 
arteries, and the consequent disturbance of the nutritive
 
supply, followed by pronounced changes in the neurons,
 
dependent to a certain degree upon the intensity of the
 
vascular lesions; but acts upon the general system in an
 
entirely different manner, and is essentially more subtle in its
 
effects upon the nerve tissues, corresponding more to the
 
action of a group of chemical poisons that leave no trace of
 
their effect after death upon the nerve cell, but during life
 
inducing symptoms directly referable to the central nervous
 
system. The tissue metabolism induced by the action of these
 
poisons upon the nerve cell we can only at present conjecture.
 
  
 +
January, 1897.]
  
  
July, 1897.]
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
11
  
  
141
 
  
 +
into consciousness of sensations of touch, pain, temperature,
 +
muscle and tendon sense, thirst, hunger and equilibrium, as
 +
well as sexual sensations, that is to say, the sensations which
 +
tell us of the condition of our bodies rather than that of
 +
external objects. It is obvious that this area must represent
 +
a complex mass of sense centres rather than a single sensory
 +
area ; indeed, we already have evidence from the pathological
 +
side indicating very different functions to the several parts of
 +
the somssthetic area, although the localization here, as might
 +
be expected, concerns that of groups of elementary rather than
 +
of single sensations. This is the area in which the body in its
 +
whole extent can be reflected in consciousness. It is possible
 +
that a similar mirroring of somatic sensations occurs in the
 +
cerebellar cortex.
  
 +
Besides being a sensory field, the soma3sthetic area is also
 +
the great motor region whence nearly all the movements
 +
serving for the voh;ntary satisfaction of the bodily instincts
 +
appear to start. When a man voluntarily swallows, chews,
 +
breathes or seizes an external object, it is this area which is
 +
active.
  
FIVE SUCCESSFUL CASES OF GENERAL SUPPURATIVE PERITONITIS TREATED
+
The nerve fibres conducting the impulses concerned in olfactory sensations terminate, according to Flechsig, mainly in the
 +
gyrus unciuatus where it touches the island of Keil, although
 +
many of them end in the frontal lobe.
  
BY A NEW METHOD.*
+
The fibres concerned in visual sensation, passing from the
 +
lateral geniculate body, the thalamus and the superior colliculus of the corpora quadrigemina, follow a direct course to
 +
terminate in the immediate neighborhood of the calcarine
 +
fissure, although subsequently fibres run out from this tract
 +
into adjacent areas, ending, however, only in that part of the
 +
cortex of the occipital lobe which shows the well known
 +
macroscopic stripe of Vicq d'Azyr. It is interesting to note
 +
that fibres from the fovea centralis are believed to go to the
 +
cortex of both cerebral hemispheres. Such a distribution
 +
would help to account for the incomplete blindness from
 +
unilateral cortical lesions.  
  
By J. M. T. Finney, M. D., Associate Professor of Surgery, The Johns Hopkins University.  
+
The fibres communicating auditory impulses to the cerebral
 +
cortex form the lateral lemniscus in the pons and are connected particularly with the median geniculate body; they
 +
run out into the temporal lobe to terminate mainly in the
 +
transverse temporal gyri, especially in the anterior one. It is
 +
obvious, therefore, that the main portion of the auditory area
 +
of the cortex is hidden in the wall of the fossa sylvii, appearing on the external surface of the hemisphere only in the
 +
middle third of the superior temporal gyrus, /. e. in that part
 +
of it which is in contact with the transverse gyri.  
  
 +
When all these sense centres have become ripe, that is, when
 +
the fibres going to them and the motor fibres passing from
 +
them to become connected with the lower motor centres, are
 +
medullated, only about one-third of the whole area of the cortical surface has been concerned. This means that approximately only one-third of the human cerebral cortex is directly
 +
connected with the paths which bring sensory impressions
 +
from the periphery into consciousness, or carry motor impressions to the periphery causing muscular contractions. Twothirds of the whole cortex appears to have nothing directly to
 +
do with the periphery, but to be reserved for another and
 +
apparently a higher work. These other areas which are left
  
  
Recovery following laparotomy for piiruleut peritonitis is
 
nufortunately of sufficient rarity to excite interest whenever
 
it occurs. My object in making this report to the Society is
 
two-fold ; first, to record five successful cases of laparotomy
 
for general suppurative peritonitis, all treated by the same
 
method; and second, to describe briefly the method itself.
 
The principle involved is not a new one; only in the manner
 
of carrying it out is there any originality claimed.
 
  
Since the appearance in 1877 of the classical work of  
+
uncolored in the diagram are the so-called association centres
Wegner, and later that of Grawitz and others, it has been
+
of Flechsig. They make up the main portion of the frontal
known that the healthy peritoneum is capable of disposing of
+
lobe, a large part of the temporal and occipital lobes, the
a considerable amount of infectious material. J. G. Clark, in
+
island of Eeil, and occupy a large area in the posterior parietal region of the brain. For a whole month after birth these
a recent article,f reviews the literature of the subject and  
+
portions of the cortex remain uuripe and are entirely devoid
gives the conclusions reached by the experimenters in this direction. All agree that the peritoneum is able under favorable
+
of myelin. But after the development of the sense areas of the  
conditions to take up a relatively large amount of infectious
+
cortex, Flechsig has been able to follow baud after band of  
material and disjjose of it effectually. These observers were
+
nerve fibres passing from the different sense areas into these
dealing with a more or less healthy peritoneum. On opening
+
other immature portions of the cerebral cortex, and ending
the abdomen of a patient suffering from general suppurative
+
there close beside one another, thus forming true centres of  
peritonitis, however, we have very different conditions with
+
association between the different sense centres. And it is his
which to deal. The observations of Pawlowsky would indicate that the lymph channels leading from the peritoneal
+
belief that these association centres represent arrangements
cavity are choked with infectious bacteria and inflammatory
+
which unite the activities of the central internal sense organs
products in purulent peritonitis, and that thus the efficiency
+
and build them up to higher units. Sensory impressions of  
of the peritoneum would be greatly impaired. Our observations clinically seemed hardly to bear this out.  
+
different qualities, visual, auditory, tactile, olfactory and gustatory, are united, or at any rate the anatomical mechanism is
 +
afforded for their union. The association centres have an
 +
entirely different microscopic structure from that to be made
 +
out in the sense centres, a topic into which, however, I cannot now enter.  
  
The question that suggested itself to our mind was this,  
+
Flechsig believes, therefore, that these association centres
whether or not the peritoneum, even under these most unfavorable conditions, still retained its absorptive power. It
+
are the portions of the cerebral cortex which above all others
seemed to us, from our experience in operating upon such  
+
are concerned in the higher intellectual manifestations, in
cases by the methods heretofore employed, that they were
+
memory, judgment and reflection. If his theory be right, the
inadequate and did not remove a sufficient quantity of the  
+
study of the association centres should be the especial object
exudate, but left the peritoneum little better off than before.  
+
of research for the neurologist and jisychologist. That they
With this idea in mind we devised a plan of treatment which,
+
really are of definite importance for the intellectual activities
so far as we know, has not been employed elsewhere.  
+
has been shown by these anatomical studies, which might of
 +
themselves be deemed conclusive. But it must be conceded
 +
that clinical experience has also afforded a large mass of evidence in favor of the view. In certain of the diseases of the
 +
mind marked disorganization of the association centres has
 +
been noted, the microscope permitting the recognition in them
 +
of the destruction of many cells and fibres. In such cases,
 +
during life, iustead of a connected train of thought, the mental
 +
processes may be confused and tangled. New mental pictures
 +
entirely foreign to the normal intelligence may appear, the
 +
capacity for using past experiences may be lost and the knowledge of the results of certain acts be gone. It is in the study
 +
of general paresis that the most convincing clinical proof of
 +
Fiechsig's doctrine of association centres is to be found, and  
 +
from a consideration of the varying symptomatology of this
 +
disease, taken together with the pathological lesions which have
 +
been proven to exist in such cases, some clues have already
 +
been gained towards the explanation of differences in function
 +
in the different parts of the association areas in the cortex.  
 +
Flechsig in the first edition of his "Gehirn und Seele" stated
 +
that the anatomically demonstrable alterations of the brainsubstance in general paresis were often limited to the intellectual domains. He refers in the second edition particularly
 +
to the monograph of Tuczek upon dementia paralytica published in 1884, and recommends strongly the study of this  
 +
paper in connection with his own classification of the different
 +
regions of the cortex.  
  
The steps of the operation are as follows : Make a sufficiently long incision to admit of easy access to all parts of
+
It seems likely from Fiechsig's studies of the brain lesions
the peritoneal cavity. Quickly withdraw the coils of small
+
in general paresis, that this disease more than any other will
intestine from the peritoneal cavity, beginning with the
+
afford the key for the deduction of psychic disturbances from
worst coils first. Remove all, or as much as is necessary of  
 
the small intestine and place it outside the abdomen, covered
 
with warm gauze or towels, thus practically disemboweling
 
the patient for the time being Then thoroughly and systematically wipe out the peritoneal cavity with large pledgets of  
 
gauze wrung out of hot salt solution, paying particular attention to the pelvic portion. In some cases it may be well in
 
addition to flush out the cavity with warm salt solution, but
 
this is rarely necessary.
 
  
  
  
* Read before the Medical and Chiriirgical Faculty of the State
+
12
of Maryland at its Annual Meeting in Baltimore, April 27, 1897.
 
tBuUetin of the Johns Hopkins Hospital, April, 1897.
 
  
  
  
Next the small intestine should be systematically examined
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
loop by loop while still outside the abdomen, and rendered
 
macroscopically clean by wiping with gauze comjiresses wrung
 
out of hot salt solution. It is necessary to wipe with considerable force at times, in order to remove adherent flakes of
 
partly organized lymph. It should be done thoroughly and
 
conscientiously, however, as upon this depends, we believe, in
 
great measure, the success of the operation. It facilitates the
 
cleansing process, as well as lessens the shock of the operation,
 
if the wiping of the intestinal coils is carried on under a constant irrigation of warm salt solution.  
 
  
After being cleansed macroscopically of all foreign material,
 
pus, feces, lymph, etc., the intestine should be replaced in the
 
abdomen — the worst or sutured coil being the last, or most
 
superficial, in order that it may be the better drained by being
 
packed about with gauze, if necessary.
 
  
The abdominal wound is then tightly closed, leaving just
 
room enough between two sutures for the gauze drain. If there
 
are any evidences of distension or pain the abdomen should
 
have the Paquelin cautery thoroughly applied, and the bowels
 
moved early by calomel in broken doses, followed by salts and
 
a turpentine enema.
 
  
It is not claimed for this method that it will cure every
+
pfo. 70.  
case of general suppurative peritonitis. We believe, however,
 
that a larger percentage of cases will recover after this method
 
than any other with which we are familiar.  
 
  
To insure success with any method it is essential that the
 
operation should be performed within a few hours after the
 
perforation has taken place. This is well brought out in the
 
very interesting series of experiments on dogs made for me by
 
Messrs. Elting and Calvert of the Johns Ilojikins Medical
 
School, a report of which is subjoined.
 
  
Five cases have been operated upon by this method up to
 
date, all of which have recovered. The first case, a case of
 
perforating typhoid ulcer, has already been published,* and
 
hence only a very brief abstract of the history will be given
 
here.
 
  
Case I. — Male, aged 47, on about eighth day of mild
+
alterations in the cerebral substance. In cases of the disease
attack of typhoid developed symptoms of perforation. Entered
+
in which the lesions are widely diffused over very many different areas of the cortex, no reliable conclusions can be drawn
hosijital 14 hours later and was operated upon immediately.
+
regarding the significance of the association centres ; but occasionally the disappearance of nerve fibres is limited almost
Peritoneum everywhere intensely congested, roughened and  
+
entirely to the association centres, and in some instances
dull, and covered with flakes of plastic lymph. Considerable
+
especially favorable for the study of function, the frontal association centre alone or the large posterior parietal association
amount of turbid purulent fluid in abdominal cavity. Perforation in ileum about 14 inches from ileo-c;ecal valve.  
+
centre alone is chiefly diseased.
Fecal matter exuding from opening. Peritoneum cleansed in  
+
 
the manner described, gauze drainage. Recovery.  
+
The study of such lesions and of the symptoms manifested
 +
by the patients during life, has not yet gone far enough to
 +
justify many positive assertions regarding the specific function
 +
of the different association centres; but enough has been done
 +
to warrant the consideration of certain statements which possess some degree of probability. Thus, where there has been
 +
bilateral disease of the frontal lobes, that is, of the anterior
 +
association centre, there has been observed in the individual
 +
during life an alteration or loss of ideas regarding his own
 +
personality and his relations to what is taking place inside
 +
and outside his body — symptoms which are quite in accord
 +
with those observed in higher apes by Bianchi after extirpation of the frontal lobes. The phenomena vary of course
 +
according to the irritative or destructive nature of the lesion.  
 +
The individual may in his mind connect his personality with
 +
mental pictures which have in reality nothing to do with
 +
himself; thus he may think himself of enormous dignity, or
 +
that he is possessed of great wealth or that he is a genius. In
 +
other cases he fails to connect his own person in any way by
 +
means of association with external perceptions, so that he
 +
may forget himself or may fail altogether to observe his surroundings. Still in possession of numerous ideas, he may
 +
speak in an orderly fashion, although he appears unable to
 +
distinguish the true from the false and the imagined from  
 +
the experienced. Besides these logical defects he may show
 +
a diminution of his capacity for ethical and esthetic judgment, so that he will perform acts entirely irreconcilable with
 +
his character as manifested earlier in his life. Even in the
 +
absence of emotion he may appear to be devoid of his normal
 +
self-command; but when subjected to unaccustomed stimuli,
 +
especially to sexual excitement, anger or vexation, he may
 +
lose all control of his movements and acts, so that some simple
 +
influence may lead him to try to satisfy his desires without
 +
any regard to custom or good taste. In late stages of the
 +
disease imbecility may appear, with entire loss of the mental
 +
pictures regarding his personality.  
 +
 
 +
The mental phenomena displayed in connection with disease
 +
of the posterior parietal association centres appear to stand in
 +
marked contrast to those just outlined. They have been
 +
studied in cases of general jjaresis, but better opportunities for
 +
the observation of such phenomena are often afforded where
 +
there has been focal softening of the cortex due to vascular
 +
disease. Here the individual may be incapable of naming
 +
correctly objects outside his body which he can touch and
 +
see ; and if this centre on both sides be widely diseased, he
 +
may not recognize at all the nature of these objects, so that he
 +
loses the power of forming intelligent conceptions of the
 +
external world. On the contrary, he may be entirely clear as
 +
regards his own personality; he may appear to possess his
 +
 
 +
 
  
Case II. — G. W., male, aged 20. Saw patient for the lirst
+
self-control, and may show deep perversity of feeling or of the
time, November 24, 1896, in consultation with Dr. Barringer
+
will, the specific character of the disease-picture consisting in
in Charlottesville, Va. Patient gave history of four previous
+
his inability to recognize external objects, that is, to associate
mild attacks of appendicitis, from which he liad promptly
+
external sensory impressions with the memories of those of
 +
his previous experiences. On this account he may use external objects falsely ; he may confuse persons ; he has no certain
 +
ideas as regards space and time. His mental conceptions of  
 +
the external world, the knowledge of these which he can put
 +
into words, and the power of interpretation of external impressions as the result of experience, are lost to him. He is in
 +
severe cases almost bankrupt in ideas, although his regard for
 +
himself and for those who are dear to him may be unaffected.
  
