Difference between revisions of "Talk:The Johns Hopkins Medical Journal 8 (1897)"

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last time three years before he presented liimself for final
 
treatment at Belle vue Hospital.
 
  
When he was admitted to the hospital, on November 6,
 
1896, he had difficulty in voiding his urine, owing to a stricture of the urethra which could not be passed by instruments.
 
  
On December 5th, at 3.30 p. m., external urethrotomy \yas
+
http://www.archive.org/details/johnshopkinsmedi08john
performed, and the patient did well until 2.30 p. m. on December 8th, when a sound was passed.  
 
  
Twenty-one hours after this procedure a chill ensued, which
 
was followed by severe pains in the joints and back, and from
 
that time the patient rapidly grew worse and died on the 10th
 
of December at 8 p. m.
 
  
At 9 p. m. on the day preceding death, an area of subcutaneous emphysema appeared over the front of the right thigh,
+
BULLETIN  OF THE JOHNS HOPKINS HOSPITAL.  
and others over both shoulders. These areas increased rapidly
 
in size up to the time of death and afterwards.  
 
  
The following notes on the bacteriological examinations of
+
Vol. VIII. - No. 70.  
material from this case and of the autopsy are kindly furnished me by my assistant, Dr. F. M. Jeffries, who conducted
 
them. At 1 p. m. on December 10th, i. e. -1 hours before the
 
death of the patient, three agar tubes were inoculated from
 
the subcutaneous tissue in the emphysematous area on the
 
thigh. These, although placed under anaerobic conditions,
 
failed to develop, probably because of excessive acidity of the
 
agar.  
 
  
At the autopsy made 18 hours after death, cultures on agar
 
and in bouillon were made from the heart, lungs, liver, brain,
 
and the emphysematous area on the thigh. These cultures
 
were incubated under anaerobic conditions in Novy jars
 
with pyrogallate of potassium.
 
  
After 24 hours the cultures from all these sources had
 
developed, with evolution of gas. They all consisted of bacilli
 
resembling the bacillus aerogenes capsulatus. They wei'e
 
not motile and stained well by Gram's method. All the cultures contained only this one bacillus, without admixture of
 
other bacteria.
 
  
Intravenous injection of a bouillon culture in a rabbit which
+
BALTIMORE, JANUARY, 1897.  
was killed five minutes later, resulted in the post-mortem
 
changes already noted in the other cases just described.  
 
  
The bacillus produced spores when cultivated on l)lood
 
serum.
 
  
The autopsy on this case was pei'formed on December 11th,
 
1896, at 2 p. m.
 
  
The general nutrition was good.
+
Contents
  
Subcutaneous emphysema was noted, extending over the
+
Presentation of Thorwaldsen's Statue of Christ to the Hospital, 1
whole body, with a greenish discoloration over the thorax, right
 
thigh and posterior surface of the body; most marked over
 
the penis, scrotum and anus Puncture of the emphysematous
 
area permitted the escape of gas, which burned with a faint
 
blue flame.
 
  
The connective tissue under the skin of the thorax and
+
The Bacilhis Proteus Zenker! in an Ovarian Abscess. By
abdomen was soft, pulpy and emphysematous. There were
+
Hunter Robb, M. D., and Albert A. Ghriskey, M. D., - 4
emphysematous areas on the pleurte and pericardium. There
 
was general emphysema of the lungs. The cavities of the
 
heart were distended, their walls soft and oedematous, and the
 
blood they contained dark and fluid.  
 
  
The liver was of a dark cliocolate color, soft and the seat
 
of emphysema.
 
  
  
 +
The Phrenology of Gall and Flechsig's Doctrine of Association Centres in the Cerebrum. By Lewellys F. Barker,
  
The spleen was dark plum-colored, extremely friable and
+
M. B., - - - - - 7
emphysematous.
 
  
The kidneys were enlarged, showed subcapsular emphysema,  
+
Notes on New Books, ......... 14,  
and were plum-colored.
 
  
The mucous membrane of the bladder was extremely
+
Books Received, 15
emphysematous.
 
  
The brain showed submeningeal emphysema, its substance
 
was soft, the ventricles normal.
 
  
Microscopical examination of smears from the organs revealed
 
the presence of large encapsulated bacilli resembling those
 
found in the cultures. (See " III," temperature chart.)
 
  
The fourth case was a man, 23 years of age, who was admitted to the J. Hood Wright Memorial Hospital on the 6th of
+
PRESENTATION OF THORWALDSEN'S STATUE OF CHRIST TO THE HOSPITAL
.January, 1897.
 
  
Four years ago he had gonorrhrea, which persisted for eight
 
months, and three years ago he had another attack of the
 
same trouble which lasted three months. Neither of these
 
attacks was accompanied by symptoms pointing to inflammation of the bladder or testes.
 
  
Two years ago, i. e. about one year after the beginning of
 
the second attack of gonorrhcEa, he felt pain on urination and
 
noticed that the stream of urine was diminished in size.
 
Shortly after this he had retention of urine, and was catheterized with some difficulty, and the urethral stricture then
 
gradually dilated with sounds, the treatment lasting for two
 
months. Since that time he had omitted all treatment.
 
  
At the time of his admission to the hospital the patient
+
Oa Wednesday afternoon, October 14, 1896, at 3 o'clock, there
complained of pain on micturition, but there was no discharge
+
was uuveiled in the rotunda of the Administration Building
from the urethra or increased frequency of urination. The
+
of the Jolms Hojjkins Hospital, in the presence of the trustees
urine was acid ; sp. gr. 1029; no albumen or sugar.  
+
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:
  
A urethral examination gave the following results :
+
"I have but a few words to say on this occasion; merely to
 +
state how it happens that this statue stands here.
  
No. 23 (French) bougie a boulu passed the meatus, but was  
+
" On a visit to Copenhagen I saw the great work of Thorwaldsen, his ideal conception in marble, of ' Christ, the Divine
stopped just bej'ond the urethral orifice.  
+
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.  
  
No. 30 entered the urethra for a distance of 24 inches.  
+
" Later on the thought came into my heart how eminently
 +
appropriate it would be to have this ideal statue placed where
 +
it now stands, in the centre of this hall, under the lofty dome
 +
of this great hospital. To every weary sufferer entering these
 +
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
 +
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
 +
up to the ever-living Divine Healer, who alone could give that
  
No. 25 slipped past a constriction at 23 inches, but was
 
arrested at about 6i inches.
 
  
No. 30 and No. 15 sounds met with an obstruction at the
 
same point.
 
  
No. 4 and No. 2 bougies also failed to pass that point, as did
+
rest. With this feeling I asked permission of the trustees to  
also a filiform bougie. Even a bunch of filiform bougies
+
present this statue to the hospital. It was cordially given,
failed to demonstrate a passage, although, subsequently, after
+
and at once I placed an order with Professor Stein, the eminent sculptor and Director of the Royal Academy of Art in
etherization in preparation for the operation, a filiform bougie
+
Copenhagen, and there it stands. How well he has executed
was successfully passed.  
+
it you will judge.  
  
External urethrotomy was pei'formed on January 9th, at  
+
"A few years ago, at the formal opening of the Hospital,
4.40 p. m., and a perineal drainage tube was left in the bladder, held in place by a silk ligature passing through the skin.  
+
President Gilman expressed the hope that some day it might
The bladder and urethra were irrigated with saline solution
+
stand there. To-day his hope is realized. And now, Mr.  
and an aseptic dressing applied to the perineal wound. The
+
President, I beg to present this statue to the Johns Hopkins
urethra admitted a No. 34 (French) sound.  
+
Hospital."
  
The patient was returned to the ward at 5.20 p. m., and
+
The statue was then unveiled by little Emily Riggs, an
a conducting tube, with its distal end immersed in a 2J per
+
infant great-granddaughter of Mr. Spence.  
cent, solution of carbolic acid, was attached to the perineal
 
drainage tube.  
 
  
At 6.30 p. m. the patient vomited some blood. The dressings were found to be saturated with blood and were renewed.
+
Mr. W. T. Dixon, the President, in behalf of the Board of
A slight oozing of blood from a wound in the bulb of the  
+
Trustees of the Hospital, accepted the gift in the following
urethra was noticed. This had ceased at 9 p. m., and the  
+
words :
patient then felt comfortable.
 
  
 +
" Mr. Spence — It gives me very great pleasure to accept, in
 +
behalf of the Board of Trustees of the Johns Hopkins Hospital,
 +
your generous gift, this beautiful and impressive statue, and to
 +
assure you of our appreciation of your motives and munificence.
  
 +
"These grateful feelings of the trustees, I am confident, will
 +
be cordially shared by all the workers in every department of
 +
the Hospital, by our many friends throughout the country, as
 +
well as by the sick and suffering who may come under our
 +
care.
  
72
+
" You have most appropriately placed this ' Divine Healer '
 +
just where it can be seen by all who may enter the doors of
 +
the Hospital, thus affording them the opportunity to derive
 +
comfort, courage and hope from its contemplation. And not
 +
only are the outstretched hands of this Christus Consolator
  
  
Line 150: Line 109:
  
  
[No. 73.  
+
[No. 70.  
  
  
  
At 10.30 the bladder was agaia irrigated.  
+
held out to this company, this community and the people of
 +
this age, but they will remain extended to tens of thousands
 +
of the generations yet to come.  
  
On January 10th the patient felt well and the bladder was
+
" There are grave responsibilities and many discouragements
draining nicely.  
+
in maintaining and conducting a hospital, especially a hospital
 +
with the high aims and beneficent purposes of the one you
 +
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."
  
At 1.30 the urethra and bladder were irrigated with a warm
+
The following hymn by Whittier was sung by a male
saturated solution of boric acid. The anterior urethra contained some dark fluid blood which was washed away, and the
+
quartet :
perineal wound then dressed.
 
  
On the 11th and 12th of January the patient was doing
+
" So stood of old the holy Christ
well and the bladder was simply washed out.  
+
Amidst the suffering throng ;
 +
With whom his lightest touch sufficed
 +
To make the weakest strong.  
  
The patient complained of some pain in the penis on the
+
That healing gift he lends to them
13th, and at 3.30 p. m. sounds were passed down to the stricture, and gradually increasing in size up to No. 33 (French).
+
 
The perineal drainage tube was then removed and a No. 33
+
Who use it in his name ;
sound passed through the entire urethra into the bladder,
+
The power that filled his garments' hem
without difficulty. The perineal wound appeared healthy,  
+
 
and there was no discharge from the urethra except a small
+
Is evermore the same.
amount of blood which followed the manipulations. The
+
 
auterior urethra was irrigated with saline solution and the  
+
For lo ! in human hearts unseen
perineal wound dressed. The patient felt somewhat chilly
+
 
and received half an ounce of whiskey.
+
The Healer dwelleth still,  
 +
And they who make his temples clean
 +
 
 +
The best subserve his will.  
 +
 
 +
That Good Physician liveth yet
 +
 
 +
Thy friend and guide to be ;
 +
The Healer by Gennesaret
 +
 
 +
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:
  
At 9.30, seven hours after the sounds were passed, the  
+
We are assembled in the presence of one of the best works
patient had a severe chill, lasting half an hour.  
+
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.  
  
At 3.30 a. m., January 14th, a slight bleeding took place
+
But we have here, not the original cast in clay, nor a plaster
from the urethra.  
+
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.  
  
At 8 a. m. pain in the left shoulder was complained of.  
+
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.  
  
At 11 a. m. a catheter was introduced throiigh the perineal wound and about 3 ounces of bloody fluid having a foul
+
This is not the first time that a hospital has been decorated
odor evacuated from the bladder, which was then irrigated
+
by a great work of art. If I remember rightly, Benjamin
with saline solution. The bladder and anterior urethra were
+
West painted the picture of " Christ Healing the Sick," for the
again washed out at 5 p. m., this time with a solution of permanganate of potash, jtW- '^^^ wound was dressed at this
+
Pennsylvania Hospital in Philadelphia; and, if I am not mistaken, in St. Luke's Hospital, New York, there is still a
time and looked clean. The patient conn^lained of pain on
 
pressure in the left buttock.  
 
  
At 9 p. m. the pains in the shoulder and buttock had
 
become severe, and at 11 p. m. these parts were found to crepitate on manipulation. The skin over these areas was not reddened and the parts were only slightly swollen. The area on
 
the left buttock did not extend to the perineum, but was limited to the region about the trochanter and the external aspect
 
of the ilium. The area at the shoulder was confined to the
 
region overlying the left scapula.
 
  
On January 15th, at 4 a. m., the emphysematous areas had
 
become somewhat larger and more swollen, firmer to the touch,
 
and a little darkened in color. The patient, who was conscious, had an anxious expression and presented an extremely
 
septic appearance.
 
  
At 7 a. m. the body was jaundiced, except over the emphysematous areas. Of these, that on the buttock looked much
+
famous picture by Daniel Huntington, "The Dream of
darker than before and was irregularly mottled with purple
+
Mercy," based upon an incident in Buuyan's Pilgrim's
spots.  
+
Progress.  
  
At 8.15 a. m. an incision, two inches in length, was made
+
Nor is this the first gift that this hospital has received. Its
into the emphysematous area on the left buttock. A considerable amount of gas escaped through the wound, and a  
+
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.  
slight oozing of sanguineous fluid took place, but there was
+
And minor gifts have come in. Not long ago we had a very
no sign of pus. Material for culture and bits of tissue for  
+
small but noteworthy present, a likeness of Florence Nightingale. At another time a friend gave us models and pictures
microscopical examination were taken from the walls of the  
+
of various public institutions throughout the country. Again,
incision.  
+
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.  
  
At 9.30 the patient was still conscious, but died at 10.10
+
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
  
  
a. m., forty-five hours after the sounds were passed on the
 
13th of January.
 
  
Dr. Brooks performed the autopsy on this case, and the following account is taken from his notes :
+
January, 1897.]
  
The autopsy was made 5 hours after death, while the body
 
was still warm.
 
  
Rigor mortis was marked; the general nutrition good.
 
  
Post-mortem discoloration was extreme from the pelvis up,
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
and there was emphysematous crepitation over the abdomen,
 
especially in the suprapubic region ; over the back, the buttocks, and the thigh, leg, and dorsum of the foot on the left
 
side ; also, though in less degree, on the right side.  
 
  
Puncture of the emphysematous areas permitted the escape
 
of a gas which burned with a blue flame.
 
  
The abdominal wall was greatly distended, and when an
 
incision was made the inflated intestines protruded.
 
  
The liver was of a light clay color and crepitated under the  
+
out by the artist, then liviug in Home; and such is the origin
fingers. Its tissues were very friable, and filled with minute
+
of the Christus Consolator upon which we are loolviug.  
vesicles containing gas. The cut surface appeared oedematous.  
 
  
The spleen was enlarged, of a dark purple color, and very
+
Not far away from this church stands the Thorwaldsen
friable.  
+
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.  
  
The kidneys were enlarged; their capsules adherent.  
+
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.  
  
The lungs were somewhat (Edematous.  
+
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.  
  
The cavities of the heart were distended on both sides by
+
I have come upon another incident perhaps more curious.
fluid blood which contained bubbles of gas.  
+
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.  
  
The autopsy was necessarily both hurried and incomplete,
+
The enterprising secretary of the Rhode Island Historical
as the relatives of the patient refused to have any of the organs
+
Society took occasion to address a letter to Thorwaldsen congratulating him not only on his honors but on his origin, and
removed from the body.  
+
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."
  
During the autopsy agar tubes were inoculated by Dr.
+
It is just one hundred years this very month, and I may
Brooks from the blood in the left auricle and from the tissues
+
say this very week, since Thorwaldsen, iu a note dated October
of the liver, spleen and kidney. A bouillon culture was also
+
16, 1796, states that he is on his way from his northern home,
made from the blood. These cultures were then incubated in
+
like the Norsemen of old, to establish himself in the south.
a Novy jar with pyrogallate of potassium, and after 14 hours
+
He was a passenger upon a government frigate which stopped
developed pure cultures of a bacillus identical with those
+
leisurely at one point and then another, so that his journey
found in the preceding cases.
+
grew tiresome. At last he abandoned the man-of-war and  
  
When grown upon blood serum these bacilli developed
 
spores identical in character with those produced by the
 
bacillus isolated from the pus from the first case.
 
  
Cover-glass preparations made at the autopsy from the same
 
organs from which cultures were taken showed the presence
 
of the bacillus.
 
  
One cubic centimeter of the bouillon culture from the blood
+
found other conveyances to carry him from Malta to Palermo,
was used to inoculate a guinea-pig subcutaneously. Within
+
to Naples, and so on to Rome. There he went to work.  
three hours the animal was manifestly ill, appearing to feel
 
cold and to wish to avoid the light. It died within 30 hours,
 
and at the autopsy presented marked emphysema of the areolar
 
tissues and orsrans.  
 
  
A rabbit was also inoculated, intravenously, with the bouillon
+
But how could this boy maintain himself in Rome ? It was  
culture, killed and put in a moderately warm place. The next
+
by the aid of a scholarship provided for him by the Royal
day it showed the emphysematous condition of the subcutaneous tissues and internal organs which has already been
+
Academy of Copenhagen. He had not been a very bright boy
described in connection with the other cases.  
+
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.  
  
The material removed when the incisions were made into
+
Now I want to remind you that scholarships just like that
the emphysematous area on the buttock at 4 p. m. on the day
+
which enabled Thorwaldsen to go forward, have been established within a short time in Baltimore. Rinehart, as you
of the death of the patient was used to inoculate agar tubes,  
+
know, left a considerable sum of money, which was carefully
part of which were cultivated with access of air, the rest
+
invested by Mr. Newcomer and Mr. Walters, until it reached
under anaerobic conditions. Those exposed to the air showed
+
the sum of $100,000, and it was then given to the Peabody
no growth. Those grown with exclusion of oxygen contained
+
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.  
  
 +
At Rome, Thorwaldsen instantly came under the modern
 +
influences of that day. Wiuckelmann, the well-known critic,
 +
had already called attention to the great value of the Greek
 +
art iu distinction from that of the Renaissance, and sculptors
 +
began to work iu the Hellenic spirit. You get an illustration
 +
of this movement in the Flaxman designs, as produced
 +
in England. You get another illustration in the work of
 +
Oanova, and you get an especially good illustration in the early
 +
work of Thorwaldsen.
  
 +
A great many illustrious people came to Rome. An amusing story is told of Sir Walter Scott. He was very desirous of
 +
meeting and talking with Thorwaldsen, and they were introduced to one another; but Thorwaldsen could not speak a
 +
word of English, and Sir AValter was not at his ease in French.
 +
All that any one could hear was "plaisir," "plaisir," "connaissance," and similar nouns, expressing gratification that
 +
they had met.
  
April, 1897.]
+
The sculptor soon came into church circles. He was a particular friend of Cardinal Consalvi, and made his monument.
 +
It was through his influence, undoubtedly, that Thorwaldsen
 +
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
  
  
Line 302: Line 373:
  
  
73
+
[No. 70.
 +
 
  
  
 +
best artist in Eome?" "Undoubtedly," was the answer.
 +
"Then let him hold the place."
  
a growth of a non-motile bacillus, positive to Gram, and morphologically resembling the bacillus aerogenes capsulatus.  
+
Thorwaldsen after a time went home, and, as I have said,  
These cultures were lost and no further observations could be
+
received the commission for a statue of Christ. He returned to
made, but as considerable work on this bacillus was being done
+
liome, and with his helpers, it took him eight or nine years to
at the time, no doubt exists as to the identity of the bacillus.  
+
complete the group of Christ and the Apostles.  
  
About 2i honi's after the death of the patient a sterile
+
You must be familiar with many of the works which he
cotton swab was introduced into the urethra, and the moisture
+
produced meanwhile. The little medallions of Night and Day
thus obtained used for the preparation of cultures.  
+
which hang in so many parlors were his. Almost every one
 +
who goes to Eurojie knows the Sleeping Lion of Lucerne and  
 +
the statue of Lord Byron at Cambridge. He made many
 +
portrait busts. He worked long on mythological subjects, till
 +
finally " he turned from Jove and Mars to nobler themes."
  
