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

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POSTURAL METHOD OF DRAINmG THE PERITONEAL CAVITY AFTER ABDOMINAL OPERATIONS.
 
  
By J. G. Clark, M. D.  
+
 
 +
http://www.archive.org/details/johnshopkinsmedi08john
  
  
 +
BULLETIN  OF THE JOHNS HOPKINS HOSPITAL.
  
The general trend of recent medical literature relating to
+
Vol. VIII. - No. 70.  
iutraperitoueal drainage tliroiigh the abdominal incision has
 
been towards the limitation or reduction of the number of
 
conditions demanding its employment, and a few European
 
gynecologists have even gone so far as to discard drainage
 
entirely, leaving the peritoneum to protect itself.  
 
  
In a forthcoming article* on drainage based upon the bacteriological study of a large number of cases and upon the
 
clinical records of 1700 cases of abdominal section performed
 
in the gynecological department of the Johns Hopkins Hospital, I have been forced, notwithstanding my preconceived
 
ideas in favor of drainage, to draw conclusions against it and
 
to coincide with those few writers who discard it altogether.
 
  
The benefits to be derived from any form of drainage when
 
used for the purpose of removing infectious matter from
 
the peritoneal cavity, are infinitesimal compared with the
 
untoward or disastrous results which may follow its use.
 
  
The greatest safety lies in closing the abdomen without
+
BALTIMORE, JANUARY, 1897.  
drainage, except in cases of purulent peritonitis or in operations when there has been extensive suturing of the intestines,  
 
and in a few other rare conditions which I shall consider in
 
detail in my paper on drainage.  
 
  
Escape of pus during an operation, oozing of blood or serum,
 
extensile raw areas in the pelvis, are usually sui:)posed toindi
 
  
  
* A Critical Review of 1700 Cases of Abdominal Section from the
+
Contents
Standpoint of Intraperitoneal Drainage. The Johns Hopkins Hospital Reports, Vol. VII.
 
  
 +
Presentation of Thorwaldsen's Statue of Christ to the Hospital, 1
  
 +
The Bacilhis Proteus Zenker! in an Ovarian Abscess. By
 +
Hunter Robb, M. D., and Albert A. Ghriskey, M. D., - 4
  
cate the necessity of some form of drain ; on the contrary,
 
these are the cases which should be left to the care of the
 
peritoneum, as demonstrated by a comparative study in our
 
series of 1700 cases of abdominal section of a hundred cases
 
each of similar pelvic inflammatory affections, drained and
 
undrained. The undrained cases presented by far the best
 
results.
 
  
Every surgeon recognizes the dangers of dead spaces in the
 
abdominal cavity and endeavors to prevent their formation,
 
but frequently this is impossible. Mikulicz first called attention to this subject in a forcible paper, and devised a siJecial
 
drain for the prevention of oozing and for the removal of
 
fluids from dead spaces; but this method, like all others, is
 
unsatisfactory because the principle upon which it is based is
 
wrong.
 
  
In an article (1889) by Laude the statement is made that it
+
The Phrenology of Gall and Flechsig's Doctrine of Association Centres in the Cerebrum. By Lewellys F. Barker,  
is not the principle but the methods of drainage which are
 
wrong. I would reverse this statement by saying that it is
 
not the method but the principle which is wrong. Zweifel
 
claims that the subject of drainage should no longer be considered in surgical treatises, but should be relegated to medical
 
history.
 
  
The chief objections to drainage of dependent pockets in
+
M. B., - - - - - 7
the pelvis or abdomen through an abdominal opening are,
 
first, fluids are frequently not removed, but on the contrary
 
are pent up by the gauze drain ; and second, instead of removing infection, the gauze or tube may be the means of introducing it from the outside into the degenerated fluids.
 
  
 +
Notes on New Books, ......... 14,
  
 +
Books Received, 15
  
60
 
  
  
 +
PRESENTATION OF THORWALDSEN'S STATUE OF CHRIST TO THE HOSPITAL
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
Oa Wednesday afternoon, October 14, 1896, at 3 o'clock, there
 +
was uuveiled in the rotunda of the Administration Building
 +
of the Jolms Hojjkins Hospital, in the presence of the trustees
 +
and officers and a large audience of invited guests. Stein's
 +
reproduction of Thorwaldsen's statue of Christ, a gift from
 +
William Wallace Spence, of Baltimore. Mr. Spence, in presenting the statue, spoke as follows:
  
[No. 73.  
+
"I have but a few words to say on this occasion; merely to
 +
state how it happens that this statue stands here.  
  
 +
" On a visit to Copenhagen I saw the great work of Thorwaldsen, his ideal conception in marble, of ' Christ, the Divine
 +
Healer.' It impressed me more than did any statue I had
 +
ever seen, and I think this is the general experience of
 +
those who have the good fortune to see it. It was stated that
 +
Thorwaldsen himself said, ' I never was satisfied with any
 +
work of my own until I executed the Christ; now I am satisfied.' He felt that his genius had reached the zenith of its
 +
powers and that he could go no higher. Well might he be
 +
satisfied, for the grace, dignity and majesty of this figure have
 +
never been surpassed.
  
 +
" 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
  
To overcome the dangers of dependent pockets and dead
 
spaces in the pelvis, I would suggest the elevation of the
 
patient's body after operation to a sufficient height to start the
 
flow of collecting fluids from the pelvis towards the diaphragm, and thus promote the rapid elimination by the
 
normal channels of exit from the peritoneal cavity, of infectious matter and of vital fluids which may stagnate in these
 
pockets and form a culture medium for pyogenic micro-organisms.
 
  
Although it would appear at first sight that this method of
 
drainage is opposed to sound surgical principles, I hope to
 
offer proof from a review of recent literature bearing upon
 
the function of the peritoneum under normal and pathological
 
conditions, sustained by the clinical report of three cases, that
 
it is not only a safe but may be a life-saving measure.
 
  
Function of the Peritoneum under Normal and  
+
rest. With this feeling I asked permission of the trustees to
Pathological Conditions.  
+
present this statue to the hospital. It was cordially given,
 +
and at once I placed an order with Professor Stein, the eminent sculptor and Director of the Royal Academy of Art in
 +
Copenhagen, and there it stands. How well he has executed
 +
it you will judge.  
  
G. Wegner,* the first investigator who by experiments upon
+
"A few years ago, at the formal opening of the Hospital,
animals endeavored to arrive at some definite conclusion concerning the ability of the peritoneum to rid itself of injurious
+
President Gilman expressed the hope that some day it might
fluids or solid particles, was convinced that a comparatively
+
stand there. To-day his hope is realized. And now, Mr.
large quantity of infectious matter could be eliminated or
+
President, I beg to present this statue to the Johns Hopkins
encapsulated by the peritoneal exudate without serious harm
+
Hospital."
to the animal.  
 
  
Grawitzf next took up the experimental study of infection
+
The statue was then unveiled by little Emily Riggs, an
of the peritoneum, pursuing his investigations under improved
+
infant great-granddaughter of Mr. Spence.
bacteriological technique, and arrived at the following conclusions :
 
  
1. The introduction of non-pyogenic organisms into the  
+
Mr. W. T. Dixon, the President, in behalf of the Board of
abdominal cavity, either in small or large quantity, or mixed
+
Trustees of the Hospital, accepted the gift in the following
with formed particles,J produces no harm.
+
words :
  
2. Great quantities of organisms which ordinarily produce
+
" Mr. Spence — It gives me very great pleasure to accept, in
no symptoms, may give rise to a general sepsis if the absorptive function of the peritoneum is impaired.  
+
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.  
  
3. Injection of pyogenic organisms into the peritoneal cavity
+
"These grateful feelings of the trustees, I am confident, will
may be quite as harmless as injections of non-pathogenic
+
be cordially shared by all the workers in every department of  
varieties. (In these experiments he injected a flocculent emulsion of staphylococcus albus and aureus and the streptococcus
+
the Hospital, by our many friends throughout the country, as
pyogenes in ten cubic centimeters of water without any visible
+
well as by the sick and suffering who may come under our
reaction.)
+
care.  
  
4. The introduction of pus-producing cocci into the normal
+
" You have most appropriately placed this ' Divine Healer '
peritoneal cavity produces a purulent peritonitis, first, if the  
+
just where it can be seen by all who may enter the doors of  
culture fluid is difficult of absorption, and second, if irritating
+
the Hospital, thus affording them the opportunity to derive
materials are present which destroy the tissues of the peritoneum, thus preparing a place for the lodgment of the organisms, and the production, of an exudate upon which they may
+
comfort, courage and hope from its contemplation. And not
grow.
+
only are the outstretched hands of this Christus Consolator
  
Pawlowsky,§ in an excellent experimental study, reviewed
 
Wegner's and Grawitz's work, with whom he agreed in many
 
  
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
* Chirurgische Beobacbtungen uber die Peritonealhole mit besonderer Beriicksichtigung der Ovariotomie. Verhandlung der deutschen Gesellschaft fiir Chirurgie, Berlin, 1877.
 
  
tCharite Annalen Jahrg., XI, 1886.
 
  
t A solution of fecal matter containing solid particles was injected ; the fluid was absorbed while the larger particles were
+
[No. 70.  
encapsulated.  
 
  
§Virchow's Archiv, No. 117, p. 469, 1889.
 
  
  
 +
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.
  
particulars, but disagreed in others. The main point of difEerence, however, between Pawlowsky and Grawitz related to  
+
" There are grave responsibilities and many discouragements
the ability of the normal peritoneum to deal with the staphylococcus aureus.  
+
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."
  
Pawlowsky found that the large quantities of staphylococci
+
The following hymn by Whittier was sung by a male
injected by Grawitz without harm into dogs produced death
+
quartet :
very rapidly in the animals upon which he experimented, and
 
that only a minimum quantity was harmless.
 
  
Reichel* went over the same ground in an experimental
+
" So stood of old the holy Christ
research, and in the main agreed with Grawitz. The essential points of value in Reichel's paper are, that peritonitis
+
Amidst the suffering throng ;
usually arises, first, because more organisms gain entrance
+
With whom his lightest touch sufficed
than can be handled by the peritoneum, and second, because
+
To make the weakest strong.  
the stagnation of degenerating fluids in dead spaces favors the
 
growth of the organisms.  
 
  
He also accounts for Grawitz's and Pawlowsky's conflicting
+
That healing gift he lends to them
results, on the ground that some animals are more susceptible
 
to infection than others, and that there are marked differences
 
in the virulence of cultures of the same organism under varying conditions.
 
  
A carefully conducted experimental research by Waterhouse,t carried out under the oversight of Orth, appears to me
+
Who use it in his name ;
to satisfactorily settle the question of the ability of the normal
+
The power that filled his garments' hem
peritoneum to take care of infection.  
+
 
 +
Is evermore the same.
 +
 
 +
For lo ! in human hearts unseen
 +
 
 +
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:
 +
 
 +
We are assembled in the presence of one of the best works
 +
of modern Christian sculpture, — a transcendent theme, treated
 +
by an illustrious artist, in his noblest manner; a work, too,
 +
that has stood the test of more than seventy-five years without
 +
a word of censorious criticism. Canova saw it in Rome, while
 +
it was modeling by the artist, and praised it. The people of
 +
Copenhagen determined to have it. It was reproduced at
 +
Potsdam (Berlin) in front of the Church of Peace, near which
 +
the Emperor Frederic lies buried. A copy, in plaster, surrounded by the twelve apostles, from the same artist, was
 +
brought to New Yoi-k at least forty years ago and exhibited
 +
in what was known as the Crystal Palace or the World's Fair.  
  
He injected 6 cc. of a cloudy culture of staphylococcus
+
But we have here, not the original cast in clay, nor a plaster
aureus into the abdominal cavity of dogs, employing both the  
+
reproduction, nor one in galvano-plastic ; but we have a  
methods of Grawitz and Pawlowsky, and all of the animals
+
marble like that which Thorwaldsen himself touched with
survived. The same results were obtained with the streptococcus, bacillus pyocyaneus and the intestinal bacteria.  
+
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.  
  
Waterhouse then endeavored to simulate the conditions
+
We are greatly indebted to that honored citizen of Baltimore who has brought here a work which from so many
occasionally met with after operations, by introducing 8 cc. of  
+
points of view delights and inspires us.  
urine and small quantities of blood with the cultures, and  
 
again the results were negative. If, however, 15 to 20 cc. of
 
fresh blood were introduced into the peritoneal cavity, followed in a few minutes by the staphylococcus aureus, severe
 
peritonitis was produced.  
 
  
In these experiments Waterhouse agreed with Pawlowsky
+
This is not the first time that a hospital has been decorated
and Grawitz that the dangers of peritonitis are increased by  
+
by a great work of art. If I remember rightly, Benjamin
tardy absorption of fluids, which in effect leaves a culture
+
West painted the picture of " Christ Healing the Sick," for the
medium for the growth of the organisms.  
+
Pennsylvania Hospital in Philadelphia; and, if I am not mistaken, in St. Luke's Hospital, New York, there is still a
  
After the introduction of blood clots 3 cm. in size, followed
 
by the staphylococcus aureus, death occurred from peritonitis
 
in 24 hours.
 
  
Waterhouse also found that the purulent exudate from
 
acute abscesses is extremely virulent, 2 cc. of the staphylococcus aureus and 1 cc. of the streptococcus from this source
 
causing death in twenty-four hours. If a very small quantity
 
of the pus, however, was introduced with water, the animals
 
frequently survived.
 
  
After the introduction of turpentine with the organisms, as
+
famous picture by Daniel Huntington, "The Dream of  
done in Grawitz's experiments, peritonitis did not follow,
+
Mercy," based upon an incident in Buuyan's Pilgrim's  
which is explained by Waterhouse on the ground that the
+
Progress.  
organisms are rendered inactive or are killed by the turpentine. He proved this point by injecting the turpentine first
 
  
 +
Nor is this the first gift that this hospital has received. Its
 +
munificent endowment by Johns Hopkins has been strengthened by fuuds provided for the foundation of a school of medicine and surgery, which supplements the work of the Hospital.
 +
And minor gifts have come in. Not long ago we had a very
 +
small but noteworthy present, a likeness of Florence Nightingale. At another time a friend gave us models and pictures
 +
of various public institutions throughout the country. Again,
 +
one who loves medical biography and history has hung upon
 +
these walls a fine collection of the portraits of illustrious physicians and surgeons who in many countries and in many
 +
generations have adorned their profession. Eecently a large
 +
gift has enabled the trustees to provide better facilities for the
 +
instruction of those who are here engaged in preparing themselves for the profession of medicine or for nursing. And now
 +
we have this work of art which, perhaps, appeals to more of
 +
us than any of the other gifts, unless it be that touching
 +
memento of a departed child, the "White Eose Fund," which
 +
enables the Superintendent every year to distribute flowers to,
 +
and to provide for the entertainment of those who are convalescing in the Children's Ward.
  
 +
Baltimore is fortunate in many ways in the gifts that are
 +
coming to it. We seem to have reached a period in the history
 +
of this city when its citizens are ready to adorn and decorate
 +
the place of their residence. Mr. Spence has presented a noble
 +
statue of William Wallace that stands in Druid Hill Park.
 +
Around the Washington Jlonument are the works of Barye, of
 +
Dubois, and of Story, and also the grand figure of Chief
 +
Justice Taney, perhaps the best portrait statue, with one or
 +
two exceptions, that has ever been produced in this country,
 +
the work of our own Rinehart. But pleasant as these tokens
 +
are, I must not dwell upon them, but must rather speak of the
 +
circumstances under which this work of Thorwaldsen was
 +
produced, and tell you some things regarding the sculptor.
  
*Beitrage zur Aetiologie u. chirurg. Therapie der Sup. Peritonitis. Deutsche Zeit. f. Chir., Vol. XXX, 1889.  
+
The city of Copeijhagen, at the entrance to the " Sound," is
t Virchow's Archiv, Vol. 119, p. 342, 1890.  
+
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
  
  
  
April, 1897.]  
+
January, 1897.]  
  
  
Line 213: Line 248:
  
  
61
+
out by the artist, then liviug in Home; and such is the origin
 +
of the Christus Consolator upon which we are loolviug.
 +
 
 +
Not far away from this church stands the Thorwaldsen
 +
Museum, constructed by the people of Copenhagen for the
 +
reception of the casts of all or nearly all the works that Thorwaldsen made. This museum was subsequently endowed by
 +
him with a very considerable sum of money, and now constitutes his monument. In the interior court his body lies
 +
buried.
  
 +
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.
  
 +
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.
  
and following it in a short time with the infecting germs ; in  
+
I have come upon another incident perhaps more curious.
every instance the animal died of peritonitis.  
+
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.  
  
Dogs with a strangulation of the intestines were easily
+
The enterprising secretary of the Rhode Island Historical
infected.  
+
Society took occasion to address a letter to Thorwaldsen congratulating him not only on his honors but on his origin, and
 +
Thorwaldsen replied, with a fine touch of courteous humor,
 +
"Let us admire those savants, for if it were uot for them, we
 +
should not know where we came from or whither we are
 +
going."
  
In three instances the staphylococcus aureus was introduced
+
It is just one hundred years this very month, and I may
into the peritoneal cavity of cats suffering from ascites, followed
+
say this very week, since Thorwaldsen, iu a note dated October
quickly by death from peritonitis, which resulted, as Waterhouse says, because there was a favorable culture material, a  
+
16, 1796, states that he is on his way from his northern home,  
diminished absorption, and an injury to the peritoneal endothelium.
+
like the Norsemen of old, to establish himself in the south.
 +
He was a passenger upon a government frigate which stopped
 +
leisurely at one point and then another, so that his journey
 +
grew tiresome. At last he abandoned the man-of-war and  
  
Burginsky* in a series of experiments also came to the conclusion that the discrepancies in the results of Pawlowsky's
 
and Grawitz's experiments were due to variations in the virulence of the cultures employed.
 
  
Halstedf confirmed and extended the views of previous
 
observers concerning the resistance of the normal peritoneum
 
to infection, and called attention to the dangers of introducing
 
pyogenic organisms about a ligated or strangulated area, or in
 
conjunction with insoluble bodies. Pieces of sterile potato
 
introduced into the peritoneal cavity of control animals were
 
soon encapsulated and produced no disturbance, but when
 
infected with pyogenic cocci, invariably caused peritonitis.
 