 +
If one of the sense areas of the cortex alone be diseased, the
 +
clinical picture is entirely different from that presented by
 +
these purely intellectual disturbances. Here again we may
 +
have to do either with phenomena of absence or phenomena of irritation. A tumor pressing upon the auditory area may give rise to noises and other subjective perceptions of sound. Pressure upon the posterior central gyrus
 +
may lead the individual to believe that he experiences movements of his thumb, although his eyes convince him that it
 +
remains station.'fl-y. Again, a tumor pressing upon the uncinate gyrus has been known to give rise to subjective odors;
 +
while a cysticercus cyst pressing upon the visual area of the
 +
occipital lobe has caused the arrival into consciousness of
 +
mental pictures of colored figures and the like. Destructive
 +
lesions of the sense centres may prevent the external sense
 +
impressions from entering into consciousness at all. There
 +
may be entire absence of mental confusion in such instances;
 +
the patient recognizes the subjective character of the
 +
hallucinations, and so is not actually mentally diseased in the
 +
ordinary sense, but if focal disease affect along with one sense
 +
centre several of the others, or the posterior large association centre, the picture of hallucinatory confusion is prominent.
  
 +
Time will not permit me to discuss the so-called functional
 +
disturbances ascribable to conditions of exhaustion of different cortical areas dependent upon prolonged and violent
 +
emotion, various intoxications, impoverishment of the blood,
 +
and other causes. Suffice it to say that, on theoretical grounds
 +
at least, more or less sharp criteria can be mentioned for the
 +
participation in the process of the different centres, especially
 +
the somresthetic area, the frontal lobes and the posterior large
 +
association centres. In many instances, however, the phenomena presented show, what we a priori might expect, that
 +
several of the sense areas and association centres are diseased
 +
at once. The various permutations and combinations possible will doubtless account for the manifold symptomatology
 +
of the great group of nervous and mental diseases, a symptomatology which as yet is in almost hopeless confusion and
 +
which calls urgently for an ordering hand. It will be the
 +
task of psychology and neurology in the future to analyse
 +
the specific activities of the various regions of the cortex, and
 +
to correlate these with the mental phenomena of human beings
 +
in health and disease.
  
*AnnalB of Surgery, March, 1897
+
Flechsig's researches have established the fact that the
 +
human cerebral cortex is made up of at least seven anatomically more or less well separated areas. As the phrenologists
  
  
  
142
+
January, 1897.]
  
  
Line 1,250: Line 1,642:
  
  
[No. 76.  
+
13
 +
 
 +
 
 +
 
 +
thought, the brain is the organ of the mind, and the whole
 +
is in reality made up of multiple organs. But instead of calling
 +
these, as did the old phrenology, after certain qualities, friendship, good-nature, wit, firmness, and the like, thanks to
 +
Flechsig's studies we can now adopt a more rational nomenclature. We can now speak of sense centres and of association centres in the cerebral cortex. The sense centres may
 +
be roughly grouped as the somssthetic area, the visual sense
 +
area, the olfactory sense area and the auditory sense area ; the
 +
association centres for the present have to be designated
 +
according to their position as frontal or anterior, insular or
 +
middle, and parieto-occipital or posterior. Thus a distinct
 +
advance has already been made, and it is hardly too much to
 +
expect that further study will permit of much more complete
 +
differentiation and more definite localization of both kinds of
 +
areas.
 +
 
 +
It is not stating too much to affirm that advances in true
 +
psychology are to be mainly hoped for from strictly scientific
 +
investigations into the structure and function of the nervous
 +
system. Pure philosophical psychology has advanced but
 +
little beyond the concepts of Aristotle and the other ancients,
 +
and as Flechsig says, " Medicine at all periods has been nearer
 +
the ideas believed in to-day mainly on account of the fact that
 +
the physician has had ever before him as the special object of
 +
his observations the human individual, presenting healthy or
 +
diseased conditions, in life and in death."
 +
 
 +
It would take too long to give even a brief resume at this
 +
time of the insight into psychological processes which are
 +
afforded by Flechsig's work. His recent publications speak
 +
for themselves, and his treatment of the subject cannot fail
 +
to prove interesting to the reader. Doubtless many of the
 +
theories which he has advanced as a result of his anatomical
 +
studies will not stand the test of time. But we owe to him a
 +
deep debt of gratitude for supplying us with a large mass of
 +
entirely new knowledge, from which further investigations
 +
may start.* The relative 2'ositions of the individual sense
 +
centres to the association centres are, as can be seen from the
 +
diagram, very peculiar. The posterior association centre is
 +
situated among the visual, auditory and somajsthetic areas of
 +
the cortex; while the anterior association centre is related, in
 +
gross at least, only to the somajsthetic area and to the olfactory
 +
sense area. The middle association centre has adjacent to it
 +
the auditory, olfactory and somaesthetic areas. When one
 +
remembers that the association centres receive bands of fibres
 +
which run into them from the adjacent sense areas, the remarks
 +
made before concerning the specific functions of the different
 +
association centres will perhaps be more easily appreciated.
 +
 
 +
Flechsig in his " Kectoratsrede," as well as in his later
 +
 
 +
 
 +
 
 +
* We should be particularly grateful for the deflnitiveness of the
 +
concepts of brain structure which Flechsig has afforded us. In
 +
this embryological self-analysis of the cerebral tracts, the bands of
 +
medullated libres, stained by the method of Weigert, stand out as
 +
clear-cut on the yellow background of non-medullated nervous
 +
tissue as the lines of a diagram. The illustrations of sections in
 +
Flechsig's book are by no means fanciful. In his regular lectures
 +
during the spring semester of 1895, Flechsig showed us a large
 +
number of his preparations which bear out fully his anatomical
 +
statements and illustrations.  
  
  
  
recovered. The night before he had eaten very heartily of  
+
address upon the " Border-lands of mental health and disease,"
apples. He was awakened about 3 a. m. with severe abdominal pain, cramp-like in character. At about 6 a. m. Dr.
+
has laid especial emphasis upon the significance of the somajsthetic area. Assuming it to be the portion of the cerebral
Barringer was called. He stated that at this time, three
+
cortex where impressions regarding the body enter into consciousness, the centre which appears to have to do with the
hours after the beginning of the attack, the patient presented
+
bodily emotions and bodily needs, and upon the excitability
the classical symptoms of peritonitis. When I saw him, 24
+
of which the crudity or delicacy of the instincts which enter
hours later, he had a temperature of 103° and a pulse of over
+
into consciousness depends, as well as the centre whence start
100, and from the first had suffered intense pain, which was
+
nearly all motor impulses which are concerned in conduct, be
controlled only by morphia hypodermically. He had had
+
they those leading to the closure of the fist, the pressure of the
nausea and vomiting all day. Examination of the abdomen
+
hand, or the most delicate embrace, Flechsig believes that this
showed slight distension and great rigidity of the abdominal
+
somsesthetic area is to be looked upon as the main organ of
muscles. A slight tumefaction could be made out just to the  
+
character. This cortical area, connected as it is on the one
inner side of the anterior superior spine of the ilium on the
+
side directly with the peripheral sensory and motor apparatus
right side. Tenderness very marked. Immediate operation
+
of the body, and on the other with the higher association
advised and agreed to. Incision 5 inches long in right linea
+
centres in the cortex, stands, as it were, like a buffer intercalated between the organs of the body and the organs of the  
semilunaris. On opening the peritoneal cavity the intestinal
+
intellect. The character of the activities manifested by these
coils in the right lower quadrant of the abdomen were found
+
complex cortical centres of which the somfesthetic area is
to be congested and dull and covered with flakes of adherent
+
made up, may thus be influenced from either of the two sides.
lymph. Elsewhere the intestinal coils were found to be
+
As Flechsig says, it represents a sort of arena in which, at
congested, but not otherwise much changed in appearance.  
+
least in the more nobly endowed natures, the lower inpnlses
The pus, of which there was perhaps 200 cc, was not walled
+
struggle for the mastery with the higher feelings and ideas.
off, but everywhere present in pockets between the adherent intestinal coils. The appendix was readily found. It was closely
+
To follow this struggle between the reciprocal influences of the  
adherent to the pelvic brim on the one side and the csecum
+
body and the intellect will form one of the most stimulating
on the other. Its distal end was swollen and distended to the  
+
problems of brain investigation, especially when it is remembered that the subject is of eminently practical significance.  
size of my thumb, perforated and gangrenous over an area
+
In the investigation of the brain it will be necessary to study
about as large as a five-cent piece. Appendix was ligated and  
+
the conditions which lead to an ennobling of the sensual
excised, and stump covered with peritoneal cuff and suture.
+
instincts, whether it come immediately through bodily influences or from the other side through the intellect. Since,  
The peritoneum was treated in the manner above described.
+
further, in these studies the presumptive existence of an
Recovery.  
+
ennobling of the intellect through refinement of the sensual instincts must be kept in view, the new brain anatomy
 +
and physiology is brought into contact with the fundamental
 +
problems of all scientific pedagogy and the aims of all true
 +
culture. The old a priori ideas concerning the antitheses of
 +
sensuality and reason, and of the " heart " and the " brain,"
 +
would seem to find some actual confirmation in recent anatomical discoveries.  
  
Case III. — This patient was seen first on December 14,  
+
Furthermore, Flechsig sees in these newer studies the essential preparation for a physiological basis of ethics, so much
1896. His history is in brief as follows : R. S., male, aged
+
desired by some of the writers of the last century. Inasmuch
33 years. Has had no previoiis similar attack. The night
+
as the health of the cerebrum is essential for the control of
before he was taken sick he attended a banquet and ate
+
the lower centres concerned with the instincts and emotions,
heartily of solid indigestible food. He was attacked with
+
as is proven by the cessation of the struggle between the instincts and the ethical feelings where the intellectual centres are
severe abdominal pain about 3 o'clock the next afternoon.
+
paralyzed, and inasmuch as we now know some of the causes
The pain at first was general and cramp-like ; nausea and
+
of the diseases of the sense centres and of the association centres,  
light vomiting during the night. Morphia was necessary to
+
and are convinced that many of these causes are removable or
relieve him. The next day he was unable to get up. Toward evening his physician gave him a cathartic, after which
+
avoidable, the etliical significance of these studies becomes
the bowels moved 8 or 10 times in quick succession. The next
+
manifest.  
morning the pain had shifted to the right side and was severe.
 
He received a hypodermic of morphia and got on fairly well
 
until about 6 p. m., about 60 hours after the onset of the  
 
attack, when he was taken with a sudden severe pain in the  
 
lower right side of the abdomen. The pain for a time was
 
excruciating at the base of the penis. Vesical and rectal
 
tenesmus marked. When I saw him, about 4 hours later, in
 
consultation with Dr. Reiche, he had a temperature of 105°
 
and pulse of 150, profoundly collapsed. I have never seen
 
such a hard and retracted abdomen as he presented. His
 
condition appeared grave. Immediate operation advised and
 
consented to.  
 
  
Incision about 5 inches long, in right linea semilunaris.  
+
It must be the aim of educators to enlighten the people concerning the hygiene of the body and especially of the brain.  
On opening abdomen the intestinal coils were fol^nd not to be
+
We must not fear to teach the intimate interdependence of
distended but considerably congested. Beginning in the  
+
bodily conditions and mental phenomena, or hesitate to let the  
right lower quadrant there was found a considerable amount
+
masses know that the abuse of alcohol, the over-indulgence of
of thin pus containing flakes of lymph. This condition
+
the passions, and mental and physical excesses of all descrip
  
  
 +
14
  
extended over into the left side, down into the pelvis and up
 
into the hypogastric region. The appendix was found to be
 
gangrenous and perforated, and was removed. The toilet of
 
the peritoneum was made in the manner already described, by
 
disemboweling and vigorously scrubbing the parietal and
 
visceral peritoneum until macroscopically clean. The intestinal coils were then replaced, a gauze drain inserted, and the
 
abdominal wound closed except a small opening for the drain.
 
He made an uninterrupted recovery.
 
  
Case IV. — M. B., boy, aged 10. Operation by Dr. J. C. Bloodgood, January 7, 1897. Five days before admission to the
 
hospital was struck in the abdomen by the fist of a playmate.
 
Next day felt severe pain in the right iliac region. This progressively increased for three days, when vomiting began and
 
the pain became general. Two days later was brought to the
 
hospital, when his condition was found to be in brief as
 
follows: Temperature 101°, pulse 128 and fairly good.
 
Slight abdominal distension. Muscular spasm marked on
 
right side, present but less marked on the left. General
 
abdominal tenderness. Under ether a definite tumefaction
 
could be made out in the region of the right kidney. This
 
proved to be an abscess behind the cjecum, extending from the
 
iliac fossa below to the liver above, and in this cavity was the
 
diseased appendix. There was foiind no walling off of this
 
from the general peritoneal cavity. The entire pelvis was filled
 
with yellow pus and all the intestinal coils were covered with
 
flakes of fibrin. The stomach and spleen were not seen, but
 
the surface of the liver looked exactly as if it had been covered with yellowish-white paint. The appendix was removed
 
and the entire abdominal cavity thoroughly wiped out with
 
gauze pledgets wrung out of salt solution. The exudate was
 
scrubbed oS the livers surface, after which it looked simply
 
congested. A gauze drain was inserted and the abdominal
 
wound partly closed. He made an uninterrupted recovery.
 
Cultures and cover-slips from the peritoneum showed colon
 
bacillus and a coccus (not differentiated).
 
  
Case V. — R. S. P., aged 9, a schoolboy, entered the Johns
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
Hopkins Hospital, Feb. 26, 1897. He had always been healthy
+
 
except for measles, whooping cough and chicken-pox.
 
  
Family history good except remote cases of tuberculosis on
 
both sides.
 
  
Just 48 hours before entering the hospital first complained
+
[No. 70.  
of pain in abdomen. Three hours later had an attack of
 
vomiting. Pain in abdomen was at first general, but in a few
 
hours became localized in the right iliac and lumbar regions.
 
After about 24 hours the pain lessened somewhat, and he sat
 
up for a little while, but shortly after pain and vomiting
 
returned with increased severity. A physician saw him after
 
about 36 hours and gave him calomel in broken doses. His
 
bowels moved twice. His condition did not improve, and by
 
advice of his physician was brought to the hospital at 8 p. m.,
 
48 hours after the onset of the attack. His condition then
 
was as follows : Face flushed and anxious. Pulse 126 ; temp.
 
102.8°; resp. 56, and entirely thoracic; abdomen generally
 
distended and tender, especially in right iliac fossa, where the
 
tenderness is extreme and muscle spasm very marked. Pain
 
is most marked here also. Liver and spleen not palpable.
 
Liver dullness on right corresponds about to costal border.  
 
  
  
  
July, 1897.]
+
tions, can lead to i-esults of a most serious nature. Only by
 +
increasing knowledge, general and special, can we hope in
 +
coming generations to strengthen and make solid the foundations of the higher ethical feelings. All will agree that for
 +
the advancement of the race we must presuppose a social
 +
arrangement which will subordinate the blind instincts of the
 +
morally and intellectually deficient to the control of the deeper
 +
insight and the better will of an intellectual ethical aristocracy. If it is in the main the remarkable development of his
 +
association centres which has raised man so far above the
 +
level of all other living creatures, it is also by virtue of the
 +
function of these same association centres that man is to be
 +
elevated in the future beyond his present status. Flechsig at
 +
the close of his " Rectoratsrede " makes brief reference to the
 +
aims other than practical of these newer studies. "Just as
 +
by means of one of the noblest faculties of our natures, namely,
 +
the thirst for knowledge, an instinct conferred upon human
 +
beings with the development of their association centres, we
 +
are forced to study the natural laws involved even in the
 +
domain of the mind, so the actual advances of our knowledge,
 +
even in this field of investigation, lead with the forcible necessity of a natural law to an ideal philosophy. The more the
 +
enormous potencies embodied in an intelligent individual
 +
become unveiled to our questioning reason, the more clearly
 +
must we feel that behind the world of phenomena there are
 +
controlling forces with which human knowledge scarcely
 +
dare lay claim to be compared."
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
NOTES ON NEW BOOKS.  
  