Two bacilli developed in these cultures, and as they were
+
The story goes that he made six models of the Christ before
both at least facultative anaerobes, efforts to separate that  
+
he was satisfied with the one which is here reproduced. At
which proved to be a strict anaerobe were unsuccessful. One
+
first he thought of giving to the figure an iiplifted hand, in
was smaller than the other and grew when air was admitted
+
the attitude of benediction. Afterwards he uplifted both arms
to the cultures. The other was morphologically identical
+
as if in prayer. The artist was standing before his statue one
with the bacillus aerogenes and did not grow in cultures
+
day, when he said to a friend, " I am not satisfied with that."
exposed to the air. The smaller bacillus was thought to be
+
His friend replied, " What was your motive in giving that
the bacillus coli communis. A mixed bouillon culture of the
+
posture; what were you thinking about?" Thorwaldsen
two bacilli was injected into one of the veins of a rabbit's
+
paused, and in a moment turned down the arms to the position
ear, and 15 minutes later the animal was killed. The next
+
in which you now see them, and then said, " I am satisfied now."
day the body was bloated and the large bacillus was found
+
 
in the subcutaneous fluids, which were both emphysematous
+
It is worth while for me to add that between five and six
and (Edematous.  
+
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.  
  
As a check upon this experiment a second rabbit was inoculated with a pure culture of the colon bacillus in the same
+
Now, ladies and gentlemen, it is not for me to draw the
manner and at about the same time as the first rabbit. The
+
lesson of the statue. I suppose (to use a phrase of Coleridge) that this statue "will find each one" of us in his own
next day there were no signs of emphysema in its body.
+
mood. To some it will be a reminiscence of travel, — of a  
(See " IV," temperature chart)
+
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
  
The fifth case occurred in the private practice of a New
 
York physician, who has kindly furnished the writer with
 
the following facts concerning the history of the case.
 
  
The patient was a man, 73 years of age. His general condition was good, there being no organic trouble except some
 
hypertrophy of the prostate.
 
  
On January 17th, 1897, the patient complained of pain and  
+
is repeated. So it is in painting, from Eaphael and Leonardo to
uneasiness in the perineum. This was traced to enlargement
+
those gifted men who are now decorating the churches in this
and tenderness of the prostate and of the tissues near the  
+
country with the illustrations of the life of Christ. So it is
rectum in the median line.  
+
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.  
  
The next day the pain was more severe, and a diagnosis of  
+
In the presence of Mr. Spence it will not do for me to
prostatitis was made. The pain was alleviated by means of
+
recount the many good deeds which he has done for the city,
opium and belladonna suppositories, and by the 20th of January the patient felt able to be about again.  
+
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.  
  
That night, because of difliculty in voiding his urine, the
 
patient passed a hard rubber catheter and drew some blood.
 
  
On the 21st, pain in the right ischio-rectal fossa was noticed,
 
and the tissues at the site of the pain were found to be firmer
 
than normal.
 
  
On the 22nd the pain in the right buttock was more severe.
+
THE BACILLUS PROTEUS ZENKERl IN AN OVARIAN ABSCESS.  
The patient was in bed, felt prostrated, and had a dry tongue
 
and some fever. Temijerature about 101°.  
 
  
On the 23rd the general condition was about the same as
+
By Hunter Robb, M. D., Professor of Gynecology, Western Reserve University, Cleveland, 0., and Albekt A. Ghriskey, M. D.,
on the day before. Temperature 102°. There was increased
 
harduess of the tissues of the right buttock, and the pain there
 
was very great.  
 
  
On the 2-l:th there was evidence of a pointing abscess in
+
former Assistant Gytiecologist to the Johns Hopkins Hosjntal.  
the buttock, in which the pain was excessive.  
 
  
At midnight a sudden rupturing of this abscess into the
 
neighboring tissues was felt, and immediately the scrotum
 
became enlarged and the pain in the buttock was relieved.
 
  
The next morning, January 25th, the attending physician
 
  
 +
Mrs. T. G. was admitted to the gynecological ward of the
 +
Johns Hopkins Hospital, August 8, 1891, with the following
 +
history :
  
 +
The patient was a Bohemian, 36 years of age, and had been
 +
married seven years. She had had three children, and said
 +
that she had never miscarried. The oldest child is six and the
 +
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
  
found the scrotum emphysematous, with spots of gangrene
 
upou it. Temperature 103°.
 
  
Later in the day the perineum was tense and distended, red
+
ally seven days, and were often profuse and painful; since
and tympanitic. The scrotum was the size of a child's head (8
+
marriage her menses have been regular, lasting five or six days,  
to 10 inches in diameter), dark in color, in places almost black,
+
being profuse but not painful. In May, 1890, she ceased to
and cold to the touch. The skin of the penis was ballooned
+
menstruate for two months, but in July her menses reappeared
with gas and dark.  
+
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
  
Very extensive incisions were made to the right of the
 
raphe, from the penis to the tuberosity of the ischium. No
 
pus was found, except at one point near the anus, where there
 
was a cavity containing a dirty grayish-yellow pus of offensive
 
odor.
 
  
The areolar tissue of the scrotum and penis were of an inky
+
January, 1897.]
blackness and emphysematous, but contained no pus. A slight
 
ojdematous condition prevailed in the deeper structures.  
 
  
The tissues were irrigated with mercuric chloride and an
 
iodoform dressing applied.
 
  
On the following day, January 26th, the emphysema had
 
extended over the pubes and the hypogastric region, the skin
 
being raised about half an inch. The color of the skin over
 
this area was either normal or had a pinkish blush.
 
  
Two free incision* were made to evacuate the gas, and it
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
was discovered that the subcutaneous areolar tissues were
 
blackened. No pus was present.  
 
  
A portion of this black slough was removed with sterile
 
instruments and put in a sterilized bottle for examination.
 
  
On the 27th the emphysema and necrotic area had extended
 
upwards to the sternum, and laterally to the shoulder-blades,
 
and fresh incisions were made. A single focus of pus found
 
above the navel.
 
  
In all the places where prior incisions had been made the  
+
smelling black clots of blood and experienced labor-like pains.
sloughing had extended so as to include the skin, but without
+
During May, June and July she was free from these laborlike pains, but complained during these months of weakness,
the formation of pus.  
+
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.  
  
The patient lapsed into a low typhoid condition, then into
+
At the examination made August 8, 1891, under chloroform
coma, and died on the 31st of January.
+
narcosis, the following note was made :
  
Cover -glass preparations of the material removed from this
+
Vaginal outlet moderately relaxed; vagina bathed with
patient on January 26th were examined on that day at the Carnegie Laboratory, and showed the presence of three species of
+
bloody fluid ; cervix small, bilaterally lacerated, pointing upwards; uterus anteflexed, sagging in the pelvis, enlarged, soft
bacteria : 1, a large bacillus, resembling the bacillus aerogenes
+
and movable. Right broad ligament thickened. Fallopian
capsulatus ; 2, a more slender bacillus; 3, streptococci.  
+
tube and ovary not definitely palpated.  
  
The slender bacillus was identified as the bacillus coli communis, and when obtained in pure culture, produced no
+
On the left side a fluctuating tumor is outlined, about the  
emj)hysema in the body of a rabbit killed shortly after the  
+
size of an orange, adherent to the uterus.  
injection of the culture into a vein of the ear.  
 
  
Experience with the mixed cultures, obtained from the
+
Diagnosis. Abscess of the left ovary. Treatment advised,  
cotton swab used to collect material from the urethra in the
+
coeliotomy.  
fourth case, had shown the difliculty of separating the
 
bacillus aerogenes capsulatus from the bacillus coli communis.
 
Without waiting, therefore, to obtain pure cultures of the
 
large bacillus found in this ca^e, a mixed bouillon culture of
 
the two bacilli was injected, intravenously, into a rabbit,
 
which was shortly afterwards killed. The usual post-mortem
 
emphysema was produced within a few houri?, and from the
 
subcutaneous fluids pure cultures of the bacillus aerogenes
 
capsulatus were finally obtained. These, unfortunately, died
 
out in future cultures, owing, it is thought, to the reaction of
 
the agar which was employed as a culture medium and which
 
was found to be strongly acid.  
 
  
 +
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.
  
74
+
Operation August 12, 1891, under chloroform narcosis.
  
 +
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.
  
 +
The Fallopian tube and ovary of the right side being bound
 +
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.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
A drainage tube was inserted in the lower angle of the
 +
wound and the usual dressings applied. Time of operation,
 +
40 minutes.  
  
 +
The specimens removed consist of the tube and ovary of the
  
  
[No. 73.
 
  
 +
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.
  
 +
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.
  
No accurate temperature chart could be obtained in this
+
The cotton immediately over the drainage tube was slightly
case, and there was no autopsy.  
+
moistened with the same character of secretion as that seen
 +
upon the plug and upon the cotton pledgets.  
  
The foregoing cases appear of interest as showing that the
+
Abdomen flat, no distension, general condition good, usual
bacillus aerogenes capsulatus is sometimes capable of rapid
+
cultures taken.  
development within the human body, during life, and of
 
causing an acute and speedily fatal infection.  
 
  
They serve also to show that the bacillus is of pretty wide
+
VIII-14-91. Second dressing. Slight amount of fluid on
distribution ; for within eleven months these five cases have
+
cotton over the drainage tube ; plug in tube moistened by a
come under the observation of a single individual and were,  
+
clear fluid holding a clot of blood at the lower end. On the
notwithstanding, wholly unconnected with each other, occurring as they did in various parts of the city of New York and  
+
gauze plug there are white opaque points of lymph, corresponding in position to the perforation in the drainage
coming under the care of different physicians.  
+
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.  
  
The mode of infection was not the same in all of the cases.  
+
VIII-19-91. Fourth dressing. Stitches removed. Line of  
But it is a striking circumstance that in three of the cases
+
union good; some suppuration about the track of the tube.
the infection started near the perineum after injury to the
+
General condition good.  
urethra, and in two of these the bacillus aerogenes capsulatus
 
was associated, as far as the wound was concerned, with the  
 
bacillus coli communis.  
 
  
In the case in which the site of infection was the wound of  
+
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.
  
 +
Analysis of temperature cliart. — The temperature was taken
 +
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.
  
 +
Bacteriological examination. — The following cultures were
 +
made from the left Fallopian tube and abscess cavity: Two
 +
sets of Esmarch's roll plates on agar-agar, one smear and one
 +
stab culture in the same medium ; a blood-serum tube (bullock's
 +
blood) and a litmus milk tube. From the right Fallopian
 +
tube, which was distended by a muco-purulent, rather viscid
 +
looking fluid, we only made gelatine Esmarch's roll jilates.
  
a compound fracture of the humerus, the history states that
+
Microscopical examination. — Cover-slips stained with gentian violet show numerous polynuclear leucocytes, with compound granular bodies, and a few cells with large round
the wound was covered with dirt. This fact naturally leads
+
nuclei resembling epithelial cells. Many bacilli were observed;  
to the suspicion that the bacillus aerogenes capsulatus, like
+
they were rather faintly stained, and were seen only occasionally within the leucocytes. These bacteria were stained
so many of the anaerobic bacteria with which we are familiar,
+
best with carbolic gentian violet.  
may occur in the soil ; and the occasional production of spores,  
 
noted in the account of the first case and also observed in similar cultures from the fourth case, might readily explain the  
 
persistent vitality of the species under conditions which would
 
otherwise be fatal to it.  
 
  
From the soil to the intestinal tract of man would be a
+
Numerous rod-shaped bacilli were found in the preparation
simple route by which the bacillus might gain access to the
 
human body and find conditions not unfavorable to its development and, perhaps, spore-formation.
 
  
If the bacillus once gained access to the intestinal tract its
 
presence in the perineal region couldoccasion no surprise. And
 
if, through the wounded urethra, or some other lesion, it once
 
reached the subcutaneous tissues and possessed sufficient virulence, the gangrenous process illustrated by these cases would
 
ensue as a matter of course.
 
  
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
OBSERVATIONS TO DETERMINE THE MOTILITY OF THE BACILLUS AEROGENES CAPSULATUS
 
  
UNDER ANAEROBIC CONDITIONS.
 
  
By E. K. Dunham, M. D.  
+
[No. 70.  
  
  
  
Bouillon cultures of the bacillus were studied in flattened
+
from the Fallopian tube on the right side. Though less
capillary tubes from which the oxygen of the air had been
+
intensely stained, they resemble tubercle bacilli somewhat
absorbed by means of pyrogallate of potassium. Although
+
morphologically. They are, however, completely decolorized
these cultures were examined at intervals varying from 15
+
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
minutes to 24 hours, at no time could any evidence of motility
+
were made.  
on the part of the bacilli be detected.  
 
  
The details of the experiment were as follows :
+
After 48 hours in the thermostat all tubes were sterile,
 +
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.
  
The cultures were obtained by putting threads, containing
+
All these tubes showed growth after 24 hours on agar; very
spores of the bacillus, which had been kept in a dry state for
+
faintly after 48 hours on gelatine, on account of the lower
11 months, into tubes containing sterile bouillon. Three
+
temperature, but more distinctly on the latter on succeeding
such tubes were prepared, and after incubation in a bottle
+
days. The appearance of the colonies in gelatine corresponded
containing pyrogallate of potassium, they all showed an
+
to that presented by the bacillus proteus, a fact suggested by
abundant growth of the bacillus within 24 hours. These
+
Dr. Booker and confirmed by Dr. Welch. These colonies
cultures proved to be pure. One cubic centimeter of one of
+
showed the typical twisted wandering offshoots (schwiirmende
these cultures was then mixed with about 3 cc. of fresh sterile
+
Colonien) characteristic of the proteus group. The gelatine
bouillon, in order that the bacilli present might have a good
+
was not liquefied.  
supply of nourishment, and this mixture used for the observations on motility.  
 
  
The capillary tubes were prepared by heating a piece of  
+
Cultures from the Dramage Tube. — First dressing 24 hours
glass tubing, about 8 inches long and with a bore measuring
+
after operation. Roll plate, agar-agar, Esmarch's tubes. The  
about i of an inch, strongly in the middle, then bringing the
+
colonies on the tubes from the gauze plug were composed of  
two halves parallel to each other and separating them about
+
the skin-coccus. Microscopical examination of stained coverglass preparations from the secretion showed a few diplococci,  
two inches (Fig. 1). In this way a U-shaped tube with a
+
and numerous bacilli identical with those found in the abscess
flatted bend was obtained. The limbs of this tube were then
+
cavity. The coccus grew on potato and in bouillon with the  
bent at right angles, so that their axes were in the same
+
characters of the streptococcus pyogenes albus, but liquefied
straight line. The ends of the tube were plugged with cotton
+
gelatine, though less rapidly than this organism.  
and the tube sterilized by dry heat (Fig. 2).  
 
  
A few moments before use, the middle of the flattened portion of the tube was heated until quite soft, and then rapidly
+
The inoculation of a guinea-pig subcutaneously in the flank
drawn out to form a capillary tube. This was then broken
+
with the serum-like secretion from the gauze plug was without result.  
in the centre and the end immersed in the bouillon culture.  
 
  
 +
Further inoculations from the drainage tube on bullock
 +
serum were not made, as the supply of culture medium was
 +
exhausted.
  
 +
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.
  
A portion of the culture quickly filled the capillary part of
+
Macroscopical and microscopical de.fcripfion of specimens from  
the tube for a distance of from 2 to 3 inches. The end of the
+
the Pathological Laboratory of the Johns Ho})kins Hospital, by  
capillary tube was then sealed in the edge of the flame of a
+
Dr. .T. Whitridge Williams.  
Bunsen burner. Enough pyrogallic acid to closely fill about
 
1 inch of the tube was then introduced into its large end, this
 
was moistened with a 50 per cent, solution of caustic potash
 
in water, and then the end of the tube was closed by means of
 
a piece of rubber tubing plugged at the other end with a bit
 
of glass rod (Fig. 3).  
 
  
 +
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.
  
  
Fto. I.
 
  
 +
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.
  
 +
Cover-slips from the pus show many thick bacilli, but no
 +
tubercle bacilli.
  
Fig. <3.  
+
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.
  
F,g.l.  
+
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.  
  
When prepared in this way the capillary tube containing the  
+
In this portion the connective tissue bands are hardly visible.
culture was so flat that it was possible to examine the whole
+
As we recede from the abscess cavity we find fewer leucocytes,
contents of the tube under a Jj oil immersion objective.  
+
more fibroblasts and connective tissue, until we gradually
 +
approach characteristic ovarian tissue.  
  
Eight such tubes were prepared, and four of them preserved
+
The bacillus corresponds morphologically to the bacillus
at the room temperature, the other four being placed in the
+
proteus Zenkeri, and stains well with methylene blue, and does
incubator where the temperature was maintained at 35° C.  
+
not entirely decolorize with the Gram or Weigert stain. It
They were examined at intervals of 15 minutes, 1 hour, 3J
+
may be observed in the abscess walls as a bacillus of varying
hours, 21 hours and 34 hours. In no case could any locomotion of the bacilli be detected.  
+
lengths and in forms simulating cocci. The fibroblasts are
 +
strikingly like the large cells of the corpus luteum.  
  
After two and a half hours the bacilli were present in  
+
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
  
  
April, 1897.]  
+
January, 1897.]  
  
  
Line 595: Line 779:
  
  
75
+
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.
 +
 
 +
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.
  
 +
Literature.
  
 +
1. Hauser: Ueber das Vorkommen von Proteus vulgaris
 +
bei einem jauchig-phlegmonosen Eiterung. Munchener medicinische Wocheuschrift No. 7, 16 Februar, 1S92, p. 103.
  
greater numbers than when the cultures were first introduced
+
2. Beck : Die Faulnisbachterieu der menschlichen Leiche.
into the tubes, showing that the conditions were favorable for
+
Baumgarten: Arbeiten auf dem Gebiete der pathologischen
their multiplication. At the end of 24 hours the number had
+
Anatomie und Bacteriologie aus dem pathologisch-anatomischen Institute zu Tiibingen, Bd. I, S. 155, 1889.
increased enormously, and there were two small bubbles of
 
gas in one of the tubes which had been kept in the incubator.  
 
It might, perhaps, be thought that the chilling, occasioned
 
by removing the tube from the incubator for the purpose of
 
examining its contents under the microscope, would be sufficient to check the locomotion of the bacilli, before a clear
 
  
 +
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.
  
view of them could be obtained. That this was not the case
 
is shown by the fact that in all the tubes the bacilli soon
 
subsided to the bottom, leaving the bouillon above them
 
free from bacilli. If the tube was turned a little about its
 
long axis and kept in that position for a time, the bacilli
 
settled towards the lower side of the tube.
 
  
These observations appear to demonstrate that this bacillus
 
does not possess the power of locomotion, even under anaerobic
 
conditions.
 
  
 +
THE PHRENOLOGY OF GALL AND FLECHSIG'S DOCTRINE OF ASSOCIATION CENTRES
  
 +
IN THE CEREBRUM.
  
MULTIPLE TUBERCULOUS ULCERS OF THE STOMACH, WITH A REPORT OF THREE CASES.  
+
Br Lewellts F. Barker, JI. B., Associate Professor of Anatomy in the Johns ffopki7is University and
 +
Assistant Resident Pathologist to the Johns Hopkins Hospital.  
  
By Alice Hamilton, M. D.  
+
[Remarks made before the Clinical Society of Maryland, November 20, 1896.]
  
[From the Pathological Laboratory of the Johns Hopkins University and ITospital.]
 
  
 +
 +
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.
  