  
A recent paper by Cobbett and Melsome,J on " Local and
+
found other conveyances to carry him from Malta to Palermo,  
General Immunity," contains some valuable observations bearing upon the resistance of the peritoneum to infection.  
+
to Naples, and so on to Rome. There he went to work.  
  
Notwithstanding the injection of large quantities of virulent streptococci, a few of their animals survived. They state
+
But how could this boy maintain himself in Rome ? It was
that " in those animals which succumbed quickest, free cocci
+
by the aid of a scholarship provided for him by the Royal
were very numerous in the peritoneal exudation, and in those
+
Academy of Copenhagen. He had not been a very bright boy
which survived longest they were either absent or contained
+
in his ordinary school instruction. His teacher could uot
within phagocytes."
+
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.  
  
These observers, in order to discover how quickly the organisms disappeared from the peritoneal cavity, killed two rabbits
+
Now I want to remind you that scholarships just like that
which appeared about to recover. " In the first, which had
+
which enabled Thorwaldsen to go forward, have been established within a short time in Baltimore. Rinehart, as you
received 5 cc. of broth culture thirty hours before, only one
+
know, left a considerable sum of money, which was carefully
chain of streptococci was found after prolonged search, but
+
invested by Mr. Newcomer and Mr. Walters, until it reached
many cocci were contained in cells, and broth inoculated with
+
the sum of $100,000, and it was then given to the Peabody
this fluid grew a good culture."
+
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.  
  
"The second rabbit having shown no signs of illness after
+
At Rome, Thorwaldsen instantly came under the modern
an injection of 6 cc. of anaerobic broth culture, received next
+
influences of that day. Wiuckelmann, the well-known critic,
day 10 cc. of a similar material swarming with streptococci.
+
had already called attention to the great value of the Greek
When killed five and a half hours later, not only could no
+
art iu distinction from that of the Renaissance, and sculptors
streptococci be seen, either free or in cells, but no growth grew
+
began to work iu the Hellenic spirit. You get an illustration
on cultures made from the abdominal fluid."
+
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.  
  
From this review of the literature bearing upon infection of  
+
A great many illustrious people came to Rome. An amusing story is told of Sir Walter Scott. He was very desirous of  
the peritoneum I make the following summary :
+
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.
  
1. Under normal conditions the peritoneum can dispose of  
+
The sculptor soon came into church circles. He was a particular friend of Cardinal Consalvi, and made his monument.
large numbers of pyogenic organisms without producing peritonitis.  
+
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
  
2. The less the absorption from the peritoneal cavity the
 
greater the danger of infection.
 
  
3. Solid sterile particles, such as fecal matter, potato, etc.,
 
are partly absorbed and the remainder are encapsulated without the production of peritonitis.
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
•Baumgarten's Jahresbericht, Vol. VII, 1891.
 
  
tThe Johns Hopkins Hospital Reports, Vol. II, 1891.  
+
[No. 70.  
  
t Journal of Pathology and Bacteriology, 1895.
 
  
  
 +
best artist in Eome?" "Undoubtedly," was the answer.
 +
"Then let him hold the place."
  
4. Death may be produced by general septicaemia, and not
+
Thorwaldsen after a time went home, and, as I have said,
by peritonitis, where large quantities of organisms are taken
+
received the commission for a statue of Christ. He returned to
up by the lymph streams.  
+
liome, and with his helpers, it took him eight or nine years to
 +
complete the group of Christ and the Apostles.  
  
5. Irritant chemical substances destroy the tissues of the  
+
You must be familiar with many of the works which he
peritoneum and prepare a place for the lodgment of organisms
+
produced meanwhile. The little medallions of Night and Day
which becomes the starting-point for peritonitis.  
+
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."
  
6. Stagnation of fluids in dead spaces favors the production
+
The story goes that he made six models of the Christ before
of peritonitis by furnishing a suitable culture medium for the  
+
he was satisfied with the one which is here reproduced. At
growth of bacteria.  
+
first he thought of giving to the figure an iiplifted hand, in  
 +
the attitude of benediction. Afterwards he uplifted both arms
 +
as if in prayer. The artist was standing before his statue one
 +
day, when he said to a friend, " I am not satisfied with that."
 +
His friend replied, " What was your motive in giving that
 +
posture; what were you thinking about?" Thorwaldsen
 +
paused, and in a moment turned down the arms to the position
 +
in which you now see them, and then said, " I am satisfied now."
  
7. The association of infectious bacteria with blood clots in  
+
It is worth while for me to add that between five and six
the peritoneal cavity is especially liable to produce peritonitis.  
+
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.  
  
8. Traumatic injury or strangulation of large areas of tissue
+
Now, ladies and gentlemen, it is not for me to draw the
are strong etiological factors in the production of peritonitis
+
lesson of the statue. I suppose (to use a phrase of Coleridge) that this statue "will find each one" of us in his own
when associated with infectious matter.  
+
mood. To some it will be a reminiscence of travel, — of a
 +
delightful day in Copenhagen. To others it will be a work
 +
that is famous in the history of modern art. To many of the  
 +
anxious and suffering it will be suggestive of hope and faith
 +
and love. To each, according to the inward eye that he brings
 +
to bear upon it, will the lesson be given. I do not propose to
 +
read a homily ; but I may remind you that throughout modern literature and art this figure appears. From the Divine
 +
Comedy of Dante to the Paradise Lost of Milton, in the
 +
Saul of Browning and Tennyson's Crossing the Bar, one name
  
The accumulated evidence of all these investigators proves
 
beyond question that the peritoneum, under normal conditions
 
or even when greatly handicapped by disease or artificial conditions, is capable of overcoming the invasion of comparatively large quantities of pyogenic bacteria.
 
  
Mechanism of Absorption of Fluids and Solid
 
Particles in the Peritoneal Cavity.
 
  
Recent investigations by Muscatello* on the histology of  
+
is repeated. So it is in painting, from Eaphael and Leonardo to
the diaphragmatic peritoneum and the mechanism of absorption of substances from the peritoneal cavity, when considered
+
those gifted men who are now decorating the churches in this
in conjunction with the above conclusions, give ample ground
+
country with the illustrations of the life of Christ. So it is
for my suggestion of the elevated posture as a prophylactic
+
in sculpture, fi'om Michael Angelo to St. Gaudens. So it is in
measure against post-operative peritonitis.  
+
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.  
  
Muscatello accepts Bizzozero's and G. Salvioli's classification of the component parts of the diaphragmatic peritoneum
+
In the presence of Mr. Spence it will not do for me to
which occur in the following order: endothelium, membrana
+
recount the many good deeds which he has done for the city,  
limitans and connective tissue framework. Up to the time of  
+
the many great services, political, financial, mercantile, philanthropic, educational and religious, which he has rendered to
Muscatello's publication, histologists were equally divided on
+
Baltimore ; but I must be allowed to say that twice when the  
the question of the presence or absence of stomata between the
+
finances of the Johns Hopkins University have been in a critical condition, he has been the one citizen to come forward and
endothelium. He proved beyond doubt that these openings
+
by his example to inspire the liberality of others. He was
are optical illusions, due to the defective preparation and  
+
kind enough to tell you that I had on a " wishing cap," or  
staining of the microscopical sections. According to Muscatello's opinion, minute foreign particles, leucocytes and fluids
+
words to that effect, seven years ago. I am going to put on
pass through openings between the endothelium of the diaphragm made by the retraction of the protoplasm of the cells.  
+
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.
 +
 
 +
 
 +
 
 +
THE BACILLUS PROTEUS ZENKERl IN AN OVARIAN ABSCESS.
 +
 
 +
By Hunter Robb, M. D., Professor of Gynecology, Western Reserve University, Cleveland, 0., and Albekt A. Ghriskey, M. D.,
  
Beneath the peritoneal endothelium of the diaphragm and
+
former Assistant Gytiecologist to the Johns Hopkins Hosjntal.  
between the connective tissue fibres are open spaces 4 to 16 mm.
 
in diameter, occurring in groups of 50 to 60, which communicate with the lymph vessels. A careful search for these
 
spaces failed to reveal them in any other portion of the peritoneum.  
 
  
G. Wegner first proved that the peritoneum was capable of
 
absorbing the most remarkable quantities of fluids, equivalent
 
to three to eight per cent of the bodily weight in one hour,
 
or the animal's entire weight in twenty-four hours.
 
  
By the injection of foreign particles suspended in a fluid
 
medium into the peritoneal cavities of dogs, Muscatello was
 
able to demonstrate the existence of an intraperitoneal current
 
which carried fluids and small particles towards the diaphragm,
 
regardless of the animal's posture. The rate of transmission
 
  
 +
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
  
Virchow'a Archiv, 1895.
 
  
 +
ally seven days, and were often profuse and painful; since
 +
marriage her menses have been regular, lasting five or six days,
 +
being profuse but not painful. In May, 1890, she ceased to
 +
menstruate for two months, but in July her menses reappeared
 +
and lasted six days. At this time they were profuse and
 +
accompanied with a great deal of backache and pain in both
 +
ovarian regions. She had never had leucorrhiva; she suffered
 +
from constipation. There was no urinary difficulty. The
 +
patient remained well until April, 1891, when a hemorrhage
 +
from the vagina occurred suddenly and continued for six days.
 +
Two hours after the hemorrhage ceased she passed foul
  
  
62
+
January, 1897.]
  
  
Line 357: Line 506:
  
  
[No. 73.  
+
smelling black clots of blood and experienced labor-like pains.  
 +
During May, June and July she was free from these laborlike pains, but complained during these months of weakness,
 +
of occasional chills and fever, of pains in the lower zone of the
 +
abdomen, and backache. On admission to the hospital she was
 +
too weak to walk. The slightest touch over the region of the
 +
left ovary provoked intense pain. The temperature on admission was normal ; the jiatient weighed 123 pounds.  
  
 +
At the examination made August 8, 1891, under chloroform
 +
narcosis, the following note was made :
  
 +
Vaginal outlet moderately relaxed; vagina bathed with
 +
bloody fluid ; cervix small, bilaterally lacerated, pointing upwards; uterus anteflexed, sagging in the pelvis, enlarged, soft
 +
and movable. Right broad ligament thickened. Fallopian
 +
tube and ovary not definitely palpated.
  
of the foreign particles from the peritoneal cavity to their
+
On the left side a fluctuating tumor is outlined, about the  
ultimate repository, the lymph glands, could, however, be
+
size of an orange, adherent to the uterus.  
increased or retarded by the influence of gravity.  
 
  
In those dogs which were suspended with head down, carmine bodies appeared in the retrosternal and thoracic lymph
+
Diagnosis. Abscess of the left ovary. Treatment advised,  
glands in from five to seven minutes, while in animals in
+
coeliotomy.  
which the posture was reversed it was five and a half hours
 
before they could be recovered from these glands.  
 
  
Muscatello proved that small particles were carried from
+
Urinary analj/sis. A voided specimen examined on August
the peritoneal cavity into the lymph spaces of the diajihragm
+
9th was turbid, straw-colored, specific gravity 1.020, reaction
through the opening made by the retraction of the endothelium, then into the mediastinal lymphatic vessels and  
+
acid. On standing it deposited a heavy bloody and mucous
glands, then into the blood current, by which they were transported to the various organs of the body, from which they were  
+
sediment. On boiling, albumen was found to be present. A
picked up by the lymph vessels and deposited in the collecting glands of each organ. For this reason the large vascular
+
large number of red blood corpuscles were revealed by the  
organs, such as the liver, stomach, spleen and pancreas, show
+
microscopical examination, as well as numerous epithelial cells
the particles first and in the greatest numbers, while the
+
both large and small.  
lymph glands of the mesentery, which gather their vessels
 
from a limited area of the intestine, contain but few of the
 
granules.  
 
  
The function of the leucocyte is of especial importance in
+
A catheterized sj3ecimen was cloudy, amber-colored, specific
the elimination of foreign particles from the peritoneal cavity.  
+
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.  
  
Muscatello and other observers find, on examining the
+
Operation August 12, 1891, under chloroform narcosis.  
precipitate in the peritoneal cavity after injecting innocuous
 
foreign particles or bacteria, wandering cells interspersed
 
among the particles, some of which are lightly laden with
 
granules, while others are apparently distended to the point
 
of bursting, and still others which have not yet taken up their
 
burdens.  
 
  
In some instances where the granules are too large for one
+
Incision 7 cm. long through thin abdominal walls. On
leucocyte to encompass it, two or more join forces to surround
+
exploration of the pelvis, the mass previously palpated on the  
the invader. The leucocytes are found in greatest abundance
+
left side was brought into view. It was bound down to the
beneath the omentum. Prom the peritoneal cavity Muscatello
+
broad ligament, uterus and pelvic walls by dense connective
traces the course of the leucocyte through the channels above
+
tissue adhesions. The tumor mass was successfully enucleated, but during its delivery a small rupture occurred at the
described and finally finds them deposited in the lymph glands
+
point at which it was adherent to the fimbriated extremity of
in various parts of the body.  
+
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.  
  
In Muscatello's experiments the leucocytes were able to
+
The Fallopian tube and ovary of the right side being bound
dispose of the innocuous particles rapidly and without apparent ill effect to the auimals. In Pawlowsky's, Cobbett's and
+
down by only a few adhesions, were enucleated without difficulty. The fimbriated extremity of the tube was occluded,  
Melsome's experiments, on the other hand, the conditions
+
enlarged and thickened. The ovary appeared inflamed, but
were different, the leucocyte having to meet an antagonistic
+
was not enlarged. The tube and ovary were removed by transfixion and the pedicle was cauterized. The jjelvic cavity was
invader. In those animals which survived the injection the
+
irrigated with three litres of a sterilized salt solution at a
infectious organisms were quickly encompassed by the leucocytes and carried into the general circulation, while in the  
+
temperature of 112° F. and sponged dry.  
fatal cases the peritoneal exudate was found swarming with  
 
free organisms and only a comparatively few enclosed in
 
leucocytes.  
 
  
The points in Wegner's and Muscatello's articles which I
+
A drainage tube was inserted in the lower angle of the
wish to draw especial attention to are :
+
wound and the usual dressings applied. Time of operation,
 +
40 minutes.
  
1. Large quantities of fluids may be absorbed by the peritoneum in a remarkably short time. (Wegner.)
+
The specimens removed consist of the tube and ovary of the  
  
3. Minute foreign particles are carried from the peritoneal
 
cavity through the diaphragm into the mediastinal lymph
 
vessels and glands, and thence into the blood, by which they
 
are transmitted to the organs of the body, especially those of
 
the abdomen, and later appear in the collecting lymph glands
 
of these organs. (Muscatello.)
 
  
  
 +
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.
  
3. The leucocytes are largely the bearers of foreign particles
+
VIII-13-91. First dressing. The gauze plug in the drainage tube is thoroughly saturated with a dark bloody discharge,
from the peritoneal cavity. (Muscatello.)
+
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.  
  
4. There is normally a current in the peritoneal cavity
+
The cotton immediately over the drainage tube was slightly
which carries fluids and foreign particles towards the diaphragm, regardless of the posture of the animal, although
+
moistened with the same character of secretion as that seen
gravity can greatly favor or retard it. (Muscatello.)
+
upon the plug and upon the cotton pledgets.  
  
Postural Method of Draining Dead Spaces in the
+
Abdomen flat, no distension, general condition good, usual
Pelvis.  
+
cultures taken.  
  
The many bacteriological studies in cases of experimental and
+
VIII-14-91. Second dressing. Slight amount of fluid on
post-operative peritonitis and in experimental infections of the  
+
cotton over the drainage tube ; plug in tube moistened by a
peritoneum show conclusively that the infecting organisms are
+
clear fluid holding a clot of blood at the lower end. On the  
quickly distributed more or less generally in the peritoneal
+
gauze plug there are white opaque points of lymph, corresponding in position to the perforation in the drainage
cavity, from whence they are carried into the system at large.  
+
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.  
  
Where there is no persistent source of infection, virulent
+
VIII-15-91. Third dressing. Gauze removed from the
species of bacteria may be destroyed effectually in this way;
+
tube track; moistened; not as much odor. Track of tube
but when a nidus of infection exists in which the microorganisms are propagated, the patient is either carried off by a
+
cleansed with peroxide of hydrogen. Abdomen flat, general
rapidly fatal septicaemia or peritonitis, or the peritoneal exudate forms a barrier to the further distribution of the infectious matter, which then follows the clinical course of any
+
condition good. Gauze reapplied to wound, but not down
localized collection of pus.  
+
the track ; abdomen sensitive. Gauze impregnated with permanganate of potassium and oxalic acid applied over the  
 +
protective dressing and track of the tube.  
  
To avoid this danger the most scrupulous care should be
+
VIII-19-91. Fourth dressing. Stitches removed. Line of
observed in every abdominal operation not to leave behind
+
union good; some suppuration about the track of the tube.
any condition which may furnish a starting point for an
+
General condition good.  
infectious process.  
 
  
Oozing should be controlled as far as possible, injury and
+
VIII-26-91. Fifth dressing. Small amount of creamy
exposure of the peritoneum should be guarded against, raw
+
fluid escaped from the track of the tube. Line of incision
areas should be covered with adjacent healthy peritoneum
+
in good apposition and well united.  
when practicable, and all debris and fluids should be removed
 
as far as possible before the abdomen is closed.  
 
  
Notwithstanding every precaution, dead spaces will be left
+
Analysis of temperature cliart. — The temperature was taken
after many operations, which may become collecting places
+
for ten days after the operation by the mouth, rectu m and vagina.
for degenerating fluids. In addition to these artiflcial spaces,  
+
The highest point registered was that on the fourth day, when
oozing serum and blood may collect in Douglas' cul-de-sac or
+
it was 102° F. by the rectum, 101.8° F. by the vagina, and  
in the ante-uterine space, and become the focus of a genei'al
+
101.2° F. by the mouth. After this it was never above 101° F.
peritonitis or a localized pelvic abscess.  
+
and on the 9th day registered 100.5° F.  
  