 +
Practical Points in Nursing, for Nurses in Private Practice, with an
 +
Appendix. By Emily A. M. Stoney, Superintendent of Training
 +
School for Nurses, Carney Hospital, Boston. Illustrated with 73
 +
engravings and 9 colored and half-tone plates. {Philadelphia:
 +
W. B. Saunders, 1896.)
  
 +
This little book is primarily designed for the instruction of
 +
private nurses, and as such it will undoubtedly serve a useful purpose. It is to be regretted, however, that it is also intended to be
 +
used for the instruction of classes, and for the home nurse, for
 +
which purposes it seems very inadequate. It may help those who
 +
are already instructed and who require a book of reference, but it
 +
presupposes a degree of previous knowledge on the part of the
 +
student which pupil nurses and home nurses do not possess.
  
143
+
The chapters on physiology and descriptive anatomy are of the
 +
most elementary character and are couched in such terms as to
 +
convey no adequate idea of the subjects treated. Witness the
 +
following: "The parotid gland is situated below and toward the
 +
front of the ear. It secretes saliva, and it is inflammation of this
 +
gland that causes mumps." — or " The skull is a box of bone containing
 +
the brain, which is a soft pulpy substance, and is the chief organ of
 +
the nervous system." Coulil tlie modicum of technical knowledge
 +
be made any smaller? The book ought to be very popular fur the
 +
instruction of nurses among those who are apprehensive of the
 +
over-education of nurses and are fearful that they will make thirdclass physicians.
  
 +
The definitions are very imperfect and are evidently written by
 +
one who is not accustomed to use language accurately. "A lotion
 +
is a medicinal application, and may be evaporating or non-evaporating." " Worms, which are of three kinds — tapeworm, tliread
 +
worms and round worms — are caused by impure drinking water and
 +
food, and also bi/ feeding food that is not properly cooked." "Oph
  
  
Percussion over right iliac and lumbar regions shows dullness; tympanitic over left side. Heart normal. Fine moist
+
thalmia neonatorum is inflammation of the conjunctiva, which is
rales over bases of both lungs. No history of any similar
+
one of the coats of the eyeball. Its causes are numerous, but in
previous attack.  
+
the newborn it is generally caused by infection during birth from
 +
the urethral or vaginal discharges of the mother."
  
Diagnosis. — Perforating appendicitis with beginning general
+
The chapter in which directions are given to nurses as to their
peritonitis. Immediate laparotomy advised and agreed to.  
+
conduct is clearly and judiciously written. Some nurses would
Ether. When thoroughly auassthetized, a small, hard mass,
+
doubtless take exceptions to the author's declaration that " it is
somewhat movable, could be felt just over the middle of
+
not degrading to the nurse to assist in tlie kitchen when emergencies arise ; it shows the true spirit of a nurse, and the kindness
Poupart's ligament. An incision about 15 cm. long was made
+
is not lost." Tlie chapters also on the Sick Room, of the Patient,  
parallel to and over the right linea semilunaris. After exposing the peritoneum and before opening it several bubbles of
+
and Accidents and Emergencies, are to be commended. The  
gas could be seen free in the peritoneal cavity. On opening
+
book is well printed and illustrated, and has a good index.  
the peritoneum a considerable amount of thin, cloudy seropuruleut fluid escaped and some gas. The mass felt before
 
was found to be the appendix with a roll of omentum adherent. The intestines, especially the CEecum, were distended
 
and congested, and covered with flakes of fresh fibrinous
 
exudate. The congestion was most marked in the immediate
 
vicinity of the appendix.  
 
  
The appendix itself was superficially placed and freely
+
Practical Notes on Urinary Analysis. By W. B. Caxfield, M. D.  
movable, not walled off, but had a portion of omentum adherent. It was rather long, and curled upon itself, with a
 
constriction at about the junction of its proximal and middle
 
thirds. It contained two concretions, the larger of which
 
was engaged tightly in the constriction, and from this point
 
to the tip the appendix was gangrenous and softened. A
 
  
 +
{Published by Oeorge 8. Davis, Detroit, 1896.3
  
 +
The second edition of this little work has recently appeared as one
 +
of the numbers of The Physician's Leisure Library. It is essentially
 +
practical, as most of the tests given are such as can be used at the
 +
bedside by the general practitioner. Although the subject is treated
 +
as briefly as possible, yet we think that if practitioners were fully conversant with the various tests described, and with the precautions to
 +
be observed in performing them, many errors in diagnosis would
 +
be prevented and much valuable assistance in the treatment of
 +
diseases affordeil. Many of the higher organic compounds found
 +
normally in the urine are, however, not even mentioned. In fact,
 +
no constituents of the urine, normal or abnormal, are treated of
 +
that cannot be tested for with the simplest apparatus and reagents.
 +
Thus, the use of the polariscope in diabetes and the influence of
 +
diabetic urine on polarized liglit, one of the most reliable tests, is
 +
entirely overlooked. Such statements as ''the diagnosis of typhoid
 +
fever is now made almost certain by the diazo-reaction of Ehrlich" should certainly be qualified, as it is well known that
 +
this reaction is very frequently obtained in tuberculosis and
 +
not infrequently in other febrile conditions : the test is merely
 +
an aid to diagnosis. One can hardly see how the practitioner
 +
is to be aided in recognizing leucin and tyrosin in the urine, by
 +
the author's statement that "leucin and tyrosin are found in the
 +
urine in certain abnormal conditions of the liver. They are
 +
easily recognized in the sediment, or may be found on evaporating the urine." It is only justice to say that a diagram of the
 +
leucin spherules and tyrosin crystals is given in the plate of urinary
 +
sediments, from which alone it would be unsafe to make a diagnosis, however. While the author's book serves a useful purpose, no general practitioner should be without a larger work on
 +
urinary analysis, for purposes of reference.
  
small perforation was present at the distal end of the dateseed like concretion. 'I'here had been an apparent attempt of  
+
Diseases of the Eye. A [Hand-book of Ophthalmic Practice for
the omentum to surround the entire gangrenous end of the
+
Students and Practitioners. By G. E. deSchweinitz, A. M., M. D.,
ajjpendix, but it had not quite succeeded. The appendix
+
Professor of Ophthalmology in Jefferson Medical College, etc.
together with the adherent omentum was ligated and excised.  
+
With 256 illustrations and 2 chromo-lithographic plates. Second
 +
edition, thoroughly revised. {Philadelphia : W. B. Saunders,
 +
1896.)
  
Pelvis was found to be full of pus, and the peritoneum
+
This admirable textbook of ophthalmology is so well and so
treated as above. He made a rapid and complete recovery.  
+
favorably known, and so short a time has elapsed since the appearance of the first edition (1892), that an extended notice seems
 +
scarcely called for at this time. In the preface to the present
 +
eilition the author states that the entire book has been thoroughly
 +
revised, and that in addition to this general revision, new paragraphs have been addeii upon Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the
 +
Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea
 +
in Infancy, Hyaline Bodies (Drusen) in the Papilla, Jlonocular
 +
Diplopia, Subconjunctival Injection of Germicides, InfiltrationAnaisthesia, and Sterilization of CoUyria.  
  
Bacteriological examination of the peritoneal exudate showed
+
For the bibliography of tlie first edition an appendix containing
the presence of streptococcus, staphylococcus, and bacillus coli
+
a description of the method of using the ophthalmometer of Javal
communis.  
+
& Schiotz and the tropometer of Stevens has been substituted. The
  
NoTK. — Since reading the above article, I have operated
 
upon one additional case of general peritonitis. The patient,
 
a young woman, was in extremis at the time of the operation,
 
which was undertaken simply as a forlorn hope. This operation was secondary to one performed several days previously
 
by another surgeon for appendicular abscess. There was
 
found present a general peritonitis, with much jjlastic lymph
 
covering the greatly distended and adherent coils of intestine.
 
There was very little purulent fluid in the abdomen. Her
 
pulse was very rapiil and thready, and her temperature had
 
risen several degrees. After the operation she was placed in
 
a continuous bath, which added greatly to her comfort. The
 
operation seemed to prolong her life, as she lived about thirtysix hours following it.
 
  
  
 +
January, 1897.]
  
AN EXPERIMENTAL STUDY OF THE TREATxMENT OF PERFORATIVE
 
  
A NEW METHOD OF OPERATION.
 
  
By Arthur W. Elting and William J. Calvert.  
+
JOHNS HOPKINS HOSPITA.L BULLETIN.  
  
  
  
'ERITONITIS IN DO(iS BY
+
15
  
  
  
[From the Anatomical Laboratory of the John) Hopkins University.']
+
chapter on operations has been enlarged and rewritten, and those
 +
on General Optical Principles and on Abnormal Refraction, which
 +
were contributed to the first edition by Dr. James Wallace, have
 +
been revised by Dr. Edward Jackson, who has also recast the  
 +
section written by himself upon Eetinoscopy.  
  
 +
Dr. Jackson's revision of these chapters has evidently been carefully done, and we note a number of instances, as, for example, in
 +
the definition of emmetropia and of ametropia (p. 140), and in the
 +
description of the refraction of light by an astigmatic eye (p. 163),
 +
in which it has resulted in the elimination of errors, some of
 +
which had previously arrested our attention in the perusal of the
 +
first edition. It is perhaps not to be wondered at that he has not,
 +
in every instance, succeeded in noting and correcting these faults.
 +
The description of the "seat of astigmatism" on p. 161, which,
 +
in the new edition as in the old, seems to warrant the inference
 +
that lenticular astigmatism is due always to an oblique position of the
 +
lens, it would appear, might easily have been improved upon. So,
 +
too, as to the description given of the well-known illustration (p.
 +
163) of the refraction of a pencil of light in regular astigmatism. It
 +
is certainly not correct to speak of the different sections of the pencil there shown, as representing the "retinal images of a point"
 +
in compound hypermetropic astigmatism, simple hypermetropic
 +
astigmatism, mixed astigmatism, etc., unless absence of accommodative power in the eye be presupposed.
  
 +
The author tells us in his preface that the book has been enriched
 +
with forty additional illustrations, but he does nottell us how much
 +
more effective many of the illustrations have been made by the substitution of well-executed photo-engravings for the woodcuts of the
 +
first edition. The illustrations of congenital ptosis and of epicanthus and congenital ptosis on p. 200, and of rodentulcerof theorbit
 +
(p. 203), are striking examples of the effectiveness of this method
 +
of representation. Having said this much in praise of the illustrations, perhaps we shall be pardoned for finding fault with the
 +
legend descriptive of Fig. 90, on p. 254 — " lipomatous dermoid of
 +
the conjunctiva."
  
At the suggestion of Dr. Finney and with the permission of
+
The publisher has performed his part of the work ip a manner
Prof. Mall, the writers have undertaken an experimental study
+
worthy of especial commendation. S. T.  
of perforative peritonitis in dogs, with especial reference to
 
the method of treatment of this disease in human beings,
 
introduced by Dr. Finney. Inasmuch as this is a preliminary
 
report, the literature upon the subject will not be considered.
 
It may be mentioned, however, that so- far as we know no previous work of this nature has been done from a surgical
 
standpoint. It was decided to divide the series of experiments
 
into four groups :
 
  
1. To scrub the intestines of a series of normal dogs and  
+
A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D.
study the condition of the abdominal cavity at varying lengths
+
With 163 illustrations in the text and 6 full-page plates. (Philadelphia: W. B. Saunders, 1896.)
of time after the operation, in order to determine the results of
+
 
the mechanical irritation.  
+
This well-printed and fully illustrated volume seems a happy
 +
mean between the more ambitious and encyclopedic works upon
 +
obstetrics and the quiz-compends, and is clearly and systematically
 +
arranged for the use of students. Although lacking the details and
 +
references of larger works, it is clearly and carefully written and
 +
will be a safe guide. There is really little to criticise.
 +
 
 +
The directions given for the disinfection of the accoucheur and
 +
of the patient are admirable and explicit. The recommendation to
 +
use a creolin douche after the expulsion of the placenta, as a matter
 +
of routine, cannot be endorsed, because it would do harm rather
 +
than good in the majority of cases. Vaginal douches should notbe
 +
given after the second stage of labor, unless they are clearly and
 +
definitely indicated. The employment of a pad above the fundus
 +
uteri and the use of am abdominal binder tightened daily for six
 +
weeks or three months are recommendations which do not seem
 +
free from danger.
 +
 
 +
Water and Water Supplies. By John C. Thrush, Medical OflBcer of
 +
 
 +
Health to the Essex Co. Council, etc. (London : The Rebman
 +
 
 +
Publiahing Co., L'i'd. Philadelphia : W. B. Saunders, 1896.)
 +
 
 +
This excellent little book can be commended unreservedly as
 +
 
 +
probably the best short treatise on Water and Water Supplies in the  
 +
 
 +
English language. The information contained in it is concise and
  
2. To determine how long it takes a perforative peritonitis
+
the whole book is thoroughly modern. It is gratifying to observe
to destroy life.
 
  
3. To perforate the intestines of a series of dogs, and after
+
that the author shares the opinion of Koch that the best of all
varying lengths of time to operate upon them again, closing
 
in the perforation and cleansing the abdominal cavity and the
 
surface of the intestine and mesentery, and after variable
 
periods of time to kill the dogs which recovered, and study the
 
condition of the abdominal cavity.
 
  
  
  
1. To perforate the intestines of a series of dogs, and after
+
water supplies for a city is that obtained from deep wells. The
varying lengths of time to close in these perforations without
+
sourcesof water pollution are clearly described and well illustrated.  
removing from the abdominal cavity any of the exudate or
+
We are pleased to see that careful directions are given for the  
foreign matter present, and to study the results of this operaation.  
+
filtration of water, and the dangers which lurk in improper filtration are distinctly stated. If the book could be in the hands of  
 +
every householder, the preventable causes of water-borne disease
 +
would unquestionably be mucli better understood. The book is
 +
well printed and sensibly illustrated, and deserves a large sale.  
  
The dogs used in these experiments varied in weight
 
between 18 and 53 pounds, most of them weighing about 25
 
pounds.
 
  
For the first group of experiments four dogs were used. By
 
a median incision the abdomiiuxl cavity was opened, the intestine and parietal peritoneum were vigorously scrubbed with
 
gauze sponges wrung out in warm normal salt solution, and
 
kept covered with warm towels. After this treatment numerous minute hemorrhages caused by the scrubbing were noticed
 
over the peritoneal surfaces, and the intestine presented an
 
extremely congested appearance. It was then thoroughly irrigated with warm normal salt solution, which had a marked
 
effect in reducing the congestion. The intestine was then
 
replaced in the abdominal cavity and the wound closed. The
 
process of scrubbing as performed by the operator and an
 
assistant required from 8 to 12 minutes. In every case the
 
dog appeared ill for about 24 hours after the operation, after
 
  
 +
BOOKS RECEIVED,
  
  
144
 
  
 +
Transactions of the Association of American Physicians. Eleventh
 +
Session held at Washington, D. C, April 30 and May 1 and 2,
 +
1896. Vol. XI. 8vo. 1896. 453 pages. Printed for the Association. Philadelphia.
  
 +
Transactions of the Medical Society of the State of Pennsylvania.
 +
Forty-sixth Annual Session, held at Harrisburg, 1896. Vol.
 +
XXVII. 8vo, 499 pages. Published by the Society. The Edwards & Docker Co., printers, Philadelphia.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
An American Text Book of Applied Therapeutics. For the use of
 +
practitioners and students. Edited by J. C. Wilson, M. D.,
 +
assisted by Augustus A. Eshner, M. D. 1896. 4to, 1326 pages.
 +
W. B. Saunders, Philadelphia.  
  
 +
An American Text-book of Physiology . Edited by William H. Howell,
 +
Ph. D., M. D. 1896. 4to, 1052 pages. W. B. Saunders, Philadelphia.
  
 +
A Te.vt-book of Histology, Descriptive and Practical. For the use of
 +
students. By Arthur Clarkson, M. B., C. M. Edin. 1896. 8vo,
 +
554 pages. W. B. Saunders, Philadelphia.
  