  
Tuberculous ulcer of the stomach is conceded by all writers
 
on pathology to be of extremely rare occurrence, some indeed
 
of the earlier ones considering that organ almost immune from
 
tubercular infection. Again, some few of the earlier writers
 
claim to have found it with comparative frequency in the
 
autopsies of tubercular subjects ; but as their results vary so
 
greatly from those of the large majority, one is forced to
 
believe that they have included cases of simple ulcer among
 
the number. Forster, Rokitansky, Cornil et Ranvier, Ziegler,
 
Orth, Birch-Hirschfeld and Klebs are unanimous in declaring
 
the extreme rarity of this lesion.
 
  
Single cases purporting to be of this disease are reported
+
Indeed, the statement has been made that the general tendency of the time to favor Schelling's philosophy did more than
from time to time in the literature, but it is imjjossible to  
+
anything else, except the curiosity of the public, to spread the
accept all of these as actually cases of tubercular ulcer. As
+
three false doctrines, animal magnetism, phrenology, and homCEopathy. Animal magnetism, fathered by the shrewd Anton
the greater number were reported before the discovery of the  
+
Mesmer, had a brilliant career until the French commission
bacillus tuberculosis, one does not expect to find the diagnosis resting on its presence; but in many of these cases no histological examination was made, and in others no details of
+
with Franklin at its head successfully demolished it. Homceopathy, founded by Christian Friedr. Samuel Hahnemann,
such examination are given. All such cases must be dismissed
+
which attempted to subordinate the whole of the healing art
as doubtful or merely probable. Only those can be classed as
+
to an arbitrary dictum, Siinilia similibus curantur, still has
proven where the report shows by a detailed description of  
+
many adherents, especially in America. Phrenology or cranioscopy, connected closely with the name of Franz Josef Gall,
the results of the microscopic examination that the histological characteristics of tubercle were present and which were confirmed or not, as the case may be, by the demonstration of the
+
has now but few disciples, and an avowal of belief in phrenological doctrines is usually received, even by the layman, with
bacillus tuberculosis.  
+
a suppressed smile.  
  
The earliest of these is Litten's. It was a case of tuberculosis of lungs and peritoneum with no lesion in the intestines,  
+
Gall was born at Tiefenbrunu, in Germany, in 1758. The  
but with a single ulcer in the anterior wall of the stomach,  
+
history of his life affords entertaining reading. He studied
which on microscopic examination showed typical caseating
+
medicine in Strassburg and Vienna, and practiced his profession
tubercles with giant cells. Talamon also describes tubercles
+
in the latter city, where he became very well known. He tells us
found in the walls of ulcers in the stomach of a child which
+
in his books how at a very early age he noticed among his playmates the existence of definite relations between the external
had died of pulmonary tuberculosis. In this case the ulcers
+
appearance of the head and face and certain mental characteristics. His lectures delivered in Vienna, in which his
were seven in number, scattered over the surface from cardla
+
phrenological doctrines were chiefly set forth, were very popular and largely attended until 1802. when at the instance of
to pylorus. Brechemin's case resembled Litten's in presenting no lesion in the intestines. There was a single ulcer— its
 
location not mentioned — with thickened edges and a floor covered with nodular elevations consisting of " caseated masses
 
surrounded by embryonic and lymphoid cells." Eppinger's
 
two cases are described in great detail and are interesting in  
 
being the first cases of multiple ulcer which have been
 
accurately reported. Here, too, the intestines in both cases
 
  
  
  
were intact. The first one was a case of general miliary tuberculosis, and the stomach contained many miliary tubercles as
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
well as innumerable small losses of substance in the mucosa.
 
These ulcers had hard, elevated, regular " rampart-like " walls,
 
and their bases were covered with whitish granulations, which
 
on section proved to be caseated. His description of the
 
microscopic appearances leaves nothing to be desired in either
 
of the cases, the second resembling the first very closely.  
 
  
Barbacci's case showed tuberculosis of lungs, peritoneum
 
and intestines, besides which the stomach contained five
 
ulcei'S near the pylorus, two of them having a diameter of
 
6 cm. These showed nodules of embryonic cells with caseation in the centre. The case of Pozzi is not quite positive.
 
He found an ulcer near the greater curvature in the stomach
 
of a man who had succumbed to pulmonary and intestinal
 
tuberculosis. The walls and base of this ulcer showed no
 
nodules, only "diffuse tubercular tissue." As it was impossible that the diagnosis here should be confirmed by the
 
discovery of the tubercular bacillus — the case was published
 
in 1868 — it must be regarded as somewhat doubtful. Duguet's
 
case of a single ulcer near the pylorus in a phthisical patient
 
is so obscurely described that one can come to no definite conclusion about it. Marfan rejects it in his resume of tubercular lesions of the stomach.
 
  
Coats was the first to demonstrate the bacillus in a gastric
 
ulcer. His case, a child with pulmonary tuberculosis, presented numerous losses of substance in the mucosa of the
 
stomach, and the examination showed not only the histological
 
elements of tubercle, but also the specific bacillus. Serafini,
 
Musser and Mathieu et Remond also found the bacillus in
 
their cases. Mathieu et Remoud's case goes to swell the list
 
of those which showed no lesion in the intestine.
 
  
J. Kiihl reports four cases from the Pathological Institute
+
[No. 70.  
at Kiel. He examined all for the tubercle bacillus, but failed
 
to demonstrate it in the two older specimens which had been
 
a long time in the museum. Nevertheless, the histological
 
appearances in the first of these cases point quite positively to
 
tuberculosis; in the second his description is too scanty and
 
obscure to place it above question. The third and fourth
 
instances, which were recent, are described as containing caseating nodules with tubercle bacilli. R. G. Hebb and G. Lava
 
  
  
  
76
+
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.
  
 +
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.
  
 +
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.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
The doctrines of the phrenologists maybe briefly summed
 +
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
  
  
[No. 73.
 
  
 +
unscientific nature of the whole system. Whereas Gall believed that there were only some 26 or 27 organs of the
 +
brain, with some of his followers the number was increased
 +
considerably. Fowler, for example, describing as many as 43
 +
different faculties. Spurzheim divided the different capacities
 +
of the human mind into (1) the feelings, including the propensities and sentiments, and (2) the intellechial families,
 +
including the perceptive and reflective activities. As examples
 +
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,
 +
benevolence, veneration and firmness. Among the perceptive
 +
faculties he included the appreciation of form, size, weight,
 +
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
  
  
report each a case of single ulcer — at the lesser curvature and
+
January, 1897.]
at the pylorus respectively — and describe the microscopic findings as tubercles with caseation and giant cells. It is to be
 
regretted that these observers failed to make any search for
 
the bacillus tuberculosis. This omission is still more striking
 
in Letorey's otherwise exhaustive description of a case of diffuse ulceration near the pylorus. He states that tubercle
 
bacilli were found in the lungs and in the diseased part of the
 
femur, but seems not to have looked for them in the ulcers,
 
where he, however, found typical caseating nodules.  
 
  
In the following cases it is difficult to decide whether the
 
lesions described are really tubercular or not, the authors having satisfied themselves of the correctness of their diagnoses,
 
but having failed to establish them by giving the facts on
 
which they were founded. So, for instance, Hattute merely
 
states that his case showed "elements of tubercle in the granulations." Lorey, Anger, Matthieu, (Jazinaud Beadles give no
 
details at all. Finally, a large number must be utterly rejected
 
as, according to the explicit statement of the authors, no
 
microscopic examiuation was ever made. Such are the cases
 
of Bignon, Paulicky, Chvostek (four), Hebb (second case),
 
Lauge, Barlow and Quenu, which last rests for its diagnosis on
 
a mere statement of the author, no description of its macroscopic appearance being given. Several others which have
 
been placed in the list of tubercular ulcer were really miliary
 
tubercles in the walls of the stomach. Kiihl's fifth case is an
 
example, also Earth's. Labadie-Lagrave's case showed a
 
cicatrix near the lesser curvature, its tubercular origin being
 
merely hypothetical. Oppolzer's is described as a perforating
 
ulcer connecting stomach and colon, supj)osedlyof tubercular
 
origin, but it was impossible to say in which organ it originated. This covers all of the authentic literature so far as I
 
have been able to discover, and it will be seen that it contains
 
fifteen undoubted cases and nine more which are probable but
 
not proven.
 
  
The two cases which I wish to report are, I think, undoubtedly tubercular, although neither could be considered as
 
strictly typical. Indeed, the histological findings in the second case were so little suggestive of tuberculosis that, had it not
 
been for the discovery of the tubercle bacillus, I should not
 
have ventured to class it as tubercular, but the large numbers
 
of bacilli present leave no doubt that they were the prime factor in causing the ulcerative process. The first case, which
 
contained very few bacilli, presented an appearance that was
 
much more characteristic of tuberculosis. I will omit the histories of these cases, which offered nothing of special interest,
 
merely stating that both patients were admitted to the Johns
 
Hopkins Hospital, to the service of Ur. Osier, in the advanced
 
stages of pulmonary phthisis. The autopsies were performed
 
by Dr. Flexner, from whose reports I will give merely the
 
essential points.
 
  
Case 1. Colored female, aged 30 years. The right lung contained near the apex a cavity about the size of a small walnut,
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
with smooth walls; the lung tissue adjacent was densely infiltrated and converted into a caseous mass. In the lower portions of
 
the upper lobe, beneath the anterior surface and near the middle
 
line, a small cavity existed with smooth walls which communicated freely with the bronchi. Its walls were caseous, and
 
  
  
  
adjacent to it were large caseous masses surrounded by oedematous and congested tissue, which often presented a gelatinous
+
lais and Swift, it was believed to be the organ of the sense of
appearance. The upper portion of the lower lobe was taken
+
the ludicrous. The capacity for recognizing faces was supposed to depend upon the width of the interval between the
np by a series of cavities, more or less communicating, the  
+
eyes, inasmuch as Gall found in a squinting girl a good
deepest of which extended almost to the pleura, and was separated from this only by thin granulation tissue in which
+
memory for faces. The murderer Thurtell, who had a large
could be seen many opaque tubercles. Over this cavity the  
+
organ of benevolence, is said by devotees to phrenology to have
two layers of the pleura were adherent. The dependent portion of this lobe anteriorly was drawn out to a tongue-like
+
been in reality generous, since it was discovered that he once
aj)pendage in which were caseous masses, the intervening lung
+
gave half a guinea to a friend. Many other laughable instances
tissue presenting a gelatinous appearance. Firm, dry and
+
might be given of these crude methods of localization and of
caseous tissue surrounded the cavity in the upper lobe, and  
+
the futile attempts of the adherents of the doctrine to bolster
most of the remainder of this lobe was converted into similar
+
up their tumbling edifices.
tissue. The lower lobe contained scattered caseous foci, while
+
 
the pleura covering all of the left lung was scattered over with
+
It is easy to understand how a shrewd man like Gall, — and
gray and opaque tubercles. The bronchi, larynx and trachea
+
any one who reads his books will be very ready to grant his
showed numerous superficial losses of substance reaching only
+
shrewdness and intelligence, — developing with great rapidity
through the mucous membrane. This ulcerative process in
+
a system full of interest for the public and stimulating their
the larynx extended to the mucous membrane of the mouth
+
curiosity by providing them with an infallible clue to the  
and tongue, but did not pass to the esophagus. The bronchial
+
determination of character and fitness for occupation in life,
lymphatic glands were pigmented, enlarged and caseous.  
+
should have attained wide-spread and lucrative popularity.
Tubercles were observed in the liver and kidneys.  
+
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
 +
 
 +
 
 +
 
 +
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.  
  
The intestines were the seat of numerous ulcerations, which  
+
In addition to the studies on aphasia there have been
occurred at intervals, beginning 165 cm. below the duodenum
+
recorded a whole series of pathological lesions which clinically were associated with definite disturbances of sensation ;
and extending to within 10 cm. of the rectum. They were
+
thus, lesions of the occipital cortex have a tendency to affect
partly circular, partly elongated — " girdle-ulcers " — and penetrated to the muscular coat. In many, small tubercles were
+
visual sensations; lesions of certain portions of the temporal
visible in the depth. On the peritoneal surface a few tubercles
+
cortex interfere with hearing; the sense of smell has been
were seen. The appendix vermiformis was free from ulceration.  
+
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.  
  
The stomach showed a large number of losses of substance,  
+
In 1870 Fritsch and Hitzig reported the results of their
from 115 to 120, scattered over the entire organ, but most
+
investigations concerning galvanic excitation of the surface of  
thickly on the anterior aspect near the greater curvature.
+
the brain of animals, in which it was shown that stimulation
These ulcers were round or oval, usually smaller than a penny,  
+
of definite regions calls forth movements of certain only of
with rounded thickened edges, generally smooth and undermined for a variable distance.  
+
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 chief interest for our purpose centers in the ulcerations
+
The studies of Goltz upon dogs supply an exceedingly interesting link in the chain of experimentation. This investigator
existing in the stomach. Our studies embraced the examination of many of these, often in serial sections, both with
+
demonstrated the possibility of keeping a dog alive for a
respect to their pathologic histology and to the presence of  
+
considerable length of time in the entire absence of a cerebral
tubercle bacilli. Ulcers of various sizes were sectioned, stained
+
cortex, and in this way was able to ascertain what faculties
and examined microscopically. The details are purposely
+
the animal possesses when only the lower parts of the brain
omitted. The ulcers vary in their histological appeai-auces,
+
are functioning uncontrolled by the cerebrum. He found
depending somewhat upon the extent of their development.
+
that an animal without a cerebrum still possesses a very complex nerve life, a fact which is not so very surprising when
Even in the youngest and most superficial the glandular
+
one recollects the observations of comparative afiatomy.
elements are much disturbed, and a considerable proliferation
+
While the dog of Goltz's experiment appeared to be devoid of  
of cells has taken place in the mucosa. The cells are small,
+
memory and judgment and incapable of finding out for himself among the objects outside of the body those necessary for
round and lymphoid in type, but among them are also some
+
the satisfaction of his needs, he showed himself to be by no
which have the character of epithelioid cells. The deeper
 
ulcers show a greater number, even a preponderance, of cells
 
of an epithelioid habitus, and an arrangement at times into
 
nodules of the size and I'oughly of the appearance of miliary
 
tubercles, whose centres are formed by epithelioid, and whose
 
peripheries by lymphoid elements. Giant cells were not discovered. On the other hand, necrosis of cells existed with fragmentation of nuclei, and, within the new tissue, even larger
 
areas suggesting definite caseation. The nodules with central
 
necrosis were sometimes in the mucous membrane, perhaps in
 
  
  
  
April, 1897.]
+
10
  
  
Line 836: Line 1,122:
  
  
77
+
[No. 70.
 +
 
 +
 
  
 +
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.
  
 +
The studies of His and Flechsig, which have done so much
 +
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.
  
the overhanging edges of the ulcers, and again upon the floor
+
Flechsig has shown, in his study of the embryonal cerebrum,  
formed by the submucosa, which was always found when
+
that it is the sensory paths which first become medullated.  
exposed to be infiltrated with new cells, partly lymphoid, partly
 
epithelioid in character. The thickened, undermined edges
 
showed an increase of spindle-S'haped cells, suggesting a new
 
growth of connective tissue, forming at times a decided band.
 
Tubercle bacilli (Ziehl-Neelsen method of staining) appeared
 
in small numbers along the free surface of the ulcers, and
 
singly, imbedded in the tissues, among the clusters of epithelioid cells.  
 
  
Case 3. Male, colored, age fifty years. The right lung was
+
*I have thought it best at this time to present, in as clear and
bound by adhesions to the chest wall and the diaphragm, and
+
brief a manner as possible and without discussion, the main tenets
the lobes were bound to each other. On section the whole lung
+
of Flechsig with regard to the structure and function of the brain.  
was quite consolidated. Old fibrous processes extended in all
+
While in such a short communication it is impossible to do justice
dii-ections through the lung, but they were most abundant
+
to so broad a subject, it is to be hoped that it may be possible to
posteriorly and at the apex. Small foci of caseation partly
+
show at least the trend of his views. The anatomical basis for his
calcified were found, and in addition actual cavities lined
+
studies is given at some length in the voluminous notes appended
with thin pyogenic membranes, the largest of them not exceeding the size of a walnut. The bronchial glands were enlarged,  
+
to his "Gehirn und S'eele " (Leipzig, Veit. Co., 189(>). An idea of
caseous and partly calcified.  
+
some of the criticisms which may be made of his doctrines can be
 +
gained by a perusal of the discussion of the address delivered by
 +
Flechsig at the Versammlung deutscher Naturforscher und Aerzte,
 +
Frankfurt, September, lS9()(cf. Centralbl. f. Nervenheilkunde und
 +
Psychiatric, October, ISOO).  
  
The left lung, on the other hand, was free from adhesions
 
except at the apex, the upper lobe was retracted at the apex,
 
slaty in color and contained caseous masses, but elsewhere
 
this lobe was quite smoothly consolidated. The lower lobe
 
was voluminous, congested, containing very little air. In some
 
smaller branches of the pulmonary artery partly decolorized
 
thrombi existed, without infarction. Both bronchial and
 
mediastinal glands were enlarged and caseous.
 
  
The small intestines were free from ulceration, but in the
 
patches of Peyer in the ileum near the valve there were
 
several elevated gray nodules, about the size of bird-shot or a
 
little larger, with central depression, doubtless small tubercles
 
with loss of substance in the centre. The large intestines
 
were free; the appendix vermiformis contained about its centre
 
an elevated grayish nodule similar to those in the ileum.
 
  
The mucous membrane of the stomach was congested and  
+
Gradually the individual fibres of one sensory path after
covered with sticky mucus, and along the greater curvature,  
+
another, beginning with that concerned in the sense of smell
almost over its entire extent, small losses of substanceoccurred,  
+
and ending with that by which are carried auditory impulses,  
70 to 75 in number. They presented worm-eaten edges and
+
passing from the sense organs of the body toward the cerebral
uneven bases, which sometimes, but rarely, were covered with
+
cortex, gain their myelin sheaths. Each sensory path includes
small granulations. They extended usually only partly through
+
a very large number of nerve fibres containing the axones of  
the mucosa. The follicles of the oesophagus were enlarged,  
+
neurones whose cell bodies are situated lower down. Following the different sensory paths to their cortical termination, it
but without ulceration.  
+
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.  
  
The histological and bacteriological examinations of these  
+
After these sensory paths in the child's brain have become
ulcers were carried out in the same manner as in the preceding case, fourteen of the ulcers in all being subjected to
+
medullated, new paths begin to develop from the points where
study. For this purpose ulcers of various sizes were chosen.  
+
the sense fibres terminate — paths which go in the opposite
With the exception of two or three, those examined involved
+
direction. These fibres as they become medullated can be
only the upper layers of the mucous membrane, and the  
+
traced passing downwards to the medulla and the spinal cord,  
deepest ones did not extend beyond the muscularis mucosae.  
+
to the nuclei of origin of the motor nerves, and connecting in
The edges of these ulcers were never deeply undermined, and
+
this way the sensory regions on the surface of the cerebrum
the infiltration of the mucous membrane passed a very little way
+
with the motor apparatus. The area of the cortex concerned
only beyond the ulcerations. In general the appearances presented were those of superficial and small ulcerations, whose
+
in the sense of touch has an especially well developed bundle
floor was formed by the infiltrated mucous membrane, still
+
of these motor fibres, the fasciculus cerebro-spinalis or so-called
showing glands or vestiges of glands, but in which the proliferation of cells had so altered the latter that they were often
+
pyramidal tract, which consists of more than 100,000 fibres on
with difficulty recognizable. The new cells consisted chiefly of
+
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.  
  
 +
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
  
  
the lymphoid variety, and they were diffusely scattered, but
 
epithelioid or larger cell elements were not entirely absent.
 
Only once was a perfectly distinct nodule, the size of a
 
miliary tubercle, discovered, and this consisted of epithelioid
 
cells more centrally and lymphoid more peripherally placed.
 