To offset these dangers all dependent spaces should be
+
Bacteriological examination. — The following cultures were
drained as rapidly as possible, thus preventing the collection
+
made from the left Fallopian tube and abscess cavity: Two
and stagnation of vital fluids, which are active germicides
+
sets of Esmarch's roll plates on agar-agar, one smear and one
when first secreted, but become excellent culture media when
+
stab culture in the same medium ; a blood-serum tube (bullock's
degenerated.  
+
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.  
  
By elevating the pelvis after operation, the normal intraperitoneal current may be assisted greatly in at once draining
+
Microscopical examination. — Cover-slips stained with gentian violet show numerous polynuclear leucocytes, with compound granular bodies, and a few cells with large round
dead spaces, and thus give the general peritoneal cavity and
+
nuclei resembling epithelial cells. Many bacilli were observed;
system at large the best opportunity to meet the invading
+
they were rather faintly stained, and were seen only occasionally within the leucocytes. These bacteria were stained
organisms before they have had time to increase in numbers.  
+
best with carbolic gentian violet.  
To remind one of the incredible rate of multiplication of
 
micro-organisms it is only necessary to quote Cohn's classical
 
statement that "one germ under proper conditions may give
 
rise to more than a half million of similar organisms within  
 
twenty-four hours."
 
  
Stagnating fluids in the dependent parts of the abdominal
+
Numerous rod-shaped bacilli were found in the preparation
cavity or in dead spaces may furnish such a favorable
 
culture bed that a few organisms may quickly generate myriads of others and overcome the most resistant germicidal
 
forces ; if on the other hand these spaces can be prevented
 
from filling with fluids the organisms may easily be overcome.
 
  
  
  
April, 1897.]
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
 +
 
  
  
 +
[No. 70.
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
from the Fallopian tube on the right side. Though less
 +
intensely stained, they resemble tubercle bacilli somewhat
 +
morphologically. They are, however, completely decolorized
 +
when treated after the method of staining for the latter organisms. It is to be noted that the organisms were very numerous in the specimen from the point at which the cultures
 +
were made.
  
63
+
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.
  
 +
All these tubes showed growth after 24 hours on agar; very
 +
faintly after 48 hours on gelatine, on account of the lower
 +
temperature, but more distinctly on the latter on succeeding
 +
days. The appearance of the colonies in gelatine corresponded
 +
to that presented by the bacillus proteus, a fact suggested by
 +
Dr. Booker and confirmed by Dr. Welch. These colonies
 +
showed the typical twisted wandering offshoots (schwiirmende
 +
Colonien) characteristic of the proteus group. The gelatine
 +
was not liquefied.
  
 +
Cultures from the Dramage Tube. — First dressing 24 hours
 +
after operation. Roll plate, agar-agar, Esmarch's tubes. The
 +
colonies on the tubes from the gauze plug were composed of
 +
the skin-coccus. Microscopical examination of stained coverglass preparations from the secretion showed a few diplococci,
 +
and numerous bacilli identical with those found in the abscess
 +
cavity. The coccus grew on potato and in bouillon with the
 +
characters of the streptococcus pyogenes albus, but liquefied
 +
gelatine, though less rapidly than this organism.
  
In additiou to tbe mere transportation of the organisms
+
The inoculation of a guinea-pig subcutaneously in the flank
from an area of decreased resistance to one of normal resistance, the irritant chemical toxines elaborated by the bacteria
+
with the serum-like secretion from the gauze plug was without result.  
are diluted and the infectious matter is divided into a fine
 
granular state, thus giving the leucocytes the best opportunity to encompass the organisms.  
 
  
Although fatal septicasmia may be produced in animals by
+
Further inoculations from the drainage tube on bullock
the absorption of large quantities of organisms from the peritoneal cavity, it appears to me correct to assume that after a
+
serum were not made, as the supply of culture medium was
well-conducted abdominal operation no such quantities of
+
exhausted.  
organisms will be left behind as are necessary to jiroduce
 
septicemia in the animal experimentally. If such a condition
 
should exist the patient would certainly die from the rapid
 
multiplication of the organisms in dependent cavities. Hence
 
I conclude that the better chance for the patient's recovery
 
lies in the direction I have indicated.  
 
  
My arguments therefore in support of this postural method
+
The case is of unusual interest on account of the results of  
of drainage are, first, stagnating fluids are prevented from  
+
the bacteriological examination. The bacillus proteus vulgaris (variety Zenkeri ?) was found in cultures from the
collecting in dead spaces in the pelvis; second, infectious
+
abscess cavity in the left ovary, and on cover-slips in the right
organisms are quickly carried into normal areas of the body
+
Fallopian tube. In all our previous examinations of abscess
where they are destroyed before they can increase in numbers;
+
cavities, cysts and Fallopian tubes, we have never met with
and third, toxic substances elaborated by the organisms are
+
another instance in which it was present.  
diluted and prevented from expending their irritant effects on
 
a wounded area.  
 
  
The method which I desire to offer is briefly as follows: At
+
Macroscopical and microscopical de.fcripfion of specimens from
the conclusion of an operation all fluids and debris should be
+
the Pathological Laboratory of the Johns Ho})kins Hospital, by  
removed as far as possible by sponges, after which the abdominal cavity should be thoroughly irrigated with normal salt
+
Dr. .T. Whitridge Williams.  
solution until the fluid comes away clear.  
 
  
When the irrigation fluid is all sponged out, 500 to 1000 cc.
+
Appendages on loth sides. Left side: Tube 6 by 0.7 by
of salt solution should be poured into the peritoneal cavity,
+
1 cm. Fimbriated end thickened and adherent to ovary, but
so that when the patient is elevated after she is returned to
+
not occluded ; some portions are still bound down to the
the ward the artificial current may be started at once towards
+
ovary, but at other places the adhesions have evidently been
the diaphragm, thus supplementing the normal current.  
+
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.  
  
After the introduation of the salt solution the omentum
 
and intestines should be replaced in an orderly way and the
 
abdomen closed.
 
  
As soon as the patient is returned to her room, the foot of
 
the bed should be elevated about 30 degrees, which gives sufficient inclination of the posterior pelvic wall to assist the flow
 
towards the general peritoneal cavity. This posture should
 
be maintained for twenty-four to thirty-six hours, after which
 
the bed may be lowered.
 
  
Leaving the salt solution in the abdominal cavity is not a  
+
The ovary is converted into a pus sac 5.5 cm. in diameter.
novel procedure, as it has been done in a large number of cases
+
The greater part of its exterior is smooth, though signs of
during the last two years in the gynecological department, and  
+
several dense adhesions are observed. On the surface are a  
other abdominal surgeons have used it with good effect.  
+
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.  
  
This postural method of drainage is offered as a prophylactic
+
Cover-slips from the pus show many thick bacilli, but no
measure against post-operative peritonitis, but not as a curative measure after the peritonitis is established.  
+
tubercle bacilli.  
  
It should therefore not be employed when an operation is
+
Right side : Tube 5 by 0.4 by 1.2 cm. ; fimbriated end
performed for the relief of purulent peritonitis or for inflammatory conditions associated with general peritonitis, as for
+
occluded ; many adhesions. Ovary 3 by 3 by 1.5 cm. Many
instance some cases of appendicitis.  
+
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.  
  
From the experiments of Waterhouse in which he proved
+
Microscopical examination. The left tube presents a marked
the danger of infection in cats suffering with ascites on
+
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
account of the defective absorptive mechanism, it would also
+
entirely disappeared, affording a picture which beautifully
appear unsafe to adopt the postural method in cases when
+
illustrates the liquefaction of tissue.
  
 +
There is also a marked endarteritis.
  
 +
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.
  
this complication is coincident with the surgical affection.  
+
In this portion the connective tissue bands are hardly visible.  
Pawlovvsky has sliown in his excellent experimental investigations that the lymph channels leading from the peritoneal
+
As we recede from the abscess cavity we find fewer leucocytes,
cavity are choked with the infectious bacteria and inflammatory products in purulent peritonitis, and therefore advises
+
more fibroblasts and connective tissue, until we gradually
free drainage through an abdominal incision.  
+
approach characteristic ovarian tissue.  
  
In these cases it is evident that the multiplication and virulence of the organism have been too great for the phagocytes
+
The bacillus corresponds morphologically to the bacillus
to overcome successfully, and that the only method of treating
+
proteus Zenkeri, and stains well with methylene blue, and does
this condition is to remove as much pus as possible by irrigation with salt solution or by mopping the peritoneal surfaces
+
not entirely decolorize with the Gram or Weigert stain. It
with sponges wet with salt solution, as suggested by Finney,
+
may be observed in the abscess walls as a bacillus of varying
and then to insert a very free drain.  
+
lengths and in forms simulating cocci. The fibroblasts are
 +
strikingly like the large cells of the corpus luteum.  
  
Only one of the cases which I report in this paper showed
+
In a contribution to the subject of the proteus vulgaris in
organisms on culture. The presence of pyogenic organisms
+
abscesses, Hauser', besides the report of his own case, gives a
is not a contraindication to the employment of the jiostural
+
resume of the instances previously reported by other writers.  
method, because all investigations have proved conclusively
+
Ilauser's case is that of an adult W'ho had a series of abscesses
that the peritoneum can overcome the invasion of large numbers of the most virulent organisms. Cases of pelvic inflammatory diseases, howevei-, rarely come to operation while the  
+
in the hand, following an injury from one of the autopsy
organisms are yet active, as shown by Miller of the Johns
+
instruments. The pus, which was of an ichorous and stinking
Hopkins Hospital, Schauta, Menge and others.  
+
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.  
  
In forty-four cases of hysterectomy, mostly for pelvic
+
Beck'' reports several cases of puerperal endometritis in
inflammatory disease, examined by Miller, the cultures made
+
which the proteus vulgaris was found, and one case of puru
from the interior of the uterus were negative, and cultures
 
from the pus obtained from 51 cases of pyosalpinx, ovarian
 
abscess and pelvic abscess, were negative in all but one case  
 
which showed gonococci.
 
  
Report of Cases in which the Postural Method of
 
Drainage was employed.
 
  
Case I.  
+
January, 1897.]
  
In this case all of the conditions usually supposed to
 
indicate imperatively the emjiloynient of some one of the
 
established methods of abdominal drainage were present.
 
  
Among these the chief indications were a sejitic temperature with great prostration of the patient before operation,
 
and during the operation the separation of wide-spread adhesions which produced extensive injury to the peritoneum and
 
free oozing of blood, the escape of a large quantity of pus
 
and degenerated blood clots into the abdominal cavity. In
 
addition to these conditions portions of the cyst wall and
 
degenerated matter, and, most dangerous of all, a large cupshaped dead space beneath the intestines and mesentery, were
 
left at the close of the operation.
 
  
Gynecological No. 4946. E. B. L., admitted January 18,
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
1897. Married, age 47 years.  
 
  
Complaint. Pain in the lower abdomen, more marked on
 
the right side. Slight cough.
 
  
Marital History. Married 16 years ; one child 16 years old;
 
labor easy, puerperium normal, no miscarriage.
 
  
Menstruation. Began at 13 years, regular, normal. Last
+
lent peritonitis, following total extirpation of the uterus for
period terminated December 18, 1896.  
+
carcinoma, in which the presence of the same organism was
 +
demonstrated.  
  
Present Illness. November 15, 1896, she had a severe chill,
+
Finally, Dilderlein' reports that in the lochia of puerperal
lasting two hours, followed by fever. The next day she had  
+
women he has often found bacilli which cause a rapid liquefaction of gelatine; but from his brief description one is not
great pain, which continued one week and was accompanied
+
able to say whether or not he was dealing with the proteus.  
with diarrlia.'a. Since then she has grown steadily weaker.  
+
 
 +
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
  
  
64
+
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.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
2. Beck : Die Faulnisbachterieu der menschlichen Leiche.
 +
Baumgarten: Arbeiten auf dem Gebiete der pathologischen
 +
Anatomie und Bacteriologie aus dem pathologisch-anatomischen Institute zu Tiibingen, Bd. I, S. 155, 1889.  
  
 +
3. Doderlein : Untersuchung iiber das Vorkommen von
 +
Spaltpilzen in den Lochien, etc. Archiv f. Gyuilkologie,
 +
1887, Bd. 31, S. 439.
  
 +
4. Fliigge: Die Microorganismen, 188G, p. 310.
  
[No. 73.
 
  
  
 +
THE PHRENOLOGY OF GALL AND FLECHSIG'S DOCTRINE OF ASSOCIATION CENTRES
  
fever and chills occurring frequently, and for the last week
+
IN THE CEREBRUM.  
she has been confined to bed.  
 
  
General Condition. Well nourished woman; tongue slightly
+
Br Lewellts F. Barker, JI. B., Associate Professor of Anatomy in the Johns ffopki7is University and  
coated, bowels regular, appetite poor. Micturition and defecation painless. For the past four weeks she has had a dry cough.  
+
Assistant Resident Pathologist to the Johns Hopkins Hospital.  
  
Examination of heart and lungs negative.  
+
[Remarks made before the Clinical Society of Maryland, November 20, 1896.]
  
Temperature on admission 103° F., pulse 110.
 
  
Diagnosis. Large suppurating ovarian cyst.
 
  
Operation by Dr. Kelly, January 20, 1897. Cystectomy;
+
In the history of medicine the 18th century stands out
part of cyst wall could not be removed.  
+
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.  
  
Complications. Extensive adhesions to mesentery, bowel and
 
vermiform appendix. Adhesions to entire posterior pelvis, to
 
omentum, to bladder, and to anterior abdominal wall. Patient
 
greatly prostrated, pulse before operation 118, at close 144,
 
during operation as high as 156.
 
  
  
 +
Indeed, the statement has been made that the general tendency of the time to favor Schelling's philosophy did more than
 +
anything else, except the curiosity of the public, to spread the
 +
three false doctrines, animal magnetism, phrenology, and homCEopathy. Animal magnetism, fathered by the shrewd Anton
 +
Mesmer, had a brilliant career until the French commission
 +
with Franklin at its head successfully demolished it. Homceopathy, founded by Christian Friedr. Samuel Hahnemann,
 +
which attempted to subordinate the whole of the healing art
 +
to an arbitrary dictum, Siinilia similibus curantur, still has
 +
many adherents, especially in America. Phrenology or cranioscopy, connected closely with the name of Franz Josef Gall,
 +
has now but few disciples, and an avowal of belief in phrenological doctrines is usually received, even by the layman, with
 +
a suppressed smile.
  
Incision 14 cm. in length, exposing red mottled and whitish
+
Gall was born at Tiefenbrunu, in Germany, in 1758. The
cyst wall, closely adherent to anterior abdominal wall over a
+
history of his life affords entertaining reading. He studied
surface 10 cm. above symphysis pubis. Omentum adherent
+
medicine in Strassburg and Vienna, and practiced his profession
to anterior face of cyst over an area 10x8 cm. Adhesions
+
in the latter city, where he became very well known. He tells us
separated; free oozing from thickened omentum checked by
+
in his books how at a very early age he noticed among his playmates the existence of definite relations between the external
catgut sutures, no omentum removed; just above this point
+
appearance of the head and face and certain mental characteristics. His lectures delivered in Vienna, in which his
there was a fringe of flat adhesions, binding cyst to intestines
+
phrenological doctrines were chiefly set forth, were very popular and largely attended until 1802. when at the instance of  
and skirting the whole upper border of tumor from left to
 
right. Adhesions so dense that separation was impossible
 
without great injury to intestines.
 
  
Tumor tapped, about 3000 cc. of thick, fetid, yellow pus
 
evacuated; the puncture was then closed with sutures.
 
  
Ten minutes were spent in separating tumor from anterior
 
abdominal wall, bladder and anterior pelvic wall.
 
  
Large Fallopian tube on left side was exposed up to a point
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
Jan.  
+
[No. 70.  
  
  
  
18
+
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.
  
19 20
+
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
  
  
21
 
  
 +
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
  
  
23
+
January, 1897.]
  
  
  
24
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
25
+
lais and Swift, it was believed to be the organ of the sense of
 +
the ludicrous. The capacity for recognizing faces was supposed to depend upon the width of the interval between the
 +
eyes, inasmuch as Gall found in a squinting girl a good
 +
memory for faces. The murderer Thurtell, who had a large
 +
organ of benevolence, is said by devotees to phrenology to have
 +
been in reality generous, since it was discovered that he once
 +
gave half a guinea to a friend. Many other laughable instances
 +
might be given of these crude methods of localization and of
 +
the futile attempts of the adherents of the doctrine to bolster
 +
up their tumbling edifices.
  
 +
It is easy to understand how a shrewd man like Gall, — and
 +
any one who reads his books will be very ready to grant his
 +
shrewdness and intelligence, — developing with great rapidity
 +
a system full of interest for the public and stimulating their
 +
curiosity by providing them with an infallible clue to the
 +
determination of character and fitness for occupation in life,
 +
should have attained wide-spread and lucrative popularity.
 +
He soon made large amounts of money, lived in state, and
 +
numbered among his personal friends some of the first names
 +
in France. Nor was he a charlatan pure and simple; he undoubtedly had a brilliant mind, and made elaborate and careful
 +
studies of the brain and skull which resulted in discoveries
 +
of permanent value concerning the anatomy and physiology
 +
of the brain. No better proof of this statement can be obtained than by perusing the volumes which I place before you,
 +
kindly loaned by the Provost of the Peabody Library. This
 +
atlas, with its well-executed copper- plates, in particular, shows
 +
the care with which much of his work must have been done.
 +
The edition, including the atlas, sold in Paris at 1000 francs.
  
 +
It is curious how nearly a man starting with false premises
 +
may often approach to actual conditions. 'I'he newer investigations bearing upon the architecture of the brain have thrown
 +
much unexpected light upon the origin of the phenomena of
 +
the mind; the significance of the brain for the psychic phenomena has been established upon the basis of exact scientific
 +
investigations, and we are now justified perhaps in speaking in
 +
a certain sense of a " new phrenology." It may be interesting
 +
to refer briefly to the series of investigations which have led
 +
up to our present knowledge upon this subject.
  
26
+
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
  
  
  
Temp.  
+
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.  
  