[No. 76.  
+
Diseases of the Eye. A hand-book of ophthalmic practice for students
 +
and practitioners. By G. E. de Schweinitz, A.M., M. D. Second
 +
edition, thoroughly revised. 1896. 8vo, 679 pages. W. B.
 +
Saunders, Philadelphia.  
  
 +
Transactions of the Michigan State Medical Society, for the year 1896.
 +
Vol. XX. 8vo, 834 pages. Published by the Society. Grand
 +
Kapids.
  
 +
A Text-Book of Materia Medica, Therapeutics and Pharmacology. By
 +
George Frank Butler, Ph. G., M.D. 1896. 8vo, 858 pages. W.
  
which a marked improvement in the condition was noticeable.  
+
B. Saunders, Philadelphia.  
Usually by the end of the second day the animal seemed quite
 
well.  
 
  
Of these four dogs one was killed by an accident one day
+
Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America.
after the operation. Autopsy showed a very small amount of  
+
Edited by Thomas L.Stedman, M. D. Vol. VII. Diseasesof the  
blood-tinged serum in the abdominal cavity. The surface of  
+
respiratory organs and blood, and functional sexual disorders.
the intestine and parietal peritoneum presented numerous
+
1896. 8vo, 796 pages. William Wood & Co., New York.  
hemorrhagic areas caused by the scrubbing at the time of
 
operation. The surface of the intestine was roughened,  
 
though not adherent. Cultures from the abdominal cavity
 
were sterile.  
 
  
A second dog was killed at the end of three days. At
+
A Treatise on Appendicitis. By John B. Deaver, M. D. Containing
autopsy no appreciable amount of fluid was found in the
+
32 full-page plates and other illustrations. 8vo. 1896. 168 pages.  
abdominal cavity. Numerous fibrinous adhesions of the coils
+
P. Blakiston, Son & Co., Philadelphia.  
of intestine to each other, to the inner surface of the abdominal wound and to the omentum were found. The surface of
 
the intestine was slightly roughened and presented numerous
 
hemorrhagic areas. Similar areas were also seen upon the
 
mesentery near its attachment to the intestine and upon the
 
parietal peritoneum. These were likewise caused by the
 
scrubbing at the time of operation. Cultures from the abdominal cavity were sterile.  
 
  
A third dog which was in excellent health and condition
+
Index-Catalogue of the Library of the Surgeon-Oeneral's Office, U.S. A.
was autopsied at the end of five weeks. No appreciable
+
Authors and subjects. Second series- Vol. I. A-Azzurri. 1896.  
amount of fluid was found in the abdominal cavity. The
+
4to, 828 pages. Government Printing Office. Wathington.  
appearance of the organs was everywhere normal except for
 
numerous adhesions of coils of the intestine to each other, to
 
the omentum, to the inner surface of the abdominal wound
 
and to the stomach. These adhesions were of a firm character,
 
being apparently composed of fully developed connective
 
tissue. Cultures from the abdominal cavity were sterile. The
 
fourth dog is still alive and will be autopsied later. From
 
this group of experiments we conclude that mere mechanical
 
irritation may cause the formation of extensive adhesions in
 
the abdominal cavity of the dog, but these seem in no way to
 
seriously interfere with the animal's general health.  
 
  
For the second group of experiments four dogs were used.  
+
Transactions of the Texas State Medical Association. 28th annual
Because of its accessibility and the comparative ease with
+
session held at Fort Worth, Texas, April 28th-30tli and May 1st,  
which the perforation could be closed, it was decided to perforate the CEBCum. By the use of a stick of caustic potash a
+
1896. 8vo, 458 pages. Eugene von Boeckmann, printer, Austin,  
perforation IJ cm. in diameter was made in the end of the
+
Texas.  
caBcum, after which it was replaced in the abdominal cavity
 
and the abdominal wound closed. These dogs showed symptoms of a severe peritonitis and died in from 12 to 20 hours
 
from the time the perforation was produced. Autopsy showed
 
practically the same pathological condition in each case. From
 
150 to 250 cc. of a turbid bloody fluid were found in the abdominal cavity. The surface of the intestine presented a
 
marked hemorrhagic condition, both diffuse and petechial in
 
character. The omentum, mesentery and parietal peritoneum
 
presented a similar appearance. Flakes of reddish yellow
 
lymph were deposited over the surface of the viscera, particularly in the region of the liver, diaphragm and lesser omentum.
 
Slight fibrinous adhesions between the coils of intestine were
 
noted. The mucosa of the intestine presented more or less of
 
a hemorrhagic appearance, and in some of the cases bloody
 
contents were found in the lumen of the gut. In short, the
 
pathological condition was one of an intense hemorrhagic
 
  
 +
The British Guiana Medical Annual. Ed. by J. S. Wallbridge and
  
 +
C. W. Daniels. Eighth year of issue. 8vo, 1896. 95 -}- xxxix
 +
pages. Printed by Baldwin & Co., Demerara.
  
peritonitis associated with a more or less extensive hemorrhagic enteritis. The bacteriology of each of these cases was carefully worked out and will be referred to later.  
+
Twenty-seventh An7iual Report of tlie Slate Board of Health of Massachusetts, 1895. 8vo, 807 pages. Wright & Potter Printing Co.,
 +
Boston. 1896.  
  
For the third group of experiments twelve dogs were used.
+
Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A. M., M. D. 2d ed. 1896. 12mo, 199 pages. W. B. Saunders, Philadelphia.  
The method of operation was as follows: An incision was
 
made on the right side just outside the rectus muscle, the
 
cajcum brought out and perforated in the same manner as
 
practiced in the experiments already described. The cajcum
 
was then replaced in the abdominal cavity and the abdominal
 
wound closed. From five to seven hours after the perforation
 
was produced these dogs were again opened by an incision in
 
the median abdominal line. The perforated end of the
 
crecum was brought out and the perforation closed by means
 
of a row of mattress sutures, after the necrotic tissue at the
 
seat of the opening had been resected. The abdominal cavity
 
was then opened, and the intestines being lifted out, were kejit
 
carefully covered with towels wet in warm normal salt solution. With gauze sponges wrung out in this solution the
 
surface of the intestine and mesentery was carefully wiped
 
till it appeared macroscopically clean. The abdominal cavity
 
was next wiped out and rendered macroscopically clean, the
 
intestine in the meantime being frequently irrigated with
 
warm salt solution and kept covered with warm towels. After
 
another thorough irrigation of the intestine with the warm
 
salt solution it was replaced in the abdominal cavity and the
 
wound closed in the usual manner. We cannot emphasize
 
too strongl}', in doing these experiments, the advisability of
 
thorough and constant irrigation of the intestine while it is
 
outside the abdominal cavity, for in every case it seemed to
 
reduce the congestion and in some cases the distension. The
 
cleansing process required from 10 to 20 minutes according
 
to the amount of exudate and foreign matter present.  
 
  
Of these 12 dogs one was operated on at 5 hours after the  
+
Atlas of the Diseases of the Skin. By H. Radcliffe Crocker, M. D.,  
perforation was produced, one at 5J hours, one at 5J hours,  
+
F. R.C. P. Fol. n. d. 2 vols. Young J. Pentland, Edinburgh
one at 6 hours, two at 6J hours, three at 6J hours, one at Gi
+
and London.  
hours, one at 7 hours, and one at 7} hours.  
 
  
In every case the dog showed marked symptoms of peritonitis and evidences of pain. When lying down the legs were
 
drawn toward the abdomen, which was held very tense. Any
 
attemjjt to straighten out the legs seemed to cause great pain.
 
In some cases the dog vomited a somewhat bile-stained fluid.
 
In every case the abdominal cavity at the time of the second
 
operation contained from 100 to 250 cc. of a turbid bloody
 
fluid. The intestine, mesentery and omentum in nine of these
 
cases presented a generalized hemorrhagic condition. In the
 
remaining three cases this condition seemed more confined
 
to the coils of intestine in the region of the ctecum, though all
 
the peritoneal surfaces seemed more injected than normally.
 
In nine of the cases more or less numerous flakes of yellowish
 
red lymjih were found adherent to the gut, mesentery, greater
 
and lesser omentum and other abdominal viscera. In eight
 
of the cases the intestines seemed more or less distended when
 
replaced in the abdominal cavity. Immediately after the
 
cleansing of the surface of the intestine and the abdominal
 
cavity the animals seemed to be much more comfortable, and
 
in the Ciise of every dog which recovered there was a jirogressive improvement in the condition.
 
  
In no instance did a dog which recovered show signs of
 
  
 +
16
  
  
JvhY, 1897.]
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
[No, 70.
  
  
145
 
  
 +
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL
  
  
pain after the cleansing operation was performed, and usually
 
in from two to three days the dog seemed to have recovered
 
completely from the peritonitis, so far as external symptoms
 
would indicate. Of course the abdominal wound made at the
 
second operation was infected, and this in nearly every case
 
failed to heal by first intention, which delayed somewhat the
 
complete recovery of the animal. Of the 12 dogs thus treated
 
three died without any apparent beneficial effect of the operation, death ensuing within 20 hours from the time the perforation was produced. These three dogs were operated upon
 
64, 7 and 7} hours respectively after the perforation was
 
produced. A fourth dog operated upon GJ hours after the
 
perforation died 30 hours later; the operation apparently prolonged its life about 20 hours. In three of these cases the
 
peritonitis was the most severe we met with in our experimentation, and the dogs in a weak condition at the time of operation, which was done comparatively late in the disease. In
 
each of these four cases the intense hemorrhagic peritonitis
 
described under the second group of experiments was found
 
at autopsy.
 
  
The remaining eight dogs were apparently cured of the peritonitis. Of these eight, one died from the protrusion of the
+
THE JOHNS HOPKINS HOSPITAL REPORTS.  
intestine, due to the breaking down of the abdominal wound
+
Volume I. 423 pages, 99 plates.  
on the fifth day after the operation. In a second case death
 
resulted on the eighth day from a localized peritonitis due to
 
the extension of the suppurative process from the abdominal
 
wall. A third dog which appeared quite well 2i days after
 
the operation died rather suddenly on the fourth day from a
 
perforation in another portion of the intestine which had come
 
into contact with the caustic potash upon the end of the perforated ca3cnm at the time the first perforation was produced.
 
A fourth dog appeared quite well at the end of twelve days
 
after the operation, having an excellent appetite and seeming
 
very lively. On the 13th day the dog seemed sick, and gradually grew worse till its death, on the 17th day after the perforation was produced. At autopsy small abscesses were found
 
extending along each stitch in the abdominal wall down to
 
the inner surface of the wound, where the intestines and
 
omentum were adherent. No distinct sinus leading into the
 
abdominal cavity could be demonstrated. The abdominal
 
cavity contained about 100 cc. of yellow pus, collected for the
 
most part in the pelvis and also extending up toward
 
the diaphragm. The coils of intestine and omentum were
 
firmly adherent in a mass in the upper part of the abdominal
 
cavity. The intestine was also adherent to the liver and gall
 
bladder. The parietal and visceral peritoneum were intensely
 
hemorrhagic in places. No apparent walling off of the pus
 
existed. An extension of the suppurative process along the
 
stitches was supposed to have been the source of the infectious material. A fifth dog also apparently made a complete
 
recovery, both wounds healing with the exception of a small
 
sinus in one of them. This dog seemed quite well for nearly
 
three weeks, when it became ill and died three weeks and two
 
days from the time it was operated upon. At autopsy the
 
abdominal cavity presented a perfectly normal appearance,  
 
with the exception of numerous adhesions of coils of the intestine to each other, to the omentum, liver and parietal peritoneum. These adhesions were not very firm in character. The
 
  
 +
Report in Putliology.
  
 +
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
  
sinus mentioned above was found to lead to an abscess cavity
+
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the  
about the size of a hen's egg, situated in the pelvis to the right
+
 
of the uterus. This abscess was completely shuf off from the  
+
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D,
rest of the abdominal cavity and was the undoubted cause of  
+
A Contribution to the Pathulog-y of the Gelatinous Type of Cerebellar Sclerosis
death.
 
  
All of these dogs which died as a result of the suppurative process following the operation would probably have
+
(Atrophy). By Henry J. Berkley, M. D.  
recovered could they have been subjected to the same treatment human beings would receive in a similar condition, for
+
Reticulated' Tissue and its Relation to the Connective Tissue Fibrils. Bv F. P.  
it must be remembered that it is practically impossible to drain
 
or treat suppurating wounds in dogs. A sixth dog, apparently
 
in the best of health and condition, was killed and autopsied
 
four weeks after operation. Both wounds had healed with
 
the exception of a small sinus leading to a stitch abscess,
 
which, however, did not penetrate the abdominal wall. On
 
examining the abdominal cavity the only abnormalities noted
 
were seven or eight slight, loose adhesions between coils of the
 
intestine, three or four loose adhesions of the omentum to the
 
intestine, and some rather firm adhesions of intestine to the
 
inner surface of the abdominal wound over an area 3x6 cm.
 
The condition of the viscera seemed everywhere normal. All
 
of the adhesions, except perhaps those uniting the intestine to  
 
the inner surface of the abdominal wound, were of such a
 
slender character that they would in all probability have disappeared entirely in a few months. The remaining two
 
animals are apparently perfectly well, one of them being a
 
bitch which was in a moderately advanced state of pregnancy
 
when operated upon. Cultures and cover-slips were made from
 
the exudate in each case of peritonitis. The bacteriology was
 
carefully worked out and will be referred to later. From
 
this group of experiments we conclude that up to 6 hours
 
after perforation the generalized peritonitis in dogs can be
 
cured by this operation in practically every case. The prognosis of operation upon these animals at 6i hours after perforation is exceedingly favorable, but from that time on rapidly
 
becomes less favorable.  
 
  
For the fourth group of experiments six dogs were used.
+
Mall, if. D.  
The method of procedure in this group was to perforate the
 
cfficum in the usual manner. From 6 to 6i hours later the
 
abdominal cavity was again opened, the cfficum brought out
 
and the perforation closed in the way before described. After
 
the replacement of the ca3cuni the abdominal cavity was
 
closed without in any way attempting to cleanse it. At the
 
second operation four of these dogs presented a generalized
 
peritonitis with the characteristics before described, though
 
in no case did the condition seem as bad as in the cases of
 
two dogs in Group 3 cured by the cleansing of the surface of
 
the intestine and the abdominal cavity. Of these four dogs
 
one died about 20 hours after the perforation was produced.
 
The other three failed to rally after the second operation, as
 
the dogs in Group 3 did, and appeared ill till their death two to
 
three and one-half days from the time the intestine was perforated. Autopsy upon two of these animals showed an
 
intense hemorrhagic peritonitis, while in the case of the third
 
the intestine and omentum were closely adherent in a mass,
 
which when pulled apart disclosed numerous pockets of pus,
 
presenting the condition of multiple abscess formation. The
 
remaining two dogs of this series presented only a localized
 
  
 +
Report in Dermatolog-y.
 +
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
  
 +
T. C. Gilchrist, M. D., and Emmet Rixford. M. D.
 +
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of
  
146
+
Protozoa, and the Blastomyces found in the preceding Cases, with the so-called
  
 +
Parasites found in Various Lesions of the Skin, etc. ; Two Cases of Molluscum
  
 +
Fibrosum; Tlie Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
T. C. Gilchrist, M. D.  
  
 +
Report in Pathologry.
 +
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration
  
 +
of Hypertrophy of this Gland. By W. S. Halsted, M. D.
  
[No. 76.
 
  
  
 +
Volume II. 570 pages, witli 28 plates and figures.
  
peritonitis. Tliere was not more than half as much of the
+
Report in Medicine.  
turbid bloody fluid in the abdominal cavity as found in the
 
other four cases, and only those coils of intestine in the
 
vicinity of the ca3cum presented a hemorrhagic appearance.
 
These were the most favorable cases we met with in all
 
our experimentation. These two dogs are still alive, though
 
their recovery has been slow.  
 