On the other hand, in the floor of the ulcer it was possible to
 
distinguish more nodular formed masses of lymphoid and
 
epithelioid cells, but definite and typical tubercles, in the
 
usual sense, were entirely wanting. The free surface of the
 
ulcers showed more or less necrosis ; the deeper layers, which
 
were in an excellent state of preservation (the tissue having
 
been perfectly fresh), were quite free from such indications.
 
Tubercle bacilli were present in great numbers; in no section
 
were they wanting, and often they occurred in great clumps.
 
The main masses were on the free surface of the ulcers, but they
 
were also found deejjer down among the glands or within their
 
luniina.
 
  
The foregoing cases seem to possess sufficient interest to
+
Gyru.cm,.r..l,{J»«;r;;p,S<,m»»>.l,.tlo.,.  
warrant recording them, even though it is now admitted generally that the stomach at one time or another becomes directly
+
 
involved in tuberculosis of the alimentary tract. It is interesting to consider for a moment a fact alluded to by many
+
 
writers, that there is a want of correspondence between the
+
 
appearance of lesions of a tuberculous nature in the stomach
+
Corpus cAllonnn
on the one hand and in the intestine on the other. While
+
 
in the great majority of cases the latter shows great disposition for the development of tuberculous ulcers, it is interesting
+
Porulx louguti,  
and striking to see how often in the cases reported in the
+
 
literature, where ulcers existed in the stomach, the intestines
+
(Septum pellucW,  
entirely or almost entirely escaped. Every pathologist must
+
 
be imjjressed with the unexpected variations in the localizations of tuberculous lesions, and must have observed instances
 
in which the alimentary tract entirely escaped infection when
 
the conditions seemed most favorable for it. It is impossible
 
at the present time to give any satisfactory explanation of
 
such occurrences.
 
  
Concerning the multiple nature of the ulcers in the two cases
 
discovered above, they are in this respect, compared with other
 
cases (except Eppingei-'s), peculiar. It is questionable whether
 
they may be considered as having shown any special predilections for situation, excej)t in the second case to avoid the
 
pylorus, apparently the most common seat of single ulcers.
 
Two points may be considered in this connection, one of
 
which is borne out by the bacteriological examination of the
 
second case. The size of some of the ulcers and their limitation to the mucous membrane agree not a little with the
 
small erosions following ecchymoses into the mucosa, the socalled hemorrhagic erosions. The absence of a specific histological structure peculiar to tubercle, in many of the more
 
superficial losses of substance, is not inconsistent with such an
 
origin. That such erosions are very common in many diseases
 
is of course well known, and it may therefore with projn'iety
 
be asked whether a part of the ulcers in the second case do
 
not owe their origin to this cause, and the tubercle bacillus
 
is responsible only secondarily for a further destruction;
 
the production of those lesions more nearly resembling histological tul)ercles. Eppinger long ago declared that the u'sophagus was invulnerable to the tuberculous virus, unless a
 
  
  
 +
"^ti^^i^r^^^j^
  
78
 
  
  
 +
^^^
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
Oolliculiia superior (corp. quad.)
 +
. Hnin nucleus of tliaUmua.
  
[No. 73.
 
  
  
  
previous lesion existed to enable it to get a foothold; and
+
Fig-. 6.  
while this statement has perhaps been disproven, yet that such
 
a previous injury may act as a predisposing cause is more
 
firmly established now than when he wrote (see Cordua). And
 
if for the oesophagus, it may be asked why not for the stomach?
 
The facts in our second case point more towards such a view,
 
namely, that many small erosions, probably of hemorrhagic
 
origin, existed in the stomach, some or all of which became
 
invaded by tubercle bacilli swallowed with the sputum, than
 
that they owe their production to a direct invasion, in the
 
absence of a previous lesion, of the mucous membrane of the
 
stomach, by the bacillus tuberculosis.  
 
  
In closing I wish to express my gratitude to Dr. Flexner
 
for the advice and assistance most kindly given me in the
 
course of this investigation.
 
  
Addendum.
 
  
After the completion of the above report, a third case of
+
Soraae»tUetic
gastric ulcer came under observation, which proved also to be of
 
tubercular origin, and the specific character of which was far
 
more easily determined than in the other two cases. The lesions
 
here conformed in every way most closely to the usual type of
 
tubercular ulcerations. The ulcers wei-e in this case but two
 
in number, of large size, and accompanied by the formation
 
of tubercles which were evident even to the naked eye.
 
  
Vase 3. The patient was a colored girl of eleven years of
 
age. She entered the medical department of the Johns Hopkins Hospital (service of Dr. Osier) on June 16th. Tubercular
 
peritonitis was diagnosed, and she was transferred to the
 
surgical side, where the diagnosis was confirmed by an exploratory operation, the peritoneum being found covered with
 
miliary tubercles and the intestines matted together. The
 
patient recovered from the operation and lingered until
 
December, when death occurred. The autopsy was performed
 
by Dr. Livingood, from whose report the following extracts
 
have been taken.
 
  
The body was much emaciated. Extending from below the
 
costal margin to a point opposite the umbilicus was the scar of
 
an imperfectly closed incision, the floor of which consisted of a
 
sloughing surface covered with pus. Near the umbilicus the
 
tissues were darkened and necrotic in appearance. On
 
attempting to open the peritoneum, the transverse colon and
 
the upper part of the omentum were found completely coherent.
 
Below, the intestines were closely matted together by fibrinous
 
and fibrous bands, which could be stripped apart, though
 
with difficulty, especially at the umbilicus. The parietal layer
 
of the peritoneum was thickened and studded with conglomerate and miliary tubercles. The peritoneal cavity contained
 
a large amount of turbid, yellowish-white fluid with fine
 
flocculi. It had a slightly faecal odor. The serous coat of
 
the intestines was studded with numerous caseous tubercles,
 
usually about the size of a cherry-stone, but ranging larger
 
and smaller. The appendix vermiformis was so matted in
 
the mass that it could not be found.
 
  
The anterior mediastinal and the lower cervical glands
 
wei-e enlarged and caseous. The visceral and parietal layers of
 
the pleura on the right side were studded with caseous
 
tubercles, some of which reached the size of a beau.
 
  
 +
Gynm hippocampi.
 +
 +
 +
 +
Fig. +.
  
  
The pleural cavity was partly obliterated by fibrous adhesions. The lung contained in its apex numerous small nodules,
 
some of them caseous ; it was congested over the remainder of
 
its extent, and small tubercles could be seen and felt scattered
 
through it. The left pleural cavity was completely obliterated, and the lower lobe of the lung could not be freed from
 
the diaphragm, but had to be removed with it. Miliary
 
tubercles were scattered over both layers of the pleura, especially thickly along the lines of the ribs. A large area of
 
caseation was formed where the lung was in contact with the
 
diaphragm, and this process seemed to have extended directly
 
through the diaphragm to the spleen and liver beneath. The
 
upper lobe of the left lung showed more extensive tuberculosis than did the right lung, being filled with numerous
 
tubercles in all stages of caseation, but without definite cavity
 
formation. Small nodules were scattered through the lower
 
lobe, which was much congested and, at its lower extremity,
 
in the early stage of consolidation.
 
  
The spleen was adherent to the diaphragm and to the parietal peritoneum. Its capsule was thickened and was the seat
 
of large caseous tubercles, but there were no distinct tubercles in the substance. One small caseous tubercle was found
 
in the right kidney. The mucous membrane of the uterus
 
was the seat of a number of yellow and gray miliary tubercles.
 
Both tubes were enlarged and adherent to the surrounding
 
structures. Some of the lymphatic glands in the broad
 
ligament were caseous, and the vaginal mucous membrane contained a single tubercle. The caj)sule of the liver was covered
 
with numeroiis minute tubercles, and others were found in the
 
substance of the organ. The pancreas was closely adherent to
 
the caseated retroperitoneal lymph glands, and its substance
 
showed large caseating areas.
 
  
The stomach was adherent to the transverse colon, the
 
pancreas, and to the mass of enlarged peripancreatic lymph
 
glands. The serous coat was covered with small and large
 
caseous tubercles. Midway between the pylorus and the
 
cardia on the posterior aspect of the lesser curvature, was a
 
large, irregularly oval, crater-like erosion, 3 cm. by 2 em. in
 
size. The edges were raised and somewhat undermined and
 
more deeply congested than the surrounding parts. The
 
floor was irregular, the deepest part of the crater measuring
 
8 mm., while the remainder was formed by projecting caseous
 
tubercles. Directly behind this ulcer was a caseous lymphatic
 
gland, so closely adherent to the stomach wall at this point
 
that it was impossible to tell whether or not it formed the
 
floor of the ulcer. A second smaller erosion was found above
 
this one, in the middle of the lesser curvature. Its edges
 
were slightly elevated, and in one place deeply undermined,
 
the floor being formed by the muscularis. Here and there
 
scattered through the mucous membrane were minute grayish
 
white and yellow points looking like, but not proven to be,
 
miliary tubercles. In the duodenum, just beyond the pyloric
 
orifice, was a large ulcer with caseous tubercles covering its
 
base; a similar but still lai-ger one was found in the cajcum,
 
and smaller ones scattered through the small intestines.
 
  
In the microscopic examination of the larger of the two
 
gastric ulcers, the section passed also through the adherent
 
lymph gland, which was found to be completely necrotic. It
 
  
 +
LEGENDS.
  
 +
Fig. 1. Sagittal section through brain of a child one month old stained by the
 +
Weigert-Pal method. lAfter FUchsig.)
  
Apbil, 1897.]
+
a. Taenia thalaini optici iretiex path tor the transference of olfactory
  
 +
impressions to the centres governing the movements of the
 +
head ?).
  
 +
b. White matter of septum pellucidum (in part running between the
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
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.)
  
79
+
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.
  
was intimately adherent to the stomach, separated only by the
+
Fio. 3. Horizontal section from the brain of a child a little over a week old.  
remains of the muscular wall from the caseous masses within
+
{After Flcchxig.)
the stomach wall proper. The mucous membrane for quite a
 
distance around the ulcer was infiltrated, becoming more or less
 
necrotic at the edges, which were elevated and undermined.  
 
The deepest part of the ulcer had for its floor the muscularis,
 
but the walls were formed by large caseous tubercles, some of  
 
which were completely necrotic. In the overhanging edge,
 
which was formed by mucosa, and throughout the mucosa
 
generally, were found small tubercles which, for the most
 
part, had originated in the submucosa or muscularis mucosse.
 
They represented all stages of tubercle formation. Giant
 
cells were present in great numbers. Sections stained by the
 
Ziehl-Neelsen method showed numerous tubercle bacilli, both
 
in the superficial and deep layers.  
 
  
In this case the question naturally arose whether or not the
+
C. Nucleus oaudatus.
ulcerative process in the stomach was merely secondary,
+
P. Putamen of the nucleus lenticularis.
having been caused by the adherent lymph gland which had
+
gp. Globus pallidus of the nucleus lenticularis.
ulcerated through to the free surface. The microscopic
+
The optic radiation is well medullated ; the auditory path is not yet medullated
examination proved, however, that the process in the stomach
+
as far as the cortex.  
was quite independent in its origin, as the still intact muscular
 
wall could be traced along the whole extent of the ulcer
 
between it and the caseous gland behind.  
 
  
Bibliography.  
+
Fig. 4. Sagittal section through the brain of a child said to have died in the
Litten : Virchow's Archiv, 1876.
+
fifth month of life. (The child was probably some months older.) (After Fleclmii.)
Talamon ; Progres Medical, 1879.  
+
All parts of the white substance medullated, only in places still mixed with
Brechemin: Bull. d. 1. Soc. Anat., May 1879.
+
non-medullated fibres.  
Eppinger: Prager Med. Wochenschrift, 1881.  
 
  
 +
C, P. (IP, as in Fig. 3.
 +
T. Thalamus (lateral nucleus).
 +
II. External geniculate body.
  
 +
X. Substantia iiinominata Rei! (gray substance between the n. lenticularis and the n. amygdalse).
 +
M. Nucleus amygdalir.
  
Barbacci : Lo Sperimentale, May 1890.  
+
x—y. Projection fibres of the anterior upper and inner part of the
 +
somiEsthetic area (KOrperfiihlsphiire); these run from the
 +
internal capsule (between P and C) forwards and bend around
 +
at an acute angle at x to pass upwards and inwards.
 +
V. Lateral ventricle.  
  
Coats : Glasgow Med. Journal, 1886.  
+
Fig. .5. External view of right cerebral hemisphere, showing sense-centres and
 +
association-centres. (After Fle.chxig.) The more closely dotted areas show the regions
 +
in which the majority of the sensory projection fibres terminate. The large areas
 +
between the dotted areas represent the association centres.  
  
Serafini : Annal. clin. del Osp. di Napoli, 1888.  
+
Fio. 6. Internal view of left cerebral hemisphere. (After FUchHg.)
  
Mathieu and Remond : In Letorey's Thesis, Paris, 1875.  
+
1. Corpus mammillare.  
  
Musser: Phila. Hosp. Reports, 1890, I.  
+
2. Median section of optic chiasm.  
  
Kiihl : Thesis, Kiel, 1889.  
+
3. Cross-section of anterior commissure.  
  
G. Hebb: Westminst. Hosp. Reports, 1888, III.  
+
4. Superior colliculus of corpora i|uadrigemina.  
 +
.5, Corpus callosum (cross-section).  
  
Lava: Gazz. Med. di Torino, 1893.  
+
6 Fornix.  
  
Letorey: These, Paris, 1895.  
+
7. Septum pellucidum.
 +
z. Pineal gland.
 +
H.S. Tegmentum.
 +
T. Basis pedunculi.  
  
Hattute: Gaz. des Hop., 1874.
 
  
Lorey: Bull. d. 1. Soc. Anat., 1874.
 
  
Anger : In Marfan's Thesis, Paris, 1887.  
+
January, 1897.]
  
Marfan : These, Paris, 1887.
 
  
Matthieu : Bull. d. 1. Soc. Anat., 1881.
 
  
Cazin : In Fernet's article. Bull, et Mem. d. 1. Soc. Med. des
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
  
Hop., 1880, t6me XVII.
 
Beadles : British Med. Journ., 1893, II.
 
Duguet: In Spillman's These, Paris, 1878.
 
Paulicky : Berlin Klin. Wochenschrift, 1867.
 
Chvostek : Wieu. Med. Blatt., 1882, V.
 
Lange: Memorabilien. Heilbroun, 1871, XVI.
 
Barlow : Path. Soc. London, 1887.
 
Pozzi : Bull. Soc. Anat., 1868.
 
Labadie-Lagrave : Bull. Soc. Anat., 1870.
 
Oppolzer: In Marfan's These, Paris, 1887.
 
Quenu : In Marfan's These, Paris, 1887.
 
Oordua: Arbeiten aus dem pathalog. Institut in Gofctingen.
 
  
Berlin, 1893.
 
  
 +
11
  
  
STUDIES ON TRICHINOSIS.
 
  
 +
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.
  
By T. R. Brown.  
+
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.  
  
 +
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.
  
 +
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.
  
[Abstract of remarks and discussion before i
+
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
  
The clinical history of the case which forms the basis of
 
these remarks resembles in some respects the classical picture,
 
though the symjjtoms were unusually mild. The patient, a
 
man 23 years of age, was admitted to the hospital on March 3,
 
1896, complaining of general muscular pains. He had been ill
 
six weeks, and for the two weeks before entry the pain had been
 
so severe that he had scarcely been able to move about. There
 
were irregular fever and extreme muscular tenderness, particularly in the arms and legs. The diagnosis of a myositis,
 
probably due to trichinosis, was made and confirmed by the
 
finding of actively motile trichinfe in pieces of muscle removed
 
from the arm.
 
  
He remained in the hospital for over two months, being
 
discharged well.
 
  
During his stay in the hospital the blood was examined
+
uncolored in the diagram are the so-called association centres
daily. The number of leucocytes per cm. was determined and  
+
of Flechsig. They make up the main portion of the frontal
a differential count was made of the various forms; frequent
+
lobe, a large part of the temporal and occipital lobes, the
examinations of the urine were made with quantitative determinations of the uric acid, urea and total nitrogen. The two
+
island of Eeil, and occupy a large area in the posterior parietal region of the brain. For a whole month after birth these
small pieces of muscle which were removed were subsequently
+
portions of the cortex remain uuripe and are entirely devoid
subjected to careful microscopical examination. The results of  
+
of myelin. But after the development of the sense areas of the
the studies may be summarized as follows:
+
cortex, Flechsig has been able to follow baud after band of
 +
nerve fibres passing from the different sense areas into these
 +
other immature portions of the cerebral cortex, and ending
 +
there close beside one another, thus forming true centres of
 +
association between the different sense centres. And it is his  
 +
belief that these association centres represent arrangements
 +
which unite the activities of the central internal sense organs
 +
and build them up to higher units. Sensory impressions of
 +
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.
 +
 
 +
Flechsig believes, therefore, that these association centres
 +
are the portions of the cerebral cortex which above all others
 +
are concerned in the higher intellectual manifestations, in
 +
memory, judgment and reflection. If his theory be right, the
 +
study of the association centres should be the especial object
 +
of research for the neurologist and jisychologist. That they
 +
really are of definite importance for the intellectual activities
 +
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.  
 +
 
 +
It seems likely from Fiechsig's studies of the brain lesions
 +
in general paresis, that this disease more than any other will
 +
afford the key for the deduction of psychic disturbances from
  
(rt) The blood. The study of the blood was carried on con
 
  
  
the Johns Hopkins Hospital Medical Society.]
+
12
  
tinnally during the course of the disease, a determination of
 
the leucocytes and a differential count of the various forms of
 
leucocytes being made daily. The result of these observations
 
showed : (a) A gradual rise of the proportion of eosinophiles,
 
reaching 68.2 per cent — 35 per cent, higher than any previous
 
record — and from this point a gradual decline to 16.8 per
 
cent, on the patient's discharge; (b) a coincident depression
 
of the polymorphonuclear neutrophiles, reaching at one time
 
6.6 per cent., while for two weeks these forms showed an absolute decrease in the blood, notwithstanding (c) the marked
 
leucocytosis, reaching on some occasions above 30,000 per cubic
 
millimetre.
 
  
In fact, the neutrophiles and eosinophiles showed at all
 
times an inversely proportional relation, and the eosinophilic
 
rise could be seen to be distinctly at the cost of the neutrophiles,
 
the other forms showing relatively little fluctuation.
 
  
The presence of such quantities of eosinophiles suggests
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
their possible diagnostic value in trichinosis, and perhaps, if it
 
be found on further studies to be characteristic of this disease,
 
may help to clear up the cases which are regarded intra vitam
 
as rheumatic in nature and which, years afterward, the
 
autopsy table shows to have been cases of trichinosis.  
 
  
As an association has for a long time been noted between
 
  
  
 +
pfo. 70.
  
80
 
  
  
 +
alterations in the cerebral substance. In cases of the disease
 +
in which the lesions are widely diffused over very many different areas of the cortex, no reliable conclusions can be drawn
 +
regarding the significance of the association centres ; but occasionally the disappearance of nerve fibres is limited almost
 +
entirely to the association centres, and in some instances
 +
especially favorable for the study of function, the frontal association centre alone or the large posterior parietal association
 +
centre alone is chiefly diseased.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
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
  
  
[No. 73.
 
  
 +
self-control, and may show deep perversity of feeling or of the
 +
will, the specific character of the disease-picture consisting in
 +
his inability to recognize external objects, that is, to associate
 +
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.
  
the eosinophiles and the Charcot-Leydea crystals, various
+
Time will not permit me to discuss the so-called functional
experiments were made with the blood which contained such
+
disturbances ascribable to conditions of exhaustion of different cortical areas dependent upon prolonged and violent
large quantities of eosinophiles, to see if the crystals could be
+
emotion, various intoxications, impoverishment of the blood,
derived directly from these cells. In all cases, however, the  
+
and other causes. Suffice it to say that, on theoretical grounds
results were negative, seeming to show that the crystals are, at  
+
at least, more or less sharp criteria can be mentioned for the  
least, not direct crystallization products from the eosinophiles,  
+
participation in the process of the different centres, especially
but that something besides the presence of these cells is necessary for their formation.  
+
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.  
  
