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

From Embryology
mNo edit summary
mNo edit summary
 
(4 intermediate revisions by the same user not shown)
Line 1: Line 1:
ds, are found. Characteristic of each type is the
morphology of the full-grown organism. In the one group
an irregularly shaped body, approximately round or polygonal,
occupies one end of the nucleated red corpuscle; the nucleus
has been displaced into a transverse position in the opposite




http://www.archive.org/details/johnshopkinsmedi08john


end. In the other group the full-grown organism is an
elongated body which lies curved along one side of the normally situated nucleus. The irregular parasite (Proteosoma,
Labbe) segments in the peripheral circulation by a process
which is almost identical with that of the malarial organisms.
Segmenting forms of the elongate parasite (Halteridium,
Labbe) are not found in the blood taken, for example, from
the wing. Associated with both types of organism are certain
large bodies, apparently degenerate and not destined to segment, characterized particularly by the fact that, unlike the
ordinary full-grown organism, they contain almost no material
with an affinity for stains as methylene blue, safranin, etc.
Organisms which flagellate as do those of malaria are observed
with both the irregular and the elongate parasites. With the
elongate organism, indeed, owing to the abundance of these
forms, the whole process of flagellation can be studied with
the greatest facility. Among the irregular parasites present
in different birds different varieties are not observed. Among
the elongate parasites, however, considerable diversity of form
exists in different hosts, but the lack of extended observations
makes it impossible to establish distinct species, although in
certain cases the morphological differences observed are very
striking.


Daiiilewsky, who first observed iutracorpuscular parasites in
BULLETIN  OF THE JOHNS HOPKINS HOSPITAL.  
the blood of birds, believed that these organisms are identical
with those of the malarial fevers. Certain subsequent observers
have attempted to establish an analogy between the different
varieties of the malarial parasite and forms which they find in
birds. Others have considered the parasites in birds to be
entirely independent of those of man. It seems probable that
there are in birds at least two distinct siJecies of intracorj^uscular parasites. In almost every detail of structure they very
closely resemble the malarial organisms of man, but they are,
nevertheless, essentially distinct.  


Dr. OsLER. — The subject which these gentlemen have presented so clearly has a very definite bearing upon the life
Vol. VIII. - No. 70.  
history of the malarial parasite in man, as it is quite possible
that we may get a clue to the outside history of the parasites
by a study of the forms in birds. In 18S(!, I think, just as I was
busily engaged for the first time in the study of the malarial
l^arasite, Mr. MacCallura's father. Dr. MacCallum, of Dunnville, Ontario, sent to the Biological Laboratory in Toronto a
goose which was supposed to have malaria. I was extremely
skejjtical about it, as I knew nothing at that time about the
parasites in birds, but to my astonishment there were in large
numbers the pigmented intracellular organisms, just such as
Mr. Opie has demonstrated to. us to-night. They were present
in very large numbers, and the spleen of the bird was also
large and deeply pigmented.  


Dr. L. F. Barkek. — I have been much interested in this
report of the very careful studies of J[essrs. MacCallum and
Ojiie. It may be worth while to emphasize the importance in
parasitic diseases of the blood and blood-making organs, of
studying not only the appearances of the blood itself by clinical
methods, but also the appearances of the blood and tissues in
microscopic sections after death. One gets a very one-sided
idea of the structure of the malarial parasites and their rela




March, 1897.]
BALTIMORE, JANUARY, 1897.  






JOHNS HOPKINS HOSPITAL BULLETIN.
Contents


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


53




The Phrenology of Gall and Flechsig's Doctrine of Association Centres in the Cerebrum. By Lewellys F. Barker,


tion to the cells, if he studies them only in fresh blood or in
M. B., - - - - - 7
smear cover-glass prei^aratious, even when dried and stained.
In tissues which have been hardened in alcohol it is very easy
in sections stained with hematoxylin and eosin or with
methylene blue, to make out within the half-grown and fullgrown tertian parasites of human malaria a relatively large
spherical area which stains usually feebly, though sometimes
very distinctly in nuclear dyes. Peripheral to this mass is a
thin superficial layer which does not stain at all in ordinary
nuclear dyes. In this peripheral non-basophile layer of the
parasite is situated the malarial pigment when it is present.
The internal stainable mass may be centrally placed, though
it is more usual to see it situated somewhat excentrically, so
that the peripheral layer of non-stainable substance may vary
in thickness in different parts of the organism. The internal
mass, which is entirely free from pigment, may stain somewhat
unevenly, and occasionally it is possible to make out in it an
intensely stained nodule which I have thought may correspond
to what has been described in stained smear preparations as the
nucleus. It would seem more rational to look upon it as the
nucleolus or as an aggregation of the chromatin within the
nucleus, though for the decision of this point we must wait
for further investigations. I should like to ask Mr. Opie and
Mv. MacCallum whether or not they have in their studies or in
their reading found any indications of or reference to macronuclei or micronuclei in malarial parasites, such as have
formed the basis of so much interesting research of late years
in the infusoria. It is indeed to be hoped that the large size
of the malarial parasites in birds will permit of the unraveling of the finer structure of these curious organisms.


I have been much imj^ressed in studying Mr. MacCallum's
Notes on New Books, ......... 14,  
specimens of the spleens of these birds, by the enormous
masses of malarial parasites to be seen there. At first it
seemed almost improbable that the huge brownish masses could
consist of malarial parasites. It appeared more likely that
they could be explained as forms of blood pigment, but careful study with the oil immersion lens will convince any one
that they are in reality aggregations of altered malarial
organisms.


Mr. Opie. — I have seen no references to the macro- and
Books Received, 15
micro-nuclei. Labbe, who studied the question most thoroughly, does not mention such structures.


Dr. Welch. — This is the first investigation of the kind, as
far as I know, in this country. It is extremely interesting, and
particularly to us, as it was made here. These have a number
of points to distinguish them from the malarial organism, and
one of the most striking is the absence of movements. I was
interested in the statement that all phases of development
occur at the same time in the circulating blood. An idea of
Golgi as to the development of organisms in groups in the
organs of the body would suggest the localized development in
this class of organisms. There is no reference here, however,
to groups, but each organism developed separately. It suggests that Golgi's observations might be explained by other
suppositions.


Dr. OsLER. — I should like to add a word ujlon the possibility
that in very malarial districts man may harbor the parasites
without showing special manifestations. We know that in


PRESENTATION OF THORWALDSEN'S STATUE OF CHRIST TO THE HOSPITAL




certain regions all dogs have filaria in the blood, and in many
parts of Africa the filaria are present in the natives without
causing much trouble. It is quite possible, too, that there may
be a minor grade of malarial infection in which the organisms
are not present in sufficient numbers to cause fever or the characteristic paroxysms.


Dr. Thayer. — Let me also congratulate Mr. Opie and Mr.  
Oa Wednesday afternoon, October 14, 1896, at 3 o'clock, there
MacCallum upon their careful piece of work.  
was uuveiled in the rotunda of the Administration Building
of the Jolms Hojjkins Hospital, in the presence of the trustees
and officers and a large audience of invited guests. Stein's
reproduction of Thorwaldsen's statue of Christ, a gift from
William Wallace Spence, of Baltimore. Mr. Spence, in presenting the statue, spoke as follows:
 
"I have but a few words to say on this occasion; merely to
state how it happens that this statue stands here.
 
" On a visit to Copenhagen I saw the great work of Thorwaldsen, his ideal conception in marble, of ' Christ, the Divine
Healer.' It impressed me more than did any statue I had
ever seen, and I think this is the general experience of
those who have the good fortune to see it. It was stated that
Thorwaldsen himself said, ' I never was satisfied with any
work of my own until I executed the Christ; now I am satisfied.' He felt that his genius had reached the zenith of its
powers and that he could go no higher. Well might he be
satisfied, for the grace, dignity and majesty of this figure have
never been surpassed.  
 
" 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


The importance of such studies was impressed upon me
several years ago by M. Laveran who expressed his conviction
that a careful study of the hrematozoa of lower animals, and
especially of those of birds, which so closely resemble the parasites of human beings, was perhaps more likely to throw light
upon some of the dark points in connection with the etiology
of malaria than any other branch of research which is at
present open to us.


Kecent observations appear to show that the parasites of
birds and human beings are not identical ; they are, however,
so similar that it is not improbable that the form in
which they exist outside of the body and their method of
entrance to the body are likewise not unlike the corresponding
phases in the life history of the parasite of human beings.


There are, of course, many more points to be studied with
rest. With this feeling I asked permission of the trustees to  
regard to the morphological and biological characteristics of
present this statue to the hospital. It was cordially given,  
these avian hasmatozoa. In these present observations, for
and at once I placed an order with Professor Stein, the eminent sculptor and Director of the Royal Academy of Art in
instance, no idea has been formed with regard to the length of
Copenhagen, and there it stands. How well he has executed
the cycle of existence of the parasites. Danilevsky believes
it you will judge.  
that he has been able to distinguish an acute and a chronic
form, while Oelli divided the parasites of birds into three forms
with cycles of existence corresponding to the quartan, tertian,  
and sestivo-autumnal parasites. Here, however, there has as
yet been nothing to point out the exact length of the cycle of
existence of each generation of parasites.  


Further, it would be advisable to make careful measurements and observations of the temperature in infected birds,  
"A few years ago, at the formal opening of the Hospital,  
observations which, to be sure, have been made by other authors,
President Gilman expressed the hope that some day it might
but with regard to which there is as yet a lack of agreement.  
stand there. To-day his hope is realized. And now, Mr.
President, I beg to present this statue to the Johns Hopkins
Hospital."


It is also, I think, very important that the intimate structure
The statue was then unveiled by little Emily Riggs, an
of the parasites of birds' blood should be carefully followed
infant great-granddaughter of Mr. Spence.  
out; this can be done with much greater facility than in the
human being, inasmuch as specimens of tissues can be instantly obtained at any time desired.  


But really the most important point, it seems to me, as
Mr. W. T. Dixon, the President, in behalf of the Board of
Bignami has emphasized in a recent paper, is to determine, if
Trustees of the Hospital, accepted the gift in the following
possible, the manner in which the parasite exists outside of the  
words :
body, or more particularly its manner and portal (Jf entry. It
may well be possible that careful and continued observations
of this sort may bring us nearer the solution of the greatest
questions in connection with malarial infection.


With regard to the remark of Prof. Osier concerning the
" Mr. Spence — It gives me very great pleasure to accept, in  
possibility that a human being may harbor the malarial parasites in an active condition for a considerable time without
behalf of the Board of Trustees of the Johns Hopkins Hospital,  
showing distinct clinical symptoms, I must say that the  
your generous gift, this beautiful and impressive statue, and to
more of the disease one sees, the more reasonable seems the
assure you of our appreciation of your motives and munificence.
possibility that this condition may exist with relative frequency. In many cases of tertian fever after insufficient
doses of quinine, or during attempts at spontaneous recovery,
a few parasites may be found in the blood for very con


"These grateful feelings of the trustees, I am confident, will
be cordially shared by all the workers in every department of
the Hospital, by our many friends throughout the country, as
well as by the sick and suffering who may come under our
care.


54
" You have most appropriately placed this ' Divine Healer '
just where it can be seen by all who may enter the doors of
the Hospital, thus affording them the opportunity to derive
comfort, courage and hope from its contemplation. And not
only are the outstretched hands of this Christus Consolator




Line 205: Line 109:




[No. 72.  
[No. 70.
 
 
 
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.
 
" There are grave responsibilities and many discouragements
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."
 
The following hymn by Whittier was sung by a male
quartet :
 
" So stood of old the holy Christ
Amidst the suffering throng ;
With whom his lightest touch sufficed
To make the weakest strong.  


That healing gift he lends to them


Who use it in his name ;
The power that filled his garments' hem


siderable periods of time without actual clinical symptoms
Is evermore the same.  
resulting. Dr. Gamble tells me that in j)rivate practice he
has found the parasite in a number of instances in the
blood of patients Complaining of vague symptoms who had
not as yet had any actual paroxysm. In these instances it
is in every way probable that the parasites had not as yet
accumulated in sufficient number to produce a chill. If now
in a certain number of instances a single tertian paroxysm
may be followed, without treatment, by so extensive a destruction of the organisms tliat fever does not I'ecur for a week or
ten days (a not very infrequent occurrence), theoretically there
would seem to be no reason why in certain instances a similar
destruction might not occur in groups which have not as yet
reached a size sufficient to produce actual manifestations ;
thus there would result au iudefinite prolongation of what one
might call the incubation period of the infection. That such
conditions exist is, I believe, not only possible but probable,
though definite proof has yet to be advanced.  


Afeeting of December 7, 1896.
For lo ! in human hearts unseen
Dr. Thayek in the Chair.


Discnssion of Dr. Rlocli's Paper on "Agglutination of Typhoid
The Healer dwelleth still,
Bacilli, etc." [See Bulletin, Nos. 68-69.]
And they who make his temples clean


Dr. Plexnek. — In this connection I wish to speak of some
The best subserve his will.  
interesting and highly suggestive results just obtained by
Pfeiffer and Kolle, with reference to the possibility of successfully vaccinating human beings against typhoid fever.
You may recall that Ktern pointed out several years ago that
the blood of typhoid fever convalescents contains protective
pi'inciples similar to those present in the blood of animals
rendered immune from experimental typhoid infection. It is
probable that these protective substances are those on which
the phenomenon of agglutination depends ; they are different
from the alexines or defensive proteids of the normal blood,
which possess little or no power of producing agglutination of
bacteria, and are destroyed at a considerably lower temperature. These protective principles are exerted against the bacterial cell, are bactericidal and not anti-toxic in nature; thus
they differ from the anti-toxines of diphtheria and tetanus,
whose actions are directed against the toxin and not the bacterial cells as such.  


Proceeding on the basis of Haffkine's results in vaccinating
That Good Physician liveth yet
against cholera, which they accept as conclusive, Pfeiffer and
Kolle have in a similar manner injected suspensions of typhoid
bacilli subcfitaneously beneath the skin of the back into three
persons who had never had typhoid fever. The symptoms
following the injections were elevation of temperati;re, chill,
malaise; but these quickly passed away without leaving
unpleasant effects. Following the cessation of the symptoms
they found the blood of the vaccinated persons to contain an
amount of the protective substances, measui'ed by the power
to protect animals from experimental typhoid infection, in
excess of what is found ordinarily in typhoid convalescents.
Assuming that there exists a relation between these principles
and immunity from tyi)hoid fever, it would appear as if in
this sinij)]e manner an artificial protection from infection with
the typhoid bacilli might be given. Appreciating the diffi


Thy friend and guide to be ;
The Healer by Gennesaret


culties in the way of a conclusive and satisfactory test of this
Shall walk tlie rounds with thee."
method in ordinary life, they suggest that it be given a trial
in outbreaks of typhoid fever in barracks and army corps,
where, as is well known, large and destructive epidemics
sometimes occur.  


Dr. Reed. — I have had no experience with the serum test.
President Gilman of the Johns Hopkins University, upon a
I have made use, however, of Johnson's modification of  
special invitation from the trustees of the Hospital, afterwards
Widal's method, and, so far, have examined the blood in  
made the following address:
thirty-four supposed cases of typhoid fever. AVhen I began
 
with this method — that is, the use of the dried blood —
We are assembled in the presence of one of the best works
Johnson's paper had not been published, so I had to feel my
of modern Christian sculpture, — a transcendent theme, treated
way, as it were. I began by examining a small quantity of  
by an illustrious artist, in his noblest manner; a work, too,
the blood dissolved in distilled water, placing a drop on a
that has stood the test of more than seventy-five years without
cover-slip and then inoculating it with an agar culture. I
a word of censorious criticism. Canova saw it in Rome, while
found the method worked fairly well in certain drops, while
it was modeling by the artist, and praised it. The people of  
in others I had introduced too many bacilli, and, while many
Copenhagen determined to have it. It was reproduced at
clumped, there were highly motile organisms to be seen after
Potsdam (Berlin) in front of the Church of Peace, near which
the lapse of two or three hours. I had just fixed upon a
the Emperor Frederic lies buried. A copy, in plaster, surrounded by the twelve apostles, from the same artist, was
bouillon culture as the proper medium when Johnson's paper
brought to New Yoi-k at least forty years ago and exhibited
ajjpeared, and being convinced then that I was on the right
in what was known as the Crystal Palace or the World's Fair.  
road, I reviewed my cases with this method. I then had distinct clumping with arrest of motility in cases in which I
 
did not get it when using the solid culture. So far I have
But we have here, not the original cast in clay, nor a plaster
examined the blood of thirty-four cases, twenty-eight of which
reproduction, nor one in galvano-plastic ; but we have a
have given me a positive reaction, that is, loss of motility and  
marble like that which Thorwaldsen himself touched with
agglutination of the bacilli. It will be seen that I have met
his chisel. The pose, the drapery, the figure, the outstretched
with success in a greater percentage of my cases than Dr.  
arms, the head, the face, are reproduced for us with exactness
Block has reported to-night. Six cases failed to give the  
by a living artist of Copenhagen.
reaction. In two of these I found the Kstivo-autumnal parasite. A third case that did not give the reaction was considered to be a severe case of typhoid fever in the Freedman's  
 
Hospital. The patient had tympanites and high temperature.  
We are greatly indebted to that honored citizen of Baltimore who has brought here a work which from so many
I examined the blood with negative result. The patient died
points of view delights and inspires us.
the following day, and it M'as found that there was general
 
peritonitis, having its origin in the appendix. The fourth
This is not the first time that a hospital has been decorated
case was a child who manifested distinct brain symptoms, and  
by a great work of art. If I remember rightly, Benjamin
the attending physician had not been certain that it was a  
West painted the picture of " Christ Healing the Sick," for the  
case of typhoid. Two other cases, one in the third and one in  
Pennsylvania Hospital in Philadelphia; and, if I am not mistaken, in St. Luke's Hospital, New York, there is still a
the sixth week, failed to give the reaction. AVhether they
 
were i-eal cases of tyj)hoid I do not know. The earliest case
 
in which I have examined the blood was that of a soldier at
 
Fort Myer. Soldiers are generally put to bed early, and the  
famous picture by Daniel Huntington, "The Dream of  
reaction here was quite distinct on the fifth day After I had
Mercy," based upon an incident in Buuyan's Pilgrim's
obtained a positive reaction in twenty-two cases, the particular
Progress.
bouillon that I was using — an old glucose bouillon (because
 
there was no other in the laboratory at the time) — became
Nor is this the first gift that this hospital has received. Its
exhausted and I began to use ordinary bouillon. I tried this
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.
latter in two new cases from the Freedman's Hospital, and  
And minor gifts have come in. Not long ago we had a very
was surprised to find prompt arrest of motility, but no clumping. For the sake of comparison I took the blood of an
small but noteworthy present, a likeness of Florence Nightingale. At another time a friend gave us models and pictures
undoubted typhoid case and tested it with plain bouillon, and  
of various public institutions throughout the country. Again,
had no clumping until more than au hour had passed. I then
one who loves medical biography and history has hung upon
tried some of my old glucose bouillon cultures, and to my
these walls a fine collection of the portraits of illustrious physicians and surgeons who in many countries and in many
surprise all three cases gave me good agglutination within
generations have adorned their profession. Eecently a large
fifteen or twenty minutes. I then began to examine my
gift has enabled the trustees to provide better facilities for the
hanging drops, in plain and glucose bouillon, at the end of  
instruction of those who are here engaged in preparing themselves for the profession of medicine or for nursing. And now
twenty-four hours, to see if I could distinguish any difference
we have this work of art which, perhaps, appeals to more of
between them, aud found that from the margins of the  
us than any of the other gifts, unless it be that touching
memento of a departed child, the "White Eose Fund," which
enables the Superintendent every year to distribute flowers to,
and to provide for the entertainment of those who are convalescing in the Children's Ward.  
 
Baltimore is fortunate in many ways in the gifts that are
coming to it. We seem to have reached a period in the history
of this city when its citizens are ready to adorn and decorate
the place of their residence. Mr. Spence has presented a noble
statue of William Wallace that stands in Druid Hill Park.  
Around the Washington Jlonument are the works of Barye, of
Dubois, and of Story, and also the grand figure of Chief
Justice Taney, perhaps the best portrait statue, with one or
two exceptions, that has ever been produced in this country,
the work of our own Rinehart. But pleasant as these tokens
are, I must not dwell upon them, but must rather speak of the
circumstances under which this work of Thorwaldsen was  
produced, and tell you some things regarding the sculptor.
 
The city of Copeijhagen, at the entrance to the " Sound," is
not a very large place; I should say not more than one-half or
two-thirds the size of Baltimore (if size is measured by population) ; but it has a port, a university, a citadel, a harbor,  
and an academy of fine arts, the latter holding high rank
among the academies of Europe. The city suffered greatly
by the bombardment of 1807 during the Napoleonic wars, and  
it was not till some twelve or thirteen years afterward that
an historic edifice, which had thus been destroyed, was reconstructed. This was the old church which bears the name of  
the " Frue Kirke." The sound would be more familiar to us if
I called it Notre Dame, or the Church of Our Lady. Denmark,
as you know, is a Protestant country, and this is a Lutheran
church. I have heard it called a Presbyterian church, and I
do not know that Mr. Spence will object to that. While in
the process of reconstruction, the commissioners had a conference with Thorwaldsen, a native of Copenhagen, and arrangements were made by which he should model a statue of Christ.
It was also agreed that the approach to the altar from the  
main portal should be lined with statues of the apostles, beginning with Peter and Paul. This arrangement was carried






March, 189^]  
January, 1897.]  




Line 332: Line 248:




55
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.
 
I have come upon another incident perhaps more curious.
You know that when a man becomes famous all the world
begins to ask " Who was his grandfather ? " and to trace his
heredity as far as possible. As soon as this Danish sculptor
became famous, people found out that he was descended from
an old Icelandic sculptor. But they did not stop there ; they
thought they found that he was a desceudant of Thor Finn.
Thor Finn is the name of one of the Norsemen who is said to
have crossed the Atlantic, not far from the year A. D. 1000, and
is said to have skirted along the New England coast and to have
established himself iu the southern part of that peninsula. A
son was born to Thor Finn in what is now Rhode Island (so at
least it is said), and to that man they have traced the genealogy of Thor-wald-sen, and thus they claim that Thorwaldseu is descended from the first person born of European
descent in the new world.


The enterprising secretary of the Rhode Island Historical
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."


It is just one hundred years this very month, and I may
say this very week, since Thorwaldsen, iu a note dated October
16, 1796, states that he is on his way from his northern home,
like the Norsemen of old, to establish himself in the south.
He was a passenger upon a government frigate which stopped
leisurely at one point and then another, so that his journey
grew tiresome. At last he abandoned the man-of-war and


clumjjs iu plain bouillou the bacilli had always grown out as
delicate threads radiating across the field and forming a network, whereas the clumps in glucose bouillon do not show
any growth. I have repeated the observation many times with
the same result. In the Fort Myer case I got good clumping
with the glucose, but not with the plain bouillon. So it has
seemed to me that possibly the bacilli grown in the glucose
bouillon are somewhat more vulnerable to this peculiar action
of typhoid blood.


In order to see whether motility of a cultui'e had anything
to do with its agglutination, I examined bouillou cultures at
periods of seven, thirteen and sixteen days, and ascertained
that the old cultures, in which there is no motility, clump
about as promptly as recent ones. I then tried, as a matter
of interest, to see whether the dead bacilli would agglutinate,
and ascertained that massing of the bacilli took place about
as promptly in the dead as in the living cultures. I also
observed that blood heated to 60° C. for half an hour acts
about as well as the non-heated blood. It occurred to me
that by heating the blood to 60° one might destroy its normal
germicidal action and still leave behind the peculiar body
upon which the clumping depends. I have observed the reaction in dried blood after twenty-six days. I have failed to
obtain arrest of motility of the bacilli in normal blood, but
in one case, probably latent tuberculosis, there was prompt,
distinct partial clumping; the non-agglutinated bacilli, however, remained actively motile at the end of three hours.


Dr. Thayer. — There is one point, it seems to me, which
found other conveyances to carry him from Malta to Palermo,  
must be carefully looked into before we draw too many conclusions, namely, the length of time during which this bacteriocidal power may remain in the blood after recovery from
to Naples, and so on to Rome. There he went to work.  
typhoid fever. In one instance at present in the Hospital
the reaction is marked 16 mouths after the attack of fever.
It must be said, however, that there is a typhoid osteomyelitis
preseut which might well be the direct cause of the reaction.  


But how could this boy maintain himself in Rome ? It was
by the aid of a scholarship provided for him by the Royal
Academy of Copenhagen. He had not been a very bright boy
in his ordinary school instruction. His teacher could uot
make anything out of him, and the pastor who was engaged
in giving him lessons for confirmation shook his head many a
time at the dulness of the artist. One day in the course of
these lessons he said, "Thorwaldsen, was that your brother
that took the j)rize iu the Academy of Fine Arts the other
day':"' " No," said the young sculptor, "it was I." "You!"
said the teacher; "Mr. Thorwaldsen [with the emphasis on
the title], go up to the front seat." It is not a bad thing for
those of us engaged in instruction to remember that sometimes boys who are dull at books, who do uot like to receive
knowledge through the printed page, may yet have talents that
are worth developing. This should never be forgotten.


Now I want to remind you that scholarships just like that
which enabled Thorwaldsen to go forward, have been established within a short time in Baltimore. Rinehart, as you
know, left a considerable sum of money, which was carefully
invested by Mr. Newcomer and Mr. Walters, until it reached
the sum of $100,000, and it was then given to the Peabody
Institute. This very week the Maryland Institute, by the aid
of that fund, has instituted a school of sculpture, to bear the
name of Rinehart, and besides this, Rinehart scholarships
have been bestowed upon two young men, selected with great
care by distinguished artists, and they are now engaged iu the
prosecution of their art-studies, one in Paris and the other in
Rome. I think it is not unreasonable to hope and believe that
as the years roll by we shall hear something proceeding from
these influences worthy to stand beside the Danish artist
whom we this day commemorate, worthy likewise of Rinehart's
bounty.


NOTES ON NEW BOOKS.  
At Rome, Thorwaldsen instantly came under the modern
influences of that day. Wiuckelmann, the well-known critic,
had already called attention to the great value of the Greek
art iu distinction from that of the Renaissance, and sculptors
began to work iu the Hellenic spirit. You get an illustration
of this movement in the Flaxman designs, as produced
in England. You get another illustration in the work of
Oanova, and you get an especially good illustration in the early
work of Thorwaldsen.  


A Treatise on Surgery, by American Authors. Edited by Koswell
A great many illustrious people came to Rome. An amusing story is told of Sir Walter Scott. He was very desirous of
Park, A. M., M. D., Professor of Surgery in the Medical Department of the University of Buffalo, etc., etc. Vol. I. General
meeting and talking with Thorwaldsen, and they were introduced to one another; but Thorwaldsen could not speak a
Surgery and Surgical Pathology. 799 pp., 356 engravings, 21 jilates
word of English, and Sir AValter was not at his ease in French.  
in colors. Lea Brothers & Co., Philadelphia and New Tork, 1890.  
All that any one could hear was "plaisir," "plaisir," "connaissance," and similar nouns, expressing gratification that
they had met.  


It was not one of the lightest proofs of the true inspiration of the
The sculptor soon came into church circles. He was a particular friend of Cardinal Consalvi, and made his monument.
sacred writers that they have handed down to us such nuggets of
It was through his influence, undoubtedly, that Thorwaldsen
truth for all ages as the familiar "Much study is a weariness of  
was selected to make for the Church of St. Peter the famous
the flesh, and of making many books there is no end."  
monument of Pius the Seventh. Some one objected that a Protestant had been selected. The Pope inquired, " Is not he the


Any volume which steps into the crowded arena of medical literature today must expect to be challenged at once to show not only
negative virtues, the absence of faults, but some positive and original ones besides, some clear raison d'etre, or excuse for its very
existence. Especially is this true of that realm of medicine known
as the surgical, in general, and of American surgery in particular,
where the new challenger must win his spurs against such giantsof
the pliocene as Gross and Agnew, and such hydra-headed antagonists of the pleistocene and contemporary as Ashurst, Dennis, and
Keen. Hence the first question to be asked is, does this particular aspirant show proof of such approved superiority or peculiarity
in weapons, or skill and training in feats of arms, as to give promise




JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 70.


of holding his own in such a contest? We believe that he does iu
several respects. One of these is that the work is, in the broadest
and best sense of the term, American, national, catholic. By this
we mean, first of all, that singularly fruitful combination of scientific knowledge and breailth with "Yankee" ingenuity of application and intensely utilitarian tendency, so well typified by its distinguished editor and part-author, which has so rapidly won a
world-wide recognition alike for American surgery and American
scientific discoveries and mechanical inventions. Our whole inventiveness, progress and enterprise are born of the double fact that
the thinker mtist needs do and the doer is able to think.


Again, in glancing over the list of contributors to the volume,
no one, I think, can fail to be impressed with the fact that it is
nationally representative in the broadest sense. Xames which
range from Maine to Louisiana, from Philadelphia to f^t. Louis, and
from Tennessee to Jlichigan, are certainly ample proof of this, and
when we remember that the proudesttriumphs of American surgery,
as represented by the names McDowell, Batty and Sims, to say
nothing of a host of minor ones, had their origin not among the polished consultants of the great centers, but among the sturdy general
practitioners of the rural districtsof theSouth and Southwest, wesee
that this arrangement has not merely its fairness, but a genuine basis
of practical scientific advantage to recommend it. At the same time
an admirable homogeneity approaching that of the classic surgical
monographs is given to the work, both by the careful supervision
exercised by the editor and the large proportion of chapters in this
volume contributed by him personally, much to the reader's satisfaction and advantage. The first five chapters of the volume covering
the domain of surgical pathology are contributed by the editor himself. The subject is presented in a comprehensive and yet concise
manner, its most prominent characteristic being the clear-cut division which its author insists upon between hypeictmia and its consequences, and the process of repair on the one hand and of inflammation upon the other. The use of the latter term is limited strictljto those reactions of the tissues which result from the introduction
of some noxious irritant, usually of bacterial origin. This limitation
possesses decided advantages in point of clearness, both of thought
and practice, and it is probably desirable that the use of the word
should be so restricted in the future from the surgical standpoint ;
and we believe that the admirable classification which is based
upon it, and which it alone makes possible, will go far to recommend
it to the profession. From a biological standpoint, as its author
himself would frankly admit, the difference between the two processes is one of degree rather than of kind. But divisions are
no longer made, either in pathology or biology, in the old hardand-fast pre-Darwinian sense, and in actual experience the two
classes are so sharply distinguished in their characters, their
origins and their results as to be entitled to the writing of true and
distinct species.


A somewhat novel feature is the introduction of a chapter upon
best artist in Eome?" "Undoubtedly," was the answer.
the pathology of the blood, which, however, abundantly vindicates
"Then let him hold the place."
its right to appear in a surgical treatise, as some excellent diagnostic and prognostic tests are based upon it.  


Another instance of the breadth of view which pervades the
Thorwaldsen after a time went home, and, as I have said,  
whole treatment of the subject is the careful discussion of the
received the commission for a statue of Christ. He returned to
many factors which, by lowering the resistance of the tissues, may
liome, and with his helpers, it took him eight or nine years to
predispose to an attack of surgical infection. With a candor which
complete the group of Christ and the Apostles.  
is rare in the operating surgeon, full credit is given to the extraordinary power on thepartof both the leucocytes and fixed cells of tlie
body to ward off infections and to rei>el invaders of every description ; and the story of the " battle of the cells " is given in the most
graphic manner. This view of the matter is particularly well
developed in what is, to our view, one of the most original and valuable chapters of the volume, that upon "Auto-Infection in Surgica.
Patients." Here the author impresses with convincing clearness
and abundant illustration the too-little recogni/.ed truth that any
secretion of the body tissues may become a poi.son to the entire system if its elimination is in any way interfered with, notonly medi


You must be familiar with many of the works which he
produced meanwhile. The little medallions of Night and Day
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."


56
The story goes that he made six models of the Christ before
he was satisfied with the one which is here reproduced. At
first he thought of giving to the figure an iiplifted hand, in
the attitude of benediction. Afterwards he uplifted both arms
as if in prayer. The artist was standing before his statue one
day, when he said to a friend, " I am not satisfied with that."
His friend replied, " What was your motive in giving that
posture; what were you thinking about?" Thorwaldsen
paused, and in a moment turned down the arms to the position
in which you now see them, and then said, " I am satisfied now."


It is worth while for me to add that between five and six
hundred works by this artist have been catalogued — a large
part of which may be seen (in the cast, if not in the original)
at the Thorwaldsen Museum in Copenhagen.


Now, ladies and gentlemen, it is not for me to draw the
lesson of the statue. I suppose (to use a phrase of Coleridge) that this statue "will find each one" of us in his own
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


JOHNS HOPKINS HOSPITAL BULLETIN.




is repeated. So it is in painting, from Eaphael and Leonardo to
those gifted men who are now decorating the churches in this
country with the illustrations of the life of Christ. So it is
in sculpture, fi'om Michael Angelo to St. Gaudens. So it is in
religious meditation, from Thomas a Kempis to Phillips
Brooks. Everywhere there is one Jiote prevalent, one name
pre-eminent. Whatever else the founder of Christianity may
have been, we cannot read the narratives of his life without a
certainty that he was the Great Physician. W'hatever else
may be found in this statue, however we may look at it, we
must be mindful that it represents to us one who lived and
walked upon this earth, and wrought more cures and more
wonderful cures than any physician or surgeon that had ever
lived. Thorwaldsen, better than any artist that I know,
has produced this thought in marble. Li " Ecce Homo "
attention is called to a fact which you will allow me to repeat
— that the founder of Christianity was not only the Great
Healer, but when he first organized his followers into a definite society, for the purpose of bearing glad tidings throughout
the world, he sent them on their mission as physicians. " Go,"
he said, "and heal the sick "; and the narratives of the Evangelists and of the Book of the Acts bring out most clearly
this distinctive character. Among its other lessons we shall
remember that this " House of Mercy," this " Hotel-Dieu," is
pervaded by the spirit which appeared upon the earth almost
nineteen hundred years ago.


[No. 72.  
In the presence of Mr. Spence it will not do for me to
recount the many good deeds which he has done for the city,
the many great services, political, financial, mercantile, philanthropic, educational and religious, which he has rendered to
Baltimore ; but I must be allowed to say that twice when the
finances of the Johns Hopkins University have been in a critical condition, he has been the one citizen to come forward and
by his example to inspire the liberality of others. He was
kind enough to tell you that I had on a " wishing cap," or
words to that effect, seven years ago. I am going to put on
my "wishing cap" now, and I am going "to wish" that as long
as Baltimore lives and flourishes it may have the presence and
influence and co-operation of such men as William Wallace
Spence.  






cally but surgically. The surgeon is urged to see to it that his
THE BACILLUS PROTEUS ZENKERl IN AN OVARIAN ABSCESS.  
patient is thoroughly aseptic externally and internally, particularly
as to the alimentary tube. As the author declares, " There is perhaps no condition which so predisposes to sapntmia, septicemia, or
even pyemia, as this vague condition of intestinal toxaemia, which
nevertheless is so often present." The " hard-and-fastness" of
some of the definitions in classification of surgical fevers will challenge decided criticism, but for enaMing the subject to be clearly
grasped, especially by the student, even this has its practical
advantages.  


A decided novelty in works upon surgery is found in two excellent chapters by theeditorupon " Diseases Common to Man and the
By Hunter Robb, M. D., Professor of Gynecology, Western Reserve University, Cleveland, 0., and Albekt A. Ghriskey, M. D.,
Domestic Animals." These fill a gap in the knowledge of the
practitioner which is already being widely felt, and will prove
among the most attractive chapters of the volume. The pathological paragraphs are particularly suggestive, the biological basis of
morbid processes and the individual part played by the various
tissue-cells being so vividly developed as to give even tubercleformation the fascination of a story from life.  


The chapter upon Syphilis, while covering the ground well, is so
former Assistant Gytiecologist to the Johns Hopkins Hosjntal.  
much compressed as to produce in places a style so bold and even
dislocated as to seriously interfere with clearness. We very much
doubt whether any student would be able to recognize a set of
Hutchinson'steethfromtheextremely brief (and inaccurate) description upon page 209. Indeed it suggests a doubt as to the clearness
of the writer's own concejition, and we are not surprised to find it
followed b}' the statement, "The appearance described is often
absent in syphilitic patients or may result from other causes."
The " wax-work-like " tints of the colored illustrations of this
chapter also leave much to be desired.  


The pathological suggestions in the chapter upon Rickets are
most interesting. One, that the disease is essentially a loss of balance between lactic or some other excrementitiousacid, on the one
hand, and calcium salts on the other, calls up atonce Loew's discovery of serious disturbances in plants on account of a similar imbalance between oxalic acid and the magnesium salts. And we doubt
if the essence of the rachitic process has ever been better epitomized than in the description of the layer of osteoid tissue of the
epiphyseal lines " which is notcartilage and will not become bone."


lu Chapter XIV we find the editor's "creed," whicli is consistently lived up to throughout tlie whole of the volume. After
speaking of the "artificial and unfortunate separation of surgery
from so-called internal medicine," he well declares that "it has
been no small part of the benefit resulting from modern teachings
that these imaginary boundaries and limitations have been swept
away, and one of the lessons which this text-book is intended to
inculcate is that broad principles underlie disease-conditions, and
that one must appreciate their bearings thoroughly in order to
practice either medicine or surgery successfully."


The chapters upon Minor Surgery are clear, concise and well
Mrs. T. G. was admitted to the gynecological ward of the
illustrated.
Johns Hopkins Hospital, August 8, 1891, with the following
history :


The discussion of Cysts and Tumors is comprehensive and thoroughly up to date, the classification (based largely upon that of
The patient was a Bohemian, 36 years of age, and had been
Sutton) being particularly commendable for its scientific simplicity
married seven years. She had had three children, and said
and ease of comprehension. Growths are regarded as aberrant or
that she had never miscarried. The oldest child is six and the  
"rebellious" groups of living tissue-cells differing mainly from
second four years old; the third child, born in Jan., 1890,  
each other in the particular tissues which they reproduce or imitate and in the perfection of their imitation. We would prefer,  
died of " summer complaint " at the age of six months. Her
however, to transfer epithelioma from the " Tumors of Epithelial
labors had been easy ; she remained in bed for two days after
Type" to those of " Glandular-tissue Type," as its deadly qualities
each, being attended only by a midwife. PIcr menses first
seem to be solely due to its power of " dipping down" or burrowing
appeared at 16 years of age. They were irregular, lasting usu
into the tissues, in its attempts to imitate the sebaceous, sweat or
mucous gland of the surface where it originates.  


The chapter upon Surgical Diseases of the Skin, while in most
respects admirable, especially in its discussion of dermal tuberculoses, includes a good deal of ground which has already been covered, such as neuroma, myoma, epithelioma, lipoma, etc., and is
disfigured throughout by the characteristic "Scabies perpetualis


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




sive septennialis " of oar dermatologist brethren, for pompous and
January, 1897.]
sonorous Latin terms of classification, whose dignified sound barely
covers their childish meaning. Thus, the common every-day wait
is teased under a dissecting microscope with a literary needle and
forceps into " Verruca vulgaris, Verruca filiformis and Verruca
acuminata"; Cancer of the skin parades as "Carcinoma cutis"
with two divisions, "Carcinoma tuberosum" and "Lenticular
cancer." It is obvious that potatoes in a bin might be "classified "
in precisely the same manner and -with as euphonious results.  


The chapter upon Diseases of the Lymphatic Vessels, by Dr. F.
H. Gerrish, is a most original and valuable contribution to a subject
which has never received the attention which its importance
merits; probably largely on account of the inherent difficulties of
the subject and our imperfect understanding of it.


The remaining chapters of the volume maintain a high average,
but present nothing sufficiently characteristic or distinctive to call
for special comment.


The illustrations throughout are excellent, with a few exceptions,
JOHNS HOPKINS HOSPITAL BULLETIN.  
and a most refreshing feature is the large proportion of them which
are entirely new, most of them from original photographs. AVe
feel almost lost, though, without our old familiar friend the " opisthotonos " man (but perhaps he will come to cheer us in the second
volume), and grievously miss those numerous and beautiful pictures
of surgical instruments, with the maker's name in large black letters
upon either the blade or handle.  


Even the camera, however, has its little weaknesses, and we are
further confirmed by these cuts in our conviction that the photograph is in many cases no more necessarily " true to life" than is
the "realism" of modern fiction. In not a few of even this carefully selected series, while the outlines are cltar, the details of the
central area are so indistinct that the assistance of the title and
side-lettering is needed to discriminate between them, while in
several even this assistance fails to render them entirely clear, as
for instance the cut of varicose ulcers (p. 541) and that of fracture
of the patella (p. 741). Most of them, however, are clear, as they
are typically illustrative, and will constitute valuable and permanent additions to our surgical picture-gallery.


As a whole, the work is fresh, clear, and practical, covering the
ground thoroughly yet briefly, and well arranged for rapid reference, so that it will be of special value to the student and busy
practitioner. The pathology is broad, clear and scientific, while
the suggestions upon treatment are clear-cut, thoroughly modern
and admirably resourceful.


Our only general criticism takes the form of a regret that the
smelling black clots of blood and experienced labor-like pains.
editor, in some of his chapters, felt himself so much under the
During May, June and July she was free from these laborlike pains, but complained during these months of weakness,  
necessity of condensing and systematizing and could not give his
of occasional chills and fever, of pains in the lower zone of the
thought fuller and freer play. But a chapter or volume which fails
abdomen, and backache. On admission to the hospital she was
by being too short is not far from a decided success, and we have
too weak to walk. The slightest touch over the region of the
Ycl. II tc look forward to for consolation. W. H.  
left ovary provoked intense pain. The temperature on admission was normal ; the jiatient weighed 123 pounds.  


A Manual of Syphilis and the Venereal Diseases. By J.4.mes Nevi.vs
At the examination made August 8, 1891, under chloroform
Hyde, A.M., M.D., and Frank H. Montgomery, M. D. 1 vol.,
narcosis, the following note was made :  
618 pages. {Philadelphia: W. B. Saunders, 1895.)


For several years there has existed the need of a condensed and
Vaginal outlet moderately relaxed; vagina bathed with
at the same time sufiiciently comprehensive book on venereal diseases, which would enable medical students and practitioners, at a
bloody fluid ; cervix small, bilaterally lacerated, pointing upwards; uterus anteflexed, sagging in the pelvis, enlarged, soft
moderate cost, to obtain the latest opinions as to syphilis, and also
and movable. Right broad ligament thickened. Fallopian
to keep up with the advancing bacteriological work which is being
tube and ovary not definitely palpated.  
done in genitourinary diseases.  


The Manual of Syphilis and the Venereal Diseases, by Hyde and
On the left side a fluctuating tumor is outlined, about the  
Montgomery, is a book which well answers this purpose. It is  
size of an orange, adherent to the uterus.  
extremely attractive in appearance, the printing and illustrations (which are numerous) being all that could be desired. The
full-page illustration in colors of "Gonococci in gonorrhoeal pus"
is a beautiful example of the possibility of enlarging from a photomicrograph.  


The chapters on Syphilis are written in a most attractive style,  
Diagnosis. Abscess of the left ovary. Treatment advised,  
coeliotomy.


Urinary analj/sis. A voided specimen examined on August
9th was turbid, straw-colored, specific gravity 1.020, reaction
acid. On standing it deposited a heavy bloody and mucous
sediment. On boiling, albumen was found to be present. A
large number of red blood corpuscles were revealed by the
microscopical examination, as well as numerous epithelial cells
both large and small.


A catheterized sj3ecimen was cloudy, amber-colored, specific
gravity 1.035, reaction acid. Albumen as in voided specimen;
mucous sediment not so deeply stained with blood. The
microscopical examination gave much the same results as those
shown by the previous specimen.


March, 1897.  
Operation August 12, 1891, under chloroform narcosis.  


Incision 7 cm. long through thin abdominal walls. On
exploration of the pelvis, the mass previously palpated on the
left side was brought into view. It was bound down to the
broad ligament, uterus and pelvic walls by dense connective
tissue adhesions. The tumor mass was successfully enucleated, but during its delivery a small rupture occurred at the
point at which it was adherent to the fimbriated extremity of
the Fallopian tube, and a small quantity of purulent fluid,
having a strong foetid odor, escaped. A ligature was immediately tied about the rent, thus preventing the escape of more
fluid. The remaining portion of the Fallopian tube, although
not adherent, was enlarged and thickened. The tumor mass
was transfixed and ligated below the round ligament, after
which it was excised and the pedicle cauterized.


The Fallopian tube and ovary of the right side being bound
down by only a few adhesions, were enucleated without difficulty. The fimbriated extremity of the tube was occluded,
enlarged and thickened. The ovary appeared inflamed, but
was not enlarged. The tube and ovary were removed by transfixion and the pedicle was cauterized. The jjelvic cavity was
irrigated with three litres of a sterilized salt solution at a
temperature of 112° F. and sponged dry.


JOHNS HOPKINS HOSPITAL BULLETIN.  
A drainage tube was inserted in the lower angle of the
wound and the usual dressings applied. Time of operation,
40 minutes.  


The specimens removed consist of the tube and ovary of the




57


right side, which are covered with villamentous adhesions, and
the tube and ovary of the left side, which are encapsulated in
connective tissue-like adhesions.


VIII-13-91. First dressing. The gauze plug in the drainage tube is thoroughly saturated with a dark bloody discharge,
and streaked with a fluid resembling pus. Tube cleansed with
20 pledgets of cotton, the last three pledgets being but faintly
stained. The discharge had a decided odor of decomposition.


and condensed so skilfully as to make a thorough review of the  
The cotton immediately over the drainage tube was slightly
whole subject in a comparatively few pages. In their discussion of
moistened with the same character of secretion as that seen
the treatment of syphilis the authors express some views as regards
upon the plug and upon the cotton pledgets.  
the inadvisability of using opium- in combination with mercury
which may not obtain the endorsement of the profession.  


The chapter on Chancroid closely follows the articles on this subject in Morrow's System of Genito-Urinary Diseases, and in addition
Abdomen flat, no distension, general condition good, usual
furnishes a valuable table, in parallel columns, for the differential
cultures taken.  
diagnosis of chancre and chancroid.  


Cystitis and pyelitis are not given the prominence or attention
VIII-14-91. Second dressing. Slight amount of fluid on
that these comparatively frequent diseases merit, and no mention
cotton over the drainage tube ; plug in tube moistened by a
is made of the value of the cystoscope as a means of diagnosis in
clear fluid holding a clot of blood at the lower end. On the
vesical and renal diseases.  
gauze plug there are white opaque points of lymph, corresponding in position to the perforation in the drainage
tube. The fluid has the same odor of decomposition. Tube
cleansed with twelve pledgets of cotton, which when withdrawn were stained with a serum-like fluid, the two last being
hardly soiled at all. Drainage tube removed and a plug of
iodoformized gauze inserted down the track of the tube.
Abdomen flat, general condition good ; usual cultures taken.  


The articles on Urethritis Acute and Chronic (including Endoscopy) are especially well written, and give a thorough and scientific presentation of the aubject.  
VIII-15-91. Third dressing. Gauze removed from the
tube track; moistened; not as much odor. Track of tube
cleansed with peroxide of hydrogen. Abdomen flat, general
condition good. Gauze reapplied to wound, but not down
the track ; abdomen sensitive. Gauze impregnated with permanganate of potassium and oxalic acid applied over the
protective dressing and track of the tube.  


The aim of the authors has been a compilation of the most recent
VIII-19-91. Fourth dressing. Stitches removed. Line of  
literature and thought on " Syphilis and the Venereal Diseases,"
union good; some suppuration about the track of the tube.
rather than to put forward any original work or ideas of their own.  
General condition good.  


A. B. G.  
VIII-26-91. Fifth dressing. Small amount of creamy
fluid escaped from the track of the tube. Line of incision
in good apposition and well united.  


Transactions of the American Gynecological Society. Vol. 21,  
Analysis of temperature cliart. — The temperature was taken
for the year 1896. {Philadelphia : Wm. J. Bornan, Printer, 1896.)
for ten days after the operation by the mouth, rectu m and vagina.  
The highest point registered was that on the fourth day, when
it was 102° F. by the rectum, 101.8° F. by the vagina, and
101.2° F. by the mouth. After this it was never above 101° F.  
and on the 9th day registered 100.5° F.  


The Society is to be congratulated upon the almost unanimous
Bacteriological examination. — The following cultures were
tendency to conservatism displayed in its papers and their discussion, which gives a tone of advance, not so prominent in past
made from the left Fallopian tube and abscess cavity: Two
meetings.  
sets of Esmarch's roll plates on agar-agar, one smear and one
stab culture in the same medium ; a blood-serum tube (bullock's
blood) and a litmus milk tube. From the right Fallopian
tube, which was distended by a muco-purulent, rather viscid
looking fluid, we only made gelatine Esmarch's roll jilates.  


It is not surprising that the paper by Segond, of Paris, on the
Microscopical examination. — Cover-slips stained with gentian violet show numerous polynuclear leucocytes, with compound granular bodies, and a few cells with large round
radical treatment of uterine myomata and inflammatory disease
nuclei resembling epithelial cells. Many bacilli were observed;  
of the tubes and ovaries by vaginal hysterectomy gave rise to a  
they were rather faintly stained, and were seen only occasionally within the leucocytes. These bacteria were stained
most vigorous discussion and met with many pertinent objections ;  
best with carbolic gentian violet.  
the consensus of opinion of the American gynecologists seeming
strongly against its unqualified acceptance.  


Dr. Kelly, in a paper on the treatment of extra-uterine pregnancy, urges strongly the vaginal puncture and drainage in cases
Numerous rod-shaped bacilli were found in the preparation
ruptured in the early months, but not in the acute stage, and proves
most conclusively the value of this conservative method by the
cases he cites.


Dr. Henrotin, in a paper on the same subject, dwells on the
necessity of immediate abdominal operation at time of rupture,
even when the patient is in shock. Now that we have come to
recognize that shock is but a term expressing all the symptoms of
hemorrhage. Dr. Henrotin's advocacy of immediate interference
is sustained.


Dr. Noble's paper on suspensio uteri with reference to its influence on labor deserves special mention. The recent condemnation
of the vaginal fixation of the uterus by its originators because of its
frequent serious interference with labor greatly increases the value
of Dr. Noble's careful study and statistics of the abdominal operation. Unfortunately, the statistics do not represent a uniform
method of suturing the uterus to the abdominal wall, and it is difficult to draw accurate conclusions. The two cases of dystocia which
he cites in his own experience were true fixations, consequently the
suspension method cannot be held responsible for the difficulties
which he has described.


The statistics collated by Dr. Byrne with reference to the remote
JOHNS HOPKINS HOSPITAL BULLETIN.  
results of operations for cancer of the uterus are most painstaking
and creditable, but do not point the way to any advance in treatment. Statistics to be of value must contain a complete picture of
every case, and here this paper is found sadly wanting, especially
on the laboratory side. In every case suitable for radical operation
a microscopic diagnosis should be made before it is undertaken. A
failure to do this may lead to most appalling mistakes. After
removal, sections should be made through the critical points for
microscopic study to determine whether the disease has all been
removed. If this were done Dr. Byrne would find that the morbid
cell changes beyond the primary growth of which he speaks, were






a simple extension of the disease into tissue which appears to the
[No. 70.  
eye and touch unsuspicious. Not until these precautions are taken
and the results put into statistical tables will one be able to judge
fairly of the remote results of operative treatment of cancer of
the uterus. The statistics of to-day are absolutely valueless.
Winter, in his most excellent article on the question of recurrences (Zeitschiift fiir Gynec. und Geburt., Band XXVII, Heft 1),
apparently depends entirely upon the macroscopic appearance to
define the limitsof the disease. One who has studied these tumors
microscopically can testify to the utter impossibility of fixing the
outermost limits of the disease by the eye or touch. On this
account one cannot accept Dr. Byrne's conclusion as to the value of
his method of performing vaginal hysterectomy by the cautery.
Df. Halsted has proved, by the astonishing results of his operation
for the removal of the breast for cancer, that a wide dissection and
removal of the glands are demanded ; and the same is true in cancer of the uterus, which can only be successfully removed by
the abdominal operation. W. W. R.  


Transactions of the Chicago Pathological Society from October,


189'1, to November, 1895. Vol. I. [Chicago: American Medical


Association Press, 1896.)
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.  


This little book contains the transactions of a society which is not
After 48 hours in the thermostat all tubes were sterile,
wholly pathological, and many of the articles are of medical rather
except the blood serum slants, which showed an opaque, very
than of pathological interest. The pathological papers, however,  
faintly granular growth, apparently due to closely set colonies.
are well done, as, for example, "The Contribution to the Study of
Only the growths from the two inoculations from the abscess
Malignant Growths in the Lower Animals," by Dr. Field, upon
contents were considered reliable for study. Inoculations were
which the paper of Dr. Livingood in a recent Bulletin is an interesting commentary ; the report of cases of Leukemia and of Pernicious
made from these on the agar-agar, blood serum, potato and  
Anemia, and the paper on Embolic Abscesses due to the Micrococcus
gelatine. Examined microscopically they proved to be pure
Lanceolatus. The papers on Appendicitis, Nephrorrhaphj' for
cultures of a bacillus.  
Movable Kidney and Tubal Pregnancy, although not strictly pathological, are of general interest to medical men.  


It is to be regretted that the volume is not uniformly printed,  
All these tubes showed growth after 24 hours on agar; very
which will not seem strange when it is stated that the matter
faintly after 48 hours on gelatine, on account of the lower
appeared first in the current numbers of a medical journal. If such
temperature, but more distinctly on the latter on succeeding
a system of printing is continued in future, it would add materially
days. The appearance of the colonies in gelatine corresponded
to the appearance of subsequent volumes to have successive reports
to that presented by the bacillus proteus, a fact suggested by
set up in a uniform type. The book deserves a better mechanical
Dr. Booker and confirmed by Dr. Welch. These colonies
appearance.  
showed the typical twisted wandering offshoots (schwiirmende
Colonien) characteristic of the proteus group. The gelatine
was not liquefied.  


Medical and Surgical Reports of the Boston City Hospital. Seventh Series. By George B. Shattuck, M. D., W. T. Councilm.\n,  
Cultures from the Dramage Tube. — First dressing 24 hours
M. D., and Herbert L. Brewell, M. D. (Boston: Puhlished by
after operation. Roll plate, agar-agar, Esmarch's tubes. The
the Tmstees, 1896.)
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.  


It is pleasant to know that the issue of reports by the Boston
The inoculation of a guinea-pig subcutaneously in the flank
City Hospital has been resumed, and the volume before us is a  
with the serum-like secretion from the gauze plug was without result.  
worthy successor of those which have preceded. A marked feature
of the book is the thoroughness of its report on pathological work.
This is notably shown in the valuable study of the Lesions in
Selected Autopsies by Prof. Councilman and Dr. Mallory, also in
Adeno-Carcinoma of the Pancreas, by Dr. Wright. The preliminary essay on Surgical Morals, by Prof. Cheever, is a new departure in hospital reports and one which can be commended. The
paper also on Methods of Routine Treatment in the Surgical Outpatient Department is of great value. Altogether the seventh
series is worthy of high praise.  


Annual Report of the Supervising General of the Marine Hospital
Further inoculations from the drainage tube on bullock
Service of the United States for 1894. [Washington: Oovernment
serum were not made, as the supply of culture medium was
Printing Office, 1895.)
exhausted.  


In addition to routine reports concerning the oper.itions of the  
The case is of unusual interest on account of the results of
Marine Hospital Service, and full accounts of the various hospitals
the bacteriological examination. The bacillus proteus vulgaris (variety Zenkeri ?) was found in cultures from the  
and quarantine stations under its control, this volume contains
abscess cavity in the left ovary, and on cover-slips in the right
much that is interesting to the medical man. Among these may be
Fallopian tube. In all our previous examinations of abscess
mentioned detailed histories of the cholera and yellow fever epidemics of 1894, and Prof. Kitasato's Preliminary Notice of the Bubonic Plague in Hongkong, China.  
cavities, cysts and Fallopian tubes, we have never met with
another instance in which it was present.  


Macroscopical and microscopical de.fcripfion of specimens from
the Pathological Laboratory of the Johns Ho})kins Hospital, by
Dr. .T. Whitridge Williams.


Appendages on loth sides. Left side: Tube 6 by 0.7 by
1 cm. Fimbriated end thickened and adherent to ovary, but
not occluded ; some portions are still bound down to the
ovary, but at other places the adhesions have evidently been
torn loose during the operation. On section it is seen that the
mucosa is much thickened and resembles a pyogenic membrane. The characteristic folding has disappeared. Scattered
through it here and there are areas which appear decidedly
caseous.


JOHNS HOPKINS HOSPITAL BULLETIN.




The ovary is converted into a pus sac 5.5 cm. in diameter.
The greater part of its exterior is smooth, though signs of
several dense adhesions are observed. On the surface are a
few dilated follicles. The abscess wall varies from 0.5 to 1
cm. in thickness, its interior being lined by a characteristic
pyogenic membrane 2 to 3 mm. thick. Externally it is glistening and presents many circular elevations, 1 to 5 mm. in
diameter, which are raised only a few mm. above the general
surface. These are found to be movable and to represent tags
of tissue. On section, the pyogenic membrane is readily divided into two layers; the one nearer to the pus cavity being
opaque, thicker, of a yellow color, and having a tuberculous
aspect (?) ; the other, lying next the ovarian stroma, is lighter
in color, more translucent, and considerably thinner than the
inner coating.


[No. 72.  
Cover-slips from the pus show many thick bacilli, but no
tubercle bacilli.  


Right side : Tube 5 by 0.4 by 1.2 cm. ; fimbriated end
occluded ; many adhesions. Ovary 3 by 3 by 1.5 cm. Many
adhesions on surface. On section, the ovary is succulent and
contains an oldish corpus luteum and a small corpus luteum
cyst, 5 mm. in diameter, with white opaque walls 1 mm. thick
and with a glistening interior. There are also several follicles with hemorrhagic contents.


Microscopical examination. The left tube presents a marked
purulent salpingitis, the folds of its mucosa being infiltrated with leucocytes and round cells. In places the epithelium is swollen and breaking down, and in others has
entirely disappeared, affording a picture which beautifully
illustrates the liquefaction of tissue.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.  
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.


In this portion the connective tissue bands are hardly visible.
As we recede from the abscess cavity we find fewer leucocytes,
more fibroblasts and connective tissue, until we gradually
approach characteristic ovarian tissue.


THE JOHNS HOPKINS HOSPITAL REPORTS.  
The bacillus corresponds morphologically to the bacillus
proteus Zenkeri, and stains well with methylene blue, and does
not entirely decolorize with the Gram or Weigert stain. It
may be observed in the abscess walls as a bacillus of varying
lengths and in forms simulating cocci. The fibroblasts are
strikingly like the large cells of the corpus luteum.  


Volume L 423 pages, 99 plates.  
In a contribution to the subject of the proteus vulgaris in
abscesses, Hauser', besides the report of his own case, gives a
resume of the instances previously reported by other writers.
Ilauser's case is that of an adult W'ho had a series of abscesses
in the hand, following an injury from one of the autopsy
instruments. The pus, which was of an ichorous and stinking
character, contained both the streptococcus and proteus. The
suppuration was regarded as induced by the streptococci, and
the peculiar character of the contents of the abscesses was
attributed to the presence of the proteus.  


Report in Pathology,  
Beck'' reports several cases of puerperal endometritis in  
which the proteus vulgaris was found, and one case of puru


The VcBsols and Walls of the Dog's Stomacli; A Study of tlie Intestinal Contraction;


Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
January, 1897.]


Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D.
A Contribution to the Pathology of the Gelatinous Type of Cerebellar SclerosiB


(Atrophy). By Henry J. Berkley, M. D.
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.


Mall, M. D.  
JOHNS HOPKINS HOSPITAL BULLETIN.  


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


T. C. Gilchrist, JI. 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
lent peritonitis, following total extirpation of the uterus for
carcinoma, in which the presence of the same organism was
demonstrated.


Parasites found in Various Lesions of the Skin, etc. ; Tvfo Cases of Molluscum
Finally, Dilderlein' reports that in the lochia of puerperal
women he has often found bacilli which cause a rapid liquefaction of gelatine; but from his brief description one is not
able to say whether or not he was dealing with the proteus.  


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


T. C. Gilchrist, M. D.  
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


Report in Pathologry.
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration


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


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


Report in Medicine,  
3. Doderlein : Untersuchung iiber das Vorkommen von
Spaltpilzen in den Lochien, etc. Archiv f. Gyuilkologie,
1887, Bd. 31, S. 439.


On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
4. Fliigge: Die Microorganismen, 188G, p. 310.


Gallstones. By William Osler, M. D.
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.
On Pyrodin. By H. A. Lafleur, M. D.
Cases of Post-febrile Insanity. By William Osler, M. D.
Acute Tuberculosis in an Infant of Four Months. Bv Harry Toulmin. M. D.
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.


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


Report in Gynecologry.
THE PHRENOLOGY OF GALL AND FLECHSIG'S DOCTRINE OF ASSOCIATION CENTRES
The Gynecological Operating Room. By Howard A. Kelly, M. D.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard


A. Kelly, M. D., and Hunter Robb, M. D.
IN THE CEREBRUM.  
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of


Abdominal Section. By Howard A. Kelly, M. D.  
Br Lewellts F. Barker, JI. B., Associate Professor of Anatomy in the Johns ffopki7is University and
The Management of the Drainage Tube in Abdominal Section, By Hunter Robb,
Assistant Resident Pathologist to the Johns Hopkins Hospital.


M. D.
[Remarks made before the Clinical Society of Maryland, November 20, 1896.]
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;


Ovarian Tumor; General Gynecological Operations from October 15, 1889, to


March 4, 1890. By Howard A. Kelly, M. D.
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howabd


A. Kelly, M. D., and Albert A. Ghriskey, M, D.
In the history of medicine the 18th century stands out
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking
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.


Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment


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


Howard A. Kelly, M. D.  
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.  


Report in Snrg-cry, I.  
Gall was born at Tiefenbrunu, in Germany, in 1758. The
The Treatment of Wounds with Especial Reference to tlie Value of the Bloud Clot
history of his life affords entertaining reading. He studied
medicine in Strassburg and Vienna, and practiced his profession
in the latter city, where he became very well known. He tells us
in his books how at a very early age he noticed among his playmates the existence of definite relations between the external
appearance of the head and face and certain mental characteristics. His lectures delivered in Vienna, in which his
phrenological doctrines were chiefly set forth, were very popular and largely attended until 1802. when at the instance of


in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in Nenrology, I,
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.
Haematomyelia. By August Hoch, M. D.
A Case of Ccrebro -Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By


Henry M. Thomas, M. D.


Report in Pathologry* I*
JOHNS HOPKINS HOSPITAL BULLETIN.  
Amogbic Dysentery. By William T. Councilman, M. D., and Henri A. Lajleub, M. D.  






Volume III. ^6Q pages, with 69 plates and figiires.  
[No. 70.  


Report in Pntliology.


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


Tuberculosis of the Female Generative Organs. By J, Whitridqe Williams, M. D.
the ecclesiastical authorities he was commanded by the Austrian government to discontinue "his public teaching. On
Report in Pathology.  
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.  


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


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


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


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


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


Report in Gynecolog-y,


Tlie Gynecological Operating Room; An External Direct Method of Measuring the  
unscientific nature of the whole system. Whereas Gall believed that there were only some 26 or 27 organs of the
Conjugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
brain, with some of his followers the number was increased
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retroflexed Uterus. By Howard A.  
considerably. Fowler, for example, describing as many as 43
Kelly, M. D.  
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


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


Intestinal Worms as a Complication in Abdominal Surgery, By A. L, Stavblt, M, D.  
January, 1897.]






Gynecological Operations not involving Coeliotomy. By Howard A. Eellt, M. D.
JOHNS HOPKINS HOSPITAL BULLETIN.  
Tabulated by A. L. Stavely, M. D.  


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


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


Traumatic Atresia of the Vagina with Hcematokolpcs and Hsematometra. By Howard
lais and Swift, it was believed to be the organ of the sense of  
A. Kelly, M. D.  
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.  


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


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


Resuscitation in Cliloroform Asphyxia. By Howard A. Kelly, M. D.  
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


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


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


Record of Deaths occurring in the Gynecological Department from June 6, 1890, to  
in the cerebrum, especially in the frontal region, could give
May i, 1892.  
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.  


Volume IV. 504 pages, 33 charts and illustrations.  
In addition to the studies on aphasia there have been
recorded a whole series of pathological lesions which clinically were associated with definite disturbances of sensation ;
thus, lesions of the occipital cortex have a tendency to affect
visual sensations; lesions of certain portions of the temporal
cortex interfere with hearing; the sense of smell has been
shown to be connected with the under surface of the cerebrum, and the sense of touch with the upper frontal and
anterior parietal regions. Physiologists by means of experiments upon animals have added most satisfactory support to
these clinical and pathological observations.  


Report on TypUoid Fever.  
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.  


By William Osler, M. D., with additional papers by W. S. Thateb, M. D., and J.
The studies of Goltz upon dogs supply an exceedingly interesting link in the chain of experimentation. This investigator
IIewetbon, M. D.
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


Report in Nenrology.


Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of i(t's mtisculus; The Intrinsic Nerves of the Th.iToid Gland of
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,
M. D.


Report in Surgery.
10
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to
January, 1894. By W. S. Halsted, M. D.


Report in Gyneeolog-y.
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. Citllen, M. B.
Report in Pntliology.
Deciduoma Malignum. By J. Whitridoe Williams, M. D.




JOHNS HOPKINS HOSPITAL BULLETIN.


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


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


Stndiea In Typboid Fever.  
[No. 70.  
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon
Flexner, M. D., Walter Reed, M. D., and H. C. Parscns, M. D.  






Volume VI. About 500 pages, many illustrations.  
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.  


Report in Neurolosy*  
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.


Studies on the Lesions produced bv the Action of Certain Poisons on the Cortical
Flechsig has shown, in his study of the embryonal cerebrum,
Nerve Cell (Studies Nos. I to V). By Hen-ry J. Berkley. M. D.  
that it is the sensory paths which first become medullated.  


Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the  
*I have thought it best at this time to present, in as clear and
Chroma'te of Silver Methods; Part I.— Alcohol Poisoning.— Experimental Lesions
brief a manner as possible and without discussion, the main tenets
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental
of Flechsig with regard to the structure and function of the brain.
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part 11. — Serum
While in such a short communication it is impossible to do justice
Poisoning. — Experimental Lesions induced by the Action of the Doff*s Serum on
to so broad a subject, it is to be hoped that it may be possible to
the Cortical Nerve Cell; Part III. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Clironic
show at least the trend of his views. The anatomical basis for his
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the' Cortical
studies is given at some length in the voluminous notes appended
Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Ner\'e Cells from tlic Effects of
to his "Gehirn und S'eele " (Leipzig, Veit. Co., 189(>). An idea of
Alcohol and Ricin Intcxication; Ner\'e Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.  
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).  


Report in Patliolosr.


Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.


CULLEN, M. B.  
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.  


Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of  
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.


0\-um and Spermatozoa. By Thomas S. Cullen, M. B.. and G. L. Wilkins, M. D.
In the diagram before you, the localization of these various
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B.
sense areas in the brain, according to the newest investigations
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By
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


William D. Booker, M. D.
The Pathology of Toxalbumin Intoxications. By Simon Flesner, M. D.
77ic price of n set hound in cloth [Vols. I-VI] of the Hosjtital Scparts kv


$30.00. Vols. J, II and III are not sold separately. The itrice of


Vols, ir, V and TI is $5,00 each.  
Gyru.cm,.r..l,{J»«;r;;p,S<,m»»>.l,.tlo.,„.  






I
Corpus cAllonnn


Porulx louguti,


(Septum pellucW,


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.
The following papers are reprinted from Vole. 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 RnroRD,


M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,


$3.00.
THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thater, M. D., and J.


Hewetson, M. D. And A STUDY OP SOME FATAL CASES OF MALARIA.
"^ti^^i^r^^^j^


By Lewellvs F. Barker, M. B. 1 volume of 280 pages. Price, in paper, |2."5.
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.\tracted


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481


pages. Price, bound in paper, $3.00.
^^^
Subscriptions for the above publications may be sent to


Tbe Johns Hopkins Press, Baltimore, Md.




Oolliculiia superior (corp. quad.)
. Hnin nucleus of tliaUmua.


The Johns Hopkins Hospital Bulletins are issued nwntKly. Tlwy are printed hy THE FRIEDENWALD CO., Baltimore. Single copies
may be procured from. Afe.<isrs. CVSHING <t- OO. and the BALTIMORE NEWf! COMPANY, Baltimore. Subscriptions, $1.00 a year, may be
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sinyk copies will be sent by mail for fifteen cents each.






BULLETIN
Fig-. 6.






OF
Soraae»tUetic






THE JOHNS HOPKINS HOSPITAL.


Gynm hippocampi.




Vol. VIII -No. 73.]


Fig. +.




BALTIMORE, APRIL, 1897.






[Price, 15 Cents.


LEGENDS.


Fig. 1. Sagittal section through brain of a child one month old stained by the
Weigert-Pal method. lAfter FUchsig.)


COnSTTIElsrTS.  
a. Taenia thalaini optici iretiex path tor the transference of olfactory


impressions to the centres governing the movements of the
head ?).


b. White matter of septum pellucidum (in part running between the


Postural Method of Draining the Peritoneal Cavity after Abdominal Operations. By J. G. Clark, M. D., ... 59
olfactory area and the gyrus hippocampi).  


Report of Five Cases of Infection by the Bacillus Aerogenes
c. Corpus callosum corresponding to the somiesthetic area.
Capsulatus (Welch). By Edward K. Dunham, M.D., - - 68
D. Superior I


Observations to Determine the Motility of the Bacillus Aerogenes Capsulatus under Anaerobic Conditions. By Edward
h. Inferior jcolliculus of corpora cjuadrigemina, cut near the middle
K. Dunham, M. D., - - - 74
line : here very few meduUated fibres are present; sections lateral
to this show many,
r. Red nucleus of the tegmentum ; below this is seen the decussatio
brachii conjunctiva
(In this and succeeding plates I have translated Flechsig's terms as tar as possible into the nomenclature of the Anatomical Society. For his sense-centres and
association-centres English terms which seemed most suitable have been employed
For the suggestion of the name " soma-sthetic area" as a translation of the German
KorperfuhUplKire I am indebted to Prof. B. L. Gildersleeve.— L. F. B.)


Fio. 2. Horizontal section through the brain of a child aged 3 months. (AHer
Flechstg.) \ j'-'»


II. Tractus opticus.


Multiple Tuberculous Ulcers of the Stomach, with a Report of  
H. Association system (cross-section) in the g. hippocampi, connecting
the olfactory cortex of the uncus with Ammon's horn, going
over into the alveus.
M. Nucleus amygdalae.
P. Pyramidal tract in cross-section.
p'. Temporal cerebro-pontal path.
p'. Frontal cerebro-pontal path.
The decussation of the nervus trochlearis is shown. The projection fibres of the
olfactory sense area and of the g. hippocampi are completely medullated. At the
tip of the frontal lobe and at the junction of the superior and middle temporal gyri
myelin is as yet entirely absent. In many other parts (darker in tint) corresponding
to the advanced age, association fibres are already medullated.


Three Cases. By Alice Hamilton, M. D., - - - - 75
Fio. 3. Horizontal section from the brain of a child a little over a week old.  
Studies on Trichinosis. By Mr. T. R. Brown, - - - - 79
{After Flcchxig.)
Proceedings of Societies :


Hospital Medical Society, 81
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.


On Certain Visceral Pathological Alterations, the Result of  
Fig. 4. Sagittal section through the brain of a child said to have died in the
Superficial Burns [Mr. Bardeen].  
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.  


Notes on New Books, 82
C, P. (IP, as in Fig. 3.
T. Thalamus (lateral nucleus).
II. External geniculate body.


Books Received, --- 83
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.


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.


POSTURAL METHOD OF DRAINmG THE PERITONEAL CAVITY AFTER ABDOMINAL OPERATIONS.  
Fio. 6. Internal view of left cerebral hemisphere. (After FUchHg.)
 
1. Corpus mammillare.  


By J. G. Clark, M. D.  
2. Median section of optic chiasm.  


3. Cross-section of anterior commissure.


4. Superior colliculus of corpora i|uadrigemina.
.5, Corpus callosum (cross-section).


The general trend of recent medical literature relating to
6 Fornix.  
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
7. Septum pellucidum.
clinical records of 1700 cases of abdominal section performed
z. Pineal gland.
in the gynecological department of the Johns Hopkins Hospital, I have been forced, notwithstanding my preconceived
H.S. Tegmentum.
ideas in favor of drainage, to draw conclusions against it and
T. Basis pedunculi.  
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
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,
January, 1897.]
extensile raw areas in the pelvis, are usually sui:)posed toindi




* A Critical Review of 1700 Cases of Abdominal Section from the
Standpoint of Intraperitoneal Drainage. The Johns Hopkins Hospital Reports, Vol. VII.


JOHNS HOPKINS HOSPITAL BULLETIN.




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
11
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
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
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.


into consciousness of sensations of touch, pain, temperature,
muscle and tendon sense, thirst, hunger and equilibrium, as
well as sexual sensations, that is to say, the sensations which
tell us of the condition of our bodies rather than that of
external objects. It is obvious that this area must represent
a complex mass of sense centres rather than a single sensory
area ; indeed, we already have evidence from the pathological
side indicating very different functions to the several parts of
the somssthetic area, although the localization here, as might
be expected, concerns that of groups of elementary rather than
of single sensations. This is the area in which the body in its
whole extent can be reflected in consciousness. It is possible
that a similar mirroring of somatic sensations occurs in the
cerebellar cortex.


Besides being a sensory field, the soma3sthetic area is also
the great motor region whence nearly all the movements
serving for the voh;ntary satisfaction of the bodily instincts
appear to start. When a man voluntarily swallows, chews,
breathes or seizes an external object, it is this area which is
active.


60
The nerve fibres conducting the impulses concerned in olfactory sensations terminate, according to Flechsig, mainly in the
gyrus unciuatus where it touches the island of Keil, although
many of them end in the frontal lobe.


The fibres concerned in visual sensation, passing from the
lateral geniculate body, the thalamus and the superior colliculus of the corpora quadrigemina, follow a direct course to
terminate in the immediate neighborhood of the calcarine
fissure, although subsequently fibres run out from this tract
into adjacent areas, ending, however, only in that part of the
cortex of the occipital lobe which shows the well known
macroscopic stripe of Vicq d'Azyr. It is interesting to note
that fibres from the fovea centralis are believed to go to the
cortex of both cerebral hemispheres. Such a distribution
would help to account for the incomplete blindness from
unilateral cortical lesions.


The fibres communicating auditory impulses to the cerebral
cortex form the lateral lemniscus in the pons and are connected particularly with the median geniculate body; they
run out into the temporal lobe to terminate mainly in the
transverse temporal gyri, especially in the anterior one. It is
obvious, therefore, that the main portion of the auditory area
of the cortex is hidden in the wall of the fossa sylvii, appearing on the external surface of the hemisphere only in the
middle third of the superior temporal gyrus, /. e. in that part
of it which is in contact with the transverse gyri.


JOHNS HOPKINS HOSPITAL BULLETIN.  
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






[No. 73.  
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.  


Flechsig believes, therefore, that these association centres
are the portions of the cerebral cortex which above all others
are concerned in the higher intellectual manifestations, in
memory, judgment and reflection. If his theory be right, the
study of the association centres should be the especial object
of research for the neurologist and jisychologist. That they
really are of definite importance for the intellectual activities
has been shown by these anatomical studies, which might of
themselves be deemed conclusive. But it must be conceded
that clinical experience has also afforded a large mass of evidence in favor of the view. In certain of the diseases of the
mind marked disorganization of the association centres has
been noted, the microscope permitting the recognition in them
of the destruction of many cells and fibres. In such cases,
during life, iustead of a connected train of thought, the mental
processes may be confused and tangled. New mental pictures
entirely foreign to the normal intelligence may appear, the
capacity for using past experiences may be lost and the knowledge of the results of certain acts be gone. It is in the study
of general paresis that the most convincing clinical proof of
Fiechsig's doctrine of association centres is to be found, and
from a consideration of the varying symptomatology of this
disease, taken together with the pathological lesions which have
been proven to exist in such cases, some clues have already
been gained towards the explanation of differences in function
in the different parts of the association areas in the cortex.
Flechsig in the first edition of his "Gehirn und Seele" stated
that the anatomically demonstrable alterations of the brainsubstance in general paresis were often limited to the intellectual domains. He refers in the second edition particularly
to the monograph of Tuczek upon dementia paralytica published in 1884, and recommends strongly the study of this
paper in connection with his own classification of the different
regions of the cortex.


It seems likely from Fiechsig's studies of the brain lesions
in general paresis, that this disease more than any other will
afford the key for the deduction of psychic disturbances from


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
12
Pathological Conditions.


G. Wegner,* the first investigator who by experiments upon
animals endeavored to arrive at some definite conclusion concerning the ability of the peritoneum to rid itself of injurious
fluids or solid particles, was convinced that a comparatively
large quantity of infectious matter could be eliminated or
encapsulated by the peritoneal exudate without serious harm
to the animal.


Grawitzf next took up the experimental study of infection
of the peritoneum, pursuing his investigations under improved
bacteriological technique, and arrived at the following conclusions :


1. The introduction of non-pyogenic organisms into the
JOHNS HOPKINS HOSPITAL BULLETIN.  
abdominal cavity, either in small or large quantity, or mixed
with formed particles,J produces no harm.  


2. Great quantities of organisms which ordinarily produce
no symptoms, may give rise to a general sepsis if the absorptive function of the peritoneum is impaired.


3. Injection of pyogenic organisms into the peritoneal cavity
may be quite as harmless as injections of non-pathogenic
varieties. (In these experiments he injected a flocculent emulsion of staphylococcus albus and aureus and the streptococcus
pyogenes in ten cubic centimeters of water without any visible
reaction.)


4. The introduction of pus-producing cocci into the normal
pfo. 70.  
peritoneal cavity produces a purulent peritonitis, first, if the
culture fluid is difficult of absorption, and second, if irritating
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
grow.  


Pawlowsky,§ in an excellent experimental study, reviewed
Wegner's and Grawitz's work, with whom he agreed in many




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.


* Chirurgische Beobacbtungen uber die Peritonealhole mit besonderer Beriicksichtigung der Ovariotomie. Verhandlung der deutschen Gesellschaft fiir Chirurgie, Berlin, 1877.  
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.  


tCharite Annalen Jahrg., XI, 1886.  
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


t A solution of fecal matter containing solid particles was injected ; the fluid was absorbed while the larger particles were
encapsulated.


§Virchow's Archiv, No. 117, p. 469, 1889.


self-control, and may show deep perversity of feeling or of the
will, the specific character of the disease-picture consisting in
his inability to recognize external objects, that is, to associate
external sensory impressions with the memories of those of
his previous experiences. On this account he may use external objects falsely ; he may confuse persons ; he has no certain
ideas as regards space and time. His mental conceptions of
the external world, the knowledge of these which he can put
into words, and the power of interpretation of external impressions as the result of experience, are lost to him. He is in
severe cases almost bankrupt in ideas, although his regard for
himself and for those who are dear to him may be unaffected.


If one of the sense areas of the cortex alone be diseased, the
clinical picture is entirely different from that presented by
these purely intellectual disturbances. Here again we may
have to do either with phenomena of absence or phenomena of irritation. A tumor pressing upon the auditory area may give rise to noises and other subjective perceptions of sound. Pressure upon the posterior central gyrus
may lead the individual to believe that he experiences movements of his thumb, although his eyes convince him that it
remains station.'fl-y. Again, a tumor pressing upon the uncinate gyrus has been known to give rise to subjective odors;
while a cysticercus cyst pressing upon the visual area of the
occipital lobe has caused the arrival into consciousness of
mental pictures of colored figures and the like. Destructive
lesions of the sense centres may prevent the external sense
impressions from entering into consciousness at all. There
may be entire absence of mental confusion in such instances;
the patient recognizes the subjective character of the
hallucinations, and so is not actually mentally diseased in the
ordinary sense, but if focal disease affect along with one sense
centre several of the others, or the posterior large association centre, the picture of hallucinatory confusion is prominent.


particulars, but disagreed in others. The main point of difEerence, however, between Pawlowsky and Grawitz related to  
Time will not permit me to discuss the so-called functional
the ability of the normal peritoneum to deal with the staphylococcus aureus.  
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.  


Pawlowsky found that the large quantities of staphylococci
Flechsig's researches have established the fact that the  
injected by Grawitz without harm into dogs produced death
human cerebral cortex is made up of at least seven anatomically more or less well separated areas. As the phrenologists
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
research, and in the main agreed with Grawitz. The essential points of value in Reichel's paper are, that peritonitis
usually arises, first, because more organisms gain entrance
than can be handled by the peritoneum, and second, because
the stagnation of degenerating fluids in dead spaces favors the
growth of the organisms.


He also accounts for Grawitz's and Pawlowsky's conflicting
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
January, 1897.]
to satisfactorily settle the question of the ability of the normal
 
peritoneum to take care of infection.  
 
 
JOHNS HOPKINS HOSPITAL BULLETIN.  
 


He injected 6 cc. of a cloudy culture of staphylococcus
aureus into the abdominal cavity of dogs, employing both the
methods of Grawitz and Pawlowsky, and all of the animals
survived. The same results were obtained with the streptococcus, bacillus pyocyaneus and the intestinal bacteria.


Waterhouse then endeavored to simulate the conditions
13
occasionally met with after operations, by introducing 8 cc. of
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
and Grawitz that the dangers of peritonitis are increased by
tardy absorption of fluids, which in effect leaves a culture
medium for the growth of the organisms.


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
thought, the brain is the organ of the mind, and the whole
acute abscesses is extremely virulent, 2 cc. of the staphylococcus aureus and 1 cc. of the streptococcus from this source
is in reality made up of multiple organs. But instead of calling
causing death in twenty-four hours. If a very small quantity
these, as did the old phrenology, after certain qualities, friendship, good-nature, wit, firmness, and the like, thanks to
of the pus, however, was introduced with water, the animals
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
frequently survived.  
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.  


After the introduction of turpentine with the organisms, as  
It is not stating too much to affirm that advances in true
done in Grawitz's experiments, peritonitis did not follow,
psychology are to be mainly hoped for from strictly scientific
which is explained by Waterhouse on the ground that the  
investigations into the structure and function of the nervous
organisms are rendered inactive or are killed by the turpentine. He proved this point by injecting the turpentine first
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


*Beitrage zur Aetiologie u. chirurg. Therapie der Sup. Peritonitis. Deutsche Zeit. f. Chir., Vol. XXX, 1889.
t Virchow's Archiv, Vol. 119, p. 342, 1890.




* 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.


April, 1897.]




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.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Furthermore, Flechsig sees in these newer studies the essential preparation for a physiological basis of ethics, so much
desired by some of the writers of the last century. Inasmuch
as the health of the cerebrum is essential for the control of
the lower centres concerned with the instincts and emotions,
as is proven by the cessation of the struggle between the instincts and the ethical feelings where the intellectual centres are
paralyzed, and inasmuch as we now know some of the causes
of the diseases of the sense centres and of the association centres,
and are convinced that many of these causes are removable or
avoidable, the etliical significance of these studies becomes
manifest.  


It must be the aim of educators to enlighten the people concerning the hygiene of the body and especially of the brain.
We must not fear to teach the intimate interdependence of
bodily conditions and mental phenomena, or hesitate to let the
masses know that the abuse of alcohol, the over-indulgence of
the passions, and mental and physical excesses of all descrip




61
14






and following it in a short time with the infecting germs ; in
JOHNS HOPKINS HOSPITAL BULLETIN.  
every instance the animal died of peritonitis.  


Dogs with a strangulation of the intestines were easily
infected.


In three instances the staphylococcus aureus was introduced
into the peritoneal cavity of cats suffering from ascites, followed
quickly by death from peritonitis, which resulted, as Waterhouse says, because there was a favorable culture material, a
diminished absorption, and an injury to the peritoneal endothelium.


Burginsky* in a series of experiments also came to the conclusion that the discrepancies in the results of Pawlowsky's
[No. 70.  
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
General Immunity," contains some valuable observations bearing upon the resistance of the peritoneum to infection.


Notwithstanding the injection of large quantities of virulent streptococci, a few of their animals survived. They state
tions, can lead to i-esults of a most serious nature. Only by
that " in those animals which succumbed quickest, free cocci
increasing knowledge, general and special, can we hope in
were very numerous in the peritoneal exudation, and in those
coming generations to strengthen and make solid the foundations of the higher ethical feelings. All will agree that for
which survived longest they were either absent or contained
the advancement of the race we must presuppose a social
within phagocytes."  
arrangement which will subordinate the blind instincts of the
morally and intellectually deficient to the control of the deeper
insight and the better will of an intellectual ethical aristocracy. If it is in the main the remarkable development of his
association centres which has raised man so far above the
level of all other living creatures, it is also by virtue of the
function of these same association centres that man is to be
elevated in the future beyond his present status. Flechsig at
the close of his " Rectoratsrede " makes brief reference to the
aims other than practical of these newer studies. "Just as
by means of one of the noblest faculties of our natures, namely,
the thirst for knowledge, an instinct conferred upon human
beings with the development of their association centres, we
are forced to study the natural laws involved even in the
domain of the mind, so the actual advances of our knowledge,  
even in this field of investigation, lead with the forcible necessity of a natural law to an ideal philosophy. The more the  
enormous potencies embodied in an intelligent individual
become unveiled to our questioning reason, the more clearly
must we feel that behind the world of phenomena there are
controlling forces with which human knowledge scarcely
dare lay claim to be compared."  


These observers, in order to discover how quickly the organisms disappeared from the peritoneal cavity, killed two rabbits
which appeared about to recover. " In the first, which had
received 5 cc. of broth culture thirty hours before, only one
chain of streptococci was found after prolonged search, but
many cocci were contained in cells, and broth inoculated with
this fluid grew a good culture."


"The second rabbit having shown no signs of illness after
an injection of 6 cc. of anaerobic broth culture, received next
day 10 cc. of a similar material swarming with streptococci.
When killed five and a half hours later, not only could no
streptococci be seen, either free or in cells, but no growth grew
on cultures made from the abdominal fluid."


From this review of the literature bearing upon infection of
NOTES ON NEW BOOKS.
the peritoneum I make the following summary :


1. Under normal conditions the peritoneum can dispose of  
Practical Points in Nursing, for Nurses in Private Practice, with an
large numbers of pyogenic organisms without producing peritonitis.  
Appendix. By Emily A. M. Stoney, Superintendent of Training
School for Nurses, Carney Hospital, Boston. Illustrated with 73
engravings and 9 colored and half-tone plates. {Philadelphia:
W. B. Saunders, 1896.)


2. The less the absorption from the peritoneal cavity the  
This little book is primarily designed for the instruction of
greater the danger of infection.  
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.  


3. Solid sterile particles, such as fecal matter, potato, etc.,
The chapters on physiology and descriptive anatomy are of the
are partly absorbed and the remainder are encapsulated without the production of peritonitis.  
most elementary character and are couched in such terms as to
convey no adequate idea of the subjects treated. Witness the
following: "The parotid gland is situated below and toward the
front of the ear. It secretes saliva, and it is inflammation of this
gland that causes mumps." — or " The skull is a box of bone containing
the brain, which is a soft pulpy substance, and is the chief organ of
the nervous system." Coulil tlie modicum of technical knowledge
be made any smaller? The book ought to be very popular fur the  
instruction of nurses among those who are apprehensive of the  
over-education of nurses and are fearful that they will make thirdclass physicians.  


The definitions are very imperfect and are evidently written by
one who is not accustomed to use language accurately. "A lotion
is a medicinal application, and may be evaporating or non-evaporating." " Worms, which are of three kinds — tapeworm, tliread
worms and round worms — are caused by impure drinking water and
food, and also bi/ feeding food that is not properly cooked." "Oph




•Baumgarten's Jahresbericht, Vol. VII, 1891.  
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."


tThe Johns Hopkins Hospital Reports, Vol. II, 1891.  
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.  


t Journal of Pathology and Bacteriology, 1895.  
Practical Notes on Urinary Analysis. By W. B. Caxfield, M. D.  


{Published by Oeorge 8. Davis, Detroit, 1896.3


The second edition of this little work has recently appeared as one
of the numbers of The Physician's Leisure Library. It is essentially
practical, as most of the tests given are such as can be used at the
bedside by the general practitioner. Although the subject is treated
as briefly as possible, yet we think that if practitioners were fully conversant with the various tests described, and with the precautions to
be observed in performing them, many errors in diagnosis would
be prevented and much valuable assistance in the treatment of
diseases affordeil. Many of the higher organic compounds found
normally in the urine are, however, not even mentioned. In fact,
no constituents of the urine, normal or abnormal, are treated of
that cannot be tested for with the simplest apparatus and reagents.
Thus, the use of the polariscope in diabetes and the influence of
diabetic urine on polarized liglit, one of the most reliable tests, is
entirely overlooked. Such statements as ''the diagnosis of typhoid
fever is now made almost certain by the diazo-reaction of Ehrlich" should certainly be qualified, as it is well known that
this reaction is very frequently obtained in tuberculosis and
not infrequently in other febrile conditions : the test is merely
an aid to diagnosis. One can hardly see how the practitioner
is to be aided in recognizing leucin and tyrosin in the urine, by
the author's statement that "leucin and tyrosin are found in the
urine in certain abnormal conditions of the liver. They are
easily recognized in the sediment, or may be found on evaporating the urine." It is only justice to say that a diagram of the
leucin spherules and tyrosin crystals is given in the plate of urinary
sediments, from which alone it would be unsafe to make a diagnosis, however. While the author's book serves a useful purpose, no general practitioner should be without a larger work on
urinary analysis, for purposes of reference.


4. Death may be produced by general septicaemia, and not
Diseases of the Eye. A [Hand-book of Ophthalmic Practice for
by peritonitis, where large quantities of organisms are taken
Students and Practitioners. By G. E. deSchweinitz, A. M., M. D.,  
up by the lymph streams.  
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.)


5. Irritant chemical substances destroy the tissues of the  
This admirable textbook of ophthalmology is so well and so
peritoneum and prepare a place for the lodgment of organisms
favorably known, and so short a time has elapsed since the appearance of the first edition (1892), that an extended notice seems
which becomes the starting-point for peritonitis.  
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.  


6. Stagnation of fluids in dead spaces favors the production
For the bibliography of tlie first edition an appendix containing
of peritonitis by furnishing a suitable culture medium for the  
a description of the method of using the ophthalmometer of Javal
growth of bacteria.  
& Schiotz and the tropometer of Stevens has been substituted. The


7. The association of infectious bacteria with blood clots in
the peritoneal cavity is especially liable to produce peritonitis.


8. Traumatic injury or strangulation of large areas of tissue
are strong etiological factors in the production of peritonitis
when associated with infectious matter.


The accumulated evidence of all these investigators proves
January, 1897.]
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
the diaphragmatic peritoneum and the mechanism of absorption of substances from the peritoneal cavity, when considered
in conjunction with the above conclusions, give ample ground
for my suggestion of the elevated posture as a prophylactic
measure against post-operative peritonitis.


Muscatello accepts Bizzozero's and G. Salvioli's classification of the component parts of the diaphragmatic peritoneum
JOHNS HOPKINS HOSPITA.L BULLETIN.  
which occur in the following order: endothelium, membrana
 
limitans and connective tissue framework. Up to the time of
 
Muscatello's publication, histologists were equally divided on
the question of the presence or absence of stomata between the
endothelium. He proved beyond doubt that these openings
are optical illusions, due to the defective preparation and
staining of the microscopical sections. According to Muscatello's opinion, minute foreign particles, leucocytes and fluids
pass through openings between the endothelium of the diaphragm made by the retraction of the protoplasm of the cells.


Beneath the peritoneal endothelium of the diaphragm and
15
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


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.


Virchow'a Archiv, 1895.  
The author tells us in his preface that the book has been enriched
with forty additional illustrations, but he does nottell us how much
more effective many of the illustrations have been made by the substitution of well-executed photo-engravings for the woodcuts of the
first edition. The illustrations of congenital ptosis and of epicanthus and congenital ptosis on p. 200, and of rodentulcerof theorbit
(p. 203), are striking examples of the effectiveness of this method
of representation. Having said this much in praise of the illustrations, perhaps we shall be pardoned for finding fault with the
legend descriptive of Fig. 90, on p. 254 — " lipomatous dermoid of
the conjunctiva."


The publisher has performed his part of the work ip a manner
worthy of especial commendation. S. T.


A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D.
With 163 illustrations in the text and 6 full-page plates. (Philadelphia: W. B. Saunders, 1896.)


62
This well-printed and fully illustrated volume seems a happy
mean between the more ambitious and encyclopedic works upon
obstetrics and the quiz-compends, and is clearly and systematically
arranged for the use of students. Although lacking the details and
references of larger works, it is clearly and carefully written and
will be a safe guide. There is really little to criticise.


The directions given for the disinfection of the accoucheur and
of the patient are admirable and explicit. The recommendation to
use a creolin douche after the expulsion of the placenta, as a matter
of routine, cannot be endorsed, because it would do harm rather
than good in the majority of cases. Vaginal douches should notbe
given after the second stage of labor, unless they are clearly and
definitely indicated. The employment of a pad above the fundus
uteri and the use of am abdominal binder tightened daily for six
weeks or three months are recommendations which do not seem
free from danger.


Water and Water Supplies. By John C. Thrush, Medical OflBcer of


JOHNS HOPKINS HOSPITAL BULLETIN.  
Health to the Essex Co. Council, etc. (London : The Rebman


Publiahing Co., L'i'd. Philadelphia : W. B. Saunders, 1896.)


This excellent little book can be commended unreservedly as


[No. 73.
probably the best short treatise on Water and Water Supplies in the


English language. The information contained in it is concise and


the whole book is thoroughly modern. It is gratifying to observe


of the foreign particles from the peritoneal cavity to their
that the author shares the opinion of Koch that the best of all
ultimate repository, the lymph glands, could, however, be
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
glands in from five to seven minutes, while in animals in
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
the peritoneal cavity into the lymph spaces of the diajihragm
through the opening made by the retraction of the endothelium, then into the mediastinal lymphatic vessels and
glands, then into the blood current, by which they were transported to the various organs of the body, from which they were
picked up by the lymph vessels and deposited in the collecting glands of each organ. For this reason the large vascular
organs, such as the liver, stomach, spleen and pancreas, show
the particles first and in the greatest numbers, while the
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
water supplies for a city is that obtained from deep wells. The  
the elimination of foreign particles from the peritoneal cavity.  
sourcesof water pollution are clearly described and well illustrated.
We are pleased to see that careful directions are given for the
filtration of water, and the dangers which lurk in improper filtration are distinctly stated. If the book could be in the hands of  
every householder, the preventable causes of water-borne disease
would unquestionably be mucli better understood. The book is
well printed and sensibly illustrated, and deserves a large sale.  


Muscatello and other observers find, on examining the
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
leucocyte to encompass it, two or more join forces to surround
the invader. The leucocytes are found in greatest abundance
beneath the omentum. Prom the peritoneal cavity Muscatello
traces the course of the leucocyte through the channels above
described and finally finds them deposited in the lymph glands
in various parts of the body.


In Muscatello's experiments the leucocytes were able to
BOOKS RECEIVED,  
dispose of the innocuous particles rapidly and without apparent ill effect to the auimals. In Pawlowsky's, Cobbett's and
Melsome's experiments, on the other hand, the conditions
were different, the leucocyte having to meet an antagonistic
invader. In those animals which survived the injection the
infectious organisms were quickly encompassed by the leucocytes and carried into the general circulation, while in the
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
wish to draw especial attention to are :


1. Large quantities of fluids may be absorbed by the peritoneum in a remarkably short time. (Wegner.)


3. Minute foreign particles are carried from the peritoneal
Transactions of the Association of American Physicians. Eleventh
cavity through the diaphragm into the mediastinal lymph
Session held at Washington, D. C, April 30 and May 1 and 2,  
vessels and glands, and thence into the blood, by which they
1896. Vol. XI. 8vo. 1896. 453 pages. Printed for the Association. Philadelphia.  
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.)


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.


3. The leucocytes are largely the bearers of foreign particles
An American Text-book of Physiology . Edited by William H. Howell,
from the peritoneal cavity. (Muscatello.)
Ph. D., M. D. 1896. 4to, 1052 pages. W. B. Saunders, Philadelphia.  


4. There is normally a current in the peritoneal cavity
A Te.vt-book of Histology, Descriptive and Practical. For the use of
which carries fluids and foreign particles towards the diaphragm, regardless of the posture of the animal, although
students. By Arthur Clarkson, M. B., C. M. Edin. 1896. 8vo,  
gravity can greatly favor or retard it. (Muscatello.)
554 pages. W. B. Saunders, Philadelphia.  


Postural Method of Draining Dead Spaces in the  
Diseases of the Eye. A hand-book of ophthalmic practice for students
Pelvis.  
and practitioners. By G. E. de Schweinitz, A.M., M. D. Second
edition, thoroughly revised. 1896. 8vo, 679 pages. W. B.
Saunders, Philadelphia.  


The many bacteriological studies in cases of experimental and
Transactions of the Michigan State Medical Society, for the year 1896.
post-operative peritonitis and in experimental infections of the  
Vol. XX. 8vo, 834 pages. Published by the Society. Grand
peritoneum show conclusively that the infecting organisms are
Kapids.  
quickly distributed more or less generally in the peritoneal
cavity, from whence they are carried into the system at large.  


Where there is no persistent source of infection, virulent
A Text-Book of Materia Medica, Therapeutics and Pharmacology. By
species of bacteria may be destroyed effectually in this way;
George Frank Butler, Ph. G., M.D. 1896. 8vo, 858 pages. W.  
but when a nidus of infection exists in which the microorganisms are propagated, the patient is either carried off by a
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
localized collection of pus.  


To avoid this danger the most scrupulous care should be
B. Saunders, Philadelphia.  
observed in every abdominal operation not to leave behind
any condition which may furnish a starting point for an
infectious process.  


Oozing should be controlled as far as possible, injury and  
Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America.
exposure of the peritoneum should be guarded against, raw
Edited by Thomas L.Stedman, M. D. Vol. VII. Diseasesof the  
areas should be covered with adjacent healthy peritoneum
respiratory organs and blood, and functional sexual disorders.
when practicable, and all debris and fluids should be removed
1896. 8vo, 796 pages. William Wood & Co., New York.  
as far as possible before the abdomen is closed.  


Notwithstanding every precaution, dead spaces will be left
A Treatise on Appendicitis. By John B. Deaver, M. D. Containing
after many operations, which may become collecting places
32 full-page plates and other illustrations. 8vo. 1896. 168 pages.
for degenerating fluids. In addition to these artiflcial spaces,  
P. Blakiston, Son & Co., Philadelphia.  
oozing serum and blood may collect in Douglas' cul-de-sac or
in the ante-uterine space, and become the focus of a genei'al
peritonitis or a localized pelvic abscess.  


To offset these dangers all dependent spaces should be
Index-Catalogue of the Library of the Surgeon-Oeneral's Office, U.S. A.
drained as rapidly as possible, thus preventing the collection
Authors and subjects. Second series- Vol. I. A-Azzurri. 1896.
and stagnation of vital fluids, which are active germicides
4to, 828 pages. Government Printing Office. Wathington.  
when first secreted, but become excellent culture media when
degenerated.  


By elevating the pelvis after operation, the normal intraperitoneal current may be assisted greatly in at once draining
Transactions of the Texas State Medical Association. 28th annual
dead spaces, and thus give the general peritoneal cavity and
session held at Fort Worth, Texas, April 28th-30tli and May 1st,  
system at large the best opportunity to meet the invading
1896. 8vo, 458 pages. Eugene von Boeckmann, printer, Austin,
organisms before they have had time to increase in numbers.  
Texas.
To remind one of the incredible rate of multiplication of  
 
micro-organisms it is only necessary to quote Cohn's classical
The British Guiana Medical Annual. Ed. by J. S. Wallbridge and  
statement that "one germ under proper conditions may give
 
rise to more than a half million of similar organisms within
C. W. Daniels. Eighth year of issue. 8vo, 1896. 95 -}- xxxix
twenty-four hours."
pages. Printed by Baldwin & Co., Demerara.  
 
Twenty-seventh An7iual Report of tlie Slate Board of Health of Massachusetts, 1895. 8vo, 807 pages. Wright & Potter Printing Co.,
Boston. 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.  


Stagnating fluids in the dependent parts of the abdominal
Atlas of the Diseases of the Skin. By H. Radcliffe Crocker, M. D.,
cavity or in dead spaces may furnish such a favorable
F. R.C. P. Fol. n. d. 2 vols. Young J. Pentland, Edinburgh
culture bed that a few organisms may quickly generate myriads of others and overcome the most resistant germicidal
and London.  
forces ; if on the other hand these spaces can be prevented
from filling with fluids the organisms may easily be overcome.  






April, 1897.]
16




Line 1,587: Line 2,077:




63
[No, 70.
 




PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL


In additiou to tbe mere transportation of the organisms
from an area of decreased resistance to one of normal resistance, the irritant chemical toxines elaborated by the bacteria
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
the absorption of large quantities of organisms from the peritoneal cavity, it appears to me correct to assume that after a
well-conducted abdominal operation no such quantities of
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 JOHNS HOPKINS HOSPITAL REPORTS.
of drainage are, first, stagnating fluids are prevented from
Volume I. 423 pages, 99 plates.  
collecting in dead spaces in the pelvis; second, infectious
organisms are quickly carried into normal areas of the body
where they are destroyed before they can increase in numbers;
and third, toxic substances elaborated by the organisms are
diluted and prevented from expending their irritant effects on
a wounded area.  


The method which I desire to offer is briefly as follows: At
Report in Putliology.  
the conclusion of an operation all fluids and debris should be
removed as far as possible by sponges, after which the abdominal cavity should be thoroughly irrigated with normal salt
solution until the fluid comes away clear.  


When the irrigation fluid is all sponged out, 500 to 1000 cc.
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
of salt solution should be poured into the peritoneal cavity,
so that when the patient is elevated after she is returned to
the ward the artificial current may be started at once towards
the diaphragm, thus supplementing the normal current.


After the introduation of the salt solution the omentum
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the  
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
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D,  
the bed should be elevated about 30 degrees, which gives sufficient inclination of the posterior pelvic wall to assist the flow
A Contribution to the Pathulog-y of the Gelatinous Type of Cerebellar Sclerosis
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
(Atrophy). By Henry J. Berkley, M. D.
novel procedure, as it has been done in a large number of cases
Reticulated' Tissue and its Relation to the Connective Tissue Fibrils. Bv F. P.  
during the last two years in the gynecological department, and
other abdominal surgeons have used it with good effect.  


This postural method of drainage is offered as a prophylactic
Mall, if. D.  
measure against post-operative peritonitis, but not as a curative measure after the peritonitis is established.  


It should therefore not be employed when an operation is
Report in Dermatolog-y.
performed for the relief of purulent peritonitis or for inflammatory conditions associated with general peritonitis, as for
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
instance some cases of appendicitis.  


From the experiments of Waterhouse in which he proved
T. C. Gilchrist, M. D., and Emmet Rixford. M. D.
the danger of infection in cats suffering with ascites on
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of
account of the defective absorptive mechanism, it would also
appear unsafe to adopt the postural method in cases when


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


this complication is coincident with the surgical affection.
Fibrosum; Tlie Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
Pawlovvsky has sliown in his excellent experimental investigations that the lymph channels leading from the peritoneal
cavity are choked with the infectious bacteria and inflammatory products in purulent peritonitis, and therefore advises
free drainage through an abdominal incision.  


In these cases it is evident that the multiplication and virulence of the organism have been too great for the phagocytes
T. C. Gilchrist, M. D.  
to overcome successfully, and that the only method of treating
this condition is to remove as much pus as possible by irrigation with salt solution or by mopping the peritoneal surfaces
with sponges wet with salt solution, as suggested by Finney,
and then to insert a very free drain.  


Only one of the cases which I report in this paper showed
Report in Pathologry.  
organisms on culture. The presence of pyogenic organisms
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration
is not a contraindication to the employment of the jiostural
method, because all investigations have proved conclusively
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  
organisms are yet active, as shown by Miller of the Johns
Hopkins Hospital, Schauta, Menge and others.


In forty-four cases of hysterectomy, mostly for pelvic
of Hypertrophy of this Gland. By W. S. Halsted, M. D.  
inflammatory disease, examined by Miller, the cultures made
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.


In this case all of the conditions usually supposed to
Volume II. 570 pages, witli 28 plates and figures.  
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,
Report in Medicine.  
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,
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
1897. Married, age 47 years.


Complaint. Pain in the lower abdomen, more marked on  
Gallstones. By William Oslek. M. D.
the right side. Slight cough.  
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.  


Marital History. Married 16 years ; one child 16 years old;
Report in Medicine.  
labor easy, puerperium normal, no miscarriage.  
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.  


Menstruation. Began at 13 years, regular, normal. Last
Report in Gynecology.  
period terminated December 18, 1896.  
Tlie Gj-neeological Operating Room. By Howard A. Kelly, M. D.  
The Laparotomies performed from October 16, 1S89, to March 3, 1890. By Howard


Present Illness. November 15, 1896, she had a severe chill,  
A. Kelly, M. D.. and Hunter Robb, M. D.
lasting two hours, followed by fever. The next day she had
The Report of the Autopsies in Two Cases Dying in the GjTiecological Wards vrith
great pain, which continued one week and was accompanied
out Operation ; Composite Temperature and Pulse Charts of Forty Cases of
with diarrlia.'a. Since then she has grown steadily weaker.


Abdominal Section. By Howard A. Kelly, M. D.
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,


M. D.
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;


64
Ovarian Tumor; General Gynecological Operations from October 15, 1SS9, to


March 4. 1890. By Howard A. Kelly, M. D.
Report of the ITrinary Examination of Ninety-one Gynecological Cases. By Howard


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


JOHNS HOPKINS HOSPITAL BULLETIN.  
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


Howard A. Kelly, M. D.


[No. 73.  
Report in Siirgery, I.  
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot


in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in Neurology, I.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
Acute Angio-Neurotic Oedema. ' By Charles E. Simon, M. D.
Haematomyelia. By August Hoch, JI. D.
A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By


Henry M. Thomas, M. D.


fever and chills occurring frequently, and for the last week
Report in Pathology, I.
she has been confined to bed.  
Ama3bic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.  


General Condition. Well nourished woman; tongue slightly
coated, bowels regular, appetite poor. Micturition and defecation painless. For the past four weeks she has had a dry cough.


Examination of heart and lungs negative.


Temperature on admission 103° F., pulse 110.  
Volume III. 766 pages, with 69 plates and figm-es.  


Diagnosis. Large suppurating ovarian cyst.  
Report in Pathology.  


Operation by Dr. Kelly, January 20, 1897. Cystectomy;
Papillomatous Tumors of the Ovarj'. By J. Whitridge Williams, M. D.  
part of cyst wall could not be removed.  


Complications. Extensive adhesions to mesentery, bowel and
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
vermiform appendix. Adhesions to entire posterior pelvis, to
Report in Patliology.  
omentum, to bladder, and to anterior abdominal wall. Patient
greatly prostrated, pulse before operation 118, at close 144,
during operation as high as 156.  


Multiple Lj-rapho -Sarcomata, with a report of Two Cases. Bv Simon Flexner, M. D,


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


Incision 14 cm. in length, exposing red mottled and whitish
A Case of Chronic Nephritis in a Cow. Bv W. T. Councilman, M. D.  
cyst wall, closely adherent to anterior abdominal wall over a  
surface 10 cm. above symphysis pubis. Omentum adherent
to anterior face of cyst over an area 10x8 cm. Adhesions
separated; free oozing from thickened omentum checked by
catgut sutures, no omentum removed; just above this point
there was a fringe of flat adhesions, binding cyst to intestines
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
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
evacuated; the puncture was then closed with sutures.  


Ten minutes were spent in separating tumor from anterior
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  
abdominal wall, bladder and anterior pelvic wall.  


Large Fallopian tube on left side was exposed up to a point
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.


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


Jan.  
Intestinal Worms as a Complication in Abdominal Sxu-gery. By A. L. Stately, M. D.  






18
Gynecological Operations not invohnng Coeliotomy, By Howard A. Kellt, M. D.
Tabulated by A. L. Stavely, M. D.


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


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


19 20
Traumatic Atresia of the Vagina with Haematokolpos and Haematometra. By Howard
A. Kelly, M. D.


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


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


21
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.


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


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


23
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
May 4, 1S92.






24
Volume IV. 504 pages, 33 charts and illustrations.


Report on Typhoid Fever.


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


25
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.


Report in Surgery.
The Results of Operations for the Cure of Cancer of the Breast, from June, 1SS9, to
January, 1894. By W. S. Halsted, M. D.


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


26




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


Temp.  
CONTENTS:
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.
Studies in Typhoid Fever.  


103
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon
102
Flexner, M. D., Walter Reed, 51. D., and H. C. Parscns, M. D.
101
100


99


98


Temp.  
Volume VI. About 500 pages, many ilhistrations.  


Pulse
Report in Neurology.  
Resp.  


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


Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the
Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol): Part II. — Serum
Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on
the Cortical Nerve Cell; Part HI. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical
Nerve Cell produced hy the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of
Alcohol and Ricin Intoxication; Addenda. By Henry J. Bereixy, M. D.


Report in Pathology.


Day of  
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Tuomas S.
Operation


Cullen, M. B.
Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of


Ov-um and Spermatozoa. By Thomas S. Cullen. M. B.. and G. L. Wilkiss, M. D.
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By


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
William D. Booker, M. D.
The Pathology of Toxalbumin Intoxications. By Simon Flesn-er, M. D.
The price of a set bound in cloth [Vols. Z-TJ] of the Hospital Jteftorts is


$30.00. Vols. I, II and III are not sold separately. The jtrice of


Vols. IV, V and VI is $5.00 each.




5(10


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,


M. D. 1 voliune of 164 pages and 41 full-page plates. Price, bound in paper,


540
?3.00.
THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thayer. M. D., and J.


Hewetson. M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.


By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, $2.75.
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.-rtracted


560
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 4S1


pages. Price, bound in paper, ?3.00.


Subscriptions for the above publications may be sent to


6()0
The Johns HorKiNS Press, Baltimore, Md.






>» •
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies
may he procured from Messrs. GUSHING d: CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.0(» a year, may he
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE ; singU copies will be sent by mail for fifteen cents each.






BULLETIN






670
OF






^'"
THE JOHNS HOPKINS HOSPITAL.






5ilO +
Vol. Vlll.-No. 71.]






^'*..  
BALTIMORE. FEBRUARY, 1897.  






190 +






,\


GOiTTZEITTS.




30 +


A Case of Dermatitis due to the x Rays. By T. C. Gilchrist,
M. R. C. S., L. S. A.,


Lesions induced by the Action of Certain Poisons on the Nerve
Cell. Study VI.— Diphtheria. By Henhy J. Berkley, M. D.,


130
Puerperal Sepsis due to Infection with the Bacillus Aerogenes
120
Capsulatus. By George W. Dobbin, M. D., - . - .
110
100
90






80
Proceedings of Societies :


70
Hospital Medical Society, 29


4 60
The Surgical Significance of Gall Stones [Dr. F. Lakge].
Correspondence :


50
A Case of Pneumo-cardial Rupture. By Geo. S. Brown, M.D., 33






Case I.
A CASE OF DERMATITIS DUE TO THE x RAYS.  
Plain line indicates temperature. Broken line indicates pulse.  


By T. 0. Gilchrist, M. E. C. S., L. S. A., Associate in Dermatology, Johns Hopkins University and Hospital.




where it was lost in the tumor. Adhesions to uterus, to pelvic
floor on right side, and to part of left pelvic wall divided.
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,  
Since the discovery of the x rays by Rontgen, thousands of
discharging a large quantity of fetid pus into the peritoneal
observations and experiments have been made with them both
cavity. This was quickly mopped out and the hole in the sac
in Europe and in this country, and hundreds of investigators have exposed various portions of the body, particularly
stuffed with gauze. Cyst cut loose, leaving a portion of
the hands, frequently, iind for long periods of time, yet, after
abscess wall 5x8 cm. in dimensions on the pelvic floor. Gauze
searching the literature, records of only twenty-three cases
(including the present one) have been given where injurious
results have followed their use, and in these, lesions of the  
skin only have been described. Of these twenty-three cases,  
twelve occurred in this country, one in Canada, four in
England and six in Germany.  


The first report which 1 have been able to find was a
communication in the Deutsche Medicinische Wochenschrift ,
No. 28, 1896 (July 9th), from 0. Leppiu, an engineer, who
had used his left hand a great deal in experimenting with the
X rays. He remarked that the rays had the power of producing cutaneous lesions like sunburn. The hand presented
a peculiar redness, was swollen, and a vesicular eruption appeared later on the middle and ring fingers. Where the skin
was hidden by a ring it was white and quite normal. Even
five weeks after discontinuing the use of the rays the altered
skin gave the hand an older look than the normal one.


Professor Daniel, of Vauderbilt University, reported a case
of alopecia as the result of exposure to the x rays three
months previous to Leppin's communication.


packed over this to protect it during the rest of the operation.
After examining the other reports (the references are given
Sac was peeled up and out of a dense bed of adhesions in
at the end of the article) it was found that the eruptions of the  
the pelvis ; it was then found that the adhesions, extending
skin presented many points of similarity, and differed chiefly in
between the entire length of the mesentery and out onto the  
intestines, were too extensive for further separation. The
outer layers of the cyst wall were slit 2 cm. from bowel on all
sides and dissected out from beneath the mesentery, thus completing the enucleation and leaving behind a large cup-shaped
dead space. Slight capillary oozing occurred from the portion
of cyst wall remaining behind.


The portion left in the pelvis also required six or eight ligatures to control oozing. Small epithelial cyst on right side




severity, according to either the length of time and frequency
of exposure to the rays or to idiosyncrasy of the patient.


April, 1897.]
In Dr. Sehrwald's case, which was described fully, the
lesion occurred after one exposure of forty-five minutes to the
X rays, and Dr. Crocker's patient had also experienced only
one exposure of one hour when an eruption appeared. In Dr.
Kolle's case, the patient, a boy, was exposed once, for forty
minutes, when a pronounced alopecia followed, and a similar
result is recorded by Professor Daniel in a man after one
sitting; but the most interesting case of all was Professor
Thomson's, of Harvard, who, being skeptical as to the deleterious results of the rays, made the only experiment which
has so far been recorded, by exposing his finger to the x rays
for half an hour and at one and a quarter inches from the
tube, with a definite purpose of producing lesions if possible.
The cutaneous trouble followed in nine days after the exposure. In two cases the patients had two sittings ; in Dr.
Dunn's case the first exposure was one hour, and the second,
seven days later, lasted one hour and a half ; and in Dr.
White's case the patient had two exposures of thirty and
forty-five minutes each on successive days.  


In Drs. Stern's and Richardson's cases the lesions appeared
after three sittings, and Dr. Skinner experienced cutaneous
lesions after three or four exposures of short duration. In
eleven cases the results had only followed after prolonged and
constant use, the duration varying.


I append a table of the cases which I have been able to find
in the literature.


JOHNS HOPKINS HOSPITAL BULLETIN.




18


65




JOHNS HOPKINS HOSPITAL BULLETIN.


piiuctured. Eight ovary normal. Eight tube adherent and
closed.


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.  
[No. 71.  
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
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.
Distribution.  
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.
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
Character of the Lesions.  
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.


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
Subjective
perfect a recovery as the most uncomplicated cases of abdominal section. The abdominal dressings were removed on the
Symptoms.  
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.


In this case the operation was very difficult and attended by
many complications. The peritoneum was injured extensively, pus escaped during the operation, the intestine was
injured and required suture, free oozing occurred during the
operation and persisted at its completion, and large denuded
areas were left in the pelvis.


Gynecological No. 4892. A. E. T., widow, aged 34 years.  
O. Leppin (person
al experience). .  


Complaint. Pain in the right inguinal region, pain in the
rectum, and swelling of the abdomen at times.




Used very frequently for
many days.


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.
Left hand and


Present Complai?it. Three years ago she was confined to
bed for three weeks with fever and chills and severe pain in
the lower abdomen, which began in the right side and then
shifted to the left. During the attack she had a constant
discharge of thick tarry blood from the uterus. After the
attack she was able to get up, but it soon recurred, and the
abdomen became greatly distended and excessively painful.
Ten days ago another attack began, which has not been so
severe up to this time as the former ones. She complains of
pain during defecation and micturition, backache and bearingdown pains. Temperature on admission 101° F., pulse 120.


Diagnosis. Pyosalpinx duplex ; retroflexio uteri adherens;
pelvi-peritonitis.


Operation. Enucleation of both ovaries and tubes.  
Peculiar redness, swollen, vesicles
on middle and ring fingers.  


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
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
Dr. Marcuee.  
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
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
Young man, 17, exposed
the iliac vessels, with which it was closely adherent, around
5-10 minutes once or
in front of the bladder. The sac contained 60 cc. of thick
twice a day for four
white pus, which partly escaped during the operation.  
weeks.  


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
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.


Dr. Feilchenfeld
Dr. Conrad.




66


Left half of Brownish redness on face, fol
face.backand lowed by desquamation ; later,
chest. patch of alopecia above right


ear ; on back, large raw patch,
exposing the corium with hemorrhagic points and exudation
and a number of bullae ; on
chest slighter changes,
exhibited a somewhat similar case (no details given) to the


JOHNS HOPKINS HOSPITAL BULLETIN.




No mention. After five weeks hand still


[No. 7.3.  
looks "older" than the
other.  


No pain in face ;lThree months later, hair




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
back much
140. Bed elevated. Four thirty P. M., pulse 120, of good
tenderness, but
volume; six o'clock, pulse 104; seven o'clock, 100; nine
no pain was felt
o'clock, 96; twelve o'clock midnight, 88. Patient recovered
until just previous to the eruption.  
quickly from ether without symptoms of shock.  


Second Day. Six o'clock A. M., temperature 100° F., pulse 9G.
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.




returning on the bald
spot. Chest and back
healed, but numerous fine
cicatricial lines on the
back and brown pigmentation.


Tliird Day. Six o'clock A. M., pulse 84, temperature
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.  
Dr. Paul Fuchs
Bowels effectually moved, well formed stool. Patient passed
(personal expe
a very comfortable day. From this time on the patient made
rience).  
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.  






Dr. Sehrwald.


V)a.y a?


Operation


S. J. R. (personal
experience).




Case II.
Plain line indicates temperaiure. Broken line indicates pulse.


Dr. H. C. Dunn.




Case III.  
 
In this case there were dense adhesions binding a large
Dr. G. C. Skinner
suppurating ovarian cyst to the intestines and the abdominal
(personal expe
wall. A suppurating fistulous track extended between the
rience).  
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






a hirge cavity in the pelvis. Pieces of the cyst wall and much
J. Macintyre (personal experience).  
debris remained behind at the completion of the operation.  


There was considerable oozing and extensive traumatism
produced by the separation of tlie wide-spread adhesions.


Pus from the cyst injected into a mouse killed it within
twenty-four hours.


Notwithstanding all these complications the patient made
Dr. Freund.  
a good recovery.  






April, 1897.]
Aphotographerbad used
the X rays very fre
quently and for some
time.  






JOHNS HOPKINS HOSPITAL BULLETIN.  
After prolonged use of
the X rays.  






67
In a boy 13 years old.
Only one exposure of
45 minutes duration
Two weeks later erup
tion appeared.






Gynecological No. 4928J. A. E. S., admitted January 9,
Used the rays several
1897. Single, age 35 years.  
hours daily and eruption appeared three
weeks after.  


Complaint. Increasing size of abdomen, severe constipation, feeling of obstruction in abdomen. Menstruation began
at 15 years, recurring every 28 days, 4 to 5 days duration,
normal.


Family History. Negative.


Present Illness. Patient was always strong and well until
Man aged 35 years. Ex
four years ago; at this time she suffered with indigestion, and
posed first for one
was treated by her physician for displacement of the uterus.
hour and afterwards
She had an attack of peritonitis in September, 1895, which
for an hour and a half,  
confined her bo bed four weeks. In October, 1896, she suffered
the second with inter
val of seven days. Two
days later eruption appeared.  






9 10 II 12 13 14 15 16 17
Exposed the wrist 10-15  
minutes for 3 or4day8
in succession. Ten
days later eruption followed.


Worked for months with
the X rays before cutaneous lesions were
produced.


10 days, child who had
hypertrichosis.


with " chills and fever," which lasted eight weeks. During
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
operation for hemorrhoids performed in 1892.


Present Condition. Body emaciated, complexion pale, expression anxious. Appetite good. Micturition normal.  
1st and 2d fin
gers, left
hand.  


Examination of heart and lungs negative. Temperature on
admission 100.5° F., pulse 120.


Diagnosis. Suppurating ovarian cyst.


Left hand and
fingers.






Case III.  
Abdomen.  


Plain line indicates temperature. Broken line indicates pulse.




Right hand and
fingers. Later
left band.


Operation by Dr. Kelly, January 16, 1897. Cystectomy.


Complications. Dense adhesions between cyst and intestine, fistulous opening between intestine and cyst. Pyogenic
urea over bladder and anterior abdominal wall.


Puncture and evacuation through the abdominal incision
Abdomen.  
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




Wrist.


a fistulous track between the two 5 cm. in diametei-. Appendix thickened and twice its normal size, adherent to a black
ragged area 2x2 cm. It was not removed, as it showed no
disease and the patient's condition was very critical.


On right side the tumor was adherent to the anterior abdominal wall over an irregular area 6x3 cm., running down to
cornu uteri. This area was scraped free of pus and lymph
and covered with peritoneum from side to side.


Eagged area on colon covered in by base of appendix, which
Neck, back, upper arm and
was sutured over it with interrupted catgut ligatures. Silk
scalp.  
sutures were used to close the opening in the colon. Abdominal
cavity thoroughly irrigated. Salt solution infusion (500 cc.)






68
Swelling and stiffness of the
joints; Istand 2d fingers swollen
and of a livid brown color on
the dorsal surface from the tips
to the carpometacarpal joints
Sense of touch greatly diminished. Mustache falling out
and color was changed.


Much swollen; skin was wrinkled
cracked and stained quite
brown ; condition of skin like a
frozen hand ; later, on further
exposure, a vesicular eruption
appeared.


At first hypersemia, then avesicu
lar eruption. Four weeks later
central portion healed, but
peripheral portion covered
whole abdomen. Brown color.
Exfoliation soon followed.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Numerous dark little blisters appeared on right fingers ; then
marked redness and inflammation of the skin, which later
became hard, very dry and
yellow like parchment. Exfoliation followed. On further
exposure tips of fingers became
much swollen and nails affected. A colorless, bad smelling
discharge came from beneath
the nails, which were gradually
thrown off. Left hand was
substituted and similar symp
toms followed.  


Three hours after first exposure
some nausea. After second
exposure, nausea, and on second
day abdomen slightly red, like
sunburn; redness increased in
intensity until fourth day, vesicles appeared, which developed
into bullae. Eighteen days
later the patch was T/zx8}i
inches between umbilicus and
chest, and was smooth, glazed
and weeping for some days,
notwithstanding treatment.


Reddening of the skin appeared
first; this increased until it was
almost purple ; considerable
swelling followed. Desquamation followed.


[No. 73.  
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.




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
Berlin Medical Society.  
was 136, having dropped 14 beats in twenty minutes. Foot
of bed elevated. Five o'clock in the evening pulse 128. Nine
o'clock, 120. Twelve o'clock, 108. Patient comfortable and
complaining of little pain.  


Second Day. Pulse 108, temperatui'e 99.4° F. Patient
Fingers extremely No mention,  
complained of pain during the night, but slept three hours.
sensitive and
Twelve o'clock noon, pulse 104, temperature 99.4° F. Six
pain was of a
o'clock, pulse 104, temperature 100.4° F. Comfortable day.
burning and
Foot of bed lowered.  
scalding character.  


Third Day. Passed an uncomfortable night. Pulse 104,
temperature 90.4° F.


Afternoon, patient comfortable, pulse 100, temperature
99.8° F. Small liquid movement.


None given.




Fourth Day. Pulse 96, temperature 99° F. Considerable
pain in abdomen.


Fifth Day. Temperature 98°, pulse 90. Patient had a
Itching when the
comfortable night.  
vesicles appeared.  


Sixth Day. Pulse 80, temperature 98° F.


Tenth Day. Convalescence has been uninterrupted. Dressiugs removed from abdomen, union of incision ^ler primam.


Patient sat up on her 20th day.  
After inflamma
tion hand smarted very much
Skin became insensible to the
touch. After
second exposure
serious discom
fort and pain
followed.  


Bacteriological Examination. Cover-glass preparations
showed many cocci and bacilli. Two cc. of pus injected into
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.




No subjective
symptoms ;
neither itching
nor pain ; the
rawsurface painless and almost
insensitive.


KEPORT OF FIVE CASES OF INFECTION BY THE BACILLUS AEROGENES CAPSULATUS (WELCH).


By Edward K. Dunham, M. D., Professor of Bacteriology, Bellevue Hospital Medical College, Neiu York.


Great pain and ex
cessive tenderness.




Within the past year the writer has had occasion to study
five cases of infection in which he believes the bacillus aerogenes capsulatus, described by Welch and Nuttal, and Welch
and Flexner, either caused or hastened death.


In all but one of these cases the bacillus was found in  
Cured in 9 or 10 weeks.  
material taken from the tissues of the patient during life.  


The first case died on the 11th of March, 1896.


The patient was a woman, aged 23 years, who was admitted
to St. Vincent's Hospital, New York, on the 7th of that
month, and then gave the following history :


Three days before her admission to the hospital she had
Results similar to those of
noticed a swelling beneath the lower jaw ou the left side of
sunburn but much more
the neck. This swelling was the seat of throbbing pain.  
acute.  
 
 
 
None given.  


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,
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
Eruption healed after 28
of listerine prescribed. She also received morphine subcutaneously, and phenacetine and quinine by mouth.  
days, but skin was like
boiled fish skin. After
cauterization of surface a
slough separated and a  
tough yellow opaque
membrane formed.  


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


Process of repair was very
slow.




excruciating; swallowing was practically impossible; the voice
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,
Authorthinksconditiondue
cedenia of the glottis set in and at one time completely
to heat and electricity ;
arrested respiration, but by means of an O'Dwyer tube and
the latter the chief cause
artificial respiration for a few minutes the patient was
of injury to the tissues.  
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
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
February, 1897.]
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 incubator. Upon these two sorts of colonies developed, one
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
JOHNS HOPKINS HOSPITAL BULLETIN.  
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




19


April, 1897.]




Dr. E. E. King.


JOHNS HOPKINS HOSPITAL BULLETIN.




Dr. M. J. Stern.


69




Dr. F. Kolle.


of these bouillon cultures and died during the following night.
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
Dr. J. C. White.  
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,
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,
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
Prof. E. Thomson
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
production of gas.


In all the media the bacillus proved to be a strict anaerobe.


The bacillus grew well in bouillon to which 1 per cent of
Dr. H.R.Crocker
glucose had been added, and these cultures evolved a considerable amount of gas when incubated in an atmosphere
deprived of oxygen by means of potassium pyrogallate.  


In order to determine the nature of this gas, six fermentation tubes containing glucose bouillon (1 per cent of glucose)
were inoculated with the bacillus, and, after 24 hours, the
gas collected in a eudiometer over mercury. 28.6 cc. of gas
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
gas was determined :


Hydrogen 64.3 per cent.  
Prof. John Daniel


CO2 27.6


Nitrogen (?) 8.1*


100.00 per cent.  
Dr. M. H. Rich
ardson.  






On the 22d of March, i. e. eleven days after the pus was
Dr. W. E. Parker.  
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
hospital, another guinea-pig was inoculated, by means of a
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
killed after the lapse of a few minutes, the bacillus caused
enormous swelling of the body of the animal within 20 hours,
and the liver, kidney and spleen, as well as the subcutaneous
tissue, were the seat of a very marked emphysema. The skin
was rendered so tense by the accumulation of gas that it
seemed on the point of rupturing.


The foregoing characters of the bacillus under study
University of  
appear to identify it with the bacillus aerogeues capsulatus of
Minnesota.  
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
Dr. Banister, U
of these spores, and it was found that when taken from the
S. Army.  
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


Dr. T.C.Gilchrist.




*The composition of the residual gas in the eudiometer was not
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
Patient used the x rays
states that the bacillus aerogenes capsulatus in his possession produced spores when cultivated on LoefHer's blood serum. This
for two and a half
observation tends to still further establish the identity of the
months from two to  
bacillus isolated by the writer.  
six hours daily before
cutaneous lesion ap
peared.  


i The author has observed that the spores of bacillus subtilis are
much more easily killed by moist heat when freshly formed than
after a lapse of time and drying.




Patient was exposed at
three sittings of 40-50
minutes duration.
Eruption appeared two
days afterward.


70
A boy 12yearsold. Whole
body exposed 40 minutes. Sixteen days
later alopecia
appeared.


Young lady exposed to
the rays 30 minutes on
one day and 45minutes
on the next day. Eruption appeared the following day.


Exposed half an hour at
a distance of one and
one-half inches from
the tube. Eruption
appeared nine days
after.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Boy aged 16. One exposure of one hour.
Eruption appeared
next day.  






[No. 7.3.  
Distribution.  






when placed iu broth at the body temperature under anaerobic
Hand, left.  
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
water, and are not decolorized by a moderate exposure to the
action of a 3 percent, solution of hydrochloric acid in absolute
alcohol.


They have an oval shape and are usually situated near the
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
Man ; exposure 1 hour
stain but faintly with methylene blue, and appear more attenuated than the individuals in fresh cultures on other media.  
Alopecia 21 days
later.  


A partial antojDsy of this first case of infection was made on
Woman. Exposed three
the day following the death of the patient by my assistant, Dr.
times to the rays, 20,  
Harlow Brooks, from whose notes I take the following data:
30 and 3.5 minutes.  
General nutrition excellent. Rigor mortis present. There
Eruption appeared two
was extensive post-mortem discoloration about the neck on
days later.  
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
Man. Exposed five
patient were opened and a focus of suppuration was found,  
times, from 20 minutes
which apparently arose from the left tonsil. The walls of
to 80 minutes.  
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
Man whose ear was exmined for several
appear emphysematous. Microscopical examination of bits
hours.  
of those organs failed to reveal the bacillus.  


Sections from the organs of the rabbit into the veins of
Man. Numerous expo
which the bacillus was injected, when stained by Gram's
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
sures.  
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
130 and very feeble.


On the 20th he was delirious throughout the day.  
ray operator. Eruption began after frequent and continued
On the 21st the dressings were removed and the arm and  
exposures.  
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.  






Free incisions were made and the subcutaneous tissues found
Extended from
in a necrotic condition. The wounds were washed with mercuric chloride and drained.  
thesideof the  
face down to
the umbilicus.  


On September 22d the patient was still delirious, very
Right side of  
weak, with a fluttering pulse. The dressings were again
head.  
removed and fresh incisions made in the arm. The cedema
had extended well into the pectoral region and down to
the elbow, and at this time, I believe, some emphysema of  
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,
Sternal region
the other half with access of air.


After 48 hours the aerobic cultures showed only colonies of
cocci, while the anaerobic cultures contained colonies in which
both cocci and bacilli had developed. The latter tubes gave
evidence of gas production, the agar being raised from the
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
ear-vein of a rabbit and five minutes later the animal killed.
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
Little finger of
much gas, aud the liver, kidneys, spleen, aud the mucous
left hand.  
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
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.  
Epigastrium.  
(See " II," temperature chart.)


The third case of infection was a man, a't. 33, of alcoholic
habits, who had suffered from urethritis on two occasions the last time three years before he presented liimself for final
treatment at Belle vue Hospital.


When he was admitted to the hospital, on November 6,
1896, he had difficulty in voiding his urine, owing to a stricture of the urethra which could not be passed by instruments.


On December 5th, at 3.30 p. m., external urethrotomy \yas
One side of
performed, and the patient did well until 2.30 p. m. on December 8th, when a sound was passed.  
scalp.  


Twenty-one hours after this procedure a chill ensued, which
Abdominal re
was followed by severe pains in the joints and back, and from
gion, particu
that time the patient rapidly grew worse and died on the 10th
larly over
of December at 8 p. m.  
liver area.  


At 9 p. m. on the day preceding death, an area of subcutaneous emphysema appeared over the front of the right thigh,
and others over both shoulders. These areas increased rapidly
in size up to the time of death and afterwards.


The following notes on the bacteriological examinations of
material from this case and of the autopsy are kindly furnished me by my assistant, Dr. F. M. Jeffries, who conducted
them. At 1 p. m. on December 10th, i. e. -1 hours before the
death of the patient, three agar tubes were inoculated from
the subcutaneous tissue in the emphysematous area on the
thigh. These, although placed under anaerobic conditions,
failed to develop, probably because of excessive acidity of the
agar.


At the autopsy made 18 hours after death, cultures on agar
Jaw and neck.  
and in bouillon were made from the heart, lungs, liver, brain,
and the emphysematous area on the thigh. These cultures
were incubated under anaerobic conditions in Novy jars
with pyrogallate of potassium.  


After 24 hours the cultures from all these sources had
developed, with evolution of gas. They all consisted of bacilli
resembling the bacillus aerogenes capsulatus. They wei'e
not motile and stained well by Gram's method. All the cultures contained only this one bacillus, without admixture of
other bacteria.


Intravenous injection of a bouillon culture in a rabbit which
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
Ear and surrounding
serum.  
scalp.  


The autopsy on this case was pei'formed on December 11th,  
Abdomen,  
1896, at 2 p. m.  
chest and
beard.  


The general nutrition was good.


Subcutaneous emphysema was noted, extending over the
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
Right hand,
abdomen was soft, pulpy and emphysematous. There were
wrist, and  
emphysematous areas on the pleurte and pericardium. There
lower portion
was general emphysema of the lungs. The cavities of the
of forearm
heart were distended, their walls soft and oedematous, and the
dorsal sursurface.  
blood they contained dark and fluid.  


The liver was of a dark cliocolate color, soft and the seat
of emphysema.




Character of Lesions.


The spleen was dark plum-colored, extremely friable and
emphysematous.


The kidneys were enlarged, showed subcapsular emphysema,
and were plum-colored.


The mucous membrane of the bladder was extremely
Hand felt stiff, then became
emphysematous.  
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.  


The brain showed submeningeal emphysema, its substance
Erythematous blush first appeared, which a few days later ap
was soft, the ventricles normal.  
peared like a severe burn, followed by a large slough.  


Microscopical examination of smears from the organs revealed
Large area of alopecia over the  
the presence of large encapsulated bacilli resembling those
region exposed to the rays
found in the cultures. (See " III," temperature chart.)
Hair fell out all at once the  
night previous. Skin slightly
cedematous.  


The fourth case was a man, 23 years of age, who was admitted to the J. Hood Wright Memorial Hospital on the 6th of
Skin was first reddened, then
.January, 1897.  
blistered. Three months later
the patch showed angry-looking
granulations which had refused
to heal.  


Four years ago he had gonorrhrea, which persisted for eight
Finger became hypersensitive,  
months, and three years ago he had another attack of the  
then dark red, swollen, stiff,
same trouble which lasted three months. Neither of these
and soon after vesiculation occurred. Pus formed and the epidermis became detached, but
attacks was accompanied by symptoms pointing to inflammation of the bladder or testes.
pustules remained over 3 weeks


Two years ago, i. e. about one year after the beginning of
A Crookes tube placed five inches
the second attack of gonorrhcEa, he felt pain on urination and
distant — flanelette shirt inter
noticed that the stream of urine was diminished in size.  
vened. Next day, skin deep
Shortly after this he had retention of urine, and was catheterized with some difficulty, and the urethral stricture then
red in color. Nine days later
gradually dilated with sounds, the treatment lasting for two
vesicles appeared. Palm-sized
months. Since that time he had omitted all treatment.  
patch, well-defined, purplish
red. Vesicles increased in number ; 9 days later the epidermis
had separated. Healing very
slow. Alopecia very slight.  


At the time of his admission to the hospital the patient
Tube was 1^'4 inches distant from
complained of pain on micturition, but there was no discharge
head. Bald spot was 2 inches
from the urethra or increased frequency of urination. The
in diameter ; skin healthy.  
urine was acid ; sp. gr. 1029; no albumen or sugar.  


A urethral examination gave the following results :
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.


No. 23 (French) bougie a boulu passed the meatus, but was
After two exposures face and
stopped just bej'ond the urethral orifice.  
neck became swollen and red.  
The later sittings were also followed by eruption.  


No. 30 entered the urethra for a distance of 24 inches.  
The parts presented later a frozen
appearance. All the hair from
this side of scalp was lost.
 
At first a patch, red, inflamed,
hypersesthetic, about half the
size of a man's hand. The
lesion increased in size until a
denuded surface .SxlS inches  
was formed. Exudation profuse and uncontrollable. Beard
turned white in places and
growth stopped.
 
Hypersemia and swelling of back
of hand ; afterwards inflammation of fingers and hand. Skin
became dark brown in color
and gradually exfoliated.  


No. 25 slipped past a constriction at 23 inches, but was
arrested at about 6i inches.


No. 30 and No. 15 sounds met with an obstruction at the
same point.


No. 4 and No. 2 bougies also failed to pass that point, as did
Subjective
also a filiform bougie. Even a bunch of filiform bougies
Symptoms.  
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
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.
Great pain follow
A slight oozing of blood from a wound in the bulb of the
ed the appear
urethra was noticed. This had ceased at 9 p. m., and the  
ance of the blis
patient then felt comfortable.  
ters.  


Second eruption
followed by
aching.


Face became tender and painful.


72




No symptoms.


JOHNS HOPKINS HOSPITAL BULLETIN.




Granulation sur
face very sen si
five and the seat
of severe neural
gic pain.


[No. 73.  
Pain.  






At 10.30 the bladder was agaia irrigated.  
Stiffnessfeltatfirsl
and soreness
when the vesicles appeared.  


On January 10th the patient felt well and the bladder was
draining nicely.


At 1.30 the urethra and bladder were irrigated with a warm
saturated solution of boric acid. The anterior urethra contained some dark fluid blood which was washed away, and the
perineal wound then dressed.


On the 11th and 12th of January the patient was doing
None.  
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
patient had a severe chill, lasting half an hour.


At 3.30 a. m., January 14th, a slight bleeding took place
Pain accompanied
from the urethra.  
the first appearance of the
lesion.  


At 8 a. m. pain in the left shoulder was complained of.


At 11 a. m. a catheter was introduced throiigh the perineal wound and about 3 ounces of bloody fluid having a foul
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
No pain or sensation at the time.  
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
Raw surface, very
become somewhat larger and more swollen, firmer to the touch,
painful and hyperjesthetic.  
and a little darkened in color. The patient, who was conscious, had an anxious expression and presented an extremely
Pain agonizing
septic appearance.  
even six weeks
after.  


At 7 a. m. the body was jaundiced, except over the emphysematous areas. Of these, that on the buttock looked much
darker than before and was irregularly mottled with purple
spots.


At 8.15 a. m. an incision, two inches in length, was made
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
No pain at first, but  
afterwards severe aching and
shooting pains,
which lasted
about 2 weeks.*






a. m., forty-five hours after the sounds were passed on the
The case has been carefully
13th of January.  
and continuously
watched.  


Dr. Brooks performed the autopsy on this case, and the following account is taken from his notes :


The autopsy was made 5 hours after death, while the body
was still warm.


Rigor mortis was marked; the general nutrition good.  
Examination of the chest
after a gun-shot wound.  


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
of a gas which burned with a blue flame.


The abdominal wall was greatly distended, and when an
Later, lanugo hairs began
incision was made the inflated intestines protruded.  
to appear.  


The liver was of a light clay color and crepitated under the
fingers. Its tissues were very friable, and filled with minute
vesicles containing gas. The cut surface appeared oedematous.


The spleen was enlarged, of a dark purple color, and very
friable.


The kidneys were enlarged; their capsules adherent.  
At the timeof writingthere
were still two open spots.  


The lungs were somewhat (Edematous.


The cavities of the heart were distended on both sides by
fluid blood which contained bubbles of gas.


The autopsy was necessarily both hurried and incomplete,  
Four months later, even
as the relatives of the patient refused to have any of the organs
after curetting, granulating surface 4 inches in
removed from the body.  
diameter still remained.  


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
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
16 days afterwards skin discolored and exfoliated.  
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
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
Patient confined to bed for
the emphysematous area on the buttock at 4 p. m. on the day
one month, and will
of the death of the patient was used to inoculate agar tubes,
probably be in bed another month.  
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


•February 5, 1897, patient writes, " My hand is much about the same. I cannot use those (first) three lingers much better : and my nails are coming off, that
Is, the old nail is like a shingle on top of the new one."




April, 1897.]






JOHNS HOPKINS HOSPITAL BULLETIN.  
As far as the cutaneous lesions were concerned, the skin of
the trunk appeared to suffer the most severely, although when
the hand was attacked the pain was the most prominent
feature.  


As to the character of the lesions produced, the majority of
observers describe a peculiar redness or erythema at first, then
swelling of the derma, followed by a deep discoloration of
the skin until it became quite a dark brown color. Exfoliation of the pigmented skin followed later. In a number of
cases vesiculation occurred after the hyperajmia, and quite a
serious eruption resulted in two cases after only two exposures.
The most severe effects followed after exposing the same
region again to the rays when the lesion had only partially or
wholly healed.


The cases of Dr. Dunn, Dr. Banister and S. J. K. showed
perhaps the most severe results. Other lesions produced were
alopecia, loss of the finger-nails, and obstinate ulceration.
In connection with the subjective symptoms, severe pain and
aching were present in the majority of the crises, especially
with the eruptions on the hands. The lesions on the abdomen
and back were, rather curiously enough, unaccompanied by
pain.


73
Many theories have been advanced to explain the injurious
lesions produced by the x rays. tSome have supposed them to
be entirely due to frequent and loug exposures ; but that is not
tenable, because in five cases (Dr. Sehrwald's, Dr. Kolle's, Dr.
Crocker's, Professor Daniel's and Professor Thomson's) marked
results followed a single exposure, and in two cases two sittings
only preceded the eruptive phenomena, and finally three other
cases experienced deleterioiis results after only three exposures.
Others again have compared all the phenomena to severe sunburn, but it can be demonstrated that more severe results
have followed the use of the rays than have ever been known
from exposure to the sun. Tesla believes that the hurtful
action of the x rays is not due to the rays but to the ozone
generated in contact with the skin. Ozone, he says, when
abundantly produced, attacks the cutaneous surface, its action
being no doubt heightened by the heat and moisture of the
skin. In his discussion of the rays themselves he speaks of
the disintegration of the electrodes, especially if they are of
alumiuum, but this is so slow that no appreciable diminution
of the weight results, even after long use; it follows, he says,
that the matter conveyed by the Eontgen stream is so minute
as to escape detection. Some bulbs which he has used for a
number of months showed that the bombarded spot of the
glass was entirely permeated with particles of the aluminum
electrode, but it would probably require years of constant use
to accumulate any appreciable amount of matter outside. He
further remarks " that no experimenter need be deterred
from carrying on an investigation of the rays for fear of poisonous or generally deleterious action, for it seems reasonable
to conclude that it would take centuries to accumulate enough
of such matter to interfere seriously with the process of life
of a person." His last remark is certainly incorrect. His
ozone theory is also incorrect, as I shall show later.


Professor Thomson, with the definite idea of producing
cutaneous lesions, exposed his finger to a bulb of low potential
and used a small 34-plate static machine. " The rays came from




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
a bombarded spot, and were limited to the area which the  
cotton swab was introduced into the urethra, and the moisture
Kontgen rays could reach. The tube was of blue glass, with
thus obtained used for the preparation of cultures.  
a clear German glass window from 1* to It inches in diameter
opposite the bombarded spot." One striking feature was the  
fact that the fingers opposite the blue glass were not affected, as
this was so dense as to absorb the rays. Only where the little
finger was opposite the clear glass was it affected with a sharp
line of demarcation. He says the blue glass would have been
transparent to the ultra-violet rays. He also thinks that
brush discharges have nothing to do with the cutaneous phenomena. His theory is that the deleterious effects are due to
the X rays themselves or something that goes with them.  


Two bacilli developed in these cultures, and as they were
The case which I will now report presents a suflBcient number of interesting points to make it worthy of record.  
both at least facultative anaerobes, efforts to separate that
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  
The patient is a healthy-looking man, Z'l years of age, who
manner and at about the same time as the first rabbit. The  
came to me November 18, 1896, with the following history:
next day there were no signs of emphysema in its body.  
During the first week in September he exposed his right
(See " IV," temperature chart)
hand, wrist and lower portion of the forearm to the x rays
while exhibiting an apparatus, each exposure lasting two or
three minutes. No bad results followed, but on October 1st
he came to Baltimore and resumed the use of the x rays for
the same jjurposes. After he had exposed his hand for three
weeks for four hours daily he noticed that the skin of the
back of the hand, wrist and forearm began to turn very red
and became " puffed up," although he suffered no pain. The
swelling first occurred on the back of the hand from the
knuckles to the wrist, then "inflammation set in " and he was
compelled to stop his demonstrations. From about October
31st the hand, wrist and lower fourth of the forearm gradually became more inflamed and swollen, and the lesions spread
to the fingers. The affected area ached and throbbed so much
that he frequently could not sleep at night; there were also
shooting pains which gradually increased in intensity and
extended up the forearm along the ulnar side. These symptoms continued for a week when the patient consulted Professor Chambers, of Baltimore, who advised him to bathe the
hand frequently in hot water and ordered bromides internally
with benefit. The symptoms were much relieved and the
swelling had gone down considerably in two weeks time.  
Three weeks after he had first sought medical advice he consulted me about the diseased condition of the skin.


The fifth case occurred in the private practice of a New
Ooii'lition at the time of the first exumination. The right
York physician, who has kindly furnished the writer with
hand on its dorsal surface presented a deeply pigmented
the following facts concerning the history of the case.  
condition. The skin over the dorsal surface of the fingers,
hand and wrist was of a very dark brown color, and part
of it was already exfoliating. The skin was dry, infiltrated
and wrinkled. The patient says the skin was more of a
greenish hue at the end of the first week after it became
affected. In places near the lateral margins of the hand a
slightly vesicular appearance was presented. They were not
true vesicles, but were due to the loosening of the surface of  
the epidermis, and contained only air. The pigmented skin
could very easily be peeled off from the hand without any
pain, leaving a dull, dry, reddish surface beneath.  


The patient was a man, 73 years of age. His general condition was good, there being no organic trouble except some
On comparing the two hands they were found to be practically of the same temperature. The fingers of both were of  
hypertrophy of the prostate.
about the same calibre. A photograph, which is represented
here (Fig. 1), was taken of the hand the first time I sawj him,


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
Febrdaet, 1897.]
patient passed a hard rubber catheter and drew some blood.  


On the 21st, pain in the right ischio-rectal fossa was noticed,
and the tissues at the site of the pain were found to be firmer
than normal.


On the 22nd the pain in the right buttock was more severe.
The 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
JOHNS HOPKINS HOSPITAL BULLETIN.  
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
21






found the scrotum emphysematous, with spots of gangrene
and it shows very well the exfoliatiou of the epidermis. It
upou it. Temperature 103°.  
also represents the position of the hand which was most restful
and least painful to the patient. The palmar surface was dry
and paler than that of the normal hand, but the palmar surface of the fingers appeared swollen.  


Later in the day the perineum was tense and distended, red
I saw the patient ten days later, and the exfoliating epidermis had all been removed; the skin now presented a glossy
and tympanitic. The scrotum was the size of a child's head (8
appearance, and over the lingers it appeared to be tighter than
to 10 inches in diameter), dark in color, in places almost black,
on the corresponding fingers of the healthy hand. The palmar
and cold to the touch. The skin of the penis was ballooned
surface was still a little drier.  
with gas and dark.  


Very extensive incisions were made to the right of the  
On careful examination the patient comjjlained of rather
raphe, from the penis to the tuberosity of the ischium. No
severe pain when the first phalanx of his right index finger
pus was found, except at one point near the anus, where there
was grasped, and it was then noticed that this bone was distinctly thickened, especially as compared with the corresponding phalanx of the other hand. The first and second phalanges
was a cavity containing a dirty grayish-yellow pus of offensive
of all the fingers were found to be thickened, but the increase
odor.  
in size was most marked in the first phalanges of the index
and second fingers. Further careful examination of the other
bones of the hand revealed a very painful spot over the wrist
joint. The metacarpals were also tender on pressure, and the
head of the second metacarpal was enlarged. The hairs were
found to be less numerous on the affected hand, but they may
have been removed in tearing off the exfoliating epidermis.  


The areolar tissue of the scrotum and penis were of an inky
Mbvemeids of the hands. All movements were found to be
blackness and emphysematous, but contained no pus. A slight  
quite difficult of accomplishment and very painful. When
ojdematous condition prevailed in the deeper structures.  
the patient first consulted me, voluntary movements of both
fingers and hand were abolished, except of the little finger,
which could be slightly flexed. Wrist movements were also
very limited in extent and caused much pain. The thumb
and fingers could scarcely be apposed. The patient could not
pick up a lead pencil or penholder, and could grasj) with but  
slight force; if he could get his finger or thumb beneath an
oVject he could pick it up. He complained of the joints being
very stiff.  


The tissues were irrigated with mercuric chloride and an
Sensation was very much impaired before exfoliation occurred,
iodoform dressing applied.  
and even after that it was much diminished as compared with
the normal hand. The sense of touch on the palmar surface
was also markedly decreased.  


On the following day, January 26th, the emphysema had
When the distinct thickening of the phalanges was detected
extended over the pubes and the hypogastric region, the skin
I requested him to obtain careful x ray photographs of both
being raised about half an inch. The color of the skin over
hands under similar conditions at the same distance from the  
this area was either normal or had a pinkish blush.  
bulb. The accom23anying photographs show the bones of the  
two hands clearly, and I am particularly indebted to Professor
W. C. A. Hammel, of Baltimore, for such excellent pictures.  


Two free incision* were made to evacuate the gas, and it
The hands were placed exactly twelve and a half inches
was discovered that the subcutaneous areolar tissues were
from the x ray tube, the distance being carefully measured
blackened. No pus was present.  
from a plane passing through the long diameter of the tube
to the fixed support on which the hand rested. The time of
exposure was exactly three minutes for each hand.  


A portion of this black slough was removed with sterile
It will at once be noticed from the photographs how much
instruments and put in a sterilized bottle for examination.  
thicker all the first phalanges of the right hand (Fig. 3) are
than those of the left normal hand (Fig. 2). The increase in
size is particularly marked in the first phalanges of the index
and second finger; that of the little finger is less marked
The second row of phalanges is also thicker than normal, but
less thick than those of the first row. The heads of the
second and third metacarpal bones are enlarged, and their
shafts are also slightly thickened. It cannot be said, from the


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
sloughing had extended so as to include the skin, but without
the formation of pus.


The patient lapsed into a low typhoid condition, then into
photographs alone, that any of the carpal bones of the affected
coma, and died on the 31st of January.  
hand were at all increased in size.  


Cover -glass preparations of the material removed from this
A number of other points were discovered from these photographs. The spaces between the bones at the joints, particularly at the metacarpo-phalangeal and the interphalangeal
patient on January 26th were examined on that day at the Carnegie Laboratory, and showed the presence of three species of  
joints, were much less marked and narrower than in those of
bacteria : 1, a large bacillus, resembling the bacillus aerogenes
the normal hand. The outline of the affected bone« was also
capsulatus ; 2, a more slender bacillus; 3, streptococci.  
more irregular and rougher than that of the left hand. On
looking at the hand as a whole, it is also, I think, noticed
that all the bones are denser in appearance in the affected
hand.*


The slender bacillus was identified as the bacillus coli communis, and when obtained in pure culture, produced no
Two portions of skin were excised for histological purposes
emj)hysema in the body of a rabbit killed shortly after the
on the first day. One portion was taken from dorsal surface
injection of the culture into a vein of the ear.  
of the phalangeal region of the third finger, and the other
from the lateral margin of the hand over tlie base of the
metacarpal of the little finger. Neither stained nor unstained
sections demonstrated the presence of any foreign particles,  
and only showed chronic inflammatory changes. The horny
layer was thickened and half of it was partially detached. A
large number of brown pigment granules were found in the
exfoliating portion. The mucous layer was not thickened,  
but it was more pigmented than normal. In the corium the
vessels were dilated, and the pigment cells of thepapillas were
almost as numerous as are usually found in a section of negro
skin. It was suggested that particles of platinum might have
passed from the tube through the glass bulb deep into the  
tissues.  


Experience with the mixed cultures, obtained from the  
Portions of the exfoliating skin were accordingly submitted
cotton swab used to collect material from the urethra in the  
to Professor Abel for chemical analysis, and he has very kindly
fourth case, had shown the difliculty of separating the  
furnished me with the following brief report: "I could find
bacillus aerogenes capsulatus from the bacillus coli communis.  
no platinum in the pieces of epidermis that you left with me
Without waiting, therefore, to obtain pure cultures of the
for analysis. These pieces weighed, just as you sent them,
large bacillus found in this ca^e, a mixed bouillon culture of  
6-iO milligrams, or about ten grains."
the two bacilli was injected, intravenously, into a rabbit,  
 
which was shortly afterwards killed. The usual post-mortem
Summary. In reviewing this case, there is here an example
emphysema was produced within a few houri?, and from the  
of a disease of the skin which was brought about by frequent
subcutaneous fluids pure cultures of the bacillus aerogenes
and prolonged exposure to the x rays. The lesions, as I have
capsulatus were finally obtained. These, unfortunately, died
already described, were first those of byperajmia, then cedema,
out in future cultures, owing, it is thought, to the reaction of  
without the accompaniment of pain. Subjective symptoms
the agar which was employed as a culture medium and which
were felt later, and continued to increase in severity (he was
was found to be strongly acid.  
still using his hand for exhibition purposes) until, on account
of the severe pain, he was compelled to stop his work. These
subjective symptoms consisted of aching, tiirobbing and shooting pains. The color of the skin gradually changed to a deep
brown, and the epidermis began to exfoliate. The bones of
the hand were very tender on pressure, particularly the first
phalanges of the index and second finger and the carpal
bones. The movements of the hand became so limited that it
was practically useless for some weeks. Sensation was also
much impaired, but after exfoliation occurred it recovered
again, but only gradually. Recovery of all the lesions has
been very gradual indeed.  


The photographs have revealed what has never been observed
before, viz. a distinct osteoplastic periostitis, and probably an
osteitis, particularly of the first and second rows of phalanges
of the index and second fingers, also of the heads of meta




74
*As .an interesting point the photographs show the outlines even
of the finger-nails and the interosaei muscles.






JOHNS HOPKINS HOSPITAL BULLETIN.
22






[No. 73.  
JOHNS HOPKINS HOSPITAL BULLETIN.  






No accurate temperature chart could be obtained in this
[No. 71.  
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
distribution ; for within eleven months these five cases have
come under the observation of a single individual and were,
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.
carpal bones of the same fingers, and judging from the symptoms, even of some of the carpal bones.  
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  
This then accounts for the severe symptoms, the aching,
throbbing and shooting pain which prevented sleep. The
density of these bones has also been increased, showing that
even bone tissue has been affected.


A complete demonstration is thus afforded of the powerful,
piercing character of the x rays, and the severe, painful symptoms which have been described by other observers are probably due to the iuflamniatiou of the periosteum, and possibly
the bone, besides the softer tissues.


This iniiammation has also extended into the joints, which
would explain the loss of movements, and pain, when they
could be used later.


a compound fracture of the humerus, the history states that
As the result of these observations, it proves that the x rays
the wound was covered with dirt. This fact naturally leads
are even more powerful than have been generally thought,
to the suspicion that the bacillus aerogenes capsulatus, like
that the deleterious effects can iu some cases be quite serious,  
so many of the anaerobic bacteria with which we are familiar,
and that the cutaneous manifestations are not the most severe
may occur in the soil ; and the occasional production of spores,  
of the lesions, but those of the deeper tissues, and particularly
noted in the account of the first case and also observed in similar cultures from the fourth case, might readily explain the
of periosteum and bones, being more severe.  
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
The discovery of this deeper and more profound effect at
simple route by which the bacillus might gain access to the  
once overthrows many of the explanations which have been
human body and find conditions not unfavorable to its development and, perhaps, spore-formation.  
advanced to account for the cutaneous lesions. Tesla's theory
of the ozone generated in contact with the skin will not
explain these deeper effects. Prof. Thomson has demonstrated
that they are not due to the ultra-violet rays. They cannot be  
compared to sunburn, since no case, as far as is at present known,
has been published wheresunburu has produced periostitis and
even osteitis. Nor can such serious results be produced by  
brush discharges, and Thomson has also proved that these
cannot be the causes. His further explanation that the effects
(he was not aware of the deeper injuries to the soft tissues and
bone) are due to the x rays themselves or something which accompanies them, is rather indefinite. It was suggested to me, as
I have already mentioned, that it might be due to the platinum
particles piercing the bulb and then attacking the tissues, but
this almost appears impossible, since serious cutaneous effects
have even followed only one exposure of half an hour {vide
Thomson's case).  


If the bacillus once gained access to the intestinal tract its
I consulted with Professor Ames, Associate Pi'ofessor of
presence in the perineal region couldoccasion no surprise. And
Physics in the Johns Hopkins University, who, after reviewing
if, through the wounded urethra, or some other lesion, it once
all the facts of the case, kindly wrote as follows concerning
reached the subcutaneous tissues and possessed sufficient virulence, the gangrenous process illustrated by these cases would
the present theory of the x rays :
ensue as a matter of course.


" The radiation in an ' a; ray tube ' may be divided provisionally into three classes: ether-waves, which may have wavelengths from 150 to 800,a/j^, approximately; kathode rays, which
undoubtedly are streams of matter, electrically charged ;
X rays, about whose nature there is no conclusive evidence at
the present time. If the walls of the tube are thin enough
and of suitable material, all these radiations will emerge and
pass into the surrounding air. It is a matter of doubt if the
kathode rays observed outside the vacuum-tube are the same
as those inside ; but the inner ones undoubtedly cause the
outer ones. There is no evidence that x rays carry with them
particles of matter, or that they directly cause a stream of
particles; in fact, all known facts seem to point to the belief
that they are ether-waves of extreme shortness."


It will thus be seen that the opinion expressed here does


OBSERVATIONS TO DETERMINE THE MOTILITY OF THE BACILLUS AEROGENES CAPSULATUS


UNDER ANAEROBIC CONDITIONS.


By E. K. Dunham, M. D.  
not make it possible for the x rays themselves to produce such
deleterious effects as have already been described, but Dr. Ames
mentions the fact that the kathode rays are undoubtedly
streams of matter electrically charged. Here then we have
some possible grounds for the theory that the lesions may be
due to the entrance of particles (platinum in our case) into
the injured tissues, and that the kathode rays which accompany the X rays may be the cause of the trouble, and not the
X rays themselves.  


On clinical grounds there is considerable support for this,
at first sight, improbable theory. If the lesion extends at all
deeply, it leads to the formation of ulcers, which are extremely
intractable, and they may be due to irritating particles still
present in the tissues.


I do not think that the possibility of injury ought to deter
one from using these wonderful rays in surgical work, because
only a few have been affected out of thousands who have been
exposed to them. By keeping, as Thomson says, some distance
away from the rays, injurious effects will hardly follow their
use, and when the exposure is for a short time, unless, as may
happen in all other diseases, idiosyncrasy plays a prominent
part.


Bouillon cultures of the bacillus were studied in flattened
When I viewed my own hand two or three times near a new
capillary tubes from which the oxygen of the air had been
Edison bulb, through a tungstate of calcium screen, after four
absorbed by means of pyrogallate of potassium. Although
or five minutes I distinctly felt a tingling sensation throughout the dorsum of the hand; this symptom lasted for ten or
these cultures were examined at intervals varying from 15
fifteen minutes and passed away without any further results.  
minutes to 24 hours, at no time could any evidence of motility
It occurred to me that x ray operators and experimenters should
on the part of the bacilli be detected.  
expose to the rays the palmar surface of the hand, which is
protected by a much thicker horny layer, rather than the back
of the hand, which is much less protected.  


The details of the experiment were as follows :
In conclusion I would strongly advise all x ray operators
and experimenters who develop any special idiosyncrasy, to
abstain from their use if they find that the slightest deleterious results follow an exposure to them.


The cultures were obtained by putting threads, containing
Bibliography.  
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
John Daniel : Medical Record, April 25, 1896, vol. 49,  
glass tubing, about 8 inches long and with a bore measuring
No. 17.  
about i of an inch, strongly in the middle, then bringing the
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
0. Leppin: Deutsche medicin. Wochensch., No. 28 (July
drawn out to form a capillary tube. This was then broken
9), 189G, p. 454-.  
in the centre and the end immersed in the bouillon culture.  


Marcuse: Deutsche medicin. Wochensch., No. 30 (July
23), 189G, and No. 42 (October 15), 1896 ; also abstract in
Brit. Med. Journal, Aug. 15, 1896.


Feilchenfeld : Deutsche medicin. Wochensch., No. 30 (July
23), 1896.


A portion of the culture quickly filled the capillary part of
Conrad: Codex Medicus, August, 1896.  
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).  


Paul Fuchs: Deutsche medicin. Wochensch., No. 35 (Aug.
27), 1896, p. 569.


Sehrwald: Deutsche medicin. Wochensch., No. 41 (Oct. 8),
1896; abstract in Brit. Med. Journal, Nov. 7, 1896.


Fto. I.  
S. J. R.: Nature, No. 1409, vol. 54, Oct. 29, 1896.  


H. C. Dunn: Brit. Med. Journal, Nov. 7, 1896.


G. C. Skinner: The Journal of the American Medical Association, No. 20, vol. XXVII, Nov. 14, 1896.


Fig. <3.  
Macintyre: Nature, No. 1412, vol. 55, Nov. 19, 1896.  


K. E. King: Canadian Practitioner, Nov. 1896.




F,g.l.


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
Case of J ray dermatitis. Photograph showing exfoliation of the epidermis.  
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




"^


April, 1897.]




•


JOHNS HOPKINS HOSPITAL BULLETIN.






75


FIG. 2.
X ray photograph of left hand (normal).




greater numbers than when the cultures were first introduced
into the tubes, showing that the conditions were favorable for
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


FIG. 3.


X ray photograph of the right hand showinj
thickening of some of the bones.


view of them could be obtained. That this was not the case
is shown by the fact that in all the tubes the bacilli soon
subsided to the bottom, leaving the bouillon above them
free from bacilli. If the tube was turned a little about its
long axis and kept in that position for a time, the bacilli
settled towards the lower side of the tube.


These observations appear to demonstrate that this bacillus
 
does not possess the power of locomotion, even under anaerobic
February, -1897.]
conditions.
 




JOHNS HOPKINS HOSPITAL BULLETIN.


MULTIPLE TUBERCULOUS ULCERS OF THE STOMACH, WITH A REPORT OF THREE CASES.


By Alice Hamilton, M. D.


[From the Pathological Laboratory of the Johns Hopkins University and ITospital.]
23






Tuberculous ulcer of the stomach is conceded by all writers
M. J. Stern : The American Medico-Surgical Bulletin, Nov.  
on pathology to be of extremely rare occurrence, some indeed
31, 1896.  
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
F. Kolle: Brooklyn Medical Journal, December, 1896, vol.  
from time to time in the literature, but it is imjjossible to
X, No. 12.  
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,  
J. C. White: Boston Medical and Surgical Journal, Dec. 3,  
but with a single ulcer in the anterior wall of the stomach,  
1896, vol. CXXXV, No. 23.  
which on microscopic examination showed typical caseating
tubercles with giant cells. Talamon also describes tubercles
found in the walls of ulcers in the stomach of a child which
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


E. Thomson : Boston Medical and Surgical Journal, Dec.
10, 1896, vol. CXXXV, No. 24.


Nikola Teslu: Abstract in Public Opinion, vol. XXI,
No. 24.


were intact. The first one was a case of general miliary tuberculosis, and the stomach contained many miliary tubercles as
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
M. H. Kichardson: The Medical News, Dec. 26, 1896, vol.
ulcer. His case, a child with pulmonary tuberculosis, presented numerous losses of substance in the mucosa of the
LXIX, No. 1250.  
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
The Medical Record : References to case at University of
at Kiel. He examined all for the tubercle bacillus, but failed
Minnesota, vol. 50, No. 25, Dec. 19, 1896.  
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


W. E. Parker : New Orleans Medical Journal, Sept. 1896,
vol. XLIX, No. 3.


H. R. Crocker: Brit. Med. Journal, Jan. 2, 1897, No. 1879.


76
W. B. Banister: Medical Record, vol. LII, No. 4, Jan. 23,
1897.


Ereund : Miinch. Med. Woch., No. 3, Jahrg. 44, Jan. 19, 1897.




JOHNS HOPKINS HOSPITAL BULLETIN.


LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE NERVE CELL


Study VI.— DIPHTHERIA.
By Henry J. Berkley, M. D.


[No. 73.




During the course of this investigation, an article by Ceni*
on the same subject came into my hands, and the results determined, by both investigations are so entirely similar that it
seems hardly necessary to repeat in full the details of the
study.


report each a case of single ulcer — at the lesser curvature and
Ceni's work was done on rabbits and horses, with an acute
at the pylorus respectively — and describe the microscopic findings as tubercles with caseation and giant cells. It is to be
and a chronic series. The first, after the inoculations with diphtheria cultures, lived from three to four days, and showed, in
regretted that these observers failed to make any search for
exquisite form, the beginning of the moniliform swellings of
the bacillus tuberculosis. This omission is still more striking
the dendrites of the cortical and hippocampal cells common
in Letorey's otherwise exhaustive description of a case of diffuse ulceration near the pylorus. He states that tubercle
to the action of all the toxins of the infectious series. The
bacilli were found in the lungs and in the diseased part of the  
chronic series lived from 36 to 41 days after the inoculation
femur, but seems not to have looked for them in the ulcers,
with the toxin, during which period they lost full half their
where he, however, found typical caseating nodules.  
weight. Ceni also utilized the cerebra of horses which had
been used in the Milan Bacteriological Laboratory to produce
diphtheria serum. In these, after three or four months of the  
treatment, he found the cortical cells far degenerated, and to
a degree not seen with the rabbits, the stouter dendrites and
corpora of the cells being extensively involved in the destructive process.  


In the following cases it is difficult to decide whether the  
Interesting to note, he also finds distinct lesions of the  
lesions described are really tubercular or not, the authors having satisfied themselves of the correctness of their diagnoses,  
vascular neuroglia, principally tumefaction of the bodies and
but having failed to establish them by giving the facts on
branches, the one attached to the blood-vessels' walls showing
which they were founded. So, for instance, Hattute merely
the alterations most distinctly, all being identical with those
states that his case showed "elements of tubercle in the granulations." Lorey, Anger, Matthieu, (Jazinaud Beadles give no
described and recorded in the III. study of this series (Art.
details at all. Finally, a large number must be utterly rejected
Ricin Poisoning).  
as, according to the explicit statement of the authors, no
 
microscopic examiuation was ever made. Such are the cases
Our present series consisted of five diphtheria guinea-pigs,  
of Bignon, Paulicky, Chvostek (four), Hebb (second case),
whose brains had been sent me by Dr. Flexner for the purposes
Lauge, Barlow and Quenu, which last rests for its diagnosis on  
of the study. The first two brains, after hardening and examination of the sections, were rejected on account of the  
a mere statement of the author, no description of its macroscopic appearance being given. Several others which have
possible presence of post-mortem changes. The other three
been placed in the list of tubercular ulcer were really miliary
cerebra were carefully hardened in Miiller's fluid and treated
tubercles in the walls of the stomach. Kiihl's fifth case is an
afterwards by the silver phospho-molybdate formula.  
example, also Earth's. Labadie-Lagrave's case showed a
 
cicatrix near the lesser curvature, its tubercular origin being
Guinea-pig No. 3 received an injection of the toxin at 2.30
merely hypothetical. Oppolzer's is described as a perforating
P. M. and died about 3 A. M. the following morning. No. 4
ulcer connecting stomach and colon, supj)osedlyof tubercular
was inoculated at 2 P. M., was re-inoculated two days later at
origin, but it was impossible to say in which organ it originated. This covers all of the authentic literature so far as I
10.30 A. M., and died two days afterwards at noon. No. 5
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.  
 
•Carlo Ceni : Riforma Medica, vol. I, 1896.  


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,
with smooth walls; the lung tissue adjacent was densely infiltrated and converted into a caseous mass. In the lower portions of
the upper lobe, beneath the anterior surface and near the middle
line, a small cavity existed with smooth walls which communicated freely with the bronchi. Its walls were caseous, and


went through the same course of treatment as No. 4 and
died approximately at the same hour.


The local manifestations at the site of the inoculation were
experimental membranes, oedema, and slight central necrosis.
The lymph glands throughout the body were enlarged, there
were small hemorrhages in the mucous membranes, and
ecchymoses and necroses of the abdominal organs, with considerable fluid in both the thoracic and abdominal cavities.


adjacent to it were large caseous masses surrounded by oedematous and congested tissue, which often presented a gelatinous
With Case 3 the dendrites only show beginning changes.  
appearance. The upper portion of the lower lobe was taken
There are numerous small moniliform swellings scattered over
np by a series of cavities, more or less communicating, the
their branches, not focally but uniformly throughout the  
deepest of which extended almost to the pleura, and was separated from this only by thin granulation tissue in which
cortex, and over the sites of these tumefactions the gemmules
could be seen many opaque tubercles. Over this cavity the
are either lost or are very sparingly present, while on those
two layers of the pleura were adherent. The dependent portion of this lobe anteriorly was drawn out to a tongue-like
that have normal dendrites they are undiminished in numbers. On the stretch of dendrite between the swellings, which
aj)pendage in which were caseous masses, the intervening lung
either appears normal or slightly below the natural calibre,
tissue presenting a gelatinous appearance. Firm, dry and  
the lateral buds are beginning to disappear, as shown by the  
caseous tissue surrounded the cavity in the upper lobe, and
paucity of their numbers and lessened tendency to assume a
most of the remainder of this lobe was converted into similar
deej) black tint. The bodies of the cells do not appear to be
tissue. The lower lobe contained scattered caseous foci, while  
in any way changed in staining properties, or to have lost in
the pleura covering all of the left lung was scattered over with
any degree the angularity of their contours.  
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
The vascular neuroglia cells are uniformly stained throughout the outer layers of the cortex, and have their tentacles,  
occurred at intervals, beginning 165 cm. below the duodenum
jiarticularly the vascular foot, somewhat swollen, the degree
and extending to within 10 cm. of the rectum. They were  
being considerably less than in some specimens we have noted
partly circular, partly elongated — " girdle-ulcers " — and penetrated to the muscular coat. In many, small tubercles were  
after the injection of other toxins. The axis-cylinders are distinct, and show no alterations. The tei-minal apparatus of  
visible in the depth. On the peritoneal surface a few tubercles
the cortical fibres were so infrequently stained that it is
were seen. The appendix vermiformis was free from ulceration.  
hardly possible to determine with certainty whether they were  
pathologically altered or no, but those found appeared to be
normal.  


The stomach showed a large number of losses of substance,
The larger vessels showed neither thickenings nor ruptures
from 115 to 120, scattered over the entire organ, but most
of their coats.  
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
With cases Nos. 4 and 5 the pathological alteration is
existing in the stomach. Our studies embraced the examination of many of these, often in serial sections, both with
similar to that in No. 3, only increased in intensity, from the  
respect to their pathologic histology and to the presence of
longer duration of the poisoning, and, perhaps, also from the  
tubercle bacilli. Ulcers of various sizes were sectioned, stained
repetition of the inoculations. The moniliform nodules are  
and examined microscopically. The details are purposely
well marked over long stretches of cells in the pyramidal
omitted. The ulcers vary in their histological appeai-auces,  
region of the sections, and are uniformly larger than in the  
depending somewhat upon the extent of their development.
more acute case. Also the denudation of the gemmules is
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.]
24




Line 3,545: Line 3,802:




77
[No. n.
 
 


marked by the greater absence of these pin-like projections
from the dendrites.


Some of the psychical cells are beginning to show alterations
of their outlines, appearing now rounded in contrast to the
third case.


the overhanging edges of the ulcers, and again upon the floor
The vascular neuroglia also shows signs of more advanced
formed by the submucosa, which was always found when
swelling, the tentacles being thicker and the pseudopodia
exposed to be infiltrated with new cells, partly lymphoid, partly
more prominent.  
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
The axons and collaterals are well stained, but show no
bound by adhesions to the chest wall and the diaphragm, and
unusual varicosity or other departure from the normal. A
the lobes were bound to each other. On section the whole lung
few of the cells having upturned axons are well stained, but  
was quite consolidated. Old fibrous processes extended in all
the morbid changes are of less intensity than with the pyramidal variety.  
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
The cerebellar cells, as in the previous studies, showed less
covered with sticky mucus, and along the greater curvature,
damage than those of the cerebrum. The Purkinje variety
almost over its entire extent, small losses of substanceoccurred,
was the only one recognisably involved. The peculiar axons
70 to 75 in number. They presented worm-eaten edges and
of the basket cells were natural, and the various nerve fibres
uneven bases, which sometimes, but rarely, were covered with
throughout the outer lamina of the cortex retained their histological appearance.
small granulations. They extended usually only partly through
 
the mucosa. The follicles of the oesophagus were enlarged,  
From the studies conducted on the cerebra of hydrophobic
but without ulceration.  
and diphtheritic guinea-pigs it would appear that all severe
infections were followed by brain-cell degeneration of an order
not dissimilar to that found in the cells of the abdominal
viscera under similar conditions, a degenerative process unaccompanied by inflammatory reaction and a tendency to atrophy
and necrosis.  
 


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


PUERPERAL SEPSIS DUE TO INFECTION WITH THE BACILLUS AEROGENES CAPSULATUS.


By George W. Dobbin, M. D., Resident Obstetrician, The Johns Hopkins Hospital.


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
The following case, which occurred in the Out-patient Obstetrical Department of the Johns Hopkins Hospital, is interesting from the fact that we have been able to lind reports of
discovered above, they are in this respect, compared with other
only a few similar cases in the literature.  
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


We were called to see the patient, Paulina A., about eleven
o'clock on the evening of March second, the messenger saying that she had been in labor about two days and the midwife was unable to deliver the child.


As the patient and midwife were Polish it was exceedingly
difficult to obtain an accurate subjective history of the case,
but after considerable difficulty it was found that she had had
an abdominal operation done a year ago in Germany, the nature
of which we were unable to ascertain. She was at the end of
her third pregnancy, and had been in labor two days.


78
Examination showed her to be a person of medium size, of
an exceedingly pinched and pale appearance about the face,
with weak and rapid pulse, running from 130 to 140 beats
per minute.


The abdomen was enlarged to about the size of a full-term
pregnancy. Just above the symphysis was the pigmented
cicatrix of the abdominal operation referred to. The fundus
of the uterus presents the bullet-shaped appearance suggestive
of pelvic contraction ; it reaches to a point midway between
the umbilicus and xyphoid cartilage, and was in a condition of
tetanic contraction. Palpation showed a large child in the lef toccipito-iliac-anterior position, with the head impacted in the
pelvis. The fojtal heart could not be heard, and the patient
was not having regular labor pains.


Measurements of the pelvis showed that she had a generally
contracted pelvis, with a conjuc/dta vera of approxinuitely 8
cm.; the other measurements were as follows : distance between
iliac spines 32.5 cm., between iliac crests 25 cm., between
trochanters 38 cm., Baudeloque diameter 17 cm., and a diagonal conjugate of 10.5 cm.


JOHNS HOPKINS HOSPITAL BULLETIN.  
By vaginal examination we found that the vaginal outlet
was much relaxed. There was a very large caput succedaueum
I)resenting in the vagina. The head was very firmly impacted in the pelvis and could not be pushed up. The
sagittal suture was in the transverse diameter of the pelvis,






[No. 73.  
with the small fontanelle to the left. The impaction of the
head was so great that the cranial bones overlapped one
another to the extent of one centimeter.  


On approaching the bed a very sweetish, offensive odor
became noticeable, and a distinct bubbling, crackling sound
could be heard. This was thought at first to be due to the
escape of gas from the rectum, but on turning down the bedclothes it was seen to come from the vulva, which was bathed
in a dirty reddish-brown fluid containing many gas-bubbles.
The bubbling, crackling sound was continuous, and was much
more apparent when the patient's genitals were exposed.


Diagnosis. Generally contracted pelvis, with conjugata vira
of about 8 cm. ; large child in left occipito-iliac anterior
position, with head impacted in the pelvis; arrest of labor.


previous lesion existed to enable it to get a foothold; and  
Owing to the mother's condition, and as the child was already
while this statement has perhaps been disproven, yet that such
dead, immediate delivery was indicated. She was given chloroform, placed across the bed in the lithotomy position, and a  
a previous injury may act as a predisposing cause is more
Tarnier axis-traction forceps was applied by Dr. Williams.
firmly established now than when he wrote (see Cordua). And
The head was brought down to the outlet with great difficulty,  
if for the oesophagus, it may be asked why not for the stomach?
and as it became more and more crushed out of shape with
The facts in our second case point more towards such a view,
each traction it allowed the forceps blades to slip several
namely, that many small erosions, probably of hemorrhagic
times. The lateral blades of the Tarnier basiotribe were then
origin, existed in the stomach, some or all of which became
applied, screwed tightly together, and the crushed head
invaded by tubercle bacilli swallowed with the sputum, than
delivered.  
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
Tractions now made on the delivered head showed that the
for the advice and assistance most kindly given me in the  
sh'oulders were so firmly impacted in the pelvis that they
course of this investigation.  
could not be delivered without tearing the head from the body.  
The blunt hook was then put into the posterior axilla and
that shoulder brought down; this manipulation caused the
separation of the epiphysis from the shaft of the humerus,
and in order to effect delivery of the trunk it was necessary to
put the blunt hook between the ribs beneath the substernal
notch and literally drag the child from the mother.  


Addendum.  
Just as the child was delivered there was an escape of gas
from the uterine cavity accompanied by an explosive sound.
The gas possessed a most sickening fa>tid odor, which was so
intense that Dr. Williams was obliged to leave the patient and
seek the outside air.  


After the completion of the above report, a third case of  
The third stage of labor also gave considerable difficulty, for
gastric ulcer came under observation, which proved also to be of
tubercular origin, and the specific character of which was far
more easily determined than in the other two cases. The lesions
here conformed in every way most closely to the usual type of
tubercular ulcerations. The ulcers wei-e in this case but two
in number, of large size, and accompanied by the formation
of tubercles which were evident even to the naked eye.


Vase 3. The patient was a colored girl of eleven years of
age. She entered the medical department of the Johns Hopkins Hospital (service of Dr. Osier) on June 16th. Tubercular
peritonitis was diagnosed, and she was transferred to the
surgical side, where the diagnosis was confirmed by an exploratory operation, the peritoneum being found covered with
miliary tubercles and the intestines matted together. The
patient recovered from the operation and lingered until
December, when death occurred. The autopsy was performed
by Dr. Livingood, from whose report the following extracts
have been taken.


The body was much emaciated. Extending from below the
costal margin to a point opposite the umbilicus was the scar of
an imperfectly closed incision, the floor of which consisted of a
sloughing surface covered with pus. Near the umbilicus the
tissues were darkened and necrotic in appearance. On
attempting to open the peritoneum, the transverse colon and
the upper part of the omentum were found completely coherent.
Below, the intestines were closely matted together by fibrinous
and fibrous bands, which could be stripped apart, though
with difficulty, especially at the umbilicus. The parietal layer
of the peritoneum was thickened and studded with conglomerate and miliary tubercles. The peritoneal cavity contained
a large amount of turbid, yellowish-white fluid with fine
flocculi. It had a slightly faecal odor. The serous coat of
the intestines was studded with numerous caseous tubercles,
usually about the size of a cherry-stone, but ranging larger
and smaller. The appendix vermiformis was so matted in
the mass that it could not be found.


The anterior mediastinal and the lower cervical glands
February, 1897.]
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.  






The pleural cavity was partly obliterated by fibrous adhesions. The lung contained in its apex numerous small nodules,
JOHNS HOPKINS HOSPITAL BULLETIN.  
some of them caseous ; it was congested over the remainder of
 
its extent, and small tubercles could be seen and felt scattered
through it. The left pleural cavity was completely obliterated, and the lower lobe of the lung could not be freed from
the diaphragm, but had to be removed with it. Miliary
tubercles were scattered over both layers of the pleura, especially thickly along the lines of the ribs. A large area of
caseation was formed where the lung was in contact with the
diaphragm, and this process seemed to have extended directly
through the diaphragm to the spleen and liver beneath. The
upper lobe of the left lung showed more extensive tuberculosis than did the right lung, being filled with numerous
tubercles in all stages of caseation, but without definite cavity
formation. Small nodules were scattered through the lower
lobe, which was much congested and, at its lower extremity,
in the early stage of consolidation.


The spleen was adherent to the diaphragm and to the parietal peritoneum. Its capsule was thickened and was the seat
of large caseous tubercles, but there were no distinct tubercles in the substance. One small caseous tubercle was found
in the right kidney. The mucous membrane of the uterus
was the seat of a number of yellow and gray miliary tubercles.
Both tubes were enlarged and adherent to the surrounding
structures. Some of the lymphatic glands in the broad
ligament were caseous, and the vaginal mucous membrane contained a single tubercle. The caj)sule of the liver was covered
with numeroiis minute tubercles, and others were found in the
substance of the organ. The pancreas was closely adherent to
the caseated retroperitoneal lymph glands, and its substance
showed large caseating areas.


The stomach was adherent to the transverse colon, the
25
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




the uterus having been for so long in a tetanic condition,
refused to retract, and it was finally necessary to deliver the
placenta manually.


Apbil, 1897.]
Retraction still being very slow, a hot intrauterine douche
of boiled water was given, which had, however, little effect;
but there being no excessive hemorrhage, the patient was put
back to bed. Her condition, while very bad, was not much
worse than at the beginning of the operation. She was given
strychnia, brandy, etc., and left for the night.  


March 3rd, 9 A. M. The patient was seen by the nurse, who
reported her condition in no way improved. She had repeated
attacks of vomiting during the night. Temperature 98.4°,
pulse 144, irregular, weak and intermittent.


5 P. M. The patient was decidedly worse than in the morning. Temperature 101.2°, pulse 144, weak, irregular and
intermittent, her face presented an anxious expression, and the
respirations were rapid and irregular.


JOHNS HOPKINS HOSPITAL BULLETIN.  
During the morning "gas bacilli" had been found in the
tissues of the fcetus and placenta, so a fatal prognosis was
given to her husband. At this time in no part of the body
could we detect the presence of emphysema. Slips and cultures
were made from the lochia, which showed staphylococci,
streptococci and large numbers of gas bacilli.  


As well as we have been able to find this is the first instance
in which a diagnosis of this form of puerperal infection has
been made before death.


10 P. M. The patient is decidedly worse, no gas detected
in the tissues. The patient died three hours later, and soon
afterwards the body began to swell.


79
March 4th, 10 A. M. Seven hours after death. The body
was enormously swollen, being almost twice its original size,
the face was swollen entirely beyond recognition, from the
mouth and nose there exuded a frothy, bloody serum, and
from time to time large bubbles of gas could be seen to escape.
The abdomen was enormously distended and gave a deep drumlike note on percussion. Over the entire body we could obtain
the characteristic crackling of gas in the subcutaneous tissues.


The husband unfortunately allowed no autopsy.


Pathological report. The foetus and placenta were brought
back to the laboratory and the following is a copy of the
pathological report :


was intimately adherent to the stomach, separated only by the  
The child weighs 2900 grammes, without the brain ; its
remains of the muscular wall from the caseous masses within
length is 55 cm. The head is entirely crushed, the right arm
the stomach wall proper. The mucous membrane for quite a
almost completely torn from the body, and there is a large
distance around the ulcer was infiltrated, becoming more or less
jagged wound in the chest, all of which were caused by the  
necrotic at the edges, which were elevated and undermined.
craniotomy instruments and blunt hook.  
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  
The fcetus is very offensive, being much decomposed and
ulcerative process in the stomach was merely secondary,
macerated. The entire body is emphysematous, and everywhere, on making pressure, we obtain the characteristic "feel "
having been caused by the adherent lymph gland which had
of gas in the subcutaneous tissue. By making pressure on the  
ulcerated through to the free surface. The microscopic
chest, lai-ge bubbles of gas are seen to escape from the wound
examination proved, however, that the process in the stomach
in the neck. The body was then put under water, and on
was quite independent in its origin, as the still intact muscular
puncturing the abdomen there was marked escape of gas,
wall could be traced along the whole extent of the ulcer
which when ignited shot up in a flame six inches high.  
between it and the caseous gland behind.  


Bibliography.
Cover-slips made from the blood and subcutaneous tissues
Litten : Virchow's Archiv, 1876.
show large numbers of bacilli morphologically similar to the
Talamon ; Progres Medical, 1879.
"gas bacillus" of Welch and Nuttall. Cultures on sugar
Brechemin: Bull. d. 1. Soc. Anat., May 1879.  
media gave the characteristic growth.  
Eppinger: Prager Med. Wochenschrift, 1881.  






Barbacci : Lo Sperimentale, May 1890.  
The placenta is of a distinctly bilobed shape, dimensions
being 18x14x1.5 cm. and 10x9x1.5 cm. for the greater and
lesser lobes respectively. Its weight is 420 grammes. The
entire placenta is of a dull brownish color, and a distinct vascular trunk runs from the insertion of the cord, in the larger
lobe, to the lesser lobe. On the maternal surface, the cotyledons are poorly marked, and here and there are seen a few
minute areas of calcification. There is a large white infarct,
3 cm. in diameter, at one margin of the lesser lobe. The
entire surface is crepitant, and in places small bubbles of gas
escape on pressure. The fojtal surface shows numerous blebs
and bulljB beneath the amnion, which contain gas. The larger
placental vessels are distended with gas, which can be pressed
into the smaller ramiKcations.  


Coats : Glasgow Med. Journal, 1886.  
The umbilical cord is 36 cm. long, it is thin and fiabby,
and its vessels have considerable gas within them. Coverslips made from the placental blood show large numbers of
typical bacilli.  


Serafini : Annal. clin. del Osp. di Napoli, 1888.  
Microscopic examination of hardened portions of the placenta.  
The decidua presents for the most part a normal appearance.  
In the serotina the cells are often necrotic and have become
converted into canalized fibrin, which in places is seen to be
continuous with the canalized fibrin of typical infarct areas
of the chorion. Infiltration with small round cells is noted
to a slight degree. The decidua is poor in gland and vessel
spaces, and when present they seem to have lost their epithelium
and endothelium.  


Mathieu and Remond : In Letorey's Thesis, Paris, 1875.  
In that part of the chorion situated near the decidua
serotina the villi present a typical appearance, they are
closely packed together, rich in vessels, and their cellular
elements take the stain well. Many small infarct areas are
seen, particularly at the margins of the placenta, which present the usual structure. As we go deeper into the chorionic
substance ((. e. toward the amniotic surface), we see that the
villi do not lie in so close relationship with one another, but
are widely separated.  


Musser: Phila. Hosp. Reports, 1890, I.  
The larger vessels of the chorion are seen to be plugged
with bacilli, identical with those seen in cover-slip preparations mentioned in the macroscopic description. In some of
these vessels the bacilli form a solid plug, completely filling
the lumen, while in others a " gas cyst " has been formed, and
the bacilli lie in a zone around its margin. As we go from
the vessels into the chorionic substance we find a few bacilli;
these do not lie in the villous capillaries, but in the stronui of
the villi, thus it is seen that while the larger vessels are filled
with organisms the capillaries are free from them. The "gas
cysts" mentioned above are found to lie in the placental
vessels and not in the intervillous spaces.  


Kiihl : Thesis, Kiel, 1889.  
The tissue surrounding one of these foci of bacilli presents
the following characteristics: Centrally we find the mass of
bacilli, which may lie either closely packed together in a
clump, completely filling the vessel lumen, or surrounding
the margin of a "gas cyst" in a zone. Going outward we
first find a zone of necrotic material, the remains of the vessel
wall ; this is entirely necrotic and shows no trace of nuclei.
We next get a zone of necrotic villi, which take a pink stain
with eosin, and show no cell structure. That portion of the
villus which formerly represented its syncytial covering takes


G. Hebb: Westminst. Hosp. Reports, 1888, III.


Lava: Gazz. Med. di Torino, 1893.


Letorey: These, Paris, 1895.
26


Hattute: Gaz. des Hop., 1874.


Lorey: Bull. d. 1. Soc. Anat., 1874.


Anger : In Marfan's Thesis, Paris, 1887.  
JOHNS HOPKINS HOSPITAL BULLETIN.  


Marfan : These, Paris, 1887.


Matthieu : Bull. d. 1. Soc. Anat., 1881.


Cazin : In Fernet's article. Bull, et Mem. d. 1. Soc. Med. des
[No. 71.  


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.


the stain somewhat deeper than the stroma. Continuing
outward, we next find a zone of partly necrotic villi, in which
each villus has retained a portion of its cell structure.


Which portion of the villus (syncytium or stroma) first succumbs to the toxic action of the organism cannot be said, for
in this zone of partly necrotic villi we sometimes see intact
syncytium surrounding necrotic stroma, and in other villi the
stroma is normal while the syncytium is represented by a
narrow necrotic band. It is probable that the syncytium is
the more resistant of the two, as more of the first variety of
villi are seen.


STUDIES ON TRICHINOSIS.  
There is apparently no reaction on the part of the tissue,
for we find no infiltration with polynuclear leucocytes. In
some of the sections we were able to demonstrate a few streptococci.  


The epithelium and Whartonian jelly of the cord are entirely
necrotic, the vessel walls partly so, and show a few nuclei.
The arteries are apjiareutly free from bacilli; in the veins,
however, they are very numerous, but show no tendency to
occur in clumps.


Bacteriological report (by Dr. Lanier). Cultures from the
placental blood show the bacillu.'^ aerogews capsulatus mixed
with staphylococci and streptococci. A pigeon was inoculated
in the pectoral muscle with 1 cc. of bloody lluid from the
placenta and died in about eight hours. At the autopsy there
was extensive gaseous crepitation to be made out over the entire
chest. On removing the skin, the subcutaneous tissue contained a number of gas bubbles. The muscles were extremely
oedematus, of a reddish brown color, and disintegrated to the
extent of being almost jjulpified. Cultures made from this
muscle grew out in the characteristic manner.


By T. R. Brown.  
A rabbit inoculated in the ear vein with a 24-hour bouillon
culture from the original placental blood was killed by a
blow on the back of the neck and left for 24 hours. At the
autopsy emphysematous crackling could be made out over the
entire abdomen and chest, the subcutaneous tissues and all of
the organs contained large quantities of gas, slips from which
showed large numbers of encapsulated bacilli. Cultures
from these organs gave the characteristic growth. The organism was also pathogenic for guinea-pigs.  


PatJiolog ical diagnosis. Bacillus aerogenes capsulatus
(Welch). Infection of placenta and foetus.


In looking over the literature of the subject we have only
been able to find a few cases which can be said to be similar
to ours. The first of these cases was reported by Leduc' as
early as 1597, he was called to see a woman who had been in
labor for three days. After a very difficult extraction by means
of the blunt hook, he says: "Immediately after the delivery
of the body of the child and placenta, a violet-colored flame
with a sulphurous odor escaped from the vulva, this flame
shot out some distance from the external genitals of the
patient, and its heat coukl be distinctly felt by the hands of
the persons who held her." She died several days later.
It is highly probable that this gas was generated by the
bacillus aerogenes capsulatus, but we can hardly blame the
author of that period for giving to his report of the case the
somewhat fantastic title of " Le diable an corps."


[Abstract of remarks and discussion before i
Doleris' reported a case of a woman dead aftei- labor, of a


The clinical history of the case which forms the basis of
these remarks resembles in some respects the classical picture,
though the symjjtoms were unusually mild. The patient, a
man 23 years of age, was admitted to the hospital on March 3,
1896, complaining of general muscular pains. He had been ill
six weeks, and for the two weeks before entry the pain had been
so severe that he had scarcely been able to move about. There
were irregular fever and extreme muscular tenderness, particularly in the arms and legs. The diagnosis of a myositis,
probably due to trichinosis, was made and confirmed by the
finding of actively motile trichinfe in pieces of muscle removed
from the arm.


He remained in the hospital for over two months, being
discharged well.


During his stay in the hospital the blood was examined
bacillar infection, this was before the work of AVelch and
daily. The number of leucocytes per cm. was determined and
Nuttall, but the clinical history is so characteristic of the form
a differential count was made of the various forms; frequent
of infection we are discussing, a short quotation from his  
examinations of the urine were made with quantitative determinations of the uric acid, urea and total nitrogen. The two
report will not be out of place.
small pieces of muscle which were removed were subsequently
 
subjected to careful microscopical examination. The results of
" In 1883 I submitted to the Anatomical Society a case of
the studies may be summarized as follows:
delivery at term, complicated by a myoma, after which the  
patient died. The labor was exceedingly difficult and marked
by successive intervention (forceps, cephalotripsy, etc.), and
I was not able to deliver the foetus. The patient succumbed
to a septicfemia having its origin in an intense putrefaction of
the uterine tissue, physometra, and putrid emphysema of the  
cellular tissue of the hypogastric region. I have studied the
case carefully from a bacteriological point of view, and can
affirm that it was a typical septicfemia caused by a bacillar
organism and not by the streptococcus or staphylococcus."
 
In 1893 we find reports of two cases, one by Graham Stewart
and Baldwin' and the other by P. Ernst.' As these cases
were both worked up very carefully from a pathological and
bacteriological standpoint, we give rather full abstracts.  


(rt) The blood. The study of the blood was carried on con
Dr. Stewart' was called at 1 P. M. to see a woman who had
been previously healthy and accustomed to hard work. He
found her suffering with intense pain in the region of the
uterus and ovaries. Miscarriage was suspected and denied.
As the pain was somewhat relieved by morphia he diagnosed
the case as acute metritis following abortion, and left the
patient. He did not see her again until several hours later,
during which time she became so much worse that another
physician had to be called. At Dr. Stewart's third visit at
9.30 P. M., about eight hours after the onset, he found her
emphysematous from " the top of her head to the soles of her
feet." Shortly after this she died, and swelling of the body
began, and increased so rapidly as to greatly alarm the undertaker when he was called in.


At the autopsy Dr. Baldwin reports "on making the usual
longitudinal incision, gas bubbles were found in the subcutaneous tissue, which ignited with a characteristic explosion,
and a small amount of gas in the peritoneal cavity. The
abdominal veins are markedly distended with gas, and numerous bubbles found in all the internal organs. The uterus
gave evidence of an abortion at about the third month."
There is no record of microscopic examination of any of the
organs.


the Johns Hopkins Hospital Medical Society.]
Bacteriological examination of a specimen of blood showed
the presence of the bacillus aerogenes capsulatus in large
numbers.  


tinnally during the course of the disease, a determination of  
It is very interesting to note that in this case production of  
the leucocytes and a differential count of the various forms of
gas took place to a very marked extent before death.  
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
Ernst,' in doing an autopsy on a woman dead after operation for removal of a macerated foetus, was struck by the  
times an inversely proportional relation, and the eosinophilic
appearance of foam on the cut surface of the liver, which on
rise could be seen to be distinctly at the cost of the neutrophiles,  
being allowed to stand increased so rapidly as to form a layer
the other forms showing relatively little fluctuation.  
several centimeters thick.  


The presence of such quantities of eosinophiles suggests
Bacteriological examination proved this case to be one of  
their possible diagnostic value in trichinosis, and perhaps, if it
infection with the bacillus aerogenes capsulatus. An abstract
be found on further studies to be characteristic of this disease,
of his case is as follows.  
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
Patient 26 years old, with anteflexion of the uterus in her
first pregnancy. Entered the hospital suffering with pain in
ilic right side of four weeks' duration. She had also lately






80
February, 1897.]




Line 3,961: Line 4,226:




[No. 73.  
27
 
 
 
noticed a tumor in the lower abdomen. Tiiere being no definite signs of pregnancy, and the microscopic examination of
scrapings from the uterus showing decidua, the cervix was
dilated to admit manual exploration of the uterine cavity.
Digital examination, however, revealing nothing, a vaginal
tampon of iodoform gauze was introduced.
 
After this the patient became so much worse that the tampon had to be removed. A macerated foetus was found and
extracted, and the uterus repeatedly douched with antiseptic
solutions ; the patient, however, became steadily worse and died.
 
The autopsy showed fibrinous adhesions between abdominal
wall and intestines ; cloudy sanguiueolent fluid in the pelvis.
The musculature of the left ventricle is thickly beset with
little miliary abscesses (?), in the centre of each of which is a
small punctiform lumen. Fresh fibrinous exudate on the
under border of the lungs. Spleen tumor with fibrinous coating and many necrotic areas appearing beneath its capsule.
Cloudy swelling of both kidneys. In the liver, which is of a
yellowish icteroid color, there are countless yellowish and
whitish-gray foci, the size of a millet seed, in the centre of
each of which there is a small lumen.  


The uterus reaches to the umbilicus, it is 15 cm. long and
its walls have an average thickness of 2 cm. The placental
site occupies the anterior wall, and here the uterus is thicker
(3i-3 cm). The entire uterine wall crackles on account of its
containing numerous gas bubbles. The cervical portion of
the uterus is 5 cm. long and is gangrenous. The uterine
cavity presents a ragged meshed surface of a dirty gray color.
A dirty, sanguineoleut fluid flows from the venous plexus of
the right broad ligament.


The uterus and ovaries are covered with a fibrinous exudate;
in the right ovary is a corpus luteum of pregnancy, undergoing cystic degeneration. There is a clot in the right iliac
vein which is riddled with gas bubbles.


the eosinophiles and the Charcot-Leydea crystals, various
Ernst was unfortunately prevented from making cultures
experiments were made with the blood which contained such
at this time,-and later the organism had died out.  
large quantities of eosinophiles, to see if the crystals could be
derived directly from these cells. In all cases, however, the
results were negative, seeming to show that the crystals are, at  
least, not direct crystallization products from the eosinophiles,
but that something besides the presence of these cells is necessary for their formation.  


{b) The uruie. The quantitative determinations of the uric
In Ernst's article he goes very thoroughly into the histological changes produced in the internal organs. These
acid, urea and total nitrogen were carried on mainly in connection with the ideas of Horbaczewski, that the uric acid,
changes are similar to those described by Welch and Nuttall,  
derived from the destruction of nuclein -holding material,  
so they will not be mentioned in this report.  
comes normally in large part from the leucocytes and is therefore increased in leucocytoses.  


Although the uric acid per 34 hours was determined on 23
The changes mentioned in connection with the uterus are
different days, and on four of these the urea and total nitrogen
especially interesting to us owing to the fact that we were
also, on no occasion did the total uric acid excretion, or the  
unable to get an autopsy in our case. Ernst mentions three
relation between the nitrogen of the uric acid to that of the  
different organisms : a large bacillus similar to those found in
urea or to the total nitrogen exceed the normal limits, showing that the views of Horbaczewski are not universally correct.  
the internal organs, viz. the bacillus aerogenes capsulatus; a
In this case, however, the leucocytosis differed somewhat from
short thick bacillus which he considers a saprophyte; and  
the ordinary in that here the eosinophiles were the cells markedly increased ; in his cases the ordinary polymorphonuclear
cocci having a tendency to chain arrangement, however, as
neutrophiles.  
he says, not the typical chains as seen in streptococci. The
short thick bacilli he finds only in the necrotic uterine
mucosa, and they show no tendency to invade the deeper
structure, while the cocci are found deep down in the uterine
muscularis. The larger bacilli, which are found all through
the internal organs, are very numerous in the uterine wall;
they have formed "gas cysts," which give to the uterus the  
ragged, mesh-like appearance mentioned above.  


(c) The mus'ie. The changes in the muscle were extensive.
In comparing these " gas cysts " with those found in the  
There was a great proliferation of the muscle nuclei throughout the section ; about the fibres containing trichina? this proliferation was very marked, especially in the second specimen ;
liver, Ernst says the principal difference is, that while in the  
not so extensive in the earlier specimen. In fact, in a few
liver the bacilli line the cyst in an unbroken zone, in the  
places where the parasite had but just wandered into the  
primitive bundle no change in the muscle substance nor any
proliferation of nuclei was visible. Most of the fibres containing the worm showed a conversion of the muscle substance
into a finely granular faintly-staining material containing
many large swollen nuclei, i. e. the proliferated muscle nuclei ;
and about many of the proliferated nuclei, both in the more
and in the less degenerated portions, distinct vacuoles could
be made out.


Throughout the specimens the muscle showed various forms
of disintegration, in some places a longitudinal splitting of
the fibres into fibrillaj, in other places the formation of what
might be called muscle cells, the muscle nucleus taking about
itself some of the muscle substance and separating itself from
the fibre; while in still other places a peculiar transverse
splitting up of the muscle into disks, the nuclei here proliferating transversely instead of in the usual longitudinal method,
was noted.


Besides these changes there were seen in the first specimen many polymorphonuclear cells, some showing a finely
granular protoplasm which did not stain to any extent with
acid stains (the so-called neutrophiles), some distinct eosinophiles with large deeply-staining granules, and beside these,
cells which somewhat suggest transitional forms, showing in
the protoplasm of the cell body fine granules, but with a
distinct affinity for the acid stain ; and all these cells seemed
to be acting as phagocytes in the disintegrating muscle, being
often seen in little lakes or bays in the degenerating bits.


In the second specimen there were decidedly fewer neutro
uterus the organisms are only found lining portions of the
cyst wall, and the cyst has a much more irregular contour.
This difference he attributes to the difference in structure of
the two organs, that of the liver being more or less homogeneous, while the uterine wall is made up of numerous fibres
running in different directions.


Thus, when a mass of bacilli begin to form gas in the liver,
the resistance met with is equal in all directions and the bubble takes the form of a sphere. On the other hand, in the
uterine wall, the resistance not being equal, the bubble when
formed will have an irregular contour, and in places along its
wall the bacilli will form a very thin zone or be entirely
absent.


philes and many more eosinophiles tlian in the first. That in
Ernst is in doubt as to whether the infection took place
along the veins or lymphatics, for in his specimens both contained large numbers of bacilli.  


both cases these were typical eosinophiles was shown by staining them in the different acid stains and in the Biondi-IIeideuhein triple stain.  
In 1895, Kronig,'' at the Sixth Congress of the Deutsche
Gesellschaft fiir Gyniikologie, reports two cases of puerperal
endometritis probably due to the bacillus aerogenes capsulatus.  


At the same time with this greatly increased projiortiou of
During the last year Schnell' reports a case which, although
eosinophiles in the extra-vascular leucocytes in the muscle,  
he does not consider it an infection, has a clinical history so
Ihe Mood vessels in the inferfascicuhir connective tissue showul
similar to our case that a short abstract will not be out of  
the same proportion of neutrophiles and eosinophiles as icas
place.  
found in the blood count for that day.  


In another specimen of muscle from a case of acute trichinosis which was obtained from the pathological museum, great
Primipara, oet. 31. 24 hours after rupture of the membranes
(juantities of eosinophiles were also found.  
was seen by a midwife from the Polyclinic, who found prolapse of an arm. Version was tried, but failed, on account of
contraction of the uterus; the child died during this attempt.
She was brought to the hospital with marked tympania uteri
and suffering intense pain ; 46 hours after the onset of labor
she was delivered by a difficult version. Immediately after
labor she did well, but later had quite a profuse hemorrhage,
for which the uterus was tamponed with iodoform gauze.
She then became steadily worse, and died three and a half
hours after delivery.  


The study of the blood, showing the steady increase of the
At the autopsy 18 hours after death, in winter, nothing
eosinophiles at the expense of the neutrophiles, together with
abnormal was found but gas in the large veins of heart, pericardial vessels, lungs, aorta, liver and spleen.  
the identical character of the nuclei of the two forms, would
tend to support the view held by some observers, that the
former variety of cells is derived by some transitional change
from the latter.  


That such a change might take place in the muscle is suggested by the presence here of neutrophiles, eosinophiles, and  
There is no record of any bacteriological examination, and  
what may be regarded as transitional forms, in large quantities.
Schnell considers the death due to air having gained entrance
Particularly suggestive is the great disproportion between
into the uterine sinuses during the successive manipulations.  
neutrophiles and eosinophiles seen in the second muscle specimen. Here the eosinophiles were much increased, the neutrophiles correspondingly decreased, while the blood-vessels in
the interfascicular connective tissue showed but the same proportion of these forms as was to be made out in the specimens of the peripheral blood for the same days. It is further
noteworthy that the eosinojihiles increased in number soon
after the increase in severity of the muscle symptoms, and
shortly after the decrease of those symptoms, diminished
gradually, descending toward the normal point as the symptoms abated. Suggestive also is the presence of large numbers of eosinophiles in a specimen of muscle from another
case of acute trichinosis.  


Dr. OsLBR. — This is the only case of trichinosis which has
On looking over and comparing these cases with our own,
been in the hospital, or it is safer to say the only case recognized, since we know that not infrequently the disease escapes
the following points are of interest: In every case the infection was very rapid and fatal. In all of the cases except that  
recognition or is mistaken for some other disorder. This is
of Graham Stewart and Baldwin, there was for some time a
the second case which I have seen clinically, while in the postmortem room I have found on eight or ten occasions the calcified cysts. Mr. Brown is to be congratulated on the very
dead fostus in the uterus, and the organism found an excellent
thorough way in which he has followed this case.
medium for development in its dead tissues and in the
 
placenta, and probably did not gain entrance to the general
Dr. Thayer. — The evidence offered by Mr. Brown in favor
circulation until after death of the patient. In the case of
of the origin of the eosinophilic cells by transition from the  
Graham Stewart and Baldwin, on the other hand, there was
so-called neutrophiles is very suggestive. The total number
nothing in the uterine cavity ; it only " gave evidence of a  
of polymorphonuclear cells found in the circulating blood
recent abortion." Here it is probable that the infection was
was practically what one would expect in a leucocytosis of that
more in the nature of a true septiciBmia, and the bacilli gained
extent. And yet, examining this percentage which normally
direct entrance to the vessels and lymphatics at the abraded
should consist almost absolutely of so-called neutrophilic
placental site. As this was the only case in which gas was
leucocytes, we find the great majority represented by eosinophiles. The fact also that in the affected parts the bloodvessels contained the same relative proportion of eosinophiles
detected in the subcutaneous tissues before death, the above
and neutrophiles as did the peripheral vessels, while the  
theory is not out of the line of probability.  
tissues round about contained an enormously greater percentage of eosinophiles, is very interesting.  


That the so-called neutrophilic granules stain often with
In Schnell's case we feel sure that had a bacteriological
acid coloring matters is well known. With good acid dyes
examination been made, the organism would have been found.  






April, 1897.]
28




Line 4,081: Line 4,366:




81
[No. 71.
 




There are in our case two questions wliich deserve consideration, in the first place, the origin of the infection, and
in the second, the action of the organism after it had entered
the body.


these granules almost always take a slight stain, and by sonie
The first question, in the absence of an accurate subjective
obseryei'S botli eosiuophiles and neutropbiles are classed as
history, cannot be answered with certainty. Suffice it to say
acidophilic cells. They stain, however, much better in fluids
that as the patient had been in labor two days before we were
consisting of a mixture of acid and basic coloring matters. As
called In, and during that time a midwife had been in constant attendance, it is more than probable that the organisms
Mr. Brown has sharply pointed out, this acid staining of the
were introduced by her during her examinations.  
smaller granules was uot to be made out at all in the specimens
of blood and in the blood-vessels in the tissues, and the fact
that outside of the vessels in the affected parts numerous
apparent transitional forms between the non-granular polymorphonuclear wandering cells and the true eosinophiles
existed is very suggestive. That these cells were true eosiuophiles in the sense of Ehrlich, Mr. Brown has proven by  
careful tests with a number of different acid coloring matters.  


The idea that the eosiuophiles represent a further change in
In regard to the action of the organism after it entered the  
the cell which we know as the neutrophile is, as Mr. Brown
body, i. e. whether the case was one of saprajmla or septicemia,
has said, not a uew one, but I am not aware that any argument
we can say as follows: Welch and Nuttall' have proved by
in favor of this view as forcible as that which he presents
inoculation into rabbits, that when the organism Is introduced
has yet been published.  
into the general circulation, death of the animal does not  
follow, but if shortly after the Inoculation the rabbit be
killed, the bacillus develops very rapidly, with abundant
formation of gas in the various organs.  


With regard to the actual blood condition — the increase of
In their experiments on rabbits, in only one case did the  
the eosinophiles — no similar case exists in the literature; the  
inoculation prove fatal. This occurred in a pregnant rabbit
percentage of eosiuophiles in this instance is moi"e than
in which two of the embryos were dead and macerated at the  
twice as large as has been reported in any other case.  
time of the experiment. Here the bacilli gained foothold and
developed.  


Dr. Barker. — Mr. Brown has referred, in speaking of the  
From the above we can then argue that the organisms were
degeneration of the muscle, to a splitting up' of the muscle
introduced by the midwife early in labor. She failed to recognize the obstruction offered by the deformed pelvis, and
fibre into transverse disks. I should like to ask him whether
allowed the case to go on. The child, after becoming firmly
or not he has been able to make out just where the splitting
impacted in the pelvis, died, and the bacilli, which had before
undergone little development, now having the most favorable
culture medium for their growth, i. e. dead tissue deficient in
oxygen, increased to an enormous extent and partly filled the  
uterine cavity with gas.


Thus, by the time we were called in to see the patient she
was not only weakened by the prolonged labor, hut also profoundly poisoned by the toxines produced in the uterine
cavity.


Why did not her general condition Improve after removal of
the dead foetus and placenta ? To this it may be replied that
the fcetus being so long under pressure, there was considerable sloughing and necrosis of the cervical and vaginal tissues ;
thus there was still a large amount of favorable media which
we could not remove.


occurred. Though several histologists have emphasized the
One other point deserves consideration. Did the infection
fact, it does uot appear to be generally kuown that the splitting iu the muscle fibre may occur with some reagents at one
of the fcEtus and placenta take place before or after fa3tal
level, with other reagents at an entirely different level. Thus
death ?
in the formation of the so-called Bowman's disks through the  
action of alcohol, the two layers Q (doubly refractive substance of Briicke) with the layer M (Hensen's line) in
between are always present in the disk. On the other hand,
ou treatment of muscle with certain acids (acetic, picric or
hydrochloric), the splitting occurs between the two layers
Q, each disk having then in its middle the layer Z (Krause's
transverse line or membrane). It would be interesting to
know, for the degeneration described, whether the splitting
occurred at either of these two levels or at still another level.


I gather from his paper that Mr. Browu favors the view
Again referring to the experiments of Welch and Nuttall,
that the eosinophile granules represent the cyto-mikrosomas
the fact of our finding the bacilli and " gas cysts" only in the  
of the cells in which they occui\ This view, recently si;pported
lumina of the placental vessels is a strong point in favor of
by Lovell Gulland, was previously urged by Martin Heidenhain, who found that the eosinojjhile granules stain black with
the theory that, just as in the mother, the organisms entered
his iron-haamatoxylin staining method, and that it is often
the blood before death, but did not undergo rapid development
possible to make out an arrangement of the granules radial to
until the fcEtus died.  
the attraction sphere of the cell. Both these observations are
in favor of the cyto-mikrosomal nature of the granules.  


The occurrence of such an enormous number of eosinophiles
From the above I think we can consider our case as one of  
in the circulating blood is truly remarkable and makes the
septic intoxication rather than a septic infection.  
case unique in the bibliography.  


Since writing the above report we have been told by Dr. N.
G. Klerle, City Autopsy Physician, that it is not a rare thing
to find conditions similar to these, viz. production of gas in
the subcutaneous tissues and Internal organs, in cases dead
after criminal abortion.




PROCEEDINGS OF SOCIETIES,


Eefeeences.


1. Welch and Nuttall : A gas-producing bacillus (bacillus
aerogenes capsulatus) capable of rapid development in the
blood-vessels after death. Bulletin of the Johns Hoi^kins
Hospital, July-August, 1892.


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.  
2. Welch and Flexner: Observations concerning the bacillus
aerogenes capsulatus. Journal of Experimental Medicine,
Vol. I, No. 1.  


Meeting of December 7, 1896.  
3. Graham Stewart and Baldwin : Bacillus aerogenes
capsulatus — Case. Columbus Medical Journal, August,
1803.  


Dr. Thayer in the Chair.  
4. P. Ernst: Ueber einen gasbilden Anaeroben im menschlichen Korper, und seine Beziehung zur " Shaumleber." Virchow Archiv, Band 133, Heft II.  


On Certain Visceral Pathological Alterations, the Result of
5. Leduc : Le diable au corps. Witkowski's Accoucheurs
Superficial Burns.— Mr. Bardebn.  
et Sage-femmes celebres, p. 184.  


Extensive superficial burus are followed by severe constitutional symptoms. The great pain felt at first is followed by a
6. Kronig : Discussion on Endometritis. VI Congress
benumbing of the senses and by sleepiness. At times there
Deutscher Gesellschaft fiir Gyniikologie.  
may be delirium and cramps. The pulse becomes weak, the
respiration shallow and irregular. The temperature, after a
short rise, falls below the normal. There may be vomiting
and diarrhcea, and haamoglobin may appear in the urine.
Death within 48 hours usually follows a burn which has
involved two-thirds of the surface of the body. The burn
need not be of an extreme grade. Death has often followed
burns so superficial as to give rise merely to an erythema.  


It is clear from this latter class of cases, at least, that alterations in the internal organs may follow the burning of the
7. Schnell : Ueber einem Fall von gasblasen im Blut einer
skin which cannot be accounted for on the supposition that
uach tympania uteri gestorben Puerpera. Mouatsschrift fiir
they are directly caused by the heat. Thus arises the question as to the nature of the physiological relations between the
Geburtshulfe und Gyniikologie, IV, 199-203, 1896.  
lesions produced in the skin and the resulting constitutional
effects. Many hypotheses have been advanced to answer this
question, some of which have been supported and others
destroyed by experimental work on animals.  


Many of these hypotheses have been based upon the con
8. Doleris : Inflammation puerperal. Arch. d'Obst. et de
Gyn., Vol. IX, pp. 97-122, and pp. 142-161.


Discussion.


ception of a loss of normal cutaneous activity. But experiment has shown quite conclusively that death after burns is
Dr. Flexner. — I was enabled, through the courtesy of Dr.
to be ascribed neither to the retention in the blood of products normally excreted through the skin, nor to heat radiation due to paralyzed blood-vessels in the latter structure.  
Dobbin, to see, during life, the patient whose case he reports.
At my first visit, some 6 or 8 hours previous to her death, I
endeavored to ascertain If there was any evidence whatever of
au ante-mortem development of gas within the tissues or vessels In parts remote from the genitalia. No such development
was discovered. The nest time I saw the case was several
hours (6 or 7) after death. At this time the appearances presented were those of extensive gas formation everywhere iu the
soft tissues and serous cavities. From the nose and mouth
frothy bloody serum exuded, which on cover-slip preparations
showed many characteristic bacilli. From the account given
by the family it was clear that rapid multiplication of the
organisms had begun almost at once after death, thus indicating a general distribution of the bacilli during life. I should
prefer to consider that other causes than merely the presence
of oxygen in the circulating blood are to be taken into account
in explaining the absence of any appreciable development of
gas, and thus presumably of bacilli, in the body during life.
I apprehend that still other factors play a part, and these
probably are of the same nature as are reckoned with in other
and more usual forms of infection with bacteria. This case
is, I believe, the first oue which has been encountered in the  
Hospital in which the invasion followed parturition. It is iu
itself a confirmation of the prediction made originally by
Welch and Nuttall, namely, that many of the cases of supposed entrance of air into the uterine sinuses would be found
to be due to infection with a gas-producing micro-organism.
The prediction had, however, been abundantly confirmed
before by Ernst and Graham, as related in Dr. Dobbin's
paper.  


Again death has been referred to changes produced in the
blood itself directly acted upon by the high temperature. It is
known that erythrocytes are destroyed by a comparatively low
temperature (55° 0.). This has led to the supposition that
the general pathological effects are due to loss of functional
red blood corpuscles, or to irritation produced in the kidneys
and other internal organs by the products of their disintegration. But a more generally accepted view is that the blood is
so altered by the elevation of temperature as to give rise to
extensive thrombosis, death resulting from the disturbances of
circulation.


Another view has been advanced more recently. Kijanitzen, who extracted from the blood of dogs experimentally
burned, substances similar to Brieger's ptomains, and Eeiss,
who found toxic substances in the urine of persons accidentally burned, believe that they have brought forward evidence
in support of the idea that the blood in severely burned
animals is rendered toxic.


During the past year five small children were brought to the
Febritart, 1897.]
Johns Hopkins Hospital so severely burned that death in each
case followed within a very few hours of the accident. At the
suggestion of Dr. Flexner I took this opportunity of studying






82
JOHNS HOPKINS HOSPITAL BULLETIN.






JOHNS HOPKINS HOSPITAL BULLETIN.
29






[No. 73.  
PROCEEDINGS OF SOCIETIES.  
 




THE JOHNS PIOPKINS HOSPITAL MEDICAL SOCIETY.


the histological alterations found in the tissues of the body
Meeting of October 19, 1896.
after burns. A careful autopsy was made in each case by Dr.  
Dr. Thayer in the chair.  
Flexner, and parts of the various organs were preserved and
The Surgical Significance of Gall Stones.— Dr. F. Lange.  
prepared for microscopic examination.  


The lesions in all five cases were strikingly similar. Of the
Every physician who has practised for a long time knows
gross lesions the most notable were cloudy swelling of the  
that there are cases in which through a number of years
liver and kidney, acute swelling of the spleen, and swelling and  
attacks of gall stones will recur and eventually the patient
congestion of the lymphatic glands and other lymphatic tissue.  
will be entirely cured. I have, for instance, for a number of  
years watched a colleague of mine, a physician, who beyond
any doubt has had gall stones, and indeed I have felt the  
gall stones in his dilated gall bladder. He had all the symptoms of cholangioitis, with frequent chills and high fever,
through months and years. He, however, did not like to
undergo surgical treatment, and he is now in flourishing
health.  


Microscopically, the most interesting lesions noted were
I have seen an old lady with a gall bladder packed with
parenchymatous degeneration of the kidneys and liver, focal
gall stones, who was not operated upon, who never had any
areas of necrosis in the liver, and pronounced focal necrosis
severe attacks that had been taken for gall stones, but in whom
in the lymphatic tissue.  
apparently the gall stones have disappeared without any serious symptoms. Pathologists know that the presence of gall
stones, especially in elderly persons, at autopsies, is of very
frequent occurrence. On the other hand, the disease may call
for very prompt and active surgical treatment, and it depends
entirely ujion the pathological changes — the consequences of
the presence of gall stones or their accompanying changes in  
the gall system — whether the case will present features that
call for surgical treatment.  


The lymphatic tissue was affected throughout the body.  
I propose to accompany a gall stone from its usual place of
The Malpighian corpuscles of the spleen, the tonsils, gastric
residence through the gall passages, and on this journey I shall
lymphatic follicles, enteric solitary and agminated follicles
mark out some clinical features which we will occasionally be
and the lymphatic glands all showed essentially the same
brought in contact with. As long as the gall stones remain
changes.  
quiet in the gall bladder they will hardly ever give rise to
any symptoms, but as soon as they become dislodged and commence to travel iuto the cystic duct or the common duct,
then the typical symptoms will commence. They may sometimes grow to a large size and cause very few symptoms. I
show you here a specimen of gall stones that came from a
lady who for a number of years had been suffering from
" dyspepsia," but not until an acute attack of peritonitis had
set in, in consequence of impaction of this very large gall
stone in the cystic duct, was she ever supposed to be suffering
from gall stones. As you see, the gall stones are almost the
size of a hen's egg. The gall bladder was full of pus, and
peritonitis had commenced. Acute impaction of the gall
stone in the cystic duct, in my experience, happens not unfrequently with solitary stones of larger size. Since the first of last
October I have had six such cases of acute cholecystitis with
septic processes on the surface of the mucous membrane of
the gall bladder, or through the entire thickness of the gall
bladder, which brought the patient iuto more or less danger of
life. In one of these cases, in which I had oj^erated three
years previously, I had the opportunity of observing the  
changes that had taken place three years after operation.  
The patient was left with a pretty extensive scar and a


The lymphatic glands were much swollen and at times congested. The earliest changes were in the follicles and consisted
of an ojdematous swelling. This was more marked towards
the centre of the follicle, in an area corresponding to the
germinal centre. In areas of less advanced alteration the
lymphocytes were merely less closely packed together than is
usual. But in the areas of more marked change, the lymphocytes were swollen and their nuclei fragmented. In these
cases the follicle presented a remarkable appearance. It was
not only greatly swollen, but at the edges a rim of closely
packed lymphocytes existed, while at the centre swollen and
distorted lymph cells, bits of protoplasm and fragments of
nuclei were seen scattered about, some lying free, others enclosed
in large flat endothelioid cells.


The lymph cords as well as the follicles were swollen, while
the lymph sinuses seemed less distinctly marked off than
usual from the reticulum in which the lymphocytes of the
cords lie imbedded. Here and there throughout the gland
groups of degenerating cells might be seen, but the areas of
distinct focal degeneration were confined as described above,
to the follicles.


Calvert has shown that the terminal artery breaks up in the  
hernia formed. She got an acute strangulation of a small
centre of the follicle into capillaries which radiate towards
omental hernia which necessitated incision. It was in the  
the periphery of the follicle. It seems possible that the lesions
immediate vicinity of the .gall bladder, and the gall bladder
focalized just at this region may in some way hold special
on that occasion was opened also. I found, to my surprise,
relation to the circulation of tlie blood. For if the blood in
that the gall bladder had assumed an hour-glass shape, through
these cases contains toxic materials, it is conceivable that it
the loss of substance which had occurred in the expulsion of
is just at the centre of the follicle that the poisonous plasma
necrotic tissue in the first attack, and there existed two compartments communicating with each other by means of a very
acts with greatest intensity on the lymph cells.  
narrow canal. In both of these compartments was a considerable amount of mucous material, but no stones. The
patient had suffered at the time from a certain degree of  
catarrh of the gall duct.  


In the lymphatic follicles of the tonsils and stomach and in
I have here a stone of not much smaller size, made up of  
the Malpighian bodies of the spleen focal degeneration essentially similar to that of the follicles of the lymphatic glands
cholesterine with lime outside. The patient had an acute
occurs. In the intestines the greatly swollen lymphatic follicles, solitary and agminated, showed extensive focal areas of
attack of cholecystitis, and this stone was found impacted in
degeneration.  
the cystic duct.  


In these areas of degeneration in the lymphatic tissue we
This third stone, of smaller size, is from a case in which
find appearances essentially similar to those seen after the  
the destruction of the gall bladder was quite extensive. Eventually the patient made a good recovery.  
injection into the body of various bacterial and other toxalbuminous substances. Indeed, the lymphatic glands from
our cases of skin-burn might readily be mistaken for the
lymphatic glands of children dead of diphtheria. The


Solitary stones are not always the cause of this affection. On
the contrary, sometimes quite the opposite condition will be
found. You will see here in this bottle a large quantity of
gravel-like material, coming from the gall bladder of a gentleman who for several years had been complaining of pain
about the region of the liver. In the second bottle you will
see an amount of tissue coming from the disintegrated mucous
membrane, and if you will take a closer look at these pieces
you will see that a large number of these small black granules
are imbedded in these shreds of membrane. The gall bladder was felt through the patient's lifetime as a very hard,
resistant, stony body, and when I tried to remove it it broke
off in the region of the cystic duct, and I was able to feel
below a hard resisting mass. The patient was in such a weak
condition that I did not try to get any further. After about
six mouths she died from a progressing carcinomatous affection of the cystic duct. The cancer of the cystic duct pressed
the common duct and led to jaundice and marasmus.


If the gall stone passes beyond the cystic duct into the common duct and is arrested there, of course the symptoms of
stagnation of the bile will make their appearance. Very frequently, however, associated with this there is inflammation
of the gall system, such as cholangioitis or pericholangioitis or
even liver abscess. These cases often necessitate very difficult
tasks, and I must say that some of them upon which I have
operated are among the most difficult operations I have done.
They are, however, very successful operations, and operations
by which the life of the patient is saved. In one of them I was
able to push the stone back through the dilated cystic duct into
the gall bladder, and then did what may be called an ideal cholecystotoniy, that is to say, I sewed the gall bladder up again
and closed the abdomen. That was ten or eleven years ago ;
of course I would neither do it again nor would I recommend
it. It is evident that through the mechanical injury of the
operation and through the inflammatory condition which is
present, a certain amount of swelling is kept up for a time,
and then the duct will not immediately become patulous after


lesions in the other organs are also essentially similar to those
found in the bodies of persons dead from the acute infectious
diseases. It seems, therefore, justifiable to consider that one
of the main causes of death after burns is to be sought in a
toxaemia caused by alterations in the blood and tissues, the
direct effect of the elevation of temperature; a view which is
further strengthened by the clinical evidences and the experimental work of Kijanitzen and others.




30


NOTES ON NEW BOOKS.


The American Year-Book of Medicine and Surgery : being a yearly
digest of scientific progress and authoritative opinion in all
branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign
authors and investigators. Collected and arranged, with critical
editorial comments, by J. M. Baldy, M, D., and twenty-six
other physicians, under the general editorial charge of George
M. Gould, M. D. [Philadelphia, 1897 : W. B. Saunders, 925 Walnut Street.)


This year-book amply justifies the high expectations which were
JOHNS HOPKINS HOSPITAL BULLETIN.  
excited by the excellent character of the similar volume published
last year. It is an encyclopedic collection of new medical literature
gathered from all lands and every field of medical knowledge. It
is not a mere aggregation, but a discriminating digest of the latest
knowledge in medicine, with frank opinions and critical comments
by painstaking and competent men. The special comments of the
editors as distinguished from the authors are enclosed in brackets,
to facilitate reference to them.  


The completeness of the department of medicine, which has had
the editorial supervision of Pepper and Stengel, is shown by the
fact that it covers more than 180 pages. Among other interesting
matter the sections on the Schott method, typhoid fever, malaria
and myxedema are probably of the most interest. In view of the
extravagant claims for the different methods of aborting typhoid
fever, it is gratifying to notice that the authors ask that all cases
treated by these methods be more carefully studied and the symptoms more minutely described.


Under the head of surgery, which occupies 248 pages of the volume, Keen and DaCosta give a valuable resume of the most recent
work in ansesthetics, with sensible comments upon the dogmatic
assertions of many experimenters. It is refreshing to read the
following: " Wunderlich, from a statistical study, concluded that
albuminuria was more apt to be induced by chloroform than ether.
Beck from a statistical study concluded that albuminuria was most
apt to be caused by ether. We are thus confronted by carefully
compiled reports which are diametrically opposed and absolutely
contradictory. The humble surgeon who venerates statistics too
much to use them is lost in uncertainty. We are told that figures
cannot lie, and yet only one of these statements can be true. Which
is the truth we cannot yet decide, as we know of no birthmark to
prove identity."


The operative treatment of perforation in enteric fever would
[Ko. 71.  
seem to be presented in too gloomy colors, in the light of Finney's
recent statistics.  


The article on diseases of the gall-bladder is quite full and satisfactory. The same may be said of the careful and conservative
article on the use of the x rays.


Obstetrics, under the editorship of Hirst and Borland, occupies
about 100 pages, and presents many topics of special interest to the
general reader, notably the sections on the pathology of pregnancy,
abortion and extra-uterine pregnancy.


The section on gynecology, by Baldy and Borland, occupies
the sewing of the wound, and so it was in this case. The
upwards of 200 pages, and touches upon a variety of interesting  
sewed-up gall bladder was put upon a tension and burst, and
the patient died from sepsis.
 
I have here a small cholesterine stone which led to a bad
condition of the patient. A lady, about forty years of age, the
wife of a physician, who was very carefully observed, had had
one attack of gall stones about four or five months previously to
the time I saw her. She was taken with chills, high fever and
deep jaundice. I found her, about nine or ten days after the
beginning of this attack, in a very low condition, so bad that
the only indication at that time was to open the gall bladder,
drain it and do away with the stagnation of the bile. About
three weeks later this stone was removed from the common
duct, and although the patient for a number of months after
this presented some febrile symptoms, with occasionally slight
chills, she eventually has entirely recovered.
 
Here is another stone, which has been removed from the
ductus choledochus, and one of exceptional size for a choledochus stone.
 
I have one specimen in which I was obliged, apart from
opening the gall bladder, to incise the cystic duct at two
different places, and also the common duct. That was a case
in which the gall stones were very small, not larger than peas,
and which were caught behind the protruding folds and diverticula of the cystic duct, so that they could not be shifted. I
sewed up the common duct as well as the cystic duct, and
drained the gall bladder. This patient made a good recovery.
 
The principal point of resistance for gall stones is the region
of the papilla in the wall of the duodenum. In a good many
instances it has been found that large stones there destroy the
surrounding parts and form fistulous communications with
the duodenum. I have had the opportunity of operating in
one such case, in which I thought I had to do with a malignant affection of the duodenum. The patient was sent to me
as a case of cancer of the pylorus. It could be made out
easily that the pylorus must be free, because vomited matters
contained a large amount of bile. By palpation nothing
certain could be made out, and in operating, I cut down
through a great many adhesions and a good deal of scar tissue
and found the duodenum obstructed by a hard mass, apparently of scar formation. I separated that, but in going
further I met with a hard firm body which was apparently
adherent to the vertebral column. I stopped the operation.
The patient was very much run down. Believing that the
duodenum was not sufficiently patulous I made a gastroenterostomy. The patient rallied from the operation fairly
well, but fell into a state of collapse five or six hours later and  
died. In making the autopsy I found, to my very great surprise, that this large mass behind the duodenum was not a
malignant affection, but a large mass of gall stones, partly
lodged behind the wall of the duodenum and partly within
the wall of the duodenum, with a number of fistulous openings into the duodenum. The constrictions from scars were
such that the contents of the duodenum could not easily pass
beyond this point, and the symptoms of obstruction of the
intestinal tract were the consequence.
 
I show you here a stone which has been excised from the
small intestine. It is a very beautiful specimen of a pure
 
 
 
cholesterine stone. Why a stone of this size cannot pass, while
a Murphy's button will pass easily, I cannot tell. The patient
in this case was an old lady. The operation was done very
smoothly and I had good hopes for recovery, but she died
in eight hours after the operation, from collapse.
 
These are the regular ways of the gall stones; but we know
that from the gall bladder or from any other point in the gall
system, through destruction of the surrounding tissues, they
may find an outlet into a neighboring viscus or through the
abdominal wall. Gases of this kind have at all times been very
interesting and full of medical interest. I show you here
specimens from one of my first cases of this kind, which
occurred about seventeen years ago. It was a case of abscess
of the abdominal wall, at the bottom of which I found gall
stones. They were still lodged in the gall bladder. The
patient would not submit to further surgical treatment and
still has a fistula which discharges bile.
 
I have here some specimens, some 300 in number, from a
case of acute cholecystitis. And here are specimens from
another case of cholecystitis, in which I might call your
attention to a point of interest, namely, on the cross-cut you see
three small gall stones matted together by a binding mass, so
that a single stone is simulated. Gall stones in the first stages
of their development are very soft masses, and, owing to the
beautiful and careful researches of Naunyn, we know that
there is an organic substructure for their development.
 
A very serious complication that has led to fatal issue in
several of my cases of advanced cholemia is an inclination of
the patients to bleeding. Three of my cases I have lost from
secondary hemorrhages. Two of these cases were complicated
with malignant disease of the pancreas; at least I think they
were cases of cancer of the pancreas. Autopsies were not
made, and I can only say that I felt in the region of the head
of the pancreas a resistant hard mass which I took for a
malignant affection. Lately, Professor Riedel, a surgeon who
has perhaps worked more in gall surgery than any other living man, has published cases in which he is inclined to assume
that occasionally these apparent malignant thickenings of the
pancreas may be but inflammatory thickenings, and he mentions one case which seems to be beyond any doubt. In an
elderly gentleman, in whom the operation was abandoned,
assuming that this was a case of cancer of the pancreas, the
stones merely were removed. A fatal issue was awaited, but
the patient lived for years and years and became healthy and
strong, and there could be no question about his not having
malignant disease. He assumes that through the presence of
stones an irritation is kept up in the pancreas, and that this
irritation, after the removal of the stone, may cease and the
condition improve.
 
I have lost one of these cases by the separation of the
Murphy's button after establishing cholecystenterostomy.
The patient had had up to that time small hemorrhages from
the inside of the gall bladder. I had purposely kept the gall
bladiler open, stitched to the abdominal wall, because I had
the impression that this probably would be a case of bleeding,
and in order to tanijion and make counter pressure I kept the
gall bladder open, and was able up to the tenth or eleventh
day to check the bleeding, but after the separation of Murphy's






Apeil, 1897.]  
February, 1897.]  




Line 4,359: Line 4,766:




83
31
 
 
 
button the patient had a profuse hemorrhage into the large
intestine and succumbed to anaemia.
 
In another case there was no proof of any malignant infection. It was a young person with impaction of gall stones in
the common duct. The operation went off very well, but on
the fifth or sixth day she had a secondary intra-peritoneal
hemorrhage which was, I am sorry to say, detected too late.
It is a fact that has been observed repeatedly, that in some
cases there is an inclination to hemorrhage a certain number
of days after operation. These patients who are apt to bleed
from cholsmia, show a great tendency to bleed while one is
incising the abdominal wall. They are, as a rule, much run
down in health.
 
I will show you here an exceptionally beautiful specimen of
gall stones from a case of sarcoma of the gall bladder, — a sarcoma which was not detected at the time of operation. I
thought it was a case of stenosis from impaction of a stone in
the apex of the cystic duct. To be sure, there was a suspiciously rough surface at the point of this stone. After a number of months a tumor mass sprung up from the gall bladder.
Evidently this stone had been lodged with its point on the
irregular surface of the tumor, and I think the roughness of the
stone is somewhat indicative of its being in contact with an
irregular surface and not with the smooth surface of the gall
bladder.
 
As far as the surgical technique of this operation is concerned: To begin with the abdominal incision, I must say
that I have entirely abandoned the longitudinal incision ; but,
according to the i)roposition of Corvisart and the experience
of other surgeons, I do exclusively the operation parallel to
the border of the ribs. Correspondingly to the thickness of
the abdominal wall, this incision occasionally must be a very
large one. A very great difficulty must occasionally be met
with through the smallness of the liver. It is an entirely mistaken idea that in consequence of stagnation of bile the liver
must be enlarged. On the contrary, I have had the experience that in occlusion of the common duct of long duration,
probably through the influence of j)ressure, an atrophic condition of the liver tissue will take place, and occasionally the
liver will be concealed high up behind the ribs, and this may
cause a great deal of difficulty in consequence of the high and
deep position of the field of operation. I have taken, in eight
of these cases, to excising the adjacent cartilages of the ribs,
and I should like to commend that. It facilitates the operation very much. On the other hand, of course the enlargement of the liver may be a great hindrance, and, esjiecially in
fat and plump persons of short build, it maybe quite difficult
to get down to the common duct. In one of the cases I was
unable, in spite of excision of the ribs, to get effectually down
to the point of the trouble, and not until I had pulled the
liver as far as I could out of the incision, almost one-third of
the liver substance being brought outside of the abdominal
wall, was I able to easily get to the cystic and common ducts.
It was the case in which I was obliged to open the cystic duct
at two different points and, besides that, the common duct at
the usual place about the middle of its course. In the cases
of acute inflammation it is of course necessary, wherever one
has reason to presume that the neighborhood of the gall blad
 
 
der is infected, to keep everything as much as possible open
and give entirely free outlet for the peritoneal secretions. At
the same time I always drain the gall bladder with a long
tube with the view of having a siphon action upon the
secreted gall, and this will act very effectually. Of course
occasionally a blockage will take place through mucus or
blood clot, and then it will be necessary to change the tube or
make a cautious washing through it. I should advise against
the injection of any irritating antisef)tic solution into the gall
bladder. I have observed that occasionally this fluid will
cause distressing symptoms, attacks of colic, probably because
it may get into the common duct and the hepatic duct and
irritate. I only use saline solution or boiled water. I have
always found that the bile itself was an antiseptic agent.
After a short time the amount of purulent secretion is insignificant, and the healing of the abdominal wounds, although
constantly in contact with the bile, is mostly uneventful and
without any untoward symptoms.
 
About stones in the liver substance I have no practical
experience. I have once found a stone in the liver after it had
perforated the walls of the gall bladder, but I have not had
any experience with stones in the liver that have formed in
the gall system above the hepatic duct. It is a fact that
these stones will occur, and that occasionally quite extensive
casts of stone formation will take place in the gall system.
 
I will not mention comparatively frequent uncomplicated
cases, where we have to deal with dilated gall bladders and
stones and where the surgical treatment is comparatively
simple.


The operation in two sittings I never do. I find that it is
entirely safe to operate in one sitting. I have always aspirated as much as possible the contents of the gall bladder
through a thick aspirating needle, protecting as cautiously as
possible the surroundings to guard against infection.


Discussion.


matter. The objection presented to Clark's radical operation for  
Dr. Halsted. Dr. Lange's talk has been instructive to all
the relief of uterine cancer, that but few patients can endure the  
of us. At one of our meetings, not very long ago, I described
shock of the prolonged etherization, seems hardly tenable in the  
three consecutive choledochotomies or incisions into the common duct for the removal of gall stones, all of which were
light of actual practice. The chapter on nervous and mental diseases, by Church and Patrick, is thoroughly well worked out, and  
successful. Two of these cases I exhibited on that occasion.
presents a good review of the work of the past year. The section
What Dr. Lange says about the enlargement of the head of
on materia medica is an excellent feature of the book. All things
the pancreas interests me, because on several occasions I too
considered, the book is well arranged, admirably edited and well
have noticed in gall-stone cases that the pancreas was hard.
printed. Every physician who does not have leisure to inform himself on the latest advances in medicine and surgery from original
On the first occasion, some four or more years ago, I was misled and thought for a time that the patient might have cancer
sources, should procure and carefully read the volume.
of the pancreas. Since then I have several times found an
indurated pancreas in these cases and have spoken of it at the  
operating table. The induration of the head of the pancreas
was especially noticeable in one case. This case was one of
great interest irrespective of this hardening. A very large
stone occupied and had almost ulcerated through the common
duct. There was, however, no local peritonitis. A little
scratch and a little pressure on the wall of the common duct
were enough to extrude the stone. The stone being extracted,
we found quite a large hole in the common duct and duodenum just where they came together. This made a plastic
operation necessary ; and a very difficult one it proved to be


Architecture of the Brain. By Wm. Fuller, M. D., Grand Rapids,
Michigan. 1896. Pages 1-183, with many illustrations.
In this volume are described and pictured the general gross relations of the brain as seen (1) from the external surface, (2) on dissection, and (3) in a series of frontal sections. The author has had
a large experience in dissection of the central nervous system and
in the preparation of castings in plaster of the dissections which he
has made. No person except one who has busied himself in work
of this kind can easily estimate the amount of labor which has preceded the publication of the book.


After a description of the membranes, thecerebro-spinal axis as a
whole is described. The cerebrum is then taken up and the method
of dissecting it outlined. A discussion of the structure of the cerebellum, of the pons varolii, of the medulla oblongata and spinal
cord follows. Throughoutthe book the mainstressis laid upon the
gross morphology, but there are brief chapters concerning the nerve
tracts of the cerebro-spinal axis and the central origin and relations
of the cranial nerves. On pages 130-133 there is a brief discussion
of topographical cerebral localization. L. F. B.


Annual Report of the Supervising Surgeon-General of the Marine
32
Hospital Service of the United States for 1893. Vols. I and II.
(Washington: Oovernment Printing Office, 1894-1895.)
These volumes present a very complete and satisfactory account
of the operations of the Marine Hospital Service for 1893. The most
valuable papers are a carefully prepared account, by Surgeon Stoner
of Baltimore, of the origin and development of this Service, which
should be read by all who desire to familiarize themselves with its
history, and the " Report of the Commission to Investigate the Cholera Epidemic," prepared by Dr. Walter Kempster and Surgeon Fairfax Irwin, who made an extensive trip in Europe to procure data for
it. It is to be regretted that the Commission, while entering into
very great detail as to its operations, does not formulate and publish its conclusions in connected form. Scattered throughout the
report are many valuable suggestions touching the prevention of
infectious diseases and the transmission of contagion, which can
only be found by reading many unimportant details. These should
have been gathered in an accessible form, so that they might be
easily read.


Medical and Surgical Report of the Presbyterian Hospital in the
City of New York. Vol. I., January, 1896. By Andrew J.
McCosH, M. D., and Walter B. James, M. D. (The Knickerbocker Press, New York.)


This report is the first of a series. It is carefully edited and
well illustrated. Many of the papers are carefully written and of
great interest to the general profession. The pathological reports
are meagre and the protocols published are in most instances brief
abstracts. Several of the papers have appeared elsewhere. One of
them, that of Dr. Northrop, on Gonorrhoeal Arthritis, is more
popular than scientific, and portions of it read as it the author were
thinking aloud. The results of thinking rather than mental operations would be preferable. Taken as a whole, the surgical papers
seem to be of the greater value. The volume, however, is worthy
of the institution from which it issues and the high character of its
editors. It is to be hoped that it will have an annual successor.


JOHNS HOPKINS HOSPITAL BULLETIN.




BOOKS RECEIVED.


Transactions of the American Gynecological Society. Vol. 21. 1890.  
[No. 71


8vo. 490 pages. Wm. J. Dornan, Printer, Philadelphia.
Prize Essays on Leprosy. By Newman, Ehlers and Impey. 1895.


8vo. 227 pages. New Sydenham Society, London.
Practical Notes on Urinary Analysis. By William B. Canfield,
A. M., M. D. Second edition. 1896. 12mo. 106 pages. G. S.
Davis, Detroit, Mich.
A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In photolithochromes from models in the Museum of the Saint-Louis
Hospital, Paris. With explanatory woodcuts and text. By E.
Besnier, A. Fournier, etc. Edited and annotated by J. J. Pringle,
M. B., F.R.C. P. Fol. Parts IV and V. 1896. W.B.Saunders,
Philadelphia.
Lectures on Pharmacology for Practitioners and Students. By Dr. C.
Binz. Translated from the second German edition by Arthur C.
Latham, M. A., M. B. Oxon., M. A. Cantab. Vol. 1. 1895. 8vo.
389 pages. The New Sydenham Society, London.
Autoscopy of the Larynx and the Trachea. (Direct Examination without
Mirror.) By Alfred Kirstein, M. D. Authorized translation
(altered, enlarged and revised by the author) by Max Thorner,
A. M., M. D. 1897. 12mo. 68 pages. The F. A. Davis Co.,
Philadelphia.
The Practice of Medicine. By James Tyson, M. D. 1896. 8vo.


1184 pages. P. Blackiston, Son & Co., Philadelphia.  
because we had to do such delicate work at such a very great
Anomalies and Curiosities of Medicine. By George M. Gould, A. M.,  
depth. Even if the parts to be stitched could have been
M. D., and Walter L. Pyle, A. M., M. D. 1897. 4to. 968 pages.  
brought to the surface it would have been no easy task to
W. B. Saunders, Phila.  
accomplish the repair of the hole. The patient made an
A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In Photo-Lithochromes from Models in the Museum of the Saint Louis
excellent recovery. She has gained nearly one hundred
Hospital, Paris, with explanatory woodcuts and text. By E.  
pounds and has no symptoms of stricture of the ductus choledoctinus. Of the other cases of stone in the common duct,
Besnier et al. Edited by J. J. Pringle, M. B., F. R. C. P. Part
one is interesting because complete obstruction was caused by
VI. 1896. W. B Saunders, Philadelphia.  
a very small stone in the diverticulum of Vater, or near it.  
A Treatise on Cholelithiasis. By B. Naunyn, M. D. Translated by  
This stone, not more than 3 mm. in diameter, could not be
Archibald E. Garrod, M. A., M. D., F. R. C. P. 8vo. 197 pages.  
pushed in either direction. After considerable manipulation
1896. The New Sydenham Society, London.
we cut down upon it and removed it. It will undoubtedly
Principles or Guides for a Better Selection or Classification of Consumptives Amenable to High Altitude Treatment and to the Selection of  
strike you as very strange that we could not manage to extrude
Patients who may be more Successfully Treated in the Environment to  
so small a stone. We might possibly have succeeded with the
which they were Accustomed Previous to their Illness. By A. Edgar
exercise of some violence ; but the choledochotomy recommended itself to me as the safer procedure. We might,  
Tussey, M. D. 1896. 8vo, 144 pages. P. Blakiston, Son & Co.,  
with a hypodermic syringe, inject oil into the duct and so
Philadelphia.  
perhaps make smooth the folds of mucous membrane and dislodge the stone by subsequent manipulation.  
Twentieth Century Practice. An international encyclopaedia of mod
 
ern medical science, by leading authorities of Europe and America
Eegarding deaths from hemorrhage: Dr. Lauge speaks of
Edited by Thomas L. Stedman, M. D. Vol. X. 1897. 859 pages
the so-called parenchymatous hemorrhage in these highly
8vo. Wm. Wood & Co., New York.  
jaundiced patients. We have had one death from this cause.  
Transactions of the College of Physicans of Philadelphia. Third SeriesVol. XVIII. 1896. 8vo. 263 pages. Printed for the College
Our first common duct case died on the tenth day from hemorrhage. There were absolutely no symptoms of peritonitis.  
Philadelphia.  
The patient made a very good recovery from the operation, notwithstanding the fact that he was so weak that we hesitated
Injuries and Diseases of the Ear. Being reprints of papers on otol
to operate upon him.  
ogy. By Macleod Yearsley, F. R. C. S. 12mo. 1897. 40 pages
 
The Rebman Publishing Co., Ltd., London.  
In 1880 or 1881 I performed my first gall-stone operation.  
The American Tear-Book of Medicine and Surgery. Being a yearly
At that time only one or two operations for gall-stones had
digest of scientific progress and authoritative opinion in all
been performed in this country. The case is one of considerable interest. Seven stones were removed from the bladder,
branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign
which was distended with pus and adherent to the abdominal
authors and investigators. Collected and arranged, with critical
wall. The common duct could not with safety have been
editorial comments, by J. M. Baldy, '^l.D.,ei al. Under the general editorial charge of George M. Gould, M. D. Profusely illustrated. 4to. 1897. 1257 pages. W. B. Saunders, Philadelphia.  
examined even if it had occurred tome to do so. The patient
Inebriety. Its Source, Prevention and Cure. By Charles Follen Palmer. 12mo. 1897. 109 pages. Fleming H. Revell Co., New York.  
lived for about two years after the operation. At no time
The Medical Annual and Practitioner's Index. A work of reference
after the operation was she entirely free from jaundice, nor was
for medical practitioners. Fifteenth year. 1897. 12mo. 851
she at any time either before or after the operation profoundly
pages. John Wright & Co., Bristol.  
jaundiced. The stools were usually acholic, but occasionally
Lectures on Angina Pectoris and Allied Stales. By William Osier,  
showed unmistakable signs of bile. The sinus which led to
M.D. 1897. 8vo. 160 pages. D. Appleton & Co., New York.  
the gall-bladder was not allowed to close until a few weeks
before the death of the patient. Death was precipitated by a
slight local peritonitis. At the autopsy all signs of the sinus
which had led to the gall-bladder had disappeared. Nothing
but a few connective tissue threads remained to indicate where
the sinus had probably been. The gall-bladder was reduced
to nothing but a little knob of connective tissue. The
liver was perhaps less than one-half its original size. The
common duct and one hepatic duct were dilated sufficiently to
permit a calculus as large as a plover's egg to glide easily up
and down from the duodenum to the interior of the liver.  
The calculus was somewhat egg-shaped, and could almost be
pushed into the duodenum through the openii)g which partly
by ulceration, partly by dilation, it had made for itself. It
became engaged at this ring of cicatricial tissue a little beyond
its middle when allowed to fall naturally, point downwards,  
in the common duct, from the liver to the duodenum. The
wall of the common duct was very thick. The stone had evidently freely traversed the entire length of this dilated canal,
 
 
 
from the very centre of the liver to, and almost into the intestine. At the autopsy which was made by a very distinguished
pathologist the calculus was not found until the liver had been
literally cut to pieces, so deeply was the stone imbedded in this
organ. The occasional presence of bile in the stools and the
absence of profound jaundice were thus readily explained by  
the findings at the autopsy. When the calculus was in the
dilated branch of the hepatic duct, bile could escape through
its other branch and appear in the feces. When the calculus
plugged tightly the orifice into the duodenum the jaundice
increased. That it should never have been profound could be
explained by the fact that the stone traveled freely everywhere
in the duct; a little bile could probably escape except when
the stone was engaged at the duodenal end of the duct.  
 
Will Dr. Lange kindly tell us if he always employs drainage of some kind in suture of the ductus choledochus; and
if so, how long does he permit his di-aiu to remain ? Does he
not think that the drainage material, gauze, etc., should be
left undisturbed until the rest of the peritoneal cavity is well
walled off and protected from reinfection ? Quite recently
one of Germany's best surgeons removed the gauze in one of
these cases on the third day. Peritonitis supervened promptly
and the patient died. I have noted that this surgeon and several well-known English surgeons state that no harm is done
by leakage from the duct after suture of it, provided one
drains down to the sutures. I think that one should, if possible, so suture the duct that its contents cannotescape. Fluid
can convey solid and infected particles to places in the general peritoneal cavity which are not protected by the gauze.  
Furthermore, I have the idea that adhesions take place more
firmly about dry gauze than about gauze which is constantly
bathed in fluids.  
 
For this reason, if we have sutured a gall-bladder to the
parietal peritoneum, or if we have packed gauze anywhere
about this gall-bladder which we have opened and propose to
drain, we endeavor to prevent leakage for the next three or four
days bypassing a purse-string suture all along the edge of our
opening into the gall-bladder, and drawing it up when we have
introduced our gauze or drainage tube into the gall-bladder.
 
We explore all the ducts and open and evacuate the gallbladder in one act. Kiedel's advice to perform the operation
in two acts, opening and evacuating the gall-bladder at the
second act, is bad. We have more than once, while removing
biliary calculi, remarked that it would have been impossible to  
extract them without the aid of fingers in the abdomen. Bimanual manipulation is of course impracticable when the
bladder is adherent, all around, to the abdominal wall, as it is
at the time of the second act in the operation in two acts.
 
Dr. Lange's suggestion to cut through one or two ribs to  
facilitate matters where the liver is very small and the gallbladder so high as to be otherwise almost inaccessible, is
undoubtedly an excellent one.*
 
*Jan. 2nd, 1897. I have recently had occasion to resort to this
procedure while removing a tuberculous kidney which was adherent to the diaphragm. After dividing two ribs I could proceed
quite easily with a dissection which otherwise might not have been
feasible. When the liver is very large this method of gaining
room is indicated quite as much a when the liver is small.  
 
 
 
February, 1897.]
 
 
 
JOHNS HOPKINS HOSPITAL BULLETIN.  
 
 
 
33
 
 
 
Dr. Laxqe. — I think that in some of my cases I had reason
to assume that there was some valve action, especially in one
case of stoue in the common duct of small size. The patient
had had an attack of gall stone some three months before this
attack, with jaundice lasting several weeks, most likely
because of obstruction from this stoue, which was solitary, as
judged by its very round, regular shape. Probably after a
time this stone shifted back and later on again caused obstruction together with an infection. This we saw not uncommonly in cases of obstruction of the common duct. Even if
the stones are ball-like or rounded, at intervals a certain
amount of bile will get into the gut. It is almost characteristic that if, in prolonged jaundice, at intervals the condition
of the fajces and the urine points to the passage of a certain
amount of bile through the duct, we have probably to deal
with obstruction from stone.  
 
Eegardiug the drainage of the common duct, I have tried
everything: I have left the duct entirely open, and I have
sewed it up with the insertion of a small drainage tube into
the lumen of the duct, and I have sewed it up entirely. In
cases where the wall of the common duct is healthy, I think
it is preferable, if it can be done, to sew up the duct entirely.  
If there is reason to assume that there is obstruction beyond
the stone, I should prefer to drain, and I do this in such a
way that I insert a small drainage tube from the wound in
the common duct and pack gauze around it. This gauze
(iodoform gauze boiled in glycerine) I leave in for five or six
days. The tube I leave for a sufficiently long time to secure
the proper outlet of any secretion as long as it exists. In
draining the gall bladder I pack the gauze around the tube
and leave the opening comparatively large, for the reason that,
at least in inflammatory cases, the surface of the gall bladder
is such that it will necessitate some thorough cleansing and
local treatment for a limited time. There will be clots of
blood or shreds of tissue or inspissated mucus which might
easily obstruct. I mostly remove this tampon in two or three
days and give the inside of the gall bladder an additional
thorough washing and cleansing.  
 
Besides this we have either sewed the peritoneum to the surface of the gall bladder where there is no infection outside of
it, or we have packed around the circumference of the gall
bladder in such a way that even if some of the contents of the
bladder escape it is not likely to cause a spreading inflammation.
 
Dr. Halsted has spoken of the necessity of having a proper
needle ; I have a proper needle.  
 
In one case I dissected the peritoneum from the walls of
the abdomen. The case was that of an old gentleman, a
physician, who had been suffering for years from attacks
which were supposed to be stomach attacks, and there was a
suspicion of his having chronic ulcer of the stomach and
malignant induration. I opened in the middle line and found
nothing, but on palpating the gall bladder I found it full of
small stones. The liver was small and the gall bladder very
high up. I was obliged to loosen the peritoneum. This
gentleman had for five or six days incessant vomiting and the
gall bladder was torn away from the peritoneum. He still
has his gall stones in his gall bladder, but for a number of
 
 
 
years he did not have any attacks. Lately, I understand, he
has had them again.  
 
I have also done the sewing of the omentum against the
gall bladder in the way that Lauenstein proposes, and have
been quite satisfied with it.  
 
Finally, I should like to say that I have regarded the invitation to come here as a very flattering one. I have come
with the greatest imaginable pleasure, and for the reason,
apart from the friendly relations which I have hei'e, that I
have the consciousness of being at a place where science is
promoted and sought for in a devoted and unselfish manner.
I regard this institution as the pride of this country, and I
hope that it will not be the only one, — that others will follow,  
and that this country will be eager to base medicine on the
sound basis of scientific conception.
 
 
 
CORRESPONDElSrCE.
 
 
 
A Case of Pnetjmo-Cardial Rupture.
To the Editor of the Johns Hopkins Hospital Bulletin.
 
Dear Sir:— I send herewith a report of a case of pneumocardial rupture which has come under my observation, which
you may deem of sufficient interest to publish.  
 
On March 36, 1896, a negro man, age 23, was brought to our
hospital in a condition of collapse, with the history that a
bank of sand or earth had fallen on him and a fellow-workman,  
the latter dying in a few hours afterwards from internal injuries. The patient's breathing was shallow, jerky, rapid and
very painful, and every few minutes he had a hard spasm of
coughing, which distressed him greatly and during which he
expectorated a good deal of bright red blood. Morphin to
relieve his pain and coughing, and strychnin were given him
freely. On the second day he complained of intense pain in
the cardiac region, and the stethoscope revealed a very interesting, if not an entirely unique state of affairs. This was a loud
double friction sound with a bubbling and splashing sound,  
which could be distinctly heard with the stethoscope two
inches from the chest wall. The diagnosis was a rupture
between the pericardium and the lung. On the third day
(losing sight of the fact that air from the lung is usually
sterile) I supposed that he had a septic pericarditis due to the
effusion of blood and air from the lung. An examination of
the blood, however, showed no leucocytosis, which proved conclusively that the pericarditis was not septic. This examination was repeated daily for three days, each time with the same
result; and as at no time had he much fever, and as the pulse
and respiration during this three days gradually improved, a
favorable prognosis was given, which was justified later by his
complete recovery. The loud splashing and bubbling disappeared by the fourth day. The rough friction sound persisted for three weeks, and after that the heart sounds were in
every respect normal.  
 
Georue S. Brown, M. D.  
 
2220 First Avknce, Birminoham, Ala.  
Vec. 10, 1898.  






84
3i




Line 4,499: Line 5,148:




[No. 73.  
[No. 71.  




Line 4,508: Line 5,157:


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


Report in Patliolopry
 
 
Volume I.
 
 
 
423 pages, 99 plates.
 
Report in Patliolosry.
 
 
 
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;  
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  
Healing of Intestinal Suturos; Reversal of the Intestine; The Contraction of the  


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


(Atrophy). By Henrt J. Berkley, M. D.  
(Atrophy). By Henry J. Berkley, M. D.  
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.  
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.  


Mall, M. D.  
Mall, M. D.  


Report in Dermatolog-y.  
Report in Derniatolog'y.  
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By  
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By  


T. C. Gilchrist, M. D., and Emmet Rixford, M. D.  
T. C. Gilchrist, M. D., and Emmet Rixford, M. D.  
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of  
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  
Protozoa, and the Blastomyces found in the preceding Cases, with tlie so-called  


Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum
Parasites found in Various Lesions of the Skin, etc.; Two Cases of MoUuscura


Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By  
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By  
Line 4,537: Line 5,196:
T. C. Gilchrist, M. D.  
T. C. Gilchrist, M. D.  


Report in Pathology.  
Report in Pntliolog-y.  
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration  
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration  


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


Volume II. 570 pages, with 28 plates and figures.  
Volume II. 570 pages, with 28 plates and figures.  
Line 4,552: Line 5,209:
Gallstones. By William Osler, M. D.  
Gallstones. By William Osler, M. D.  
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.  
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.  
On Pyrodin. By H. A. Lafleur, M. D.  
On Pyrodin. By H. A. Lafledr, M. D.  
Cases of Post-febrile Insanity. By William Osler, M. D.  
Cases of Post-febrile Insanity. By William Osler, M. D.  
Acute Tuberculosis in an Infant of Four Months. By Harry TotJLMiN, M. D.  
Acute Tuberculosis in an Infant of Four Months. By Harry Toulmin, M. D.  
Rare Forms of Cardiac Thrombi. By William Osler, M. D.  
Rare Forms of Cardiac Thrombi. By William Osler, M. D.  
Notes on Endocarditis in Phthisis. By William Osler, M. D.  
Notes on Endocarditis in Phthisis. By William Osler, M. D.  
Line 4,563: Line 5,220:
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  


Report in Gynecolog-yThe Gynecological Operating Room. By Howard A. Kelly, M. D.  
Report in Gynecology.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard  
The Gynecological Operating Room. By Howard A. Kelly, M. D.  
The Laparotomies performed from October 16, 18S9, to March 3, 1890. By Howard  


A. Kelly, M. D.. and Hunter Robb, M. D.  
A. Kelly, M. D., and Hunter Robb, M. D.  
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards mth
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of  
out Operation ; Composite Temperature and Pulse Charts of Forty Cases of  


Abdominal Section. By Howard A. Kelly, M. D.  
Abdominal Section. By Howard A. Kelly, M. D.  
Line 4,576: Line 5,233:
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;  
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;  


Ovarian Tumor; General Gynecological Operations from October 15, 1889, to  
Ovarian Tumor; General Gynecological Operations from October 15, 18S9, to  


March 4, 1890. By Howard A. Kelly, M. D.  
March 4, 1890. By Howard A. Kelly, M. D.  
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howard  
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howard  


A. Kellt, M. D., and Albert A. Ghrisrey, M. D.  
A. Kelly, M. D., and Albert A. Ghriskey, M. D.  
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking  
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking  


Line 4,587: Line 5,244:
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.  
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.  
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.  
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.  
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.  
My.xo-Sarcoma of the Clitoris. By Hunter Robb. M. D.  
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment  
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment  


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


HowARD A. Kellt, M. D.  
Howard A. Kelly, M. D.  


Report in Surgery, I.  
Report in Snrgrcry, I.  
The Treatment of Wounds with Especial Reference to the Value of the Blo.d C!ol
The Treatment of Wounds with Especial Reference to the Value of the Bloi-d Clot


in the Management of Dead Spaces. By W. S. Halsted, M. D.  
in the Management of Dead Spaces. By W. S. Halsted, M. D.  
Report in Nenrology, I.  
Report in Nenrologry, I.  
A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.  
A Case of Chorea Insaniens. By Henry J. Berkley, M. T).  
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.  
Haematomyelia. By August Hoch, M. D.  
Haematomyelia. By August Hoch, M. D.  
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. liv
A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By


Henry M. Thomas, M. D.  
Henry M. Thomas, M. D.  


Report tn Pattiologry, I.  
Report In Pntliology, I.  
Amoebic Dysentery. By William T. Councilman, M. D., and Henhi A. Lafleur, M. \\
Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleor, M. D.




Line 4,612: Line 5,270:
Volume III. 766 pages, with 69 plates and figures.  
Volume III. 766 pages, with 69 plates and figures.  


Report in Patliology.  
Report in Patlio1og:y.  


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


Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
Report in Patliolosry.  
Report in Patliology.  


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


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


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


Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
Line 4,629: Line 5,287:
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  


Report in Gyneeolog-y.  
Report in GJ-neeolog-y.  


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


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


Intestinal Worms as a Complication in Abdominal Sui^ery. By A. L. Stavely, M. D.  
Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavblt, M. D.  






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


Line 4,651: Line 5,309:
Photography applied to Surgery. By A. S. Murray.  
Photography applied to Surgery. By A. S. Murray.  


Traumatic Atresia of the Vagina with Hamatokolpos and Hamatomctra. By Howard  
Traumatic Atresia of the Vagina with H^matokolpos and Hasmatometra. By Howard  
A. Kelly, M. D.  
A. Kelly, M. D.  


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


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


Resuscitation in Chloroform Asphyxia. By Howard A. Kellt, M. D.  
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.  


One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.  
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.  
Line 4,667: Line 5,325:


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


Volume IV. 504 pages, 33 charts and illustrations.  
Volume IV. 504 pages, 33 charts and illustrations.  


Report on Typhoid Fever.
Report on Typhoid Fever,


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


Report in Neurolog-y*
Report in Nenrolog-y.


Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The  
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The  
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the  
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the  
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of Mm mnscidus; The Intrinsic Nerves of the Thyroid Gland of  
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of Mux musculuf. The Intrinsic Nerves of the Thyroid Gland of  
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berklet.
M. D.  
M. D.  


Report in Snrg-ery,
Report In Surg^ery.
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to  
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to  
January, 1894. By W. S. Halsted, M. D.  
January, 1894. By W. S. Halsted. M. D.  


Report in Gynecologr.  
Report in Gyneeology.  
Hydrosalpinx, with a report of twenty-spven cases; Post-Operative Septic Peritonitis;  
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;  
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.  
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.  
Report in Patliology.  
Report in Patliologry.  
Deciduoma Malignum. By J. Whitridge Willlams, M. D.  
Deciduoma Malignum. By J. Whitridge Williams, M. D.  




Line 4,702: Line 5,358:
CONTENTS:  
CONTENTS:  
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.  
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.  
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M, B.  
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  


Studies in Typliold Fever.  
Studies in Typlioid Fever.  
By WiLUAM Osler, M. D., with additional papers by G. Bltjmer, M. D., Simon  
By William Osler, M. D., with additional papers by G. Bluher, M. D., Simon  
Flexner, M. D., Walter Reed, M. D., and H. C. Parscss, M. D.  
Flexner, M. D., Walter Reed, M. D., and H. C. Parscns, M. D.  




Line 4,712: Line 5,368:
Volume VI. About 500 pages, many illustrations.  
Volume VI. About 500 pages, many illustrations.  


Report in Nenrolofo**
Report in NenrolOKy
 
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical  
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical  
Nerve Cell (Studies Nob. I to V). By He.vry J. Berkley. M. D.  
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley. M. D.  


Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the  
Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the  
Chromate of Silver Methods; Part 1. — Alcohol Poisoning. — Experimental Lesions  
Chromate of Silver Methods; Part I.— Alcohol Poisoning.— Experimontal Lesions  
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental  
produced bv Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental  
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part II. — Senrni
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part H. — Sonim
Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on  
Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on  
the Cortical Nerve Cell; Part III. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by O.rwnic
the Cortical Nerve Cell; Part III.— Ricin Poisoning.— Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Oifonic
Ricin Poisoning; Part IV. — Hydrophobic Toxaemia. — Lesions of the Cortical  
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical  
Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Ner\*e Cells from the Effects of  
Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Patliological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of  
Alcohol and Ricin Intoxication; Nen-e Fibre Terminal .apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.  
Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.  


Report in Patliologry.  
Report In Patliologry.  


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


Cullen, M. B.
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death. Probable Migration of  
Pregnancy in a Rudimentary LTtcrine Horn. Rupture, Death, Probable Migration of  
Ovum and Spermatozoa. Bv Thomas S. Cullen, M. B.. and G. L. Wilkins, M. D.
 
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen. SL B.


Ovum and Spermatozoa. By Thomas S. Cdllen, M. B., and G. L. Wilkins, M, D.
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. C'ullen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By  
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By  
William D. Booker. M. D.


William D. Booker, M. D.
The Pathology of Toxalbumin Intoxications. By Simon Flexner, M. D.  
The Pathology of Toxalburain Intoxications. By Simon Flexner, M. D.  
Tfie price of a set bound in cloth [Vots. I-TI] of the Hospital Itejwrts is


$30.00. Vols. I, II ami III arc not sold scjiaratehj. The price of  
Thr pricf of a set hound /» Hoth [To/.*. I-VI\ of the Uoftpitftl Jit-ports is
$.•$0.00. Vols. J, IT and III are not sold scparateUj. The price of  
Vols, ir, V and VI is $.'».00 each.


Vols, ir, V and VI is $5.00 each.




 
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER,
Tlie following papers are reprinted from Vols. I, IV and V of the Reports, for those  
The following papers are reprinted from Vols. I, IV and V of the Reports, for those  
who desire to purchase in this form:  
who desire to purchase in this form:  
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rcepord,  
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixford,  


M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,  
M. D. 1 vohmie of 164 pages and 41 full-page plates. Price, bound in paper,  


$3.00.  
$3.00.  
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thaykr, M. D., and J.  
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.  


Hewetsos, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.  
Hewetson, M. D. And A STUDY OF SOME FAT.\L CASES OF MAL.VRIA.  


By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ?2.T5.  
By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.7^.  
STUDIES IN TYPHOID FEVER. By William Osler. M. D., and others. Extracted  
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted  


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481  
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481  
Line 4,768: Line 5,423:
Subscriptions for the above publications may be sent to  
Subscriptions for the above publications may be sent to  


The Johns Hopkins Press, Baltihorb, Md.  
The Johns Hopkins Press, Baltimore, Md.  






The Johns Hopkins Hospital BvUctins are isstied mwiihly. They arc printed lij THE FRIEDENWALD CO., Baltimore. Single copies  
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies  
may be procured from Messrs. CURBING rf CO. and the BALTIMORE NEWS COMPAXT, Baltimore. Subscriptions, $1.00 a year, tnay be  
may he procured from Messrs. GUSHINO <fe CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a year, may be  
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sin<jU- copies will be sent by mml for fifteen cents each.  
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE ; single copies will be sent by mail for fifteen cents each.  




Line 4,790: Line 5,445:




Vol. Vlll.-No. 74.]  
Vol. VIII.- No. 72.]  






BALTIMORE. MAY, 1897.  
BALTIMORE, MARCH, 1897.  






[Price, 15 Cents.






GO]srT:E3srTS.


GOisrTEisrTS.




PAGE.


The Association between the so-called Perinuclear Basophilic
Is Malaria a Water-Borne Disease ? By Rupert Norton, M. D. 35
Granules and the Elimination of the Alloxuric Bodies in the
Tlie Radical Cure of Hernia by Implanting a Section of Sterilized Sponge. By W. B. Platt, F. R. C. S. (Eng.), - - 44
Urine. By T. B. Fittcher, M. B., 85
Additional Cases of Dermatitis due to the x Rays. By T. C.


Encysted Dropsy of the Peritoneum secondary to Utero-tubal
Gilchrist, M.R.C.S., L.S. A., 46
Tuberculosis and associated with Tubercular Pleurisy, Generalized Tuberculosis and Pyococcal Infection. By ClariBEL Cone, :M. D., 91


A Visit to Bad Nauheim, with the Purpose of Investigating the
Proceedings of Societies :
"Schott Treatment" for Chronic Heart Disease. By C. N. B.
Camac, M. D., - - - 101


A Case of Porokeratosis (Mibelli) or Hyperkeratosis Excen
Hospital Medical Society, 47


Rarer Cases of and Observation on Streptococcus Infection [Dr. Bloodgood] ;— Ophthalmoplegia Externa [Dr. H.


trica (Respighi) with a remarkable Family History. By T.


Caspar Gilchrist, M. B.C. S., L.S. A.,


A Rapid Method of making Permanent Specimens from Frozen
Woods] ; — A Simple Contrivance for Effecting Pneumatic
Massage of the Tympanal Membrane and Ossicles [Dr.
Theobald] ; — Excision of a Parovarian Cyst without Removal of its Ovary or Tube [Dr. Kelly] ;— On the Pathology
of Hpematozoan Infections in Birds [W. G. MacCalu'm] ;
— On the HiBmocytozoa of Birds [Eugene L. Opie] ; — Discussion of Dr. Bloch's Paper on "Agglutination of Typhoid
Bacilli, etc."
Notes on New Books,
 
 
 
 
IS MALARIA A WATER-BORNE DISEASE ?=
 
By Rupert Norton, M. D., Washinf/ton, D. C.
 
 
 
There are several points in the consideration of this question
which make an exact answer e.xtremely difficult. First and
foremost stands the fact that the malarial organisms, those
forms producing malarial fever in mankind, have not been
recognized outside the blood of human beings. Other similar
types or species of organisms have been found in the blood of
birds, frogs, etc., but these do not seem to be of the same
species as that which fji'oduces the fever in human beings.
Thus at the outset we are hindered in the investigation of this
question by not being able to find and study the life-history of
these organisms in any extra-corporeal form. Another difficulty, and not a minor one, is the occurrence of malarial fevers
and typhoid fever in the same places at the same time of the
year, oftentimes with very similar types of fever. And again
it is generally supposed that the malarial organisms exist in
the soil, in damp soils, and so possibly in actual water, whether
stagnant or running, and as the germs of typhoid fever
exist in water, and we know that typhoid fever may be
communicated by drinking-water, the belief is a common one
that malarial fevers may be induced in the same way.


Sections by the Use of Formalin. By Thomas S. Cullen,  
Proof that malaria is a water-borne disease rests only
on evidence that after drinking certain waters people sometimes suffer from so-called malarial chills or fever. It may
be shown that they have the malarial organism in their blood,  


M.B.,
Proceedings of Societies :


Hospital Medical Society,


Typhoid Perforation treated by Surgical Operation [Dr.  
•Read before the Johns Hopkins Hospital Medical Society, Nov.  
Finney].  
16, 1896.  


Notes on New Books,


Books Received, - ..


but it cannot as yet be proved that the water they drank contained this organism, so that the chain of evidence is incomplete. We believe there is almost no one who denies the
possibility and even probability that malaria is ordinarily
an air-borne infection. This makes the proof of the waterborne theory still more difficult, for in every case where the
air-borne theory might be tenable as against the water-borne,
proof must be brought that the patient was not infected
through the air — an almost impossible task. Malaria is almost
as wide-spread a disease as typhoid, and yet does not occur in
epidemics. No group of cases of malarial fever on land has
ever been traced to a single source of infection, as has been
done so frequently in epidemics of several of the infectious
diseases, especially of typhoid fever. We do not find groups
of patients with malarial fevers in towns or elsewhere whose
infection can be traced to a single supply of water or milk.
We see cases of malarial fever springing up sporadically,
apparently having no direct connection with each other, except
through the medium of the air: the very name of the disease
throws light upon the common idea of its origin. Popular
beliefs are against, rather than in favor of the water-l)orne
theory ; for example, the general conviction in Rome of the
danger of being out after sunset in the Campagna for fear of
"catching" malaria, or rather being "caught" by it, and the
belief in the security derived from living in the second story
of houses in malarious countries, where the dwellers in the
first story suffer severely. A similar thought existed among


107




36


108




JOHNS HOPKINS HOSPITAL BULLETIN.


113
113




[No. 72.


THE ASSOCIATION BETWEEN THE SO-CALLED PERINUCLEAR BASOPHILIC GRANULES AND
THE ELIMINATION OF THE ALLOXURIC BODIES IN THE URINE.


(From the Medical GUnic of Prof. Eravs in Oraz.)
By T. B. Futcher, M. B., Instructor in Medicine, Johns Hopkins University and Asst. Res. Physician, Johns Hopkins Hospital.


the laborers on the Panama Canal, and they, to escape the
effluvia arising at night from the soil, slept iu the trees or
built houses on stakes high above the ground level. This, of
course, is no positive proof against the water-borne theory,
but sliows what the feeling has been amongst many people as
to the lai'ger share which air, rather than water, plays in the
etiology of this disease.


To show the difficulty in properly differentiating typhoid
and malaria] fever, we need only to look at a few statistics and
remarks made by men of repute who have written about
malaria. Chapiu,' iu 1884, reviewing all the cases that had
occurred in New England since 1861, gives the following data.
He I'eports the deaths due to malaria and typhoid fever in
Massachusetts, Connecticut, and Rhode Island, and states that
from 1878 to 1882, in Connecticut 1217 persons died of malaria
and only 124:2 from typhoid. Iu Massachusetts during the
same time there were only 159 deaths from malaria to 4349
from typhoid, and in Rhode Island 24 to 794. The table from
Connecticut is an interesting one to look at :


In 1894 Neusser described a peculiar granulation in the
Deaths from Malaria. From Typhoid.  
leucocytes of patients suffering from a uratic diathesis. This
term was given a wide meaning, and under it he included gout,
uratic lithiasis, as well as the various forms of "irregular
gout," as muscular rheumatism, nervous asthma, skin affections, gastro-intestinal derangements, diabetes, leuksemia, neuralgia aud neurasthenia. These granules were brought out
by staining freshly dried specimens of the blood with a modified Ehrlich's triacid mixture in which the basic ingredient
was relatively increased. They are basic staining granules,
and with this mixture appear as greenish black or dense black
droplets over and about the nuclei of the leucocytes. They
vary considerably in size, the smallest being about the size of
the neutrophilic granules, and the largest considerably larger
than the eosinophilic granules. Often they have a glistening
or refractile appearance. They are always in immediate contact with the nucleus, never being present amongst the ordinary granules of the leucocytes. They give one the idea that
they constitute some substance which has been squeezed out
of the nucleus. Neusser found them most abundant in the
mononuclear leucocytes, in which they often form a complete


1876 22 327


1877 73 321


ring about the nucleus, but stated that they were also present
1878 143 260
in the polynuelear leucocytes and eosinophiles. He believed
that they were of the nature of a nucleo-albumin in composition, and saw in their i^resence a sign for an increased uric
acid production in the organism. This assumption was based
on the analysis of the urine of 100 patients, in whom, along
with the already described blood condition, an elimination of
from 0.8 to 1.5 grams of uric acid, and a uric acid coefficient
within the limits of 1 : 30 to 1 : 20 (1 : 50 being normal) were
found. It is important to note that the patients on whom
these observations were made were not brought under a condition of nitrogenous equilibrium.


The clinical interest of these basojihilic granules would be
1879 198 159
very great if it could be proven that in an extended series of
cases they were associated only with a uric acid diathesis and
were entirely absent in other affections. If such could be
proven we would then have a ready clinical means of differentiating symptoms due to a uratic diathesis from those arising
from some other cause. Neusser himself states that they are
also to be found in a certain percentage of cases of tuberculosis,
and believes them to be of prognostic value. He claims to have


1880 265 242


1881 357 257


86
1882 264 324


As seen from these figures, during the years 1879, 1880
and 1881 there were fewer deaths from typhoid than from
malaria. It is not worth while to discuss them. It may be
said from what we now know of malaria that the records upon
which they are based are absolutely untrustworthy.


Griswold' says : " For the main interest of this article, I
accept the term 'malaria' as implying that undetermined
potency producing the general class of fevers of which intermittent is the most pronounced type, and in which class is
included various other diseases that have been very generally
regarded as the results of paludal poisoning. In the absence
of such specific knowledge as would enable us to give the
class a more definite and satisfactory designation, the term
answers as well as would any other equally arbitrai'y." This
was written after Laveran's discoveries. Here are two extracts
from j^apers on malaria as seen in New England. Greenleaf
states that malaria may be due to drinking water or to
food contaminated by the hands, or to air ; but he believes
that "intermittent fever is a disease always originating locally,
thus excluding as etiological factors all causes of a general
character." Certainly air and water are causes of a general
character, especially the former. Green" believes that possibly
in the cases reported by him, the water of wells was poisoned
by backing up of water, due to a dam or causeway which prevented natural drainage of the adjacent soil.


It is impossible to di-aw correct conclusions as to the
etiology of malarial fevers from such general statements.
Finally in the Fourth Annual Report of State Board of
Health, New York, 1883, on Malarial Fever at Lakeville,
Washington county, we read as follows:


found that cases showing the granules run a more favorable
course, and that the lung infiltration is more likely to undergo
fibroid change than in cases where the granules are absent.


Kolisch, a pujiil of Neusser's, has advanced the theory that a
uric acid diathesis is not due to an anomaly of in the formation of
or in the relative solubility of uric acid, but in the increased production of the alloxuric bodies (uric acid -|- xanthin bases), out
of the products of nuclein destruction. He found that in cases
where the perinuclear granules were abundant that there was
a definite increase in the quantity of alloxuric bodies eliminated. The increase was due to a marked increase of the
xanthin bases, the uric acid being relatively diminished ; and it
was to the presence of these bases circulating in the blood that
the symptoms of a uratic diathesis were due, and not to any
anomaly in the formation or excretion of uric acid. Neusser
and Kolisch, although they both believe that the basophilic
granules bear an intimate association with the causation of the
uratic diathesis, differ in their views as to which ingredient of
the urine is increased by their presence. Neusser found an
increased elimination of uric acid, while Kolisch found that
the uric acid was relatively diminished, and the xanthin bases
markedly increased, resulting in a total increase in the amount
of the alloxuric bodies eliminated.


With the exception of the above difference, Neusser and
" Malarial fever has also appeared at the house of Mr. Donald Reid, about one-third of a mile from Lake Cossayuna, up
Kolisch agree that the occurrence of the perinuclear basophilic
the Summit pond brook at a height of one hundred feet above
granules indicates an increase in the nuclein constituents
the lake. No other cases of fever were reported in this direction. An examination of the premises of Mr. Reid showed
of the blood. Direct analyses of the blood for the amount
that his house stands upon rock, covered with a comparatively
of nuclein contained in it were naturally not made; and  
thin layer of clay, and that while the roads and ground a short
pure color reactions, even from a qualitative standpoint, are
distance away from the house were dry and dusty, the clay
unreliable, as shown by L. Heine. If one accept without
around this dwelling was saturated with water. This water
further questioning Neusser's view that the perinuclear granulation is a morfihological criterium for an over-production
comes from a sjn-ing north of the house. The water is brought
of nuclein derivatives from the cell nuclei, it is not easily
from the spring to the barnyard through a pipe, and empties
explainable why an increase in the quantity of the alloxuric bodies eliminated in the urine should follow. If one considers these granules identical with the pyrenogenic granules
into an open trough, the overflow of which saturated the  
of Lowit found in the leucocytes of the river crab (in the arthropoda the uric acid is not formed from the nuclein materials)
surrounding ground. The surface of the ground here is
and in certain normal leucocytes of the bone-marrow, then
twelve feet higher than that about the dwelling The upper
they fall under the general heading of karyorhexis or breaking up of the nucleus, and would more likely indicate a chromatolytic degeneration of the leucocytes. Prof. Kraus was
stratum is a loose soil some two feet deep, through this the  
able to demonstrate similar granules in the liver cells when
water percolates until it reaches the clay over the rock, along
portions of the liver substance were removed from the body
which it readily finds its way down the steep slope to the  
while still warm and kept in a moist chamber at 40° C. At a
house and saturates the clay about the dwelling. Water is
definite stage in the breaking down of the nuclei he found
also brought directly from the spring to the house and empties
granules in the protoplasm of the liver cells resembling and
into a trough on the east side of the dwelling. The overflow
staining similarly to those found in the leucocytes by Neusser.
of this trough is allowed to saturate the ground within ten feet
If such a condition takes place under any circumstances, either
of the eastern wall of the house. From these facts it appears
physiological or pathological, in the living person, an increase
that saturation of the soil about this dwelling, for which the
in the alloxuric bodies eliminated might be expected.  
owner is entirely responsible, is a sufficient cause for malarial
fever in a region bordering upon such extensive swamps."


In studying the subject of Neusser's granules I have endeavored to determine whether there is any regular coincidence
There can be but little doubt that these cases were not malaria, but typhoid; certainly the conditions existing were just
between the presence of these granules and the elimination of
such as to produce typhoid. Such unreliable statements as
the alloxuric bodies, and further, whether the granules are
those quoted have led many who have not had the opportunity
found only in cases showing the symptoms of a uratic diathesis.  
to investigate the question for themselves to believe that
malaria was a water-borne disease.  


Doubt as to this intimate association arose in my own mind
It is a curious fact that almost all observers who want to
while examining the blood of patients for the basophilic
prove that malaria may be due to drinking water refer to the
cases of illness which broke out on the now famous ship
Argo. The pros and cons of the evidence that these cases
were or were not malaria have frequently been discussed and
there is no general agreement. It seems quite fair, however
and more than probable, to conclude that these cases were nol
malaria. At any rate the burden of proof lies with those who
maintain that the cases were malaria, and the proof they
offer is unsatisfactory. If these were malaria, then the watei"borne theory needs no further demonstration ; but for those
who doubt, new proof must be furnished. The story related
by Boudin" is as follows. I translate freely:


" In the mouth of July, 1834, the Sardinian ship Argo
sailed from Bone (Algeria) with 120 soldiers in good health,
and arrived at Marseilles. Thirteen men had died during this
short voyage and had been buried at sea; 90 men were brought
to the hospital in Marseilles, showing pronounced ('• les moins
equivoques ") symptoms of paludal intoxication, iu all its forms
and types ; in some cases the disease was most severe, or if one
prefers to say so, showed the greatest degree of perniciousness.
Whereas the soldiers were attacked by choleriform, epileptic,
comatose, tetanic and other types of fever, which yielded as
though by enchantment to large doses of quinine, the sailors
showed a marked contrast in their perfect health. Now what
could be the cause of such a difference in individuals who
were apparently, at least, subjected to identical conditions?




granules, at first without studying their effect on metabolism.
In a very large number of cases examined, both in healthy and
diseased persons, I have never failed to find the granules
present. Four of these cases were cases of true gout with
typical joint affections and well defined tophi in the ears. In
two of these cases the granules were very abundant, but not
more so in the mononuclear than in the polymorphonuclear
leucocytes. In the remaining two cases they were on the
whole not very abundant, and the polymorphonuclears showed
the granules more numerous than did the mononuclears.
Further, I was able to convince myself, both in Baltimore and
in Graz, that the granules were not more marked in the blood
of patients suffering from the so-called uratic diathesis than
in other diseases, or even in certain apparently healthy individuals. The fact that the granules are found in other
diseases than in uratic diathesis, and also in healthy persons,
lessens their clinical interest. Neusser believed their presence in tuberculosis was a favorable sign. In this disease I
have observed cases with abundant granules and others with
few granules without noticing any difference in its subsequent
course. The granules vary in richness in the leucocytes from
day to day in the same individual, notwithstanding his living
under the same conditions of nourishment, etc. This fact
seems to diminish the significance of the granules. It seems
more common for variations of this kind to occur than for the
granules to remain constant from day to day. No method
seemed practicable for making an accurate count of these granules, and in the following cases reported it seemed sufficient
for all practical purjioses to stain the specimens of dried
blood and to compare from day to day the amount of granulation present in the different forms of leucocytes.


The following cases, in which the basophilic granules and
March, 1897.J
their effect on metabolism were studied, were undertaken
 
especially to ascertain whether the amount of granulation
 
present really influenced the quantity of the alloxuric bodies
eliminated in the urine.


In all, 8 cases were carefully studied. Blood specimens were
JOHNS HOPKINS HOSPITAL BULLETIN.  
stained each day with Neusser's staining mixture, and the same
technique followed from day to day. The patients were as nearly
as possible brought under the conditions of nitrogenous equilibrium before the observations on the urine were concluded.
Each case was followed for a period of 5 to 6 days, and during this time the same amount of food was taken each day,
and the body weight from day to da\' remained practically
constant. The total amount of nitrogen ingested in the food
and eliminated in the urine and fteces was estimated daily.
In all the cases the alloxuric bodies were estimated, and in two
cases the uric acid as well. The nitrogen was detei-mined
according to the method of Kjeldahl, the uric acid according to Ludwig's, and the alloxuric bodies according to the
Kriiger-Wulf* methods.  


In order to assist in the understanding of the following
tables I give what is considered the normal amount of nitrogen in grams contained in the alloxuric bodies for the 24
hours, as found by various observers who have made determinations up to the present date.




37


•Zeit. flir physiol. Chemie, Bd. XX.




An official inquiry, of which I had the direction, gave me the
most complete information. The investigation showed that
if the sailors had kept their good health they owed it to the
purity of the drinking water, of v/hich they had a special
supply, while the soldiers were forced to drink water drawn
from a well in a marshy spot near Bone, which water had been
taken on board just on the eve of departure. The soldiers
who escaped this poisoning were those who, having saved a
little money, were able to buy water from the Sardinian
sailors. This fact demonstrates in a peremptory manner how
paludal matter absorbed in a liquid form from the gastrointestinal surface, as by the lungs in a gaseous form, causes
intoxication."* In another place the author himself admits
that his evidence is not conclusive. He says : " Le faitsuivant,
dont nous avons ete temoiu au lazaret de Marseille, in 1834,
pourra paraitre concluant au premier abord, et pourtant, en y
regardant de pres, on est contrait de rester dans le doute."


May, 1897.]
It is strange that nothing is said in this story as to the
length of the voyage, nor whether the sailors had been allowed
to land at Bone. Algeria is a malarious country, and if the
cases were malaria, the soldiers may have been infected on
land, and the drinking water may have only aggravated
the sickness. In fact there ai-e many points in the story
which need elucidation and without which the story is scientifically unreliable.  


Oswald Baker' relates some cases of a similar sort, but here,
too, his proof is insufficient, not so convincing even as that of
the Argo. He attributes the cases of illness, which are not
described, to the drinking water on board a vessel. Kershner°
relates the case of a ship in which malaria (?) broke out, and
where all the evidence went to prove that it was not due to
drinking water. The author does not believe in the waterborne theory. The evidence is not clear as to what the illness
really was. These are all the cases that I have found to
prove or not to prove the development of malaria on shipboard as due to drinking water. If one case could be definitely shown to have occurred in this way, far from land,
where the possibility of an air infection would be reduced to a
minimum, the case, even then, would not be proven, for we
know that the case might be one of latent infection, developing
long after a stay in a malarious country.


On the origin of malaria we find many articles by medical
men in various countries, and it will be better to examine these
systematically, and thus see what proof has been brought forward to confirm the water-borne theory. Let us first look at
some of the Reports of the Surgeon-General of the United
States Army. In the report for 1889, pp. 32-33, it is stated:


JOHNS HOPKINS HOSPITAL BULLETIN.  
"Much of this improvement has been attributed, and I
believe correctly so, to the introduction of wholesome water
supplies. In a recent communication, Col. Charles Page,
Assistant Surgeon-General, makes an exception of Fort Sill,






87
*"I have said above that the patients showed signs of paludal
intoxication in all its types; actually and for the first time at Marseilles, I observed cases of continued fevers, although quinine was
administered (" des fiovres continues a quinquina"). Now my investigation showed that the patients with continued fevers were
precisely those who appeared to be the most saturated with the
marshy water."






For the 24 hours :  
Indian Territory, in this connection, claiming that the diminished malarial sick list which followed the introduction of a
good water supply cannot be referred to the water, because
there was a diminution of malarial diseases at Fort Supply,
which had no new water supply, as well as Fort Sill, for several years after the introduction of the water supply at the
latter post. He attributes the improvement to some general
condition which affected Fort Supply as well as Fort Sill, and
considers, therefore, that the theory of a water propagation of
malarial fever does not always hold good. He says :  


Kolisch gives 0.260 gram.  
'An examination of the consolidated reports of the medical
department of Fort Sill for several years will convince one
that the supply of spring water did not diminish the ratio of
malarial disease materially. The diarrhoeas diminished and
the general health of the command was improved, most probably by the beneficial effects of a full sujiply of good water for
drinking and bathing.'


Weiutraud (1) 0.344-0.360
" Here is an example of a garrison suffering from malarial
poisoning supposed to be contained in the drinking water,
which continued to feel the effects of malaria although the
supply of water was changed from that of a doubtful character to one absolutely pure, being filtered for miles through
sand, gravel, and lime-stone rock. It is apparent that the
poison producing malarial diseases must be sought for in
another source than in the drinking water. It is there at
Fort Sill in the heat, moisture and soil which produce malarial fevers anywhere, or furnish good culture material for the
bacteria that cause it. In New Mexico, where the climate is
dry, though hot, malarial fevers do not exist; but turn the
waters from the rivers upon the soil by means of acequias, and
malarial fevers soon abound, regardless of the source of the
water used for drinking. It will be observed that for several
years before the improvement of the water supply at Fort Sill
the ratio of malarial diseases was smaller than after the development of the spring which gave the garrison a pure filtered
water. ... In 1881 the ratio was remarkably small, being
but 59 per 1000 of mean strength ; surely that could not be
accounted for by any improved source of the drinking water.
There may have been some meteorological cause ; we know
that in different years there is a marked variation in the prevalence of malarial diseases. . . . The diminution of the cases
of malarial diseases at Fort Sill after 1884, when it appears
that the greatest number prevailed, must be considered a
sequence and not a consequence of the development of the
spring of excellent drinking water. The ratio of malarial
diseases at Fort Supply for the years 1884, 1885 and 188(5
shows a decrease of sickness after 1884. Fort Supply, where
the water supply was not improved, like Fort Sill, has a reputation of being malarious. The water supply of this post has
recently been materially improved . . . but it remains to be
seen if the ratio of malarial fevers will be diminished."


(2) 0.433-0.534
In the report for 1890 it is stated: "Relatively fewer of
Richter 0.380
the colored troops were attacked, but the proportion of remittents to intermittents was greater among them, and the average duration of the remittent was longer— 34.8 days for the
colored, and only 21.2 days for the white men— an illustration of a well established fact, that when the negro becomes
seriously ill he does not rally so readily as the Caucasian."


Magnus-Levy 0.506


Richter 0.387


I myself found in healthy persons (1) 0.499
38


(2) 0.551


Judging from these analyses it may be considered that
values above 0.4 gram are physiologically high, while those
above 0.5 gram may be regarded as pathological.


Case 1. — Dr. K., aged 32 years, weight 79.5 kilograms, with
JOHNS HOPKINS HOSPITAL BULLETIN.  
a well-marked tendency to a gradually increasing corpulence.
Not inclined to undertake great muscular exertion, but in
every respect perfectly healthy. After nitrogenous equilibrium
had been established, 1.5 liters of Carlsbad water (Miihlbrunn)
were drank daily for a period of 8 days.  


The daily diet was as follows: Ham, 150 grams; roast
beef, 100 grams ; milk, 500 grams ; 6 breakfast rolls ; butter,
65 grams; rice, 60 grams; sugar, 3 pieces; black coffee (infusion), 100 grams ; sherry, 100 grams ; soda water, 2 bottles.


The above diet represented about 1968 calories (about 25
calories per kilogram body weight), which were made up as
follows :


[No. n.




Albumin
Pat


Carbohydrates
The duratiou of the sickness in these cases is much against
Alcohol
any considerable number of them having been malaria, and
the use of the words "remittents" and "intermittents" adds
to our difficulty in determining the etiology.


In 1890, Fort Brown, Texas, was supplied with distilled
water, and the improvement in the general condition of the
post after that year is attributed entirely to this factor.


The following quotation is found in the report for 1894,
p. 52: Capt. W. Fitzhugh Carter, the post surgeon at Fort
Sill, Oklahoma, writing on malarial diseases, says: "There is
almost conclusive evidence that the water of the streams in
this section of the country is a concentrated malarial poison,
and at certain times of the year will give rise to malarial fevers
in a large percentage of those who drink it," and he looks to
the use of distilled water for the same beneficial results that
have already been obtained at Fort Brown, Texas. But in
the report for 1895, p. 41, we find that Fort Brown was the
fourth army post having highest admission rate for malarial
diseases. Washington Barracks, D. C, and Fort Meyer, Va.,
just across the river from Washington, came first and second
in this list; both these places are well-known hotbeds of
malaria. The third in rank was Fort Hamilton, in New
York liay, where it is more than probable that the percentage
of cases attributed to malaria is too large. From this we do
not see that there could have been anj' great imjjrovement in
the condition of Fort Brown, as it never ranked first on the
list. The purer water supply does not seem to have reduced
the cases of malaria very greatly. On the same page of the
report for 1895 we find that "nearly one-fourth of the malarial
cases of the army were remittent, with an average duration of
21.5 days; the average of the intermittents was 5.75 days" — •
a long period for remittent, if by that we are meant to understand malarial fevers, and closely corresponding to the length
of time usually given to typhoid. A supply of water supposed
to be quite pure has not modified to an appreciable extent
the number of cases occurring at the two army posts in
Washington. Dr. Charles Smart, of the U. S. A., is an ardent
supporter of the water-borne theory, but he has brought forward no convincing evidence of the truth of this theory. He
believes surface waters, when used for drinking purposes, to
be more dangerous than water from deep wells.


Total
The best, and a very interesting paper that has appeared on
malarial fever in these reports is by Dr. Walter Keed in the
number issued this year. He has paid special attention to the
cases of fever at Washington Barracks and Fort Meyer, and
has examined the blood of many patients. Dr. Heed does not
believe in the water-borne theory. He tells me that "the
water supply at Washington Barracks has not been changed ;
it has always been the same as that of the city. The sujiply
at Fort Meyer was changed in November, 1894, from well
water to Potomac river water. The following year the men
and officers drank, as a rule, filtered and boiled Potomac river
water, with the result that there were more cases of malarial
fever in 1895 at Fort Meyer than during any one of the
previous 23 years. It was also higher at the Barracks in 1895
than during any of the previous 23 years." There is much
malarial fever in the city of Washington, and it is really endemic
along the river flats, but has no apparent connection with the






362.17 calories.  
drinking water of the city, since otherwise the people in the
837.73
upper part of the city should naturally suffer as much, which
646.35
they do not. The reports from the army posts are hard to
122.15
analyze, since the officers in charge are frequently changed,
and their personal views as to malaria and typhoid fever vary
materially. But, as yet, all the evidence coming from the
army posts is rather against than for the water-borne theory.  


1968.40
Through the kindness of Dr. G. M. Sternberg, Surgeon-General of the U. S. Army, I have received to-day proof-sheets of
an address lately delivered by him in New York. In this he
says : The facts which have been developed with reference to the
transmission of cholera and typhoid fever, considered in connection with numerous recorded observations relating to the
supposed development of malarial fevers as a result of drinking
surface waters, have led some authors to the conclusion that
malarial infection, also, commonly results from the introduction of the malarial parasite in this way. Without denying
that this may occur, I am disposed to believe that much of the
evidence which has been advanced in favor of this view is
unreliable. In many cases the so-called malarial fevers which
have been traced to the use of surface water from wells, streams,
etc., have been of a " continued type " and not controlled by
quinine. In the absence of positive evidence of the presence
of the malarial parasite in the blood, continued or remittent
fevers which resist the specific action of quinine cannot, in
our opinion, be properly classed with the malarial fevers. If
not due to infection by the typhoid bacillus, they are, at least,
more nearly allied to typhoid than to the typical malarial
fevers."


A large number of general jiractitioners throughout the
United States believe firmly in the water-borne theory, among
them Zwisohn,' West,' Waggener," and Hylaud,'" but the
evidence they show to support their view is most incomplete.


Daly" wrote a long article attempting to prove this theory,
and thought that vegetables washed in marshy water might
produce malaria, but his paper is unconvincing. This called
forth other articles by Norbury,"" Jones," and Cadwallader;"
the first two mentioned agree with Daly, but Norbury gives
an account of an epidemic which might have been typhoid,
and Jones' paper is still less satisfactory than Norbury's.
Cadwallader does not believe in the water-borne theory, but
thinks the home of the plasmodia is in the sap of vegetable
life rich in sugar, and thinks there is danger of infection
in eating maple sugar and sorghum molasses. This startling
theory is balanced by an equally strange one put forth by
Newton," who thinks "the consumption of water-melons
seemed to be provocative of malarial fever." He believes
both the air- and water-borne theories have been proven, but
most of his evidence is taken from the works of other men,
some of whom I have mentioned, and his paper adds nothing
material to strengthen the water-borne theory. Hurley," like
Daly, attributes malaria to drinking w.ater, " though fruits
and vegetables eaten raw may carry it." He does not believe
it enters through the lungs. His proof is based on some
eases, where people using boiled water were not attacked by
some vague symptoms, which those who did not purify their
water in this way, suffered from.


Table 1. — The Urine.
Lewis'" believes "water to be one of the chief avenues, if not






Date.  
March, 1897.]




Q


JOHNS HOPKINS HOSPITAL BULLETIN.






a
39


U ID




at  
the most important, by which malaria gets into the human
system." His ideas are based on inquiries as to the origin of
malaria sent to various doctors and laymen in the South ; the
replies of these gentlemen are almost all of them in favor
of the water-borne theory ; but the cases given are not
described with sufficient detail to rule out typhoid in many
instances, nor can infection through the air be eliminated,
nor the possibility that the disease was acquired in some
other locality than that where the patient was living when
found sick. Many of the reports are founded on the disappearance of illness and fewer deaths in families when
the supj)ly of water was changed ; the source of the drinking water often stood below the level of the houses and
could easily have been polluted ; many cases of illness were
said to be the result of drinking cistern water. The health
of the people was improved by a change in position of
a well, or from driving deep wells, and not depending on
surface water for drinking purposes. Such evidence cannot
be accepted as satisfactory proof of malaria being the result
of drinking impure water. Cowan" reports a number of cases
which he believes support the water-borne theory, but his
ideas on the subject of malaria are so opposed to the exact
knowledge we have at present in regard to that disease that
his evidence may be fairly thrown aside as valueless. He
says : " We shall, however, assert as true that the malignant
types of malarial fever, and in fact almost all forms of
malarial fever, are indebted to the water we drink, and not
to atmospheric conditions, for the etiological factor in the
transmission or rece^ition of the pathogenic material which
produces malarial fever. ... In contradistinction, allow me
to say that water in globule never produces malaria, but becomes an absorber and retainer of this pathogenic material,
and may become loaded with this poison almost to saturation.
Trees, wells, springs, creeks and branches may become so
loaded with this poison that a single glass of water may contiiin pathogenic material sufficient to produce a case of intermittent fever. Without entering further into the manner of
its formation or the power of water in globule to absorb or
retain this pathogenic factor and disease producer, we will
endeavor to give proof that the water we drink is the great
factor and principal source of malarial fever in all its forms,
but especially in the malignant types."


'"C in  
If the cases reported by Quine"' could be accepted without
hesitation, their evidence might be looked upon as strongly in
favor of the water-borne theory, but many of the facts given
are so entirely contradictory of what has been proved as regards
the effect of quinine on the malarial parasite that we cannot
accept them — we feel sure that some mistake was made in the
diagnosis. We quote the following cases in behalf of the
stand we take :


Case 4. "Miss H., aged 16; has lived in Chicago many years
in a good house and neighborhood. No excavations near. .
April, 1894, she began to be sick gradually with a continued
type of fever marked by irregular fluctuations, which was
labeled by the attending physician. Dr. Samuel Cole, 'typhoid
fever with malarial features.' The fever continued about four
weeks, and then, after an .interval of normal temperature, lasting a few days, there was a relapse. The patient had taken


if




quinine freely from the beginning. Upon the basis of two
examinations made by myself during the month of May, 1894,
the diagnosis of the family physician was sustained. Later the
blood of the patient was examined by Dr. F. S. Johnson and the
fact of malarial infection, previously assumed to exist, was demonstrated. Quinine was administered with great freedom by the
mouth, rectum and hypodermic method, and arsenic and iron
were also pressed systematically, but without affecting the
course of the disease. The patient was seen at this time by
Dr. N. S. Davis. Her illness continued over four months,
uninfluenced by treatment to an important extent, and finally
came to be attended with acute pulmonary tulierculosis.
Death occurred five or six weeks later. The blood of the jiatient
crowded with plisiiwdin to the last." [The italics are mine.—
K. N.]


Such resistance on the part of the plasmodia is unknown,
especially when persisting in this manner for weeks. It is
contrary to all the best evidence we have. Equally doubtful
are the following cases reported by him.


July 6
Case 5. A girl with an alveolar abscess was thought to
" 7
have contracted malaria in New York, or on her way to
" 8
Chicago; but evidently the case was one of acute septica3mia,
" 9
although Dr. Cole examined the patient's blood and found it
" 10
stocked with malarial organisms: for "notwithstanding the
" 11
administration of 40 to 60 grains daily [of quinine], and the
" 12
fact that the patient was kept profoundly cinchonized, the
" 13*
chills and fever increased in frequency and severity. Some
" 14
abscesses occurred in the site of subcutaneous injections.
" 15
Malarial infection of the blood continued till the death of
" 16
the patient."  
" 17
" 18
" 19
" 20


Case 10. March, 1895. Woman with rlieuuuitic symptoms
and erythematous nodes. "Examination cff the blood discovered small endoglobular bodies, and large amoeboid endoglobnlar bodies containing pigmented particles in active
motion." "Under anti-malarial treatment the rheumatoid
pains disappeared; the erythematous nodes continued, but
were lessened in number; iut the chills and fever irerc not
benefited." [Italics mine. — R. N.]


1
Case 13. A child 3 months old was supposed to have contracted malaria from a nurse. "An examination of her blood
[the nurse's] showed malarial infection. Examination of the
infant's blood revealed large and a few small endoglobular
bodies." "No fever." [Italics mine. — E. N.]


3
In Case 10 the fact that " the chills and fever " were not
4
benefited by quinine, if they were due to malaria, is incredible;
and in Case 13 the statement that the child had " no fever,"
and yet its blood showed numerous malarial parasites, is
also questionable. But the following remarks, quoted from
his article, show that he does not agree with the best authorities on malaria. He says : " The proofs of water infection are
quite as strong as those of air infection, and there is not a
doubt that impure water is responsible for the occurrence of
paludal disease with immensely greater frequency than is
generally known. . . . Nor is the therapeutic test a reliable
guide to diagnosis. . . . The entire absence of fever is a
characteristic of many cases. . . . Quinine causes some symptoms to disappear, while others persist; and those showing
periodicity may be the ones to persist." Such observations


5
()
7
8
(1


10
11
12
13
14
15


40


995
1240
1630
1200
1080
1160
1630
2270


2«no


2345
JOHNS HOPKINS HOSPITAL BULLETIN.
27C0
3120
3045
2920
2810




14.7638
12.8898
14.7759
14.0700
15.5547
15.0666
15.4947
15.7682
14.1159
15.3560
13.9482
15.5719
12.9062
14.9825
14.. 3732


[No. 72.


0.6042
0.4.318
0.5262
0.4169
0.4430
0.5602
0.5058
0.4149
0.4459
0.4042
0.3780
0.3849
0.3810
0.3244
0.4025




0.2550
and the doubtful proof of malaria in the cases he relates,
0.2613
minimize the value of the article.  