  
In connection with the last two cases it is interesting to
+
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with  
note that in two of the cases of Group 3 some exudate had
 
collected in the abdominal cavity between the time the intestine was replaced and the abdominal wound closed, thus making it evident that the abdominal cavity possessed the power
 
of caring for a considerable amount of the exudate. The
 
bacteriology of this group of experiments was also carefully
 
worked out and will be referred to along with the reports of
 
the other cases of peritonitis.
 
  
This group of experiments seems to demonstrate that the
+
Gallstones. By William Oslek. M. D.
mere closure of the perforation, though it may in some cases
+
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, H. D.
prolong life slightly, is not sufficient to cure a case of generalized peritonitis in dogs, and makes it very evident that
+
On Pyrodin. By H. A. LxFLEnR, M. D.
without a careful cleansing of the surface of the intestines
+
Cases of Post-febrile Insanity. By William Osler, M. D.
and the abdominal cavity recovery in such cases will be
+
Acute Tubercuiosis in an Infant of Four Months. By Harry Toulmin, M. D.  
exceedingly rare. It must be borne in mind that the length
+
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
of time which had elapsed since the perforation was produced and the condition of the abdomiual cavity would have
+
Notes on Endocarditis in PhtMsis. By William Osler, M. D.  
afforded a most favorable prognosis in these cases had the
 
cleansing operation been performed.  
 
  
Cultures were made from the 4 cases of Group 2, 13
+
Report in Medicine.
cases of Group 3, and 6 cases of Group 4. In one case of
+
Tubercular Peritonitis. By William Osler, M. D.
Group 3 the cultures failed to grow, although cover-slips
+
A Case of Raynaud's Disease. By H. M. Thomas, M. D.  
 +
Acute Nephritis in Typhoid Fever. By William Osler, M. D.
  
 +
Report in Gynecology.
 +
Tlie Gj-neeological Operating Room. By Howard A. Kelly, M. D.
 +
The Laparotomies performed from October 16, 1S89, to March 3, 1890. By Howard
  
 +
A. Kelly, M. D.. and Hunter Robb, M. D.
 +
The Report of the Autopsies in Two Cases Dying in the GjTiecological Wards vrith
 +
out Operation ; Composite Temperature and Pulse Charts of Forty Cases of
  
showed a few cocci and bacilli. Also in one case of Group 4,  
+
Abdominal Section. By Howard A. Kelly, M. D.  
in which the peritonitis was not yet generalized, the cultures
+
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,  
were negative. In the twenty cases in which bacteria developed in the cultures, from one to three species of microorganisms were found in each case. Members of the colon
+
 
group were found 18 times, 4 times alone and 14 times in  
+
M. D.  
association. Streptococcus pyogenes was found 8 times, once
+
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;
alone and 7 times in association. Staphylococcus albus was
+
 
found 5 times, in each case in association. Staphylococcus
+
Ovarian Tumor; General Gynecological Operations from October 15, 1SS9, to
aureus was found 4 times, once alone and 3 times in association,
 
and staphylococcus citreus was found 4 times, in each case in
 
association. Cultures were also made from the heart blood at
 
several of the autopsies, but in each case were sterile. Coverslips from the exudate in the abdominal cavity were examined
 
in each case and more or less numerous bacteria were seen.
 
An abundance of leucocytes was found in nearly every coverslip. The bacteria in general were outside the cells.
 
  
From our experimental work we feel justified in stating the  
+
March 4. 1890. By Howard A. Kelly, M. D.
following conclusions :
+
Report of the ITrinary Examination of Ninety-one Gynecological Cases. By Howard
  
1. That mere mechanical irritation of the peritoneal surfaces will lead to the formation of adhesions.
+
A. Kelly, M. D., and Albert A. Ghriskey, M. D.
 +
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking
  
3. That peritonitis in dogs caused by a perforation of the  
+
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.  
intestine is of an intensely hemorrhagic character, and if left
+
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, il. D.
to itself rapidly proves fatal.  
+
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
 +
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.
 +
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
  
3. That generalized peritonitis of this character, in dogs,
+
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
can be cured as late as 6* hours after the perforation, by the
 
cleansing operation introduced by Dr. Finney.  
 
  
4. That mere closure of the perforation without this cleansing operation will rarely, if ever, cure a case of generalized
+
Howard A. Kelly, M. D.  
peritonitis in dogs.  
 
  
 +
Report in Siirgery, I.
 +
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot
  
 +
in the Management of Dead Spaces. By W. S. Halsted, M. D.
 +
Report in Neurology, I.
 +
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
 +
Acute Angio-Neurotic Oedema. ' By Charles E. Simon, M. D.
 +
Haematomyelia. By August Hoch, JI. D.
 +
A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By
  
SQUAMOUS EPITHELIOMA AND EPITHELIAL HYPERPLASIA IN SINUSES AND BONE
+
Henry M. Thomas, M. D.
  
FOLLOWING OSTEOMYELITIS.  
+
Report in Pathology, I.
 +
Ama3bic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.  
  
  
  
By S. M. Cone, M. D., Assisfcmt in Surgical Pathology, The Johns Hopkins University.  
+
Volume III. 766 pages, with 69 plates and figm-es.  
  
 +
Report in Pathology.
  
 +
Papillomatous Tumors of the Ovarj'. By J. Whitridge Williams, M. D.
  
In view of the interest manifested in the pathology of bone,  
+
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
the two cases about to be reported seem to be of value. They are
+
Report in Patliology.  
striking examples of malignant and benign epithelial growth
 
into old sinuses and medulla of bone.  
 
  
Case I. — John H., colored, set. 45, laborer, was admitted
+
Multiple Lj-rapho -Sarcomata, with a report of Two Cases. Bv Simon Flexner, M. D,  
to Dr. Halsted's wards, January 2, 1897.
 
  
Patient gives a history of injury to bis left tibia 19 years
+
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M". D.  
ago, with subsequent formation of a sinus and discharge of
 
sequestra. One month before entering the hospital the
 
patient began to feel pain in the leg, and the odor of the discharge became foul. No sequestra have come away for eight
 
months. There is pulsation of discharging material synchronous with the radial pulse.  
 
  
Upon Jan. 4, Dr. Bloodgood excised the sinus aud chiseled
+
A Case of Chronic Nephritis in a Cow. Bv W. T. Councilman, M. D.  
and curetted the bone. The bone was fractured 10 cm. below
 
the knee, where the cavity was largest. The operator's note
 
estimates the cavity communicating with the sinus as 3 cm.  
 
deep, 2 to 3 cm. wide, aud 14 cm. long. The diagnosis,
 
squamous epithelioma, being confirmed, and the growth
 
  
 +
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.
  
 +
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
  
recurring withiu two weeks, the leg was amputated above
+
Report in Gynecology.  
the knee, and glands of the groin excised by Dr. Finney on
 
Jan. 29th. On Feb. 25th patient was discharged, the wounds
 
having healed per primam.  
 
  
Pathological rejmrt of the first operation. — Tiie specimen
+
The Gynecological Operating Room; An Kxtornal Direct Method of Measurins: the  
consists of the skin, sinus, eburnated bone, and soft material
+
Conjugata Vera; Prolapsus Uteri witliout Diverticulum and with Anterior Entorocele; Lipoma of the- Labium Majus; Deviations of the Rectum and Sigmoid
filling the cavity in the bone. The edges of the sinus are
+
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofiexed Uterus. By Howard A.  
dense and pearly in appearance. The skin within i cni. of the  
+
Kelly, M. D.  
sinus edge has lost its dark pigmentation. The bone next to
 
the soft central mass is soft and crumbly, but outside of this
 
is eburnated. It appears directly continuous with the skin
 
at the orifice of the sinus. The sinus is lined by the same
 
papillary growth that fills the cavity in the bone, and this
 
same growth projects between the periosteum and eburnated
 
bone, indenting it, causiug a jagged appearance. The medullary cavity is filled with a soft, necrotic-looking material, made
 
up of soft yellowish white masses, aud with white papillary
 
granular projections from a rather dense translucent pink
 
ground substance looking like granulation tissue. The papil
 
  
 +
Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci.
 +
By Mary Sherwood. M. D.
  
July, 1897.]
+
Intestinal Worms as a Complication in Abdominal Sxu-gery. By A. L. Stately, M. D.  
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
Gynecological Operations not invohnng Coeliotomy, By Howard A. Kellt, M. D.
 +
Tabulated by A. L. Stavely, M. D.  
  
 +
The Employment of an Artificial Retroposition of the Uterus in covering Extensive
 +
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.
  
 +
Photography applied to Surgery. By A. S. Murray.
  
147
+
Traumatic Atresia of the Vagina with Haematokolpos and Haematometra. By Howard
 +
A. Kelly, M. D.
  
 +
Urinalysis in Gynecology. By W. W. Russell, M. D.
  
 +
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.
  
lary projectious average 2 mm. diameter, aud are of varying
+
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.
length up to 4 mm. The growth within the cavity erodes the
+
 
bone, leaving small spicules and granules in the soft necrotic
+
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.
mass. In places the dense bone has become granular and  
+
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.  
crumbles readily. There is no sequestrum nor cancellous bone.  
+
 
The periosteum is very much thickened aud not to be well
+
Abdominal Operations performed in the Gynecological Department, from March 5,
differentiated from the subcutaneous tissue; it is invaded by
+
1890, to December 17, 1892. By Howard A. Kelly, M. D.  
the epithelial growth. The microscopical description of the
 
original sections is the same as of the recurrent growth, so
 
they will be included together.  
 
  
The leg and lower third of the thigh removed at the second
+
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
operation present no abnormal appearance outside of the
+
May 4, 1S92.  
gajiing granulating wound in the tibia, the seat of an osteotomy performed January ith. The wound, measuring 16s
 
4x4 cm., is surrounded by edges of skin inverted over the
 
bone, which for the most part is covered by apparently healthy
 
granulations. Only at one place is the bone exposed ; this is
 
at the upper angle of the wound, where an edge of eburnated
 
bone is left uncovered. At the outer rim of the excavated
 
tibia, 4 cm. from the upper angle of the wound, is a projecting mass of papillary excrescences 4 cm. in diameter, whose
 
surface is covered by a dry blood-stained crust. Scraping the
 
up[)er layer away leaves the deeper papillae, pearly in appearance, closely aggregated and more or less intimately connected
 
with the velvety granulations about them. Some of these epithelial uests are so closely packed without any apparent stroma
 
that at first glance they give the appearance, on section, of a
 
cheesy mass. Careful observation shows this to be made up
 
of individual uests. This mass is at the seat of fracture
 
alluded to. Similar uests of cells are seen iu smaller discrete
 
masses over the whole surface in the granulations.  
 
  
One area on the inner wall of the excavated tibia, 5 cm.
 
from the uf)per angle of the wound and 2 cm. from the fracture, can be made out as a mass sharply defined from the
 
surrounding granulations. The bone here seems excavated to
 
fit the growth which is eroding it. Spicules of bone project
 
into the growth between the epithelial plugs at the jjeriphery.
 
Between the ends of the fracture the new growth projects,
 
invading muscle and adjacent tissues. The ends of the bone
 
are rough, and the papillary masses are seen indenting the
 
ivory-like bone to a depth of 1 to 3 mm., giving it a wormeaten appearance ou removing the growth. The granulations,
 
2 to 4 mm. thick, covering the surface of the bone also groove
 
it and cause a rough and gnawed appearance.
 
  
The bone sawn through at several places is dense aud eburnated aud shows no evidence of tumor formation which is not
 
directly connected with the surface growth. The heads of
 
femur, tibia aud fibula aud the astragalus are normal. The
 
tibia and fibula are anchylosed by bony union at the interosseous ligament. No tumor can be traced from the bone along
 
the vessels. The muscles and soft parts, except at the seat of
 
fracture and ulcer edge, appear normal. The cartilage of the
 
patella is softened, that over the outer head of the femur is
 
depressed and soft. The synovial membrane is hemorrhagic
 
where it envelops the crucial ligaments at their insertion
 
into the head of the tibia.
 
  
The popliteal aud inguinal glands are firm, eularged and  
+
Volume IV. 504 pages, 33 charts and illustrations.  
harder than normal, but do not show any areas of metastasis.  
 
  
 +
Report on Typhoid Fever.
  
 +
By William Osler, M. D., with additional papers by W, S. Thayer, M. D., and J.
 +
Hewetson, M. D.
  
Microscopical Description.  
+
Report in Neurology.
 +
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
 +
Intrinsic Pulmonao' Nerves in Mammalia; The Intrinsic Nerve Supply of the
 +
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of ifu'^ muscuhir. The Intrinsic Nerves of the Thyroid Gland of
 +
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berklet,
 +
M. D.  
  
Tumor iiivading musde at the seat of fracture. The tumor
+
Report in Surgery.  
mass is sharply circumscribed. At that part nearest the  
+
The Results of Operations for the Cure of Cancer of the Breast, from June, 1SS9, to
invaded tissue the tumor is made up of single cells and small
+
January, 1894. By W. S. Halsted, M. D.  
masses of cells in a fine reticulum; this passes, further away,  
 
into small non-cornified, non-cystic masses of cells, theu larger
 
alveoli with cornified epithelium in the centre of the stratum
 
mucosum layers. Furthest away from the muscle and nearest
 
the periphery of the tumor mass are seen cystic dilatations
 
with anastomosing alveoli lined by a few layers of columnar
 
cells and containing scales of cornified epithelium aud fatty
 
detritus. The invaded fibrous tissue shows no change. The
 
muscle fibres are granular and fragmented ; the fragments and
 
individual fibres contain many nuclei, giving the appearance
 
of elongated giant cells. The vessel walls show round cell
 
infiltration. There are newly formed capillaries among the
 
degenerating fibres. There is evidence of endothelial proliferation in the capillaries.  
 
  
Tumor mass and ski7i, the mass projecting betiveen the fractured ends of the tiiia. Where skiu and tumor pass over into
+
Report in Gynecology.
one another the regular papills of the skin cease, as does the
+
Hydrosalpinx, with a report of twentv-seven cases; Post -Operative Septic Peritonitis;
deep pigmentation. The pigment is no longer seen between
+
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.
the stratum mucosum cells as in the skin, aud is much less
+
Report in Pathology.  
developed in the stratum granulosum and deepest columnar
+
Deciduoma Malignum. By J. Whitridge W^illiams, M. D.  
epithelium of the Malpighean layer.  
 
  
It looks as if the stratum mucosum aud granulosum were
 
continuous with like layers of cells lining the stroma of the
 
tumor, keeping on over the tortuous papillary bulgings and
 
corresponding depressions of the tumor mass. Similarly can
 
the stratum corneum be followed, but it changes its appearance over the tumor, becoming less compact and scattered in
 
flakes on the surface, or loosely filling cystic cavities along
 
with cellular detritus, or it may be lacking on some of the
 
plugs.
 
  
In the cornified layers over the tumor are masses of brown
 
granular pigment containing crystals of hsematoidin. The
 
tumor growth is divided by deep grooves caused by keratinizing and fatty degeneration of epithelial down-growths.
 
This causes the follicular appearance described macroscopically.
 
  
Papillse, or stroma strands, better named, push the epithelium up into bulging papillary masses. These stroma strands
+
Volume V. 480 pages, mth 32 charts and illustrations.
vary in size, as do the corresponding cyliuders and plugs of
+
 
epithelium lining them. The plugs aud cylinders anastomose
+
CONTENTS:
freely at the surface. One cyst thus caused measures 1 X ^
+
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.  
cm. aud is made up of numerous small plugs containing
+
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.
keratinized epithelium and detritus around the margin. The
+
Studies in Typhoid Fever.  
contents must have fallen out in great part. The surface is
 
covered with epithelial cells, polymorpho-nuclear leucocytes,  
 
and keratinized epithelium iu a mass of coagulation necrosis.  
 