103
+
In addition to the studies on aphasia there have been
102
+
recorded a whole series of pathological lesions which clinically were associated with definite disturbances of sensation ;
101
+
thus, lesions of the occipital cortex have a tendency to affect
100
+
visual sensations; lesions of certain portions of the temporal
 +
cortex interfere with hearing; the sense of smell has been
 +
shown to be connected with the under surface of the cerebrum, and the sense of touch with the upper frontal and
 +
anterior parietal regions. Physiologists by means of experiments upon animals have added most satisfactory support to
 +
these clinical and pathological observations.
  
99
+
In 1870 Fritsch and Hitzig reported the results of their
 +
investigations concerning galvanic excitation of the surface of
 +
the brain of animals, in which it was shown that stimulation
 +
of definite regions calls forth movements of certain only of
 +
the parts of the body. Three years later Ferrier used faradic
 +
stimulation of the cortex and was able to elicit quite complicated movements of different parts of the body, movements
 +
which seemed to be purposeful, inasmuch as they correspond
 +
to those employed by the animal when utilizing its sense
 +
organs, that is to say, movements such as are employed in
 +
listening, touching, looking at, or smelling external objects.
 +
Munk proved fiirther that by the removal of certain convolutions it was possible to produce in animals disturbances of
 +
sensory activity quite analogous to those which had been
 +
observed in the clinical and pathological study of diseased
 +
human beings.
  
98
+
The studies of Goltz upon dogs supply an exceedingly interesting link in the chain of experimentation. This investigator
 +
demonstrated the possibility of keeping a dog alive for a
 +
considerable length of time in the entire absence of a cerebral
 +
cortex, and in this way was able to ascertain what faculties
 +
the animal possesses when only the lower parts of the brain
 +
are functioning uncontrolled by the cerebrum. He found
 +
that an animal without a cerebrum still possesses a very complex nerve life, a fact which is not so very surprising when
 +
one recollects the observations of comparative afiatomy.
 +
While the dog of Goltz's experiment appeared to be devoid of
 +
memory and judgment and incapable of finding out for himself among the objects outside of the body those necessary for
 +
the satisfaction of his needs, he showed himself to be by no
  
Temp.
 
  
Pulse
 
Resp.
 
  
Stools
+
10
  
  
  
Day of
+
JOHNS HOPKINS HOSPITAL BULLETIN.
Operation
 
  
  
  
6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 le 6 12 6 l2 P^l'se
+
[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.
  
5(10
+
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.
  
 +
Flechsig has shown, in his study of the embryonal cerebrum,
 +
that it is the sensory paths which first become medullated.
  
 +
*I have thought it best at this time to present, in as clear and
 +
brief a manner as possible and without discussion, the main tenets
 +
of Flechsig with regard to the structure and function of the brain.
 +
While in such a short communication it is impossible to do justice
 +
to so broad a subject, it is to be hoped that it may be possible to
 +
show at least the trend of his views. The anatomical basis for his
 +
studies is given at some length in the voluminous notes appended
 +
to his "Gehirn und S'eele " (Leipzig, Veit. Co., 189(>). An idea of
 +
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).
  
540
 
  
  
 +
Gradually the individual fibres of one sensory path after
 +
another, beginning with that concerned in the sense of smell
 +
and ending with that by which are carried auditory impulses,
 +
passing from the sense organs of the body toward the cerebral
 +
cortex, gain their myelin sheaths. Each sensory path includes
 +
a very large number of nerve fibres containing the axones of
 +
neurones whose cell bodies are situated lower down. Following the different sensory paths to their cortical termination, it
 +
is easy to show in these early stages, in which very little of
 +
the brain is medullated, that the individual sensory paths
 +
terminate in tolerably sharply circumscribed cortical regions,
 +
for the most part widely removed from one another, being
 +
separated by masses of cortical sitbstauce which remain for a
 +
considerable period entirely unripe. Indeed, the cortical
 +
terminations of the individual sense paths correspond entirely
 +
to those regions of the surface of the brain which pathological
 +
observation has shown to stand in relation to the different
 +
qualities of sensation. It is the destruction of these internal
 +
sense organs which results in cortical blindness, cortical deafness, etc.
  
560
+
After these sensory paths in the child's brain have become
 +
medullated, new paths begin to develop from the points where
 +
the sense fibres terminate — paths which go in the opposite
 +
direction. These fibres as they become medullated can be
 +
traced passing downwards to the medulla and the spinal cord,
 +
to the nuclei of origin of the motor nerves, and connecting in
 +
this way the sensory regions on the surface of the cerebrum
 +
with the motor apparatus. The area of the cortex concerned
 +
in the sense of touch has an especially well developed bundle
 +
of these motor fibres, the fasciculus cerebro-spinalis or so-called
 +
pyramidal tract, which consists of more than 100,000 fibres on
 +
each side, an arrangement which permits the carrying out of
 +
very delicate movements, especially of the parts of the body
 +
concerned in the sense of touch. Connections between the
 +
cortical sensory areas and the lower centres which appear to be
 +
concerned more directly with the bodily instincts, have already
 +
been made out. It is clear, therefore, that bodily instincts
 +
and external sense impressions may reciprocally influence one
 +
another. According to Flechsig, the sense of smell is moat
 +
intimately connected, the sense of hearing least associated
 +
with the centres concerned in the exercise of the lower
 +
instincts, a fact which, if confirmed, might account for the
 +
more ideal character of auditory impressions.
  
 +
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
  
  
6()0
 
  
 +
Gyru.cm,.r..l,{J»«;r;;p,S<,m»»>.l,.tlo.,„.
  
  
>» •
 
  
 +
Corpus cAllonnn
  
 +
Porulx louguti,
  
 +
(Septum pellucW,
  
  
  
670
 
  
 +
"^ti^^i^r^^^j^
  
  
^'"
 
  
 +
^^^
  
  
5ilO +
 
  
 +
Oolliculiia superior (corp. quad.)
 +
. Hnin nucleus of tliaUmua.
  
  
^'*..
 
  
  
 +
Fig-. 6.
  
190 +
 
  
  
 +
Soraae»tUetic
  
,\
 
  
  
  
30 +
+
Gynm hippocampi.
  
  
  
130
+
Fig. +.
120
 
110
 
100
 
90
 
  
  
  
80
 
  
70
 
  
4 60
 
  
50
+
LEGENDS.
  
 +
Fig. 1. Sagittal section through brain of a child one month old stained by the
 +
Weigert-Pal method. lAfter FUchsig.)
  
 +
a. Taenia thalaini optici iretiex path tor the transference of olfactory
  
Case I.
+
impressions to the centres governing the movements of the
Plain line indicates temperature. Broken line indicates pulse.  
+
head ?).  
  
 +
b. White matter of septum pellucidum (in part running between the
  
 +
olfactory area and the gyrus hippocampi).
  
where it was lost in the tumor. Adhesions to uterus, to pelvic
+
c. Corpus callosum corresponding to the somiesthetic area.  
floor on right side, and to part of left pelvic wall divided.
+
D. Superior I
On floor of pelvis a sac coutaining 300 cc. of thick brown
 
pasty blood was evacuated. Ovarian vessels at left pelvic
 
brim exposed by dissecting with knife, fingers and scissors,
 
and ligated, the left cornu uteri was then tied off and cyst
 
cut loose from top of left broad ligament.  
 
  
In separating adhesions on pelvic floor a sac was ruptured,  
+
h. Inferior jcolliculus of corpora cjuadrigemina, cut near the middle
discharging a large quantity of fetid pus into the peritoneal
+
line : here very few meduUated fibres are present; sections lateral
cavity. This was quickly mopped out and the hole in the sac
+
to this show many,  
stuffed with gauze. Cyst cut loose, leaving a portion of  
+
r. Red nucleus of the tegmentum ; below this is seen the decussatio
abscess wall 5x8 cm. in dimensions on the pelvic floor. Gauze
+
brachii conjunctiva
 +
(In this and succeeding plates I have translated Flechsig's terms as tar as possible into the nomenclature of the Anatomical Society. For his sense-centres and  
 +
association-centres English terms which seemed most suitable have been employed
 +
For the suggestion of the name " soma-sthetic area" as a translation of the German
 +
KorperfuhUplKire I am indebted to Prof. B. L. Gildersleeve.— L. F. B.)
  
 +
Fio. 2. Horizontal section through the brain of a child aged 3 months. (AHer
 +
Flechstg.) \ j'-'»
  
 +
II. Tractus opticus.
  
packed over this to protect it during the rest of the operation.  
+
H. Association system (cross-section) in the g. hippocampi, connecting
Sac was peeled up and out of a dense bed of adhesions in  
+
the olfactory cortex of the uncus with Ammon's horn, going
the pelvis ; it was then found that the adhesions, extending
+
over into the alveus.  
between the entire length of the mesentery and out onto the  
+
M. Nucleus amygdalae.
intestines, were too extensive for further separation. The
+
P. Pyramidal tract in cross-section.
outer layers of the cyst wall were slit 2 cm. from bowel on all
+
p'. Temporal cerebro-pontal path.
sides and dissected out from beneath the mesentery, thus completing the enucleation and leaving behind a large cup-shaped
+
p'. Frontal cerebro-pontal path.
dead space. Slight capillary oozing occurred from the portion
+
The decussation of the nervus trochlearis is shown. The projection fibres of the  
of cyst wall remaining behind.  
+
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.  
  
The portion left in the pelvis also required six or eight ligatures to control oozing. Small epithelial cyst on right side
+
Fio. 3. Horizontal section from the brain of a child a little over a week old.
 +
{After Flcchxig.)
  
 +
C. Nucleus oaudatus.
 +
P. Putamen of the nucleus lenticularis.
 +
gp. Globus pallidus of the nucleus lenticularis.
 +
The optic radiation is well medullated ; the auditory path is not yet medullated
 +
as far as the cortex.
  
 +
Fig. 4. Sagittal section through the brain of a child said to have died in the
 +
fifth month of life. (The child was probably some months older.) (After Fleclmii.)
 +
All parts of the white substance medullated, only in places still mixed with
 +
non-medullated fibres.
  
April, 1897.]
+
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.
  
 +
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.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
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.  
  
 +
Fio. 6. Internal view of left cerebral hemisphere. (After FUchHg.)
  
 +
1. Corpus mammillare.
  
65
+
2. Median section of optic chiasm.
  
 +
3. Cross-section of anterior commissure.
  
 +
4. Superior colliculus of corpora i|uadrigemina.
 +
.5, Corpus callosum (cross-section).
  
piiuctured. Eight ovary normal. Eight tube adherent and
+
6 Fornix.  
closed.  
+
 
 +
7. Septum pellucidum.  
 +
z. Pineal gland.
 +
H.S. Tegmentum.
 +
T. Basis pedunculi.  
  
Adhesions of right ovary to sac bled freely, requiring two
 
sutures to control hemorrhage.
 
  
At completion of operation the abdomen was freely irrigated with many litres of salt solution, after which 700 cc.
 
of salt solution were left in the abdomen. Abdomen closed
 
with buried silkworm gut and subcutaneous catgut sutures.
 
  
Day of Operation. Patient's cough very troublesome, pulse
+
January, 1897.]
116, temperature 101° F. before operation. Eeturned from
 
operating, room at eleven o'clock, pulse 140, respiration -18,
 
profuse perspiration over entire body. Twelve o'clock, pulse
 
132, respiration 46. One o'clock, pulse 129, respiration 44.
 
Two o'clock, foot of bed elevated twenty inches. Five o'clock,
 
pulse 116. Six o'clock, pulse 116, temperature 100.4° F.
 
Twelve o'clock, temperature 100.3° F., pulse 128. Patient
 
uncomfortable, but not suffering great pain.  
 
  
Second Day. Six o'clock A. M., temperature 99.6° F., pulse
 
126. Patient slept in all about two hours, often rendered
 
uncomfortable by cough and heavy perspiration. Bed lowered.
 
  
Twelve o'clock noon, temperature 98.8° F., pulse 126.
 
Patient has been comfortable up to this time, cough more
 
troublesome, she now feels nauseated. Six o'clock, patient
 
has vomited four times during afternoon, but is now comfortable, temperature 99.4° F., pulse 120.
 
  
Twelve o'clock midnight, temperature 99.3° F., pulse 124.
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
Cough troublesome.  
 
  
Third Day. Patient slept most of the night, awakened at
 
intervals by paroxysms of coughing. Bowels moved. Temperature 98.8° F., pulse 124.
 
  
Twelve o'clock noon, temjDerature 98.6° F., pulse 114. Six
 
o'clock, temperature 98.8°, pulse 108. With exception of pain
 
produced by coughing, patient has passed a comfortable day.
 
  
Twelve o'clock midnight, temperature 100.4° F., pulse 118.
+
11
  
Fourth Day. Six o'clock, temperature 99.6° F., pulse 118.
 
Bowels well moved, patient comfortable. Twelve o'clock noon,
 
temperature 99.4° F., pulse 116, patient very comfortable.
 
Six o'clock, temperature 99° F., pulse 110.
 
  
From the fourth until the tenth day the patient made as
 
perfect a recovery as the most uncomplicated cases of abdominal section. The abdominal dressings were removed on the
 
tenth day; incision healed /;er primam, subcutaneous suture
 
entirely absorbed. Cough ceased about this time. Patient sat
 
up in bed on the sixteenth day, and was out of bed in a wheel
 
chair on her nineteenth day, and was able to walk on her
 
twenty-fifth day. She was discharged from the hospital on
 
her thirty-fifth day, feeling perfectly well.
 
  
Case II.  
+
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.  
  
In this case the operation was very difficult and attended by
+
Besides being a sensory field, the soma3sthetic area is also
many complications. The peritoneum was injured extensively, pus escaped during the operation, the intestine was
+
the great motor region whence nearly all the movements
injured and required suture, free oozing occurred during the
+
serving for the voh;ntary satisfaction of the bodily instincts
operation and persisted at its completion, and large denuded
+
appear to start. When a man voluntarily swallows, chews,  
areas were left in the pelvis.  
+
breathes or seizes an external object, it is this area which is
 +
active.  
  
Gynecological No. 4892. A. E. T., widow, aged 34 years.  
+
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.  
  
Complaint. Pain in the right inguinal region, pain in the  
+
The fibres concerned in visual sensation, passing from the  
rectum, and swelling of the abdomen at times.  
+
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.
  
 +
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
  
Menstruation began at fourteen, flov scanty but regular,
 
lasting two to three days; always painful before marriage,
 
since then painless.
 
  
Marital History. Married 14 years ago ; husband has been
 
dead eight years. Four children, oldest 14 years, youngest 8
 
years of age. First labor instrumental, the others were easy.
 
No miscarriages.
 
  
Family History. Negative.  
+
uncolored in the diagram are the so-called association centres
 +
of Flechsig. They make up the main portion of the frontal
 +
lobe, a large part of the temporal and occipital lobes, the
 +
island of Eeil, and occupy a large area in the posterior parietal region of the brain. For a whole month after birth these
 +
portions of the cortex remain uuripe and are entirely devoid
 +
of myelin. But after the development of the sense areas of the
 +
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.  
  
Present Complai?it. Three years ago she was confined to
+
Flechsig believes, therefore, that these association centres
bed for three weeks with fever and chills and severe pain in  
+
are the portions of the cerebral cortex which above all others
the lower abdomen, which began in the right side and then
+
are concerned in the higher intellectual manifestations, in
shifted to the left. During the attack she had a constant
+
memory, judgment and reflection. If his theory be right, the
discharge of thick tarry blood from the uterus. After the  
+
study of the association centres should be the especial object
attack she was able to get up, but it soon recurred, and the  
+
of research for the neurologist and jisychologist. That they
abdomen became greatly distended and excessively painful.
+
really are of definite importance for the intellectual activities
Ten days ago another attack began, which has not been so
+
has been shown by these anatomical studies, which might of
severe up to this time as the former ones. She complains of  
+
themselves be deemed conclusive. But it must be conceded
pain during defecation and micturition, backache and bearingdown pains. Temperature on admission 101° F., pulse 120.  
+
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.  
  
Diagnosis. Pyosalpinx duplex ; retroflexio uteri adherens;
+
It seems likely from Fiechsig's studies of the brain lesions
pelvi-peritonitis.
+
in general paresis, that this disease more than any other will
 +
afford the key for the deduction of psychic disturbances from
  
Operation. Enucleation of both ovaries and tubes.
 
  
Complications. Dense adhesions binding pus sacs to pelvic
 
walls and rectum, close relation of abscess on right side with
 
the iliac vessels, persistent oozing following operation,
 
escape of pus during the operation into the abdominal cavity.
 
  
Incision 12 cm. through thin abdominal walls, intestines
+
12  
packed back into abdomen with gauze bolsters. Impossible
 
to differentiate pelvic structures at first on account of the
 
dense adhesions covering in and binding all of the organs
 
together.
 
  
Sigmoid flexure released from mass to which it was bound
 
by dense adhesions. Outer coat of the bowel torn for about
 
3 cm. during the separation, but was at once closed with
 
interrupted catgut sutures.
 
  
The enucleation was then begun on the floor of the pelvis,
 
working upward and freeing the ovary and tube which formed
 
a sac containing 30 cc. of pus. These structures were then
 
tied off and cut away from the pelvic wall.
 
  
The fundus of the uterus was then partially liberated from
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
adhesions, but this was discontinued on account of the free
 
bleeding and danger of tearing into the rectum.  
 
  
A long fusiform mass on the right side extended along
 
the iliac vessels, with which it was closely adherent, around
 
in front of the bladder. The sac contained 60 cc. of thick
 
white pus, which partly escaped during the operation.
 
  
After freeing all the adhesions, the round ligament and
 
ovarian vessels were tied off and the mass excised.
 
  
Active oozing to the right of the fundus over the ureteral
+
pfo. 70.  
area, also posterior to the fundus. After controlling several
 
of these points there was still free hemorrhage at a point on
 
the pelvic floor to the left of the rectum and from another
 
point on the under surface of the broad ligament. This
 
oozing was sufficient to stain a sponge as fast as it could be
 
applied. The abdomen was irrigated thoroughly with salt
 
solution, after which the bladder and fundus and the fundus
 
and parietal peritoneum were stitched together to control
 
oozing and to cover the raw areas with peritoneum.  
 