Such is the evidence coming from American physicians,
and certainly it is not sufficient to prove the water-borne
theory. Let us now look at that offered by certain doctors
in India; three papers by Boss,'" Rogers,^" and Hehir"' may
furnish some further proof one way or the other. Ross
believes that " malaria must be originally a disease among
mosquitoes" (a view brought into more prominence by Manson), and says: "We may conjecture that infection may arise
from the bite, or from deposition of the parasite by the mosquito on the skin of the patient or in his drinking water."
Rogers brings no proof, but states : " In addition to the undoubted effect of drinking water in causing malarial fever, it
is also universally admitted that perhaps an even commoner
mode of entrance of the organism is through being inhaled
into the lungs and so reaching the blood of the capillaries."
In Hehir's article we find the following :


4.16
" Malaria is mixible with water. It is capable of being
3.35
carried by currents of water through distances and periods of
3.56
time altogether undetermined, without losing either its toxic
2.97
effects or faculty of reproduction. It is possible that this
2.84
means of conveyance has affected its distributions to continents
3.71
and islands too widely separated to justify a belief that it was
3.26
wind-wafted. No observations need be adduced to establish
2.63
the water-borne habit of the malarial {poison, or the positive
3.16
liability to its toxic effects, when received into the stomach
2.63
throiTgh this medium. These facts have been well understood
2.71
from the time of Hippocrates. The inhabitants of tracts of
2.47
marshy country are pretty generally agreed that these waters
2.95
may produce fevers."
2.16
2.80


He also thinks that milk left outdoors through the night
in open pans may catch sufficient quantities of swamp poison
to produce sickness, if exposed where malaria is rife. Daly
\loc. cit.^ also thinks that milk may carry malarial infection,
through the cans in which the milk is stored being infected
by dirty water in washing them. The ancients may have
believed that water could cause malaria, but we cannot accept
their statement as proof, nor this one of Hehir's. This evidence which comes from India, where as yet the exact differentiation between typhoid fever and malaria is evidently not
generally well understood, or where the discoveries of Laveran
are not accepted (ex: Surg.-Gen. Laurie), adds nothing convincing to the water-borne theory.


In Germany malaria is not common, but much has been
written on this disease by Germans who have studied it
in foreign countries. Shellong,'" who wrote on the malarial
fevers in New Guinea, does not believe in the water-borne
theory. His is a careful study and his ideas deserve consideration. Steudel," also writing on foreign fevers, believes in the
water-borne theory, and refers, like so many other authors, to
Hirsch for confirmation. Hirsch's work, " Handbuch d. Historisch-geographischen Pathologic," was published, however,
in 1860 and, though valuable as a reference book, cannot be
accepted as an authority on malaria. Leonhardt," in a long
and careful study, comes to the conclusion that malaria is not
water-borne. He says those who believe it taken in with
drinking water cannot prove this, because patients are subject


From 13 to 20 Carlsbad water was drunk.




to infection by the atmosphere also. Two out of three Germans, we see, do not believe in the water-borne theory. Let us
now review the beliefs of the French and Italian observers
on this point.


Table II. — Nitrogen Balance (N in Grams).  
Taking up the papers first whicli have appeared in French,
we find articles by Verdan," Nicolas," Pepper," and Kelsch
and Kiener." These contributions, like the German, are on
malarial diseases as seen outside of France. The malarial
fevers in Algiers are ascribed by Verdau to the water supply,
which is very foul, and to effluvia carried by the winds. The
work by Nicolas is a long one, but there is no proper differentiation made between typhoid, malaria and other forms of
fever, so that his conclusions are not much to be relied upon.
He believes stagnant water to be one of the main sources of
origin of malarial fevers (" mais nous en savons assez deja pour
nous convaincre que la stagnation de I'eau est necessaire pour
engendrer la malaria"), but says little about drinking water.
However, it may be surmised that he believes also in the waterborne theory, since the supplies of drinking water in the countries of which he writes are often stagnant. He recommends
good, pure drinking water, and says, "en ce qui concerne la
malaria la preuve semble faite: I'eau d'alimentation n'y est
pour rien." But as regards typhoid fever he makes the following statement: "en realite rien n'est moins prouve que ces relations de causalite eutre I'eau et la fievre typhoide en particulier si savamment defendues par des observatenrs tres recommandables." Such statements diminish the value of his
observations.  


Pep25er, who like Verdau wrote on the fevers in Algiers,
concludes his paper, which is not a brief one, with certain
aphorisms, from which I quote the following :


1. "Dans une region malarienne, la malaria doniiae presque toute la pathologic."


Date.  
2. "La malaria est, selon nous, raerotellurisme proteiforme."


3. "L'intoxication se produit durant Facte de la respiration et atteint principalement le systeme nerveux."


0%
The first statement is very true, not only in Algiers but in
P
many other countries, practitioners commonly attributing
many maladies to malaria as a cause where malaria has actually no causal relation to the diseases in question. His third
aphorism shows that he lays no special stress on water as producing malaria.


The final paper by Kelsch and Kiener is also against
the water-borne theory. They believe infection is through
the lungs, that this at least is the most common method.
They think the water-borne theory is not confirmed by
facts, and that the cases on the Argo do not support the
theory. They say, however, that malaria may arise at sea, and
relate one instance which furnishes no stronger proof than
that of the Argo. Soldiers in Algeria, they note, who while
marching drink foul water, are no more affected with fevers
than when in camp using pure water. Towns on heights
around the Roman C'ampagna are free of malaria, although
their inhabitants drink water coming from malarious regions.
This they bring forward as proof against the water-borne
theory and say that foul water simply acts as a force to
reduce the resistance of the body to morbid Influences.


41




£ Si
March, 1897.]




NITROGEN ELIMINATED.


JOHNS HOPKINS HOSPITAL BULLETIN.


i ,


a — "3
|a|


41


S




Brlue.  
" Professor Colin, of Val de Grace, who is so well known for
his researches on intermittent fever, is inclined to question
the production of paroxysmal fevers by marsh water. He cites
numerous cases in Algiers and Italy where impure marsh
water gave rise to indigestion, diarrhcea and dysentery, but
in no case to intermittent fever, and in all his observations
he had never met with an instance of such an origin of ague."
(Sternberg: Malaria and Malarial Diseases, 1884.) According to these French observers, then, the weight of evidence is
against the water-borne theory.  


The observations made by Italian physicians are among the
most interesting we have. Celli," one of the best students of
malarial fever, has written a paper of great value on this subject. It is a short article going to prove that water does not
transmit malaria. He gives a chart showing that introduction
of new water supply into a certain city did not diminish the
number of cases of malaria. He says popular ideas on this
matter are fallacious, and notes that persons may live in a
malarious place and drink pure water and yet have malaria,
while others in the same place drinking foul or "paludal"
water do not have malaria. He himself gave water from the
Pontine Marshes, which are acknowledged to be very malarious,
in large quantities to a certain number of patients who had
never had malaria, without its giving birth to this disease in
them. Similar evidence is furnished by Salomoue-Marino."
He experimented in the' same manner as Celli, giving 5 to 24
litres daily of paludal water for from G to 24 days, and did
not succeed in a single instance in producing malaria. He
says that those cases of malaria which are suspected to have
been caused by infection through the digestive tract are usually grave cases with short periods of incubation. He relates
two such cases, which, as the blood was not examined iu either
case, do not furnish proof of his statement. One patient was
vei-y ill and took three weeks to recover (typhoid ?). Stagnant water is likely, he thinks, to contain poisonous or noxious
bodies which could produce gastro-intestinal symptoms similar
to those sometimes caused by malaria. Bonizzardi," without
relating any cases, concludes one short article with a number
of deductions, from which I take the two following: "Intermittent fever may be contracted as well by drinking water as
by air," and "infection by air is far more fatal than by water."
Moscato," who has also carefully studied the question of malarial fevers, states, without furnishing any proof, that drinking water as a source of infection has been noted daily by
observers : " I'acqua potabile, come sorgente del velino palustre
f u riconosciuta auche da Ippocrate ; quale verita e stata anche
sanzionata dagli osservatori odierui." The statement has been
made that malaria may be transported from one infected district to another healthy one by a new water supjjly, but the
proof here is not sufficient, since the turning up of the soil for
the pipes may have been the real cause. Most of the Italian
observers, it is seen, are opposed to the water-borne theory.


FcBoes.  
Such is the evidence that exists for aud against this theory,
and though we cannot say that malaria is never contracted
from drinking water, yet the best proof is against this
common belief. It is impossible to demonstrate that something never occurs, and we must be satisfied with showing
that all the evidence that has been so far collected to confirm




a


the water-borne theory is not of sufficiently exact quality to
carry much weight. To prove that malaria is water-borne
in a given case demands conditions of a peculiar character:
first the patient must never have had malaria, and must live
and have lived in a district supposedly quite free of malaria;
after drinking a certain supply of water and allowing for
the proper period of incubation, the malarial parasite must
be found in the patient's blood. In the meantime no soil
should have been turned up in the patient's neighborhood,
he should not have exposed himself to infection in any way,
as by traveling into a malarious country, sleeping out at
night, etc. Even if all these demands could be satisfactorily met, there would at the present time still be the proof
lacking that the malarial parasite lived in the water. Outside of the human body, we know nothing of the life-history
of this jiarasite. It may be discovered later and found to
thrive in water, in which case the probability of frequent infection through drinking water would be strongly enhanced.
But it may turn out that it does not live in water for any
length of time, aud then the possibility of infection through
this medium would be greatly diminished. All we can say is
that no case among all those recorded as water-borne gives a
positive finding of the malarial parasite in the blood, certainly
one of the most necessary proofs to show that the patient
really had malaria.


July 10
To confirm our view we have the definite knowledge that
" 11
drinking water from malarial places does not produce the
" 12
fever experimentally. And finally, it is probable that a large
number of the cases attributed to malarial infection are not
malaria, but rather typhoid, and if not the latter, then
due to some auto-intoxication from the intestine. We know
how many illnesses starting in with vomiting, headache,
chills, diarrhcea, and even blood in the stools, sometimes
rapidly ending in death, are due to poisonous articles of food ;
why then should we not have similar attacks which do in a
measure simulate malarial infection, where the most marked
symptoms are intestinal, as a result of drinking foul waters,
as one of the Italian physicians mentioned above suggests?
This does not seem unlikely, and until we know more of the
life-history of the malarial parasite outside of the human
body it is fair to question the water-borne theory of malaria.


" 19
Much light may be thrown on this question iu the future by
" 20
further study on the climatic and telluric conditions underlying the existence of malaria in different places; but as yet,
though an enormous amount of study has beeu given to these
very points, the results obtained by the observers do not agree
altogether, and we are unable to form any definite conclusions which elucidate the life of this obscure parasite. Above
all, in the study of this subject it is absolutely necessary that
malaria and typhoid fever should not be confounded, as they
have been so often in the past.


In conclusion I would simply add the two following paragraphs from Sternberg's Malaria and Malarial Diseases, which,
though written in 1884, are as true to-day as then. He says :
" It is well established that enteric fever and certain alvine fluxes
may result from the use of contaminated drinking water. And
in the case of the former disease, we know that even very great
dilution does not destroy the infectious properties of the con


5
6


7
14
15


42


79.300
79.800
79.900
79.050
79.050




16. 2347
JOHNS HOPKINS HOSPITAL BULLETIN.  
15.9769


18.6598




15.5547
[No. 72.  
15.0666
15.4947
14.9825
14.3732




1.1832
1.1832


'3.3325
taminated water, e. g. in those cases where it has been used
to wash vessels in which milk was placed, aud in which
typhoid fever has resulted from drinking this.  


"That fevers having an intermittent or remittent character
may also be produced in the same way cannot be doubted. But
we have already seen, in the introduction to the present volume, that enteric fever frequently presents these characters;
that in this case the differential diagnosis from malarial
fevers presents great difficulties, and that in many parts of the
world fevers of this character are attributed, without question,
to malaria. We therefore feel inclined to accept the evidence
with a great deal of caution. Moreover, we think that considerable weight should be accorded to the negative evidence.
It Avould seem that if this mode of infection occurs at all, it
should occur frequently, and in that case that it would be
more generally recognized. From what has been said in the
introduction, it will be seen that we cannot accept evidence
relating to the iiroductiou of ' nuilarial diarrhoea,' or ' malarial
dysentery,' or ' mountain fever,' or ' continued remittent fever,'
or ' typho-malarial fever' in any of its forms."


16!2498
Bibliography.
16 6779


17! 7057
1. Chapin, C. V. : " The Origin and Progress of the Malarial
Fevers now prevalent in New England." 1884. Fiske Fund
Prize Dissertation No. 32.


2. Griswold, R. W. : " On the Epidemic of Malarial Fevers
at present prevalent in Southwestern New England. Historical and Etiological." Gaillard's M. J., New York, 1885.


— o'.7oio
3. Baker, 0. : " Malaria on Shipboard." Brit. M. J., 1893.  


+b'.954i
4. Greeuleaf, K. AV.: "The Charles River in its Relation to
the Etiology of Intermittent Fever." Boston M. and S. J.,
Vol. CXXX, 1891.  


5. Green, J. S. : "The Appearance of Intermittent Fever
near the Neponset River." Boston M. and S. J., 1887.


6. Kershner, E.: " Is Malaria a Water-borne Disease?" N.
Y. Med. Rec, 1895.


Condition of the leucocytes with reference to Neusser's
7. Zwisohn, L. W. : " Is Malaria a Water-borne Disease ?"
granules : During the jjeriod in which no Carlsbad water was
N. Y. Med. Rec, 1895.  
taken the granules were present only in very moderate numbers. On the other hand, from July 16th to 20th, during
which the water was drank, there was a very distinct increase
in the number of granules present in all the forms, particularly in the mononuclear leucocytes. At the same time it will
be seen that there was a marked diminution in the allo.xuric
bodies as represented by the amount of nitrogen eliminated.  


Observation II. — Dr. L., a perfectly healthy man, aged 25
8. West, G. H.: "Good Drinking Water vs. Malaria."
and weighing 69.5 kilograms. Muscular, moderate panniculus adiposus, and of a quiet disposition. My colleague, after
North Carolina M. J., Wilmington, 1895.  
bringing himself to a point of equal daily nitrogen elimination, drank Carlsbad water for a period of 4 days (1.5 liter of
Muhlbruun per day).  


The daily diet was as follows : Ham, 250 grams ; veal,
9. Waggener, R. : " Drinkiug Water — a Source of Malaria." New Orleans M. and S. J., 1891-92.  
250 grams; milk, 100 grams; wine, 500 grams; tea (black
infusion), 250 grams; rum, 15 grams; butter, 50 grams;
breakfast rolls, 3.  


The above food represented about 1895 calories daily (27
10. Hylaud, C. S. : "Water a Source of Malarial Fever."
calories per kilo body weight), which were made up as
New Orleans M. and S. J., 1893-94.
follows:


11. Daly, W. H. : "Some Practical Observations on socalled Malaria being a Water-borne Disease." N. Y. Med.
Rec, 1894.


12. Norbury, F. P. : " Is Malaria a Water-borne Disease ?"
N. Y. Med. Rec, 1894.


Albumin
13. Jones, .J. J.,: "Is Malaria a Water-borne Disease?" N.
Fat
Y. Med. Rec, 1894.


Carbohydrates
14. Cadwallader, R. : " Malaria and Drinking Water." N.
Alcohol
Y. Med. Rec, 1894.


15. Newton, R. C. : "Some Observations which appear to
establish the Aerial Transportation of Malarial Germs." Internat. M. Mag., Phila., 1895-9G.


16. Lewis, R. II.: "Drinking Water in its Relation to Malarial Diseases." The Sanitarian, Brooklyn, 1894.


511.73 calories.
785.49
341.69
256.88




17. Cowan, .1. B. : "Water vs. Atmosphere — the Cause of
Malignant Malarial Fevers." Nashville .J. of M. and S., 1896.


Total
18. Quine, W. E. : "The Malarial Disorders of Large Cities
with especial reference to Chicago." J. of the Amer. Med.
Assoc, 1895.


19. Ross, R. : "Some Practical Points respecting the Malarial Parasite." Indian Med. Gaz., Calcutta, 189G.


20. Rogers, L. : " The Etiology of Malarial Fever, with
Special Reference to the Ground-water Level and the Parasite." Indian Med. Gaz., Calcutta, L896.


1895.79
21. Ilehir, P.: "An Inquiry regarding Drinking Water in
Relation to Malaria." The Indian Med. Chirurg. Review, 1895.  


22. Shcllong, 0. : " Die Malaria-Krankheiten, etc." Berlin,
1890.


23. Steudel, B. : "Die Perniciose Malaria in Deutsch Ost.
Africa." Leipzig, 1894.


Table III.— Urine.  
24. Leonhardt : " Entstehung und Wesen d. Malaria Erkrankungen, etc" Zeitschrift fiir kliu. Med., Berlin, 188586.  


25. Verdan: "Considerations sur la fievre intermittente a
Ouargla, etc." Archives de Medecine et de Pharmacia militaires, Paris, 1885.


26. Nicolas, Ad. : " Chantiers de terrassements en pays
paludeen." Paris, 1889.


Q
27. Pepper, E. : "De la malaria." Paris, 1891.


28. Kelsch and Kiener: "Le poison palustre." Ann.
d'llyg., Paris, 1888.


0^
29. Celli, A.: "Acqua potabile e uuilaria." Gior. d. Soc.
Ital. d'Eg. Milano, 1886.


30. Salomone-Marino, S. : "L'acqua die luoghi malarice
porta infezione ?" Sicilia Med. Palermo, 1891.


Dally amount
31. Bouizzardi, T.: " Sulle Risaie." Salute Pubb. Perugia,
of urine In
189L
com.


32. Moscato, P.: "Etiologia e cura della malaria." II
Morgagni. Milano, 1893.


S Ml
33. Hurley, J. M. : " Pacific M. J., San Francisco, 1895.
if


34. Boudin, J. C. M. : "Traite des fievres intermittentes,
etc." Paris, 1842.


- u a
DlSCUSSIOIi^.


|g|i
Dr. Welch. — It is clear from Dr. Norton's careful analysis
of the existing evidence for and against the water-borne theory
of malaria, that the weight of evidence aud of authority is
decidedly opposed to this theory. It is curious how prevalent is the belief in this theory among both the general public
and practitioners of medicine, especially in the southern part
of this country. As a matter of fact, the only infectious
diseases whose germs we have good reason to believe to be
conveyed by drinking water, are typhoid fever, Asiatic cholera,
and dysentery. To this meagre list may be added indefinite
gastro-enteric disturbances resulting from infection or intoxication from drinking water. The numerous claims that
various other infectious diseases, including malaria, may
result from infection through the drinking water, do not rest
at present upon any substantial basis of demonstrated facts,
altliougli it must be ailmitted that some of these claims have
not been positively disproved. The criticism of the drinkingwater theory of malaria by Celli and Leri, aud above all their




A,


March, 1897.]


Percentage of
alloxurlc
body— N of
total nitrogen.




June 12
JOHNS HOPKINS HOSPITAL BULLETIN.




1


43


1430




25.2421
couvinciug experimeutal iuvestigatious of this riiiestion, iadicate decidedly that drinking water is not a carrier of the malarial
organism in a condition capable of producing infection through
the alimentary canal underany ordinary conditions. There seem
to me to be at present only two theories of the mode of malarial
infection which deserve serious consideration, viz. the theory
that infection occurs through the air, and the theory that infection is the result of inoculation with the malarial jjarasite
through the agency of mosquitoes and perhaps other suctorial
insects. The question whether or not the malarial parasite
may live and jjerhaps multiply in water would of course not
be decided by the exclusion of water as a vehicle of infection,
for it is possible, even probable from experiments, that infection with the malarial parasite does not occur from the intact
alimentary canal, and the mucous membranes of this canal
would be the only natural portal of entry for infectious agents
in drinking water. The majority of authoritative writers on
malaria have advocated the theory of air-borne infection, but
we shall probably, since Hanson's publication, hear more and
more of the inoculation theory.  


Dr. Reed. — Dr. Norton has kindly referred to a report which
I made to the Surgeon-General during August last, upon the
etiology of malarial fevers at Washington Barracks and Fort
Myer, during a period extending over twenty-six years. Washington Barracks is situated in the midst of marshy lands at
an elevation of not more than twenty feet above the Potomac
river, and upon soil deposited from this rivei". The post has
had but one supply of water, viz. Potomac river water. During this time malarial fevers have prevailed to a greater or less
extent, certain years being exceedingly severe and others comparatively light. I compared the malarial curve of that station
with that of Fort Myer, wlMch is 240 feet above the Potomac
and on high ground. I was sui'prised to find such a close
agreement between the two. Indeed, in the last eleven years
of this investigation the lines ran accurately together. If the
line at Washington Barracks fell below that of Fort Myer, it
was accounted for by the fact that the garrison had been sent
into summer camp during the malarial season. In investigating the water supply at Fort Myer, I ascertained that until
1886 pure spring water had been furnished. During the
latter year certain wells were sunk in low marshy soil, from
which the garrison was supplied until 1894. It was curious
to note that the supply of " marshy water," which was so much
condemned by the various medical officers, did not increase the
malarial cases; but that, on the contrary, during the six
years immediately following the introduction of this supply, the
disease was less prevalent than at any other jjcriod in the history
of the post. In 1894, wells were discontinued and Potomac


0.5710




water introduced. Filters were placed in the men's quarters
and, in addition, the filtered water which the officers drank
was boiled. Notwithstanding these precautions, the sick-rate
from malarial diseases was higher in 1895 than during the
previous twenty-three years, and corresponded accurately with
the rate at Washington Barracks. All of which proved to
my miud that the water supply had nothing to do with the
prevalence of malarial diseases, and that their etiology was to
be found in the low marshy lands lying along the Potomac
river.


Dr. Tn.iTER. — Certainly all experimeutal evidence points
directly against the idea that malarial fever can be conveyed
by drinking water, and more than that against the idea of an
infection through the alimentary tract. Grassi and FeTetti fed
patients upon the dew collected from malarious districts, and
further upon fresh blood taken from patients suffering from
malarial fever, blood which, as is well known, if introduced
hypodermically or intravenously, always results in a transference of the infection, without any positive result. Despite
the fact that the patients on whom these experiments were
made were often debilitated individuals suffering from chronic
nervous diseases, etc., yet as they were, in almost all instances,
in hospitals or in situations where they were well fed and well
cared for, it would be impossible to entirely refute the critic
who might suggest that it was the good surroundings which
saved the patients from a progressive infection which otherwise would have occurred. Such a critic might suggest that
had these individuals been suffering from distinct gastro-iutestinal lesions, infection would readily have occurred. In connection with this possibility it is interesting that out of 4G
cases of amosbic dysentery which we have had in the Johns
Hopkins Hospital, 5, or nearly 11 per cent, have suffered at the
same time from malarial infection. May it be possible that the
amcebic ulcers were in these instances the portals of entry for
the malarial parasite ? It must of course be said, upon the
other hand, that most of these instances of amoebic dysentery
occurred during the malarial season and came from districts
where the malarial parasite is doubtless endemic.


2.27
Dr. Norton's quotation from the author who thought he had
found a large number of endoglobular, hyaline parasites in
infant's blood is interesting, inasmuch as any observer who is
familiar with examinations of fresh blood will immediately
see how the author quoted has deceived himself. The vacuoliclike figures found particularly in the blood of children or
infants who are auffimic or suffering from fever of any sort,
simulate often very closely the malarial parasite, and always
deceive the uninitiated ; to the skilled observer, iiowever, they
are readily recognizable.  




" 13


JOIJRl^ALS, ETC., ISSUED BY THE JOHNS HOPKINS PRESS OF BALTIMORE.


9




1815
American Journal of Mathematics. S. Newcomb and T, Craig, Editors. Quarterl}'. 4to. Vol. XVIII in progress. $5 per volume.


iiinerican Chemical Journal. I. Kemsen, Editor. 10 Nos. yearly. 8vo.
Vol. XVIll in progress. 14 per volume.


30.1310
American Journal of Philology. B. L. Gilderslekve, Editor. Quarterly.
8vo. Vol. XVII in progress. $3 per volume.  


Studies from the Biological Laboratory. Svo. Vol. V complete. $5 per
volume.


0.5595
Studies in Historical and Political Science. H. B. Adams, Editor.
Monthly. Svo. Vol. XV in progress. $3 per volume.  


Johns Hopkins Hospital Bulletin. Mouthly. 4to. Vol. VIII in progress.
$1 per year.






1.85
Johns Hopkins Hospital Keports. 4to. Vol. VI iu progress. $5 per


volume.
Johns Hoplilns University Circulars. Containing reports oC ecientiflc


" 14
and literary work in progress in llaltiinore. 4to. Vol. XV in progress.


$1 per year.
Memoirs from the Biological Laboratory. W. K. Hhgoks, Editor. Vol.


3
incomplete. It7..')0 per volume.
Annual Heporc of ihe Johns Hopkins University. Tlie Annuiil Report


of the PrcsidiTit to the liourd of Trustees.
The Annual Register ot the Johns Hopkins Universiiy. Giving the


1800
list of ollieers jinil students, and .statinj.- t he regulations, etc., of the University. Published at the end of the Academic year.




28.1925


44


0.5237




JOHNS HOPKINS HOSPITAL BULLETIN.




1.85


[No. 72.


" 15




4
THE RADICAL CURE OF HERNIA BY IMPLANTING A SECTION OF STERILIZED SPONGE.


By W. B. Platt, F. K. C. S. (Eng.)
[Ueud before the Johns Hopkins Medical Society, January 4, 1897.]


1880




30.3996
The radical cure of hernia has long enlisted the attention of
surgeons, and a method which is efficient, safe, reasonably
simple, sacrificing no important part or function, causing
little inconvenience and demanding but a short confinement
to bed, has been eagerly sought. To simplify matters, the
older surgeons cut the Gordian knot by removing the testicle
and cord of the affected side. The presence of the cord at the
end of a shallow funnel seemed to be the obstacle to the complete closure of the inguinal canal and rings, the pressure of
the intestines acting as a wedge to keep them open.  


To remove the cord by transplanting it to another location
was the next step of the modern surgeon, and an efficient
means of cure. The hernia oftener failed to return than by
other methods. Certain drawbacks in this procedure are often
noted, such as prolonged confinement to bed and great swelling
of the testicle, so great in fact as to throw some doubt upon
the future function of that organ, while very large incisions
in the abdominal wall, a long cicatrix, a multitude of buried
sutures, made the opei'ation more complicated to the surgeon
and less agreeable in the end to the patient.


0.5791
The writer has endeavored to efficiently close the inguinal
rings and canal by a more simple procedure, and this can be
done. The cases are all too recent to prove the permanency of
the cure. He can only say that two cases of intractable hernia
have been up and about for several months, and have never
worn any truss or support of any kind since getting out of bed.  


The idea of implanting a section of sponge in the inguinal
canal which should form a firm connective tissue barrier to
the descent of the hernia, occurred to the writer while experimenting upon rabbits in the Physiological Laboratory of the
Johns Hopkins University in the spring of 1882, and observing the normal retraction of the testicle into the abdominal
cavity in these animals.


As inguinal hernias are not readily produced in animals of
this kind, I endeavored to so implant a piece of sponge within
the inguinal canal as to retain the testicle in the scrotal
pouch. The aseptic technique of that day was so imperfect
that suppuration ensued and the sponge came out.


Later, I operated on a number of patients at the Garrett
Hospital for Children, by simply removing the sac, suturing
the conjoined tendon to Poupart's ligament, and sewing up the
inguinal canal.


1.90
This succeeded very well in most cases. I have one of these
cases here to-night, done five years ago. He has had no return
of the hernia and wears no support or truss. The return of the
hernia, however, in a case where I had every reason to hope for
a permanent cure, led me to try the implantation of a section
of sterilized sponge. The result certainly proved one thing,
viz. that a piece of sterilized sponge as large as half a dollar
could be introduced beneath the internal ring and remain
there without causing any irritation, the wound healing over
it and remaining healed.  




" 16


Before this healing took place there was in my first case a
small sinus at the upper part of the incision and I feared it
might be due to the sponge. It turned out to be due to sutures,
and these being removed, the wound healed without further
trouble, but after five months the hernia came down. I operated upon this patient a second time, intending to insert a
second piece of sponge. To my surprise I found an opening
less than one-fourth of an inch in diameter in the location of
the external ring. I inserted two small sutures, the wound
healing promptly over them. The sponge in this first case
was simjily laid beneath the ring.


5
In the succeeding three cases the section of sponge was
secured to the cord. One description of the operation will
suffice for these cases.


An incision about two and one-half inches long is made
directly over the inguinal canal, following its course, the lower
end extending about half an inch uj)on the scrotum. If the
hernia is down, the operation is so much the easier. The
canal is laid freely open. The sac, whether congenital or
acquired, is opened in its entire length, the hernial contents
reduced, and the sac cut away close to the internal ring, if
congenital, while if it is an acquired sac it is cut square oflf
after being ligated as high up as possible, and dropped beneath
the ring. In the case of the congenital sac it is often necessary
to leave the thin inferior \ajev in siiu and adherent to the cord.


2000
Next, a section of fine, firm, surgical sponge is cut about
one and one-half inches in diameter and one-eighth of an
inch in thickness. This is sterilized without boiling, by
immersion in soda solution, washed in sterilized water, treated
with permanganate of potash and oxalic acid, and thoroughly
washed in sterile normal saline solution. A radial cut is made
in the section. The constituents of the cord are gathered together as high up as possible and placed in the center of the
section and at a right augle to it. The edges of the cut in
the sponge are now slightly overlapped, and two sutures
inserted in the sponge to keep it in place on the cord which
now pierces its centei-. The sponge section is spread out
beneath the internal ring, and the conjoined tendon sewed
firmly by two or more qiiilted sutures to Poupart's ligament,
using a needle in a handle.


The inguinal canal is now snugly sewed up with silk
sutures, and over all the skin sewed with silk-worm gut. It
is absolutely necessary to use some kind of drainage in the
upper augle of the wound, as there is invariably some serous
oozing and swelling. This may be removed after 2-J: hours.


30.0650
The patient is confined to bed and on his back for three
weeks. If the patient is a boy it is well to use the Bradford
frame, to keep him from sitting up and twisting about in bed.
The skin sutures are removed on the 9th or 10th day, the
wouud being treated on ordinary aseptic principles.  


After three weeks the patient is allowed to sit up in bed a
day or two, then sits for two or three days in a chair, after


0.5217




0.4222
March, 1897.]




1.73


JOHNS HOPKINS HOSPITAL BULLETIN.


" 17*




6
45




1890


which he goes about as usual. It is unnecessary to use any
support over tlie site of the operation beyond a light strip of
gaxize to protect the fresh cicatrix from friction.


27.2868
In two of these cases where I was obliged to remove the
deep silk-worm gut sutures before the patient left the hospital
in order to close an obstinate little sinus in the upper angle of
the wound, the hernia returned, as might have been expected.
The trouble with these sutures may have been due to too great
tension, or to a defect in the sterilization of the sutures. In
none of the four cases was there any trouble from the sponge.
In the two cases mentioned the wound healed promptly on
removing the offending sutures. In the two other cases there
was no difficulty whatever in securing complete permanent
first-intention union, and there has been thus far no return of
the hernia.  


It is of course premature to say that there may never be a
return of the hernia, nor do I know the ultimate fate of the
sponge, whether it remains as organized tissue or whether it is
absorbed.


0.6515
From its open structure and the ease with which it is
retained in the tissues it is not improbable that blood-vessels
pass into it, and that it makes a framework for connective
tissue, a close imitation of that barrier which nature places
beneath all normal, internal, inguinal rings and which prevents every male from being a subject of hernia.  


It is hardly necessary to say that the greatest care must be
exercised in the perfect preparation of the sponge section to
insure perfect sterilization. I have the pleasure of showing
three of the four sponge cases ; also one of the older cases,
where the rings were simply sewed up and no sponge section
used.


Abstract of Gases.


All the following cases were operated ujion at the Garrett
Hospital for Children, Baltimore.


2.38
1) G. L., set. 4. Complete inguinal hernia, right side,
developed at two years of age, and is not kept up by
trusses. Operation August 21, 1895. One deep suture
causing a small sinus was removed 55 days after operation. Patient was discharged from the hospital, October 23,
1895, with the wound entirely healed. It has never since
reopened. Hernia reappeared 5 months after operation. The
return of the hernia doubtless due to the early removal of the
suture closing the internal ring.  


2) S. J., set. 8 years. Complete inguinal hernia, right side.
Hernia developed when 2 years old. No truss effectually
keeps up hernia. Admitted June 9, 1896. Operation June
17, 1896. Congenital variety of sac. Patient was walking
about July 20, 1896. Discharged with the wound entirely
healed, August 7, 1896. There has been no return of the
hernia at the date of this paper.


" 18
3) T. W., aet. 12 years. Acquired inguinal hernia, right
side. Kuptured since 2 to 3 years of age, and has been kept
up with difficulty. Admitted to hospital August 4, 1896.
Operation August 19, 1896. Out of bed September 18th.
Walking about September 23. Discharged well with wound
healed September 25, 1896. Patient is a student at the
McDonogh Institute. There has been no return of the hernia
up to the date of this paper.




7


4) G. M., Eet. 5 years. Complete inguinal hernia, leftside.
Hernia appeared at 3 years of age. Trusses do not retain the
hernia. Admitted to hospital August 18, 1896. Operation
August 26. The wound healed at first. After about a week
a small sinus appeared at the upper angle of the incision.
This persisted, until on December 10th two deep sutures were
removed, after which the wound promptly healed, and patient
was discharged well with wound healed, December 24, 1896.
Patient was seen January 1, 1897, when the hernia had begun
to return, as evidenced by an elastic bulging tumor at the seat
of the internal ring.


3110
Notes.


In Oases 1 and 4, where the hernia returned, it is clear that
the soft tissues of the recent operation were subjected to undue
strain by the early removal of the most important sutures
concerned in the operation, viz. those binding the conjoined
tendon to Poupart's ligament. In all four cases the sponge
remained without causing any irritation, the incision healing
in each case.


29.4983
I have not had an opportunity in any case to discover the
actual condition of the implanted sponge after the lapse of
time.  


If sponge will thus heal in the depth of a wound, there is no
reason why mats of silk or of other animal tissue might not
also be used, and sutured firmly in place to close the openings
of exit for heruiaj.


0.5421
It is not impossible that the addition of these animal tissue
barriers may be the element necessary to make the former
operation of suturing the rings and canal without transplanting the cord, a success in the very great majority of cases.  


In no case was any supjiort worn after the patient got out
of bed, and in all cases the hernia was operated on because of
the intractable nature of the hernia, no truss or support keeping the hernial contents in the abdomen, with the exception
of No. 3, where a truss proved so great an annoyance that his
family desired operation.


Discussion.


Dr. Bloodgood. — I cannot say from observation whether
the scar tissue formed with the sponge is any stronger than
that formed without it. A study of the statistics of operations
for hernia will show that sometimes very simple operations
will cure hernia in children. In looking over the cases of
different operations, such as MacKewen's, Banks' and others,
we find very few recurrences in children. We have found it
so here, even in the cases where the wound suppurated and
healed by granulation. It is interesting to know tliat a foreign
body can be implanted in the tissues without giving rise to
any trouble. Our observations here have caused us to think
that silk sutures are more apt to cause suppuration than silver
wire, and that the ideal suture would be an absorbable one.


1.83
It is unfortunate that Dr. Piatt has not had an opportunity
to operate upon a recurrence in order to see what becomes of
the sponge. I would ask him if he thinks the sponge remains
permanently and if he has any observations to show that the
scar tissue about the sponge is any firmer than ordinary scar
tissue.  




" 19


46


8




2840
JOHNS HOPKINS HOSPITAL BULLETIN.




28.40


[No. 72.


0.6908




0.4222
Dr. Platt. — I have not yet had a chance to learn the ultimate fate of the sponge, but I think I shall determine it
in the case of this boy whose hernia has returned. I have
been surprised that his hernia has not returned sooner, for
when I was obliged to remove the deep sutures to close the
sinus I expected that it would soon recur.  


My belief is that the sponge becomes incorporated into the
tissues by aid of leucocytes and the blood-vessels which enter
its meshes from the adjacent structures, and that when their
work is done these probably atrophy, leaving scar-connective


2 43




" 20
tissue. Whether it is stronger and thicker than other scar
tissue I do not know, but will take the first opportunity to find
out. After the ordinary Banks operation a funnel opening is
left, and the cord acts as a guide to further the descent of
hernia. I^Iy idea is that by putting in the sponge j-ou obviated
perhaps the last fault in the stitching operation, and thus get
on without trausplauting the cord. It is, of course, too soon
to draw conclusions as to the final result from these four
cases. I shall report again after operating upon this patient.




9


ADDITIONAL OASES OF DERMATITIS DUE TO THE x RAYS


2730
By T. C. Gilchrist, M. R. C. S., L. S. A.




27.30


During the time which intervened between the correction of
the proofs of my article on "A Case of Dermatitis due to x
Rays " and its publication, there have appeared in the literature a number of quite recent cases which have come
under my notice and which could not be incorporated in my
paper {vide Johns Hopkins Bulletin, February, 1897). I
therefore add five more cases which have been recorded in
various journals. Dr. Reid's case is of particular interest
because a cutaneous lesion was not only produced on the anterior surface of the chest which was exposed to the rays, but


0.6162




also on the posterior aspect of the chest and on an area which
he thinks corresponded to the exit of the rays.


Literature.
W. Downe: Lancet. 1896. Vol.11, p. 1049. (Abstract.)
Sewell : Lancet. 1896. Vol. II, p. 1049. (Abstract.)
W. Reid: Brit. Med. Journal. 1896. Vol. II, p. 1744.
A. B. Kibbe: New York Medical Journal. January 16,


2.10
1897. Vol. LXV. No. 3.  


M. Rendu : New York Med. Journal. February 20, 1897.


(Abstract from Progres Medicale. January 30, 1897.)


f From June 17 to 20 Carlsbad water was drunk.


Table IV.— Nitrogen Balance (N in Grams).


Dr. W. Downe.






Eruption appeared 10
days after exposure.


1^




38
Distribution.




t


S
Back of neck
and scalp.


NITBOGEN eliminated.




Character of Lesions.




S


Extensive vesication on the back
of the neck. The hair fell out
over occiput, but the skin remained normal.






Urine.  
Subjective
Symptoms.  




FsBces.


At first a sense of


a


n


pricking heat. given.


June 14
" 15
" 16
" 19
'• 20




3
No further observations


4
5
8
9




69.700
Dr. Sewell exhibited a similar case at the same society meeting. (See references.)
6".700
69.800
70.200
70.000




31.7345
31..=S645
31.6679
31.5979


Dr. W. Reid (personal).


36.3996
30 ('650
28.40
29.30




l.'3V42
Dr. A. B. Kibbe.  
1.2619




31.3792
36.5702


Dr. M. Rendu.


+0 8536
-|-'l'.5643




Eruption appeared in the
evening of the same
day. Two exposures,
varying from 20-90
minutes.


Relation of Neusser's granules in the leucocytes: In the
20 exposures from l/i-b
period before Carlsbad water was taken, with the amount of  
minutes of left hand,
the alloxurlc bodies above the normal (and with a large amount
and 3 exposures of  
of uric acid), the granules were not particularly abundant.  
elhow. Eruption appeared in a day or two.  
In the second half (June 17-20), when the water was taken,
the amount of the alloxurlc bodies eliminated was still higher,






88
Rays applied daily for
55 minutes.






Chest and abdomen.


whereas the granules had become distinctly diminished in
nnmber, particularly in the small mononuclears.


Observation III. — A. F., a young woman, 33 years old, and
a cook by occupation. She bad a severe anasmia (red corpuscles 1,900,000 per ccm., leucocytes 6800, and hiemoglobin
35 per cent, according to Fleischl's ha^monieter). The temperature was normal during the observation. Pulse averaged
110 per min. Slight dyspnoea even when at rest. Patient was
of rather large frame, and the panniculus adiposus was not
particularly reduced. No oedema ; urine free from albumin.
Had suffered previously from some gastric trouble, but the
symptoms had disappeared. From June 35th to July 7th her
weight had become reduced from 57 to 53.4 kilograms.


The daily diet was as follows : Ham, 100 grams ; white
Both hands and
bread, 100 grams ; milk, 500 grams; wine (white), 350 grams;
elbow.  
water, about 1000 grams.  


The diet administered represented about 938 calories (17 per
kilo body weight), which were made up as follows :




First an erythema, followed by
papules, and later by exfoliation
of the epidermis, which exposed
a raw, painful, weeping surface
16 days after exposure.


Albumin
First a slight tingling, then a
Fat
sense of irritation and itching;
10 days later extensive discoloration round elbow. No vesicles appeared.


Carbohydrates
Alcohol




After first application of rays intense erythema appeared, followed by vesicles and later by
an eschar which did not heal
for several weeks.


307.46 calories.
319.30
379.49
133.50




Painful after trie
weej)ing surface
was formed.


Total




At first tingling
followed by itching ; but there
wasnosensitiveness or pain.


938.65




10-inch coil was used 3
inches from the skin.


Table V. — Ukinb.




Arm was covered by the
usual clothing, viz. heavy
woolen clothin<.' and coat
sleeve. Portion of the
skin was excised from
forearm for histological
examination.


Date.




1
THE MALARIAL FEVERS OF BALTIMORE.


An Analysis of 6i6 cases of Malarial Fever, with Special Reference to the


a
Relations existing between different Types of Haematozoa


h
and different Types of Fever.


By William Sidney Thayer, M.D., and John Hewetson, M. D.,
ABSisUints in the Medical Clinic of The Johns I/opktns VoBpital.


.a
218 pages, qiiarlo, with platen and charts. I'rice ItiS.OO, Postage paid.  


[Forming part of Tlie Johns Hophliis Ilospltal ileports. Vol. V, 1895.]
Orders should bo addressed to TnK Johns Hopkins Phkss, Hai.timohk, Mu.


2


a a 2


THE JOHNS HOPKINS HOSPITAL BULLETIN,


a-2
Volume VIII.


The Bulletin ot the .Tolms HnpUlus Hospital entered upon Its eighth volume
laiumryl, 1897. It contAlus original communications relating to medical, surgical and gyuocologlcal topics, reports of dispensary iiracltce, reports from the
pathological, anatomical, physlologlco-chemlcal, pharmacological and clinical
laboracorle.-i, abstracts of papers road before, and of discussions In the various
societies connected with the Huspllal, reports of lectures and other matters of
general Interest In the work ot the Johns Hopkins Hospital and the Johns Hopkins
Medical School.


ntage of
The subscription price la $1.00 por year. Volume VII. bound In cloth. $1.50.
uric
-Nof
otal nl






March, 1897.]






JOHNS HOPKINS HOSPITAL BULLETIN.






47






PROCEEDINGS OF SOCIETIES.






THE JOFINS HOPKINS HOSPITAL MEDICAL SOCIETY.


Meeting of October 19, 1896.


t>
Dr. Thayer in the Chair.


Rarer Cases of and Observation on Strcptococcns Infection.


? a
— Dr. Bloodgood.


Case I. — Tliefirskcase isof especial interest because the patient
recovered, although on two occasions pure cultures of the streptococcus were obtained from the blood by aspiration of a vein
in the arm. In the records of the liospital only one other such
observation had been made— that of Dr. Blumer, in a case of
broncho-pneumonia.


1
In all other cases of streptococcus infection which have
recovered, from which blood cultures have been taken, negative
results have been obtained.


This case also presents the rare condition of a streptococcus
infection of the finger, with an abscess situated between thepectoral muscles, but no evidence of any enlargement of the glands
in the axilla. The abscess was distinctly localized and no
other abscesses developed.


The patient presented to you to-night was admitted into the
hospital, January 28, 1896. A history could not be obtained,
as the patient spoke only Polish. He appeared about 25 years
of age, strong and well nourished. There were two healed
wounds covered with a dry scab on the index and middle fingers
of the left hand. The fingers and entire arm presented no
evidence of inflammation. The axilla was soft and not tender.
The skin over the upper part of the chest was slightly red and
(Edematous. The greater pectoral muscle was more prominent,
and beneath it there seemed to be a fluctuating swelling. The
aspirating needle withdrew some thin purulent material.
Examination of coverslips demonstrated polymorjAous leucocytes and cocci in short and long chains. Thei'ectal temperature registered 104°, pulse 80, respiration 24.


An incision was made through the skin and through the
greater pectoral muscle in the direction of its fibres, opening a
large localized abscess.


g « o «
Cultures from this abscess and from the blood taken from a
vein in the opposite forearm contained in 48 hours numerous
colonies of streptococci. Two days later blood cultures also
showed colonies of streptococcus ; three observations after the
fifth day were negative.


The patient had fever for IG days, the rise of temperature
being from 101° to 104° and frequently 105°. Recovery followed. The wound healed and there was no loss of function
of the muscles.


Perc
The early diagnosis of fluctuation, due to fluid beneath a
alio
large muscle, is a very difficult one. The muscle itself, when
bod
relaxed, gives to the fingers a sensation of fluctuation. For
the  
this reason in this case the aspirating needle was used to
trog
confirm the diagnosis of a deep abscess.


Omo II. — The second case presented to-night is of interest
becauseof the very high temperature — 106.5° rectal — which was
associated with the beginning of an attack of erysipelas of the
neck and face. The patient recovered. Five weeks before the
attack of erysipelas a large mass of suppurating and adherent


July 1




1
glands had been removed from the neck. The wound had
healed with the exception of the small granulating area. The
patient had been walking about for two or three weeks, with
no rise of temperature. There were no cases of erysipelas in
the wards. The attack began with a chill, and a temperature
of 106.5°, taken one hour after the chill. Coverslips made
from the granulating area showed cocci in long chains. No
erythema could be seen. The patient was a colored man and
only very deep redness can be made out. He was immediately transferred to the isolating ward and given a bath for 30
minutes, the temperature of the water being 70° F. The fever
was reduced to 103° and did not rise above 104.6° afterwards.
Later the skin of the neck and face became very red and oedematous; no abscesses formed. Coverslip and ciilture demonstrated streptococcus. Two blood cultures were negative.


The only treatment followed was cold sponging and local
application of cold cloths to the neck and face.


1300
During the last two years we have made a great number of
coverslip examinations from the surfaces of granulating
wounds, and also from cases in which there has been an attack
of erysipelas. In almost every case in which there has been an
infection of tlie streptococcus of erysipelas we have demonstrated in the coverslips taken from the granulating wound
cocci in short and long chains, and in every case cultures and
the clinical course have demonstrated the infection to have
been due to the streptococcus. In thercoverslips from healthy
granulating wounds we have never found .' r "occi in chains.
But only a few were studied also by cultun > i '•(> few, only


staphylococci grew. These observations \\^" \i-w\ \.t.\\' llic
early diagnosis of erysipelas.


1022
Death from streptococcus infection has Dei,n a verv rare
event. These organisms do not seem to have with us uL.
virulence which in former years they must have had. In
reading Billroth's and others of the older surgeries one is
impressed with the large death rate from erysipelas and
streptococcus infection of wounds.


There have been two interesting observations, in both of
which, although the skin over a large area, including the lines
of incision, was the seat of a very intense erysipelas, yet the
healing of the wound was not interfered with. Both patients
recovered.


The first patient was an old man, from whom a V-shaped
piece had been removed from the lower lip for epithelioma,
and the entire chain of glands beneath both sides of the jaw
excised. Both wounds were closed. An attack of erysipelas
began on the second day, starting from the lip and extending
over the entire face and neck. The lines of incision healed
per primani, and there was no deep suppuration.


The second case was a boy, from whom a large mass of
inflamed glands had been excised from the axilla. The mass
was very large and very adherent to the vein. Both pectoral
muscles were divided to aid in the. complete removal. During
the dissection along the vein a small abscess cavity was opened,
infecting the wound. The wound was irrigated with j-jViy bichloride, the pectoral muscles sutured and the skin closed.
Cultures from the glands demonstrated strejitococcus. The






48




" 2


JOHNS HOPKINS HOSPITAL BULLETIN.


9




1400
[No. 72.




1010


adenitis followed an infection of the' finger. 24 hours after
the operation an attack of erysipelas set in, beginning in the
line of the incision. The erythema covered part of the chest
and neclv. Coverslips and cultures from a small opening in the
line of the incision demonstrated streptococci. The patient
recovered ; there was no suppuration of the closed wound ;
there was no impairment of the use of the pectoral muscles.


10.0940
These two cases demonstrate that the skin over a closed
wound may be the seat of erysipelas and yet the healing of the
deep wound may not be interfered with.  


Dr. Flexner. — The case reported by Dr. Bloodgood is of
much interest from a theoretical as tvell as a practical standpoint. Experiments upon animals have led us to consider that
the invasion of the blood by pathogenic bacteria, capable of
setting up actual septicaemias, takes place a short time only
before death, and in the great majority of instances, if not in
all, presages a fatal termination. Flugge pointed out that in
anthrax infection in the rabbit the bactericidal effect of the
blood-serum is lost before this micro-organism is found in the
larger blood-vessels. In pueumococcus infection in the same
animal the blood invasion occurs a short time only before
death.


0.4827
Now since cultures are so readily made from the circulating blood of human beings we may expect important contributions to our knowledge of the occurrence of pathogenic
bacteria in this fluid, and also of the capacity of the human
organism to resist and overcome these parasites when they
have once entered the blood and perhaps even increased there.  


The elimination of the primary focus of infection must be
of the greatest importance in these cases, for it is certainly
probable thut from this site where the parasites are rapidly
increasing not a single infection occurs, but a succession of
invasions of the blood takes place. Perhaps after all, where
recovery occurs, the power of the body fluids and cells to dispose of considerable numbers of the pyogenic cocci is not
actually lost, and those present in the blood have entered from
without and temporarily, at least, have not increased in the
circulating blood. Under these circumstances the removal
of the primary focus of infection before the bactericidal
effect is lost, would in all probability determine the issue of
the case.


4.78
We are told by Baumgarteu and by Stern that one does not
meet in human beings examples of septicremia comparable to
those seen in some of the lower animals. I think there is
reason to doubt these statements, for we have seen at autopsy
cases of streptococcus and staphylococcus infection in which
the blood was crowded with the organisms and wide-spread
capillary thrombi of cocci existed in the internal organs.  


Much discrepancy has been noted by writers upon the subject of the virulence of streptococci obtained from severe infectious processes in human beings. The results of the cultivation experiments of Marmorek seem to give the explanation of
the variations observed. It is an old observation that a
minute quantity of the fluid containing streptococci from the
inflamed peritoneum might show great virulence and set up
a severe and perhaps fatal infection, while the cultures from
this source may be quite without pathogenic effects. Marmorek has made it probable that the difference depends upon


" 3




3
the unfitness of artificial culture media for preserving the
virulence of the streptococcus pyogenes. Through the use of
human blood serum as a medium of cultivation he succeeded
not alone in retaining the virulence of these micro-organisms
for a time, but actually of increasing it, by successive passages through the bodies of animals and recultivation, to a
remarkable degree. Finally it is no criterion of the vitality
of streptococcei to test them upon artificial media, for Marmorek has also shown that cultures apparently dead are
still capable of growth when transplanted to his blood serum
medium.


Ophtlialmoplefjia Externa.— Dr. H. Woods.


1100
On taking charge of the Presbyterian Eye, Ear and Throat
Hospital in September, 1895, I found in the ward, D. 0., 73
years of age, under treatment for corneal ulcer of the left eye.
This, I was told by my friend and associate. Dr. F. M.
Ghisolm, had followed an operation performed by him during
his service in August, for complete left ptosis. A slight
iritis developed after he came under my care, but from this
as well as from the ulcer he made a good recovery. Corneal
ojjacity is peripheral, and a few pigment pin-point stains are
on the capsule. The right eye is centrally blind from choroidal atrophy, but has eccentric vision. It was discovered
during this visit to the Hospital that the extrinsic eye muscles
were paralyzed. The paralysis is not absolute, for both eyes
can move perceptibly up, down and laterally. He left the
Hospital before the corneal ulcer was completely healed,
returning in March, 189G. He gives the following history:


Prior to 1801, when he enlisted in the Federal army, he had
good sight. He claims to have undergone medical examination at Williamsport, Pa., before enlistment. This is important, for the " Surgeon's Certificate of Disability for Discharge," which I have obtained from Washington, is as
follows: "The injury to the eyes of said soldier was caused
by over-exertion in lifting heavy timber in the year 1857."
Signed by Captain.


1014
The Brigade Surgeon's certificate is : " This is a case of
ptosis; but having a suspicion that the loss of vision is
feigned, the subject is respectfully referred to the Medical
Director for decision." The discharge was approved by the
Board of Inspectors. This bears date of February 15, 1862.
It appears, then, that the only testimony of trouble before
enlistment comes from the captain of his company. Against
this there are the patient's statement, the nature of the
trouble as given by the Brigade Surgeon — -ptosis, and the
somewhat weighty improbability of a man with double ptosis
being enlisted.


To return to the history, as given by the patient. In
November, 1861, while marching rapidly early in the morning, he fell, with a number of others, into a stream and was
thoroughly drenched. Within an hour afterwards both eyes
were closed. He was unable to raise his lids. He was sent to
camp, and discharged the following year, as recorded. For
several months he was blind, being able to see only by
elevating the upper lid. Then some power slowly returned
in the right lid. In 1867, Dr. Brown, of Addison, New York,
removed a piece of skin from the riglit upper lid, adding


8.8358




4832
March, 1897.]




5.46


JOHNS HOPKINS HOSPITAL BULLETIN.


" 4




4
49




950


greatly to liis comfort. From '67 to '95 he relied entirely
iipou his right eye. Left ptosis remained complete. His
occupation was gardeuiug. lu the early summer of '95 he
noticed occasional floating specks before the right eye ; " frequently tried to brush away a fly."


1018
One Monday morning in July he went to his gardening as
usual, but soon found he could not see clearly, also that he
"put his foot where he did not mean to, on, instead of between
his cabbage rows." He held open the left eye to make his
way back to the house, and early in August appeared at the
Presbyterian Eye and Ear Hospital. A central choroiditis
explained his right blindness. Dr. Chisolm operated as
stated, to give him use of his left eye, upon which he now
depends. The muscular condition, noted partially in (September, and more accurately in March, is as follows : Complete
ptosis both sides. The operation on the left upjier lid has
given a larger palpebral opening than that on the right. The
right orbicularis is constantly twitching. Though he can
close each eye and wink, that power in the orbiculares is
diminished is shown by failure to close the lids tightly — as
in blepharospasm, for instance — or to resist in the slightest
degree forcible separation of the lids. He seems to retain
control of the paljiebral and to have lost use of the orbital
portion of the orbicularis. The eyes themselves are fixed, the
right diverging slightly out and up. When told to look in
different directions he turns his head. There is, however,
such slight motion up, down and laterally as already mentioned. Convergence and, so far as can be ascertained, rotation by the obliques are lost. The intrinsic eye muscles are
spared. Each pupil responds to light, possibly a little tardily
in contraction to moderate light, dilates under cocaine and
contracts to eserine. He reads ordinary print with a convex
3.5 D, and has with this a range of 2 or 3 inches. Distant
vision in the left eye is y^^, owing, most probably, to pigment
deposit on lens capsule. Each paj)illa is normal. In the
right eye there is central choroidal atrophy. Form field,
barring the right central scotoma, is normal. This scotoma
extends 10 degrees in all directions, except downwards, where
it is 20 degrees.


When C. returned to the Hospital in March he asked,
"Why, when I want to put my foot on a place, do I put it
where it ain't?" This question is at the bottom of some
curious things for which an explanation is not easy. With
both eyes open he will reach to the right of an object held in
front of him, with his right hand, but grasp it correctly with
his left. Similarly, he will put his right foot to the right of
an object, a narrow ruler, for instance, upon which he is told
to step, but place his left foot correctly. With the right eye
closed he grasps correctly with either hand and places each
foot correctly. If the left eye be closed he either feels for
the object or, turning his head for eccentric fixation, reaches
it. When he leans far over, getting close to the niler on the
floor, he places his right foot at times correctly. He did not
know his eye muscles were affected until told so at the
Hospital last September. I asked my friend. Dr. Thomas, to
examine the patient, and his report is appended:


8.0964
"The frontalis muscles are in constant over-action and
possess a normal amount of power. The corrugator supercillii




0.3608


acts with a fair amount of power on both sides. The right
orbicularis palpebrarum is the seat of frequent momentary
contractions ; at intervals there can be seen in the left lower
eyelid muscular contractions which are synchronous with
these. The right orbiculai-is is able to close the eye completely, but it is much weaker than normal, as the patient is
unable to resist even slight traction on either eyelid. The
left orbicularis, weaker than the right, is just strong enongh
to close the eye. The other facial muscles act well and with
equal force on the two sides.


4.44
" The muscles of mastication and those of the tongue act
normally. No disturbance of sensation can be discovered in
the face.  


" The electrical examination shows that the facial nerve on
both sides can be stimulated with a faradic current of moderate strength, the orbicularis palpebrarum taking part in the
muscular contraction.


" 5
"To direct stimulation the orbicularis on both sides responds
to the faradic and galvanic currents, but stronger currents
must be used than is usual. The response to the galvanic
current is sharp and quick. The right orbicularis responds to
currents of less intensity than the left. The other facial
muscles act normally.


"The involvement of the orbicularis in association with
ophthalmoplegia is of great interest, bearing out, as it does,
Mendel's view that this muscle receives nerve-fibres from the
nucleus of the third and fourth nerves. Birdsall and Hughlings-Jackson have reported similar cases.


ft
[Signed] H. M. Thomas."


Dr. Theobald. — I do not know of a case tliat I have met
with in which there was a paralysis of the orbicularis associated with general ophthalmoplegia. I have, however, met with
several instances where all of the external muscles of both
eyes were involved. I have also met with cases where all of
the recti muscles were involved without implication of the
oblique muscles. These cases were almost invariably of
specific origin.


1100
A Simple Contrivance for Effecting Pneumatic Massage of tlie
Tympanal Membrane and Ossicles.— Dr. Theobald.


Any apparatus which proves of use in dealing with affections of the middle ear is likely to be of especial value, for
the reason that middle ear troubles are very common. Probably more than 75 per cent, of all the cases of impaired hearing
which we encounter are due to changes in the middle ear.
Deafness from nerve lesions is comparatively rare, forming not
more than 2 or 3 per cent, of the cases of deafness met with
in hospital and dispensary practice. Middle ear deafness is
commonly the result of a chronic catarrhal inflammation, or
perhaps of an acute inflammation of a higher grade, with plastic
exudation. The changes are of one or two characters; either
we have a sclerosis of the articulation of the ossicles, especially of the stapes, where it articulates in the oval window ;
or there is a formation of bands which attach one ossicle to
another, or one ossicle to some part of the wall of the tympanic
cavity, in such a way as to interfere with the movement of
the ossicles in response to the sound waves. Various devices


1016




9.9715
50




0.3735


JOHNS HOPKINS HOSPITAL BULLETIN.


3.72




" 6
[No. 72.




6


have been made to overcome this rigidity or aukylosis of the
delicate joints in the middle ear, and especially contrivances
which have been described as effecting one form or another of
massage. There have been several distinct kinds of massage
of the ossicles and tynipaniini proposed. One is a direct form
of massage, pressure massage. The original way in which
this was accomplished was by pressure with a delicate probe
upon some portion of the malleus, either upon the short or
the long process. This produced a certain amount of motion
throughout the ossicular chain and in the various joints. More
recently electricity has been brought into jjlay in this direction,
and one contrivance has been made by which the rapid motion
obtainable from the electric current has been made use of to
operate a delicate probe which has a spiral spring in it. This
probe strikes repeated delicate blows upon the long or short
process of the malleus. Another form of massage is designated as phonetic massage ; that is, sound is used to produce
vibrations of the tympanic membrane and ossicles. Several
contrivances have been used for this purpose. One form is
the phonograph, in which the sound is carried by tubes to the
ear. The phonograph cylinders are cut deeply, so that the
sounds are especially sharp and distinct and produce greater
mechanical effect.


750
Pneumatic massage obtained by means of variations in the
pressure of the air in the auditory canal is a third method.
As far back as 1771 this method of influencing the movement
of the ossicles was suggested by Cleland. More recently, this
early experiment having been lost sight of. Moos suggested
it again. There are several ways in which this has been
brought about. The use of the Politzer bag is one method.
This forces out the tympanic membrane and moves the delicate
joints of the ossicular chain. Another method is with Siegel's
pneumatic speculum, by means of which the air in the auditory canal is alternately condensed and rarefied, and thus the
tympanal membrane is moved back and forth. One objection
to this and other similar contrivances is that the jiower exerted
is too great, and unless they are used with much care, serious
injury may be done. If the pressure either outward or inward
is too great there is a possibility of rupture of the tympanic
membrane, or hemorrhage may be jiroduced. I do not think
that marked beneficial results can be claimed for any of these
forms of massage, although undoubtedly in some instances
they do good, and it is a method which every one should be
able to employ in treating ear maladies. One or two things are
essential in order that this method may be employed with the
hope of doing good. In the first place, the nature of the
contrivance should be such that harm is not likely to be done
in its use, as is the case when large air bulbs are used. If
one uses a large air bag like the Politzer bag, a very little pressure of the hand will produce a marked variation in the density of the air in the auditory canal. Such a contrivance as
this it is out of the question to place in the hands of a patient.
It is essential in these cases, which are almost always chronic,
that the massage should be of such a character that the patient
may be able himself to practice it, and this is what I had in
mind in contriving this apparatus. The bulb should be so
small that one can do no harm in using it. This instrument
consists simply of the rubber bulb taken from an eye-dropjier,




1028


placed upon a small hard rubber tube with a bulbous tip
which fits tightly into the auditory canal, rendering it air
tight. This can be used in two ways. In the first place, we
can compress the bulb before inserting the tube in the ear, and
then by letting go the small bulb we rarefy the air and draw
the membrane out. On the other hand, we can place it in the
ear tiglitly, and then by squeezing the little bulb we drive the
drum membrane in. I direct my patients to reverse the action,
at one time drawing the membrane out, at another pressing it
in. Ilynson & Westcott have made these instruments for me
of several different sizes, so that they will fit any ear.


7.7963
Excision of a Parovarian Cyst witliont Removal of its
Ovary or Tube.— Dr. Kblly.  


I will speak this evening of a new step in the conservative
treatment of the uterus and its appendages. Before speaking
of the subject in hand, I will call attention to a few of the
advances we have made in the past few years. We no longer
think of taking out the ovaries for enlarged Graafian follicles.
If such a follicle is found it is simply exsected and the
ovaries sewed up; small follicles maybe punctured or treated
by the cautery as recommended by Pozzi. Cysts of the corpus
luteum may be treated in like manner.


0.3793
These parovarian cysts (showing pictures) were all removed
several years ago and treated radically by i-emoviug the tube
and ovary as well. I would not treat them so now, as I shall
shortly demonstrate. This conservatism extends also to the
tubes. Prof. Martin of Berlin has succeeded in saving quite a
number of diseased tubes without hurt to the patient and
with full restoration to health. Last year I removed from a
patient the tube' of one side and the ovary of the other, laid
the ovary and the tube both down behind the uterus, and the
lady, who is the wife of a physician, returned home and has
since borne a child. Still graver affections also come under
this conservative treatment. We have for some years past
been treating accumulations of pus behind the uterus, by
puncture, evacuation and simple drainage through the vaginal
outlet, even when the pus is in both tubes and ovaries. This
has been followed by a large number of perfect recoveries.
Occasionally the patient will return and require another
drainage operation ; the ovaries and tubes can be removed
later with greater ease, if necessary. In cases of myomatous
uteri I have removed as many as 9 myoma through 7 incisions
and had perfect recovery and perfect relief follow. I demonstrated last week the possibility of exsecting as many as 16
myoma without opening the uterine cavity.  


The particular new subject along these lines of which I
wish to speak to-night is simpler than many of the steps
already taken, from a surgical standpoint, and yet, so far as I
know, it is novel and is one of the last to follow in the line of
conservative effort: that is, the removal of certain parovarian
cysts without sacrifice of the correlated ovary and tube. To
show how simply this may be done, I pass around specimens of such cysts in which the tubes and ovaries were also
removed. It is evident at a glance how simple a matter it
would be to remove these parovarian tumors and then to sew
up the incision area after the enucleation. The first case I
operated upon conservatively was in November, '95. The


4.86




March, 1897.]






Table VI. — Nitkoqen Ingested (in Grams).  
JOHNS HOPKINS HOSPITAL BULLETIN.  






51


Date.




Day of observation.  
patient was suffering a great deal with pelvic pain, and the
doctor who had examined her felt two tumors in the pelvis
and sent her to me with the statement that both ovaries
would have to be removed. I found one cyst the size of a
hen's egg before the uterus and another behind it. On
opening the abdomen the cysts were both found to be parovarian; they were in the mesosalpinx, and the ovaries were displaced and separated from the tubes by them. I treated the
tumors in two different ways, both giving the same result. In
oue, after ligating the larger vessels a little distance from the
tumor, I made an incision through the jjeritoueum where the
vessels were fewest, and I easily shelled the tumor out of its
bed and then sewed up the peritoneum with a continuous
catgut suture. On the other side I excised a portion of the
redundant peritoneum while the circulation was controlled
by the finger of an assistant, turned the tumor out and
stitched up the wound with catgut. The uterus which had
lain in retroflexion was suspended by two silk sutures by my
method. Both ovaries were thus left intact. The patient
made a perfect recovery, has kept her functions, is normal and
regular, and in good health. This, I think, with the other
circumstances cited, is one of the last and not least important
of our gynecological advances, of particular importance to
young women and women in the prime of life.  


Dr. Welch. — How large a proportion of these cases are
eligible to this treatment? As one who sees the ordinary
parovarian cysts after operation and at autopsy, it is not clear
to me how they can be taken out without removing at least
the tube. The cyst grows between the layers of the broad
ligament (there is no mesosalpinx, the layers are all separated), and the cyst comes i;p against the Fallopian tube, and,
in some cases at least, it would be impossible to dissect it
from the tube. The ovary may be quite well preserved, but
not unfrequently it is sj^read out over the surface of the cyst.
I sup2)ose Dr. Kelly does not mean that the conservative
operation can be done in tumors of that kind, but refers to
tumors of only moderate size.


Ham.  
Dr. Kelly. — Yes, the operation is most easily applicable to
tumors of medium size, but can also be applied to many of
the larger ones. In all of those cases where the cyst is thin
walled and more or less pellucid, by slitting the capsule and
evacuating the tumor, it can then be drawn out from under
the tube, even though the tube is flattened out as shown in
this specimen which I pass around. I would exclude from
such treatment all those cases in which papillary elements are
visible.  


Meeting of November 16, 1896.


White
Dr. TnAVEE in the Chair.  
bread.  


On the Pathology of Heematozoan Infections in Birds.— W.


Milk.  
G. MAcC'ALLUiV.  


Peculiar advantages are offered by the tissues of birds for
the study of hsematozoan infections, in that all stages and
degrees of infection may be examined without any difficulty
in obtaining the materials. The material for the following
observations was furnished in the tissues of the birds whose
blood has just been described, and often the extent of the


wine.




Total
changes in the organs was surprising when contrasted with
nitrogen.  
the apparently good health of the birds.  


Kruse, Danilewsky and Labbe have noted in a general way
pigmentation of the spleen, liver and bone-marrow, and have
observed the enclosure of pigment masses in niakrophages in
the capillaries of these organs. There is nowhere any mention
of inequality in the distribution of the parasites as such in the
organs of the body, such as has been described in malaria in
the human body giving rise to corresponding symptoms ; in
no communication on the subject have any symptoms been
described occurring in infected birds such as to lead to the
suspicion of a definitely localized invasion of organisms,
nor have we been able to demonstrate in any of our birds such
localization or such symptoms.


July 1
As to the effects of the products of the organisms on the
tissues we cannot speak definitely. No mention is made in
the literature of such effects, but we have observed various
degenerated areas in liver and spleen, some of which are
explained by concurrent bacterial infections, others apparently
by the presence of peculiar ovoid bodies with central nuclear
particle, which occur in the cells in groups resembling a
segmenting organism, while a third variety is still unexplained.


" 3
The invasion of the parasite into the red corpuscle appears
" 4
to be followed eventually by the breaking down of the corpuscle, from the altered hasmoglobin of which there results
" 5
a straw-colored pigment. This is seen deposited in considerable masses together with the dark pigment formed directly
" 6
by the parasite. The process of storing these pigments away
from the blood stream is similar to that observed in man.
The phagocytic cells of the blood are apparently the cells
which we have named Kubinophilcs,* and in a lesser degree
the eosiuophiles, although neither of these is very active in
engulfing extruded organisms and pigment. Indeed we have
never observed in a fresh slide of blood a single pigmented
leucocyte, and, although they have been observed to engulf
parasites, they have also been seen to attack the jiarasite, and
after disintegrating it to a great extent, to leave the pigment
and wander away. Labbe denies the existence of true phagocytosis, and considers the presence of infected corpuscles
within leucocytes to a certain extent accidental.


Danilewsky and Sakharoff describe the occurrence of organisms within leucocytes where they undergo part of their
development, but we have observed nothing analogous to this.
The hemopoietic organs are of especial interest, and it is iu
these that the pigmentation has been noted by European
writers. The spleen at autopsy is generally somewhat blackened, and on section shows a network of black lines corresponding to the pulp bands where the bulk of the pigment is
deposited. This pigment occurs either iu large, clear or palely
staining niakrophages with single or double vesicular nucleus,
or iu the swollen endothelial cells of the capillaries. In the
spleen the large cndothelioid cells of the pulp take on the
character of makrophages, but iu the liver the pigmented


1
2
3
4
5
6
4.4480
4.4480
4.4480
4.4480
4.4480
4.4480




1.5236
*Cells with whetstone-shaped granules wliicli take on an eosin
1.5236
stain after long standing, but are colored nmcli more readily by
1.5236
acid fuchsin.  
1.5236
1.5236
1.5236




2.9925
2.9925
2.9225
2.9225
2.9575
2.9575


52


0.0568
0.0568
0.0.i68
0.0568
0.0568
0.0568




9.0209
JOHNS HOPKINS HOSPITAL BULLETIN.  
9.0209
8.9.509
8.9509
8.9859
8.9859






Table VII. — Nitkogen Balance (N in Grams).  
[No. 72




cells are all intracapillary. These large cells are seen to
contain masses of yellow pigment, masses of black pigment, scattered grains of black pigment, infected corpuscles,
shrunken parasites which at first sight look like small masses
of yellow pigment, and debris of broken-down red corpuscles
and parasites. The liver shows a less marked pigmentation
than the spleen, but the character of the deposit is similar.
In the bone-marrow which European authors have found so
deeply pigmented we have found almost no pigment and but
few organisms. The brain, heart, lungs, kidneys, stomach,
intestine, pancreas, thyroid and voluntary muscle show no
changes and only the presence of organisms which would be
expected from the rich blood supply of these organs.


On the Hscinocytozoa of Birds.— Eugene L. Opie.


The presence of parasites closely resembling the malarial
organisms of man, within the red corpuscles of birds, is well
known. These organisms have been found in varying abundance in the blood of birds of many parts of Europe, but up to
the present time they have not apparently been studied in this
country. At the suggestion of Dr. Thayer these intracorpuscular parasites have been studied in the Clinical Laboratory
of the Hospital. During the mouths of June, July, August
and September one hundred and twenty-five birds have been
examined. Of these the greater number, one hundred, were
from the neighborhood of Baltimore. Of eighty English
sparrows (Passer domesticus) from this locality, nine were
infected with intracorpuscular parasites; of twelve red wing
blackbirds (Agelaius phceniceus) six were infected; two
swamp sparrows (Melospiza georgiaua) and one song sparrow
(Melospiza fasciata) contained organisms. Of twenty-five
birds, including a variety of species from the neighborhood of
Dunnville, near Toronto, Ontario, five were similarly infected,
namely, one great horned owl (Bubo virginianus) and four
crows (Corvus americanus).


o g
Although the small number of the infected birds makes it
impossible to arrive at any genera] conclusions as to the particular species prone to infection or the local conditions favoring infection, a fairly accurate idea of the character of the
parasites present in these localities can be obtained. The
organisms found resemble the malarial parasites in that they
undergo their whole development within the red corpuscle at
the expense of its substance, transforming its hemoglobin
into chai'acteristic pigment granules. Like the malarial
organism they reproduce by segmentation, and the young
parasites come to occupy other red corpuscles. Unlike the
malarial organisms the younger parasites do not exhibit active
amoeboid movements. Unlike the tertian and (juartan malarial organisms they show no cyclic development in great
groups of which every organism is in approximately the same
phase of development, and hence the length of their cycle of
growth cannot be readily determined.


Two types of organism, similar to those observed in
European birds, are found. Characteristic of each type is the
morphology of the full-grown organism. In the one group
an irregularly shaped body, approximately round or polygonal,
occupies one end of the nucleated red corpuscle; the nucleus
has been displaced into a transverse position in the opposite


>,SS


1^


end. In the other group the full-grown organism is an
elongated body which lies curved along one side of the normally situated nucleus. The irregular parasite (Proteosoma,
Labbe) segments in the peripheral circulation by a process
which is almost identical with that of the malarial organisms.
Segmenting forms of the elongate parasite (Halteridium,
Labbe) are not found in the blood taken, for example, from
the wing. Associated with both types of organism are certain
large bodies, apparently degenerate and not destined to segment, characterized particularly by the fact that, unlike the
ordinary full-grown organism, they contain almost no material
with an affinity for stains as methylene blue, safranin, etc.
Organisms which flagellate as do those of malaria are observed
with both the irregular and the elongate parasites. With the
elongate organism, indeed, owing to the abundance of these
forms, the whole process of flagellation can be studied with
the greatest facility. Among the irregular parasites present
in different birds different varieties are not observed. Among
the elongate parasites, however, considerable diversity of form
exists in different hosts, but the lack of extended observations
makes it impossible to establish distinct species, although in
certain cases the morphological differences observed are very
striking.


ll
Daiiilewsky, who first observed iutracorpuscular parasites in
the blood of birds, believed that these organisms are identical
with those of the malarial fevers. Certain subsequent observers
have attempted to establish an analogy between the different
varieties of the malarial parasite and forms which they find in
birds. Others have considered the parasites in birds to be
entirely independent of those of man. It seems probable that
there are in birds at least two distinct siJecies of intracorj^uscular parasites. In almost every detail of structure they very
closely resemble the malarial organisms of man, but they are,
nevertheless, essentially distinct.


Dr. OsLER. — The subject which these gentlemen have presented so clearly has a very definite bearing upon the life
history of the malarial parasite in man, as it is quite possible
that we may get a clue to the outside history of the parasites
by a study of the forms in birds. In 18S(!, I think, just as I was
busily engaged for the first time in the study of the malarial
l^arasite, Mr. MacCallura's father. Dr. MacCallum, of Dunnville, Ontario, sent to the Biological Laboratory in Toronto a
goose which was supposed to have malaria. I was extremely
skejjtical about it, as I knew nothing at that time about the
parasites in birds, but to my astonishment there were in large
numbers the pigmented intracellular organisms, just such as
Mr. Opie has demonstrated to. us to-night. They were present
in very large numbers, and the spleen of the bird was also
large and deeply pigmented.


NITBOGEN ELIMINATED.  
Dr. L. F. Barkek. — I have been much interested in this
report of the very careful studies of J[essrs. MacCallum and
Ojiie. It may be worth while to emphasize the importance in
parasitic diseases of the blood and blood-making organs, of
studying not only the appearances of the blood itself by clinical
methods, but also the appearances of the blood and tissues in
microscopic sections after death. One gets a very one-sided
idea of the structure of the malarial parasites and their rela




111
March, 1897.]


53


g




tion to the cells, if he studies them only in fresh blood or in
smear cover-glass prei^aratious, even when dried and stained.
In tissues which have been hardened in alcohol it is very easy
in sections stained with hematoxylin and eosin or with
methylene blue, to make out within the half-grown and fullgrown tertian parasites of human malaria a relatively large
spherical area which stains usually feebly, though sometimes
very distinctly in nuclear dyes. Peripheral to this mass is a
thin superficial layer which does not stain at all in ordinary
nuclear dyes. In this peripheral non-basophile layer of the
parasite is situated the malarial pigment when it is present.
The internal stainable mass may be centrally placed, though
it is more usual to see it situated somewhat excentrically, so
that the peripheral layer of non-stainable substance may vary
in thickness in different parts of the organism. The internal
mass, which is entirely free from pigment, may stain somewhat
unevenly, and occasionally it is possible to make out in it an
intensely stained nodule which I have thought may correspond
to what has been described in stained smear preparations as the
nucleus. It would seem more rational to look upon it as the
nucleolus or as an aggregation of the chromatin within the
nucleus, though for the decision of this point we must wait
for further investigations. I should like to ask Mr. Opie and
Mv. MacCallum whether or not they have in their studies or in
their reading found any indications of or reference to macronuclei or micronuclei in malarial parasites, such as have
formed the basis of so much interesting research of late years
in the infusoria. It is indeed to be hoped that the large size
of the malarial parasites in birds will permit of the unraveling of the finer structure of these curious organisms.


I have been much imj^ressed in studying Mr. MacCallum's
specimens of the spleens of these birds, by the enormous
masses of malarial parasites to be seen there. At first it
seemed almost improbable that the huge brownish masses could
consist of malarial parasites. It appeared more likely that
they could be explained as forms of blood pigment, but careful study with the oil immersion lens will convince any one
that they are in reality aggregations of altered malarial
organisms.


Drluo.  
Mr. Opie. — I have seen no references to the macro- and
micro-nuclei. Labbe, who studied the question most thoroughly, does not mention such structures.  


Dr. Welch. — This is the first investigation of the kind, as
far as I know, in this country. It is extremely interesting, and
particularly to us, as it was made here. These have a number
of points to distinguish them from the malarial organism, and
one of the most striking is the absence of movements. I was
interested in the statement that all phases of development
occur at the same time in the circulating blood. An idea of
Golgi as to the development of organisms in groups in the
organs of the body would suggest the localized development in
this class of organisms. There is no reference here, however,
to groups, but each organism developed separately. It suggests that Golgi's observations might be explained by other
suppositions.


Fceces.  
Dr. OsLER. — I should like to add a word ujlon the possibility
that in very malarial districts man may harbor the parasites
without showing special manifestations. We know that in




B


certain regions all dogs have filaria in the blood, and in many
parts of Africa the filaria are present in the natives without
causing much trouble. It is quite possible, too, that there may
be a minor grade of malarial infection in which the organisms
are not present in sufficient numbers to cause fever or the characteristic paroxysms.


July 1
Dr. Thayer. — Let me also congratulate Mr. Opie and Mr.
" 2
MacCallum upon their careful piece of work.
" 3
" 4
" 5
" 6


The importance of such studies was impressed upon me
several years ago by M. Laveran who expressed his conviction
that a careful study of the hrematozoa of lower animals, and
especially of those of birds, which so closely resemble the parasites of human beings, was perhaps more likely to throw light
upon some of the dark points in connection with the etiology
of malaria than any other branch of research which is at
present open to us.


1
Kecent observations appear to show that the parasites of
2
birds and human beings are not identical ; they are, however,
3
so similar that it is not improbable that the form in
4
which they exist outside of the body and their method of
5
entrance to the body are likewise not unlike the corresponding
6
phases in the life history of the parasite of human beings.


There are, of course, many more points to be studied with
regard to the morphological and biological characteristics of
these avian hasmatozoa. In these present observations, for
instance, no idea has been formed with regard to the length of
the cycle of existence of the parasites. Danilevsky believes
that he has been able to distinguish an acute and a chronic
form, while Oelli divided the parasites of birds into three forms
with cycles of existence corresponding to the quartan, tertian,
and sestivo-autumnal parasites. Here, however, there has as
yet been nothing to point out the exact length of the cycle of
existence of each generation of parasites.


54.200
Further, it would be advisable to make careful measurements and observations of the temperature in infected birds,
54.300
observations which, to be sure, have been made by other authors,
54 200
but with regard to which there is as yet a lack of agreement.  
53 9011
53.600
53.200


It is also, I think, very important that the intimate structure
of the parasites of birds' blood should be carefully followed
out; this can be done with much greater facility than in the
human being, inasmuch as specimens of tissues can be instantly obtained at any time desired.


9.0209
But really the most important point, it seems to me, as
9 0209
Bignami has emphasized in a recent paper, is to determine, if
8.9509
possible, the manner in which the parasite exists outside of the
8.9509
body, or more particularly its manner and portal (Jf entry. It
8.9859
may well be possible that careful and continued observations
8.9859
of this sort may bring us nearer the solution of the greatest
questions in connection with malarial infection.  


With regard to the remark of Prof. Osier concerning the
possibility that a human being may harbor the malarial parasites in an active condition for a considerable time without
showing distinct clinical symptoms, I must say that the
more of the disease one sees, the more reasonable seems the
possibility that this condition may exist with relative frequency. In many cases of tertian fever after insufficient
doses of quinine, or during attempts at spontaneous recovery,
a few parasites may be found in the blood for very con


lb'.6940
8.8358
8.0964
9.9715
7.7963


54


b;3879
[No. 72.  
0.3879
0.3879
0.3879
0.3879
 


10.4819
9.2237
9.4843


10.3.594
8.1842


siderable periods of time without actual clinical symptoms
resulting. Dr. Gamble tells me that in j)rivate practice he
has found the parasite in a number of instances in the
blood of patients Complaining of vague symptoms who had
not as yet had any actual paroxysm. In these instances it
is in every way probable that the parasites had not as yet
accumulated in sufficient number to produce a chill. If now
in a certain number of instances a single tertian paroxysm
may be followed, without treatment, by so extensive a destruction of the organisms tliat fever does not I'ecur for a week or
ten days (a not very infrequent occurrence), theoretically there
would seem to be no reason why in certain instances a similar
destruction might not occur in groups which have not as yet
reached a size sufficient to produce actual manifestations ;
thus there would result au iudefinite prolongation of what one
might call the incubation period of the infection. That such
conditions exist is, I believe, not only possible but probable,
though definite proof has yet to be advanced.


— l'.46i6
Afeeting of December 7, 1896.  
—0.2728
Dr. Thayek in the Chair.  
-0.5333
—1.3735
+0.8017


Discnssion of Dr. Rlocli's Paper on "Agglutination of Typhoid
Bacilli, etc." [See Bulletin, Nos. 68-69.]


Dr. Plexnek. — In this connection I wish to speak of some
interesting and highly suggestive results just obtained by
Pfeiffer and Kolle, with reference to the possibility of successfully vaccinating human beings against typhoid fever.
You may recall that Ktern pointed out several years ago that
the blood of typhoid fever convalescents contains protective
pi'inciples similar to those present in the blood of animals
rendered immune from experimental typhoid infection. It is
probable that these protective substances are those on which
the phenomenon of agglutination depends ; they are different
from the alexines or defensive proteids of the normal blood,
which possess little or no power of producing agglutination of
bacteria, and are destroyed at a considerably lower temperature. These protective principles are exerted against the bacterial cell, are bactericidal and not anti-toxic in nature; thus
they differ from the anti-toxines of diphtheria and tetanus,
whose actions are directed against the toxin and not the bacterial cells as such.


Relation of Neusser's granules in the leucocytes : On the
Proceeding on the basis of Haffkine's results in vaccinating
day before the analyses were begun the granules were present
against cholera, which they accept as conclusive, Pfeiffer and
in very small numbers in the leucocytes. This was also the  
Kolle have in a similar manner injected suspensions of typhoid
 
bacilli subcfitaneously beneath the skin of the back into three
 
persons who had never had typhoid fever. The symptoms
 
following the injections were elevation of temperati;re, chill,
case on July 1st and 3nd, when a relatively high amount of
malaise; but these quickly passed away without leaving
alloxuric bodies was being eliminated. On July 3rd there was
unpleasant effects. Following the cessation of the symptoms
an apparent and on the following days a very marked increase
they found the blood of the vaccinated persons to contain an
in the number of granules, whilst the nitrogen of the alloxuric
amount of the protective substances, measui'ed by the power
1)odies both absolutely and in percentage became diminished.
to protect animals from experimental typhoid infection, in
Observation IV. — Patient was a woman 45 years of age.
excess of what is found ordinarily in typhoid convalescents.  
Fourteen years ago she had her first severe attack of articular
Assuming that there exists a relation between these principles
rheumatism, although she has had milder attacks since 1881.
and immunity from tyi)hoid fever, it would appear as if in
Both hands at present show characteristic deformities. Since
this sinij)]e manner an artificial protection from infection with
1891 she has had symptoms of some cardiac lesion. In 1895,
the typhoid bacilli might be given. Appreciating the diffi
tricuspid and aortic insufficiency was diagnosed. During the
period that the patient was under observation she was comparatively well ; good diuresis and no cedema. Average pulserate, 80 ; respirations, 23. Moderate body exertion was possible
without dyspnoea. Cyanosis was quite marked.  


The diet was as follows : Ham, 100 grams ; breakfast rolls
(4), 308 grams; milk, 500 grams; wine (white), 350 grams;
tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces),
30 grams ; Rohitsch water, 300 grams.


These food materials represented about 1386 calories (36
culties in the way of a conclusive and satisfactory test of this
calories per kilo body weight), which were made up as follows:
method in ordinary life, they suggest that it be given a trial
in outbreaks of typhoid fever in barracks and army corps,
where, as is well known, large and destructive epidemics
sometimes occur.


Albumin 334.19 calories.  
Dr. Reed. — I have had no experience with the serum test.
I have made use, however, of Johnson's modification of
Widal's method, and, so far, have examined the blood in
thirty-four supposed cases of typhoid fever. AVhen I began
with this method — that is, the use of the dried blood —
Johnson's paper had not been published, so I had to feel my
way, as it were. I began by examining a small quantity of
the blood dissolved in distilled water, placing a drop on a
cover-slip and then inoculating it with an agar culture. I
found the method worked fairly well in certain drops, while
in others I had introduced too many bacilli, and, while many
clumped, there were highly motile organisms to be seen after
the lapse of two or three hours. I had just fixed upon a
bouillon culture as the proper medium when Johnson's paper
ajjpeared, and being convinced then that I was on the right
road, I reviewed my cases with this method. I then had distinct clumping with arrest of motility in cases in which I
did not get it when using the solid culture. So far I have
examined the blood of thirty-four cases, twenty-eight of which
have given me a positive reaction, that is, loss of motility and
agglutination of the bacilli. It will be seen that I have met
with success in a greater percentage of my cases than Dr.
Block has reported to-night. Six cases failed to give the
reaction. In two of these I found the Kstivo-autumnal parasite. A third case that did not give the reaction was considered to be a severe case of typhoid fever in the Freedman's
Hospital. The patient had tympanites and high temperature.
I examined the blood with negative result. The patient died
the following day, and it M'as found that there was general
peritonitis, having its origin in the appendix. The fourth
case was a child who manifested distinct brain symptoms, and
the attending physician had not been certain that it was a
case of typhoid. Two other cases, one in the third and one in
the sixth week, failed to give the reaction. AVhether they
were i-eal cases of tyj)hoid I do not know. The earliest case
in which I have examined the blood was that of a soldier at
Fort Myer. Soldiers are generally put to bed early, and the
reaction here was quite distinct on the fifth day After I had
obtained a positive reaction in twenty-two cases, the particular
bouillon that I was using — an old glucose bouillon (because
there was no other in the laboratory at the time) — became
exhausted and I began to use ordinary bouillon. I tried this
latter in two new cases from the Freedman's Hospital, and
was surprised to find prompt arrest of motility, but no clumping. For the sake of comparison I took the blood of an
undoubted typhoid case and tested it with plain bouillon, and
had no clumping until more than au hour had passed. I then
tried some of my old glucose bouillon cultures, and to my
surprise all three cases gave me good agglutination within
fifteen or twenty minutes. I then began to examine my
hanging drops, in plain and glucose bouillon, at the end of
twenty-four hours, to see if I could distinguish any difference
between them, aud found that from the margins of the


Fat 323.47


Carbohydrates 643.19


Alcohol 185.50
March, 189^]


55


Total 1386.35
Table VIII.— Urine.




clumjjs iu plain bouillou the bacilli had always grown out as
delicate threads radiating across the field and forming a network, whereas the clumps in glucose bouillon do not show
any growth. I have repeated the observation many times with
the same result. In the Fort Myer case I got good clumping
with the glucose, but not with the plain bouillon. So it has
seemed to me that possibly the bacilli grown in the glucose
bouillon are somewhat more vulnerable to this peculiar action
of typhoid blood.


In order to see whether motility of a cultui'e had anything
to do with its agglutination, I examined bouillou cultures at
periods of seven, thirteen and sixteen days, and ascertained
that the old cultures, in which there is no motility, clump
about as promptly as recent ones. I then tried, as a matter
of interest, to see whether the dead bacilli would agglutinate,
and ascertained that massing of the bacilli took place about
as promptly in the dead as in the living cultures. I also
observed that blood heated to 60° C. for half an hour acts
about as well as the non-heated blood. It occurred to me
that by heating the blood to 60° one might destroy its normal
germicidal action and still leave behind the peculiar body
upon which the clumping depends. I have observed the reaction in dried blood after twenty-six days. I have failed to
obtain arrest of motility of the bacilli in normal blood, but
in one case, probably latent tuberculosis, there was prompt,
distinct partial clumping; the non-agglutinated bacilli, however, remained actively motile at the end of three hours.


Dr. Thayer. — There is one point, it seems to me, which
must be carefully looked into before we draw too many conclusions, namely, the length of time during which this bacteriocidal power may remain in the blood after recovery from
typhoid fever. In one instance at present in the Hospital
the reaction is marked 16 mouths after the attack of fever.
It must be said, however, that there is a typhoid osteomyelitis
preseut which might well be the direct cause of the reaction.


i




a
NOTES ON NEW BOOKS.
ga


A Treatise on Surgery, by American Authors. Edited by Koswell
Park, A. M., M. D., Professor of Surgery in the Medical Department of the University of Buffalo, etc., etc. Vol. I. General
Surgery and Surgical Pathology. 799 pp., 356 engravings, 21 jilates
in colors. Lea Brothers & Co., Philadelphia and New Tork, 1890.


It was not one of the lightest proofs of the true inspiration of the
sacred writers that they have handed down to us such nuggets of
truth for all ages as the familiar "Much study is a weariness of
the flesh, and of making many books there is no end."


Any volume which steps into the crowded arena of medical literature today must expect to be challenged at once to show not only
negative virtues, the absence of faults, but some positive and original ones besides, some clear raison d'etre, or excuse for its very
existence. Especially is this true of that realm of medicine known
as the surgical, in general, and of American surgery in particular,
where the new challenger must win his spurs against such giantsof
the pliocene as Gross and Agnew, and such hydra-headed antagonists of the pleistocene and contemporary as Ashurst, Dennis, and
Keen. Hence the first question to be asked is, does this particular aspirant show proof of such approved superiority or peculiarity
in weapons, or skill and training in feats of arms, as to give promise


,




^
of holding his own in such a contest? We believe that he does iu
several respects. One of these is that the work is, in the broadest
and best sense of the term, American, national, catholic. By this
we mean, first of all, that singularly fruitful combination of scientific knowledge and breailth with "Yankee" ingenuity of application and intensely utilitarian tendency, so well typified by its distinguished editor and part-author, which has so rapidly won a
world-wide recognition alike for American surgery and American
scientific discoveries and mechanical inventions. Our whole inventiveness, progress and enterprise are born of the double fact that
the thinker mtist needs do and the doer is able to think.


Again, in glancing over the list of contributors to the volume,
no one, I think, can fail to be impressed with the fact that it is
nationally representative in the broadest sense. Xames which
range from Maine to Louisiana, from Philadelphia to f^t. Louis, and
from Tennessee to Jlichigan, are certainly ample proof of this, and
when we remember that the proudesttriumphs of American surgery,
as represented by the names McDowell, Batty and Sims, to say
nothing of a host of minor ones, had their origin not among the polished consultants of the great centers, but among the sturdy general
practitioners of the rural districtsof theSouth and Southwest, wesee
that this arrangement has not merely its fairness, but a genuine basis
of practical scientific advantage to recommend it. At the same time
an admirable homogeneity approaching that of the classic surgical
monographs is given to the work, both by the careful supervision
exercised by the editor and the large proportion of chapters in this
volume contributed by him personally, much to the reader's satisfaction and advantage. The first five chapters of the volume covering
the domain of surgical pathology are contributed by the editor himself. The subject is presented in a comprehensive and yet concise
manner, its most prominent characteristic being the clear-cut division which its author insists upon between hypeictmia and its consequences, and the process of repair on the one hand and of inflammation upon the other. The use of the latter term is limited strictljto those reactions of the tissues which result from the introduction
of some noxious irritant, usually of bacterial origin. This limitation
possesses decided advantages in point of clearness, both of thought
and practice, and it is probably desirable that the use of the word
should be so restricted in the future from the surgical standpoint ;
and we believe that the admirable classification which is based
upon it, and which it alone makes possible, will go far to recommend
it to the profession. From a biological standpoint, as its author
himself would frankly admit, the difference between the two processes is one of degree rather than of kind. But divisions are
no longer made, either in pathology or biology, in the old hardand-fast pre-Darwinian sense, and in actual experience the two
classes are so sharply distinguished in their characters, their
origins and their results as to be entitled to the writing of true and
distinct species.


% oo
A somewhat novel feature is the introduction of a chapter upon
the pathology of the blood, which, however, abundantly vindicates
its right to appear in a surgical treatise, as some excellent diagnostic and prognostic tests are based upon it.


Another instance of the breadth of view which pervades the
whole treatment of the subject is the careful discussion of the
many factors which, by lowering the resistance of the tissues, may
predispose to an attack of surgical infection. With a candor which
is rare in the operating surgeon, full credit is given to the extraordinary power on thepartof both the leucocytes and fixed cells of tlie
body to ward off infections and to rei>el invaders of every description ; and the story of the " battle of the cells " is given in the most
graphic manner. This view of the matter is particularly well
developed in what is, to our view, one of the most original and valuable chapters of the volume, that upon "Auto-Infection in Surgica.
Patients." Here the author impresses with convincing clearness
and abundant illustration the too-little recogni/.ed truth that any
secretion of the body tissues may become a poi.son to the entire system if its elimination is in any way interfered with, notonly medi


Date.


56


°
[No. 72.




Eg .


cally but surgically. The surgeon is urged to see to it that his
patient is thoroughly aseptic externally and internally, particularly
as to the alimentary tube. As the author declares, " There is perhaps no condition which so predisposes to sapntmia, septicemia, or
even pyemia, as this vague condition of intestinal toxaemia, which
nevertheless is so often present." The " hard-and-fastness" of
some of the definitions in classification of surgical fevers will challenge decided criticism, but for enaMing the subject to be clearly
grasped, especially by the student, even this has its practical
advantages.


i
A decided novelty in works upon surgery is found in two excellent chapters by theeditorupon " Diseases Common to Man and the
Domestic Animals." These fill a gap in the knowledge of the
practitioner which is already being widely felt, and will prove
among the most attractive chapters of the volume. The pathological paragraphs are particularly suggestive, the biological basis of
morbid processes and the individual part played by the various
tissue-cells being so vividly developed as to give even tubercleformation the fascination of a story from life.


The chapter upon Syphilis, while covering the ground well, is so
much compressed as to produce in places a style so bold and even
dislocated as to seriously interfere with clearness. We very much
doubt whether any student would be able to recognize a set of
Hutchinson'steethfromtheextremely brief (and inaccurate) description upon page 209. Indeed it suggests a doubt as to the clearness
of the writer's own concejition, and we are not surprised to find it
followed b}' the statement, "The appearance described is often
absent in syphilitic patients or may result from other causes."
The " wax-work-like " tints of the colored illustrations of this
chapter also leave much to be desired.


d j
The pathological suggestions in the chapter upon Rickets are
 
most interesting. One, that the disease is essentially a loss of balance between lactic or some other excrementitiousacid, on the one
 
hand, and calcium salts on the other, calls up atonce Loew's discovery of serious disturbances in plants on account of a similar imbalance between oxalic acid and the magnesium salts. And we doubt
§ "^ ffl 
if the essence of the rachitic process has ever been better epitomized than in the description of the layer of osteoid tissue of the
epiphyseal lines " which is notcartilage and will not become bone."  


lu Chapter XIV we find the editor's "creed," whicli is consistently lived up to throughout tlie whole of the volume. After
speaking of the "artificial and unfortunate separation of surgery
from so-called internal medicine," he well declares that "it has
been no small part of the benefit resulting from modern teachings
that these imaginary boundaries and limitations have been swept
away, and one of the lessons which this text-book is intended to
inculcate is that broad principles underlie disease-conditions, and
that one must appreciate their bearings thoroughly in order to
practice either medicine or surgery successfully."


¥^i'u
The chapters upon Minor Surgery are clear, concise and well
illustrated.


The discussion of Cysts and Tumors is comprehensive and thoroughly up to date, the classification (based largely upon that of
Sutton) being particularly commendable for its scientific simplicity
and ease of comprehension. Growths are regarded as aberrant or
"rebellious" groups of living tissue-cells differing mainly from
each other in the particular tissues which they reproduce or imitate and in the perfection of their imitation. We would prefer,
however, to transfer epithelioma from the " Tumors of Epithelial
Type" to those of " Glandular-tissue Type," as its deadly qualities
seem to be solely due to its power of " dipping down" or burrowing
into the tissues, in its attempts to imitate the sebaceous, sweat or
mucous gland of the surface where it originates.


The chapter upon Surgical Diseases of the Skin, while in most
respects admirable, especially in its discussion of dermal tuberculoses, includes a good deal of ground which has already been covered, such as neuroma, myoma, epithelioma, lipoma, etc., and is
disfigured throughout by the characteristic "Scabies perpetualis






sive septennialis " of oar dermatologist brethren, for pompous and
sonorous Latin terms of classification, whose dignified sound barely
covers their childish meaning. Thus, the common every-day wait
is teased under a dissecting microscope with a literary needle and
forceps into " Verruca vulgaris, Verruca filiformis and Verruca
acuminata"; Cancer of the skin parades as "Carcinoma cutis"
with two divisions, "Carcinoma tuberosum" and "Lenticular
cancer." It is obvious that potatoes in a bin might be "classified "
in precisely the same manner and -with as euphonious results.


The chapter upon Diseases of the Lymphatic Vessels, by Dr. F.
H. Gerrish, is a most original and valuable contribution to a subject
which has never received the attention which its importance
merits; probably largely on account of the inherent difficulties of
the subject and our imperfect understanding of it.


The remaining chapters of the volume maintain a high average,
but present nothing sufficiently characteristic or distinctive to call
for special comment.


The illustrations throughout are excellent, with a few exceptions,
and a most refreshing feature is the large proportion of them which
are entirely new, most of them from original photographs. AVe
feel almost lost, though, without our old familiar friend the " opisthotonos " man (but perhaps he will come to cheer us in the second
volume), and grievously miss those numerous and beautiful pictures
of surgical instruments, with the maker's name in large black letters
upon either the blade or handle.


Even the camera, however, has its little weaknesses, and we are
further confirmed by these cuts in our conviction that the photograph is in many cases no more necessarily " true to life" than is
the "realism" of modern fiction. In not a few of even this carefully selected series, while the outlines are cltar, the details of the
central area are so indistinct that the assistance of the title and
side-lettering is needed to discriminate between them, while in
several even this assistance fails to render them entirely clear, as
for instance the cut of varicose ulcers (p. 541) and that of fracture
of the patella (p. 741). Most of them, however, are clear, as they
are typically illustrative, and will constitute valuable and permanent additions to our surgical picture-gallery.


As a whole, the work is fresh, clear, and practical, covering the
ground thoroughly yet briefly, and well arranged for rapid reference, so that it will be of special value to the student and busy
practitioner. The pathology is broad, clear and scientific, while
the suggestions upon treatment are clear-cut, thoroughly modern
and admirably resourceful.


Our only general criticism takes the form of a regret that the
editor, in some of his chapters, felt himself so much under the
necessity of condensing and systematizing and could not give his
thought fuller and freer play. But a chapter or volume which fails
by being too short is not far from a decided success, and we have
Ycl. II tc look forward to for consolation. W. H.


A Manual of Syphilis and the Venereal Diseases. By J.4.mes Nevi.vs
Hyde, A.M., M.D., and Frank H. Montgomery, M. D. 1 vol.,
618 pages. {Philadelphia: W. B. Saunders, 1895.)


For several years there has existed the need of a condensed and
at the same time sufiiciently comprehensive book on venereal diseases, which would enable medical students and practitioners, at a
moderate cost, to obtain the latest opinions as to syphilis, and also
to keep up with the advancing bacteriological work which is being
done in genitourinary diseases.


The Manual of Syphilis and the Venereal Diseases, by Hyde and
Montgomery, is a book which well answers this purpose. It is
extremely attractive in appearance, the printing and illustrations (which are numerous) being all that could be desired. The
full-page illustration in colors of "Gonococci in gonorrhoeal pus"
is a beautiful example of the possibility of enlarging from a photomicrograph.


The chapters on Syphilis are written in a most attractive style,






f^
March, 1897.


57


fi°"




% g
and condensed so skilfully as to make a thorough review of the
whole subject in a comparatively few pages. In their discussion of
the treatment of syphilis the authors express some views as regards
the inadvisability of using opium- in combination with mercury
which may not obtain the endorsement of the profession.


The chapter on Chancroid closely follows the articles on this subject in Morrow's System of Genito-Urinary Diseases, and in addition
furnishes a valuable table, in parallel columns, for the differential
diagnosis of chancre and chancroid.


|gi
Cystitis and pyelitis are not given the prominence or attention
that these comparatively frequent diseases merit, and no mention
is made of the value of the cystoscope as a means of diagnosis in
vesical and renal diseases.


The articles on Urethritis Acute and Chronic (including Endoscopy) are especially well written, and give a thorough and scientific presentation of the aubject.


§5?g
The aim of the authors has been a compilation of the most recent
literature and thought on " Syphilis and the Venereal Diseases,"
rather than to put forward any original work or ideas of their own.


A. B. G.


Perc
Transactions of the American Gynecological Society. Vol. 21,
for the year 1896. {Philadelphia : Wm. J. Bornan, Printer, 1896.)


bod
The Society is to be congratulated upon the almost unanimous
tho
tendency to conservatism displayed in its papers and their discussion, which gives a tone of advance, not so prominent in past
trof
meetings.


It is not surprising that the paper by Segond, of Paris, on the
radical treatment of uterine myomata and inflammatory disease
of the tubes and ovaries by vaginal hysterectomy gave rise to a
most vigorous discussion and met with many pertinent objections ;
the consensus of opinion of the American gynecologists seeming
strongly against its unqualified acceptance.


July 19
Dr. Kelly, in a paper on the treatment of extra-uterine pregnancy, urges strongly the vaginal puncture and drainage in cases
 
ruptured in the early months, but not in the acute stage, and proves
most conclusively the value of this conservative method by the
cases he cites.


1
Dr. Henrotin, in a paper on the same subject, dwells on the
necessity of immediate abdominal operation at time of rupture,
even when the patient is in shock. Now that we have come to
recognize that shock is but a term expressing all the symptoms of
hemorrhage. Dr. Henrotin's advocacy of immediate interference
is sustained.


Dr. Noble's paper on suspensio uteri with reference to its influence on labor deserves special mention. The recent condemnation
of the vaginal fixation of the uterus by its originators because of its
frequent serious interference with labor greatly increases the value
of Dr. Noble's careful study and statistics of the abdominal operation. Unfortunately, the statistics do not represent a uniform
method of suturing the uterus to the abdominal wall, and it is difficult to draw accurate conclusions. The two cases of dystocia which
he cites in his own experience were true fixations, consequently the
suspension method cannot be held responsible for the difficulties
which he has described.


2400
The statistics collated by Dr. Byrne with reference to the remote
results of operations for cancer of the uterus are most painstaking
and creditable, but do not point the way to any advance in treatment. Statistics to be of value must contain a complete picture of
every case, and here this paper is found sadly wanting, especially
on the laboratory side. In every case suitable for radical operation
a microscopic diagnosis should be made before it is undertaken. A
failure to do this may lead to most appalling mistakes. After
removal, sections should be made through the critical points for
microscopic study to determine whether the disease has all been
removed. If this were done Dr. Byrne would find that the morbid
cell changes beyond the primary growth of which he speaks, were




1012


a simple extension of the disease into tissue which appears to the
eye and touch unsuspicious. Not until these precautions are taken
and the results put into statistical tables will one be able to judge
fairly of the remote results of operative treatment of cancer of
the uterus. The statistics of to-day are absolutely valueless.
Winter, in his most excellent article on the question of recurrences (Zeitschiift fiir Gynec. und Geburt., Band XXVII, Heft 1),
apparently depends entirely upon the macroscopic appearance to
define the limitsof the disease. One who has studied these tumors
microscopically can testify to the utter impossibility of fixing the
outermost limits of the disease by the eye or touch. On this
account one cannot accept Dr. Byrne's conclusion as to the value of
his method of performing vaginal hysterectomy by the cautery.
Df. Halsted has proved, by the astonishing results of his operation
for the removal of the breast for cancer, that a wide dissection and
removal of the glands are demanded ; and the same is true in cancer of the uterus, which can only be successfully removed by
the abdominal operation. W. W. R.


8.2320
Transactions of the Chicago Pathological Society from October,


189'1, to November, 1895. Vol. I. [Chicago: American Medical


0.3276
Association Press, 1896.)


This little book contains the transactions of a society which is not
wholly pathological, and many of the articles are of medical rather
than of pathological interest. The pathological papers, however,
are well done, as, for example, "The Contribution to the Study of
Malignant Growths in the Lower Animals," by Dr. Field, upon
which the paper of Dr. Livingood in a recent Bulletin is an interesting commentary ; the report of cases of Leukemia and of Pernicious
Anemia, and the paper on Embolic Abscesses due to the Micrococcus
Lanceolatus. The papers on Appendicitis, Nephrorrhaphj' for
Movable Kidney and Tubal Pregnancy, although not strictly pathological, are of general interest to medical men.


3.97
It is to be regretted that the volume is not uniformly printed,
which will not seem strange when it is stated that the matter
appeared first in the current numbers of a medical journal. If such
a system of printing is continued in future, it would add materially
to the appearance of subsequent volumes to have successive reports
set up in a uniform type. The book deserves a better mechanical
appearance.  


Medical and Surgical Reports of the Boston City Hospital. Seventh Series. By George B. Shattuck, M. D., W. T. Councilm.\n,
M. D., and Herbert L. Brewell, M. D. (Boston: Puhlished by
the Tmstees, 1896.)


" 20
It is pleasant to know that the issue of reports by the Boston
City Hospital has been resumed, and the volume before us is a
worthy successor of those which have preceded. A marked feature
of the book is the thoroughness of its report on pathological work.
This is notably shown in the valuable study of the Lesions in
Selected Autopsies by Prof. Councilman and Dr. Mallory, also in
Adeno-Carcinoma of the Pancreas, by Dr. Wright. The preliminary essay on Surgical Morals, by Prof. Cheever, is a new departure in hospital reports and one which can be commended. The
paper also on Methods of Routine Treatment in the Surgical Outpatient Department is of great value. Altogether the seventh
series is worthy of high praise.


Annual Report of the Supervising General of the Marine Hospital
Service of the United States for 1894. [Washington: Oovernment
Printing Office, 1895.)


2
In addition to routine reports concerning the oper.itions of the
Marine Hospital Service, and full accounts of the various hospitals
and quarantine stations under its control, this volume contains
much that is interesting to the medical man. Among these may be
mentioned detailed histories of the cholera and yellow fever epidemics of 1894, and Prof. Kitasato's Preliminary Notice of the Bubonic Plague in Hongkong, China.


[No. 72.


2800




1007
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.




9.6530


THE JOHNS HOPKINS HOSPITAL REPORTS.


0.4459
Volume L 423 pages, 99 plates.  


Report in Pathology,


4.61
The VcBsols and Walls of the Dog's Stomacli; A Study of tlie Intestinal Contraction;


Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the


" 21
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D.
A Contribution to the Pathology of the Gelatinous Type of Cerebellar SclerosiB


(Atrophy). By Henry J. Berkley, M. D.
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.


3
Mall, M. D.


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


2150
T. C. Gilchrist, JI. 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


1012
Parasites found in Various Lesions of the Skin, etc. ; Tvfo Cases of Molluscum


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


9.9706
T. C. Gilchrist, M. D.  


Report in Pathologry.
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration


0.3517
of Hypertrophy of this Gland. By W. S. Halsted, M. D.  




3.52


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


" 22
Report in Medicine,


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


4
Gallstones. By William Osler, M. D.
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.
On Pyrodin. By H. A. Lafleur, M. D.
Cases of Post-febrile Insanity. By William Osler, M. D.
Acute Tuberculosis in an Infant of Four Months. Bv Harry Toulmin. M. D.
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.


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


1400
Report in Gynecologry.
The Gynecological Operating Room. By Howard A. Kelly, M. D.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard


A. Kelly, M. D., and Hunter Robb, M. D.
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of


1014
Abdominal Section. By Howard A. Kelly, M. D.
The Management of the Drainage Tube in Abdominal Section, By Hunter Robb,


M. D.
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;


9.6530
Ovarian Tumor; General Gynecological Operations from October 15, 1889, to


March 4, 1890. By Howard A. Kelly, M. D.
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howabd


0.3463
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, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment


3.58
of Ureteral Stricture; Record of Deaths following GjTiecological Operations. By


Howard A. Kelly, M. D.


" 23
Report in Snrg-cry, I.
The Treatment of Wounds with Especial Reference to tlie Value of the Bloud Clot


in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in Nenrology, I,
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.
Haematomyelia. By August Hoch, M. D.
A Case of Ccrebro -Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By


5
Henry M. Thomas, M. D.


Report in Pathologry* I*
Amogbic Dysentery. By William T. Councilman, M. D., and Henri A. Lajleub, M. D.


700




1023
Volume III. ^6Q pages, with 69 plates and figiires.


Report in Pntliology.


9.9356
Papillomatous Tumors of the Ovary. By J. Whitridqe Williams, M. D.  


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


0.4383
Multiple Lympho -Sarcomata, with a report of Two Cases. By Simon Flexneb, M. D.  


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


4.41
A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.  


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


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


Table IX. — Nitrogen Ingested (in Grams).
Report in Gynecolog-y,


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


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


Intestinal Worms as a Complication in Abdominal Surgery, By A. L, Stavblt, M, D.




Day of


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


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


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


Date.  
Traumatic Atresia of the Vagina with Hcematokolpcs and Hsematometra. By Howard
A. Kelly, M. D.  


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


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


Resuscitation in Cliloroform Asphyxia. By Howard A. Kelly, M. D.


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


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


July 19
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
May i, 1892.


Volume IV. 504 pages, 33 charts and illustrations.


1
Report on TypUoid Fever.


By William Osler, M. D., with additional papers by W. S. Thateb, M. D., and J.
IIewetbon, M. D.


5.2052
Report in Nenrology.  


Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of i(t's mtisculus; The Intrinsic Nerves of the Th.iToid Gland of
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,
M. D.


" 20
Report in Surgery.
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to
January, 1894. By W. S. Halsted, M. D.


Report in Gyneeolog-y.
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. Citllen, M. B.
Report in Pntliology.
Deciduoma Malignum. By J. Whitridoe Williams, M. D.


2




5.2052
VoLUJiE V. 480 pages, with 32 charts and illustrations.  


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


" 21
Stndiea In Typboid Fever.
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon
Flexner, M. D., Walter Reed, M. D., and H. C. Parscns, M. D.




3


Volume VI. About 500 pages, many illustrations.


5.2052
Report in Neurolosy*


Studies on the Lesions produced bv the Action of Certain Poisons on the Cortical
Nerve Cell (Studies Nos. I to V). By Hen-ry J. Berkley. M. D.


" 22
Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the
Chroma'te 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 11. — Serum
Poisoning. — Experimental Lesions induced by the Action of the Doff*s Serum on
the Cortical Nerve Cell; Part III. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Clironic
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the' Cortical
Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Ner\'e Cells from tlic Effects of
Alcohol and Ricin Intcxication; Ner\'e Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.


Report in Patliolosr.


4
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.


CULLEN, M. B.


5.2052
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of


0\-um and Spermatozoa. By Thomas S. Cullen, M. B.. and G. L. Wilkins, M. D.
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By


" 23
William D. Booker, M. D.
The Pathology of Toxalbumin Intoxications. By Simon Flesner, M. D.
77ic price of n set hound in cloth [Vols. I-VI] of the Hosjtital Scparts kv


$30.00. Vols. J, II and III are not sold separately. The itrice of


5  
Vols, ir, V and TI is $5,00 each.




5.2052


I




3.3473 2.9837


3.3473 2.9837
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.  
The following papers are reprinted from Vole. 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 RnroRD,


3.3473 2.8787
M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,


3.3473 2.6950
$3.00.
THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thater, M. D., and J.  


3.3473 2.9312
Hewetson, M. D. And A STUDY OP SOME FATAL CASES OF MALARIA.  


By Lewellvs F. Barker, M. B. 1 volume of 280 pages. Price, in paper, |2."5.
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.\tracted


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481


0.0785
pages. Price, bound in paper, $3.00.  
0.0785
Subscriptions for the above publications may be sent to
0.0785
0.0785
0.0785


Tbe Johns Hopkins Press, Baltimore, Md.




0.1312
0.1312
0.1312
0.1312
0.1312


The Johns Hopkins Hospital Bulletins are issued nwntKly. Tlwy are printed hy THE FRIEDENWALD CO., Baltimore. Single copies
may be procured from. Afe.<isrs. CVSHING <t- OO. and the BALTIMORE NEWf! COMPANY, Baltimore. Subscriptions, $1.00 a year, may be
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sinyk copies will be sent by mail for fifteen cents each.




11.7459
11.7459
11.6409
11.4572
11.6934


BULLETIN




Table X. — Nitrogen Balance (N in Grams).


OF




Date.


THE JOHNS HOPKINS HOSPITAL.






.1
Vol. VIII -No. 73.]




2


NITBOGEN ELIMINATED.  
BALTIMORE, APRIL, 1897.  




i .




§




Urine.


COnSTTIElsrTS.


Fffices.




Postural Method of Draining the Peritoneal Cavity after Abdominal Operations. By J. G. Clark, M. D., ... 59


Report of Five Cases of Infection by the Bacillus Aerogenes
Capsulatus (Welch). By Edward K. Dunham, M.D., - - 68


July 19
Observations to Determine the Motility of the Bacillus Aerogenes Capsulatus under Anaerobic Conditions. By Edward
" 20
K. Dunham, M. D., - - - 74
" 21
" 22
" 23




1
2


3
Multiple Tuberculous Ulcers of the Stomach, with a Report of


4
Three Cases. By Alice Hamilton, M. D., - - - - 75
5
Studies on Trichinosis. By Mr. T. R. Brown, - - - - 79
Proceedings of Societies :


Hospital Medical Society, 81


47.700
On Certain Visceral Pathological Alterations, the Result of
47.400
Superficial Burns [Mr. Bardeen].  
46.800
45.700
46.000


Notes on New Books, 82


11.7459
Books Received, --- 83
11.7459
11.6400
11.4572
11.6934




8.2320
9.6530
9.9706
9.6530
9.9356


POSTURAL METHOD OF DRAINmG THE PERITONEAL CAVITY AFTER ABDOMINAL OPERATIONS.


0.9985
By J. G. Clark, M. D.  
0.9985
0.9985
0.9985
0.9985




9.2305
10.6515
10.9691
10.6488
10.9341


The general trend of recent medical literature relating to
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.


+2.5158
In a forthcoming article* on drainage based upon the bacteriological study of a large number of cases and upon the
+1.0944
clinical records of 1700 cases of abdominal section performed
+0.6718
in the gynecological department of the Johns Hopkins Hospital, I have been forced, notwithstanding my preconceived
+0.80S4
ideas in favor of drainage, to draw conclusions against it and
+0.7593
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
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.


Relation of Neusser's granules in the leucocytes: On the
Escape of pus during an operation, oozing of blood or serum,  
first two days of the observation the granules were comparatively few. On Jiily 21 they were relatively increased, whilst
extensile raw areas in the pelvis, are usually sui:)posed toindi
the alloxuric bodies, which had been comparatively high on the
20th, were distinctly diminished in quantity.


Observation Y. — The patient was a brewer, 30 years old, with
hypertrophic cirrhosis of the liver. Since 1895 he has had
icterus, with tenderness in the region of the liver. The jaundice has had a tendency to disappear and reappear. The faeces
at times would be distinctly bile-tinged, and at other times
free from biliary coloring matter. Appetite good. At present
there is a characteristic enlargement of the liver and spleen,
no ascites, and no well marked evidence of collateral circulation. No elevation of temperature. Rather poorly nourished ;
weight has varied between 62 and 59 kilograms since April
10. Has a retinitis. Urine is free from albumin.


The daily diet was as follows : Ham, 300 grams ; bread, 700
* A Critical Review of 1700 Cases of Abdominal Section from the
grams ; wine, 500 grams ; tea (infusion), 500 grams ; mm, 30
Standpoint of Intraperitoneal Drainage. The Johns Hopkins Hospital Reports, Vol. VII.  
grams ; sugar (6 pieces), 30 grams ; soda water, 4 bottles.  


These food materials represent about 2806 calories (47
calories per kilo body weight), which were arranged as follows:




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.


Albumin
Every surgeon recognizes the dangers of dead spaces in the
Fat
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.


Carbohydrates
In an article (1889) by Laude the statement is made that it
Alcohol
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
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.




516.27 calories.
256.21
1726.10
308.00


60


[No. 73.


Total 2806.58


Table XI. — Urine.


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
Pathological Conditions.


G. Wegner,* the first investigator who by experiments upon
animals endeavored to arrive at some definite conclusion concerning the ability of the peritoneum to rid itself of injurious
fluids or solid particles, was convinced that a comparatively
large quantity of infectious matter could be eliminated or
encapsulated by the peritoneal exudate without serious harm
to the animal.


Grawitzf next took up the experimental study of infection
of the peritoneum, pursuing his investigations under improved
bacteriological technique, and arrived at the following conclusions :


1. The introduction of non-pyogenic organisms into the
abdominal cavity, either in small or large quantity, or mixed
with formed particles,J produces no harm.


2. Great quantities of organisms which ordinarily produce
no symptoms, may give rise to a general sepsis if the absorptive function of the peritoneum is impaired.


3. Injection of pyogenic organisms into the peritoneal cavity
may be quite as harmless as injections of non-pathogenic
varieties. (In these experiments he injected a flocculent emulsion of staphylococcus albus and aureus and the streptococcus
pyogenes in ten cubic centimeters of water without any visible
reaction.)


4. The introduction of pus-producing cocci into the normal
peritoneal cavity produces a purulent peritonitis, first, if the
culture fluid is difficult of absorption, and second, if irritating
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
grow.


Pawlowsky,§ in an excellent experimental study, reviewed
Wegner's and Grawitz's work, with whom he agreed in many






* 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
encapsulated.


§Virchow's Archiv, No. 117, p. 469, 1889.


Date.




1
particulars, but disagreed in others. The main point of difEerence, however, between Pawlowsky and Grawitz related to
the ability of the normal peritoneum to deal with the staphylococcus aureus.


Pawlowsky found that the large quantities of staphylococci
injected by Grawitz without harm into dogs produced death
very rapidly in the animals upon which he experimented, and
that only a minimum quantity was harmless.


i
Reichel* went over the same ground in an experimental
research, and in the main agreed with Grawitz. The essential points of value in Reichel's paper are, that peritonitis
usually arises, first, because more organisms gain entrance
than can be handled by the peritoneum, and second, because
the stagnation of degenerating fluids in dead spaces favors the
growth of the organisms.


He also accounts for Grawitz's and Pawlowsky's conflicting
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
to satisfactorily settle the question of the ability of the normal
peritoneum to take care of infection.


He injected 6 cc. of a cloudy culture of staphylococcus
aureus into the abdominal cavity of dogs, employing both the
methods of Grawitz and Pawlowsky, and all of the animals
survived. The same results were obtained with the streptococcus, bacillus pyocyaneus and the intestinal bacteria.


Is
Waterhouse then endeavored to simulate the conditions
occasionally met with after operations, by introducing 8 cc. of
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.


a 5
In these experiments Waterhouse agreed with Pawlowsky
and Grawitz that the dangers of peritonitis are increased by
tardy absorption of fluids, which in effect leaves a culture
medium for the growth of the organisms.


After the introduction of blood clots 3 cm. in size, followed
by the staphylococcus aureus, death occurred from peritonitis
in 24 hours.


s?3i2 i
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
done in Grawitz's experiments, peritonitis did not follow,
which is explained by Waterhouse on the ground that the
organisms are rendered inactive or are killed by the turpentine. He proved this point by injecting the turpentine first


HS^.^




*Beitrage zur Aetiologie u. chirurg. Therapie der Sup. Peritonitis. Deutsche Zeit. f. Chir., Vol. XXX, 1889.
t Virchow's Archiv, Vol. 119, p. 342, 1890.




P^


April, 1897.]


¥
61




aui


and following it in a short time with the infecting germs ; in
every instance the animal died of peritonitis.


s 3i
Dogs with a strangulation of the intestines were easily
infected.


o a  
In three instances the staphylococcus aureus was introduced
into the peritoneal cavity of cats suffering from ascites, followed
quickly by death from peritonitis, which resulted, as Waterhouse says, because there was a favorable culture material, a
diminished absorption, and an injury to the peritoneal endothelium.


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
General Immunity," contains some valuable observations bearing upon the resistance of the peritoneum to infection.


Notwithstanding the injection of large quantities of virulent streptococci, a few of their animals survived. They state
that " in those animals which succumbed quickest, free cocci
were very numerous in the peritoneal exudation, and in those
which survived longest they were either absent or contained
within phagocytes."


These observers, in order to discover how quickly the organisms disappeared from the peritoneal cavity, killed two rabbits
which appeared about to recover. " In the first, which had
received 5 cc. of broth culture thirty hours before, only one
chain of streptococci was found after prolonged search, but
many cocci were contained in cells, and broth inoculated with
this fluid grew a good culture."


May 15
"The second rabbit having shown no signs of illness after
an injection of 6 cc. of anaerobic broth culture, received next
day 10 cc. of a similar material swarming with streptococci.
When killed five and a half hours later, not only could no
streptococci be seen, either free or in cells, but no growth grew
on cultures made from the abdominal fluid."


From this review of the literature bearing upon infection of
the peritoneum I make the following summary :


1  
1. Under normal conditions the peritoneum can dispose of
large numbers of pyogenic organisms without producing peritonitis.


2. The less the absorption from the peritoneal cavity the
greater the danger of infection.


1630
3. Solid sterile particles, such as fecal matter, potato, etc.,
are partly absorbed and the remainder are encapsulated without the production of peritonitis.




1026


•Baumgarten's Jahresbericht, Vol. VII, 1891.


13.2511
tThe Johns Hopkins Hospital Reports, Vol. II, 1891.  


t Journal of Pathology and Bacteriology, 1895.


0.4773




3.60
4. Death may be produced by general septicaemia, and not
by peritonitis, where large quantities of organisms are taken
up by the lymph streams.  


5. Irritant chemical substances destroy the tissues of the
peritoneum and prepare a place for the lodgment of organisms
which becomes the starting-point for peritonitis.


" 16
6. Stagnation of fluids in dead spaces favors the production
of peritonitis by furnishing a suitable culture medium for the
growth of bacteria.


7. The association of infectious bacteria with blood clots in
the peritoneal cavity is especially liable to produce peritonitis.


2
8. Traumatic injury or strangulation of large areas of tissue
are strong etiological factors in the production of peritonitis
when associated with infectious matter.


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.


1830
Mechanism of Absorption of Fluids and Solid
Particles in the Peritoneal Cavity.


Recent investigations by Muscatello* on the histology of
the diaphragmatic peritoneum and the mechanism of absorption of substances from the peritoneal cavity, when considered
in conjunction with the above conclusions, give ample ground
for my suggestion of the elevated posture as a prophylactic
measure against post-operative peritonitis.


10:i3
Muscatello accepts Bizzozero's and G. Salvioli's classification of the component parts of the diaphragmatic peritoneum
which occur in the following order: endothelium, membrana
limitans and connective tissue framework. Up to the time of
Muscatello's publication, histologists were equally divided on
the question of the presence or absence of stomata between the
endothelium. He proved beyond doubt that these openings
are optical illusions, due to the defective preparation and
staining of the microscopical sections. According to Muscatello's opinion, minute foreign particles, leucocytes and fluids
pass through openings between the endothelium of the diaphragm made by the retraction of the protoplasm of the cells.


Beneath the peritoneal endothelium of the diaphragm and
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.


14.6564
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


0.4153




2.83
Virchow'a Archiv, 1895.  




" 17


62


3
[No. 73.
 


1550




1023
of the foreign particles from the peritoneal cavity to their
ultimate repository, the lymph glands, could, however, be
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
glands in from five to seven minutes, while in animals in
which the posture was reversed it was five and a half hours
before they could be recovered from these glands.


16.2778
Muscatello proved that small particles were carried from
the peritoneal cavity into the lymph spaces of the diajihragm
through the opening made by the retraction of the endothelium, then into the mediastinal lymphatic vessels and
glands, then into the blood current, by which they were transported to the various organs of the body, from which they were
picked up by the lymph vessels and deposited in the collecting glands of each organ. For this reason the large vascular
organs, such as the liver, stomach, spleen and pancreas, show
the particles first and in the greatest numbers, while the
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
the elimination of foreign particles from the peritoneal cavity.


0.5089
Muscatello and other observers find, on examining the
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
leucocyte to encompass it, two or more join forces to surround
the invader. The leucocytes are found in greatest abundance
beneath the omentum. Prom the peritoneal cavity Muscatello
traces the course of the leucocyte through the channels above
described and finally finds them deposited in the lymph glands
in various parts of the body.


3.12
In Muscatello's experiments the leucocytes were able to
dispose of the innocuous particles rapidly and without apparent ill effect to the auimals. In Pawlowsky's, Cobbett's and
Melsome's experiments, on the other hand, the conditions
were different, the leucocyte having to meet an antagonistic
invader. In those animals which survived the injection the
infectious organisms were quickly encompassed by the leucocytes and carried into the general circulation, while in the
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
wish to draw especial attention to are :


" 18
1. Large quantities of fluids may be absorbed by the peritoneum in a remarkably short time. (Wegner.)


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.)


4




nno
3. The leucocytes are largely the bearers of foreign particles
from the peritoneal cavity. (Muscatello.)


4. There is normally a current in the peritoneal cavity
which carries fluids and foreign particles towards the diaphragm, regardless of the posture of the animal, although
gravity can greatly favor or retard it. (Muscatello.)


1024
Postural Method of Draining Dead Spaces in the
Pelvis.


The many bacteriological studies in cases of experimental and
post-operative peritonitis and in experimental infections of the
peritoneum show conclusively that the infecting organisms are
quickly distributed more or less generally in the peritoneal
cavity, from whence they are carried into the system at large.


17.2238
Where there is no persistent source of infection, virulent
species of bacteria may be destroyed effectually in this way;
but when a nidus of infection exists in which the microorganisms are propagated, the patient is either carried off by a
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
localized collection of pus.  


To avoid this danger the most scrupulous care should be
observed in every abdominal operation not to leave behind
any condition which may furnish a starting point for an
infectious process.


0.4918
Oozing should be controlled as far as possible, injury and
exposure of the peritoneum should be guarded against, raw
areas should be covered with adjacent healthy peritoneum
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
after many operations, which may become collecting places
for degenerating fluids. In addition to these artiflcial spaces,
oozing serum and blood may collect in Douglas' cul-de-sac or
in the ante-uterine space, and become the focus of a genei'al
peritonitis or a localized pelvic abscess.


2.85
To offset these dangers all dependent spaces should be
drained as rapidly as possible, thus preventing the collection
and stagnation of vital fluids, which are active germicides
when first secreted, but become excellent culture media when
degenerated.  


By elevating the pelvis after operation, the normal intraperitoneal current may be assisted greatly in at once draining
dead spaces, and thus give the general peritoneal cavity and
system at large the best opportunity to meet the invading
organisms before they have had time to increase in numbers.
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."


" 19
Stagnating fluids in the dependent parts of the abdominal
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.




5


April, 1897.]


2040
63




1024


In additiou to tbe mere transportation of the organisms
from an area of decreased resistance to one of normal resistance, the irritant chemical toxines elaborated by the bacteria
are diluted and the infectious matter is divided into a fine
granular state, thus giving the leucocytes the best opportunity to encompass the organisms.


20.2051
Although fatal septicasmia may be produced in animals by
the absorption of large quantities of organisms from the peritoneal cavity, it appears to me correct to assume that after a
well-conducted abdominal operation no such quantities of
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
of drainage are, first, stagnating fluids are prevented from
collecting in dead spaces in the pelvis; second, infectious
organisms are quickly carried into normal areas of the body
where they are destroyed before they can increase in numbers;
and third, toxic substances elaborated by the organisms are
diluted and prevented from expending their irritant effects on
a wounded area.


0.4118
The method which I desire to offer is briefly as follows: At
the conclusion of an operation all fluids and debris should be
removed as far as possible by sponges, after which the abdominal cavity should be thoroughly irrigated with normal salt
solution until the fluid comes away clear.  


When the irrigation fluid is all sponged out, 500 to 1000 cc.
of salt solution should be poured into the peritoneal cavity,
so that when the patient is elevated after she is returned to
the ward the artificial current may be started at once towards
the diaphragm, thus supplementing the normal current.


2.03
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.


" 20
Leaving the salt solution in the abdominal cavity is not a
novel procedure, as it has been done in a large number of cases
during the last two years in the gynecological department, and
other abdominal surgeons have used it with good effect.


This postural method of drainage is offered as a prophylactic
measure against post-operative peritonitis, but not as a curative measure after the peritonitis is established.


6
It should therefore not be employed when an operation is
performed for the relief of purulent peritonitis or for inflammatory conditions associated with general peritonitis, as for
instance some cases of appendicitis.


From the experiments of Waterhouse in which he proved
the danger of infection in cats suffering with ascites on
account of the defective absorptive mechanism, it would also
appear unsafe to adopt the postural method in cases when


1690




1022
this complication is coincident with the surgical affection.
Pawlovvsky has sliown in his excellent experimental investigations that the lymph channels leading from the peritoneal
cavity are choked with the infectious bacteria and inflammatory products in purulent peritonitis, and therefore advises
free drainage through an abdominal incision.


In these cases it is evident that the multiplication and virulence of the organism have been too great for the phagocytes
to overcome successfully, and that the only method of treating
this condition is to remove as much pus as possible by irrigation with salt solution or by mopping the peritoneal surfaces
with sponges wet with salt solution, as suggested by Finney,
and then to insert a very free drain.


16.4352
Only one of the cases which I report in this paper showed
organisms on culture. The presence of pyogenic organisms
is not a contraindication to the employment of the jiostural
method, because all investigations have proved conclusively
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
organisms are yet active, as shown by Miller of the Johns
Hopkins Hospital, Schauta, Menge and others.  


In forty-four cases of hysterectomy, mostly for pelvic
inflammatory disease, examined by Miller, the cultures made
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.


0.4771
Report of Cases in which the Postural Method of
Drainage was employed.  


Case I.


2.90
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,
1897. Married, age 47 years.


Table XII. — Nitrogen Ingested (in Grams).  
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
period terminated December 18, 1896.


Date.  
Present Illness. November 15, 1896, she had a severe chill,
lasting two hours, followed by fever. The next day she had
great pain, which continued one week and was accompanied
with diarrlia.'a. Since then she has grown steadily weaker.  




Day of observation.


64


Ham.  
[No. 73.  




Bread.


fever and chills occurring frequently, and for the last week
she has been confined to bed.


White wine.  
General Condition. Well nourished woman; tongue slightly
coated, bowels regular, appetite poor. Micturition and defecation painless. For the past four weeks she has had a dry cough.  


Examination of heart and lungs negative.


Total nitrogen.  
Temperature on admission 103° F., pulse 110.  


Diagnosis. Large suppurating ovarian cyst.


May 15-19
Operation by Dr. Kelly, January 20, 1897. Cystectomy;
" 20
part of cyst wall could not be removed.


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.


1-5
6




13.0454
Incision 14 cm. in length, exposing red mottled and whitish
11.3237
cyst wall, closely adherent to anterior abdominal wall over a
surface 10 cm. above symphysis pubis. Omentum adherent
to anterior face of cyst over an area 10x8 cm. Adhesions
separated; free oozing from thickened omentum checked by
catgut sutures, no omentum removed; just above this point
there was a fringe of flat adhesions, binding cyst to intestines
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.


7.9398
Ten minutes were spent in separating tumor from anterior
7.9398
abdominal wall, bladder and anterior pelvic wall.  


Large Fallopian tube on left side was exposed up to a point


0.2625
0.2625




21.2477
Jan.  
19.5260






Table XIII. — Nitrogen Balance (N in Grams).
18






19 20






21






23




NITROGEN ELIMIN


o^
24






25






26




^


Temp.


§2
103
102
101
100


99


ATED.
98


Temp.


a — t3
Pulse
Resp.


Stools


<0




Date.
Day of
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








5(10






540






560


1^




1?
6()0




§1


>» •


Urine.




Faeces.




5gi


670


n




May 15
^'"




1


5ilO +


59.200




21.2477
^'*..  




13.2510


190 +


2.2526




15.5036
,\




-1-5.7741


30 +


" 16




2
130
120
110
100
90




58.500


80


21.2477
70


4 60


14.6564
50




2.2526


 
Case I.
16.9090
Plain line indicates temperature. Broken line indicates pulse.  




-1-4.3387


where it was lost in the tumor. Adhesions to uterus, to pelvic
floor on right side, and to part of left pelvic wall divided.
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.


" 17
In separating adhesions on pelvic floor a sac was ruptured,
 
discharging a large quantity of fetid pus into the peritoneal
cavity. This was quickly mopped out and the hole in the sac
stuffed with gauze. Cyst cut loose, leaving a portion of
abscess wall 5x8 cm. in dimensions on the pelvic floor. Gauze


3




58.500
packed over this to protect it during the rest of the operation.
Sac was peeled up and out of a dense bed of adhesions in
the pelvis ; it was then found that the adhesions, extending
between the entire length of the mesentery and out onto the
intestines, were too extensive for further separation. The
outer layers of the cyst wall were slit 2 cm. from bowel on all
sides and dissected out from beneath the mesentery, thus completing the enucleation and leaving behind a large cup-shaped
dead space. Slight capillary oozing occurred from the portion
of cyst wall remaining behind.  


The portion left in the pelvis also required six or eight ligatures to control oozing. Small epithelial cyst on right side


21.2477




16.2778
April, 1897.]


65


2.2526




18.5304
piiuctured. Eight ovary normal. Eight tube adherent and
closed.  


Adhesions of right ovary to sac bled freely, requiring two
sutures to control hemorrhage.


-f2.7173
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
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.


" 18
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.


4
Twelve o'clock midnight, temperature 99.3° F., pulse 124.
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.


58.9(10
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.


21.2477
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.


17.2238
Case II.  


In this case the operation was very difficult and attended by
many complications. The peritoneum was injured extensively, pus escaped during the operation, the intestine was
injured and required suture, free oozing occurred during the
operation and persisted at its completion, and large denuded
areas were left in the pelvis.


2,2526
Gynecological No. 4892. A. E. T., widow, aged 34 years.


Complaint. Pain in the right inguinal region, pain in the
rectum, and swelling of the abdomen at times.


19.4764




-hi 7713
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.


" 19
Family History. Negative.


Present Complai?it. Three years ago she was confined to
bed for three weeks with fever and chills and severe pain in
the lower abdomen, which began in the right side and then
shifted to the left. During the attack she had a constant
discharge of thick tarry blood from the uterus. After the
attack she was able to get up, but it soon recurred, and the
abdomen became greatly distended and excessively painful.
Ten days ago another attack began, which has not been so
severe up to this time as the former ones. She complains of
pain during defecation and micturition, backache and bearingdown pains. Temperature on admission 101° F., pulse 120.


5
Diagnosis. Pyosalpinx duplex ; retroflexio uteri adherens;
pelvi-peritonitis.


Operation. Enucleation of both ovaries and tubes.


59.400
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
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.


21.2477
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.


20.2051
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
adhesions, but this was discontinued on account of the free
bleeding and danger of tearing into the rectum.


2.2526
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.


22.4577
Active oozing to the right of the fundus over the ureteral
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.  




-0 7900


66


" 20
[No. 7.3.




6


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.


60.000
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.
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.


19.52G0




16.4352
Tliird Day. Six o'clock A. M., pulse 84, temperature
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.


2 2o26
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.




18.6878




-t-0.3611
V)a.y a?


Operation




Relation of Neusser's granules in the leucocytes : Several
days before the commencement of the chemical analyses the
granules were much more numerous than they were during
the period of examination. There was no variation observed


Case II.
Plain line indicates temperaiure. Broken line indicates pulse.




during the latter period. Altogether the granules were only
moderately numerous, but not more so in the mononuclear
than in the other varieties of leucocytes. Some of the mononuclears were without granules. It will be seen that the
amount of the alloxuric bodies was relatively high.


Observation VI. — This patient was a man also with hypertrophic cirrhosis of the liver. Since 1893 he had complained
Case III.  
of gastric and intestinal symptoms. In 1895 enlargement of  
In this case there were dense adhesions binding a large
the liver and spleen was noticed. Icterus has been persistent,
suppurating ovarian cyst to the intestines and the abdominal
with the exception of one interval when he was free. Weighed
wall. A suppurating fistulous track extended between the
49 kilo when he came to the clinic, but has gained slightly
caput coli and one loculus of the cyst, requiring a number of  
since. The blood examination showed 2,500,000 red corpuscles, 7900 leucocytes, and 55 per cent hajmoglobin (Fleischl).
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


The daily diet was as follows: Ham, 300 grams; white
bread, 450 grams ; milk, 500 grams; wine (red), 300 grams;
tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces),
30 grams : Kohitsch water, 2 bottles.


The above diet represented about 2370 calories (48 per kilo
body weight), which were made up as follows :


a hirge cavity in the pelvis. Pieces of the cyst wall and much
debris remained behind at the completion of the operation.


There was considerable oozing and extensive traumatism
produced by the separation of tlie wide-spread adhesions.


Albumin
Pus from the cyst injected into a mouse killed it within
Fat
twenty-four hours.


Carbohydrates
Notwithstanding all these complications the patient made
Alcohol
a good recovery.






515.65 calories.
April, 1897.]
385.02
1161.38
308.00


67




Total 2370.05


Table XIV. — Urine.  
Gynecological No. 4928J. A. E. S., admitted January 9,
1897. Single, age 35 years.  


Complaint. Increasing size of abdomen, severe constipation, feeling of obstruction in abdomen. Menstruation began
at 15 years, recurring every 28 days, 4 to 5 days duration,
normal.


Family History. Negative.


Present Illness. Patient was always strong and well until
four years ago; at this time she suffered with indigestion, and
was treated by her physician for displacement of the uterus.
She had an attack of peritonitis in September, 1895, which
confined her bo bed four weeks. In October, 1896, she suffered




C*


9 10 II 12 13 14 15 16 17


2




with " chills and fever," which lasted eight weeks. During
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
operation for hemorrhoids performed in 1892.


g
Present Condition. Body emaciated, complexion pale, expression anxious. Appetite good. Micturition normal.


Examination of heart and lungs negative. Temperature on
admission 100.5° F., pulse 120.


Diagnosis. Suppurating ovarian cyst.




o




Date.  
Case III.  


Plain line indicates temperature. Broken line indicates pulse.


Q^




g^8
Operation by Dr. Kelly, January 16, 1897. Cystectomy.


Complications. Dense adhesions between cyst and intestine, fistulous opening between intestine and cyst. Pyogenic
urea over bladder and anterior abdominal wall.


as
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


-2 2
a a


1 °


|a  
a fistulous track between the two 5 cm. in diametei-. Appendix thickened and twice its normal size, adherent to a black
ragged area 2x2 cm. It was not removed, as it showed no
disease and the patient's condition was very critical.


On right side the tumor was adherent to the anterior abdominal wall over an irregular area 6x3 cm., running down to
cornu uteri. This area was scraped free of pus and lymph
and covered with peritoneum from side to side.


Alloxuric
Eagged area on colon covered in by base of appendix, which
was sutured over it with interrupted catgut ligatures. Silk
sutures were used to close the opening in the colon. Abdominal
cavity thoroughly irrigated. Salt solution infusion (500 cc.)


body— N 1
grams.




Percentage
68
alloxurlo
body— N
the total n
trogen.


[No. 73.


June 7




1
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
was 136, having dropped 14 beats in twenty minutes. Foot
of bed elevated. Five o'clock in the evening pulse 128. Nine
o'clock, 120. Twelve o'clock, 108. Patient comfortable and
complaining of little pain.


2500
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.


1015
Afternoon, patient comfortable, pulse 100, temperature
99.8° F. Small liquid movement.




14.4813


Fourth Day. Pulse 96, temperature 99° F. Considerable
pain in abdomen.


0.6650
Fifth Day. Temperature 98°, pulse 90. Patient had a
comfortable night.  


Sixth Day. Pulse 80, temperature 98° F.


4.59
Tenth Day. Convalescence has been uninterrupted. Dressiugs removed from abdomen, union of incision ^ler primam.  


Patient sat up on her 20th day.


" 8
Bacteriological Examination. Cover-glass preparations
showed many cocci and bacilli. Two cc. of pus injected into
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.




2


KEPORT OF FIVE CASES OF INFECTION BY THE BACILLUS AEROGENES CAPSULATUS (WELCH).


2050
By Edward K. Dunham, M. D., Professor of Bacteriology, Bellevue Hospital Medical College, Neiu York.




1017


Within the past year the writer has had occasion to study
five cases of infection in which he believes the bacillus aerogenes capsulatus, described by Welch and Nuttal, and Welch
and Flexner, either caused or hastened death.


16.3590
In all but one of these cases the bacillus was found in
 
material taken from the tissues of the patient during life.  


0.6188
The first case died on the 11th of March, 1896.  


The patient was a woman, aged 23 years, who was admitted
to St. Vincent's Hospital, New York, on the 7th of that
month, and then gave the following history :


3.78
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.


" 9
At the time of her admission she had diflBculty in swallowing, stiffness of the jaw, and pain, with a sense of constriction,
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.


3
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


3200




1013
excruciating; swallowing was practically impossible; the voice
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.


15.5680
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
from the wound, but emphysematous crackling was felt at the
angle of the jaw. At 6 A. M. the patient was dead.


0.7056
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.


4.53
Agar tubes iu four dilutions were prepared and placed in
the incubator. Upon these two sorts of colonies developed, one
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
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.


" 10
A guinea-pig was inoculated subcutaueously with 1 cc. of one




4


April, 1897.]


4000
69




1011


of these bouillon cultures and died during the following night.
At the autopsy the subcutaneous tissue was oedematous and
emphysematous, and the fluid contained both cocci and bacilli,
the lattei" predominating.


16.2400
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.


0.5425
The bacillus was a large straight rod, about 0.9,a in diameter, with rounded ends, usually occurring singly or in pairs,
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,
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.


3.34
Bouillon was rendered cloudy, and usually a few bubbles
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
production of gas.


" 11
In all the media the bacillus proved to be a strict anaerobe.


The bacillus grew well in bouillon to which 1 per cent of
glucose had been added, and these cultures evolved a considerable amount of gas when incubated in an atmosphere
deprived of oxygen by means of potassium pyrogallate.


5
In order to determine the nature of this gas, six fermentation tubes containing glucose bouillon (1 per cent of glucose)
were inoculated with the bacillus, and, after 24 hours, the
gas collected in a eudiometer over mercury. 28.6 cc. of gas
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
gas was determined :


2500
Hydrogen 64.3 per cent.


CO2 27.6


1014
Nitrogen (?) 8.1*


100.00 per cent.


15.8375




0.7131
On the 22d of March, i. e. eleven days after the pus was
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
hospital, another guinea-pig was inoculated, by means of a
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.


4.50
When injected into the blood of a rabbit, which was then
killed after the lapse of a few minutes, the bacillus caused
enormous swelling of the body of the animal within 20 hours,
and the liver, kidney and spleen, as well as the subcutaneous
tissue, were the seat of a very marked emphysema. The skin
was rendered so tense by the accumulation of gas that it
seemed on the point of rupturing.  


The foregoing characters of the bacillus under study
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
of these spores, and it was found that when taken from the
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


Table XV. — Nitrogen Ingested (in Grams).*




*The composition of the residual gas in the eudiometer was not
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
states that the bacillus aerogenes capsulatus in his possession produced spores when cultivated on LoefHer's blood serum. This
observation tends to still further establish the identity of the
bacillus isolated by the writer.


Date.  
i The author has observed that the spores of bacillus subtilis are
much more easily killed by moist heat when freshly formed than
after a lapse of time and drying.  




Day ot observation.


70


5am.  
[No. 7.3.  




Bread.


when placed iu broth at the body temperature under anaerobic
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.


Milk.  
The spores stain readily in hot solutions of fuchsin in anilin
water, and are not decolorized by a moderate exposure to the
action of a 3 percent, solution of hydrochloric acid in absolute
alcohol.  


They have an oval shape and are usually situated near the
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.


Red wine.  
The cultures containing the spores frequently contain involution forms of the bacilli and threads of the latter, which
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
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.


Total nitrogen.  
The incisions in the neck made before the death of the
patient were opened and a focus of suppuration was found,
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
appear emphysematous. Microscopical examination of bits
of those organs failed to reveal the bacillus.


June7A8
Sections from the organs of the rabbit into the veins of
" 9&lfi
which the bacillus was injected, when stained by Gram's
" 11
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.


1 &2
After being under the care of a physician not connected
3<s4
with the hospital for a couple of hours, the patient was
5
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
130 and very feeble.


12.2257
On the 20th he was delirious throughout the day.  
12.2257
On the 21st the dressings were removed and the arm and
12.2257
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.  




6.3503
6.3503
6.3503


Free incisions were made and the subcutaneous tissues found
in a necrotic condition. The wounds were washed with mercuric chloride and drained.


2.8525
On September 22d the patient was still delirious, very
2.8175
weak, with a fluttering pulse. The dressings were again
2.6162
removed and fresh incisions made in the arm. The cedema
had extended well into the pectoral region and down to
the elbow, and at this time, I believe, some emphysema of
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.


0.1225
Some of the discharge from the incisions made on the 2l8t
0.1225
of September was collected in a sterilized test-tube and sent to
0.1225
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,
the other half with access of air.


21.5510
After 48 hours the aerobic cultures showed only colonies of
21.5160
cocci, while the anaerobic cultures contained colonies in which
21.3147
both cocci and bacilli had developed. The latter tubes gave
evidence of gas production, the agar being raised from the
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
ear-vein of a rabbit and five minutes later the animal killed.
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.


^Tea, rum and sugar not analyzed.  
Cover-glass preparations from the viscera and subcutaneous
fluid demonstrated the presence of the bacillus, accompanied
by a few cocci.  


Table XVI. — Nitrogen Balance (in Grams).  
Agar cultures prepared from the organs of this rabbit
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.
(See " II," temperature chart.)


The third case of infection was a man, a't. 33, of alcoholic
habits, who had suffered from urethritis on two occasions the last time three years before he presented liimself for final
treatment at Belle vue Hospital.


When he was admitted to the hospital, on November 6,
1896, he had difficulty in voiding his urine, owing to a stricture of the urethra which could not be passed by instruments.


On December 5th, at 3.30 p. m., external urethrotomy \yas
performed, and the patient did well until 2.30 p. m. on December 8th, when a sound was passed.


Twenty-one hours after this procedure a chill ensued, which
was followed by severe pains in the joints and back, and from
that time the patient rapidly grew worse and died on the 10th
of December at 8 p. m.


At 9 p. m. on the day preceding death, an area of subcutaneous emphysema appeared over the front of the right thigh,
and others over both shoulders. These areas increased rapidly
in size up to the time of death and afterwards.


1^
The following notes on the bacteriological examinations of
material from this case and of the autopsy are kindly furnished me by my assistant, Dr. F. M. Jeffries, who conducted
them. At 1 p. m. on December 10th, i. e. -1 hours before the
death of the patient, three agar tubes were inoculated from
the subcutaneous tissue in the emphysematous area on the
thigh. These, although placed under anaerobic conditions,
failed to develop, probably because of excessive acidity of the
agar.


At the autopsy made 18 hours after death, cultures on agar
and in bouillon were made from the heart, lungs, liver, brain,
and the emphysematous area on the thigh. These cultures
were incubated under anaerobic conditions in Novy jars
with pyrogallate of potassium.


S
After 24 hours the cultures from all these sources had
developed, with evolution of gas. They all consisted of bacilli
resembling the bacillus aerogenes capsulatus. They wei'e
not motile and stained well by Gram's method. All the cultures contained only this one bacillus, without admixture of
other bacteria.


NITBOQEN eliminated.  
Intravenous injection of a bouillon culture in a rabbit which
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.


g
Subcutaneous emphysema was noted, extending over the
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
abdomen was soft, pulpy and emphysematous. There were
emphysematous areas on the pleurte and pericardium. There
was general emphysema of the lungs. The cavities of the
heart were distended, their walls soft and oedematous, and the
blood they contained dark and fluid.


The liver was of a dark cliocolate color, soft and the seat
of emphysema.




Drlne.


The spleen was dark plum-colored, extremely friable and
emphysematous.


Faeces.  
The kidneys were enlarged, showed subcapsular emphysema,
and were plum-colored.  


The mucous membrane of the bladder was extremely
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.)


June 7
The fourth case was a man, 23 years of age, who was admitted to the J. Hood Wright Memorial Hospital on the 6th of
" 8
.January, 1897.
" 9
" 10
" 11


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.


1
Two years ago, i. e. about one year after the beginning of
the second attack of gonorrhcEa, he felt pain on urination and
noticed that the stream of urine was diminished in size.
Shortly after this he had retention of urine, and was catheterized with some difficulty, and the urethral stricture then
gradually dilated with sounds, the treatment lasting for two
months. Since that time he had omitted all treatment.


2
At the time of his admission to the hospital the patient
3
complained of pain on micturition, but there was no discharge
4
from the urethra or increased frequency of urination. The
5
urine was acid ; sp. gr. 1029; no albumen or sugar.


A urethral examination gave the following results :


49.500
No. 23 (French) bougie a boulu passed the meatus, but was
49.400
stopped just bej'ond the urethral orifice.  
49.200
50.000
49.600


No. 30 entered the urethra for a distance of 24 inches.


21.5510
No. 25 slipped past a constriction at 23 inches, but was
21.5510
arrested at about 6i inches.  
21.5160
21.5160
21.3147


No. 30 and No. 15 sounds met with an obstruction at the
same point.


14.4812
No. 4 and No. 2 bougies also failed to pass that point, as did
16.3590
also a filiform bougie. Even a bunch of filiform bougies
15.5681)
failed to demonstrate a passage, although, subsequently, after
16.2-100
etherization in preparation for the operation, a filiform bougie
15.8375
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.


1.6595
The patient was returned to the ward at 5.20 p. m., and
1.6-95
a conducting tube, with its distal end immersed in a 2J per
1.6595
cent, solution of carbolic acid, was attached to the perineal
1.659.i
drainage tube.  
1.659.-,


 
At 6.30 p. m. the patient vomited some blood. The dressings were found to be saturated with blood and were renewed.  
16. 14071-1-5.4 103
A slight oozing of blood from a wound in the bulb of the
IS !)l85l-f-3 5325
urethra was noticed. This had ceased at 9 p. m., and the
17 227^1-1-4.2885
patient then felt comfortable.  
17.8995-|-V61(i5
17.49704-3.8177






Relation of the Neusser's granules in the leucocytes: Altoo-ether the granules were very few in all the different forms.
72
Most of the white corpuscles are entirely free from the granules, and many almost entirely free. During the period that


[No. 73.




90


At 10.30 the bladder was agaia irrigated.


On January 10th the patient felt well and the bladder was
draining nicely.


At 1.30 the urethra and bladder were irrigated with a warm
saturated solution of boric acid. The anterior urethra contained some dark fluid blood which was washed away, and the
perineal wound then dressed.


the patient was under observation there was no apparent
On the 11th and 12th of January the patient was doing
variation in the richness of the grannies. On the other hand,
well and the bladder was simply washed out.  
the alloxuric body nitrogen was both absolutely and relatively
high (0.67, 0.71 gram per day).  


Observation VII.— A. man, 20 years old, with physical signs of
The patient complained of some pain in the penis on the
a commencing left-sided pulmonary tuberculosis. No tubercle
13th, and at 3.30 p. m. sounds were passed down to the stricture, and gradually increasing in size up to No. 33 (French).
bacilli were found in the sputum, however, after repeated
The perineal drainage tube was then removed and a No. 33
examinations. His weight on May 26th was 57 kilo ; he was  
sound passed through the entire urethra into the bladder,  
fairly well nourished. During the period of observation he
without difficulty. The perineal wound appeared healthy,  
was free from fever. Leucocytes were 10,000 per cmm. ;
and there was no discharge from the urethra except a small
hemoglobin 70 per cent (Fleischl).  
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.  


The daily diet was as follows: Ham, 300 grams,; white
At 9.30, seven hours after the sounds were passed, the
bread, 450 grams; milk, 500 grams; wine, 500 grams; tea
patient had a severe chill, lasting half an hour.  
(infusion), 500 grams; rum, 30 grams; sugar (6 pieces), 30
grams; Eohitsch water, 2 bottles.  


The above food represented about 2370 calories (41 per kilo
At 3.30 a. m., January 14th, a slight bleeding took place
body weight), which were made up as follows:
from the urethra.


At 8 a. m. pain in the left shoulder was complained of.


At 11 a. m. a catheter was introduced throiigh the perineal wound and about 3 ounces of bloody fluid having a foul
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.


Albumin
At 9 p. m. the pains in the shoulder and buttock had
Fat
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.


Carbohydrates
On January 15th, at 4 a. m., the emphysematous areas had
Alcohol
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.


Total
At 7 a. m. the body was jaundiced, except over the emphysematous areas. Of these, that on the buttock looked much
darker than before and was irregularly mottled with purple
spots.


At 8.15 a. m. an incision, two inches in length, was made
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


615.65 calories.
385.02
1161.38
308.00


2370.05


a. m., forty-five hours after the sounds were passed on the
13th of January.


Dr. Brooks performed the autopsy on this case, and the following account is taken from his notes :


The autopsy was made 5 hours after death, while the body
was still warm.


Rigor mortis was marked; the general nutrition good.


Post-mortem discoloration was extreme from the pelvis up,
and there was emphysematous crepitation over the abdomen,
especially in the suprapubic region ; over the back, the buttocks, and the thigh, leg, and dorsum of the foot on the left
side ; also, though in less degree, on the right side.


Puncture of the emphysematous areas permitted the escape
of a gas which burned with a blue flame.


Table XVII.—
The abdominal wall was greatly distended, and when an
incision was made the inflated intestines protruded.  


The liver was of a light clay color and crepitated under the
fingers. Its tissues were very friable, and filled with minute
vesicles containing gas. The cut surface appeared oedematous.


Urine.  
The spleen was enlarged, of a dark purple color, and very
 
friable.  


The kidneys were enlarged; their capsules adherent.


The lungs were somewhat (Edematous.


The cavities of the heart were distended on both sides by
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
spores identical in character with those produced by the
bacillus isolated from the pus from the first case.


i
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.


I
A rabbit was also inoculated, intravenously, with the bouillon
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






April, 1897.]


73


a




» O
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.


Date.  
Two bacilli developed in these cultures, and as they were
both at least facultative anaerobes, efforts to separate that
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
hypertrophy of the prostate.


§H
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.


uj?
That night, because of difliculty in voiding his urine, the
patient passed a hard rubber catheter and drew some blood.


On the 21st, pain in the right ischio-rectal fossa was noticed,
and the tissues at the site of the pain were found to be firmer
than normal.


a a «
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
on the day before. Temperature 102°. There was increased
harduess of the tissues of the right buttock, and the pain there
was very great.


S 1 2  
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.


S S 1 1 a
The next morning, January 25th, the attending physician






found the scrotum emphysematous, with spots of gangrene
upou it. Temperature 103°.


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.


>.H
The areolar tissue of the scrotum and penis were of an inky
 
blackness and emphysematous, but contained no pus. A slight
ojdematous condition prevailed in the deeper structures.


The tissues were irrigated with mercuric chloride and an
iodoform dressing applied.


On the following day, January 26th, the emphysema had
extended over the pubes and the hypogastric region, the skin
being raised about half an inch. The color of the skin over
this area was either normal or had a pinkish blush.


Two free incision* were made to evacuate the gas, and it
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
sloughing had extended so as to include the skin, but without
the formation of pus.


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
emj)hysema in the body of a rabbit killed shortly after the
injection of the culture into a vein of the ear.


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.


a "




a"
74


[No. 73.






g MM
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.


S o 2
They serve also to show that the bacillus is of pretty wide
distribution ; for within eleven months these five cases have
come under the observation of a single individual and were,
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.


^O M
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


Perc
alio
bod


the
troj


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.


May 27
From the soil to the intestinal tract of man would be a
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.


1




4200
OBSERVATIONS TO DETERMINE THE MOTILITY OF THE BACILLUS AEROGENES CAPSULATUS


UNDER ANAEROBIC CONDITIONS.


1010
By E. K. Dunham, M. D.




15.5820


Bouillon cultures of the bacillus were studied in flattened
capillary tubes from which the oxygen of the air had been
absorbed by means of pyrogallate of potassium. Although
these cultures were examined at intervals varying from 15
minutes to 24 hours, at no time could any evidence of motility
on the part of the bacilli be detected.


0.6064
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.


3.89
The capillary tubes were prepared by heating a piece of
glass tubing, about 8 inches long and with a bore measuring
about i of an inch, strongly in the middle, then bringing the
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
•' 28
drawn out to form a capillary tube. This was then broken
in the centre and the end immersed in the bouillon culture.




2


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).


3450




1012
Fto. I.




19.6822


Fig. <3.


0.5796




2.89
F,g.l.  


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.


" 29
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


3




2700
April, 1897.]


75


1013




21 3097
greater numbers than when the cultures were first introduced
into the tubes, showing that the conditions were favorable for
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




0.5953


view of them could be obtained. That this was not the case
is shown by the fact that in all the tubes the bacilli soon
subsided to the bottom, leaving the bouillon above them
free from bacilli. If the tube was turned a little about its
long axis and kept in that position for a time, the bacilli
settled towards the lower side of the tube.


2.79
These observations appear to demonstrate that this bacillus
does not possess the power of locomotion, even under anaerobic
conditions.  




" 30


MULTIPLE TUBERCULOUS ULCERS OF THE STOMACH, WITH A REPORT OF THREE CASES.


4
By Alice Hamilton, M. D.


[From the Pathological Laboratory of the Johns Hopkins University and ITospital.]


3000




1012
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
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.


18.7950
The earliest of these is Litten's. It was a case of tuberculosis of lungs and peritoneum with no lesion in the intestines,
but with a single ulcer in the anterior wall of the stomach,
which on microscopic examination showed typical caseating
tubercles with giant cells. Talamon also describes tubercles
found in the walls of ulcers in the stomach of a child which
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




0.5853


were intact. The first one was a case of general miliary tuberculosis, and the stomach contained many miliary tubercles as
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.


3.11
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
" 31
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
5
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.


3400
J. Kiihl reports four cases from the Pathological Institute
at Kiel. He examined all for the tubercle bacillus, but failed
to demonstrate it in the two older specimens which had been
a long time in the museum. Nevertheless, the histological
appearances in the first of these cases point quite positively to
tuberculosis; in the second his description is too scanty and
obscure to place it above question. The third and fourth
instances, which were recent, are described as containing caseating nodules with tubercle bacilli. R. G. Hebb and G. Lava




1014


76


20.3490
[No. 73.  




0.5533


report each a case of single ulcer — at the lesser curvature and
at the pylorus respectively — and describe the microscopic findings as tubercles with caseation and giant cells. It is to be
regretted that these observers failed to make any search for
the bacillus tuberculosis. This omission is still more striking
in Letorey's otherwise exhaustive description of a case of diffuse ulceration near the pylorus. He states that tubercle
bacilli were found in the lungs and in the diseased part of the
femur, but seems not to have looked for them in the ulcers,
where he, however, found typical caseating nodules.


2.72
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.


June 1  
Case 1. Colored female, aged 30 years. The right lung contained near the apex a cavity about the size of a small walnut,
with smooth walls; the lung tissue adjacent was densely infiltrated and converted into a caseous mass. In the lower portions of
the upper lobe, beneath the anterior surface and near the middle
line, a small cavity existed with smooth walls which communicated freely with the bronchi. Its walls were caseous, and




6


adjacent to it were large caseous masses surrounded by oedematous and congested tissue, which often presented a gelatinous
appearance. The upper portion of the lower lobe was taken
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.


3350
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.


1012
The chief interest for our purpose centers in the ulcerations
 
existing in the stomach. Our studies embraced the examination of many of these, often in serial sections, both with
 
respect to their pathologic histology and to the presence of
20.2842
tubercle bacilli. Ulcers of various sizes were sectioned, stained
 
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


0.5803




2.86
April, 1897.]


77




Table XVIII.— Nitrogen Ingested (in Grams)


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
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.


Date.  
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
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.


Day of  
The histological and bacteriological examinations of these
observatlou.  
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




Ham.


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.


Bread.  
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
Hllk.  
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
wine.  
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




Total nitrogen.


78


May 27 & 28
[No. 73.
" 29
" 30
Maj 31 & June 1




1 42
3
4
5


previous lesion existed to enable it to get a foothold; and
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.


15.3515
In closing I wish to express my gratitude to Dr. Flexner
15.3515
for the advice and assistance most kindly given me in the
17.4240
course of this investigation.  
17.4240


Addendum.


5.8262
After the completion of the above report, a third case of
5.8262
gastric ulcer came under observation, which proved also to be of
5.8262
tubercular origin, and the specific character of which was far
5.8262
more easily determined than in the other two cases. The lesions
here conformed in every way most closely to the usual type of
tubercular ulcerations. The ulcers wei-e in this case but two
in number, of large size, and accompanied by the formation
of tubercles which were evident even to the naked eye.  


Vase 3. The patient was a colored girl of eleven years of
age. She entered the medical department of the Johns Hopkins Hospital (service of Dr. Osier) on June 16th. Tubercular
peritonitis was diagnosed, and she was transferred to the
surgical side, where the diagnosis was confirmed by an exploratory operation, the peritoneum being found covered with
miliary tubercles and the intestines matted together. The
patient recovered from the operation and lingered until
December, when death occurred. The autopsy was performed
by Dr. Livingood, from whose report the following extracts
have been taken.


3.9094
The body was much emaciated. Extending from below the
2.7956
costal margin to a point opposite the umbilicus was the scar of
2.7956
an imperfectly closed incision, the floor of which consisted of a
2.9198
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.


0.0350
0.0350
0.0350
0.0350




25.1220
The pleural cavity was partly obliterated by fibrous adhesions. The lung contained in its apex numerous small nodules,
24.0083
some of them caseous ; it was congested over the remainder of
26.0808
its extent, and small tubercles could be seen and felt scattered
26.2050
through it. The left pleural cavity was completely obliterated, and the lower lobe of the lung could not be freed from
the diaphragm, but had to be removed with it. Miliary
tubercles were scattered over both layers of the pleura, especially thickly along the lines of the ribs. A large area of
caseation was formed where the lung was in contact with the
diaphragm, and this process seemed to have extended directly
through the diaphragm to the spleen and liver beneath. The
upper lobe of the left lung showed more extensive tuberculosis than did the right lung, being filled with numerous
tubercles in all stages of caseation, but without definite cavity
formation. Small nodules were scattered through the lower
lobe, which was much congested and, at its lower extremity,
in the early stage of consolidation.  


The spleen was adherent to the diaphragm and to the parietal peritoneum. Its capsule was thickened and was the seat
of large caseous tubercles, but there were no distinct tubercles in the substance. One small caseous tubercle was found
in the right kidney. The mucous membrane of the uterus
was the seat of a number of yellow and gray miliary tubercles.
Both tubes were enlarged and adherent to the surrounding
structures. Some of the lymphatic glands in the broad
ligament were caseous, and the vaginal mucous membrane contained a single tubercle. The caj)sule of the liver was covered
with numeroiis minute tubercles, and others were found in the
substance of the organ. The pancreas was closely adherent to
the caseated retroperitoneal lymph glands, and its substance
showed large caseating areas.


The stomach was adherent to the transverse colon, the
pancreas, and to the mass of enlarged peripancreatic lymph
glands. The serous coat was covered with small and large
caseous tubercles. Midway between the pylorus and the
cardia on the posterior aspect of the lesser curvature, was a
large, irregularly oval, crater-like erosion, 3 cm. by 2 em. in
size. The edges were raised and somewhat undermined and
more deeply congested than the surrounding parts. The
floor was irregular, the deepest part of the crater measuring
8 mm., while the remainder was formed by projecting caseous
tubercles. Directly behind this ulcer was a caseous lymphatic
gland, so closely adherent to the stomach wall at this point
that it was impossible to tell whether or not it formed the
floor of the ulcer. A second smaller erosion was found above
this one, in the middle of the lesser curvature. Its edges
were slightly elevated, and in one place deeply undermined,
the floor being formed by the muscularis. Here and there
scattered through the mucous membrane were minute grayish
white and yellow points looking like, but not proven to be,
miliary tubercles. In the duodenum, just beyond the pyloric
orifice, was a large ulcer with caseous tubercles covering its
base; a similar but still lai-ger one was found in the cajcum,
and smaller ones scattered through the small intestines.


*Tea, rum and sugar not analyzed.  
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






Table
Apbil, 1897.]


79


XIX.— Nitrogen Balance (in Grams).




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.


ig
Bibliography.
Litten : Virchow's Archiv, 1876.
Talamon ; Progres Medical, 1879.
Brechemin: Bull. d. 1. Soc. Anat., May 1879.
Eppinger: Prager Med. Wochenschrift, 1881.






Barbacci : Lo Sperimentale, May 1890.


Coats : Glasgow Med. Journal, 1886.


Serafini : Annal. clin. del Osp. di Napoli, 1888.


NITROGEN ELIMIN
Mathieu and Remond : In Letorey's Thesis, Paris, 1875.


itroIm
Musser: Phila. Hosp. Reports, 1890, I.


Kiihl : Thesis, Kiel, 1889.


G. Hebb: Westminst. Hosp. Reports, 1888, III.


Lava: Gazz. Med. di Torino, 1893.


Letorey: These, Paris, 1895.


Hattute: Gaz. des Hop., 1874.


Lorey: Bull. d. 1. Soc. Anat., 1874.


Anger : In Marfan's Thesis, Paris, 1887.


Marfan : These, Paris, 1887.


Matthieu : Bull. d. 1. Soc. Anat., 1881.


Cazin : In Fernet's article. Bull, et Mem. d. 1. Soc. Med. des


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.


o«




Ji,
STUDIES ON TRICHINOSIS.


win




By T. R. Brown.






[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
discharged well.


During his stay in the hospital the blood was examined
daily. The number of leucocytes per cm. was determined and
a differential count was made of the various forms; frequent
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.]


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
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






Jat i
80


[No. 73.






O "
the eosinophiles and the Charcot-Leydea crystals, various
experiments were made with the blood which contained such
large quantities of eosinophiles, to see if the crystals could be
derived directly from these cells. In all cases, however, the
results were negative, seeming to show that the crystals are, at
least, not direct crystallization products from the eosinophiles,
but that something besides the presence of these cells is necessary for their formation.


{b) The uruie. The quantitative determinations of the uric
acid, urea and total nitrogen were carried on mainly in connection with the ideas of Horbaczewski, that the uric acid,
derived from the destruction of nuclein -holding material,
comes normally in large part from the leucocytes and is therefore increased in leucocytoses.


S^
Although the uric acid per 34 hours was determined on 23
different days, and on four of these the urea and total nitrogen
also, on no occasion did the total uric acid excretion, or the
relation between the nitrogen of the uric acid to that of the
urea or to the total nitrogen exceed the normal limits, showing that the views of Horbaczewski are not universally correct.
In this case, however, the leucocytosis differed somewhat from
the ordinary in that here the eosinophiles were the cells markedly increased ; in his cases the ordinary polymorphonuclear
neutrophiles.


(c) The mus'ie. The changes in the muscle were extensive.
There was a great proliferation of the muscle nuclei throughout the section ; about the fibres containing trichina? this proliferation was very marked, especially in the second specimen ;
not so extensive in the earlier specimen. In fact, in a few
places where the parasite had but just wandered into the
primitive bundle no change in the muscle substance nor any
proliferation of nuclei was visible. Most of the fibres containing the worm showed a conversion of the muscle substance
into a finely granular faintly-staining material containing
many large swollen nuclei, i. e. the proliferated muscle nuclei ;
and about many of the proliferated nuclei, both in the more
and in the less degenerated portions, distinct vacuoles could
be made out.


»i
Throughout the specimens the muscle showed various forms
of disintegration, in some places a longitudinal splitting of
the fibres into fibrillaj, in other places the formation of what
might be called muscle cells, the muscle nucleus taking about
itself some of the muscle substance and separating itself from
the fibre; while in still other places a peculiar transverse
splitting up of the muscle into disks, the nuclei here proliferating transversely instead of in the usual longitudinal method,
was noted.


TJrlne.  
Besides these changes there were seen in the first specimen many polymorphonuclear cells, some showing a finely
granular protoplasm which did not stain to any extent with
acid stains (the so-called neutrophiles), some distinct eosinophiles with large deeply-staining granules, and beside these,
cells which somewhat suggest transitional forms, showing in
the protoplasm of the cell body fine granules, but with a
distinct affinity for the acid stain ; and all these cells seemed
to be acting as phagocytes in the disintegrating muscle, being
often seen in little lakes or bays in the degenerating bits.  


In the second specimen there were decidedly fewer neutro


Faeces.


philes and many more eosinophiles tlian in the first. That in


gss «
both cases these were typical eosinophiles was shown by staining them in the different acid stains and in the Biondi-IIeideuhein triple stain.


At the same time with this greatly increased projiortiou of
eosinophiles in the extra-vascular leucocytes in the muscle,
Ihe Mood vessels in the inferfascicuhir connective tissue showul
the same proportion of neutrophiles and eosinophiles as icas
found in the blood count for that day.


May 27
In another specimen of muscle from a case of acute trichinosis which was obtained from the pathological museum, great
(juantities of eosinophiles were also found.


The study of the blood, showing the steady increase of the
eosinophiles at the expense of the neutrophiles, together with
the identical character of the nuclei of the two forms, would
tend to support the view held by some observers, that the
former variety of cells is derived by some transitional change
from the latter.


I
That such a change might take place in the muscle is suggested by the presence here of neutrophiles, eosinophiles, and
what may be regarded as transitional forms, in large quantities.
Particularly suggestive is the great disproportion between
neutrophiles and eosinophiles seen in the second muscle specimen. Here the eosinophiles were much increased, the neutrophiles correspondingly decreased, while the blood-vessels in
the interfascicular connective tissue showed but the same proportion of these forms as was to be made out in the specimens of the peripheral blood for the same days. It is further
noteworthy that the eosinojihiles increased in number soon
after the increase in severity of the muscle symptoms, and
shortly after the decrease of those symptoms, diminished
gradually, descending toward the normal point as the symptoms abated. Suggestive also is the presence of large numbers of eosinophiles in a specimen of muscle from another
case of acute trichinosis.


Dr. OsLBR. — This is the only case of trichinosis which has
been in the hospital, or it is safer to say the only case recognized, since we know that not infrequently the disease escapes
recognition or is mistaken for some other disorder. This is
the second case which I have seen clinically, while in the postmortem room I have found on eight or ten occasions the calcified cysts. Mr. Brown is to be congratulated on the very
thorough way in which he has followed this case.


57.700
Dr. Thayer. — The evidence offered by Mr. Brown in favor
of the origin of the eosinophilic cells by transition from the
so-called neutrophiles is very suggestive. The total number
of polymorphonuclear cells found in the circulating blood
was practically what one would expect in a leucocytosis of that
extent. And yet, examining this percentage which normally
should consist almost absolutely of so-called neutrophilic
leucocytes, we find the great majority represented by eosinophiles. The fact also that in the affected parts the bloodvessels contained the same relative proportion of eosinophiles
and neutrophiles as did the peripheral vessels, while the
tissues round about contained an enormously greater percentage of eosinophiles, is very interesting.  


That the so-called neutrophilic granules stain often with
acid coloring matters is well known. With good acid dyes


25.1222




15.5820
April, 1897.]


81


1.2634




16.8454+8.2763
these granules almost always take a slight stain, and by sonie
obseryei'S botli eosiuophiles and neutropbiles are classed as
acidophilic cells. They stain, however, much better in fluids
consisting of a mixture of acid and basic coloring matters. As
Mr. Brown has sharply pointed out, this acid staining of the
smaller granules was uot to be made out at all in the specimens
of blood and in the blood-vessels in the tissues, and the fact
that outside of the vessels in the affected parts numerous
apparent transitional forms between the non-granular polymorphonuclear wandering cells and the true eosinophiles
existed is very suggestive. That these cells were true eosiuophiles in the sense of Ehrlich, Mr. Brown has proven by
careful tests with a number of different acid coloring matters.  


The idea that the eosiuophiles represent a further change in
the cell which we know as the neutrophile is, as Mr. Brown
has said, not a uew one, but I am not aware that any argument
in favor of this view as forcible as that which he presents
has yet been published.


" 28
With regard to the actual blood condition — the increase of
the eosinophiles — no similar case exists in the literature; the
percentage of eosiuophiles in this instance is moi"e than
twice as large as has been reported in any other case.


Dr. Barker. — Mr. Brown has referred, in speaking of the
degeneration of the muscle, to a splitting up' of the muscle
fibre into transverse disks. I should like to ask him whether
or not he has been able to make out just where the splitting


2




.'>6.20(i
occurred. Though several histologists have emphasized the
fact, it does uot appear to be generally kuown that the splitting iu the muscle fibre may occur with some reagents at one
level, with other reagents at an entirely different level. Thus
in the formation of the so-called Bowman's disks through the
action of alcohol, the two layers Q (doubly refractive substance of Briicke) with the layer M (Hensen's line) in
between are always present in the disk. On the other hand,
ou treatment of muscle with certain acids (acetic, picric or
hydrochloric), the splitting occurs between the two layers
Q, each disk having then in its middle the layer Z (Krause's
transverse line or membrane). It would be interesting to
know, for the degeneration described, whether the splitting
occurred at either of these two levels or at still another level.


I gather from his paper that Mr. Browu favors the view
that the eosinophile granules represent the cyto-mikrosomas
of the cells in which they occui\ This view, recently si;pported
by Lovell Gulland, was previously urged by Martin Heidenhain, who found that the eosinojjhile granules stain black with
his iron-haamatoxylin staining method, and that it is often
possible to make out an arrangement of the granules radial to
the attraction sphere of the cell. Both these observations are
in favor of the cyto-mikrosomal nature of the granules.


25.1222
The occurrence of such an enormous number of eosinophiles
in the circulating blood is truly remarkable and makes the
case unique in the bibliography.  




19.6822


PROCEEDINGS OF SOCIETIES,


1.2634




20.9456+4.1766
THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.  


Meeting of December 7, 1896.


" 29
Dr. Thayer in the Chair.


On Certain Visceral Pathological Alterations, the Result of
Superficial Burns.— Mr. Bardebn.


3
Extensive superficial burus are followed by severe constitutional symptoms. The great pain felt at first is followed by a
benumbing of the senses and by sleepiness. At times there
may be delirium and cramps. The pulse becomes weak, the
respiration shallow and irregular. The temperature, after a
short rise, falls below the normal. There may be vomiting
and diarrhcea, and haamoglobin may appear in the urine.
Death within 48 hours usually follows a burn which has
involved two-thirds of the surface of the body. The burn
need not be of an extreme grade. Death has often followed
burns so superficial as to give rise merely to an erythema.


It is clear from this latter class of cases, at least, that alterations in the internal organs may follow the burning of the
skin which cannot be accounted for on the supposition that
they are directly caused by the heat. Thus arises the question as to the nature of the physiological relations between the
lesions produced in the skin and the resulting constitutional
effects. Many hypotheses have been advanced to answer this
question, some of which have been supported and others
destroyed by experimental work on animals.


55 400
Many of these hypotheses have been based upon the con




24.0083
ception of a loss of normal cutaneous activity. But experiment has shown quite conclusively that death after burns is
to be ascribed neither to the retention in the blood of products normally excreted through the skin, nor to heat radiation due to paralyzed blood-vessels in the latter structure.  


Again death has been referred to changes produced in the
blood itself directly acted upon by the high temperature. It is
known that erythrocytes are destroyed by a comparatively low
temperature (55° 0.). This has led to the supposition that
the general pathological effects are due to loss of functional
red blood corpuscles, or to irritation produced in the kidneys
and other internal organs by the products of their disintegration. But a more generally accepted view is that the blood is
so altered by the elevation of temperature as to give rise to
extensive thrombosis, death resulting from the disturbances of
circulation.


21.3097
Another view has been advanced more recently. Kijanitzen, who extracted from the blood of dogs experimentally
burned, substances similar to Brieger's ptomains, and Eeiss,
who found toxic substances in the urine of persons accidentally burned, believe that they have brought forward evidence
in support of the idea that the blood in severely burned
animals is rendered toxic.  


During the past year five small children were brought to the
Johns Hopkins Hospital so severely burned that death in each
case followed within a very few hours of the accident. At the
suggestion of Dr. Flexner I took this opportunity of studying


1.2634




22.5731+1.7352
82


[No. 73.


" 30




4
the histological alterations found in the tissues of the body
after burns. A careful autopsy was made in each case by Dr.
Flexner, and parts of the various organs were preserved and
prepared for microscopic examination.


The lesions in all five cases were strikingly similar. Of the
gross lesions the most notable were cloudy swelling of the
liver and kidney, acute swelling of the spleen, and swelling and
congestion of the lymphatic glands and other lymphatic tissue.


56.2011
Microscopically, the most interesting lesions noted were
parenchymatous degeneration of the kidneys and liver, focal
areas of necrosis in the liver, and pronounced focal necrosis
in the lymphatic tissue.  


The lymphatic tissue was affected throughout the body.
The Malpighian corpuscles of the spleen, the tonsils, gastric
lymphatic follicles, enteric solitary and agminated follicles
and the lymphatic glands all showed essentially the same
changes.


26.0808 1 18.79.50
The lymphatic glands were much swollen and at times congested. The earliest changes were in the follicles and consisted
of an ojdematous swelling. This was more marked towards
the centre of the follicle, in an area corresponding to the
germinal centre. In areas of less advanced alteration the
lymphocytes were merely less closely packed together than is
usual. But in the areas of more marked change, the lymphocytes were swollen and their nuclei fragmented. In these
cases the follicle presented a remarkable appearance. It was
not only greatly swollen, but at the edges a rim of closely
packed lymphocytes existed, while at the centre swollen and
distorted lymph cells, bits of protoplasm and fragments of
nuclei were seen scattered about, some lying free, others enclosed
in large flat endothelioid cells.  


The lymph cords as well as the follicles were swollen, while
the lymph sinuses seemed less distinctly marked off than
usual from the reticulum in which the lymphocytes of the
cords lie imbedded. Here and there throughout the gland
groups of degenerating cells might be seen, but the areas of
distinct focal degeneration were confined as described above,
to the follicles.


1.2634
Calvert has shown that the terminal artery breaks up in the
centre of the follicle into capillaries which radiate towards
the periphery of the follicle. It seems possible that the lesions
focalized just at this region may in some way hold special
relation to the circulation of tlie blood. For if the blood in
these cases contains toxic materials, it is conceivable that it
is just at the centre of the follicle that the poisonous plasma
acts with greatest intensity on the lymph cells.  


In the lymphatic follicles of the tonsils and stomach and in
the Malpighian bodies of the spleen focal degeneration essentially similar to that of the follicles of the lymphatic glands
occurs. In the intestines the greatly swollen lymphatic follicles, solitary and agminated, showed extensive focal areas of
degeneration.


20.0584+5.9214
In these areas of degeneration in the lymphatic tissue we
find appearances essentially similar to those seen after the
injection into the body of various bacterial and other toxalbuminous substances. Indeed, the lymphatic glands from
our cases of skin-burn might readily be mistaken for the
lymphatic glands of children dead of diphtheria. The




" 31


lesions in the other organs are also essentially similar to those
found in the bodies of persons dead from the acute infectious
diseases. It seems, therefore, justifiable to consider that one
of the main causes of death after burns is to be sought in a
toxaemia caused by alterations in the blood and tissues, the
direct effect of the elevation of temperature; a view which is
further strengthened by the clinical evidences and the experimental work of Kijanitzen and others.


5




56.2(0
NOTES ON NEW BOOKS.  


The American Year-Book of Medicine and Surgery : being a yearly
digest of scientific progress and authoritative opinion in all
branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign
authors and investigators. Collected and arranged, with critical
editorial comments, by J. M. Baldy, M, D., and twenty-six
other physicians, under the general editorial charge of George
M. Gould, M. D. [Philadelphia, 1897 : W. B. Saunders, 925 Walnut Street.)


26.2050 j 21.1.3490
This year-book amply justifies the high expectations which were
excited by the excellent character of the similar volume published
last year. It is an encyclopedic collection of new medical literature
gathered from all lands and every field of medical knowledge. It
is not a mere aggregation, but a discriminating digest of the latest
knowledge in medicine, with frank opinions and critical comments
by painstaking and competent men. The special comments of the
editors as distinguished from the authors are enclosed in brackets,
to facilitate reference to them.  


The completeness of the department of medicine, which has had
the editorial supervision of Pepper and Stengel, is shown by the
fact that it covers more than 180 pages. Among other interesting
matter the sections on the Schott method, typhoid fever, malaria
and myxedema are probably of the most interest. In view of the
extravagant claims for the different methods of aborting typhoid
fever, it is gratifying to notice that the authors ask that all cases
treated by these methods be more carefully studied and the symptoms more minutely described.


1.2634
Under the head of surgery, which occupies 248 pages of the volume, Keen and DaCosta give a valuable resume of the most recent
work in ansesthetics, with sensible comments upon the dogmatic
assertions of many experimenters. It is refreshing to read the
following: " Wunderlich, from a statistical study, concluded that
albuminuria was more apt to be induced by chloroform than ether.
Beck from a statistical study concluded that albuminuria was most
apt to be caused by ether. We are thus confronted by carefully
compiled reports which are diametrically opposed and absolutely
contradictory. The humble surgeon who venerates statistics too
much to use them is lost in uncertainty. We are told that figures
cannot lie, and yet only one of these statements can be true. Which
is the truth we cannot yet decide, as we know of no birthmark to
prove identity."


The operative treatment of perforation in enteric fever would
seem to be presented in too gloomy colors, in the light of Finney's
recent statistics.


21.6124+4.5826
The article on diseases of the gall-bladder is quite full and satisfactory. The same may be said of the careful and conservative
article on the use of the x rays.  


Obstetrics, under the editorship of Hirst and Borland, occupies
about 100 pages, and presents many topics of special interest to the
general reader, notably the sections on the pathology of pregnancy,
abortion and extra-uterine pregnancy.


June 1
The section on gynecology, by Baldy and Borland, occupies
upwards of 200 pages, and touches upon a variety of interesting






Apeil, 1897.]


83


50.200




26.2050 i 20.2842
matter. The objection presented to Clark's radical operation for
the relief of uterine cancer, that but few patients can endure the
shock of the prolonged etherization, seems hardly tenable in the
light of actual practice. The chapter on nervous and mental diseases, by Church and Patrick, is thoroughly well worked out, and
presents a good review of the work of the past year. The section
on materia medica is an excellent feature of the book. All things
considered, the book is well arranged, admirably edited and well
printed. Every physician who does not have leisure to inform himself on the latest advances in medicine and surgery from original
sources, should procure and carefully read the volume.  


1  
Architecture of the Brain. By Wm. Fuller, M. D., Grand Rapids,
Michigan. 1896. Pages 1-183, with many illustrations.
In this volume are described and pictured the general gross relations of the brain as seen (1) from the external surface, (2) on dissection, and (3) in a series of frontal sections. The author has had
a large experience in dissection of the central nervous system and
in the preparation of castings in plaster of the dissections which he
has made. No person except one who has busied himself in work
of this kind can easily estimate the amount of labor which has preceded the publication of the book.


After a description of the membranes, thecerebro-spinal axis as a
whole is described. The cerebrum is then taken up and the method
of dissecting it outlined. A discussion of the structure of the cerebellum, of the pons varolii, of the medulla oblongata and spinal
cord follows. Throughoutthe book the mainstressis laid upon the
gross morphology, but there are brief chapters concerning the nerve
tracts of the cerebro-spinal axis and the central origin and relations
of the cranial nerves. On pages 130-133 there is a brief discussion
of topographical cerebral localization. L. F. B.


1.2634
Annual Report of the Supervising Surgeon-General of the Marine
Hospital Service of the United States for 1893. Vols. I and II.
(Washington: Oovernment Printing Office, 1894-1895.)
These volumes present a very complete and satisfactory account
of the operations of the Marine Hospital Service for 1893. The most
valuable papers are a carefully prepared account, by Surgeon Stoner
of Baltimore, of the origin and development of this Service, which
should be read by all who desire to familiarize themselves with its
history, and the " Report of the Commission to Investigate the Cholera Epidemic," prepared by Dr. Walter Kempster and Surgeon Fairfax Irwin, who made an extensive trip in Europe to procure data for
it. It is to be regretted that the Commission, while entering into
very great detail as to its operations, does not formulate and publish its conclusions in connected form. Scattered throughout the
report are many valuable suggestions touching the prevention of
infectious diseases and the transmission of contagion, which can
only be found by reading many unimportant details. These should
have been gathered in an accessible form, so that they might be
easily read.  


Medical and Surgical Report of the Presbyterian Hospital in the
City of New York. Vol. I., January, 1896. By Andrew J.
McCosH, M. D., and Walter B. James, M. D. (The Knickerbocker Press, New York.)


21.5476+4.5574
This report is the first of a series. It is carefully edited and
well illustrated. Many of the papers are carefully written and of
great interest to the general profession. The pathological reports
are meagre and the protocols published are in most instances brief
abstracts. Several of the papers have appeared elsewhere. One of
them, that of Dr. Northrop, on Gonorrhoeal Arthritis, is more
popular than scientific, and portions of it read as it the author were
thinking aloud. The results of thinking rather than mental operations would be preferable. Taken as a whole, the surgical papers
seem to be of the greater value. The volume, however, is worthy
of the institution from which it issues and the high character of its
editors. It is to be hoped that it will have an annual successor.  






Eelation of Neusser's granules in the leucocytes : The
BOOKS RECEIVED.  
granules are altogether extremely numerous, particularly in
the small mononuclears. There was no appreciable variation
in the granules from day to day. In this case, with the large


Transactions of the American Gynecological Society. Vol. 21. 1890.


8vo. 490 pages. Wm. J. Dornan, Printer, Philadelphia.
Prize Essays on Leprosy. By Newman, Ehlers and Impey. 1895.


number of granules, there was found to be an elimination of  
8vo. 227 pages. New Sydenham Society, London.
a large quantity of alloxuric body nitrogen.  
Practical Notes on Urinary Analysis. By William B. Canfield,
A. M., M. D. Second edition. 1896. 12mo. 106 pages. G. S.
Davis, Detroit, Mich.
A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In photolithochromes from models in the Museum of the Saint-Louis
Hospital, Paris. With explanatory woodcuts and text. By E.
Besnier, A. Fournier, etc. Edited and annotated by J. J. Pringle,
M. B., F.R.C. P. Fol. Parts IV and V. 1896. W.B.Saunders,
Philadelphia.
Lectures on Pharmacology for Practitioners and Students. By Dr. C.
Binz. Translated from the second German edition by Arthur C.
Latham, M. A., M. B. Oxon., M. A. Cantab. Vol. 1. 1895. 8vo.
389 pages. The New Sydenham Society, London.
Autoscopy of the Larynx and the Trachea. (Direct Examination without
Mirror.) By Alfred Kirstein, M. D. Authorized translation
(altered, enlarged and revised by the author) by Max Thorner,
A. M., M. D. 1897. 12mo. 68 pages. The F. A. Davis Co.,
Philadelphia.
The Practice of Medicine. By James Tyson, M. D. 1896. 8vo.  


Observation VIII. — The patient was a woman 45 years of  
1184 pages. P. Blackiston, Son & Co., Philadelphia.
age, with cirrhosis of the liver. Since 1895 she had complained
Anomalies and Curiosities of Medicine. By George M. Gould, A. M.,
of gastric symptoms ; pain in the epigastrium. Had emaciated
M. D., and Walter L. Pyle, A. M., M. D. 1897. 4to. 968 pages.
considerably. Had been jaundiced. Thegastric juice showed
W. B. Saunders, Phila.
a very marked acidity ; free and combined HCl 0.35 to 0.41
A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In Photo-Lithochromes from Models in the Museum of the Saint Louis
per cent, and free HCl alone 0.22 to 0.28 per cent. The liver
Hospital, Paris, with explanatory woodcuts and text. By E.
was enlarged, hard and nodular. Spleen was not much
Besnier et al. Edited by J. J. Pringle, M. B., F. R. C. P. Part
enlarged, but was hard and could be palpated at the costal
VI. 1896. W. B Saunders, Philadelphia.
margin. Body weight averaged about 60 kilos. Vomiting
A Treatise on Cholelithiasis. By B. Naunyn, M. D. Translated by
was frequent and patient was moderately ansemic.  
Archibald E. Garrod, M. A., M. D., F. R. C. P. 8vo. 197 pages.
1896. The New Sydenham Society, London.  
Principles or Guides for a Better Selection or Classification of Consumptives Amenable to High Altitude Treatment and to the Selection of  
Patients who may be more Successfully Treated in the Environment to
which they were Accustomed Previous to their Illness. By A. Edgar
Tussey, M. D. 1896. 8vo, 144 pages. P. Blakiston, Son & Co.,
Philadelphia.  
Twentieth Century Practice. An international encyclopaedia of mod
ern medical science, by leading authorities of Europe and America
Edited by Thomas L. Stedman, M. D. Vol. X. 1897. 859 pages
8vo. Wm. Wood & Co., New York.
Transactions of the College of Physicans of Philadelphia. Third SeriesVol. XVIII. 1896. 8vo. 263 pages. Printed for the College
Philadelphia.
Injuries and Diseases of the Ear. Being reprints of papers on otol
ogy. By Macleod Yearsley, F. R. C. S. 12mo. 1897. 40 pages
The Rebman Publishing Co., Ltd., London.  
The American Tear-Book of Medicine and Surgery. Being a yearly
digest of scientific progress and authoritative opinion in all
branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign
authors and investigators. Collected and arranged, with critical
editorial comments, by J. M. Baldy, '^l.D.,ei al. Under the general editorial charge of George M. Gould, M. D. Profusely illustrated. 4to. 1897. 1257 pages. W. B. Saunders, Philadelphia.  
Inebriety. Its Source, Prevention and Cure. By Charles Follen Palmer. 12mo. 1897. 109 pages. Fleming H. Revell Co., New York.
The Medical Annual and Practitioner's Index. A work of reference
for medical practitioners. Fifteenth year. 1897. 12mo. 851
pages. John Wright & Co., Bristol.  
Lectures on Angina Pectoris and Allied Stales. By William Osier,
M.D. 1897. 8vo. 160 pages. D. Appleton & Co., New York.  


The daily diet was as follows : Bread, 300 grams ; milk,
500 ; wine, 500 ; tea (infusion from 6 grams), 250 grams ; rum,
30 grams; sugar (6 pieces), 30 grams; Eohitsch water, i
bottle.


These food stuffs yielded about 1752 calories (28 calories
per kilo body weight), which were made up as follows:


84


[No. 73.


Albumin
Pat


Carbohydrates
Alcohol


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.




283.31 calories.
233.43
927.33
308.00


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


Report in Patliolopry
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;


Total 1752.07
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the


Table XX.— Urine.  
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D,
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis


(Atrophy). By Henrt J. Berkley, M. D.
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.


Mall, M. D.


Date.  
Report in Dermatolog-y.  
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By


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


Protozoa, and the Blastomyces found in the preceding Cases, with the so-called


Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum


3
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By


a 2
T. C. Gilchrist, M. D.


.bo
Report in Pathology.  
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration


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






a a o!
Volume II. 570 pages, with 28 plates and figures.


Sis
Report in Medicine.


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


SoSS
Gallstones. By William Osler, M. D.
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.
On Pyrodin. By H. A. Lafleur, M. D.
Cases of Post-febrile Insanity. By William Osler, M. D.
Acute Tuberculosis in an Infant of Four Months. By Harry TotJLMiN, M. D.
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.


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


Percentage of
Report in Gynecolog-yThe Gynecological Operating Room. By Howard A. Kelly, M. D.
alloxuric
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard
body— N of
the total nitrogen.  


A. Kelly, M. D.. and Hunter Robb, M. D.
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards mth
out Operation ; Composite Temperature and Pulse Charts of Forty Cases of


June 24
Abdominal Section. By Howard A. Kelly, M. D.
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,


M. D.
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;


1
Ovarian Tumor; General Gynecological Operations from October 15, 1889, to


March 4, 1890. By Howard A. Kelly, M. D.
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howard


1350
A. Kellt, M. D., and Albert A. Ghrisrey, 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, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment


1023
of Ureteral Stricture; Record of Deaths following Gynecological Operations. Bv


HowARD A. Kellt, M. D.


12.4504
Report in Surgery, I.  
The Treatment of Wounds with Especial Reference to the Value of the Blo.d C!ol


in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in Nenrology, I.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.
Haematomyelia. By August Hoch, M. D.
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. liv


0.4831
Henry M. Thomas, M. D.  


Report tn Pattiologry, I.
Amoebic Dysentery. By William T. Councilman, M. D., and Henhi A. Lafleur, M. \\


3.87




" 25
Volume III. 766 pages, with 69 plates and figures.


Report in Patliology.


2
Papillomatous Tumors of the Ovary. By J. Whitridge Williams, M. D.


Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.
Report in Patliolosry.


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


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


1022
A Case of Chronic Nephritis in a Cow. By W. T. Councilman. M. D.


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


10.7800
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  


Report in Gyneeolog-y.


0.4498
The Gynecological Operating Room; An External Direct Method of Measuring the
Conjugata Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofiexed Uterus. By Howard A.
Kelly, M. D.  


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


4.17
Intestinal Worms as a Complication in Abdominal Sui^ery. By A. L. Stavely, M. D.  




" 26


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


3
The Employment of an Artificial Retroposition of the Uterus in covering Extensive
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.


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


550
Traumatic Atresia of the Vagina with Hamatokolpos and Hamatomctra. By Howard
A. Kelly, M. D.


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


1027
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gynecological. Conditions. By Hunter Robb, M. D.


Resuscitation in Chloroform Asphyxia. By Howard A. Kellt, M. D.


8.1428
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.  


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


0.4591
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
May 4, 1892.  




5.63


Volume IV. 504 pages, 33 charts and illustrations.


" 27
Report on Typhoid Fever.


By WiLLLAM Osler, M. D., with additional papers by W. S. Thayer, M. D., and J.
Uewetson, M. D.


4
Report in Neurolog-y*


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


850
Report in Snrg-ery,
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to
January, 1894. By W. S. Halsted, M. D.


Report in Gynecologr.
Hydrosalpinx, with a report of twenty-spven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.
Report in Patliology.
Deciduoma Malignum. By J. Whitridge Willlams, M. D.


1025




11.5133
Volume V. 480 pages, with 32 charts and illustrations.  


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


0.5087
Studies in Typliold Fever.
By WiLUAM Osler, M. D., with additional papers by G. Bltjmer, M. D., Simon
Flexner, M. D., Walter Reed, M. D., and H. C. Parscss, M. D.  




4.32


Volume VI. About 500 pages, many illustrations.


" 28
Report in Nenrolofo**


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


5
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the
Chromate of Silver Methods; Part 1. — Alcohol Poisoning. — Experimental Lesions
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part II. — Senrni
Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on
the Cortical Nerve Cell; Part III. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by O.rwnic
Ricin Poisoning; Part IV. — Hydrophobic Toxaemia. — Lesions of the Cortical
Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Ner\*e Cells from the Effects of
Alcohol and Ricin Intoxication; Nen-e Fibre Terminal .apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.


Report in Patliologry.


1050
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.


Cullen, M. B.
Pregnancy in a Rudimentary LTtcrine Horn. Rupture, Death, Probable Migration of


1020
Ovum and Spermatozoa. By Thomas S. Cdllen, M. B., and G. L. Wilkins, M, D.
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. C'ullen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By


William D. Booker, M. D.
The Pathology of Toxalburain Intoxications. By Simon Flexner, M. D.
Tfie price of a set bound in cloth [Vots. I-TI] of the Hospital Itejwrts is


11.0618
$30.00. Vols. I, II ami III arc not sold scjiaratehj. The price of


Vols, ir, V and VI is $5.00 each.


5375




4.85
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID 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 Rcepord,


M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,


" 29
$3.00.
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thaykr, M. D., and J.


Hewetsos, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.


6
By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ?2.T5.
STUDIES IN TYPHOID FEVER. By William Osler. M. D., and others. Extracted


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481


1500
pages. Price, bound in paper, $3.00.
Subscriptions for the above publications may be sent to


The Johns Hopkins Press, Baltihorb, Md.


1018




11.1938
The Johns Hopkins Hospital BvUctins are isstied mwiihly. They arc printed lij THE FRIEDENWALD CO., Baltimore. Single copies
may be procured from Messrs. CURBING rf CO. and the BALTIMORE NEWS COMPAXT, Baltimore. Subscriptions, $1.00 a year, tnay be
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sin<jU- copies will be sent by mml for fifteen cents each.  




0.4594


BULLETIN


4.10




OF






Table XXI. — Nitrogen Ingested (in
THE JOHNS HOPKINS HOSPITAL.  




Grams).*


Vol. Vlll.-No. 74.]






Date.  
BALTIMORE. MAY, 1897.  




Day of observation.




Ham.




Bread.


GO]srT:E3srTS.


Milk.




wine.  
PAGE.  


The Association between the so-called Perinuclear Basophilic
Granules and the Elimination of the Alloxuric Bodies in the
Urine. By T. B. Fittcher, M. B., 85


Total nitrogen.  
Encysted Dropsy of the Peritoneum secondary to Utero-tubal
Tuberculosis and associated with Tubercular Pleurisy, Generalized Tuberculosis and Pyococcal Infection. By ClariBEL Cone, :M. D., 91


A Visit to Bad Nauheim, with the Purpose of Investigating the
"Schott Treatment" for Chronic Heart Disease. By C. N. B.
Camac, M. D., - - - 101


June 24
A Case of Porokeratosis (Mibelli) or Hyperkeratosis Excen
" 25
" 26427
"28429




1
trica (Respighi) with a remarkable Family History. By T.


2
Caspar Gilchrist, M. B.C. S., L.S. A.,
3&4
546


A Rapid Method of making Permanent Specimens from Frozen


8.8242
Sections by the Use of Formalin. By Thomas S. Cullen,
6.3491
48425
4.8425


M.B.,
Proceedings of Societies :


5.6056
Hospital Medical Society,
5.6056
5.6056
5.6056


Typhoid Perforation treated by Surgical Operation [Dr.
Finney].


2.7037
Notes on New Books,
2.70J7
2.6C95
2.8875


Books Received, - ..


0.0350
0.0350
0.0350
0.0350


107


17.1685
14.6934
13.0926
13.3706




108


*The variation in the nitrogen in the ham was due to the fact
that the patient could not continue to take the full quantity (220
grams) that she was first given.




113
113






Table XXII.—
THE ASSOCIATION BETWEEN THE SO-CALLED PERINUCLEAR BASOPHILIC GRANULES AND
THE ELIMINATION OF THE ALLOXURIC BODIES IN THE URINE.  


(From the Medical GUnic of Prof. Eravs in Oraz.)
By T. B. Futcher, M. B., Instructor in Medicine, Johns Hopkins University and Asst. Res. Physician, Johns Hopkins Hospital.


Nitrogen Balance (in Grams).




In 1894 Neusser described a peculiar granulation in the
leucocytes of patients suffering from a uratic diathesis. This
term was given a wide meaning, and under it he included gout,
uratic lithiasis, as well as the various forms of "irregular
gout," as muscular rheumatism, nervous asthma, skin affections, gastro-intestinal derangements, diabetes, leuksemia, neuralgia aud neurasthenia. These granules were brought out
by staining freshly dried specimens of the blood with a modified Ehrlich's triacid mixture in which the basic ingredient
was relatively increased. They are basic staining granules,
and with this mixture appear as greenish black or dense black
droplets over and about the nuclei of the leucocytes. They
vary considerably in size, the smallest being about the size of
the neutrophilic granules, and the largest considerably larger
than the eosinophilic granules. Often they have a glistening
or refractile appearance. They are always in immediate contact with the nucleus, never being present amongst the ordinary granules of the leucocytes. They give one the idea that
they constitute some substance which has been squeezed out
of the nucleus. Neusser found them most abundant in the
mononuclear leucocytes, in which they often form a complete






ring about the nucleus, but stated that they were also present
in the polynuelear leucocytes and eosinophiles. He believed
that they were of the nature of a nucleo-albumin in composition, and saw in their i^resence a sign for an increased uric
acid production in the organism. This assumption was based
on the analysis of the urine of 100 patients, in whom, along
with the already described blood condition, an elimination of
from 0.8 to 1.5 grams of uric acid, and a uric acid coefficient
within the limits of 1 : 30 to 1 : 20 (1 : 50 being normal) were
found. It is important to note that the patients on whom
these observations were made were not brought under a condition of nitrogenous equilibrium.


Ǥ
The clinical interest of these basojihilic granules would be
 
very great if it could be proven that in an extended series of
 
cases they were associated only with a uric acid diathesis and
 
were entirely absent in other affections. If such could be
 
proven we would then have a ready clinical means of differentiating symptoms due to a uratic diathesis from those arising
from some other cause. Neusser himself states that they are
also to be found in a certain percentage of cases of tuberculosis,
and believes them to be of prognostic value. He claims to have




NITKOGEN ELIMIN


i .
86
US .








found that cases showing the granules run a more favorable
course, and that the lung infiltration is more likely to undergo
fibroid change than in cases where the granules are absent.


Kolisch, a pujiil of Neusser's, has advanced the theory that a
uric acid diathesis is not due to an anomaly of in the formation of
or in the relative solubility of uric acid, but in the increased production of the alloxuric bodies (uric acid -|- xanthin bases), out
of the products of nuclein destruction. He found that in cases
where the perinuclear granules were abundant that there was
a definite increase in the quantity of alloxuric bodies eliminated. The increase was due to a marked increase of the
xanthin bases, the uric acid being relatively diminished ; and it
was to the presence of these bases circulating in the blood that
the symptoms of a uratic diathesis were due, and not to any
anomaly in the formation or excretion of uric acid. Neusser
and Kolisch, although they both believe that the basophilic
granules bear an intimate association with the causation of the
uratic diathesis, differ in their views as to which ingredient of
the urine is increased by their presence. Neusser found an
increased elimination of uric acid, while Kolisch found that
the uric acid was relatively diminished, and the xanthin bases
markedly increased, resulting in a total increase in the amount
of the alloxuric bodies eliminated.


With the exception of the above difference, Neusser and
Kolisch agree that the occurrence of the perinuclear basophilic
granules indicates an increase in the nuclein constituents
of the blood. Direct analyses of the blood for the amount
of nuclein contained in it were naturally not made; and
pure color reactions, even from a qualitative standpoint, are
unreliable, as shown by L. Heine. If one accept without
further questioning Neusser's view that the perinuclear granulation is a morfihological criterium for an over-production
of nuclein derivatives from the cell nuclei, it is not easily
explainable why an increase in the quantity of the alloxuric bodies eliminated in the urine should follow. If one considers these granules identical with the pyrenogenic granules
of Lowit found in the leucocytes of the river crab (in the arthropoda the uric acid is not formed from the nuclein materials)
and in certain normal leucocytes of the bone-marrow, then
they fall under the general heading of karyorhexis or breaking up of the nucleus, and would more likely indicate a chromatolytic degeneration of the leucocytes. Prof. Kraus was
able to demonstrate similar granules in the liver cells when
portions of the liver substance were removed from the body
while still warm and kept in a moist chamber at 40° C. At a
definite stage in the breaking down of the nuclei he found
granules in the protoplasm of the liver cells resembling and
staining similarly to those found in the leucocytes by Neusser.
If such a condition takes place under any circumstances, either
physiological or pathological, in the living person, an increase
in the alloxuric bodies eliminated might be expected.


In studying the subject of Neusser's granules I have endeavored to determine whether there is any regular coincidence
between the presence of these granules and the elimination of
the alloxuric bodies, and further, whether the granules are
found only in cases showing the symptoms of a uratic diathesis.


s
Doubt as to this intimate association arose in my own mind
while examining the blood of patients for the basophilic




as


granules, at first without studying their effect on metabolism.
In a very large number of cases examined, both in healthy and
diseased persons, I have never failed to find the granules
present. Four of these cases were cases of true gout with
typical joint affections and well defined tophi in the ears. In
two of these cases the granules were very abundant, but not
more so in the mononuclear than in the polymorphonuclear
leucocytes. In the remaining two cases they were on the
whole not very abundant, and the polymorphonuclears showed
the granules more numerous than did the mononuclears.
Further, I was able to convince myself, both in Baltimore and
in Graz, that the granules were not more marked in the blood
of patients suffering from the so-called uratic diathesis than
in other diseases, or even in certain apparently healthy individuals. The fact that the granules are found in other
diseases than in uratic diathesis, and also in healthy persons,
lessens their clinical interest. Neusser believed their presence in tuberculosis was a favorable sign. In this disease I
have observed cases with abundant granules and others with
few granules without noticing any difference in its subsequent
course. The granules vary in richness in the leucocytes from
day to day in the same individual, notwithstanding his living
under the same conditions of nourishment, etc. This fact
seems to diminish the significance of the granules. It seems
more common for variations of this kind to occur than for the
granules to remain constant from day to day. No method
seemed practicable for making an accurate count of these granules, and in the following cases reported it seemed sufficient
for all practical purjioses to stain the specimens of dried
blood and to compare from day to day the amount of granulation present in the different forms of leucocytes.


ATED.  
The following cases, in which the basophilic granules and
 
their effect on metabolism were studied, were undertaken
especially to ascertain whether the amount of granulation
present really influenced the quantity of the alloxuric bodies
eliminated in the urine.  


8  
In all, 8 cases were carefully studied. Blood specimens were
stained each day with Neusser's staining mixture, and the same
technique followed from day to day. The patients were as nearly
as possible brought under the conditions of nitrogenous equilibrium before the observations on the urine were concluded.
Each case was followed for a period of 5 to 6 days, and during this time the same amount of food was taken each day,
and the body weight from day to da\' remained practically
constant. The total amount of nitrogen ingested in the food
and eliminated in the urine and fteces was estimated daily.
In all the cases the alloxuric bodies were estimated, and in two
cases the uric acid as well. The nitrogen was detei-mined
according to the method of Kjeldahl, the uric acid according to Ludwig's, and the alloxuric bodies according to the
Kriiger-Wulf* methods.


In order to assist in the understanding of the following
tables I give what is considered the normal amount of nitrogen in grams contained in the alloxuric bodies for the 24
hours, as found by various observers who have made determinations up to the present date.


' ®*




•Zeit. flir physiol. Chemie, Bd. XX.






May, 1897.]


£ Si
87






For the 24 hours :


Kolisch gives 0.260 gram.


Weiutraud (1) 0.344-0.360


is^
(2) 0.433-0.534
Richter 0.380


Magnus-Levy 0.506


§
Richter 0.387


I myself found in healthy persons (1) 0.499


(2) 0.551


Judging from these analyses it may be considered that
values above 0.4 gram are physiologically high, while those
above 0.5 gram may be regarded as pathological.


a"
Case 1. — Dr. K., aged 32 years, weight 79.5 kilograms, with
a well-marked tendency to a gradually increasing corpulence.
Not inclined to undertake great muscular exertion, but in
every respect perfectly healthy. After nitrogenous equilibrium
had been established, 1.5 liters of Carlsbad water (Miihlbrunn)
were drank daily for a period of 8 days.


The daily diet was as follows: Ham, 150 grams; roast
beef, 100 grams ; milk, 500 grams ; 6 breakfast rolls ; butter,
65 grams; rice, 60 grams; sugar, 3 pieces; black coffee (infusion), 100 grams ; sherry, 100 grams ; soda water, 2 bottles.


S^
The above diet represented about 1968 calories (about 25
calories per kilogram body weight), which were made up as
follows :




a


Urine.
Albumin
Pat


Carbohydrates
Alcohol


FtBces.




oS2
Total




a


362.17 calories.
837.73
646.35
122.15


June 24
1968.40




1


Table 1. — The Urine.


60.700




17.1685
Date.  




12.4503
Q




1.3508




13.8011
a


U ID


+3.3674


at


" 25
'"C in




2
if




60.400




14.6934
July 6
" 7
" 8
" 9
" 10
" 11
" 12
" 13*
" 14  
" 15
" 16
" 17
" 18
" 19
" 20




10.7810
1


3
4


1.3508
5
()
7
8
(1  


10
11
12
13
14
15


12.1308


995
1240
1630
1200
1080
1160
1630
2270


+2.5626
2«no


2345
27C0
3120
3045
2920
2810


" 26


14.7638
12.8898
14.7759
14.0700
15.5547
15.0666
15.4947
15.7682
14.1159
15.3560
13.9482
15.5719
12.9062
14.9825
14.. 3732


3


0.6042
0.4.318
0.5262
0.4169
0.4430
0.5602
0.5058
0.4149
0.4459
0.4042
0.3780
0.3849
0.3810
0.3244
0.4025


59.600


0.2550
0.2613


13.0926


4.16
3.35
3.56
2.97
2.84
3.71
3.26
2.63
3.16
2.63
2.71
2.47
2.95
2.16
2.80


8.1427




1.3508
From 13 to 20 Carlsbad water was drunk.  




9 4935


Table II. — Nitrogen Balance (N in Grams).


+3.5991




" 27
Date.




4
0%
P




59.900
41




13.0926
£ Si




11.5132
NITROGEN ELIMINATED.  




1.3508
i ,


a — "3
|a|


12.86401+0.2286


S


" 28


Brlue.


5


FcBoes.


59.700


a


13.3706


July 10
" 11
" 12


11.0617
" 19
" 20




1.3508
5
6


7
14
15


12.41251+0.9580


79.300
79.800
79.900
79.050
79.050


" 29


16. 2347
15.9769


6
18.6598




59.500
15.5547
15.0666
15.4947
14.9825
14.3732




13.3706
1.1832
1.1832


'3.3325


11.1937


16!2498
16 6779


1 .3-^08
17! 7057




12.5445|+0.8261
— o'.7oio


+b'.954i




Eelation of Neusser's granules in the leucocytes: The
granules were very numerous, especially in the mononuclears.


Condition of the leucocytes with reference to Neusser's
granules : During the jjeriod in which no Carlsbad water was
taken the granules were present only in very moderate numbers. On the other hand, from July 16th to 20th, during
which the water was drank, there was a very distinct increase
in the number of granules present in all the forms, particularly in the mononuclear leucocytes. At the same time it will
be seen that there was a marked diminution in the allo.xuric
bodies as represented by the amount of nitrogen eliminated.


Observation II. — Dr. L., a perfectly healthy man, aged 25
and weighing 69.5 kilograms. Muscular, moderate panniculus adiposus, and of a quiet disposition. My colleague, after
bringing himself to a point of equal daily nitrogen elimination, drank Carlsbad water for a period of 4 days (1.5 liter of
Muhlbruun per day).


Mat, 1897.]
The daily diet was as follows : Ham, 250 grams ; veal,
250 grams; milk, 100 grams; wine, 500 grams; tea (black
infusion), 250 grams; rum, 15 grams; butter, 50 grams;
breakfast rolls, 3.  


The above food represented about 1895 calories daily (27
calories per kilo body weight), which were made up as
follows:




JOHNS HOPKINS HOSPITAL BULLETIN.


Albumin
Fat


Carbohydrates
Alcohol


91




511.73 calories.
785.49
341.69
256.88


although there was considerable variation in the granules
from day to day. As will be seen from the table there was a
large amount of alloxuric body nitrogen eliminated.


These observations that have been made do not in any way
confirm the theory that there is a regular coincidence between
an abundance of the granules and an increased excretion of
the alloxuric bodies, nor do they favor the view that Neusser's
granules occur exclusively in patients with an alloxuric
diathesis. Cases occur in which, with numerous grannies in
the leucocytes, there is a relatively small amount of the alloxuric bodies eliminated in the urine, while on the other hand
the granules may be almost entirely absent and the alloxuric
bodies be excreted in increased amount. Such directly opposed
conditions may occur in different individuals having the same


Total




disease, as in the two cases of hypertrophic cirrhosis of the
liver. Not infrequently the granules become increased or
diminished in the same person without there being a corresponding increase or diminution in the excretion of the alloxuric bodies. In fact, increase in the number of granules may
be accompanied by a diminution of the alloxuric bodies and
vice versa.


From the information obtained by the study of the above
1895.79
cases one seems justified in concluding thattlie supposed relationship between the perinuclear basophilic granules and an
alloxuric diathesis, as claimed by Kolisch, is purely empirical.  


In conclusion, I must thank Professor Kraus and his
assistants for many kindnesses and for valuable aid in carrying on the above analyses.




Table III.— Urine.


ENCYSTED DROPSY OF THE PERITONEUM SECONDARY TO UTERO-TUBAL TUBERCULOSIS AND


ASSOCIATED WITH TUBERCULAR PLEURISY, GENERALIZED TUBERCULOSIS


AND PYOCOCCAL INFECTION.
Q


By Claribel Cone, M. D., Professor of Puthology, Woman's Medical College, Baltimore.
[From the Pathological Laboratory of the Johns Hopkins University and Hospital]


0^




The following case is of interest not so much because of
Dally amount
lesions in themselves unique, as because of the rare combination of many lesions, the extensive character of these lesions,
of urine In
and the multiple nature of the infection.  
com.  


The case has many features in common with that reported
by Gardner,' of Montreal, in the year 1885, and is similar to
those described by Wm. T. Howard,' of Baltimore, the same
year.


Clinical History.
S Ml
if


N. A., primipara, aged 30 years ; colored. Admitted to the
Maternite of the Hospital of the Good Samaritan, in the
service of Dr. B. B. Browne, November 19, 1894.


The patient had been married several years ; had no children, no miscarriages. Menstruation commenced at the age of
- u a
15 ; it had always been regular, painful and profuse, lasting
from six to eight days, during which time she was compelled
to remain in bed. Her last jieriod occurred about the middle
of March, 1894.


Past History. No family history could be obtained. The
|g|i
patient had measles after reaching adult life. Five years ago
she suffered with an attack of " malaria " which lasted three
months ; at this time she claims to have been " very sick."
The attack recurred in September, 1894.


History of Present Condition. The patient is in the eighth
month of her pregnancy. Throughout this time she has been
feeling ill ; she has had pain in the back and abdomen,
increased on exertion. At present there are constant backache, and pain in the lower part of the abdomen. Appetite is
good ; bowels constipated ; urine of low specific gravity, otherwise normal.


E.t'xmination. Fcetus occupies the left occipito-posterior
A,  
position. In the right iliac region is a mass, partly soft, partly
resistant, which seems to be connected with the uterus, and is
not painful except on deep pressure.




Percentage of
alloxurlc
body— N of
total nitrogen.


On November 18 at 9.30 p. m. the woman was delivered of a
healthy child, but owing to uterine inertia the placenta had to
be removed. The labor was protracted, lasting 38 hours. The
perineum was lacerated and repaired at once. Two days after
delivery the patient was attacked with a chill followed by fever
and sweating. The record of the puerperium shows an irregular temperature of septic character whose highest point was
104.3°, whose average was 103°. There was no fever after the
second week and the patient's condition was recorded as good.


On January 19, 1895, she was discharged from the hospital
June 12
apparently in fair health. The following April the patient
visited the hospital clinic for treatment, considering herself
again pregnant since February. In July, 1895, she returned
with enlarged abdomen and general discomfort. At this time
she claimed to have felt the foetal movements; in August she
was seen at the clinic by Dr. B. B. Browne, who, after examination, did not think her pregnant.


Second Admission. In October, still believing herself pregnant, the woman was readmitted to the Maternite. After
careful examination under an anaesthetic, pregnancy was definitely excluded from the diagnosis. At this time a large hard
mass was found to the right of the uterus and apparently connected with it. The nature of the tumor could not be determined. Following the ether examination the woman became
quite ill. There was great pain in the lower part of the abdomen and sudden rise of temperature. The patient was then
transferred to the gynecological department of the Hospital of
the Good Samaritan. After the second day the abdomen
beo-an gradually to swell, and on December 1st it was much
distended. The patient was losing flesh and strength. The
temperature showed a typical hectic range, being normal or
subnormal in the morning, with an afternoon rise fluctuating
between 100° and 103°. The lowest point reached was 95.4°,
the highest point 104°.


1




92
1430




25.2421




Repeated examinatious of the sijutum showed no tubercle
0.5710
bacilli.  


Diagnosis. Encysted dropsy of the peritoneum, probably
tubercular.


Operation. For removal of the dropsical fluid. On February 26 th a laparotomy was performed by Dr. Browne. Au
incision 5 cm. long was made in the median line of the abdomen. From this opening about eight litres of transparent,
pale greenish fluid escaped. The entire anterior portion of
the peritoneal cavity was found to be converted into a suppurating cyst. An additional litre of semi-solid caseous
material resembling masses of congealed fat was removed by
the hand of the oj)erator from the lower part of the sac where
it covered the pelvic viscera on the right side. After evacuation of the fluid the surface of the peritoneum was found
thickened and converted into a necrotic membrane resembling
the caseous masses which floated in the jius.


Examination of Fresh Abdominal Fluid. The macroscopic
appearance was that of a turbid, pale greenish yellow fluid in
which floated shreds and flakes of caseous material. On
standing it separated into two layers, au upper transparent,
greenish fluid and a lower dense, creamy mass. The microscopic examination of this fluid showed numerous pvis cells,
some red blood corpuscles and shreds of necrotic tissue
entangling pus cells. Staiued cover-sliji preparations of the
fluid exhibited numerous cocci in jjairs, clusters and short
chains, but no tubercle bacilli were found.


Immediately following the operation the patient's condition
2.27
was much depressed. She rallied, however, resi^ondiug to
stimulation. Her general condition improved and she became
much more comfortable until the tenth day, when without
pain or other distressing symptom she died suddenly, March
6, 1896. The autopsy was made three hours after death.  


Anatomical Diagnosis. Tuberculosis of the Fallopian tubes,
uterus, ovaries, peritoneum, pleura, and viscera generally.
Acute flbrino-puruleut and caseous peritonitis; acute serofibrinous and hemorrhagic pleurisy ; mixed tubercular,
staphylococcus and streptococcus infection ; congestion of
viscera; general arterio-sclerosis.


The body is much emaciated. In the median line of the
" 13
abdomen is a gaping incision. It begins 3.7 cm. below the
umbilicus and extends 5 cm. downward, exposing a sloughing, puriform cavity from which bubbles of gas are evolved
ou pressure. The subcutaneous fat is quite absent; the
muscles are brownish red in color.


Abdomen. On opening the abdomen the entire anterior portion of the peritoneal cavity is found to be converted into a
suppurating cyst. This extends from the liver above to the
pelvis below, and traverses the lateral diameter of the abdomen from flank to flank, dipping deeply on both sides. The
walls of the sac are made up of dense, opaqire, yellow necrotic
material about 5 cm. in thickness. The cavity contains a small
amount of the same puriform material found at operation.
Extending across the cavity obliquely downward, and from
before backward, as if to support its somewhat flaccid walls, are
four or five dense fibrous bands covered by caseous material,
continuous with that lining the general suppurating sac. Of
these the largest is in the median line. It is long and almost


9




cylindrical, measuring 3.7x2.5 cm. in diameter. Its anterior
1815
and upper attachment is to the abdominal wall 2 cm. below
the umbilicus. Its jjosterior attachment below is by a broad
expansion upon the posterior wall of the sac where it dips
down to cover the pelvic viscera. A second organized band,
smaller, but similar in character to the one just described, is
found on the left side. A few adhesions are also found in the
posterior wall of the sac on the right side. On transverse
section these bauds show an organized, pink, fibrous groundwork thickly inlaid with miliary tubercles and limited by a
zone of caseous material. The j)osterior wall of the pus sac is
found so densely adherent to the intestines and other adjacent
viscera that separation is diflicult. No trace of the normal
omentum can be found, and the probabilities are that it
enters largely into the comjiosition of the suppurating cyst
and the traversing fibro-caseous bands.


The coils of intestine are densely matted together by old
tilirous bands and by more recent and lighter adhesions, studded
everywhere with yellow miliary tubercles, and form a single
compact mass filling the greater part of the abdominal
cavity. Not only are the intestinal coils adherent to each
other, but they are bound to all neighboring viscera. The
mesentery is greatly thickened and contracted, and is thickly
infiltrated with yellow miliai-y tubercles.


The mesenteric lymph glands are enlarged, indurated and
30.1310
caseous.  


Upon separation of the more delicate adhesions between the
ui)per coils of intestine, several smaller cysts about the size
of a hen's egg are found. They contain clear straw-colored
fluid. There is a slight excess of clear fluid in the posterior
peritoneal cavity, which appears to have been more recently
infected.


Liver. The liver measures 35x17.5x8.7 cm. in its various
0.5595
dimensions. The capsule is much thickened, and strong adhesions unite it firmly to the diaphragm. The left lobe is drawn
out into a tongue-like process, which extends completely
across the abdomen, covering the spleen on its anterior
and left lateral stirfaces. So completely adherent are these
two organs that only on section can a line of organized union
be made out. The lower surface of the liver is also in contact with the upper wall of the pus sac, with the stomach and
with the intestines, to which it is bound by firm adhesions.
On breaking up these adhesions and freeing the surface of its
caseous membrane, the capsule is found thickly beset with
yellow miliary tubercles. The surface is mottled. Ou section
the parenchyma shows the characteristic appearance of nutmeg
liver. Scattered throughout its substance are numerous
tubercles, both grey and caseous. They are mostly submiliary,
but larger ones exist.  


Spleen. The spleen is considerably enlarged. It is densely
bound down by old fibrous adhesions to all neighboring structures. Its anterior and lateral surfaces are almost completely
concealed from view by the tongue-like expansion of liver.
The capsule is irregularly thickened and contains caseous
miliary tubercles. The consistence is much diminished. It
tears readily. Ou section it is congested and contains grey
and yellow tubercles, miliary, submiliary and conglomerate
in form.






1.85


Kidneys. The kidneys are slightly enlarged; the capsules
are somewhat thickened, but strip off with moderate ease.
The surface of the right kidney shows a shallow circular scarlike depression about 12 mm. in diameter,somewhat paler than
the surrounding cortex. Under the capsule of this kidney is
also seen a solitary caseous tubercle about the size of a split pea.
Upon section the kidneys are congested, somewhat increased
in consistence, and contain an occasional isolated tubercle of
large size. The circular depression seen upon the surface of
the right kidney is found to be the base of a dense, pale, pyramidal area which extends quite down through both cortical
and boundary zones, and contains in its centre a small cyst.


Ureters. The ureters ai'e normal, except for a slight dilatation of the right ureter in its upper jiortion.
" 14


Pancreas. The pancreas is pink and firm. Its capsule is
thickly studded with miliary and conglomerate tubercles;
none, however, can be seen in its substance.


Stomach. The stomach is adherent to all adjacent structures. Its mucous membrane shows congestion, most marked
3
along the rugas. Some ecchymoses are found at the cardiac
end.


Intestines. In some places the felt-like adherent sac wall
forms a partial covering to the intestines. Beneath it, as elsewhere, the peritoneal coat is tolerably §mootb, congested, and
contains numerous miliary and conglomerate tubercles. The
mucous membrane is more or less congested throughout the
entire extent. The congestion is most intense upon the valvulas conniventes. There are no tubercular ulcers, but in
places tubercles can be seen extending inward from the peritoneal coat. The walls of the large intestine are thin and very
deejily congested. The abdominal lymj)h glands are enlarged
and caseous.


TJiorax. The sternum aud costal cartilages cannot be
1800
readily lifted because of adhesions between the two layers of
the pleura on the right side.


Left Pleural Cavity. The left pleural cavity contains about
2.5 litres of blood-stained lluid with flocculi of fibrin. There
is one dense organized baud of tissue connecting the two layers
of the pleura (about the region of the seventh rib). There
are also a few delicate adhesions in the posterior and lower
part of the cavity. The apex is firmly adherent to the chest
wall. The lung is compressed by the excess of fluid in the
pleural cavity. Both layers of the pleura present a coarse
reticulated mottling, as though a loose-meshed network of
fibrin had been laid upon a dark red hemorrhagic background.
Tubercles are also seen.


Upon the parietal pleura, as it covers the sixth rib, are seen
28.1925
two softened caseous tubercles, each about the size of a split
pea. Cover-slip preparations made from one of these immediately at autopsy show the presence of tubercle bacilli and
micrococci in large numbers.  


Left Ln7ig. The left lung is compressed and atelectatic,
except the anterior margin of the upper lobe, which contains a
little air. Scattered irregularly and sparsely through the lung
substance are miliary and conglomerate grey and caseous
tubercles. No cavities nor old tubercular foci can be made
out.


Right Pleural Cavity. The right pleural cavity is dry.  
0.5237






The lung is bound down throughout its entire extent by easily
detached adhesions. At the base and posteriorly the adhesions are pretty firm.


The pleura is covered with a layer of fibrin of irregular
1.85
thickness, more or less organized at the base of the lung. It
contains caseous tubercles.  


Right Lung. The right lung is also considerably contracted by the upward pressure from the abdomen and
the lateral pressure from the left thorax. The lower lobes
are atelectatic and congested. The upper lobe contains
a little air and exhibits along its anterior margin a few
emphysematous patches. The distribution of tubercles in its
substance corresponds with that of the left lung.


The bi'onchial aud mediastinal lymph glands are enlarged
" 15
and caseous.


Heart. Owing to the excess of fluid in the left ])leural
cavity, the heart occupies a position behind the sternum,
almost in the median line. The pericardium, the pericardial
fluid, the endocardium and heart valves are normal. The
aorta contains thickened yellow atheromatous plaques.


Cranial Cavity. There is a slight increase of cerel)i'al fluid.
4
The meninges of both cerebrum and cerebelliun are congested,
particularly on the under surface. The pia arachnoid at the
base of the cerebellum contains two or tliree yellowisli wliite
bodies resembling miliary tubercles.


Cover-slip preparations made from these nodules show no
tubercle bacilli.


The pelvic viscera were removed at autopsy aud jjlaced iu
1880
formalin, for detailed description later.


Pelvic Viscera. Uterus. The uterus is S.-"> cm. long, 5 cm.
broad aud 3.5 cm. iu the antero-posterior diameter. Both the
anterior and posterior surfaces are covered by an opaijue,
yellowish white, felt-like membrane, varying from 2 to mm. in
thickness. This membrane passes directly from the uterine
walls to the other pelvic viscera, forming a complete blanket,
and constituting the lower part of the large jiu.s sac which
occupied the anterior portion of the peritone.il cavity. Projecting from the middle third of the posterior wall is a myomatous nodule about the size of a large walnut, attached to the
uterus by a short and broad pedicle, Fig. 1, M. Springing
from the fundus of the uterus about 2 cm. anterior to the
right cornu is another pedunculated myoma, large, ovoid, and
9.5x7.5x5.5 cm. in diameter, Fig. 1, M. From the left surface
of this tumor springs a cylindrical band about :j cm. long and
13 mm. iu diameter, attaching it loosely to the coiled-up mass
of intestines behind. This band is of the same general nature
as the fibro-caseous bauds which traverse the abdominal cyst.
Another band, broad, flattened, and 6 mm. thick, is attached
to the right surface of the tumor. This forms part of the
general peritoneal sac. On stripping back the dense, felt-like
membrane covering these tumors, their surfaces are found
studded with tubercular nodules of a yellowish white color,
and from one to three mm. in diameter. The snuiller tumor
can be easily shelled out of its capsule, owing to a peculiar
orange-yellow caseous material separating the two in the
regio^n of the pedicle. The myomata, so far as can be seen, do
not contain tubercles in their interior. The uterine wall
measures 1 cm. in thickness at the fundus. Fig. 1, F. U., 2 cm.


30.3996




94
0.5791
 






1.90


anteriorly and 1 cm. posteriorly. It is pale pink in color and
is studded with sparsely scattered, yellowish, miliary and con glomerate nodules.


The cervix is 2.5 cm. in length. The mucous membrane
" 16
of the body presents a shaggy, moth-eaten appearance, of yellowish color and friable consistence. The mucous membrane
of the cervix, which is much less rough and friable, still presents indications of the normal rugte. The mucosa varies from
2 to 5 mm. in thickness.


Right Appendages. Springing from the right uterine cornu
and extending backward and downward, so as to be completely
concealed from view by the large myomatous tumor which
filled the right inguinal region, is a mass 8 cm.x5.5 cm.x2.5 cm.
in size. It presents at first sight the appearance of an enlarged
ovary, covered by the general pyogenic membrane, beneath
which, as in the uterus and elsewhere, are miliary and conglomerate tubercles studding the surface. Upon section, however, it is seen to consist of the convoluted tube, thickened
and necrosed, with its exaggerated coils held together in a
stroma of dense organized connective tissue studded with
miliary tubercles. Beneath the lower part of this convoluted
mass is seen a portion of the ovary, so completely covered by
and adherent to the tube as almost to have lost its own identity. Fig. 1, r. Ov. A longitudinal section through this tuboovarian tumor gives transverse, oblique and longitudinal
sections of the much distorted tube. They lie like scattered
caseous islands with ulcerated centres, in the tubercle-dotted
stroma. The walls of the tube are from 3 to 8 mm. thick, and
are for the most part uniformly caseous. Here and there is a
nodular studding which gives the mucosa an uneven surface;
or again a rich infiltration of the other coats with barely
agglomerated caseous tubercles is observed. The fimbriated
extremity, dilated, and curled outward in trumpet-like expansion, is directly continuous throughout its circumference with
the anterior peritoneal sac. Fig. 1, r. F. E. The folds of the
fimbriated end are everywhere visible and appear densely
thickened and ragged; the extremity itself measures 2.5 cm.
in diameter.


Left Appendages. The left tube is exceedingly tortuous, and
5  
from the uterine cornu outward gradually increases in size,
terminating in a fimbriated extremity 4.5 cm. in diameter. It
is 11 cm. long in its contracted state. Fig. 1, F. E. The folds
of the fimbria are transformed into a greatly thickened, motheaten membrane, from whose surface project numerous papillary processes varying in size and shape and measuring from
10 to 14 mm. in length. The interior of the tube bears some
general resemblance to the necrotic membrane which covers
its surface and which represents the walls of the abdominal
sac with which both tubes appear to be directly continuous.
The convolutions of this tube, while excessive, as are those of
the right side, are not embedded in a dense organized stroma,
but are held together by tolerably firm adhesions. These, as
well as the surface of the tube, exhibit caseous, miliary tubercles. Fig. 1, 1. T. Longitudinal and transverse sections through
the tube show extreme necrosis of its walls. They are more
extensively ulcerated toward the outer third, where the condition is most advanced. The lumen at this point is increased
to 13 mm. iu diameter. The walls of the tube are here from




2000


3 to 5 mm. thick and consist mainly of caseous material with
a narrow outer border of organized tissue. This forms a capsule which can be readily stripped away from the central
necrotic mass. The thickness of the tube about its middle
portion is 2 cm. There is no lumen visible on cross section,
but the entire tube seems made up of one dense, yellowish,
homogeneous mass.


'J'he left ovary lies behind and beneath the tube, to which
30.0650
it is bound by adhesions similar to those connecting the convolutions of the tube. Fig. 1, 1. Ov. From this it may be
detached with moderate ease. It is about normal in size and
position. The surface is covered by the same necrotic membrane, and exhibits upon its removal sago-like bodies. On
section the structure is smooth, firm, grey and glistening,
showing several corpora fibrosa, and one flattened tubercle Just
beneath the surface.  


t'onnected with thepelvic viscera and binding them together
are portions of the peritoneum which went to make up the
original sac wall but which were torn away at autopsy. They
are of the same general appearance bs, the necrotic membrane
covering the viscera. A similar sac, collapsed and dipping
down behind and to the left of the cervix uteri, is covered in
by the small myoma above described. This represents the
remains of an abscess about the size of an orange which ruptured at autopsy, discharging thick, greenish yellow pus.


The Vagina. There are several small, greyish, flattened
0.5217
elevations upon the surface of the mucous membrane, irregular
iu size and shape, some round, measuring from 1 to 2 mm. in
diameter ; others with irregular edges measuring about 6x3 mm.
in diameter. There is also ^ small superficial ulcer in the posterior vaginal wall just below the cervix. It is about the size of
a split pea, has sharp irregular edges, but contains no tubercles in its walls. The vagina is otherwise normal.  


The bladder is contracted and is apparently normal.


The rediim is partly covered by necrotic membrane, but
0.4222
shows no abnormalities.  


Histological ExAiiisATioif.
Pelvic Viscera.


Uterus. The surface epithelium has entirely disappeared,
1.73
and the uterine mucosa shows a granular necrosis throughout
the inner fourth of its thickness. Beneath this the normal
stroma is invaded by diffuse tubercle tissue with discrete
caseating nodules. It is the union of these nodules near
the surface of the mucosa which results in the granular
necrosis. In the depth of the membrane the uterine glands
are preserved, although the epithelium is swollen and invaded
by mononuclear and polymorphonuclear cells. They are
often dilated, and contain swollen desquamated epithelial
cells, polymorphonuclear leucocytes and granular detritus. The
diffuse tubercle tissue consists largely of lymphoid and epithelioid cells, with an occasional giant cell. The discrete caseating
nodules present the typical structure of caseous tubercles. The
giant cells of both stroma and nodule are round, oval or irregular in shape, with a mural or polar arrangement of the nuclei.
The epithelioid cells of the diffuse tubercle tissue are usuallyj
round or polyhedral, with small vesicular nuclei. Those ofi




" 17*


May, 1897.]


6




JOHNS HOPKINS HOSPITAL BULLETIN.
1890




27.2868


95


0.6515




the caseating nodules are irregular and elongated, with oval,
bizarre and wavy nuclei, the close packing of which in the
periphery of the nodule gives the appearance of a radiating
fringe.


The muscular coat is infiltrated throughout its entire thickness with diffuse tubercle tissue and discrete miliary nodules,
most of which are caseous. The diffuse infiltration is represented by small cells with solid and vesicular nuclei, arranged
in longitudinal strands between the muscle bundles. The
caseous nodules lie next to the peritoneal surface, and are
irregularly triangular in shape, with bases toward the serosa.
Sometimes the bases coalesce and form a continuous scalloped
caseous zone. The muscle cells are increased in number,
and here and there are myomatous foci which consist of
dense aggregations of cells containing elongated club-shaped
nuclei.


The blood-vessels of the muscular coat present interesting
2.38
features; some of them show the typical changes of endarteritis obliterans, with more or less encroachment upon the
lumen. But the most characteristic lesion is the tubercular
involvement of the vessel walls. This process sometimes
begins in the intima and remains limited to this coat, or
extends to the media or adventitia. Sometimes it takes origin
in the adventitia and perivascular tissues, and spreads inward
in like manner through the other coats. It may be diffuse or
circumscribed, it may be a cellular proliferation simply, or
show all stages of degeneration, from an early nuclear fragmentation and karyolysis, to advanced caseation in which all
the coats and even the vessel contents are transformed into a
dense hyaline mass. The corpuscular contents of the vessels
are often preserved intact, notwithstanding advanced changes in
the vessel walls. Again there are thrombi, hyaline or mixed, in
various stages of transformation. Sometimes the vessels are
the centre of a tubercular process, in which case their fibrinous
contents are continuous with a fibrillated fibrin which extends
out into the surrounding tissues. Where the tubercular change
is early and begins in the intima, the endothelium is sometimes preserved intact; here there is subendothelial proliferation of the connective tissue cells, forming ejDithelioid cells
of a round or jjolyhedral shape, with moderate or abundant
protoplasm and small round nuclei. But in other cases there
is evidence of endothelial proliferation, these cells enlarging,
becoming at times cul)oidal, and forming a lining of two or
more rows to the lumen, with occasional complete occlusion.  


In the serous membrane the changes are most marked ; on
the surface is a dense, opaque, necrotic coat, granular, fibrillated and hyaline. Beneath this is a narrow zone of nuclear
fragmentation, while yet below and forming aline of demarcation between the necrotic portion of the serous coat and the
scalloped caseous zone of the muscular coat is a narrow band
of (Edematous, vascular connective tissue containing a few
muscle fasciculi, and showing infiltration with lymphoid,
epithelioid, polymorphonuclear and occasional giant cells.


The process is least advanced in the cervix, most advanced
" 18
in the fundus. In the cervix there is no invasion of the
muscular coat, and the vaginal portion contains no evidence
of tubercular involvement other than a solitary cellular
tubercle under the stratified epithelium in its upper part, and




7


a cellular proliferation of the corium, gradually disappearing
as the outlet is approached.


Among the diffuse tubercular tissue are found numerous
3110
homogeneous, highly refractive globules of various sizes, occurring singly or in groups. They show especial affiuity for acid
aniline dyes, and also stain intensely with gentian violet. In
shape they are invariably round; in size they vary from that
of a micrococcus or a basophilic granule to that of a lymphoid
cell, some even exceeding this. Their average diameter is
that of a red blood corpuscle ; in fact, when uniform in size,
and occurring in masses, they are readily mistaken for such in
specimens which have been stained with ha^matoxyliu and
eosin. The little globules are, however, more homogeneous
and solid and more highly refractive than red blood corpuscles. These appear of tenest more or less closely packed within
cell bodies, the nuclei of which are still preserved. Sometimes
they accompany a more advanced degeneration, in which case
the nucleus stains poorly or not at all. Again, they are free
from cellular inclusion, and lie in groups or scattered through
the tissues. The groups are circular, elongated or irregular,
and contain from two to thirty or more members. With Weigert's fibrin stain they stand out conspicuously as deep blue
spheres, homogeneous and structureless. With Russell's
fuchsin stain they strike a bright red hue; with eosin they
stain pink. In many respects they correspond with the hyaline bodies considered by Lubarsch" as a form of albuminous
degeneration, found by various observers in both normal and
pathological conditions, and described by Russell" as " Fuchsin bodies." In the present case they contain neither nuclei
nor spores such as Russell and others have described.


In all three coats of the uterus micrococci are found arranged
in pairs, clusters, or chains of greater or less length, numbering from three to sixteen members. They are especially
numerous along the superficial caseous zone of the peritoneal coat, where they form a thick, irregialar border and
extend deep into all fissures of its necrotic structure. In the
muscular coat they are less numerous, and are found for the
most part within and about blood-vessels in the bands of the
infiltrated tubercle. In the mucous membrane they are again
present in considerable number, somewhat sparsely scattered
at times or occurring on the surface as dense aggregations.
Where scattered, their arrangement is usually in the form of
pairs and chains.


Tubercle bacilli are also found in the uterine tissues. They
29.4983
occur in the interior of vessels, either free or enclosed within
cells, in the vessel walls, and in the tubercle tissue outside.  


The uterine myoma is covered by newly formed connective
tissue, with rich infiltration of diffuse and circumscribed
tubercles and many pus cells. The capsule is made up of
strata of well preserved fibro-muscular bands. But the interior
of the tumor is necrotic throughout. Near the surface of the
necrotic myoma is a narrow zone of calcareous matter; the
walls of all blood-vessels in its vicinity are likewise calcified.
A still broader zoueof necrotic myomatous structure, including
the calcareous baud, is dotted over with spiculated spherules
of golden yellow pigment. No tubercles are seen. Russell's
fuchsin bodies are numerous in the tissue covering the myoma,
but none are found in its substance. Micro-organisms similar


0.5421




96




1.83




to those found iu the utei'us are likewise found in the tubercular coFcring of the tumor.
" 19


Uiyhl Fallopian Tube. The mucous membrane of the right
Fallopian tube at its uterine end has an almost intact epithelium. In one place, however, the epithelium is wanting, and
here the stroma is invaded by a mass of tubercle tissue,
some of which has broken off and lies free and degenerating
in the centre of the lumen, together with the desquamated
epithelium. The middle coat of this part of the tube retains
its muscular structure; bands of muscle, however, are separated from each other by serous infiltration or by alternating
baiuls of diffuse tubercle tissue. The serous coat is composed
of solitary caseous tubercles so blended as to form a continuous scalloped zone. On passing outward from the uterine end
the tuliercular process becomes more marked, and when the
middle portion of the tube is reached the walls are so intensely
involved as to form a thickened necrotic mass, with no evidences of structure except a narrow fibro-cellular zone encircling the tube about 2 mm. from the periphery. The necrotic
substance is hyaline in the centre, where it is pierced by a
ragged slit- like lumen. It corresponds here with the remains
of the mucous membrane. There is nuclear fragmentation
within the fibro-cellular zone, and among the nuclear fragments isolated bands of muscle are preserved in scanty
nnnil)c'r The surface necrosis corresponds essentially with
tliat of the uterine serosa, while the middle fibro cellular zone
is continuous with the thickened, cedematous, vascular connective tissue of the uterus, which there formed a line of
demarcation between the necrotic portion of the serous coat and
the scalloped caseous zone of the muscular coat. Here, as
there, it contains a few isolated muscle bundles, the only
normal elements of the original Fallojjian tubes. Here, as
there, it is infiltrated with tubercular cellular tissue and
polymorphonuclear cells, and here, as there, it shows many
vascular changes, both sclerotic and tubercular, similar to
those described in the uterine muscular coat.


There are numerous dilated lymph spaces and blood-vessels
8
with subeudothelial proliferation or a lining of cuboidal cells.
Occasionally a well-defined giant cell takes origin iu the endothelium of a vessel and projects into the lumen, filling it
more or less completely. Sometimes such a cell is found free
in the vessel. Indeed, the giant cells are numerous thi-oughout the middle coat, and are especially abundant near the
necrotic mucosa. They are often situated in little caverns,
which are sometimes surrounded by lymphoid cells. Where
not so situated, they are more apt to be surrounded by an
irregular zone of epithelioid cells. They are elongated or
irregularly ovoid in shape, of various sizes, and contain nuclei
at their poles or about the periphery, seldom in the centre.
Sometimes they are invaded by polymorphonuclear and
lymphoid cells.


In the fimbriated extremity the degeneration is extreme.
The lumen is considerably dilated, the walls are convoluted
and thick. The mucous membrane is composed of three
strata representing gradations of tubercular change. Next to
the lumen is a narrow necrotic border, which takes an intense
eosin stain. It gives occasional evidence of original structure
in the preserved outlines of old blood-vessels, of connective


2840




tissue bands, of g^ant cells, and even of an occasional caseous
28.40
tubercle which has not yet lost its identity by coalescence with
the general necrotic border. Outside of this is nuclear fragmentation with structural outlines still better preserved ; while
yet beyond is the normal stroma invaded by infiltrated tubercle.
Tlie middle coat is a comparatively narrow band of fibrocellular tissue, not yet degenerated, forming less than a third
of the whole tubal thickness, .and presenting the same interesting features as the corresponding coat of the middle portion of the tube. The thickest part of the wall is the peritoneal coat; it is entirely involved in an extensive necrosis
which is at one time fibrillated, at another granular or hyaline.  


The little refractive globules described iu thecellular tubercular tissue of the uterus as Russell's fuchsin bodies are
present also in the tube iu considerable number. They lie by
preference in the middle coat, in which the tubercle tissue is
best preserved. They pi-esent the same general characteristics
as the hyaline bodies of the uterus, but are somewhat smaller.
Indeed, whereas in the uterus their average diameter is that
of a red blood corjjuscle, in the tube their average size is that
of a micrococcus ; and, where Weigert's fibrin stain is used,
they could readily be mistaken for such, were it not that upon
careful examination they show less uniformity in size, take a
more solid stain, and because larger globules, both free aud in
cells, are found in the same neighborhood. Extra-cellular
spheres of large size grouped with smaller hyaline globules
are sometimes found occupying open spaces iu the tissues.


The borders of the necrotic zones, both mucous and serous,
0.6908
iu all parts of the tube, are invaded to some depth by deeply
staining micrococci, which in form, size, grouping and
arrangement in the tissues, resemble the organisms found in
the uterine coats. Similar organisms are found at times in
the blood-vessels of the middle coat. Tlie streptococci predominate, and the average length of the chains is six members.
Tubercular bacilli are likewise found.  


Rigid Ovary. The right ovary is somewhat enlarged. Its
surface presents a smooth, wavy outline and is covered by a
thick, cedematous, vascular connective tissue which contains
lymphoid and epithelioid cells, but no giant cells. There are
also numerous dilated lymphatic vessels filled with lymphocytes. The edges of this connective tissue covering are ragged
and represent the remains of old fibrous adhesions between the
ovary and neighboring structures. Deep within the ovarian
stroma are several isolated and conglomerate caseous tubercles.
There are many advanced corpora fibrosa, aiul an unruptured
Graafian follicle in the process of retrograde metamorphosis,
liussell's fuchsin bodies are numerous in the tubercular tissue
covering the ovary, and iu the ovarian tissue itself. They are
present where the degeneration is least advanced, aud may be
seen, not only in the tubercular areas, but in association with
other degenerative changes — in the hyaline degeneration of
corpora fibrosa and in the retrograde metamorphosis of unruptured Graafian follicles.


Streptococci, staphylococci and tubercle bacilli are present.  
0.4222
Of these the streptococci are most abundant and occur iu
long chains, at times reaching the length of fourteen members.
They are located within the lumen of blood-vessels, in the
blood-vessel walls, or in the perivascular lymphatics of the




2 43


May, 1897.]


" 20




JOHNS HOPKINS HOSPITAL BULLETIN.
9




2730


97


27.30




coimective tissue covering the ovary, and are ofteuest free,
0.6162
but may be found enclosed in cells.  


Left Fallopian Tule. The left Fallopian tube has the same
general structure as the right, the only difference being that the
tubercular lesion is more advanced. The middle portion of the
tube is converted into a dense neci'otic cord, the transverse section of which shows a ragged longitudinal rift in the centre of
an oval area of hyaline necrotic material. This is surrounded
bv a fibro-cellular border, whose surface is roughened by
fibrous shreds torn in the process of separation from adjacent
structures. The fibro-cellular border corresponds with both
middle and outer zones of the other tube. The fimbriated
extremity, like its fellow, is extensively degenerated, and the
lumen is also much enlarged. Its walls, however, are less
uneven and are but half the thickness of those of the corresponding tube. Continuous with the middle portion of the
tube the fimbriated extremity likewise has an outer border of
fibro-cellular tissue and an inner hyaline necrotic coat. In
this tube there are fewer giant cells than in the other, and the
tubercle tissue in places shows fibroid change. Russell's fuchsin bodies are present in small number.


The micro-organisms found are similar to those in the
other tube.


Thus, while both tubes show in the main the same tubercular lesions, they differ in that the left tube has somewhat
thinner walls, contains a smaller number of giant cells,
exhibits in places fibroid change, and the thickened necrotic
serous coat is wanting.


Left Ovary. The left ovary is smaller than the right and
2.10
is surrounded by diffuse tubercular tissue. In gland-like
spaces near the surface are found great accumulations of
nuclei, bound together by hyaline and fibrillated fibrin, and
often presenting the appearance of the tubercle giant cell. In
this ovary there is but one solitary caseous tubercle, about the
size of a split pea, which projects slightly above the surface
and dips down into the stroma. Fuchsia bodies and microorganisms are present, resembling in every respect those found
in the right ovary.  


The Vagina. The vagina shows no tubercular involvement.
The elevated greyish white patches observed on macroscopic
examination consist of swollen, distorted, stratified epithelial
cells. Occasional polymorphonuclear and mononuclear cells
have wandered up into the epithelium. There is slight proliferation of the cellular elements in the upper portion of the
corium. Fuchsin bodies are found in these proliferating areas.
More densely stained globules are seen in the swollen epithelium above. Upon the surface of the mucous membrane there
are a few cocci and long bacilli. Within the blood-vessels of
the vaginal wall, and especially in the larger ones, cocci occur
in pairs and chains, both within cells and outside of them.


The bladder and urethra show nothing abnormal.


Pus Sac. The wall of the pus sac, portions of which
f From June 17 to 20 Carlsbad water was drunk.  
remain adherent to the pelvic viscera, is from 4 to 6 mm. in
thickness. It consists of three coats not sharply differentiated
one from the other. In the inner necrotic coat, which represents about one-third of the thickness of the sac wall, the
degeneration is extreme. Its surface is edged by dense aggregations of micrococci which in places extend deep into the


Table IV.— Nitrogen Balance (N in Grams).




necrotic structure. The middle coat is fibro-cellular and con
tains a few isolated clusters of fat cells. It is infiltrated with
diffuse tubercular tissue. The outermost coat is not sharply
separated from the middle, and differs from this in containing
numerous closely packed caseous tubercles. Fuchsin bodies
are present as intracellular and extracellular globules. They
are of all sizes, and contrary to what occurs elsewhere, they are
found in the most advanced necrosis. In such places theytake a less intense gentian-violet stain and merge gradually
into the surrounding necrotic structure. Micrococci are found
in all three coats arranged in pairs, clusters and chains.
They are especially numerous upon the inner surface of the
sac, where they form a continuous irregular layer. Tubercle
bacilli are also present in small number.


General Viscera.


The lung shows very little that is abnormal. The visceral
pleura is considerably thickened and presents an irregular
wavy outline. Its surface is covered by a layer of fibrin
formed by the coalescence of highly refractive clumps. These,
in places, extend deep into the tissues, where they appear as
densely hyaline whorls, or the fibrin remains limited to the
surface, where it forms a meshwork enclosing polymorphonuclear cells. The more hyaline portions are at times invaded
by organizing connective tissue. Beneath the fibrinous covering
is a layer of highly vascular granulation tissue which contains
closely-set flattened tubercles. These tubercles project here
and there between the clumps of hyaline fibrin, extending at
times to the surface, or dip down into the lung substance.
They are more or less caseous and show the same general
structure as the tubercles already described. Where less advanced they contain many giant cells. The deeper layers of
the pleura contain dark brown and black granular pigment,
both free and enclosed in cells.


The parietal pleura resembles the visceral in its general histological features. It is composed of a superficial laj'er of
1^
fibrin, beneath which are granulation tissue and caseous tubercles. Quite beneath is a third layer consisting of cedematous
connective tissue, the meshes of which are widely separated
by serum and the spaces of which are occupied by swollen
mononuclear cells. In the parietal pleura there are small
extravasations of blood. Both layers of the pleura contain
the fuchsin bodies and basophilic cells. A few pairs and
chains of cocci and tubercle bacilli are present.


Liver. The capsule is thickened by tubercular growth.
The lobules show dilatation of the central veins and adjacent
capillaries. The hepatic cells in the centre of the lobule contain a brownish yellow pigment. The peripheral cells are
filled with fatty globules.


Distributed thickly through the liver substance, in close
38
relation with the blood-vessels, are countless tubercles, most of
which are of microscopic size. Large nodules evident to the
naked eye are less abundant. The former consist for the
most part of lymphoid cells or of lymphoid with a central
accumulation of epithelioid cells. The larger tubercles are
evidently older and exhibit the typical structure of miliary
tubercles with advanced central necrosis. There are a few
pairs and chains of cocci in the liver capillaries.




t


98
S


NITBOGEN eliminated.






Spleen. The capsule is thickened by a new growth of cellular connective tissue containing caseous miliary tubercles.
The spleen parenchyma shows an increase in its cellular elements. Much blood pigment and many red blood corpuscles
are found. The arterial walls are considerably thickened, and
an occasional hyaline thrombus in one of the smaller vessels
is seen. There are numerous tubercles, both young and old,
scattered through the splenic substance. Fuchsin bodies are
present. Micrococci in pairs, masses and chains are found.
They are sometimes arranged within cells, but are usually
extra-cellular.


Kidney. The kidney shows parenchymatous and fatty degeneration of the epithelium lining the Malpighian tufts and
S
the convoluted tubules. There is a slight increase of connective tissue, especially under the capsule. The tubules are here
compressed, but elsewhere they are at times dilated. Hyaline
and granular casts are found. The wedge-shaped area described among the macroscopic lesions is found to consist
almost entirely of connective tissue in various stages of development. It compresses the tubules, many of which are completely obliterated ; while others persist with intact epithelium
or with lumen distended by hyaline casts. The Malpighian
tufts are small and fibrous, and in places are converted into
hyaline balls. Indeed, the connective tissue invades all
structures in the triangular area, and tubules, blood-vessels
and glomeruli are alike involved. The central cyst is lined
by cuboidal or flattened epithelium. Its walls appear to contain a large number of muscle fibres which have an irregular
arrangement and include masses of lymphoid cells. It is
continuous with several smaller tubular dilatations and is
undoubtedly a retention cyst. At the apes of the triangle is
a large dilated blood-vessel with irregular thickened walls and
lumen containing remnants of a probable thrombus. The area
resembles an infarct in the process of cicatrization, but for the
presence of apparently functioning structures. A few cocci
arranged in pairs are found within a blood-vessel of the
kidney.


Pancreas. The capsule is considerably thickened by a new
growth of connective tissue, alternately fibrous, cellular, vascular and cedematous. Numerous closely-set tubercles are
embedded in the capsule. They are round and project beyond the surface, or they may be flattened and elongated.
They show the typical structure of cellular, caseous and
fibroid tubercles. The capsule contains the fuchsin bodies
and masses of micrococci.


Lymph Glands. The bronchial lymph glands are invaded
by lymphoid, epithelioid and giant cells and show a tendency
to fibroid change. Some of the central arteries are sclerotic,
others show tubercular lesions. Masses of basophiles are
present in the centre of the glands, especially grouped around
blood-vessels, and the fuchsin bodies are found at times occupying the interior of basophilic cells. Micrococci occur in
pairs and chains within blood-vessels and in the perivascular
connective tissue.


In the mesenteric lymph glands the tubercular process is
more advanced. The centre is necrotic, with original structural outlines still preserved. The periphery of the gland
retains its lymphoid nodules, but these are invaded by tubercle


Urine.




tissue. The blood-vessels are thickened, and basophiles are
FsBces.  
found. The gland is covered by (Edematous tubercular tissue.
Diplococci and stajihylococci are numerous in the surrounding
connective tissue, and beaded tubercle bacilli are found in the
interior of the gland.
 
The aortic valve, the aorta and the coronary arteries show
irregular thickening of the intima due to increase of connective tissue which in places is swollen, and the interstices
between the branching connective tissue cells are occupied by
translucent, highly refractive masses. Or again, the tissue is
non-cellular and diffusely hyaline. On the edge of the aortic
valve where it appears necrotic a few diplococci are found.  


Fibro-caseous bands. The fibro-caseous bands extending
across the abdominal pus cavity, and those in the pleural
sac, are made up of fibrillated connective tissue, everywhere
invaded by diffuse tubercle tissue and circumscribed tubercles
in all stages of gi'owth or of retrograde metamorphosis. The
peripheries of the bands consist of necrotic zones edged by
a closely packed layer of micrococci. The connective tissue
stroma shows every stage of organization from young granulation tissue to dense hyaline bands ; the bloodvessel walls
are thin and easily rupture"d, and extravasations of blood
are sometimes found. The diffuse tubercle tissue consists
for the most part of lymphoid and epithelioid cells grouped
usually in the neighborhood of blood-vessels. Few giant
cells and some basophiles are found. The tubercles exhibit
every stage of growth and of retrogi'ade metamorphosis. At
times they present a typical cellular structure with giant
cells in the centre. Again, the centre is occupied by a
blood-vessel, and the lumen of such vessel may contain well
preserved fluid contents, fibrillated fibrin, or a hyaline or
mixed thrombus. The caseous peripheral zone is from 2 to 6
mm. in thickness. It contains no cells nor nuclear fragments,
but is made upof a structureless necrotic substance, alternately
granular, fibrillated and hyaline. Fuchsin bodies are easily
demonstrable. They are of all sizes, from that of a basophilic
granule to a lymphoid cell, and are both intracellular and
extracellular. They occur in the diffuse tubercle tissue where
degeneration has just begun. The micrococci found on the
surface of the band sometimes extend deep into its substance ; they occur in pairs, in masses and in chains. In the
bands of the abdominal pus cavity compressed lobules of
adipose tissue exist.


Bacteriological Examinatiox.
a


Cover-slip preparations made at autopsy from a tubercle
n
upon the pleura demonstrated large numbers of long beaded
tubercle bacilli and clusters of micrococci. Cultures made
from this tubercle enable one to isolate white, lemon yellow
and orange colored colonies Inoculations from these colonies
into the various culture media exhibit the peculiar cultural
characteristics of the staphylococcus pyogenes aureus, citreus
and albus, and cover-slip preparations from the various cultures invariably show cocci arranged in clusters and in pairs.
Unfortunately, no cultures could be made from the abdominal
viscera, but hardened sections of the organs stained by Gram's,
Weigert's and Gabbet's methods exhibit staphylococci, streptococci and tubercle bacilli in all.




June 14
" 15
" 16
" 19
'• 20


JlAY, 1897.]


3


4
5
8
9


JOHNS HOPKINS HOSPITAL BULLETIN.


69.700
6".700
69.800
70.200
70.000




99
31.7345
31..=S645
31.6679
31.5979




36.3996
30 ('650
28.40
29.30


Summary of Histologhcal and Bacteriological
examinatiok.


(1) The condition is a mixed infection due to the tubercle
l.'3V42
bacillus, the streptococcus pyogenes, and the staphylococcus
1.2619
pyogenes aureus, citreus and albus.  


(3) Miliary tubercles, both grey and caseous, are found in
all the viscera of the body except the heart and pancreas ; in
the lymph glands, and in all serous membranes excefit the
pericardium.


(3) Diffuse tubercle tissue is found only in the more chronic
31.3792
lesions — in the pelvic viscera, the lymph glands, the pleura,
36.5702
the peritoneum, in the wall of the newly formed abdominal
sac, and fibro-caseous bands. In the viscera this is usually
cellular, but may be caseous. In the serous membranes it is
always caseous.  


(4) Tubercle bacilli are numerous in the tubercular lesions
throughout the body. They are especially numerous in the
pelvic viscera, lymph glands and alidominal pus sac.


(5) The products of ordinary inflammation are often found
+0 8536
associated with the tubercular lesions.  
-|-'l'.5643


(6) Staphylococci are found in all the organs. They are
most numerous in the lining of the abdominal pus sac and the
tibro-caseous bands.


(7) Streptococci are likewise found throughout the body, but
are especially abundant in the pelvic viscera, the pus sac and
the fibro-caseous bands.


(8) Kussell's fuchsin bodies are found wherever the tubercular tissue is beginning to degenerate and occasionally where
Relation of Neusser's granules in the leucocytes: In the
the degeneration is extreme.  
period before Carlsbad water was taken, with the amount of
the alloxurlc bodies above the normal (and with a large amount
of uric acid), the granules were not particularly abundant.  
In the second half (June 17-20), when the water was taken,
the amount of the alloxurlc bodies eliminated was still higher,


(9) The viscera are congested and there is general arteriosclerosis.


Conclusions.


From the clinical history, gross anatomical lesions and histological appearances, we therefore conclude that the disease
88
began as a tubercular inflammation of low grade in the pelvic
viscera some time before pregnancy.


That the tubercular process spread by direct extension or by
the lymph channels to the anterior part of the abdomen, which
thus became shut off from the rest of the peritoneal cavity by
chronic adhesions.


That the phenomena incident to pregnancy and the puerperium excited the process to increased activity, to which,
either at this time or later, was probably superadded a pyogenic infection.


That this infection remained limited to the pelvic organs
because of occlusion of the tubes by previous tubercular adhesions or by the more receutinflammatory process, until manual
examination of the already much diseased organs caused unavoidable rupture into the anterior abdominal sac.


The pain, rise of temperature and abdominal distension were
whereas the granules had become distinctly diminished in
the result of the secondary pyogenic infection of this cavity,  
nnmber, particularly in the small mononuclears.  
from which the general infection took place.  
I The general tubercular infection doubtless spread, partly


by direct extension, partly by the lymph channels, but principally through the blood-vessels. The first two modes of invasion are shown by the extensive diffuse infiltration of all
Observation III. — A. F., a young woman, 33 years old, and
structures continuous with and contiguous to the pelvic viscera
a cook by occupation. She bad a severe anasmia (red corpuscles 1,900,000 per ccm., leucocytes 6800, and hiemoglobin
35 per cent, according to Fleischl's ha^monieter). The temperature was normal during the observation. Pulse averaged
110 per min. Slight dyspnoea even when at rest. Patient was
of rather large frame, and the panniculus adiposus was not
particularly reduced. No oedema ; urine free from albumin.
Had suffered previously from some gastric trouble, but the  
symptoms had disappeared. From June 35th to July 7th her
weight had become reduced from 57 to 53.4 kilograms.


The daily diet was as follows : Ham, 100 grams ; white
bread, 100 grams ; milk, 500 grams; wine (white), 350 grams;
water, about 1000 grams.


The diet administered represented about 938 calories (17 per
kilo body weight), which were made up as follows :


and the abdominal pus sac. Infection through the blood is
evidenced by the general miliary tuberculosis of all the viscera
of the body.


Tuberculosis of the tubes and peritoneum is usually a secondary condition. It may follow tubercular disease of any
organ of the body, but is seen most commonly associated
with tuberculosis of the lungs. In this case, however, the
process must have originated either in the peritoneum or in
the tubes. The lungs showed no old tubercular foci, but were
involved only in the general miliary tuberculosis. The pleura
was diseased, but to a much less extent than the peritoneum
or the tubes. The intestines were not at all involved, and the
lymph glands were enlarged and caseous, but not extensively
diseased.


The question arises, what was the relation of the tubercular
Albumin
disease in the tubes to that in the peritoneum ? Which was
Fat
primary, which secondary? Considerable difference of ojnnion
exists as to the relation between tubercular peritonitis and
tuberculosis of the tubes. In his monograph on "Tubercular
Peritonitis" Osier" says: "The Fallopian tubes are often
affected, but the proportion given by various writers differs
much. It is safe to say, I think, that in .30 to 40 per cent, of
the cases in women the tubes are found affected. The process is commonly confined to the distal ends and may be
primary — which is usual — or is secondary to the peritoneal
involvement."


In this opinion of primary tubal involvement the majority
Carbohydrates
of observers agree.
Alcohol


On the other hand Williams" asserts that "Tuberculosis of
the Fallopian tubes is far more frequently of secondary than
of primary origin, and when it occurs in combination with
tubercular peritonitis, it is far more often the result of than
the cause of the latter. The fact that the fimbriated extremity
of the tube is the portion most frequently affected is of itself
evidence in favor of its secondary origin, and in several cases of
tubercular peritonitis we have found tubercles on the exterior
ofthe tube and its fimbriated end, but none in its interior,showing that the process was extending from above downward."
Among others, Siinger and Borschike confirm his view.


In this case the only indication pointing to the peritoneum
as the source of disease is the extensive caseous involvement of
its anterior part. On the other hand, primary disease of the
tubes is indicated by the still more extensive involvement of
their walls, by the presence of numerous giant cells, considered
by Baumgarten' as significant of jDrimary tubal disease, and by
the clinical history which points to the pelvic organs as the
first affected. As shown by the foregoing studies, the fimbriated extremity of the left Fallopian tube must be regarded as
the probable starting point of the whole tubercular process.


If then the tubercular disease of the tube is of primary
307.46 calories.
origin, the further question presents itself, how did the disease
319.30
arise ? Primary tuberculosis of the tubes may originate in two
379.49
possible ways: (1) By infection through the blood, and (2) by
133.50
infection from without. Primary infection through the blood
is a matter of pure speculation and is highly improbable.  
The more likely source of infection is through the vagina
from without. Although no history of such invasion could






100
Total






JOHNS HOPKINS HOSPITAL BULLETIN.  
938.65






[No. 74,
Table V. — Ukinb.  






be obtained in this case, yet it is regarded as tliemost probable
Date.  
portal of entry. The fact that the nterus was less involved
than the tube, and that the vagina was not all diseased, does
not negative this theory of infection, since the tubercle bacilli,
failing to find conditions favorable for their growth until the
left fimbriated extremity was reached, here set up their characteristic lesions. Thence they probably sjiread to the fundus
of the uterus, to the uterine cavity and cervix, to the opposite
tube, and to the peritoneal cavity, from which the general
infection took place.  


The associated involvement of pleura and peritoneum must
be considered of diagnostic value, since coincident inflammation of both these membranes is so often of tubercular origin.


Besides the extensive character of the lesions, there are several unusual features in the case. In the first place, considerable interest attaches to the fuchsin bodies so numerous in
1
this case. These bodies resemble the little globular masses
described by Russell"' in 1890 as " a characteristic organisnx
of carcinom.a," and correspond in every particular with the
description of these bodies as given by Lubarsch' under the
head of "Albuminous Degeneration."


There is scarcely a normal condition or pathological process
in which they have not been found, but their relation to malignant tumors has been especially noted. They are not of constant occurrence in any pathological change.


With regard to their nature, the view of Eussell that they
a  
may be considered as yeast fungi is no longer held. Tliey have
been variously interpreted as protozoa, hyaline thrombi, altered
Altmann's granules, von Recklinghausen's hyaline, bodies
resembling corpora amylacea, transformation of the cell protoplasm, and as a product of the tissue fluids in which a degenerative process is added to a beginning coagulation process.


Lubarsch himself inclines to the view that the Russell's
h
fuchsin bodies ai'e the product of cell protoplasm, the granules
of which have undergone certain chemical and physical
changes. He believes that they may be due either to a secretion or to a degeneration of the cell, the former occurring in
normal conditions, the latter in pathological processes. Lubarsch also refers to the relative increase of basophiles in
areasin which the fuchsin bodies abound — a phenomenon noted
by Niehus and Klien, and observed also in the present case. In
explanation of their coincident occurrence he attributes the
formation of the fuchsin bodies to a chemical change and
confluence of the granules of the former and some of the
wandering cells, and suggests that both are due to active
tissue transformation. From the description given in the
present case, this mode of origin seems probable.


A second point of interest is the rare combination of tuberculosis in both body and cervix of the uterus. Regarding
this Williams" says: "The affection is almost always limited
to the body of the uterus, rarely extending beyond the os to
involve the cervix ; and of the few cases of tuberculosis of the
cervix on record, a considerable portion occurred without any
involvement of the rest of the uterus. Tuberculosis of the
uterus which also involves the cervix is rarely met with, and
as far as we can ascertain from a careful survey of the literature, has ouly been noted in seven cases."


.a




In this connection may also be mentioned the tubercular
2
invasion of the muscular coat of the tube, which, as a rule,
escapes involvement even in advanced tuberculosis.


The large sacculated exudation occupying the anterior portion of the peritoneal cavity and simulating ovarian cyst is
a a 2
rare. Among the few recorded cases of tubercular peritonitis
with encysted collection of fluid are those reported by Bernutz,
Spencer Wells, Gardner, Howard, Erich, Ewing, Mears and
Atlee.


A feature of special interest is the thick fibro-caseous band
which extends across the pus sac in the median line of the
abdomen, and is probably the remains of the rolled-up omentum. In structure it bears some resemblance to the thickened
strands described by Klebs' as passing transversely across the
abdominal cavity below the umbilicus, and which he attributed to retraction of the omentum. Such omental tumors are
not uncommon and have frequently been described. In location, however, this fibro-caseous band does not correspond
with the transverse omental tumors, since its direction is anteroposterior and from above downward, and its attachment is by
its extremities. In explanation of this formation one can
only assume some distortion of the original omentum, with
displacement, thickening, caseation and complete transformation into the fibro-caseous band.


In conclusion, I wish to thank Dr. Flexner for valuable
a-2
suggestions during the course of this work. Dr. B. B. Browne
 
for kindly allowing the use of his clinical notes, and Mr. Max
 
Briklel for the accurate drawing which accompanies the text.
ntage of  
uric
-Nof
otal nl
 


Bibliography.


1. Baumgarten: Zeitschrift f. kliu. Med., Bd. IX and X,
Wien, 1885.


2. Oullen, Thos. S. : Tuberculosis of Endometrium. Johns
Hopkins Hospital Reports, Vol. IV, Nos. 7 and 8, 1895.


3. Flint: General Jliliary Tuberculosis, Tubercular Peritonitis, Pulmonary Phthisis. Principles and Practice of Medicine, 1886.


4. Gardner: Tuberculosis of Anterior Peritoneal Cavity.
Canada Medical Journal, Vol. 13, 1885.


5. Hegar: Monograph, Genital-Tuberculose des AVeibes.
Stuttgart, 1886.


6. IIektoen,Ludwig: Vascular Changes of Tubercular Meningitis, especially the Tubercular Endarteritis. The Journal
of Experimental Medicine, V^ol. I, No. 1, January, 1896.


7. Howard, Wni. T. : The President's Address, Transactions
American Gynaecological Society, Vol. X, 1885.


8. Klebs : Handbuch der path. Anatomie, Bd. I, p. 335.


9. Lubarsch, O., and Ostertag, 0.: Diealbuminosen Degenerationen, Ergebnisse der allgemeinen pathologischen Morphologic und I'hysiologie des Menschen und der Thiere, Vol. II,
1S95.


10. McFarland, Joseph : The (iiant Cell of Tubercle. International Medical Magazine, Vol. I, No. 10, 1892.


11. Osier, Wm. : Tubercular Peritonitis. Johns Hopkins
Hospital Reports, Vol. II, 1890.


13. Russell, Wm. : An Address on the Characteristic Organism of Carcinoma. British Medical Journal, Vol. II, 1890.






May, 189r.]
t>




? a


JOHNS HOPKINS HOSPITAL BULLETIN.


1




101




g « o «


13. Williams, J. Whitridge: Tuberculosis of the Female
Generative Organs. Johns Hopkins Hospital Reports, Vol.
Ill, 1893.


14. Williams, J. Whitridge: Tubercular Peritonitis. Maryland Medical Journal, Vol. 32, K^os. 3 and 4, 1894.
Perc
alio
bod
the
trog


15. Lenhart, C. M. : Tubercular Peritonitis. Medical Record, Vol. XLVIII, October, 1895.


Description of Plate.
July 1


Pelvic viscera fixed in formalin and hardened in alcohol,
viewed from above. Right tubo-ovariau mass seen in crosssection.


1




F. U., fundus of uterus.
1300


Right tube, showing cross-sections of tubercular lumen.


r. F. E., fimbriated extremity of right tube.
1022


r. Ov., right ovary.


if., myoma.


Rd. Lig., round ligament (left).


I. T., left tube.


I. F. E., fimbriated extremity of left tube.


I. Ov., left ovary.


From the left surface of the larger myoma projects a fibrocaseous band. To the right is attached a portion of the
abdominal pus sac.


" 2




A VISIT TO BAD NAUHEIM, WITH THE PURPOSE OF INVESTIGATING THE "SCHOTT
9
TREATMENT" FOR CHRONIC HEART DISEASE.


By C. N. B. Camac, M. D., First Assistant Resident Physician.


1400




Last November, at Dr. Osier's suggestion, we undertook to
1010
introduce into the hospital the Schott treatment of exercises
and medicated baths for cases of chronic heart disease. After
consulting the bibliography of the subject, several cases were
placed under treatment according to the instructions contained therein. At once, however, we were confronted by
numerous questions, answers to which it seemed quite impossible to find in any of the references at hand. Although the
literature dealt at length with changes in the cardiac outline,
the position of the cardiac maximum impulse and the respiration, the theories upon which the beneficial effects were based,
etc., no answers to such practical questions as the following
were given :


(1) Is any massage to be employed during or after the
bath ?


(2) What drugs are to be employed daring the treatment,
10.0940
and what drugs are contraindicated ?


(3) Should the baths and exercises be given together; or if
separately, which should precede?


(4) Are stimulants to be administered before or after the
0.4827
bath ?


(5) What should be the diet of the patient?


(6) Are cases of hydrothorax or ascites to be tapped ? etc.,
4.78
through quite a list with which it is hardly necessary to weary
you.  


Finding many of these questions unanswered, it was with
considerable interest that I received Dr. Osier's suggestion to
visit Bad Nauheim, the home of the treatment and of Dr.
Schott, its originator.


Nauheim is in the Grand Duchy of Hesse, three-quarters of
" 3
an hour from Frankfurt a. M. and two hours from Homburg.
Nearly in the centre of the northeastern half of what geologists
have called the Mayence Basin (Mainzerbecken) Frankfurt is
located, and at the eastern slope of the Johannesburg, the
last spur of the Taunus mountains, is situated Bad Nauheim.
As one approaches Nauheim he is struck by the great trestlework structures in the midst of the fields. On examining
these more closely they are found to be frame structures about




3


200 to 300 feet long and about 50 feet high, supporting switches
closely stacked one upon another. The salt waters are raised
to the top of these trestles and allowed to filter through the
interlacing switches, upon which, by the evaporation of the
water, the salt is deposited. These switches are removed
every few months or so, the salt broken from the branches,
ground and refined, and serves as the commercial salt of the
surrounding country. The most beautiful forms result from
these deposits, and by the clever devices of the natives the
most grotesque figures are produced. I have some of the
figures thus produced.


An estimation of the commercial value of these works today
1100
may be made by the value put upon them in 1806, when they
 
were considered by Napoleon an adequate reward to Marshal
Louis Nicolas Davout (erroneously written Davoust) for his
services in the French army ; and again in 1866, when they
fell to Hesse Darmstadt in exchange for Homburg. Since
1834 the reputation of Nauheim for the efficacy of its springs
has been steadily coming to the notice of Europeans. Frankfurt up to this time forming the centre and battlefield of
many of the German disputes with France, rendered Nauheim
scarcely a fit place for invalids.


It was therefore not until 1834 that we begin to hear of
1014
Nauheim as a resort for invalids. It was not until 18G0, however, that Dr. Beneke of Marburg considered scientifically
the value of the medicated bath treatment. From 1859-1870
several articles by Beneke of Marburg, upon the waters of
Nauheim, appeared in the Berlin. Klin. Woch. From 1870 to
1890 August and Theodore Schott and J. Groedel were frequent contributors on this subject to the Berlin. Klin. Woch.,
also to the Deutsch. Med. Zeitung. August Schott died, but
his brother Theodore continued the work, and published in
1892 an article in the Lancet which caused little comment.


In 1894 W. Bezley Thorn became an ardent advocate of the
bath treatment, and published an article in the Lancet and
also a small book in which he described quite fully the baths
and exercises. AVith the appearance of this systematic little
book up to the present the treatment has been very popular in


8.8358




102
4832




5.46




England. Nauheim, its waters, and the resistance exercises,
" 4
have been frequent topics in English and German medical
journals. lu France and America the treatment has as yet
received no very thorough trial. It is interesting to note here
the increase in the number of visitors from 1871 to 1895. In
1871 the visitors numbered 5,249; in 1891, 9,244; 1892,
10,272; 1893, 10,-384; 1894, 11,0)81; 1895, 14,136.


Although the season was over when I visited Bad Nauheim,
I had the opportunity of seeing the baths through the courtesy of Dr. Hirsch, Dr. Schott's assistant, who showed me
over the grounds and described very fully the details of the
treatment. It can best be described in Dr. Schott's own words :
" The springs of Nauheim may be divided into two classes,
those suitable for bathing and those suitable for drinking.
Together with other ingredients the bath waters contain from
two to three per cent of sodium chloride, from two to three
per 1000 of calcium chloride, various salts of iron, above all,
very large amounts of carbonic acid.


Coming from the dejiths of the earth, they have a temperature of 83-95° F. Springing from a depth of 180 metres,
4
supercharged with carbonic acid gas by the pressure to which
they are subjected, the waters gush far above the surface;
for example, spring No. 12 rises to a height of 56 feet and falls
again in white seething masses." This is a most sti-iking
condition ; so richly charged with carbonic acid are these
waters that the reservoir into which they fall has the appearance of a great mass of clouds. " Conveyed directly from the
main by means of subterranean pipes, these waters charged
with their natural gas are allowed to completely cover the
body of the bather. Little bubbles of gas are seen to immediately cover the whole surface of the body; the waters of
springs Nos. 7 and 12 escape from a pressui-e of from IJ to
2i atmospheres, and afford a surf bath which compares
accurately with the strongest surf bath of sea water."


The first question which arose when this matter came to be
scientifically investigated was, how do these baths and exercises act ? That they were vei'y efficacious in the relief of
chronic cardiac disease had been demonstrated for some years
back, but their action had never been investigated. There are
several explanations given :


(1) That given by Dr. Schott in the following woi'ds:
950
" Physiological research of recent years seems to show that
the salts held in solution in water externally applied have uo
direct action on the system; the light and mobile molecules of
the gas, on the other hand, pass rapidly through the skin to the
corium with its rich supply of blood. We must look upon the
salts held in solution as passing by imbibition through the
outermost layer of the epidermis, and so acting on the terminal nerves of the skin as to exert a reflex action on the
internal organs. The warm baths act in their own peculiar
manner on the organism as a whole ; increased tissue change
seems to be induced by an increase of the oxygen absorbing
power of the cells, and hence follows the sense of the need of
rest and sleep as an immediate consequence of the bath, as well
as influences speedily brought to bear on the nervous system
as a whole. Excessive bathing induces an excitable state of
the nervous system, sleeplessness, loss of appetite and consequent loss of strength. The principal changes which ensue




1018


in the system and in the function of the special organs are
that the heart beats more slowly and strongly, the jnilse
becomes full and increases in force, and the blood pressure
may rise to the extent of 20, 30 mm. of mercury; the breathing becomes regular and quiet, and the capacity of the lungs
increased.


While the patient is in the bath he becomes flushed and a
8.0964
feeling of comfort and warmth ensues which may even rise to
one of an agreeable intoxicating character. Almost invariably
the excretion of urine is increased; exudates in the body cavities, especially from the peritoneum, pericardium and pleura,
are absorbed. This latter action and that on the valves of the
heart can only be exjjlained on the theory of reflex action produced by influences acting upon the terminal nerves."


Another explanation is that given by Dr. Bezley Thorn,
that there is a dilatation of the muscular arteries and afterwards those of the skin, and thus there is a relief of the
heart from backward pressure.


In Lauder-Brunton's massage experiments he demonstrates
0.3608
that more blood flows through the massaged part and that
blood pressure at first rises and then falls, and that on the
conclusion of massage more blood collects in the massaged
part. These exjjeriments were confirmed by Dr. Oliver.* T.
Grainger Stewartf concludes that the passive exercises (I)
improve the circulation of lymph within the tissues, and (2)
bring a larger volume of blood into the muscles. He quotes
the conclusion of Ludwig to the effect that the capacity of
muscles for blood is equal to the combined capacities of the
internal organs and the skin. If therefore this be so and
Dr. Lai^der-Brunton's experiments be correct, the increased
amount of blood in the muscles must indicate a relief of the
congestion in the internal organs.  


In Dr. Schott's explanation there are two actions :


(1) A cutaneous excitation induced by the mineral and
4.44
gaseous constituents, and


(2) a more prolonged stimulation of the sensory nerves
excited by imbibition into the superficial layer of the corium.
The salt producing this excitation is the calcium chloride.


Whatever the explanation of their action may be, two points
" 5
seem established:


(1) That the apex beat alters its position ;


(2) the area of cardiac dulness is diminished. These two
ft
facts, esjDecially the first one, were most strikingly obvious in
our first cases, and both facts were most forcibly demonstrated
to me in the cases which I saw abroad. One can scarcely
credit the results published until he has seen for himself these
marked changes.


The case rej^orted by Dr. Bowles in the Practitioner for
July, 1896, shows a change of 3 cm. in the apex beat before
and after a bath of ten minutes duration, and he says after
his visit to Nauheim, which was made for the purpose of seeing for himself, " that which I thought impossible is shown
to be quite possible." This case reported by Dr. Bowles was
one of chronic myocarditis, moderate pleural effusion, general
aiuisarca and general enlargement of the heart. The age of


1100




• Brit. Med. Jour., .Tune 13, 1896.
1016
1 //'«/., September 19, 1896.




9.9715


May, 1897.]


0.3735




JOHNS HOPKINS HOSPITAL BULLETIN.  
3.72




" 6


103
 
6




750


the patient was not given. I shall not at this time attempt to
report cases, but merely mention this one of Bowles in order
to contirm what has been our experience of the effect of the
bath upon the j.osition of the apex beat, and many other
reports confirmatory of this remarkable change are to be found
in the literature on this subject.


The diagrams of the cardiac outline made by Dr. Bowles
1028
are not quite accurate, but there can be little difference in
opinion as to the position of the maximum cardiac impulse.


To quote Hr. Schott again: "The methods of administering the baths are of the greatest importance. It is advisable
to begin with a 1 per cent salt bath containing Yawn '^^ chloride of calcium, freed from gas and at temperatures varying
from 93° to 95° F., the bath lasting from six to eight minutes.
The course of treatment should be interrujited by frequent
intervals of one day. The temperature of the bath should,
if possible, be gradually lowered, while the proportion of
solids in solution and the duration of the bath are gradually increased. At a later stage it is permissible to proceed
to the baths containing carbonic acid. The temperature
may then be rapidly lowered, especially if chloride of calcium be added in order to increase the mineral strength of
the bath."


The course consists of six baths: the first and the second
7.7963
being simply with salts, calcium chloride and the sodium
chloride; the third, fourth, fifth and sixth contain carbonic
acid as well as these salts.  


The preparation of the baths artificially was taken up especially by W. Bezley Thorn, in London, in 1895, since which
time Ewart, Bowles and Broadbent have employed them in
London, Moeller in Brussels, and Heiuemann in New York.
Following the analysis of the Nauheim waters made by the
chemist Fresenius of Wiesbaden, the artificial baths may be
readily prepared. We have now packages made up at our
pharmacy each containing the proportion of salts for the different strengths of the baths, each package corresponding to
40 gallons of water, which is just about enough to entirely
immerse the body. The baths of different strengths are given
to appropriate cases.


I have not attempted in this note in any way to speak for or
0.3793
against the treatment nor to report cases. I have thought it
best for the present simply to give an outline of the trip to
Bad Nauheim, the purpose of which was to see the effects of
the treatment and to learn something about it with the object
of trying it in the Hospital here. We have now five cases
under treatment, and I trust by keeping careful records of the
effects of these baths and exercises that we shall be able to pass
judgment upon the weak points as well as the strong points
of the method. Only by a careful trial can one place himself
in a position either to recommend or to condemn the treatment.
I take this opportunity of exjjressiug my apjireciation of the
patience with which Dr. Schott heard and answered my many
questions. I also wish to thank Dr. Ileineman for the instruction in the movements which he so carefully gave me.  


In regard to the exercises, which are worthy of a lengthy
description, something must be said. They consist of nineteen
movements, each movement restrained by the very lightest
resistance. This part of the treatment, under the supervision


4.86




of a physician, is entrusted to the nurses, to whom we have
given careful instructions as to the method of carrying it out.
The following are the instructions which we have laid down
for the nurses in the administration of the bath, also the chart
showing the observation which should be made.*


Rules fok Schott Bath.


(1) Always understand clearly from the doctor the following
points: (V) Strength of the bath to be given; (3) temperature of the bath; (3) length of time patient is to remain in the
bath. Note. — Give the bath in the morning unless otherwise
ordered.


(3) Observe carefully the chart and note the points therein
Table VI. — Nitkoqen Ingested (in Grams).  
called for. (1) Give bath on an empty stomach. (2) Note
the time from the moment patient is immersed to that when he
is taken out. (3) Allow the patient to make as little exertion
as possible; assist him in every way. (4) A sheet may be
drawn over the tub, but not around the patient. (5) Be sure
the entire body is immersed. (6) Keep the finger on the pulse
during the entire time the patient is in the bath.  


Danger Signals. — Cyanosis (bluing of the face), dyspnoea
(diflicult breathing), apncea (gasping), inappreciable pulse.
On the appearance of any of these, take the f)atient out of the
bath immediately, put him to bed and keej) him as quiet as
possible. Friction while in the bath is not necessary, but if
the fingers and toes become bluish the extremities may be
rubbed slightly towards the trunk. Friction should be cautiously employed ; when the patient is out of the tub rub hini
to a glow; give him a glass of milk or cup of bouillon and
allow him to rest for an hour.


Diet. — Small quantity q. 4 h. Meat — boiled chicken, mutton
chops ; eggs, two a day ; oysters, raw or panned ; vegetables —
peas, beans, lettuce; liquids — beef tea, bouillon, cocoa, lemonade, milk. Note. — Never give more than 4 ounces of fluid at
a time. Should be sipped. Wine — Port, Ehine, sherry,
brandy, dram to half ounce.


Note. — Something light (cocoa and toast) should be taken
one-half hour before the bath ; something light and hot
(bouillon, milk piuncb and toasted crackers) should be taken
directly after the bath. If the heart's action is poor, sherry,
brandy or port wine may be given after the bath. Last meal
to be taken three hours before retiring.


Bath No. I. Sodium chloride, 4 pounds; cal. chlor., 6 ozs.  
Date.  


Bath No. IT. Sodium chloride, 5 pounds; cal. chlor., 8 ozs.


Bath No. HI. Sodium chloride, 6 pounds; cal. chlor., 10
Day of observation.  
ounces; sodium bicarb., 6 ounces; HCl, 7 ounces.  


Bath No. IV. Sodium chloride, 7 pounds; cal. chlor., 10
ounces; sodium bicarb., 8 ounces; HCl, 13 ounces.


Batli No. V. Sodium chloride, 9 pounds; cal. chlor., 11
Ham.  
ounces; sodium bicarb., 1 pound; HCl, 1 pound.  


Bath No. VI. Sodium chloride, 11 pounds; cal. chlor., 12
ounces; sodium bicarb., 1 pound; IICl, 2 pounds.


Each bath consists of 40 gallons of water.  
White
bread.  


Note. — By using a little more NallCOn than is required


Milk.




* These rules are made after perus.al of the literature, also from
wine.  
instruction obtained from Dr. Schott personally.  




Total
nitrogen.


104


July 1


" 3
" 4
" 5
" 6




to take up the HCl, the metal tubs may be employed without
1
doing them auy harm.
2
3
4
5
6


NaHCOs + HCl = NaCl + H=0 +00^.


4.4480
4.4480
4.4480
4.4480
4.4480
4.4480




83.75
1.5236
1.5236
1.5236
1.5236
1.5236
1.5236




2.9925
2.9925
2.9225
2.9225
2.9575
2.9575


36.37
The Exercises.*


0.0568
0.0568
0.0.i68
0.0568
0.0568
0.0568




The exercises are called by Dr. Schott "Widerstandgymnastik," or resistance gymnastics, and consist in slow
9.0209
movements executed by the patient and resisted by the physician or operator. A short interval is allowed after each
9.0209
movement, during which the patient sits down. The exertion
8.9.509
employed must be very small, and should cause no increase in
8.9509
resjjiratory movements, flushing or j)allor. The patient should
8.9859
be loosely and lightly clothed, and instructed to breathe
8.9859
quietly. The resistance made should be of such a kind that
the patient may always feel himself easily the master. The
operator must not grasp or in any way constrict the limb, but
should oppose by the hand held flatly. The movements are
nineteen in number:


Arm. (1) Arms extended in front of body on a level with
shoulder, hands meeting; arms carried out until in line, and
brought back to original position. (2) Arms hanging at sides,
palms forwards; arms flexed at elbow until tips of fingers
touch shoulder, back to original position ; one arm only moved
at a time. (3) Arms down, palms forward, arms carried outwards and upwards until thumbs meet over head; back to
original position ; one arm only moved at a time. Not always
advisable. (4) Hands in front of abdomen, fingers flexed so
that the second phalanges touch those of opposite hand; arms
raised until hands rest on top of head ; back to original position. (5) Arms down, palms against thighs, arms raised in
parallel planes as high as possible; back to original position.


Trunk. (6) Trunk flexed on hips ; return to original position. Resist tvith hoth hands. (7) Trunk rotated to left,
to right; return to original position. Resist with both hands.
(8) Trunk flexed laterally. Resist with both hands. (9) As
No. 1, but fists clenched. Resist with both hands. (10) As
No. 2, but fist clenched. Resist with both hands.


Large Arm Movements. (11) Arms down, palms against
Table VII. — Nitkogen Balance (N in Grams).


*The description of each movement is taken (with a few modifications) from "Chronic Disease of the Heart" by W. Bezley
Thome.






thighs, each in turn raised forwards and upwards until arm is
alongside of ear, then turned outward, and arm descends backwards. Not always safe. (12) Arms down, palms to thighs,
both together moved backwards in parallel planes as far as
possible without bending the trunk forwards. Not always
safe.


Legs. (13) Thighs in turn flexed on trunk, opposite hand
o g
resting on chair. (14) Lower extremities in turn extended
fully, and bent on trunk forwards and backwards to extreme
limits of movement, opposite hand resting on chair. (15)
Legs in turn flexed on thigh, both hands on chair. (16) Feet
together, lower extremities in turn abducted as far as possible
and brought back to original position, opposite hand on chair.


Hands and Feet. (17) The arms, extended horizontally outwards, are rotated from the shoulder-joint to the extreme
limits forwards and backwards. (18) The hands in turn are
extended and flexed on the forearm to extreme limits, and
brought back in line with arm. Resist tuith both hands. (19)
The feet in turn are flexed and extended to extreme limits,
and then brought back to their natural position. Resist with
both hands.


We have arranged these in 5 groups, as in this way they
>,SS
may be more readily committed to memory.


Rules for Operators.
1^


1. Each movement to be performed slowly and evenly at an
uniform rate.


2. No movement to be repeated twice in succession in the
ll
same limb or group of muscles.


3. Each single or combined movement to be followed by
interval of rest. Count five.


4. Patient's breathing should not be accelerated.  
NITBOGEN ELIMINATED.  


I. Avoid. 1. Dilatation of the ala? nasi (dilating of nostrils).


2. Drawing of corners of mouth.
111


3. Duskiness and pallor of cheeks and lips.


4. Yawning.
g


5. Sweating.


6. Palpitation.


If any of the above make a complete interval, or if excessive, stop the exercises for the day.


5. Direct patient to breathe regularly. If he holds his
Drluo.  
breath, make him count in a whisper.  


(i. Do not constrict the part which is being moved.


Fceces.




SCHOTT METHOD OF BATHS AND RESISTED MOVEMEN"
B
Diagnosis Name Hospital No.




Johns fi
July 1
" 2
" 3
" 4
" 5
" 6


rs.


1
2
3
4
5
6


0PKIN^


54.200
54.300
54 200
53 9011
53.600
53.200


Hospital.
Ward


9.0209
9 0209
8.9509
8.9509
8.9859
8.9859




lb'.6940
8.8358
8.0964
9.9715
7.7963


• Balh !


l| ana
b;3879
0.3879
0.3879
0.3879
0.3879




TIME
10.4819
9.2237
9.4843


10.3.594
8.1842


Respiration. Pulse and Heart [P,".|-Jr;?ile f SEE HISTORY '«''-n?e\%''e°e°jr']


— l'.46i6
—0.2728
-0.5333
—1.3735
+0.8017






It
Relation of Neusser's granules in the leucocytes : On the
day before the analyses were begun the granules were present
in very small numbers in the leucocytes. This was also the


as




case on July 1st and 3nd, when a relatively high amount of
alloxuric bodies was being eliminated. On July 3rd there was
an apparent and on the following days a very marked increase
in the number of granules, whilst the nitrogen of the alloxuric
1)odies both absolutely and in percentage became diminished.
Observation IV. — Patient was a woman 45 years of age.
Fourteen years ago she had her first severe attack of articular
rheumatism, although she has had milder attacks since 1881.
Both hands at present show characteristic deformities. Since
1891 she has had symptoms of some cardiac lesion. In 1895,
tricuspid and aortic insufficiency was diagnosed. During the
period that the patient was under observation she was comparatively well ; good diuresis and no cedema. Average pulserate, 80 ; respirations, 23. Moderate body exertion was possible
without dyspnoea. Cyanosis was quite marked.


The diet was as follows : Ham, 100 grams ; breakfast rolls
(4), 308 grams; milk, 500 grams; wine (white), 350 grams;
tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces),
30 grams ; Rohitsch water, 300 grams.


Date
These food materials represented about 1386 calories (36
 
calories per kilo body weight), which were made up as follows:


of samel
Albumin 334.19 calories.
aud
Movements


Fat 323.47


In bod
Carbohydrates 643.19


Alcohol 185.50


Just
before




1st halt
Total 1386.35


Table VIII.— Urine.


2nd halt




Immed.
after




10 mtu.
i
after




Pulse
a
Pressure
ga




Calibre of
Radial




Point Maximum
,  
Impulse,  




Remarks
^




% oo




Begin
Date.




End
°




R.  
Eg .  




P.
i




R.
d j




P.
§ "^ ffl 




R.
¥^i'u




P.




B.




P.




R.




P.




K.




P.




Before




After
f^




Before
fi°"




After
% g




Before
|gi




During
§5?g




Afterl>Betore
Perc


bod
tho
trof


During


July 19


Atter


1




2400




1012




8.2320




0.3276




3.97




" 20




2




2800




1007




9.6530




0.4459




4.61




May, 1897.]
" 21




3


JOHNS HOPKINS HOSPITAL BULLETIN.


2150




105
1012




9.9706


Bibliography.


[Those references without the asterisk the writer was unable to
0.3517
consult. Arranged in chronological onler.]


Beueke, F. W.: Ueber Naiilieim's Soolthermen, etc. Marburg, 1859.


Weitere Mittheihmgen iiber die Wirkungen der Sool
3.52
thermen Nauheims. Marburg, 1861.  


* Nauheim's Soolthermeu gegen Gelenkrheuiuatismus mit


oder ohne Herzaffection. Berlin, kliu. Wocheuschr., No.
" 22
33, 1870, p. 269.


Zur Therapie des Gelenkrheumatismus luid der damit


verbundenen Herzkraukheiten. Berlin, Hirschwald, 1872.
4


* Neue Erfahruugen iiber die Wirkungen der kohlen
siiurehaltigeu 8oolthermen Nauheims, etc. Berlin, klin.
Wochenschr., 1875, No. 9, p. 109 ; No. 10, p. 134.


*Groedel, J. : Ein Beitrag zur Behandlung der Lilhniungeu
1400
bei Apoplektikern mit Herzfehlern. Berlin, klin. Med.
AVoeheuschr., No. 10, 1878, p. 137.


* Pneumatometrische Beobachtuugen iiber den Eiufluss


verschiedener Biider auf die Kespiration. Berlin, klin.
1014
Wochenschr., No. 32, 1880, p. 314.


* Die Wirkung der Biider auf das Herz. Berl. klin.


Wochenschrift, 1880, No. 20, p. 438.  
9.6530


* Zur Behandlung Herzkranker. Berlin, kliu. Wochenschr., No. 35, 1883, p. 381.


*Schott, T. : Beitrag zur tonisirenden Wirkung kohlensiiurehaltiger Theramalsoolbilder auf's Herz. Berl. klin. Wochenschrift, 1883, No. 28, p. 428.  
0.3463


*Schott, A. und Theo. : Die Nauheimer Sprudel und Sprudelstrombiider. Berlin, klin. Wochensch., 1884, No. 19, p. 394.


*Schott, A. : Zur Therapie der chronischen Herzkraukheiten.
3.58
Berl. klin. Wochenschrift, No. 33, p. 534. 1885.  


Leichtenstern, 0. : General Balneotherapeutics. Ziemssen's
Handbook of Therapeutics, Vol. IV, p. 395. London,
1885.


Schott, August: Die Bedeutuug der Gymnastik fiir Diagnose, Prognose und Therapie der Herzkraukheiten. Zeitsch.
" 23
f. Therapie, 1885.


Schott, Th. : Die Hautresorption und ihre Bedeutuug fiir die
Physiologie der Badewirkungen. Deut. Med. Zeitung, 1885.


Oertel, M. J. : Therapeutics of Circulatory Derangements.
5
Ibid., Vol. 7, 1887.


Schott, Th. : Die Behandlung der chronischen Herzkraukheiten. Berlin, Grosser, 1887.


Zur Pathologie und Therapie der Angina Pectoris.
700


Deut. med. Zeitung, 1888, No. 35-38.


Wiborgh, Aug. : Bad Nauheim, etc. Stockholm, 1888.
1023


Bode, W. : Bad Nauheim, seine Curmittel, Indicationen und
Erfolge. Zweite Aufl., Wiesbaden, 1889.


*Schott, Theodore: Herzkraukheiten. Separat-Abdruck aus
9.9356
der Keal-Encyc. der gesammten Heilkunde. Wien und
Leipzig, 1890. (Reprint.;


* Zur acuten L^eberanstrengung des Herzens und dereu


Behandlung. 1890. Separ. Abdr. aus den Verhandlungen
0.4383
des IX. Congresses fiir innere Medicin zu Wien. (Eeprint.)


* Herzkraukheiten. Keal-Encycl. der gesammten Heilkunde. Wien und Leipzig, 1890. (Reprint.)


4.41




*Groedel, J. : Ueber abnorme Herzthiitigkeit in Folge von
lunervationsstoruugen. No. 21, 1890, p. 467.


*Schott, Theodore: The Treatment of Chronic Diseases of
Table IX. — Nitrogen Ingested (in Grams).  
the Heart by means of Baths and Gymnastics. Lancet,
1891, Vol. I, p. 1143. Concluded on p. 1199. (Reprint.)


Israel, E. : Om Nauheimkur, etc. Copenhagen, 1891.


Schott, Th.: Balneo-therapeutic and Mechano-therapeutics
applied to the Treatment of Chronic Heart Disease. Medical Record, No. 7, Vol. XXXIX, 1891.


* Zur Differentialdiagnose des Pericardialexudats uud


der Herzdilatation. (Reprint.) Berlin, klin. Wocheuschrift, 1891, No. 18.


Ueber Herzneurosen. 1893. Separ. Abdr. aus der Real-Encycl.
Day of
der gesammten Heilkunde.


*Moeller: Traitement des maladies du coeur par la methode
des Drs. Schott. Bruxelles, 1893. (Repriut.)


*Babcock : Schott Method of treating Chronic Diseases of the
Heart. Journal of American Medical Assoc, XXI, pp.
717-734, 1893.


Summers, Guillermo: Tratamiento de las enfermades cronicas
del corazon por el metodo del Dr. Schott. Gaceta Medica
de Cadiz, 1893.


Groedel: Bad Nauheim and the Treatment of Chronic Heart
Date.  
Disease. St. Petersburg Med. Woch., 1893.  


*Schott, T. : The Mineral Waters of Nauheim, their Action,
Uses and Effects. Eyre & Spottiswoode, London,
1894.


Smyly, P. C. : On the Treatment of Enlarged Heart by Certain Movements as taught by Dr. Schott, Nauheim. Dublin Jour, of Med. Scieu., 1894, Vol. 3, p. 185.  
observation.  


*Thorne, W. Bezley : Treatment of Chronic Diseases of the
Heart by Baths and Exercises according to the Methods
of Dr. Schott. 1894. Churchill, London.


*Thorne, W. B. : The Treatment of Chronic Diseases of the
Ham.  
Heart by Baths and Exercises according to the Method of
Dr. Schott. Lancet, 1894, Vol. I, p. 1117.  


*Wethered, F. J. : The Treatment of Chronic Diseases of the
Heart by Baths and Gymnastics as practised at Nauheim.
Brit. Med. Jour., 1894, Vol. II, p. 1045.


*Brunton, T. L. : The Harveian Oration, 1894. London.
July 19


♦Campbell, H. : The Mechanical Treatment of Heart Disease.
British Med. Journal, 1894, Vol. 2, p. 1101.


*Eccles, A. Symous: Mechanotherapy in Chronic Diseases of
1
the Heart. The Practitioner, 1894, Vol. I, p. 107.


*Pagenstecher de Mexico, G. : Du traitement balneomechanique des maladies chroniques du coeur d'apres la m6thode des docteurs Schott de Nauheim. Bulletin General
de Therapeutique, Paris, 1894, Nos. 15-30, Juin. (Reprint.)


*Babcock, Robert H. : Report of Cases of Chronic Heart
5.2052
Disease treated by the Schott Method of Baths and Gymnastics. N. Y. M. J., LX, pp. 705-710, 1894.  


*Schott, Th. : Zur Behandlung des Fettherzens. Deut. Med.
Wochensch., XX, 561, 1894.


Armstrong: Nauheim Treatment of Chronic Cardiac and
" 20
Allied Diseases. Liverpool Medico-Chirurgical Journal,
July, 1895.


*Sturge, W. A. : Note ou the Treatment of Dilated Heart as


2




106
5.2052




" 21




practised at Naiiheim. Brit. Med. Jour., 1895, Vol. I,
3


p. 537.
*Thorne, W. B. : Tlie Treatment of Chronic Affections of the


Heart by Baths and Esereises. Brit. Med. Jour., 1895,
5.2052


Vol. I, p. 524.
* The Schott Method of Treatment in Chronic Diseases


of the Heart. London, 1895.
" 22
*Practitioner, May, 1895, p. 385. The Treatment of Chronic


Heart Disease by the Method of Dr. Schott, Nauheim. By


John F. H. Broadbeut. With some remarks on the mode
4


of action of the treatment and its indications. By Sir


William Broadbent, Sen. Physician to St. Mary's Hospital.
5.2052
*Thorne, W. B. : The Treatment of Chronic Affection of


the Heart. Brit. Med. Jour., 1895, I, p. 524.
Kraus, W. C. : Some Advances in Cardiac Therapeutics. Med.


Press and Circ, Loudon, 1895.
" 23
*CTroedel: The Mechanico-Gymuastic and Balneo-Tliera
peutic Treatment of Chronic Cardiac Disorders. Lancet,


London, pp. 802-804, 1895.


Baths in Cases of Arterio-sclerosis. Deut, Med. Zeitung,
5


1895.


Green, C. L. : The Treatment of Chronic Heart Disease by
5.2052
the Schott Method. N. W. Lancet, St. Paul, XV, 345-349,
1895.  


Pospischil: Hydrotherapie bei organischen Herzkrankheiten.
Deutsch. med. Ztg., Berlin, XVI, 581-586, 1895.


de Bosia, H. : Des indications des eaux minerales dans les
traitemeut des maladies da coeur. Cong. Franc, de MC'd.,
Paris, 845-852, 1895.


*Sauudby, Robert: Remarks on the Nauheim (Schott) Treatment of Heart Disease. B. M. J., Nov. 2, 1895, p. 1081.
3.3473 2.9837
Discussion, p. 1129.  


Birmingham Medical Review, Vol. XXXVIII, 1895, No.  
3.3473 2.9837


208.  
3.3473 2.8787


Fisher, T. : The Treatment of Heart Disease. The Hospital,
3.3473 2.6950
August 24, 1895.  


*Heinemauu, PI. N. : Experiences with the Physical and Schott
3.3473 2.9312
Treatment of Chronic Heart Disease. N. Y. Medical
Record, 1896, L, 847-852.  


*Mason, A. L. : The Baths of Nauheim in Heart Disease. Boston M. and S. J., 1896, CXXXV, 302.


*Morrison, A. : The " Schott Treatment " of Heart Disease.
Practitioner, London, 1896, LVII, 268-275.


♦Report of the Lancet Commission on Balneological and
0.0785
Gymnastic Treatment of Heart Disease at Nauheim. Lancet, London, 1896, II, 619-621.  
0.0785
0.0785
0.0785
0.0785


*McArthur, A. N. : Heart Disease treated by Saline Baths.
B. M. J., 1896, I, 1384.


♦Carter, A. H. : The Schott Treatment of Heart Disease. Practitioner, 1896, LVII, 166. [No direct bearing upon the
treatment.]


*Erebuske, C. J.: Gymnastics in Heart Disease. Bost. M. &
0.1312
S. J., 1896, CXXXIV, 610-612. (Discussion) 618-620.  
0.1312
0.1312
0.1312
0.1312


*Graiipner. Die Balneotherapie der chronischeu Herzkrankheiten, ihrMechanismus und ihre Beziehung zur Dynamik
des Kreislaufs. Deutsche Med. Wochensch., 1896, XXII,
529-531.


Nauheimer Mineralbader und einfache Wasserbader:


11.7459
11.7459
11.6409
11.4572
11.6934




ihr Einfluss auf Blutdruck und Herzthiltigkeit. Allg. Med.
Centr. Ztg., Berl., 1896, LXV.


Cireene, C. L. : Extreme Dilatation of the Heart due to
Table X. — Nitrogen Balance (N in Grams).  
Valvular Disease, with Special Reference to Treatment
by the Schott Method. luternat. Clin., Phila., 1896, 6 s.,
II, 63-73.  


Yeo, F. B. : Rest, Exercise and Baths in the Treatment of
Cardiac Affections. luternat. Clinic, Phila., 1896, 6 s.,
II, 31-42.