  
The stroma varies in different parts, from edematous young
+
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon
granulation tissue with stellate, epithelioid aud giant cells at
+
Flexner, M. D., Walter Reed, 51. D., and H. C. Parscns, M. D.  
the surface under the coagulation necrosis, to a very cellular
 
fibrous tissue, with numerous capillaries aud spindle-shaped
 
long nuclei deeper down. In places the stroma is homogeneous aud stains pink with eosin, like hyaline. There are areas
 
of round cell infiltration in the stronui. The included plugs
 
  
  
  
148
+
Volume VI. About 500 pages, many ilhistrations.
  
 +
Report in Neurology.
  
 +
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical
 +
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the
 +
Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions
 +
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental
 +
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol): Part II. — Serum
 +
Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on
 +
the Cortical Nerve Cell; Part HI. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic
 +
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical
 +
Nerve Cell produced hy the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of
 +
Alcohol and Ricin Intoxication; Addenda. By Henry J. Bereixy, M. D.
 +
 
 +
Report in Pathology.  
  
 +
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Tuomas S.
  
 +
Cullen, M. B.
 +
Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of
  
[No. 76.  
+
Ov-um and Spermatozoa. By Thomas S. Cullen. M. B.. and G. L. Wilkiss, M. D.
 +
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B.
 +
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By
 +
 
 +
William D. Booker, M. D.
 +
The Pathology of Toxalbumin Intoxications. By Simon Flesn-er, M. D.
 +
The price of a set bound in cloth [Vols. Z-TJ] of the Hospital Jteftorts is
  
 +
$30.00. Vols. I, II and III are not sold separately. The jtrice of
  
 +
Vols. IV, V and VI is $5.00 each.
  
and cylinders of epiLhelinm comprise all the epidermis layers
 
arranged in the same order as in the skin — a cylindrical or
 
cuboidal layer next to the stroma, then polyhedral cells of
 
the stratuna mucosum showing prickles most distinctly with
 
Van Gieseu's stain, then two or three layers of spindle cells
 
with pigment which takes the hEematoxyliu stain — the stratum
 
granulosum. The outermost layer lining or filling the Ciivity
 
of the plugs or cylinders is of loose keratinized epithelium,
 
sometimes arranged compactly,
 
  
Where the centres are cystic we find besides the keratinized
 
epithelial flakes, fat cells, cells which have undergone fatty
 
degeneration, leucocytes and salts, granular and deeply stained
 
with bajmatosylin. Cell multiplication is very active, as evidenced by the many divided and dividing nuclei ; 2 to 5
 
nuclei are contained in some cells, connected as if budding.
 
  
Tnto the basal layer of these cylinders there may be
+
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TATHOID FEVER.
ingrowths of papilla?, explaining an unusual appearance,  
+
The following papers are reprinted from Vols. I, IV and V of the Reports, for those
namely, a mass of fibres and connective tissue cells cut
+
who desire to purchase in this form:
across in the centre of one of the above described plugs of
+
STUDIES IN DERMATOLOGY. By T. C. Gilchrist. M. D., and Emmet Rixford,
epithelial cells. In the deepest part of the invading tumor
 
the cylinders become very small, even narrowed to single cells
 
separated by the same cellular stroma. Anastomosis is very
 
free, many branches spreading throughout a loose stroma.
 
The arteries included in the section show marked endarteritis
 
and round cell infiltration of the adventitia also.
 
  
In staining the sections the Van Giesen method was found
+
M. D. 1 voliune of 164 pages and 41 full-page plates. Price, bound in paper,  
valuable in staining the stroma and the prickle cells. The
 
keratinized cells stain yellow, the young stroma stains dull
 
red. Gram's stain used for keratohyalin by Ernst' shows it
 
well, staining these cells deep blue.
 
  
Sections of the pink granulations over the surface of the
+
?3.00.
bone show granulation tissue without evidence of tumor.  
+
THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thayer. M. D., and J.  
  
The lymph glands of the popliteal space and groin show
+
Hewetson. M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.  
fatty atrophy and connective tissue formation, thickened capsules and endothelial hyperplasia. There are no metastases.  
 
  
The popliteal artery and vein with surrounding tissue show
+
By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, $2.75.  
no evidence of tumor growth about them. They are united
+
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.-rtracted
by dense fibrous tissue. There is evidence of endarteritis.  
 
  
The synovial membrane described as hemorrhagic shows
+
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 4S1
round cell infiltration and vessels filled with blood, which also
 
suffuses the surrounding tissue.  
 
  
The bone cut across near the knee shows no microscopic
+
pages. Price, bound in paper, ?3.00.  
evidence of carcinoma; it appears normal.  
 
  
Section of fragments of hone with tumor and granulations
+
Subscriptions for the above publications may be sent to  
mixed in an irregular friable mass. The tumor alveoli and
 
stroma are as described above. Adjoining whorls are seen to
 
become conglomerate, mixing together their contents of
 
keratinized epithelium and fatty necrotic substances and
 
bounding this by their several epidermis layers. Secondary
 
papilla; project into the primary alveoli, giving a complicated
 
appearance on section. In the proximity of the bone the
 
cellular stroma is strewn with giant cells with centrally
 
massed large oval vesicular nuclei containing big nucleoli.
 
These are osteoclasts, for wherever the bone is seen undergoing absorption it is lacunar in nature and the Howship's
 
lacunae contain osteoclasts to fit them. The tumor cells do
 
not come in direct contact with the bone, being separated by
 
stroma and osteoclasts.
 
  
 +
The Johns HorKiNS Press, Baltimore, Md.
 +
 +
 +
 +
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies
 +
may he procured from Messrs. GUSHING d: CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.0(» a year, may he
 +
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE ; singU copies will be sent by mail for fifteen cents each.
 +
 +
 +
 +
BULLETIN
  
  
The bone is very dense, with narrow compact lamella; containing few corpuscles, and these are small and far apart.
 
The Haversian canals are filled with cellular connective
 
tissue, vessels, old bone fragments looking as if shelled off,
 
and osteoclasts in lacunaj. Branching canaliculi are distinctly seen. There is new formation of bone going on. The
 
new lamellse are arranged at an angle to the old ones, they
 
take the eosin stain deejier and are lined by osteoblasts,
 
cuboidal and spindle-shaped. There is a granular line stained
 
with hsematoxylin between old and new bone.
 
  
Section of hone zvith invading tumor at the seat of fracture.
+
OF
The lamellae are narrow and closely packed and enclose bone
 
corpuscles at rather wide intervals. Some of the corpuscles
 
nearest the invading tumor are enlarged and the cells are
 
deeply stained. The Haversian canals are irregular in contour, of various sizes, and filled with granular detritus and
 
fragments of bone. About their rim there is lacunar absorption, the grooves being small. The bone, where invaded, is
 
being absorbed by the osteoclasts, for in every Howship"s
 
lacuna can be seen a giant cell such as Kolliker' describes,
 
or large osteoblasts which here take on the function of osteoclasts and are such.
 
  
These osteoclasts vary in size and shape, each fitting exactly
 
a groove in the bone hollowed out to fit the absorbing agent.
 
Some of the cells are seen completely surrounded by bone,
 
others have only one-third of their body enclosed by the
 
lacuna. The shape varies from oval, round, oblong, large
 
cells to elongated flat cells lining quite a large part of the
 
bone surface, looking almost as if one of the outer lamellae
 
had broken off abruptly and taken in many large nuclei. The
 
size varies from an osteoblast to cells five or six times as big.
 
  
The nuclei are either massed in the centre or arranged
 
around the perijihery ; they are large, round or oval, and vesicular. The protoplasm of these osteoclasts is granular and
 
stains deeply with eosin, especially at the centre. The edge
 
of the cell next the bone is rough ; the other borders of some
 
cells seem of double contour and quite smooth.
 
  
No foreign bodies were detected in any of these bodies next
+
THE JOHNS HOPKINS HOSPITAL.  
the bone, yet some of the giant cells near by included epithelial debris.  
 
  
The protoplasm of some osteoclasts is drawn out like a
 
pseudopod and pushes in between the connective tissue cells.
 
Where granulations seem to fill the lacuna? one finds osteoclasts between them and the bone wall.
 
  
There is evidence of new bone formation. To the characteristics of newly deposited bone already mentioned can be
 
added the closer approxinuitiou of bone cells — there being
 
more of them than in the older adjacent bone. The medullary
 
spaces between the cancel li of bone are filled with newly
 
formed fibrous tissue and granulation tissue containing giant
 
cells and all the cells usually found in embryonal tissue.
 
There are also numerous capilhmes and larger vessels in the
 
spaces. The bone cells vary in size and appearance, as do the
 
bone corpuscles, some being round and spindle-shaped, others
 
stellate. They can be best studied in the newly deposited
 
bone or in bone undergoing absorption. It would seem as if
 
when about to be freed from their imprisonment they take ou
 
active functions again and are stained more readily.
 
  
 +
Vol. Vlll.-No. 71.]
  
  
July, 1897.]
 
  
 +
BALTIMORE. FEBRUARY, 1897.
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
  
149
 
  
  
 +
GOiTTZEITTS.
  
As in other sections of bone, no tumor cells come in direct
 
contact with the bone. The tumor advances as described
 
above. There are small fragments of bone in the granulations, which look as if they had been eaten off and left.
 
There is a deposit of new bone in the vicinity of the tumor
 
and evidence of absorption going on in the same microscopic
 
field.
 
  
Case II.— W. J. R., white, a3t. 5i, admitted June 26, '95.
 
  
For 49 years the patient has had discharging sinuses in the  
+
A Case of Dermatitis due to the x Rays. By T. C. Gilchrist,
thigh communicating with necrotic bone.  
+
M. R. C. S., L. S. A.,
  
Operation, June 28th, by Dr. Bloodgood. Amputation of
+
Lesions induced by the Action of Certain Poisons on the Nerve
thigh at the upper third. Notes made at the operation refer
+
Cell. Study VI.— Diphtheria. By Henhy J. Berkley, M. D.,  
to the great friability of the bone, the thickened periosteum,  
 
thin shaft and presence of a sequestrum.
 
  
Nov. '96. Patient reports himself well.  
+
Puerperal Sepsis due to Infection with the Bacillus Aerogenes
 +
Capsulatus. By George W. Dobbin, M. D., - . - .  
  
The pathological report is as follows : The diseased condition of the bone begins 26 cm. above the condyles and involves
 
the shaft for 16 cm. The last jjiece of bone removed, 3 cm.
 
below the trochanter, appetu'S healthy. The periosteum is
 
thickened, the shaft, stripped of periosteum, is rough and
 
presents minute spicules. The shaft varies in thickness from
 
3 to 6 mm., and there is very little cancellous bone. It is
 
brittle, fracturing easily. The medulla above seat of disease
 
contains much fat and oily material. At the seat of disease
 
there is no involucrum. In the sinus leading from the
 
diseased bone there is a sequestrum 6 cm. long and li cm.
 
wide. The periosteum about the necrotic portion is 5 to 6
 
mm. thick, and on section is peai'ly white and appears
 
striated at right angles to the long axis of the bone. On the
 
surface nest to the shaft it is covered with a yellow necrotic
 
friable tissue covering a leathery surface. Fine spicules of
 
bone are imbedded in this. The odor is foul. The surface of
 
the shaft is rough and hard. The medullary cavity is filled
 
with hard bone mixed with thick leathery tissue, and is riddled with small cavities containing the same material as
 
covers the shaft. The only attemjit at new bone formation is
 
in the medullary cavity. No attempt at formation of healthy
 
granulations is evident. About the area of disease the shaft
 
exhibits exostoses 1 to 1^ cm. in length. The knee joint is
 
normal in appearance.
 
  
Microscojiical examination of the tissue between the periosteum and bone described as striated and friable with necrotic
+
 
border next to the shaft, shows it to be made up in the main
+
Proceedings of Societies :
of large swollen polygonal cells with oval vesicular nuclei.
+
 
The arrangement is such as one sees in the stratum mucosum
+
Hospital Medical Society, 29
of the skin. There are papillas jirojecting into the mass from
+
 
the periosteum, which is thickened and infiltrated with small
+
The Surgical Significance of Gall Stones [Dr. F. Lakge].  
round cells. The cells next the papilla} are prickle cells;
+
Correspondence :
those nearer the shaft do not show the prickles. The cells
+
 
arc massed in varying density. According to the location of
+
A Case of Pneumo-cardial Rupture. By Geo. S. Brown, M.D., 33
the papilla} we get lighter and darker stained masses, the
+
 
darker being more comjiact and approaching the cancroid
 
pearl in appearance, but there is no cornified nor degenerated
 
centre. Toward the bone the cells are flat and the nuclei lose
 
the ability to stain. A thin layer of cornification covers their
 
surface. Many of the nuclei are vacuolated. The papilla are
 
very cellular. There is an absence of the stratum granulosum
 
and lucidum ; simply a uniform growth of the mucosum
 
  
  
 +
A CASE OF DERMATITIS DUE TO THE x RAYS.
  
and corneum. There is considerable endo- and periarteritis.  
+
By T. 0. Gilchrist, M. E. C. S., L. S. A., Associate in Dermatology, Johns Hopkins University and Hospital.  
The muscle and connective tissue show no tumor invasion.  
 
The leathery material described in the medulla is like that
 
just described.  
 
  
Examination of the cortical bone from the shaft shows no
 
tumor growth into it. The dense bone presents a feathery
 
appearance commonly seen in eburnated bone. The edges
 
show lacunar absorption.
 
  
A number of cases of squamous epithelioma developing in
 
sinuses antl old scars which would come under the grouping
 
I have purj)osely omitted, since the pathological description of
 
the tumor is in every case essentially the same as in Case I.
 
Two of the cases might be considered carcinoma developing
 
in osteomyelitic sinuses, but the history does not fully substantiate this. In these cases the sinuses were lined by the
 
tubules and plugs of epithelial cells continuous with the
 
tumor mass in the bone itself. The invasion of the bone
 
resembled that described in Case I.
 
  
The cases reported bring to mind several most interesting
+
Since the discovery of the x rays by Rontgen, thousands of
subjects in pathological histology: the development of carcinoma in sinuses, scars and ulcers, its invasion of bone, the  
+
observations and experiments have been made with them both
peculiar character of epithelial growth, and the bone formation and absorption due to the invading tumor. They are
+
in Europe and in this country, and hundreds of investigators have exposed various portions of the body, particularly
interesting especially because they show side by side the  
+
the hands, frequently, iind for long periods of time, yet, after
picture of a typical squamous epithelioma and a mere enormous hyperplasia of the epithelial elements of the stratum
+
searching the literature, records of only twenty-three cases
mucosum in bone. The one is evidently quite malignant; the
+
(including the present one) have been given where injurious
other does not appear to be very destructive in its growth, but
+
results have followed their use, and in these, lesions of the  
merely a filling in of the space made void by the osteomyelitic
+
skin only have been described. Of these twenty-three cases,
process. The two tumors have their homologues in the
+
twelve occurred in this country, one in Canada, four in
epithelial growths in sinuses, ulcers and scars, some being
+
England and six in Germany.  
typical epitheliomata, others simply hyperplastic growths of
 
epithelium lining the sinus walls.  
 
  
There is this point to be noted in Case II differing from  
+
The first report which 1 have been able to find was a
any yet described — the great development of the cells of the  
+
communication in the Deutsche Medicinische Wochenschrift ,
stratum mucosum to the exclusion of the granulosnm and
+
No. 28, 1896 (July 9th), from 0. Leppiu, an engineer, who
lucidum. There is simply a single layer of cuboidal cells
+
had used his left hand a great deal in experimenting with the  
covering the papilte, then 10 to 15 layers of large swollen  
+
X rays. He remarked that the rays had the power of producing cutaneous lesions like sunburn. The hand presented
polygonal cells covered by a thin layer of cornified epithelium.  
+
a peculiar redness, was swollen, and a vesicular eruption appeared later on the middle and ring fingers. Where the skin
This not only fills the sinus and medullary cavity, but pushes
+
was hidden by a ring it was white and quite normal. Even
in between the periosteum and the shaft, nowhere penetrating
+
five weeks after discontinuing the use of the rays the altered
the bone itself. It may be compared in a way with a case of
+
skin gave the hand an older look than the normal one.  
great epithelial cell hyperplasia of the outermost layers of
 
the epidermis described by Busch'" in a case of lupus. Here
 
there was an epithelial papillary growth covered by thickened,
 
horny epithelium spread over the surface, finally breaking
 
into the connective tissue and forming carcinoma.  
 