{b) The uruie. The quantitative determinations of the uric
+
Flechsig's researches have established the fact that the  
acid, urea and total nitrogen were carried on mainly in connection with the ideas of Horbaczewski, that the uric acid,
+
human cerebral cortex is made up of at least seven anatomically more or less well separated areas. As the phrenologists
derived from the destruction of nuclein -holding material,
 
comes normally in large part from the leucocytes and is therefore increased in leucocytoses.
 
  
Although the uric acid per 34 hours was determined on 23
 
different days, and on four of these the urea and total nitrogen
 
also, on no occasion did the total uric acid excretion, or the
 
relation between the nitrogen of the uric acid to that of the
 
urea or to the total nitrogen exceed the normal limits, showing that the views of Horbaczewski are not universally correct.
 
In this case, however, the leucocytosis differed somewhat from
 
the ordinary in that here the eosinophiles were the cells markedly increased ; in his cases the ordinary polymorphonuclear
 
neutrophiles.
 
  
(c) The mus'ie. The changes in the muscle were extensive.
 
There was a great proliferation of the muscle nuclei throughout the section ; about the fibres containing trichina? this proliferation was very marked, especially in the second specimen ;
 
not so extensive in the earlier specimen. In fact, in a few
 
places where the parasite had but just wandered into the
 
primitive bundle no change in the muscle substance nor any
 
proliferation of nuclei was visible. Most of the fibres containing the worm showed a conversion of the muscle substance
 
into a finely granular faintly-staining material containing
 
many large swollen nuclei, i. e. the proliferated muscle nuclei ;
 
and about many of the proliferated nuclei, both in the more
 
and in the less degenerated portions, distinct vacuoles could
 
be made out.
 
  
Throughout the specimens the muscle showed various forms
+
January, 1897.]
of disintegration, in some places a longitudinal splitting of
 
the fibres into fibrillaj, in other places the formation of what
 
might be called muscle cells, the muscle nucleus taking about
 
itself some of the muscle substance and separating itself from
 
the fibre; while in still other places a peculiar transverse
 
splitting up of the muscle into disks, the nuclei here proliferating transversely instead of in the usual longitudinal method,
 
was noted.  
 
  
Besides these changes there were seen in the first specimen many polymorphonuclear cells, some showing a finely
 
granular protoplasm which did not stain to any extent with
 
acid stains (the so-called neutrophiles), some distinct eosinophiles with large deeply-staining granules, and beside these,
 
cells which somewhat suggest transitional forms, showing in
 
the protoplasm of the cell body fine granules, but with a
 
distinct affinity for the acid stain ; and all these cells seemed
 
to be acting as phagocytes in the disintegrating muscle, being
 
often seen in little lakes or bays in the degenerating bits.
 
  
In the second specimen there were decidedly fewer neutro
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
philes and many more eosinophiles tlian in the first. That in
 
  
both cases these were typical eosinophiles was shown by staining them in the different acid stains and in the Biondi-IIeideuhein triple stain.
 
  
At the same time with this greatly increased projiortiou of
+
13
eosinophiles in the extra-vascular leucocytes in the muscle,
 
Ihe Mood vessels in the inferfascicuhir connective tissue showul
 
the same proportion of neutrophiles and eosinophiles as icas
 
found in the blood count for that day.
 
  
In another specimen of muscle from a case of acute trichinosis which was obtained from the pathological museum, great
 
(juantities of eosinophiles were also found.
 
  
The study of the blood, showing the steady increase of the
 
eosinophiles at the expense of the neutrophiles, together with
 
the identical character of the nuclei of the two forms, would
 
tend to support the view held by some observers, that the
 
former variety of cells is derived by some transitional change
 
from the latter.
 
  
That such a change might take place in the muscle is suggested by the presence here of neutrophiles, eosinophiles, and  
+
thought, the brain is the organ of the mind, and the whole
what may be regarded as transitional forms, in large quantities.  
+
is in reality made up of multiple organs. But instead of calling
Particularly suggestive is the great disproportion between
+
these, as did the old phrenology, after certain qualities, friendship, good-nature, wit, firmness, and the like, thanks to
neutrophiles and eosinophiles seen in the second muscle specimen. Here the eosinophiles were much increased, the neutrophiles correspondingly decreased, while the blood-vessels in  
+
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  
the interfascicular connective tissue showed but the same proportion of these forms as was to be made out in the specimens of the peripheral blood for the same days. It is further
+
be roughly grouped as the somssthetic area, the visual sense
noteworthy that the eosinojihiles increased in number soon
+
area, the olfactory sense area and the auditory sense area ; the
after the increase in severity of the muscle symptoms, and
+
association centres for the present have to be designated
shortly after the decrease of those symptoms, diminished
+
according to their position as frontal or anterior, insular or
gradually, descending toward the normal point as the symptoms abated. Suggestive also is the presence of large numbers of eosinophiles in a specimen of muscle from another
+
middle, and parieto-occipital or posterior. Thus a distinct
case of acute trichinosis.  
+
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.  
 +
 
  
Dr. OsLBR. — This is the only case of trichinosis which has
 
been in the hospital, or it is safer to say the only case recognized, since we know that not infrequently the disease escapes
 
recognition or is mistaken for some other disorder. This is
 
the second case which I have seen clinically, while in the postmortem room I have found on eight or ten occasions the calcified cysts. Mr. Brown is to be congratulated on the very
 
thorough way in which he has followed this case.
 
  
Dr. Thayer. — The evidence offered by Mr. Brown in favor
+
address upon the " Border-lands of mental health and disease,"
of the origin of the eosinophilic cells by transition from the  
+
has laid especial emphasis upon the significance of the somajsthetic area. Assuming it to be the portion of the cerebral
so-called neutrophiles is very suggestive. The total number
+
cortex where impressions regarding the body enter into consciousness, the centre which appears to have to do with the
of polymorphonuclear cells found in the circulating blood
+
bodily emotions and bodily needs, and upon the excitability
was practically what one would expect in a leucocytosis of that
+
of which the crudity or delicacy of the instincts which enter
extent. And yet, examining this percentage which normally
+
into consciousness depends, as well as the centre whence start
should consist almost absolutely of so-called neutrophilic
+
nearly all motor impulses which are concerned in conduct, be
leucocytes, we find the great majority represented by eosinophiles. The fact also that in the affected parts the bloodvessels contained the same relative proportion of eosinophiles
+
they those leading to the closure of the fist, the pressure of the  
and neutrophiles as did the peripheral vessels, while the  
+
hand, or the most delicate embrace, Flechsig believes that this
tissues round about contained an enormously greater percentage of eosinophiles, is very interesting.  
+
somsesthetic area is to be looked upon as the main organ of
 +
character. This cortical area, connected as it is on the one
 +
side directly with the peripheral sensory and motor apparatus
 +
of the body, and on the other with the higher association
 +
centres in the cortex, stands, as it were, like a buffer intercalated between the organs of the body and the organs of the
 +
intellect. The character of the activities manifested by these
 +
complex cortical centres of which the somfesthetic area is
 +
made up, may thus be influenced from either of the two sides.  
 +
As Flechsig says, it represents a sort of arena in which, at
 +
least in the more nobly endowed natures, the lower inpnlses
 +
struggle for the mastery with the higher feelings and ideas.
 +
To follow this struggle between the reciprocal influences of the
 +
body and the intellect will form one of the most stimulating
 +
problems of brain investigation, especially when it is remembered that the subject is of eminently practical significance.
 +
In the investigation of the brain it will be necessary to study
 +
the conditions which lead to an ennobling of the sensual
 +
instincts, whether it come immediately through bodily influences or from the other side through the intellect. Since,
 +
further, in these studies the presumptive existence of an  
 +
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.  
  
That the so-called neutrophilic granules stain often with  
+
Furthermore, Flechsig sees in these newer studies the essential preparation for a physiological basis of ethics, so much
acid coloring matters is well known. With good acid dyes
+
desired by some of the writers of the last century. Inasmuch
 +
as the health of the cerebrum is essential for the control of
 +
the lower centres concerned with the instincts and emotions,
 +
as is proven by the cessation of the struggle between the instincts and the ethical feelings where the intellectual centres are
 +
paralyzed, and inasmuch as we now know some of the causes
 +
of the diseases of the sense centres and of the association centres,
 +
and are convinced that many of these causes are removable or
 +
avoidable, the etliical significance of these studies becomes
 +
manifest.  
  
 +
It must be the aim of educators to enlighten the people concerning the hygiene of the body and especially of the brain.
 +
We must not fear to teach the intimate interdependence of
 +
bodily conditions and mental phenomena, or hesitate to let the
 +
masses know that the abuse of alcohol, the over-indulgence of
 +
the passions, and mental and physical excesses of all descrip
  
  
April, 1897.]
+
14
  
  
Line 1,372: Line 1,770:
  
  
81
+
[No. 70.
 +
 
 +
 
  
 +
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."
  
  
these granules almost always take a slight stain, and by sonie
 
obseryei'S botli eosiuophiles and neutropbiles are classed as
 
acidophilic cells. They stain, however, much better in fluids
 
consisting of a mixture of acid and basic coloring matters. As
 
Mr. Brown has sharply pointed out, this acid staining of the
 
smaller granules was uot to be made out at all in the specimens
 
of blood and in the blood-vessels in the tissues, and the fact
 
that outside of the vessels in the affected parts numerous
 
apparent transitional forms between the non-granular polymorphonuclear wandering cells and the true eosinophiles
 
existed is very suggestive. That these cells were true eosiuophiles in the sense of Ehrlich, Mr. Brown has proven by
 
careful tests with a number of different acid coloring matters.
 
  
The idea that the eosiuophiles represent a further change in
+
NOTES ON NEW BOOKS.  
the cell which we know as the neutrophile is, as Mr. Brown
 
has said, not a uew one, but I am not aware that any argument
 
in favor of this view as forcible as that which he presents
 
has yet been published.  
 
  
With regard to the actual blood condition — the increase of  
+
Practical Points in Nursing, for Nurses in Private Practice, with an
the eosinophiles — no similar case exists in the literature; the
+
Appendix. By Emily A. M. Stoney, Superintendent of Training
percentage of eosiuophiles in this instance is moi"e than
+
School for Nurses, Carney Hospital, Boston. Illustrated with 73
twice as large as has been reported in any other case.  
+
engravings and 9 colored and half-tone plates. {Philadelphia:
 +
W. B. Saunders, 1896.)
  
Dr. Barker. — Mr. Brown has referred, in speaking of the  
+
This little book is primarily designed for the instruction of
degeneration of the muscle, to a splitting up' of the muscle
+
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
fibre into transverse disks. I should like to ask him whether
+
used for the instruction of classes, and for the home nurse, for
or not he has been able to make out just where the splitting
+
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.  
  
 +
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
  
occurred. Though several histologists have emphasized the
 
fact, it does uot appear to be generally kuown that the splitting iu the muscle fibre may occur with some reagents at one
 
level, with other reagents at an entirely different level. Thus
 
in the formation of the so-called Bowman's disks through the
 
action of alcohol, the two layers Q (doubly refractive substance of Briicke) with the layer M (Hensen's line) in
 
between are always present in the disk. On the other hand,
 
ou treatment of muscle with certain acids (acetic, picric or
 
hydrochloric), the splitting occurs between the two layers
 
Q, each disk having then in its middle the layer Z (Krause's
 
transverse line or membrane). It would be interesting to
 
know, for the degeneration described, whether the splitting
 
occurred at either of these two levels or at still another level.
 
  
I gather from his paper that Mr. Browu favors the view
+
thalmia neonatorum is inflammation of the conjunctiva, which is  
that the eosinophile granules represent the cyto-mikrosomas
+
one of the coats of the eyeball. Its causes are numerous, but in
of the cells in which they occui\ This view, recently si;pported
+
the newborn it is generally caused by infection during birth from
by Lovell Gulland, was previously urged by Martin Heidenhain, who found that the eosinojjhile granules stain black with
+
the urethral or vaginal discharges of the mother."
his iron-haamatoxylin staining method, and that it is often
 
possible to make out an arrangement of the granules radial to
 
the attraction sphere of the cell. Both these observations are  
 
in favor of the cyto-mikrosomal nature of the granules.  
 
  
The occurrence of such an enormous number of eosinophiles
+
The chapter in which directions are given to nurses as to their
in the circulating blood is truly remarkable and makes the  
+
conduct is clearly and judiciously written. Some nurses would
case unique in the bibliography.  
+
doubtless take exceptions to the author's declaration that " it is
 +
not degrading to the nurse to assist in tlie kitchen when emergencies arise ; it shows the true spirit of a nurse, and the kindness
 +
is not lost." Tlie chapters also on the Sick Room, of the Patient,
 +
and Accidents and Emergencies, are to be commended. The
 +
book is well printed and illustrated, and has a good index.  
  
 +
Practical Notes on Urinary Analysis. By W. B. Caxfield, M. D.
  
 +
{Published by Oeorge 8. Davis, Detroit, 1896.3
  
PROCEEDINGS OF SOCIETIES,  
+
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.
  
 +
Diseases of the Eye. A [Hand-book of Ophthalmic Practice for
 +
Students and Practitioners. By G. E. deSchweinitz, A. M., M. D.,
 +
Professor of Ophthalmology in Jefferson Medical College, etc.
 +
With 256 illustrations and 2 chromo-lithographic plates. Second
 +
edition, thoroughly revised. {Philadelphia : W. B. Saunders,
 +
1896.)
  
 +
This admirable textbook of ophthalmology is so well and so
 +
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.
  
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.  
+
For the bibliography of tlie first edition an appendix containing
 +
a description of the method of using the ophthalmometer of Javal
 +
& Schiotz and the tropometer of Stevens has been substituted. The
  
Meeting of December 7, 1896.
 
  
Dr. Thayer in the Chair.
 
  
On Certain Visceral Pathological Alterations, the Result of
+
January, 1897.]
Superficial Burns.— Mr. Bardebn.  
 
  
Extensive superficial burus are followed by severe constitutional symptoms. The great pain felt at first is followed by a
 
benumbing of the senses and by sleepiness. At times there
 
may be delirium and cramps. The pulse becomes weak, the
 
respiration shallow and irregular. The temperature, after a
 
short rise, falls below the normal. There may be vomiting
 
and diarrhcea, and haamoglobin may appear in the urine.
 
Death within 48 hours usually follows a burn which has
 
involved two-thirds of the surface of the body. The burn
 
need not be of an extreme grade. Death has often followed
 
burns so superficial as to give rise merely to an erythema.
 
  
It is clear from this latter class of cases, at least, that alterations in the internal organs may follow the burning of the
 
skin which cannot be accounted for on the supposition that
 
they are directly caused by the heat. Thus arises the question as to the nature of the physiological relations between the
 
lesions produced in the skin and the resulting constitutional
 
effects. Many hypotheses have been advanced to answer this
 
question, some of which have been supported and others
 
destroyed by experimental work on animals.
 
  
Many of these hypotheses have been based upon the con
+
JOHNS HOPKINS HOSPITA.L BULLETIN.
  
  
ception of a loss of normal cutaneous activity. But experiment has shown quite conclusively that death after burns is
 
to be ascribed neither to the retention in the blood of products normally excreted through the skin, nor to heat radiation due to paralyzed blood-vessels in the latter structure.
 
  
Again death has been referred to changes produced in the  
+
15
blood itself directly acted upon by the high temperature. It is
+
 
known that erythrocytes are destroyed by a comparatively low
+
 
temperature (55° 0.). This has led to the supposition that
+
 
the general pathological effects are due to loss of functional
+
chapter on operations has been enlarged and rewritten, and those
red blood corpuscles, or to irritation produced in the kidneys
+
on General Optical Principles and on Abnormal Refraction, which
and other internal organs by the products of their disintegration. But a more generally accepted view is that the blood is
+
were contributed to the first edition by Dr. James Wallace, have
so altered by the elevation of temperature as to give rise to
+
been revised by Dr. Edward Jackson, who has also recast the  
extensive thrombosis, death resulting from the disturbances of  
+
section written by himself upon Eetinoscopy.  
circulation.  
+
 
 +
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."
  
Another view has been advanced more recently. Kijanitzen, who extracted from the blood of dogs experimentally
+
The publisher has performed his part of the work ip a manner
burned, substances similar to Brieger's ptomains, and Eeiss,
+
worthy of especial commendation. S. T.  
who found toxic substances in the urine of persons accidentally burned, believe that they have brought forward evidence
 
in support of the idea that the blood in severely burned
 
animals is rendered toxic.  
 
  
During the past year five small children were brought to the
+
A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D.
Johns Hopkins Hospital so severely burned that death in each
+
With 163 illustrations in the text and 6 full-page plates. (Philadelphia: W. B. Saunders, 1896.)
case followed within a very few hours of the accident. At the
 
suggestion of Dr. Flexner I took this opportunity of studying
 
  
 +
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.
  
82
+
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.)
  
JOHNS HOPKINS HOSPITAL BULLETIN.
+
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
  
[No. 73.  
+
the whole book is thoroughly modern. It is gratifying to observe
  
 +
that the author shares the opinion of Koch that the best of all
  
  
the histological alterations found in the tissues of the body
 
after burns. A careful autopsy was made in each case by Dr.
 
Flexner, and parts of the various organs were preserved and
 
prepared for microscopic examination.
 
  
The lesions in all five cases were strikingly similar. Of the  
+
water supplies for a city is that obtained from deep wells. The  
gross lesions the most notable were cloudy swelling of the
+
sourcesof water pollution are clearly described and well illustrated.
liver and kidney, acute swelling of the spleen, and swelling and
+
We are pleased to see that careful directions are given for the
congestion of the lymphatic glands and other lymphatic tissue.  
+
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.  
  
Microscopically, the most interesting lesions noted were
 
parenchymatous degeneration of the kidneys and liver, focal
 
areas of necrosis in the liver, and pronounced focal necrosis
 
in the lymphatic tissue.
 
  
The lymphatic tissue was affected throughout the body.
 
The Malpighian corpuscles of the spleen, the tonsils, gastric
 
lymphatic follicles, enteric solitary and agminated follicles
 
and the lymphatic glands all showed essentially the same
 
changes.
 
  
The lymphatic glands were much swollen and at times congested. The earliest changes were in the follicles and consisted
+
BOOKS RECEIVED,  
of an ojdematous swelling. This was more marked towards
 
the centre of the follicle, in an area corresponding to the
 
germinal centre. In areas of less advanced alteration the
 
lymphocytes were merely less closely packed together than is
 
usual. But in the areas of more marked change, the lymphocytes were swollen and their nuclei fragmented. In these
 
cases the follicle presented a remarkable appearance. It was
 
not only greatly swollen, but at the edges a rim of closely
 
packed lymphocytes existed, while at the centre swollen and
 
distorted lymph cells, bits of protoplasm and fragments of
 
nuclei were seen scattered about, some lying free, others enclosed
 
in large flat endothelioid cells.
 
  
The lymph cords as well as the follicles were swollen, while
 
the lymph sinuses seemed less distinctly marked off than
 
usual from the reticulum in which the lymphocytes of the
 
cords lie imbedded. Here and there throughout the gland
 
groups of degenerating cells might be seen, but the areas of
 
distinct focal degeneration were confined as described above,
 
to the follicles.
 
  
Calvert has shown that the terminal artery breaks up in the
 
centre of the follicle into capillaries which radiate towards
 
the periphery of the follicle. It seems possible that the lesions
 
focalized just at this region may in some way hold special
 
relation to the circulation of tlie blood. For if the blood in
 
these cases contains toxic materials, it is conceivable that it
 
is just at the centre of the follicle that the poisonous plasma
 
acts with greatest intensity on the lymph cells.
 