Bowles, R. L. : Nauheim and the Schott Treatment of Diseases of the Heart. Med. Press and Circ, London, 1896,
N. S., LXI, 339. Discussion, 345.


*Kingscote, E. : Fifteen Months' Practice of the Schott Methods for the Treatment of Chronic Affections of the Heart.
Date.  
Lancet, London, 1896, I, 761-7C3.  


*Nebel, H. : The Treatment of Heart Diseases by Baths and
Gymnastics. N. Y. Med. Record, 1896, XLIX, 7)7. (Early
literature.)


*Broadbent, Sir W. N. : Note on Auscultatory Percussion and
the Schott Treatment of Heart Disease. Brit. M. J.,
1896, I, 769.


*Leith, R. F. C. : An Inquiry into the Physiology of the
Action of Thermal Saline Baths and Resistance Exercises
in the Treatment of Chronic Heart Disease (the Nauheim
and Schott System). Edinb. M. J., 1895-6, XLI, 804,
814. Also Lancet, 1896, I, 757, 841.


♦Campbell, H. : The Schott Treatment of Heart Disease.
.1
Lancet, 1896, I, 951. [Communication on Leith's paper.]


*The Schott Treatment as carried out at Sidmouth. Brit. M.
J., 1896, I, 924.


Anderson, McO. : Dilatation of the Heart treated by Exercises on the Schott Principle. Glasgow M. J., 1896, XLV,
2
266, 268.


♦Poore, G. V.: Two Cases of Heart Disease treated by Saline
NITBOGEN ELIMINATED.  
Baths. B. M. J., London, 1896, I, 1139.  


*Rives, W. C. : The Baths of Nauheim in the Treatment of
Disease of the Heart and the Therapeutic Methods of the
Doctors Schott. N. Y. M. J., 1896, LXIII, 471-479.


Steven, J. L. : On the Nauheim (Schott) Methods of Treatment as applied to Cases of Cardiac Valve Disease of
i .  
Rheumatic Origin. Glasgow M. J., 1896, XLV, 339-361.  


*Thorne, W. B. : Self -Poisoning in Heart Disease ; its Relation to Schott Methods of Treatment. Lancet, Loudon,
1896, I, 755-757.


♦Schott, T.: Ueber gichtische Herzaffectiouen und dereu
§
Behandlung. Berliner klin. Wochenschrift, XXXIII,
 
457-519, 1896.


♦Stewart, Grainger: Discussion on Treatment of Cardiac Failure. Brit. Med. Journal, September 19, 1896.  
Urine.  


♦Bowles, R. L. : An Experimental Inquiry into the " Schott
Treatment" of Certain Diseases of the Heart at Bad Nauheim. The Practitioner, July, 1896. (Reprint.)


♦Ileinenmu, H. Newton: Die physikalische Behandlung der
Fffices.  
chronischen Herzkrankheiten. Deut. Med. Woch., 1896,
No. 33, Leipzig. (Reprint.)


♦Cohen, Solomon Solis : The Schott Method of Gymnastics in
Chronic Heart Disease. JIaryland Jledical Journal, Feb.
20, 1897.






May, 1897.]
July 19
" 20
" 21
" 22
" 23




1
2


JOHNS HOPKINS HOSPITAL BULLETIN.
3


4
5




107
47.700
47.400
46.800
45.700
46.000
 
 
11.7459
11.7459
11.6400
11.4572
11.6934




8.2320
9.6530
9.9706
9.6530
9.9356


A CASE OF POROKERATOSIS
WITH


0.9985
0.9985
0.9985
0.9985
0.9985




(MIBELLI) OR HYPERKERATOSIS EXCENTRICA (RESPIGHD
9.2305
A REMARKABLE FAMILY HISTORY.*
10.6515
10.9691
10.6488
10.9341




+2.5158
+1.0944
+0.6718
+0.80S4
+0.7593


PKELIMINAEY NOTICE.




Relation of Neusser's granules in the leucocytes: On the
first two days of the observation the granules were comparatively few. On Jiily 21 they were relatively increased, whilst
the alloxuric bodies, which had been comparatively high on the
20th, were distinctly diminished in quantity.


By T. Caspar CtILCHRist, M. 11. C. S., L. S. A., Associate in Dermafologi/, Johns Hopki)is Unicersifi/.  
Observation Y. — The patient was a brewer, 30 years old, with
hypertrophic cirrhosis of the liver. Since 1895 he has had
icterus, with tenderness in the region of the liver. The jaundice has had a tendency to disappear and reappear. The faeces
at times would be distinctly bile-tinged, and at other times
free from biliary coloring matter. Appetite good. At present
there is a characteristic enlargement of the liver and spleen,  
no ascites, and no well marked evidence of collateral circulation. No elevation of temperature. Rather poorly nourished ;
weight has varied between 62 and 59 kilograms since April
10. Has a retinitis. Urine is free from albumin.  


The daily diet was as follows : Ham, 300 grams ; bread, 700
grams ; wine, 500 grams ; tea (infusion), 500 grams ; mm, 30
grams ; sugar (6 pieces), 30 grams ; soda water, 4 bottles.


These food materials represent about 2806 calories (47
calories per kilo body weight), which were arranged as follows:


In October, 1893, Mibelli, of Italy, described three (slight
references were made to three others) cases of a new disease
which, after a careful and detailed histological examination,
he named Porokeratosis. The disease began at an early age,
and was chiefly distributed on the backs of the hands, feet,
other portions of the extremities, neck, face and scalp. The
lesions commenced as minute, dirty brown, dry, cone-shaped
elevations of different sizes and forms, which became much
altered as they very slowly increased in size. The lesions extended centrifugally, and the central portion gradually sank in
and still remained callous, but the margin was represented by
a raised wavy ridge which presented the features of a raised
seam. Some patches grew to a very large size and covered
almost the whole forearm. Mibelli gave the name porokeratosis
to this disease because the most important anatomical lesion
was the hyperkeratosis of the sweat duct and sweat pore. In
one instance a brother and sister had the disease, mainly on
the face and neck. The disease was exceedingly chronic and
was unaccompanied by any inflammation or any subjective
symptoms.


On January 15, 189-1, Respighi, also of Italy, described seven
cases of a disease which was recognized by Mibelli as belonging to the same group. Respighi gave the name of " Hyper


Albumin
Fat


*Exhibited before the Johns Hopkins Hospital Medical Society,
Carbohydrates
March 1, 1897.
Alcohol






keratosis excentrica" to this affection. In one of the cases
516.27 calories.  
the father of the patient also was affected with similar lesions.
256.21
Two years later, three more cases were described by the same
1726.10
author. A single case has been recorded outside of Italy, by
308.00
Dr. M. B. Hutchius, of Atlanta, Ga., in the Journal of Cutaneous and Genito- Urinary Diseases for October, 1890. In
 
Hutchins' case the disease began at two years of age, on the
 
2)alni of the left hand. The patient is now a man, 33 years
old, and has the disease on the left palm, the back of the hand
and forearm, and on the face. No histological examination
was made. Hutchins compares the boundary of the patches
to the "outside of a seam with a thread-like line dividing its
lateral halves, and consisting of horny epidermis." No other
member of the family had it. In all the cases which have
thus far been recorded, only two gave histories of other members of the same family having the disease. In the one case
(Mibelli's) a brother had it, and in another (Respighi's), the
father of the i^atient had it.


The patient whom I exhibit this evening is a young man,
Total 2806.58
21 years of age, who has had the disease since he was five
years old, when it commenced on his ears, nose, chin, neck,
back of hands and right forearm. The lesions were extremely
slow in ap2)earing and in growing. The most remarkable
feature about the whole case is the family history, which is
here given in a tabular form, together with a very brief descrijitiou of the disease in each case.  


Table XI. — Urine.




Grandmother.


Disease on the face ;
commeuced when she
was a child iu 1813,
now dead.






One Brother.


Lesions on the face,
oommeucing at an
early afie and lasting
until death.






Father.






Disease began at about
8 years of age and is on
the face, palms, back
of hands, forearms,
legs, feet, and sole of
one foot.




^


One Brother.


Disease commenced at
Date.
about 9 years of age,
on face and leg; died




1


One Son.
No eruption.


i




28 years old, married.
Disease commenced
at 7 years, on face.




Is


Brother 0).
a 5


Aged 30 ; four lesions
on left side of nose,
commenced at 5 yrs.


s?3i2 i




Brother i2).
HS^.^
Aged 17; disease just
commencing (?), one
lesion on neck.  






Aged 15; number «)f
lesions on face which
began at about 9.


P^




9 years old: disease
¥
commenced at 7 and
quite extensive on
face.




aui


Aged 11; disease commenced at 9 years on
face.


s 3i


o a


108








It will be seen that eleven persons in one family have had
this disease. The patient gave me this history after careful
inquiry, and I have since been able to verify his statements
with reference to seven of the cases, viz. father, three brothers,
a married sister and two of her children, by personal observation. The patient's description of the lesions in his father
and brothers, whom I examined later, was so correct that I
feel confident the other descriptions are also true, especially
since the remaining family history was verified by his father
and mother. The father of the patient also described to me
the disease as it existed on his mother, an uncle and brother.
I will not go any further into the history or description of the
lesions occurring in other members of the family, but will
reserve that for a more detailed histological description with
photograph and drawings, which will appear later.


The patient first came under my care eighteen months ago,
May 15
and my attention was then only directed to the lesions on the
face. I did not diagnose the disease until I had made ten or
more histological examinations of excised portions and had
seen Mibelli's and llespighi's articles.


The eruption consists of lesions of various sizes and forms
which appear to take on two characters according to their
age. The smallest variety, which are distributed chiefly over
the face, consist of minute (less than 1 mm. in diameter), dirty brown, semi-globular elevations of a horny nature.
When they reach the size of a small pinhead the centre becomes depressed and the margin in some is slightly raised, round,
oval or slightly irregular, and presents the appearance of a
raised seam, along the centre of which runs a thin black line.
As the patch becomes very slowly larger the base takes on a
somewhat atrophic character. In a few of the lesions, especially those on the neck, a number of minute conical elevations
are distributed along the ridge, giving it an irregular appearance, and sometimes one or two of these minute cones appear
in the central portion of the plaque. The largest patches are
about the size of a split pea.


After removing some of the diseased portions with a curette and applying very thoroughly the silver nitrate stick, I
1




1630


have seen on four or five occasions the disease return within a
month or two in the manner described, viz. a very minute,
dirty brown papule, which within two or three weeks apparently began to clear up in the centre. Other lesions return in
the form of a ring or oval ridge. If one of the patches is
curetted it is fairly easily removed, but the operation is
followed by almost as much bleeding as the removal of a small
epithelioma. Examination of the scrapings, either fresh or
after treatment with liquor potassaj, is negative. While watching the course of the disease week by week, I have seen new
lesions arise which I had not detected the week previous.


One or two of the lesions appeared to have formed round a
1026
hair follicle, but others did not exhibit any such relationship.  
 
 
13.2511
 


A histological examination of a large number of sections
0.4773
from the most recent as well as from the oldest patches showed
that the disease consisted of a marked hyperkeratosis of the
sweat pore and duct and of the adjacent hair follicle. In
some of the material excised from the face it was not
clear tliat the hyperkeratosis had commenced in the mouth of
a hair follicle, but in other sections, especially of the smallest
variety of lesions, the disease had undoubtedly commenced
about the sweat pore. The oldest lesion, especially from the
ear, presented a picture almost identical with that of a mild
psorospermosis foUicularis (Darier).  


From the clinical and histological characters of the disease
there was no doubt of the diagnosis of all the cases, but the
special feature of this rare lesion was perhaps most marked
in the case of the father of the patient, who presented on the
hands lesions which showed the well-defined raised wavy edge
with a thin blackish line along the centre.


The character of the disease on the hands agreed perfectly
3.60
with the descriptions of Mibelli and Hutchins. JSfibelli has
reported 6 cases, Eespighi 10 cases, and Hutchins 1. I am
able to record a group of eleven in one family, which fact
seems at first sight to point to a strong hereditary taint. The
histological features will be discussed in detail and a fuller
clinical description will be given in a later article.  




" 16


A RAPID METHOD OF MAKING PERMANENT SPECIMENS FROM FROZEN SECTIONS BY


THE USE OF FORMALIN.
2


By Thomas S. Gdllen, M. B., Resident Gynecologist.


1830




In April, 1895, I published two methods under the above
10:i3
title in the Bulletin.


Since then, numerous requests have been made for reprints
or for copies of the Bulletin of that number, and as the
supply is exhausted, it has been thought best to publish the
article again with one or two minor alterations. The methods
have been continuously employed in the Hospital, and especially in the gynecological department, and have proved uniformly satisfactory.


A complete freezing outfit has been placed in close proximity
14.6564
to the operating room, so that as little delay as possible may
occur in examining a specimen. For example, if a carcinoma




0.4153


of the uterus is suspected, the patient is brought to the
operating room prepared for hysterectomy. The uterus is
curetted and the scrapings are examined while the usual preparations for abdominal section are being made. By the time
all prejsarations are completed the diagnosis is given; if negative, the patient is returned to the ward with the assurance
that there is no cause for alarm ; if positive, the organ is
immediately removed. The woman is thus saved from taking
an anajsthetic twice, and avoids the period of anxious suspense
of four or five days generally required by the ordinary methods to ascertain whether she has malignant trouble or not.
Any one who has hardened tissues in formalin will be im


2.83


May, 1897.]


" 17




JOHNS HOPKINS HOSPITAL BULLETIN.
3




1550


109


1023




pressed with the rapidity of its action, with the firm consistence of the tissue, and with the absence of the contraction of
16.2778
the specimen so often seen when alcoliol is used as the
hardening medium. Microscopical examination of a specimen
hardened in formalin, as we all know, shows almost perfect
preservation of the cellular structure. Recently it occurred
to me that formalin might be used in the preparation of frozen
sections.  


One of the greatest difficulties experienced in rendering
frozen sections permanent lies in the fact that when passed
through alcohol the section frequently not only contracts but
contracts irregularly, distorting the specimen ; further, such
specimens will often stain imperfectly. The use of formalin
will obviate these difficulties, allowing one to make an excellent permanent specimen from the frozen section. My
method is as follows: The tissue to be examined is frozen
with carbonic acid or ether aud then cut; the sections are
then placed in 5 per cent, watery solution of formalin for 3 to
5 minutes, or longer if desired; in 50 per cent, alcohol 3
minutes, and in absolute alcohol 1 minute. The tissue is now
thoroughly hardened aud can be treated as an ordinary celloidin section, being stained and mounted in the usual way.
On examining this mounted section one might readily take it
for a well preserved alcoholic specimen. Supposing we stain
with hematoxylin and eosin, the entire process is as follows :


Method I. a. Place the frozen section in 5 per cent. aq. sol.
0.5089
formalin for 3 to 5 minutes.  


b. Leave in 50 per cent, alcohol 3 minutes.*


c. In absolute alcohol 1 minute.  
3.12


d. Wash out in water.


e. Stain in ha^matoxylin for 2 minutes.
" 18
/. Decolorize in acid alcohol.


g. Rinse in water.


h. Stain with eosin.
4


i. Transfer to 95 j)er cent, alcohol.


j. Pass through absolute alcohol, then through either creasote or oil of cloves, and mount in Canada balsam.  
nno
 
 
1024
 
 
17.2238
 
 
0.4918


The blood is lost in frozen sections. To overcome this Prof.
Welch suggested that the sjiecimen be first fixed in formalin
and then frozen. I tried this aud found that we were able
to preserve the blood, but that it did not stain very distinctly.
For convenience this second procedure will be called method
II. The essential factor is the same in each case. The latter
process, however, requires at least two hours. A small piece
of the tissue is thrown into 10 per cent, solution formalin for
two or three hours. It is then put on the freezing microtome
and thin sections can be readily made. The sections are
stained in the usual way. The detailed procedure of method
II is as follows:


2.85




*The sliglit modification of Method 1, recently suggested by L.
" 19
Pick, Centralblalt f. Gyn., Bd. XX, S. 1016, 1896, I cannot recomirieiul. When first experimenting with formalin, among other prolures I tried staining the sections after hardening in the formalin
I before placing them in alcohol, as Pick now suggests. The
ifsulls were fair, but the definition so obtained was not to be compared with that gained by first passing through 60 per cent, and
absolute alcohol for the short period. I accordingly abandoned it
and did not think it worthy of publication.




5


Metliod II. a. A piece of tissue lx.5x.2 cm. is placed in 10
per cent. aq. sol. formalin for 3 hours. Rinsed in water.


1). Frozen sections are made.
2040


c. Left in 50 per cent, alcohol 3 minutes.*


(/. In absolute alcohol 1 minute.
1024


e. The sections are now run through water and stained in
hsematoxylin for 3 minutes.


/. Decolorized in acid alcohol.  
20.2051


g. Rinsed in water.


/;. Stained in eosin.  
0.4118


/. Transferred to 95 per cent, alcohol.


j. Passed through absolute alcohol, then either through
2.03
creasote or oil of cloves, and mounted in Canada balsam.  


For ordinary use method I is all that is required. Given a
piece of tumor from the operating room, it is possible to give
as definite a report in 15 minutes as one would be able to give
after examining the alcoholic or Miiller's fl.uid sjjecinieus at
the expiration of two weeks. Method II is of especial value
in the examination of uterine scrapings. Instead of putting
them in the 95 per cent, alcohol in the operating room, they
may be immediately dropped into 10 per cent. aq. sol. formalin.
By the time the pathologist receives them, which is at least
two hours afterwards, they are firm enough to be frozen without difficulty, and permanent sections can be immediately
made. The second method is to be recommended for all delicate tissues. In employing these methods one must remember,
as for example in epithelioma, that some of the cell-nests will
drop out, there not being anything to hold them in situ, as
there is when celloidin is used. AYe have, however, hardened
and stained epithelioma of the cervix by this method without
the slightest difficulty.


" 20




NOTICE.
6


All inquiries concerning the admission of free, part pay, or
private patients to the Johns Hopkins Hospital should be addressed
to Dr. Henry M. Hurd, the Superintendent, at the Hospital.


Letters of inquiry can be sent, which will receive prompt answer,
1690
or personal interviews may be held.


Under the directions of the founder of the Hospital the free beds
are reserved for the sick poor of Baltimore and its suburbs and for
accident cases from Baltimore and the State of Maryland. To
other indigent patients a uniform rate of $5.00 per week has been
established. The Superintendent has authority to modify these
terms to meet the necessity of urgent cases.


The Hospital is designed for cases of acute disease. Cases of
1022
chronic disease are not admitted except temporarily. Private
patients can be received irrespective of residence. The rates in
the private wards are governed by the locality of rooms and range
from $20.00 to $35.00 per week. The extras are laundry expenses,
massage, the services of an exclusive nurse, the services of a
throat, eye, ear and skin or nervous specialist, and surgical fees.
Wherever room exists in the private wards and the condition of
the patient does not forbid it, companions can be accommodated at
the rate of $15.00 per week.


One week's board is payable when a patient is admitted.


DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL
16.4352


Bv John s. lin.i.iNos, M. D., LL. D.
C.mtalulng 60 Urgo cjuartu pl.-iiofl, phototyDOS, and llth<.gi-apli», wli.h vIbwb
lilaua and detail drawings ot all tUo bulldiugs, aud Uielr liuerl"!- arranguniouts—
also wood-cuts of apparatus and flxtures; also U6 pages of letter-press describing
the plans followed In the cnnstruoUou, and giving full details ot heatlug-apparatua,
ventilation, sewerage and plumbing. Price, bound In cloth, $7.50.


0.4771




2.90




PROCEEDINGS OF SOCIETIES THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.


Meeting of December 7, 1896.  
Table XII. — Nitrogen Ingested (in Grams).  


Dr. Thayer in the Chair.


Typlioid Perforation treated by Surgical Operation.— Dr.


FiNNKY.  
Date.  


In 1762 Richter, in Vienna, first suggested the advisability
of oiJeuiug and draining the peritoneal cavity in cases of general suppurative peritonitis. The operation did not come to
general notice, however, until 1884, and was not applied to
cases of suspected perforation of the intestine in typhoid fever
until 1887. Since that date 46 cases have been reported, to
which may be added 6 unpublished cases, including 3 of Dr.
Finney's, making a total of 53.


According to statistics taken from various sources, perforation of the intestine occurs in from 1 per cent, to 2 per cent.  
Day of observation.  
of all typhoid fever cases. In 80 per cent, of the cases it
 
occurs in a thickened and iutlamed Peyer's patch of the ileum,
 
from 2 cm. to 1 m. above the ileo-cascal valve. In over 12 per
Ham.  
cent, it occurs in the large intestine, and in 5 per cent, in the
 
appendix vermiformis. There is usually but one perforation.
 
In twelve cases, however, multiple inflamed Peyer's patches
Bread.  
were observed. It occurs more often in men than in women ;
 
more frequently between the ages of 20 and 30 years, and usually during the third week of the disease. The duration of
life is usually short. In typhoid fever, perforation is always
followed by suppurative peritonitis, either general or local ;
howevei', peritonitis may arise during the fever without any
discoverable perforation. It occurs much more frequently in
mild than in severe forms, and the symptoms may be severe,
mild, or wanting. The most constant and characteristic symptom is sudden, severe abdominal pain, persisting with increasing
intensity ; there may be collapse, nausea and vomiting. A few
of the cases have shown chill, hiccough, a marked fall of temperature, and absence of the liver dulness. Owing to the great
difficulties of diagnosis it is impossible to get data as to the
number of recoveries without operation.


A study of the reports of the operations brings out the
White wine.  
following facts. The time between theonsetof the symptoms
of perforation and the oj)eration varied between 2 and 12 hours.
The condition of the patients at the time of operation was
usually markedly unfavorable. Ether and chloroform were
used about equally ; in one case both were used. The median
incision was the most common. Thirty-three of the cases
showed marked general septic peritonitis with foul pus and
exudate. Faecal matter was usually present, and the mesenteric glands opposite the ulcerated Peyer's patches were, as a
rule, enlarged and softened. In the treatment, irrigation of
the peritoneal cavity was employed more often than simply
wiping. As regards the perforation itself, in 8 cases the edges
were incised before suturing; in 2 a wedge-shaped piece of the
bowel was removed, and in 1 the edges of the bowel were
stitched to tlie abdominal wound while an artificial anus was
established. Including all of the 52 cases, there have been 17
recoveries; but if doubtful cases are excluded, the result is




Total nitrogen.


13 recoveries from 47 cases,making a percentage of 27.65. In
19 of the fatal cases autopsies were obtained.


These data are hardly sufficient for general conclusions, but
May 15-19
several points are brought out quite prominently in studying
" 20
the group as a whole. The best time for operation is apparently as soon as possible after the patient has recovered from
the shock attending the perforation. This is usually in a few
hours. There is a remarkable uniformity in the condition of
the peritoneum and viscera ; intense congestion, much feculent
pus and exudate, with distension of the bowel. As the ileum
is the usual place of perforation, it should be examined first ;
a suture should be taken over any suspicious-looking patches,
and the appendix should be removed if it be at all abnormal.
If the inflammation does not involve the whole peritoneal surface, irrigation with the necessarily mild fluids might tend to
spread the infection. In dealing with the perforation, to
excise the edges takes too long, and healing usually takes place
without. Should the wall be in such a condition as to make
suture impossible, it would be better to pull out the loop of
intestine and leave it until the patient had recovered from his
fever. The line of suture must be determined by circumstances; the mattress suture of Halsted is to be preferred.
Drainage should always be employed. The fact that in 8
cases a wrong diagnosis was made shows how little dependence
can be placed on the so-called characteristic symptoms. However, the systematic examination of the blood promises to be
of the greatest assistance. During typhoid fever there is no
leucocytosis, but immediately after a perforation a marked
increase in the number of white corpuscles occurs. Cabot
mentions a case of 8,300 before and 24,000 after ; in Porter's
case the figures are 6,500 and 10,600 ; in his (Dr. Finney's),
3,000 and 16,400.


Fitz has pointed out the striking similarity of the symptoms of typhoid perforation to those of inflammation of the
appendix. Dieulafoy recognizes two forms of typhoid appendicitis capable of producing peritonitis ; one, "peritonitis by
propagation," involving the lymphoid tissue of the appendix,
the other, " para-appendicitis," which is of the usual variety.


The symptoms of peritonitis quickly follow perforation.
1-5
Examination shows that pyogenic cocci, especially the streptococcus pyogenes, are rarely absent, indicating that they are
6
common inhabitants of the intestine. The Johns Hopkins
Hospital autopsy reports show in 4 cases a mixed infection of
streptococcus pyogenes and bacillus coli communis, in one a
pure culture of the streptococcus, and in one a pure culture
of the colon bacillus. The absence of the bacillus of Eberth
and Gaifky is probably due to its being destroyed by its more
active companions, streptococcus pyogenes and bacillus coli
communis. In Dr. Finney's third case pure colon bacillus
was found; in other cases the typhoid bacilli were present in
liver or spleen or in a peritoneal abscess.


As regards the incision, the median has obvious advantages
in general, but if the abdominal muscles are too rigid, it is
lielter made over the part most often affected. Its length
should always be amply suflicient. On the other hand, the


13.0454
11.3237




May, 1897.]
7.9398
7.9398




0.2625
0.2625


JOHNS HOPKINS HOSPITAL BULLETIN.


21.2477
19.5260




Ill
 
Table XIII. — Nitrogen Balance (N in Grams).






time consumed in operation should be as short as possible.
The autopsies showed that healing was always well under way.
Death usually occurred from septic absorption, but the records
show some other complications, obstruction of the intestine, a
second perforation, defective drainage or an abscess. General
peritonitis makes a case very serious, but with operation the
chances are about 1 in 4. The treatment of a case of perforating typhoid ulcer involves three things: (1) Finding and
closing the perforation ; (3) emptying and cleansing the peritoneal cavity; (3) the establishment and maintenance of
effective drainage.


For these ends the following method, employed in his (Dr.
Finney's) third case, has proved the most satisfactory. An
oblique incision, about 6 inches, is made in the right iliac
fossa. The Ciscum is found as a guide to the ileum (or
appendix); the coils of small intestine, beginning with the
ileum, are pulled out systematically. One assistant wipes
vigorously and thoroughly the coils with a gauze sponge
wrung out of hot salt solution as they are withdrawn, while
another keeps them covered with warm sterile gauze. If
necessary the entire small intestine is pulled out through
the wound and laid to one side, covered with warm gauze.
The peritoneal cavity is then wiped out thoroughly, and the
coils uncovered and irrigated outside the abdomen with hot
salt solution. They are then replaced in the abdomen. The
worst or sutured coil is placed with its suture next the
abdominal wound, and is packed about with strips of bismuth
gauze to insure good drainage. The abdominal wound is
closed tightly except a small opening for the gauze drain. In
case of distension the bowels should be moved early and
thoroughly by calomel in broken doses, followed by salts,
and if necessary, a high turpentine and soapsuds enema.
If stimulation is necessary, use hypodermics of strychnia,
enemata of hot black coffee, or transfusion of a quart or more
of the normal salt solution into the cellular tissues under
the breast.


Finally, in summing up the experience of himself and
others, he concludes that (1) of all the so-called diagnostic
signs of perforating typhoid ulcer, most reliance is to be
placed upon the development during the third or fourth week
of an attack of typhoid fever, of severe, continued abdominal
pain, coupled with nausea and vomiting, and at the same time
a marked increase in the number of white blood corpuscles.


(2) The surgical is the only rational treatment of perforating typhoid ulcer. •


(3) There is no contraindication to the operation, surgically speaking, save a moribund condition of the patient.*


Case I. — Mr. M.,aged about fifty-five years, was taken sick about
October 15, 1894, complaining of headaclie, general malaise, pains
in limbs and joints, togettier with irritability of the bladder. Was






•Since the above was written one other case has been reported by
NITROGEN ELIMIN
Armstrong, of Montreal (Montreal Med. Journal, Vol. XXV, No. 8,
1897). This case recovered from an operation for the relief of first
perforation. Twenty-four days later, however, a second, and four
days later a third perforation occurred, from the effects of which
the patient finally succumbed. Reference is also made to the fact
that two other fatal cases had occurred in that vicinity.


o^




seen on October 19 by his physician, Dr. Wesley C. Stick, of Glenville, Pa., to whom I am indebted for the notes of the case. " He
gave an indefinite history of having felt badly for about ten days.
He had at this time a temperature of 102° F., frequent micturition,
bowels constipated, pulse 100. Patient up and dressed ; was put to
bed and bowels opened by enemata. In a few days temperature
came down to about 100° F., pulse to 90. Would not stay in bed.
Irritation of bladder ceased. Was getting along very nicely until
the night of October 2(ith, when he was suddenly seized witli a
violent pain in his abdomen while lying in bed. Was seen the
next morning. Pain in abdomen very severe, relieved somewhat
by emptying the over-distended bladder through a catheter. He
had been unable to void urine during the night, although having
frequent and urgent desire to do so. Several hypodermics of morphine were necessary, however, before he became easy. An enema
was given with little result. His abdomen was moderately distended, and not very tender to the touch. In the evening of the same
day he was seen again and found to have considerable pain, which was
relieved by a hypodermic. Had vomited some during the day. His
pulse was about 90 ; temperature 99° to 100° F. The following day,
October 28, he vomited frequently a coffee-ground-looking fluid.
On the fourth day, October 29, his condition remained about the
same ; he could get in and out of bed by himself (he was a largeframed, heavy man, weighing about 225 pounds) ; pulse regular and
not above 90 ; cheerful ; the constant regurgitation of coffee-ground
fluid being the most troublesome symptom. On the next day,
October 30, he was able to sit up in bed, but his pulse had risen to
100 and his temperature to 100° F. Abdomen still not much distended nor very tender."


I saw him at eleven o'clock the night of October 30; his condition
then was fairly good, temperature and pulse about 100. Abdomen not
much distended, rather retracted ; muscles, especially the recti, very
rigid ; tenderness general, but not marked ; frequent and copious
vomiting of a dark brownish fluid ; countenance pallid and anxious.
The diagnosis was general peritonitis, cause unknown, probably
appendicitis, although Dr. Stick had from the first suspected
typhoid fever with a subsequent perforation of the intestine. The
patient had been exposed to typhoid contagion during a recent
visit.


As his condition was evidently becoming worse, it was thought
best to open the abdomen. The operation was accordingly performed, and under most disadvantageous conditions, about midnight, in a small log house, with very poor light. On opening the
peritoneum it was found to be everywhere intensely congested, of
a dark chocolate color ; the coils of intestine distended and covered
here and there with flakes of exudate. There was a considerable
quantity of turbid feculent fluid everywhere in the abdomen. A
perforation was found in the ileum, about six inches from the
cKcum, about one and a half centimetres in diameter, with sloughy
edges. These were turned in and sutured with Halsted's mattress
suture. The peritoneal cavity was cleansed as thoroughly as possible by sponging, the sutured coil irrigated with salt solution and
replaced. The appendix was found normal, save the inflammation
of its serous covering. The abdominal cavity was thoroughly
drained with strips of iodoform gauze, the ends of which were
brought out through the wound. The operation took about one
hour. His condition at the end was somewhat collapsed, but he
rallied under stimulation, administered hypodermically and by
rectum. He began to fail, however, and died about seven hours
after the operation. No autopsy.


Case II.— J. P. D., aged twenty-six years; single; American;
tailor; entered the Medical Ward of Johns Hopkins Hospital,
August 3, 1895. Family history is negative, except that his father
died of some intestinal trouble, the nature of which was unknown,
and one brother died, a year ago, of typhoid fever.


Has had diseases of childhood and several attacks of chills and




^


112


§2




JOHNS HOPKINS HOSPITAL BULLETIN.  
ATED.  




a — t3


[No. 74.


<0




fever at varying intervals. With these exceptions has been well.
Date.  
Smokes much, does not ilrink, denies venereal contagion. Present
illness l)egan six days before entrance, with severe frontal lieadaches and a slight chill followed by fever. These symptoms have
persisted, together with anorexia ; no nose-bleed. For past two days,
diarrhoea ; has vomited twice ; slight abdominal pain, especially
before micturition. Temperature on admission, 103.8° F.; pulse,
92. Blood examination negative as to malarial organism ; abdomen
generally tender, slightly distended ; no rose spots ; spleen palpal)le. Leucocytes 3000 per cubic millimetre.  


The patient's disease ran a more or less typical severe typhoid
course, up to August 16, a. m., thirteen days after entering the hospital, when the following note appeared in the medical history:
" Last night patient began to complain of a sharp pain at base of
penis, notrelieved by catheterization. Temperature has been rather
higher, reaching 105° F., pulse 108, regular, though soft and dicrotic.
Very nervous ; abdomen very tense, though not greatly distended.
Everywhere tympanitic ; complains of pain ; tenderness marked ;
tongue coated ; sweating profusely, and frequently cries out with
pain ; baths discontinued and cold sponging substituted." P. M.
" Patient has been comparatively quiet since a. m., but at about 4
p. m. liegan to cry out and complain of intense pain in abdomen.
Morphine administered hypodermically. Leucocytes, 16,400 per
cubic millimetre."


The patient was seen by me with Dr. Thayer at 9.30 p. m., and
operation decided upon.


Operatio7i. — Median incision. Peritoneal cavity filled with cloudy,
sero-purulent fluid. Peritoneum dark red and much congested.
Coils of intestine distended and covered here and there by flakes
of lymph. A single perforation, about one centimetre in diameter,
was found in the ileum, about sixteen centimetres from ileo-csecal
valve. It was situated, apparently, in the centre of a thickened
Peyer's patch, and had sharply punched-out edges. Numbers of
raised, red areas could be seen here and there along the lower few
feet of the ileum. The loop containing the perforation was drawn
out of the abdomen, carefully cleaned of the exuded lymph and
fiEcal matter, and the rent closed transversely with eight fine,
black-silk mattress sutures (Halsted's). Owing to the rigidity of
the abdominal walls and the distension of the bowels, puncture of
the intestine in several places was necessary, in order to allow of
the escape of gas. The loops of intestine were carefully cleansed
by irrigation with hot salt solution, and the entire peritoneal cavity
thoroughly wiped out with dry gauze. Iodoform gauze was used
for drainage, and the abdominal wound closed except where the
gauze drainage was brought out.


At end of operation, which lasted a little over an hour, the
patient was somewhat collapsed ; temperature 103.3° F. ; pulse, 150 ;
respiration, 56. He recovered from this somewhat, under vigorous
stimulation, and in four hours his temperature was 101.6° F.; pulse,
130 ; and respiration, 28. His condition did not change materially,
except that he became gradually weaker, and died twenty-six hours
after the operation. I regret to say tliat no bacteriological examination was made, and no autopsy allowed.


C.\seIII. — Charles H., German, aged forty-seven years; married;
laborer; admitted to Johns Hopkins Hospital, .\ugust 15, 1896.
Family history good ; no cancer or tuberculosis. Has had the usual
diseases of childhood, since which time has been strong and well,
except an attack of malaria with chills and fevers eight years ago.
I'his attack lasted four weeks. Denies venereal disease; smokes
and drinks in moderation. One week before was taken ill with a
lieadache, general malaise, and loss of appetite, and later in the
day had a distinct chill, followed by fever. Next day felt somewhat better, but was weak and unable to work. He kept in bed
until his admission to the hospital one week later. During this
time had had several chills and more or less fever, appetite fairly
good, but had eaten nothing but liquids and soft solids. He had no






epistaxis nor vomiting ; no pain, nod-arrhoea, bowels had been regular. At about 8 o'clock on the evening before admission (August 14),
wliile at stool, he was seized with sharp, stabbing pains in right side
of abdomen, with marked tenderness to the touch. Nauseaand vomiting were present. His physician was called in and gave him morphine hypodermically, which relieved thepain. He passedafairly
comfortable night and was brought to the hospital early the next
a. m., when the following condition was noted :


Face pallid and expression anxious ; tongue coated, margin and
tip clean and red. Temperature, 101° F.; pulse, 116, regular and of
good volume. Lungs and heart negative ; alidomen is uniformly
distended, no undue prominence in any region noted ; skin normal;
tympanitic throughout ; rigidity of abdominal muscles throughout,
especially of the right rectus in its lower part. In iliac region
indistinct tumefaction felt ; tenderness general, but more markeil
over right lower quadrant. Rectal examination negative ; no eruption on skin ; urine showed nothing abnormal.


A diagnosis of beginning general peritonitis, jirobably due to
appendicitis, was made. I confess, at the time, the possibility of
perforating typhoid ulcer did not occur to me.


Immediate operation advised and agreed to. After the usual
])reliminary preparation the abdomen was opened through an
incision along outer border of right rectus. Abdominal wall distinctly cedematous. The peritoneum was everywhere intensely
congested, roughened and dull, with flakes of plastic lymph. In
the pockets between coils of intestine and extending down into
the pelvis there was an accumulation of thin, yellowish, turbid
fluid, containing flakes of exudate. There was no marked fsecal
odor to this fluid. The intestines were distended, congested, and
dark colored. In passing towards the median line and hypogastric
region the congestion and peritonitis became less marked, and in
the upper left quadrant the peritoneum seemed fairly normal. At
no place was there the slightest attempt apparent at walling off the
inflammatory process. The appendix was found in its normal
position, somewhat thickened and congested, and constricted at
about its centre, due to old adhesions. It was ligated, excised, and
stump covered with peritoneal cuflf. About fourteen inches from
ileo-cascal valve, in the ileum on its free border, a small hole, about
four millimetres in diameter, was found. It was sharply defined,
edges bright red and thickened. It was in the middle of what
appeared to be a swollen and enlarged Pej'er's patch. Soft yellow
ftecal matter was exuding from the opening. Opposite the ulcer
was a mesenteric gland enlarged to the size of an olive, soft and of
a bright red color. The loop of ileum was brought out through the
wound and packed about with gauze. The edges of the ulcer were
turned in and sutured with eight mattress sutures of fine black silk.
The edges of the ulcer were not excised. After suturing, the loop
was thoroughly cleansed with salt solution and dry gauze and
returned, the peritoneal cavity thoroughly and systematically wiped
out with pledgets of dry gauze. Some distance below in the ileum
a second swollen Peyer's patch could be made out. Bismuth gauze
in strips was packed loosely about the sutured portion, and theends
brought out through the lower end of the incision. Tiie rest of it
was closed with buried sutures of silver wire. The wound was
dressed with silver foil and sterile gauze. His condition at the end
of the operation was good. Time of operation one and a half hours.
Pulse, 120, and of good volume ; respiration. 20 to 25, regular ; color
good ; no sweating or coldness of extremities. Shortly after operation an enema of several ounces of black coffee and peptonized milk
given.


August 16. Patient passed a fairly comfortable night. Pain not
so severe as before oi>eration ; very little ^listension ; says he feels
better. Temperature and pulse still somewhat elevated, 102° F. and
110 respectively. liis general condition improved steadily forabout
a week, when his temperature and pulse began to go up a little.
His tongue became more coated, but abdomen not distended nor
tender. Spleen not palpable ; no rose spots. An offensive discharge




1^


May, 1897.]


1?




JOHNS HOPKINS HOSPITAL BULLETIN.
§1




Urine.


113
 
Faeces.




5gi


of pus from the right ear indicated an otitis media. About this
time a severe pain in the lower part of left thorax developed. Auscultation detected a slight friction rub beginning just below the
nipple and running into axillary line.


Blood cultures aspirated from spleen were negative. His temperature and pulse almost reached the normal on August 28, and
n
remained there for a week, when a sharp rise, accompanied by a
chill, occurred. His second relapse was quite a severe and prolonged one, so much so that he was transferred to Dr. Osier's ward,
where he could be given the cold-bath treatment more conveniently.
On September 14 the following note was made by Dr. Osier:
" Tongue a little dry ; temperature has been continuously elevated
since Septembers. Between 6th and 9th not above 100° F. Since
9th above 101° F. On the 12th and 13th, 104°, and on 14th,
105° F.; pulse, 128. Complains of pain in abdomen, which is fiat
and natural looking. Respiratory movements well marked ; no tension ; everywhere soft. Pain referred to hypogastric region and
about navel. Edge of spleen not palpable." During the ten days,
from September 17 to 27, his temperature ranged about 103° F.,
occasionally going above 104° F. He was given thirty-eight tubbaths during this period. It reached the normal on October 6, and
remained there.


During this time he developed great tenderness in the toes of
both feet, and extending up the front of right leg to the knee
was some redness and stiffness. This gradually subsided. Several
small furuncles on buttocks and sacrum appeared, which were
opened. On October 23 he was well enough to be up for the first
time. Improved steadily up to November 2, when a phlebitis of
right femoral vein with pain and swelling of leg developed. This
gradually subsided, and he eventually made a perfect recovery.


Cultures taken at the time of operation from the peritoneal
May 15
cavity and edges of ulcer showed pure culture of bacillus coli communis.


Dr. OsLER. — It may interest you to know of the number of
cases of perforation in our series. Since the hospital opened
we have had about 530 cases (I have not the exact figures for
this year) of typhoid fever, with 48 deaths, of which 16 occurred from perforation. The percentage of death from this
cause is unusually high, for I think Dr. Finney mentioned it
was the cause of death only in about six per cent, of the fatal
cases.


That two of Dr. Finney's cases were supposed to be appendicitis is a point of great interest. It is not the first nor will it
1
be the last time that this mistake has been made. There are
instances in which patients with typhoid fever without perforation have been operated upon for appendicitis with a fever
of five or six days' duration and a swelling in the right iliac
fossa. Patient has been admitted to the hospital, operated
upon for apjiendicitis, no perforation found, but an enlarged
ileum and swollen mesenteric glands. It is to be borne in
mind, however, how frequent is perforation of the appendix
among cases of perforation in typhoid. We have had at least
four or five in our cases. There have been two cases of recovery in which symptoms of appendicitis in typhoid seemed very
clear.


One word as to the time of the operation. This case was unusually favorable inasmuch as it was seen early and the perforation occurred before the 8th day, which is, perhaps, as soon as
ever it occurs in typhoid fever. I think the very early and
the very late cases will probably be the most favorable for
operation. The statistics that Dr. Finney gives are certainly
most encouraging.


59.200




NOTES ON NEW BOOKS.  
21.2477


Transactions of the American Pediatric Society, held at Virginia


Hot Springs, May 27, 28, 29, 1895. Edited by Floyd M. Cran
13.2510
DALL. (Philadelphia, 1896. Reprinted from the Archives of


Pediatrics.)


The meetings of this society are characterized by the practical
2.2526
papers presented and the general discussion of them by the members present.  


The present report of its seventh session contains a number of
articles relative to the more important diseases of infancy and childhood, with discussion of many of the newer remedies. The list of
contributors includes many of the best-known writers on the subjects mentioned.


The treatment of diphtheria with antitoxin as an immunizing
15.5036
agent, and its toxic effects, are especially dwelt upon. A resolution
was finally adopted that in the opinion of the society the evidences
thus far produced of the beneficial action of this remedy justify
its further and extensive trial.  


Several papers on anomalous forms of scarlet fever and eruptions
simulating this disease, and one on the use of icthyol ointment for
the local treatment of the eruption of scarlet fever, are worthy of
special notice.


With regard to the use of the antitoxin of tetanus in tetanus of
-1-5.7741
the newborn, the evidence seems to show that up to this time it
is uncertain in its action, and that chloral hydrate with one of the
bromides is to be preferred.  


The antitoxin of erysipelas seems to have had no influence in
treatment of sarcoma of the kidney, but the author of the paper is
inclined to the view that any foreign substance injected into or near
the substance of a sarcoma tends to effect a cure, by setting up
degenerative changes in the neoplasm, hence the apparent favorable
action of erysipelas antitoxin in sarcomata which are external
and accessible, and its failure in visceral sarcomata.


There are also papers on purulent otitis media, " inanition " fever
" 16
in the newly born, the frequency of typhoid fever in children
under three or four years, hyperpyrexia, pygopagus, the neuroses of childhood, tetany, symmetrical gangrene following scarlet
fever, angina resembling diphtheria with absence of the bacillus,
cardiac anomaly, and the association of enormous heart hypertrophy, chronic proliferative peritonitis and recurring ascites
with adherent pericardium, in which the view is expressed of
the probable progress of the chronic proliferative process along
the veins, through the diaphragm, until it involves the peritoneum.


The report is in good type, well edited and arranged.


2




BOOKS RECEIVED.  
58.500




21.2477


A Collection of the Published Writings of William Withey Oull, Bart.,
M. D., F. R. S. Edited by Theodore Dyke Acland, M. D. Memoir
and Addresses. 1806. 8vo. 184 pages. The New Sydenham
Society, London.


Proceedings of the American Medico-Psychological Association, at the
14.6564
Fifty-Second Annual Meeting, held in Boston, May 26-29, 1896. 8vo.
332 pages. Published by American Medico-Psychological Association.  


Saint Thomas's Hospital Reports. New Series. Edited by Dr. T. D.
Acland and Mr. Bernard Pitts. . Vol. XXIV. 1897. 8vo. 510 -i118 pages. J. and A. Churchill, London.


Archives of Clinical Skiagraphy. Edited by Sydney Rowland, B. A.
2.2526
Camb. Vol. I, No. 3, December, 1896. Fol. The Rebman Pub.
Co., Limited, London.  


Pathological Report Illinois Eastern Hospital for the Insane. 1896.
8vo. 236 pages. The Blakely Printing Co., Chicago.


Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and
16.9090
America. Edited by T. L. Stedman, M. D. Vol. IX. Diseases
of the Digestive Organs. 1897. 8vo. 820 pages. William Wood
& Co., New York.  




-1-4.3387


114


" 17




JOHNS HOPKINS HOSPITAL BULLETIN.
3




58.500


[No. 74.


21.2477




PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.  
16.2778




2.2526


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


Report In Patliologry.  
18.5304


The VesselB 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
-f2.7173


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


(Atrophy). By Heney J. Berkley, M. D.
" 18
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By P. P.


Mall, M. D.


Report In Dermatology.
4
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By


T. C. GlLCHKiST, M. D., and Emmet RliroRD, 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
58.9(10


Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum


Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
21.2477


T. C. Gilchrist, M. D.


Report In PatliologTAn Experimental Study of the Thyroid Gland of Dogs, with especial consideration
17.2238


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


2,2526




Volume II. 570 pages, with 28 plates and figures.  
19.4764


Report In Medicine.


On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
-hi 7713


Gallstones. By William Osler, M. D.
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.
On Pyrodin. By H. A. Laelecr, M. D.
Cases of Post-febrile Insanity. By William Oslbk, M. D.
Acute Tuberculosis in an Infant of Four Months. By Hahkt Todlmin, M. D.
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.


Report In Medicine.
" 19
Tubercular Peritonitis. By William Osler, M. D.
A Case of Raynaud's Disease. By H. M. Thomas, M. D.
Acute Nephritis in Typhoid Fever. By William Osler, M. D.


Report in Gynecolosry.
The Gynecological Operating Room. By Howard A. Kelly, M. D.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard


A. Kelly, M. D., and Hunter Robb, M. D.
5
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of


Abdominal Section. By Howard A. Kelly, M. D.
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,


M. D.
59.400
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;


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


March 4, 1890. By Howard A. Kelly, M. D.
21.2477
Report of the Urinary Examination of Ninety-one Gynecological Cases. By HowABD


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.
20.2051
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxosarcoma of the CHitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment


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


Howard A. Kelly, M. D.  
2.2526


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


in the Management of Dead Spaces. By W. S. Halbted, M. D.
22.4577
Report in Neurology, I.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.
Haematomyelia. By AoonsT HocH, M. D.
A Case of Cerebrospinal Syphilis, with an unusual Lesion in the Spinal Cord. By


Henry M. Thomas, M. D.


Report in Patlioloery* I.
-0 7900
Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafledk, M. D.




" 20


Volume III. 766 pages, with G9 plates and figures.


Report in Patliology.
6


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


Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D.
60.000
Report in Pathology.  


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


The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.  
19.52G0


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


Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
16.4352
 


Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
2 2o26


Report in Gynecology.


The Gynecological Operating Room; An External Direct Method of Measuring the
18.6878
Conjugata Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retroflcxed Uterus. By Howard A.
Kelly, M. D.  


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


Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavely, M. D.  
-t-0.3611






Gynecological Operations not involving Cceliotomy. By Howard A. Kelly, M. D.  
Relation of Neusser's granules in the leucocytes : Several
days before the commencement of the chemical analyses the
granules were much more numerous than they were during
the period of examination. There was no variation observed


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 Abdo
minal Pelvic Operations. By Howard A. Kelly, M. D.
Photography applied to Surgery. By A. S. Murray.
Traumatic Atresia of the Vagina with Haematokolpos and Hxmatometra. By Howard


A. Kelly, M. D.
during the latter period. Altogether the granules were only
Urinalysis in Gynecology. By W. W. Russell, M. D.  
moderately numerous, but not more so in the mononuclear
than in the other varieties of leucocytes. Some of the mononuclears were without granules. It will be seen that the
amount of the alloxuric bodies was relatively high.  


The Importance of employing Ansesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.  
Observation VI. — This patient was a man also with hypertrophic cirrhosis of the liver. Since 1893 he had complained
Resuscitation in Cihloroform Asphyxia. By Howard A. Kelly, M. D.
of gastric and intestinal symptoms. In 1895 enlargement of
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.  
the liver and spleen was noticed. Icterus has been persistent,  
with the exception of one interval when he was free. Weighed
49 kilo when he came to the clinic, but has gained slightly
since. The blood examination showed 2,500,000 red corpuscles, 7900 leucocytes, and 55 per cent hajmoglobin (Fleischl).  


By Howard A. Kelly, M. D., and Mary Sherwood, M. D.
The daily diet was as follows: Ham, 300 grams; white
Abdominal Operations performed in the Gynecological Department, from March 5,  
bread, 450 grams ; milk, 500 grams; wine (red), 300 grams;
tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces),
30 grams : Kohitsch water, 2 bottles.


1890, to December 17, 1892. By Howard A. Kelly, JI. D.
The above diet represented about 2370 calories (48 per kilo
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
body weight), which were made up as follows :


May 4, 1892.




Albumin
Fat


Volume IV. 504 pages, 33 charts and illustrations.
Carbohydrates
Alcohol


Report on Typhoid Fever.


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


Report in Neurology.  
515.65 calories.
385.02
1161.38
308.00


Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of J/«s mitsculus; The Intrinsic Nerves of the Thyroid Gland of
the Dog: The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,
M. D.


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


Report in Gynecology.
Total 2370.05
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. CtlLLEN, M. B.
Report In Pathology.
Deciduoma Malignum. By J. Whitridoe Williams, M. D.  


Table XIV. — Urine.




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


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


Studies in Typhoid Fever.
By William Osler, M. D., with additional papers by G. Bluueb, M. D., Simon
Flexner, M. D., Walter Reed, M. D., and U. C. Pabscns, M. D.


C*




Volume VI. About 500 pages, many illustrations.
2


Report In Neurology.


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


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


Report in Pathology.
g


Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.


CULLEN, M. B.
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of


Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins, M. D.
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. C^ullen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By


William D. Booker, M. D.
o
The Pathology of Toxalbumin Intoxications. By Simon Flexner, M. D.
Tlie price of a set hound in cloth iJols. I-VI] oftlir Hospital Reports is


$30.00. Vols. I, Jl ami JII are not sold sejKiratcli/. The price of


Vols. IV, r and VI is $5.00 each.  
Date.  


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID 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 Rufobd,


M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,
Q^
 


$3.00.
g^8
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.


Hewetson, II. D. And A STUDY OF SOME FAT.\L CASES OF MAI^ARIA.


My Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ^.76.
as
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted


from Vols. IV and V of the Johns Hopkins Hospital Reports, 1 volume of 481


pages. Price, bound in paper, $3.00.
-2 2
Subscriptions for the above publications may be sent to
a a


The Johns HorKiNS Press, Baltihors, Ud.
1 °


|a




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


body— N 1
grams.




BULLETIN
Percentage
alloxurlo
body— N
the total n
trogen.




June 7


OF


1




THE JOHNS HOPKINS HOSPITAL.
2500




1015


Vol. Vlll.-No. 75.]


14.4813




BALTIMORE. JUNE. 1897.  
0.6650




4.59


[Price, 15 Cents.


" 8




COIsTTEIsTTS.
2




2050


Report of a Case of Polybacterial Infection in Typhoid Fever,
with especial Reference to certain Involutions exhibited by
the Bacillus Typhosus. By Edward Perkins Carter, M. D., 115


A Case of Typhoid Fever in which the Typhoid Bacillus was obtained twice from the Blood during Life. By E. Bates
1017
Block, JI. D., 119


Successful Cultivation of Gonococcus in two Cases of Gonorrheal Arthritis and one of Tfenosynoviti4, with Remarks on
a New Medium. By Francis R. Hagner, M. D., - - -121


A New ^sthesiometer. By Lewellys F. Barker, M. B., - 125
16.3590


Edinger on " The Development of Brain Paths in the Animal
Series." By C. R. Bardben, M. D.. 126


0.6188




page.  
3.78
By Simon Flex-" - - - 128




" 9


Pseudo-Tuberculosis Hominis Streptotricha.


NER, M.D.,
3


Proceedings of Societies :


Hospital Medical Society, 129
3200


Discussion of Dr. Friedenwald's paper on Congenital Motor
Defects of the Eyeballs; — Congenital Facial Diplegia [Dr.
Thomas]; — A Case of Acquired Paralysis of both External
Recti Muscles, with Unilateral Facial Paralysis [ Dr. S. Theobald]; — Exhibition of Ophthalmological Cases: Bilateral
Dacryo-adenitis, Operations for Cataract [Dr. Randolph]; —
Demonstration of Florence's Iodine Test for Seminal Stains
[Dr. Lewellys F. Barker].


Notes on New Books, - - 133
1013


Books Received, 185


15.5680




REPORT OF A CASE OF POLYBACTERIAL LNFECTIOX IN TYPHOID FEVER, WITH ESPECIAL
0.7056
REFERENCE TO CERTAIN INVOLUTIONS EXHIBITED BY THE BACILLUS TYPHOSUS.  


By Edward Perkins Carter, M. D., FeUov) in Pathology.
[From the Pnthologieal Laboratory of the Johns Hopkins University and Ilospital.]


4.53




The following case seems worthy of publication in view of
" 10
the opportunity it afforded to study an unusual variation in
morphology of the bacillus typhosus isolated from it, and
because of the interesting poly-infection with bacteria which
existed at autopsy.


The patient, G. C, was admitted to the Johns Hopkins
Hospital on October 11, 1896, complaining of fever, weakness
and loss of appetite. He had not been feeling well for three
weeks, and had been unable to work for the past seven days.


Family history negative. Personal history negative. For
4
the past four years he had led an active out-of-door life, and
had up to the onset of present illness enjoyed "good health."


His illness began wnth a general feeling of weakness, which
increased until on Monday, October .5th, 1896, he was unable
to go to work, and complained of fever, loss of appetite and
pains in the back and legs. He kept up until October 9th,
and on October 11th, 1896, when admitted to the ward, he
had a temperature of 102.5°, pulse 100 to the minute, and


4000




respirations 20. E.xamination of the blood at this time and
1011
at all subsequent examinations was negative for malarial
organisms. Examinations of the thorax and heart were negative. Abdomen was not distended. No tenderness and no
gurgling in right iliac fossa. Several suggestive rose spots.
Spleen was just palpable. Liver dulness normal. The diagnosis of typhoid fever was made and the patient put upon a
strictly typhoid treatment.


I have abstracted the following notes from the history of
the case, omitting the treatment as being foreign to our
purpose.


October 12th, '96, at 7 a. m. The patient had a large semiliquid stool, containing some formed particles, and a considerable amount of blood fairly bright red in color. At
16.2400
8.30 a. m. a second hemorrhage, rather brighter red than preceding. Both considerable in amount. Temperature 103.5°,
pulse 102.  


October 14th. Patient flushed, looks well. Tongue furred,


0.5425




116
3.34




" 11


JOHNS HOPKINS HOSPITAL BULLETIN.


5




[No. 75.
2500




1014


not tremulous, pulse good. Two fresh rose spots. Abdomen
flat, uo distension.


October 16th, 1.40 p. m. Hemorrhage, somewhat thick
15.8375
tarry consistence, with some blood clots. Amount of movement about 400-500 cc. 5.30-6.30 p. m., patient had two
movements like preceding, quantity same, about 400-500 cc.
Pulse very running and feeble. Temperature at 8 a. m.
101.5°, pulse 124.  


October 17th. This a. m. condition is distinctly better.
Pulse at visit 29 to the quarter. Abdomen not distended
and nowhere tender. 11.30 p. m. the patient had a stool of
about 250 cc. in amount, which contained blood dark in color.


October 18th, 10 p. m. A stool, about 200 cc, containing
0.7131
blood, no clots. The patient's condition did not show any
material change. Temperature at a. m. 102.8°, pulse 120.  


October 25th, 2 p. m. The patient had a large movement,
1000 cc. Total amount of blood estimated 500 cc. Temperature at 8 p. m. 101.5°, pulse 148.


From this time, though he had no subsequent hemorrhages,
4.50
the patient's condition remained critical until his death.  


On October 28th he developed well marked signs of consolidation in the lower left back over a small area, and on
November 1st the same signs were found in the lower right
back.


November 9th. Breath sounds at left base seem almost
clear. Percussion at right base impaired, breath sounds
distant. Temperature at 8 a. m. 103°, pulse 124.


November 11th. This a. m. pulse 32 to the quarter. The
patient passed a restless night, complaining considerably of
pain in the left side. Lying on left side, skin moist. Tongue
dry and tremulous. Eespirations 13 to the quarter. Profuse
sweating. Eespiration on left side is enfeebled. Back not
examined.


The patient's general condition gradually grew weaker and
he died at 12.30 a. m., November 12th, 1896. The temperature just before death touched 105°; the pulse was 160.


The autopsy was held 34 hours after death, and the body,
Table XV. — Nitrogen Ingested (in Grams).*
apart from slight post-mortem gas development, showed no
other distinctive signs of decomposition.  


Anatomical Diagnosis. Typhoid fever. Small number of
healing ulcers in the ileum ; little glandular enlargement.
Subacute spleen tumor, parenchymatous degeneration of the
viscera, abscess of prostate gland, necrosis of the cricoid
cartilage, pneumonia, fibrino-serous pleurisy.


Body 170 cm. long, pale, no oedema. Moderate emaciation.
Rigor mortis in both extremities. Abdomen greatly distended,
tympanitic and greenish in color.


The spleen weighed 210 grams. It was free from adhesions. On section moderately firm, pale grayish red in color.
Malpighian bodies not prominent. Several phleboliths of the
size of bird-shot in cut surface.


The small intestine was moderately distended, the mucosa
Date.  
opaque, containing soft fa3ces. No ulceration until within
100 cm. of the valve, where a small, clear, punched-out ulcer
1 cm. in diameter existed. The surrounding mucosa was
congested. No more ulcers found for the next 50 cm., where
a large group of coalescent clean ulcers with united edges
occurred, which were shallow and rapidly skinning over.  




Day ot observation.


These measured 3x5 cm. in extent, and the individuals composing the group were hardly larger than the above single
one. The most important group of ulcers was located a hand's
breadth above the valve; these numbered nine (2.5 cm. in
diameter), the largest not much exceeding a silver twentyfive cent piece in size. They were perfectly clean and rapidly
healing, judging from the manner in which their bases were
filled up; and they appeared to be skinning over at the same
time from the edges. The caecum and appendix vermiformis
were free from ulceration.


The larynx on the left side shows a small aperture measuring 1 cm. in diameter, which leads into a cavity in relation
5am.  
to the cricoid cartilage. On dissection a cavity the size of the
little finger, lined by granulation tissue, is found, and into
the cavity the upper and eroded end of the cricoid cartilage
projects. The upper surface gives the impression of being
calcified ; it is eroded and hard. The contents of the cavity
are semi-fluid pus of rather dark color.  


In the right lobe of the prostate gland there existed a small
abscess the size of a hazel-nut, containing creamy pus. The
walls of the cavity are thin and ill-formed. No communication existed with the bladder.


The mesenteric and retroperitoneal glands were little if at
Bread.  
all enlarged.  


Bacteriological Examixation.


Cover-slip preparations made at the time of the autopsy
Milk.  
showed from the fj^ewra large numbers of streptococci, which
occurred in threads of 6-8 segments, and a few long evenly
staining straight bacilli.  


From the abscess in jjwstafe gland great numbers of small
thin straight bacilli, which looked not unlike the bacillus of
typhoid fever; also numbers of cocci, appearing chiefly in
pairs (diplococci).


From the heart's Hood a number of long straight bacilli
Red wine.  
resembling closely those seen in the cover-slips from the
j)leura ; also a few single cocci were seen.  


Cultures.


Pleura. The agar-agar plate was studded with minute
Total nitrogen.  
pin-point, finely granular colonies.  


Microscopically these proved to be streptococci, which were
identified as the streptococcus pyogenes.


Lung. The plate on the same medium resembled identically that from the pleura and contained the same microorganism in pure culture.
June7A8
" 9&lfi
" 11
 
 
1 &2
3<s4
5
 


Larynx. The agar-agar plate showed superficially many
12.2257
round grayish brown pin-bead colonies, limited to one-half of
12.2257
surface, the remaining area being overgrown with colonies
12.2257
which exhibited a bluish green color. In the substance of
 
the medium were great numbers of small, finely granular pinpoint colonies and smaller numbers of large whetstone and
 
irregularly round colonies. This plate being so crowded, a
6.3503
series of plates was made, and from the third dilution the
6.3503
following micro-organisms were isolated and identified : streptococcus pyogenes, bacillus lactis aerogenes and bacillus pyocyaneus.  
6.3503


Kidney. The agar-agar plate was studded with small


2.8525
2.8175
2.6162




June, 1897.]
0.1225
0.1225
0.1225




21.5510
21.5160
21.3147


JOHNS HOPKINS HOSPITAL BULLETIN.




^Tea, rum and sugar not analyzed.


117
Table XVI. — Nitrogen Balance (in Grams).






round dark granular colonies, much larger than the usual
streptococcus colonies. In the substance of the medium
there were also a number of whetstone and irregularly round
colonies, and on the surface two grayish white spreading
colonies and five slightly smaller grayish white more ti-anslucent ones. The small granular colonies were composed of
the streptococcus pyogenes. From the other colonies two
bacilli were isolated and identified as the bacillus coli communis and the bacillus typhosus. (See notes below.)


Liver. The agar-agar plate presented practically the same
appearance as that from the kidney, and the same microorganisms were isolated from it.


Heart. The agar-agar plate showed two sets of colonies.
The substance of the medium was studded with small finely
granular colonies, and here and there a few scattered grayish
white whetstone forms occurred, while on the surface there
were a number of grayish white, small, fairly round and
slightly elevated forms. From the small granular colonies
the streptococcus pyogenes was isolated, and from the whetstone colonies in the depth and the round colonies on the
surface of the medium a bacillus was isolated which was
identified as the bacillus typhosus.


Mesenteric gland. The agar-agar plate showed two superficial, spreading, grayish white irregular colonies, and numbers of whetstone colonies in the substance of the medium.
From the plate two bacilli were isolated and identified as the
bacillus coli communis and the bacillus typhosus.


Abscess in the prostate gland. The agar-agar plate was
1^
studded with small finely granular colonies, and in addition
showed a few scattered whetstone colonies in the substance,
and several small, reddish brown, irregular, spreading forms
on the surface of the medium. From the finely granular
colonies the streptococcus pyogenes was isolated. From the
superficial colonies a bacillus was isolated which was identified
as the proteus vulgaris.


Spleen. The agar-agar plate from the spleen remained
sterile after 48 hours in the thermostat.


The bacillus which is, however, of greatest interest in this
S
case is that which was isolated from the heart, liver, kidney,
mesenteric gland, and by Mr. Potter from the bile by means of
Eisner's method, and which, though it shows great variation
upon certain media, must, we think, be considered the true
bacillus of Eberth.


Culturally and morphologically this bacillus was proven
NITBOQEN eliminated.  
identical, from all of the above given sources, and our study
of it has therefore been made with the cultures obtained from
the kidney and bile. At the same time there was carried
along with these for control a culture of an established typhoid
bacillus. The bacillus isolated from the case under consideration, taken from a 24-hour growth upon agar-agar, is of
medium size, straight and thin, with slightly rounded ends,
taking the stain deeply and uniformly. It stains with all the
ordinary aniline dyes, though most satisfactorily with gentian
violet.  


The Eisner plates made by Mr. Potter directly from the
bile gave what has been and is considered the typical reaction
for a mixture of typhoid and colon colonies. The colon
colonies were larger, more coarsely granular and more numer




ous than the small, very pale, transparent and faintly granular
colonies from which the typhoid bacillus was isolated in pure
culture.


Upon agar-agar plates the colonies of the bacillus under
g
study are small, grayish white in color, slightly elevated and
 
irregularly round upon the surface of the medium, while in
its substance they presented the common small whetstone or
irregularly round outline. By transmitted light under low
power they are of a reddish brown color and faintly granular
structure. Upon gelatine plates the colonies are, after 34
hours, small, very finely granular, irregular in outline, and
tend to increase in size very slightly during the second 48
hours, thus appearing as typical typhoid colonies.


Agar slant. The growth upon a moderately dry agar tube
was, after 24 hours, of a slight, narrow, rail-like character
along the track of the needle, being slightly elevated and of
a grayish white color. On the moist agar slant it grows
somewhat more profusely, covering the surface of the medium
more irregularly. This was equally true of the control
typhoid culture.


Bouillon at the end of 24 hours is clouded and somewhat
opaque. The reaction for indol was negative. In order to
establish the certainty of the negative indol reaction beyond
a doubt, a culture in bouillon, together with a culture of the
control typhoid, and an uninoculated tube of bouillon were
placed in the thermostat for three days and then tested for
indol, adding at the same time the H2S0» and NaNO: to the
uninoculated tube of bouillon and watching these three carefully for a few hours, and then replacing them in the thermostat over night. When examined the following day all
three tubes presented the same appearance, and it could not
be said that a true indol reaction was obtained. The test
for indol was made again and again without obtaining a
positive reaction.


Litmus milk after 24 hours was only faintly acidulated, and
Drlne.  
reached apparently its greatest degree of acidulation, which is
very slight, on the third day. At the end of a month there
was no increase of acidulation, as evidenced by the pale pink
color which remained quite as noted on the third day following inoculation. Coagulation of the milk did not ensue.  


Upon potato the growth bears an extremely close resemblance to the control typhoid. It shows at the same time
under the microscope the most remarkable involution forms,
which begin to appear upon the third day after inoculation.


If the potato is strongly acid the growth after 24 hours is
Faeces.  
just visible as a delicate white membrane over the surface of
the potato extending from the track of the needle. The
macroscopic appearance of the growth remains unaltered,
being only Just visible after thirty days, while the potato
remained undiscolored.  


Upon a neutral potato, on the other hand, the growth after
24 hours appears as a slightly yellowish white line along
the track of the needle, spreading out somewhat at the base
of the potato, being plainly visible and much more luxuriant than is ordinarily true of the bacillus of typhoid fever.
After five days the potato itself becomes a very little discolored, while the growth remains unaltered after the third
day. At the end of three weeks no further change was noted.






118
June 7
" 8
" 9
" 10
" 11




1


JOHNS HOPKINS HOSPITAL BULLETIN.
2
3
4
5




49.500
49.400
49.200
50.000
49.600


[No. 7.5.


21.5510
21.5510
21.5160
21.5160
21.3147




Under the microscope this bacillus shows the greatest variation in morphology, and apparently without relation to the
14.4812
reaction of the potato. After the third day involution forms
16.3590
appear, first as long rods with unstained bulbous ends, and
15.5681)
these are quickly followed by the most extraordinary forms,
16.2-100
such as long threads, irregular rods with unstained poles
15.8375
closely resembling spores, and shorter oval forms, a picture
unlike anything one finds in cultures of the true bacillus
typhosus.  


Glucose agar. In a deep stab this organism again agrees
well with the control typhoid. After 24 hours there is a delicate, small, nail-head growth upon the surface of the medium,
while along the line of puncture the growth extends downwards for one-half the distance. This appearance remains in
general the same, the growth increasing very gradually until
at the end of thirty days there is only a more irregular nailhead appearance upon the surface with a slight growth along
the line of the needle stab, thus bearing a striking similarity
to the control culture. At no time was there gas formation.
Here again under the microscope the cover-glasses made after
the third day show the same remarkable involution forms seen
in the growth upon the potato.


In a gelatine stab there is a slight nail-head growth on the
1.6595
surface of the medium after 24 hours, extending along the
1.6-95
course of the needle for a short distance as a delicate linear
1.6595
growth, and giving identically the same picture as that seen
1.659.i
in the control. Liquefaction of 5 per cent, or 10 per cent,
1.659.-,
gelatine does not occur, and the growth increases very slowly,
showing after three weeks a surface growth of the size of the
head of a small tack. Microscopically, after the fifth day, we
find involution forms in the shape of straight and slightly
curved threads, longer by at least twelve times than the bacillus as it appears after 24 hours. The very unusual forms
seen in the growth upon potato and sugar agar are not present.  


Motility. Hanging drops made from an agar-agar culture
of any age always showed great numbers of the bacilli in the
field in active motion, but the greatest motility was seen
when examined from agar-agar slants of from eight to ten
hours' growth; at this age all the bacilli in the field appeared
to be in active motion.


It decolorizes by Gram's stain.  
16. 14071-1-5.4 103
IS !)l85l-f-3 5325
17 227^1-1-4.2885
17.8995-|-V61(i5
17.49704-3.8177


Fermentation tubes of glucose, lactose and saccharose bouillon failed to show any development of gas after eighteen days
in the thermostat.


The thermal death-point of this bacillus as established by
means of Sternberg's bulbs is between 53° and 55° C. at an
exposure of ten minutes.


By means of Pittfield's stain the presence of flagella can be
Relation of the Neusser's granules in the leucocytes: Altoo-ether the granules were very few in all the different forms.
demonstrated extending around the entire organism.  
Most of the white corpuscles are entirely free from the granules, and many almost entirely free. During the period that


Widal's test. Upon adding from i to Jj the volume of
blood serum obtained from a case of typhoid fever to a 24hours-old bouillon culture of this organism, a control typhoid
bacillus culture and a culture of the bacillus coli communis
according to the method of Widal, the following results were
obtained :


The control culture and the culture of the organism under
 
study gave characteristic precipitates in the same time, while
90
that of the bacillus coli communis remained unaffected.






A number of tests for agglutination were made by the
Wyatt Johnston method, using blood of known activity. The
control typhoid bacillus gave immediate clumping, and the
organism under study showed a similar reaction in from
twenty minutes to one hour.


It is interesting to note that cultures made from potato,
the patient was under observation there was no apparent
sugar agar and gelatine, which showed the involution forms
variation in the richness of the grannies. On the other hand,  
in great numbers, always grew upon re-transplantation as the  
the alloxuric body nitrogen was both absolutely and relatively
normal-sized, straight bacilli which were originally met with.  
high (0.67, 0.71 gram per day).  


Upon plain agar-agar in bouillon and in milk the growth
Observation VII.— A. man, 20 years old, with physical signs of
varied but slightly from what seemed to be the normal.  
a commencing left-sided pulmonary tuberculosis. No tubercle
bacilli were found in the sputum, however, after repeated
examinations. His weight on May 26th was 57 kilo ; he was
fairly well nourished. During the period of observation he
was free from fever. Leucocytes were 10,000 per cmm. ;
hemoglobin 70 per cent (Fleischl).  


Animal Experiments.  
The daily diet was as follows: Ham, 300 grams,; white
bread, 450 grams; milk, 500 grams; wine, 500 grams; tea
(infusion), 500 grams; rum, 30 grams; sugar (6 pieces), 30
grams; Eohitsch water, 2 bottles.  


A mouse inoculated subcutaueously with two loops from a
The above food represented about 2370 calories (41 per kilo
34-hour agar growth died in less than 48 hours.
body weight), which were made up as follows:


The autopsy showed no excess of fluid in the abdominal
cavity and no focal visceral lesions. The lymphatic glands
were nowhere enlarged. The spleen, liver and kidneys appeared normal. At the seat of inoculation the skin was bound
down by quite firm fibrinous adhesions. In the cover-slips
from the seat of inoculation great numbers of bacteria were
seen. Cover-slips from heart and spleen were negative. Cultures from heart and spleen remained sterile after 48 hours.


A guinea-pig inoculated with 1 cc. of a 24-hours bouillon
culture intraperitoneally died after thirty days. The autopsy
showed the lymphatic glands somewhat swollen and injected.
No excess of fluid in abdominal cavity. Peritoneum perhaps
reddened and vessels somewhat congested, but no peritonitis
present. Liver, spleen and kidneys appeared normal. Coverslips from peritoneum and from all the organs negative. Cultures from same sources remained sterile.


A rabbit inoculated with 1 cc. of a 24-hours bouillon culture intravenously was still alive after two months.
Albumin
Fat


We have then a bacillus which agrees culturally with the
Carbohydrates
typhoid organism, which reacts to all the known tests for the
Alcohol
true bacillus of typhoid fever, and yet which, after the third
day, upon certain media, potato, sugar agar, and gelatine, shows
very unusual involution forms; forms so remarkable that
were it not for the evidence given by the fulfilment of every
test, it would seem impossible to consider this the true bacillus of Eberth.


During the past few years a number of bacilli, found under
Total
conditions which would seem to exclude the presence of the
true bacillus of typhoid fever, have been isolated and studied
by Losener,* Babes,! FiillesJ and Cassedebat.§ These bacilli
resembled the true typhoid organism so closely in cultural
and morphological properties, with the exception of a slight
variation in the organisms reported by Cassedebat and by
Babes, that it has thus far been very difficult, if not impossible,
to distinguish between them and the bacillus typhosus.






* Losener, Arbeiten aus ilem Kaiserl. Gesundheitsamte, XI.  
615.65 calories.  
385.02
1161.38
308.00


t Babes, Variabilitat und Varietiiten des Typhus-bacillus. Zeitschrift fur Hygiene, IX, 1890, p. 323.  
2370.05


I Fulles, Bacteriologische Untersuchung des Bodens in der Uingebung von Freiburg i. B. Zeitschrift fur Hygiene, X, 1S90, p. 225.


§ Cassedebat, Sur un bacille pseudo-typhique trouve dans les
eaux de riviere. Compt. rend, de I'Academie de Paris, CX, No. 15,
1S90, p. 798.






f 1


as*, B


Table XVII.—




Urine.








- \


(






i




I




(






1


a




-- 5
» O




Date.


June, 1897.]






JOHNS HOPKINS HOSPITAL BULLETIN.
§H




uj?


119


a a «




These forms have therefore been designated pseudo-typhoid
S 1 2
bacilli.


In addition to the irregular forms described by Babes as
seen in growths upon agar-agar, and those in the bacillus
studied by Oassedebat, Ohantemesse and Widal* have noted
certain variations from the normal which appeared as longer
thread-like forms upon gelatine, and as straight rods containing irregular vacuoles and unstained poles upon potato.
Vilchurf further, in a study made of some 200 cultures from
the organs of four tyj^hoid patients, describes variations in
form, particularly on old gelatine cultures and upon potato.
These occurred as vacuoles which after 73 hours took the
stain and then more intensely than the rest of the organism.
Aside from these irregular forms I have been unable to find
in the literature any reference to such involution forms as are
noted in this case.


The growth upon agar-agar in bouillon and in milk showed
S S 1 1 a
no variation from the normal, the irregular forms being seen
only upon potato, sugar agar and gelatine, as noted above.






*Chanteme8se et Widal, Recherches sur le bacille typhique et
I'etiologie de la fiSvre typhoide. Archives de Physiologie, I, 1887.


f Vilchur, Cultivation of Typhoid Bacillus from Organs and
Evacuations of Typhoid Patients. Vrach, St. Petersburg, 1886,
VII, pp. 456-458. Eef. Lancet, London, 1886, II, p. 137.




>.H


The control culture used in the study of this case did not at
any time show such involution forms as the bacillus under
consideration, while culturally the two organisms appeared
identical.


It seems therefore unavoidable to consider that this bacillus, which was found in a patient dead of typhoid fever, being
isolated from five different sources, and reacting to every test in
the manner of the true bacillus of typhoid fever, is, in spite of
the peculiar involutions it undergoes, no other than the
bacillus typhosus.


In conclusion I wish to express my appreciation to Dr.
Simon Flexner for his kindness and interest in the study of
this case, and also to Dr. Gray of the Army Medical Museum,
Washington, for his kindness in taking the photographs
which illustrate this report.


Description of Plate.


Figs. I and II. Bacillus typhosus obtained from this case
as it appears after a growth of 24 hours upon agar-agar.
Zeiss II mm. apochromatic objective, No. IV projection ocular.
Gentian violet staining.


Figs. Ill and IV. The same organism as it appears after
a growth of two weeks upon glucose agar-agar. Same magnification. Gentian violet staining.






A CASE OF TYPHOID FEVER IN WHICH THE TYPHOID BACILLUS WAS OBTAINED TWICE


FROM THE BLOOD DURING LIFE.


By E. Bates Block, M. D., Assistant Resident Physician, The Johns Hopkins Hospital.


a "




Evidence is strongly in favor of the fact that, at some period
a"
of the disease, the typhoid bacillus is present in the blood in
nearly all patients suffering from typhoid fever, gaining entrance from time to time at the site of the intestinal lesions.
It is the rule for the typhoid bacillus to be cultivated from
the internal organs (spleen, mesenteric glands, etc.) after
death, and sections of these organs usually show bacilli which
resemble the bacillus typhosus, in clumps or masses in the
capillary vessels. The early experiments of Wyssokowitsch*
show that these organs are principally concerned in removing
from the blood introduced bacteria. It was shown by Welch
and Nuttallf in 1891 that human blood serum is capable of
destroying many typhoid bacilli, and later by other observers
that the blood serum from typhoid patients also possesses this
power, so that the peculiar conditions which allow these
organisms to live in the capillary vessels of the organs cannot,
at least in the majority of cases, depend upon a simple loss of
this power of the blood serum. That the invasion of the
blood or organs by other micro-organisms, more particularly
the streptococcus pyogenes, modifies the relation of the patient
to the typhoid bacillus, has been clearly shown by VincentJ
in experiments upon animals and by cultures made at autopsy


*Zeit8chrifl fiir Hygiene, 1886.


f Verbal communication.


t Annales de I'lnst. Pasteur, 1883.


g MM




in human cases. In six out of 31 such autopsies he found the
S o 2  
streptococcus associated with the typhoid bacillus. In one
case a typhoid patient whose temperature had become normal
developed a streptococcus angina, the temperature rose and
on the fourth day the patient died. At autopsy the typhoid
bacillus and streptococcus were obtained from the organs and
the latter from the blood. The streptococcus pyogenes has
also been found in association with typhoid bacillus post mortem by Flexner* in 5 out of 6 cases reported, by Wright and
Stokesf in 2 out of 9 autopsies, by KleinJ in the blood, once in
association with B. typhosus, by Netter, E. Fraeukel, and
others. Karliuski§ has found streptoccoci in the pulmonary
complications of typhoid fever in six out of nine cases, some
of them being associated with the typhoid bacillus in the
lungs. A similar case is reported by Flexner {op. cit.) In
forty-one abscesses in typhoid cases examined by Vincent {op.
cit.) the staph, pyogenes aureus was present thirty-two times,
all of these patients recovering. In eight cases streptococcus
alone or associated with the bacillus typhosus was met with,
and of these, five died. Assuming that in these instances the
typhoid bacillus was increased in virulence, it may be said that


^O M




* Johns Hopkins Hospital Reports, Vol. V.
Perc
alio
bod


t Boston Med. and Surg. Jour., March-April, 1895.
the
troj


tBaumgarten's Jahresb., 1894, Vol. 10.


§See Vincent, op. cit.
May 27




a similar modification of the physiological characters of the
1
typhoid bacillus infection is produced (.Sanarelli*) by inoculating cultures together with the soluble products of the
bacillus coli communis and the bacillus proteus.


The clinical history of this case presents points of interest
in connection with the bacteriological investigations both
before and after death.


M. Z., female, age 30, born in Poland, was admitted to Professor Osier's wards on Saturday the 4th of July, 1896. She
4200
could not speak English, so no history could be obtained.
Upon admission she was restless, listless, weak, and gave evidence of shortness of breath and abdominal pain, frequently
passing her hand over the abdomen. Soon after admission
she became delirious. The examination of the thorax was
negative. The abdomen was tender upon pressure, and resistant, especially in the splenic area. The pharynx was somewhat reddened and its vessels were injected.


On the 5th of July Dr. Thayer made the following note:
Eespirations 44 to the minute, pulse 104; patient looks dull
and a little confused ; the tongue has a thick pasty coat; the
lungs are clear on auscultation and percussion; the heart
sounds are feeble but clear; the abdomen is full, generally
tympanitic, does not seem tender — it is held very tense so that
palpation of the spleen is impossible. A number of small
spots are seen on the abdomen, some of them apparently
ecchymotic, others not unlike rose spots. There is slight cyanosis of the face and lips, which in connection with the rapidity of respiration suggests some pulmonary affection. The
patient has had one liquid stool.


On the 8th of July Dr. Thayer noted further: The general
1010
condition of the patient is about the same; she is still dull,
 
drowsy, delirious, and quite irresponsive when questioned.
There is marked muscular resistance in the splenic region, and
pressure here causes the patient to wince. There are no definite rose spots to-day.


The urine did not give the diazo reaction.  
15.5820


The temperature upon admission was 101.3°, respirations 44,
and the pulse 120. Three hours later the temperature was
104.6°, and during the fourth, fifth and sixth of July ranged
between 101° F. and 104.3° F., the low temperature being due
to cold baths, to which she reacted well. From then on the
temperature gradually declined and reached normal on the
8th of July. It remained practically normal for about 18
hours. On the following day it rose gradually, the highest
point reached being 102.6°.


The respirations during her illness remained rapid and on
0.6064
the 9th of July became more labored, the pulse became more
rapid and feeble, and the patient died at 12.45 a. m. on the
10th of July.  


On the 5th of July a culture was taken from the stool of
the patient, by Eisner's method, with a negative result.


On the 6th of July a hypodermic syringeful of blood was
3.89
taken from a vein of the forearm with due antiseptic precautions. A few drops were allowed to fall on an agar slant, and
the rest of the blood was mixed with melted gelatine and




•' 28


•Ann. de I'lnst. Pasteur, 1892.


2




placed in a Buchner jar in the thermostat. The agar slant
3450
subsequently showed one colony, while the gelatine tube
which contained a greater volume of blood showed about a
dozen colonies identical in appearance. Several of these colonies were grown on the usual culture media. They did not
coagulate milk, grew characteristically on Eisner's medium ;
inconspicuous growth on potato with increase of moisture;
did not form gas in glucose agar ; were actively motile ; did
not liquefy gelatine, and morphologically resembled the
typhoid bacillus.


On the 9th of July a second culture was taken by the same
method. The volume of blood obtained was smaller than in
the former culture and was allowed to fall on the surface of
an agar slant, which 20 hours later showed one colony. Inoculations of other media from this showed the same reactions
as in the previous instance. In addition these bacilli did not
produce indol; grew anaerobically; did not change the color
of Wurtz's medium; gave the agglutinative reaction with
over 40 specimens of typhoid blood, and morphologically was
identical with the bacillus obtained three days before.


A culture from the throat on the same day did not show
1012
diphtheria bacilli ; the chief organism found was the streptococcus.


I am indebted to Dr. Flexner for the privilege of making
an abstract of the post-mortem examination.


The autopsy was held at 2 p. m. on the 11th of July, 37
19.6822
hours after death.  


Anatomical diagnosis : Typhoid fever; ulceration of small
intestine; acute sjjleen tumor; swelling of the mesenteric
glands; parenchymatous degeneration of the viscera; postmortem invasion of a gas-forming bacillus ; oedema of the
lungs.


Body cold, has been on ice. No odor of decomposition.  
0.5796


The upper portion of the body shows dark spots and
splotches. The face is discolored and swollen. The greatest
discoloration is over the back.


Crepitation is present over the face, the neck, the upper
2.89
portion of the thorax and over the back. The neck is much
swollen, thick and discolored.  


No oedema and no crepitation of lower extremities.


The abdomen is distended and contains gas which has a
" 29
somewhat putrefactive odor. The intestines are distended,
but not discolored.


The tissues about the kidneys, pancreas, caecum and the
root of the mesentery are emphysematous. The mesenteric
and cascal glands are enlarged, softened and reddened.


The spleen is enlarged and softened, and on section appears
3
dark in color, almost diffluent.


The liver shows many gas bubbles under the capsule, and
on section it is found to be penetrated throughout by small
gas vesicles, and the blood which escapes from the cut ends
of the portal veins is frothy. The organ is pale, homogeneous, and cloudy yellow in color.


Both kidneys are emphysematous, the capsules adherent,
2700
the cortex increased, and the stria? coarse.


The duodenum shows many gas cysts. The small intestine
shows swollen patches of Peyer; lower down the patches
exhibit small erosions. As the valve is approached the enlarge


1013


y


21 3097




June, 1897.]
0.5953




2.79


JOHNS HOPKINS HOSPITAL BULLETIN.


" 30




121
4




3000


ment of the patches increases, as does the extent of erosion.
Occasionally these patches show hemorrhagic infiltration.
At the valve nearly the whole of the intestine is involved in
deep ulceration which presents a sloughy and necrotic appearance and is nearly black from imbibition of blood.


The lungs are deep in color, crepitate throughout, and almost
1012
sink in water. The cut surface is smooth and dark. The
bronchi are dark in color from imbibed blood. The blood in
the vessels is frothy. The right side of the heart is enormously distended. On incision there is escape of gas and
collapse. The intima of the vessels, and endocardium, are
deeply blood stained.


In the right upper angle of the cavity of the uterus is a
portion of placenta the size of a walnut, apparently the
remains of a recent abortion. It is oval in shape, firmly
attached, dark in color, porous in consistence, and has a deep
red color. The mucosa is congested.


Cover-slips from the heart's blood, liver, spleen and intestinal ulcer showed, along with other bacterial forms, a large
18.7950
capsulated bacillus resembling closely the bacillus aerogenes
capsulatus. These were not seen upon cover-slips from the
bile and placenta. Anaerobic cultures were taken from all of
the organs, but the large bacillus failed to grow.  


Cultures upon agar plates yielded the following results:
Bacillus typhosus in placenta, spleen, liver and kidney. Bacillus coli communis in the kidney and heart's blood. Bacillus
pyocyaueus in the heart's blood. Bacillus proteus in the bile.


Some of the appearances found at the autopsy must be
0.5853
regarded as due to post-mortem changes, so that the invasion
of the bacillus coli communis and the bacillus proteus after
death cannot be entirely excluded. It is not improbable, however, that they may have been present in the orgaiis or body
fluids during life. The bacillus pyocyaneus is not a common
post-mortem invader.  


In reading over the available literature I find that the
typhoid bacillus has been obtained during life from the
blood of patients suffering from typhoid fever by three other
writers. Thiemich* found it once in blood taken from a vein


3.11




' Baumgarten's Jahresbericht, Vol. 10, 1894, p. 266.
" 31




5


of the forearm. Ettlinger* obtained it twice by the same
method, and Stern twice.f


Other writers report a negative result. NeuhausJ failed in
3400
twelve cases from blood taken from a vein of the forearm, and
twenty-four cultures§ from blood obtained by pricking the
skin of the forearm; Frilnkel and Simmonds|| in sis cases.
Ettlinger** reports eight negative results with blood taken
from the forearm, and Klein ten.|f Failvires are also reported
by Gaffky, Riitimeyer, Chantemesse and Widal, v. Jaksch, and
Vaquez.


In six other cases I failed to obtain the typhoid bacillus,
although a syringeful (1.5 cc.) of blood was employed in each
instance.


The typhoid bacillus has been obtained from the blood
1014
after death by several observers: Viucent,|| Friinkel and Simmonds,§§ Flexner,|||| Klein,*** and by Wright and Stokes.fft


Heretofore not much importance has been attached to the
work of Letzerich,JII Almquist,m Maragliano,||| Riitimeyer,§§§ Pasquale,§§§ Guarnierl,§§§ and Karliuski,§§§ because
their examinations were made at a time when the differentiation of the typhoid bacillus from other micro-organisms
closely resembling it in morphological and biological characters, was not so clearly understood as it is at present. However, it is probable now, that since definite proofs exist of
the not very infrequent occurrence of the bacillus typhosus in
the blood, either before or after death, their work may come
to have more significance.


20.3490




* Wirtz, Precis de Bacteriologie Clinique.
0.5533
■fCentralb. f. innere Med. 1896, No. 49, p. 1249.  


I See Wurtz.


§ Berliner klin. Wochenschr., No. 6, 1886.  
2.72


II Sternberg, Text-book of Bacteriology, p. 352.
** Loc. cit.


■H-Baumgarten, Vol. 10, 1894, p. 266.
June 1


XI Ann. d. I'lnst. Pastesr, 1893 ; Le Mercredi medical, 17 fev. 1892.


§§ Sternberg, Text-book of Bacteriology, 1896, p. 352.
6


ill Op. cit.


*** Baumgarten, 1894, Vol. 10.
3350
tttOp. cit.


ttl Sternberg, op. cit.
§§§See Flexner, op. cit.


1012




SUCCESSFUL CULTIVATION OF GONOCOCCUS IN TWO CASES OF GONORRHEAL ARTHRITIS
20.2842
AND ONE OF TiENOSYNOVITIS, WITH REMARKS ON A NEW MEDIUM.  


By Francis R. Hagner, M. D., Assistant Resident Surgeon, Johns Hopkins Hospital.


0.5803




The more successful attempts to cultivate the gonococcus
2.86
from pathological conditions other than urethritis and conjunctivitis, have widened our view concerning the part played
by this organism in human pathology.  


Even now it would take much space to enumerate all the
different lesions and parts of the body in which this organism
has been found. The gonococcus, as is well known, cannot be
cultivated with the facility of the other pyogenic cocci, and it
has for this reason not lent itself so readily as an aid to diagnosis in obscure cases, unless perchance it could be found in




Table XVIII.— Nitrogen Ingested (in Grams)


cover-slips, where its peculiar form and definite staining reaction might suflBce for its identification.


Greater experience, on the other hand, has shown that,
.*
although this organism does not grow at all, or at least most
feebly and unsatisfactorily, upon the ordinary culture media,
its choice of substance is still not a small one.  


Since Steinschneider's observation of the great value of
urine in the composition of a culture medium for the gonococcus, no really easy practicable method of preparing a
medium containing this fluid has been devised.


Date.




122
Day of
observatlou.




Ham.


JOHNS HOPKINS HOSPITAL BULLETIN.


Bread.




[No. 75.  
Hllk.  




wine.


We offer iu the accompanying paper a simple method which,
in the limited number of cases at our disposal, has proven successful.


It is in part my object in presenting these cases to draw
Total nitrogen.  
attention to the ease with which, by the use of this medium,
the gonococcus may be cultivated.  


I must state that the value of the medium was further
tested and proven by cultivating this micro-organism from
urethral piis. The cases themselves are of interest from their
clinical aspects, and as illustrating the good results which
surgical interference gives when undertaken in time.


The possibility of making a positive diagnosis before opening the infected joint enhances the likelihood of good which
May 27 & 28
may be confidently expected from these measures.
" 29
" 30
Maj 31 & June 1


No question is likely to arise as to the identity of the cocci
isolated in these cases, even in view of the fact that in one case
the organism did not completely decolorize when treated
according to Gram's method.


The later writers on the subject, among whom I shall only
1 42
mention Caplewski,* concede great difference in the behavior
3
of cocci from different sources.
4
5


Most samples of gonococci are quickly and readily decolorized; some few are more refractory and may retain the stain in
part. On the other hand, the ordinary pyogenic cocci which
resist Gram's method sometimes become decolorized.


No small part in this procedure is played by the composition
15.3515
of the stain and decolorizing agents.  
15.3515
17.4240
17.4240


But when all the facts are gathered, namely, the source of
the organisms, their morphological properties, their diflBculty
of culture, and slight viability, together with their staining
reaction, no doubt is likely to be entertained concerning their
nature.


Case I.  
5.8262
5.8262
5.8262
5.8262


B. B., set. 21, female, colored. Domestic. Admitted December 5, 1896.


Previous History. Patient has never been very healthy.  
3.9094
One year ago she had an attack of rheumatism; at this time
2.7956
the right knee was swollen and painful. The jjatient was
2.7956
confined to bed for one month, and has never had any trouble
2.9198
with the joint since. There was no history of any vaginal
discharge at this time.  


Present Illness. Patient acknowledges exposure within the
last month. Has had vaginal discharge for three weeks. Six
days before entrance to the hospital she noticed pain and
swelling of the left knee. Pain more marked at night and
increased by motion.


Examination. The patient is a rather poorly nourished,
0.0350
unintelligent woman, with a slight blowing murmur over the
0.0350
apex of the heart, transmitted to axilla. The joint is quite
0.0350
tense, painful on palpation and motion. Patella floats. There
0.0350
is marked induration and thickening of the peri-articular
tissues, which are boggy. Distinct fluctuation over the joint.
A purulent discharge observed to be present in vagina and
urethra. The examination of cover-slips was negative for
typical gonococcus-like organisms.  




25.1220
24.0083
26.0808
26.2050


*Hygienische Rundschau, Vol. 6, No. 21, p. 1029.




*Tea, rum and sugar not analyzed.


December 5th. Knee aspirated with sterile syringe and a
straw-colored fluid obtained; this showed under the microscope a great many polymorphonuclear leucocytes, and a few
large diplococci which were not contained in the pus cells.
Cultures made on agar-agar, gelatin, potato and bouillon were
negative after forty-eight hours in the thermostat. Cultures
made at the same time on albuminous urine agar in twentyfour hours showed no perceptible growth, but at the end of
forty-eight hours in the thermostat about a dozen isolated
colonies, a little larger than ordinary streptococcus colonies,
elevated above the surface of the medium, presenting an
opaque white color, but still translucent, were easily seen.


Cover-slips were made, staiued with Sterling's gentian violet,
mounted in water. The examination showed diplococci morphologically identical with the gonococcus. The same specimens were then stained by Gram's method and almost completely decolorized, a faint outline still being visible here and
there. The ordinary media (mentioned previously) were inoculated from the cultures with negative results; but another
albuminous urine agar tube, inoculated, gave a similar growth
to the first after forty-eight hours in the thermostat, and this
showed the same morphological characteristics.


Another generation, third in succession, was obtained on
the albuminous urine agar medium; this one was feebler than
the preceding ones, and no further growth was obtainable.


December 8lh. Knee again aspirated, the fluid giving the
same growth when inoculated on the albuminous urine agar
tube.


The same negative results as described previously were
Table
obtained on the ordinary media. The growth mentioned was
carried through three generations, but again would not grow
on the fourth transplantation.


December 17th. The knee joint was opened and cultures
taken, two tubes of the albuminous urine agar being inoculated. One of these became contaminated ; in the other the
growth was very slight and did not survive for a second transplantation.


The following is a brief description of the mode of preparation of the albuminous urine agar, which was prepared by Dr.  
XIX.— Nitrogen Balance (in Grams).  
Hugh Young and myself.  


Acid urine containing 0.05 albumen or more should be
collected and allowed to stand for twenty-four hours, no effort
being made to prevent decomposition. The urine is boiled
until a large albuminous precipitate is formed ; it is filtered
through paper, when the resulting fluid will be clear. The
filtered urine is boiled, and agar-agar, peptone, beef extract
and sodium chloride are added in the same proportion as making ordinary agar.


The other steps are the same as in making ordinary agar,
except that filtered albuminous urine instead of water is used
throughout the preparation of the medium. It is important
to see that the medium before being placed in tubes has a
neutral or slightly acid reaction.


The advantages of using albuminous urine are, first, that iu
such urine albumens are always present, which are not coagulated by heat, and second, the albumen that is coagulated
acts as a clarifying agent in the removal of the salts that usually cause the cloudiness of urine agar-agar as prepared by


ig




June, 1897.]






JOHNS HOPKINS HOSPITAL BULLETIN.


NITROGEN ELIMIN


itroIm


123






mixing the urine agar separately and sterilizing by discontinuous heating below the point of coagulation. It is important to have the medium very moist when inoculated.


The operation consisted of opening and irrigating with
bichloride of mercury 1 to 1000, followed by salt solution, an
Esmarch bandage being applied above the joint to prevent
absorption of the bichloride solution.


The wound was approximated with subcutaneous silver
wire sutures, silver foil dressing applied, and the leg put up
in plaster. Of course very strict cleanliness is necessary in
these operations — in all cases the operator and assistants
wearing rubber gloves. The wound healed perprimani.


At the time of operation the subcutaneous tissues were
found very edematous and thickened, and minute hemorrhagic areas were seen in the tissues near the joint. The
fluid within the joint was serous in character, although flakes
of fibrin were contained in it. The synovial membrane was
thickened and its surface covered with hemorrhagic material
that in places had a plush-like appearance, having lost its
gloss. At the junctions of the cartilages and synovial membrane there were a number of tessellated, very vascular fringes
of fibrinous material 3 to 5 mm. in length.


The cartilages showed no change.


The patient is at present more comfortable, but has not
entirely recovered.


Case II.


A. D., female, fet. 20 years, colored, domestic. Admitted
August 25, 1895.


No history of rheumatism.


Has had vaginal discharge for two weeks. (Patient acknowledges exposure several days before the discharge was noted.)
o«


Three days before entrance left knee joint became painful
and swollen, pain being more marked at night; fever was
present, the highest temperature recorded being 103° F.


Examination. Large, well nourished woman.
Ji,  


Left knee slightly flexed, and warmer than adjacent parts.
Slight fluctuation on inner side of patella ; movement of the
affected joint caused great pain.


The peri-articular tissues were indurated and boggy.
win


There was a purulent discharge from the vagina and urethra
that contained diplococci. These were in a manner suggestive of the gonococcus and occurred within the pus cells; they
completely decolorized when stained according to Gram's
method.


The operation was done on the fifth day of the disease, and
consisted in the application of an Esmarch bandage, incision
of the joint, irrigation with 1 to 1000 bichloride of mercury
followed by salt solution, and closure of wound with silver
wire. Silver foil dressing and plaster cast applied.


Patient made good recovery.


The examination of joint at time of operation showed the
peri-articular tissues to be in an cedematous and hemorrhagic
condition.


The joint contained about 25 cc. of blood-stained fluid in
which floated small pieces of a fibrinous material.


The synovial membrane was roughened, thickened and had
the same appearance described in the preceding case.






Larger tessellated masses of fibrin adhered to synovial
membrane wherever it came in contact with the cartilage.


Bacteriological Examination.


The fluid for culture was removed from the joint with a
sterile Volkman spoon, and placed in sterile test tube. A
small quantity of blood was obtained by allowing a stream
from a small artery to spurt into a sterile test tube.


The tube containing the blood was allowed to stand for two
hours, during which time the serum had separated from the
clot and could be pipetted off. An ordinary agar tube was
melted and cooled to 46° C, so as to prevent the blood serum
from coagulating when added. About 5 cc. of the human
blood serum was added, making the proportion one-third
human blood serum and two-thirds nutrient agar-agar; the
resulting medium was perfectly clear. The fluid medium
was then mixed thoroughly, and inoculated with three loops
of fluid obtained from the joint, great care being taken not to
add the fluid until the medium was observed to be on the point
of solidifying, so as to prevent all chances of destruction of
the organism by heat.


The inoculated medium was poured into a Petri's dish and
placed in thermostat at 37° C. No growth was visible at the
end of the first twenty-four hours, but at the expiration of
forty-eight hours five or six small colonies could be seen.
These were isolated and about the size of the ordinary streptococcus colonies, but they were more elevated when they
appeared on the surface of the medium, and of a more opaque
white color; they were, however, slightly translucent.


Cover-slips prepared from such a colony and stained with
Sterling's gentian violet, mounted in water, showed numerous
diplococci somewhat larger than the ordinary pyogenic cocci,
composed of two hemispheres separated by a narrow unstained
interval ; a few tetrad forms were also seen. The same preparation treated by Gram's method was completely decolorized.


Agar-agar, bouillon, potato, gelatin, and glycerine-agar
were then inoculated from one of the colonies.


At the same time another culture was made on the serum
agar. No growth could be seen after forty-eight hours on any
of the tubes except the one containing the human serum agar,
and on this a growth similar in appearance to the ones
described before, consisting of cocci with the same morphological properties, was found; further transplantation was
not successful on this medium.


As no perceptible growth occurred on any of the ordinary
cultural media, and cover-slips taken from their surfaces were
negative, the conclusion that the organism was the gonococcus was considered justified.


It is interesting to note that although numerous coverslips were made from the fluid at the time of operation, and
Jat i
numbers of polymorphonuclear leucocytes were found, no
micro-organisms could be discovered.


Case III.
A. P., male, white, single, 39 years. Admitted May 20,
1896.


Denied any venereal disease. (Very questionable.)
Patient felt, without any premonitory symptoms, great pain




O "


124


S^




JOHNS HOPKINS HOSPITAL BULLETIN.
»i


TJrlne.




[No. 75.  
Faeces.  




gss «
May 27


in the left aukle joint, and at the same time noticed that there
was considerable swelling and redness of the skin over the
joint.


The pain was more marked at night, and increased with
I
movement.


The condition mentioned gradually grew worse until the
twenty-fourth day after the beginning of the disease, when
patient was transferred to the surgical ward.


Examination. Patient was a well nourished man. Temperature on entrance 100° F. There was a fluctuating swelling
57.700
extending from the juncture of middle and lower third of
tibia, following the sheaths of extensor muscles, to a point on
the dorsum of foot 3 cm. below the ankle joint.  


May '21st, Operation. Same operation as described previously.


Incision of abscess and excision of fibrinous material from
25.1222
tendon sheaths. Irrigation of bichloride of mercury 1 to 1000,
wounds closed with silver wire and dressed with silver foil,
and leg put up in plaster. Patieut made good recovery in
three weeks, wound healing per prima?/!. On incision the
subcutaneous tissues were oedematous and slightly hemorrhagic. The tendon sheaths were thickened and covered with
hemorrhagic fibrinous material.  


The pus was confined principally to the sheaths of tibialis
anticus and extensor proprius poUicis, chiefly about the annular ligament, but followed the pollicis to a distance of 3 cm.
below. The sheaths were opened and about 100 cc. of bloodstained fluid escaped, which was placed by means of a Volkman spoon in a sterile test tube.


The internal portions of the sheaths were covered with a
15.5820
hemorrhagic fibrinous material and some granulation tissue.  


I am indebted to Dr. Flexner for the privilege of reporting
his successful cultivation of the gonococcus in this case.
The pus collected at operation in a sterile manner was sent to
the Pathological Laboratory.


Cover-slips when stained with Sterling's gentian violet
1.2634
showed polymorphonuclear leucocytes filled with diplococci
morphologically resembling the gonococcus; a few of the
organisms seen were extra-cellular.  


When stained according to Gram's method the organisms
were completely decolorized. Inoculations of the pus were
made on the mixture of Steinschneider,* on a mixture composed of human ascitic fluid and agar-agar,t on a mixture of
human blood serum and uriue,J on an infusion of pig-fcetuses
and nutrient agar,§ and also upon ordinary agar slants. The


16.8454+8.2763




*Steinschneider'8 medium consists of a mixture of bullock's
" 28
serum, urine, and agar-agar.


tThe mixture of ascitic fluid i and agar-agar J, which after being
placed in tubes is sterilized and slanted. An albuminous flaky
precipitate collects at the bottom of the medium, leaving surface
clear.


t Human blood serum and urine medium is composed of J urine,
2
f human blood serum sterilized in autoclave at 220° F. (Human
serum derived from placenta.)


§ Preparation of pig-failvt a<]ar : Fresh pig-foetuses not exceeding 5 cm. in length separated from placenta and membranes
are minced in a sausage machine. An equal volume of distilled
water is added to the finely divided foetuses, and after thoroughly
stirring, the mixture is allowed to macerate in a cool place for from


.'>6.20(i




cultures were placed in a thermostat at 37° C, and at end of
25.1222
twenty-four hours a scarcely perceptible growth was found on
all the inoculated tubes except the agar slants, which last
remained sterile, whereas the growth on the other tubes increased somewhat during the next twenty-four hours.  


The appearance of the growth was the same as that
described in previous cases.


Growth on pig-fcBtus agar was more abundant and apparently more vigorous than on the other media.  
19.6822


Cover-slips from the cultures showed the same diplococcus
as was found in the pus, and it became decolorized completely
by Gram's method.


Transplantations at intervals of forty-eight hours were made
1.2634
on pig-foetus medium mentioned and growth obtained for
four generations, but from the fifth inoculation no growth
resulted.  


It is interesting to note that the condition of synovial membranes and peri-articular tissues in these cases was practically
the same, namely subcutaneous oedema, thickening and induration of peri-articular tissues, with small hemorrhagic
areas.


The synovial membrane was thickened, very hemorrhagic
20.9456+4.1766
and had the appearance of plush, having lost the glossy
condition.  


The fringe-like pieces of fibrin were very hemorrhagic.
In neither case was the cartilaginous portion of joint
affected.


" 29




six to twelve hours. The fluid is then freed from contamination
3
by filtration through a Chamberland filter under a pressure of 150
to 200 lbs.


Two per cent, sterilized nutrient agar is then melted and cooled
to 40° C. and to it J of its volume of the infusion of foetuses is
added. The tubes are then slanted.


55 400




NOTICE.  
24.0083


All inquiries concerning the admission of free, part pay, or
private patients to the Johns Hopkins Hospital should be addressed
to Dr. Henry M. Hurd, the Superintendent, at the Hospital.


Letters of inquiry can be sent, which will receive prompt answer,
21.3097
or personal interviews may be held.  


Under the directions of the founder of the Hospital the free beds
are reserved for the sick poor of Baltimore and its suburbs and for
accident cases from Baltimore and the State of Maryland. To
other indigent patients a uniform rate of $5.00 per week has been
established. The Superintendent has authority to modify these
terms to meet the necessity of urgent cases.


The Hospital is designed for cases of acute disease. Cases of
1.2634
chronic disease are not admitted except temporarily. Private
 
patients can be received irrespective of residence. The rates in
the private wards are governed by the locality of rooms and range
from $20.00 to $35.00 per week. The extras are laundry expenses,
massage, the services of an exclusive nurse, the services of a
throat, eye, ear and skin or nervous specialist, and surgical fees.
Wherever room exists in the private wards and the condition of
the patient does not forbid it, companions can be accommodated at
the rate of $15.00 per week.


One week's board is payable when a patient is admitted.  
22.5731+1.7352




" 30


June, 1897.]


4




JOHNS HOPKINS HOSPITAL BULLETIN.  
56.2011




26.0808 1 18.79.50


J^ NEW ^ESTHESIOMETER.


By Lewellts F. Barkee, M. B.
1.2634
{Exhibited to the Johns Hopkins Hospital Medical Society, January 18th, 1897.]




20.0584+5.9214


I exhibited at this Society some time ago the test hairs employed by Professor von Frey in studying pain and pressure
sense. These consisted, it may be recalled, of short wooden
handles of suitable length, to which finer and coarser hairs
were fastened at one end at right angles with sealing wax.
The most suitable form is perhaps a four-sided wooden handle
measuring 4 mm. on each side and 80 mm. in length. Hairs
of different strength are obtained from the scalp of men,
women and children ; hairs from the beard, from the horse's
tail and hog bristles are also of service where stronger
stimuli are required. The advantage of these test hairs consisted, it will be remembei'ed, (1) in the very small surface of
skin acted upon, and (2) in the possibility of grading accurately the intensity of the stimulus applied. In order to test
the stimulus- value of the hair, its area in cross section must
be determined, as well as the weight which can be lifted by
the hair when it is pressed with its cross section against one
of the scale pans of a delicate balance. I described on the
former occasion the methods of determining these two constants and shall not now repeat the details. Suffice it to say
that with time and patience a set of such test hairs can
be prepared varying in stimulus-value from 0.1 gr./mm^ to
300 gr./nim', though, as Professor von Frey says, the jireparation of them is " nicht jedermanns Sache."


A
" 31




5


B


56.2(0




26.2050 j 21.1.3490


FlQ. 1.


The form of the hair and its mode of action are shown in
1.2634
Fig. 1. A represents the test hair when it is placed upon
the skin at the point F, though as yet no pressure has been
exerted. In B the handle is nearer the skin, through pressure
made parallel to the surface of the skin, and the hair is bent
into an S-shaped curve, the turning point of which is at W.
If W is perpendicularly above the point F, then the hair
exerts exclusively an influence of pressure upon the skin ; but if
W be directed to one side, there arises along with the pressure
a "shoving" component. The latter appears, as one finds on
bending the hair, as soon as it begins to twist out of one plane;
that is, a space-curve arises instead of the plane-curves.




21.6124+4.5826


The set of hairs which I pass around
were prepared under Professor von
Frey's direction in Leipzig in the
spring of 1895. I have tested them at
intervals since that time and find that
they have undergone very little variation. For accurate testing of pressure
and pain sense some such delicate testing mechanism is indispensable. Such
hairs, however, are not in the market,
and I fear if one wished a set of them
he would have to prepare them for
himself.


Kecently, however. Prof, von Frey, //
June 1
with the aid of the mechanician Zimmermann, has prepared a simple instrument which, for purposes of clinical examination at least, will take the
place of the set of test hairs. This
Ksthesiometer, which depends upon the
same principle as that involved in the
construction of the test hairs, has the
advantage that with a single hair one
can obtain a large series of pressurevalues at will. It consists of a long
hair pushed through a capillary tube
of very narrow lumen, much like that
of a thermometer tube; the hair can
be shoved through the lumen easily,
but on pressure only the part of the
' hair outside the capillary tube can
bend, and the force exerted is always g
greater the less the amount of hair outside the tube, and feebler the greater
the length of hair not inside the capillary tube. In Fig. 2 the mechanism
is shown, though the sample which I
pass around has some improvements
not illustrated in the figure. The
capillary tube consists of a brass tube,
S, of very narrow bore, over which a
sheath H glides with slight friction.
In the axis of the siieath, and of the
same length as this, runs a wire, which
fits in the bore of the tube S, and at the
end of which the test hair is fastened.
If the sheath be shoved entirely over
the scale the hair projects in its greatest length, and has accordingly only
very slight force. On the other hand,
if the sheath be drawn back as far as
possible the greatest part of thf iiair






K7




50.200


126


26.2050 i 20.2842


1


JOHNS HOPKINS HOSPITAL BULLETIN.


1.2634




[No. 75.  
21.5476+4.5574






disappears within the bore, and the short still projecting part
Eelation of Neusser's granules in the leucocytes : The
is capable of exercising very considerable pressure force. By
granules are altogether extremely numerous, particularly in
means of a screw the sheath can be held iirmly in any position
the small mononuclears. There was no appreciable variation
corresponding to a test hair of any desired length. There is a  
in the granules from day to day. In this case, with the large
millimetre scale on the tube, by the help of which a given
 
length of test hair can always be found again, together with
 
a protecting tube for the free end of the hair to complete the  
 
instrument.  
number of granules, there was found to be an elimination of
a large quantity of alloxuric body nitrogen.  
 
Observation VIII. — The patient was a woman 45 years of
age, with cirrhosis of the liver. Since 1895 she had complained
of gastric symptoms ; pain in the epigastrium. Had emaciated
considerably. Had been jaundiced. Thegastric juice showed
a very marked acidity ; free and combined HCl 0.35 to 0.41
per cent, and free HCl alone 0.22 to 0.28 per cent. The liver
was enlarged, hard and nodular. Spleen was not much
enlarged, but was hard and could be palpated at the costal
margin. Body weight averaged about 60 kilos. Vomiting
was frequent and patient was moderately ansemic.  


The testing of the hair for its pressure values at different
The daily diet was as follows : Bread, 300 grams ; milk,
lengths can be carried out with the aid of a delicate balance,  
500 ; wine, 500 ; tea (infusion from 6 grams), 250 grams ; rum,  
and if one makes determinations for every fifth or tenth line
30 grams; sugar (6 pieces), 30 grams; Eohitsch water, i
of the millimetre scale he can easily calculate the values for
bottle.  
the intervening lines. With this instrument it is easy to pass
from very low pressure values, even below the threshold for the
most delicate pressure points, to pressure values above the pain
threshold in parts of the body where the pain threshold is high.  


The value of this instrument was demonsitrated with Dr.
These food stuffs yielded about 1752 calories (28 calories
per kilo body weight), which were made up as follows:






Gushing in the ward the other day. In a case in which ordinary slight stimuli appeared to call forth pain constantly, the
Albumin
idea had arisen that pressure sense was absent, the pain sense
Pat
being very much exaggerated. It was easy with this instrument
to show that the pressure sense was not abolished, though the
threshold for pain was almost at the same level as the threshold for touch. With care, however, the pressure points could
easily be made out. The significance of careful examinations
in such cases is obvious, for it would be easy for the clinician
to make the statement that tactile sense was destroyed in a
given case in which in reality it was unaffected or but little
affected. If such a case should come to autopsy, one might
be entirely misled in interpreting the lesions found.


The sesthesiometer is not expensive, costing I believe five
Carbohydrates
marks, when purchased from E. Zimmermaun of Leipzig. I
Alcohol
cannot recommend it too highly for use in clinical examinations.






EDINGER ON "THE DEVELOPMENT OF BRAIN PATHS IN THE ANIMAL SERIES."*
283.31 calories.
233.43
927.33
308.00


[Abstract of a Keport made by C. K. Bardeen, M. D., before the Journal Club of the Johns Hopkins Hospital.]




Total 1752.07


In this address Edinger speaks in a most interesting way of
Table XX.— Urine.  
the value and possibilities of a comparative psychology based
on careful biological and morphological study. He himself,
he says, was led to undertake this line of research by the
knowledge that the lowest vertebrates have no cerebral cortex.
In man and in the higher vertebrates the finer conscious
activities take place in this part of the brain, and in the
ascending vertebrate series there is a gradual development of
the cerebral cortex up to man. " Indeed, in man," says Edinger, " the evolution of the brain cortex is still under way."
The interesting questions arose. What nervous activities are
possible in animals without a cerebral cortex ? and What
nervous and mental activities have been added as the cortex
has been evolved in the animal series ? The solution of these
questions involved the broader task of studying the finer
structure of the nervous system of the lower vertebrates. It
was found on investigation that those parts of the brain which,
as opposed to the cortex, are designated as the " lower parts "
are essentially similar in all vertebrates. The spinal cord and
medulla of the fish and of man do not differ fundamentally.  


"So far as we know to-day," says Edinger, "we may ascribe
to similar structure similar function." If this be true we may
hope by careful study of the morphology of the nervous system to have opened up new points of view for physiology and
psychology. If to the spinal cord, for example, the functions




Date.


* " Die Eatwickelung der Gehirnbahnen in der Thiereihe," delivered before the medical section of the " Gesellschatt deutschcr
Naturforscher und Aerzte," in Frankfurt a. M., Sept. 23, 1896, and
reported in the Deutsche medicinische Woehenschrift, Sept. 24,
1896, Vol. XXII, No. 39. [Prof. L Edinger of FrankCort is well
known in America as the author of a very lucid text-book on the
structure of the brain, "Der Bau des Gehirne." He is perhaps
the foremost worker in the line of research of which he speaks in
his address.]






of which are well known, comparative anatomical study shows
3
that other structures are added little by little, we may suppose
 
corresponding additions in functional capacity.  
a 2
 
.bo
 


Edinger lays special stress on the need of care in forming
our conceptions of the operations of the nervous system of the
simpler animals. We must carefully rid ourselves of all preconceived notions of perception and desire as the necessary
accompaniments of complex reactions to stimuli. We have,
he says, no grounds for belief that such states of consciousness arise outside the higher centres of the cerebrum. We
have no right to assume that in the lower animals the simpler
nervous system performs functions like those performed by
the higher centres of the nervous system in the higher vertebrates. " I trust I may be able to prove," says Edinger,
" that the latter assumption, so commonly made, cannot be
maintained."


To show how easily one might falsely attribute a conscious
origin to complex movements, two or three examples are given
from the invertebrate kingdom. Loeb's interesting experiments with the actinia are quoted. If a bit of fish be placed
on the tentacle ring of one of these animals the tentacles close
in and force the food into the mouth between the tentacles.
But a piece of white paper put in the same situation is left
undisturbed. This at first sight might seem a voluntary
choice between the food and the paper, involving a conscious
perception of taste. But if the mouth be destroyed and the
bit of fish be again put on the tentacle ring the actiniau will
double itself up trying vainly to force the morsel into the
closed mouth. The definite activity caused by the meat is,
roughly speaking, a direct reaction of the tissues to a chemical stimulus. The actiniau has no very definite nervous
.system, though certain of its cells are taken to represent nerve


rrlLs.
a a o!


Hdiu^er also refers to the recent studies on the nervous
Sis




SoSS


June, 1897.]


Percentage of
alloxuric
body— N of
the total nitrogen.




JOHNS HOPKINS HOSPITAL BULLETIN.
June 24




1


127


1350




system of tlie earth-worm. Thanks to the work of Loeb aud
1023
Friedlaender on the living earth-worm, and that of Retzius
aad von Lenhossek on the morphology of its nervous system,
the task of comparing its structure with its psycho-physiological activity has been greatly lightened. If the earth-worm
be cut into pieces not too short, and one of the pieces is stimulated to move, it will continue creeping. The movement is
produced as follows: from large epithelial cells in the external skin the earth-worm's sensory fibres pass into the central
ganglia situated in the ventral band ; here the process divides
into at least two parts. These lie in contact with the dendrites of large ganglion cells lying in this ganglion and in
those immediately adjoining. These large cells send processes
to the muscles. Each ganglion sends motor fibres, not only
to the muscles of the segment within which it lies, but also
to those of the neighboring segments. Some of the fibres
cross the median line. A third set of cells have processes
which run up and down the veutral band connecting different
ganglia. Thus a sensory impulse started in a large epithelial
cell is carried to the neighboring ganglion. Here the motor
and associative cells are called into activity, and the muscles
in the vicinity of the segment whose surface has been stimulated contract. This throws increased tension on the surface
of the neighboring segments and they in turn are stimulated
to contraction. A contraction wave is thus started along the
worm, called forth by simple reflex action. This scheme is
not diagramatic; it is based on the actual observations of
trained observers.


The mechanism which controls intestinal contraction in the
higher animals is very similar.


The nervous mechanism found in the vertebrate spinal cord
12.4504
is fundamentally the same. Here again we find motor cells
sending processes to the muscles; here again processes from
sensory cells terminating in gray matter ; here ag.ain, but in
a far more developed degree, association neurones. That the
spinal cord is capable, unassisted by the higher centres, of carrying out very complex movements is shown by the complex activity of the frog deprived of a cerebrum, the jumping
of the brainless rabbit and the swimming of the brainless




0.4831


The morphological structure on which the functions of the
spinal cord depend has now been fairly well determined.
Beside the factors already mentioned there enter into its
structure paths connecting it with the brain. In the fish
paths connect mid-brain and cerebellum with the spinal cord.
Connections between the cerebrum and the spinal cord
first appear in mammals. " The direct influence of the cerebrum on the activities controlled by the spinal cord varies,
therefore, according to the class of animal, and it does not
even exist among the lower vertebrates." The pyramidal
tract is not found in birds.


The medulla, while, like the cord, serving as a primary centre
3.87
for the reception of sensory and the origin of motor fibres,
has a much more highly developed associative mechanism than
the cord. Yet the development of these paths of association
varies greatly in different animals. In the carps and many
other fishes it has a more complex development than in man.
The complexity of development of the medulla depends chiefly




" 25


on the uses to which the cranial nerves are put. The terminal area of the fifth nerve, so well developed in the sensitive-faced mammals, is but slightly developed in the snakes,
but the motor area of the fifth nerve in snakes is relatively
more developed than in the mammals, owing to the snake's
powerful jaw muscles.


The cerebellum varies greatly in development, even among
2
the fishes. Those that swim actively have it more highly
developed than the mud-seeking varieties. Birds being animals of delicate sense of balance have it well developed. In
snakes it is very rudimentary. Whatever the functions of the
cerebellum may be, this organ is well developed in all animals
executing carefully poised movements. The hemispheres of
the cerebellum first appear in the mammals.


The connections of the cerebellum with other parts of the
central nervous system are interesting. The pons fibres first
appear in the mammals, and it is probable that the olivary
paths do not occur in the lower forms. On the other hand
the connections with the spinal cord through the corpus restiforme and with the thalamus through the suj)erior cerebellar
peduncle are primordially old. The latter are more highly
developed in fishes than in man.


Next to the spinal cord the mid-brain is that part of the
lOOO
central nervous system most alike in all vertebrates. It is the
primary terminus for the optic fibres, and in it end a large
part of the secondary sensory fibres transmitting impulses
from the other sense organs. It is the great centre for the
association of sensory impulses in the animals without a well
developed cerebrum.


The cerebrum in all vertebrates is composed of olfactory
apparatus, basal ganglia and cortex.


The olfactory region varies greatly in development. In
1022
reptiles and in fishes it makes up half the brain mass. In
 
birds it is scarcely to be traced.  
 
10.7800


The corpus striatum, which lies just behind the olfactory
apparatus, appears developed throughout the vertebrates. It
plays a chief part in connecting thalamus and fore-brain, but
in large part its functions are ill understood. The optic
thalamus is likewise complexly developed throughout the
vertebrates. The cortex stands in marked contrast to the
lower parts of the central nervous system which are so much
alike among all the vertebrates. In fishes the cortex consists
of a thin epithelial plate. In the amphibia it contains a
simple nervous apparatus. In reptiles a true cortex appears
for the first time.


Within the last twenty-five years it has been definitely
0.4498
shown that the cortex performs the highest functions of the
nervous system. On the existence of a normal cortex depend
all those functions which may be learned, almost all which
are carried out by memory pictures, and, above all, those complex conscious processes designated "associative." The silver
stain has shown into what a complexity of relations each
nerve cell is brought by its processes. From the reptiles to
man this associative complexity increases.  


It seems probable that various sensory areas in the cortex
have been added as the need has arisen for more highly developed associative processes connected with the special senses.
The earliest cortical relations are with the sense of smell


4.17




128
" 26




3


JOHNS HOPKINS HOSPITAL BULLETIN.


550




[No. 75.
1027




8.1428


only. Reptiles, we may assume, differ from fishes in that
they can "retain their smell impressions, associate them and
choose." For the reptile the cortex is an olfactory centre and
out little more.


" This first inheritance of the cortex, the olfactory centre,
0.4591
remains throughout the entire series ; in birds alone is it
somewhat uncertain. There is no difficulty in following the
cortex of the reptiles into the Amnion's horu and the uncinate
gyrus of mammals and mau."


But in the course of evolutionary development other brain
centres have been added to this ; the cortex has been built up
piece by piece. Unfortunately most of the steps are still uncertain. Something is, however, known of the optic paths.
In fishes the optic nerve ends in the mid-brain. And so too
in man at birth the only functional fibres end there. The
babe is not blind, but it has no association centres for sight
impressions. During the second mouth of life paths are
developed from mid-brain to occipital lobe, the cortical sightcentre is called into activity, and association paths are formed
between it and the rest of the cortex. The child only then
begins to perceive what it sees.


It is because the fish has no cortical centre for sight that
5.63
it can be hooked. To a similar reason is due the fact that
reptiles and amphibia often go hungry when they do not smell
their prey and it does not move. Snakes which do not eat
dead mice will seize and devour, without a trace of dislike,
dead mice artificially made to move.  


Birds have a well marked cortical area for sight, and hence
they exhibit many phenomena which indicate reason and
memory founded on sight impressions.


It is clear, however, that in the lower animals many functions are performed without the influence or control of a cortex, and the question naturally arises as to the real nature of
" 27




4


the functions of the lower centres. It is well known that man
and the higher mammals are more injured in normal activity
by loss of the cortex than are the lower vertebrates ; that
the cortex becomes indispensable iu proportion as it becomes
well developed and is brought into close association with the
lower centres. This has been shown by the study of the diseased human brain and by experiments on animals. But nature
offers us animals with no cortices and with cortices variously developed along special lines. We have here a beautiful
opportunity to study the functions of the cortex in the animal
economy. Most interesting points of view might be obtained
by excitation of the olfactory nerves of fishes which have no
cortical centres, and of snakes which have cortical centres for
smell ; or by comparing the effects of visible objects on snakes
which have no developed associative centre for sight, and on
birds which have them well developed.


And this same sort of study carried to man will also prove
850
productive. The great man need not necessarily have a
heavier brain than the average man, but we should expect that
part of his brain which he had occasion to use to be better
developed than the average. The great painter should have a
well developed occipital lobe ; the great musician a well developed temporal lobe. Gambetta's brain was not above the
average in size and weight, but the speech area was very greatly
developed. For the present, Edinger points out, we may willingly refrain from speculating about convolution anomalies
and criminal types. More fruitful fields of investigation are
offered the scientist. The field of comparative psycho-physiology and comparative morphology gives every promise of
being most fertile. One thing seems sure, " there is no
boundary to be established between the conscious activities of
the lowest and those of the highest vertebrates."




1025


PSEUDO-TUBERCULOSIS HOMINIS STREPTOTRICHA.


[A PRELIMINARY NOTE.]
11.5133


Bt Simon Flexnee, M.D.


[From the Pathological Laboratory of the Johns Hopkins University and Hotpital.'\
0.5087




4.32


At the meeting of the Johns Hopkins Hospital Medical Society held on October 19th, 1896, 1 presented specimens from the
lungs and peritoneum of a man who had succumbed to a disease
characterized by symptoms which resembled those of phthisis
pulmonum, but in the lesions of which, instead of the bacillus
tuberculosis, another and probably entirely distinct microorganism was discovered, for which I have proposed the name
of streptothrix pseudo-tuberculosa. As the publication of the
full report of the case and the complete description of the
micro-organism has been somewhat delayed, a brief outline of
the case may be of interest at the present time.


The patient was a male, colored, aged 70 years, in whom
" 28
extensive consolidation was made out in both lungs. The
symptoms were generally those of pulmonary tuberculosis.
Sputum was carefully watched for during his stay in the




5


Hospital (Dr. Osier's clinic), but none was obtained. No
microscopical examination could therefore be made.


Autojjsy. The body was that of a slightly built, somewhat
1050
emaciated man. The abdomen was moderately distended. The
autopsy was made 19 hours after death, the body having iu
the meantime been kept on ice. No evidences of post-mortem
decomposition were noticeable. The description of the viscera is limited here to the organs especially affected.


The Lungs are voluminous and meet in the middle line
anteriorly. They are not bound to the chest wall. Left. The
entire lung, except the anterior edge of the upper lobe, which
is insufflated, is consolidated more or less perfectly. Where the
consolidation is frank the lung presents an opaque appearance, is gray in color, and beginning softening (disintegration
with early cavity formation) is going on. The cavities often


1020




June, 1897.]
11.0618




5375


JOHNS HOPKINS HOSPITAL BULLETIN.


4.85




129
" 29




6


still contain the products of disintegration, and all appearances of reactive encapsulation are wanting. Where the hepatization is less complete the lung tissue is cedematous and
swollen, although perhaps not completely airless, and discrete
tubercle-like nodules may be seen. The pleura over the hepatized areas is covered with a fibrinous exudate. Right. The
consolidation is less extensive and more focal in character, but
occupies in places areas as large in extent as 4x5 cm. The
pleural cavity contains a small quantity of fluid, pink in color,
in which flakes of fibrin occur.


The intestines are moderately distended. The omentum is
1500
rolled up ; it occupies a position beneath the transverse colon
and extends across the abdominal cavity. The pelvis contains
about 15 cc. of fluid of brownish color and mucilaginous consistence. Between the intestinal loops delicate shreds of
fibrin exist. In addition smaller and larger nodules resembling tubercles, usually translucent, are scattered irregularly
over all the exposed peritoneal surfaces, and occur more uniformly upon and within the thickened, rolled-up omentum.
The liver and spleen on section show similar nodules.


The bacteriological examination consisted in the study of
cover-slips from the fresh lungs, the inoculation of glycerineagar tubes, and the injection of a suspension from the consolidated lung subcutaneously into a guinea-pig. The histological study embraced all the organs of the body. Cover-slips
from the lungs, stained by Gabbett's method, showed no micro-organisms which resembled the bacillus tuberculosis in
their morphology. There remained faintly stained in carbolfuchsin upon the cover-slips numerous examples of a branching organism, occurring often in clumps or convoluted masses,
among which no ordinary bacillary forms were discovered.
From the history of the case, the character of the lesions and
the known variation in morphology of the bacillus tuberculosis, it was, for the time, assumed that the organism was a
streptothrix form of the former bacillus. Its subsequent
study has rendered this assumption highly improbable.


The cultures from the left pleural cavity and the peritoneum remained sterile. Three separate sets of cultures were
1018
prepared from the lungs. In all these, at the end of 34 hours,
a vigorous growth of a bacillus, identified as belonging to the




11.1938


group of B. coli communis, had taken place. The streptothrix did not grow. The guinea-pig showed no reaction to
speak of at the site of inoculation, the adjacent lymph glands
could not at any time be felt; the animal, however, lost in
weight and died at the end of the 7th week, at the autopsy
showing great emaciation. None of the lymphatic glands were
found enlarged ; there were no lesions resembling tubercles in
these and other organs, and cultures upon glycerine agar, made
from several sources, remained sterile. Cover-slips from the
serous cavities, blood and viscera were negative for any kind
of bacteria.


The further study of the staining proj^erties of this organism in cover-slips, made from the lungs at the time of the
0.4594
autopsy, shows that as stained by the ordinary methods employed for tubercle bacilli, and decolorized by means of acids,
the dye is held very loosely and quite readily given up. The
best method of staining is either Gram's or Weigert's modified
fibrin stain. The same holds true for its demonstration in
the tissues.  


The lesions in the tissues are of two kinds, depending in
part upon their situation. In the peritoneal cavity tuberclelike nodules are formed, consisting of epithelioid and lymphoid cells with an occasional giant cell. Necrosis by fragmentation is not unusual in the centers of the tubercles, and
fibrin, either before or coincident with the necrosis, is commonly observed in the nodules. In the lungs tubercles also
exist, but they are less striking than a diffuse exudation of
leucocytes, plasma and fibrin which fills the air cells, infiltrates the stroma and tends to undergo necrosis, producing
larger and smaller spreading caseous foci of degeneration.
The number of masses of the streptothrix is very great indeed
and they are in intimate relation to the pathological process.


From these and some other considerations which will
4.10
appear in the full report, it is believed that the organism is
probably a new species, for which the name streptothrix pseudotuberculosa is proposed, and, further, that it is capable of causing in human beings a rapidly spreading and destructive disease resembling phthisis florida, for which the appellation of
pseudo- tuberculosis hominis streptotricha seems warranted.  






PROCEEDINGS OF SOCIETIES




Table XXI. — Nitrogen Ingested (in


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.


Meeting of December 7, 1896.  
Grams).*


Dr. Thayer in the Chair.


Discussion of Dr. Frledenwald's Paper on Consjenital Motor
Defects of tlie Eyeballs. See p. 203, Nov.-Dec. Bulletin, 1896.


Dr. Paton. — This case is of very great interest, and so
unique that I feel interested from an anatomical standpoint.
Cases of unilateral paralysis are easily explained, but for cases
of double paralysis of the 6th nerve there is no anatomical
explanation. As yet there has been no demonstration of the
crossing of the 6th nerve in man. It has been demonstrated
in monkeys. The crossing of the 4th nerve has been demon


Date.


strated in man. The further interesting fact that this case
brings forward is the relation of the 6th nerve to the oculomotor. There are two possible ways in which these nerves
can be related. If you take a section of medulla at the level
of the 6th nerve and look at the right side, the fibres are seen
to pass across to the left side, and then upward in the posterior
longitudinal bundle as far as the nucleus of the third nerve.
The main function of that bundle is to connect the nuclei of
the cranial nerves, and there you find the connection between
the 6th and 3rd. Recently another path has been marked out.
The 6th on the right side may pass up on the same side as the
rio-ht nucleus, and join the fibres of the 3rd nerve from the
other side ; so you have two possible connections. Either the


Day of observation.




130
Ham.




Bread.


JOHNS HOPKINS HOSPITAL BULLETIN.


Milk.




[No. 75.  
wine.  




Total nitrogen.


6th nerve crosses or the third nerve crosses, and the probability is the latter, because the crossing higher up of the 3rd
nerve fibres is the simplest physiological explanation.


Dr. Theobald. — Dr. Friedenwald has had an exceptional
June 24
experience in meeting with so many of these very interesting
" 25
cases. It would seem that in this case there is a marked want
" 26427
of power of the internal rectus of the left eye as well as of the
"28429
extei'nal rectus. This suggests the related cases of congenital
 
ptosis sometimes accompanied by inability to turn the eyes
upwards, that one meets with. It is well known that in this
case the defect is not central, but is due to absence of or
faulty development of the levator muscle of the upper lid and
of the rectus superior. Such cases are not so rare as the one
shown. I have met with several of quite marked degree.
Frequently they are associated with epicanthus. It seems to
me that the most probable explanation of this case is that we
have here a similar want of development of the external recti.
Indeed all the eye muscles here appear to be more or less
faulty or weak, for it is difficult to induce the patient to turn
his eyes in any direction, all of the movements being defective.
We not uufrequently meet with cases of pronounced weakness
of the recti muscles, particularly of the external recti, but
such cases as the one shown are rare and extremely interesting.


Congenital Facial Diplegia.— Dr. Thomas.
1


In connection with the case which Dr. Friedenwald has
2
exhibited. Dr. Thayer thought it might be interesting to have
3&4
this rather unusual case presented to the Society. He has
546
asked me to bring it before you.


The patient, a youth of 19, came to the Hospital from a
neighboring State, in the hope that something might be done
to improve bis uiifortunate appearance. Dr. Halsted has
admitted him to his wards, and it is through his kindness that
I have had the opportunity of examining him.


The family history is important. Father and mother are
8.8242
healthy and there is no history of any hereditary taint in
6.3491
either of their families. Patient is the third child of a family
48425
of nine. Three children died young, one of these having a
4.8425
niisformed foot. The eldest child, a girl, is perfectly healthy;
the second child, a boy, now twenty-one years old, was born in
a condition similar to that of our patient. The patient's birth
was not particularly difficult and was non-instrumental. It
was noticed soon after he was born that he was unable to
close his eyes and that his underlip dropped while nursing.
In crying his face remained motionless and he was unable to
smile. He learned to speak at the usual time but was never
able to pronounce certain letters. His general development
was good except that he had some glandular trouble. He
played with other boys and was able to do everything they did.  


You see what a remarkable appearance the patient has ; the
face is mask-like and expressionless, the mouth open, the
lower lip pendulous, and the lower jaw protruded. He is absolutely nnable to move the muscles of his forehead, and when
told to close his eyes he simply rolls the eyeballs up and
relaxes the upper lid. He is unable to elevate or pucker his
lips, but can move the angles of the moxxth out and down ; in
doing this, you see, he brings into play the platysmata. In
speaking he cannot pronounce the sounds which require the


5.6056
5.6056
5.6056
5.6056




use of the lips, viz. b, f, m, p, v. His eyes are prominent;
2.7037
the pupils are equal and react normally to light and during
2.70J7
accommodation ; all movements of eyeballs are normal. He
2.6C95
complains of being somewhat near-sighted ; there is no disturbance of the visual field. Muscles of mastication unaffected.
2.8875
There is no disturbance of sensation and taste is normal.
Tongue is well developed and freely movable, indeed he makes
his tongue take the place of his lips as much as possible,
drinks and smokes by its aid. I have been unable to discover
any abnormality in the muscular development of his trunk or
limbs. Stimulating the facial nerves by electricity causes
contraction in the muscles back of the ear and of theplatysma.  
By direct stimulation the platysma can be made to contract.  


Before leaving the patient I should like to call your attention to the congenital defect in the right lobe of his ear. You
will see that it is notched.


This, then, is a case of congenital facial diplegia. Dr.  
0.0350
Friedenwald has told you that certain of the cases of congenital defect of the ocular movements have been associated
0.0350
with a similar condition in the facial muscles, and it is on
0.0350
account of this association that I have brought the case before
0.0350
you at this time.  


Dr. Chisolm, of this city, reported one of the very first
examples of this condition. In his case there was bilateral
paralysis of the sixth and seventh nerves, a combination of
the symptoms seen in Dr. Friedenwald's case and of those in
the boy whom I have just shown you.


Moebius had a somewhat similar case, which he described
17.1685
in 1888, after which he made a fairly complete collection of
14.6934
all like and analogous cases. These he published in 1892. In
13.0926
this article he expresses the view to which, as Dr. Friedenwald has said, Kiihn takes exception, that the disease depends
13.3706
upon an atrophy of the nuclei, and he proposes the name " Infantiler Kernschwund."
 
 
 
*The variation in the nitrogen in the ham was due to the fact
that the patient could not continue to take the full quantity (220
grams) that she was first given.  


Moebius was unable to find the record of any case in which
congenital facial paralysis was unassociated with any defect
of the eye muscles. Since then, however, two or three such
cases have been described, but these cases were all unilateral,
and, as far as I have been able to discover, the case which I
have shown you to-night is the first one of its kind to be
reported, although I have no doubt that others have been
observed.


As to the anatomical condition which underlies these cases
not much is known, and it seems scarcely worth while, at this
time, to examine the theories which have been advanced.


The aspect and condition of the face in the patient whom
we have seen suggest strongly the myopathic face which
occurs in certain forms of progressive muscular dystrophy.
We have examined the patient thoroughly with this point in
view and have been unable to discover any other muscular
abnormality, either hypertrophy or atrophy.


It tlierefore seems to me that the case cannot be classed
with the progressive muscular dystrophies, although it
might be considered as an abortive form of this disease, an
explanation which has been given of a somewhat similar
condition. As we do not understand the pathology of the
muscular dystrophies, such an explanation helps but little.
In this connection the condition of the patient's brother is of


Table XXII.—




June, 1897.]
Nitrogen Balance (in Grams).  






JOHNS HOPKINS HOSPITAL BULLETIN.






131
Ǥ






importance, for if, as we are told, his symptoms are quite
similar to those of our patient, and no other muscles are
involved, it will make the classing of the case with the muscular dystrophies still more far-fetched.*


Dr. OsLER. — I do not think there are any muscular dystrophies of this kind that have that extreme atrophy without
any involvement of other muscles. None that I have seen
presented that appearance. You will probably find the
brother the same as this patient.


Dr. Halsted. — Is the jaw of the brother the same?


Dr. Thomas.— The patient tells me that it is not quite so
NITKOGEN ELIMIN
much so.


Dr. Theobald. — Were there any cases in the family previous to this ?
i .  
US .  


Dr. Thomas. — Not as far as I can find out, not even an
ocular palsy.


Dr. Barker. — The absence of ocular paralysis in Dr.
Thomas's case is an interesting feature. In consideration of
the anatomical relations of the sixth and seventh nuclei, the
occurrence of paralysis of the abducens along with paralysis
of the seventh nerve is rather to be expected, if the lesions
be in the region of the nucleus and due to pressure or hemorrhage. One of the most curious facts with which the anatomist has to deal is the relation of the fibres of the seventh
nerve to the sixth nucleus after they leave the facial nucleus.
Why these fibres should run up toward the middle line, turn
and run along the fioor of the fourth ventricle and then turn
again ventrally and laterally has never been satisfactorily
explained. Such an out-of-the-way coui'se seems unnecessary.


During the development of the motor nerves whose nuclei
of origin are situated in the medulla and poQS, the motor
fibres belonging to the N. accessorius, N. hypoglossus, N. vagus,
N. glossopharyngeus, N. abducens, etc., pass directly toward
the periphery of the medullary tube and pass through the
marginal veil to form the peripheral cranial nerves. The fibres
of the N. facialis alone show the well known remarkable discursion. Whatever be the factors which determine the course
of these fibres, they are active at a very early period of development, for the relations mentioned are visible in very young
embryos. In his lectures on vertebrate embryology last year,
Professor His of Leipzig made the ingenious suggestion that
the cause of the deviation of the fibi'es of the N. facialis from
the course we would expect them to take may possibly depend
upon mechanical factors associated with the development of
the auditory vesicle, since the ear vesicle is laid down laterally
exactly in the region of the sixth and seventh nuclei.


It would be easy to speculate further and to think of such
cases as the one before us as instances of congenital nuclear
destruction from disturbances of the relations which ordinarily
exist between the auditory apparatus and the neural tube, due
either to an unfortunate variation or to early intra-uterine
pathological lesions. That the affection is bilateral and that
more than one member of the same family is diseased would






•The elder brother was seen at his house and was found to be
in an almost exactly similar condition to that described above in
the case of his brother. Both cases will be reported more fully at
a later date.


s




favor rather than oppose such an hypothesis. It is surprising,
as  
considering the extremely complex character of the developmental relations of the internal, middle and external ear, that
vicious developments of these parts are not more common than
they are. It is interesting to note that, as Dr. Thomas has
pointed out in this individual, there is faulty development of
a portion of the external ear. Should this man or his brother
be the father of children it would be important to determine
the presence or absence in them of similar lesions, since, as is
well known, variations favorable or unfavorable show a marked
tendency to become inherited. That instances of extremely
unfavorable variation persisting through many generations are
comparatively rare need not surprise us, inasmuch as in the
progress of the race, in the course of a very few generations,
individuals bearing such peculiarities, owing to their unattractiveness and unfitness, are, as a rule, gently killed out without offspring.


While modern embryology permits the formation of hypotheses such as those here hinted at, it is to be remembered that
for any real explanation we must await the results of pathological findings in actual cases. In view, however, of what
has recently been done, the problem might perhaps be advantageously approached from the side of teratological experiment.


Meeting ofiDecemher 31, 1896.  
ATED.  
 
 
8
 
 
' ®*
 


Dr. Thayer in the Chair.


A Case of Acquired Paralysis of both External Recti Muscles, with Unilateral Facial Paralysis.— Dr. S. Theobald.


I thought this case would be of interest to show as supplementary to the one exhibited by Dr. Friedenwald several weeks
ago. His was a case of congenital paralysis, or perhaps defective development, of the external recti muscles. He pointed
out, as one of the interesting features of that form of paralysis,
that there was no squint, and explained that in cases of congenital paralysis secondary squint does not usually occur. In
the case which I exhibit we have the usual secondary squint
found in acquired paralysis of the ocular muscles, and as
both external recti are involved, it is of high degree.


This patient is 33 years of age and until August last was
employed as a laboring man. His history shows that ten years
ago he had a facial paralysis of the left side, and at the same
time a paralysis of the right external rectus. There has been
little or no change in his condition, so far as we can judge, in
all that time. During August last he first developed a paralysis of the left external rectus. As to the cause of these
paralyses the history is rather indefinite. It is more than
probable, I think, that they are of syphilitic origin. He
admits having once had gonorrhcea, and I think there must
have been specific trouble also, though the history as to this
is not clear. The points of interest are that so many years ago
he should have had paralysis of the facial nerve occurring at
the same time as the ocular paralysis. If the two had been on
the same side it would not be so difficult to explain their
co-existence, for we know that the nuclei of the 4th and 6th
nerves lie close together in the floor of the fourth ventricle,
and it is not uncommon to find both these nerves involved in
the same case. It is of great interest, too, that after so long a


£ Si




132






JOHNS HOPKINS HOSPITAL BULLETIN.


is^




[No. 75.
§






lapse of time the external rectus of the other eye should
have become iuvolved. The paralyses are evidently nuclear,
and it would seem that some central change, either inflammatory or degenerative, involved the nucleus of left 7th nerve
and the nucleus, which is quite close to it but on the other side
of the brain, of the right external rectus, and that after a long
lapse of time the left external rectus also became involved.


Paralyses of the ocular muscles are not uncommon. Their
a"
origin may be cortical, fascicular, nuclear, basilar, or orbital.
Probably the commonest cause of paralysis of the ocular muscles is syphilis. We also often have a paralysis of the ocular
muscles in tabes which is quite marked and yet which may in
time entirely disappear. Paralysis of the ocular muscles may
also be caused by diphtheria, disseminated sclerosis, poisoning
by alcohol, nicotine, etc., and a certain class of cases certainly
are due to cold. I have seen recently four cases of paresis of
the external rectus due to cold or exposure. Such cases frequently occur in rheumatic subjects and are usually due to
inflammation in the orbital portion of the nerve, and the prognosis is good.


The most marked symptom in cases of acute paralysis of
ths eye muscles is diplopia, which is very annoying. In squint
due to hypermetropia there is no complaint of dijjlopia, possibly because it usually develops in childhood ; but in paralytic
squint, which oftener occurs in ^ults, diplopia is the most
common symptom complained of.


There is one point in regard to this case which I have neglected to mention : this patient has well advanced atrophy of
S^  
both optic nerves. The discs are decidedly white and the
vision greatly impaired, in one eye being only ^^, in the other
^^. The treatment has been the administration of large
doses of potassium iodide, and I think there is some slight
improvement, but an operation will probably be necessary. It
will not be sufficient to perform a tenotomy of the internal
recti, but it will be necessary to combine with this an advancement of the externi.


Dr. Thomas. — There is the history of a decided facial
paralysis ten years ago, and at present there is contracture of
the muscles of the right side of the face. We know that in
cases of severe facial paralysis there is very generally developed a secondary contracture of the paralyzed muscles. After
a hurried examination it seems to me that upon voluntary
effort the patient does move the left side of his face more
than the right. An electrical examination would determine
the point, but even now I am strongly inclined to the belief
that it was the right side that was paralyzed. If this is
found to be the case we can easily understand how a single
lesion could cause a paralysis of the right 6th and 7th nerves;
in fact there are many such cases reported. But on the other
hand it is difficult to imagine a lesion involving the right 6th
and the left 7th nerves.


Dr. OsLER. — One other point is of interest in this case :
a
whether this may not be a facial paralysis and external rectus
paralysis occurring with the secondary symptoms of syphilis,
and whether his present paralysis and atrophy may not be the
signs of tabes. The fact that he has the knee jerk is somewhat against this, but the persistence of these ocular paralyses is occasionally seen as an initial symptom of tabes.


Urine.




Dr. Theobald. — I would only say in closing that the knee
FtBces.  
jerk was examined and found to be up to the usual normal
standard. The suggestion of Dr. Osier is well worth considering, whether we are dealing with a greatly different state of
affairs now from what originally existed ; whether this present paralysis is a tertiary, while the other was a secondary
symptom.  


I will be glad to have the patient come to Dr. Thomas's
clinic and have the electrical examination made. My diagnosis of left facial paralysis was made simply on the drawing of
the face to the right side and the fact that there is a certain
blank expression about the left side of the face.


Exhibition of Opiithalmological Cases.— Dr. R. L. Randolph.
oS2
Bilateral Dacryo-adenitis.


Dr. Randolph reported a case of bilateral dacryo-adenitis
(mumps of the lachrymal glands, Hirschberg) in a negro
woman thirty-nine years old. He spoke of the case as being
one of the few cases reported in this country, the disease being
very rare. Both lachrymal glands were so swollen that the
upper lids had been pressed down at the outer canthus to such
an extent as to hide the outer half of the eyeball. In the case
of the left eye the hypertrophied gland had pressed the eyeball inward and slightly downward. The tumors were
exceedingly painful to pressure, but at other times she suffered
no local pain, the pain then being refeiTed to the sides of the
face. There was nothing in her history that would give one
a clue as to the origin of her trouble. She was put on small
doses of bichloride of mercury and ten grains of iodide of potash three times daily, and frequent hot applications were made
to the tumors, and after a month there was a noticeable diminution in their size. Six months after the beginning of the
trouble there remained only a slight enlargement of the left


a




The trouble having passed away it is no longer interesting to
June 24
show the patient, so she is not here this evening. It is the
first case reported in the city, and certainly less than a dozen
have been reported in this country.


Dr. Thayer. — In connection with Dr. Randolph's case I
 
should like to say a word with regard to a somewhat similar
1
instance which has been under our observation in the hospital.
 
In 1894 a little girl, 10 years of age, was admitted to the hospital with bilateral hard enlargement of the lachrymal, parotid
 
and salivary glands, for which we were unable to find any
60.700
cause. The lachrymal glands were to be felt on either
 
side as two small hard shot-like bodies. The child stayed in
 
the wards for many months, and while there developed an ozoena
17.1685
and caries of the nasal bones which was clearly syphilitic in
nature. Under treatment with mercury and iodide of potassium the glandular swellings slowly but completely disappeared. While in the hospital, however, some of the cervical
and lymphatic glands became enlarged and remained so after
treatment with mercury and iodide of potassium, and the
child has since showed evidences of a tuberculous peritonitis.
The enlargement of the lachrymal glands was very striking,
though never as marked as in Dr. Randolph's case; it has
entirely disappeared.  




12.4503


June, 1897.]


1.3508




JOHNS HOPKINS HOSPITAL BULLETIN.  
13.8011




+3.3674


133


" 25




Operations for Cataract.
2


The other cases which I have to exhibit are some of the
cataract cases upon which I have operated in this Hospital
during the last summer. There are 12 or 13 here to-night.
Some of them have interesting histories. One, an old man,
88 years of age, was operated upon early in September, and on
the night of the operation had an attack of acute mania. He
tore the bandage off several times, and finally had to be tied
in bed, but in spite of that has a good result. When we consider how slight a disturbance may sometimes cause the operation to go to the bad this is rather a remarkable recovery.
The bandage was disarranged at least three times. After the
atropia was withdrawn he regained his senses and was rational
for three days. One night after that he had another attack,
jumped from his window, scaled the fence and was making
his way homeward when found. Strange to say it had no
effect upon the ultimate result.


The next case is a rare one. I operated for cataract early
60.400
in June and the anterior chamber remained open after the
operation for 17 days. At the last meeting of the American
Ophthalmological Society I asked several of the members
what was the longest time they had ever seen the anterior
chamber remain open, and the longest period given in reply
was 11 days. Four weeks after the operation when this patient
left the hospital he had i^ vision, which is very good practical vision.  


Very frequently in cataracts there seems to be a stage where
they make no progress toward maturity. That was the case
with this woman, aged 63, who, while having sight enough to
get about, was unable to do work. Here I performed the
maturing operation. This consists in doing an iridectomy
and practicing massage upon the lens through the cornea.
The cataract was ripened, then exti'acted. With the exception
of that case I have performed the simple extraction, and in
several of them there is no objective evidence of an operation
having been performed.


Demonstration of Florence's Iodine Test for Seminal Stains.  
14.6934


— Dr. Lewellys F. Barker.


Professor Florence of Lyon has recently published in the
10.7810
Archiv d'Anthropologie a very delicate test for human seminal stains. He uses a mixture of iodine, iodide of potash and
water not unlike the ordinary Lugol's solution.  


To apply the test, if the seminal stain be upon linen, a small
piece of the stained fabric is moistened with water, placed
upon a glass slide and a drop of the reagent added beneath
the cover-glass. If the stain be due to semen a very distinct
precipitate of crystals results. The form of crystals is not
unlike that of ordinary haemin.


We have used the test in the course in normal histology and
1.3508
find it very easy to apply and extremely delicate. The reaction is not yielded by blood, saliva, nasal mucus, vaginal
mucus, urethral mucus, nor by the semen of other animals. I
have placed under the microscope one specimen in which the
seminal reaction is apparent, and under the other microscopes
a number of other fluids mentioned in which no reaction has
taken place. Urine sometimes throws down yellow-brown
globules, but as far as we have been able to make tests, defi




nite crystals, likely to be confused with those of the reaction,
12.1308
are never deposited. Whether or not urine containing semen
would yield the reaction I have not yet had the opportunity
of testing; but inasmuch as minute quantities of the seminal
fluid on linen will afford the reaction, it is very probable that
urine containing this substance would also yield it. Some
alkaloids are capable of yielding similar precipitates, a fact
which must be borne in mind in medico-legal cases. Just
what portion of the semen is concerned in the reaction has
not yet been made out; it would be easy to ascertain this by
testing the individual constituents of the seminal fluid
obtained, say from the vas deferens, vesiculiE seminales, prostate and Cowper's glands at autopsy. Urethral mucus, as will
be seen under one of the microscopes, does not yield the reaction. In case no single one of these constituents afforded the
reaction, the latter must be due to some substance produced on
their admixture.  




+2.5626


NOTES ON NEW BOOKS.


" 26




The Practice of Medicine. A Text-book for Practitioners and
3
Students, with special reference to Diagnosis and Treatment. By
Jambs Tyson, M. D., Professor of Clinical Medicine in the Unisity of Pennsylvania, etc. Illustrated. {Philadelphia: P. Blakision, Sondb Co., 1896.)


This is in every respect an admirable boolt. The author's statement that it tias taken several years of labor is borne out by the
careful and thorouglily conscientious way in which the suliject has
been treated. It is a work of nearly 1200 pages, larger than the
recent text-books issued in this country, containing on the whole
rather more mattereven than Flint's, which is a very closely printed
book.


Ttie author's method of dealing with a subject is well illustrated
59.600
in the consideration of the important subject of myxoedema. Following the definition — and by the way the text-book is quite
 
strong in clear, practical paragraphs defining diseases— the history
 
of our knowledge of the affection is considered in nearly threefourths of a page. Dr. Tyson has in nearly every section dealt in a
13.0926
most instructive way with the historical development of the knowledge of the different diseases, and in myxoedema it is of course particularly interesting. I do not think that the statement is altogether clear about the dispute between Reverdin and Kocher as to
 
the discovery of operative myxcedema. Unquestionably Reverdin
 
published the first note in October, 1882, but he did not at that
8.1427
time appreciate fully the remarkable character of the changes following thyroidectomy. Kocher distinctly states that in the autumn
 
of 1882, in Geneva, he spoke to Professor Reverdin of the remarkable sequences of the operation, and that Reverdin six days later
 
read a paper on the subject. In Kocher's paper, which appeared in
1.3508
the spring of 1883, the description of operative myxoedema as we
 
know it now, and which he called cachexia strumipriva, was fully
and clearly drawn, and he certainly appreciated at that time, as
Reverdin did not, the serious effects which might follow total extirpation. In the succeeding paper by the brothers Reverdin they
recognized the condition as identical with myxoedema and called
it myxoedeme operatoire. Three forms of myxoedema are recognized :
pure myxoedema, myxcedema associated with congenital or sporadic
cretinism, and operative myxcedema. There is in addition a full
description of cretinism. On the subject of exophthalmic goitre,
though the disease is placed under diseases of the thyroid gland,
Dr. Tyson states that the neurotic nature of the disease is now generally admitted. He holds that the sympathetic neurosis theory


9 4935


explains the symptoms rather more satisfactorily than any other.
His practice is better than his precept in this respect, since he
places the disease where it probably belongs, among those of the
tliyroid gland. We are glad to notice that he insists upon the priority of the description by Graves. Of this, of course, there can
be no doubt, though Parry and others published individual cases.
Graves' clinical lecture in 1835 gave the first good description of
the affection.


Naturally in a new textbook one turns to certain of the diseases
+3.5991
about which there is still a good deal of difference of opinion. Appendicitis receives a very thorough and satisfactory treatment.
There is no work in English which gives so good an account of the
history of the affection. We are glad to see that Dr. Tyson does
not consider it necessary to speak of a typhlitis, stercoral or otherwise. It is satisfactory to see that the name even does not occur in
the index. lie describes catarrhal, ulcerative and interstitial forms
of appendicitis. The clinical description of the different varieties
is admirable. On the all-important matter of treatment the author
takes rather advanced ground, stating that "the diagnosis being
established, operative treatment should be recommended, except
in those cases where the disease is so far advanced as to make it
unlikely that the patient will be saved by operation." He thinks
that the operation after the first attack is safer than during the first
attack. On the much debated point of purgatives he leaves the
matter to the circumstances of the case and the good judgment of
the attendant, as the results may be either very happy or very mischievous. He believes that if there is doubt it is best not to purge.  


The article on typhoid fever, with which the book opens, is in
every way worthy of the great importance of the subject. The
author is a strong believer in the use of the cold bath, and on the
question of treatment he everywhere displays sound judgment.


We have said enough to indicate the importance of the work, its
" 27
thoroughness, and its reliability in all practical details. The publishers are to be congratulated on the appearance of the volume.
It is one of the handsomest works issued of late years in this country,
and the type and paper are very much above the average. Altogether Tyson's Practice forms a very welcome addition to our textbooks, and we predict for it a most successful career.


An American Text-book of Applied Therapeutics, for the use of
Practitioners and Students. Edited by J. C. Wilson, M. D.,
assisted by Augustcs A. Eshnek, M. D. Pp. 1-1326. {Philadelphia: W. B. Saunders, 1896.)


Since the main object of medical studies must always be the formulation of methods for the prevention and cure or alleviation of
4
disease, it necessarily results that laboratory researches and clinical
observations must ultimately be valued in proportion as they have
brought us nearer to the attainment of these aims — in other words,
according to the advances which have been derived from them in
the establishment of a rational system of therapeutics. The world
at large is apt to look at results rather than methods, and the
busy practitioner may justly demand that the previous studies and
experience of others should be presented to him in aconcrete form.
For these reasons the status of medicine at any particular period
will, to a great extent, be gauged by the therapeutic measures
which prevail at that time, and of which the textbooks dealing
with the subject are the exponents.


Graduates of twenty years ago will probably remember a time in
the first few years of their practice during which they were tempted to become adherents of the doctrines of therapeutic nihilism.
They had gone forth armed, they had been taught and for a time
had firmly believed, with agents with which they could infallibly
combat each and every untoward symptom. Is it to be wondered
at that many of them in a short time exchanged their early therapeutic optimism for a hopeless therapeutic pessimism? Could
they not justly reproach for this the faulty teaching which had
been accorded to them?


59.900




Medicine is still to a great extent an empirical art, but although
13.0926
we can hardly hope that it will ever be numbered among the exact
sciences, there are signs which indicate that by slow degrees we are
attaining to a therapeusis which may always be at least rational.  


The book before us shows a decided advance, not only because it
registers real progress made in our knowledge of disease processes
and in our methods of treatment, but because it shows that the
difficult subject of therapeutics is now being attacked in a frank and
true scientific spirit. The writers have been chosen from among
men who have brought to bear upon the subjects allotted to them
not not only the results of a profound study of the existing literature, but also those which can be obtained only by a wide personal
experience. They are not mere compilers; they know whereof
they speak. If not all of them have added much that is new, they
have at least accepted the dicta of others only after a painstaking
proving of their statements. They have chosen the middle ground,
and while confident that much can be accomplished by the use of
the various therapeutic measures which they recommend, they do
not by the employment of specious generalities attempt to conceal
those points upon which our present knowledge is still defective.
They hold a strong position midway between therapeutic optimism
and therapeutic nihilism. Above all and first of all they preach
the doctrine of prophylaxis.


In many of the articles a short account of the more prominent
11.5132
manifestations of the disease underdiscussion will be found, which,
although adding considerably to the bulk of the book, will assist
the reader materially in better appreciating the treatment recommended later. It is impossible to speak here in detail of all or of
any of the various contributions. In his article on tuberculosis,
Whittaker summarizes our present knowledge upon prophylaxis in
general, hygiene and climatology, and has ably marshaled all the
recent experience, upon which he formulates a treatment which, if
it contains little that is really new, is perhaps the best at hand. If
his conclusions as to the advantages to be obtained by the use of
tuberculin are not in accordance with those of other authors, his
results certainly deserve the most respectful consideration. Tyson's article upon the diseases of the kidney is brief but admirably
comprehensive. In speaking of typhoid fever, Wilson, after a
careful consideration of other methods, not only endorses the cold
bath treatment but repudiates the notion that it is cruel. This
latter view will certainly not be conceded by many even of the
most enthusiastic supporters of the procedure. Serum therapy
receives a full share of attention, and the subject has been treated,
by the writers upon the conditions for which it has been advised,
with a full appreciation of its importance. Whatever may be the
opinion with respect to Laveran's vie w as to the identity of the parasite for the different forms of malarial fever, the careful and precise
treatment which he lays down will not easily be improved upon.  


Another point to be noted is the comparative simplicity of the
prescriptions which are given ; we are grateful for further evidence of the decline of polypharmacy. It would seem that we are
beginning to appreciate Huxham's advice, " The physician should
select a few (drugs) of the most effectual forhis useof each sortand
stick to them and not run into an immense farrago which some
are so fond of." Many of the illustrations are good, but not a few
are superfluous. As might be expected, the book lays no claim to
perfection. The student who looks to it for infallible remedies for
every disease will naturally be disappointed ; the man of more moderate demands will find in it much that will help him in his daily
work, and much that will stimulate him to the observation of disease processes and of the way in which they may best be met.


Frank R. Smith.  
1.3508


Die Fiirbetechnik desNervensystems. By Dr. B. Poll.^ck. {Pub
lishcd by 8. Karger, Berlin, 1897.) Pp. 1-130.


This little book will be welcomed by neuro-histologists everywhere. It gives briefly the important steps in all the more impor
12.86401+0.2286




June, 1897.]
" 28




5


JOHNS HOPKINS HOSPITAL BULLETIN.


59.700




135
13.3706




11.0617


tant methods used in microscopic examination of the nervous
system, including those of recent date. In the first section the
technique of cutting up the brain at autopsy is described, togetlier
with the methods for preserving the brain whole and forreproduc.
ing plastically the specimens found at autopsy. In section two the
general technique of hardening, staining, emliedding and section.
ing is discussed. The methods of making serial sections, including
the recent method of Flatau for making serial longitudinal sections
of the whole spinal cord, are considered. We are glad to find mention made in section three of the work of Donaldson and others
concerning the alteration in weight of the brain and cord after
pri-servation in different hardening fluids. Too little attention has
been paid to such alterations in previous books on technique. Apparatus for drawing and photography are described in section four.
In the next section the methods of staining and impregnation are
taken up. The various ways of demonstrating nerve cells and their
axones and myelin sheaths are outlined. Golgi's method, Ehrlich's metliod and the new stains for neuroglia have been carefully
considered. Nissl's method is given, and also Held's modification of it. The differentiation with alum solution is simple, easy to
manage, very inexpensive, and yields in the reviewer's experience
results fully as satisfactory as those afforded by the method with
anilin oil and alcohol. In the sixth section certain general points
to be borne in mind in the examination of normal and pathological
cases are emphasized. It is particularly gratifying to find epitomized at the end of this section the routine methods employed in
Waldeyer's laboratory for the study of the central and peripheral
nervous systems. A brief bibliography is appended as well as an
index. The book costs only two marks, and will probably find its
way into many laboratories, where it will prove a safe and convenient guide. L. F. B.


Arbeiten aus dem Institut fiir Anatomie und Physiologic des Centralnervensystems an der Wiener Universitiit. Herausgegeben
1.3508
von Professor Dr. Heinrich Obeesteiner. Y. Heft, mit 5 Tafeln
und 46 Abbildungen im Texte. (Leipzig und Wien : Franz Deuticke, 1897.)


The most recent number of the fasciculi which are appearing at
intervals from Obersteiner's laboratory is fully up to the general
standard set by the preceding numbers. Itcontains seven articles,
one of which, on the innervation of the blood-vessels of the
brain, is by Obersteiner himself. In this article Obersteiner discusses the work of previous investigators and describes and pictures
a small artery of the pia mater stained with gold, in which he
brings the direct anatomical proof that the finer intra-cranial vessels, at least within the pia mater, possess their own nerves. He
refers briefly to the physiological and pathological significance of
such innervation.


Schlagenhaufer contributes an article on the course of the fibres
12.41251+0.9580
in the optic paths, in which is discussed also the tabetic atrophy of
the optic nerve. He believes that there exists sometimes, at any
rate, a compact uncrossed optic bundle which, however, forms only
a part of the uncrossed bundle, and probably corresponds to the
inferior (external) fibres. The direction of the course of this bundle
gives, he thinks, in all probability, the anatomical course of the
uncrossed bundle. The question of the total or partial crossing of
the optic nerves in man must, therefore, be regarded as decided in
favor of the latter through anatomical investigation. He thinks
that by means of a scheme constructed accordingly it is possible to
explain all the hemianopsias. As regards Gudden's commissure, he
makes out that a part of the fibres stream into the ansa lenticularis
to become connected with both lenticular nuclei. Some of the
fibres run in the peduncle of the hypophysis. In front of Meynert's
commissure in the upper anterior part of the chiasm there is a
small system of fibres which remains intact when the optic nerves
and chiasm atrophy. He thinks it possible that the tabetic atrophy
of the optic nerves may be due to pressure at the foramen opticum.  




" 29


F. Rezek describes and pictures a primary polymorphous sarcoma
of the brain.


Pfiegler and Pilcz contribute along article entitled "Beitriige zur
6
Lehre von der Mikrocephalie." They describe twelve cases of their
own, with consideration of no less than 365 bibliographic references.


An interesting study of the histology of the ganglion cells of the
horse in normal conditions and after arsenic poisoning is given by
H. Dexler. Two beautiful plates accompany his article. The same
writer publishes also a short note on the course of the fibres in the
optic chiasm of the horse.


Julius Zappert, in an article on degenerations in the spinal cord
59.500
and medulla oblongata in the child, embodies the results of his
studies on the spinal cord and medulla of children who have died
during the first three years of life. He has used Marchi's method
and describes his findings with especial reference to the changes in
the various nerve roots. L. F. B.  




13.3706


BOOKS RECEIVED.


11.1937




Tuberculosis. By William Osier, M. D. 8vo. 1897. Reprinted
1 .3-^08
from " Loomis' System of the Practice of Medicine," New York
and Philadelphia, I, pp. 731-848.


Diseases of the Ear, Nose and Throat and their Accessory Camties. A
condensed text-book. By Seth Scott Bishop, M. D., LL. D. 1897.
8vo, -196 pp. The F. A. Davis Co., Philadelphia, New York,
Chicago.


Annual Report of the Trustees of the State Hospital for the Insane, at
12.5445|+0.8261
Warren, Pennsylvania, for the year ending No-oember 30, 1896, to the
Board of Commissioners of Public Charities. 1897. 120 pp. Herald
Printing and Publishing Co., Erie, Pa.  


Medical and Surgical Report of the Presbyterian Hospital in the City of
New York. Edited by A. J. McCosh, M. D., and W. B. James, M. D.
Vol. II, Jan., 1897. 8vo, 272 pp. Trow Directory Printing and
Bookbinding Co., New York.


Ouy's Hospital Reports. Edited by E. C. Perry, M. A., M. D., and
W. H. A. Jacobson, M. A., M. Ch. Vol. LI, being Vol. XXXVI
of the third series. 1895. 8vo, 272 pp. J. & A. Churchill,
London.


Guy's Hospital Reports. Edited by E. C. Perry, M. A., M.D. , and
Eelation of Neusser's granules in the leucocytes: The
W. H. A. Jacobson, M. A., M.Ch. Vol. LII, being Vol. XXXVII
granules were very numerous, especially in the mononuclears.  
of the .third series. 8vo. 1896. 230 pp. J. & A. Churchill,
London.  


Lectures on Pharmacology for Practitioners and Students. By Dr. C.
Binz. Translated from the second German edition by Peter AV.
Latham, M. A., M.D. Vol. II, 1897. 451 pp. 8vo. New Sydenham Society, London.


A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in Photolithochromes from Models in the Museum of the St. Louis Hospital,
Paris. With explanatory woodcuts and text. By E. Besnier,
A. Founier, et al. Edited and annotated by J. J. Pringle, M.B.,
F. R. C. P. Fol. 1897. Part IX. W. B. Saunders, Philadelphia.


Transactions of the Indiana State Medical Society, 1895. Forty-sixth
Mat, 1897.]
annual session held in Indianapolis, Ind., June 6th and 7th, 1895.
Svo, 534 pp. Carlon & Hollenbeck, Indianapolis.  


Hysteria and Certain Allied Conditions. By George J. Preston, M. D.
91
1897. Svo, 298 pp. P. Blakiston, Son & Co., Philadelphia.


DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL


Bv JOHN s. Billings, m. D., ll. D.


Contaiulng 56 large quarto plates, phototypes, and litliographa, with views,
although there was considerable variation in the granules
plans and detail drawings of all the buildings , and their Interior arrangements—
from day to day. As will be seen from the table there was a
also wood-cuts of apparatus and fixtures; also 116 pages of letter-press describing
large amount of alloxuric body nitrogen eliminated.  
the plans followed In the construction, and giving full details of heating-apparatus,
ventilation, sewerage and plumbing. Price, bound in cloth, $7.60.  


These observations that have been made do not in any way
confirm the theory that there is a regular coincidence between
an abundance of the granules and an increased excretion of
the alloxuric bodies, nor do they favor the view that Neusser's
granules occur exclusively in patients with an alloxuric
diathesis. Cases occur in which, with numerous grannies in
the leucocytes, there is a relatively small amount of the alloxuric bodies eliminated in the urine, while on the other hand
the granules may be almost entirely absent and the alloxuric
bodies be excreted in increased amount. Such directly opposed
conditions may occur in different individuals having the same




136


disease, as in the two cases of hypertrophic cirrhosis of the
liver. Not infrequently the granules become increased or
diminished in the same person without there being a corresponding increase or diminution in the excretion of the alloxuric bodies. In fact, increase in the number of granules may
be accompanied by a diminution of the alloxuric bodies and
vice versa.


From the information obtained by the study of the above
cases one seems justified in concluding thattlie supposed relationship between the perinuclear basophilic granules and an
alloxuric diathesis, as claimed by Kolisch, is purely empirical.


JOHNS HOPKINS HOSPITAL BULLETIN.  
In conclusion, I must thank Professor Kraus and his
assistants for many kindnesses and for valuable aid in carrying on the above analyses.  






rXo. 75.
ENCYSTED DROPSY OF THE PERITONEUM SECONDARY TO UTERO-TUBAL TUBERCULOSIS AND


ASSOCIATED WITH TUBERCULAR PLEURISY, GENERALIZED TUBERCULOSIS


AND PYOCOCCAL INFECTION.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.  
By Claribel Cone, M. D., Professor of Puthology, Woman's Medical College, Baltimore.
[From the Pathological Laboratory of the Johns Hopkins University and Hospital]






THE JOHNS HOPKINS HOSPITAL REPORTS.
The following case is of interest not so much because of
Volume I. 423 pages, 99 plates.  
lesions in themselves unique, as because of the rare combination of many lesions, the extensive character of these lesions,
and the multiple nature of the infection.  


Report In Pathology.  
The case has many features in common with that reported
by Gardner,' of Montreal, in the year 1885, and is similar to
those described by Wm. T. Howard,' of Baltimore, the same
year.  


The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
Clinical History.


Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the  
N. A., primipara, aged 30 years ; colored. Admitted to the
Maternite of the Hospital of the Good Samaritan, in the
service of Dr. B. B. Browne, November 19, 1894.


Vena Portae and its Influence upon the Circulation. By P. P. Mall, M. D.
The patient had been married several years ; had no children, no miscarriages. Menstruation commenced at the age of
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis
15 ; it had always been regular, painful and profuse, lasting
from six to eight days, during which time she was compelled
to remain in bed. Her last jieriod occurred about the middle
of March, 1894.


(Atrophy). By Henry J. Berklet, M. D.  
Past History. No family history could be obtained. The
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.  
patient had measles after reaching adult life. Five years ago
she suffered with an attack of " malaria " which lasted three
months ; at this time she claims to have been " very sick."
The attack recurred in September, 1894.  


Mall, M. D.  
History of Present Condition. The patient is in the eighth
month of her pregnancy. Throughout this time she has been
feeling ill ; she has had pain in the back and abdomen,  
increased on exertion. At present there are constant backache, and pain in the lower part of the abdomen. Appetite is
good ; bowels constipated ; urine of low specific gravity, otherwise normal.  


Report in Dermatology.  
E.t'xmination. Fcetus occupies the left occipito-posterior
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
position. In the right iliac region is a mass, partly soft, partly
resistant, which seems to be connected with the uterus, and is
not painful except on deep pressure.  


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
On November 18 at 9.30 p. m. the woman was delivered of a
healthy child, but owing to uterine inertia the placenta had to
be removed. The labor was protracted, lasting 38 hours. The
perineum was lacerated and repaired at once. Two days after
delivery the patient was attacked with a chill followed by fever
and sweating. The record of the puerperium shows an irregular temperature of septic character whose highest point was
104.3°, whose average was 103°. There was no fever after the
second week and the patient's condition was recorded as good.


Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
On January 19, 1895, she was discharged from the hospital
apparently in fair health. The following April the patient
visited the hospital clinic for treatment, considering herself
again pregnant since February. In July, 1895, she returned
with enlarged abdomen and general discomfort. At this time
she claimed to have felt the foetal movements; in August she
was seen at the clinic by Dr. B. B. Browne, who, after examination, did not think her pregnant.  


T. C. Gilchrist, M. D.  
Second Admission. In October, still believing herself pregnant, the woman was readmitted to the Maternite. After
careful examination under an anaesthetic, pregnancy was definitely excluded from the diagnosis. At this time a large hard
mass was found to the right of the uterus and apparently connected with it. The nature of the tumor could not be determined. Following the ether examination the woman became
quite ill. There was great pain in the lower part of the abdomen and sudden rise of temperature. The patient was then
transferred to the gynecological department of the Hospital of
the Good Samaritan. After the second day the abdomen
beo-an gradually to swell, and on December 1st it was much
distended. The patient was losing flesh and strength. The
temperature showed a typical hectic range, being normal or
subnormal in the morning, with an afternoon rise fluctuating
between 100° and 103°. The lowest point reached was 95.4°,
the highest point 104°.  


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


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


92




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


Report in Medicine.


On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
Repeated examinatious of the sijutum showed no tubercle
bacilli.


Gallstones. By William Osler, M. D.
Diagnosis. Encysted dropsy of the peritoneum, probably
Some Remarks on Anomalies of the Uvula. By JoHX N. Mackenzie, M. D.
tubercular.  
On Pyrodin. By H. A. Lafleor, M. D.
Cases of Post-febrile Insanity. By William Obler, M. D.
Acute Tuberculosis in an Infant of Four Months. By Hahrt Toclmin, M. D.
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.  


Report in Medicine.  
Operation. For removal of the dropsical fluid. On February 26 th a laparotomy was performed by Dr. Browne. Au
Tubercular Peritonitis. By William Osler, JI. D.  
incision 5 cm. long was made in the median line of the abdomen. From this opening about eight litres of transparent,
A Case of Raynaud's Disease. By H. M. Thomas, M. D.  
pale greenish fluid escaped. The entire anterior portion of
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  
the peritoneal cavity was found to be converted into a suppurating cyst. An additional litre of semi-solid caseous
material resembling masses of congealed fat was removed by
the hand of the oj)erator from the lower part of the sac where
it covered the pelvic viscera on the right side. After evacuation of the fluid the surface of the peritoneum was found
thickened and converted into a necrotic membrane resembling
the caseous masses which floated in the jius.  


Report in Gynecology.  
Examination of Fresh Abdominal Fluid. The macroscopic
The Gynecological Operating Room. By Howard A. Kelly, M. D.  
appearance was that of a turbid, pale greenish yellow fluid in  
The Laparotomies performed from October 16, 1889, to March S, 1890. By Howard
which floated shreds and flakes of caseous material. On
standing it separated into two layers, au upper transparent,
greenish fluid and a lower dense, creamy mass. The microscopic examination of this fluid showed numerous pvis cells,  
some red blood corpuscles and shreds of necrotic tissue
entangling pus cells. Staiued cover-sliji preparations of the
fluid exhibited numerous cocci in jjairs, clusters and short
chains, but no tubercle bacilli were found.  


A. Kelly, M. D., and Hunter Robb, M. D,  
Immediately following the operation the patient's condition
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of
was much depressed. She rallied, however, resi^ondiug to
stimulation. Her general condition improved and she became
much more comfortable until the tenth day, when without
pain or other distressing symptom she died suddenly, March
6, 1896. The autopsy was made three hours after death.


Abdominal Section. By Howard A. Kelly, M. D.
Anatomical Diagnosis. Tuberculosis of the Fallopian tubes,
The Management of the Drainage Tube in Abdominal Section. By HnuTER Robb,
uterus, ovaries, peritoneum, pleura, and viscera generally.  
Acute flbrino-puruleut and caseous peritonitis; acute serofibrinous and hemorrhagic pleurisy ; mixed tubercular,  
staphylococcus and streptococcus infection ; congestion of  
viscera; general arterio-sclerosis.  


M. D.  
The body is much emaciated. In the median line of the
The GonococcuB in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Pentoneum;
abdomen is a gaping incision. It begins 3.7 cm. below the
umbilicus and extends 5 cm. downward, exposing a sloughing, puriform cavity from which bubbles of gas are evolved
ou pressure. The subcutaneous fat is quite absent; the  
muscles are brownish red in color.


Ovarian Tumor; General Gynecological Operations from October 15, 1889, to  
Abdomen. On opening the abdomen the entire anterior portion of the peritoneal cavity is found to be converted into a
suppurating cyst. This extends from the liver above to the
pelvis below, and traverses the lateral diameter of the abdomen from flank to flank, dipping deeply on both sides. The
walls of the sac are made up of dense, opaqire, yellow necrotic
material about 5 cm. in thickness. The cavity contains a small
amount of the same puriform material found at operation.
Extending across the cavity obliquely downward, and from
before backward, as if to support its somewhat flaccid walls, are
four or five dense fibrous bands covered by caseous material,
continuous with that lining the general suppurating sac. Of
these the largest is in the median line. It is long and almost


March 4, 1890. By Howard A. Kelly, M. D.
Report of the Urinary Examination of Ninety-one GjTiecological Cases. By Howabd


A. Kelly, M. D., and Albert A. Ghriskey, M. D.
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (3hecking


Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.  
cylindrical, measuring 3.7x2.5 cm. in diameter. Its anterior
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.  
and upper attachment is to the abdominal wall 2 cm. below
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.  
the umbilicus. Its jjosterior attachment below is by a broad
Myxo-Sarcoma of the Oitoris. By Hunter Robb, M. D.  
expansion upon the posterior wall of the sac where it dips
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
down to cover the pelvic viscera. A second organized band,
smaller, but similar in character to the one just described, is
found on the left side. A few adhesions are also found in the
posterior wall of the sac on the right side. On transverse
section these bauds show an organized, pink, fibrous groundwork thickly inlaid with miliary tubercles and limited by a
zone of caseous material. The j)osterior wall of the pus sac is
found so densely adherent to the intestines and other adjacent
viscera that separation is diflicult. No trace of the normal
omentum can be found, and the probabilities are that it
enters largely into the comjiosition of the suppurating cyst
and the traversing fibro-caseous bands.


of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
The coils of intestine are densely matted together by old
tilirous bands and by more recent and lighter adhesions, studded
everywhere with yellow miliary tubercles, and form a single
compact mass filling the greater part of the abdominal
cavity. Not only are the intestinal coils adherent to each
other, but they are bound to all neighboring viscera. The
mesentery is greatly thickened and contracted, and is thickly
infiltrated with yellow miliai-y tubercles.  


Howard A. Kelly, M. D.  
The mesenteric lymph glands are enlarged, indurated and
caseous.  


Report in Surgery, I.  
Upon separation of the more delicate adhesions between the
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot
ui)per coils of intestine, several smaller cysts about the size
of a hen's egg are found. They contain clear straw-colored
fluid. There is a slight excess of clear fluid in the posterior
peritoneal cavity, which appears to have been more recently
infected.


in the Management of Dead Spaces. By W. S. Halsted, M. D.  
Liver. The liver measures 35x17.5x8.7 cm. in its various
Report in Neurology, 1.  
dimensions. The capsule is much thickened, and strong adhesions unite it firmly to the diaphragm. The left lobe is drawn
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.  
out into a tongue-like process, which extends completely
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.  
across the abdomen, covering the spleen on its anterior
Haematomyelia. By Adqdst Hoch, M. D.  
and left lateral stirfaces. So completely adherent are these
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By
two organs that only on section can a line of organized union
be made out. The lower surface of the liver is also in contact with the upper wall of the pus sac, with the stomach and
with the intestines, to which it is bound by firm adhesions.  
On breaking up these adhesions and freeing the surface of its
caseous membrane, the capsule is found thickly beset with
yellow miliary tubercles. The surface is mottled. Ou section
the parenchyma shows the characteristic appearance of nutmeg
liver. Scattered throughout its substance are numerous
tubercles, both grey and caseous. They are mostly submiliary,
but larger ones exist.  


Henry M. Thomas, M. D.  
Spleen. The spleen is considerably enlarged. It is densely
bound down by old fibrous adhesions to all neighboring structures. Its anterior and lateral surfaces are almost completely
concealed from view by the tongue-like expansion of liver.
The capsule is irregularly thickened and contains caseous
miliary tubercles. The consistence is much diminished. It
tears readily. Ou section it is congested and contains grey
and yellow tubercles, miliary, submiliary and conglomerate
in form.


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






Volume III. 766 pages, with 69 plates and figures.  
Kidneys. The kidneys are slightly enlarged; the capsules
are somewhat thickened, but strip off with moderate ease.
The surface of the right kidney shows a shallow circular scarlike depression about 12 mm. in diameter,somewhat paler than
the surrounding cortex. Under the capsule of this kidney is
also seen a solitary caseous tubercle about the size of a split pea.
Upon section the kidneys are congested, somewhat increased
in consistence, and contain an occasional isolated tubercle of
large size. The circular depression seen upon the surface of
the right kidney is found to be the base of a dense, pale, pyramidal area which extends quite down through both cortical
and boundary zones, and contains in its centre a small cyst.  


Report in Pathology.  
Ureters. The ureters ai'e normal, except for a slight dilatation of the right ureter in its upper jiortion.  


Papillomatous Tumors of the Ovary. By J. Whitridqe Williams, M. D.  
Pancreas. The pancreas is pink and firm. Its capsule is
thickly studded with miliary and conglomerate tubercles;
none, however, can be seen in its substance.  


Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D.  
Stomach. The stomach is adherent to all adjacent structures. Its mucous membrane shows congestion, most marked
Report in Pathology.  
along the rugas. Some ecchymoses are found at the cardiac
end.  


Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Flexner, M. D.  
Intestines. In some places the felt-like adherent sac wall
forms a partial covering to the intestines. Beneath it, as elsewhere, the peritoneal coat is tolerably §mootb, congested, and
contains numerous miliary and conglomerate tubercles. The
mucous membrane is more or less congested throughout the
entire extent. The congestion is most intense upon the valvulas conniventes. There are no tubercular ulcers, but in
places tubercles can be seen extending inward from the peritoneal coat. The walls of the large intestine are thin and very
deejily congested. The abdominal lymj)h glands are enlarged
and caseous.  


The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.  
TJiorax. The sternum aud costal cartilages cannot be
readily lifted because of adhesions between the two layers of  
the pleura on the right side.  


A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.  
Left Pleural Cavity. The left pleural cavity contains about
2.5 litres of blood-stained lluid with flocculi of fibrin. There
is one dense organized baud of tissue connecting the two layers
of the pleura (about the region of the seventh rib). There
are also a few delicate adhesions in the posterior and lower
part of the cavity. The apex is firmly adherent to the chest
wall. The lung is compressed by the excess of fluid in the
pleural cavity. Both layers of the pleura present a coarse
reticulated mottling, as though a loose-meshed network of
fibrin had been laid upon a dark red hemorrhagic background.  
Tubercles are also seen.  


Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
Upon the parietal pleura, as it covers the sixth rib, are seen
two softened caseous tubercles, each about the size of a split
pea. Cover-slip preparations made from one of these immediately at autopsy show the presence of tubercle bacilli and
micrococci in large numbers.  


Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  
Left Ln7ig. The left lung is compressed and atelectatic,
except the anterior margin of the upper lobe, which contains a
little air. Scattered irregularly and sparsely through the lung
substance are miliary and conglomerate grey and caseous
tubercles. No cavities nor old tubercular foci can be made
out.  


Report In Gynecology.  
Right Pleural Cavity. The right pleural cavity is dry.  


The Gynecological Operating Room; An External Direct Method of Measuring the
Co'njugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofle.xed Uterus. By Howard A
Kelly, M. D.


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


Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavelt, M. D.  
The lung is bound down throughout its entire extent by easily
detached adhesions. At the base and posteriorly the adhesions are pretty firm.  


The pleura is covered with a layer of fibrin of irregular
thickness, more or less organized at the base of the lung. It
contains caseous tubercles.


Right Lung. The right lung is also considerably contracted by the upward pressure from the abdomen and
the lateral pressure from the left thorax. The lower lobes
are atelectatic and congested. The upper lobe contains
a little air and exhibits along its anterior margin a few
emphysematous patches. The distribution of tubercles in its
substance corresponds with that of the left lung.


Gynecological Operations not involving Cceliotomy. By Howard A. Kelly, M. D.
The bi'onchial aud mediastinal lymph glands are enlarged
Tabulated by A. L. Stavely, M. D.  
and caseous.  


The Employment of an Artificial Retroposition of the Uterus in covering Extensive
Heart. Owing to the excess of fluid in the left ])leural
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.  
cavity, the heart occupies a position behind the sternum,
almost in the median line. The pericardium, the pericardial
fluid, the endocardium and heart valves are normal. The
aorta contains thickened yellow atheromatous plaques.  


Photography applied to Surgery. By A. S. Murray.  
Cranial Cavity. There is a slight increase of cerel)i'al fluid.  
The meninges of both cerebrum and cerebelliun are congested,
particularly on the under surface. The pia arachnoid at the
base of the cerebellum contains two or tliree yellowisli wliite
bodies resembling miliary tubercles.  


Traumatic Atresia of the Vagina with Hsmatokolpos and Bxmatometra. By Howard
Cover-slip preparations made from these nodules show no
A. Kelly, M. D.  
tubercle bacilli.  


Urinalysis in Gynecology. By W. W. Russell, M. D.  
The pelvic viscera were removed at autopsy aud jjlaced iu
formalin, for detailed description later.  


The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.  
Pelvic Viscera. Uterus. The uterus is S.-"> cm. long, 5 cm.
broad aud 3.5 cm. iu the antero-posterior diameter. Both the
anterior and posterior surfaces are covered by an opaijue,
yellowish white, felt-like membrane, varying from 2 to mm. in
thickness. This membrane passes directly from the uterine
walls to the other pelvic viscera, forming a complete blanket,
and constituting the lower part of the large jiu.s sac which
occupied the anterior portion of the peritone.il cavity. Projecting from the middle third of the posterior wall is a myomatous nodule about the size of a large walnut, attached to the
uterus by a short and broad pedicle, Fig. 1, M. Springing
from the fundus of the uterus about 2 cm. anterior to the
right cornu is another pedunculated myoma, large, ovoid, and
9.5x7.5x5.5 cm. in diameter, Fig. 1, M. From the left surface
of this tumor springs a cylindrical band about :j cm. long and
13 mm. iu diameter, attaching it loosely to the coiled-up mass
of intestines behind. This band is of the same general nature
as the fibro-caseous bauds which traverse the abdominal cyst.
Another band, broad, flattened, and 6 mm. thick, is attached
to the right surface of the tumor. This forms part of the
general peritoneal sac. On stripping back the dense, felt-like
membrane covering these tumors, their surfaces are found
studded with tubercular nodules of a yellowish white color,
and from one to three mm. in diameter. The snuiller tumor
can be easily shelled out of its capsule, owing to a peculiar
orange-yellow caseous material separating the two in the
regio^n of the pedicle. The myomata, so far as can be seen, do
not contain tubercles in their interior. The uterine wall
measures 1 cm. in thickness at the fundus. Fig. 1, F. U., 2 cm.  


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


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


Abdominal Operations performed in the Gynecological Department, from March 5,
94
1890, to December 17, 1892. By Howard A. Kelly, M. D.


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






Volume IV. 504 pages, 33 charts and illustrations.  
anteriorly and 1 cm. posteriorly. It is pale pink in color and
is studded with sparsely scattered, yellowish, miliary and con glomerate nodules.  


Report on Typhoid Fever.  
The cervix is 2.5 cm. in length. The mucous membrane
of the body presents a shaggy, moth-eaten appearance, of yellowish color and friable consistence. The mucous membrane
of the cervix, which is much less rough and friable, still presents indications of the normal rugte. The mucosa varies from
2 to 5 mm. in thickness.  


By William Osler, M. D., with additional papers by W. S. Thayer, M. D., and J.  
Right Appendages. Springing from the right uterine cornu
Hewetson, M. D.  
and extending backward and downward, so as to be completely
 
concealed from view by the large myomatous tumor which
Report in Neurology.  
filled the right inguinal region, is a mass 8 cm.x5.5 cm.x2.5 cm.  
Dementia Paralj-tica in the Negro Race; Studies in the Histology of the Liver; The
in size. It presents at first sight the appearance of an enlarged
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the  
ovary, covered by the general pyogenic membrane, beneath
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of .Whs- musculu^; The Intrinsic Nerves of the ThjToid <31and of
which, as in the uterus and elsewhere, are miliary and conglomerate tubercles studding the surface. Upon section, however, it is seen to consist of the convoluted tube, thickened
the Dog; The Nerve Elements of the Pituitarj' Gland. By Henry J. Berkley,  
and necrosed, with its exaggerated coils held together in a
M. D.  
stroma of dense organized connective tissue studded with
miliary tubercles. Beneath the lower part of this convoluted
mass is seen a portion of the ovary, so completely covered by
and adherent to the tube as almost to have lost its own identity. Fig. 1, r. Ov. A longitudinal section through this tuboovarian tumor gives transverse, oblique and longitudinal
sections of the much distorted tube. They lie like scattered
caseous islands with ulcerated centres, in the tubercle-dotted
stroma. The walls of the tube are from 3 to 8 mm. thick, and
are for the most part uniformly caseous. Here and there is a
nodular studding which gives the mucosa an uneven surface;  
or again a rich infiltration of the other coats with barely
agglomerated caseous tubercles is observed. The fimbriated
extremity, dilated, and curled outward in trumpet-like expansion, is directly continuous throughout its circumference with
the anterior peritoneal sac. Fig. 1, r. F. E. The folds of the
fimbriated end are everywhere visible and appear densely
thickened and ragged; the extremity itself measures 2.5 cm.  
in diameter.  


Report in Surgery.  
Left Appendages. The left tube is exceedingly tortuous, and
The Results of Operations for the Cure of Cancer of the Breast, from Jime, 1889, to
from the uterine cornu outward gradually increases in size,
January, 1894. By W. S. Halsted, M. D.  
terminating in a fimbriated extremity 4.5 cm. in diameter. It
is 11 cm. long in its contracted state. Fig. 1, F. E. The folds
of the fimbria are transformed into a greatly thickened, motheaten membrane, from whose surface project numerous papillary processes varying in size and shape and measuring from
10 to 14 mm. in length. The interior of the tube bears some
general resemblance to the necrotic membrane which covers
its surface and which represents the walls of the abdominal
sac with which both tubes appear to be directly continuous.
The convolutions of this tube, while excessive, as are those of  
the right side, are not embedded in a dense organized stroma,  
but are held together by tolerably firm adhesions. These, as
well as the surface of the tube, exhibit caseous, miliary tubercles. Fig. 1, 1. T. Longitudinal and transverse sections through
the tube show extreme necrosis of its walls. They are more
extensively ulcerated toward the outer third, where the condition is most advanced. The lumen at this point is increased
to 13 mm. iu diameter. The walls of the tube are here from


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




3 to 5 mm. thick and consist mainly of caseous material with
a narrow outer border of organized tissue. This forms a capsule which can be readily stripped away from the central
necrotic mass. The thickness of the tube about its middle
portion is 2 cm. There is no lumen visible on cross section,
but the entire tube seems made up of one dense, yellowish,
homogeneous mass.


Volume V. 480 pages, with 32 charts and illustrations.  
'J'he left ovary lies behind and beneath the tube, to which
it is bound by adhesions similar to those connecting the convolutions of the tube. Fig. 1, 1. Ov. From this it may be
detached with moderate ease. It is about normal in size and
position. The surface is covered by the same necrotic membrane, and exhibits upon its removal sago-like bodies. On
section the structure is smooth, firm, grey and glistening,
showing several corpora fibrosa, and one flattened tubercle Just
beneath the surface.  


CONTENTS:
t'onnected with thepelvic viscera and binding them together
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D.. and J. Hewetson, M. D.  
are portions of the peritoneum which went to make up the
A Study of some Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  
original sac wall but which were torn away at autopsy. They
are of the same general appearance bs, the necrotic membrane
covering the viscera. A similar sac, collapsed and dipping
down behind and to the left of the cervix uteri, is covered in
by the small myoma above described. This represents the
remains of an abscess about the size of an orange which ruptured at autopsy, discharging thick, greenish yellow pus.  


Studies in Typhoid Feyer.  
The Vagina. There are several small, greyish, flattened
By William Osler, M. D., n-ith additional papers by G. Bluher, M. D., Simok
elevations upon the surface of the mucous membrane, irregular
Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.  
iu size and shape, some round, measuring from 1 to 2 mm. in
diameter ; others with irregular edges measuring about 6x3 mm.  
in diameter. There is also ^ small superficial ulcer in the posterior vaginal wall just below the cervix. It is about the size of
a split pea, has sharp irregular edges, but contains no tubercles in its walls. The vagina is otherwise normal.  


The bladder is contracted and is apparently normal.


The rediim is partly covered by necrotic membrane, but
shows no abnormalities.


Volume VI. About 500 pages, many illustrations.  
Histological ExAiiisATioif.  
Pelvic Viscera.  


Report in Neurology.  
Uterus. The surface epithelium has entirely disappeared,
and the uterine mucosa shows a granular necrosis throughout
the inner fourth of its thickness. Beneath this the normal
stroma is invaded by diffuse tubercle tissue with discrete
caseating nodules. It is the union of these nodules near
the surface of the mucosa which results in the granular
necrosis. In the depth of the membrane the uterine glands
are preserved, although the epithelium is swollen and invaded
by mononuclear and polymorphonuclear cells. They are
often dilated, and contain swollen desquamated epithelial
cells, polymorphonuclear leucocytes and granular detritus. The
diffuse tubercle tissue consists largely of lymphoid and epithelioid cells, with an occasional giant cell. The discrete caseating
nodules present the typical structure of caseous tubercles. The
giant cells of both stroma and nodule are round, oval or irregular in shape, with a mural or polar arrangement of the nuclei.
The epithelioid cells of the diffuse tubercle tissue are usuallyj
round or polyhedral, with small vesicular nuclei. Those ofi


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


Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the
Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. E.xperimental
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 by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of
Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.


Report in Pathology.  
May, 1897.]


Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.
95
Cullen, M. B.


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


Adeno-Myoma Uteri Diffusum Benignmn. By Thomas S. CJullen, M. B.


A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. Bj
the caseating nodules are irregular and elongated, with oval,
William D. Booker, M. D.  
bizarre and wavy nuclei, the close packing of which in the
periphery of the nodule gives the appearance of a radiating
fringe.  


The Pathology of Toxalbumin Intoxications. By Simon Flbxnieb, M. D.  
The muscular coat is infiltrated throughout its entire thickness with diffuse tubercle tissue and discrete miliary nodules,
most of which are caseous. The diffuse infiltration is represented by small cells with solid and vesicular nuclei, arranged
in longitudinal strands between the muscle bundles. The
caseous nodules lie next to the peritoneal surface, and are
irregularly triangular in shape, with bases toward the serosa.
Sometimes the bases coalesce and form a continuous scalloped
caseous zone. The muscle cells are increased in number,
and here and there are myomatous foci which consist of
dense aggregations of cells containing elongated club-shaped
nuclei.  


TJie price of n set hound in cloth [Vols. I-1'I'\ of the Hospital JSepoi-ts is  
The blood-vessels of the muscular coat present interesting
$30.00. Vols. I, II and III are not sold separately. The price of  
features; some of them show the typical changes of endarteritis obliterans, with more or less encroachment upon the
Vols. IV, V and VI is $5.00 each.  
lumen. But the most characteristic lesion is the tubercular
involvement of the vessel walls. This process sometimes
begins in the intima and remains limited to this coat, or
extends to the media or adventitia. Sometimes it takes origin
in the adventitia and perivascular tissues, and spreads inward
in like manner through the other coats. It may be diffuse or
circumscribed, it may be a cellular proliferation simply, or
show all stages of degeneration, from an early nuclear fragmentation and karyolysis, to advanced caseation in which all
the coats and even the vessel contents are transformed into a
dense hyaline mass. The corpuscular contents of the vessels
are often preserved intact, notwithstanding advanced changes in
the vessel walls. Again there are thrombi, hyaline or mixed, in
various stages of transformation. Sometimes the vessels are
the centre of a tubercular process, in which case their fibrinous
contents are continuous with a fibrillated fibrin which extends
out into the surrounding tissues. Where the tubercular change
is early and begins in the intima, the endothelium is sometimes preserved intact; here there is subendothelial proliferation of the connective tissue cells, forming ejDithelioid cells
of a round or jjolyhedral shape, with moderate or abundant
protoplasm and small round nuclei. But in other cases there
is evidence of endothelial proliferation, these cells enlarging,
becoming at times cul)oidal, and forming a lining of two or
more rows to the lumen, with occasional complete occlusion.  


In the serous membrane the changes are most marked ; on
the surface is a dense, opaque, necrotic coat, granular, fibrillated and hyaline. Beneath this is a narrow zone of nuclear
fragmentation, while yet below and forming aline of demarcation between the necrotic portion of the serous coat and the
scalloped caseous zone of the muscular coat is a narrow band
of (Edematous, vascular connective tissue containing a few
muscle fasciculi, and showing infiltration with lymphoid,
epithelioid, polymorphonuclear and occasional giant cells.


The process is least advanced in the cervix, most advanced
in the fundus. In the cervix there is no invasion of the
muscular coat, and the vaginal portion contains no evidence
of tubercular involvement other than a solitary cellular
tubercle under the stratified epithelium in its upper part, and


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.
The following papers are reprinted from Vols. I, IV and V of the Reports, for thoee
who desire to purchase in this form:
STUDIES IN DERMATOLOGY. By T. C. GiLCHRiST, M. D., and Emmet Koeord,


M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,


J3.00.
a cellular proliferation of the corium, gradually disappearing
THE MALARIAL FEVERS OF B.-ILTIMORE. By W. S. ThaTER, M. D., and J.  
as the outlet is approached.  


Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARH.  
Among the diffuse tubercular tissue are found numerous
homogeneous, highly refractive globules of various sizes, occurring singly or in groups. They show especial affiuity for acid
aniline dyes, and also stain intensely with gentian violet. In
shape they are invariably round; in size they vary from that
of a micrococcus or a basophilic granule to that of a lymphoid
cell, some even exceeding this. Their average diameter is
that of a red blood corpuscle ; in fact, when uniform in size,
and occurring in masses, they are readily mistaken for such in
specimens which have been stained with ha^matoxyliu and
eosin. The little globules are, however, more homogeneous
and solid and more highly refractive than red blood corpuscles. These appear of tenest more or less closely packed within
cell bodies, the nuclei of which are still preserved. Sometimes
they accompany a more advanced degeneration, in which case
the nucleus stains poorly or not at all. Again, they are free
from cellular inclusion, and lie in groups or scattered through
the tissues. The groups are circular, elongated or irregular,
and contain from two to thirty or more members. With Weigert's fibrin stain they stand out conspicuously as deep blue
spheres, homogeneous and structureless. With Russell's
fuchsin stain they strike a bright red hue; with eosin they
stain pink. In many respects they correspond with the hyaline bodies considered by Lubarsch" as a form of albuminous
degeneration, found by various observers in both normal and
pathological conditions, and described by Russell" as " Fuchsin bodies." In the present case they contain neither nuclei
nor spores such as Russell and others have described.  


By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.75.  
In all three coats of the uterus micrococci are found arranged
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted
in pairs, clusters, or chains of greater or less length, numbering from three to sixteen members. They are especially
numerous along the superficial caseous zone of the peritoneal coat, where they form a thick, irregialar border and
extend deep into all fissures of its necrotic structure. In the
muscular coat they are less numerous, and are found for the
most part within and about blood-vessels in the bands of the
infiltrated tubercle. In the mucous membrane they are again
present in considerable number, somewhat sparsely scattered
at times or occurring on the surface as dense aggregations.  
Where scattered, their arrangement is usually in the form of
pairs and chains.  


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481
Tubercle bacilli are also found in the uterine tissues. They
occur in the interior of vessels, either free or enclosed within
cells, in the vessel walls, and in the tubercle tissue outside.  


pages. Price, bound in paper, $3.00.  
The uterine myoma is covered by newly formed connective
Subscriptions for the above publications may be sent to
tissue, with rich infiltration of diffuse and circumscribed
tubercles and many pus cells. The capsule is made up of
strata of well preserved fibro-muscular bands. But the interior
of the tumor is necrotic throughout. Near the surface of the
necrotic myoma is a narrow zone of calcareous matter; the
walls of all blood-vessels in its vicinity are likewise calcified.
A still broader zoueof necrotic myomatous structure, including
the calcareous baud, is dotted over with spiculated spherules
of golden yellow pigment. No tubercles are seen. Russell's
fuchsin bodies are numerous in the tissue covering the myoma,
but none are found in its substance. Micro-organisms similar


The Johns Hopkins Press, Baltimore, Md.




96


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






BULLETIN
to those found iu the utei'us are likewise found in the tubercular coFcring of the tumor.


Uiyhl Fallopian Tube. The mucous membrane of the right
Fallopian tube at its uterine end has an almost intact epithelium. In one place, however, the epithelium is wanting, and
here the stroma is invaded by a mass of tubercle tissue,
some of which has broken off and lies free and degenerating
in the centre of the lumen, together with the desquamated
epithelium. The middle coat of this part of the tube retains
its muscular structure; bands of muscle, however, are separated from each other by serous infiltration or by alternating
baiuls of diffuse tubercle tissue. The serous coat is composed
of solitary caseous tubercles so blended as to form a continuous scalloped zone. On passing outward from the uterine end
the tuliercular process becomes more marked, and when the
middle portion of the tube is reached the walls are so intensely
involved as to form a thickened necrotic mass, with no evidences of structure except a narrow fibro-cellular zone encircling the tube about 2 mm. from the periphery. The necrotic
substance is hyaline in the centre, where it is pierced by a
ragged slit- like lumen. It corresponds here with the remains
of the mucous membrane. There is nuclear fragmentation
within the fibro-cellular zone, and among the nuclear fragments isolated bands of muscle are preserved in scanty
nnnil)c'r The surface necrosis corresponds essentially with
tliat of the uterine serosa, while the middle fibro cellular zone
is continuous with the thickened, cedematous, vascular connective tissue of the uterus, which there formed a line of
demarcation between the necrotic portion of the serous coat and
the scalloped caseous zone of the muscular coat. Here, as
there, it contains a few isolated muscle bundles, the only
normal elements of the original Fallojjian tubes. Here, as
there, it is infiltrated with tubercular cellular tissue and
polymorphonuclear cells, and here, as there, it shows many
vascular changes, both sclerotic and tubercular, similar to
those described in the uterine muscular coat.


There are numerous dilated lymph spaces and blood-vessels
with subeudothelial proliferation or a lining of cuboidal cells.
Occasionally a well-defined giant cell takes origin iu the endothelium of a vessel and projects into the lumen, filling it
more or less completely. Sometimes such a cell is found free
in the vessel. Indeed, the giant cells are numerous thi-oughout the middle coat, and are especially abundant near the
necrotic mucosa. They are often situated in little caverns,
which are sometimes surrounded by lymphoid cells. Where
not so situated, they are more apt to be surrounded by an
irregular zone of epithelioid cells. They are elongated or
irregularly ovoid in shape, of various sizes, and contain nuclei
at their poles or about the periphery, seldom in the centre.
Sometimes they are invaded by polymorphonuclear and
lymphoid cells.


OF
In the fimbriated extremity the degeneration is extreme.
The lumen is considerably dilated, the walls are convoluted
and thick. The mucous membrane is composed of three
strata representing gradations of tubercular change. Next to
the lumen is a narrow necrotic border, which takes an intense
eosin stain. It gives occasional evidence of original structure
in the preserved outlines of old blood-vessels, of connective






THE JOHNS HOPKINS HOSPITAL.  
tissue bands, of g^ant cells, and even of an occasional caseous
tubercle which has not yet lost its identity by coalescence with
the general necrotic border. Outside of this is nuclear fragmentation with structural outlines still better preserved ; while
yet beyond is the normal stroma invaded by infiltrated tubercle.
Tlie middle coat is a comparatively narrow band of fibrocellular tissue, not yet degenerated, forming less than a third
of the whole tubal thickness, .and presenting the same interesting features as the corresponding coat of the middle portion of the tube. The thickest part of the wall is the peritoneal coat; it is entirely involved in an extensive necrosis
which is at one time fibrillated, at another granular or hyaline.  


The little refractive globules described iu thecellular tubercular tissue of the uterus as Russell's fuchsin bodies are
present also in the tube iu considerable number. They lie by
preference in the middle coat, in which the tubercle tissue is
best preserved. They pi-esent the same general characteristics
as the hyaline bodies of the uterus, but are somewhat smaller.
Indeed, whereas in the uterus their average diameter is that
of a red blood corjjuscle, in the tube their average size is that
of a micrococcus ; and, where Weigert's fibrin stain is used,
they could readily be mistaken for such, were it not that upon
careful examination they show less uniformity in size, take a
more solid stain, and because larger globules, both free aud in
cells, are found in the same neighborhood. Extra-cellular
spheres of large size grouped with smaller hyaline globules
are sometimes found occupying open spaces iu the tissues.


The borders of the necrotic zones, both mucous and serous,
iu all parts of the tube, are invaded to some depth by deeply
staining micrococci, which in form, size, grouping and
arrangement in the tissues, resemble the organisms found in
the uterine coats. Similar organisms are found at times in
the blood-vessels of the middle coat. Tlie streptococci predominate, and the average length of the chains is six members.
Tubercular bacilli are likewise found.


Vol. VIII -No. 76.]
Rigid Ovary. The right ovary is somewhat enlarged. Its
surface presents a smooth, wavy outline and is covered by a
thick, cedematous, vascular connective tissue which contains
lymphoid and epithelioid cells, but no giant cells. There are
also numerous dilated lymphatic vessels filled with lymphocytes. The edges of this connective tissue covering are ragged
and represent the remains of old fibrous adhesions between the
ovary and neighboring structures. Deep within the ovarian
stroma are several isolated and conglomerate caseous tubercles.
There are many advanced corpora fibrosa, aiul an unruptured
Graafian follicle in the process of retrograde metamorphosis,
liussell's fuchsin bodies are numerous in the tubercular tissue
covering the ovary, and iu the ovarian tissue itself. They are
present where the degeneration is least advanced, aud may be
seen, not only in the tubercular areas, but in association with
other degenerative changes — in the hyaline degeneration of
corpora fibrosa and in the retrograde metamorphosis of unruptured Graafian follicles.  


Streptococci, staphylococci and tubercle bacilli are present.
Of these the streptococci are most abundant and occur iu
long chains, at times reaching the length of fourteen members.
They are located within the lumen of blood-vessels, in the
blood-vessel walls, or in the perivascular lymphatics of the




BALTIMORE. JULY, 1897.


May, 1897.]


97


IPrice, (5 Cents.




coimective tissue covering the ovary, and are ofteuest free,
but may be found enclosed in cells.


coisrT:E]isrTS.  
Left Fallopian Tule. The left Fallopian tube has the same
 
general structure as the right, the only difference being that the
 
tubercular lesion is more advanced. The middle portion of the
 
tube is converted into a dense neci'otic cord, the transverse section of which shows a ragged longitudinal rift in the centre of
PAGE
an oval area of hyaline necrotic material. This is surrounded
bv a fibro-cellular border, whose surface is roughened by
fibrous shreds torn in the process of separation from adjacent
structures. The fibro-cellular border corresponds with both
middle and outer zones of the other tube. The fimbriated
extremity, like its fellow, is extensively degenerated, and the
lumen is also much enlarged. Its walls, however, are less
uneven and are but half the thickness of those of the corresponding tube. Continuous with the middle portion of the
tube the fimbriated extremity likewise has an outer border of
fibro-cellular tissue and an inner hyaline necrotic coat. In
this tube there are fewer giant cells than in the other, and the
tubercle tissue in places shows fibroid change. Russell's fuchsin bodies are present in small number.


Studies on the Lesions induced by the Action of certain Poisons on the Cortical Nerve Cell. Study VII : Poisoning
The micro-organisms found are similar to those in the  
with Preparations of the Thyroid Gland. By Henry J
other tube.  
Berkley, M.D.,
Five Successful Cases of General Suppurative Peritonitis treat
ed hy a New Method. By J. M. T. Finney, M. D.,


An Experimental Study of the Treatment of Perforative Peri'
Thus, while both tubes show in the main the same tubercular lesions, they differ in that the left tube has somewhat
thinner walls, contains a smaller number of giant cells,
exhibits in places fibroid change, and the thickened necrotic
serous coat is wanting.


Left Ovary. The left ovary is smaller than the right and
is surrounded by diffuse tubercular tissue. In gland-like
spaces near the surface are found great accumulations of
nuclei, bound together by hyaline and fibrillated fibrin, and
often presenting the appearance of the tubercle giant cell. In
this ovary there is but one solitary caseous tubercle, about the
size of a split pea, which projects slightly above the surface
and dips down into the stroma. Fuchsia bodies and microorganisms are present, resembling in every respect those found
in the right ovary.


The Vagina. The vagina shows no tubercular involvement.
The elevated greyish white patches observed on macroscopic
examination consist of swollen, distorted, stratified epithelial
cells. Occasional polymorphonuclear and mononuclear cells
have wandered up into the epithelium. There is slight proliferation of the cellular elements in the upper portion of the
corium. Fuchsin bodies are found in these proliferating areas.
More densely stained globules are seen in the swollen epithelium above. Upon the surface of the mucous membrane there
are a few cocci and long bacilli. Within the blood-vessels of
the vaginal wall, and especially in the larger ones, cocci occur
in pairs and chains, both within cells and outside of them.


137
The bladder and urethra show nothing abnormal.


Pus Sac. The wall of the pus sac, portions of which
remain adherent to the pelvic viscera, is from 4 to 6 mm. in
thickness. It consists of three coats not sharply differentiated
one from the other. In the inner necrotic coat, which represents about one-third of the thickness of the sac wall, the
degeneration is extreme. Its surface is edged by dense aggregations of micrococci which in places extend deep into the




141


necrotic structure. The middle coat is fibro-cellular and con
tains a few isolated clusters of fat cells. It is infiltrated with
diffuse tubercular tissue. The outermost coat is not sharply
separated from the middle, and differs from this in containing
numerous closely packed caseous tubercles. Fuchsin bodies
are present as intracellular and extracellular globules. They
are of all sizes, and contrary to what occurs elsewhere, they are
found in the most advanced necrosis. In such places theytake a less intense gentian-violet stain and merge gradually
into the surrounding necrotic structure. Micrococci are found
in all three coats arranged in pairs, clusters and chains.
They are especially numerous upon the inner surface of the
sac, where they form a continuous irregular layer. Tubercle
bacilli are also present in small number.


General Viscera.


PAGE.  
The lung shows very little that is abnormal. The visceral
pleura is considerably thickened and presents an irregular
wavy outline. Its surface is covered by a layer of fibrin
formed by the coalescence of highly refractive clumps. These,
in places, extend deep into the tissues, where they appear as
densely hyaline whorls, or the fibrin remains limited to the
surface, where it forms a meshwork enclosing polymorphonuclear cells. The more hyaline portions are at times invaded
by organizing connective tissue. Beneath the fibrinous covering
is a layer of highly vascular granulation tissue which contains
closely-set flattened tubercles. These tubercles project here
and there between the clumps of hyaline fibrin, extending at
times to the surface, or dip down into the lung substance.
They are more or less caseous and show the same general
structure as the tubercles already described. Where less advanced they contain many giant cells. The deeper layers of
the pleura contain dark brown and black granular pigment,
both free and enclosed in cells.  


By Arthur
The parietal pleura resembles the visceral in its general histological features. It is composed of a superficial laj'er of
fibrin, beneath which are granulation tissue and caseous tubercles. Quite beneath is a third layer consisting of cedematous
connective tissue, the meshes of which are widely separated
by serum and the spaces of which are occupied by swollen
mononuclear cells. In the parietal pleura there are small
extravasations of blood. Both layers of the pleura contain
the fuchsin bodies and basophilic cells. A few pairs and
chains of cocci and tubercle bacilli are present.


Liver. The capsule is thickened by tubercular growth.
The lobules show dilatation of the central veins and adjacent
capillaries. The hepatic cells in the centre of the lobule contain a brownish yellow pigment. The peripheral cells are
filled with fatty globules.


Distributed thickly through the liver substance, in close
relation with the blood-vessels, are countless tubercles, most of
which are of microscopic size. Large nodules evident to the
naked eye are less abundant. The former consist for the
most part of lymphoid cells or of lymphoid with a central
accumulation of epithelioid cells. The larger tubercles are
evidently older and exhibit the typical structure of miliary
tubercles with advanced central necrosis. There are a few
pairs and chains of cocci in the liver capillaries.


tonitis in Dogs by a New Method of Operation


W. Elting and Wm. J. Calvert, ......


Squamous Epithelioma and Epithelial Hyperplasia in Sinuses
98
and Bone following Osteomyelitis. By S. M. Cone, M. D., ■
 
On the Blood-Pressure-Raising Constituent of the Sui)rarenal
Capsule. By John J. Abel, M. D., and Albert C. Crawford,
M. D.,


Notes on New Books,






151
Spleen. The capsule is thickened by a new growth of cellular connective tissue containing caseous miliary tubercles.
The spleen parenchyma shows an increase in its cellular elements. Much blood pigment and many red blood corpuscles
are found. The arterial walls are considerably thickened, and
an occasional hyaline thrombus in one of the smaller vessels
is seen. There are numerous tubercles, both young and old,
scattered through the splenic substance. Fuchsin bodies are
present. Micrococci in pairs, masses and chains are found.
They are sometimes arranged within cells, but are usually
extra-cellular.


158
Kidney. The kidney shows parenchymatous and fatty degeneration of the epithelium lining the Malpighian tufts and
the convoluted tubules. There is a slight increase of connective tissue, especially under the capsule. The tubules are here
compressed, but elsewhere they are at times dilated. Hyaline
and granular casts are found. The wedge-shaped area described among the macroscopic lesions is found to consist
almost entirely of connective tissue in various stages of development. It compresses the tubules, many of which are completely obliterated ; while others persist with intact epithelium
or with lumen distended by hyaline casts. The Malpighian
tufts are small and fibrous, and in places are converted into
hyaline balls. Indeed, the connective tissue invades all
structures in the triangular area, and tubules, blood-vessels
and glomeruli are alike involved. The central cyst is lined
by cuboidal or flattened epithelium. Its walls appear to contain a large number of muscle fibres which have an irregular
arrangement and include masses of lymphoid cells. It is
continuous with several smaller tubular dilatations and is
undoubtedly a retention cyst. At the apes of the triangle is
a large dilated blood-vessel with irregular thickened walls and
lumen containing remnants of a probable thrombus. The area
resembles an infarct in the process of cicatrization, but for the
presence of apparently functioning structures. A few cocci
arranged in pairs are found within a blood-vessel of the
kidney.


Pancreas. The capsule is considerably thickened by a new
growth of connective tissue, alternately fibrous, cellular, vascular and cedematous. Numerous closely-set tubercles are
embedded in the capsule. They are round and project beyond the surface, or they may be flattened and elongated.
They show the typical structure of cellular, caseous and
fibroid tubercles. The capsule contains the fuchsin bodies
and masses of micrococci.


Lymph Glands. The bronchial lymph glands are invaded
by lymphoid, epithelioid and giant cells and show a tendency
to fibroid change. Some of the central arteries are sclerotic,
others show tubercular lesions. Masses of basophiles are
present in the centre of the glands, especially grouped around
blood-vessels, and the fuchsin bodies are found at times occupying the interior of basophilic cells. Micrococci occur in
pairs and chains within blood-vessels and in the perivascular
connective tissue.


STUDIES ON THE LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE
In the mesenteric lymph glands the tubercular process is
more advanced. The centre is necrotic, with original structural outlines still preserved. The periphery of the gland
retains its lymphoid nodules, but these are invaded by tubercle


CORTICAL NERVE CELL


STUDY vn.


POISONING WITH PREPARATIONS OF THE THYROID GLAND.  
tissue. The blood-vessels are thickened, and basophiles are
By Henry J. Berkley, M. D., Associite in Neuro-Patholoyii, The Johns Hopkins Universily.  
found. The gland is covered by (Edematous tubercular tissue.  
Diplococci and stajihylococci are numerous in the surrounding
connective tissue, and beaded tubercle bacilli are found in the
interior of the gland.  


The aortic valve, the aorta and the coronary arteries show
irregular thickening of the intima due to increase of connective tissue which in places is swollen, and the interstices
between the branching connective tissue cells are occupied by
translucent, highly refractive masses. Or again, the tissue is
non-cellular and diffusely hyaline. On the edge of the aortic
valve where it appears necrotic a few diplococci are found.


Fibro-caseous bands. The fibro-caseous bands extending
across the abdominal pus cavity, and those in the pleural
sac, are made up of fibrillated connective tissue, everywhere
invaded by diffuse tubercle tissue and circumscribed tubercles
in all stages of gi'owth or of retrograde metamorphosis. The
peripheries of the bands consist of necrotic zones edged by
a closely packed layer of micrococci. The connective tissue
stroma shows every stage of organization from young granulation tissue to dense hyaline bands ; the bloodvessel walls
are thin and easily rupture"d, and extravasations of blood
are sometimes found. The diffuse tubercle tissue consists
for the most part of lymphoid and epithelioid cells grouped
usually in the neighborhood of blood-vessels. Few giant
cells and some basophiles are found. The tubercles exhibit
every stage of growth and of retrogi'ade metamorphosis. At
times they present a typical cellular structure with giant
cells in the centre. Again, the centre is occupied by a
blood-vessel, and the lumen of such vessel may contain well
preserved fluid contents, fibrillated fibrin, or a hyaline or
mixed thrombus. The caseous peripheral zone is from 2 to 6
mm. in thickness. It contains no cells nor nuclear fragments,
but is made upof a structureless necrotic substance, alternately
granular, fibrillated and hyaline. Fuchsin bodies are easily
demonstrable. They are of all sizes, from that of a basophilic
granule to a lymphoid cell, and are both intracellular and
extracellular. They occur in the diffuse tubercle tissue where
degeneration has just begun. The micrococci found on the
surface of the band sometimes extend deep into its substance ; they occur in pairs, in masses and in chains. In the
bands of the abdominal pus cavity compressed lobules of
adipose tissue exist.


The favorable side of the administration of the thyroid
Bacteriological Examinatiox.  
extracts is shown in the very numerous articles in current
medical literature published both in this country and in
Europe. Comparatively few of these papers treat of other
than the bare clinical results from the most auspicious standpoint, and it is quite safe to say, after a review of some of
them, that the results would have been as brilliant had no
medicament been administered.  


It is nevertheless true that the extract, when administered
Cover-slip preparations made at autopsy from a tubercle
to either man or the lower animals, will occasion very grave
upon the pleura demonstrated large numbers of long beaded
symptoms of a toxasmic nature, symptoms that involve the
tubercle bacilli and clusters of micrococci. Cultures made
cerebral, the vaso-motor and digestive functions, and perhaps
from this tubercle enable one to isolate white, lemon yellow
also the normal action of those ductless glands that throw into
and orange colored colonies Inoculations from these colonies
the circulation a potent though unknown substance ; and  
into the various culture media exhibit the peculiar cultural
when this administration is pushed even to a moderate degree
characteristics of the staphylococcus pyogenes aureus, citreus
death is almost invariably the result, either through the  
and albus, and cover-slip preparations from the various cultures invariably show cocci arranged in clusters and in pairs.
advent of convulsions, or extensive loss of weight with indications of profound poisoning of the central nervous system,  
Unfortunately, no cultures could be made from the abdominal
shown by the change in the heart's action and in the respiratory movements.  
viscera, but hardened sections of the organs stained by Gram's,  
Weigert's and Gabbet's methods exhibit staphylococci, streptococci and tubercle bacilli in all.  


A medicament having these qualities cannot, therefore, be
administered with impunity to every sane or insane patient,




JlAY, 1897.]


and it was therefore directly for the purpose of ascertaining
99
the toxicity of one of the best known varieties of the thyroid
extract that the following series of experiments was undertaken.


The first portion of the investigation was made upon eight
patients at the City Asylum, who, with one exception (No. 1),
had either passed or were about to pass the limit of time in
which recovery could be confidently expected. To these
patients the thyroid tablets, each pill representing five grains
of the fresh sheep's gland, were administered, the dosage beginning always with a single pill daily for a period of three days,
then, after a certain tolerance had been established the dosage
was increased to two tablets daily, and, unless the symptoms
induced became grave, the number of pills was increased to
three daily, the length of continuance depending upon the
results.


Loss of weight always attended the administration of the
tablets, as did disturbances of the circulation in the form of
tachycardia and enfeeblement of the cardiac action. Digestive disturbances and slight pyrexia were present in more than
half the cases. A peculiar odorous sweating was noticed with
two patients, and increase of the cutaneous transpiration in


Summary of Histologhcal and Bacteriological
examinatiok.


(1) The condition is a mixed infection due to the tubercle
bacillus, the streptococcus pyogenes, and the staphylococcus
pyogenes aureus, citreus and albus.


138
(3) Miliary tubercles, both grey and caseous, are found in
all the viscera of the body except the heart and pancreas ; in
the lymph glands, and in all serous membranes excefit the
pericardium.


(3) Diffuse tubercle tissue is found only in the more chronic
lesions — in the pelvic viscera, the lymph glands, the pleura,
the peritoneum, in the wall of the newly formed abdominal
sac, and fibro-caseous bands. In the viscera this is usually
cellular, but may be caseous. In the serous membranes it is
always caseous.


(4) Tubercle bacilli are numerous in the tubercular lesions
throughout the body. They are especially numerous in the
pelvic viscera, lymph glands and alidominal pus sac.


JOHNS HOPKINS HOSPITAL BULLETIN.  
(5) The products of ordinary inflammation are often found
associated with the tubercular lesions.  


(6) Staphylococci are found in all the organs. They are
most numerous in the lining of the abdominal pus sac and the
tibro-caseous bands.


(7) Streptococci are likewise found throughout the body, but
are especially abundant in the pelvic viscera, the pus sac and
the fibro-caseous bands.


[No. 76.  
(8) Kussell's fuchsin bodies are found wherever the tubercular tissue is beginning to degenerate and occasionally where
the degeneration is extreme.  


(9) The viscera are congested and there is general arteriosclerosis.


Conclusions.


all. Irritability and a greater or less degree of mental and
From the clinical history, gross anatomical lesions and histological appearances, we therefore conclude that the disease
motor excitement were remarked in all cases, no matter how
began as a tubercular inflammation of low grade in the pelvic
depressed or demented they had been previous to the administrations. Two jjatients became frenzied, and of these one
viscera some time before pregnancy.  
died before the excitement had subsided, the immediate cause
of the exitus being an acute disseminated tuberculosis. A
peculiar gelatinous feel to the integument of the forehead and
cheeks, precisely similar to that in myxcedema, combined
with puflBness of the skin about the malar prominences, was
very noticeable in those cases in which the administration of
the extract was continued for any length of time. Urinary
examinations were made several times before the commencement of the administration of the thyroid, and several times
during its administration, but only for the purpose of noting
the presence or absence of albumen and sugar. In the
abstracts this analysis is mentioned only when there is evidence of the presence of these abnormal constituents.  


Abstracts of Histories of Insane Patients Treated
That the tubercular process spread by direct extension or by
WITH Thyroid Extract.  
the lymph channels to the anterior part of the abdomen, which
thus became shut off from the rest of the peritoneal cavity by
chronic adhesions.  


I. Adolescent insanity. Martha H., set. 17. Sister insane.
That the phenomena incident to pregnancy and the puerperium excited the process to increased activity, to which,  
Admitted with melancholic symptoms accompanied by considerable mental confusion. Occasionally had to be fed with
either at this time or later, was probably superadded a pyogenic infection.  
stomach tube. Could not speak, and it was imjoossible to
determine what delusions were present. After being several
weeks in the Asylum she partly recovered, and then relapsed,
and there appeared to be considerable mental reduction after
the lapse of several months. Then began to brighten, and take
more interest in her surroundings, also to gain flesh. The
thyroid gland was, apparently, small on palpation. Weight at
beginning of the thyroid administration 115 pounds. A single
thyroid tablet was administered for ten consecutive days, at  
the end of which time there was slight febrile reaction, with
a pulse ranging from 100 to 110 (normal 78). The mental
change was very slight, patient exhibiting some irritability,
but nothing more. The weight is now 109 pounds.  


On the fourteenth day, the thyroid being continued, the first
That this infection remained limited to the pelvic organs
signs of improvement were noticed. Patient became brighter,
because of occlusion of the tubes by previous tubercular adhesions or by the more receutinflammatory process, until manual
ate food without compulsion, and on the twentieth day volunteered to do work about the ward and conversed rationally.
examination of the already much diseased organs caused unavoidable rupture into the anterior abdominal sac.  
The thyroid extract was discontinued on the twenty-second
day, and patient was discharged one week later, six months
after her admission, and did not relapse.  


II. Melancholia folloioed hij deep dementia. Olivia P., ist.
The pain, rise of temperature and abdominal distension were
37. Education fair. No heredity. Married. Nutrition
the result of the secondary pyogenic infection of this cavity,
poor. Thyroid fairly well developed. Weight 100 pounds.  
from which the general infection took place.  
Oil admission refused to speak, and would not take food.
I The general tubercular infection doubtless spread, partly


Patient was deeply demented, and quiet for several months
by direct extension, partly by the lymph channels, but principally through the blood-vessels. The first two modes of invasion are shown by the extensive diffuse infiltration of all
before the thyroid treatment was begun. She lost flesh very
structures continuous with and contiguous to the pelvic viscera
rapidly, and on the eleventh day of the treatment showed
pronounced mental and motor excitement. Slight febrile
reaction, accompanied by a pulse rate of 120 beats. On
the twelfth day she passed into a state of frenzy, the motor
excitement being more pronounced than the mental symptoms. The thyroid extract was now discontinued, but the
excitement kept up, despite numerous attempts, with narcotics, baths, and systematic exercise, to allay it, for seven
weeks, at the end of which time she died with the clinical






evidences of acute miliary tuberculosis. An autopsy was not
and the abdominal pus sac. Infection through the blood is
permitted.  
evidenced by the general miliary tuberculosis of all the viscera
of the body.  


III. Beginning dementia. Frank G., aet. 20, well educated,
Tuberculosis of the tubes and peritoneum is usually a secondary condition. It may follow tubercular disease of any
was admitted to the asylum suffering from an attack of acute
organ of the body, but is seen most commonly associated
mania. There he improved, but was taken out too soon,
with tuberculosis of the lungs. In this case, however, the  
relapsed, was readmitted, and then gradually demented.
process must have originated either in the peritoneum or in
Thyroid of normal size. Is good tempered. Weight at beginning of thyroid administration 125 pounds. On the seventh
the tubes. The lungs showed no old tubercular foci, but were
day of the treatment became quite irritable and impatient.
involved only in the general miliary tuberculosis. The pleura
By the fifteenth day he was so quarrelsome that it was necessary to restrain him. During these 15 days he lost five
was diseased, but to a much less extent than the peritoneum
pounds, and there was considerable tachycardia and sweating.
or the tubes. The intestines were not at all involved, and the  
The myxoedematous symptoms were not so pronounced as in  
lymph glands were enlarged and caseous, but not extensively
some of the other cases. The administration of the extract
diseased.  
now being discontinued, he regained weight, became more
quiet, and after the lapse of several weeks he was sent to his
friends somewhat improved.  


IV. Dementia. John B., fet. 31, admitted as a case of acute
The question arises, what was the relation of the tubercular
mania, and after a period of four months gradually demented,
disease in the tubes to that in the peritoneum ? Which was  
became quiet, and not at all irritable. Thyroid gland normal.
primary, which secondary? Considerable difference of ojnnion
Treatment was now begun, and within a week there was  
exists as to the relation between tubercular peritonitis and
j^ronounced febrile reaction, with tachycardia and sweating.
tuberculosis of the tubes. In his monograph on "Tubercular
There is a marked difference in the asjject of the face, which
Peritonitis" Osier" says: "The Fallopian tubes are often
now appears puffed and rounded, in contrast to the former
affected, but the proportion given by various writers differs
rather emaciated appearance. The facial expression also
much. It is safe to say, I think, that in .30 to 40 per cent, of
became anxious, but there was no pronounced excitement.  
the cases in women the tubes are found affected. The process is commonly confined to the distal ends and may be
The treatment was continued thr»c weeks longer, without
primary — which is usual — or is secondary to the peritoneal
producing other change than an increase of the myxcedematons characteristics, and was then discontinued. From a
involvement."
mental standjwint, the course of the patient's disease was
now rapidly downward, and he became absolutely demented
and degraded.  


V. Chronic vielancholia. Marcus Z., set. 30, Russian Jew,
In this opinion of primary tubal involvement the majority
admitted to the asylum with alternating melancholia and
of observers agree.  
mania. Thyroid normal. Much emaciated from chronic
diarrhcea. Refused food at first. Has been quiet for some
months, suffering from well marked delusions of persecution.
Under enforced feeding became well nourished, but not less
melancholic. Six months after admission treatment with
thyroid extract begun. One tablet for ten days, two for four
days, and three daily for two weeks longer. On the 11th
day became much excited, complaining that his countrymen
wished to kill him. There was slight febrile reaction and
increase in the pulse rate to 120 (normal 75). The cheeks
soon began to assume a marked puflBness, and on palpation
had a jelly-like feel. No other phenomena were noticed,
except that at the end of the month's treatment he had lost
eight pounds, which he rapidly regained after it was discontinued. Then he also became quiet, and at the date of writing
still remains an inmate of the institution, retaining his oldtime delusions.  


VI. Dementia following puerperal melancholia. Katie S.,
On the other hand Williams" asserts that "Tuberculosis of
ret, 35, was admitted in 1893, four weeks after confinement.  
the Fallopian tubes is far more frequently of secondary than
Recovered in about six weeks, was taken home, and there
of primary origin, and when it occurs in combination with
relapsed and became permanently demented. Is untidy, mischievous, but never excited. Pulse rate normally 85 to 90.  
tubercular peritonitis, it is far more often the result of than
Thyroid normal. Was placed on thyroid extract, one pill,
the cause of the latter. The fact that the fimbriated extremity
then two pills ilaily. lu second week marked febrile reaction.  
of the tube is the portion most frequently affected is of itself
evidence in favor of its secondary origin, and in several cases of
tubercular peritonitis we have found tubercles on the exterior
ofthe tube and its fimbriated end, but none in its interior,showing that the process was extending from above downward."
Among others, Siinger and Borschike confirm his view.  


In this case the only indication pointing to the peritoneum
as the source of disease is the extensive caseous involvement of
its anterior part. On the other hand, primary disease of the
tubes is indicated by the still more extensive involvement of
their walls, by the presence of numerous giant cells, considered
by Baumgarten' as significant of jDrimary tubal disease, and by
the clinical history which points to the pelvic organs as the
first affected. As shown by the foregoing studies, the fimbriated extremity of the left Fallopian tube must be regarded as
the probable starting point of the whole tubercular process.


If then the tubercular disease of the tube is of primary
origin, the further question presents itself, how did the disease
arise ? Primary tuberculosis of the tubes may originate in two
possible ways: (1) By infection through the blood, and (2) by
infection from without. Primary infection through the blood
is a matter of pure speculation and is highly improbable.
The more likely source of infection is through the vagina
from without. Although no history of such invasion could


July, 1897.]




100


JOHNS HOPKINS HOSPITAL BULLETIN.  
[No. 74,






139
be obtained in this case, yet it is regarded as tliemost probable
portal of entry. The fact that the nterus was less involved
than the tube, and that the vagina was not all diseased, does
not negative this theory of infection, since the tubercle bacilli,
failing to find conditions favorable for their growth until the
left fimbriated extremity was reached, here set up their characteristic lesions. Thence they probably sjiread to the fundus
of the uterus, to the uterine cavity and cervix, to the opposite
tube, and to the peritoneal cavity, from which the general
infection took place.


The associated involvement of pleura and peritoneum must
be considered of diagnostic value, since coincident inflammation of both these membranes is so often of tubercular origin.
Besides the extensive character of the lesions, there are several unusual features in the case. In the first place, considerable interest attaches to the fuchsin bodies so numerous in
this case. These bodies resemble the little globular masses
described by Russell"' in 1890 as " a characteristic organisnx
of carcinom.a," and correspond in every particular with the
description of these bodies as given by Lubarsch' under the
head of "Albuminous Degeneration."


There is scarcely a normal condition or pathological process
in which they have not been found, but their relation to malignant tumors has been especially noted. They are not of constant occurrence in any pathological change.


pulse 120 to 1.30, very weak. There is considerable sweating.  
With regard to their nature, the view of Eussell that they
Facial puffiaess well marked. Has become very irritable,  
may be considered as yeast fungi is no longer held. Tliey have
restless, aud difficalt to control. Thyroid extract discontinued after three weeks' administration, after which she gradually returned to her usual condition.  
been variously interpreted as protozoa, hyaline thrombi, altered
Altmann's granules, von Recklinghausen's hyaline, bodies
resembling corpora amylacea, transformation of the cell protoplasm, and as a product of the tissue fluids in which a degenerative process is added to a beginning coagulation process.  


Vn. Deep dementia foIJoioing confimonal mclnnrlioliu.
Lubarsch himself inclines to the view that the Russell's
ilaggie E., set. 2.5, was admitted in December, 1893. Thyroid
fuchsin bodies ai'e the product of cell protoplasm, the granules
normal. When treatment with the thyroid extract was commenced was untidy and deeply demented. On the tenth day
of which have undergone certain chemical and physical
there was slight febrile reaction accompanied by slight motor
changes. He believes that they may be due either to a secretion or to a degeneration of the cell, the former occurring in  
excitement. These symptoms abated in the course of a few
normal conditions, the latter in pathological processes. Lubarsch also refers to the relative increase of basophiles in
days, though the administration of the thyroid extract was
areasin which the fuchsin bodies abound — a phenomenon noted
continued, and, after three weeks, no improvement having
by Niehus and Klien, and observed also in the present case. In
been noticed, it was discontinued.  
explanation of their coincident occurrence he attributes the  
formation of the fuchsin bodies to a chemical change and
confluence of the granules of the former and some of the  
wandering cells, and suggests that both are due to active
tissue transformation. From the description given in the
present case, this mode of origin seems probable.  


VIII. Imbecility with recurrent mania, followed by apparent
A second point of interest is the rare combination of tuberculosis in both body and cervix of the uterus. Regarding
dementia. C. B., aet. 21, admitted with second attack of  
this Williams" says: "The affection is almost always limited
excitement in December, 1895, and within a few weeks became
to the body of the uterus, rarely extending beyond the os to
apparently deeply demented. Thyroid gland very small.
involve the cervix ; and of the few cases of tuberculosis of the
Administration of the extract was begun, and after a few  
cervix on record, a considerable portion occurred without any
days there was febrile reaction, considerable sweating, and a
involvement of the rest of the uterus. Tuberculosis of the  
myxcedeniatous appearance of the integument of the face.  
uterus which also involves the cervix is rarely met with, and
The pulse rate altered from 72 to 110, and the patient lost
as far as we can ascertain from a careful survey of the literature, has ouly been noted in seven cases."
weight rapidly. There were also considerable motor and
mental excitement, with the febrile symptoms, all of which
gi'adualiy abated, though the treatment was faithfully kept
up for a considerably longer time. The patient has had
several lucid intervals during the fall of 1896, but now seems
completely demented.  


The above experiment upon eight human subjects points
out conclusively that the administration of even the very best
and purest of the commercial desiccated thyroid tablets is not
unattended by danger to the health and life of the patient,
and that at times the administration of very limited amounts
of the gland may be followed by symptoms not only difficult
to control, but of very marked influence upon the future
mental powers of the subject.*


These results obtained, we then decided to further pursue
our experiments upon the lower animals, to determine the
amount necessary per kilo of weight to cause death, the immediate cause of the dissolution, and the lesions, both macroscopic and microscopic, present at death, especially those pertaining to the cerebrum.


Through the kindness of Dr. Crawford of the Pharmacological Laboratory, who undertook the ordering of the administration to the animals, we obtained material from five mice
In this connection may also be mentioned the tubercular
and three guinea-pigs, to which the same desiccated sheep's
invasion of the muscular coat of the tube, which, as a rule,
thyroid tablets used in the first part of the investigation had
escapes involvement even in advanced tuberculosis.  
been fed; also the cerebrum from one guinea-pig to which  
had been administered thyroid extract, and the cerebrum of a  
dog from which the thyroid had been extirpated about one
year previous to its death, but in which, at the autopsy, supernumerary thyroids were discovered, though the animal during
life had exhibited minor symptoms of a cachexia.  


A portion of the material for microscopic examination was
The large sacculated exudation occupying the anterior portion of the peritoneal cavity and simulating ovarian cyst is
rare. Among the few recorded cases of tubercular peritonitis
with encysted collection of fluid are those reported by Bernutz,
Spencer Wells, Gardner, Howard, Erich, Ewing, Mears and
Atlee.


*I do not take into consideration the possible presence of putrefactive products in the tablets, as they were perfectly free from all
A feature of special interest is the thick fibro-caseous band
evidences of decomposition.  
which extends across the pus sac in the median line of the  
abdomen, and is probably the remains of the rolled-up omentum. In structure it bears some resemblance to the thickened
strands described by Klebs' as passing transversely across the
abdominal cavity below the umbilicus, and which he attributed to retraction of the omentum. Such omental tumors are
not uncommon and have frequently been described. In location, however, this fibro-caseous band does not correspond
with the transverse omental tumors, since its direction is anteroposterior and from above downward, and its attachment is by
its extremities. In explanation of this formation one can
only assume some distortion of the original omentum, with
displacement, thickening, caseation and complete transformation into the fibro-caseous band.  


In conclusion, I wish to thank Dr. Flexner for valuable
suggestions during the course of this work. Dr. B. B. Browne
for kindly allowing the use of his clinical notes, and Mr. Max
Briklel for the accurate drawing which accompanies the text.


Bibliography.


hardened in Muller's fluid for after-treatment according to
1. Baumgarten: Zeitschrift f. kliu. Med., Bd. IX and X,
the silver-phospho-molybdate formula, and another portion in
Wien, 1885.
alcohol, for staining with the anilines, hematoxylin, aud more
 
particularly to examine into the lesions of the blood-vessels,  
2. Oullen, Thos. S. : Tuberculosis of Endometrium. Johns
both in the abdominal viscera and cerebrum.  
Hopkins Hospital Reports, Vol. IV, Nos. 7 and 8, 1895.
 
3. Flint: General Jliliary Tuberculosis, Tubercular Peritonitis, Pulmonary Phthisis. Principles and Practice of Medicine, 1886.  


The five mice were first fed with the tablets. All of them
4. Gardner: Tuberculosis of Anterior Peritoneal Cavity.  
ate the pills readily to obtain the sugar coating them. For a
Canada Medical Journal, Vol. 13, 1885.  
few days there was no appreciable effect. Then they grew
dull, the cheeks became puffy, there was trembling and increase
of the frequency of the respiratory movements, and death
rather suddenly.  


Abstract of the Histories of the Thyroid Mice.  
5. Hegar: Monograph, Genital-Tuberculose des AVeibes.
Stuttgart, 1886.  


No. I. Administration of the tablets commenced Aug. 22, '96.
6. IIektoen,Ludwig: Vascular Changes of Tubercular Meningitis, especially the Tubercular Endarteritis. The Journal
One pill 32nd; three, 24th. Animal remains bright and eats
of Experimental Medicine, V^ol. I, No. 1, January, 1896.  
other food ; 2.5th, two tablets. On 26th, it seems frightened
and the face appears swollen ; on the 37th instant, it is still
trembling very greatly, and no pill was given. On the 28th,
it is very much brighter and the trembling has almost ceased.
On the 29th, is bright, and feeding of the thyroid was again
begun. Sept. 1st, three pills were fed, the animal eating
nearly the whole quantity. The 2nd instant, the face is
again swollen, and on the 3rd, refused to eat a portion of the
tablets, and has become quite dull. On the 4th and .5th
instant, the animal continued dull, trembling, aud looks weak
and sick. On the 7th, the eyes are very bright, and there
is slight emaciation. Five pills were given, but not all were
eaten. On the 8th, only two pills were taken ; there is much
trembling. Died during the night of the 9th instant, having
eaten a portion of the tablets left in the cage.  


The autopsy showed congestion of all the viscera, but without hemorrhage. The brain was soft.  
7. Howard, Wni. T. : The President's Address, Transactions
American Gynaecological Society, Vol. X, 1885.  


No. II. On the 33nd August, cue pill administered, on the
8. Klebs : Handbuch der path. Anatomie, Bd. I, p. 335.  
23rd aud 24th, the same quantity, but little not being eaten.
On the 35th, two pills were eaten, the animal still remaining
bright. On the 36th, two tablets were eaten, and the face
shows signs of swelling. On the 27th, the testes have become
swollen, in addition to the face, but the appetite is still
retained. On the 38th, the eyes are partly closed, and on the
29th, the animal is trembling, the legs are dragged, but it still
takes care of its coat.  


September 1st, the animal is dull, the face much swollen.  
9. Lubarsch, O., and Ostertag, 0.: Diealbuminosen Degenerationen, Ergebnisse der allgemeinen pathologischen Morphologic und I'hysiologie des Menschen und der Thiere, Vol. II,  
Three pills were eaten. On the 3rd, is much brighter, sleeps
1S95.  
well, but has not taken all the pills during the last two days.
On the 5th instant, will hardly touch the sugar-coated tablet.  
On the 7th, the face is markedly swollen, the animal is dull,  
the hair less sleek, and the eyes almost closed. Kespi ration
134 per minute. Died in convulsions at 2.30 1*. M.  


The autopsy was performed immediately. Besides some
10. McFarland, Joseph : The (iiant Cell of Tubercle. International Medical Magazine, Vol. I, No. 10, 1892.  
unimportant congestion of the abdominal viscera there were
no ascertainable lesions.  


No. III. Commenced feeding on 33ud August, but no symptoms were noticed uutil the 36th, when the face became
11. Osier, Wm. : Tubercular Peritonitis. Johns Hopkins
slightly swollen and the animal declined to eat the pill. On
Hospital Reports, Vol. II, 1890.  
the 28th, there is slight trembling. On the 30th, the trembling continues. On Sept. 3nd and 3rd, took daily three pills.  
On the 5th, is dull, tottering, very weak. On the 7th
instant, the hair is rough, and it seems weak, hut eats the pills


13. Russell, Wm. : An Address on the Characteristic Organism of Carcinoma. British Medical Journal, Vol. II, 1890.




140


May, 189r.]


101


JOHNS HOPKINS HOSPITAL BULLETIN.




13. Williams, J. Whitridge: Tuberculosis of the Female
Generative Organs. Johns Hopkins Hospital Reports, Vol.
Ill, 1893.


[No. 76.  
14. Williams, J. Whitridge: Tubercular Peritonitis. Maryland Medical Journal, Vol. 32, K^os. 3 and 4, 1894.  


15. Lenhart, C. M. : Tubercular Peritonitis. Medical Record, Vol. XLVIII, October, 1895.


Description of Plate.


well. On the 8th, is trembling very much, but eats the pills.  
Pelvic viscera fixed in formalin and hardened in alcohol,  
Died during night.  
viewed from above. Right tubo-ovariau mass seen in crosssection.  


Autopsy showed congestion of the abdominal viscera.
Brain rather soft.


No. IV. Feeding commenced on August 'Z2nd, but does not
eat the tablet well, hardly averaging J of a pill daily. On
the 26th, the animal is bright, but the face is slightly swollen.
On the 29th, refused to eat pill, but remaiued dull until
September 3nd, and thereafter refused to eat pill at all. On
the 12th instant, had apparently fully recovered.


No. V. Administration commenced on the 22nd August,  
F. U., fundus of uterus.  
and the dried gland was all eaten. On the 26th instant, the
face is swollen. On the 28th, there is much trembling, but
three pills were eaten. On the 29th, would not eat pill, but
on Sept. 1st ate four pills. On the 5th instant, is trembling
considerably, but ate two pills. On 8th instant, was bright,
though trembling. On morning of 9th instant, found dead in
cage. The autopsy showed the usual congestion.  


Abstract op the Histories of the Thyroid
Right tube, showing cross-sections of tubercular lumen.  
Ctuinea-Pigs.  


No. I. Fed with thyroid extract, 20 mg. daily, from Oct.
r. F. E., fimbriated extremity of right tube.  
21st until Oct. 30th, on which day it died. Weight at beginning of experiment, 620 grammes. The animal became dull and
gradually emaciated. Weight at autopsy, 380 grammes. All
intei-nal organs very much congested. The animal received a
total of 180 mg. of extract.  


No. II. Pig fed on the same desiccated thyroid as in the
r. Ov., right ovary.  
former experiments. Weight, 810 grammes. On Oct. 21st, one
and a half pills administered; on 22nd, four pills; on the
23rd, the same quantity. The respiration had now reached
144 per minute. On the 24th, 2.5th and 26th, four tablets were
fed daily, and during the night of the 26th, the animal died.
At the autopsy the abdominal organs were found to be
much congested. Weight, 620 grammes (loss 190 grammes).
This animal received about seven grammes of the dried thyroid
gland, or less than one per cent. (.864j of its bodily weight to
produce a lethal effect.  


No. III. Fed on desiccated thyroid tablets. Weight, 580
if., myoma.  
grammes. Oct. 21st, one pill ; on 22ud, three tablets ; on the
23rd instant, four; on the 24th, 25th and 26th, the same; on
the 27th instant, six pills; on the 28th, four tablets; on the
29th, five ; on the 30th, five. The animal had been for several
days very dull and had rapidly emaciated. The exitus took
place on the morning of the 30th instant. At the autopsy the
viscera were found to be much congested. The weight was 320
grammes. Loss of weight during the nine days of the experiment, 260 grammes. The animal received more than 2 per
cent, of its weight in the dried gland to produce dissolution.  


No. I\". The same thyroid preparation fed. Weight at
Rd. Lig., round ligament (left).  
beginning of the administration, 610 grammes. On Oct. 22ud,
two tablets were fed to the animal ; on the 23rd, three ; on
the 4th, four pills; on the 26th, six pills; on the 27th, four
pills ; on the 28th, five pills. The pig has become very dull
and does not take care of its fur. Died Oct. 30th. At the
autopsy the animal weighed 370 grammes (loss, 240 grammes)  
and the viscera were much congested. This animal received
1.30 per cent, of its bodily weight of the gland to cause death.  


I. T., left tube.


I. F. E., fimbriated extremity of left tube.


No. V. Thyroid dog (Dr. Abel). Thyroid gland extirpated
I. Ov., left ovary.  
i)i loto in Oct. 1895 ; died one year later, after showing profound emaciation and a dermatitis suggestive of myxoedema.
At the autopsy several parathyroid bodies the size of a small
pea were discovered. This animal was fed for several mouths
on thyroids and thyroid extracts, seemingly without benefit.
The autopsy showed no demonstrable lesions.  


The guinea-pig series may be looked upon as an example of
From the left surface of the larger myoma projects a fibrocaseous band. To the right is attached a portion of the  
the acute type of poisoning by the administration of thyroid
abdominal pus sac.  
gland, while the mice are of a more chronic order. It is  
impossible to estimate the exact percentage necessary to produce lethal results with the mice, for the reason that these
small animals always left some crumbs of the tablets on the
floor of their cages which it was not practicable to collect.
The guinea-pigs on the other hand were fed with the entire
pill without loss, and but in one case was less than about one
per cent, of desiccated gland found to produce lethal results,
the administration being distributed over five days.
 
The microscopic examination of the cerebra of the eight
mice and guinea pigs showed, both with the silver phospliomolybdate, and aniline and hematoxylin stains, an absolutely
normal condition of the nerve elements and neuroglia ; none
of the varicose and atrophied dendrites, with loss of the gemmulffi, of the former studies being discovered. The corpora
retain their angularity and sharp outlines, and the axons
with their appendages, the collaterals, retaining their natural
appearances. The sections stained with anilines and hematoxylin showed the normal appearances of the nucleus and
nucleolus, and not even in the tunics of the blood-vessels,
where pathological changes were most carefully sought for,
could any demonstrable lesion be discovered.  


The nearest approach to any pathological condition found
was in the cerebrum of the dog that had had its thyroid gland
extirpated a number of months before death, though even
here the lesions were confined to a very few tumefied dendrites,
a condition that was most probably caused by the long continued state of mal-nutrition into which the animal had fallen.


More particular attention was paid to the examination of
the liver than to the other organs of the abdominal cavity,
but here again we failed to find more than a turgescence of
the blood-vessels, the liver cells retaining their natural characteristics.


It is obvious from these results that the death of the various
A VISIT TO BAD NAUHEIM, WITH THE PURPOSE OF INVESTIGATING THE "SCHOTT
animals was induced by an entirely different kind of intoxication than that causing the lesions of the nerve elements in
TREATMENT" FOR CHRONIC HEART DISEASE.  
riciu and alcohol tox£emias, and it is therefore a poison that
does not induce degenerative alterations in the sheaths of the
arteries, and the consequent disturbance of the nutritive
supply, followed by pronounced changes in the neurons,
dependent to a certain degree upon the intensity of the
vascular lesions; but acts upon the general system in an
entirely different manner, and is essentially more subtle in its
effects upon the nerve tissues, corresponding more to the
action of a group of chemical poisons that leave no trace of
their effect after death upon the nerve cell, but during life
inducing symptoms directly referable to the central nervous
system. The tissue metabolism induced by the action of these
poisons upon the nerve cell we can only at present conjecture.  


By C. N. B. Camac, M. D., First Assistant Resident Physician.




July, 1897.]


Last November, at Dr. Osier's suggestion, we undertook to
introduce into the hospital the Schott treatment of exercises
and medicated baths for cases of chronic heart disease. After
consulting the bibliography of the subject, several cases were
placed under treatment according to the instructions contained therein. At once, however, we were confronted by
numerous questions, answers to which it seemed quite impossible to find in any of the references at hand. Although the
literature dealt at length with changes in the cardiac outline,
the position of the cardiac maximum impulse and the respiration, the theories upon which the beneficial effects were based,
etc., no answers to such practical questions as the following
were given :


(1) Is any massage to be employed during or after the
bath ?


JOHNS HOPKINS HOSPITAL BULLETIN.
(2) What drugs are to be employed daring the treatment,
and what drugs are contraindicated ?


(3) Should the baths and exercises be given together; or if
separately, which should precede?


(4) Are stimulants to be administered before or after the
bath ?


141
(5) What should be the diet of the patient?


(6) Are cases of hydrothorax or ascites to be tapped ? etc.,
through quite a list with which it is hardly necessary to weary
you.


Finding many of these questions unanswered, it was with
considerable interest that I received Dr. Osier's suggestion to
visit Bad Nauheim, the home of the treatment and of Dr.
Schott, its originator.


FIVE SUCCESSFUL CASES OF GENERAL SUPPURATIVE PERITONITIS TREATED
Nauheim is in the Grand Duchy of Hesse, three-quarters of
an hour from Frankfurt a. M. and two hours from Homburg.
Nearly in the centre of the northeastern half of what geologists
have called the Mayence Basin (Mainzerbecken) Frankfurt is
located, and at the eastern slope of the Johannesburg, the
last spur of the Taunus mountains, is situated Bad Nauheim.
As one approaches Nauheim he is struck by the great trestlework structures in the midst of the fields. On examining
these more closely they are found to be frame structures about


BY A NEW METHOD.*


By J. M. T. Finney, M. D., Associate Professor of Surgery, The Johns Hopkins University.


200 to 300 feet long and about 50 feet high, supporting switches
closely stacked one upon another. The salt waters are raised
to the top of these trestles and allowed to filter through the
interlacing switches, upon which, by the evaporation of the
water, the salt is deposited. These switches are removed
every few months or so, the salt broken from the branches,
ground and refined, and serves as the commercial salt of the
surrounding country. The most beautiful forms result from
these deposits, and by the clever devices of the natives the
most grotesque figures are produced. I have some of the
figures thus produced.


An estimation of the commercial value of these works today
may be made by the value put upon them in 1806, when they
were considered by Napoleon an adequate reward to Marshal
Louis Nicolas Davout (erroneously written Davoust) for his
services in the French army ; and again in 1866, when they
fell to Hesse Darmstadt in exchange for Homburg. Since
1834 the reputation of Nauheim for the efficacy of its springs
has been steadily coming to the notice of Europeans. Frankfurt up to this time forming the centre and battlefield of
many of the German disputes with France, rendered Nauheim
scarcely a fit place for invalids.


Recovery following laparotomy for piiruleut peritonitis is
It was therefore not until 1834 that we begin to hear of
nufortunately of sufficient rarity to excite interest whenever
Nauheim as a resort for invalids. It was not until 18G0, however, that Dr. Beneke of Marburg considered scientifically
it occurs. My object in making this report to the Society is
the value of the medicated bath treatment. From 1859-1870
two-fold ; first, to record five successful cases of laparotomy
several articles by Beneke of Marburg, upon the waters of  
for general suppurative peritonitis, all treated by the same
Nauheim, appeared in the Berlin. Klin. Woch. From 1870 to
method; and second, to describe briefly the method itself.  
1890 August and Theodore Schott and J. Groedel were frequent contributors on this subject to the Berlin. Klin. Woch.,  
The principle involved is not a new one; only in the manner
also to the Deutsch. Med. Zeitung. August Schott died, but
of carrying it out is there any originality claimed.  
his brother Theodore continued the work, and published in
1892 an article in the Lancet which caused little comment.  


Since the appearance in 1877 of the classical work of
In 1894 W. Bezley Thorn became an ardent advocate of the  
Wegner, and later that of Grawitz and others, it has been
bath treatment, and published an article in the Lancet and  
known that the healthy peritoneum is capable of disposing of
also a small book in which he described quite fully the baths
a considerable amount of infectious material. J. G. Clark, in  
and exercises. AVith the appearance of this systematic little
a recent article,f reviews the literature of the subject and  
book up to the present the treatment has been very popular in  
gives the conclusions reached by the experimenters in this direction. All agree that the peritoneum is able under favorable
conditions to take up a relatively large amount of infectious
material and disjjose of it effectually. These observers were
dealing with a more or less healthy peritoneum. On opening
the abdomen of a patient suffering from general suppurative
peritonitis, however, we have very different conditions with
which to deal. The observations of Pawlowsky would indicate that the lymph channels leading from the peritoneal
cavity are choked with infectious bacteria and inflammatory
products in purulent peritonitis, and that thus the efficiency
of the peritoneum would be greatly impaired. Our observations clinically seemed hardly to bear this out.


The question that suggested itself to our mind was this,
whether or not the peritoneum, even under these most unfavorable conditions, still retained its absorptive power. It
seemed to us, from our experience in operating upon such
cases by the methods heretofore employed, that they were
inadequate and did not remove a sufficient quantity of the
exudate, but left the peritoneum little better off than before.
With this idea in mind we devised a plan of treatment which,
so far as we know, has not been employed elsewhere.


The steps of the operation are as follows : Make a sufficiently long incision to admit of easy access to all parts of
the peritoneal cavity. Quickly withdraw the coils of small
intestine from the peritoneal cavity, beginning with the
worst coils first. Remove all, or as much as is necessary of
the small intestine and place it outside the abdomen, covered
with warm gauze or towels, thus practically disemboweling
the patient for the time being Then thoroughly and systematically wipe out the peritoneal cavity with large pledgets of
gauze wrung out of hot salt solution, paying particular attention to the pelvic portion. In some cases it may be well in
addition to flush out the cavity with warm salt solution, but
this is rarely necessary.


102




* Read before the Medical and Chiriirgical Faculty of the State
of Maryland at its Annual Meeting in Baltimore, April 27, 1897.
tBuUetin of the Johns Hopkins Hospital, April, 1897.




England. Nauheim, its waters, and the resistance exercises,
have been frequent topics in English and German medical
journals. lu France and America the treatment has as yet
received no very thorough trial. It is interesting to note here
the increase in the number of visitors from 1871 to 1895. In
1871 the visitors numbered 5,249; in 1891, 9,244; 1892,
10,272; 1893, 10,-384; 1894, 11,0)81; 1895, 14,136.


Next the small intestine should be systematically examined
Although the season was over when I visited Bad Nauheim,
loop by loop while still outside the abdomen, and rendered
I had the opportunity of seeing the baths through the courtesy of Dr. Hirsch, Dr. Schott's assistant, who showed me
macroscopically clean by wiping with gauze comjiresses wrung
over the grounds and described very fully the details of the
out of hot salt solution. It is necessary to wipe with considerable force at times, in order to remove adherent flakes of  
treatment. It can best be described in Dr. Schott's own words :
partly organized lymph. It should be done thoroughly and
" The springs of Nauheim may be divided into two classes,  
conscientiously, however, as upon this depends, we believe, in
those suitable for bathing and those suitable for drinking.
great measure, the success of the operation. It facilitates the
Together with other ingredients the bath waters contain from
cleansing process, as well as lessens the shock of the operation,  
two to three per cent of sodium chloride, from two to three
if the wiping of the intestinal coils is carried on under a constant irrigation of warm salt solution.  
per 1000 of calcium chloride, various salts of iron, above all,  
very large amounts of carbonic acid.  


After being cleansed macroscopically of all foreign material,  
Coming from the dejiths of the earth, they have a temperature of 83-95° F. Springing from a depth of 180 metres,  
pus, feces, lymph, etc., the intestine should be replaced in the
supercharged with carbonic acid gas by the pressure to which
abdomen — the worst or sutured coil being the last, or most  
they are subjected, the waters gush far above the surface;
superficial, in order that it may be the better drained by being
for example, spring No. 12 rises to a height of 56 feet and falls
packed about with gauze, if necessary.  
again in white seething masses." This is a most sti-iking
condition ; so richly charged with carbonic acid are these
waters that the reservoir into which they fall has the appearance of a great mass of clouds. " Conveyed directly from the
main by means of subterranean pipes, these waters charged
with their natural gas are allowed to completely cover the
body of the bather. Little bubbles of gas are seen to immediately cover the whole surface of the body; the waters of
springs Nos. 7 and 12 escape from a pressui-e of from IJ to
2i atmospheres, and afford a surf bath which compares
accurately with the strongest surf bath of sea water."


The abdominal wound is then tightly closed, leaving just
The first question which arose when this matter came to be
room enough between two sutures for the gauze drain. If there
scientifically investigated was, how do these baths and exercises act ? That they were vei'y efficacious in the relief of  
are any evidences of distension or pain the abdomen should
chronic cardiac disease had been demonstrated for some years
have the Paquelin cautery thoroughly applied, and the bowels
back, but their action had never been investigated. There are
moved early by calomel in broken doses, followed by salts and
several explanations given :
a turpentine enema.


It is not claimed for this method that it will cure every
(1) That given by Dr. Schott in the following woi'ds:
case of general suppurative peritonitis. We believe, however,  
" Physiological research of recent years seems to show that  
that a larger percentage of cases will recover after this method
the salts held in solution in water externally applied have uo
than any other with which we are familiar.
direct action on the system; the light and mobile molecules of
the gas, on the other hand, pass rapidly through the skin to the
corium with its rich supply of blood. We must look upon the
salts held in solution as passing by imbibition through the
outermost layer of the epidermis, and so acting on the terminal nerves of the skin as to exert a reflex action on the
internal organs. The warm baths act in their own peculiar
manner on the organism as a whole ; increased tissue change
seems to be induced by an increase of the oxygen absorbing
power of the cells, and hence follows the sense of the need of
rest and sleep as an immediate consequence of the bath, as well
as influences speedily brought to bear on the nervous system
as a whole. Excessive bathing induces an excitable state of  
the nervous system, sleeplessness, loss of appetite and consequent loss of strength. The principal changes which ensue


To insure success with any method it is essential that the
operation should be performed within a few hours after the
perforation has taken place. This is well brought out in the
very interesting series of experiments on dogs made for me by
Messrs. Elting and Calvert of the Johns Ilojikins Medical
School, a report of which is subjoined.


Five cases have been operated upon by this method up to
date, all of which have recovered. The first case, a case of
perforating typhoid ulcer, has already been published,* and
hence only a very brief abstract of the history will be given
here.


Case I. — Male, aged 47, on about eighth day of mild
in the system and in the function of the special organs are
attack of typhoid developed symptoms of perforation. Entered
that the heart beats more slowly and strongly, the jnilse
hosijital 14 hours later and was operated upon immediately.
becomes full and increases in force, and the blood pressure
Peritoneum everywhere intensely congested, roughened and  
may rise to the extent of 20, 30 mm. of mercury; the breathing becomes regular and quiet, and the capacity of the lungs
dull, and covered with flakes of plastic lymph. Considerable
increased.  
amount of turbid purulent fluid in abdominal cavity. Perforation in ileum about 14 inches from ileo-c;ecal valve.
Fecal matter exuding from opening. Peritoneum cleansed in
the manner described, gauze drainage. Recovery.  


Case II. — G. W., male, aged 20. Saw patient for the lirst
While the patient is in the bath he becomes flushed and a
time, November 24, 1896, in consultation with Dr. Barringer
feeling of comfort and warmth ensues which may even rise to
in Charlottesville, Va. Patient gave history of four previous
one of an agreeable intoxicating character. Almost invariably
mild attacks of appendicitis, from which he liad promptly
the excretion of urine is increased; exudates in the body cavities, especially from the peritoneum, pericardium and pleura,  
are absorbed. This latter action and that on the valves of the
heart can only be exjjlained on the theory of reflex action produced by influences acting upon the terminal nerves."


Another explanation is that given by Dr. Bezley Thorn,
that there is a dilatation of the muscular arteries and afterwards those of the skin, and thus there is a relief of the
heart from backward pressure.


In Lauder-Brunton's massage experiments he demonstrates
that more blood flows through the massaged part and that
blood pressure at first rises and then falls, and that on the
conclusion of massage more blood collects in the massaged
part. These exjjeriments were confirmed by Dr. Oliver.* T.
Grainger Stewartf concludes that the passive exercises (I)
improve the circulation of lymph within the tissues, and (2)
bring a larger volume of blood into the muscles. He quotes
the conclusion of Ludwig to the effect that the capacity of
muscles for blood is equal to the combined capacities of the
internal organs and the skin. If therefore this be so and
Dr. Lai^der-Brunton's experiments be correct, the increased
amount of blood in the muscles must indicate a relief of the
congestion in the internal organs.


*AnnalB of Surgery, March, 1897
In Dr. Schott's explanation there are two actions :


(1) A cutaneous excitation induced by the mineral and
gaseous constituents, and


(2) a more prolonged stimulation of the sensory nerves
excited by imbibition into the superficial layer of the corium.
The salt producing this excitation is the calcium chloride.


142
Whatever the explanation of their action may be, two points
seem established:


(1) That the apex beat alters its position ;


(2) the area of cardiac dulness is diminished. These two
facts, esjDecially the first one, were most strikingly obvious in
our first cases, and both facts were most forcibly demonstrated
to me in the cases which I saw abroad. One can scarcely
credit the results published until he has seen for himself these
marked changes.


JOHNS HOPKINS HOSPITAL BULLETIN.  
The case rej^orted by Dr. Bowles in the Practitioner for
July, 1896, shows a change of 3 cm. in the apex beat before
and after a bath of ten minutes duration, and he says after
his visit to Nauheim, which was made for the purpose of seeing for himself, " that which I thought impossible is shown
to be quite possible." This case reported by Dr. Bowles was
one of chronic myocarditis, moderate pleural effusion, general
aiuisarca and general enlargement of the heart. The age of






[No. 76.  
• Brit. Med. Jour., .Tune 13, 1896.
1 //'«/., September 19, 1896.  






recovered. The night before he had eaten very heartily of
May, 1897.]
apples. He was awakened about 3 a. m. with severe abdominal pain, cramp-like in character. At about 6 a. m. Dr.
Barringer was called. He stated that at this time, three
hours after the beginning of the attack, the patient presented
the classical symptoms of peritonitis. When I saw him, 24
hours later, he had a temperature of 103° and a pulse of over
100, and from the first had suffered intense pain, which was
controlled only by morphia hypodermically. He had had
nausea and vomiting all day. Examination of the abdomen
showed slight distension and great rigidity of the abdominal
muscles. A slight tumefaction could be made out just to the
inner side of the anterior superior spine of the ilium on the
right side. Tenderness very marked. Immediate operation
advised and agreed to. Incision 5 inches long in right linea
semilunaris. On opening the peritoneal cavity the intestinal
coils in the right lower quadrant of the abdomen were found
to be congested and dull and covered with flakes of adherent
lymph. Elsewhere the intestinal coils were found to be
congested, but not otherwise much changed in appearance.
The pus, of which there was perhaps 200 cc, was not walled
off, but everywhere present in pockets between the adherent intestinal coils. The appendix was readily found. It was closely
adherent to the pelvic brim on the one side and the csecum
on the other. Its distal end was swollen and distended to the
size of my thumb, perforated and gangrenous over an area
about as large as a five-cent piece. Appendix was ligated and
excised, and stump covered with peritoneal cuff and suture.
The peritoneum was treated in the manner above described.
Recovery.  


Case III. — This patient was seen first on December 14,
103
1896. His history is in brief as follows : R. S., male, aged
33 years. Has had no previoiis similar attack. The night
before he was taken sick he attended a banquet and ate
heartily of solid indigestible food. He was attacked with
severe abdominal pain about 3 o'clock the next afternoon.
The pain at first was general and cramp-like ; nausea and
light vomiting during the night. Morphia was necessary to
relieve him. The next day he was unable to get up. Toward evening his physician gave him a cathartic, after which
the bowels moved 8 or 10 times in quick succession. The next
morning the pain had shifted to the right side and was severe.
He received a hypodermic of morphia and got on fairly well
until about 6 p. m., about 60 hours after the onset of the
attack, when he was taken with a sudden severe pain in the
lower right side of the abdomen. The pain for a time was
excruciating at the base of the penis. Vesical and rectal
tenesmus marked. When I saw him, about 4 hours later, in
consultation with Dr. Reiche, he had a temperature of 105°
and pulse of 150, profoundly collapsed. I have never seen
such a hard and retracted abdomen as he presented. His
condition appeared grave. Immediate operation advised and
consented to.


Incision about 5 inches long, in right linea semilunaris.
On opening abdomen the intestinal coils were fol^nd not to be
distended but considerably congested. Beginning in the
right lower quadrant there was found a considerable amount
of thin pus containing flakes of lymph. This condition




the patient was not given. I shall not at this time attempt to
report cases, but merely mention this one of Bowles in order
to contirm what has been our experience of the effect of the
bath upon the j.osition of the apex beat, and many other
reports confirmatory of this remarkable change are to be found
in the literature on this subject.


extended over into the left side, down into the pelvis and up
The diagrams of the cardiac outline made by Dr. Bowles
into the hypogastric region. The appendix was found to be
are not quite accurate, but there can be little difference in
gangrenous and perforated, and was removed. The toilet of  
opinion as to the position of the maximum cardiac impulse.  
the peritoneum was made in the manner already described, by  
disemboweling and vigorously scrubbing the parietal and
visceral peritoneum until macroscopically clean. The intestinal coils were then replaced, a gauze drain inserted, and the  
abdominal wound closed except a small opening for the drain.
He made an uninterrupted recovery.  


Case IV. — M. B., boy, aged 10. Operation by Dr. J. C. Bloodgood, January 7, 1897. Five days before admission to the  
To quote Hr. Schott again: "The methods of administering the baths are of the greatest importance. It is advisable
hospital was struck in the abdomen by the fist of a playmate.
to begin with a 1 per cent salt bath containing Yawn '^^ chloride of calcium, freed from gas and at temperatures varying
Next day felt severe pain in the right iliac region. This progressively increased for three days, when vomiting began and
from 93° to 95° F., the bath lasting from six to eight minutes.  
the pain became general. Two days later was brought to the
The course of treatment should be interrujited by frequent
hospital, when his condition was found to be in brief as
intervals of one day. The temperature of the bath should,  
follows: Temperature 101°, pulse 128 and fairly good.
if possible, be gradually lowered, while the proportion of  
Slight abdominal distension. Muscular spasm marked on
solids in solution and the duration of the bath are gradually increased. At a later stage it is permissible to proceed
right side, present but less marked on the left. General
to the baths containing carbonic acid. The temperature
abdominal tenderness. Under ether a definite tumefaction
may then be rapidly lowered, especially if chloride of calcium be added in order to increase the mineral strength of
could be made out in the region of the right kidney. This
the bath."
proved to be an abscess behind the cjecum, extending from the
iliac fossa below to the liver above, and in this cavity was the  
diseased appendix. There was foiind no walling off of this
from the general peritoneal cavity. The entire pelvis was filled
with yellow pus and all the intestinal coils were covered with
flakes of fibrin. The stomach and spleen were not seen, but
the surface of the liver looked exactly as if it had been covered with yellowish-white paint. The appendix was removed
and the entire abdominal cavity thoroughly wiped out with
gauze pledgets wrung out of salt solution. The exudate was
scrubbed oS the livers surface, after which it looked simply
congested. A gauze drain was inserted and the abdominal
wound partly closed. He made an uninterrupted recovery.
Cultures and cover-slips from the peritoneum showed colon
bacillus and a coccus (not differentiated).  


Case V. — R. S. P., aged 9, a schoolboy, entered the Johns
The course consists of six baths: the first and the second
Hopkins Hospital, Feb. 26, 1897. He had always been healthy
being simply with salts, calcium chloride and the sodium
except for measles, whooping cough and chicken-pox.  
chloride; the third, fourth, fifth and sixth contain carbonic
acid as well as these salts.  
 
The preparation of the baths artificially was taken up especially by W. Bezley Thorn, in London, in 1895, since which
time Ewart, Bowles and Broadbent have employed them in
London, Moeller in Brussels, and Heiuemann in New York.  
Following the analysis of the Nauheim waters made by the
chemist Fresenius of Wiesbaden, the artificial baths may be
readily prepared. We have now packages made up at our
pharmacy each containing the proportion of salts for the different strengths of the baths, each package corresponding to
40 gallons of water, which is just about enough to entirely
immerse the body. The baths of different strengths are given
to appropriate cases.  


Family history good except remote cases of tuberculosis on
I have not attempted in this note in any way to speak for or
both sides.  
against the treatment nor to report cases. I have thought it
best for the present simply to give an outline of the trip to
Bad Nauheim, the purpose of which was to see the effects of
the treatment and to learn something about it with the object
of trying it in the Hospital here. We have now five cases
under treatment, and I trust by keeping careful records of the
effects of these baths and exercises that we shall be able to pass
judgment upon the weak points as well as the strong points
of the method. Only by a careful trial can one place himself
in a position either to recommend or to condemn the treatment.
I take this opportunity of exjjressiug my apjireciation of the
patience with which Dr. Schott heard and answered my many
questions. I also wish to thank Dr. Ileineman for the instruction in the movements which he so carefully gave me.  


Just 48 hours before entering the hospital first complained
In regard to the exercises, which are worthy of a lengthy
of pain in abdomen. Three hours later had an attack of  
description, something must be said. They consist of nineteen
vomiting. Pain in abdomen was at first general, but in a few
movements, each movement restrained by the very lightest
hours became localized in the right iliac and lumbar regions.
resistance. This part of the treatment, under the supervision
After about 24 hours the pain lessened somewhat, and he sat
up for a little while, but shortly after pain and vomiting
returned with increased severity. A physician saw him after
about 36 hours and gave him calomel in broken doses. His
bowels moved twice. His condition did not improve, and by  
advice of his physician was brought to the hospital at 8 p. m.,
48 hours after the onset of the attack. His condition then
was as follows : Face flushed and anxious. Pulse 126 ; temp.
102.8°; resp. 56, and entirely thoracic; abdomen generally
distended and tender, especially in right iliac fossa, where the  
tenderness is extreme and muscle spasm very marked. Pain
is most marked here also. Liver and spleen not palpable.
Liver dullness on right corresponds about to costal border.






July, 1897.]
of a physician, is entrusted to the nurses, to whom we have
given careful instructions as to the method of carrying it out.
The following are the instructions which we have laid down
for the nurses in the administration of the bath, also the chart
showing the observation which should be made.*


Rules fok Schott Bath.


(1) Always understand clearly from the doctor the following
points: (V) Strength of the bath to be given; (3) temperature of the bath; (3) length of time patient is to remain in the
bath. Note. — Give the bath in the morning unless otherwise
ordered.


JOHNS HOPKINS HOSPITAL BULLETIN.  
(3) Observe carefully the chart and note the points therein
called for. (1) Give bath on an empty stomach. (2) Note
the time from the moment patient is immersed to that when he
is taken out. (3) Allow the patient to make as little exertion
as possible; assist him in every way. (4) A sheet may be
drawn over the tub, but not around the patient. (5) Be sure
the entire body is immersed. (6) Keep the finger on the pulse
during the entire time the patient is in the bath.  


Danger Signals. — Cyanosis (bluing of the face), dyspnoea
(diflicult breathing), apncea (gasping), inappreciable pulse.
On the appearance of any of these, take the f)atient out of the
bath immediately, put him to bed and keej) him as quiet as
possible. Friction while in the bath is not necessary, but if
the fingers and toes become bluish the extremities may be
rubbed slightly towards the trunk. Friction should be cautiously employed ; when the patient is out of the tub rub hini
to a glow; give him a glass of milk or cup of bouillon and
allow him to rest for an hour.


Diet. — Small quantity q. 4 h. Meat — boiled chicken, mutton
chops ; eggs, two a day ; oysters, raw or panned ; vegetables —
peas, beans, lettuce; liquids — beef tea, bouillon, cocoa, lemonade, milk. Note. — Never give more than 4 ounces of fluid at
a time. Should be sipped. Wine — Port, Ehine, sherry,
brandy, dram to half ounce.


143
Note. — Something light (cocoa and toast) should be taken
one-half hour before the bath ; something light and hot
(bouillon, milk piuncb and toasted crackers) should be taken
directly after the bath. If the heart's action is poor, sherry,
brandy or port wine may be given after the bath. Last meal
to be taken three hours before retiring.


Bath No. I. Sodium chloride, 4 pounds; cal. chlor., 6 ozs.


Bath No. IT. Sodium chloride, 5 pounds; cal. chlor., 8 ozs.


Percussion over right iliac and lumbar regions shows dullness; tympanitic over left side. Heart normal. Fine moist
Bath No. HI. Sodium chloride, 6 pounds; cal. chlor., 10
rales over bases of both lungs. No history of any similar
ounces; sodium bicarb., 6 ounces; HCl, 7 ounces.  
previous attack.  


Diagnosis. — Perforating appendicitis with beginning general
Bath No. IV. Sodium chloride, 7 pounds; cal. chlor., 10
peritonitis. Immediate laparotomy advised and agreed to.
ounces; sodium bicarb., 8 ounces; HCl, 13 ounces.  
Ether. When thoroughly auassthetized, a small, hard mass,  
somewhat movable, could be felt just over the middle of
Poupart's ligament. An incision about 15 cm. long was made
parallel to and over the right linea semilunaris. After exposing the peritoneum and before opening it several bubbles of
gas could be seen free in the peritoneal cavity. On opening
the peritoneum a considerable amount of thin, cloudy seropuruleut fluid escaped and some gas. The mass felt before
was found to be the appendix with a roll of omentum adherent. The intestines, especially the CEecum, were distended
and congested, and covered with flakes of fresh fibrinous
exudate. The congestion was most marked in the immediate
vicinity of the appendix.  


The appendix itself was superficially placed and freely
Batli No. V. Sodium chloride, 9 pounds; cal. chlor., 11
movable, not walled off, but had a portion of omentum adherent. It was rather long, and curled upon itself, with a
ounces; sodium bicarb., 1 pound; HCl, 1 pound.  
constriction at about the junction of its proximal and middle
thirds. It contained two concretions, the larger of which
was engaged tightly in the constriction, and from this point
to the tip the appendix was gangrenous and softened. A


Bath No. VI. Sodium chloride, 11 pounds; cal. chlor., 12
ounces; sodium bicarb., 1 pound; IICl, 2 pounds.


Each bath consists of 40 gallons of water.


small perforation was present at the distal end of the dateseed like concretion. 'I'here had been an apparent attempt of
Note. — By using a little more NallCOn than is required
the omentum to surround the entire gangrenous end of the
ajjpendix, but it had not quite succeeded. The appendix
together with the adherent omentum was ligated and excised.  


Pelvis was found to be full of pus, and the peritoneum
treated as above. He made a rapid and complete recovery.


Bacteriological examination of the peritoneal exudate showed
the presence of streptococcus, staphylococcus, and bacillus coli
communis.


NoTK. — Since reading the above article, I have operated
* These rules are made after perus.al of the literature, also from
upon one additional case of general peritonitis. The patient,
instruction obtained from Dr. Schott personally.  
a young woman, was in extremis at the time of the operation,
which was undertaken simply as a forlorn hope. This operation was secondary to one performed several days previously
by another surgeon for appendicular abscess. There was
found present a general peritonitis, with much jjlastic lymph
covering the greatly distended and adherent coils of intestine.
There was very little purulent fluid in the abdomen. Her
pulse was very rapiil and thready, and her temperature had
risen several degrees. After the operation she was placed in
a continuous bath, which added greatly to her comfort. The
operation seemed to prolong her life, as she lived about thirtysix hours following it.  






AN EXPERIMENTAL STUDY OF THE TREATxMENT OF PERFORATIVE
104


A NEW METHOD OF OPERATION.


By Arthur W. Elting and William J. Calvert.




to take up the HCl, the metal tubs may be employed without
doing them auy harm.


'ERITONITIS IN DO(iS BY
NaHCOs + HCl = NaCl + H=0 +00^.






[From the Anatomical Laboratory of the John) Hopkins University.']
83.75






At the suggestion of Dr. Finney and with the permission of
36.37
Prof. Mall, the writers have undertaken an experimental study
The Exercises.*
of perforative peritonitis in dogs, with especial reference to
the method of treatment of this disease in human beings,
introduced by Dr. Finney. Inasmuch as this is a preliminary
report, the literature upon the subject will not be considered.
It may be mentioned, however, that so- far as we know no previous work of this nature has been done from a surgical
standpoint. It was decided to divide the series of experiments
into four groups :


1. To scrub the intestines of a series of normal dogs and
study the condition of the abdominal cavity at varying lengths
of time after the operation, in order to determine the results of
the mechanical irritation.


2. To determine how long it takes a perforative peritonitis
to destroy life.


3. To perforate the intestines of a series of dogs, and after  
The exercises are called by Dr. Schott "Widerstandgymnastik," or resistance gymnastics, and consist in slow
varying lengths of time to operate upon them again, closing
movements executed by the patient and resisted by the physician or operator. A short interval is allowed after each
in the perforation and cleansing the abdominal cavity and the
movement, during which the patient sits down. The exertion
surface of the intestine and mesentery, and after variable
employed must be very small, and should cause no increase in  
periods of time to kill the dogs which recovered, and study the
resjjiratory movements, flushing or j)allor. The patient should
condition of the abdominal cavity.  
be loosely and lightly clothed, and instructed to breathe
quietly. The resistance made should be of such a kind that
the patient may always feel himself easily the master. The
operator must not grasp or in any way constrict the limb, but
should oppose by the hand held flatly. The movements are
nineteen in number:


Arm. (1) Arms extended in front of body on a level with
shoulder, hands meeting; arms carried out until in line, and
brought back to original position. (2) Arms hanging at sides,
palms forwards; arms flexed at elbow until tips of fingers
touch shoulder, back to original position ; one arm only moved
at a time. (3) Arms down, palms forward, arms carried outwards and upwards until thumbs meet over head; back to
original position ; one arm only moved at a time. Not always
advisable. (4) Hands in front of abdomen, fingers flexed so
that the second phalanges touch those of opposite hand; arms
raised until hands rest on top of head ; back to original position. (5) Arms down, palms against thighs, arms raised in
parallel planes as high as possible; back to original position.


Trunk. (6) Trunk flexed on hips ; return to original position. Resist tvith hoth hands. (7) Trunk rotated to left,
to right; return to original position. Resist with both hands.
(8) Trunk flexed laterally. Resist with both hands. (9) As
No. 1, but fists clenched. Resist with both hands. (10) As
No. 2, but fist clenched. Resist with both hands.


1. To perforate the intestines of a series of dogs, and after
Large Arm Movements. (11) Arms down, palms against
varying lengths of time to close in these perforations without
removing from the abdominal cavity any of the exudate or
foreign matter present, and to study the results of this operaation.


The dogs used in these experiments varied in weight
*The description of each movement is taken (with a few modifications) from "Chronic Disease of the Heart" by W. Bezley
between 18 and 53 pounds, most of them weighing about 25
Thome.  
pounds.  


For the first group of experiments four dogs were used. By
a median incision the abdomiiuxl cavity was opened, the intestine and parietal peritoneum were vigorously scrubbed with
gauze sponges wrung out in warm normal salt solution, and
kept covered with warm towels. After this treatment numerous minute hemorrhages caused by the scrubbing were noticed
over the peritoneal surfaces, and the intestine presented an
extremely congested appearance. It was then thoroughly irrigated with warm normal salt solution, which had a marked
effect in reducing the congestion. The intestine was then
replaced in the abdominal cavity and the wound closed. The
process of scrubbing as performed by the operator and an
assistant required from 8 to 12 minutes. In every case the
dog appeared ill for about 24 hours after the operation, after




thighs, each in turn raised forwards and upwards until arm is
alongside of ear, then turned outward, and arm descends backwards. Not always safe. (12) Arms down, palms to thighs,
both together moved backwards in parallel planes as far as
possible without bending the trunk forwards. Not always
safe.


144
Legs. (13) Thighs in turn flexed on trunk, opposite hand
resting on chair. (14) Lower extremities in turn extended
fully, and bent on trunk forwards and backwards to extreme
limits of movement, opposite hand resting on chair. (15)
Legs in turn flexed on thigh, both hands on chair. (16) Feet
together, lower extremities in turn abducted as far as possible
and brought back to original position, opposite hand on chair.


Hands and Feet. (17) The arms, extended horizontally outwards, are rotated from the shoulder-joint to the extreme
limits forwards and backwards. (18) The hands in turn are
extended and flexed on the forearm to extreme limits, and
brought back in line with arm. Resist tuith both hands. (19)
The feet in turn are flexed and extended to extreme limits,
and then brought back to their natural position. Resist with
both hands.


We have arranged these in 5 groups, as in this way they
may be more readily committed to memory.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Rules for Operators.  


1. Each movement to be performed slowly and evenly at an
uniform rate.


2. No movement to be repeated twice in succession in the
same limb or group of muscles.


[No. 76.  
3. Each single or combined movement to be followed by
interval of rest. Count five.  


4. Patient's breathing should not be accelerated.


I. Avoid. 1. Dilatation of the ala? nasi (dilating of nostrils).


which a marked improvement in the condition was noticeable.  
2. Drawing of corners of mouth.  
Usually by the end of the second day the animal seemed quite
well.  


Of these four dogs one was killed by an accident one day
3. Duskiness and pallor of cheeks and lips.  
after the operation. Autopsy showed a very small amount of
blood-tinged serum in the abdominal cavity. The surface of  
the intestine and parietal peritoneum presented numerous
hemorrhagic areas caused by the scrubbing at the time of
operation. The surface of the intestine was roughened,
though not adherent. Cultures from the abdominal cavity
were sterile.  


A second dog was killed at the end of three days. At
4. Yawning.  
autopsy no appreciable amount of fluid was found in the
abdominal cavity. Numerous fibrinous adhesions of the coils
of intestine to each other, to the inner surface of the abdominal wound and to the omentum were found. The surface of
the intestine was slightly roughened and presented numerous
hemorrhagic areas. Similar areas were also seen upon the
mesentery near its attachment to the intestine and upon the
parietal peritoneum. These were likewise caused by the
scrubbing at the time of operation. Cultures from the abdominal cavity were sterile.  


A third dog which was in excellent health and condition
5. Sweating.  
was autopsied at the end of five weeks. No appreciable
amount of fluid was found in the abdominal cavity. The
appearance of the organs was everywhere normal except for
numerous adhesions of coils of the intestine to each other, to
the omentum, to the inner surface of the abdominal wound
and to the stomach. These adhesions were of a firm character,
being apparently composed of fully developed connective
tissue. Cultures from the abdominal cavity were sterile. The
fourth dog is still alive and will be autopsied later. From
this group of experiments we conclude that mere mechanical
irritation may cause the formation of extensive adhesions in
the abdominal cavity of the dog, but these seem in no way to
seriously interfere with the animal's general health.  


For the second group of experiments four dogs were used.  
6. Palpitation.  
Because of its accessibility and the comparative ease with
which the perforation could be closed, it was decided to perforate the CEBCum. By the use of a stick of caustic potash a
perforation IJ cm. in diameter was made in the end of the
caBcum, after which it was replaced in the abdominal cavity
and the abdominal wound closed. These dogs showed symptoms of a severe peritonitis and died in from 12 to 20 hours
from the time the perforation was produced. Autopsy showed
practically the same pathological condition in each case. From
150 to 250 cc. of a turbid bloody fluid were found in the abdominal cavity. The surface of the intestine presented a
marked hemorrhagic condition, both diffuse and petechial in
character. The omentum, mesentery and parietal peritoneum
presented a similar appearance. Flakes of reddish yellow
lymph were deposited over the surface of the viscera, particularly in the region of the liver, diaphragm and lesser omentum.
Slight fibrinous adhesions between the coils of intestine were
noted. The mucosa of the intestine presented more or less of
a hemorrhagic appearance, and in some of the cases bloody
contents were found in the lumen of the gut. In short, the
pathological condition was one of an intense hemorrhagic


If any of the above make a complete interval, or if excessive, stop the exercises for the day.


5. Direct patient to breathe regularly. If he holds his
breath, make him count in a whisper.


peritonitis associated with a more or less extensive hemorrhagic enteritis. The bacteriology of each of these cases was carefully worked out and will be referred to later.  
(i. Do not constrict the part which is being moved.  


For the third group of experiments twelve dogs were used.
The method of operation was as follows: An incision was
made on the right side just outside the rectus muscle, the
cajcum brought out and perforated in the same manner as
practiced in the experiments already described. The cajcum
was then replaced in the abdominal cavity and the abdominal
wound closed. From five to seven hours after the perforation
was produced these dogs were again opened by an incision in
the median abdominal line. The perforated end of the
crecum was brought out and the perforation closed by means
of a row of mattress sutures, after the necrotic tissue at the
seat of the opening had been resected. The abdominal cavity
was then opened, and the intestines being lifted out, were kejit
carefully covered with towels wet in warm normal salt solution. With gauze sponges wrung out in this solution the
surface of the intestine and mesentery was carefully wiped
till it appeared macroscopically clean. The abdominal cavity
was next wiped out and rendered macroscopically clean, the
intestine in the meantime being frequently irrigated with
warm salt solution and kept covered with warm towels. After
another thorough irrigation of the intestine with the warm
salt solution it was replaced in the abdominal cavity and the
wound closed in the usual manner. We cannot emphasize
too strongl}', in doing these experiments, the advisability of
thorough and constant irrigation of the intestine while it is
outside the abdominal cavity, for in every case it seemed to
reduce the congestion and in some cases the distension. The
cleansing process required from 10 to 20 minutes according
to the amount of exudate and foreign matter present.


Of these 12 dogs one was operated on at 5 hours after the
perforation was produced, one at 5J hours, one at 5J hours,
one at 6 hours, two at 6J hours, three at 6J hours, one at Gi
hours, one at 7 hours, and one at 7} hours.


In every case the dog showed marked symptoms of peritonitis and evidences of pain. When lying down the legs were
SCHOTT METHOD OF BATHS AND RESISTED MOVEMEN"
drawn toward the abdomen, which was held very tense. Any
Diagnosis Name Hospital No.  
attemjjt to straighten out the legs seemed to cause great pain.
 
In some cases the dog vomited a somewhat bile-stained fluid.
In every case the abdominal cavity at the time of the second
operation contained from 100 to 250 cc. of a turbid bloody
fluid. The intestine, mesentery and omentum in nine of these
cases presented a generalized hemorrhagic condition. In the
remaining three cases this condition seemed more confined
to the coils of intestine in the region of the ctecum, though all
the peritoneal surfaces seemed more injected than normally.  
In nine of the cases more or less numerous flakes of yellowish
red lymjih were found adherent to the gut, mesentery, greater
and lesser omentum and other abdominal viscera. In eight
of the cases the intestines seemed more or less distended when
replaced in the abdominal cavity. Immediately after the
cleansing of the surface of the intestine and the abdominal
cavity the animals seemed to be much more comfortable, and
in the Ciise of every dog which recovered there was a jirogressive improvement in the condition.


In no instance did a dog which recovered show signs of
Johns fi


rs.




JvhY, 1897.]
0PKIN^




Hospital.
Ward


JOHNS HOPKINS HOSPITAL BULLETIN.






145
• Balh !


l| ana




pain after the cleansing operation was performed, and usually
TIME
in from two to three days the dog seemed to have recovered
completely from the peritonitis, so far as external symptoms
would indicate. Of course the abdominal wound made at the
second operation was infected, and this in nearly every case
failed to heal by first intention, which delayed somewhat the
complete recovery of the animal. Of the 12 dogs thus treated
three died without any apparent beneficial effect of the operation, death ensuing within 20 hours from the time the perforation was produced. These three dogs were operated upon
64, 7 and 7} hours respectively after the perforation was
produced. A fourth dog operated upon GJ hours after the
perforation died 30 hours later; the operation apparently prolonged its life about 20 hours. In three of these cases the
peritonitis was the most severe we met with in our experimentation, and the dogs in a weak condition at the time of operation, which was done comparatively late in the disease. In
each of these four cases the intense hemorrhagic peritonitis
described under the second group of experiments was found
at autopsy.


The remaining eight dogs were apparently cured of the peritonitis. Of these eight, one died from the protrusion of the
intestine, due to the breaking down of the abdominal wound
on the fifth day after the operation. In a second case death
resulted on the eighth day from a localized peritonitis due to
the extension of the suppurative process from the abdominal
wall. A third dog which appeared quite well 2i days after
the operation died rather suddenly on the fourth day from a
perforation in another portion of the intestine which had come
into contact with the caustic potash upon the end of the perforated ca3cnm at the time the first perforation was produced.
A fourth dog appeared quite well at the end of twelve days
after the operation, having an excellent appetite and seeming
very lively. On the 13th day the dog seemed sick, and gradually grew worse till its death, on the 17th day after the perforation was produced. At autopsy small abscesses were found
extending along each stitch in the abdominal wall down to
the inner surface of the wound, where the intestines and
omentum were adherent. No distinct sinus leading into the
abdominal cavity could be demonstrated. The abdominal
cavity contained about 100 cc. of yellow pus, collected for the
most part in the pelvis and also extending up toward
the diaphragm. The coils of intestine and omentum were
firmly adherent in a mass in the upper part of the abdominal
cavity. The intestine was also adherent to the liver and gall
bladder. The parietal and visceral peritoneum were intensely
hemorrhagic in places. No apparent walling off of the pus
existed. An extension of the suppurative process along the
stitches was supposed to have been the source of the infectious material. A fifth dog also apparently made a complete
recovery, both wounds healing with the exception of a small
sinus in one of them. This dog seemed quite well for nearly
three weeks, when it became ill and died three weeks and two
days from the time it was operated upon. At autopsy the
abdominal cavity presented a perfectly normal appearance,
with the exception of numerous adhesions of coils of the intestine to each other, to the omentum, liver and parietal peritoneum. These adhesions were not very firm in character. The


Respiration. Pulse and Heart [P,".|-Jr;?ile f SEE HISTORY '«''-n?e\%''e°e°jr']




sinus mentioned above was found to lead to an abscess cavity
about the size of a hen's egg, situated in the pelvis to the right
of the uterus. This abscess was completely shuf off from the
rest of the abdominal cavity and was the undoubted cause of
death.


All of these dogs which died as a result of the suppurative process following the operation would probably have
recovered could they have been subjected to the same treatment human beings would receive in a similar condition, for
it must be remembered that it is practically impossible to drain
or treat suppurating wounds in dogs. A sixth dog, apparently
in the best of health and condition, was killed and autopsied
four weeks after operation. Both wounds had healed with
the exception of a small sinus leading to a stitch abscess,
which, however, did not penetrate the abdominal wall. On
examining the abdominal cavity the only abnormalities noted
were seven or eight slight, loose adhesions between coils of the
intestine, three or four loose adhesions of the omentum to the
intestine, and some rather firm adhesions of intestine to the
inner surface of the abdominal wound over an area 3x6 cm.
The condition of the viscera seemed everywhere normal. All
of the adhesions, except perhaps those uniting the intestine to
the inner surface of the abdominal wound, were of such a
slender character that they would in all probability have disappeared entirely in a few months. The remaining two
animals are apparently perfectly well, one of them being a
bitch which was in a moderately advanced state of pregnancy
when operated upon. Cultures and cover-slips were made from
the exudate in each case of peritonitis. The bacteriology was
carefully worked out and will be referred to later. From
this group of experiments we conclude that up to 6 hours
after perforation the generalized peritonitis in dogs can be
cured by this operation in practically every case. The prognosis of operation upon these animals at 6i hours after perforation is exceedingly favorable, but from that time on rapidly
becomes less favorable.


For the fourth group of experiments six dogs were used.
It
The method of procedure in this group was to perforate the
cfficum in the usual manner. From 6 to 6i hours later the
abdominal cavity was again opened, the cfficum brought out
and the perforation closed in the way before described. After
the replacement of the ca3cuni the abdominal cavity was
closed without in any way attempting to cleanse it. At the
second operation four of these dogs presented a generalized
peritonitis with the characteristics before described, though
in no case did the condition seem as bad as in the cases of
two dogs in Group 3 cured by the cleansing of the surface of
the intestine and the abdominal cavity. Of these four dogs
one died about 20 hours after the perforation was produced.
The other three failed to rally after the second operation, as
the dogs in Group 3 did, and appeared ill till their death two to
three and one-half days from the time the intestine was perforated. Autopsy upon two of these animals showed an
intense hemorrhagic peritonitis, while in the case of the third
the intestine and omentum were closely adherent in a mass,
which when pulled apart disclosed numerous pockets of pus,
presenting the condition of multiple abscess formation. The
remaining two dogs of this series presented only a localized


as




146




Date


JOHNS HOPKINS HOSPITAL BULLETIN.


of samel
aud
Movements




[No. 76.
In bod




Just
before


peritonitis. Tliere was not more than half as much of the
turbid bloody fluid in the abdominal cavity as found in the
other four cases, and only those coils of intestine in the
vicinity of the ca3cum presented a hemorrhagic appearance.
These were the most favorable cases we met with in all
our experimentation. These two dogs are still alive, though
their recovery has been slow.


In connection with the last two cases it is interesting to
1st halt
note that in two of the cases of Group 3 some exudate had
collected in the abdominal cavity between the time the intestine was replaced and the abdominal wound closed, thus making it evident that the abdominal cavity possessed the power
of caring for a considerable amount of the exudate. The
bacteriology of this group of experiments was also carefully
worked out and will be referred to along with the reports of
the other cases of peritonitis.


This group of experiments seems to demonstrate that the
mere closure of the perforation, though it may in some cases
prolong life slightly, is not sufficient to cure a case of generalized peritonitis in dogs, and makes it very evident that
without a careful cleansing of the surface of the intestines
and the abdominal cavity recovery in such cases will be
exceedingly rare. It must be borne in mind that the length
of time which had elapsed since the perforation was produced and the condition of the abdomiual cavity would have
afforded a most favorable prognosis in these cases had the
cleansing operation been performed.


Cultures were made from the 4 cases of Group 2, 13
2nd halt
cases of Group 3, and 6 cases of Group 4. In one case of
Group 3 the cultures failed to grow, although cover-slips




Immed.
after


showed a few cocci and bacilli. Also in one case of Group 4,
in which the peritonitis was not yet generalized, the cultures
were negative. In the twenty cases in which bacteria developed in the cultures, from one to three species of microorganisms were found in each case. Members of the colon
group were found 18 times, 4 times alone and 14 times in
association. Streptococcus pyogenes was found 8 times, once
alone and 7 times in association. Staphylococcus albus was
found 5 times, in each case in association. Staphylococcus
aureus was found 4 times, once alone and 3 times in association,
and staphylococcus citreus was found 4 times, in each case in
association. Cultures were also made from the heart blood at
several of the autopsies, but in each case were sterile. Coverslips from the exudate in the abdominal cavity were examined
in each case and more or less numerous bacteria were seen.
An abundance of leucocytes was found in nearly every coverslip. The bacteria in general were outside the cells.


From our experimental work we feel justified in stating the
10 mtu.
following conclusions :
after


1. That mere mechanical irritation of the peritoneal surfaces will lead to the formation of adhesions.


3. That peritonitis in dogs caused by a perforation of the
Pulse
intestine is of an intensely hemorrhagic character, and if left
Pressure
to itself rapidly proves fatal.


3. That generalized peritonitis of this character, in dogs,
can be cured as late as 6* hours after the perforation, by the
cleansing operation introduced by Dr. Finney.


4. That mere closure of the perforation without this cleansing operation will rarely, if ever, cure a case of generalized
Calibre of  
peritonitis in dogs.
Radial




Point Maximum
Impulse,


SQUAMOUS EPITHELIOMA AND EPITHELIAL HYPERPLASIA IN SINUSES AND BONE


FOLLOWING OSTEOMYELITIS.
Remarks






By S. M. Cone, M. D., Assisfcmt in Surgical Pathology, The Johns Hopkins University.


Begin




In view of the interest manifested in the pathology of bone,
End
the two cases about to be reported seem to be of value. They are
striking examples of malignant and benign epithelial growth
into old sinuses and medulla of bone.


Case I. — John H., colored, set. 45, laborer, was admitted
to Dr. Halsted's wards, January 2, 1897.


Patient gives a history of injury to bis left tibia 19 years
R.  
ago, with subsequent formation of a sinus and discharge of
sequestra. One month before entering the hospital the
patient began to feel pain in the leg, and the odor of the discharge became foul. No sequestra have come away for eight
months. There is pulsation of discharging material synchronous with the radial pulse.  


Upon Jan. 4, Dr. Bloodgood excised the sinus aud chiseled
and curetted the bone. The bone was fractured 10 cm. below
the knee, where the cavity was largest. The operator's note
estimates the cavity communicating with the sinus as 3 cm.
deep, 2 to 3 cm. wide, aud 14 cm. long. The diagnosis,
squamous epithelioma, being confirmed, and the growth


P.




recurring withiu two weeks, the leg was amputated above
R.  
the knee, and glands of the groin excised by Dr. Finney on
Jan. 29th. On Feb. 25th patient was discharged, the wounds
having healed per primam.  


Pathological rejmrt of the first operation. — Tiie specimen
consists of the skin, sinus, eburnated bone, and soft material
filling the cavity in the bone. The edges of the sinus are
dense and pearly in appearance. The skin within i cni. of the
sinus edge has lost its dark pigmentation. The bone next to
the soft central mass is soft and crumbly, but outside of this
is eburnated. It appears directly continuous with the skin
at the orifice of the sinus. The sinus is lined by the same
papillary growth that fills the cavity in the bone, and this
same growth projects between the periosteum and eburnated
bone, indenting it, causiug a jagged appearance. The medullary cavity is filled with a soft, necrotic-looking material, made
up of soft yellowish white masses, aud with white papillary
granular projections from a rather dense translucent pink
ground substance looking like granulation tissue. The papil


P.


July, 1897.]


R.




JOHNS HOPKINS HOSPITAL BULLETIN.  
P.  




B.


147


P.




lary projectious average 2 mm. diameter, aud are of varying
R.  
length up to 4 mm. The growth within the cavity erodes the
bone, leaving small spicules and granules in the soft necrotic
mass. In places the dense bone has become granular and
crumbles readily. There is no sequestrum nor cancellous bone.
The periosteum is very much thickened aud not to be well
differentiated from the subcutaneous tissue; it is invaded by
the epithelial growth. The microscopical description of the
original sections is the same as of the recurrent growth, so
they will be included together.  


The leg and lower third of the thigh removed at the second
operation present no abnormal appearance outside of the
gajiing granulating wound in the tibia, the seat of an osteotomy performed January ith. The wound, measuring 16s
4x4 cm., is surrounded by edges of skin inverted over the
bone, which for the most part is covered by apparently healthy
granulations. Only at one place is the bone exposed ; this is
at the upper angle of the wound, where an edge of eburnated
bone is left uncovered. At the outer rim of the excavated
tibia, 4 cm. from the upper angle of the wound, is a projecting mass of papillary excrescences 4 cm. in diameter, whose
surface is covered by a dry blood-stained crust. Scraping the
up[)er layer away leaves the deeper papillae, pearly in appearance, closely aggregated and more or less intimately connected
with the velvety granulations about them. Some of these epithelial uests are so closely packed without any apparent stroma
that at first glance they give the appearance, on section, of a
cheesy mass. Careful observation shows this to be made up
of individual uests. This mass is at the seat of fracture
alluded to. Similar uests of cells are seen iu smaller discrete
masses over the whole surface in the granulations.


One area on the inner wall of the excavated tibia, 5 cm.
P.  
from the uf)per angle of the wound and 2 cm. from the fracture, can be made out as a mass sharply defined from the
surrounding granulations. The bone here seems excavated to
fit the growth which is eroding it. Spicules of bone project
into the growth between the epithelial plugs at the jjeriphery.
Between the ends of the fracture the new growth projects,
invading muscle and adjacent tissues. The ends of the bone
are rough, and the papillary masses are seen indenting the
ivory-like bone to a depth of 1 to 3 mm., giving it a wormeaten appearance ou removing the growth. The granulations,
2 to 4 mm. thick, covering the surface of the bone also groove
it and cause a rough and gnawed appearance.  


The bone sawn through at several places is dense aud eburnated aud shows no evidence of tumor formation which is not
directly connected with the surface growth. The heads of
femur, tibia aud fibula aud the astragalus are normal. The
tibia and fibula are anchylosed by bony union at the interosseous ligament. No tumor can be traced from the bone along
the vessels. The muscles and soft parts, except at the seat of
fracture and ulcer edge, appear normal. The cartilage of the
patella is softened, that over the outer head of the femur is
depressed and soft. The synovial membrane is hemorrhagic
where it envelops the crucial ligaments at their insertion
into the head of the tibia.


The popliteal aud inguinal glands are firm, eularged and
K.  
harder than normal, but do not show any areas of metastasis.  




P.


Microscopical Description.


Tumor iiivading musde at the seat of fracture. The tumor
Before
mass is sharply circumscribed. At that part nearest the
invaded tissue the tumor is made up of single cells and small
masses of cells in a fine reticulum; this passes, further away,
into small non-cornified, non-cystic masses of cells, theu larger
alveoli with cornified epithelium in the centre of the stratum
mucosum layers. Furthest away from the muscle and nearest
the periphery of the tumor mass are seen cystic dilatations
with anastomosing alveoli lined by a few layers of columnar
cells and containing scales of cornified epithelium aud fatty
detritus. The invaded fibrous tissue shows no change. The
muscle fibres are granular and fragmented ; the fragments and
individual fibres contain many nuclei, giving the appearance
of elongated giant cells. The vessel walls show round cell
infiltration. There are newly formed capillaries among the
degenerating fibres. There is evidence of endothelial proliferation in the capillaries.


Tumor mass and ski7i, the mass projecting betiveen the fractured ends of the tiiia. Where skiu and tumor pass over into
one another the regular papills of the skin cease, as does the
deep pigmentation. The pigment is no longer seen between
the stratum mucosum cells as in the skin, aud is much less
developed in the stratum granulosum and deepest columnar
epithelium of the Malpighean layer.


It looks as if the stratum mucosum aud granulosum were
After
continuous with like layers of cells lining the stroma of the
tumor, keeping on over the tortuous papillary bulgings and
corresponding depressions of the tumor mass. Similarly can
the stratum corneum be followed, but it changes its appearance over the tumor, becoming less compact and scattered in
flakes on the surface, or loosely filling cystic cavities along
with cellular detritus, or it may be lacking on some of the
plugs.


In the cornified layers over the tumor are masses of brown
granular pigment containing crystals of hsematoidin. The
tumor growth is divided by deep grooves caused by keratinizing and fatty degeneration of epithelial down-growths.
This causes the follicular appearance described macroscopically.


Papillse, or stroma strands, better named, push the epithelium up into bulging papillary masses. These stroma strands
Before
vary in size, as do the corresponding cyliuders and plugs of
 
epithelium lining them. The plugs aud cylinders anastomose
freely at the surface. One cyst thus caused measures 1 X ^
cm. aud is made up of numerous small plugs containing
keratinized epithelium and detritus around the margin. The
contents must have fallen out in great part. The surface is
covered with epithelial cells, polymorpho-nuclear leucocytes,
and keratinized epithelium iu a mass of coagulation necrosis.