  
Typical squamous epitheliomata in scars, ulcers and sinuses
+
Professor Daniel, of Vauderbilt University, reported a case
are not uncommon. There are only twenty-eight cases
+
of alopecia as the result of exposure to the x rays three
reported in which the epithelioma developed in the sinus following osteomyelitis. From the histories of many cases
+
months previous to Leppin's communication.  
of epithelioma in ulcers I infer that a few if more accurately
 
described would come under the heading of carcinoma in
 
sinuses following osteomyelitis. Some give a history of
 
osteomyelitis. See Van Hook,' Schindler,' Boegchold." Borchers' iu 1891 collected all the cases up to his time, numbering
 
twenty-five. He records cases of Konig, Dittrich,'" Nicoladoni," Esmarch,'' Fischer," Bartens, Coruil and Kanvier,'
 
  
 +
After examining the other reports (the references are given
 +
at the end of the article) it was found that the eruptions of the
 +
skin presented many points of similarity, and differed chiefly in
  
  
150
 
  
 +
severity, according to either the length of time and frequency
 +
of exposure to the rays or to idiosyncrasy of the patient.
  
 +
In Dr. Sehrwald's case, which was described fully, the
 +
lesion occurred after one exposure of forty-five minutes to the
 +
X rays, and Dr. Crocker's patient had also experienced only
 +
one exposure of one hour when an eruption appeared. In Dr.
 +
Kolle's case, the patient, a boy, was exposed once, for forty
 +
minutes, when a pronounced alopecia followed, and a similar
 +
result is recorded by Professor Daniel in a man after one
 +
sitting; but the most interesting case of all was Professor
 +
Thomson's, of Harvard, who, being skeptical as to the deleterious results of the rays, made the only experiment which
 +
has so far been recorded, by exposing his finger to the x rays
 +
for half an hour and at one and a quarter inches from the
 +
tube, with a definite purpose of producing lesions if possible.
 +
The cutaneous trouble followed in nine days after the exposure. In two cases the patients had two sittings ; in Dr.
 +
Dunn's case the first exposure was one hour, and the second,
 +
seven days later, lasted one hour and a half ; and in Dr.
 +
White's case the patient had two exposures of thirty and
 +
forty-five minutes each on successive days.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
In Drs. Stern's and Richardson's cases the lesions appeared
 +
after three sittings, and Dr. Skinner experienced cutaneous
 +
lesions after three or four exposures of short duration. In
 +
eleven cases the results had only followed after prolonged and
 +
constant use, the duration varying.  
  
 +
I append a table of the cases which I have been able to find
 +
in the literature.
  
  
[No. 76.
 
  
 +
18
  
  
Winiwarter," Hauuover"^ and Volkmauu." Another case is
 
recorded by Feigel.' One of Van Hook's' two cases was
 
undoubtedly carcinoma developed in an old fistula communicating with necrotic bone. Von Friedlander's" three cases,
 
reported in 1894:, are the last recorded. All of the cases
 
described have many points in common with our first case.
 
  
Clinically, the development of the disease in those beyond
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
40 years of age, the common involvement of the lower
 
extremities, the uncertainty of fixing the exact time of development, its slow growth, the foul odor, the long existence of
 
the fistulaj, the absence of pain until the carcinoma begins to
 
develop, the ease with which the bone is broken, the fixation
 
of the neighboring joints and ankylosis of adjoining bones,
 
the infrequent involvement of lymphatic glands or other
 
organs, and its almost sure recurrence unless the limb be
 
amputated, are all most noteworthy points.  
 
  
Volkmann" says that recurrence occurs in a few weeks or
 
months after the operation, if at all; if not Avithin 1 to Ih
 
years, it seldom occurs.
 
  
The pathological picture is not to be confused with any
 
known disease of bone or sinus. The crater-like ulcer or
 
cauliflower excrescences made up of individual oval yellowish
 
white masses, are enough to make the diagnosis. Finding the
 
same papillary growths in the medullary cavity is not calculated to make one think of simple osteomyelitis. The bone
 
next the tumor is either soft and spongy or denser than normal
 
bone. It is increased in circumference and the medullary
 
canal may be smaller than normal. Osteophytes may form
 
on the surface and the bone may rarely present the appearance
 
of spina ventosa. Fracture is common.
 
  
The microscopical picture is that of squamous epithelioma
+
[No. 71.  
modified in appearance according to the amount of degeneration and bone absorption and the greater or less development
 
of tubules, alveoli or cysts. The tumor cells nowhere come in
 
direct contact with the bone, being separated by connective
 
tissue and giant cells or osteoblasts. The thickness of the
 
growth varies, but it is thickest in the cloaca, and in places
 
looking like granulation tissue. The sequestra in Nicoladoni's"
 
cases were not invaded by epithelial cells.  
 
  
Borchers' refers to the advance of the tumor into the
 
Haversian canals. Our cases do not substantiate this, the
 
epithelial cells never being found separate from the main
 
growth.
 
  
In none of the cases were metastases found in the internal
 
organs and rarely even in the lymph glands. The swollen
 
glands usually became of normal size after amputation of the
 
limb. The reason of the infrequent metastases is found in
 
the sclerosis and condensation of tissues about the tumor and
 
its very slow growth.
 
  
Thinking of the etiology and histogenesis of the tumors,
+
Distribution.  
one would naturally class those described with tumors developing in ulcers, fistulas and old scars. Many theories have
 
been advanced to explain them: Virchow's" idea of chronic
 
irritation, mechanical and chemical, being most naturally first
 
alluded to. The question whether the connective tissue
 
growth or epithelial proliferation be the primary factor
 
has been most actively debated since Ribbert" so strongly
 
advocated the former view. Boegehold,* who reported several
 
  
  
  
cases like my first one, believes in their connective tissue origin,
+
Character of the Lesions.  
and says that the epithelium is lost over scars and ulcers. He
 
says : " If the surface epithelium cannot cover over the granulation surface, one cannot see why it shall grow into the
 
depths of the granulation tissue."
 
  
Langeubeck,''" in discussing the development of carcinoma
 
in lupus, expresses the view that the cause of development is
 
like that in traumatic scars, a continuoiis irritation and the
 
carcinoma develops from remaining epithelial cells. It is
 
distinct from the lupus growth. "It is difficult to reconcile
 
the notion of lupus — a granulation tissue — passing directly
 
into carcinoma, because of our view that epithelioma must
 
come from pre-existing epithelial cells."
 
  
AVenk,"' who believes in this direct transition, concedes that
 
the epidermis projections have not been entirely destroyed.
 
Langenbeck"" attributes its formation to development of epithelium in the outlying scar. Schindler'' cites cases to prove
 
the development from the scars — either from the covering
 
epithelium or glandular organs of the skin left intact by the
 
lupus process. He answers Boegehold's* argument cited
 
above, by explaining that the surface epithelium is prevented
 
from spreading superficially by continual irritation (pressure or secretion) and therefore it dips down deeply where
 
not exposed to these influences. Hulke,'"' in describing two
 
cases of carcinoma in old scars, ascribes them to purely
 
local causes. Pedraglia^^ refers to old age and periodic irritation as predisposing causes. This view that old age influences the growth corresponds with that of Verneuil
 
referred to by Marcuse:" "Ein locus minoris resistentiae"
 
of the connective tissues, the epithelium retaining and
 
increasing its activity. Marcuse uses this theory in explaining the growths in the granulations covering ulcers — the
 
granulation tissue, when not going on to scar formation, being
 
not so resistant to epithelial hyperplasia as normal tissues.
 
Here the epithelium grows into the tissues as stated by
 
Thiersch'"' in his most valuable contribution to the etiology
 
of epithelioma of the skin.
 
  
It is not much disputed now that epithelium only forms
+
Subjective
from preformed epithelium and not from leucocytes or connective tissue cells. This materially aids the histogenetic
+
Symptoms.  
study of these tumors. Whatever the cause, the practical
 
lessons obtained from them are of much value to the surgeon,
 
and one is not tempted to use tentative measures to stop a
 
growth which he knows by experience and microscopical
 
study to go steadily onward in its course until it is excised
 
radically.  
 
  
1. Van Hook, W. : Carcinomas arising in Inveterate Ulcers
 
and in Ancient Sinuses. North Amer. Practit., Sept., 1890.
 
  
2. Schindler, J. : Beitrag zur Eutwicklung maligner Tunioren aus Narben. Inaugural Diss., Strassburg, 1885.
 
  
3. Borchers, F. : Ueber das Carciuom welches sich in alten
+
O. Leppin (person
Fistelgiingen der Haut entwickelt. Inaug. Diss., Giittiugeu,
+
al experience). .  
1891.  
 
  
4. Boegehold : Ueber die Eutstehung maligner Tumoreu aus
 
Narben. Virchow's Arch., No. 88, p. 229.
 
  
5. Feigel, L.: Ein Fall von primiirem Ki-ebs der Tibia.
 
I'rzeglad lekarski, Nos. 3G and 37, 1891.
 
  
 +
Used very frequently for
 +
many days.
  
  
July, 1897.]
 
  
 +
Left hand and
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
Peculiar redness, swollen, vesicles
 +
on middle and ring fingers.
  
  
151
 
  
 +
Dr. Marcuee.
  
  
6. Cornil andKauvier: Journal de rAiiatoiiiie, 1SGIJ-G7, p.
 
277.
 
  
7. Erust, P. : Sfcudien iiber normale Verhornniig mit Hilfe
+
Young man, 17, exposed
der Gramscher Methode. Arch. f. mik. Aiiat. und Eutwickluugsgeschichte, Bd. 47, p. 669, 1896.  
+
5-10 minutes once or
 +
twice a day for four
 +
weeks.  
  
8. KoUiker: Die normale Kesorptiou des Kuocheiigewebes.
 
Leipzig, 1873.
 
  
9. Ribbert: Miinchuer Med. Wocheusch., 1894, No. 17;
 
Vircbow's Arcb., Bd. 135.
 
  
10. Dittrich : Prager Vierteljahresschrift, 1847, II.  
+
Dr. Feilchenfeld
 +
Dr. Conrad.  
  
11. Nicoladoni: Arch. f. klin. Cbir., No. 26, 1881.
 
  
12. Esmarcb: Langeubeck's Arch., XXII.
 
  
13. Fischer, S.: Zeitschr. f. Chir., 1881.  
+
Left half of Brownish redness on face, fol
 +
face.backand lowed by desquamation ; later,  
 +
chest. patch of alopecia above right
  
14. Winiwarter: Beitriige ziir Statistik des Carcinoms.
+
ear ; on back, large raw patch,
Stuttgart, 1878.
+
exposing the corium with hemorrhagic points and exudation
 +
and a number of bullae ; on
 +
chest slighter changes,  
 +
exhibited a somewhat similar case (no details given) to the
  
15. Volkmann, Rud. : ITeber das primilre Krebs der Extremitiiteu. Volkmann's Sammlung klin. Vortrage, 1889.
 
  
16. Hauuover : Das Epitheliom. Leipsic, 1855-56.
 
  
 +
No mention. After five weeks hand still
  
 +
looks "older" than the
 +
other.
  
17. V. Friedlander: Beitrag zur Kenntnissder Carcinomentwickelung in Sequesterhohlen und Fisteln. Deutsche Zeitschr.
+
No pain in face ;lThree months later, hair
f. Chir., 1894.
 
  
18. Busch: Langenbeck's Archiv, XV, p. 48.
 
  
19. Virchow : Die krankhafteu Gescbwiilste, Bd. II, p.
 
487.
 
  
20. Langenbeck: Berlin, klin. Wochenschr., 1879, p. 329.  
+
back much
 +
tenderness, but
 +
no pain was felt
 +
until just previous to the eruption.  
  
21. Wenk, L. H. : De exemplis nonnullis carciuomatia
 
epithelialis exorti in cicatrice post lupnm exedentem relicto.
 
Kiel, 1867. Reference from Schindler, see above.
 
  
22. Hulke, J. W.: London Medical Times, Vol. 1, 1873,
 
p. 135.
 
  
23. Pedraglia: Vier Fiille von Epithelialkrebs anf alten
+
returning on the bald
Narben. Giessen, 1853.  
+
spot. Chest and back
 +
healed, but numerous fine
 +
cicatricial lines on the
 +
back and brown pigmentation.  
  
24. Marcuse, J.: Deutsche Zeitschr. f. Chirurgie, Bd. VII,
 
p. 550.
 
  
25. Thiersch: Der Epithelialkrebs, uamentlich der Haut.
 
Leipzig, 1865.
 
  
 +
Dr. Paul Fuchs
 +
(personal expe
 +
rience).
  
  
ON THE BLOOD-PRESSURE-RAISING CONSTITUENT OF THE SUPRARENAL CAPSULE.*
 
  
By John J. Abel, M. D., and Albert C. Crawford, M. D.  
+
Dr. Sehrwald.  
  
[From the Pharmacological Laboratory of the Johns Hopkins University .'[
 
  
  
 +
S. J. R. (personal
 +
experience).
  
Both clinical experience and laboratory research have
 
shown that the suprarenal capsule is an organ of vital importance.
 
  
Physiologistst have proved that a very small quantity of
 
an aqueous extract of the medullary substance raises the
 
blood pressure to a great height above the normal. It has
 
also uuequaled power in reviving a poisoned heart. Gottlieb,J
 
for example, has shown that it will revive the heart of a rabbit which has practically stopped beating in consequence of
 
an intravenous injection of chloral hydrate.
 
  
Bates§ applied an aqueous solution to the eye and found
+
Dr. H. C. Dunn.  
that it exerted a marked vaso-constricting action. In numerous cases of congestion a small quantity dropped into the conjunctival sac brought about an immediate pallor, lasting for
 
some time. According to this writer the extract is very useful
 
in prolonged operations, for, when repeatedly applied, hajniorrhage is prevented and cocaine anfesthesia is in consequence
 
indefinitely prolonged. As the result of his two years' use of
 
the extract Bates concludes " that within the limits of its
 
sphere of activity there is absolutely no other substance which
 
can take its place."
 
  
Other experiments|| go to show that the aqueous extract is
 
  
  
 +
Dr. G. C. Skinner
 +
(personal expe
 +
rience).
  
•Read before the Association of American Physicians, May 6,
 
1897.
 
  
tSehiifer and Oliver, Journal of Physiology, xvi (1894) and
 
xvii (1895); Szymonowicz and Cybulski, Wien. med. WochenBchrift, 18'JG, No. 6.
 
  
JArch. f. exp. Pathol, u. Pharmakol., xxxviii, 106.  
+
J. Macintyre (personal experience).  
  
§New York Medical Journal, Ixiii (189G), iiil .
 
  
||Foa and Pellacani, cited in Maly's Jahresb. d. Thier-Chemie,
 
xiii, 129; M.arino-Zuco, ibid., xviii, 231 ; Gourfein, Rev. Med. de
 
la Suisse Romande, Oct. 20, 1895; Compt. rend., cxxi (1895), 311314.
 
  
 +
Dr. Freund.
  
  
a powerful poison when injected directly into the circulation
 
and may lead to fatal results.
 
  
The various extracts that have been used in these experiments were mixtures of unknown substances, and it is as yet
+
Aphotographerbad used  
an unsolved question whether the various actions at present
+
the X rays very fre
ascribed to the gland are due to one and the same substance.  
+
quently and for some
 +
time.  
  