  
  
  
66
+
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.
  
 +
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
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
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.
  
[No. 7.3.  
+
If one of the sense areas of the cortex alone be diseased, the
 +
clinical picture is entirely different from that presented by
 +
these purely intellectual disturbances. Here again we may
 +
have to do either with phenomena of absence or phenomena of irritation. A tumor pressing upon the auditory area may give rise to noises and other subjective perceptions of sound. Pressure upon the posterior central gyrus
 +
may lead the individual to believe that he experiences movements of his thumb, although his eyes convince him that it
 +
remains station.'fl-y. Again, a tumor pressing upon the uncinate gyrus has been known to give rise to subjective odors;
 +
while a cysticercus cyst pressing upon the visual area of the
 +
occipital lobe has caused the arrival into consciousness of
 +
mental pictures of colored figures and the like. Destructive
 +
lesions of the sense centres may prevent the external sense
 +
impressions from entering into consciousness at all. There
 +
may be entire absence of mental confusion in such instances;
 +
the patient recognizes the subjective character of the
 +
hallucinations, and so is not actually mentally diseased in the
 +
ordinary sense, but if focal disease affect along with one sense
 +
centre several of the others, or the posterior large association centre, the picture of hallucinatory confusion is prominent.  
  
 +
Time will not permit me to discuss the so-called functional
 +
disturbances ascribable to conditions of exhaustion of different cortical areas dependent upon prolonged and violent
 +
emotion, various intoxications, impoverishment of the blood,
 +
and other causes. Suffice it to say that, on theoretical grounds
 +
at least, more or less sharp criteria can be mentioned for the
 +
participation in the process of the different centres, especially
 +
the somresthetic area, the frontal lobes and the posterior large
 +
association centres. In many instances, however, the phenomena presented show, what we a priori might expect, that
 +
several of the sense areas and association centres are diseased
 +
at once. The various permutations and combinations possible will doubtless account for the manifold symptomatology
 +
of the great group of nervous and mental diseases, a symptomatology which as yet is in almost hopeless confusion and
 +
which calls urgently for an ordering hand. It will be the
 +
task of psychology and neurology in the future to analyse
 +
the specific activities of the various regions of the cortex, and
 +
to correlate these with the mental phenomena of human beings
 +
in health and disease.
  
 +
Flechsig's researches have established the fact that the
 +
human cerebral cortex is made up of at least seven anatomically more or less well separated areas. As the phrenologists
  
500 cc. of salt solution left in abdomen. Pulse at beginning
 
of operation 93, at end 150. Time of operation one hour and
 
a half.
 
  
First Day. Patient returned to ward at four P. M., pulse
 
140. Bed elevated. Four thirty P. M., pulse 120, of good
 
volume; six o'clock, pulse 104; seven o'clock, 100; nine
 
o'clock, 96; twelve o'clock midnight, 88. Patient recovered
 
quickly from ether without symptoms of shock.
 
  
Second Day. Six o'clock A. M., temperature 100° F., pulse 9G.
+
January, 1897.]
Patient complains of much pain. Twelve o'clock, pulse 92,
 
temperature 100.8° F., patient sleeping quietly. Six o'clock
 
P. M., temperature 100° F., pulse 100. Twelve o'clock midnight,
 
temperature 99.8° F., pulse 92. Patient sleeping quietly.  
 
  
  
  
Tliird Day. Six o'clock A. M., pulse 84, temperature
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
99.3° F. Bowels slightly moved. Condition remained about
 
the same during day. Patient complained of some nausea,
 
but did not vomit.  
 
  
Fourth Day. Six o'clock A. M., pulse 80, temperature
 
99.4° F. Patient rested well, still slightly nauseated.
 
  
Fifth Day. Six o'clock A. M., temperature 99.6°, pulse 72.
 
Bowels effectually moved, well formed stool. Patient passed
 
a very comfortable day. From this time on the patient made
 
a good recovery. On the tenth day after her operation the
 
temperature rose to 100° F., and continued about this point
 
until her seventeenth day, when it dropped to normal. At
 
the time of her discharge she was feeling well.
 
  
 +
13
  
  
  
V)a.y a?
+
thought, the brain is the organ of the mind, and the whole
 +
is in reality made up of multiple organs. But instead of calling
 +
these, as did the old phrenology, after certain qualities, friendship, good-nature, wit, firmness, and the like, thanks to
 +
Flechsig's studies we can now adopt a more rational nomenclature. We can now speak of sense centres and of association centres in the cerebral cortex. The sense centres may
 +
be roughly grouped as the somssthetic area, the visual sense
 +
area, the olfactory sense area and the auditory sense area ; the
 +
association centres for the present have to be designated
 +
according to their position as frontal or anterior, insular or
 +
middle, and parieto-occipital or posterior. Thus a distinct
 +
advance has already been made, and it is hardly too much to
 +
expect that further study will permit of much more complete
 +
differentiation and more definite localization of both kinds of
 +
areas.
  
Operation
+
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
  
Case II.
 
Plain line indicates temperaiure. Broken line indicates pulse.
 
  
  
 +
* 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.
  
Case III.
 
In this case there were dense adhesions binding a large
 
suppurating ovarian cyst to the intestines and the abdominal
 
wall. A suppurating fistulous track extended between the
 
caput coli and one loculus of the cyst, requiring a number of
 
silk sutures to repair the opening in the intestine left after
 
the enucleation of the cyst. Pus escaped into the abdominal
 
cavity, and large handfuls of clotted blood were ladled out of
 
  
  
 +
address upon the " Border-lands of mental health and disease,"
 +
has laid especial emphasis upon the significance of the somajsthetic area. Assuming it to be the portion of the cerebral
 +
cortex where impressions regarding the body enter into consciousness, the centre which appears to have to do with the
 +
bodily emotions and bodily needs, and upon the excitability
 +
of which the crudity or delicacy of the instincts which enter
 +
into consciousness depends, as well as the centre whence start
 +
nearly all motor impulses which are concerned in conduct, be
 +
they those leading to the closure of the fist, the pressure of the
 +
hand, or the most delicate embrace, Flechsig believes that this
 +
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.
  
a hirge cavity in the pelvis. Pieces of the cyst wall and much
+
Furthermore, Flechsig sees in these newer studies the essential preparation for a physiological basis of ethics, so much
debris remained behind at the completion of the operation.  
+
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.  
  
There was considerable oozing and extensive traumatism
+
It must be the aim of educators to enlighten the people concerning the hygiene of the body and especially of the brain.
produced by the separation of tlie wide-spread adhesions.
+
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
  
Pus from the cyst injected into a mouse killed it within
 
twenty-four hours.
 
  
Notwithstanding all these complications the patient made
+
14
a good recovery.
 
  
  
  
April, 1897.]
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
[No. 70.  
  
  
  
67
+
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."
  
  
  
Gynecological No. 4928J. A. E. S., admitted January 9,
+
NOTES ON NEW BOOKS.  
1897. Single, age 35 years.  
 
  
Complaint. Increasing size of abdomen, severe constipation, feeling of obstruction in abdomen. Menstruation began
+
Practical Points in Nursing, for Nurses in Private Practice, with an
at 15 years, recurring every 28 days, 4 to 5 days duration,  
+
Appendix. By Emily A. M. Stoney, Superintendent of Training
normal.  
+
School for Nurses, Carney Hospital, Boston. Illustrated with 73
 +
engravings and 9 colored and half-tone plates. {Philadelphia:
 +
W. B. Saunders, 1896.)
  
Family History. Negative.  
+
This little book is primarily designed for the instruction of
 +
private nurses, and as such it will undoubtedly serve a useful purpose. It is to be regretted, however, that it is also intended to be
 +
used for the instruction of classes, and for the home nurse, for
 +
which purposes it seems very inadequate. It may help those who
 +
are already instructed and who require a book of reference, but it
 +
presupposes a degree of previous knowledge on the part of the
 +
student which pupil nurses and home nurses do not possess.  
  
Present Illness. Patient was always strong and well until
+
The chapters on physiology and descriptive anatomy are of the
four years ago; at this time she suffered with indigestion, and  
+
most elementary character and are couched in such terms as to
was treated by her physician for displacement of the uterus.  
+
convey no adequate idea of the subjects treated. Witness the
She had an attack of peritonitis in September, 1895, which
+
following: "The parotid gland is situated below and toward the
confined her bo bed four weeks. In October, 1896, she suffered
+
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
  
  
9 10 II 12 13 14 15 16 17
+
thalmia neonatorum is inflammation of the conjunctiva, which is
 +
one of the coats of the eyeball. Its causes are numerous, but in
 +
the newborn it is generally caused by infection during birth from
 +
the urethral or vaginal discharges of the mother."
  
 +
The chapter in which directions are given to nurses as to their
 +
conduct is clearly and judiciously written. Some nurses would
 +
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.
  
with " chills and fever," which lasted eight weeks. During
+
{Published by Oeorge 8. Davis, Detroit, 1896.3
the attack she passed pus from the rectum, her abdomen was
 
swollen and very tender to pressure. Enlargement of the
 
abdomen persisted after this attack, and has lately been increasing rapidly.  
 
  
She suffers from stricture of the rectum, which followed an
+
The second edition of this little work has recently appeared as one
operation for hemorrhoids performed in 1892.  
+
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.  
  
Present Condition. Body emaciated, complexion pale, expression anxious. Appetite good. Micturition normal.  
+
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.)
  
Examination of heart and lungs negative. Temperature on
+
This admirable textbook of ophthalmology is so well and so
admission 100.5° F., pulse 120.  
+
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.  
  
Diagnosis. Suppurating ovarian cyst.  
+
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
  
  
  
 +
January, 1897.]
  
Case III.
 
  
Plain line indicates temperature. Broken line indicates pulse.
 
  
 +
JOHNS HOPKINS HOSPITA.L BULLETIN.
  
  
Operation by Dr. Kelly, January 16, 1897. Cystectomy.
 
  
Complications. Dense adhesions between cyst and intestine, fistulous opening between intestine and cyst. Pyogenic
+
15
urea over bladder and anterior abdominal wall.
 
  
Puncture and evacuation through the abdominal incision
 
of 2800 cc. of fetid pus, part of which escaped into the
 
abdominal cavity. During enucleation of cyst it tore, allowing 150 cc. of pus to escape. Large hematoma filling lower
 
pelvis opened and handfuls of thick putty-like blood were
 
ladled out, in all about 200 cc. ITydrosalpinx and adherent
 
ovary on the right side released, but not removed.
 
  
Adhesions between caput coli and tumor released, exposing
 
  
 +
chapter on operations has been enlarged and rewritten, and those
 +
on General Optical Principles and on Abnormal Refraction, which
 +
were contributed to the first edition by Dr. James Wallace, have
 +
been revised by Dr. Edward Jackson, who has also recast the
 +
section written by himself upon Eetinoscopy.
  
 +
Dr. Jackson's revision of these chapters has evidently been carefully done, and we note a number of instances, as, for example, in
 +
the definition of emmetropia and of ametropia (p. 140), and in the
 +
description of the refraction of light by an astigmatic eye (p. 163),
 +
in which it has resulted in the elimination of errors, some of
 +
which had previously arrested our attention in the perusal of the
 +
first edition. It is perhaps not to be wondered at that he has not,
 +
in every instance, succeeded in noting and correcting these faults.
 +
The description of the "seat of astigmatism" on p. 161, which,
 +
in the new edition as in the old, seems to warrant the inference
 +
that lenticular astigmatism is due always to an oblique position of the
 +
lens, it would appear, might easily have been improved upon. So,
 +
too, as to the description given of the well-known illustration (p.
 +
163) of the refraction of a pencil of light in regular astigmatism. It
 +
is certainly not correct to speak of the different sections of the pencil there shown, as representing the "retinal images of a point"
 +
in compound hypermetropic astigmatism, simple hypermetropic
 +
astigmatism, mixed astigmatism, etc., unless absence of accommodative power in the eye be presupposed.
  
a fistulous track between the two 5 cm. in diametei-. Appendix thickened and twice its normal size, adherent to a black
+
The author tells us in his preface that the book has been enriched
ragged area 2x2 cm. It was not removed, as it showed no
+
with forty additional illustrations, but he does nottell us how much
disease and the patient's condition was very critical.  
+
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."
  
On right side the tumor was adherent to the anterior abdominal wall over an irregular area 6x3 cm., running down to
+
The publisher has performed his part of the work ip a manner
cornu uteri. This area was scraped free of pus and lymph
+
worthy of especial commendation. S. T.  
and covered with peritoneum from side to side.  
 
  
Eagged area on colon covered in by base of appendix, which
+
A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D.  
was sutured over it with interrupted catgut ligatures. Silk
+
With 163 illustrations in the text and 6 full-page plates. (Philadelphia: W. B. Saunders, 1896.)  
sutures were used to close the opening in the colon. Abdominal
 
cavity thoroughly irrigated. Salt solution infusion (500 cc.)  
 
  
 +
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.
  
68
+
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
  
  
under breasts, 500 cc. of salt solution left in the abdominal
 
cavity. Pulse before operation 132, after 150.
 
  
First Day. On returning from operating room the pulse
+
water supplies for a city is that obtained from deep wells. The
was 136, having dropped 14 beats in twenty minutes. Foot
+
sourcesof water pollution are clearly described and well illustrated.  
of bed elevated. Five o'clock in the evening pulse 128. Nine
+
We are pleased to see that careful directions are given for the  
o'clock, 120. Twelve o'clock, 108. Patient comfortable and  
+
filtration of water, and the dangers which lurk in improper filtration are distinctly stated. If the book could be in the hands of
complaining of little pain.  
+
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.  
  
Second Day. Pulse 108, temperatui'e 99.4° F. Patient
 
complained of pain during the night, but slept three hours.
 
Twelve o'clock noon, pulse 104, temperature 99.4° F. Six
 
o'clock, pulse 104, temperature 100.4° F. Comfortable day.
 
Foot of bed lowered.
 
  
Third Day. Passed an uncomfortable night. Pulse 104,
 
temperature 90.4° F.
 
  
Afternoon, patient comfortable, pulse 100, temperature
+
BOOKS RECEIVED,  
99.8° F. Small liquid movement.
 
  
  
  
Fourth Day. Pulse 96, temperature 99° F. Considerable
+
Transactions of the Association of American Physicians. Eleventh
pain in abdomen.  
+
Session held at Washington, D. C, April 30 and May 1 and 2,
 +
1896. Vol. XI. 8vo. 1896. 453 pages. Printed for the Association. Philadelphia.
 +
 
 +
Transactions of the Medical Society of the State of Pennsylvania.
 +
Forty-sixth Annual Session, held at Harrisburg, 1896. Vol.  
 +
XXVII. 8vo, 499 pages. Published by the Society. The Edwards & Docker Co., printers, Philadelphia.
 +
 
 +
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.  
  
Fifth Day. Temperature 98°, pulse 90. Patient had a
+
An American Text-book of Physiology . Edited by William H. Howell,  
comfortable night.  
+
Ph. D., M. D. 1896. 4to, 1052 pages. W. B. Saunders, Philadelphia.  
  
Sixth Day. Pulse 80, temperature 98° F.  
+
A Te.vt-book of Histology, Descriptive and Practical. For the use of
 +
students. By Arthur Clarkson, M. B., C. M. Edin. 1896. 8vo,
 +
554 pages. W. B. Saunders, Philadelphia.  
  
Tenth Day. Convalescence has been uninterrupted. Dressiugs removed from abdomen, union of incision ^ler primam.  
+
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.  
  
Patient sat up on her 20th day.  
+
Transactions of the Michigan State Medical Society, for the year 1896.
 +
Vol. XX. 8vo, 834 pages. Published by the Society. Grand
 +
Kapids.  
  
Bacteriological Examination. Cover-glass preparations
+
A Text-Book of Materia Medica, Therapeutics and Pharmacology. By
showed many cocci and bacilli. Two cc. of pus injected into
+
George Frank Butler, Ph. G., M.D. 1896. 8vo, 858 pages. W.  
a guinea jjig produced death from septicaemia in twenty-four
 
hours. Cultures from pus at the time of operation and from
 
autopsy of guinea-pig became contaminated, consequently it
 
is impossible to make a definite statement as to the species of
 
organisms present. The fact, however, that the cyst communicated with the intestine makes it practically certain that
 
all of the intestinal bacteria were present in the pus.  
 
  
 +
B. Saunders, Philadelphia.
  
 +
Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America.
 +
Edited by Thomas L.Stedman, M. D. Vol. VII. Diseasesof the
 +
respiratory organs and blood, and functional sexual disorders.
 +
1896. 8vo, 796 pages. William Wood & Co., New York.
  
KEPORT OF FIVE CASES OF INFECTION BY THE BACILLUS AEROGENES CAPSULATUS (WELCH).  
+
A Treatise on Appendicitis. By John B. Deaver, M. D. Containing
 +
32 full-page plates and other illustrations. 8vo. 1896. 168 pages.
 +
P. Blakiston, Son & Co., Philadelphia.  
  
By Edward K. Dunham, M. D., Professor of Bacteriology, Bellevue Hospital Medical College, Neiu York.  
+
Index-Catalogue of the Library of the Surgeon-Oeneral's Office, U.S. A.
 +
Authors and subjects. Second series- Vol. I. A-Azzurri. 1896.  
 +
4to, 828 pages. Government Printing Office. Wathington.  
  
 +
Transactions of the Texas State Medical Association. 28th annual
 +
session held at Fort Worth, Texas, April 28th-30tli and May 1st,
 +
1896. 8vo, 458 pages. Eugene von Boeckmann, printer, Austin,
 +
Texas.
  
 +
The British Guiana Medical Annual. Ed. by J. S. Wallbridge and
  
Within the past year the writer has had occasion to study
+
C. W. Daniels. Eighth year of issue. 8vo, 1896. 95 -}- xxxix
five cases of infection in which he believes the bacillus aerogenes capsulatus, described by Welch and Nuttal, and Welch
+
pages. Printed by Baldwin & Co., Demerara.  
and Flexner, either caused or hastened death.  
 