The stroma varies in different parts, from edematous young
After
granulation tissue with stellate, epithelioid aud giant cells at
the surface under the coagulation necrosis, to a very cellular
fibrous tissue, with numerous capillaries aud spindle-shaped
long nuclei deeper down. In places the stroma is homogeneous aud stains pink with eosin, like hyaline. There are areas
of round cell infiltration in the stronui. The included plugs




Before


148


During




JOHNS HOPKINS HOSPITAL BULLETIN.
Afterl>Betore




During
Atter


[No. 76.






and cylinders of epiLhelinm comprise all the epidermis layers
arranged in the same order as in the skin — a cylindrical or
cuboidal layer next to the stroma, then polyhedral cells of
the stratuna mucosum showing prickles most distinctly with
Van Gieseu's stain, then two or three layers of spindle cells
with pigment which takes the hEematoxyliu stain — the stratum
granulosum. The outermost layer lining or filling the Ciivity
of the plugs or cylinders is of loose keratinized epithelium,
sometimes arranged compactly,


Where the centres are cystic we find besides the keratinized
epithelial flakes, fat cells, cells which have undergone fatty
degeneration, leucocytes and salts, granular and deeply stained
with bajmatosylin. Cell multiplication is very active, as evidenced by the many divided and dividing nuclei ; 2 to 5
nuclei are contained in some cells, connected as if budding.


Tnto the basal layer of these cylinders there may be
ingrowths of papilla?, explaining an unusual appearance,
namely, a mass of fibres and connective tissue cells cut
across in the centre of one of the above described plugs of
epithelial cells. In the deepest part of the invading tumor
the cylinders become very small, even narrowed to single cells
separated by the same cellular stroma. Anastomosis is very
free, many branches spreading throughout a loose stroma.
The arteries included in the section show marked endarteritis
and round cell infiltration of the adventitia also.


In staining the sections the Van Giesen method was found
valuable in staining the stroma and the prickle cells. The
keratinized cells stain yellow, the young stroma stains dull
red. Gram's stain used for keratohyalin by Ernst' shows it
well, staining these cells deep blue.


Sections of the pink granulations over the surface of the
bone show granulation tissue without evidence of tumor.


The lymph glands of the popliteal space and groin show
fatty atrophy and connective tissue formation, thickened capsules and endothelial hyperplasia. There are no metastases.


The popliteal artery and vein with surrounding tissue show
no evidence of tumor growth about them. They are united
by dense fibrous tissue. There is evidence of endarteritis.


The synovial membrane described as hemorrhagic shows
round cell infiltration and vessels filled with blood, which also
suffuses the surrounding tissue.


The bone cut across near the knee shows no microscopic
evidence of carcinoma; it appears normal.


Section of fragments of hone with tumor and granulations
mixed in an irregular friable mass. The tumor alveoli and
stroma are as described above. Adjoining whorls are seen to
become conglomerate, mixing together their contents of
keratinized epithelium and fatty necrotic substances and
bounding this by their several epidermis layers. Secondary
papilla; project into the primary alveoli, giving a complicated
appearance on section. In the proximity of the bone the
cellular stroma is strewn with giant cells with centrally
massed large oval vesicular nuclei containing big nucleoli.
These are osteoclasts, for wherever the bone is seen undergoing absorption it is lacunar in nature and the Howship's
lacunae contain osteoclasts to fit them. The tumor cells do
not come in direct contact with the bone, being separated by
stroma and osteoclasts.






The bone is very dense, with narrow compact lamella; containing few corpuscles, and these are small and far apart.
The Haversian canals are filled with cellular connective
tissue, vessels, old bone fragments looking as if shelled off,
and osteoclasts in lacunaj. Branching canaliculi are distinctly seen. There is new formation of bone going on. The
new lamellse are arranged at an angle to the old ones, they
take the eosin stain deejier and are lined by osteoblasts,
cuboidal and spindle-shaped. There is a granular line stained
with hsematoxylin between old and new bone.


Section of hone zvith invading tumor at the seat of fracture.
The lamellae are narrow and closely packed and enclose bone
corpuscles at rather wide intervals. Some of the corpuscles
nearest the invading tumor are enlarged and the cells are
deeply stained. The Haversian canals are irregular in contour, of various sizes, and filled with granular detritus and
fragments of bone. About their rim there is lacunar absorption, the grooves being small. The bone, where invaded, is
being absorbed by the osteoclasts, for in every Howship"s
lacuna can be seen a giant cell such as Kolliker' describes,
or large osteoblasts which here take on the function of osteoclasts and are such.


These osteoclasts vary in size and shape, each fitting exactly
a groove in the bone hollowed out to fit the absorbing agent.
Some of the cells are seen completely surrounded by bone,
others have only one-third of their body enclosed by the
lacuna. The shape varies from oval, round, oblong, large
cells to elongated flat cells lining quite a large part of the
bone surface, looking almost as if one of the outer lamellae
had broken off abruptly and taken in many large nuclei. The
size varies from an osteoblast to cells five or six times as big.


The nuclei are either massed in the centre or arranged
around the perijihery ; they are large, round or oval, and vesicular. The protoplasm of these osteoclasts is granular and
stains deeply with eosin, especially at the centre. The edge
of the cell next the bone is rough ; the other borders of some
cells seem of double contour and quite smooth.


No foreign bodies were detected in any of these bodies next
the bone, yet some of the giant cells near by included epithelial debris.


The protoplasm of some osteoclasts is drawn out like a
pseudopod and pushes in between the connective tissue cells.
Where granulations seem to fill the lacuna? one finds osteoclasts between them and the bone wall.


There is evidence of new bone formation. To the characteristics of newly deposited bone already mentioned can be
added the closer approxinuitiou of bone cells — there being
more of them than in the older adjacent bone. The medullary
spaces between the cancel li of bone are filled with newly
formed fibrous tissue and granulation tissue containing giant
cells and all the cells usually found in embryonal tissue.
There are also numerous capilhmes and larger vessels in the
spaces. The bone cells vary in size and appearance, as do the
bone corpuscles, some being round and spindle-shaped, others
stellate. They can be best studied in the newly deposited
bone or in bone undergoing absorption. It would seem as if
when about to be freed from their imprisonment they take ou
active functions again and are stained more readily.






July, 1897.]




May, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.
105






149
Bibliography.


[Those references without the asterisk the writer was unable to
consult. Arranged in chronological onler.]


Beueke, F. W.: Ueber Naiilieim's Soolthermen, etc. Marburg, 1859.


As in other sections of bone, no tumor cells come in direct
Weitere Mittheihmgen iiber die Wirkungen der Sool
contact with the bone. The tumor advances as described
thermen Nauheims. Marburg, 1861.  
above. There are small fragments of bone in the granulations, which look as if they had been eaten off and left.
There is a deposit of new bone in the vicinity of the tumor
and evidence of absorption going on in the same microscopic
field.  


Case II.— W. J. R., white, a3t. 5i, admitted June 26, '95.
* Nauheim's Soolthermeu gegen Gelenkrheuiuatismus mit


For 49 years the patient has had discharging sinuses in the
oder ohne Herzaffection. Berlin, kliu. Wocheuschr., No.
thigh communicating with necrotic bone.  
33, 1870, p. 269.  


Operation, June 28th, by Dr. Bloodgood. Amputation of
Zur Therapie des Gelenkrheumatismus luid der damit
thigh at the upper third. Notes made at the operation refer
to the great friability of the bone, the thickened periosteum,
thin shaft and presence of a sequestrum.


Nov. '96. Patient reports himself well.  
verbundenen Herzkraukheiten. Berlin, Hirschwald, 1872.  


The pathological report is as follows : The diseased condition of the bone begins 26 cm. above the condyles and involves
* Neue Erfahruugen iiber die Wirkungen der kohlen
the shaft for 16 cm. The last jjiece of bone removed, 3 cm.  
siiurehaltigeu 8oolthermen Nauheims, etc. Berlin, klin.  
below the trochanter, appetu'S healthy. The periosteum is
Wochenschr., 1875, No. 9, p. 109 ; No. 10, p. 134.  
thickened, the shaft, stripped of periosteum, is rough and
presents minute spicules. The shaft varies in thickness from
3 to 6 mm., and there is very little cancellous bone. It is
brittle, fracturing easily. The medulla above seat of disease
contains much fat and oily material. At the seat of disease
there is no involucrum. In the sinus leading from the
diseased bone there is a sequestrum 6 cm. long and li cm.
wide. The periosteum about the necrotic portion is 5 to 6
mm. thick, and on section is peai'ly white and appears
striated at right angles to the long axis of the bone. On the
surface nest to the shaft it is covered with a yellow necrotic
friable tissue covering a leathery surface. Fine spicules of
bone are imbedded in this. The odor is foul. The surface of
the shaft is rough and hard. The medullary cavity is filled
with hard bone mixed with thick leathery tissue, and is riddled with small cavities containing the same material as
covers the shaft. The only attemjit at new bone formation is
in the medullary cavity. No attempt at formation of healthy
granulations is evident. About the area of disease the shaft
exhibits exostoses 1 to 1^ cm. in length. The knee joint is
normal in appearance.  


Microscojiical examination of the tissue between the periosteum and bone described as striated and friable with necrotic
*Groedel, J. : Ein Beitrag zur Behandlung der Lilhniungeu
border next to the shaft, shows it to be made up in the main
bei Apoplektikern mit Herzfehlern. Berlin, klin. Med.  
of large swollen polygonal cells with oval vesicular nuclei.  
AVoeheuschr., No. 10, 1878, p. 137.  
The arrangement is such as one sees in the stratum mucosum
of the skin. There are papillas jirojecting into the mass from
the periosteum, which is thickened and infiltrated with small
round cells. The cells next the papilla} are prickle cells;
those nearer the shaft do not show the prickles. The cells
arc massed in varying density. According to the location of
the papilla} we get lighter and darker stained masses, the
darker being more comjiact and approaching the cancroid
pearl in appearance, but there is no cornified nor degenerated
centre. Toward the bone the cells are flat and the nuclei lose
the ability to stain. A thin layer of cornification covers their
surface. Many of the nuclei are vacuolated. The papilla are
very cellular. There is an absence of the stratum granulosum
and lucidum ; simply a uniform growth of the mucosum


* Pneumatometrische Beobachtuugen iiber den Eiufluss


verschiedener Biider auf die Kespiration. Berlin, klin.
Wochenschr., No. 32, 1880, p. 314.


and corneum. There is considerable endo- and periarteritis.  
* Die Wirkung der Biider auf das Herz. Berl. klin.  
The muscle and connective tissue show no tumor invasion.
The leathery material described in the medulla is like that
just described.  


Examination of the cortical bone from the shaft shows no
Wochenschrift, 1880, No. 20, p. 438.  
tumor growth into it. The dense bone presents a feathery
appearance commonly seen in eburnated bone. The edges
show lacunar absorption.  


A number of cases of squamous epithelioma developing in
* Zur Behandlung Herzkranker. Berlin, kliu. Wochenschr., No. 35, 1883, p. 381.  
sinuses antl old scars which would come under the grouping
I have purj)osely omitted, since the pathological description of
the tumor is in every case essentially the same as in Case I.  
Two of the cases might be considered carcinoma developing
in osteomyelitic sinuses, but the history does not fully substantiate this. In these cases the sinuses were lined by the
tubules and plugs of epithelial cells continuous with the
tumor mass in the bone itself. The invasion of the bone
resembled that described in Case I.  


The cases reported bring to mind several most interesting
*Schott, T. : Beitrag zur tonisirenden Wirkung kohlensiiurehaltiger Theramalsoolbilder auf's Herz. Berl. klin. Wochenschrift, 1883, No. 28, p. 428.
subjects in pathological histology: the development of carcinoma in sinuses, scars and ulcers, its invasion of bone, the
 
peculiar character of epithelial growth, and the bone formation and absorption due to the invading tumor. They are
*Schott, A. und Theo. : Die Nauheimer Sprudel und Sprudelstrombiider. Berlin, klin. Wochensch., 1884, No. 19, p. 394.
interesting especially because they show side by side the
 
picture of a typical squamous epithelioma and a mere enormous hyperplasia of the epithelial elements of the stratum
*Schott, A. : Zur Therapie der chronischen Herzkraukheiten.  
mucosum in bone. The one is evidently quite malignant; the
Berl. klin. Wochenschrift, No. 33, p. 534. 1885.  
other does not appear to be very destructive in its growth, but
merely a filling in of the space made void by the osteomyelitic
process. The two tumors have their homologues in the
epithelial growths in sinuses, ulcers and scars, some being
typical epitheliomata, others simply hyperplastic growths of
epithelium lining the sinus walls.  


There is this point to be noted in Case II differing from
Leichtenstern, 0. : General Balneotherapeutics. Ziemssen's
any yet described — the great development of the cells of the
Handbook of Therapeutics, Vol. IV, p. 395. London,  
stratum mucosum to the exclusion of the granulosnm and
1885.  
lucidum. There is simply a single layer of cuboidal cells
covering the papilte, then 10 to 15 layers of large swollen
polygonal cells covered by a thin layer of cornified epithelium.  
This not only fills the sinus and medullary cavity, but pushes
in between the periosteum and the shaft, nowhere penetrating
the bone itself. It may be compared in a way with a case of
great epithelial cell hyperplasia of the outermost layers of
the epidermis described by Busch'" in a case of lupus. Here
there was an epithelial papillary growth covered by thickened,
horny epithelium spread over the surface, finally breaking
into the connective tissue and forming carcinoma.  


Typical squamous epitheliomata in scars, ulcers and sinuses
Schott, August: Die Bedeutuug der Gymnastik fiir Diagnose, Prognose und Therapie der Herzkraukheiten. Zeitsch.  
are not uncommon. There are only twenty-eight cases
f. Therapie, 1885.  
reported in which the epithelioma developed in the sinus following osteomyelitis. From the histories of many cases
of epithelioma in ulcers I infer that a few if more accurately
described would come under the heading of carcinoma in
sinuses following osteomyelitis. Some give a history of
osteomyelitis. See Van Hook,' Schindler,' Boegchold." Borchers' iu 1891 collected all the cases up to his time, numbering
twenty-five. He records cases of Konig, Dittrich,'" Nicoladoni," Esmarch,'' Fischer," Bartens, Coruil and Kanvier,'


Schott, Th. : Die Hautresorption und ihre Bedeutuug fiir die
Physiologie der Badewirkungen. Deut. Med. Zeitung, 1885.


Oertel, M. J. : Therapeutics of Circulatory Derangements.
Ibid., Vol. 7, 1887.


150
Schott, Th. : Die Behandlung der chronischen Herzkraukheiten. Berlin, Grosser, 1887.


Zur Pathologie und Therapie der Angina Pectoris.


Deut. med. Zeitung, 1888, No. 35-38.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Wiborgh, Aug. : Bad Nauheim, etc. Stockholm, 1888.  


Bode, W. : Bad Nauheim, seine Curmittel, Indicationen und
Erfolge. Zweite Aufl., Wiesbaden, 1889.


*Schott, Theodore: Herzkraukheiten. Separat-Abdruck aus
der Keal-Encyc. der gesammten Heilkunde. Wien und
Leipzig, 1890. (Reprint.;


[No. 76.
* Zur acuten L^eberanstrengung des Herzens und dereu


Behandlung. 1890. Separ. Abdr. aus den Verhandlungen
des IX. Congresses fiir innere Medicin zu Wien. (Eeprint.)


* Herzkraukheiten. Keal-Encycl. der gesammten Heilkunde. Wien und Leipzig, 1890. (Reprint.)


Winiwarter," Hauuover"^ and Volkmauu." Another case is
recorded by Feigel.' One of Van Hook's' two cases was
undoubtedly carcinoma developed in an old fistula communicating with necrotic bone. Von Friedlander's" three cases,
reported in 1894:, are the last recorded. All of the cases
described have many points in common with our first case.


Clinically, the development of the disease in those beyond
40 years of age, the common involvement of the lower
extremities, the uncertainty of fixing the exact time of development, its slow growth, the foul odor, the long existence of
the fistulaj, the absence of pain until the carcinoma begins to
develop, the ease with which the bone is broken, the fixation
of the neighboring joints and ankylosis of adjoining bones,
the infrequent involvement of lymphatic glands or other
organs, and its almost sure recurrence unless the limb be
amputated, are all most noteworthy points.


Volkmann" says that recurrence occurs in a few weeks or
*Groedel, J. : Ueber abnorme Herzthiitigkeit in Folge von
months after the operation, if at all; if not Avithin 1 to Ih
lunervationsstoruugen. No. 21, 1890, p. 467.  
years, it seldom occurs.  


The pathological picture is not to be confused with any
*Schott, Theodore: The Treatment of Chronic Diseases of  
known disease of bone or sinus. The crater-like ulcer or
the Heart by means of Baths and Gymnastics. Lancet,
cauliflower excrescences made up of individual oval yellowish
1891, Vol. I, p. 1143. Concluded on p. 1199. (Reprint.)
white masses, are enough to make the diagnosis. Finding the
same papillary growths in the medullary cavity is not calculated to make one think of simple osteomyelitis. The bone
next the tumor is either soft and spongy or denser than normal
bone. It is increased in circumference and the medullary
canal may be smaller than normal. Osteophytes may form
on the surface and the bone may rarely present the appearance
of spina ventosa. Fracture is common.  


The microscopical picture is that of squamous epithelioma
Israel, E. : Om Nauheimkur, etc. Copenhagen, 1891.  
modified in appearance according to the amount of degeneration and bone absorption and the greater or less development
of tubules, alveoli or cysts. The tumor cells nowhere come in
direct contact with the bone, being separated by connective
tissue and giant cells or osteoblasts. The thickness of the
growth varies, but it is thickest in the cloaca, and in places
looking like granulation tissue. The sequestra in Nicoladoni's"
cases were not invaded by epithelial cells.  


Borchers' refers to the advance of the tumor into the
Schott, Th.: Balneo-therapeutic and Mechano-therapeutics
Haversian canals. Our cases do not substantiate this, the
applied to the Treatment of Chronic Heart Disease. Medical Record, No. 7, Vol. XXXIX, 1891.  
epithelial cells never being found separate from the main
growth.  


In none of the cases were metastases found in the internal
* Zur Differentialdiagnose des Pericardialexudats uud
organs and rarely even in the lymph glands. The swollen
glands usually became of normal size after amputation of the
limb. The reason of the infrequent metastases is found in
the sclerosis and condensation of tissues about the tumor and
its very slow growth.


Thinking of the etiology and histogenesis of the tumors,
der Herzdilatation. (Reprint.) Berlin, klin. Wocheuschrift, 1891, No. 18.  
one would naturally class those described with tumors developing in ulcers, fistulas and old scars. Many theories have
been advanced to explain them: Virchow's" idea of chronic
irritation, mechanical and chemical, being most naturally first
alluded to. The question whether the connective tissue
growth or epithelial proliferation be the primary factor
has been most actively debated since Ribbert" so strongly
advocated the former view. Boegehold,* who reported several


Ueber Herzneurosen. 1893. Separ. Abdr. aus der Real-Encycl.
der gesammten Heilkunde.


*Moeller: Traitement des maladies du coeur par la methode
des Drs. Schott. Bruxelles, 1893. (Repriut.)


cases like my first one, believes in their connective tissue origin,  
*Babcock : Schott Method of treating Chronic Diseases of the
and says that the epithelium is lost over scars and ulcers. He
Heart. Journal of American Medical Assoc, XXI, pp.  
says : " If the surface epithelium cannot cover over the granulation surface, one cannot see why it shall grow into the
717-734, 1893.  
depths of the granulation tissue."


Langeubeck,''" in discussing the development of carcinoma
Summers, Guillermo: Tratamiento de las enfermades cronicas
in lupus, expresses the view that the cause of development is
del corazon por el metodo del Dr. Schott. Gaceta Medica
like that in traumatic scars, a continuoiis irritation and the
de Cadiz, 1893.  
carcinoma develops from remaining epithelial cells. It is
distinct from the lupus growth. "It is difficult to reconcile
the notion of lupus — a granulation tissue — passing directly
into carcinoma, because of our view that epithelioma must
come from pre-existing epithelial cells."


AVenk,"' who believes in this direct transition, concedes that
Groedel: Bad Nauheim and the Treatment of Chronic Heart
the epidermis projections have not been entirely destroyed.
Disease. St. Petersburg Med. Woch., 1893.  
Langenbeck"" attributes its formation to development of epithelium in the outlying scar. Schindler'' cites cases to prove
the development from the scars — either from the covering
epithelium or glandular organs of the skin left intact by the
lupus process. He answers Boegehold's* argument cited
above, by explaining that the surface epithelium is prevented
from spreading superficially by continual irritation (pressure or secretion) and therefore it dips down deeply where
not exposed to these influences. Hulke,'"' in describing two
cases of carcinoma in old scars, ascribes them to purely
local causes. Pedraglia^^ refers to old age and periodic irritation as predisposing causes. This view that old age influences the growth corresponds with that of Verneuil
referred to by Marcuse:" "Ein locus minoris resistentiae"
of the connective tissues, the epithelium retaining and
increasing its activity. Marcuse uses this theory in explaining the growths in the granulations covering ulcers — the
granulation tissue, when not going on to scar formation, being
not so resistant to epithelial hyperplasia as normal tissues.
Here the epithelium grows into the tissues as stated by
Thiersch'"' in his most valuable contribution to the etiology
of epithelioma of the skin.  


It is not much disputed now that epithelium only forms
*Schott, T. : The Mineral Waters of Nauheim, their Action,  
from preformed epithelium and not from leucocytes or connective tissue cells. This materially aids the histogenetic
Uses and Effects. Eyre & Spottiswoode, London,
study of these tumors. Whatever the cause, the practical
1894.  
lessons obtained from them are of much value to the surgeon,  
and one is not tempted to use tentative measures to stop a
growth which he knows by experience and microscopical
study to go steadily onward in its course until it is excised
radically.  


1. Van Hook, W. : Carcinomas arising in Inveterate Ulcers
Smyly, P. C. : On the Treatment of Enlarged Heart by Certain Movements as taught by Dr. Schott, Nauheim. Dublin Jour, of Med. Scieu., 1894, Vol. 3, p. 185.  
and in Ancient Sinuses. North Amer. Practit., Sept., 1890.  


2. Schindler, J. : Beitrag zur Eutwicklung maligner Tunioren aus Narben. Inaugural Diss., Strassburg, 1885.  
*Thorne, W. Bezley : Treatment of Chronic Diseases of the
Heart by Baths and Exercises according to the Methods
of Dr. Schott. 1894. Churchill, London.  


3. Borchers, F. : Ueber das Carciuom welches sich in alten
*Thorne, W. B. : The Treatment of Chronic Diseases of the
Fistelgiingen der Haut entwickelt. Inaug. Diss., Giittiugeu,
Heart by Baths and Exercises according to the Method of
1891.  
Dr. Schott. Lancet, 1894, Vol. I, p. 1117.  


4. Boegehold : Ueber die Eutstehung maligner Tumoreu aus
*Wethered, F. J. : The Treatment of Chronic Diseases of the
Narben. Virchow's Arch., No. 88, p. 229.  
Heart by Baths and Gymnastics as practised at Nauheim.
Brit. Med. Jour., 1894, Vol. II, p. 1045.  


5. Feigel, L.: Ein Fall von primiirem Ki-ebs der Tibia.
*Brunton, T. L. : The Harveian Oration, 1894. London.  
I'rzeglad lekarski, Nos. 3G and 37, 1891.  


♦Campbell, H. : The Mechanical Treatment of Heart Disease.
British Med. Journal, 1894, Vol. 2, p. 1101.


*Eccles, A. Symous: Mechanotherapy in Chronic Diseases of
the Heart. The Practitioner, 1894, Vol. I, p. 107.


July, 1897.]
*Pagenstecher de Mexico, G. : Du traitement balneomechanique des maladies chroniques du coeur d'apres la m6thode des docteurs Schott de Nauheim. Bulletin General
de Therapeutique, Paris, 1894, Nos. 15-30, Juin. (Reprint.)


*Babcock, Robert H. : Report of Cases of Chronic Heart
Disease treated by the Schott Method of Baths and Gymnastics. N. Y. M. J., LX, pp. 705-710, 1894.


*Schott, Th. : Zur Behandlung des Fettherzens. Deut. Med.
Wochensch., XX, 561, 1894.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Armstrong: Nauheim Treatment of Chronic Cardiac and
Allied Diseases. Liverpool Medico-Chirurgical Journal,
July, 1895.  


*Sturge, W. A. : Note ou the Treatment of Dilated Heart as




151


106




6. Cornil andKauvier: Journal de rAiiatoiiiie, 1SGIJ-G7, p.
277.


7. Erust, P. : Sfcudien iiber normale Verhornniig mit Hilfe
der Gramscher Methode. Arch. f. mik. Aiiat. und Eutwickluugsgeschichte, Bd. 47, p. 669, 1896.


8. KoUiker: Die normale Kesorptiou des Kuocheiigewebes.  
practised at Naiiheim. Brit. Med. Jour., 1895, Vol. I,
Leipzig, 1873.  


9. Ribbert: Miinchuer Med. Wocheusch., 1894, No. 17;
p. 537.  
Vircbow's Arcb., Bd. 135.  
*Thorne, W. B. : Tlie Treatment of Chronic Affections of the


10. Dittrich : Prager Vierteljahresschrift, 1847, II.
Heart by Baths and Esereises. Brit. Med. Jour., 1895,  


11. Nicoladoni: Arch. f. klin. Cbir., No. 26, 1881.  
Vol. I, p. 524.  
* The Schott Method of Treatment in Chronic Diseases


12. Esmarcb: Langeubeck's Arch., XXII.  
of the Heart. London, 1895.  
*Practitioner, May, 1895, p. 385. The Treatment of Chronic


13. Fischer, S.: Zeitschr. f. Chir., 1881.  
Heart Disease by the Method of Dr. Schott, Nauheim. By


14. Winiwarter: Beitriige ziir Statistik des Carcinoms.  
John F. H. Broadbeut. With some remarks on the mode
Stuttgart, 1878.  


15. Volkmann, Rud. : ITeber das primilre Krebs der Extremitiiteu. Volkmann's Sammlung klin. Vortrage, 1889.  
of action of the treatment and its indications. By Sir


16. Hauuover : Das Epitheliom. Leipsic, 1855-56.  
William Broadbent, Sen. Physician to St. Mary's Hospital.  
*Thorne, W. B. : The Treatment of Chronic Affection of


the Heart. Brit. Med. Jour., 1895, I, p. 524.
Kraus, W. C. : Some Advances in Cardiac Therapeutics. Med.


Press and Circ, Loudon, 1895.
*CTroedel: The Mechanico-Gymuastic and Balneo-Tliera
peutic Treatment of Chronic Cardiac Disorders. Lancet,


17. V. Friedlander: Beitrag zur Kenntnissder Carcinomentwickelung in Sequesterhohlen und Fisteln. Deutsche Zeitschr.
London, pp. 802-804, 1895.  
f. Chir., 1894.  


18. Busch: Langenbeck's Archiv, XV, p. 48.
Baths in Cases of Arterio-sclerosis. Deut, Med. Zeitung,  


19. Virchow : Die krankhafteu Gescbwiilste, Bd. II, p.
1895.  
487.  


20. Langenbeck: Berlin, klin. Wochenschr., 1879, p. 329.  
Green, C. L. : The Treatment of Chronic Heart Disease by
the Schott Method. N. W. Lancet, St. Paul, XV, 345-349,  
1895.  


21. Wenk, L. H. : De exemplis nonnullis carciuomatia
Pospischil: Hydrotherapie bei organischen Herzkrankheiten.  
epithelialis exorti in cicatrice post lupnm exedentem relicto.  
Deutsch. med. Ztg., Berlin, XVI, 581-586, 1895.  
Kiel, 1867. Reference from Schindler, see above.  


22. Hulke, J. W.: London Medical Times, Vol. 1, 1873,  
de Bosia, H. : Des indications des eaux minerales dans les
p. 135.  
traitemeut des maladies da coeur. Cong. Franc, de MC'd.,  
Paris, 845-852, 1895.  


23. Pedraglia: Vier Fiille von Epithelialkrebs anf alten
*Sauudby, Robert: Remarks on the Nauheim (Schott) Treatment of Heart Disease. B. M. J., Nov. 2, 1895, p. 1081.  
Narben. Giessen, 1853.  
Discussion, p. 1129.  


24. Marcuse, J.: Deutsche Zeitschr. f. Chirurgie, Bd. VII,  
Birmingham Medical Review, Vol. XXXVIII, 1895, No.  
p. 550.  


25. Thiersch: Der Epithelialkrebs, uamentlich der Haut.
208.  
Leipzig, 1865.  


Fisher, T. : The Treatment of Heart Disease. The Hospital,
August 24, 1895.


*Heinemauu, PI. N. : Experiences with the Physical and Schott
Treatment of Chronic Heart Disease. N. Y. Medical
Record, 1896, L, 847-852.


ON THE BLOOD-PRESSURE-RAISING CONSTITUENT OF THE SUPRARENAL CAPSULE.*
*Mason, A. L. : The Baths of Nauheim in Heart Disease. Boston M. and S. J., 1896, CXXXV, 302.  


By John J. Abel, M. D., and Albert C. Crawford, M. D.  
*Morrison, A. : The " Schott Treatment " of Heart Disease.  
Practitioner, London, 1896, LVII, 268-275.  


[From the Pharmacological Laboratory of the Johns Hopkins University .'[
♦Report of the Lancet Commission on Balneological and
Gymnastic Treatment of Heart Disease at Nauheim. Lancet, London, 1896, II, 619-621.  


*McArthur, A. N. : Heart Disease treated by Saline Baths.
B. M. J., 1896, I, 1384.


♦Carter, A. H. : The Schott Treatment of Heart Disease. Practitioner, 1896, LVII, 166. [No direct bearing upon the
treatment.]


Both clinical experience and laboratory research have
*Erebuske, C. J.: Gymnastics in Heart Disease. Bost. M. &
shown that the suprarenal capsule is an organ of vital importance.  
S. J., 1896, CXXXIV, 610-612. (Discussion) 618-620.  


Physiologistst have proved that a very small quantity of
*Graiipner. Die Balneotherapie der chronischeu Herzkrankheiten, ihrMechanismus und ihre Beziehung zur Dynamik
an aqueous extract of the medullary substance raises the
des Kreislaufs. Deutsche Med. Wochensch., 1896, XXII,  
blood pressure to a great height above the normal. It has
529-531.  
also uuequaled power in reviving a poisoned heart. Gottlieb,J
for example, has shown that it will revive the heart of a rabbit which has practically stopped beating in consequence of
an intravenous injection of chloral hydrate.  


Bates§ applied an aqueous solution to the eye and found
Nauheimer Mineralbader und einfache Wasserbader:
that it exerted a marked vaso-constricting action. In numerous cases of congestion a small quantity dropped into the conjunctival sac brought about an immediate pallor, lasting for
some time. According to this writer the extract is very useful
in prolonged operations, for, when repeatedly applied, hajniorrhage is prevented and cocaine anfesthesia is in consequence
indefinitely prolonged. As the result of his two years' use of
the extract Bates concludes " that within the limits of its
sphere of activity there is absolutely no other substance which
can take its place."


Other experiments|| go to show that the aqueous extract is




ihr Einfluss auf Blutdruck und Herzthiltigkeit. Allg. Med.
Centr. Ztg., Berl., 1896, LXV.


•Read before the Association of American Physicians, May 6,  
Cireene, C. L. : Extreme Dilatation of the Heart due to
1897.  
Valvular Disease, with Special Reference to Treatment
by the Schott Method. luternat. Clin., Phila., 1896, 6 s.,  
II, 63-73.  


tSehiifer and Oliver, Journal of Physiology, xvi (1894) and  
Yeo, F. B. : Rest, Exercise and Baths in the Treatment of
xvii (1895); Szymonowicz and Cybulski, Wien. med. WochenBchrift, 18'JG, No. 6.  
Cardiac Affections. luternat. Clinic, Phila., 1896, 6 s.,  
II, 31-42.  


JArch. f. exp. Pathol, u. Pharmakol., xxxviii, 106.  
Bowles, R. L. : Nauheim and the Schott Treatment of Diseases of the Heart. Med. Press and Circ, London, 1896,  
N. S., LXI, 339. Discussion, 345.  


§New York Medical Journal, Ixiii (189G), iiil .  
*Kingscote, E. : Fifteen Months' Practice of the Schott Methods for the Treatment of Chronic Affections of the Heart.
Lancet, London, 1896, I, 761-7C3.  


||Foa and Pellacani, cited in Maly's Jahresb. d. Thier-Chemie,
*Nebel, H. : The Treatment of Heart Diseases by Baths and
xiii, 129; M.arino-Zuco, ibid., xviii, 231 ; Gourfein, Rev. Med. de
Gymnastics. N. Y. Med. Record, 1896, XLIX, 7)7. (Early
la Suisse Romande, Oct. 20, 1895; Compt. rend., cxxi (1895), 311314.
literature.)  


*Broadbent, Sir W. N. : Note on Auscultatory Percussion and
the Schott Treatment of Heart Disease. Brit. M. J.,
1896, I, 769.


*Leith, R. F. C. : An Inquiry into the Physiology of the
Action of Thermal Saline Baths and Resistance Exercises
in the Treatment of Chronic Heart Disease (the Nauheim
and Schott System). Edinb. M. J., 1895-6, XLI, 804,
814. Also Lancet, 1896, I, 757, 841.


a powerful poison when injected directly into the circulation
♦Campbell, H. : The Schott Treatment of Heart Disease.
and may lead to fatal results.  
Lancet, 1896, I, 951. [Communication on Leith's paper.]
 
The various extracts that have been used in these experiments were mixtures of unknown substances, and it is as yet
an unsolved question whether the various actions at present
ascribed to the gland are due to one and the same substance.  


We are at present interested in the isolation of the bloodpressure-raising constituent, for in a purified state, separated
*The Schott Treatment as carried out at Sidmouth. Brit. M.
from all other constituents, it might become a therapeutic
J., 1896, I, 924.  
agent of great importance.  


On the chemical side but little advance has been made over
Anderson, McO. : Dilatation of the Heart treated by Exercises on the Schott Principle. Glasgow M. J., 1896, XLV,  
Vulpian's* striking original contribution more than forty
266, 268.  
years ago. Vulpian observed that the juice expressed from
the suprarenal capsule of many different animals behaved in a
striking manner toward ferric chloride and toward solutions
of iodine, giving with the former reagent an emerald green
color, and with the latter a beautiful rose carmine tint. No
other tissue of the body, so far as investigated by Vulpian,  
gave these reactions.  


Virchowt substantiated Vulpian's statements, but added
♦Poore, G. V.: Two Cases of Heart Disease treated by Saline
nothing new. A year after Vulpian's first announcement his
Baths. B. M. J., London, 1896, I, 1139.  
second paper appeared in conjunction with Cloez,J verifying
and extending his first observations and stating his failure to
isolate the chromogenic substance or substances to which the
above reactions are due.  


Equally unsuccessful were Arnold§ and Ilolm.ji Kruken
*Rives, W. C. : The Baths of Nauheim in the Treatment of
Disease of the Heart and the Therapeutic Methods of the
Doctors Schott. N. Y. M. J., 1896, LXIII, 471-479.  


Steven, J. L. : On the Nauheim (Schott) Methods of Treatment as applied to Cases of Cardiac Valve Disease of
Rheumatic Origin. Glasgow M. J., 1896, XLV, 339-361.


* Note sur quelqiies reactions propres i la substance des capsules
*Thorne, W. B. : Self -Poisoning in Heart Disease ; its Relation to Schott Methods of Treatment. Lancet, Loudon,  
surrenales, Compt. rend., xliii (1856), 063-665.  
1896, I, 755-757.  
■)■ Virchow'a Archiv, xii (1857), 481-483.
X Compt. rend., xlv (1857), 340-343.
§ Virchow's Archiv, xxxv (1866), 64-107.
II Journ. f. prakt. ('hemie, c (1867), 150.  


♦Schott, T.: Ueber gichtische Herzaffectiouen und dereu
Behandlung. Berliner klin. Wochenschrift, XXXIII,
457-519, 1896.


♦Stewart, Grainger: Discussion on Treatment of Cardiac Failure. Brit. Med. Journal, September 19, 1896.


152
♦Bowles, R. L. : An Experimental Inquiry into the " Schott
Treatment" of Certain Diseases of the Heart at Bad Nauheim. The Practitioner, July, 1896. (Reprint.)


♦Ileinenmu, H. Newton: Die physikalische Behandlung der
chronischen Herzkrankheiten. Deut. Med. Woch., 1896,
No. 33, Leipzig. (Reprint.)


♦Cohen, Solomon Solis : The Schott Method of Gymnastics in
Chronic Heart Disease. JIaryland Jledical Journal, Feb.
20, 1897.


JOHNS HOPKINS HOSPITAL BULLETIN.




May, 1897.]


[No. 7ri.
107






berg,* years after, repeated the work of Arnold and came to
A CASE OF POROKERATOSIS
the conclusion that the chromogeu of the suprarenal capsule
WITH
is a nou-volatile, nitrogenous and ferruginous organic acid
which is probably related to the tnracin of the musophagidai
and to chlorophyll. He assumed that the substance giving
the green color with ferric chloride is not the chromogenic
substance of Vulpian, but more likely pyrocatechiu accompanying the chromogen. Attention being thus attracted to the
possible occurrence of pyrocatechiu in the suprarenal capsule,
others took up the subject.


Brunnerf found that an alcoholic extract cau be made to
give nearly all of the reactions of pyrocatechiu ; thus, it gives
the well-known green color with ferric chloride, passing into
a fine red on the addition of ammonium tartrate and a few
drops of an alkali; it reduces silver nitrate at room temperature, and Fehliug's solution on boiling. The addition of an
alkali soon causes it to take on a dark brown color, lead acetate gives a precipitate, sodium nitroprusside and very dilute
ammonia give a wine-red color. All of the above reactions
being given also by pyrocatechiu, Brunuer concluded that
Krukenberg was right in his belief that pyrocatechiu is present in the suprarenal gland.


After the discovery of the blood-pressure-raisiug property
of the suprarenal gland, B. Moore,J working in Schilfer's
laboratory, came to the conclusion that Vulpiau's chromogen
and the blood-pressure-raising constituent are identical. He
based his ojjinion on the fact that chemical operations which
destroy the color reactions by oxidizing the reducing agent
appear also to destroy the blood-pressure-raising constituent.
That the solubilities of the active principle are the same as
those of the reducing agent appears also to support this
opinion.


Fraenkel§ worked with residues obtained with the help of
(MIBELLI) OR HYPERKERATOSIS EXCENTRICA (RESPIGHD
alcohol and acetone as solvents. These residues raise the
A REMARKABLE FAMILY HISTORY.*
blood pressure and do not contain pyrocatechiu, and on the
strength of the ferric chloride reaction and its reducing power
he concludes that the essential principle of the residue is a
nitrogenous derivative of the o?'</(odihydroxy-benzene series.  


According to Fraeukel both Krukenberg and Brunuer are
wrong in their opinion that the suprarenal glaud contains
pyrocatechiu. Fraeukel concludes, like Moore, that the bloodpressure-raising constituent and Vulpiau's chromogen are one
and the same substance.


More recently still, Muhlmann|| has attempted to prove that
the blood-pressure-raisiug constituent is a pyrocatechiu derivative. He asserts that on boiling fresh suprarenal capsules
with dilute hydrochloric acid the active principle is decomposed and the pyrocatechiu which is split off may be taken up
with ether. Miihlmann has not, however, furnished conclusive chemical proofs for his assertion. Both Miihlmann and
Brunner might have settled this point by precipitating the
supposed pyrocatechiu with lead acetate and analyzing the
lead salt thus obtained. Pyrocatechiu may be preseut in


PKELIMINAEY NOTICE.




* Virchow's Archiv, ci (1885), 542-591.


fSchweizer. Wochensclir. f. Ph.armacie, xxx (1892), 121-123.  
By T. Caspar CtILCHRist, M. 11. C. S., L. S. A., Associate in Dermafologi/, Johns Hopki)is Unicersifi/.  


} Journal of Physiology, xvii (1895), Pron. Physiol. See, p. xiv.


'i Wiener med. Blatter, 1896, No. 14-16.


II Deutsche med. Wochenschr., 1896, No. 26, 409-411.  
In October, 1893, Mibelli, of Italy, described three (slight
references were made to three others) cases of a new disease
which, after a careful and detailed histological examination,
he named Porokeratosis. The disease began at an early age,
and was chiefly distributed on the backs of the hands, feet,
other portions of the extremities, neck, face and scalp. The
lesions commenced as minute, dirty brown, dry, cone-shaped
elevations of different sizes and forms, which became much
altered as they very slowly increased in size. The lesions extended centrifugally, and the central portion gradually sank in
and still remained callous, but the margin was represented by
a raised wavy ridge which presented the features of a raised
seam. Some patches grew to a very large size and covered
almost the whole forearm. Mibelli gave the name porokeratosis
to this disease because the most important anatomical lesion
was the hyperkeratosis of the sweat duct and sweat pore. In
one instance a brother and sister had the disease, mainly on
the face and neck. The disease was exceedingly chronic and
was unaccompanied by any inflammation or any subjective
symptoms.  
 
On January 15, 189-1, Respighi, also of Italy, described seven
cases of a disease which was recognized by Mibelli as belonging to the same group. Respighi gave the name of " Hyper




*Exhibited before the Johns Hopkins Hospital Medical Society,
March 1, 1897.


small amounts in the gland, but no proof of this has yet been
furnished.


There is therefore at present great diversity of opinion as
to the chemical character of the blood-pressure-raising constituent of the gland.


Whatever the probability may be of the correctness of this
keratosis excentrica" to this affection. In one of the cases
or that view, it is to be noted that all of the above-named
the father of the patient also was affected with similar lesions.
investigators have based their conclusions on reactions made  
Two years later, three more cases were described by the same
with aqueous, alcoholic or acetonic extracts ; none of them
author. A single case has been recorded outside of Italy, by
have even roughly isolated a definite chemical comjiound.  
Dr. M. B. Hutchius, of Atlanta, Ga., in the Journal of Cutaneous and Genito- Urinary Diseases for October, 1890. In
The subject is one of great diflBculty, and our own work is at
Hutchins' case the disease began at two years of age, on the
jjreseut merely preliminary, but we have arrived at the  
2)alni of the left hand. The patient is now a man, 33 years
following conclusions which we believe to be borne out by
old, and has the disease on the left palm, the back of the hand
our experiments.  
and forearm, and on the face. No histological examination
was made. Hutchins compares the boundary of the patches
to the "outside of a seam with a thread-like line dividing its
lateral halves, and consisting of horny epidermis." No other
member of the family had it. In all the cases which have  
thus far been recorded, only two gave histories of other members of the same family having the disease. In the one case
(Mibelli's) a brother had it, and in another (Respighi's), the  
father of the i^atient had it.  


First, we have found by isolating the blood-pressure-raising
The patient whom I exhibit this evening is a young man,
constituent in the form of a benzoyl compound and decomposing it, that the active principle is a substance with basic
21 years of age, who has had the disease since he was five
characteristics and that it must in all probability be classed
years old, when it commenced on his ears, nose, chin, neck,
with the pyrrol compounds or with the pyridine bases or
back of hands and right forearm. The lesions were extremely
alkaloids.  
slow in ap2)earing and in growing. The most remarkable
feature about the whole case is the family history, which is
here given in a tabular form, together with a very brief descrijitiou of the disease in each case.  


Second, that pyrocatechiu caunot be split off from the isolated active compound by boiling with acids, as has been
asserted.


Third, we have found that a carmiue-red pigment can be
separated from the sulphate of the active principle without
destroying its jiower to raise the blood pressure.


Fourth, iu addition to this, we have isolated from the crude
Grandmother.  
benzoyl product a volatile basic body which fumes iu the air
and which emits an odor very much like that of coniiue.  


Method of Isolating the Active Principle in the  
Disease on the face ;
Form of a Benzoyl Compound.  
commeuced when she
was a child iu 1813,
now dead.  


We have used sheep's glands in large quantity. The medullary substance of the fresh glands was scraped out, dried on
the water-bath at 60° 0., ground up finely, and extracted with
ether for several days until the fats and the substance known
as Manasse's jecorin were removed. In this way a fine dry
powder of a grayish white appearance is obtained, the aqueous
extract of which is very active in raising the blood pressure.


AVith 100 grammes or more of this powder, representing one
kg. in weight or about 1000 fresh glands, we proceeded as
follows:. The powder is repeatedly extracted with warm
water acidulated with a few drops of dilute sulphuric acid
until the gland has yielded up all of its chromogenic substances, as tested by Vulpian's reactions. This aqueous
extract is evajiorated on the water-bath to a small bulk, a
large excess of strong alcohol is then added and the whole
allowed to stand 24 hours, by which time the proteids have all
settled out. The alcoholic fluid is then filtered and the greater
part of the alcohol removed by distillation ; the remainder is
driven off on the water-bath. The entire removal of the alcohol is necessary, and in order to avoid too great concentration of the acid fluid, which seems to destroy some of the
active principle, water has now and then to be added. The
brownish fluid when filtered gives all the well-known reactions characteristic of Vulpian's chromogeu, and on neutralizing the sulplmric acid we found the filtrate to be physiologically very active.


One Brother.


Lesions on the face,
oommeucing at an
early afie and lasting
until death.


July, 1897.]




Father.


JOHNS HOPKINS HOSPITAL BULLETIN.




Disease began at about
8 years of age and is on
the face, palms, back
of hands, forearms,
legs, feet, and sole of
one foot.


153




One Brother.


This filtered fluid is next treated with the proper quantity
Disease commenced at
of benzoyl chloride and sodium hydrate according to the Baumauu-Schotten method of forming a benzoyl compound.
about 9 years of age,
There results a tarry substance of a light yellow color which
on face and leg; died
sticks to the sides of the separator funnel and which is collected
and washed until the wash fluid no longer gives an alkaline
reaction. It is next dissolved as far as possible in alcohol and
the alcohol evaporated. The residue is then treated with
ether, which takes up the greater part of it, the ethereal solution is filtered and the ether driven oft.


The residue, which is of tarry consistence and amber color,
is taken up in strong alcohol from which all basic substances
have been removed by distilling from tartaric acid. It is then
boiled for two hours with animal charcoal previously well
washed with purified alcohol. After filtration and the evaporation of the alcohol a considerable quantity of crystalline
residue is obtained which is found to consist of the benzoyl
compound of the active principle contaminated with other benzoyl derivatives and which we may call the crude benzoyl product. It is insoluble in water, alkalies or acids of ordinary
strength, is soluble in alcohol, ether, glacial acetic acid and
concentrated sulphuric acid.


It is of interest in this connection to note that benzoyl
chloride effects the complete removal of the blood-pressureraisiug constituent from an aqueous solution. This is proved
by the fact that the filtrate from the insoluble benzoate no
longer gives the characteristic chemical reactions of the active
principle, and that chemical manipulations no longer yield a
blood-pressure-raising constituent. Indeed, an injection of a
sufficient amount of the material left after the sodium benzoate and the excess of alkali have been removed, causes a sharp
and sudden fall of pressure instead of a rise.


It was not until long after we had made use of benzoyl
One Son.  
chloride as a precipitant of the active jjrinciple that we obtained
No eruption.  
access to Fraenkel's* pai)er. From it we learned that a syrupy
substance is thrown out when benzoyl chloride is shaken uj)
with a pyridine solution of an extract of the gland. Fraeukel
did not succeed in crystallizing this benzoyl conijjound, nor did
he attempt to decompose it in order to ascertain whether it was
in reality a benzoate of the blood-pressure-raising principle.  


Methods of Decomposing the Benzoyl Compound.


A quick method always used by us as a qualitative test is
as follows : The compound is dissolved in as little concentrated
sulphuric acid as possible, crushed ice is slowly added, and
the benzoic acid which has been split off is shaken out with
ether. On neutralizing the solution we found it to give the
reactions characteristic of aqueous solutions of the medullary
substance. We have not considered this method adapted to
the decomposition of large quantities of the product.


Decomposition of this benzoyl product was effected by means
28 years old, married.
of an alcoholic solution of sodium alcoholate, and also with
Disease commenced
strong hydrochloric acid and alcohol, but these methods were
at 7 years, on face.  
found to be less satisfactory in practice than the following,  
which is the method on which we now rely. The benzoyl
compound is dissolved in glacial acetic acid, the solution






*VVien. med. BliiUer, IS'Jti, No. 14-16.  
Brother 0).  


Aged 30 ; four lesions
on left side of nose,
commenced at 5 yrs.




heated to near the boiling point, and an equal volume of a 25
per cent, solution of sulphuric acid actively boiling is slowly
poured into the hot acetic acid solution, the whole being
shaken meanwhile. The flask is now attached to a back-flow
condenser ami heated on a small flame for about ten minutes.


The solution is next diluted with water and allowed to cool,
Brother i2).
the benzoic acid, which has been thrown out, is filtered off
Aged 17; disease just
and the rest is removed with the help of ether.  
commencing (?), one
lesion on neck.  


Mixed with the benzoic acid which has been removed by
filtration is found a dark brittle substance which softens on
the water-bath, and which we assume to be a benzoyl compound of unknown composition which was apparently unaffected by the dilute sulphuric acid. On dissolving it in concentrated suljjhuric acid and diluting with crushed ice, the
resulting fluid gives none of the reactions characteristic of
suprarenal extracts.


After decomposing the benzoyl product with hot dilute
sulphuric acid and removing the benzoic acid thus split off,
we next get rid of the acetic acid by repeated partial evaporations, taking care not to let the solution become too concentrated and thus perhaps injure the active principle. After
the removal of the acetic acid the sulphuric acid is precipitated with the help of lead carbonate. The lead sulphate is
removed and the filtrate is allowed to stand in vacuo over sulphuric acid until it has become of tarry consistency. It is
then exhausted with ether, acetone and absolute alcohol in
succession.


The residue is physiologically very active, and it gives all
Aged 15; number «)f
the reactions characteristic of an aqueous solution of the
lesions on face which
gland — a beautiful rose color on the addition of an alkali, a
began at about 9.  
green color with ferric chloride, reducing silver nitrate, etc.  


However, we are not yet dealing with a pure substance. If
we neutralize an aqueous solution of the product thus obtained
with a free alkali or with a carbonate of the alkalies, an overpowering odor much like that of coniiue is jierceived. As
this odor passes that of pyridine seems to take its place.
The basic substance thus liberated fumes in the air or when
a glass rod moistened with hydrochloric acid is brought into
its neighborhood. To remove this basic substance we made
an aqueous solution of the active principle as above isolated,
rendered it faintly alkaline with sodium carbonate and shook
out with ether several times in succession. But this method
does not remove all of the coniiue-like substance. To effect
this we were obliged to make the active principle strongly
alkaline with sodium hydrate before shaking out with ether.
The aqueous solution, in consequence of the addition of the
free alkali, takes on a deep red color, and carmine red flocks
are thrown out. After the removal of the coniine-like substance with ether, the fluid containing the red flocks was
acidulated with sulphuric acid and the carmine-red substance
was filtered off". The clear filtrate, which was a pale straw
color, was concentrated in vacuo, and the active priuciiile taken
up in weak alcohol. On account of the insolubility of the sulphate of the active principle in absolute alcohol it is difficult
to obtain this entirely free of sodium sulphate. We hope in
future to remove both the coniine-like substance and the pigment with the help of ammonia. The presence of pyridine in
our ammonia prevented our using it for this purpose.


9 years old: disease
commenced at 7 and
quite extensive on
face.




154


Aged 11; disease commenced at 9 years on
face.




JOHNS HOPKINS HOSPITAL BULLETIN.


108




[No. 76.




It will be seen that eleven persons in one family have had
this disease. The patient gave me this history after careful
inquiry, and I have since been able to verify his statements
with reference to seven of the cases, viz. father, three brothers,
a married sister and two of her children, by personal observation. The patient's description of the lesions in his father
and brothers, whom I examined later, was so correct that I
feel confident the other descriptions are also true, especially
since the remaining family history was verified by his father
and mother. The father of the patient also described to me
the disease as it existed on his mother, an uncle and brother.
I will not go any further into the history or description of the
lesions occurring in other members of the family, but will
reserve that for a more detailed histological description with
photograph and drawings, which will appear later.


This volatile base of a coniine-like odor has not hitherto
The patient first came under my care eighteen months ago,  
been described as a constituent of the suprarenal capsule.
and my attention was then only directed to the lesions on the  
The beautiful carmine-red pigment we take to be identical
face. I did not diagnose the disease until I had made ten or
with the red substance which many other observers have
more histological examinations of excised portions and had
found to be thrown out as a precipitate when ammonia is
seen Mibelli's and llespighi's articles.  
added to a concentrated aqueous solution of the gland, or
when a solution is evaporated in the presence of lead acetate.*
Others have believed this red precipitate to be the oxidation
product of the active principle of the gland, but we shall presently see that the active principle is still present in the filtrate
from the carmine-red body. We have as yet made no experiments with this pigment except to note that it is but slightly
soluble in dilute alkalies and insoluble in dilute acids, and  
that iodine destroys the color. Our method appears to make
the further study of this substance possible.  


The coniine-like substance we have secured in the form of  
The eruption consists of lesions of various sizes and forms
its hydrochlorate, and with it we have made certain studies
which appear to take on two characters according to their
which will be published at a later date.  
age. The smallest variety, which are distributed chiefly over
the face, consist of minute (less than 1 mm. in diameter), dirty brown, semi-globular elevations of a horny nature.
When they reach the size of a small pinhead the centre becomes depressed and the margin in some is slightly raised, round,
oval or slightly irregular, and presents the appearance of a
raised seam, along the centre of which runs a thin black line.
As the patch becomes very slowly larger the base takes on a
somewhat atrophic character. In a few of the lesions, especially those on the neck, a number of minute conical elevations
are distributed along the ridge, giving it an irregular appearance, and sometimes one or two of these minute cones appear
in the central portion of the plaque. The largest patches are
about the size of a split pea.  


Chaeacteristics of the Blood-Pressure-Eaising Constituent AS obtained by decomposing its
After removing some of the diseased portions with a curette and applying very thoroughly the silver nitrate stick, I
Benzoyl Compound.


We have now obtained the active principle in the form of a
sulphate. As thus far isolated it is a hygroscopic, strawcolored residue which tends to crystallize on standing over
sulphuric acid, agglomerates of small crystals forming on the
edge of the bowl and the entire residue taking on a semicrystalline appearance. This sulphate does not contain the
volatile coniine-like substance, nor do we find the carminered pigment which falls out on the addition of an alkali.
Alkalies no longer liberate the coniine-like substance, nor do
they throw out the red pigment, but they cause a brownish
discoloration, and on heating, alkaline vapoi's, probably
ammonia, are given off.


Our sulphate is very active physiologically. A small
quantity suffices to raise the blood-jjressure as seen in Fig. 1,
and it is therefore evident that we have isolated the active
principle but slightly contaminated with other substances.


A final product even more active in small quantities is that
have seen on four or five occasions the disease return within a
whose action is shown in Fig. 2, where the mercury is driven
month or two in the manner described, viz. a very minute,  
out of the manometer. This more active compound still contains much of the coniine-like substance, and at once throws
dirty brown papule, which within two or three weeks apparently began to clear up in the centre. Other lesions return in
out the carmine-red pigment on the addition of alkalies. The
the form of a ring or oval ridge. If one of the patches is
sulphate of the coniine-like substance does not, as we have
curetted it is fairly easily removed, but the operation is
seen, raise the blood pressure; it therefore remains for us to
followed by almost as much bleeding as the removal of a small
consider whether the carmine-red substance which is precipitated on the addition of alkalies, either alone or in conjunction with small quantities of oxidizing agents, has any j)hysiological significance or stands in any chemical relation to the
epithelioma. Examination of the scrapings, either fresh or  
blood-pressure-raising constituent. We incline to the opinion
after treatment with liquor potassaj, is negative. While watching the course of the disease week by week, I have seen new
that this substance, which in the original aqueous solution of  
lesions arise which I had not detected the week previous.  
the gland gives with iodine water the " teinte rose-carmin
tout a fait remarquable" of Vulpiau, is in nowise connected with the blood-pressure-raisiug constituent. We have
repeatedly removed or destroyed this substance by boiling
solutions containing it with strong ammonia or with sodium


•Holm, Journ. f. prakt. Chemie, c (1867), 150.  
One or two of the lesions appeared to have formed round a
hair follicle, but others did not exhibit any such relationship.  


A histological examination of a large number of sections
from the most recent as well as from the oldest patches showed
that the disease consisted of a marked hyperkeratosis of the
sweat pore and duct and of the adjacent hair follicle. In
some of the material excised from the face it was not
clear tliat the hyperkeratosis had commenced in the mouth of
a hair follicle, but in other sections, especially of the smallest
variety of lesions, the disease had undoubtedly commenced
about the sweat pore. The oldest lesion, especially from the
ear, presented a picture almost identical with that of a mild
psorospermosis foUicularis (Darier).
From the clinical and histological characters of the disease
there was no doubt of the diagnosis of all the cases, but the
special feature of this rare lesion was perhaps most marked
in the case of the father of the patient, who presented on the
hands lesions which showed the well-defined raised wavy edge
with a thin blackish line along the centre.
The character of the disease on the hands agreed perfectly
with the descriptions of Mibelli and Hutchins. JSfibelli has
reported 6 cases, Eespighi 10 cases, and Hutchins 1. I am
able to record a group of eleven in one family, which fact
seems at first sight to point to a strong hereditary taint. The
histological features will be discussed in detail and a fuller
clinical description will be given in a later article.




hydrate, and have always been able to separate subsequently
an active material. In proof of this we append Fig. 3, showing a great rise of blood pressure, although the material from
which this active principle was obtained had been boiled for
one hour with a 5 per cent, solution of sodium hydrate.
After such treatment with alkalies, care must be taken in the
subsequent evaporation of the alcohol with which the active
principle is removed, to keep an acid reaction, as otherwise
the greater part, if not all of it, will be destroyed by oxidation. And unless all evaporations are carried on under
reduced pressure, much material will be lost, even with the
above precaution.


Although somewhat contaminated with its own decomposition products, this final sulphate has all the characteristics
A RAPID METHOD OF MAKING PERMANENT SPECIMENS FROM FROZEN SECTIONS BY
of an active substance. As shown by repeated experiments, it
promptly raises the blood pressure, it constricts the vessels of
an inflamed eye, and when injected into the dorsal lymph sac
of the frog it acts like a narcotic or cerebro-spinal poison.


As freed of the red substance the sulphate of the active
THE USE OF FORMALIN.  
principle behaves as follows: It is very soluble in water,
fairly soluble in weak alcohol (50 per cent), almost insoluble
in absolute alcohol, and quite insoluble in ether, acetone,
ligroine and chloroform. Its aqueous solution, even when
freed from adherent sulphuric acid, has a slightly acid reaction. The addition of iodine water to a neutral solution does
not give a rose-red color. Alkalies added to a strong solution give a brown color which deepens on heating. Ferric
chloride gives a purplish brown, almost black in concentrated
solution, which ou the addition of tartaric acid and an alkali
passes into a deep red color. Before the removal of the carmine-red substance the addition of ferric chloride gives the
well-known emerald green color, which passes into red on the
addition of an alkali.  


It is evident that our sulphate gives V^ulpian's ferric chloride reaction, though somewhat changed by the removal of
By Thomas S. Gdllen, M. B., Resident Gynecologist.  
what we take to be the chromogenic substance which gave his
iodine reaction. It also promptly reduces silver nitrate in
alkaline solution, but does not reduce Fehling's solution even
on boiling.  


Probable Eelation to the Alkaloids.


More than a year ago, during our first studies with suprarenal extract, we were struck with the fact that every extract
entirely free of proteids and physiologically active gave a fine
pyrrol reaction when subjected to dry distillation. This is
evidenced both by the odor and by the pine sliver reaction.
A small quantity of the isolated sulphate also gives the
pyrrol reaction when heated either alone or with zinc dust.


We attach considerable importance to this reaction. As is
In April, 1895, I published two methods under the above
well known, alkaloids in general give pyrrol ou dry distillation ; morphine, for instance, on being heated with 10 parts
title in the Bulletin.  
of zinc dust gives off pyrrol, ammonia, trimethylamine, pyridine, phenanthrene, etc.* During the past winter we made


Since then, numerous requests have been made for reprints
or for copies of the Bulletin of that number, and as the
supply is exhausted, it has been thought best to publish the
article again with one or two minor alterations. The methods
have been continuously employed in the Hospital, and especially in the gynecological department, and have proved uniformly satisfactory.


A complete freezing outfit has been placed in close proximity
to the operating room, so that as little delay as possible may
occur in examining a specimen. For example, if a carcinoma


* We are well aware that certain salts of glutaminic, pyromucic
and its related acids also yield pyrrol on dry distillation. These
compouuds, however, like the proteids and their allies, appear to
us to be excluded.




of the uterus is suspected, the patient is brought to the
operating room prepared for hysterectomy. The uterus is
curetted and the scrapings are examined while the usual preparations for abdominal section are being made. By the time
all prejsarations are completed the diagnosis is given; if negative, the patient is returned to the ward with the assurance
that there is no cause for alarm ; if positive, the organ is
immediately removed. The woman is thus saved from taking
an anajsthetic twice, and avoids the period of anxious suspense
of four or five days generally required by the ordinary methods to ascertain whether she has malignant trouble or not.
Any one who has hardened tissues in formalin will be im


July, 1897.]


May, 1897.]


109


JOHNS HOPKINS HOSPITAL BULLETIN.




pressed with the rapidity of its action, with the firm consistence of the tissue, and with the absence of the contraction of
the specimen so often seen when alcoliol is used as the
hardening medium. Microscopical examination of a specimen
hardened in formalin, as we all know, shows almost perfect
preservation of the cellular structure. Recently it occurred
to me that formalin might be used in the preparation of frozen
sections.


155
One of the greatest difficulties experienced in rendering
frozen sections permanent lies in the fact that when passed
through alcohol the section frequently not only contracts but
contracts irregularly, distorting the specimen ; further, such
specimens will often stain imperfectly. The use of formalin
will obviate these difficulties, allowing one to make an excellent permanent specimen from the frozen section. My
method is as follows: The tissue to be examined is frozen
with carbonic acid or ether aud then cut; the sections are
then placed in 5 per cent, watery solution of formalin for 3 to
5 minutes, or longer if desired; in 50 per cent, alcohol 3
minutes, and in absolute alcohol 1 minute. The tissue is now
thoroughly hardened aud can be treated as an ordinary celloidin section, being stained and mounted in the usual way.
On examining this mounted section one might readily take it
for a well preserved alcoholic specimen. Supposing we stain
with hematoxylin and eosin, the entire process is as follows :


Method I. a. Place the frozen section in 5 per cent. aq. sol.
formalin for 3 to 5 minutes.


b. Leave in 50 per cent, alcohol 3 minutes.*


several attempts to prove the presence of pyridine among the
c. In absolute alcohol 1 minute.  
products of dry distillation of the active principle as above
isolated, as its detection would prove that our principle was to
be classed among the alkaloids.  


In attempting to show the presence of pyridine we heated
d. Wash out in water.  
the active principle with zinc dust in a current of dry
hydrogen and passed the distillation products through a test
tube and two small flasks, the tube being placed in a cooling
mixture, the first flask being partly filled with dilute sodium
hydrate, and the second with dilute hydrochloric acid.  


At the close of the experiment the test tube gave off alkaline vapors that smelled strongly of trimethylamine and had
e. Stain in ha^matoxylin for 2 minutes.  
in addition a peculiar sweetish odor. The contents of the
/. Decolorize in acid alcohol.  
test tube diluted with water gave a jDrecipitate with bromine
 
water and with copjier sulphate, but with the latter reagent
g. Rinse in water.  
the fine blue color characteristic of pyridine did not appear.  
The presence of amines seems to render difficult the detection
of small quantities of pyridine. The contents of the third
flask on exposure to the air took on a rose-red color and after
a time threw out a precipitate of the same tint. Both flasks
gave off the odor of benzaldehyde.  


The following experiment was also made with a little of the
h. Stain with eosin.  
sulphate, which no longer gave the rose-red reaction with
iodine but which still contained a little of the coniine-like
substance. For two hours it was kept at 150° C. in a sealed
tube with 35 per cent, hydrochloric acid. On shaking out
with ether a considerable crystalline residue was obtained
which, without much purification, melted sharply at 130° C.
and had all the properties of benzoic acid.  


In the above decomposition experiments the quantity of
i. Transfer to 95 j)er cent, alcohol.  
material at command was small, perhaps not more than onefifth of a gramme at a time, and not entirely pure. We do
not, therefore, lay much stress on our failure to detect pyridine.  


The fact that the nitrogen of our compound is given off in
j. Pass through absolute alcohol, then through either creasote or oil of cloves, and mount in Canada balsam.  
the form of amines and pyrrol gives strong ground to believe
that our substance is to be classed with the pyridine bases,
using this term in a broad way. Its basic character, its
ability to take up acid radicles, as illustrated by the formation
of a benzoyl product, its reducing power and its color reaction
with ferric chloride are all points which can be urged in support of this view. Furthermore, cupric acetate, the serviceableness of which as a precipitant of carbo-pyridine bases has
been shown by Gautier and Landi,* also precipitates our
active principle; and iodine chloride, which Dittmarf found
to give brown or yellow halogen addition-derivatives with a
large number of the alkaloids, gives with a neutral or slightly
acid solution of our active sulphate a brownish flocculeut precipitate.  


Of less weight in this connection, but nevertheless of some
The blood is lost in frozen sections. To overcome this Prof.
value, is the fact that its physiological action and its power in  
Welch suggested that the sjiecimen be first fixed in formalin
small doses is again in accord with what is known of alkaloids. Strychnine, thebaine and other alkaloids are readily
and then frozen. I tried this aud found that we were able
called to mind as able to raise the blood pressure, and recently
to preserve the blood, but that it did not stain very distinctly.
TunnicliffeJ has placed piperidine in the same list. The  
For convenience this second procedure will be called method
II. The essential factor is the same in each case. The latter
process, however, requires at least two hours. A small piece
of the tissue is thrown into 10 per cent, solution formalin for
two or three hours. It is then put on the freezing microtome
and thin sections can be readily made. The sections are
stained in the usual way. The detailed procedure of method
II is as follows:






•Compt. rend., cxiv (1892), 1154-1159.  
*The sliglit modification of Method 1, recently suggested by L.
Pick, Centralblalt f. Gyn., Bd. XX, S. 1016, 1896, I cannot recomirieiul. When first experimenting with formalin, among other prolures I tried staining the sections after hardening in the formalin
I before placing them in alcohol, as Pick now suggests. The
ifsulls were fair, but the definition so obtained was not to be compared with that gained by first passing through 60 per cent, and
absolute alcohol for the short period. I accordingly abandoned it
and did not think it worthy of publication.  


fBerichte d. deutscb. chem. Gesellsch., xviii, 1612.


tCentralbl. f. Physiol., x, No. 25, 777.


Metliod II. a. A piece of tissue lx.5x.2 cm. is placed in 10
per cent. aq. sol. formalin for 3 hours. Rinsed in water.


1). Frozen sections are made.


pyrrol* bases are also physiologically active, although less
c. Left in 50 per cent, alcohol 3 minutes.*
attention has been paid to them.  


Pyrocatechin cannot be split off from the
(/. In absolute alcohol 1 minute.  
Blood-Pressuke-Raising Constituent.  


As already said, Miihlmann has stated with great positiveness that the blood-pressure-raising constituent is pyrocatechin joined to some other substance, probably an acid. Miihlmann does not offer sufficient proof for his conclusion ; and  
e. The sections are now run through water and stained in  
even had he proved the presence of pyrocatechiu in the gland
hsematoxylin for 3 minutes.  
itself, this is a very different thing from showing that it enters
into the chemical constitution of the blood-pressureraising
constituent.  


We have repeated Miihlmann's work and have found that
/. Decolorized in acid alcohol.  
after boiling the medullary substance with hydrochloric acid,
the ether takes up a trace of Vulpian's substance, as well as a
substance that reduces Fehliug's solution.  


The ether residue also gives a precipitate with neutral lead
g. Rinsed in water.  
acetate which, on decomposition with dilute sulphuric acid,
sets free a compound that gives with ferric chloride the reaction so characteristic of pyrocatechiu. Our blood-pressureraising constituent is not precipitated by lead acetate and
could not, therefore, have been responsible for this result.  


Furthermore, on decomposing a fairly large quantity of the
/;. Stained in eosin.  
crude benzoyl product before referred to and shaking out the
resulting benzoic acid with ether, we have twice found that
the ether has taken up in addition to the benzoic acid a small
quantity of a substance which reduces Fehling's solution and
gives a precipitate with neutral lead acetate. On decomposing
the resulting lead compound with dilute sulphuric acid and
neutralizing the filtrate, we obtained a solution which
behaved with ferric chloride in the way characteristic of pyrocatechiu. The quantity of this lead compound obtained has
been too small for analytical purposes.  


We consider it, therefore, still uncertain whether or not a
/. Transferred to 95 per cent, alcohol.  
little pyrocatechiu is present in the gland.  


That the blood-pressure-i-aising constituent is, however, not
j. Passed through absolute alcohol, then either through
a pyrocatechiu derivative seems to us certain. To prove this
creasote or oil of cloves, and mounted in Canada balsam.  
we used, not the entire gland nor the medullary substance,  
but the active principle itself, as isolated by us by decomposing the benzoyl compound.  


We have used large quantities of material representing in  
For ordinary use method I is all that is required. Given a
each experiment the active principle of several thousand
piece of tumor from the operating room, it is possible to give
glands. We have boiled this with hydrochloric acid of varying strength and for varying lengths of time, and in no case
as definite a report in 15 minutes as one would be able to give
have we been able to find in the ether used as a solvent any
after examining the alcoholic or Miiller's fl.uid sjjecinieus at
trace of a substance that would reduce Fehling's solution or
the expiration of two weeks. Method II is of especial value
give a precipitate with lead acetate. Inasmuch as some of the  
in the examination of uterine scrapings. Instead of putting
chromogenic substance always passes into the ether from acid
them in the 95 per cent, alcohol in the operating room, they
solutions, these two reactions are both necessary to establish
may be immediately dropped into 10 per cent. aq. sol. formalin.
the presence of pyrocatechin. In other words, we have failed
By the time the pathologist receives them, which is at least
to split off pyrocatechin from the active principle as isolated
two hours afterwards, they are firm enough to be frozen without difficulty, and permanent sections can be immediately
by us. If present, it could hardly have eluded our search,  
made. The second method is to be recommended for all delicate tissues. In employing these methods one must remember,  
for even a minute quantity may be made to give a precipitate
as for example in epithelioma, that some of the cell-nests will
with neutral lead acetate.  
drop out, there not being anything to hold them in situ, as  
there is when celloidin is used. AYe have, however, hardened
and stained epithelioma of the cervix by this method without
the slightest difficulty.  






*Jac. Ginzberg, Ueber das Verhalten des Pyrrols, etc., luaug.
NOTICE.  
Diss., Konigsberg, 1890.  


All inquiries concerning the admission of free, part pay, or
private patients to the Johns Hopkins Hospital should be addressed
to Dr. Henry M. Hurd, the Superintendent, at the Hospital.


Letters of inquiry can be sent, which will receive prompt answer,
or personal interviews may be held.


15G
Under the directions of the founder of the Hospital the free beds
are reserved for the sick poor of Baltimore and its suburbs and for
accident cases from Baltimore and the State of Maryland. To
other indigent patients a uniform rate of $5.00 per week has been
established. The Superintendent has authority to modify these
terms to meet the necessity of urgent cases.


The Hospital is designed for cases of acute disease. Cases of
chronic disease are not admitted except temporarily. Private
patients can be received irrespective of residence. The rates in
the private wards are governed by the locality of rooms and range
from $20.00 to $35.00 per week. The extras are laundry expenses,
massage, the services of an exclusive nurse, the services of a
throat, eye, ear and skin or nervous specialist, and surgical fees.
Wherever room exists in the private wards and the condition of
the patient does not forbid it, companions can be accommodated at
the rate of $15.00 per week.


One week's board is payable when a patient is admitted.


JOHNS HOPKINS HOSPITAL BULLETIN.
DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL  


Bv John s. lin.i.iNos, M. D., LL. D.
C.mtalulng 60 Urgo cjuartu pl.-iiofl, phototyDOS, and llth<.gi-apli», wli.h vIbwb
lilaua and detail drawings ot all tUo bulldiugs, aud Uielr liuerl"!- arranguniouts—
also wood-cuts of apparatus and flxtures; also U6 pages of letter-press describing
the plans followed In the cnnstruoUou, and giving full details ot heatlug-apparatua,
ventilation, sewerage and plumbing. Price, bound In cloth, $7.50.




[No. 76.






We propose during the coming autumn to continue this
PROCEEDINGS OF SOCIETIES THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.  
work. Having made arrangements for the use of a large
amount of material, we hope to secure both the benzoate and
the sulphate in a form pure enough for analysis and for
further chemical study.  


(Summary.  
Meeting of December 7, 1896.  


We may sunnnarize the results of our work as follows :
Dr. Thayer in the Chair.


The blood-pressure-raising constituent of the suprarenal
Typlioid Perforation treated by Surgical Operation.— Dr.  
capsule may be completely precipitated fi-om an aqueous
extract by treatment with benzoyl chlorideand sodium hydrate,
according to the Schotten-Baumann method.  


On decomposing the resulting benzoyl products, a residue
FiNNKY.  
is obtained which possesses great physiological activity. It
gives the color reactions of Vulpian, reduces silver nitrate
and possesses the other specific qualities of suprarenal extracts.  


AVith the help of alkalies a carmine-red pigment may also
In 1762 Richter, in Vienna, first suggested the advisability
be separated from these decomposition products. We take
of oiJeuiug and draining the peritoneal cavity in cases of general suppurative peritonitis. The operation did not come to
this pigment to be that one of the chromogenic substances
general notice, however, until 1884, and was not applied to
of Vulpian which gives the rose-carmine color when suprarenal extracts are treated with oxidizing agents or alkalies.  
cases of suspected perforation of the intestine in typhoid fever
until 1887. Since that date 46 cases have been reported, to
which may be added 6 unpublished cases, including 3 of Dr.
Finney's, making a total of 53.  


A volatile, basic substance of a coniiue-like odor is always
According to statistics taken from various sources, perforation of the intestine occurs in from 1 per cent, to 2 per cent.
found to accompany the crude benzoate. When these substances ai'e removed the active principle is left as a highly
of all typhoid fever cases. In 80 per cent, of the cases it
active sulphate or hydrochlorate, as the case may be. It is  
occurs in a thickened and iutlamed Peyer's patch of the ileum,
therefore a basic substance. Its salts give a color reaction
from 2 cm. to 1 m. above the ileo-cascal valve. In over 12 per
with ferric chloride; they also reduce silver nitrate, but not
cent, it occurs in the large intestine, and in 5 per cent, in the  
Fehling's solution.  
appendix vermiformis. There is usually but one perforation.  
In twelve cases, however, multiple inflamed Peyer's patches
were observed. It occurs more often in men than in women ;
more frequently between the ages of 20 and 30 years, and usually during the third week of the disease. The duration of
life is usually short. In typhoid fever, perforation is always
followed by suppurative peritonitis, either general or local ;
howevei', peritonitis may arise during the fever without any
discoverable perforation. It occurs much more frequently in
mild than in severe forms, and the symptoms may be severe,
mild, or wanting. The most constant and characteristic symptom is sudden, severe abdominal pain, persisting with increasing
intensity ; there may be collapse, nausea and vomiting. A few
of the cases have shown chill, hiccough, a marked fall of temperature, and absence of the liver dulness. Owing to the great
difficulties of diagnosis it is impossible to get data as to the
number of recoveries without operation.
 
A study of the reports of the operations brings out the
following facts. The time between theonsetof the symptoms
of perforation and the oj)eration varied between 2 and 12 hours.
The condition of the patients at the time of operation was
usually markedly unfavorable. Ether and chloroform were
used about equally ; in one case both were used. The median
incision was the most common. Thirty-three of the cases
showed marked general septic peritonitis with foul pus and
exudate. Faecal matter was usually present, and the mesenteric glands opposite the ulcerated Peyer's patches were, as a  
rule, enlarged and softened. In the treatment, irrigation of
the peritoneal cavity was employed more often than simply
wiping. As regards the perforation itself, in 8 cases the edges
were incised before suturing; in 2 a wedge-shaped piece of the
bowel was removed, and in 1 the edges of the bowel were
stitched to tlie abdominal wound while an artificial anus was
established. Including all of the 52 cases, there have been 17
recoveries; but if doubtful cases are excluded, the result is


It is not j)ossible to split oft' pyj'ocatechin from this isolated
active principle. The fact that dry distillation causes the
appearance of amines and pyrrol in abundance, taken in connection with its ability to take up acid radicles, its reducing
power, its precipitability by cupric acetate and iodine chloride,
and its jihysiological action, lead us to conclude that our active
principle is to be classed with the pyridine bases or alkaloids.


Addendum, June 15, 1897.


Since the foregoing paper was read before the Association
13 recoveries from 47 cases,making a percentage of 27.65. In
of American Physicians on May 6, 1897, B. Moore has published a paper in the Jotcrnal of Physiology, vol. xxi, Nos.  
19 of the fatal cases autopsies were obtained.  
4 and 5, May 12, 1897, entitled, "On the Chromogen and on
the active Physiological Substance of the Suprarenal Gland."
In this paper it is suggested that the active principle may
be a pyridine derivative. Moore's conjecture is based, lirst,
on a formula calculated by him from a combustion analysis of Krukenberg, made with an impure, hygroscopic, noncrystalline residue obtained by merely decomposing and
drying a precipitate secured out of an alcoholic extract of the
gland with the help of basic lead acetate. The calculated
formula, the carbon content of which differs by 1.33 per
cent, from that actually found by Krukenberg, is CsHuNO.!,
and Moore points out that in it the ratio in which the elements
carbon and nitrogen stand to each other is the same as in
pyridine, CrHr.N. Now such a calculation, though suggestive
to the investigator, furnishes no proof of the presence of
pyridine, for Krukenberg could not possibly have had in hand
a chemical individual uncontaminated with other constituents of the gland. Krukenberg himself admits that his


These data are hardly sufficient for general conclusions, but
several points are brought out quite prominently in studying
the group as a whole. The best time for operation is apparently as soon as possible after the patient has recovered from
the shock attending the perforation. This is usually in a few
hours. There is a remarkable uniformity in the condition of
the peritoneum and viscera ; intense congestion, much feculent
pus and exudate, with distension of the bowel. As the ileum
is the usual place of perforation, it should be examined first ;
a suture should be taken over any suspicious-looking patches,
and the appendix should be removed if it be at all abnormal.
If the inflammation does not involve the whole peritoneal surface, irrigation with the necessarily mild fluids might tend to
spread the infection. In dealing with the perforation, to
excise the edges takes too long, and healing usually takes place
without. Should the wall be in such a condition as to make
suture impossible, it would be better to pull out the loop of
intestine and leave it until the patient had recovered from his
fever. The line of suture must be determined by circumstances; the mattress suture of Halsted is to be preferred.
Drainage should always be employed. The fact that in 8
cases a wrong diagnosis was made shows how little dependence
can be placed on the so-called characteristic symptoms. However, the systematic examination of the blood promises to be
of the greatest assistance. During typhoid fever there is no
leucocytosis, but immediately after a perforation a marked
increase in the number of white corpuscles occurs. Cabot
mentions a case of 8,300 before and 24,000 after ; in Porter's
case the figures are 6,500 and 10,600 ; in his (Dr. Finney's),
3,000 and 16,400.


Fitz has pointed out the striking similarity of the symptoms of typhoid perforation to those of inflammation of the
appendix. Dieulafoy recognizes two forms of typhoid appendicitis capable of producing peritonitis ; one, "peritonitis by
propagation," involving the lymphoid tissue of the appendix,
the other, " para-appendicitis," which is of the usual variety.


material was a mixture of unaltered pigment and its decomposition products. It is also certain that it was contaminated
The symptoms of peritonitis quickly follow perforation.  
with other constituents of the gland. This is proved by the  
Examination shows that pyogenic cocci, especially the streptococcus pyogenes, are rarely absent, indicating that they are
fact that basic lead acetate precipitates several of the constituents of the gland which pass into alcohol, and also by  
common inhabitants of the intestine. The Johns Hopkins
the fact that the analysed material contained 0.0(38 per cent,  
Hospital autopsy reports show in 4 cases a mixed infection of
of sulphur and from 1.18 per cent, to 1.44 per cent, of ash.  
streptococcus pyogenes and bacillus coli communis, in one a
pure culture of the streptococcus, and in one a pure culture
of the colon bacillus. The absence of the bacillus of Eberth
and Gaifky is probably due to its being destroyed by its more
active companions, streptococcus pyogenes and bacillus coli
communis. In Dr. Finney's third case pure colon bacillus
was found; in other cases the typhoid bacilli were present in
liver or spleen or in a peritoneal abscess.  


A second reason given by Moore in supj)ort of his conjecture is that when "some suprarenal extract was cautiously
As regards the incision, the median has obvious advantages
fused with caustic potash so as to avoid charring, the peculiar
in general, but if the abdominal muscles are too rigid, it is  
odor of pyridine was at ouce obtained." He admits that
lielter made over the part most often affected. Its length
proteids were present in this extract, and that jjyridine and
should always be amply suflicient. On the other hand, the  
its homologues arc formed in the destructive distillation of
proteids, but states that the experiment was "conducted so
as to avoid charring," and considers this a sufficient safeguard.
This experiment has also no value, for the odor of pyridine
can always be obtained when a mixture of dry, powdered
proteid and powdered caustic potash are fused together so as
to avoid charring. This experiment, therefore, must be made
with material entirely free of proteids. Since reading Moore's
paper we have fused a little of our active i)rinciple with
caustic potash, but have failed to detect pyridine. If present
in the molecule of the active principle, it is evident that larger
quantities of the material must be used to prove it. Only indisputable chemical proofs can establish the presence of Jiyridine ; the odor is not enough. We have frequently in various
manipulations with the active substance met with what we
took to be the odor of pyridine, but on shaking out with ether
and adding an ethereal solution of hydrochloric acid and
evaporating the ether we have been unable to detect pyridine
in the residue.


Description of the Tracings.


Fig. 1. Tracing. Dog aniesthetized with morj)hine ; curare
and artilicial respiration, both vagi cut. Injection of the
active sulphate, freed from the carmiuesubstanceaud coniinelike body, at X.


A =: running base line.  
May, 1897.]


i?z::time record.
Ill


(7 z= curve of the blood pressure, canula in the right carotid
artery.


Fig. 3. Tracing. C!onditions of the experiment as in Fig.
I. Injection at X of a highly active sulphate which still
gives the rose-carmine color with iodine water and still contains some of the coniine-like substance which does not raise
the blood pressure. The blood pressure is so high that the
mercury is driven out of the manometer.


Fig. 3. Tracing. Conditions as in 1. Injection at X of a  
time consumed in operation should be as short as possible.  
material which is still highly active although it had been
The autopsies showed that healing was always well under way.  
boiled with 5 per cent, sodium hydrate for one hour. In this
Death usually occurred from septic absorption, but the records
experiment a number of injections had already been made; the  
show some other complications, obstruction of the intestine, a  
pressure had fallen to the normal before the injection indicated at X was made.  
second perforation, defective drainage or an abscess. General
peritonitis makes a case very serious, but with operation the
chances are about 1 in 4. The treatment of a case of perforating typhoid ulcer involves three things: (1) Finding and
closing the perforation ; (3) emptying and cleansing the peritoneal cavity; (3) the establishment and maintenance of
effective drainage.  


DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL
For these ends the following method, employed in his (Dr.
Finney's) third case, has proved the most satisfactory. An
oblique incision, about 6 inches, is made in the right iliac
fossa. The Ciscum is found as a guide to the ileum (or
appendix); the coils of small intestine, beginning with the
ileum, are pulled out systematically. One assistant wipes
vigorously and thoroughly the coils with a gauze sponge
wrung out of hot salt solution as they are withdrawn, while
another keeps them covered with warm sterile gauze. If
necessary the entire small intestine is pulled out through
the wound and laid to one side, covered with warm gauze.
The peritoneal cavity is then wiped out thoroughly, and the
coils uncovered and irrigated outside the abdomen with hot
salt solution. They are then replaced in the abdomen. The
worst or sutured coil is placed with its suture next the
abdominal wound, and is packed about with strips of bismuth
gauze to insure good drainage. The abdominal wound is
closed tightly except a small opening for the gauze drain. In
case of distension the bowels should be moved early and
thoroughly by calomel in broken doses, followed by salts,
and if necessary, a high turpentine and soapsuds enema.
If stimulation is necessary, use hypodermics of strychnia,
enemata of hot black coffee, or transfusion of a quart or more
of the normal salt solution into the cellular tissues under
the breast.


IJy JOHN S. lili, LINOS, M. I)., LL. D.  
Finally, in summing up the experience of himself and
others, he concludes that (1) of all the so-called diagnostic
signs of perforating typhoid ulcer, most reliance is to be
placed upon the development during the third or fourth week
of an attack of typhoid fever, of severe, continued abdominal
pain, coupled with nausea and vomiting, and at the same time
a marked increase in the number of white blood corpuscles.  


Ctmtalnlng 56 largo quarto plates, phototypes, and lithographs, wlih views,
(2) The surgical is the only rational treatment of perforating typhoid ulcer. •
plaiiH iiutl ilotatl drawlugaof all the butldlugs.aiul their Interior arraugemeuts—
also wood-cula of apparatus aud Uxtures; also 116 pages of letter-press describing
the plans followed lu thecoustruollou, and giving full details of heatlug-apparatut,
veutUatlou, sewerage aud plumblug. Price, bound lu cloth, $7.oO.  


(3) There is no contraindication to the operation, surgically speaking, save a moribund condition of the patient.*


Case I. — Mr. M.,aged about fifty-five years, was taken sick about
October 15, 1894, complaining of headaclie, general malaise, pains
in limbs and joints, togettier with irritability of the bladder. Was




NOTES ON NEW BOOKS.


Anomalies and Curiosities of Medicine, being an encyclopedic collection of rare and extraordinary cases, and of the most striking
•Since the above was written one other case has been reported by
instances of abnormality in all branches of Medicine and Surgery,  
Armstrong, of Montreal (Montreal Med. Journal, Vol. XXV, No. 8,  
derived from an exhaustive research of medical literature from
1897). This case recovered from an operation for the relief of first
its origin to the present day, abstracted, classi fled and indexed.  
perforation. Twenty-four days later, however, a second, and four
By Georqe M. Gould, A. M., M. D.,and Walter L. Pyi.e, A. M.,  
days later a third perforation occurred, from the effects of which
M. D. With 295 illustrations and 12 half-tone and colored plate.s.  
the patient finally succumbed. Reference is also made to the fact
908 pp. (Philadelphia : W. B. Saunders, 1897.)
that two other fatal cases had occurred in that vicinity.  


Tliestatementof Gibbon that objects which are only singular without being pleasing may excite surprise but soon lead to satiety and
<iisgust, does not apply to this volume, which is thoroughly interesting from beginning to end. The attempt of the authors "to
briefly epitomize and to arrange in order the records of the most
curious, bizarre and abnormal cases thatare found in medical literature of all ages and all languages," has been most successful. The
book is thoroughly scientiflc in its treatment of the varied material
which has been gathered with an industry which calls forth admiration. The Urst six chapters will probably be read most generally
and relate to anomalies of conception, birth and development, and
are of special interest to the gynecologist, obstetrician and student
of legal medicine. Chapter seven relates to gigantism, dwarflshness, obesity and abnormal leanness, and the accompanying illustrations form a curious collection of anomalies suggestive of a dime
museum.


The chapter on longevity taxes one's faith rather more than any
other. Think of Henry Jenkins dying at the age of 169 years ;
Thomas Parr at 152 ; Jean Korinat 172 and his wife atl64, and ason
left an orphan by their untimely death at the tender age of 116 ;
Petretsh Zartan at 185 or 187 (authorities differing), who walked a
mile to the post ofiice a few days before his death to ask for alms ;
and many other well-authenticated instances of nearly equal age.


The chapter on anomalous mental and nervous diseases is so complete it is a matter of surprise that it does not include the history
seen on October 19 by his physician, Dr. Wesley C. Stick, of Glenville, Pa., to whom I am indebted for the notes of the case. " He
of the young man in Ohio who became totally blind at the age of  
gave an indefinite history of having felt badly for about ten days.
seven months, and who, while receiving an education at the school
He had at this time a temperature of 102° F., frequent micturition,
for the blind, in consequence of a fall, lost both hearing and speech.  
bowels constipated, pulse 100. Patient up and dressed ; was put to
After a time, his eyesight being restored by the fall, he was transferred to an establishment for the education of deaf mutes. Here
bed and bowels opened by enemata. In a few days temperature
eventually his hearing was suddenly restored, but epileptic attacks
came down to about 100° F., pulse to 90. Would not stay in bed.
developed which required hospital treatment, this time in an institution for the insane. This well-authenticated tale was published
Irritation of bladder ceased. Was getting along very nicely until
in considerable detail in one of the State repoits and deserves a  
the night of October 2(ith, when he was suddenly seized witli a
place in these annals. The chapter on Historic Epidemics is timely,  
violent pain in his abdomen while lying in bed. Was seen the  
especially the full account of the bubonic plagues of the middle
next morning. Pain in abdomen very severe, relieved somewhat
ages.  
by emptying the over-distended bladder through a catheter. He
 
had been unable to void urine during the night, although having
An excellent feature of the book is the judicial spirit shown by
frequent and urgent desire to do so. Several hypodermics of morphine were necessary, however, before he became easy. An enema
the authors. Facts are weighed and reasons are advanced for the  
was given with little result. His abdomen was moderately distended, and not very tender to the touch. In the evening of the same
conclusions which are reached. The book is well printed and
day he was seen again and found to have considerable pain, which was
finely illustrated and is worthy of a large success. Every chapter
relieved by a hypodermic. Had vomited some during the day. His
is of interest to every physician.
pulse was about 90 ; temperature 99° to 100° F. The following day,
October 28, he vomited frequently a coffee-ground-looking fluid.
On the fourth day, October 29, his condition remained about the
same ; he could get in and out of bed by himself (he was a largeframed, heavy man, weighing about 225 pounds) ; pulse regular and  
not above 90 ; cheerful ; the constant regurgitation of coffee-ground
fluid being the most troublesome symptom. On the next day,
October 30, he was able to sit up in bed, but his pulse had risen to
100 and his temperature to 100° F. Abdomen still not much distended nor very tender."
 
I saw him at eleven o'clock the night of October 30; his condition
then was fairly good, temperature and pulse about 100. Abdomen not
much distended, rather retracted ; muscles, especially the recti, very
rigid ; tenderness general, but not marked ; frequent and copious
vomiting of a dark brownish fluid ; countenance pallid and anxious.
The diagnosis was general peritonitis, cause unknown, probably
appendicitis, although Dr. Stick had from the first suspected
typhoid fever with a subsequent perforation of the intestine. The
patient had been exposed to typhoid contagion during a recent
visit.
 
As his condition was evidently becoming worse, it was thought
best to open the abdomen. The operation was accordingly performed, and under most disadvantageous conditions, about midnight, in a small log house, with very poor light. On opening the
peritoneum it was found to be everywhere intensely congested, of
a dark chocolate color ; the coils of intestine distended and covered
here and there with flakes of exudate. There was a considerable
quantity of turbid feculent fluid everywhere in the abdomen. A
perforation was found in the ileum, about six inches from the
cKcum, about one and a half centimetres in diameter, with sloughy
edges. These were turned in and sutured with Halsted's mattress
suture. The peritoneal cavity was cleansed as thoroughly as possible by sponging, the sutured coil irrigated with salt solution and
replaced. The appendix was found normal, save the inflammation
of its serous covering. The abdominal cavity was thoroughly
drained with strips of iodoform gauze, the ends of which were
brought out through the wound. The operation took about one
hour. His condition at the end was somewhat collapsed, but he
rallied under stimulation, administered hypodermically and by
rectum. He began to fail, however, and died about seven hours
after the operation. No autopsy.
 
Case II.— J. P. D., aged twenty-six years; single; American;
tailor; entered the Medical Ward of Johns Hopkins Hospital,
August 3, 1895. Family history is negative, except that his father
died of some intestinal trouble, the nature of which was unknown,
and one brother died, a year ago, of typhoid fever.  
 
Has had diseases of childhood and several attacks of chills and


Text-Book of Materia Medica, Therapeutics and Pharmacology.
By G. F. Butler, M. D. [Philadelphia: W. B. Saundem, 1896.)


This work is dedicated to the " Medical Students of the United
States," and we have no doubt that many of them who enjoy buying
the latest work on this branch of medicine will find it serviceable.
It cannot be said to replace the oliier works of Wood, Hare and
others. There is very little true original thought in it, which
should be the the real reason for the publication of any new book,
especially to-day, when there is altogether too much production of
simply transient works. As the author states in the preface :
" From the U. S. Pharmacopeia chiefly, and from the National Dispensatory, have been adopted almost verbatim, the ' origin ' and
'description and properties' of tlie various drugs under consideration," so it is more in his arrangement of his material that we must


112


[No. 74.


look for originality. He classifies the drugs by their properties,
rather than alphabetically, as is done by Hare. Both methodshave
their advocates, and [lersonally, as it is much the most rapid way to
look up any given drug, we prefer the latter method. Butler still
further cljftsifies the drugs into so called " Disease-Medicines," a
very unscientific term, as he himself recognizes, and "SymptomMedicines." In such a classification no two persons willagree as to
the class to which certain medicines will belong most properly, and
thus it becomes confusing and time-consuming to search for the drug
wanted. The author says: "A genuine specific is tolerated only
by the system in which it antagonizes some disease. For instance,
A and B are put under a prolonged course of mercury ; A is salivated
beyond recognition, while B's health improves — simply for the
re.ison that B had syphilis, which A had not." Such general
remarks are often not true, and the example given is a very poor
one, for we all know that syphilitic patients may be salivated, and
sometimes as severely as those who are not syphilitic. Also many
]>atients who have not sypliilis may take mercury in large doses for
long periods of time without becoming salivated. We do not
understand the following sentence: "Quinine was formerly considered a specific in malaria, until the fact was recognized that the
drug is analogous to a normal constituent of healthy bile in its
action upon plasmodia malariae." W^e believe that by most
authorities quinine is still considered to be a specific in malaria,
whatever the action of bile may be. In a work which covers so
much ground as this text-book, the value depends on an equal balancing of the different parts, and especially, in the description of
the drugs, of careful omission of all unnecessary parts, and still
more exact and concise information on all important points. Each
author naturally finds special interest in certain parts of his work,
and so not knowing these it is hard to criticise the book justly. But
in the 650 pages given to drugs and their actions we feel that much
improvement could have been made with careful revision — some
parts omitted, and other information of more importance added.
We think it quite out of place to introduce in such a work declensions of simple Latin words and other rules of Latin grammar,
which should be known by every student before he begins the
studj- of medicine, and if he does not know them, he should not be
helped to the knowledge in this superficial manner.


Diseases of the Ear, Nose and Throat. By S. P. Bishop, M. D.
(Philadelphia : F. A. Davis Co., 1897.)


This book, we think, fulfills pretty satisfactorily the object of the
fever at varying intervals. With these exceptions has been well.
author, as expressed in the preface; he says: "This work was
Smokes much, does not ilrink, denies venereal contagion. Present
designed, first to help students in preparing for their degree ; second, for those progressive practitioners who wish to acquire the
illness l)egan six days before entrance, with severe frontal lieadaches and a slight chill followed by fever. These symptoms have
proficiency necessary to properly treat those patients who are unable to visit specialists ; and third, for those who are gradually
persisted, together with anorexia ; no nose-bleed. For past two days,  
exchanging their general practice for special work in these
diarrhoea ; has vomited twice ; slight abdominal pain, especially
branches." The chapter on blood-serum therapy in diphtheria seems
before micturition. Temperature on admission, 103.8° F.; pulse,
out of place ; it is merely an abstract of a few of the articles which
92. Blood examination negative as to malarial organism ; abdomen
liave appeared on this subject during the past two years, and we see no
generally tender, slightly distended ; no rose spots ; spleen palpal)le. Leucocytes 3000 per cubic millimetre.  
good reason for introducing it here. The work on the whole is a
fair presentation of our knowledge in these diseases, without any
attempt to take up any of them at length. The treatment as given
is generally satisfactory and simple. We do not agree with the
author in considering hay-fever, or "nervous catarrh," as he prefers to call it, a result of uric acid diathesis. There are many
questions in the study of this disease which are as yet quite inexl)licable, and this theory of its causation is insufficient to explain
them all ; the neurotic character of the disease is well established,
and that uric acid may in some caees play an inijiortant role in this
nervous affection is undoubted, but it is also equally certain that
other important causes play their role too in determining this
malady.  


This book is clieaply gotten up and the cuts are of poor quality ;  
The patient's disease ran a more or less typical severe typhoid
tlie colored illustrations also seem very unsatisfactory. Many of  
course, up to August 16, a. m., thirteen days after entering the hospital, when the following note appeared in the medical history:
" Last night patient began to complain of a sharp pain at base of
penis, notrelieved by catheterization. Temperature has been rather
higher, reaching 105° F., pulse 108, regular, though soft and dicrotic.
Very nervous ; abdomen very tense, though not greatly distended.
Everywhere tympanitic ; complains of pain ; tenderness marked ;
tongue coated ; sweating profusely, and frequently cries out with
pain ; baths discontinued and cold sponging substituted." P. M.
" Patient has been comparatively quiet since a. m., but at about 4
p. m. liegan to cry out and complain of intense pain in abdomen.
Morphine administered hypodermically. Leucocytes, 16,400 per
cubic millimetre."


The patient was seen by me with Dr. Thayer at 9.30 p. m., and
operation decided upon.


Operatio7i. — Median incision. Peritoneal cavity filled with cloudy,
sero-purulent fluid. Peritoneum dark red and much congested.
Coils of intestine distended and covered here and there by flakes
of lymph. A single perforation, about one centimetre in diameter,
was found in the ileum, about sixteen centimetres from ileo-csecal
valve. It was situated, apparently, in the centre of a thickened
Peyer's patch, and had sharply punched-out edges. Numbers of
raised, red areas could be seen here and there along the lower few
feet of the ileum. The loop containing the perforation was drawn
out of the abdomen, carefully cleaned of the exuded lymph and
fiEcal matter, and the rent closed transversely with eight fine,
black-silk mattress sutures (Halsted's). Owing to the rigidity of
the abdominal walls and the distension of the bowels, puncture of
the intestine in several places was necessary, in order to allow of
the escape of gas. The loops of intestine were carefully cleansed
by irrigation with hot salt solution, and the entire peritoneal cavity
thoroughly wiped out with dry gauze. Iodoform gauze was used
for drainage, and the abdominal wound closed except where the
gauze drainage was brought out.


July, 1897.]
At end of operation, which lasted a little over an hour, the
patient was somewhat collapsed ; temperature 103.3° F. ; pulse, 150 ;
respiration, 56. He recovered from this somewhat, under vigorous
stimulation, and in four hours his temperature was 101.6° F.; pulse,
130 ; and respiration, 28. His condition did not change materially,
except that he became gradually weaker, and died twenty-six hours
after the operation. I regret to say tliat no bacteriological examination was made, and no autopsy allowed.  


C.\seIII. — Charles H., German, aged forty-seven years; married;
laborer; admitted to Johns Hopkins Hospital, .\ugust 15, 1896.
Family history good ; no cancer or tuberculosis. Has had the usual
diseases of childhood, since which time has been strong and well,
except an attack of malaria with chills and fevers eight years ago.
I'his attack lasted four weeks. Denies venereal disease; smokes
and drinks in moderation. One week before was taken ill with a
lieadache, general malaise, and loss of appetite, and later in the
day had a distinct chill, followed by fever. Next day felt somewhat better, but was weak and unable to work. He kept in bed
until his admission to the hospital one week later. During this
time had had several chills and more or less fever, appetite fairly
good, but had eaten nothing but liquids and soft solids. He had no




JOHNS HOPKINS HOSPITAL BULLETIN.


epistaxis nor vomiting ; no pain, nod-arrhoea, bowels had been regular. At about 8 o'clock on the evening before admission (August 14),
wliile at stool, he was seized with sharp, stabbing pains in right side
of abdomen, with marked tenderness to the touch. Nauseaand vomiting were present. His physician was called in and gave him morphine hypodermically, which relieved thepain. He passedafairly
comfortable night and was brought to the hospital early the next
a. m., when the following condition was noted :


Face pallid and expression anxious ; tongue coated, margin and
tip clean and red. Temperature, 101° F.; pulse, 116, regular and of
good volume. Lungs and heart negative ; alidomen is uniformly
distended, no undue prominence in any region noted ; skin normal;
tympanitic throughout ; rigidity of abdominal muscles throughout,
especially of the right rectus in its lower part. In iliac region
indistinct tumefaction felt ; tenderness general, but more markeil
over right lower quadrant. Rectal examination negative ; no eruption on skin ; urine showed nothing abnormal.


159
A diagnosis of beginning general peritonitis, jirobably due to
appendicitis, was made. I confess, at the time, the possibility of
perforating typhoid ulcer did not occur to me.


Immediate operation advised and agreed to. After the usual
])reliminary preparation the abdomen was opened through an
incision along outer border of right rectus. Abdominal wall distinctly cedematous. The peritoneum was everywhere intensely
congested, roughened and dull, with flakes of plastic lymph. In
the pockets between coils of intestine and extending down into
the pelvis there was an accumulation of thin, yellowish, turbid
fluid, containing flakes of exudate. There was no marked fsecal
odor to this fluid. The intestines were distended, congested, and
dark colored. In passing towards the median line and hypogastric
region the congestion and peritonitis became less marked, and in
the upper left quadrant the peritoneum seemed fairly normal. At
no place was there the slightest attempt apparent at walling off the
inflammatory process. The appendix was found in its normal
position, somewhat thickened and congested, and constricted at
about its centre, due to old adhesions. It was ligated, excised, and
stump covered with peritoneal cuflf. About fourteen inches from
ileo-cascal valve, in the ileum on its free border, a small hole, about
four millimetres in diameter, was found. It was sharply defined,
edges bright red and thickened. It was in the middle of what
appeared to be a swollen and enlarged Pej'er's patch. Soft yellow
ftecal matter was exuding from the opening. Opposite the ulcer
was a mesenteric gland enlarged to the size of an olive, soft and of
a bright red color. The loop of ileum was brought out through the
wound and packed about with gauze. The edges of the ulcer were
turned in and sutured with eight mattress sutures of fine black silk.
The edges of the ulcer were not excised. After suturing, the loop
was thoroughly cleansed with salt solution and dry gauze and
returned, the peritoneal cavity thoroughly and systematically wiped
out with pledgets of dry gauze. Some distance below in the ileum
a second swollen Peyer's patch could be made out. Bismuth gauze
in strips was packed loosely about the sutured portion, and theends
brought out through the lower end of the incision. Tiie rest of it
was closed with buried sutures of silver wire. The wound was
dressed with silver foil and sterile gauze. His condition at the end
of the operation was good. Time of operation one and a half hours.
Pulse, 120, and of good volume ; respiration. 20 to 25, regular ; color
good ; no sweating or coldness of extremities. Shortly after operation an enema of several ounces of black coffee and peptonized milk
given.
August 16. Patient passed a fairly comfortable night. Pain not
so severe as before oi>eration ; very little ^listension ; says he feels
better. Temperature and pulse still somewhat elevated, 102° F. and
110 respectively. liis general condition improved steadily forabout
a week, when his temperature and pulse began to go up a little.
His tongue became more coated, but abdomen not distended nor
tender. Spleen not palpable ; no rose spots. An offensive discharge




the cuts are reproductions of instruments wliich by this time should
be l^nown to all practitioners and to every student graduating from
a medical college. These simply add to the expense of the book
without adding to its intrinsic value.
Essentials of Physical Diagnosis of the Thorax. Second Edition.
By Arthur M. Cokwin, M. D. (Philadelphia: W. B. Saunders,
189a.)
That there is a demand for such a quiz-compend or aid in cramming for an examination is shown by the fact that a second edition
of this small book has been called for. We cannot recommend it,
however, for like other similar works it fails in attempting to condense much knowledge in a very limited space and although tolerably well arranged, there are numerous statements of fact with
which we cannot agree. The varieties of tympany (p. 69) are confusing and not generally used and were better omitted in such a
work. In the discussion of heart murmurs there is much needless
repetition, and on p. 176 the mitral systolic murmur described
as occurring in aortic insufficiency, otherwise known as Flint's
murmur, is presystolic in time. The chapter on congenital lesions
of the heart is treated too briefly to be of service, as is also the one
on hydatid cyst of the lung, which, when jiriniary, is not a condition easy to diagnose, nor could the signs of it as given by the author
differentiate it from pleurisy. 8pasm of the columnar carnese is a
condition which may occur, but it is hardly one of which a diagnosis could be made. Acute endocarditis without valvular lesion
is not a condition which can be recognized clinically, and inorganic
aortic systolic murmurs should usually be doubted. The ratio of
the inspiratory sound to the expiratory is not as tiiree to one, nor
in asthma is the dyspnosa (orthopncea) chiefly expiratory. CheyneStokes respiration does not ordinarily accompany opium poisoning.
No worse instrument for clinical instruction could well be devised
than the multiplex stethoscope, of which there is an illustration
in the beginning of this work.
Pathological Report of the Illinois Eastern Hospital tor the I
(Chicago: Blakely rrinting Co., 1896.)
This is an excellent report, full of much valuable mateiial, and
Dr. Adolf Meyer deserves much credit for it, considering the difficulties under which the work was prosecuted, due to a lack of general facilities for carrying it on. We cannot criticise any shortcomings when we read his closing remarks. He says: "It may
justly be said that the publication of so much raw material is of
little use. To polish the report, away from the records and the
material, did not seem to he in the interest of the accuracy of a
picture of the working of the laboratory which had barely come
into existence at the end of the period covered. The work was
planned on a broader basis than it was feasible to carry out in the
short period. The idea was that the plan of publishing ' interesting' cases only was not in the interest of sober study of the daily
experience, that selecting cases might lead to illustration of preconceived ideas instead of the facts as they present themselves in
reality, and that at the present stage of psychiatry a consideration
of all the things seen wouM be less dangerous than arbitrary selection. The same jirinciple should be carried out in the clinical side
as well." Although much of the material is raw, yet many facts of
interest are to be found — perhaps the most interesting being that 32
per cent, out of 49 cases of terminal dementia, and 27 per cent, of
192 cases of mental diseases, including the first series, died of florid
tuberculosis. Of course without fuller statistics as to the class of
patients in the hospital, too much stress should not be laidon these
figures, but nevertheless the percentage is high. A case of acute
mania, dying presumably of sulphonal poisoning, shows the necessity of the utmost care being used in the administration of drug.ito
patients with mental diseases to avoid accidents of this sort. We
shall await with pleasure sui cessive reports from Dr. Meyer, who
has now transferred his work to the Worcester State Hospital and


May, 1897.]


113


nsane.




of pus from the right ear indicated an otitis media. About this
time a severe pain in the lower part of left thorax developed. Auscultation detected a slight friction rub beginning just below the
nipple and running into axillary line.


Clark University, and trust he will be able to describe some of the  
Blood cultures aspirated from spleen were negative. His temperature and pulse almost reached the normal on August 28, and
finer microscopical findings in brain and cord lesions from the interesting material at his disposal.  
remained there for a week, when a sharp rise, accompanied by a
chill, occurred. His second relapse was quite a severe and prolonged one, so much so that he was transferred to Dr. Osier's ward,
where he could be given the cold-bath treatment more conveniently.
On September 14 the following note was made by Dr. Osier:
" Tongue a little dry ; temperature has been continuously elevated
since Septembers. Between 6th and 9th not above 100° F. Since
9th above 101° F. On the 12th and 13th, 104°, and on 14th,
105° F.; pulse, 128. Complains of pain in abdomen, which is fiat
and natural looking. Respiratory movements well marked ; no tension ; everywhere soft. Pain referred to hypogastric region and
about navel. Edge of spleen not palpable." During the ten days,
from September 17 to 27, his temperature ranged about 103° F.,
occasionally going above 104° F. He was given thirty-eight tubbaths during this period. It reached the normal on October 6, and
remained there.  


St. Thomas's Hospital Reports. New Series. Vol. XXIV. i London,  
During this time he developed great tenderness in the toes of
both feet, and extending up the front of right leg to the knee
was some redness and stiffness. This gradually subsided. Several
small furuncles on buttocks and sacrum appeared, which were
opened. On October 23 he was well enough to be up for the first
time. Improved steadily up to November 2, when a phlebitis of
right femoral vein with pain and swelling of leg developed. This
gradually subsided, and he eventually made a perfect recovery.


1895.)
Cultures taken at the time of operation from the peritoneal
cavity and edges of ulcer showed pure culture of bacillus coli communis.  


The first half only of this volume is taken up with detailed
Dr. OsLER. — It may interest you to know of the number of  
papers, and the second half with statistics of the different departments of the hospital, and brief abstracts of cases, medical and
cases of perforation in our series. Since the hospital opened
surgical. Among the papers here preseuted, two are worthy of
we have had about 530 cases (I have not the exact figures for
special note. The article on " Osteo-arthropathy and its Relationships," with report of a case of pulmonary hypertrophic osteoarthropathy, both by Dr. Walters, is a very valuable contribution
this year) of typhoid fever, with 48 deaths, of which 16 occurred from perforation. The percentage of death from this
to our knowledge of this curious condition and its relationship to
cause is unusually high, for I think Dr. Finney mentioned it
akromegaly. It is an exhaustive study, with a brief abstract of all
was the cause of death only in about six per cent, of the fatal
the cases reported of this bone disease up to the time of the publication of this volume. The other paper is on "Enteric Fever and
cases.  
Sewage Gas," in which 11 cases of typhoid fever are described as
resulting from poisoning with sewer gas in one hospital within a
short space of time. Here milk, water and food as possible sources
of the contagion could apparently be eliminated without doubt, and
the only other discoverable source was a water-closet into which
typhoid organisms had probably been discharged but a few weeks
before the outbreak of this small epidemic, which ceased as soon
as the sewage pipes were overhauled and modified. With the
modern belief that typhoid fever in nearly every case re>ult8 from  
milk, water or food contaminated by the typhoid organism, this
epidemic raises the most interesting question as to whether or not
typhoid bacilli may enter the body through the lungs and thus
cause the fever. There are other articles on tuberculous disease in  
the knee-joint, and relapse in the si)ecific fevers, which will repay
careful reading.  


Feeding in Early Infancy. By Arthur V. Meigs, 51. D. (Vhiladelphia: W. B. Saunders, 1896.)
That two of Dr. Finney's cases were supposed to be appendicitis is a point of great interest. It is not the first nor will it
be the last time that this mistake has been made. There are
instances in which patients with typhoid fever without perforation have been operated upon for appendicitis with a fever
of five or six days' duration and a swelling in the right iliac
fossa. Patient has been admitted to the hospital, operated
upon for apjiendicitis, no perforation found, but an enlarged
ileum and swollen mesenteric glands. It is to be borne in
mind, however, how frequent is perforation of the appendix
among cases of perforation in typhoid. We have had at least
four or five in our cases. There have been two cases of recovery in which symptoms of appendicitis in typhoid seemed very
clear.  


In this paper Dr. Meigs emphasizes the results of his milk
One word as to the time of the operation. This case was unusually favorable inasmuch as it was seen early and the perforation occurred before the 8th day, which is, perhaps, as soon as
analyses as expressed in his earlier publication, and describes in
ever it occurs in typhoid fever. I think the very early and  
detail the preparation of his food, based on these results.  
the very late cases will probably be the most favorable for
operation. The statistics that Dr. Finney gives are certainly
most encouraging.  


He finds that human milk never contains more than one percent,
casein, cow's milk three times this amount, other constituents
being present in about equal quantities. In his preparation cow's
milk is therefore diluted with lime water, and cream and sugar
added in definite proportions. The food, piepared after this
manner, has been used for a number of years by the author, with
satisfactory results.


He thinks thatsulijecting milktohightemperaturesdetracts from
its usefulness as an infant food ; therefore it is better to be assured
of its source and avoid sterilization.


This course seems hardly practicable, and the injurious effect
NOTES ON NEW BOOKS.  
accredited to sterilization is not sustained by most writers on the
subject.  


Proceedings of the American Medico-Psychological Af-sociation
Transactions of the American Pediatric Society, held at Virginia
at the 52d Annual Meeting, held in Boston, May 26-29, 1896.
{American Medico-Psychological Associaiion, 1896.)


The proceedings of this society occupy nearly 300 large papers,  
Hot Springs, May 27, 28, 29, 1895. Edited by Floyd M. Cran
pretty closely printed ; but all the papers are good, while some are
DALL. (Philadelphia, 1896. Reprinted from the Archives of  
of especial value. There is an interesting address on psychological
education by Stanley Hall, a leading authority on such a subject;
and there are important contributions by Brush, Worcester, Hoch,
and Berkley. The paper by Hoch, on " General Paralysis in Two
Sisters," is perhaps, while one of the most thorough articles, the
one of most general interest. To students who have given much
time to the study of the blood, the paper on " Leucocytosis Associated with Convulsions," by Burrows, will open up a point of much
interest as to the cause of leucocytosis, whether or not it be due to a
form of auto-intoxication.


Pediatrics.)


The meetings of this society are characterized by the practical
papers presented and the general discussion of them by the members present.


160
The present report of its seventh session contains a number of
articles relative to the more important diseases of infancy and childhood, with discussion of many of the newer remedies. The list of
contributors includes many of the best-known writers on the subjects mentioned.


The treatment of diphtheria with antitoxin as an immunizing
agent, and its toxic effects, are especially dwelt upon. A resolution
was finally adopted that in the opinion of the society the evidences
thus far produced of the beneficial action of this remedy justify
its further and extensive trial.


Several papers on anomalous forms of scarlet fever and eruptions
simulating this disease, and one on the use of icthyol ointment for
the local treatment of the eruption of scarlet fever, are worthy of
special notice.


JOHNS HOPKINS HOSPITAL BULLETIN.  
With regard to the use of the antitoxin of tetanus in tetanus of
the newborn, the evidence seems to show that up to this time it
is uncertain in its action, and that chloral hydrate with one of the
bromides is to be preferred.  


The antitoxin of erysipelas seems to have had no influence in
treatment of sarcoma of the kidney, but the author of the paper is
inclined to the view that any foreign substance injected into or near
the substance of a sarcoma tends to effect a cure, by setting up
degenerative changes in the neoplasm, hence the apparent favorable
action of erysipelas antitoxin in sarcomata which are external
and accessible, and its failure in visceral sarcomata.


There are also papers on purulent otitis media, " inanition " fever
in the newly born, the frequency of typhoid fever in children
under three or four years, hyperpyrexia, pygopagus, the neuroses of childhood, tetany, symmetrical gangrene following scarlet
fever, angina resembling diphtheria with absence of the bacillus,
cardiac anomaly, and the association of enormous heart hypertrophy, chronic proliferative peritonitis and recurring ascites
with adherent pericardium, in which the view is expressed of
the probable progress of the chronic proliferative process along
the veins, through the diaphragm, until it involves the peritoneum.


[So, 76.  
The report is in good type, well edited and arranged.  






PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.  
BOOKS RECEIVED.  






THE JOHNS HOPKINS HOSPITAL REPORTS.  
A Collection of the Published Writings of William Withey Oull, Bart.,
Volume I. 423 i>ages, 99 plates.  
M. D., F. R. S. Edited by Theodore Dyke Acland, M. D. Memoir
and Addresses. 1806. 8vo. 184 pages. The New Sydenham
Society, London.  


Report in Pntliologry.  
Proceedings of the American Medico-Psychological Association, at the
Fifty-Second Annual Meeting, held in Boston, May 26-29, 1896. 8vo.
332 pages. Published by American Medico-Psychological Association.
 
Saint Thomas's Hospital Reports. New Series. Edited by Dr. T. D.
Acland and Mr. Bernard Pitts. . Vol. XXIV. 1897. 8vo. 510 -i118 pages. J. and A. Churchill, London.
 
Archives of Clinical Skiagraphy. Edited by Sydney Rowland, B. A.
Camb. Vol. I, No. 3, December, 1896. Fol. The Rebman Pub.
Co., Limited, London.
 
Pathological Report Illinois Eastern Hospital for the Insane. 1896.
8vo. 236 pages. The Blakely Printing Co., Chicago.
 
Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and
America. Edited by T. L. Stedman, M. D. Vol. IX. Diseases
of the Digestive Organs. 1897. 8vo. 820 pages. William Wood
& Co., New York.
 
 
 
114
 
[No. 74.  


The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;  
 
 
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.
 
 
 
THE JOHNS HOPKINS HOSPITAL REPORTS.
Volume I. 423 pages, 99 plates.
 
Report In Patliologry.
 
The VesselB 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  
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the  
Line 18,172: Line 19,398:
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis  
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis  


(Atrophy). By Henry J. Berkley, M. D.  
(Atrophy). By Heney J. Berkley, M. D.  
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.  
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By P. P.  


Mall, M. D.  
Mall, M. D.  


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


T. C. Gilchrist, M. D., and Emmf.t Rixford, M. D.  
T. C. GlLCHKiST, M. D., and Emmet RliroRD, M. D.  
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of  
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of  


Protozoa, and the Blastomyces found in the preceding Cases, with the BO-called  
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 MoUuscuni
Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum


Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By  
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By  
Line 18,191: Line 19,417:
T. C. Gilchrist, M. D.  
T. C. Gilchrist, M. D.  


Report In Patholog^y.
Report In PatliologTAn Experimental Study of the Thyroid Gland of Dogs, with especial consideration  
An Experimental Study of tin' Thyroid Gland of Dogs, with especial consideration  


of Hypertrophy of this Gland. By W. S. Halsted, M. D.  
of Hypertrophy of this Gland. By W. S. Halsted, M. D.  
Line 18,200: Line 19,425:
Volume II. 570 pages, with 28 plates and figures.  
Volume II. 570 pages, with 28 plates and figures.  


Report in Meillcine.  
Report In Medicine.  


On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with  
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with  
Line 18,206: Line 19,431:
Gallstones. By William Osler, M. D.  
Gallstones. By William Osler, M. D.  
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.  
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.  
On Pyrodin. By H. A. Lafleur, M. D.  
On Pyrodin. By H. A. Laelecr, M. D.  
Cases of Post-febrile Insanity. By William Osler, M. D.  
Cases of Post-febrile Insanity. By William Oslbk, M. D.  
Acute Tuberculosis in an Infant of Four Months. By Harry Toulmin. M. D.  
Acute Tuberculosis in an Infant of Four Months. By Hahkt Todlmin, M. D.  
Rare Forms of Cardiac Thrombi. By WtLLiAM Osler, M. D.  
Rare Forms of Cardiac Thrombi. By William Osler, M. D.  
Notes on Endocarditis in Phthisis. By William Osler, M. D.  
Notes on Endocarditis in Phthisis. By William Osler, M. D.  


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


Report in Gynecology.  
Report in Gynecolosry.  
The Gynecological Operating Room. By Howard A. Kelly, M. D.  
The Gynecological Operating Room. By Howard A. Kelly, M. D.  
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard  
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard  


A. Kelly, M. D.. and Hunter Robh, M. D.  
A. Kelly, M. D., and Hunter Robb, M. D.  
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of  
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of  


Line 18,230: Line 19,455:
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;  
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;  


Ovarian Tumor; General Gynecological Operations from October 15, 1889, to  
Ovarian Tumor; General Gynecological Operations from October 16, 1889, to  


March 4, 1890. By Howard A. Kelly, M. D.  
March 4, 1890. By Howard A. Kelly, M. D.  
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howasd
Report of the Urinary Examination of Ninety-one Gynecological Cases. By HowABD


A. Kelly, M. D., and Albert A. Ghrisket, M. D.  
A. Kelly, M. D., and Albert A. Ghriskey, M. D.  
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking  
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking  


Line 18,241: Line 19,466:
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.  
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.  
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.  
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.  
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.  
Myxosarcoma of the CHitoris. By Hunter Robb, M. D.  
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment  
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment  


Line 18,248: Line 19,473:
Howard A. Kelly, M. D.  
Howard A. Kelly, M. D.  


Report in Snri;:ery, I.  
Report In Snrgery, I.  
The Treatment of Wounds with Especial Reference to the VaUu^ of the Blond Clol
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot


in the Management of Dead Spaces. By W. S. Halsted, M. D.  
in the Management of Dead Spaces. By W. S. Halbted, M. D.  
Report in tVenrologT-, I.  
Report in Neurology, I.  
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.  
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.  
.\cute Angio-Ncurotic Oedema. By Charles E. Simon, M. D.  
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.  
Haematomyelia. By August Hoch, M. D.  
Haematomyelia. By AoonsT HocH, M. D.  
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By  
A Case of Cerebrospinal Syphilis, with an unusual Lesion in the Spinal Cord. By  


Henry M. Thomas, M. D.  
Henry M. Thomas, M. D.  


Report in Patbolo^y, I.  
Report in Patlioloery* I.  
Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.  
Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafledk, M. D.  






Volume III. 706 pages, with 69 plates and figures.  
Volume III. 766 pages, with G9 plates and figures.  


Report in Patholosry*
Report in Patliology.


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


Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D.  
Report in Piitliologry*
Report in Pathology.


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


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


A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.  
A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.  
Line 18,284: Line 19,509:
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  


Report in Gynecology,
Report in Gynecology.


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


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


Intestinal Worms as a Complication in Abdominal Surgery. Bj A. L. Stavklt, M, D.  
Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavely, M. D.  
 




Gynecological Operations not involving Cceliotomy. By Howard A. Kelly, M. D.


Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. D.
Tabulated by A. L. Stavely, M. D.  
Tabulated by A. L. Stavely, M. D.  
The Employment of an Artificial Retroposition of the Uterus in covering Extensive  
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.


Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdo
minal Pelvic Operations. By Howard A. Kelly, M. D.
Photography applied to Surgery. By A. S. Murray.  
Photography applied to Surgery. By A. S. Murray.  
Traumatic Atresia of the Vagina with Haematokolpos and Hxmatometra. By Howard


Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howard
A. Kelly, M. D.  
A. Kelly, M. D.  
Urinalysis in Gynecology. By W. W. Russell, M. D.  
Urinalysis in Gynecology. By W. W. Russell, M. D.  


The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.  
The Importance of employing Ansesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.  
 
Resuscitation in Cihloroform Asphyxia. By Howard A. Kelly, M. D.
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.  
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.  


<)ne Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.  
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.  
Abdominal Operations performed in the Gynecological Department, from March 5,  
Abdominal Operations performed in the Gynecological Department, from March 5,  
1890, to December 17, 1892. By Howard A. Kelly, M. D.


1890, to December 17, 1892. By Howard A. Kelly, JI. D.
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to  
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to  
May 4, 1892.  
May 4, 1892.  


Line 18,330: Line 19,554:
Report on Typhoid Fever.  
Report on Typhoid Fever.  


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


Line 18,337: Line 19,561:
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The  
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The  
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the  
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the  
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of Mu^ miisruln.^; The Intrinsic Nerves of the Thyroid Gland of  
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of J/«s mitsculus; The Intrinsic Nerves of the Thyroid Gland of  
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley.
the Dog: The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,
M. D.  
M. D.  


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


Report in Gynecolof^y.  
Report in Gynecology.  
Hydn)salpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;  
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;  
Tuberculosis of the Endometrium. By T. S. Ctllen, M. B.  
Tuberculosis of the Endometrium. By T. S. CtlLLEN, M. B.  
Report in Patlioloe^y.  
Report In Pathology.  
Deciduoma Malignum. By J. Whitridge Williams, M. D.  
Deciduoma Malignum. By J. Whitridoe Williams, M. D.  






\\)LUME V. 480 pageSj with 32 charts and illustrations.  
Volume V. 480 pages, with 32 charts and illustrations.  


CONTENTS:  
CONTENTS:  
Line 18,359: Line 19,583:
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  


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




Line 18,367: Line 19,591:
Volume VI. About 500 pages, many illustrations.  
Volume VI. About 500 pages, many illustrations.  


Report in Nenrolojsry.  
Report In Neurology.  


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


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


Report in Pntliologry.  
Report in Pathology.  


Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. Bv Thomas S.  
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.  


<'l-LLEN. M. B.  
CULLEN, M. B.  
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of


fii^aiancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of
Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins, M. D.  
 
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. C^ullen, M. B.  
Ovum and Spermatozoa. By Thomas S. Cullen. M. B., and G. L. Wilkins. M. D.  
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By  
Adciio-Myoma Uteri Diffusum Benignum. By Thomas S. Cttllen, M. B.  
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infanta. By  


William D. Booker, M. D.  
William D. Booker, M. D.  
The Pathology of Toxalburain Intoxications. By Simon Flexner, M. D.  
The Pathology of Toxalbumin Intoxications. By Simon Flexner, M. D.  
The price of a set houiid in cloth [VoU. I-Vl] of the Hospital Reports m
Tlie price of a set hound in cloth iJols. I-VI] oftlir Hospital Reports is  
 
$30.00. Vols. If II and III are not sold seimrateltj. The price o/
 
Vols. 11% r and ri is $5.00 each.


$30.00. Vols. I, Jl ami JII are not sold sejKiratcli/. The price of


Vols. IV, r and VI is $5.00 each.


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.  
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.  
The following papers are reprinted from Vols. I, IV and V of the Reports, for those  
The following papers are reprinted from Vols. I, IV and V of the Reports, for those  
who desire to purchase in this form:  
who desire to purchase in this form:  
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmkt Rixford,  
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rufobd,  


M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,  
M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,  


$3.00.  
$3.00.  
THE MALARIAL FEVERS OF BALTIMORE. By W. S, Thayer, M. D., and J.  
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.  


Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.  
Hewetson, II. D. And A STUDY OF SOME FAT.\L CASES OF MAI^ARIA.  


By Lewellvs F. Barker, M. B. 1 volume of 280 pages. Price, in paper, f3.75.  
My Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ^.76.  
STUDIES IN TYPHOID FEVER. Bv William Osler. M. D., and othere. Extracted  
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted  


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481  
from Vols. IV and V of the Johns Hopkins Hospital Reports, 1 volume of 481  


pages. Price, bound in paper, $3.00.  
pages. Price, bound in paper, $3.00.  
Subscriptions for the above publications may be sent to  
Subscriptions for the above publications may be sent to  


The Johns Hopkins Press, Baltimore, Md.  
The Johns HorKiNS Press, Baltihors, Ud.  






The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimwr, Single copies  
The Johns Hopkins Hospital Bulletins are issued monthly. They arc printed by THE FRIEDENWALD CO., Baltimore. Single copies  
nuiy he pronired from Messrs. GUSHING & CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a tityir, may tte
may be procured frnm Messrs. CUSHINO & CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a year, may be
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sini/lv topics will be sent by mail for fifteen cents each.  
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies will be sent by mail for fifteen cents each.  




Line 18,446: Line 19,667:




Vol. Vm.-Nos. 77-78.]  
Vol. Vlll.-No. 75.]  






BALTIMORE, AUGUST-SEPTEMBER, 1897.  
BALTIMORE. JUNE. 1897.  






[Price, 15 Cents.






GOnSTTEJaSTTS.


COIsTTEIsTTS.




PAGE.


Influence of Louis on American Medicine. By Willia.m
Report of a Case of Polybacterial Infection in Typhoid Fever,
O.SLEB, M. D., - - - 161
with especial Reference to certain Involutions exhibited by
the Bacillus Typhosus. By Edward Perkins Carter, M. D., 115


AVilliam Harvey as an Embryologist. By William K. Brooks,  
A Case of Typhoid Fever in which the Typhoid Bacillus was obtained twice from the Blood during Life. By E. Bates
LL. D., - - - - - - 167
Block, JI. D., 119


Long, the Discoverer of Anaesthesia. A Presentation of lii.s
Successful Cultivation of Gonococcus in two Cases of Gonorrheal Arthritis and one of Tfenosynoviti4, with Remarks on
Original Documents. By Hugh H. Young, A. M., M. D., - 174
a New Medium. By Francis R. Hagner, M. D., - - -121


The Early History of Ophthalmology and Otology in Baltimore (1800-1850). By Harry Friedknwald, A. B , M. D., - 184
A New ^sthesiometer. By Lewellys F. Barker, M. B., - 125


Edinger on " The Development of Brain Paths in the Animal
Series." By C. R. Bardben, M. D.. 126




Joseph Friederich Piringer: His Methods and Investigations.


By Harry Friedenwald, A.B., M. D., 191
page.
By Simon Flex-" - - - 128


Proceedings of Societies :


Hospital Medical Society, " - 195


Hsematomyelia from Gunshot Wound of the Cervical
Pseudo-Tuberculosis Hominis Streptotricha.  
Spine [Dr. Gushing].  


Notes on New Books, _ . - _ 197
NER, M.D.,


Books Received, 197
Proceedings of Societies :


Hospital Medical Society, 129


Discussion of Dr. Friedenwald's paper on Congenital Motor
Defects of the Eyeballs; — Congenital Facial Diplegia [Dr.
Thomas]; — A Case of Acquired Paralysis of both External
Recti Muscles, with Unilateral Facial Paralysis [ Dr. S. Theobald]; — Exhibition of Ophthalmological Cases: Bilateral
Dacryo-adenitis, Operations for Cataract [Dr. Randolph]; —
Demonstration of Florence's Iodine Test for Seminal Stains
[Dr. Lewellys F. Barker].


INFLUENCE OF LOUIS ON AMERICAN MEDICINE.
Notes on New Books, - - 133


By William Oslek, M. D.
Books Received, 185






Harvey and Sydenham, types of the scientific and the
REPORT OF A CASE OF POLYBACTERIAL LNFECTIOX IN TYPHOID FEVER, WITH ESPECIAL
practical physician, though contemporaries, were uninfluenced,
REFERENCE TO CERTAIN INVOLUTIONS EXHIBITED BY THE BACILLUS TYPHOSUS.  
80 far as we know, by the other's work or method. Harvey
had little reputation us a practical physician, and Sydenham
cared little for theories or e.\periment. Modern scientific
medicine, in which these two great types meet, liad its rise in
France in the early days of this century. True, there had
lived and worked in England the greatest anatomist and medical thinker of modern times; but John Hunter, to whose
broad vision disease was but one of the processes of nature to
be studied, was as a voice crying in the wilderness to the speculative, theoretical physicians of his day.  


Bichat's Anatomie Gaicrale laid the foundation of the positive or modern method of the study of medicine, in which
By Edward Perkins Carter, M. D., FeUov) in Pathology.  
theory and reasoning were replaced by observation and analysis.  
[From the Pnthologieal Laboratory of the Johns Hopkins University and Ilospital.]
Laennec, with the stethoscope, and with an accurate study of  
disease at the bedside and in the post-mortem room, almost
created clinical medicine as we know it to-day.  


The study of fevers occupied the attention of all the great
physicians of the time. Fever — what it was, how it should
be treated. What a vast literature exists between Sydenham
and BroussaisI What a desolate sea of theory and speculation !




The following case seems worthy of publication in view of
the opportunity it afforded to study an unusual variation in
morphology of the bacillus typhosus isolated from it, and
because of the interesting poly-infection with bacteria which
existed at autopsy.


•Read before the Stille Society of the Medical Department of the  
The patient, G. C, was admitted to the Johns Hopkins
University of Pennsylvania.  
Hospital on October 11, 1896, complaining of fever, weakness
and loss of appetite. He had not been feeling well for three
weeks, and had been unable to work for the past seven days.  


Family history negative. Personal history negative. For
the past four years he had led an active out-of-door life, and
had up to the onset of present illness enjoyed "good health."


His illness began wnth a general feeling of weakness, which
increased until on Monday, October .5th, 1896, he was unable
to go to work, and complained of fever, loss of appetite and
pains in the back and legs. He kept up until October 9th,
and on October 11th, 1896, when admitted to the ward, he
had a temperature of 102.5°, pulse 100 to the minute, and


No one had been more influenced by Bichat's brilliant
teachings than Broussais, who ruled supreme in the medical
world of Paris in the early decades of this century. A strong
believer in careful observations at the bedside and in the jiostniortem room, he was led into hoj)eless error in attributing
fevers and many other disorders to irritation in the stomach
and intestines — his gastro-enteritis.


Writing in the American Medical Recorder, July, 1831, an
American student, Dr. F. J. Didier, says of the Paris professors of that date, "They were always talking of Hippocrates,
Galen, Oelsns, etc., as if not a particle had been added to the
stock of knowledge since their time." And again, " The doctrines of John Brown, mixed up with the reninantsof humoral
pathology, form the basis of the present system."


The same mi.xture prevailed early in the fourth decade,
respirations 20. E.xamination of the blood at this time and
as you may see from Broussais' Pathology, the American
at all subsequent examinations was negative for malarial
edition of which was issued in 1833, and from Jackson's
organisms. Examinations of the thorax and heart were negative. Abdomen was not distended. No tenderness and no
(Samuel) Principles of Medicine, published in the same year.  
gurgling in right iliac fossa. Several suggestive rose spots.
Spleen was just palpable. Liver dulness normal. The diagnosis of typhoid fever was made and the patient put upon a
strictly typhoid treatment.  


Upon this scene, when Broussais was at the height of his
I have abstracted the following notes from the history of  
fame, came Louis. He, with his friends Andral and Chomel,  
the case, omitting the treatment as being foreign to our
were very important factors in substituting finally in the  
purpose.  
study of medicine, for speculation and theory, observation and
method.  


The chief facts in Louis' life may be thus briefly stated. He
October 12th, '96, at 7 a. m. The patient had a large semiliquid stool, containing some formed particles, and a considerable amount of blood fairly bright red in color. At
was born in 1787 at Ai. He began the study of law, but
8.30 a. m. a second hemorrhage, rather brighter red than preceding. Both considerable in amount. Temperature 103.5°,  
abandoned it for that of medicine. He seems not to have
pulse 102.  


October 14th. Patient flushed, looks well. Tongue furred,




162


116


[No. 75.


JOHNS HOPKINS HOSPITAL BULLETIN.




not tremulous, pulse good. Two fresh rose spots. Abdomen
flat, uo distension.


[Nos. 77-78.  
October 16th, 1.40 p. m. Hemorrhage, somewhat thick
tarry consistence, with some blood clots. Amount of movement about 400-500 cc. 5.30-6.30 p. m., patient had two
movements like preceding, quantity same, about 400-500 cc.
Pulse very running and feeble. Temperature at 8 a. m.
101.5°, pulse 124.  


October 17th. This a. m. condition is distinctly better.
Pulse at visit 29 to the quarter. Abdomen not distended
and nowhere tender. 11.30 p. m. the patient had a stool of
about 250 cc. in amount, which contained blood dark in color.


October 18th, 10 p. m. A stool, about 200 cc, containing
blood, no clots. The patient's condition did not show any
material change. Temperature at a. m. 102.8°, pulse 120.


beeu of a very strong constitution, as he did not pass the inspection for military service. He began the study of medicine
October 25th, 2 p. m. The patient had a large movement,  
at Eheinis, and completed his course in Paris, where he graduated in 1813, in the twenty-seventh year of his age. While
1000 cc. Total amount of blood estimated 500 cc. Temperature at 8 p. m. 101.5°, pulse 148.  
waiting at home, hesitating what he should do, M. le conite
de Saint-Priest, who occupied au official position in Russia,
hajipened to stay for a few hours in the town of Ai to see
Louis' family, and it was suggested that the young physician
should accompany him to Russia. He consented and in
St. Petersburg obtained a diploma to practice. For three
years he seems to have had no settled abode, but wandered
about with his friend, who was Governor of one of the provinces. He then settled in Odessa, where he remained for four
years and practiced with great success. In the last year of  
his stay in Odessa he was very much disturbed by the high
rate of mortality in children with diphtheria, and this appears
to have determined him to abandon for a time the practice of
medicine and to devote himself to study. With this object
in view he returned to Paris and for six months attended the
practice at the Children's Hospital. Among the younger
physicians in Paris he found an old fellow-pupil, Chomel,
physician to La Oharite, who offered him opportunities for
work in his wards. Louis at this time was thirty-four years
of age. Here for six years uninterruptedly he set himself to
work to study disease in the wards and in the post-mortem
i"oom. At first he appears to have occupied the position simply
as a voluntary assistant and friend of Chomel, but subsequently
he became his chef-de-cliniqiie, and during this period he occupied a room in the entresol of the hospital. He was a voluminous note-taker and collected in this time au enormous number of important facts.  


This remarkable feature in Louis' life has scarcely been
From this time, though he had no subsequent hemorrhages,
dwelt upon sufficiently. I know of no other parallel instance
the patient's condition remained critical until his death.  
in the history of medicine. It is worth while reading the brief
extract from Dr. Cowan's introduction to his translation of the
work on Phthisis. " He entered the hospital of La Oharite as
a clinical clerk, under his friend. Professor Chomel. For nearly
seven years, including the flower of his bodily and mental
powers (from the age of thirty-three to forty), he consecrated
the whole of his time and talents to rigorous, impartial observation. All private practice was relimiuished, and he allowed no  
considerations of personal emolument to interfere with the  
resolution he had formed. For some time his extreme minuteness of inquiry and accuracy of description wei'e the subjects
of sneering and ridicule, and cui bonof was not infrequently
and tauntingly asked. The absence of any immediate result
seemed for a time to justify their contempt of a method involving too much labor and personal sacrifice to be generally
popular or easily imitated ; and M. Louis himself, at moments,
almost yielded to the increasing difficulties of the task he had
undertaken. No sooner, however, were his facts sufficiently
numerous to admit of numerical analysis than all doubt and
hesitation were dissi2}ated, and the conviction that the path he
was pursuing could alone conduct him to the discovery of
truth became the animating motive for future perseverance.  
Many of the results to which he arrived soon attracted general attention, and among those who had formerly derided his
method while they admired his zeal, he found many toapplaud


On October 28th he developed well marked signs of consolidation in the lower left back over a small area, and on
November 1st the same signs were found in the lower right
back.


November 9th. Breath sounds at left base seem almost
clear. Percussion at right base impaired, breath sounds
distant. Temperature at 8 a. m. 103°, pulse 124.


and a few to imitate. From this moment may be dated the
November 11th. This a. m. pulse 32 to the quarter. The
presence of that strong impression of the necessity of exact
patient passed a restless night, complaining considerably of  
observation by which the school of Paris has beeu since so
pain in the left side. Lying on left side, skin moist. Tongue
distinguished, and which is now gradually pervading the
dry and tremulous. Eespirations 13 to the quarter. Profuse
medical institutions of the continent and our own country; it
sweating. Eespiration on left side is enfeebled. Back not
is undoubtedly to the author of the present volume that we
examined.  
ought to ascribe the practical revival of that system, which
had for ages been verbally recognized but never before rigorously exemplified."


The following works appeared as a direct result of his
The patient's general condition gradually grew weaker and
studies during these six years:*
he died at 12.30 a. m., November 12th, 1896. The temperature just before death touched 105°; the pulse was 160.


" In 1823, a memoir on perforation of the small intestines,  
The autopsy was held 34 hours after death, and the body,
in acute diseases; a second, on croup in the adult; a third, on
apart from slight post-mortem gas development, showed no
the communications between the right and left cavities of the
other distinctive signs of decomposition.
heart (Archives de medecine).  
 
Anatomical Diagnosis. Typhoid fever. Small number of
healing ulcers in the ileum ; little glandular enlargement.
Subacute spleen tumor, parenchymatous degeneration of the
viscera, abscess of prostate gland, necrosis of the cricoid
cartilage, pneumonia, fibrino-serous pleurisy.
 
Body 170 cm. long, pale, no oedema. Moderate emaciation.
Rigor mortis in both extremities. Abdomen greatly distended,  
tympanitic and greenish in color.
 
The spleen weighed 210 grams. It was free from adhesions. On section moderately firm, pale grayish red in color.
Malpighian bodies not prominent. Several phleboliths of the  
size of bird-shot in cut surface.
 
The small intestine was moderately distended, the mucosa
opaque, containing soft fa3ces. No ulceration until within
100 cm. of the valve, where a small, clear, punched-out ulcer
1 cm. in diameter existed. The surrounding mucosa was
congested. No more ulcers found for the next 50 cm., where
a large group of coalescent clean ulcers with united edges
occurred, which were shallow and rapidly skinning over.  


" In 1824, two memoirs on the pathological anatomy of the
mucous membrane of the stomach ; another on pericarditis.


"In 1826, a memoir on abscess of the liver; another on the
condition of the spinal marrow in Pott's disease; a third on
sudden and unforeseen deaths; a fourth upon slow but anticipated deaths, but which anatomy will not explain; a fifth on
the treatment of tajuia by the Darbon potion (Archives de
medecine).


"In 1825, his Anatomical Researches, etc., on Phthisis (1
These measured 3x5 cm. in extent, and the individuals composing the group were hardly larger than the above single
vol. 8vo) ; reprinted with many additions in 1843.  
one. The most important group of ulcers was located a hand's
breadth above the valve; these numbered nine (2.5 cm. in
diameter), the largest not much exceeding a silver twentyfive cent piece in size. They were perfectly clean and rapidly
healing, judging from the manner in which their bases were
filled up; and they appeared to be skinning over at the same
time from the edges. The caecum and appendix vermiformis
were free from ulceration.  


" In 1828, Researches on the Typhoid Affection or Fever
The larynx on the left side shows a small aperture measuring 1 cm. in diameter, which leads into a cavity in relation
(2 vols. 8vo); reprinted with many additions in 1841."
to the cricoid cartilage. On dissection a cavity the size of the
little finger, lined by granulation tissue, is found, and into
the cavity the upper and eroded end of the cricoid cartilage
projects. The upper surface gives the impression of being
calcified ; it is eroded and hard. The contents of the cavity
are semi-fluid pus of rather dark color.  


Louis introduced what is known as the Numerical Jlethod,
In the right lobe of the prostate gland there existed a small
a plan which we use every day, though the phrase is not now
abscess the size of a hazel-nut, containing creamy pus. The  
very often on our lips. The guiding motto of his life was
walls of the cavity are thin and ill-formed. No communication existed with the bladder.  
"Ars medica tota in observation ibus," in carefully observing
facts, carefully collating them, carefully analyzing them. To
get an accurate knowledge of any disease it is necessary to
study a large series of cases and to go into all the particulars
— the conditions under which it is met, the subjects specially
liable, the various symptoms, the pathological changes, the
effects of drugs. This method, so simple, so self-evident, we
owe largely to Louis, in whose hands it proved an invaluable
instrument of research. He remarks in one place that the  
edifice of medicine reposes entirely upon facts, and that truth
cannot be elicited but from those which have been well and
completely observed.  


American medicine felt the influence of Louis through two
The mesenteric and retroperitoneal glands were little if at  
channels, his books and his pupils. Let us speak first of the
all enlarged.  
former. No French writer of the century has had such a
large audience in this country; all of his important works
were translated and widely read. The work on phthisis, the
first important outcome of five years' hard work at La Oharite
in Ohomel's wards, was published in 1825. Much had already
been done by physicians of the French school on this subject.
Bayle's important Recherchcs had been issued in 1810, and
Laennec had revolutionized the study of phthisis by the publication of his treatise on auscultation. I cannot enter into
any detailed analysis of the work, but it is one which I can
commend to your notice as still of great value, particularly as


Bacteriological Examixation.


Cover-slip preparations made at the time of the autopsy
showed from the fj^ewra large numbers of streptococci, which
occurred in threads of 6-8 segments, and a few long evenly
staining straight bacilli.


* Brief Memories of Louis and some of his Contemporaries. H.
From the abscess in jjwstafe gland great numbers of small
I. Bowditch, Boston, 1872.  
thin straight bacilli, which looked not unlike the bacillus of  
typhoid fever; also numbers of cocci, appearing chiefly in
pairs (diplococci).  


From the heart's Hood a number of long straight bacilli
resembling closely those seen in the cover-slips from the
j)leura ; also a few single cocci were seen.


Cultures.


Adgust-September, 1897.]
Pleura. The agar-agar plate was studded with minute
pin-point, finely granular colonies.  


Microscopically these proved to be streptococci, which were
identified as the streptococcus pyogenes.


Lung. The plate on the same medium resembled identically that from the pleura and contained the same microorganism in pure culture.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Larynx. The agar-agar plate showed superficially many
round grayish brown pin-bead colonies, limited to one-half of
surface, the remaining area being overgrown with colonies
which exhibited a bluish green color. In the substance of
the medium were great numbers of small, finely granular pinpoint colonies and smaller numbers of large whetstone and
irregularly round colonies. This plate being so crowded, a
series of plates was made, and from the third dilution the
following micro-organisms were isolated and identified : streptococcus pyogenes, bacillus lactis aerogenes and bacillus pyocyaneus.  


Kidney. The agar-agar plate was studded with small




163


June, 1897.]


117


a model of careful observation. The work was based ujjou the
study of 133 cases observed in Chomel's clinic. The lesions
observed at autopsy are first described under the different
organs, with great accuracy and detail, and then summarized,
following which is an elaborate description of the symjitomatology. I do not know of any single work on pulmonary
tuberculosis which can be studied with greater profit to-day by
the young physician. The fifty years which have elapsed,
since its publication, and the changes which have taken place
in our ideas of tuberculosis, diminish naught from the value
of his careful anatomical and clinical presentation of the subject.


In 1829 appeared his second great work, Anatomical, Pathological and Therapeutical Researches upon the disease knoivn
under the name of yctstro-enterite, putrid, adynamic, ataxic,
typhoid fever, etc., com^mred with the most common acute diseases. It was based upon 138 observations made between 1822
and 1837. He analyzed and determined the lesions found in
fifty patients who had died of the typhus fever, and compared
these with alterations found in other acute diseases. Altogether for this work he states that he analyzed the changes in
the viscera of 133 subjects and the symptoms of nearly 900.
In his introduction to this work he quotes a sentence from
Rousseau which is always to be kept in mind : " I know that
truth lies in the facts, and not in the mind that judges of
them, and that the less I introduce what is merely my own
into the deductions I make from them, the more certain I
shall be of approaching the truth." This work was translated
by Dr. H. I. Bowditch in 1836. At the time of Louis' observations, although differences were recognized between the
various forms of continued fevers, the profession had no accurate knowledge of the subject. It so happened that at this
period the disease prevailing at Paris known as tyjihus was
almost entirely what we now call typhoid fever, so that the
anatomical lesions found by Louis in his fifty autopsies were
chiefly in the intestines ; in all the Peyer's glands were diseased.
His method was to analyze carefully the appearances found
in the different organs in the series of fever cases, and compare them with patients who had died of other acute diseases;
thus of course the contrast was striking in the very matter of
involvement of Peyer's glands, which were more or less seriously changed in structure in all of the patients with the fever,
while in the persons dead of other acute diseases the elliptical
patches had no special redness or softening.


The symptomatology was also given in great detail, and the  
round dark granular colonies, much larger than the usual
same painstaking comparisons were instituted between the  
streptococcus colonies. In the substance of the medium
subjects of the typhoid affection and those of other acute diseases. Louis' work convinced a majority of the members of  
there were also a number of whetstone and irregularly round
the Paris school that the essential lesions in continued fevers
colonies, and on the surface two grayish white spreading
were in the intestines, and Louis himself apjiears not to have
colonies and five slightly smaller grayish white more ti-anslucent ones. The small granular colonies were composed of
had any idea whatever that the disease which he was studying
the streptococcus pyogenes. From the other colonies two
was in any way different from the disease jirevailing in other  
bacilli were isolated and identified as the bacillus coli communis and the bacillus typhosus. (See notes below.)
parts of Europe and which we now know as tyjjlius fever.  


The next important memoir, the essay on Blood-letting,
Liver. The agar-agar plate presented practically the same
had a very potent influence on professional opinion in this
appearance as that from the kidney, and the same microorganisms were isolated from it.  
country. It appeared in Paris in 1835 and was translated by
G. C. Putnam, with an introduction and appendix by Dr.
James Jackson. As this learned physician remarks in his


Heart. The agar-agar plate showed two sets of colonies.
The substance of the medium was studded with small finely
granular colonies, and here and there a few scattered grayish
white whetstone forms occurred, while on the surface there
were a number of grayish white, small, fairly round and
slightly elevated forms. From the small granular colonies
the streptococcus pyogenes was isolated, and from the whetstone colonies in the depth and the round colonies on the
surface of the medium a bacillus was isolated which was
identified as the bacillus typhosus.


Mesenteric gland. The agar-agar plate showed two superficial, spreading, grayish white irregular colonies, and numbers of whetstone colonies in the substance of the medium.
From the plate two bacilli were isolated and identified as the
bacillus coli communis and the bacillus typhosus.


preface, " If anything may be regarded as settled in the treatment of disease, it is that blood-letting is useful in the class
Abscess in the prostate gland. The agar-agar plate was
of diseases called inflammatory, and especially in inflammations of the thoracic viscera." When one i-eads the reports of
studded with small finely granular colonies, and in addition
the treatment by bleeding up to about the year 1840, one is
showed a few scattered whetstone colonies in the substance,
almost forced to ask the question, are the diseases the same ?
and several small, reddish brown, irregular, spreading forms
or surely the patients must have possessed much more
on the surface of the medium. From the finely granular
powerful constitutions than those which we are called upon
colonies the streptococcus pyogenes was isolated. From the  
to treat at the end of the century.  
superficial colonies a bacillus was isolated which was identified
as the proteus vulgaris.  


At the time of Louis' return to Paris, under the influence
Spleen. The agar-agar plate from the spleen remained
of Broussais' doctrine of irritation, local and general bloodletting was practised more extensively than at any previous
sterile after 48 hours in the thermostat.  
period in the history of medicine. As an interesting illustration it may be mentioned that the trade in France and Spain
in leeches had developed to proportions which assumed really
those of a national industry, and even in this country I
believe one of the medical societies offered a prize for the
best demonstration of the practical method of cultivating
leeches for medicinal purposes.  


It must have been a terrible shock to Broussais and his
The bacillus which is, however, of greatest interest in this  
adherents when Louis attacked the subject of blood-letting in  
case is that which was isolated from the heart, liver, kidney,  
pneumonia with his numerical method. For this purpose he
mesenteric gland, and by Mr. Potter from the bile by means of  
analyzed 78 cases, 28 of which proved fatal, and in a second
Eisner's method, and which, though it shows great variation
series 39 cases with 4 deaths. Among his conclusions were
upon certain media, must, we think, be considered the true
that pneumonitis is never arrested at once by blood-letting, and
bacillus of Eberth.  
that the supposed haj)py effect on the progress of the disease
was very much less than was commonly believed. Incidentally he remarks with reference to the practice of blistering which was in vogue at the time, that he had rejected the
practice .after the treatment of 140 cases of pleurisy without
losing a case. I would refer you particularly to Putnam's  
translation of this article, which you can obtain in any of the
libraries, not only for Louis' work, but for the excellent
introduction by Dr. Jackson on the value of the numerical
method in medicine, and also for the appendices, analyzing
the pneumonia cases of the Massachusetts General Hospital
from 1834 to 1834 (inclusive).  


To American students one of Louis' most valuable works is
Culturally and morphologically this bacillus was proven
his Research on the Yellow Fever in 1828. On the 1st of
identical, from all of the above given sources, and our study
November, 1838, Louis, with Ghervin and Trousseau, left for
of it has therefore been made with the cultures obtained from
Gibraltar, where the disease prevailed. They made a very
the kidney and bile. At the same time there was carried
careful study of the symptoms and morbid anatomy, and on
along with these for control a culture of an established typhoid
their return to Paris made a report to the Academy of Medicine, but the work remained in manuscript until Dr. Geo. C.
bacillus. The bacillus isolated from the case under consideration, taken from a 24-hour growth upon agar-agar, is of
Shattuck translated it into English and it was published by
medium size, straight and thin, with slightly rounded ends,
the Massachusetts Medical Society as Vol. X of their Library
taking the stain deeply and uniformly. It stains with all the
of Practical Medicine. The work did not ajjpear in French
ordinary aniline dyes, though most satisfactorily with gentian
until 1844. It is chiefly valuable as a very accurate and
violet.  
careful record of a series of cases studied clinically and
anatomically.  


Powerful as was the effect of Louis' writings on American
The Eisner plates made by Mr. Potter directly from the  
medicine, it cannot compare with the influence which he
bile gave what has been and is considered the typical reaction
exerted through his pupils, who " caught his clear accents,
for a mixture of typhoid and colon colonies. The colon
learned his great language, made him their model." Of the  
colonies were larger, more coarsely granular and more numer
great triumvirate of the French school of the fourth decade,
Louis possessed a singular power of attracting hard-working,
capable men, and this in spite of the fact that his rivals and  
friends, Chomel and Audral, possessed more brilliant gifts of




ous than the small, very pale, transparent and faintly granular
colonies from which the typhoid bacillus was isolated in pure
culture.


164
Upon agar-agar plates the colonies of the bacillus under
study are small, grayish white in color, slightly elevated and
irregularly round upon the surface of the medium, while in
its substance they presented the common small whetstone or
irregularly round outline. By transmitted light under low
power they are of a reddish brown color and faintly granular
structure. Upon gelatine plates the colonies are, after 34
hours, small, very finely granular, irregular in outline, and
tend to increase in size very slightly during the second 48
hours, thus appearing as typical typhoid colonies.


Agar slant. The growth upon a moderately dry agar tube
was, after 24 hours, of a slight, narrow, rail-like character
along the track of the needle, being slightly elevated and of
a grayish white color. On the moist agar slant it grows
somewhat more profusely, covering the surface of the medium
more irregularly. This was equally true of the control
typhoid culture.


Bouillon at the end of 24 hours is clouded and somewhat
opaque. The reaction for indol was negative. In order to
establish the certainty of the negative indol reaction beyond
a doubt, a culture in bouillon, together with a culture of the
control typhoid, and an uninoculated tube of bouillon were
placed in the thermostat for three days and then tested for
indol, adding at the same time the H2S0» and NaNO: to the
uninoculated tube of bouillon and watching these three carefully for a few hours, and then replacing them in the thermostat over night. When examined the following day all
three tubes presented the same appearance, and it could not
be said that a true indol reaction was obtained. The test
for indol was made again and again without obtaining a
positive reaction.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Litmus milk after 24 hours was only faintly acidulated, and
reached apparently its greatest degree of acidulation, which is
very slight, on the third day. At the end of a month there
was no increase of acidulation, as evidenced by the pale pink
color which remained quite as noted on the third day following inoculation. Coagulation of the milk did not ensue.  


Upon potato the growth bears an extremely close resemblance to the control typhoid. It shows at the same time
under the microscope the most remarkable involution forms,
which begin to appear upon the third day after inoculation.


If the potato is strongly acid the growth after 24 hours is
just visible as a delicate white membrane over the surface of
the potato extending from the track of the needle. The
macroscopic appearance of the growth remains unaltered,
being only Just visible after thirty days, while the potato
remained undiscolored.


[Nos. 77-78.  
Upon a neutral potato, on the other hand, the growth after
24 hours appears as a slightly yellowish white line along
the track of the needle, spreading out somewhat at the base
of the potato, being plainly visible and much more luxuriant than is ordinarily true of the bacillus of typhoid fever.  
After five days the potato itself becomes a very little discolored, while the growth remains unaltered after the third
day. At the end of three weeks no further change was noted.  






a certain kind. As a writer in the Lancet said (1872, II),
118
" Year by year fresh bands of students came to imbibe from
his lips the instruction which their predecessors had abandoned
with reluctance, till his academic progeny knew no distinction of race or even color, but coalesced into a noble band of
enthusiasts in the cause of medicine, of science and of
humanity." In this academic progeny Louis' American
pupils take a very unusual position. Among the thousands
in the profession of this country who have during this
century sought light and learning in the older lands, the
group of young men who studied in Paris, between 1830 and
1840, had no predecessors and have had no successors.
Partly because the time was ripe and they were active agents
in bringing the new art and science to the New World, partly
owing to inherent capabilities, etc., but not a little because
the brightest minds among them fell under the influence of
Louis — they more than any others gave an impetus, which it
still feels, to the scientific study of medicine in the United
States.


There had been, of course, in Paris many students from this
[No. 7.5.  
country prior to 1830, but they do not form a school, recognizable to us at present. One name comes to my mind, that
of the Rhode Island philosopher, Eiisha Bartlett, a jjeripatetic
of the peripatetics, in the days when men moved from city to
city, like the Sophists of ancient Greece. I do not know
whether when in Paris in 1828 he came personally under
Louis' influence— probably not, as Louis spent part of that
year in Spain — but he brought back recent French methods,
with Gallic lucidity and a keen appreciation of the value of
the numerical method. His well known work on Typhus and
Typhoid Fever, issued in 1842, is in itself a lasting witness to
the intelligence and progressive character of the younger
teachers of that day. With a clear separation of Typhus,
Typhoid, the Periodic and Yellow Fevers, it had at the date
of its publication no counterpart in Eurojiean literature, and
is in remarkable contrast to the chaotic treatises of Armstrong, Fordyce, Tweedie, Southwood Smith and othei'S.  


Without attempting to give a comjilete list, the following
were among the American students in Paris between 1830
and 1840:


From Boston, James Jackson, Jr., H. I. Bowditch, Oliver
Wendell Holmes, Geo. 0. Shattuck, Jr., John D. Fisher, J. C.
Warren (then past middle age), and J. Mason Warren.


From New York, John A. Swett, Abraham Dubois, Alonzo
Under the microscope this bacillus shows the greatest variation in morphology, and apparently without relation to the
Clark, Charles L. Mitchell, Charles D. Smith, Valentine
reaction of the potato. After the third day involution forms
Mott, Sr., and John T. Metcalf.  
appear, first as long rods with unstained bulbous ends, and
these are quickly followed by the most extraordinary forms,  
such as long threads, irregular rods with unstained poles
closely resembling spores, and shorter oval forms, a picture
unlike anything one finds in cultures of the true bacillus
typhosus.  


From Philadelphia, Geo. W. Norris, W. W. Gerhard, Casper
Glucose agar. In a deep stab this organism again agrees
W. Pennock, Thomas Stewardson, Alfred Stille, Thomas D.  
well with the control typhoid. After 24 hours there is a delicate, small, nail-head growth upon the surface of the medium,  
Muter, J. Campbell Stewart, Charles Bell Gibson, John B.
while along the line of puncture the growth extends downwards for one-half the distance. This appearance remains in
Biddle, David H. Tucker, Meredith Clymer, Wm. P. Johnston,
general the same, the growth increasing very gradually until
W. S. W. Itusheuberger, Edward Peace, William Pep2)er, Sr.  
at the end of thirty days there is only a more irregular nailhead appearance upon the surface with a slight growth along
the line of the needle stab, thus bearing a striking similarity
to the control culture. At no time was there gas formation.  
Here again under the microscope the cover-glasses made after
the third day show the same remarkable involution forms seen
in the growth upon the potato.  


Fi-om Baltimore, William Power.  
In a gelatine stab there is a slight nail-head growth on the
surface of the medium after 24 hours, extending along the
course of the needle for a short distance as a delicate linear
growth, and giving identically the same picture as that seen
in the control. Liquefaction of 5 per cent, or 10 per cent,
gelatine does not occur, and the growth increases very slowly,
showing after three weeks a surface growth of the size of the
head of a small tack. Microscopically, after the fifth day, we
find involution forms in the shape of straight and slightly
curved threads, longer by at least twelve times than the bacillus as it appears after 24 hours. The very unusual forms
seen in the growth upon potato and sugar agar are not present.  


From the South, Peter C. Gaillard, Gibbs, and Peyre Porcher of Charleston ; J. L. Cabell, L. S. Joyues, Selden and
Motility. Hanging drops made from an agar-agar culture
Randolph of Virginia.  
of any age always showed great numbers of the bacilli in the
field in active motion, but the greatest motility was seen
when examined from agar-agar slants of from eight to ten
hours' growth; at this age all the bacilli in the field appeared
to be in active motion.  


" And many more whose names on earth are dark " — men
It decolorizes by Gram's stain.  
of the stamp of Dr. Bassett of Alabama, who felt the strong
impulsion to know the best that the world offei'ed, every one


Fermentation tubes of glucose, lactose and saccharose bouillon failed to show any development of gas after eighteen days
in the thermostat.


The thermal death-point of this bacillus as established by
means of Sternberg's bulbs is between 53° and 55° C. at an
exposure of ten minutes.


of whom has left a deep and enduring impression in his sphere
By means of Pittfield's stain the presence of flagella can be
of work.  
demonstrated extending around the entire organism.  


It would be impossible to tell in detail how Louis' students
Widal's test. Upon adding from i to Jj the volume of
brought back his spirit and his methods to their daily work,  
blood serum obtained from a case of typhoid fever to a 24hours-old bouillon culture of this organism, a control typhoid
and of the revolution which they gradually effected in the
bacillus culture and a culture of the bacillus coli communis
study and in the treatment of disease. I can best, perhaps,
according to the method of Widal, the following results were
fulfill my object by referring somewhat fully to two of the  
obtained :
most distinguished among them, James Jackson, Jr., and W.
W. Gerhard.


James Jackson, Jr., is the young Marcellus among the physicians of this country, "the young Marcellus, young, but great
The control culture and the culture of the organism under
and good." I do not know in our profession of a man who
study gave characteristic precipitates in the same time, while
died so young who has left so touching a memory. He was
that of the bacillus coli communis remained unaffected.  
the son of Dr. James Jackson, of Harvard, one of the most
distinguished of New England's physicians, a man to whom
our generation owes a heavy debt, since he, with Jacob Bigelow,
was mainly instrumental in bringing about more rational
ideas on the treatment of disease. Of Louis' pupils from this
side of the water, young .lackson seems to have been his special
favorite. After taking the B. A. degree at Cambridge in 1828,
Jackson attended the medical lectures at Harvard, and in the
spring of 1831 went to Paris, where he remained until the
summer of 1832. Returning home in 1833, he graduated in
medicine at Harvard in 1834. In the two years and a half of
his studies in this country before going abroad he had had
exceptional opi)ortunities with his father at the Massachusetts General Hospital, and showed his early industry and
ability by taking one of the lioylston Prize Essays before the
completion of his second year of study.  


In Paris he attended the practice of La Pitie and St. Louis.
He soon became devoted to Louis, and by him was utilized
to the full in the cholera epidemic in 1832. Two letters from
Louis to James Jackson, Sr., show how important he thought
a prolonged period of study was for a young man. He says:
" I pointed out to him (James Jackson, Jr.) the advantage
it would be for science and for himself if he would devote
several years exclusively to the observation of diseases. I now
retain the same opinion and am strengthened in it; for the
more T become acquainted with, and the more I notice him
applying himself to observation, the more I am persuaded
that he is fitted to render real service to science, to promote
its progress. I find that he would be well pleased to follow
for a certain period the vocation for which nature has fitted
him ; but he has stated to me that there are many difKculties
which would prevent his devoting himself exclusively to
observation for several years. But can these difKculties be
insurmountable?"


xVud again : " Let us sup2)ose that he should pass four
more years without engaging in the practice of medicine, what
amass of positive knowledge will he have acquired! How
many important results will he have been able to publisli to
the world during that period ! After that he must necessarily
become one of the bright lights of his country; others will
resort to him for instruction, and he will be able to impart it
with distinguished honor to himself. If all things be duly
weighed, it will appear that he will soon redeem the four
years, which men of superficial views will believe him to have
lost." In another letter, the following year, just before young


A number of tests for agglutination were made by the
Wyatt Johnston method, using blood of known activity. The
control typhoid bacillus gave immediate clumping, and the
organism under study showed a similar reaction in from
twenty minutes to one hour.


It is interesting to note that cultures made from potato,
sugar agar and gelatine, which showed the involution forms
in great numbers, always grew upon re-transplantation as the
normal-sized, straight bacilli which were originally met with.
Upon plain agar-agar in bouillon and in milk the growth
varied but slightly from what seemed to be the normal.
Animal Experiments.
A mouse inoculated subcutaueously with two loops from a
34-hour agar growth died in less than 48 hours.


August-September, 1897.]
The autopsy showed no excess of fluid in the abdominal
cavity and no focal visceral lesions. The lymphatic glands
were nowhere enlarged. The spleen, liver and kidneys appeared normal. At the seat of inoculation the skin was bound
down by quite firm fibrinous adhesions. In the cover-slips
from the seat of inoculation great numbers of bacteria were
seen. Cover-slips from heart and spleen were negative. Cultures from heart and spleen remained sterile after 48 hours.  


A guinea-pig inoculated with 1 cc. of a 24-hours bouillon
culture intraperitoneally died after thirty days. The autopsy
showed the lymphatic glands somewhat swollen and injected.
No excess of fluid in abdominal cavity. Peritoneum perhaps
reddened and vessels somewhat congested, but no peritonitis
present. Liver, spleen and kidneys appeared normal. Coverslips from peritoneum and from all the organs negative. Cultures from same sources remained sterile.


A rabbit inoculated with 1 cc. of a 24-hours bouillon culture intravenously was still alive after two months.


JOHNS HOPKINS HOSPITAL BULLETIN.  
We have then a bacillus which agrees culturally with the
typhoid organism, which reacts to all the known tests for the
true bacillus of typhoid fever, and yet which, after the third
day, upon certain media, potato, sugar agar, and gelatine, shows
very unusual involution forms; forms so remarkable that
were it not for the evidence given by the fulfilment of every
test, it would seem impossible to consider this the true bacillus of Eberth.
 
During the past few years a number of bacilli, found under
conditions which would seem to exclude the presence of the
true bacillus of typhoid fever, have been isolated and studied
by Losener,* Babes,! FiillesJ and Cassedebat.§ These bacilli
resembled the true typhoid organism so closely in cultural
and morphological properties, with the exception of a slight
variation in the organisms reported by Cassedebat and by
Babes, that it has thus far been very difficult, if not impossible,
to distinguish between them and the bacillus typhosus.  






165
* Losener, Arbeiten aus ilem Kaiserl. Gesundheitsamte, XI.


t Babes, Variabilitat und Varietiiten des Typhus-bacillus. Zeitschrift fur Hygiene, IX, 1890, p. 323.


I Fulles, Bacteriologische Untersuchung des Bodens in der Uingebung von Freiburg i. B. Zeitschrift fur Hygiene, X, 1S90, p. 225.


Jackson's departure from Paris, he refers again to this question and urges Dr. Jackson to allow his son to devote himself exclusively to observation for several years in Boston.
§ Cassedebat, Sur un bacille pseudo-typhique trouve dans les
The extract from this letter is worth quoting. "Think
eaux de riviere. Compt. rend, de I'Academie de Paris, CX, No. 15,  
for a moment, sir, of the situation in which we physicians are placed. We have no legislative chambers to enact
1S90, p. 798.  
laws for us. We are our own lawgivers ; or rather we must
discover the laws on which our profession rests. We must
discover them and not invent them ; for the laws of nature
are not to be invented. And who is to discover these laws?
Who should be a diligent observer of nature for this purpose, if not the son of a physician, who has himself experienced the difficulties of the observation of disease, who
knows how few minds are fitted for it, and how few have at
once the talents and inclination requisite for the task ? The
inclination especially, for this requires that the observer should
possess a thorough regard for truth, and a certain elevation of
mind, or rather of character, which we rarely meet with. All
this is united in your son. You ought — for in my opinion it
is a duty — you ought to consecrate him for a few years to science. This, sir, is my conviction, and I hope it will be yours
also. I know very well that every one will not be of the same
opinion ; but what matters it, if it be yours ? — if you look upon
a physician, as I do, as holding a sacred office, which demands
greater sacrifices than are to be made in any other profession."


Young Jackson's letter to his father, just as he was quitting
Paris, indicates on what affectionate terms he had lived with
Louis. " In two hours I am out of Paris. I will not attempt
to describe to you the agony it gives me to quit Louis. He is
my second father, and God knows that is a name I of all
men cannot use lightly. I may not persuade you to look upon
him with my eyes exactly as a scientific man ; but in your
heart he must have the share of a brother; for he almost
shares my affection with you. From one upon whom I had
no claims but those which my life and mind and habits gave
me, I have experienced a care, an affection which I never could
dare expect from any but my dear father, and which I shall
ever feel to be the most honorable and truly worthy prize of
my life."


He seems to have inspired the same tender feelings in all
his American students. In the Memoir of Dr. Bowditch, to
which I have already referred, he speaks of Louis' fatherly
kindness to him during a prolonged attack of rheumatic fever
lasting for many weeks.


Young Jackson was one of the founders, in 1833, of the
f 1
Society for Medical Observation, which consisted of the ablest
 
of the students of Louis, Chomel and Andral. During his stay
as*, B
in Paris he made an important study of cholera, which was
 
published in this country in 1833. It was most timely, as it gave
the profession here a very clear and accurate description of the
disease, of which up to that time they had had no experience.
Jackson's name, too, will always be associated with the studies
upon emphysema, and he is the discoverer of the prolonged
expiration in early pulmonary tuberculosis.


Returning to Boston in the autumn of 1833, he spent the
winter preparing for his degree and elaborating the notes which
he had taken in Paris. In March he fell ill with a dysentery, which proved fatal on the 37th of the month, in the






twenty-fifth year of his age. I know of no young man in the
profession who had given pledges of such exceptional eminence. His influence in extending Louis' methods and views
throughout New England was chiefly through his father, who,
though a man approaching his sixtieth year, became an ardent
follower of Louis and the numerical method.


In Oliver Wendell Holmes' recently issued Biography you
will find a delightful description of life at the Medical School
of Paris at this period. He bears witness to the good effect
which Jackson's warm friendship with Louis had had in promoting the interests of American students. I may conclude
with a quotation from Dr. Jackson's, Sr., memoir: "At the suggestion and request of one of my most judicious brethren I shall
add that my sou's influence on the profession here, in the
short time he was with us, was of a very salutary description.
This gentleman states that my son not only caused others, who
had not yet read the works of M. Louis, to study them with
care, but that he induced among the rising members of the
profession in our own city the habits of thorough observation
of the phenomena of disease in the living and in the dead,
which he had learned from the same great pathologist. He
also taught us much in respect to the physical signs of disease
in the thorax, with which we were imperfectly acquainted
before; at least I may say this was true as to myself. Indeed
I ought to say more, for he aided me very much in regard to
the diagnosis of the more obscure diseases of that region,
derived from the combination of the physical and rational
signs. On emphysema of the lungs he threw, for me, quite a
new light."


Wm. W. Gerhard was the most distinguished of the American pupils in Paris between 1830 and 1840. When you call
- \
to mind the men whom I have mentioned, this may seem a
strong statement, but I feel certain that could we take their
suffrages they would accord him the place of merit in consequence of the character of his work. Dr. Gerhard was born
in Philadelphia, in 1809, and was graduated from the University of Pennsylvania in 1831. Early in the year he went to
Paris and attached himself to Louis at La Pitie. In one of
his letters* to his brother, dated January 18, 1833, he says:
"Dr. Louis is delivering an interesting clinic at La Pitie ; he
is a remarkable man, very different from the physicians of
Eni^land or America, and remarkable even at Paris by the
strict mathematical accuracy with which he arrives at his
results ; he is not a brilliant man, not of the same grade of
intellect as his colleague at La Pitie, Andral." In another
letter he gives an account of his day's work. "The morning
from seven to ten is occupied with the visit and clinic at the
hospital ; there are several distinct clinics now in actual proo-ress; each of them has its advantages. I shall vary my attendance at the different hospitals and select those lecturers
who are of real merit. At this moment we are following
ing Piorry at the SalpetriOre, a very distant hospital, two or
three miles from our lodgings; his patients are all old women,
and not interesting. My object in following his course is to
obtain some interesting information on the best mode of


(




* I am indebted to members of Dr. Gerhard's family for the letters
from which these extracts are taken.






166




(


JOHNS HOPKINS HOSPITAL BULLETIN.




1


[Nos. 77-78.




-- 5


investigating the diseases of the chest. M. Piorry has devoted
special attention to this subject. From Salpetriere we hurry
to La Pitie; we hear a surgical lecture, reach home to breakfast, and then to the school of medicine. The lectures at the
school, with a private course of anatomy during the hour of
intermission, fill up the remainder of the day until four. Fortunately a private clinic at La Charite introduces me to a set
of very interesting cases, especially on pectoral cases. Dr.
Dagueau has a class who pay him ten francs a month and
enjoy the privilege of examining the patients much more conveniently than is practicable during the morning visit in the
midst of a crowd of students. We dine at five-thirty and then
lectures again until eight o'clock. Imagine the facilities, the
delightful advantage of acquiring positive information, and
what is at least as important, of learning the mode of obtaining these positive results. We see and hear the men who are
so well known to us in America, learn to form a correct estimate of their relative worth — in short, one of the most striking
advantages of a medical visit to Europe is to acquire the sort
of liberal professional feeling which is rarely secured by the
continued intercourse with the same men, and the unpleasant
medical politics which divide the profession in America."


Evidently Broussais made no special impression on Dr.
Gerhard. He says, " Broussais is the best known, his reputation is universal, and the benefits he has conferred on medicine are immense, but unfortunately he is a wretched lecturer.
His own opinions are given in the most awkward, clumsy
manner; the manner and style of lecturing are coarse and
vulgar."


In another letter of February 3, 1833, he tells how he
June, 1897.]
induced Louis to give them private instruction. To his
brother he writes : " I must write you at least a few days before
the excitement has passed off : can you imagine how fortunate
I am — devinez si vous pouvez— two or three days ago, Jackson,
Pennock and myself were talking of hospitals and morbid
anatomy, when the idea occurred of attempting the study
of pathology in a particular manner. It was this: to obtain
the specimens and study them, the authors in our hand,
exactly and carefully comparing authorities with the subject
before us. We addressed ourselves to two of the internes at La
Pitie attached to the salles of Louis and And-ral, and they agree
to procure all facilities in their power and communicate their
own information for the compensation of 60 francs from each
of us ; we accordingly visit La Pitie on three afternoons of the
week and examine the parts at the hospital, afterwards carrying home such portions as require minute investigation. Our
first success in this opening of new sources of instruction
emboldened tis to attempt something of higher importance.
We were all desirous of studying auscultation, of studying it
in such a manner as to be sure of our ground on our return,
and to be capable of appreciating the advantages of the art.  
Louis' public instructions were valuable, but his private
lessons upon a subject demanding minute and patient inquiry
we knew would be infinitely moi'e so. I therefore in the name
of my friends addressed him a polite note, accomjianied by a
handsome pecuniary offer; we did this with little hopes of
success, but happily for us he accepted our proposition, and
next week we are his private pupils at La Pitie. We are, I


119




believe, the first who have made this arrangement with M.
Louis, and you may estimate its importance when I tell you
that he is considered in excellence of diagnosis the successor
of Laennec. Our advantages for the study of pathology and
the diagnosis of diseases of ttie chest are now superior ; they
are indeed the very best in the world, and our eagerness to
embrace them will, I hope, render them of real utility ; of
course they involve an additional expenditure of 400 or ."300
fr., but I should be happy to shorten my stay at Paris a mouth
to improve the remainder of my time in this manner, if such
were necessary for me. Pennock and myself are very happy
to have become intimate with .Jackson ; he has superior talents,
and his excellent education, conducted by his father, unquestionably the first physician in America, has cultivated his mind
and developed an ardent attachment to medicine."


Few American students have occupied their time abroad
These forms have therefore been designated pseudo-typhoid
to greater purpose than Dr. Gerhard. He appears to have
bacilli.  
been an indefatigable worker, and the papers which he published based upon material collected in Paris are among the
most important which we have from his pen. Thus with
Pennock he described Asiatic cholera in 1832. Devoting
himself particularly to the study of diseases of children, he
issued a very interesting paper on small-pox, and two papers
of very special value, the first on tuberculous meningitis and
the other upon pneumonia in children. Both of these papers
mark a distinct point in our knowledge of these two diseases.
He is usually accorded the credit of the first accurate clinical
study of tuberculous meningitis.  


Late in the year 1833 he returned to Philadelphia, and at
In addition to the irregular forms described by Babes as  
his suggestion his friends had secured him the appointment
seen in growths upon agar-agar, and those in the bacillus
as resident physician at the Pennsylvania Hospital, which he
studied by Oassedebat, Ohantemesse and Widal* have noted
took early in 1831. This step indicated how carefully he had
certain variations from the normal which appeared as longer
weighed the important influence in Louis' career of the years
thread-like forms upon gelatine, and as straight rods containing irregular vacuoles and unstained poles upon potato.
of quiet work at La Charite. At the Pennsylvania Hospital
Vilchurf further, in a study made of some 200 cultures from
he had an opportunity to study the common continued fever
the organs of four tyj^hoid patients, describes variations in  
of the country, and determined that it was identical, clinically
form, particularly on old gelatine cultures and upon potato.  
and anatomically, with the typhoid fever of Louis, and characterized by a special lesion in the glands of Peyer. I do not
These occurred as vacuoles which after 73 hours took the  
know exactly how long he remained resident physician at the  
stain and then more intensely than the rest of the organism.  
Pennsylvania Hospital, but he was soon after appointed one
Aside from these irregular forms I have been unable to find
of the physicians at Blockley, and here in 1836 he was able io
in the literature any reference to such involution forms as are
carry out his most important piece of work. The general
noted in this case.  
opinion prevailed that the fever which Louis described and
which had the lesions in the small bowel was only a modification of the ordinary typhus fever which at that time prevailed so extensively, particularly in Great Britain and  
Ireland. In London, Edinburgh and Dublin the intestinal
lesions were regarded as only accidental, and not indicative of
a special affection. Dr. Gerhard knew the typhoid fever of
Louis well, and had had an opportunity of studying it again
at the Pennsylvania Hospital, so that when the epidemic of
typhus fever developed in 1836 he was in a very good position
to make an accurate study of the disease. Two hundred and
fourteen cases were observed, and as a result of his study he
declared positively that the typhus fever, which was similar
to the disease which he had also seen in Edinburgh, was a
different affection altogether from the typhoid fever with
intestinal lesions. These observations, vou must remember.  


The growth upon agar-agar in bouillon and in milk showed
no variation from the normal, the irregular forms being seen
only upon potato, sugar agar and gelatine, as noted above.




August-September, 1897.]


*Chanteme8se et Widal, Recherches sur le bacille typhique et
I'etiologie de la fiSvre typhoide. Archives de Physiologie, I, 1887.


f Vilchur, Cultivation of Typhoid Bacillus from Organs and
Evacuations of Typhoid Patients. Vrach, St. Petersburg, 1886,
VII, pp. 456-458. Eef. Lancet, London, 1886, II, p. 137.


JOHNS HOPKINS HOSPITAL BULLETIN.




The control culture used in the study of this case did not at
any time show such involution forms as the bacillus under
consideration, while culturally the two organisms appeared
identical.


167
It seems therefore unavoidable to consider that this bacillus, which was found in a patient dead of typhoid fever, being
isolated from five different sources, and reacting to every test in
the manner of the true bacillus of typhoid fever, is, in spite of
the peculiar involutions it undergoes, no other than the
bacillus typhosus.


In conclusion I wish to express my appreciation to Dr.
Simon Flexner for his kindness and interest in the study of
this case, and also to Dr. Gray of the Army Medical Museum,
Washington, for his kindness in taking the photographs
which illustrate this report.


Description of Plate.


were made in 1836, at a time when the greatest confusion
Figs. I and II. Bacillus typhosus obtained from this case
existed as to the forms of fever. It took a great many years
as it appears after a growth of 24 hours upon agar-agar.  
in Great Britain before the duality of the prevalent fever was
Zeiss II mm. apochromatic objective, No. IV projection ocular.
recognized, but owing to the influence of Gerhard's paper,  
Gentian violet staining.  
and to the accurate knowledge of fever brought to this
country by Louis' pupils, the differentiation of the two
diseases was here quickly recognized, since, as already mentioned, Bartlett in 1812 considered them apart.  


Gerhard's work influenced his Paris friends greatly, and  
Figs. Ill and IV. The same organism as it appears after
this was strengthened by the papers read before the Society
a growth of two weeks upon glucose agar-agar. Same magnification. Gentian violet staining.  
for Medical Observation by Geo. C. Sbattuck and Alfred
Stille, of whom the former had had opportunities of studying
typhus fever in Great Britain, while the latter had been one
of Gerhard's house physicians in the typhus epidemic at
Blockley. Shattuck's paper is published in the Medical
Examiner for 1840. I have always regretted that Dr. Stille's
paper has never appeared in print. He was kind enough to
let me see it, and, as I have mentioned elsewhere, the differential points between typhus and tyi^hoid fever are nowhei-e
more clearly laid down.  


The University of Pennsylvania early took advantage of
Gerhard's training and utilized him as clinical lecturer at the
Philadelphia Hospital. He soon acquired a special reputation
in diseases of the heart and lungs. In 1842 appeared the first
edition of his work on Diseases of the Chest, which ran through
four editions, and is still a valuable work of reference. One of
his fellow-students in Paris, Stewardson, has given a very pleasing picture of him as a clinical teacher : " As a clinical teacher
he was remarkably successful and exerted a powerful and
commanding influence. Without any pretension to eloquence,
he nevertheless riveted the attention of his hearers and
stimulated their enthusiasm. Himself deeply interested in
bis subject, he communicated this interest to his audience by
the sheer force of truth. Students saw that truth was his
object, not display ; the advancement of science, and not the
gratification of personal feelings, whether of vanity or ambition; in short, that in his mind, a deep interest in his subject
and a thorough conscientiousness in the pursuit of it were
the overmastering motives. In an easy and conversational




A CASE OF TYPHOID FEVER IN WHICH THE TYPHOID BACILLUS WAS OBTAINED TWICE


style he presented to his hearers a graphic portraiture of the
FROM THE BLOOD DURING LIFE.  
case before them, bringing into relief its most important
symptoms; impressing upon their minds the most striking
features in its history; pointing out, by a few clear and
practical expressions, the bearing of any particular fact upon
interesting medical questions, but avoiding long and labored
arguments, or general disquisitions upon the nature of
diseased action. He neither stimulated the fancy by the
flowers of rhetoric, nor amused the intellect with episodes upon
theoretical questions, but confined himself to drawing such
practical conclusions as were clearly deducible from the facts
presented. No man of his day enjoyed so high a reputation
as a clinical teacher, and not only did he succeed in an eminent
degree in arousing the enthusiasm of students and putting
them in sympathy with himself, by infusing into them his
own ardor in his favorite study ; but he produced an influence
upon the profession here which is felt still, which has fostered
the establishment of clinical teaching among us, and done
much to give it that rank which it now occupies here as a
branch of medical instruction."


Of the work of Louis' other students in this country time
By E. Bates Block, M. D., Assistant Resident Physician, The Johns Hopkins Hospital.  
would fail me to tell — of the influence of Bowditch, Holmes
and Shattuck in Boston, of Swett, Clark and others in New
York, of Pennock, Stewardson, Stille in Philadelphia, and of
Power in Baltimore. To them all we owe a heavy debt of
gratitude. They brought from Paris enthusiasm, faith in the
future, faith in the profession of their choice, accurate
methods and a loyal love of truth. Endowed with the spirit
and zeal of their master, they carried his great message to the
New World ; and more than this, touched with those finer
qualities which made Louis so lovable, they have become
bright ideals for all future generations of American students.  


There remain, so far as I know, three only of the Paris
students of whom I have spoken, John T. Metcalf, Meredith
. Clymer, and your honored patron, Alfred Stille. They, too,
must soon go the way of all the earth ; but among the consolations of old age what greater solace can they feel than that
the lives of the men whose fathers and grandfathers they
taught are still made better by their presence.




Evidence is strongly in favor of the fact that, at some period
of the disease, the typhoid bacillus is present in the blood in
nearly all patients suffering from typhoid fever, gaining entrance from time to time at the site of the intestinal lesions.
It is the rule for the typhoid bacillus to be cultivated from
the internal organs (spleen, mesenteric glands, etc.) after
death, and sections of these organs usually show bacilli which
resemble the bacillus typhosus, in clumps or masses in the
capillary vessels. The early experiments of Wyssokowitsch*
show that these organs are principally concerned in removing
from the blood introduced bacteria. It was shown by Welch
and Nuttallf in 1891 that human blood serum is capable of
destroying many typhoid bacilli, and later by other observers
that the blood serum from typhoid patients also possesses this
power, so that the peculiar conditions which allow these
organisms to live in the capillary vessels of the organs cannot,
at least in the majority of cases, depend upon a simple loss of
this power of the blood serum. That the invasion of the
blood or organs by other micro-organisms, more particularly
the streptococcus pyogenes, modifies the relation of the patient
to the typhoid bacillus, has been clearly shown by VincentJ
in experiments upon animals and by cultures made at autopsy


WILLIAM HARVEY AS AN EMBRYOLOGIST.*
*Zeit8chrifl fiir Hygiene, 1886.  


By William K. Brooks, LL. D., Professor of Zoology, Johns Hoiikins JJniversUy.  
f Verbal communication.  


t Annales de I'lnst. Pasteur, 1883.




The immortal discoverer of the circulation of the blood is
held to be also the discoverer of the law of embryology —
"that all animals are produced out of ova" (Encyc. Brit.,
9th ed., art. Embryology, p. 164); and he is also held to have
had some vague premonition, scarcely worth mentioning in
history, of the great law that the complex animal arises, from
a relatively homogeneous germ, by gradual differentiation or
epigenesis.


I hope to show, by quotations from his work on embryology
in human cases. In six out of 31 such autopsies he found the
(Exercitationes de Generatione Animalium, Amstelodami,  
streptococcus associated with the typhoid bacillus. In one
case a typhoid patient whose temperature had become normal
developed a streptococcus angina, the temperature rose and
on the fourth day the patient died. At autopsy the typhoid
bacillus and streptococcus were obtained from the organs and
the latter from the blood. The streptococcus pyogenes has
also been found in association with typhoid bacillus post mortem by Flexner* in 5 out of 6 cases reported, by Wright and
Stokesf in 2 out of 9 autopsies, by KleinJ in the blood, once in
association with B. typhosus, by Netter, E. Fraeukel, and
others. Karliuski§ has found streptoccoci in the pulmonary
complications of typhoid fever in six out of nine cases, some
of them being associated with the typhoid bacillus in the
lungs. A similar case is reported by Flexner {op. cit.) In
forty-one abscesses in typhoid cases examined by Vincent {op.
cit.) the staph, pyogenes aureus was present thirty-two times,
all of these patients recovering. In eight cases streptococcus
alone or associated with the bacillus typhosus was met with,
and of these, five died. Assuming that in these instances the
typhoid bacillus was increased in virulence, it may be said that






■ Read before the Johns Hopkins Historical Club, February, 1897.  
* Johns Hopkins Hospital Reports, Vol. V.  


t Boston Med. and Surg. Jour., March-April, 1895.


tBaumgarten's Jahresb., 1894, Vol. 10.


1651, translated into English by Robert Willis, M. D., London,
§See Vincent, op. cit.  
1848), that both these current impressions are erroneous. He
not only formulated but demonstrated epigenesis. liis statement of this law is clear, definite and thoroughly modern,
and it is based upon actual observations which are fully
described.  


On the other hand the conception which he sought to
express by the dictum "omne vivum ex ovo" is totally foreign
to the principles of modern embryology. Harvey was a worker,
not a dreamer, and his dictum is no mere guess or happy inspiration. It sums up results reached by laborious research, and
as a generalization based on actual study it still has value,


a similar modification of the physiological characters of the
typhoid bacillus infection is produced (.Sanarelli*) by inoculating cultures together with the soluble products of the
bacillus coli communis and the bacillus proteus.


The clinical history of this case presents points of interest
in connection with the bacteriological investigations both
before and after death.


although its meaning has nothing in common with tliat
M. Z., female, age 30, born in Poland, was admitted to Professor Osier's wards on Saturday the 4th of July, 1896. She
which the words have as we now use them. He repudiates in
could not speak English, so no history could be obtained.
most energetic language the opinions, current at his time,  
Upon admission she was restless, listless, weak, and gave evidence of shortness of breath and abdominal pain, frequently
which come nearest to the modern discovery that the physical
passing her hand over the abdomen. Soon after admission
continuity of living matter is never broken. In fact the chief
she became delirious. The examination of the thorax was
aim of his treatise is to show that his observations, as he interpreted them, prove that there is no physical or " corporeal "
negative. The abdomen was tender upon pressure, and resistant, especially in the splenic area. The pharynx was somewhat reddened and its vessels were injected.
continuity between parent and child.  
 
On the 5th of July Dr. Thayer made the following note:
Eespirations 44 to the minute, pulse 104; patient looks dull
and a little confused ; the tongue has a thick pasty coat; the
lungs are clear on auscultation and percussion; the heart
sounds are feeble but clear; the abdomen is full, generally
tympanitic, does not seem tender — it is held very tense so that  
palpation of the spleen is impossible. A number of small
spots are seen on the abdomen, some of them apparently
ecchymotic, others not unlike rose spots. There is slight cyanosis of the face and lips, which in connection with the rapidity of respiration suggests some pulmonary affection. The
patient has had one liquid stool.  
 
On the 8th of July Dr. Thayer noted further: The general
condition of the patient is about the same; she is still dull,
drowsy, delirious, and quite irresponsive when questioned.
There is marked muscular resistance in the splenic region, and
pressure here causes the patient to wince. There are no definite rose spots to-day.
 
The urine did not give the diazo reaction.  


Embryologists who permit Germans to write the history of
The temperature upon admission was 101.3°, respirations 44,
their science, and make no protest when the demonstration
and the pulse 120. Three hours later the temperature was
that the embryo arises from the egg by epigenesis is attributed to Wolff (1759), and to Von Baer (1839), are either
104.6°, and during the fourth, fifth and sixth of July ranged
ignorant of Harvey's researches (1651) or indifferent to the  
between 101° F. and 104.3° F., the low temperature being due
fame of this great Englishman, who studied the history of  
to cold baths, to which she reacted well. From then on the  
the chick as laboriously and faithfully as Von Baer, nearly
temperature gradually declined and reached normal on the  
two hundred years before. While his resources were more
8th of July. It remained practically normal for about 18
limited, his ability to reflect upon the meaning of his observations and to state in clear and energetic words the results of his
hours. On the following day it rose gradually, the highest
" Beobachtung und Eeflexion," were inferior in no way to those
point reached being 102.6°.  
of the justly famous author of the "Entwickeluugsgeschichte
der Thiere."


Harvey means just what more modern writers mean by
The respirations during her illness remained rapid and on
"epigenesis," but the strangeness of the views he opposed
the 9th of July became more labored, the pulse became more
gives us difficulty. The form of words into which an account
rapid and feeble, and the patient died at 12.45 a. m. on the  
of a scientific discovery falls is fixed by the view of the matter
10th of July.  
which is current at the writer's day, and later generations of
readers may be puzzled by inability to occupy his standpoint.
Thus it is with Harvey, and we thus explain the prevalence
of the opinion that he had no more than a dim adumbration
of truths the demonstration of which is generally credited to
Wolff and Von Baer.  


The evolutionary teachings of Bonnet are quite intelligible
On the 5th of July a culture was taken from the stool of  
to us; and as we easily put ourselves in Von Baer's place, his
the patient, by Eisner's method, with a negative result.  
refutation of Bonnet appeals to us with all its native force;
but it is much harder for us to stand where Harvey stood.  


So far as I can discover, no notion at all equivalent to
On the 6th of July a hypodermic syringeful of blood was
Bonnet's conception of germs ever entered Harvey's mind or
taken from a vein of the forearm with due antiseptic precautions. A few drops were allowed to fall on an agar slant, and  
the mind of any one before his time. He presents the evidence
the rest of the blood was mixed with melted gelatine and
for epigenesis as opposed, not to "evolution," but to "metamorphosis," and his way of using the last word is so unfamiliar
to us that we cannot grasp what he has in mind without
effort.


They who studied embryology before him held one modification or another of the very ancient belief that embryos arise
from "excrement"; that they are products of decomposition.


He gives the evidence for epigenesis as opposed to this
opinion which finds no pigeon-hole in the modern mind.
Fortunately he is a ready writer. Hlustrations and analogies
overflow his brain and pen; and patient study enables us to
pick out passages which give his views on epigenesis uncomplicated by reference to " metamorphosis." When we have
done this we find his reasoning as modern and definite as that
of Von Baer, although his resources did not qualify him to
sum up the evidence with modern exhaustiveness.


While Harvey does not deny that some " imperfect " animals
•Ann. de I'lnst. Pasteur, 1892.
may be genei-ated "out of a putrescent material, the drying of
a moist substance, or the moistening of a dry one," he tells us,
clearly and definitely enough, that the generation of all "per




fect " animals, such as the lion and the cock, " is the result of
epigenesis as the man proceeds from the boy; the edifice of
the body, to wit, is raised on the punctum saliens as a foundation ; as a ship is made from the keel, and as a potter makes a
vessel . . . For out of the same material from which the first
part of the chick or its smallest particle springs, from the
very same is the whole chick born ; whence the first little
droji of blood, thence also proceeds its whole mass by means
of generation in the egg ; nor is there any difference between
the elements which constitute and form the limbs or organs
of the body, and those out of which all their similar [i. e.
homogeneous] parts, to wit, the skin, the flesh, veins, membranes, nerves, cartilages, and bones derive their origin. For
the part that was at first soft and fleshy, afterwards, without
any change in the matter of nutrition, becomes a nerve, a
ligament, a tendon ; what was a simple membrane becomes an
investing tunic ; what had been cartilage is afterwards found
to be a spinous process of bone, all variously diversified out of
the same similar [homogeneous] material." From what "appears to be homogeneous in the beginning and resembles the
spermatic jelly" the structure of the body arises; its parts
being "at first delineated by an obscure division, and afterwards become separate and distinct organs."


He says the result of the process of development is just
placed in a Buchner jar in the thermostat. The agar slant
as if the chick were created by a command to this effect:
subsequently showed one colony, while the gelatine tube
" Let there be a similar [homogeneous] colorless mass, and let
which contained a greater volume of blood showed about a
it be divided into parts and made to increase, and in the  
dozen colonies identical in appearance. Several of these colonies were grown on the usual culture media. They did not
meantime, while it is growing, let there be a separation and
coagulate milk, grew characteristically on Eisner's medium ;
delineation of parts ; and let this part be harder and denser
inconspicuous growth on potato with increase of moisture;
and more glistening, that be softer and more colored."
did not form gas in glucose agar ; were actively motile ; did
not liquefy gelatine, and morphologically resembled the
typhoid bacillus.
 
On the 9th of July a second culture was taken by the same
method. The volume of blood obtained was smaller than in
the former culture and was allowed to fall on the surface of
an agar slant, which 20 hours later showed one colony. Inoculations of other media from this showed the same reactions
as in the previous instance. In addition these bacilli did not
produce indol; grew anaerobically; did not change the color
of Wurtz's medium; gave the agglutinative reaction with
over 40 specimens of typhoid blood, and morphologically was
identical with the bacillus obtained three days before.
 
A culture from the throat on the same day did not show
diphtheria bacilli ; the chief organism found was the streptococcus.
 
I am indebted to Dr. Flexner for the privilege of making
an abstract of the post-mortem examination.
 
The autopsy was held at 2 p. m. on the 11th of July, 37
hours after death.
 
Anatomical diagnosis : Typhoid fever; ulceration of small
intestine; acute sjjleen tumor; swelling of the mesenteric
glands; parenchymatous degeneration of the viscera; postmortem invasion of a gas-forming bacillus ; oedema of the
lungs.  


" Now it is in this very manner that the structure of the
Body cold, has been on ice. No odor of decomposition.  
chick in the egg goes on from day to day; all its parts are
formed, nourished and augmented out of the same material.  
. . . For there is a greater and more divine mystery in the
generation of animals than the simple collecting together,
alteration and composition of the whole out of parts would
seem to imply; inasmuch as here the whole has a separate
constitution and existence before its parts, the mixture before
the elements."


These passages summarize conclusions from observations
The upper portion of the body shows dark spots and
which have been more fully described in forty-four preceding chapters or "exercises," and it would be difficult, even at
splotches. The face is discolored and swollen. The greatest
the present day, to state in more definite language the truth
discoloration is over the back.  
that the developing embryo passes " from indefinite, incoherent
homogeneity to definite, coherent heterogeneity by successive
integrations and differentiations."


While we have no desire to ignore the merits of Wolff or to
Crepitation is present over the face, the neck, the upper
belittle the greatness of Von Baer, we find it hard to understand how any one who knows Harvey's works can, without
portion of the thorax and over the back. The neck is much
protest, read this assertion or similar ones in the German
swollen, thick and discolored.
works from which it is derived:


" It was reserved for Caspar Frederick Wolff, a German by
No oedema and no crepitation of lower extremities.  
birth ... to bring forward observations which . . . established
the theory of epigenesis upon the secure basis of ascertained
facts" (Encyc. Brit., 9th ed.. Embryology, 1(35).  


We now know that the germ itself is an organism of wonderful complexity ; that its homogeneity is relative, not absolute ; but there is great mystery to us as well as to Harvey in the
The abdomen is distended and contains gas which has a
somewhat putrefactive odor. The intestines are distended,  
but not discolored.


The tissues about the kidneys, pancreas, caecum and the
root of the mesentery are emphysematous. The mesenteric
and cascal glands are enlarged, softened and reddened.


The spleen is enlarged and softened, and on section appears
dark in color, almost diffluent.


August-September, 1897.J
The liver shows many gas bubbles under the capsule, and
on section it is found to be penetrated throughout by small
gas vesicles, and the blood which escapes from the cut ends
of the portal veins is frothy. The organ is pale, homogeneous, and cloudy yellow in color.  


Both kidneys are emphysematous, the capsules adherent,
the cortex increased, and the stria? coarse.


The duodenum shows many gas cysts. The small intestine
shows swollen patches of Peyer; lower down the patches
exhibit small erosions. As the valve is approached the enlarge


JOHNS HOPKINS HOSPITAL BULLETIN.


y




169


June, 1897.]


121


manner in which " the whole has a separate constitution and
existence before its parts," and while the doctrine of "metamorphosis " as held in Harvey's day has vanished from
science, I venture to believe that we shall Knd in his discussion of this doctrine, clear statement of other difficulties
which are still as grave as he found them.


It is hard to decide just what his opinion on spontaneous
generation was. No less careful a student than Huxley tells
us (Encyc. Brit., 9th ed., art. Evolution, p. 746) that "Harvey
believed as implicitly as Aristotle did in the equivocal generation of the lower animals." "Harvey shared the belief of
Aristotle — whose writings he often quotes, and of whom he
speaks as his precursor and model, with the generous respect
with which one genuine worker should regard another — that
such germs may arise by a process of 'equivocal generation'
out of non-living matter."


1 am by no means confident that this assertion does justice
ment of the patches increases, as does the extent of erosion.  
to Harvey, or that the quotations from Aristotle prove anything except that Harvey was not yet quite prepared to
Occasionally these patches show hemorrhagic infiltration.
demonstrate their error. I believe there is ample evidence that
At the valve nearly the whole of the intestine is involved in  
he had made many observations which, while he never published them, led him to distrust most of the familiar examples of spontaneous generation, although he may not have
deep ulceration which presents a sloughy and necrotic appearance and is nearly black from imbibition of blood.  
been fully armed to attack the teachings of " my leader,"
Aristotle, "one of nature's most diligent inquirers," "whose
authority has such weight with me that I never think of differing from him inconsiderately." It is true that he quotes without comment, and occasionally without credit, many passages
in which Aristotle affirms sjjontaneous generation ; but as an
offset to this he tells us explicitly (Exercise the forty-first)
that he shall show in another place " that many animals,
especially insects, arise and are propagated from elements and
seeds so small as to be invisible (like atoms flying in the air),
scattered and dispersed here and there by the winds ; and yet
these animals are supposed to have arisen spontaneously, or
from decomposition, because their ova are nowhere to be
found." He was far too cautious to have ventured to criticise " the philosopher," even to this extent, without pretty
good evidence; and in Exercise the sixty-ninth he tells us
why this evidence was never published. "Let gentle minds
forgive me," he asks, "if, recalling the irreparable injuries I
have suffered, I here give vent to a sigh. This is the cause
of my sorrow: — whilst in attendance on his majesty the king,
during our late trouble and more than civil wars, not only
with the permission but by the command of the Parliament,
certain rapacious hands stripped not only my house of all its
furniture, but, what is subject of far greater regret with me,
my enemies abstracted from my museum the fruits of many
years of toil. Whence it has come to pass that many observations, parlictilarly on the generation of insects, have perished, with detriment, I venture to say, to the republic of
letters."


Is there not reason to believe that, if they are ever discovered,
The lungs are deep in color, crepitate throughout, and almost
those lost observations will be found to cover some of the  
sink in water. The cut surface is smooth and dark. The
ground which was so successfully explored by Spalanzanni
bronchi are dark in color from imbibed blood. The blood in
more than a hundred years later ?
the vessels is frothy. The right side of the heart is enormously distended. On incision there is escape of gas and
collapse. The intima of the vessels, and endocardium, are
deeply blood stained.


Harvey's reference (Exercise the twenty-seventh) to " the  
In the right upper angle of the cavity of the uterus is a
animalculae which are engendered in our bodies . . . lumbrici,
portion of placenta the size of a walnut, apparently the
remains of a recent abortion. It is oval in shape, firmly
attached, dark in color, porous in consistence, and has a deep
red color. The mucosa is congested.  


Cover-slips from the heart's blood, liver, spleen and intestinal ulcer showed, along with other bacterial forms, a large
capsulated bacillus resembling closely the bacillus aerogenes
capsulatus. These were not seen upon cover-slips from the
bile and placenta. Anaerobic cultures were taken from all of
the organs, but the large bacillus failed to grow.


Cultures upon agar plates yielded the following results:
Bacillus typhosus in placenta, spleen, liver and kidney. Bacillus coli communis in the kidney and heart's blood. Bacillus
pyocyaueus in the heart's blood. Bacillus proteus in the bile.


ascarides, lice, nits, syrones and acari," and to " the worms
Some of the appearances found at the autopsy must be
which are produced from plants and their fruits, as from gallnuts, the dog-rose, and various others," might be held to imply
regarded as due to post-mortem changes, so that the invasion
belief in heterogenesis, if he did not tell us, almost immediately,  
of the bacillus coli communis and the bacillus proteus after
that: "It certainly cannot be that the living principles of
death cannot be entirely excluded. It is not improbable, however, that they may have been present in the orgaiis or body
these animals which arise in the gall-nuts existed in the oak,
fluids during life. The bacillus pyocyaneus is not a common
although these animals live attached to the oak and derive
post-mortem invader.  
their sustenance from its juices."


Notwithstanding Huxley's opinion, Harvey seems to have
In reading over the available literature I find that the
been nearer than any of his successors for a hundred years to
typhoid bacillus has been obtained during life from the  
the modern discovery that all living things come from germs,
blood of patients suffering from typhoid fever by three other
although I shall show soon that he did not intend to imply
writers. Thiemich* found it once in blood taken from a vein
anything at all like the modern view by his statement that
this is true.  


In his discussion of epigenesis as contrasted with " metamorphosis," he assumes the reality of " equivocal " generation, as he does in many other places, although, in view of the
passages I have quoted, I believe that this is admitted out of
courtesy to Aristotle, and for the sake of the argument, as
something which he is not yet fully prepared to disprove.


He tells us (Exercise the forty-fifth) that there are two ways
in which one thing may be made out of another. When a
workman cuts the material already prepared, divides it and
rejects what is superfluous, till he leaves it in the desired
shape, as in nuiking a statue from a block of stone, the whole
material of the future piece of work has already been in existence before it is finished into form or any part of the work is
yet begun. AVhen on the other hand a potter educes a form
out of clay by the addition of parts, increasing its mass, and
giving it a figure, at the same time that he provides the material, which he prepares, adapts and applies to his work, "the
form may be said rather to have been made than educed."
" So exactly it is with regard to the generation of animals.
Some, out of a material previously concocted and that has
already attained its bulk, receive their forms and transfigurations ; and all their parts are fashioned simultaneously, each
with its distinctive characteristics, by the process called metamorphosis, and in this way a perfect animal is at once born;
on the other hand, there are some iu which one part is made
before another, and these from the same material afterwards
receive at once nutrition, bulk and form ; that is to say, they
have some parts made before, some after others, and these are
at the same time increased in size and altered in form. The
structure of these animals commences from some one part as its
nucleus and origin, by the instrumentality of which the rest
of the limbs are joined on, and this we say takes place by the
method of epigenesis, namely by degrees, part after part; and
this is, in preference to the other mode, generation properly
so called. In the former of the ways mentioned, the generation of insects is effected when by metamorphosis a worm is born
from an egg ; or out of a putrescent material, the drying of a
moist substance or the moistening of a dry one, rudiments are
created from which, as from a caterpillar grown to its full size,
or from an aurelia, springs a butterfly or fly already of a
proper size, which never attains to any larger growth after it
is first born. But the more perfect animals with red blood are
made by epigenesis or the superposition of parts. In the
former, chance or hazard seems the principal promoter of gen


' Baumgarten's Jahresbericht, Vol. 10, 1894, p. 266.


170




of the forearm. Ettlinger* obtained it twice by the same
method, and Stern twice.f
Other writers report a negative result. NeuhausJ failed in
twelve cases from blood taken from a vein of the forearm, and
twenty-four cultures§ from blood obtained by pricking the
skin of the forearm; Frilnkel and Simmonds|| in sis cases.
Ettlinger** reports eight negative results with blood taken
from the forearm, and Klein ten.|f Failvires are also reported
by Gaffky, Riitimeyer, Chantemesse and Widal, v. Jaksch, and
Vaquez.
In six other cases I failed to obtain the typhoid bacillus,
although a syringeful (1.5 cc.) of blood was employed in each
instance.
The typhoid bacillus has been obtained from the blood
after death by several observers: Viucent,|| Friinkel and Simmonds,§§ Flexner,|||| Klein,*** and by Wright and Stokes.fft
Heretofore not much importance has been attached to the
work of Letzerich,JII Almquist,m Maragliano,||| Riitimeyer,§§§ Pasquale,§§§ Guarnierl,§§§ and Karliuski,§§§ because
their examinations were made at a time when the differentiation of the typhoid bacillus from other micro-organisms
closely resembling it in morphological and biological characters, was not so clearly understood as it is at present. However, it is probable now, that since definite proofs exist of
the not very infrequent occurrence of the bacillus typhosus in
the blood, either before or after death, their work may come
to have more significance.


JOHNS HOPKINS HOSPITAL BULLETIN.




* Wirtz, Precis de Bacteriologie Clinique.
■fCentralb. f. innere Med. 1896, No. 49, p. 1249.


[Nos. 77-78.  
I See Wurtz.  


§ Berliner klin. Wochenschr., No. 6, 1886.


II Sternberg, Text-book of Bacteriology, p. 352.
** Loc. cit.


eration, aud the form is due to the potency of a pre-existing
■H-Baumgarten, Vol. 10, 1894, p. 266.  
material ; and the first cause of generation is 'matter ' rather
 
than an ' external efficient,' while the more perfect animals
XI Ann. d. I'lnst. Pastesr, 1893 ; Le Mercredi medical, 17 fev. 1892.  
owe their immortality to one constant source — the perpetuation of the same species . . . Bees, wasj^s, butterflies, and whatever is generated from caterpillars by metamorphosis, are said
to have sprung from chance, aud therefore to be not preservative of their own race. . . . The lion and the cock owe their
existence, as it were, to nature, or an operative faculty of a
divine quality, and require for their propagation an identity of
species, rather than any supply of fitting material." " In the
generation by metamorphosis forms are created as if by the
impression of a seal, or as if they were adjusted in a mould . . .  
but an animal which is created by epigenesis attracts, prepares, elaborates, and makes use of the material all at the same
time. The processes of formation aud growth are simultaneous.
In generation by metamorphosis the whole is distributed and
separated into parts, but in that by epigeuesis the whole is put
together out of parts, in a certain order, and constituted /ro?»
them. In the one case the result is due to matter ; in the other
the animal makes itself.  


" Now it appears clear from my history that the generation
§§ Sternberg, Text-book of Bacteriology, 1896, p. 352.  
of the chick from the egg is the result of ejjigenesis rather than
of metamorphosis, and that all its parts are not fashioned
simultaneously, but emerge in their due succession and order;
it appears, too, that its form proceeds simultaueously with its
growth, aud its growth with its form; also that the generation of  
some parts supervenes on others previously existing, from which
they become distinct; lastly, that its origin, growth aud consummation are brought about by the method of nutrition.  


" The formative faculty of the chick rather acquires and
ill Op. cit.  
prepares its own material than only finds it when prepared,
aud the chick seems to receive its growth from no other than
itself. And as all things receive their growth from the same
power by which they were created, so likewise should we
believe that the chick is created by the same power by which
it is preserved and caused to grow."


The meaning of this rather puzzling passage will be somewhat clearer after we have examined Harvey's views on generation, but when we omit the complications which come from
*** Baumgarten, 1894, Vol. 10.
the reference to "metamorphosis," its meaning as interpreted
tttOp. cit.
by the rest of the essay is about as follows :


The substance which composes the body of all "perfect"
ttl Sternberg, op. cit.  
animals does not exist as such before the body itself is formed;
§§§See Flexner, op. cit.  
but it consists of unorganized or "homogeneous " food which
is changed by nutrition into all the diversified parts of the
complicated body, so that nutrition, growth aud development
go on together. As the organized body is constructed by the
assimilation of unorganized food, its structure cannot be the
outcome of the ordinary or physical properties of this food.
There must be some organizing iufiuence at work making use
of these properties to construct out of homogeneous matter a
definite organism belonging to the same species with the
parents. To the question what this organizing influence is,
he answers that this is a " divine mystery," or, in plain
English, that he does not know, although he finds clear evidence of its existence. He says in many places that the egg
has a ■' vital principle," but the context shows that he means






by this no more than we mean when we say it is " alive," and
SUCCESSFUL CULTIVATION OF GONOCOCCUS IN TWO CASES OF GONORRHEAL ARTHRITIS
nothing is farther from his thoughts than recourse to supernatural agencies, for he tells us clearly that while the cause of
AND ONE OF TiENOSYNOVITIS, WITH REMARKS ON A NEW MEDIUM.  
its development is a " divine mystery," " the egg is a natural
body endowed with animal virtues ... it is moreover a body
which under favorable circumstances has the capacity to
pass into an animal form; heavy bodies, indeed, do not sink
more naturally, nor light ones float, when they are unimpeded,
than do seeds aud eggs in virtue of their inherent capacity
become changed into vegetables aud animals." (Exercise the
twenty-sixth, p. 373.)


It would be a gross error to infer, from this passage or
By Francis R. Hagner, M. D., Assistant Resident Surgeon, Johns Hopkins Hospital.  
from others like it, any further similarity between Harvey's
opinions aud the results of moderu microscopic study of ova
and male cells. In order to understand the meaning of his
celebrated dictum " omne vivum ex ovo " we must undertake
more extended analysis of his observations aud reflections on
generation, aud of the opinions of his predecessors.  


Aristotle saw nothing strange or exceptional in the generation of animals from decomposing organic matter, for he
believed that all generation takes place in essentially the same
way ; and he regarded the generation of insects from putrescent slime as a simple or typical example, what we should
now call a primitive type, of generation in general, in comparison with which more complicated instances are to be
interpreted.


As a bloody substance is discharged at intervals from the
reproductive organs of woman, during the fertile period of her
life, and as its apjiearance marks the beginning and its cessation the end of fertility, he believed that the mammalian
embryo is formed out of this substance just as other animals
are generated from decomposing matter of other kinds.


" Milk aud the menstrual discharge," he tells us (De Gen.
The more successful attempts to cultivate the gonococcus
II, i), " are of the same nature." " When the semen masculinum enters the female uterus it coagulates the purest part
from pathological conditions other than urethritis and conjunctivitis, have widened our view concerning the part played
of the catamenia," aud when this has " set in the uterus " it
by this organism in human pathology.  
forms a coagulum like curdled milk. As heat causes milk to  
curdle, so " the semeu or geniture of the male bears the same
affinity to the nature of the catamenia " aud causes it to " set "
without itself contributing any part of the substance of the
coagulum. " The female always supplies the matter, the
male the power of creation, and this it is which constitutes
one male and another fenuile." "The male is the efficient
agent, aud by the motion of his geniture creates what is
intended from the matter contained in the female." " The
body and the bulk therefore are necessarily supplied by the
female; nothing of the kind is required from the male; for
it is not even requisite that the instrument, nor the efficient
agent itself, be present in the thing that is produced. The
body then proceeds from the female ; the life (anima) from
the male."


Harvey points out the inconsistency of Aristotle's admission
Even now it would take much space to enumerate all the  
that hybrids "partake of the species of both parents" (De
different lesions and parts of the body in which this organism
Gen. Anim. II, 3), and his assertion that '• the conception or
has been found. The gonococcus, as is well known, cannot be
egg receives '" "from the feuuile its body solely and its dimensions," and that the mother has no part in the trausmissiou
cultivated with the facility of the other pyogenic cocci, and it
of "form, species and life"; for the studj" of jiybrids shows
has for this reason not lent itself so readily as an aid to diagnosis in obscure cases, unless perchance it could be found in
the error of his opinion that creative force or vital power is






August-September, 1897,  
cover-slips, where its peculiar form and definite staining reaction might suflBce for its identification.


Greater experience, on the other hand, has shown that,
although this organism does not grow at all, or at least most
feebly and unsatisfactorily, upon the ordinary culture media,
its choice of substance is still not a small one.


Since Steinschneider's observation of the great value of
urine in the composition of a culture medium for the gonococcus, no really easy practicable method of preparing a
medium containing this fluid has been devised.


JOHNS HOPKINS HOSPITAL BULLETIN.




122


171
[No. 75.






derived exclusively from the male, and proves that both
We offer iu the accompanying paper a simple method which,  
parents must be efficient in determining form or species.  
in the limited number of cases at our disposal, has proven successful.  


The medical men of Harvey's day held a different opinion,
It is in part my object in presenting these cases to draw
as he tells us iu Exercise the thirty-second. Like Aristotle,
attention to the ease with which, by the use of this medium,
they held that the embryo arises from "excrement"; but
the gonococcus may be cultivated.  
they held, in opposition to his teaching, " that the prime
matter of conception is not blood, but the mingled geuitures
of both sexes." They also held, iu opposition to Aristotle,
the opinion, which Harvey shares, that the male is no more
" the efficient cause of generation " than the female.  


"Conception, according to the opinion of medical men,
I must state that the value of the medium was further
takes place in the following way: during intercourse the  
tested and proven by cultivating this micro-organism from
male and female dissolve in one voluptuous sensation, and  
urethral piis. The cases themselves are of interest from their  
eject their seminal fluids (geniturae) into the cavity of the
clinical aspects, and as illustrating the good results which
uterus, where that which each contributes is mingled with
surgical interference gives when undertaken in time.  
that which the other supplies, the mixture having both
equally the faculty of action and the force of matter; and
according to the predominance of this or that geniture does
the progeny turn out male or female. It is further imagined
that immediately after the intercourse something of the conception is formed iu the uterus."


If the uterus contains a " conception " immediately after a  
The possibility of making a positive diagnosis before opening the infected joint enhances the likelihood of good which
fertile union, in the form of a bloody coagulum, as Aristotle
may be confidently expected from these measures.  
supposes, or iu the form of the mingled emissions or geuitures
of both sexes, as the medical men taught, this ought to be  
discoverable, and Harvey, a true scientific investigator, set
himself to hunt for it without a microscope.  


His facilities for making the search, and its results, are best
No question is likely to arise as to the identity of the cocci
described in his own words. He was the attending physician
isolated in these cases, even in view of the fact that in one case
of the King of England, and he tells us : " It was customary
the organism did not completely decolorize when treated
with his Serene Majesty, King Charles, after he had come to  
according to Gram's method.  
man's estate, to take the diversion of hunting almost every
week, both for the sake of finding relaxation from grave cares
and for his health; the chase was principally the buck and
the doe, and no prince iu the world had greater herds of deer.
This gave me an opportunity of dissecting these animals
almost every day during the whole of the season when they
were rutting, taking the male and falling with young. I had
occasion so often as I desired it to examine and study all their
parts, particularly those devoted to the offices of generation."


His studies upon the development of the embryo of the
The later writers on the subject, among whom I shall only  
deer are fully described at length in the essay on generation,  
mention Caplewski,* concede great difference in the behavior
but only those which relate to the question of conception
of cocci from different sources.  
concern us at present. Here his researches had a very definite
result, "llepeated dissections performed in the course of the
month of October, both before the rutting season was over
and after it had passed, never enabled me to discover any
blood or semen or a trace of anything else, either in the body
of the uterus or its cornua." Neither the bloody coagulum
of Aristotle nor the geniture of the medical men has any existence. The "conception" which should be discoverable iu
the uterus if their teachings are correct, cannot be found there
when a search is made for it, and actual observation shows
that their teachings are erroneous and fanciful.  


The keepers and huntsmen said " that I was both deceiving
Most samples of gonococci are quickly and readily decolorized; some few are more refractory and may retain the stain in
myself and had misled the king, and that there must of
part. On the other hand, the ordinary pyogenic cocci which
necessity be something of the conception to be found in the  
resist Gram's method sometimes become decolorized.  
uterus. These men, however, when I got them to bring their


No small part in this procedure is played by the composition
of the stain and decolorizing agents.


But when all the facts are gathered, namely, the source of
the organisms, their morphological properties, their diflBculty
of culture, and slight viability, together with their staining
reaction, no doubt is likely to be entertained concerning their
nature.


own eyes to the inquiry, gave up the point." Harvey tells us
Case I.  
that the king fully appreciated the value of the investigation,
and in order " that this important question might be the more
satisfactorily settled in all time to come," provided means for
isolating the does and for proving that there was no error as
to the fact of conception ; but the physicians were still unconvinced, and "held it among their impossibilities that any
conception should ever be formed without the presence of the
semeu masculinum, or some trace remaining of a fertile intercourse within the cavity of the womb." But the man who
had proved the error of their teachings regarding the function of the heart and blood-vessels had little tolerance for
their belief iu anything which they were unable to demonstrate.  


If they had insisted that Harvey's resources were inadequate, that the "conception" for which he sought is too
B. B., set. 21, female, colored. Domestic. Admitted December 5, 1896.  
minute to be found by such rough means, we now know they
would have been in the right, for even at the present day our
knowledge of the essential facts of mammalian conception is,
for the most part, a deduction from observations on the eggs
of animals which were almost or quite uuknown to Harvey,
the sea-urchin and ascaris, for example. But his proof of
the non-existence, in the uterus of the doe, of anything corresponding to their teachings is conclusive. He did not stop
here, however, for he tells us: " In the dog, rabbit and several
other animals, I have found nothing iu the uterus for several
days after intercourse ; I therefore regard it as demonstrated
that after fertile intercourse among viviparous as well as
oviparous animals there are no remains in the uterus either of
the semen of the male or of the female emitted in the act;
nothing produced by any mixture of these two fluids, as medical writers maintain, nothing of the menstrual blood present
as 'matter' iu the way Aristotle will have it; in a word, that
there is not necessarily even a trace of the conception to be
seen immediately after fruitful union of the sexes. It is not
true, consequently, that in a prolific connexion there must be
any prepared matter in the uterus, which the semen masculinum, acting as a coagulating agent, should congeal, concoct and
fashion or bring into a positive genei'ative act."


His study of the generation of birds leads him to the same
Previous History. Patient has never been very healthy.  
result. "As the hen does not emit any seminal fluid, and as
One year ago she had an attack of rheumatism; at this time
the seminal fluid of the cock does not reach the uterus of the
the right knee was swollen and painful. The jjatient was
heu, and as there is no trace of an egg to be found in the
confined to bed for one month, and has never had any trouble
uterus immediately after intercourse, it is obvious that it is not
with the joint since. There was no history of any vaginal
engendered" by the mixture of seminal fluid in the way the
discharge at this time.  
medical men teach (Exercise the thirty-second). After quoting
Aristotle's opinion that the chick is formed out of menstrual
blood coagulated by the influence of the cock, he says (Exercise
the twenty-first) : " The business in the generation of an egg is
very different from this; for neither does the semen or rather
the 'genitura' proceeding from the male in the act of intercourse, enter the uterus in any way, nor has the hen after
she conceives any particle of excremeutitious matter, even of
the purest kind, or any blood in her uterus which might be
fashioned or perfected by the discharge of the male. Neither
are the parts of the egg produced by any kind of coagulation ;
neither is there anything like curdled milk to be discovered
iu the uterus. The cock, I say, contributes neither form nor


Present Illness. Patient acknowledges exposure within the
last month. Has had vaginal discharge for three weeks. Six
days before entrance to the hospital she noticed pain and
swelling of the left knee. Pain more marked at night and
increased by motion.


Examination. The patient is a rather poorly nourished,
unintelligent woman, with a slight blowing murmur over the
apex of the heart, transmitted to axilla. The joint is quite
tense, painful on palpation and motion. Patella floats. There
is marked induration and thickening of the peri-articular
tissues, which are boggy. Distinct fluctuation over the joint.
A purulent discharge observed to be present in vagina and
urethra. The examination of cover-slips was negative for
typical gonococcus-like organisms.


172




*Hygienische Rundschau, Vol. 6, No. 21, p. 1029.


JOHNS HOPKINS HOSPITAL BULLETIN.




December 5th. Knee aspirated with sterile syringe and a
straw-colored fluid obtained; this showed under the microscope a great many polymorphonuclear leucocytes, and a few
large diplococci which were not contained in the pus cells.
Cultures made on agar-agar, gelatin, potato and bouillon were
negative after forty-eight hours in the thermostat. Cultures
made at the same time on albuminous urine agar in twentyfour hours showed no perceptible growth, but at the end of
forty-eight hours in the thermostat about a dozen isolated
colonies, a little larger than ordinary streptococcus colonies,
elevated above the surface of the medium, presenting an
opaque white color, but still translucent, were easily seen.


[Nos. 77-78.  
Cover-slips were made, staiued with Sterling's gentian violet,
mounted in water. The examination showed diplococci morphologically identical with the gonococcus. The same specimens were then stained by Gram's method and almost completely decolorized, a faint outline still being visible here and
there. The ordinary media (mentioned previously) were inoculated from the cultures with negative results; but another
albuminous urine agar tube, inoculated, gave a similar growth
to the first after forty-eight hours in the thermostat, and this
showed the same morphological characteristics.  


Another generation, third in succession, was obtained on
the albuminous urine agar medium; this one was feebler than
the preceding ones, and no further growth was obtainable.


December 8lh. Knee again aspirated, the fluid giving the
same growth when inoculated on the albuminous urine agar
tube.


matter to the egg, but that only by which it becomes fertile and
The same negative results as described previously were
fit to engender a chick. And this faculty the cock confers by
obtained on the ordinary media. The growth mentioned was
his semen (genitura) emitted in the act of intercourse, not  
carried through three generations, but again would not grow
only on the egg which is already begun, but on the uterus
on the fourth transplantation.  
and ovary and even on the body of the fowl herself, in such
wise that eggs which have yet to be produced, eggs, none of
the matter of which yet exists either in the ovary or in any
other part of the body, are thence produced possessed of
fecundity." "Inflammable material is not set on fire by the
contact of flame more quickly than is the hen made pregnant
by intercourse with the cock" (315).  


Careful observation on the fowl, the deer, the dog, the rabbit,
December 17th. The knee joint was opened and cultures
and on many other animals, jiroves that none of them are
taken, two tubes of the albuminous urine agar being inoculated. One of these became contaminated ; in the other the  
generated out of excrement or decomposing matter. There is no
growth was very slight and did not survive for a second transplantation.  
basis in nature for Aristotle's opinion or that of the medical
men, and all these teachings break down when brought to the  
test of actual observation. It is no small thing to prove the  
error of the belief, which had been current for two thousand
years, and is even now embodied, through a quotation from St.
Paul, in our burial service, that all forms of reproduction find
their type in generation from dead putrescent matter. This
Harvey accomplished by methods which are rigorously scientific ; and with this accurate but very imperfect knowledge
he boldly faced and tried to answer the question, what is it
which the cock contributes in virtue of which the egg "becomes fertile and fit to engender a chick '"?


He undertakes "to seek the truth regarding the following  
The following is a brief description of the mode of preparation of the albuminous urine agar, which was prepared by Dr.
difficult questions : Which and what principle is it whence
Hugh Young and myself.  
motion and generation proceed':' By what virtue does the
semeuact":' What is it that renders the semen itself fruitful? Whether is that which in the egg is canse, artificer and
principle of generation and of all the vital and vegetative
operations — conservation, nutrition, growth — innate or superadded ? and whether does it inhere primarily, of itself, and as a
kind of nature, or intervene by accident, as the physician in
curing disease? Whether is that which transfers the egg into
a jiullet inherent or acquii-ed, or is it already conceived in the
ovary, and does it nourish, augment, and perfect the egg there ?
What is it besides that pireserves the egg sweet after it is
laid ? What is it that renders an egg fruitful ?" (374).  


" In truth, there is no proposition more magnificent to investigate or more useful to ascertain than this : How are all
Acid urine containing 0.05 albumen or more should be
things formed by an ' univocal agent ' ? How does the like
collected and allowed to stand for twenty-four hours, no effort
ever generate the like? . . . Why may not the thoughts, opinions, and manners now prevalent, many years hence return
being made to prevent decomposition. The urine is boiled
again, after an intermediate period of neglect? " (583).  
until a large albuminous precipitate is formed ; it is filtered
through paper, when the resulting fluid will be clear. The
filtered urine is boiled, and agar-agar, peptone, beef extract
and sodium chloride are added in the same proportion as making ordinary agar.  


As we find the embryologists of the present day vexing
The other steps are the same as in making ordinary agar,
themselves over the question, " AVhether is that which transfers the egg into a pullet inherent or acquired?" we need not
except that filtered albuminous urine instead of water is used
wonder if Harvey's success in the investigation of this magnificent proposition seems small to us. At least we must
throughout the preparation of the medium. It is important
follow him in order to understand his dictum.  
to see that the medium before being placed in tubes has a  
neutral or slightly acid reaction.  


As a starting-point this much seems to be certain. "The  
The advantages of using albuminous urine are, first, that iu
egg, even when contained in the ovary, does not live by the  
such urine albumens are always present, which are not coagulated by heat, and second, the albumen that is coagulated
vitality of the mother, but is like the youth who comes of age,
acts as a clarifying agent in the removal of the salts that usually cause the cloudiness of urine agar-agar as prepared by
made independent even from its first apj)earauce; as the acorn
taken from the oak, and the seeds of jjlants in general are no
longer to be considered parts of the tree or herb that supported






them, but things made in their own right, and which already
June, 1897.]
enjoy life in virtue of a proper and inherent vegetative power"
(375).  


Furthermore, "although some animals . . . are produced
123
from females alone" (386); "it is manifest that a fruitful
[hen's] egg cannot be jjroduced without the concurrence of a
cock and a hen ; without the hen no egg can be formed ;
without the cock it cannot become fruitful. But this view
is opposed to the opinion of those who derive the origin of
animals from the slime of the ground " (384).


" The egg is the terminus from which all fowls, male and
female, have sprung, and to which all their lives tend — it is the
result which nature has proposed to herself in their being"
(371).


"And this is the round that makes the race of the common fowl eternal; now pullet, now egg, the series is continued in perpetuity; from frail and perishing individuals an
immortal species is engendered" (385).


" We cannot conceive an egg without the concurrence of a
mixing the urine agar separately and sterilizing by discontinuous heating below the point of coagulation. It is important to have the medium very moist when inoculated.  
male and female fowl any more than we can conceive fruit to
be produced without a tree. We therefore see individuals,
males as well as females, existingr for the sake of preparing
eggs, that the species may be perennial though their authors
pass away. And it is indeed obvious that the parents are no
longer youthful or beautiful, or lusty, and fitted to enjoy life,
than while they jDOSsess the power of jiroducing and fecundating eggs, and by the medium of these, of engendering their like.
But when they have accomplished this grand purpose of
nature, they have already attained to the height, the dxnrj of
their being ; the final end of their existence has been accouij)lished ; after this, effete and useless, they begin to wither, and,
as if cast off and forsaken of nature and the Deity, they grow
old, aud, a-weary of their lives, they hasten to the end. How
different the males when they make themselves up for intercourse, aud swelling with desire are excited by venereal
impulse! It is surprising to see with what passion they are
inflamed, and then how trimly they are feathered, how vainglorious they show themselves, how proud of their strength,
aud how pugnacious they prove. But the grand business of
life accomplished, how suddenly, and with failing strength
and pristine fervor quenched, do they take iu their swelling
sails, and from late pugnacity, grow timid and desponding.
Even during the season of jocund masking in Yeuus's domains, male animals in general are dejiressed by intercourse,
aud become submissive and pusillanimous, as if reminded that
in imparting life to others they were contributing to their
own destruction. The cock alone, replete with spirit and
fecundity, still shows himself alert aud gay, clapping his
wings and ci'owiug triumphantly he sings the nuptial song at
each of his espousals; yet even he after some length of timeiu
Veuus's service, begins to fail; like the veteran soldier, he by
and by craves discharge from active duty, and the hen, too,
like the tree that is past bearing, becomes effete, aud is finally
exhausted."


Having come to the end of his means of observation, Harvey turns to reflection, the second resource of the man of
The operation consisted of opening and irrigating with
science, to see how this may help him to discover how "from
bichloride of mercury 1 to 1000, followed by salt solution, an
frail and perishing individuals an immortal species is engen
Esmarch bandage being applied above the joint to prevent
absorption of the bichloride solution.


The wound was approximated with subcutaneous silver
wire sutures, silver foil dressing applied, and the leg put up
in plaster. Of course very strict cleanliness is necessary in
these operations — in all cases the operator and assistants
wearing rubber gloves. The wound healed perprimani.
At the time of operation the subcutaneous tissues were
found very edematous and thickened, and minute hemorrhagic areas were seen in the tissues near the joint. The
fluid within the joint was serous in character, although flakes
of fibrin were contained in it. The synovial membrane was
thickened and its surface covered with hemorrhagic material
that in places had a plush-like appearance, having lost its
gloss. At the junctions of the cartilages and synovial membrane there were a number of tessellated, very vascular fringes
of fibrinous material 3 to 5 mm. in length.
The cartilages showed no change.
The patient is at present more comfortable, but has not
entirely recovered.
Case II.


August-September, 1897.]
A. D., female, fet. 20 years, colored, domestic. Admitted
 
August 25, 1895.  


No history of rheumatism.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Has had vaginal discharge for two weeks. (Patient acknowledges exposure several days before the discharge was noted.)


Three days before entrance left knee joint became painful
and swollen, pain being more marked at night; fever was
present, the highest temperature recorded being 103° F.


Examination. Large, well nourished woman.


173
Left knee slightly flexed, and warmer than adjacent parts.
Slight fluctuation on inner side of patella ; movement of the
affected joint caused great pain.


The peri-articular tissues were indurated and boggy.


There was a purulent discharge from the vagina and urethra
that contained diplococci. These were in a manner suggestive of the gonococcus and occurred within the pus cells; they
completely decolorized when stained according to Gram's
method.


dered." As liis studies seemed to prove that the contagion
The operation was done on the fifth day of the disease, and
which remains in the female "after intercourse, as the efficient
consisted in the application of an Esmarch bandage, incision
of the future offspring, is not of the nature of any corporeal
of the joint, irrigation with 1 to 1000 bichloride of mercury
substance," he was unable to escape the admission that it is
followed by salt solution, and closure of wound with silver
"incorporeal." Thus driven to the wall, if he had taken
wire. Silver foil dressing and plaster cast applied.  
refuge in "soul " or "spirit," no one could greatly blame him,
for spiritual agents had been the resource of philosophers for
many ages before his time. He was a true soldier of science,
however, seeing as clearly as we do that this venerable formula
can do notliing to help us, and preferring outspoken ignorance
to this antiquated and threadbare cloak for intellectual poverty.  


" If on further inquiry it should appear that it [the efficient]
Patient made good recovery.  
is neither spirit nor demon, nor soul, nor any part of a soul,
as I believe can be proved by various arguments and experiments, what remains, since I am unable myself to conjecture
anything beside . . . but to confess myself at a standstill ? "


What does the modern man of science in such a case? Does
The examination of joint at time of operation showed the  
he not search through the whole province of knowledge to see
peri-articular tissues to be in an cedematous and hemorrhagic
if perchance he may find some other natural phenomenon
condition.  
which bears some resemblance to the subject of his studies ?
Harvey says he knows well " that some censorious persons
will laugh at this . . . Yet this that I do is the practice of
philosophers, who when they cannot clearly comprehend how
a thing really is brought to pass, devise some mode for it in  
accordance with the other works of nature, and as near as possible to what is true."


" Since, tlien, nothing can be apprehended by the senses in  
The joint contained about 25 cc. of blood-stained fluid in  
the uterus after coition, and since it is necessary that there be
which floated small pieces of a fibrinous material.  
something to render the female fruitful, and as this is probably not material, it remains for us to take refuge in a mere
conception."


Men of science in all ages, from Aristotle to Tyndall, have
The synovial membrane was roughened, thickened and had
believed in the virtues of the provisional hypothesis; and,
the same appearance described in the preceding case.  
armed by eminent authority, Harvey undertakes, by comparing a "mere conception" with other things in nature, to
frame a provisional hypothesis of generation; but natural
science seems to be an uncongenial soil for the nurture of
such attempts, and if time has shown that Harvey's hypothesis
has little value, he errs in good company, and he also takes
pains to say he does not wish it "to be taken as if I thought
it a voice from an oracle," although he does hope it may "stir
up the intellects of the studious to search more deeply into so
obscure a subject."


Starting with the belief that "the semen of the male does
not so much as reach the cavity of the uterus . . . and that
it carries with it a fecundating power by a kind of contagious
property " from which the female "seems to receive influence
and to become fecundated without the co-operation of any
sensible corporeal agent, in the same way as iron touched by
the magnet is endowed with its powers and can attract other
iron to itself," he holds that "when this virtue is once
received the woman exercises a plastic power and produces a
being after her own image."


" Yet it is a matter of wonder where this faculty abides
after intercourse is completed. ... To what is the active
power of the male committed ? . . . Does the woman conceive
in the womb as we see by the eye and think by the brain?"
" Since there are no manifest signs of conception before the


Larger tessellated masses of fibrin adhered to synovial
membrane wherever it came in contact with the cartilage.


Bacteriological Examination.


uterus begins to relax . . . and since the substance of the  
The fluid for culture was removed from the joint with a  
uterus, when ready to conceive, is very like the structure of
sterile Volkman spoon, and placed in sterile test tube. A
the brain, why should we not suppose that the function of
small quantity of blood was obtained by allowing a stream
both is similar, and that there is excited by coitus within the
from a small artery to spurt into a sterile test tube.  
uterus a something identical with or at least analogous to
an imagination or a desire in the brain, whence comes the
generation or procreation of the ovum ?" "For the functions
of both are termed conceptions, and both, although the
primary source of every action throughout the body, are immaterial, the one of natural or organic, the other of animal
action . . . Just as a desire arises as a conception of the
brain, and this conception springs from some external object
of desire, so also from the male, as being the more perfect
animal, and as it were the most natural object of desire, does
the natural (organic) conception arise in the icterus, even as
the animal concej)tiou does in the brain. From this desire,
or conception, it results that the female produces au offspring
like the father. For just as we, from the conception of the
'form' or 'idea' in the brain, fashion in our works a form
resembling it, so in like manner the 'idea' or 'form ' of the
father, existing in the uterus, generates au offspring like himself with the help of the formative faculty.  


"Whoever has pondered with himself how the brain of the  
The tube containing the blood was allowed to stand for two
artist, or rather the artist by means of his brain, pictures to  
hours, during which time the serum had separated from the  
the life things which are not present in him, but which he
clot and could be pipetted off. An ordinary agar tube was
has once seen ; also in what manner birds immured in cages
melted and cooled to 46° C, so as to prevent the blood serum
recall to mind the spring, and chant exactly the songs they
from coagulating when added. About 5 cc. of the human
had learned the preceding summer, although meanwhile they
blood serum was added, making the proportion one-third
had never practiced them; again, and this is more strange,
human blood serum and two-thirds nutrient agar-agar; the
how the bird artistically builds its nest, the copy of which it
resulting medium was perfectly clear. The fluid medium
had never seen, and this not from memory or habit, but by
was then mixed thoroughly, and inoculated with three loops
means of an imaginative faculty, and how the spider weaves
of fluid obtained from the joint, great care being taken not to
its web, without either copy or brain, solely by the help of
add the fluid until the medium was observed to be on the point
this imaginative power ; whoever, I say, ponders these things,  
of solidifying, so as to prevent all chances of destruction of  
will not, I think, regard it as absurd or monstrous, that the  
the organism by heat.  
woman should be impregnated by the conception of a general
immaterial ' idea ' and become the artificer of generation."


"For my own part then, when I see nothing left in the  
The inoculated medium was poured into a Petri's dish and
uterus after intercourse, to which I can ascribe the principle
placed in thermostat at 37° C. No growth was visible at the  
of generation, any more than there is in the brain anything
end of the first twenty-four hours, but at the expiration of
discoverable after sensation and experience, which are the  
forty-eight hours five or six small colonies could be seen.
prime sources of art, and when I find the structure of both
These were isolated and about the size of the ordinary streptococcus colonies, but they were more elevated when they
alike, I have devised this fable."
appeared on the surface of the medium, and of a more opaque
white color; they were, however, slightly translucent.  


Whatever the value of this hypothesis may be, it serves well
Cover-slips prepared from such a colony and stained with
to emphasize the fact that Harvey's opinions on generation
Sterling's gentian violet, mounted in water, showed numerous
have nothing in common with the modern discovery of the  
diplococci somewhat larger than the ordinary pyogenic cocci,
physical continuity of living matter, and it shows that his
composed of two hemispheres separated by a narrow unstained
teaching that all animals come from eggs cannot possibly
interval ; a few tetrad forms were also seen. The same preparation treated by Gram's method was completely decolorized.  
mean what the words now mean.  


He believes the uterus conceives an animal in the same way
Agar-agar, bouillon, potato, gelatin, and glycerine-agar
that the brain conceives an idea; and he also tells us that he
were then inoculated from one of the colonies.  
agrees with Fabricius that " the egg [of the hen] is in a certain sense an exposed uterus " (290).  


Furthermore, "the hen is not the efficient cause of a perfect egg, but that she is made so in virtue of an authority, if
At the same time another culture was made on the serum
I may use the word, or power required of the cock. For the
agar. No growth could be seen after forty-eight hours on any
egg, unless prolific, can with no kind of propriety be accounted
of the tubes except the one containing the human serum agar,
perfect; it only obtains perfection from the male, or rather
and on this a growth similar in appearance to the ones
described before, consisting of cocci with the same morphological properties, was found; further transplantation was
not successful on this medium.


As no perceptible growth occurred on any of the ordinary
cultural media, and cover-slips taken from their surfaces were
negative, the conclusion that the organism was the gonococcus was considered justified.


It is interesting to note that although numerous coverslips were made from the fluid at the time of operation, and
numbers of polymorphonuclear leucocytes were found, no
micro-organisms could be discovered.


174
Case III.
A. P., male, white, single, 39 years. Admitted May 20,
1896.


Denied any venereal disease. (Very questionable.)
Patient felt, without any premonitory symptoms, great pain




JOHNS HOPKINS HOSPITAL BULLETIN.


124


[No. 75.


[Nos. 77-78.




in the left aukle joint, and at the same time noticed that there
was considerable swelling and redness of the skin over the
joint.


from the female, as it were upon precept from the male, as if
The pain was more marked at night, and increased with
the hen received the art and reason, the form and laws of the
movement.  
future embryo from his addresses" (290). Ho much for the
generation of the fowl. In Exercise the sixty-ninth he
describes the embryo of the doe at about seven weeks, and the
human embryo about the second month after conception, but,
following Aristotle, he regards these embryos in their membranes, not as embryos, but as eggs without shells. " In the
way above indicated do the hind and doe, affected by a kind
of contagion, finally conceive and produce primordia, of the
nature of eggs, or the seeds of plants, or the fruit of trees,
although for a whole month and more they had exhibited
nothing in the uterus."


In this sense, then, he holds that viviparous animals are
The condition mentioned gradually grew worse until the  
generated from eggs. He therefore maintains (as contrasted
twenty-fourth day after the beginning of the disease, when
with Fabricius, who held that the greater number of animals
patient was transferred to the surgical ward.  
are produced from ova) "that all animals, even the vivipara,
and man himself not excepted, are produced from ova; that
the first conception, from which the foetus proceeds in all, is
an ovum of one description or another, as well as the seed of
all kinds of plants. Empedocles therefore spoke not improperly of the ' egg-bearing race of trees.' The history of the  
egg is therefore of the widest scope, as it illustrates generation
of every description. . . . Fabricius has these additional
words: "The foetus of animals is engendered in one case
from an ovum, in another from the seminal fluid, in a third
from putrefaction ; whence some creatures are oviparous, some


Examination. Patient was a well nourished man. Temperature on entrance 100° F. There was a fluctuating swelling
extending from the juncture of middle and lower third of
tibia, following the sheaths of extensor muscles, to a point on
the dorsum of foot 3 cm. below the ankle joint.


May '21st, Operation. Same operation as described previously.


viviparous, and yet others born of putrefaction or by the
Incision of abscess and excision of fibrinous material from
spontaneous act of nature, automatically."
tendon sheaths. Irrigation of bichloride of mercury 1 to 1000,
wounds closed with silver wire and dressed with silver foil,
and leg put up in plaster. Patieut made good recovery in
three weeks, wound healing per prima?/!. On incision the
subcutaneous tissues were oedematous and slightly hemorrhagic. The tendon sheaths were thickened and covered with
hemorrhagic fibrinous material.  


" Such a division as this, however, does not satisfy me,
The pus was confined principally to the sheaths of tibialis
inasmuch as all animals whatsoever may be said in a certain
anticus and extensor proprius poUicis, chiefly about the annular ligament, but followed the pollicis to a distance of 3 cm.
sense to spring from ova, and in another sense from seminal
below. The sheaths were opened and about 100 cc. of bloodstained fluid escaped, which was placed by means of a Volkman spoon in a sterile test tube.  
fluid, and they are entitled oviparous, viviparous or vermiparous rather in resjoect of their mode of bringing forth than
of their first formation."


We see then that, unfamiliar as his words often seem, and
The internal portions of the sheaths were covered with a  
while he holds that the organizing influence which produces
hemorrhagic fibrinous material and some granulation tissue.
the chick from the egg is a "divine mystery," we owe to
Harvey the demonstration and clear formulation of the following truths :


There is no basis for the venerable doctrine that the higher
I am indebted to Dr. Flexner for the privilege of reporting
animals are generated from excrement.  
his successful cultivation of the gonococcus in this case.
The pus collected at operation in a sterile manner was sent to
the Pathological Laboratory.  


The hen's egg, even before it leaves the ovary, is an independent orgauism, which enjoys life by its own right, and
Cover-slips when stained with Sterling's gentian violet
perfects itself by nutrition.  
showed polymorphonuclear leucocytes filled with diplococci
morphologically resembling the gonococcus; a few of the  
organisms seen were extra-cellular.  


The embryo assimilates homogeneous food, and by means of  
When stained according to Gram's method the organisms
an inherent organizing power converts it into the structure of  
were completely decolorized. Inoculations of the pus were
the living animal Nutrition, growth and development go on
made on the mixture of Steinschneider,* on a mixture composed of human ascitic fluid and agar-agar,t on a mixture of  
together, and the embryo arises by epigenesis or differentiation.  
human blood serum and uriue,J on an infusion of pig-fcetuses
and nutrient agar,§ and also upon ordinary agar slants. The


Many animals which have been held to arise from putrescent slime actually come from microscopic eggs.


"Animals are entitled viviparous or oviparous or vermiparous rather in respect of their mode of bringing forth
than of their first formation."


*Steinschneider'8 medium consists of a mixture of bullock's
serum, urine, and agar-agar.


tThe mixture of ascitic fluid i and agar-agar J, which after being
placed in tubes is sterilized and slanted. An albuminous flaky
precipitate collects at the bottom of the medium, leaving surface
clear.


LONG, THE DISCOVERER OF ANESTHESIA.  
t Human blood serum and urine medium is composed of J urine,  
f human blood serum sterilized in autoclave at 220° F. (Human
serum derived from placenta.)


A PRESENTATION OF HIS ORIGINAL DOCUMENTS.  
§ Preparation of pig-failvt a<]ar : Fresh pig-foetuses not exceeding 5 cm. in length separated from placenta and membranes
are minced in a sausage machine. An equal volume of distilled
water is added to the finely divided foetuses, and after thoroughly
stirring, the mixture is allowed to macerate in a cool place for from


By Hugh II. Young, A. M., M. D., Assistant Besident Siirgeon, Johns Hopkins Hospital, Baltimore.


[Being in substance a paper read before the Johns Hopkins Hospital Historical Society, Xorember 8, 1890, with additions.]


cultures were placed in a thermostat at 37° C, and at end of
twenty-four hours a scarcely perceptible growth was found on
all the inoculated tubes except the agar slants, which last
remained sterile, whereas the growth on the other tubes increased somewhat during the next twenty-four hours.


The appearance of the growth was the same as that
described in previous cases.


It was my good fortune last summer to meet Mrs. Fanny
Growth on pig-fcBtus agar was more abundant and apparently more vigorous than on the other media.  
Long Taylor, whose father, Dr. Crawford W. Long, is thought
by many to be the original discoverer of anesthesia.  


As she put me in possession of her father's papers, I thought
Cover-slips from the cultures showed the same diplococcus
they might prove sufficiently interesting to warrant their presentation to this Society.  
as was found in the pus, and it became decolorized completely
by Gram's method.  


During the famous ether controversy which was waged in
Transplantations at intervals of forty-eight hours were made
the forties and fifties the work of Long received little attention. A modest, retiring man, who abhorred public strife
on pig-foetus medium mentioned and growth obtained for  
and controversy, too honorable to wish pecuniary reward for  
four generations, but from the fifth inoculation no growth
his discovery, it is not strange that he made no effort to get
resulted.  
the reward from Congress, but preferred to let the justice of
his claim be judged by an unbiased posterity.  


Crawford W. Long was born in Danielsville, Ga., on the  
It is interesting to note that the condition of synovial membranes and peri-articular tissues in these cases was practically
first of November, 1815. His grandfather was Capt. Samuel
the same, namely subcutaneous oedema, thickening and induration of peri-articular tissues, with small hemorrhagic
Long of Pennsylvania, who made a brilliant record in the
areas.  
Revolutionary war and was one of Lafayette's captains at
Yorktown. Soon after the close of that eventful struggle he
left his native State and took his family to Georgia, where
they settled along with a large colony of Peunsylvanians.  
His son, James Long, received every educational advantage


The synovial membrane was thickened, very hemorrhagic
and had the appearance of plush, having lost the glossy
condition.


The fringe-like pieces of fibrin were very hemorrhagic.
In neither case was the cartilaginous portion of joint
affected.


there obtainable, and inheriting his father's executive ability,
became one of the prominent men of his State. Although
engaged in mercantile pursuits he was a hard student of the
law, and so well versed in the principles of jurisprudence
that he was often consulted by judges in difficult cases.


He represented his people in the Senate for a number of
years and was the intimate friend, adviser and confidant of
Wm. H. Crawford, Georgia's greatest statesman, at different
times Secretary of State, minister to France and candidate for
the Vice-Presidency. As an evidence of attachment he gave
his eldest son the name of Crawford. Coming from such
ancestry it is not wonderful that young Crawford early
showed promise of rare ability. As a boy he was studious
and mature beyond his years, and entered Franklin College at
so early an age that he was known as " baby." Notwithstanding this fact he graduated as Master of Arts second in
his class at the age of nineteen. Alexander II. Stephens
was his room-mate, and so much older that he was dubbed
"daddy" by the college boys. Though pursuing different
paths, Stephens and Long kept up an inti.nate friendship all
their lives. After studying under a preceptor for one year


six to twelve hours. The fluid is then freed from contamination
by filtration through a Chamberland filter under a pressure of 150
to 200 lbs.


Two per cent, sterilized nutrient agar is then melted and cooled
to 40° C. and to it J of its volume of the infusion of foetuses is
added. The tubes are then slanted.


August-September, 1897.]




NOTICE.


JOHNS HOPKINS HOSPITAL BULLETIN.  
All inquiries concerning the admission of free, part pay, or
private patients to the Johns Hopkins Hospital should be addressed
to Dr. Henry M. Hurd, the Superintendent, at the Hospital.  


Letters of inquiry can be sent, which will receive prompt answer,
or personal interviews may be held.


Under the directions of the founder of the Hospital the free beds
are reserved for the sick poor of Baltimore and its suburbs and for
accident cases from Baltimore and the State of Maryland. To
other indigent patients a uniform rate of $5.00 per week has been
established. The Superintendent has authority to modify these
terms to meet the necessity of urgent cases.


175
The Hospital is designed for cases of acute disease. Cases of
chronic disease are not admitted except temporarily. Private
patients can be received irrespective of residence. The rates in
the private wards are governed by the locality of rooms and range
from $20.00 to $35.00 per week. The extras are laundry expenses,
massage, the services of an exclusive nurse, the services of a
throat, eye, ear and skin or nervous specialist, and surgical fees.
Wherever room exists in the private wards and the condition of
the patient does not forbid it, companions can be accommodated at
the rate of $15.00 per week.
 
One week's board is payable when a patient is admitted.






Long graduated at the University of Pennsylvania in 1839.
June, 1897.]
While there he was recognized as a man of marked ability and
fond of experimental work.  


After graduation he spent one year in a New York hospital,
J^ NEW ^ESTHESIOMETER.  
where, it is said, he made such a reputation for himself as a
surgeon that he was urged to apply for the position of surgeon
in the U. S. Navy. Obedient to his father's wishes, however,
he returned to practice in his native State and located in
Jefferson, .Jackson Uo., Georgia, in 1841, at that time a small
country town, far removed from any railroad, in the midst of
a farming community whose only factory was the cotton gin.  


Here Dr. Long soon acquired an extensive and lucrative
By Lewellts F. Barkee, M. B.  
practice, and although young was noted for his quiet, dignified bearing, which endeared him to all. His office was a
{Exhibited to the Johns Hopkins Hospital Medical Society, January 18th, 1897.]
favorite meeting-place for the young men of the town, who
would often gather there to pass a merry evening together.  


About this time it became fashionable to inhale laughinggas for its exhilarating effects. Itinerant lecturers on chemistry would conclude an evening's entertainment with a
nitrous-oxide party in which the participants would get gloriously drunk from its inspiration.


The practice spread throughout the country, and at -Jefferson
during the early part of the winter of '41 a coterie of young
friends begged Dr. Long to let them indulge in the far-famed
luxury.


Dr. Long replied that he had uo means of preparing nitrousoxide gas, but that sulphuric ether would produce similar
I exhibited at this Society some time ago the test hairs employed by Professor von Frey in studying pain and pressure
exhilaration. The company being anxious to try it, the ether
sense. These consisted, it may be recalled, of short wooden
was produced, all inhaled of it and soon became hilarious.  
handles of suitable length, to which finer and coarser hairs
were fastened at one end at right angles with sealing wax.
The most suitable form is perhaps a four-sided wooden handle
measuring 4 mm. on each side and 80 mm. in length. Hairs
of different strength are obtained from the scalp of men,  
women and children ; hairs from the beard, from the horse's
tail and hog bristles are also of service where stronger
stimuli are required. The advantage of these test hairs consisted, it will be remembei'ed, (1) in the very small surface of
skin acted upon, and (2) in the possibility of grading accurately the intensity of the stimulus applied. In order to test
the stimulus- value of the hair, its area in cross section must
be determined, as well as the weight which can be lifted by
the hair when it is pressed with its cross section against one
of the scale pans of a delicate balance. I described on the
former occasion the methods of determining these two constants and shall not now repeat the details. Suffice it to say
that with time and patience a set of such test hairs can
be prepared varying in stimulus-value from 0.1 gr./mm^ to
300 gr./nim', though, as Professor von Frey says, the jireparation of them is " nicht jedermanns Sache."


The young men were delighted and hastened to tell their
A
friends of Dr. Long's wonderful drug, and thus the inhalation
of ether for sport soon became very popular over that section
of Georgia, and almost every party ended up with an " ether
frolic," as it was called.


During January, 1842, the ether frolics at Dr. Ijong's office
became very frequent and were well attended, and some of the
young men probably became pretty thoroughly intoxicated, as
Dr. Long discovered that he and others would afterward have
considerable bruises about their persons of which they had no
knowledge.


Being a thoughtful man, he at once remarked thai ether must
have the poiver of rendering one insensibU to pain, and therefore
available for prevent itig pain in stirgical operations.


This was January, 1842, and Dr. Long at once determined
B
to prove his discovery on the tirst surgical case_ he should
have. That opportunity came on March 30th, when Long
administered ether to Mr. James M. Venable till completely
anaesthetized, and then excised a small cystic tumor from the
back of his neck. Imagine the surprise of the patient when
on regaining consciousness he was told that the operation was
over, and his amazement when he saw the tumor in the hands
of the surgeon and he had not felt a scratch. This was four
and one-half years before Morton's earliest claims.


An original paper read by Dr. Long before the Georgia
State Medical Society in 1852, describing these events in his
own words, is appended to this paper — see Appendix I.


It is worthy of note that two and a half years later Wells of
Hartford discovered the ansesthetic powers of nitrous oxide




FlQ. 1.
The form of the hair and its mode of action are shown in
Fig. 1. A represents the test hair when it is placed upon
the skin at the point F, though as yet no pressure has been
exerted. In B the handle is nearer the skin, through pressure
made parallel to the surface of the skin, and the hair is bent
into an S-shaped curve, the turning point of which is at W.
If W is perpendicularly above the point F, then the hair
exerts exclusively an influence of pressure upon the skin ; but if
W be directed to one side, there arises along with the pressure
a "shoving" component. The latter appears, as one finds on
bending the hair, as soon as it begins to twist out of one plane;
that is, a space-curve arises instead of the plane-curves.


under very similar circumstances. He attended an entertainment given by a popular lecturer on chemistry, inhaled
nitrous oxide for its exhilaration, and saw a man under its
influence injure his ankle severely without being conscious of
it. From this he concluded that nitrous oxide was capable of
producing anesthesia and proved it in extracting a tooth.


Morton, on the other hand, got his suggestion as to the
ansEsthetic power of ether from Jackson, who, after using
ether to relieve the pain and dyspnoea following the accidental inhalation of chlorine gas — an antidote well known in
chemistry then — inferred that it might be useful as an anajsthetic. Jackson did not test the correctness of this observation, which he claims to have made about the same time that
Long etherized his first case, but left it for Morton to prove
practically four and a half years later.


Dr. liOng reports the first five cases in which he used
The set of hairs which I pass around
ether, being desirous only of establishing priority of use. An
were prepared under Professor von
examination of the letters and certificates before me, however,
Frey's direction in Leipzig in the  
shows that he must have operated on at least eight cases
spring of 1895. I have tested them at
before ^Morton's "discovery." This number seems small, but
intervals since that time and find that
is not so astonishing when we remember that the country was
they have undergone very little variation. For accurate testing of pressure
sparsely settled, that Jefferson was a mere village, and Long
and pain sense some such delicate testing mechanism is indispensable. Such
had just entered practice.  
hairs, however, are not in the market,
and I fear if one wished a set of them
he would have to prepare them for
himself.  


I will now read in substantiation of these statements a  
Kecently, however. Prof, von Frey, //
copy of the original account in Dr. Long's journal against
with the aid of the mechanician Zimmermann, has prepared a simple instrument which, for purposes of clinical examination at least, will take the
Mr. Venable for medical services rendered, certified to by a  
place of the set of test hairs. This
clerk of the Superior Court.  
Ksthesiometer, which depends upon the
same principle as that involved in the
construction of the test hairs, has the
advantage that with a single hair one
can obtain a large series of pressurevalues at will. It consists of a long
hair pushed through a capillary tube
of very narrow lumen, much like that
of a thermometer tube; the hair can
be shoved through the lumen easily,
but on pressure only the part of the  
' hair outside the capillary tube can
bend, and the force exerted is always g
greater the less the amount of hair outside the tube, and feebler the greater
the length of hair not inside the capillary tube. In Fig. 2 the mechanism
is shown, though the sample which I
pass around has some improvements
not illustrated in the figure. The
capillary tube consists of a brass tube,
S, of very narrow bore, over which a
sheath H glides with slight friction.  
In the axis of the siieath, and of the
same length as this, runs a wire, which
fits in the bore of the tube S, and at the
end of which the test hair is fastened.
If the sheath be shoved entirely over
the scale the hair projects in its greatest length, and has accordingly only
very slight force. On the other hand,
if the sheath be drawn back as far as
possible the greatest part of thf iiair


"James Venable


To Dr. C. W. Long, Dr.
1842. cts.


January 28th, sulphuric ether, .25
K7


March 30th, sulphuric ether and exsecting tumor, 2.00
May 13th, sul. ether, .25


June 6th, exsecting tumor, 2.00


Georgia, I
126


Jackson County. ' I, P. F. Hinton, clerk of the superior court of
[No. 75.  
said county, do certify that the above account is a correct copy of
an original entry made in his book for medical services for the
year 1842.
Given under my name and seal of office this 27th of March, 1854.
[Seal] (Signed) V. ¥. Hitfms, Vlerl.- S."


The following paper relative to the fashion of inhaling
ether for its exhilarating effects is interesting as showing how
the custom in Georgia started with Dr. Long :


" I certify that on the first of January, 1842, I resided in .Jefferson, Jackson Co., Georgia, and that about that time myself with
several other young men were in the habit of meeting at Doct. C.
W. Long's shop, and other rooms in the village, and inhaling ether
which he adminutered to us.


On the 20th of January of the same year I removed to Athens,  
disappears within the bore, and the short still projecting part
where I introduced the inhalation of ether. I and several of my
is capable of exercising very considerable pressure force. By
young associates frequently assembled ourselves together and took
means of a screw the sheath can be held iirmly in any position
it for the excitement it produced. After that I know it became
corresponding to a test hair of any desired length. There is a
very common to inhale ether in Athens, and tbat it was frequently taken in the college campus and on the street.  
millimetre scale on the tube, by the help of which a given
length of test hair can always be found again, together with
a protecting tube for the free end of the hair to complete the  
instrument.  


(Signed) R. H. Goodman,
The testing of the hair for its pressure values at different
lengths can be carried out with the aid of a delicate balance,
and if one makes determinations for every fifth or tenth line
of the millimetre scale he can easily calculate the values for
the intervening lines. With this instrument it is easy to pass
from very low pressure values, even below the threshold for the
most delicate pressure points, to pressure values above the pain
threshold in parts of the body where the pain threshold is high.  


August 4th, 1849. Athens, Georgia."
The value of this instrument was demonsitrated with Dr.  


When we see daily the dreadful distaste patients who have
been etherized have for ether, it seems strange that any one
could become fond of its use.




Gushing in the ward the other day. In a case in which ordinary slight stimuli appeared to call forth pain constantly, the
idea had arisen that pressure sense was absent, the pain sense
being very much exaggerated. It was easy with this instrument
to show that the pressure sense was not abolished, though the
threshold for pain was almost at the same level as the threshold for touch. With care, however, the pressure points could
easily be made out. The significance of careful examinations
in such cases is obvious, for it would be easy for the clinician
to make the statement that tactile sense was destroyed in a
given case in which in reality it was unaffected or but little
affected. If such a case should come to autopsy, one might
be entirely misled in interpreting the lesions found.


176
The sesthesiometer is not expensive, costing I believe five
marks, when purchased from E. Zimmermaun of Leipzig. I
cannot recommend it too highly for use in clinical examinations.






JOHNS HOPKINS HOSPITAL BULLETIN.  
EDINGER ON "THE DEVELOPMENT OF BRAIN PATHS IN THE ANIMAL SERIES."*


[Abstract of a Keport made by C. K. Bardeen, M. D., before the Journal Club of the Johns Hopkins Hospital.]




[Nos. 77-78.


In this address Edinger speaks in a most interesting way of
the value and possibilities of a comparative psychology based
on careful biological and morphological study. He himself,
he says, was led to undertake this line of research by the
knowledge that the lowest vertebrates have no cerebral cortex.
In man and in the higher vertebrates the finer conscious
activities take place in this part of the brain, and in the
ascending vertebrate series there is a gradual development of
the cerebral cortex up to man. " Indeed, in man," says Edinger, " the evolution of the brain cortex is still under way."
The interesting questions arose. What nervous activities are
possible in animals without a cerebral cortex ? and What
nervous and mental activities have been added as the cortex
has been evolved in the animal series ? The solution of these
questions involved the broader task of studying the finer
structure of the nervous system of the lower vertebrates. It
was found on investigation that those parts of the brain which,
as opposed to the cortex, are designated as the " lower parts "
are essentially similar in all vertebrates. The spinal cord and
medulla of the fish and of man do not differ fundamentally.


"So far as we know to-day," says Edinger, "we may ascribe
to similar structure similar function." If this be true we may
hope by careful study of the morphology of the nervous system to have opened up new points of view for physiology and
psychology. If to the spinal cord, for example, the functions


I will now read an account of the first operation as given
by Mr. James M. Venable:


"I, James M. Venable, of the county of Cobb and State of
Georgia, on oath depose and say, that in the year 1842 I resided at
my mother's in Jaclcson County, about two miles from the village
of Jefferson, and attended the village academy that year.


In the early part of the year the young men of Jefferson and the
* " Die Eatwickelung der Gehirnbahnen in der Thiereihe," delivered before the medical section of the " Gesellschatt deutschcr
country adjoining were in the habit of inhaling ether for its exhilarating powers, and I inhaled it frequently for that purpose, and was
Naturforscher und Aerzte," in Frankfurt a. M., Sept. 23, 1896, and
very fond of its use.  
reported in the Deutsche medicinische Woehenschrift, Sept. 24,
1896, Vol. XXII, No. 39. [Prof. L Edinger of FrankCort is well
known in America as the author of a very lucid text-book on the
structure of the brain, "Der Bau des Gehirne." He is perhaps
the foremost worker in the line of research of which he speaks in
his address.]


While attending the academy I was frequently in the office of
Dr. C. W. Long, and having two tumors on the back of my neck, I
several times spoke to him about the propriety of cutting them
out, but postponed the operation from time to time. On one occasion we had some conversation about the probability that the
tumors might be cut out while I was under the influence of s.
ether, without my experiencing pain, and he proposed operating
on me while under its influence.


I agreed to have one tumor cut out and had the operation performed that evening after school was dismissed. This was in the
early part of the spring of 1842.


I commenced inhaling the ether before the operation was commenced and continued it until the operation was over. I did not
of which are well known, comparative anatomical study shows
feel the slightest pain from the operation and could not believe
that other structures are added little by little, we may suppose
the tumor was removed until it was shown to me.  
corresponding additions in functional capacity.  


A month or two after this time Dr. C. W. Long cut out the other
Edinger lays special stress on the need of care in forming
tumor, situated on the same side of my neck. In this operation I
our conceptions of the operations of the nervous system of the  
did not feel the least pain until the last cut was made, when I felt
simpler animals. We must carefully rid ourselves of all preconceived notions of perception and desire as the necessary
a little pain. In this operation I stopped inhaling the ether
accompaniments of complex reactions to stimuli. We have,
before the operation was finished.  
he says, no grounds for belief that such states of consciousness arise outside the higher centres of the cerebrum. We
 
have no right to assume that in the lower animals the simpler
I inhaled the ether, in both cases, from a towel, which was the  
nervous system performs functions like those performed by
common method of taking it.
the higher centres of the nervous system in the higher vertebrates. " I trust I may be able to prove," says Edinger,  
Georgia, -v (Signed) James M. Ven.\blk.  
" that the latter assumption, so commonly made, cannot be
maintained."


Cobb Co., > Sworn to before me.  
To show how easily one might falsely attribute a conscious
origin to complex movements, two or three examples are given
from the invertebrate kingdom. Loeb's interesting experiments with the actinia are quoted. If a bit of fish be placed
on the tentacle ring of one of these animals the tentacles close
in and force the food into the mouth between the tentacles.
But a piece of white paper put in the same situation is left
undisturbed. This at first sight might seem a voluntary
choice between the food and the paper, involving a conscious
perception of taste. But if the mouth be destroyed and the
bit of fish be again put on the tentacle ring the actiniau will
double itself up trying vainly to force the morsel into the
closed mouth. The definite activity caused by the meat is,
roughly speaking, a direct reaction of the tissues to a chemical stimulus. The actiniau has no very definite nervous
.system, though certain of its cells are taken to represent nerve


July 23rd, 1849. J Alfred Manes, J. P."
rrlLs.  


This operation was clone in the presence of fonr witnesses,
Hdiu^er also refers to the recent studies on the nervous
Jas. E. Hayes, A. T. Thurmond, W. H. Thurmond, principal
of the academy, and Edmund S. Rawls, the last of whom
testifies as follows :


"Georgia, -i I, Edmund S. Rawls, of Rome, Floyd Co., Ga., on
Clarke Co. J oath depose and say that ... on one occasion during
that year (1842) I was present with James M. Venable in the office
of Dr. C. W. Long in Jefferson, Jackson Co., Ga., and witnessed
Dr. C. W. Long cut out a tumor from the side of neck of J. M.
Venable while said Venable was fully under the effects of the
vapor of s. ether inhaled from a towel, and without his exhibiting
the least symptoms of suffering pain from the operation. J. M.
Venable was so unconscious of the operation having been performed that he would not believe the tumor was removed until it
was shown him. (Signed) E. S. Rawls.


Sworn to and subscribed before me this 2nd November, 1853.


E. L. Newton, /. J. C."
June, 1897.]


The patient continued to inhale ether until the operation
127
was over, was entirely unconscious of its performance, and
felt no pain. Surely this was complete ansEsthesia. This
fact has been denied by Dr. Wm. J. Morton, son of the Boston
discoverer, who says it was no more than mere exhilaration.


It has been stated that Long kept his discovery secret and
that he therefore deserved no credit for it. I present certificates from Drs. Laperriere and Carlton, which show that his
work was well known to citizens of the town of Jefferson and
neighboring cities, particularly Athens, which was then the




system of tlie earth-worm. Thanks to the work of Loeb aud
Friedlaender on the living earth-worm, and that of Retzius
aad von Lenhossek on the morphology of its nervous system,
the task of comparing its structure with its psycho-physiological activity has been greatly lightened. If the earth-worm
be cut into pieces not too short, and one of the pieces is stimulated to move, it will continue creeping. The movement is
produced as follows: from large epithelial cells in the external skin the earth-worm's sensory fibres pass into the central
ganglia situated in the ventral band ; here the process divides
into at least two parts. These lie in contact with the dendrites of large ganglion cells lying in this ganglion and in
those immediately adjoining. These large cells send processes
to the muscles. Each ganglion sends motor fibres, not only
to the muscles of the segment within which it lies, but also
to those of the neighboring segments. Some of the fibres
cross the median line. A third set of cells have processes
which run up and down the veutral band connecting different
ganglia. Thus a sensory impulse started in a large epithelial
cell is carried to the neighboring ganglion. Here the motor
and associative cells are called into activity, and the muscles
in the vicinity of the segment whose surface has been stimulated contract. This throws increased tension on the surface
of the neighboring segments and they in turn are stimulated
to contraction. A contraction wave is thus started along the
worm, called forth by simple reflex action. This scheme is
not diagramatic; it is based on the actual observations of
trained observers.


centre of learning and culture in Georgia; that it was considered a remarkable discovery by the populace, and that the
The mechanism which controls intestinal contraction in the  
prominent physicians knew of it and realized its importance.
higher animals is very similar.  
See Appendix II.  


Dr. Carlton was then a student under Dr. Moore. One
The nervous mechanism found in the vertebrate spinal cord
year later (1844) he used ether in extracting a tooth. This
is fundamentally the same. Here again we find motor cells
was probably the first use of ether in extracting teeth. Dr.  
sending processes to the muscles; here again processes from
James Camak, another student of Moore, was present and
sensory cells terminating in gray matter ; here ag.ain, but in
assisted in the same operation and corroborates Carlton's
a far more developed degree, association neurones. That the
statements.
spinal cord is capable, unassisted by the higher centres, of carrying out very complex movements is shown by the complex activity of the frog deprived of a cerebrum, the jumping
of the brainless rabbit and the swimming of the brainless


Can Dr. Long be blamed for not publishing at once a report
of his first case or two when they were well known to the
physicians of that part of the State ? He had no Massachusetts General Hospital at his back, and he knew that such
startling claims coming from one so young (he had not been
practicing one year) would be severely criticised. It is but
natural that he should be satisfied for the time being with the
local and State publicity which was given to his great discovery,
and waited until he could make a comprehensive report embracing all kinds of cases, such as every careful investigator
does to-day.


But he kept on with his work, ojierating on two more cases
under ether in 1842, and about three more during the next
year, for most of which I find sworn certificates.


I have a letter from his first student. Dr. J. F. Groves,
The morphological structure on which the functions of the  
which is of particular interest as giving an insight into the  
spinal cord depend has now been fairly well determined.  
character of Dr. Long and his work at that time. It is quite
Beside the factors already mentioned there enter into its
lengthy and I omit portions of it. The letter is written to
structure paths connecting it with the brain. In the fish
Mrs. Taylor, Dr. Long's eldest daughter. See Appendix TIL
paths connect mid-brain and cerebellum with the spinal cord.  
 
Connections between the cerebrum and the spinal cord
This letter shows conclusively that Dr. Long was thoroughly convinced of the anesthetic powers of ether, but was
first appear in mammals. " The direct influence of the cerebrum on the activities controlled by the spinal cord varies,  
anxious to put it to a severe test in capital surgery. He
therefore, according to the class of animal, and it does not
withheld his cases of minor surgery because he wished to
even exist among the lower vertebrates." The pyramidal
determine accurately the limitations and possibilities of
tract is not found in birds.  
ether.  


In his paper Dr. Long does not give the details of the etherization with the minuteness we should desire. For instance,  
The medulla, while, like the cord, serving as a primary centre
he does not say who gave the ether, the patient or himself,
for the reception of sensory and the origin of motor fibres,  
and he does not explain whether the patient was entirely
has a much more highly developed associative mechanism than
unconscious or not, but simply remarks that he suffered no
the cord. Yet the development of these paths of association
pain and did not know the tumor had been removed.
varies greatly in different animals. In the carps and many
other fishes it has a more complex development than in man.
The complexity of development of the medulla depends chiefly


These omissions of Dr. Long led Dr. Wm. J. Morton, of
New York, to write a forty-eight-page article in the Virginia
j\Iedical Monthly, March, 1880, in which by dexterously quibbling with Long's innocent statements he arrives at the conclusion by a skilful process of deduction, that Long never did
anything. I will read parts of this article :


"The Invention of An.esthetic Inhalation.


* * * But we will proceed slowly. We must know who is giving the ether. Of the first operation Venable deposes under oath,  
on the uses to which the cranial nerves are put. The terminal area of the fifth nerve, so well developed in the sensitive-faced mammals, is but slightly developed in the snakes,  
'I commenced inhaling the vapor before the ojieration was commenced and continued it until the operation was over.'
but the motor area of the fifth nerve in snakes is relatively
more developed than in the mammals, owing to the snake's
powerful jaw muscles.  


Tlius Venable kept his eye on the whole affair, knew just what
The cerebellum varies greatly in development, even among
was going on, otherwise how could he knowand swear to it thatbe
the fishes. Those that swim actively have it more highly
continued the inhalation until the operation was over. Surely Veiiahlc administered the ether to himself and remained conscious all the  
developed than the mud-seeking varieties. Birds being animals of delicate sense of balance have it well developed. In
time."
snakes it is very rudimentary. Whatever the functions of the  
cerebellum may be, this organ is well developed in all animals
executing carefully poised movements. The hemispheres of
the cerebellum first appear in the mammals.  


This is erroneous, for according to good legal authority
The connections of the cerebellum with other parts of the
central nervous system are interesting. The pons fibres first
appear in the mammals, and it is probable that the olivary
paths do not occur in the lower forms. On the other hand
the connections with the spinal cord through the corpus restiforme and with the thalamus through the suj)erior cerebellar
peduncle are primordially old. The latter are more highly
developed in fishes than in man.


Next to the spinal cord the mid-brain is that part of the
central nervous system most alike in all vertebrates. It is the
primary terminus for the optic fibres, and in it end a large
part of the secondary sensory fibres transmitting impulses
from the other sense organs. It is the great centre for the
association of sensory impulses in the animals without a well
developed cerebrum.


The cerebrum in all vertebrates is composed of olfactory
apparatus, basal ganglia and cortex.


August-September, 1897
The olfactory region varies greatly in development. In
reptiles and in fishes it makes up half the brain mass. In
birds it is scarcely to be traced.


The corpus striatum, which lies just behind the olfactory
apparatus, appears developed throughout the vertebrates. It
plays a chief part in connecting thalamus and fore-brain, but
in large part its functions are ill understood. The optic
thalamus is likewise complexly developed throughout the
vertebrates. The cortex stands in marked contrast to the
lower parts of the central nervous system which are so much
alike among all the vertebrates. In fishes the cortex consists
of a thin epithelial plate. In the amphibia it contains a
simple nervous apparatus. In reptiles a true cortex appears
for the first time.


Within the last twenty-five years it has been definitely
shown that the cortex performs the highest functions of the
nervous system. On the existence of a normal cortex depend
all those functions which may be learned, almost all which
are carried out by memory pictures, and, above all, those complex conscious processes designated "associative." The silver
stain has shown into what a complexity of relations each
nerve cell is brought by its processes. From the reptiles to
man this associative complexity increases.


JOHNS HOPKINS HOSPITAL BULLETIN.  
It seems probable that various sensory areas in the cortex
have been added as the need has arisen for more highly developed associative processes connected with the special senses.  
The earliest cortical relations are with the sense of smell






177
128


[No. 75.




such a statement as Veiiable's could be made fi-um a knowledge based on satisfactory hearsaj' evidence and would be
accepted in law.


But he goe.s on : "But now comes the damnatory point of this
only. Reptiles, we may assume, differ from fishes in that
second experiment. The patient felt pain. Tliis both Long and  
they can "retain their smell impressions, associate them and  
Venable confess. Here tlien is positive failure ; Dr. Long's ansesthetic state was nothing more nor less tiian the fleeting peripheral
choose." For the reptile the cortex is an olfactory centre and
numbness often associated with the first or e.Khilaratmg stage of
out little more.  
the complete anesthesia of to-day. But why did Dr. Long not take
the towel into his own hand and force the ether? Why not make
his patient insensible to pain if he knew tliis could be done?


" Knowing what medicine knows to-day, how wonderful this halting of Long — tliis pause at a most critical moment — on the very
" This first inheritance of the cortex, the olfactory centre,
threshold of discovery! So nicely balanced is the situation thiit it  
remains throughout the entire series ; in birds alone is it  
almost seems as if he would topple
somewhat uncertain. There is no difficulty in following the
over into discovery; but he falls
cortex of the reptiles into the Amnion's horu and the uncinate
the other way.  
gyrus of mammals and mau."


" It seems almost inexplicable
But in the course of evolutionary development other brain
that he did not seize the towel,  
centres have been added to this ; the cortex has been built up
force the anaesthesia to the stage
piece by piece. Unfortunately most of the steps are still uncertain. Something is, however, known of the optic paths.
of stupor, perform the operation,  
In fishes the optic nerve ends in the mid-brain. And so too
and proclaim the discovery to the  
in man at birth the only functional fibres end there. The
worUi," —
babe is not blind, but it has no association centres for sight
impressions. During the second mouth of life paths are
developed from mid-brain to occipital lobe, the cortical sightcentre is called into activity, and association paths are formed
between it and the rest of the cortex. The child only then
begins to perceive what it sees.
 
It is because the fish has no cortical centre for sight that
it can be hooked. To a similar reason is due the fact that
reptiles and amphibia often go hungry when they do not smell
their prey and it does not move. Snakes which do not eat
dead mice will seize and devour, without a trace of dislike,
dead mice artificially made to move.


and we might add, patent it at
Birds have a well marked cortical area for sight, and hence
once I
they exhibit many phenomena which indicate reason and  
memory founded on sight impressions.


It is a fact well known to all
It is clear, however, that in the lower animals many functions are performed without the influence or control of a cortex, and the question naturally arises as to the real nature of  
surgeons that a patient may be
entirely unconscious and still
retain sensibility to pain. This
is evidenced by the flinching
before the knife when in this
state. He may give evidence
of feeling pain, but have no
recollection of it afterward.
All witnesses agree that Tenable gave no evidence of feeling pain in the first operation.
He must have been jjretty thocoughly anffisthetiiied. The second operation was merely a test
case to determine the length of  
the anaesthetic state, aud although the ether was discontinued from the beginning of the
operation (which Long says was tolerably difficult on account
of adhesions), still the anajsthetic state lasted until the last
cut was made. We would consider .such a patient pretty
thoroughly anaesthetized in Baltimore.


I have recently tested a number of patients who were being
anaesthetized and found invariably that consciousness was lost
before sensibility to pain — as evinced by movement of a member when pricked with a pin.


It was therefore practically certain that no j)erson could
administer ether to himself, an act requiring consciousness —
aud become sufficiently anaesthetized for even very small
operations; but in order to settle the question definitely I
determined to administer ether to myself, using the same
methods as were employed by Long in 1842.


Accordingly, under the direction of Dr. F. II. Hagner of  
the functions of the lower centres. It is well known that man
Washington, I placed a folded towel over my face and poured
and the higher mammals are more injured in normal activity
by loss of the cortex than are the lower vertebrates ; that
the cortex becomes indispensable iu proportion as it becomes
well developed and is brought into close association with the
lower centres. This has been shown by the study of the diseased human brain and by experiments on animals. But nature
offers us animals with no cortices and with cortices variously developed along special lines. We have here a beautiful
opportunity to study the functions of the cortex in the animal
economy. Most interesting points of view might be obtained
by excitation of the olfactory nerves of fishes which have no
cortical centres, and of snakes which have cortical centres for
smell ; or by comparing the effects of visible objects on snakes
which have no developed associative centre for sight, and on
birds which have them well developed.


And this same sort of study carried to man will also prove
productive. The great man need not necessarily have a
heavier brain than the average man, but we should expect that
part of his brain which he had occasion to use to be better
developed than the average. The great painter should have a
well developed occipital lobe ; the great musician a well developed temporal lobe. Gambetta's brain was not above the
average in size and weight, but the speech area was very greatly
developed. For the present, Edinger points out, we may willingly refrain from speculating about convolution anomalies
and criminal types. More fruitful fields of investigation are
offered the scientist. The field of comparative psycho-physiology and comparative morphology gives every promise of
being most fertile. One thing seems sure, " there is no
boundary to be established between the conscious activities of
the lowest and those of the highest vertebrates."






Dr. CRAWFORD W. LONG
PSEUDO-TUBERCULOSIS HOMINIS STREPTOTRICHA.  


[A PRELIMINARY NOTE.]


Bt Simon Flexnee, M.D.


ether upon it from time to time at his bidding, as long as 1
[From the Pathological Laboratory of the Johns Hopkins University and Hotpital.'\
was conscious. During this time Dr. Hagner pricked me with
pins up to the last application that I remember. Toward the
last the pin pricks did not produce the usual sensation of  
pain, but a peculiar disagreeable clanging sound in the ear.  


Dr. Hagner thus briefly describes the experiment: "Dr.
Young jjoured ether on the towel when so instructed by me.
After a number of such additions the movements of his arm
became very unsteady and he would spill some of the ether on
his neck. Soon after the last application, made at my request,
I pricked him with a pin and he moved his leg. I then
instructed him several times to add more, but he made no
attempt to do so and seemed unconscious. I then pricked
him with pins several times,
but received no response for
about a minute, when he again
responded to a prick of pin and
suddenly became conscious.
Comjilete consciousness returned almost immediately.


" I feel certain that he lost
consciousness before sensibility
to pain, and that if I had attempted to do the smallest surgical operation he would have
been conscious of pain before
its completion."


It is therefore certain that
At the meeting of the Johns Hopkins Hospital Medical Society held on October 19th, 1896, 1 presented specimens from the  
Yenable would have been conscious long before the small
lungs and peritoneum of a man who had succumbed to a disease
tumor was removed and would
characterized by symptoms which resembled those of phthisis
have suffered considerable pain,
pulmonum, but in the lesions of which, instead of the bacillus
if he had conducted his own
tuberculosis, another and probably entirely distinct microorganism was discovered, for which I have proposed the name
etherization. Nor is it probable that Long intended to convey that idea. We might with
of streptothrix pseudo-tuberculosa. As the publication of the
propriety say to-day that our
full report of the case and the complete description of the
patients "inhale ether until
micro-organism has been somewhat delayed, a brief outline of  
anesthetized," if we did not
the case may be of interest at the present time.  
care to specify the details of  
etherization. Hut in a document quoted above R. H. Goodman
says, in speaking of the ether frolics, " We were in the habit of  
meeting at Dr. Long's shop and inhaling ether which he administered to vs." It seems probable therefore that some one
administered ether to the persons on whom he operated, too.  


Desirous of settling these trivial points on which Morton
The patient was a male, colored, aged 70 years, in whom
would have Long deprived of every honor, I addressed a letter
extensive consolidation was made out in both lungs. The
a few days ago to Long's first student. Dr. J. F. Groves, w'hose
symptoms were generally those of pulmonary tuberculosis.  
document I have quoted above. I saw that he would now be
Sputum was carefully watched for during his stay in the  
about 75 years of age and waited for an answer with considerable au.xiety. To my surprise and delight I received a letter
from him yesterday which supplies all of Dr. Long's omissions. Dr. Groves did not see the first operations, as he did
not enter Dr. Long's office till 18W, but soon after his  
entrance he assisted in the operation on the negro boy in
which two fingers were amputated, early in 18-t5, aud at my
request he describes this etherization in detail.






178
Hospital (Dr. Osier's clinic), but none was obtained. No
microscopical examination could therefore be made.


Autojjsy. The body was that of a slightly built, somewhat
emaciated man. The abdomen was moderately distended. The
autopsy was made 19 hours after death, the body having iu
the meantime been kept on ice. No evidences of post-mortem
decomposition were noticeable. The description of the viscera is limited here to the organs especially affected.


The Lungs are voluminous and meet in the middle line
anteriorly. They are not bound to the chest wall. Left. The
entire lung, except the anterior edge of the upper lobe, which
is insufflated, is consolidated more or less perfectly. Where the
consolidation is frank the lung presents an opaque appearance, is gray in color, and beginning softening (disintegration
with early cavity formation) is going on. The cavities often


JOHNS HOPKINS HOSPITAL BULLETIN.




June, 1897.]


[Nos. 77-78.
129






As this case occurred a year ami a half before Morton's
still contain the products of disintegration, and all appearances of reactive encapsulation are wanting. Where the hepatization is less complete the lung tissue is cedematous and
discovery, it is equally good as the first for my purposes. It
swollen, although perhaps not completely airless, and discrete
is as follows :
tubercle-like nodules may be seen. The pleura over the hepatized areas is covered with a fibrinous exudate. Right. The
consolidation is less extensive and more focal in character, but
occupies in places areas as large in extent as 4x5 cm. The
pleural cavity contains a small quantity of fluid, pink in color,
in which flakes of fibrin occur.


A Recent Letter fkom Long's First Student.  
The intestines are moderately distended. The omentum is
rolled up ; it occupies a position beneath the transverse colon
and extends across the abdominal cavity. The pelvis contains
about 15 cc. of fluid of brownish color and mucilaginous consistence. Between the intestinal loops delicate shreds of
fibrin exist. In addition smaller and larger nodules resembling tubercles, usually translucent, are scattered irregularly
over all the exposed peritoneal surfaces, and occur more uniformly upon and within the thickened, rolled-up omentum.
The liver and spleen on section show similar nodules.  


"CoHUTTA, Ga., Jan. 15th, 1897.  
The bacteriological examination consisted in the study of
Dr. Hugh H. Young,
cover-slips from the fresh lungs, the inoculation of glycerineagar tubes, and the injection of a suspension from the consolidated lung subcutaneously into a guinea-pig. The histological study embraced all the organs of the body. Cover-slips
from the lungs, stained by Gabbett's method, showed no micro-organisms which resembled the bacillus tuberculosis in
their morphology. There remained faintly stained in carbolfuchsin upon the cover-slips numerous examples of a branching organism, occurring often in clumps or convoluted masses,  
among which no ordinary bacillary forms were discovered.  
From the history of the case, the character of the lesions and
the known variation in morphology of the bacillus tuberculosis, it was, for the time, assumed that the organism was a
streptothrix form of the former bacillus. Its subsequent
study has rendered this assumption highly improbable.  


Dear Sir ; * * * The patient was placed in a recumbent position, on a bed, with hand to be operated on to the front for convenience to tlie surgeon. Dr. Long poured etiier on a towel and held
The cultures from the left pleural cavity and the peritoneum remained sterile. Three separate sets of cultures were
it to the patient's nose and mouth, too, to get the benefit of inhalation from both sources. Dr. Long determined when the patient
prepared from the lungs. In all these, at the end of 34 hours,
was sufficiently etherized to begin the operation by pinching or
a vigorous growth of a bacillus, identified as belonging to the  
pricking him with a pin. Believing that no liarm would come of
its use for a reasonable length of time he profoundly anesthetized
the patient, then gave me the towel and I kept up the influence by
holding it still to the patient's nose. The patient was entirely
unconscious — no struggling — patient passive in the hands of  
operator. After a lapse of lifty years you would hardly suppose
that a man could remember every minute detail, but I have clearly
in mind all the facts I have given you.


Your ob't servant,


(Signed J J. F. Groves, M. D."


Long then administered ether as it is done to-day. He did  
group of B. coli communis, had taken place. The streptothrix did not grow. The guinea-pig showed no reaction to
not pause at the threshold of discovery or topple the other  
speak of at the site of inoculation, the adjacent lymph glands
way, but kept right ahead and by careful observation, experimentation and reflection discovered that ether was a safe,  
could not at any time be felt; the animal, however, lost in
sure and complete anajsthetic.  
weight and died at the end of the 7th week, at the autopsy
showing great emaciation. None of the lymphatic glands were
found enlarged ; there were no lesions resembling tubercles in
these and other organs, and cultures upon glycerine agar, made
from several sources, remained sterile. Cover-slips from the
serous cavities, blood and viscera were negative for any kind
of bacteria.  


Nor did his patients etherize themselves and at the same
The further study of the staining proj^erties of this organism in cover-slips, made from the lungs at the time of the  
time superintend the operation, as Dr. Morton would have us
autopsy, shows that as stained by the ordinary methods employed for tubercle bacilli, and decolorized by means of acids,
believe.  
the dye is held very loosely and quite readily given up. The
best method of staining is either Gram's or Weigert's modified
fibrin stain. The same holds true for its demonstration in
the tissues.  


As quoted above, Morton grasps eagerly at the acknowledgment of pain at the end of the second operation, where the  
The lesions in the tissues are of two kinds, depending in
ether had been discontinued, and from tnat isolated instance
part upon their situation. In the peritoneal cavity tuberclelike nodules are formed, consisting of epithelioid and lymphoid cells with an occasional giant cell. Necrosis by fragmentation is not unusual in the centers of the tubercles, and
characterizes all of Dr. Long's cases as failures. But in his
fibrin, either before or coincident with the necrosis, is commonly observed in the nodules. In the lungs tubercles also
eagerness to annihilate Dr. Long he seems to have overlooked
exist, but they are less striking than a diffuse exudation of
the fact that in the first report of anassthesia with Morton's
leucocytes, plasma and fibrin which fills the air cells, infiltrates the stroma and tends to undergo necrosis, producing
" Letheou " at the Massachusetts General in 1846, Dr. Bigelow* says, in speaking of the first operation, "During the  
larger and smaller spreading caseous foci of degeneration.  
operation the patient muttered as in a semi-unconscious state,  
The number of masses of the streptothrix is very great indeed
and afterwards stated that the pain was considerable," and in
and they are in intimate relation to the pathological process.  
the second, " The operation lasted four or five minutes, during which time the patient betrayed occasional marks of  
uneasiness." But these certainly were not failures, although
the ausesthesia was not as complete as in Dr. Long's previous
cases.  


Li his paper Long speaks of "those high in authority who
From these and some other considerations which will
were advocating the mesmeric state as adequate to prevent
appear in the full report, it is believed that the organism is
pain in surgical operations." Contemporary medical literature furnishes ample verification of these statements, according to Dr. Grandy,t who says :
probably a new species, for which the name streptothrix pseudotuberculosa is proposed, and, further, that it is capable of causing in human beings a rapidly spreading and destructive disease resembling phthisis florida, for which the appellation of  
pseudo- tuberculosis hominis streptotricha seems warranted.  


" The journals were full of discussions upon the phenomena
of mesmerism, animal magnetism, etc., and wonderful reports
were coming from European hospitals of operations done
without pain during the ' magnetic sleep.'


"Jules Gloquet had excised a cancerous breast with the
axillary glands and the patient showed no sign of pain. Top


PROCEEDINGS OF SOCIETIES


* Boston Medical and Surgical Journal, Nov. 1846.
t Va. Med. Monthly, Oct. 1893.




THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.


ham of London, in 1843, had amputated a thigh, and Dr.
Meeting of December 7, 1896.  
Diigas of Augusta, Georgia, in 184.5, twice extirpated the
mamma of a female under the mesmeric sleep.  


"We can imagine what efEect these cases had on the mind
Dr. Thayer in the Chair.  
of Long. Need we wonder therefore that he was the more
particular in his experiments on etherization. Such were the
reasons for his silence, and while the sequel was unfortunate,
his course was cautious and commendable."


While thus waiting, his opportunity was lost. A second
Discussion of Dr. Frledenwald's Paper on Consjenital Motor
discovery was made in Boston in 1846, was published immediately, and anesthesia became the property of the world.  
Defects of tlie Eyeballs. See p. 203, Nov.-Dec. Bulletin, 1896.  


Friends of the other " discoverers " have often stated that  
Dr. Paton. — This case is of very great interest, and so
as Long made no publication of his work he deserved no  
unique that I feel interested from an anatomical standpoint.
credit for it. To this Dr. J. Marion Sims responds very
Cases of unilateral paralysis are easily explained, but for cases
forcibly as follows:*
of double paralysis of the 6th nerve there is no anatomical
explanation. As yet there has been no demonstration of the
crossing of the 6th nerve in man. It has been demonstrated
in monkeys. The crossing of the 4th nerve has been demon


" Now upon this point Long, Wells, Morton and Jackson
stand individually upon the same level.


Long exhibited to medical men and to the community
strated in man. The further interesting fact that this case
his operations under ether in 1842. Wells exhibited to
brings forward is the relation of the 6th nerve to the oculomotor. There are two possible ways in which these nerves
medical men and to the community his operations of the  
can be related. If you take a section of medulla at the level
extraction of teeth under nitrous oxide gas in 1844. Morton
of the 6th nerve and look at the right side, the fibres are seen
exhibited to medical men and the community the use of
to pass across to the left side, and then upward in the posterior
his secret remedy "Letheon," 1846, as an anesthetic. But
longitudinal bundle as far as the nucleus of the third nerve.
Morton was fortunate in showing his patent remedy to
The main function of that bundle is to connect the nuclei of  
the great surgeons of Boston, and it was not Morton, but it
the cranial nerves, and there you find the connection between
was Warren and Ilayward and Bigelow who performed the  
the 6th and 3rd. Recently another path has been marked out.  
operations to which the world owes the immediate and universal use of anfesthesia in surgery. If Morton could have had
The 6th on the right side may pass up on the same side as the  
his w,iy he would have deodorized the ether and kept it secret
rio-ht nucleus, and join the fibres of the 3rd nerve from the  
from the world. Neither Wells nor Morton nor Jackson ever
other side ; so you have two possible connections. Either the
published a word on the subject till it burst forth in a blaze
from the labors of the hospital surgeons already named.
When Warren and Hay ward and Bigelow proved the real
greatness of the discovery [and published it broadcast], then
it was that Wells, Morton and Jackson began the war of pamjihlets, and not till then did either of them publish in any
scientific journal a line about ana'sthesia."


The Famous Ether Controversy.


In 1849 Morton petitioned Congress for a reward for his
discovery. He was at once opposed by Jackson and the friends
of Wells, who was then dead. The celebrated ether controversy, thus begun, occupied the attention of Congress for
many years, and was characterized by the greatest animosity
between these former bosom friends and companions.


For five years Long i-efused to take part in the conflict, but
130
finally in 1854, persuaded by his friends that in that way alone
could he obtain recognition of his claims, he wrote to Senator
Dawson giving an account of his work. It seems that Dawson
was a friend of Jackson, for he wrote to him of this new
claimant and requested him to investigate his case. This
.Jackson did, calling upon Long at his home in Athens on
March 8th, 1854.


The Ixtekview betweej^ Loxa .vxd Jacksox.
[No. 75.  
At this interview lion. C. W. Andrews, a prominent justice.  






*Va. Med. :\ronthly, :\Iay, 187
6th nerve crosses or the third nerve crosses, and the probability is the latter, because the crossing higher up of the 3rd
 
nerve fibres is the simplest physiological explanation.  
 
 
August-September, 1807.]
 


Dr. Theobald. — Dr. Friedenwald has had an exceptional
experience in meeting with so many of these very interesting
cases. It would seem that in this case there is a marked want
of power of the internal rectus of the left eye as well as of the
extei'nal rectus. This suggests the related cases of congenital
ptosis sometimes accompanied by inability to turn the eyes
upwards, that one meets with. It is well known that in this
case the defect is not central, but is due to absence of or
faulty development of the levator muscle of the upper lid and
of the rectus superior. Such cases are not so rare as the one
shown. I have met with several of quite marked degree.
Frequently they are associated with epicanthus. It seems to
me that the most probable explanation of this case is that we
have here a similar want of development of the external recti.
Indeed all the eye muscles here appear to be more or less
faulty or weak, for it is difficult to induce the patient to turn
his eyes in any direction, all of the movements being defective.
We not uufrequently meet with cases of pronounced weakness
of the recti muscles, particularly of the external recti, but
such cases as the one shown are rare and extremely interesting.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Congenital Facial Diplegia.— Dr. Thomas.  


In connection with the case which Dr. Friedenwald has
exhibited. Dr. Thayer thought it might be interesting to have
this rather unusual case presented to the Society. He has
asked me to bring it before you.


The patient, a youth of 19, came to the Hospital from a
neighboring State, in the hope that something might be done
to improve bis uiifortunate appearance. Dr. Halsted has
admitted him to his wards, and it is through his kindness that
I have had the opportunity of examining him.


179
The family history is important. Father and mother are
healthy and there is no history of any hereditary taint in
either of their families. Patient is the third child of a family
of nine. Three children died young, one of these having a
niisformed foot. The eldest child, a girl, is perfectly healthy;
the second child, a boy, now twenty-one years old, was born in
a condition similar to that of our patient. The patient's birth
was not particularly difficult and was non-instrumental. It
was noticed soon after he was born that he was unable to
close his eyes and that his underlip dropped while nursing.
In crying his face remained motionless and he was unable to
smile. He learned to speak at the usual time but was never
able to pronounce certain letters. His general development
was good except that he had some glandular trouble. He
played with other boys and was able to do everything they did.


You see what a remarkable appearance the patient has ; the
face is mask-like and expressionless, the mouth open, the
lower lip pendulous, and the lower jaw protruded. He is absolutely nnable to move the muscles of his forehead, and when
told to close his eyes he simply rolls the eyeballs up and
relaxes the upper lid. He is unable to elevate or pucker his
lips, but can move the angles of the moxxth out and down ; in
doing this, you see, he brings into play the platysmata. In
speaking he cannot pronounce the sounds which require the




was present, and certifies that after satisfying himself of the
genuineness of the claims, Jackson proposed to Long to lay
their claims conjointly before Congress — he, Jackson, to claim
the discovery, and Long to claim the first practical use, — his
object evidently being to get ahead of Morton.


This proposition Dr. Long rejected, being satisfied that he
use of the lips, viz. b, f, m, p, v. His eyes are prominent;
was entitled to both. In a letter to Hon. D. L. Swain, ex-governor of North Carolina, which I have here, he says in regard
the pupils are equal and react normally to light and during
to this transaction: "The only ground Dr. Jackson urged
accommodation ; all movements of eyeballs are normal. He
for his right to the discovery was that while suffering
complains of being somewhat near-sighted ; there is no disturbance of the visual field. Muscles of mastication unaffected.  
with pain and dyspncea, in February, 1842, from breathing
There is no disturbance of sensation and taste is normal.  
chlorine gas, he inhaled ether and found that while under its  
Tongue is well developed and freely movable, indeed he makes
influence he was free from pain. He does not claim that he
his tongue take the place of his lips as much as possible,  
suggested its use to jjrevent pain in surgical operations until
drinks and smokes by its aid. I have been unable to discover
more than one year after my first operation was performed. I
any abnormality in the muscular development of his trunk or
cannot give the exact date when I was first led to believe that
limbs. Stimulating the facial nerves by electricity causes
ether would prevent pain in surgical operations, but I know it
contraction in the muscles back of the ear and of theplatysma.
was as early as February, 1S42."
By direct stimulation the platysma can be made to contract.  


Now in 1839 Pereira, in his "Elements of Materia Medica,"
Before leaving the patient I should like to call your attention to the congenital defect in the right lobe of his ear. You
states : " The vapor of ether is inhaled to relieve the effects
will see that it is notched.  
caused by accidental inhalation of chlorine gas. If the air be
too strongly impregnated with ether, stujjefactiou ensues."


So there was very little new in Dr. Jackson's " discovery,"
This, then, is a case of congenital facial diplegia. Dr.  
and a mere untried inference hardly deserves the title of discovery.  
Friedenwald has told you that certain of the cases of congenital defect of the ocular movements have been associated
with a similar condition in the facial muscles, and it is on
account of this association that I have brought the case before
you at this time.  


Dr. Jackson finally acknowledged the justice of Dr. Long's  
Dr. Chisolm, of this city, reported one of the very first
claims and wrote to Senator Dawson to that effect.  
examples of this condition. In his case there was bilateral
paralysis of the sixth and seventh nerves, a combination of
the symptoms seen in Dr. Friedenwald's case and of those in
the boy whom I have just shown you.  


On April 15th, 185-t, the appropriation bill was up before
Moebius had a somewhat similar case, which he described
the Senate for its final reading. The friends of Wells and
in 1888, after which he made a fairly complete collection of  
Morton, relying on the volumes of manuscript they had presented, were confidently awaiting the result, when Senator
all like and analogous cases. These he published in 1892. In
Dawson arose and said that he had a letter from Dr. Jackson
this article he expresses the view to which, as Dr. Friedenwald has said, Kiihn takes exception, that the disease depends
which acknowledged that a Dr. Long in Georgia had undoubtedly used ether before any of the claimants for the  
upon an atrophy of the nuclei, and he proposes the name " Infantiler Kernschwund."
appropriation.  


Coming as it did from so prominent a contestant, this announcement fell like a thunderbolt on the rival claimants, and
Moebius was unable to find the record of any case in which
from that time they seem to have lost all Iwpe of gaining the
congenital facial paralysis was unassociated with any defect
reward and passively allowed the bill to die.
of the eye muscles. Since then, however, two or three such
 
cases have been described, but these cases were all unilateral,  
Desirous only of preventing another from being recognized
and, as far as I have been able to discover, the case which I
by Congress as the discoverer, and not wishing any pecuniary
have shown you to-night is the first one of its kind to be
reward himself, Long never pushed the matter farther, and  
reported, although I have no doubt that others have been
his documents of proof were never even brought uj) before
observed.  
Congress.  


I have here an interesting memento of that conference
As to the anatomical condition which underlies these cases
between the two discoverers, in a card on which Jackson has
not much is known, and it seems scarcely worth while, at this
written a note to Long. On one side it reads :
time, to examine the theories which have been advanced.  


"For Dr. C. W.Long,
The aspect and condition of the face in the patient whom
we have seen suggest strongly the myopathic face which
occurs in certain forms of progressive muscular dystrophy.  
We have examined the patient thoroughly with this point in
view and have been unable to discover any other muscular
abnormality, either hypertrophy or atrophy.  


of Athens, (Ja.  
It tlierefore seems to me that the case cannot be classed
C. T. Jackson,
with the progressive muscular dystrophies, although it
might be considered as an abortive form of this disease, an
explanation which has been given of a somewhat similar
condition. As we do not understand the pathology of the
muscular dystrophies, such an explanation helps but little.  
In this connection the condition of the patient's brother is of


New York Hotel,
(over) "
and on the reverse :


"Telegraph from J. L. Hayes, Washington.
'Assignee struck out by request of Mr. Everett.'
Bill probably will come up in House July next."


Edward Everett was then senator from Massachusetts. In
June, 1897.]


131




the transactions of the Senate, April 19th, 1854, I find the
following explanation of the bill by Senator AValker:


" The bill as amen. led recites that a discovery of anaesthesia has
importance, for if, as we are told, his symptoms are quite
Ijeen made — that it is believed the discovery was made by some
similar to those of our patient, and no other muscles are
one of the following persons, W. T. G. Morton, Chas. T. Jackson
involved, it will make the classing of the case with the muscular dystrophies still more far-fetched.*
and Horace Wells, but it does not appear to the satisfaction of Congress which of those parties was the original, true and first discoverer thereof. It proposes to ap|>ropriato $100,0(0.00 as a recompense for the real discoverer. In order to determine this it shall
bo the duty of the district attorney of the United States for the
Northern District of New York, to file in the circuit court of the
United States for that district a bill of interpleader wherein reciting the act or its substance, the Secretary of tlie Treasury shall be
complainant, and AV. T. G. Jlorton, Chas. T. Jackson and the personal representatives of Horace Wells or any other person who
may make application to thecourt for that purpose shall be defendants. The issue is to be which of the parties named was the
original, true and first discoverer of anseathesia, and the court is to
decide which one that is and direst that the sum of $100,000 he
paid over to him."


At the instance of Senator Dawson Dr. Long's name was
Dr. OsLER. — I do not think there are any muscular dystrophies of this kind that have that extreme atrophy without
also inserted in the bill.  
any involvement of other muscles. None that I have seen
presented that appearance. You will probably find the
brother the same as this patient.  


I have carefully searched the Congressional Eecords and
Dr. Halsted. — Is the jaw of the brother the same?
find that this bill never came up before the House for final
passage, and conseqixently never reached the district court of
New York. It seems to have been abandoned.


Several years later Dr. Jackson wrote an article in the
Dr. Thomas.— The patient tells me that it is not quite so  
Boston Medical and Surgical Journal giving Long the credit
much so.
for the first use of ether in surgery. I have here Dr. Long's
copy of that journal. The communication is so imjiortant
that I will read most of it :


" The Boston Medical and Surgical Journal.  
Dr. Theobald. — Were there any cases in the family previous to this ?


Boston, Thursday, Apr. 11, ]8()1.  
Dr. Thomas. — Not as far as I can find out, not even an
ocular palsy.  


First Peactical Use of Ether in Surgical Operations.  
Dr. Barker. — The absence of ocular paralysis in Dr.
Thomas's case is an interesting feature. In consideration of
the anatomical relations of the sixth and seventh nuclei, the
occurrence of paralysis of the abducens along with paralysis
of the seventh nerve is rather to be expected, if the lesions
be in the region of the nucleus and due to pressure or hemorrhage. One of the most curious facts with which the anatomist has to deal is the relation of the fibres of the seventh
nerve to the sixth nucleus after they leave the facial nucleus.
Why these fibres should run up toward the middle line, turn
and run along the fioor of the fourth ventricle and then turn
again ventrally and laterally has never been satisfactorily
explained. Such an out-of-the-way coui'se seems unnecessary.  