We are at present interested in the isolation of the bloodpressure-raising constituent, for in a purified state, separated
 
from all other constituents, it might become a therapeutic
 
agent of great importance.
 
  
On the chemical side but little advance has been made over
 
Vulpian's* striking original contribution more than forty
 
years ago. Vulpian observed that the juice expressed from
 
the suprarenal capsule of many different animals behaved in a
 
striking manner toward ferric chloride and toward solutions
 
of iodine, giving with the former reagent an emerald green
 
color, and with the latter a beautiful rose carmine tint. No
 
other tissue of the body, so far as investigated by Vulpian,
 
gave these reactions.
 
  
Virchowt substantiated Vulpian's statements, but added
+
After prolonged use of
nothing new. A year after Vulpian's first announcement his
+
the X rays.  
second paper appeared in conjunction with Cloez,J verifying
 
and extending his first observations and stating his failure to
 
isolate the chromogenic substance or substances to which the
 
above reactions are due.  
 
  
Equally unsuccessful were Arnold§ and Ilolm.ji Kruken
 
  
  
* Note sur quelqiies reactions propres i la substance des capsules
+
In a boy 13 years old.  
surrenales, Compt. rend., xliii (1856), 063-665.  
+
Only one exposure of
■)■ Virchow'a Archiv, xii (1857), 481-483.
+
45 minutes duration
X Compt. rend., xlv (1857), 340-343.
+
Two weeks later erup
§ Virchow's Archiv, xxxv (1866), 64-107.
+
tion appeared.  
II Journ. f. prakt. ('hemie, c (1867), 150.  
 
  
  
  
152
+
Used the rays several
 +
hours daily and eruption appeared three
 +
weeks after.
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
Man aged 35 years. Ex
 +
posed first for one
 +
hour and afterwards
 +
for an hour and a half,
 +
the second with inter
 +
val of seven days. Two
 +
days later eruption appeared.  
  
  
  
[No. 7ri.  
+
Exposed the wrist 10-15
 +
minutes for 3 or4day8
 +
in succession. Ten
 +
days later eruption followed.  
  
 +
Worked for months with
 +
the X rays before cutaneous lesions were
 +
produced.
  
 +
10 days, child who had
 +
hypertrichosis.
  
berg,* years after, repeated the work of Arnold and came to
 
the conclusion that the chromogeu of the suprarenal capsule
 
is a nou-volatile, nitrogenous and ferruginous organic acid
 
which is probably related to the tnracin of the musophagidai
 
and to chlorophyll. He assumed that the substance giving
 
the green color with ferric chloride is not the chromogenic
 
substance of Vulpian, but more likely pyrocatechiu accompanying the chromogen. Attention being thus attracted to the
 
possible occurrence of pyrocatechiu in the suprarenal capsule,
 
others took up the subject.
 
  
Brunnerf found that an alcoholic extract cau be made to
 
give nearly all of the reactions of pyrocatechiu ; thus, it gives
 
the well-known green color with ferric chloride, passing into
 
a fine red on the addition of ammonium tartrate and a few
 
drops of an alkali; it reduces silver nitrate at room temperature, and Fehliug's solution on boiling. The addition of an
 
alkali soon causes it to take on a dark brown color, lead acetate gives a precipitate, sodium nitroprusside and very dilute
 
ammonia give a wine-red color. All of the above reactions
 
being given also by pyrocatechiu, Brunuer concluded that
 
Krukenberg was right in his belief that pyrocatechiu is present in the suprarenal gland.
 
  
After the discovery of the blood-pressure-raisiug property
+
1st and 2d fin
of the suprarenal gland, B. Moore,J working in Schilfer's
+
gers, left
laboratory, came to the conclusion that Vulpiau's chromogen
+
hand.  
and the blood-pressure-raising constituent are identical. He
+
 
based his ojjinion on the fact that chemical operations which
 
destroy the color reactions by oxidizing the reducing agent
 
appear also to destroy the blood-pressure-raising constituent.
 
That the solubilities of the active principle are the same as
 
those of the reducing agent appears also to support this
 
opinion.
 
  
Fraenkel§ worked with residues obtained with the help of
 
alcohol and acetone as solvents. These residues raise the
 
blood pressure and do not contain pyrocatechiu, and on the
 
strength of the ferric chloride reaction and its reducing power
 
he concludes that the essential principle of the residue is a
 
nitrogenous derivative of the o?'</(odihydroxy-benzene series.
 
  
According to Fraeukel both Krukenberg and Brunuer are
+
Left hand and  
wrong in their opinion that the suprarenal glaud contains
+
fingers.  
pyrocatechiu. Fraeukel concludes, like Moore, that the bloodpressure-raising constituent and Vulpiau's chromogen are one
 
and the same substance.  
 
  
More recently still, Muhlmann|| has attempted to prove that
 
the blood-pressure-raisiug constituent is a pyrocatechiu derivative. He asserts that on boiling fresh suprarenal capsules
 
with dilute hydrochloric acid the active principle is decomposed and the pyrocatechiu which is split off may be taken up
 
with ether. Miihlmann has not, however, furnished conclusive chemical proofs for his assertion. Both Miihlmann and
 
Brunner might have settled this point by precipitating the
 
supposed pyrocatechiu with lead acetate and analyzing the
 
lead salt thus obtained. Pyrocatechiu may be preseut in
 
  
  
 +
Abdomen.
  
* Virchow's Archiv, ci (1885), 542-591.
 
  
fSchweizer. Wochensclir. f. Ph.armacie, xxx (1892), 121-123.
 
  
} Journal of Physiology, xvii (1895), Pron. Physiol. See, p. xiv.  
+
Right hand and
 +
fingers. Later
 +
left band.  
  
'i Wiener med. Blatter, 1896, No. 14-16.
 
  
II Deutsche med. Wochenschr., 1896, No. 26, 409-411.
 
  
 +
Abdomen.
  
  
small amounts in the gland, but no proof of this has yet been
 
furnished.
 
  
There is therefore at present great diversity of opinion as
+
Wrist.  
to the chemical character of the blood-pressure-raising constituent of the gland.  
 
  
Whatever the probability may be of the correctness of this
 
or that view, it is to be noted that all of the above-named
 
investigators have based their conclusions on reactions made
 
with aqueous, alcoholic or acetonic extracts ; none of them
 
have even roughly isolated a definite chemical comjiound.
 
The subject is one of great diflBculty, and our own work is at
 
jjreseut merely preliminary, but we have arrived at the
 
following conclusions which we believe to be borne out by
 
our experiments.
 
  
First, we have found by isolating the blood-pressure-raising
 
constituent in the form of a benzoyl compound and decomposing it, that the active principle is a substance with basic
 
characteristics and that it must in all probability be classed
 
with the pyrrol compounds or with the pyridine bases or
 
alkaloids.
 
  
Second, that pyrocatechiu caunot be split off from the isolated active compound by boiling with acids, as has been
+
Neck, back, upper arm and
asserted.  
+
scalp.  
  
Third, we have found that a carmiue-red pigment can be
 
separated from the sulphate of the active principle without
 
destroying its jiower to raise the blood pressure.
 
  
Fourth, iu addition to this, we have isolated from the crude
 
benzoyl product a volatile basic body which fumes iu the air
 
and which emits an odor very much like that of coniiue.
 
  
Method of Isolating the Active Principle in the  
+
Swelling and stiffness of the  
Form of a Benzoyl Compound.  
+
joints; Istand 2d fingers swollen
 +
and of a livid brown color on
 +
the dorsal surface from the tips
 +
to the carpometacarpal joints
 +
Sense of touch greatly diminished. Mustache falling out
 +
and color was changed.  
  
We have used sheep's glands in large quantity. The medullary substance of the fresh glands was scraped out, dried on
+
Much swollen; skin was wrinkled
the water-bath at 60° 0., ground up finely, and extracted with
+
cracked and stained quite
ether for several days until the fats and the substance known
+
brown ; condition of skin like a
as Manasse's jecorin were removed. In this way a fine dry
+
frozen hand ; later, on further
powder of a grayish white appearance is obtained, the aqueous
+
exposure, a vesicular eruption
extract of which is very active in raising the blood pressure.  
+
appeared.  
  
AVith 100 grammes or more of this powder, representing one
+
At first hypersemia, then avesicu
kg. in weight or about 1000 fresh glands, we proceeded as
+
lar eruption. Four weeks later
follows:. The powder is repeatedly extracted with warm
+
central portion healed, but
water acidulated with a few drops of dilute sulphuric acid
+
peripheral portion covered
until the gland has yielded up all of its chromogenic substances, as tested by Vulpian's reactions. This aqueous
+
whole abdomen. Brown color.  
extract is evajiorated on the water-bath to a small bulk, a
+
Exfoliation soon followed.  
large excess of strong alcohol is then added and the whole  
 
allowed to stand 24 hours, by which time the proteids have all
 
settled out. The alcoholic fluid is then filtered and the greater
 
part of the alcohol removed by distillation ; the remainder is
 
driven off on the water-bath. The entire removal of the alcohol is necessary, and in order to avoid too great concentration of the acid fluid, which seems to destroy some of the
 
active principle, water has now and then to be added. The
 
brownish fluid when filtered gives all the well-known reactions characteristic of Vulpian's chromogeu, and on neutralizing the sulplmric acid we found the filtrate to be physiologically very active.  
 
  
 +
Numerous dark little blisters appeared on right fingers ; then
 +
marked redness and inflammation of the skin, which later
 +
became hard, very dry and
 +
yellow like parchment. Exfoliation followed. On further
 +
exposure tips of fingers became
 +
much swollen and nails affected. A colorless, bad smelling
 +
discharge came from beneath
 +
the nails, which were gradually
 +
thrown off. Left hand was
 +
substituted and similar symp
 +
toms followed.
  
 +
Three hours after first exposure
 +
some nausea. After second
 +
exposure, nausea, and on second
 +
day abdomen slightly red, like
 +
sunburn; redness increased in
 +
intensity until fourth day, vesicles appeared, which developed
 +
into bullae. Eighteen days
 +
later the patch was T/zx8}i
 +
inches between umbilicus and
 +
chest, and was smooth, glazed
 +
and weeping for some days,
 +
notwithstanding treatment.
  
July, 1897.]
+
Reddening of the skin appeared
 +
first; this increased until it was
 +
almost purple ; considerable
 +
swelling followed. Desquamation followed.  
  
 +
Appearance of a sunburn. Skin
 +
red and swollen, followed by
 +
exfoliation of the " epidermis"
 +
and loss of hair.
  
 +
X rays used as a depilatory for 10
 +
days, when the hair began to
 +
fall nut.
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
Berlin Medical Society.
  
153
+
Fingers extremely No mention,
 +
sensitive and
 +
pain was of a
 +
burning and
 +
scalding character.
  
  
  
This filtered fluid is next treated with the proper quantity
+
None given.  
of benzoyl chloride and sodium hydrate according to the Baumauu-Schotten method of forming a benzoyl compound.
 
There results a tarry substance of a light yellow color which
 
sticks to the sides of the separator funnel and which is collected
 
and washed until the wash fluid no longer gives an alkaline
 
reaction. It is next dissolved as far as possible in alcohol and
 
the alcohol evaporated. The residue is then treated with
 
ether, which takes up the greater part of it, the ethereal solution is filtered and the ether driven oft.  
 
  
The residue, which is of tarry consistence and amber color,
 
is taken up in strong alcohol from which all basic substances
 
have been removed by distilling from tartaric acid. It is then
 
boiled for two hours with animal charcoal previously well
 
washed with purified alcohol. After filtration and the evaporation of the alcohol a considerable quantity of crystalline
 
residue is obtained which is found to consist of the benzoyl
 
compound of the active principle contaminated with other benzoyl derivatives and which we may call the crude benzoyl product. It is insoluble in water, alkalies or acids of ordinary
 
strength, is soluble in alcohol, ether, glacial acetic acid and
 
concentrated sulphuric acid.
 
  
It is of interest in this connection to note that benzoyl
 
chloride effects the complete removal of the blood-pressureraisiug constituent from an aqueous solution. This is proved
 
by the fact that the filtrate from the insoluble benzoate no
 
longer gives the characteristic chemical reactions of the active
 
principle, and that chemical manipulations no longer yield a
 
blood-pressure-raising constituent. Indeed, an injection of a
 
sufficient amount of the material left after the sodium benzoate and the excess of alkali have been removed, causes a sharp
 
and sudden fall of pressure instead of a rise.
 
  
It was not until long after we had made use of benzoyl
+
Itching when the  
chloride as a precipitant of the active jjrinciple that we obtained
+
vesicles appeared.  
access to Fraenkel's* pai)er. From it we learned that a syrupy
+
 
substance is thrown out when benzoyl chloride is shaken uj)
 
with a pyridine solution of an extract of the gland. Fraeukel
 
did not succeed in crystallizing this benzoyl conijjound, nor did
 
he attempt to decompose it in order to ascertain whether it was
 
in reality a benzoate of the blood-pressure-raising principle.
 
  
Methods of Decomposing the Benzoyl Compound.
 
  
A quick method always used by us as a qualitative test is
+
After inflamma
as follows : The compound is dissolved in as little concentrated
+
tion hand smarted very much
sulphuric acid as possible, crushed ice is slowly added, and
+
Skin became insensible to the  
the benzoic acid which has been split off is shaken out with
+
touch. After
ether. On neutralizing the solution we found it to give the
+
second exposure
reactions characteristic of aqueous solutions of the medullary
+
serious discom
substance. We have not considered this method adapted to
+
fort and pain
the decomposition of large quantities of the product.  
+
followed.  
  
Decomposition of this benzoyl product was effected by means
 
of an alcoholic solution of sodium alcoholate, and also with
 
strong hydrochloric acid and alcohol, but these methods were
 
found to be less satisfactory in practice than the following,
 
which is the method on which we now rely. The benzoyl
 
compound is dissolved in glacial acetic acid, the solution
 
  
  
 +
No subjective
 +
symptoms ;
 +
neither itching
 +
nor pain ; the
 +
rawsurface painless and almost
 +
insensitive.
  
*VVien. med. BliiUer, IS'Jti, No. 14-16.
 
  
  
 +
Great pain and ex
 +
cessive tenderness.
  
heated to near the boiling point, and an equal volume of a 25
 
per cent, solution of sulphuric acid actively boiling is slowly
 
poured into the hot acetic acid solution, the whole being
 
shaken meanwhile. The flask is now attached to a back-flow
 
condenser ami heated on a small flame for about ten minutes.
 
  
The solution is next diluted with water and allowed to cool,
 
the benzoic acid, which has been thrown out, is filtered off
 
and the rest is removed with the help of ether.
 
  
Mixed with the benzoic acid which has been removed by
+
Cured in 9 or 10 weeks.  
filtration is found a dark brittle substance which softens on
 
the water-bath, and which we assume to be a benzoyl compound of unknown composition which was apparently unaffected by the dilute sulphuric acid. On dissolving it in concentrated suljjhuric acid and diluting with crushed ice, the
 
resulting fluid gives none of the reactions characteristic of
 
suprarenal extracts.  
 
  
After decomposing the benzoyl product with hot dilute
 
sulphuric acid and removing the benzoic acid thus split off,
 
we next get rid of the acetic acid by repeated partial evaporations, taking care not to let the solution become too concentrated and thus perhaps injure the active principle. After
 
the removal of the acetic acid the sulphuric acid is precipitated with the help of lead carbonate. The lead sulphate is
 
removed and the filtrate is allowed to stand in vacuo over sulphuric acid until it has become of tarry consistency. It is
 
then exhausted with ether, acetone and absolute alcohol in
 
succession.
 
  
The residue is physiologically very active, and it gives all
 
the reactions characteristic of an aqueous solution of the
 
gland — a beautiful rose color on the addition of an alkali, a
 
green color with ferric chloride, reducing silver nitrate, etc.