  
In the lymphatic follicles of the tonsils and stomach and in
+
Transactions of the Association of American Physicians. Eleventh
the Malpighian bodies of the spleen focal degeneration essentially similar to that of the follicles of the lymphatic glands
+
Session held at Washington, D. C, April 30 and May 1 and 2,  
occurs. In the intestines the greatly swollen lymphatic follicles, solitary and agminated, showed extensive focal areas of
+
1896. Vol. XI. 8vo. 1896. 453 pages. Printed for the Association. Philadelphia.  
degeneration.  
 
  
In these areas of degeneration in the lymphatic tissue we
+
Transactions of the Medical Society of the State of Pennsylvania.  
find appearances essentially similar to those seen after the
+
Forty-sixth Annual Session, held at Harrisburg, 1896. Vol.
injection into the body of various bacterial and other toxalbuminous substances. Indeed, the lymphatic glands from
+
XXVII. 8vo, 499 pages. Published by the Society. The Edwards & Docker Co., printers, Philadelphia.
our cases of skin-burn might readily be mistaken for the  
 
lymphatic glands of children dead of diphtheria. The  
 
  
 +
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.
  
lesions in the other organs are also essentially similar to those
+
A Te.vt-book of Histology, Descriptive and Practical. For the use of  
found in the bodies of persons dead from the acute infectious
+
students. By Arthur Clarkson, M. B., C. M. Edin. 1896. 8vo,  
diseases. It seems, therefore, justifiable to consider that one
+
554 pages. W. B. Saunders, Philadelphia.  
of the main causes of death after burns is to be sought in a
 
toxaemia caused by alterations in the blood and tissues, the
 
direct effect of the elevation of temperature; a view which is
 
further strengthened by the clinical evidences and the experimental work of Kijanitzen and others.  
 
  
 +
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.
  
NOTES ON NEW BOOKS.  
+
A Text-Book of Materia Medica, Therapeutics and Pharmacology. By
 +
George Frank Butler, Ph. G., M.D. 1896. 8vo, 858 pages. W.  
  
The American Year-Book of Medicine and Surgery : being a yearly
+
B. Saunders, Philadelphia.  
digest of scientific progress and authoritative opinion in all
 
branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign
 
authors and investigators. Collected and arranged, with critical
 
editorial comments, by J. M. Baldy, M, D., and twenty-six
 
other physicians, under the general editorial charge of George
 
M. Gould, M. D. [Philadelphia, 1897 : W. B. Saunders, 925 Walnut Street.)
 
  
This year-book amply justifies the high expectations which were
+
Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America.  
excited by the excellent character of the similar volume published
+
Edited by Thomas L.Stedman, M. D. Vol. VII. Diseasesof the  
last year. It is an encyclopedic collection of new medical literature
+
respiratory organs and blood, and functional sexual disorders.
gathered from all lands and every field of medical knowledge. It
+
1896. 8vo, 796 pages. William Wood & Co., New York.  
is not a mere aggregation, but a discriminating digest of the latest
 
knowledge in medicine, with frank opinions and critical comments
 
by painstaking and competent men. The special comments of the
 
editors as distinguished from the authors are enclosed in brackets,  
 
to facilitate reference to them.  
 
  
The completeness of the department of medicine, which has had
+
A Treatise on Appendicitis. By John B. Deaver, M. D. Containing
the editorial supervision of Pepper and Stengel, is shown by the
+
32 full-page plates and other illustrations. 8vo. 1896. 168 pages.  
fact that it covers more than 180 pages. Among other interesting
+
P. Blakiston, Son & Co., Philadelphia.  
matter the sections on the Schott method, typhoid fever, malaria
 
and myxedema are probably of the most interest. In view of the
 
extravagant claims for the different methods of aborting typhoid
 
fever, it is gratifying to notice that the authors ask that all cases
 
treated by these methods be more carefully studied and the symptoms more minutely described.  
 
  
Under the head of surgery, which occupies 248 pages of the volume, Keen and DaCosta give a valuable resume of the most recent
+
Index-Catalogue of the Library of the Surgeon-Oeneral's Office, U.S. A.
work in ansesthetics, with sensible comments upon the dogmatic
+
Authors and subjects. Second series- Vol. I. A-Azzurri. 1896.
assertions of many experimenters. It is refreshing to read the
+
4to, 828 pages. Government Printing Office. Wathington.
following: " Wunderlich, from a statistical study, concluded that
+
 
albuminuria was more apt to be induced by chloroform than ether.  
+
Transactions of the Texas State Medical Association. 28th annual
Beck from a statistical study concluded that albuminuria was most
+
session held at Fort Worth, Texas, April 28th-30tli and May 1st,  
apt to be caused by ether. We are thus confronted by carefully
+
1896. 8vo, 458 pages. Eugene von Boeckmann, printer, Austin,
compiled reports which are diametrically opposed and absolutely
+
Texas.  
contradictory. The humble surgeon who venerates statistics too
+
 
much to use them is lost in uncertainty. We are told that figures
+
The British Guiana Medical Annual. Ed. by J. S. Wallbridge and
cannot lie, and yet only one of these statements can be true. Which
 
is the truth we cannot yet decide, as we know of no birthmark to
 
prove identity."
 
  
The operative treatment of perforation in enteric fever would
+
C. W. Daniels. Eighth year of issue. 8vo, 1896. 95 -}- xxxix
seem to be presented in too gloomy colors, in the light of Finney's
+
pages. Printed by Baldwin & Co., Demerara.  
recent statistics.  
 
  
The article on diseases of the gall-bladder is quite full and satisfactory. The same may be said of the careful and conservative
+
Twenty-seventh An7iual Report of tlie Slate Board of Health of Massachusetts, 1895. 8vo, 807 pages. Wright & Potter Printing Co.,
article on the use of the x rays.  
+
Boston. 1896.  
  
Obstetrics, under the editorship of Hirst and Borland, occupies
+
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.  
about 100 pages, and presents many topics of special interest to the
 
general reader, notably the sections on the pathology of pregnancy,  
 
abortion and extra-uterine pregnancy.  
 
  
The section on gynecology, by Baldy and Borland, occupies
+
Atlas of the Diseases of the Skin. By H. Radcliffe Crocker, M. D.,  
upwards of 200 pages, and touches upon a variety of interesting
+
F. R.C. P. Fol. n. d. 2 vols. Young J. Pentland, Edinburgh
 +
and London.
  
  
  
Apeil, 1897.]
+
16
  
  
Line 1,650: Line 2,077:
  
  
83
+
[No, 70.
 +
 
  
  
 +
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL
  
matter. The objection presented to Clark's radical operation for
 
the relief of uterine cancer, that but few patients can endure the
 
shock of the prolonged etherization, seems hardly tenable in the
 
light of actual practice. The chapter on nervous and mental diseases, by Church and Patrick, is thoroughly well worked out, and
 
presents a good review of the work of the past year. The section
 
on materia medica is an excellent feature of the book. All things
 
considered, the book is well arranged, admirably edited and well
 
printed. Every physician who does not have leisure to inform himself on the latest advances in medicine and surgery from original
 
sources, should procure and carefully read the volume.
 
  
Architecture of the Brain. By Wm. Fuller, M. D., Grand Rapids,
 
Michigan. 1896. Pages 1-183, with many illustrations.
 
In this volume are described and pictured the general gross relations of the brain as seen (1) from the external surface, (2) on dissection, and (3) in a series of frontal sections. The author has had
 
a large experience in dissection of the central nervous system and
 
in the preparation of castings in plaster of the dissections which he
 
has made. No person except one who has busied himself in work
 
of this kind can easily estimate the amount of labor which has preceded the publication of the book.
 
  
After a description of the membranes, thecerebro-spinal axis as a
+
THE JOHNS HOPKINS HOSPITAL REPORTS.  
whole is described. The cerebrum is then taken up and the method
+
Volume I. 423 pages, 99 plates.  
of dissecting it outlined. A discussion of the structure of the cerebellum, of the pons varolii, of the medulla oblongata and spinal
 
cord follows. Throughoutthe book the mainstressis laid upon the
 
gross morphology, but there are brief chapters concerning the nerve
 
tracts of the cerebro-spinal axis and the central origin and relations
 
of the cranial nerves. On pages 130-133 there is a brief discussion
 
of topographical cerebral localization. L. F. B.  
 
  
Annual Report of the Supervising Surgeon-General of the Marine
+
Report in Putliology.  
Hospital Service of the United States for 1893. Vols. I and II.
 
(Washington: Oovernment Printing Office, 1894-1895.)
 
These volumes present a very complete and satisfactory account
 
of the operations of the Marine Hospital Service for 1893. The most
 
valuable papers are a carefully prepared account, by Surgeon Stoner
 
of Baltimore, of the origin and development of this Service, which
 
should be read by all who desire to familiarize themselves with its
 
history, and the " Report of the Commission to Investigate the Cholera Epidemic," prepared by Dr. Walter Kempster and Surgeon Fairfax Irwin, who made an extensive trip in Europe to procure data for
 
it. It is to be regretted that the Commission, while entering into
 
very great detail as to its operations, does not formulate and publish its conclusions in connected form. Scattered throughout the
 
report are many valuable suggestions touching the prevention of
 
infectious diseases and the transmission of contagion, which can
 
only be found by reading many unimportant details. These should
 
have been gathered in an accessible form, so that they might be
 
easily read.  
 
  
Medical and Surgical Report of the Presbyterian Hospital in the  
+
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
City of New York. Vol. I., January, 1896. By Andrew J.
 
McCosH, M. D., and Walter B. James, M. D. (The Knickerbocker Press, New York.)
 
  
This report is the first of a series. It is carefully edited and
+
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the  
well illustrated. Many of the papers are carefully written and of
 
great interest to the general profession. The pathological reports
 
are meagre and the protocols published are in most instances brief
 
abstracts. Several of the papers have appeared elsewhere. One of  
 
them, that of Dr. Northrop, on Gonorrhoeal Arthritis, is more
 
popular than scientific, and portions of it read as it the author were
 
thinking aloud. The results of thinking rather than mental operations would be preferable. Taken as a whole, the surgical papers
 
seem to be of the greater value. The volume, however, is worthy
 
of the institution from which it issues and the high character of its
 
editors. It is to be hoped that it will have an annual successor.
 
  
 +
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D,
 +
A Contribution to the Pathulog-y of the Gelatinous Type of Cerebellar Sclerosis
  
 +
(Atrophy). By Henry J. Berkley, M. D.
 +
Reticulated' Tissue and its Relation to the Connective Tissue Fibrils. Bv F. P.
  
BOOKS RECEIVED.  
+
Mall, if. D.  
  
Transactions of the American Gynecological Society. Vol. 21. 1890.  
+
Report in Dermatolog-y.
 +
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
  
8vo. 490 pages. Wm. J. Dornan, Printer, Philadelphia.  
+
T. C. Gilchrist, M. D., and Emmet Rixford. M. D.
Prize Essays on Leprosy. By Newman, Ehlers and Impey. 1895.  
+
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of
  
8vo. 227 pages. New Sydenham Society, London.
+
Protozoa, and the Blastomyces found in the preceding Cases, with the so-called
Practical Notes on Urinary Analysis. By William B. Canfield,
 
A. M., M. D. Second edition. 1896. 12mo. 106 pages. G. S.
 
Davis, Detroit, Mich.
 
A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In photolithochromes from models in the Museum of the Saint-Louis
 
Hospital, Paris. With explanatory woodcuts and text. By E.
 
Besnier, A. Fournier, etc. Edited and annotated by J. J. Pringle,
 
M. B., F.R.C. P. Fol. Parts IV and V. 1896. W.B.Saunders,
 
Philadelphia.
 
Lectures on Pharmacology for Practitioners and Students. By Dr. C.
 
Binz. Translated from the second German edition by Arthur C.
 
Latham, M. A., M. B. Oxon., M. A. Cantab. Vol. 1. 1895. 8vo.
 
389 pages. The New Sydenham Society, London.
 
Autoscopy of the Larynx and the Trachea. (Direct Examination without
 
Mirror.) By Alfred Kirstein, M. D. Authorized translation
 
(altered, enlarged and revised by the author) by Max Thorner,
 
A. M., M. D. 1897. 12mo. 68 pages. The F. A. Davis Co.,
 
Philadelphia.
 
The Practice of Medicine. By James Tyson, M. D. 1896. 8vo.
 
 
 
1184 pages. P. Blackiston, Son & Co., Philadelphia.
 
Anomalies and Curiosities of Medicine. By George M. Gould, A. M.,
 
M. D., and Walter L. Pyle, A. M., M. D. 1897. 4to. 968 pages.
 
W. B. Saunders, Phila.
 
A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In Photo-Lithochromes from Models in the Museum of the Saint Louis
 
Hospital, Paris, with explanatory woodcuts and text. By E.
 
Besnier et al. Edited by J. J. Pringle, M. B., F. R. C. P. Part
 
VI. 1896. W. B Saunders, Philadelphia.
 
A Treatise on Cholelithiasis. By B. Naunyn, M. D. Translated by
 
Archibald E. Garrod, M. A., M. D., F. R. C. P. 8vo. 197 pages.
 
1896. The New Sydenham Society, London.
 
Principles or Guides for a Better Selection or Classification of Consumptives Amenable to High Altitude Treatment and to the Selection of
 
Patients who may be more Successfully Treated in the Environment to
 
which they were Accustomed Previous to their Illness. By A. Edgar
 
Tussey, M. D. 1896. 8vo, 144 pages. P. Blakiston, Son & Co.,
 
Philadelphia.
 
Twentieth Century Practice. An international encyclopaedia of mod
 
ern medical science, by leading authorities of Europe and America
 
Edited by Thomas L. Stedman, M. D. Vol. X. 1897. 859 pages
 
8vo. Wm. Wood & Co., New York.
 
Transactions of the College of Physicans of Philadelphia. Third SeriesVol. XVIII. 1896. 8vo. 263 pages. Printed for the College
 
Philadelphia.
 
Injuries and Diseases of the Ear. Being reprints of papers on otol
 
ogy. By Macleod Yearsley, F. R. C. S. 12mo. 1897. 40 pages
 
The Rebman Publishing Co., Ltd., London.
 
The American Tear-Book of Medicine and Surgery. Being a yearly
 
digest of scientific progress and authoritative opinion in all
 
branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign
 
authors and investigators. Collected and arranged, with critical
 
editorial comments, by J. M. Baldy, '^l.D.,ei al. Under the general editorial charge of George M. Gould, M. D. Profusely illustrated. 4to. 1897. 1257 pages. W. B. Saunders, Philadelphia.
 
Inebriety. Its Source, Prevention and Cure. By Charles Follen Palmer. 12mo. 1897. 109 pages. Fleming H. Revell Co., New York.
 
The Medical Annual and Practitioner's Index. A work of reference
 
for medical practitioners. Fifteenth year. 1897. 12mo. 851
 
pages. John Wright & Co., Bristol.
 
Lectures on Angina Pectoris and Allied Stales. By William Osier,
 
M.D. 1897. 8vo. 160 pages. D. Appleton & Co., New York.
 
  
 +
Parasites found in Various Lesions of the Skin, etc. ; Two Cases of Molluscum
  
 
+
Fibrosum; Tlie Pathology of a Case of Dermatitis Herpetiformis (Duhring). By  
84
 
 
 
 
 
 
 
JOHNS HOPKINS HOSPITAL BULLETIN.
 
 
 
 
 
 
 
[No. 73.
 
 
 
 
 
 
 
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.
 
 
 
 
 
 
 
THE JOHNS HOPKINS HOSPITAL REPORTS.
 
Volume I. 423 pages, 99 plates.
 
 
 
Report in Patliolopry
 
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
 
 
 
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
 
 
 
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D,
 
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis
 
 
 
(Atrophy). By Henrt J. Berkley, M. D.
 
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.
 
 
 
Mall, M. D.
 
 
 
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
 
 
 
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 MoUuscum
 
 
 
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By  
 
  
 
T. C. Gilchrist, M. D.  
 
T. C. Gilchrist, M. D.  
  
Report in Pathology.  
+
Report in Pathologry.  
 
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration  
 
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration  
  
Line 1,835: Line 2,123:
  
  
Volume II. 570 pages, with 28 plates and figures.  
+
Volume II. 570 pages, witli 28 plates and figures.  
  
 
Report in Medicine.  
 
Report in Medicine.  
Line 1,841: Line 2,129:
 
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with  
 
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with  
  
Gallstones. By William Osler, M. D.  
+
Gallstones. By William Oslek. M. D.  
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.  
+
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, H. D.  
On Pyrodin. By H. A. Lafleur, M. D.  
+
On Pyrodin. By H. A. LxFLEnR, M. D.  
 
Cases of Post-febrile Insanity. By William Osler, M. D.  
 
Cases of Post-febrile Insanity. By William Osler, M. D.  
Acute Tuberculosis in an Infant of Four Months. By Harry TotJLMiN, M. D.  
+
Acute Tubercuiosis in an Infant of Four Months. By Harry Toulmin, M. D.  
 
Rare Forms of Cardiac Thrombi. By William Osler, M. D.  
 
Rare Forms of Cardiac Thrombi. By William Osler, M. D.  
Notes on Endocarditis in Phthisis. By William Osler, M. D.  
+
Notes on Endocarditis in PhtMsis. By William Osler, M. D.  
  
 
Report in Medicine.  
 
Report in Medicine.  
Line 1,854: Line 2,142:
 
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  
 
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  
  
Report in Gynecolog-yThe Gynecological Operating Room. By Howard A. Kelly, M. D.  
+
Report in Gynecology.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard  
+
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.  
 
A. Kelly, M. D.. and Hunter Robb, M. D.  
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards mth
+
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  
 
out Operation ; Composite Temperature and Pulse Charts of Forty Cases of  
  
Line 1,867: Line 2,156:
 
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;  
 
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;  
  
Ovarian Tumor; General Gynecological Operations from October 15, 1889, to  
+
Ovarian Tumor; General Gynecological Operations from October 15, 1SS9, to  
  
March 4, 1890. By Howard A. Kelly, M. D.  
+
March 4. 1890. By Howard A. Kelly, M. D.  
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howard  
+
Report of the ITrinary Examination of Ninety-one Gynecological Cases. By Howard  
  
A. Kellt, M. D., and Albert A. Ghrisrey, M. D.  
+
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  
 
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking  
  
 
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.  
 
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.  
+
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, il. D.  
 
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.  
 
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.  
 
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.  
 
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.  
 
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment  
 
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment  
  
of Ureteral Stricture; Record of Deaths following Gynecological Operations. Bv
+
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
  
HowARD A. Kellt, M. D.  
+
Howard A. Kelly, M. D.  
  
Report in Surgery, I.  
+
Report in Siirgery, I.  
The Treatment of Wounds with Especial Reference to the Value of the Blo.d C!ol
+
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.  
 
in the Management of Dead Spaces. By W. S. Halsted, M. D.  
Report in Nenrology, I.  
+
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.  
+
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.  
Haematomyelia. By August Hoch, M. D.  
+
Acute Angio-Neurotic Oedema. ' By Charles E. Simon, M. D.  
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. liv
+
Haematomyelia. By August Hoch, JI. D.  
 +
A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By
  
 
Henry M. Thomas, M. D.  
 
Henry M. Thomas, M. D.  
  
Report tn Pattiologry, I.  
+
Report in Pathology, I.  
Amoebic Dysentery. By William T. Councilman, M. D., and Henhi A. Lafleur, M. \\
+
Ama3bic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.
  
  
  
Volume III. 766 pages, with 69 plates and figures.  
+
Volume III. 766 pages, with 69 plates and figm-es.  
  