Messrs. Editors: — At the request of the Hon. Mr. Dawson, U. S.  
During the development of the motor nerves whose nuclei
Senator from Georgia, on March Sth, 1854, 1 called upon Dr. C. W.  
of origin are situated in the medulla and poQS, the motor
Long, of Athens, Georgia, while on my way to the Dahlonega gold
fibres belonging to the N. accessorius, N. hypoglossus, N. vagus,
mines, and examined Dr. Long's evidence, on which his claims to  
N. glossopharyngeus, N. abducens, etc., pass directly toward
the first practical operations with ether in surgery were founded,
the periphery of the medullary tube and pass through the
and wrote, as requested, to Mr. Dawson, who was then in the  
marginal veil to form the peripheral cranial nerves. The fibres
U. S. Senate, all I learned on the subiect. From the documents
of the N. facialis alone show the well known remarkable discursion. Whatever be the factors which determine the course
shown me by Dr. Long, it appears that he employed sulphuric
of these fibres, they are active at a very early period of development, for the relations mentioned are visible in very young
ether as an anaesthetic agent :
embryos. In his lectures on vertebrate embryology last year,  
Professor His of Leipzig made the ingenious suggestion that
the cause of the deviation of the fibi'es of the N. facialis from
the course we would expect them to take may possibly depend
upon mechanical factors associated with the development of
the auditory vesicle, since the ear vesicle is laid down laterally
exactly in the region of the sixth and seventh nuclei.  


1st, March 30th, 1812, when he extirpated a small glandular
It would be easy to speculate further and to think of such
tumor from the neck of James M. Venable, a boy in Jefferson,  
cases as the one before us as instances of congenital nuclear
Georgia, now dead.  
destruction from disturbances of the relations which ordinarily
exist between the auditory apparatus and the neural tube, due
either to an unfortunate variation or to early intra-uterine
pathological lesions. That the affection is bilateral and that
more than one member of the same family is diseased would


2nd, July 3rd, 1842, in the amputation of the toe of a negro boy
lielonging to Jlrs. Hemphill, of Jackson, Ga.


3rd, Sep. 9th, 1843, in extirpation of a tumor from the head of
Mary Vincent, of JacKson, Ga.


4th, Jan. Sth, 1845, in the amputation of a finger of a negro boy
•The elder brother was seen at his house and was found to be
belonging to Ralph Bailey, of Jackson, Ga.  
in an almost exactly similar condition to that described above in  
the case of his brother. Both cases will be reported more fully at
a later date.  


Copies of the letters and depositions proving these operations
with ether were all shown me by Dr. Long. * * *


I then called on Profs. Joseph and John Le Conte, then of the
University of Georgia, at Athens, and inquired if they knew Dr.
Long, and what his character was for truth and veracity. They
both assured me that they knew him well, and that no one who
knew him in that town would doubt his word, and that he was an
honorable man in all respects.


Subsequently, on revisiting Athens, Dr. Long showed me his  
favor rather than oppose such an hypothesis. It is surprising,
folio journal, or accountbook, in which stand the following entries :
considering the extremely complex character of the developmental relations of the internal, middle and external ear, that
vicious developments of these parts are not more common than
they are. It is interesting to note that, as Dr. Thomas has
pointed out in this individual, there is faulty development of
a portion of the external ear. Should this man or his brother
be the father of children it would be important to determine
the presence or absence in them of similar lesions, since, as is
well known, variations favorable or unfavorable show a marked
tendency to become inherited. That instances of extremely
unfavorable variation persisting through many generations are
comparatively rare need not surprise us, inasmuch as in the
progress of the race, in the course of a very few generations,
individuals bearing such peculiarities, owing to their unattractiveness and unfitness, are, as a rule, gently killed out without offspring.


While modern embryology permits the formation of hypotheses such as those here hinted at, it is to be remembered that
for any real explanation we must await the results of pathological findings in actual cases. In view, however, of what
has recently been done, the problem might perhaps be advantageously approached from the side of teratological experiment.


Meeting ofiDecemher 31, 1896.


180
Dr. Thayer in the Chair.


A Case of Acquired Paralysis of both External Recti Muscles, with Unilateral Facial Paralysis.— Dr. S. Theobald.


I thought this case would be of interest to show as supplementary to the one exhibited by Dr. Friedenwald several weeks
ago. His was a case of congenital paralysis, or perhaps defective development, of the external recti muscles. He pointed
out, as one of the interesting features of that form of paralysis,
that there was no squint, and explained that in cases of congenital paralysis secondary squint does not usually occur. In
the case which I exhibit we have the usual secondary squint
found in acquired paralysis of the ocular muscles, and as
both external recti are involved, it is of high degree.


JOHNS HOPKINS HOSPITAL BULLETIN.  
This patient is 33 years of age and until August last was
employed as a laboring man. His history shows that ten years
ago he had a facial paralysis of the left side, and at the same
time a paralysis of the right external rectus. There has been
little or no change in his condition, so far as we can judge, in
all that time. During August last he first developed a paralysis of the left external rectus. As to the cause of these
paralyses the history is rather indefinite. It is more than
probable, I think, that they are of syphilitic origin. He
admits having once had gonorrhcea, and I think there must
have been specific trouble also, though the history as to this
is not clear. The points of interest are that so many years ago
he should have had paralysis of the facial nerve occurring at
the same time as the ocular paralysis. If the two had been on
the same side it would not be so difficult to explain their
co-existence, for we know that the nuclei of the 4th and 6th
nerves lie close together in the floor of the fourth ventricle,
and it is not uncommon to find both these nerves involved in
the same case. It is of great interest, too, that after so long a






[Nos. 77-78.
132


[No. 75.




' James Venable


March 30th, 1842, Ether and excising tumor, $2.00
lapse of time the external rectus of the other eye should
May 13th, Sul. Ether, .25
have become iuvolved. The paralyses are evidently nuclear,
and it would seem that some central change, either inflammatory or degenerative, involved the nucleus of left 7th nerve
and the nucleus, which is quite close to it but on the other side
of the brain, of the right external rectus, and that after a long
lapse of time the left external rectus also became involved.  


June 6th, Excising tumor, 2.00'
Paralyses of the ocular muscles are not uncommon. Their
origin may be cortical, fascicular, nuclear, basilar, or orbital.
Probably the commonest cause of paralysis of the ocular muscles is syphilis. We also often have a paralysis of the ocular
muscles in tabes which is quite marked and yet which may in
time entirely disappear. Paralysis of the ocular muscles may
also be caused by diphtheria, disseminated sclerosis, poisoning
by alcohol, nicotine, etc., and a certain class of cases certainly
are due to cold. I have seen recently four cases of paresis of
the external rectus due to cold or exposure. Such cases frequently occur in rheumatic subjects and are usually due to
inflammation in the orbital portion of the nerve, and the prognosis is good.  


On the upper half of the same page, several charges for ether
The most marked symptom in cases of acute paralysis of  
sold to the teacher of the Jefferson Academy are recorded, which
ths eye muscles is diplopia, which is very annoying. In squint
ether Dr. Long told me was used by the teacher in exhibiting its
due to hypermetropia there is no complaint of dijjlopia, possibly because it usually develops in childhood ; but in paralytic
exhilarating effects, and he said the boys used it for the same purpose in the academy. I observed that all these records bore the
squint, which oftener occurs in ^ults, diplopia is the most
appearance of old and original entries in the book.  
common symptom complained of.  


On asking Dr. Long why he did not write to me or make known
There is one point in regard to this case which I have neglected to mention : this patient has well advanced atrophy of
what he had done, he said, when he saw my dates he perceived
both optic nerves. The discs are decidedly white and the
that I made the discovery before him, and he did not suppose that
vision greatly impaired, in one eye being only ^^, in the other
anything done after that would be considered of much importance,  
^^. The treatment has been the administration of large
and that he was awakened to the idea of asserting his claims to  
doses of potassium iodide, and I think there is some slight
the first practical use of ether in operations, by learning that such
improvement, but an operation will probably be necessary. It
claims were set up by others for this merit, and consequently he
will not be sufficient to perform a tenotomy of the internal
wrote to the Georgia delegation at Washington, stating the facts
recti, but it will be necessary to combine with this an advancement of the externi.
which Senator Dawson had requested me to inquire into.  
 
Dr. Thomas. — There is the history of a decided facial
paralysis ten years ago, and at present there is contracture of
the muscles of the right side of the face. We know that in
cases of severe facial paralysis there is very generally developed a secondary contracture of the paralyzed muscles. After
a hurried examination it seems to me that upon voluntary
effort the patient does move the left side of his face more
than the right. An electrical examination would determine
the point, but even now I am strongly inclined to the belief
that it was the right side that was paralyzed. If this is
found to be the case we can easily understand how a single
lesion could cause a paralysis of the right 6th and 7th nerves;
in fact there are many such cases reported. But on the other
hand it is difficult to imagine a lesion involving the right 6th
and the left 7th nerves.  


I have waited expecting Dr. Long to publish his statements and  
Dr. OsLER. — One other point is of interest in this case :
evidence in full, and therefore have not before published what I
whether this may not be a facial paralysis and external rectus
learned from him. He is a very modest, retiring man and not disposed to bring his claims before any but a medical or scientific
paralysis occurring with the secondary symptoms of syphilis,  
tribunal. * * *
and whether his present paralysis and atrophy may not be the
signs of tabes. The fact that he has the knee jerk is somewhat against this, but the persistence of these ocular paralyses is occasionally seen as an initial symptom of tabes.  


Had he written to me in season I would have presented his
claims to the Academy of Sciences of France, but he allowed his
case to go by default, and the academy knew no more of his claims
to the practical use of ether in surgical operations than I did.


Boston, >ipril 3, 1861. Charles T. Jackson, M. D."


The list of operations as given by Dr. Jackson is not complete, as he has omitted the second operation on Venable, and  
Dr. Theobald. — I would only say in closing that the knee
a number of the later operations. In a letter to Dr. Sims,  
jerk was examined and found to be up to the usual normal
which I have, Dr. Long denies absolutely that he ever
standard. The suggestion of Dr. Osier is well worth considering, whether we are dealing with a greatly different state of
acknowledged that Dr. .Jackson was the prior discoverer. He
affairs now from what originally existed ; whether this present paralysis is a tertiary, while the other was a secondary
had been led to infer that ether had ana3sthetic powers several
symptom.  
months before he got a chance to verify it, and before Jacksou claims to have made similar inferences, but he dated bis
claims of discovery from the time of his first practical demonstration. Before that it was a mere supposition, as was Jackson's also.  


But barring these inaccuracies, Dr. Jackson's paper, coming
I will be glad to have the patient come to Dr. Thomas's  
as it does from one who so zealously coveted the title of discoverer, is a remarkable admission.  
clinic and have the electrical examination made. My diagnosis of left facial paralysis was made simply on the drawing of  
the face to the right side and the fact that there is a certain
blank expression about the left side of the face.  


The interview between Long and Jackson must have been
Exhibition of Opiithalmological Cases.— Dr. R. L. Randolph.
most amicable, and Long evidently felt the greatest respect
Bilateral Dacryo-adenitis.
for Jackson, as shown in the following letter:


"Athkns, Ga., Nov. 15th, 1854.  
Dr. Randolph reported a case of bilateral dacryo-adenitis
Dr. C. T. Jackson.  
(mumps of the lachrymal glands, Hirschberg) in a negro
woman thirty-nine years old. He spoke of the case as being
one of the few cases reported in this country, the disease being
very rare. Both lachrymal glands were so swollen that the
upper lids had been pressed down at the outer canthus to such
an extent as to hide the outer half of the eyeball. In the case
of the left eye the hypertrophied gland had pressed the eyeball inward and slightly downward. The tumors were
exceedingly painful to pressure, but at other times she suffered
no local pain, the pain then being refeiTed to the sides of the
face. There was nothing in her history that would give one
a clue as to the origin of her trouble. She was put on small
doses of bichloride of mercury and ten grains of iodide of potash three times daily, and frequent hot applications were made
to the tumors, and after a month there was a noticeable diminution in their size. Six months after the beginning of the
trouble there remained only a slight enlargement of the left


Dear Sir: — I design to prepare an article with the proofs of the
priority of my claims of the discovery of the anresthetic powers of
ether and of its applicability to surgical operations. I design having
this published in pamphlet form for distribution among the members of the medical profession, and I expect to present such proof
with the article as will satisfy all that I am entitled to all I claim.


Ours are rival claims, and permit me, sir, to say that although our
claims are conflicting, I would not knowingly say anything in the
article which would be displeasing to you. I entertain high respect
for you as a gentleman and man of science and feel honored by your
acquaintance.


Still it becomes each one of us to use all honorable means to  
The trouble having passed away it is no longer interesting to  
advance his own claims, and I know you will not blame me for
show the patient, so she is not here this evening. It is the
attending to this matter, which so much concerns my reputation.  
first case reported in the city, and certainly less than a dozen
have been reported in this country.  


Shall it meet with your approbation, I may refer to your admis
Dr. Thayer. — In connection with Dr. Randolph's case I
should like to say a word with regard to a somewhat similar
instance which has been under our observation in the hospital.
In 1894 a little girl, 10 years of age, was admitted to the hospital with bilateral hard enlargement of the lachrymal, parotid
and salivary glands, for which we were unable to find any
cause. The lachrymal glands were to be felt on either
side as two small hard shot-like bodies. The child stayed in
the wards for many months, and while there developed an ozoena
and caries of the nasal bones which was clearly syphilitic in
nature. Under treatment with mercury and iodide of potassium the glandular swellings slowly but completely disappeared. While in the hospital, however, some of the cervical
and lymphatic glands became enlarged and remained so after
treatment with mercury and iodide of potassium, and the
child has since showed evidences of a tuberculous peritonitis.
The enlargement of the lachrymal glands was very striking,
though never as marked as in Dr. Randolph's case; it has
entirely disappeared.




sions to Hon. W. C. Dawson and myself, of the belief of the correctness of my claims. I will, however, make no allusion to your
letter to Mr. Dawson or to the conversation held with myself unless


it meets with your sanction
June, 1897.]


Your obedient servant, C. AV. Long."
133


Morton's Patent.


It has often been stated by the friends of ilorton that he
never attempted to enforce his patent. This statement has
lately been reiterated by his wife in McClure's Magazine. On
this point the following letter from a prominent army surgeon
to Long may be of interest:


" U. S. Marine Hospital,
Operations for Cataract.  


Chelsea, Mass., April, 1859.  
The other cases which I have to exhibit are some of the
Dr. Crawford W. Long, Athens, Ga.  
cataract cases upon which I have operated in this Hospital
during the last summer. There are 12 or 13 here to-night.
Some of them have interesting histories. One, an old man,
88 years of age, was operated upon early in September, and on
the night of the operation had an attack of acute mania. He
tore the bandage off several times, and finally had to be tied
in bed, but in spite of that has a good result. When we consider how slight a disturbance may sometimes cause the operation to go to the bad this is rather a remarkable recovery.  
The bandage was disarranged at least three times. After the
atropia was withdrawn he regained his senses and was rational
for three days. One night after that he had another attack,  
jumped from his window, scaled the fence and was making
his way homeward when found. Strange to say it had no
effect upon the ultimate result.  


Sir: — Hon. Judge Hyllier, Solicitor of Treasury Department,
The next case is a rare one. I operated for cataract early
informed me about a year since, and recently repeated the same,
in June and the anterior chamber remained open after the
that some years since you used sulph. ether as an anaesthetic and
operation for 17 days. At the last meeting of the American
had a record of the same. If it is not asking too much of you, I
Ophthalmological Society I asked several of the members
would be greatly obliged if at your earliest convenience you would
what was the longest time they had ever seen the anterior
forward me a statement of the facts.  
chamber remain open, and the longest period given in reply
was 11 days. Four weeks after the operation when this patient
left the hospital he had i^ vision, which is very good practical vision.  


I take the liberty to ask this of you because Mr. W. T. G. Morton,  
Very frequently in cataracts there seems to be a stage where
to whom in conjunction with Dr. C. T. Jackson a patent was  
they make no progress toward maturity. That was the case
granted in Nov., 1846, for using ether, has brought a suit against me
with this woman, aged 63, who, while having sight enough to
as a government officer for an infringement of his patent.  
get about, was unable to do work. Here I performed the
maturing operation. This consists in doing an iridectomy
and practicing massage upon the lens through the cornea.  
The cataract was ripened, then exti'acted. With the exception
of that case I have performed the simple extraction, and in  
several of them there is no objective evidence of an operation
having been performed.  


Judge Hyllier was confident that you could furnish me with
Demonstration of Florence's Iodine Test for Seminal Stains.  
proof sufficient to satisfy a jury that you used it way before he or
Jackson claimed to have made the discovery. I should have asked
for these proofs through my attorney and had them properly witnessed, etc., but the Secretary of the Treasury having decided that
I used the article on my own responsibility and therefore the Govt,
were not bound to defend me, I wish to save as much expense as
possible. Very respectfully,


[Signed] Charles A. Davis, M. D.,
— Dr. Lewellys F. Barker.  


Physician and Superintendent."
Professor Florence of Lyon has recently published in the
Archiv d'Anthropologie a very delicate test for human seminal stains. He uses a mixture of iodine, iodide of potash and  
water not unlike the ordinary Lugol's solution.  


In reply Long gives a detailed account of his work, and  
To apply the test, if the seminal stain be upon linen, a small
then adds : " I presume Dr. Jackson is not party to the prosecution, as I know he entertains no good feelings towards W. T.
piece of the stained fabric is moistened with water, placed
Morton. If you think proper you can see him and ascertain
upon a glass slide and a drop of the reagent added beneath
the character of proof I can make. From the little acquaintance formed with him I entertain a high opinion of him as a
the cover-glass. If the stain be due to semen a very distinct
gentleman and think he will do me justice notwithstanding
precipitate of crystals results. The form of crystals is not
he himself claims to have made the discovery and has received
unlike that of ordinary haemin.  
several awards."


Dr. Davis's letter was written twelve years after Morton's
We have used the test in the course in normal histology and
" Letheon " was patented, and many years after ether was the  
find it very easy to apply and extremely delicate. The reaction is not yielded by blood, saliva, nasal mucus, vaginal
common property of the world. It was probably Morton's
mucus, urethral mucus, nor by the semen of other animals. I
last attempt to get money from the U. S. Government.
have placed under the microscope one specimen in which the
seminal reaction is apparent, and under the other microscopes
a number of other fluids mentioned in which no reaction has
taken place. Urine sometimes throws down yellow-brown
globules, but as far as we have been able to make tests, defi


The ether controversy was never reopened and Long's work
was unknown to the world until 1877, when J. Marion Sims
learning of him through accident, investigated his claims,
was fully convinced of their merit, and vigorously demanded
their recognition by the medical profession. His paper
appeared in the Virginia Medical Monthly, May, 1877.


The Wilhite Cl.\ims.  
nite crystals, likely to be confused with those of the reaction,
are never deposited. Whether or not urine containing semen
would yield the reaction I have not yet had the opportunity
of testing; but inasmuch as minute quantities of the seminal
fluid on linen will afford the reaction, it is very probable that
urine containing this substance would also yield it. Some
alkaloids are capable of yielding similar precipitates, a fact
which must be borne in mind in medico-legal cases. Just
what portion of the semen is concerned in the reaction has
not yet been made out; it would be easy to ascertain this by
testing the individual constituents of the seminal fluid
obtained, say from the vas deferens, vesiculiE seminales, prostate and Cowper's glands at autopsy. Urethral mucus, as will
be seen under one of the microscopes, does not yield the reaction. In case no single one of these constituents afforded the
reaction, the latter must be due to some substance produced on
their admixture.  


This article, which obtiviued for Long the first recognition
of any consequence, was the outcome of a conversation which
Sims had with a Dr. P. A. Wilhite, of Anderson, S. C.
Wilhite told Sims that be had witnessed the first surgical
o])eration ever done under ether, and recounted Dr. Long's




NOTES ON NEW BOOKS.


August-September, 1897.]




The Practice of Medicine. A Text-book for Practitioners and
Students, with special reference to Diagnosis and Treatment. By
Jambs Tyson, M. D., Professor of Clinical Medicine in the Unisity of Pennsylvania, etc. Illustrated. {Philadelphia: P. Blakision, Sondb Co., 1896.)


JOHNS HOPKINS HOSPITAL BULLETIN.  
This is in every respect an admirable boolt. The author's statement that it tias taken several years of labor is borne out by the
careful and thorouglily conscientious way in which the suliject has
been treated. It is a work of nearly 1200 pages, larger than the
recent text-books issued in this country, containing on the whole
rather more mattereven than Flint's, which is a very closely printed
book.  


Ttie author's method of dealing with a subject is well illustrated
in the consideration of the important subject of myxoedema. Following the definition — and by the way the text-book is quite
strong in clear, practical paragraphs defining diseases— the history
of our knowledge of the affection is considered in nearly threefourths of a page. Dr. Tyson has in nearly every section dealt in a
most instructive way with the historical development of the knowledge of the different diseases, and in myxoedema it is of course particularly interesting. I do not think that the statement is altogether clear about the dispute between Reverdin and Kocher as to
the discovery of operative myxcedema. Unquestionably Reverdin
published the first note in October, 1882, but he did not at that
time appreciate fully the remarkable character of the changes following thyroidectomy. Kocher distinctly states that in the autumn
of 1882, in Geneva, he spoke to Professor Reverdin of the remarkable sequences of the operation, and that Reverdin six days later
read a paper on the subject. In Kocher's paper, which appeared in
the spring of 1883, the description of operative myxoedema as we
know it now, and which he called cachexia strumipriva, was fully
and clearly drawn, and he certainly appreciated at that time, as
Reverdin did not, the serious effects which might follow total extirpation. In the succeeding paper by the brothers Reverdin they
recognized the condition as identical with myxoedema and called
it myxoedeme operatoire. Three forms of myxoedema are recognized :
pure myxoedema, myxcedema associated with congenital or sporadic
cretinism, and operative myxcedema. There is in addition a full
description of cretinism. On the subject of exophthalmic goitre,
though the disease is placed under diseases of the thyroid gland,
Dr. Tyson states that the neurotic nature of the disease is now generally admitted. He holds that the sympathetic neurosis theory




181
explains the symptoms rather more satisfactorily than any other.
His practice is better than his precept in this respect, since he
places the disease where it probably belongs, among those of the
tliyroid gland. We are glad to notice that he insists upon the priority of the description by Graves. Of this, of course, there can
be no doubt, though Parry and others published individual cases.
Graves' clinical lecture in 1835 gave the first good description of
the affection.


Naturally in a new textbook one turns to certain of the diseases
about which there is still a good deal of difference of opinion. Appendicitis receives a very thorough and satisfactory treatment.
There is no work in English which gives so good an account of the
history of the affection. We are glad to see that Dr. Tyson does
not consider it necessary to speak of a typhlitis, stercoral or otherwise. It is satisfactory to see that the name even does not occur in
the index. lie describes catarrhal, ulcerative and interstitial forms
of appendicitis. The clinical description of the different varieties
is admirable. On the all-important matter of treatment the author
takes rather advanced ground, stating that "the diagnosis being
established, operative treatment should be recommended, except
in those cases where the disease is so far advanced as to make it
unlikely that the patient will be saved by operation." He thinks
that the operation after the first attack is safer than during the first
attack. On the much debated point of purgatives he leaves the
matter to the circumstances of the case and the good judgment of
the attendant, as the results may be either very happy or very mischievous. He believes that if there is doubt it is best not to purge.


The article on typhoid fever, with which the book opens, is in
every way worthy of the great importance of the subject. The
author is a strong believer in the use of the cold bath, and on the
question of treatment he everywhere displays sound judgment.


first case, saying that lie was one of four students who were
We have said enough to indicate the importance of the work, its
then in Dr. Long's office.  
thoroughness, and its reliability in all practical details. The publishers are to be congratulated on the appearance of the volume.
It is one of the handsomest works issued of late years in this country,
and the type and paper are very much above the average. Altogether Tyson's Practice forms a very welcome addition to our textbooks, and we predict for it a most successful career.  


He also said that " he presumed that he was the first j)erson
An American Text-book of Applied Therapeutics, for the use of
who ever profoundly etherized any one," and told how he was
Practitioners and Students. Edited by J. C. Wilson, M. D.,  
at a quilting party in which the boys and girls had concluded
assisted by Augustcs A. Eshnek, M. D. Pp. 1-1326. {Philadelphia: W. B. Saunders, 1896.)
the evening by inhaling ether for sjiort; how they had caught
a negro boy, and as he refused to inhale the ether, had firmly
held a handkerchief soaked with ether over his face, when to
their horror his breathing became stertorous and he could not
be aroused. He then vividly pictured their alarm when they
realized that they had murdered a fellow-being, and thdr
determination to leave the country, which was prevented by
the timely arrival of a physician who restored the boy to consciousness.  


Wilhite iheu related how when the idea of using ether to  
Since the main object of medical studies must always be the formulation of methods for the prevention and cure or alleviation of
prevent pain in surgical operations had occurred to Long, he
disease, it necessarily results that laboratory researches and clinical
had eiicoura<jed him hy relating the story of the negro boy.  
observations must ultimately be valued in proportion as they have
brought us nearer to the attainment of these aims — in other words,
according to the advances which have been derived from them in  
the establishment of a rational system of therapeutics. The world
at large is apt to look at results rather than methods, and the
busy practitioner may justly demand that the previous studies and
experience of others should be presented to him in aconcrete form.
For these reasons the status of medicine at any particular period
will, to a great extent, be gauged by the therapeutic measures
which prevail at that time, and of which the textbooks dealing
with the subject are the exponents.  


Dr. Sims at once communicated with Dr. Long and soon
Graduates of twenty years ago will probably remember a time in
convinced himself of the truth of his claims, but unfortunately he failed to investigate Wilhite's statements, but
the first few years of their practice during which they were tempted to become adherents of the doctrines of therapeutic nihilism.
embodied them in full in his article, giving to Wilhite the  
They had gone forth armed, they had been taught and for a time
credit of first intentionally producing profound ana;sthesia
had firmly believed, with agents with which they could infallibly
with ether.
combat each and every untoward symptom. Is it to be wondered
at that many of them in a short time exchanged their early therapeutic optimism for a hopeless therapeutic pessimism? Could
they not justly reproach for this the faulty teaching which had
been accorded to them?


Dr. Sims' paper was given great publicity and the Wilhite
story has been accej^ted as true, and copied by many writers
on the subject, most notably by Sir Jas. Paget.*


The negro boy story lacks probability, as Wilhite did not
enter Long's office until 1844, two years after the first operation, as the following letter from Long to Wilhite shows :


"Athens, Ga., May 20th, 1S77.
Medicine is still to a great extent an empirical art, but although
Dk. p. a. Wilhite.  
we can hardly hope that it will ever be numbered among the exact
sciences, there are signs which indicate that by slow degrees we are
attaining to a therapeusis which may always be at least rational.  


Bear Sir : — I received Br. Sims' article on anaesthesia yesterday
The book before us shows a decided advance, not only because it
and find several mistakes. Dr. Sims states that yourself, Dr.  
registers real progress made in our knowledge of disease processes
Groves, and Drs. J. D. and H. E. J. Long were students of mine
and in our methods of treatment, but because it shows that the
and witnessed the operation performed on Venable in 1842. Your
difficult subject of therapeutics is now being attacked in a frank and
recollection failed you at the time. As it was several years, at
true scientific spirit. The writers have been chosen from among
least two, before either entered my office, you will see that you
men who have brought to bear upon the subjects allotted to them
were mistaken in giving Dr. Sims this information. You also
not not only the results of a profound study of the existing literature, but also those which can be obtained only by a wide personal
make a mistake in saying that the first inhalation in Jefferson of  
experience. They are not mere compilers; they know whereof
ether for its exhilarating effects was before the same persons.  
they speak. If not all of them have added much that is new, they
have at least accepted the dicta of others only after a painstaking
proving of their statements. They have chosen the middle ground,
and while confident that much can be accomplished by the use of
the various therapeutic measures which they recommend, they do
not by the employment of specious generalities attempt to conceal
those points upon which our present knowledge is still defective.  
They hold a strong position midway between therapeutic optimism
and therapeutic nihilism. Above all and first of all they preach
the doctrine of prophylaxis.  


* * * I wrote to Dr. Sims informing him of the errors and  
In many of the articles a short account of the more prominent
asking him if he considered the mistakes of sufficient importance
manifestations of the disease underdiscussion will be found, which,
to be noticed, etc. (Signed) 0. W. Long."
although adding considerably to the bulk of the book, will assist
the reader materially in better appreciating the treatment recommended later. It is impossible to speak here in detail of all or of
any of the various contributions. In his article on tuberculosis,
Whittaker summarizes our present knowledge upon prophylaxis in
general, hygiene and climatology, and has ably marshaled all the
recent experience, upon which he formulates a treatment which, if  
it contains little that is really new, is perhaps the best at hand. If
his conclusions as to the advantages to be obtained by the use of
tuberculin are not in accordance with those of other authors, his
results certainly deserve the most respectful consideration. Tyson's article upon the diseases of the kidney is brief but admirably
comprehensive. In speaking of typhoid fever, Wilson, after a
careful consideration of other methods, not only endorses the cold
bath treatment but repudiates the notion that it is cruel. This
latter view will certainly not be conceded by many even of the
most enthusiastic supporters of the procedure. Serum therapy
receives a full share of attention, and the subject has been treated,
by the writers upon the conditions for which it has been advised,
with a full appreciation of its importance. Whatever may be the
opinion with respect to Laveran's vie w as to the identity of the parasite for the different forms of malarial fever, the careful and precise
treatment which he lays down will not easily be improved upon.  


Dr. Wilhite replied as follows :
Another point to be noted is the comparative simplicity of the
prescriptions which are given ; we are grateful for further evidence of the decline of polypharmacy. It would seem that we are
beginning to appreciate Huxham's advice, " The physician should
select a few (drugs) of the most effectual forhis useof each sortand
stick to them and not run into an immense farrago which some
are so fond of." Many of the illustrations are good, but not a few
are superfluous. As might be expected, the book lays no claim to
perfection. The student who looks to it for infallible remedies for
every disease will naturally be disappointed ; the man of more moderate demands will find in it much that will help him in his daily
work, and much that will stimulate him to the observation of disease processes and of the way in which they may best be met.  


"Anderson, S. C, June 27, '77.
Frank R. Smith.  
Dr. C W. Long.  


Dear Doctor : — Yours of the 22nd inst. is at hand, and I have also
Die Fiirbetechnik desNervensystems. By Dr. B. Poll.^ck. {Pub
just received a letter from Dr. J. M. Sims, which I will answer
lishcd by 8. Karger, Berlin, 1897.) Pp. 1-130.  
to-day. » » *


In my statement I did make a mistake in regard to my being
This little book will be welcomed by neuro-histologists everywhere. It gives briefly the important steps in all the more impor
present at the first or second operation, which mistake I will
correct. But if you still prefer I will send a certificate. * * •


Let me know and I will give you any information or assistance
in this great matter. Yours truly, etc.,


(Signed ) P. A. Wilhite."
June, 1897.]


Ill the letter to Wilhite, Long makes no comment on the
135
negro-boy incident, but his daughter informs me that he






*The Nineteenth Cenliiry, 1880.  
tant methods used in microscopic examination of the nervous
system, including those of recent date. In the first section the
technique of cutting up the brain at autopsy is described, togetlier
with the methods for preserving the brain whole and forreproduc.
ing plastically the specimens found at autopsy. In section two the
general technique of hardening, staining, emliedding and section.
ing is discussed. The methods of making serial sections, including
the recent method of Flatau for making serial longitudinal sections
of the whole spinal cord, are considered. We are glad to find mention made in section three of the work of Donaldson and others
concerning the alteration in weight of the brain and cord after
pri-servation in different hardening fluids. Too little attention has
been paid to such alterations in previous books on technique. Apparatus for drawing and photography are described in section four.
In the next section the methods of staining and impregnation are
taken up. The various ways of demonstrating nerve cells and their
axones and myelin sheaths are outlined. Golgi's method, Ehrlich's metliod and the new stains for neuroglia have been carefully
considered. Nissl's method is given, and also Held's modification of it. The differentiation with alum solution is simple, easy to
manage, very inexpensive, and yields in the reviewer's experience
results fully as satisfactory as those afforded by the method with
anilin oil and alcohol. In the sixth section certain general points
to be borne in mind in the examination of normal and pathological
cases are emphasized. It is particularly gratifying to find epitomized at the end of this section the routine methods employed in
Waldeyer's laboratory for the study of the central and peripheral
nervous systems. A brief bibliography is appended as well as an
index. The book costs only two marks, and will probably find its
way into many laboratories, where it will prove a safe and convenient guide. L. F. B.  


Arbeiten aus dem Institut fiir Anatomie und Physiologic des Centralnervensystems an der Wiener Universitiit. Herausgegeben
von Professor Dr. Heinrich Obeesteiner. Y. Heft, mit 5 Tafeln
und 46 Abbildungen im Texte. (Leipzig und Wien : Franz Deuticke, 1897.)


The most recent number of the fasciculi which are appearing at
intervals from Obersteiner's laboratory is fully up to the general
standard set by the preceding numbers. Itcontains seven articles,
one of which, on the innervation of the blood-vessels of the
brain, is by Obersteiner himself. In this article Obersteiner discusses the work of previous investigators and describes and pictures
a small artery of the pia mater stained with gold, in which he
brings the direct anatomical proof that the finer intra-cranial vessels, at least within the pia mater, possess their own nerves. He
refers briefly to the physiological and pathological significance of
such innervation.


repeatedly told her that he had never heard of it before it
Schlagenhaufer contributes an article on the course of the fibres
appeared in Sims' article.  
in the optic paths, in which is discussed also the tabetic atrophy of
 
the optic nerve. He believes that there exists sometimes, at any
It is to be regretted that the justification of Long's claims
rate, a compact uncrossed optic bundle which, however, forms only
should have been linked so closely with such misstatements.  
a part of the uncrossed bundle, and probably corresponds to the
inferior (external) fibres. The direction of the course of this bundle
gives, he thinks, in all probability, the anatomical course of the
uncrossed bundle. The question of the total or partial crossing of  
the optic nerves in man must, therefore, be regarded as decided in  
favor of the latter through anatomical investigation. He thinks
that by means of a scheme constructed accordingly it is possible to  
explain all the hemianopsias. As regards Gudden's commissure, he
makes out that a part of the fibres stream into the ansa lenticularis
to become connected with both lenticular nuclei. Some of the
fibres run in the peduncle of the hypophysis. In front of Meynert's  
commissure in the upper anterior part of the chiasm there is a
small system of fibres which remains intact when the optic nerves
and chiasm atrophy. He thinks it possible that the tabetic atrophy
of the optic nerves may be due to pressure at the foramen opticum.  


Sims sailed for Europe soon after the publication of his
article, and Long died in a few months, and Wilhite's statements went unchallenged for many years.*


Among Dr. Long's papers are many more documents —
affidavits of persons operated on and witnesses to them, and
letters to different prominent men — but their recital would
take up too much time, so I will close with a few words
regarding his after life.


In 1842 Dr. Long was married to Miss Caroline Swain, a  
F. Rezek describes and pictures a primary polymorphous sarcoma
niece of Governor Swain of North Carolina, a very handsome
of the brain.  
and attractive woman, who proved a devoted wife. She survived her husband many years.  


Long remained in Jefferson for ten years, when he removed
Pfiegler and Pilcz contribute along article entitled "Beitriige zur
to Athens and there spent the rest of his days. By inheritance
Lehre von der Mikrocephalie." They describe twelve cases of their
and professional labors Dr. Long had amassed a fortune,
own, with consideration of no less than 365 bibliographic references.  
which was largely swept away by the war of secession, and at
its close he found himself reduced to poverty, with a large
family to support.  


Although he soon regained an extensive practice, the desolation of the country and the general poverty of the people
An interesting study of the histology of the ganglion cells of the  
made the remainder of his life a continual struggle against
horse in normal conditions and after arsenic poisoning is given by
poverty. His life, which, up to the time of Dr. Sims' article,
H. Dexler. Two beautiful plates accompany his article. The same
had been one of disappointments, after that suddenly became
writer publishes also a short note on the course of the fibres in the  
brighter, for from all parts of the world men prominent in the  
optic chiasm of the horse.  
medical profession hastened to give him the credit which had
so long been withheld.  


His claims were never investigated by the American Medical
Julius Zappert, in an article on degenerations in the spinal cord
Association, as he often desired, but many minor societies and  
and medulla oblongata in the child, embodies the results of his
the "Eclectic" Medical Association passed decrees in his
studies on the spinal cord and medulla of children who have died
favor, and a statue was erected in his honor in Paris, France.  
during the first three years of life. He has used Marchi's method
and describes his findings with especial reference to the changes in  
the various nerve roots. L. F. B.  


But he was not long to enjoy the praise and long-delayed
honors which were now heaped upon him. Within a few
months, while laboring at the bedside of a delicate patient, he
was stricken with apoplexy and died the next day, June 16th,
1878, at the age of sixty-two, poor in worldly goods but rich
in the gratitude of his people. His oft-repeated wish to die
in harness had been granted.


A strange fatality seemed to hang over the lives of all connected with the discovery of auajsthesia !


Wells, disappointed and disheartened by the rejection of his
BOOKS RECEIVED.  
claims by the French Academy, became insane and committed
suicide in 1848.  


Morton gave up a very lucrative practice and vainly spent
his life in trying to enforce his patent and get a reward from
Congress. He died in 1868 from congestion of the brain,
brought on by excitement occasioned by an article attempting
to deprive him of the honor he so jealously coveted.


Long died in poverty, from apoplexy brought on by overwork in 1878.


Jackson, like Wells, became insane from the bitter contentions of his life and died in an asylum in 1880.  
Tuberculosis. By William Osier, M. D. 8vo. 1897. Reprinted
from " Loomis' System of the Practice of Medicine," New York
and Philadelphia, I, pp. 731-848.  


Diseases of the Ear, Nose and Throat and their Accessory Camties. A
condensed text-book. By Seth Scott Bishop, M. D., LL. D. 1897.
8vo, -196 pp. The F. A. Davis Co., Philadelphia, New York,
Chicago.


Annual Report of the Trustees of the State Hospital for the Insane, at
Warren, Pennsylvania, for the year ending No-oember 30, 1896, to the
Board of Commissioners of Public Charities. 1897. 120 pp. Herald
Printing and Publishing Co., Erie, Pa.


*ln an article in the Virginia Medical Monthly, 1893, Dr. L. 15.  
Medical and Surgical Report of the Presbyterian Hospital in the City of
Grandy, of Atlanta, showed the error of Wilhite's statements.  
New York. Edited by A. J. McCosh, M. D., and W. B. James, M. D.  
Vol. II, Jan., 1897. 8vo, 272 pp. Trow Directory Printing and
Bookbinding Co., New York.  


Ouy's Hospital Reports. Edited by E. C. Perry, M. A., M. D., and
W. H. A. Jacobson, M. A., M. Ch. Vol. LI, being Vol. XXXVI
of the third series. 1895. 8vo, 272 pp. J. & A. Churchill,
London.


Guy's Hospital Reports. Edited by E. C. Perry, M. A., M.D. , and
W. H. A. Jacobson, M. A., M.Ch. Vol. LII, being Vol. XXXVII
of the .third series. 8vo. 1896. 230 pp. J. & A. Churchill,
London.


182
Lectures on Pharmacology for Practitioners and Students. By Dr. C.
Binz. Translated from the second German edition by Peter AV.
Latham, M. A., M.D. Vol. II, 1897. 451 pp. 8vo. New Sydenham Society, London.


A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in Photolithochromes from Models in the Museum of the St. Louis Hospital,
Paris. With explanatory woodcuts and text. By E. Besnier,
A. Founier, et al. Edited and annotated by J. J. Pringle, M.B.,
F. R. C. P. Fol. 1897. Part IX. W. B. Saunders, Philadelphia.


Transactions of the Indiana State Medical Society, 1895. Forty-sixth
annual session held in Indianapolis, Ind., June 6th and 7th, 1895.
Svo, 534 pp. Carlon & Hollenbeck, Indianapolis.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Hysteria and Certain Allied Conditions. By George J. Preston, M. D.
1897. Svo, 298 pp. P. Blakiston, Son & Co., Philadelphia.  


DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL


Bv JOHN s. Billings, m. D., ll. D.


[Nos. 77-78.  
Contaiulng 56 large quarto plates, phototypes, and litliographa, with views,
plans and detail drawings of all the buildings , and their Interior arrangements—
also wood-cuts of apparatus and fixtures; also 116 pages of letter-press describing
the plans followed In the construction, and giving full details of heating-apparatus,
ventilation, sewerage and plumbing. Price, bound in cloth, $7.60.  






Henri L. Stuart, founder of the Woman's Hospital, aud a
136
great New York philanthropist, became interested in Long's
claims and presented a portrait of him to tlie University of
Georgia. After seeing it unveiled with great ceremony in the
capitol in Atlanta, one year after Long's death, he went to
Athens as a guest of the Longs, to visit the grave of the discoverer of anaesthesia. Arriving at night, he waited till
morning to fulfil his heart's desire. But this was never gratified. IJuring the night he had a paralytic stroke aud died
at the home of the Longs after lingering several weeks. At
his own request his remains were interred next to those of
Crawford Long — two great benefactors side by side.


Appendix I.  
rXo. 75.  
Dr. Long's Original Paper.*


In the month of Dec, 1841, or Jan., 1842, the subject of the inhalation of nitrous oxide gas was introduced in a company of young
men assembled at night in the village of Jefferson, Ga., and the
party requested me to prepare tliem some. I informed them I had
not the requisite apparatus for preparing or preserving the gas, but
that I had an article (sul. ether) which would produce equally exhilarating effects and was as safe. The company were anxious to
witness its effects, the ether was introduced and all present in turn
inhaled. They were so. much pleased with its effects that they
afterwards frequently used it and induced others to do the same,
and the practice soon became quite fashionable in the county and
some of the contiguous counties.


On numerous occasions I inhaled ether for its exhilarating properties, and would frequently, at some short time subsequent to its
inhalation, discover bruised or painful spots on my person which
I had no recollection of causing and which I felt satisfied were
received while under the influence of ether. I noticed my friends
while etherized received falls and blows which I believed were
sufiicientto produce pain on a person not in a state of anaesthesia,
and on questioning them they uniformly assured me that they did
not feel the least pain from these accidents. Observing these facts
I was led to believe that anesthesia was produced by the inhalation of ether, and that its use would be applicable in surgical
operations.


The first patient to whom I administered ether in a surgical operation was Mr. James M. Venable, who then resided within two
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.  
miles of Jefferson, and at present lives in Cobb Co., Ga. Mr. Venable consulted me on several occasions in regard to the propriety
of removing two small tumors situated on the back part of his neck,
but would postpone from time to time having the operation performed, from dread of pain. At length I mentioned to him the fact
of my receiving bruises while under the influence of the vapor of
ether without suffering, and as I knew him to be fond of and accustomed to inhale ether, I suggested to him the probability that the
operations might be performed without pain, and proposed operating on him while under its influence. He consented to have one
tumor removed, and the operation was performed the same evening. The ether was given to Mr. Venable on a towel, and when
fully under its influence I extirpated the tumor.  


It was encysted and about half an inch in diameter. The patient
continued to inhale ether during the time of the operation, and
when informed it was over, seemed incredulous until the tumor
was shown him.


He gave no evidence of suffering during the operation, and
assured me, after it was over, that he did not experience the least
degree of pain from its performance. This operation was performed on the 30th ]\rarch, lSt2.


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


Report In Pathology.


' Read liefore Georgia State Medical .Society in 18.')3.
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 P. P. Mall, M. D.
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis


The second I performed on a patient etherized was on the 6th
(Atrophy). By Henry J. Berklet, M. D.  
June, 1812, and was on the same person, for the removal of the
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.  
other small tumor. This operation required more time than the
first, from the cyst of the tumor having formed adhesions to the  
adjoining parts.  


The patient was insensible to pain during the operation until
Mall, M. D.  
the last attachment of the cyst was separated, when he exhibited
signs of slight suffering, but asserted after the operation was over
that the sensation of pain was so slight as scarcely to be perceived.
In this operation the inhalation of ether ceasrd before the first incision was made. Since that time I have invariabh' desired
patients, when practicable, to continue the inhalation during the
time of the operation.  


Having permitted such a length of time toelapse without making
Report in Dermatology.  
public my experiments in etherization, in order to show the correctness of my statements I procured the certificate of the patient
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
on whom the first operation was performed, the certificate of two
who were present at the time of the oper.ation, and also those of
his mother, brothers and sisters and a number of his immediate
friends who heard him speak of the operations soon after they
were performed. The Southern ]Med. and Surg. Journal* contained
but two of the certificates. I have a number of others which can
be seen or read if desired by the Society. My third case was a
negro boy who had a disease of a toe which rendered amputation
necessary, and the operation was performed July 3rd, 18)2, without the boy evincing the slightest sign of pain.  


These were all the surgical operations performed by me during
T. C. Gilchrist, M. D., and Emmet Rixford, M. D.
the year 1842 upon patients etherized, no other case occurring in
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of  
which I believed the inhalation of ether applicable. Since '42 I
have performed one or more surgical operations annually, on
patients in a state of etherization.


I procured some certificates in regard to these operations, but
Protozoa, and the Blastomyces found in the preceding Cases, with the so-called
not with the same particularity as in regard to the first operations,  
from the fact of my sole object in the publication being to establish my claim to priority of discovery of power of ether to produce
anasthesia. However, these certificates can be examined.


Tlie reasons which influenced me in not publishing earlier are
Parasites found in Various Lesions of the Skin, etc. ; Two Cases of Molluscum
.as follows:


I was anxious, before making my publication, to try etherization
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
in a sufficient number of cases to fully satisfy my mind that an£Bstliesia was produced by the ether, and was not the effect of the
imagination or owing to any peculiar insusceptibility to pain in the
persons experimented on.  


At the time I was experimenting with ether there were physicians high in authority and of justly distinguished character who
T. C. Gilchrist, M. D.  
were the advocates of mesmerism, and recommended the induction
of the me.wierjcs/a?*' as adequate to prevent pain in surgical operations. Notwithstanding thus sanctioned I was an unbeliever in
tlie science, and of the oiiinion that if the mesmeric state could be
produced at all it was only on those of strong imaginations and
weak minds, and was to be ascribed solely to the workings of the
patient's imagination. Entertaining this opinion, I was the more
particular in my experiments in etherization.  


Surgical operations are not of frequent occurrence in a country
Report In Pathology.
practice, and especially in the practice of a young phj'sician, yet I
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration
was fortunate enough to meet with two cases in which I could satisfactorily test the anEesthetic power of ether. From one of these
patients I removed three tumors the same day ; the inhalation of
ether was used only in the second operation, and was effectual in
preventing pain, while the patient suffered severely from the extirpation of the other tumors. In the other case I amputated two
fingers of a negro boy ; the boy was etherized during one amputation
and not during the other ; he suffered from one operation and was
insensible during the other.


After fully satisfying myself of the power of ether to produce
of Hypertrophy of this Gland. By W. S. Halsted, M. D.
aniesthesia, I was desirous of administering it in a severer surgical






FAC-SIMILE OF LONG'S MANUSCRIPT. SEE PAGE 182.  
Volume II. 570 pages, with 28 plates and figures.  


operation than any I had performeii. In my practice, prior to the
Report in Medicine.  
published account of the use of ether as an antesthetic, I had no
opportunity of experimenting with it in a capital operation, my
cases being confined, with one exception, to the extirpation of small
tumors and the amputation of fingers and toes.  


While cautiously experimenting with ether, as cases occurred,
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
with the view of fully testing its antesthetic powers and its applicability to severe as well as minor surgical operations, others
more favorably situated engaged in similar experiments, and consequently the publication of etherization did not " bide my time."


I know that I deferred the publication too long to receive any
Gallstones. By William Osler, M. D.
honor from the priority of discovery, but having by the persuasion
Some Remarks on Anomalies of the Uvula. By JoHX N. Mackenzie, M. D.
of my friends presented my claim before the profession, I prefer
On Pyrodin. By H. A. Lafleor, M. D.  
that its correctness be fully investigated before the Med. Society.  
Cases of Post-febrile Insanity. By William Obler, M. D.
Should the society say that the claim, though well founded, is forfeited by not being presented earlier, I will cheerfully respond,  
Acute Tuberculosis in an Infant of Four Months. By Hahrt Toclmin, M. D.
so mote it be.  
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.  


Not wishing to intrude upon the time of the Society, I have made
Report in Medicine.
this short compendium of all the material points stated in my
Tubercular Peritonitis. By William Osler, JI. D.
article in the Journal, and if the Society wishes any fuller information on the subject I will cheerfully comply with their wishes.  
A Case of Raynaud's Disease. By H. M. Thomas, M. D.
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  


Appendix II.  
Report in Gynecology.  
The Gynecological Operating Room. By Howard A. Kelly, M. D.
The Laparotomies performed from October 16, 1889, to March S, 1890. By Howard


" Georgia, 1 I, Ange De Laperriere, M. D., do certify that I
A. Kelly, M. D., and Hunter Robb, M. D,  
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of


Jackson County. > resided in Jefferson, Jackson County, Georgia,
Abdominal Section. By Howard A. Kelly, M. D.  
in the year 1842, and that some time in that year I heard James M.  
The Management of the Drainage Tube in Abdominal Section. By HnuTER Robb,  
Venable, then of said county, speak of Dr. C. W. Long's cutting out
two tumours from his neck while under the influence of the inhalation of sulphuric ether, without pain or being conscious of the performance of the operation.


I do further certify that the fact of Dr. C. W. Long using sulphuric ether by inhalation to prevent pain in surgical operations was
M. D.  
frequently spoken of and notorious in the county of Jackson,
The GonococcuB in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Pentoneum;
Georgia, in the year of 1842. A. De Laperriere, M. D.


Sworn to and subscribed before me this 30th of March, 1854.
Ovarian Tumor; General Gynecological Operations from October 15, 1889, to  


N. H. Pe.ndergrass, J. P."
March 4, 1890. By Howard A. Kelly, M. D.  
Report of the Urinary Examination of Ninety-one GjTiecological Cases. By Howabd


"Athens, Clarke Co., Georgia.
A. Kelly, M. D., and Albert A. Ghriskey, M. D.  
I, the undersigned, do certify that in May, 1843, 1 assisted Dr. R.
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (3hecking
D. Moore in amputating the leg of a colored boy Augustus, then the
property of Mr. Wm. Stroud, who resided in this county ; and that
I distinctly recollect hearing Dr. R. D. Moore say, If I had thought
of it before leaving home I would have tried Dr. C. W. Long's
great discovery, namely, the administration of sulphuric ether
as an anaisthetic in performing the operation. Having neglected
to bring the ether. Dr. Moore finally concluded to influence the


Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoma of the Oitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment


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


patient with morphia ; under which influence the operation was
Howard A. Kelly, M. D.  
performed. Jos. B. Carlton, M. D."


Appendix III.  
Report in Surgery, I.  
From Dr. Long's First Student.
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot


"CoHUTTA, Ga., Dec. 13th, 1894.  
in the Management of Dead Spaces. By W. S. Halsted, M. D.
Mrs. Frances Long Taylor,  
Report in Neurology, 1.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.  
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.  
Haematomyelia. By Adqdst Hoch, M. D.
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By


Dea7' Madam :—* * * In 1844, soon after I attained my majority,
Henry M. Thomas, M. D.  
I decided to adopt medicine as my profession, and began to think
where and under whom I should begin the preparatory study. My
father asked me to choose from among the number of physicians
whom 1 knew the one I preferred to act as preceptor to me.  


Knowing Dr. Long so well and believing him to be a man of no
Report in Pathology, I.
ordinary ability, I at once fixed upon him as my choice.  
Amffibic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleub, M. D.  


I entered Dr. Long's office in May, 1844, as the first student ever
under his care. As I progressed with my studies he saw fit to make
known to me his discovery, by the use of which he could perform
surgical operations without giving any pain to his patient. [Here
follows a description of the first cases.]


Notsatisfied, however, that there was not more to learn about this
great disco very, he proposed that we test it further personally, which
we did in his office, where with closed doors we administered it to
each other to prove its perfect anaesthetic effect and also to discover
any bad effect to the subject etherized. Owing to the prejudice and
ignorance of the populace Dr. Long was prevented from using ether
in as many cases as he might have.


Thus in the two years preceding my entering Dr. Long's office he
Volume III. 766 pages, with 69 plates and figures.  
had had only about six cases in which to try the anaesthetic effects
of ether.  


The first case thatcame under his care where its use was applicable after my going into his office was not till January 8th, 1845,
Report in Pathology.  
which was the case of a negro boy having two fingers to amputate,
caused by neglected burn. I, as the only student still with the
doctor, he had me to accompany him to see the operation and assist
ill the administration of the ether. The first finger was removed while
under the influence of ether, the little fellow evincing no pain ; the
second without ether, the child suffered extremely. This was done
to prove that insensibility to pain was due to the agent used.  


Soon after this, in January, Mr. J. D. Long came into the office as
Papillomatous Tumors of the Ovary. By J. Whitridqe Williams, M. D.  
a fellow-student ; later, toward spring, came P. A. Wilhite, and in
August came Dr. Long's brother, H. R. J. Long. We four remained
there at Dr. Long's oflBce as students until the opening of the fall
term of the medical colleges. » * *


[Signed] J. F. Groves, M. D.  
Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D.
Report in Pathology.  


Sworn and subscribed to before me, Dec. 15th, 1894.  
Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Flexner, M. D.  


\V.M. H. Wilson, N. P."
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.  


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


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


THE EARLY HISTORY OF OPHTHALMOLOGY AND OTOLOGY IN BALTIMORE (1800-1850).*
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  


By Harhy Friedenwald, A. B., M. D., Associate Professor of Ophthilmologij and Otology, College of Fliysicians and Sii-rgcons,
Report In Gynecology.  


Baltimore, Md.  
The Gynecological Operating Room; An External Direct Method of Measuring the
Co'njugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofle.xed Uterus. By Howard A
Kelly, M. D.  


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


Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavelt, M. D.


An old book tells us that each generation may be looked
upon as standing on the shoulders of its fathers. If its vision
is clearer, its intellectual view less obstructed, its horizon
broader, it is in great part due to the height to which others
have raised it, to tlie support others have given. Unmindful
of this, it is apt to exaggerate its greatness and the importance
of its own work.




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


* Read before the Johns Hopkius Hospital Historical Club,
The Employment of an Artificial Retroposition of the Uterus in covering Extensive
April, 1897.  
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.  


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


Traumatic Atresia of the Vagina with Hsmatokolpos and Bxmatometra. By Howard
A. Kelly, M. D.


In the following narrative I have brought together all that I
Urinalysis in Gynecology. By W. W. Russell, M. D.  
could find relating to tlie lives and labors of those who, in the
earlier years of this century and in our own city, tilled the
soil of ophthalmology and otology. Some have been forgotten,
few have been accorded deserved recogniiion.  


Are not many of us as ignorant of their names and works as
The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.
an old physician from whose memories I liad hoped to obtain
information, but whose response was, "No work was done in
Baltimore in those departments of medicine before 1850"? I
must confess tliat when iny attention was first drawn to this


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


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


August-September, 1897.]
Abdominal Operations performed in the Gynecological Department, from March 5,
1890, to December 17, 1892. By Howard A. Kelly, M. D.  


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




JOHNS HOPKINS HOSPITAL BULLETIN.


Volume IV. 504 pages, 33 charts and illustrations.


Report on Typhoid Fever.


185
By William Osler, M. D., with additional papers by W. S. Thayer, M. D., and J.
Hewetson, M. D.


Report in Neurology.
Dementia Paralj-tica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of .Whs- musculu^; The Intrinsic Nerves of the ThjToid <31and of
the Dog; The Nerve Elements of the Pituitarj' Gland. By Henry J. Berkley,
M. D.


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


subject I knew of biit one work of importance which a Baltimore physician had rendered to ophthalmology.  
Report in Gynecology.
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.
Report in Pathology.
Deciduoma Malignura. By J. Whitridqe Williams, M. D.  


There is no reference in literature to anything done in
Baltimore in the two branches we are considering before the
beginning of this century. We must remember that in 1800
the population of Baltimore City was 26,614 and that in 1802
there were but 44 physicians.


It is probable that there were here as elsewhere those who
confined themselves to diseases of the eye. This is indicated
by a resolution adopted at the convention of the Medical and
Chirurgical Faculty of Maryland in 1805.* It was resolved
that " the Board of Examiners be authorised to grant special
licenses to dentists and occulists to practice in their respective
branches, subjecting them to an examination only on the
branches they possess; and that such licentiates shall pay ten
dollars for each license so obtained; provided it shall be the
opinion of the attorney-general that the law authorizes the
examiners to grant such licenses. The secretary having submitted the preceding resolution to the then attorney-general,
he gave it as his opinion that the law authorized the board to
act according to the spirit of the resolution." These "occulists" did not, it appears, stand in very good repute.


In the review in 1825 of an American treatise on diseases of
Volume V. 480 pages, with 32 charts and illustrations.  
the eye, the writer, who was probably Dr. Isaac Hays, the distinguished editor of the American Journal of Medical Sciences
and an ophthalmologist of note, describes the condition of
ophthalmology in the early years of this century. He tells us
that " the neglect to which disorders of the eye were too long
consigned is truly astonishing. Prepossessed with an idea
that there was something peculiar in the diseases attacking
different parts, physicians entirely abandoned these affections to
persons who were exclusively devoted to them and were totally
ignorant of the laws which influence diseases of other organs.
To this cause is to be attributed the slow progress which tlie
science of ophthalmology made during many centuries. The
history of this science shows that while it made most rapid
advances in improvementby the investigations of medical men,
it invariably, when abandoned to professed oculists, not only
ceased to advance but actually retrograded ... In this country
much apathy has existed, and we fear still exists, with regard
to these affections. Some of our distinguished surgeons have
not, it is true, entirely neglected them ; yet the mass of
medical practitioners have paid little attention to them, and
the science has advanced so rapidly during the few years that
we believe few have kept pace with the improvements that
have been made. The length of time that generally elapses
before opinions of European writers are diffused in this
country — the want of regular lectures — and above all, clinical
instruction and the opportunities furnished of observing these
diseases in institutions established for the reception of these
cases, are the cause, no doubt, of the present state of the science
among us."


He mentions that the New York Eye Infirmary was established in 1830, the Pennsylvania Infirmary for Diseases of the
CONTENTS:
Eye and Ear in 1822, and "with respect to the institution at
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D.. and J. Hewetson, M. D.
Baltimore he has but little information to communicate. It is
A Study of some Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  


Studies in Typhoid Feyer.
By William Osler, M. D., n-ith additional papers by G. Bluher, M. D., Simok
Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.




'Summary of Proceedings, &c., published in 1817


Volume VI. About 500 pages, many illustrations.


Report in Neurology.


attached to the Baltimore Dispensary and is committed to the  
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical
care of the author of this work." [Dr. Geo. Frick.]
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.  


Pierre Chatard.  
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the
Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. E.xperimental
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 by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of
Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.  


The earliest Baltimore publication having reference to
Report in Pathology.  
diseases of the eye is found in a paper written by Dr. Pierre
Chatard in the Medical Repository, vol. VII, p. 28. Dr.
Chatard was born and educated in France, and had settled in
Baltimore in 1797. He was a prolific writer, the paper referred
to being one of the earliest. It was entitled "An account of a
case of Fistula Lachrymalis, with reflections on the diflerent
modes of operating in that disease." The paper describes a
case of lachrymal fistula relieved by introducing threads of
silk after the manner of a seton through the lachrymal duct
and gradually increasing their number. He discusses at length
the various methods in vogue at that time of treating the
disease. It is written in an interesting and elegant manner.
None of the other writings of Chatard relate to diseases of
the eye.  


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


During the second decade of this century the celebrated
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of  
surgeon, Wm. Gibson, practiced in Baltimore. Win. Gibson
Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. WiLKlNS, M. D.  
was born in 1784 in Baltimore, and was graduated in medicine
in Edinburgh in 1809. He was a physician to the Baltimore
General Dispensary in 1818-19, and professor of surgery at the
University of Maryland from 1812-19, resigning to occupy the
same chair at the University of Pennsylvania from 1819-54.  
He died about 1858 (?)•


His numerous publications date mainly from the latter
Adeno-Myoma Uteri Diffusum Benignmn. By Thomas S. CJullen, M. B.  
period of his activity, but there are two notable and very interesting references to ophthalmic surgery dating from the Baltimore period.  


In Hirsch's History of Ophthalmology* we find the statement
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. Bj
that Prof. Gibson of Baltimore had made the experiment of  
William D. Booker, M. D.  
introducing a seton through the cataractous lens, witli the view
of producing its absorption, so original an experiment that
Hirsch cites the description given by Dr. John Revere untranslated. My friend. Dr. O'Connor of Boston, had the kindness
of looking up the reference in the New England Journal of
Medicine, vol. VIII, p. 119, of 1819, and I will give this
account in full because of its intense interest.  


Extract of a letter to one of the editors:
The Pathology of Toxalbumin Intoxications. By Simon Flbxnieb, M. D.


" lam desirous of communicating through the medium of the New
TJie price of n set hound in cloth [Vols. I-1'I'\ of the Hospital JSepoi-ts is
England Journal a new mode of operating for cataract, which has
$30.00. Vols. I, II and III are not sold separately. The price of  
been projected and jiracticed recently, in two cases, with the mot;t .satisfactory success, by my friend, Dr. Gibson, professor of surgery at
Vols. IV, V and VI is $5.00 each.  
the University of Maryland.  


The operation was performed in the following manner : The iris
was in the first place dilated by the application of atropa belladonna. A common sewing needle, slightly curved and armed with
a single thread of silk, was then passed through the tunica sclerotica about two lines from the cornea, where the couching needle is
usually introduced, through the opaque lens and out of the opposite side of the cornea, at a point corresponding to the one at which
it was introduced. The silk being drawn through, and the ends
cut off, a single thread was thus left passing through tlie ball of the
eye, and acting on the diseased lens in the mauner of a seton. It




MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.
The following papers are reprinted from Vols. I, IV and V of the Reports, for thoee
who desire to purchase in this form:
STUDIES IN DERMATOLOGY. By T. C. GiLCHRiST, M. D., and Emmet Koeord,


•Graefe and Saemisch's Handbuch, Vol. VII, p. 517.
M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,  


J3.00.
THE MALARIAL FEVERS OF B.-ILTIMORE. By W. S. ThaTER, M. D., and J.


Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARH.


186
By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.75.
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481


pages. Price, bound in paper, $3.00.
Subscriptions for the above publications may be sent to


JOHNS HOPKINS HOSPITAL BULLETIN.  
The Johns Hopkins Press, Baltimore, Md.  






[Nos. 77-78.  
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed hy THE FRJEDENWALD CO., Baltimore. Single copies
may he procured from Messrs. CVSHINO & CO. and the BALTIMORE NEWS COMPACT, Baltimore. Subscriptions, $1.00 o year, may he
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies will be sent by mail for fifteen cents each.  






was feared that serious inconvenience might arise from the irritation produced upon the tunica conjunctiva, from the excessive
BULLETIN
sensibility of this membrane. Fortunately, however, neither this
nor any other accident intervened, and at tlie end of ten days, in
both cases tlie diseased lens had disap])eared, and, in its place, the
silk was distinctly seen passing like a bar across the pupil of the
eye. Tlie silk was withdrawn, and in a few days the vision was
restored. In the third and last case in wliich this operation was
performed it failed in consequence of the iris being wounded.
This caused such an inflammation of the organ that it was deemed
proper to withdraw the seton at a very early period. This accident was attributed to not using the belladonna. One would think
that a common sewing nee<lle is not the most convenient instrument that could be devised for this purpose, on account of the dense
structure of the part througli wliich it is to pass, and the difficulty
of having the perfect command of any instrument without a handle.
From the nature ot the disease, from the known eflects of this
remedy when applied to other parts of tlie body, and from the
success which has already been experienced, there seems to be
good reason to hope that this will be found an important improvement on the established practice in many forms, if not in every
variety of the disease. But the practical benefit to be derived
from this operation can only be tested by a more enlarged observation than in this country ever falls to the lot of any individual.
I remain yours, J. Eeverb.


Balto.. Mch. 2nd. 1819."


We learn from Hirsch that Loewenhardt in 1828 operated in
a similar manner for secondary cataract with anterior and posterior synechia, likewise with good resnlt; it ajopears that
others have not attempted the operation.


In the American Appendix to the second edition of Cooper's
OF
Dictionary of Practical Surgery, edited in America in 1844
by David Meredith Keese, who in 1843 and 1843 was professor in Washington University of Baltimore, we find a
very curious reference to Professor Gibson under the head of
strabismus: "It apjiears from the Institutes of Surgery that
Professor Gibson attempted the cure of strabismus by dividing
the recti muscles of the eye, precisely as now practiced, some
twenty years since, in Baltimore. Soon after he repeated it
unsuccessfully in Philadelphia in several cases, and was induced to abandon it by unfavorable opinions exjiressed on the
operation by Dr. Physick. He, however, inculcated the propriety of the operation upon his class many years since, and
Dr. A. E. Hosack, of New York, then one of his pupils, distinctly recollects Dr. Gibson's expressions of confidence that
the operation would ultimately succeed."


I had no little difiiciilty in finding the reference to which
Dr. Reese refers. The first five editions of Gibson's Institutes
of Surgery (published between 1824 and 1838) contain no
chapter devoted to strabismus, and in the seventh edition the
long account of strabismus and its treatment consists almost
entirely in a paper written by Charles Bell and sent by him to
Gibson. In this chapter the above reference is likewise not to
be found. It is only in the sixth edition, published in 1841,
that we find the reference. It is of such importance that I
shall give it in detail. On page 375 Gibson states that:


"In the year 181S, while practising my profession extensively in
Baltimore, the late Mr. B. J. consulted me about his daughter, a
child of eleven or twelve years of age, both of whose eyes were
directed very much inwards, and were thereby greatly deformed
by a squint. I advised a pair of goggles, so contrived, by having a


THE JOHNS HOPKINS HOSPITAL.




small opening in the centre of each, as to oblige the ckild to direct
the cornea to these openings, and by i)erseverance for several
weeks, succeeded in diminishing the deformity but not effecting a
cure. In the course of my visits the child remarked at different
times that her eyes felt as if tied by a string. Struck with this observation, and conceiving the disease might depend upon shortening of the internal rectus muscle, I determined, the first opportunity, to try the result of divison of that muscle ; and as the friends
of my young patient were unwilling the experiment should be first
tried upon lier, I selected a hospital patient, and after some difficulty
in fixing the eyeball and in cutting the muscle across, succeeded in
restoring the eye partially to its natural situation. Upontwoother
patients I repeated the experiment, without mucli better success,
but on dividing a muscle in a fourth patient, after my removal to
Philadelphia, the eye was so completely turned to the opposite
direction as to bury the cornea beneath the lids and create a much
greater deformity tlian liad previously existed. Upon showing the
patient to Dr. Physick, he advised the experiments to be abandoned, as likely to be followed by very unfavorable results. I
mention these circumstances, not from a desire to receive credit
as an inventor or to detract from the claims of the distinguisiied
surgeon with whom the modern operationof strabismus originated,
but merely as a curious fact, calculating to show the importance of
not laying aside processes apparently founded upon correct principles, simply because we are at first foiled in our attempts to execute them. How much benefit would have resulted to the community if I had followed up my operations until I ascertained the
proper mode of correcting them, or how much injury I might have
inflicted upon individuals by perseverance in ihe attempt, I shall
not stop to inquire. It is sufficient for me to announce the fact —
wliich I have no doubt could be easily substantiated by many
pupils who attended my early lectures, some of whom have indeed
already proffered their testimony — without being over-solicitous,
in setting up a claim as an inventor, of exposing my aw kwardness
and perhaps want of knowledge of the principles that should have
guided me in following out the practice I had attempted to institute."


It may not be out of place to mention that; Stromeyer's
Vol. VIII -No. 76.]
important monograph, in which he recommended division of
the muscle for strabismus appeared in 1838!


The chapters devoted to diseases of the eye in Gibson's Institutes are important, but as the book appeared after the
author had left Baltimore, it is not proper to discuss them
here.


Another reference which shows Gibson's interest in the eye
occurs in the American Medical Eecorder (vol. II, p. 383).
It is a "Letter of Charles Bell to Professor Gibson, of Baltimore," and its subject is, " The New Coat of the Eye discovered by McCarthy's demonstrator, Jacobs."


George Fkick.*
BALTIMORE. JULY, 1897.  


We may next take up the most important name of this
narrative, that of Dr. George Frick, the author of a valuable
treatise on diseases of the eye, the first ^\■ork of the kind that
appeared in America.


George Frick was born in Baltimore in 1703. After obtaining a broad classical education he entered the University of
Pennsylvania, where he obtained the degree of doctor of medi


IPrice, (5 Cents.


*The accompanying portrait of Dr. Frick is copied from one
recently presented to the Medical andChirurgical Faculty, together
with a case of instruments which belonged to the doctor, by his
niece, Mrs. AVhite and her daughter. Miss Mary White.




coisrT:E]isrTS.


August- September, 1897.]




PAGE


JOHNS HOPKINS HOSPITAL BULLETIN.  
Studies on the Lesions induced by the Action of certain Poisons on the Cortical Nerve Cell. Study VII : Poisoning
with Preparations of the Thyroid Gland. By Henry J
Berkley, M.D.,
Five Successful Cases of General Suppurative Peritonitis treat
ed hy a New Method. By J. M. T. Finney, M. D.,
 
An Experimental Study of the Treatment of Perforative Peri'






187
137






cine in 1815, and in 1&17 he was admitted as licentiate of medicine into the Medical and C'hirurgical Faculty of Maryland.
141
He then spent several years abroad, returning to Baltimore about
1819 to engage in the practice of ophthalmology. He was
api)ointed surgeon to the Baltimore General Dispensary, where
he established the first Eye Dispensary in Baltimore, in 1824.
In 18^3 he delivered clinical lectures at the Maryland Hospital. His name is found on the list of vaccine physicians for
1821.


He was a member of various medical societies; was secretary
of the Faculty in 1823, and
joined the Maryland Medical
Society in 1822. He was much
interested in general science,
and was one of four physicians
to organize a society for promoting science, in 1819. He
was likewise a member of the
Maryland Academy of Sciences,
its librarian in 1824 and curator
in 1836.


He devoted himself to the
practice of ophthalmology and
to the cultivation of general
scientific stvrdies, as well as to
music for a number of years.
He was unfortunate in growing
very deaf before middle life, and
it is probable that this interfered greatly with his practice
of medicine ; for somewhere
about 1840 he entirely relinquished it and left Baltimore
to spend most of his time in
Europe, paying occasional visits
to this country. He died in
Dresden, March 36th, 1870,
aged 77 years. Dr. Frick had
never married. He was a man
of very retiring and modest
character and of kind disposition. He was a careful scientific student and his work and
writings deserve high praise.


His first writing was his thesis
PAGE.  
for the degree in medicine; its subject was "On the Meloe
Vfsicatorium" (1815). In 1820-31 his article on " Observations on Cataract and the various modes of operating for its
cure" appeared in the American Medical Kecorder of Philadelphia. These articles cover over 40 pages. In 1821 an article
on "Observation of the various forms of Conjunctivitis" appeared in the same journal, and in 1823 his paper on " Observation on Artificial Pupil and the modes of operating for its
cure."* His most important work, however, was "A Treatise
on the Diseases of the Eye; including the doctrines and practice
of the most eminent modern surgeons and particularly those of


*This curious error is cited as it is found.
By Arthur






tonitis in Dogs by a New Method of Operation


Professor Beer," which was published in Baltimore by Fielding
W. Elting and Wm. J. Calvert, ......  
Lucas, .Jr., in 1823. It was inscribed to his teachei-, Dr. Physick
of Philadelphia. The articles above referred to, though somewhat more elaborate, were in the main identical with the corresponding chapters of the treatise and do not therefore require
special consideration. The treatise is of considerable value.*
It is well and clearly written, the system irpon which it is
classified is excellent, and no greater praise could be given it
than stating the fact that it was republished three years lateiin London by an English surgeon, Richard Welbank, a member
of the Royal College of Surgeons and of the Medical and
Chirurgical Society of London,
and dedicated to the ophthalmologist William Lawrence.  
Numerous foot-notes were added, but the te-xt suffered no
change.  


The reviews which the book
Squamous Epithelioma and Epithelial Hyperplasia in Sinuses
received were very complimentary. The Philadelphia Journal of Medical and Physical
and Bone following Osteomyelitis. By S. M. Cone, M. D., ■
Sciences (probably Dr. Isaac
Hays) contains a review covering 18 pages: "The author
evidently possesses a cultivated
and well disciplined mind; he
appears to be intimately familiar
with German writers, and we
feel much indebted to him for
making us acquainted with their
writings."


In the American Medical Recorder of 1824 a still longer
On the Blood-Pressure-Raising Constituent of the Sui)rarenal
review is to be found, covering
Capsule. By John J. Abel, M. D., and Albert C. Crawford,  
32 pages. The writer describes
M. D.,  
the book in terms of high praise.  
He "offers the humble tribute
of (his) thanks to the author for
the benefits which he has conferred on the profession generally, by presenting them with a
volume of great value and utility, and one which was much


Notes on New Books,




* It is interesting to find numerous pencil notes in the articles in
the copies of the American Medical Recorder at the library of
tlie Medical and Chirurgical Faculty of Maryland, notes suggesting slight changes in the phraseology, paragrap'-ing, etc., every
one of which has been adopted in the treatise. I have been able
to trace this copy, which was bought with other books by Dr.
,Iohn Morris at a public sale of the library of Dr. John Buckler,
who was related by marriage to Dr. Frick, and whose library thus
passed into Dr. Buckler's. Numerous books at our library contain
Dr. Frick's autograph, and one, a copy of Gibson's Institutes of
Surgery, has an inscription of the author to his friend Dr. Frick.
In Beer's work on ophthalmology there are interesting pencil notes
and several pages of written matter which correspond so thoroughly
with Dr. Frick's writing that I have no hesitation in stating that
tbev are his.


151


158


188




STUDIES ON THE LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE


JOHNS HOPKINS HOSPITAL BULLETIN.
CORTICAL NERVE CELL


STUDY vn.


POISONING WITH PREPARATIONS OF THE THYROID GLAND.
By Henry J. Berkley, M. D., Associite in Neuro-Patholoyii, The Johns Hopkins Universily.


[Nos. 77-78.




The favorable side of the administration of the thyroid
extracts is shown in the very numerous articles in current
medical literature published both in this country and in
Europe. Comparatively few of these papers treat of other
than the bare clinical results from the most auspicious standpoint, and it is quite safe to say, after a review of some of
them, that the results would have been as brilliant had no
medicament been administered.


wanted. As a manual of the diseases of the eye, we believe it to be the best which has been published. It contains all the improvements which have enriched ophthalmic
It is nevertheless true that the extract, when administered
surgery, in such a siirpi'ising degree within a few years
to either man or the lower animals, will occasion very grave
past," etc.  
symptoms of a toxasmic nature, symptoms that involve the
cerebral, the vaso-motor and digestive functions, and perhaps
also the normal action of those ductless glands that throw into
the circulation a potent though unknown substance ; and
when this administration is pushed even to a moderate degree
death is almost invariably the result, either through the  
advent of convulsions, or extensive loss of weight with indications of profound poisoning of the central nervous system,
shown by the change in the heart's action and in the respiratory movements.  


In 1835 this work was placed on the list of those which the
A medicament having these qualities cannot, therefore, be
student was required to liave read before applying to the
administered with impunity to every sane or insane patient,
Medical and Chirurgical Faculty of Maryland for the examination for licentiate in medicine.


Hirsch in his history of ophthalmology says that " George
Frick was the apostle of the ophthalmological school of
Vienna in North America; his treatise was next to Saunders's,
the first large treatise on ophthalmology in America, and
was received by physicians with great praise." Saunders's
book was an English work and was republished in Philadelphia
in 1831, two years before Frick's. The only other book in the
English language of a similar kind was that of Travers, which
appeared in London in 1820-31-24.


We thus see that Frick's book was the first American
treatise (and for a number of years it remained alone). The
work is much quoted in Cooper's Dictionary of Surgery.


In Quinan's Medical Annals of Baltimore I find a reference
and it was therefore directly for the purpose of ascertaining
to a paper of Dr. Frick's " On the Senses," which he tells us was
the toxicity of one of the best known varieties of the thyroid
read before the Medical Society of Maryland in 1821. I have
extract that the following series of experiments was undertaken.  
been unable to find this paper.  


In Cordell's History of the University of Maryland we learn
The first portion of the investigation was made upon eight
that the foiindation of the Infirmary was laid in 1823 and that
patients at the City Asylum, who, with one exception (No. 1),  
patients were received in the same year. Of the four wards,  
had either passed or were about to pass the limit of time in  
"one was reserved for eye cases, instruction in ophthalmic
which recovery could be confidently expected. To these
surgery forming a prominent feature in the course. This was
patients the thyroid tablets, each pill representing five grains
during the time of Frick's greatest activity, and it is possible
of the fresh sheep's gland, were administered, the dosage beginning always with a single pill daily for a period of three days,  
that the prominence given to ophthalmology was through him,  
then, after a certain tolerance had been established the dosage
and that he delivered the clinical lectures in this branch. I
was increased to two tablets daily, and, unless the symptoms
am unable to verify this.  
induced became grave, the number of pills was increased to  
three daily, the length of continuance depending upon the
results.  


In conclusion it is interesting to call attention to the fact
Loss of weight always attended the administration of the  
that Dr. George Frick was the uncle of the distinguished
tablets, as did disturbances of the circulation in the form of
clinician, Professor Charles Frick.
tachycardia and enfeeblement of the cardiac action. Digestive disturbances and slight pyrexia were present in more than
half the cases. A peculiar odorous sweating was noticed with
two patients, and increase of the cutaneous transpiration in


Horatio G. Jameson.


Horatio G. Jameson, born in Pennsylvania about 1793, graduated in medicine at the University of Maryland in 1813. He
held a number of important public positions, having been consulting surgeon of the Baltimore City Hospital from 1819 to
1835, consulting physician of the board of healtli of Baltimore
City in 1827-35 ; he was incorporator of the AVashington Medical University in 1827, and professor of surgery and surgical
anatomy in the same from 1827-35, when he became professor of surgery in the Cincinnati Medical College. He was
one of the most prominent surgeons of Baltimore for a number
of years, and a very active contributor to medical journals,
writing important papers in medicine and in surgery. He was
the editor of the Maryland Medical Recorder during its existence of several years (Sept. 1829-Nov. 1832), and a large
number of its articles are from his pen.


Jameson appears to have been much interested in diseases of
138
the eye. AVe find frequent references to publications on these
subjects throughout his journal, several of which have remarks
added by the editor. In vol. 2 there is an article on the


[No. 76.




"Pathological Sympathy between Eye and Larynx" (p. 117)
This article is without any value, indeed it is difficult to understand the real significance of his report after careful reading.
An article on "A case of Enlargement of the Eye following
the entrance of steel into the eye" describes the panophthalmitis followed by bursting and shrinking of the eyeball
(p. 601).


In another paper he described " two cases of ossification
all. Irritability and a greater or less degree of mental and
of the lens with luxation through the pupil." These cases  
motor excitement were remarked in all cases, no matter how
are of some interest. He extracted the lenses and the patients did well (p. 608). An article on amaurosis associated
depressed or demented they had been previous to the administrations. Two jjatients became frenzied, and of these one
with inordinate thirst was probably written by Jameson (p.  
died before the excitement had subsided, the immediate cause
664).  
of the exitus being an acute disseminated tuberculosis. A
peculiar gelatinous feel to the integument of the forehead and
cheeks, precisely similar to that in myxcedema, combined
with puflBness of the skin about the malar prominences, was
very noticeable in those cases in which the administration of
the extract was continued for any length of time. Urinary
examinations were made several times before the commencement of the administration of the thyroid, and several times
during its administration, but only for the purpose of noting
the presence or absence of albumen and sugar. In the
abstracts this analysis is mentioned only when there is evidence of the presence of these abnormal constituents.  


In the American Medical Recorder of Philadelphia (vol.
Abstracts of Histories of Insane Patients Treated
XII, p. 340) we find an interesting account of the successful
WITH Thyroid Extract.  
removal of " An encysted tumor of tiie orbit."


In discussing a letter on "Ophthalmia in the Philadelphia
I. Adolescent insanity. Martha H., set. 17. Sister insane.
Alms House," written to Dr. Rusii, Jameson considers the
Admitted with melancholic symptoms accompanied by considerable mental confusion. Occasionally had to be fed with
question of the endemic or .contagious character of the
stomach tube. Could not speak, and it was imjoossible to
ophthalmia, excludes the latter view, and attributes the very
determine what delusions were present. After being several
severe disease to the vitiated state of the atmosphere. He
weeks in the Asylum she partly recovered, and then relapsed,
states that " we do not as a general rule of practice bleed
and there appeared to be considerable mental reduction after
sufficiently in cases of ophthalmia."
the lapse of several months. Then began to brighten, and take
more interest in her surroundings, also to gain flesh. The
thyroid gland was, apparently, small on palpation. Weight at
beginning of the thyroid administration 115 pounds. A single
thyroid tablet was administered for ten consecutive days, at
the end of which time there was slight febrile reaction, with
a pulse ranging from 100 to 110 (normal 78). The mental
change was very slight, patient exhibiting some irritability,
but nothing more. The weight is now 109 pounds.  


John Mason Gibson.  
On the fourteenth day, the thyroid being continued, the first
signs of improvement were noticed. Patient became brighter,
ate food without compulsion, and on the twentieth day volunteered to do work about the ward and conversed rationally.
The thyroid extract was discontinued on the twenty-second
day, and patient was discharged one week later, six months
after her admission, and did not relapse.  


John Mason Gibson in 1832 published in Baltimore (W. R.  
II. Melancholia folloioed hij deep dementia. Olivia P., ist.  
Lucas) a " Condensation of Matter ujwn the Anatomy, Surgical Oj)erations and Treatment of Diseases of the Eye,
37. Education fair. No heredity. Married. Nutrition
together with remarks. Embellished with twelve lithographic plates, illustrative of the anatomy, operations, and  
poor. Thyroid fairly well developed. Weight 100 pounds.  
morbid appearance."
Oil admission refused to speak, and would not take food.  


I am unable to give any details of this author's life. I find
Patient was deeply demented, and quiet for several months
that he vvas admitted into the Faculty in 1825, and that his
before the thyroid treatment was begun. She lost flesh very
name appears as late as 1848 in the list of members with the  
rapidly, and on the eleventh day of the treatment showed
title of L. M. In the next succeeding list published in ISoS
pronounced mental and motor excitement. Slight febrile
Gibson's name is missing.
reaction, accompanied by a pulse rate of 120 beats. On
the twelfth day she passed into a state of frenzy, the motor
excitement being more pronounced than the mental symptoms. The thyroid extract was now discontinued, but the  
excitement kept up, despite numerous attempts, with narcotics, baths, and systematic exercise, to allay it, for seven
weeks, at the end of which time she died with the clinical


In the preface he tells us that his book is an " attempt at
collecting the best matter on diseases of the eye." That
" diseases casiral to vision are many and frequently met with
in this country; the curative practice has not been sufficiently
inculcated in our universities, by impressing upon the mind of
the student where and when the importance and great nicety
of judgment are requisite in the treatment of them, and that
by inadvertent and mal-practice the victim may grope through
his existence here in the valley of darkness."


The work is one of compilation, "being made up of exten- f


sive quotations from the classical writers of the day." He
evidences of acute miliary tuberculosis. An autopsy was not
claims originality only in the construction of his plates, and so
permitted.  
far he is certainly correct, for the drawings are quite unlike
anything seen in nature.  


The arrangement of the work is very curious. The chapters
III. Beginning dementia. Frank G., aet. 20, well educated,  
follow in this order: Anatomy of the eyeball, cataract, ophthalmia, corneitis, iritis, choroiditis, retinitis, inflammation of  
was admitted to the asylum suffering from an attack of acute
the lens and its capsule, ulcers of the cornea, ojiacities of the  
mania. There he improved, but was taken out too soon,  
cornea, ptergium, prolapse of the iris, extirpation of the eyeball, extraneous bodies, diseases of the lachrymal apparatus,
relapsed, was readmitted, and then gradually demented.
under which is included entropium, ectropiuni, epiphorn,  
Thyroid of normal size. Is good tempered. Weight at beginning of thyroid administration 125 pounds. On the seventh
encaiitlius, injury of lids, ophthalmia tarsi and fistula hiclirv
day of the treatment became quite irritable and impatient.
By the fifteenth day he was so quarrelsome that it was necessary to restrain him. During these 15 days he lost five
pounds, and there was considerable tachycardia and sweating.
The myxoedematous symptoms were not so pronounced as in
some of the other cases. The administration of the extract
now being discontinued, he regained weight, became more
quiet, and after the lapse of several weeks he was sent to his
friends somewhat improved.


IV. Dementia. John B., fet. 31, admitted as a case of acute
mania, and after a period of four months gradually demented,
became quiet, and not at all irritable. Thyroid gland normal.
Treatment was now begun, and within a week there was
j^ronounced febrile reaction, with tachycardia and sweating.
There is a marked difference in the asjject of the face, which
now appears puffed and rounded, in contrast to the former
rather emaciated appearance. The facial expression also
became anxious, but there was no pronounced excitement.
The treatment was continued thr»c weeks longer, without
producing other change than an increase of the myxcedematons characteristics, and was then discontinued. From a
mental standjwint, the course of the patient's disease was
now rapidly downward, and he became absolutely demented
and degraded.


August-Septembek, 1897.]
V. Chronic vielancholia. Marcus Z., set. 30, Russian Jew,
 
admitted to the asylum with alternating melancholia and
mania. Thyroid normal. Much emaciated from chronic
diarrhcea. Refused food at first. Has been quiet for some
months, suffering from well marked delusions of persecution.
Under enforced feeding became well nourished, but not less
melancholic. Six months after admission treatment with
thyroid extract begun. One tablet for ten days, two for four
days, and three daily for two weeks longer. On the 11th
day became much excited, complaining that his countrymen
wished to kill him. There was slight febrile reaction and
increase in the pulse rate to 120 (normal 75). The cheeks
soon began to assume a marked puflBness, and on palpation
had a jelly-like feel. No other phenomena were noticed,
except that at the end of the month's treatment he had lost
eight pounds, which he rapidly regained after it was discontinued. Then he also became quiet, and at the date of writing
still remains an inmate of the institution, retaining his oldtime delusions.


VI. Dementia following puerperal melancholia. Katie S.,
ret, 35, was admitted in 1893, four weeks after confinement.
Recovered in about six weeks, was taken home, and there
relapsed and became permanently demented. Is untidy, mischievous, but never excited. Pulse rate normally 85 to 90.
Thyroid normal. Was placed on thyroid extract, one pill,
then two pills ilaily. lu second week marked febrile reaction.


JOHNS HOPKINS HOSPITAL BULLETIN.




July, 1897.]


189
139






malis, looking very much as tlioxigh the subjects had been
pulse 120 to 1.30, very weak. There is considerable sweating.
drawn haphazard from a grab-bag.*
Facial puffiaess well marked. Has become very irritable,
restless, aud difficalt to control. Thyroid extract discontinued after three weeks' administration, after which she gradually returned to her usual condition.  


At the end of several chapters the author adds original
Vn. Deep dementia foIJoioing confimonal mclnnrlioliu.
remarks. When we consider the very excellent and systematic
ilaggie E., set. 2.5, was admitted in December, 1893. Thyroid
work which Frick had published, nine years previously, as well
normal. When treatment with the thyroid extract was commenced was untidy and deeply demented. On the tenth day
as such other works from which copious quotations are made,  
there was slight febrile reaction accompanied by slight motor
it is quite inexplicable why Gibson showed such disregard of  
excitement. These symptoms abated in the course of a few
systematic classification, or indeed what purpose he had in
days, though the administration of the thyroid extract was
publishing the work at all.  
continued, and, after three weeks, no improvement having
been noticed, it was discontinued.  


Dr. John Hakper.  
VIII. Imbecility with recurrent mania, followed by apparent
dementia. C. B., aet. 21, admitted with second attack of
excitement in December, 1895, and within a few weeks became
apparently deeply demented. Thyroid gland very small.
Administration of the extract was begun, and after a few
days there was febrile reaction, considerable sweating, and a
myxcedeniatous appearance of the integument of the face.
The pulse rate altered from 72 to 110, and the patient lost
weight rapidly. There were also considerable motor and
mental excitement, with the febrile symptoms, all of which
gi'adualiy abated, though the treatment was faithfully kept
up for a considerably longer time. The patient has had
several lucid intervals during the fall of 1896, but now seems
completely demented.  


Dr. David Jleredith Reese, in his American edition of
The above experiment upon eight human subjects points
Cooper's Dictionary of Practical Surgery, first published in
out conclusively that the administration of even the very best
1833, tells us, under the section of cataract, that "one of the  
and purest of the commercial desiccated thyroid tablets is not
most successful operators in this country is Dr. John Harper,
unattended by danger to the health and life of the patient,  
of Baltimore, and he seldom adopts any other operation than
and that at times the administration of very limited amounts
this (laceration of the capsule and lens substance), which he
of the gland may be followed by symptoms not only difficult
repeats as often as necessary on the same eye." I have given
to control, but of very marked influence upon the future
myself great pains to obtain some information concerning this
mental powers of the subject.*
" successful operator," but his memories appear to have been
completely effaced. One single reference is to be found, a
short obituary notice. In the Maryland Medical Recorder
(vol. II, 179) there is a notice of the death of four members
of the Medical and Chirurgical Faculty of the State of Maryland. One of these reads as follows : " Died in the month of
January, 1831, Doctor John Harper. Doctor Harper was a
native of Ireland, and graduated at Ghisgow. He was wellknown as an oculist." The title of oculist appears to have
been elevated to the dignity of a special practice of medicine
within a few years. For Harper was a member of the Faculty,  
and not of the despised class of oculists mentioned in the  
beginning of this paper.  


William Alexander Clendinen.  
These results obtained, we then decided to further pursue
our experiments upon the lower animals, to determine the
amount necessary per kilo of weight to cause death, the immediate cause of the dissolution, and the lesions, both macroscopic and microscopic, present at death, especially those pertaining to the cerebrum.  


Wni. A. Clendinen graduated in the medical department
Through the kindness of Dr. Crawford of the Pharmacological Laboratory, who undertook the ordering of the administration to the animals, we obtained material from five mice
of the University of Maryland in 1840, a classmate of Dr.  
and three guinea-pigs, to which the same desiccated sheep's
G. W. Miltenberger. He died of cholera at New Orleans
thyroid tablets used in the first part of the investigation had
in 18-1:9, having been seized with the disease while dissecting
been fed; also the cerebrum from one guinea-pig to which
a victim of the epidemic. After his graduation he traveled
had been administered thyroid extract, and the cerebrum of a
extensively, devoting his time to the study of medicine. In
dog from which the thyroid had been extirpated about one
the Boston Medical and Surgical Journal in 1847 we find
year previous to its death, but in which, at the autopsy, supernumerary thyroids were discovered, though the animal during
several papers which were translations from the work of Prof.
life had exhibited minor symptoms of a cachexia.  
Desmarres. In his letter to the editors he tells us that the
extracts are part of a "translation upon which he is now
engaged"; he expresses his gratitude to Prof. Desmarres, who
" has entrusted to him an onerous but useful task, one which
from (his) connection with him (he) may be able to perform
advantageously to readers of the English language." In the
second article, published in the same journal, we find after the
name of the author, " Chef de la clinique oculaire." There
were in all but three articles, and the promised book never
made its appearance, perhaps on acco^^nt of the untimely death
of the author.  


A portion of the material for microscopic examination was


*I do not take into consideration the possible presence of putrefactive products in the tablets, as they were perfectly free from all
evidences of decomposition.


* Not a few important subjects are entirely ignored, viz. errors
of refraction, strabismus, etc.




hardened in Muller's fluid for after-treatment according to
the silver-phospho-molybdate formula, and another portion in
alcohol, for staining with the anilines, hematoxylin, aud more
particularly to examine into the lesions of the blood-vessels,
both in the abdominal viscera and cerebrum.


OTOLOGY.  
The five mice were first fed with the tablets. All of them
ate the pills readily to obtain the sugar coating them. For a
few days there was no appreciable effect. Then they grew
dull, the cheeks became puffy, there was trembling and increase
of the frequency of the respiratory movements, and death
rather suddenly.
 
Abstract of the Histories of the Thyroid Mice.
 
No. I. Administration of the tablets commenced Aug. 22, '96.
One pill 32nd; three, 24th. Animal remains bright and eats
other food ; 2.5th, two tablets. On 26th, it seems frightened
and the face appears swollen ; on the 37th instant, it is still
trembling very greatly, and no pill was given. On the 28th,
it is very much brighter and the trembling has almost ceased.
On the 29th, is bright, and feeding of the thyroid was again
begun. Sept. 1st, three pills were fed, the animal eating
nearly the whole quantity. The 2nd instant, the face is
again swollen, and on the 3rd, refused to eat a portion of the
tablets, and has become quite dull. On the 4th and .5th
instant, the animal continued dull, trembling, aud looks weak
and sick. On the 7th, the eyes are very bright, and there
is slight emaciation. Five pills were given, but not all were
eaten. On the 8th, only two pills were taken ; there is much
trembling. Died during the night of the 9th instant, having
eaten a portion of the tablets left in the cage.  


The early contributions to Otology in Baltimore were very
The autopsy showed congestion of all the viscera, but without hemorrhage. The brain was soft.
few. Two names deserve recognition ; the first of these is that
of the renowned surgeon,  


Nathan Rhyno Sjiith.  
No. II. On the 33nd August, cue pill administered, on the
23rd aud 24th, the same quantity, but little not being eaten.
On the 35th, two pills were eaten, the animal still remaining
bright. On the 36th, two tablets were eaten, and the face
shows signs of swelling. On the 27th, the testes have become
swollen, in addition to the face, but the appetite is still
retained. On the 38th, the eyes are partly closed, and on the
29th, the animal is trembling, the legs are dragged, but it still
takes care of its coat.  


It is beyond the province of this paper to give a biographical
September 1st, the animal is dull, the face much swollen.  
sketch of Dr. Smith. A very complete sketch can be found in
Three pills were eaten. On the 3rd, is much brighter, sleeps
Dr. Cordell's History of the University of Maryland. He was
well, but has not taken all the pills during the last two days.  
born in 1797 in New Hampshire, graduated as A. M. in 1817,  
On the 5th instant, will hardly touch the sugar-coated tablet.  
and as M. D. in 18-^3 in Yale College. He was professor of
On the 7th, the face is markedly swollen, the animal is dull,  
anatomy and surgery in the University of Vermont in 1825,  
the hair less sleek, and the eyes almost closed. Kespi ration
soon leaving to occupy the chair of anatomy in the newly
134 per minute. Died in convulsions at 2.30 1*. M.  
organized Jefferson Medical College of Philadelphia. From
1827-39 he was professor of anatomy in the University of
Maryland, and from 1829-38 he occupied the chair of surgery
at the same university, leaving this for three years to occupy
the chair of theory and practice in the Transylvania University.  
He resumed it again in 1841 and held it until 1869.  


One of the earliest writings of this prolific worker was the
The autopsy was performed immediately. Besides some
translation of a treatise on the ear from the French of Saissy,*
unimportant congestion of the abdominal viscera there were
with additions by the translator on diseases of the external ear.  
no ascertainable lesions.  
This book was published in Baltimore in 1829, and was, so
far as I can learn, the second book on diseases of the ear printed
in America, the first having been an American edition of Saunders on the eye and ear in 1821.  


Saissy's work was "highly esteemed in France," and was
No. III. Commenced feeding on 33ud August, but no symptoms were noticed uutil the 36th, when the face became
one of the important factors in the revival of modern otology.  
slightly swollen and the animal declined to eat the pill. On
In his preface Dr. Smith tells us that " a concise manual on
the 28th, there is slight trembling. On the 30th, the trembling continues. On Sept. 3nd and 3rd, took daily three pills.  
the diseases of the ear is an acknowledged desideratum in our
On the 5th, is dull, tottering, very weak. On the 7th
medical literature. No sufficient work on the subject has ever
instant, the hair is rough, and it seems weak, hut eats the pills
been issued from the American press. With a view to supply
this deficiency (he has) translated the following pages from the  
French of Saissy . . . corrected and enlarged by its author,  
and after his death published in 1827 by his friend Montaion, etc.


" It embodies the excellencies of Saunders, Cooper, Leschevin,
Maunoir, Itard and Alard . . .


" The attention of the reader will be particularly occupied
with Saissy's excellent method of injecting the ear through the
eustachian tube. We very well know how frequently the external ear is obstructed by its own secretions, free as is their
egress from this cavity. The internal ear is also lined with a
membrane which furnishes an excrementitious fluid. It can
escape only by the narrow channel of the eustachian tube.
How frequently then must it be delayed in the cavity of the
tympanum and mastoid cells, giving rise to any degree of
mischief."


To render " the work more complete and useful to the medical
140
pupil (he has) added a brief supplement on diseases of the
external ear. On this score, however, (he) claims nothing, as
(his) addition is made up of commonplace iirinciples and


[No. 76.




*An Essay on the Diseases of the Internal Ear, by J. A. Saissy,
M. D., translated from the French by Nathan Rhyno Smith, M. D.,
Professor of Surgery in the University of Maryland, with a supplement on Diseases of the External Ear, by the translator. Published by Hatch & Dunning, Baltimore, 1829.


well. On the 8th, is trembling very much, but eats the pills.
Died during night.


Autopsy showed congestion of the abdominal viscera.
Brain rather soft.


190
No. IV. Feeding commenced on August 'Z2nd, but does not
eat the tablet well, hardly averaging J of a pill daily. On
the 26th, the animal is bright, but the face is slightly swollen.
On the 29th, refused to eat pill, but remaiued dull until
September 3nd, and thereafter refused to eat pill at all. On
the 12th instant, had apparently fully recovered.


No. V. Administration commenced on the 22nd August,
and the dried gland was all eaten. On the 26th instant, the
face is swollen. On the 28th, there is much trembling, but
three pills were eaten. On the 29th, would not eat pill, but
on Sept. 1st ate four pills. On the 5th instant, is trembling
considerably, but ate two pills. On 8th instant, was bright,
though trembling. On morning of 9th instant, found dead in
cage. The autopsy showed the usual congestion.


Abstract op the Histories of the Thyroid
Ctuinea-Pigs.


JOHNS HOPKINS HOSPITAL BULLETIN.  
No. I. Fed with thyroid extract, 20 mg. daily, from Oct.
21st until Oct. 30th, on which day it died. Weight at beginning of experiment, 620 grammes. The animal became dull and
gradually emaciated. Weight at autopsy, 380 grammes. All
intei-nal organs very much congested. The animal received a
total of 180 mg. of extract.  


No. II. Pig fed on the same desiccated thyroid as in the
former experiments. Weight, 810 grammes. On Oct. 21st, one
and a half pills administered; on 22nd, four pills; on the
23rd, the same quantity. The respiration had now reached
144 per minute. On the 24th, 2.5th and 26th, four tablets were
fed daily, and during the night of the 26th, the animal died.
At the autopsy the abdominal organs were found to be
much congested. Weight, 620 grammes (loss 190 grammes).
This animal received about seven grammes of the dried thyroid
gland, or less than one per cent. (.864j of its bodily weight to
produce a lethal effect.


No. III. Fed on desiccated thyroid tablets. Weight, 580
grammes. Oct. 21st, one pill ; on 22ud, three tablets ; on the
23rd instant, four; on the 24th, 25th and 26th, the same; on
the 27th instant, six pills; on the 28th, four tablets; on the
29th, five ; on the 30th, five. The animal had been for several
days very dull and had rapidly emaciated. The exitus took
place on the morning of the 30th instant. At the autopsy the
viscera were found to be much congested. The weight was 320
grammes. Loss of weight during the nine days of the experiment, 260 grammes. The animal received more than 2 per
cent, of its weight in the dried gland to produce dissolution.


[Nos. 77-78.  
No. I\". The same thyroid preparation fed. Weight at
beginning of the administration, 610 grammes. On Oct. 22ud,
two tablets were fed to the animal ; on the 23rd, three ; on
the 4th, four pills; on the 26th, six pills; on the 27th, four
pills ; on the 28th, five pills. The pig has become very dull
and does not take care of its fur. Died Oct. 30th. At the
autopsy the animal weighed 370 grammes (loss, 240 grammes)
and the viscera were much congested. This animal received
1.30 per cent, of its bodily weight of the gland to cause death.  






precepts subjoined merely for the purpose named above." He
No. V. Thyroid dog (Dr. Abel). Thyroid gland extirpated
concludes: "I have, it is true, for perforating tlie tympanum
i)i loto in Oct. 1895 ; died one year later, after showing profound emaciation and a dermatitis suggestive of myxoedema.
devised a new instrument wliich I trust will be useful."
At the autopsy several parathyroid bodies the size of a small
pea were discovered. This animal was fed for several mouths
on thyroids and thyroid extracts, seemingly without benefit.
The autopsy showed no demonstrable lesions.  


The part of the book most interesting to us is the supplement on diseases of the external ear, covering about twenty
The guinea-pig series may be looked upon as an example of
pages. These chapters are written in the most concise and
the acute type of poisoning by the administration of thyroid
simple manner and cover most of the inflammatory afiections
gland, while the mice are of a more chronic order. It is
of the auditory canal, congenital deformities, injuries as well as
impossible to estimate the exact percentage necessary to produce lethal results with the mice, for the reason that these
the treatment of foreign bodies, insects and indurated wax in
small animals always left some crumbs of the tablets on the
the auditory canal.  
floor of their cages which it was not practicable to collect.
The guinea-pigs on the other hand were fed with the entire
pill without loss, and but in one case was less than about one
per cent, of desiccated gland found to produce lethal results,  
the administration being distributed over five days.  


He describes his method of inspecting the canal as being
The microscopic examination of the cerebra of the eight
" best accomplished by placing the head in such an attitude
mice and guinea pigs showed, both with the silver phospliomolybdate, and aniline and hematoxylin stains, an absolutely
as to suffer the sun's rays to enter the meatus and impinge
normal condition of the nerve elements and neuroglia ; none
upon the tympanum. To effect this, the operator must seize
of the varicose and atrophied dendrites, with loss of the gemmulffi, of the former studies being discovered. The corpora
the external ear, and drawing it outward from the head, extend
retain their angularity and sharp outlines, and the axons
and straighten the cartilaginous part of the meatus. I have
with their appendages, the collaterals, retaining their natural
been able to inspect the ear more perfectly by introducing, at
appearances. The sections stained with anilines and hematoxylin showed the normal appearances of the nucleus and  
the same moment, a steel director, with its groove toward the  
nucleolus, and not even in the tunics of the blood-vessels,
meatus and its convex side pressed firmly against the anterior
where pathological changes were most carefully sought for,
walls. The passage is thereby straightened and expanded. If
could any demonstrable lesion be discovered.  
there be no wax present the tympanum will be seen of a pearly
white color and concave."


The little instrument which he devised for perforating the  
The nearest approach to any pathological condition found
membrani tympaui is a minute trephine, by revolving which
was in the cerebrum of the dog that had had its thyroid gland
a circular piece of the drum was excised. His object in constructing this instrument was to obtain a larger opening, for
extirpated a number of months before death, though even
he tells us that in two instances in which he had occasion to
here the lesions were confined to a very few tumefied dendrites,  
perforate the membrani tympani he found the beneficial effects
a condition that was most probably caused by the long continued state of mal-nutrition into which the animal had fallen.  
of the operation soon to cease in consequence of the speedy
closure of the artificial opening. The Maryland Medical Recorder of 1839 reviews the work extensively, the review covering twenty pages. The review is by no means flattering.  


It is very apparent that Dr. Nathan R. Smith must have
More particular attention was paid to the examination of  
been deeply interested in the subject of the diseases of the  
the liver than to the other organs of the abdominal cavity,  
ear. He had an extensive j^ractice in diseases of the ear, and
but here again we failed to find more than a turgescence of  
also of the eye, though none of his publications deal with the
the blood-vessels, the liver cells retaining their natural characteristics.  
latter organ. Dr. Theobald has recently found a drawing of a
knife designed by Dr. Smith to slit the lachrymal canal.  


Dr. Joshua I. Cohen.  
It is obvious from these results that the death of the various
animals was induced by an entirely different kind of intoxication than that causing the lesions of the nerve elements in
riciu and alcohol tox£emias, and it is therefore a poison that
does not induce degenerative alterations in the sheaths of the
arteries, and the consequent disturbance of the nutritive
supply, followed by pronounced changes in the neurons,
dependent to a certain degree upon the intensity of the
vascular lesions; but acts upon the general system in an
entirely different manner, and is essentially more subtle in its
effects upon the nerve tissues, corresponding more to the
action of a group of chemical poisons that leave no trace of
their effect after death upon the nerve cell, but during life
inducing symptoms directly referable to the central nervous
system. The tissue metabolism induced by the action of these
poisons upon the nerve cell we can only at present conjecture.  


Dr. Cohen, born in Maryland in 1800, graduated at the University of Maryland in 1833, having been a student in Dr.
Nathaniel Potter's office, and soon after devoted himself to the
study of diseases of the ear. He was an intimate friend of
Dr. George Frick, the oculist, and, like his friend, had wide
interest in science beyond the domain of medicine. He thus
for a time became professor of mineralogy in the academic department of the University of Maryland. He was much interested in the Medical and Chirurgical Faculty of Maryland, was
its treasurer from 1839 to 1856 and president from 57-58. He
was also much interested in the Maryland Academy of Sciences.


He practiced until about 1851, devoting himself almost exclusively to otology. His reputation as an aurist must have
been quite great, for we read in Reese's American edition of
Cooper's Dictionary of Practical Surgery (2nd ed., vol. 2, p. 73,
under the heading "Ear"): "In the United States there have
been a few surgeons who have distinguished themselves by
their success in the treatment of diseases of the ear.


July, 1897.]


141


" Dr. Cohen of Baltimore and Dr. Dix of Boston have for
several years directed their particular attention to diseases of
the internal ear, and to the investigation of the abnormal condition of the tympanum and eustachian tube in cases of deafness. These gentlemen have employed condensing apparatus
for administering the air douche through the eustachian tube
after the plan of Kramer and others. By the air and also by
the water douche, these gentlemen have acquired great tact in
the diagnosis and treatment of obstructions in the tube and
upon the tympanum."
In 1840 he established, in connection with his friend, Dr.
Samuel Chew, an eye and ear institute in Baltimore, in which
Dr. Chew had charge of the eye department. Dr. S. C. Chew
has had the kindness to inform me that this association between
Dr. Cohen and bis father lasted for a short time, as his father's
appointment to a chair in the University of Maryland compelled him to withdraw from it.


Dr. Cohen was one of the earliest, perhaps the first, aurist in
this country. He has left us, however, but one publication
which pertains to diseases of the ear. It is entitled " Postmortem Appearances in a Case of Deafness."* The paper is
very short, but is written in the most scientific manner.


In a note written by the editor of the Journal we read that
FIVE SUCCESSFUL CASES OF GENERAL SUPPURATIVE PERITONITIS TREATED
this "valuable communication was read before the American
Philosophical Society, at a recent meeting, and is noticed in the
proceedings of that body. It has rarely happened that opportunities have been embraced for examining into the condition
of the organ of hearing in cases of deafness, or that they have
fallen within the observation of an investigator so competent as
the author of this paper." The case was that of a patient who
died of phthisis. The brain and seventh pair of nerves were
examined carefully, but no changes observed. The lower part
of the skull was then removed and the ear examined in minute
detail.


In the right ear he found the drum-head dull and dark in
BY A NEW METHOD.*
appearance, irregularly thickened and retracted as a whole, thus
diminishing the cavity of the tympanum. The tympanum
itself was filled with muco-fibrous membranes passing from the
membrani tympani to the posterior walls, presenting a cellular
structure. These were carefully divided, exposing the tensor
tympani muscle, the tendon of which was found to be of unusual shortness and attached to the handle of the hammer
throughout its whole length, thus drawing the bone and the
membrani tympani to within a line of cochlear process. Interesting irregularities in the ossicula were noted. The malleus
was normal. The incus was undeveloped, diminutive in size.
The stapes was wanting with the exception of the base, which
was held in place by the circular ligament. The depression of
the oval window was filled with membranous tissue, which likewise covered the fenestra rotunda. The tensor tympani muscle
was strongly developed, its tendon short and thick as mentioned above. The stapedius muscle existed, but there was no
tendon.  


In the left ear the membrana tympani was found to have
By J. M. T. Finney, M. D., Associate Professor of Surgery, The Johns Hopkins University.  
been entirely destroyed, with the exception of a very thin slip
at the anterior inferior edge. The tympanum contained a






•Amer. Med. Intelligencer, July 1841 to July 1S42, p. 220 (Vol.1).
Recovery following laparotomy for piiruleut peritonitis is
 
nufortunately of sufficient rarity to excite interest whenever
it occurs. My object in making this report to the Society is
two-fold ; first, to record five successful cases of laparotomy
for general suppurative peritonitis, all treated by the same
method; and second, to describe briefly the method itself.  
The principle involved is not a new one; only in the manner
of carrying it out is there any originality claimed.  


Since the appearance in 1877 of the classical work of
Wegner, and later that of Grawitz and others, it has been
known that the healthy peritoneum is capable of disposing of
a considerable amount of infectious material. J. G. Clark, in
a recent article,f reviews the literature of the subject and
gives the conclusions reached by the experimenters in this direction. All agree that the peritoneum is able under favorable
conditions to take up a relatively large amount of infectious
material and disjjose of it effectually. These observers were
dealing with a more or less healthy peritoneum. On opening
the abdomen of a patient suffering from general suppurative
peritonitis, however, we have very different conditions with
which to deal. The observations of Pawlowsky would indicate that the lymph channels leading from the peritoneal
cavity are choked with infectious bacteria and inflammatory
products in purulent peritonitis, and that thus the efficiency
of the peritoneum would be greatly impaired. Our observations clinically seemed hardly to bear this out.


August-September, 1897.]
The question that suggested itself to our mind was this,  
whether or not the peritoneum, even under these most unfavorable conditions, still retained its absorptive power. It
seemed to us, from our experience in operating upon such
cases by the methods heretofore employed, that they were
inadequate and did not remove a sufficient quantity of the
exudate, but left the peritoneum little better off than before.
With this idea in mind we devised a plan of treatment which,
so far as we know, has not been employed elsewhere.  


The steps of the operation are as follows : Make a sufficiently long incision to admit of easy access to all parts of
the peritoneal cavity. Quickly withdraw the coils of small
intestine from the peritoneal cavity, beginning with the
worst coils first. Remove all, or as much as is necessary of
the small intestine and place it outside the abdomen, covered
with warm gauze or towels, thus practically disemboweling
the patient for the time being Then thoroughly and systematically wipe out the peritoneal cavity with large pledgets of
gauze wrung out of hot salt solution, paying particular attention to the pelvic portion. In some cases it may be well in
addition to flush out the cavity with warm salt solution, but
this is rarely necessary.




JOHNS HOPKINS HOSPITAL BULLETIN.


* Read before the Medical and Chiriirgical Faculty of the State
of Maryland at its Annual Meeting in Baltimore, April 27, 1897.
tBuUetin of the Johns Hopkins Hospital, April, 1897.




191


Next the small intestine should be systematically examined
loop by loop while still outside the abdomen, and rendered
macroscopically clean by wiping with gauze comjiresses wrung
out of hot salt solution. It is necessary to wipe with considerable force at times, in order to remove adherent flakes of
partly organized lymph. It should be done thoroughly and
conscientiously, however, as upon this depends, we believe, in
great measure, the success of the operation. It facilitates the
cleansing process, as well as lessens the shock of the operation,
if the wiping of the intestinal coils is carried on under a constant irrigation of warm salt solution.


After being cleansed macroscopically of all foreign material,
pus, feces, lymph, etc., the intestine should be replaced in the
abdomen — the worst or sutured coil being the last, or most
superficial, in order that it may be the better drained by being
packed about with gauze, if necessary.


quantity of yellowish fetid matter, and its lining membrane
The abdominal wound is then tightly closed, leaving just
was completely disorganized. The union between the ossicula
room enough between two sutures for the gauze drain. If there
was slight, owing to the general disorganization of the ligamentous and mnco-fibroiis connections. The incus was in place,
are any evidences of distension or pain the abdomen should
but the handle of the malleus was depressed. The stapes was
have the Paquelin cautery thoroughly applied, and the bowels
not bound down in the oval window, for the annular ligament
moved early by calomel in broken doses, followed by salts and  
was entirely destroyed. Tiie tendon of the tensor tympani was
a turpentine enema.  
disorganized and that of the stapedius destroyed; the whole
condition of tiie tympanum showed a recent active suppuration
which did not confine itself to this part; the vestibule was
penetrated as well as the mastoid cells; the latter were covered
with pus. Tlie cochlea and one of the semicircular canals
were examined a day or two subsequently, but there was nothing remarkable about them at this time worthy of note.  


Inquiry about the patient led the author to conclude that the
It is not claimed for this method that it will cure every
faculty of hearing in the right earhad been entirely wantingor
case of general suppurative peritonitis. We believe, however,
was very much impaired for many years.  
that a larger percentage of cases will recover after this method
than any other with which we are familiar.  


Though he seems to regard the condition of the right ear to
To insure success with any method it is essential that the  
have been congenital, his critical analysis is as acute as the  
operation should be performed within a few hours after the  
observations tliemselves are accurate. He cites cases of Morgagni in which membranes filled the cavity of the tympanum.  
perforation has taken place. This is well brought out in the  
very interesting series of experiments on dogs made for me by
Messrs. Elting and Calvert of the Johns Ilojikins Medical
School, a report of which is subjoined.  


Five cases have been operated upon by this method up to
date, all of which have recovered. The first case, a case of
perforating typhoid ulcer, has already been published,* and
hence only a very brief abstract of the history will be given
here.


Case I. — Male, aged 47, on about eighth day of mild
attack of typhoid developed symptoms of perforation. Entered
hosijital 14 hours later and was operated upon immediately.
Peritoneum everywhere intensely congested, roughened and
dull, and covered with flakes of plastic lymph. Considerable
amount of turbid purulent fluid in abdominal cavity. Perforation in ileum about 14 inches from ileo-c;ecal valve.
Fecal matter exuding from opening. Peritoneum cleansed in
the manner described, gauze drainage. Recovery.


and another in which there was immobility or contracture of
Case II. — G. W., male, aged 20. Saw patient for the lirst
the muscles. At the conclusion of his paper he says: "In the  
time, November 24, 1896, in consultation with Dr. Barringer
case described in this paper, does not the absence of every part
in Charlottesville, Va. Patient gave history of four previous
of the stapes, with the exception of the base, liken it to the
mild attacks of appendicitis, from which he liad promptly
osseous operculum found in the bombinatores, land salamander, and cfBciliffi ; of the effect of wliich, in the communication
of sonoro:is undulations, I have already spoken ? " I am unable
to find any other reference to this paper on undulations and do
not know whether it was ever published.


This sketch must be brouglit to a close. Is it necessary to
remark what any careful reader must have observed, that there
were physicians in Baltimore in the first half of this century
who labored faithfully and well in Ophthalmology and Otology?
Their contributions were among the earliest and most important in this country.


In conclusion I desire to express my thanks to Dr. G. W.
Miltenberger, to Dr. John Morris and to Dr. Eugene F. Cordell, who furnished me with important notes, as well as my
indebtedness to Dr. John R. Quinan's "Jledical Annalsof Baltimore," and Dr. Cordell's " History of the Universiiy of Maryland."


*AnnalB of Surgery, March, 1897




JOSEPH FRIEDERICH PIRINGER: HIS METHODS AND INVESTIGATIONS.*


By Harry Friedenwald, A. B., M. D., Baltimore.
142


[No. 76.




"Joseph FreiJerich Piringer was born, March 31st, 1800, in
Klein-Zell in Upper Austria. He studied medicine in Vienna ; he
afterwards turned his attention to ophthalmology in 1824. He
was at first an assistant of Jaeger, then for three years of Rosas
(beginning in 1825). He next obtained the extraordinary professorship of ophlhalmology in the medical school at Gratz. Here
he founded a much-needed eye hospital, an institution out of
which the ophthalmic department of the AUgemeines Krankenhaus gradually developed through his energy. Here he held a
high position and was active as a teacher until ISGO. His clinical
and experimental stuilies on blennorrhcea were made at this
hospital. He wrote a work on blennorrho;a which was awarded
a prize by the German Society of Physicians in St. Petersburg.
Piringer has the merit of having shown that intentional infection
of blennorrhceic secretion in pannus leads to clearing of the cornea.
He founded a reputation upon this which extended far beyond the
boundaries of Germany. He was for many years attached, as
visiting physician, to the Elizabeth Hospital and to the City
Asylum for the Aged, and published several other articles up to
the time of his death, Sept. 22nd, 1879, including: Ueber Veratrinbehandlung des acuten Gelenk-Rheumatismus ; Die Behandlung der Variola mittelst lodtiuctur; Die richtige Pflege der
neugebornen und kleinen Kinder ; Studien ueber die MortalitatsStatietik in Graz."f — (From Hirsch's Biographisches Lexikon,
1886, vol. IV, p. 575.)


Piringer's work on blennorrbceaj was awarded a prize, and  
recovered. The night before he had eaten very heartily of
the earlier works in ophtiialmology refer to his studies, especially to his investigations in the treatment of pannus.§ Arlt
apples. He was awakened about 3 a. m. with severe abdominal pain, cramp-like in character. At about 6 a. m. Dr.
Barringer was called. He stated that at this time, three
hours after the beginning of the attack, the patient presented
the classical symptoms of peritonitis. When I saw him, 24
hours later, he had a temperature of 103° and a pulse of over
100, and from the first had suffered intense pain, which was
controlled only by morphia hypodermically. He had had
nausea and vomiting all day. Examination of the abdomen
showed slight distension and great rigidity of the abdominal
muscles. A slight tumefaction could be made out just to the
inner side of the anterior superior spine of the ilium on the
right side. Tenderness very marked. Immediate operation
advised and agreed to. Incision 5 inches long in right linea
semilunaris. On opening the peritoneal cavity the intestinal
coils in the right lower quadrant of the abdomen were found
to be congested and dull and covered with flakes of adherent
lymph. Elsewhere the intestinal coils were found to be
congested, but not otherwise much changed in appearance.
The pus, of which there was perhaps 200 cc, was not walled
off, but everywhere present in pockets between the adherent intestinal coils. The appendix was readily found. It was closely
adherent to the pelvic brim on the one side and the csecum
on the other. Its distal end was swollen and distended to the
size of my thumb, perforated and gangrenous over an area
about as large as a five-cent piece. Appendix was ligated and
excised, and stump covered with peritoneal cuff and suture.
The peritoneum was treated in the manner above described.
Recovery.  


Case III. — This patient was seen first on December 14,
1896. His history is in brief as follows : R. S., male, aged
33 years. Has had no previoiis similar attack. The night
before he was taken sick he attended a banquet and ate
heartily of solid indigestible food. He was attacked with
severe abdominal pain about 3 o'clock the next afternoon.
The pain at first was general and cramp-like ; nausea and
light vomiting during the night. Morphia was necessary to
relieve him. The next day he was unable to get up. Toward evening his physician gave him a cathartic, after which
the bowels moved 8 or 10 times in quick succession. The next
morning the pain had shifted to the right side and was severe.
He received a hypodermic of morphia and got on fairly well
until about 6 p. m., about 60 hours after the onset of the
attack, when he was taken with a sudden severe pain in the
lower right side of the abdomen. The pain for a time was
excruciating at the base of the penis. Vesical and rectal
tenesmus marked. When I saw him, about 4 hours later, in
consultation with Dr. Reiche, he had a temperature of 105°
and pulse of 150, profoundly collapsed. I have never seen
such a hard and retracted abdomen as he presented. His
condition appeared grave. Immediate operation advised and
consented to.


Incision about 5 inches long, in right linea semilunaris.
On opening abdomen the intestinal coils were fol^nd not to be
distended but considerably congested. Beginning in the
right lower quadrant there was found a considerable amount
of thin pus containing flakes of lymph. This condition


•Read before the Johns Hopkins Hospital Historical Club.
1 1 am indebted to Professor Wm. H. Welch for having called my
attention to this account of Piringer's life.


t Die Blennorrhoe am ^Menschenauge. Graz, 1841.
lOest. Med. Jahrb., 1838, and chapter 8 of the monograph.


extended over into the left side, down into the pelvis and up
into the hypogastric region. The appendix was found to be
gangrenous and perforated, and was removed. The toilet of
the peritoneum was made in the manner already described, by
disemboweling and vigorously scrubbing the parietal and
visceral peritoneum until macroscopically clean. The intestinal coils were then replaced, a gauze drain inserted, and the
abdominal wound closed except a small opening for the drain.
He made an uninterrupted recovery.


Case IV. — M. B., boy, aged 10. Operation by Dr. J. C. Bloodgood, January 7, 1897. Five days before admission to the
hospital was struck in the abdomen by the fist of a playmate.
Next day felt severe pain in the right iliac region. This progressively increased for three days, when vomiting began and
the pain became general. Two days later was brought to the
hospital, when his condition was found to be in brief as
follows: Temperature 101°, pulse 128 and fairly good.
Slight abdominal distension. Muscular spasm marked on
right side, present but less marked on the left. General
abdominal tenderness. Under ether a definite tumefaction
could be made out in the region of the right kidney. This
proved to be an abscess behind the cjecum, extending from the
iliac fossa below to the liver above, and in this cavity was the
diseased appendix. There was foiind no walling off of this
from the general peritoneal cavity. The entire pelvis was filled
with yellow pus and all the intestinal coils were covered with
flakes of fibrin. The stomach and spleen were not seen, but
the surface of the liver looked exactly as if it had been covered with yellowish-white paint. The appendix was removed
and the entire abdominal cavity thoroughly wiped out with
gauze pledgets wrung out of salt solution. The exudate was
scrubbed oS the livers surface, after which it looked simply
congested. A gauze drain was inserted and the abdominal
wound partly closed. He made an uninterrupted recovery.
Cultures and cover-slips from the peritoneum showed colon
bacillus and a coccus (not differentiated).


devotes some space to a summary of the work on blenuorrhcea.*
Case V. — R. S. P., aged 9, a schoolboy, entered the Johns
But more recent works in ophthalmology make no mention of
Hopkins Hospital, Feb. 26, 1897. He had always been healthy
these important studies and their no less important results; in
except for measles, whooping cough and chicken-pox.  
works on bacteriology I do not find his name, nor even in works
on gonorrhcEa, such as that of Finger. Piringer's work was of
such importance that it does not deserve to be thus forgotten.  


The absence of any other references in ophthalmic literature
Family history good except remote cases of tuberculosis on
leads me to believe that Piringer's studies in ophthalmology
both sides.  
were confined to the subject of inquiry contained in the work
above mentioned. This is the more readily understood when
we read in his preface " that his itntiring efibrts during fifteen
years were given up to the solution of the natural laws governing blennorrhoeas of the eye, as far as this lay in the limited
powers of a single individual." We may aptly apply to
Piringer the words, "therefore by their fruits ye sliall know
them." Judged by this standard, Piringer stands out boldly
as one of the greater luminaries of medical science in tlie first
half of this century.  


In order to properly estimate the importance of his investigations it will be necessary to examine into the state of knowledge of the subject previous to 1840.  
Just 48 hours before entering the hospital first complained
of pain in abdomen. Three hours later had an attack of
vomiting. Pain in abdomen was at first general, but in a few
hours became localized in the right iliac and lumbar regions.
After about 24 hours the pain lessened somewhat, and he sat
up for a little while, but shortly after pain and vomiting
returned with increased severity. A physician saw him after
about 36 hours and gave him calomel in broken doses. His
bowels moved twice. His condition did not improve, and by
advice of his physician was brought to the hospital at 8 p. m.,
48 hours after the onset of the attack. His condition then
was as follows : Face flushed and anxious. Pulse 126 ; temp.
102.8°; resp. 56, and entirely thoracic; abdomen generally
distended and tender, especially in right iliac fossa, where the
tenderness is extreme and muscle spasm very marked. Pain
is most marked here also. Liver and spleen not palpable.
Liver dullness on right corresponds about to costal border.  


In 1780 a treatise on diseases of the eye appeared, written by
George Chandler, surgeon, of London, in which he gives this
account of "venereal ophthalmy." He divides it into two
varieties, the translative and the symptomatic.


"The translative ophthalmy begins with a copious discharge of
a sebaceous humor of a yellowish white color, and is known by the
tumor, lividness, sharp and lancing pain of tlie sclerotica, the


July, 1897.]


143


*Klin. Daratellung d. Krankheiten d. Auges. Vienna, 18S1, pp.
35-37.




Percussion over right iliac and lumbar regions shows dullness; tympanitic over left side. Heart normal. Fine moist
rales over bases of both lungs. No history of any similar
previous attack.


192
Diagnosis. — Perforating appendicitis with beginning general
peritonitis. Immediate laparotomy advised and agreed to.
Ether. When thoroughly auassthetized, a small, hard mass,
somewhat movable, could be felt just over the middle of
Poupart's ligament. An incision about 15 cm. long was made
parallel to and over the right linea semilunaris. After exposing the peritoneum and before opening it several bubbles of
gas could be seen free in the peritoneal cavity. On opening
the peritoneum a considerable amount of thin, cloudy seropuruleut fluid escaped and some gas. The mass felt before
was found to be the appendix with a roll of omentum adherent. The intestines, especially the CEecum, were distended
and congested, and covered with flakes of fresh fibrinous
exudate. The congestion was most marked in the immediate
vicinity of the appendix.


The appendix itself was superficially placed and freely
movable, not walled off, but had a portion of omentum adherent. It was rather long, and curled upon itself, with a
constriction at about the junction of its proximal and middle
thirds. It contained two concretions, the larger of which
was engaged tightly in the constriction, and from this point
to the tip the appendix was gangrenous and softened. A




JOHNS HOPKINS HOSPITAL BULLETIN.


small perforation was present at the distal end of the dateseed like concretion. 'I'here had been an apparent attempt of
the omentum to surround the entire gangrenous end of the
ajjpendix, but it had not quite succeeded. The appendix
together with the adherent omentum was ligated and excised.


Pelvis was found to be full of pus, and the peritoneum
treated as above. He made a rapid and complete recovery.


[Nos. 77-78.  
Bacteriological examination of the peritoneal exudate showed
the presence of streptococcus, staphylococcus, and bacillus coli
communis.  


NoTK. — Since reading the above article, I have operated
upon one additional case of general peritonitis. The patient,
a young woman, was in extremis at the time of the operation,
which was undertaken simply as a forlorn hope. This operation was secondary to one performed several days previously
by another surgeon for appendicular abscess. There was
found present a general peritonitis, with much jjlastic lymph
covering the greatly distended and adherent coils of intestine.
There was very little purulent fluid in the abdomen. Her
pulse was very rapiil and thready, and her temperature had
risen several degrees. After the operation she was placed in
a continuous bath, which added greatly to her comfort. The
operation seemed to prolong her life, as she lived about thirtysix hours following it.




cornea at the same time being as it were depressed within a pit.
It frequently follows soon after an injudicious stoppage of a gonorrhoea, the venereal virus being translated into the eye. It has also
been observed that a gonorrhoea which before seemed incurable
has, upon the coming on of this ophthalmy, suddenly vanished ;
and in like manner the ophthalmy has gone off upon the return of
the gonorrha?a . . . The symptomatic remits towards morning,
never turns into a chemosis, the morbid matter does not change
place, the pains are milder, it is removed when the hies is cured,
and is also attended with less danger."


He admits that "sometimes a venereal ophthalmy has been
AN EXPERIMENTAL STUDY OF THE TREATxMENT OF PERFORATIVE
produced by the immediate application of the virus to the
eyes."


Concerning the treatment he tells us that —
A NEW METHOD OF OPERATION.


"The venereal ophthalmy in general is subdued and its poison
By Arthur W. Elting and William J. Calvert.  
extinguished by mercury, but it should never be applied to the
eyes. The patient should be bled and purged, and his eye washed
continually with brandy and water, etc. It is necessary also to
evacuate the virulent matter collected in the cellular texture of the
sclerotica and eyelids by slight incisions of each membrane ; an
ichor, very like that of gonorrhtea, will be discharged."


This was the older view.


About the beginning of this century a remarkable development occurred in ophthalmology. Beer and Schmidt in
Vienna, and Himly, Langenbeck, Graefe the elder, and others
gave a new impetus to the scientific study of this branch of
medicine. This was followed by the publication of a number
of important treatises and monographs in ophthalmology,
principally in Austria and Germany, but also in France, England
and our own country. I shall pass these by and take up the
subject as we find it in the third edition of one of the most
important and valuable treatises on " Diseases of the Eye "
written in the first half of this century, that of William
Mackenzie of Glasgow. I take the third edition as it appeared
in 1840, one year before Piringer's work. Here we find under
the section of ophthalmia in new-born children, that "there is
reason to suspect that this disease is not unfrequently an
inoculation of the conjunctiva," etc., and "that therefore it
may often be prevented by carefully washing the eyes of the
infant with tepid water," etc.; secondly, "that the purulent
ophthalmia of infants in its worst form is the result of the
application of gonorrhceal matter, is generally admitted."


Concerning gonorrha'al ophthalmia he tells us that —
'ERITONITIS IN DO(iS BY


" Different views have been entertained of the purulent inflammation of the conjunctiva which is frequently found to attend or
succeed gonorrhtea. First, this ophthalmia has been ascribed to
inoculation with matter from the urethra; secondly, it has been
supposed to be metastatic ; and thirdly, it has been considered, at
least in certain cases, as an effect owing to irritation merely, without either inoculation or metastasis. It is quite possible that there
may be three such varieties of this ophthalmia. The existence of
the first I consider beyond all doubt ; but the second and third are
somewhat problematical."


His description of the first form is quite clear, and in several
cases which he reports the infection is definitely proved. He
did not succeed in separating gonorrhcEal from what was called
Egyptian ophthalmia, excepting as differing in degree. This
distinction was not definitely made until about ten years later
(by Bendz). Mackenzie's criticism of the views entertained by


[From the Anatomical Laboratory of the John) Hopkins University.']




some eminent ophthalmologists is so interesting that I shall
quote the entire paragraph:


" Dr. Vetch tells us that in a soldier in a very advanced stage of
At the suggestion of Dr. Finney and with the permission of  
Egyptian oplithalmia he attempted to divert the disease from the  
Prof. Mall, the writers have undertaken an experimental study
eyes to the urethra, by applying some of the matter taken from the
of perforative peritonitis in dogs, with especial reference to
eyes to the orifice of the urethra. No effect followed this trial. It
the method of treatment of this disease in human beings,  
was repeated in some other patients, all laboring under the most
introduced by Dr. Finney. Inasmuch as this is a preliminary
virulent state of the Egyptian disease; and in all the application
report, the literature upon the subject will not be considered.  
was perfectly innocuous. But in another case, where the matter
It may be mentioned, however, that so- far as we know no previous work of this nature has been done from a surgical
was taken from the eye of one man laboring under i)urulent ophthalmia, and applied to the urethra of another, the purulent inflammation commenced in 36 hours afterwards and became a very
standpoint. It was decided to divide the series of experiments  
severe attack of gonorrhrea. From the result of these experiments, Dr. Vetch, while he admits that gonorrhceal matter taken
into four groups :
from one person and applied to the conjunctiva of another will
excite a highly purulent ophthalmia, regards himself justified in
no longer admitting the possibility of infection being conveyed to
the eyes from the gonorrhceal discharge of the same person. He
adds that the impossibility of this effect was rendered decisive by
an hospital assistant who, with more faith than prudence, conveyed the matter of a gonorrhcea into his eyes without any affection of the conjunctiva being the consequence. It is remarkable
that Dr. Guillie has fallen into the same error of reasoning as Dr.
Vetch, onlythathis negative experiments have led him to the very
opposite conclusion. He applied the matter taken from the conjunctiva of one patient to the urethra of another; no effect followed, and hence he concludes that the notion of some regarding
the propagation of puro-mucous inflammation from one mucous
membrane to another in different individuals, is unfounded."


Mackenzie, however, devotes considerable space to the discussion of gonorrhceal ophthalmia from metastasis, though
1. To scrub the intestines of a series of normal dogs and  
nothing could be better than his statement that writers had
study the condition of the abdominal cavity at varying lengths
adopted these views " with too little hesitation and appear not
of time after the operation, in order to determine the results of  
to have sufficiently investigated the probability of the ophthalmia arising rather from inoculation than from metastasis."
the mechanical irritation.  
He goes on to enumerate " the causes of the suppression of the
gonorrhcea, to which the rise of metastatic gonorrhct-al ophthalmia is attributed," and cites an illustrative case from a French
writer. It is evident that ilackenzie had little confidence in
the existence of this form of gonorrhceal ophthalmia.  


A third form of gonorrhceal ophthalmia without inoculation
2. To determine how long it takes a perforative peritonitis
or metastasis is described : "an alternation has been observed
to destroy life.  
between the two diseases; that is to say, when the gonorrhcea
came, the ophthalmia went, and vice versa." Mackenzie says that
the cases reported "show the diversity which exists in opinions
entertained regarding the ophthalmiaj which in some individuals are found to attend gonorrha'a, or to alternate with this
disease"; and that "it is quite evident that the ophthalmia?
which have been observed to do so are far from being uniform,"
that some are probably ophthalmia tarsi, others catarrhal
ophthalmia. What is most important is his statement that '■ it
may fairly be doubted whether there is any connexion between
diseases of urethra and that of the eye, farther than that they
occurred in the same iudividtials, while the occurrence of both
might be attributed to a susceptibility for disease arising from
peculiar or debilitated constitutions." We are somewhat surprised to see this statement followed by such a one as this,
that "Swediar's hint to employ the bougie in cases of ophthalmia alternating with gonorrhcva may probably be found of
use; it is evident, however, that this remedy cannot be trusted
alone, but that the ophthalmia must be treated according to


3. To perforate the intestines of a series of dogs, and after
varying lengths of time to operate upon them again, closing
in the perforation and cleansing the abdominal cavity and the
surface of the intestine and mesentery, and after variable
periods of time to kill the dogs which recovered, and study the
condition of the abdominal cavity.




August-September, 1897.]


1. To perforate the intestines of a series of dogs, and after
varying lengths of time to close in these perforations without
removing from the abdominal cavity any of the exudate or
foreign matter present, and to study the results of this operaation.


The dogs used in these experiments varied in weight
between 18 and 53 pounds, most of them weighing about 25
pounds.


JOHNS HOPKINS HOSPITAL BULLETIN.  
For the first group of experiments four dogs were used. By
 
a median incision the abdomiiuxl cavity was opened, the intestine and parietal peritoneum were vigorously scrubbed with
gauze sponges wrung out in warm normal salt solution, and
kept covered with warm towels. After this treatment numerous minute hemorrhages caused by the scrubbing were noticed
over the peritoneal surfaces, and the intestine presented an
extremely congested appearance. It was then thoroughly irrigated with warm normal salt solution, which had a marked
effect in reducing the congestion. The intestine was then
replaced in the abdominal cavity and the wound closed. The
process of scrubbing as performed by the operator and an
assistant required from 8 to 12 minutes. In every case the
dog appeared ill for about 24 hours after the operation, after




193


144


[No. 76.


the particular symptoms it presents, not according to tlie conjectural notions entertained regarding its origin."
Concerning Egyptian ophthalmia jMackenzie says:


"I think it probable that the ophthalmia which attacked the
British anil the French armies in Egj'pt was an atmospheric
puro-mucous conjunctivitis [described at another place as "excited by exposure to atmospheric alternations "], but that it afterwards degenerated into a contagious, perhaps infectious disease;
that is to say, that it was propagated by actual contact of the discharge, and perhaps by miasmata from the eyes floating through
the air."


Mackenzie's views may fairly be taken as the most advanced
which a marked improvement in the condition was noticeable.
of this period and will serve as the proper point from which to
Usually by the end of the second day the animal seemed quite
view the investigations of Piringer.  
well.  


It should be mentioned here that many subsequent writers
Of these four dogs one was killed by an accident one day
held on tenaciously to these and older views for many years
after the operation. Autopsy showed a very small amount of
after Piringer's discovery had been made.  
blood-tinged serum in the abdominal cavity. The surface of
the intestine and parietal peritoneum presented numerous
hemorrhagic areas caused by the scrubbing at the time of
operation. The surface of the intestine was roughened,
though not adherent. Cultures from the abdominal cavity
were sterile.  


We may first direct our attention to Piringer's experiments
A second dog was killed at the end of three days. At
in curing pannns by producing acute purulent ophthalmia.
autopsy no appreciable amount of fluid was found in the  
This method, we are told, was first suggested by Friederich
abdominal cavity. Numerous fibrinous adhesions of the coils
Jiiger* some time during the second decade of this century, but
of intestine to each other, to the inner surface of the abdominal wound and to the omentum were found. The surface of  
little or no attention had been given it before Piringer's experiments were made. He tried the metliod in more than sixty
the intestine was slightly roughened and presented numerous
cases, using the pus of various kinds and stages of purulent
hemorrhagic areas. Similar areas were also seen upon the
ophthalmia of bo(h adult and new-born. All of his cases were
mesentery near its attachment to the intestine and upon the
improved and not one was injured by the treatment. In the  
parietal peritoneum. These were likewise caused by the  
great majority of cases the cure was complete, so that no sign
scrubbing at the time of operation. Cultures from the abdominal cavity were sterile.  
of the former disease could be discovered, and permanent. He
therefore recommends this method of curing paunus in these
words: "After so many highly successful experiments and observations, the inoculation of tlie blennorrhoea for the cure of
pannus is no longer a doubtful measure which requires great
courage, but an excellent method (ein grossartiges llittel)."
This method remained in use for many years and is still being
applied in a modified manner. The modification consists in the  
use of jequirity to produce a purulent ophthalmia instead of
blennorrhceic matter.  


It was in the study of this method of treatment that Piringer
A third dog which was in excellent health and condition
made his investigations as to the nature of blennorrhceaand the  
was autopsied at the end of five weeks. No appreciable
contagious property of the secretion. For this purjjose his experiments were varied inevery conceivable manner. Most of the  
amount of fluid was found in the abdominal cavity. The
experiments were made upon eyes which were already diseased,  
appearance of the organs was everywhere normal except for
but these were controlled by other experiments upon amaurotic
numerous adhesions of coils of the intestine to each other, to
eyes with perfectly healthy conjunctiva, or by the accidental
the omentum, to the inner surface of the abdominal wound
infection of normal eyes.  
and to the stomach. These adhesions were of a firm character,
being apparently composed of fully developed connective
tissue. Cultures from the abdominal cavity were sterile. The
fourth dog is still alive and will be autopsied later. From
this group of experiments we conclude that mere mechanical
irritation may cause the formation of extensive adhesions in
the abdominal cavity of the dog, but these seem in no way to
seriously interfere with the animal's general health.  


After describing the various forms of purulent inflammation of the conjunctiva he takes up the causes. Under this
For the second group of experiments four dogs were used.
head he discusses the question as to the production of gonorrhoeal ophthalmia by metastasis. In the course of fifteen years
Because of its accessibility and the comparative ease with
he had never seen a case of suppression of a gonorrhoea with an
which the perforation could be closed, it was decided to perforate the CEBCum. By the use of a stick of caustic potash a
outbreak at another point, excepting in the neighboring tissues.  
perforation IJ cm. in diameter was made in the end of the
caBcum, after which it was replaced in the abdominal cavity
and the abdominal wound closed. These dogs showed symptoms of a severe peritonitis and died in from 12 to 20 hours
from the time the perforation was produced. Autopsy showed
practically the same pathological condition in each case. From
150 to 250 cc. of a turbid bloody fluid were found in the abdominal cavity. The surface of the intestine presented a  
marked hemorrhagic condition, both diffuse and petechial in
character. The omentum, mesentery and parietal peritoneum
presented a similar appearance. Flakes of reddish yellow
lymph were deposited over the surface of the viscera, particularly in the region of the liver, diaphragm and lesser omentum.
Slight fibrinous adhesions between the coils of intestine were
noted. The mucosa of the intestine presented more or less of
a hemorrhagic appearance, and in some of the cases bloody
contents were found in the lumen of the gut. In short, the
pathological condition was one of an intense hemorrhagic






* In Hirsch's History of Ophthalmology, p. 441, we read thatLudwig reported the successful use of this method at the hands of a
peritonitis associated with a more or less extensive hemorrhagic enteritis. The bacteriology of each of these cases was carefully worked out and will be referred to later.  
friend, probably Friederich Jiiger.  


Wharton Jones (in a manual on Ophth. Med. and Surg, published
For the third group of experiments twelve dogs were used.
in 1847) states that Dr. Henry Walker was the first to suggest the  
The method of operation was as follows: An incision was
method (Edinburgh Medical and Surgical Recorder) in 1811. I am
made on the right side just outside the rectus muscle, the
unable to verify this citation.  
cajcum brought out and perforated in the same manner as
practiced in the experiments already described. The cajcum
was then replaced in the abdominal cavity and the abdominal
wound closed. From five to seven hours after the perforation
was produced these dogs were again opened by an incision in
the median abdominal line. The perforated end of the
crecum was brought out and the perforation closed by means
of a row of mattress sutures, after the necrotic tissue at the
seat of the opening had been resected. The abdominal cavity
was then opened, and the intestines being lifted out, were kejit
carefully covered with towels wet in warm normal salt solution. With gauze sponges wrung out in this solution the
surface of the intestine and mesentery was carefully wiped
till it appeared macroscopically clean. The abdominal cavity
was next wiped out and rendered macroscopically clean, the
intestine in the meantime being frequently irrigated with
warm salt solution and kept covered with warm towels. After
another thorough irrigation of the intestine with the warm
salt solution it was replaced in the abdominal cavity and the
wound closed in the usual manner. We cannot emphasize
too strongl}', in doing these experiments, the advisability of
thorough and constant irrigation of the intestine while it is
outside the abdominal cavity, for in every case it seemed to  
reduce the congestion and in some cases the distension. The
cleansing process required from 10 to 20 minutes according
to the amount of exudate and foreign matter present.  


Of these 12 dogs one was operated on at 5 hours after the
perforation was produced, one at 5J hours, one at 5J hours,
one at 6 hours, two at 6J hours, three at 6J hours, one at Gi
hours, one at 7 hours, and one at 7} hours.


In every case the dog showed marked symptoms of peritonitis and evidences of pain. When lying down the legs were
drawn toward the abdomen, which was held very tense. Any
attemjjt to straighten out the legs seemed to cause great pain.
In some cases the dog vomited a somewhat bile-stained fluid.
In every case the abdominal cavity at the time of the second
operation contained from 100 to 250 cc. of a turbid bloody
fluid. The intestine, mesentery and omentum in nine of these
cases presented a generalized hemorrhagic condition. In the
remaining three cases this condition seemed more confined
to the coils of intestine in the region of the ctecum, though all
the peritoneal surfaces seemed more injected than normally.
In nine of the cases more or less numerous flakes of yellowish
red lymjih were found adherent to the gut, mesentery, greater
and lesser omentum and other abdominal viscera. In eight
of the cases the intestines seemed more or less distended when
replaced in the abdominal cavity. Immediately after the
cleansing of the surface of the intestine and the abdominal
cavity the animals seemed to be much more comfortable, and
in the Ciise of every dog which recovered there was a jirogressive improvement in the condition.


Many physicians of great practice had likewise never seen true
In no instance did a dog which recovered show signs of  
metatastic gonorrhcsal ophthalmia. He denies the occurrence
of such a form of disease, and characterizes it as a very pretty
fable which one after the other has been telling in the best of
faith. Gonorrhceal ophthalmia is always due to the transference of infectious material directly into the conjunctiva!
 
In a similar manner he disproves the existence of a consensual form of gonorrhceal ophthalmia, supposed to be due to a
sympathetic connection between the affected parts.
 
Gonorrhceal ophthalmia is known to be more common
toward the end of the primary affection than during the period
of its greatest virulence. He explains this very properly on
the ground that Avhen the discharge is great much care is used
in cleansing the fingers. It is after the discharge has become
scant that patients become careless. The right eye is usually
the one first affected, because most patients are right-handed.


Ilis experiments proved that the generally accepted view
that the transference to the eye of gonorrhceal pus results in a
simple conjunctivitis or a mild purulent ophthalmia, and only
rarely in a severe inflammation, is false. On the contrary, he
asserts that the result is always a purulent ophthalmia of a
severe degree. The only exception occurs in those cases in
■which early treatment is successfully applied.


The contagious character of the secretion of ophthalmia neonatorum had been looked upon as ridiculous ;* when .Tuengken
stated that a ni;rse had developed severe i)urulent ophthalmia
during the night of the same day when she had infected them
with a sponge that had been used to cleanse the eyes of an
infant with ophthalmia, it was laughed at. No one can deny
the infection in his own cases, because the material was carried
across the street into another house and yet the result was
always the same.


His experiments on the production of purulent ophthalmia
JvhY, 1897.]
embrace almost one hundred eyes, and this does not include a
number of accidental infections which were observed with the
same care. The matter with which infection was produced
was obtained from eyes afl'ected with different forms of purulent ophthalmia as well as from genital blennorrhcea. All ages
and both sexes were found to be equally predisposed.  


One of the most interesting chapters is the one on the character of the blennorrhceic contagion. Though the pus from the
145
conjunctiva causes infection when applied to the eyes of human
beings, he was unable to produce any result when he applied it
to the eyes of such animals as dogs, cats, hogs, and various
birds. Others had claimed that they had produced effects in
such cases. Our jiresent knowledge of the immunity of animals to gonorrhcea shows that Piringer was not deceived.


The granulation from which the pus is secreted carries the
contagious property with it, as was shown in 1833 by Werwick,
who experimented upon two nurses. Piringer never made
any experiments w'ith granulations because it lacked any practical bearing.




pain after the cleansing operation was performed, and usually
in from two to three days the dog seemed to have recovered
completely from the peritonitis, so far as external symptoms
would indicate. Of course the abdominal wound made at the
second operation was infected, and this in nearly every case
failed to heal by first intention, which delayed somewhat the
complete recovery of the animal. Of the 12 dogs thus treated
three died without any apparent beneficial effect of the operation, death ensuing within 20 hours from the time the perforation was produced. These three dogs were operated upon
64, 7 and 7} hours respectively after the perforation was
produced. A fourth dog operated upon GJ hours after the
perforation died 30 hours later; the operation apparently prolonged its life about 20 hours. In three of these cases the
peritonitis was the most severe we met with in our experimentation, and the dogs in a weak condition at the time of operation, which was done comparatively late in the disease. In
each of these four cases the intense hemorrhagic peritonitis
described under the second group of experiments was found
at autopsy.


*The faith with which this opinion has been held can be measured by the much-quoted citation of Dr. Vetch, referreil to above.  
The remaining eight dogs were apparently cured of the peritonitis. Of these eight, one died from the protrusion of the
Piringer likewise ciuotes Adams, who rubbed his eyes with a finger
intestine, due to the breaking down of the abdominal wound
smeared with purulent matter without producing ill results, as did
on the fifth day after the operation. In a second case death
Van Sevenoeck and Kriebel. Morburgo smeared the eyes of 300
resulted on the eighth day from a localized peritonitis due to
soldiers without effect.  
the extension of the suppurative process from the abdominal
wall. A third dog which appeared quite well 2i days after
the operation died rather suddenly on the fourth day from a
perforation in another portion of the intestine which had come
into contact with the caustic potash upon the end of the perforated ca3cnm at the time the first perforation was produced.
A fourth dog appeared quite well at the end of twelve days
after the operation, having an excellent appetite and seeming
very lively. On the 13th day the dog seemed sick, and gradually grew worse till its death, on the 17th day after the perforation was produced. At autopsy small abscesses were found
extending along each stitch in the abdominal wall down to
the inner surface of the wound, where the intestines and
omentum were adherent. No distinct sinus leading into the
abdominal cavity could be demonstrated. The abdominal
cavity contained about 100 cc. of yellow pus, collected for the
most part in the pelvis and also extending up toward
the diaphragm. The coils of intestine and omentum were
firmly adherent in a mass in the upper part of the abdominal
cavity. The intestine was also adherent to the liver and gall
bladder. The parietal and visceral peritoneum were intensely
hemorrhagic in places. No apparent walling off of the pus
existed. An extension of the suppurative process along the
stitches was supposed to have been the source of the infectious material. A fifth dog also apparently made a complete
recovery, both wounds healing with the exception of a small
sinus in one of them. This dog seemed quite well for nearly
three weeks, when it became ill and died three weeks and two
days from the time it was operated upon. At autopsy the
abdominal cavity presented a perfectly normal appearance,  
with the exception of numerous adhesions of coils of the intestine to each other, to the omentum, liver and parietal peritoneum. These adhesions were not very firm in character. The






194
sinus mentioned above was found to lead to an abscess cavity
about the size of a hen's egg, situated in the pelvis to the right
of the uterus. This abscess was completely shuf off from the
rest of the abdominal cavity and was the undoubted cause of
death.


All of these dogs which died as a result of the suppurative process following the operation would probably have
recovered could they have been subjected to the same treatment human beings would receive in a similar condition, for
it must be remembered that it is practically impossible to drain
or treat suppurating wounds in dogs. A sixth dog, apparently
in the best of health and condition, was killed and autopsied
four weeks after operation. Both wounds had healed with
the exception of a small sinus leading to a stitch abscess,
which, however, did not penetrate the abdominal wall. On
examining the abdominal cavity the only abnormalities noted
were seven or eight slight, loose adhesions between coils of the
intestine, three or four loose adhesions of the omentum to the
intestine, and some rather firm adhesions of intestine to the
inner surface of the abdominal wound over an area 3x6 cm.
The condition of the viscera seemed everywhere normal. All
of the adhesions, except perhaps those uniting the intestine to
the inner surface of the abdominal wound, were of such a
slender character that they would in all probability have disappeared entirely in a few months. The remaining two
animals are apparently perfectly well, one of them being a
bitch which was in a moderately advanced state of pregnancy
when operated upon. Cultures and cover-slips were made from
the exudate in each case of peritonitis. The bacteriology was
carefully worked out and will be referred to later. From
this group of experiments we conclude that up to 6 hours
after perforation the generalized peritonitis in dogs can be
cured by this operation in practically every case. The prognosis of operation upon these animals at 6i hours after perforation is exceedingly favorable, but from that time on rapidly
becomes less favorable.


For the fourth group of experiments six dogs were used.
The method of procedure in this group was to perforate the
cfficum in the usual manner. From 6 to 6i hours later the
abdominal cavity was again opened, the cfficum brought out
and the perforation closed in the way before described. After
the replacement of the ca3cuni the abdominal cavity was
closed without in any way attempting to cleanse it. At the
second operation four of these dogs presented a generalized
peritonitis with the characteristics before described, though
in no case did the condition seem as bad as in the cases of
two dogs in Group 3 cured by the cleansing of the surface of
the intestine and the abdominal cavity. Of these four dogs
one died about 20 hours after the perforation was produced.
The other three failed to rally after the second operation, as
the dogs in Group 3 did, and appeared ill till their death two to
three and one-half days from the time the intestine was perforated. Autopsy upon two of these animals showed an
intense hemorrhagic peritonitis, while in the case of the third
the intestine and omentum were closely adherent in a mass,
which when pulled apart disclosed numerous pockets of pus,
presenting the condition of multiple abscess formation. The
remaining two dogs of this series presented only a localized


JOHNS HOPKINS HOSPITAL BULLETIN.




146


[Nos. 77-78.  
[No. 76.  






The pure lachrymal fluid of a blennorrhoeic eye was found not
peritonitis. Tliere was not more than half as much of the
to possess conhigioiis properties. An experiment is related in  
turbid bloody fluid in the abdominal cavity as found in the
which lachrymal fluid collected upon a canielliair brush did
other four cases, and only those coils of intestine in the
not produce infection, while the purulent secretion gathered a
vicinity of the ca3cum presented a hemorrhagic appearance.
few days later did.  
These were the most favorable cases we met with in all
our experimentation. These two dogs are still alive, though
their recovery has been slow.  


The question of contagion far distance (per miasma) was
In connection with the last two cases it is interesting to
studied in his hospital, where numerous blennorrhceic patients were placed beside those unaffected, in small wards.  
note that in two of the cases of Group 3 some exudate had
He was able to prove definitely that such contagion does not  
collected in the abdominal cavity between the time the intestine was replaced and the abdominal wound closed, thus making it evident that the abdominal cavity possessed the power
occur and that the cases in which it is suspected can always be
of caring for a considerable amount of the exudate. The
traced to direct infection.
bacteriology of this group of experiments was also carefully
worked out and will be referred to along with the reports of
the other cases of peritonitis.
 
This group of experiments seems to demonstrate that the
mere closure of the perforation, though it may in some cases
prolong life slightly, is not sufficient to cure a case of generalized peritonitis in dogs, and makes it very evident that
without a careful cleansing of the surface of the intestines
and the abdominal cavity recovery in such cases will be
exceedingly rare. It must be borne in mind that the length
of time which had elapsed since the perforation was produced and the condition of the abdomiual cavity would have
afforded a most favorable prognosis in these cases had the
cleansing operation been performed.
 
Cultures were made from the 4 cases of Group 2, 13
cases of Group 3, and 6 cases of Group 4. In one case of
Group 3 the cultures failed to grow, although cover-slips


The vapor of drying secretion has no power of infection.
Even those secretions which are perfectly serous leave a residue
when evaporated, and it is this which still retains the contagious {)roperties.
The fluid secretion when kept for three or four days, even
without evaporation, is no longer contagious.


If a finger is covered with blennorrhceic secretion and washed
immediately in clear fresh water and well dried, it will cause
no infection if rubbed over the conjunctiva.


Blennorrhoeic matter may be smeared over the eyelids if the  
showed a few cocci and bacilli. Also in one case of Group 4,
palpebral fissure is kept firmly closed by adhesive plaster, and  
in which the peritonitis was not yet generalized, the cultures
no infection will occur. In order to produce infection the  
were negative. In the twenty cases in which bacteria developed in the cultures, from one to three species of microorganisms were found in each case. Members of the colon
secretion must reach the conjunctiva.  
group were found 18 times, 4 times alone and 14 times in
association. Streptococcus pyogenes was found 8 times, once
alone and 7 times in association. Staphylococcus albus was
found 5 times, in each case in association. Staphylococcus
aureus was found 4 times, once alone and 3 times in association,
and staphylococcus citreus was found 4 times, in each case in
association. Cultures were also made from the heart blood at
several of the autopsies, but in each case were sterile. Coverslips from the exudate in the abdominal cavity were examined
in each case and more or less numerous bacteria were seen.
An abundance of leucocytes was found in nearly every coverslip. The bacteria in general were outside the cells.  


The secretion of acute blennorrhoea of a moderate degree is
From our experimental work we feel justified in stating the  
just as contagious as that of the most severe. Such pus is
following conclusions :
capable of producing infection even when diluted with 50 or
100 parts of water. The pus of a very mild purulent ophthalmia and of chronic ophthalmia has much less power of infection.


As long as there is any secretion in any case of purulent
1. That mere mechanical irritation of the peritoneal surfaces will lead to the formation of adhesions.  
ophthalmia, whether mild or severe, so long the case is contagious. Wiien the secretion ceases, tiiough there maybe considerable congestion and photophobia, the infectious properties are
lost.  


The properties of infection inherent in the secretion do not
3. That peritonitis in dogs caused by a perforation of the  
vary in different seasons of the year nor under changed atmospheric condition, whether exposed to the glare of the sun or to
intestine is of an intensely hemorrhagic character, and if left
the cold of the winter. Experiments .to determine this may
to itself rapidly proves fatal.  
appear meaningless to us, but we must not forget the opinions
prevalent in Piringer's time.  


Numerous experiments were made to determine the effect
3. That generalized peritonitis of this character, in dogs,
upon the contagious properties of the pus when separated for
can be cured as late as 6* hours after the perforation, by the  
varying intervals of time from the human body. Thus the
cleansing operation introduced by Dr. Finney.  
secretion was collected upon a camel-hair brush and allowed to
become as dry as possible (" dry as glass ") in from three to six
hours. If then applied to the conjunctival sac, but not allowed
to soften in the tears, no infection occurred ; if softened in the  
tears, or previously in water, infection was sure to occur.  


In seven cases the secretion which had been allowed to dry
4. That mere closure of the perforation without this cleansing operation will rarely, if ever, cure a case of generalized
for thirty-six or forty hours in the open air had lost all contagious property, but in two in which the secretion had been
peritonitis in dogs.  
allowed to get dry thirty- three or thirty-four hours in the room
and was then softened it produced very severe ophthalmia blennorrhcea. Piecesof linen smeared with fresh blennorrhceic matter
and given to a pannus patient to wipe his eyes produced infection, but if the cloth had been dried in the air for several days,
the patient could use it about the eyes witiiout harm, and the






secretion when scraped off" the cloth and inserted into the conjunctival sac produced infection only when it was less than
SQUAMOUS EPITHELIOMA AND EPITHELIAL HYPERPLASIA IN SINUSES AND BONE
thirty-six hours old. On the other hand, if the secretion was
placed in a vaccine case and hermetically sealed it retained its
contagious property for forty-eight hours, but lost it entirely
when kept for three days. The pus fioma case of ophthalmia
neonatorum produced infection when kept in this way for two
and a half days. Piringer therefore concludes that "?/Ze««orrJiieic pus loses its contagious properties as it hecornes older, and
(jraduaUy dies in from twenty-six to forty -eight hours, jjossessing
no more organic life token three days have passed." It is upon
the discovery of this fact that Piringer bases important rules of
prophylaxis, and explains the relative infrccjnency of gonorrhoeal ojDhthalmia among the common people.


Piringer studied carefully the length of time intervening
FOLLOWING OSTEOMYELITIS.  
between the entrance of the infectious material and the first
signs of the developing disease, the period of incubation. This
he found to vary according to the manner and the amount of
the infection, as well as according to the individual peculiarity
of the patient. The higher the degree of inflammation, the
more rapidly did its pus infect. Thus the pus from a very
severe ophthalmia produced infection in from six to twelve
hours, or at most in thirty-six hours ; while that of very mild
blennorrhoea might rec|uire sixty to seventy hours, and that of a
case of chronic blennorrhcea seventy-two to ninety-six hours.  


The secretion of the second stage of acute ophthalmia acts
more slowly than that of the first; thus the pus from a case of
very acute blenuorrhrea in which the secretion was markedly
diminishing may take sixty hours to produce the first symptoms.


If the secretion while still warm is immediately transferred
from an acute blennorrhcea, but six or eight hours are required
for the first signs to show themselves, and in twelve or eighteen
hours the disease is fully developed. In this respect the conjunctiva responds more rapidly than the genital mucous membrane. The longer the secretion is kept before it is placed in
the conjunctiva, the less rapidly does it act. The rapidity likewise varies with the amount of secretion brought into the eye.


Piringer gave the prophylaxis of gonorrheal ophthalmia his
By S. M. Cone, M. D., Assisfcmt in Surgical Pathology, The Johns Hopkins University.  
careful attention and the results were very important. Can
tiie inflammation be aborted after the infectious material has
once reached the conjunctiva? Several cases in which the
very early and continued application of ice comitresses produces
this effect are described. In order to determine whether the
infectious material can be removed and the outbreak of the
disease prevented, several series of experiments were made.  
The method which required the application of very strong
solutions of bichloride of mercury, concentrated acetic acid,
etc., appeared to him too severe, and in the few cases in which
it was tried the desired result was not obtained.  


On the otiier hand he found that washing out the eye with
water after the contagious material had been inserted prevented the development of the disease, provided that it is done
sufficiently early. These experiments were made on three
patients. In the first case he touched the eye with a large
quantity of matter from a newborn babe, cleaned it out after a
minute with a sponge dipped in cold water, and had cold water
apiilicatioMs made for ten hours. No inflammation resulted.




In view of the interest manifested in the pathology of bone,
the two cases about to be reported seem to be of value. They are
striking examples of malignant and benign epithelial growth
into old sinuses and medulla of bone.


August-September, 1897.]
Case I. — John H., colored, set. 45, laborer, was admitted
to Dr. Halsted's wards, January 2, 1897.  


Patient gives a history of injury to bis left tibia 19 years
ago, with subsequent formation of a sinus and discharge of
sequestra. One month before entering the hospital the
patient began to feel pain in the leg, and the odor of the discharge became foul. No sequestra have come away for eight
months. There is pulsation of discharging material synchronous with the radial pulse.


Upon Jan. 4, Dr. Bloodgood excised the sinus aud chiseled
and curetted the bone. The bone was fractured 10 cm. below
the knee, where the cavity was largest. The operator's note
estimates the cavity communicating with the sinus as 3 cm.
deep, 2 to 3 cm. wide, aud 14 cm. long. The diagnosis,
squamous epithelioma, being confirmed, and the growth


JOHNS HOPKINS HOSPITAL BULLETIN.




recurring withiu two weeks, the leg was amputated above
the knee, and glands of the groin excised by Dr. Finney on
Jan. 29th. On Feb. 25th patient was discharged, the wounds
having healed per primam.


195
Pathological rejmrt of the first operation. — Tiie specimen
consists of the skin, sinus, eburnated bone, and soft material
filling the cavity in the bone. The edges of the sinus are
dense and pearly in appearance. The skin within i cni. of the
sinus edge has lost its dark pigmentation. The bone next to
the soft central mass is soft and crumbly, but outside of this
is eburnated. It appears directly continuous with the skin
at the orifice of the sinus. The sinus is lined by the same
papillary growth that fills the cavity in the bone, and this
same growth projects between the periosteum and eburnated
bone, indenting it, causiug a jagged appearance. The medullary cavity is filled with a soft, necrotic-looking material, made
up of soft yellowish white masses, aud with white papillary
granular projections from a rather dense translucent pink
ground substance looking like granulation tissue. The papil




July, 1897.]


Four days later he varied the experiment by allowing the
147
matter to remain two minutes and again no inflammation
occurred. After another interval of four days the experiment
was again repeated, the pus remaining in the eye for three
minutes and the result was again the same. After another
interval of 6ve days pus was inserted and allowed to remain in
the eye for live minutes; no cold applications were made; the
result was a violent inflammation. This patient had pannus,
which was cured by the treatment.


In order to try tiiese experiments upon a perfectly normal
conjunctiva he selected the eyes of an amaurotic beggar whom
he paid for these privileges. In this case he found that no disease resulted if the blennorrhoeic matter was washed out within
three minutes after its entrance into the conjunctival sac and
cold water applied. In three minutes any one who has accidentally infected his eyes can obtain fresh water with which
to wash them !


In order to determine whether the washing out of the conjunctival sac would accomplish the same result without the
use of ice applications, he infected the eye of a girl suffering
with pannus with blennorrhoeic matter and washed out the
conjunctiva in three minutes. Ninety hours later a severe
ophthalmia developed. And in a second case the experiment
again resulted in the development of a purulent ophthalmia,
but not until the fifth day, and in this case the ophthalmia
was of a milder character. For these reasons he considers the
cold water application as essential to the prevention of conjunctival blennorrhci'a after infection has occurred. Many
other questions are considered by Piringer, but this review
embraces the essential points, and will, I trust, suffice to show
its importance.


The care, the true scientific spirit, the accuracy of observation and experiment, the unbiased search for truth, form
lary projectious average 2 mm. diameter, aud are of varying
marked characteristics of I'iringer's work. And yet he is so
length up to 4 mm. The growth within the cavity erodes the
modest as not to claim that his results are "the absolute
bone, leaving small spicules and granules in the soft necrotic
truth," though they are his own firm convictions; experiments and observations, he tells us, by other physicians at
mass. In places the dense bone has become granular and  
other times and places, made with care and without prejudice.  
crumbles readily. There is no sequestrum nor cancellous bone.
The periosteum is very much thickened aud not to be well
differentiated from the subcutaneous tissue; it is invaded by  
the epithelial growth. The microscopical description of the
original sections is the same as of the recurrent growth, so
they will be included together.  


The leg and lower third of the thigh removed at the second
operation present no abnormal appearance outside of the
gajiing granulating wound in the tibia, the seat of an osteotomy performed January ith. The wound, measuring 16s
4x4 cm., is surrounded by edges of skin inverted over the
bone, which for the most part is covered by apparently healthy
granulations. Only at one place is the bone exposed ; this is
at the upper angle of the wound, where an edge of eburnated
bone is left uncovered. At the outer rim of the excavated
tibia, 4 cm. from the upper angle of the wound, is a projecting mass of papillary excrescences 4 cm. in diameter, whose
surface is covered by a dry blood-stained crust. Scraping the
up[)er layer away leaves the deeper papillae, pearly in appearance, closely aggregated and more or less intimately connected
with the velvety granulations about them. Some of these epithelial uests are so closely packed without any apparent stroma
that at first glance they give the appearance, on section, of a
cheesy mass. Careful observation shows this to be made up
of individual uests. This mass is at the seat of fracture
alluded to. Similar uests of cells are seen iu smaller discrete
masses over the whole surface in the granulations.


One area on the inner wall of the excavated tibia, 5 cm.
from the uf)per angle of the wound and 2 cm. from the fracture, can be made out as a mass sharply defined from the
surrounding granulations. The bone here seems excavated to
fit the growth which is eroding it. Spicules of bone project
into the growth between the epithelial plugs at the jjeriphery.
Between the ends of the fracture the new growth projects,
invading muscle and adjacent tissues. The ends of the bone
are rough, and the papillary masses are seen indenting the
ivory-like bone to a depth of 1 to 3 mm., giving it a wormeaten appearance ou removing the growth. The granulations,
2 to 4 mm. thick, covering the surface of the bone also groove
it and cause a rough and gnawed appearance.


are needed to confirm them as well as to clear away any errors.
The bone sawn through at several places is dense aud eburnated aud shows no evidence of tumor formation which is not
His experiments were arranged carefully and judiciously to
directly connected with the surface growth. The heads of  
determine the character and the attributes of the contagion,
femur, tibia aud fibula aud the astragalus are normal. The
the time during which it acted, the gradual diminution of its
tibia and fibula are anchylosed by bony union at the interosseous ligament. No tumor can be traced from the bone along
powers to the point when they were entirely lost, the intensity
the vessels. The muscles and soft parts, except at the seat of  
of the contagion, and the degrees of dilution which could be
fracture and ulcer edge, appear normal. The cartilage of the
borne without loss of all contagious properties. Many of these
patella is softened, that over the outer head of the femur is
questions were given their final solution by Piringer. He
depressed and soft. The synovial membrane is hemorrhagic
separated the fluid portions of the pus which could be evaporated, from the more solid matter which contained the contagious quality. He proved that the unknown cause of contagion
where it envelops the crucial ligaments at their insertion
was a something which had to be transferred in substance
into the head of the tibia.  
from one mucous membrane to the other, and which never
acted at a distance, thus disproving the old miasmatic principles which were still current in those days.  


In what is our knowledge today greater than that of
The popliteal aud inguinal glands are firm, eularged and  
Piringer, excepting that the active agent, the living microorganism, the gonococcus, has been discovered, a discovery
harder than normal, but do not show any areas of metastasis.  
only made in 1879 ? That it was a living organism even
Piringer surmised, for, as we read above, he speaks of it as
"growing older," and "dying," and "possessing organic life."
Let us not forget when it was that Piringer worked. Though
micro-organisms had been discovered toward the end of the
seventeenth century, and micro-organisms were assigned as the
causes of numerous diseases during the eighteenth century, it
was not until 1840 that Henle first established the germ theory
of disease upon the solid foundation of logic and fact.  


One aspect of Piringer's experiments still deserves mention.
Others had likewise made experiments with a view of transferring the disease which we have been considering; but most
of these were unsystematic, few in number, and led only to
confusion. Piringer's work was such as to give a definite
solution to important questions, results which have stood the
tests of time. His work was not in vain. His hopes were
fulfilled that "the medical world would read not entirely without pleasure a number of results, whose collection in the field
of practice had been made at the cost of much strain, great
pains and many a sleepless night."




Microscopical Description.


PROCEEDINGS OF SOCIETIES
Tumor iiivading musde at the seat of fracture. The tumor
mass is sharply circumscribed. At that part nearest the
invaded tissue the tumor is made up of single cells and small
masses of cells in a fine reticulum; this passes, further away,
into small non-cornified, non-cystic masses of cells, theu larger
alveoli with cornified epithelium in the centre of the stratum
mucosum layers. Furthest away from the muscle and nearest
the periphery of the tumor mass are seen cystic dilatations
with anastomosing alveoli lined by a few layers of columnar
cells and containing scales of cornified epithelium aud fatty
detritus. The invaded fibrous tissue shows no change. The
muscle fibres are granular and fragmented ; the fragments and
individual fibres contain many nuclei, giving the appearance
of elongated giant cells. The vessel walls show round cell
infiltration. There are newly formed capillaries among the
degenerating fibres. There is evidence of endothelial proliferation in the capillaries.


Tumor mass and ski7i, the mass projecting betiveen the fractured ends of the tiiia. Where skiu and tumor pass over into
one another the regular papills of the skin cease, as does the
deep pigmentation. The pigment is no longer seen between
the stratum mucosum cells as in the skin, aud is much less
developed in the stratum granulosum and deepest columnar
epithelium of the Malpighean layer.


It looks as if the stratum mucosum aud granulosum were
continuous with like layers of cells lining the stroma of the
tumor, keeping on over the tortuous papillary bulgings and
corresponding depressions of the tumor mass. Similarly can
the stratum corneum be followed, but it changes its appearance over the tumor, becoming less compact and scattered in
flakes on the surface, or loosely filling cystic cavities along
with cellular detritus, or it may be lacking on some of the
plugs.


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.  
In the cornified layers over the tumor are masses of brown
granular pigment containing crystals of hsematoidin. The
tumor growth is divided by deep grooves caused by keratinizing and fatty degeneration of epithelial down-growths.
This causes the follicular appearance described macroscopically.  


Meeting of May 3, 1897.  
Papillse, or stroma strands, better named, push the epithelium up into bulging papillary masses. These stroma strands
vary in size, as do the corresponding cyliuders and plugs of  
epithelium lining them. The plugs aud cylinders anastomose
freely at the surface. One cyst thus caused measures 1 X ^
cm. aud is made up of numerous small plugs containing
keratinized epithelium and detritus around the margin. The
contents must have fallen out in great part. The surface is
covered with epithelial cells, polymorpho-nuclear leucocytes,
and keratinized epithelium iu a mass of coagulation necrosis.  


Dr. Thayer in the Chair.  
The stroma varies in different parts, from edematous young
granulation tissue with stellate, epithelioid aud giant cells at
the surface under the coagulation necrosis, to a very cellular
fibrous tissue, with numerous capillaries aud spindle-shaped
long nuclei deeper down. In places the stroma is homogeneous aud stains pink with eosin, like hyaline. There are areas
of round cell infiltration in the stronui. The included plugs


Haeniatoniyelia from (xunshot Wonnd of tlie Cervical Spine.—
Dr. CiisniNG.


This patient, a young woman of 27 years, was brought into
Prof. Ilalsted's service, November Gth, 1896, with the hiotory
of having been shot twice in the neck a few hours before
entrance. Our chief interest centres in the injury produced
by the missile, whose wound of enti-ance is situated here on
the right side of the neck at the level of the cricoid cartilage.
These skiagraphs show the point of lodgment of the bullet in
the centrum of the sixth cervical vertebra.


The case illustrates some unusual features of one type of
148


[No. 76.




the so-called Brown-Seqnard paralysis; the value of the
X-rays in locating the offending missile; a practical recovery
without operative interference; a residuum of symptoms
resembling those of syringomyelia.


At entrance she was suffering from agonizing " pains " of a
and cylinders of epiLhelinm comprise all the epidermis layers
" pins and needles " character, especially in the arms, so
arranged in the same order as in the skin — a cylindrical or
severe she would cry out when they were touched. No radiating pains, such as are described iu the meningeal form of
cuboidal layer next to the stroma, then polyhedral cells of  
hemorrhage, were present. There had been no loss of consciousness. Motor paralysis was complete on the right side
the stratuna mucosum showing prickles most distinctly with
below the level of Thorburn's "5th root group." On the left
Van Gieseu's stain, then two or three layers of spindle cells
there was a brachial monoplegia up to this same segmental
with pigment which takes the hEematoxyliu stain — the stratum
level, namely that for the deltoid biceps and supinator longus
granulosum. The outermost layer lining or filling the Ciivity
muscles whose ventral horn ganglion cells lie in the 5th
of the plugs or cylinders is of loose keratinized epithelium,
cervical segment, as you may see by comparison with this
sometimes arranged compactly,  


Where the centres are cystic we find besides the keratinized
epithelial flakes, fat cells, cells which have undergone fatty
degeneration, leucocytes and salts, granular and deeply stained
with bajmatosylin. Cell multiplication is very active, as evidenced by the many divided and dividing nuclei ; 2 to 5
nuclei are contained in some cells, connected as if budding.


Tnto the basal layer of these cylinders there may be
ingrowths of papilla?, explaining an unusual appearance,
namely, a mass of fibres and connective tissue cells cut
across in the centre of one of the above described plugs of
epithelial cells. In the deepest part of the invading tumor
the cylinders become very small, even narrowed to single cells
separated by the same cellular stroma. Anastomosis is very
free, many branches spreading throughout a loose stroma.
The arteries included in the section show marked endarteritis
and round cell infiltration of the adventitia also.


196
In staining the sections the Van Giesen method was found
valuable in staining the stroma and the prickle cells. The
keratinized cells stain yellow, the young stroma stains dull
red. Gram's stain used for keratohyalin by Ernst' shows it
well, staining these cells deep blue.


Sections of the pink granulations over the surface of the
bone show granulation tissue without evidence of tumor.


The lymph glands of the popliteal space and groin show
fatty atrophy and connective tissue formation, thickened capsules and endothelial hyperplasia. There are no metastases.


JOHNS HOPKINS HOSPITAL BULLETIN.  
The popliteal artery and vein with surrounding tissue show
no evidence of tumor growth about them. They are united
by dense fibrous tissue. There is evidence of endarteritis.
 
The synovial membrane described as hemorrhagic shows
round cell infiltration and vessels filled with blood, which also
suffuses the surrounding tissue.
 
The bone cut across near the knee shows no microscopic
evidence of carcinoma; it appears normal.  


Section of fragments of hone with tumor and granulations
mixed in an irregular friable mass. The tumor alveoli and
stroma are as described above. Adjoining whorls are seen to
become conglomerate, mixing together their contents of
keratinized epithelium and fatty necrotic substances and
bounding this by their several epidermis layers. Secondary
papilla; project into the primary alveoli, giving a complicated
appearance on section. In the proximity of the bone the
cellular stroma is strewn with giant cells with centrally
massed large oval vesicular nuclei containing big nucleoli.
These are osteoclasts, for wherever the bone is seen undergoing absorption it is lacunar in nature and the Howship's
lacunae contain osteoclasts to fit them. The tumor cells do
not come in direct contact with the bone, being separated by
stroma and osteoclasts.




[Nos. 77-78.


The bone is very dense, with narrow compact lamella; containing few corpuscles, and these are small and far apart.
The Haversian canals are filled with cellular connective
tissue, vessels, old bone fragments looking as if shelled off,
and osteoclasts in lacunaj. Branching canaliculi are distinctly seen. There is new formation of bone going on. The
new lamellse are arranged at an angle to the old ones, they
take the eosin stain deejier and are lined by osteoblasts,
cuboidal and spindle-shaped. There is a granular line stained
with hsematoxylin between old and new bone.


Section of hone zvith invading tumor at the seat of fracture.
The lamellae are narrow and closely packed and enclose bone
corpuscles at rather wide intervals. Some of the corpuscles
nearest the invading tumor are enlarged and the cells are
deeply stained. The Haversian canals are irregular in contour, of various sizes, and filled with granular detritus and
fragments of bone. About their rim there is lacunar absorption, the grooves being small. The bone, where invaded, is
being absorbed by the osteoclasts, for in every Howship"s
lacuna can be seen a giant cell such as Kolliker' describes,
or large osteoblasts which here take on the function of osteoclasts and are such.


familiar table of Starr's. Respiration was purely diaphragmatic.  
These osteoclasts vary in size and shape, each fitting exactly
a groove in the bone hollowed out to fit the absorbing agent.
Some of the cells are seen completely surrounded by bone,
others have only one-third of their body enclosed by the
lacuna. The shape varies from oval, round, oblong, large
cells to elongated flat cells lining quite a large part of the
bone surface, looking almost as if one of the outer lamellae
had broken off abruptly and taken in many large nuclei. The
size varies from an osteoblast to cells five or six times as big.  


On the left side, uji to the second intercostal space and
The nuclei are either massed in the centre or arranged
down the ulnar side of the arm over an area which corresponds,  
around the perijihery ; they are large, round or oval, and vesicular. The protoplasm of these osteoclasts is granular and  
as these diagrams taken from Starr and Kocher demonstrate,
stains deeply with eosin, especially at the centre. The edge
to the cutaneous sensory fields of the eighth cervical and first
of the cell next the bone is rough ; the other borders of some
dorsal segments, there existed anassthesia to pain and thermic
cells seem of double contour and quite smooth.  
stimuli, aud a slight dulling of tactile or pressure sensibility.  
A segmental zone of similar anaesthesia was present on the  
side of motor paralysis across the chest aud including most of  
the right arm.  


There was a marked elevation of surface temperature, cousiderable hyperalgesia, and also a diminution of reflex activity
No foreign bodies were detected in any of these bodies next
on the paralyzed side. Loss of sphincteric control over the
the bone, yet some of the giant cells near by included epithelial debris.  
contents of the bladder aud rectum was also jjresent.  


liestitution from these paralytic symptoms has taken place
The protoplasm of some osteoclasts is drawn out like a  
up to the excellent conditiou in which you see the patient at
pseudopod and pushes in between the connective tissue cells.  
present. The motor paralysis disapjjeared gradually. On the
Where granulations seem to fill the lacuna? one finds osteoclasts between them and the bone wall.  
tenth day, motion, as is usual, was first observed in a slight
flexion of the thigh. Turner in his experimental work called
attention to this. At the present time there remains evidence
of the degeneration of the right j)yramidal tract iu Wernicke's
residuary paralysis of the dorsal flexors of the foot, giving the
late hemiplegic character to the jjatient's gait. Mann has
recently called attention to this residuum of motor paralysis
aud has shown that it selects a certain muscle unit (bewegung
einheit), this unit being that which lifts and shortens the leg
in the first stage of walking, as can be demonstrated in
this patient. Paralysis remains alone complete in some of
the small muscles of the right hand, representing destruction
of ganglion cells at the site of the lesion. There is au exaggeration of all the deep reflexes of both extremities. Myotatic
contractions, as you see, are elicited iu the muscles of the right
arm by gentle blows on the tendons. Resolution of the sensory disturbances has been less complete. Slight anEesthesia
to painful aud especially thermic stimuli persists on the
left.  


A month ago there was present a peculiar distribution of  
There is evidence of new bone formation. To the characteristics of newly deposited bone already mentioned can be
areas of hyperesthesia, over which cold produced paiu without thermic sense, and the threshold for pain was so low to
added the closer approxinuitiou of bone cells — there being
touch or pressure stimuli that the latter could only be elicited
more of them than in the older adjacent bone. The medullary
with difficulty by v. Frey's assthesiometer. This is illustrated
spaces between the cancel li of bone are filled with newly
by these diagrams.  
formed fibrous tissue and granulation tissue containing giant
cells and all the cells usually found in embryonal tissue.
There are also numerous capilhmes and larger vessels in the
spaces. The bone cells vary in size and appearance, as do the
bone corpuscles, some being round and spindle-shaped, others
stellate. They can be best studied in the newly deposited
bone or in bone undergoing absorption. It would seem as if
when about to be freed from their imprisonment they take ou
active functions again and are stained more readily.  


The lesion was presumably due, as in Mann's case, to an
intramedullary hemorrhage, the occurrence of which, especially in the cervical enlargement, as emphasized by Thorburn, is not uncommon. It seems that not only is traumatic
hajmatomyelia much more common here than elsewhere in the
cord, but that there is a certain level iu this enlargement giving symptoms corresponding to the "typus inferior" of
Krause, iu which intramedullary hemorrhage is most likely
to occur. This list of cases, collected from the literature,
tends to confirm this view of a site of predilection in the lower
cervical enlargement for hajmatomyelia, and illustrates the
fact that not only in cases attributable to acute flexions of the
neck does it occur, as was believed by Thorburn, but also iu
those due to a great variety of traumatic causes. The hemorrhage also is apt to occur most extensively on one side of the




July, 1897.]


cord, thus often producing the symptom complex of a Brown
149
Sequard type of paralysis.


That the hemorrhage also in these cases selects by preference the gray matter of the cord, presumably from the greater
vascularity aud less support given to the vessels there, is well
recognized. Frequent note has also been made of cavity formation at the original nidus of hemorrhage, which is interesting iu consideration of the association of the syndrome of
syringomyelia which Minor and others have pointed out to be
a common sequence of traumatic ha'matomyelia and which
persists in this patient.


The case which Maun has recently reported in full with
post-mortem examination of the cord, in the Dent. Zeit. f.
Nervenheil. for 1896, and which clinically bears such close
similarity to this case, illustrates many of these points very
completely.


Dr. Thomas. — This case seems to me to be one of particular
As in other sections of bone, no tumor cells come in direct
interest, aud the Society is to be congratulated on having it so
contact with the bone. The tumor advances as described  
admirably presented. Those of you who have had the opportunity of examining a similar case will recognize the difficulty of making such au exhaustive examination. I know of
above. There are small fragments of bone in the granulations, which look as if they had been eaten off and left.  
no case in the hospital records that has been worked up so
There is a deposit of new bone in the vicinity of the tumor
carefully as this. Dr. Gushing was kind enough to bring the
and evidence of absorption going on in the same microscopic
patient to me ou several occasions for examination, and I confirmed the results which he had already obtained. The  
field.  
patient's condition, after she had been in the hospital for some
time, was, as Dr. Gushing has described to you, briefly as follows : there was weakness of the right leg and right arm. The
muscles of the right arm were atrophied, aud there were sensory
disturbances, as shown in the charts. The wound in the
right side of the neck was in such a position that the bullet
might have injured the brachial plexus before entering the
spinal columu, and thus have produced the condition found
in the right arm. An electrical examination of tlie paralysed
and atrophied muscles showed that they responded normally
to the currents. This was believed to indicate that the brachial plexus was not injured, aud also that the paralysis was
not due to destruction of the anterior horns from which the
nerves forming this plexus arise. I do not believe that there
can be extensive destruction of the anterior horns without the
occurrence of degenerative atrophy of those muscles which
receive their nerves from that segment of the cord. In the case
of Maun, to which Dr. Gushing has referred, there was paralysis and atrophy of the muscles of the left arm. This was
completely recovered from, but, at the autopsy, a lesion iu corresponding anterior horn was found. This case is, as far as I
know, the only one bearing on this poiut, and it does not seem to
me to be conclusive. The lesion was limited to the eighth cervical segment, as shown by the fact that the eighth root was degenerated, while the seventh was not, and the first thoracic root
was only slightly so. We know that each muscle is represented
in more than one spinal segment, and it can be understood how
a limited lesion in one segment need not necessarily produce
degenerative atrophy to such a degree that it could be discovered during life. The autopsy on Mann's case was incomplete,
in that neither the muscles nor the peripheral nerves were
examined.  


Dr. Cushing's case is of interest from so many standpoints
Case II.— W. J. R., white, a3t. 5i, admitted June 26, '95.


For 49 years the patient has had discharging sinuses in the
thigh communicating with necrotic bone.


Operation, June 28th, by Dr. Bloodgood. Amputation of
thigh at the upper third. Notes made at the operation refer
to the great friability of the bone, the thickened periosteum,
thin shaft and presence of a sequestrum.


August-September, 1897.]
Nov. '96. Patient reports himself well.  


The pathological report is as follows : The diseased condition of the bone begins 26 cm. above the condyles and involves
the shaft for 16 cm. The last jjiece of bone removed, 3 cm.
below the trochanter, appetu'S healthy. The periosteum is
thickened, the shaft, stripped of periosteum, is rough and
presents minute spicules. The shaft varies in thickness from
3 to 6 mm., and there is very little cancellous bone. It is
brittle, fracturing easily. The medulla above seat of disease
contains much fat and oily material. At the seat of disease
there is no involucrum. In the sinus leading from the
diseased bone there is a sequestrum 6 cm. long and li cm.
wide. The periosteum about the necrotic portion is 5 to 6
mm. thick, and on section is peai'ly white and appears
striated at right angles to the long axis of the bone. On the
surface nest to the shaft it is covered with a yellow necrotic
friable tissue covering a leathery surface. Fine spicules of
bone are imbedded in this. The odor is foul. The surface of
the shaft is rough and hard. The medullary cavity is filled
with hard bone mixed with thick leathery tissue, and is riddled with small cavities containing the same material as
covers the shaft. The only attemjit at new bone formation is
in the medullary cavity. No attempt at formation of healthy
granulations is evident. About the area of disease the shaft
exhibits exostoses 1 to 1^ cm. in length. The knee joint is
normal in appearance.
Microscojiical examination of the tissue between the periosteum and bone described as striated and friable with necrotic
border next to the shaft, shows it to be made up in the main
of large swollen polygonal cells with oval vesicular nuclei.
The arrangement is such as one sees in the stratum mucosum
of the skin. There are papillas jirojecting into the mass from
the periosteum, which is thickened and infiltrated with small
round cells. The cells next the papilla} are prickle cells;
those nearer the shaft do not show the prickles. The cells
arc massed in varying density. According to the location of
the papilla} we get lighter and darker stained masses, the
darker being more comjiact and approaching the cancroid
pearl in appearance, but there is no cornified nor degenerated
centre. Toward the bone the cells are flat and the nuclei lose
the ability to stain. A thin layer of cornification covers their
surface. Many of the nuclei are vacuolated. The papilla are
very cellular. There is an absence of the stratum granulosum
and lucidum ; simply a uniform growth of the mucosum


JOHNS HOPKINS HOSPITAL BULLETIN.
197




that it is impossible to discuss it fully. Unilateral lesions
and corneum. There is considerable endo- and periarteritis.  
of the cord are not very common. In the dispensary we
The muscle and connective tissue show no tumor invasion.  
have the records of only two typical cases. I have at present
The leathery material described in the medulla is like that  
under observation a very beautiful example of this form of
just described.  
paralysis. The patient is a woman whose right leg is paralysed and who shows the disturbances of sensation in the left
leg which Mann has pointed out as characteristic, i. e.  
the sensory conduction for touch is undisturbed, whereas
pain, heat and cold stimuli do not produce their normal effect.  
The paths of sensory conduction within the cord have been
and are the subject of much discussion. Of late the anatomists and physiologists have been inclined to the view that the
paths do not cross, but remain on the same side of the cord
until they reach the medulla. Clinicians, on the other hand,
from the study of the cases of unilateral lesion of the spinal
cord, have held to the belief that the sensory jiaths decussate
soon after entering the spinal cord. That there must be an
anatomical basis for the constant occurrence of the classical
symptoms of Brown-Sequard's paralysis seems to me to be
self-evident. The burden of jiroof must rest ujiou the anatomists and physiologists.  


Examination of the cortical bone from the shaft shows no
tumor growth into it. The dense bone presents a feathery
appearance commonly seen in eburnated bone. The edges
show lacunar absorption.


A number of cases of squamous epithelioma developing in
sinuses antl old scars which would come under the grouping
I have purj)osely omitted, since the pathological description of
the tumor is in every case essentially the same as in Case I.
Two of the cases might be considered carcinoma developing
in osteomyelitic sinuses, but the history does not fully substantiate this. In these cases the sinuses were lined by the
tubules and plugs of epithelial cells continuous with the
tumor mass in the bone itself. The invasion of the bone
resembled that described in Case I.


NOTES ON NEW BOOKS.  
The cases reported bring to mind several most interesting
subjects in pathological histology: the development of carcinoma in sinuses, scars and ulcers, its invasion of bone, the
peculiar character of epithelial growth, and the bone formation and absorption due to the invading tumor. They are
interesting especially because they show side by side the
picture of a typical squamous epithelioma and a mere enormous hyperplasia of the epithelial elements of the stratum
mucosum in bone. The one is evidently quite malignant; the
other does not appear to be very destructive in its growth, but
merely a filling in of the space made void by the osteomyelitic
process. The two tumors have their homologues in the
epithelial growths in sinuses, ulcers and scars, some being
typical epitheliomata, others simply hyperplastic growths of
epithelium lining the sinus walls.  


Diseases of the Rectum, Anus and Contiguous Textures. By S. G.  
There is this point to be noted in Case II differing from
Gant, M. D. (Philadelphia : F. A. Davis, 1896.)
any yet described — the great development of the cells of the  
stratum mucosum to the exclusion of the granulosnm and  
lucidum. There is simply a single layer of cuboidal cells
covering the papilte, then 10 to 15 layers of large swollen
polygonal cells covered by a thin layer of cornified epithelium.  
This not only fills the sinus and medullary cavity, but pushes
in between the periosteum and the shaft, nowhere penetrating
the bone itself. It may be compared in a way with a case of
great epithelial cell hyperplasia of the outermost layers of
the epidermis described by Busch'" in a case of lupus. Here
there was an epithelial papillary growth covered by thickened,
horny epithelium spread over the surface, finally breaking
into the connective tissue and forming carcinoma.  


With the exception of two chapters on Cancer of the Rectum and  
Typical squamous epitheliomata in scars, ulcers and sinuses
Colotomy by Allingliam, a recognized authority on these subjects,
are not uncommon. There are only twenty-eight cases
the worls of Dr. Gant is not to be commended. The booli contains
reported in which the epithelioma developed in the sinus following osteomyelitis. From the histories of many cases  
nothing new, and there are many superior works on this subject.
of epithelioma in ulcers I infer that a few if more accurately
The two cliapters in which the author seems to talce special pride,
described would come under the heading of carcinoma in  
one on auto-infection, tlie other on effects of railroading on diseases
sinuses following osteomyelitis. Some give a history of  
of the rectum, are not remarkable, and the first is unsatisfactory.
osteomyelitis. See Van Hook,' Schindler,' Boegchold." Borchers' iu 1891 collected all the cases up to his time, numbering
That employes of railroads suffer much from constipation and hemorrhoids as a result of their occupation may be true, but the figures
twenty-five. He records cases of Konig, Dittrich,'" Nicoladoni," Esmarch,'' Fischer," Bartens, Coruil and Kanvier,'
he gives can be handled in many ways. If we eliminate from the
author's statistics all cases suffering from these two very common
conditions, we have less than 1 per cent, out of over 170,000 cases
seen in various hospitals suffering from other diseases of the rectum
and anus; and 5.7 per cent, in the same number of cases does not
seem to us an excessive number to be suffering from the two conditions mentioned. We believe that among the poor laboring class
constipation is the usual condition found, and that figures more
striking than these could easily be collected to show that constipation was one of the commonest symptoms in all hospital cases. We
question whether the jarring of a railroad train will continually
rock a stomach from side to side, produce a "sea-sick stomach," or
whether it is suiEcient to bring about by itself dilatation of the veins
about the anus and rectum by causing a venous stasis, and we know
that swelling of the feet in railroad travelers is not an ordinary
condition, to say the least. The chapter on sodomy might better
have been omitted or much abbreviated ; such a book does not call
for a psychological explanation of this practice. In speaking of the  
relation of pulmonary tuberculosis to fistula, the author states :
"So we meet with two kinds of tubercular fistula — one as a result
of localized tubercular ulceration with or without any lung complication ; the other a fistula in persons who have lung trouble, due to
the absorption of fat about the iscliia, general debility, and abscess.
In the feces of the first variety can be found the tubercle bacilli of
Koch, while in the second variety they cannot be found unless the
sputum containing them has been swallowed, and gastric digestion
has been impaired to such an e.Ntent as not to destroy them or their
spores." In either form the fistula is tubercular and the bacilli






can be found without these coming from the sputum ; and gastric
150
digestion, even when normal, does not ordinarily destroy them, as
we know from the large number of cases of primary intestinal
tuberculosis which occur. We do not think that the following
statements as regards auto-infection are true. On p. 271 we read :
" Our Creator, however, foresaw all dangers and provided us abundantly with safeguards with which we can destroy or neutralize
the poisons on the one hand, or throw them off on the other, as
soon as they are formed"; and on p. 272, "Just so long, however, as
the emunctories are working in harmony and perform their individual functions, and there is no lesion of the intestinal mucosa, all
is well, and all poisons, no matter whether theyare the products of
decomposition or of bacterial action, will do noharm, forthe reason
that they are thrown into a special reservoir (the liver) where they
are destroyed or neutralized and afterward discharged from the
body."


The colored illustrations in this work are hideous and unnatural,
[No. 76.  
and the woodcuts are not models of artistic excellence. Would it
not be well for authors to cease to reproduce cuts of the most common and onlinary instruments, and of well-known positions and
procedures in operations, which are quite valueless (cf. cuts on pp.
20, 21, 22, 25, 218,219, 220). Wedislike extremely to see theauthor's
autograph on the outside cover, and the long list of societies to
which he belongs following his name on the title-page. If the
book possesses merit of its own, this sort of cheap advertisement
does it no good ; and it does not help the work in any case.  






BOOKS RECEIVED.  
Winiwarter," Hauuover"^ and Volkmauu." Another case is
recorded by Feigel.' One of Van Hook's' two cases was
undoubtedly carcinoma developed in an old fistula communicating with necrotic bone. Von Friedlander's" three cases,
reported in 1894:, are the last recorded. All of the cases
described have many points in common with our first case.  


Second CtUalogne of the Library of the Peabody Institute of the City of  
Clinically, the development of the disease in those beyond
Baltimore. Including theadditions made sinceI882. Parts I-II.
40 years of age, the common involvement of the lower
A— D. 1890-97. 4to. Baltimore.  
extremities, the uncertainty of fixing the exact time of development, its slow growth, the foul odor, the long existence of  
the fistulaj, the absence of pain until the carcinoma begins to
develop, the ease with which the bone is broken, the fixation
of the neighboring joints and ankylosis of adjoining bones,
the infrequent involvement of lymphatic glands or other
organs, and its almost sure recurrence unless the limb be
amputated, are all most noteworthy points.  


The Semi-Centennial of Anmsthesia. October 16, 1846-October 16
Volkmann" says that recurrence occurs in a few weeks or
1896. 4to, 95 pages. 1897. Massachusetts General Hospital,
months after the operation, if at all; if not Avithin 1 to Ih
Boston.  
years, it seldom occurs.  


Saint Bartholomeio' s Hospital Reports. Edited by S. West, M. D., and  
The pathological picture is not to be confused with any
W. J. Walsham, F. R. C. S. 1896. Vol. XXXII. 8vo, 518 '+ 197
known disease of bone or sinus. The crater-like ulcer or
pages. 1897. Smith, Elder & C >., London.  
cauliflower excrescences made up of individual oval yellowish
white masses, are enough to make the diagnosis. Finding the
same papillary growths in the medullary cavity is not calculated to make one think of simple osteomyelitis. The bone
next the tumor is either soft and spongy or denser than normal
bone. It is increased in circumference and the medullary
canal may be smaller than normal. Osteophytes may form
on the surface and the bone may rarely present the appearance
of spina ventosa. Fracture is common.  


Transactions of the American Pediatric Society. Eighth session
The microscopical picture is that of squamous epithelioma
held in Montreal, Canada, May 25, 26 and 27, 1896. Edited by  
modified in appearance according to the amount of degeneration and bone absorption and the greater or less development
Floyd M. Crandall, M. D. Vol. VIII. 1896. 8vo, 243 pages.  
of tubules, alveoli or cysts. The tumor cells nowhere come in
Reprinted from the Archives of Pediatrics. New York.  
direct contact with the bone, being separated by connective
tissue and giant cells or osteoblasts. The thickness of the
growth varies, but it is thickest in the cloaca, and in places
looking like granulation tissue. The sequestra in Nicoladoni's"
cases were not invaded by epithelial cells.  


Medical and Surpical Reports of the Boston City Hospital. Eighth
Borchers' refers to the advance of the tumor into the
Series. Edited by G. B. Shattuck, M. D , W. T. Councilman,  
Haversian canals. Our cases do not substantiate this, the
M. D., and H. L. Burrell, M. D. 1897. 8vo, 391 pages. Published by the Trustees, Boston.  
epithelial cells never being found separate from the main
growth.  


King's College Hospital Rejiorts. Being the annual report of King's
In none of the cases were metastases found in the internal
College Hospital and the medical department of King's College.
organs and rarely even in the lymph glands. The swollen
Edited by N. Tirard, M. D., F. R. C. P., et al. Vol. III. (Oct. 1st,
glands usually became of normal size after amputation of the
1895-Sept. 30th, 1896.) 8vo. 1897. 332 pp. Printed by Adlard
limb. The reason of the infrequent metastases is found in
& Son, London.  
the sclerosis and condensation of tissues about the tumor and
its very slow growth.  


Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America. Edited by T. L. Stedman, M. D. In twenty volumes. Vol.  
Thinking of the etiology and histogenesis of the tumors,
XI: Diseases of the Nervous System. 8vo. 1897. 962 pp.
one would naturally class those described with tumors developing in ulcers, fistulas and old scars. Many theories have
William Wood &, Co., New York.
been advanced to explain them: Virchow's" idea of chronic
irritation, mechanical and chemical, being most naturally first
alluded to. The question whether the connective tissue
growth or epithelial proliferation be the primary factor
has been most actively debated since Ribbert" so strongly
advocated the former view. Boegehold,* who reported several


Burdett's Hospitals and Charities, 1897. Being the year-book of philanthropy. By Henry C. Burdett. 12mo. 1897. 1018 pages.
The Scientific Press, London.


Archives of Skiagraphy. Edited by Sydney Rowland, B. A., Camb.
Fol. Vol. I, No. 4. April, 1897. The Rebman PublishingCo.,
Limited, London.


A Pictorial Atlas of Skin Diseases and Syphilitic Affections in PhotoLithochromes from Models in the Museum of the Saint Louis Hospital,  
cases like my first one, believes in their connective tissue origin,  
Paris. With explanatory woodcuts and text by E. Besnier, A.  
and says that the epithelium is lost over scars and ulcers. He
Fournier et al. Edited and annotated by J. J. Pringle, M.B.,  
says : " If the surface epithelium cannot cover over the granulation surface, one cannot see why it shall grow into the
F. R. C. P. Part X, 1897. W. B. Saunders, Philadelphia.  
depths of the granulation tissue."


Langeubeck,''" in discussing the development of carcinoma
in lupus, expresses the view that the cause of development is
like that in traumatic scars, a continuoiis irritation and the
carcinoma develops from remaining epithelial cells. It is
distinct from the lupus growth. "It is difficult to reconcile
the notion of lupus — a granulation tissue — passing directly
into carcinoma, because of our view that epithelioma must
come from pre-existing epithelial cells."


AVenk,"' who believes in this direct transition, concedes that
the epidermis projections have not been entirely destroyed.
Langenbeck"" attributes its formation to development of epithelium in the outlying scar. Schindler'' cites cases to prove
the development from the scars — either from the covering
epithelium or glandular organs of the skin left intact by the
lupus process. He answers Boegehold's* argument cited
above, by explaining that the surface epithelium is prevented
from spreading superficially by continual irritation (pressure or secretion) and therefore it dips down deeply where
not exposed to these influences. Hulke,'"' in describing two
cases of carcinoma in old scars, ascribes them to purely
local causes. Pedraglia^^ refers to old age and periodic irritation as predisposing causes. This view that old age influences the growth corresponds with that of Verneuil
referred to by Marcuse:" "Ein locus minoris resistentiae"
of the connective tissues, the epithelium retaining and
increasing its activity. Marcuse uses this theory in explaining the growths in the granulations covering ulcers — the
granulation tissue, when not going on to scar formation, being
not so resistant to epithelial hyperplasia as normal tissues.
Here the epithelium grows into the tissues as stated by
Thiersch'"' in his most valuable contribution to the etiology
of epithelioma of the skin.


198
It is not much disputed now that epithelium only forms
from preformed epithelium and not from leucocytes or connective tissue cells. This materially aids the histogenetic
study of these tumors. Whatever the cause, the practical
lessons obtained from them are of much value to the surgeon,
and one is not tempted to use tentative measures to stop a
growth which he knows by experience and microscopical
study to go steadily onward in its course until it is excised
radically.


1. Van Hook, W. : Carcinomas arising in Inveterate Ulcers
and in Ancient Sinuses. North Amer. Practit., Sept., 1890.


2. Schindler, J. : Beitrag zur Eutwicklung maligner Tunioren aus Narben. Inaugural Diss., Strassburg, 1885.


JOHNS HOPKINS HOSPITAL BULLETIN.  
3. Borchers, F. : Ueber das Carciuom welches sich in alten
Fistelgiingen der Haut entwickelt. Inaug. Diss., Giittiugeu,
1891.  


4. Boegehold : Ueber die Eutstehung maligner Tumoreu aus
Narben. Virchow's Arch., No. 88, p. 229.


5. Feigel, L.: Ein Fall von primiirem Ki-ebs der Tibia.
I'rzeglad lekarski, Nos. 3G and 37, 1891.


[Nos. 77-78.




July, 1897.]


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.
151






THE JOHNS HOPKINS HOSPITAL REPORTS.  
6. Cornil andKauvier: Journal de rAiiatoiiiie, 1SGIJ-G7, p.  
Volume I. 423 pages, 99 plates.  
277.  


Reiiort in Patbologry.  
7. Erust, P. : Sfcudien iiber normale Verhornniig mit Hilfe
der Gramscher Methode. Arch. f. mik. Aiiat. und Eutwickluugsgeschichte, Bd. 47, p. 669, 1896.  


The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
8. KoUiker: Die normale Kesorptiou des Kuocheiigewebes.
Leipzig, 1873.


Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
9. Ribbert: Miinchuer Med. Wocheusch., 1894, No. 17;  
Vircbow's Arcb., Bd. 135.


Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D.  
10. Dittrich : Prager Vierteljahresschrift, 1847, II.  
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis


(Atrophy). By Henry J. Berklev, M. D.  
11. Nicoladoni: Arch. f. klin. Cbir., No. 26, 1881.  
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.  


MiLL, M. D.  
12. Esmarcb: Langeubeck's Arch., XXII.  


Report in Derniatolos-y.  
13. Fischer, S.: Zeitschr. f. Chir., 1881.  
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By


T. C. Gilchrist, M. U., and Emmet Rixford, M. D.
14. Winiwarter: Beitriige ziir Statistik des Carcinoms.  
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of
Stuttgart, 1878.  


Protozoa, and the Blastomyces found in the preceding Cases, with the so-called
15. Volkmann, Rud. : ITeber das primilre Krebs der Extremitiiteu. Volkmann's Sammlung klin. Vortrage, 1889.


Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum
16. Hauuover : Das Epitheliom. Leipsic, 1855-56.  


Fihrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duliring). By


T. C. Gilchrist, M. D.


Report in Patliology.  
17. V. Friedlander: Beitrag zur Kenntnissder Carcinomentwickelung in Sequesterhohlen und Fisteln. Deutsche Zeitschr.  
An E.xperiniental Study of the Thyroid Gland of Dogs, with especial consideration
f. Chir., 1894.


of Hypertrophy of this Gland. By W. S. Halsted, M. D.  
18. Busch: Langenbeck's Archiv, XV, p. 48.  


19. Virchow : Die krankhafteu Gescbwiilste, Bd. II, p.
487.


20. Langenbeck: Berlin, klin. Wochenschr., 1879, p. 329.


Volume II. 570 pages, with 28 plates and figures.  
21. Wenk, L. H. : De exemplis nonnullis carciuomatia
epithelialis exorti in cicatrice post lupnm exedentem relicto.
Kiel, 1867. Reference from Schindler, see above.  


Report in Medicine.  
22. Hulke, J. W.: London Medical Times, Vol. 1, 1873,
p. 135.  


On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
23. Pedraglia: Vier Fiille von Epithelialkrebs anf alten
Narben. Giessen, 1853.


Gallstones. By William Osler, M. D.  
24. Marcuse, J.: Deutsche Zeitschr. f. Chirurgie, Bd. VII,  
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.
p. 550.  
On Pyrodin. By H. A. Lafleur, M. D.
Cases of Postfebrile Insanity. By William Osler, M. D.
Acute Tuberculosis in an Infant of Four Months. By Harry TonLUIN, M. D.
Rare Forms of Cardiac Thrombi. By William Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.  


Report in ftleilieine.  
25. Thiersch: Der Epithelialkrebs, uamentlich der Haut.  
Tubercular Peritonitis. By William Oslek, M. D.
Leipzig, 1865.  
A Case of Raynaud's Disease. By H. M. Thomas, M. D.  
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  


Report in Gynecology.
The Gynecological Operating Room. By Howard A. Kelly, M. D.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard


A. Kelly, M. D., and Hunter Robb, M. D.
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of


Abdominal Section. By Howard A. Kelly, M. D.
ON THE BLOOD-PRESSURE-RAISING CONSTITUENT OF THE SUPRARENAL CAPSULE.*
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,


M. D.  
By John J. Abel, M. D., and Albert C. Crawford, M. D.
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;


Ovarian Tumor; General Gynecological Operations from October 15, 1889, to
[From the Pharmacological Laboratory of the Johns Hopkins University .'[


March 4, 1890. By Howard A. Kelly, M. D.
Report of the Urinary Examination of Ninety-one Gj-nccological Cases. By Howaed


A. Kelly, M. D., and Albert A. Ghbiskey, M. D.
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (decking


Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.
Both clinical experience and laboratory research have
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.
shown that the suprarenal capsule is an organ of vital importance.  
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoraa of the Clitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of tlie Ureter through the Vagina, for the treatment


of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
Physiologistst have proved that a very small quantity of  
an aqueous extract of the medullary substance raises the
blood pressure to a great height above the normal. It has
also uuequaled power in reviving a poisoned heart. Gottlieb,J
for example, has shown that it will revive the heart of a rabbit which has practically stopped beating in consequence of
an intravenous injection of chloral hydrate.  


Howard A. Kelly, M. D.  
Bates§ applied an aqueous solution to the eye and found
that it exerted a marked vaso-constricting action. In numerous cases of congestion a small quantity dropped into the conjunctival sac brought about an immediate pallor, lasting for
some time. According to this writer the extract is very useful
in prolonged operations, for, when repeatedly applied, hajniorrhage is prevented and cocaine anfesthesia is in consequence
indefinitely prolonged. As the result of his two years' use of
the extract Bates concludes " that within the limits of its
sphere of activity there is absolutely no other substance which
can take its place."


Report in Snrgery, I.
Other experiments|| go to show that the aqueous extract is
The Treatment of Wounds with Especial Reference to the V.-ilue of the Ulocid Clul


in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in Neurology, I.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.
Ilaeniatomyelia. Bv August Hoch, M. D.
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By


Henky M. Thomas, M. D.


Report in Fntliology, I.
•Read before the Association of American Physicians, May 6,  
Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleue, M. D.  
1897.  


tSehiifer and Oliver, Journal of Physiology, xvi (1894) and
xvii (1895); Szymonowicz and Cybulski, Wien. med. WochenBchrift, 18'JG, No. 6.


JArch. f. exp. Pathol, u. Pharmakol., xxxviii, 106.


Volume III. 766 pages, with 69 plates and figures.  
§New York Medical Journal, Ixiii (189G), iiil .  


Report in PatUology.  
||Foa and Pellacani, cited in Maly's Jahresb. d. Thier-Chemie,
xiii, 129; M.arino-Zuco, ibid., xviii, 231 ; Gourfein, Rev. Med. de
la Suisse Romande, Oct. 20, 1895; Compt. rend., cxxi (1895), 311314.  


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




a powerful poison when injected directly into the circulation
and may lead to fatal results.


Tuberculoais of the Female Generative Organs. By J. Whitridge Williams, M. D.
The various extracts that have been used in these experiments were mixtures of unknown substances, and it is as yet
Report in Pjitliology.  
an unsolved question whether the various actions at present
ascribed to the gland are due to one and the same substance.  


Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Flexner, M. D.  
We are at present interested in the isolation of the bloodpressure-raising constituent, for in a purified state, separated
from all other constituents, it might become a therapeutic
agent of great importance.  


The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.  
On the chemical side but little advance has been made over
Vulpian's* striking original contribution more than forty
years ago. Vulpian observed that the juice expressed from
the suprarenal capsule of many different animals behaved in a
striking manner toward ferric chloride and toward solutions
of iodine, giving with the former reagent an emerald green
color, and with the latter a beautiful rose carmine tint. No
other tissue of the body, so far as investigated by Vulpian,  
gave these reactions.  


A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.  
Virchowt substantiated Vulpian's statements, but added
nothing new. A year after Vulpian's first announcement his
second paper appeared in conjunction with Cloez,J verifying
and extending his first observations and stating his failure to
isolate the chromogenic substance or substances to which the
above reactions are due.  


Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
Equally unsuccessful were Arnold§ and Ilolm.ji Kruken


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


Report in Gynecology.  
* Note sur quelqiies reactions propres i la substance des capsules
surrenales, Compt. rend., xliii (1856), 063-665.
■)■ Virchow'a Archiv, xii (1857), 481-483.
X Compt. rend., xlv (1857), 340-343.
§ Virchow's Archiv, xxxv (1866), 64-107.
II Journ. f. prakt. ('hemie, c (1867), 150.  


The Gynecological Operating Room; An External Direct Method of Measuring tlie
Conjugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Knterocele; 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 Retroflexcd Uterus. By Howard A.
Kelly, M. D.


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


Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavely, M. D.
152


[No. 7ri.




Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. D.


Tabulated by A. L. Stavely, M. D.  
berg,* years after, repeated the work of Arnold and came to
The Employment of an Artificial Retroposition of the Uterus in covering Extensive
the conclusion that the chromogeu of the suprarenal capsule
is a nou-volatile, nitrogenous and ferruginous organic acid
which is probably related to the tnracin of the musophagidai
and to chlorophyll. He assumed that the substance giving
the green color with ferric chloride is not the chromogenic
substance of Vulpian, but more likely pyrocatechiu accompanying the chromogen. Attention being thus attracted to the
possible occurrence of pyrocatechiu in the suprarenal capsule,
others took up the subject.


Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.  
Brunnerf found that an alcoholic extract cau be made to
Photography applied to Surgery. By A. S. Murray.  
give nearly all of the reactions of pyrocatechiu ; thus, it gives
Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howa&d
the well-known green color with ferric chloride, passing into
a fine red on the addition of ammonium tartrate and a few
drops of an alkali; it reduces silver nitrate at room temperature, and Fehliug's solution on boiling. The addition of an
alkali soon causes it to take on a dark brown color, lead acetate gives a precipitate, sodium nitroprusside and very dilute
ammonia give a wine-red color. All of the above reactions
being given also by pyrocatechiu, Brunuer concluded that
Krukenberg was right in his belief that pyrocatechiu is present in the suprarenal gland.  


A. Kelly, M. D.
After the discovery of the blood-pressure-raisiug property
Urinalysis in Gynecology. By W. W. Russell, M. D.
of the suprarenal gland, B. Moore,J working in Schilfer's
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gj-neco
laboratory, came to the conclusion that Vulpiau's chromogen
logical Conditions. By Hunter Robb, M. D.
and the blood-pressure-raising constituent are identical. He
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D,
based his ojjinion on the fact that chemical operations which
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.  
destroy the color reactions by oxidizing the reducing agent
appear also to destroy the blood-pressure-raising constituent.  
That the solubilities of the active principle are the same as
those of the reducing agent appears also to support this
opinion.  


By Howard A. Kelly, M. D., and Mary Sherwood, M. D.
Fraenkel§ worked with residues obtained with the help of
.\bdominal Operations performed in the Gynecological Department, from March 6,
alcohol and acetone as solvents. These residues raise the
blood pressure and do not contain pyrocatechiu, and on the
strength of the ferric chloride reaction and its reducing power
he concludes that the essential principle of the residue is a
nitrogenous derivative of the o?'</(odihydroxy-benzene series.  


1890, to December 17, 1892. By Howard A. Kelly, M. D.
According to Fraeukel both Krukenberg and Brunuer are
Record of Deatlis occurring in the Gynecological Department from June 6, 1890, to
wrong in their opinion that the suprarenal glaud contains
pyrocatechiu. Fraeukel concludes, like Moore, that the bloodpressure-raising constituent and Vulpiau's chromogen are one
and the same substance.


May 4, 1892.  
More recently still, Muhlmann|| has attempted to prove that
the blood-pressure-raisiug constituent is a pyrocatechiu derivative. He asserts that on boiling fresh suprarenal capsules
with dilute hydrochloric acid the active principle is decomposed and the pyrocatechiu which is split off may be taken up
with ether. Miihlmann has not, however, furnished conclusive chemical proofs for his assertion. Both Miihlmann and
Brunner might have settled this point by precipitating the
supposed pyrocatechiu with lead acetate and analyzing the
lead salt thus obtained. Pyrocatechiu may be preseut in






Volume IV. 504 pages, 33 charts and illustrations.  
* Virchow's Archiv, ci (1885), 542-591.  


Report on Typliold Fever.  
fSchweizer. Wochensclir. f. Ph.armacie, xxx (1892), 121-123.  


By William Osler, M. D., with additional papers by W. S. Thayer, M. D., and J.  
} Journal of Physiology, xvii (1895), Pron. Physiol. See, p. xiv.  
Hewetson, M. D.  


Report in Pfenrology,  
'i Wiener med. Blatter, 1896, No. 14-16.  
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of J/us musculu^; The Intrinsic Nerves of the Thyroid Gland of
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,  
M. D.  


Report in Surgery.  
II Deutsche med. Wochenschr., 1896, No. 26, 409-411.  
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to
January, 1891. By W. S. Halsted, M. D.  


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




small amounts in the gland, but no proof of this has yet been
furnished.


Volume V. 480 pages, with 32 charts and illustrations.  
There is therefore at present great diversity of opinion as
to the chemical character of the blood-pressure-raising constituent of the gland.  


CONTENTS:
Whatever the probability may be of the correctness of this
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.
or that view, it is to be noted that all of the above-named
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  
investigators have based their conclusions on reactions made
with aqueous, alcoholic or acetonic extracts ; none of them
have even roughly isolated a definite chemical comjiound.  
The subject is one of great diflBculty, and our own work is at
jjreseut merely preliminary, but we have arrived at the
following conclusions which we believe to be borne out by
our experiments.  


Studies in Typhoid Fever.
First, we have found by isolating the blood-pressure-raising
By William Osler, M. D., with additional papers by G. Blumer, SI. D., Simon
constituent in the form of a benzoyl compound and decomposing it, that the active principle is a substance with basic
Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, >I. D.  
characteristics and that it must in all probability be classed
with the pyrrol compounds or with the pyridine bases or
alkaloids.  


Second, that pyrocatechiu caunot be split off from the isolated active compound by boiling with acids, as has been
asserted.


Third, we have found that a carmiue-red pigment can be
separated from the sulphate of the active principle without
destroying its jiower to raise the blood pressure.


A'olume VI. 414 pajif.s, with 7') plates and figures.  
Fourth, iu addition to this, we have isolated from the crude
benzoyl product a volatile basic body which fumes iu the air
and which emits an odor very much like that of coniiue.
 
Method of Isolating the Active Principle in the
Form of a Benzoyl Compound.  


Report in Neurology.  
We have used sheep's glands in large quantity. The medullary substance of the fresh glands was scraped out, dried on
the water-bath at 60° 0., ground up finely, and extracted with
ether for several days until the fats and the substance known
as Manasse's jecorin were removed. In this way a fine dry
powder of a grayish white appearance is obtained, the aqueous
extract of which is very active in raising the blood pressure.  


studies on the Lesions produced by the Action of Certain Poisons on the Cortical
AVith 100 grammes or more of this powder, representing one
Nerve Cell (Studies Nos. 1 to V). By Henry J. Berkley, M. D.  
kg. in weight or about 1000 fresh glands, we proceeded as
follows:. The powder is repeatedly extracted with warm
water acidulated with a few drops of dilute sulphuric acid
until the gland has yielded up all of its chromogenic substances, as tested by Vulpian's reactions. This aqueous
extract is evajiorated on the water-bath to a small bulk, a
large excess of strong alcohol is then added and the whole
allowed to stand 24 hours, by which time the proteids have all
settled out. The alcoholic fluid is then filtered and the greater
part of the alcohol removed by distillation ; the remainder is
driven off on the water-bath. The entire removal of the alcohol is necessary, and in order to avoid too great concentration of the acid fluid, which seems to destroy some of the
active principle, water has now and then to be added. The
brownish fluid when filtered gives all the well-known reactions characteristic of Vulpian's chromogeu, and on neutralizing the sulplmric acid we found the filtrate to be physiologically very active.  


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


Report in Patliology.


Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.  
July, 1897.]


(3lTLLEN, M. B.
153
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of


Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. WiLSlNS, M. D.
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, JI. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By


William D. Booker, M. D.
Tlie Pathology of Toxalbumin Intoxications. By Simon Flexnkr, M. D.
Thr price of a .sit liuiiiid in cliith [Vul.i. I-VI] of tlir Ilospilnl Brportx is


$30.00. Voi.t. I, 11 niirl III iivr not sold stpiiratcli/. The price of
This filtered fluid is next treated with the proper quantity
Vols, ir, r and VI is $S.OO nirli.  
of benzoyl chloride and sodium hydrate according to the Baumauu-Schotten method of forming a benzoyl compound.  
There results a tarry substance of a light yellow color which
sticks to the sides of the separator funnel and which is collected
and washed until the wash fluid no longer gives an alkaline
reaction. It is next dissolved as far as possible in alcohol and
the alcohol evaporated. The residue is then treated with
ether, which takes up the greater part of it, the ethereal solution is filtered and the ether driven oft.  


The residue, which is of tarry consistence and amber color,
is taken up in strong alcohol from which all basic substances
have been removed by distilling from tartaric acid. It is then
boiled for two hours with animal charcoal previously well
washed with purified alcohol. After filtration and the evaporation of the alcohol a considerable quantity of crystalline
residue is obtained which is found to consist of the benzoyl
compound of the active principle contaminated with other benzoyl derivatives and which we may call the crude benzoyl product. It is insoluble in water, alkalies or acids of ordinary
strength, is soluble in alcohol, ether, glacial acetic acid and
concentrated sulphuric acid.


It is of interest in this connection to note that benzoyl
chloride effects the complete removal of the blood-pressureraisiug constituent from an aqueous solution. This is proved
by the fact that the filtrate from the insoluble benzoate no
longer gives the characteristic chemical reactions of the active
principle, and that chemical manipulations no longer yield a
blood-pressure-raising constituent. Indeed, an injection of a
sufficient amount of the material left after the sodium benzoate and the excess of alkali have been removed, causes a sharp
and sudden fall of pressure instead of a rise.


AIonogrnpliH.  
It was not until long after we had made use of benzoyl
chloride as a precipitant of the active jjrinciple that we obtained
access to Fraenkel's* pai)er. From it we learned that a syrupy
substance is thrown out when benzoyl chloride is shaken uj)
with a pyridine solution of an extract of the gland. Fraeukel
did not succeed in crystallizing this benzoyl conijjound, nor did
he attempt to decompose it in order to ascertain whether it was
in reality a benzoate of the blood-pressure-raising principle.  


The followini; papers arc reprinted from Vols. I, IV, V ami VI of the Keports. for thoee
Methods of Decomposing the Benzoyl Compound.  
who desire to purcliase in this form ;
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixkord,


M. D. 1 volume of 104 pages and 41 full-page plates. Price, bound in paper,
A quick method always used by us as a qualitative test is
as follows : The compound is dissolved in as little concentrated
sulphuric acid as possible, crushed ice is slowly added, and
the benzoic acid which has been split off is shaken out with
ether. On neutralizing the solution we found it to give the
reactions characteristic of aqueous solutions of the medullary
substance. We have not considered this method adapted to
the decomposition of large quantities of the product.  


?3.00.
Decomposition of this benzoyl product was effected by means
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.
of an alcoholic solution of sodium alcoholate, and also with
strong hydrochloric acid and alcohol, but these methods were
found to be less satisfactory in practice than the following,  
which is the method on which we now rely. The benzoyl
compound is dissolved in glacial acetic acid, the solution


Hewetson, M. D. And A STUDY OF SOME F.\TAL CASES OF MALARIA.


By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, 12.7.").
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481
*VVien. med. BliiUer, IS'Jti, No. 14-16.  


pages. Price, bound in paper, $3.00.
THE PATHllLdliY Ol' TO.XALIUMIN INTOXR'.VTIONS. Hy «m»n Flexner, M. U. 1


volume of 150 pages with 4 fuU-page lithographs. 1 rice, bounil in paper, $','.0(<.
Subscriptions for the above publications may be sent to


The Johns Hopkins Press, Baltihorx, Md.  
heated to near the boiling point, and an equal volume of a 25
per cent, solution of sulphuric acid actively boiling is slowly
poured into the hot acetic acid solution, the whole being
shaken meanwhile. The flask is now attached to a back-flow
condenser ami heated on a small flame for about ten minutes.  


The solution is next diluted with water and allowed to cool,
the benzoic acid, which has been thrown out, is filtered off
and the rest is removed with the help of ether.


Mixed with the benzoic acid which has been removed by
filtration is found a dark brittle substance which softens on
the water-bath, and which we assume to be a benzoyl compound of unknown composition which was apparently unaffected by the dilute sulphuric acid. On dissolving it in concentrated suljjhuric acid and diluting with crushed ice, the
resulting fluid gives none of the reactions characteristic of
suprarenal extracts.


The Johns Hopkins Hospital Bulletins are issued monthly. They arc printed by THE FRIEDENWALD CO., Baltimore. Single copies
After decomposing the benzoyl product with hot dilute
may be procured from Messrs. CVSBI^'O iC- CO. and the BALTIMORE TfEWS COMP.iNT, Baltimore. Subscriptions, $1.00 a year, may be
sulphuric acid and removing the benzoic acid thus split off,
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; siiiylc copies will be sent by mail for fifteen caits each.  
we next get rid of the acetic acid by repeated partial evaporations, taking care not to let the solution become too concentrated and thus perhaps injure the active principle. After
the removal of the acetic acid the sulphuric acid is precipitated with the help of lead carbonate. The lead sulphate is
removed and the filtrate is allowed to stand in vacuo over sulphuric acid until it has become of tarry consistency. It is
then exhausted with ether, acetone and absolute alcohol in
succession.  


The residue is physiologically very active, and it gives all
the reactions characteristic of an aqueous solution of the
gland — a beautiful rose color on the addition of an alkali, a
green color with ferric chloride, reducing silver nitrate, etc.


However, we are not yet dealing with a pure substance. If
we neutralize an aqueous solution of the product thus obtained
with a free alkali or with a carbonate of the alkalies, an overpowering odor much like that of coniiue is jierceived. As
this odor passes that of pyridine seems to take its place.
The basic substance thus liberated fumes in the air or when
a glass rod moistened with hydrochloric acid is brought into
its neighborhood. To remove this basic substance we made
an aqueous solution of the active principle as above isolated,
rendered it faintly alkaline with sodium carbonate and shook
out with ether several times in succession. But this method
does not remove all of the coniiue-like substance. To effect
this we were obliged to make the active principle strongly
alkaline with sodium hydrate before shaking out with ether.
The aqueous solution, in consequence of the addition of the
free alkali, takes on a deep red color, and carmine red flocks
are thrown out. After the removal of the coniine-like substance with ether, the fluid containing the red flocks was
acidulated with sulphuric acid and the carmine-red substance
was filtered off". The clear filtrate, which was a pale straw
color, was concentrated in vacuo, and the active priuciiile taken
up in weak alcohol. On account of the insolubility of the sulphate of the active principle in absolute alcohol it is difficult
to obtain this entirely free of sodium sulphate. We hope in
future to remove both the coniine-like substance and the pigment with the help of ammonia. The presence of pyridine in
our ammonia prevented our using it for this purpose.


BULLETIN




154


OF
[No. 76.






THE JOHNS HOPKINS HOSPITAL.  
This volatile base of a coniine-like odor has not hitherto
been described as a constituent of the suprarenal capsule.
The beautiful carmine-red pigment we take to be identical
with the red substance which many other observers have
found to be thrown out as a precipitate when ammonia is
added to a concentrated aqueous solution of the gland, or
when a solution is evaporated in the presence of lead acetate.*
Others have believed this red precipitate to be the oxidation
product of the active principle of the gland, but we shall presently see that the active principle is still present in the filtrate
from the carmine-red body. We have as yet made no experiments with this pigment except to note that it is but slightly
soluble in dilute alkalies and insoluble in dilute acids, and
that iodine destroys the color. Our method appears to make
the further study of this substance possible.  


The coniine-like substance we have secured in the form of
its hydrochlorate, and with it we have made certain studies
which will be published at a later date.


Chaeacteristics of the Blood-Pressure-Eaising Constituent AS obtained by decomposing its
Benzoyl Compound.


Vol. Vlll.-No. 79.]
We have now obtained the active principle in the form of a
sulphate. As thus far isolated it is a hygroscopic, strawcolored residue which tends to crystallize on standing over
sulphuric acid, agglomerates of small crystals forming on the
edge of the bowl and the entire residue taking on a semicrystalline appearance. This sulphate does not contain the
volatile coniine-like substance, nor do we find the carminered pigment which falls out on the addition of an alkali.  
Alkalies no longer liberate the coniine-like substance, nor do
they throw out the red pigment, but they cause a brownish
discoloration, and on heating, alkaline vapoi's, probably
ammonia, are given off.  


Our sulphate is very active physiologically. A small
quantity suffices to raise the blood-jjressure as seen in Fig. 1,
and it is therefore evident that we have isolated the active
principle but slightly contaminated with other substances.


A final product even more active in small quantities is that
whose action is shown in Fig. 2, where the mercury is driven
out of the manometer. This more active compound still contains much of the coniine-like substance, and at once throws
out the carmine-red pigment on the addition of alkalies. The
sulphate of the coniine-like substance does not, as we have
seen, raise the blood pressure; it therefore remains for us to
consider whether the carmine-red substance which is precipitated on the addition of alkalies, either alone or in conjunction with small quantities of oxidizing agents, has any j)hysiological significance or stands in any chemical relation to the
blood-pressure-raising constituent. We incline to the opinion
that this substance, which in the original aqueous solution of
the gland gives with iodine water the " teinte rose-carmin
tout a fait remarquable" of Vulpiau, is in nowise connected with the blood-pressure-raisiug constituent. We have
repeatedly removed or destroyed this substance by boiling
solutions containing it with strong ammonia or with sodium


BALTIMORE, OCTOBER, 1897.  
•Holm, Journ. f. prakt. Chemie, c (1867), 150.  






[Price, 15 Cents.  
hydrate, and have always been able to separate subsequently
 
an active material. In proof of this we append Fig. 3, showing a great rise of blood pressure, although the material from
 
which this active principle was obtained had been boiled for
 
one hour with a 5 per cent, solution of sodium hydrate.
COlsTTIElNrTS.  
After such treatment with alkalies, care must be taken in the
subsequent evaporation of the alcohol with which the active
principle is removed, to keep an acid reaction, as otherwise
the greater part, if not all of it, will be destroyed by oxidation. And unless all evaporations are carried on under
reduced pressure, much material will be lost, even with the
above precaution.
 
Although somewhat contaminated with its own decomposition products, this final sulphate has all the characteristics
of an active substance. As shown by repeated experiments, it
promptly raises the blood pressure, it constricts the vessels of
an inflamed eye, and when injected into the dorsal lymph sac
of the frog it acts like a narcotic or cerebro-spinal poison.  


As freed of the red substance the sulphate of the active
principle behaves as follows: It is very soluble in water,
fairly soluble in weak alcohol (50 per cent), almost insoluble
in absolute alcohol, and quite insoluble in ether, acetone,
ligroine and chloroform. Its aqueous solution, even when
freed from adherent sulphuric acid, has a slightly acid reaction. The addition of iodine water to a neutral solution does
not give a rose-red color. Alkalies added to a strong solution give a brown color which deepens on heating. Ferric
chloride gives a purplish brown, almost black in concentrated
solution, which ou the addition of tartaric acid and an alkali
passes into a deep red color. Before the removal of the carmine-red substance the addition of ferric chloride gives the
well-known emerald green color, which passes into red on the
addition of an alkali.


It is evident that our sulphate gives V^ulpian's ferric chloride reaction, though somewhat changed by the removal of
what we take to be the chromogenic substance which gave his
iodine reaction. It also promptly reduces silver nitrate in
alkaline solution, but does not reduce Fehling's solution even
on boiling.


A Second Series of Cataract Operations (One Hundred and
Probable Eelation to the Alkaloids.


Fifty-eight). By Robert L. Randolph, M. D., . . Parotitis following Visceral Inflammation. — A Report of Two
More than a year ago, during our first studies with suprarenal extract, we were struck with the fact that every extract
entirely free of proteids and physiologically active gave a fine
pyrrol reaction when subjected to dry distillation. This is
evidenced both by the odor and by the pine sliver reaction.  
A small quantity of the isolated sulphate also gives the
pyrrol reaction when heated either alone or with zinc dust.


Cases. By A. Duval Atkinson, M. D.,
We attach considerable importance to this reaction. As is
well known, alkaloids in general give pyrrol ou dry distillation ; morphine, for instance, on being heated with 10 parts
of zinc dust gives off pyrrol, ammonia, trimethylamine, pyridine, phenanthrene, etc.* During the past winter we made


Palpation of the Foetal Heart Impulse in Pregnancy. By


Douglas F. Duval, M. D.,


Squamous Epithelioma in a Dermoid of the Jaw. By S. M.  
* We are well aware that certain salts of glutaminic, pyromucic
and its related acids also yield pyrrol on dry distillation. These
compouuds, however, like the proteids and their allies, appear to
us to be excluded.  


Cone, M. D.,


The Infectiousness of Chronic Urethritis. By E. R. Owings,


M. D., . .
July, 1897.]


155




The Importance of employing Pure Salts in the Preparation of
the Schott Bath. [Communication.] By C. N. B. Camac,
M. D., 214


Proceedings of Societies :
several attempts to prove the presence of pyridine among the
products of dry distillation of the active principle as above
isolated, as its detection would prove that our principle was to
be classed among the alkaloids.


Hospital Medical Society, 215
In attempting to show the presence of pyridine we heated
the active principle with zinc dust in a current of dry
hydrogen and passed the distillation products through a test
tube and two small flasks, the tube being placed in a cooling
mixture, the first flask being partly filled with dilute sodium
hydrate, and the second with dilute hydrochloric acid.


Demonstration of a Case. Probable Brain Tumor [Dr.  
At the close of the experiment the test tube gave off alkaline vapors that smelled strongly of trimethylamine and had
Thomas] ; — Demonstration of Specimens [Dr. Cullen].  
in addition a peculiar sweetish odor. The contents of the
test tube diluted with water gave a jDrecipitate with bromine
water and with copjier sulphate, but with the latter reagent
the fine blue color characteristic of pyridine did not appear.  
The presence of amines seems to render difficult the detection
of small quantities of pyridine. The contents of the third
flask on exposure to the air took on a rose-red color and after
a time threw out a precipitate of the same tint. Both flasks
gave off the odor of benzaldehyde.  


Notes on New Books, 218
The following experiment was also made with a little of the
sulphate, which no longer gave the rose-red reaction with
iodine but which still contained a little of the coniine-like
substance. For two hours it was kept at 150° C. in a sealed
tube with 35 per cent, hydrochloric acid. On shaking out
with ether a considerable crystalline residue was obtained
which, without much purification, melted sharply at 130° C.
and had all the properties of benzoic acid.


In the above decomposition experiments the quantity of
material at command was small, perhaps not more than onefifth of a gramme at a time, and not entirely pure. We do
not, therefore, lay much stress on our failure to detect pyridine.


The fact that the nitrogen of our compound is given off in
the form of amines and pyrrol gives strong ground to believe
that our substance is to be classed with the pyridine bases,
using this term in a broad way. Its basic character, its
ability to take up acid radicles, as illustrated by the formation
of a benzoyl product, its reducing power and its color reaction
with ferric chloride are all points which can be urged in support of this view. Furthermore, cupric acetate, the serviceableness of which as a precipitant of carbo-pyridine bases has
been shown by Gautier and Landi,* also precipitates our
active principle; and iodine chloride, which Dittmarf found
to give brown or yellow halogen addition-derivatives with a
large number of the alkaloids, gives with a neutral or slightly
acid solution of our active sulphate a brownish flocculeut precipitate.


A SECOND SERIES OF CATARACT OPERATIONS (ONE HUNDRED AND FIFTY-EIGHT).*
Of less weight in this connection, but nevertheless of some
value, is the fact that its physiological action and its power in
small doses is again in accord with what is known of alkaloids. Strychnine, thebaine and other alkaloids are readily
called to mind as able to raise the blood pressure, and recently
TunnicliffeJ has placed piperidine in the same list. The


By Egbert L. Randolph, M. D.




•Compt. rend., cxiv (1892), 1154-1159.


Five years ago I reported in the Bulletin of the Johns
fBerichte d. deutscb. chem. Gesellsch., xviii, 1612.  
Hopkins Hospital a series of fifty consecutive cataract operations. Of these fifty operations six were performed in a hospital. With the exception of eighteen, the remaining twentysix were among the poorer classes of a country population in
 
Virginia and in a mining region in the western part of Maryland. This series then is chiefly interesting from the rather
tCentralbl. f. Physiol., x, No. 25, 777.  
unusual conditions which surrounded most of the patients.  
For instance, the first case reported (Series I, Case 1) was
operated on in a log cabin near Warrenton, Va., and the old
man was nursed by his daughter, who saw him only at meal
times and at night (she being in service), and as a consequence
he was exposed not infrequently to risks during her absence.  
He went through the same experience a year later with his
other eye and, as in the first instance, obtained excellent vision.  
Case 8 (in the same series) had been blind for three years and
lived at a remote point on a plantation in Virginia, and he
was nursed by his wife. His cabin was too dark for the operation and I put him on a cot and operated out in the yard.
He was very timid and jumped when the iridectomy was performed, causing some loss of vitreous. He counted my fingers
after the operation and I assisted him upstairs to a room next






*Read at the annual meeting of the American Ophthalmological
pyrrol* bases are also physiologically active, although less
Society, AVashington, D. C, May, 1897.  
attention has been paid to them.  


Pyrocatechin cannot be split off from the
Blood-Pressuke-Raising Constituent.


As already said, Miihlmann has stated with great positiveness that the blood-pressure-raising constituent is pyrocatechin joined to some other substance, probably an acid. Miihlmann does not offer sufficient proof for his conclusion ; and
even had he proved the presence of pyrocatechiu in the gland
itself, this is a very different thing from showing that it enters
into the chemical constitution of the blood-pressureraising
constituent.


to the roof, as the only other room in the house opened out
We have repeated Miihlmann's work and have found that
into the yard. He remained there for a week, and at the
after boiling the medullary substance with hydrochloric acid,  
end of that time was allowed to come downstairs. He subsequently obtained perfect vision. Case 39 (Series I) was
the ether takes up a trace of Vulpian's substance, as well as a
operated on in a cabin full of negro children, and he was
substance that reduces Fehliug's solution.  
looked after by his daughter. The result was most satisfactory. In this series of fifty, two failed to recover sight, and as
 
the circumstances peculiar to these were rather unusual and  
The ether residue also gives a precipitate with neutral lead
as such might explain the failure, I shall relate the histories.
acetate which, on decomposition with dilute sulphuric acid,  
Case 49, woman 78 years old, had been troubled many years
sets free a compound that gives with ferric chloride the reaction so characteristic of pyrocatechiu. Our blood-pressureraising constituent is not precipitated by lead acetate and  
with dacryocystitis, more marked in the left eye than in the
could not, therefore, have been responsible for this result.  
right. She had been blind from cataract for three years.  
 
Refused treatment for the lachrymal trouble, saying she was
Furthermore, on decomposing a fairly large quantity of the  
too weak and old to stand the pain incident itpou the probing.
crude benzoyl product before referred to and shaking out the  
She was made acquainted with the additional risk of a cataract
resulting benzoic acid with ether, we have twice found that
operation performed on an eye where there was disease of the  
the ether has taken up in addition to the benzoic acid a small
lachrymal sac. She was willing, however, to run the risk of  
quantity of a substance which reduces Fehling's solution and
infection from this source, so I operated on the least affected
gives a precipitate with neutral lead acetate. On decomposing
eye. The result was a perfect success. A year later she presented herself for operation upon the second eye. The operation was smooth and she counted fingers with ease immediately
the resulting lead compound with dilute sulphuric acid and  
afterward. I left the city that evening, not expecting to see
neutralizing the filtrate, we obtained a solution which
her again for two weeks. She was entrusted to the care of  
behaved with ferric chloride in the way characteristic of pyrocatechiu. The quantity of this lead compound obtained has
the physician who assisted me in the operation. It is well to
been too small for analytical purposes.  
state here that she belonged to a most ignorant class of white


We consider it, therefore, still uncertain whether or not a
little pyrocatechiu is present in the gland.


That the blood-pressure-i-aising constituent is, however, not
a pyrocatechiu derivative seems to us certain. To prove this
we used, not the entire gland nor the medullary substance,
but the active principle itself, as isolated by us by decomposing the benzoyl compound.


200
We have used large quantities of material representing in
each experiment the active principle of several thousand
glands. We have boiled this with hydrochloric acid of varying strength and for varying lengths of time, and in no case
have we been able to find in the ether used as a solvent any
trace of a substance that would reduce Fehling's solution or
give a precipitate with lead acetate. Inasmuch as some of the
chromogenic substance always passes into the ether from acid
solutions, these two reactions are both necessary to establish
the presence of pyrocatechin. In other words, we have failed
to split off pyrocatechin from the active principle as isolated
by us. If present, it could hardly have eluded our search,
for even a minute quantity may be made to give a precipitate
with neutral lead acetate.






JOHNS HOPKINS HOSPITAL BULLETIN.  
*Jac. Ginzberg, Ueber das Verhalten des Pyrrols, etc., luaug.
Diss., Konigsberg, 1890.  






[No. 79.
15G


[No. 76.




people, and though nearly eighty years of age, was accustomed
to going barefooted in tvarm weather. The first time I operated she had shown herself unmanageable and walked around
the house three days after the operation. That was in the
winter time. The second operation was in June last, and
when I saw the patient two weeks after the operation her
physician told me that she got up out of bed the next
day, tore the plaster off her good eye and came downstairs
and sat in the yard and smoked her pipe. The second day
after the operation she walked nearly a mile barefooted to see
her daughter. Whatever were the causes which produced it,
when I saw her the second time the eye was lost. It is impossible, then, to say whether to attribute the loss of the eye to
infection from the mucocele or to carelessness and exposure
after the operation. Before each operation the contents of the
lachrymal sac were pressed out, and, as far as possible, the
conjunctival sac was rendered aseptic by irrigating it with a
solution of corrosive sublimate t^^jtj-.


The second case (Case No. 47) is that of a man sixty-one
We propose during the coming autumn to continue this
years old. He had been subject for many years to rheumatism, and had suffered also for a long time with varicose veins
work. Having made arrangements for the use of a large
on both legs, and as a result of the latter condition his right
amount of material, we hope to secure both the benzoate and  
leg was covered with an eczema. The blood-vessels at his
the sulphate in a form pure enough for analysis and for
wrists and temples were tortuous and hard. Left eye, total
further chemical study.  
cataract and good field of vision for light. The operation
was absolutely smooth, and after the delivery of the lens
the patient could see my face and count fingers readily.
I removed the speculum and closed the eye, putting on the
usual bandage. Ten minutes later, and just before I was
about to leave the house, he complained of violent pain in
the eye. I suspected hemorrhage and immediately removed
the bandage to investigate. I found the latter soaked with
blood. The mass of blood and protruding vitreous were
cleaned away and strong pressure applied. On returning six
hours later it was found that the oozing had continued and
he was still suffering pain. The lids were opened and a clot
of vitreous was discovered between the edges of the wound.
This was removed, and after first irrigating the conjunctival
sac with a very weak sublimate solution, a pressure bandage
was applied. At my visit the next day I found the bandage
quite moist and there was every evidence that the oozing was
persisting. I cleaned out the sac again and renewed the
bandage. On the afternoon of the second day I saw him
again and there were still signs of hemorrhage. The same
course of treatment was pursued and on the third day I
found the bandage clean. Of course he was told that vision
was irrevocably gone from the onset of the hemorrhage. In
nearly all cases of this class the cornea sloughs, but this
termination I fortunately escaped. Hemorrhage after cataract extraction is rare. Dr. Knapp reports in a recent number of the Archives of Ophthalmology his only case. In my
own case I can account for the hemorrhage only by the condition of the blood-vessels throughout his body. ,v, No doubt
the vessels of the retina were tortuous and their walls
atheromatous, and when the lens was removed and intraocular tension thereby lowered, the blood-vessel walls could
not withstand the pressure from the increased volume of blood
pouring into them; so they ruptured. The whole condition of


(Summary.


We may sunnnarize the results of our work as follows :


the patient pointed to a diseased state of the circulatory
The blood-pressure-raising constituent of the suprarenal
apparatus. It is impossible to guard against such a termination, though I should regard it as a contra-indication for
capsule may be completely precipitated fi-om an aqueous
operation upon the other eye, for no matter how smooth the
extract by treatment with benzoyl chlorideand sodium hydrate,  
operation might be, the chances are that hemorrhage would
according to the Schotten-Baumann method.  
follow the delivery of the lens.  


Out of this series, then, all obtained useful vision but Cases
On decomposing the resulting benzoyl products, a residue
47 and 49.  
is obtained which possesses great physiological activity. It
gives the color reactions of Vulpian, reduces silver nitrate
and possesses the other specific qualities of suprarenal extracts.  


Since the publication of this series I have operated upon
AVith the help of alkalies a carmine-red pigment may also
158* cases and the tabular statement is herewith appended.
be separated from these decomposition products. We take
Two of the cases are especially interesting as being instances
this pigment to be that one of the chromogenic substances
of maniacal excitement, possibly due to the use of atropine
of Vulpian which gives the rose-carmine color when suprarenal extracts are treated with oxidizing agents or alkalies.  
after the operation. The first case was a colored man, operated upon in the poorhouse of Mineral Co., W. Va. He was
seventy-five years old and had been practically helpless from  
cataract for a year. Atropine was instilled immediately after
the operation. The next morning the physician. Dr. C. S.
Hoifman of Keyser, W. Va., was sent for and he wrote me
that the patient had gotten up during the night, torn the bandage off, secured a razor from one of the inmates of the room
and had gashed his throat in several places and was bleeding
profusely when found. In the excitement which followed the
eye was forgotten and it was some time before the bandage
was replaced. He was quieted, and seven days later, that is,
on the eighth day after the operation, he disappeared from the
jDOorhouse and two mouths afterward was seen by Dr. Hoffman, in Piedmont, W. Va., 20 miles distant, where he was
chopping wood and apparently getting along with absolute
comfort. It might be added that he was entirely bliud in the
other eye.  


The other case was also a very old colored man (88 years
A volatile, basic substance of a coniiue-like odor is always
old). The operation was simple extraction, and atropine was
found to accompany the crude benzoate. When these substances ai'e removed the active principle is left as a highly
instilled as usual at the operation. Before daybreak of the  
active sulphate or hydrochlorate, as the case may be. It is
next day he was a raving maniac and had to be tied down to
therefore a basic substance. Its salts give a color reaction
his bed. His bandage was torn off several times and he was
with ferric chloride; they also reduce silver nitrate, but not
incessantly tossing his head from side to side, until that too
Fehling's solution.  
had to be secured so as to be as far as possible immovable. I
did not dare look at the eye, as I supposed that it was lost.  
He did not recover his reason for a week, and all that was done
was to apply hot moist compi-esses to the eye. When he
became rational and I was enabled to get a satisfactory view
of the eye I found a rather small pupil, a slight prolapse, but  
very little pericorneal congestion. On the tenth day he seemed
to be completely himself again, and as the eye evidently
needed a mydriatic, one drop of a solution of atropine (4 gr.
— si) was instilled and the nurse was instructed to repeat the
dose at bedtime. When I returned to the hospitiil the next
day I found that during the night he had jumped out of the
window — 20 feet from the ground — scaled a high iron-spiked
fence and was making off when overtaken by an orderly.
Notwithstanding all this exposure he obtained 4^ vision.
Nothing was done for the prolapse, which flattened out entirely.  


Another interesting case was where the auterior chamber
It is not j)ossible to split oft' pyj'ocatechin from this isolated
active principle. The fact that dry distillation causes the  
appearance of amines and pyrrol in abundance, taken in connection with its ability to take up acid radicles, its reducing
power, its precipitability by cupric acetate and iodine chloride,
and its jihysiological action, lead us to conclude that our active
principle is to be classed with the pyridine bases or alkaloids.


Addendum, June 15, 1897.


 
Since the foregoing paper was read before the Association
*At the meeting of the Amer. Oph. Soc. only 147 cases were
of American Physicians on May 6, 1897, B. Moore has published a paper in the Jotcrnal of Physiology, vol. xxi, Nos.
reported in my second series. Since the meeting I have operated
4 and 5, May 12, 1897, entitled, "On the Chromogen and on
upon eleven cases.  
the active Physiological Substance of the Suprarenal Gland."
 
In this paper it is suggested that the active principle may
be a pyridine derivative. Moore's conjecture is based, lirst,
on a formula calculated by him from a combustion analysis of Krukenberg, made with an impure, hygroscopic, noncrystalline residue obtained by merely decomposing and
drying a precipitate secured out of an alcoholic extract of the
gland with the help of basic lead acetate. The calculated
formula, the carbon content of which differs by 1.33 per
cent, from that actually found by Krukenberg, is CsHuNO.!,
and Moore points out that in it the ratio in which the elements
carbon and nitrogen stand to each other is the same as in  
pyridine, CrHr.N. Now such a calculation, though suggestive
to the investigator, furnishes no proof of the presence of
pyridine, for Krukenberg could not possibly have had in hand
a chemical individual uncontaminated with other constituents of the gland. Krukenberg himself admits that his




October, 1897.J


material was a mixture of unaltered pigment and its decomposition products. It is also certain that it was contaminated
with other constituents of the gland. This is proved by the
fact that basic lead acetate precipitates several of the constituents of the gland which pass into alcohol, and also by
the fact that the analysed material contained 0.0(38 per cent,
of sulphur and from 1.18 per cent, to 1.44 per cent, of ash.


A second reason given by Moore in supj)ort of his conjecture is that when "some suprarenal extract was cautiously
fused with caustic potash so as to avoid charring, the peculiar
odor of pyridine was at ouce obtained." He admits that
proteids were present in this extract, and that jjyridine and
its homologues arc formed in the destructive distillation of
proteids, but states that the experiment was "conducted so
as to avoid charring," and considers this a sufficient safeguard.
This experiment has also no value, for the odor of pyridine
can always be obtained when a mixture of dry, powdered
proteid and powdered caustic potash are fused together so as
to avoid charring. This experiment, therefore, must be made
with material entirely free of proteids. Since reading Moore's
paper we have fused a little of our active i)rinciple with
caustic potash, but have failed to detect pyridine. If present
in the molecule of the active principle, it is evident that larger
quantities of the material must be used to prove it. Only indisputable chemical proofs can establish the presence of Jiyridine ; the odor is not enough. We have frequently in various
manipulations with the active substance met with what we
took to be the odor of pyridine, but on shaking out with ether
and adding an ethereal solution of hydrochloric acid and
evaporating the ether we have been unable to detect pyridine
in the residue.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Description of the Tracings.  


Fig. 1. Tracing. Dog aniesthetized with morj)hine ; curare
and artilicial respiration, both vagi cut. Injection of the
active sulphate, freed from the carmiuesubstanceaud coniinelike body, at X.


A =: running base line.


201
i?z::time record.


(7 z= curve of the blood pressure, canula in the right carotid
artery.


Fig. 3. Tracing. C!onditions of the experiment as in Fig.
I. Injection at X of a highly active sulphate which still
gives the rose-carmine color with iodine water and still contains some of the coniine-like substance which does not raise
the blood pressure. The blood pressure is so high that the
mercury is driven out of the manometer.


remained open for seventeen days. I have seen explanations
Fig. 3. Tracing. Conditions as in 1. Injection at X of a
for tliis phenomenon, but none seem adequate. The opei'ation
material which is still highly active although it had been
was the combined one, and the wound had united about half
boiled with 5 per cent, sodium hydrate for one hour. In this
way ujj on one side and the rest of the incision remained open.  
experiment a number of injections had already been made; the  
More than once during these seventeen days a spatula was
pressure had fallen to the normal before the injection indicated at X was made.  
jmssed beneath, the corneal flap, and it was easily seen that no
uuion had taken place. The operation so far as could be seen
appealed to have been normal, that is to say there was not
the slightest hitch in any of the steps. Atropine and compress bandage were employed, and two weeks after he left the  
hospital his vision was jW Eight months later he returned
to the hospital with serious iritis, and since then vision has
been lost, though he still has light perception.  


Iridectomy was pei-formed in 102 cases and simple extraction in 42 cases. Soft cataract was operated upon by needling
DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL
in three cases.


In thirty-one cases the vision was not tested. Three of
IJy JOHN S. lili, LINOS, M. I)., LL. D.  
these cases were in very young children and any subjective test
would have been very unreliable. The remaining twenty-eight
were ones which I had operated upon at a distance and most
of whom I saw only once after the operation. A number of
cataract glasses were sent to them from which to make a
selection, and in this way I learned to what extent the operation had benefited the patient. It will be seen from the
table that the operation and healing process were uncomplicated in all of these cases and all obtained useful vision.  


Tlie failures were as follows: C«*e 54. The operation was
Ctmtalnlng 56 largo quarto plates, phototypes, and lithographs, wlih views,
smooth, and when the bandage was removed she could see
plaiiH iiutl ilotatl drawlugaof all the butldlugs.aiul their Interior arraugemeuts—
large objects in the room. This was on the seventh day. Two
also wood-cula of apparatus aud Uxtures; also 116 pages of letter-press describing
days later iritis of a very sluggish character developed, and in
the plans followed lu thecoustruollou, and giving full details of heatlug-apparatut,
spite of all treatment ended in closed pujjil and light perception. Dr. H. Harlan of this city operated on the other eye
veutUatlou, sewerage aud plumblug. Price, bound lu cloth, $7.oO.  
and obtained good vision, but he told me that the ojDeration
was also followed by iritis.  


Cage 72 had an exactly similar history.
Case 95 was one which I had treated for several months for
dacryocystitis. Her left eye had been operated upon by a
New York oculist two years previously, and the cause of the
failure in the case of that eye was no doubt the same as in the
case of the eye upon which I operated, for both eyes were
affected with dacryocystitis. When first seen she had a fistulous opening which had been discharging for several months.
Before operation she was under treatment for at least five
months, during which time the fistula had closed and the
epiphora had almost disappeared. She understood the danger,
but being totally blind in the other eye, wanted the operation
performed. The cornea sloughed within a week after the
operation.


Case 137 was that of a man 81 years old. On opening the
eye on the third day there was a very offensive discharge on the
bandage and between the lids, and beginning clouding at the
edge of the corneal wound. Vigorous local and constitutional
treatment, however, prevented the corneal trouble from extending and he was left with a clear cornea and closed pupil. I
think that I could have converted this failure into a success
(as in Case 190) by iridotomy, but a few days before the proposed operation he was attacked with pneumonia and died on
the eighth day.




NOTES ON NEW BOOKS.


The last case was that of an old colored man (Case 128)
Anomalies and Curiosities of Medicine, being an encyclopedic collection of rare and extraordinary cases, and of the most striking
and the history here was similar to Cases 54 and 72.  
instances of abnormality in all branches of Medicine and Surgery,
derived from an exhaustive research of medical literature from
its origin to the present day, abstracted, classi fled and indexed.
By Georqe M. Gould, A. M., M. D.,and Walter L. Pyi.e, A. M.,
M. D. With 295 illustrations and 12 half-tone and colored plate.s.
908 pp. (Philadelphia : W. B. Saunders, 1897.)


In one case (male, both eyes, 67 and 68), the patient had
Tliestatementof Gibbon that objects which are only singular without being pleasing may excite surprise but soon lead to satiety and
good light perception, but after the extraction of the cataracts
<iisgust, does not apply to this volume, which is thoroughly interesting from beginning to end. The attempt of the authors "to
it was observed that while he could move about somewhat
briefly epitomize and to arrange in order the records of the most
better, his sight continued very poor, and this was explained
curious, bizarre and abnormal cases thatare found in medical literature of all ages and all languages," has been most successful. The
by the existence of optic nerve atrophy in both eyes.  
book is thoroughly scientiflc in its treatment of the varied material
which has been gathered with an industry which calls forth admiration. The Urst six chapters will probably be read most generally
and relate to anomalies of conception, birth and development, and
are of special interest to the gynecologist, obstetrician and student
of legal medicine. Chapter seven relates to gigantism, dwarflshness, obesity and abnormal leanness, and the accompanying illustrations form a curious collection of anomalies suggestive of a dime
museum.  


In Cases 53 and 307 a cataractous lens (congenital) had
The chapter on longevity taxes one's faith rather more than any
undergone calcification and presented a bright white mass in
other. Think of Henry Jenkins dying at the age of 169 years ;
the pupil. The operation was simply for cosmetic purposes.  
Thomas Parr at 152 ; Jean Korinat 172 and his wife atl64, and ason
left an orphan by their untimely death at the tender age of 116 ;
Petretsh Zartan at 185 or 187 (authorities differing), who walked a  
mile to the post ofiice a few days before his death to ask for alms ;
and many other well-authenticated instances of nearly equal age.  


As to prolajjse of the iris. In the 42 cases of simple extraction there were five prolapses. In three of these cases nothing
The chapter on anomalous mental and nervous diseases is so complete it is a matter of surprise that it does not include the history
was done, though in Case 181 the prolapse looked as though
of the young man in Ohio who became totally blind at the age of  
it would extend throiigh the entire wound. Under a compress bandage, however, and atropine the hernia smoothed over
seven months, and who, while receiving an education at the school
and she has now vision f^. In Case 182 the prolapse got
for the blind, in consequence of a fall, lost both hearing and speech.
worse from day to day till it nearly filled the wound, and it
After a time, his eyesight being restored by the fall, he was transferred to an establishment for the education of deaf mutes. Here
continued bulging more and more. There was no hernia on
eventually his hearing was suddenly restored, but epileptic attacks
the second day when the eye was inspected, but he bad a little
developed which required hospital treatment, this time in an institution for the insane. This well-authenticated tale was published
gush of tears that night followed by pain, and a small hernia
in considerable detail in one of the State repoits and deserves a
was visible the next day. On the eighth day, fearing that the
place in these annals. The chapter on Historic Epidemics is timely,
eyeball would be permanently disfigured (to say nothing of  
especially the full account of the bubonic plagues of the middle
loss of sight), the protruding iris was cut off. There is now
ages.  
not the slightest ectasia of the cornea so far as can be seen,
and the patient has f^ vision.  


In these last two cases lachrymation and photophobia were
An excellent feature of the book is the judicial spirit shown by
present to a marked extent and some little pain was felt at
the authors. Facts are weighed and reasons are advanced for the  
the time when the prolapse occurred, but after this pain was
conclusions which are reached. The book is well printed and
conspicuously absent. So far as could be seen there were no
finely illustrated and is worthy of a large success. Every chapter
evidences of infection in any of the cases of prolapse. When
is of interest to every physician.  
I say evidences I mean cloudy media and exudates. I think
that the absence of infection in these and similar cases is to
be attributed to the fact that the wound is filled with the
protruded iris and probably there is no way for the bacteria
to make entrance into the anterior chamber. The profuse
lachrymation which is usually present must be regarded as a
more or less protection from a mechanical point of view, i. e.
to some extent in washing away bacteria. And I think that
an examination of the statistics of simple extraction will disclose the fact that the failures are as a rule not associated
with prolapse.  


In commenting upon the visual results it will probably
Text-Book of Materia Medica, Therapeutics and Pharmacology.
strike many as singular that |J was obtained only four times,  
By G. F. Butler, M. D. [Philadelphia: W. B. Saundem, 1896.)  
but this may be explained by the fact that discission was performed only ten times and that in quite a number of cases
(31) I made no test of the vision.


In all of the operations the incision was made well within
This work is dedicated to the " Medical Students of the United
the liinbus of the cornea and still a little further in at the top
States," and we have no doubt that many of them who enjoy buying
of the incision. The latter includes usually something less
the latest work on this branch of medicine will find it serviceable.
than half the circumference of the cornea.
It cannot be said to replace the oliier works of Wood, Hare and  
others. There is very little true original thought in it, which
should be the the real reason for the publication of any new book,
especially to-day, when there is altogether too much production of  
simply transient works. As the author states in the preface :
" From the U. S. Pharmacopeia chiefly, and from the National Dispensatory, have been adopted almost verbatim, the ' origin ' and
'description and properties' of tlie various drugs under consideration," so it is more in his arrangement of his material that we must


The instruments with the exception of the knife are boiled.
The knife is allowed to remain in Squibb's absolute alcohol
for 20 minutes. The eyebrows and that side of the face are
covered with a cloth saturated with a solution of sublimate
1:1000. Both the cocaine and atropine solutions are boiled
in test tubes and only used once. Small pledgets of cotton
secured by sponge holders and boiled are used for removino- debris from the field of operation, such for instance as strings of mucus and small clots of blood. The
uuoperated eye is closed till the second day and a small pad
of sterilized absorbent cotton is placed over the operated eye
and over this a four-tail bandage. The eye is inspected on the
second day, and earlier if there be unusual pain. The room is
darkened, but is not uncomfortably dark. The patient is
allowed to get up on the second day, and the bandage is
removed on the seventh day, though there was a time when I
removed it earlier. The following is the arrangement of the
visual results:


20 I 1


TS '^^
look for originality. He classifies the drugs by their properties,
 
rather than alphabetically, as is done by Hare. Both methodshave
U 35
their advocates, and [lersonally, as it is much the most rapid way to
look up any given drug, we prefer the latter method. Butler still
further cljftsifies the drugs into so called " Disease-Medicines," a
very unscientific term, as he himself recognizes, and "SymptomMedicines." In such a classification no two persons willagree as to
the class to which certain medicines will belong most properly, and
thus it becomes confusing and time-consuming to search for the drug
wanted. The author says: "A genuine specific is tolerated only
by the system in which it antagonizes some disease. For instance,
A and B are put under a prolonged course of mercury ; A is salivated
beyond recognition, while B's health improves — simply for the
re.ison that B had syphilis, which A had not." Such general
remarks are often not true, and the example given is a very poor
one, for we all know that syphilitic patients may be salivated, and
sometimes as severely as those who are not syphilitic. Also many
]>atients who have not sypliilis may take mercury in large doses for
long periods of time without becoming salivated. We do not
understand the following sentence: "Quinine was formerly considered a specific in malaria, until the fact was recognized that the
drug is analogous to a normal constituent of healthy bile in its
action upon plasmodia malariae." W^e believe that by most
authorities quinine is still considered to be a specific in malaria,
whatever the action of bile may be. In a work which covers so
much ground as this text-book, the value depends on an equal balancing of the different parts, and especially, in the description of
the drugs, of careful omission of all unnecessary parts, and still
more exact and concise information on all important points. Each
author naturally finds special interest in certain parts of his work,
and so not knowing these it is hard to criticise the book justly. But
in the 650 pages given to drugs and their actions we feel that much
improvement could have been made with careful revision — some
parts omitted, and other information of more importance added.
We think it quite out of place to introduce in such a work declensions of simple Latin words and other rules of Latin grammar,
which should be known by every student before he begins the
studj- of medicine, and if he does not know them, he should not be
helped to the knowledge in this superficial manner.


Diseases of the Ear, Nose and Throat. By S. P. Bishop, M. D.
(Philadelphia : F. A. Davis Co., 1897.)


This book, we think, fulfills pretty satisfactorily the object of the
author, as expressed in the preface; he says: "This work was
designed, first to help students in preparing for their degree ; second, for those progressive practitioners who wish to acquire the
proficiency necessary to properly treat those patients who are unable to visit specialists ; and third, for those who are gradually
exchanging their general practice for special work in these
branches." The chapter on blood-serum therapy in diphtheria seems
out of place ; it is merely an abstract of a few of the articles which
liave appeared on this subject during the past two years, and we see no
good reason for introducing it here. The work on the whole is a
fair presentation of our knowledge in these diseases, without any
attempt to take up any of them at length. The treatment as given
is generally satisfactory and simple. We do not agree with the
author in considering hay-fever, or "nervous catarrh," as he prefers to call it, a result of uric acid diathesis. There are many
questions in the study of this disease which are as yet quite inexl)licable, and this theory of its causation is insufficient to explain
them all ; the neurotic character of the disease is well established,
and that uric acid may in some caees play an inijiortant role in this
nervous affection is undoubted, but it is also equally certain that
other important causes play their role too in determining this
malady.


2 Qfi
This book is clieaply gotten up and the cuts are of poor quality ;
 
tlie colored illustrations also seem very unsatisfactory. Many of
717 ^°


20 Of?


20 R


2110 "
July, 1897.]


Vision not tested .31
159


Atrophy of the optic nerve 2


Cosmetic purposes 2


Failures 5
the cuts are reproductions of instruments wliich by this time should
be l^nown to all practitioners and to every student graduating from
a medical college. These simply add to the expense of the book
without adding to its intrinsic value.


158
Essentials of Physical Diagnosis of the Thorax. Second Edition.


Successes in the first series 48
By Arthur M. Cokwin, M. D. (Philadelphia: W. B. Saunders,


Failures iu the first series 2
189a.)


Total number of cases operated upon 208
That there is a demand for such a quiz-compend or aid in cramming for an examination is shown by the fact that a second edition
of this small book has been called for. We cannot recommend it,
however, for like other similar works it fails in attempting to condense much knowledge in a very limited space and although tolerably well arranged, there are numerous statements of fact with
which we cannot agree. The varieties of tympany (p. 69) are confusing and not generally used and were better omitted in such a
work. In the discussion of heart murmurs there is much needless
repetition, and on p. 176 the mitral systolic murmur described
as occurring in aortic insufficiency, otherwise known as Flint's
murmur, is presystolic in time. The chapter on congenital lesions
of the heart is treated too briefly to be of service, as is also the one
on hydatid cyst of the lung, which, when jiriniary, is not a condition easy to diagnose, nor could the signs of it as given by the author
differentiate it from pleurisy. 8pasm of the columnar carnese is a
condition which may occur, but it is hardly one of which a diagnosis could be made. Acute endocarditis without valvular lesion
is not a condition which can be recognized clinically, and inorganic
aortic systolic murmurs should usually be doubted. The ratio of
the inspiratory sound to the expiratory is not as tiiree to one, nor
in asthma is the dyspnosa (orthopncea) chiefly expiratory. CheyneStokes respiration does not ordinarily accompany opium poisoning.
No worse instrument for clinical instruction could well be devised
than the multiplex stethoscope, of which there is an illustration
in the beginning of this work.


Pathological Report of the Illinois Eastern Hospital tor the I
(Chicago: Blakely rrinting Co., 1896.)


 
This is an excellent report, full of much valuable mateiial, and
No.  
Dr. Adolf Meyer deserves much credit for it, considering the difficulties under which the work was prosecuted, due to a lack of general facilities for carrying it on. We cannot criticise any shortcomings when we read his closing remarks. He says: "It may
 
justly be said that the publication of so much raw material is of
 
little use. To polish the report, away from the records and the
Sex.  
material, did not seem to he in the interest of the accuracy of a
 
picture of the working of the laboratory which had barely come
 
into existence at the end of the period covered. The work was
Age.  
planned on a broader basis than it was feasible to carry out in the
short period. The idea was that the plan of publishing ' interesting' cases only was not in the interest of sober study of the daily
experience, that selecting cases might lead to illustration of preconceived ideas instead of the facts as they present themselves in
reality, and that at the present stage of psychiatry a consideration
of all the things seen wouM be less dangerous than arbitrary selection. The same jirinciple should be carried out in the clinical side
as well." Although much of the material is raw, yet many facts of
interest are to be found — perhaps the most interesting being that 32
per cent, out of 49 cases of terminal dementia, and 27 per cent, of
192 cases of mental diseases, including the first series, died of florid
tuberculosis. Of course without fuller statistics as to the class of
patients in the hospital, too much stress should not be laidon these
figures, but nevertheless the percentage is high. A case of acute
mania, dying presumably of sulphonal poisoning, shows the necessity of the utmost care being used in the administration of drug.ito
patients with mental diseases to avoid accidents of this sort. We
shall await with pleasure sui cessive reports from Dr. Meyer, who
has now transferred his work to the Worcester State Hospital and




Health.


nsane.


Cataract,




Operation.  
Clark University, and trust he will be able to describe some of the
finer microscopical findings in brain and cord lesions from the interesting material at his disposal.  


St. Thomas's Hospital Reports. New Series. Vol. XXIV. i London,


Healii.g- process. Duration of treatment.  
1895.)


The first half only of this volume is taken up with detailed
papers, and the second half with statistics of the different departments of the hospital, and brief abstracts of cases, medical and
surgical. Among the papers here preseuted, two are worthy of
special note. The article on " Osteo-arthropathy and its Relationships," with report of a case of pulmonary hypertrophic osteoarthropathy, both by Dr. Walters, is a very valuable contribution
to our knowledge of this curious condition and its relationship to
akromegaly. It is an exhaustive study, with a brief abstract of all
the cases reported of this bone disease up to the time of the publication of this volume. The other paper is on "Enteric Fever and
Sewage Gas," in which 11 cases of typhoid fever are described as
resulting from poisoning with sewer gas in one hospital within a
short space of time. Here milk, water and food as possible sources
of the contagion could apparently be eliminated without doubt, and
the only other discoverable source was a water-closet into which
typhoid organisms had probably been discharged but a few weeks
before the outbreak of this small epidemic, which ceased as soon
as the sewage pipes were overhauled and modified. With the
modern belief that typhoid fever in nearly every case re>ult8 from
milk, water or food contaminated by the typhoid organism, this
epidemic raises the most interesting question as to whether or not
typhoid bacilli may enter the body through the lungs and thus
cause the fever. There are other articles on tuberculous disease in
the knee-joint, and relapse in the si)ecific fevers, which will repay
careful reading.


Primary Vision.  
Feeding in Early Infancy. By Arthur V. Meigs, 51. D. (Vhiladelphia: W. B. Saunders, 1896.)


In this paper Dr. Meigs emphasizes the results of his milk
analyses as expressed in his earlier publication, and describes in
detail the preparation of his food, based on these results.


51
He finds that human milk never contains more than one percent,
casein, cow's milk three times this amount, other constituents
being present in about equal quantities. In his preparation cow's
milk is therefore diluted with lime water, and cream and sugar
added in definite proportions. The food, piepared after this
manner, has been used for a number of years by the author, with
satisfactory results.


He thinks thatsulijecting milktohightemperaturesdetracts from
its usefulness as an infant food ; therefore it is better to be assured
of its source and avoid sterilization.


Male.  
This course seems hardly practicable, and the injurious effect
accredited to sterilization is not sustained by most writers on the
subject.  


Proceedings of the American Medico-Psychological Af-sociation
at the 52d Annual Meeting, held in Boston, May 26-29, 1896.
{American Medico-Psychological Associaiion, 1896.)


77.  
The proceedings of this society occupy nearly 300 large papers,
pretty closely printed ; but all the papers are good, while some are
of especial value. There is an interesting address on psychological
education by Stanley Hall, a leading authority on such a subject;
and there are important contributions by Brush, Worcester, Hoch,
and Berkley. The paper by Hoch, on " General Paralysis in Two
Sisters," is perhaps, while one of the most thorough articles, the
one of most general interest. To students who have given much
time to the study of the blood, the paper on " Leucocytosis Associated with Convulsions," by Burrows, will open up a point of much
interest as to the cause of leucocytosis, whether or not it be due to a
form of auto-intoxication.  




Good.


160


Hard. R. E.  
[So, 76.  




Iridectomy, smooth.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


Uncomplicated.




2 weeks.  
THE JOHNS HOPKINS HOSPITAL REPORTS.
Volume I. 423 i>ages, 99 plates.  


Report in Pntliologry.


20/70
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


52
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D.
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis


(Atrophy). By Henry J. Berkley, M. D.
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.


Male.  
Mall, M. D.  


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


75.  
T. C. Gilchrist, M. D., and Emmf.t 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 BO-called


Good.  
Parasites found in Various Lesions of the Skin, etc.; Two Cases of MoUuscuni


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


" "
T. C. Gilchrist, M. D.


Report In Patholog^y.
An Experimental Study of tin' Thyroid Gland of Dogs, with especial consideration


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




Mild iritis.


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


2 "
Report in Meillcine.


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


20/100
Gallstones. By William Osler, M. D.
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.
On Pyrodin. By H. A. Lafleur, M. D.
Cases of Post-febrile Insanity. By William Osler, M. D.
Acute Tuberculosis in an Infant of Four Months. By Harry Toulmin. M. D.
Rare Forms of Cardiac Thrombi. By WtLLiAM Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.


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


53
Report in Gynecology.
The Gynecological Operating Room. By Howard A. Kelly, M. D.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard


A. Kelly, M. D.. and Hunter Robh, M. D.
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of


Male.  
Abdominal Section. By Howard A. Kelly, M. D.
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,


M. D.
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;


36.
Ovarian Tumor; General Gynecological Operations from October 15, 1889, to


March 4, 1890. By Howard A. Kelly, M. D.
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howasd


Good.  
A. Kelly, M. D., and Albert A. Ghrisket, 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, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment


Calcareous. R. E.  
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By


Howard A. Kelly, M. D.


.1 11
Report in Snri;:ery, I.  
The Treatment of Wounds with Especial Reference to the VaUu^ of the Blond Clol


in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in tVenrologT-, I.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
.\cute Angio-Ncurotic Oedema. By Charles E. Simon, M. D.
Haematomyelia. By August Hoch, M. D.
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By


Uncomplicated.  
Henry M. Thomas, M. D.  


Report in Patbolo^y, I.
Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.


2 "




Light perception.  
Volume III. 706 pages, with 69 plates and figures.  


Report in Patholosry*


54
Papillomatous Tumors of the Ovary. By J. Whitridge Williams, M. D.


Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.
Report in Piitliologry*


Female.  
Multiple Lympho-Sarcomata, with a report of Two Cases. By SiMON Flexner, M. D.  


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


50.  
A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.  


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


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


Report in Gynecology,


Hard. L. E.  
The Gynecological Operating Room; An External Direct Method of Measuring the
Conjugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
Flexure associated with Constipation a Sourrc of Error in Gynecological Diagnosis; Operation for the Suspension of the Retroflexed Uterus. By Howard A.  
KiXLY, M. D.  


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


" "
Intestinal Worms as a Complication in Abdominal Surgery. Bj A. L. Stavklt, M, D.




Iritis.


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


6 "
The Employment of an Artificial Retroposition of the Uterus in covering Extensive
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.


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


" "
Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howard
A. Kelly, M. D.


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


55
The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.


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


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


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


71.  
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
May 4, 1892.  




Good.


Volume IV. 504 pages, 33 charts and illustrations.


" "
Report on Typhoid Fever.


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


It 11
Report in Neurology.


Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of Mu^ miisruln.^; The Intrinsic Nerves of the Thyroid Gland of
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley.
M. D.


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


Report in Gynecolof^y.
Hydn)salpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. Ctllen, M. B.
Report in Patlioloe^y.
Deciduoma Malignum. By J. Whitridge Williams, M. D.


2 "




20/.30
\\)LUME V. 480 pageSj with 32 charts and illustrations.  


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


56
Studies in Typlioid Fever.
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon
Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.




Female.


Volume VI. About 500 pages, many illustrations.


68.  
Report in Nenrolojsry.  


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


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


Report in Pntliologry.


" "
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. Bv Thomas S.


<'l-LLEN. M. B.


Escape vitreous.  
fii^aiancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of


Ovum and Spermatozoa. By Thomas S. Cullen. M. B., and G. L. Wilkins. M. D.
Adciio-Myoma Uteri Diffusum Benignum. By Thomas S. Cttllen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infanta. By


Iritis.  
William D. Booker, M. D.
The Pathology of Toxalburain Intoxications. By Simon Flexner, M. D.
The price of a set houiid in cloth [VoU. I-Vl] of the Hospital Reports m


$30.00. Vols. If II and III are not sold seimrateltj. The price o/


5 "
Vols. 11% r and ri is $5.00 each.




20/70


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID 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 Emmkt Rixford,


57
M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,


$3.00.
THE MALARIAL FEVERS OF BALTIMORE. By W. S, Thayer, M. D., and J.


Female.  
Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.  


By Lewellvs F. Barker, M. B. 1 volume of 280 pages. Price, in paper, f3.75.
STUDIES IN TYPHOID FEVER. Bv William Osler. M. D., and othere. Extracted


66.  
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481


pages. Price, bound in paper, $3.00.
Subscriptions for the above publications may be sent to


Good.  
The Johns Hopkins Press, Baltimore, Md.  




" "


The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimwr, Single copies
nuiy he pronired from Messrs. GUSHING & CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a tityir, may tte
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sini/lv topics will be sent by mail for fifteen cents each.


Iridectomy, smooth.




Uncomplicated.
BULLETIN




2 "


OF


Not tested.




58
THE JOHNS HOPKINS HOSPITAL.




Female.


Vol. Vm.-Nos. 77-78.]


72.




Good.  
BALTIMORE, AUGUST-SEPTEMBER, 1897.  




R. E.




11 II




"


GOnSTTEJaSTTS.


2 "




20/26
PAGE.


Influence of Louis on American Medicine. By Willia.m
O.SLEB, M. D., - - - 161


59
AVilliam Harvey as an Embryologist. By William K. Brooks,
LL. D., - - - - - - 167


Long, the Discoverer of Anaesthesia. A Presentation of lii.s
Original Documents. By Hugh H. Young, A. M., M. D., - 174


Female.  
The Early History of Ophthalmology and Otology in Baltimore (1800-1850). By Harry Friedknwald, A. B , M. D., - 184




65.


Joseph Friederich Piringer: His Methods and Investigations.


Bad.  
By Harry Friedenwald, A.B., M. D., 191


Proceedings of Societies :


L. E.
Hospital Medical Society, " - 195


Hsematomyelia from Gunshot Wound of the Cervical
Spine [Dr. Gushing].


11 11
Notes on New Books, _ . - _ 197


Books Received, 197


Iritis.




4 "
INFLUENCE OF LOUIS ON AMERICAN MEDICINE.


By William Oslek, M. D.


20/100




60
Harvey and Sydenham, types of the scientific and the
practical physician, though contemporaries, were uninfluenced,
80 far as we know, by the other's work or method. Harvey
had little reputation us a practical physician, and Sydenham
cared little for theories or e.\periment. Modern scientific
medicine, in which these two great types meet, liad its rise in
France in the early days of this century. True, there had
lived and worked in England the greatest anatomist and medical thinker of modern times; but John Hunter, to whose
broad vision disease was but one of the processes of nature to
be studied, was as a voice crying in the wilderness to the speculative, theoretical physicians of his day.


Bichat's Anatomie Gaicrale laid the foundation of the positive or modern method of the study of medicine, in which
theory and reasoning were replaced by observation and analysis.
Laennec, with the stethoscope, and with an accurate study of
disease at the bedside and in the post-mortem room, almost
created clinical medicine as we know it to-day.


Male.  
The study of fevers occupied the attention of all the great
physicians of the time. Fever — what it was, how it should
be treated. What a vast literature exists between Sydenham
and BroussaisI What a desolate sea of theory and speculation !




70.


•Read before the Stille Society of the Medical Department of the
University of Pennsylvania.


Good.




R. E.  
No one had been more influenced by Bichat's brilliant
teachings than Broussais, who ruled supreme in the medical
world of Paris in the early decades of this century. A strong
believer in careful observations at the bedside and in the jiostniortem room, he was led into hoj)eless error in attributing
fevers and many other disorders to irritation in the stomach
and intestines — his gastro-enteritis.  


Writing in the American Medical Recorder, July, 1831, an
American student, Dr. F. J. Didier, says of the Paris professors of that date, "They were always talking of Hippocrates,
Galen, Oelsns, etc., as if not a particle had been added to the
stock of knowledge since their time." And again, " The doctrines of John Brown, mixed up with the reninantsof humoral
pathology, form the basis of the present system."


" "
The same mi.xture prevailed early in the fourth decade,
as you may see from Broussais' Pathology, the American
edition of which was issued in 1833, and from Jackson's
(Samuel) Principles of Medicine, published in the same year.


Upon this scene, when Broussais was at the height of his
fame, came Louis. He, with his friends Andral and Chomel,
were very important factors in substituting finally in the
study of medicine, for speculation and theory, observation and
method.


Uncomplicated.  
The chief facts in Louis' life may be thus briefly stated. He
was born in 1787 at Ai. He began the study of law, but
abandoned it for that of medicine. He seems not to have




2 "


162


20/30
[Nos. 77-78.




61


beeu of a very strong constitution, as he did not pass the inspection for military service. He began the study of medicine
at Eheinis, and completed his course in Paris, where he graduated in 1813, in the twenty-seventh year of his age. While
waiting at home, hesitating what he should do, M. le conite
de Saint-Priest, who occupied au official position in Russia,
hajipened to stay for a few hours in the town of Ai to see
Louis' family, and it was suggested that the young physician
should accompany him to Russia. He consented and in
St. Petersburg obtained a diploma to practice. For three
years he seems to have had no settled abode, but wandered
about with his friend, who was Governor of one of the provinces. He then settled in Odessa, where he remained for four
years and practiced with great success. In the last year of
his stay in Odessa he was very much disturbed by the high
rate of mortality in children with diphtheria, and this appears
to have determined him to abandon for a time the practice of
medicine and to devote himself to study. With this object
in view he returned to Paris and for six months attended the
practice at the Children's Hospital. Among the younger
physicians in Paris he found an old fellow-pupil, Chomel,
physician to La Oharite, who offered him opportunities for
work in his wards. Louis at this time was thirty-four years
of age. Here for six years uninterruptedly he set himself to
work to study disease in the wards and in the post-mortem
i"oom. At first he appears to have occupied the position simply
as a voluntary assistant and friend of Chomel, but subsequently
he became his chef-de-cliniqiie, and during this period he occupied a room in the entresol of the hospital. He was a voluminous note-taker and collected in this time au enormous number of important facts.


Male.  
This remarkable feature in Louis' life has scarcely been
dwelt upon sufficiently. I know of no other parallel instance
in the history of medicine. It is worth while reading the brief
extract from Dr. Cowan's introduction to his translation of the
work on Phthisis. " He entered the hospital of La Oharite as
a clinical clerk, under his friend. Professor Chomel. For nearly
seven years, including the flower of his bodily and mental
powers (from the age of thirty-three to forty), he consecrated
the whole of his time and talents to rigorous, impartial observation. All private practice was relimiuished, and he allowed no
considerations of personal emolument to interfere with the
resolution he had formed. For some time his extreme minuteness of inquiry and accuracy of description wei'e the subjects
of sneering and ridicule, and cui bonof was not infrequently
and tauntingly asked. The absence of any immediate result
seemed for a time to justify their contempt of a method involving too much labor and personal sacrifice to be generally
popular or easily imitated ; and M. Louis himself, at moments,
almost yielded to the increasing difficulties of the task he had
undertaken. No sooner, however, were his facts sufficiently
numerous to admit of numerical analysis than all doubt and
hesitation were dissi2}ated, and the conviction that the path he
was pursuing could alone conduct him to the discovery of
truth became the animating motive for future perseverance.
Many of the results to which he arrived soon attracted general attention, and among those who had formerly derided his
method while they admired his zeal, he found many toapplaud




50.


and a few to imitate. From this moment may be dated the
presence of that strong impression of the necessity of exact
observation by which the school of Paris has beeu since so
distinguished, and which is now gradually pervading the
medical institutions of the continent and our own country; it
is undoubtedly to the author of the present volume that we
ought to ascribe the practical revival of that system, which
had for ages been verbally recognized but never before rigorously exemplified."


Good.
The following works appeared as a direct result of his
studies during these six years:*


" In 1823, a memoir on perforation of the small intestines,
in acute diseases; a second, on croup in the adult; a third, on
the communications between the right and left cavities of the
heart (Archives de medecine).


" "
" In 1824, two memoirs on the pathological anatomy of the
 
mucous membrane of the stomach ; another on pericarditis.


11 11
"In 1826, a memoir on abscess of the liver; another on the
condition of the spinal marrow in Pott's disease; a third on
sudden and unforeseen deaths; a fourth upon slow but anticipated deaths, but which anatomy will not explain; a fifth on
the treatment of tajuia by the Darbon potion (Archives de
medecine).


"In 1825, his Anatomical Researches, etc., on Phthisis (1
vol. 8vo) ; reprinted with many additions in 1843.


"  
" In 1828, Researches on the Typhoid Affection or Fever
(2 vols. 8vo); reprinted with many additions in 1841."  


Louis introduced what is known as the Numerical Jlethod,
a plan which we use every day, though the phrase is not now
very often on our lips. The guiding motto of his life was
"Ars medica tota in observation ibus," in carefully observing
facts, carefully collating them, carefully analyzing them. To
get an accurate knowledge of any disease it is necessary to
study a large series of cases and to go into all the particulars
— the conditions under which it is met, the subjects specially
liable, the various symptoms, the pathological changes, the
effects of drugs. This method, so simple, so self-evident, we
owe largely to Louis, in whose hands it proved an invaluable
instrument of research. He remarks in one place that the
edifice of medicine reposes entirely upon facts, and that truth
cannot be elicited but from those which have been well and
completely observed.


2 "
American medicine felt the influence of Louis through two
channels, his books and his pupils. Let us speak first of the
former. No French writer of the century has had such a
large audience in this country; all of his important works
were translated and widely read. The work on phthisis, the
first important outcome of five years' hard work at La Oharite
in Ohomel's wards, was published in 1825. Much had already
been done by physicians of the French school on this subject.
Bayle's important Recherchcs had been issued in 1810, and
Laennec had revolutionized the study of phthisis by the publication of his treatise on auscultation. I cannot enter into
any detailed analysis of the work, but it is one which I can
commend to your notice as still of great value, particularly as




20/40


* Brief Memories of Louis and some of his Contemporaries. H.
I. Bowditch, Boston, 1872.


62




Male.  
Adgust-September, 1897.]


163


50.




Good.  
a model of careful observation. The work was based ujjou the
study of 133 cases observed in Chomel's clinic. The lesions
observed at autopsy are first described under the different
organs, with great accuracy and detail, and then summarized,
following which is an elaborate description of the symjitomatology. I do not know of any single work on pulmonary
tuberculosis which can be studied with greater profit to-day by
the young physician. The fifty years which have elapsed,
since its publication, and the changes which have taken place
in our ideas of tuberculosis, diminish naught from the value
of his careful anatomical and clinical presentation of the subject.  


In 1829 appeared his second great work, Anatomical, Pathological and Therapeutical Researches upon the disease knoivn
under the name of yctstro-enterite, putrid, adynamic, ataxic,
typhoid fever, etc., com^mred with the most common acute diseases. It was based upon 138 observations made between 1822
and 1837. He analyzed and determined the lesions found in
fifty patients who had died of the typhus fever, and compared
these with alterations found in other acute diseases. Altogether for this work he states that he analyzed the changes in
the viscera of 133 subjects and the symptoms of nearly 900.
In his introduction to this work he quotes a sentence from
Rousseau which is always to be kept in mind : " I know that
truth lies in the facts, and not in the mind that judges of
them, and that the less I introduce what is merely my own
into the deductions I make from them, the more certain I
shall be of approaching the truth." This work was translated
by Dr. H. I. Bowditch in 1836. At the time of Louis' observations, although differences were recognized between the
various forms of continued fevers, the profession had no accurate knowledge of the subject. It so happened that at this
period the disease prevailing at Paris known as tyjihus was
almost entirely what we now call typhoid fever, so that the
anatomical lesions found by Louis in his fifty autopsies were
chiefly in the intestines ; in all the Peyer's glands were diseased.
His method was to analyze carefully the appearances found
in the different organs in the series of fever cases, and compare them with patients who had died of other acute diseases;
thus of course the contrast was striking in the very matter of
involvement of Peyer's glands, which were more or less seriously changed in structure in all of the patients with the fever,
while in the persons dead of other acute diseases the elliptical
patches had no special redness or softening.


L. E.  
The symptomatology was also given in great detail, and the
same painstaking comparisons were instituted between the
subjects of the typhoid affection and those of other acute diseases. Louis' work convinced a majority of the members of
the Paris school that the essential lesions in continued fevers
were in the intestines, and Louis himself apjiears not to have
had any idea whatever that the disease which he was studying
was in any way different from the disease jirevailing in other
parts of Europe and which we now know as tyjjlius fever.  


The next important memoir, the essay on Blood-letting,
had a very potent influence on professional opinion in this
country. It appeared in Paris in 1835 and was translated by
G. C. Putnam, with an introduction and appendix by Dr.
James Jackson. As this learned physician remarks in his


II II




"  
preface, " If anything may be regarded as settled in the treatment of disease, it is that blood-letting is useful in the class
 
of diseases called inflammatory, and especially in inflammations of the thoracic viscera." When one i-eads the reports of
 
the treatment by bleeding up to about the year 1840, one is
2 "
almost forced to ask the question, are the diseases the same ?
or surely the patients must have possessed much more
powerful constitutions than those which we are called upon
to treat at the end of the century.


At the time of Louis' return to Paris, under the influence
of Broussais' doctrine of irritation, local and general bloodletting was practised more extensively than at any previous
period in the history of medicine. As an interesting illustration it may be mentioned that the trade in France and Spain
in leeches had developed to proportions which assumed really
those of a national industry, and even in this country I
believe one of the medical societies offered a prize for the
best demonstration of the practical method of cultivating
leeches for medicinal purposes.


20/40
It must have been a terrible shock to Broussais and his
adherents when Louis attacked the subject of blood-letting in
pneumonia with his numerical method. For this purpose he
analyzed 78 cases, 28 of which proved fatal, and in a second
series 39 cases with 4 deaths. Among his conclusions were
that pneumonitis is never arrested at once by blood-letting, and
that the supposed haj)py effect on the progress of the disease
was very much less than was commonly believed. Incidentally he remarks with reference to the practice of blistering which was in vogue at the time, that he had rejected the
practice .after the treatment of 140 cases of pleurisy without
losing a case. I would refer you particularly to Putnam's
translation of this article, which you can obtain in any of the
libraries, not only for Louis' work, but for the excellent
introduction by Dr. Jackson on the value of the numerical
method in medicine, and also for the appendices, analyzing
the pneumonia cases of the Massachusetts General Hospital
from 1834 to 1834 (inclusive).


To American students one of Louis' most valuable works is
his Research on the Yellow Fever in 1828. On the 1st of
November, 1838, Louis, with Ghervin and Trousseau, left for
Gibraltar, where the disease prevailed. They made a very
careful study of the symptoms and morbid anatomy, and on
their return to Paris made a report to the Academy of Medicine, but the work remained in manuscript until Dr. Geo. C.
Shattuck translated it into English and it was published by
the Massachusetts Medical Society as Vol. X of their Library
of Practical Medicine. The work did not ajjpear in French
until 1844. It is chiefly valuable as a very accurate and
careful record of a series of cases studied clinically and
anatomically.


63
Powerful as was the effect of Louis' writings on American
medicine, it cannot compare with the influence which he
exerted through his pupils, who " caught his clear accents,
learned his great language, made him their model." Of the
great triumvirate of the French school of the fourth decade,
Louis possessed a singular power of attracting hard-working,
capable men, and this in spite of the fact that his rivals and
friends, Chomel and Audral, possessed more brilliant gifts of




Female.


164


55.  
[Nos. 77-78.  




Good.


a certain kind. As a writer in the Lancet said (1872, II),
" Year by year fresh bands of students came to imbibe from
his lips the instruction which their predecessors had abandoned
with reluctance, till his academic progeny knew no distinction of race or even color, but coalesced into a noble band of
enthusiasts in the cause of medicine, of science and of
humanity." In this academic progeny Louis' American
pupils take a very unusual position. Among the thousands
in the profession of this country who have during this
century sought light and learning in the older lands, the
group of young men who studied in Paris, between 1830 and
1840, had no predecessors and have had no successors.
Partly because the time was ripe and they were active agents
in bringing the new art and science to the New World, partly
owing to inherent capabilities, etc., but not a little because
the brightest minds among them fell under the influence of
Louis — they more than any others gave an impetus, which it
still feels, to the scientific study of medicine in the United
States.


"i ^.•■■^■
There had been, of course, in Paris many students from this
country prior to 1830, but they do not form a school, recognizable to us at present. One name comes to my mind, that
of the Rhode Island philosopher, Eiisha Bartlett, a jjeripatetic
of the peripatetics, in the days when men moved from city to
city, like the Sophists of ancient Greece. I do not know
whether when in Paris in 1828 he came personally under
Louis' influence— probably not, as Louis spent part of that
year in Spain — but he brought back recent French methods,
with Gallic lucidity and a keen appreciation of the value of
the numerical method. His well known work on Typhus and
Typhoid Fever, issued in 1842, is in itself a lasting witness to
the intelligence and progressive character of the younger
teachers of that day. With a clear separation of Typhus,
Typhoid, the Periodic and Yellow Fevers, it had at the date
of its publication no counterpart in Eurojiean literature, and
is in remarkable contrast to the chaotic treatises of Armstrong, Fordyce, Tweedie, Southwood Smith and othei'S.  


Without attempting to give a comjilete list, the following
were among the American students in Paris between 1830
and 1840:


11 11
From Boston, James Jackson, Jr., H. I. Bowditch, Oliver
Wendell Holmes, Geo. 0. Shattuck, Jr., John D. Fisher, J. C.
Warren (then past middle age), and J. Mason Warren.


From New York, John A. Swett, Abraham Dubois, Alonzo
Clark, Charles L. Mitchell, Charles D. Smith, Valentine
Mott, Sr., and John T. Metcalf.


''
From Philadelphia, Geo. W. Norris, W. W. Gerhard, Casper
W. Pennock, Thomas Stewardson, Alfred Stille, Thomas D.
Muter, J. Campbell Stewart, Charles Bell Gibson, John B.
Biddle, David H. Tucker, Meredith Clymer, Wm. P. Johnston,
W. S. W. Itusheuberger, Edward Peace, William Pep2)er, Sr.


Fi-om Baltimore, William Power.


2 "
From the South, Peter C. Gaillard, Gibbs, and Peyre Porcher of Charleston ; J. L. Cabell, L. S. Joyues, Selden and
Randolph of Virginia.


" And many more whose names on earth are dark " — men
of the stamp of Dr. Bassett of Alabama, who felt the strong
impulsion to know the best that the world offei'ed, every one


211/100




64
of whom has left a deep and enduring impression in his sphere
of work.


It would be impossible to tell in detail how Louis' students
brought back his spirit and his methods to their daily work,
and of the revolution which they gradually effected in the
study and in the treatment of disease. I can best, perhaps,
fulfill my object by referring somewhat fully to two of the
most distinguished among them, James Jackson, Jr., and W.
W. Gerhard.


Female.  
James Jackson, Jr., is the young Marcellus among the physicians of this country, "the young Marcellus, young, but great
and good." I do not know in our profession of a man who
died so young who has left so touching a memory. He was
the son of Dr. James Jackson, of Harvard, one of the most
distinguished of New England's physicians, a man to whom
our generation owes a heavy debt, since he, with Jacob Bigelow,
was mainly instrumental in bringing about more rational
ideas on the treatment of disease. Of Louis' pupils from this
side of the water, young .lackson seems to have been his special
favorite. After taking the B. A. degree at Cambridge in 1828,
Jackson attended the medical lectures at Harvard, and in the
spring of 1831 went to Paris, where he remained until the
summer of 1832. Returning home in 1833, he graduated in
medicine at Harvard in 1834. In the two years and a half of
his studies in this country before going abroad he had had
exceptional opi)ortunities with his father at the Massachusetts General Hospital, and showed his early industry and
ability by taking one of the lioylston Prize Essays before the
completion of his second year of study.  


In Paris he attended the practice of La Pitie and St. Louis.
He soon became devoted to Louis, and by him was utilized
to the full in the cholera epidemic in 1832. Two letters from
Louis to James Jackson, Sr., show how important he thought
a prolonged period of study was for a young man. He says:
" I pointed out to him (James Jackson, Jr.) the advantage
it would be for science and for himself if he would devote
several years exclusively to the observation of diseases. I now
retain the same opinion and am strengthened in it; for the
more T become acquainted with, and the more I notice him
applying himself to observation, the more I am persuaded
that he is fitted to render real service to science, to promote
its progress. I find that he would be well pleased to follow
for a certain period the vocation for which nature has fitted
him ; but he has stated to me that there are many difKculties
which would prevent his devoting himself exclusively to
observation for several years. But can these difKculties be
insurmountable?"


60.  
xVud again : " Let us sup2)ose that he should pass four
more years without engaging in the practice of medicine, what
amass of positive knowledge will he have acquired! How
many important results will he have been able to publisli to
the world during that period ! After that he must necessarily
become one of the bright lights of his country; others will
resort to him for instruction, and he will be able to impart it
with distinguished honor to himself. If all things be duly
weighed, it will appear that he will soon redeem the four
years, which men of superficial views will believe him to have
lost." In another letter, the following year, just before young




Bad.


August-September, 1897.]


165




11 11


Jackson's departure from Paris, he refers again to this question and urges Dr. Jackson to allow his son to devote himself exclusively to observation for several years in Boston.
The extract from this letter is worth quoting. "Think
for a moment, sir, of the situation in which we physicians are placed. We have no legislative chambers to enact
laws for us. We are our own lawgivers ; or rather we must
discover the laws on which our profession rests. We must
discover them and not invent them ; for the laws of nature
are not to be invented. And who is to discover these laws?
Who should be a diligent observer of nature for this purpose, if not the son of a physician, who has himself experienced the difficulties of the observation of disease, who
knows how few minds are fitted for it, and how few have at
once the talents and inclination requisite for the task ? The
inclination especially, for this requires that the observer should
possess a thorough regard for truth, and a certain elevation of
mind, or rather of character, which we rarely meet with. All
this is united in your son. You ought — for in my opinion it
is a duty — you ought to consecrate him for a few years to science. This, sir, is my conviction, and I hope it will be yours
also. I know very well that every one will not be of the same
opinion ; but what matters it, if it be yours ? — if you look upon
a physician, as I do, as holding a sacred office, which demands
greater sacrifices than are to be made in any other profession."


"  
Young Jackson's letter to his father, just as he was quitting
Paris, indicates on what affectionate terms he had lived with
Louis. " In two hours I am out of Paris. I will not attempt
to describe to you the agony it gives me to quit Louis. He is
my second father, and God knows that is a name I of all
men cannot use lightly. I may not persuade you to look upon
him with my eyes exactly as a scientific man ; but in your
heart he must have the share of a brother; for he almost
shares my affection with you. From one upon whom I had
no claims but those which my life and mind and habits gave
me, I have experienced a care, an affection which I never could
dare expect from any but my dear father, and which I shall
ever feel to be the most honorable and truly worthy prize of
my life."  


He seems to have inspired the same tender feelings in all
his American students. In the Memoir of Dr. Bowditch, to
which I have already referred, he speaks of Louis' fatherly
kindness to him during a prolonged attack of rheumatic fever
lasting for many weeks.


2 "
Young Jackson was one of the founders, in 1833, of the
Society for Medical Observation, which consisted of the ablest
of the students of Louis, Chomel and Andral. During his stay
in Paris he made an important study of cholera, which was
published in this country in 1833. It was most timely, as it gave
the profession here a very clear and accurate description of the
disease, of which up to that time they had had no experience.
Jackson's name, too, will always be associated with the studies
upon emphysema, and he is the discoverer of the prolonged
expiration in early pulmonary tuberculosis.


Returning to Boston in the autumn of 1833, he spent the
winter preparing for his degree and elaborating the notes which
he had taken in Paris. In March he fell ill with a dysentery, which proved fatal on the 37th of the month, in the


24/40




65
twenty-fifth year of his age. I know of no young man in the
 
profession who had given pledges of such exceptional eminence. His influence in extending Louis' methods and views
 
throughout New England was chiefly through his father, who,
Male.  
though a man approaching his sixtieth year, became an ardent
follower of Louis and the numerical method.  


In Oliver Wendell Holmes' recently issued Biography you
will find a delightful description of life at the Medical School
of Paris at this period. He bears witness to the good effect
which Jackson's warm friendship with Louis had had in promoting the interests of American students. I may conclude
with a quotation from Dr. Jackson's, Sr., memoir: "At the suggestion and request of one of my most judicious brethren I shall
add that my sou's influence on the profession here, in the
short time he was with us, was of a very salutary description.
This gentleman states that my son not only caused others, who
had not yet read the works of M. Louis, to study them with
care, but that he induced among the rising members of the
profession in our own city the habits of thorough observation
of the phenomena of disease in the living and in the dead,
which he had learned from the same great pathologist. He
also taught us much in respect to the physical signs of disease
in the thorax, with which we were imperfectly acquainted
before; at least I may say this was true as to myself. Indeed
I ought to say more, for he aided me very much in regard to
the diagnosis of the more obscure diseases of that region,
derived from the combination of the physical and rational
signs. On emphysema of the lungs he threw, for me, quite a
new light."


55.  
Wm. W. Gerhard was the most distinguished of the American pupils in Paris between 1830 and 1840. When you call
to mind the men whom I have mentioned, this may seem a
strong statement, but I feel certain that could we take their
suffrages they would accord him the place of merit in consequence of the character of his work. Dr. Gerhard was born
in Philadelphia, in 1809, and was graduated from the University of Pennsylvania in 1831. Early in the year he went to
Paris and attached himself to Louis at La Pitie. In one of
his letters* to his brother, dated January 18, 1833, he says:
"Dr. Louis is delivering an interesting clinic at La Pitie ; he
is a remarkable man, very different from the physicians of
Eni^land or America, and remarkable even at Paris by the
strict mathematical accuracy with which he arrives at his
results ; he is not a brilliant man, not of the same grade of
intellect as his colleague at La Pitie, Andral." In another
letter he gives an account of his day's work. "The morning
from seven to ten is occupied with the visit and clinic at the
hospital ; there are several distinct clinics now in actual proo-ress; each of them has its advantages. I shall vary my attendance at the different hospitals and select those lecturers
who are of real merit. At this moment we are following
ing Piorry at the SalpetriOre, a very distant hospital, two or
three miles from our lodgings; his patients are all old women,
and not interesting. My object in following his course is to
obtain some interesting information on the best mode of




Good.


* I am indebted to members of Dr. Gerhard's family for the letters
from which these extracts are taken.


!! L.E.




11 11
166


[Nos. 77-78.


Mild iritis.




5 "  
investigating the diseases of the chest. M. Piorry has devoted
special attention to this subject. From Salpetriere we hurry
to La Pitie; we hear a surgical lecture, reach home to breakfast, and then to the school of medicine. The lectures at the
school, with a private course of anatomy during the hour of
intermission, fill up the remainder of the day until four. Fortunately a private clinic at La Charite introduces me to a set
of very interesting cases, especially on pectoral cases. Dr.
Dagueau has a class who pay him ten francs a month and
enjoy the privilege of examining the patients much more conveniently than is practicable during the morning visit in the
midst of a crowd of students. We dine at five-thirty and then
lectures again until eight o'clock. Imagine the facilities, the
delightful advantage of acquiring positive information, and
what is at least as important, of learning the mode of obtaining these positive results. We see and hear the men who are
so well known to us in America, learn to form a correct estimate of their relative worth — in short, one of the most striking
advantages of a medical visit to Europe is to acquire the sort
of liberal professional feeling which is rarely secured by the
continued intercourse with the same men, and the unpleasant
medical politics which divide the profession in America."  


Evidently Broussais made no special impression on Dr.
Gerhard. He says, " Broussais is the best known, his reputation is universal, and the benefits he has conferred on medicine are immense, but unfortunately he is a wretched lecturer.
His own opinions are given in the most awkward, clumsy
manner; the manner and style of lecturing are coarse and
vulgar."


20/70
In another letter of February 3, 1833, he tells how he
induced Louis to give them private instruction. To his
brother he writes : " I must write you at least a few days before
the excitement has passed off : can you imagine how fortunate
I am — devinez si vous pouvez— two or three days ago, Jackson,
Pennock and myself were talking of hospitals and morbid
anatomy, when the idea occurred of attempting the study
of pathology in a particular manner. It was this: to obtain
the specimens and study them, the authors in our hand,
exactly and carefully comparing authorities with the subject
before us. We addressed ourselves to two of the internes at La
Pitie attached to the salles of Louis and And-ral, and they agree
to procure all facilities in their power and communicate their
own information for the compensation of 60 francs from each
of us ; we accordingly visit La Pitie on three afternoons of the
week and examine the parts at the hospital, afterwards carrying home such portions as require minute investigation. Our
first success in this opening of new sources of instruction
emboldened tis to attempt something of higher importance.
We were all desirous of studying auscultation, of studying it
in such a manner as to be sure of our ground on our return,
and to be capable of appreciating the advantages of the art.
Louis' public instructions were valuable, but his private
lessons upon a subject demanding minute and patient inquiry
we knew would be infinitely moi'e so. I therefore in the name
of my friends addressed him a polite note, accomjianied by a
handsome pecuniary offer; we did this with little hopes of
success, but happily for us he accepted our proposition, and
next week we are his private pupils at La Pitie. We are, I




66


believe, the first who have made this arrangement with M.
Louis, and you may estimate its importance when I tell you
that he is considered in excellence of diagnosis the successor
of Laennec. Our advantages for the study of pathology and
the diagnosis of diseases of ttie chest are now superior ; they
are indeed the very best in the world, and our eagerness to
embrace them will, I hope, render them of real utility ; of
course they involve an additional expenditure of 400 or ."300
fr., but I should be happy to shorten my stay at Paris a mouth
to improve the remainder of my time in this manner, if such
were necessary for me. Pennock and myself are very happy
to have become intimate with .Jackson ; he has superior talents,
and his excellent education, conducted by his father, unquestionably the first physician in America, has cultivated his mind
and developed an ardent attachment to medicine."


Female.  
Few American students have occupied their time abroad
 
to greater purpose than Dr. Gerhard. He appears to have
been an indefatigable worker, and the papers which he published based upon material collected in Paris are among the
most important which we have from his pen. Thus with
Pennock he described Asiatic cholera in 1832. Devoting
himself particularly to the study of diseases of children, he
issued a very interesting paper on small-pox, and two papers
of very special value, the first on tuberculous meningitis and
the other upon pneumonia in children. Both of these papers
mark a distinct point in our knowledge of these two diseases.  
He is usually accorded the credit of the first accurate clinical
study of tuberculous meningitis.


62.  
Late in the year 1833 he returned to Philadelphia, and at
his suggestion his friends had secured him the appointment
as resident physician at the Pennsylvania Hospital, which he
took early in 1831. This step indicated how carefully he had
weighed the important influence in Louis' career of the years
of quiet work at La Charite. At the Pennsylvania Hospital
he had an opportunity to study the common continued fever
of the country, and determined that it was identical, clinically
and anatomically, with the typhoid fever of Louis, and characterized by a special lesion in the glands of Peyer. I do not
know exactly how long he remained resident physician at the
Pennsylvania Hospital, but he was soon after appointed one
of the physicians at Blockley, and here in 1836 he was able io
carry out his most important piece of work. The general
opinion prevailed that the fever which Louis described and
which had the lesions in the small bowel was only a modification of the ordinary typhus fever which at that time prevailed so extensively, particularly in Great Britain and
Ireland. In London, Edinburgh and Dublin the intestinal
lesions were regarded as only accidental, and not indicative of
a special affection. Dr. Gerhard knew the typhoid fever of
Louis well, and had had an opportunity of studying it again
at the Pennsylvania Hospital, so that when the epidemic of
typhus fever developed in 1836 he was in a very good position
to make an accurate study of the disease. Two hundred and
fourteen cases were observed, and as a result of his study he
declared positively that the typhus fever, which was similar
to the disease which he had also seen in Edinburgh, was a
different affection altogether from the typhoid fever with
intestinal lesions. These observations, vou must remember.  




Good.


August-September, 1897.]


167




11 11


were made in 1836, at a time when the greatest confusion
existed as to the forms of fever. It took a great many years
in Great Britain before the duality of the prevalent fever was
recognized, but owing to the influence of Gerhard's paper,
and to the accurate knowledge of fever brought to this
country by Louis' pupils, the differentiation of the two
diseases was here quickly recognized, since, as already mentioned, Bartlett in 1812 considered them apart.


Uncomplicated.  
Gerhard's work influenced his Paris friends greatly, and
this was strengthened by the papers read before the Society
for Medical Observation by Geo. C. Sbattuck and Alfred
Stille, of whom the former had had opportunities of studying
typhus fever in Great Britain, while the latter had been one
of Gerhard's house physicians in the typhus epidemic at
Blockley. Shattuck's paper is published in the Medical
Examiner for 1840. I have always regretted that Dr. Stille's
paper has never appeared in print. He was kind enough to
let me see it, and, as I have mentioned elsewhere, the differential points between typhus and tyi^hoid fever are nowhei-e
more clearly laid down.  