  
In all but one of these cases the bacillus was found in
+
Twenty-seventh An7iual Report of tlie Slate Board of Health of Massachusetts, 1895. 8vo, 807 pages. Wright & Potter Printing Co.,
material taken from the tissues of the patient during life.  
+
Boston. 1896.  
  
The first case died on the 11th of March, 1896.  
+
Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A. M., M. D. 2d ed. 1896. 12mo, 199 pages. W. B. Saunders, Philadelphia.  
  
The patient was a woman, aged 23 years, who was admitted
+
Atlas of the Diseases of the Skin. By H. Radcliffe Crocker, M. D.,  
to St. Vincent's Hospital, New York, on the 7th of that
+
F. R.C. P. Fol. n. d. 2 vols. Young J. Pentland, Edinburgh
month, and then gave the following history :
+
and London.
  
Three days before her admission to the hospital she had
 
noticed a swelling beneath the lower jaw ou the left side of
 
the neck. This swelling was the seat of throbbing pain.
 
  
From the time she first noticed this swelling she suffered
 
increasing malaise, with chilliness, headache, loss of appetite,
 
nausea, and pains in the back.
 
  
At the time of her admission she had diflBculty in swallowing, stiffness of the jaw, and pain, with a sense of constriction,
+
16
in the throat. The left submaxillary triangle was swollen,
 
pale and oedematous. There was no fluctuation in the swelling, though it appeared somewhat softer near the angle of
 
the jaw. On the left side of the lower jaw some of the teeth
 
were carious. The floor of the mouth bulged upwards and
 
was tense. The left tonsil was enlarged, but showed no signs
 
of inflammation. Temperature 101.2°, respiration 22, pulse 98.
 
  
Hot applications were made to the neck, and a mouth-wash
 
of listerine prescribed. She also received morphine subcutaneously, and phenacetine and quinine by mouth.
 
  
The next day, March 8th, the swelling had increased considerably in size, swallowing was very difficult, and the patient
 
suffered somewhat from dyspnoea. The neck was stiff and
 
gave great pain on the slightest motion. Articulation was
 
also interfered with. An exploratory puncture of the swelling failed to reveal the presence of pus.
 
  
On the day following, March 9th, the pain in the neck was
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
excruciating; swallowing was practically impossible; the voice
+
[No, 70.  
was husky and the dyspncea marked. The swelling was
 
hard and rapidly increasing in size, the pulse rapid and weak,
 
the facies drawn and anxious. The urine was found to contain " 5 per cent." of albumen. On this day the patient
 
began to show signs of delirium.  
 
  
During the afternoon of the succeeding day, March 10th,
 
cedenia of the glottis set in and at one time completely
 
arrested respiration, but by means of an O'Dwyer tube and
 
artificial respiration for a few minutes the patient was
 
restored and the tube could be removed. The patient gradually lapsed into a comatose condition.
 
  
Ou this day an incision was made into the swelling and a
 
small quantity of fetid, " very virulent-looking " pus obtained.
 
  
The next morning, March 11th, there was no discharge
+
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL
from the wound, but emphysematous crackling was felt at the
 
angle of the jaw. At 6 A. M. the patient was dead.
 
  
The pus obtained on the 10th of March reached the Carnegie
 
Laboratory on the 11th, accompanied by a message stating
 
that it came from an acutely septic case in which infection
 
with the anthrax bacillus was suspected.
 
  
Cover-glass preparations of the very fluid pus revealed the
 
presence of cocci and of bacilli of large size.
 
  
Agar tubes iu four dilutions were prepared and placed in
+
THE JOHNS HOPKINS HOSPITAL REPORTS.  
the incubator. Upon these two sorts of colonies developed, one
+
Volume I. 423 pages, 99 plates.  
of a yellow color and the other white. All of these colonies
 
were made up of cocci, the bacilli in the pus having failed to
 
grow. Subsequent cultures of the cocci served to identify
 
them as the staphylococcus pyogenes aureus and albus.  
 
  
On the same day that the pus was received bouillon tubes were
+
Report in Putliology.  
inoculated from it and placed in a Novy jar, in an atmosphere
 
of hydrogen, at 37° C. The next day the broth in these tubes
 
was cloudy, and a hanging drop showed the presence of cocci
 
and bacilli.  
 
  
A guinea-pig was inoculated subcutaueously with 1 cc. of one
+
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 Pathulog-y of the Gelatinous Type of Cerebellar Sclerosis
  
April, 1897.]
+
(Atrophy). By Henry J. Berkley, M. D.
 +
Reticulated' Tissue and its Relation to the Connective Tissue Fibrils. Bv F. P.  
  
 +
Mall, if. D.
  
 +
Report in Dermatolog-y.
 +
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
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 Molluscum
  
69
+
Fibrosum; Tlie Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
  
 +
T. C. Gilchrist, M. D.
  
 +
Report in Pathologry.
 +
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration
  
of these bouillon cultures and died during the following night.  
+
of Hypertrophy of this Gland. By W. S. Halsted, M. D.  
At the autopsy the subcutaneous tissue was oedematous and
 
emphysematous, and the fluid contained both cocci and bacilli,
 
the lattei" predominating.  
 
  
An effort was now made to isolate the bacillus and obtain it
 
in pure culture for the purpose of identifying it.
 
  
A minute quantity of the broth culture used to inoculate
 
the guinea-pig was distributed over the surfaces of several
 
oblique agar tubes, which were placed in hydrogen in the
 
incubator. No colony entirely devoid of cocci was found in
 
any of these tubes, but one in which the bacilli greatly predominated was used to inoculate four rather dry blood-serum
 
tubes, and upon these pure colonies of the bacillus were
 
obtained and utilized for further study.
 
  
The bacillus was a large straight rod, about 0.9,a in diameter, with rounded ends, usually occurring singly or in pairs,
+
Volume II. 570 pages, witli 28 plates and figures.  
but occasionally forming threads made up of four or five individuals. It stained readily with methylene blue, gentian
 
violet and carbol fuchsin, and was very retentive of the dye
 
when stained by Gram's method, resisting the decolorizing
 
solution of iodine for ten minutes or longer. No spores were
 
observed in any of the cultures, except those upon blood
 
serum, though occasionally old agar cultures contained involution forms with an intimation of beginning sporulation, but
 
without spores demonstrable by differential staining. In the
 
subcutaneous fluid of animals it possessed a capsule, but this
 
was usually not observed in cultures on artificial media.  
 
  
It formed a moderately thin, moist, gray growth upon agar,
+
Report in Medicine.  
and sometimes produced bubbles of gas in the condensation
 
water at the bottom of the tube or between the agar and the
 
wall of the tube.  
 
  
Bouillon was rendered cloudy, and usually a few bubbles
+
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
formed at its surface, while a gray sediment appeared at the  
 
bottom. In hanging drops, to which air had access, no evidence of motility could be detected.
 
  
Milk was coagulated in 24 hours and rendered acid, with a
+
Gallstones. By William Oslek. M. D.
production of gas.  
+
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, H. D.
 +
On Pyrodin. By H. A. LxFLEnR, M. D.
 +
Cases of Post-febrile Insanity. By William Osler, 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.
 +
Notes on Endocarditis in PhtMsis. By William Osler, M. D.  
  
In all the media the bacillus proved to be a strict anaerobe.  
+
Report in Medicine.
 +
Tubercular Peritonitis. By William Osler, M. D.
 +
A Case of Raynaud's Disease. By H. M. Thomas, M. D.
 +
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  
  
The bacillus grew well in bouillon to which 1 per cent of
+
Report in Gynecology.
glucose had been added, and these cultures evolved a considerable amount of gas when incubated in an atmosphere
+
Tlie Gj-neeological Operating Room. By Howard A. Kelly, M. D.
deprived of oxygen by means of potassium pyrogallate.  
+
The Laparotomies performed from October 16, 1S89, to March 3, 1890. By Howard
  
In order to determine the nature of this gas, six fermentation tubes containing glucose bouillon (1 per cent of glucose)
+
A. Kelly, M. D.. and Hunter Robb, M. D.  
were inoculated with the bacillus, and, after 24 hours, the
+
The Report of the Autopsies in Two Cases Dying in the GjTiecological Wards vrith
gas collected in a eudiometer over mercury. 28.6 cc. of gas
+
out Operation ; Composite Temperature and Pulse Charts of Forty Cases of  
were obtained. This was subjected to the action of caustic
 
potash, and when no more shrinkage in volume took place, air
 
was introduced and an electric spark passed through the
 
mixture. This was repeated until no more shrinkage in the  
 
bulk of the mixture resulted after the passage of a spark.
 
  
In this way the following approximate composition of the  
+
Abdominal Section. By Howard A. Kelly, M. D.
gas was determined :
+
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,
  
Hydrogen 64.3 per cent.  
+
M. D.  
 +
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;
  
CO2 27.6
+
Ovarian Tumor; General Gynecological Operations from October 15, 1SS9, to
  
Nitrogen (?) 8.1*
+
March 4. 1890. By Howard A. Kelly, M. D.
 +
Report of the ITrinary Examination of Ninety-one Gynecological Cases. By Howard
  
100.00 per cent.  
+
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
  
 +
Hemorrhage from the Uterus, etc. By Howard A. Kelly, 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.
 +
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.
 +
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
  
 +
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
  
On the 22d of March, i. e. eleven days after the pus was
+
Howard A. Kelly, M. D.  
received at the laboratory, a guinea-pig was inoculated, subcutaueously, with a pure 24 hour culture of the bacillus in
 
bouillon, one cubic centimeter being injected. The animal
 
was found dead the next morning. The hair over the body
 
was loosened so that it could be readily plucked from the
 
skin, leaving it smooth and clean. The subcutaneous tissue
 
was (Edematous, and so friable and filled with gas that the skin
 
could be reflected from the abdominal wall without dissection.
 
The gas burnt with a pale blue flame. The organs were of
 
a dull gray color and very friable. The subcutaneous fluid
 
contained great numbers of the bacilli surrounded by capsules,
 
and apparently no other micro-organisms.  
 
  
On April 3d, 23 days after obtaining the material from the
+
Report in Siirgery, I.
hospital, another guinea-pig was inoculated, by means of a
+
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot
platinum needle, with a very small amount of a three-day
 
culture of the bacillus on agar. The animal became very ill
 
on the second day after inoculation and it was thought at that
 
time that he would surely die in the following night, but he
 
recovered after two days and remained well.
 
  
When injected into the blood of a rabbit, which was then
+
in the Management of Dead Spaces. By W. S. Halsted, M. D.
killed after the lapse of a few minutes, the bacillus caused
+
Report in Neurology, I.
enormous swelling of the body of the animal within 20 hours,  
+
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
and the liver, kidney and spleen, as well as the subcutaneous
+
Acute Angio-Neurotic Oedema. ' By Charles E. Simon, M. D.
tissue, were the seat of a very marked emphysema. The skin
+
Haematomyelia. By August Hoch, JI. D.  
was rendered so tense by the accumulation of gas that it
+
A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By
seemed on the point of rupturing.  
 
  
The foregoing characters of the bacillus under study
+
Henry M. Thomas, M. D.  
appear to identify it with the bacillus aerogeues capsulatus of
 
Welch, the only point of difference being the spore-formation
 
which was observed in cultures on blood serum. As the
 
authors mentioned do not describe cultures on this medium,
 
this spore-formation cannot be regarded as evidence against
 
the identity of the two bacteria.f
 
  
A number of observations were made upon the resistance
+
Report in Pathology, I.
of these spores, and it was found that when taken from the
+
Ama3bic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.  
condensation water of a blood-serum tube they could endure
 
a temperature of 94° C. for one minute, but that an exposure
 
of 5 seconds to the temperature of boiling water (99.5° C. at
 
the time the observations were made) killed them. After
 
being dried upon threads for 5 months and then immersed in
 
water, they survived a temperature of 99° C. when subjected
 
to it for one miuute.J
 
  
The vegetative form of the bacillus appeared to be killed by
 
a temperature of 55° C. within one minute.
 
  
Ten mouths of desiccation and exposure to the air failed to
 
kill the spores, which, at the end of that time, grew readily
 
  
 +
Volume III. 766 pages, with 69 plates and figm-es.
  
 +
Report in Pathology.
  
*The composition of the residual gas in the eudiometer was not
+
Papillomatous Tumors of the Ovarj'. By J. Whitridge Williams, M. D.  
determined, but it did not contain CO3, for no diminution occurred
 
when a fresh piece of caustic potash was introduced. This fact
 
proves the absence of marsh gas or of any other hydrocarbon.  
 
  
+ In a letter to the writer, dated February 19th, 1897, Dr. Welch
+
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
states that the bacillus aerogenes capsulatus in his possession produced spores when cultivated on LoefHer's blood serum. This
+
Report in Patliology.  
observation tends to still further establish the identity of the
+
 
bacillus isolated by the writer.  
+
Multiple Lj-rapho -Sarcomata, with a report of Two Cases. Bv Simon Flexner, M. D,
  
i The author has observed that the spores of bacillus subtilis are
+
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M". D.  
much more easily killed by moist heat when freshly formed than
 
after a lapse of time and drying.  
 
  
 +
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.
  
70
+
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
  
 +
Report in Gynecology.
  
 +
The Gynecological Operating Room; An Kxtornal Direct Method of Measurins: the
 +
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.
 +
Kelly, M. D.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci.
 +
By Mary Sherwood. M. D.  
  
 +
Intestinal Worms as a Complication in Abdominal Sxu-gery. By A. L. Stately, M. D.
  
  
[No. 7.3.
 
  
 +
Gynecological Operations not invohnng Coeliotomy, By Howard A. Kellt, M. D.
 +
Tabulated by A. L. Stavely, M. D.
  
 +
The Employment of an Artificial Retroposition of the Uterus in covering Extensive
 +
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.
  
when placed iu broth at the body temperature under anaerobic
+
Photography applied to Surgery. By A. S. Murray.  
conditions, and those cultures caused the same extensive production of gas when injected into the blood of a rabbit which
 
was soon thereafter killed, as did the earlier cultures obtained
 
from the original material.  
 
  
The spores stain readily in hot solutions of fuchsin in anilin
+
Traumatic Atresia of the Vagina with Haematokolpos and Haematometra. By Howard
water, and are not decolorized by a moderate exposure to the
+
A. Kelly, M. D.  
action of a 3 percent, solution of hydrochloric acid in absolute
 
alcohol.  
 
  
They have an oval shape and are usually situated near the
+
Urinalysis in Gynecology. By W. W. Russell, M. D.  
middle of the bacilli in which they have been formed, their
 
long axes coinciding with those of the bacilli. Their short
 
diameter exceeds the diameter of the bacilli, so that the latter
 
appear swollen at the points where the spores are situated.  
 
  
The cultures containing the spores frequently contain involution forms of the bacilli and threads of the latter, which
+
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.  
stain but faintly with methylene blue, and appear more attenuated than the individuals in fresh cultures on other media.  
 
  
A partial antojDsy of this first case of infection was made on
+
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.  
the day following the death of the patient by my assistant, Dr.  
 
Harlow Brooks, from whose notes I take the following data:
 
General nutrition excellent. Rigor mortis present. There
 
was extensive post-mortem discoloration about the neck on
 
the left side, and the tissues in this region were the seat of
 
marked emphysema.  
 
  
The incisions in the neck made before the death of the
+
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.
patient were opened and a focus of suppuration was found,
+
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.  
which apparently arose from the left tonsil. The walls of
 
this abscess cavity were not well defined, but appeared necrotic,  
 
and this condition extended far into the fascise of the neck.  
 
  
The liver, kidneys and spleen were examined, but did not
+
Abdominal Operations performed in the Gynecological Department, from March 5,  
appear emphysematous. Microscopical examination of bits
+
1890, to December 17, 1892. By Howard A. Kelly, M. D.  
of those organs failed to reveal the bacillus.  
 
  
Sections from the organs of the rabbit into the veins of
+
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
which the bacillus was injected, when stained by Gram's
+
May 4, 1S92.  
method, revealed the presence of the bacillus in great numbers
 
in the blood-vessels. (See " I," temperature chart.)
 
  
The second case of infection occurred in a boy, seven years
 
of age, who fell over a banister from the fourth to the ground
 
floor of a house and sustained a compound comminuted fracture of the right humerus. This accident took jjlace at 3 j). m.
 
on the 19th of September, 1896.
 
  
After being under the care of a physician not connected
 
with the hospital for a couple of hours, the patient was
 
admitted to the Gouverueur Hospital at 6 p. m., in a semi-conscious and delirious condition. He had a lacerated wound of
 
the forehead as well as a fracture of the humerus. The arm
 
was very dirty and its tissues much contused. The wounds
 
were treated antiseptically and the patient sent to the ward iu
 
a poor condition.
 
  
At 8 p. m. his temperature was 100°, respiration H, pulse
+
Volume IV. 504 pages, 33 charts and illustrations.  
130 and very feeble.  
 
  
On the 20th he was delirious throughout the day.
+
Report on Typhoid Fever.  
On the 21st the dressings were removed and the arm and
 
shoulder found to be much swollen, the skin over them tense
 
and of a greenish bronze color, the discoloration extending
 
over the pectoral region. There was no sign of emphysema
 
noted at this time.  
 
  
 +
By William Osler, M. D., with additional papers by W, S. Thayer, M. D., and J.
 +
Hewetson, M. D.
  
 +
Report in Neurology.
 +
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
 +
Intrinsic Pulmonao' Nerves in Mammalia; The Intrinsic Nerve Supply of the
 +
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of ifu'^ muscuhir. The Intrinsic Nerves of the Thyroid Gland of
 +
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berklet,
 +
M. D.
  
Free incisions were made and the subcutaneous tissues found
+
Report in Surgery.
in a necrotic condition. The wounds were washed with mercuric chloride and drained.  
+
The Results of Operations for the Cure of Cancer of the Breast, from June, 1SS9, to
 +
January, 1894. By W. S. Halsted, M. D.  
  
On September 22d the patient was still delirious, very
+
Report in Gynecology.
weak, with a fluttering pulse. The dressings were again
+
Hydrosalpinx, with a report of twentv-seven cases; Post -Operative Septic Peritonitis;
removed and fresh incisions made in the arm. The cedema
+
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.
had extended well into the pectoral region and down to
+
Report in Pathology.  
the elbow, and at this time, I believe, some emphysema of
+
Deciduoma Malignum. By J. Whitridge W^illiams, M. D.  
the tissue was noticed. There was, however, no discharge
 
from the wounds, owing to the prostration of the patient.  
 