Report in Patliology.  
+
Report in Pathology.  
  
Papillomatous Tumors of the Ovary. By J. Whitridge Williams, M. D.  
+
Papillomatous Tumors of the Ovarj'. By J. Whitridge Williams, M. D.  
  
 
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
 
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
Report in Patliolosry.  
+
Report in Patliology.  
  
Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Flexner. M. D.
+
Multiple Lj-rapho -Sarcomata, with a report of Two Cases. Bv Simon Flexner, M. D,
  
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.  
+
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M". D.  
  
A Case of Chronic Nephritis in a Cow. By W. T. Councilman. M. D.  
+
A Case of Chronic Nephritis in a Cow. Bv W. T. Councilman, M. D.  
  
 
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
 
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
Line 1,920: Line 2,210:
 
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  
 
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  
  
Report in Gyneeolog-y.  
+
Report in Gynecology.  
  
The Gynecological Operating Room; An External Direct Method of Measuring the  
+
The Gynecological Operating Room; An Kxtornal Direct Method of Measurins: the  
Conjugata Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid  
+
Conjugata Vera; Prolapsus Uteri witliout Diverticulum and with Anterior Entorocele; Lipoma of the- Labium Majus; Deviations of the Rectum and Sigmoid  
 
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofiexed Uterus. By Howard A.  
 
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofiexed Uterus. By Howard A.  
 
Kelly, M. D.  
 
Kelly, M. D.  
Line 1,930: Line 2,220:
 
By Mary Sherwood. M. D.  
 
By Mary Sherwood. M. D.  
  
Intestinal Worms as a Complication in Abdominal Sui^ery. By A. L. Stavely, M. D.  
+
Intestinal Worms as a Complication in Abdominal Sxu-gery. By A. L. Stately, M. D.  
  
  
  
Gynecological Operations not involving Cceliotomy. By Howard A. Kelly, M. D.  
+
Gynecological Operations not invohnng Coeliotomy, By Howard A. Kellt, M. D.  
 
Tabulated by A. L. Stavely, M. D.  
 
Tabulated by A. L. Stavely, M. D.  
  
Line 1,942: Line 2,232:
 
Photography applied to Surgery. By A. S. Murray.  
 
Photography applied to Surgery. By A. S. Murray.  
  
Traumatic Atresia of the Vagina with Hamatokolpos and Hamatomctra. By Howard  
+
Traumatic Atresia of the Vagina with Haematokolpos and Haematometra. By Howard  
 
A. Kelly, M. D.  
 
A. Kelly, M. D.  
  
 
Urinalysis in Gynecology. By W. W. Russell, 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.  
+
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.  
  
Resuscitation in Chloroform Asphyxia. By Howard A. Kellt, M. D.  
+
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.  
  
 
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.  
 
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.  
Line 1,958: Line 2,248:
  
 
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to  
 
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to  
May 4, 1892.  
+
May 4, 1S92.  
  
  
Line 1,966: Line 2,256:
 
Report on Typhoid Fever.  
 
Report on Typhoid Fever.  
  
By WiLLLAM Osler, M. D., with additional papers by W. S. Thayer, M. D., and J.  
+
By William Osler, M. D., with additional papers by W, S. Thayer, M. D., and J.  
Uewetson, M. D.  
+
Hewetson, M. D.  
 
 
Report in Neurolog-y*
 
  
 +
Report in Neurology.
 
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The  
 
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The  
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the  
+
Intrinsic Pulmonao' Nerves in Mammalia; The Intrinsic Nerve Supply of the  
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of Mm mnscidus; The Intrinsic Nerves of the Thyroid Gland of  
+
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. Berkley,  
+
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berklet,  
 
M. D.  
 
M. D.  
  
Report in Snrg-ery,
+
Report in Surgery.
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to  
+
The Results of Operations for the Cure of Cancer of the Breast, from June, 1SS9, to  
 
January, 1894. By W. S. Halsted, M. D.  
 
January, 1894. By W. S. Halsted, M. D.  
  
Report in Gynecologr.  
+
Report in Gynecology.  
Hydrosalpinx, with a report of twenty-spven cases; Post-Operative Septic Peritonitis;  
+
Hydrosalpinx, with a report of twentv-seven cases; Post -Operative Septic Peritonitis;  
 
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.  
 
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.  
Report in Patliology.  
+
Report in Pathology.  
Deciduoma Malignum. By J. Whitridge Willlams, M. D.  
+
Deciduoma Malignum. By J. Whitridge W^illiams, M. D.  
  
  
  
Volume V. 480 pages, with 32 charts and illustrations.  
+
Volume V. 480 pages, mth 32 charts and illustrations.  
  
 
CONTENTS:  
 
CONTENTS:  
 
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.  
 
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.  
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M, B.  
+
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.
 +
Studies in Typhoid Fever.  
  
Studies in Typliold Fever.
+
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon  
By WiLUAM Osler, M. D., with additional papers by G. Bltjmer, M. D., Simon  
+
Flexner, M. D., Walter Reed, 51. D., and H. C. Parscns, M. D.  
Flexner, M. D., Walter Reed, M. D., and H. C. Parscss, M. D.  
 
  
  
  
Volume VI. About 500 pages, many illustrations.  
+
Volume VI. About 500 pages, many ilhistrations.  
  
Report in Nenrolofo**
+
Report in Neurology.
  
 
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical  
 
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical  
Nerve Cell (Studies Nob. I to V). By He.vry J. Berkley. M. D.  
+
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.  
  
 
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the  
 
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the  
Chromate of Silver Methods; Part 1. — Alcohol Poisoning. — Experimental Lesions  
+
Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions  
 
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental  
 
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental  
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part II. — Senrni
+
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol): Part II. — Serum
Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on  
+
Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on  
the Cortical Nerve Cell; Part III. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by O.rwnic
+
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  
+
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical  
Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Ner\*e Cells from the Effects of  
+
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; Nen-e Fibre Terminal .apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.  
+
Alcohol and Ricin Intoxication; Addenda. By Henry J. Bereixy, M. D.  
  
Report in Patliologry.  
+
Report in Pathology.  
  
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.  
+
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Tuomas S.  
  
 
Cullen, M. B.  
 
Cullen, M. B.  
Pregnancy in a Rudimentary LTtcrine Horn. Rupture, Death, Probable Migration of  
+
Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of  
  
Ovum and Spermatozoa. By Thomas S. Cdllen, M. B., and G. L. Wilkins, M, D.  
+
Ov-um and Spermatozoa. By Thomas S. Cullen. M. B.. and G. L. Wilkiss, M. D.  
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. C'ullen, M. B.  
+
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B.  
 
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By  
 
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By  
  
 
William D. Booker, M. D.  
 
William D. Booker, M. D.  
The Pathology of Toxalburain Intoxications. By Simon Flexner, M. D.  
+
The Pathology of Toxalbumin Intoxications. By Simon Flesn-er, M. D.  
Tfie price of a set bound in cloth [Vots. I-TI] of the Hospital Itejwrts is  
+
The price of a set bound in cloth [Vols. Z-TJ] of the Hospital Jteftorts is  
  
$30.00. Vols. I, II ami III arc not sold scjiaratehj. The price of  
+
$30.00. Vols. I, II and III are not sold separately. The jtrice of  
  
Vols, ir, V and VI is $5.00 each.  
+
Vols. IV, V and VI is $5.00 each.  
  
  
  
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER,
+
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TATHOID FEVER.
 
The following papers are reprinted from Vols. I, IV and V of the Reports, for those  
 
The following papers are reprinted from Vols. I, IV and V of the Reports, for those  
 
who desire to purchase in this form:  
 
who desire to purchase in this form:  
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rcepord,  
+
STUDIES IN DERMATOLOGY. By T. C. Gilchrist. M. D., and Emmet Rixford,
 +
 
 +
M. D. 1 voliune of 164 pages and 41 full-page plates. Price, bound in paper,  
  
M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,
+
?3.00.
 +
THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thayer. M. D., and J.  
  
$3.00.
+
Hewetson. M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.  
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thaykr, M. D., and J.  
 
  
Hewetsos, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.  
+
By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, $2.75.
 +
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.-rtracted
  
By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ?2.T5.
+
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 4S1
STUDIES IN TYPHOID FEVER. By William Osler. M. D., and others. Extracted
 
  
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481
+
pages. Price, bound in paper, ?3.00.  
  
pages. Price, bound in paper, $3.00.
 
 
Subscriptions for the above publications may be sent to  
 
Subscriptions for the above publications may be sent to  
  
The Johns Hopkins Press, Baltihorb, Md.  
+
The Johns HorKiNS Press, Baltimore, Md.  
  
  
  
The Johns Hopkins Hospital BvUctins are isstied mwiihly. They arc printed lij THE FRIEDENWALD CO., Baltimore. Single copies  
+
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies  
may be procured from Messrs. CURBING rf CO. and the BALTIMORE NEWS COMPAXT, Baltimore. Subscriptions, $1.00 a year, tnay be
+
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; sin<jU- copies will be sent by mml for fifteen cents each.  
+
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE ; singU copies will be sent by mail for fifteen cents each.  
  
  
Line 2,081: Line 2,371:
  
  
Vol. Vlll.-No. 74.]  
+
Vol. Vlll.-No. 71.]  
  
  
  
BALTIMORE. MAY, 1897.  
+
BALTIMORE. FEBRUARY, 1897.  
  
  
  
[Price, 15 Cents.
 
  
  
  
GO]srT:E3srTS.
 
  
 +
GOiTTZEITTS.
  
  
PAGE.
 
  
The Association between the so-called Perinuclear Basophilic
+
A Case of Dermatitis due to the x Rays. By T. C. Gilchrist,  
Granules and the Elimination of the Alloxuric Bodies in the
+
M. R. C. S., L. S. A.,  
Urine. By T. B. Fittcher, M. B., 85
 
  
Encysted Dropsy of the Peritoneum secondary to Utero-tubal
+
Lesions induced by the Action of Certain Poisons on the Nerve
Tuberculosis and associated with Tubercular Pleurisy, Generalized Tuberculosis and Pyococcal Infection. By ClariBEL Cone, :M. D., 91
+
Cell. Study VI.— Diphtheria. By Henhy J. Berkley, M. D.,  
  
A Visit to Bad Nauheim, with the Purpose of Investigating the
+
Puerperal Sepsis due to Infection with the Bacillus Aerogenes
"Schott Treatment" for Chronic Heart Disease. By C. N. B.  
+
Capsulatus. By George W. Dobbin, M. D., - . - .
Camac, M. D., - - - 101
 
  
A Case of Porokeratosis (Mibelli) or Hyperkeratosis Excen
 
  
  
trica (Respighi) with a remarkable Family History. By T.
+
Proceedings of Societies :
  
Caspar Gilchrist, M. B.C. S., L.S. A.,  
+
Hospital Medical Society, 29
  
A Rapid Method of making Permanent Specimens from Frozen
+
The Surgical Significance of Gall Stones [Dr. F. Lakge].
 +
Correspondence :
  
Sections by the Use of Formalin. By Thomas S. Cullen,  
+
A Case of Pneumo-cardial Rupture. By Geo. S. Brown, M.D., 33
  
M.B.,
 
Proceedings of Societies :
 
  
Hospital Medical Society,
 
  
Typhoid Perforation treated by Surgical Operation [Dr.
+
A CASE OF DERMATITIS DUE TO THE x RAYS.  
Finney].  
 
  
Notes on New Books,  
+
By T. 0. Gilchrist, M. E. C. S., L. S. A., Associate in Dermatology, Johns Hopkins University and Hospital.
  
Books Received, - ..
 
  
  
107
+
Since the discovery of the x rays by Rontgen, thousands of
 +
observations and experiments have been made with them both
 +
in Europe and in this country, and hundreds of investigators have exposed various portions of the body, particularly
 +
the hands, frequently, iind for long periods of time, yet, after
 +
searching the literature, records of only twenty-three cases
 +
(including the present one) have been given where injurious
 +
results have followed their use, and in these, lesions of the
 +
skin only have been described. Of these twenty-three cases,
 +
twelve occurred in this country, one in Canada, four in
 +
England and six in Germany.
  
 +
The first report which 1 have been able to find was a
 +
communication in the Deutsche Medicinische Wochenschrift ,
 +
No. 28, 1896 (July 9th), from 0. Leppiu, an engineer, who
 +
had used his left hand a great deal in experimenting with the
 +
X rays. He remarked that the rays had the power of producing cutaneous lesions like sunburn. The hand presented
 +
a peculiar redness, was swollen, and a vesicular eruption appeared later on the middle and ring fingers. Where the skin
 +
was hidden by a ring it was white and quite normal. Even
 +
five weeks after discontinuing the use of the rays the altered
 +
skin gave the hand an older look than the normal one.
 +
 +
Professor Daniel, of Vauderbilt University, reported a case
 +
of alopecia as the result of exposure to the x rays three
 +
months previous to Leppin's communication.
 +
 +
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
 +
 +
 +
 +
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.
 +
 +
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.
 +
 +
 +
 +
18
  
  
108
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
113
 
113
 
  
 +
[No. 71.
  
  
THE ASSOCIATION BETWEEN THE SO-CALLED PERINUCLEAR BASOPHILIC GRANULES AND
 
THE ELIMINATION OF THE ALLOXURIC BODIES IN THE URINE.
 
  
(From the Medical GUnic of Prof. Eravs in Oraz.)
+
Distribution.  
By T. B. Futcher, M. B., Instructor in Medicine, Johns Hopkins University and Asst. Res. Physician, Johns Hopkins Hospital.  
 
  
  
  
In 1894 Neusser described a peculiar granulation in the
+
Character of the Lesions.  
leucocytes of patients suffering from a uratic diathesis. This
 
term was given a wide meaning, and under it he included gout,
 
uratic lithiasis, as well as the various forms of "irregular
 
gout," as muscular rheumatism, nervous asthma, skin affections, gastro-intestinal derangements, diabetes, leuksemia, neuralgia aud neurasthenia. These granules were brought out
 
by staining freshly dried specimens of the blood with a modified Ehrlich's triacid mixture in which the basic ingredient
 
was relatively increased. They are basic staining granules,
 
and with this mixture appear as greenish black or dense black
 
droplets over and about the nuclei of the leucocytes. They
 
vary considerably in size, the smallest being about the size of
 
the neutrophilic granules, and the largest considerably larger
 
than the eosinophilic granules. Often they have a glistening
 
or refractile appearance. They are always in immediate contact with the nucleus, never being present amongst the ordinary granules of the leucocytes. They give one the idea that
 
they constitute some substance which has been squeezed out
 
of the nucleus. Neusser found them most abundant in the
 
mononuclear leucocytes, in which they often form a complete
 
  
  
  
ring about the nucleus, but stated that they were also present
+
Subjective
in the polynuelear leucocytes and eosinophiles. He believed
+
Symptoms.  
that they were of the nature of a nucleo-albumin in composition, and saw in their i^resence a sign for an increased uric
 
acid production in the organism. This assumption was based
 
on the analysis of the urine of 100 patients, in whom, along
 
with the already described blood condition, an elimination of
 
from 0.8 to 1.5 grams of uric acid, and a uric acid coefficient
 
within the limits of 1 : 30 to 1 : 20 (1 : 50 being normal) were
 
found. It is important to note that the patients on whom
 
these observations were made were not brought under a condition of nitrogenous equilibrium.  
 
  
The clinical interest of these basojihilic granules would be
 
very great if it could be proven that in an extended series of
 
cases they were associated only with a uric acid diathesis and
 
were entirely absent in other affections. If such could be
 
proven we would then have a ready clinical means of differentiating symptoms due to a uratic diathesis from those arising
 
from some other cause. Neusser himself states that they are
 
also to be found in a certain percentage of cases of tuberculosis,
 
and believes them to be of prognostic value. He claims to have
 
  
  
 +
O. Leppin (person
 +
al experience). .
  
86
 
  
  
 +
Used very frequently for
 +
many days.
  
  
found that cases showing the granules run a more favorable
 
course, and that the lung infiltration is more likely to undergo
 
fibroid change than in cases where the granules are absent.
 
  
Kolisch, a pujiil of Neusser's, has advanced the theory that a
+
Left hand and  
uric acid diathesis is not due to an anomaly of in the formation of
 
or in the relative solubility of uric acid, but in the increased production of the alloxuric bodies (uric acid -|- xanthin bases), out
 
of the products of nuclein destruction. He found that in cases
 
where the perinuclear granules were abundant that there was
 
a definite increase in the quantity of alloxuric bodies eliminated. The increase was due to a marked increase of the
 
xanthin bases, the uric acid being relatively diminished ; and it
 
was to the presence of these bases circulating in the blood that
 
the symptoms of a uratic diathesis were due, and not to any
 
anomaly in the formation or excretion of uric acid. Neusser
 
and Kolisch, although they both believe that the basophilic
 
granules bear an intimate association with the causation of the
 
uratic diathesis, differ in their views as to which ingredient of
 
the urine is increased by their presence. Neusser found an
 
increased elimination of uric acid, while Kolisch found that
 
the uric acid was relatively diminished, and the xanthin bases
 
markedly increased, resulting in a total increase in the amount
 
of the alloxuric bodies eliminated.
 
  
With the exception of the above difference, Neusser and
 
Kolisch agree that the occurrence of the perinuclear basophilic
 
granules indicates an increase in the nuclein constituents
 
of the blood. Direct analyses of the blood for the amount
 
of nuclein contained in it were naturally not made; and
 
pure color reactions, even from a qualitative standpoint, are
 
unreliable, as shown by L. Heine. If one accept without
 
further questioning Neusser's view that the perinuclear granulation is a morfihological criterium for an over-production
 
of nuclein derivatives from the cell nuclei, it is not easily
 
explainable why an increase in the quantity of the alloxuric bodies eliminated in the urine should follow. If one considers these granules identical with the pyrenogenic granules
 
of Lowit found in the leucocytes of the river crab (in the arthropoda the uric acid is not formed from the nuclein materials)
 
and in certain normal leucocytes of the bone-marrow, then
 
they fall under the general heading of karyorhexis or breaking up of the nucleus, and would more likely indicate a chromatolytic degeneration of the leucocytes. Prof. Kraus was
 
able to demonstrate similar granules in the liver cells when
 
portions of the liver substance were removed from the body
 
while still warm and kept in a moist chamber at 40° C. At a
 
definite stage in the breaking down of the nuclei he found
 
granules in the protoplasm of the liver cells resembling and
 
staining similarly to those found in the leucocytes by Neusser.
 
If such a condition takes place under any circumstances, either
 
physiological or pathological, in the living person, an increase
 
in the alloxuric bodies eliminated might be expected.
 
  
In studying the subject of Neusser's granules I have endeavored to determine whether there is any regular coincidence
 
between the presence of these granules and the elimination of
 
the alloxuric bodies, and further, whether the granules are
 
found only in cases showing the symptoms of a uratic diathesis.
 
  
Doubt as to this intimate association arose in my own mind
+
Peculiar redness, swollen, vesicles
while examining the blood of patients for the basophilic
+
on middle and ring fingers.
  
  
  
granules, at first without studying their effect on metabolism.  
+
Dr. Marcuee.  
In a very large number of cases examined, both in healthy and
+
 
diseased persons, I have never failed to find the granules
+
 
present. Four of these cases were cases of true gout with
 
typical joint affections and well defined tophi in the ears. In
 
two of these cases the granules were very abundant, but not
 
more so in the mononuclear than in the polymorphonuclear
 
leucocytes. In the remaining two cases they were on the
 
whole not very abundant, and the polymorphonuclears showed
 
the granules more numerous than did the mononuclears.
 