The University of Pennsylvania early took advantage of
Gerhard's training and utilized him as clinical lecturer at the
Philadelphia Hospital. He soon acquired a special reputation
in diseases of the heart and lungs. In 1842 appeared the first
edition of his work on Diseases of the Chest, which ran through
four editions, and is still a valuable work of reference. One of
his fellow-students in Paris, Stewardson, has given a very pleasing picture of him as a clinical teacher : " As a clinical teacher
he was remarkably successful and exerted a powerful and
commanding influence. Without any pretension to eloquence,
he nevertheless riveted the attention of his hearers and
stimulated their enthusiasm. Himself deeply interested in
bis subject, he communicated this interest to his audience by
the sheer force of truth. Students saw that truth was his
object, not display ; the advancement of science, and not the
gratification of personal feelings, whether of vanity or ambition; in short, that in his mind, a deep interest in his subject
and a thorough conscientiousness in the pursuit of it were
the overmastering motives. In an easy and conversational


2 "




Not tested.  
style he presented to his hearers a graphic portraiture of the
case before them, bringing into relief its most important
symptoms; impressing upon their minds the most striking
features in its history; pointing out, by a few clear and
practical expressions, the bearing of any particular fact upon
interesting medical questions, but avoiding long and labored
arguments, or general disquisitions upon the nature of
diseased action. He neither stimulated the fancy by the
flowers of rhetoric, nor amused the intellect with episodes upon
theoretical questions, but confined himself to drawing such
practical conclusions as were clearly deducible from the facts
presented. No man of his day enjoyed so high a reputation
as a clinical teacher, and not only did he succeed in an eminent
degree in arousing the enthusiasm of students and putting
them in sympathy with himself, by infusing into them his
own ardor in his favorite study ; but he produced an influence
upon the profession here which is felt still, which has fostered
the establishment of clinical teaching among us, and done
much to give it that rank which it now occupies here as a
branch of medical instruction."


Of the work of Louis' other students in this country time
would fail me to tell — of the influence of Bowditch, Holmes
and Shattuck in Boston, of Swett, Clark and others in New
York, of Pennock, Stewardson, Stille in Philadelphia, and of
Power in Baltimore. To them all we owe a heavy debt of
gratitude. They brought from Paris enthusiasm, faith in the
future, faith in the profession of their choice, accurate
methods and a loyal love of truth. Endowed with the spirit
and zeal of their master, they carried his great message to the
New World ; and more than this, touched with those finer
qualities which made Louis so lovable, they have become
bright ideals for all future generations of American students.


67
There remain, so far as I know, three only of the Paris
 
students of whom I have spoken, John T. Metcalf, Meredith
 
. Clymer, and your honored patron, Alfred Stille. They, too,
Male.  
must soon go the way of all the earth ; but among the consolations of old age what greater solace can they feel than that
the lives of the men whose fathers and grandfathers they
taught are still made better by their presence.  




75.


WILLIAM HARVEY AS AN EMBRYOLOGIST.*


Bad.  
By William K. Brooks, LL. D., Professor of Zoology, Johns Hoiikins JJniversUy.  




" "


The immortal discoverer of the circulation of the blood is
held to be also the discoverer of the law of embryology —
"that all animals are produced out of ova" (Encyc. Brit.,
9th ed., art. Embryology, p. 164); and he is also held to have
had some vague premonition, scarcely worth mentioning in
history, of the great law that the complex animal arises, from
a relatively homogeneous germ, by gradual differentiation or
epigenesis.


Simple Ext.
I hope to show, by quotations from his work on embryology
(Exercitationes de Generatione Animalium, Amstelodami,




"


■ Read before the Johns Hopkins Historical Club, February, 1897.


2 "




Atrophy.  
1651, translated into English by Robert Willis, M. D., London,
1848), that both these current impressions are erroneous. He
not only formulated but demonstrated epigenesis. liis statement of this law is clear, definite and thoroughly modern,
and it is based upon actual observations which are fully
described.  


On the other hand the conception which he sought to
express by the dictum "omne vivum ex ovo" is totally foreign
to the principles of modern embryology. Harvey was a worker,
not a dreamer, and his dictum is no mere guess or happy inspiration. It sums up results reached by laborious research, and
as a generalization based on actual study it still has value,


68




Male.  
although its meaning has nothing in common with tliat
which the words have as we now use them. He repudiates in
most energetic language the opinions, current at his time,
which come nearest to the modern discovery that the physical
continuity of living matter is never broken. In fact the chief
aim of his treatise is to show that his observations, as he interpreted them, prove that there is no physical or " corporeal "
continuity between parent and child.  


Embryologists who permit Germans to write the history of
their science, and make no protest when the demonstration
that the embryo arises from the egg by epigenesis is attributed to Wolff (1759), and to Von Baer (1839), are either
ignorant of Harvey's researches (1651) or indifferent to the
fame of this great Englishman, who studied the history of
the chick as laboriously and faithfully as Von Baer, nearly
two hundred years before. While his resources were more
limited, his ability to reflect upon the meaning of his observations and to state in clear and energetic words the results of his
" Beobachtung und Eeflexion," were inferior in no way to those
of the justly famous author of the "Entwickeluugsgeschichte
der Thiere."


75.  
Harvey means just what more modern writers mean by
"epigenesis," but the strangeness of the views he opposed
gives us difficulty. The form of words into which an account
of a scientific discovery falls is fixed by the view of the matter
which is current at the writer's day, and later generations of
readers may be puzzled by inability to occupy his standpoint.
Thus it is with Harvey, and we thus explain the prevalence
of the opinion that he had no more than a dim adumbration
of truths the demonstration of which is generally credited to
Wolff and Von Baer.  


The evolutionary teachings of Bonnet are quite intelligible
to us; and as we easily put ourselves in Von Baer's place, his
refutation of Bonnet appeals to us with all its native force;
but it is much harder for us to stand where Harvey stood.


Bad.  
So far as I can discover, no notion at all equivalent to
Bonnet's conception of germs ever entered Harvey's mind or
the mind of any one before his time. He presents the evidence
for epigenesis as opposed, not to "evolution," but to "metamorphosis," and his way of using the last word is so unfamiliar
to us that we cannot grasp what he has in mind without
effort.  


They who studied embryology before him held one modification or another of the very ancient belief that embryos arise
from "excrement"; that they are products of decomposition.


R. E.  
He gives the evidence for epigenesis as opposed to this
opinion which finds no pigeon-hole in the modern mind.  
Fortunately he is a ready writer. Hlustrations and analogies
overflow his brain and pen; and patient study enables us to
pick out passages which give his views on epigenesis uncomplicated by reference to " metamorphosis." When we have
done this we find his reasoning as modern and definite as that
of Von Baer, although his resources did not qualify him to
sum up the evidence with modern exhaustiveness.  


While Harvey does not deny that some " imperfect " animals
may be genei-ated "out of a putrescent material, the drying of
a moist substance, or the moistening of a dry one," he tells us,
clearly and definitely enough, that the generation of all "per


Iridectomy.


fect " animals, such as the lion and the cock, " is the result of
epigenesis as the man proceeds from the boy; the edifice of
the body, to wit, is raised on the punctum saliens as a foundation ; as a ship is made from the keel, and as a potter makes a
vessel . . . For out of the same material from which the first
part of the chick or its smallest particle springs, from the
very same is the whole chick born ; whence the first little
droji of blood, thence also proceeds its whole mass by means
of generation in the egg ; nor is there any difference between
the elements which constitute and form the limbs or organs
of the body, and those out of which all their similar [i. e.
homogeneous] parts, to wit, the skin, the flesh, veins, membranes, nerves, cartilages, and bones derive their origin. For
the part that was at first soft and fleshy, afterwards, without
any change in the matter of nutrition, becomes a nerve, a
ligament, a tendon ; what was a simple membrane becomes an
investing tunic ; what had been cartilage is afterwards found
to be a spinous process of bone, all variously diversified out of
the same similar [homogeneous] material." From what "appears to be homogeneous in the beginning and resembles the
spermatic jelly" the structure of the body arises; its parts
being "at first delineated by an obscure division, and afterwards become separate and distinct organs."


"  
He says the result of the process of development is just
 
as if the chick were created by a command to this effect:
 
" Let there be a similar [homogeneous] colorless mass, and let
2 '•
it be divided into parts and made to increase, and in the
meantime, while it is growing, let there be a separation and
delineation of parts ; and let this part be harder and denser
and more glistening, that be softer and more colored."


" Now it is in this very manner that the structure of the
chick in the egg goes on from day to day; all its parts are
formed, nourished and augmented out of the same material.
. . . For there is a greater and more divine mystery in the
generation of animals than the simple collecting together,
alteration and composition of the whole out of parts would
seem to imply; inasmuch as here the whole has a separate
constitution and existence before its parts, the mixture before
the elements."


0. Nerve.  
These passages summarize conclusions from observations
which have been more fully described in forty-four preceding chapters or "exercises," and it would be difficult, even at
the present day, to state in more definite language the truth
that the developing embryo passes " from indefinite, incoherent
homogeneity to definite, coherent heterogeneity by successive
integrations and differentiations."


While we have no desire to ignore the merits of Wolff or to
belittle the greatness of Von Baer, we find it hard to understand how any one who knows Harvey's works can, without
protest, read this assertion or similar ones in the German
works from which it is derived:


69
" It was reserved for Caspar Frederick Wolff, a German by
birth ... to bring forward observations which . . . established
the theory of epigenesis upon the secure basis of ascertained
facts" (Encyc. Brit., 9th ed.. Embryology, 1(35).


We now know that the germ itself is an organism of wonderful complexity ; that its homogeneity is relative, not absolute ; but there is great mystery to us as well as to Harvey in the


Female.




60.  
August-September, 1897.J


169


Good.




" "  
manner in which " the whole has a separate constitution and
existence before its parts," and while the doctrine of "metamorphosis " as held in Harvey's day has vanished from
science, I venture to believe that we shall Knd in his discussion of this doctrine, clear statement of other difficulties
which are still as grave as he found them.


It is hard to decide just what his opinion on spontaneous
generation was. No less careful a student than Huxley tells
us (Encyc. Brit., 9th ed., art. Evolution, p. 746) that "Harvey
believed as implicitly as Aristotle did in the equivocal generation of the lower animals." "Harvey shared the belief of
Aristotle — whose writings he often quotes, and of whom he
speaks as his precursor and model, with the generous respect
with which one genuine worker should regard another — that
such germs may arise by a process of 'equivocal generation'
out of non-living matter."


"  
1 am by no means confident that this assertion does justice
to Harvey, or that the quotations from Aristotle prove anything except that Harvey was not yet quite prepared to
demonstrate their error. I believe there is ample evidence that
he had made many observations which, while he never published them, led him to distrust most of the familiar examples of spontaneous generation, although he may not have
been fully armed to attack the teachings of " my leader,"
Aristotle, "one of nature's most diligent inquirers," "whose
authority has such weight with me that I never think of differing from him inconsiderately." It is true that he quotes without comment, and occasionally without credit, many passages
in which Aristotle affirms sjjontaneous generation ; but as an
offset to this he tells us explicitly (Exercise the forty-first)
that he shall show in another place " that many animals,
especially insects, arise and are propagated from elements and
seeds so small as to be invisible (like atoms flying in the air),
scattered and dispersed here and there by the winds ; and yet
these animals are supposed to have arisen spontaneously, or
from decomposition, because their ova are nowhere to be
found." He was far too cautious to have ventured to criticise " the philosopher," even to this extent, without pretty
good evidence; and in Exercise the sixty-ninth he tells us
why this evidence was never published. "Let gentle minds
forgive me," he asks, "if, recalling the irreparable injuries I
have suffered, I here give vent to a sigh. This is the cause
of my sorrow: — whilst in attendance on his majesty the king,
during our late trouble and more than civil wars, not only
with the permission but by the command of the Parliament,
certain rapacious hands stripped not only my house of all its
furniture, but, what is subject of far greater regret with me,
my enemies abstracted from my museum the fruits of many
years of toil. Whence it has come to pass that many observations, parlictilarly on the generation of insects, have perished, with detriment, I venture to say, to the republic of
letters."  


Is there not reason to believe that, if they are ever discovered,
those lost observations will be found to cover some of the
ground which was so successfully explored by Spalanzanni
more than a hundred years later ?


"  
Harvey's reference (Exercise the twenty-seventh) to " the
animalculae which are engendered in our bodies . . . lumbrici,




2 "


ascarides, lice, nits, syrones and acari," and to " the worms
which are produced from plants and their fruits, as from gallnuts, the dog-rose, and various others," might be held to imply
belief in heterogenesis, if he did not tell us, almost immediately,
that: "It certainly cannot be that the living principles of
these animals which arise in the gall-nuts existed in the oak,
although these animals live attached to the oak and derive
their sustenance from its juices."


20/40
Notwithstanding Huxley's opinion, Harvey seems to have
been nearer than any of his successors for a hundred years to
the modern discovery that all living things come from germs,
although I shall show soon that he did not intend to imply
anything at all like the modern view by his statement that
this is true.


In his discussion of epigenesis as contrasted with " metamorphosis," he assumes the reality of " equivocal " generation, as he does in many other places, although, in view of the
passages I have quoted, I believe that this is admitted out of
courtesy to Aristotle, and for the sake of the argument, as
something which he is not yet fully prepared to disprove.


70
He tells us (Exercise the forty-fifth) that there are two ways
 
in which one thing may be made out of another. When a
 
workman cuts the material already prepared, divides it and
Female.  
rejects what is superfluous, till he leaves it in the desired
 
shape, as in nuiking a statue from a block of stone, the whole
 
material of the future piece of work has already been in existence before it is finished into form or any part of the work is
60.  
yet begun. AVhen on the other hand a potter educes a form
out of clay by the addition of parts, increasing its mass, and
giving it a figure, at the same time that he provides the material, which he prepares, adapts and applies to his work, "the
form may be said rather to have been made than educed."
" So exactly it is with regard to the generation of animals.
Some, out of a material previously concocted and that has
already attained its bulk, receive their forms and transfigurations ; and all their parts are fashioned simultaneously, each
with its distinctive characteristics, by the process called metamorphosis, and in this way a perfect animal is at once born;
on the other hand, there are some iu which one part is made
before another, and these from the same material afterwards
receive at once nutrition, bulk and form ; that is to say, they
have some parts made before, some after others, and these are
at the same time increased in size and altered in form. The
structure of these animals commences from some one part as its
nucleus and origin, by the instrumentality of which the rest
of the limbs are joined on, and this we say takes place by the
method of epigenesis, namely by degrees, part after part; and
this is, in preference to the other mode, generation properly
so called. In the former of the ways mentioned, the generation of insects is effected when by metamorphosis a worm is born
from an egg ; or out of a putrescent material, the drying of a
moist substance or the moistening of a dry one, rudiments are
created from which, as from a caterpillar grown to its full size,
or from an aurelia, springs a butterfly or fly already of a
proper size, which never attains to any larger growth after it
is first born. But the more perfect animals with red blood are
made by epigenesis or the superposition of parts. In the
former, chance or hazard seems the principal promoter of gen




Good.
170


[Nos. 77-78.


L. E.




"  
eration, aud the form is due to the potency of a pre-existing
material ; and the first cause of generation is 'matter ' rather
than an ' external efficient,' while the more perfect animals
owe their immortality to one constant source — the perpetuation of the same species . . . Bees, wasj^s, butterflies, and whatever is generated from caterpillars by metamorphosis, are said
to have sprung from chance, aud therefore to be not preservative of their own race. . . . The lion and the cock owe their
existence, as it were, to nature, or an operative faculty of a
divine quality, and require for their propagation an identity of
species, rather than any supply of fitting material." " In the
generation by metamorphosis forms are created as if by the
impression of a seal, or as if they were adjusted in a mould . . .
but an animal which is created by epigenesis attracts, prepares, elaborates, and makes use of the material all at the same
time. The processes of formation aud growth are simultaneous.
In generation by metamorphosis the whole is distributed and
separated into parts, but in that by epigeuesis the whole is put
together out of parts, in a certain order, and constituted /ro?»
them. In the one case the result is due to matter ; in the other
the animal makes itself.


" Now it appears clear from my history that the generation
of the chick from the egg is the result of ejjigenesis rather than
of metamorphosis, and that all its parts are not fashioned
simultaneously, but emerge in their due succession and order;
it appears, too, that its form proceeds simultaueously with its
growth, aud its growth with its form; also that the generation of
some parts supervenes on others previously existing, from which
they become distinct; lastly, that its origin, growth aud consummation are brought about by the method of nutrition.


"  
" The formative faculty of the chick rather acquires and
prepares its own material than only finds it when prepared,
aud the chick seems to receive its growth from no other than
itself. And as all things receive their growth from the same
power by which they were created, so likewise should we
believe that the chick is created by the same power by which
it is preserved and caused to grow."  


The meaning of this rather puzzling passage will be somewhat clearer after we have examined Harvey's views on generation, but when we omit the complications which come from
the reference to "metamorphosis," its meaning as interpreted
by the rest of the essay is about as follows :


2 "  
The substance which composes the body of all "perfect"
animals does not exist as such before the body itself is formed;
but it consists of unorganized or "homogeneous " food which
is changed by nutrition into all the diversified parts of the
complicated body, so that nutrition, growth aud development
go on together. As the organized body is constructed by the
assimilation of unorganized food, its structure cannot be the
outcome of the ordinary or physical properties of this food.
There must be some organizing iufiuence at work making use
of these properties to construct out of homogeneous matter a
definite organism belonging to the same species with the
parents. To the question what this organizing influence is,
he answers that this is a " divine mystery," or, in plain
English, that he does not know, although he finds clear evidence of its existence. He says in many places that the egg
has a ■' vital principle," but the context shows that he means




20/70


by this no more than we mean when we say it is " alive," and
nothing is farther from his thoughts than recourse to supernatural agencies, for he tells us clearly that while the cause of
its development is a " divine mystery," " the egg is a natural
body endowed with animal virtues ... it is moreover a body
which under favorable circumstances has the capacity to
pass into an animal form; heavy bodies, indeed, do not sink
more naturally, nor light ones float, when they are unimpeded,
than do seeds aud eggs in virtue of their inherent capacity
become changed into vegetables aud animals." (Exercise the
twenty-sixth, p. 373.)


71
It would be a gross error to infer, from this passage or
from others like it, any further similarity between Harvey's
opinions aud the results of moderu microscopic study of ova
and male cells. In order to understand the meaning of his
celebrated dictum " omne vivum ex ovo " we must undertake
more extended analysis of his observations aud reflections on
generation, aud of the opinions of his predecessors.


Aristotle saw nothing strange or exceptional in the generation of animals from decomposing organic matter, for he
believed that all generation takes place in essentially the same
way ; and he regarded the generation of insects from putrescent slime as a simple or typical example, what we should
now call a primitive type, of generation in general, in comparison with which more complicated instances are to be
interpreted.


Female.  
As a bloody substance is discharged at intervals from the
reproductive organs of woman, during the fertile period of her
life, and as its apjiearance marks the beginning and its cessation the end of fertility, he believed that the mammalian
embryo is formed out of this substance just as other animals
are generated from decomposing matter of other kinds.  


" Milk aud the menstrual discharge," he tells us (De Gen.
II, i), " are of the same nature." " When the semen masculinum enters the female uterus it coagulates the purest part
of the catamenia," aud when this has " set in the uterus " it
forms a coagulum like curdled milk. As heat causes milk to
curdle, so " the semeu or geniture of the male bears the same
affinity to the nature of the catamenia " aud causes it to " set "
without itself contributing any part of the substance of the
coagulum. " The female always supplies the matter, the
male the power of creation, and this it is which constitutes
one male and another fenuile." "The male is the efficient
agent, aud by the motion of his geniture creates what is
intended from the matter contained in the female." " The
body and the bulk therefore are necessarily supplied by the
female; nothing of the kind is required from the male; for
it is not even requisite that the instrument, nor the efficient
agent itself, be present in the thing that is produced. The
body then proceeds from the female ; the life (anima) from
the male."


66.  
Harvey points out the inconsistency of Aristotle's admission
 
that hybrids "partake of the species of both parents" (De
Gen. Anim. II, 3), and his assertion that '• the conception or
egg receives '" "from the feuuile its body solely and its dimensions," and that the mother has no part in the trausmissiou
of "form, species and life"; for the studj" of jiybrids shows
the error of his opinion that creative force or vital power is


Good.




R. E.
August-September, 1897,


171


"




Iritis.  
derived exclusively from the male, and proves that both
parents must be efficient in determining form or species.  


The medical men of Harvey's day held a different opinion,
as he tells us iu Exercise the thirty-second. Like Aristotle,
they held that the embryo arises from "excrement"; but
they held, in opposition to his teaching, " that the prime
matter of conception is not blood, but the mingled geuitures
of both sexes." They also held, iu opposition to Aristotle,
the opinion, which Harvey shares, that the male is no more
" the efficient cause of generation " than the female.


3 "  
"Conception, according to the opinion of medical men,
takes place in the following way: during intercourse the
male and female dissolve in one voluptuous sensation, and
eject their seminal fluids (geniturae) into the cavity of the
uterus, where that which each contributes is mingled with
that which the other supplies, the mixture having both
equally the faculty of action and the force of matter; and
according to the predominance of this or that geniture does
the progeny turn out male or female. It is further imagined
that immediately after the intercourse something of the conception is formed iu the uterus."  


If the uterus contains a " conception " immediately after a
fertile union, in the form of a bloody coagulum, as Aristotle
supposes, or iu the form of the mingled emissions or geuitures
of both sexes, as the medical men taught, this ought to be
discoverable, and Harvey, a true scientific investigator, set
himself to hunt for it without a microscope.


20/100
His facilities for making the search, and its results, are best
described in his own words. He was the attending physician
of the King of England, and he tells us : " It was customary
with his Serene Majesty, King Charles, after he had come to
man's estate, to take the diversion of hunting almost every
week, both for the sake of finding relaxation from grave cares
and for his health; the chase was principally the buck and
the doe, and no prince iu the world had greater herds of deer.
This gave me an opportunity of dissecting these animals
almost every day during the whole of the season when they
were rutting, taking the male and falling with young. I had
occasion so often as I desired it to examine and study all their
parts, particularly those devoted to the offices of generation."


His studies upon the development of the embryo of the
deer are fully described at length in the essay on generation,
but only those which relate to the question of conception
concern us at present. Here his researches had a very definite
result, "llepeated dissections performed in the course of the
month of October, both before the rutting season was over
and after it had passed, never enabled me to discover any
blood or semen or a trace of anything else, either in the body
of the uterus or its cornua." Neither the bloody coagulum
of Aristotle nor the geniture of the medical men has any existence. The "conception" which should be discoverable iu
the uterus if their teachings are correct, cannot be found there
when a search is made for it, and actual observation shows
that their teachings are erroneous and fanciful.


72
The keepers and huntsmen said " that I was both deceiving
myself and had misled the king, and that there must of
necessity be something of the conception to be found in the
uterus. These men, however, when I got them to bring their




Male.


own eyes to the inquiry, gave up the point." Harvey tells us
that the king fully appreciated the value of the investigation,
and in order " that this important question might be the more
satisfactorily settled in all time to come," provided means for
isolating the does and for proving that there was no error as
to the fact of conception ; but the physicians were still unconvinced, and "held it among their impossibilities that any
conception should ever be formed without the presence of the
semeu masculinum, or some trace remaining of a fertile intercourse within the cavity of the womb." But the man who
had proved the error of their teachings regarding the function of the heart and blood-vessels had little tolerance for
their belief iu anything which they were unable to demonstrate.


80.  
If they had insisted that Harvey's resources were inadequate, that the "conception" for which he sought is too
 
minute to be found by such rough means, we now know they
 
would have been in the right, for even at the present day our
Good.
knowledge of the essential facts of mammalian conception is,
 
for the most part, a deduction from observations on the eggs
 
of animals which were almost or quite uuknown to Harvey,
L. E.  
the sea-urchin and ascaris, for example. But his proof of
 
the non-existence, in the uterus of the doe, of anything corresponding to their teachings is conclusive. He did not stop
 
here, however, for he tells us: " In the dog, rabbit and several
"  
other animals, I have found nothing iu the uterus for several
days after intercourse ; I therefore regard it as demonstrated
that after fertile intercourse among viviparous as well as
oviparous animals there are no remains in the uterus either of
the semen of the male or of the female emitted in the act;
nothing produced by any mixture of these two fluids, as medical writers maintain, nothing of the menstrual blood present
as 'matter' iu the way Aristotle will have it; in a word, that
there is not necessarily even a trace of the conception to be
seen immediately after fruitful union of the sexes. It is not
true, consequently, that in a prolific connexion there must be
any prepared matter in the uterus, which the semen masculinum, acting as a coagulating agent, should congeal, concoct and
fashion or bring into a positive genei'ative act."  


His study of the generation of birds leads him to the same
result. "As the hen does not emit any seminal fluid, and as
the seminal fluid of the cock does not reach the uterus of the
heu, and as there is no trace of an egg to be found in the
uterus immediately after intercourse, it is obvious that it is not
engendered" by the mixture of seminal fluid in the way the
medical men teach (Exercise the thirty-second). After quoting
Aristotle's opinion that the chick is formed out of menstrual
blood coagulated by the influence of the cock, he says (Exercise
the twenty-first) : " The business in the generation of an egg is
very different from this; for neither does the semen or rather
the 'genitura' proceeding from the male in the act of intercourse, enter the uterus in any way, nor has the hen after
she conceives any particle of excremeutitious matter, even of
the purest kind, or any blood in her uterus which might be
fashioned or perfected by the discharge of the male. Neither
are the parts of the egg produced by any kind of coagulation ;
neither is there anything like curdled milk to be discovered
iu the uterus. The cock, I say, contributes neither form nor


Irido-cyclitis.




8 "
172


[Nos. 77-78.


Light perception.




73
matter to the egg, but that only by which it becomes fertile and
fit to engender a chick. And this faculty the cock confers by
his semen (genitura) emitted in the act of intercourse, not
only on the egg which is already begun, but on the uterus
and ovary and even on the body of the fowl herself, in such
wise that eggs which have yet to be produced, eggs, none of
the matter of which yet exists either in the ovary or in any
other part of the body, are thence produced possessed of
fecundity." "Inflammable material is not set on fire by the
contact of flame more quickly than is the hen made pregnant
by intercourse with the cock" (315).


Careful observation on the fowl, the deer, the dog, the rabbit,
and on many other animals, jiroves that none of them are
generated out of excrement or decomposing matter. There is no
basis in nature for Aristotle's opinion or that of the medical
men, and all these teachings break down when brought to the
test of actual observation. It is no small thing to prove the
error of the belief, which had been current for two thousand
years, and is even now embodied, through a quotation from St.
Paul, in our burial service, that all forms of reproduction find
their type in generation from dead putrescent matter. This
Harvey accomplished by methods which are rigorously scientific ; and with this accurate but very imperfect knowledge
he boldly faced and tried to answer the question, what is it
which the cock contributes in virtue of which the egg "becomes fertile and fit to engender a chick '"?


Male.  
He undertakes "to seek the truth regarding the following
difficult questions : Which and what principle is it whence
motion and generation proceed':' By what virtue does the
semeuact":' What is it that renders the semen itself fruitful? Whether is that which in the egg is canse, artificer and
principle of generation and of all the vital and vegetative
operations — conservation, nutrition, growth — innate or superadded ? and whether does it inhere primarily, of itself, and as a
kind of nature, or intervene by accident, as the physician in
curing disease? Whether is that which transfers the egg into
a jiullet inherent or acquii-ed, or is it already conceived in the
ovary, and does it nourish, augment, and perfect the egg there ?
What is it besides that pireserves the egg sweet after it is
laid ? What is it that renders an egg fruitful ?" (374).  


" In truth, there is no proposition more magnificent to investigate or more useful to ascertain than this : How are all
things formed by an ' univocal agent ' ? How does the like
ever generate the like? . . . Why may not the thoughts, opinions, and manners now prevalent, many years hence return
again, after an intermediate period of neglect? " (583).


63.  
As we find the embryologists of the present day vexing
themselves over the question, " AVhether is that which transfers the egg into a pullet inherent or acquired?" we need not
wonder if Harvey's success in the investigation of this magnificent proposition seems small to us. At least we must
follow him in order to understand his dictum.  


As a starting-point this much seems to be certain. "The
egg, even when contained in the ovary, does not live by the
vitality of the mother, but is like the youth who comes of age,
made independent even from its first apj)earauce; as the acorn
taken from the oak, and the seeds of jjlants in general are no
longer to be considered parts of the tree or herb that supported


Good.




" "
them, but things made in their own right, and which already
enjoy life in virtue of a proper and inherent vegetative power"  
(375).


Furthermore, "although some animals . . . are produced
from females alone" (386); "it is manifest that a fruitful
[hen's] egg cannot be jjroduced without the concurrence of a
cock and a hen ; without the hen no egg can be formed ;
without the cock it cannot become fruitful. But this view
is opposed to the opinion of those who derive the origin of
animals from the slime of the ground " (384).


"  
" The egg is the terminus from which all fowls, male and
female, have sprung, and to which all their lives tend — it is the
result which nature has proposed to herself in their being"
(371).


"And this is the round that makes the race of the common fowl eternal; now pullet, now egg, the series is continued in perpetuity; from frail and perishing individuals an
immortal species is engendered" (385).


Uncomplicated.  
" We cannot conceive an egg without the concurrence of a
 
male and female fowl any more than we can conceive fruit to
 
be produced without a tree. We therefore see individuals,
2 "
males as well as females, existingr for the sake of preparing
 
eggs, that the species may be perennial though their authors
 
pass away. And it is indeed obvious that the parents are no
20/30
longer youthful or beautiful, or lusty, and fitted to enjoy life,
than while they jDOSsess the power of jiroducing and fecundating eggs, and by the medium of these, of engendering their like.
But when they have accomplished this grand purpose of
nature, they have already attained to the height, the dxnrj of
their being ; the final end of their existence has been accouij)lished ; after this, effete and useless, they begin to wither, and,
as if cast off and forsaken of nature and the Deity, they grow
old, aud, a-weary of their lives, they hasten to the end. How
different the males when they make themselves up for intercourse, aud swelling with desire are excited by venereal
impulse! It is surprising to see with what passion they are
inflamed, and then how trimly they are feathered, how vainglorious they show themselves, how proud of their strength,
aud how pugnacious they prove. But the grand business of
life accomplished, how suddenly, and with failing strength
and pristine fervor quenched, do they take iu their swelling
sails, and from late pugnacity, grow timid and desponding.
Even during the season of jocund masking in Yeuus's domains, male animals in general are dejiressed by intercourse,
aud become submissive and pusillanimous, as if reminded that
in imparting life to others they were contributing to their
own destruction. The cock alone, replete with spirit and
fecundity, still shows himself alert aud gay, clapping his
wings and ci'owiug triumphantly he sings the nuptial song at
each of his espousals; yet even he after some length of timeiu
Veuus's service, begins to fail; like the veteran soldier, he by
and by craves discharge from active duty, and the hen, too,
like the tree that is past bearing, becomes effete, aud is finally
exhausted."


Having come to the end of his means of observation, Harvey turns to reflection, the second resource of the man of
science, to see how this may help him to discover how "from
frail and perishing individuals an immortal species is engen


74


August-September, 1897.]


Male.
173




66.


dered." As liis studies seemed to prove that the contagion
which remains in the female "after intercourse, as the efficient
of the future offspring, is not of the nature of any corporeal
substance," he was unable to escape the admission that it is
"incorporeal." Thus driven to the wall, if he had taken
refuge in "soul " or "spirit," no one could greatly blame him,
for spiritual agents had been the resource of philosophers for
many ages before his time. He was a true soldier of science,
however, seeing as clearly as we do that this venerable formula
can do notliing to help us, and preferring outspoken ignorance
to this antiquated and threadbare cloak for intellectual poverty.


Good.  
" If on further inquiry it should appear that it [the efficient]
is neither spirit nor demon, nor soul, nor any part of a soul,
as I believe can be proved by various arguments and experiments, what remains, since I am unable myself to conjecture
anything beside . . . but to confess myself at a standstill ? "


What does the modern man of science in such a case? Does
he not search through the whole province of knowledge to see
if perchance he may find some other natural phenomenon
which bears some resemblance to the subject of his studies ?
Harvey says he knows well " that some censorious persons
will laugh at this . . . Yet this that I do is the practice of
philosophers, who when they cannot clearly comprehend how
a thing really is brought to pass, devise some mode for it in
accordance with the other works of nature, and as near as possible to what is true."


R. E.  
" Since, tlien, nothing can be apprehended by the senses in
the uterus after coition, and since it is necessary that there be
something to render the female fruitful, and as this is probably not material, it remains for us to take refuge in a mere
conception."


Men of science in all ages, from Aristotle to Tyndall, have
believed in the virtues of the provisional hypothesis; and,
armed by eminent authority, Harvey undertakes, by comparing a "mere conception" with other things in nature, to
frame a provisional hypothesis of generation; but natural
science seems to be an uncongenial soil for the nurture of
such attempts, and if time has shown that Harvey's hypothesis
has little value, he errs in good company, and he also takes
pains to say he does not wish it "to be taken as if I thought
it a voice from an oracle," although he does hope it may "stir
up the intellects of the studious to search more deeply into so
obscure a subject."


"  
Starting with the belief that "the semen of the male does
not so much as reach the cavity of the uterus . . . and that
it carries with it a fecundating power by a kind of contagious
property " from which the female "seems to receive influence
and to become fecundated without the co-operation of any
sensible corporeal agent, in the same way as iron touched by
the magnet is endowed with its powers and can attract other
iron to itself," he holds that "when this virtue is once
received the woman exercises a plastic power and produces a
being after her own image."  


" Yet it is a matter of wonder where this faculty abides
after intercourse is completed. ... To what is the active
power of the male committed ? . . . Does the woman conceive
in the womb as we see by the eye and think by the brain?"
" Since there are no manifest signs of conception before the






2 "  
uterus begins to relax . . . and since the substance of the
 
uterus, when ready to conceive, is very like the structure of
 
the brain, why should we not suppose that the function of
20/20
both is similar, and that there is excited by coitus within the
uterus a something identical with or at least analogous to
an imagination or a desire in the brain, whence comes the
generation or procreation of the ovum ?" "For the functions
of both are termed conceptions, and both, although the
primary source of every action throughout the body, are immaterial, the one of natural or organic, the other of animal
action . . . Just as a desire arises as a conception of the
brain, and this conception springs from some external object
of desire, so also from the male, as being the more perfect
animal, and as it were the most natural object of desire, does
the natural (organic) conception arise in the icterus, even as
the animal concej)tiou does in the brain. From this desire,
or conception, it results that the female produces au offspring
like the father. For just as we, from the conception of the
'form' or 'idea' in the brain, fashion in our works a form
resembling it, so in like manner the 'idea' or 'form ' of the
father, existing in the uterus, generates au offspring like himself with the help of the formative faculty.


"Whoever has pondered with himself how the brain of the
artist, or rather the artist by means of his brain, pictures to
the life things which are not present in him, but which he
has once seen ; also in what manner birds immured in cages
recall to mind the spring, and chant exactly the songs they
had learned the preceding summer, although meanwhile they
had never practiced them; again, and this is more strange,
how the bird artistically builds its nest, the copy of which it
had never seen, and this not from memory or habit, but by
means of an imaginative faculty, and how the spider weaves
its web, without either copy or brain, solely by the help of
this imaginative power ; whoever, I say, ponders these things,
will not, I think, regard it as absurd or monstrous, that the
woman should be impregnated by the conception of a general
immaterial ' idea ' and become the artificer of generation."


75
"For my own part then, when I see nothing left in the
uterus after intercourse, to which I can ascribe the principle
of generation, any more than there is in the brain anything
discoverable after sensation and experience, which are the
prime sources of art, and when I find the structure of both
alike, I have devised this fable."


Whatever the value of this hypothesis may be, it serves well
to emphasize the fact that Harvey's opinions on generation
have nothing in common with the modern discovery of the
physical continuity of living matter, and it shows that his
teaching that all animals come from eggs cannot possibly
mean what the words now mean.


Female.  
He believes the uterus conceives an animal in the same way
that the brain conceives an idea; and he also tells us that he
agrees with Fabricius that " the egg [of the hen] is in a certain sense an exposed uterus " (290).  


Furthermore, "the hen is not the efficient cause of a perfect egg, but that she is made so in virtue of an authority, if
I may use the word, or power required of the cock. For the
egg, unless prolific, can with no kind of propriety be accounted
perfect; it only obtains perfection from the male, or rather


71.




Good.
174


[Nos. 77-78.


L. E.




"  
from the female, as it were upon precept from the male, as if
the hen received the art and reason, the form and laws of the
future embryo from his addresses" (290). Ho much for the
generation of the fowl. In Exercise the sixty-ninth he
describes the embryo of the doe at about seven weeks, and the
human embryo about the second month after conception, but,
following Aristotle, he regards these embryos in their membranes, not as embryos, but as eggs without shells. " In the
way above indicated do the hind and doe, affected by a kind
of contagion, finally conceive and produce primordia, of the
nature of eggs, or the seeds of plants, or the fruit of trees,
although for a whole month and more they had exhibited
nothing in the uterus."  


In this sense, then, he holds that viviparous animals are
generated from eggs. He therefore maintains (as contrasted
with Fabricius, who held that the greater number of animals
are produced from ova) "that all animals, even the vivipara,
and man himself not excepted, are produced from ova; that
the first conception, from which the foetus proceeds in all, is
an ovum of one description or another, as well as the seed of
all kinds of plants. Empedocles therefore spoke not improperly of the ' egg-bearing race of trees.' The history of the
egg is therefore of the widest scope, as it illustrates generation
of every description. . . . Fabricius has these additional
words: "The foetus of animals is engendered in one case
from an ovum, in another from the seminal fluid, in a third
from putrefaction ; whence some creatures are oviparous, some


"




2 "  
viviparous, and yet others born of putrefaction or by the
spontaneous act of nature, automatically."  


" Such a division as this, however, does not satisfy me,
inasmuch as all animals whatsoever may be said in a certain
sense to spring from ova, and in another sense from seminal
fluid, and they are entitled oviparous, viviparous or vermiparous rather in resjoect of their mode of bringing forth than
of their first formation."


20/70
We see then that, unfamiliar as his words often seem, and
while he holds that the organizing influence which produces
the chick from the egg is a "divine mystery," we owe to
Harvey the demonstration and clear formulation of the following truths :


There is no basis for the venerable doctrine that the higher
animals are generated from excrement.


76
The hen's egg, even before it leaves the ovary, is an independent orgauism, which enjoys life by its own right, and
perfects itself by nutrition.


The embryo assimilates homogeneous food, and by means of
an inherent organizing power converts it into the structure of
the living animal Nutrition, growth and development go on
together, and the embryo arises by epigenesis or differentiation.


Female.  
Many animals which have been held to arise from putrescent slime actually come from microscopic eggs.  


"Animals are entitled viviparous or oviparous or vermiparous rather in respect of their mode of bringing forth
than of their first formation."


50.




Good.  
LONG, THE DISCOVERER OF ANESTHESIA.  


A PRESENTATION OF HIS ORIGINAL DOCUMENTS.


R, E.  
By Hugh II. Young, A. M., M. D., Assistant Besident Siirgeon, Johns Hopkins Hospital, Baltimore.  


[Being in substance a paper read before the Johns Hopkins Hospital Historical Society, Xorember 8, 1890, with additions.]


"




"
It was my good fortune last summer to meet Mrs. Fanny
Long Taylor, whose father, Dr. Crawford W. Long, is thought
by many to be the original discoverer of anesthesia.


As she put me in possession of her father's papers, I thought
they might prove sufficiently interesting to warrant their presentation to this Society.


2 "
During the famous ether controversy which was waged in
 
the forties and fifties the work of Long received little attention. A modest, retiring man, who abhorred public strife
 
and controversy, too honorable to wish pecuniary reward for
Not tested.  
his discovery, it is not strange that he made no effort to get
the reward from Congress, but preferred to let the justice of
his claim be judged by an unbiased posterity.  


Crawford W. Long was born in Danielsville, Ga., on the
first of November, 1815. His grandfather was Capt. Samuel
Long of Pennsylvania, who made a brilliant record in the
Revolutionary war and was one of Lafayette's captains at
Yorktown. Soon after the close of that eventful struggle he
left his native State and took his family to Georgia, where
they settled along with a large colony of Peunsylvanians.
His son, James Long, received every educational advantage


77




Female.  
there obtainable, and inheriting his father's executive ability,
became one of the prominent men of his State. Although
engaged in mercantile pursuits he was a hard student of the
law, and so well versed in the principles of jurisprudence
that he was often consulted by judges in difficult cases.  


He represented his people in the Senate for a number of
years and was the intimate friend, adviser and confidant of
Wm. H. Crawford, Georgia's greatest statesman, at different
times Secretary of State, minister to France and candidate for
the Vice-Presidency. As an evidence of attachment he gave
his eldest son the name of Crawford. Coming from such
ancestry it is not wonderful that young Crawford early
showed promise of rare ability. As a boy he was studious
and mature beyond his years, and entered Franklin College at
so early an age that he was known as " baby." Notwithstanding this fact he graduated as Master of Arts second in
his class at the age of nineteen. Alexander II. Stephens
was his room-mate, and so much older that he was dubbed
"daddy" by the college boys. Though pursuing different
paths, Stephens and Long kept up an inti.nate friendship all
their lives. After studying under a preceptor for one year


61.




Good.  
August-September, 1897.]


175


L. E.




"
Long graduated at the University of Pennsylvania in 1839.
While there he was recognized as a man of marked ability and
fond of experimental work.


After graduation he spent one year in a New York hospital,
where, it is said, he made such a reputation for himself as a
surgeon that he was urged to apply for the position of surgeon
in the U. S. Navy. Obedient to his father's wishes, however,
he returned to practice in his native State and located in
Jefferson, .Jackson Uo., Georgia, in 1841, at that time a small
country town, far removed from any railroad, in the midst of
a farming community whose only factory was the cotton gin.


Mild iritis.  
Here Dr. Long soon acquired an extensive and lucrative
practice, and although young was noted for his quiet, dignified bearing, which endeared him to all. His office was a
favorite meeting-place for the young men of the town, who
would often gather there to pass a merry evening together.  


About this time it became fashionable to inhale laughinggas for its exhilarating effects. Itinerant lecturers on chemistry would conclude an evening's entertainment with a
nitrous-oxide party in which the participants would get gloriously drunk from its inspiration.


3 "
The practice spread throughout the country, and at -Jefferson
during the early part of the winter of '41 a coterie of young
friends begged Dr. Long to let them indulge in the far-famed
luxury.


Dr. Long replied that he had uo means of preparing nitrousoxide gas, but that sulphuric ether would produce similar
exhilaration. The company being anxious to try it, the ether
was produced, all inhaled of it and soon became hilarious.


20/40
The young men were delighted and hastened to tell their
friends of Dr. Long's wonderful drug, and thus the inhalation
of ether for sport soon became very popular over that section
of Georgia, and almost every party ended up with an " ether
frolic," as it was called.


During January, 1842, the ether frolics at Dr. Ijong's office
became very frequent and were well attended, and some of the
young men probably became pretty thoroughly intoxicated, as
Dr. Long discovered that he and others would afterward have
considerable bruises about their persons of which they had no
knowledge.


78
Being a thoughtful man, he at once remarked thai ether must
have the poiver of rendering one insensibU to pain, and therefore
available for prevent itig pain in stirgical operations.


This was January, 1842, and Dr. Long at once determined
to prove his discovery on the tirst surgical case_ he should
have. That opportunity came on March 30th, when Long
administered ether to Mr. James M. Venable till completely
anaesthetized, and then excised a small cystic tumor from the
back of his neck. Imagine the surprise of the patient when
on regaining consciousness he was told that the operation was
over, and his amazement when he saw the tumor in the hands
of the surgeon and he had not felt a scratch. This was four
and one-half years before Morton's earliest claims.


Female.  
An original paper read by Dr. Long before the Georgia
State Medical Society in 1852, describing these events in his
own words, is appended to this paper — see Appendix I.  


It is worthy of note that two and a half years later Wells of
Hartford discovered the ansesthetic powers of nitrous oxide


66.




Good.  
under very similar circumstances. He attended an entertainment given by a popular lecturer on chemistry, inhaled
nitrous oxide for its exhilaration, and saw a man under its
influence injure his ankle severely without being conscious of
it. From this he concluded that nitrous oxide was capable of
producing anesthesia and proved it in extracting a tooth.  


Morton, on the other hand, got his suggestion as to the
ansEsthetic power of ether from Jackson, who, after using
ether to relieve the pain and dyspnoea following the accidental inhalation of chlorine gas — an antidote well known in
chemistry then — inferred that it might be useful as an anajsthetic. Jackson did not test the correctness of this observation, which he claims to have made about the same time that
Long etherized his first case, but left it for Morton to prove
practically four and a half years later.


R. E.  
Dr. liOng reports the first five cases in which he used
ether, being desirous only of establishing priority of use. An
examination of the letters and certificates before me, however,
shows that he must have operated on at least eight cases
before ^Morton's "discovery." This number seems small, but
is not so astonishing when we remember that the country was
sparsely settled, that Jefferson was a mere village, and Long
had just entered practice.  


I will now read in substantiation of these statements a
copy of the original account in Dr. Long's journal against
Mr. Venable for medical services rendered, certified to by a
clerk of the Superior Court.


"  
"James Venable


To Dr. C. W. Long, Dr.
1842. cts.


Uncomplicated.  
January 28th, sulphuric ether, .25


March 30th, sulphuric ether and exsecting tumor, 2.00
May 13th, sul. ether, .25


2 "
June 6th, exsecting tumor, 2.00


Georgia, I


20/40
Jackson County. ' I, P. F. Hinton, clerk of the superior court of
said county, do certify that the above account is a correct copy of
an original entry made in his book for medical services for the
year 1842.
Given under my name and seal of office this 27th of March, 1854.
[Seal] (Signed) V. ¥. Hitfms, Vlerl.- S."


The following paper relative to the fashion of inhaling
ether for its exhilarating effects is interesting as showing how
the custom in Georgia started with Dr. Long :


79
" I certify that on the first of January, 1842, I resided in .Jefferson, Jackson Co., Georgia, and that about that time myself with
several other young men were in the habit of meeting at Doct. C.
W. Long's shop, and other rooms in the village, and inhaling ether
which he adminutered to us.


On the 20th of January of the same year I removed to Athens,
where I introduced the inhalation of ether. I and several of my
young associates frequently assembled ourselves together and took
it for the excitement it produced. After that I know it became
very common to inhale ether in Athens, and tbat it was frequently taken in the college campus and on the street.


Female.  
(Signed) R. H. Goodman,


August 4th, 1849. Athens, Georgia."


54.  
When we see daily the dreadful distaste patients who have
been etherized have for ether, it seems strange that any one
could become fond of its use.  




Good.


176


L. E.  
[Nos. 77-78.  




"


I will now read an account of the first operation as given
by Mr. James M. Venable:


"  
"I, James M. Venable, of the county of Cobb and State of
Georgia, on oath depose and say, that in the year 1842 I resided at
my mother's in Jaclcson County, about two miles from the village
of Jefferson, and attended the village academy that year.


In the early part of the year the young men of Jefferson and the
country adjoining were in the habit of inhaling ether for its exhilarating powers, and I inhaled it frequently for that purpose, and was
very fond of its use.


2 "
While attending the academy I was frequently in the office of
Dr. C. W. Long, and having two tumors on the back of my neck, I
several times spoke to him about the propriety of cutting them
out, but postponed the operation from time to time. On one occasion we had some conversation about the probability that the
tumors might be cut out while I was under the influence of s.
ether, without my experiencing pain, and he proposed operating
on me while under its influence.


I agreed to have one tumor cut out and had the operation performed that evening after school was dismissed. This was in the
early part of the spring of 1842.


20/40
I commenced inhaling the ether before the operation was commenced and continued it until the operation was over. I did not
feel the slightest pain from the operation and could not believe
the tumor was removed until it was shown to me.


A month or two after this time Dr. C. W. Long cut out the other
tumor, situated on the same side of my neck. In this operation I
did not feel the least pain until the last cut was made, when I felt
a little pain. In this operation I stopped inhaling the ether
before the operation was finished.


80
I inhaled the ether, in both cases, from a towel, which was the
common method of taking it.
Georgia, -v (Signed) James M. Ven.\blk.


Cobb Co., > Sworn to before me.


Male.  
July 23rd, 1849. J Alfred Manes, J. P."


This operation was clone in the presence of fonr witnesses,
Jas. E. Hayes, A. T. Thurmond, W. H. Thurmond, principal
of the academy, and Edmund S. Rawls, the last of whom
testifies as follows :


75.  
"Georgia, -i I, Edmund S. Rawls, of Rome, Floyd Co., Ga., on
Clarke Co. J oath depose and say that ... on one occasion during
that year (1842) I was present with James M. Venable in the office
of Dr. C. W. Long in Jefferson, Jackson Co., Ga., and witnessed
Dr. C. W. Long cut out a tumor from the side of neck of J. M.
Venable while said Venable was fully under the effects of the
vapor of s. ether inhaled from a towel, and without his exhibiting
the least symptoms of suffering pain from the operation. J. M.
Venable was so unconscious of the operation having been performed that he would not believe the tumor was removed until it
was shown him. (Signed) E. S. Rawls.  


Sworn to and subscribed before me this 2nd November, 1853.


Good.  
E. L. Newton, /. J. C."


The patient continued to inhale ether until the operation
was over, was entirely unconscious of its performance, and
felt no pain. Surely this was complete ansEsthesia. This
fact has been denied by Dr. Wm. J. Morton, son of the Boston
discoverer, who says it was no more than mere exhilaration.


R. E.  
It has been stated that Long kept his discovery secret and
that he therefore deserved no credit for it. I present certificates from Drs. Laperriere and Carlton, which show that his
work was well known to citizens of the town of Jefferson and
neighboring cities, particularly Athens, which was then the




"


centre of learning and culture in Georgia; that it was considered a remarkable discovery by the populace, and that the
prominent physicians knew of it and realized its importance.
See Appendix II.


"
Dr. Carlton was then a student under Dr. Moore. One
year later (1844) he used ether in extracting a tooth. This
was probably the first use of ether in extracting teeth. Dr.
James Camak, another student of Moore, was present and
assisted in the same operation and corroborates Carlton's
statements.


Can Dr. Long be blamed for not publishing at once a report
of his first case or two when they were well known to the
physicians of that part of the State ? He had no Massachusetts General Hospital at his back, and he knew that such
startling claims coming from one so young (he had not been
practicing one year) would be severely criticised. It is but
natural that he should be satisfied for the time being with the
local and State publicity which was given to his great discovery,
and waited until he could make a comprehensive report embracing all kinds of cases, such as every careful investigator
does to-day.


2 "
But he kept on with his work, ojierating on two more cases
 
under ether in 1842, and about three more during the next
year, for most of which I find sworn certificates.


20/70
I have a letter from his first student. Dr. J. F. Groves,
which is of particular interest as giving an insight into the
character of Dr. Long and his work at that time. It is quite
lengthy and I omit portions of it. The letter is written to
Mrs. Taylor, Dr. Long's eldest daughter. See Appendix TIL


This letter shows conclusively that Dr. Long was thoroughly convinced of the anesthetic powers of ether, but was
anxious to put it to a severe test in capital surgery. He
withheld his cases of minor surgery because he wished to
determine accurately the limitations and possibilities of
ether.


81
In his paper Dr. Long does not give the details of the etherization with the minuteness we should desire. For instance,
he does not say who gave the ether, the patient or himself,
and he does not explain whether the patient was entirely
unconscious or not, but simply remarks that he suffered no
pain and did not know the tumor had been removed.


These omissions of Dr. Long led Dr. Wm. J. Morton, of
New York, to write a forty-eight-page article in the Virginia
j\Iedical Monthly, March, 1880, in which by dexterously quibbling with Long's innocent statements he arrives at the conclusion by a skilful process of deduction, that Long never did
anything. I will read parts of this article :


Male.  
"The Invention of An.esthetic Inhalation.  


* * * But we will proceed slowly. We must know who is giving the ether. Of the first operation Venable deposes under oath,
'I commenced inhaling the vapor before the ojieration was commenced and continued it until the operation was over.'


71.  
Tlius Venable kept his eye on the whole affair, knew just what
was going on, otherwise how could he knowand swear to it thatbe
continued the inhalation until the operation was over. Surely Veiiahlc administered the ether to himself and remained conscious all the
time."


This is erroneous, for according to good legal authority


Good.




" "
August-September, 1897


177


"




"
such a statement as Veiiable's could be made fi-um a knowledge based on satisfactory hearsaj' evidence and would be
accepted in law.


But he goe.s on : "But now comes the damnatory point of this
second experiment. The patient felt pain. Tliis both Long and
Venable confess. Here tlien is positive failure ; Dr. Long's ansesthetic state was nothing more nor less tiian the fleeting peripheral
numbness often associated with the first or e.Khilaratmg stage of
the complete anesthesia of to-day. But why did Dr. Long not take
the towel into his own hand and force the ether? Why not make
his patient insensible to pain if he knew tliis could be done?


2 "  
" Knowing what medicine knows to-day, how wonderful this halting of Long — tliis pause at a most critical moment — on the very
threshold of discovery! So nicely balanced is the situation thiit it
almost seems as if he would topple
over into discovery; but he falls
the other way.


" It seems almost inexplicable
that he did not seize the towel,
force the anaesthesia to the stage
of stupor, perform the operation,
and proclaim the discovery to the
worUi," —


Not tested.
and we might add, patent it at
once I


It is a fact well known to all
surgeons that a patient may be
entirely unconscious and still
retain sensibility to pain. This
is evidenced by the flinching
before the knife when in this
state. He may give evidence
of feeling pain, but have no
recollection of it afterward.
All witnesses agree that Tenable gave no evidence of feeling pain in the first operation.
He must have been jjretty thocoughly anffisthetiiied. The second operation was merely a test
case to determine the length of
the anaesthetic state, aud although the ether was discontinued from the beginning of the
operation (which Long says was tolerably difficult on account
of adhesions), still the anajsthetic state lasted until the last
cut was made. We would consider .such a patient pretty
thoroughly anaesthetized in Baltimore.


82
I have recently tested a number of patients who were being
anaesthetized and found invariably that consciousness was lost
before sensibility to pain — as evinced by movement of a member when pricked with a pin.


It was therefore practically certain that no j)erson could
administer ether to himself, an act requiring consciousness —
aud become sufficiently anaesthetized for even very small
operations; but in order to settle the question definitely I
determined to administer ether to myself, using the same
methods as were employed by Long in 1842.


Female.  
Accordingly, under the direction of Dr. F. II. Hagner of
Washington, I placed a folded towel over my face and poured




63.




Good.  
Dr. CRAWFORD W. LONG




',! L.^E.


ether upon it from time to time at his bidding, as long as 1
was conscious. During this time Dr. Hagner pricked me with
pins up to the last application that I remember. Toward the
last the pin pricks did not produce the usual sensation of
pain, but a peculiar disagreeable clanging sound in the ear.


•'
Dr. Hagner thus briefly describes the experiment: "Dr.
 
Young jjoured ether on the towel when so instructed by me.
 
After a number of such additions the movements of his arm
Vitreous lost. Iritis.  
became very unsteady and he would spill some of the ether on
his neck. Soon after the last application, made at my request,
I pricked him with a pin and he moved his leg. I then
instructed him several times to add more, but he made no
attempt to do so and seemed unconscious. I then pricked
him with pins several times,
but received no response for
about a minute, when he again
responded to a prick of pin and
suddenly became conscious.  
Comjilete consciousness returned almost immediately.  


" I feel certain that he lost
consciousness before sensibility
to pain, and that if I had attempted to do the smallest surgical operation he would have
been conscious of pain before
its completion."


4 "  
It is therefore certain that
Yenable would have been conscious long before the small
tumor was removed and would
have suffered considerable pain,
if he had conducted his own
etherization. Nor is it probable that Long intended to convey that idea. We might with
propriety say to-day that our
patients "inhale ether until
anesthetized," if we did not
care to specify the details of
etherization. Hut in a document quoted above R. H. Goodman
says, in speaking of the ether frolics, " We were in the habit of
meeting at Dr. Long's shop and inhaling ether which he administered to vs." It seems probable therefore that some one
administered ether to the persons on whom he operated, too.


Desirous of settling these trivial points on which Morton
would have Long deprived of every honor, I addressed a letter
a few days ago to Long's first student. Dr. J. F. Groves, w'hose
document I have quoted above. I saw that he would now be
about 75 years of age and waited for an answer with considerable au.xiety. To my surprise and delight I received a letter
from him yesterday which supplies all of Dr. Long's omissions. Dr. Groves did not see the first operations, as he did
not enter Dr. Long's office till 18W, but soon after his
entrance he assisted in the operation on the negro boy in
which two fingers were amputated, early in 18-t5, aud at my
request he describes this etherization in detail.


20/100




83
178


[Nos. 77-78.


Female.




50.  
As this case occurred a year ami a half before Morton's
discovery, it is equally good as the first for my purposes. It
is as follows :


A Recent Letter fkom Long's First Student.


Good.  
"CoHUTTA, Ga., Jan. 15th, 1897.
Dr. Hugh H. Young,


Dear Sir ; * * * The patient was placed in a recumbent position, on a bed, with hand to be operated on to the front for convenience to tlie surgeon. Dr. Long poured etiier on a towel and held
it to the patient's nose and mouth, too, to get the benefit of inhalation from both sources. Dr. Long determined when the patient
was sufficiently etherized to begin the operation by pinching or
pricking him with a pin. Believing that no liarm would come of
its use for a reasonable length of time he profoundly anesthetized
the patient, then gave me the towel and I kept up the influence by
holding it still to the patient's nose. The patient was entirely
unconscious — no struggling — patient passive in the hands of
operator. After a lapse of lifty years you would hardly suppose
that a man could remember every minute detail, but I have clearly
in mind all the facts I have given you.


(t  
Your ob't servant,


(Signed J J. F. Groves, M. D."


"
Long then administered ether as it is done to-day. He did
not pause at the threshold of discovery or topple the other
way, but kept right ahead and by careful observation, experimentation and reflection discovered that ether was a safe,
sure and complete anajsthetic.


Nor did his patients etherize themselves and at the same
time superintend the operation, as Dr. Morton would have us
believe.


Uncomplicated.  
As quoted above, Morton grasps eagerly at the acknowledgment of pain at the end of the second operation, where the
ether had been discontinued, and from tnat isolated instance
characterizes all of Dr. Long's cases as failures. But in his
eagerness to annihilate Dr. Long he seems to have overlooked
the fact that in the first report of anassthesia with Morton's
" Letheou " at the Massachusetts General in 1846, Dr. Bigelow* says, in speaking of the first operation, "During the
operation the patient muttered as in a semi-unconscious state,
and afterwards stated that the pain was considerable," and in
the second, " The operation lasted four or five minutes, during which time the patient betrayed occasional marks of
uneasiness." But these certainly were not failures, although
the ausesthesia was not as complete as in Dr. Long's previous
cases.  


Li his paper Long speaks of "those high in authority who
were advocating the mesmeric state as adequate to prevent
pain in surgical operations." Contemporary medical literature furnishes ample verification of these statements, according to Dr. Grandy,t who says :


2 "  
" The journals were full of discussions upon the phenomena
of mesmerism, animal magnetism, etc., and wonderful reports
were coming from European hospitals of operations done
without pain during the ' magnetic sleep.'


"Jules Gloquet had excised a cancerous breast with the
axillary glands and the patient showed no sign of pain. Top


20/70


* Boston Medical and Surgical Journal, Nov. 1846.
t Va. Med. Monthly, Oct. 1893.


84




Female.  
ham of London, in 1843, had amputated a thigh, and Dr.
Diigas of Augusta, Georgia, in 184.5, twice extirpated the
mamma of a female under the mesmeric sleep.  


"We can imagine what efEect these cases had on the mind
of Long. Need we wonder therefore that he was the more
particular in his experiments on etherization. Such were the
reasons for his silence, and while the sequel was unfortunate,
his course was cautious and commendable."


51.  
While thus waiting, his opportunity was lost. A second
discovery was made in Boston in 1846, was published immediately, and anesthesia became the property of the world.  


Friends of the other " discoverers " have often stated that
as Long made no publication of his work he deserved no
credit for it. To this Dr. J. Marion Sims responds very
forcibly as follows:*


Good.  
" Now upon this point Long, Wells, Morton and Jackson
 
stand individually upon the same level.  


R. E.  
Long exhibited to medical men and to the community
his operations under ether in 1842. Wells exhibited to
medical men and to the community his operations of the
extraction of teeth under nitrous oxide gas in 1844. Morton
exhibited to medical men and the community the use of
his secret remedy "Letheon," 1846, as an anesthetic. But
Morton was fortunate in showing his patent remedy to
the great surgeons of Boston, and it was not Morton, but it
was Warren and Ilayward and Bigelow who performed the
operations to which the world owes the immediate and universal use of anfesthesia in surgery. If Morton could have had
his w,iy he would have deodorized the ether and kept it secret
from the world. Neither Wells nor Morton nor Jackson ever
published a word on the subject till it burst forth in a blaze
from the labors of the hospital surgeons already named.
When Warren and Hay ward and Bigelow proved the real
greatness of the discovery [and published it broadcast], then
it was that Wells, Morton and Jackson began the war of pamjihlets, and not till then did either of them publish in any
scientific journal a line about ana'sthesia."


The Famous Ether Controversy.


"
In 1849 Morton petitioned Congress for a reward for his
discovery. He was at once opposed by Jackson and the friends
of Wells, who was then dead. The celebrated ether controversy, thus begun, occupied the attention of Congress for
many years, and was characterized by the greatest animosity
between these former bosom friends and companions.


For five years Long i-efused to take part in the conflict, but
finally in 1854, persuaded by his friends that in that way alone
could he obtain recognition of his claims, he wrote to Senator
Dawson giving an account of his work. It seems that Dawson
was a friend of Jackson, for he wrote to him of this new
claimant and requested him to investigate his case. This
.Jackson did, calling upon Long at his home in Athens on
March 8th, 1854.


"
The Ixtekview betweej^ Loxa .vxd Jacksox.
At this interview lion. C. W. Andrews, a prominent justice.




2 **


*Va. Med. :\ronthly, :\Iay, 187


20/40




85
August-September, 1807.]


179


Male.




80.  
was present, and certifies that after satisfying himself of the
genuineness of the claims, Jackson proposed to Long to lay
their claims conjointly before Congress — he, Jackson, to claim
the discovery, and Long to claim the first practical use, — his
object evidently being to get ahead of Morton.  


This proposition Dr. Long rejected, being satisfied that he
was entitled to both. In a letter to Hon. D. L. Swain, ex-governor of North Carolina, which I have here, he says in regard
to this transaction: "The only ground Dr. Jackson urged
for his right to the discovery was that while suffering
with pain and dyspncea, in February, 1842, from breathing
chlorine gas, he inhaled ether and found that while under its
influence he was free from pain. He does not claim that he
suggested its use to jjrevent pain in surgical operations until
more than one year after my first operation was performed. I
cannot give the exact date when I was first led to believe that
ether would prevent pain in surgical operations, but I know it
was as early as February, 1S42."


Bad.  
Now in 1839 Pereira, in his "Elements of Materia Medica,"
states : " The vapor of ether is inhaled to relieve the effects
caused by accidental inhalation of chlorine gas. If the air be
too strongly impregnated with ether, stujjefactiou ensues."


So there was very little new in Dr. Jackson's " discovery,"
and a mere untried inference hardly deserves the title of discovery.


" "
Dr. Jackson finally acknowledged the justice of Dr. Long's
claims and wrote to Senator Dawson to that effect.


On April 15th, 185-t, the appropriation bill was up before
the Senate for its final reading. The friends of Wells and
Morton, relying on the volumes of manuscript they had presented, were confidently awaiting the result, when Senator
Dawson arose and said that he had a letter from Dr. Jackson
which acknowledged that a Dr. Long in Georgia had undoubtedly used ether before any of the claimants for the
appropriation.


"
Coming as it did from so prominent a contestant, this announcement fell like a thunderbolt on the rival claimants, and
from that time they seem to have lost all Iwpe of gaining the
reward and passively allowed the bill to die.


Desirous only of preventing another from being recognized
by Congress as the discoverer, and not wishing any pecuniary
reward himself, Long never pushed the matter farther, and
his documents of proof were never even brought uj) before
Congress.


"
I have here an interesting memento of that conference
between the two discoverers, in a card on which Jackson has
written a note to Long. On one side it reads :


"For Dr. C. W.Long,


5 "
of Athens, (Ja.
C. T. Jackson,


New York Hotel,
(over) "
and on the reverse :


20/100
"Telegraph from J. L. Hayes, Washington.
'Assignee struck out by request of Mr. Everett.'
Bill probably will come up in House July next."


Edward Everett was then senator from Massachusetts. In


86




Male.
the transactions of the Senate, April 19th, 1854, I find the
following explanation of the bill by Senator AValker:


" The bill as amen. led recites that a discovery of anaesthesia has
Ijeen made — that it is believed the discovery was made by some
one of the following persons, W. T. G. Morton, Chas. T. Jackson
and Horace Wells, but it does not appear to the satisfaction of Congress which of those parties was the original, true and first discoverer thereof. It proposes to ap|>ropriato $100,0(0.00 as a recompense for the real discoverer. In order to determine this it shall
bo the duty of the district attorney of the United States for the
Northern District of New York, to file in the circuit court of the
United States for that district a bill of interpleader wherein reciting the act or its substance, the Secretary of tlie Treasury shall be
complainant, and AV. T. G. Jlorton, Chas. T. Jackson and the personal representatives of Horace Wells or any other person who
may make application to thecourt for that purpose shall be defendants. The issue is to be which of the parties named was the
original, true and first discoverer of anseathesia, and the court is to
decide which one that is and direst that the sum of $100,000 he
paid over to him."


64.  
At the instance of Senator Dawson Dr. Long's name was
 
also inserted in the bill.


Good.  
I have carefully searched the Congressional Eecords and
find that this bill never came up before the House for final
passage, and conseqixently never reached the district court of
New York. It seems to have been abandoned.  


Several years later Dr. Jackson wrote an article in the
Boston Medical and Surgical Journal giving Long the credit
for the first use of ether in surgery. I have here Dr. Long's
copy of that journal. The communication is so imjiortant
that I will read most of it :


" The Boston Medical and Surgical Journal.


Boston, Thursday, Apr. 11, ]8()1.


"
First Peactical Use of Ether in Surgical Operations.


Messrs. Editors: — At the request of the Hon. Mr. Dawson, U. S.
Senator from Georgia, on March Sth, 1854, 1 called upon Dr. C. W.
Long, of Athens, Georgia, while on my way to the Dahlonega gold
mines, and examined Dr. Long's evidence, on which his claims to
the first practical operations with ether in surgery were founded,
and wrote, as requested, to Mr. Dawson, who was then in the
U. S. Senate, all I learned on the subiect. From the documents
shown me by Dr. Long, it appears that he employed sulphuric
ether as an anaesthetic agent :


"
1st, March 30th, 1812, when he extirpated a small glandular
tumor from the neck of James M. Venable, a boy in Jefferson,
Georgia, now dead.


2nd, July 3rd, 1842, in the amputation of the toe of a negro boy
lielonging to Jlrs. Hemphill, of Jackson, Ga.


2 "
3rd, Sep. 9th, 1843, in extirpation of a tumor from the head of
Mary Vincent, of JacKson, Ga.


4th, Jan. Sth, 1845, in the amputation of a finger of a negro boy
belonging to Ralph Bailey, of Jackson, Ga.


20/70
Copies of the letters and depositions proving these operations
with ether were all shown me by Dr. Long. * * *


I then called on Profs. Joseph and John Le Conte, then of the
University of Georgia, at Athens, and inquired if they knew Dr.
Long, and what his character was for truth and veracity. They
both assured me that they knew him well, and that no one who
knew him in that town would doubt his word, and that he was an
honorable man in all respects.


87
Subsequently, on revisiting Athens, Dr. Long showed me his
folio journal, or accountbook, in which stand the following entries :




Male.


180


54.  
[Nos. 77-78.  




Good.


' James Venable


L. E.  
March 30th, 1842, Ether and excising tumor, $2.00
May 13th, Sul. Ether, .25


June 6th, Excising tumor, 2.00'


"
On the upper half of the same page, several charges for ether
sold to the teacher of the Jefferson Academy are recorded, which
ether Dr. Long told me was used by the teacher in exhibiting its
exhilarating effects, and he said the boys used it for the same purpose in the academy. I observed that all these records bore the
appearance of old and original entries in the book.


On asking Dr. Long why he did not write to me or make known
what he had done, he said, when he saw my dates he perceived
that I made the discovery before him, and he did not suppose that
anything done after that would be considered of much importance,
and that he was awakened to the idea of asserting his claims to
the first practical use of ether in operations, by learning that such
claims were set up by others for this merit, and consequently he
wrote to the Georgia delegation at Washington, stating the facts
which Senator Dawson had requested me to inquire into.


"
I have waited expecting Dr. Long to publish his statements and
evidence in full, and therefore have not before published what I
learned from him. He is a very modest, retiring man and not disposed to bring his claims before any but a medical or scientific
tribunal. * * *


Had he written to me in season I would have presented his
claims to the Academy of Sciences of France, but he allowed his
case to go by default, and the academy knew no more of his claims
to the practical use of ether in surgical operations than I did.


2 "  
Boston, >ipril 3, 1861. Charles T. Jackson, M. D."  


The list of operations as given by Dr. Jackson is not complete, as he has omitted the second operation on Venable, and
a number of the later operations. In a letter to Dr. Sims,
which I have, Dr. Long denies absolutely that he ever
acknowledged that Dr. .Jackson was the prior discoverer. He
had been led to infer that ether had ana3sthetic powers several
months before he got a chance to verify it, and before Jacksou claims to have made similar inferences, but he dated bis
claims of discovery from the time of his first practical demonstration. Before that it was a mere supposition, as was Jackson's also.


20/40
But barring these inaccuracies, Dr. Jackson's paper, coming
as it does from one who so zealously coveted the title of discoverer, is a remarkable admission.


The interview between Long and Jackson must have been
most amicable, and Long evidently felt the greatest respect
for Jackson, as shown in the following letter:


88
"Athkns, Ga., Nov. 15th, 1854.
Dr. C. T. Jackson.


Dear Sir: — I design to prepare an article with the proofs of the
priority of my claims of the discovery of the anresthetic powers of
ether and of its applicability to surgical operations. I design having
this published in pamphlet form for distribution among the members of the medical profession, and I expect to present such proof
with the article as will satisfy all that I am entitled to all I claim.


Male.  
Ours are rival claims, and permit me, sir, to say that although our
 
claims are conflicting, I would not knowingly say anything in the
article which would be displeasing to you. I entertain high respect
for you as a gentleman and man of science and feel honored by your
acquaintance.


66.  
Still it becomes each one of us to use all honorable means to
advance his own claims, and I know you will not blame me for
attending to this matter, which so much concerns my reputation.  


Shall it meet with your approbation, I may refer to your admis


Good.


sions to Hon. W. C. Dawson and myself, of the belief of the correctness of my claims. I will, however, make no allusion to your
letter to Mr. Dawson or to the conversation held with myself unless


R. E.
it meets with your sanction


Your obedient servant, C. AV. Long."


"
Morton's Patent.


It has often been stated by the friends of ilorton that he
never attempted to enforce his patent. This statement has
lately been reiterated by his wife in McClure's Magazine. On
this point the following letter from a prominent army surgeon
to Long may be of interest:


"  
" U. S. Marine Hospital,


Chelsea, Mass., April, 1859.
Dr. Crawford W. Long, Athens, Ga.


2 "
Sir: — Hon. Judge Hyllier, Solicitor of Treasury Department,
informed me about a year since, and recently repeated the same,
that some years since you used sulph. ether as an anaesthetic and
had a record of the same. If it is not asking too much of you, I
would be greatly obliged if at your earliest convenience you would
forward me a statement of the facts.


I take the liberty to ask this of you because Mr. W. T. G. Morton,
to whom in conjunction with Dr. C. T. Jackson a patent was
granted in Nov., 1846, for using ether, has brought a suit against me
as a government officer for an infringement of his patent.


Not tested.  
Judge Hyllier was confident that you could furnish me with
proof sufficient to satisfy a jury that you used it way before he or
Jackson claimed to have made the discovery. I should have asked
for these proofs through my attorney and had them properly witnessed, etc., but the Secretary of the Treasury having decided that
I used the article on my own responsibility and therefore the Govt,
were not bound to defend me, I wish to save as much expense as
possible. Very respectfully,


[Signed] Charles A. Davis, M. D.,


89
Physician and Superintendent."


In reply Long gives a detailed account of his work, and
then adds : " I presume Dr. Jackson is not party to the prosecution, as I know he entertains no good feelings towards W. T.
Morton. If you think proper you can see him and ascertain
the character of proof I can make. From the little acquaintance formed with him I entertain a high opinion of him as a
gentleman and think he will do me justice notwithstanding
he himself claims to have made the discovery and has received
several awards."


Male.  
Dr. Davis's letter was written twelve years after Morton's
" Letheon " was patented, and many years after ether was the
common property of the world. It was probably Morton's
last attempt to get money from the U. S. Government.  


The ether controversy was never reopened and Long's work
was unknown to the world until 1877, when J. Marion Sims
learning of him through accident, investigated his claims,
was fully convinced of their merit, and vigorously demanded
their recognition by the medical profession. His paper
appeared in the Virginia Medical Monthly, May, 1877.


60.  
The Wilhite Cl.\ims.  


This article, which obtiviued for Long the first recognition
of any consequence, was the outcome of a conversation which
Sims had with a Dr. P. A. Wilhite, of Anderson, S. C.
Wilhite told Sims that be had witnessed the first surgical
o])eration ever done under ether, and recounted Dr. Long's


Good.




" L. E.  
August-September, 1897.]


181


"




"
first case, saying that lie was one of four students who were
then in Dr. Long's office.


He also said that " he presumed that he was the first j)erson
who ever profoundly etherized any one," and told how he was
at a quilting party in which the boys and girls had concluded
the evening by inhaling ether for sjiort; how they had caught
a negro boy, and as he refused to inhale the ether, had firmly
held a handkerchief soaked with ether over his face, when to
their horror his breathing became stertorous and he could not
be aroused. He then vividly pictured their alarm when they
realized that they had murdered a fellow-being, and thdr
determination to leave the country, which was prevented by
the timely arrival of a physician who restored the boy to consciousness.


2 "
Wilhite iheu related how when the idea of using ether to
prevent pain in surgical operations had occurred to Long, he
had eiicoura<jed him hy relating the story of the negro boy.


Dr. Sims at once communicated with Dr. Long and soon
convinced himself of the truth of his claims, but unfortunately he failed to investigate Wilhite's statements, but
embodied them in full in his article, giving to Wilhite the
credit of first intentionally producing profound ana;sthesia
with ether.


11 11
Dr. Sims' paper was given great publicity and the Wilhite
story has been accej^ted as true, and copied by many writers
on the subject, most notably by Sir Jas. Paget.*


The negro boy story lacks probability, as Wilhite did not
enter Long's office until 1844, two years after the first operation, as the following letter from Long to Wilhite shows :


90
"Athens, Ga., May 20th, 1S77.
Dk. p. a. Wilhite.


Bear Sir : — I received Br. Sims' article on anaesthesia yesterday
and find several mistakes. Dr. Sims states that yourself, Dr.
Groves, and Drs. J. D. and H. E. J. Long were students of mine
and witnessed the operation performed on Venable in 1842. Your
recollection failed you at the time. As it was several years, at
least two, before either entered my office, you will see that you
were mistaken in giving Dr. Sims this information. You also
make a mistake in saying that the first inhalation in Jefferson of
ether for its exhilarating effects was before the same persons.


Male.  
* * * I wrote to Dr. Sims informing him of the errors and
asking him if he considered the mistakes of sufficient importance
to be noticed, etc. (Signed) 0. W. Long."


Dr. Wilhite replied as follows :


.57.  
"Anderson, S. C, June 27, '77.
Dr. C W. Long.  


Dear Doctor : — Yours of the 22nd inst. is at hand, and I have also
just received a letter from Dr. J. M. Sims, which I will answer
to-day. » » *


Good.  
In my statement I did make a mistake in regard to my being
present at the first or second operation, which mistake I will
correct. But if you still prefer I will send a certificate. * * •


Let me know and I will give you any information or assistance
in this great matter. Yours truly, etc.,


R. E.  
(Signed ) P. A. Wilhite."


Ill the letter to Wilhite, Long makes no comment on the
negro-boy incident, but his daughter informs me that he


"




1'
*The Nineteenth Cenliiry, 1880.




2 *'


repeatedly told her that he had never heard of it before it
appeared in Sims' article.


20/40
It is to be regretted that the justification of Long's claims
should have been linked so closely with such misstatements.


Sims sailed for Europe soon after the publication of his
article, and Long died in a few months, and Wilhite's statements went unchallenged for many years.*


91
Among Dr. Long's papers are many more documents —
affidavits of persons operated on and witnesses to them, and
letters to different prominent men — but their recital would
take up too much time, so I will close with a few words
regarding his after life.


In 1842 Dr. Long was married to Miss Caroline Swain, a
niece of Governor Swain of North Carolina, a very handsome
and attractive woman, who proved a devoted wife. She survived her husband many years.


Male.  
Long remained in Jefferson for ten years, when he removed
to Athens and there spent the rest of his days. By inheritance
and professional labors Dr. Long had amassed a fortune,
which was largely swept away by the war of secession, and at
its close he found himself reduced to poverty, with a large
family to support.  


Although he soon regained an extensive practice, the desolation of the country and the general poverty of the people
made the remainder of his life a continual struggle against
poverty. His life, which, up to the time of Dr. Sims' article,
had been one of disappointments, after that suddenly became
brighter, for from all parts of the world men prominent in the
medical profession hastened to give him the credit which had
so long been withheld.


51.  
His claims were never investigated by the American Medical
Association, as he often desired, but many minor societies and
the "Eclectic" Medical Association passed decrees in his
favor, and a statue was erected in his honor in Paris, France.  


But he was not long to enjoy the praise and long-delayed
honors which were now heaped upon him. Within a few
months, while laboring at the bedside of a delicate patient, he
was stricken with apoplexy and died the next day, June 16th,
1878, at the age of sixty-two, poor in worldly goods but rich
in the gratitude of his people. His oft-repeated wish to die
in harness had been granted.


Good.
A strange fatality seemed to hang over the lives of all connected with the discovery of auajsthesia !


Wells, disappointed and disheartened by the rejection of his
claims by the French Academy, became insane and committed
suicide in 1848.


L. E.  
Morton gave up a very lucrative practice and vainly spent
his life in trying to enforce his patent and get a reward from
Congress. He died in 1868 from congestion of the brain,
brought on by excitement occasioned by an article attempting
to deprive him of the honor he so jealously coveted.  


Long died in poverty, from apoplexy brought on by overwork in 1878.


"
Jackson, like Wells, became insane from the bitter contentions of his life and died in an asylum in 1880.




"


*ln an article in the Virginia Medical Monthly, 1893, Dr. L. 15.
Grandy, of Atlanta, showed the error of Wilhite's statements.


2 "




20/100
182


[Nos. 77-78.


92




Female.  
Henri L. Stuart, founder of the Woman's Hospital, aud a
great New York philanthropist, became interested in Long's
claims and presented a portrait of him to tlie University of
Georgia. After seeing it unveiled with great ceremony in the
capitol in Atlanta, one year after Long's death, he went to
Athens as a guest of the Longs, to visit the grave of the discoverer of anaesthesia. Arriving at night, he waited till
morning to fulfil his heart's desire. But this was never gratified. IJuring the night he had a paralytic stroke aud died
at the home of the Longs after lingering several weeks. At
his own request his remains were interred next to those of
Crawford Long — two great benefactors side by side.  


Appendix I.
Dr. Long's Original Paper.*


47.  
In the month of Dec, 1841, or Jan., 1842, the subject of the inhalation of nitrous oxide gas was introduced in a company of young
men assembled at night in the village of Jefferson, Ga., and the
party requested me to prepare tliem some. I informed them I had
not the requisite apparatus for preparing or preserving the gas, but
that I had an article (sul. ether) which would produce equally exhilarating effects and was as safe. The company were anxious to
witness its effects, the ether was introduced and all present in turn
inhaled. They were so. much pleased with its effects that they
afterwards frequently used it and induced others to do the same,
and the practice soon became quite fashionable in the county and
some of the contiguous counties.  


On numerous occasions I inhaled ether for its exhilarating properties, and would frequently, at some short time subsequent to its
inhalation, discover bruised or painful spots on my person which
I had no recollection of causing and which I felt satisfied were
received while under the influence of ether. I noticed my friends
while etherized received falls and blows which I believed were
sufiicientto produce pain on a person not in a state of anaesthesia,
and on questioning them they uniformly assured me that they did
not feel the least pain from these accidents. Observing these facts
I was led to believe that anesthesia was produced by the inhalation of ether, and that its use would be applicable in surgical
operations.


Good.  
The first patient to whom I administered ether in a surgical operation was Mr. James M. Venable, who then resided within two
 
miles of Jefferson, and at present lives in Cobb Co., Ga. Mr. Venable consulted me on several occasions in regard to the propriety
of removing two small tumors situated on the back part of his neck,
but would postpone from time to time having the operation performed, from dread of pain. At length I mentioned to him the fact
of my receiving bruises while under the influence of the vapor of
ether without suffering, and as I knew him to be fond of and accustomed to inhale ether, I suggested to him the probability that the
operations might be performed without pain, and proposed operating on him while under its influence. He consented to have one
tumor removed, and the operation was performed the same evening. The ether was given to Mr. Venable on a towel, and when
fully under its influence I extirpated the tumor.


II .1
It was encysted and about half an inch in diameter. The patient
continued to inhale ether during the time of the operation, and
when informed it was over, seemed incredulous until the tumor
was shown him.  


He gave no evidence of suffering during the operation, and
assured me, after it was over, that he did not experience the least
degree of pain from its performance. This operation was performed on the 30th ]\rarch, lSt2.


"




"
' Read liefore Georgia State Medical .Society in 18.')3.




2 "


The second I performed on a patient etherized was on the 6th
June, 1812, and was on the same person, for the removal of the
other small tumor. This operation required more time than the
first, from the cyst of the tumor having formed adhesions to the
adjoining parts.


20/100
The patient was insensible to pain during the operation until
the last attachment of the cyst was separated, when he exhibited
signs of slight suffering, but asserted after the operation was over
that the sensation of pain was so slight as scarcely to be perceived.
In this operation the inhalation of ether ceasrd before the first incision was made. Since that time I have invariabh' desired
patients, when practicable, to continue the inhalation during the
time of the operation.


Having permitted such a length of time toelapse without making
public my experiments in etherization, in order to show the correctness of my statements I procured the certificate of the patient
on whom the first operation was performed, the certificate of two
who were present at the time of the oper.ation, and also those of
his mother, brothers and sisters and a number of his immediate
friends who heard him speak of the operations soon after they
were performed. The Southern ]Med. and Surg. Journal* contained
but two of the certificates. I have a number of others which can
be seen or read if desired by the Society. My third case was a
negro boy who had a disease of a toe which rendered amputation
necessary, and the operation was performed July 3rd, 18)2, without the boy evincing the slightest sign of pain.


93
These were all the surgical operations performed by me during
the year 1842 upon patients etherized, no other case occurring in
which I believed the inhalation of ether applicable. Since '42 I
have performed one or more surgical operations annually, on
patients in a state of etherization.


I procured some certificates in regard to these operations, but
not with the same particularity as in regard to the first operations,
from the fact of my sole object in the publication being to establish my claim to priority of discovery of power of ether to produce
anasthesia. However, these certificates can be examined.


Male.  
Tlie reasons which influenced me in not publishing earlier are
.as follows:


I was anxious, before making my publication, to try etherization
in a sufficient number of cases to fully satisfy my mind that an£Bstliesia was produced by the ether, and was not the effect of the
imagination or owing to any peculiar insusceptibility to pain in the
persons experimented on.


55.  
At the time I was experimenting with ether there were physicians high in authority and of justly distinguished character who
were the advocates of mesmerism, and recommended the induction
of the me.wierjcs/a?*' as adequate to prevent pain in surgical operations. Notwithstanding thus sanctioned I was an unbeliever in
tlie science, and of the oiiinion that if the mesmeric state could be
produced at all it was only on those of strong imaginations and
weak minds, and was to be ascribed solely to the workings of the
patient's imagination. Entertaining this opinion, I was the more
particular in my experiments in etherization.  


Surgical operations are not of frequent occurrence in a country
practice, and especially in the practice of a young phj'sician, yet I
was fortunate enough to meet with two cases in which I could satisfactorily test the anEesthetic power of ether. From one of these
patients I removed three tumors the same day ; the inhalation of
ether was used only in the second operation, and was effectual in
preventing pain, while the patient suffered severely from the extirpation of the other tumors. In the other case I amputated two
fingers of a negro boy ; the boy was etherized during one amputation
and not during the other ; he suffered from one operation and was
insensible during the other.


Good.
After fully satisfying myself of the power of ether to produce
aniesthesia, I was desirous of administering it in a severer surgical




R. E.


FAC-SIMILE OF LONG'S MANUSCRIPT. SEE PAGE 182.


"
operation than any I had performeii. In my practice, prior to the
published account of the use of ether as an antesthetic, I had no
opportunity of experimenting with it in a capital operation, my
cases being confined, with one exception, to the extirpation of small
tumors and the amputation of fingers and toes.


While cautiously experimenting with ether, as cases occurred,
with the view of fully testing its antesthetic powers and its applicability to severe as well as minor surgical operations, others
more favorably situated engaged in similar experiments, and consequently the publication of etherization did not " bide my time."


"
I know that I deferred the publication too long to receive any
honor from the priority of discovery, but having by the persuasion
of my friends presented my claim before the profession, I prefer
that its correctness be fully investigated before the Med. Society.
Should the society say that the claim, though well founded, is forfeited by not being presented earlier, I will cheerfully respond,
so mote it be.


Not wishing to intrude upon the time of the Society, I have made
this short compendium of all the material points stated in my
article in the Journal, and if the Society wishes any fuller information on the subject I will cheerfully comply with their wishes.


2 "
Appendix II.


" Georgia, 1 I, Ange De Laperriere, M. D., do certify that I


20/70
Jackson County. > resided in Jefferson, Jackson County, Georgia,
 
in the year 1842, and that some time in that year I heard James M.
Venable, then of said county, speak of Dr. C. W. Long's cutting out
two tumours from his neck while under the influence of the inhalation of sulphuric ether, without pain or being conscious of the performance of the operation.


94
I do further certify that the fact of Dr. C. W. Long using sulphuric ether by inhalation to prevent pain in surgical operations was
frequently spoken of and notorious in the county of Jackson,
Georgia, in the year of 1842. A. De Laperriere, M. D.


Sworn to and subscribed before me this 30th of March, 1854.


Male.  
N. H. Pe.ndergrass, J. P."


"Athens, Clarke Co., Georgia.
I, the undersigned, do certify that in May, 1843, 1 assisted Dr. R.
D. Moore in amputating the leg of a colored boy Augustus, then the
property of Mr. Wm. Stroud, who resided in this county ; and that
I distinctly recollect hearing Dr. R. D. Moore say, If I had thought
of it before leaving home I would have tried Dr. C. W. Long's
great discovery, namely, the administration of sulphuric ether
as an anaisthetic in performing the operation. Having neglected
to bring the ether. Dr. Moore finally concluded to influence the


71,




Good.  
patient with morphia ; under which influence the operation was
performed. Jos. B. Carlton, M. D."


Appendix III.
From Dr. Long's First Student.


" "
"CoHUTTA, Ga., Dec. 13th, 1894.
Mrs. Frances Long Taylor,


Dea7' Madam :—* * * In 1844, soon after I attained my majority,
I decided to adopt medicine as my profession, and began to think
where and under whom I should begin the preparatory study. My
father asked me to choose from among the number of physicians
whom 1 knew the one I preferred to act as preceptor to me.


"
Knowing Dr. Long so well and believing him to be a man of no
ordinary ability, I at once fixed upon him as my choice.


I entered Dr. Long's office in May, 1844, as the first student ever
under his care. As I progressed with my studies he saw fit to make
known to me his discovery, by the use of which he could perform
surgical operations without giving any pain to his patient. [Here
follows a description of the first cases.]


"
Notsatisfied, however, that there was not more to learn about this
great disco very, he proposed that we test it further personally, which
we did in his office, where with closed doors we administered it to
each other to prove its perfect anaesthetic effect and also to discover
any bad effect to the subject etherized. Owing to the prejudice and
ignorance of the populace Dr. Long was prevented from using ether
in as many cases as he might have.


Thus in the two years preceding my entering Dr. Long's office he
had had only about six cases in which to try the anaesthetic effects
of ether.


2 "
The first case thatcame under his care where its use was applicable after my going into his office was not till January 8th, 1845,
which was the case of a negro boy having two fingers to amputate,
caused by neglected burn. I, as the only student still with the
doctor, he had me to accompany him to see the operation and assist
ill the administration of the ether. The first finger was removed while
under the influence of ether, the little fellow evincing no pain ; the
second without ether, the child suffered extremely. This was done
to prove that insensibility to pain was due to the agent used.


Soon after this, in January, Mr. J. D. Long came into the office as
a fellow-student ; later, toward spring, came P. A. Wilhite, and in
August came Dr. Long's brother, H. R. J. Long. We four remained
there at Dr. Long's oflBce as students until the opening of the fall
term of the medical colleges. » * *


20/70
[Signed] J. F. Groves, M. D.


Sworn and subscribed to before me, Dec. 15th, 1894.


95
\V.M. H. Wilson, N. P."




Female.


THE EARLY HISTORY OF OPHTHALMOLOGY AND OTOLOGY IN BALTIMORE (1800-1850).*


65.  
By Harhy Friedenwald, A. B., M. D., Associate Professor of Ophthilmologij and Otology, College of Fliysicians and Sii-rgcons,


Baltimore, Md.


Bad.




" "
An old book tells us that each generation may be looked
upon as standing on the shoulders of its fathers. If its vision
is clearer, its intellectual view less obstructed, its horizon
broader, it is in great part due to the height to which others
have raised it, to tlie support others have given. Unmindful
of this, it is apt to exaggerate its greatness and the importance
of its own work.




Escape vitreous.


* Read before the Johns Hopkius Hospital Historical Club,
April, 1897.


Irido-cyclitis,




2 "
In the following narrative I have brought together all that I
could find relating to tlie lives and labors of those who, in the
earlier years of this century and in our own city, tilled the
soil of ophthalmology and otology. Some have been forgotten,
few have been accorded deserved recogniiion.


Are not many of us as ignorant of their names and works as
an old physician from whose memories I liad hoped to obtain
information, but whose response was, "No work was done in
Baltimore in those departments of medicine before 1850"? I
must confess tliat when iny attention was first drawn to this






96
August-September, 1897.]


185


Female.




52.  
subject I knew of biit one work of importance which a Baltimore physician had rendered to ophthalmology.  


There is no reference in literature to anything done in
Baltimore in the two branches we are considering before the
beginning of this century. We must remember that in 1800
the population of Baltimore City was 26,614 and that in 1802
there were but 44 physicians.


Good,  
It is probable that there were here as elsewhere those who
 
confined themselves to diseases of the eye. This is indicated
 
by a resolution adopted at the convention of the Medical and
L. E.  
Chirurgical Faculty of Maryland in 1805.* It was resolved
that " the Board of Examiners be authorised to grant special
licenses to dentists and occulists to practice in their respective
branches, subjecting them to an examination only on the
branches they possess; and that such licentiates shall pay ten
dollars for each license so obtained; provided it shall be the
opinion of the attorney-general that the law authorizes the
examiners to grant such licenses. The secretary having submitted the preceding resolution to the then attorney-general,
he gave it as his opinion that the law authorized the board to
act according to the spirit of the resolution." These "occulists" did not, it appears, stand in very good repute.  


In the review in 1825 of an American treatise on diseases of
the eye, the writer, who was probably Dr. Isaac Hays, the distinguished editor of the American Journal of Medical Sciences
and an ophthalmologist of note, describes the condition of
ophthalmology in the early years of this century. He tells us
that " the neglect to which disorders of the eye were too long
consigned is truly astonishing. Prepossessed with an idea
that there was something peculiar in the diseases attacking
different parts, physicians entirely abandoned these affections to
persons who were exclusively devoted to them and were totally
ignorant of the laws which influence diseases of other organs.
To this cause is to be attributed the slow progress which tlie
science of ophthalmology made during many centuries. The
history of this science shows that while it made most rapid
advances in improvementby the investigations of medical men,
it invariably, when abandoned to professed oculists, not only
ceased to advance but actually retrograded ... In this country
much apathy has existed, and we fear still exists, with regard
to these affections. Some of our distinguished surgeons have
not, it is true, entirely neglected them ; yet the mass of
medical practitioners have paid little attention to them, and
the science has advanced so rapidly during the few years that
we believe few have kept pace with the improvements that
have been made. The length of time that generally elapses
before opinions of European writers are diffused in this
country — the want of regular lectures — and above all, clinical
instruction and the opportunities furnished of observing these
diseases in institutions established for the reception of these
cases, are the cause, no doubt, of the present state of the science
among us."


Iridectomy.  
He mentions that the New York Eye Infirmary was established in 1830, the Pennsylvania Infirmary for Diseases of the
Eye and Ear in 1822, and "with respect to the institution at
Baltimore he has but little information to communicate. It is




Uncomplicated.


'Summary of Proceedings, &c., published in 1817


3 "




20/200
attached to the Baltimore Dispensary and is committed to the
care of the author of this work." [Dr. Geo. Frick.]


Pierre Chatard.


97
The earliest Baltimore publication having reference to
diseases of the eye is found in a paper written by Dr. Pierre
Chatard in the Medical Repository, vol. VII, p. 28. Dr.
Chatard was born and educated in France, and had settled in
Baltimore in 1797. He was a prolific writer, the paper referred
to being one of the earliest. It was entitled "An account of a
case of Fistula Lachrymalis, with reflections on the diflerent
modes of operating in that disease." The paper describes a
case of lachrymal fistula relieved by introducing threads of
silk after the manner of a seton through the lachrymal duct
and gradually increasing their number. He discusses at length
the various methods in vogue at that time of treating the
disease. It is written in an interesting and elegant manner.
None of the other writings of Chatard relate to diseases of
the eye.


William Gibson.


Female.  
During the second decade of this century the celebrated
surgeon, Wm. Gibson, practiced in Baltimore. Win. Gibson
was born in 1784 in Baltimore, and was graduated in medicine
in Edinburgh in 1809. He was a physician to the Baltimore
General Dispensary in 1818-19, and professor of surgery at the
University of Maryland from 1812-19, resigning to occupy the
same chair at the University of Pennsylvania from 1819-54.
He died about 1858 (?)•


His numerous publications date mainly from the latter
period of his activity, but there are two notable and very interesting references to ophthalmic surgery dating from the Baltimore period.


53.  
In Hirsch's History of Ophthalmology* we find the statement
that Prof. Gibson of Baltimore had made the experiment of
introducing a seton through the cataractous lens, witli the view
of producing its absorption, so original an experiment that
Hirsch cites the description given by Dr. John Revere untranslated. My friend. Dr. O'Connor of Boston, had the kindness
of looking up the reference in the New England Journal of
Medicine, vol. VIII, p. 119, of 1819, and I will give this
account in full because of its intense interest.  


Extract of a letter to one of the editors:


Good.  
" lam desirous of communicating through the medium of the New
England Journal a new mode of operating for cataract, which has
been projected and jiracticed recently, in two cases, with the mot;t .satisfactory success, by my friend, Dr. Gibson, professor of surgery at
the University of Maryland.  


The operation was performed in the following manner : The iris
was in the first place dilated by the application of atropa belladonna. A common sewing needle, slightly curved and armed with
a single thread of silk, was then passed through the tunica sclerotica about two lines from the cornea, where the couching needle is
usually introduced, through the opaque lens and out of the opposite side of the cornea, at a point corresponding to the one at which
it was introduced. The silk being drawn through, and the ends
cut off, a single thread was thus left passing through tlie ball of the
eye, and acting on the diseased lens in the mauner of a seton. It


R. E.




"
•Graefe and Saemisch's Handbuch, Vol. VII, p. 517.




"


186


3 "
[Nos. 77-78.




Not tested.


was feared that serious inconvenience might arise from the irritation produced upon the tunica conjunctiva, from the excessive
sensibility of this membrane. Fortunately, however, neither this
nor any other accident intervened, and at tlie end of ten days, in
both cases tlie diseased lens had disap])eared, and, in its place, the
silk was distinctly seen passing like a bar across the pupil of the
eye. Tlie silk was withdrawn, and in a few days the vision was
restored. In the third and last case in wliich this operation was
performed it failed in consequence of the iris being wounded.
This caused such an inflammation of the organ that it was deemed
proper to withdraw the seton at a very early period. This accident was attributed to not using the belladonna. One would think
that a common sewing nee<lle is not the most convenient instrument that could be devised for this purpose, on account of the dense
structure of the part througli wliich it is to pass, and the difficulty
of having the perfect command of any instrument without a handle.
From the nature ot the disease, from the known eflects of this
remedy when applied to other parts of tlie body, and from the
success which has already been experienced, there seems to be
good reason to hope that this will be found an important improvement on the established practice in many forms, if not in every
variety of the disease. But the practical benefit to be derived
from this operation can only be tested by a more enlarged observation than in this country ever falls to the lot of any individual.
I remain yours, J. Eeverb.


98
Balto.. Mch. 2nd. 1819."
 
 
Female.  
 


77.  
We learn from Hirsch that Loewenhardt in 1828 operated in
a similar manner for secondary cataract with anterior and posterior synechia, likewise with good resnlt; it ajopears that
others have not attempted the operation.  


In the American Appendix to the second edition of Cooper's
Dictionary of Practical Surgery, edited in America in 1844
by David Meredith Keese, who in 1843 and 1843 was professor in Washington University of Baltimore, we find a
very curious reference to Professor Gibson under the head of
strabismus: "It apjiears from the Institutes of Surgery that
Professor Gibson attempted the cure of strabismus by dividing
the recti muscles of the eye, precisely as now practiced, some
twenty years since, in Baltimore. Soon after he repeated it
unsuccessfully in Philadelphia in several cases, and was induced to abandon it by unfavorable opinions exjiressed on the
operation by Dr. Physick. He, however, inculcated the propriety of the operation upon his class many years since, and
Dr. A. E. Hosack, of New York, then one of his pupils, distinctly recollects Dr. Gibson's expressions of confidence that
the operation would ultimately succeed."


Good.  
I had no little difiiciilty in finding the reference to which
Dr. Reese refers. The first five editions of Gibson's Institutes
of Surgery (published between 1824 and 1838) contain no
chapter devoted to strabismus, and in the seventh edition the
long account of strabismus and its treatment consists almost
entirely in a paper written by Charles Bell and sent by him to
Gibson. In this chapter the above reference is likewise not to
be found. It is only in the sixth edition, published in 1841,
that we find the reference. It is of such importance that I
shall give it in detail. On page 375 Gibson states that:


"In the year 181S, while practising my profession extensively in
Baltimore, the late Mr. B. J. consulted me about his daughter, a
child of eleven or twelve years of age, both of whose eyes were
directed very much inwards, and were thereby greatly deformed
by a squint. I advised a pair of goggles, so contrived, by having a


L. E.




"  
small opening in the centre of each, as to oblige the ckild to direct
the cornea to these openings, and by i)erseverance for several
weeks, succeeded in diminishing the deformity but not effecting a
cure. In the course of my visits the child remarked at different
times that her eyes felt as if tied by a string. Struck with this observation, and conceiving the disease might depend upon shortening of the internal rectus muscle, I determined, the first opportunity, to try the result of divison of that muscle ; and as the friends
of my young patient were unwilling the experiment should be first
tried upon lier, I selected a hospital patient, and after some difficulty
in fixing the eyeball and in cutting the muscle across, succeeded in
restoring the eye partially to its natural situation. Upontwoother
patients I repeated the experiment, without mucli better success,
but on dividing a muscle in a fourth patient, after my removal to
Philadelphia, the eye was so completely turned to the opposite
direction as to bury the cornea beneath the lids and create a much
greater deformity tlian liad previously existed. Upon showing the
patient to Dr. Physick, he advised the experiments to be abandoned, as likely to be followed by very unfavorable results. I
mention these circumstances, not from a desire to receive credit
as an inventor or to detract from the claims of the distinguisiied
surgeon with whom the modern operationof strabismus originated,
but merely as a curious fact, calculating to show the importance of
not laying aside processes apparently founded upon correct principles, simply because we are at first foiled in our attempts to execute them. How much benefit would have resulted to the community if I had followed up my operations until I ascertained the
proper mode of correcting them, or how much injury I might have
inflicted upon individuals by perseverance in ihe attempt, I shall
not stop to inquire. It is sufficient for me to announce the fact —
wliich I have no doubt could be easily substantiated by many
pupils who attended my early lectures, some of whom have indeed
already proffered their testimony — without being over-solicitous,
in setting up a claim as an inventor, of exposing my aw kwardness
and perhaps want of knowledge of the principles that should have
guided me in following out the practice I had attempted to institute."  


It may not be out of place to mention that; Stromeyer's
important monograph, in which he recommended division of
the muscle for strabismus appeared in 1838!


Iritis.  
The chapters devoted to diseases of the eye in Gibson's Institutes are important, but as the book appeared after the
author had left Baltimore, it is not proper to discuss them
here.  


Another reference which shows Gibson's interest in the eye
occurs in the American Medical Eecorder (vol. II, p. 383).
It is a "Letter of Charles Bell to Professor Gibson, of Baltimore," and its subject is, " The New Coat of the Eye discovered by McCarthy's demonstrator, Jacobs."


4 "
George Fkick.*


We may next take up the most important name of this
narrative, that of Dr. George Frick, the author of a valuable
treatise on diseases of the eye, the first ^\■ork of the kind that
appeared in America.


20/100
George Frick was born in Baltimore in 1703. After obtaining a broad classical education he entered the University of
Pennsylvania, where he obtained the degree of doctor of medi




99
*The accompanying portrait of Dr. Frick is copied from one
recently presented to the Medical andChirurgical Faculty, together
with a case of instruments which belonged to the doctor, by his
niece, Mrs. AVhite and her daughter. Miss Mary White.




Male.


August- September, 1897.]


56.
187




Bad.


cine in 1815, and in 1&17 he was admitted as licentiate of medicine into the Medical and C'hirurgical Faculty of Maryland.
He then spent several years abroad, returning to Baltimore about
1819 to engage in the practice of ophthalmology. He was
api)ointed surgeon to the Baltimore General Dispensary, where
he established the first Eye Dispensary in Baltimore, in 1824.
In 18^3 he delivered clinical lectures at the Maryland Hospital. His name is found on the list of vaccine physicians for
1821.


R. E,  
He was a member of various medical societies; was secretary
 
of the Faculty in 1823, and
joined the Maryland Medical
Society in 1822. He was much
interested in general science,
and was one of four physicians
to organize a society for promoting science, in 1819. He
was likewise a member of the
Maryland Academy of Sciences,  
its librarian in 1824 and curator
in 1836.


■'
He devoted himself to the
practice of ophthalmology and
to the cultivation of general
scientific stvrdies, as well as to
music for a number of years.
He was unfortunate in growing
very deaf before middle life, and
it is probable that this interfered greatly with his practice
of medicine ; for somewhere
about 1840 he entirely relinquished it and left Baltimore
to spend most of his time in
Europe, paying occasional visits
to this country. He died in
Dresden, March 36th, 1870,
aged 77 years. Dr. Frick had
never married. He was a man
of very retiring and modest
character and of kind disposition. He was a careful scientific student and his work and
writings deserve high praise.


His first writing was his thesis
for the degree in medicine; its subject was "On the Meloe
Vfsicatorium" (1815). In 1820-31 his article on " Observations on Cataract and the various modes of operating for its
cure" appeared in the American Medical Kecorder of Philadelphia. These articles cover over 40 pages. In 1821 an article
on "Observation of the various forms of Conjunctivitis" appeared in the same journal, and in 1823 his paper on " Observation on Artificial Pupil and the modes of operating for its
cure."* His most important work, however, was "A Treatise
on the Diseases of the Eye; including the doctrines and practice
of the most eminent modern surgeons and particularly those of


Uncomplicated.  
*This curious error is cited as it is found.  




2 "




20/30
Professor Beer," which was published in Baltimore by Fielding
Lucas, .Jr., in 1823. It was inscribed to his teachei-, Dr. Physick
of Philadelphia. The articles above referred to, though somewhat more elaborate, were in the main identical with the corresponding chapters of the treatise and do not therefore require
special consideration. The treatise is of considerable value.*
It is well and clearly written, the system irpon which it is
classified is excellent, and no greater praise could be given it
than stating the fact that it was republished three years lateiin London by an English surgeon, Richard Welbank, a member
of the Royal College of Surgeons and of the Medical and
Chirurgical Society of London,
and dedicated to the ophthalmologist William Lawrence.
Numerous foot-notes were added, but the te-xt suffered no
change.


The reviews which the book
received were very complimentary. The Philadelphia Journal of Medical and Physical
Sciences (probably Dr. Isaac
Hays) contains a review covering 18 pages: "The author
evidently possesses a cultivated
and well disciplined mind; he
appears to be intimately familiar
with German writers, and we
feel much indebted to him for
making us acquainted with their
writings."


100
In the American Medical Recorder of 1824 a still longer
review is to be found, covering
32 pages. The writer describes
the book in terms of high praise.
He "offers the humble tribute
of (his) thanks to the author for
the benefits which he has conferred on the profession generally, by presenting them with a
volume of great value and utility, and one which was much




Male.


* It is interesting to find numerous pencil notes in the articles in
the copies of the American Medical Recorder at the library of
tlie Medical and Chirurgical Faculty of Maryland, notes suggesting slight changes in the phraseology, paragrap'-ing, etc., every
one of which has been adopted in the treatise. I have been able
to trace this copy, which was bought with other books by Dr.
,Iohn Morris at a public sale of the library of Dr. John Buckler,
who was related by marriage to Dr. Frick, and whose library thus
passed into Dr. Buckler's. Numerous books at our library contain
Dr. Frick's autograph, and one, a copy of Gibson's Institutes of
Surgery, has an inscription of the author to his friend Dr. Frick.
In Beer's work on ophthalmology there are interesting pencil notes
and several pages of written matter which correspond so thoroughly
with Dr. Frick's writing that I have no hesitation in stating that
tbev are his.


58.




Good.
188


[Nos. 77-78.


L. E.




"  
wanted. As a manual of the diseases of the eye, we believe it to be the best which has been published. It contains all the improvements which have enriched ophthalmic
surgery, in such a siirpi'ising degree within a few years
past," etc.


In 1835 this work was placed on the list of those which the
student was required to liave read before applying to the
Medical and Chirurgical Faculty of Maryland for the examination for licentiate in medicine.


"  
Hirsch in his history of ophthalmology says that " George
Frick was the apostle of the ophthalmological school of
Vienna in North America; his treatise was next to Saunders's,
the first large treatise on ophthalmology in America, and
was received by physicians with great praise." Saunders's
book was an English work and was republished in Philadelphia
in 1831, two years before Frick's. The only other book in the
English language of a similar kind was that of Travers, which
appeared in London in 1820-31-24.


We thus see that Frick's book was the first American
treatise (and for a number of years it remained alone). The
work is much quoted in Cooper's Dictionary of Surgery.


2 "  
In Quinan's Medical Annals of Baltimore I find a reference
to a paper of Dr. Frick's " On the Senses," which he tells us was
read before the Medical Society of Maryland in 1821. I have
been unable to find this paper.


In Cordell's History of the University of Maryland we learn
that the foiindation of the Infirmary was laid in 1823 and that
patients were received in the same year. Of the four wards,
"one was reserved for eye cases, instruction in ophthalmic
surgery forming a prominent feature in the course. This was
during the time of Frick's greatest activity, and it is possible
that the prominence given to ophthalmology was through him,
and that he delivered the clinical lectures in this branch. I
am unable to verify this.


Not tested.  
In conclusion it is interesting to call attention to the fact
that Dr. George Frick was the uncle of the distinguished
clinician, Professor Charles Frick.  


Horatio G. Jameson.


101
Horatio G. Jameson, born in Pennsylvania about 1793, graduated in medicine at the University of Maryland in 1813. He
held a number of important public positions, having been consulting surgeon of the Baltimore City Hospital from 1819 to
1835, consulting physician of the board of healtli of Baltimore
City in 1827-35 ; he was incorporator of the AVashington Medical University in 1827, and professor of surgery and surgical
anatomy in the same from 1827-35, when he became professor of surgery in the Cincinnati Medical College. He was
one of the most prominent surgeons of Baltimore for a number
of years, and a very active contributor to medical journals,
writing important papers in medicine and in surgery. He was
the editor of the Maryland Medical Recorder during its existence of several years (Sept. 1829-Nov. 1832), and a large
number of its articles are from his pen.


Jameson appears to have been much interested in diseases of
the eye. AVe find frequent references to publications on these
subjects throughout his journal, several of which have remarks
added by the editor. In vol. 2 there is an article on the


Male.




54.  
"Pathological Sympathy between Eye and Larynx" (p. 117)
This article is without any value, indeed it is difficult to understand the real significance of his report after careful reading.
An article on "A case of Enlargement of the Eye following
the entrance of steel into the eye" describes the panophthalmitis followed by bursting and shrinking of the eyeball
(p. 601).  


In another paper he described " two cases of ossification
of the lens with luxation through the pupil." These cases
are of some interest. He extracted the lenses and the patients did well (p. 608). An article on amaurosis associated
with inordinate thirst was probably written by Jameson (p.
664).


Good.  
In the American Medical Recorder of Philadelphia (vol.  
XII, p. 340) we find an interesting account of the successful
removal of " An encysted tumor of tiie orbit."


In discussing a letter on "Ophthalmia in the Philadelphia
Alms House," written to Dr. Rusii, Jameson considers the
question of the endemic or .contagious character of the
ophthalmia, excludes the latter view, and attributes the very
severe disease to the vitiated state of the atmosphere. He
states that " we do not as a general rule of practice bleed
sufficiently in cases of ophthalmia."


R. E.  
John Mason Gibson.  


John Mason Gibson in 1832 published in Baltimore (W. R.
Lucas) a " Condensation of Matter ujwn the Anatomy, Surgical Oj)erations and Treatment of Diseases of the Eye,
together with remarks. Embellished with twelve lithographic plates, illustrative of the anatomy, operations, and
morbid appearance."


"
I am unable to give any details of this author's life. I find
that he vvas admitted into the Faculty in 1825, and that his
name appears as late as 1848 in the list of members with the
title of L. M. In the next succeeding list published in ISoS
Gibson's name is missing.


In the preface he tells us that his book is an " attempt at
collecting the best matter on diseases of the eye." That
" diseases casiral to vision are many and frequently met with
in this country; the curative practice has not been sufficiently
inculcated in our universities, by impressing upon the mind of
the student where and when the importance and great nicety
of judgment are requisite in the treatment of them, and that
by inadvertent and mal-practice the victim may grope through
his existence here in the valley of darkness."


"  
The work is one of compilation, "being made up of exten- f


sive quotations from the classical writers of the day." He
claims originality only in the construction of his plates, and so
far he is certainly correct, for the drawings are quite unlike
anything seen in nature.


2 "
The arrangement of the work is very curious. The chapters
follow in this order: Anatomy of the eyeball, cataract, ophthalmia, corneitis, iritis, choroiditis, retinitis, inflammation of
the lens and its capsule, ulcers of the cornea, ojiacities of the
cornea, ptergium, prolapse of the iris, extirpation of the eyeball, extraneous bodies, diseases of the lachrymal apparatus,
under which is included entropium, ectropiuni, epiphorn,
encaiitlius, injury of lids, ophthalmia tarsi and fistula hiclirv




20/40
August-Septembek, 1897.]


189


102




Male.  
malis, looking very much as tlioxigh the subjects had been
drawn haphazard from a grab-bag.*


At the end of several chapters the author adds original
remarks. When we consider the very excellent and systematic
work which Frick had published, nine years previously, as well
as such other works from which copious quotations are made,
it is quite inexplicable why Gibson showed such disregard of
systematic classification, or indeed what purpose he had in
publishing the work at all.


46.  
Dr. John Hakper.  


Dr. David Jleredith Reese, in his American edition of
Cooper's Dictionary of Practical Surgery, first published in
1833, tells us, under the section of cataract, that "one of the
most successful operators in this country is Dr. John Harper,
of Baltimore, and he seldom adopts any other operation than
this (laceration of the capsule and lens substance), which he
repeats as often as necessary on the same eye." I have given
myself great pains to obtain some information concerning this
" successful operator," but his memories appear to have been
completely effaced. One single reference is to be found, a
short obituary notice. In the Maryland Medical Recorder
(vol. II, 179) there is a notice of the death of four members
of the Medical and Chirurgical Faculty of the State of Maryland. One of these reads as follows : " Died in the month of
January, 1831, Doctor John Harper. Doctor Harper was a
native of Ireland, and graduated at Ghisgow. He was wellknown as an oculist." The title of oculist appears to have
been elevated to the dignity of a special practice of medicine
within a few years. For Harper was a member of the Faculty,
and not of the despised class of oculists mentioned in the
beginning of this paper.


Good.  
William Alexander Clendinen.  
 
 
L. E.
 
 
"
 


••
Wni. A. Clendinen graduated in the medical department
of the University of Maryland in 1840, a classmate of Dr.
G. W. Miltenberger. He died of cholera at New Orleans
in 18-1:9, having been seized with the disease while dissecting
a victim of the epidemic. After his graduation he traveled
extensively, devoting his time to the study of medicine. In
the Boston Medical and Surgical Journal in 1847 we find
several papers which were translations from the work of Prof.
Desmarres. In his letter to the editors he tells us that the
extracts are part of a "translation upon which he is now
engaged"; he expresses his gratitude to Prof. Desmarres, who
" has entrusted to him an onerous but useful task, one which
from (his) connection with him (he) may be able to perform
advantageously to readers of the English language." In the
second article, published in the same journal, we find after the
name of the author, " Chef de la clinique oculaire." There
were in all but three articles, and the promised book never
made its appearance, perhaps on acco^^nt of the untimely death
of the author.




2 "


* Not a few important subjects are entirely ignored, viz. errors
of refraction, strabismus, etc.


20/70




103
OTOLOGY.


The early contributions to Otology in Baltimore were very
few. Two names deserve recognition ; the first of these is that
of the renowned surgeon,


Female.  
Nathan Rhyno Sjiith.  


It is beyond the province of this paper to give a biographical
sketch of Dr. Smith. A very complete sketch can be found in
Dr. Cordell's History of the University of Maryland. He was
born in 1797 in New Hampshire, graduated as A. M. in 1817,
and as M. D. in 18-^3 in Yale College. He was professor of
anatomy and surgery in the University of Vermont in 1825,
soon leaving to occupy the chair of anatomy in the newly
organized Jefferson Medical College of Philadelphia. From
1827-39 he was professor of anatomy in the University of
Maryland, and from 1829-38 he occupied the chair of surgery
at the same university, leaving this for three years to occupy
the chair of theory and practice in the Transylvania University.
He resumed it again in 1841 and held it until 1869.


76.  
One of the earliest writings of this prolific worker was the
translation of a treatise on the ear from the French of Saissy,*
with additions by the translator on diseases of the external ear.
This book was published in Baltimore in 1829, and was, so
far as I can learn, the second book on diseases of the ear printed
in America, the first having been an American edition of Saunders on the eye and ear in 1821.  


Saissy's work was "highly esteemed in France," and was
one of the important factors in the revival of modern otology.
In his preface Dr. Smith tells us that " a concise manual on
the diseases of the ear is an acknowledged desideratum in our
medical literature. No sufficient work on the subject has ever
been issued from the American press. With a view to supply
this deficiency (he has) translated the following pages from the
French of Saissy . . . corrected and enlarged by its author,
and after his death published in 1827 by his friend Montaion, etc.


Bad.  
" It embodies the excellencies of Saunders, Cooper, Leschevin,
Maunoir, Itard and Alard . . .  


" The attention of the reader will be particularly occupied
with Saissy's excellent method of injecting the ear through the
eustachian tube. We very well know how frequently the external ear is obstructed by its own secretions, free as is their
egress from this cavity. The internal ear is also lined with a
membrane which furnishes an excrementitious fluid. It can
escape only by the narrow channel of the eustachian tube.
How frequently then must it be delayed in the cavity of the
tympanum and mastoid cells, giving rise to any degree of
mischief."


R. E.  
To render " the work more complete and useful to the medical
pupil (he has) added a brief supplement on diseases of the
external ear. On this score, however, (he) claims nothing, as
(his) addition is made up of commonplace iirinciples and




"


*An Essay on the Diseases of the Internal Ear, by J. A. Saissy,
M. D., translated from the French by Nathan Rhyno Smith, M. D.,
Professor of Surgery in the University of Maryland, with a supplement on Diseases of the External Ear, by the translator. Published by Hatch & Dunning, Baltimore, 1829.


"




2 "
190


[Nos. 77-78.


Not tested.




104
precepts subjoined merely for the purpose named above." He
concludes: "I have, it is true, for perforating tlie tympanum
devised a new instrument wliich I trust will be useful."


The part of the book most interesting to us is the supplement on diseases of the external ear, covering about twenty
pages. These chapters are written in the most concise and
simple manner and cover most of the inflammatory afiections
of the auditory canal, congenital deformities, injuries as well as
the treatment of foreign bodies, insects and indurated wax in
the auditory canal.


Female.  
He describes his method of inspecting the canal as being
 
" best accomplished by placing the head in such an attitude
 
as to suffer the sun's rays to enter the meatus and impinge
64.  
upon the tympanum. To effect this, the operator must seize
 
the external ear, and drawing it outward from the head, extend
and straighten the cartilaginous part of the meatus. I have
been able to inspect the ear more perfectly by introducing, at
the same moment, a steel director, with its groove toward the
meatus and its convex side pressed firmly against the anterior
walls. The passage is thereby straightened and expanded. If
there be no wax present the tympanum will be seen of a pearly
white color and concave."


Good.  
The little instrument which he devised for perforating the
membrani tympaui is a minute trephine, by revolving which
a circular piece of the drum was excised. His object in constructing this instrument was to obtain a larger opening, for
he tells us that in two instances in which he had occasion to
perforate the membrani tympani he found the beneficial effects
of the operation soon to cease in consequence of the speedy
closure of the artificial opening. The Maryland Medical Recorder of 1839 reviews the work extensively, the review covering twenty pages. The review is by no means flattering.  


It is very apparent that Dr. Nathan R. Smith must have
been deeply interested in the subject of the diseases of the
ear. He had an extensive j^ractice in diseases of the ear, and
also of the eye, though none of his publications deal with the
latter organ. Dr. Theobald has recently found a drawing of a
knife designed by Dr. Smith to slit the lachrymal canal.


11 11
Dr. Joshua I. Cohen.


Dr. Cohen, born in Maryland in 1800, graduated at the University of Maryland in 1833, having been a student in Dr.
Nathaniel Potter's office, and soon after devoted himself to the
study of diseases of the ear. He was an intimate friend of
Dr. George Frick, the oculist, and, like his friend, had wide
interest in science beyond the domain of medicine. He thus
for a time became professor of mineralogy in the academic department of the University of Maryland. He was much interested in the Medical and Chirurgical Faculty of Maryland, was
its treasurer from 1839 to 1856 and president from 57-58. He
was also much interested in the Maryland Academy of Sciences.


1'  
He practiced until about 1851, devoting himself almost exclusively to otology. His reputation as an aurist must have
been quite great, for we read in Reese's American edition of
Cooper's Dictionary of Practical Surgery (2nd ed., vol. 2, p. 73,
under the heading "Ear"): "In the United States there have
been a few surgeons who have distinguished themselves by
their success in the treatment of diseases of the ear.




"


" Dr. Cohen of Baltimore and Dr. Dix of Boston have for
several years directed their particular attention to diseases of
the internal ear, and to the investigation of the abnormal condition of the tympanum and eustachian tube in cases of deafness. These gentlemen have employed condensing apparatus
for administering the air douche through the eustachian tube
after the plan of Kramer and others. By the air and also by
the water douche, these gentlemen have acquired great tact in
the diagnosis and treatment of obstructions in the tube and
upon the tympanum."


3 "
In 1840 he established, in connection with his friend, Dr.
Samuel Chew, an eye and ear institute in Baltimore, in which
Dr. Chew had charge of the eye department. Dr. S. C. Chew
has had the kindness to inform me that this association between
Dr. Cohen and bis father lasted for a short time, as his father's
appointment to a chair in the University of Maryland compelled him to withdraw from it.


Dr. Cohen was one of the earliest, perhaps the first, aurist in
this country. He has left us, however, but one publication
which pertains to diseases of the ear. It is entitled " Postmortem Appearances in a Case of Deafness."* The paper is
very short, but is written in the most scientific manner.


20/40
In a note written by the editor of the Journal we read that
this "valuable communication was read before the American
Philosophical Society, at a recent meeting, and is noticed in the
proceedings of that body. It has rarely happened that opportunities have been embraced for examining into the condition
of the organ of hearing in cases of deafness, or that they have
fallen within the observation of an investigator so competent as
the author of this paper." The case was that of a patient who
died of phthisis. The brain and seventh pair of nerves were
examined carefully, but no changes observed. The lower part
of the skull was then removed and the ear examined in minute
detail.


In the right ear he found the drum-head dull and dark in
appearance, irregularly thickened and retracted as a whole, thus
diminishing the cavity of the tympanum. The tympanum
itself was filled with muco-fibrous membranes passing from the
membrani tympani to the posterior walls, presenting a cellular
structure. These were carefully divided, exposing the tensor
tympani muscle, the tendon of which was found to be of unusual shortness and attached to the handle of the hammer
throughout its whole length, thus drawing the bone and the
membrani tympani to within a line of cochlear process. Interesting irregularities in the ossicula were noted. The malleus
was normal. The incus was undeveloped, diminutive in size.
The stapes was wanting with the exception of the base, which
was held in place by the circular ligament. The depression of
the oval window was filled with membranous tissue, which likewise covered the fenestra rotunda. The tensor tympani muscle
was strongly developed, its tendon short and thick as mentioned above. The stapedius muscle existed, but there was no
tendon.


105
In the left ear the membrana tympani was found to have
been entirely destroyed, with the exception of a very thin slip
at the anterior inferior edge. The tympanum contained a




Male.


•Amer. Med. Intelligencer, July 1841 to July 1S42, p. 220 (Vol.1).


.50.




Good.  
August-September, 1897.]


191


II 11




"
quantity of yellowish fetid matter, and its lining membrane
was completely disorganized. The union between the ossicula
was slight, owing to the general disorganization of the ligamentous and mnco-fibroiis connections. The incus was in place,
but the handle of the malleus was depressed. The stapes was
not bound down in the oval window, for the annular ligament
was entirely destroyed. Tiie tendon of the tensor tympani was
disorganized and that of the stapedius destroyed; the whole
condition of tiie tympanum showed a recent active suppuration
which did not confine itself to this part; the vestibule was
penetrated as well as the mastoid cells; the latter were covered
with pus. Tlie cochlea and one of the semicircular canals
were examined a day or two subsequently, but there was nothing remarkable about them at this time worthy of note.


Inquiry about the patient led the author to conclude that the
faculty of hearing in the right earhad been entirely wantingor
was very much impaired for many years.


"
Though he seems to regard the condition of the right ear to
have been congenital, his critical analysis is as acute as the
observations tliemselves are accurate. He cites cases of Morgagni in which membranes filled the cavity of the tympanum.




2 "


and another in which there was immobility or contracture of
the muscles. At the conclusion of his paper he says: "In the
case described in this paper, does not the absence of every part
of the stapes, with the exception of the base, liken it to the
osseous operculum found in the bombinatores, land salamander, and cfBciliffi ; of the effect of wliich, in the communication
of sonoro:is undulations, I have already spoken ? " I am unable
to find any other reference to this paper on undulations and do
not know whether it was ever published.


20/70
This sketch must be brouglit to a close. Is it necessary to
remark what any careful reader must have observed, that there
were physicians in Baltimore in the first half of this century
who labored faithfully and well in Ophthalmology and Otology?
Their contributions were among the earliest and most important in this country.


In conclusion I desire to express my thanks to Dr. G. W.
Miltenberger, to Dr. John Morris and to Dr. Eugene F. Cordell, who furnished me with important notes, as well as my
indebtedness to Dr. John R. Quinan's "Jledical Annalsof Baltimore," and Dr. Cordell's " History of the Universiiy of Maryland."


106




Male.  
JOSEPH FRIEDERICH PIRINGER: HIS METHODS AND INVESTIGATIONS.*


By Harry Friedenwald, A. B., M. D., Baltimore.


65.




Bad.  
"Joseph FreiJerich Piringer was born, March 31st, 1800, in
Klein-Zell in Upper Austria. He studied medicine in Vienna ; he
afterwards turned his attention to ophthalmology in 1824. He
was at first an assistant of Jaeger, then for three years of Rosas
(beginning in 1825). He next obtained the extraordinary professorship of ophlhalmology in the medical school at Gratz. Here
he founded a much-needed eye hospital, an institution out of
which the ophthalmic department of the AUgemeines Krankenhaus gradually developed through his energy. Here he held a
high position and was active as a teacher until ISGO. His clinical
and experimental stuilies on blennorrhcea were made at this
hospital. He wrote a work on blennorrho;a which was awarded
a prize by the German Society of Physicians in St. Petersburg.
Piringer has the merit of having shown that intentional infection
of blennorrhceic secretion in pannus leads to clearing of the cornea.
He founded a reputation upon this which extended far beyond the
boundaries of Germany. He was for many years attached, as
visiting physician, to the Elizabeth Hospital and to the City
Asylum for the Aged, and published several other articles up to
the time of his death, Sept. 22nd, 1879, including: Ueber Veratrinbehandlung des acuten Gelenk-Rheumatismus ; Die Behandlung der Variola mittelst lodtiuctur; Die richtige Pflege der
neugebornen und kleinen Kinder ; Studien ueber die MortalitatsStatietik in Graz."f — (From Hirsch's Biographisches Lexikon,
1886, vol. IV, p. 575.)


Piringer's work on blennorrbceaj was awarded a prize, and
the earlier works in ophtiialmology refer to his studies, especially to his investigations in the treatment of pannus.§ Arlt


L. E.




"
•Read before the Johns Hopkins Hospital Historical Club.
1 1 am indebted to Professor Wm. H. Welch for having called my
attention to this account of Piringer's life.


t Die Blennorrhoe am ^Menschenauge. Graz, 1841.
lOest. Med. Jahrb., 1838, and chapter 8 of the monograph.


"




2 *'  
devotes some space to a summary of the work on blenuorrhcea.*  
But more recent works in ophthalmology make no mention of
these important studies and their no less important results; in
works on bacteriology I do not find his name, nor even in works
on gonorrhcEa, such as that of Finger. Piringer's work was of
such importance that it does not deserve to be thus forgotten.


The absence of any other references in ophthalmic literature
leads me to believe that Piringer's studies in ophthalmology
were confined to the subject of inquiry contained in the work
above mentioned. This is the more readily understood when
we read in his preface " that his itntiring efibrts during fifteen
years were given up to the solution of the natural laws governing blennorrhoeas of the eye, as far as this lay in the limited
powers of a single individual." We may aptly apply to
Piringer the words, "therefore by their fruits ye sliall know
them." Judged by this standard, Piringer stands out boldly
as one of the greater luminaries of medical science in tlie first
half of this century.


20/70
In order to properly estimate the importance of his investigations it will be necessary to examine into the state of knowledge of the subject previous to 1840.


In 1780 a treatise on diseases of the eye appeared, written by
George Chandler, surgeon, of London, in which he gives this
account of "venereal ophthalmy." He divides it into two
varieties, the translative and the symptomatic.


107
"The translative ophthalmy begins with a copious discharge of
a sebaceous humor of a yellowish white color, and is known by the
tumor, lividness, sharp and lancing pain of tlie sclerotica, the




Female.


*Klin. Daratellung d. Krankheiten d. Auges. Vienna, 18S1, pp.
35-37.


60.




Good.
192


[Nos. 77-78.


" "




"  
cornea at the same time being as it were depressed within a pit.
It frequently follows soon after an injudicious stoppage of a gonorrhoea, the venereal virus being translated into the eye. It has also
been observed that a gonorrhoea which before seemed incurable
has, upon the coming on of this ophthalmy, suddenly vanished ;
and in like manner the ophthalmy has gone off upon the return of
the gonorrha?a . . . The symptomatic remits towards morning,
never turns into a chemosis, the morbid matter does not change
place, the pains are milder, it is removed when the hies is cured,
and is also attended with less danger."  


He admits that "sometimes a venereal ophthalmy has been
produced by the immediate application of the virus to the
eyes."


"
Concerning the treatment he tells us that —


"The venereal ophthalmy in general is subdued and its poison
extinguished by mercury, but it should never be applied to the
eyes. The patient should be bled and purged, and his eye washed
continually with brandy and water, etc. It is necessary also to
evacuate the virulent matter collected in the cellular texture of the
sclerotica and eyelids by slight incisions of each membrane ; an
ichor, very like that of gonorrhtea, will be discharged."


2 "
This was the older view.
 
 
20/40


About the beginning of this century a remarkable development occurred in ophthalmology. Beer and Schmidt in
Vienna, and Himly, Langenbeck, Graefe the elder, and others
gave a new impetus to the scientific study of this branch of
medicine. This was followed by the publication of a number
of important treatises and monographs in ophthalmology,
principally in Austria and Germany, but also in France, England
and our own country. I shall pass these by and take up the
subject as we find it in the third edition of one of the most
important and valuable treatises on " Diseases of the Eye "
written in the first half of this century, that of William
Mackenzie of Glasgow. I take the third edition as it appeared
in 1840, one year before Piringer's work. Here we find under
the section of ophthalmia in new-born children, that "there is
reason to suspect that this disease is not unfrequently an
inoculation of the conjunctiva," etc., and "that therefore it
may often be prevented by carefully washing the eyes of the
infant with tepid water," etc.; secondly, "that the purulent
ophthalmia of infants in its worst form is the result of the
application of gonorrhceal matter, is generally admitted."


108
Concerning gonorrha'al ophthalmia he tells us that —


" Different views have been entertained of the purulent inflammation of the conjunctiva which is frequently found to attend or
succeed gonorrhtea. First, this ophthalmia has been ascribed to
inoculation with matter from the urethra; secondly, it has been
supposed to be metastatic ; and thirdly, it has been considered, at
least in certain cases, as an effect owing to irritation merely, without either inoculation or metastasis. It is quite possible that there
may be three such varieties of this ophthalmia. The existence of
the first I consider beyond all doubt ; but the second and third are
somewhat problematical."


Male.  
His description of the first form is quite clear, and in several
cases which he reports the infection is definitely proved. He
did not succeed in separating gonorrhcEal from what was called
Egyptian ophthalmia, excepting as differing in degree. This
distinction was not definitely made until about ten years later
(by Bendz). Mackenzie's criticism of the views entertained by




72.


some eminent ophthalmologists is so interesting that I shall
quote the entire paragraph:


Good.  
" Dr. Vetch tells us that in a soldier in a very advanced stage of
Egyptian oplithalmia he attempted to divert the disease from the
eyes to the urethra, by applying some of the matter taken from the
eyes to the orifice of the urethra. No effect followed this trial. It
was repeated in some other patients, all laboring under the most
virulent state of the Egyptian disease; and in all the application
was perfectly innocuous. But in another case, where the matter
was taken from the eye of one man laboring under i)urulent ophthalmia, and applied to the urethra of another, the purulent inflammation commenced in 36 hours afterwards and became a very
severe attack of gonorrhrea. From the result of these experiments, Dr. Vetch, while he admits that gonorrhceal matter taken
from one person and applied to the conjunctiva of another will
excite a highly purulent ophthalmia, regards himself justified in
no longer admitting the possibility of infection being conveyed to
the eyes from the gonorrhceal discharge of the same person. He
adds that the impossibility of this effect was rendered decisive by
an hospital assistant who, with more faith than prudence, conveyed the matter of a gonorrhcea into his eyes without any affection of the conjunctiva being the consequence. It is remarkable
that Dr. Guillie has fallen into the same error of reasoning as Dr.
Vetch, onlythathis negative experiments have led him to the very
opposite conclusion. He applied the matter taken from the conjunctiva of one patient to the urethra of another; no effect followed, and hence he concludes that the notion of some regarding
the propagation of puro-mucous inflammation from one mucous
membrane to another in different individuals, is unfounded."


Mackenzie, however, devotes considerable space to the discussion of gonorrhceal ophthalmia from metastasis, though
nothing could be better than his statement that writers had
adopted these views " with too little hesitation and appear not
to have sufficiently investigated the probability of the ophthalmia arising rather from inoculation than from metastasis."
He goes on to enumerate " the causes of the suppression of the
gonorrhcea, to which the rise of metastatic gonorrhct-al ophthalmia is attributed," and cites an illustrative case from a French
writer. It is evident that ilackenzie had little confidence in
the existence of this form of gonorrhceal ophthalmia.


R. E.  
A third form of gonorrhceal ophthalmia without inoculation
or metastasis is described : "an alternation has been observed
between the two diseases; that is to say, when the gonorrhcea
came, the ophthalmia went, and vice versa." Mackenzie says that
the cases reported "show the diversity which exists in opinions
entertained regarding the ophthalmiaj which in some individuals are found to attend gonorrha'a, or to alternate with this
disease"; and that "it is quite evident that the ophthalmia?
which have been observed to do so are far from being uniform,"
that some are probably ophthalmia tarsi, others catarrhal
ophthalmia. What is most important is his statement that '■ it
may fairly be doubted whether there is any connexion between
diseases of urethra and that of the eye, farther than that they
occurred in the same iudividtials, while the occurrence of both
might be attributed to a susceptibility for disease arising from
peculiar or debilitated constitutions." We are somewhat surprised to see this statement followed by such a one as this,
that "Swediar's hint to employ the bougie in cases of ophthalmia alternating with gonorrhcva may probably be found of
use; it is evident, however, that this remedy cannot be trusted
alone, but that the ophthalmia must be treated according to




"


August-September, 1897.]


"
193




2 "


the particular symptoms it presents, not according to tlie conjectural notions entertained regarding its origin."
Concerning Egyptian ophthalmia jMackenzie says:


20/40
"I think it probable that the ophthalmia which attacked the
British anil the French armies in Egj'pt was an atmospheric
puro-mucous conjunctivitis [described at another place as "excited by exposure to atmospheric alternations "], but that it afterwards degenerated into a contagious, perhaps infectious disease;
that is to say, that it was propagated by actual contact of the discharge, and perhaps by miasmata from the eyes floating through
the air."


Mackenzie's views may fairly be taken as the most advanced
of this period and will serve as the proper point from which to
view the investigations of Piringer.


It should be mentioned here that many subsequent writers
held on tenaciously to these and older views for many years
after Piringer's discovery had been made.


October, 1897.1
We may first direct our attention to Piringer's experiments
 
in curing pannns by producing acute purulent ophthalmia.
 
This method, we are told, was first suggested by Friederich
 
Jiiger* some time during the second decade of this century, but
JOHNS HOPKINS HOSPITAL BULLETIN.  
little or no attention had been given it before Piringer's experiments were made. He tried the metliod in more than sixty
 
cases, using the pus of various kinds and stages of purulent
 
ophthalmia of bo(h adult and new-born. All of his cases were
improved and not one was injured by the treatment. In the
great majority of cases the cure was complete, so that no sign
of the former disease could be discovered, and permanent. He
therefore recommends this method of curing paunus in these
words: "After so many highly successful experiments and observations, the inoculation of tlie blennorrhoea for the cure of
pannus is no longer a doubtful measure which requires great
courage, but an excellent method (ein grossartiges llittel)."
This method remained in use for many years and is still being
applied in a modified manner. The modification consists in the
use of jequirity to produce a purulent ophthalmia instead of
blennorrhceic matter.


203
It was in the study of this method of treatment that Piringer
made his investigations as to the nature of blennorrhceaand the
contagious property of the secretion. For this purjjose his experiments were varied inevery conceivable manner. Most of the
experiments were made upon eyes which were already diseased,
but these were controlled by other experiments upon amaurotic
eyes with perfectly healthy conjunctiva, or by the accidental
infection of normal eyes.


After describing the various forms of purulent inflammation of the conjunctiva he takes up the causes. Under this
head he discusses the question as to the production of gonorrhoeal ophthalmia by metastasis. In the course of fifteen years
he had never seen a case of suppression of a gonorrhoea with an
outbreak at another point, excepting in the neighboring tissues.




No.


* In Hirsch's History of Ophthalmology, p. 441, we read thatLudwig reported the successful use of this method at the hands of a
friend, probably Friederich Jiiger.


Sex.  
Wharton Jones (in a manual on Ophth. Med. and Surg, published
in 1847) states that Dr. Henry Walker was the first to suggest the
method (Edinburgh Medical and Surgical Recorder) in 1811. I am
unable to verify this citation.  




Age.


Many physicians of great practice had likewise never seen true
metatastic gonorrhcsal ophthalmia. He denies the occurrence
of such a form of disease, and characterizes it as a very pretty
fable which one after the other has been telling in the best of
faith. Gonorrhceal ophthalmia is always due to the transference of infectious material directly into the conjunctiva!


Health.  
In a similar manner he disproves the existence of a consensual form of gonorrhceal ophthalmia, supposed to be due to a
sympathetic connection between the affected parts.  


Gonorrhceal ophthalmia is known to be more common
toward the end of the primary affection than during the period
of its greatest virulence. He explains this very properly on
the ground that Avhen the discharge is great much care is used
in cleansing the fingers. It is after the discharge has become
scant that patients become careless. The right eye is usually
the one first affected, because most patients are right-handed.


Cataract.  
Ilis experiments proved that the generally accepted view
that the transference to the eye of gonorrhceal pus results in a
simple conjunctivitis or a mild purulent ophthalmia, and only
rarely in a severe inflammation, is false. On the contrary, he
asserts that the result is always a purulent ophthalmia of a
severe degree. The only exception occurs in those cases in
■which early treatment is successfully applied.  


The contagious character of the secretion of ophthalmia neonatorum had been looked upon as ridiculous ;* when .Tuengken
stated that a ni;rse had developed severe i)urulent ophthalmia
during the night of the same day when she had infected them
with a sponge that had been used to cleanse the eyes of an
infant with ophthalmia, it was laughed at. No one can deny
the infection in his own cases, because the material was carried
across the street into another house and yet the result was
always the same.


Operation.  
His experiments on the production of purulent ophthalmia
embrace almost one hundred eyes, and this does not include a
number of accidental infections which were observed with the
same care. The matter with which infection was produced
was obtained from eyes afl'ected with different forms of purulent ophthalmia as well as from genital blennorrhcea. All ages
and both sexes were found to be equally predisposed.  


One of the most interesting chapters is the one on the character of the blennorrhceic contagion. Though the pus from the
conjunctiva causes infection when applied to the eyes of human
beings, he was unable to produce any result when he applied it
to the eyes of such animals as dogs, cats, hogs, and various
birds. Others had claimed that they had produced effects in
such cases. Our jiresent knowledge of the immunity of animals to gonorrhcea shows that Piringer was not deceived.


Healing process. Duration of treatment.  
The granulation from which the pus is secreted carries the
contagious property with it, as was shown in 1833 by Werwick,
who experimented upon two nurses. Piringer never made
any experiments w'ith granulations because it lacked any practical bearing.  




Primary Vision.


*The faith with which this opinion has been held can be measured by the much-quoted citation of Dr. Vetch, referreil to above.
Piringer likewise ciuotes Adams, who rubbed his eyes with a finger
smeared with purulent matter without producing ill results, as did
Van Sevenoeck and Kriebel. Morburgo smeared the eyes of 300
soldiers without effect.


109




Female.
194


[Nos. 77-78.


61.




Good.  
The pure lachrymal fluid of a blennorrhoeic eye was found not
to possess conhigioiis properties. An experiment is related in
which lachrymal fluid collected upon a canielliair brush did
not produce infection, while the purulent secretion gathered a
few days later did.  


The question of contagion far distance (per miasma) was
studied in his hospital, where numerous blennorrhceic patients were placed beside those unaffected, in small wards.
He was able to prove definitely that such contagion does not
occur and that the cases in which it is suspected can always be
traced to direct infection.


Hard. L. E.  
The vapor of drying secretion has no power of infection.  
Even those secretions which are perfectly serous leave a residue
when evaporated, and it is this which still retains the contagious {)roperties.  


The fluid secretion when kept for three or four days, even
without evaporation, is no longer contagious.


Iridectomy.  
If a finger is covered with blennorrhceic secretion and washed
immediately in clear fresh water and well dried, it will cause
no infection if rubbed over the conjunctiva.  


Blennorrhoeic matter may be smeared over the eyelids if the
palpebral fissure is kept firmly closed by adhesive plaster, and
no infection will occur. In order to produce infection the
secretion must reach the conjunctiva.


Uncomplicated.  
The secretion of acute blennorrhoea of a moderate degree is
just as contagious as that of the most severe. Such pus is
capable of producing infection even when diluted with 50 or
100 parts of water. The pus of a very mild purulent ophthalmia and of chronic ophthalmia has much less power of infection.  


As long as there is any secretion in any case of purulent
ophthalmia, whether mild or severe, so long the case is contagious. Wiien the secretion ceases, tiiough there maybe considerable congestion and photophobia, the infectious properties are
lost.


3 weeljs.  
The properties of infection inherent in the secretion do not
vary in different seasons of the year nor under changed atmospheric condition, whether exposed to the glare of the sun or to
the cold of the winter. Experiments .to determine this may
appear meaningless to us, but we must not forget the opinions
prevalent in Piringer's time.  


Numerous experiments were made to determine the effect
upon the contagious properties of the pus when separated for
varying intervals of time from the human body. Thus the
secretion was collected upon a camel-hair brush and allowed to
become as dry as possible (" dry as glass ") in from three to six
hours. If then applied to the conjunctival sac, but not allowed
to soften in the tears, no infection occurred ; if softened in the
tears, or previously in water, infection was sure to occur.


20/70
In seven cases the secretion which had been allowed to dry
for thirty-six or forty hours in the open air had lost all contagious property, but in two in which the secretion had been
allowed to get dry thirty- three or thirty-four hours in the room
and was then softened it produced very severe ophthalmia blennorrhcea. Piecesof linen smeared with fresh blennorrhceic matter
and given to a pannus patient to wipe his eyes produced infection, but if the cloth had been dried in the air for several days,
the patient could use it about the eyes witiiout harm, and the




110


secretion when scraped off" the cloth and inserted into the conjunctival sac produced infection only when it was less than
thirty-six hours old. On the other hand, if the secretion was
placed in a vaccine case and hermetically sealed it retained its
contagious property for forty-eight hours, but lost it entirely
when kept for three days. The pus fioma case of ophthalmia
neonatorum produced infection when kept in this way for two
and a half days. Piringer therefore concludes that "?/Ze««orrJiieic pus loses its contagious properties as it hecornes older, and
(jraduaUy dies in from twenty-six to forty -eight hours, jjossessing
no more organic life token three days have passed." It is upon
the discovery of this fact that Piringer bases important rules of
prophylaxis, and explains the relative infrccjnency of gonorrhoeal ojDhthalmia among the common people.


Male.  
Piringer studied carefully the length of time intervening
between the entrance of the infectious material and the first
signs of the developing disease, the period of incubation. This
he found to vary according to the manner and the amount of
the infection, as well as according to the individual peculiarity
of the patient. The higher the degree of inflammation, the
more rapidly did its pus infect. Thus the pus from a very
severe ophthalmia produced infection in from six to twelve
hours, or at most in thirty-six hours ; while that of very mild
blennorrhoea might rec|uire sixty to seventy hours, and that of a
case of chronic blennorrhcea seventy-two to ninety-six hours.  


The secretion of the second stage of acute ophthalmia acts
more slowly than that of the first; thus the pus from a case of
very acute blenuorrhrea in which the secretion was markedly
diminishing may take sixty hours to produce the first symptoms.


79.  
If the secretion while still warm is immediately transferred
from an acute blennorrhcea, but six or eight hours are required
for the first signs to show themselves, and in twelve or eighteen
hours the disease is fully developed. In this respect the conjunctiva responds more rapidly than the genital mucous membrane. The longer the secretion is kept before it is placed in
the conjunctiva, the less rapidly does it act. The rapidity likewise varies with the amount of secretion brought into the eye.  


Piringer gave the prophylaxis of gonorrheal ophthalmia his
careful attention and the results were very important. Can
tiie inflammation be aborted after the infectious material has
once reached the conjunctiva? Several cases in which the
very early and continued application of ice comitresses produces
this effect are described. In order to determine whether the
infectious material can be removed and the outbreak of the
disease prevented, several series of experiments were made.
The method which required the application of very strong
solutions of bichloride of mercury, concentrated acetic acid,
etc., appeared to him too severe, and in the few cases in which
it was tried the desired result was not obtained.


Good.  
On the otiier hand he found that washing out the eye with
water after the contagious material had been inserted prevented the development of the disease, provided that it is done
sufficiently early. These experiments were made on three
patients. In the first case he touched the eye with a large
quantity of matter from a newborn babe, cleaned it out after a
minute with a sponge dipped in cold water, and had cold water
apiilicatioMs made for ten hours. No inflammation resulted.  




" "


August-September, 1897.]


195






Four days later he varied the experiment by allowing the
matter to remain two minutes and again no inflammation
occurred. After another interval of four days the experiment
was again repeated, the pus remaining in the eye for three
minutes and the result was again the same. After another
interval of 6ve days pus was inserted and allowed to remain in
the eye for live minutes; no cold applications were made; the
result was a violent inflammation. This patient had pannus,
which was cured by the treatment.


"
In order to try tiiese experiments upon a perfectly normal
conjunctiva he selected the eyes of an amaurotic beggar whom
he paid for these privileges. In this case he found that no disease resulted if the blennorrhoeic matter was washed out within
three minutes after its entrance into the conjunctival sac and
cold water applied. In three minutes any one who has accidentally infected his eyes can obtain fresh water with which
to wash them !


In order to determine whether the washing out of the conjunctival sac would accomplish the same result without the
use of ice applications, he infected the eye of a girl suffering
with pannus with blennorrhoeic matter and washed out the
conjunctiva in three minutes. Ninety hours later a severe
ophthalmia developed. And in a second case the experiment
again resulted in the development of a purulent ophthalmia,
but not until the fifth day, and in this case the ophthalmia
was of a milder character. For these reasons he considers the
cold water application as essential to the prevention of conjunctival blennorrhci'a after infection has occurred. Many
other questions are considered by Piringer, but this review
embraces the essential points, and will, I trust, suffice to show
its importance.


2 "  
The care, the true scientific spirit, the accuracy of observation and experiment, the unbiased search for truth, form
marked characteristics of I'iringer's work. And yet he is so
modest as not to claim that his results are "the absolute
truth," though they are his own firm convictions; experiments and observations, he tells us, by other physicians at
other times and places, made with care and without prejudice.




20/100


are needed to confirm them as well as to clear away any errors.
His experiments were arranged carefully and judiciously to
determine the character and the attributes of the contagion,
the time during which it acted, the gradual diminution of its
powers to the point when they were entirely lost, the intensity
of the contagion, and the degrees of dilution which could be
borne without loss of all contagious properties. Many of these
questions were given their final solution by Piringer. He
separated the fluid portions of the pus which could be evaporated, from the more solid matter which contained the contagious quality. He proved that the unknown cause of contagion
was a something which had to be transferred in substance
from one mucous membrane to the other, and which never
acted at a distance, thus disproving the old miasmatic principles which were still current in those days.


111
In what is our knowledge today greater than that of
Piringer, excepting that the active agent, the living microorganism, the gonococcus, has been discovered, a discovery
only made in 1879 ? That it was a living organism even
Piringer surmised, for, as we read above, he speaks of it as
"growing older," and "dying," and "possessing organic life."
Let us not forget when it was that Piringer worked. Though
micro-organisms had been discovered toward the end of the
seventeenth century, and micro-organisms were assigned as the
causes of numerous diseases during the eighteenth century, it
was not until 1840 that Henle first established the germ theory
of disease upon the solid foundation of logic and fact.


One aspect of Piringer's experiments still deserves mention.
Others had likewise made experiments with a view of transferring the disease which we have been considering; but most
of these were unsystematic, few in number, and led only to
confusion. Piringer's work was such as to give a definite
solution to important questions, results which have stood the
tests of time. His work was not in vain. His hopes were
fulfilled that "the medical world would read not entirely without pleasure a number of results, whose collection in the field
of practice had been made at the cost of much strain, great
pains and many a sleepless night."


Male.




55.
PROCEEDINGS OF SOCIETIES




Good.


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.


R. E.  
Meeting of May 3, 1897.  


Dr. Thayer in the Chair.


Haeniatoniyelia from (xunshot Wonnd of tlie Cervical Spine.—
Dr. CiisniNG.


This patient, a young woman of 27 years, was brought into
Prof. Ilalsted's service, November Gth, 1896, with the hiotory
of having been shot twice in the neck a few hours before
entrance. Our chief interest centres in the injury produced
by the missile, whose wound of enti-ance is situated here on
the right side of the neck at the level of the cricoid cartilage.
These skiagraphs show the point of lodgment of the bullet in
the centrum of the sixth cervical vertebra.


The case illustrates some unusual features of one type of




"


the so-called Brown-Seqnard paralysis; the value of the
X-rays in locating the offending missile; a practical recovery
without operative interference; a residuum of symptoms
resembling those of syringomyelia.


2 "  
At entrance she was suffering from agonizing " pains " of a
" pins and needles " character, especially in the arms, so
severe she would cry out when they were touched. No radiating pains, such as are described iu the meningeal form of
hemorrhage, were present. There had been no loss of consciousness. Motor paralysis was complete on the right side
below the level of Thorburn's "5th root group." On the left
there was a brachial monoplegia up to this same segmental
level, namely that for the deltoid biceps and supinator longus
muscles whose ventral horn ganglion cells lie in the 5th
cervical segment, as you may see by comparison with this




20/40


196


112
[Nos. 77-78.




Male.


familiar table of Starr's. Respiration was purely diaphragmatic.


80.  
On the left side, uji to the second intercostal space and
down the ulnar side of the arm over an area which corresponds,
as these diagrams taken from Starr and Kocher demonstrate,
to the cutaneous sensory fields of the eighth cervical and first
dorsal segments, there existed anassthesia to pain and thermic
stimuli, aud a slight dulling of tactile or pressure sensibility.
A segmental zone of similar anaesthesia was present on the
side of motor paralysis across the chest aud including most of
the right arm.  


There was a marked elevation of surface temperature, cousiderable hyperalgesia, and also a diminution of reflex activity
on the paralyzed side. Loss of sphincteric control over the
contents of the bladder aud rectum was also jjresent.


Good.  
liestitution from these paralytic symptoms has taken place
up to the excellent conditiou in which you see the patient at
present. The motor paralysis disapjjeared gradually. On the
tenth day, motion, as is usual, was first observed in a slight
flexion of the thigh. Turner in his experimental work called
attention to this. At the present time there remains evidence
of the degeneration of the right j)yramidal tract iu Wernicke's
residuary paralysis of the dorsal flexors of the foot, giving the
late hemiplegic character to the jjatient's gait. Mann has
recently called attention to this residuum of motor paralysis
aud has shown that it selects a certain muscle unit (bewegung
einheit), this unit being that which lifts and shortens the leg
in the first stage of walking, as can be demonstrated in
this patient. Paralysis remains alone complete in some of
the small muscles of the right hand, representing destruction
of ganglion cells at the site of the lesion. There is au exaggeration of all the deep reflexes of both extremities. Myotatic
contractions, as you see, are elicited iu the muscles of the right
arm by gentle blows on the tendons. Resolution of the sensory disturbances has been less complete. Slight anEesthesia
to painful aud especially thermic stimuli persists on the
left.  


A month ago there was present a peculiar distribution of
areas of hyperesthesia, over which cold produced paiu without thermic sense, and the threshold for pain was so low to
touch or pressure stimuli that the latter could only be elicited
with difficulty by v. Frey's assthesiometer. This is illustrated
by these diagrams.


L. E.  
The lesion was presumably due, as in Mann's case, to an
 
intramedullary hemorrhage, the occurrence of which, especially in the cervical enlargement, as emphasized by Thorburn, is not uncommon. It seems that not only is traumatic
hajmatomyelia much more common here than elsewhere in the
cord, but that there is a certain level iu this enlargement giving symptoms corresponding to the "typus inferior" of
Krause, iu which intramedullary hemorrhage is most likely
to occur. This list of cases, collected from the literature,
tends to confirm this view of a site of predilection in the lower
cervical enlargement for hajmatomyelia, and illustrates the
fact that not only in cases attributable to acute flexions of the
neck does it occur, as was believed by Thorburn, but also iu
those due to a great variety of traumatic causes. The hemorrhage also is apt to occur most extensively on one side of the






cord, thus often producing the symptom complex of a Brown
Sequard type of paralysis.


That the hemorrhage also in these cases selects by preference the gray matter of the cord, presumably from the greater
vascularity aud less support given to the vessels there, is well
recognized. Frequent note has also been made of cavity formation at the original nidus of hemorrhage, which is interesting iu consideration of the association of the syndrome of
syringomyelia which Minor and others have pointed out to be
a common sequence of traumatic ha'matomyelia and which
persists in this patient.


"
The case which Maun has recently reported in full with
post-mortem examination of the cord, in the Dent. Zeit. f.
Nervenheil. for 1896, and which clinically bears such close
similarity to this case, illustrates many of these points very
completely.


Dr. Thomas. — This case seems to me to be one of particular
interest, aud the Society is to be congratulated on having it so
admirably presented. Those of you who have had the opportunity of examining a similar case will recognize the difficulty of making such au exhaustive examination. I know of
no case in the hospital records that has been worked up so
carefully as this. Dr. Gushing was kind enough to bring the
patient to me ou several occasions for examination, and I confirmed the results which he had already obtained. The
patient's condition, after she had been in the hospital for some
time, was, as Dr. Gushing has described to you, briefly as follows : there was weakness of the right leg and right arm. The
muscles of the right arm were atrophied, aud there were sensory
disturbances, as shown in the charts. The wound in the
right side of the neck was in such a position that the bullet
might have injured the brachial plexus before entering the
spinal columu, and thus have produced the condition found
in the right arm. An electrical examination of tlie paralysed
and atrophied muscles showed that they responded normally
to the currents. This was believed to indicate that the brachial plexus was not injured, aud also that the paralysis was
not due to destruction of the anterior horns from which the
nerves forming this plexus arise. I do not believe that there
can be extensive destruction of the anterior horns without the
occurrence of degenerative atrophy of those muscles which
receive their nerves from that segment of the cord. In the case
of Maun, to which Dr. Gushing has referred, there was paralysis and atrophy of the muscles of the left arm. This was
completely recovered from, but, at the autopsy, a lesion iu corresponding anterior horn was found. This case is, as far as I
know, the only one bearing on this poiut, and it does not seem to
me to be conclusive. The lesion was limited to the eighth cervical segment, as shown by the fact that the eighth root was degenerated, while the seventh was not, and the first thoracic root
was only slightly so. We know that each muscle is represented
in more than one spinal segment, and it can be understood how
a limited lesion in one segment need not necessarily produce
degenerative atrophy to such a degree that it could be discovered during life. The autopsy on Mann's case was incomplete,
in that neither the muscles nor the peripheral nerves were
examined.


2 "
Dr. Cushing's case is of interest from so many standpoints




20/70


August-September, 1897.]


113
197




Female.


that it is impossible to discuss it fully. Unilateral lesions
of the cord are not very common. In the dispensary we
have the records of only two typical cases. I have at present
under observation a very beautiful example of this form of
paralysis. The patient is a woman whose right leg is paralysed and who shows the disturbances of sensation in the left
leg which Mann has pointed out as characteristic, i. e.
the sensory conduction for touch is undisturbed, whereas
pain, heat and cold stimuli do not produce their normal effect.
The paths of sensory conduction within the cord have been
and are the subject of much discussion. Of late the anatomists and physiologists have been inclined to the view that the
paths do not cross, but remain on the same side of the cord
until they reach the medulla. Clinicians, on the other hand,
from the study of the cases of unilateral lesion of the spinal
cord, have held to the belief that the sensory jiaths decussate
soon after entering the spinal cord. That there must be an
anatomical basis for the constant occurrence of the classical
symptoms of Brown-Sequard's paralysis seems to me to be
self-evident. The burden of jiroof must rest ujiou the anatomists and physiologists.


56.




Good.  
NOTES ON NEW BOOKS.  


Diseases of the Rectum, Anus and Contiguous Textures. By S. G.
Gant, M. D. (Philadelphia : F. A. Davis, 1896.)


" "  
With the exception of two chapters on Cancer of the Rectum and
Colotomy by Allingliam, a recognized authority on these subjects,
the worls of Dr. Gant is not to be commended. The booli contains
nothing new, and there are many superior works on this subject.
The two cliapters in which the author seems to talce special pride,
one on auto-infection, tlie other on effects of railroading on diseases
of the rectum, are not remarkable, and the first is unsatisfactory.
That employes of railroads suffer much from constipation and hemorrhoids as a result of their occupation may be true, but the figures
he gives can be handled in many ways. If we eliminate from the
author's statistics all cases suffering from these two very common
conditions, we have less than 1 per cent, out of over 170,000 cases
seen in various hospitals suffering from other diseases of the rectum
and anus; and 5.7 per cent, in the same number of cases does not
seem to us an excessive number to be suffering from the two conditions mentioned. We believe that among the poor laboring class
constipation is the usual condition found, and that figures more
striking than these could easily be collected to show that constipation was one of the commonest symptoms in all hospital cases. We
question whether the jarring of a railroad train will continually
rock a stomach from side to side, produce a "sea-sick stomach," or
whether it is suiEcient to bring about by itself dilatation of the veins
about the anus and rectum by causing a venous stasis, and we know
that swelling of the feet in railroad travelers is not an ordinary
condition, to say the least. The chapter on sodomy might better
have been omitted or much abbreviated ; such a book does not call
for a psychological explanation of this practice. In speaking of the
relation of pulmonary tuberculosis to fistula, the author states :
"So we meet with two kinds of tubercular fistula — one as a result
of localized tubercular ulceration with or without any lung complication ; the other a fistula in persons who have lung trouble, due to
the absorption of fat about the iscliia, general debility, and abscess.
In the feces of the first variety can be found the tubercle bacilli of
Koch, while in the second variety they cannot be found unless the
sputum containing them has been swallowed, and gastric digestion
has been impaired to such an e.Ntent as not to destroy them or their
spores." In either form the fistula is tubercular and the bacilli






can be found without these coming from the sputum ; and gastric
digestion, even when normal, does not ordinarily destroy them, as
we know from the large number of cases of primary intestinal
tuberculosis which occur. We do not think that the following
statements as regards auto-infection are true. On p. 271 we read :
" Our Creator, however, foresaw all dangers and provided us abundantly with safeguards with which we can destroy or neutralize
the poisons on the one hand, or throw them off on the other, as
soon as they are formed"; and on p. 272, "Just so long, however, as
the emunctories are working in harmony and perform their individual functions, and there is no lesion of the intestinal mucosa, all
is well, and all poisons, no matter whether theyare the products of
decomposition or of bacterial action, will do noharm, forthe reason
that they are thrown into a special reservoir (the liver) where they
are destroyed or neutralized and afterward discharged from the
body."


The colored illustrations in this work are hideous and unnatural,
and the woodcuts are not models of artistic excellence. Would it
not be well for authors to cease to reproduce cuts of the most common and onlinary instruments, and of well-known positions and
procedures in operations, which are quite valueless (cf. cuts on pp.
20, 21, 22, 25, 218,219, 220). Wedislike extremely to see theauthor's
autograph on the outside cover, and the long list of societies to
which he belongs following his name on the title-page. If the
book possesses merit of its own, this sort of cheap advertisement
does it no good ; and it does not help the work in any case.




"


BOOKS RECEIVED.


3 "
Second CtUalogne of the Library of the Peabody Institute of the City of
Baltimore. Including theadditions made sinceI882. Parts I-II.
A— D. 1890-97. 4to. Baltimore.


The Semi-Centennial of Anmsthesia. October 16, 1846-October 16
1896. 4to, 95 pages. 1897. Massachusetts General Hospital,
Boston.


20/100
Saint Bartholomeio' s Hospital Reports. Edited by S. West, M. D., and
W. J. Walsham, F. R. C. S. 1896. Vol. XXXII. 8vo, 518 '+ 197
pages. 1897. Smith, Elder & C >., London.


Transactions of the American Pediatric Society. Eighth session
held in Montreal, Canada, May 25, 26 and 27, 1896. Edited by
Floyd M. Crandall, M. D. Vol. VIII. 1896. 8vo, 243 pages.
Reprinted from the Archives of Pediatrics. New York.


114
Medical and Surpical Reports of the Boston City Hospital. Eighth
Series. Edited by G. B. Shattuck, M. D , W. T. Councilman,
M. D., and H. L. Burrell, M. D. 1897. 8vo, 391 pages. Published by the Trustees, Boston.


King's College Hospital Rejiorts. Being the annual report of King's
College Hospital and the medical department of King's College.
Edited by N. Tirard, M. D., F. R. C. P., et al. Vol. III. (Oct. 1st,
1895-Sept. 30th, 1896.) 8vo. 1897. 332 pp. Printed by Adlard
& Son, London.


Female.  
Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America. Edited by T. L. Stedman, M. D. In twenty volumes. Vol.
XI: Diseases of the Nervous System. 8vo. 1897. 962 pp.
William Wood &, Co., New York.  


Burdett's Hospitals and Charities, 1897. Being the year-book of philanthropy. By Henry C. Burdett. 12mo. 1897. 1018 pages.
The Scientific Press, London.


63.  
Archives of Skiagraphy. Edited by Sydney Rowland, B. A., Camb.
Fol. Vol. I, No. 4. April, 1897. The Rebman PublishingCo.,
Limited, London.  


A Pictorial Atlas of Skin Diseases and Syphilitic Affections in PhotoLithochromes from Models in the Museum of the Saint Louis Hospital,
Paris. With explanatory woodcuts and text by E. Besnier, A.
Fournier et al. Edited and annotated by J. J. Pringle, M.B.,
F. R. C. P. Part X, 1897. W. B. Saunders, Philadelphia.


Good.




" "
198


[Nos. 77-78.






PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.




"


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


3 "
Reiiort in Patbologry.


The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;


Not tested .
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the


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


115
(Atrophy). By Henry J. Berklev, M. D.
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.


MiLL, M. D.


Male.  
Report in Derniatolos-y.  
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By


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


72.
Protozoa, and the Blastomyces found in the preceding Cases, with the so-called


Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum


Good.  
Fihrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duliring). By


T. C. Gilchrist, M. D.


" '•
Report in Patliology.
An E.xperiniental Study of the Thyroid Gland of Dogs, with especial consideration


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






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


Report in Medicine.


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


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


2 "
Report in ftleilieine.
Tubercular Peritonitis. By William Oslek, M. D.
A Case of Raynaud's Disease. By H. M. Thomas, M. D.
Acute Nephritis in Typhoid Fever. By William Osler, M. D.


Report in Gynecology.
The Gynecological Operating Room. By Howard A. Kelly, M. D.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard


20/100
A. Kelly, M. D., and Hunter Robb, M. D.
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of


Abdominal Section. By Howard A. Kelly, M. D.
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,


116
M. D.
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;


Ovarian Tumor; General Gynecological Operations from October 15, 1889, to


Male.  
March 4, 1890. By Howard A. Kelly, M. D.
Report of the Urinary Examination of Ninety-one Gj-nccological Cases. By Howaed


A. Kelly, M. D., and Albert A. Ghbiskey, M. D.
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (decking


81.'
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoraa of the Clitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of tlie Ureter through the Vagina, for the treatment


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


Good.  
Howard A. Kelly, M. D.  


Report in Snrgery, I.
The Treatment of Wounds with Especial Reference to the V.-ilue of the Ulocid Clul


" "
in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in Neurology, I.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D.
Ilaeniatomyelia. Bv August Hoch, M. D.
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By


Henky M. Thomas, M. D.


Report in Fntliology, I.
Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleue, M. D.






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


"
Report in PatUology.


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


2 "




20/7(t
Tuberculoais of the Female Generative Organs. By J. Whitridge Williams, M. D.
Report in Pjitliology.


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


117
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.


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


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


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


66.  
Report in Gynecology.  


The Gynecological Operating Room; An External Direct Method of Measuring tlie
Conjugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Knterocele; 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 Retroflexcd Uterus. By Howard A.
Kelly, M. D.


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


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


R. E.




Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. D.


Tabulated by A. L. Stavely, M. D.
The Employment of an Artificial Retroposition of the Uterus in covering Extensive


Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.
Photography applied to Surgery. By A. S. Murray.
Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howa&d


A. Kelly, M. D.
Urinalysis in Gynecology. By W. W. Russell, M. D.
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gj-neco
logical Conditions. By Hunter Robb, M. D.
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D,
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.


"
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.
.\bdominal Operations performed in the Gynecological Department, from March 6,


1890, to December 17, 1892. By Howard A. Kelly, M. D.
Record of Deatlis occurring in the Gynecological Department from June 6, 1890, to


2 "
May 4, 1892.




20/70


Volume IV. 504 pages, 33 charts and illustrations.


118
Report on Typliold Fever.


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


Female.  
Report in Pfenrology,
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of J/us musculu^; The Intrinsic Nerves of the Thyroid Gland of
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,
M. D.  


Report in Surgery.
The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to
January, 1891. By W. S. Halsted, M. D.


50.  
Report in Gynecology.
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.
Report in Patliology.
Deciduoma Malignum. By J. Whitridge Williams, M. D.  




Good.


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


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


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






A'olume VI. 414 pajif.s, with 7') plates and figures.


Report in Neurology.


"
studies on the Lesions produced by the Action of Certain Poisons on the Cortical
Nerve Cell (Studies Nos. 1 to V). By Henry J. Berkley, M. D.


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


2 •'
Report in Patliology.
 


20/40
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.


(3lTLLEN, M. B.
Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of


119
Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. WiLSlNS, M. D.
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, JI. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By


William D. Booker, M. D.
Tlie Pathology of Toxalbumin Intoxications. By Simon Flexnkr, M. D.
Thr price of a .sit liuiiiid in cliith [Vul.i. I-VI] of tlir Ilospilnl Brportx is


Female.  
$30.00. Voi.t. I, 11 niirl III iivr not sold stpiiratcli/. The price of
Vols, ir, r and VI is $S.OO nirli.  




49.


AIonogrnpliH.


Good.  
The followini; papers arc reprinted from Vols. I, IV, V ami VI of the Keports. for thoee
who desire to purcliase in this form ;
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixkord,


M. D. 1 volume of 104 pages and 41 full-page plates. Price, bound in paper,


L. E.  
?3.00.
THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.  


Hewetson, M. D. And A STUDY OF SOME F.\TAL CASES OF MALARIA.


By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, 12.7.").
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted


from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481


pages. Price, bound in paper, $3.00.
THE PATHllLdliY Ol' TO.XALIUMIN INTOXR'.VTIONS. Hy «m»n Flexner, M. U. 1


volume of 150 pages with 4 fuU-page lithographs. 1 rice, bounil in paper, $','.0(<.
Subscriptions for the above publications may be sent to


"
The Johns Hopkins Press, Baltihorx, Md.




2 "


The Johns Hopkins Hospital Bulletins are issued monthly. They arc printed by THE FRIEDENWALD CO., Baltimore. Single copies
may be procured from Messrs. CVSBI^'O iC- CO. and the BALTIMORE TfEWS COMP.iNT, Baltimore. Subscriptions, $1.00 a year, may be
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; siiiylc copies will be sent by mail for fifteen caits each.


20/100




120
BULLETIN




Female.


OF


48.




Good.  
THE JOHNS HOPKINS HOSPITAL.  




R. E.


Vol. Vlll.-No. 79.]






BALTIMORE, OCTOBER, 1897.




"
3 "




20/70




121


COlsTTIElNrTS.


Female.




53.
A Second Series of Cataract Operations (One Hundred and


Fifty-eight). By Robert L. Randolph, M. D., . . Parotitis following Visceral Inflammation. — A Report of Two


Good.  
Cases. By A. Duval Atkinson, M. D.,


Palpation of the Foetal Heart Impulse in Pregnancy. By


" "
Douglas F. Duval, M. D.,


Squamous Epithelioma in a Dermoid of the Jaw. By S. M.


Cone, M. D.,


The Infectiousness of Chronic Urethritis. By E. R. Owings,


M. D., . .




"


The Importance of employing Pure Salts in the Preparation of
the Schott Bath. [Communication.] By C. N. B. Camac,
M. D., 214


2 "
Proceedings of Societies :


Hospital Medical Society, 215


20/30
Demonstration of a Case. Probable Brain Tumor [Dr.
Thomas] ; — Demonstration of Specimens [Dr. Cullen].


Notes on New Books, 218


122




Male.  
A SECOND SERIES OF CATARACT OPERATIONS (ONE HUNDRED AND FIFTY-EIGHT).*


By Egbert L. Randolph, M. D.


68.




Good.  
Five years ago I reported in the Bulletin of the Johns
Hopkins Hospital a series of fifty consecutive cataract operations. Of these fifty operations six were performed in a hospital. With the exception of eighteen, the remaining twentysix were among the poorer classes of a country population in
Virginia and in a mining region in the western part of Maryland. This series then is chiefly interesting from the rather
unusual conditions which surrounded most of the patients.
For instance, the first case reported (Series I, Case 1) was
operated on in a log cabin near Warrenton, Va., and the old
man was nursed by his daughter, who saw him only at meal
times and at night (she being in service), and as a consequence
he was exposed not infrequently to risks during her absence.
He went through the same experience a year later with his
other eye and, as in the first instance, obtained excellent vision.
Case 8 (in the same series) had been blind for three years and
lived at a remote point on a plantation in Virginia, and he
was nursed by his wife. His cabin was too dark for the operation and I put him on a cot and operated out in the yard.
He was very timid and jumped when the iridectomy was performed, causing some loss of vitreous. He counted my fingers
after the operation and I assisted him upstairs to a room next




L. E.


*Read at the annual meeting of the American Ophthalmological
Society, AVashington, D. C, May, 1897.






to the roof, as the only other room in the house opened out
into the yard. He remained there for a week, and at the
end of that time was allowed to come downstairs. He subsequently obtained perfect vision. Case 39 (Series I) was
operated on in a cabin full of negro children, and he was
looked after by his daughter. The result was most satisfactory. In this series of fifty, two failed to recover sight, and as
the circumstances peculiar to these were rather unusual and
as such might explain the failure, I shall relate the histories.
Case 49, woman 78 years old, had been troubled many years
with dacryocystitis, more marked in the left eye than in the
right. She had been blind from cataract for three years.
Refused treatment for the lachrymal trouble, saying she was
too weak and old to stand the pain incident itpou the probing.
She was made acquainted with the additional risk of a cataract
operation performed on an eye where there was disease of the
lachrymal sac. She was willing, however, to run the risk of
infection from this source, so I operated on the least affected
eye. The result was a perfect success. A year later she presented herself for operation upon the second eye. The operation was smooth and she counted fingers with ease immediately
afterward. I left the city that evening, not expecting to see
her again for two weeks. She was entrusted to the care of
the physician who assisted me in the operation. It is well to
state here that she belonged to a most ignorant class of white




"
2 "


200


20/40
[No. 79.




123


people, and though nearly eighty years of age, was accustomed
to going barefooted in tvarm weather. The first time I operated she had shown herself unmanageable and walked around
the house three days after the operation. That was in the
winter time. The second operation was in June last, and
when I saw the patient two weeks after the operation her
physician told me that she got up out of bed the next
day, tore the plaster off her good eye and came downstairs
and sat in the yard and smoked her pipe. The second day
after the operation she walked nearly a mile barefooted to see
her daughter. Whatever were the causes which produced it,
when I saw her the second time the eye was lost. It is impossible, then, to say whether to attribute the loss of the eye to
infection from the mucocele or to carelessness and exposure
after the operation. Before each operation the contents of the
lachrymal sac were pressed out, and, as far as possible, the
conjunctival sac was rendered aseptic by irrigating it with a
solution of corrosive sublimate t^^jtj-.


Male.  
The second case (Case No. 47) is that of a man sixty-one
years old. He had been subject for many years to rheumatism, and had suffered also for a long time with varicose veins
on both legs, and as a result of the latter condition his right
leg was covered with an eczema. The blood-vessels at his
wrists and temples were tortuous and hard. Left eye, total
cataract and good field of vision for light. The operation
was absolutely smooth, and after the delivery of the lens
the patient could see my face and count fingers readily.
I removed the speculum and closed the eye, putting on the
usual bandage. Ten minutes later, and just before I was
about to leave the house, he complained of violent pain in
the eye. I suspected hemorrhage and immediately removed
the bandage to investigate. I found the latter soaked with
blood. The mass of blood and protruding vitreous were
cleaned away and strong pressure applied. On returning six
hours later it was found that the oozing had continued and
he was still suffering pain. The lids were opened and a clot
of vitreous was discovered between the edges of the wound.
This was removed, and after first irrigating the conjunctival
sac with a very weak sublimate solution, a pressure bandage
was applied. At my visit the next day I found the bandage
quite moist and there was every evidence that the oozing was
persisting. I cleaned out the sac again and renewed the
bandage. On the afternoon of the second day I saw him
again and there were still signs of hemorrhage. The same
course of treatment was pursued and on the third day I
found the bandage clean. Of course he was told that vision
was irrevocably gone from the onset of the hemorrhage. In
nearly all cases of this class the cornea sloughs, but this
termination I fortunately escaped. Hemorrhage after cataract extraction is rare. Dr. Knapp reports in a recent number of the Archives of Ophthalmology his only case. In my
own case I can account for the hemorrhage only by the condition of the blood-vessels throughout his body. ,v, No doubt
the vessels of the retina were tortuous and their walls
atheromatous, and when the lens was removed and intraocular tension thereby lowered, the blood-vessel walls could
not withstand the pressure from the increased volume of blood
pouring into them; so they ruptured. The whole condition of




64.


the patient pointed to a diseased state of the circulatory
apparatus. It is impossible to guard against such a termination, though I should regard it as a contra-indication for
operation upon the other eye, for no matter how smooth the
operation might be, the chances are that hemorrhage would
follow the delivery of the lens.


Good.  
Out of this series, then, all obtained useful vision but Cases
47 and 49.  


Since the publication of this series I have operated upon
158* cases and the tabular statement is herewith appended.
Two of the cases are especially interesting as being instances
of maniacal excitement, possibly due to the use of atropine
after the operation. The first case was a colored man, operated upon in the poorhouse of Mineral Co., W. Va. He was
seventy-five years old and had been practically helpless from
cataract for a year. Atropine was instilled immediately after
the operation. The next morning the physician. Dr. C. S.
Hoifman of Keyser, W. Va., was sent for and he wrote me
that the patient had gotten up during the night, torn the bandage off, secured a razor from one of the inmates of the room
and had gashed his throat in several places and was bleeding
profusely when found. In the excitement which followed the
eye was forgotten and it was some time before the bandage
was replaced. He was quieted, and seven days later, that is,
on the eighth day after the operation, he disappeared from the
jDOorhouse and two mouths afterward was seen by Dr. Hoffman, in Piedmont, W. Va., 20 miles distant, where he was
chopping wood and apparently getting along with absolute
comfort. It might be added that he was entirely bliud in the
other eye.


" "
The other case was also a very old colored man (88 years
 
old). The operation was simple extraction, and atropine was
 
instilled as usual at the operation. Before daybreak of the
 
next day he was a raving maniac and had to be tied down to
 
his bed. His bandage was torn off several times and he was
 
incessantly tossing his head from side to side, until that too
 
had to be secured so as to be as far as possible immovable. I
"
did not dare look at the eye, as I supposed that it was lost.
He did not recover his reason for a week, and all that was done
was to apply hot moist compi-esses to the eye. When he
became rational and I was enabled to get a satisfactory view
of the eye I found a rather small pupil, a slight prolapse, but
very little pericorneal congestion. On the tenth day he seemed
to be completely himself again, and as the eye evidently
needed a mydriatic, one drop of a solution of atropine (4 gr.
— si) was instilled and the nurse was instructed to repeat the
dose at bedtime. When I returned to the hospitiil the next
day I found that during the night he had jumped out of the
window — 20 feet from the ground — scaled a high iron-spiked
fence and was making off when overtaken by an orderly.
Notwithstanding all this exposure he obtained 4^ vision.
Nothing was done for the prolapse, which flattened out entirely.


Another interesting case was where the auterior chamber


2 "




Not tested.  
*At the meeting of the Amer. Oph. Soc. only 147 cases were
reported in my second series. Since the meeting I have operated
upon eleven cases.  




124


October, 1897.J


Female.
201




62.


remained open for seventeen days. I have seen explanations
for tliis phenomenon, but none seem adequate. The opei'ation
was the combined one, and the wound had united about half
way ujj on one side and the rest of the incision remained open.
More than once during these seventeen days a spatula was
jmssed beneath, the corneal flap, and it was easily seen that no
uuion had taken place. The operation so far as could be seen
appealed to have been normal, that is to say there was not
the slightest hitch in any of the steps. Atropine and compress bandage were employed, and two weeks after he left the
hospital his vision was jW Eight months later he returned
to the hospital with serious iritis, and since then vision has
been lost, though he still has light perception.


Good.  
Iridectomy was pei-formed in 102 cases and simple extraction in 42 cases. Soft cataract was operated upon by needling
in three cases.  


In thirty-one cases the vision was not tested. Three of
these cases were in very young children and any subjective test
would have been very unreliable. The remaining twenty-eight
were ones which I had operated upon at a distance and most
of whom I saw only once after the operation. A number of
cataract glasses were sent to them from which to make a
selection, and in this way I learned to what extent the operation had benefited the patient. It will be seen from the
table that the operation and healing process were uncomplicated in all of these cases and all obtained useful vision.


" "
Tlie failures were as follows: C«*e 54. The operation was
smooth, and when the bandage was removed she could see
large objects in the room. This was on the seventh day. Two
days later iritis of a very sluggish character developed, and in
spite of all treatment ended in closed pujjil and light perception. Dr. H. Harlan of this city operated on the other eye
and obtained good vision, but he told me that the ojDeration
was also followed by iritis.


Cage 72 had an exactly similar history.
Case 95 was one which I had treated for several months for
dacryocystitis. Her left eye had been operated upon by a
New York oculist two years previously, and the cause of the
failure in the case of that eye was no doubt the same as in the
case of the eye upon which I operated, for both eyes were
affected with dacryocystitis. When first seen she had a fistulous opening which had been discharging for several months.
Before operation she was under treatment for at least five
months, during which time the fistula had closed and the
epiphora had almost disappeared. She understood the danger,
but being totally blind in the other eye, wanted the operation
performed. The cornea sloughed within a week after the
operation.


Case 137 was that of a man 81 years old. On opening the
eye on the third day there was a very offensive discharge on the
bandage and between the lids, and beginning clouding at the
edge of the corneal wound. Vigorous local and constitutional
treatment, however, prevented the corneal trouble from extending and he was left with a clear cornea and closed pupil. I
think that I could have converted this failure into a success
(as in Case 190) by iridotomy, but a few days before the proposed operation he was attacked with pneumonia and died on
the eighth day.






The last case was that of an old colored man (Case 128)
and the history here was similar to Cases 54 and 72.


"
In one case (male, both eyes, 67 and 68), the patient had
good light perception, but after the extraction of the cataracts
it was observed that while he could move about somewhat
better, his sight continued very poor, and this was explained
by the existence of optic nerve atrophy in both eyes.


In Cases 53 and 307 a cataractous lens (congenital) had
undergone calcification and presented a bright white mass in
the pupil. The operation was simply for cosmetic purposes.


2 "
As to prolajjse of the iris. In the 42 cases of simple extraction there were five prolapses. In three of these cases nothing
was done, though in Case 181 the prolapse looked as though
it would extend throiigh the entire wound. Under a compress bandage, however, and atropine the hernia smoothed over
and she has now vision f^. In Case 182 the prolapse got
worse from day to day till it nearly filled the wound, and it
continued bulging more and more. There was no hernia on
the second day when the eye was inspected, but he bad a little
gush of tears that night followed by pain, and a small hernia
was visible the next day. On the eighth day, fearing that the
eyeball would be permanently disfigured (to say nothing of
loss of sight), the protruding iris was cut off. There is now
not the slightest ectasia of the cornea so far as can be seen,
and the patient has f^ vision.


In these last two cases lachrymation and photophobia were
present to a marked extent and some little pain was felt at
the time when the prolapse occurred, but after this pain was
conspicuously absent. So far as could be seen there were no
evidences of infection in any of the cases of prolapse. When
I say evidences I mean cloudy media and exudates. I think
that the absence of infection in these and similar cases is to
be attributed to the fact that the wound is filled with the
protruded iris and probably there is no way for the bacteria
to make entrance into the anterior chamber. The profuse
lachrymation which is usually present must be regarded as a
more or less protection from a mechanical point of view, i. e.
to some extent in washing away bacteria. And I think that
an examination of the statistics of simple extraction will disclose the fact that the failures are as a rule not associated
with prolapse.


II II
In commenting upon the visual results it will probably
strike many as singular that |J was obtained only four times,
but this may be explained by the fact that discission was performed only ten times and that in quite a number of cases
(31) I made no test of the vision.
 
In all of the operations the incision was made well within
the liinbus of the cornea and still a little further in at the top
of the incision. The latter includes usually something less
than half the circumference of the cornea.


The instruments with the exception of the knife are boiled.
The knife is allowed to remain in Squibb's absolute alcohol
for 20 minutes. The eyebrows and that side of the face are
covered with a cloth saturated with a solution of sublimate
1:1000. Both the cocaine and atropine solutions are boiled
in test tubes and only used once. Small pledgets of cotton
secured by sponge holders and boiled are used for removino- debris from the field of operation, such for instance as strings of mucus and small clots of blood. The
uuoperated eye is closed till the second day and a small pad
of sterilized absorbent cotton is placed over the operated eye
and over this a four-tail bandage. The eye is inspected on the
second day, and earlier if there be unusual pain. The room is
darkened, but is not uncomfortably dark. The patient is
allowed to get up on the second day, and the bandage is
removed on the seventh day, though there was a time when I
removed it earlier. The following is the arrangement of the
visual results:


125
20 I 1


TS '^^


Male.
U 35




7.


2 Qfi


Bad.
717 ^°


20 Of?


Soft. R E.
20 R  


2110 "


Needling.  
Vision not tested .31


Atrophy of the optic nerve 2


"
Cosmetic purposes 2


Failures 5


2 operations.
158


Successes in the first series 48


" "
Failures iu the first series 2


Total number of cases operated upon 208


126




Male.  
No.  




7
Sex.




Bad.  
Age.  




L. E.  
Health.  




"
Cataract,




"
Operation.




Healii.g- process. Duration of treatment.




11 11
Primary Vision.




127
51




Line 26,138: Line 31,199:




Si'.  
77.  




Bad.  
Good.  




Hard. L. E.  
Hard. R. E.  




Iridectomy.  
Iridectomy, smooth.  




"
Uncomplicated.




3 weeks.  
2 weeks.  




20/40
20/70




128
52




Line 26,165: Line 31,226:




81.  
75.  




Bad.  
Good.  




R. E.
" "




"
11 II




Iridocyclitis.  
Mild iritis.  




2 "




Light perception.
20/100




129
53




Line 26,191: Line 31,253:




22
36.




Line 26,197: Line 31,259:




Soft. R. E.  
Calcareous. R. E.  




Simple.  
.1 11




Line 26,206: Line 31,268:




2 weeks.
2 "




Not tested.  
Light perception.  




130
54




Male.  
Female.  




30'.  
50.  




Line 26,224: Line 31,286:




" "
Hard. L. E.




if
" "




"
Iritis.




2 "  
6 "  




20/200
" "




131
55




Line 26,245: Line 31,307:




44.  
71.  




Line 26,251: Line 31,313:




Hard. L. E.
" "




Iridectomy.
It 11




"
Uncomplicated.




Line 26,263: Line 31,325:




20/100
20/.30




132
56




Male.  
Female.  




4.  
68.  




Good.  
Bad.  




Soft. L. E.
" "




Needling.  
Escape vitreous.  




"
Iritis.




5 "




Not tested.
20/70




133
57




Male.  
Female.  




77.  
66.  




Line 26,304: Line 31,367:




Hard. R. E.
" "




Combined.  
Iridectomy, smooth.  




"
Uncomplicated.




6 "  
2 "  




20/100
Not tested.




134
58




Male.  
Female.  




77.  
72.  




Line 26,331: Line 31,394:




L. E.  
R. E.  
 
 




11 II




Line 26,344: Line 31,406:




Not tested.
20/26




135
59




Line 26,353: Line 31,415:




52.  
65.  




Good.  
Bad.  




R.E.  
L. E.  




11 11




Iritis.




"  
4 "  




2 "
20/100




20/200
60
 
 
136




Line 26,381: Line 31,442:




65.  
70.  




Line 26,387: Line 31,448:




R. E.




" "




 
Uncomplicated.
 
"




Line 26,399: Line 31,460:




20/70
20/30




137
61




Female.  
Male.  




57.  
50.  




Line 26,414: Line 31,475:




L. E.
" "
 
 




11 11




Line 26,430: Line 31,490:




138
62




Line 26,436: Line 31,496:




69.  
50.  




Line 26,442: Line 31,502:




L. E.




II II




"




''
2 "
 
 
2 '■




Line 26,457: Line 31,517:




139
63




Male.  
Female.  




82.  
55.  




Bad.  
Good.  




(I (1
"i ^.•■■^■




"
11 11




Escape vitreous.
''




2 "




No change but 3 weeks'
211/100
vision. 20/70.




140
64




Male.  
Female.  




34.  
60.  




Good.  
Bad.  




Hard. R. E.




Simple Ext.
11 11




Uncomplicated.
"




2 weeks.
2 "




20/40  
24/40  




141
65




Female.  
Male.  




51.  
55.  




Line 26,523: Line 31,582:




" "
!! L.E.




11 11




Mild iritis.




"
5 "  
 
 
2 "  




Line 26,539: Line 31,597:




142
66




Line 26,545: Line 31,603:




51.  
62.  




Line 26,551: Line 31,609:




L. E.




11 11




 
Uncomplicated.
 
"




Line 26,564: Line 31,620:




20/40
Not tested.




143
67




Female.  
Male.  




45.  
75.  




Good.
Bad.  
 
 
R. E.  




" "




Simple Ext.




Line 26,592: Line 31,647:




20/200
Atrophy.




144
68




Line 26,601: Line 31,656:




58.  
75.  




Good.  
Bad.  
 
 
II II




R. E.




Iridectomy.




Line 26,617: Line 31,671:




2 "
2 '•




20/100
0. Nerve.




145
69




Male.  
Female.  




58.  
60.  




Line 26,635: Line 31,689:




L. E.
" "




"




 
"
 
'<




Line 26,648: Line 31,701:




20/70
20/40




146
70




Male.  
Female.  




61.  
60.  




Line 26,663: Line 31,716:




<i 11
L. E.




"




"




Escape vitreous.
2 "




Iritis. 4 "
20/70




20/30,
71
 
 
147




Line 26,685: Line 31,737:




47.  
66.  




Line 26,694: Line 31,746:




"




Iritis.




Uncomplicated.
3 "




2 "
20/100




20/40
72




148
Male.




Female.
80.  
 
 
60.  




Line 26,719: Line 31,770:




II 1.  
L. E.  




"




Irido-cyclitis.




"  
8 "  




2 "
Light perception.




Not tested.
73




149
Male.




Female.
63.  
 
 
50.  




Line 26,747: Line 31,797:




w L.E.
" "




"




 
Uncomplicated.
 
"




Line 26,760: Line 31,809:




11 11
20/30




150
74




Line 26,769: Line 31,818:




60.  
66.  




Line 26,775: Line 31,824:




R. E.




"




"




Line 26,787: Line 31,835:




20/40
20/20




151
75




Male.  
Female.  




55.  
71.  




Line 26,802: Line 31,850:




II •!
L. E.
 
 




"




Line 26,818: Line 31,865:




152
76




Male.  
Female.  




44.  
50.  




Line 26,830: Line 31,877:




" "
R, E.
 
 




"




Line 26,843: Line 31,889:




20/70
Not tested.




153
77




Male.  
Female.  




48.  
61.  




Line 26,858: Line 31,904:




U II
L. E.




"




Mild iritis.




"
3 "  
 
 
2 "  




Line 26,874: Line 31,919:




154
78




Male.  
Female.  




51.  
66.  




Line 26,886: Line 31,931:




!'i ^;.^
R. E.  




"




 
Uncomplicated.
"




Line 26,898: Line 31,943:




20/70
20/40




1.55
79




Male.  
Female.  




62.  
54.  




Line 26,913: Line 31,958:




L. E.




 
"
 




Line 26,925: Line 31,970:




20/70
20/40




1.56
80




Female.  
Male.  




59.  
75.  




Line 26,940: Line 31,985:




II II
R. E.
 
 




"




Line 26,953: Line 31,997:




20/100
20/70




157
81




Female.  
Male.  




Line 26,968: Line 32,012:




L. E.
" "




"




 
"
 
'•




Line 26,981: Line 32,024:




20/70
Not tested.




1.58
82




Line 26,990: Line 32,033:




73.  
63.  




Line 26,996: Line 32,039:




<" B;E.  
',! L.^E.  




•'




Vitreous lost. Iritis.




"  
4 "  




2 "
20/100




20/40
83




159
Female.




Male.
50.  
 
 
47.  




Line 27,024: Line 32,066:




(t




"




 
Uncomplicated.
 
"




Line 27,036: Line 32,078:




20/30
20/70




IGO
84




Line 27,045: Line 32,087:




53.  
51.  




Line 27,051: Line 32,093:




11 11
R. E.
 
 




"




Line 27,061: Line 32,102:




2 "
2 **




Not tested.
20/40




161
85




Female.  
Male.  




62.  
80.  




Good.  
Bad.  
 
 
II <I




" "




"




Line 27,089: Line 32,129:




2 "  
5 "  




20/80
20/100




162
86




Female.  
Male.  




50.  
64.  




Line 27,107: Line 32,147:




II II




"




"




Iritis.
2 "




4 "
20/70




20/100
87




163
Male.




Female.
54.  
 
 
.58.  




Line 27,135: Line 32,173:




U tl
L. E.
 
 




"




Line 27,145: Line 32,182:




5 "  
2 "  




20/70
20/40




164
88




Female.  
Male.  




78.  
66.  




Bad.  
Good.  




L. E.  
R. E.  




Iridectomy.
"




Line 27,172: Line 32,209:




7 "  
2 "  




Closed pupil.  
Not tested.  




165
89




Female.  
Male.  




66.  
60.  




Line 27,190: Line 32,227:




U II
" L. E.




Line 27,196: Line 32,233:




Uncomplicated.
"




Line 27,202: Line 32,239:




20/70
11 11




166
90




Female.  
Male.  




66.  
.57.  




Line 27,223: Line 32,260:




"
1'




2 "
2 *'




20/100
20/40




167
91




Line 27,238: Line 32,275:




68.  
51.  




Line 27,244: Line 32,281:




11 <i
L. E.




Line 27,250: Line 32,287:




Ant. C, open
"




17 davs.
2 "




20/200
20/100




168
92




Male.  
Female.  




28.  
47.  




Line 27,271: Line 32,308:




Soft.  
II .1




S. L. Extracture.
"




Uncomplicated.
"




10 "■
2 "  




Not tested.
20/100




169
93




Female.  
Male.  




47.  
55.  




Line 27,298: Line 32,335:




Hard. L. E.  
R. E.  




Simple Ext.
"




*'
"




2 weeks.
2 "




20/10
20/70




170
94




Female.  
Male.  




80.
71,




Bad.  
Good.  




R. E.
" "




Iridectomy.
"




Iritis.
"




5 "  
2 "  




20/200
20/70




171
95




Line 27,349: Line 32,386:




Good.  
Bad.  




II 11
" "




"
Escape vitreous.




Uncomplicated.
Irido-cyclitis,




Line 27,364: Line 32,401:




20/70




172
96




Male.  
Female.  




88.  
52.  




Good.
Good,




Line 27,382: Line 32,418:




Simple Ext.  
Iridectomy.  




Prolapse iris.  
Uncomplicated.  




Line 27,391: Line 32,427:




20/100
20/200




173
97




Line 27,400: Line 32,436:




70.  
53.  




Bad.  
Good.  




Line 27,409: Line 32,445:




II II
"




Iritis.
"




4 "  
3 "  




20/70
Not tested.




174
98




Line 27,427: Line 32,463:




70.  
77.  




Bad.  
Good.  




Line 27,436: Line 32,472:




Iridectomy.
"




Uncomplicated.  
Iritis.  




2 "  
4 "  




20/70
20/100




175
99




Line 27,454: Line 32,490:




44.  
56.  




Good.  
Bad.  
 


R. E,


'<! ^;.^


Simple Ext.
■'




"
Uncomplicated.




3 "  
2 "  




20/40
20/30




176
100




Line 27,480: Line 32,517:




48.  
58.  




Line 27,486: Line 32,523:




L. E.




Prolapse.
"
 
 
"




5 "  
2 "  




20/30
Not tested.




177
101




Line 27,503: Line 32,544:




71.  
54.  




Line 27,509: Line 32,550:




II 11
R. E.




Iridectomy.
"




Uncomplicated.
"




Line 27,521: Line 32,562:




Not tested.
20/40




178
102




Female.  
Male.  




70.  
46.  




Line 27,536: Line 32,577:




II II
L. E.




Line 27,542: Line 32,583:




"
••




Line 27,548: Line 32,589:




20/100
20/70




179
103




Line 27,557: Line 32,598:




61.  
76.  




Good.  
Bad.  




L. E.  
R. E.  




Line 27,575: Line 32,616:




20/40
Not tested.




180
104




Line 27,584: Line 32,625:




67.  
64.  




Line 27,590: Line 32,631:




R. E.
11 11
 
 
1'




Line 27,596: Line 32,640:




Iritis.
3 "  
 
 
4 "  




Line 27,605: Line 32,646:




181
105




Female.  
Male.  




66.  
.50.  




Line 27,617: Line 32,658:




L. E.
II 11




Simple Ext.
"




Big prolapse.
"




5 "  
2 "  




20/40
20/70




182
106




Line 27,638: Line 32,679:




47.  
65.  
 


Bad.


Good.


L. E.


!' •^■i'^


"  
"  




II
"




4 "
2 *'




20/30
20/70




183
107




Line 27,664: Line 32,706:




58.  
60.  




Line 27,670: Line 32,712:




" "




Iridectomy.
"




Uncomplicated.
"




Line 27,684: Line 32,727:




184
108




Female.  
Male.  




70.  
72.  




Line 27,696: Line 32,739:




11 11
R. E.




Line 27,708: Line 32,751:




Not tested.  
20/40
 
 
 
October, 1897.1


203


185




Female.  
No.  




50.  
Sex.  




Good.  
Age.  




11 11
Health.




Simple Ext.  
Cataract.  




"
Operation.




2 "
Healing process. Duration of treatment.




20/100
Primary Vision.




186
109




Male.  
Female.  




67.  
61.  




Line 27,750: Line 32,797:




!'. ^u-^
Hard. L. E.
 


Iridectomy.  
Iridectomy.  




"
Uncomplicated.
 
 
3 weeljs.




2 "
20/70




20/20
110




187
Male.




Female.  
79.  




77.  
Good.  




Bad.
" "








Simple Ext.




Line 27,790: Line 32,840:




188
111




Female.  
Male.  




77.  
55.  




Bad.  
Good.  




Line 27,805: Line 32,855:




Irid




Bctomy.




Iritis.
"




4 "  
2 "  




20/100
20/40
 
 
112




Male.


204


80.




JOHNS HOPKINS HOSPITAL BULLETIN.  
Good.  




L. E.


[No. 79.






No.




Sex.
"




Age.
2 "




Health.
20/70




Cataract.
113




Operation.  
Female.  




Healing process. Duration of treatment.  
56.  




Primary Vision.  
Good.  




189
" "




Male.




83.




Good
"




Hard. L. E.
3 "




Simple Ext.
20/100




Uncomplicated.
114




2 "
Female.




Not tested.  
63.  




190
Good.




Female.
" "




80.




Good.




U It
"




Iridectomy.
3 "




Closed pupil, but
Not tested .




iridotomy pave.
115




20/2C0
Male.




191
72.




Female.  
Good.  




70.
" '•




Good.




R. E.




Line 27,929: Line 32,974:




Uncomplicated.
2 "




2 weeks.
20/100




20/30
116




192
Male.




Female.  
81.'




62.  
Good.  




Good .
" "




" "




"




"




Line 27,961: Line 33,005:




20/70
20/7(t




193
117




Male.  
Female.  




50.  
66.  




Line 27,976: Line 33,020:




" "
R. E.
 




Simple Ext.




"




Line 27,990: Line 33,036:




194
118




Male.  
Female.  




55.  
50.  




Line 28,005: Line 33,051:




" "
 
 




Line 28,011: Line 33,058:




2 "
2 •'




Not tested.
20/40




195
119




Male.  
Female.  




60.  
49.  




Line 28,029: Line 33,076:




" "
L. E.
 
 




" "




Line 28,044: Line 33,092:




196
120




Male.  
Female.  




72.  
48.  




Line 28,056: Line 33,104:




" "
R. E.
 
 




" "




Line 28,065: Line 33,114:




2 "  
3 "  




Line 28,071: Line 33,120:




197
121




Male.  
Female.  




72.  
53.  




Line 28,083: Line 33,132:




L. E.
" "
 
 




" "




Line 28,095: Line 33,145:




20/70
20/30




198
122




Female.  
Male.  




70.  
68.  




Line 28,110: Line 33,160:




" "
L. E.
 
 




Iridectomy.




Line 28,122: Line 33,173:




2(1/20
20/40




199
123




Female.  
Male.  




70.  
64.  




Line 28,137: Line 33,188:




R. E.
" "
 
 




"




Slight iritis.
"




3 "  
2 "  




2<i/100
Not tested.




200
124




Line 28,158: Line 33,210:




68.  
62.  




Line 28,164: Line 33,216:




L. E.
" "
 
 




Simple Ext.




Uncomplicated.
"




Line 28,176: Line 33,229:




20/40
II II




201
125




Female.  
Male.  




66.  
7.  




Line 28,191: Line 33,244:




R. E.  
Soft. R E.  




" "
Needling.




Iritis.
"




4 "
2 operations.




Not tested.
" "




202
126




Female.  
Male.  




68.
7




Delicate.  
Bad.  




" "
L. E.




Iridectomy.
"




Uncomiilicated.
"




2 "




" "
11 11




203
127




Female.  
Male.  




65.  
Si'.  




Good.  
Bad.  




" "
Hard. L. E.




"
Iridectomy.




Line 28,254: Line 33,306:




2 "
3 weeks.




Line 28,260: Line 33,312:




204
128




Female.  
Male.  




66.  
81.  




Good.  
Bad.  




L. E.  
R. E.  




Line 28,278: Line 33,330:




"
Iridocyclitis.




2 "




Not te&ted.  
Light perception.  




2 '5
129




Female.  
Male.  




60.
22




Line 28,299: Line 33,350:




R. E.  
Soft. R. E.  




"
Simple.




"
Uncomplicated.




2 "
2 weeks.




Not tested.




20(i
130




Line 28,319: Line 33,371:




44.  
30'.  




Line 28,325: Line 33,377:




L. E.
" "




"
if




Line 28,334: Line 33,386:




2 '■
2 "




" "
20/200




207
131




Line 28,346: Line 33,398:




50.  
44.  




Good .  
Good.  




R. E.  
Hard. L. E.  




"
Iridectomy.




Line 28,361: Line 33,413:




2 "




Cosmetic.
20/100




20S
132




Female.  
Male.  




55.  
4.  




Line 28,378: Line 33,431:




" "
Soft. L. E.




"
Needling.




Line 28,387: Line 33,440:




2 "




Line 28,393: Line 33,445:




133


PAROTITIS FOLLOWING VISCERAL INFLAMMATION.-A REPORT OF TWO CASES.


Male.




(Service of Dr. O.sler.)
77.  
By a. Duval Atkinson, M. D.  




Good.


It is well known that parotitis is a complication in pyaamia
and many infections diseases. There seems also to be a relation between the parotid gland and the generative organs, and
an apparent sympathy (as pointed out by Stephen Paget in
1886) between the parotid gland and the abdominal viscera.
Cases illustrating it are, however, of sufficient rarity to
warrant the rej)ort of the following histories.


Case J. Parotitis following a supposed gastric ulcer. — A
Hard. R. E.  
female, aged 34, single, by occupation housemaid, was
admitted December 16th, 1895, complaining of general weakness and vertigo. Her family history was good ; her mother
died of "dropsy": there was no history of titberculosis. She
had always enjoyed good health until one year ago. She had
had none of the diseases of childhood. The catamenia began
at fourteen and were always regular until a year ago. She had
not menstruated for four months. She had been sick during
the past year, but not confined to bed. At the beginning of
the illness her chief complaint was of a continual dull pain in
the epigastrium and "cramps" in the legs, a condition which
lasted for about one month, when the pain left the abdomen,
but not the extremities. In them it persisted with the utmost
severity, being of a shooting, darting character, coming on
often in paroxysms lasting several minutes. At the height
of these pains a feeling of "pins and needles" would be felt
in the hands and fingers. During the six months previous to
her admission her arms and hands had been swollen to some
extent, also her eyelids, the latter especially in the early
morning ; her eyesight had been failing.  


She took to bed December 9th, 1895 (eight days before
entrance. Late in the afternoon of that day she began to feel
weak and nervous, and had a gnawing sensation in the epigastric region. Nausea immediately followed, and she vomited a
considerable ([uantity of bloody-looking material. Four hours
later she again vomited a considerable quantity of material
which the patient thought was pure blood. She remained in


Combined.




bed on account of her extreme weakness until she came to
"
the hospital.


Physical Examinatioii. Patient's skin and mucous membranes were j)ale ; sordes on lips ; tongue pale, moist, and
somewhat cracked. Distinct pulsation in external jugulars;
pulse 25 to the quarter, regular in force and rhythm, tension
distinctly raised ; vessel wall a little thickened.


The thorax was long ; costal angle narrow ; expansion only
6 "
fair, but apparently equal. Respiration over front of chest
 
was negative; clear on percussion. Over the back the breath
 
sounds were quite clear.
20/100
 


Heart. Point of maximum cardiac iinpulse diffuse over
134
fifth and sixth spaces, in and a little outside the nipple line;
relative dullness was at the upper border of the third rib,
extending to the nipple line and a little beyond the left sternal
margin. At the point of maximum cardiac impulse the first
sound was loud and booming, accompanied by a blowing
systolic murmur which was heard as far out as the anterior
axillary line. The second sound was accentuated. A systolic
murmur was also heard in the aortic region, where the second
sound was sharp and loud. Over the sternum the murmur
was increased and the second sound was more booming. At
the costal angle the murmur was very distinct and the second
sound was greatly increased in intensity.


Hepatic flatness began at the sixth intercostal space and
extended to the costal margin in the mammillary line; the
border was indistinctly felt. Spleen not palpable. No cedema.
Eefiexes normal. Blood count showed 2,314,000 red corpuscles to the cubic millimetre; white corpuscles, 8000;
hajnioglobin 30 per cent. The urine was pale yellow in color ;
specific gravity varied from 1010 to 1006; there was a decided
trace of albumen. Microscopically granular casts were seen.
There were no rigors.


During the night of Dec. 16th, 1895, the patient began to
Male.  
complain of pain, and tliero was some swelling in the region




77.


OCTOBEll, 1897.]


Good.




JOHNS HOPKINS HOSPITAL BULLETIN.  
L. E.  






205






of the left parotid gland. The next morning (two days after
"
entrance) the following condition was noted. The patient
presents great swelling of the left parotid gland. The swelling extends nji above the zygoma, and behind far over the
mastoid. Below there is a marked amount of infiltration in
side of neck, extending to the angle of the mouth. The
swelling lifts the lobe of the ear. It is rounded, tense, hot,
and very painful. The tongue is a little swollen. Nothing
exudes from Steno's duct when external pressure is made over
the gland. The abdomen is negative. There is no general
enlargement of the superficial glands of the body.


At 13 noon, although no fluctuation was obtained, the
gland was incised. Numerous small foci of inflammation
were discovered, from which exuded a little creamy pus.
Cover-s]ij)s from these areas showed streptococci and a large
bacillus ; the latter was supposed to have come from the
mouth. Cultures showed a pure growth of streptococcus, the
bacillus not growing.


The following day, December 20th, the pain in the region
2 "
of the neck had in a measure subsided; the swelling, however,
remained about the same ; there was marked oedema of left
eyelid.


The patient did fairly well until the 34th, the swelling and
tedema of eyelids remaining about the same. On that day
she was extremely pale, pulse 100, dropping a beat occasionally. The swelling of the cheek was perhaps a trifle less;
she breathed noisily ; no infiltration in the lower neck. The
patient sank rapidly and died. Unfortunately no autopsy was
allowed. The diagnosis of parotitis, gastric ulcer, and chronic
interstitial nephritis was made.


Case II. Cholecystitis (post typhoidal) complicated by
Not tested.  
double parotitis. — J. L., single, age 34, German, butcher by
occupation, was admitted to Ward F, November 25, 1895,
complaining of continual headache, pains in his muscles and
joints. His family history was good ; there was no history of
tuberculosis. His only disease during childhood was scarlet
fever, from which he made a complete recovery, with no
sequelae, and excepting an attack of rheumatism, which confined him to bed nine months in 1893, had always been a
strong, able-bodied man. He gave no history of syphilis or
gouorrhoeal infection. Had been a moderate drinker. The
history of his present illness was that about one week before
his admission he began to have headache, chills and nausea,
accompanied by vomiting. The diagnosis of typhoid fever
was made, and the patient had a typically mild course of fever,
which was treated by means of the ice-baths. His temperature reached normal on December 5th, ten days after entrance.
The urine showed a distinct diazo reaction, and there was a
trace of albumen. The spleen was easily palpable, and there
were a few typical rose spots. The liver was never palpable.
Blood negative for malarial organisms. No leucocytosis.
His convalescence was uninterrupted, and he was discharged
well, January 1, 1896.  


The patient was readmitted November 30, 1896, eleven
months afterwards, complaining of headache and general
weakness, stating that he had been feeling badly for ten
days. The chief symptoms seemed to have been headache,
muscular and slight abdominal pain. Two days before


135




entrance he had had a slight chill followed by fever and
Female.  
sweating. On entrance his temperature registered 103.4°,
pulse 27 to the quarter minute, full and strong. The
physical examination was negative save for a slight enlargement of the spleen and some rigidity of the right rectus
muscle. The liver was not palpable and the hepatic flatness
was not increased. The blood was entirely negative for
malarial organisms, and there was no leucocytosis. The
conjuuctivEe were injected, but there was no jaundice. No
bile was found in the urine. His temperature, which reached
103° on the evening of his entrance, quickly dropped to
normal, and the man was discharged December 15th, quite
well, with no definite conclusions being reached concerning
the nature of his trouble.  


He again applied for admission March 5, 1897, stating that
for three days he had had chills, accompanied, he thought, by
fever, headache and pains in his back and limbs. His bowels
had been very costive for some time.


The physical examination was as follows : Well nourished,
52.  
strong-looking man ; face flushed; eyes bloodshot ; lips a trifle
cedematous ; tongue had a slight brown coat. Pulse, 33 to the
quarter minute, dicrotic ; capillavy circulation rather sluggish. Thorax symmetrical, expansion equal; an occasional
sonorous rale was to be heard over chest and axillae. Heart
sounds clear. Spleen just palpable on deep inspiration.
Hepatic flatness began at the sixth rib, extending one finger's
breadth below the costal margin. The muscular resistance of
the abdominal wall was such that it was utterly impossible to
palpate it. In the mammillary line there were 13 cm. of
hepatic flatness. (Pain was complained of whenever deep
palpation was attempted in the hypocondriac region.) On
the following day, March 6th, there was no essential change
in his condition. The morning temperature registered 104.3°,
and that of evening 103°. There was well-marked tenderness
on pressure in the hypocondriac region, and pressure between
the crest of the ilium and ribs on the right side caused pain.
The most tender part appeared to be just at the region of the
gall-bladder. The conjunctivae were a little muddy, but not
distinctly jaundiced. There was- a leucocytosis amounting to
11.300 to the cubic mm. The urine was negative, but no test
for bile was made. On March 9th the conjunctivae were
slightly yellow, and the urine reacted for bile. There was
still great tenderness in the region of the gall-bladder. His
temperature, which had been gradually falling, reached
normal at 2 a. ni., where it remained until the 12th, when it
was again elevated. On that day both parotid glands were
swollen, the right more than the left. They were hot and
very tender to pressure. No fluctuation was obtained. On
the loth both glands were greatly swollen, the tissue of the
face and neck was infiltrated, and eyelids (Edematous. The
skin over the parotid glands was red, the gland itself imparting a hard infiltrated sensation to the examining hand. Both
papillae at orifice of duct were swollen, and pus could be
forced out. Although the patient was in poor condition, his
temperature registering 102.8°, he insisted upon leaving the
hospital, and was therefore discharged.  


Cultures from the Ijlood on agar-agar and bouillon proved
neo-ative. Diagnosis: Cholecystitis (post-typhoidal), com


Good.


206


R.E.




JOHNS HOPKINS HOSPITAL BULLETIN.






[No. 79.


"




plicated by double parotitis. Later both parotids were
2 "
incised, the bacteriological esamiuation showing a pure
growth of staphylococcus aureus. The patient is now quite
well.


The cases in many ways correspond to some of those
referred to by Stephen Paget in the London Lancet for 1886,
and spoken of in more detail in the British Medical Journal
in 1887. In his series parotitis followed injury and diseases
of the peritoneum, generative organs, and abdominal viscera.
Two followed a supposed gastric ulcer. Of the 101 cases
cited, 10 were due to injury of the urinary tract; 18 to
diseases of the alimentary tract; 33 to injury or disease of
the abdominal wall and peritoneum, or to the pelvic cellular
tissues, and 50 to temporary derangement of the generative
tract. He states that parotitis after abdominal or pelvic
injury or disease is not as a rule accompanied by signs of
septiegemia or pya3mia. Of his 101 cases mention is only
made in 15 of septic symptoms. 37 died; of these 3 were
over eighty years of age ; 3 had internal cancer ; 3 had perforation of the bowel ; and 3 had strangulated hernia; 7 had
undergone severe surgical operation involving abdominal section ; 13 had septicEemia or pyfemia; 1 had infantile syphilis ;
1 had marasmus; and 1 had heart trouble. He adds that death
was not due to parotitis joer se, but to a primary lesion, and he
is ujiable to state to what extent parotitis is a dangerous complication. Its period of incubation is unknown, but in his
opinion it is from one to thirteen days. There is as a rule no
marked disturbance to general health, no rigors, and no high
fever. On the other hand symptoms may be more severe from
the onset, and great disturbance in general health may be
noted. Eigors were noted in only 4 cases. In regard to
the termination of the parotitis, whether by resolution or by
suppuration, the figures show that out of 73 cases which give
information on the point, 45 suppurated and 33 were resolved,
and out of 45 that suppurated 34 died; but out of the 33 that
resolved without suppuration only one died (in all probability
from cancer). In other words, he thinks that they did not
die because the parotids went on to suppuration, but that the
parotids suppurated because they were going to die. In cases
of undoubted septicasmia or pyemia the parotids always went
on to sujipuration.


'I'he only autopsy reported by Paget is that of a woman
20/200
dying from the effects of the removal of a sarcomatous growth
of the mesentery, having parotitis as a complication. On
section the parotid was found to be evenly and in every part
infiltrated, not with pus, but with a reddish, slightly turbid
fluid, causing it to look like a section of the spleen. There
were no abscesses anywhere. Just in the proximal end of the
duct where it left the gland lay two or three drops of healthy
pus and a tiny calculus. The acini were separated, compressed, and breaking up, and here and there were seen ducts
filled with the same small round cells as were infiltrated
among the acini. No bacteriological examination was made.
Mr. Paget cites a case reported by Rosenbach of parotitis following operation for strangulated hernia, in which staphylococcus
aureus was obtained. He further states that this form of
parotitis is in many ways a peculiar lesion, so far as l)eingdue




136


to septicemia. It was in 93 cases an isolated lesion, unaccompanied by any other lesion like itself, having no fixed period
of incubation, and running no common course. Its invasion
is not as a rule marked by rigors or great rise of temperature.
It may subside and swell up and subside again. These facts
make it impossible to say that this form of parotitis is due to
any ordinary form of septicaemia. It is not, he thinks, due to
inflammation following a parched and sore mouth, as the
mouths of pyaBmic or septicaemic patients are not, as a rule,
more parched than those of other patients. Also, he does
not think that it is merely due to inflammation of the
lymphatic tissue which is in the gland substance. " Admitting that the general condition of the patient, especially in
cases of septicemia and pyaemia, is considered in the production of this form of parotitis, must we not take into consideration the reflex action of the nervous system, as the influence,
direct and reflex, of the nervous system upon the salivary
glands is shown in countless ways; viz. gastritis may be
followed by salivation or arrest of salivary secretion. Parotitis may follow gastric ulcer, gastrotomy, etc. Even operations on the rectum and again diseases of the thoracic viscera
cause inequality of the pupils, differing not only in size, but
in their susceptibility to light. Thus, with regard to pyjemia
after abdominal or pelvic lesions, we may admit that the
general condition of the patient may help to cause it, without
denying the local influence of the nervous system."


A. J. Oribb (Lancet, 1886) reports two cases ; in one jiarotitis followed irritation of the genito-urinary tract, and
Male.  
in the other ovaritis occurred in connection with parotitis.
 
And again, Harkin (Lancet, 1886) reports parotitis in a
 
woman aged 43 as one of the first symptoms of three successive pregnancies, no suppuration being present. These
65.  
cases seem to point undoubtedly to some latent sympathy
 
between the parotid glands and the organs either covered by
or closely adjacent to the peritoneum. It is, however, difficult
for us, with our present bacteriological knowledge, to conceive
of inflammation being established in organs far remote from
the seat of irritation by reflex causes alone, without the
presence of micro-organisms. An interesting case, and one
bearing a close resemblance in some respects to those cited, is
one reported by W. Legg in the Pathological Society Reports
for 1869, in which parotitis was a complication in contracted
kidney and atheroma in a lad aged 16, who was admitted to
the University College Hosjiital for albuminuria. Nine days
after admission he complained of pain on right side of face.
The day after well-marked right parotitis was noted. The
swelling continued for eight days, when the patient died
suddenly. There was found to be no obstruction to Steno's
duct; the gland tissue was pale grey in color, not at all
reddened, rather harder than natural, and on section there
flowed from the cut surface a large quantity of pale greyish
white fluid, somewhat thin, showing under the microscope a
large number of rounded cells, larger on the average than pus
corpuscles, having rather granular contents, and single small
bright nuclei. The gland was the seat of small abscesses
varying in size from a pin head to a barley corn. Microscopically was seen a great increase in epitiielial elements, the
acini being iilled with them. The arteries wore atheromatous


Good.




October, 1897.]






JOHNS HOPKINS HOSPITAL BULLETIN.






207
"




2 "


and the kidneys contracted. No mention is made of lesions
in other organs.


W. B. Morrow, in the Montreal Medical Journal of March,
20/70
'96, has related the histories of three cases of parotitis fol]pwing pelvic disease. And Herbert and Hawkins, in the British




137


Medical Journal of April 10, 1897, report two cases of operation for jjerforation of gastric ulcer, in one of which there
was a double parotitis three days after operation, the patient
eventually making a complete recovery, the glands subsiding
without incision being necessary.


Female.




PALPATION OF THE FCETAL HEART IMPULSE IN PREGNANCY.  
57.  


By Douglas F. Duval, M. D., Assistant Resident Ognecologist.


Good.




It is not generally known that the impulse of the fcetal
L. E.  
heart may under certain conditions be actually felt beating
through the abdominal walls of the pregnant woman.  


In this country but two cases have been observed, those of
Dr. Kelly, which I now report. The first was in 1884 and the
second in 1895. They represented the right bregmatic-iliacanterior and left occipito-iliac-posterior presentations, the
latter being observed in the eighth month of pregnancy, all
previous cases having been during labor.


Of the other observers, Fischel, in 1881, was the first to
publish a definite account describing accurately three cases in
which this phenomenon occurred. These cases represented
the left bregmatic-iliac-anterior, the right occipito-iliac-posterior and the left mento-iliac-auterior presentations. Valenta,
however, in 1885, claimed priority of observation, stating that
he had noted it in 1860 in a first face presentation, and had
recorded it in his "Text-Book on Midwifery," and that since
then he had repeatedly spoken of its importance as a diagnostic sign in anterior face presentations. Fleischman in 1885,
stimulated by Fischel's communications, published an interesting case in which this phenomenon was observed in a right
men to-iliac-anterior presentation.


The following is a brief account of the various cases :


Case I. Observed by Dr. Kelly, in Kensington, Philadelphia, in 1884. Multipara, of medium build, mother of four
or five children, abdominal walls moderately thin. A right
bregmatic-iliac-anterior presentation. Membranes ruptured,
OS half dilated, brow just engaging. The impulse of the foetal
heart was forcible and distinctly palpated over an area about
3 cm in diameter ; to the right and about half way between
the umbilicus and Poupart's ligament, separate beats were
easily counted, 130. The child was born living after a protracted labor and manual rectification of position.


Case II. Observed by Dr. Kelly. Patient short brunette,
well nourished, abdominal walls not thin, eighth month of her
first pregnancy. A left occipito-iliac-posterior presentation.
Heart sounds heard loud over an area 10x10 cm., and easily
counted 140. On moderate pressure a rapid fluttering sensation was clearly distinguished over an area about 2.5 cm. in
diameter. The separate beats could not be distinguished; a
few days later, on examination, the heart impulse could not
be felt. The patient has since passed through a normal confinement.


Fischel's Cases.
"


Case I. Mi. 36, 1 para, well nourished, strong. Pains
began on 30th at 1) p. m. Li(juor auinii discharged on 31st at


2 "




13.15 a. m. At 7.45 a. m. os 6 cm. in diameter. Foetus in
20/40
left bregmatic-iliac-anterior presentation. Heart sounds to
the left and below umbilicus. At 13.15 fcetal heart impulse
palpated to left and beside umbilicus, synchronous with foetal
heart sounds, frequency 156-160. This phenomenon was
observed for several hours. Change of presentation being
impossible, craniotomy was performed.


Case II. Mt. 31. Well built, large, strong. Pains began
at midnight. At 3 a. m. liquor amnii discharged. Entered
hospital at 4 a. m. Cervix obliterated, back to the right, feet
to the left above the umbilicus, chin 8 cm. above left os pubis,
heart sounds above the symphysis. From this description very
probably a right occipito-iliac-posterior presentation. The
fcetal heart impulse was palpated just above the chin, easily
demonstrable, frequency 156, maternal pulse 113. In the
further course of labor, which was rapid and favorable, the
impulse was palpated in the pauses between the pains, descending toward the symphysis and finally disappearing
entirely, though the sounds continued to be heard. Examination of the child's heart after labor showed clearly that the
sounds were of normal strength and clearness.


Case III. Mi. 30. 1 para, small, strongly built, moderately fat, abdominal walls thin. Pains began at 10 a. m.
138
Entered hospital in the afternoon. External examination :
 
Occiput above right os pubis, extremities to the left, heart
sounds to the left of the umbilicus, loud and slow.' The presentation in this case was then a left meuto-iliac anterior. At
6.30 p. m. the heart impulse was clearly palpated 5 cm. to left
of umbilicus. At 7.30 p. m. was 5 cm. to left of umbilicus,
but lower. At 8 p. m. frequency ranged between 80 and 150 ;
maternal pulse 66-73. At 11.30 p. m. heart impulse to left
of umbilicus, but lower. Labor terminated at 13 m., fcetal
heart sounds ceased two minutes before delivery, child stillborn.


Fleischman's Case.  
Male.  


Case I. Mt. 35. Abdominal walls thin and flabby. Entered hospital at 11 p. m., three hours after discharge of liquor
amnii. Occiput over left os pubis, back to the left, heart
sounds clearest four fingers' breadth to right of midline, chin
to right and forward, forehead to left and backward. Evidently a right mento-iliac-anterior presentation. On the following morning the foetal heart impulse was palpated in the
right hypogastrium, at the junction of the middle and lower
thirds of a line drawn between the umbilicus and middle of
Poupart's liganit'nt. In frequency doubled that of the maternal. 'J"he sounds were loud and clear.


69.




208
Good.






JOHNS HOPKINS HOSPITAL BULLETIN.






[No. 79.




''


Fleischmau says: "The conditious iu this case for the
observation of the pheuomenon were most favorable, the
abdominal walls were thin and flabby and the liquor amnii
had previously discharged, thus permitting the uterine walls
to clasp firmly the foetal thorax."


The following is a summary of all the cases :
2 '■


Fischel, 1881, three cases: Left bregmatic-iliac-auterior,
right occipito-iliac-posterior, left meuto-iliac-anterior.


Valenta, 1885, one case: First face presentation (K. m. i.
20/40
ant.)


Fleischman, 1885, one case: Right meuto-iliac-anterior.


Kelly, two cases : First iu 1884, a right bregmatic iliacanterior presentation; second iu 1895, left occipito-iliac-posterior presentation.
139


From the above it will be seen that the observation has
been made in face, brow and occipito-posterior presentations —
two of each. One may therefore infer that these are the most
favorable presentations for the observation of this phenome


Male.


non ; especially is this the case in face and brow presentations,
the fcetal thorax being arched forward and therefore in closer
proximity to the maternal abdominal walls. In occipito-posterior jjresentations the festal curve is directed backward and
consequently less favorable.


The liquor amnii also plays an important part, as shown by
82.  
the fact that in all cases, with the exception of the second case
of Dr. Kelly, the observation was made during labor. In this
case one must naturally suppose that a small amount of liquor
amuii was present. As for the maternal abdominal walls, they
should be thin and flabby in order that there may be little
hindrance to the transmission of the im^iulse of the foetal
heart.  


References.


American Text-Book of Obstetrics, Hirst, 1888.
Bad.  
Fischel, Prager medicinische Wochenschrift, Nos. 13, 13,
39, 30, 1881.  


Fleischman, ibid.. No. 35, 1885.
Valenta, ibid., No. 45, 1885.


(I (1




SQUAMOUS EPITHELIOMA IN A DERMOID OF THE JAW.
"


By S. M. Cone, M. D., Assistant in Surgical Pathology, Tlie Johns Hopkins University.


Escape vitreous.




Few cases of epithelioma arising in dermoid cysts have
been described. Taufier, whose article on carcinoma arising
in dermoids of the ovary is very complete, knows of none
originating in dermoids elsewhere. In none of the dissertations on dermoids of the ovary with carcinoma in their walls
do we find reference to like tumors in other regions of the
body. I can find but three cases and they are not very fully
described. That of Franke, on an epidermoid of the ball of
the thumb with carcinoma originating in it, is most complete. Czerny in 1869 reported a case in the coccygeal region,
the first to be noted anywhere, which is interesting moreover
because of the expression of the opinion that the squamous
epithelium developed from cylindrical epithelium snch as is
found in the intestinal tract, and the idea is expressed of the
possibility of epithelium arising from connective tissue and
lymph cells. Briddon reported a case before the New York
Surgical Society and Dr. Thacher made the pathological report.
This tumor was also from the coccygeal region. The sections
which were kindly given me have some resemblance to the
one I shall describe. The descriptions of those found in the
ovaries are so much better described that it is best to reach
our conclusions regarding origin and development through
the gynecological literature.


Yamagiwa and Thumim have both reported cases this year.
Thumim gives the literature on the subject up to date.
Yamagiwa reports two cases, one of which he puts down as a
glandular carcinoma developing from remains of a mammary
gland in the dermoid. Thumim objects to including this
among the dermoids with "carcinomatous degeneration" and
rather thinks it to be part of a misplaced mammary gland
forming a part of a teratoma of the ovary. ' If it is a true
carcinoma it is the only one of its kind described ; the remain


No change but 3 weeks'
vision. 20/70.


ing eight cases arising in the ovary ;ind three elsewhere are all
of the squamous cell variety.


All authors are careful to exclude the possibility of the
140
growth of the epithelioma "per contiguitatem," both Tauffer
and Thumim giving a list of doubtful cases. The analogous
origin of carcinoma iu atheromas and other cysts lined by
epithelium is mentioned by Lubarsch in his review of the
subject, and many others refer to the subject as something not
long discovered. A very interesting point is alluded to by
Yamagiwa when in writing of his first case he refers to its
resemblance to alveolar sarcoma or endothelioma. Such cases
have been reported, but are rare.


The case to be reported is that of Patrick D., age i'i, blacksmith, who entered the surgical ward of the Johns Hopkins
Hospital, June 30, 1894, with a tumor of the left lower jaw.
Family history good ; past history good.


Present Illness. — In September, 1893, the patient noticed a
Male.  
pea-sized growth under the horizontal ramus of his left lower
 
jaw. It began to pain him in November and grew rapidly
 
with incessant pain. He refers its quickened growth to a fall
34.  
when he injured the jaw.  
 
 
Good.  


Physical Examination. — The tumor extends from 1 cm. in
front of the angle to the junction of the middle and outer
third of the horizontal ramus of the lower jaw. It extends to
the hyoid bone and appears to be the size of a small orange.
It is fixed firmly, is sharply circumscribed and has smooth,
rounded borders. It is firm in consistency except at the most
prominent portion, where slight fluctuation can be felt. The
skin is cedematous and red. At one point there is a small
opening from which serum exudes on pressure. Teeth are
normal. Alveolar process is not involved.


On June 35th the patient was operated on by Dr. Halsted.  
Hard. R. E.  




Simple Ext.


OCTOBEE, 1897.J


Uncomplicated.




JOHNS HOPKINS HOSPITAL BULLETIN.  
2 weeks.  




20/40


209


141




Tracheotomy was first performed, aud the pharynx being
Female.  
tamponed the tumor and left lower jaw were excised. The
patient's recovery from the operation was uuinterrnptedly
good. He was discharged on July 13th. He returned September 6, 1894, aud was treated for phthisis pulmonalis —
tubercle bacilli beiug found in his sputum. He was discharged on September 14th unimproved and died at home of
phthisis pulmoualis. No autopsy was performed.  


Descrip/ioH of the tumor by Dr. Bloodf/ood. — The tumor is
removed with an area of skin 8x6 cm. and a piece of the lower
jaw 7 cm. long, including the angle of the jaw. This mass is
surrounded by skin, periosteum and healthy muscle at every
point except one, which is at the inner side of the jaw 3i cm.
from the angle where the tumor tissue is exposed. A second
piece of the jaw including the two molar teeth and alveolar
processes includes the remainder of the tumor, which is well
circumscribed by muscle and mucous membrane; so that,
putting the two pieces together, the entire mass is circumscribed. The point at which it is most superficial is beneath
the myo-hyo-glossus muscle at its attachment to the alveolar
process of bone which was removed.


The tumor has not invaded mucous membrane nor bone.
51.  
On section from the skin to bone it consists of an encapsulated
mass, the capsule beiug firmly adhereut to periosteum on one
hand and skin on the other. There are several points on the
skin communicating with the cyst contents and through
which the contents can be expressed. The capsule is 4-5 mm.
in thickness. The inner surface is rough and granular. The
fatty granular contents are easily removed; they resemble
those of a dermoid cyst except at the outer third of the tumor
near the symphysis of the jaw. Here the contents are firm in
consistency, greyish iu color, with pin-point dots of hemorrhage. In this tissue masses of the same consistency as that
of the cyst can be found. The tumor presents the characteristics of a dermoid cyst.  


On section of the mass within the jaw the submaxillary
gland is found to be adhereut to the capsule of the cyst. The
contents of the cyst show fatty squamous epithelium and crystals of cholesterin.


Microscopical Examination. — Sections of the cyst wall with
Good.  
adjacent structures were made at many points. The cyst
varies in thickness. The inner lining is of horny epithelium
which is more or less loose and swollen and mixed with the
cyst contents. The same cornified epithelium is found in
whorls on the surface mixed with the cyst contents. These
cells look like long flakes, some containing nuclei, others
being free of them, which stain deeply with eosin aud carbol
fuchsin. Beneath this loosely arranged epithelium we see a
denser layer aud then the gradation of epithelium as in normal
skin, only not so thick.  


The stratum grauulosum is much better marked in some
 
places than in others. The stratum mucosum comprises the
" "
main mass of epidermis; the deeper cells of the malpighian
layer are not pigmented. The cells appear swollen and oedematous. Some of the nuclei are vacuolated and irregular
while others are fragmented. In the epidermis are a few
irregular areas, about the size of the cells, which are granular
and take the hcematoxylon stain deeply — evidence of calca




reous degeneration in the cyst wall. The cell borders are not
nearly so well defined as iu normal epidermis. The papillai
are fairly well marked, but there is an entire absence of sweat
glands and hairs. A few sebaceoiis glands are to be seen iu
the corium, which is not well marked because of the invasion
of its territory by profuse round cell infiltration about epithelial projections.


These epithelial downgrowths between the papillary stroma
into the deepest parts of the cyst wall are made up of masses
of cells such as are found in the stratum mucosum and enclose
cells of the more superficial layers of epidermis. These cells
of the outer epidermal layers are sometimes formed into
whorls iu the deepest ingrowths of the squamous epithelium,
aud form the " pearly bodies."


The epithelium of these downshoots has better staining
nuclei than that on the surface. These inter-papillary
growths seem to be kept in definite paths for the most part,
but when the deepest portion of the cyst wall is reached one
can see epithelial cells spread throughout the tissue, some
being isolated without any demonstrable relation to the primary
downgrowth. This sprouting of epithelium deeply and irregularly into the wall of the dermoid is seen throughout the entire
tumor wall, but does not go any further, for it is always preceded by a zone of round cell infiltration made up of mononuclear cells. This zone is preceded by one of connective
tissue of varying thickness which invariably intervenes
between the epithelial cells and adjacent tissues and organs.
There are papillary projections into the cyst of various lengths
from 1 mm. to 2 cm. which all show a lining of epithelium
already described, and have a supporting conuective tissue
basis. Between the stratum corneumand malpighian layer are
to be seen hemorrhagic foci in some sections.


The round cell infitration is intensely marked throughout
the cyst wall. The papillary stroma aud deep layers of the
dermoid are full of mononuclear leucocytes which are aggregated in some places, resembling lymphoid nodules. These
cells have also penetrated between the epithelial cells of the
surface and ingrowths. The centres of the "pearly bodies"
contain both mono- and polyuuclear leucocytes and fragments
of nuclei. There are typical tubercles in several sections
which are most distinct in the sections containing muscle,
including the sinuses alluded to above. No tubercle bacilli
can be found iu them, however.


The lining wall of the dermoid shows evidence of degeneration in areas; the epithelium is invaded by mono- and polymorpho-nuclear leucocytes. The nuclei stain poorly and are
"
fragmented. The cells appear separated from one another and
are swollen.


Sections including skin and dermoid wall made at different
points have essentially the same appearance. The points iu
which the histology differs from the foregoing description are
the giant cell formation between subcutaneous tissue and
the fibrous limiting line of the dermoid and the openings in
the skin alluded to in the macroscopic description. The
giant cells are like the customary foreign body giant cells
and are seen singly aud in groups at the margin of the
dermoid wall. They are especially numerous on the dermoid
side of the dividing fibrous tissue. Where these are in


2 "




210
20/70




142


JOHNS HOPKINS HOSPITAL BULLETIN.


Female.




[No. 79.  
51.  




Good.


greatest number and collected in groups the fibrous separating
line has been almost completely substituted by them and the
accompanying mono- and polynuclear leucocytes. Here the
definition between dermoid and skin is not so good as elsewhere.


The giant cells in the subcutaneous tissue are grouped about
L. E.  
hair shafts ; in the dermoid walls they enclose horny particles
(stained deeply with carbol fuchsin), polynuclear leucocytes,
fragmented nuclei and granules (stained deeply with hffimatoxylon and probably calcareous). Some have no contents and
are vacuolated. Most of them contain large vesicular nuclei,
grouped in the centre of the cell ; in some the nuclei have a
polar arrangement.  


Beneath the epidermis of the skin there are masses of red
blood corpuscles, polynuclear leucocytes and fragmented
nuclei. Here no papillary arrangement of the skin exists and
the epidermis is flattened and thinned. The epidermis, too, is
infiltrated with leucocytes. Adjoining this area of hemorrhage
and necrosis a discontinuity in the epithelial covering is detected. The edges of epidermis are turned in and are continuous with a sinus which can be traced deep into the subcutaneous tissue, but not so far as the fibrous demarcation
between skin and dermoid. This sinus is lined by necrotic
tissue containing blood and fragmented nuclei. In its depths
the connective tissue of the part is denser, but there is no evidence of new formation of tissue. There is no epithelial
lining. Vessels included between the dermoid walls and
subcutaneous tissue are obliterated by endarteritis. Their
walls are all thickened.


In one of the sections there is a variation from the usual
structure of the dermoid wall. Instead of the interpapillary growths of epithelium dipping down at once into the
depths of the wall, we see a network of epithelial rods one
and two cells thick surrounded by small round cells. The
epithelial lining is very thin at this point, being composed
only of cornified epithelium. Beneath this interlacing network of cells we see the larger groups containing pearly bodies
described in the other sections.


The submaxillary gland is included in several sections of
the tumor and in none does the epithelioma invade the gland.
The capsule of the submaxillary is greatly thickened and only
at one point is there any suspicion of invasion. Here the
round cell infiltration is most marked, the connective tissue
formation not being evident. Into the round cells can be seen
jutting epithelial sprouts, but they do not enter the interlobular connective tissue of the submaxillary. The changes in the






submaxillary are due to pressure and infiltration of its connective tissue framework with small round cells. The connective tissue is thickened and some of the cells in the alveoli do
"
not take the stain well. The cyst-wall next the submaxillary
varies from 1 to 3 mm. in thickness and consists of epithelial
masses and single cells included in the stroma, which is deeply
infiltrated with small ronnd cells. The epithelial cells are of
the same kind as in the stratum mucosum, but Ijetter defined
and with more regular nuclei.


The muscle next the tumor is densely infiltrated with small
round cells and is atrophied. The nuclei of the muscle cells
next to the dermoid wall are greatly increased in number and
arranged in rows. The muscle substance stains but faintly
and there is no striation in the first rows next to the fibrous
line between tumor and muscle. It appears like a homogeneous mass containing rows and bunches of nuclei. There are
no giant cells nor necrotic areas to be seen. A nerve is included in the section with muscle. It is surrounded by dense
fibrous tissue. The epithelial cells crowd close up upon the epineurium, but do not penetrate it. The round cell infiltration
and new formation of connective tissue are very prolific about
the nerve.


The presence of tubercles in the cyst walls, the great and
2 "
uniform round cell infiltration, the profusion of giant cells of
both the foreign body and tuberculosis variety, and the uniform distribution of the epithelioma in the wall of the dermoid, are all striking points.


References.


TaufEer: Virch. Arch., No. 143. Ueber die primilr carcinomatose Degeneration von Dermoidcysteu.
20/40


Frauke : Virch. Arch., No. 131, p. 444. Carcinomatus entartetes Epidermoid des Daumenballes.


Briddon : Annals of Surgery, Aug., 1894. Not a complete description.
143


Y. Czerny: Arch. f. klin. Chir., No. 10, 1869, p. 894.
Entwickelung einesEpithelialcarcinoma aus eiuer angeboreuen
Sacralgeschwulst.


Yamagiwa: Virch. Ai-ch., No. 147, Heft i. Zwei Piille von
Female.  
Dermoidcysten des Ovariums mit carcinomatosen Degeneration und Metastasenbildung.  


Thumim: Arch. f. Gynek., liii. Ueber carcinomatose Degeneration der Eierstocksdermoide.


Lubarsch: Ergeb. der allg. Path. Morph. und Phys., Vol.
45.  
II, 1894.  




Good.


THE INFECTIOUSNESS OF CHRONIC URETHRITIS.


R. E.




By E. R. Owings, M. D., Assisianf in Genito- Urinary Surgery, The Johns Hopkins Hospital Dispensary.






The possibility of infection from old cases of gonorrhoea is
an important and by no means infrequent problem, presenting
itself not only to the gynecologist and genito-urinary
specialist, but also to the general practitioner.


Many cases of gonorrhoea extend over mouths or even years,
"
often in spite of persistent and systematic treatment, and in




2 "
20/200
144


response to the inquiries, " Could I infect another?" or " Is
my condition such that I may safely marry ? " the physician
must often give evasive or unsatisfactory replies.


There is no fact better established than that a gonorrheal
Male.
urethritis is due to the entrance and development within
the urethra of a specific organism, the gonococcus Neisser,




58.


October, 1897.]


Good.




JOHNS HOPKINS HOSPITAL BULLETIN.
II II






211






which is constantly present in the discharge of an acute
"
gonorrhoea.


The gouococcus, first described by Neisser' in 1879, has
been isolated; a pure culture made first by Bumm,^ since by
Wertheim,* Steinschueider'' and other observers ; and a gonorrhoeal urethritis produced by the introduction of pure culture
within healthy urethra proving conclusively its etiological
relation.


The infectiousness (i. e. jrower to produce gonorrhcea)
2 "
therefore of an urethral inflaniuiation depends upon the
presence of the gonococcus; and upon the demonstration of
the presence of this organism rests the determination of the
infectiousness of an urethral inflammation.


The gonococcus is a diplococcus, J to 1 micromillimeter in
diameter, not round, but of biscuit or coffee-bean shajie, with
flattened or concave surfaces contiguous, found within the leucocyte, around, never within the nuclei, and as determined by
Roux,' if a preparation containing gonococci after being stained
with aniline stain, be placed in Gram's solution, then decolorized
by alcohol, the stain is not fixed by Gram's method, and the
gonococci may be differentiated from other organisms found
within the urethra, in that they are alone decolorized.


In 1887, Lustgarten and Mannaberg" in a series of investigations on the healthy urethra found among other organisms
20/100
a coccus which they declare cannot be distinguished from
the gonococcus Neisser by its morphology or staining reaction.


Petit and Wasserman,' on the contrary, in a large number
of examinations (over 1000) of the normal urethra, have
never found the organism described by Lustgarten, and in a
number of cases of chronic urethritis were unable to demonstrate its presence.


Steinschueider" recognized beside the gonococcus four diplococci in the urethra, two of which were decolorized by Gram's
145
method as follows :


No.


Urethra healthy, never infected by
Male.


gonococcus, 13


Urethra healthy, no gonorrhoea for
58.


years.
Chronic gonorrhoea,


Acute " (uuti-eated),
Good.


" " (under treatment), 22


L. E.




3








'<




2 "




15
20/70




2
146




11
Male.




33
61.




1
Good.




33
<i 11




22








Escape vitreous.


32


Iritis. 4 "




86
20/30,




147


66


Female.




In 86 cases there was present in four a diplococcus decolorized by Gram's method, or about 4J per cent., making Roux's
47.  
test certain in about 95 J per cent, of all cases. He believes,
however, that Roux's test, together with the characteristic
grouping of the gonococcus within the pus cell around the
nuclei, gives a definite result.  


M. von Zeissl" has in the secretion of an urethritis due to
chemical or medicinal irritants, found a diplococcus within
the pus cell, which is decolorized by Gram's method ; whether
this is readily differentiated by grouping from the gonococcus
he does not state.


Wendt" believes " Roux's color test never fails to gives correct interpretation."
Good.  




R. E.


Allen," who worked conjointly with Wendt, believes "Roux's
test final."


Carpenter'" says : " Peculiar characteristics of the gonococcus almost positively diagnostic when confirmed by Roux's
test practically leaves no room for doubt."


Heiman '" says : " Diplococci found in normal urethra can
be positively differentiated by Gram's stain."


Koplik-' says: "In skilled and tutored hands a mistake of
identity is not possible."


Finger" says : " There is no doubt that in addition to gonococci other organisms are present in blenorrhagic pus, but
these never give rise to the slightest diagnostic doubt. The
number of foreign organisms is so slight, and they are found
to such a large exteut outside the pus cells, their shape and
grouping are so different, that the differences in staining are
unnecessary to make a positive differential diagnosis."


Lustgarten", 1893, says: "If in a chronic torpid urethritis
Uncomplicated.  
with a scanty whitish or greyish discharge, diplococci with
all the characteristics of the gonococcus are found ; it does not
prove that the affection is contagious, especially if these diplococci are found in comparatively small number and are
accompanied by a variety of organisms. As far as personal
experience goes I believe that many of these cases are not
contagious and that the wives of such men remain healthy and
prolific."


In the absence of confirmatory proof by cultivation, which
is not always practicable owing to the difficulty attending the
growth of the gonococcus, ordinary media being unsuitable
for its growth, and as in chronic urethritis where its demonstration is especially desirable the jiresence of other organisms
by their rapid growth makes it impossible to secure discrete
colonies of the organism, we are compelled in these cases to
rely solely upon its morphology and Roux's test for identification. By these methods the gonococcus may be differentiated from micro-organisms found within the urethra, with the
possible excejition of the diplococcus described by Lustgarten,
which at most is present in but a small per cent, of cases.
The presence, in the secretion of an urethral inflammation, of
a diplococcus with the characteristics and color reaction of
the gonococcus is sufficient clinical though not medico-legal
evidence of the infectiousness of same.


The examinations recorded in the paper were confined to
2 "  
chronic cases entirely. In many there was no discharge
visible at the meatus, and in no case was there more than the
"goutte militaire." Their duration varied from three months
to four years. The majority were under active treatment at
the Johns Hopkins Hospital Dispensary, and so far as was
possible examinations were made on date of first visit and
subsequently at short intervals. Unfortunately, as in all
dispensaries, many failed to return after one or two visits,
making it impossible in these instances to secure repeated
examinations. The examinations recorded are of the tripperfilden, as in many of the cases this was the only material
available.


The method pursued was as follows : The urine, and where
possible the morning urine, was secured, one or two trijjperfilden were drawn uj) with a pipette and after being gently
teazed-out on a slide, were dried over a flame and then washed  carefully in warm water to dissolve out as far as possible
salts of urine which were precipitated by evaporation. Specimens thus obtained were stained two minutes in aniline
gentian violet solution, prepared by adding 1 cc. filtered concentrated solution to 15 cc. water.


In decolorizing the slides were placed in Gram's solution for
20/40
2 minutes, then in alcohol until no more blue color was
extracted, generally from two to three minutes. A watery
solution of Bismarck brown was used as counter stain.


In 15 instances no micro-organisms were found; in these
cases the fiiden consisted almost entirely of epithelial cells
with here and there a few leucocytes.


In the 35 remaining micro-organisms were fou nd ; these were
148
identical with varieties already described by Lustgarten and
other observers, and consisted of 4 varieties of cocci and !<!
bacilli, as follows :


I. Small coccus in zoogleae.


II. Small coccus in chains.  
Female.  


III. Diplococcus about size of gonococcus.


IV. Large coccus, li to 3 mm. in diameter, generally in
60.  
pairs.  


V. Long slender bacillus (smegma bacillus?).


VI. Short thick bacillus with rounded ends (suggestive of
Good.  
colon bacillus).  


These were not all present in every specimen examined, nor
did they occur in equal frequency. I, small coccus in zoogleffi,
and IV, large coccus, IJ to 2 mm. in diameter, were almost
constantly present, while the smegma bacillus ? was noted in
comparatively few instances, and VI, bacillus, short, with
rounded ends, in one case only.


In five specimens examined, in addition to one or more of
II 1.  
the varieties already described, diplococci were seen lying
within leucocyte, morphologically identical with the gonococcus and decolorized by Gram's method.  


These were the only organisms seen within the leucocytes.
Others were either free in the intercellular space, lying on
epithelial cells or on, not within, leucocytes, as could be determined by careful focusing.


In 5 cases then we have an organism which could be positively identified as the gonococcus Neisser.


Three of these 5 cases were of from 4 to 6 months' duration,
1 was of 9 months' and 1 of 2 years' duration, or, tabulating
cases as regards age of disease —






13
"




2 "


6
50


Not tested.




Duration. Gonococei.
149


Under 6 months. 3


6 to 9 " 1
Female.


1 year.


2 " 1
50.


3 ■'
over 3 years


Good.




other
w L.E.


mlcro
org:anisms.






35




"


Negative


as to
2 "
organisms.


4
3
2
3
2
1


15
11 11




150


Out of 38 cases of more than 6 months' duration, in 2
instances only were gonococei demonstrated, and in 30 of more
than a year's duration, in one case only could they be fou-nd.


Male.




Goll" in 1891 made repeated examinations of cases of
60.
chronic urethritis with the following results :
 


Good.




Durati(jn.


6 months


1 year


2 "


3 "


Over 3 years


"




No. of
2 "
cases.


55
83
135
80
59


412
20/40




151


Gonococei.


Male.




12
55.


7


Good.




29
II •!






cocci. Percent.


47 14


71 14


128 5
"


78 25


59
2 "


383


20/70




Petit and Wasserman' in their examination of chronic urethritis found various organisms, and believe them to be accidental or saprophytic, and that they vary with the individual.
152


Janet'-' has studied cases of chronic urethritis with respect
to various organisms present, and divides them into three
classes :


I. Gonococei present alone.  
Male.  


II. Gonococei and other micro-organisms.


III. No gonococei, but varied micro-organisms.  
44.  


He believes that these organisms invade the urethra, probably in coitus, and the catarrhal mucous membrane presenting
a favorable medium, they are able to keep up the inflammatory
process after the disappearance of the gonococcus, producing
an obstinate pseudo-gonorrhoea.


Hasse," 1893, "in 625 cases of chronic urethritis found
Good.  
gonococei unattended by other organisms in 37 cases. In
acute gonorrhoea he found gonococei alone and their presence constant; with their disappearance and an increase in the
epithelial cells in the discharge, other bacteria, both bacilli
and cocci, appeared in large numbers."


In the small percentage of cases where the gonococcus is
definitely determined to be present, we can without hesitation
declare their infectiousness. Unfortunately, however, in the
large majority we are unable to say with certainty that we
have to do with a non-infectious malady, that is. in those
where the gonococei are uniformly absent or present in so
few numbers as to elude detection. For while the detection of
the gonococcus renders infectiousness certain, a failure to
detect it does not guarantee its absence, as often after many
negative examinations the gonococei may suddenly appear in
considerable numbers.


In one of the above recorded cases, that of 2 years' duration, the examination of which extended over several months,
" "
after 3 or 4 negative examinations, following an injection
of 3 to 5 per cent, of AgNOs, with Tommasoli syringe, the gonococei could readily be detected.


In these cases then where there is still doubt, the test first
proposed and still insisted upon by Neisser" is an invaluable
adjunct, viz. the injection within the urethra of a solution of argent, nitrat. or hydrarg. chlor. corrosive, sufficiently strong to produce an inflammation with free purulent
discharge, when, if the gonococei have been present but have
escaped detection, they will be found in the discharge in
sufficient number to make1,heir identification positive, and at
the same time with the desquamation of the epithelium the
accidental micro-organisms are removed to a large extent.






October, 1897.]




"


JOHNS HOPKINS HOSPITAL BULLETIN.


2 "




213
20/70




153


Finger" "only permits marital intercourse after frequent
examinations of the secretion or tripperfiklen show an absence
of pus cells; and the discharge following the application of
Neisser's test contains no gonococci."


Morel Lavallee'" says:
Male.


I. " The gonococcus may rest latent for months or even
years in the urethra.


II. It is impossible to permit marriage in a man that has
48.  
the slightest discharge until by Neisser's test it has been
proved free of organisms."


It is reasonably certain that the gonococci suffer enfeeblement during their stay in the urethra. This attenuation is
due probably to alteration of medium, viz. the urethral
mucous membrane, consequent upon growth of organism. In
this way we can readily account for their presence without
resultant inflammatory reaction. A localized chronic urethritis does not, however, confer any immunity from fresh
infection. Finger" has produced in four instances an acute
gonorrhoea on patients with chronic urethritis by inoculation with pure culture of gonococcus.


He believes that the gonococcus is attenuated by long
Good.  
residence in the urethra, and that women infected by their
husbands who suffer from chronic gonorrhoea have a urethritis which runs a chronic course.  


Jamain'" believes " that the gonococcus becomes attenuated,
but that in contact with a healthy mucous membrane in
another individual it is rejuvenated and produces an acute
gonorrhoea."


The secretion in cases of chronic urethritis being small as
U II
compared to an acute one, so small in many cases that it
 
appears in the urine only as tripperfiklen, it follows that after
being washed off by the urine, it requires some time for
regeneration. (Hence arises the importance of examining the
first urine passed after an interval of several hours, 23referably
the morning urine, for if the patient has urinated within an
hour or two the urine may be free from shreds.) So that a
single act of coitus with an individual suffering from chronic
urethritis and with a secretion bearing gonococci does not
always produce infection.


Since we can only demonstrate the presence of the gonococcus in a small percentage of cases of chronic urethritis
(in 37 of 625 reported by Hasse, or 6 per cent.; in 21 of 357
reported by Goll, of a duration of a year or more, or 6 per
cent.; in 2 of 38, of same duration, reported in this paper, or
5J per cent.), and since when present they are, as compared
to an acute gonorrhoea, few in number, often only demonstrated after frequent, careful and repeated examination, and
since they are from attenuation probably less virulent, we
must conclude that:


I. In many cases of chronic urethritis we are unable to
demonstrate the presence of the gonococcus ; these cases are
probably non-infectious.


II. In any case the possibility of infection as compared to
an acute urethritis is small.


III. An urethritis due to an attenuated organism, and consequently modified in intensity, may be contracted from a
chronic urethritis. Conversely:


"




IV. Several negative examinations of the secretion from a
2 "
chronic urethritis do not prove its non-infectiousness.
 


V. The infectiousness or non-infectiousness of a chronic
20/40
urethritis can only be determined by frequent and careful
examinatious of the secretion, and if these prove negative, by
the non-appearance of the gonococcus after the application of
Neisser's test.


Bibliography.


1. Neisser: Oentralblatt f. d. med. Wissenschaft, 1879.
154


2. Bumm : Gonococcus Neisser. Wiesbaden, 1887.


3. Wertheim: Archiv. f. Gynakol., 1892.  
Male.  


■1. Steinschneider : Berlin klin. Wochensch., 1893.


5. Koux : Archives gen. de Medecine, 1886.  
51.  


6. Lustgarteu and Mannaberg: Vierteljahresschrift f.
Derm, und Syph., 1887.


7. Petit and Wasserman : Annales des maladies des (frg.
Good.  
genito-urin., June, 1891.  


8. Steinschneider: Berlin klin. Wochensch., June, 1890.


9. Wendt: Medical News, Phil., 1887.  
!'i ^;.^


10. Carpenter: University Med. Magazine, Dec, 1892.


11. Finger: Blenorrhoea v. d. Sex. Organ. Leipzig and
Wien, 1893.


12. Lustgarten : Etiology of Gonorrhoea. (Morrow's System,
Cutaneous and Genito-Urinary Diseases )


13. Goll: Internat. Centralblatt fiir die Phys. u. Path, der
Ham i;nd Sex. Organe, 1891.


14. Hasse: Inaug. Dissertation, Strassburg, 1893.
"


15. Morel Laval lee : Annales des mal. des org. genito-urin ,
Dec, 1893.


16. Jamain : Annales des mal. des org. genito-urin., Nov.,
2 "
1894.


17. Allen : Journal of Cutaneous and Genito-Urinary Dis.,
1887.


18. M. vonZeissl: Die acuten Krankheiten der miinnlichen
20/70
Hai-nrohre. Leipzig, 1894.


19. Neisser: Deut. Med. Wocheuschrift, 1893.


30. Heiman : ]\Iedical Kecord, June, 1895; Archiv fiir
1.55
Dermatologie uiid Syphilis, 1896, Vol. 34.  


21. Koplik : Journal of Cutaneous and Genito Urinary Dis.,
1893.


22. Annales des mal. des org. genito-urin. Aout-Juin,
Male.  
1892.  


THE JOHNS HOPKINS HOSPITAL BULLETIN,


Volume VIII.  
62.  


The Bulletin of the Johns Hopklus Hospital entered upon Its eighth volume
January 1, 1897. It contains original communlcatJous relating to medical, surgical and gynecological topics, reports of dispensary practice, reports from the
pathological, anatomical, physlologlco-chemicai, pharmacological and clinical
laboratories, abstracts of papers read before, and of discussions in the various
societies connected with the Hospital, reports of lectures and other matters of
general Interest In the work of the Johns Hopkins Hospital and the Johns Hopkins
Medical School.


The subscription price Is $1.00 per year. Volume VII, bound la cloth $1.50.  
Good.  






THE MALARIAL FEVERS OF BALTIMORE.


An Analysis of 6l6 cases of Malarial Fever, with Special Reference to the


Relations existing between different Types of Haematozoa


and different Types of Fever.


By William Sidney Thayee, M. D., and John Hewetson, M. D.,


A8»l8ta7its iti the Medical Clinic of The Johns Hopkins Eospital.
"
SIR p.-i^es, (|iiHr«a. wild plate and charts, rrlre $3.' O. Pnslngr paid.


[KoriniriK- part of The Johns Hopltinx Hnxpital Hcparts, Vol, V, 18U.5.]
Orders should Ije addressed to TiiK Johns Hopkins Press, Ualtimore, Md.


2 "




214
20/70




1.56


JOHNS HOPKINS HOSPITAL BULLETIN.


Female.




[\o. 79.  
59.  




Good.


THE IMPORTANCE OF EMPLOYING PURE SALTS IN THE PREPARATION OF THE SCHOTT BATH.


The reason the carbonic acid is given off when bicarbonate
II II
of soda and hydrochloric acid are combined is because the
 
hydrochloric acid has a greater affinity for the sodium than
has the carbonic acid; the latter is, therefore, displaced,
appearing as carbonic acid gas and the salt sodium chloride
resulting.


The following would be the formula for this reaction:






Editor of Johns Hopkins Hospital Bulletin.


Dear Sir: I am lately in receipt of the following letter from
"
a physician in the West. I submit to you the letter and my
reply in full for publication, if you see fit, as I trust by so
doing a similar mistake maybe averted.


I am very truly,


G. N. B. Camac.
2 "
[communication.]
Dr. C. N. B. Camac, Johns Hopkins Hospital, Baltimore, Md.


Dear Doctor: — The instructions contained in your article in
the May issue of the Johns Hopkins Hospital Bulletin on
the Schott treatment of heart disease have recently been followed by me in a case of hypertrophy with organic lesions.


We nearly had a disastrous result owing to an evident error
20/100
in those instructions.


Bath V calls for sodium bicarb. 1 lb., HCl 1 lb. Bath VI
increases the HCl to 3 lbs., but leaves the sodium bicarb, still
at 1 lb., thereby producing an excess of 1 lb. of HCl which is
not provided for.


I gave the journal to the hospital druggist with instructions
157
to prepare each bath in order in accordance with the directions, paying no thought to chemical results. When bath VI
was given the patient was attended by only one nurse, while
usually two or three had been present. She noticed the
chlorine gas rising from the tub, but supposed it was all right
and put the patient in. He had no sooner stepped in than he
was nearly suffocated and was quickly assisted out without
harm.


The nurse seemed seriously prostrated for a time with a very
severe bronchitis and laryngitis and the hospital attendants
had a lively time to relieve her.


I relate these circumstances in order to call your attention
Female.  
to a mistake that must have been made in the article in question.  


The patient has been rather worse during the course of
baths, but that may be due to the progress of the disease,
which is serious. As it takes more than one swallow to make
a summer, I cannot pass an opinion on the method of treatment. Very truly yours,


Baltimore, Md., Sept. 4, 1897.  
71.  


Dear Doctor: — I am indebted to you for your communication in reference to the Schott treatment.


We have had no experience similar to yours in using bath
Good.  
No. VI, which I may say is seldom called for. Chemically,
the results which you had seem an impossibility, no matter
how excessive the amount of hydrochloric acid may be. Suppose, for exampje, we take a formula expressing an excess of
hydrochloric acid as follows :


NaHCO=-f5HCl=NaCl-fH«0 + CO;-t-4HCl.


The other two salts, sodium-chloride and calcium-chloride,
L. E.  
are already in solution, and being bases in combination with
the acid hydrochloric, remain chemically unchanged.  






NaHOCOi + HCl = NaCl -I- IhO + C0=.


I can only account for your unhappy accident by supposing
that one of two mistakes was made :


1st. Your druggist may have given you sulphuric or nitric
acid instead of hydrochloric, both of which acids have a
greater affinity for the bases sodium and calcium than has
liydrochloric acid, and which would have combined with
these to form sulphates or nitrates, free HCl being formed.
(Formula see below. Experiment No. 3.)


2d. The calcium chloride (which is the more likely to have
'•
occurred) may have been adulterated with chloride of lime, or
indeed chloride of lime may have been given to you instead of
calcium chloride. This hypochlorite of calcium being the
ordinary bleaching powder and much cheaper than the pure
salt calcium chloride, forms a ready salt for adulteration,
which in the presence of only a small amount of hydrochloric
acid yields chlorine gas and would be, I can readily understand, not only dangerous to a heart case but even seriously
injurious to a healthy individual. (Formula see below. Experiments 4 and 5.)


Actuated by your letter I made the following experiments:


1st. Bath No. 6 with the amounts of constituents as
2 "
directed in my pamphlet from which you quote. Eesult:
Abundance of carbonic acid gas. No unj)leasant effects.


2d. The same amount of constituents with excess of
hydrochloric acid. Result: Same as experiment No. 1.
(Nos. 1 and 2 performed in bath tub.)


3d. Small amount of sodium chloride, calcium chloride,
20/70
and bicarbonate of soda and sulphuric acid (experiment performed in beaker glass). Kesult: Stifling odor;- no fumes
visible. This "stifling" odor was probably due to the HCl
forming.


4th. Salts, sodium chloride, calcium hypochlorite (bleaching powder), bicarbonate of soda, dilute hydrochloric acid.
Result: Chlorine given off; suffocating; beaker had to be
placed under the hood.


5th. Sodium chloride, calcium hypochlorite bicarb, soda
1.58
and sulphuric acid. Result : More pronounced than in experiment No. IV.  


Allow me to thauk you for your communication, which I
consider of sufficient importance to publish in order that a
like so serious mistake may not again be made.
Very truly yours,


C. N. B. Camac.  
Female.  


Formula:


Experiment No. 1. Same as formula given at beginning of
73.  


letter.


Good.




OCTOBEK, 1807.]
<" B;E.  






JOHNS HOPKINS HOSPITAL BULLETIN.






215
"




2 "


Experiment No. 3. (Same as foruuihi given at beginning of
letter.


Experiment No. 3. 2NaCl + CaCL + 2NaH003 + 3H.S04 =
20/40
3Na.S0. + CaSO^ + 3H=0 + 2C0= + 4HC1.
 
 
159


Experiment No. 4. Ca(CIO). ■t-4HCl = CaCl. + 2HvO + 20L.


Male.




Experiment No. 5. L'u(,C10> + CaCh + 2ll.:SOi=3CaS04 +
47.  
31LO + 20k


Note. — I have not included iu these hist two formulfe — tlie
NaCl, as it would have no effect upon the reaction — neither is
the NallCOjincluded, as 00= would be evolved as already noted.


Good.




PROCEEDINGS OF SOCIETIES






TIIE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.


Meeting of Monday, May 17, 1897.
Dr. Flexner in the Chair.


Denionstratioii of a Case. Probable Brain Tumor. — Dr.


Thomas.
"


The patient whom I wish to present to the Society will he
brought from the ward in a few moments. She is a young,
unmarried woman of twenty-six, with a good family history,
except that one brother is believed to have tuberculosis. She
has been a fairly strong girl, and has had no serious illness of
any kind. Her occupation is that of a sewing woman, and
she has been learning stenography and type-writing.


About a year ago she had an attack of unconsciousness ;
2 "  
this began with a painful contraction of the right hand,
which lasted for a minute or two, and passed up the arm,
when she became unconscious. She was found about half an
hour afterwards by her brother, who shook lier and brought
her to herself. After this attack she was comparatively well,
and went to her employment the next day as usual. In
August of last year she was under a great deal of nervous
strain on account of the death of a relative. About this time
she had several nervous attacks, which she calls " nervous
chills," and which seem to have been hysterical. Ou November 8, 1896, while sitting with her arm resting ou the table,
she became conscious of a sensation of numbness in the elbow
of her right arm. This arm and the leg on the same side
became suddenly powerless, and she has been told that her
face was drawn to the left, but of this she was not conscious.
With the onset of this paralysis she became absolutely unable
to speak. She was put to bed, and showed so much nervousness that the attending physician, a very competent man,
made the diagnosis of hysteria, and it was impressed upon
her that she could, if she would, get up and walk and talk.
The description which she gives of the loss of speech is
remarkably distinct and clear. She says that she understood
everything that was said to her, and remembers much of it.
She knew every one who came into the room, but was absolutely unable to say a word. She thinks that she knew what
she wanted to say, but had forgotten how to say it. She
I tried to write with the left hand, but could not foi-m the
letters and had forgotten how to spell the words. Upon
making the attempt to read, after she had been sick about
four days, she was unable to make anything of it, and three
weeks afterwards she could not read the paper easily. After
a week of complete speechlessness, during which every one
arouud her had endeavored to make her talk, she was able to




20/30


repeat the first four words of a text of scripture which had
been said to her over and over again. By being taught day
by day, her speech gradually improved; the first words that
she said voluntarily were "go out." These she said to her
sister, who had been sitting with her constantly for a good
many days. She knew all the time just what she wanted to
say, but it was only after a good deal of silent practice, and
several attempts, that she was able to utter the two words.
Her speech improved slowly, but steadily, until she regained
the speech which she now has, which shows no defect.


The first of last December she had another attack, and
IGO
another on the twelfth of February, and still another on the
3Gth of April. These attacks have all been of the same
character, beginning with a painful contraction of the fingers
of the right hand ; this passes up the arm, and she describes
an intense pain iu her liead. At this time she says that she
loses all knowledge that the arm belongs to herself, although
she still exjieriences pain in it. This is a remarkable statement. Iu these three attacks, consciousness seems not to
have been lost.


As the patient enters the room, you will notice that she
walks with a slight limp, and that the right hand is held iu
the manner so characteristic of hemiplegia. I have been
unable to find the slightest disturbance of her speech. She
now speaks voluntarily, without difficulty, writes long and
short hand, understands everything that is said to her, and
reads with ease. The ophthalmoscopic examination showed
that the fundus was normal, although there is a slight
degree of hypersemia. She has a congenital squint and a
slight nystagmus, but other than this, no abnormality of the
cranial nerves. Her chief disability is in regard to her right
arm, which, as you see, is very tremulous and nearly useless.
She is unable to oppose the thumb to the little finger, and the
movements of the finger are very weak. The movements at
the wrist are better retained, and those at the elbow and
shoulder better still. The movement of outward rotation of
the arm is very weak indeed, whereas the inward rotation is
comparatively strong. The deep reflexes are markedly exago-erated, percussion on any of the tendons causing active
muscular contraction, and there is a well-marked wrist clonus.
Objectively, there is not much muscular weakness of the
right leg. Sensation is everywhere perfectly normal. , I have
tested particularly for any abnormality of the muscular sense
of the right arm, and found that she appreciates even very
slight movements of any of the joints. There is no muscular
atrophy. The examination of the chest shows no abnormality,
and we have been unable to discover anything that indicates
a preceding specific infection (syphilitic).


Female.




216
53.




Good.


JOHNS HOPKINS HOSPITAL BULLETIN.


11 11




[No. 79.






I have been much interested in this patient, and it is surely
an unusual case. That a young woman of her age should
have been affected with a hemiplegia associated with a temporary loss of speech, and followed by recurring attacks simulating closely Jacksouian epilepsy. Is very remarkable. The
diagnosis of hysteria seems at first sight the most probable
one. Organic vascular lesions are very fare at her age, except
when they are associated with syphilis. In this case there is
nothing in the previous history or in the present condition
that suggests such a cause. The patient was at the onset
undoubtedly very hysterical, and you will remember that she
gave the history of preceding hysterical attacks, all of which
speak for the diagnosis of hysteria ; but the condition in
which you have seen the patient suggests an organic paralysis
more than an hysterical one. Maun and other observers have
studied the distribution of the paralysis due to organic brain
disease, and have determined that there are certain movements which are most apt to be paralysed. The movements
which are most often jjaralysed are those of the thumb, and
next in order of importance is the outward rotation of the
arm. In the case before you, these are just the muscles which
are paralysed. The excessive increase of the deep reflexes,
which is ijresent in this case, is also unusual in association
with hysterical paralysis, so I think we are justified in stating that the character of the pai'alysis is that due to an
organic brain lesiou, rather than to hysteria. The character
of the convulsive attacks also points to an organic lesion, as
true Jacksonian attacks are, as far as my knowledge goes,
extremely rare in hysteria. Although I am not very positive
about it, still I believe that we have a definite disease of the
brain in this ease, and I am inclined to think that this
disease is a slow-growing tumor. I have been led to this
belief from an experience which we have lately had. Some
of you will remember that I reported to this Society last fall
the clinical history of a case upon which we had advised
operation. The case was that of a man who, for six years,
had had recurring attacks of Jacksonian epilepsy, beginning in
his right foot, and which had later involved the right arm
and face, and in whom there had developed paralysis of the
leg, and of the arm. There were none of the general symptoms of brain tumor, and the operation revealed nothing
abnormal; but the microscopical examination of the brain
showed a most interesting new growth of the motor region,
about which I hope Dr. Flexner will have something to say.
The case which I have presented to you to-night, although
not quite similar, will suggest this case strongly, and we fear
is of a like nature.


Note. — While in the Hospital, in the early part of June,
"
the patient had another attack. She was in the dining-room,
 
talking with some friends, when the fingers of her right hand
 
became stiff and painful. This extended up the arm, the
2 "
hand and arm drew up, her head was drawn to the right side,
and there was intense pain in her head. She then lost consciousness. Those who were about her say that her eyes were
turned to the right and that her right leg was stiffened out,
and that she fell to the floor. When she became conscious, in
about five minutes, she could not talk for a few moments, and
felt weak and badly, but was not hysterical.




Not tested.


Demonstration of Specimens.— By De. Ccllen.


Several weeks ago at a meeting of this Society, Dr. Kelly
161
spoke at length on the operative treatment of myomata and
pointed out tiie ease with which these growths could be
removed. Since that time I have operated upon two patients
where the conditions present rendered the enucleation very
diflicult. Both of these cases present so many clinical points
of interest that we may proiitably discuss them for a few
moments.


Case 1. Umbilical hernia; multinodular myomatous icterus;
large ovarian abscess communicating with the small intestine;
hysterectomy.


K. L., aet. 40. Admitted to Dr. Kelly's service March 23,
Female.  
1897. Complaint, abdominal tumor, pains in the lower right
abdomen and leg. She had been married 20 years, but gave no
history of pregnancy. Menses began at 13 years, and were
regular until August 15, 1896, when they ceased fori months,
since which time they reappeared. Flow moderate, at times
clotted; occasionally it is painful.  


Family history negative.


Previous history unimportant.  
62.  


Present condition. Ten years ago she noticed a tumor about
the size of an Qgg in the right side of the pelvis. This has
steadily increased in size and has been almost constantly associated with a gnawing pain over its most prominent part.
The pain has been so severe that she has at times been confined to bed, on one occasion for 3 months. The last attack
was 3 months ago. Locomotion very difficult on account of
pain in the legs. These are at times swollen and pit on pressure. No chills. No fever. The patient is well nourished,
has a good appetite, bowels constipated. For the last two
years she has had night sweats regularly.


The abdomen is much distended and presents an irregular
Good.  
lobulated appearance. At the umbilicus is a hernial sac
fully 9 cm. in diameter. The skin over this can be drawn out
for a distance of 6 cm., while the hernial ring whose margins are
very sharply defined is 3 cm. in diameter. The following are
the abdominal measurements : Distance from symphysis to
umbilicus 1-1 cm.; from umbilicus to xyphoid 29 cm.; circumference at most prominent part of tumor 126 cm.; midway
between umbilicus and xyphoid process 96 cm. Examination
occasioned little pain.  


Operation March 24, 1897. On account of the irregular
hernial protrusion the abdominal incision was commenced at
a point midway between the xyphoid cartilage and the umbilicus and continued downward to within a short distance of the
pubes, the hernial sac being encircled and removed. At the
umbilicus the omentum which was firmly adherent was ligated
and then freed. Presenting at the incision were several subperitoneal myomata ; to these the omentum was also firmly
adherent. After loosening up these adhesions, the nodular
myomatous uterus, 28x21 cm., was delivered. (See the accompanying figure.)


Occupying the posterior part of the pelvic cavity was an
II <I
elastic tumor 17 cm. in diameter ; this looked like an ovarian
cyst and was intinuitely adherent to two loops of snnill intestine. On attempting to shell off the outer layers of the cyst






October, 1897.]






JOHNS HOPKINS HOSPITAL BULLETIN.
"




2 "


217


20/80




leaving them attached to the intestines, the cyst ruptured and
162
was found to contain about 900 cc. of greyish foetid pus. A
 
glass trocar was introduced and the pus evacuated. The
 
uterus was then removed in the usual way from left to right,
Female.  
but the left tube and ovary were left in situ. After bringing
the cervical stump together the ovarian abscess was freed and
the vessels at its pedicle controlled by silk ligatures. It was
necessary, however, to leave a small part of the sac attached to
the intestines, and on careful examination an opening 1 cm.
in diameter was found between the intestine and the abscess
sac. The margins of the intestinal opening were almost as
dense as cartilage and at the same time very friable. After a
good deal of dissection it was possible to turn the edges in and
the opening was closed by fine silk sutures. This now was
supported by a second and a third row.  




50.




A longitudinal section of the abdomen, showing from above downward the large multinodular mj-omatoug uterus, to the upper and anterior
Good.  
surface of which the omentum is adherent, an umbilical hernia to whose
ring the omentum has become adherent, a pus tube and an unusually
large ovarian abscess which communicates with a loop of small intestine.
The abscess wastoore on the right side of the body, but has been drawn
on the same level to bring it out more clearly.  


During the entire operation, which lasted 5 hours, the
patient did not lose 3 oz. of blood. The abdomen was thoroughly cleansed with two litres of salt solution, the pelvic
peritoneum drawn over the cervical stump and the abdomen
closed without drainage.


On the eighth day the temperature rose to 100.8° and about
II II
the "^Oth day reached 101°. At that time there was consider




able pain in the left iliac fossa and an indefinite thickening
could be made out, but from this time on she rapidly recovered and was discharged May 4th feeling comparatively well.
From this case we may learn that where there is an umbilical hernia or adhesions are suspected it is well to begin the
incision at a point above this; the finger can then be introduced
into the abdomen to act as a guide. The presence of the
ovarian abscess is very readily explained. There has evidently
been an ovarian cyst. With the increase in size of the myoma
the cyst has been firmly pressed against the intestines, adhesions have formed, and as continuous pressure promotes
absorption, the walls have gradually atrophied until an opening has formed between the two. Attention may also be
drawn to the fact that no drainage was emj^loyed.


Case 2. Large tnyomatous uterus extending out laterally
betiveen folds of broad ligament; complete hysterectoiny necessary
as no cervix was left; danger of injuring the ureters.


M. F., aet. 40, admitted to Dr. Kelly's service March 29,
1897. Complaint, an abdominal tumor. Menstrual history
somewhat indefinite, but the periods were regular until two
years ago, since which time the patient has had a continuous
bitt not excessive bloody discharge.


Family History. Mother's family showed a decided tuberculous tendency.


Present Condition. She first noticed abdoaiinal enlargement during the summer of 1896. It has steadily increased
Iritis.  
since then and showed more advancement on the left than
right side. During the last four years she has had on an average one profuse uterine hemorrhage each year; the last was
one week before admission and continued three days. For one
year there has been marked but not constant pain in the lower
abdomen. Micturition frequent. No history of chills or
fever.  


Abdominal Examination. The abdomen is the size of a full
term pregnancy, the greatest prominence is to the left of the
umbilicus. Just below the umbilicus in the mid-line is a hard
flattened area 8 cm. broad, to the right of which is a second
nodule. From the character and consistence of the nodules
one instantly suspects myomata.


Measurements. Distance from symphysis pubes to umbilicus 24 cm.; from umbilicus to xyphoid process 20 cm.; from
4 "
right ant. sup. spine to umbilicus 25 cm.; from left aijt. sup.
spine to umbilicus 24.5 cm., girth at umbilicus 88 cm., greatest girth which is 8 cm. below the umbilicus is 91 cm.


On vaginal examination the cervix was felt as a half-moonshaped slit directly behind the pubes, while the whole upper
part of the pelvis was filled with a hard globular mass, forming a part of that occupying the abdomen.


Operation March 31, 1897. Hysteromyomectomy. The
20/100
abdominal incision extended from a point 4 cm. above the umbilicus almost to the pubes. The myoma was delivered without difficulty, but found firmly fixed in the pelvis. Upward
it reached a point midway between the umbilicus and xyphoid
cartilage, was lobulated and laterally stretched out under the
broad ligaments. The right round ligament was tied and cut,
the vessels of the right tube and ovary were controlled and the
appendages on this side were left in situ. On the left side the




163


218


Female.




JOHNS HOPKINS HOSPITAL BULLETIN.  
.58.  




Good.


[No. 79.
 
U tl






tube aud ovary were fouud lying on the ujiper surface of the
tumor and could not be saved. After ligating and cutting the
left round ligament the folds of the broad ligament were
separated, exposing an artery 2 mm. in diameter lying on the
surface of the tumor — this was probably the ovarian artery ; it
was tied off and the bladder peritoneum freed from the tumor.
The myoma was then rolled upward and to the right, but on
the left side the uterine vessels as such could not be isolated ;
they were, however, controlled by passiug stout sutures at
their usual site.


It was now my intention to amputate at the cervix, but as
this was entirely involved by the tumor the vault of the
vagina was opened into, its upper portion being removed.
The right uterine vessels were caught by the forceps and
the tumor was freed. lu both broad ligaments were many
dilated lymph spaces. After controlling the large vessels
with silk and checking all oozing along the vaginal cut
surface with catgut the vaginal mucosa was turned down
into the vagina and the i-aw surfaces were brought together,
thus shutting off the pelvic cavity. The bladder peritoneum
was then drawn backward over the stump aud united with
that of Douglas' sac. Considerable anxiety was felt as to the
safety of the ureters, as it was necessary on account of the
vaginal vault being so widely opened to control the uterine
'vessels further out than usual. On the left side a rounded
cord was seen included in the ligature, but on unraveling this
it was found to be a fold of peritoneum. After washing out
the pelvis with two litres of salt solution the abdominal cavity
was closed. The patient made a perfect recovery and was
discharged May 3, 1897.


In this case the chief anxiety was centred around the ureters. We were loath to close the abdomen without further
examination as to their safety, but the patient's condition did
not warrant any delay. Strict orders were given to have all
the urine measured to determine if sufficient were secreted.
The amount obtained satisfied us that both kidneys were doing
their normal amount of work. Had a ureter been tied the
abdomen would have been again opened and the ureter anastomosed into the bladder.


"




NOTKS OX NEW BOOKS.
5 "


Archives of Clinical Skiagraphy. Sydney Rowland, B. A. Camb.,
Editor. Volume I, Parts I-IV. 1890-7. (The Rebman Publishing Company, Limited, London.)


A publication whose ol)ject is "to put on record in permanent
20/70
form some of the most striking ai)plicationsof the ' New Photography to the Needs of Medicine and Surgery,' is being edited by Mr.
Sydney Rowland, the special commissioner appointed by the British Medical Journal to make inquiry into the above-mentioned
applications. The Archives of Clinical Skiagraphy published its
first number iu May, 1886. Since then three more numbers have
appeared at irregular intervals. Each of them contains a series of
six collotype plates, taken from some excellent X-ray negatives, to
which a brief clinical and explanatory note is appended. Most of
the plates are of simple skeletal lesions of the extremities, illustrative of fractures, malformations and neoplasms.


There are few reproductions of .the more difficult exposures
through tlie pelvis or chest, and but cur.sory mention of attempts to


164




recognize lesions other than osseous ones, euch as intra-thoracic
Female.


aneurism, changes in the cardiac area, pulmonary affections, renal
calculi and the like. There is an excellent skiagrai)li of tubercular arthritis of the hip in No. 3 and of congenital dislocation of the
hip in No. 4, evidently in children.


In the last number (April, 1897) the scope of the publication has
78.  
been enlarged somewhat, and reijroductions of subjects other than
purely clinical ones are presented, such as of zoological specimens,
and reference is made to the possibility of taking moving shadow
pictures for cinematographic purposes.  


The life of such a publication, if devoted purely to clinical subjects, seems to come to a natural termination when its mission of
calling attention to the great usefulness of the X-rays for the diagnosis of many pathological conditions has been fulfilled.


To-day an X-ray apparatus has become an almost necessary
Bad.  
adjunct to the hospital or private armamentarium, and skiagraphs
are as much to be expected in a clinical report as ordinary photographs, and will occupy an equally important place in the forthcoming text-books on fractures, orthopsedic?, etc.  


It seems, therefore, that the value of such a periodical would be
enhanced if it aimed, as do some of the better photographic journals, towards the perfection of the ways and means of betteringthe
art of skiagraphy rather than towards the mere reproduction of its
quite familiar results.


The Archives are very handsomely published by the Rebman
L. E.  
Publishing Company. The reproductions are good. Such type,
paper and broad margins would be welcomed in many better known
and more generally useful medical magazines. H. W. C.  


Injuries and Diseases of the Ear, being Reprints of Papers on Otology. By Macleod Yearsley, F. R C. S., Fellow of the British
Laryngological, Rhinologiial and Otological Association, etc.
(1897, London: The Rebman Publishing Co., Limited, 11 Adams St.,
Strand.)


This little book is an interesting collection of monographs, and is
Iridectomy.  
not a systematic treatise on diseases of the ear. All of the articles
are interesting and suggestive. We would especially commend
" Foreign bodies in the ear and their treatment," " What not to do
in diseases of the ear," and " On the care of the ear in children."
The chapter on "Aural Reflexes" is too brief to be .satisfactory.
It is to be hoped that the author will at some future time esjtand it
into a book.  


Inebriety. Its Source, Prevention and Cure. By C. F. Palmer.


(New York: F. H. Retell Co., IS97.)
"


This short tract or sermon is not in any way a scientific discussion
of this subject, and so lacks all special value for a physician. It is
only suitable for that body of the laity who have a small amount
of scientific knowledge. The point on which the author lays most
stress is that inebriety is due to a neuropsychopathic constitution,
and that consequently it is a result of mental deformity rather than
a moral infraction, and he believes that almost all inebriety may
be traced back to a mentally or physically diseased ancestry. But
his remarks might be applied with almost as much fitness to any
other form of mental deformity as inebriety.


Medical and Surgical Report of the Presbyterian Hospital in the
7 "


City of New York. Vol. II, January, 1897.


This report compares very favorably with Volume I, and with
Closed pupil.  
more supervision in the editing would be still better. Many of the
papers published in this volume have appeared before in the New
York medical journals, which detracts from their vivid interest. For
those who have not read the journals there are good papers on
tj'phoid fever, tuberculosis, and a variety of other topics both
surgical and medical, reported at greater or lesser length. The
description of the operating pavilion as an aid in construction for
other hospitals is most valuable.  




165


October, 1897.J


Female.




JOHNS HOPKINS HOSPITAL BULLETIN.  
66.  




Good.


219


U II




Hysteria and Certain Allied Conditions. Their Nature and Treatment with Special Reference to the Application of the Best
"
Cure, Massage, Electro-therapy, Hypnotism, etc. By Geokqe J.
Prbston, M. D., Professor of the Diseases of the Nervous System,
College of Physicians and Surgeons, Baltimore, etc. 8vo, pp. 298.
(P. Bktckision, Son & Go., Philadelphia, 1897.)


Dr. Preston modestly prefaces his book with an explanatory
apology. Two reasons, he says, may perhaps be deemed of sufficient weight to warrant its appearance ; first the great importance
of hysteria, and secondly tlie lack of a recent book in English on
the subject. The book is intended for the American general practitioner. Its "object is to present the symptomatology and differential diagnosis of hysteria in as concise a manner as possible, and
to indicate the various therapeutic measures that have been found
useful in the treatment of the disorder."


The author first gives a short sketch of the history of hysteria,
Uncomplicated.  
in which special attention is given to tlie epidemics of hysteria so
common in the Middle Ages and occasionally seen since then. An
interesting account is given of the hysterical " orgies" enacted at
the religious revivals of Kentucky and Tennessee in the early part
of this century, and of the camp-meeting "trances " of the Southern negro.  


The historical account is followed by a chapter on the " Nature of
Hysteria." The etiology is considered in some detail. Sex, age,
race, climate, heredity, diathesis, education and environment, and
" reflex irritation" are discussed. In regard to " race," the author,
who has had considerable experience with hysteria in the negro,
thinks that the disorder is more frequent in that race to-day than
it was during the slavery period. Indeed, it is at present by no
means uncommon. Special stress is put upon the part that environment plays in the etiology of hysteria. The part played by " reflex
irritation " is considered undetermined. It is rare that an abnormal condition of the organs of generation gives rise to the disease,
though a morbid train of associated ideas often makes the hysterical woman refer her troubles to these parts.


The consideration of the etiology of the disease is followed by a
2 "
brief review of the many theories that have been held as to its
 
nature. The author concludes that hysteria is an affection of the
hij;her brain centres, perhaps an actual though temporary loss of
protoplasm. In bringing together his reason for this conclusion
Dr. Preston shows an acquaintance with the more recent work on
the fine anatomy of the cerebral cortex and an admirable hesitancy in making deductions from the suggestive results of the
histologists.


There follows a chapter on "Symptomatology." Hysteria is
20/70
considered as a single disease, though most protean in nature.
The symptoms of the disease are divided into the following categories: 1. Disturbances of sensation: anaesthesia, paraesthesia,
hyperaesthesia, affecting both the general sensibility and also tlie
special senses. 2. Disturbances of motion : paralysis, contracture,
tremor, convulsive seizures. 3. Vaso-motor, visceral, and nutritive disturbances. 4. Mental symptoms. 5. Miscellaneous symptoms.


The disturbances of sensation are treated with the fulness of
detail which the subject warrants. Special attention is given to
" hysterogenesis." The author feels convinced from cases of his
own that the hysterogenic zones, first described by Charcot, have a
real existence and are not the result of suggestion.


A good description is given of the various disturbances of the
166
motor-system. The author draws an interesting comparison
between the manifestations of liysteria in this country and those
in France. " 1 have often been struck," he says, " with the similarity between the cases of hysteria in negroes, who, of course,
have never been in any possible manner under the influence of
suggestion, and the so-called ' show cases' at the Salpetriere."




Female.


Under "mental symptoms" are considered the general mental
state of the hysterical patient,* hysterical insanity, lethargy, narcolepsy, catalepsy, ecstasy, somnambulism, and vigil ambulism.
Somnambulism, while not necessarily hysterical in nature, is considered to be very closely allied to hysteria on the one hand and to
hypnotism on the other.


The visceral disturbances include contracture of the oesophagus,
66.  
vomiting, hematemesis, hysterical anorexia, intestinal disturbances; affections of the genito-urinary apparatus ; disturbances of
the respiration and of the voice. Under cardiac and vaso-motor
symptoms are considered tachycardia, flushing of the face and
upper part of the body, autographism and cutaneous affections.
Nutritional disturbances include muscular atrophy and hysterical
fever. The latter, the author concludes, is a real though rare
condition.  


A third of the book is given up to a detailed consideration of the
diagnosis and treatment of hysteria. There has been an evident
and successful effort to make this clear, practical and helpful.
Under differential diagnosis emphasis is put upon the fact that
though hysteria is manifold in nature it is almost always characterized by certain stigmata, as for instance anaesthesia, which as a
rule may be clearly distinguished from similar disturbances due to
organic disease. "The central idea in the treatment of hysteria
may be expressed in the word 'suggestion.' " The physician must
have the confidence of his patient. In the general treatment of
the disease the main reliance is to be placed upon a careful regulation of the diet, the meals, rest, exercise, occupation, and habits.
Drugs are useful mainly because the patient is apt to have faith in
medicine. The treatment of special symptoms likewise depends
chiefly on suggestion. In case of severe attacks pressure on the
hysterogenic zones, ice suppositories, apomorphia, chloroform, at
times hypnotism, may help to terminate the attack.


Electricity, which has proved so valuable in the treatment of
Good.  
hysteria, owes its main effects to the power of suggestion. On the
other hand, water as a therapeutic agent has a direct marked
beneficial physiological effect in addition to its suggestive use.
For the routine treatment of hysteria the alternate warm and cold
douche is warmly recommended. Massage is chiefly applicable to
those cases of hysteria, often complicated with neurasthenia, in
which the patient cannot or will not take out-door exercise. The
Weir Mitchell Rest Cure is considered in some detail. Hypnotism,
of which the author gives a very interesting account, is considered
very valuable in some cases, though on the whole it has proved
disappointing as a therapeutic agent. Its great value is "that it
has taught us how to make our treatment of the hysterical subject
suggestive." Surgical interference is rarely necessary or of value.
The author deplores the frequency with which ovariotomy has
been done in this country merely for the relief of hysteria.  


The book as a whole is admirably fitted for the purpose for which
it was designed. The author makes no attempt at an original
treatment of hysteria. He has drawn extensively from the literature on the subject, giving references to the more important articles.
Yet he is far from being a mere compiler. He views the subject
throughout from a modest yet independent standpoint, based on
an experience with hysterical patients rendered the more valuable
by an evident deep personal interest in the subject. The style is
direct, clear, and interesting, though at times rough. The book is
illustrated by diagrams taken from Charcot and Gilles de la Tourette, and by pictures from the drawings of Richer. It is well
printed and well bound. It should prove not only most valuable
to the general practitioner, but also of interest to the specialist in
nervous diseases. C. R. B.


R. E.




» "As has been aptly put, the hysterical patient says ' I cannot,' it loolis like
"  
'I will not,' but it really is 'I cannot will.'"  




"


220


2 "




JOHNS HOPKINS HOSPITAL BULLETIN.
20/100




167


[No. 79.


Male.




THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.  
68.  




Good.


FACULTY.


11 <i




Daniel C. Gilman, LL. D., President.
"


William H. Welch, M. D., LL. D., Dean and Professor of Pathology.


Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.
Ant. C, open


WiLLiAJi OsLER, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice


of Medicine.
17 davs.  
Henry M. Hdrd, M. D., LL. D., Professor of Psychiatry.
William S. IIalsted, M. D., Professor of Surgery.
Howard A. Kelly, M. D., Professor of Gynecology and Obstetrics.
Franklin P. Mall, M. D., Professor of Anatomy.
John J. Abel, M. D., Professor of Pharmacology.
William H. Howell, Ph. D., M. D., Professor of Physiology.  


William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology.
John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine.
Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology.
William D. Booker, M. D., Clinical Professor of Diseases of Children.
John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology.
Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology.
Henry M. Thomas, M. D., Clinical Professor of Diseases of the Nervous System.
Simon Flexner, M. D., Associate Professor of Pathology.
J. Whitridge Williams, M. D., Associate Professor of Obstetrics.
Lewellys F. Barker, M. B., Associate Professor of Anatomy.


20/200




William S. Thayer, M. D., Associate Professor of Medicine.
168


John M. T. Finney, M. D., Associate Professor of Surgery.


George P. Dreyer, Ph. D., Associate in Physiology.  
Male.  


William W. Russell, M. D., Associate in Gynecology.


Henry J. Berkley, M. D., Associate in N euro- Pathology.  
28.  


J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.


T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.  
Good.  


Robert L. Randolph, M. D., Associate in Ophthalmology and Otology,


Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.  
Soft.  


Thomas B. Futcher, M. B., Associate in Medicine.


Joseph C. Bl-oodgood, M. D., Instructor in Surgery.  
S. L. Extracture.  


Thomas S. Cullen, M. B., Instructor in Gynecologj'.


Frank R. Smith, M. D., Instructor in Medicine.  
Uncomplicated.  


George W. Dobbin, M. D., Assistant in Obstetrics.


Walter Jones, Ph. D., Assistant in Physiological Chemistry.
10 "■


Adolph G. Hoen, M. D., Instructor in Photo-Micrography.


Sydney M. Cone, M. D., Assistant in Surgical Pathology.  
Not tested.  


Louis E. Livingood, M. D., Assistant in Pathology.


Ross G. Harrison, Ph. D., Instructor in Anatomy.
169


Henry Barton Jacobs, M. D., Instructor in Medicine.


Charles R. Bardeen, M. D., Assistant in Anatomy.  
Female.  




47.


GENERAL STATEMENT.


The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is
Good.  
an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from Its close affiliation with the Johns
Hopkins Hospital.  


The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the
middle of June, with short recesses at Christmas and Easter.


The course of instruction is planned for the professional education of those who have received a liberal education, as indicated by a collegiate
Hard. L. E.  
degree iu arts or science, including a reading knowledge of French and German and adequate training in those branches of science, such as physics,
chemistry and biology, which underlie the medical sciences. Men and women are admitted upon the same terms.  


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


REQUIREMENTS FOR ADMISSION.  
Simple Ext.  


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


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


3. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading
knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as Is Imparted by the regular minor
courses given in these subjects in this university.


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


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


Applicants for admission will receive blanks to be filled out relating to their previous courses of study.
20/10


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


Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the
170
beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2)
then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree In this
University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only
in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.


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


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


SPECIAL COURSES FOR GRADUATES IN MEDICINE.


Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance
80.  
upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afl'orded.
With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period
of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the
majority of those desiring to take the courses than the former one.  


The special courses of instruction for graduates in medicine are now given annually during the months of May and June. During April there is
a preliminary course in Normal Histology.


These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children,
Bad.  
Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended
to meet the requirements of practitioners of medicine, and Is almost wholly of a practical character. It includes laboratory courses, demonstrations,
beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital.  


These courses are open to those who have taken a medical degree aud who give evidence satisfactory to the several instructors that they are
prepared to profit by the opportunities here otTered. The number of students who can be accommodated In some of the practical courses Is necessarily limited. For these the places are assigned according to the date of application.


The Annual Announcement and Catalogue will be scut upon application. Inquiries should be addressed to the
R. E.  


HEGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.


Iridectomy.




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




5 "


BULLETIN
 
20/200




171


OF


Female.




THE JOHNS HOPKINS HOSPITAL.  
65.  




Good.


Vol. VIII.- No. 80.]


II 11




BALTIMORE, NOVEMBER, 1897.
"




Uncomplicated.


[Price, (5 Cents.


2 "




coisrTEisrTS.
20/70




172


PACK.


A Rare Case of Lithopedion. By J. G. Clark, M. D., - - 221
Male.  
On Tuberculosis of the (Esophagus, with the Report of a Case


of Unusual Infection. By Clahibel Coxe, M. D., - - 229


A Rare Anomaly of the Arch of the Aorta, with an Additional
88.


Muscle in the Neck. By A. B. Herrick, . . - - 234


Good.




On the Hsematozoan Infections of Birds. By W. G. MacCalLUM, M.D., - - - - - - - - - - 235
L. E.  


A Case of Cavernous Angioma (Vascular Nkvus) of the Tunica


Conjunctiva. By Dr. H. O. Reik, - - - . - 236
Simple Ext.  
Books Received, . - - 237




Prolapse iris.


A RARE CASE OF LITHOPEDION.


3 "




By J. G. Clark, M. D.
20/100




173


During the month of August, 1896, a patient suffering
with an abdominal tumor, dyspncea and pain in the lower
abdomen, was admitted to the gynecological wards of the
Johns Hopkins Hospital for treatment, and, through the
kindness of Dr. Kelly, I was given charge of the case.


The patient's history was strongly suggestive of the rupture,
Female.  
four years previous to her admission, of an extra-uterine pregnancy sac, with the extrusion of the fcetus into the abdominal
cavity, and the physical examination revealed a stony-like
mass, resembling a foetus in form, which proved at operation
to be a lithopedion.  


As the formation of a true lithopedion is of rare occurrence,
and as this was a typical case, I have thought it worthy of
publication.


History of Case.  
70.  


B. H., colored, married, age 45 years. Admitted August 8,
1896.


Chief Complaints. Pains in the lower abdomen, enlargement of the abdomen, and dyspnoea.  
Bad.  


Marital History. Married 14 years, three children, oldest
12, youngest 7 years old.


First labor difficult, attended by a midwife, who had to call
R. E.  
in a physician to remove an adherent placenta. Last two
labors easy, slight chills and fever after birth of last child.  


Menstrual History. Flow appeared first in her thirteenth
year, always regular, but accompanied by much pain in the
left side. For the last three years the flow has been regular,
lasting 4 to 5 days.


II II




Family History. Mother is insane, otherwise no history of
Iritis.  
hereditary disease.  


Present Illness. Four years ago the menstrual flow ceased
and the patient had all the symptoms of early pregnancy.


Towards the end of term her lower extremities swelled very
4 "
much, and she felt so weak and miserable that she was compelled to go to bed, where she remained itntil long after the
regular term. During the latter months of pregnancy foetal
movements were distinctly felt. About the time for her confinement she had an attack of severe pain in the left side and
felt something break. Much watery fluid was passed by the
vagina.


At the end of a week her physician was called, who told
her that she had an extra-uterine pregnancy and advised an
operation, which she declined. During the time while her
legs were oedematous she became almost blind. The size of
the abdomen has decreased slightly, but the pains in the left
side still persist, and of late have grown more severe.


General Condition. Tall, emaciated woman, tongue slightly
20/70
coated, lips and mucous membranes pale, patient seems moody
and of a despondent disposition.


Bowels constipated, at times she goes a week or ten days
without a movement.


Micturition painless. Appetite poor.
174


Examination.
Abdomen irregularly distended by a tumor which presents most prominently on the left side. It is quite hard,


Female.




222
70.




Bad.


JOHNS HOPKINS HOSPITAL BULLETIN.


L. E.




[No. 80.  
Iridectomy.  




Uncomplicated.


only slightly movable, and is apparently connected by adhesions with the anterior and lateral abdominal walls.


The tumor lies in an obliqne position within the abdomen,
2 "
the upper extremity is felt beneath the left lower rib, the
lower extremity being crowded down into the right inguinal
regiou.


The general surface of the tumor is smooth, but numerous
hard projections are felt over it, which are denser than the
main body of the tumor.


Abdomen tympanitic over right half. Immediately below
20/70
and one inch to the left of the umbilicus, where the most
resistant part of the mass is felt, the percussion note is flat.


No percussion wave.


Examination under anmsthena. Outlet relaxed, cervix in
175
axis of vagina. Uterus normal in size, in anteposition, pushed
forward against pubes by a mass posterior and above uterus.


The left tube and ovary are enlarged; nothing detected on
right side except general, ill-defined bogginess.


The main body of the tumor may be pushed away from the
Male.  
uterus, but seems to have a slender pedicle.  


The ill-defined mass in the right side, by rectal examination,
feels very boggy and is in close relationship with the hard
tumor.


Urinary Exainination. Color clear amber, slight cloudy
44.  
sediment, sp. gr. 1035, acid reaction, no sugar or albumen.
A few pus cells.  


Operation.


Operation by Dr. Clark, August 14, 1896.  
Good.  


Abdominal section for the removal of a lithopedion, double
salpingo-oophorectomy for hydrosalpinx and cystic ovary on
left side, and for the removal of the right tube and ovary,
which were converted into an ectopic gestation sac.


Complications. Adhesions between the anterior abdominal
'<! ^;.^
wall and back of foetus. Dense adhesions binding the gestation sac to the intestines. Placenta necrotic.  


Incision 10 cm. in length, revealing a mottled yellow tumor
Simple Ext.  
closely adherent to the abdominal wall.  


On releasing these adhesions and passing the hand up
beneath the left lower rib, the foetal head was felt lying in
close contact with the spleen. The left arm and shoulder
were closely adherent to the anterior abdominal wall near the
umbilicus.


In order to facilitate the delivery of the fostus the abdominal incision was enlarged to a point midway between the
"
ensiform cartilage and umbilicus.


Numerous bleeding tags of adhesions were ligated.


The foetus occupied an oblique position in the abdomen, its
3 "
chest lying in close contact with the aorta, from which it
derived a distinct pulsation impulse.


The fo?tal head was grasped and gently delivered from the
abdominal incision, after which the umbilical cord was cut
close to its placental attachment in the pelvis. On inspecting
the pelvic structures the fimbriated end of the tube was found
adherent to the ectopic sac, having been apparently torn from
the body of the Fallopian tube at the time of the primary
rupture.


The secondary or adventitious sac was situated between the
20/40
folds of the broad ligament. On the floor of the pelvis a large




176


placenta was attached. The larger portion of the sac projected up into the abdominal cavity, and was densely adherent
to the vermiform appendix, ceecum and intestine. Secondary
rupture had occurred in the superior wall of the sac, the
umbilical cord projecting through it into the abdominal
cavity.


The placenta was very friable, and on attempting to detach
Male.  
it, broke up into small bits, requiring its removal piecemeal.
The ectopic sac was dissected free from the intestine and
its attachments in the pelvis, and enucleated with the right
tube. The ovary could not be distinguished in the necrotic
mass.  


A large cystic ovary and hydrosalpinx were removed from
the left side.


Abdominal cavity irrigated with .5 litres of salt solution.
48.  
Abdomen closed with buried silver and subcutaneous cat-gut
sutures.  


Pulse at beginning of operation 120, at completion 90 beats
a minute.


Patient made an uncomplicated recovery, temperature at no
Good.  
time after operation rising above 100° F.  


Discharged 28 days after operation, well.


Db. Barnum's History of the Case.
In a private letter. Dr. Barnum, of Lancaster, Va., has given
the following account of the case :


I remember the case of Mrs. Harris very well, owing to the fact
that it is the only one of the kind ever seen by me. I was called
to see the case in October, 1S92. I found the patient weak, nervous, despondent, and at times wicha mind decidedly unbalanced.
From her and her husband, who is a colored man of intelligence
and good standing, I learned that she became pregnant the previous November. There was the usual suppression of the menses,
morning sickness, quickening, filling out of the breasts, and all of
the signs which she, as the mother of several children, recognized
as indications of the pregnant condition.


In August she was taken with perfectly normal labor pains and
Prolapse.  
the colored midwife was sent for. Neither the patient nor her
colored attendant suspected that anything was wrong until forced
to believe it by the delay in the delivery.  


At my first visit to the patient, two months later, an external
examination showed her pregnant condition.


Digital examination, however, revealed the uterus of a nonpregnant woman.
5 "


At a still later visit I was able to grasp a knee of the foetus
through the abdominal walls of the mother.


A rigid questioning of both husband and wife failed to elicit any
20/30
history of previous abnormal pregnancy or miscarriage.


As this pregnancy had not been interru))ted by any unusual
sickness, I gave it as my opinion that this was a case of abdominal
pregnancy ;.or if it at any time had been one of tubal pregnancy, the
tube must have ruptured early in the pregnancy.


At my first and at all of my subsequent visits I urged the patient
177
to go to the hospital for treatment. As she was not willing to do
this, I gave her tonics and remedies to improve her mental condition. She gradually improved, and has employed no physician, I
think, during the past year. Allow me to thank you for your
letter announcing the operation which confirmed my diagnosis.


Pathological Report.
Extra-uterine foetus removed from the abdominal cavity
four years after the rupture of the gestation sac.


Male.




November, i897.J
71.  




Good.


JOHNS HOPKINS HOSPITAL BULLETIN.


II 11




223
Iridectomy.




Uncomplicated.


Foetal measurements :


Occipito-mental diameter, 12.3 cm.
2 "


frontal " 9.3 "
Siib-occipito bregmatic diameter, 9.2 "


Bitemporal diameter, 7.9 "
Not tested.  


Biparietal " 7.9 "


Circumference of head, .30. "
178


" " shoulders, 32. "


Length of fcetus, 43. "
Female.  


Weight of fcetus, 4J lbs.


70.




Good.


The fcetus is entirely covered with a thin translucent membrane which is easily peeled off.


Only the general outlines of the face can be distinguished,
II II
the eyes, nose, mouth and ears being entirely covered in with




"


the membranous covering, through which the hair of the
fa?tus can be seen as a black mat.


Scattered throughout the foetal envelope are numerous
"
yellowish white spots composed of a fatty, saponaceous
material.


The cheeks are quite prominent, the left being much more
so than the right.


The skin covering the face and forehead is of a brownish
2 "
red color resembling burut leather, slightly mottled, and is
firm and resistant, having lost all of its pliability.


On cutting into the skin at this point the knife encounters
numerous gritty particles, but the general body of the skin is
composed of adipocere.


The occiput and a part of the parietal bones may be seen
20/100
projecting immediately beneath the membranous covering.


The parietal bones overlap the occipital, and the jagged
sutures feel like saw-teeth.


The skin covering the left side of the head is of a white,
179
bleached appearance, similar to the washerwoman's skin.


The membranous envelope, which is probably the remains
of the amnion, is closely attached to the foetus, but can be
peeled off. It is ten millimetres in thickness and has no
visible blood-vessels when held up to the light.


The arm on the right side is closely glued to the body, and
Female.  
the space between the axilla and elbow is entirely obliterated.  


The right forearm is flexed on the arm, and the fingers on
the hand.


The dorsal tendons of the hand are seen as glistening cords
61.  
beneath the mummified fcetal skin.  


The left forearm is half-way flexed upon the arm and
presents the same general appearance as the right side


The feet are flexed upon the legs, the legs upon the thighs,
Good.  
and the thighs partially upon the abdomen.  


There is a considerable accumulation of adipocere aud
calcareous matter in slightly raised plaques over the lower
extremities.


The genital organs are entirely hidden by the enveloping
L. E.  
membrane, so that it is impossible to differentiate the sex of
the foetus without further dissection. The entire posterior
aspect of the fretus is covered with glistening white organized
tags of adhesions which have connected the foetus with the
maternal tissues. On floating these adhesions out in water
thev are seen to form a thick wavy veil.  


On dissecting this layer of adhesions, loose numerous fatty
plaques are seen in the skin.


The dorsal vertebraj form a prominent ridge, aud at points
"
where the spinous processes shimmer through the translucent
skin are seen to be in a cartilaginous state.


The skin of the buttocks and the underlying fat and
gluteal muscles have undergone saponaceous change, with
here and there patches of calcareous matter sparingly interspersed through the external portions of the tissues


The umbilical cord is shrunken to about half its usual size
"
and contains many calcareous nodules.


Median incision from the neck down to and through the
symphysis pubis reveals the following condition : Superficially the body is covered with a membranous layer which can
be peeled off easily, next comes the thick brawny bacon-like


2 "




224
20/40




180


JOHNS HOPKINS HOSPITAL BULLETIN.


Female.




[No. 80.  
67.  




Good.


skin, and beneath it the brownish red muscle which contains
multiple fatty areas about the size of millet seeds.


The jjeritoneum is of a dull slate color, like that seen in an
R. E.  
old post-mortem subject.  


The intestines are collapsed, soft, pliable, and, except for
the shrinking of the tissues from absorption of the watery
elements, appear to have undergone little or no change.


The liver is of a light brownish red tint interspersed with
"
slate colored patches.


On section the liver is found to be much denser than
normal, the stroma is of a greenish brown color, with many
minute yellowish spots.


The lungs are atelectatic and have a dense fleshy feeling.
Iritis.  
The color is brownish red, resembling the color of the liver.  


On section, gritty particles are encountered with the knife.


The heart is collapsed, wrinkled, and of a dark brown color.
4 "


The spleen is small and dense.


On freeing the genital organs of the enveloping membrane
20/40
the fcetus is found to be of the male sex.


Microscojiical Examination. Lungs : the air spaces are
small and the epithelial lining is not visible, bui appears to be
changed into fatty detritus and star-shaped crystals.


The connective tissue between the air spaces is pale, opaque
181
and of a uniform homogeneous appearance, the separate connective tissue fibres not being distinguishable.


Interspersed throughout the connective tissue septa are
many star-shaj^ed crystals.