  
At 3 p. m. the patient died, just three days after the accident which resulted in the fracture of the humerus.
 
  
Some of the discharge from the incisions made on the 2l8t
 
of September was collected in a sterilized test-tube and sent to
 
the Carnegie Laboratory. It was delayed in transit and had
 
an offensive odor when received. Cover-glass preparations
 
showed it to contain cocci and a large bacillus, with I'ounded
 
ends, positive to Gram's stain, and, in some fields, surrouuded
 
by a capsule.
 
  
Slant tubes of agar were prepared and placed in the incubator; one-half in a Novy jar with pyrogallate of potassium,
+
Volume V. 480 pages, mth 32 charts and illustrations.  
the other half with access of air.  
 
  
After 48 hours the aerobic cultures showed only colonies of
+
CONTENTS:
cocci, while the anaerobic cultures contained colonies in which
+
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.  
both cocci and bacilli had developed. The latter tubes gave
+
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  
evidence of gas production, the agar being raised from the
+
Studies in Typhoid Fever.  
bottoms of the tubes. These colonies, though not pure, were
 
used for the preparation of bouillon cultures grown under
 
anaerobic conditions, aud, after 2-1 hours, they were cloudy and  
 
covered with a froth, due to the evolution of gas. Jn hanging drops both cocci and bacilli were found, the latter iu
 
greater number. One cubic centimeter of one of these cultures
 
was injected under the skin of a guinea-pig, and iu a few
 
hours the animal showed signs of illness. Its fur was ruflled,  
 
the animal drew itself together and avoided the light. But it
 
recovered, and after three days appeared to be quite well again.  
 
  
A few drops of the same culture were introduced into an
+
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon
ear-vein of a rabbit and five minutes later the animal killed.  
+
Flexner, M. D., Walter Reed, 51. D., and H. C. Parscns, M. D.  
The next morning its body was greatly distended by universal
 
emphysema of the subcutaneous tissues. Puncture of the skin
 
permitted the escape of a gas which burned with a pale blue
 
flame.  
 
  
On autopsy the abdominal cavity was found to contain
 
much gas, aud the liver, kidneys, spleen, aud the mucous
 
membranes of the digestive tract aud bladder were emphysematous.
 
  
Cover-glass preparations from the viscera and subcutaneous
 
fluid demonstrated the presence of the bacillus, accompanied
 
by a few cocci.
 
  
Agar cultures prepared from the organs of this rabbit
+
Volume VI. About 500 pages, many ilhistrations.  
formed the basis of future pure cultures, which served to
 
identify this bacillus with that found in the first case. No
 
spores were found in any of the cultures, but, unfortunately,  
 
the bacillus was not grown on blood serum.  
 
  
No autopsy was performed on this second case of infection.  
+
Report in Neurology.  
(See " II," temperature chart.)
 
  
The third case of infection was a man, a't. 33, of alcoholic
+
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical
habits, who had suffered from urethritis on two occasions the last time three years before he presented liimself for final
+
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.  
treatment at Belle vue Hospital.  
 
  
When he was admitted to the hospital, on November 6,
+
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the
1896, he had difficulty in voiding his urine, owing to a stricture of the urethra which could not be passed by instruments.  
+
Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions
 +
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental
 +
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol): Part II. — Serum
 +
Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on  
 +
the Cortical Nerve Cell; Part HI. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic
 +
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical
 +
Nerve Cell produced hy the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of
 +
Alcohol and Ricin Intoxication; Addenda. By Henry J. Bereixy, M. D.  
  
On December 5th, at 3.30 p. m., external urethrotomy \yas
+
Report in Pathology.  
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
+
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Tuomas S.  
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,
+
Cullen, M. B.  
and others over both shoulders. These areas increased rapidly
+
Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of  
in size up to the time of death and afterwards.
 
  
The following notes on the bacteriological examinations of
+
Ov-um and Spermatozoa. By Thomas S. Cullen. M. B.. and G. L. Wilkiss, M. D.  
material from this case and of the autopsy are kindly furnished me by my assistant, Dr. F. M. Jeffries, who conducted
+
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B.  
them. At 1 p. m. on December 10th, i. e. -1 hours before the
+
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By
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
+
William D. Booker, M. D.
and in bouillon were made from the heart, lungs, liver, brain,
+
The Pathology of Toxalbumin Intoxications. By Simon Flesn-er, M. D.  
and the emphysematous area on the thigh. These cultures
+
The price of a set bound in cloth [Vols. Z-TJ] of the Hospital Jteftorts is
were incubated under anaerobic conditions in Novy jars
 
with pyrogallate of potassium.
 
  
After 24 hours the cultures from all these sources had
+
$30.00. Vols. I, II and III are not sold separately. The jtrice of  
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
+
Vols. IV, V and VI is $5.00 each.  
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.  
+
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TATHOID FEVER.
 +
The following papers are reprinted from Vols. I, IV and V of the Reports, for those
 +
who desire to purchase in this form:
 +
STUDIES IN DERMATOLOGY. By T. C. Gilchrist. M. D., and Emmet Rixford,
  
Subcutaneous emphysema was noted, extending over the
+
M. D. 1 voliune of 164 pages and 41 full-page plates. Price, bound in paper,  
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
+
?3.00.
abdomen was soft, pulpy and emphysematous. There were
+
THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thayer. M. D., and J.  
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
+
Hewetson. M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.  
of emphysema.  
 
  
 +
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
  
 +
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 4S1
  
The spleen was dark plum-colored, extremely friable and
+
pages. Price, bound in paper, ?3.00.  
emphysematous.  
 
  
The kidneys were enlarged, showed subcapsular emphysema,
+
Subscriptions for the above publications may be sent to
and were plum-colored.
 
  
The mucous membrane of the bladder was extremely
+
The Johns HorKiNS Press, Baltimore, Md.  
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
+
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies
.January, 1897.
+
may he procured from Messrs. GUSHING d: CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.0(» a year, may he
 +
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE ; singU copies will be sent by mail for fifteen cents each.  
 +
 
  
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
+
BULLETIN
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
 
complained of pain on micturition, but there was no discharge
 
from the urethra or increased frequency of urination. The
 
urine was acid ; sp. gr. 1029; no albumen or sugar.
 
  
A urethral examination gave the following results :
 
  
No. 23 (French) bougie a boulu passed the meatus, but was
+
OF
stopped just bej'ond the urethral orifice.
 
  
No. 30 entered the urethra for a distance of 24 inches.
 
  
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
+
THE JOHNS HOPKINS HOSPITAL.  
same point.  
 
  
No. 4 and No. 2 bougies also failed to pass that point, as did
 
also a filiform bougie. Even a bunch of filiform bougies
 
failed to demonstrate a passage, although, subsequently, after
 
etherization in preparation for the operation, a filiform bougie
 
was successfully passed.
 
  
External urethrotomy was pei'formed on January 9th, at
 
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.
 
The bladder and urethra were irrigated with saline solution
 
and an aseptic dressing applied to the perineal wound. The
 
urethra admitted a No. 34 (French) sound.
 
  
The patient was returned to the ward at 5.20 p. m., and
+
Vol. Vlll.-No. 71.]
a conducting tube, with its distal end immersed in a 2J per
 
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.
 
A slight oozing of blood from a wound in the bulb of the
 
urethra was noticed. This had ceased at 9 p. m., and the
 
patient then felt comfortable.
 
  
  
 +
BALTIMORE. FEBRUARY, 1897.
  
72
 
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
  
[No. 73.  
+
GOiTTZEITTS.  
  
  
  
At 10.30 the bladder was agaia irrigated.  
+
A Case of Dermatitis due to the x Rays. By T. C. Gilchrist,
 +
M. R. C. S., L. S. A.,
  
On January 10th the patient felt well and the bladder was
+
Lesions induced by the Action of Certain Poisons on the Nerve
draining nicely.  
+
Cell. Study VI.— Diphtheria. By Henhy J. Berkley, M. D.,
  
At 1.30 the urethra and bladder were irrigated with a warm
+
Puerperal Sepsis due to Infection with the Bacillus Aerogenes
saturated solution of boric acid. The anterior urethra contained some dark fluid blood which was washed away, and the
+
Capsulatus. By George W. Dobbin, M. D., - . - .  
perineal wound then dressed.  
 
  
On the 11th and 12th of January the patient was doing
 
well and the bladder was simply washed out.
 
  
The patient complained of some pain in the penis on the
 
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
 
sound passed through the entire urethra into the bladder,
 
without difficulty. The perineal wound appeared healthy,
 
and there was no discharge from the urethra except a small
 
amount of blood which followed the manipulations. The
 
auterior urethra was irrigated with saline solution and the
 
perineal wound dressed. The patient felt somewhat chilly
 
and received half an ounce of whiskey.
 
  
At 9.30, seven hours after the sounds were passed, the
+
Proceedings of Societies :
patient had a severe chill, lasting half an hour.
 
  
At 3.30 a. m., January 14th, a slight bleeding took place
+
Hospital Medical Society, 29
from the urethra.
 
  
At 8 a. m. pain in the left shoulder was complained of.  
+
The Surgical Significance of Gall Stones [Dr. F. Lakge].  
 +
Correspondence :
  
At 11 a. m. a catheter was introduced throiigh the perineal wound and about 3 ounces of bloody fluid having a foul
+
A Case of Pneumo-cardial Rupture. By Geo. S. Brown, M.D., 33
odor evacuated from the bladder, which was then irrigated
 
with saline solution. The bladder and anterior urethra were
 
again washed out at 5 p. m., this time with a solution of permanganate of potash, jtW- '^^^ wound was dressed at this
 
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
+
A CASE OF DERMATITIS DUE TO THE x RAYS.  
darker than before and was irregularly mottled with purple
 
spots.  
 
  
At 8.15 a. m. an incision, two inches in length, was made
+
By T. 0. Gilchrist, M. E. C. S., L. S. A., Associate in Dermatology, Johns Hopkins University and Hospital.  
into the emphysematous area on the left buttock. A considerable amount of gas escaped through the wound, and a
 
slight oozing of sanguineous fluid took place, but there was
 
no sign of pus. Material for culture and bits of tissue for
 
microscopical examination were taken from the walls of the
 
incision.  
 
  
At 9.30 the patient was still conscious, but died at 10.10
 
  
  
 +
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.
  
a. m., forty-five hours after the sounds were passed on the  
+
The first report which 1 have been able to find was a  
13th of January.  
+
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.  
  
Dr. Brooks performed the autopsy on this case, and the following account is taken from his notes :
+
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.
  
The autopsy was made 5 hours after death, while the body
+
After examining the other reports (the references are given
was still warm.
+
at the end of the article) it was found that the eruptions of the  
 +
skin presented many points of similarity, and differed chiefly in
  
Rigor mortis was marked; the general nutrition good.
 
  
Post-mortem discoloration was extreme from the pelvis up,
 
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
+
severity, according to either the length of time and frequency
of a gas which burned with a blue flame.  
+
of exposure to the rays or to idiosyncrasy of the patient.  
  
The abdominal wall was greatly distended, and when an  
+
In Dr. Sehrwald's case, which was described fully, the
incision was made the inflated intestines protruded.  
+
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.  
  
The liver was of a light clay color and crepitated under the  
+
In Drs. Stern's and Richardson's cases the lesions appeared
fingers. Its tissues were very friable, and filled with minute
+
after three sittings, and Dr. Skinner experienced cutaneous
vesicles containing gas. The cut surface appeared oedematous.  
+
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.  
  
The spleen was enlarged, of a dark purple color, and very
+
I append a table of the cases which I have been able to find
friable.  
+
in the literature.  
  
The kidneys were enlarged; their capsules adherent.
 
  
The lungs were somewhat (Edematous.
 
  
The cavities of the heart were distended on both sides by
+
18
fluid blood which contained bubbles of gas.
 
  
The autopsy was necessarily both hurried and incomplete,
 
as the relatives of the patient refused to have any of the organs
 
removed from the body.
 
  
During the autopsy agar tubes were inoculated by Dr.
 
Brooks from the blood in the left auricle and from the tissues
 
of the liver, spleen and kidney. A bouillon culture was also
 
made from the blood. These cultures were then incubated in
 
a Novy jar with pyrogallate of potassium, and after 14 hours
 
developed pure cultures of a bacillus identical with those
 
found in the preceding cases.
 
  
When grown upon blood serum these bacilli developed
+
JOHNS HOPKINS HOSPITAL BULLETIN.  
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
 
was used to inoculate a guinea-pig subcutaneously. Within
 
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
+
[No. 71.  
culture, killed and put in a moderately warm place. The next
 
day it showed the emphysematous condition of the subcutaneous tissues and internal organs which has already been
 
described in connection with the other cases.  
 
  
The material removed when the incisions were made into
 
the emphysematous area on the buttock at 4 p. m. on the day
 
of the death of the patient was used to inoculate agar tubes,
 
part of which were cultivated with access of air, the rest
 
under anaerobic conditions. Those exposed to the air showed
 
no growth. Those grown with exclusion of oxygen contained
 
  
  
 +
Distribution.
  
April, 1897.]
 
  
  
 +
Character of the Lesions.
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
Subjective
 +
Symptoms.
  
73
 
  
  
 +
O. Leppin (person
 +
al experience). .
  
a growth of a non-motile bacillus, positive to Gram, and morphologically resembling the bacillus aerogenes capsulatus.
 
These cultures were lost and no further observations could be
 
made, but as considerable work on this bacillus was being done
 
at the time, no doubt exists as to the identity of the bacillus.
 
  
About 2i honi's after the death of the patient a sterile
 
cotton swab was introduced into the urethra, and the moisture
 
thus obtained used for the preparation of cultures.
 
  
Two bacilli developed in these cultures, and as they were
+
Used very frequently for
both at least facultative anaerobes, efforts to separate that
+
many days.  
which proved to be a strict anaerobe were unsuccessful. One
 
was smaller than the other and grew when air was admitted
 
to the cultures. The other was morphologically identical
 
with the bacillus aerogenes and did not grow in cultures
 
exposed to the air. The smaller bacillus was thought to be
 
the bacillus coli communis. A mixed bouillon culture of the
 
two bacilli was injected into one of the veins of a rabbit's
 
ear, and 15 minutes later the animal was killed. The next
 
day the body was bloated and the large bacillus was found
 
in the subcutaneous fluids, which were both emphysematous
 
and (Edematous.  
 
  
As a check upon this experiment a second rabbit was inoculated with a pure culture of the colon bacillus in the same
 
manner and at about the same time as the first rabbit. The
 
next day there were no signs of emphysema in its body.
 
(See " IV," temperature chart)
 
  
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
+
Left hand and
hypertrophy of the prostate.
 
  
On January 17th, 1897, the patient complained of pain and
 
uneasiness in the perineum. This was traced to enlargement
 
and tenderness of the prostate and of the tissues near the
 
rectum in the median line.
 
  
The next day the pain was more severe, and a diagnosis of
 
prostatitis was made. The pain was alleviated by means of
 
opium and belladonna suppositories, and by the 20th of January the patient felt able to be about again.
 
  
That night, because of difliculty in voiding his urine, the
+
Peculiar redness, swollen, vesicles
patient passed a hard rubber catheter and drew some blood.  
+
on middle and ring fingers.  
  
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 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
+
Dr. Marcuee.  
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
 
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
+
Young man, 17, exposed
 +
5-10 minutes once or
 +
twice a day for four
 +
weeks.
  
  
  
found the scrotum emphysematous, with spots of gangrene
+
Dr. Feilchenfeld
upou it. Temperature 103°.  
+
Dr. Conrad.  
  
Later in the day the perineum was tense and distended, red
 
and tympanitic. The scrotum was the size of a child's head (8
 
to 10 inches in diameter), dark in color, in places almost black,
 
and cold to the touch. The skin of the penis was ballooned
 
with gas and dark.
 
  
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
+
Left half of Brownish redness on face, fol
blackness and emphysematous, but contained no pus. A slight
+
face.backand lowed by desquamation ; later,  
ojdematous condition prevailed in the deeper structures.  
+
chest. patch of alopecia above right
  
The tissues were irrigated with mercuric chloride and an
+
ear ; on back, large raw patch,
iodoform dressing applied.  
+
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
 +
 
 +
 
 +
 
 +
No mention. After five weeks hand still
  
On the following day, January 26th, the emphysema had
+
looks "older" than the  
extended over the pubes and the hypogastric region, the skin
+
other.  
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
+
No pain in face ;lThree months later, hair
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
+
back much
sloughing had extended so as to include the skin, but without
+
tenderness, but  
the formation of pus.  
+
no pain was felt
 +
until just previous to the eruption.  
  
The patient lapsed into a low typhoid condition, then into
 
coma, and died on the 31st of January.
 
  
Cover -glass preparations of the material removed from this
 
patient on January 26th were examined on that day at the Carnegie Laboratory, and showed the presence of three species of
 
bacteria : 1, a large bacillus, resembling the bacillus aerogenes
 
capsulatus ; 2, a more slender bacillus; 3, streptococci.
 
  
The slender bacillus was identified as the bacillus coli communis, and when obtained in pure culture, produced no
+
returning on the bald
emj)hysema in the body of a rabbit killed shortly after the  
+
spot. Chest and back
injection of the culture into a vein of the ear.  
+
healed, but numerous fine
 +
cicatricial lines on the  
 +
back and brown pigmentation.  
  
Experience with the mixed cultures, obtained from the
 
cotton swab used to collect material from the urethra in the
 
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.
 
  
  
 +
Dr. Paul Fuchs
 +
(personal expe
 +
rience).
  
74
 
  
  
 +
Dr. Sehrwald.
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
S. J. R. (personal
 +
experience).
  
[No. 73.
 
  
  
 +
Dr. H. C. Dunn.
  
No accurate temperature chart could be obtained in this
 
case, and there was no autopsy.
 