Further, I was able to convince myself, both in Baltimore and
 
in Graz, that the granules were not more marked in the blood
 
of patients suffering from the so-called uratic diathesis than
 
in other diseases, or even in certain apparently healthy individuals. The fact that the granules are found in other
 
diseases than in uratic diathesis, and also in healthy persons,
 
lessens their clinical interest. Neusser believed their presence in tuberculosis was a favorable sign. In this disease I
 
have observed cases with abundant granules and others with
 
few granules without noticing any difference in its subsequent
 
course. The granules vary in richness in the leucocytes from
 
day to day in the same individual, notwithstanding his living
 
under the same conditions of nourishment, etc. This fact
 
seems to diminish the significance of the granules. It seems
 
more common for variations of this kind to occur than for the
 
granules to remain constant from day to day. No method
 
seemed practicable for making an accurate count of these granules, and in the following cases reported it seemed sufficient
 
for all practical purjioses to stain the specimens of dried
 
blood and to compare from day to day the amount of granulation present in the different forms of leucocytes.
 
  
The following cases, in which the basophilic granules and
+
Young man, 17, exposed
their effect on metabolism were studied, were undertaken
+
5-10 minutes once or
especially to ascertain whether the amount of granulation
+
twice a day for four
present really influenced the quantity of the alloxuric bodies
+
weeks.  
eliminated in the urine.  
 
  
In all, 8 cases were carefully studied. Blood specimens were
 
stained each day with Neusser's staining mixture, and the same
 
technique followed from day to day. The patients were as nearly
 
as possible brought under the conditions of nitrogenous equilibrium before the observations on the urine were concluded.
 
Each case was followed for a period of 5 to 6 days, and during this time the same amount of food was taken each day,
 
and the body weight from day to da\' remained practically
 
constant. The total amount of nitrogen ingested in the food
 
and eliminated in the urine and fteces was estimated daily.
 
In all the cases the alloxuric bodies were estimated, and in two
 
cases the uric acid as well. The nitrogen was detei-mined
 
according to the method of Kjeldahl, the uric acid according to Ludwig's, and the alloxuric bodies according to the
 
Kriiger-Wulf* methods.
 
  
In order to assist in the understanding of the following
 
tables I give what is considered the normal amount of nitrogen in grams contained in the alloxuric bodies for the 24
 
hours, as found by various observers who have made determinations up to the present date.
 
  
 +
Dr. Feilchenfeld
 +
Dr. Conrad.
  
  
•Zeit. flir physiol. Chemie, Bd. XX.
 
  
 +
Left half of Brownish redness on face, fol
 +
face.backand lowed by desquamation ; later,
 +
chest. patch of alopecia above right
  
 +
ear ; on back, large raw patch,
 +
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
  
May, 1897.]
 
  
  
 +
No mention. After five weeks hand still
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
looks "older" than the
 +
other.  
  
 +
No pain in face ;lThree months later, hair
  
  
87
 
  
 +
back much
 +
tenderness, but
 +
no pain was felt
 +
until just previous to the eruption.
  
  
For the 24 hours :
 
  
Kolisch gives 0.260 gram.  
+
returning on the bald
 +
spot. Chest and back
 +
healed, but numerous fine
 +
cicatricial lines on the
 +
back and brown pigmentation.  
  
Weiutraud (1) 0.344-0.360
 
  
(2) 0.433-0.534
 
Richter 0.380
 
  
Magnus-Levy 0.506
+
Dr. Paul Fuchs
 +
(personal expe
 +
rience).  
  
Richter 0.387
 
  
I myself found in healthy persons (1) 0.499
 
  
(2) 0.551
+
Dr. Sehrwald.  
  
Judging from these analyses it may be considered that
 
values above 0.4 gram are physiologically high, while those
 
above 0.5 gram may be regarded as pathological.
 
  
Case 1. — Dr. K., aged 32 years, weight 79.5 kilograms, with
 
a well-marked tendency to a gradually increasing corpulence.
 
Not inclined to undertake great muscular exertion, but in
 
every respect perfectly healthy. After nitrogenous equilibrium
 
had been established, 1.5 liters of Carlsbad water (Miihlbrunn)
 
were drank daily for a period of 8 days.
 
  
The daily diet was as follows: Ham, 150 grams; roast
+
S. J. R. (personal
beef, 100 grams ; milk, 500 grams ; 6 breakfast rolls ; butter,
+
experience).  
65 grams; rice, 60 grams; sugar, 3 pieces; black coffee (infusion), 100 grams ; sherry, 100 grams ; soda water, 2 bottles.  
 
  
The above diet represented about 1968 calories (about 25
 
calories per kilogram body weight), which were made up as
 
follows :
 
  
  
 +
Dr. H. C. Dunn.
  
Albumin
 
Pat
 
  
Carbohydrates
 
Alcohol
 
  
 +
Dr. G. C. Skinner
 +
(personal expe
 +
rience).
  
  
Total
 
  
 +
J. Macintyre (personal experience).
  
  
362.17 calories.
 
837.73
 
646.35
 
122.15
 
  
1968.40
+
Dr. Freund.  
  
  
  
Table 1. — The Urine.  
+
Aphotographerbad used
 +
the X rays very fre
 +
quently and for some
 +
time.  
  
  
  
Date.  
+
After prolonged use of
 +
the X rays.  
  
  
Q
 
  
 +
In a boy 13 years old.
 +
Only one exposure of
 +
45 minutes duration
 +
Two weeks later erup
 +
tion appeared.
  
  
  
a
+
Used the rays several
 +
hours daily and eruption appeared three
 +
weeks after.
  
U ID
 
  
  
at
+
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.
  
'"C in
 
  
  
if
+
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.
  
  
July 6
 
" 7
 
" 8
 
" 9
 
" 10
 
" 11
 
" 12
 
" 13*
 
" 14
 
" 15
 
" 16
 
" 17
 
" 18
 
" 19
 
" 20
 
  
 +
1st and 2d fin
 +
gers, left
 +
hand.
  
1
 
  
3
 
4
 
  
5
+
Left hand and
()
+
fingers.
7
 
8
 
(1
 
  
10
 
11
 
12
 
13
 
14
 
15
 
  
  
995
+
Abdomen.
1240
+
 
1630
+
 
1200
 
1080
 
1160
 
1630
 
2270
 
  
2«no
+
Right hand and
 +
fingers. Later
 +
left band.
  
2345
 
27C0
 
3120
 
3045
 
2920
 
2810
 
  
  
14.7638
+
Abdomen.  
12.8898
 
14.7759
 
14.0700
 
15.5547
 
15.0666
 
15.4947
 
15.7682
 
14.1159
 
15.3560
 
13.9482
 
15.5719
 
12.9062
 
14.9825
 
14.. 3732
 
  
  
0.6042
 
0.4.318
 
0.5262
 
0.4169
 
0.4430
 
0.5602
 
0.5058
 
0.4149
 
0.4459
 
0.4042
 
0.3780
 
0.3849
 
0.3810
 
0.3244
 
0.4025
 
  
 +
Wrist.
  
0.2550
 
0.2613
 
  
  
4.16
+
Neck, back, upper arm and
3.35
+
scalp.  
3.56
 
2.97
 
2.84
 
3.71
 
3.26
 
2.63
 
3.16
 
2.63
 
2.71
 
2.47
 
2.95
 
2.16
 
2.80
 
  
  
  
From 13 to 20 Carlsbad water was drunk.  
+
Swelling and stiffness of the
 +
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.  
  
 +
Much swollen; skin was wrinkled
 +
cracked and stained quite
 +
brown ; condition of skin like a
 +
frozen hand ; later, on further
 +
exposure, a vesicular eruption
 +
appeared.
  
 +
At first hypersemia, then avesicu
 +
lar eruption. Four weeks later
 +
central portion healed, but
 +
peripheral portion covered
 +
whole abdomen. Brown color.
 +
Exfoliation soon followed.
  
Table II. — Nitrogen Balance (N in Grams).  
+
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.
  
 +
Reddening of the skin appeared
 +
first; this increased until it was
 +
almost purple ; considerable
 +
swelling followed. Desquamation followed.
  
Date.  
+
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.
  
0%
 
P
 
  
  
41
+
Berlin Medical Society.
  
 +
Fingers extremely No mention,
 +
sensitive and
 +
pain was of a
 +
burning and
 +
scalding character.
  
£ Si
 
  
  
NITROGEN ELIMINATED.  
+
None given.  
  
  
i ,
 
  
a — "3
+
Itching when the
|a|
+
vesicles appeared.
  
  
S
 
  
 +
After inflamma
 +
tion hand smarted very much
 +
Skin became insensible to the
 +
touch. After
 +
second exposure
 +
serious discom
 +
fort and pain
 +
followed.
  
Brlue.
 
  
  
FcBoes.  
+
No subjective
 +
symptoms ;
 +
neither itching
 +
nor pain ; the
 +
rawsurface painless and almost
 +
insensitive.  
  
  
a
 
  
 +
Great pain and ex
 +
cessive tenderness.
  
July 10
 
" 11
 
" 12
 
  
" 19
 
" 20
 
  
 +
Cured in 9 or 10 weeks.
  
5
 
6
 
  
7
 
14
 
15
 
  
 +
Results similar to those of
 +
sunburn but much more
 +
acute.
  
79.300
 
79.800
 
79.900
 
79.050
 
79.050
 
  
  
16. 2347
+
None given.  
15.9769
 
  
18.6598
 
  
  
15.5547
+
Eruption healed after 28
15.0666
+
days, but skin was like
15.4947
+
boiled fish skin. After
14.9825
+
cauterization of surface a
14.3732
+
slough separated and a
 +
tough yellow opaque
 +
membrane formed.  
  
  
1.1832
 
1.1832
 
  
'3.3325
+
Process of repair was very
 +
slow.  
  
  
16!2498
 
16 6779
 
  
17! 7057
+
Authorthinksconditiondue
 +
to heat and electricity ;
 +
the latter the chief cause
 +
of injury to the tissues.
  
  
— o'.7oio
 
  
+b'.954i
+
February, 1897.]
  
  
  
Condition of the leucocytes with reference to Neusser's
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
granules : During the jjeriod in which no Carlsbad water was
+
 
taken the granules were present only in very moderate numbers. On the other hand, from July 16th to 20th, during
 
which the water was drank, there was a very distinct increase
 
in the number of granules present in all the forms, particularly in the mononuclear leucocytes. At the same time it will
 
be seen that there was a marked diminution in the allo.xuric
 
bodies as represented by the amount of nitrogen eliminated.
 
  
Observation II. — Dr. L., a perfectly healthy man, aged 25
 
and weighing 69.5 kilograms. Muscular, moderate panniculus adiposus, and of a quiet disposition. My colleague, after
 
bringing himself to a point of equal daily nitrogen elimination, drank Carlsbad water for a period of 4 days (1.5 liter of
 
Muhlbruun per day).
 
  
The daily diet was as follows : Ham, 250 grams ; veal,
+
19
250 grams; milk, 100 grams; wine, 500 grams; tea (black
 
infusion), 250 grams; rum, 15 grams; butter, 50 grams;
 
breakfast rolls, 3.
 
  
The above food represented about 1895 calories daily (27
 
calories per kilo body weight), which were made up as
 
follows:
 
  
  
 +
Dr. E. E. King.
  
Albumin
 
Fat
 
  
Carbohydrates
 
Alcohol
 
  
 +
Dr. M. J. Stern.
  
  
511.73 calories.
 
785.49
 
341.69
 
256.88
 
  
 +
Dr. F. Kolle.
  
  
Total
 
  
 +
Dr. J. C. White.
  
  
1895.79
 
  
 +
Prof. E. Thomson
  
  
Table III.— Urine.
 
  
 +
Dr. H.R.Crocker
  
  
Q
 
  
 +
Prof. John Daniel
  
0^
 
  
  
Dally amount
+
Dr. M. H. Rich
of urine In
+
ardson.  
com.  
 
  
  
S Ml
 
if
 
  
 +
Dr. W. E. Parker.
  
- u a
 
  
|g|i
 
  
 +
University of
 +
Minnesota.
  
A,  
+
Dr. Banister, U
 +
S. Army.
  
  
Percentage of
 
alloxurlc
 
body— N of
 
total nitrogen.
 
  
 +
Dr. T.C.Gilchrist.
  
June 12
 
  
  
1
+
Patient used the x rays
 +
for two and a half
 +
months from two to
 +
six hours daily before
 +
cutaneous lesion ap
 +
peared.
  
  
1430
 
  
 +
Patient was exposed at
 +
three sittings of 40-50
 +
minutes duration.
 +
Eruption appeared two
 +
days afterward.
  
25.2421
+
A boy 12yearsold. Whole
 +
body exposed 40 minutes. Sixteen days
 +
later alopecia
 +
appeared.  
  
 +
Young lady exposed to
 +
the rays 30 minutes on
 +
one day and 45minutes
 +
on the next day. Eruption appeared the following day.
  
0.5710
+
Exposed half an hour at
 +
a distance of one and
 +
one-half inches from
 +
the tube. Eruption
 +
appeared nine days
 +
after.  
  
 +
Boy aged 16. One exposure of one hour.
 +
Eruption appeared
 +
next day.
  
  
  
2.27
+
Distribution.  
  
  
" 13
 
  
 +
Hand, left.
  
9
 
  
  
1815
+
Man ; exposure 1 hour
 +
Alopecia 21 days
 +
later.
  
 +
Woman. Exposed three
 +
times to the rays, 20,
 +
30 and 3.5 minutes.
 +
Eruption appeared two
 +
days later.
  
30.1310
+
Man. Exposed five
 +
times, from 20 minutes
 +
to 80 minutes.  
  
 +
Man whose ear was exmined for several
 +
hours.
  
0.5595
+
Man. Numerous expo
  
 +
sures.
  
  
  
1.85
+
ray operator. Eruption began after frequent and continued
 +
exposures.  
  
  
" 14
 
  
 +
Extended from
 +
thesideof the
 +
face down to
 +
the umbilicus.
  
3
+
Right side of
 +
head.
  
  
1800
 
  
 +
Sternal region
  
28.1925
 
  
  
0.5237
+
Little finger of
 +
left hand.  
  
  
  
 +
Epigastrium.
  
1.85
 
  
  
" 15
+
One side of
 +
scalp.
  
 +
Abdominal re
 +
gion, particu
 +
larly over
 +
liver area.
  
4
 
  
  
1880
+
Jaw and neck.
  
  
30.3996
 
  
 +
Ear and surrounding
 +
scalp.
  
0.5791
+
Abdomen,
 +
chest and
 +
beard.  
  
  
  
 +
Right hand,
 +
wrist, and
 +
lower portion
 +
of forearm
 +
dorsal sursurface.
  
1.90
 
  
  
" 16
+
Character of Lesions.
  
  
5
 
  
 +
Hand felt stiff, then became
 +
swollen and large " blisters
 +
formed ; after five weeks rest
 +
he exposed the hand again 7-8
 +
hours daily. In two weeks left
 +
hand became swollen, tender,
 +
discolored ; vesicles followed,
 +
and the fingernails began to
 +
fall off. The hairs disappeared.
 +
Left side of the face was also
 +
affected. The skin was swollen
 +
and erythematous, and the hair
 +
over the temple disappeared.
 +
Eyebrows were almost gone and
 +
left side of the mustache had
 +
almost disappeared.
  
2000
+
Erythematous blush first appeared, which a few days later ap
 +
peared like a severe burn, followed by a large slough.
  
 +
Large area of alopecia over the
 +
region exposed to the rays
 +
Hair fell out all at once the
 +
night previous. Skin slightly
 +
cedematous.
  
30.0650
+
Skin was first reddened, then
 +
blistered. Three months later
 +
the patch showed angry-looking
 +
granulations which had refused
 +
to heal.  
  
 +
Finger became hypersensitive,
 +
then dark red, swollen, stiff,
 +
and soon after vesiculation occurred. Pus formed and the epidermis became detached, but
 +
pustules remained over 3 weeks
  
0.5217
+
A Crookes tube placed five inches
 +
distant — flanelette shirt inter
 +
vened. Next day, skin deep
 +
red in color. Nine days later
 +
vesicles appeared. Palm-sized
 +
patch, well-defined, purplish
 +
red. Vesicles increased in number ; 9 days later the epidermis
 +
had separated. Healing very
 +
slow. Alopecia very slight.  
  
 +
Tube was 1^'4 inches distant from
 +
head. Bald spot was 2 inches
 +
in diameter ; skin healthy.
  
0.4222
+
Bulb was 18 inches distant. First
 +
appearance was that of sunburn, gradually became brown,
 +
and ulcer, 8 inches in diameter,
 +
formed ; slough thrown off ;
 +
very slow in healing.  
  
 +
After two exposures face and
 +
neck became swollen and red.
 +
The later sittings were also followed by eruption.
  
1.73
+
The parts presented later a frozen
 +
appearance. All the hair from
 +
this side of scalp was lost.  
  
 +
At first a patch, red, inflamed,
 +
hypersesthetic, about half the
 +
size of a man's hand. The
 +
lesion increased in size until a
 +
denuded surface .SxlS inches
 +
was formed. Exudation profuse and uncontrollable. Beard
 +
turned white in places and
 +
growth stopped.
  
" 17*
+
Hypersemia and swelling of back
 +
of hand ; afterwards inflammation of fingers and hand. Skin
 +
became dark brown in color
 +
and gradually exfoliated.
  
  
6
 
  
 +
Subjective
 +
Symptoms.
  
1890
 
  
  
27.2868
+
Great pain follow
 +
ed the appear
 +
ance of the blis
 +
ters.  
  
 +
Second eruption
 +
followed by
 +
aching.
  
0.6515
+
Face became tender and painful.  
  
  
  
 +
No symptoms.
  
2.38
 
  
  
" 18
+
Granulation sur
 +
face very sen si
 +
five and the seat
 +
of severe neural
 +
gic pain.
  
 +
Pain.
  
7
 
  
  
3110
+
Stiffnessfeltatfirsl
 +
and soreness
 +
when the vesicles appeared.
  
  
29.4983
 
  
 +
None.
  
0.5421
 
  
  
 +
Pain accompanied
 +
the first appearance of the
 +
lesion.
  
  
1.83
 
  
 +
No pain or sensation at the time.
  
" 19
+
Raw surface, very
 +
painful and hyperjesthetic.
 +
Pain agonizing
 +
even six weeks
 +
after.
  
  
8
 
  
 +
No pain at first, but
 +
afterwards severe aching and
 +
shooting pains,
 +
which lasted
 +
about 2 weeks.*
  
2840
 
  
  
28.40
+
The case has been carefully
 +
and continuously
 +
watched.  
  
  
0.6908
 
  
 +
Examination of the chest
 +
after a gun-shot wound.
  
0.4222
 
  
  
2 43
+
Later, lanugo hairs began
 +
to appear.
  
  
" 20
 
  
 +
At the timeof writingthere
 +
were still two open spots.
  
9
 
  
  
2730
+
Four months later, even
 +
after curetting, granulating surface 4 inches in
 +
diameter still remained.
  
  
27.30
 
  
 +
16 days afterwards skin discolored and exfoliated.
  
0.6162
 
  
  
 +
Patient confined to bed for
 +
one month, and will
 +
probably be in bed another month.
  
  
2.10
 
  
 +
•February 5, 1897, patient writes, " My hand is much about the same. I cannot use those (first) three lingers much better : and my nails are coming off, that
 +
Is, the old nail is like a shingle on top of the new one."
  
  
f From June 17 to 20 Carlsbad water was drunk.
 
  
Table IV.— Nitrogen Balance (N in Grams).
 
  
  
 +
As far as the cutaneous lesions were concerned, the skin of
 +
the trunk appeared to suffer the most severely, although when
 +
the hand was attacked the pain was the most prominent
 +
feature.
  
 +
As to the character of the lesions produced, the majority of
 +
observers describe a peculiar redness or erythema at first, then
 +
swelling of the derma, followed by a deep discoloration of
 +
the skin until it became quite a dark brown color. Exfoliation of the pigmented skin followed later. In a number of
 +
cases vesiculation occurred after the hyperajmia, and quite a