The muscular tissue of the heart still maintains its characteristic form, although undergoing marked fatty degeneration.
Female.  
No calcareous changes visible.  


The general histological structure of theliveris unchanged,
although the liver cells are undergoing fatty degeneration.


Diagnosis. Extra-uterine foetus undergoing saponaceous
66.  
mummification and calcareous changes. (Lithopedion.) The
calcareous change is limited to the enveloping membrane, skin
and lungs, the remainder of the internal organs showing only
those changes due to fatty degeneration and absorption of
their watery constituents.  


Kuchenmeister makes the following classification of the calcareous changes which may occur in an extra-uterine embryo
after its death :


Lithokelyphos, a condition in which the fcetal envelopes
Good.  
alone undergo calcareous changes, the foetus shrinking to a
mummified mass after the absorption of the amniotic fluid.  


Lithokelyphopedion, a condition in which the foetal envelopes and those parts of the fcetus which come in contact with
the membranes undergo calcareous changes.


Lithopedion, a condition in which the fcetus after its expulsion into the abdominal cavity undergoes calcareous change,
L. E.  
beginning externally in the vernix caseosa.  


Li ectopic pregnancy cases which survive the primary or secondary rupture of the gestation sac and are not subjected to
operation, the embryo may be disposed of in various ways, depending upon its age and the maternal conditions surrounding it.


Complete absorption only occurs when the embryonic tissues
Simple Ext.
are largely composed of watery elements and the bones are yet
in a cartilaginous state; it is therefore highly improbable that




Big prolapse.


an embryo more than three months old ever completely disappears in this way.


In order to arrive at an approximate idea concerning the
5 "
ability of the human peritoneum to dispose of a young extrauterine embryo when expelled into the abdominal cavity,
Leopold* made an extremely interesting experimental study
upon rabbits.


For this purpose he selected four series of pregnant animals
at different stages of pregnancy, from which he removed the
embryos by abdominal section and implanted them in the peritoneal cavity of other rabbits.


The embryos were of the following sizes : 2.-5 cm. long, 5 to 6
20/40
cm. long, 8 cm. long, and the fully matured fcetus with intact
membranes.


Some of the animals became infected and died from ])uru]ent
peritonitis.


In these cases the rate of absorption was much more rapid
182
than in those where the peritoneum remained normal.


Although the many experimental studies upon the function
of the peritoneum have demonstrated its phenomenal absorptive ability, we are hardly prepared for Leopold's statement
that when there was an accompanying peritonitis an embryo
2.5 cm. long was so completely absorbed by the end of the
second day that no further trace of it could be found ; that a
5-cm. long foetus at the end of 24 hours showed only a small
mass of bones, the epidermis and all of the internal organs
having been absorbed; that of an 8-cm. long foetus th«re
remained only a small mass of tissue consisting of the skin,
paws and nails and the shrunken internal organs and skeleton ; and finally that the fully matured fcetus with its enveloping membranes was little less rajiidly absorbed.


As the rupture of an ectopic pregnancy sac is in the majority
Male.  
of cases a sterile process, the results obtained in those experiments of Leopold in which there was no accompanying peritonitis probably more nearly indicate the approximate rate of
absorption in the human being.  


In those animals the absorption was quite as effective,
although much slower.


After a few days embryos 2.5 cm. long were very much
47.  
softened; in two instances, at the end of fourteen days they
were only the size of a lentil, after thirty-four days they I
were still smaller, and at the end of fifty-two days were either \
completely absorbed or only a small trace of them could be
found.  


From these experiments Leopold concludes that a small
embryo may be absorbed completely.


The accumulated observations upon the clinical course of
Good.  
exti-a-uterine pregnancy tend to prove that the great majority
of cases will rupture within the first two months of pregnancy,
and also that probably many accidents of this kind occur
without the patient dying from their effects or being subjected
to operation.  


The natural course, therefore, in these cases will be for the
embryo to be absorbed completely. It is only when the primary
rupture is delayed beyond the third month, or when the
embryo survives the rupture and continues to develop in an


!' •^■i'^


"


•Archiv f. Gyn., vol. XVIII, p. 53.


II




November, 1897.]
4 "




20/30


JOHNS HOPKINS HOSPITAL BULLETIN.


183




225
Female.




58.


adventitious sac until a secondary rupture occurs, that a lithopedion is likely to be formed.


In these cases the extruded embryo may lie free in the
Good.  
abdominal cavity as a non-irritant foreign body, or as is more
likely, a wall of adhesions will form about it and thus shut it
oif from the peritoneal cavity. The close proximity of these
encapsulated masses to the intestines and rectum renders them
liable to infection at any time.  


In the event of this complication extensive suppuration will
occur and the fcetus quickly becomes skeletonized, and its bones
may be discharged through a fistulous track into the rectum,
vagina, bladder, or through the abdominal wall. It is only in
the non-infected cases that mummification, saponaceous and
calcareous changes take place.


The first cases of lithopediou recorded excited the liveliest
curiosity and speculation among physicians as to their origin,
and usually the conclusion was reached that no law governed
their formation and that their origin was due to some mysterious or occult influence.


As an evidence of the views held by these earlier physicians,
we find the case referred to by Spachius prefaced by the following lines: "Deucalion cast stones behind him and thus fashioned the human race, hence comes it that nowadays the tender
flesh of babes is formed of stone."


In 1881 Kuchenmeister* reported a case in which a lithopedion had lain in the abdominal cavity of a woman 57 years.
Iridectomy.  
He carefully reviewed the literature bearing upon the subject
of lithopediou, covering the period between the report of Albosius's case in 1582 and the time of the publication of his
article in 1880.  


From the fact that a lithopedion has always been considered such a unique production it is safe to assume that
more of these cases in proportion to the number which have
actually occurred, have been reported than of almost any other
pathological anomaly, and yet from 1583 until 1880 Kuchenmeister was able to collect only 47 cases of mummified, skeletonized and calcified fcetuses, and of this number only a few
can be accepted as true lithopedions.


Many of the earlier cases were dignified by special titles,
Uncomplicated.  
such as the Lithopjedion Senoeuse, Das Ileidelberger Lithopiidion von Nebel (1767), Das Berliner Lithopildion von Walter (1775), Das Dresdener Lithopildion von Seller, Sen. (1819),
etc.  


Notwithstanding the great activity in the field of abdominal
surgery since 1880, the year of Kuchenmeister's publication,
comparatively few additional cases have been reported, a fact
which still further proves that they are of very rare occurrence. If we select those cases from Kuchenmeister's review
which represent a definite epoch or interesting fact in the
history of this subject, we find that Albosius's case (1583) was
the first reported. Varnier and Mangin's case (1785) was the
first of double ectopic fcetation with the formation of a skeletonized foetus and a lithokelyphos. Von Weinhardt's case
(1802) was the first successfully operated upon by abdominal
section, Bonisch's case (1831) the first successfully removed
through the vagina, Lee Heiskell's case (1828) the first reported


•Archiv f. Gyn., vol. XVII, p. 153.
2 "




20/40


in the United States, and Kuchenmeister's case (1880) the one
of longest standing. The case which I now report is the
largest lithopedion yet removed by abdominal operation
followed by recovery of the patient.


The cases just referred to are of sufficient interest to merit
184
a short resume of their histories.


In Varnier and Mangin's case (1785) there were two extrauterine foetuses of different ages found at autopsy.


A woman who had borne twelve children again became
Female.  
pregnant and went on to an apparently normal labor, March,
1753. The labor pains continued many days; water and considerable blood were expelled from the uterus, causing her to
become weak and faint. After this false labor the patient
gradually recovered, the abdomen, however, remaining enlarged. Eighteen mouths later she again had bleeding, from
which she recovered, and continued well until the time of her
death, 1785, in her 75th year.  


At autopsy a white, moderately hard tumor of 5J pounds
weight was found adherent to the abdominal wall, intestines
and mesentery. The outer surface was partly calcified, and
within the tumor a male fcetus with its placenta and umbilical
cord was found. The joints were flexible, not friable; the
extremities were hard, but still fleshy and not calcified. The
muscles were hard and brown ; the skin dense and yellow.


Ovaries and tubes normal. Close to the left uterine wall
70.  
and between it and the rectum, a hard, chalky tumor the size
of a hen's egg was found, which contained a thick reddish
slime and the bones of a two or three months foetus.  


This sac communicated through perforations in the uterine
wall with the uterine cavity.


Von Weinhardt's case, 1802, should occupy a prominent
Good.  
place in the history of abdominal surgery on account of the
courage exhibited by this barber-surgeon in attempting such
a hazardous operation.  


In this case the patient gave a history so characteristic of


' the rupture of an extra-uterine pregnancy sac that V. Wein
11 11
hardt, after making an examination, not only diagnosed her


true condition, but advised an operation, which he performed


Sept. 35, 1801.
"


After exposing through an abdominal incision the tumor
mass, the surface of which was covered with veins, he delivered
it with a " flesh hook." Within the mass the foetal bones
could be felt distinctly. The foetus was removed, but no
attempt was made to enucleate the placenta. The umbilical
cord was brought out through the abdominal incision. The
abdominal wound was dressed with cotton and a solution of
balsam Peru and adhesive plaster. The patient recovered.


In this case the foetal envelope alone had undergone calcareous changes, the foetus having become skeletonized. Kuchenmeister therefore classified it as a lithokelyphos.
"


In the case of Bonisch (1815) the fcetus had lain in the
abdomen for seven years before the operation.


The patient first noticed a large lump in her left side,
2 "
accompanied by pain which she referred to the region of the
umbilicus. This was her eighth pregnancy. The foetal
movements had been quite vigorous, and at full term all of the
usual symptoms of labor came on and continued for three
days, after which they ceased and her breasts decreased in




Not tested.


226


185




JOHNS HOPKINS HOSPITAL BULLETIN.  
Female.  




50.


[No. 80.


Good.




size. For five weeks she had a bloody vaginal discharge. At
11 11
the end of nine months the menses returned. The patient did
not wholly recover, but suffered from dysuria, constipation,
occasional abdominal pains, and emaciation. In 1817 and in
1819 she again bore children, but the pain and emaciation
which had previously existed continued, and in addition she
had a foul-smelling vaginal discharge.


At the time of the operation a sharp bone (frontal bone)
projected into the vagina ; this was first removed, accompanied
by the escape of pus, after which the cranium was crushed
with bone forceps and removed piecemeal. The left arm was
then torn off with a hook, but remained attached by adhesions
to the abdomjnal wall.


The bone was removed, leaving the soft parts behind. The
Simple Ext.  
hook was then fastened to the right arm, and all of the parts
removed except the right thigh. This bone with the adherent parts was removed later.  


The patient recovered, but had an occasional discharge of
calcareous and cheesy masses, and the soft parts which were
left behind formed a hard swelling over thepubes. Involuntary urination still continued.


Lee Heiskell's case is of interest merely because it was the
"
first reported in the United States. The lithopedion was
removed at autopsy and weighed four pounds and six ounces.


The clinical history of Kuclienmeister's case was reported
by Hirt, an accoucheur in Zittau, in V. Siebold's Journal fiir
Geburtshiilfe in 18.34.


The patient gave birth to a dead foetus in 1819, after which
2 "
she again menstruated regularly until the end of the year
1823, when symptoms of another pregnancy appeared.


During the second half of her pregnancy she began to have
much pain, which increased as the fcetal movements grew
stronger, until she did not have an hour free from suffering.
At the time of her expected confinement she experienced
labor-like pains for a few days.


On Oct. 25th, after eating a light midday meal, she suddenly had a feeling of heart anguish, cramp and lancinating
20/100
pain in the abdomen accompanied by vomiting.


After this time she became very sick and no longer felt the
foetal movements or labor pains. Three days later Hirt was
called and found the woman in an unconscious condition, with
all the signs of a septic fever associated with an inflammatory
attack in the abdomen. On account of the tympanitic condition of the abdomen Hirt was only able to make out rather
indefinitely the transverse position of the foetus above the
umbilicus.


After an examination of the uterus, which he found empty,
186
he felt convinced that this was a case of "abdominal pregnancy." On account of the serious condition of the patient
and the death of the foetus he did not consider the recovery of
the patient possible without an operation, but under the
administration of medicines "nature asserted herself," and
Hirt says, "Truly I had the pleasure of seeing a slow recovery
set in." After this time the patient had an ill-smelling
diarrhoea which gradually disappeared. Milk appeared in
the breasts on the 21st day and was present for 14 days.
Nine weeks after the first day of her illness she had a bright
red flow of blood mixed with pieces of skin and fibres.




Male.


From this time on the patient made a good recovery, and
with the exception of pain which she noticed in certain movements of the body as in bending far forwards, and an occasional sharp, sticking pain in the right side, she suffered no
inconvenience. Ten years after the attack Hirt examined the
patient and found the foetus still in a transverse position, the
head towards the right side of the mother. Through the
posterior wall of the vagina a part of the foetus which he
took for one of the upper extremities could be felt.


In 1846, 13 years after Hirt's last note, Kuchenmeister first
67.  
saw the case and found a tumor one and a half times as large
as a head adherent to the abdominal wall in a transverse
direction, making a prominent conical tumor near the
umbilicus. The tumor was closely adherent to the abdominal
wall and was only movable in so far as the abdominal wall was
movable. The foetal parts could not be recognized. The
uterus was normal in size and form and at most slightly anteverted. By the vagina the tumor could not be felt.  


The patient continued in good health until 1880, when she
died in her 88th year. The autopsy was performed by
Kuchenmeister, June 3d, 1880. The body was greatly emaciated, and the abdomen presented a prominent conical appearance, most marked near the umbilicus. The tumor was intimately adherent to the mesentery and anterior abdominal
wall, requiring the knife to separate the adhesions. The
tumor was in part directly adherent beneath and at the sides
to the adjacent intestine, and in part connected by band-like
adhesions with the more distant intestines and especially
with the uterine appendages. The broadest adhesions resembled the bursted tubal sac. From one part of the tumor
a foetal foot projected, the skin over which was dry and the
tendons stood out prominently like those seen in dried anatomical preparations. The tumor was hard, inflexible and calcified. The placenta was soft and easily differentiated from
the ectopic sac.


On opening the sac a full-term mummified foetus was found.
Good.  
It was very much shrunken, the face was distorted but not
calcified and was covered by the right arm. The umbilical
cord was wound ai'ound the thorax of the foetus and easily
visible. All of the inner organs could be recognized without difficulty. The general appearance of the scalp, cranium,
- brain, lungs, heart, pericardial sac, diaphragm, spleen and liver
was preserved, but the intestines had shrunk into an unrecognizable mass.  


A microscopical examination of this and another specimen
was made by T. Wyder, who found only calcareous deposits
in the skin and amniotic sac and not in the internal organs.
The various tissues were mostly easily recognized and in
part were wholly ))reserved. In the denser tissues the cell
elements were most resistant and retained their normal appearance and arrangement. In all localities where fat had
previously existed margarine and cholesterine crystals were
found.


As Kuchenuieister's table possesses considerable historical
!'. ^u-^
interest I have rearranged it according to the chronological
report of the cases and append it to this paper.  


Since the publication of Kuclienmeister's paper cases have
Iridectomy.
been reported by the following writers, but none of them




"


November, 1897.]


2 "




JOHNS HOPKINS HOSPITAL BULLETIN.
20/20




187


227


Female.




-possess any special poiuts of interest over the cases found in
77.
his report:


Dahlmann, Archiv f. Gyn., 1879, Vol. XV, p. 128.


Oettinger, Progrus Med., 1884, Vol. XII, p. 196.  
Bad.  


Sarrante, Archiv de Tocol., 1885, Vol. XII, p. 237.


Oppel, A., Miinch. med. Wochen., 1888, Vol. XIII, p. 151.


Stonham, Tr. Path. Soc. Loudon, 1886-7, Vol. XXXVIII,
p. 445.


Hammer, Prag. med. Wochen., 1888, Vol. XIII, p. 151.  
Simple Ext.  


Fales, W. H., Boston M. and S. J., 1887, Vol. CX VII, p. 131.


Tarnier, Bull. Acad, de M6d., 1889, Vol. XXII, p. 57.
"


Schotte, G., Miinch. med. Woch., 1890, Vol. XXXVII, pp.
471, 489, 503.


2 "




Wilson, E. H., Brooklyn M. J., 1891, p. 515.
20/100


Elbiug, R., St. Petersb. med. Woch., 1890, Vol. VII, p.
299.


Lusk, Med. Eec, N. Y., 1892, Vol. XLII, p. 405.
188


Hofmeier, Sitzungs. d. phys.-med. Gesellsch., Wiirzburg,
1892, p. 134.


Gottschalk, Canad. Pract., 1893.  
Female.  


Patellani, Ann. di Obstet, Milano, 1893, Vol. XV, p. 817.


Dean and Marnoch, J. Anat. and Physiol., London, 1893-94,
77.  
p. 77.  


Fabbrovich, Gazz. d. Osp. Milano, 1894, Vol. XV, p. 890.


Djemil-Bey, Ann. de Gynec. et d'Obstet., Paris, 1894, Vol.
Bad.  
XLII, p. 333.  




R. E.




Irid




Bctomy.


KUCHENMEISTER'S TABLE OF C.4.SES REPORTED BETWEEN THE YEARS 1582 AND


Iritis.


1880.


4 "




20/100


Case
No.




204


[No. 79.


Name of
observer.




Number
No.  
of births
before the
ectopic
pregnancy.  




Time
Sex.  
wheu labor pains
or symptoms of
rupture
occurred.  




Length
Age.


of time


foetus
Health.


was


retained.  
Cataract.  




3^
Operation.




he
Healing process. Duration of treatment.


11


Si
Primary Vision.




•sj
189


3"°


Male.


i|.g


83.


M


Good


Primary


site.  
Hard. L. E.  




Age of the
Simple Ext.  
woman
at death.  




Uncomplicated.




Escape of
2 "


decidua


from
Not tested.


uterus.


190


Return of
menses.


Female.


Other births
after the ectopic pregnancy.


80.


Remarks.


Good.


1


U It


1583


Iridectomy.


Albosius.


Closed pupil, but


None.


iridotomy pave.




20/2C0


28yrs.


191




Female.


1


70.




Good.




R. E.




"


Normal
uterus.


Uncomplicated.


66 years.


2 weeks.


Yes.


20/30


Yes.


192




Female.




62.




Good .


2


" "


1659


"


Densius, Pont a
Mousson.






2 "


6th month


20/70


?


193




Male.


1


50.




Good.




" "




Simple Ext.








2 "




20/70




194




Male.




55.




Good.


3


" "


1661


" "


Schnorffs in Dole


"




2 "


9th month


Not tested.




195




Male.




60.


1


Good.




" "




" "




"


53 years.


2 "




20/100




196


Yes.


Male.




72.




Good.


4


" "


1675


" "


de Blegny (Toulouse).


"


10


2 "


Full term


20/70


28 yrs.


197




Male.




72.


1


Good.




L. E.




" "


Tube.


"


25 years.


2 "




20/70


Prolonged
purulent
discbarge


198




Female.




70.


Pregnancy in the
uterine end of the
Fallopian tube.
Fcetal head in fundus uteri.


Good.


5


" "


1719


Iridectomy.


Bompard.


"




2 "


7th month
2 days in
labor.


2(1/20


15 yrs.


199




Female.




70.




Good.


1


R. E.




"


Uterus ?


Slight iritis.




3 "




2<i/100




200




Female.




68.


Skeletonization and
softening of the
foetus with partial
spontaneous extrusion.


Good.


6


L. E.


1720


Simple Ext.


Orth, Steinkind,


Uncomplicated.




2 "


Full term.


20/40


51 yrs.


201




Female.


1


66.




Bad.




R. E.




" "


Probably


Iritis.


91 years.


4 "




Not tested.




202




Female.


2


68.




Delicate.




" "


Von Leinzell.


Iridectomy.




Uncomiilicated.


Labor
pains 3 to
4 weeks.


2 "




" "




203




Female.




65.




Good.




" "


in one
horn of
uterus.


"




"




2 "




20/40




204




Female.




66.


7


Good.


1728


L. E.


Bianchi.


"


2


"


In the 9th
month.


2 "


15 yrs.


Not te&ted.


1


2 '5




Female.




60.




Good.




R. E.


Ovary.


"




"




2 "








20(i




Male.




44.


8


Good.


1741


L. E.


Bromfleld.


"




"


Fullterm.


2 '■


9 yrs.


" "


1


207




Male.




50.




Good .




R. E.


Uterus,
perforation of
the cervix
uteri.


"




"








Cosmetic.




20S




Female.




55.


9


Good.


1747


" "


Middleton.


"




"


Full term.


2 "


16 yrs.


Not tested.






PAROTITIS FOLLOWING VISCERAL INFLAMMATION.-A REPORT OF TWO CASES.




1


(Service of Dr. O.sler.)
By a. Duval Atkinson, M. D.






It is well known that parotitis is a complication in pyaamia
and many infections diseases. There seems also to be a relation between the parotid gland and the generative organs, and
an apparent sympathy (as pointed out by Stephen Paget in
1886) between the parotid gland and the abdominal viscera.
Cases illustrating it are, however, of sufficient rarity to
warrant the rej)ort of the following histories.


Case J. Parotitis following a supposed gastric ulcer. — A
female, aged 34, single, by occupation housemaid, was
admitted December 16th, 1895, complaining of general weakness and vertigo. Her family history was good ; her mother
died of "dropsy": there was no history of titberculosis. She
had always enjoyed good health until one year ago. She had
had none of the diseases of childhood. The catamenia began
at fourteen and were always regular until a year ago. She had
not menstruated for four months. She had been sick during
the past year, but not confined to bed. At the beginning of
the illness her chief complaint was of a continual dull pain in
the epigastrium and "cramps" in the legs, a condition which
lasted for about one month, when the pain left the abdomen,
but not the extremities. In them it persisted with the utmost
severity, being of a shooting, darting character, coming on
often in paroxysms lasting several minutes. At the height
of these pains a feeling of "pins and needles" would be felt
in the hands and fingers. During the six months previous to
her admission her arms and hands had been swollen to some
extent, also her eyelids, the latter especially in the early
morning ; her eyesight had been failing.


Fimbriated extremity
She took to bed December 9th, 1895 (eight days before
of tube.  
entrance. Late in the afternoon of that day she began to feel
weak and nervous, and had a gnawing sensation in the epigastric region. Nausea immediately followed, and she vomited a
considerable ([uantity of bloody-looking material. Four hours
later she again vomited a considerable quantity of material
which the patient thought was pure blood. She remained in






bed on account of her extreme weakness until she came to
the hospital.


Yes.  
Physical Examinatioii. Patient's skin and mucous membranes were j)ale ; sordes on lips ; tongue pale, moist, and
somewhat cracked. Distinct pulsation in external jugulars;
pulse 25 to the quarter, regular in force and rhythm, tension
distinctly raised ; vessel wall a little thickened.  


The thorax was long ; costal angle narrow ; expansion only
fair, but apparently equal. Respiration over front of chest
was negative; clear on percussion. Over the back the breath
sounds were quite clear.


Heart. Point of maximum cardiac iinpulse diffuse over
fifth and sixth spaces, in and a little outside the nipple line;
relative dullness was at the upper border of the third rib,
extending to the nipple line and a little beyond the left sternal
margin. At the point of maximum cardiac impulse the first
sound was loud and booming, accompanied by a blowing
systolic murmur which was heard as far out as the anterior
axillary line. The second sound was accentuated. A systolic
murmur was also heard in the aortic region, where the second
sound was sharp and loud. Over the sternum the murmur
was increased and the second sound was more booming. At
the costal angle the murmur was very distinct and the second
sound was greatly increased in intensity.


Hepatic flatness began at the sixth intercostal space and
extended to the costal margin in the mammillary line; the
border was indistinctly felt. Spleen not palpable. No cedema.
Eefiexes normal. Blood count showed 2,314,000 red corpuscles to the cubic millimetre; white corpuscles, 8000;
hajnioglobin 30 per cent. The urine was pale yellow in color ;
specific gravity varied from 1010 to 1006; there was a decided
trace of albumen. Microscopically granular casts were seen.
There were no rigors.


During the night of Dec. 16th, 1895, the patient began to
complain of pain, and tliero was some swelling in the region




4


OCTOBEll, 1897.]


205




10


of the left parotid gland. The next morning (two days after
entrance) the following condition was noted. The patient
presents great swelling of the left parotid gland. The swelling extends nji above the zygoma, and behind far over the
mastoid. Below there is a marked amount of infiltration in
side of neck, extending to the angle of the mouth. The
swelling lifts the lobe of the ear. It is rounded, tense, hot,
and very painful. The tongue is a little swollen. Nothing
exudes from Steno's duct when external pressure is made over
the gland. The abdomen is negative. There is no general
enlargement of the superficial glands of the body.


1748
At 13 noon, although no fluctuation was obtained, the
gland was incised. Numerous small foci of inflammation
were discovered, from which exuded a little creamy pus.
Cover-s]ij)s from these areas showed streptococci and a large
bacillus ; the latter was supposed to have come from the
mouth. Cultures showed a pure growth of streptococcus, the
bacillus not growing.


The following day, December 20th, the pain in the region
of the neck had in a measure subsided; the swelling, however,
remained about the same ; there was marked oedema of left
eyelid.


Bourdon and  
The patient did fairly well until the 34th, the swelling and  
Chamerau in  
tedema of eyelids remaining about the same. On that day
Troyes.  
she was extremely pale, pulse 100, dropping a beat occasionally. The swelling of the cheek was perhaps a trifle less;
she breathed noisily ; no infiltration in the lower neck. The
patient sank rapidly and died. Unfortunately no autopsy was
allowed. The diagnosis of parotitis, gastric ulcer, and chronic
interstitial nephritis was made.  


Case II. Cholecystitis (post typhoidal) complicated by
double parotitis. — J. L., single, age 34, German, butcher by
occupation, was admitted to Ward F, November 25, 1895,
complaining of continual headache, pains in his muscles and
joints. His family history was good ; there was no history of
tuberculosis. His only disease during childhood was scarlet
fever, from which he made a complete recovery, with no
sequelae, and excepting an attack of rheumatism, which confined him to bed nine months in 1893, had always been a
strong, able-bodied man. He gave no history of syphilis or
gouorrhoeal infection. Had been a moderate drinker. The
history of his present illness was that about one week before
his admission he began to have headache, chills and nausea,
accompanied by vomiting. The diagnosis of typhoid fever
was made, and the patient had a typically mild course of fever,
which was treated by means of the ice-baths. His temperature reached normal on December 5th, ten days after entrance.
The urine showed a distinct diazo reaction, and there was a
trace of albumen. The spleen was easily palpable, and there
were a few typical rose spots. The liver was never palpable.
Blood negative for malarial organisms. No leucocytosis.
His convalescence was uninterrupted, and he was discharged
well, January 1, 1896.


1 miscarriage.  
The patient was readmitted November 30, 1896, eleven
months afterwards, complaining of headache and general
weakness, stating that he had been feeling badly for ten
days. The chief symptoms seemed to have been headache,
muscular and slight abdominal pain. Two days before




Fullterm.


Labor
entrance he had had a slight chill followed by fever and
sweating. On entrance his temperature registered 103.4°,
pulse 27 to the quarter minute, full and strong. The
physical examination was negative save for a slight enlargement of the spleen and some rigidity of the right rectus
muscle. The liver was not palpable and the hepatic flatness
was not increased. The blood was entirely negative for
malarial organisms, and there was no leucocytosis. The
conjuuctivEe were injected, but there was no jaundice. No
bile was found in the urine. His temperature, which reached
103° on the evening of his entrance, quickly dropped to
normal, and the man was discharged December 15th, quite
well, with no definite conclusions being reached concerning
the nature of his trouble.


pains 2
He again applied for admission March 5, 1897, stating that
for three days he had had chills, accompanied, he thought, by
fever, headache and pains in his back and limbs. His bowels
had been very costive for some time.


days.  
The physical examination was as follows : Well nourished,
Fullterm.  
strong-looking man ; face flushed; eyes bloodshot ; lips a trifle
cedematous ; tongue had a slight brown coat. Pulse, 33 to the
quarter minute, dicrotic ; capillavy circulation rather sluggish. Thorax symmetrical, expansion equal; an occasional
sonorous rale was to be heard over chest and axillae. Heart
sounds clear. Spleen just palpable on deep inspiration.
Hepatic flatness began at the sixth rib, extending one finger's
breadth below the costal margin. The muscular resistance of
the abdominal wall was such that it was utterly impossible to
palpate it. In the mammillary line there were 13 cm. of
hepatic flatness. (Pain was complained of whenever deep
palpation was attempted in the hypocondriac region.) On
the following day, March 6th, there was no essential change
in his condition. The morning temperature registered 104.3°,
and that of evening 103°. There was well-marked tenderness
on pressure in the hypocondriac region, and pressure between
the crest of the ilium and ribs on the right side caused pain.
The most tender part appeared to be just at the region of the
gall-bladder. The conjunctivae were a little muddy, but not
distinctly jaundiced. There was- a leucocytosis amounting to
11.300 to the cubic mm. The urine was negative, but no test
for bile was made. On March 9th the conjunctivae were
slightly yellow, and the urine reacted for bile. There was
still great tenderness in the region of the gall-bladder. His
temperature, which had been gradually falling, reached
normal at 2 a. ni., where it remained until the 12th, when it
was again elevated. On that day both parotid glands were
swollen, the right more than the left. They were hot and
very tender to pressure. No fluctuation was obtained. On
the loth both glands were greatly swollen, the tissue of the
face and neck was infiltrated, and eyelids (Edematous. The
skin over the parotid glands was red, the gland itself imparting a hard infiltrated sensation to the examining hand. Both
papillae at orifice of duct were swollen, and pus could be
forced out. Although the patient was in poor condition, his
temperature registering 102.8°, he insisted upon leaving the
hospital, and was therefore discharged.  


Cultures from the Ijlood on agar-agar and bouillon proved
neo-ative. Diagnosis: Cholecystitis (post-typhoidal), com


30 yrs.


206


1
[No. 79.






plicated by double parotitis. Later both parotids were
incised, the bacteriological esamiuation showing a pure
growth of staphylococcus aureus. The patient is now quite
well.


The cases in many ways correspond to some of those
referred to by Stephen Paget in the London Lancet for 1886,
and spoken of in more detail in the British Medical Journal
in 1887. In his series parotitis followed injury and diseases
of the peritoneum, generative organs, and abdominal viscera.
Two followed a supposed gastric ulcer. Of the 101 cases
cited, 10 were due to injury of the urinary tract; 18 to
diseases of the alimentary tract; 33 to injury or disease of
the abdominal wall and peritoneum, or to the pelvic cellular
tissues, and 50 to temporary derangement of the generative
tract. He states that parotitis after abdominal or pelvic
injury or disease is not as a rule accompanied by signs of
septiegemia or pya3mia. Of his 101 cases mention is only
made in 15 of septic symptoms. 37 died; of these 3 were
over eighty years of age ; 3 had internal cancer ; 3 had perforation of the bowel ; and 3 had strangulated hernia; 7 had
undergone severe surgical operation involving abdominal section ; 13 had septicEemia or pyfemia; 1 had infantile syphilis ;
1 had marasmus; and 1 had heart trouble. He adds that death
was not due to parotitis joer se, but to a primary lesion, and he
is ujiable to state to what extent parotitis is a dangerous complication. Its period of incubation is unknown, but in his
opinion it is from one to thirteen days. There is as a rule no
marked disturbance to general health, no rigors, and no high
fever. On the other hand symptoms may be more severe from
the onset, and great disturbance in general health may be
noted. Eigors were noted in only 4 cases. In regard to
the termination of the parotitis, whether by resolution or by
suppuration, the figures show that out of 73 cases which give
information on the point, 45 suppurated and 33 were resolved,
and out of 45 that suppurated 34 died; but out of the 33 that
resolved without suppuration only one died (in all probability
from cancer). In other words, he thinks that they did not
die because the parotids went on to suppuration, but that the
parotids suppurated because they were going to die. In cases
of undoubted septicasmia or pyemia the parotids always went
on to sujipuration.


'I'he only autopsy reported by Paget is that of a woman
dying from the effects of the removal of a sarcomatous growth
of the mesentery, having parotitis as a complication. On
section the parotid was found to be evenly and in every part
infiltrated, not with pus, but with a reddish, slightly turbid
fluid, causing it to look like a section of the spleen. There
were no abscesses anywhere. Just in the proximal end of the
duct where it left the gland lay two or three drops of healthy
pus and a tiny calculus. The acini were separated, compressed, and breaking up, and here and there were seen ducts
filled with the same small round cells as were infiltrated
among the acini. No bacteriological examination was made.
Mr. Paget cites a case reported by Rosenbach of parotitis following operation for strangulated hernia, in which staphylococcus
aureus was obtained. He further states that this form of
parotitis is in many ways a peculiar lesion, so far as l)eingdue






to septicemia. It was in 93 cases an isolated lesion, unaccompanied by any other lesion like itself, having no fixed period
of incubation, and running no common course. Its invasion
is not as a rule marked by rigors or great rise of temperature.
It may subside and swell up and subside again. These facts
make it impossible to say that this form of parotitis is due to
any ordinary form of septicaemia. It is not, he thinks, due to
inflammation following a parched and sore mouth, as the
mouths of pyaBmic or septicaemic patients are not, as a rule,
more parched than those of other patients. Also, he does
not think that it is merely due to inflammation of the
lymphatic tissue which is in the gland substance. " Admitting that the general condition of the patient, especially in
cases of septicemia and pyaemia, is considered in the production of this form of parotitis, must we not take into consideration the reflex action of the nervous system, as the influence,
direct and reflex, of the nervous system upon the salivary
glands is shown in countless ways; viz. gastritis may be
followed by salivation or arrest of salivary secretion. Parotitis may follow gastric ulcer, gastrotomy, etc. Even operations on the rectum and again diseases of the thoracic viscera
cause inequality of the pupils, differing not only in size, but
in their susceptibility to light. Thus, with regard to pyjemia
after abdominal or pelvic lesions, we may admit that the
general condition of the patient may help to cause it, without
denying the local influence of the nervous system."


 
A. J. Oribb (Lancet, 1886) reports two cases ; in one jiarotitis followed irritation of the genito-urinary tract, and
Right
in the other ovaritis occurred in connection with parotitis.
tube.  
And again, Harkin (Lancet, 1886) reports parotitis in a
 
woman aged 43 as one of the first symptoms of three successive pregnancies, no suppuration being present. These
 
cases seem to point undoubtedly to some latent sympathy
61 years.  
between the parotid glands and the organs either covered by
 
or closely adjacent to the peritoneum. It is, however, difficult
 
for us, with our present bacteriological knowledge, to conceive
 
of inflammation being established in organs far remote from
the seat of irritation by reflex causes alone, without the
presence of micro-organisms. An interesting case, and one
bearing a close resemblance in some respects to those cited, is
one reported by W. Legg in the Pathological Society Reports
for 1869, in which parotitis was a complication in contracted
kidney and atheroma in a lad aged 16, who was admitted to
the University College Hosjiital for albuminuria. Nine days
after admission he complained of pain on right side of face.  
The day after well-marked right parotitis was noted. The
swelling continued for eight days, when the patient died
suddenly. There was found to be no obstruction to Steno's
duct; the gland tissue was pale grey in color, not at all
reddened, rather harder than natural, and on section there
flowed from the cut surface a large quantity of pale greyish
white fluid, somewhat thin, showing under the microscope a
large number of rounded cells, larger on the average than pus
corpuscles, having rather granular contents, and single small
bright nuclei. The gland was the seat of small abscesses
varying in size from a pin head to a barley corn. Microscopically was seen a great increase in epitiielial elements, the
acini being iilled with them. The arteries wore atheromatous






October, 1897.]


207






Two incisor teeth
and the kidneys contracted. No mention is made of lesions
in jaw.  
in other organs.  


W. B. Morrow, in the Montreal Medical Journal of March,
'96, has related the histories of three cases of parotitis fol]pwing pelvic disease. And Herbert and Hawkins, in the British


U




1767
Medical Journal of April 10, 1897, report two cases of operation for jjerforation of gastric ulcer, in one of which there
was a double parotitis three days after operation, the patient
eventually making a complete recovery, the glands subsiding
without incision being necessary.




Heidelberg case


PALPATION OF THE FCETAL HEART IMPULSE IN PREGNANCY.


2
By Douglas F. Duval, M. D., Assistant Resident Ognecologist.




54 yrs.


It is not generally known that the impulse of the fcetal
heart may under certain conditions be actually felt beating
through the abdominal walls of the pregnant woman.


In this country but two cases have been observed, those of
Dr. Kelly, which I now report. The first was in 1884 and the
second in 1895. They represented the right bregmatic-iliacanterior and left occipito-iliac-posterior presentations, the
latter being observed in the eighth month of pregnancy, all
previous cases having been during labor.


Of the other observers, Fischel, in 1881, was the first to
publish a definite account describing accurately three cases in
which this phenomenon occurred. These cases represented
the left bregmatic-iliac-anterior, the right occipito-iliac-posterior and the left mento-iliac-auterior presentations. Valenta,
however, in 1885, claimed priority of observation, stating that
he had noted it in 1860 in a first face presentation, and had
recorded it in his "Text-Book on Midwifery," and that since
then he had repeatedly spoken of its importance as a diagnostic sign in anterior face presentations. Fleischman in 1885,
stimulated by Fischel's communications, published an interesting case in which this phenomenon was observed in a right
men to-iliac-anterior presentation.


The following is a brief account of the various cases :


Case I. Observed by Dr. Kelly, in Kensington, Philadelphia, in 1884. Multipara, of medium build, mother of four
or five children, abdominal walls moderately thin. A right
bregmatic-iliac-anterior presentation. Membranes ruptured,
OS half dilated, brow just engaging. The impulse of the foetal
heart was forcible and distinctly palpated over an area about
3 cm in diameter ; to the right and about half way between
the umbilicus and Poupart's ligament, separate beats were
easily counted, 130. The child was born living after a protracted labor and manual rectification of position.


1
Case II. Observed by Dr. Kelly. Patient short brunette,
well nourished, abdominal walls not thin, eighth month of her
first pregnancy. A left occipito-iliac-posterior presentation.
Heart sounds heard loud over an area 10x10 cm., and easily
counted 140. On moderate pressure a rapid fluttering sensation was clearly distinguished over an area about 2.5 cm. in
diameter. The separate beats could not be distinguished; a
few days later, on examination, the heart impulse could not
be felt. The patient has since passed through a normal confinement.


Fischel's Cases.


Case I. Mi. 36, 1 para, well nourished, strong. Pains
began on 30th at 1) p. m. Li(juor auinii discharged on 31st at






13.15 a. m. At 7.45 a. m. os 6 cm. in diameter. Foetus in
left bregmatic-iliac-anterior presentation. Heart sounds to
the left and below umbilicus. At 13.15 fcetal heart impulse
palpated to left and beside umbilicus, synchronous with foetal
heart sounds, frequency 156-160. This phenomenon was
observed for several hours. Change of presentation being
impossible, craniotomy was performed.


Case II. Mt. 31. Well built, large, strong. Pains began
at midnight. At 3 a. m. liquor amnii discharged. Entered
hospital at 4 a. m. Cervix obliterated, back to the right, feet
to the left above the umbilicus, chin 8 cm. above left os pubis,
heart sounds above the symphysis. From this description very
probably a right occipito-iliac-posterior presentation. The
fcetal heart impulse was palpated just above the chin, easily
demonstrable, frequency 156, maternal pulse 113. In the
further course of labor, which was rapid and favorable, the
impulse was palpated in the pauses between the pains, descending toward the symphysis and finally disappearing
entirely, though the sounds continued to be heard. Examination of the child's heart after labor showed clearly that the
sounds were of normal strength and clearness.


Case III. Mi. 30. 1 para, small, strongly built, moderately fat, abdominal walls thin. Pains began at 10 a. m.
Entered hospital in the afternoon. External examination :
Occiput above right os pubis, extremities to the left, heart
sounds to the left of the umbilicus, loud and slow.' The presentation in this case was then a left meuto-iliac anterior. At
6.30 p. m. the heart impulse was clearly palpated 5 cm. to left
of umbilicus. At 7.30 p. m. was 5 cm. to left of umbilicus,
but lower. At 8 p. m. frequency ranged between 80 and 150 ;
maternal pulse 66-73. At 11.30 p. m. heart impulse to left
of umbilicus, but lower. Labor terminated at 13 m., fcetal
heart sounds ceased two minutes before delivery, child stillborn.


91 years.  
Fleischman's Case.  


Case I. Mt. 35. Abdominal walls thin and flabby. Entered hospital at 11 p. m., three hours after discharge of liquor
amnii. Occiput over left os pubis, back to the left, heart
sounds clearest four fingers' breadth to right of midline, chin
to right and forward, forehead to left and backward. Evidently a right mento-iliac-anterior presentation. On the following morning the foetal heart impulse was palpated in the
right hypogastrium, at the junction of the middle and lower
thirds of a line drawn between the umbilicus and middle of
Poupart's liganit'nt. In frequency doubled that of the maternal. 'J"he sounds were loud and clear.


Yes.




208


[No. 79.


Yes.




2 abor
Fleischmau says: "The conditious iu this case for the
observation of the pheuomenon were most favorable, the
abdominal walls were thin and flabby and the liquor amnii
had previously discharged, thus permitting the uterine walls
to clasp firmly the foetal thorax."


Patient recovered
The following is a summary of all the cases :


Fischel, 1881, three cases: Left bregmatic-iliac-auterior,
right occipito-iliac-posterior, left meuto-iliac-anterior.


Valenta, 1885, one case: First face presentation (K. m. i.
ant.)


Fleischman, 1885, one case: Right meuto-iliac-anterior.


Kelly, two cases : First iu 1884, a right bregmatic iliacanterior presentation; second iu 1895, left occipito-iliac-posterior presentation.


 
From the above it will be seen that the observation has
of Nebel.  
been made in face, brow and occipito-posterior presentations —
 
two of each. One may therefore infer that these are the most
 
favorable presentations for the observation of this phenome




non ; especially is this the case in face and brow presentations,
the fcetal thorax being arched forward and therefore in closer
proximity to the maternal abdominal walls. In occipito-posterior jjresentations the festal curve is directed backward and
consequently less favorable.


The liquor amnii also plays an important part, as shown by
the fact that in all cases, with the exception of the second case
of Dr. Kelly, the observation was made during labor. In this
case one must naturally suppose that a small amount of liquor
amuii was present. As for the maternal abdominal walls, they
should be thin and flabby in order that there may be little
hindrance to the transmission of the im^iulse of the foetal
heart.


References.


American Text-Book of Obstetrics, Hirst, 1888.
Fischel, Prager medicinische Wochenschrift, Nos. 13, 13,
39, 30, 1881.


Fleischman, ibid.. No. 35, 1885.
Valenta, ibid., No. 45, 1885.






SQUAMOUS EPITHELIOMA IN A DERMOID OF THE JAW.


By S. M. Cone, M. D., Assistant in Surgical Pathology, Tlie Johns Hopkins University.






Few cases of epithelioma arising in dermoid cysts have
been described. Taufier, whose article on carcinoma arising
in dermoids of the ovary is very complete, knows of none
originating in dermoids elsewhere. In none of the dissertations on dermoids of the ovary with carcinoma in their walls
do we find reference to like tumors in other regions of the
body. I can find but three cases and they are not very fully
described. That of Franke, on an epidermoid of the ball of
the thumb with carcinoma originating in it, is most complete. Czerny in 1869 reported a case in the coccygeal region,
the first to be noted anywhere, which is interesting moreover
because of the expression of the opinion that the squamous
epithelium developed from cylindrical epithelium snch as is
found in the intestinal tract, and the idea is expressed of the
possibility of epithelium arising from connective tissue and
lymph cells. Briddon reported a case before the New York
Surgical Society and Dr. Thacher made the pathological report.
This tumor was also from the coccygeal region. The sections
which were kindly given me have some resemblance to the
one I shall describe. The descriptions of those found in the
ovaries are so much better described that it is best to reach
our conclusions regarding origin and development through
the gynecological literature.


Yamagiwa and Thumim have both reported cases this year.
Thumim gives the literature on the subject up to date.
Yamagiwa reports two cases, one of which he puts down as a
glandular carcinoma developing from remains of a mammary
gland in the dermoid. Thumim objects to including this
among the dermoids with "carcinomatous degeneration" and
rather thinks it to be part of a misplaced mammary gland
forming a part of a teratoma of the ovary. ' If it is a true
carcinoma it is the only one of its kind described ; the remain




ing eight cases arising in the ovary ;ind three elsewhere are all
of the squamous cell variety.


All authors are careful to exclude the possibility of the
growth of the epithelioma "per contiguitatem," both Tauffer
and Thumim giving a list of doubtful cases. The analogous
origin of carcinoma iu atheromas and other cysts lined by
epithelium is mentioned by Lubarsch in his review of the
subject, and many others refer to the subject as something not
long discovered. A very interesting point is alluded to by
Yamagiwa when in writing of his first case he refers to its
resemblance to alveolar sarcoma or endothelioma. Such cases
have been reported, but are rare.


The case to be reported is that of Patrick D., age i'i, blacksmith, who entered the surgical ward of the Johns Hopkins
Hospital, June 30, 1894, with a tumor of the left lower jaw.
Family history good ; past history good.


Present Illness. — In September, 1893, the patient noticed a
pea-sized growth under the horizontal ramus of his left lower
jaw. It began to pain him in November and grew rapidly
with incessant pain. He refers its quickened growth to a fall
when he injured the jaw.


Physical Examination. — The tumor extends from 1 cm. in
front of the angle to the junction of the middle and outer
third of the horizontal ramus of the lower jaw. It extends to
the hyoid bone and appears to be the size of a small orange.
It is fixed firmly, is sharply circumscribed and has smooth,
rounded borders. It is firm in consistency except at the most
prominent portion, where slight fluctuation can be felt. The
skin is cedematous and red. At one point there is a small
opening from which serum exudes on pressure. Teeth are
normal. Alveolar process is not involved.


On June 35th the patient was operated on by Dr. Halsted.






OCTOBEE, 1897.J


209


tions.




after many weeks.  
Tracheotomy was first performed, aud the pharynx being
tamponed the tumor and left lower jaw were excised. The
patient's recovery from the operation was uuinterrnptedly
good. He was discharged on July 13th. He returned September 6, 1894, aud was treated for phthisis pulmonalis —
tubercle bacilli beiug found in his sputum. He was discharged on September 14th unimproved and died at home of
phthisis pulmoualis. No autopsy was performed.  


Descrip/ioH of the tumor by Dr. Bloodf/ood. — The tumor is
removed with an area of skin 8x6 cm. and a piece of the lower
jaw 7 cm. long, including the angle of the jaw. This mass is
surrounded by skin, periosteum and healthy muscle at every
point except one, which is at the inner side of the jaw 3i cm.
from the angle where the tumor tissue is exposed. A second
piece of the jaw including the two molar teeth and alveolar
processes includes the remainder of the tumor, which is well
circumscribed by muscle and mucous membrane; so that,
putting the two pieces together, the entire mass is circumscribed. The point at which it is most superficial is beneath
the myo-hyo-glossus muscle at its attachment to the alveolar
process of bone which was removed.


12
The tumor has not invaded mucous membrane nor bone.
On section from the skin to bone it consists of an encapsulated
mass, the capsule beiug firmly adhereut to periosteum on one
hand and skin on the other. There are several points on the
skin communicating with the cyst contents and through
which the contents can be expressed. The capsule is 4-5 mm.
in thickness. The inner surface is rough and granular. The
fatty granular contents are easily removed; they resemble
those of a dermoid cyst except at the outer third of the tumor
near the symphysis of the jaw. Here the contents are firm in
consistency, greyish iu color, with pin-point dots of hemorrhage. In this tissue masses of the same consistency as that
of the cyst can be found. The tumor presents the characteristics of a dermoid cyst.


On section of the mass within the jaw the submaxillary
gland is found to be adhereut to the capsule of the cyst. The
contents of the cyst show fatty squamous epithelium and crystals of cholesterin.


1775
Microscopical Examination. — Sections of the cyst wall with
adjacent structures were made at many points. The cyst
varies in thickness. The inner lining is of horny epithelium
which is more or less loose and swollen and mixed with the
cyst contents. The same cornified epithelium is found in
whorls on the surface mixed with the cyst contents. These
cells look like long flakes, some containing nuclei, others
being free of them, which stain deeply with eosin aud carbol
fuchsin. Beneath this loosely arranged epithelium we see a
denser layer aud then the gradation of epithelium as in normal
skin, only not so thick.


The stratum grauulosum is much better marked in some
places than in others. The stratum mucosum comprises the
main mass of epidermis; the deeper cells of the malpighian
layer are not pigmented. The cells appear swollen and oedematous. Some of the nuclei are vacuolated and irregular
while others are fragmented. In the epidermis are a few
irregular areas, about the size of the cells, which are granular
and take the hcematoxylon stain deeply — evidence of calca


Walter, of Berlin.


reous degeneration in the cyst wall. The cell borders are not
nearly so well defined as iu normal epidermis. The papillai
are fairly well marked, but there is an entire absence of sweat
glands and hairs. A few sebaceoiis glands are to be seen iu
the corium, which is not well marked because of the invasion
of its territory by profuse round cell infiltration about epithelial projections.


1
These epithelial downgrowths between the papillary stroma
 
into the deepest parts of the cyst wall are made up of masses
of cells such as are found in the stratum mucosum and enclose
cells of the more superficial layers of epidermis. These cells
of the outer epidermal layers are sometimes formed into
whorls iu the deepest ingrowths of the squamous epithelium,
aud form the " pearly bodies."


9th month.  
The epithelium of these downshoots has better staining
nuclei than that on the surface. These inter-papillary
growths seem to be kept in definite paths for the most part,
but when the deepest portion of the cyst wall is reached one
can see epithelial cells spread throughout the tissue, some
being isolated without any demonstrable relation to the primary
downgrowth. This sprouting of epithelium deeply and irregularly into the wall of the dermoid is seen throughout the entire
tumor wall, but does not go any further, for it is always preceded by a zone of round cell infiltration made up of mononuclear cells. This zone is preceded by one of connective
tissue of varying thickness which invariably intervenes
between the epithelial cells and adjacent tissues and organs.
There are papillary projections into the cyst of various lengths
from 1 mm. to 2 cm. which all show a lining of epithelium
already described, and have a supporting conuective tissue
basis. Between the stratum corneumand malpighian layer are
to be seen hemorrhagic foci in some sections.  


The round cell infitration is intensely marked throughout
the cyst wall. The papillary stroma aud deep layers of the
dermoid are full of mononuclear leucocytes which are aggregated in some places, resembling lymphoid nodules. These
cells have also penetrated between the epithelial cells of the
surface and ingrowths. The centres of the "pearly bodies"
contain both mono- and polyuuclear leucocytes and fragments
of nuclei. There are typical tubercles in several sections
which are most distinct in the sections containing muscle,
including the sinuses alluded to above. No tubercle bacilli
can be found iu them, however.


22 yrs.  
The lining wall of the dermoid shows evidence of degeneration in areas; the epithelium is invaded by mono- and polymorpho-nuclear leucocytes. The nuclei stain poorly and are
fragmented. The cells appear separated from one another and
are swollen.  


Sections including skin and dermoid wall made at different
points have essentially the same appearance. The points iu
which the histology differs from the foregoing description are
the giant cell formation between subcutaneous tissue and
the fibrous limiting line of the dermoid and the openings in
the skin alluded to in the macroscopic description. The
giant cells are like the customary foreign body giant cells
and are seen singly aud in groups at the margin of the
dermoid wall. They are especially numerous on the dermoid
side of the dividing fibrous tissue. Where these are in






210


[No. 79.


1




greatest number and collected in groups the fibrous separating
line has been almost completely substituted by them and the
accompanying mono- and polynuclear leucocytes. Here the
definition between dermoid and skin is not so good as elsewhere.


The giant cells in the subcutaneous tissue are grouped about
hair shafts ; in the dermoid walls they enclose horny particles
(stained deeply with carbol fuchsin), polynuclear leucocytes,
fragmented nuclei and granules (stained deeply with hffimatoxylon and probably calcareous). Some have no contents and
are vacuolated. Most of them contain large vesicular nuclei,
grouped in the centre of the cell ; in some the nuclei have a
polar arrangement.


Beneath the epidermis of the skin there are masses of red
blood corpuscles, polynuclear leucocytes and fragmented
nuclei. Here no papillary arrangement of the skin exists and
the epidermis is flattened and thinned. The epidermis, too, is
infiltrated with leucocytes. Adjoining this area of hemorrhage
and necrosis a discontinuity in the epithelial covering is detected. The edges of epidermis are turned in and are continuous with a sinus which can be traced deep into the subcutaneous tissue, but not so far as the fibrous demarcation
between skin and dermoid. This sinus is lined by necrotic
tissue containing blood and fragmented nuclei. In its depths
the connective tissue of the part is denser, but there is no evidence of new formation of tissue. There is no epithelial
lining. Vessels included between the dermoid walls and
subcutaneous tissue are obliterated by endarteritis. Their
walls are all thickened.


In one of the sections there is a variation from the usual
structure of the dermoid wall. Instead of the interpapillary growths of epithelium dipping down at once into the
depths of the wall, we see a network of epithelial rods one
and two cells thick surrounded by small round cells. The
epithelial lining is very thin at this point, being composed
only of cornified epithelium. Beneath this interlacing network of cells we see the larger groups containing pearly bodies
described in the other sections.


Right
The submaxillary gland is included in several sections of
ovary.  
the tumor and in none does the epithelioma invade the gland.  
The capsule of the submaxillary is greatly thickened and only
at one point is there any suspicion of invasion. Here the
round cell infiltration is most marked, the connective tissue
formation not being evident. Into the round cells can be seen
jutting epithelial sprouts, but they do not enter the interlobular connective tissue of the submaxillary. The changes in the






submaxillary are due to pressure and infiltration of its connective tissue framework with small round cells. The connective tissue is thickened and some of the cells in the alveoli do
not take the stain well. The cyst-wall next the submaxillary
varies from 1 to 3 mm. in thickness and consists of epithelial
masses and single cells included in the stroma, which is deeply
infiltrated with small ronnd cells. The epithelial cells are of
the same kind as in the stratum mucosum, but Ijetter defined
and with more regular nuclei.


The muscle next the tumor is densely infiltrated with small
round cells and is atrophied. The nuclei of the muscle cells
next to the dermoid wall are greatly increased in number and
arranged in rows. The muscle substance stains but faintly
and there is no striation in the first rows next to the fibrous
line between tumor and muscle. It appears like a homogeneous mass containing rows and bunches of nuclei. There are
no giant cells nor necrotic areas to be seen. A nerve is included in the section with muscle. It is surrounded by dense
fibrous tissue. The epithelial cells crowd close up upon the epineurium, but do not penetrate it. The round cell infiltration
and new formation of connective tissue are very prolific about
the nerve.


The presence of tubercles in the cyst walls, the great and
uniform round cell infiltration, the profusion of giant cells of
both the foreign body and tuberculosis variety, and the uniform distribution of the epithelioma in the wall of the dermoid, are all striking points.


References.


TaufEer: Virch. Arch., No. 143. Ueber die primilr carcinomatose Degeneration von Dermoidcysteu.


Frauke : Virch. Arch., No. 131, p. 444. Carcinomatus entartetes Epidermoid des Daumenballes.


Briddon : Annals of Surgery, Aug., 1894. Not a complete description.


Y. Czerny: Arch. f. klin. Chir., No. 10, 1869, p. 894.
Entwickelung einesEpithelialcarcinoma aus eiuer angeboreuen
Sacralgeschwulst.


Yamagiwa: Virch. Ai-ch., No. 147, Heft i. Zwei Piille von
Dermoidcysten des Ovariums mit carcinomatosen Degeneration und Metastasenbildung.


Thumim: Arch. f. Gynek., liii. Ueber carcinomatose Degeneration der Eierstocksdermoide.


Lubarsch: Ergeb. der allg. Path. Morph. und Phys., Vol.
II, 1894.


13




1784
THE INFECTIOUSNESS OF CHRONIC URETHRITIS.






By E. R. Owings, M. D., Assisianf in Genito- Urinary Surgery, The Johns Hopkins Hospital Dispensary.






Fullterm.  
The possibility of infection from old cases of gonorrhoea is
an important and by no means infrequent problem, presenting
itself not only to the gynecologist and genito-urinary
specialist, but also to the general practitioner.  


Labor
Many cases of gonorrhoea extend over mouths or even years,
often in spite of persistent and systematic treatment, and in


pains for


3 days.
Fullterm.


response to the inquiries, " Could I infect another?" or " Is
my condition such that I may safely marry ? " the physician
must often give evasive or unsatisfactory replies.


8 yrs.
There is no fact better established than that a gonorrheal
urethritis is due to the entrance and development within
the urethra of a specific organism, the gonococcus Neisser,




1


October, 1897.]


211






which is constantly present in the discharge of an acute
gonorrhoea.


The gouococcus, first described by Neisser' in 1879, has
been isolated; a pure culture made first by Bumm,^ since by
Wertheim,* Steinschueider'' and other observers ; and a gonorrhoeal urethritis produced by the introduction of pure culture
within healthy urethra proving conclusively its etiological
relation.


The infectiousness (i. e. jrower to produce gonorrhcea)
therefore of an urethral inflaniuiation depends upon the
presence of the gonococcus; and upon the demonstration of
the presence of this organism rests the determination of the
infectiousness of an urethral inflammation.


The gonococcus is a diplococcus, J to 1 micromillimeter in
diameter, not round, but of biscuit or coffee-bean shajie, with
flattened or concave surfaces contiguous, found within the leucocyte, around, never within the nuclei, and as determined by
Roux,' if a preparation containing gonococci after being stained
with aniline stain, be placed in Gram's solution, then decolorized
by alcohol, the stain is not fixed by Gram's method, and the
gonococci may be differentiated from other organisms found
within the urethra, in that they are alone decolorized.


In 1887, Lustgarten and Mannaberg" in a series of investigations on the healthy urethra found among other organisms
a coccus which they declare cannot be distinguished from
the gonococcus Neisser by its morphology or staining reaction.


Left
Petit and Wasserman,' on the contrary, in a large number
tube.  
of examinations (over 1000) of the normal urethra, have
never found the organism described by Lustgarten, and in a
number of cases of chronic urethritis were unable to demonstrate its presence.  


Steinschueider" recognized beside the gonococcus four diplococci in the urethra, two of which were decolorized by Gram's
method as follows :


45 years.  
No.  


Urethra healthy, never infected by


gonococcus, 13


Urethra healthy, no gonorrhoea for


Yes.  
years.  
Chronic gonorrhoea,


Acute " (uuti-eated),


Two years
" " (under treatment), 22
later.






3






14




1785




Varnier and


15


12


 
2
33 yrs.
 
 
1




11




33




Line 32,549: Line 36,453:




33




One fcetus
22




75 years.




Escape of


32


Probably




18 months
86






66


One foetus fully




In 86 cases there was present in four a diplococcus decolorized by Gram's method, or about 4J per cent., making Roux's
test certain in about 95 J per cent, of all cases. He believes,
however, that Roux's test, together with the characteristic
grouping of the gonococcus within the pus cell around the
nuclei, gives a definite result.


M. von Zeissl" has in the secretion of an urethritis due to
chemical or medicinal irritants, found a diplococcus within
the pus cell, which is decolorized by Gram's method ; whether
this is readily differentiated by grouping from the gonococcus
he does not state.


Wendt" believes " Roux's color test never fails to gives correct interpretation."




Mangin.


Allen," who worked conjointly with Wendt, believes "Roux's
test final."


Carpenter'" says : " Peculiar characteristics of the gonococcus almost positively diagnostic when confirmed by Roux's
test practically leaves no room for doubt."


Heiman '" says : " Diplococci found in normal urethra can
be positively differentiated by Gram's stain."


Labor
Koplik-' says: "In skilled and tutored hands a mistake of
pains tor
identity is not possible."
many
days.  


Finger" says : " There is no doubt that in addition to gonococci other organisms are present in blenorrhagic pus, but
these never give rise to the slightest diagnostic doubt. The
number of foreign organisms is so slight, and they are found
to such a large exteut outside the pus cells, their shape and
grouping are so different, that the differences in staining are
unnecessary to make a positive differential diagnosis."


Lustgarten", 1893, says: "If in a chronic torpid urethritis
with a scanty whitish or greyish discharge, diplococci with
all the characteristics of the gonococcus are found ; it does not
prove that the affection is contagious, especially if these diplococci are found in comparatively small number and are
accompanied by a variety of organisms. As far as personal
experience goes I believe that many of these cases are not
contagious and that the wives of such men remain healthy and
prolific."


In the absence of confirmatory proof by cultivation, which
is not always practicable owing to the difficulty attending the
growth of the gonococcus, ordinary media being unsuitable
for its growth, and as in chronic urethritis where its demonstration is especially desirable the jiresence of other organisms
by their rapid growth makes it impossible to secure discrete
colonies of the organism, we are compelled in these cases to
rely solely upon its morphology and Roux's test for identification. By these methods the gonococcus may be differentiated from micro-organisms found within the urethra, with the
possible excejition of the diplococcus described by Lustgarten,
which at most is present in but a small per cent, of cases.
The presence, in the secretion of an urethral inflammation, of
a diplococcus with the characteristics and color reaction of
the gonococcus is sufficient clinical though not medico-legal
evidence of the infectiousness of same.


The examinations recorded in the paper were confined to
chronic cases entirely. In many there was no discharge
visible at the meatus, and in no case was there more than the
"goutte militaire." Their duration varied from three months
to four years. The majority were under active treatment at
the Johns Hopkins Hospital Dispensary, and so far as was
possible examinations were made on date of first visit and
subsequently at short intervals. Unfortunately, as in all
dispensaries, many failed to return after one or two visits,
making it impossible in these instances to secure repeated
examinations. The examinations recorded are of the tripperfilden, as in many of the cases this was the only material
available.


The method pursued was as follows : The urine, and where
possible the morning urine, was secured, one or two trijjperfilden were drawn uj) with a pipette and after being gently
teazed-out on a slide, were dried over a flame and then washed  carefully in warm water to dissolve out as far as possible
salts of urine which were precipitated by evaporation. Specimens thus obtained were stained two minutes in aniline
gentian violet solution, prepared by adding 1 cc. filtered concentrated solution to 15 cc. water.


In decolorizing the slides were placed in Gram's solution for
2 minutes, then in alcohol until no more blue color was
extracted, generally from two to three minutes. A watery
solution of Bismarck brown was used as counter stain.


In 15 instances no micro-organisms were found; in these
cases the fiiden consisted almost entirely of epithelial cells
with here and there a few leucocytes.


In the 35 remaining micro-organisms were fou nd ; these were
identical with varieties already described by Lustgarten and
other observers, and consisted of 4 varieties of cocci and !<!
bacilli, as follows :


I. Small coccus in zoogleae.


II. Small coccus in chains.


III. Diplococcus about size of gonococcus.


IV. Large coccus, li to 3 mm. in diameter, generally in
pairs.


V. Long slender bacillus (smegma bacillus?).


in abdom.  
VI. Short thick bacillus with rounded ends (suggestive of
cavity,
colon bacillus).  
the other
n sac communicating with  
uterus.  


These were not all present in every specimen examined, nor
did they occur in equal frequency. I, small coccus in zoogleffi,
and IV, large coccus, IJ to 2 mm. in diameter, were almost
constantly present, while the smegma bacillus ? was noted in
comparatively few instances, and VI, bacillus, short, with
rounded ends, in one case only.


In five specimens examined, in addition to one or more of
the varieties already described, diplococci were seen lying
within leucocyte, morphologically identical with the gonococcus and decolorized by Gram's method.


These were the only organisms seen within the leucocytes.
Others were either free in the intercellular space, lying on
epithelial cells or on, not within, leucocytes, as could be determined by careful focusing.


water
In 5 cases then we have an organism which could be positively identified as the gonococcus Neisser.


with
Three of these 5 cases were of from 4 to 6 months' duration,
1 was of 9 months' and 1 of 2 years' duration, or, tabulating
cases as regards age of disease —


blood.




decidua.
13




later.


6
50






developed (9th
Duration. Gonococei.  
month), the other
3 months old.  


Under 6 months. 3


15
6 to 9 " 1


1 year.


1786
2 " 1


3 ■'
over 3 years


MQhlbeck.




1
other


mlcro
org:anisms.


11th
month.




U}i yrs.
35
 






Negative


as to
organisms.


4
3
2
3
2
1  
1  


15






Out of 38 cases of more than 6 months' duration, in 2
instances only were gonococei demonstrated, and in 30 of more
than a year's duration, in one case only could they be fou-nd.




Uterus.


Goll" in 1891 made repeated examinations of cases of
chronic urethritis with the following results :






Yes.  
Durati(jn.  


6 months


1 year


2 "


3 "


Over 3 years






Foetus died in the
No. of
7th month.  
cases.  


55
83
135
80
59


16
412




1798


Gonococei.


Cheston(ca8ell.




3
12


7


Fullterm.
Labor
pains 3
weeks.




50 yrs.
29




1


cocci. Percent.


47 14


71 14


128 5


78 25


59


383






Uterus
Petit and Wasserman' in their examination of chronic urethritis found various organisms, and believe them to be accidental or saprophytic, and that they vary with the individual.  
unicornis
unicoUis
(mit Nebenhorn).  


Janet'-' has studied cases of chronic urethritis with respect
to various organisms present, and divides them into three
classes :


80 years.  
I. Gonococei present alone.  


II. Gonococei and other micro-organisms.


III. No gonococei, but varied micro-organisms.


He believes that these organisms invade the urethra, probably in coitus, and the catarrhal mucous membrane presenting
a favorable medium, they are able to keep up the inflammatory
process after the disappearance of the gonococcus, producing
an obstinate pseudo-gonorrhoea.


Hasse," 1893, "in 625 cases of chronic urethritis found
gonococei unattended by other organisms in 37 cases. In
acute gonorrhoea he found gonococei alone and their presence constant; with their disappearance and an increase in the
epithelial cells in the discharge, other bacteria, both bacilli
and cocci, appeared in large numbers."


In the small percentage of cases where the gonococcus is
definitely determined to be present, we can without hesitation
declare their infectiousness. Unfortunately, however, in the
large majority we are unable to say with certainty that we
have to do with a non-infectious malady, that is. in those
where the gonococei are uniformly absent or present in so
few numbers as to elude detection. For while the detection of
the gonococcus renders infectiousness certain, a failure to
detect it does not guarantee its absence, as often after many
negative examinations the gonococei may suddenly appear in
considerable numbers.


In one of the above recorded cases, that of 2 years' duration, the examination of which extended over several months,
after 3 or 4 negative examinations, following an injection
of 3 to 5 per cent, of AgNOs, with Tommasoli syringe, the gonococei could readily be detected.


In these cases then where there is still doubt, the test first
proposed and still insisted upon by Neisser" is an invaluable
adjunct, viz. the injection within the urethra of a solution of argent, nitrat. or hydrarg. chlor. corrosive, sufficiently strong to produce an inflammation with free purulent
discharge, when, if the gonococei have been present but have
escaped detection, they will be found in the discharge in
sufficient number to make1,heir identification positive, and at
the same time with the desquamation of the epithelium the
accidental micro-organisms are removed to a large extent.






October, 1897.]


213


17




1798
Finger" "only permits marital intercourse after frequent
examinations of the secretion or tripperfiklen show an absence
of pus cells; and the discharge following the application of
Neisser's test contains no gonococci."


Morel Lavallee'" says:


Chcston (case 2).  
I. " The gonococcus may rest latent for months or even
years in the urethra.  


II. It is impossible to permit marriage in a man that has
the slightest discharge until by Neisser's test it has been
proved free of organisms."


It is reasonably certain that the gonococci suffer enfeeblement during their stay in the urethra. This attenuation is
due probably to alteration of medium, viz. the urethral
mucous membrane, consequent upon growth of organism. In
this way we can readily account for their presence without
resultant inflammatory reaction. A localized chronic urethritis does not, however, confer any immunity from fresh
infection. Finger" has produced in four instances an acute
gonorrhoea on patients with chronic urethritis by inoculation with pure culture of gonococcus.


He believes that the gonococcus is attenuated by long
residence in the urethra, and that women infected by their
husbands who suffer from chronic gonorrhoea have a urethritis which runs a chronic course.


Fullterm.
Jamain'" believes " that the gonococcus becomes attenuated,
 
but that in contact with a healthy mucous membrane in
 
another individual it is rejuvenated and produces an acute
4 yrs.  
gonorrhoea."


The secretion in cases of chronic urethritis being small as
compared to an acute one, so small in many cases that it
appears in the urine only as tripperfiklen, it follows that after
being washed off by the urine, it requires some time for
regeneration. (Hence arises the importance of examining the
first urine passed after an interval of several hours, 23referably
the morning urine, for if the patient has urinated within an
hour or two the urine may be free from shreds.) So that a
single act of coitus with an individual suffering from chronic
urethritis and with a secretion bearing gonococci does not
always produce infection.


Since we can only demonstrate the presence of the gonococcus in a small percentage of cases of chronic urethritis
(in 37 of 625 reported by Hasse, or 6 per cent.; in 21 of 357
reported by Goll, of a duration of a year or more, or 6 per
cent.; in 2 of 38, of same duration, reported in this paper, or
5J per cent.), and since when present they are, as compared
to an acute gonorrhoea, few in number, often only demonstrated after frequent, careful and repeated examination, and
since they are from attenuation probably less virulent, we
must conclude that:


I. In many cases of chronic urethritis we are unable to
demonstrate the presence of the gonococcus ; these cases are
probably non-infectious.


II. In any case the possibility of infection as compared to
an acute urethritis is small.


III. An urethritis due to an attenuated organism, and consequently modified in intensity, may be contracted from a
chronic urethritis. Conversely:






1
IV. Several negative examinations of the secretion from a
chronic urethritis do not prove its non-infectiousness.


V. The infectiousness or non-infectiousness of a chronic
urethritis can only be determined by frequent and careful
examinatious of the secretion, and if these prove negative, by
the non-appearance of the gonococcus after the application of
Neisser's test.


Bibliography.


1. Neisser: Oentralblatt f. d. med. Wissenschaft, 1879.


Normal
2. Bumm : Gonococcus Neisser. Wiesbaden, 1887.  
uterus.  


3. Wertheim: Archiv. f. Gynakol., 1892.


Operated
■1. Steinschneider : Berlin klin. Wochensch., 1893.  
upon in
29th year.  


5. Koux : Archives gen. de Medecine, 1886.


Flow of
6. Lustgarteu and Mannaberg: Vierteljahresschrift f.
fetid
Derm, und Syph., 1887.


water for
7. Petit and Wasserman : Annales des maladies des (frg.
15 months
genito-urin., June, 1891.


8. Steinschneider: Berlin klin. Wochensch., June, 1890.


9. Wendt: Medical News, Phil., 1887.


10. Carpenter: University Med. Magazine, Dec, 1892.


1 years
11. Finger: Blenorrhoea v. d. Sex. Organ. Leipzig and
after
Wien, 1893.  
operation.  


12. Lustgarten : Etiology of Gonorrhoea. (Morrow's System,
Cutaneous and Genito-Urinary Diseases )


13. Goll: Internat. Centralblatt fiir die Phys. u. Path, der
Ham i;nd Sex. Organe, 1891.


14. Hasse: Inaug. Dissertation, Strassburg, 1893.


15. Morel Laval lee : Annales des mal. des org. genito-urin ,
Dec, 1893.


16. Jamain : Annales des mal. des org. genito-urin., Nov.,
1894.


18
17. Allen : Journal of Cutaneous and Genito-Urinary Dis.,
1887.


18. M. vonZeissl: Die acuten Krankheiten der miinnlichen
Hai-nrohre. Leipzig, 1894.


1800
19. Neisser: Deut. Med. Wocheuschrift, 1893.


30. Heiman : ]\Iedical Kecord, June, 1895; Archiv fiir
Dermatologie uiid Syphilis, 1896, Vol. 34.


Denmann.  
21. Koplik : Journal of Cutaneous and Genito Urinary Dis.,
1893.  


22. Annales des mal. des org. genito-urin. Aout-Juin,
1892.


Ifullterm.
THE JOHNS HOPKINS HOSPITAL BULLETIN,
Many mis


9th month.  
Volume VIII.  


The Bulletin of the Johns Hopklus Hospital entered upon Its eighth volume
January 1, 1897. It contains original communlcatJous relating to medical, surgical and gynecological topics, reports of dispensary practice, reports from the
pathological, anatomical, physlologlco-chemicai, pharmacological and clinical
laboratories, abstracts of papers read before, and of discussions in the various
societies connected with the Hospital, reports of lectures and other matters of
general Interest In the work of the Johns Hopkins Hospital and the Johns Hopkins
Medical School.


32 yrs.  
The subscription price Is $1.00 per year. Volume VII, bound la cloth $1.50.  






THE MALARIAL FEVERS OF BALTIMORE.


An Analysis of 6l6 cases of Malarial Fever, with Special Reference to the


Relations existing between different Types of Haematozoa


and different Types of Fever.


By William Sidney Thayee, M. D., and John Hewetson, M. D.,


A8»l8ta7its iti the Medical Clinic of The Johns Hopkins Eospital.
SIR p.-i^es, (|iiHr«a. wild plate and charts, rrlre $3.' O. Pnslngr paid.


[KoriniriK- part of The Johns Hopltinx Hnxpital Hcparts, Vol, V, 18U.5.]
Orders should Ije addressed to TiiK Johns Hopkins Press, Ualtimore, Md.






214


[\o. 79.






THE IMPORTANCE OF EMPLOYING PURE SALTS IN THE PREPARATION OF THE SCHOTT BATH.


The reason the carbonic acid is given off when bicarbonate
of soda and hydrochloric acid are combined is because the
hydrochloric acid has a greater affinity for the sodium than
has the carbonic acid; the latter is, therefore, displaced,
appearing as carbonic acid gas and the salt sodium chloride
resulting.


The following would be the formula for this reaction:






Editor of Johns Hopkins Hospital Bulletin.


Dear Sir: I am lately in receipt of the following letter from
a physician in the West. I submit to you the letter and my
reply in full for publication, if you see fit, as I trust by so
doing a similar mistake maybe averted.


I am very truly,


History of case
G. N. B. Camac.
very imperfect.  
[communication.]
Dr. C. N. B. Camac, Johns Hopkins Hospital, Baltimore, Md.  


Dear Doctor: — The instructions contained in your article in
the May issue of the Johns Hopkins Hospital Bulletin on
the Schott treatment of heart disease have recently been followed by me in a case of hypertrophy with organic lesions.


19
We nearly had a disastrous result owing to an evident error
in those instructions.


Bath V calls for sodium bicarb. 1 lb., HCl 1 lb. Bath VI
increases the HCl to 3 lbs., but leaves the sodium bicarb, still
at 1 lb., thereby producing an excess of 1 lb. of HCl which is
not provided for.


1802
I gave the journal to the hospital druggist with instructions
to prepare each bath in order in accordance with the directions, paying no thought to chemical results. When bath VI
was given the patient was attended by only one nurse, while
usually two or three had been present. She noticed the
chlorine gas rising from the tub, but supposed it was all right
and put the patient in. He had no sooner stepped in than he
was nearly suffocated and was quickly assisted out without
harm.


The nurse seemed seriously prostrated for a time with a very
severe bronchitis and laryngitis and the hospital attendants
had a lively time to relieve her.


Von Weinhardt.  
I relate these circumstances in order to call your attention
to a mistake that must have been made in the article in question.  


The patient has been rather worse during the course of
baths, but that may be due to the progress of the disease,
which is serious. As it takes more than one swallow to make
a summer, I cannot pass an opinion on the method of treatment. Very truly yours,


carriages.  
Baltimore, Md., Sept. 4, 1897.  


Dear Doctor: — I am indebted to you for your communication in reference to the Schott treatment.


Near the  
We have had no experience similar to yours in using bath
No. VI, which I may say is seldom called for. Chemically,
the results which you had seem an impossibility, no matter
how excessive the amount of hydrochloric acid may be. Suppose, for exampje, we take a formula expressing an excess of
hydrochloric acid as follows :


NaHCO=-f5HCl=NaCl-fH«0 + CO;-t-4HCl.


7 yrs. to
The other two salts, sodium-chloride and calcium-chloride,
the time
are already in solution, and being bases in combination with
the acid hydrochloric, remain chemically unchanged.




1


NaHOCOi + HCl = NaCl -I- IhO + C0=.


I can only account for your unhappy accident by supposing
that one of two mistakes was made :


1st. Your druggist may have given you sulphuric or nitric
acid instead of hydrochloric, both of which acids have a
greater affinity for the bases sodium and calcium than has
liydrochloric acid, and which would have combined with
these to form sulphates or nitrates, free HCl being formed.
(Formula see below. Experiment No. 3.)


2d. The calcium chloride (which is the more likely to have
occurred) may have been adulterated with chloride of lime, or
indeed chloride of lime may have been given to you instead of
calcium chloride. This hypochlorite of calcium being the
ordinary bleaching powder and much cheaper than the pure
salt calcium chloride, forms a ready salt for adulteration,
which in the presence of only a small amount of hydrochloric
acid yields chlorine gas and would be, I can readily understand, not only dangerous to a heart case but even seriously
injurious to a healthy individual. (Formula see below. Experiments 4 and 5.)


Actuated by your letter I made the following experiments:


1st. Bath No. 6 with the amounts of constituents as
directed in my pamphlet from which you quote. Eesult:
Abundance of carbonic acid gas. No unj)leasant effects.


2d. The same amount of constituents with excess of
hydrochloric acid. Result: Same as experiment No. 1.
(Nos. 1 and 2 performed in bath tub.)


3d. Small amount of sodium chloride, calcium chloride,
and bicarbonate of soda and sulphuric acid (experiment performed in beaker glass). Kesult: Stifling odor;- no fumes
visible. This "stifling" odor was probably due to the HCl
forming.


4th. Salts, sodium chloride, calcium hypochlorite (bleaching powder), bicarbonate of soda, dilute hydrochloric acid.
Result: Chlorine given off; suffocating; beaker had to be
placed under the hood.


Probably
5th. Sodium chloride, calcium hypochlorite bicarb, soda
and sulphuric acid. Result : More pronounced than in experiment No. IV.


Allow me to thauk you for your communication, which I
consider of sufficient importance to publish in order that a
like so serious mistake may not again be made.
Very truly yours,


C. N. B. Camac.


Formula:


Yes, one
Experiment No. 1. Same as formula given at beginning of


letter.


Blood and




OCTOBEK, 1807.]


215






Recovery.  
Experiment No. 3. (Same as foruuihi given at beginning of
letter.  


Experiment No. 3. 2NaCl + CaCL + 2NaH003 + 3H.S04 =
3Na.S0. + CaSO^ + 3H=0 + 2C0= + 4HC1.


Experiment No. 4. Ca(CIO). ■t-4HCl = CaCl. + 2HvO + 20L.






Experiment No. 5. L'u(,C10> + CaCh + 2ll.:SOi=3CaS04 +
31LO + 20k


Note. — I have not included iu these hist two formulfe — tlie
NaCl, as it would have no effect upon the reaction — neither is
the NallCOjincluded, as 00= would be evolved as already noted.






PROCEEDINGS OF SOCIETIES


7th




TIIE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.


Meeting of Monday, May 17, 1897.
Dr. Flexner in the Chair.


Denionstratioii of a Case. Probable Brain Tumor. — Dr.


Thomas.


The patient whom I wish to present to the Society will he
brought from the ward in a few moments. She is a young,
unmarried woman of twenty-six, with a good family history,
except that one brother is believed to have tuberculosis. She
has been a fairly strong girl, and has had no serious illness of
any kind. Her occupation is that of a sewing woman, and
she has been learning stenography and type-writing.


About a year ago she had an attack of unconsciousness ;
this began with a painful contraction of the right hand,
which lasted for a minute or two, and passed up the arm,
when she became unconscious. She was found about half an
hour afterwards by her brother, who shook lier and brought
her to herself. After this attack she was comparatively well,
and went to her employment the next day as usual. In
August of last year she was under a great deal of nervous
strain on account of the death of a relative. About this time
she had several nervous attacks, which she calls " nervous
chills," and which seem to have been hysterical. Ou November 8, 1896, while sitting with her arm resting ou the table,
she became conscious of a sensation of numbness in the elbow
of her right arm. This arm and the leg on the same side
became suddenly powerless, and she has been told that her
face was drawn to the left, but of this she was not conscious.
With the onset of this paralysis she became absolutely unable
to speak. She was put to bed, and showed so much nervousness that the attending physician, a very competent man,
made the diagnosis of hysteria, and it was impressed upon
her that she could, if she would, get up and walk and talk.
The description which she gives of the loss of speech is
remarkably distinct and clear. She says that she understood
everything that was said to her, and remembers much of it.
She knew every one who came into the room, but was absolutely unable to say a word. She thinks that she knew what
she wanted to say, but had forgotten how to say it. She
I tried to write with the left hand, but could not foi-m the
letters and had forgotten how to spell the words. Upon
making the attempt to read, after she had been sick about
four days, she was unable to make anything of it, and three
weeks afterwards she could not read the paper easily. After
a week of complete speechlessness, during which every one
arouud her had endeavored to make her talk, she was able to






repeat the first four words of a text of scripture which had
been said to her over and over again. By being taught day
by day, her speech gradually improved; the first words that
she said voluntarily were "go out." These she said to her
sister, who had been sitting with her constantly for a good
many days. She knew all the time just what she wanted to
say, but it was only after a good deal of silent practice, and
several attempts, that she was able to utter the two words.
Her speech improved slowly, but steadily, until she regained
the speech which she now has, which shows no defect.


The first of last December she had another attack, and
another on the twelfth of February, and still another on the
3Gth of April. These attacks have all been of the same
character, beginning with a painful contraction of the fingers
of the right hand ; this passes up the arm, and she describes
an intense pain iu her liead. At this time she says that she
loses all knowledge that the arm belongs to herself, although
she still exjieriences pain in it. This is a remarkable statement. Iu these three attacks, consciousness seems not to
have been lost.


extra
As the patient enters the room, you will notice that she
 
walks with a slight limp, and that the right hand is held iu
 
the manner so characteristic of hemiplegia. I have been
 
unable to find the slightest disturbance of her speech. She
week.  
now speaks voluntarily, without difficulty, writes long and
 
short hand, understands everything that is said to her, and
 
reads with ease. The ophthalmoscopic examination showed
fleshy
that the fundus was normal, although there is a slight
 
degree of hypersemia. She has a congenital squint and a
slight nystagmus, but other than this, no abnormality of the
cranial nerves. Her chief disability is in regard to her right
arm, which, as you see, is very tremulous and nearly useless.
She is unable to oppose the thumb to the little finger, and the
movements of the finger are very weak. The movements at
the wrist are better retained, and those at the elbow and
shoulder better still. The movement of outward rotation of
the arm is very weak indeed, whereas the inward rotation is
comparatively strong. The deep reflexes are markedly exago-erated, percussion on any of the tendons causing active
muscular contraction, and there is a well-marked wrist clonus.
Objectively, there is not much muscular weakness of the
right leg. Sensation is everywhere perfectly normal. , I have
tested particularly for any abnormality of the muscular sense
of the right arm, and found that she appreciates even very
slight movements of any of the joints. There is no muscular
atrophy. The examination of the chest shows no abnormality,
and we have been unable to discover anything that indicates
a preceding specific infection (syphilitic).






216


[No. 79.






I have been much interested in this patient, and it is surely
an unusual case. That a young woman of her age should
have been affected with a hemiplegia associated with a temporary loss of speech, and followed by recurring attacks simulating closely Jacksouian epilepsy. Is very remarkable. The
diagnosis of hysteria seems at first sight the most probable
one. Organic vascular lesions are very fare at her age, except
when they are associated with syphilis. In this case there is
nothing in the previous history or in the present condition
that suggests such a cause. The patient was at the onset
undoubtedly very hysterical, and you will remember that she
gave the history of preceding hysterical attacks, all of which
speak for the diagnosis of hysteria ; but the condition in
which you have seen the patient suggests an organic paralysis
more than an hysterical one. Maun and other observers have
studied the distribution of the paralysis due to organic brain
disease, and have determined that there are certain movements which are most apt to be paralysed. The movements
which are most often jjaralysed are those of the thumb, and
next in order of importance is the outward rotation of the
arm. In the case before you, these are just the muscles which
are paralysed. The excessive increase of the deep reflexes,
which is ijresent in this case, is also unusual in association
with hysterical paralysis, so I think we are justified in stating that the character of the pai'alysis is that due to an
organic brain lesiou, rather than to hysteria. The character
of the convulsive attacks also points to an organic lesion, as
true Jacksonian attacks are, as far as my knowledge goes,
extremely rare in hysteria. Although I am not very positive
about it, still I believe that we have a definite disease of the
brain in this ease, and I am inclined to think that this
disease is a slow-growing tumor. I have been led to this
belief from an experience which we have lately had. Some
of you will remember that I reported to this Society last fall
the clinical history of a case upon which we had advised
operation. The case was that of a man who, for six years,
had had recurring attacks of Jacksonian epilepsy, beginning in
his right foot, and which had later involved the right arm
and face, and in whom there had developed paralysis of the
leg, and of the arm. There were none of the general symptoms of brain tumor, and the operation revealed nothing
abnormal; but the microscopical examination of the brain
showed a most interesting new growth of the motor region,
about which I hope Dr. Flexner will have something to say.
The case which I have presented to you to-night, although
not quite similar, will suggest this case strongly, and we fear
is of a like nature.


Note. — While in the Hospital, in the early part of June,
the patient had another attack. She was in the dining-room,
talking with some friends, when the fingers of her right hand
became stiff and painful. This extended up the arm, the
hand and arm drew up, her head was drawn to the right side,
and there was intense pain in her head. She then lost consciousness. Those who were about her say that her eyes were
turned to the right and that her right leg was stiffened out,
and that she fell to the floor. When she became conscious, in
about five minutes, she could not talk for a few moments, and
felt weak and badly, but was not hysterical.






Demonstration of Specimens.— By De. Ccllen.


Several weeks ago at a meeting of this Society, Dr. Kelly
spoke at length on the operative treatment of myomata and
pointed out tiie ease with which these growths could be
removed. Since that time I have operated upon two patients
where the conditions present rendered the enucleation very
diflicult. Both of these cases present so many clinical points
of interest that we may proiitably discuss them for a few
moments.


Case 1. Umbilical hernia; multinodular myomatous icterus;
large ovarian abscess communicating with the small intestine;
hysterectomy.


K. L., aet. 40. Admitted to Dr. Kelly's service March 23,
1897. Complaint, abdominal tumor, pains in the lower right
abdomen and leg. She had been married 20 years, but gave no
history of pregnancy. Menses began at 13 years, and were
regular until August 15, 1896, when they ceased fori months,
since which time they reappeared. Flow moderate, at times
clotted; occasionally it is painful.


month.  
Family history negative.  


Previous history unimportant.


of operation.  
Present condition. Ten years ago she noticed a tumor about
the size of an Qgg in the right side of the pelvis. This has
steadily increased in size and has been almost constantly associated with a gnawing pain over its most prominent part.
The pain has been so severe that she has at times been confined to bed, on one occasion for 3 months. The last attack
was 3 months ago. Locomotion very difficult on account of
pain in the legs. These are at times swollen and pit on pressure. No chills. No fever. The patient is well nourished,
has a good appetite, bowels constipated. For the last two
years she has had night sweats regularly.  


The abdomen is much distended and presents an irregular
lobulated appearance. At the umbilicus is a hernial sac
fully 9 cm. in diameter. The skin over this can be drawn out
for a distance of 6 cm., while the hernial ring whose margins are
very sharply defined is 3 cm. in diameter. The following are
the abdominal measurements : Distance from symphysis to
umbilicus 1-1 cm.; from umbilicus to xyphoid 29 cm.; circumference at most prominent part of tumor 126 cm.; midway
between umbilicus and xyphoid process 96 cm. Examination
occasioned little pain.


Operation March 24, 1897. On account of the irregular
hernial protrusion the abdominal incision was commenced at
a point midway between the xyphoid cartilage and the umbilicus and continued downward to within a short distance of the
pubes, the hernial sac being encircled and removed. At the
umbilicus the omentum which was firmly adherent was ligated
and then freed. Presenting at the incision were several subperitoneal myomata ; to these the omentum was also firmly
adherent. After loosening up these adhesions, the nodular
myomatous uterus, 28x21 cm., was delivered. (See the accompanying figure.)


Occupying the posterior part of the pelvic cavity was an
elastic tumor 17 cm. in diameter ; this looked like an ovarian
cyst and was intinuitely adherent to two loops of snnill intestine. On attempting to shell off the outer layers of the cyst






October, 1897.]


217






 
leaving them attached to the intestines, the cyst ruptured and
 
was found to contain about 900 cc. of greyish foetid pus. A
uterine.  
glass trocar was introduced and the pus evacuated. The
uterus was then removed in the usual way from left to right,
but the left tube and ovary were left in situ. After bringing
the cervical stump together the ovarian abscess was freed and
the vessels at its pedicle controlled by silk ligatures. It was
necessary, however, to leave a small part of the sac attached to
the intestines, and on careful examination an opening 1 cm.
in diameter was found between the intestine and the abscess
sac. The margins of the intestinal opening were almost as
dense as cartilage and at the same time very friable. After a
good deal of dissection it was possible to turn the edges in and
the opening was closed by fine silk sutures. This now was
supported by a second and a third row.  








A longitudinal section of the abdomen, showing from above downward the large multinodular mj-omatoug uterus, to the upper and anterior
surface of which the omentum is adherent, an umbilical hernia to whose
ring the omentum has become adherent, a pus tube and an unusually
large ovarian abscess which communicates with a loop of small intestine.
The abscess wastoore on the right side of the body, but has been drawn
on the same level to bring it out more clearly.


During the entire operation, which lasted 5 hours, the
patient did not lose 3 oz. of blood. The abdomen was thoroughly cleansed with two litres of salt solution, the pelvic
peritoneum drawn over the cervical stump and the abdomen
closed without drainage.


matter.  
On the eighth day the temperature rose to 100.8° and about
the "^Oth day reached 101°. At that time there was consider




able pain in the left iliac fossa and an indefinite thickening
could be made out, but from this time on she rapidly recovered and was discharged May 4th feeling comparatively well.
From this case we may learn that where there is an umbilical hernia or adhesions are suspected it is well to begin the
incision at a point above this; the finger can then be introduced
into the abdomen to act as a guide. The presence of the
ovarian abscess is very readily explained. There has evidently
been an ovarian cyst. With the increase in size of the myoma
the cyst has been firmly pressed against the intestines, adhesions have formed, and as continuous pressure promotes
absorption, the walls have gradually atrophied until an opening has formed between the two. Attention may also be
drawn to the fact that no drainage was emj^loyed.


Case 2. Large tnyomatous uterus extending out laterally
betiveen folds of broad ligament; complete hysterectoiny necessary
as no cervix was left; danger of injuring the ureters.


M. F., aet. 40, admitted to Dr. Kelly's service March 29,
1897. Complaint, an abdominal tumor. Menstrual history
somewhat indefinite, but the periods were regular until two
years ago, since which time the patient has had a continuous
bitt not excessive bloody discharge.


Family History. Mother's family showed a decided tuberculous tendency.


Present Condition. She first noticed abdoaiinal enlargement during the summer of 1896. It has steadily increased
since then and showed more advancement on the left than
right side. During the last four years she has had on an average one profuse uterine hemorrhage each year; the last was
one week before admission and continued three days. For one
year there has been marked but not constant pain in the lower
abdomen. Micturition frequent. No history of chills or
fever.


Abdominal Examination. The abdomen is the size of a full
term pregnancy, the greatest prominence is to the left of the
umbilicus. Just below the umbilicus in the mid-line is a hard
flattened area 8 cm. broad, to the right of which is a second
nodule. From the character and consistence of the nodules
one instantly suspects myomata.


20  
Measurements. Distance from symphysis pubes to umbilicus 24 cm.; from umbilicus to xyphoid process 20 cm.; from
right ant. sup. spine to umbilicus 25 cm.; from left aijt. sup.
spine to umbilicus 24.5 cm., girth at umbilicus 88 cm., greatest girth which is 8 cm. below the umbilicus is 91 cm.


On vaginal examination the cervix was felt as a half-moonshaped slit directly behind the pubes, while the whole upper
part of the pelvis was filled with a hard globular mass, forming a part of that occupying the abdomen.


1805
Operation March 31, 1897. Hysteromyomectomy. The
abdominal incision extended from a point 4 cm. above the umbilicus almost to the pubes. The myoma was delivered without difficulty, but found firmly fixed in the pelvis. Upward
it reached a point midway between the umbilicus and xyphoid
cartilage, was lobulated and laterally stretched out under the
broad ligaments. The right round ligament was tied and cut,
the vessels of the right tube and ovary were controlled and the
appendages on this side were left in situ. On the left side the




Cad well.


218


No.  
[No. 79.  




Fullterm.
Labor
pains one


tube aud ovary were fouud lying on the ujiper surface of the
tumor and could not be saved. After ligating and cutting the
left round ligament the folds of the broad ligament were
separated, exposing an artery 2 mm. in diameter lying on the
surface of the tumor — this was probably the ovarian artery ; it
was tied off and the bladder peritoneum freed from the tumor.
The myoma was then rolled upward and to the right, but on
the left side the uterine vessels as such could not be isolated ;
they were, however, controlled by passiug stout sutures at
their usual site.


26 yrs.  
It was now my intention to amputate at the cervix, but as
this was entirely involved by the tumor the vault of the
vagina was opened into, its upper portion being removed.
The right uterine vessels were caught by the forceps and
the tumor was freed. lu both broad ligaments were many
dilated lymph spaces. After controlling the large vessels
with silk and checking all oozing along the vaginal cut
surface with catgut the vaginal mucosa was turned down
into the vagina and the i-aw surfaces were brought together,
thus shutting off the pelvic cavity. The bladder peritoneum
was then drawn backward over the stump aud united with
that of Douglas' sac. Considerable anxiety was felt as to the
safety of the ureters, as it was necessary on account of the
vaginal vault being so widely opened to control the uterine
'vessels further out than usual. On the left side a rounded
cord was seen included in the ligature, but on unraveling this
it was found to be a fold of peritoneum. After washing out
the pelvis with two litres of salt solution the abdominal cavity
was closed. The patient made a perfect recovery and was
discharged May 3, 1897.  


In this case the chief anxiety was centred around the ureters. We were loath to close the abdomen without further
examination as to their safety, but the patient's condition did
not warrant any delay. Strict orders were given to have all
the urine measured to determine if sufficient were secreted.
The amount obtained satisfied us that both kidneys were doing
their normal amount of work. Had a ureter been tied the
abdomen would have been again opened and the ureter anastomosed into the bladder.






NOTKS OX NEW BOOKS.


Archives of Clinical Skiagraphy. Sydney Rowland, B. A. Camb.,
Editor. Volume I, Parts I-IV. 1890-7. (The Rebman Publishing Company, Limited, London.)


1
A publication whose ol)ject is "to put on record in permanent
form some of the most striking ai)plicationsof the ' New Photography to the Needs of Medicine and Surgery,' is being edited by Mr.
Sydney Rowland, the special commissioner appointed by the British Medical Journal to make inquiry into the above-mentioned
applications. The Archives of Clinical Skiagraphy published its
first number iu May, 1886. Since then three more numbers have
appeared at irregular intervals. Each of them contains a series of
six collotype plates, taken from some excellent X-ray negatives, to
which a brief clinical and explanatory note is appended. Most of
the plates are of simple skeletal lesions of the extremities, illustrative of fractures, malformations and neoplasms.


There are few reproductions of .the more difficult exposures
through tlie pelvis or chest, and but cur.sory mention of attempts to






recognize lesions other than osseous ones, euch as intra-thoracic


aneurism, changes in the cardiac area, pulmonary affections, renal
calculi and the like. There is an excellent skiagrai)li of tubercular arthritis of the hip in No. 3 and of congenital dislocation of the
hip in No. 4, evidently in children.


Retained
In the last number (April, 1897) the scope of the publication has
in uterus.  
been enlarged somewhat, and reijroductions of subjects other than
purely clinical ones are presented, such as of zoological specimens,
and reference is made to the possibility of taking moving shadow
pictures for cinematographic purposes.  


The life of such a publication, if devoted purely to clinical subjects, seems to come to a natural termination when its mission of
calling attention to the great usefulness of the X-rays for the diagnosis of many pathological conditions has been fulfilled.


To-day an X-ray apparatus has become an almost necessary
adjunct to the hospital or private armamentarium, and skiagraphs
are as much to be expected in a clinical report as ordinary photographs, and will occupy an equally important place in the forthcoming text-books on fractures, orthopsedic?, etc.


It seems, therefore, that the value of such a periodical would be
enhanced if it aimed, as do some of the better photographic journals, towards the perfection of the ways and means of betteringthe
art of skiagraphy rather than towards the mere reproduction of its
quite familiar results.


The Archives are very handsomely published by the Rebman
Publishing Company. The reproductions are good. Such type,
paper and broad margins would be welcomed in many better known
and more generally useful medical magazines. H. W. C.


Injuries and Diseases of the Ear, being Reprints of Papers on Otology. By Macleod Yearsley, F. R C. S., Fellow of the British
Laryngological, Rhinologiial and Otological Association, etc.
(1897, London: The Rebman Publishing Co., Limited, 11 Adams St.,
Strand.)


Yes.  
This little book is an interesting collection of monographs, and is
not a systematic treatise on diseases of the ear. All of the articles
are interesting and suggestive. We would especially commend
" Foreign bodies in the ear and their treatment," " What not to do
in diseases of the ear," and " On the care of the ear in children."
The chapter on "Aural Reflexes" is too brief to be .satisfactory.
It is to be hoped that the author will at some future time esjtand it
into a book.  


Inebriety. Its Source, Prevention and Cure. By C. F. Palmer.


(New York: F. H. Retell Co., IS97.)


This short tract or sermon is not in any way a scientific discussion
of this subject, and so lacks all special value for a physician. It is
only suitable for that body of the laity who have a small amount
of scientific knowledge. The point on which the author lays most
stress is that inebriety is due to a neuropsychopathic constitution,
and that consequently it is a result of mental deformity rather than
a moral infraction, and he believes that almost all inebriety may
be traced back to a mentally or physically diseased ancestry. But
his remarks might be applied with almost as much fitness to any
other form of mental deformity as inebriety.


Medical and Surgical Report of the Presbyterian Hospital in the


City of New York. Vol. II, January, 1897.


Died from operation performed
This report compares very favorably with Volume I, and with
through the .cer
more supervision in the editing would be still better. Many of the
papers published in this volume have appeared before in the New
York medical journals, which detracts from their vivid interest. For
those who have not read the journals there are good papers on
tj'phoid fever, tuberculosis, and a variety of other topics both
surgical and medical, reported at greater or lesser length. The
description of the operating pavilion as an aid in construction for
other hospitals is most valuable.  


21




1806
October, 1897.J


219


Grivel.




Hysteria and Certain Allied Conditions. Their Nature and Treatment with Special Reference to the Application of the Best
Cure, Massage, Electro-therapy, Hypnotism, etc. By Geokqe J.
Prbston, M. D., Professor of the Diseases of the Nervous System,
College of Physicians and Surgeons, Baltimore, etc. 8vo, pp. 298.
(P. Bktckision, Son & Go., Philadelphia, 1897.)


Dr. Preston modestly prefaces his book with an explanatory
apology. Two reasons, he says, may perhaps be deemed of sufficient weight to warrant its appearance ; first the great importance
of hysteria, and secondly tlie lack of a recent book in English on
the subject. The book is intended for the American general practitioner. Its "object is to present the symptomatology and differential diagnosis of hysteria in as concise a manner as possible, and
to indicate the various therapeutic measures that have been found
useful in the treatment of the disorder."


day.  
The author first gives a short sketch of the history of hysteria,
 
in which special attention is given to tlie epidemics of hysteria so
 
common in the Middle Ages and occasionally seen since then. An
interesting account is given of the hysterical " orgies" enacted at
the religious revivals of Kentucky and Tennessee in the early part
of this century, and of the camp-meeting "trances " of the Southern negro.


The historical account is followed by a chapter on the " Nature of
Hysteria." The etiology is considered in some detail. Sex, age,
race, climate, heredity, diathesis, education and environment, and
" reflex irritation" are discussed. In regard to " race," the author,
who has had considerable experience with hysteria in the negro,
thinks that the disorder is more frequent in that race to-day than
it was during the slavery period. Indeed, it is at present by no
means uncommon. Special stress is put upon the part that environment plays in the etiology of hysteria. The part played by " reflex
irritation " is considered undetermined. It is rare that an abnormal condition of the organs of generation gives rise to the disease,
though a morbid train of associated ideas often makes the hysterical woman refer her troubles to these parts.


The consideration of the etiology of the disease is followed by a
brief review of the many theories that have been held as to its
nature. The author concludes that hysteria is an affection of the
hij;her brain centres, perhaps an actual though temporary loss of
protoplasm. In bringing together his reason for this conclusion
Dr. Preston shows an acquaintance with the more recent work on
the fine anatomy of the cerebral cortex and an admirable hesitancy in making deductions from the suggestive results of the
histologists.


There follows a chapter on "Symptomatology." Hysteria is
considered as a single disease, though most protean in nature.
The symptoms of the disease are divided into the following categories: 1. Disturbances of sensation: anaesthesia, paraesthesia,
hyperaesthesia, affecting both the general sensibility and also tlie
special senses. 2. Disturbances of motion : paralysis, contracture,
tremor, convulsive seizures. 3. Vaso-motor, visceral, and nutritive disturbances. 4. Mental symptoms. 5. Miscellaneous symptoms.


The disturbances of sensation are treated with the fulness of
detail which the subject warrants. Special attention is given to
" hysterogenesis." The author feels convinced from cases of his
own that the hysterogenic zones, first described by Charcot, have a
real existence and are not the result of suggestion.


A good description is given of the various disturbances of the
motor-system. The author draws an interesting comparison
between the manifestations of liysteria in this country and those
in France. " 1 have often been struck," he says, " with the similarity between the cases of hysteria in negroes, who, of course,
have never been in any possible manner under the influence of
suggestion, and the so-called ' show cases' at the Salpetriere."






Under "mental symptoms" are considered the general mental
state of the hysterical patient,* hysterical insanity, lethargy, narcolepsy, catalepsy, ecstasy, somnambulism, and vigil ambulism.
Somnambulism, while not necessarily hysterical in nature, is considered to be very closely allied to hysteria on the one hand and to
hypnotism on the other.


The visceral disturbances include contracture of the oesophagus,
vomiting, hematemesis, hysterical anorexia, intestinal disturbances; affections of the genito-urinary apparatus ; disturbances of
the respiration and of the voice. Under cardiac and vaso-motor
symptoms are considered tachycardia, flushing of the face and
upper part of the body, autographism and cutaneous affections.
Nutritional disturbances include muscular atrophy and hysterical
fever. The latter, the author concludes, is a real though rare
condition.


A third of the book is given up to a detailed consideration of the
diagnosis and treatment of hysteria. There has been an evident
and successful effort to make this clear, practical and helpful.
Under differential diagnosis emphasis is put upon the fact that
though hysteria is manifold in nature it is almost always characterized by certain stigmata, as for instance anaesthesia, which as a
rule may be clearly distinguished from similar disturbances due to
organic disease. "The central idea in the treatment of hysteria
may be expressed in the word 'suggestion.' " The physician must
have the confidence of his patient. In the general treatment of
the disease the main reliance is to be placed upon a careful regulation of the diet, the meals, rest, exercise, occupation, and habits.
Drugs are useful mainly because the patient is apt to have faith in
medicine. The treatment of special symptoms likewise depends
chiefly on suggestion. In case of severe attacks pressure on the
hysterogenic zones, ice suppositories, apomorphia, chloroform, at
times hypnotism, may help to terminate the attack.


Electricity, which has proved so valuable in the treatment of
hysteria, owes its main effects to the power of suggestion. On the
other hand, water as a therapeutic agent has a direct marked
beneficial physiological effect in addition to its suggestive use.
For the routine treatment of hysteria the alternate warm and cold
douche is warmly recommended. Massage is chiefly applicable to
those cases of hysteria, often complicated with neurasthenia, in
which the patient cannot or will not take out-door exercise. The
Weir Mitchell Rest Cure is considered in some detail. Hypnotism,
of which the author gives a very interesting account, is considered
very valuable in some cases, though on the whole it has proved
disappointing as a therapeutic agent. Its great value is "that it
has taught us how to make our treatment of the hysterical subject
suggestive." Surgical interference is rarely necessary or of value.
The author deplores the frequency with which ovariotomy has
been done in this country merely for the relief of hysteria.


Abdomen.  
The book as a whole is admirably fitted for the purpose for which
it was designed. The author makes no attempt at an original
treatment of hysteria. He has drawn extensively from the literature on the subject, giving references to the more important articles.
Yet he is far from being a mere compiler. He views the subject
throughout from a modest yet independent standpoint, based on
an experience with hysterical patients rendered the more valuable
by an evident deep personal interest in the subject. The style is
direct, clear, and interesting, though at times rough. The book is
illustrated by diagrams taken from Charcot and Gilles de la Tourette, and by pictures from the drawings of Richer. It is well
printed and well bound. It should prove not only most valuable
to the general practitioner, but also of interest to the specialist in
nervous diseases. C. R. B.  




8;) years.


» "As has been aptly put, the hysterical patient says ' I cannot,' it loolis like
'I will not,' but it really is 'I cannot will.'"






220


[No. 79.






THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.




vix.


FACULTY.




228


Daniel C. Gilman, LL. D., President.


William H. Welch, M. D., LL. D., Dean and Professor of Pathology.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.  


WiLLiAJi OsLER, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice


of Medicine.
Henry M. Hdrd, M. D., LL. D., Professor of Psychiatry.
William S. IIalsted, M. D., Professor of Surgery.
Howard A. Kelly, M. D., Professor of Gynecology and Obstetrics.
Franklin P. Mall, M. D., Professor of Anatomy.
John J. Abel, M. D., Professor of Pharmacology.
William H. Howell, Ph. D., M. D., Professor of Physiology.


[No. 80.  
William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology.
John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine.
Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology.
William D. Booker, M. D., Clinical Professor of Diseases of Children.
John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology.
Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology.
Henry M. Thomas, M. D., Clinical Professor of Diseases of the Nervous System.
Simon Flexner, M. D., Associate Professor of Pathology.
J. Whitridge Williams, M. D., Associate Professor of Obstetrics.
Lewellys F. Barker, M. B., Associate Professor of Anatomy.  






KUCHENMEISTER'S TABLE OF CASES REPORTED BETWEEN THE YEARS i582 AND 1880. -Continued.  
William S. Thayer, M. D., Associate Professor of Medicine.  


John M. T. Finney, M. D., Associate Professor of Surgery.


George P. Dreyer, Ph. D., Associate in Physiology.


1819
William W. Russell, M. D., Associate in Gynecology.


Henry J. Berkley, M. D., Associate in N euro- Pathology.


Seller.  
J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.  


T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.


1819
Robert L. Randolph, M. D., Associate in Ophthalmology and Otology,


Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.


Prael.  
Thomas B. Futcher, M. B., Associate in Medicine.  


Joseph C. Bl-oodgood, M. D., Instructor in Surgery.


1830
Thomas S. Cullen, M. B., Instructor in Gynecologj'.


Frank R. Smith, M. D., Instructor in Medicine.


Bruns.  
George W. Dobbin, M. D., Assistant in Obstetrics.  


Walter Jones, Ph. D., Assistant in Physiological Chemistry.


1831
Adolph G. Hoen, M. D., Instructor in Photo-Micrography.


Sydney M. Cone, M. D., Assistant in Surgical Pathology.


nonisch.  
Louis E. Livingood, M. D., Assistant in Pathology.  


Ross G. Harrison, Ph. D., Instructor in Anatomy.


1825
Henry Barton Jacobs, M. D., Instructor in Medicine.


Charles R. Bardeen, M. D., Assistant in Anatomy.


Cruveilhier.




1828
GENERAL STATEMENT.


The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is
an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from Its close affiliation with the Johns
Hopkins Hospital.


Lee Heiskell
The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the
middle of June, with short recesses at Christmas and Easter.


The course of instruction is planned for the professional education of those who have received a liberal education, as indicated by a collegiate
degree iu arts or science, including a reading knowledge of French and German and adequate training in those branches of science, such as physics,
chemistry and biology, which underlie the medical sciences. Men and women are admitted upon the same terms.


1832
In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and iu the Dispensary and Wards of the Hospital.
While the aim 'of the School is primarily to train practitioners of medicine and surgery, It is recognized that the medical art should rest upon a
suitable preliminary education and upon thorough training in the medical sciences. The first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in tlie Laboratories of Anatomy, Physiology, Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. During the last two years the student is given "abundant opportunity
for the personal study of cases of disease, his time being spent largely in the Hospital Wards and Dispensary and in the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage In practical work In the
Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.


REQUIREMENTS FOR ADMISSION.


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


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


3. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading
knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as Is Imparted by the regular minor
courses given in these subjects in this university.


Case reported
The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises
from the city of
and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week In the laboratory in
Danzii?, author
each subject.  
not cited.  


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


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


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


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


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


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


SPECIAL COURSES FOR GRADUATES IN MEDICINE.


Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance
upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afl'orded.
With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period
of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the
majority of those desiring to take the courses than the former one.


Playfair.  
The special courses of instruction for graduates in medicine are now given annually during the months of May and June. During April there is
a preliminary course in Normal Histology.  


These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children,
Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended
to meet the requirements of practitioners of medicine, and Is almost wholly of a practical character. It includes laboratory courses, demonstrations,
beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital.


These courses are open to those who have taken a medical degree aud who give evidence satisfactory to the several instructors that they are
prepared to profit by the opportunities here otTered. The number of students who can be accommodated In some of the practical courses Is necessarily limited. For these the places are assigned according to the date of application.


Chiari.  
The Annual Announcement and Catalogue will be scut upon application. Inquiries should be addressed to the


Galli.  
HEGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.  


Deschamps.




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


Kuchenmeister.




BULLETIN


Number
of births
before the
ectopic
pregnancy.




OF


I full


terms, 3
abortions.


THE JOHNS HOPKINS HOSPITAL.




Time
when labor pains
or symptoms of
rupture
occurred.


Vol. VIII.- No. 80.]




At the end
of the 9th
month


BALTIMORE, NOVEMBER, 1897.




No symptoms of
labor.


[Price, (5 Cents.




Full term,
3 days
long.


coisrTEisrTS.




End of the


9tb
PACK.


month
A Rare Case of Lithopedion. By J. G. Clark, M. D., - - 221
On Tuberculosis of the (Esophagus, with the Report of a Case


of Unusual Infection. By Clahibel Coxe, M. D., - - 229


A Rare Anomaly of the Arch of the Aorta, with an Additional


Labor
Muscle in the Neck. By A. B. Herrick, . . - - 234
pains at
full term


Labor
pains at
full term


Full term.
Labor
pains continued 3
days.


On the Hsematozoan Infections of Birds. By W. G. MacCalLUM, M.D., - - - - - - - - - - 235


A Case of Cavernous Angioma (Vascular Nkvus) of the Tunica


Full term.  
Conjunctiva. By Dr. H. O. Reik, - - - . - 236
Labor
Books Received, . - - 237
pains 14
days.  






8th month.  
A RARE CASE OF LITHOPEDION.  




49yrs


By J. G. Clark, M. D.


75 months.




87 yrs
During the month of August, 1896, a patient suffering
with an abdominal tumor, dyspncea and pain in the lower
abdomen, was admitted to the gynecological wards of the
Johns Hopkins Hospital for treatment, and, through the
kindness of Dr. Kelly, I was given charge of the case.


The patient's history was strongly suggestive of the rupture,
four years previous to her admission, of an extra-uterine pregnancy sac, with the extrusion of the fcetus into the abdominal
cavity, and the physical examination revealed a stony-like
mass, resembling a foetus in form, which proved at operation
to be a lithopedion.


Pull term.
As the formation of a true lithopedion is of rare occurrence,
Labor
and as this was a typical case, I have thought it worthy of
pains for
publication.  
3 days.  


History of Case.


7yrs.  
B. H., colored, married, age 45 years. Admitted August 8,
1896.  


yrs.  
Chief Complaints. Pains in the lower abdomen, enlargement of the abdomen, and dyspnoea.  


Marital History. Married 14 years, three children, oldest
12, youngest 7 years old.


Full term.  
First labor difficult, attended by a midwife, who had to call
in a physician to remove an adherent placenta. Last two
labors easy, slight chills and fever after birth of last child.  


Labor
Menstrual History. Flow appeared first in her thirteenth
year, always regular, but accompanied by much pain in the
left side. For the last three years the flow has been regular,
lasting 4 to 5 days.


pains 33


hours.
Full term.


Few days.  
Family History. Mother is insane, otherwise no history of
hereditary disease.  


Present Illness. Four years ago the menstrual flow ceased
and the patient had all the symptoms of early pregnancy.


11 yrs
Towards the end of term her lower extremities swelled very
much, and she felt so weak and miserable that she was compelled to go to bed, where she remained itntil long after the
regular term. During the latter months of pregnancy foetal
movements were distinctly felt. About the time for her confinement she had an attack of severe pain in the left side and
felt something break. Much watery fluid was passed by the
vagina.


67 yrs
At the end of a week her physician was called, who told
her that she had an extra-uterine pregnancy and advised an
operation, which she declined. During the time while her
legs were oedematous she became almost blind. The size of
the abdomen has decreased slightly, but the pains in the left
side still persist, and of late have grown more severe.


General Condition. Tall, emaciated woman, tongue slightly
coated, lips and mucous membranes pale, patient seems moody
and of a despondent disposition.


Bowels constipated, at times she goes a week or ten days
without a movement.


Length
Micturition painless. Appetite poor.


of time
Examination.
Abdomen irregularly distended by a tumor which presents most prominently on the left side. It is quite hard,


fa'tus


was


retained
222


[No. 80.




46 yrs.
28 yrs.


only slightly movable, and is apparently connected by adhesions with the anterior and lateral abdominal walls.


The tumor lies in an obliqne position within the abdomen,
the upper extremity is felt beneath the left lower rib, the
lower extremity being crowded down into the right inguinal
regiou.


7 yrs. up
The general surface of the tumor is smooth, but numerous
to time
hard projections are felt over it, which are denser than the
of operation.
main body of the tumor.  
47yis.  


40 yrs.  
Abdomen tympanitic over right half. Immediately below
 
and one inch to the left of the umbilicus, where the most
2 yrs.  
resistant part of the mass is felt, the percussion note is flat.  


No percussion wave.


Examination under anmsthena. Outlet relaxed, cervix in
axis of vagina. Uterus normal in size, in anteposition, pushed
forward against pubes by a mass posterior and above uterus.


26 yrs.
The left tube and ovary are enlarged; nothing detected on
10 yrs.
right side except general, ill-defined bogginess.  
>iyr.  


The main body of the tumor may be pushed away from the
uterus, but seems to have a slender pedicle.


The ill-defined mass in the right side, by rectal examination,
feels very boggy and is in close relationship with the hard
tumor.


^yr.  
Urinary Exainination. Color clear amber, slight cloudy
sediment, sp. gr. 1035, acid reaction, no sugar or albumen.
A few pus cells.  


Operation.


Operation by Dr. Clark, August 14, 1896.


Abdomen.
Abdominal section for the removal of a lithopedion, double
Uterus.  
salpingo-oophorectomy for hydrosalpinx and cystic ovary on
left side, and for the removal of the right tube and ovary,
which were converted into an ectopic gestation sac.  


Complications. Adhesions between the anterior abdominal
wall and back of foetus. Dense adhesions binding the gestation sac to the intestines. Placenta necrotic.


Incision 10 cm. in length, revealing a mottled yellow tumor
closely adherent to the abdominal wall.


3.. tube
On releasing these adhesions and passing the hand up
beneath the left lower rib, the foetal head was felt lying in
close contact with the spleen. The left arm and shoulder
were closely adherent to the anterior abdominal wall near the
umbilicus.  


and ovary
In order to facilitate the delivery of the fostus the abdominal incision was enlarged to a point midway between the
Abdomi
ensiform cartilage and umbilicus.


oal cavity
Numerous bleeding tags of adhesions were ligated.
Posterior


wall of
The foetus occupied an oblique position in the abdomen, its
chest lying in close contact with the aorta, from which it
derived a distinct pulsation impulse.


uterus
The fo?tal head was grasped and gently delivered from the
abdominal incision, after which the umbilical cord was cut
close to its placental attachment in the pelvis. On inspecting
the pelvic structures the fimbriated end of the tube was found
adherent to the ectopic sac, having been apparently torn from
the body of the Fallopian tube at the time of the primary
rupture.


and its
The secondary or adventitious sac was situated between the
folds of the broad ligament. On the floor of the pelvis a large


adductor.


Possibly


in one
placenta was attached. The larger portion of the sac projected up into the abdominal cavity, and was densely adherent
to the vermiform appendix, ceecum and intestine. Secondary
rupture had occurred in the superior wall of the sac, the
umbilical cord projecting through it into the abdominal
cavity.


corner of
The placenta was very friable, and on attempting to detach
it, broke up into small bits, requiring its removal piecemeal.
The ectopic sac was dissected free from the intestine and
its attachments in the pelvis, and enucleated with the right
tube. The ovary could not be distinguished in the necrotic
mass.


uterus.
A large cystic ovary and hydrosalpinx were removed from
Abdominal cavity.  
the left side.  


Abdominal cavity irrigated with .5 litres of salt solution.
Abdomen closed with buried silver and subcutaneous cat-gut
sutures.


Pulse at beginning of operation 120, at completion 90 beats
a minute.


L. ovary.
Patient made an uncomplicated recovery, temperature at no
L. ovary?
time after operation rising above 100° F.  


Discharged 28 days after operation, well.


Db. Barnum's History of the Case.
In a private letter. Dr. Barnum, of Lancaster, Va., has given
the following account of the case :


R. ovar.  
I remember the case of Mrs. Harris very well, owing to the fact
and parov.  
that it is the only one of the kind ever seen by me. I was called
to see the case in October, 1S92. I found the patient weak, nervous, despondent, and at times wicha mind decidedly unbalanced.
From her and her husband, who is a colored man of intelligence
and good standing, I learned that she became pregnant the previous November. There was the usual suppression of the menses,
morning sickness, quickening, filling out of the breasts, and all of
the signs which she, as the mother of several children, recognized
as indications of the pregnant condition.  


In August she was taken with perfectly normal labor pains and
the colored midwife was sent for. Neither the patient nor her
colored attendant suspected that anything was wrong until forced
to believe it by the delay in the delivery.


At my first visit to the patient, two months later, an external
examination showed her pregnant condition.


Tube and
Digital examination, however, revealed the uterus of a nonpregnant woman.  
ovary.  


At a still later visit I was able to grasp a knee of the foetus
through the abdominal walls of the mother.


A rigid questioning of both husband and wife failed to elicit any
history of previous abnormal pregnancy or miscarriage.


Fimbriated end
As this pregnancy had not been interru))ted by any unusual
of left
sickness, I gave it as my opinion that this was a case of abdominal
tube and
pregnancy ;.or if it at any time had been one of tubal pregnancy, the
1. ovary
tube must have ruptured early in the pregnancy.  


Inonecornu uteri.  
At my first and at all of my subsequent visits I urged the patient
to go to the hospital for treatment. As she was not willing to do
this, I gave her tonics and remedies to improve her mental condition. She gradually improved, and has employed no physician, I
think, during the past year. Allow me to thank you for your
letter announcing the operation which confirmed my diagnosis.  


Pathological Report.
Extra-uterine foetus removed from the abdominal cavity
four years after the rupture of the gestation sac.




Tube and
ovary.


November, i897.J


223


Canalis
intercanaliculi.




Foetal measurements :


Age of the
Occipito-mental diameter, 12.3 cm.  
woman
at death.  


frontal " 9.3 "
Siib-occipito bregmatic diameter, 9.2 "


Bitemporal diameter, 7.9 "


) years.
Biparietal " 7.9 "
! years.  


Circumference of head, .30. "


" " shoulders, 32. "


Length of fcetus, 43. "


Weight of fcetus, 4J lbs.




Escape of
decidua


from
uterus.


The fcetus is entirely covered with a thin translucent membrane which is easily peeled off.


Only the general outlines of the face can be distinguished,
the eyes, nose, mouth and ears being entirely covered in with


Small
amount
of blood.




the membranous covering, through which the hair of the
fa?tus can be seen as a black mat.


Bloody
Scattered throughout the foetal envelope are numerous
discharge.  
yellowish white spots composed of a fatty, saponaceous
material.  


The cheeks are quite prominent, the left being much more
so than the right.


The skin covering the face and forehead is of a brownish
red color resembling burut leather, slightly mottled, and is
firm and resistant, having lost all of its pliability.


4 months
On cutting into the skin at this point the knife encounters
after the  
numerous gritty particles, but the general body of the skin is
death of  
composed of adipocere.  
the fcetus.  


The occiput and a part of the parietal bones may be seen
projecting immediately beneath the membranous covering.


The parietal bones overlap the occipital, and the jagged
sutures feel like saw-teeth.


Nine days
The skin covering the left side of the head is of a white,
after the  
bleached appearance, similar to the washerwoman's skin.
death of


foetus.  
The membranous envelope, which is probably the remains
of the amnion, is closely attached to the foetus, but can be
peeled off. It is ten millimetres in thickness and has no
visible blood-vessels when held up to the light.  


The arm on the right side is closely glued to the body, and
the space between the axilla and elbow is entirely obliterated.


The right forearm is flexed on the arm, and the fingers on
the hand.


Nine days
The dorsal tendons of the hand are seen as glistening cords
after the  
beneath the mummified fcetal skin.  
death of
foetus.  


The left forearm is half-way flexed upon the arm and
presents the same general appearance as the right side


The feet are flexed upon the legs, the legs upon the thighs,
and the thighs partially upon the abdomen.


2S'5.D
There is a considerable accumulation of adipocere aud
calcareous matter in slightly raised plaques over the lower
extremities.  


The genital organs are entirely hidden by the enveloping
membrane, so that it is impossible to differentiate the sex of
the foetus without further dissection. The entire posterior
aspect of the fretus is covered with glistening white organized
tags of adhesions which have connected the foetus with the
maternal tissues. On floating these adhesions out in water
thev are seen to form a thick wavy veil.


On dissecting this layer of adhesions, loose numerous fatty
plaques are seen in the skin.


Spontaneous delivery through  
The dorsal vertebraj form a prominent ridge, aud at points
vagina and rectum.  
where the spinous processes shimmer through the translucent
skin are seen to be in a cartilaginous state.  


The skin of the buttocks and the underlying fat and
gluteal muscles have undergone saponaceous change, with
here and there patches of calcareous matter sparingly interspersed through the external portions of the tissues


The umbilical cord is shrunken to about half its usual size
and contains many calcareous nodules.


History of case imperfect.
Median incision from the neck down to and through the
symphysis pubis reveals the following condition : Superficially the body is covered with a membranous layer which can
be peeled off easily, next comes the thick brawny bacon-like


Recovery. Fcetus
removed through
the vagina.




224


Vienna paste applied to the sac
[No. 80.  
per vag. Before it
was eroded the patient died.  






The foetuswas more
skin, and beneath it the brownish red muscle which contains
than a half year
multiple fatty areas about the size of millet seeds.  
over term before
it was delivered.  


The jjeritoneum is of a dull slate color, like that seen in an
old post-mortem subject.


The intestines are collapsed, soft, pliable, and, except for
the shrinking of the tissues from absorption of the watery
elements, appear to have undergone little or no change.


4 times
The liver is of a light brownish red tint interspersed with
delivered artificially
slate colored patches.


On section the liver is found to be much denser than
normal, the stroma is of a greenish brown color, with many
minute yellowish spots.


The lungs are atelectatic and have a dense fleshy feeling.
The color is brownish red, resembling the color of the liver.


The foetus was
On section, gritty particles are encountered with the knife.  
undergoing suppuration.  


The heart is collapsed, wrinkled, and of a dark brown color.


ON TUBERCULOSIS OF THE (ESOPHAGUS, WITH THE REPORT OF A CASE OF UNUSUAL INFECTION.  
The spleen is small and dense.  


By Claribel Cone, M. D., Professor of Pathology, Woman's Medical Colli ge, Bait i more.
On freeing the genital organs of the enveloping membrane
[From the Pathological Laboratory of the Johns Hopkins University and Hospital.^
the fcetus is found to be of the male sex.  


Microscojiical Examination. Lungs : the air spaces are
small and the epithelial lining is not visible, bui appears to be
changed into fatty detritus and star-shaped crystals.


The connective tissue between the air spaces is pale, opaque
and of a uniform homogeneous appearance, the separate connective tissue fibres not being distinguishable.


Keuewed attention to the subject of tuberculosis of the
Interspersed throughout the connective tissue septa are
oesophagus has shown that this organ is not so often spared in
many star-shaj^ed crystals.  
tuberculous affections as was at one time believed. Thus, in
a critical review of the subject published in 1893, Dr. Flexner,* who reported a new case, was able to collect from the
literature up to that date only eighteen undoubted cases.
Since his publication there have appeared, so far as has come
to the writer's notice, twenty-eight additional cases. Of these
twenty-eight cases it is worthy of remark that nine were
described by one observer, Mazzotti.f


Another case from this pathological laboratory is to be
The muscular tissue of the heart still maintains its characteristic form, although undergoing marked fatty degeneration.  
added to the list, and now that the affection is no longer
No calcareous changes visible.  
recognized as of great rarity, its report is suggested as much
by the peculiar distribution of the tubercles as by the pathological condition itself. It seems worth while at the same
time to re-collect all the cases and to consider the classification
with reference to their ajtiology.  


The classification suggested by Flexner is as follows:
The general histological structure of theliveris unchanged,
although the liver cells are undergoing fatty degeneration.


I. Instances in which the tuberculous process arises through
Diagnosis. Extra-uterine foetus undergoing saponaceous
continuity or contiguity of structure.  
mummification and calcareous changes. (Lithopedion.) The
calcareous change is limited to the enveloping membrane, skin
and lungs, the remainder of the internal organs showing only
those changes due to fatty degeneration and absorption of
their watery constituents.  


(ji) Where a caseous bronchial gland or group of glands becomes adherent to the cesophagus and ulcerates into the latter.
Kuchenmeister makes the following classification of the calcareous changes which may occur in an extra-uterine embryo
after its death :


{b) In consequence of perforation of abscesses associated
Lithokelyphos, a condition in which the fcetal envelopes
with caries of the vertebraj.  
alone undergo calcareous changes, the foetus shrinking to a
mummified mass after the absorption of the amniotic fluid.  


(c) Where tuberculous ulcers of the pharynx pass down and
Lithokelyphopedion, a condition in which the foetal envelopes and those parts of the fcetus which come in contact with
invade the cesophugus.  
the membranes undergo calcareous changes.  


II. Cases in which there exists in the CBSophageal mucous
Lithopedion, a condition in which the fcetus after its expulsion into the abdominal cavity undergoes calcareous change,
membrane a previous lesion to be regarded as predisposing to
beginning externally in the vernix caseosa.  
the tuberculous infection.  


III. Instances in which («) the cesophagus is affected in the  
Li ectopic pregnancy cases which survive the primary or secondary rupture of the gestation sac and are not subjected to
course of a general disseminated miliary tuberculosis, and (b)
operation, the embryo may be disposed of in various ways, depending upon its age and the maternal conditions surrounding it.  
in which there is infection of the mucous membrane from
tuberculous sputum where no previous lesion existed.  


Of the nineteen cases collected by Flexner,^ eleven belong
Complete absorption only occurs when the embryonic tissues
to the first class, two to the second, and six to the third. In
are largely composed of watery elements and the bones are yet
the first group are included the cases of Weichselbaum (1),
in a cartilaginous state; it is therefore highly improbable that
Beck (2), Penzoldt (.3), Orth (2), Pitt (1), and Zenker (2) ;
in the second group those of Eppinger (1) and Breus (1);  
while the third class includes the cases of Mazzotti (3), Spillman (1), Freriehs (1), and Flexner (1).


Of the six cases comprising the last group, one only occurred
in the course of a disseminated miliary tuberculosis giving
rise to an eruption of miliary tubercles in the cesophagus. This
case, which was reported by Mazzotti, § is the only published
account of miliary tuberculosis affecting the cesophagus.




an embryo more than three months old ever completely disappears in this way.


*KlexQer: Tuberculosis of the (Esophagus. .Toluis Hopkins
In order to arrive at an approximate idea concerning the
Hospital Bulletin, IV, 1893-4.  
ability of the human peritoneum to dispose of a young extrauterine embryo when expelled into the abdominal cavity,
Leopold* made an extremely interesting experimental study
upon rabbits.  


t Mazzotti : Nuove osservazioni intorno alia tuberculosi dell'
For this purpose he selected four series of pregnant animals
esofago. Dal Bulletino d. Scienze IMediche ili Bologna, VII, ser.
at different stages of pregnancy, from which he removed the
VII, 1896, 553-579.  
embryos by abdominal section and implanted them in the peritoneal cavity of other rabbits.  


X Flexner : Op. cit.  
The embryos were of the following sizes : 2.-5 cm. long, 5 to 6
cm. long, 8 cm. long, and the fully matured fcetus with intact
membranes.  


gMazzotti: Revisla Clinica, .Jannar, 1885.  
Some of the animals became infected and died from ])uru]ent
peritonitis.  


In these cases the rate of absorption was much more rapid
than in those where the peritoneum remained normal.


Although the many experimental studies upon the function
of the peritoneum have demonstrated its phenomenal absorptive ability, we are hardly prepared for Leopold's statement
that when there was an accompanying peritonitis an embryo
2.5 cm. long was so completely absorbed by the end of the
second day that no further trace of it could be found ; that a
5-cm. long foetus at the end of 24 hours showed only a small
mass of bones, the epidermis and all of the internal organs
having been absorbed; that of an 8-cm. long foetus th«re
remained only a small mass of tissue consisting of the skin,
paws and nails and the shrunken internal organs and skeleton ; and finally that the fully matured fcetus with its enveloping membranes was little less rajiidly absorbed.


The additional twenty-eight cases which have been reported
As the rupture of an ectopic pregnancy sac is in the majority
since 1893, including cases omitted from Flexner's original
of cases a sterile process, the results obtained in those experiments of Leopold in which there was no accompanying peritonitis probably more nearly indicate the approximate rate of
publication, can be divided so that thirteen fall in the first,
absorption in the human being.  
three in the second, and twelve in the third class.  


A. — Infection by Continuity or Contiguity of
In those animals the absorption was quite as effective,
Structure.  
although much slower.  


1. Selenkow* reported a case of partial destruction of the
After a few days embryos 2.5 cm. long were very much
cesophagus by tuberculosis. Gastrostomy was followed by
softened; in two instances, at the end of fourteen days they
impaired nutrition and death. In the lungs were found old
were only the size of a lentil, after thirty-four days they I
tuberculous lesions, which, approaching the root on the right
were still smaller, and at the end of fifty-two days were either \
side, invaded the lymph glands. The latter became adherent
completely absorbed or only a small trace of them could be  
to one another, forming a diffuse caseous mass both anterior
found.  
and posterior to the oesophagus, and finally ulcerated into the  
anterior wall of the tube below the bifurcation of the trachea.
A cavity about the size of a hen's egg was produced in the
enlarged and caseous lymph glands, which"" was filled with
detritus and into which the lumen of the oesophagus opened
freely. Two distinct perforations occupying an area 5 cm.
long and separated by a narrow strip of tissue existed. The
lumen of the cesophagus was constricted in the lower segment
and was only about half the size of the upper part. Although
no bacteriological or histological examination was made in this
case, the tuberculous nature of the lesions can scarcely be  
doubted.  


3. Voelckerf reports the case of a boy, aged 9 years, in whom
From these experiments Leopold concludes that a small
the post-mortem examination showed a mass of cretaceous
embryo may be absorbed completely.  
glands at the hilum of the right lung. On opening the
cesophagus a perforation was found on the anterior wall, a
little to the right of the middle line and a little below the
level of the bifurcation of the trachea. The opening was
about 5 mm. in diameter; the edges were puckered and led
into a cavity in which caseous material could be seen.  


Voelcker has also collected from 2504 autopsies in the postmortem records of the Hospital for Sick Children, four other
The accumulated observations upon the clinical course of  
cases of tuberculosis of the cesophagus associated with general
exti-a-uterine pregnancy tend to prove that the great majority
tuberculosis, to which he briefiy refers.  
of cases will rupture within the first two months of pregnancy,
and also that probably many accidents of this kind occur
without the patient dying from their effects or being subjected
to operation.  


3_4_5. lu three of these cases caseous glands ruptured into
The natural course, therefore, in these cases will be for the
the cesophagus.J
embryo to be absorbed completely. It is only when the primary
rupture is delayed beyond the third month, or when the
embryo survives the rupture and continues to develop in an


Letulle§ reports three cases, one of Londe and two of his own.




•Archiv f. Gyn., vol. XVIII, p. 53.


* Selenkow: Kasuistische Mittheilungen a. il. ausser-staJti.sclien
Hospital. St. Petershurger raed. Wochenschr., IX, 1884, 491.


fVoelcker, A. F. Caseous Gland opening into the (Esophagus.
Tr. Path. So'c, Lond., XLII, 1890-91, 87.


|Tlie additional case was one in which an oval ulcer, threequarters of an inch long, existed at the level of the bifurcation of
November, 1897.]
the trachea ; but in this case the note says: "The muscular coat
remains, the floor is smooth as if healed up, although in the neighborhood of a caseatina gland. The ulceration, as far as could be
seen, had not started froniorbeen in any way caused bythegland."
The Ktiology in this case must certainly be regardid as doubtful.  


§Letulle: Lesions tuberculeusesde I'oesophage. Bull. Soc. Anat.
225
de Paris, LXVIII, 1893,246.






230
adventitious sac until a secondary rupture occurs, that a lithopedion is likely to be formed.


In these cases the extruded embryo may lie free in the
abdominal cavity as a non-irritant foreign body, or as is more
likely, a wall of adhesions will form about it and thus shut it
oif from the peritoneal cavity. The close proximity of these
encapsulated masses to the intestines and rectum renders them
liable to infection at any time.


In the event of this complication extensive suppuration will
occur and the fcetus quickly becomes skeletonized, and its bones
may be discharged through a fistulous track into the rectum,
vagina, bladder, or through the abdominal wall. It is only in
the non-infected cases that mummification, saponaceous and
calcareous changes take place.


JOHNS HOPKINS HOSPITAL BULLETIN.  
The first cases of lithopediou recorded excited the liveliest
curiosity and speculation among physicians as to their origin,
and usually the conclusion was reached that no law governed
their formation and that their origin was due to some mysterious or occult influence.  


As an evidence of the views held by these earlier physicians,
we find the case referred to by Spachius prefaced by the following lines: "Deucalion cast stones behind him and thus fashioned the human race, hence comes it that nowadays the tender
flesh of babes is formed of stone."


In 1881 Kuchenmeister* reported a case in which a lithopedion had lain in the abdominal cavity of a woman 57 years.
He carefully reviewed the literature bearing upon the subject
of lithopediou, covering the period between the report of Albosius's case in 1582 and the time of the publication of his
article in 1880.


[No. 80.  
From the fact that a lithopedion has always been considered such a unique production it is safe to assume that
more of these cases in proportion to the number which have
actually occurred, have been reported than of almost any other
pathological anomaly, and yet from 1583 until 1880 Kuchenmeister was able to collect only 47 cases of mummified, skeletonized and calcified fcetuses, and of this number only a few
can be accepted as true lithopedions.  


Many of the earlier cases were dignified by special titles,
such as the Lithopjedion Senoeuse, Das Ileidelberger Lithopiidion von Nebel (1767), Das Berliner Lithopildion von Walter (1775), Das Dresdener Lithopildion von Seller, Sen. (1819),
etc.


Notwithstanding the great activity in the field of abdominal
surgery since 1880, the year of Kuchenmeister's publication,
comparatively few additional cases have been reported, a fact
which still further proves that they are of very rare occurrence. If we select those cases from Kuchenmeister's review
which represent a definite epoch or interesting fact in the
history of this subject, we find that Albosius's case (1583) was
the first reported. Varnier and Mangin's case (1785) was the
first of double ectopic fcetation with the formation of a skeletonized foetus and a lithokelyphos. Von Weinhardt's case
(1802) was the first successfully operated upon by abdominal
section, Bonisch's case (1831) the first successfully removed
through the vagina, Lee Heiskell's case (1828) the first reported


6. Loude's case was that of a man 50 years old, who died
•Archiv f. Gyn., vol. XVII, p. 153.  
suddenly of hfematemesis. The autopsy revealed a fistula in
the anterior surface of the (esophagus immediately below the
bifurcation of the trachea, still filled with blood aud leading
into a small tuberculous cavity which had developed in a
caseous bronchial lymph gland. The starting point of the
tuberculous lesions was found in a miliary tuberculosis of the
pleura which, invading the thoracic glands, produced caseation and calcification, and later adhesion between the affected
bronchial glands and the oesophagus, with ultimate perforation of the latter.  


7. Letulle states that his first case was very similar to that
of Loude and omits in his publication all details.


8. His second case occurred in a young man, the subject of
a tuberculous empyema which had ruptured into the oesophagus. On microscopic examination the cesophagus showed
infiltration of the muscular and submucous coats with embryonic cells, little caseation and no giant cells. Tubercle bacilli
were not found.*


K. Zenker! adds four cases, of which two belong to the  
in the United States, and Kuchenmeister's case (1880) the one
present class.  
of longest standing. The case which I now report is the  
largest lithopedion yet removed by abdominal operation
followed by recovery of the patient.  


9. In the first case the tuberculous lesion of the cesophagus
The cases just referred to are of sufficient interest to merit
occurring in a young consumptive was accidentally discovered at autopsy. The tuberculosis originated in the lungs,
a short resume of their histories.  
spread to the bronchial lymph glands, the peri-glandular tissue,
and the cesophagus, infiltrating the walls of the latter from
without inward until ulceration and perforation were produced. The mici-oscopic examination showed tubercles in the
muscular and submucous coats chieily, and numerous tubercle bacilli.  


10. Zenker's second case was a man 46 years old who had
In Varnier and Mangin's case (1785) there were two extrauterine foetuses of different ages found at autopsy.  
tuberculosis of the serous membranes. The bronchial glands
were considerably enlarged and caseous, and had ulcerated
into the cesophagus at its mid-portion in three places. The
histological examination of theresophagus showed tuberculous
infiltration of the muscularis and submucosa, while the
epithelium was scarcely affected. In the neighborhood of the
ulcers, tubercles were found in the submucosa. These contained tiibercle bacilli.  


11. A case reported by DanelJ: also belongs to this group.  
A woman who had borne twelve children again became
There were tubercle nodules in both lungs, general glandular
pregnant and went on to an apparently normal labor, March,
enlargement, and tubercles, some of which had ulcerated in
1753. The labor pains continued many days; water and considerable blood were expelled from the uterus, causing her to
the mucosa of the pharynx. The (Esophagus in its jiosterior
become weak and faint. After this false labor the patient
portion showed an extensive ulceration of the mucosa. The
gradually recovered, the abdomen, however, remaining enlarged. Eighteen mouths later she again had bleeding, from
ulcer was about 10 cm. long and extended longitudinally.
which she recovered, and continued well until the time of her
Its edges were eroded and it contained granules resembling
death, 1785, in her 75th year.  
tubercles. Other nodules taken to be tubercles were found


At autopsy a white, moderately hard tumor of 5J pounds
weight was found adherent to the abdominal wall, intestines
and mesentery. The outer surface was partly calcified, and
within the tumor a male fcetus with its placenta and umbilical
cord was found. The joints were flexible, not friable; the
extremities were hard, but still fleshy and not calcified. The
muscles were hard and brown ; the skin dense and yellow.


Ovaries and tubes normal. Close to the left uterine wall
and between it and the rectum, a hard, chalky tumor the size
of a hen's egg was found, which contained a thick reddish
slime and the bones of a two or three months foetus.


*The validity of this case may well be questioned. Mixed infections in empyema are by no means unknown, so that the possibility of the invasion of the oesophagus by other micro-organisms
This sac communicated through perforations in the uterine
(pyogenic cocci?) is well worth considering.  
wall with the uterine cavity.  


f K.Zenker: Carcinom und Tuberkel in selben Organe. Deut.
Von Weinhardt's case, 1802, should occupy a prominent
Arch. f. klin. Med., XLVII, 1891, 191 ; Beitrag zur Aetiologie und
place in the history of abdominal surgery on account of the
Casuistik der Tuberculose der Speiserohre. Deut. Arch. f. klin.
courage exhibited by this barber-surgeon in attempting such
Med., LV, 1895, 405.  
a hazardous operation.  


I Danel : CEsophagite tuberculeuse consecutive ii une ancienne
In this case the patient gave a history so characteristic of
tuberculose peribronchique generalisation ganglionnaire. J. d. Sc.
med. de Lille, XIX, 1896, 1, 520.


' the rupture of an extra-uterine pregnancy sac that V. Wein
hardt, after making an examination, not only diagnosed her


true condition, but advised an operation, which he performed


on the anterior surface. The cause of the infection of the
Sept. 35, 1801.  
cesophagus was a softened bronchial lymphatic gland situated
at about the bifurcation of the trachea, which, having become
adherent to the oesojihagus, perforated into this organ. The
opening between the gland and the cesophagus measured about
1 cm. Although no histological or bacteriological examination was made, there can be no doubt of the specific nature of
this case.  


Of the nine cases added by Mazzotti to the three previously
After exposing through an abdominal incision the tumor
reported by him only one belongs to the present group. He
mass, the surface of which was covered with veins, he delivered
confirmed his diagnosis of tuberculosis in each case by the
it with a " flesh hook." Within the mass the foetal bones
demonstration of tubercle bacilli. His experience is remarkable, not only because of the large collection of cases of a
could be felt distinctly. The foetus was removed, but no
pathological condition, the rarity of which is generally
attempt was made to enucleate the placenta. The umbilical
acknowledged, but also because of the predominance among
cord was brought out through the abdominal incision. The
them of that form of lesion which is admitted to be most
abdominal wound was dressed with cotton and a solution of
infrecjuent. In eight of his cases the process began within
balsam Peru and adhesive plaster. The patient recovered.  
the cesophagus, while, as stated, in one only there was an
extension inward from caseous bronchial glands.  


12. This case was that of a man aged 21 years, who died of
In this case the foetal envelope alone had undergone calcareous changes, the foetus having become skeletonized. Kuchenmeister therefore classified it as a lithokelyphos.  
pulmonary and intestinal tuberculosis. The oesophagus at
the union of the upper with the middle third showed two
ulcers, one near the other, somewhat elongated and of the  
size of a nentedmo. The edges of the ulcers were smooth and
of a greenish color ; the irregular bases were also green. The
ulcers perforated all the coats of the cesophagus, and their
bases were formed by a collection of detritus situated under
the cesophagus itself, and found to proceed from softened
caseous bronchial glands. Two similar ulcers, also close
together, communicating with each other beneath the mucosa,
were seen at the junction of the middle and lower thirds of
the oesophagus ; while yet below, were small superficial elliptical ulcers in the longitudinal direction of the canal. The
lymph glands had also ulcerated into the left bronchus just
at its origin from the trachea.  


13. A case arising through continuity of structure is
In the case of Bonisch (1815) the fcetus had lain in the  
reported briefly by Birch-Hirschfeld.* At the autopsy (sex
abdomen for seven years before the operation.  
and age not given) there were found tuberculosis of the lungs
and numerous tuberculous ulcers in the larynx, pharynx and
upper third of the oesophagus. Tubercle bacilli were demonstrated.  


B. — Pkedisposition to Infection due to a Previous
The patient first noticed a large lump in her left side,
Lesion.
accompanied by pain which she referred to the region of the  
 
umbilicus. This was her eighth pregnancy. The foetal
1. K. Zenker's third case was an example of coincident
movements had been quite vigorous, and at full term all of the  
carcinoma and tuberculosis of the cesophagus. A stricture of  
usual symptoms of labor came on and continued for three
the tube, produced by a girdle ulcer of rodent character,
days, after which they ceased and her breasts decreased in  
existed, which on microscopic examination showed the typical
appearance of squamous epithelioma. This growth invaded
the deeper strata of the mucosa and at times penetrated the  
muscularis. In the border of the cancerous portion, toward
the normal tissue, typical tubercles existed, some of which  
were caseous. The neighboring lymph glands also were
involved in the cancerous and tuberculous conditions.
Tubercle bacilli were found in small number in the tubercles.


Zenker does not commit himself as to whether the carciiio




*Birch-Hirschfeia: Lehrbuch der path. Anat., II, 1894, 620.
226


[No. 80.




November, 1897.]


size. For five weeks she had a bloody vaginal discharge. At
the end of nine months the menses returned. The patient did
not wholly recover, but suffered from dysuria, constipation,
occasional abdominal pains, and emaciation. In 1817 and in
1819 she again bore children, but the pain and emaciation
which had previously existed continued, and in addition she
had a foul-smelling vaginal discharge.


At the time of the operation a sharp bone (frontal bone)
projected into the vagina ; this was first removed, accompanied
by the escape of pus, after which the cranium was crushed
with bone forceps and removed piecemeal. The left arm was
then torn off with a hook, but remained attached by adhesions
to the abdomjnal wall.


JOHNS HOPKINS HOSPITAL BULLETIN.  
The bone was removed, leaving the soft parts behind. The
hook was then fastened to the right arm, and all of the parts
removed except the right thigh. This bone with the adherent parts was removed later.  


The patient recovered, but had an occasional discharge of
calcareous and cheesy masses, and the soft parts which were
left behind formed a hard swelling over thepubes. Involuntary urination still continued.


Lee Heiskell's case is of interest merely because it was the
first reported in the United States. The lithopedion was
removed at autopsy and weighed four pounds and six ounces.


231
The clinical history of Kuclienmeister's case was reported
by Hirt, an accoucheur in Zittau, in V. Siebold's Journal fiir
Geburtshiilfe in 18.34.


The patient gave birth to a dead foetus in 1819, after which
she again menstruated regularly until the end of the year
1823, when symptoms of another pregnancy appeared.


During the second half of her pregnancy she began to have
much pain, which increased as the fcetal movements grew
stronger, until she did not have an hour free from suffering.
At the time of her expected confinement she experienced
labor-like pains for a few days.


matotis or tuberculous lesion was primary, but favors the
On Oct. 25th, after eating a light midday meal, she suddenly had a feeling of heart anguish, cramp and lancinating
former view because of the admitted resistance offered by the
pain in the abdomen accompanied by vomiting.  
intact epithelium to tuberculous infection.  


2. In this group of cases the one reported by Cordua* is to  
After this time she became very sick and no longer felt the
be placed.  
foetal movements or labor pains. Three days later Hirt was
called and found the woman in an unconscious condition, with
all the signs of a septic fever associated with an inflammatory
attack in the abdomen. On account of the tympanitic condition of the abdomen Hirt was only able to make out rather
indefinitely the transverse position of the foetus above the
umbilicus.  


A man 60 years of age came to autopsy, the clinical diagnosis of carcinoma of the oesophagus, incipient pulmonary
After an examination of the uterus, which he found empty,  
tuberculosis, and adhesive pleuritis having been made. In the
he felt convinced that this was a case of "abdominal pregnancy." On account of the serious condition of the patient
(esophagus, at about the bifurcation of the trachea, was found
and the death of the foetus he did not consider the recovery of
an ulcer 10 to 15 cm. long, which affected this structure in its
the patient possible without an operation, but under the  
entire circumference. The edges of the ulcer were somewhat
administration of medicines "nature asserted herself," and
elevated and firm; the base was very soft and pulpy. A sound
Hirt says, "Truly I had the pleasure of seeing a slow recovery
could be passed from the middle of the ulcer far into the pericesophageal tissues, but not into the air passages. Upon sectioning the ulcer, the entire wall of the oesophagus was found
set in." After this time the patient had an ill-smelling
to be almost destroyed, forming a small tumor mass. The
diarrhoea which gradually disappeared. Milk appeared in  
microscopic examination showed, in addition to the carcinomatous, a tuberculous infection. Tubercles in process of
the breasts on the 21st day and was present for 14 days.  
caseation were found in the middle of the cancerous ulcer
Nine weeks after the first day of her illness she had a bright
and about its periphery. Careful search failed to reveal
red flow of blood mixed with pieces of skin and fibres.  
tubercle bacilli.  


Cordua favors the view that the tuberculous invasion of
the cancerous ulcer took place through the lymphatics leading from tuberculous areas in the lungs ; and he assigns as
reasons for his belief in this mode of infection, the absence of
cancerous metastases and the presence of coal pigment in the
lymph glands, the deep location of the older tubercles in the
cancerous ulcer, and the more superficial situation of the
younger ones. It would seem, however, more probable that the
secondary tuberculous infection was due to sputum deglutition.


3. Pepper and Edsallf report the case of a man, 42 years of
age, who had tuberculosis of the lungs, larynx, cervical glands
and ojsophagus. The oesophagus was patulous and normal
as high up as the level of the arch of the aorta. Above this
point and to the junction with the pharynx, the lumen had
entirely disappeared. The oesophageal walls and surrounding
tissues had formed a band of dense fibrous tissue, about
1.35 cm. thick and 3.75 cm. broad, which was firmly bound to
the vertebra. Sections of the growth examined microscopically showed cancerous tissue in a dense fibrous tissue basis,
tubercle-like masses undergoing fibroid change, an occasional
giant cell, and tubercle bacilli.


The central and deeper portions of the tumor were composed mainly of fibrous tissue, and this appearance led the  
From this time on the patient made a good recovery, and  
authors to conclude that tuberculosis was evidently the  
with the exception of pain which she noticed in certain movements of the body as in bending far forwards, and an occasional sharp, sticking pain in the right side, she suffered no
original cause of the disease, while cancer subsequently infiltrated the occlusion. (?) That the cancer was primary they consider improbable, both from the microscopic appearance of
inconvenience. Ten years after the attack Hirt examined the  
"infiltration of a previously existing mass, and from the history
patient and found the foetus still in a transverse position, the  
of cancer being here as elsewhere one of inexorable growth
head towards the right side of the mother. Through the  
and onward progress, ulceration, and sloughing."
posterior wall of the vagina a part of the foetus which he
took for one of the upper extremities could be felt.  


In 1846, 13 years after Hirt's last note, Kuchenmeister first
saw the case and found a tumor one and a half times as large
as a head adherent to the abdominal wall in a transverse
direction, making a prominent conical tumor near the
umbilicus. The tumor was closely adherent to the abdominal
wall and was only movable in so far as the abdominal wall was
movable. The foetal parts could not be recognized. The
uterus was normal in size and form and at most slightly anteverted. By the vagina the tumor could not be felt.


The patient continued in good health until 1880, when she
died in her 88th year. The autopsy was performed by
Kuchenmeister, June 3d, 1880. The body was greatly emaciated, and the abdomen presented a prominent conical appearance, most marked near the umbilicus. The tumor was intimately adherent to the mesentery and anterior abdominal
wall, requiring the knife to separate the adhesions. The
tumor was in part directly adherent beneath and at the sides
to the adjacent intestine, and in part connected by band-like
adhesions with the more distant intestines and especially
with the uterine appendages. The broadest adhesions resembled the bursted tubal sac. From one part of the tumor
a foetal foot projected, the skin over which was dry and the
tendons stood out prominently like those seen in dried anatomical preparations. The tumor was hard, inflexible and calcified. The placenta was soft and easily differentiated from
the ectopic sac.


*Cordua: Ein Fall von krebsig-tuberculosem Geschwiir des
On opening the sac a full-term mummified foetus was found.
Oesophagus. Arbeiten a. d. pathologischen Institut in GiJttingen,  
It was very much shrunken, the face was distorted but not
1893, 147.  
calcified and was covered by the right arm. The umbilical
cord was wound ai'ound the thorax of the foetus and easily
visible. All of the inner organs could be recognized without difficulty. The general appearance of the scalp, cranium,
- brain, lungs, heart, pericardial sac, diaphragm, spleen and liver
was preserved, but the intestines had shrunk into an unrecognizable mass.  


f Pepper and Edsall : Tuberculous occlusion of the rosophagus
A microscopical examination of this and another specimen
with partial cancerous infiltration. Amer. Jour, of the Med. Sci.,
was made by T. Wyder, who found only calcareous deposits
CXIV, 1897, 44.  
in the skin and amniotic sac and not in the internal organs.  
The various tissues were mostly easily recognized and in
part were wholly ))reserved. In the denser tissues the cell
elements were most resistant and retained their normal appearance and arrangement. In all localities where fat had
previously existed margarine and cholesterine crystals were
found.  


As Kuchenuieister's table possesses considerable historical
interest I have rearranged it according to the chronological
report of the cases and append it to this paper.


Since the publication of Kuclienmeister's paper cases have
been reported by the following writers, but none of them


C. — Infection of the Intact Membrane directly (by
Sputa) or from the Circulating Blood.


This class embraces those lesions which heretofore were
regarded as most unusual, but which from Mazzotti's experience must rank in frequency with those described in class I.
The eight cases of Mazzotti belonging to this group would
seem for the most part to have been caused by the deglutition
of tuberculous sputum, though the coexistence of ulcers and
nodules makes it difficult in some instances to differentiate
certainly the inoculation of tuberculous sputum from infection through the blood.


1. The first case reported by Mazzotti was a woman, aged 33
November, 1897.]
years, who died of pulmonary and (Esophageal tuberculosis.
 
At autopsy the mucosa of the ossophagus, normal in its upper
227
part, was found reddened below. The redness increased in
intensity from above downward, becoming scarlet near the
cardiac orifice of the stomach. On this red base were scattered numerous tuberculous ulcers. These were small and
superficial in the upper segment, measuring several millimetres in diameter, becoming larger lower down, until near
the cardiac orifice of the stomach several of them coalesced,
forming an extensive loss of substance. The large ulcer thus
produced was more irregular and deeper than the others,
extending indeed to the muscular tunic.


2. The second occurred in a man, aged 40 years, who died
of pulmonary phthisis. The oesophagus presented above, and
in the anterior wall at its junction with the larynx, several
white, rounded prominences, slightly larger than the head of
a pin, with ulcerated centres. A little lower down there was
an elliptical longitudinal ulcer with smooth base and slightly
elevated edge, 5 cm. in circumference. Lower still, and rather
near the end of the oesophagus, a yellowish nodule projected
from the mucosa. This had ulcerated, and in all respects
resembled the elliptical ulcer described. The mucous membrane in general was pale, but near the stomach there was
some injection without ulceration.


3. The third case was a woman, aged 35 years, who had died
of pulmonary tuberculosis. The (esophagus was normal in its
upper part. At about the middle third the mucosa was of a
greyish black color and contained several superficial ulcers
with smooth margins and regular white bases. They were
elliptical in the longitudinal direction. In the lower third
the mucosa was pale, but here, too, were elliptical ulcers,
smaller than the former, which they resembled in every other
particular. The deepest of these ulcers scarcely reached the
muscular coat.


4. The fourth was a man, aged 60 years, who succumbed to
-possess any special poiuts of interest over the cases found in  
pulmonary and intestinal tuberculosis. The mucosa of the  
his report:
oesophagus in its lower half contained about 30 elliptical
ulcers with smooth, regular margins and bases. They were
smaller and more superficial above, but on descending the
canal approached each other more closely, became larger and
deeper, extending finally to the submucosa.


5. The fifth example was furnished by a male, aged 18 years,  
Dahlmann, Archiv f. Gyn., 1879, Vol. XV, p. 128.  
who died of pulmonary phthisis. Throughout the oesophagus
were scattered numerous ulcers. They were elliptical in form,
the larger ones being relatively longer than the smaller. In


Oettinger, Progrus Med., 1884, Vol. XII, p. 196.


Sarrante, Archiv de Tocol., 1885, Vol. XII, p. 237.


232
Oppel, A., Miinch. med. Wochen., 1888, Vol. XIII, p. 151.


Stonham, Tr. Path. Soc. Loudon, 1886-7, Vol. XXXVIII,
p. 445.


Hammer, Prag. med. Wochen., 1888, Vol. XIII, p. 151.


JOHNS HOPKINS HOSPITAL BULLETIN.  
Fales, W. H., Boston M. and S. J., 1887, Vol. CX VII, p. 131.  


Tarnier, Bull. Acad, de M6d., 1889, Vol. XXII, p. 57.


Schotte, G., Miinch. med. Woch., 1890, Vol. XXXVII, pp.
471, 489, 503.


[No. 80.




Wilson, E. H., Brooklyn M. J., 1891, p. 515.


some places several ulcers were united in such a way as to
Elbiug, R., St. Petersb. med. Woch., 1890, Vol. VII, p.
present an irregular shape. In other places the ulcers were
299.  
separated by little tracts of healthy mucosa, giviug the
appearance of a network. They were not very deep, touching
at most the submucous tissue, aud had greyish bases and
smooth, regular, slightly elevated edges.  


6. The sixth was a man, aged 67 years, in whom pulmonary
Lusk, Med. Eec, N. Y., 1892, Vol. XLII, p. 405.  
and iutestinal tuberculosis were also found. In the oesophagus,  
three inches from its origin, was an ulcer of the mucosa 5 cm.
in length. Near this were two small ulcers, while a little
below was one of intermediate size. The remainder of the
mucosa contained only smooth white elevations about the size
of a piu-head. At the junction of the middle and lower third
of the ojsophagus, was a diverticulum as large as the end of
the little finger.  


7. The seventh was a woman, aged 48 years, who presented
Hofmeier, Sitzungs. d. phys.-med. Gesellsch., Wiirzburg,  
the lesions of pulmonary and intestinal tuberculosis. In the
1892, p. 134.  
lower two-thirds of the oesophagus the mucosa attracted
attention by an intense redness which extended over a wide
area. In the midst of this were twelve or fifteen ulcers of
various sizes. The smaller ones were round, measuring 0.5 cm.  
in diameter; the larger were elongated, the diameter of the
largest reaching more than 3 cm. The rest were all regular,  
with smooth superficial margins, except a single deeper one
situated at the union of the middle and lower thirds.  


8. Mazzotti's final case was a man, aged 61 years, who succumbed to pulmonary phthisis. The oesophagus in its upper
Gottschalk, Canad. Pract., 1893.  
part presented four or five scars several millimetres in length,
with ulcerated centres, in the vicinity of which the mucosa
was pale, but otherwise of normal appearance.  


9. Zenker's fourth case belongs to this class. It occurred
Patellani, Ann. di Obstet, Milano, 1893, Vol. XV, p. 817.  
in a man 38 years old, who suffered from tuberculosis of the
lungs, nose and throat, enlarged lymjDhatic glands, and
stenosis of the oesophagus. At the autopsy, the oesophagus in
its uppermost part presented a large superficial scar-like
ulcer which included almost the entire circumference of the
canal, and formed a marked constriction. At about its
middle portion the oesophagus showed an elevated nodule the
size of a bean, from which thiu pus escajjed. The bronchial
and peri-oesophageal lymph glands were enlarged and caseous.  
The microscopic examination of the lesions in the cBSophagus
exhibited the histological characters of tuberculosis, which was
limited to the mucosa aud submucosa. Numerous tubercle
bacilli were demonstratetl in the tubercles and pus.  


Zenker* believes that the infection in this case was due to
Dean and Marnoch, J. Anat. and Physiol., London, 1893-94,
sputum deglutition, and brings forward the fact of the superficial character of the ulcers in support of this view.  
p. 77.  


10. Hasselmannf describes the case of a boy sis months old,  
Fabbrovich, Gazz. d. Osp. Milano, 1894, Vol. XV, p. 890.  
in whom, in addition to tuberculosis of the oesophagus, there
existed tuberculosis of the lungs and lymph glands. In the
lower part of the oesophagus three crater-like ulcers were
found which had no connection with either the trachea or the
caseous lymph glands. The microscopic examination proved


Djemil-Bey, Ann. de Gynec. et d'Obstet., Paris, 1894, Vol.
XLII, p. 333.




* Zenker: Op. cit.


t Haaselmann : Ueber Tuberculose des Oesophagus. luaug. -Dissertation, Miinchen, 1895.






them to be tuberculous in nature. The infection is believed
to have taken place from the swallowed sputum.


11. The case reported by E. Friinkel* occurred in a man 33
KUCHENMEISTER'S TABLE OF C.4.SES REPORTED BETWEEN THE YEARS 1582 AND
years of age, who died of pulmonary and intestinal tuberculosis. The oesophagus contained a large number of yellowish
 
spherical nodules about the size of a hemp seed, some with
 
sujierficial loss of substance, others still covered with the
1880.  
intact mucosa. Adjacent to these were found small masses
with irregular edges and uneven bases, and several small
round ulcers with abrupt edges and perfectly smooth bases,
averaging 3 mm. in diameter. The larynx, trachea and peritracheal lymph glands were quite intact. The microscopic
examination of the lesions showed besides epithelioid and
giant cells, tubercle bacilli.  


Regarding the mode of infection in this case, Friinkel does
not consider it possible to conclude certainly between a htematogenous origin and the inoculation of tuberculous sputum,
but he inclines to the latter view.


1 3. Glocknerf describes a case which he regards as of haematogeuous origin, and which is peculiar in the limitation of
the tubercles to the muscular coat of the oesophagus.


It occurred in a man, 48 years of age, in whom the autopsy
showed old tuberculous areas in the apices of both lungs,
tuberculosis of the pleura, peribronchial and mesenteric
lymph glands, oesophagus aud viscera generally. The oesophagus at its mid-portion contained an irregular thickened zone,
encircling the wall of the tube, 5 cm. in width, and from 5 to
7 mm. in thickness. On section of this thickened area it was
found to consist of numerous caseous tubercles, varying in
size from a piu-head to a hemp seed, irregularly infiltrating
the muscular coat, to which they were strictly limited. The
mucosa and submucosa were perfectly intact and freely
movable over the deeper lying structures. The peri-cesophageal tissue was likewise free from diffuse infiltration, but contained several small strands with interrupted nodular swellings the size of a millet seed. These strands were interpreted
by Glockuer as tubercle-infiltrated afferent vessels of lymph
glands. The lymph glands in the neighborhood of the thickening, as well as those about 3 cm. above, were somewhat
enlarged and caseous, but not abnormally adherent to the
peri-cesophageal tissue. Microscopic examination showed
the typical structure of caseous tubercles, and tubercle bacilli
in great numbers were found.


Glockner regards this case as certainly of ha?matogenous
Case
origin and believes that he excludes all other modes of infection. Infection through continuity he eliminates by the
No.  
absence of lesions in the continuous structures; direct inoculation of the inner surface of the mucous membrane is rendered improbable by the intact condition of both mucosa
and submucosa; invasion from the peribronchial lymphatic
glands, through lymph transport of tubercle bacilli, he
excludes by the freedom from tuberculous infiltration of the
peri-oesophageal tissue. In favor of hi^matogenous infection






* E. Friinkel: Ueber Beltene Localisation lier TuberculoFC.
Miinch. med. Wochenschr., XLIII, ISOli, 27.


f Glockner: Ueber eine neue Form von Oesopliagns-Tuberciilose.
Name of
Piag. med. Woch XXI, 1890, 114, 127, 138.  
observer.  




Number
of births
before the
ectopic
pregnancy.




Time
wheu labor pains
or symptoms of
rupture
occurred.




Length


section of the esophagus showing discrete tubercles .opposed of epitheUoid a^d ^-* -Jl;^;; V" ™''"
of time
node extending into the mucosa, Ha.matoxylin staining. /e,ss objeot.vc DO. e>e-p.cce No. 1.


foetus


was


November, 1897.]
retained.  




3^


JOHNS HOPKINS HOSPITAL BULLETIN.


he


11


233
Si




•sj


is adduced not only tlie peculiar localization of tubercles in
3"°
the nuiscnlar coat of the resophagus, but also the dissemination of miliary tubercles in the viscera generally.


To this last series of cases may be added the one from this
laboratory. It occurred in a colored man, aged 33 years,
admitted to the surgical wards of the Johns Hopkins Hospital, service of Dr. Halsted, to whom we are indebted for the
clinical notes. The history, however, has but little bearing
upon the lesions in the resophagus, and may therefore be
briefly stated.


Clinical History. The first admission to the hosi^ital was
i|.g
on September 16th, 1895, for an enlarged right testicle. There
was a tuberculous family history. The patient had previously
suffered from typhoid fever, gonorrhoea and syphilis, and for
the past four years had been short of breath. His general
health, however, had been good until a few months before
admission. The examination showed, besides tuberculosis
of the right testicle, a slight involvement of the right lung at
the apex, and a dark and mottled condition of the mucous
membrane of the mouth. The right testicle was removed, the
wound healed promptly, and the patient was discharged from
the hospital, October 22nd, 1895.  


On February 7th, 1897, he returned to the hospital suffering
with tuberculosis of the left testicle and cough. He failed
rapidly and died March 1st, 1897.


The autopsy was performed by Dr. Flexner four hours
M
after death. I shall abstract the protocol and give only the
anatomical diagnosis and such notes as bear upon the lesions
in the cesophagus.


A natomical Diagnosis. Kemoval of testicle (for tuberculosis)
eighteen months previously ; tubei'culosis of epididymis and
remaining testicle, seminal vesicles and prostate gland; generalized tuberculosis; chronic tuberculosis of lungs; peculiar
nodular form of tuberculosis of spleen and kidneys ; tuberculosis of adrenal glands; Addison's disease; jiigmentation of
mucous membrane of mouth.


The cesophagus shows in its lower two-thirds elevated dots
Primary
and larger nodules in great numbei-s. None of these are caseous, but the smaller points resemble the individual tubercles
found in the spleen, liver and other glands.


The tubercles in these organs are minute granulomata, submiliary in size, of pale grayish-white color, opaque and noncaseating.  
site.  


Histological Examination. The elevated dots and nodules
 
found in the lower two-thirds of the cesophagus are seen to be  
Age of the
enlarged lymphoid follicles, invaded by miliary tubercles  
woman
which at times become conglomerated. A section of one of  
at death.
the larger oval nodules, measuring 1.25x1.50 mm., contains  
 
nine small, pale, Irregularly circular areas of different sizes,  
 
with more or less definite contours, arranged in horse-shoe  
 
fashion around the periphery of the nodule. These pale  
 
areas contrast sharply with the more deeply-stained normal  
Escape of
lymphoid structure.  
 
 
decidua
Under somewhat greater magnification the pale areas are  
 
seen to consist of epithelioid cells, at times distinctly separated  
from
one from the other by irregular spaces in which are found  
 
sparsely scattered lymphoid cells. A scant reticulum holds  
uterus.
these elements loosely together. The epithelioid cells are  
 
 
 
 
Return of
 
menses.
round or oval, with abundant protoplasm and vesicular nuclei.  
 
The nuclei are round, oval, elongated or kidney-shaped.  
 
Some of these cells contain two or more nuclei, and occasionally is seen a well-defined giant cell with a mural arrangement  
Other births
of its nuclei. The epithelioid clumps are surrounded by  
after the ectopic pregnancy.
lymphoid cells, but these cannot be differentiated from the  
 
normal structure of the lymphoid nodule. At other levels the  
 
nodule shows partial coalescence of the discrete tubercles, thus  
Remarks.
giving an appearance of more diffuse infiltration.  
 
 
 
Other nodules examined show an appearance similar to that  
1
just described ; while the smaller dots, at times of microscopic  
 
size, often contain a single cellular tubercle.  
 
 
1583
Tubercle bacilli are present in small number.  
 
 
 
Nowhere are the tubercles found outside the lymphoid  
Albosius.
nodules, and in no instance do they extend beneath the  
 
mucosa The oesophagus is otherwise normal.  
 
 
None.
The mode of infection in this case offers no difficulties ; it is  
 
clearly of hematogenous origin, the original focus being the  
 
diseased testicle. The case forms, together with the one  
 
instance of miliary tuberculosis of Mazzotti, excluding for the  
 
time the less certain cases of E. Friinkel and Glockner, the  
28yrs.
instances of undoubted blood infection of the cesophagus.  
 
 
 
No other instance of the localization of the tuberculous  
 
lesions in the lymphoid structures of the oesophagus has thus  
 
far been published. According to Diirck* the relative insusceptibility of the cesophagus to tuberculosis depends in part  
1
upon the slight development of its lymphatic apparatus. There  
 
is, however, no great dearth of small nodular accumulations  
 
of lymphoid cells in the snbmucosa and mucous membrane of  
 
this organ, which may after all be oftener the seat of tubercles  
 
than is generally considered. The insignificance of these structures, even when, as in this case, they are involved in a general  
 
tuberculosis, may easily lead to their being overlooked. Without the microscopical examination of many different segments  
 
in a given case, the disease could readily escape observation.  
 
 
 
The relative immunity of the oesophagus from other forms  
Normal
of tuberculosis, especially from those varieties included under  
uterus.
classes II and III, may be explained in part upon purely  
 
mechanical grounds; namely, the rapid passage of infectious  
 
material over the mucous membrane of the oesophagus, and  
66 years.
the resistance to such infection offered by the stratified pavement epithelium.  
 
 
 
A review of the entire subject tends, however, to modify  
Yes.
considerably the opinion once held that tuberculosis of the  
 
oesophagus arises in a large majority of cases through continuity or contiguity of structure. Thus, of the total fortyeight cases collected, only twenty-four took origin in this  
 
way, five arose through the addition of the tuberculous process to a previous predisposing lesion, four by blood infection,  
Yes.
while the remaining fifteen arose through the inoculation of  
 
the mucous membrane by tuberculous sputum, without the  
 
existence of a previous demonstrable legion.  
 
 
 
The study of this subject was undertaken at the suggestion  
 
of Dr. Flexner, to wliom the writer is indebted for kind assistance in the preparation of these notes.  
 
 
 
 
 
 
2
*Durik: Ueber Tub('ii;ulu.se iles Oesopljagus. Ergebniste <ler  
 
Palhologie, I, 1897.  
 
 
1659
 
 
 
 
234
Densius, Pont a
 
Mousson.
 
 
 
 
JOHNS HOPKINS HOSPITAL BULLETIN.
 
 
 
 
6th month
 
 
[No. 80.
 
 
?
 
 
 
 
A RARE ANOMALY OF THE ARCH OF THE AORTA, WITH AN ADDITIONAL MUSCLE IN  
 
 
 
THE NECK.  
1
 
 
 
 
 
 
By a. B. Herrick.  
 
 
 
 
 
 
 
The variation herewith reported is from the cadaver of a  
 
negro dissected in the Anatomical Laboratory of the Johns  
 
Hopkins University. With the exception of the snpernume  
 
rary muscle, the variation can easily be explained by an arrest  
 
of the development of the aortic arches, showing also that in  
 
these cases the inferior laryngeal nerve is no longer held down  
 
by the fifth aortic arch and drawn into the chest.  
 
 
 
 
 
 
 
 
 
a.. HE
 
 
 
 
 
 
 
Fig. 1. The aortic arch and its branches, showing their relations to  
3
the trachea and oesophagus, and the position of the recurrent laryngeal  
 
nerves.  
 
 
1661
00, common trunk of the two carotids ; RS, right subclavian ; LS, left  
 
subclavian; KC, right carotid ; iC, left carotid ; iJF, right vagus; LV,  
 
left vagus; RRL, right recurrent laryngeal; LRL, left recurrent laryngeal.  
Schnorffs in Dole
 
 
The number of arteries arising from the arch was normal,  
 
but their arrangement was unusual ; the two carotids arising  
 
nearest the heart by a common trunlv, then the left subclavian,  
 
9th month
 
 
 
 
 
 
 
 
1
 
 
 
 
 
 
 
 
53 years.
 
 
 
 
 
 
Yes.
 
 
 
 
 
 
4
 
 
1675
 
 
de Blegny (Toulouse).
 
 
10
 
 
Full term
 
 
28 yrs.
 
 
 
 
 
 
1
 
 
 
 
 
 
Tube.
 
 
25 years.
 
 
 
 
Prolonged
purulent
discbarge
 
 
 
 
 
 
Pregnancy in the
uterine end of the
Fallopian tube.
Fcetal head in fundus uteri.
 
 
5
 
 
1719
 
 
Bompard.
 
 
 
 
7th month
2 days in
labor.
 
 
15 yrs.
 
 
 
 
 
 
 
 
1
 
 
 
 
Uterus ?
 
 
 
 
 
 
 
 
 
 
 
 
Skeletonization and
softening of the
foetus with partial
spontaneous extrusion.
 
 
6
 
 
1720
 
 
Orth, Steinkind,
 
 
 
 
Full term.
 
 
51 yrs.
 
 
 
 
1
 
 
 
 
 
 
 
 
Probably
 
 
91 years.
 
 
 
 
 
 
 
 
2
 
 
 
 
 
 
Von Leinzell.
 
 
 
 
Labor
pains 3 to
4 weeks.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
in one
horn of
uterus.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
7
 
 
1728
 
 
Bianchi.
 
 
2
 
 
In the 9th
month.
 
 
15 yrs.
 
 
1
 
 
 
 
 
 
 
 
 
 
Ovary.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
8
 
 
1741
 
 
Bromfleld.
 
 
 
 
Fullterm.
 
 
9 yrs.
 
 
1
 
 
 
 
 
 
 
 
 
 
Uterus,
perforation of
the cervix
uteri.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
9
 
 
1747
 
 
Middleton.
 
 
 
 
Full term.
 
 
16 yrs.
 
 
 
 
 
 
1
 
 
 
 
 
 
Fimbriated extremity
of tube.
 
 
 
 
Yes.
 
 
 
 
 
 
4
 
 
 
 
10
 
 
1748
 
 
Bourdon and
Chamerau in
Troyes.
 
 
1 miscarriage.
 
 
Fullterm.
 
Labor
 
pains 2
 
days.
Fullterm.
 
 
30 yrs.
 
 
1
 
 
 
 
 
 
 
 
 
 
Right
tube.
 
 
61 years.
 
 
 
 
 
 
 
 
 
 
Two incisor teeth
in jaw.
 
 
U
 
 
1767
 
 
Heidelberg case
 
 
2
 
 
54 yrs.
 
 
 
 
 
 
1
 
 
 
 
 
 
 
 
91 years.
 
 
Yes.
 
 
 
 
Yes.
 
 
2 abor
 
Patient recovered
 
 
 
 
 
 
of Nebel.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
tions.
 
 
after many weeks.
 
 
12
 
 
1775
 
 
Walter, of Berlin.
 
 
1
 
 
9th month.
 
 
22 yrs.
 
 
 
 
 
 
1
 
 
 
 
 
 
Right
ovary.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
13
 
 
1784
 
 
 
 
 
 
Fullterm.
 
Labor
 
pains for
 
3 days.
Fullterm.
 
 
8 yrs.
 
 
1
 
 
 
 
 
 
 
 
 
 
Left
tube.
 
 
45 years.
 
 
 
 
Yes.
 
 
Two years
later.
 
 
 
 
 
 
14
 
 
1785
 
 
Varnier and
 
 
12
 
 
33 yrs.
 
 
1
 
 
 
 
 
 
1
 
 
 
 
One fcetus
 
 
75 years.
 
 
Escape of
 
 
Probably
 
 
18 months
 
 
 
 
One foetus fully
 
 
 
 
 
 
Mangin.
 
 
 
 
Labor
pains tor
many
days.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
in abdom.
cavity,
the other
n sac communicating with
uterus.
 
 
 
 
water
 
with
 
blood.
 
 
decidua.
 
 
later.
 
 
 
 
developed (9th
month), the other
3 months old.
 
 
15
 
 
1786
 
 
MQhlbeck.
 
 
1
 
 
11th
month.
 
 
U}i yrs.
 
 
 
 
 
 
1
 
 
 
 
 
 
Uterus.
 
 
 
 
Yes.
 
 
 
 
 
 
 
 
Foetus died in the
7th month.
 
 
16
 
 
1798
 
 
Cheston(ca8ell.
 
 
3
 
 
Fullterm.
Labor
pains 3
weeks.
 
 
50 yrs.
 
 
1
 
 
 
 
 
 
 
 
 
 
Uterus
unicornis
unicoUis
(mit Nebenhorn).
 
 
80 years.
 
 
 
 
 
 
 
 
 
 
 
 
17
 
 
1798
 
 
Chcston (case 2).
 
 
 
 
Fullterm.
 
 
4 yrs.
 
 
 
 
 
 
 
 
1
 
 
 
 
Normal
uterus.
 
 
Operated
upon in
29th year.
 
 
Flow of
fetid
 
water for
15 months
 
 
 
 
1 years
after
operation.
 
 
 
 
 
 
18
 
 
1800
 
 
Denmann.
 
 
Ifullterm.
Many mis
 
9th month.
 
 
32 yrs.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of case
very imperfect.
 
 
19
 
 
1802
 
 
Von Weinhardt.
 
 
carriages.
 
 
Near the
 
 
7 yrs. to
the time
 
 
1
 
 
 
 
 
 
 
 
 
 
Probably
 
 
 
 
Yes, one
 
 
Blood and
 
 
 
 
 
 
Recovery.
 
 
 
 
 
 
 
 
 
 
7th
 
 
 
 
 
 
 
 
 
 
 
 
extra
 
 
 
week.
 
 
fleshy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
month.
 
 
of operation.
 
 
 
 
 
 
 
 
 
 
 
 
uterine.
 
 
 
 
 
 
matter.
 
 
 
 
 
 
 
 
20
 
 
1805
 
 
Cad well.
 
 
No.
 
 
Fullterm.
Labor
pains one
 
 
26 yrs.
 
 
 
 
 
 
1
 
 
 
 
 
 
Retained
in uterus.
 
 
 
 
 
 
Yes.
 
 
 
 
 
 
Died from operation performed
through the .cer
 
21
 
 
1806
 
 
Grivel.
 
 
 
 
day.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abdomen.
 
 
8;) years.
 
 
 
 
 
 
 
 
 
 
vix.
 
 
 
228
 
[No. 80.
 
 
 
KUCHENMEISTER'S TABLE OF CASES REPORTED BETWEEN THE YEARS i582 AND 1880. -Continued.
 
 
 
1819
 
 
Seller.
 
 
1819
 
 
Prael.
 
 
1830
 
 
Bruns.
 
 
1831
 
 
nonisch.
 
 
1825
 
 
Cruveilhier.
 
 
1828
 
 
Lee Heiskell
 
 
1832
 
 
Stoltz.
 
 
 
Case reported
from the city of
Danzii?, author
not cited.
 
Bondet.
 
 
 
Virchow.
 
Will.
 
SteiQ in Steinau
 
 
 
Playfair.
 
 
 
Chiari.
 
Galli.
 
Deschamps.
 
 
 
Kuchenmeister.
 
 
 
Number
of births
before the
ectopic
pregnancy.
 
 
 
I full
 
terms, 3
abortions.
 
 
 
Time
when labor pains
or symptoms of
rupture
occurred.
 
 
 
At the end
of the 9th
month
 
 
 
No symptoms of
labor.
 
 
 
Full term,
3 days
long.
 
 
 
End of the
 
9tb
 
month
 
 
 
Labor
pains at
full term
 
Labor
pains at
full term
 
Full term.
Labor
pains continued 3
days.
 
 
 
Full term.
Labor
pains 14
days.
 
 
 
8th month.
 
 
49yrs
 
 
75 months.
 
 
87 yrs
 
 
Pull term.
Labor
pains for
3 days.
 
 
7yrs.
 
yrs.
 
 
Full term.
 
Labor
 
pains 33
 
hours.
Full term.
 
Few days.
 
 
11 yrs
 
67 yrs
 
 
 
Length
 
of time
 
fa'tus
 
was
 
retained
 
 
 
46 yrs.
28 yrs.
 
 
 
7 yrs. up
to time
of operation.
47yis.
 
40 yrs.
 
2 yrs.
 
 
 
26 yrs.
10 yrs.
>iyr.
 
 
 
^yr.
 
 
 
Abdomen.
Uterus.
 
 
 
3.. tube
 
and ovary
Abdomi
 
oal cavity
Posterior
 
wall of
 
uterus
 
and its
 
adductor.
 
Possibly
 
in one
 
corner of
 
uterus.
Abdominal cavity.
 
 
 
L. ovary.
L. ovary?
 
 
 
R. ovar.
and parov.
 
 
 
Tube and
ovary.
 
 
 
Fimbriated end
of left
tube and
1. ovary
 
Inonecornu uteri.
 
 
 
Tube and
ovary.
 
 
 
Canalis
intercanaliculi.
 
 
 
Age of the
woman
at death.
 
 
 
) years.
! years.
 
 
 
 
 
 
Escape of
decidua
 
from
uterus.
 
 
 
Small
amount
of blood.
 
 
 
Bloody
discharge.
 
 
 
4 months
after the
death of
the fcetus.
 
 
 
Nine days
after the
death of
 
foetus.
 
 
 
Nine days
after the
death of
foetus.
 
 
 
2S'5.D
 
 
 
Spontaneous delivery through
vagina and rectum.
 
 
 
History of case imperfect.
 
Recovery. Fcetus
removed through
the vagina.
 
 
 
Vienna paste applied to the sac
per vag. Before it
was eroded the patient died.
 
 
 
The foetuswas more
than a half year
over term before
it was delivered.
 
 
 
4 times
delivered artificially
 
 
 
The foetus was
undergoing suppuration.
 
 
ON TUBERCULOSIS OF THE (ESOPHAGUS, WITH THE REPORT OF A CASE OF UNUSUAL INFECTION.
 
By Claribel Cone, M. D., Professor of Pathology, Woman's Medical Colli ge, Bait i more.
[From the Pathological Laboratory of the Johns Hopkins University and Hospital.^
 
 
 
Keuewed attention to the subject of tuberculosis of the
oesophagus has shown that this organ is not so often spared in
tuberculous affections as was at one time believed. Thus, in
a critical review of the subject published in 1893, Dr. Flexner,* who reported a new case, was able to collect from the
literature up to that date only eighteen undoubted cases.
Since his publication there have appeared, so far as has come
to the writer's notice, twenty-eight additional cases. Of these
twenty-eight cases it is worthy of remark that nine were
described by one observer, Mazzotti.f
 
Another case from this pathological laboratory is to be
added to the list, and now that the affection is no longer
recognized as of great rarity, its report is suggested as much
by the peculiar distribution of the tubercles as by the pathological condition itself. It seems worth while at the same
time to re-collect all the cases and to consider the classification
with reference to their ajtiology.
 
The classification suggested by Flexner is as follows:
 
I. Instances in which the tuberculous process arises through
continuity or contiguity of structure.
 
(ji) Where a caseous bronchial gland or group of glands becomes adherent to the cesophagus and ulcerates into the latter.
 
{b) In consequence of perforation of abscesses associated
with caries of the vertebraj.
 
(c) Where tuberculous ulcers of the pharynx pass down and
invade the cesophugus.
 
II. Cases in which there exists in the CBSophageal mucous
membrane a previous lesion to be regarded as predisposing to
the tuberculous infection.
 
III. Instances in which («) the cesophagus is affected in the
course of a general disseminated miliary tuberculosis, and (b)
in which there is infection of the mucous membrane from
tuberculous sputum where no previous lesion existed.
 
Of the nineteen cases collected by Flexner,^ eleven belong
to the first class, two to the second, and six to the third. In
the first group are included the cases of Weichselbaum (1),
Beck (2), Penzoldt (.3), Orth (2), Pitt (1), and Zenker (2) ;
in the second group those of Eppinger (1) and Breus (1);
while the third class includes the cases of Mazzotti (3), Spillman (1), Freriehs (1), and Flexner (1).
 
Of the six cases comprising the last group, one only occurred
in the course of a disseminated miliary tuberculosis giving
rise to an eruption of miliary tubercles in the cesophagus. This
case, which was reported by Mazzotti, § is the only published
account of miliary tuberculosis affecting the cesophagus.
 
 
 
*KlexQer: Tuberculosis of the (Esophagus. .Toluis Hopkins
Hospital Bulletin, IV, 1893-4.
 
t Mazzotti : Nuove osservazioni intorno alia tuberculosi dell'
esofago. Dal Bulletino d. Scienze IMediche ili Bologna, VII, ser.
VII, 1896, 553-579.
 
X Flexner : Op. cit.
 
gMazzotti: Revisla Clinica, .Jannar, 1885.
 
 
 
The additional twenty-eight cases which have been reported
since 1893, including cases omitted from Flexner's original
publication, can be divided so that thirteen fall in the first,
three in the second, and twelve in the third class.
 
A. — Infection by Continuity or Contiguity of
Structure.
 
1. Selenkow* reported a case of partial destruction of the
cesophagus by tuberculosis. Gastrostomy was followed by
impaired nutrition and death. In the lungs were found old
tuberculous lesions, which, approaching the root on the right
side, invaded the lymph glands. The latter became adherent
to one another, forming a diffuse caseous mass both anterior
and posterior to the oesophagus, and finally ulcerated into the
anterior wall of the tube below the bifurcation of the trachea.
A cavity about the size of a hen's egg was produced in the
enlarged and caseous lymph glands, which"" was filled with
detritus and into which the lumen of the oesophagus opened
freely. Two distinct perforations occupying an area 5 cm.
long and separated by a narrow strip of tissue existed. The
lumen of the cesophagus was constricted in the lower segment
and was only about half the size of the upper part. Although
no bacteriological or histological examination was made in this
case, the tuberculous nature of the lesions can scarcely be
doubted.
 
3. Voelckerf reports the case of a boy, aged 9 years, in whom
the post-mortem examination showed a mass of cretaceous
glands at the hilum of the right lung. On opening the
cesophagus a perforation was found on the anterior wall, a
little to the right of the middle line and a little below the
level of the bifurcation of the trachea. The opening was
about 5 mm. in diameter; the edges were puckered and led
into a cavity in which caseous material could be seen.
 
Voelcker has also collected from 2504 autopsies in the postmortem records of the Hospital for Sick Children, four other
cases of tuberculosis of the cesophagus associated with general
tuberculosis, to which he briefiy refers.
 
3_4_5. lu three of these cases caseous glands ruptured into
the cesophagus.J
 
Letulle§ reports three cases, one of Londe and two of his own.
 
 
 
* Selenkow: Kasuistische Mittheilungen a. il. ausser-staJti.sclien
Hospital. St. Petershurger raed. Wochenschr., IX, 1884, 491.
 
fVoelcker, A. F. Caseous Gland opening into the (Esophagus.
Tr. Path. So'c, Lond., XLII, 1890-91, 87.
 
|Tlie additional case was one in which an oval ulcer, threequarters of an inch long, existed at the level of the bifurcation of
the trachea ; but in this case the note says: "The muscular coat
remains, the floor is smooth as if healed up, although in the neighborhood of a caseatina gland. The ulceration, as far as could be
seen, had not started froniorbeen in any way caused bythegland."
The Ktiology in this case must certainly be regardid as doubtful.
 
§Letulle: Lesions tuberculeusesde I'oesophage. Bull. Soc. Anat.
de Paris, LXVIII, 1893,246.
 
 
 
230
 
[No. 80.
 
 
 
6. Loude's case was that of a man 50 years old, who died
suddenly of hfematemesis. The autopsy revealed a fistula in
the anterior surface of the (esophagus immediately below the
bifurcation of the trachea, still filled with blood aud leading
into a small tuberculous cavity which had developed in a
caseous bronchial lymph gland. The starting point of the
tuberculous lesions was found in a miliary tuberculosis of the
pleura which, invading the thoracic glands, produced caseation and calcification, and later adhesion between the affected
bronchial glands and the oesophagus, with ultimate perforation of the latter.
 
7. Letulle states that his first case was very similar to that
of Loude and omits in his publication all details.
 
8. His second case occurred in a young man, the subject of
a tuberculous empyema which had ruptured into the oesophagus. On microscopic examination the cesophagus showed
infiltration of the muscular and submucous coats with embryonic cells, little caseation and no giant cells. Tubercle bacilli
were not found.*
 
K. Zenker! adds four cases, of which two belong to the
present class.
 
9. In the first case the tuberculous lesion of the cesophagus
occurring in a young consumptive was accidentally discovered at autopsy. The tuberculosis originated in the lungs,
spread to the bronchial lymph glands, the peri-glandular tissue,
and the cesophagus, infiltrating the walls of the latter from
without inward until ulceration and perforation were produced. The mici-oscopic examination showed tubercles in the
muscular and submucous coats chieily, and numerous tubercle bacilli.
 
10. Zenker's second case was a man 46 years old who had
tuberculosis of the serous membranes. The bronchial glands
were considerably enlarged and caseous, and had ulcerated
into the cesophagus at its mid-portion in three places. The
histological examination of theresophagus showed tuberculous
infiltration of the muscularis and submucosa, while the
epithelium was scarcely affected. In the neighborhood of the
ulcers, tubercles were found in the submucosa. These contained tiibercle bacilli.
 
11. A case reported by DanelJ: also belongs to this group.
There were tubercle nodules in both lungs, general glandular
enlargement, and tubercles, some of which had ulcerated in
the mucosa of the pharynx. The (Esophagus in its jiosterior
portion showed an extensive ulceration of the mucosa. The
ulcer was about 10 cm. long and extended longitudinally.
Its edges were eroded and it contained granules resembling
tubercles. Other nodules taken to be tubercles were found
 
 
 
*The validity of this case may well be questioned. Mixed infections in empyema are by no means unknown, so that the possibility of the invasion of the oesophagus by other micro-organisms
(pyogenic cocci?) is well worth considering.
 
f K.Zenker: Carcinom und Tuberkel in selben Organe. Deut.
Arch. f. klin. Med., XLVII, 1891, 191 ; Beitrag zur Aetiologie und
Casuistik der Tuberculose der Speiserohre. Deut. Arch. f. klin.
Med., LV, 1895, 405.
 
I Danel : CEsophagite tuberculeuse consecutive ii une ancienne
tuberculose peribronchique generalisation ganglionnaire. J. d. Sc.
med. de Lille, XIX, 1896, 1, 520.
 
 
 
on the anterior surface. The cause of the infection of the
cesophagus was a softened bronchial lymphatic gland situated
at about the bifurcation of the trachea, which, having become
adherent to the oesojihagus, perforated into this organ. The
opening between the gland and the cesophagus measured about
1 cm. Although no histological or bacteriological examination was made, there can be no doubt of the specific nature of
this case.
 
Of the nine cases added by Mazzotti to the three previously
reported by him only one belongs to the present group. He
confirmed his diagnosis of tuberculosis in each case by the
demonstration of tubercle bacilli. His experience is remarkable, not only because of the large collection of cases of a
pathological condition, the rarity of which is generally
acknowledged, but also because of the predominance among
them of that form of lesion which is admitted to be most
infrecjuent. In eight of his cases the process began within
the cesophagus, while, as stated, in one only there was an
extension inward from caseous bronchial glands.
 
12. This case was that of a man aged 21 years, who died of
pulmonary and intestinal tuberculosis. The oesophagus at
the union of the upper with the middle third showed two
ulcers, one near the other, somewhat elongated and of the
size of a nentedmo. The edges of the ulcers were smooth and
of a greenish color ; the irregular bases were also green. The
ulcers perforated all the coats of the cesophagus, and their
bases were formed by a collection of detritus situated under
the cesophagus itself, and found to proceed from softened
caseous bronchial glands. Two similar ulcers, also close
together, communicating with each other beneath the mucosa,
were seen at the junction of the middle and lower thirds of
the oesophagus ; while yet below, were small superficial elliptical ulcers in the longitudinal direction of the canal. The
lymph glands had also ulcerated into the left bronchus just
at its origin from the trachea.
 
13. A case arising through continuity of structure is
reported briefly by Birch-Hirschfeld.* At the autopsy (sex
and age not given) there were found tuberculosis of the lungs
and numerous tuberculous ulcers in the larynx, pharynx and
upper third of the oesophagus. Tubercle bacilli were demonstrated.
 
B. — Pkedisposition to Infection due to a Previous
Lesion.
 
1. K. Zenker's third case was an example of coincident
carcinoma and tuberculosis of the cesophagus. A stricture of
the tube, produced by a girdle ulcer of rodent character,
existed, which on microscopic examination showed the typical
appearance of squamous epithelioma. This growth invaded
the deeper strata of the mucosa and at times penetrated the
muscularis. In the border of the cancerous portion, toward
the normal tissue, typical tubercles existed, some of which
were caseous. The neighboring lymph glands also were
involved in the cancerous and tuberculous conditions.
Tubercle bacilli were found in small number in the tubercles.
 
Zenker does not commit himself as to whether the carciiio
 
 
*Birch-Hirschfeia: Lehrbuch der path. Anat., II, 1894, 620.
 
 
 
November, 1897.]
 
231
 
 
 
matotis or tuberculous lesion was primary, but favors the
former view because of the admitted resistance offered by the
intact epithelium to tuberculous infection.
 
2. In this group of cases the one reported by Cordua* is to
be placed.
 
A man 60 years of age came to autopsy, the clinical diagnosis of carcinoma of the oesophagus, incipient pulmonary
tuberculosis, and adhesive pleuritis having been made. In the
(esophagus, at about the bifurcation of the trachea, was found
an ulcer 10 to 15 cm. long, which affected this structure in its
entire circumference. The edges of the ulcer were somewhat
elevated and firm; the base was very soft and pulpy. A sound
could be passed from the middle of the ulcer far into the pericesophageal tissues, but not into the air passages. Upon sectioning the ulcer, the entire wall of the oesophagus was found
to be almost destroyed, forming a small tumor mass. The
microscopic examination showed, in addition to the carcinomatous, a tuberculous infection. Tubercles in process of
caseation were found in the middle of the cancerous ulcer
and about its periphery. Careful search failed to reveal
tubercle bacilli.
 
Cordua favors the view that the tuberculous invasion of
the cancerous ulcer took place through the lymphatics leading from tuberculous areas in the lungs ; and he assigns as
reasons for his belief in this mode of infection, the absence of
cancerous metastases and the presence of coal pigment in the
lymph glands, the deep location of the older tubercles in the
cancerous ulcer, and the more superficial situation of the
younger ones. It would seem, however, more probable that the
secondary tuberculous infection was due to sputum deglutition.
 
3. Pepper and Edsallf report the case of a man, 42 years of
age, who had tuberculosis of the lungs, larynx, cervical glands
and ojsophagus. The oesophagus was patulous and normal
as high up as the level of the arch of the aorta. Above this
point and to the junction with the pharynx, the lumen had
entirely disappeared. The oesophageal walls and surrounding
tissues had formed a band of dense fibrous tissue, about
1.35 cm. thick and 3.75 cm. broad, which was firmly bound to
the vertebra. Sections of the growth examined microscopically showed cancerous tissue in a dense fibrous tissue basis,
tubercle-like masses undergoing fibroid change, an occasional
giant cell, and tubercle bacilli.
 
The central and deeper portions of the tumor were composed mainly of fibrous tissue, and this appearance led the
authors to conclude that tuberculosis was evidently the
original cause of the disease, while cancer subsequently infiltrated the occlusion. (?) That the cancer was primary they consider improbable, both from the microscopic appearance of
"infiltration of a previously existing mass, and from the history
of cancer being here as elsewhere one of inexorable growth
and onward progress, ulceration, and sloughing."
 
 
 
*Cordua: Ein Fall von krebsig-tuberculosem Geschwiir des
Oesophagus. Arbeiten a. d. pathologischen Institut in GiJttingen,
1893, 147.
 
f Pepper and Edsall : Tuberculous occlusion of the rosophagus
with partial cancerous infiltration. Amer. Jour, of the Med. Sci.,
CXIV, 1897, 44.
 
 
 
C. — Infection of the Intact Membrane directly (by
Sputa) or from the Circulating Blood.
 
This class embraces those lesions which heretofore were
regarded as most unusual, but which from Mazzotti's experience must rank in frequency with those described in class I.
The eight cases of Mazzotti belonging to this group would
seem for the most part to have been caused by the deglutition
of tuberculous sputum, though the coexistence of ulcers and
nodules makes it difficult in some instances to differentiate
certainly the inoculation of tuberculous sputum from infection through the blood.
 
1. The first case reported by Mazzotti was a woman, aged 33
years, who died of pulmonary and (Esophageal tuberculosis.
At autopsy the mucosa of the ossophagus, normal in its upper
part, was found reddened below. The redness increased in
intensity from above downward, becoming scarlet near the
cardiac orifice of the stomach. On this red base were scattered numerous tuberculous ulcers. These were small and
superficial in the upper segment, measuring several millimetres in diameter, becoming larger lower down, until near
the cardiac orifice of the stomach several of them coalesced,
forming an extensive loss of substance. The large ulcer thus
produced was more irregular and deeper than the others,
extending indeed to the muscular tunic.
 
2. The second occurred in a man, aged 40 years, who died
of pulmonary phthisis. The oesophagus presented above, and
in the anterior wall at its junction with the larynx, several
white, rounded prominences, slightly larger than the head of
a pin, with ulcerated centres. A little lower down there was
an elliptical longitudinal ulcer with smooth base and slightly
elevated edge, 5 cm. in circumference. Lower still, and rather
near the end of the oesophagus, a yellowish nodule projected
from the mucosa. This had ulcerated, and in all respects
resembled the elliptical ulcer described. The mucous membrane in general was pale, but near the stomach there was
some injection without ulceration.
 
3. The third case was a woman, aged 35 years, who had died
of pulmonary tuberculosis. The (esophagus was normal in its
upper part. At about the middle third the mucosa was of a
greyish black color and contained several superficial ulcers
with smooth margins and regular white bases. They were
elliptical in the longitudinal direction. In the lower third
the mucosa was pale, but here, too, were elliptical ulcers,
smaller than the former, which they resembled in every other
particular. The deepest of these ulcers scarcely reached the
muscular coat.
 
4. The fourth was a man, aged 60 years, who succumbed to
pulmonary and intestinal tuberculosis. The mucosa of the
oesophagus in its lower half contained about 30 elliptical
ulcers with smooth, regular margins and bases. They were
smaller and more superficial above, but on descending the
canal approached each other more closely, became larger and
deeper, extending finally to the submucosa.
 
5. The fifth example was furnished by a male, aged 18 years,
who died of pulmonary phthisis. Throughout the oesophagus
were scattered numerous ulcers. They were elliptical in form,
the larger ones being relatively longer than the smaller. In
 
 
 
232
 
[No. 80.
 
 
 
some places several ulcers were united in such a way as to
present an irregular shape. In other places the ulcers were
separated by little tracts of healthy mucosa, giviug the
appearance of a network. They were not very deep, touching
at most the submucous tissue, aud had greyish bases and
smooth, regular, slightly elevated edges.
 
6. The sixth was a man, aged 67 years, in whom pulmonary
and iutestinal tuberculosis were also found. In the oesophagus,
three inches from its origin, was an ulcer of the mucosa 5 cm.
in length. Near this were two small ulcers, while a little
below was one of intermediate size. The remainder of the
mucosa contained only smooth white elevations about the size
of a piu-head. At the junction of the middle and lower third
of the ojsophagus, was a diverticulum as large as the end of
the little finger.
 
7. The seventh was a woman, aged 48 years, who presented
the lesions of pulmonary and intestinal tuberculosis. In the
lower two-thirds of the oesophagus the mucosa attracted
attention by an intense redness which extended over a wide
area. In the midst of this were twelve or fifteen ulcers of
various sizes. The smaller ones were round, measuring 0.5 cm.
in diameter; the larger were elongated, the diameter of the
largest reaching more than 3 cm. The rest were all regular,
with smooth superficial margins, except a single deeper one
situated at the union of the middle and lower thirds.
 
8. Mazzotti's final case was a man, aged 61 years, who succumbed to pulmonary phthisis. The oesophagus in its upper
part presented four or five scars several millimetres in length,
with ulcerated centres, in the vicinity of which the mucosa
was pale, but otherwise of normal appearance.
 
9. Zenker's fourth case belongs to this class. It occurred
in a man 38 years old, who suffered from tuberculosis of the
lungs, nose and throat, enlarged lymjDhatic glands, and
stenosis of the oesophagus. At the autopsy, the oesophagus in
its uppermost part presented a large superficial scar-like
ulcer which included almost the entire circumference of the
canal, and formed a marked constriction. At about its
middle portion the oesophagus showed an elevated nodule the
size of a bean, from which thiu pus escajjed. The bronchial
and peri-oesophageal lymph glands were enlarged and caseous.
The microscopic examination of the lesions in the cBSophagus
exhibited the histological characters of tuberculosis, which was
limited to the mucosa aud submucosa. Numerous tubercle
bacilli were demonstratetl in the tubercles and pus.
 
Zenker* believes that the infection in this case was due to
sputum deglutition, and brings forward the fact of the superficial character of the ulcers in support of this view.
 
10. Hasselmannf describes the case of a boy sis months old,
in whom, in addition to tuberculosis of the oesophagus, there
existed tuberculosis of the lungs and lymph glands. In the
lower part of the oesophagus three crater-like ulcers were
found which had no connection with either the trachea or the
caseous lymph glands. The microscopic examination proved
 
 
 
* Zenker: Op. cit.
 
t Haaselmann : Ueber Tuberculose des Oesophagus. luaug. -Dissertation, Miinchen, 1895.
 
 
 
them to be tuberculous in nature. The infection is believed
to have taken place from the swallowed sputum.
 
11. The case reported by E. Friinkel* occurred in a man 33
years of age, who died of pulmonary and intestinal tuberculosis. The oesophagus contained a large number of yellowish
spherical nodules about the size of a hemp seed, some with
sujierficial loss of substance, others still covered with the
intact mucosa. Adjacent to these were found small masses
with irregular edges and uneven bases, and several small
round ulcers with abrupt edges and perfectly smooth bases,
averaging 3 mm. in diameter. The larynx, trachea and peritracheal lymph glands were quite intact. The microscopic
examination of the lesions showed besides epithelioid and
giant cells, tubercle bacilli.
 
Regarding the mode of infection in this case, Friinkel does
not consider it possible to conclude certainly between a htematogenous origin and the inoculation of tuberculous sputum,
but he inclines to the latter view.
 
1 3. Glocknerf describes a case which he regards as of haematogeuous origin, and which is peculiar in the limitation of
the tubercles to the muscular coat of the oesophagus.
 
It occurred in a man, 48 years of age, in whom the autopsy
showed old tuberculous areas in the apices of both lungs,
tuberculosis of the pleura, peribronchial and mesenteric
lymph glands, oesophagus aud viscera generally. The oesophagus at its mid-portion contained an irregular thickened zone,
encircling the wall of the tube, 5 cm. in width, and from 5 to
7 mm. in thickness. On section of this thickened area it was
found to consist of numerous caseous tubercles, varying in
size from a piu-head to a hemp seed, irregularly infiltrating
the muscular coat, to which they were strictly limited. The
mucosa and submucosa were perfectly intact and freely
movable over the deeper lying structures. The peri-cesophageal tissue was likewise free from diffuse infiltration, but contained several small strands with interrupted nodular swellings the size of a millet seed. These strands were interpreted
by Glockuer as tubercle-infiltrated afferent vessels of lymph
glands. The lymph glands in the neighborhood of the thickening, as well as those about 3 cm. above, were somewhat
enlarged and caseous, but not abnormally adherent to the
peri-cesophageal tissue. Microscopic examination showed
the typical structure of caseous tubercles, and tubercle bacilli
in great numbers were found.
 
Glockner regards this case as certainly of ha?matogenous
origin and believes that he excludes all other modes of infection. Infection through continuity he eliminates by the
absence of lesions in the continuous structures; direct inoculation of the inner surface of the mucous membrane is rendered improbable by the intact condition of both mucosa
and submucosa; invasion from the peribronchial lymphatic
glands, through lymph transport of tubercle bacilli, he
excludes by the freedom from tuberculous infiltration of the
peri-oesophageal tissue. In favor of hi^matogenous infection
 
 
 
* E. Friinkel: Ueber Beltene Localisation lier TuberculoFC.
Miinch. med. Wochenschr., XLIII, ISOli, 27.
 
f Glockner: Ueber eine neue Form von Oesopliagns-Tuberciilose.
Piag. med. Woch XXI, 1890, 114, 127, 138.
 
 
 
 
 
 
 
section of the esophagus showing discrete tubercles .opposed of epitheUoid a^d ^-* -Jl;^;; V" ™''"
node extending into the mucosa, Ha.matoxylin staining. /e,ss objeot.vc DO. e>e-p.cce No. 1.
 
 
 
November, 1897.]
 
233
 
 
 
is adduced not only tlie peculiar localization of tubercles in
the nuiscnlar coat of the resophagus, but also the dissemination of miliary tubercles in the viscera generally.
 
To this last series of cases may be added the one from this
laboratory. It occurred in a colored man, aged 33 years,
admitted to the surgical wards of the Johns Hopkins Hospital, service of Dr. Halsted, to whom we are indebted for the
clinical notes. The history, however, has but little bearing
upon the lesions in the resophagus, and may therefore be
briefly stated.
 
Clinical History. The first admission to the hosi^ital was
on September 16th, 1895, for an enlarged right testicle. There
was a tuberculous family history. The patient had previously
suffered from typhoid fever, gonorrhoea and syphilis, and for
the past four years had been short of breath. His general
health, however, had been good until a few months before
admission. The examination showed, besides tuberculosis
of the right testicle, a slight involvement of the right lung at
the apex, and a dark and mottled condition of the mucous
membrane of the mouth. The right testicle was removed, the
wound healed promptly, and the patient was discharged from
the hospital, October 22nd, 1895.
 
On February 7th, 1897, he returned to the hospital suffering
with tuberculosis of the left testicle and cough. He failed
rapidly and died March 1st, 1897.
 
The autopsy was performed by Dr. Flexner four hours
after death. I shall abstract the protocol and give only the
anatomical diagnosis and such notes as bear upon the lesions
in the cesophagus.
 
A natomical Diagnosis. Kemoval of testicle (for tuberculosis)
eighteen months previously ; tubei'culosis of epididymis and
remaining testicle, seminal vesicles and prostate gland; generalized tuberculosis; chronic tuberculosis of lungs; peculiar
nodular form of tuberculosis of spleen and kidneys ; tuberculosis of adrenal glands; Addison's disease; jiigmentation of
mucous membrane of mouth.
 
The cesophagus shows in its lower two-thirds elevated dots
and larger nodules in great numbei-s. None of these are caseous, but the smaller points resemble the individual tubercles
found in the spleen, liver and other glands.
 
The tubercles in these organs are minute granulomata, submiliary in size, of pale grayish-white color, opaque and noncaseating.
 
Histological Examination. The elevated dots and nodules
found in the lower two-thirds of the cesophagus are seen to be  
enlarged lymphoid follicles, invaded by miliary tubercles  
which at times become conglomerated. A section of one of  
the larger oval nodules, measuring 1.25x1.50 mm., contains  
nine small, pale, Irregularly circular areas of different sizes,  
with more or less definite contours, arranged in horse-shoe  
fashion around the periphery of the nodule. These pale  
areas contrast sharply with the more deeply-stained normal  
lymphoid structure.  
 
Under somewhat greater magnification the pale areas are  
seen to consist of epithelioid cells, at times distinctly separated  
one from the other by irregular spaces in which are found  
sparsely scattered lymphoid cells. A scant reticulum holds  
these elements loosely together. The epithelioid cells are  
 
 
 
round or oval, with abundant protoplasm and vesicular nuclei.  
The nuclei are round, oval, elongated or kidney-shaped.  
Some of these cells contain two or more nuclei, and occasionally is seen a well-defined giant cell with a mural arrangement  
of its nuclei. The epithelioid clumps are surrounded by  
lymphoid cells, but these cannot be differentiated from the  
normal structure of the lymphoid nodule. At other levels the  
nodule shows partial coalescence of the discrete tubercles, thus  
giving an appearance of more diffuse infiltration.  
 
Other nodules examined show an appearance similar to that  
just described ; while the smaller dots, at times of microscopic  
size, often contain a single cellular tubercle.  
 
Tubercle bacilli are present in small number.  
 
Nowhere are the tubercles found outside the lymphoid  
nodules, and in no instance do they extend beneath the  
mucosa The oesophagus is otherwise normal.  
 
The mode of infection in this case offers no difficulties ; it is  
clearly of hematogenous origin, the original focus being the  
diseased testicle. The case forms, together with the one  
instance of miliary tuberculosis of Mazzotti, excluding for the  
time the less certain cases of E. Friinkel and Glockner, the  
instances of undoubted blood infection of the cesophagus.  
 
No other instance of the localization of the tuberculous  
lesions in the lymphoid structures of the oesophagus has thus  
far been published. According to Diirck* the relative insusceptibility of the cesophagus to tuberculosis depends in part  
upon the slight development of its lymphatic apparatus. There  
is, however, no great dearth of small nodular accumulations  
of lymphoid cells in the snbmucosa and mucous membrane of  
this organ, which may after all be oftener the seat of tubercles  
than is generally considered. The insignificance of these structures, even when, as in this case, they are involved in a general  
tuberculosis, may easily lead to their being overlooked. Without the microscopical examination of many different segments  
in a given case, the disease could readily escape observation.  
 
The relative immunity of the oesophagus from other forms  
of tuberculosis, especially from those varieties included under  
classes II and III, may be explained in part upon purely  
mechanical grounds; namely, the rapid passage of infectious  
material over the mucous membrane of the oesophagus, and  
the resistance to such infection offered by the stratified pavement epithelium.  
 
A review of the entire subject tends, however, to modify  
considerably the opinion once held that tuberculosis of the  
oesophagus arises in a large majority of cases through continuity or contiguity of structure. Thus, of the total fortyeight cases collected, only twenty-four took origin in this  
way, five arose through the addition of the tuberculous process to a previous predisposing lesion, four by blood infection,  
while the remaining fifteen arose through the inoculation of  
the mucous membrane by tuberculous sputum, without the  
existence of a previous demonstrable legion.  
 
The study of this subject was undertaken at the suggestion  
of Dr. Flexner, to wliom the writer is indebted for kind assistance in the preparation of these notes.  
 
 
 
*Durik: Ueber Tub('ii;ulu.se iles Oesopljagus. Ergebniste <ler  
Palhologie, I, 1897.  
 
 
A RARE ANOMALY OF THE ARCH OF THE AORTA, WITH AN ADDITIONAL MUSCLE IN  
 
THE NECK.  
 
 
 
By a. B. Herrick.  
 
 
 
The variation herewith reported is from the cadaver of a  
negro dissected in the Anatomical Laboratory of the Johns  
Hopkins University. With the exception of the snpernume  
rary muscle, the variation can easily be explained by an arrest  
of the development of the aortic arches, showing also that in  
these cases the inferior laryngeal nerve is no longer held down  
by the fifth aortic arch and drawn into the chest.  
 
 
 
 
Fig. 1. The aortic arch and its branches, showing their relations to  
the trachea and oesophagus, and the position of the recurrent laryngeal  
nerves.  
 
00, common trunk of the two carotids ; RS, right subclavian ; LS, left  
subclavian; KC, right carotid ; iC, left carotid ; iJF, right vagus; LV,  
left vagus; RRL, right recurrent laryngeal; LRL, left recurrent laryngeal.  
 
The number of arteries arising from the arch was normal,  
but their arrangement was unusual ; the two carotids arising  
nearest the heart by a common trunlv, then the left subclavian,  
and lastly the right subclavian passing behind the trachea  
and lastly the right subclavian passing behind the trachea  
and oesophagus. The common trunk of the two carotids is  
and oesophagus. The common trunk of the two carotids is  
Line 34,238: Line 41,212:


November, 1897.]  
November, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


235  
235  
Line 34,370: Line 41,338:


236  
236  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 80.  
[No. 80.  
Line 34,512: Line 41,474:


NOVEMBEE, 1897.]  
NOVEMBEE, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


237  
237  
Line 34,661: Line 41,617:
JBeitriige zur Augenheilkunde, June, 1894.  
JBeitriige zur Augenheilkunde, June, 1894.  


238
JOHNS HOPKINS HOSPITAL BULLETIN.
[No. 80.




Line 34,867: Line 41,812:




[Price, 15 Cents.
 




Line 34,965: Line 41,910:
and more untarnished ideals than the effeminate and selfconscious echoes of later-day rhymesters. Better adultery  
and more untarnished ideals than the effeminate and selfconscious echoes of later-day rhymesters. Better adultery  
with bravery and honor unto death, than adultery without  
with bravery and honor unto death, than adultery without  
these things !
these things
 
 
 
240
 
 
 
JOHNS HOPKINS HOSPITAL BULLETIN.
 
 
 
[No. 81.
 




Line 35,037: Line 41,969:


Despite Tennyson, neither war nor wantonness was the  
Despite Tennyson, neither war nor wantonness was the  
essential spirit, the inner Trieb of this age. Its dominant  
essential spirit, the inner Trieb of this age. Its dominant characteristic, the source of both the war and the wantonness  
 
 
 
characteristic, the source of both the war and the wantonness  
(thb latter a belieing and a belittling word), was the abounding sense of exuberant life, the fulness and immediacy of  
(thb latter a belieing and a belittling word), was the abounding sense of exuberant life, the fulness and immediacy of  
health that filled the actors and made of the women eternal  
health that filled the actors and made of the women eternal  
Line 35,103: Line 42,031:
December, 1897.]  
December, 1897.]  


241




JOHNS HOPKINS HOSPITAL BULLETIN.


times varied according to the time of day or the intensity of
the sun's rays. It is said that "Syr Gauwayn had siiche a
grace and gyfte that an holy man had gyuen to him, that
euery day in the yere from uuderue tyl hyhe none hys myght
eucreaced tho thre houres as moche as thryse hys strengthe,
and tliat caused Syr Gauwayn to wyune grete honour."*
Another reference to this curious belief is in that narrative of
Sir Beaumayn, who is warned not to challenge the Knyght of
the reed laund until afternoon, as all the forenoon his strength
increased and at high noon be had the strength of seven men.


The surgical interest in the results of encounters is that
most frequently excited. In the competitive jousts the object
was to overcome by superior strength, skill and horsemanship.
In them the mortality did not probably exceed that of a
modern game of football or cross-country riding. To intentionally maim or kill was the greatest shame of which a
knight could be guilty. Sir Launcelot is said to have
nnhorsed five hundred knights, winning the victory over
them all, and yet none is killed.


241
Even though severely wounded the spirit is not conquered ;
 
with a spear-head in his side Sir Launcelot fights all day,
overcoming more than thirty knights. And he recovers in a
few days. In the conflict between Balan and Balin they
"hadde eyther symtem other seuen grete woundes so that the
lest of them myght have ben the dethe of the myghtyest
gyaunt in the world." Sir Percyval and a knight inflict
upon each other fifteen wounds, and they " bledde soo moche
that it was merueyl that they stoode on their feet." Alysander " had no foote ne myght to staude upon the ertbe, for he
had syxtene grete wounds and in especyl one of them was
lyke to be his dethe." Exhaustion from profuse hemorrhage
with the signs of extreme collapse is a frequent ending of a
genuine combat. In such accounts the romancer's imagination is doubtless frequently evident, but in all the stories are
descriptions too peculiar and detailed not to be the result of
direct observation.
 
We find that it was quite possible to kill a man with a
single blow. It is related that Marhaus kills a knight "stark
dede " at a single encounter. The most common injuries were
about the chest or side, as these were the points at which the
spears were most directed. After an opponent is unhorsed a
hand-to-hand combat on foot usually ensued, in which the
principals hacked and struck at one another with swords ;
and it is in these latter battles that the most serious wounds
were inflicted.


 
Cerebral concussion is, of course, frequent. The modern  
times varied according to the time of day or the intensity of
lay description of " seeing stars " has its analogue in several  
the sun's rays. It is said that "Syr Gauwayn had siiche a
passages. It is even said that a maiden gives Alysander such  
grace and gyfte that an holy man had gyuen to him, that
a buffet " that he thought the fyre flewe oute of his eyen."  
euery day in the yere from uuderue tyl hyhe none hys myght
In one of his combats Sir Launcelot is struck on the helm  
eucreaced tho thre houres as moche as thryse hys strengthe,
so hard that " fyre sprange out of his eyen." Cerebral concussion followed by death, possibly by contrecoup, is evident  
and tliat caused Syr Gauwayn to wyune grete honour."*
in the account that Sir Gawayne smote his (helmeted) opponent so hard that " it went to the braynes and the Knyght
Another reference to this curious belief is in that narrative of
felle downe dede."
Sir Beaumayn, who is warned not to challenge the Knyght of
the reed laund until afternoon, as all the forenoon his strength
increased and at high noon be had the strength of seven men.
 
The surgical interest in the results of encounters is that
most frequently excited. In the competitive jousts the object
was to overcome by superior strength, skill and horsemanship.
In them the mortality did not probably exceed that of a
modern game of football or cross-country riding. To intentionally maim or kill was the greatest shame of which a
knight could be guilty. Sir Launcelot is said to have
nnhorsed five hundred knights, winning the victory over
them all, and yet none is killed.
 
Even though severely wounded the spirit is not conquered ;
with a spear-head in his side Sir Launcelot fights all day,
overcoming more than thirty knights. And he recovers in a
few days. In the conflict between Balan and Balin they
"hadde eyther symtem other seuen grete woundes so that the
lest of them myght have ben the dethe of the myghtyest
gyaunt in the world." Sir Percyval and a knight inflict
upon each other fifteen wounds, and they " bledde soo moche
that it was merueyl that they stoode on their feet." Alysander " had no foote ne myght to staude upon the ertbe, for he
had syxtene grete wounds and in especyl one of them was
lyke to be his dethe." Exhaustion from profuse hemorrhage
with the signs of extreme collapse is a frequent ending of a
genuine combat. In such accounts the romancer's imagination is doubtless frequently evident, but in all the stories are
descriptions too peculiar and detailed not to be the result of
direct observation.
 
We find that it was quite possible to kill a man with a
single blow. It is related that Marhaus kills a knight "stark
dede " at a single encounter. The most common injuries were
about the chest or side, as these were the points at which the
spears were most directed. After an opponent is unhorsed a
hand-to-hand combat on foot usually ensued, in which the
principals hacked and struck at one another with swords ;
and it is in these latter battles that the most serious wounds
were inflicted.
 
Cerebral concussion is, of course, frequent. The modern  
lay description of " seeing stars " has its analogue in several  
passages. It is even said that a maiden gives Alysander such  
a buffet " that he thought the fyre flewe oute of his eyen."  
In one of his combats Sir Launcelot is struck on the helm  
so hard that " fyre sprange out of his eyen." Cerebral concussion followed by death, possibly by contrecoup, is evident  
in the account that Sir Gawayne smote his (helmeted) oppo




Line 35,175: Line 42,098:




nent so hard that " it went to the braynes and the Knyght
felle downe dede."


The common sign of basal fracture — hemorrhage froiji the  
The common sign of basal fracture — hemorrhage froiji the  
Line 35,242: Line 42,163:


242  
242  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 35,376: Line 42,291:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


243  
243  
Line 35,507: Line 42,416:


244  
244  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 35,644: Line 42,547:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


246  
246  
Line 35,781: Line 42,678:


246  
246  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 35,912: Line 42,803:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


247  
247  
Line 36,034: Line 42,919:


248  
248  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 36,166: Line 43,045:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


249  
249  
Line 36,293: Line 43,166:


250  
250  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 36,466: Line 43,333:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


251  
251  
Line 36,661: Line 43,522:


252  
252  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 36,810: Line 43,665:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


25S  
25S  
Line 36,952: Line 43,801:


264  
264  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 37,219: Line 44,062:


256  
256  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 37,348: Line 44,185:


258  
258  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 37,405: Line 44,236:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


259  
259  
Line 37,534: Line 44,359:


260  
260  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 37,672: Line 44,491:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


261  
261  
Line 37,805: Line 44,618:


262  
262  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 37,934: Line 44,741:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


263  
263  
Line 38,082: Line 44,883:


264  
264  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 38,213: Line 45,008:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


265  
265  
Line 38,354: Line 45,143:


266  
266  
JOHNS HOPKINS HOSPITAL BULLETIN.


[Ko. 81.  
[Ko. 81.  
Line 38,489: Line 45,272:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


267  
267  
Line 38,640: Line 45,417:


268  
268  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  
Line 38,832: Line 45,603:
peritonitis treated by a new method, 141 ;— Typhoid perforation  
peritonitis treated by a new method, 141 ;— Typhoid perforation  
treated by surgical operation, 110.  
treated by surgical operation, 110.  
December, 1897.]
JOHNS HOPKINS HOSPITAL BULLETIN.
269




Line 39,019: Line 45,777:


270  
270  
JOHNS HOPKINS HOSPITAL BULLETIN.


[Xo. 81.  
[Xo. 81.  
Line 39,246: Line 45,998:


December, 1897.]  
December, 1897.]  
JOHNS HOPKINS HOSPITAL BULLETIN.


271  
271  
Line 39,492: Line 46,238:


The Pathology of Toxalbumin Intoxications. By Simon Flexn'ER, M. D.  
The Pathology of Toxalbumin Intoxications. By Simon Flexn'ER, M. D.  
Tlie price of a srt hound In cloth [Vols. I-T'I} of the Hosjiital licparts is
$30.00. Vols. I, 11 and III ni-e not sold sejMimtel!/. The price 0/
Vols. IV, V and VI is $S.OO each.




Line 39,528: Line 46,270:


272  
272  
JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.  
[No. 81.  

Latest revision as of 11:28, 16 February 2020


http://www.archive.org/details/johnshopkinsmedi08john


BULLETIN OF THE JOHNS HOPKINS HOSPITAL.

Vol. VIII. - No. 70.


BALTIMORE, JANUARY, 1897.


Contents

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


The Phrenology of Gall and Flechsig's Doctrine of Association Centres in the Cerebrum. By Lewellys F. Barker,

M. B., - - - - - 7

Notes on New Books, ......... 14,

Books Received, 15


PRESENTATION OF THORWALDSEN'S STATUE OF CHRIST TO THE HOSPITAL


Oa Wednesday afternoon, October 14, 1896, at 3 o'clock, there was uuveiled in the rotunda of the Administration Building of the Jolms Hojjkins Hospital, in the presence of the trustees and officers and a large audience of invited guests. Stein's reproduction of Thorwaldsen's statue of Christ, a gift from William Wallace Spence, of Baltimore. Mr. Spence, in presenting the statue, spoke as follows:

"I have but a few words to say on this occasion; merely to state how it happens that this statue stands here.

" On a visit to Copenhagen I saw the great work of Thorwaldsen, his ideal conception in marble, of ' Christ, the Divine Healer.' It impressed me more than did any statue I had ever seen, and I think this is the general experience of those who have the good fortune to see it. It was stated that Thorwaldsen himself said, ' I never was satisfied with any work of my own until I executed the Christ; now I am satisfied.' He felt that his genius had reached the zenith of its powers and that he could go no higher. Well might he be satisfied, for the grace, dignity and majesty of this figure have never been surpassed.

" 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


rest. With this feeling I asked permission of the trustees to 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.

"A few years ago, at the formal opening of the Hospital, President Gilman expressed the hope that some day it might stand there. To-day his hope is realized. And now, Mr. President, I beg to present this statue to the Johns Hopkins Hospital."

The statue was then unveiled by little Emily Riggs, an infant great-granddaughter of Mr. Spence.

Mr. W. T. Dixon, the President, in behalf of the Board of Trustees of the Hospital, accepted the gift in the following words :

" Mr. Spence — It gives me very great pleasure to accept, in behalf of the Board of Trustees of the Johns Hopkins Hospital, your generous gift, this beautiful and impressive statue, and to assure you of our appreciation of your motives and munificence.

"These grateful feelings of the trustees, I am confident, will be cordially shared by all the workers in every department of the Hospital, by our many friends throughout the country, as well as by the sick and suffering who may come under our care.

" You have most appropriately placed this ' Divine Healer ' just where it can be seen by all who may enter the doors of the Hospital, thus affording them the opportunity to derive comfort, courage and hope from its contemplation. And not only are the outstretched hands of this Christus Consolator


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 70.


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.

" There are grave responsibilities and many discouragements 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."

The following hymn by Whittier was sung by a male quartet :

" So stood of old the holy Christ Amidst the suffering throng ; With whom his lightest touch sufficed To make the weakest strong.

That healing gift he lends to them

Who use it in his name ; The power that filled his garments' hem

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.

But we have here, not the original cast in clay, nor a plaster reproduction, nor one in galvano-plastic ; but we have a marble like that which Thorwaldsen himself touched with his chisel. The pose, the drapery, the figure, the outstretched arms, the head, the face, are reproduced for us with exactness by a living artist of Copenhagen.

We are greatly indebted to that honored citizen of Baltimore who has brought here a work which from so many points of view delights and inspires us.

This is not the first time that a hospital has been decorated by a great work of art. If I remember rightly, Benjamin West painted the picture of " Christ Healing the Sick," for the Pennsylvania Hospital in Philadelphia; and, if I am not mistaken, in St. Luke's Hospital, New York, there is still a


famous picture by Daniel Huntington, "The Dream of Mercy," based upon an incident in Buuyan's Pilgrim's Progress.

Nor is this the first gift that this hospital has received. Its munificent endowment by Johns Hopkins has been strengthened by fuuds provided for the foundation of a school of medicine and surgery, which supplements the work of the Hospital. And minor gifts have come in. Not long ago we had a very small but noteworthy present, a likeness of Florence Nightingale. At another time a friend gave us models and pictures of various public institutions throughout the country. Again, one who loves medical biography and history has hung upon these walls a fine collection of the portraits of illustrious physicians and surgeons who in many countries and in many generations have adorned their profession. Eecently a large gift has enabled the trustees to provide better facilities for the instruction of those who are here engaged in preparing themselves for the profession of medicine or for nursing. And now we have this work of art which, perhaps, appeals to more of us than any of the other gifts, unless it be that touching memento of a departed child, the "White Eose Fund," which enables the Superintendent every year to distribute flowers to, and to provide for the entertainment of those who are convalescing in the Children's Ward.

Baltimore is fortunate in many ways in the gifts that are coming to it. We seem to have reached a period in the history of this city when its citizens are ready to adorn and decorate the place of their residence. Mr. Spence has presented a noble statue of William Wallace that stands in Druid Hill Park. Around the Washington Jlonument are the works of Barye, of Dubois, and of Story, and also the grand figure of Chief Justice Taney, perhaps the best portrait statue, with one or two exceptions, that has ever been produced in this country, the work of our own Rinehart. But pleasant as these tokens are, I must not dwell upon them, but must rather speak of the circumstances under which this work of Thorwaldsen was produced, and tell you some things regarding the sculptor.

The city of Copeijhagen, at the entrance to the " Sound," is not a very large place; I should say not more than one-half or two-thirds the size of Baltimore (if size is measured by population) ; but it has a port, a university, a citadel, a harbor, and an academy of fine arts, the latter holding high rank among the academies of Europe. The city suffered greatly by the bombardment of 1807 during the Napoleonic wars, and it was not till some twelve or thirteen years afterward that an historic edifice, which had thus been destroyed, was reconstructed. This was the old church which bears the name of the " Frue Kirke." The sound would be more familiar to us if I called it Notre Dame, or the Church of Our Lady. Denmark, as you know, is a Protestant country, and this is a Lutheran church. I have heard it called a Presbyterian church, and I do not know that Mr. Spence will object to that. While in the process of reconstruction, the commissioners had a conference with Thorwaldsen, a native of Copenhagen, and arrangements were made by which he should model a statue of Christ. It was also agreed that the approach to the altar from the main portal should be lined with statues of the apostles, beginning with Peter and Paul. This arrangement was carried


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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.

I have come upon another incident perhaps more curious. You know that when a man becomes famous all the world begins to ask " Who was his grandfather ? " and to trace his heredity as far as possible. As soon as this Danish sculptor became famous, people found out that he was descended from an old Icelandic sculptor. But they did not stop there ; they thought they found that he was a desceudant of Thor Finn. Thor Finn is the name of one of the Norsemen who is said to have crossed the Atlantic, not far from the year A. D. 1000, and is said to have skirted along the New England coast and to have established himself iu the southern part of that peninsula. A son was born to Thor Finn in what is now Rhode Island (so at least it is said), and to that man they have traced the genealogy of Thor-wald-sen, and thus they claim that Thorwaldseu is descended from the first person born of European descent in the new world.

The enterprising secretary of the Rhode Island Historical 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."

It is just one hundred years this very month, and I may say this very week, since Thorwaldsen, iu a note dated October 16, 1796, states that he is on his way from his northern home, like the Norsemen of old, to establish himself in the south. He was a passenger upon a government frigate which stopped leisurely at one point and then another, so that his journey grew tiresome. At last he abandoned the man-of-war and


found other conveyances to carry him from Malta to Palermo, to Naples, and so on to Rome. There he went to work.

But how could this boy maintain himself in Rome ? It was by the aid of a scholarship provided for him by the Royal Academy of Copenhagen. He had not been a very bright boy in his ordinary school instruction. His teacher could uot make anything out of him, and the pastor who was engaged in giving him lessons for confirmation shook his head many a time at the dulness of the artist. One day in the course of these lessons he said, "Thorwaldsen, was that your brother that took the j)rize iu the Academy of Fine Arts the other day':"' " No," said the young sculptor, "it was I." "You!" said the teacher; "Mr. Thorwaldsen [with the emphasis on the title], go up to the front seat." It is not a bad thing for those of us engaged in instruction to remember that sometimes boys who are dull at books, who do uot like to receive knowledge through the printed page, may yet have talents that are worth developing. This should never be forgotten.

Now I want to remind you that scholarships just like that which enabled Thorwaldsen to go forward, have been established within a short time in Baltimore. Rinehart, as you know, left a considerable sum of money, which was carefully invested by Mr. Newcomer and Mr. Walters, until it reached the sum of $100,000, and it was then given to the Peabody Institute. This very week the Maryland Institute, by the aid of that fund, has instituted a school of sculpture, to bear the name of Rinehart, and besides this, Rinehart scholarships have been bestowed upon two young men, selected with great care by distinguished artists, and they are now engaged iu the prosecution of their art-studies, one in Paris and the other in Rome. I think it is not unreasonable to hope and believe that as the years roll by we shall hear something proceeding from these influences worthy to stand beside the Danish artist whom we this day commemorate, worthy likewise of Rinehart's bounty.

At Rome, Thorwaldsen instantly came under the modern influences of that day. Wiuckelmann, the well-known critic, had already called attention to the great value of the Greek art iu distinction from that of the Renaissance, and sculptors began to work iu the Hellenic spirit. You get an illustration of this movement in the Flaxman designs, as produced in England. You get another illustration in the work of Oanova, and you get an especially good illustration in the early work of Thorwaldsen.

A great many illustrious people came to Rome. An amusing story is told of Sir Walter Scott. He was very desirous of meeting and talking with Thorwaldsen, and they were introduced to one another; but Thorwaldsen could not speak a word of English, and Sir AValter was not at his ease in French. All that any one could hear was "plaisir," "plaisir," "connaissance," and similar nouns, expressing gratification that they had met.

The sculptor soon came into church circles. He was a particular friend of Cardinal Consalvi, and made his monument. It was through his influence, undoubtedly, that Thorwaldsen was selected to make for the Church of St. Peter the famous monument of Pius the Seventh. Some one objected that a Protestant had been selected. The Pope inquired, " Is not he the


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 70.


best artist in Eome?" "Undoubtedly," was the answer. "Then let him hold the place."

Thorwaldsen after a time went home, and, as I have said, received the commission for a statue of Christ. He returned to liome, and with his helpers, it took him eight or nine years to complete the group of Christ and the Apostles.

You must be familiar with many of the works which he produced meanwhile. The little medallions of Night and Day 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."

The story goes that he made six models of the Christ before he was satisfied with the one which is here reproduced. At first he thought of giving to the figure an iiplifted hand, in the attitude of benediction. Afterwards he uplifted both arms as if in prayer. The artist was standing before his statue one day, when he said to a friend, " I am not satisfied with that." His friend replied, " What was your motive in giving that posture; what were you thinking about?" Thorwaldsen paused, and in a moment turned down the arms to the position in which you now see them, and then said, " I am satisfied now."

It is worth while for me to add that between five and six hundred works by this artist have been catalogued — a large part of which may be seen (in the cast, if not in the original) at the Thorwaldsen Museum in Copenhagen.

Now, ladies and gentlemen, it is not for me to draw the lesson of the statue. I suppose (to use a phrase of Coleridge) that this statue "will find each one" of us in his own 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


is repeated. So it is in painting, from Eaphael and Leonardo to those gifted men who are now decorating the churches in this country with the illustrations of the life of Christ. So it is in sculpture, fi'om Michael Angelo to St. Gaudens. So it is in religious meditation, from Thomas a Kempis to Phillips Brooks. Everywhere there is one Jiote prevalent, one name pre-eminent. Whatever else the founder of Christianity may have been, we cannot read the narratives of his life without a certainty that he was the Great Physician. W'hatever else may be found in this statue, however we may look at it, we must be mindful that it represents to us one who lived and walked upon this earth, and wrought more cures and more wonderful cures than any physician or surgeon that had ever lived. Thorwaldsen, better than any artist that I know, has produced this thought in marble. Li " Ecce Homo " attention is called to a fact which you will allow me to repeat — that the founder of Christianity was not only the Great Healer, but when he first organized his followers into a definite society, for the purpose of bearing glad tidings throughout the world, he sent them on their mission as physicians. " Go," he said, "and heal the sick "; and the narratives of the Evangelists and of the Book of the Acts bring out most clearly this distinctive character. Among its other lessons we shall remember that this " House of Mercy," this " Hotel-Dieu," is pervaded by the spirit which appeared upon the earth almost nineteen hundred years ago.

In the presence of Mr. Spence it will not do for me to recount the many good deeds which he has done for the city, the many great services, political, financial, mercantile, philanthropic, educational and religious, which he has rendered to Baltimore ; but I must be allowed to say that twice when the finances of the Johns Hopkins University have been in a critical condition, he has been the one citizen to come forward and by his example to inspire the liberality of others. He was kind enough to tell you that I had on a " wishing cap," or words to that effect, seven years ago. I am going to put on my "wishing cap" now, and I am going "to wish" that as long as Baltimore lives and flourishes it may have the presence and influence and co-operation of such men as William Wallace Spence.


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.,

former Assistant Gytiecologist to the Johns Hopkins Hosjntal.


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


ally seven days, and were often profuse and painful; since marriage her menses have been regular, lasting five or six days, being profuse but not painful. In May, 1890, she ceased to menstruate for two months, but in July her menses reappeared and lasted six days. At this time they were profuse and accompanied with a great deal of backache and pain in both ovarian regions. She had never had leucorrhiva; she suffered from constipation. There was no urinary difficulty. The patient remained well until April, 1891, when a hemorrhage from the vagina occurred suddenly and continued for six days. Two hours after the hemorrhage ceased she passed foul


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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.

On the left side a fluctuating tumor is outlined, about the size of an orange, adherent to the uterus.

Diagnosis. Abscess of the left ovary. Treatment advised, coeliotomy.

Urinary analj/sis. A voided specimen examined on August 9th was turbid, straw-colored, specific gravity 1.020, reaction acid. On standing it deposited a heavy bloody and mucous sediment. On boiling, albumen was found to be present. A large number of red blood corpuscles were revealed by the microscopical examination, as well as numerous epithelial cells both large and small.

A catheterized sj3ecimen was cloudy, amber-colored, specific gravity 1.035, reaction acid. Albumen as in voided specimen; mucous sediment not so deeply stained with blood. The microscopical examination gave much the same results as those shown by the previous specimen.

Operation August 12, 1891, under chloroform narcosis.

Incision 7 cm. long through thin abdominal walls. On exploration of the pelvis, the mass previously palpated on the left side was brought into view. It was bound down to the broad ligament, uterus and pelvic walls by dense connective tissue adhesions. The tumor mass was successfully enucleated, but during its delivery a small rupture occurred at the point at which it was adherent to the fimbriated extremity of the Fallopian tube, and a small quantity of purulent fluid, having a strong foetid odor, escaped. A ligature was immediately tied about the rent, thus preventing the escape of more fluid. The remaining portion of the Fallopian tube, although not adherent, was enlarged and thickened. The tumor mass was transfixed and ligated below the round ligament, after which it was excised and the pedicle cauterized.

The Fallopian tube and ovary of the right side being bound down by only a few adhesions, were enucleated without difficulty. The fimbriated extremity of the tube was occluded, enlarged and thickened. The ovary appeared inflamed, but was not enlarged. The tube and ovary were removed by transfixion and the pedicle was cauterized. The jjelvic cavity was irrigated with three litres of a sterilized salt solution at a temperature of 112° F. and sponged dry.

A drainage tube was inserted in the lower angle of the wound and the usual dressings applied. Time of operation, 40 minutes.

The specimens removed consist of the tube and ovary of the


right side, which are covered with villamentous adhesions, and the tube and ovary of the left side, which are encapsulated in connective tissue-like adhesions.

VIII-13-91. First dressing. The gauze plug in the drainage tube is thoroughly saturated with a dark bloody discharge, and streaked with a fluid resembling pus. Tube cleansed with 20 pledgets of cotton, the last three pledgets being but faintly stained. The discharge had a decided odor of decomposition.

The cotton immediately over the drainage tube was slightly moistened with the same character of secretion as that seen upon the plug and upon the cotton pledgets.

Abdomen flat, no distension, general condition good, usual cultures taken.

VIII-14-91. Second dressing. Slight amount of fluid on cotton over the drainage tube ; plug in tube moistened by a clear fluid holding a clot of blood at the lower end. On the gauze plug there are white opaque points of lymph, corresponding in position to the perforation in the drainage tube. The fluid has the same odor of decomposition. Tube cleansed with twelve pledgets of cotton, which when withdrawn were stained with a serum-like fluid, the two last being hardly soiled at all. Drainage tube removed and a plug of iodoformized gauze inserted down the track of the tube. Abdomen flat, general condition good ; usual cultures taken.

VIII-15-91. Third dressing. Gauze removed from the tube track; moistened; not as much odor. Track of tube cleansed with peroxide of hydrogen. Abdomen flat, general condition good. Gauze reapplied to wound, but not down the track ; abdomen sensitive. Gauze impregnated with permanganate of potassium and oxalic acid applied over the protective dressing and track of the tube.

VIII-19-91. Fourth dressing. Stitches removed. Line of union good; some suppuration about the track of the tube. General condition good.

VIII-26-91. Fifth dressing. Small amount of creamy fluid escaped from the track of the tube. Line of incision in good apposition and well united.

Analysis of temperature cliart. — The temperature was taken for ten days after the operation by the mouth, rectu m and vagina. The highest point registered was that on the fourth day, when it was 102° F. by the rectum, 101.8° F. by the vagina, and 101.2° F. by the mouth. After this it was never above 101° F. and on the 9th day registered 100.5° F.

Bacteriological examination. — The following cultures were made from the left Fallopian tube and abscess cavity: Two sets of Esmarch's roll plates on agar-agar, one smear and one stab culture in the same medium ; a blood-serum tube (bullock's blood) and a litmus milk tube. From the right Fallopian tube, which was distended by a muco-purulent, rather viscid looking fluid, we only made gelatine Esmarch's roll jilates.

Microscopical examination. — Cover-slips stained with gentian violet show numerous polynuclear leucocytes, with compound granular bodies, and a few cells with large round nuclei resembling epithelial cells. Many bacilli were observed; they were rather faintly stained, and were seen only occasionally within the leucocytes. These bacteria were stained best with carbolic gentian violet.

Numerous rod-shaped bacilli were found in the preparation


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 70.


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.

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.

The inoculation of a guinea-pig subcutaneously in the flank with the serum-like secretion from the gauze plug was without result.

Further inoculations from the drainage tube on bullock serum were not made, as the supply of culture medium was exhausted.

The case is of unusual interest on account of the results of the bacteriological examination. The bacillus proteus vulgaris (variety Zenkeri ?) was found in cultures from the abscess cavity in the left ovary, and on cover-slips in the right Fallopian tube. In all our previous examinations of abscess cavities, cysts and Fallopian tubes, we have never met with another instance in which it was present.

Macroscopical and microscopical de.fcripfion of specimens from the Pathological Laboratory of the Johns Ho})kins Hospital, by Dr. .T. Whitridge Williams.

Appendages on loth sides. Left side: Tube 6 by 0.7 by 1 cm. Fimbriated end thickened and adherent to ovary, but not occluded ; some portions are still bound down to the ovary, but at other places the adhesions have evidently been torn loose during the operation. On section it is seen that the mucosa is much thickened and resembles a pyogenic membrane. The characteristic folding has disappeared. Scattered through it here and there are areas which appear decidedly caseous.


The ovary is converted into a pus sac 5.5 cm. in diameter. The greater part of its exterior is smooth, though signs of several dense adhesions are observed. On the surface are a few dilated follicles. The abscess wall varies from 0.5 to 1 cm. in thickness, its interior being lined by a characteristic pyogenic membrane 2 to 3 mm. thick. Externally it is glistening and presents many circular elevations, 1 to 5 mm. in diameter, which are raised only a few mm. above the general surface. These are found to be movable and to represent tags of tissue. On section, the pyogenic membrane is readily divided into two layers; the one nearer to the pus cavity being opaque, thicker, of a yellow color, and having a tuberculous aspect (?) ; the other, lying next the ovarian stroma, is lighter in color, more translucent, and considerably thinner than the inner coating.

Cover-slips from the pus show many thick bacilli, but no tubercle bacilli.

Right side : Tube 5 by 0.4 by 1.2 cm. ; fimbriated end occluded ; many adhesions. Ovary 3 by 3 by 1.5 cm. Many adhesions on surface. On section, the ovary is succulent and contains an oldish corpus luteum and a small corpus luteum cyst, 5 mm. in diameter, with white opaque walls 1 mm. thick and with a glistening interior. There are also several follicles with hemorrhagic contents.

Microscopical examination. The left tube presents a marked purulent salpingitis, the folds of its mucosa being infiltrated with leucocytes and round cells. In places the epithelium is swollen and breaking down, and in others has entirely disappeared, affording a picture which beautifully illustrates the liquefaction of tissue.

There is also a marked endarteritis.

Sections through the wall of the ovarian abscess show that the jDortion adjacent to the cavity contains many newly formed blood-vessels; it is filled with leucocytes and most beautiful fibroblasts, which are rapidly proliferating, nuclear figures and cell division being well seen.

In this portion the connective tissue bands are hardly visible. As we recede from the abscess cavity we find fewer leucocytes, more fibroblasts and connective tissue, until we gradually approach characteristic ovarian tissue.

The bacillus corresponds morphologically to the bacillus proteus Zenkeri, and stains well with methylene blue, and does not entirely decolorize with the Gram or Weigert stain. It may be observed in the abscess walls as a bacillus of varying lengths and in forms simulating cocci. The fibroblasts are strikingly like the large cells of the corpus luteum.

In a contribution to the subject of the proteus vulgaris in abscesses, Hauser', besides the report of his own case, gives a resume of the instances previously reported by other writers. Ilauser's case is that of an adult W'ho had a series of abscesses in the hand, following an injury from one of the autopsy instruments. The pus, which was of an ichorous and stinking character, contained both the streptococcus and proteus. The suppuration was regarded as induced by the streptococci, and the peculiar character of the contents of the abscesses was attributed to the presence of the proteus.

Beck reports several cases of puerperal endometritis in which the proteus vulgaris was found, and one case of puru


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


lent peritonitis, following total extirpation of the uterus for carcinoma, in which the presence of the same organism was demonstrated.

Finally, Dilderlein' reports that in the lochia of puerperal women he has often found bacilli which cause a rapid liquefaction of gelatine; but from his brief description one is not able to say whether or not he was dealing with the proteus.

It seems fair to assume that our patient had a puerperal endometritis following the abortion which occurred last April, and that the infection subsequently involved the Fallopian tube and ovary.

The proteus Zenkeri, which he classifies among the anaerobes of putrefaction, is described by Hauser' as follows: The organisms 0.4 in bi'eadth, and of an average length of 1.65; in some instances the forms are rounder, at other times longer. After inoculation on gelatine, a layer which towards the periphery becomes thinner and has the appearance of the steps of stairs, is formed around the point of inoculation, and from the margin of this layer numerous threads and rods begin to pass out; after 24 hours we find large numbers of moving islands, composed of rods and threads presenting exactly the same appearance as in the case of proteus mirabilis. The deposit becomes gradually thicker and opaque, but no lique


faction of the gelatine occurs except sometimes quite at the surface. The formation of spirilla is seldom observed. Cultures in gelatine and blood serum do not show any marked odor; meat infusion, on the other hand, is decomposed by the organism with the production of a strong smell. In its other effects the proteus Zenkeri resembles the proteus mirabilis and the proteus vulgaris, and as Hauser' has pointed out, there is probably only one species of proteus, the vulgaris, of which the other forms are to be regarded as simple physiological variations.

Literature.

1. Hauser: Ueber das Vorkommen von Proteus vulgaris bei einem jauchig-phlegmonosen Eiterung. Munchener medicinische Wocheuschrift No. 7, 16 Februar, 1S92, p. 103.

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.


THE PHRENOLOGY OF GALL AND FLECHSIG'S DOCTRINE OF ASSOCIATION CENTRES

IN THE CEREBRUM.

Br Lewellts F. Barker, JI. B., Associate Professor of Anatomy in the Johns ffopki7is University and Assistant Resident Pathologist to the Johns Hopkins Hospital.

[Remarks made before the Clinical Society of Maryland, November 20, 1896.]


In the history of medicine the 18th century stands out prominently as a period in which flourished a whole host of so-called medical systems and theories. The animismus of Stahl and the nerve-ether theory of Hoffman had been displaced by the system of Boerhaave ; the last, in turn, being gradually supplanted by the doctrine of irritability advanced by Albrecht von Haller, who had formulated a new theory based upon his experiments in physiology. William Cullen, again, combining Hoffman's system with the doctrine of irritability of Haller, sought the cause for all pathological processes in the nervous system. Each individual attempted to subordinate the most varied phenomena met with in disease to his own particular principle, and as yet the newer studies in anatomy and physiology were not wide-reaching enough in their influence to prevent the development of the most diverse and contradictory medical theories. The " excitation theory " introduced by John Brown met with an enthusiastic reception not only in England but also on the Continent, although it was gradually undermined by the vigorous opposition of Stieglitz and of Hufeland. It was only toward the end of the 18th century and the beginning of the 19th that the investigations in the field of natural science began to affect medical ideas to any very considerable degree. The natural philosophy of Schelling, which was accepted widely by physicians, especially in Germany, benefited medicine very little, if at all.


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.

Gall was born at Tiefenbrunu, in Germany, in 1758. The history of his life affords entertaining reading. He studied medicine in Strassburg and Vienna, and practiced his profession in the latter city, where he became very well known. He tells us in his books how at a very early age he noticed among his playmates the existence of definite relations between the external appearance of the head and face and certain mental characteristics. His lectures delivered in Vienna, in which his phrenological doctrines were chiefly set forth, were very popular and largely attended until 1802. when at the instance of


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 70.


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.

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


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


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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.

In so far as his doctrine maintained that the convolutions represented the most important substratum of the mental activity, and that the single convolutions of the cerebral cortex are not of equal significance for intellectual life, Gall most certainly approached the modern theory of cerebral localization. The investigations of Flourens led him to very different conclusions, and in 1812 he published his well-known " Examen de la Phrenologie," which was thought to have demolished the phrenological doctrines. It was Flourens' idea that every portion of the substance of the cerebral cortex had precisely the same significance. He believed that the removal of any given mass of the grey matter affected all the mental functions in exactly the same way, so that visual or olfactory perceptions would not be diminished in different proportions, no matter what area was extirpated. The facts which have been discovered by pathologists and clinicians concerning aphasia were, however, in entire opposition to these ideas of Flourens. Gall and Bouillaud had recognized that circumscribed lesions


in the cerebrum, especially in the frontal region, could give rise to definite disturbances in speech. Later, Marc Dax pointed out that aphasia occurred practically only when the left half of the cerebrum was diseased, and in 1863 Broca established the fact that in right-handed people the third left frontal convolution is the portion of the grey matter of the cerebral cortex which is important for articular speech. Subsequent studies upon aphasia have shown that there are several dift'erent kinds of the affection, only one variety of which depends upon disease of Broca's convolution, i. e. the one in which the capacity to speak out the word which the individual has in his consciousness is lost; the inability to understand spoken words, and the incapacity to call into consciousness the names of objects which are visible to the individual, being associated with disease of other parts. These facts alone prove that different regions of the brain are of different significance for the intellectual functions.

In addition to the studies on aphasia there have been recorded a whole series of pathological lesions which clinically were associated with definite disturbances of sensation ; thus, lesions of the occipital cortex have a tendency to affect visual sensations; lesions of certain portions of the temporal cortex interfere with hearing; the sense of smell has been shown to be connected with the under surface of the cerebrum, and the sense of touch with the upper frontal and anterior parietal regions. Physiologists by means of experiments upon animals have added most satisfactory support to these clinical and pathological observations.

In 1870 Fritsch and Hitzig reported the results of their investigations concerning galvanic excitation of the surface of the brain of animals, in which it was shown that stimulation of definite regions calls forth movements of certain only of the parts of the body. Three years later Ferrier used faradic stimulation of the cortex and was able to elicit quite complicated movements of different parts of the body, movements which seemed to be purposeful, inasmuch as they correspond to those employed by the animal when utilizing its sense organs, that is to say, movements such as are employed in listening, touching, looking at, or smelling external objects. Munk proved fiirther that by the removal of certain convolutions it was possible to produce in animals disturbances of sensory activity quite analogous to those which had been observed in the clinical and pathological study of diseased human beings.

The studies of Goltz upon dogs supply an exceedingly interesting link in the chain of experimentation. This investigator demonstrated the possibility of keeping a dog alive for a considerable length of time in the entire absence of a cerebral cortex, and in this way was able to ascertain what faculties the animal possesses when only the lower parts of the brain are functioning uncontrolled by the cerebrum. He found that an animal without a cerebrum still possesses a very complex nerve life, a fact which is not so very surprising when one recollects the observations of comparative afiatomy. While the dog of Goltz's experiment appeared to be devoid of memory and judgment and incapable of finding out for himself among the objects outside of the body those necessary for the satisfaction of his needs, he showed himself to be by no


10


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 70.


means an involuntary machine. Goltz states that he could stand upright, could run, could be set in motion by external stimuli of various kinds, that he could show evidences of emotion, becoming angry and biting and howling under provocation. When hungry the whole body entered into lively motion, and after food had been taken the animal again became restful and showed evident signs of satisfaction. As Flechsig points out, these experiments do not permit any conclusion regarding the condition of consciousness after the loss of the cerebrum, but they do show distinctly the power and the independence of the bodily instincts, and teach us that no small part of the acts concerned in these can be set free simply through bodily influences, entirely independent of the higher mental faculties.

The studies of His and Flechsig, which have done so much in recent years to give us an insight into the finer organization of the nervous system, have been especially devoted to the development of the nervous system. It is to the work of Flechsig to which I wish on this occasion to especially direct your attention.* His method of outlining tracts by the observation of successive periods of myelinization is not new. His larger work, published many yeai'S ago and entitled "Die Leitungsbahnen iniGehirn und Riickenmark," is based almost entirely upon studies made after this fashion. The tracts which function first, receive their myelin sheaths before the others, and a tolerably definite idea of the physiological capacities of a develojiing animal at a given moment, up to a certain period at least, can be gained by ascertaining the number of tracts which have already been medullated. Thus the spinal cord, medulla, pons and corpora quadrigemina are almost entirely medullated at a time when the parts higher up show very little or no myelin. Even in the new-born child, Flechsig has shown that the cerebrum is almost entirely unripe, inasmuch as extremely few of the myriads of nerve fibres which it contains are at this period medullated. Man, therefore, at the beginning of his earthly experience, resembles very closely the dog of Goltz's experiments; he is practically a being without a cerebrum, and yet, as in Goltz's dog, even with the drawing of the first breath, the bodily instincts in the child demand satisfaction. The new-born infant, with satisfied impulses and unaffected by external stimuli of a disagreeable nature, shows no evidence of consciousness. H it become hungry or be exposed to cold, or if painful stimuli be applied to it, active movements of the body result.

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).


Gradually the individual fibres of one sensory path after another, beginning with that concerned in the sense of smell and ending with that by which are carried auditory impulses, passing from the sense organs of the body toward the cerebral cortex, gain their myelin sheaths. Each sensory path includes a very large number of nerve fibres containing the axones of neurones whose cell bodies are situated lower down. Following the different sensory paths to their cortical termination, it is easy to show in these early stages, in which very little of the brain is medullated, that the individual sensory paths terminate in tolerably sharply circumscribed cortical regions, for the most part widely removed from one another, being separated by masses of cortical sitbstauce which remain for a considerable period entirely unripe. Indeed, the cortical terminations of the individual sense paths correspond entirely to those regions of the surface of the brain which pathological observation has shown to stand in relation to the different qualities of sensation. It is the destruction of these internal sense organs which results in cortical blindness, cortical deafness, etc.

After these sensory paths in the child's brain have become medullated, new paths begin to develop from the points where the sense fibres terminate — paths which go in the opposite direction. These fibres as they become medullated can be traced passing downwards to the medulla and the spinal cord, to the nuclei of origin of the motor nerves, and connecting in this way the sensory regions on the surface of the cerebrum with the motor apparatus. The area of the cortex concerned in the sense of touch has an especially well developed bundle of these motor fibres, the fasciculus cerebro-spinalis or so-called pyramidal tract, which consists of more than 100,000 fibres on each side, an arrangement which permits the carrying out of very delicate movements, especially of the parts of the body concerned in the sense of touch. Connections between the cortical sensory areas and the lower centres which appear to be concerned more directly with the bodily instincts, have already been made out. It is clear, therefore, that bodily instincts and external sense impressions may reciprocally influence one another. According to Flechsig, the sense of smell is moat intimately connected, the sense of hearing least associated with the centres concerned in the exercise of the lower instincts, a fact which, if confirmed, might account for the more ideal character of auditory impressions.

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


Gyru.cm,.r..l,{J»«;r;;p,S<,m»»>.l,.tlo.,„.


Corpus cAllonnn

Porulx louguti,

(Septum pellucW,



"^ti^^i^r^^^j^


^^^


Oolliculiia superior (corp. quad.) . Hnin nucleus of tliaUmua.



Fig-. 6.


Soraae»tUetic



Gynm hippocampi.


Fig. +.




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

impressions to the centres governing the movements of the head ?).

b. White matter of septum pellucidum (in part running between the

olfactory area and the gyrus hippocampi).

c. Corpus callosum corresponding to the somiesthetic area. D. Superior I

h. Inferior jcolliculus of corpora cjuadrigemina, cut near the middle line : here very few meduUated fibres are present; sections lateral to this show many, r. Red nucleus of the tegmentum ; below this is seen the decussatio brachii conjunctiva (In this and succeeding plates I have translated Flechsig's terms as tar as possible into the nomenclature of the Anatomical Society. For his sense-centres and association-centres English terms which seemed most suitable have been employed For the suggestion of the name " soma-sthetic area" as a translation of the German KorperfuhUplKire I am indebted to Prof. B. L. Gildersleeve.— L. F. B.)

Fio. 2. Horizontal section through the brain of a child aged 3 months. (AHer Flechstg.) \ j'-'»

II. Tractus opticus.

H. Association system (cross-section) in the g. hippocampi, connecting the olfactory cortex of the uncus with Ammon's horn, going over into the alveus. M. Nucleus amygdalae. P. Pyramidal tract in cross-section. p'. Temporal cerebro-pontal path. p'. Frontal cerebro-pontal path. The decussation of the nervus trochlearis is shown. The projection fibres of the olfactory sense area and of the g. hippocampi are completely medullated. At the tip of the frontal lobe and at the junction of the superior and middle temporal gyri myelin is as yet entirely absent. In many other parts (darker in tint) corresponding to the advanced age, association fibres are already medullated.

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.

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.

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.

2. Median section of optic chiasm.

3. Cross-section of anterior commissure.

4. Superior colliculus of corpora i|uadrigemina. .5, Corpus callosum (cross-section).

6 Fornix.

7. Septum pellucidum. z. Pineal gland. H.S. Tegmentum. T. Basis pedunculi.


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


11


into consciousness of sensations of touch, pain, temperature, muscle and tendon sense, thirst, hunger and equilibrium, as well as sexual sensations, that is to say, the sensations which tell us of the condition of our bodies rather than that of external objects. It is obvious that this area must represent a complex mass of sense centres rather than a single sensory area ; indeed, we already have evidence from the pathological side indicating very different functions to the several parts of the somssthetic area, although the localization here, as might be expected, concerns that of groups of elementary rather than of single sensations. This is the area in which the body in its whole extent can be reflected in consciousness. It is possible that a similar mirroring of somatic sensations occurs in the cerebellar cortex.

Besides being a sensory field, the soma3sthetic area is also the great motor region whence nearly all the movements serving for the voh;ntary satisfaction of the bodily instincts appear to start. When a man voluntarily swallows, chews, breathes or seizes an external object, it is this area which is active.

The nerve fibres conducting the impulses concerned in olfactory sensations terminate, according to Flechsig, mainly in the gyrus unciuatus where it touches the island of Keil, although many of them end in the frontal lobe.

The fibres concerned in visual sensation, passing from the lateral geniculate body, the thalamus and the superior colliculus of the corpora quadrigemina, follow a direct course to terminate in the immediate neighborhood of the calcarine fissure, although subsequently fibres run out from this tract into adjacent areas, ending, however, only in that part of the cortex of the occipital lobe which shows the well known macroscopic stripe of Vicq d'Azyr. It is interesting to note that fibres from the fovea centralis are believed to go to the cortex of both cerebral hemispheres. Such a distribution would help to account for the incomplete blindness from unilateral cortical lesions.

The fibres communicating auditory impulses to the cerebral cortex form the lateral lemniscus in the pons and are connected particularly with the median geniculate body; they run out into the temporal lobe to terminate mainly in the transverse temporal gyri, especially in the anterior one. It is obvious, therefore, that the main portion of the auditory area of the cortex is hidden in the wall of the fossa sylvii, appearing on the external surface of the hemisphere only in the middle third of the superior temporal gyrus, /. e. in that part of it which is in contact with the transverse gyri.

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


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.

Flechsig believes, therefore, that these association centres are the portions of the cerebral cortex which above all others are concerned in the higher intellectual manifestations, in memory, judgment and reflection. If his theory be right, the study of the association centres should be the especial object of research for the neurologist and jisychologist. That they really are of definite importance for the intellectual activities has been shown by these anatomical studies, which might of themselves be deemed conclusive. But it must be conceded that clinical experience has also afforded a large mass of evidence in favor of the view. In certain of the diseases of the mind marked disorganization of the association centres has been noted, the microscope permitting the recognition in them of the destruction of many cells and fibres. In such cases, during life, iustead of a connected train of thought, the mental processes may be confused and tangled. New mental pictures entirely foreign to the normal intelligence may appear, the capacity for using past experiences may be lost and the knowledge of the results of certain acts be gone. It is in the study of general paresis that the most convincing clinical proof of Fiechsig's doctrine of association centres is to be found, and from a consideration of the varying symptomatology of this disease, taken together with the pathological lesions which have been proven to exist in such cases, some clues have already been gained towards the explanation of differences in function in the different parts of the association areas in the cortex. Flechsig in the first edition of his "Gehirn und Seele" stated that the anatomically demonstrable alterations of the brainsubstance in general paresis were often limited to the intellectual domains. He refers in the second edition particularly to the monograph of Tuczek upon dementia paralytica published in 1884, and recommends strongly the study of this paper in connection with his own classification of the different regions of the cortex.

It seems likely from Fiechsig's studies of the brain lesions in general paresis, that this disease more than any other will afford the key for the deduction of psychic disturbances from


12


JOHNS HOPKINS HOSPITAL BULLETIN.


pfo. 70.


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


self-control, and may show deep perversity of feeling or of the will, the specific character of the disease-picture consisting in his inability to recognize external objects, that is, to associate external sensory impressions with the memories of those of his previous experiences. On this account he may use external objects falsely ; he may confuse persons ; he has no certain ideas as regards space and time. His mental conceptions of the external world, the knowledge of these which he can put into words, and the power of interpretation of external impressions as the result of experience, are lost to him. He is in severe cases almost bankrupt in ideas, although his regard for himself and for those who are dear to him may be unaffected.

If one of the sense areas of the cortex alone be diseased, the clinical picture is entirely different from that presented by these purely intellectual disturbances. Here again we may have to do either with phenomena of absence or phenomena of irritation. A tumor pressing upon the auditory area may give rise to noises and other subjective perceptions of sound. Pressure upon the posterior central gyrus may lead the individual to believe that he experiences movements of his thumb, although his eyes convince him that it remains station.'fl-y. Again, a tumor pressing upon the uncinate gyrus has been known to give rise to subjective odors; while a cysticercus cyst pressing upon the visual area of the occipital lobe has caused the arrival into consciousness of mental pictures of colored figures and the like. Destructive lesions of the sense centres may prevent the external sense impressions from entering into consciousness at all. There may be entire absence of mental confusion in such instances; the patient recognizes the subjective character of the hallucinations, and so is not actually mentally diseased in the ordinary sense, but if focal disease affect along with one sense centre several of the others, or the posterior large association centre, the picture of hallucinatory confusion is prominent.

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


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


13


thought, the brain is the organ of the mind, and the whole is in reality made up of multiple organs. But instead of calling these, as did the old phrenology, after certain qualities, friendship, good-nature, wit, firmness, and the like, thanks to Flechsig's studies we can now adopt a more rational nomenclature. We can now speak of sense centres and of association centres in the cerebral cortex. The sense centres may be roughly grouped as the somssthetic area, the visual sense area, the olfactory sense area and the auditory sense area ; the association centres for the present have to be designated according to their position as frontal or anterior, insular or middle, and parieto-occipital or posterior. Thus a distinct advance has already been made, and it is hardly too much to expect that further study will permit of much more complete differentiation and more definite localization of both kinds of areas.

It is not stating too much to affirm that advances in true psychology are to be mainly hoped for from strictly scientific investigations into the structure and function of the nervous system. Pure philosophical psychology has advanced but little beyond the concepts of Aristotle and the other ancients, and as Flechsig says, " Medicine at all periods has been nearer the ideas believed in to-day mainly on account of the fact that the physician has had ever before him as the special object of his observations the human individual, presenting healthy or diseased conditions, in life and in death."

It would take too long to give even a brief resume at this time of the insight into psychological processes which are afforded by Flechsig's work. His recent publications speak for themselves, and his treatment of the subject cannot fail to prove interesting to the reader. Doubtless many of the theories which he has advanced as a result of his anatomical studies will not stand the test of time. But we owe to him a deep debt of gratitude for supplying us with a large mass of entirely new knowledge, from which further investigations may start.* The relative 2'ositions of the individual sense centres to the association centres are, as can be seen from the diagram, very peculiar. The posterior association centre is situated among the visual, auditory and somajsthetic areas of the cortex; while the anterior association centre is related, in gross at least, only to the somajsthetic area and to the olfactory sense area. The middle association centre has adjacent to it the auditory, olfactory and somaesthetic areas. When one remembers that the association centres receive bands of fibres which run into them from the adjacent sense areas, the remarks made before concerning the specific functions of the different association centres will perhaps be more easily appreciated.

Flechsig in his " Kectoratsrede," as well as in his later


  • We should be particularly grateful for the deflnitiveness of the

concepts of brain structure which Flechsig has afforded us. In this embryological self-analysis of the cerebral tracts, the bands of medullated libres, stained by the method of Weigert, stand out as clear-cut on the yellow background of non-medullated nervous tissue as the lines of a diagram. The illustrations of sections in Flechsig's book are by no means fanciful. In his regular lectures during the spring semester of 1895, Flechsig showed us a large number of his preparations which bear out fully his anatomical statements and illustrations.


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.

Furthermore, Flechsig sees in these newer studies the essential preparation for a physiological basis of ethics, so much desired by some of the writers of the last century. Inasmuch as the health of the cerebrum is essential for the control of the lower centres concerned with the instincts and emotions, as is proven by the cessation of the struggle between the instincts and the ethical feelings where the intellectual centres are paralyzed, and inasmuch as we now know some of the causes of the diseases of the sense centres and of the association centres, and are convinced that many of these causes are removable or avoidable, the etliical significance of these studies becomes manifest.

It must be the aim of educators to enlighten the people concerning the hygiene of the body and especially of the brain. We must not fear to teach the intimate interdependence of bodily conditions and mental phenomena, or hesitate to let the masses know that the abuse of alcohol, the over-indulgence of the passions, and mental and physical excesses of all descrip


14


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 70.


tions, can lead to i-esults of a most serious nature. Only by increasing knowledge, general and special, can we hope in coming generations to strengthen and make solid the foundations of the higher ethical feelings. All will agree that for the advancement of the race we must presuppose a social arrangement which will subordinate the blind instincts of the morally and intellectually deficient to the control of the deeper insight and the better will of an intellectual ethical aristocracy. If it is in the main the remarkable development of his association centres which has raised man so far above the level of all other living creatures, it is also by virtue of the function of these same association centres that man is to be elevated in the future beyond his present status. Flechsig at the close of his " Rectoratsrede " makes brief reference to the aims other than practical of these newer studies. "Just as by means of one of the noblest faculties of our natures, namely, the thirst for knowledge, an instinct conferred upon human beings with the development of their association centres, we are forced to study the natural laws involved even in the domain of the mind, so the actual advances of our knowledge, even in this field of investigation, lead with the forcible necessity of a natural law to an ideal philosophy. The more the enormous potencies embodied in an intelligent individual become unveiled to our questioning reason, the more clearly must we feel that behind the world of phenomena there are controlling forces with which human knowledge scarcely dare lay claim to be compared."


NOTES ON NEW BOOKS.

Practical Points in Nursing, for Nurses in Private Practice, with an Appendix. By Emily A. M. Stoney, Superintendent of Training School for Nurses, Carney Hospital, Boston. Illustrated with 73 engravings and 9 colored and half-tone plates. {Philadelphia: W. B. Saunders, 1896.)

This little book is primarily designed for the instruction of private nurses, and as such it will undoubtedly serve a useful purpose. It is to be regretted, however, that it is also intended to be used for the instruction of classes, and for the home nurse, for which purposes it seems very inadequate. It may help those who are already instructed and who require a book of reference, but it presupposes a degree of previous knowledge on the part of the student which pupil nurses and home nurses do not possess.

The chapters on physiology and descriptive anatomy are of the most elementary character and are couched in such terms as to convey no adequate idea of the subjects treated. Witness the following: "The parotid gland is situated below and toward the front of the ear. It secretes saliva, and it is inflammation of this gland that causes mumps." — or " The skull is a box of bone containing the brain, which is a soft pulpy substance, and is the chief organ of the nervous system." Coulil tlie modicum of technical knowledge be made any smaller? The book ought to be very popular fur the instruction of nurses among those who are apprehensive of the over-education of nurses and are fearful that they will make thirdclass physicians.

The definitions are very imperfect and are evidently written by one who is not accustomed to use language accurately. "A lotion is a medicinal application, and may be evaporating or non-evaporating." " Worms, which are of three kinds — tapeworm, tliread worms and round worms — are caused by impure drinking water and food, and also bi/ feeding food that is not properly cooked." "Oph


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.

{Published by Oeorge 8. Davis, Detroit, 1896.3

The second edition of this little work has recently appeared as one of the numbers of The Physician's Leisure Library. It is essentially practical, as most of the tests given are such as can be used at the bedside by the general practitioner. Although the subject is treated as briefly as possible, yet we think that if practitioners were fully conversant with the various tests described, and with the precautions to be observed in performing them, many errors in diagnosis would be prevented and much valuable assistance in the treatment of diseases affordeil. Many of the higher organic compounds found normally in the urine are, however, not even mentioned. In fact, no constituents of the urine, normal or abnormal, are treated of that cannot be tested for with the simplest apparatus and reagents. Thus, the use of the polariscope in diabetes and the influence of diabetic urine on polarized liglit, one of the most reliable tests, is entirely overlooked. Such statements as the diagnosis of typhoid fever is now made almost certain by the diazo-reaction of Ehrlich" should certainly be qualified, as it is well known that this reaction is very frequently obtained in tuberculosis and not infrequently in other febrile conditions : the test is merely an aid to diagnosis. One can hardly see how the practitioner is to be aided in recognizing leucin and tyrosin in the urine, by the author's statement that "leucin and tyrosin are found in the urine in certain abnormal conditions of the liver. They are easily recognized in the sediment, or may be found on evaporating the urine." It is only justice to say that a diagram of the leucin spherules and tyrosin crystals is given in the plate of urinary sediments, from which alone it would be unsafe to make a diagnosis, however. While the author's book serves a useful purpose, no general practitioner should be without a larger work on urinary analysis, for purposes of reference.

Diseases of the Eye. A [Hand-book of Ophthalmic Practice for Students and Practitioners. By G. E. deSchweinitz, A. M., M. D., Professor of Ophthalmology in Jefferson Medical College, etc. With 256 illustrations and 2 chromo-lithographic plates. Second edition, thoroughly revised. {Philadelphia : W. B. Saunders, 1896.)

This admirable textbook of ophthalmology is so well and so favorably known, and so short a time has elapsed since the appearance of the first edition (1892), that an extended notice seems scarcely called for at this time. In the preface to the present eilition the author states that the entire book has been thoroughly revised, and that in addition to this general revision, new paragraphs have been addeii upon Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies (Drusen) in the Papilla, Jlonocular Diplopia, Subconjunctival Injection of Germicides, InfiltrationAnaisthesia, and Sterilization of CoUyria.

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.]


JOHNS HOPKINS HOSPITA.L BULLETIN.


15


chapter on operations has been enlarged and rewritten, and those on General Optical Principles and on Abnormal Refraction, which were contributed to the first edition by Dr. James Wallace, have been revised by Dr. Edward Jackson, who has also recast the section written by himself upon Eetinoscopy.

Dr. Jackson's revision of these chapters has evidently been carefully done, and we note a number of instances, as, for example, in the definition of emmetropia and of ametropia (p. 140), and in the description of the refraction of light by an astigmatic eye (p. 163), in which it has resulted in the elimination of errors, some of which had previously arrested our attention in the perusal of the first edition. It is perhaps not to be wondered at that he has not, in every instance, succeeded in noting and correcting these faults. The description of the "seat of astigmatism" on p. 161, which, in the new edition as in the old, seems to warrant the inference that lenticular astigmatism is due always to an oblique position of the lens, it would appear, might easily have been improved upon. So, too, as to the description given of the well-known illustration (p. 163) of the refraction of a pencil of light in regular astigmatism. It is certainly not correct to speak of the different sections of the pencil there shown, as representing the "retinal images of a point" in compound hypermetropic astigmatism, simple hypermetropic astigmatism, mixed astigmatism, etc., unless absence of accommodative power in the eye be presupposed.

The author tells us in his preface that the book has been enriched with forty additional illustrations, but he does nottell us how much more effective many of the illustrations have been made by the substitution of well-executed photo-engravings for the woodcuts of the first edition. The illustrations of congenital ptosis and of epicanthus and congenital ptosis on p. 200, and of rodentulcerof theorbit (p. 203), are striking examples of the effectiveness of this method of representation. Having said this much in praise of the illustrations, perhaps we shall be pardoned for finding fault with the legend descriptive of Fig. 90, on p. 254 — " lipomatous dermoid of the conjunctiva."

The publisher has performed his part of the work ip a manner worthy of especial commendation. S. T.

A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D. With 163 illustrations in the text and 6 full-page plates. (Philadelphia: W. B. Saunders, 1896.)

This well-printed and fully illustrated volume seems a happy mean between the more ambitious and encyclopedic works upon obstetrics and the quiz-compends, and is clearly and systematically arranged for the use of students. Although lacking the details and references of larger works, it is clearly and carefully written and will be a safe guide. There is really little to criticise.

The directions given for the disinfection of the accoucheur and of the patient are admirable and explicit. The recommendation to use a creolin douche after the expulsion of the placenta, as a matter of routine, cannot be endorsed, because it would do harm rather than good in the majority of cases. Vaginal douches should notbe given after the second stage of labor, unless they are clearly and definitely indicated. The employment of a pad above the fundus uteri and the use of am abdominal binder tightened daily for six weeks or three months are recommendations which do not seem free from danger.

Water and Water Supplies. By John C. Thrush, Medical OflBcer of

Health to the Essex Co. Council, etc. (London : The Rebman

Publiahing Co., L'i'd. Philadelphia : W. B. Saunders, 1896.)

This excellent little book can be commended unreservedly as

probably the best short treatise on Water and Water Supplies in the

English language. The information contained in it is concise and

the whole book is thoroughly modern. It is gratifying to observe

that the author shares the opinion of Koch that the best of all


water supplies for a city is that obtained from deep wells. The sourcesof water pollution are clearly described and well illustrated. We are pleased to see that careful directions are given for the filtration of water, and the dangers which lurk in improper filtration are distinctly stated. If the book could be in the hands of every householder, the preventable causes of water-borne disease would unquestionably be mucli better understood. The book is well printed and sensibly illustrated, and deserves a large sale.


BOOKS RECEIVED,


Transactions of the Association of American Physicians. Eleventh Session held at Washington, D. C, April 30 and May 1 and 2, 1896. Vol. XI. 8vo. 1896. 453 pages. Printed for the Association. Philadelphia.

Transactions of the Medical Society of the State of Pennsylvania. Forty-sixth Annual Session, held at Harrisburg, 1896. Vol. XXVII. 8vo, 499 pages. Published by the Society. The Edwards & Docker Co., printers, Philadelphia.

An American Text Book of Applied Therapeutics. For the use of practitioners and students. Edited by J. C. Wilson, M. D., assisted by Augustus A. Eshner, M. D. 1896. 4to, 1326 pages. W. B. Saunders, Philadelphia.

An American Text-book of Physiology . Edited by William H. Howell, Ph. D., M. D. 1896. 4to, 1052 pages. W. B. Saunders, Philadelphia.

A Te.vt-book of Histology, Descriptive and Practical. For the use of students. By Arthur Clarkson, M. B., C. M. Edin. 1896. 8vo, 554 pages. W. B. Saunders, Philadelphia.

Diseases of the Eye. A hand-book of ophthalmic practice for students and practitioners. By G. E. de Schweinitz, A.M., M. D. Second edition, thoroughly revised. 1896. 8vo, 679 pages. W. B. Saunders, Philadelphia.

Transactions of the Michigan State Medical Society, for the year 1896. Vol. XX. 8vo, 834 pages. Published by the Society. Grand Kapids.

A Text-Book of Materia Medica, Therapeutics and Pharmacology. By George Frank Butler, Ph. G., M.D. 1896. 8vo, 858 pages. W.

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.

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.

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

C. W. Daniels. Eighth year of issue. 8vo, 1896. 95 -}- xxxix pages. Printed by Baldwin & Co., Demerara.

Twenty-seventh An7iual Report of tlie Slate Board of Health of Massachusetts, 1895. 8vo, 807 pages. Wright & Potter Printing Co., Boston. 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.

Atlas of the Diseases of the Skin. By H. Radcliffe Crocker, M. D., F. R.C. P. Fol. n. d. 2 vols. Young J. Pentland, Edinburgh and London.


16


JOHNS HOPKINS HOSPITAL BULLETIN.


[No, 70.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL


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

Report in Putliology.

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

(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

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

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


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

Report in Medicine.

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

Gallstones. By William Oslek. M. D. 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.

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

Report in Gynecology. Tlie Gj-neeological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1S89, to March 3, 1890. By Howard

A. Kelly, M. D.. and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the GjTiecological Wards vrith out Operation ; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,

M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

Ovarian Tumor; General Gynecological Operations from October 15, 1SS9, to

March 4. 1890. By Howard A. Kelly, M. D. Report of the ITrinary Examination of Ninety-one Gynecological Cases. By Howard

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

Howard A. Kelly, M. D.

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

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Neurology, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. ' By Charles E. Simon, M. D. Haematomyelia. By August Hoch, JI. D. A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report in Pathology, I. Ama3bic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.


Volume III. 766 pages, with 69 plates and figm-es.

Report in Pathology.

Papillomatous Tumors of the Ovarj'. By J. Whitridge Williams, M. D.

Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D. Report in Patliology.

Multiple Lj-rapho -Sarcomata, with a report of Two Cases. Bv Simon Flexner, M. D,

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

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.

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.

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.


Gynecological Operations not invohnng Coeliotomy, By Howard A. Kellt, M. D. Tabulated by A. L. Stavely, M. D.

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

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

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

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

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

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

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

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

Record of Deaths occurring in the Gynecological Department from June 6, 1890, to May 4, 1S92.


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

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

Report in Neurology. Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic 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.

Report in Surgery. The Results of Operations for the Cure of Cancer of the Breast, from June, 1SS9, to January, 1894. By W. S. Halsted, M. D.

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


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

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

By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon Flexner, M. D., Walter Reed, 51. D., and H. C. Parscns, M. D.


Volume VI. About 500 pages, many ilhistrations.

Report in Neurology.

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

Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol): Part II. — Serum Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part HI. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical Nerve Cell produced hy the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Addenda. By Henry J. Bereixy, M. D.

Report in Pathology.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Tuomas S.

Cullen, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of

Ov-um and Spermatozoa. By Thomas S. Cullen. M. B.. and G. L. Wilkiss, M. D. Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By

William D. Booker, M. D. The Pathology of Toxalbumin Intoxications. By Simon Flesn-er, M. D. The price of a set bound in cloth [Vols. Z-TJ] of the Hospital Jteftorts is

$30.00. Vols. I, II and III are not sold separately. The jtrice of

Vols. IV, V and VI is $5.00 each.


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,

M. D. 1 voliune of 164 pages and 41 full-page plates. Price, bound in paper,

?3.00. THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thayer. M. D., and J.

Hewetson. M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.

By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, $2.75. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.-rtracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 4S1

pages. Price, bound in paper, ?3.00.

Subscriptions for the above publications may be sent to

The Johns HorKiNS Press, Baltimore, Md.


The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may he procured from Messrs. GUSHING d: CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.0(» a year, may he addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE ; singU copies will be sent by mail for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No. 71.]


BALTIMORE. FEBRUARY, 1897.




GOiTTZEITTS.


A Case of Dermatitis due to the x Rays. By T. C. Gilchrist, M. R. C. S., L. S. A.,

Lesions induced by the Action of Certain Poisons on the Nerve Cell. Study VI.— Diphtheria. By Henhy J. Berkley, M. D.,

Puerperal Sepsis due to Infection with the Bacillus Aerogenes Capsulatus. By George W. Dobbin, M. D., - . - .


Proceedings of Societies :

Hospital Medical Society, 29

The Surgical Significance of Gall Stones [Dr. F. Lakge]. Correspondence :

A Case of Pneumo-cardial Rupture. By Geo. S. Brown, M.D., 33


A CASE OF DERMATITIS DUE TO THE x RAYS.

By T. 0. Gilchrist, M. E. C. S., L. S. A., Associate in Dermatology, Johns Hopkins University and Hospital.


Since the discovery of the x rays by Rontgen, thousands of observations and experiments have been made with them both in Europe and in this country, and hundreds of investigators have exposed various portions of the body, particularly the hands, frequently, iind for long periods of time, yet, after searching the literature, records of only twenty-three cases (including the present one) have been given where injurious results have followed their use, and in these, lesions of the skin only have been described. Of these twenty-three cases, twelve occurred in this country, one in Canada, four in England and six in Germany.

The first report which 1 have been able to find was a communication in the Deutsche Medicinische Wochenschrift , No. 28, 1896 (July 9th), from 0. Leppiu, an engineer, who had used his left hand a great deal in experimenting with the X rays. He remarked that the rays had the power of producing cutaneous lesions like sunburn. The hand presented a peculiar redness, was swollen, and a vesicular eruption appeared later on the middle and ring fingers. Where the skin was hidden by a ring it was white and quite normal. Even five weeks after discontinuing the use of the rays the altered skin gave the hand an older look than the normal one.

Professor Daniel, of Vauderbilt University, reported a case of alopecia as the result of exposure to the x rays three months previous to Leppin's communication.

After examining the other reports (the references are given at the end of the article) it was found that the eruptions of the skin presented many points of similarity, and differed chiefly in


severity, according to either the length of time and frequency of exposure to the rays or to idiosyncrasy of the patient.

In Dr. Sehrwald's case, which was described fully, the lesion occurred after one exposure of forty-five minutes to the X rays, and Dr. Crocker's patient had also experienced only one exposure of one hour when an eruption appeared. In Dr. Kolle's case, the patient, a boy, was exposed once, for forty minutes, when a pronounced alopecia followed, and a similar result is recorded by Professor Daniel in a man after one sitting; but the most interesting case of all was Professor Thomson's, of Harvard, who, being skeptical as to the deleterious results of the rays, made the only experiment which has so far been recorded, by exposing his finger to the x rays for half an hour and at one and a quarter inches from the tube, with a definite purpose of producing lesions if possible. The cutaneous trouble followed in nine days after the exposure. In two cases the patients had two sittings ; in Dr. Dunn's case the first exposure was one hour, and the second, seven days later, lasted one hour and a half ; and in Dr. White's case the patient had two exposures of thirty and forty-five minutes each on successive days.

In Drs. Stern's and Richardson's cases the lesions appeared after three sittings, and Dr. Skinner experienced cutaneous lesions after three or four exposures of short duration. In eleven cases the results had only followed after prolonged and constant use, the duration varying.

I append a table of the cases which I have been able to find in the literature.


18


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71.


Distribution.


Character of the Lesions.


Subjective Symptoms.


O. Leppin (person al experience). .


Used very frequently for many days.


Left hand and


Peculiar redness, swollen, vesicles on middle and ring fingers.


Dr. Marcuee.


Young man, 17, exposed 5-10 minutes once or twice a day for four weeks.


Dr. Feilchenfeld Dr. Conrad.


Left half of Brownish redness on face, fol face.backand lowed by desquamation ; later, chest. patch of alopecia above right

ear ; on back, large raw patch, exposing the corium with hemorrhagic points and exudation and a number of bullae ; on chest slighter changes, exhibited a somewhat similar case (no details given) to the


No mention. After five weeks hand still

looks "older" than the other.

No pain in face ;lThree months later, hair


back much tenderness, but no pain was felt until just previous to the eruption.


returning on the bald spot. Chest and back healed, but numerous fine cicatricial lines on the back and brown pigmentation.


Dr. Paul Fuchs (personal expe rience).


Dr. Sehrwald.


S. J. R. (personal experience).


Dr. H. C. Dunn.


Dr. G. C. Skinner (personal expe rience).


J. Macintyre (personal experience).


Dr. Freund.


Aphotographerbad used the X rays very fre quently and for some time.


After prolonged use of the X rays.


In a boy 13 years old. Only one exposure of 45 minutes duration Two weeks later erup tion appeared.


Used the rays several hours daily and eruption appeared three weeks after.


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.


Exposed the wrist 10-15 minutes for 3 or4day8 in succession. Ten days later eruption followed.

Worked for months with the X rays before cutaneous lesions were produced.

10 days, child who had hypertrichosis.


1st and 2d fin gers, left hand.


Left hand and fingers.


Abdomen.


Right hand and fingers. Later left band.


Abdomen.


Wrist.


Neck, back, upper arm and scalp.


Swelling and stiffness of the joints; Istand 2d fingers swollen and of a livid brown color on the dorsal surface from the tips to the carpometacarpal joints Sense of touch greatly diminished. Mustache falling out and color was changed.

Much swollen; skin was wrinkled cracked and stained quite brown ; condition of skin like a frozen hand ; later, on further exposure, a vesicular eruption appeared.

At first hypersemia, then avesicu lar eruption. Four weeks later central portion healed, but peripheral portion covered whole abdomen. Brown color. Exfoliation soon followed.

Numerous dark little blisters appeared on right fingers ; then marked redness and inflammation of the skin, which later became hard, very dry and yellow like parchment. Exfoliation followed. On further exposure tips of fingers became much swollen and nails affected. A colorless, bad smelling discharge came from beneath the nails, which were gradually thrown off. Left hand was substituted and similar symp toms followed.

Three hours after first exposure some nausea. After second exposure, nausea, and on second day abdomen slightly red, like sunburn; redness increased in intensity until fourth day, vesicles appeared, which developed into bullae. Eighteen days later the patch was T/zx8}i inches between umbilicus and chest, and was smooth, glazed and weeping for some days, notwithstanding treatment.

Reddening of the skin appeared first; this increased until it was almost purple ; considerable swelling followed. Desquamation followed.

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.


Berlin Medical Society.

Fingers extremely No mention, sensitive and pain was of a burning and scalding character.


None given.


Itching when the vesicles appeared.


After inflamma tion hand smarted very much Skin became insensible to the touch. After second exposure serious discom fort and pain followed.


No subjective symptoms ; neither itching nor pain ; the rawsurface painless and almost insensitive.


Great pain and ex cessive tenderness.


Cured in 9 or 10 weeks.


Results similar to those of sunburn but much more acute.


None given.


Eruption healed after 28 days, but skin was like boiled fish skin. After cauterization of surface a slough separated and a tough yellow opaque membrane formed.


Process of repair was very slow.


Authorthinksconditiondue to heat and electricity ; the latter the chief cause of injury to the tissues.


February, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


19


Dr. E. E. King.


Dr. M. J. Stern.


Dr. F. Kolle.


Dr. J. C. White.


Prof. E. Thomson


Dr. H.R.Crocker


Prof. John Daniel


Dr. M. H. Rich ardson.


Dr. W. E. Parker.


University of Minnesota.

Dr. Banister, U S. Army.


Dr. T.C.Gilchrist.


Patient used the x rays for two and a half months from two to six hours daily before cutaneous lesion ap peared.


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.

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.


Distribution.


Hand, left.


Man ; exposure 1 hour Alopecia 21 days later.

Woman. Exposed three times to the rays, 20, 30 and 3.5 minutes. Eruption appeared two days later.

Man. Exposed five times, from 20 minutes to 80 minutes.

Man whose ear was exmined for several hours.

Man. Numerous expo

sures.


ray operator. Eruption began after frequent and continued exposures.


Extended from thesideof the face down to the umbilicus.

Right side of head.


Sternal region


Little finger of left hand.


Epigastrium.


One side of scalp.

Abdominal re gion, particu larly over liver area.


Jaw and neck.


Ear and surrounding scalp.

Abdomen, chest and beard.


Right hand, wrist, and lower portion of forearm dorsal sursurface.


Character of Lesions.


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.

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.

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.

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.

At first a patch, red, inflamed, hypersesthetic, about half the size of a man's hand. The lesion increased in size until a denuded surface .SxlS inches was formed. Exudation profuse and uncontrollable. Beard turned white in places and growth stopped.

Hypersemia and swelling of back of hand ; afterwards inflammation of fingers and hand. Skin became dark brown in color and gradually exfoliated.


Subjective Symptoms.


Great pain follow ed the appear ance of the blis ters.

Second eruption followed by aching.

Face became tender and painful.


No symptoms.


Granulation sur face very sen si five and the seat of severe neural gic pain.

Pain.


Stiffnessfeltatfirsl and soreness when the vesicles appeared.


None.


Pain accompanied the first appearance of the lesion.


No pain or sensation at the time.

Raw surface, very painful and hyperjesthetic. Pain agonizing even six weeks after.


No pain at first, but afterwards severe aching and shooting pains, which lasted about 2 weeks.*


The case has been carefully and continuously watched.


Examination of the chest after a gun-shot wound.


Later, lanugo hairs began to appear.


At the timeof writingthere were still two open spots.


Four months later, even after curetting, granulating surface 4 inches in diameter still remained.


16 days afterwards skin discolored and exfoliated.


Patient confined to bed for one month, and will probably be in bed another month.


•February 5, 1897, patient writes, " My hand is much about the same. I cannot use those (first) three lingers much better : and my nails are coming off, that Is, the old nail is like a shingle on top of the new one."



As far as the cutaneous lesions were concerned, the skin of the trunk appeared to suffer the most severely, although when the hand was attacked the pain was the most prominent feature.

As to the character of the lesions produced, the majority of observers describe a peculiar redness or erythema at first, then swelling of the derma, followed by a deep discoloration of the skin until it became quite a dark brown color. Exfoliation of the pigmented skin followed later. In a number of cases vesiculation occurred after the hyperajmia, and quite a serious eruption resulted in two cases after only two exposures. The most severe effects followed after exposing the same region again to the rays when the lesion had only partially or wholly healed.

The cases of Dr. Dunn, Dr. Banister and S. J. K. showed perhaps the most severe results. Other lesions produced were alopecia, loss of the finger-nails, and obstinate ulceration. In connection with the subjective symptoms, severe pain and aching were present in the majority of the crises, especially with the eruptions on the hands. The lesions on the abdomen and back were, rather curiously enough, unaccompanied by pain.

Many theories have been advanced to explain the injurious lesions produced by the x rays. tSome have supposed them to be entirely due to frequent and loug exposures ; but that is not tenable, because in five cases (Dr. Sehrwald's, Dr. Kolle's, Dr. Crocker's, Professor Daniel's and Professor Thomson's) marked results followed a single exposure, and in two cases two sittings only preceded the eruptive phenomena, and finally three other cases experienced deleterioiis results after only three exposures. Others again have compared all the phenomena to severe sunburn, but it can be demonstrated that more severe results have followed the use of the rays than have ever been known from exposure to the sun. Tesla believes that the hurtful action of the x rays is not due to the rays but to the ozone generated in contact with the skin. Ozone, he says, when abundantly produced, attacks the cutaneous surface, its action being no doubt heightened by the heat and moisture of the skin. In his discussion of the rays themselves he speaks of the disintegration of the electrodes, especially if they are of alumiuum, but this is so slow that no appreciable diminution of the weight results, even after long use; it follows, he says, that the matter conveyed by the Eontgen stream is so minute as to escape detection. Some bulbs which he has used for a number of months showed that the bombarded spot of the glass was entirely permeated with particles of the aluminum electrode, but it would probably require years of constant use to accumulate any appreciable amount of matter outside. He further remarks " that no experimenter need be deterred from carrying on an investigation of the rays for fear of poisonous or generally deleterious action, for it seems reasonable to conclude that it would take centuries to accumulate enough of such matter to interfere seriously with the process of life of a person." His last remark is certainly incorrect. His ozone theory is also incorrect, as I shall show later.

Professor Thomson, with the definite idea of producing cutaneous lesions, exposed his finger to a bulb of low potential and used a small 34-plate static machine. " The rays came from


a bombarded spot, and were limited to the area which the Kontgen rays could reach. The tube was of blue glass, with a clear German glass window from 1* to It inches in diameter opposite the bombarded spot." One striking feature was the fact that the fingers opposite the blue glass were not affected, as this was so dense as to absorb the rays. Only where the little finger was opposite the clear glass was it affected with a sharp line of demarcation. He says the blue glass would have been transparent to the ultra-violet rays. He also thinks that brush discharges have nothing to do with the cutaneous phenomena. His theory is that the deleterious effects are due to the X rays themselves or something that goes with them.

The case which I will now report presents a suflBcient number of interesting points to make it worthy of record.

The patient is a healthy-looking man, Z'l years of age, who came to me November 18, 1896, with the following history: During the first week in September he exposed his right hand, wrist and lower portion of the forearm to the x rays while exhibiting an apparatus, each exposure lasting two or three minutes. No bad results followed, but on October 1st he came to Baltimore and resumed the use of the x rays for the same jjurposes. After he had exposed his hand for three weeks for four hours daily he noticed that the skin of the back of the hand, wrist and forearm began to turn very red and became " puffed up," although he suffered no pain. The swelling first occurred on the back of the hand from the knuckles to the wrist, then "inflammation set in " and he was compelled to stop his demonstrations. From about October 31st the hand, wrist and lower fourth of the forearm gradually became more inflamed and swollen, and the lesions spread to the fingers. The affected area ached and throbbed so much that he frequently could not sleep at night; there were also shooting pains which gradually increased in intensity and extended up the forearm along the ulnar side. These symptoms continued for a week when the patient consulted Professor Chambers, of Baltimore, who advised him to bathe the hand frequently in hot water and ordered bromides internally with benefit. The symptoms were much relieved and the swelling had gone down considerably in two weeks time. Three weeks after he had first sought medical advice he consulted me about the diseased condition of the skin.

Ooii'lition at the time of the first exumination. The right hand on its dorsal surface presented a deeply pigmented condition. The skin over the dorsal surface of the fingers, hand and wrist was of a very dark brown color, and part of it was already exfoliating. The skin was dry, infiltrated and wrinkled. The patient says the skin was more of a greenish hue at the end of the first week after it became affected. In places near the lateral margins of the hand a slightly vesicular appearance was presented. They were not true vesicles, but were due to the loosening of the surface of the epidermis, and contained only air. The pigmented skin could very easily be peeled off from the hand without any pain, leaving a dull, dry, reddish surface beneath.

On comparing the two hands they were found to be practically of the same temperature. The fingers of both were of about the same calibre. A photograph, which is represented here (Fig. 1), was taken of the hand the first time I sawj him,


Febrdaet, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


21


and it shows very well the exfoliatiou of the epidermis. It also represents the position of the hand which was most restful and least painful to the patient. The palmar surface was dry and paler than that of the normal hand, but the palmar surface of the fingers appeared swollen.

I saw the patient ten days later, and the exfoliating epidermis had all been removed; the skin now presented a glossy appearance, and over the lingers it appeared to be tighter than on the corresponding fingers of the healthy hand. The palmar surface was still a little drier.

On careful examination the patient comjjlained of rather severe pain when the first phalanx of his right index finger was grasped, and it was then noticed that this bone was distinctly thickened, especially as compared with the corresponding phalanx of the other hand. The first and second phalanges of all the fingers were found to be thickened, but the increase in size was most marked in the first phalanges of the index and second fingers. Further careful examination of the other bones of the hand revealed a very painful spot over the wrist joint. The metacarpals were also tender on pressure, and the head of the second metacarpal was enlarged. The hairs were found to be less numerous on the affected hand, but they may have been removed in tearing off the exfoliating epidermis.

Mbvemeids of the hands. All movements were found to be quite difficult of accomplishment and very painful. When the patient first consulted me, voluntary movements of both fingers and hand were abolished, except of the little finger, which could be slightly flexed. Wrist movements were also very limited in extent and caused much pain. The thumb and fingers could scarcely be apposed. The patient could not pick up a lead pencil or penholder, and could grasj) with but slight force; if he could get his finger or thumb beneath an oVject he could pick it up. He complained of the joints being very stiff.

Sensation was very much impaired before exfoliation occurred, and even after that it was much diminished as compared with the normal hand. The sense of touch on the palmar surface was also markedly decreased.

When the distinct thickening of the phalanges was detected I requested him to obtain careful x ray photographs of both hands under similar conditions at the same distance from the bulb. The accom23anying photographs show the bones of the two hands clearly, and I am particularly indebted to Professor W. C. A. Hammel, of Baltimore, for such excellent pictures.

The hands were placed exactly twelve and a half inches from the x ray tube, the distance being carefully measured from a plane passing through the long diameter of the tube to the fixed support on which the hand rested. The time of exposure was exactly three minutes for each hand.

It will at once be noticed from the photographs how much thicker all the first phalanges of the right hand (Fig. 3) are than those of the left normal hand (Fig. 2). The increase in size is particularly marked in the first phalanges of the index and second finger; that of the little finger is less marked The second row of phalanges is also thicker than normal, but less thick than those of the first row. The heads of the second and third metacarpal bones are enlarged, and their shafts are also slightly thickened. It cannot be said, from the


photographs alone, that any of the carpal bones of the affected hand were at all increased in size.

A number of other points were discovered from these photographs. The spaces between the bones at the joints, particularly at the metacarpo-phalangeal and the interphalangeal joints, were much less marked and narrower than in those of the normal hand. The outline of the affected bone« was also more irregular and rougher than that of the left hand. On looking at the hand as a whole, it is also, I think, noticed that all the bones are denser in appearance in the affected hand.*

Two portions of skin were excised for histological purposes on the first day. One portion was taken from dorsal surface of the phalangeal region of the third finger, and the other from the lateral margin of the hand over tlie base of the metacarpal of the little finger. Neither stained nor unstained sections demonstrated the presence of any foreign particles, and only showed chronic inflammatory changes. The horny layer was thickened and half of it was partially detached. A large number of brown pigment granules were found in the exfoliating portion. The mucous layer was not thickened, but it was more pigmented than normal. In the corium the vessels were dilated, and the pigment cells of thepapillas were almost as numerous as are usually found in a section of negro skin. It was suggested that particles of platinum might have passed from the tube through the glass bulb deep into the tissues.

Portions of the exfoliating skin were accordingly submitted to Professor Abel for chemical analysis, and he has very kindly furnished me with the following brief report: "I could find no platinum in the pieces of epidermis that you left with me for analysis. These pieces weighed, just as you sent them, 6-iO milligrams, or about ten grains."

Summary. In reviewing this case, there is here an example of a disease of the skin which was brought about by frequent and prolonged exposure to the x rays. The lesions, as I have already described, were first those of byperajmia, then cedema, without the accompaniment of pain. Subjective symptoms were felt later, and continued to increase in severity (he was still using his hand for exhibition purposes) until, on account of the severe pain, he was compelled to stop his work. These subjective symptoms consisted of aching, tiirobbing and shooting pains. The color of the skin gradually changed to a deep brown, and the epidermis began to exfoliate. The bones of the hand were very tender on pressure, particularly the first phalanges of the index and second finger and the carpal bones. The movements of the hand became so limited that it was practically useless for some weeks. Sensation was also much impaired, but after exfoliation occurred it recovered again, but only gradually. Recovery of all the lesions has been very gradual indeed.

The photographs have revealed what has never been observed before, viz. a distinct osteoplastic periostitis, and probably an osteitis, particularly of the first and second rows of phalanges of the index and second fingers, also of the heads of meta


  • As .an interesting point the photographs show the outlines even

of the finger-nails and the interosaei muscles.


22


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71.


carpal bones of the same fingers, and judging from the symptoms, even of some of the carpal bones.

This then accounts for the severe symptoms, the aching, throbbing and shooting pain which prevented sleep. The density of these bones has also been increased, showing that even bone tissue has been affected.

A complete demonstration is thus afforded of the powerful, piercing character of the x rays, and the severe, painful symptoms which have been described by other observers are probably due to the iuflamniatiou of the periosteum, and possibly the bone, besides the softer tissues.

This iniiammation has also extended into the joints, which would explain the loss of movements, and pain, when they could be used later.

As the result of these observations, it proves that the x rays are even more powerful than have been generally thought, that the deleterious effects can iu some cases be quite serious, and that the cutaneous manifestations are not the most severe of the lesions, but those of the deeper tissues, and particularly of periosteum and bones, being more severe.

The discovery of this deeper and more profound effect at once overthrows many of the explanations which have been advanced to account for the cutaneous lesions. Tesla's theory of the ozone generated in contact with the skin will not explain these deeper effects. Prof. Thomson has demonstrated that they are not due to the ultra-violet rays. They cannot be compared to sunburn, since no case, as far as is at present known, has been published wheresunburu has produced periostitis and even osteitis. Nor can such serious results be produced by brush discharges, and Thomson has also proved that these cannot be the causes. His further explanation that the effects (he was not aware of the deeper injuries to the soft tissues and bone) are due to the x rays themselves or something which accompanies them, is rather indefinite. It was suggested to me, as I have already mentioned, that it might be due to the platinum particles piercing the bulb and then attacking the tissues, but this almost appears impossible, since serious cutaneous effects have even followed only one exposure of half an hour {vide Thomson's case).

I consulted with Professor Ames, Associate Pi'ofessor of Physics in the Johns Hopkins University, who, after reviewing all the facts of the case, kindly wrote as follows concerning the present theory of the x rays :

" The radiation in an ' a; ray tube ' may be divided provisionally into three classes: ether-waves, which may have wavelengths from 150 to 800,a/j^, approximately; kathode rays, which undoubtedly are streams of matter, electrically charged ; X rays, about whose nature there is no conclusive evidence at the present time. If the walls of the tube are thin enough and of suitable material, all these radiations will emerge and pass into the surrounding air. It is a matter of doubt if the kathode rays observed outside the vacuum-tube are the same as those inside ; but the inner ones undoubtedly cause the outer ones. There is no evidence that x rays carry with them particles of matter, or that they directly cause a stream of particles; in fact, all known facts seem to point to the belief that they are ether-waves of extreme shortness."

It will thus be seen that the opinion expressed here does


not make it possible for the x rays themselves to produce such deleterious effects as have already been described, but Dr. Ames mentions the fact that the kathode rays are undoubtedly streams of matter electrically charged. Here then we have some possible grounds for the theory that the lesions may be due to the entrance of particles (platinum in our case) into the injured tissues, and that the kathode rays which accompany the X rays may be the cause of the trouble, and not the X rays themselves.

On clinical grounds there is considerable support for this, at first sight, improbable theory. If the lesion extends at all deeply, it leads to the formation of ulcers, which are extremely intractable, and they may be due to irritating particles still present in the tissues.

I do not think that the possibility of injury ought to deter one from using these wonderful rays in surgical work, because only a few have been affected out of thousands who have been exposed to them. By keeping, as Thomson says, some distance away from the rays, injurious effects will hardly follow their use, and when the exposure is for a short time, unless, as may happen in all other diseases, idiosyncrasy plays a prominent part.

When I viewed my own hand two or three times near a new Edison bulb, through a tungstate of calcium screen, after four or five minutes I distinctly felt a tingling sensation throughout the dorsum of the hand; this symptom lasted for ten or fifteen minutes and passed away without any further results. It occurred to me that x ray operators and experimenters should expose to the rays the palmar surface of the hand, which is protected by a much thicker horny layer, rather than the back of the hand, which is much less protected.

In conclusion I would strongly advise all x ray operators and experimenters who develop any special idiosyncrasy, to abstain from their use if they find that the slightest deleterious results follow an exposure to them.

Bibliography.

John Daniel : Medical Record, April 25, 1896, vol. 49, No. 17.

0. Leppin: Deutsche medicin. Wochensch., No. 28 (July 9), 189G, p. 454-.

Marcuse: Deutsche medicin. Wochensch., No. 30 (July 23), 189G, and No. 42 (October 15), 1896 ; also abstract in Brit. Med. Journal, Aug. 15, 1896.

Feilchenfeld : Deutsche medicin. Wochensch., No. 30 (July 23), 1896.

Conrad: Codex Medicus, August, 1896.

Paul Fuchs: Deutsche medicin. Wochensch., No. 35 (Aug. 27), 1896, p. 569.

Sehrwald: Deutsche medicin. Wochensch., No. 41 (Oct. 8), 1896; abstract in Brit. Med. Journal, Nov. 7, 1896.

S. J. R.: Nature, No. 1409, vol. 54, Oct. 29, 1896.

H. C. Dunn: Brit. Med. Journal, Nov. 7, 1896.

G. C. Skinner: The Journal of the American Medical Association, No. 20, vol. XXVII, Nov. 14, 1896.

Macintyre: Nature, No. 1412, vol. 55, Nov. 19, 1896.

K. E. King: Canadian Practitioner, Nov. 1896.



Case of J ray dermatitis. Photograph showing exfoliation of the epidermis.


"^


•



FIG. 2. X ray photograph of left hand (normal).


FIG. 3.

X ray photograph of the right hand showinj thickening of some of the bones.


February, -1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


23


M. J. Stern : The American Medico-Surgical Bulletin, Nov. 31, 1896.

F. Kolle: Brooklyn Medical Journal, December, 1896, vol. X, No. 12.

J. C. White: Boston Medical and Surgical Journal, Dec. 3, 1896, vol. CXXXV, No. 23.

E. Thomson : Boston Medical and Surgical Journal, Dec. 10, 1896, vol. CXXXV, No. 24.

Nikola Teslu: Abstract in Public Opinion, vol. XXI, No. 24.


M. H. Kichardson: The Medical News, Dec. 26, 1896, vol. LXIX, No. 1250.

The Medical Record : References to case at University of Minnesota, vol. 50, No. 25, Dec. 19, 1896.

W. E. Parker : New Orleans Medical Journal, Sept. 1896, vol. XLIX, No. 3.

H. R. Crocker: Brit. Med. Journal, Jan. 2, 1897, No. 1879.

W. B. Banister: Medical Record, vol. LII, No. 4, Jan. 23, 1897.

Ereund : Miinch. Med. Woch., No. 3, Jahrg. 44, Jan. 19, 1897.


LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE NERVE CELL

Study VI.— DIPHTHERIA. By Henry J. Berkley, M. D.


During the course of this investigation, an article by Ceni* on the same subject came into my hands, and the results determined, by both investigations are so entirely similar that it seems hardly necessary to repeat in full the details of the study.