  
The foregoing cases appear of interest as showing that the
 
bacillus aerogenes capsulatus is sometimes capable of rapid
 
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
+
Dr. G. C. Skinner
distribution ; for within eleven months these five cases have
+
(personal expe
come under the observation of a single individual and were,
+
rience).  
notwithstanding, wholly unconnected with each other, occurring as they did in various parts of the city of New York and
 
coming under the care of different physicians.  
 
  
The mode of infection was not the same in all of the cases.
 
But it is a striking circumstance that in three of the cases
 
the infection started near the perineum after injury to the
 
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
 
  
 +
J. Macintyre (personal experience).
  
  
a compound fracture of the humerus, the history states that
 
the wound was covered with dirt. This fact naturally leads
 
to the suspicion that the bacillus aerogenes capsulatus, like
 
so many of the anaerobic bacteria with which we are familiar,
 
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
+
Dr. Freund.  
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.
 
  
  
 +
Aphotographerbad used
 +
the X rays very fre
 +
quently and for some
 +
time.
  
OBSERVATIONS TO DETERMINE THE MOTILITY OF THE BACILLUS AEROGENES CAPSULATUS
 
  
UNDER ANAEROBIC CONDITIONS.
 
  
By E. K. Dunham, M. D.  
+
After prolonged use of
 +
the X rays.  
  
  
  
Bouillon cultures of the bacillus were studied in flattened
+
In a boy 13 years old.
capillary tubes from which the oxygen of the air had been
+
Only one exposure of  
absorbed by means of pyrogallate of potassium. Although
+
45 minutes duration
these cultures were examined at intervals varying from 15
+
Two weeks later erup
minutes to 24 hours, at no time could any evidence of motility
+
tion appeared.  
on the part of the bacilli be detected.  
 
  
The details of the experiment were as follows :
 
  
The cultures were obtained by putting threads, containing
 
spores of the bacillus, which had been kept in a dry state for
 
11 months, into tubes containing sterile bouillon. Three
 
such tubes were prepared, and after incubation in a bottle
 
containing pyrogallate of potassium, they all showed an
 
abundant growth of the bacillus within 24 hours. These
 
cultures proved to be pure. One cubic centimeter of one of
 
these cultures was then mixed with about 3 cc. of fresh sterile
 
bouillon, in order that the bacilli present might have a good
 
supply of nourishment, and this mixture used for the observations on motility.
 
  
The capillary tubes were prepared by heating a piece of
+
Used the rays several
glass tubing, about 8 inches long and with a bore measuring
+
hours daily and eruption appeared three
about i of an inch, strongly in the middle, then bringing the  
+
weeks after.  
two halves parallel to each other and separating them about
 
two inches (Fig. 1). In this way a U-shaped tube with a
 
flatted bend was obtained. The limbs of this tube were then
 
bent at right angles, so that their axes were in the same
 
straight line. The ends of the tube were plugged with cotton
 
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
 
drawn out to form a capillary tube. This was then broken
 
in the centre and the end immersed in the bouillon culture.
 
  
 +
 +
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.
  
  
A portion of the culture quickly filled the capillary part of
 
the tube for a distance of from 2 to 3 inches. The end of the
 
capillary tube was then sealed in the edge of the flame of a
 
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).
 
  
 +
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.
  
Fto. I.  
+
10 days, child who had
 +
hypertrichosis.  
  
  
  
Fig. <3.  
+
1st and 2d fin
 +
gers, left
 +
hand.  
  
  
  
F,g.l.  
+
Left hand and
 +
fingers.  
  
When prepared in this way the capillary tube containing the
 
culture was so flat that it was possible to examine the whole
 
contents of the tube under a Jj oil immersion objective.
 
  
Eight such tubes were prepared, and four of them preserved
 
at the room temperature, the other four being placed in the
 
incubator where the temperature was maintained at 35° C.
 
They were examined at intervals of 15 minutes, 1 hour, 3J
 
hours, 21 hours and 34 hours. In no case could any locomotion of the bacilli be detected.
 
  
After two and a half hours the bacilli were present in
+
Abdomen.
  
  
  
April, 1897.]
+
Right hand and
 +
fingers. Later
 +
left band.  
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
Abdomen.  
  
  
  
75
+
Wrist.
  
  
  
greater numbers than when the cultures were first introduced
+
Neck, back, upper arm and  
into the tubes, showing that the conditions were favorable for
+
scalp.  
their multiplication. At the end of 24 hours the number had
 
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
 
  
  
  
view of them could be obtained. That this was not the case
+
Swelling and stiffness of the  
is shown by the fact that in all the tubes the bacilli soon
+
joints; Istand 2d fingers swollen
subsided to the bottom, leaving the bouillon above them
+
and of a livid brown color on
free from bacilli. If the tube was turned a little about its
+
the dorsal surface from the tips
long axis and kept in that position for a time, the bacilli
+
to the carpometacarpal joints
settled towards the lower side of the tube.  
+
Sense of touch greatly diminished. Mustache falling out
 +
and color was changed.  
  
These observations appear to demonstrate that this bacillus
+
Much swollen; skin was wrinkled
does not possess the power of locomotion, even under anaerobic
+
cracked and stained quite
conditions.  
+
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.
  
 +
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.
  
MULTIPLE TUBERCULOUS ULCERS OF THE STOMACH, WITH A REPORT OF THREE CASES.  
+
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.  
  
By Alice Hamilton, M. D.  
+
Reddening of the skin appeared
 +
first; this increased until it was
 +
almost purple ; considerable
 +
swelling followed. Desquamation followed.  
  
[From the Pathological Laboratory of the Johns Hopkins University and ITospital.]
+
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.
  
  
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
+
Berlin Medical Society.  
from time to time in the literature, but it is imjjossible to
 
accept all of these as actually cases of tubercular ulcer. As
 
the greater number were reported before the discovery of the
 
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
 
such examination are given. All such cases must be dismissed
 
as doubtful or merely probable. Only those can be classed as
 
proven where the report shows by a detailed description of
 
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
 
bacillus tuberculosis.  
 
  
The earliest of these is Litten's. It was a case of tuberculosis of lungs and peritoneum with no lesion in the intestines,  
+
Fingers extremely No mention,  
but with a single ulcer in the anterior wall of the stomach,
+
sensitive and
which on microscopic examination showed typical caseating
+
pain was of a  
tubercles with giant cells. Talamon also describes tubercles
+
burning and  
found in the walls of ulcers in the stomach of a child which
+
scalding character.  
had died of pulmonary tuberculosis. In this case the ulcers
 
were seven in number, scattered over the surface from cardla
 
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
+
None given.  
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
+
Itching when the  
at Kiel. He examined all for the tubercle bacillus, but failed
+
vesicles appeared.  
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
+
After inflamma
 +
tion hand smarted very much
 +
Skin became insensible to the
 +
touch. After
 +
second exposure
 +
serious discom
 +
fort and pain
 +
followed.
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
No subjective
 +
symptoms ;
 +
neither itching
 +
nor pain ; the
 +
rawsurface painless and almost
 +
insensitive.  
  
  
  
[No. 73.  
+
Great pain and ex
 +
cessive tenderness.  
  
  
  
report each a case of single ulcer — at the lesser curvature and
+
Cured in 9 or 10 weeks.
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
+
Results similar to those of
bacilli were found in the lungs and in the diseased part of the
+
sunburn but much more  
femur, but seems not to have looked for them in the ulcers,
+
acute.  
where he, however, found typical caseating nodules.  
+
 
 +
 
 +
 
 +
None given.  
  
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,
+
Eruption healed after 28
with smooth walls; the lung tissue adjacent was densely infiltrated and converted into a caseous mass. In the lower portions of
+
days, but skin was like
the upper lobe, beneath the anterior surface and near the middle
+
boiled fish skin. After
line, a small cavity existed with smooth walls which communicated freely with the bronchi. Its walls were caseous, and
+
cauterization of surface a  
 +
slough separated and a  
 +
tough yellow opaque
 +
membrane formed.  
  
  
  
adjacent to it were large caseous masses surrounded by oedematous and congested tissue, which often presented a gelatinous
+
Process of repair was very
appearance. The upper portion of the lower lobe was taken
+
slow.  
np by a series of cavities, more or less communicating, the
 
deepest of which extended almost to the pleura, and was separated from this only by thin granulation tissue in which
 
could be seen many opaque tubercles. Over this cavity the
 
two layers of the pleura were adherent. The dependent portion of this lobe anteriorly was drawn out to a tongue-like
 
aj)pendage in which were caseous masses, the intervening lung
 
tissue presenting a gelatinous appearance. Firm, dry and
 
caseous tissue surrounded the cavity in the upper lobe, and
 
most of the remainder of this lobe was converted into similar
 
tissue. The lower lobe contained scattered caseous foci, while
 
the pleura covering all of the left lung was scattered over with
 
gray and opaque tubercles. The bronchi, larynx and trachea
 
showed numerous superficial losses of substance reaching only
 
through the mucous membrane. This ulcerative process in
 
the larynx extended to the mucous membrane of the mouth
 
and tongue, but did not pass to the esophagus. The bronchial
 
lymphatic glands were pigmented, enlarged and caseous.
 
Tubercles were observed in the liver and kidneys.  
 
  
The intestines were the seat of numerous ulcerations, which
 
occurred at intervals, beginning 165 cm. below the duodenum
 
and extending to within 10 cm. of the rectum. They were
 
partly circular, partly elongated — " girdle-ulcers " — and penetrated to the muscular coat. In many, small tubercles were
 
visible in the depth. On the peritoneal surface a few tubercles
 
were seen. The appendix vermiformis was free from ulceration.
 
  
The stomach showed a large number of losses of substance,
 
from 115 to 120, scattered over the entire organ, but most
 
thickly on the anterior aspect near the greater curvature.
 
These ulcers were round or oval, usually smaller than a penny,
 
with rounded thickened edges, generally smooth and undermined for a variable distance.
 
  
The chief interest for our purpose centers in the ulcerations
+
Authorthinksconditiondue
existing in the stomach. Our studies embraced the examination of many of these, often in serial sections, both with
+
to heat and electricity ;
respect to their pathologic histology and to the presence of
+
the latter the chief cause
tubercle bacilli. Ulcers of various sizes were sectioned, stained
+
of injury to the tissues.  
and examined microscopically. The details are purposely
 
omitted. The ulcers vary in their histological appeai-auces,
 
depending somewhat upon the extent of their development.
 
Even in the youngest and most superficial the glandular
 
elements are much disturbed, and a considerable proliferation
 
of cells has taken place in the mucosa. The cells are small,
 
round and lymphoid in type, but among them are also some
 
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.]  
+
February, 1897.]  
  
  
Line 2,454: Line 2,842:
  
  
77
+
19
 +
 
 +
 
  
 +
Dr. E. E. King.
  
  
the overhanging edges of the ulcers, and again upon the floor
 
formed by the submucosa, which was always found when
 
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
+
Dr. M. J. Stern.  
bound by adhesions to the chest wall and the diaphragm, and
 
the lobes were bound to each other. On section the whole lung
 
was quite consolidated. Old fibrous processes extended in all
 
dii-ections through the lung, but they were most abundant
 
posteriorly and at the apex. Small foci of caseation partly
 
calcified were found, and in addition actual cavities lined
 
with thin pyogenic membranes, the largest of them not exceeding the size of a walnut. The bronchial glands were enlarged,
 
caseous and partly calcified.  
 
  
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
+
Dr. F. Kolle.  
covered with sticky mucus, and along the greater curvature,
 
almost over its entire extent, small losses of substanceoccurred,
 
70 to 75 in number. They presented worm-eaten edges and
 
uneven bases, which sometimes, but rarely, were covered with
 
small granulations. They extended usually only partly through
 
the mucosa. The follicles of the oesophagus were enlarged,
 
but without ulceration.  
 
  
The histological and bacteriological examinations of these
 
ulcers were carried out in the same manner as in the preceding case, fourteen of the ulcers in all being subjected to
 
study. For this purpose ulcers of various sizes were chosen.
 
With the exception of two or three, those examined involved
 
only the upper layers of the mucous membrane, and the
 
deepest ones did not extend beyond the muscularis mucosae.
 
The edges of these ulcers were never deeply undermined, and
 
the infiltration of the mucous membrane passed a very little way
 
only beyond the ulcerations. In general the appearances presented were those of superficial and small ulcerations, whose
 
floor was formed by the infiltrated mucous membrane, still
 
showing glands or vestiges of glands, but in which the proliferation of cells had so altered the latter that they were often
 
with difficulty recognizable. The new cells consisted chiefly of
 
  
  
 +
Dr. J. C. White.
  
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
 
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
 
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
 
and striking to see how often in the cases reported in the
 
literature, where ulcers existed in the stomach, the intestines
 
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
+
Prof. E. Thomson
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
 
  
  
  
78
+
Dr. H.R.Crocker
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
Prof. John Daniel
  
  
  
[No. 73.  
+
Dr. M. H. Rich
 +
ardson.  
  
  
  
previous lesion existed to enable it to get a foothold; and
+
Dr. W. E. Parker.  
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
+
University of  
gastric ulcer came under observation, which proved also to be of
+
Minnesota.  
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
+
Dr. Banister, U
age. She entered the medical department of the Johns Hopkins Hospital (service of Dr. Osier) on June 16th. Tubercular
+
S. Army.  
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.
 
  
 +
Dr. T.C.Gilchrist.
  
  
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
+
Patient used the x rays
of large caseous tubercles, but there were no distinct tubercles in the substance. One small caseous tubercle was found
+
for two and a half
in the right kidney. The mucous membrane of the uterus
+
months from two to  
was the seat of a number of yellow and gray miliary tubercles.
+
six hours daily before
Both tubes were enlarged and adherent to the surrounding
+
cutaneous lesion ap
structures. Some of the lymphatic glands in the broad
+
peared.  
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
 
  
 +
Patient was exposed at
 +
three sittings of 40-50
 +
minutes duration.
 +
Eruption appeared two
 +
days afterward.
  
 +
A boy 12yearsold. Whole
 +
body exposed 40 minutes. Sixteen days
 +
later alopecia
 +
appeared.
  
Apbil, 1897.]
+
Young lady exposed to
 +
the rays 30 minutes on
 +
one day and 45minutes
 +
on the next day. Eruption appeared the following day.  
  
 +
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.
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
  
 +
Distribution.
  
79
 
  
  
 +
Hand, left.
  
was intimately adherent to the stomach, separated only by the
 
remains of the muscular wall from the caseous masses within
 
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
 
ulcerative process in the stomach was merely secondary,
 
having been caused by the adherent lymph gland which had
 
ulcerated through to the free surface. The microscopic
 
examination proved, however, that the process in the stomach
 
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.
+
Man ; exposure 1 hour
Litten : Virchow's Archiv, 1876.
+
Alopecia 21 days
Talamon ; Progres Medical, 1879.
+
later.  
Brechemin: Bull. d. 1. Soc. Anat., May 1879.
 
Eppinger: Prager Med. Wochenschrift, 1881.  
 
  
 +
Woman. Exposed three
 +
times to the rays, 20,
 +
30 and 3.5 minutes.
 +
Eruption appeared two
 +
days later.
  
 +
Man. Exposed five
 +
times, from 20 minutes
 +
to 80 minutes.
  
Barbacci : Lo Sperimentale, May 1890.  
+
Man whose ear was exmined for several
 +
hours.  
  
Coats : Glasgow Med. Journal, 1886.  
+
Man. Numerous expo
 +
 
 +
sures.  
  
Serafini : Annal. clin. del Osp. di Napoli, 1888.
 
  
Mathieu and Remond : In Letorey's Thesis, Paris, 1875.
 
  
Musser: Phila. Hosp. Reports, 1890, I.  
+
ray operator. Eruption began after frequent and continued
 +
exposures.  
  
Kiihl : Thesis, Kiel, 1889.
 
  
G. Hebb: Westminst. Hosp. Reports, 1888, III.
 
  
Lava: Gazz. Med. di Torino, 1893.  
+
Extended from
 +
thesideof the
 +
face down to
 +
the umbilicus.  
  
Letorey: These, Paris, 1895.  
+
Right side of
 +
head.  
  
Hattute: Gaz. des Hop., 1874.
 
  
Lorey: Bull. d. 1. Soc. Anat., 1874.
 
  
Anger : In Marfan's Thesis, Paris, 1887.
+
Sternal region
  
Marfan : These, Paris, 1887.
 
  
Matthieu : Bull. d. 1. Soc. Anat., 1881.
 
  
Cazin : In Fernet's article. Bull, et Mem. d. 1. Soc. Med. des
+
Little finger of
 +
left hand.  
  
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.
 
  
 +
Epigastrium.
  
  
STUDIES ON TRICHINOSIS.
 
  
 +
One side of
 +
scalp.
  
 +
Abdominal re
 +
gion, particu
 +
larly over
 +
liver area.
  
By T. R. Brown.
 
  
  
 +
Jaw and neck.
  
[Abstract of remarks and discussion before i
 
  
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
+
Ear and surrounding
discharged well.  
+
scalp.  
  
During his stay in the hospital the blood was examined
+
Abdomen,
daily. The number of leucocytes per cm. was determined and
+
chest and  
a differential count was made of the various forms; frequent
+
beard.  
examinations of the urine were made with quantitative determinations of the uric acid, urea and total nitrogen. The two
 
small pieces of muscle which were removed were subsequently
 
subjected to careful microscopical examination. The results of
 
the studies may be summarized as follows:
 
  
(rt) The blood. The study of the blood was carried on con
 
  
  
the Johns Hopkins Hospital Medical Society.]
+
Right hand,
 +
wrist, and
 +
lower portion
 +
of forearm
 +
dorsal sursurface.  
  
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
+
Character of Lesions.  
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
 
  
  
 +
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.
  
80
+
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.
  
 +
Skin was first reddened, then
 +
blistered. Three months later
 +
the patch showed angry-looking
 +
granulations which had refused
 +
to heal.
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
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
  
 +
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.
  
[No. 73.  
+
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.
  
 +
The parts presented later a frozen
 +
appearance. All the hair from
 +
this side of scalp was lost.
  
the eosinophiles and the Charcot-Leydea crystals, various
+
At first a patch, red, inflamed,  
experiments were made with the blood which contained such
+
hypersesthetic, about half the  
large quantities of eosinophiles, to see if the crystals could be
+