Ceni's work was done on rabbits and horses, with an acute and a chronic series. The first, after the inoculations with diphtheria cultures, lived from three to four days, and showed, in exquisite form, the beginning of the moniliform swellings of the dendrites of the cortical and hippocampal cells common to the action of all the toxins of the infectious series. The chronic series lived from 36 to 41 days after the inoculation with the toxin, during which period they lost full half their weight. Ceni also utilized the cerebra of horses which had been used in the Milan Bacteriological Laboratory to produce diphtheria serum. In these, after three or four months of the treatment, he found the cortical cells far degenerated, and to a degree not seen with the rabbits, the stouter dendrites and corpora of the cells being extensively involved in the destructive process.

Interesting to note, he also finds distinct lesions of the vascular neuroglia, principally tumefaction of the bodies and branches, the one attached to the blood-vessels' walls showing the alterations most distinctly, all being identical with those described and recorded in the III. study of this series (Art. Ricin Poisoning).

Our present series consisted of five diphtheria guinea-pigs, whose brains had been sent me by Dr. Flexner for the purposes of the study. The first two brains, after hardening and examination of the sections, were rejected on account of the possible presence of post-mortem changes. The other three cerebra were carefully hardened in Miiller's fluid and treated afterwards by the silver phospho-molybdate formula.

Guinea-pig No. 3 received an injection of the toxin at 2.30 P. M. and died about 3 A. M. the following morning. No. 4 was inoculated at 2 P. M., was re-inoculated two days later at 10.30 A. M., and died two days afterwards at noon. No. 5


•Carlo Ceni : Riforma Medica, vol. I, 1896.


went through the same course of treatment as No. 4 and died approximately at the same hour.

The local manifestations at the site of the inoculation were experimental membranes, oedema, and slight central necrosis. The lymph glands throughout the body were enlarged, there were small hemorrhages in the mucous membranes, and ecchymoses and necroses of the abdominal organs, with considerable fluid in both the thoracic and abdominal cavities.

With Case 3 the dendrites only show beginning changes. There are numerous small moniliform swellings scattered over their branches, not focally but uniformly throughout the cortex, and over the sites of these tumefactions the gemmules are either lost or are very sparingly present, while on those that have normal dendrites they are undiminished in numbers. On the stretch of dendrite between the swellings, which either appears normal or slightly below the natural calibre, the lateral buds are beginning to disappear, as shown by the paucity of their numbers and lessened tendency to assume a deej) black tint. The bodies of the cells do not appear to be in any way changed in staining properties, or to have lost in any degree the angularity of their contours.

The vascular neuroglia cells are uniformly stained throughout the outer layers of the cortex, and have their tentacles, jiarticularly the vascular foot, somewhat swollen, the degree being considerably less than in some specimens we have noted after the injection of other toxins. The axis-cylinders are distinct, and show no alterations. The tei-minal apparatus of the cortical fibres were so infrequently stained that it is hardly possible to determine with certainty whether they were pathologically altered or no, but those found appeared to be normal.

The larger vessels showed neither thickenings nor ruptures of their coats.

With cases Nos. 4 and 5 the pathological alteration is similar to that in No. 3, only increased in intensity, from the longer duration of the poisoning, and, perhaps, also from the repetition of the inoculations. The moniliform nodules are well marked over long stretches of cells in the pyramidal region of the sections, and are uniformly larger than in the more acute case. Also the denudation of the gemmules is


24


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. n.


marked by the greater absence of these pin-like projections from the dendrites.

Some of the psychical cells are beginning to show alterations of their outlines, appearing now rounded in contrast to the third case.

The vascular neuroglia also shows signs of more advanced swelling, the tentacles being thicker and the pseudopodia more prominent.

The axons and collaterals are well stained, but show no unusual varicosity or other departure from the normal. A few of the cells having upturned axons are well stained, but the morbid changes are of less intensity than with the pyramidal variety.


The cerebellar cells, as in the previous studies, showed less damage than those of the cerebrum. The Purkinje variety was the only one recognisably involved. The peculiar axons of the basket cells were natural, and the various nerve fibres throughout the outer lamina of the cortex retained their histological appearance.

From the studies conducted on the cerebra of hydrophobic and diphtheritic guinea-pigs it would appear that all severe infections were followed by brain-cell degeneration of an order not dissimilar to that found in the cells of the abdominal viscera under similar conditions, a degenerative process unaccompanied by inflammatory reaction and a tendency to atrophy and necrosis.


PUERPERAL SEPSIS DUE TO INFECTION WITH THE BACILLUS AEROGENES CAPSULATUS.

By George W. Dobbin, M. D., Resident Obstetrician, The Johns Hopkins Hospital.


The following case, which occurred in the Out-patient Obstetrical Department of the Johns Hopkins Hospital, is interesting from the fact that we have been able to lind reports of only a few similar cases in the literature.

We were called to see the patient, Paulina A., about eleven o'clock on the evening of March second, the messenger saying that she had been in labor about two days and the midwife was unable to deliver the child.

As the patient and midwife were Polish it was exceedingly difficult to obtain an accurate subjective history of the case, but after considerable difficulty it was found that she had had an abdominal operation done a year ago in Germany, the nature of which we were unable to ascertain. She was at the end of her third pregnancy, and had been in labor two days.

Examination showed her to be a person of medium size, of an exceedingly pinched and pale appearance about the face, with weak and rapid pulse, running from 130 to 140 beats per minute.

The abdomen was enlarged to about the size of a full-term pregnancy. Just above the symphysis was the pigmented cicatrix of the abdominal operation referred to. The fundus of the uterus presents the bullet-shaped appearance suggestive of pelvic contraction ; it reaches to a point midway between the umbilicus and xyphoid cartilage, and was in a condition of tetanic contraction. Palpation showed a large child in the lef toccipito-iliac-anterior position, with the head impacted in the pelvis. The fojtal heart could not be heard, and the patient was not having regular labor pains.

Measurements of the pelvis showed that she had a generally contracted pelvis, with a conjuc/dta vera of approxinuitely 8 cm.; the other measurements were as follows : distance between iliac spines 32.5 cm., between iliac crests 25 cm., between trochanters 38 cm., Baudeloque diameter 17 cm., and a diagonal conjugate of 10.5 cm.

By vaginal examination we found that the vaginal outlet was much relaxed. There was a very large caput succedaueum I)resenting in the vagina. The head was very firmly impacted in the pelvis and could not be pushed up. The sagittal suture was in the transverse diameter of the pelvis,


with the small fontanelle to the left. The impaction of the head was so great that the cranial bones overlapped one another to the extent of one centimeter.

On approaching the bed a very sweetish, offensive odor became noticeable, and a distinct bubbling, crackling sound could be heard. This was thought at first to be due to the escape of gas from the rectum, but on turning down the bedclothes it was seen to come from the vulva, which was bathed in a dirty reddish-brown fluid containing many gas-bubbles. The bubbling, crackling sound was continuous, and was much more apparent when the patient's genitals were exposed.

Diagnosis. Generally contracted pelvis, with conjugata vira of about 8 cm. ; large child in left occipito-iliac anterior position, with head impacted in the pelvis; arrest of labor.

Owing to the mother's condition, and as the child was already dead, immediate delivery was indicated. She was given chloroform, placed across the bed in the lithotomy position, and a Tarnier axis-traction forceps was applied by Dr. Williams. The head was brought down to the outlet with great difficulty, and as it became more and more crushed out of shape with each traction it allowed the forceps blades to slip several times. The lateral blades of the Tarnier basiotribe were then applied, screwed tightly together, and the crushed head delivered.

Tractions now made on the delivered head showed that the sh'oulders were so firmly impacted in the pelvis that they could not be delivered without tearing the head from the body. The blunt hook was then put into the posterior axilla and that shoulder brought down; this manipulation caused the separation of the epiphysis from the shaft of the humerus, and in order to effect delivery of the trunk it was necessary to put the blunt hook between the ribs beneath the substernal notch and literally drag the child from the mother.

Just as the child was delivered there was an escape of gas from the uterine cavity accompanied by an explosive sound. The gas possessed a most sickening fa>tid odor, which was so intense that Dr. Williams was obliged to leave the patient and seek the outside air.

The third stage of labor also gave considerable difficulty, for


February, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


25


the uterus having been for so long in a tetanic condition, refused to retract, and it was finally necessary to deliver the placenta manually.

Retraction still being very slow, a hot intrauterine douche of boiled water was given, which had, however, little effect; but there being no excessive hemorrhage, the patient was put back to bed. Her condition, while very bad, was not much worse than at the beginning of the operation. She was given strychnia, brandy, etc., and left for the night.

March 3rd, 9 A. M. The patient was seen by the nurse, who reported her condition in no way improved. She had repeated attacks of vomiting during the night. Temperature 98.4°, pulse 144, irregular, weak and intermittent.

5 P. M. The patient was decidedly worse than in the morning. Temperature 101.2°, pulse 144, weak, irregular and intermittent, her face presented an anxious expression, and the respirations were rapid and irregular.

During the morning "gas bacilli" had been found in the tissues of the fcetus and placenta, so a fatal prognosis was given to her husband. At this time in no part of the body could we detect the presence of emphysema. Slips and cultures were made from the lochia, which showed staphylococci, streptococci and large numbers of gas bacilli.

As well as we have been able to find this is the first instance in which a diagnosis of this form of puerperal infection has been made before death.

10 P. M. The patient is decidedly worse, no gas detected in the tissues. The patient died three hours later, and soon afterwards the body began to swell.

March 4th, 10 A. M. Seven hours after death. The body was enormously swollen, being almost twice its original size, the face was swollen entirely beyond recognition, from the mouth and nose there exuded a frothy, bloody serum, and from time to time large bubbles of gas could be seen to escape. The abdomen was enormously distended and gave a deep drumlike note on percussion. Over the entire body we could obtain the characteristic crackling of gas in the subcutaneous tissues.

The husband unfortunately allowed no autopsy.

Pathological report. The foetus and placenta were brought back to the laboratory and the following is a copy of the pathological report :

The child weighs 2900 grammes, without the brain ; its length is 55 cm. The head is entirely crushed, the right arm almost completely torn from the body, and there is a large jagged wound in the chest, all of which were caused by the craniotomy instruments and blunt hook.

The fcetus is very offensive, being much decomposed and macerated. The entire body is emphysematous, and everywhere, on making pressure, we obtain the characteristic "feel " of gas in the subcutaneous tissue. By making pressure on the chest, lai-ge bubbles of gas are seen to escape from the wound in the neck. The body was then put under water, and on puncturing the abdomen there was marked escape of gas, which when ignited shot up in a flame six inches high.

Cover-slips made from the blood and subcutaneous tissues show large numbers of bacilli morphologically similar to the "gas bacillus" of Welch and Nuttall. Cultures on sugar media gave the characteristic growth.


The placenta is of a distinctly bilobed shape, dimensions being 18x14x1.5 cm. and 10x9x1.5 cm. for the greater and lesser lobes respectively. Its weight is 420 grammes. The entire placenta is of a dull brownish color, and a distinct vascular trunk runs from the insertion of the cord, in the larger lobe, to the lesser lobe. On the maternal surface, the cotyledons are poorly marked, and here and there are seen a few minute areas of calcification. There is a large white infarct, 3 cm. in diameter, at one margin of the lesser lobe. The entire surface is crepitant, and in places small bubbles of gas escape on pressure. The fojtal surface shows numerous blebs and bulljB beneath the amnion, which contain gas. The larger placental vessels are distended with gas, which can be pressed into the smaller ramiKcations.

The umbilical cord is 36 cm. long, it is thin and fiabby, and its vessels have considerable gas within them. Coverslips made from the placental blood show large numbers of typical bacilli.

Microscopic examination of hardened portions of the placenta. The decidua presents for the most part a normal appearance. In the serotina the cells are often necrotic and have become converted into canalized fibrin, which in places is seen to be continuous with the canalized fibrin of typical infarct areas of the chorion. Infiltration with small round cells is noted to a slight degree. The decidua is poor in gland and vessel spaces, and when present they seem to have lost their epithelium and endothelium.

In that part of the chorion situated near the decidua serotina the villi present a typical appearance, they are closely packed together, rich in vessels, and their cellular elements take the stain well. Many small infarct areas are seen, particularly at the margins of the placenta, which present the usual structure. As we go deeper into the chorionic substance ((. e. toward the amniotic surface), we see that the villi do not lie in so close relationship with one another, but are widely separated.

The larger vessels of the chorion are seen to be plugged with bacilli, identical with those seen in cover-slip preparations mentioned in the macroscopic description. In some of these vessels the bacilli form a solid plug, completely filling the lumen, while in others a " gas cyst " has been formed, and the bacilli lie in a zone around its margin. As we go from the vessels into the chorionic substance we find a few bacilli; these do not lie in the villous capillaries, but in the stronui of the villi, thus it is seen that while the larger vessels are filled with organisms the capillaries are free from them. The "gas cysts" mentioned above are found to lie in the placental vessels and not in the intervillous spaces.

The tissue surrounding one of these foci of bacilli presents the following characteristics: Centrally we find the mass of bacilli, which may lie either closely packed together in a clump, completely filling the vessel lumen, or surrounding the margin of a "gas cyst" in a zone. Going outward we first find a zone of necrotic material, the remains of the vessel wall ; this is entirely necrotic and shows no trace of nuclei. We next get a zone of necrotic villi, which take a pink stain with eosin, and show no cell structure. That portion of the villus which formerly represented its syncytial covering takes


26


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71.


the stain somewhat deeper than the stroma. Continuing outward, we next find a zone of partly necrotic villi, in which each villus has retained a portion of its cell structure.

Which portion of the villus (syncytium or stroma) first succumbs to the toxic action of the organism cannot be said, for in this zone of partly necrotic villi we sometimes see intact syncytium surrounding necrotic stroma, and in other villi the stroma is normal while the syncytium is represented by a narrow necrotic band. It is probable that the syncytium is the more resistant of the two, as more of the first variety of villi are seen.

There is apparently no reaction on the part of the tissue, for we find no infiltration with polynuclear leucocytes. In some of the sections we were able to demonstrate a few streptococci.

The epithelium and Whartonian jelly of the cord are entirely necrotic, the vessel walls partly so, and show a few nuclei. The arteries are apjiareutly free from bacilli; in the veins, however, they are very numerous, but show no tendency to occur in clumps.

Bacteriological report (by Dr. Lanier). Cultures from the placental blood show the bacillu.'^ aerogews capsulatus mixed with staphylococci and streptococci. A pigeon was inoculated in the pectoral muscle with 1 cc. of bloody lluid from the placenta and died in about eight hours. At the autopsy there was extensive gaseous crepitation to be made out over the entire chest. On removing the skin, the subcutaneous tissue contained a number of gas bubbles. The muscles were extremely oedematus, of a reddish brown color, and disintegrated to the extent of being almost jjulpified. Cultures made from this muscle grew out in the characteristic manner.

A rabbit inoculated in the ear vein with a 24-hour bouillon culture from the original placental blood was killed by a blow on the back of the neck and left for 24 hours. At the autopsy emphysematous crackling could be made out over the entire abdomen and chest, the subcutaneous tissues and all of the organs contained large quantities of gas, slips from which showed large numbers of encapsulated bacilli. Cultures from these organs gave the characteristic growth. The organism was also pathogenic for guinea-pigs.

PatJiolog ical diagnosis. Bacillus aerogenes capsulatus (Welch). Infection of placenta and foetus.

In looking over the literature of the subject we have only been able to find a few cases which can be said to be similar to ours. The first of these cases was reported by Leduc' as early as 1597, he was called to see a woman who had been in labor for three days. After a very difficult extraction by means of the blunt hook, he says: "Immediately after the delivery of the body of the child and placenta, a violet-colored flame with a sulphurous odor escaped from the vulva, this flame shot out some distance from the external genitals of the patient, and its heat coukl be distinctly felt by the hands of the persons who held her." She died several days later. It is highly probable that this gas was generated by the bacillus aerogenes capsulatus, but we can hardly blame the author of that period for giving to his report of the case the somewhat fantastic title of " Le diable an corps."

Doleris' reported a case of a woman dead aftei- labor, of a


bacillar infection, this was before the work of AVelch and Nuttall, but the clinical history is so characteristic of the form of infection we are discussing, a short quotation from his report will not be out of place.

" In 1883 I submitted to the Anatomical Society a case of delivery at term, complicated by a myoma, after which the patient died. The labor was exceedingly difficult and marked by successive intervention (forceps, cephalotripsy, etc.), and I was not able to deliver the foetus. The patient succumbed to a septicfemia having its origin in an intense putrefaction of the uterine tissue, physometra, and putrid emphysema of the cellular tissue of the hypogastric region. I have studied the case carefully from a bacteriological point of view, and can affirm that it was a typical septicfemia caused by a bacillar organism and not by the streptococcus or staphylococcus."

In 1893 we find reports of two cases, one by Graham Stewart and Baldwin' and the other by P. Ernst.' As these cases were both worked up very carefully from a pathological and bacteriological standpoint, we give rather full abstracts.

Dr. Stewart' was called at 1 P. M. to see a woman who had been previously healthy and accustomed to hard work. He found her suffering with intense pain in the region of the uterus and ovaries. Miscarriage was suspected and denied. As the pain was somewhat relieved by morphia he diagnosed the case as acute metritis following abortion, and left the patient. He did not see her again until several hours later, during which time she became so much worse that another physician had to be called. At Dr. Stewart's third visit at 9.30 P. M., about eight hours after the onset, he found her emphysematous from " the top of her head to the soles of her feet." Shortly after this she died, and swelling of the body began, and increased so rapidly as to greatly alarm the undertaker when he was called in.

At the autopsy Dr. Baldwin reports "on making the usual longitudinal incision, gas bubbles were found in the subcutaneous tissue, which ignited with a characteristic explosion, and a small amount of gas in the peritoneal cavity. The abdominal veins are markedly distended with gas, and numerous bubbles found in all the internal organs. The uterus gave evidence of an abortion at about the third month." There is no record of microscopic examination of any of the organs.

Bacteriological examination of a specimen of blood showed the presence of the bacillus aerogenes capsulatus in large numbers.

It is very interesting to note that in this case production of gas took place to a very marked extent before death.

Ernst,' in doing an autopsy on a woman dead after operation for removal of a macerated foetus, was struck by the appearance of foam on the cut surface of the liver, which on being allowed to stand increased so rapidly as to form a layer several centimeters thick.

Bacteriological examination proved this case to be one of infection with the bacillus aerogenes capsulatus. An abstract of his case is as follows.

Patient 26 years old, with anteflexion of the uterus in her first pregnancy. Entered the hospital suffering with pain in ilic right side of four weeks' duration. She had also lately


February, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


27


noticed a tumor in the lower abdomen. Tiiere being no definite signs of pregnancy, and the microscopic examination of scrapings from the uterus showing decidua, the cervix was dilated to admit manual exploration of the uterine cavity. Digital examination, however, revealing nothing, a vaginal tampon of iodoform gauze was introduced.

After this the patient became so much worse that the tampon had to be removed. A macerated foetus was found and extracted, and the uterus repeatedly douched with antiseptic solutions ; the patient, however, became steadily worse and died.

The autopsy showed fibrinous adhesions between abdominal wall and intestines ; cloudy sanguiueolent fluid in the pelvis. The musculature of the left ventricle is thickly beset with little miliary abscesses (?), in the centre of each of which is a small punctiform lumen. Fresh fibrinous exudate on the under border of the lungs. Spleen tumor with fibrinous coating and many necrotic areas appearing beneath its capsule. Cloudy swelling of both kidneys. In the liver, which is of a yellowish icteroid color, there are countless yellowish and whitish-gray foci, the size of a millet seed, in the centre of each of which there is a small lumen.

The uterus reaches to the umbilicus, it is 15 cm. long and its walls have an average thickness of 2 cm. The placental site occupies the anterior wall, and here the uterus is thicker (3i-3 cm). The entire uterine wall crackles on account of its containing numerous gas bubbles. The cervical portion of the uterus is 5 cm. long and is gangrenous. The uterine cavity presents a ragged meshed surface of a dirty gray color. A dirty, sanguineoleut fluid flows from the venous plexus of the right broad ligament.

The uterus and ovaries are covered with a fibrinous exudate; in the right ovary is a corpus luteum of pregnancy, undergoing cystic degeneration. There is a clot in the right iliac vein which is riddled with gas bubbles.

Ernst was unfortunately prevented from making cultures at this time,-and later the organism had died out.

In Ernst's article he goes very thoroughly into the histological changes produced in the internal organs. These changes are similar to those described by Welch and Nuttall, so they will not be mentioned in this report.

The changes mentioned in connection with the uterus are especially interesting to us owing to the fact that we were unable to get an autopsy in our case. Ernst mentions three different organisms : a large bacillus similar to those found in the internal organs, viz. the bacillus aerogenes capsulatus; a short thick bacillus which he considers a saprophyte; and cocci having a tendency to chain arrangement, however, as he says, not the typical chains as seen in streptococci. The short thick bacilli he finds only in the necrotic uterine mucosa, and they show no tendency to invade the deeper structure, while the cocci are found deep down in the uterine muscularis. The larger bacilli, which are found all through the internal organs, are very numerous in the uterine wall; they have formed "gas cysts," which give to the uterus the ragged, mesh-like appearance mentioned above.

In comparing these " gas cysts " with those found in the liver, Ernst says the principal difference is, that while in the liver the bacilli line the cyst in an unbroken zone, in the


uterus the organisms are only found lining portions of the cyst wall, and the cyst has a much more irregular contour. This difference he attributes to the difference in structure of the two organs, that of the liver being more or less homogeneous, while the uterine wall is made up of numerous fibres running in different directions.

Thus, when a mass of bacilli begin to form gas in the liver, the resistance met with is equal in all directions and the bubble takes the form of a sphere. On the other hand, in the uterine wall, the resistance not being equal, the bubble when formed will have an irregular contour, and in places along its wall the bacilli will form a very thin zone or be entirely absent.

Ernst is in doubt as to whether the infection took place along the veins or lymphatics, for in his specimens both contained large numbers of bacilli.

In 1895, Kronig, at the Sixth Congress of the Deutsche Gesellschaft fiir Gyniikologie, reports two cases of puerperal endometritis probably due to the bacillus aerogenes capsulatus.

During the last year Schnell' reports a case which, although he does not consider it an infection, has a clinical history so similar to our case that a short abstract will not be out of place.

Primipara, oet. 31. 24 hours after rupture of the membranes was seen by a midwife from the Polyclinic, who found prolapse of an arm. Version was tried, but failed, on account of contraction of the uterus; the child died during this attempt. She was brought to the hospital with marked tympania uteri and suffering intense pain ; 46 hours after the onset of labor she was delivered by a difficult version. Immediately after labor she did well, but later had quite a profuse hemorrhage, for which the uterus was tamponed with iodoform gauze. She then became steadily worse, and died three and a half hours after delivery.

At the autopsy 18 hours after death, in winter, nothing abnormal was found but gas in the large veins of heart, pericardial vessels, lungs, aorta, liver and spleen.

There is no record of any bacteriological examination, and Schnell considers the death due to air having gained entrance into the uterine sinuses during the successive manipulations.

On looking over and comparing these cases with our own, the following points are of interest: In every case the infection was very rapid and fatal. In all of the cases except that of Graham Stewart and Baldwin, there was for some time a dead fostus in the uterus, and the organism found an excellent medium for development in its dead tissues and in the placenta, and probably did not gain entrance to the general circulation until after death of the patient. In the case of Graham Stewart and Baldwin, on the other hand, there was nothing in the uterine cavity ; it only " gave evidence of a recent abortion." Here it is probable that the infection was more in the nature of a true septiciBmia, and the bacilli gained direct entrance to the vessels and lymphatics at the abraded placental site. As this was the only case in which gas was detected in the subcutaneous tissues before death, the above theory is not out of the line of probability.

In Schnell's case we feel sure that had a bacteriological examination been made, the organism would have been found.


28


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71.


There are in our case two questions wliich deserve consideration, in the first place, the origin of the infection, and in the second, the action of the organism after it had entered the body.

The first question, in the absence of an accurate subjective history, cannot be answered with certainty. Suffice it to say that as the patient had been in labor two days before we were called In, and during that time a midwife had been in constant attendance, it is more than probable that the organisms were introduced by her during her examinations.

In regard to the action of the organism after it entered the body, i. e. whether the case was one of saprajmla or septicemia, we can say as follows: Welch and Nuttall' have proved by inoculation into rabbits, that when the organism Is introduced into the general circulation, death of the animal does not follow, but if shortly after the Inoculation the rabbit be killed, the bacillus develops very rapidly, with abundant formation of gas in the various organs.

In their experiments on rabbits, in only one case did the inoculation prove fatal. This occurred in a pregnant rabbit in which two of the embryos were dead and macerated at the time of the experiment. Here the bacilli gained foothold and developed.

From the above we can then argue that the organisms were introduced by the midwife early in labor. She failed to recognize the obstruction offered by the deformed pelvis, and allowed the case to go on. The child, after becoming firmly impacted in the pelvis, died, and the bacilli, which had before undergone little development, now having the most favorable culture medium for their growth, i. e. dead tissue deficient in oxygen, increased to an enormous extent and partly filled the uterine cavity with gas.

Thus, by the time we were called in to see the patient she was not only weakened by the prolonged labor, hut also profoundly poisoned by the toxines produced in the uterine cavity.

Why did not her general condition Improve after removal of the dead foetus and placenta ? To this it may be replied that the fcetus being so long under pressure, there was considerable sloughing and necrosis of the cervical and vaginal tissues ; thus there was still a large amount of favorable media which we could not remove.

One other point deserves consideration. Did the infection of the fcEtus and placenta take place before or after fa3tal death ?

Again referring to the experiments of Welch and Nuttall, the fact of our finding the bacilli and " gas cysts" only in the lumina of the placental vessels is a strong point in favor of the theory that, just as in the mother, the organisms entered the blood before death, but did not undergo rapid development until the fcEtus died.

From the above I think we can consider our case as one of septic intoxication rather than a septic infection.

Since writing the above report we have been told by Dr. N. G. Klerle, City Autopsy Physician, that it is not a rare thing to find conditions similar to these, viz. production of gas in the subcutaneous tissues and Internal organs, in cases dead after criminal abortion.


Eefeeences.

1. Welch and Nuttall : A gas-producing bacillus (bacillus aerogenes capsulatus) capable of rapid development in the blood-vessels after death. Bulletin of the Johns Hoi^kins Hospital, July-August, 1892.

2. Welch and Flexner: Observations concerning the bacillus aerogenes capsulatus. Journal of Experimental Medicine, Vol. I, No. 1.

3. Graham Stewart and Baldwin : Bacillus aerogenes capsulatus — Case. Columbus Medical Journal, August, 1803.

4. P. Ernst: Ueber einen gasbilden Anaeroben im menschlichen Korper, und seine Beziehung zur " Shaumleber." Virchow Archiv, Band 133, Heft II.

5. Leduc : Le diable au corps. Witkowski's Accoucheurs et Sage-femmes celebres, p. 184.

6. Kronig : Discussion on Endometritis. VI Congress Deutscher Gesellschaft fiir Gyniikologie.

7. Schnell : Ueber einem Fall von gasblasen im Blut einer uach tympania uteri gestorben Puerpera. Mouatsschrift fiir Geburtshulfe und Gyniikologie, IV, 199-203, 1896.

8. Doleris : Inflammation puerperal. Arch. d'Obst. et de Gyn., Vol. IX, pp. 97-122, and pp. 142-161.

Discussion.

Dr. Flexner. — I was enabled, through the courtesy of Dr. Dobbin, to see, during life, the patient whose case he reports. At my first visit, some 6 or 8 hours previous to her death, I endeavored to ascertain If there was any evidence whatever of au ante-mortem development of gas within the tissues or vessels In parts remote from the genitalia. No such development was discovered. The nest time I saw the case was several hours (6 or 7) after death. At this time the appearances presented were those of extensive gas formation everywhere iu the soft tissues and serous cavities. From the nose and mouth frothy bloody serum exuded, which on cover-slip preparations showed many characteristic bacilli. From the account given by the family it was clear that rapid multiplication of the organisms had begun almost at once after death, thus indicating a general distribution of the bacilli during life. I should prefer to consider that other causes than merely the presence of oxygen in the circulating blood are to be taken into account in explaining the absence of any appreciable development of gas, and thus presumably of bacilli, in the body during life. I apprehend that still other factors play a part, and these probably are of the same nature as are reckoned with in other and more usual forms of infection with bacteria. This case is, I believe, the first oue which has been encountered in the Hospital in which the invasion followed parturition. It is iu itself a confirmation of the prediction made originally by Welch and Nuttall, namely, that many of the cases of supposed entrance of air into the uterine sinuses would be found to be due to infection with a gas-producing micro-organism. The prediction had, however, been abundantly confirmed before by Ernst and Graham, as related in Dr. Dobbin's paper.


Febritart, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


29


PROCEEDINGS OF SOCIETIES.


THE JOHNS PIOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of October 19, 1896. Dr. Thayer in the chair. The Surgical Significance of Gall Stones.— Dr. F. Lange.

Every physician who has practised for a long time knows that there are cases in which through a number of years attacks of gall stones will recur and eventually the patient will be entirely cured. I have, for instance, for a number of years watched a colleague of mine, a physician, who beyond any doubt has had gall stones, and indeed I have felt the gall stones in his dilated gall bladder. He had all the symptoms of cholangioitis, with frequent chills and high fever, through months and years. He, however, did not like to undergo surgical treatment, and he is now in flourishing health.

I have seen an old lady with a gall bladder packed with gall stones, who was not operated upon, who never had any severe attacks that had been taken for gall stones, but in whom apparently the gall stones have disappeared without any serious symptoms. Pathologists know that the presence of gall stones, especially in elderly persons, at autopsies, is of very frequent occurrence. On the other hand, the disease may call for very prompt and active surgical treatment, and it depends entirely ujion the pathological changes — the consequences of the presence of gall stones or their accompanying changes in the gall system — whether the case will present features that call for surgical treatment.

I propose to accompany a gall stone from its usual place of residence through the gall passages, and on this journey I shall mark out some clinical features which we will occasionally be brought in contact with. As long as the gall stones remain quiet in the gall bladder they will hardly ever give rise to any symptoms, but as soon as they become dislodged and commence to travel iuto the cystic duct or the common duct, then the typical symptoms will commence. They may sometimes grow to a large size and cause very few symptoms. I show you here a specimen of gall stones that came from a lady who for a number of years had been suffering from " dyspepsia," but not until an acute attack of peritonitis had set in, in consequence of impaction of this very large gall stone in the cystic duct, was she ever supposed to be suffering from gall stones. As you see, the gall stones are almost the size of a hen's egg. The gall bladder was full of pus, and peritonitis had commenced. Acute impaction of the gall stone in the cystic duct, in my experience, happens not unfrequently with solitary stones of larger size. Since the first of last October I have had six such cases of acute cholecystitis with septic processes on the surface of the mucous membrane of the gall bladder, or through the entire thickness of the gall bladder, which brought the patient iuto more or less danger of life. In one of these cases, in which I had oj^erated three years previously, I had the opportunity of observing the changes that had taken place three years after operation. The patient was left with a pretty extensive scar and a


hernia formed. She got an acute strangulation of a small omental hernia which necessitated incision. It was in the immediate vicinity of the .gall bladder, and the gall bladder on that occasion was opened also. I found, to my surprise, that the gall bladder had assumed an hour-glass shape, through the loss of substance which had occurred in the expulsion of necrotic tissue in the first attack, and there existed two compartments communicating with each other by means of a very narrow canal. In both of these compartments was a considerable amount of mucous material, but no stones. The patient had suffered at the time from a certain degree of catarrh of the gall duct.

I have here a stone of not much smaller size, made up of cholesterine with lime outside. The patient had an acute attack of cholecystitis, and this stone was found impacted in the cystic duct.

This third stone, of smaller size, is from a case in which the destruction of the gall bladder was quite extensive. Eventually the patient made a good recovery.

Solitary stones are not always the cause of this affection. On the contrary, sometimes quite the opposite condition will be found. You will see here in this bottle a large quantity of gravel-like material, coming from the gall bladder of a gentleman who for several years had been complaining of pain about the region of the liver. In the second bottle you will see an amount of tissue coming from the disintegrated mucous membrane, and if you will take a closer look at these pieces you will see that a large number of these small black granules are imbedded in these shreds of membrane. The gall bladder was felt through the patient's lifetime as a very hard, resistant, stony body, and when I tried to remove it it broke off in the region of the cystic duct, and I was able to feel below a hard resisting mass. The patient was in such a weak condition that I did not try to get any further. After about six mouths she died from a progressing carcinomatous affection of the cystic duct. The cancer of the cystic duct pressed the common duct and led to jaundice and marasmus.

If the gall stone passes beyond the cystic duct into the common duct and is arrested there, of course the symptoms of stagnation of the bile will make their appearance. Very frequently, however, associated with this there is inflammation of the gall system, such as cholangioitis or pericholangioitis or even liver abscess. These cases often necessitate very difficult tasks, and I must say that some of them upon which I have operated are among the most difficult operations I have done. They are, however, very successful operations, and operations by which the life of the patient is saved. In one of them I was able to push the stone back through the dilated cystic duct into the gall bladder, and then did what may be called an ideal cholecystotoniy, that is to say, I sewed the gall bladder up again and closed the abdomen. That was ten or eleven years ago ; of course I would neither do it again nor would I recommend it. It is evident that through the mechanical injury of the operation and through the inflammatory condition which is present, a certain amount of swelling is kept up for a time, and then the duct will not immediately become patulous after


30


JOHNS HOPKINS HOSPITAL BULLETIN.


[Ko. 71.


the sewing of the wound, and so it was in this case. The sewed-up gall bladder was put upon a tension and burst, and the patient died from sepsis.

I have here a small cholesterine stone which led to a bad condition of the patient. A lady, about forty years of age, the wife of a physician, who was very carefully observed, had had one attack of gall stones about four or five months previously to the time I saw her. She was taken with chills, high fever and deep jaundice. I found her, about nine or ten days after the beginning of this attack, in a very low condition, so bad that the only indication at that time was to open the gall bladder, drain it and do away with the stagnation of the bile. About three weeks later this stone was removed from the common duct, and although the patient for a number of months after this presented some febrile symptoms, with occasionally slight chills, she eventually has entirely recovered.

Here is another stone, which has been removed from the ductus choledochus, and one of exceptional size for a choledochus stone.

I have one specimen in which I was obliged, apart from opening the gall bladder, to incise the cystic duct at two different places, and also the common duct. That was a case in which the gall stones were very small, not larger than peas, and which were caught behind the protruding folds and diverticula of the cystic duct, so that they could not be shifted. I sewed up the common duct as well as the cystic duct, and drained the gall bladder. This patient made a good recovery.

The principal point of resistance for gall stones is the region of the papilla in the wall of the duodenum. In a good many instances it has been found that large stones there destroy the surrounding parts and form fistulous communications with the duodenum. I have had the opportunity of operating in one such case, in which I thought I had to do with a malignant affection of the duodenum. The patient was sent to me as a case of cancer of the pylorus. It could be made out easily that the pylorus must be free, because vomited matters contained a large amount of bile. By palpation nothing certain could be made out, and in operating, I cut down through a great many adhesions and a good deal of scar tissue and found the duodenum obstructed by a hard mass, apparently of scar formation. I separated that, but in going further I met with a hard firm body which was apparently adherent to the vertebral column. I stopped the operation. The patient was very much run down. Believing that the duodenum was not sufficiently patulous I made a gastroenterostomy. The patient rallied from the operation fairly well, but fell into a state of collapse five or six hours later and died. In making the autopsy I found, to my very great surprise, that this large mass behind the duodenum was not a malignant affection, but a large mass of gall stones, partly lodged behind the wall of the duodenum and partly within the wall of the duodenum, with a number of fistulous openings into the duodenum. The constrictions from scars were such that the contents of the duodenum could not easily pass beyond this point, and the symptoms of obstruction of the intestinal tract were the consequence.

I show you here a stone which has been excised from the small intestine. It is a very beautiful specimen of a pure


cholesterine stone. Why a stone of this size cannot pass, while a Murphy's button will pass easily, I cannot tell. The patient in this case was an old lady. The operation was done very smoothly and I had good hopes for recovery, but she died in eight hours after the operation, from collapse.

These are the regular ways of the gall stones; but we know that from the gall bladder or from any other point in the gall system, through destruction of the surrounding tissues, they may find an outlet into a neighboring viscus or through the abdominal wall. Gases of this kind have at all times been very interesting and full of medical interest. I show you here specimens from one of my first cases of this kind, which occurred about seventeen years ago. It was a case of abscess of the abdominal wall, at the bottom of which I found gall stones. They were still lodged in the gall bladder. The patient would not submit to further surgical treatment and still has a fistula which discharges bile.

I have here some specimens, some 300 in number, from a case of acute cholecystitis. And here are specimens from another case of cholecystitis, in which I might call your attention to a point of interest, namely, on the cross-cut you see three small gall stones matted together by a binding mass, so that a single stone is simulated. Gall stones in the first stages of their development are very soft masses, and, owing to the beautiful and careful researches of Naunyn, we know that there is an organic substructure for their development.

A very serious complication that has led to fatal issue in several of my cases of advanced cholemia is an inclination of the patients to bleeding. Three of my cases I have lost from secondary hemorrhages. Two of these cases were complicated with malignant disease of the pancreas; at least I think they were cases of cancer of the pancreas. Autopsies were not made, and I can only say that I felt in the region of the head of the pancreas a resistant hard mass which I took for a malignant affection. Lately, Professor Riedel, a surgeon who has perhaps worked more in gall surgery than any other living man, has published cases in which he is inclined to assume that occasionally these apparent malignant thickenings of the pancreas may be but inflammatory thickenings, and he mentions one case which seems to be beyond any doubt. In an elderly gentleman, in whom the operation was abandoned, assuming that this was a case of cancer of the pancreas, the stones merely were removed. A fatal issue was awaited, but the patient lived for years and years and became healthy and strong, and there could be no question about his not having malignant disease. He assumes that through the presence of stones an irritation is kept up in the pancreas, and that this irritation, after the removal of the stone, may cease and the condition improve.

I have lost one of these cases by the separation of the Murphy's button after establishing cholecystenterostomy. The patient had had up to that time small hemorrhages from the inside of the gall bladder. I had purposely kept the gall bladiler open, stitched to the abdominal wall, because I had the impression that this probably would be a case of bleeding, and in order to tanijion and make counter pressure I kept the gall bladder open, and was able up to the tenth or eleventh day to check the bleeding, but after the separation of Murphy's


February, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


31


button the patient had a profuse hemorrhage into the large intestine and succumbed to anaemia.

In another case there was no proof of any malignant infection. It was a young person with impaction of gall stones in the common duct. The operation went off very well, but on the fifth or sixth day she had a secondary intra-peritoneal hemorrhage which was, I am sorry to say, detected too late. It is a fact that has been observed repeatedly, that in some cases there is an inclination to hemorrhage a certain number of days after operation. These patients who are apt to bleed from cholsmia, show a great tendency to bleed while one is incising the abdominal wall. They are, as a rule, much run down in health.

I will show you here an exceptionally beautiful specimen of gall stones from a case of sarcoma of the gall bladder, — a sarcoma which was not detected at the time of operation. I thought it was a case of stenosis from impaction of a stone in the apex of the cystic duct. To be sure, there was a suspiciously rough surface at the point of this stone. After a number of months a tumor mass sprung up from the gall bladder. Evidently this stone had been lodged with its point on the irregular surface of the tumor, and I think the roughness of the stone is somewhat indicative of its being in contact with an irregular surface and not with the smooth surface of the gall bladder.

As far as the surgical technique of this operation is concerned: To begin with the abdominal incision, I must say that I have entirely abandoned the longitudinal incision ; but, according to the i)roposition of Corvisart and the experience of other surgeons, I do exclusively the operation parallel to the border of the ribs. Correspondingly to the thickness of the abdominal wall, this incision occasionally must be a very large one. A very great difficulty must occasionally be met with through the smallness of the liver. It is an entirely mistaken idea that in consequence of stagnation of bile the liver must be enlarged. On the contrary, I have had the experience that in occlusion of the common duct of long duration, probably through the influence of j)ressure, an atrophic condition of the liver tissue will take place, and occasionally the liver will be concealed high up behind the ribs, and this may cause a great deal of difficulty in consequence of the high and deep position of the field of operation. I have taken, in eight of these cases, to excising the adjacent cartilages of the ribs, and I should like to commend that. It facilitates the operation very much. On the other hand, of course the enlargement of the liver may be a great hindrance, and, esjiecially in fat and plump persons of short build, it maybe quite difficult to get down to the common duct. In one of the cases I was unable, in spite of excision of the ribs, to get effectually down to the point of the trouble, and not until I had pulled the liver as far as I could out of the incision, almost one-third of the liver substance being brought outside of the abdominal wall, was I able to easily get to the cystic and common ducts. It was the case in which I was obliged to open the cystic duct at two different points and, besides that, the common duct at the usual place about the middle of its course. In the cases of acute inflammation it is of course necessary, wherever one has reason to presume that the neighborhood of the gall blad


der is infected, to keep everything as much as possible open and give entirely free outlet for the peritoneal secretions. At the same time I always drain the gall bladder with a long tube with the view of having a siphon action upon the secreted gall, and this will act very effectually. Of course occasionally a blockage will take place through mucus or blood clot, and then it will be necessary to change the tube or make a cautious washing through it. I should advise against the injection of any irritating antisef)tic solution into the gall bladder. I have observed that occasionally this fluid will cause distressing symptoms, attacks of colic, probably because it may get into the common duct and the hepatic duct and irritate. I only use saline solution or boiled water. I have always found that the bile itself was an antiseptic agent. After a short time the amount of purulent secretion is insignificant, and the healing of the abdominal wounds, although constantly in contact with the bile, is mostly uneventful and without any untoward symptoms.

About stones in the liver substance I have no practical experience. I have once found a stone in the liver after it had perforated the walls of the gall bladder, but I have not had any experience with stones in the liver that have formed in the gall system above the hepatic duct. It is a fact that these stones will occur, and that occasionally quite extensive casts of stone formation will take place in the gall system.

I will not mention comparatively frequent uncomplicated cases, where we have to deal with dilated gall bladders and stones and where the surgical treatment is comparatively simple.

The operation in two sittings I never do. I find that it is entirely safe to operate in one sitting. I have always aspirated as much as possible the contents of the gall bladder through a thick aspirating needle, protecting as cautiously as possible the surroundings to guard against infection.

Discussion.

Dr. Halsted. Dr. Lange's talk has been instructive to all of us. At one of our meetings, not very long ago, I described three consecutive choledochotomies or incisions into the common duct for the removal of gall stones, all of which were successful. Two of these cases I exhibited on that occasion. What Dr. Lange says about the enlargement of the head of the pancreas interests me, because on several occasions I too have noticed in gall-stone cases that the pancreas was hard. On the first occasion, some four or more years ago, I was misled and thought for a time that the patient might have cancer of the pancreas. Since then I have several times found an indurated pancreas in these cases and have spoken of it at the operating table. The induration of the head of the pancreas was especially noticeable in one case. This case was one of great interest irrespective of this hardening. A very large stone occupied and had almost ulcerated through the common duct. There was, however, no local peritonitis. A little scratch and a little pressure on the wall of the common duct were enough to extrude the stone. The stone being extracted, we found quite a large hole in the common duct and duodenum just where they came together. This made a plastic operation necessary ; and a very difficult one it proved to be


32


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71


because we had to do such delicate work at such a very great depth. Even if the parts to be stitched could have been brought to the surface it would have been no easy task to accomplish the repair of the hole. The patient made an excellent recovery. She has gained nearly one hundred pounds and has no symptoms of stricture of the ductus choledoctinus. Of the other cases of stone in the common duct, one is interesting because complete obstruction was caused by a very small stone in the diverticulum of Vater, or near it. This stone, not more than 3 mm. in diameter, could not be pushed in either direction. After considerable manipulation we cut down upon it and removed it. It will undoubtedly strike you as very strange that we could not manage to extrude so small a stone. We might possibly have succeeded with the exercise of some violence ; but the choledochotomy recommended itself to me as the safer procedure. We might, with a hypodermic syringe, inject oil into the duct and so perhaps make smooth the folds of mucous membrane and dislodge the stone by subsequent manipulation.

Eegarding deaths from hemorrhage: Dr. Lauge speaks of the so-called parenchymatous hemorrhage in these highly jaundiced patients. We have had one death from this cause. Our first common duct case died on the tenth day from hemorrhage. There were absolutely no symptoms of peritonitis. The patient made a very good recovery from the operation, notwithstanding the fact that he was so weak that we hesitated to operate upon him.

In 1880 or 1881 I performed my first gall-stone operation. At that time only one or two operations for gall-stones had been performed in this country. The case is one of considerable interest. Seven stones were removed from the bladder, which was distended with pus and adherent to the abdominal wall. The common duct could not with safety have been examined even if it had occurred tome to do so. The patient lived for about two years after the operation. At no time after the operation was she entirely free from jaundice, nor was she at any time either before or after the operation profoundly jaundiced. The stools were usually acholic, but occasionally showed unmistakable signs of bile. The sinus which led to the gall-bladder was not allowed to close until a few weeks before the death of the patient. Death was precipitated by a slight local peritonitis. At the autopsy all signs of the sinus which had led to the gall-bladder had disappeared. Nothing but a few connective tissue threads remained to indicate where the sinus had probably been. The gall-bladder was reduced to nothing but a little knob of connective tissue. The liver was perhaps less than one-half its original size. The common duct and one hepatic duct were dilated sufficiently to permit a calculus as large as a plover's egg to glide easily up and down from the duodenum to the interior of the liver. The calculus was somewhat egg-shaped, and could almost be pushed into the duodenum through the openii)g which partly by ulceration, partly by dilation, it had made for itself. It became engaged at this ring of cicatricial tissue a little beyond its middle when allowed to fall naturally, point downwards, in the common duct, from the liver to the duodenum. The wall of the common duct was very thick. The stone had evidently freely traversed the entire length of this dilated canal,


from the very centre of the liver to, and almost into the intestine. At the autopsy which was made by a very distinguished pathologist the calculus was not found until the liver had been literally cut to pieces, so deeply was the stone imbedded in this organ. The occasional presence of bile in the stools and the absence of profound jaundice were thus readily explained by the findings at the autopsy. When the calculus was in the dilated branch of the hepatic duct, bile could escape through its other branch and appear in the feces. When the calculus plugged tightly the orifice into the duodenum the jaundice increased. That it should never have been profound could be explained by the fact that the stone traveled freely everywhere in the duct; a little bile could probably escape except when the stone was engaged at the duodenal end of the duct.

Will Dr. Lange kindly tell us if he always employs drainage of some kind in suture of the ductus choledochus; and if so, how long does he permit his di-aiu to remain ? Does he not think that the drainage material, gauze, etc., should be left undisturbed until the rest of the peritoneal cavity is well walled off and protected from reinfection ? Quite recently one of Germany's best surgeons removed the gauze in one of these cases on the third day. Peritonitis supervened promptly and the patient died. I have noted that this surgeon and several well-known English surgeons state that no harm is done by leakage from the duct after suture of it, provided one drains down to the sutures. I think that one should, if possible, so suture the duct that its contents cannotescape. Fluid can convey solid and infected particles to places in the general peritoneal cavity which are not protected by the gauze. Furthermore, I have the idea that adhesions take place more firmly about dry gauze than about gauze which is constantly bathed in fluids.

For this reason, if we have sutured a gall-bladder to the parietal peritoneum, or if we have packed gauze anywhere about this gall-bladder which we have opened and propose to drain, we endeavor to prevent leakage for the next three or four days bypassing a purse-string suture all along the edge of our opening into the gall-bladder, and drawing it up when we have introduced our gauze or drainage tube into the gall-bladder.

We explore all the ducts and open and evacuate the gallbladder in one act. Kiedel's advice to perform the operation in two acts, opening and evacuating the gall-bladder at the second act, is bad. We have more than once, while removing biliary calculi, remarked that it would have been impossible to extract them without the aid of fingers in the abdomen. Bimanual manipulation is of course impracticable when the bladder is adherent, all around, to the abdominal wall, as it is at the time of the second act in the operation in two acts.

Dr. Lange's suggestion to cut through one or two ribs to facilitate matters where the liver is very small and the gallbladder so high as to be otherwise almost inaccessible, is undoubtedly an excellent one.*

  • Jan. 2nd, 1897. I have recently had occasion to resort to this

procedure while removing a tuberculous kidney which was adherent to the diaphragm. After dividing two ribs I could proceed quite easily with a dissection which otherwise might not have been feasible. When the liver is very large this method of gaining room is indicated quite as much a when the liver is small.


February, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


33


Dr. Laxqe. — I think that in some of my cases I had reason to assume that there was some valve action, especially in one case of stoue in the common duct of small size. The patient had had an attack of gall stone some three months before this attack, with jaundice lasting several weeks, most likely because of obstruction from this stoue, which was solitary, as judged by its very round, regular shape. Probably after a time this stone shifted back and later on again caused obstruction together with an infection. This we saw not uncommonly in cases of obstruction of the common duct. Even if the stones are ball-like or rounded, at intervals a certain amount of bile will get into the gut. It is almost characteristic that if, in prolonged jaundice, at intervals the condition of the fajces and the urine points to the passage of a certain amount of bile through the duct, we have probably to deal with obstruction from stone.

Eegardiug the drainage of the common duct, I have tried everything: I have left the duct entirely open, and I have sewed it up with the insertion of a small drainage tube into the lumen of the duct, and I have sewed it up entirely. In cases where the wall of the common duct is healthy, I think it is preferable, if it can be done, to sew up the duct entirely. If there is reason to assume that there is obstruction beyond the stone, I should prefer to drain, and I do this in such a way that I insert a small drainage tube from the wound in the common duct and pack gauze around it. This gauze (iodoform gauze boiled in glycerine) I leave in for five or six days. The tube I leave for a sufficiently long time to secure the proper outlet of any secretion as long as it exists. In draining the gall bladder I pack the gauze around the tube and leave the opening comparatively large, for the reason that, at least in inflammatory cases, the surface of the gall bladder is such that it will necessitate some thorough cleansing and local treatment for a limited time. There will be clots of blood or shreds of tissue or inspissated mucus which might easily obstruct. I mostly remove this tampon in two or three days and give the inside of the gall bladder an additional thorough washing and cleansing.

Besides this we have either sewed the peritoneum to the surface of the gall bladder where there is no infection outside of it, or we have packed around the circumference of the gall bladder in such a way that even if some of the contents of the bladder escape it is not likely to cause a spreading inflammation.

Dr. Halsted has spoken of the necessity of having a proper needle ; I have a proper needle.

In one case I dissected the peritoneum from the walls of the abdomen. The case was that of an old gentleman, a physician, who had been suffering for years from attacks which were supposed to be stomach attacks, and there was a suspicion of his having chronic ulcer of the stomach and malignant induration. I opened in the middle line and found nothing, but on palpating the gall bladder I found it full of small stones. The liver was small and the gall bladder very high up. I was obliged to loosen the peritoneum. This gentleman had for five or six days incessant vomiting and the gall bladder was torn away from the peritoneum. He still has his gall stones in his gall bladder, but for a number of


years he did not have any attacks. Lately, I understand, he has had them again.

I have also done the sewing of the omentum against the gall bladder in the way that Lauenstein proposes, and have been quite satisfied with it.

Finally, I should like to say that I have regarded the invitation to come here as a very flattering one. I have come with the greatest imaginable pleasure, and for the reason, apart from the friendly relations which I have hei'e, that I have the consciousness of being at a place where science is promoted and sought for in a devoted and unselfish manner. I regard this institution as the pride of this country, and I hope that it will not be the only one, — that others will follow, and that this country will be eager to base medicine on the sound basis of scientific conception.


CORRESPONDElSrCE.


A Case of Pnetjmo-Cardial Rupture. To the Editor of the Johns Hopkins Hospital Bulletin.

Dear Sir:— I send herewith a report of a case of pneumocardial rupture which has come under my observation, which you may deem of sufficient interest to publish.

On March 36, 1896, a negro man, age 23, was brought to our hospital in a condition of collapse, with the history that a bank of sand or earth had fallen on him and a fellow-workman, the latter dying in a few hours afterwards from internal injuries. The patient's breathing was shallow, jerky, rapid and very painful, and every few minutes he had a hard spasm of coughing, which distressed him greatly and during which he expectorated a good deal of bright red blood. Morphin to relieve his pain and coughing, and strychnin were given him freely. On the second day he complained of intense pain in the cardiac region, and the stethoscope revealed a very interesting, if not an entirely unique state of affairs. This was a loud double friction sound with a bubbling and splashing sound, which could be distinctly heard with the stethoscope two inches from the chest wall. The diagnosis was a rupture between the pericardium and the lung. On the third day (losing sight of the fact that air from the lung is usually sterile) I supposed that he had a septic pericarditis due to the effusion of blood and air from the lung. An examination of the blood, however, showed no leucocytosis, which proved conclusively that the pericarditis was not septic. This examination was repeated daily for three days, each time with the same result; and as at no time had he much fever, and as the pulse and respiration during this three days gradually improved, a favorable prognosis was given, which was justified later by his complete recovery. The loud splashing and bubbling disappeared by the fourth day. The rough friction sound persisted for three weeks, and after that the heart sounds were in every respect normal.

Georue S. Brown, M. D.

2220 First Avknce, Birminoham, Ala. Vec. 10, 1898.


3i


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


THE JOHNS HOPKINS HOSPITAL REPORTS.


Volume I.


423 pages, 99 plates.

Report in Patliolosry.


The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Suturos; Reversal of the Intestine; The Contraction of the

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

(Atrophy). By Henry J. Berkley, M. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

Mall, M. D.

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

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

Protozoa, and the Blastomyces found in the preceding Cases, with tlie so-called

Parasites found in Various Lesions of the Skin, etc.; Two Cases of MoUuscura

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

T. C. Gilchrist, M. D.

Report in Pntliolog-y. An Experimental Study of the Thyroid Gland of Dogs, with especial consideration

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

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

Report in Medicine.

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

Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafledr, M. D. Cases of Post-febrile Insanity. By William Osler, M. D. Acute Tuberculosis in an Infant of Four Months. By Harry Toulmin, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

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

Report in Gynecology. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 18S9, to March 3, 1890. By Howard

A. Kelly, M. D., and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,

M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

Ovarian Tumor; General Gynecological Operations from October 15, 18S9, to

March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howard

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, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. My.xo-Sarcoma of the Clitoris. By Hunter Robb. M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment

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

Howard A. Kelly, M. D.

Report in Snrgrcry, I. The Treatment of Wounds with Especial Reference to the Value of the Bloi-d Clot

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Nenrologry, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. T). Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By August Hoch, M. D. A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report In Pntliology, I. Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleor, M. D.


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

Report in Patlio1og:y.

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

Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D. Report in Patliology.

Multiple Lympho-Sarconiata, with a report of Two Cases. By Simon Flexner. M. D.

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

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

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

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

Report in GJ-neeolog-y.

Tlie Gynecological Operating Room; An External Direct Method of Measuring the Conjugata Vera; Prolapsus Uteri without Diverticulum and with .interior Enterocele; 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 Retroflexed Uterus. By Howard A. Kelly, M. D.

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

Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavblt, M. D.


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

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

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

Traumatic Atresia of the Vagina with H^matokolpos and Hasmatometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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

Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever,

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

Report in Nenrolog-y.

Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of Mux musculuf. The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berklet. M. D.

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

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


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

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

Studies in Typlioid Fever. By William Osler, M. D., with additional papers by G. Bluher, M. D., Simon Flexner, M. D., Walter Reed, M. D., and H. C. Parscns, M. D.


Volume VI. About 500 pages, many illustrations.

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

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

Report In Patliologry.

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

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

Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen. SL B.

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

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

Thr pricf of a set hound /» Hoth [To/.*. I-VI\ of the Uoftpitftl Jit-ports is $.•$0.00. Vols. J, IT and III are not sold scparateUj. The price of Vols, ir, V and VI is $.'».00 each.


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER. Tlie 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,

M. D. 1 vohmie of 164 pages and 41 full-page plates. Price, bound in paper,

$3.00. THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.

Hewetson, M. D. And A STUDY OF SOME FAT.\L CASES OF MAL.VRIA.

By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.7^. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. Subscriptions for the above publications may be sent to

The Johns Hopkins Press, Baltimore, Md.


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


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. VIII.- No. 72.]


BALTIMORE, MARCH, 1897.




GOisrTEisrTS.


Is Malaria a Water-Borne Disease ? By Rupert Norton, M. D. 35 Tlie Radical Cure of Hernia by Implanting a Section of Sterilized Sponge. By W. B. Platt, F. R. C. S. (Eng.), - - 44 Additional Cases of Dermatitis due to the x Rays. By T. C.

Gilchrist, M.R.C.S., L.S. A., 46

Proceedings of Societies :

Hospital Medical Society, 47

Rarer Cases of and Observation on Streptococcus Infection [Dr. Bloodgood] ;— Ophthalmoplegia Externa [Dr. H.


Woods] ; — A Simple Contrivance for Effecting Pneumatic Massage of the Tympanal Membrane and Ossicles [Dr. Theobald] ; — Excision of a Parovarian Cyst without Removal of its Ovary or Tube [Dr. Kelly] ;— On the Pathology of Hpematozoan Infections in Birds [W. G. MacCalu'm] ; — On the HiBmocytozoa of Birds [Eugene L. Opie] ; — Discussion of Dr. Bloch's Paper on "Agglutination of Typhoid Bacilli, etc." Notes on New Books,



IS MALARIA A WATER-BORNE DISEASE ?=

By Rupert Norton, M. D., Washinf/ton, D. C.


There are several points in the consideration of this question which make an exact answer e.xtremely difficult. First and foremost stands the fact that the malarial organisms, those forms producing malarial fever in mankind, have not been recognized outside the blood of human beings. Other similar types or species of organisms have been found in the blood of birds, frogs, etc., but these do not seem to be of the same species as that which fji'oduces the fever in human beings. Thus at the outset we are hindered in the investigation of this question by not being able to find and study the life-history of these organisms in any extra-corporeal form. Another difficulty, and not a minor one, is the occurrence of malarial fevers and typhoid fever in the same places at the same time of the year, oftentimes with very similar types of fever. And again it is generally supposed that the malarial organisms exist in the soil, in damp soils, and so possibly in actual water, whether stagnant or running, and as the germs of typhoid fever exist in water, and we know that typhoid fever may be communicated by drinking-water, the belief is a common one that malarial fevers may be induced in the same way.

Proof that malaria is a water-borne disease rests only on evidence that after drinking certain waters people sometimes suffer from so-called malarial chills or fever. It may be shown that they have the malarial organism in their blood,


•Read before the Johns Hopkins Hospital Medical Society, Nov. 16, 1896.


but it cannot as yet be proved that the water they drank contained this organism, so that the chain of evidence is incomplete. We believe there is almost no one who denies the possibility and even probability that malaria is ordinarily an air-borne infection. This makes the proof of the waterborne theory still more difficult, for in every case where the air-borne theory might be tenable as against the water-borne, proof must be brought that the patient was not infected through the air — an almost impossible task. Malaria is almost as wide-spread a disease as typhoid, and yet does not occur in epidemics. No group of cases of malarial fever on land has ever been traced to a single source of infection, as has been done so frequently in epidemics of several of the infectious diseases, especially of typhoid fever. We do not find groups of patients with malarial fevers in towns or elsewhere whose infection can be traced to a single supply of water or milk. We see cases of malarial fever springing up sporadically, apparently having no direct connection with each other, except through the medium of the air: the very name of the disease throws light upon the common idea of its origin. Popular beliefs are against, rather than in favor of the water-l)orne theory ; for example, the general conviction in Rome of the danger of being out after sunset in the Campagna for fear of "catching" malaria, or rather being "caught" by it, and the belief in the security derived from living in the second story of houses in malarious countries, where the dwellers in the first story suffer severely. A similar thought existed among


36


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


the laborers on the Panama Canal, and they, to escape the effluvia arising at night from the soil, slept iu the trees or built houses on stakes high above the ground level. This, of course, is no positive proof against the water-borne theory, but sliows what the feeling has been amongst many people as to the lai'ger share which air, rather than water, plays in the etiology of this disease.

To show the difficulty in properly differentiating typhoid and malaria] fever, we need only to look at a few statistics and remarks made by men of repute who have written about malaria. Chapiu,' iu 1884, reviewing all the cases that had occurred in New England since 1861, gives the following data. He I'eports the deaths due to malaria and typhoid fever in Massachusetts, Connecticut, and Rhode Island, and states that from 1878 to 1882, in Connecticut 1217 persons died of malaria and only 124:2 from typhoid. Iu Massachusetts during the same time there were only 159 deaths from malaria to 4349 from typhoid, and in Rhode Island 24 to 794. The table from Connecticut is an interesting one to look at :

Deaths from Malaria. From Typhoid.

1876 22 327

1877 73 321

1878 143 260

1879 198 159

1880 265 242

1881 357 257

1882 264 324

As seen from these figures, during the years 1879, 1880 and 1881 there were fewer deaths from typhoid than from malaria. It is not worth while to discuss them. It may be said from what we now know of malaria that the records upon which they are based are absolutely untrustworthy.

Griswold' says : " For the main interest of this article, I accept the term 'malaria' as implying that undetermined potency producing the general class of fevers of which intermittent is the most pronounced type, and in which class is included various other diseases that have been very generally regarded as the results of paludal poisoning. In the absence of such specific knowledge as would enable us to give the class a more definite and satisfactory designation, the term answers as well as would any other equally arbitrai'y." This was written after Laveran's discoveries. Here are two extracts from j^apers on malaria as seen in New England. Greenleaf states that malaria may be due to drinking water or to food contaminated by the hands, or to air ; but he believes that "intermittent fever is a disease always originating locally, thus excluding as etiological factors all causes of a general character." Certainly air and water are causes of a general character, especially the former. Green" believes that possibly in the cases reported by him, the water of wells was poisoned by backing up of water, due to a dam or causeway which prevented natural drainage of the adjacent soil.

It is impossible to di-aw correct conclusions as to the etiology of malarial fevers from such general statements. Finally in the Fourth Annual Report of State Board of Health, New York, 1883, on Malarial Fever at Lakeville, Washington county, we read as follows:


" Malarial fever has also appeared at the house of Mr. Donald Reid, about one-third of a mile from Lake Cossayuna, up the Summit pond brook at a height of one hundred feet above the lake. No other cases of fever were reported in this direction. An examination of the premises of Mr. Reid showed that his house stands upon rock, covered with a comparatively thin layer of clay, and that while the roads and ground a short distance away from the house were dry and dusty, the clay around this dwelling was saturated with water. This water comes from a sjn-ing north of the house. The water is brought from the spring to the barnyard through a pipe, and empties into an open trough, the overflow of which saturated the surrounding ground. The surface of the ground here is twelve feet higher than that about the dwelling The upper stratum is a loose soil some two feet deep, through this the water percolates until it reaches the clay over the rock, along which it readily finds its way down the steep slope to the house and saturates the clay about the dwelling. Water is also brought directly from the spring to the house and empties into a trough on the east side of the dwelling. The overflow of this trough is allowed to saturate the ground within ten feet of the eastern wall of the house. From these facts it appears that saturation of the soil about this dwelling, for which the owner is entirely responsible, is a sufficient cause for malarial fever in a region bordering upon such extensive swamps."

There can be but little doubt that these cases were not malaria, but typhoid; certainly the conditions existing were just such as to produce typhoid. Such unreliable statements as those quoted have led many who have not had the opportunity to investigate the question for themselves to believe that malaria was a water-borne disease.

It is a curious fact that almost all observers who want to prove that malaria may be due to drinking water refer to the cases of illness which broke out on the now famous ship Argo. The pros and cons of the evidence that these cases were or were not malaria have frequently been discussed and there is no general agreement. It seems quite fair, however and more than probable, to conclude that these cases were nol malaria. At any rate the burden of proof lies with those who maintain that the cases were malaria, and the proof they offer is unsatisfactory. If these were malaria, then the watei"borne theory needs no further demonstration ; but for those who doubt, new proof must be furnished. The story related by Boudin" is as follows. I translate freely:

" In the mouth of July, 1834, the Sardinian ship Argo sailed from Bone (Algeria) with 120 soldiers in good health, and arrived at Marseilles. Thirteen men had died during this short voyage and had been buried at sea; 90 men were brought to the hospital in Marseilles, showing pronounced ('• les moins equivoques ") symptoms of paludal intoxication, iu all its forms and types ; in some cases the disease was most severe, or if one prefers to say so, showed the greatest degree of perniciousness. Whereas the soldiers were attacked by choleriform, epileptic, comatose, tetanic and other types of fever, which yielded as though by enchantment to large doses of quinine, the sailors showed a marked contrast in their perfect health. Now what could be the cause of such a difference in individuals who were apparently, at least, subjected to identical conditions?


March, 1897.J


JOHNS HOPKINS HOSPITAL BULLETIN.


37


An official inquiry, of which I had the direction, gave me the most complete information. The investigation showed that if the sailors had kept their good health they owed it to the purity of the drinking water, of v/hich they had a special supply, while the soldiers were forced to drink water drawn from a well in a marshy spot near Bone, which water had been taken on board just on the eve of departure. The soldiers who escaped this poisoning were those who, having saved a little money, were able to buy water from the Sardinian sailors. This fact demonstrates in a peremptory manner how paludal matter absorbed in a liquid form from the gastrointestinal surface, as by the lungs in a gaseous form, causes intoxication."* In another place the author himself admits that his evidence is not conclusive. He says : " Le faitsuivant, dont nous avons ete temoiu au lazaret de Marseille, in 1834, pourra paraitre concluant au premier abord, et pourtant, en y regardant de pres, on est contrait de rester dans le doute."

It is strange that nothing is said in this story as to the length of the voyage, nor whether the sailors had been allowed to land at Bone. Algeria is a malarious country, and if the cases were malaria, the soldiers may have been infected on land, and the drinking water may have only aggravated the sickness. In fact there ai-e many points in the story which need elucidation and without which the story is scientifically unreliable.

Oswald Baker' relates some cases of a similar sort, but here, too, his proof is insufficient, not so convincing even as that of the Argo. He attributes the cases of illness, which are not described, to the drinking water on board a vessel. Kershner° relates the case of a ship in which malaria (?) broke out, and where all the evidence went to prove that it was not due to drinking water. The author does not believe in the waterborne theory. The evidence is not clear as to what the illness really was. These are all the cases that I have found to prove or not to prove the development of malaria on shipboard as due to drinking water. If one case could be definitely shown to have occurred in this way, far from land, where the possibility of an air infection would be reduced to a minimum, the case, even then, would not be proven, for we know that the case might be one of latent infection, developing long after a stay in a malarious country.

On the origin of malaria we find many articles by medical men in various countries, and it will be better to examine these systematically, and thus see what proof has been brought forward to confirm the water-borne theory. Let us first look at some of the Reports of the Surgeon-General of the United States Army. In the report for 1889, pp. 32-33, it is stated:

"Much of this improvement has been attributed, and I believe correctly so, to the introduction of wholesome water supplies. In a recent communication, Col. Charles Page, Assistant Surgeon-General, makes an exception of Fort Sill,


  • "I have said above that the patients showed signs of paludal

intoxication in all its types; actually and for the first time at Marseilles, I observed cases of continued fevers, although quinine was administered (" des fiovres continues a quinquina"). Now my investigation showed that the patients with continued fevers were precisely those who appeared to be the most saturated with the marshy water."


Indian Territory, in this connection, claiming that the diminished malarial sick list which followed the introduction of a good water supply cannot be referred to the water, because there was a diminution of malarial diseases at Fort Supply, which had no new water supply, as well as Fort Sill, for several years after the introduction of the water supply at the latter post. He attributes the improvement to some general condition which affected Fort Supply as well as Fort Sill, and considers, therefore, that the theory of a water propagation of malarial fever does not always hold good. He says :

'An examination of the consolidated reports of the medical department of Fort Sill for several years will convince one that the supply of spring water did not diminish the ratio of malarial disease materially. The diarrhoeas diminished and the general health of the command was improved, most probably by the beneficial effects of a full sujiply of good water for drinking and bathing.'

" Here is an example of a garrison suffering from malarial poisoning supposed to be contained in the drinking water, which continued to feel the effects of malaria although the supply of water was changed from that of a doubtful character to one absolutely pure, being filtered for miles through sand, gravel, and lime-stone rock. It is apparent that the poison producing malarial diseases must be sought for in another source than in the drinking water. It is there at Fort Sill in the heat, moisture and soil which produce malarial fevers anywhere, or furnish good culture material for the bacteria that cause it. In New Mexico, where the climate is dry, though hot, malarial fevers do not exist; but turn the waters from the rivers upon the soil by means of acequias, and malarial fevers soon abound, regardless of the source of the water used for drinking. It will be observed that for several years before the improvement of the water supply at Fort Sill the ratio of malarial diseases was smaller than after the development of the spring which gave the garrison a pure filtered water. ... In 1881 the ratio was remarkably small, being but 59 per 1000 of mean strength ; surely that could not be accounted for by any improved source of the drinking water. There may have been some meteorological cause ; we know that in different years there is a marked variation in the prevalence of malarial diseases. . . . The diminution of the cases of malarial diseases at Fort Sill after 1884, when it appears that the greatest number prevailed, must be considered a sequence and not a consequence of the development of the spring of excellent drinking water. The ratio of malarial diseases at Fort Supply for the years 1884, 1885 and 188(5 shows a decrease of sickness after 1884. Fort Supply, where the water supply was not improved, like Fort Sill, has a reputation of being malarious. The water supply of this post has recently been materially improved . . . but it remains to be seen if the ratio of malarial fevers will be diminished."

In the report for 1890 it is stated: "Relatively fewer of the colored troops were attacked, but the proportion of remittents to intermittents was greater among them, and the average duration of the remittent was longer— 34.8 days for the colored, and only 21.2 days for the white men— an illustration of a well established fact, that when the negro becomes seriously ill he does not rally so readily as the Caucasian."


38


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. n.


The duratiou of the sickness in these cases is much against any considerable number of them having been malaria, and the use of the words "remittents" and "intermittents" adds to our difficulty in determining the etiology.

In 1890, Fort Brown, Texas, was supplied with distilled water, and the improvement in the general condition of the post after that year is attributed entirely to this factor.

The following quotation is found in the report for 1894, p. 52: Capt. W. Fitzhugh Carter, the post surgeon at Fort Sill, Oklahoma, writing on malarial diseases, says: "There is almost conclusive evidence that the water of the streams in this section of the country is a concentrated malarial poison, and at certain times of the year will give rise to malarial fevers in a large percentage of those who drink it," and he looks to the use of distilled water for the same beneficial results that have already been obtained at Fort Brown, Texas. But in the report for 1895, p. 41, we find that Fort Brown was the fourth army post having highest admission rate for malarial diseases. Washington Barracks, D. C, and Fort Meyer, Va., just across the river from Washington, came first and second in this list; both these places are well-known hotbeds of malaria. The third in rank was Fort Hamilton, in New York liay, where it is more than probable that the percentage of cases attributed to malaria is too large. From this we do not see that there could have been anj' great imjjrovement in the condition of Fort Brown, as it never ranked first on the list. The purer water supply does not seem to have reduced the cases of malaria very greatly. On the same page of the report for 1895 we find that "nearly one-fourth of the malarial cases of the army were remittent, with an average duration of 21.5 days; the average of the intermittents was 5.75 days" — • a long period for remittent, if by that we are meant to understand malarial fevers, and closely corresponding to the length of time usually given to typhoid. A supply of water supposed to be quite pure has not modified to an appreciable extent the number of cases occurring at the two army posts in Washington. Dr. Charles Smart, of the U. S. A., is an ardent supporter of the water-borne theory, but he has brought forward no convincing evidence of the truth of this theory. He believes surface waters, when used for drinking purposes, to be more dangerous than water from deep wells.

The best, and a very interesting paper that has appeared on malarial fever in these reports is by Dr. Walter Keed in the number issued this year. He has paid special attention to the cases of fever at Washington Barracks and Fort Meyer, and has examined the blood of many patients. Dr. Heed does not believe in the water-borne theory. He tells me that "the water supply at Washington Barracks has not been changed ; it has always been the same as that of the city. The sujiply at Fort Meyer was changed in November, 1894, from well water to Potomac river water. The following year the men and officers drank, as a rule, filtered and boiled Potomac river water, with the result that there were more cases of malarial fever in 1895 at Fort Meyer than during any one of the previous 23 years. It was also higher at the Barracks in 1895 than during any of the previous 23 years." There is much malarial fever in the city of Washington, and it is really endemic along the river flats, but has no apparent connection with the


drinking water of the city, since otherwise the people in the upper part of the city should naturally suffer as much, which they do not. The reports from the army posts are hard to analyze, since the officers in charge are frequently changed, and their personal views as to malaria and typhoid fever vary materially. But, as yet, all the evidence coming from the army posts is rather against than for the water-borne theory.

Through the kindness of Dr. G. M. Sternberg, Surgeon-General of the U. S. Army, I have received to-day proof-sheets of an address lately delivered by him in New York. In this he says : The facts which have been developed with reference to the transmission of cholera and typhoid fever, considered in connection with numerous recorded observations relating to the supposed development of malarial fevers as a result of drinking surface waters, have led some authors to the conclusion that malarial infection, also, commonly results from the introduction of the malarial parasite in this way. Without denying that this may occur, I am disposed to believe that much of the evidence which has been advanced in favor of this view is unreliable. In many cases the so-called malarial fevers which have been traced to the use of surface water from wells, streams, etc., have been of a " continued type " and not controlled by quinine. In the absence of positive evidence of the presence of the malarial parasite in the blood, continued or remittent fevers which resist the specific action of quinine cannot, in our opinion, be properly classed with the malarial fevers. If not due to infection by the typhoid bacillus, they are, at least, more nearly allied to typhoid than to the typical malarial fevers."

A large number of general jiractitioners throughout the United States believe firmly in the water-borne theory, among them Zwisohn,' West,' Waggener," and Hylaud,'" but the evidence they show to support their view is most incomplete.

Daly" wrote a long article attempting to prove this theory, and thought that vegetables washed in marshy water might produce malaria, but his paper is unconvincing. This called forth other articles by Norbury,"" Jones," and Cadwallader;" the first two mentioned agree with Daly, but Norbury gives an account of an epidemic which might have been typhoid, and Jones' paper is still less satisfactory than Norbury's. Cadwallader does not believe in the water-borne theory, but thinks the home of the plasmodia is in the sap of vegetable life rich in sugar, and thinks there is danger of infection in eating maple sugar and sorghum molasses. This startling theory is balanced by an equally strange one put forth by Newton," who thinks "the consumption of water-melons seemed to be provocative of malarial fever." He believes both the air- and water-borne theories have been proven, but most of his evidence is taken from the works of other men, some of whom I have mentioned, and his paper adds nothing material to strengthen the water-borne theory. Hurley," like Daly, attributes malaria to drinking w.ater, " though fruits and vegetables eaten raw may carry it." He does not believe it enters through the lungs. His proof is based on some eases, where people using boiled water were not attacked by some vague symptoms, which those who did not purify their water in this way, suffered from.

Lewis'" believes "water to be one of the chief avenues, if not


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


39


the most important, by which malaria gets into the human system." His ideas are based on inquiries as to the origin of malaria sent to various doctors and laymen in the South ; the replies of these gentlemen are almost all of them in favor of the water-borne theory ; but the cases given are not described with sufficient detail to rule out typhoid in many instances, nor can infection through the air be eliminated, nor the possibility that the disease was acquired in some other locality than that where the patient was living when found sick. Many of the reports are founded on the disappearance of illness and fewer deaths in families when the supj)ly of water was changed ; the source of the drinking water often stood below the level of the houses and could easily have been polluted ; many cases of illness were said to be the result of drinking cistern water. The health of the people was improved by a change in position of a well, or from driving deep wells, and not depending on surface water for drinking purposes. Such evidence cannot be accepted as satisfactory proof of malaria being the result of drinking impure water. Cowan" reports a number of cases which he believes support the water-borne theory, but his ideas on the subject of malaria are so opposed to the exact knowledge we have at present in regard to that disease that his evidence may be fairly thrown aside as valueless. He says : " We shall, however, assert as true that the malignant types of malarial fever, and in fact almost all forms of malarial fever, are indebted to the water we drink, and not to atmospheric conditions, for the etiological factor in the transmission or rece^ition of the pathogenic material which produces malarial fever. ... In contradistinction, allow me to say that water in globule never produces malaria, but becomes an absorber and retainer of this pathogenic material, and may become loaded with this poison almost to saturation. Trees, wells, springs, creeks and branches may become so loaded with this poison that a single glass of water may contiiin pathogenic material sufficient to produce a case of intermittent fever. Without entering further into the manner of its formation or the power of water in globule to absorb or retain this pathogenic factor and disease producer, we will endeavor to give proof that the water we drink is the great factor and principal source of malarial fever in all its forms, but especially in the malignant types."

If the cases reported by Quine"' could be accepted without hesitation, their evidence might be looked upon as strongly in favor of the water-borne theory, but many of the facts given are so entirely contradictory of what has been proved as regards the effect of quinine on the malarial parasite that we cannot accept them — we feel sure that some mistake was made in the diagnosis. We quote the following cases in behalf of the stand we take :

Case 4. "Miss H., aged 16; has lived in Chicago many years in a good house and neighborhood. No excavations near. . April, 1894, she began to be sick gradually with a continued type of fever marked by irregular fluctuations, which was labeled by the attending physician. Dr. Samuel Cole, 'typhoid fever with malarial features.' The fever continued about four weeks, and then, after an .interval of normal temperature, lasting a few days, there was a relapse. The patient had taken


quinine freely from the beginning. Upon the basis of two examinations made by myself during the month of May, 1894, the diagnosis of the family physician was sustained. Later the blood of the patient was examined by Dr. F. S. Johnson and the fact of malarial infection, previously assumed to exist, was demonstrated. Quinine was administered with great freedom by the mouth, rectum and hypodermic method, and arsenic and iron were also pressed systematically, but without affecting the course of the disease. The patient was seen at this time by Dr. N. S. Davis. Her illness continued over four months, uninfluenced by treatment to an important extent, and finally came to be attended with acute pulmonary tulierculosis. Death occurred five or six weeks later. The blood of the jiatient crowded with plisiiwdin to the last." [The italics are mine.— K. N.]

Such resistance on the part of the plasmodia is unknown, especially when persisting in this manner for weeks. It is contrary to all the best evidence we have. Equally doubtful are the following cases reported by him.

Case 5. A girl with an alveolar abscess was thought to have contracted malaria in New York, or on her way to Chicago; but evidently the case was one of acute septica3mia, although Dr. Cole examined the patient's blood and found it stocked with malarial organisms: for "notwithstanding the administration of 40 to 60 grains daily [of quinine], and the fact that the patient was kept profoundly cinchonized, the chills and fever increased in frequency and severity. Some abscesses occurred in the site of subcutaneous injections. Malarial infection of the blood continued till the death of the patient."

Case 10. March, 1895. Woman with rlieuuuitic symptoms and erythematous nodes. "Examination cff the blood discovered small endoglobular bodies, and large amoeboid endoglobnlar bodies containing pigmented particles in active motion." "Under anti-malarial treatment the rheumatoid pains disappeared; the erythematous nodes continued, but were lessened in number; iut the chills and fever irerc not benefited." [Italics mine. — R. N.]

Case 13. A child 3 months old was supposed to have contracted malaria from a nurse. "An examination of her blood [the nurse's] showed malarial infection. Examination of the infant's blood revealed large and a few small endoglobular bodies." "No fever." [Italics mine. — E. N.]

In Case 10 the fact that " the chills and fever " were not benefited by quinine, if they were due to malaria, is incredible; and in Case 13 the statement that the child had " no fever," and yet its blood showed numerous malarial parasites, is also questionable. But the following remarks, quoted from his article, show that he does not agree with the best authorities on malaria. He says : " The proofs of water infection are quite as strong as those of air infection, and there is not a doubt that impure water is responsible for the occurrence of paludal disease with immensely greater frequency than is generally known. . . . Nor is the therapeutic test a reliable guide to diagnosis. . . . The entire absence of fever is a characteristic of many cases. . . . Quinine causes some symptoms to disappear, while others persist; and those showing periodicity may be the ones to persist." Such observations


40


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


and the doubtful proof of malaria in the cases he relates, minimize the value of the article.

Such is the evidence coming from American physicians, and certainly it is not sufficient to prove the water-borne theory. Let us now look at that offered by certain doctors in India; three papers by Boss,'" Rogers,^" and Hehir"' may furnish some further proof one way or the other. Ross believes that " malaria must be originally a disease among mosquitoes" (a view brought into more prominence by Manson), and says: "We may conjecture that infection may arise from the bite, or from deposition of the parasite by the mosquito on the skin of the patient or in his drinking water." Rogers brings no proof, but states : " In addition to the undoubted effect of drinking water in causing malarial fever, it is also universally admitted that perhaps an even commoner mode of entrance of the organism is through being inhaled into the lungs and so reaching the blood of the capillaries." In Hehir's article we find the following :

" Malaria is mixible with water. It is capable of being carried by currents of water through distances and periods of time altogether undetermined, without losing either its toxic effects or faculty of reproduction. It is possible that this means of conveyance has affected its distributions to continents and islands too widely separated to justify a belief that it was wind-wafted. No observations need be adduced to establish the water-borne habit of the malarial {poison, or the positive liability to its toxic effects, when received into the stomach throiTgh this medium. These facts have been well understood from the time of Hippocrates. The inhabitants of tracts of marshy country are pretty generally agreed that these waters may produce fevers."

He also thinks that milk left outdoors through the night in open pans may catch sufficient quantities of swamp poison to produce sickness, if exposed where malaria is rife. Daly \loc. cit.^ also thinks that milk may carry malarial infection, through the cans in which the milk is stored being infected by dirty water in washing them. The ancients may have believed that water could cause malaria, but we cannot accept their statement as proof, nor this one of Hehir's. This evidence which comes from India, where as yet the exact differentiation between typhoid fever and malaria is evidently not generally well understood, or where the discoveries of Laveran are not accepted (ex: Surg.-Gen. Laurie), adds nothing convincing to the water-borne theory.

In Germany malaria is not common, but much has been written on this disease by Germans who have studied it in foreign countries. Shellong,'" who wrote on the malarial fevers in New Guinea, does not believe in the water-borne theory. His is a careful study and his ideas deserve consideration. Steudel," also writing on foreign fevers, believes in the water-borne theory, and refers, like so many other authors, to Hirsch for confirmation. Hirsch's work, " Handbuch d. Historisch-geographischen Pathologic," was published, however, in 1860 and, though valuable as a reference book, cannot be accepted as an authority on malaria. Leonhardt," in a long and careful study, comes to the conclusion that malaria is not water-borne. He says those who believe it taken in with drinking water cannot prove this, because patients are subject


to infection by the atmosphere also. Two out of three Germans, we see, do not believe in the water-borne theory. Let us now review the beliefs of the French and Italian observers on this point.

Taking up the papers first whicli have appeared in French, we find articles by Verdan," Nicolas," Pepper," and Kelsch and Kiener." These contributions, like the German, are on malarial diseases as seen outside of France. The malarial fevers in Algiers are ascribed by Verdau to the water supply, which is very foul, and to effluvia carried by the winds. The work by Nicolas is a long one, but there is no proper differentiation made between typhoid, malaria and other forms of fever, so that his conclusions are not much to be relied upon. He believes stagnant water to be one of the main sources of origin of malarial fevers (" mais nous en savons assez deja pour nous convaincre que la stagnation de I'eau est necessaire pour engendrer la malaria"), but says little about drinking water. However, it may be surmised that he believes also in the waterborne theory, since the supplies of drinking water in the countries of which he writes are often stagnant. He recommends good, pure drinking water, and says, "en ce qui concerne la malaria la preuve semble faite: I'eau d'alimentation n'y est pour rien." But as regards typhoid fever he makes the following statement: "en realite rien n'est moins prouve que ces relations de causalite eutre I'eau et la fievre typhoide en particulier si savamment defendues par des observatenrs tres recommandables." Such statements diminish the value of his observations.

Pep25er, who like Verdau wrote on the fevers in Algiers, concludes his paper, which is not a brief one, with certain aphorisms, from which I quote the following :

1. "Dans une region malarienne, la malaria doniiae presque toute la pathologic."

2. "La malaria est, selon nous, raerotellurisme proteiforme."

3. "L'intoxication se produit durant Facte de la respiration et atteint principalement le systeme nerveux."

The first statement is very true, not only in Algiers but in many other countries, practitioners commonly attributing many maladies to malaria as a cause where malaria has actually no causal relation to the diseases in question. His third aphorism shows that he lays no special stress on water as producing malaria.

The final paper by Kelsch and Kiener is also against the water-borne theory. They believe infection is through the lungs, that this at least is the most common method. They think the water-borne theory is not confirmed by facts, and that the cases on the Argo do not support the theory. They say, however, that malaria may arise at sea, and relate one instance which furnishes no stronger proof than that of the Argo. Soldiers in Algeria, they note, who while marching drink foul water, are no more affected with fevers than when in camp using pure water. Towns on heights around the Roman C'ampagna are free of malaria, although their inhabitants drink water coming from malarious regions. This they bring forward as proof against the water-borne theory and say that foul water simply acts as a force to reduce the resistance of the body to morbid Influences.


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


41


" Professor Colin, of Val de Grace, who is so well known for his researches on intermittent fever, is inclined to question the production of paroxysmal fevers by marsh water. He cites numerous cases in Algiers and Italy where impure marsh water gave rise to indigestion, diarrhcea and dysentery, but in no case to intermittent fever, and in all his observations he had never met with an instance of such an origin of ague." (Sternberg: Malaria and Malarial Diseases, 1884.) According to these French observers, then, the weight of evidence is against the water-borne theory.

The observations made by Italian physicians are among the most interesting we have. Celli," one of the best students of malarial fever, has written a paper of great value on this subject. It is a short article going to prove that water does not transmit malaria. He gives a chart showing that introduction of new water supply into a certain city did not diminish the number of cases of malaria. He says popular ideas on this matter are fallacious, and notes that persons may live in a malarious place and drink pure water and yet have malaria, while others in the same place drinking foul or "paludal" water do not have malaria. He himself gave water from the Pontine Marshes, which are acknowledged to be very malarious, in large quantities to a certain number of patients who had never had malaria, without its giving birth to this disease in them. Similar evidence is furnished by Salomoue-Marino." He experimented in the' same manner as Celli, giving 5 to 24 litres daily of paludal water for from G to 24 days, and did not succeed in a single instance in producing malaria. He says that those cases of malaria which are suspected to have been caused by infection through the digestive tract are usually grave cases with short periods of incubation. He relates two such cases, which, as the blood was not examined iu either case, do not furnish proof of his statement. One patient was vei-y ill and took three weeks to recover (typhoid ?). Stagnant water is likely, he thinks, to contain poisonous or noxious bodies which could produce gastro-intestinal symptoms similar to those sometimes caused by malaria. Bonizzardi," without relating any cases, concludes one short article with a number of deductions, from which I take the two following: "Intermittent fever may be contracted as well by drinking water as by air," and "infection by air is far more fatal than by water." Moscato," who has also carefully studied the question of malarial fevers, states, without furnishing any proof, that drinking water as a source of infection has been noted daily by observers : " I'acqua potabile, come sorgente del velino palustre f u riconosciuta auche da Ippocrate ; quale verita e stata anche sanzionata dagli osservatori odierui." The statement has been made that malaria may be transported from one infected district to another healthy one by a new water supjjly, but the proof here is not sufficient, since the turning up of the soil for the pipes may have been the real cause. Most of the Italian observers, it is seen, are opposed to the water-borne theory.

Such is the evidence that exists for aud against this theory, and though we cannot say that malaria is never contracted from drinking water, yet the best proof is against this common belief. It is impossible to demonstrate that something never occurs, and we must be satisfied with showing that all the evidence that has been so far collected to confirm


the water-borne theory is not of sufficiently exact quality to carry much weight. To prove that malaria is water-borne in a given case demands conditions of a peculiar character: first the patient must never have had malaria, and must live and have lived in a district supposedly quite free of malaria; after drinking a certain supply of water and allowing for the proper period of incubation, the malarial parasite must be found in the patient's blood. In the meantime no soil should have been turned up in the patient's neighborhood, he should not have exposed himself to infection in any way, as by traveling into a malarious country, sleeping out at night, etc. Even if all these demands could be satisfactorily met, there would at the present time still be the proof lacking that the malarial parasite lived in the water. Outside of the human body, we know nothing of the life-history of this jiarasite. It may be discovered later and found to thrive in water, in which case the probability of frequent infection through drinking water would be strongly enhanced. But it may turn out that it does not live in water for any length of time, aud then the possibility of infection through this medium would be greatly diminished. All we can say is that no case among all those recorded as water-borne gives a positive finding of the malarial parasite in the blood, certainly one of the most necessary proofs to show that the patient really had malaria.

To confirm our view we have the definite knowledge that drinking water from malarial places does not produce the fever experimentally. And finally, it is probable that a large number of the cases attributed to malarial infection are not malaria, but rather typhoid, and if not the latter, then due to some auto-intoxication from the intestine. We know how many illnesses starting in with vomiting, headache, chills, diarrhcea, and even blood in the stools, sometimes rapidly ending in death, are due to poisonous articles of food ; why then should we not have similar attacks which do in a measure simulate malarial infection, where the most marked symptoms are intestinal, as a result of drinking foul waters, as one of the Italian physicians mentioned above suggests? This does not seem unlikely, and until we know more of the life-history of the malarial parasite outside of the human body it is fair to question the water-borne theory of malaria.

Much light may be thrown on this question iu the future by further study on the climatic and telluric conditions underlying the existence of malaria in different places; but as yet, though an enormous amount of study has beeu given to these very points, the results obtained by the observers do not agree altogether, and we are unable to form any definite conclusions which elucidate the life of this obscure parasite. Above all, in the study of this subject it is absolutely necessary that malaria and typhoid fever should not be confounded, as they have been so often in the past.

In conclusion I would simply add the two following paragraphs from Sternberg's Malaria and Malarial Diseases, which, though written in 1884, are as true to-day as then. He says : " It is well established that enteric fever and certain alvine fluxes may result from the use of contaminated drinking water. And in the case of the former disease, we know that even very great dilution does not destroy the infectious properties of the con


42


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


taminated water, e. g. in those cases where it has been used to wash vessels in which milk was placed, aud in which typhoid fever has resulted from drinking this.

"That fevers having an intermittent or remittent character may also be produced in the same way cannot be doubted. But we have already seen, in the introduction to the present volume, that enteric fever frequently presents these characters; that in this case the differential diagnosis from malarial fevers presents great difficulties, and that in many parts of the world fevers of this character are attributed, without question, to malaria. We therefore feel inclined to accept the evidence with a great deal of caution. Moreover, we think that considerable weight should be accorded to the negative evidence. It Avould seem that if this mode of infection occurs at all, it should occur frequently, and in that case that it would be more generally recognized. From what has been said in the introduction, it will be seen that we cannot accept evidence relating to the iiroductiou of ' nuilarial diarrhoea,' or ' malarial dysentery,' or ' mountain fever,' or ' continued remittent fever,' or ' typho-malarial fever' in any of its forms."

Bibliography.

1. Chapin, C. V. : " The Origin and Progress of the Malarial Fevers now prevalent in New England." 1884. Fiske Fund Prize Dissertation No. 32.

2. Griswold, R. W. : " On the Epidemic of Malarial Fevers at present prevalent in Southwestern New England. Historical and Etiological." Gaillard's M. J., New York, 1885.

3. Baker, 0. : " Malaria on Shipboard." Brit. M. J., 1893.

4. Greeuleaf, K. AV.: "The Charles River in its Relation to the Etiology of Intermittent Fever." Boston M. and S. J., Vol. CXXX, 1891.

5. Green, J. S. : "The Appearance of Intermittent Fever near the Neponset River." Boston M. and S. J., 1887.

6. Kershner, E.: " Is Malaria a Water-borne Disease?" N. Y. Med. Rec, 1895.

7. Zwisohn, L. W. : " Is Malaria a Water-borne Disease ?" N. Y. Med. Rec, 1895.

8. West, G. H.: "Good Drinking Water vs. Malaria." North Carolina M. J., Wilmington, 1895.

9. Waggener, R. : " Drinkiug Water — a Source of Malaria." New Orleans M. and S. J., 1891-92.

10. Hylaud, C. S. : "Water a Source of Malarial Fever." New Orleans M. and S. J., 1893-94.

11. Daly, W. H. : "Some Practical Observations on socalled Malaria being a Water-borne Disease." N. Y. Med. Rec, 1894.

12. Norbury, F. P. : " Is Malaria a Water-borne Disease ?" N. Y. Med. Rec, 1894.

13. Jones, .J. J.,: "Is Malaria a Water-borne Disease?" N. Y. Med. Rec, 1894.

14. Cadwallader, R. : " Malaria and Drinking Water." N. Y. Med. Rec, 1894.

15. Newton, R. C. : "Some Observations which appear to establish the Aerial Transportation of Malarial Germs." Internat. M. Mag., Phila., 1895-9G.

16. Lewis, R. II.: "Drinking Water in its Relation to Malarial Diseases." The Sanitarian, Brooklyn, 1894.


17. Cowan, .1. B. : "Water vs. Atmosphere — the Cause of Malignant Malarial Fevers." Nashville .J. of M. and S., 1896.

18. Quine, W. E. : "The Malarial Disorders of Large Cities with especial reference to Chicago." J. of the Amer. Med. Assoc, 1895.

19. Ross, R. : "Some Practical Points respecting the Malarial Parasite." Indian Med. Gaz., Calcutta, 189G.

20. Rogers, L. : " The Etiology of Malarial Fever, with Special Reference to the Ground-water Level and the Parasite." Indian Med. Gaz., Calcutta, L896.

21. Ilehir, P.: "An Inquiry regarding Drinking Water in Relation to Malaria." The Indian Med. Chirurg. Review, 1895.

22. Shcllong, 0. : " Die Malaria-Krankheiten, etc." Berlin, 1890.

23. Steudel, B. : "Die Perniciose Malaria in Deutsch Ost. Africa." Leipzig, 1894.

24. Leonhardt : " Entstehung und Wesen d. Malaria Erkrankungen, etc" Zeitschrift fiir kliu. Med., Berlin, 188586.

25. Verdan: "Considerations sur la fievre intermittente a Ouargla, etc." Archives de Medecine et de Pharmacia militaires, Paris, 1885.

26. Nicolas, Ad. : " Chantiers de terrassements en pays paludeen." Paris, 1889.

27. Pepper, E. : "De la malaria." Paris, 1891.

28. Kelsch and Kiener: "Le poison palustre." Ann. d'llyg., Paris, 1888.

29. Celli, A.: "Acqua potabile e uuilaria." Gior. d. Soc. Ital. d'Eg. Milano, 1886.

30. Salomone-Marino, S. : "L'acqua die luoghi malarice porta infezione ?" Sicilia Med. Palermo, 1891.

31. Bouizzardi, T.: " Sulle Risaie." Salute Pubb. Perugia, 189L

32. Moscato, P.: "Etiologia e cura della malaria." II Morgagni. Milano, 1893.

33. Hurley, J. M. : " Pacific M. J., San Francisco, 1895.

34. Boudin, J. C. M. : "Traite des fievres intermittentes, etc." Paris, 1842.

DlSCUSSIOIi^.

Dr. Welch. — It is clear from Dr. Norton's careful analysis of the existing evidence for and against the water-borne theory of malaria, that the weight of evidence aud of authority is decidedly opposed to this theory. It is curious how prevalent is the belief in this theory among both the general public and practitioners of medicine, especially in the southern part of this country. As a matter of fact, the only infectious diseases whose germs we have good reason to believe to be conveyed by drinking water, are typhoid fever, Asiatic cholera, and dysentery. To this meagre list may be added indefinite gastro-enteric disturbances resulting from infection or intoxication from drinking water. The numerous claims that various other infectious diseases, including malaria, may result from infection through the drinking water, do not rest at present upon any substantial basis of demonstrated facts, altliougli it must be ailmitted that some of these claims have not been positively disproved. The criticism of the drinkingwater theory of malaria by Celli and Leri, aud above all their


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


43


couvinciug experimeutal iuvestigatious of this riiiestion, iadicate decidedly that drinking water is not a carrier of the malarial organism in a condition capable of producing infection through the alimentary canal underany ordinary conditions. There seem to me to be at present only two theories of the mode of malarial infection which deserve serious consideration, viz. the theory that infection occurs through the air, and the theory that infection is the result of inoculation with the malarial jjarasite through the agency of mosquitoes and perhaps other suctorial 

insects. The question whether or not the malarial parasite

may live and jjerhaps multiply in water would of course not be decided by the exclusion of water as a vehicle of infection, for it is possible, even probable from experiments, that infection with the malarial parasite does not occur from the intact alimentary canal, and the mucous membranes of this canal would be the only natural portal of entry for infectious agents in drinking water. The majority of authoritative writers on malaria have advocated the theory of air-borne infection, but we shall probably, since Hanson's publication, hear more and more of the inoculation theory.

Dr. Reed. — Dr. Norton has kindly referred to a report which I made to the Surgeon-General during August last, upon the etiology of malarial fevers at Washington Barracks and Fort Myer, during a period extending over twenty-six years. Washington Barracks is situated in the midst of marshy lands at an elevation of not more than twenty feet above the Potomac river, and upon soil deposited from this rivei". The post has had but one supply of water, viz. Potomac river water. During this time malarial fevers have prevailed to a greater or less extent, certain years being exceedingly severe and others comparatively light. I compared the malarial curve of that station with that of Fort Myer, wlMch is 240 feet above the Potomac and on high ground. I was sui'prised to find such a close agreement between the two. Indeed, in the last eleven years of this investigation the lines ran accurately together. If the line at Washington Barracks fell below that of Fort Myer, it was accounted for by the fact that the garrison had been sent into summer camp during the malarial season. In investigating the water supply at Fort Myer, I ascertained that until 1886 pure spring water had been furnished. During the latter year certain wells were sunk in low marshy soil, from which the garrison was supplied until 1894. It was curious to note that the supply of " marshy water," which was so much condemned by the various medical officers, did not increase the malarial cases; but that, on the contrary, during the six years immediately following the introduction of this supply, the disease was less prevalent than at any other jjcriod in the history of the post. In 1894, wells were discontinued and Potomac


water introduced. Filters were placed in the men's quarters and, in addition, the filtered water which the officers drank was boiled. Notwithstanding these precautions, the sick-rate from malarial diseases was higher in 1895 than during the previous twenty-three years, and corresponded accurately with the rate at Washington Barracks. All of which proved to my miud that the water supply had nothing to do with the prevalence of malarial diseases, and that their etiology was to be found in the low marshy lands lying along the Potomac river.

Dr. Tn.iTER. — Certainly all experimeutal evidence points directly against the idea that malarial fever can be conveyed by drinking water, and more than that against the idea of an infection through the alimentary tract. Grassi and FeTetti fed patients upon the dew collected from malarious districts, and further upon fresh blood taken from patients suffering from malarial fever, blood which, as is well known, if introduced hypodermically or intravenously, always results in a transference of the infection, without any positive result. Despite the fact that the patients on whom these experiments were made were often debilitated individuals suffering from chronic nervous diseases, etc., yet as they were, in almost all instances, in hospitals or in situations where they were well fed and well cared for, it would be impossible to entirely refute the critic who might suggest that it was the good surroundings which saved the patients from a progressive infection which otherwise would have occurred. Such a critic might suggest that had these individuals been suffering from distinct gastro-iutestinal lesions, infection would readily have occurred. In connection with this possibility it is interesting that out of 4G cases of amosbic dysentery which we have had in the Johns Hopkins Hospital, 5, or nearly 11 per cent, have suffered at the same time from malarial infection. May it be possible that the amcebic ulcers were in these instances the portals of entry for the malarial parasite ? It must of course be said, upon the other hand, that most of these instances of amoebic dysentery occurred during the malarial season and came from districts where the malarial parasite is doubtless endemic.

Dr. Norton's quotation from the author who thought he had found a large number of endoglobular, hyaline parasites in infant's blood is interesting, inasmuch as any observer who is familiar with examinations of fresh blood will immediately see how the author quoted has deceived himself. The vacuoliclike figures found particularly in the blood of children or infants who are auffimic or suffering from fever of any sort, simulate often very closely the malarial parasite, and always deceive the uninitiated ; to the skilled observer, iiowever, they are readily recognizable.


JOIJRl^ALS, ETC., ISSUED BY THE JOHNS HOPKINS PRESS OF BALTIMORE.


American Journal of Mathematics. S. Newcomb and T, Craig, Editors. Quarterl}'. 4to. Vol. XVIII in progress. $5 per volume.

iiinerican Chemical Journal. I. Kemsen, Editor. 10 Nos. yearly. 8vo. Vol. XVIll in progress. 14 per volume.

American Journal of Philology. B. L. Gilderslekve, Editor. Quarterly. 8vo. Vol. XVII in progress. $3 per volume.

Studies from the Biological Laboratory. Svo. Vol. V complete. $5 per volume.

Studies in Historical and Political Science. H. B. Adams, Editor. Monthly. Svo. Vol. XV in progress. $3 per volume.

Johns Hopkins Hospital Bulletin. Mouthly. 4to. Vol. VIII in progress. $1 per year.


Johns Hopkins Hospital Keports. 4to. Vol. VI iu progress. $5 per

volume. Johns Hoplilns University Circulars. Containing reports oC ecientiflc

and literary work in progress in llaltiinore. 4to. Vol. XV in progress.

$1 per year. Memoirs from the Biological Laboratory. W. K. Hhgoks, Editor. Vol.

incomplete. It7..')0 per volume. Annual Heporc of ihe Johns Hopkins University. Tlie Annuiil Report

of the PrcsidiTit to the liourd of Trustees. The Annual Register ot the Johns Hopkins Universiiy. Giving the

list of ollieers jinil students, and .statinj.- t he regulations, etc., of the University. Published at the end of the Academic year.


44


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


THE RADICAL CURE OF HERNIA BY IMPLANTING A SECTION OF STERILIZED SPONGE.

By W. B. Platt, F. K. C. S. (Eng.) [Ueud before the Johns Hopkins Medical Society, January 4, 1897.]


The radical cure of hernia has long enlisted the attention of surgeons, and a method which is efficient, safe, reasonably simple, sacrificing no important part or function, causing little inconvenience and demanding but a short confinement to bed, has been eagerly sought. To simplify matters, the older surgeons cut the Gordian knot by removing the testicle and cord of the affected side. The presence of the cord at the end of a shallow funnel seemed to be the obstacle to the complete closure of the inguinal canal and rings, the pressure of the intestines acting as a wedge to keep them open.

To remove the cord by transplanting it to another location was the next step of the modern surgeon, and an efficient means of cure. The hernia oftener failed to return than by other methods. Certain drawbacks in this procedure are often noted, such as prolonged confinement to bed and great swelling of the testicle, so great in fact as to throw some doubt upon the future function of that organ, while very large incisions in the abdominal wall, a long cicatrix, a multitude of buried sutures, made the opei'ation more complicated to the surgeon and less agreeable in the end to the patient.

The writer has endeavored to efficiently close the inguinal rings and canal by a more simple procedure, and this can be done. The cases are all too recent to prove the permanency of the cure. He can only say that two cases of intractable hernia have been up and about for several months, and have never worn any truss or support of any kind since getting out of bed.

The idea of implanting a section of sponge in the inguinal canal which should form a firm connective tissue barrier to the descent of the hernia, occurred to the writer while experimenting upon rabbits in the Physiological Laboratory of the Johns Hopkins University in the spring of 1882, and observing the normal retraction of the testicle into the abdominal cavity in these animals.

As inguinal hernias are not readily produced in animals of this kind, I endeavored to so implant a piece of sponge within the inguinal canal as to retain the testicle in the scrotal pouch. The aseptic technique of that day was so imperfect that suppuration ensued and the sponge came out.

Later, I operated on a number of patients at the Garrett Hospital for Children, by simply removing the sac, suturing the conjoined tendon to Poupart's ligament, and sewing up the inguinal canal.

This succeeded very well in most cases. I have one of these cases here to-night, done five years ago. He has had no return of the hernia and wears no support or truss. The return of the hernia, however, in a case where I had every reason to hope for a permanent cure, led me to try the implantation of a section of sterilized sponge. The result certainly proved one thing, viz. that a piece of sterilized sponge as large as half a dollar could be introduced beneath the internal ring and remain there without causing any irritation, the wound healing over it and remaining healed.


Before this healing took place there was in my first case a small sinus at the upper part of the incision and I feared it might be due to the sponge. It turned out to be due to sutures, and these being removed, the wound healed without further trouble, but after five months the hernia came down. I operated upon this patient a second time, intending to insert a second piece of sponge. To my surprise I found an opening less than one-fourth of an inch in diameter in the location of the external ring. I inserted two small sutures, the wound healing promptly over them. The sponge in this first case was simjily laid beneath the ring.

In the succeeding three cases the section of sponge was secured to the cord. One description of the operation will suffice for these cases.

An incision about two and one-half inches long is made directly over the inguinal canal, following its course, the lower end extending about half an inch uj)on the scrotum. If the hernia is down, the operation is so much the easier. The canal is laid freely open. The sac, whether congenital or acquired, is opened in its entire length, the hernial contents reduced, and the sac cut away close to the internal ring, if congenital, while if it is an acquired sac it is cut square oflf after being ligated as high up as possible, and dropped beneath the ring. In the case of the congenital sac it is often necessary to leave the thin inferior \ajev in siiu and adherent to the cord.

Next, a section of fine, firm, surgical sponge is cut about one and one-half inches in diameter and one-eighth of an inch in thickness. This is sterilized without boiling, by immersion in soda solution, washed in sterilized water, treated with permanganate of potash and oxalic acid, and thoroughly washed in sterile normal saline solution. A radial cut is made in the section. The constituents of the cord are gathered together as high up as possible and placed in the center of the section and at a right augle to it. The edges of the cut in the sponge are now slightly overlapped, and two sutures inserted in the sponge to keep it in place on the cord which now pierces its centei-. The sponge section is spread out beneath the internal ring, and the conjoined tendon sewed firmly by two or more qiiilted sutures to Poupart's ligament, using a needle in a handle.

The inguinal canal is now snugly sewed up with silk sutures, and over all the skin sewed with silk-worm gut. It is absolutely necessary to use some kind of drainage in the upper augle of the wound, as there is invariably some serous oozing and swelling. This may be removed after 2-J: hours.

The patient is confined to bed and on his back for three weeks. If the patient is a boy it is well to use the Bradford frame, to keep him from sitting up and twisting about in bed. The skin sutures are removed on the 9th or 10th day, the wouud being treated on ordinary aseptic principles.

After three weeks the patient is allowed to sit up in bed a day or two, then sits for two or three days in a chair, after


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


45


which he goes about as usual. It is unnecessary to use any support over tlie site of the operation beyond a light strip of gaxize to protect the fresh cicatrix from friction.

In two of these cases where I was obliged to remove the deep silk-worm gut sutures before the patient left the hospital in order to close an obstinate little sinus in the upper angle of the wound, the hernia returned, as might have been expected. The trouble with these sutures may have been due to too great tension, or to a defect in the sterilization of the sutures. In none of the four cases was there any trouble from the sponge. In the two cases mentioned the wound healed promptly on removing the offending sutures. In the two other cases there was no difficulty whatever in securing complete permanent first-intention union, and there has been thus far no return of the hernia.

It is of course premature to say that there may never be a return of the hernia, nor do I know the ultimate fate of the sponge, whether it remains as organized tissue or whether it is absorbed.

From its open structure and the ease with which it is retained in the tissues it is not improbable that blood-vessels pass into it, and that it makes a framework for connective tissue, a close imitation of that barrier which nature places beneath all normal, internal, inguinal rings and which prevents every male from being a subject of hernia.

It is hardly necessary to say that the greatest care must be exercised in the perfect preparation of the sponge section to insure perfect sterilization. I have the pleasure of showing three of the four sponge cases ; also one of the older cases, where the rings were simply sewed up and no sponge section used.

Abstract of Gases.

All the following cases were operated ujion at the Garrett Hospital for Children, Baltimore.

1) G. L., set. 4. Complete inguinal hernia, right side, developed at two years of age, and is not kept up by trusses. Operation August 21, 1895. One deep suture causing a small sinus was removed 55 days after operation. Patient was discharged from the hospital, October 23, 1895, with the wound entirely healed. It has never since reopened. Hernia reappeared 5 months after operation. The return of the hernia doubtless due to the early removal of the suture closing the internal ring.

2) S. J., set. 8 years. Complete inguinal hernia, right side. Hernia developed when 2 years old. No truss effectually keeps up hernia. Admitted June 9, 1896. Operation June 17, 1896. Congenital variety of sac. Patient was walking about July 20, 1896. Discharged with the wound entirely healed, August 7, 1896. There has been no return of the hernia at the date of this paper.

3) T. W., aet. 12 years. Acquired inguinal hernia, right side. Kuptured since 2 to 3 years of age, and has been kept up with difficulty. Admitted to hospital August 4, 1896. Operation August 19, 1896. Out of bed September 18th. Walking about September 23. Discharged well with wound healed September 25, 1896. Patient is a student at the McDonogh Institute. There has been no return of the hernia up to the date of this paper.


4) G. M., Eet. 5 years. Complete inguinal hernia, leftside. Hernia appeared at 3 years of age. Trusses do not retain the hernia. Admitted to hospital August 18, 1896. Operation August 26. The wound healed at first. After about a week a small sinus appeared at the upper angle of the incision. This persisted, until on December 10th two deep sutures were removed, after which the wound promptly healed, and patient was discharged well with wound healed, December 24, 1896. Patient was seen January 1, 1897, when the hernia had begun to return, as evidenced by an elastic bulging tumor at the seat of the internal ring.

Notes.

In Oases 1 and 4, where the hernia returned, it is clear that the soft tissues of the recent operation were subjected to undue strain by the early removal of the most important sutures concerned in the operation, viz. those binding the conjoined tendon to Poupart's ligament. In all four cases the sponge remained without causing any irritation, the incision healing in each case.

I have not had an opportunity in any case to discover the actual condition of the implanted sponge after the lapse of time.

If sponge will thus heal in the depth of a wound, there is no reason why mats of silk or of other animal tissue might not also be used, and sutured firmly in place to close the openings of exit for heruiaj.

It is not impossible that the addition of these animal tissue barriers may be the element necessary to make the former operation of suturing the rings and canal without transplanting the cord, a success in the very great majority of cases.

In no case was any supjiort worn after the patient got out of bed, and in all cases the hernia was operated on because of the intractable nature of the hernia, no truss or support keeping the hernial contents in the abdomen, with the exception of No. 3, where a truss proved so great an annoyance that his family desired operation.

Discussion.

Dr. Bloodgood. — I cannot say from observation whether the scar tissue formed with the sponge is any stronger than that formed without it. A study of the statistics of operations for hernia will show that sometimes very simple operations will cure hernia in children. In looking over the cases of different operations, such as MacKewen's, Banks' and others, we find very few recurrences in children. We have found it so here, even in the cases where the wound suppurated and healed by granulation. It is interesting to know tliat a foreign body can be implanted in the tissues without giving rise to any trouble. Our observations here have caused us to think that silk sutures are more apt to cause suppuration than silver wire, and that the ideal suture would be an absorbable one.

It is unfortunate that Dr. Piatt has not had an opportunity to operate upon a recurrence in order to see what becomes of the sponge. I would ask him if he thinks the sponge remains permanently and if he has any observations to show that the scar tissue about the sponge is any firmer than ordinary scar tissue.


46


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


Dr. Platt. — I have not yet had a chance to learn the ultimate fate of the sponge, but I think I shall determine it in the case of this boy whose hernia has returned. I have been surprised that his hernia has not returned sooner, for when I was obliged to remove the deep sutures to close the sinus I expected that it would soon recur.

My belief is that the sponge becomes incorporated into the tissues by aid of leucocytes and the blood-vessels which enter its meshes from the adjacent structures, and that when their work is done these probably atrophy, leaving scar-connective


tissue. Whether it is stronger and thicker than other scar tissue I do not know, but will take the first opportunity to find out. After the ordinary Banks operation a funnel opening is left, and the cord acts as a guide to further the descent of hernia. I^Iy idea is that by putting in the sponge j-ou obviated perhaps the last fault in the stitching operation, and thus get on without trausplauting the cord. It is, of course, too soon to draw conclusions as to the final result from these four cases. I shall report again after operating upon this patient.


ADDITIONAL OASES OF DERMATITIS DUE TO THE x RAYS

By T. C. Gilchrist, M. R. C. S., L. S. A.


During the time which intervened between the correction of the proofs of my article on "A Case of Dermatitis due to x Rays " and its publication, there have appeared in the literature a number of quite recent cases which have come under my notice and which could not be incorporated in my paper {vide Johns Hopkins Bulletin, February, 1897). I therefore add five more cases which have been recorded in various journals. Dr. Reid's case is of particular interest because a cutaneous lesion was not only produced on the anterior surface of the chest which was exposed to the rays, but


also on the posterior aspect of the chest and on an area which he thinks corresponded to the exit of the rays.

Literature. W. Downe: Lancet. 1896. Vol.11, p. 1049. (Abstract.) Sewell : Lancet. 1896. Vol. II, p. 1049. (Abstract.) W. Reid: Brit. Med. Journal. 1896. Vol. II, p. 1744. A. B. Kibbe: New York Medical Journal. January 16,

1897. Vol. LXV. No. 3.

M. Rendu : New York Med. Journal. February 20, 1897.

(Abstract from Progres Medicale. January 30, 1897.)


Dr. W. Downe.


Eruption appeared 10 days after exposure.


Distribution.


Back of neck and scalp.


Character of Lesions.


Extensive vesication on the back of the neck. The hair fell out over occiput, but the skin remained normal.


Subjective Symptoms.


At first a sense of


pricking heat. given.


No further observations


Dr. Sewell exhibited a similar case at the same society meeting. (See references.)


Dr. W. Reid (personal).


Dr. A. B. Kibbe.


Dr. M. Rendu.


Eruption appeared in the evening of the same day. Two exposures, varying from 20-90 minutes.

20 exposures from l/i-b minutes of left hand, and 3 exposures of elhow. Eruption appeared in a day or two.


Rays applied daily for 55 minutes.


Chest and abdomen.


Both hands and elbow.


First an erythema, followed by papules, and later by exfoliation of the epidermis, which exposed a raw, painful, weeping surface 16 days after exposure.

First a slight tingling, then a sense of irritation and itching; 10 days later extensive discoloration round elbow. No vesicles appeared.


After first application of rays intense erythema appeared, followed by vesicles and later by an eschar which did not heal for several weeks.


Painful after trie weej)ing surface was formed.


At first tingling followed by itching ; but there wasnosensitiveness or pain.


10-inch coil was used 3 inches from the skin.


Arm was covered by the usual clothing, viz. heavy woolen clothin<.' and coat sleeve. Portion of the skin was excised from forearm for histological examination.


THE MALARIAL FEVERS OF BALTIMORE.

An Analysis of 6i6 cases of Malarial Fever, with Special Reference to the

Relations existing between different Types of Haematozoa

and different Types of Fever.

By William Sidney Thayer, M.D., and John Hewetson, M. D., ABSisUints in the Medical Clinic of The Johns I/opktns VoBpital.

218 pages, qiiarlo, with platen and charts. I'rice ItiS.OO, Postage paid.

[Forming part of Tlie Johns Hophliis Ilospltal ileports. Vol. V, 1895.] Orders should bo addressed to TnK Johns Hopkins Phkss, Hai.timohk, Mu.


THE JOHNS HOPKINS HOSPITAL BULLETIN,

Volume VIII.

The Bulletin ot the .Tolms HnpUlus Hospital entered upon Its eighth volume laiumryl, 1897. It contAlus original communications relating to medical, surgical and gyuocologlcal topics, reports of dispensary iiracltce, reports from the pathological, anatomical, physlologlco-chemlcal, pharmacological and clinical laboracorle.-i, abstracts of papers road before, and of discussions In the various societies connected with the Huspllal, reports of lectures and other matters of general Interest In the work ot the Johns Hopkins Hospital and the Johns Hopkins Medical School.

The subscription price la $1.00 por year. Volume VII. bound In cloth. $1.50.


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


47


PROCEEDINGS OF SOCIETIES.


THE JOFINS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of October 19, 1896.

Dr. Thayer in the Chair.

Rarer Cases of and Observation on Strcptococcns Infection.

— Dr. Bloodgood.

Case I. — Tliefirskcase isof especial interest because the patient recovered, although on two occasions pure cultures of the streptococcus were obtained from the blood by aspiration of a vein in the arm. In the records of the liospital only one other such observation had been made— that of Dr. Blumer, in a case of broncho-pneumonia.

In all other cases of streptococcus infection which have recovered, from which blood cultures have been taken, negative results have been obtained.

This case also presents the rare condition of a streptococcus infection of the finger, with an abscess situated between thepectoral muscles, but no evidence of any enlargement of the glands in the axilla. The abscess was distinctly localized and no other abscesses developed.

The patient presented to you to-night was admitted into the hospital, January 28, 1896. A history could not be obtained, as the patient spoke only Polish. He appeared about 25 years of age, strong and well nourished. There were two healed wounds covered with a dry scab on the index and middle fingers of the left hand. The fingers and entire arm presented no evidence of inflammation. The axilla was soft and not tender. The skin over the upper part of the chest was slightly red and (Edematous. The greater pectoral muscle was more prominent, and beneath it there seemed to be a fluctuating swelling. The aspirating needle withdrew some thin purulent material. Examination of coverslips demonstrated polymorjAous leucocytes and cocci in short and long chains. Thei'ectal temperature registered 104°, pulse 80, respiration 24.

An incision was made through the skin and through the greater pectoral muscle in the direction of its fibres, opening a large localized abscess.

Cultures from this abscess and from the blood taken from a vein in the opposite forearm contained in 48 hours numerous colonies of streptococci. Two days later blood cultures also showed colonies of streptococcus ; three observations after the fifth day were negative.

The patient had fever for IG days, the rise of temperature being from 101° to 104° and frequently 105°. Recovery followed. The wound healed and there was no loss of function of the muscles.

The early diagnosis of fluctuation, due to fluid beneath a large muscle, is a very difficult one. The muscle itself, when relaxed, gives to the fingers a sensation of fluctuation. For this reason in this case the aspirating needle was used to confirm the diagnosis of a deep abscess.

Omo II. — The second case presented to-night is of interest becauseof the very high temperature — 106.5° rectal — which was associated with the beginning of an attack of erysipelas of the neck and face. The patient recovered. Five weeks before the attack of erysipelas a large mass of suppurating and adherent


glands had been removed from the neck. The wound had healed with the exception of the small granulating area. The patient had been walking about for two or three weeks, with no rise of temperature. There were no cases of erysipelas in the wards. The attack began with a chill, and a temperature of 106.5°, taken one hour after the chill. Coverslips made from the granulating area showed cocci in long chains. No erythema could be seen. The patient was a colored man and only very deep redness can be made out. He was immediately transferred to the isolating ward and given a bath for 30 minutes, the temperature of the water being 70° F. The fever was reduced to 103° and did not rise above 104.6° afterwards. Later the skin of the neck and face became very red and oedematous; no abscesses formed. Coverslip and ciilture demonstrated streptococcus. Two blood cultures were negative.

The only treatment followed was cold sponging and local application of cold cloths to the neck and face.

During the last two years we have made a great number of coverslip examinations from the surfaces of granulating wounds, and also from cases in which there has been an attack of erysipelas. In almost every case in which there has been an infection of tlie streptococcus of erysipelas we have demonstrated in the coverslips taken from the granulating wound cocci in short and long chains, and in every case cultures and the clinical course have demonstrated the infection to have been due to the streptococcus. In thercoverslips from healthy granulating wounds we have never found .' r "occi in chains. But only a few were studied also by cultun > i '•(> few, only

staphylococci grew. These observations \\^" \i-w\ \.t.\\' llic early diagnosis of erysipelas.

Death from streptococcus infection has Dei,n a verv rare event. These organisms do not seem to have with us uL. virulence which in former years they must have had. In reading Billroth's and others of the older surgeries one is impressed with the large death rate from erysipelas and streptococcus infection of wounds.

There have been two interesting observations, in both of which, although the skin over a large area, including the lines of incision, was the seat of a very intense erysipelas, yet the healing of the wound was not interfered with. Both patients recovered.

The first patient was an old man, from whom a V-shaped piece had been removed from the lower lip for epithelioma, and the entire chain of glands beneath both sides of the jaw excised. Both wounds were closed. An attack of erysipelas began on the second day, starting from the lip and extending over the entire face and neck. The lines of incision healed per primani, and there was no deep suppuration.

The second case was a boy, from whom a large mass of inflamed glands had been excised from the axilla. The mass was very large and very adherent to the vein. Both pectoral muscles were divided to aid in the. complete removal. During the dissection along the vein a small abscess cavity was opened, infecting the wound. The wound was irrigated with j-jViy bichloride, the pectoral muscles sutured and the skin closed. Cultures from the glands demonstrated strejitococcus. The


48


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


adenitis followed an infection of the' finger. 24 hours after the operation an attack of erysipelas set in, beginning in the line of the incision. The erythema covered part of the chest and neclv. Coverslips and cultures from a small opening in the line of the incision demonstrated streptococci. The patient recovered ; there was no suppuration of the closed wound ; there was no impairment of the use of the pectoral muscles.

These two cases demonstrate that the skin over a closed wound may be the seat of erysipelas and yet the healing of the deep wound may not be interfered with.

Dr. Flexner. — The case reported by Dr. Bloodgood is of much interest from a theoretical as tvell as a practical standpoint. Experiments upon animals have led us to consider that the invasion of the blood by pathogenic bacteria, capable of setting up actual septicaemias, takes place a short time only before death, and in the great majority of instances, if not in all, presages a fatal termination. Flugge pointed out that in anthrax infection in the rabbit the bactericidal effect of the blood-serum is lost before this micro-organism is found in the larger blood-vessels. In pueumococcus infection in the same animal the blood invasion occurs a short time only before death.

Now since cultures are so readily made from the circulating blood of human beings we may expect important contributions to our knowledge of the occurrence of pathogenic bacteria in this fluid, and also of the capacity of the human organism to resist and overcome these parasites when they have once entered the blood and perhaps even increased there.

The elimination of the primary focus of infection must be of the greatest importance in these cases, for it is certainly probable thut from this site where the parasites are rapidly increasing not a single infection occurs, but a succession of invasions of the blood takes place. Perhaps after all, where recovery occurs, the power of the body fluids and cells to dispose of considerable numbers of the pyogenic cocci is not actually lost, and those present in the blood have entered from without and temporarily, at least, have not increased in the circulating blood. Under these circumstances the removal of the primary focus of infection before the bactericidal effect is lost, would in all probability determine the issue of the case.

We are told by Baumgarteu and by Stern that one does not meet in human beings examples of septicremia comparable to those seen in some of the lower animals. I think there is reason to doubt these statements, for we have seen at autopsy cases of streptococcus and staphylococcus infection in which the blood was crowded with the organisms and wide-spread capillary thrombi of cocci existed in the internal organs.

Much discrepancy has been noted by writers upon the subject of the virulence of streptococci obtained from severe infectious processes in human beings. The results of the cultivation experiments of Marmorek seem to give the explanation of the variations observed. It is an old observation that a minute quantity of the fluid containing streptococci from the inflamed peritoneum might show great virulence and set up a severe and perhaps fatal infection, while the cultures from this source may be quite without pathogenic effects. Marmorek has made it probable that the difference depends upon


the unfitness of artificial culture media for preserving the virulence of the streptococcus pyogenes. Through the use of human blood serum as a medium of cultivation he succeeded not alone in retaining the virulence of these micro-organisms for a time, but actually of increasing it, by successive passages through the bodies of animals and recultivation, to a remarkable degree. Finally it is no criterion of the vitality of streptococcei to test them upon artificial media, for Marmorek has also shown that cultures apparently dead are still capable of growth when transplanted to his blood serum medium.

Ophtlialmoplefjia Externa.— Dr. H. Woods.

On taking charge of the Presbyterian Eye, Ear and Throat Hospital in September, 1895, I found in the ward, D. 0., 73 years of age, under treatment for corneal ulcer of the left eye. This, I was told by my friend and associate. Dr. F. M. Ghisolm, had followed an operation performed by him during his service in August, for complete left ptosis. A slight iritis developed after he came under my care, but from this as well as from the ulcer he made a good recovery. Corneal ojjacity is peripheral, and a few pigment pin-point stains are on the capsule. The right eye is centrally blind from choroidal atrophy, but has eccentric vision. It was discovered during this visit to the Hospital that the extrinsic eye muscles were paralyzed. The paralysis is not absolute, for both eyes can move perceptibly up, down and laterally. He left the Hospital before the corneal ulcer was completely healed, returning in March, 189G. He gives the following history:

Prior to 1801, when he enlisted in the Federal army, he had good sight. He claims to have undergone medical examination at Williamsport, Pa., before enlistment. This is important, for the " Surgeon's Certificate of Disability for Discharge," which I have obtained from Washington, is as follows: "The injury to the eyes of said soldier was caused by over-exertion in lifting heavy timber in the year 1857." Signed by Captain.

The Brigade Surgeon's certificate is : " This is a case of ptosis; but having a suspicion that the loss of vision is feigned, the subject is respectfully referred to the Medical Director for decision." The discharge was approved by the Board of Inspectors. This bears date of February 15, 1862. It appears, then, that the only testimony of trouble before enlistment comes from the captain of his company. Against this there are the patient's statement, the nature of the trouble as given by the Brigade Surgeon — -ptosis, and the somewhat weighty improbability of a man with double ptosis being enlisted.

To return to the history, as given by the patient. In November, 1861, while marching rapidly early in the morning, he fell, with a number of others, into a stream and was thoroughly drenched. Within an hour afterwards both eyes were closed. He was unable to raise his lids. He was sent to camp, and discharged the following year, as recorded. For several months he was blind, being able to see only by elevating the upper lid. Then some power slowly returned in the right lid. In 1867, Dr. Brown, of Addison, New York, removed a piece of skin from the riglit upper lid, adding


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


49


greatly to liis comfort. From '67 to '95 he relied entirely iipou his right eye. Left ptosis remained complete. His occupation was gardeuiug. lu the early summer of '95 he noticed occasional floating specks before the right eye ; " frequently tried to brush away a fly."

One Monday morning in July he went to his gardening as usual, but soon found he could not see clearly, also that he "put his foot where he did not mean to, on, instead of between his cabbage rows." He held open the left eye to make his way back to the house, and early in August appeared at the Presbyterian Eye and Ear Hospital. A central choroiditis explained his right blindness. Dr. Chisolm operated as stated, to give him use of his left eye, upon which he now depends. The muscular condition, noted partially in (September, and more accurately in March, is as follows : Complete ptosis both sides. The operation on the left upjier lid has given a larger palpebral opening than that on the right. The right orbicularis is constantly twitching. Though he can close each eye and wink, that power in the orbiculares is diminished is shown by failure to close the lids tightly — as in blepharospasm, for instance — or to resist in the slightest degree forcible separation of the lids. He seems to retain control of the paljiebral and to have lost use of the orbital portion of the orbicularis. The eyes themselves are fixed, the right diverging slightly out and up. When told to look in different directions he turns his head. There is, however, such slight motion up, down and laterally as already mentioned. Convergence and, so far as can be ascertained, rotation by the obliques are lost. The intrinsic eye muscles are spared. Each pupil responds to light, possibly a little tardily in contraction to moderate light, dilates under cocaine and contracts to eserine. He reads ordinary print with a convex 3.5 D, and has with this a range of 2 or 3 inches. Distant vision in the left eye is y^^, owing, most probably, to pigment deposit on lens capsule. Each paj)illa is normal. In the right eye there is central choroidal atrophy. Form field, barring the right central scotoma, is normal. This scotoma extends 10 degrees in all directions, except downwards, where it is 20 degrees.

When C. returned to the Hospital in March he asked, "Why, when I want to put my foot on a place, do I put it where it ain't?" This question is at the bottom of some curious things for which an explanation is not easy. With both eyes open he will reach to the right of an object held in front of him, with his right hand, but grasp it correctly with his left. Similarly, he will put his right foot to the right of an object, a narrow ruler, for instance, upon which he is told to step, but place his left foot correctly. With the right eye closed he grasps correctly with either hand and places each foot correctly. If the left eye be closed he either feels for the object or, turning his head for eccentric fixation, reaches it. When he leans far over, getting close to the niler on the floor, he places his right foot at times correctly. He did not know his eye muscles were affected until told so at the Hospital last September. I asked my friend. Dr. Thomas, to examine the patient, and his report is appended:

"The frontalis muscles are in constant over-action and possess a normal amount of power. The corrugator supercillii


acts with a fair amount of power on both sides. The right orbicularis palpebrarum is the seat of frequent momentary contractions ; at intervals there can be seen in the left lower eyelid muscular contractions which are synchronous with these. The right orbiculai-is is able to close the eye completely, but it is much weaker than normal, as the patient is unable to resist even slight traction on either eyelid. The left orbicularis, weaker than the right, is just strong enongh to close the eye. The other facial muscles act well and with equal force on the two sides.

" The muscles of mastication and those of the tongue act normally. No disturbance of sensation can be discovered in the face.

" The electrical examination shows that the facial nerve on both sides can be stimulated with a faradic current of moderate strength, the orbicularis palpebrarum taking part in the muscular contraction.

"To direct stimulation the orbicularis on both sides responds to the faradic and galvanic currents, but stronger currents must be used than is usual. The response to the galvanic current is sharp and quick. The right orbicularis responds to currents of less intensity than the left. The other facial muscles act normally.

"The involvement of the orbicularis in association with ophthalmoplegia is of great interest, bearing out, as it does, Mendel's view that this muscle receives nerve-fibres from the nucleus of the third and fourth nerves. Birdsall and Hughlings-Jackson have reported similar cases.

[Signed] H. M. Thomas."

Dr. Theobald. — I do not know of a case tliat I have met with in which there was a paralysis of the orbicularis associated with general ophthalmoplegia. I have, however, met with several instances where all of the external muscles of both eyes were involved. I have also met with cases where all of the recti muscles were involved without implication of the oblique muscles. These cases were almost invariably of specific origin.

A Simple Contrivance for Effecting Pneumatic Massage of tlie Tympanal Membrane and Ossicles.— Dr. Theobald.

Any apparatus which proves of use in dealing with affections of the middle ear is likely to be of especial value, for the reason that middle ear troubles are very common. Probably more than 75 per cent, of all the cases of impaired hearing which we encounter are due to changes in the middle ear. Deafness from nerve lesions is comparatively rare, forming not more than 2 or 3 per cent, of the cases of deafness met with in hospital and dispensary practice. Middle ear deafness is commonly the result of a chronic catarrhal inflammation, or perhaps of an acute inflammation of a higher grade, with plastic exudation. The changes are of one or two characters; either we have a sclerosis of the articulation of the ossicles, especially of the stapes, where it articulates in the oval window ; or there is a formation of bands which attach one ossicle to another, or one ossicle to some part of the wall of the tympanic cavity, in such a way as to interfere with the movement of the ossicles in response to the sound waves. Various devices


50


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


have been made to overcome this rigidity or aukylosis of the delicate joints in the middle ear, and especially contrivances which have been described as effecting one form or another of massage. There have been several distinct kinds of massage of the ossicles and tynipaniini proposed. One is a direct form of massage, pressure massage. The original way in which this was accomplished was by pressure with a delicate probe upon some portion of the malleus, either upon the short or the long process. This produced a certain amount of motion throughout the ossicular chain and in the various joints. More recently electricity has been brought into jjlay in this direction, and one contrivance has been made by which the rapid motion obtainable from the electric current has been made use of to operate a delicate probe which has a spiral spring in it. This probe strikes repeated delicate blows upon the long or short process of the malleus. Another form of massage is designated as phonetic massage ; that is, sound is used to produce vibrations of the tympanic membrane and ossicles. Several contrivances have been used for this purpose. One form is the phonograph, in which the sound is carried by tubes to the ear. The phonograph cylinders are cut deeply, so that the sounds are especially sharp and distinct and produce greater mechanical effect.

Pneumatic massage obtained by means of variations in the pressure of the air in the auditory canal is a third method. As far back as 1771 this method of influencing the movement of the ossicles was suggested by Cleland. More recently, this early experiment having been lost sight of. Moos suggested it again. There are several ways in which this has been brought about. The use of the Politzer bag is one method. This forces out the tympanic membrane and moves the delicate joints of the ossicular chain. Another method is with Siegel's pneumatic speculum, by means of which the air in the auditory canal is alternately condensed and rarefied, and thus the tympanal membrane is moved back and forth. One objection to this and other similar contrivances is that the jiower exerted is too great, and unless they are used with much care, serious injury may be done. If the pressure either outward or inward is too great there is a possibility of rupture of the tympanic membrane, or hemorrhage may be jiroduced. I do not think that marked beneficial results can be claimed for any of these forms of massage, although undoubtedly in some instances they do good, and it is a method which every one should be able to employ in treating ear maladies. One or two things are essential in order that this method may be employed with the hope of doing good. In the first place, the nature of the contrivance should be such that harm is not likely to be done in its use, as is the case when large air bulbs are used. If one uses a large air bag like the Politzer bag, a very little pressure of the hand will produce a marked variation in the density of the air in the auditory canal. Such a contrivance as this it is out of the question to place in the hands of a patient. It is essential in these cases, which are almost always chronic, that the massage should be of such a character that the patient may be able himself to practice it, and this is what I had in mind in contriving this apparatus. The bulb should be so small that one can do no harm in using it. This instrument consists simply of the rubber bulb taken from an eye-dropjier,


placed upon a small hard rubber tube with a bulbous tip which fits tightly into the auditory canal, rendering it air tight. This can be used in two ways. In the first place, we can compress the bulb before inserting the tube in the ear, and then by letting go the small bulb we rarefy the air and draw the membrane out. On the other hand, we can place it in the ear tiglitly, and then by squeezing the little bulb we drive the drum membrane in. I direct my patients to reverse the action, at one time drawing the membrane out, at another pressing it in. Ilynson & Westcott have made these instruments for me of several different sizes, so that they will fit any ear.

Excision of a Parovarian Cyst witliont Removal of its Ovary or Tube.— Dr. Kblly.

I will speak this evening of a new step in the conservative treatment of the uterus and its appendages. Before speaking of the subject in hand, I will call attention to a few of the advances we have made in the past few years. We no longer think of taking out the ovaries for enlarged Graafian follicles. If such a follicle is found it is simply exsected and the ovaries sewed up; small follicles maybe punctured or treated by the cautery as recommended by Pozzi. Cysts of the corpus luteum may be treated in like manner.

These parovarian cysts (showing pictures) were all removed several years ago and treated radically by i-emoviug the tube and ovary as well. I would not treat them so now, as I shall shortly demonstrate. This conservatism extends also to the tubes. Prof. Martin of Berlin has succeeded in saving quite a number of diseased tubes without hurt to the patient and with full restoration to health. Last year I removed from a patient the tube' of one side and the ovary of the other, laid the ovary and the tube both down behind the uterus, and the lady, who is the wife of a physician, returned home and has since borne a child. Still graver affections also come under this conservative treatment. We have for some years past been treating accumulations of pus behind the uterus, by puncture, evacuation and simple drainage through the vaginal outlet, even when the pus is in both tubes and ovaries. This has been followed by a large number of perfect recoveries. Occasionally the patient will return and require another drainage operation ; the ovaries and tubes can be removed later with greater ease, if necessary. In cases of myomatous uteri I have removed as many as 9 myoma through 7 incisions and had perfect recovery and perfect relief follow. I demonstrated last week the possibility of exsecting as many as 16 myoma without opening the uterine cavity.

The particular new subject along these lines of which I wish to speak to-night is simpler than many of the steps already taken, from a surgical standpoint, and yet, so far as I know, it is novel and is one of the last to follow in the line of conservative effort: that is, the removal of certain parovarian cysts without sacrifice of the correlated ovary and tube. To show how simply this may be done, I pass around specimens of such cysts in which the tubes and ovaries were also removed. It is evident at a glance how simple a matter it would be to remove these parovarian tumors and then to sew up the incision area after the enucleation. The first case I operated upon conservatively was in November, '95. The


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


51


patient was suffering a great deal with pelvic pain, and the doctor who had examined her felt two tumors in the pelvis and sent her to me with the statement that both ovaries would have to be removed. I found one cyst the size of a hen's egg before the uterus and another behind it. On opening the abdomen the cysts were both found to be parovarian; they were in the mesosalpinx, and the ovaries were displaced and separated from the tubes by them. I treated the tumors in two different ways, both giving the same result. In oue, after ligating the larger vessels a little distance from the tumor, I made an incision through the jjeritoueum where the vessels were fewest, and I easily shelled the tumor out of its bed and then sewed up the peritoneum with a continuous catgut suture. On the other side I excised a portion of the redundant peritoneum while the circulation was controlled by the finger of an assistant, turned the tumor out and stitched up the wound with catgut. The uterus which had lain in retroflexion was suspended by two silk sutures by my method. Both ovaries were thus left intact. The patient made a perfect recovery, has kept her functions, is normal and regular, and in good health. This, I think, with the other circumstances cited, is one of the last and not least important of our gynecological advances, of particular importance to young women and women in the prime of life.

Dr. Welch. — How large a proportion of these cases are eligible to this treatment? As one who sees the ordinary parovarian cysts after operation and at autopsy, it is not clear to me how they can be taken out without removing at least the tube. The cyst grows between the layers of the broad ligament (there is no mesosalpinx, the layers are all separated), and the cyst comes i;p against the Fallopian tube, and, in some cases at least, it would be impossible to dissect it from the tube. The ovary may be quite well preserved, but not unfrequently it is sj^read out over the surface of the cyst. I sup2)ose Dr. Kelly does not mean that the conservative operation can be done in tumors of that kind, but refers to tumors of only moderate size.

Dr. Kelly. — Yes, the operation is most easily applicable to tumors of medium size, but can also be applied to many of the larger ones. In all of those cases where the cyst is thin walled and more or less pellucid, by slitting the capsule and evacuating the tumor, it can then be drawn out from under the tube, even though the tube is flattened out as shown in this specimen which I pass around. I would exclude from such treatment all those cases in which papillary elements are visible.

Meeting of November 16, 1896.

Dr. TnAVEE in the Chair.

On the Pathology of Heematozoan Infections in Birds.— W.

G. MAcC'ALLUiV.

Peculiar advantages are offered by the tissues of birds for the study of hsematozoan infections, in that all stages and degrees of infection may be examined without any difficulty in obtaining the materials. The material for the following observations was furnished in the tissues of the birds whose blood has just been described, and often the extent of the


changes in the organs was surprising when contrasted with the apparently good health of the birds.

Kruse, Danilewsky and Labbe have noted in a general way pigmentation of the spleen, liver and bone-marrow, and have observed the enclosure of pigment masses in niakrophages in the capillaries of these organs. There is nowhere any mention of inequality in the distribution of the parasites as such in the organs of the body, such as has been described in malaria in the human body giving rise to corresponding symptoms ; in no communication on the subject have any symptoms been described occurring in infected birds such as to lead to the suspicion of a definitely localized invasion of organisms, nor have we been able to demonstrate in any of our birds such localization or such symptoms.

As to the effects of the products of the organisms on the tissues we cannot speak definitely. No mention is made in the literature of such effects, but we have observed various degenerated areas in liver and spleen, some of which are explained by concurrent bacterial infections, others apparently by the presence of peculiar ovoid bodies with central nuclear particle, which occur in the cells in groups resembling a segmenting organism, while a third variety is still unexplained.

The invasion of the parasite into the red corpuscle appears to be followed eventually by the breaking down of the corpuscle, from the altered hasmoglobin of which there results a straw-colored pigment. This is seen deposited in considerable masses together with the dark pigment formed directly by the parasite. The process of storing these pigments away from the blood stream is similar to that observed in man. The phagocytic cells of the blood are apparently the cells which we have named Kubinophilcs,* and in a lesser degree the eosiuophiles, although neither of these is very active in engulfing extruded organisms and pigment. Indeed we have never observed in a fresh slide of blood a single pigmented leucocyte, and, although they have been observed to engulf parasites, they have also been seen to attack the jiarasite, and after disintegrating it to a great extent, to leave the pigment and wander away. Labbe denies the existence of true phagocytosis, and considers the presence of infected corpuscles within leucocytes to a certain extent accidental.

Danilewsky and Sakharoff describe the occurrence of organisms within leucocytes where they undergo part of their development, but we have observed nothing analogous to this. The hemopoietic organs are of especial interest, and it is iu these that the pigmentation has been noted by European writers. The spleen at autopsy is generally somewhat blackened, and on section shows a network of black lines corresponding to the pulp bands where the bulk of the pigment is deposited. This pigment occurs either iu large, clear or palely staining niakrophages with single or double vesicular nucleus, or iu the swollen endothelial cells of the capillaries. In the spleen the large cndothelioid cells of the pulp take on the character of makrophages, but iu the liver the pigmented


  • Cells with whetstone-shaped granules wliicli take on an eosin

stain after long standing, but are colored nmcli more readily by acid fuchsin.


52


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72


cells are all intracapillary. These large cells are seen to contain masses of yellow pigment, masses of black pigment, scattered grains of black pigment, infected corpuscles, shrunken parasites which at first sight look like small masses of yellow pigment, and debris of broken-down red corpuscles and parasites. The liver shows a less marked pigmentation than the spleen, but the character of the deposit is similar. In the bone-marrow which European authors have found so deeply pigmented we have found almost no pigment and but few organisms. The brain, heart, lungs, kidneys, stomach, intestine, pancreas, thyroid and voluntary muscle show no changes and only the presence of organisms which would be expected from the rich blood supply of these organs.

On the Hscinocytozoa of Birds.— Eugene L. Opie.

The presence of parasites closely resembling the malarial organisms of man, within the red corpuscles of birds, is well known. These organisms have been found in varying abundance in the blood of birds of many parts of Europe, but up to the present time they have not apparently been studied in this country. At the suggestion of Dr. Thayer these intracorpuscular parasites have been studied in the Clinical Laboratory of the Hospital. During the mouths of June, July, August and September one hundred and twenty-five birds have been examined. Of these the greater number, one hundred, were from the neighborhood of Baltimore. Of eighty English sparrows (Passer domesticus) from this locality, nine were infected with intracorpuscular parasites; of twelve red wing blackbirds (Agelaius phceniceus) six were infected; two swamp sparrows (Melospiza georgiaua) and one song sparrow (Melospiza fasciata) contained organisms. Of twenty-five birds, including a variety of species from the neighborhood of Dunnville, near Toronto, Ontario, five were similarly infected, namely, one great horned owl (Bubo virginianus) and four crows (Corvus americanus).

Although the small number of the infected birds makes it impossible to arrive at any genera] conclusions as to the particular species prone to infection or the local conditions favoring infection, a fairly accurate idea of the character of the parasites present in these localities can be obtained. The organisms found resemble the malarial parasites in that they undergo their whole development within the red corpuscle at the expense of its substance, transforming its hemoglobin into chai'acteristic pigment granules. Like the malarial organism they reproduce by segmentation, and the young parasites come to occupy other red corpuscles. Unlike the malarial organisms the younger parasites do not exhibit active amoeboid movements. Unlike the tertian and (juartan malarial organisms they show no cyclic development in great groups of which every organism is in approximately the same phase of development, and hence the length of their cycle of growth cannot be readily determined.

Two types of organism, similar to those observed in European birds, are found. Characteristic of each type is the morphology of the full-grown organism. In the one group an irregularly shaped body, approximately round or polygonal, occupies one end of the nucleated red corpuscle; the nucleus has been displaced into a transverse position in the opposite


end. In the other group the full-grown organism is an elongated body which lies curved along one side of the normally situated nucleus. The irregular parasite (Proteosoma, Labbe) segments in the peripheral circulation by a process which is almost identical with that of the malarial organisms. Segmenting forms of the elongate parasite (Halteridium, Labbe) are not found in the blood taken, for example, from the wing. Associated with both types of organism are certain large bodies, apparently degenerate and not destined to segment, characterized particularly by the fact that, unlike the ordinary full-grown organism, they contain almost no material with an affinity for stains as methylene blue, safranin, etc. Organisms which flagellate as do those of malaria are observed with both the irregular and the elongate parasites. With the elongate organism, indeed, owing to the abundance of these forms, the whole process of flagellation can be studied with the greatest facility. Among the irregular parasites present in different birds different varieties are not observed. Among the elongate parasites, however, considerable diversity of form exists in different hosts, but the lack of extended observations makes it impossible to establish distinct species, although in certain cases the morphological differences observed are very striking.

Daiiilewsky, who first observed iutracorpuscular parasites in the blood of birds, believed that these organisms are identical with those of the malarial fevers. Certain subsequent observers have attempted to establish an analogy between the different varieties of the malarial parasite and forms which they find in birds. Others have considered the parasites in birds to be entirely independent of those of man. It seems probable that there are in birds at least two distinct siJecies of intracorj^uscular parasites. In almost every detail of structure they very closely resemble the malarial organisms of man, but they are, nevertheless, essentially distinct.

Dr. OsLER. — The subject which these gentlemen have presented so clearly has a very definite bearing upon the life history of the malarial parasite in man, as it is quite possible that we may get a clue to the outside history of the parasites by a study of the forms in birds. In 18S(!, I think, just as I was busily engaged for the first time in the study of the malarial l^arasite, Mr. MacCallura's father. Dr. MacCallum, of Dunnville, Ontario, sent to the Biological Laboratory in Toronto a goose which was supposed to have malaria. I was extremely skejjtical about it, as I knew nothing at that time about the parasites in birds, but to my astonishment there were in large numbers the pigmented intracellular organisms, just such as Mr. Opie has demonstrated to. us to-night. They were present in very large numbers, and the spleen of the bird was also large and deeply pigmented.

Dr. L. F. Barkek. — I have been much interested in this report of the very careful studies of J[essrs. MacCallum and Ojiie. It may be worth while to emphasize the importance in parasitic diseases of the blood and blood-making organs, of studying not only the appearances of the blood itself by clinical methods, but also the appearances of the blood and tissues in microscopic sections after death. One gets a very one-sided idea of the structure of the malarial parasites and their rela


March, 1897.]

53


tion to the cells, if he studies them only in fresh blood or in smear cover-glass prei^aratious, even when dried and stained. In tissues which have been hardened in alcohol it is very easy in sections stained with hematoxylin and eosin or with methylene blue, to make out within the half-grown and fullgrown tertian parasites of human malaria a relatively large spherical area which stains usually feebly, though sometimes very distinctly in nuclear dyes. Peripheral to this mass is a thin superficial layer which does not stain at all in ordinary nuclear dyes. In this peripheral non-basophile layer of the parasite is situated the malarial pigment when it is present. The internal stainable mass may be centrally placed, though it is more usual to see it situated somewhat excentrically, so that the peripheral layer of non-stainable substance may vary in thickness in different parts of the organism. The internal mass, which is entirely free from pigment, may stain somewhat unevenly, and occasionally it is possible to make out in it an intensely stained nodule which I have thought may correspond to what has been described in stained smear preparations as the nucleus. It would seem more rational to look upon it as the nucleolus or as an aggregation of the chromatin within the nucleus, though for the decision of this point we must wait for further investigations. I should like to ask Mr. Opie and Mv. MacCallum whether or not they have in their studies or in their reading found any indications of or reference to macronuclei or micronuclei in malarial parasites, such as have formed the basis of so much interesting research of late years in the infusoria. It is indeed to be hoped that the large size of the malarial parasites in birds will permit of the unraveling of the finer structure of these curious organisms.

I have been much imj^ressed in studying Mr. MacCallum's specimens of the spleens of these birds, by the enormous masses of malarial parasites to be seen there. At first it seemed almost improbable that the huge brownish masses could consist of malarial parasites. It appeared more likely that they could be explained as forms of blood pigment, but careful study with the oil immersion lens will convince any one that they are in reality aggregations of altered malarial organisms.

Mr. Opie. — I have seen no references to the macro- and micro-nuclei. Labbe, who studied the question most thoroughly, does not mention such structures.

Dr. Welch. — This is the first investigation of the kind, as far as I know, in this country. It is extremely interesting, and particularly to us, as it was made here. These have a number of points to distinguish them from the malarial organism, and one of the most striking is the absence of movements. I was interested in the statement that all phases of development occur at the same time in the circulating blood. An idea of Golgi as to the development of organisms in groups in the organs of the body would suggest the localized development in this class of organisms. There is no reference here, however, to groups, but each organism developed separately. It suggests that Golgi's observations might be explained by other suppositions.

Dr. OsLER. — I should like to add a word ujlon the possibility that in very malarial districts man may harbor the parasites without showing special manifestations. We know that in


certain regions all dogs have filaria in the blood, and in many parts of Africa the filaria are present in the natives without causing much trouble. It is quite possible, too, that there may be a minor grade of malarial infection in which the organisms are not present in sufficient numbers to cause fever or the characteristic paroxysms.

Dr. Thayer. — Let me also congratulate Mr. Opie and Mr. MacCallum upon their careful piece of work.

The importance of such studies was impressed upon me several years ago by M. Laveran who expressed his conviction that a careful study of the hrematozoa of lower animals, and especially of those of birds, which so closely resemble the parasites of human beings, was perhaps more likely to throw light upon some of the dark points in connection with the etiology of malaria than any other branch of research which is at present open to us.

Kecent observations appear to show that the parasites of birds and human beings are not identical ; they are, however, so similar that it is not improbable that the form in which they exist outside of the body and their method of entrance to the body are likewise not unlike the corresponding phases in the life history of the parasite of human beings.

There are, of course, many more points to be studied with regard to the morphological and biological characteristics of these avian hasmatozoa. In these present observations, for instance, no idea has been formed with regard to the length of the cycle of existence of the parasites. Danilevsky believes that he has been able to distinguish an acute and a chronic form, while Oelli divided the parasites of birds into three forms with cycles of existence corresponding to the quartan, tertian, and sestivo-autumnal parasites. Here, however, there has as yet been nothing to point out the exact length of the cycle of existence of each generation of parasites.

Further, it would be advisable to make careful measurements and observations of the temperature in infected birds, observations which, to be sure, have been made by other authors, but with regard to which there is as yet a lack of agreement.

It is also, I think, very important that the intimate structure of the parasites of birds' blood should be carefully followed out; this can be done with much greater facility than in the human being, inasmuch as specimens of tissues can be instantly obtained at any time desired.

But really the most important point, it seems to me, as Bignami has emphasized in a recent paper, is to determine, if possible, the manner in which the parasite exists outside of the body, or more particularly its manner and portal (Jf entry. It may well be possible that careful and continued observations of this sort may bring us nearer the solution of the greatest questions in connection with malarial infection.

With regard to the remark of Prof. Osier concerning the possibility that a human being may harbor the malarial parasites in an active condition for a considerable time without showing distinct clinical symptoms, I must say that the more of the disease one sees, the more reasonable seems the possibility that this condition may exist with relative frequency. In many cases of tertian fever after insufficient doses of quinine, or during attempts at spontaneous recovery, a few parasites may be found in the blood for very con


54

[No. 72.


siderable periods of time without actual clinical symptoms resulting. Dr. Gamble tells me that in j)rivate practice he has found the parasite in a number of instances in the blood of patients Complaining of vague symptoms who had not as yet had any actual paroxysm. In these instances it is in every way probable that the parasites had not as yet accumulated in sufficient number to produce a chill. If now in a certain number of instances a single tertian paroxysm may be followed, without treatment, by so extensive a destruction of the organisms tliat fever does not I'ecur for a week or ten days (a not very infrequent occurrence), theoretically there would seem to be no reason why in certain instances a similar destruction might not occur in groups which have not as yet reached a size sufficient to produce actual manifestations ; thus there would result au iudefinite prolongation of what one might call the incubation period of the infection. That such conditions exist is, I believe, not only possible but probable, though definite proof has yet to be advanced.

Afeeting of December 7, 1896. Dr. Thayek in the Chair.

Discnssion of Dr. Rlocli's Paper on "Agglutination of Typhoid Bacilli, etc." [See Bulletin, Nos. 68-69.]

Dr. Plexnek. — In this connection I wish to speak of some interesting and highly suggestive results just obtained by Pfeiffer and Kolle, with reference to the possibility of successfully vaccinating human beings against typhoid fever. You may recall that Ktern pointed out several years ago that the blood of typhoid fever convalescents contains protective pi'inciples similar to those present in the blood of animals rendered immune from experimental typhoid infection. It is probable that these protective substances are those on which the phenomenon of agglutination depends ; they are different from the alexines or defensive proteids of the normal blood, which possess little or no power of producing agglutination of bacteria, and are destroyed at a considerably lower temperature. These protective principles are exerted against the bacterial cell, are bactericidal and not anti-toxic in nature; thus they differ from the anti-toxines of diphtheria and tetanus, whose actions are directed against the toxin and not the bacterial cells as such.

Proceeding on the basis of Haffkine's results in vaccinating against cholera, which they accept as conclusive, Pfeiffer and Kolle have in a similar manner injected suspensions of typhoid bacilli subcfitaneously beneath the skin of the back into three persons who had never had typhoid fever. The symptoms following the injections were elevation of temperati;re, chill, malaise; but these quickly passed away without leaving unpleasant effects. Following the cessation of the symptoms they found the blood of the vaccinated persons to contain an amount of the protective substances, measui'ed by the power to protect animals from experimental typhoid infection, in excess of what is found ordinarily in typhoid convalescents. Assuming that there exists a relation between these principles and immunity from tyi)hoid fever, it would appear as if in this sinij)]e manner an artificial protection from infection with the typhoid bacilli might be given. Appreciating the diffi


culties in the way of a conclusive and satisfactory test of this method in ordinary life, they suggest that it be given a trial in outbreaks of typhoid fever in barracks and army corps, where, as is well known, large and destructive epidemics sometimes occur.

Dr. Reed. — I have had no experience with the serum test. I have made use, however, of Johnson's modification of Widal's method, and, so far, have examined the blood in thirty-four supposed cases of typhoid fever. AVhen I began with this method — that is, the use of the dried blood — Johnson's paper had not been published, so I had to feel my way, as it were. I began by examining a small quantity of the blood dissolved in distilled water, placing a drop on a cover-slip and then inoculating it with an agar culture. I found the method worked fairly well in certain drops, while in others I had introduced too many bacilli, and, while many clumped, there were highly motile organisms to be seen after the lapse of two or three hours. I had just fixed upon a bouillon culture as the proper medium when Johnson's paper ajjpeared, and being convinced then that I was on the right road, I reviewed my cases with this method. I then had distinct clumping with arrest of motility in cases in which I did not get it when using the solid culture. So far I have examined the blood of thirty-four cases, twenty-eight of which have given me a positive reaction, that is, loss of motility and agglutination of the bacilli. It will be seen that I have met with success in a greater percentage of my cases than Dr. Block has reported to-night. Six cases failed to give the reaction. In two of these I found the Kstivo-autumnal parasite. A third case that did not give the reaction was considered to be a severe case of typhoid fever in the Freedman's Hospital. The patient had tympanites and high temperature. I examined the blood with negative result. The patient died the following day, and it M'as found that there was general peritonitis, having its origin in the appendix. The fourth case was a child who manifested distinct brain symptoms, and the attending physician had not been certain that it was a case of typhoid. Two other cases, one in the third and one in the sixth week, failed to give the reaction. AVhether they were i-eal cases of tyj)hoid I do not know. The earliest case in which I have examined the blood was that of a soldier at Fort Myer. Soldiers are generally put to bed early, and the reaction here was quite distinct on the fifth day After I had obtained a positive reaction in twenty-two cases, the particular bouillon that I was using — an old glucose bouillon (because there was no other in the laboratory at the time) — became exhausted and I began to use ordinary bouillon. I tried this latter in two new cases from the Freedman's Hospital, and was surprised to find prompt arrest of motility, but no clumping. For the sake of comparison I took the blood of an undoubted typhoid case and tested it with plain bouillon, and had no clumping until more than au hour had passed. I then tried some of my old glucose bouillon cultures, and to my surprise all three cases gave me good agglutination within fifteen or twenty minutes. I then began to examine my hanging drops, in plain and glucose bouillon, at the end of twenty-four hours, to see if I could distinguish any difference between them, aud found that from the margins of the


March, 189^]

55


clumjjs iu plain bouillou the bacilli had always grown out as delicate threads radiating across the field and forming a network, whereas the clumps in glucose bouillon do not show any growth. I have repeated the observation many times with the same result. In the Fort Myer case I got good clumping with the glucose, but not with the plain bouillon. So it has seemed to me that possibly the bacilli grown in the glucose bouillon are somewhat more vulnerable to this peculiar action of typhoid blood.

In order to see whether motility of a cultui'e had anything to do with its agglutination, I examined bouillou cultures at periods of seven, thirteen and sixteen days, and ascertained that the old cultures, in which there is no motility, clump about as promptly as recent ones. I then tried, as a matter of interest, to see whether the dead bacilli would agglutinate, and ascertained that massing of the bacilli took place about as promptly in the dead as in the living cultures. I also observed that blood heated to 60° C. for half an hour acts about as well as the non-heated blood. It occurred to me that by heating the blood to 60° one might destroy its normal germicidal action and still leave behind the peculiar body upon which the clumping depends. I have observed the reaction in dried blood after twenty-six days. I have failed to obtain arrest of motility of the bacilli in normal blood, but in one case, probably latent tuberculosis, there was prompt, distinct partial clumping; the non-agglutinated bacilli, however, remained actively motile at the end of three hours.

Dr. Thayer. — There is one point, it seems to me, which must be carefully looked into before we draw too many conclusions, namely, the length of time during which this bacteriocidal power may remain in the blood after recovery from typhoid fever. In one instance at present in the Hospital the reaction is marked 16 mouths after the attack of fever. It must be said, however, that there is a typhoid osteomyelitis preseut which might well be the direct cause of the reaction.


NOTES ON NEW BOOKS.

A Treatise on Surgery, by American Authors. Edited by Koswell Park, A. M., M. D., Professor of Surgery in the Medical Department of the University of Buffalo, etc., etc. Vol. I. General Surgery and Surgical Pathology. 799 pp., 356 engravings, 21 jilates in colors. Lea Brothers & Co., Philadelphia and New Tork, 1890.

It was not one of the lightest proofs of the true inspiration of the sacred writers that they have handed down to us such nuggets of truth for all ages as the familiar "Much study is a weariness of the flesh, and of making many books there is no end."

Any volume which steps into the crowded arena of medical literature today must expect to be challenged at once to show not only negative virtues, the absence of faults, but some positive and original ones besides, some clear raison d'etre, or excuse for its very existence. Especially is this true of that realm of medicine known as the surgical, in general, and of American surgery in particular, where the new challenger must win his spurs against such giantsof the pliocene as Gross and Agnew, and such hydra-headed antagonists of the pleistocene and contemporary as Ashurst, Dennis, and Keen. Hence the first question to be asked is, does this particular aspirant show proof of such approved superiority or peculiarity in weapons, or skill and training in feats of arms, as to give promise


of holding his own in such a contest? We believe that he does iu several respects. One of these is that the work is, in the broadest and best sense of the term, American, national, catholic. By this we mean, first of all, that singularly fruitful combination of scientific knowledge and breailth with "Yankee" ingenuity of application and intensely utilitarian tendency, so well typified by its distinguished editor and part-author, which has so rapidly won a world-wide recognition alike for American surgery and American scientific discoveries and mechanical inventions. Our whole inventiveness, progress and enterprise are born of the double fact that the thinker mtist needs do and the doer is able to think.

Again, in glancing over the list of contributors to the volume, no one, I think, can fail to be impressed with the fact that it is nationally representative in the broadest sense. Xames which range from Maine to Louisiana, from Philadelphia to f^t. Louis, and from Tennessee to Jlichigan, are certainly ample proof of this, and when we remember that the proudesttriumphs of American surgery, as represented by the names McDowell, Batty and Sims, to say nothing of a host of minor ones, had their origin not among the polished consultants of the great centers, but among the sturdy general practitioners of the rural districtsof theSouth and Southwest, wesee that this arrangement has not merely its fairness, but a genuine basis of practical scientific advantage to recommend it. At the same time an admirable homogeneity approaching that of the classic surgical monographs is given to the work, both by the careful supervision exercised by the editor and the large proportion of chapters in this volume contributed by him personally, much to the reader's satisfaction and advantage. The first five chapters of the volume covering the domain of surgical pathology are contributed by the editor himself. The subject is presented in a comprehensive and yet concise manner, its most prominent characteristic being the clear-cut division which its author insists upon between hypeictmia and its consequences, and the process of repair on the one hand and of inflammation upon the other. The use of the latter term is limited strictljto those reactions of the tissues which result from the introduction of some noxious irritant, usually of bacterial origin. This limitation possesses decided advantages in point of clearness, both of thought and practice, and it is probably desirable that the use of the word should be so restricted in the future from the surgical standpoint ; and we believe that the admirable classification which is based upon it, and which it alone makes possible, will go far to recommend it to the profession. From a biological standpoint, as its author himself would frankly admit, the difference between the two processes is one of degree rather than of kind. But divisions are no longer made, either in pathology or biology, in the old hardand-fast pre-Darwinian sense, and in actual experience the two classes are so sharply distinguished in their characters, their origins and their results as to be entitled to the writing of true and distinct species.

A somewhat novel feature is the introduction of a chapter upon the pathology of the blood, which, however, abundantly vindicates its right to appear in a surgical treatise, as some excellent diagnostic and prognostic tests are based upon it.

Another instance of the breadth of view which pervades the whole treatment of the subject is the careful discussion of the many factors which, by lowering the resistance of the tissues, may predispose to an attack of surgical infection. With a candor which is rare in the operating surgeon, full credit is given to the extraordinary power on thepartof both the leucocytes and fixed cells of tlie body to ward off infections and to rei>el invaders of every description ; and the story of the " battle of the cells " is given in the most graphic manner. This view of the matter is particularly well developed in what is, to our view, one of the most original and valuable chapters of the volume, that upon "Auto-Infection in Surgica. Patients." Here the author impresses with convincing clearness and abundant illustration the too-little recogni/.ed truth that any secretion of the body tissues may become a poi.son to the entire system if its elimination is in any way interfered with, notonly medi


56

[No. 72.


cally but surgically. The surgeon is urged to see to it that his patient is thoroughly aseptic externally and internally, particularly as to the alimentary tube. As the author declares, " There is perhaps no condition which so predisposes to sapntmia, septicemia, or even pyemia, as this vague condition of intestinal toxaemia, which nevertheless is so often present." The " hard-and-fastness" of some of the definitions in classification of surgical fevers will challenge decided criticism, but for enaMing the subject to be clearly grasped, especially by the student, even this has its practical advantages.

A decided novelty in works upon surgery is found in two excellent chapters by theeditorupon " Diseases Common to Man and the Domestic Animals." These fill a gap in the knowledge of the practitioner which is already being widely felt, and will prove among the most attractive chapters of the volume. The pathological paragraphs are particularly suggestive, the biological basis of morbid processes and the individual part played by the various tissue-cells being so vividly developed as to give even tubercleformation the fascination of a story from life.

The chapter upon Syphilis, while covering the ground well, is so much compressed as to produce in places a style so bold and even dislocated as to seriously interfere with clearness. We very much doubt whether any student would be able to recognize a set of Hutchinson'steethfromtheextremely brief (and inaccurate) description upon page 209. Indeed it suggests a doubt as to the clearness of the writer's own concejition, and we are not surprised to find it followed b}' the statement, "The appearance described is often absent in syphilitic patients or may result from other causes." The " wax-work-like " tints of the colored illustrations of this chapter also leave much to be desired.

The pathological suggestions in the chapter upon Rickets are most interesting. One, that the disease is essentially a loss of balance between lactic or some other excrementitiousacid, on the one hand, and calcium salts on the other, calls up atonce Loew's discovery of serious disturbances in plants on account of a similar imbalance between oxalic acid and the magnesium salts. And we doubt if the essence of the rachitic process has ever been better epitomized than in the description of the layer of osteoid tissue of the epiphyseal lines " which is notcartilage and will not become bone."

lu Chapter XIV we find the editor's "creed," whicli is consistently lived up to throughout tlie whole of the volume. After speaking of the "artificial and unfortunate separation of surgery from so-called internal medicine," he well declares that "it has been no small part of the benefit resulting from modern teachings that these imaginary boundaries and limitations have been swept away, and one of the lessons which this text-book is intended to inculcate is that broad principles underlie disease-conditions, and that one must appreciate their bearings thoroughly in order to practice either medicine or surgery successfully."

The chapters upon Minor Surgery are clear, concise and well illustrated.

The discussion of Cysts and Tumors is comprehensive and thoroughly up to date, the classification (based largely upon that of Sutton) being particularly commendable for its scientific simplicity and ease of comprehension. Growths are regarded as aberrant or "rebellious" groups of living tissue-cells differing mainly from each other in the particular tissues which they reproduce or imitate and in the perfection of their imitation. We would prefer, however, to transfer epithelioma from the " Tumors of Epithelial Type" to those of " Glandular-tissue Type," as its deadly qualities seem to be solely due to its power of " dipping down" or burrowing into the tissues, in its attempts to imitate the sebaceous, sweat or mucous gland of the surface where it originates.

The chapter upon Surgical Diseases of the Skin, while in most respects admirable, especially in its discussion of dermal tuberculoses, includes a good deal of ground which has already been covered, such as neuroma, myoma, epithelioma, lipoma, etc., and is disfigured throughout by the characteristic "Scabies perpetualis


sive septennialis " of oar dermatologist brethren, for pompous and sonorous Latin terms of classification, whose dignified sound barely covers their childish meaning. Thus, the common every-day wait is teased under a dissecting microscope with a literary needle and forceps into " Verruca vulgaris, Verruca filiformis and Verruca acuminata"; Cancer of the skin parades as "Carcinoma cutis" with two divisions, "Carcinoma tuberosum" and "Lenticular cancer." It is obvious that potatoes in a bin might be "classified " in precisely the same manner and -with as euphonious results.

The chapter upon Diseases of the Lymphatic Vessels, by Dr. F. H. Gerrish, is a most original and valuable contribution to a subject which has never received the attention which its importance merits; probably largely on account of the inherent difficulties of the subject and our imperfect understanding of it.

The remaining chapters of the volume maintain a high average, but present nothing sufficiently characteristic or distinctive to call for special comment.

The illustrations throughout are excellent, with a few exceptions, and a most refreshing feature is the large proportion of them which are entirely new, most of them from original photographs. AVe feel almost lost, though, without our old familiar friend the " opisthotonos " man (but perhaps he will come to cheer us in the second volume), and grievously miss those numerous and beautiful pictures of surgical instruments, with the maker's name in large black letters upon either the blade or handle.

Even the camera, however, has its little weaknesses, and we are further confirmed by these cuts in our conviction that the photograph is in many cases no more necessarily " true to life" than is the "realism" of modern fiction. In not a few of even this carefully selected series, while the outlines are cltar, the details of the central area are so indistinct that the assistance of the title and side-lettering is needed to discriminate between them, while in several even this assistance fails to render them entirely clear, as for instance the cut of varicose ulcers (p. 541) and that of fracture of the patella (p. 741). Most of them, however, are clear, as they are typically illustrative, and will constitute valuable and permanent additions to our surgical picture-gallery.

As a whole, the work is fresh, clear, and practical, covering the ground thoroughly yet briefly, and well arranged for rapid reference, so that it will be of special value to the student and busy practitioner. The pathology is broad, clear and scientific, while the suggestions upon treatment are clear-cut, thoroughly modern and admirably resourceful.

Our only general criticism takes the form of a regret that the editor, in some of his chapters, felt himself so much under the necessity of condensing and systematizing and could not give his thought fuller and freer play. But a chapter or volume which fails by being too short is not far from a decided success, and we have Ycl. II tc look forward to for consolation. W. H.

A Manual of Syphilis and the Venereal Diseases. By J.4.mes Nevi.vs Hyde, A.M., M.D., and Frank H. Montgomery, M. D. 1 vol., 618 pages. {Philadelphia: W. B. Saunders, 1895.)

For several years there has existed the need of a condensed and at the same time sufiiciently comprehensive book on venereal diseases, which would enable medical students and practitioners, at a moderate cost, to obtain the latest opinions as to syphilis, and also to keep up with the advancing bacteriological work which is being done in genitourinary diseases.

The Manual of Syphilis and the Venereal Diseases, by Hyde and Montgomery, is a book which well answers this purpose. It is extremely attractive in appearance, the printing and illustrations (which are numerous) being all that could be desired. The full-page illustration in colors of "Gonococci in gonorrhoeal pus" is a beautiful example of the possibility of enlarging from a photomicrograph.

The chapters on Syphilis are written in a most attractive style,


March, 1897.

57


and condensed so skilfully as to make a thorough review of the whole subject in a comparatively few pages. In their discussion of the treatment of syphilis the authors express some views as regards the inadvisability of using opium- in combination with mercury which may not obtain the endorsement of the profession.

The chapter on Chancroid closely follows the articles on this subject in Morrow's System of Genito-Urinary Diseases, and in addition furnishes a valuable table, in parallel columns, for the differential diagnosis of chancre and chancroid.

Cystitis and pyelitis are not given the prominence or attention that these comparatively frequent diseases merit, and no mention is made of the value of the cystoscope as a means of diagnosis in vesical and renal diseases.

The articles on Urethritis Acute and Chronic (including Endoscopy) are especially well written, and give a thorough and scientific presentation of the aubject.

The aim of the authors has been a compilation of the most recent literature and thought on " Syphilis and the Venereal Diseases," rather than to put forward any original work or ideas of their own.

A. B. G.

Transactions of the American Gynecological Society. Vol. 21, for the year 1896. {Philadelphia : Wm. J. Bornan, Printer, 1896.)

The Society is to be congratulated upon the almost unanimous tendency to conservatism displayed in its papers and their discussion, which gives a tone of advance, not so prominent in past meetings.

It is not surprising that the paper by Segond, of Paris, on the radical treatment of uterine myomata and inflammatory disease of the tubes and ovaries by vaginal hysterectomy gave rise to a most vigorous discussion and met with many pertinent objections ; the consensus of opinion of the American gynecologists seeming strongly against its unqualified acceptance.

Dr. Kelly, in a paper on the treatment of extra-uterine pregnancy, urges strongly the vaginal puncture and drainage in cases ruptured in the early months, but not in the acute stage, and proves most conclusively the value of this conservative method by the cases he cites.

Dr. Henrotin, in a paper on the same subject, dwells on the necessity of immediate abdominal operation at time of rupture, even when the patient is in shock. Now that we have come to recognize that shock is but a term expressing all the symptoms of hemorrhage. Dr. Henrotin's advocacy of immediate interference is sustained.

Dr. Noble's paper on suspensio uteri with reference to its influence on labor deserves special mention. The recent condemnation of the vaginal fixation of the uterus by its originators because of its frequent serious interference with labor greatly increases the value of Dr. Noble's careful study and statistics of the abdominal operation. Unfortunately, the statistics do not represent a uniform method of suturing the uterus to the abdominal wall, and it is difficult to draw accurate conclusions. The two cases of dystocia which he cites in his own experience were true fixations, consequently the suspension method cannot be held responsible for the difficulties which he has described.

The statistics collated by Dr. Byrne with reference to the remote results of operations for cancer of the uterus are most painstaking and creditable, but do not point the way to any advance in treatment. Statistics to be of value must contain a complete picture of every case, and here this paper is found sadly wanting, especially on the laboratory side. In every case suitable for radical operation a microscopic diagnosis should be made before it is undertaken. A failure to do this may lead to most appalling mistakes. After removal, sections should be made through the critical points for microscopic study to determine whether the disease has all been removed. If this were done Dr. Byrne would find that the morbid cell changes beyond the primary growth of which he speaks, were


a simple extension of the disease into tissue which appears to the eye and touch unsuspicious. Not until these precautions are taken and the results put into statistical tables will one be able to judge fairly of the remote results of operative treatment of cancer of the uterus. The statistics of to-day are absolutely valueless. Winter, in his most excellent article on the question of recurrences (Zeitschiift fiir Gynec. und Geburt., Band XXVII, Heft 1), apparently depends entirely upon the macroscopic appearance to define the limitsof the disease. One who has studied these tumors microscopically can testify to the utter impossibility of fixing the outermost limits of the disease by the eye or touch. On this account one cannot accept Dr. Byrne's conclusion as to the value of his method of performing vaginal hysterectomy by the cautery. Df. Halsted has proved, by the astonishing results of his operation for the removal of the breast for cancer, that a wide dissection and removal of the glands are demanded ; and the same is true in cancer of the uterus, which can only be successfully removed by the abdominal operation. W. W. R.

Transactions of the Chicago Pathological Society from October,

189'1, to November, 1895. Vol. I. [Chicago: American Medical

Association Press, 1896.)

This little book contains the transactions of a society which is not wholly pathological, and many of the articles are of medical rather than of pathological interest. The pathological papers, however, are well done, as, for example, "The Contribution to the Study of Malignant Growths in the Lower Animals," by Dr. Field, upon which the paper of Dr. Livingood in a recent Bulletin is an interesting commentary ; the report of cases of Leukemia and of Pernicious Anemia, and the paper on Embolic Abscesses due to the Micrococcus Lanceolatus. The papers on Appendicitis, Nephrorrhaphj' for Movable Kidney and Tubal Pregnancy, although not strictly pathological, are of general interest to medical men.

It is to be regretted that the volume is not uniformly printed, which will not seem strange when it is stated that the matter appeared first in the current numbers of a medical journal. If such a system of printing is continued in future, it would add materially to the appearance of subsequent volumes to have successive reports set up in a uniform type. The book deserves a better mechanical appearance.

Medical and Surgical Reports of the Boston City Hospital. Seventh Series. By George B. Shattuck, M. D., W. T. Councilm.\n, M. D., and Herbert L. Brewell, M. D. (Boston: Puhlished by the Tmstees, 1896.)

It is pleasant to know that the issue of reports by the Boston City Hospital has been resumed, and the volume before us is a worthy successor of those which have preceded. A marked feature of the book is the thoroughness of its report on pathological work. This is notably shown in the valuable study of the Lesions in Selected Autopsies by Prof. Councilman and Dr. Mallory, also in Adeno-Carcinoma of the Pancreas, by Dr. Wright. The preliminary essay on Surgical Morals, by Prof. Cheever, is a new departure in hospital reports and one which can be commended. The paper also on Methods of Routine Treatment in the Surgical Outpatient Department is of great value. Altogether the seventh series is worthy of high praise.

Annual Report of the Supervising General of the Marine Hospital Service of the United States for 1894. [Washington: Oovernment Printing Office, 1895.)

In addition to routine reports concerning the oper.itions of the Marine Hospital Service, and full accounts of the various hospitals and quarantine stations under its control, this volume contains much that is interesting to the medical man. Among these may be mentioned detailed histories of the cholera and yellow fever epidemics of 1894, and Prof. Kitasato's Preliminary Notice of the Bubonic Plague in Hongkong, China.

[No. 72.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


THE JOHNS HOPKINS HOSPITAL REPORTS.

Volume L 423 pages, 99 plates.

Report in Pathology,

The VcBsols and Walls of the Dog's Stomacli; A Study of tlie Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D. A Contribution to the Pathology of the Gelatinous Type of Cerebellar SclerosiB

(Atrophy). By Henry J. Berkley, M. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

Mall, M. D.

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

T. C. Gilchrist, JI. 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. ; Tvfo Cases of Molluscum

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


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

Report in Medicine,

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

Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleur, M. D. Cases of Post-febrile Insanity. By William Osler, M. D. Acute Tuberculosis in an Infant of Four Months. Bv Harry Toulmin. M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

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

Report in Gynecologry. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

A. Kelly, M. D., and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section, By Hunter Robb,

M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

Ovarian Tumor; General Gynecological Operations from October 15, 1889, to

March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howabd

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, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment

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

Howard A. Kelly, M. D.

Report in Snrg-cry, I. The Treatment of Wounds with Especial Reference to tlie Value of the Bloud Clot

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Nenrology, I, A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By August Hoch, M. D. A Case of Ccrebro -Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report in Pathologry* I* Amogbic Dysentery. By William T. Councilman, M. D., and Henri A. Lajleub, M. D.


Volume III. ^6Q pages, with 69 plates and figiires.

Report in Pntliology.

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

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

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

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

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

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

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

Report in Gynecolog-y,

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

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

Intestinal Worms as a Complication in Abdominal Surgery, By A. L, Stavblt, M, D.


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

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

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

Traumatic Atresia of the Vagina with Hcematokolpcs and Hsematometra. By Howard A. Kelly, M. D.

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

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

Resuscitation in Cliloroform Asphyxia. By Howard A. Kelly, M. D.

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

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

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

Volume IV. 504 pages, 33 charts and illustrations.

Report on TypUoid Fever.

By William Osler, M. D., with additional papers by W. S. Thateb, M. D., and J. IIewetbon, M. D.

Report in Nenrology.

Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of i(t's mtisculus; The Intrinsic Nerves of the Th.iToid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley, M. D.

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

Report in Gyneeolog-y. Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Citllen, M. B. Report in Pntliology. Deciduoma Malignum. By J. Whitridoe Williams, M. D.


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

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

Stndiea In Typboid Fever. By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon Flexner, M. D., Walter Reed, M. D., and H. C. Parscns, M. D.


Volume VI. About 500 pages, many illustrations.

Report in Neurolosy*

Studies on the Lesions produced bv the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nos. I to V). By Hen-ry J. Berkley. M. D.

Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the Chroma'te 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 11. — Serum Poisoning. — Experimental Lesions induced by the Action of the Doff*s Serum on the Cortical Nerve Cell; Part III. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Clironic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the' Cortical Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Ner\'e Cells from tlic Effects of Alcohol and Ricin Intcxication; Ner\'e Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Patliolosr.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.

CULLEN, M. B.

Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of

0\-um and Spermatozoa. By Thomas S. Cullen, M. B.. and G. L. Wilkins, M. D. Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By

William D. Booker, M. D. The Pathology of Toxalbumin Intoxications. By Simon Flesner, M. D. 77ic price of n set hound in cloth [Vols. I-VI] of the Hosjtital Scparts kv

$30.00. Vols. J, II and III are not sold separately. The itrice of

Vols, ir, V and TI is $5,00 each.


I


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER. The following papers are reprinted from Vole. 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 RnroRD,

M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,

$3.00. THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thater, M. D., and J.

Hewetson, M. D. And A STUDY OP SOME FATAL CASES OF MALARIA.

By Lewellvs F. Barker, M. B. 1 volume of 280 pages. Price, in paper, |2."5. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.\tracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. Subscriptions for the above publications may be sent to

Tbe Johns Hopkins Press, Baltimore, Md.


The Johns Hopkins Hospital Bulletins are issued nwntKly. Tlwy are printed hy THE FRIEDENWALD CO., Baltimore. Single copies may be procured from. Afe.<isrs. CVSHING <t- OO. and the BALTIMORE NEWf! COMPANY, Baltimore. Subscriptions, $1.00 a year, may be addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sinyk copies will be sent by mail for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. VIII -No. 73.]


BALTIMORE, APRIL, 1897.




COnSTTIElsrTS.


Postural Method of Draining the Peritoneal Cavity after Abdominal Operations. By J. G. Clark, M. D., ... 59

Report of Five Cases of Infection by the Bacillus Aerogenes Capsulatus (Welch). By Edward K. Dunham, M.D., - - 68

Observations to Determine the Motility of the Bacillus Aerogenes Capsulatus under Anaerobic Conditions. By Edward K. Dunham, M. D., - - - 74


Multiple Tuberculous Ulcers of the Stomach, with a Report of

Three Cases. By Alice Hamilton, M. D., - - - - 75 Studies on Trichinosis. By Mr. T. R. Brown, - - - - 79 Proceedings of Societies :

Hospital Medical Society, 81

On Certain Visceral Pathological Alterations, the Result of Superficial Burns [Mr. Bardeen].

Notes on New Books, 82

Books Received, --- 83


POSTURAL METHOD OF DRAINmG THE PERITONEAL CAVITY AFTER ABDOMINAL OPERATIONS.

By J. G. Clark, M. D.


The general trend of recent medical literature relating to 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 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

Standpoint of Intraperitoneal Drainage. The Johns Hopkins Hospital Reports, Vol. VII.


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 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 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.


60

[No. 73.


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 Pathological Conditions.

G. Wegner,* the first investigator who by experiments upon animals endeavored to arrive at some definite conclusion concerning the ability of the peritoneum to rid itself of injurious fluids or solid particles, was convinced that a comparatively large quantity of infectious matter could be eliminated or encapsulated by the peritoneal exudate without serious harm to the animal.

Grawitzf next took up the experimental study of infection of the peritoneum, pursuing his investigations under improved bacteriological technique, and arrived at the following conclusions :

1. The introduction of non-pyogenic organisms into the abdominal cavity, either in small or large quantity, or mixed with formed particles,J produces no harm.

2. Great quantities of organisms which ordinarily produce no symptoms, may give rise to a general sepsis if the absorptive function of the peritoneum is impaired.

3. Injection of pyogenic organisms into the peritoneal cavity may be quite as harmless as injections of non-pathogenic varieties. (In these experiments he injected a flocculent emulsion of staphylococcus albus and aureus and the streptococcus pyogenes in ten cubic centimeters of water without any visible reaction.)

4. The introduction of pus-producing cocci into the normal peritoneal cavity produces a purulent peritonitis, first, if the culture fluid is difficult of absorption, and second, if irritating 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 grow.

Pawlowsky,§ in an excellent experimental study, reviewed Wegner's and Grawitz's work, with whom he agreed in many


  • 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 encapsulated.

§Virchow's Archiv, No. 117, p. 469, 1889.


particulars, but disagreed in others. The main point of difEerence, however, between Pawlowsky and Grawitz related to the ability of the normal peritoneum to deal with the staphylococcus aureus.

Pawlowsky found that the large quantities of staphylococci injected by Grawitz without harm into dogs produced death 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 research, and in the main agreed with Grawitz. The essential points of value in Reichel's paper are, that peritonitis usually arises, first, because more organisms gain entrance than can be handled by the peritoneum, and second, because the stagnation of degenerating fluids in dead spaces favors the growth of the organisms.

He also accounts for Grawitz's and Pawlowsky's conflicting 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 to satisfactorily settle the question of the ability of the normal peritoneum to take care of infection.

He injected 6 cc. of a cloudy culture of staphylococcus aureus into the abdominal cavity of dogs, employing both the methods of Grawitz and Pawlowsky, and all of the animals survived. The same results were obtained with the streptococcus, bacillus pyocyaneus and the intestinal bacteria.

Waterhouse then endeavored to simulate the conditions occasionally met with after operations, by introducing 8 cc. of 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 and Grawitz that the dangers of peritonitis are increased by tardy absorption of fluids, which in effect leaves a culture medium for the growth of the organisms.

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 done in Grawitz's experiments, peritonitis did not follow, which is explained by Waterhouse on the ground that the organisms are rendered inactive or are killed by the turpentine. He proved this point by injecting the turpentine first


  • Beitrage zur Aetiologie u. chirurg. Therapie der Sup. Peritonitis. Deutsche Zeit. f. Chir., Vol. XXX, 1889.

t Virchow's Archiv, Vol. 119, p. 342, 1890.


April, 1897.]

61


and following it in a short time with the infecting germs ; in every instance the animal died of peritonitis.

Dogs with a strangulation of the intestines were easily infected.

In three instances the staphylococcus aureus was introduced into the peritoneal cavity of cats suffering from ascites, followed quickly by death from peritonitis, which resulted, as Waterhouse says, because there was a favorable culture material, a diminished absorption, and an injury to the peritoneal endothelium.

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 General Immunity," contains some valuable observations bearing upon the resistance of the peritoneum to infection.

Notwithstanding the injection of large quantities of virulent streptococci, a few of their animals survived. They state that " in those animals which succumbed quickest, free cocci were very numerous in the peritoneal exudation, and in those which survived longest they were either absent or contained within phagocytes."

These observers, in order to discover how quickly the organisms disappeared from the peritoneal cavity, killed two rabbits which appeared about to recover. " In the first, which had received 5 cc. of broth culture thirty hours before, only one chain of streptococci was found after prolonged search, but many cocci were contained in cells, and broth inoculated with this fluid grew a good culture."

"The second rabbit having shown no signs of illness after an injection of 6 cc. of anaerobic broth culture, received next day 10 cc. of a similar material swarming with streptococci. When killed five and a half hours later, not only could no streptococci be seen, either free or in cells, but no growth grew on cultures made from the abdominal fluid."

From this review of the literature bearing upon infection of the peritoneum I make the following summary :

1. Under normal conditions the peritoneum can dispose of large numbers of pyogenic organisms without producing peritonitis.

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.


•Baumgarten's Jahresbericht, Vol. VII, 1891.

tThe Johns Hopkins Hospital Reports, Vol. II, 1891.

t Journal of Pathology and Bacteriology, 1895.


4. Death may be produced by general septicaemia, and not by peritonitis, where large quantities of organisms are taken up by the lymph streams.

5. Irritant chemical substances destroy the tissues of the peritoneum and prepare a place for the lodgment of organisms which becomes the starting-point for peritonitis.

6. Stagnation of fluids in dead spaces favors the production of peritonitis by furnishing a suitable culture medium for the growth of bacteria.

7. The association of infectious bacteria with blood clots in the peritoneal cavity is especially liable to produce peritonitis.

8. Traumatic injury or strangulation of large areas of tissue are strong etiological factors in the production of peritonitis when associated with infectious matter.

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 the diaphragmatic peritoneum and the mechanism of absorption of substances from the peritoneal cavity, when considered in conjunction with the above conclusions, give ample ground for my suggestion of the elevated posture as a prophylactic measure against post-operative peritonitis.

Muscatello accepts Bizzozero's and G. Salvioli's classification of the component parts of the diaphragmatic peritoneum which occur in the following order: endothelium, membrana limitans and connective tissue framework. Up to the time of Muscatello's publication, histologists were equally divided on the question of the presence or absence of stomata between the endothelium. He proved beyond doubt that these openings are optical illusions, due to the defective preparation and staining of the microscopical sections. According to Muscatello's opinion, minute foreign particles, leucocytes and fluids pass through openings between the endothelium of the diaphragm made by the retraction of the protoplasm of the cells.

Beneath the peritoneal endothelium of the diaphragm and 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


Virchow'a Archiv, 1895.


62

[No. 73.


of the foreign particles from the peritoneal cavity to their ultimate repository, the lymph glands, could, however, be 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 glands in from five to seven minutes, while in animals in 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 the peritoneal cavity into the lymph spaces of the diajihragm through the opening made by the retraction of the endothelium, then into the mediastinal lymphatic vessels and glands, then into the blood current, by which they were transported to the various organs of the body, from which they were picked up by the lymph vessels and deposited in the collecting glands of each organ. For this reason the large vascular organs, such as the liver, stomach, spleen and pancreas, show the particles first and in the greatest numbers, while the 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 the elimination of foreign particles from the peritoneal cavity.

Muscatello and other observers find, on examining the 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 leucocyte to encompass it, two or more join forces to surround the invader. The leucocytes are found in greatest abundance beneath the omentum. Prom the peritoneal cavity Muscatello traces the course of the leucocyte through the channels above described and finally finds them deposited in the lymph glands in various parts of the body.

In Muscatello's experiments the leucocytes were able to dispose of the innocuous particles rapidly and without apparent ill effect to the auimals. In Pawlowsky's, Cobbett's and Melsome's experiments, on the other hand, the conditions were different, the leucocyte having to meet an antagonistic invader. In those animals which survived the injection the infectious organisms were quickly encompassed by the leucocytes and carried into the general circulation, while in the 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 wish to draw especial attention to are :

1. Large quantities of fluids may be absorbed by the peritoneum in a remarkably short time. (Wegner.)

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.)


3. The leucocytes are largely the bearers of foreign particles from the peritoneal cavity. (Muscatello.)

4. There is normally a current in the peritoneal cavity which carries fluids and foreign particles towards the diaphragm, regardless of the posture of the animal, although gravity can greatly favor or retard it. (Muscatello.)

Postural Method of Draining Dead Spaces in the Pelvis.

The many bacteriological studies in cases of experimental and post-operative peritonitis and in experimental infections of the peritoneum show conclusively that the infecting organisms are quickly distributed more or less generally in the peritoneal cavity, from whence they are carried into the system at large.

Where there is no persistent source of infection, virulent species of bacteria may be destroyed effectually in this way; but when a nidus of infection exists in which the microorganisms are propagated, the patient is either carried off by a 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 localized collection of pus.

To avoid this danger the most scrupulous care should be observed in every abdominal operation not to leave behind any condition which may furnish a starting point for an infectious process.

Oozing should be controlled as far as possible, injury and exposure of the peritoneum should be guarded against, raw areas should be covered with adjacent healthy peritoneum 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 after many operations, which may become collecting places for degenerating fluids. In addition to these artiflcial spaces, oozing serum and blood may collect in Douglas' cul-de-sac or in the ante-uterine space, and become the focus of a genei'al peritonitis or a localized pelvic abscess.

To offset these dangers all dependent spaces should be drained as rapidly as possible, thus preventing the collection and stagnation of vital fluids, which are active germicides when first secreted, but become excellent culture media when degenerated.

By elevating the pelvis after operation, the normal intraperitoneal current may be assisted greatly in at once draining dead spaces, and thus give the general peritoneal cavity and system at large the best opportunity to meet the invading organisms before they have had time to increase in numbers. 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 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.]

63


In additiou to tbe mere transportation of the organisms from an area of decreased resistance to one of normal resistance, the irritant chemical toxines elaborated by the bacteria 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 the absorption of large quantities of organisms from the peritoneal cavity, it appears to me correct to assume that after a well-conducted abdominal operation no such quantities of 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 of drainage are, first, stagnating fluids are prevented from collecting in dead spaces in the pelvis; second, infectious organisms are quickly carried into normal areas of the body where they are destroyed before they can increase in numbers; and third, toxic substances elaborated by the organisms are diluted and prevented from expending their irritant effects on a wounded area.

The method which I desire to offer is briefly as follows: At the conclusion of an operation all fluids and debris should be removed as far as possible by sponges, after which the abdominal cavity should be thoroughly irrigated with normal salt solution until the fluid comes away clear.

When the irrigation fluid is all sponged out, 500 to 1000 cc. of salt solution should be poured into the peritoneal cavity, so that when the patient is elevated after she is returned to the ward the artificial current may be started at once towards the diaphragm, thus supplementing the normal current.

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 novel procedure, as it has been done in a large number of cases during the last two years in the gynecological department, and other abdominal surgeons have used it with good effect.

This postural method of drainage is offered as a prophylactic measure against post-operative peritonitis, but not as a curative measure after the peritonitis is established.

It should therefore not be employed when an operation is performed for the relief of purulent peritonitis or for inflammatory conditions associated with general peritonitis, as for instance some cases of appendicitis.

From the experiments of Waterhouse in which he proved the danger of infection in cats suffering with ascites on account of the defective absorptive mechanism, it would also appear unsafe to adopt the postural method in cases when


this complication is coincident with the surgical affection. Pawlovvsky has sliown in his excellent experimental investigations that the lymph channels leading from the peritoneal cavity are choked with the infectious bacteria and inflammatory products in purulent peritonitis, and therefore advises free drainage through an abdominal incision.

In these cases it is evident that the multiplication and virulence of the organism have been too great for the phagocytes to overcome successfully, and that the only method of treating this condition is to remove as much pus as possible by irrigation with salt solution or by mopping the peritoneal surfaces with sponges wet with salt solution, as suggested by Finney, and then to insert a very free drain.

Only one of the cases which I report in this paper showed organisms on culture. The presence of pyogenic organisms is not a contraindication to the employment of the jiostural method, because all investigations have proved conclusively 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 organisms are yet active, as shown by Miller of the Johns Hopkins Hospital, Schauta, Menge and others.

In forty-four cases of hysterectomy, mostly for pelvic inflammatory disease, examined by Miller, the cultures made 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.

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, 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 period terminated December 18, 1896.

Present Illness. November 15, 1896, she had a severe chill, lasting two hours, followed by fever. The next day she had great pain, which continued one week and was accompanied with diarrlia.'a. Since then she has grown steadily weaker.


64

[No. 73.


fever and chills occurring frequently, and for the last week she has been confined to bed.

General Condition. Well nourished woman; tongue slightly coated, bowels regular, appetite poor. Micturition and defecation painless. For the past four weeks she has had a dry cough.

Examination of heart and lungs negative.

Temperature on admission 103° F., pulse 110.

Diagnosis. Large suppurating ovarian cyst.

Operation by Dr. Kelly, January 20, 1897. Cystectomy; part of cyst wall could not be removed.

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.


Incision 14 cm. in length, exposing red mottled and whitish cyst wall, closely adherent to anterior abdominal wall over a surface 10 cm. above symphysis pubis. Omentum adherent to anterior face of cyst over an area 10x8 cm. Adhesions separated; free oozing from thickened omentum checked by catgut sutures, no omentum removed; just above this point there was a fringe of flat adhesions, binding cyst to intestines 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


Jan.


18


19 20


21


23


24


25


26


Temp.

103 102 101 100

99

98

Temp.

Pulse Resp.

Stools


Day of 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



5(10


540


560


6()0


>» •




670


^'"


5ilO +


^'*..


190 +


,\


30 +


130 120 110 100 90


80

70

4 60

50


Case I. Plain line indicates temperature. Broken line indicates pulse.


where it was lost in the tumor. Adhesions to uterus, to pelvic floor on right side, and to part of left pelvic wall divided. 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, discharging a large quantity of fetid pus into the peritoneal cavity. This was quickly mopped out and the hole in the sac stuffed with gauze. Cyst cut loose, leaving a portion of abscess wall 5x8 cm. in dimensions on the pelvic floor. Gauze


packed over this to protect it during the rest of the operation. Sac was peeled up and out of a dense bed of adhesions in the pelvis ; it was then found that the adhesions, extending between the entire length of the mesentery and out onto the intestines, were too extensive for further separation. The outer layers of the cyst wall were slit 2 cm. from bowel on all sides and dissected out from beneath the mesentery, thus completing the enucleation and leaving behind a large cup-shaped dead space. Slight capillary oozing occurred from the portion of cyst wall remaining behind.

The portion left in the pelvis also required six or eight ligatures to control oozing. Small epithelial cyst on right side


April, 1897.]

65


piiuctured. Eight ovary normal. Eight tube adherent and closed.

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 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. 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.

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.

In this case the operation was very difficult and attended by many complications. The peritoneum was injured extensively, pus escaped during the operation, the intestine was injured and required suture, free oozing occurred during the operation and persisted at its completion, and large denuded areas were left in the pelvis.

Gynecological No. 4892. A. E. T., widow, aged 34 years.

Complaint. Pain in the right inguinal region, pain in the rectum, and swelling of the abdomen at times.


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.

Present Complai?it. Three years ago she was confined to bed for three weeks with fever and chills and severe pain in the lower abdomen, which began in the right side and then shifted to the left. During the attack she had a constant discharge of thick tarry blood from the uterus. After the attack she was able to get up, but it soon recurred, and the abdomen became greatly distended and excessively painful. Ten days ago another attack began, which has not been so severe up to this time as the former ones. She complains of pain during defecation and micturition, backache and bearingdown pains. Temperature on admission 101° F., pulse 120.

Diagnosis. Pyosalpinx duplex ; retroflexio uteri adherens; pelvi-peritonitis.

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 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 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 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

[No. 7.3.


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. 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 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.



V)a.y a?

Operation


Case II. Plain line indicates temperaiure. Broken line indicates pulse.


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


a hirge cavity in the pelvis. Pieces of the cyst wall and much debris remained behind at the completion of the operation.

There was considerable oozing and extensive traumatism produced by the separation of tlie wide-spread adhesions.

Pus from the cyst injected into a mouse killed it within twenty-four hours.

Notwithstanding all these complications the patient made a good recovery.


April, 1897.]

67


Gynecological No. 4928J. A. E. S., admitted January 9, 1897. Single, age 35 years.

Complaint. Increasing size of abdomen, severe constipation, feeling of obstruction in abdomen. Menstruation began at 15 years, recurring every 28 days, 4 to 5 days duration, normal.

Family History. Negative.

Present Illness. Patient was always strong and well until four years ago; at this time she suffered with indigestion, and was treated by her physician for displacement of the uterus. She had an attack of peritonitis in September, 1895, which confined her bo bed four weeks. In October, 1896, she suffered


9 10 II 12 13 14 15 16 17


with " chills and fever," which lasted eight weeks. During 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 operation for hemorrhoids performed in 1892.

Present Condition. Body emaciated, complexion pale, expression anxious. Appetite good. Micturition normal.

Examination of heart and lungs negative. Temperature on admission 100.5° F., pulse 120.

Diagnosis. Suppurating ovarian cyst.



Case III.

Plain line indicates temperature. Broken line indicates pulse.


Operation by Dr. Kelly, January 16, 1897. Cystectomy.

Complications. Dense adhesions between cyst and intestine, fistulous opening between intestine and cyst. Pyogenic 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


a fistulous track between the two 5 cm. in diametei-. Appendix thickened and twice its normal size, adherent to a black ragged area 2x2 cm. It was not removed, as it showed no disease and the patient's condition was very critical.

On right side the tumor was adherent to the anterior abdominal wall over an irregular area 6x3 cm., running down to cornu uteri. This area was scraped free of pus and lymph and covered with peritoneum from side to side.

Eagged area on colon covered in by base of appendix, which was sutured over it with interrupted catgut ligatures. Silk sutures were used to close the opening in the colon. Abdominal cavity thoroughly irrigated. Salt solution infusion (500 cc.)


68

[No. 73.


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 was 136, having dropped 14 beats in twenty minutes. Foot of bed elevated. Five o'clock in the evening pulse 128. Nine o'clock, 120. Twelve o'clock, 108. Patient comfortable and complaining of little pain.

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 99.8° F. Small liquid movement.


Fourth Day. Pulse 96, temperature 99° F. Considerable pain in abdomen.

Fifth Day. Temperature 98°, pulse 90. Patient had a comfortable night.

Sixth Day. Pulse 80, temperature 98° F.

Tenth Day. Convalescence has been uninterrupted. Dressiugs removed from abdomen, union of incision ^ler primam.

Patient sat up on her 20th day.

Bacteriological Examination. Cover-glass preparations showed many cocci and bacilli. Two cc. of pus injected into 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.


KEPORT OF FIVE CASES OF INFECTION BY THE BACILLUS AEROGENES CAPSULATUS (WELCH).

By Edward K. Dunham, M. D., Professor of Bacteriology, Bellevue Hospital Medical College, Neiu York.


Within the past year the writer has had occasion to study five cases of infection in which he believes the bacillus aerogenes capsulatus, described by Welch and Nuttal, and Welch and Flexner, either caused or hastened death.

In all but one of these cases the bacillus was found in material taken from the tissues of the patient during life.

The first case died on the 11th of March, 1896.

The patient was a woman, aged 23 years, who was admitted to St. Vincent's Hospital, New York, on the 7th of that month, and then gave the following history :

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, 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


excruciating; swallowing was practically impossible; the voice 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 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 incubator. Upon these two sorts of colonies developed, one 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 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


April, 1897.]

69


of these bouillon cultures and died during the following night. 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, 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, 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 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 production of gas.

In all the media the bacillus proved to be a strict anaerobe.

The bacillus grew well in bouillon to which 1 per cent of glucose had been added, and these cultures evolved a considerable amount of gas when incubated in an atmosphere deprived of oxygen by means of potassium pyrogallate.

In order to determine the nature of this gas, six fermentation tubes containing glucose bouillon (1 per cent of glucose) were inoculated with the bacillus, and, after 24 hours, the gas collected in a eudiometer over mercury. 28.6 cc. of gas 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 gas was determined :

Hydrogen 64.3 per cent.

CO2 27.6

Nitrogen (?) 8.1*

100.00 per cent.


On the 22d of March, i. e. eleven days after the pus was 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 hospital, another guinea-pig was inoculated, by means of a 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 killed after the lapse of a few minutes, the bacillus caused enormous swelling of the body of the animal within 20 hours, and the liver, kidney and spleen, as well as the subcutaneous tissue, were the seat of a very marked emphysema. The skin was rendered so tense by the accumulation of gas that it seemed on the point of rupturing.

The foregoing characters of the bacillus under study 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 of these spores, and it was found that when taken from the 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


  • The composition of the residual gas in the eudiometer was not

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 states that the bacillus aerogenes capsulatus in his possession produced spores when cultivated on LoefHer's blood serum. This observation tends to still further establish the identity of the bacillus isolated by the writer.

i The author has observed that the spores of bacillus subtilis are much more easily killed by moist heat when freshly formed than after a lapse of time and drying.


70

[No. 7.3.


when placed iu broth at the body temperature under anaerobic 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 water, and are not decolorized by a moderate exposure to the action of a 3 percent, solution of hydrochloric acid in absolute alcohol.

They have an oval shape and are usually situated near the 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 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 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 patient were opened and a focus of suppuration was found, 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 appear emphysematous. Microscopical examination of bits of those organs failed to reveal the bacillus.

Sections from the organs of the rabbit into the veins of which the bacillus was injected, when stained by Gram's 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 130 and very feeble.

On the 20th he was delirious throughout the day. 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.


Free incisions were made and the subcutaneous tissues found in a necrotic condition. The wounds were washed with mercuric chloride and drained.

On September 22d the patient was still delirious, very weak, with a fluttering pulse. The dressings were again removed and fresh incisions made in the arm. The cedema had extended well into the pectoral region and down to the elbow, and at this time, I believe, some emphysema of 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, the other half with access of air.

After 48 hours the aerobic cultures showed only colonies of cocci, while the anaerobic cultures contained colonies in which both cocci and bacilli had developed. The latter tubes gave evidence of gas production, the agar being raised from the 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 ear-vein of a rabbit and five minutes later the animal killed. 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 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. (See " II," temperature chart.)

The third case of infection was a man, a't. 33, of alcoholic habits, who had suffered from urethritis on two occasions the last time three years before he presented liimself for final treatment at Belle vue Hospital.

When he was admitted to the hospital, on November 6, 1896, he had difficulty in voiding his urine, owing to a stricture of the urethra which could not be passed by instruments.

On December 5th, at 3.30 p. m., external urethrotomy \yas performed, and the patient did well until 2.30 p. m. on December 8th, when a sound was passed.

Twenty-one hours after this procedure a chill ensued, which was followed by severe pains in the joints and back, and from that time the patient rapidly grew worse and died on the 10th of December at 8 p. m.

At 9 p. m. on the day preceding death, an area of subcutaneous emphysema appeared over the front of the right thigh, and others over both shoulders. These areas increased rapidly in size up to the time of death and afterwards.

The following notes on the bacteriological examinations of material from this case and of the autopsy are kindly furnished me by my assistant, Dr. F. M. Jeffries, who conducted them. At 1 p. m. on December 10th, i. e. -1 hours before the death of the patient, three agar tubes were inoculated from the subcutaneous tissue in the emphysematous area on the thigh. These, although placed under anaerobic conditions, failed to develop, probably because of excessive acidity of the agar.

At the autopsy made 18 hours after death, cultures on agar and in bouillon were made from the heart, lungs, liver, brain, and the emphysematous area on the thigh. These cultures were incubated under anaerobic conditions in Novy jars with pyrogallate of potassium.

After 24 hours the cultures from all these sources had developed, with evolution of gas. They all consisted of bacilli resembling the bacillus aerogenes capsulatus. They wei'e not motile and stained well by Gram's method. All the cultures contained only this one bacillus, without admixture of other bacteria.

Intravenous injection of a bouillon culture in a rabbit which 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.

Subcutaneous emphysema was noted, extending over the 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 abdomen was soft, pulpy and emphysematous. There were emphysematous areas on the pleurte and pericardium. There was general emphysema of the lungs. The cavities of the heart were distended, their walls soft and oedematous, and the blood they contained dark and fluid.

The liver was of a dark cliocolate color, soft and the seat of emphysema.


The spleen was dark plum-colored, extremely friable and emphysematous.

The kidneys were enlarged, showed subcapsular emphysema, and were plum-colored.

The mucous membrane of the bladder was extremely 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 .January, 1897.

Four years ago he had gonorrhrea, which persisted for eight months, and three years ago he had another attack of the same trouble which lasted three months. Neither of these attacks was accompanied by symptoms pointing to inflammation of the bladder or testes.

Two years ago, i. e. about one year after the beginning of the second attack of gonorrhcEa, he felt pain on urination and noticed that the stream of urine was diminished in size. Shortly after this he had retention of urine, and was catheterized with some difficulty, and the urethral stricture then gradually dilated with sounds, the treatment lasting for two months. Since that time he had omitted all treatment.

At the time of his admission to the hospital the patient 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 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 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 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.


72

[No. 73.


At 10.30 the bladder was agaia irrigated.

On January 10th the patient felt well and the bladder was draining nicely.

At 1.30 the urethra and bladder were irrigated with a warm saturated solution of boric acid. The anterior urethra contained some dark fluid blood which was washed away, and the 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 patient had a severe chill, lasting half an hour.

At 3.30 a. m., January 14th, a slight bleeding took place from the urethra.

At 8 a. m. pain in the left shoulder was complained of.

At 11 a. m. a catheter was introduced throiigh the perineal wound and about 3 ounces of bloody fluid having a foul 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 darker than before and was irregularly mottled with purple spots.

At 8.15 a. m. an incision, two inches in length, was made 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


a. m., forty-five hours after the sounds were passed on the 13th of January.

Dr. Brooks performed the autopsy on this case, and the following account is taken from his notes :

The autopsy was made 5 hours after death, while the body was still warm.

Rigor mortis was marked; the general nutrition good.

Post-mortem discoloration was extreme from the pelvis up, and there was emphysematous crepitation over the abdomen, especially in the suprapubic region ; over the back, the buttocks, and the thigh, leg, and dorsum of the foot on the left side ; also, though in less degree, on the right side.

Puncture of the emphysematous areas permitted the escape of a gas which burned with a blue flame.

The abdominal wall was greatly distended, and when an incision was made the inflated intestines protruded.

The liver was of a light clay color and crepitated under the fingers. Its tissues were very friable, and filled with minute vesicles containing gas. The cut surface appeared oedematous.

The spleen was enlarged, of a dark purple color, and very friable.

The kidneys were enlarged; their capsules adherent.

The lungs were somewhat (Edematous.

The cavities of the heart were distended on both sides by 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 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 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


April, 1897.]

73


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 both at least facultative anaerobes, efforts to separate that 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 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 patient passed a hard rubber catheter and drew some blood.

On the 21st, pain in the right ischio-rectal fossa was noticed, and the tissues at the site of the pain were found to be firmer than normal.

On the 22nd the pain in the right buttock was more severe. The 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 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


found the scrotum emphysematous, with spots of gangrene upou it. Temperature 103°.

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 blackness and emphysematous, but contained no pus. A slight ojdematous condition prevailed in the deeper structures.

The tissues were irrigated with mercuric chloride and an iodoform dressing applied.

On the following day, January 26th, the emphysema had extended over the pubes and the hypogastric region, the skin being raised about half an inch. The color of the skin over this area was either normal or had a pinkish blush.

Two free incision* were made to evacuate the gas, and it 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 sloughing had extended so as to include the skin, but without the formation of pus.

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 emj)hysema in the body of a rabbit killed shortly after the injection of the culture into a vein of the ear.

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.


74

[No. 73.


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 distribution ; for within eleven months these five cases have come under the observation of a single individual and were, 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


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 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.


OBSERVATIONS TO DETERMINE THE MOTILITY OF THE BACILLUS AEROGENES CAPSULATUS

UNDER ANAEROBIC CONDITIONS.

By E. K. Dunham, M. D.


Bouillon cultures of the bacillus were studied in flattened capillary tubes from which the oxygen of the air had been absorbed by means of pyrogallate of potassium. Although these cultures were examined at intervals varying from 15 minutes to 24 hours, at no time could any evidence of motility 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 glass tubing, about 8 inches long and with a bore measuring about i of an inch, strongly in the middle, then bringing the 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.


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).


Fto. I.


Fig. <3.


F,g.l.

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


April, 1897.]

75


greater numbers than when the cultures were first introduced into the tubes, showing that the conditions were favorable for 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 is shown by the fact that in all the tubes the bacilli soon subsided to the bottom, leaving the bouillon above them free from bacilli. If the tube was turned a little about its long axis and kept in that position for a time, the bacilli settled towards the lower side of the tube.

These observations appear to demonstrate that this bacillus does not possess the power of locomotion, even under anaerobic conditions.


MULTIPLE TUBERCULOUS ULCERS OF THE STOMACH, WITH A REPORT OF THREE CASES.

By Alice Hamilton, M. D.

[From the Pathological Laboratory of the Johns Hopkins University and ITospital.]


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 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, but with a single ulcer in the anterior wall of the stomach, which on microscopic examination showed typical caseating tubercles with giant cells. Talamon also describes tubercles found in the walls of ulcers in the stomach of a child which 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 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 at Kiel. He examined all for the tubercle bacillus, but failed to demonstrate it in the two older specimens which had been a long time in the museum. Nevertheless, the histological appearances in the first of these cases point quite positively to tuberculosis; in the second his description is too scanty and obscure to place it above question. The third and fourth instances, which were recent, are described as containing caseating nodules with tubercle bacilli. R. G. Hebb and G. Lava


76

[No. 73.


report each a case of single ulcer — at the lesser curvature and at the pylorus respectively — and describe the microscopic findings as tubercles with caseation and giant cells. It is to be regretted that these observers failed to make any search for the bacillus tuberculosis. This omission is still more striking in Letorey's otherwise exhaustive description of a case of diffuse ulceration near the pylorus. He states that tubercle bacilli were found in the lungs and in the diseased part of the femur, but seems not to have looked for them in the ulcers, where he, however, found typical caseating nodules.

In the following cases it is difficult to decide whether the lesions described are really tubercular or not, the authors having satisfied themselves of the correctness of their diagnoses, but having failed to establish them by giving the facts on which they were founded. So, for instance, Hattute merely states that his case showed "elements of tubercle in the granulations." Lorey, Anger, Matthieu, (Jazinaud Beadles give no details at all. Finally, a large number must be utterly rejected as, according to the explicit statement of the authors, no microscopic examiuation was ever made. Such are the cases of Bignon, Paulicky, Chvostek (four), Hebb (second case), Lauge, Barlow and Quenu, which last rests for its diagnosis on a mere statement of the author, no description of its macroscopic appearance being given. Several others which have been placed in the list of tubercular ulcer were really miliary tubercles in the walls of the stomach. Kiihl's fifth case is an example, also Earth's. Labadie-Lagrave's case showed a cicatrix near the lesser curvature, its tubercular origin being merely hypothetical. Oppolzer's is described as a perforating ulcer connecting stomach and colon, supj)osedlyof tubercular origin, but it was impossible to say in which organ it originated. This covers all of the authentic literature so far as I have been able to discover, and it will be seen that it contains fifteen undoubted cases and nine more which are probable but not proven.

The two cases which I wish to report are, I think, undoubtedly tubercular, although neither could be considered as strictly typical. Indeed, the histological findings in the second case were so little suggestive of tuberculosis that, had it not been for the discovery of the tubercle bacillus, I should not have ventured to class it as tubercular, but the large numbers of bacilli present leave no doubt that they were the prime factor in causing the ulcerative process. The first case, which contained very few bacilli, presented an appearance that was much more characteristic of tuberculosis. I will omit the histories of these cases, which offered nothing of special interest, merely stating that both patients were admitted to the Johns Hopkins Hospital, to the service of Ur. Osier, in the advanced stages of pulmonary phthisis. The autopsies were performed by Dr. Flexner, from whose reports I will give merely the essential points.

Case 1. Colored female, aged 30 years. The right lung contained near the apex a cavity about the size of a small walnut, with smooth walls; the lung tissue adjacent was densely infiltrated and converted into a caseous mass. In the lower portions of the upper lobe, beneath the anterior surface and near the middle line, a small cavity existed with smooth walls which communicated freely with the bronchi. Its walls were caseous, and


adjacent to it were large caseous masses surrounded by oedematous and congested tissue, which often presented a gelatinous appearance. The upper portion of the lower lobe was taken 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 existing in the stomach. Our studies embraced the examination of many of these, often in serial sections, both with respect to their pathologic histology and to the presence of tubercle bacilli. Ulcers of various sizes were sectioned, stained 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.]

77


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 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 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


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 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

[No. 73.


previous lesion existed to enable it to get a foothold; and 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 gastric ulcer came under observation, which proved also to be of tubercular origin, and the specific character of which was far more easily determined than in the other two cases. The lesions here conformed in every way most closely to the usual type of tubercular ulcerations. The ulcers wei-e in this case but two in number, of large size, and accompanied by the formation of tubercles which were evident even to the naked eye.

Vase 3. The patient was a colored girl of eleven years of age. She entered the medical department of the Johns Hopkins Hospital (service of Dr. Osier) on June 16th. Tubercular peritonitis was diagnosed, and she was transferred to the surgical side, where the diagnosis was confirmed by an exploratory operation, the peritoneum being found covered with miliary tubercles and the intestines matted together. The patient recovered from the operation and lingered until December, when death occurred. The autopsy was performed by Dr. Livingood, from whose report the following extracts have been taken.

The body was much emaciated. Extending from below the costal margin to a point opposite the umbilicus was the scar of an imperfectly closed incision, the floor of which consisted of a sloughing surface covered with pus. Near the umbilicus the tissues were darkened and necrotic in appearance. On attempting to open the peritoneum, the transverse colon and the upper part of the omentum were found completely coherent. Below, the intestines were closely matted together by fibrinous and fibrous bands, which could be stripped apart, though with difficulty, especially at the umbilicus. The parietal layer of the peritoneum was thickened and studded with conglomerate and miliary tubercles. The peritoneal cavity contained a large amount of turbid, yellowish-white fluid with fine flocculi. It had a slightly faecal odor. The serous coat of the intestines was studded with numerous caseous tubercles, usually about the size of a cherry-stone, but ranging larger and smaller. The appendix vermiformis was so matted in the mass that it could not be found.

The anterior mediastinal and the lower cervical glands wei-e enlarged and caseous. The visceral and parietal layers of the pleura on the right side were studded with caseous tubercles, some of which reached the size of a beau.


The pleural cavity was partly obliterated by fibrous adhesions. The lung contained in its apex numerous small nodules, some of them caseous ; it was congested over the remainder of its extent, and small tubercles could be seen and felt scattered through it. The left pleural cavity was completely obliterated, and the lower lobe of the lung could not be freed from the diaphragm, but had to be removed with it. Miliary tubercles were scattered over both layers of the pleura, especially thickly along the lines of the ribs. A large area of caseation was formed where the lung was in contact with the diaphragm, and this process seemed to have extended directly through the diaphragm to the spleen and liver beneath. The upper lobe of the left lung showed more extensive tuberculosis than did the right lung, being filled with numerous tubercles in all stages of caseation, but without definite cavity formation. Small nodules were scattered through the lower lobe, which was much congested and, at its lower extremity, in the early stage of consolidation.

The spleen was adherent to the diaphragm and to the parietal peritoneum. Its capsule was thickened and was the seat of large caseous tubercles, but there were no distinct tubercles in the substance. One small caseous tubercle was found in the right kidney. The mucous membrane of the uterus was the seat of a number of yellow and gray miliary tubercles. Both tubes were enlarged and adherent to the surrounding structures. Some of the lymphatic glands in the broad ligament were caseous, and the vaginal mucous membrane contained a single tubercle. The caj)sule of the liver was covered with numeroiis minute tubercles, and others were found in the substance of the organ. The pancreas was closely adherent to the caseated retroperitoneal lymph glands, and its substance showed large caseating areas.

The stomach was adherent to the transverse colon, the pancreas, and to the mass of enlarged peripancreatic lymph glands. The serous coat was covered with small and large caseous tubercles. Midway between the pylorus and the cardia on the posterior aspect of the lesser curvature, was a large, irregularly oval, crater-like erosion, 3 cm. by 2 em. in size. The edges were raised and somewhat undermined and more deeply congested than the surrounding parts. The floor was irregular, the deepest part of the crater measuring 8 mm., while the remainder was formed by projecting caseous tubercles. Directly behind this ulcer was a caseous lymphatic gland, so closely adherent to the stomach wall at this point that it was impossible to tell whether or not it formed the floor of the ulcer. A second smaller erosion was found above this one, in the middle of the lesser curvature. Its edges were slightly elevated, and in one place deeply undermined, the floor being formed by the muscularis. Here and there scattered through the mucous membrane were minute grayish white and yellow points looking like, but not proven to be, miliary tubercles. In the duodenum, just beyond the pyloric orifice, was a large ulcer with caseous tubercles covering its base; a similar but still lai-ger one was found in the cajcum, and smaller ones scattered through the small intestines.

In the microscopic examination of the larger of the two gastric ulcers, the section passed also through the adherent lymph gland, which was found to be completely necrotic. It


Apbil, 1897.]

79


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. Litten : Virchow's Archiv, 1876. Talamon ; Progres Medical, 1879. Brechemin: Bull. d. 1. Soc. Anat., May 1879. Eppinger: Prager Med. Wochenschrift, 1881.


Barbacci : Lo Sperimentale, May 1890.

Coats : Glasgow Med. Journal, 1886.

Serafini : Annal. clin. del Osp. di Napoli, 1888.

Mathieu and Remond : In Letorey's Thesis, Paris, 1875.

Musser: Phila. Hosp. Reports, 1890, I.

Kiihl : Thesis, Kiel, 1889.

G. Hebb: Westminst. Hosp. Reports, 1888, III.

Lava: Gazz. Med. di Torino, 1893.

Letorey: These, Paris, 1895.

Hattute: Gaz. des Hop., 1874.

Lorey: Bull. d. 1. Soc. Anat., 1874.

Anger : In Marfan's Thesis, Paris, 1887.

Marfan : These, Paris, 1887.

Matthieu : Bull. d. 1. Soc. Anat., 1881.

Cazin : In Fernet's article. Bull, et Mem. d. 1. Soc. Med. des

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.


STUDIES ON TRICHINOSIS.


By T. R. Brown.


[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 discharged well.

During his stay in the hospital the blood was examined daily. The number of leucocytes per cm. was determined and a differential count was made of the various forms; frequent 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.]

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 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


80

[No. 73.


the eosinophiles and the Charcot-Leydea crystals, various experiments were made with the blood which contained such large quantities of eosinophiles, to see if the crystals could be derived directly from these cells. In all cases, however, the results were negative, seeming to show that the crystals are, at least, not direct crystallization products from the eosinophiles, but that something besides the presence of these cells is necessary for their formation.

{b) The uruie. The quantitative determinations of the uric acid, urea and total nitrogen were carried on mainly in connection with the ideas of Horbaczewski, that the uric acid, derived from the destruction of nuclein -holding material, comes normally in large part from the leucocytes and is therefore increased in leucocytoses.

Although the uric acid per 34 hours was determined on 23 different days, and on four of these the urea and total nitrogen also, on no occasion did the total uric acid excretion, or the relation between the nitrogen of the uric acid to that of the urea or to the total nitrogen exceed the normal limits, showing that the views of Horbaczewski are not universally correct. In this case, however, the leucocytosis differed somewhat from the ordinary in that here the eosinophiles were the cells markedly increased ; in his cases the ordinary polymorphonuclear neutrophiles.

(c) The mus'ie. The changes in the muscle were extensive. There was a great proliferation of the muscle nuclei throughout the section ; about the fibres containing trichina? this proliferation was very marked, especially in the second specimen ; not so extensive in the earlier specimen. In fact, in a few places where the parasite had but just wandered into the primitive bundle no change in the muscle substance nor any proliferation of nuclei was visible. Most of the fibres containing the worm showed a conversion of the muscle substance into a finely granular faintly-staining material containing many large swollen nuclei, i. e. the proliferated muscle nuclei ; and about many of the proliferated nuclei, both in the more and in the less degenerated portions, distinct vacuoles could be made out.

Throughout the specimens the muscle showed various forms of disintegration, in some places a longitudinal splitting of the fibres into fibrillaj, in other places the formation of what might be called muscle cells, the muscle nucleus taking about itself some of the muscle substance and separating itself from the fibre; while in still other places a peculiar transverse splitting up of the muscle into disks, the nuclei here proliferating transversely instead of in the usual longitudinal method, was noted.

Besides these changes there were seen in the first specimen many polymorphonuclear cells, some showing a finely granular protoplasm which did not stain to any extent with acid stains (the so-called neutrophiles), some distinct eosinophiles with large deeply-staining granules, and beside these, cells which somewhat suggest transitional forms, showing in the protoplasm of the cell body fine granules, but with a distinct affinity for the acid stain ; and all these cells seemed to be acting as phagocytes in the disintegrating muscle, being often seen in little lakes or bays in the degenerating bits.

In the second specimen there were decidedly fewer neutro


philes and many more eosinophiles tlian in the first. That in

both cases these were typical eosinophiles was shown by staining them in the different acid stains and in the Biondi-IIeideuhein triple stain.

At the same time with this greatly increased projiortiou of eosinophiles in the extra-vascular leucocytes in the muscle, Ihe Mood vessels in the inferfascicuhir connective tissue showul the same proportion of neutrophiles and eosinophiles as icas found in the blood count for that day.

In another specimen of muscle from a case of acute trichinosis which was obtained from the pathological museum, great (juantities of eosinophiles were also found.

The study of the blood, showing the steady increase of the eosinophiles at the expense of the neutrophiles, together with the identical character of the nuclei of the two forms, would tend to support the view held by some observers, that the former variety of cells is derived by some transitional change from the latter.

That such a change might take place in the muscle is suggested by the presence here of neutrophiles, eosinophiles, and what may be regarded as transitional forms, in large quantities. Particularly suggestive is the great disproportion between neutrophiles and eosinophiles seen in the second muscle specimen. Here the eosinophiles were much increased, the neutrophiles correspondingly decreased, while the blood-vessels in the interfascicular connective tissue showed but the same proportion of these forms as was to be made out in the specimens of the peripheral blood for the same days. It is further noteworthy that the eosinojihiles increased in number soon after the increase in severity of the muscle symptoms, and shortly after the decrease of those symptoms, diminished gradually, descending toward the normal point as the symptoms abated. Suggestive also is the presence of large numbers of eosinophiles in a specimen of muscle from another case of acute trichinosis.

Dr. OsLBR. — This is the only case of trichinosis which has been in the hospital, or it is safer to say the only case recognized, since we know that not infrequently the disease escapes recognition or is mistaken for some other disorder. This is the second case which I have seen clinically, while in the postmortem room I have found on eight or ten occasions the calcified cysts. Mr. Brown is to be congratulated on the very thorough way in which he has followed this case.

Dr. Thayer. — The evidence offered by Mr. Brown in favor of the origin of the eosinophilic cells by transition from the so-called neutrophiles is very suggestive. The total number of polymorphonuclear cells found in the circulating blood was practically what one would expect in a leucocytosis of that extent. And yet, examining this percentage which normally should consist almost absolutely of so-called neutrophilic leucocytes, we find the great majority represented by eosinophiles. The fact also that in the affected parts the bloodvessels contained the same relative proportion of eosinophiles and neutrophiles as did the peripheral vessels, while the tissues round about contained an enormously greater percentage of eosinophiles, is very interesting.

That the so-called neutrophilic granules stain often with acid coloring matters is well known. With good acid dyes


April, 1897.]

81


these granules almost always take a slight stain, and by sonie obseryei'S botli eosiuophiles and neutropbiles are classed as acidophilic cells. They stain, however, much better in fluids consisting of a mixture of acid and basic coloring matters. As Mr. Brown has sharply pointed out, this acid staining of the smaller granules was uot to be made out at all in the specimens of blood and in the blood-vessels in the tissues, and the fact that outside of the vessels in the affected parts numerous apparent transitional forms between the non-granular polymorphonuclear wandering cells and the true eosinophiles existed is very suggestive. That these cells were true eosiuophiles in the sense of Ehrlich, Mr. Brown has proven by careful tests with a number of different acid coloring matters.

The idea that the eosiuophiles represent a further change in the cell which we know as the neutrophile is, as Mr. Brown has said, not a uew one, but I am not aware that any argument in favor of this view as forcible as that which he presents has yet been published.

With regard to the actual blood condition — the increase of the eosinophiles — no similar case exists in the literature; the percentage of eosiuophiles in this instance is moi"e than twice as large as has been reported in any other case.

Dr. Barker. — Mr. Brown has referred, in speaking of the degeneration of the muscle, to a splitting up' of the muscle fibre into transverse disks. I should like to ask him whether or not he has been able to make out just where the splitting


occurred. Though several histologists have emphasized the fact, it does uot appear to be generally kuown that the splitting iu the muscle fibre may occur with some reagents at one level, with other reagents at an entirely different level. Thus in the formation of the so-called Bowman's disks through the action of alcohol, the two layers Q (doubly refractive substance of Briicke) with the layer M (Hensen's line) in between are always present in the disk. On the other hand, ou treatment of muscle with certain acids (acetic, picric or hydrochloric), the splitting occurs between the two layers Q, each disk having then in its middle the layer Z (Krause's transverse line or membrane). It would be interesting to know, for the degeneration described, whether the splitting occurred at either of these two levels or at still another level.

I gather from his paper that Mr. Browu favors the view that the eosinophile granules represent the cyto-mikrosomas of the cells in which they occui\ This view, recently si;pported by Lovell Gulland, was previously urged by Martin Heidenhain, who found that the eosinojjhile granules stain black with his iron-haamatoxylin staining method, and that it is often possible to make out an arrangement of the granules radial to the attraction sphere of the cell. Both these observations are in favor of the cyto-mikrosomal nature of the granules.

The occurrence of such an enormous number of eosinophiles in the circulating blood is truly remarkable and makes the case unique in the bibliography.


PROCEEDINGS OF SOCIETIES,


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of December 7, 1896.

Dr. Thayer in the Chair.

On Certain Visceral Pathological Alterations, the Result of Superficial Burns.— Mr. Bardebn.

Extensive superficial burus are followed by severe constitutional symptoms. The great pain felt at first is followed by a benumbing of the senses and by sleepiness. At times there may be delirium and cramps. The pulse becomes weak, the respiration shallow and irregular. The temperature, after a short rise, falls below the normal. There may be vomiting and diarrhcea, and haamoglobin may appear in the urine. Death within 48 hours usually follows a burn which has involved two-thirds of the surface of the body. The burn need not be of an extreme grade. Death has often followed burns so superficial as to give rise merely to an erythema.

It is clear from this latter class of cases, at least, that alterations in the internal organs may follow the burning of the skin which cannot be accounted for on the supposition that they are directly caused by the heat. Thus arises the question as to the nature of the physiological relations between the lesions produced in the skin and the resulting constitutional effects. Many hypotheses have been advanced to answer this question, some of which have been supported and others destroyed by experimental work on animals.

Many of these hypotheses have been based upon the con


ception of a loss of normal cutaneous activity. But experiment has shown quite conclusively that death after burns is to be ascribed neither to the retention in the blood of products normally excreted through the skin, nor to heat radiation due to paralyzed blood-vessels in the latter structure.

Again death has been referred to changes produced in the blood itself directly acted upon by the high temperature. It is known that erythrocytes are destroyed by a comparatively low temperature (55° 0.). This has led to the supposition that the general pathological effects are due to loss of functional red blood corpuscles, or to irritation produced in the kidneys and other internal organs by the products of their disintegration. But a more generally accepted view is that the blood is so altered by the elevation of temperature as to give rise to extensive thrombosis, death resulting from the disturbances of circulation.

Another view has been advanced more recently. Kijanitzen, who extracted from the blood of dogs experimentally burned, substances similar to Brieger's ptomains, and Eeiss, who found toxic substances in the urine of persons accidentally burned, believe that they have brought forward evidence in support of the idea that the blood in severely burned animals is rendered toxic.

During the past year five small children were brought to the Johns Hopkins Hospital so severely burned that death in each case followed within a very few hours of the accident. At the suggestion of Dr. Flexner I took this opportunity of studying


82

[No. 73.


the histological alterations found in the tissues of the body after burns. A careful autopsy was made in each case by Dr. Flexner, and parts of the various organs were preserved and prepared for microscopic examination.

The lesions in all five cases were strikingly similar. Of the gross lesions the most notable were cloudy swelling of the liver and kidney, acute swelling of the spleen, and swelling and congestion of the lymphatic glands and other lymphatic tissue.

Microscopically, the most interesting lesions noted were parenchymatous degeneration of the kidneys and liver, focal areas of necrosis in the liver, and pronounced focal necrosis in the lymphatic tissue.

The lymphatic tissue was affected throughout the body. The Malpighian corpuscles of the spleen, the tonsils, gastric lymphatic follicles, enteric solitary and agminated follicles and the lymphatic glands all showed essentially the same changes.

The lymphatic glands were much swollen and at times congested. The earliest changes were in the follicles and consisted of an ojdematous swelling. This was more marked towards the centre of the follicle, in an area corresponding to the germinal centre. In areas of less advanced alteration the lymphocytes were merely less closely packed together than is usual. But in the areas of more marked change, the lymphocytes were swollen and their nuclei fragmented. In these cases the follicle presented a remarkable appearance. It was not only greatly swollen, but at the edges a rim of closely packed lymphocytes existed, while at the centre swollen and distorted lymph cells, bits of protoplasm and fragments of nuclei were seen scattered about, some lying free, others enclosed in large flat endothelioid cells.

The lymph cords as well as the follicles were swollen, while the lymph sinuses seemed less distinctly marked off than usual from the reticulum in which the lymphocytes of the cords lie imbedded. Here and there throughout the gland groups of degenerating cells might be seen, but the areas of distinct focal degeneration were confined as described above, to the follicles.

Calvert has shown that the terminal artery breaks up in the centre of the follicle into capillaries which radiate towards the periphery of the follicle. It seems possible that the lesions focalized just at this region may in some way hold special relation to the circulation of tlie blood. For if the blood in these cases contains toxic materials, it is conceivable that it is just at the centre of the follicle that the poisonous plasma acts with greatest intensity on the lymph cells.

In the lymphatic follicles of the tonsils and stomach and in the Malpighian bodies of the spleen focal degeneration essentially similar to that of the follicles of the lymphatic glands occurs. In the intestines the greatly swollen lymphatic follicles, solitary and agminated, showed extensive focal areas of degeneration.

In these areas of degeneration in the lymphatic tissue we find appearances essentially similar to those seen after the injection into the body of various bacterial and other toxalbuminous substances. Indeed, the lymphatic glands from our cases of skin-burn might readily be mistaken for the lymphatic glands of children dead of diphtheria. The


lesions in the other organs are also essentially similar to those found in the bodies of persons dead from the acute infectious diseases. It seems, therefore, justifiable to consider that one of the main causes of death after burns is to be sought in a toxaemia caused by alterations in the blood and tissues, the direct effect of the elevation of temperature; a view which is further strengthened by the clinical evidences and the experimental work of Kijanitzen and others.


NOTES ON NEW BOOKS.

The American Year-Book of Medicine and Surgery : being a yearly digest of scientific progress and authoritative opinion in all branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign authors and investigators. Collected and arranged, with critical editorial comments, by J. M. Baldy, M, D., and twenty-six other physicians, under the general editorial charge of George M. Gould, M. D. [Philadelphia, 1897 : W. B. Saunders, 925 Walnut Street.)

This year-book amply justifies the high expectations which were excited by the excellent character of the similar volume published last year. It is an encyclopedic collection of new medical literature gathered from all lands and every field of medical knowledge. It is not a mere aggregation, but a discriminating digest of the latest knowledge in medicine, with frank opinions and critical comments by painstaking and competent men. The special comments of the editors as distinguished from the authors are enclosed in brackets, to facilitate reference to them.

The completeness of the department of medicine, which has had the editorial supervision of Pepper and Stengel, is shown by the fact that it covers more than 180 pages. Among other interesting matter the sections on the Schott method, typhoid fever, malaria and myxedema are probably of the most interest. In view of the extravagant claims for the different methods of aborting typhoid fever, it is gratifying to notice that the authors ask that all cases treated by these methods be more carefully studied and the symptoms more minutely described.

Under the head of surgery, which occupies 248 pages of the volume, Keen and DaCosta give a valuable resume of the most recent work in ansesthetics, with sensible comments upon the dogmatic assertions of many experimenters. It is refreshing to read the following: " Wunderlich, from a statistical study, concluded that albuminuria was more apt to be induced by chloroform than ether. Beck from a statistical study concluded that albuminuria was most apt to be caused by ether. We are thus confronted by carefully compiled reports which are diametrically opposed and absolutely contradictory. The humble surgeon who venerates statistics too much to use them is lost in uncertainty. We are told that figures cannot lie, and yet only one of these statements can be true. Which is the truth we cannot yet decide, as we know of no birthmark to prove identity."

The operative treatment of perforation in enteric fever would seem to be presented in too gloomy colors, in the light of Finney's recent statistics.

The article on diseases of the gall-bladder is quite full and satisfactory. The same may be said of the careful and conservative article on the use of the x rays.

Obstetrics, under the editorship of Hirst and Borland, occupies about 100 pages, and presents many topics of special interest to the general reader, notably the sections on the pathology of pregnancy, abortion and extra-uterine pregnancy.

The section on gynecology, by Baldy and Borland, occupies upwards of 200 pages, and touches upon a variety of interesting


Apeil, 1897.]

83


matter. The objection presented to Clark's radical operation for the relief of uterine cancer, that but few patients can endure the shock of the prolonged etherization, seems hardly tenable in the light of actual practice. The chapter on nervous and mental diseases, by Church and Patrick, is thoroughly well worked out, and presents a good review of the work of the past year. The section on materia medica is an excellent feature of the book. All things considered, the book is well arranged, admirably edited and well printed. Every physician who does not have leisure to inform himself on the latest advances in medicine and surgery from original sources, should procure and carefully read the volume.

Architecture of the Brain. By Wm. Fuller, M. D., Grand Rapids, Michigan. 1896. Pages 1-183, with many illustrations. In this volume are described and pictured the general gross relations of the brain as seen (1) from the external surface, (2) on dissection, and (3) in a series of frontal sections. The author has had a large experience in dissection of the central nervous system and in the preparation of castings in plaster of the dissections which he has made. No person except one who has busied himself in work of this kind can easily estimate the amount of labor which has preceded the publication of the book.

After a description of the membranes, thecerebro-spinal axis as a whole is described. The cerebrum is then taken up and the method of dissecting it outlined. A discussion of the structure of the cerebellum, of the pons varolii, of the medulla oblongata and spinal cord follows. Throughoutthe book the mainstressis laid upon the gross morphology, but there are brief chapters concerning the nerve tracts of the cerebro-spinal axis and the central origin and relations of the cranial nerves. On pages 130-133 there is a brief discussion of topographical cerebral localization. L. F. B.

Annual Report of the Supervising Surgeon-General of the Marine Hospital Service of the United States for 1893. Vols. I and II. (Washington: Oovernment Printing Office, 1894-1895.) These volumes present a very complete and satisfactory account of the operations of the Marine Hospital Service for 1893. The most valuable papers are a carefully prepared account, by Surgeon Stoner of Baltimore, of the origin and development of this Service, which should be read by all who desire to familiarize themselves with its history, and the " Report of the Commission to Investigate the Cholera Epidemic," prepared by Dr. Walter Kempster and Surgeon Fairfax Irwin, who made an extensive trip in Europe to procure data for it. It is to be regretted that the Commission, while entering into very great detail as to its operations, does not formulate and publish its conclusions in connected form. Scattered throughout the report are many valuable suggestions touching the prevention of infectious diseases and the transmission of contagion, which can only be found by reading many unimportant details. These should have been gathered in an accessible form, so that they might be easily read.

Medical and Surgical Report of the Presbyterian Hospital in the City of New York. Vol. I., January, 1896. By Andrew J. McCosH, M. D., and Walter B. James, M. D. (The Knickerbocker Press, New York.)

This report is the first of a series. It is carefully edited and well illustrated. Many of the papers are carefully written and of great interest to the general profession. The pathological reports are meagre and the protocols published are in most instances brief abstracts. Several of the papers have appeared elsewhere. One of them, that of Dr. Northrop, on Gonorrhoeal Arthritis, is more popular than scientific, and portions of it read as it the author were thinking aloud. The results of thinking rather than mental operations would be preferable. Taken as a whole, the surgical papers seem to be of the greater value. The volume, however, is worthy of the institution from which it issues and the high character of its editors. It is to be hoped that it will have an annual successor.


BOOKS RECEIVED.

Transactions of the American Gynecological Society. Vol. 21. 1890.

8vo. 490 pages. Wm. J. Dornan, Printer, Philadelphia. Prize Essays on Leprosy. By Newman, Ehlers and Impey. 1895.

8vo. 227 pages. New Sydenham Society, London. Practical Notes on Urinary Analysis. By William B. Canfield, A. M., M. D. Second edition. 1896. 12mo. 106 pages. G. S. Davis, Detroit, Mich. A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In photolithochromes from models in the Museum of the Saint-Louis Hospital, Paris. With explanatory woodcuts and text. By E. Besnier, A. Fournier, etc. Edited and annotated by J. J. Pringle, M. B., F.R.C. P. Fol. Parts IV and V. 1896. W.B.Saunders, Philadelphia. Lectures on Pharmacology for Practitioners and Students. By Dr. C. Binz. Translated from the second German edition by Arthur C. Latham, M. A., M. B. Oxon., M. A. Cantab. Vol. 1. 1895. 8vo. 389 pages. The New Sydenham Society, London. Autoscopy of the Larynx and the Trachea. (Direct Examination without Mirror.) By Alfred Kirstein, M. D. Authorized translation (altered, enlarged and revised by the author) by Max Thorner, A. M., M. D. 1897. 12mo. 68 pages. The F. A. Davis Co., Philadelphia. The Practice of Medicine. By James Tyson, M. D. 1896. 8vo.

1184 pages. P. Blackiston, Son & Co., Philadelphia. Anomalies and Curiosities of Medicine. By George M. Gould, A. M., M. D., and Walter L. Pyle, A. M., M. D. 1897. 4to. 968 pages. W. B. Saunders, Phila. A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In Photo-Lithochromes from Models in the Museum of the Saint Louis Hospital, Paris, with explanatory woodcuts and text. By E. Besnier et al. Edited by J. J. Pringle, M. B., F. R. C. P. Part VI. 1896. W. B Saunders, Philadelphia. A Treatise on Cholelithiasis. By B. Naunyn, M. D. Translated by Archibald E. Garrod, M. A., M. D., F. R. C. P. 8vo. 197 pages. 1896. The New Sydenham Society, London. Principles or Guides for a Better Selection or Classification of Consumptives Amenable to High Altitude Treatment and to the Selection of Patients who may be more Successfully Treated in the Environment to which they were Accustomed Previous to their Illness. By A. Edgar Tussey, M. D. 1896. 8vo, 144 pages. P. Blakiston, Son & Co., Philadelphia. Twentieth Century Practice. An international encyclopaedia of mod ern medical science, by leading authorities of Europe and America Edited by Thomas L. Stedman, M. D. Vol. X. 1897. 859 pages 8vo. Wm. Wood & Co., New York. Transactions of the College of Physicans of Philadelphia. Third SeriesVol. XVIII. 1896. 8vo. 263 pages. Printed for the College Philadelphia. Injuries and Diseases of the Ear. Being reprints of papers on otol ogy. By Macleod Yearsley, F. R. C. S. 12mo. 1897. 40 pages The Rebman Publishing Co., Ltd., London. The American Tear-Book of Medicine and Surgery. Being a yearly digest of scientific progress and authoritative opinion in all branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign authors and investigators. Collected and arranged, with critical editorial comments, by J. M. Baldy, '^l.D.,ei al. Under the general editorial charge of George M. Gould, M. D. Profusely illustrated. 4to. 1897. 1257 pages. W. B. Saunders, Philadelphia. Inebriety. Its Source, Prevention and Cure. By Charles Follen Palmer. 12mo. 1897. 109 pages. Fleming H. Revell Co., New York. The Medical Annual and Practitioner's Index. A work of reference for medical practitioners. Fifteenth year. 1897. 12mo. 851 pages. John Wright & Co., Bristol. Lectures on Angina Pectoris and Allied Stales. By William Osier, M.D. 1897. 8vo. 160 pages. D. Appleton & Co., New York.


84

[No. 73.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report in Patliolopry The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

(Atrophy). By Henrt J. Berkley, M. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

Mall, M. D.

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

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

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum

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

T. C. Gilchrist, M. D.

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

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


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

Report in Medicine.

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

Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleur, M. D. Cases of Post-febrile Insanity. By William Osler, M. D. Acute Tuberculosis in an Infant of Four Months. By Harry TotJLMiN, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

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

Report in Gynecolog-yThe Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

A. Kelly, M. D.. and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards mth out Operation ; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,

M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

Ovarian Tumor; General Gynecological Operations from October 15, 1889, to

March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howard

A. Kellt, M. D., and Albert A. Ghrisrey, 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, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment

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

HowARD A. Kellt, M. D.

Report in Surgery, I. The Treatment of Wounds with Especial Reference to the Value of the Blo.d C!ol

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Nenrology, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By August Hoch, M. D. A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. liv

Henry M. Thomas, M. D.

Report tn Pattiologry, I. Amoebic Dysentery. By William T. Councilman, M. D., and Henhi A. Lafleur, M. \\


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

Report in Patliology.

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

Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D. Report in Patliolosry.

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

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

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

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

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

Report in Gyneeolog-y.

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

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

Intestinal Worms as a Complication in Abdominal Sui^ery. By A. L. Stavely, M. D.


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

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

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

Traumatic Atresia of the Vagina with Hamatokolpos and Hamatomctra. By Howard A. Kelly, M. D.

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

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

Resuscitation in Chloroform Asphyxia. By Howard A. Kellt, M. D.

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

By WiLLLAM Osler, M. D., with additional papers by W. S. Thayer, M. D., and J. Uewetson, M. D.

Report in Neurolog-y*

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

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

Report in Gynecologr. Hydrosalpinx, with a report of twenty-spven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Cullen, M. B. Report in Patliology. Deciduoma Malignum. By J. Whitridge Willlams, M. D.


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

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

Studies in Typliold Fever. By WiLUAM Osler, M. D., with additional papers by G. Bltjmer, M. D., Simon Flexner, M. D., Walter Reed, M. D., and H. C. Parscss, M. D.


Volume VI. About 500 pages, many illustrations.

Report in Nenrolofo**

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

Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part 1. — Alcohol Poisoning. — Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part II. — Senrni Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part III. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by O.rwnic Ricin Poisoning; Part IV. — Hydrophobic Toxaemia. — Lesions of the Cortical Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Ner\*e Cells from the Effects of Alcohol and Ricin Intoxication; Nen-e Fibre Terminal .apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Patliologry.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.

Cullen, M. B. Pregnancy in a Rudimentary LTtcrine Horn. Rupture, Death, Probable Migration of

Ovum and Spermatozoa. By Thomas S. Cdllen, M. B., and G. L. Wilkins, M, D. Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. C'ullen, M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By

William D. Booker, M. D. The Pathology of Toxalburain Intoxications. By Simon Flexner, M. D. Tfie price of a set bound in cloth [Vots. I-TI] of the Hospital Itejwrts is

$30.00. Vols. I, II ami III arc not sold scjiaratehj. The price of

Vols, ir, V and VI is $5.00 each.


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID 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 Rcepord,

M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,

$3.00. THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thaykr, M. D., and J.

Hewetsos, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.

By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ?2.T5. STUDIES IN TYPHOID FEVER. By William Osler. M. D., and others. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. Subscriptions for the above publications may be sent to

The Johns Hopkins Press, Baltihorb, Md.


The Johns Hopkins Hospital BvUctins are isstied mwiihly. They arc printed lij THE FRIEDENWALD CO., Baltimore. Single copies may be procured from Messrs. CURBING rf CO. and the BALTIMORE NEWS COMPAXT, Baltimore. Subscriptions, $1.00 a year, tnay be addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sin<jU- copies will be sent by mml for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No. 74.]


BALTIMORE. MAY, 1897.




GO]srT:E3srTS.


PAGE.

The Association between the so-called Perinuclear Basophilic Granules and the Elimination of the Alloxuric Bodies in the Urine. By T. B. Fittcher, M. B., 85

Encysted Dropsy of the Peritoneum secondary to Utero-tubal Tuberculosis and associated with Tubercular Pleurisy, Generalized Tuberculosis and Pyococcal Infection. By ClariBEL Cone, :M. D., 91

A Visit to Bad Nauheim, with the Purpose of Investigating the "Schott Treatment" for Chronic Heart Disease. By C. N. B. Camac, M. D., - - - 101

A Case of Porokeratosis (Mibelli) or Hyperkeratosis Excen


trica (Respighi) with a remarkable Family History. By T.

Caspar Gilchrist, M. B.C. S., L.S. A.,

A Rapid Method of making Permanent Specimens from Frozen

Sections by the Use of Formalin. By Thomas S. Cullen,

M.B., Proceedings of Societies :

Hospital Medical Society,

Typhoid Perforation treated by Surgical Operation [Dr. Finney].

Notes on New Books,

Books Received, - ..


107


108


113 113


THE ASSOCIATION BETWEEN THE SO-CALLED PERINUCLEAR BASOPHILIC GRANULES AND THE ELIMINATION OF THE ALLOXURIC BODIES IN THE URINE.

(From the Medical GUnic of Prof. Eravs in Oraz.) By T. B. Futcher, M. B., Instructor in Medicine, Johns Hopkins University and Asst. Res. Physician, Johns Hopkins Hospital.


In 1894 Neusser described a peculiar granulation in the leucocytes of patients suffering from a uratic diathesis. This term was given a wide meaning, and under it he included gout, uratic lithiasis, as well as the various forms of "irregular gout," as muscular rheumatism, nervous asthma, skin affections, gastro-intestinal derangements, diabetes, leuksemia, neuralgia aud neurasthenia. These granules were brought out by staining freshly dried specimens of the blood with a modified Ehrlich's triacid mixture in which the basic ingredient was relatively increased. They are basic staining granules, and with this mixture appear as greenish black or dense black droplets over and about the nuclei of the leucocytes. They vary considerably in size, the smallest being about the size of the neutrophilic granules, and the largest considerably larger than the eosinophilic granules. Often they have a glistening or refractile appearance. They are always in immediate contact with the nucleus, never being present amongst the ordinary granules of the leucocytes. They give one the idea that they constitute some substance which has been squeezed out of the nucleus. Neusser found them most abundant in the mononuclear leucocytes, in which they often form a complete


ring about the nucleus, but stated that they were also present in the polynuelear leucocytes and eosinophiles. He believed that they were of the nature of a nucleo-albumin in composition, and saw in their i^resence a sign for an increased uric acid production in the organism. This assumption was based on the analysis of the urine of 100 patients, in whom, along with the already described blood condition, an elimination of from 0.8 to 1.5 grams of uric acid, and a uric acid coefficient within the limits of 1 : 30 to 1 : 20 (1 : 50 being normal) were found. It is important to note that the patients on whom these observations were made were not brought under a condition of nitrogenous equilibrium.

The clinical interest of these basojihilic granules would be very great if it could be proven that in an extended series of cases they were associated only with a uric acid diathesis and were entirely absent in other affections. If such could be proven we would then have a ready clinical means of differentiating symptoms due to a uratic diathesis from those arising from some other cause. Neusser himself states that they are also to be found in a certain percentage of cases of tuberculosis, and believes them to be of prognostic value. He claims to have


86



found that cases showing the granules run a more favorable course, and that the lung infiltration is more likely to undergo fibroid change than in cases where the granules are absent.

Kolisch, a pujiil of Neusser's, has advanced the theory that a uric acid diathesis is not due to an anomaly of in the formation of or in the relative solubility of uric acid, but in the increased production of the alloxuric bodies (uric acid -|- xanthin bases), out of the products of nuclein destruction. He found that in cases where the perinuclear granules were abundant that there was a definite increase in the quantity of alloxuric bodies eliminated. The increase was due to a marked increase of the xanthin bases, the uric acid being relatively diminished ; and it was to the presence of these bases circulating in the blood that the symptoms of a uratic diathesis were due, and not to any anomaly in the formation or excretion of uric acid. Neusser and Kolisch, although they both believe that the basophilic granules bear an intimate association with the causation of the uratic diathesis, differ in their views as to which ingredient of the urine is increased by their presence. Neusser found an increased elimination of uric acid, while Kolisch found that the uric acid was relatively diminished, and the xanthin bases markedly increased, resulting in a total increase in the amount of the alloxuric bodies eliminated.

With the exception of the above difference, Neusser and Kolisch agree that the occurrence of the perinuclear basophilic granules indicates an increase in the nuclein constituents of the blood. Direct analyses of the blood for the amount of nuclein contained in it were naturally not made; and pure color reactions, even from a qualitative standpoint, are unreliable, as shown by L. Heine. If one accept without further questioning Neusser's view that the perinuclear granulation is a morfihological criterium for an over-production of nuclein derivatives from the cell nuclei, it is not easily explainable why an increase in the quantity of the alloxuric bodies eliminated in the urine should follow. If one considers these granules identical with the pyrenogenic granules of Lowit found in the leucocytes of the river crab (in the arthropoda the uric acid is not formed from the nuclein materials) and in certain normal leucocytes of the bone-marrow, then they fall under the general heading of karyorhexis or breaking up of the nucleus, and would more likely indicate a chromatolytic degeneration of the leucocytes. Prof. Kraus was able to demonstrate similar granules in the liver cells when portions of the liver substance were removed from the body while still warm and kept in a moist chamber at 40° C. At a definite stage in the breaking down of the nuclei he found granules in the protoplasm of the liver cells resembling and staining similarly to those found in the leucocytes by Neusser. If such a condition takes place under any circumstances, either physiological or pathological, in the living person, an increase in the alloxuric bodies eliminated might be expected.

In studying the subject of Neusser's granules I have endeavored to determine whether there is any regular coincidence between the presence of these granules and the elimination of the alloxuric bodies, and further, whether the granules are found only in cases showing the symptoms of a uratic diathesis.

Doubt as to this intimate association arose in my own mind while examining the blood of patients for the basophilic


granules, at first without studying their effect on metabolism. In a very large number of cases examined, both in healthy and diseased persons, I have never failed to find the granules present. Four of these cases were cases of true gout with typical joint affections and well defined tophi in the ears. In two of these cases the granules were very abundant, but not more so in the mononuclear than in the polymorphonuclear leucocytes. In the remaining two cases they were on the whole not very abundant, and the polymorphonuclears showed the granules more numerous than did the mononuclears. Further, I was able to convince myself, both in Baltimore and in Graz, that the granules were not more marked in the blood of patients suffering from the so-called uratic diathesis than in other diseases, or even in certain apparently healthy individuals. The fact that the granules are found in other diseases than in uratic diathesis, and also in healthy persons, lessens their clinical interest. Neusser believed their presence in tuberculosis was a favorable sign. In this disease I have observed cases with abundant granules and others with few granules without noticing any difference in its subsequent course. The granules vary in richness in the leucocytes from day to day in the same individual, notwithstanding his living under the same conditions of nourishment, etc. This fact seems to diminish the significance of the granules. It seems more common for variations of this kind to occur than for the granules to remain constant from day to day. No method seemed practicable for making an accurate count of these granules, and in the following cases reported it seemed sufficient for all practical purjioses to stain the specimens of dried blood and to compare from day to day the amount of granulation present in the different forms of leucocytes.

The following cases, in which the basophilic granules and their effect on metabolism were studied, were undertaken especially to ascertain whether the amount of granulation present really influenced the quantity of the alloxuric bodies eliminated in the urine.

In all, 8 cases were carefully studied. Blood specimens were stained each day with Neusser's staining mixture, and the same technique followed from day to day. The patients were as nearly as possible brought under the conditions of nitrogenous equilibrium before the observations on the urine were concluded. Each case was followed for a period of 5 to 6 days, and during this time the same amount of food was taken each day, and the body weight from day to da\' remained practically constant. The total amount of nitrogen ingested in the food and eliminated in the urine and fteces was estimated daily. In all the cases the alloxuric bodies were estimated, and in two cases the uric acid as well. The nitrogen was detei-mined according to the method of Kjeldahl, the uric acid according to Ludwig's, and the alloxuric bodies according to the Kriiger-Wulf* methods.

In order to assist in the understanding of the following tables I give what is considered the normal amount of nitrogen in grams contained in the alloxuric bodies for the 24 hours, as found by various observers who have made determinations up to the present date.


•Zeit. flir physiol. Chemie, Bd. XX.


May, 1897.]

87


For the 24 hours :

Kolisch gives 0.260 gram.

Weiutraud (1) 0.344-0.360

(2) 0.433-0.534 Richter 0.380

Magnus-Levy 0.506

Richter 0.387

I myself found in healthy persons (1) 0.499

(2) 0.551

Judging from these analyses it may be considered that values above 0.4 gram are physiologically high, while those above 0.5 gram may be regarded as pathological.

Case 1. — Dr. K., aged 32 years, weight 79.5 kilograms, with a well-marked tendency to a gradually increasing corpulence. Not inclined to undertake great muscular exertion, but in every respect perfectly healthy. After nitrogenous equilibrium had been established, 1.5 liters of Carlsbad water (Miihlbrunn) were drank daily for a period of 8 days.

The daily diet was as follows: Ham, 150 grams; roast beef, 100 grams ; milk, 500 grams ; 6 breakfast rolls ; butter, 65 grams; rice, 60 grams; sugar, 3 pieces; black coffee (infusion), 100 grams ; sherry, 100 grams ; soda water, 2 bottles.

The above diet represented about 1968 calories (about 25 calories per kilogram body weight), which were made up as follows :


Albumin Pat

Carbohydrates Alcohol


Total


362.17 calories. 837.73 646.35 122.15

1968.40


Table 1. — The Urine.


Date.


Q



a

U ID


at

'"C in


if



July 6 " 7 " 8 " 9 " 10 " 11 " 12 " 13* " 14 " 15 " 16 " 17 " 18 " 19 " 20


1

3 4

5 () 7 8 (1

10 11 12 13 14 15


995 1240 1630 1200 1080 1160 1630 2270

2«no

2345 27C0 3120 3045 2920 2810


14.7638 12.8898 14.7759 14.0700 15.5547 15.0666 15.4947 15.7682 14.1159 15.3560 13.9482 15.5719 12.9062 14.9825 14.. 3732


0.6042 0.4.318 0.5262 0.4169 0.4430 0.5602 0.5058 0.4149 0.4459 0.4042 0.3780 0.3849 0.3810 0.3244 0.4025


0.2550 0.2613


4.16 3.35 3.56 2.97 2.84 3.71 3.26 2.63 3.16 2.63 2.71 2.47 2.95 2.16 2.80 


From 13 to 20 Carlsbad water was drunk.


Table II. — Nitrogen Balance (N in Grams).


Date.


0% P


41


£ Si


NITROGEN ELIMINATED.


i ,

a — "3 |a|


S


Brlue.


FcBoes.


a


July 10 " 11 " 12

" 19 " 20


5 6

7 14 15


79.300 79.800 79.900 79.050 79.050


16. 2347 15.9769

18.6598


15.5547 15.0666 15.4947 14.9825 14.3732


1.1832 1.1832

'3.3325


16!2498 16 6779

17! 7057


— o'.7oio

+b'.954i


Condition of the leucocytes with reference to Neusser's granules : During the jjeriod in which no Carlsbad water was taken the granules were present only in very moderate numbers. On the other hand, from July 16th to 20th, during which the water was drank, there was a very distinct increase in the number of granules present in all the forms, particularly in the mononuclear leucocytes. At the same time it will be seen that there was a marked diminution in the allo.xuric bodies as represented by the amount of nitrogen eliminated.

Observation II. — Dr. L., a perfectly healthy man, aged 25 and weighing 69.5 kilograms. Muscular, moderate panniculus adiposus, and of a quiet disposition. My colleague, after bringing himself to a point of equal daily nitrogen elimination, drank Carlsbad water for a period of 4 days (1.5 liter of Muhlbruun per day).

The daily diet was as follows : Ham, 250 grams ; veal, 250 grams; milk, 100 grams; wine, 500 grams; tea (black infusion), 250 grams; rum, 15 grams; butter, 50 grams; breakfast rolls, 3.

The above food represented about 1895 calories daily (27 calories per kilo body weight), which were made up as follows:


Albumin Fat

Carbohydrates Alcohol


511.73 calories. 785.49 341.69 256.88


Total


1895.79


Table III.— Urine.


Q


0^


Dally amount of urine In com.


S Ml if


- u a

|g|i


A,


Percentage of alloxurlc body— N of total nitrogen.


June 12


1


1430


25.2421


0.5710



2.27


" 13


9


1815


30.1310


0.5595



1.85


" 14


3


1800


28.1925


0.5237



1.85


" 15


4


1880


30.3996


0.5791



1.90


" 16


5


2000


30.0650


0.5217


0.4222


1.73


" 17*


6


1890


27.2868


0.6515



2.38


" 18


7


3110


29.4983


0.5421



1.83


" 19


8


2840


28.40


0.6908


0.4222


2 43


" 20


9


2730


27.30


0.6162



2.10


f From June 17 to 20 Carlsbad water was drunk.

Table IV.— Nitrogen Balance (N in Grams).



1^


38


t

S

NITBOGEN eliminated.



S



Urine.


FsBces.


a

n


June 14 " 15 " 16 " 19 '• 20


3

4 5 8 9


69.700 6".700 69.800 70.200 70.000


31.7345 31..=S645 31.6679 31.5979


36.3996 30 ('650 28.40 29.30


l.'3V42 1.2619


31.3792 36.5702


+0 8536 -|-'l'.5643


Relation of Neusser's granules in the leucocytes: In the period before Carlsbad water was taken, with the amount of the alloxurlc bodies above the normal (and with a large amount of uric acid), the granules were not particularly abundant. In the second half (June 17-20), when the water was taken, the amount of the alloxurlc bodies eliminated was still higher,


88



whereas the granules had become distinctly diminished in nnmber, particularly in the small mononuclears.

Observation III. — A. F., a young woman, 33 years old, and a cook by occupation. She bad a severe anasmia (red corpuscles 1,900,000 per ccm., leucocytes 6800, and hiemoglobin 35 per cent, according to Fleischl's ha^monieter). The temperature was normal during the observation. Pulse averaged 110 per min. Slight dyspnoea even when at rest. Patient was of rather large frame, and the panniculus adiposus was not particularly reduced. No oedema ; urine free from albumin. Had suffered previously from some gastric trouble, but the symptoms had disappeared. From June 35th to July 7th her weight had become reduced from 57 to 53.4 kilograms.

The daily diet was as follows : Ham, 100 grams ; white bread, 100 grams ; milk, 500 grams; wine (white), 350 grams; water, about 1000 grams.

The diet administered represented about 938 calories (17 per kilo body weight), which were made up as follows :


Albumin Fat

Carbohydrates Alcohol


307.46 calories. 319.30 379.49 133.50


Total


938.65


Table V. — Ukinb.


Date.


1


a

h


.a


2

a a 2


a-2


ntage of uric -Nof otal nl









t>


? a


1



g « o « 


Perc alio bod the trog


July 1


1


1300


1022





" 2


9


1400


1010


10.0940


0.4827


4.78


" 3


3


1100


1014


8.8358


4832


5.46


" 4


4


950


1018


8.0964


0.3608


4.44


" 5


ft


1100


1016


9.9715


0.3735


3.72


" 6


6


750


1028


7.7963


0.3793


4.86



Table VI. — Nitkoqen Ingested (in Grams).



Date.


Day of observation.


Ham.


White bread.


Milk.


wine.


Total nitrogen.


July 1

" 3 " 4 " 5 " 6


1 2 3 4 5 6


4.4480 4.4480 4.4480 4.4480 4.4480 4.4480


1.5236 1.5236 1.5236 1.5236 1.5236 1.5236


2.9925 2.9925 2.9225 2.9225 2.9575 2.9575


0.0568 0.0568 0.0.i68 0.0568 0.0568 0.0568


9.0209 9.0209 8.9.509 8.9509 8.9859 8.9859


Table VII. — Nitkogen Balance (N in Grams).



o g


>,SS

1^


ll


NITBOGEN ELIMINATED.


111


g



Drluo.


Fceces.


B


July 1 " 2 " 3 " 4 " 5 " 6


1 2 3 4 5 6


54.200 54.300 54 200 53 9011 53.600 53.200


9.0209 9 0209 8.9509 8.9509 8.9859 8.9859


lb'.6940 8.8358 8.0964 9.9715 7.7963


b;3879 0.3879 0.3879 0.3879 0.3879


10.4819 9.2237 9.4843

10.3.594 8.1842


— l'.46i6 —0.2728 -0.5333 —1.3735 +0.8017


Relation of Neusser's granules in the leucocytes : On the day before the analyses were begun the granules were present in very small numbers in the leucocytes. This was also the


case on July 1st and 3nd, when a relatively high amount of alloxuric bodies was being eliminated. On July 3rd there was an apparent and on the following days a very marked increase in the number of granules, whilst the nitrogen of the alloxuric 1)odies both absolutely and in percentage became diminished. Observation IV. — Patient was a woman 45 years of age. Fourteen years ago she had her first severe attack of articular rheumatism, although she has had milder attacks since 1881. Both hands at present show characteristic deformities. Since 1891 she has had symptoms of some cardiac lesion. In 1895, tricuspid and aortic insufficiency was diagnosed. During the period that the patient was under observation she was comparatively well ; good diuresis and no cedema. Average pulserate, 80 ; respirations, 23. Moderate body exertion was possible without dyspnoea. Cyanosis was quite marked.

The diet was as follows : Ham, 100 grams ; breakfast rolls (4), 308 grams; milk, 500 grams; wine (white), 350 grams; tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces), 30 grams ; Rohitsch water, 300 grams.

These food materials represented about 1386 calories (36 calories per kilo body weight), which were made up as follows:

Albumin 334.19 calories.

Fat 323.47

Carbohydrates 643.19

Alcohol 185.50


Total 1386.35

Table VIII.— Urine.



i


a ga



,


^


% oo


Date.


°


Eg .


i


d j


§ "^ ffl


¥^i'u










f^


fi°"


% g


|gi


§5?g


Perc

bod tho trof


July 19


1


2400


1012


8.2320


0.3276


3.97


" 20


2


2800


1007


9.6530


0.4459


4.61


" 21


3


2150


1012


9.9706


0.3517


3.52


" 22


4


1400


1014


9.6530


0.3463


3.58


" 23


5


700


1023


9.9356


0.4383


4.41


Table IX. — Nitrogen Ingested (in Grams).



Day of



Date.


observation.


Ham.


July 19


1


5.2052


" 20


2


5.2052


" 21


3


5.2052


" 22


4


5.2052


" 23


5


5.2052


3.3473 2.9837

3.3473 2.9837

3.3473 2.8787

3.3473 2.6950

3.3473 2.9312


0.0785 0.0785 0.0785 0.0785 0.0785


0.1312 0.1312 0.1312 0.1312 0.1312


11.7459 11.7459 11.6409 11.4572 11.6934


Table X. — Nitrogen Balance (N in Grams).


Date.



.1


2

NITBOGEN ELIMINATED.


i .


§


Urine.


Fffices.



July 19 " 20 " 21 " 22 " 23


1 2

3

4 5


47.700 47.400 46.800 45.700 46.000


11.7459 11.7459 11.6400 11.4572 11.6934


8.2320 9.6530 9.9706 9.6530 9.9356


0.9985 0.9985 0.9985 0.9985 0.9985


9.2305 10.6515 10.9691 10.6488 10.9341


+2.5158 +1.0944 +0.6718 +0.80S4 +0.7593


Relation of Neusser's granules in the leucocytes: On the first two days of the observation the granules were comparatively few. On Jiily 21 they were relatively increased, whilst the alloxuric bodies, which had been comparatively high on the 20th, were distinctly diminished in quantity.

Observation Y. — The patient was a brewer, 30 years old, with hypertrophic cirrhosis of the liver. Since 1895 he has had icterus, with tenderness in the region of the liver. The jaundice has had a tendency to disappear and reappear. The faeces at times would be distinctly bile-tinged, and at other times free from biliary coloring matter. Appetite good. At present there is a characteristic enlargement of the liver and spleen, no ascites, and no well marked evidence of collateral circulation. No elevation of temperature. Rather poorly nourished ; weight has varied between 62 and 59 kilograms since April 10. Has a retinitis. Urine is free from albumin.

The daily diet was as follows : Ham, 300 grams ; bread, 700 grams ; wine, 500 grams ; tea (infusion), 500 grams ; mm, 30 grams ; sugar (6 pieces), 30 grams ; soda water, 4 bottles.

These food materials represent about 2806 calories (47 calories per kilo body weight), which were arranged as follows:


Albumin Fat

Carbohydrates Alcohol


516.27 calories. 256.21 1726.10 308.00


Total 2806.58

Table XI. — Urine.








^


Date.


1


i



Is

a 5


s?3i2 i


HS^.^



P^


¥


aui


s 3i

o a




May 15


1


1630


1026


13.2511


0.4773


3.60


" 16


2


1830


10:i3


14.6564


0.4153


2.83


" 17


3


1550


1023


16.2778


0.5089


3.12


" 18


4


nno


1024


17.2238


0.4918


2.85


" 19


5


2040


1024


20.2051


0.4118


2.03


" 20


6


1690


1022


16.4352


0.4771


2.90


Table XII. — Nitrogen Ingested (in Grams).


Date.


Day of observation.


Ham.


Bread.


White wine.


Total nitrogen.


May 15-19 " 20


1-5 6


13.0454 11.3237


7.9398 7.9398


0.2625 0.2625


21.2477 19.5260


Table XIII. — Nitrogen Balance (N in Grams).






NITROGEN ELIMIN

o^





^


§2


ATED.


a — t3


<0


Date.








1^


1?


§1


Urine.


Faeces.


5gi


n


May 15


1


59.200


21.2477


13.2510


2.2526


15.5036


-1-5.7741


" 16


2


58.500


21.2477


14.6564


2.2526


16.9090


-1-4.3387


" 17


3


58.500


21.2477


16.2778


2.2526


18.5304


-f2.7173


" 18


4


58.9(10


21.2477


17.2238


2,2526


19.4764


-hi 7713


" 19


5


59.400


21.2477


20.2051


2.2526


22.4577


-0 7900


" 20


6


60.000


19.52G0


16.4352


2 2o26


18.6878


-t-0.3611


Relation of Neusser's granules in the leucocytes : Several days before the commencement of the chemical analyses the granules were much more numerous than they were during the period of examination. There was no variation observed


during the latter period. Altogether the granules were only moderately numerous, but not more so in the mononuclear than in the other varieties of leucocytes. Some of the mononuclears were without granules. It will be seen that the amount of the alloxuric bodies was relatively high.

Observation VI. — This patient was a man also with hypertrophic cirrhosis of the liver. Since 1893 he had complained of gastric and intestinal symptoms. In 1895 enlargement of the liver and spleen was noticed. Icterus has been persistent, with the exception of one interval when he was free. Weighed 49 kilo when he came to the clinic, but has gained slightly since. The blood examination showed 2,500,000 red corpuscles, 7900 leucocytes, and 55 per cent hajmoglobin (Fleischl).

The daily diet was as follows: Ham, 300 grams; white bread, 450 grams ; milk, 500 grams; wine (red), 300 grams; tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces), 30 grams : Kohitsch water, 2 bottles.

The above diet represented about 2370 calories (48 per kilo body weight), which were made up as follows :


Albumin Fat

Carbohydrates Alcohol


515.65 calories. 385.02 1161.38 308.00


Total 2370.05

Table XIV. — Urine.



C*


2



g



o


Date.


Q^


g^8


as


-2 2 a a

1 °

|a


Alloxuric

body— N 1 grams.


Percentage alloxurlo body— N the total n trogen.


June 7


1


2500


1015


14.4813


0.6650


4.59


" 8


2


2050


1017


16.3590


0.6188


3.78


" 9


3


3200


1013


15.5680


0.7056


4.53


" 10


4


4000


1011


16.2400


0.5425


3.34


" 11


5


2500


1014


15.8375


0.7131


4.50



Table XV. — Nitrogen Ingested (in Grams).*



Date.


Day ot observation.


5am.


Bread.


Milk.


Red wine.


Total nitrogen.


June7A8 " 9&lfi " 11


1 &2 3<s4 5


12.2257 12.2257 12.2257


6.3503 6.3503 6.3503


2.8525 2.8175 2.6162


0.1225 0.1225 0.1225


21.5510 21.5160 21.3147


^Tea, rum and sugar not analyzed.

Table XVI. — Nitrogen Balance (in Grams).




1^


S

NITBOQEN eliminated.



g



Drlne.


Faeces.



June 7 " 8 " 9 " 10 " 11


1

2 3 4 5


49.500 49.400 49.200 50.000 49.600


21.5510 21.5510 21.5160 21.5160 21.3147


14.4812 16.3590 15.5681) 16.2-100 15.8375


1.6595 1.6-95 1.6595 1.659.i 1.659.-,


16. 14071-1-5.4 103 IS !)l85l-f-3 5325 17 227^1-1-4.2885 17.8995-|-V61(i5 17.49704-3.8177


Relation of the Neusser's granules in the leucocytes: Altoo-ether the granules were very few in all the different forms. Most of the white corpuscles are entirely free from the granules, and many almost entirely free. During the period that


90



the patient was under observation there was no apparent variation in the richness of the grannies. On the other hand, the alloxuric body nitrogen was both absolutely and relatively high (0.67, 0.71 gram per day).

Observation VII.— A. man, 20 years old, with physical signs of a commencing left-sided pulmonary tuberculosis. No tubercle bacilli were found in the sputum, however, after repeated examinations. His weight on May 26th was 57 kilo ; he was fairly well nourished. During the period of observation he was free from fever. Leucocytes were 10,000 per cmm. ; hemoglobin 70 per cent (Fleischl).

The daily diet was as follows: Ham, 300 grams,; white bread, 450 grams; milk, 500 grams; wine, 500 grams; tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces), 30 grams; Eohitsch water, 2 bottles.

The above food represented about 2370 calories (41 per kilo body weight), which were made up as follows:


Albumin Fat

Carbohydrates Alcohol

Total


615.65 calories. 385.02 1161.38 308.00

2370.05




Table XVII.—


Urine.





i


I




a


» O


Date.



§H


uj?


a a « 


S 1 2


S S 1 1 a




>.H







a "


a"



g MM


S o 2

^O M


Perc alio bod

the troj


May 27


1


4200


1010


15.5820


0.6064


3.89


•' 28


2


3450


1012


19.6822


0.5796


2.89


" 29


3


2700


1013


21 3097


0.5953


2.79


" 30


4


3000


1012


18.7950


0.5853


3.11


" 31


5


3400


1014


20.3490


0.5533


2.72


June 1


6


3350


1012


20.2842


0.5803


2.86


Table XVIII.— Nitrogen Ingested (in Grams)


.*


Date.


Day of observatlou.


Ham.


Bread.


Hllk.


wine.


Total nitrogen.


May 27 & 28 " 29 " 30 Maj 31 & June 1


1 42 3 4 5


15.3515 15.3515 17.4240 17.4240


5.8262 5.8262 5.8262 5.8262


3.9094 2.7956 2.7956 2.9198


0.0350 0.0350 0.0350 0.0350


25.1220 24.0083 26.0808 26.2050


  • Tea, rum and sugar not analyzed.



Table


XIX.— Nitrogen Balance (in Grams).



ig




NITROGEN ELIMIN

itroIm







o« 


Ji,


win










Jat i



O "


S^


»i

TJrlne.


Faeces.


gss « 


May 27


I


57.700


25.1222


15.5820


1.2634


16.8454+8.2763


" 28


2


.'>6.20(i


25.1222


19.6822


1.2634


20.9456+4.1766


" 29


3


55 400


24.0083


21.3097


1.2634


22.5731+1.7352


" 30


4


56.2011


26.0808 1 18.79.50


1.2634


20.0584+5.9214


" 31


5


56.2(0


26.2050 j 21.1.3490


1.2634


21.6124+4.5826


June 1



50.200


26.2050 i 20.2842

1


1.2634


21.5476+4.5574


Eelation of Neusser's granules in the leucocytes : The granules are altogether extremely numerous, particularly in the small mononuclears. There was no appreciable variation in the granules from day to day. In this case, with the large


number of granules, there was found to be an elimination of a large quantity of alloxuric body nitrogen.

Observation VIII. — The patient was a woman 45 years of age, with cirrhosis of the liver. Since 1895 she had complained of gastric symptoms ; pain in the epigastrium. Had emaciated considerably. Had been jaundiced. Thegastric juice showed a very marked acidity ; free and combined HCl 0.35 to 0.41 per cent, and free HCl alone 0.22 to 0.28 per cent. The liver was enlarged, hard and nodular. Spleen was not much enlarged, but was hard and could be palpated at the costal margin. Body weight averaged about 60 kilos. Vomiting was frequent and patient was moderately ansemic.

The daily diet was as follows : Bread, 300 grams ; milk, 500 ; wine, 500 ; tea (infusion from 6 grams), 250 grams ; rum, 30 grams; sugar (6 pieces), 30 grams; Eohitsch water, i bottle.

These food stuffs yielded about 1752 calories (28 calories per kilo body weight), which were made up as follows:


Albumin Pat

Carbohydrates Alcohol


283.31 calories. 233.43 927.33 308.00


Total 1752.07

Table XX.— Urine.


Date.



3

a 2

.bo



a a o!

Sis


SoSS


Percentage of alloxuric body— N of the total nitrogen.


June 24


1


1350


1023


12.4504


0.4831


3.87


" 25


2


lOOO


1022


10.7800


0.4498


4.17


" 26


3


550


1027


8.1428


0.4591


5.63


" 27


4


850


1025


11.5133


0.5087


4.32


" 28


5


1050


1020


11.0618


5375


4.85


" 29


6


1500


1018


11.1938


0.4594


4.10



Table XXI. — Nitrogen Ingested (in


Grams).*



Date.


Day of observation.


Ham.


Bread.


Milk.


wine.


Total nitrogen.


June 24 " 25 " 26427 "28429


1

2 3&4 546


8.8242 6.3491 48425 4.8425


5.6056 5.6056 5.6056 5.6056


2.7037 2.70J7 2.6C95 2.8875


0.0350 0.0350 0.0350 0.0350


17.1685 14.6934 13.0926 13.3706


  • The variation in the nitrogen in the ham was due to the fact

that the patient could not continue to take the full quantity (220 grams) that she was first given.



Table XXII.—


Nitrogen Balance (in Grams).




Ǥ




NITKOGEN ELIMIN

i . US .





s


as


ATED.


8


' ®*




£ Si




is^


§



a"


S^


a

Urine.


FtBces.


oS2


a


June 24


1


60.700


17.1685


12.4503


1.3508


13.8011


+3.3674


" 25


2


60.400


14.6934


10.7810


1.3508


12.1308


+2.5626


" 26


3


59.600


13.0926


8.1427


1.3508


9 4935


+3.5991


" 27


4


59.900


13.0926


11.5132


1.3508


12.86401+0.2286


" 28


5


59.700


13.3706


11.0617


1.3508


12.41251+0.9580


" 29


6


59.500


13.3706


11.1937


1 .3-^08


12.5445|+0.8261


Eelation of Neusser's granules in the leucocytes: The granules were very numerous, especially in the mononuclears.


Mat, 1897.]

91


although there was considerable variation in the granules from day to day. As will be seen from the table there was a large amount of alloxuric body nitrogen eliminated.

These observations that have been made do not in any way confirm the theory that there is a regular coincidence between an abundance of the granules and an increased excretion of the alloxuric bodies, nor do they favor the view that Neusser's granules occur exclusively in patients with an alloxuric diathesis. Cases occur in which, with numerous grannies in the leucocytes, there is a relatively small amount of the alloxuric bodies eliminated in the urine, while on the other hand the granules may be almost entirely absent and the alloxuric bodies be excreted in increased amount. Such directly opposed conditions may occur in different individuals having the same


disease, as in the two cases of hypertrophic cirrhosis of the liver. Not infrequently the granules become increased or diminished in the same person without there being a corresponding increase or diminution in the excretion of the alloxuric bodies. In fact, increase in the number of granules may be accompanied by a diminution of the alloxuric bodies and vice versa.

From the information obtained by the study of the above cases one seems justified in concluding thattlie supposed relationship between the perinuclear basophilic granules and an alloxuric diathesis, as claimed by Kolisch, is purely empirical.

In conclusion, I must thank Professor Kraus and his assistants for many kindnesses and for valuable aid in carrying on the above analyses.


ENCYSTED DROPSY OF THE PERITONEUM SECONDARY TO UTERO-TUBAL TUBERCULOSIS AND

ASSOCIATED WITH TUBERCULAR PLEURISY, GENERALIZED TUBERCULOSIS

AND PYOCOCCAL INFECTION.

By Claribel Cone, M. D., Professor of Puthology, Woman's Medical College, Baltimore. [From the Pathological Laboratory of the Johns Hopkins University and Hospital]


The following case is of interest not so much because of lesions in themselves unique, as because of the rare combination of many lesions, the extensive character of these lesions, and the multiple nature of the infection.

The case has many features in common with that reported by Gardner,' of Montreal, in the year 1885, and is similar to those described by Wm. T. Howard,' of Baltimore, the same year.

Clinical History.

N. A., primipara, aged 30 years ; colored. Admitted to the Maternite of the Hospital of the Good Samaritan, in the service of Dr. B. B. Browne, November 19, 1894.

The patient had been married several years ; had no children, no miscarriages. Menstruation commenced at the age of 15 ; it had always been regular, painful and profuse, lasting from six to eight days, during which time she was compelled to remain in bed. Her last jieriod occurred about the middle of March, 1894.

Past History. No family history could be obtained. The patient had measles after reaching adult life. Five years ago she suffered with an attack of " malaria " which lasted three months ; at this time she claims to have been " very sick." The attack recurred in September, 1894.

History of Present Condition. The patient is in the eighth month of her pregnancy. Throughout this time she has been feeling ill ; she has had pain in the back and abdomen, increased on exertion. At present there are constant backache, and pain in the lower part of the abdomen. Appetite is good ; bowels constipated ; urine of low specific gravity, otherwise normal.

E.t'xmination. Fcetus occupies the left occipito-posterior position. In the right iliac region is a mass, partly soft, partly resistant, which seems to be connected with the uterus, and is not painful except on deep pressure.


On November 18 at 9.30 p. m. the woman was delivered of a healthy child, but owing to uterine inertia the placenta had to be removed. The labor was protracted, lasting 38 hours. The perineum was lacerated and repaired at once. Two days after delivery the patient was attacked with a chill followed by fever and sweating. The record of the puerperium shows an irregular temperature of septic character whose highest point was 104.3°, whose average was 103°. There was no fever after the second week and the patient's condition was recorded as good.

On January 19, 1895, she was discharged from the hospital apparently in fair health. The following April the patient visited the hospital clinic for treatment, considering herself again pregnant since February. In July, 1895, she returned with enlarged abdomen and general discomfort. At this time she claimed to have felt the foetal movements; in August she was seen at the clinic by Dr. B. B. Browne, who, after examination, did not think her pregnant.

Second Admission. In October, still believing herself pregnant, the woman was readmitted to the Maternite. After careful examination under an anaesthetic, pregnancy was definitely excluded from the diagnosis. At this time a large hard mass was found to the right of the uterus and apparently connected with it. The nature of the tumor could not be determined. Following the ether examination the woman became quite ill. There was great pain in the lower part of the abdomen and sudden rise of temperature. The patient was then transferred to the gynecological department of the Hospital of the Good Samaritan. After the second day the abdomen beo-an gradually to swell, and on December 1st it was much distended. The patient was losing flesh and strength. The temperature showed a typical hectic range, being normal or subnormal in the morning, with an afternoon rise fluctuating between 100° and 103°. The lowest point reached was 95.4°, the highest point 104°.


92



Repeated examinatious of the sijutum showed no tubercle bacilli.

Diagnosis. Encysted dropsy of the peritoneum, probably tubercular.

Operation. For removal of the dropsical fluid. On February 26 th a laparotomy was performed by Dr. Browne. Au incision 5 cm. long was made in the median line of the abdomen. From this opening about eight litres of transparent, pale greenish fluid escaped. The entire anterior portion of the peritoneal cavity was found to be converted into a suppurating cyst. An additional litre of semi-solid caseous material resembling masses of congealed fat was removed by the hand of the oj)erator from the lower part of the sac where it covered the pelvic viscera on the right side. After evacuation of the fluid the surface of the peritoneum was found thickened and converted into a necrotic membrane resembling the caseous masses which floated in the jius.

Examination of Fresh Abdominal Fluid. The macroscopic appearance was that of a turbid, pale greenish yellow fluid in which floated shreds and flakes of caseous material. On standing it separated into two layers, au upper transparent, greenish fluid and a lower dense, creamy mass. The microscopic examination of this fluid showed numerous pvis cells, some red blood corpuscles and shreds of necrotic tissue entangling pus cells. Staiued cover-sliji preparations of the fluid exhibited numerous cocci in jjairs, clusters and short chains, but no tubercle bacilli were found.

Immediately following the operation the patient's condition was much depressed. She rallied, however, resi^ondiug to stimulation. Her general condition improved and she became much more comfortable until the tenth day, when without pain or other distressing symptom she died suddenly, March 6, 1896. The autopsy was made three hours after death.

Anatomical Diagnosis. Tuberculosis of the Fallopian tubes, uterus, ovaries, peritoneum, pleura, and viscera generally. Acute flbrino-puruleut and caseous peritonitis; acute serofibrinous and hemorrhagic pleurisy ; mixed tubercular, staphylococcus and streptococcus infection ; congestion of viscera; general arterio-sclerosis.

The body is much emaciated. In the median line of the abdomen is a gaping incision. It begins 3.7 cm. below the umbilicus and extends 5 cm. downward, exposing a sloughing, puriform cavity from which bubbles of gas are evolved ou pressure. The subcutaneous fat is quite absent; the muscles are brownish red in color.

Abdomen. On opening the abdomen the entire anterior portion of the peritoneal cavity is found to be converted into a suppurating cyst. This extends from the liver above to the pelvis below, and traverses the lateral diameter of the abdomen from flank to flank, dipping deeply on both sides. The walls of the sac are made up of dense, opaqire, yellow necrotic material about 5 cm. in thickness. The cavity contains a small amount of the same puriform material found at operation. Extending across the cavity obliquely downward, and from before backward, as if to support its somewhat flaccid walls, are four or five dense fibrous bands covered by caseous material, continuous with that lining the general suppurating sac. Of these the largest is in the median line. It is long and almost


cylindrical, measuring 3.7x2.5 cm. in diameter. Its anterior and upper attachment is to the abdominal wall 2 cm. below the umbilicus. Its jjosterior attachment below is by a broad expansion upon the posterior wall of the sac where it dips down to cover the pelvic viscera. A second organized band, smaller, but similar in character to the one just described, is found on the left side. A few adhesions are also found in the posterior wall of the sac on the right side. On transverse section these bauds show an organized, pink, fibrous groundwork thickly inlaid with miliary tubercles and limited by a zone of caseous material. The j)osterior wall of the pus sac is found so densely adherent to the intestines and other adjacent viscera that separation is diflicult. No trace of the normal omentum can be found, and the probabilities are that it enters largely into the comjiosition of the suppurating cyst and the traversing fibro-caseous bands.

The coils of intestine are densely matted together by old tilirous bands and by more recent and lighter adhesions, studded everywhere with yellow miliary tubercles, and form a single compact mass filling the greater part of the abdominal cavity. Not only are the intestinal coils adherent to each other, but they are bound to all neighboring viscera. The mesentery is greatly thickened and contracted, and is thickly infiltrated with yellow miliai-y tubercles.

The mesenteric lymph glands are enlarged, indurated and caseous.

Upon separation of the more delicate adhesions between the ui)per coils of intestine, several smaller cysts about the size of a hen's egg are found. They contain clear straw-colored fluid. There is a slight excess of clear fluid in the posterior peritoneal cavity, which appears to have been more recently infected.

Liver. The liver measures 35x17.5x8.7 cm. in its various dimensions. The capsule is much thickened, and strong adhesions unite it firmly to the diaphragm. The left lobe is drawn out into a tongue-like process, which extends completely across the abdomen, covering the spleen on its anterior and left lateral stirfaces. So completely adherent are these two organs that only on section can a line of organized union be made out. The lower surface of the liver is also in contact with the upper wall of the pus sac, with the stomach and with the intestines, to which it is bound by firm adhesions. On breaking up these adhesions and freeing the surface of its caseous membrane, the capsule is found thickly beset with yellow miliary tubercles. The surface is mottled. Ou section the parenchyma shows the characteristic appearance of nutmeg liver. Scattered throughout its substance are numerous tubercles, both grey and caseous. They are mostly submiliary, but larger ones exist.

Spleen. The spleen is considerably enlarged. It is densely bound down by old fibrous adhesions to all neighboring structures. Its anterior and lateral surfaces are almost completely concealed from view by the tongue-like expansion of liver. The capsule is irregularly thickened and contains caseous miliary tubercles. The consistence is much diminished. It tears readily. Ou section it is congested and contains grey and yellow tubercles, miliary, submiliary and conglomerate in form.



Kidneys. The kidneys are slightly enlarged; the capsules are somewhat thickened, but strip off with moderate ease. The surface of the right kidney shows a shallow circular scarlike depression about 12 mm. in diameter,somewhat paler than the surrounding cortex. Under the capsule of this kidney is also seen a solitary caseous tubercle about the size of a split pea. Upon section the kidneys are congested, somewhat increased in consistence, and contain an occasional isolated tubercle of large size. The circular depression seen upon the surface of the right kidney is found to be the base of a dense, pale, pyramidal area which extends quite down through both cortical and boundary zones, and contains in its centre a small cyst.

Ureters. The ureters ai'e normal, except for a slight dilatation of the right ureter in its upper jiortion.

Pancreas. The pancreas is pink and firm. Its capsule is thickly studded with miliary and conglomerate tubercles; none, however, can be seen in its substance.

Stomach. The stomach is adherent to all adjacent structures. Its mucous membrane shows congestion, most marked along the rugas. Some ecchymoses are found at the cardiac end.

Intestines. In some places the felt-like adherent sac wall forms a partial covering to the intestines. Beneath it, as elsewhere, the peritoneal coat is tolerably §mootb, congested, and contains numerous miliary and conglomerate tubercles. The mucous membrane is more or less congested throughout the entire extent. The congestion is most intense upon the valvulas conniventes. There are no tubercular ulcers, but in places tubercles can be seen extending inward from the peritoneal coat. The walls of the large intestine are thin and very deejily congested. The abdominal lymj)h glands are enlarged and caseous.

TJiorax. The sternum aud costal cartilages cannot be readily lifted because of adhesions between the two layers of the pleura on the right side.

Left Pleural Cavity. The left pleural cavity contains about 2.5 litres of blood-stained lluid with flocculi of fibrin. There is one dense organized baud of tissue connecting the two layers of the pleura (about the region of the seventh rib). There are also a few delicate adhesions in the posterior and lower part of the cavity. The apex is firmly adherent to the chest wall. The lung is compressed by the excess of fluid in the pleural cavity. Both layers of the pleura present a coarse reticulated mottling, as though a loose-meshed network of fibrin had been laid upon a dark red hemorrhagic background. Tubercles are also seen.

Upon the parietal pleura, as it covers the sixth rib, are seen two softened caseous tubercles, each about the size of a split pea. Cover-slip preparations made from one of these immediately at autopsy show the presence of tubercle bacilli and micrococci in large numbers.

Left Ln7ig. The left lung is compressed and atelectatic, except the anterior margin of the upper lobe, which contains a little air. Scattered irregularly and sparsely through the lung substance are miliary and conglomerate grey and caseous tubercles. No cavities nor old tubercular foci can be made out.

Right Pleural Cavity. The right pleural cavity is dry.


The lung is bound down throughout its entire extent by easily detached adhesions. At the base and posteriorly the adhesions are pretty firm.

The pleura is covered with a layer of fibrin of irregular thickness, more or less organized at the base of the lung. It contains caseous tubercles.

Right Lung. The right lung is also considerably contracted by the upward pressure from the abdomen and the lateral pressure from the left thorax. The lower lobes are atelectatic and congested. The upper lobe contains a little air and exhibits along its anterior margin a few emphysematous patches. The distribution of tubercles in its substance corresponds with that of the left lung.

The bi'onchial aud mediastinal lymph glands are enlarged and caseous.

Heart. Owing to the excess of fluid in the left ])leural cavity, the heart occupies a position behind the sternum, almost in the median line. The pericardium, the pericardial fluid, the endocardium and heart valves are normal. The aorta contains thickened yellow atheromatous plaques.

Cranial Cavity. There is a slight increase of cerel)i'al fluid. The meninges of both cerebrum and cerebelliun are congested, particularly on the under surface. The pia arachnoid at the base of the cerebellum contains two or tliree yellowisli wliite bodies resembling miliary tubercles.

Cover-slip preparations made from these nodules show no tubercle bacilli.

The pelvic viscera were removed at autopsy aud jjlaced iu formalin, for detailed description later.

Pelvic Viscera. Uterus. The uterus is S.-"> cm. long, 5 cm. broad aud 3.5 cm. iu the antero-posterior diameter. Both the anterior and posterior surfaces are covered by an opaijue, yellowish white, felt-like membrane, varying from 2 to mm. in thickness. This membrane passes directly from the uterine walls to the other pelvic viscera, forming a complete blanket, and constituting the lower part of the large jiu.s sac which occupied the anterior portion of the peritone.il cavity. Projecting from the middle third of the posterior wall is a myomatous nodule about the size of a large walnut, attached to the uterus by a short and broad pedicle, Fig. 1, M. Springing from the fundus of the uterus about 2 cm. anterior to the right cornu is another pedunculated myoma, large, ovoid, and 9.5x7.5x5.5 cm. in diameter, Fig. 1, M. From the left surface of this tumor springs a cylindrical band about :j cm. long and 13 mm. iu diameter, attaching it loosely to the coiled-up mass of intestines behind. This band is of the same general nature as the fibro-caseous bauds which traverse the abdominal cyst. Another band, broad, flattened, and 6 mm. thick, is attached to the right surface of the tumor. This forms part of the general peritoneal sac. On stripping back the dense, felt-like membrane covering these tumors, their surfaces are found studded with tubercular nodules of a yellowish white color, and from one to three mm. in diameter. The snuiller tumor can be easily shelled out of its capsule, owing to a peculiar orange-yellow caseous material separating the two in the regio^n of the pedicle. The myomata, so far as can be seen, do not contain tubercles in their interior. The uterine wall measures 1 cm. in thickness at the fundus. Fig. 1, F. U., 2 cm.


94



anteriorly and 1 cm. posteriorly. It is pale pink in color and is studded with sparsely scattered, yellowish, miliary and con glomerate nodules.

The cervix is 2.5 cm. in length. The mucous membrane of the body presents a shaggy, moth-eaten appearance, of yellowish color and friable consistence. The mucous membrane of the cervix, which is much less rough and friable, still presents indications of the normal rugte. The mucosa varies from 2 to 5 mm. in thickness.

Right Appendages. Springing from the right uterine cornu and extending backward and downward, so as to be completely concealed from view by the large myomatous tumor which filled the right inguinal region, is a mass 8 cm.x5.5 cm.x2.5 cm. in size. It presents at first sight the appearance of an enlarged ovary, covered by the general pyogenic membrane, beneath which, as in the uterus and elsewhere, are miliary and conglomerate tubercles studding the surface. Upon section, however, it is seen to consist of the convoluted tube, thickened and necrosed, with its exaggerated coils held together in a stroma of dense organized connective tissue studded with miliary tubercles. Beneath the lower part of this convoluted mass is seen a portion of the ovary, so completely covered by and adherent to the tube as almost to have lost its own identity. Fig. 1, r. Ov. A longitudinal section through this tuboovarian tumor gives transverse, oblique and longitudinal sections of the much distorted tube. They lie like scattered caseous islands with ulcerated centres, in the tubercle-dotted stroma. The walls of the tube are from 3 to 8 mm. thick, and are for the most part uniformly caseous. Here and there is a nodular studding which gives the mucosa an uneven surface; or again a rich infiltration of the other coats with barely agglomerated caseous tubercles is observed. The fimbriated extremity, dilated, and curled outward in trumpet-like expansion, is directly continuous throughout its circumference with the anterior peritoneal sac. Fig. 1, r. F. E. The folds of the fimbriated end are everywhere visible and appear densely thickened and ragged; the extremity itself measures 2.5 cm. in diameter.

Left Appendages. The left tube is exceedingly tortuous, and from the uterine cornu outward gradually increases in size, terminating in a fimbriated extremity 4.5 cm. in diameter. It is 11 cm. long in its contracted state. Fig. 1, F. E. The folds of the fimbria are transformed into a greatly thickened, motheaten membrane, from whose surface project numerous papillary processes varying in size and shape and measuring from 10 to 14 mm. in length. The interior of the tube bears some general resemblance to the necrotic membrane which covers its surface and which represents the walls of the abdominal sac with which both tubes appear to be directly continuous. The convolutions of this tube, while excessive, as are those of the right side, are not embedded in a dense organized stroma, but are held together by tolerably firm adhesions. These, as well as the surface of the tube, exhibit caseous, miliary tubercles. Fig. 1, 1. T. Longitudinal and transverse sections through the tube show extreme necrosis of its walls. They are more extensively ulcerated toward the outer third, where the condition is most advanced. The lumen at this point is increased to 13 mm. iu diameter. The walls of the tube are here from


3 to 5 mm. thick and consist mainly of caseous material with a narrow outer border of organized tissue. This forms a capsule which can be readily stripped away from the central necrotic mass. The thickness of the tube about its middle portion is 2 cm. There is no lumen visible on cross section, but the entire tube seems made up of one dense, yellowish, homogeneous mass.

'J'he left ovary lies behind and beneath the tube, to which it is bound by adhesions similar to those connecting the convolutions of the tube. Fig. 1, 1. Ov. From this it may be detached with moderate ease. It is about normal in size and position. The surface is covered by the same necrotic membrane, and exhibits upon its removal sago-like bodies. On section the structure is smooth, firm, grey and glistening, showing several corpora fibrosa, and one flattened tubercle Just beneath the surface.

t'onnected with thepelvic viscera and binding them together are portions of the peritoneum which went to make up the original sac wall but which were torn away at autopsy. They are of the same general appearance bs, the necrotic membrane covering the viscera. A similar sac, collapsed and dipping down behind and to the left of the cervix uteri, is covered in by the small myoma above described. This represents the remains of an abscess about the size of an orange which ruptured at autopsy, discharging thick, greenish yellow pus.

The Vagina. There are several small, greyish, flattened elevations upon the surface of the mucous membrane, irregular iu size and shape, some round, measuring from 1 to 2 mm. in diameter ; others with irregular edges measuring about 6x3 mm. in diameter. There is also ^ small superficial ulcer in the posterior vaginal wall just below the cervix. It is about the size of a split pea, has sharp irregular edges, but contains no tubercles in its walls. The vagina is otherwise normal.

The bladder is contracted and is apparently normal.

The rediim is partly covered by necrotic membrane, but shows no abnormalities.

Histological ExAiiisATioif. Pelvic Viscera.

Uterus. The surface epithelium has entirely disappeared, and the uterine mucosa shows a granular necrosis throughout the inner fourth of its thickness. Beneath this the normal stroma is invaded by diffuse tubercle tissue with discrete caseating nodules. It is the union of these nodules near the surface of the mucosa which results in the granular necrosis. In the depth of the membrane the uterine glands are preserved, although the epithelium is swollen and invaded by mononuclear and polymorphonuclear cells. They are often dilated, and contain swollen desquamated epithelial cells, polymorphonuclear leucocytes and granular detritus. The diffuse tubercle tissue consists largely of lymphoid and epithelioid cells, with an occasional giant cell. The discrete caseating nodules present the typical structure of caseous tubercles. The giant cells of both stroma and nodule are round, oval or irregular in shape, with a mural or polar arrangement of the nuclei. The epithelioid cells of the diffuse tubercle tissue are usuallyj round or polyhedral, with small vesicular nuclei. Those ofi


May, 1897.]

95


the caseating nodules are irregular and elongated, with oval, bizarre and wavy nuclei, the close packing of which in the periphery of the nodule gives the appearance of a radiating fringe.

The muscular coat is infiltrated throughout its entire thickness with diffuse tubercle tissue and discrete miliary nodules, most of which are caseous. The diffuse infiltration is represented by small cells with solid and vesicular nuclei, arranged in longitudinal strands between the muscle bundles. The caseous nodules lie next to the peritoneal surface, and are irregularly triangular in shape, with bases toward the serosa. Sometimes the bases coalesce and form a continuous scalloped caseous zone. The muscle cells are increased in number, and here and there are myomatous foci which consist of dense aggregations of cells containing elongated club-shaped nuclei.

The blood-vessels of the muscular coat present interesting features; some of them show the typical changes of endarteritis obliterans, with more or less encroachment upon the lumen. But the most characteristic lesion is the tubercular involvement of the vessel walls. This process sometimes begins in the intima and remains limited to this coat, or extends to the media or adventitia. Sometimes it takes origin in the adventitia and perivascular tissues, and spreads inward in like manner through the other coats. It may be diffuse or circumscribed, it may be a cellular proliferation simply, or show all stages of degeneration, from an early nuclear fragmentation and karyolysis, to advanced caseation in which all the coats and even the vessel contents are transformed into a dense hyaline mass. The corpuscular contents of the vessels are often preserved intact, notwithstanding advanced changes in the vessel walls. Again there are thrombi, hyaline or mixed, in various stages of transformation. Sometimes the vessels are the centre of a tubercular process, in which case their fibrinous contents are continuous with a fibrillated fibrin which extends out into the surrounding tissues. Where the tubercular change is early and begins in the intima, the endothelium is sometimes preserved intact; here there is subendothelial proliferation of the connective tissue cells, forming ejDithelioid cells of a round or jjolyhedral shape, with moderate or abundant protoplasm and small round nuclei. But in other cases there is evidence of endothelial proliferation, these cells enlarging, becoming at times cul)oidal, and forming a lining of two or more rows to the lumen, with occasional complete occlusion.

In the serous membrane the changes are most marked ; on the surface is a dense, opaque, necrotic coat, granular, fibrillated and hyaline. Beneath this is a narrow zone of nuclear fragmentation, while yet below and forming aline of demarcation between the necrotic portion of the serous coat and the scalloped caseous zone of the muscular coat is a narrow band of (Edematous, vascular connective tissue containing a few muscle fasciculi, and showing infiltration with lymphoid, epithelioid, polymorphonuclear and occasional giant cells.

The process is least advanced in the cervix, most advanced in the fundus. In the cervix there is no invasion of the muscular coat, and the vaginal portion contains no evidence of tubercular involvement other than a solitary cellular tubercle under the stratified epithelium in its upper part, and


a cellular proliferation of the corium, gradually disappearing as the outlet is approached.

Among the diffuse tubercular tissue are found numerous homogeneous, highly refractive globules of various sizes, occurring singly or in groups. They show especial affiuity for acid aniline dyes, and also stain intensely with gentian violet. In shape they are invariably round; in size they vary from that of a micrococcus or a basophilic granule to that of a lymphoid cell, some even exceeding this. Their average diameter is that of a red blood corpuscle ; in fact, when uniform in size, and occurring in masses, they are readily mistaken for such in specimens which have been stained with ha^matoxyliu and eosin. The little globules are, however, more homogeneous and solid and more highly refractive than red blood corpuscles. These appear of tenest more or less closely packed within cell bodies, the nuclei of which are still preserved. Sometimes they accompany a more advanced degeneration, in which case the nucleus stains poorly or not at all. Again, they are free from cellular inclusion, and lie in groups or scattered through the tissues. The groups are circular, elongated or irregular, and contain from two to thirty or more members. With Weigert's fibrin stain they stand out conspicuously as deep blue spheres, homogeneous and structureless. With Russell's fuchsin stain they strike a bright red hue; with eosin they stain pink. In many respects they correspond with the hyaline bodies considered by Lubarsch" as a form of albuminous degeneration, found by various observers in both normal and pathological conditions, and described by Russell" as " Fuchsin bodies." In the present case they contain neither nuclei nor spores such as Russell and others have described.

In all three coats of the uterus micrococci are found arranged in pairs, clusters, or chains of greater or less length, numbering from three to sixteen members. They are especially numerous along the superficial caseous zone of the peritoneal coat, where they form a thick, irregialar border and extend deep into all fissures of its necrotic structure. In the muscular coat they are less numerous, and are found for the most part within and about blood-vessels in the bands of the infiltrated tubercle. In the mucous membrane they are again present in considerable number, somewhat sparsely scattered at times or occurring on the surface as dense aggregations. Where scattered, their arrangement is usually in the form of pairs and chains.

Tubercle bacilli are also found in the uterine tissues. They occur in the interior of vessels, either free or enclosed within cells, in the vessel walls, and in the tubercle tissue outside.

The uterine myoma is covered by newly formed connective tissue, with rich infiltration of diffuse and circumscribed tubercles and many pus cells. The capsule is made up of strata of well preserved fibro-muscular bands. But the interior of the tumor is necrotic throughout. Near the surface of the necrotic myoma is a narrow zone of calcareous matter; the walls of all blood-vessels in its vicinity are likewise calcified. A still broader zoueof necrotic myomatous structure, including the calcareous baud, is dotted over with spiculated spherules of golden yellow pigment. No tubercles are seen. Russell's fuchsin bodies are numerous in the tissue covering the myoma, but none are found in its substance. Micro-organisms similar


96



to those found iu the utei'us are likewise found in the tubercular coFcring of the tumor.

Uiyhl Fallopian Tube. The mucous membrane of the right Fallopian tube at its uterine end has an almost intact epithelium. In one place, however, the epithelium is wanting, and here the stroma is invaded by a mass of tubercle tissue, some of which has broken off and lies free and degenerating in the centre of the lumen, together with the desquamated epithelium. The middle coat of this part of the tube retains its muscular structure; bands of muscle, however, are separated from each other by serous infiltration or by alternating baiuls of diffuse tubercle tissue. The serous coat is composed of solitary caseous tubercles so blended as to form a continuous scalloped zone. On passing outward from the uterine end the tuliercular process becomes more marked, and when the middle portion of the tube is reached the walls are so intensely involved as to form a thickened necrotic mass, with no evidences of structure except a narrow fibro-cellular zone encircling the tube about 2 mm. from the periphery. The necrotic substance is hyaline in the centre, where it is pierced by a ragged slit- like lumen. It corresponds here with the remains of the mucous membrane. There is nuclear fragmentation within the fibro-cellular zone, and among the nuclear fragments isolated bands of muscle are preserved in scanty nnnil)c'r The surface necrosis corresponds essentially with tliat of the uterine serosa, while the middle fibro cellular zone is continuous with the thickened, cedematous, vascular connective tissue of the uterus, which there formed a line of demarcation between the necrotic portion of the serous coat and the scalloped caseous zone of the muscular coat. Here, as there, it contains a few isolated muscle bundles, the only normal elements of the original Fallojjian tubes. Here, as there, it is infiltrated with tubercular cellular tissue and polymorphonuclear cells, and here, as there, it shows many vascular changes, both sclerotic and tubercular, similar to those described in the uterine muscular coat.

There are numerous dilated lymph spaces and blood-vessels with subeudothelial proliferation or a lining of cuboidal cells. Occasionally a well-defined giant cell takes origin iu the endothelium of a vessel and projects into the lumen, filling it more or less completely. Sometimes such a cell is found free in the vessel. Indeed, the giant cells are numerous thi-oughout the middle coat, and are especially abundant near the necrotic mucosa. They are often situated in little caverns, which are sometimes surrounded by lymphoid cells. Where not so situated, they are more apt to be surrounded by an irregular zone of epithelioid cells. They are elongated or irregularly ovoid in shape, of various sizes, and contain nuclei at their poles or about the periphery, seldom in the centre. Sometimes they are invaded by polymorphonuclear and lymphoid cells.

In the fimbriated extremity the degeneration is extreme. The lumen is considerably dilated, the walls are convoluted and thick. The mucous membrane is composed of three strata representing gradations of tubercular change. Next to the lumen is a narrow necrotic border, which takes an intense eosin stain. It gives occasional evidence of original structure in the preserved outlines of old blood-vessels, of connective


tissue bands, of g^ant cells, and even of an occasional caseous tubercle which has not yet lost its identity by coalescence with the general necrotic border. Outside of this is nuclear fragmentation with structural outlines still better preserved ; while yet beyond is the normal stroma invaded by infiltrated tubercle. Tlie middle coat is a comparatively narrow band of fibrocellular tissue, not yet degenerated, forming less than a third of the whole tubal thickness, .and presenting the same interesting features as the corresponding coat of the middle portion of the tube. The thickest part of the wall is the peritoneal coat; it is entirely involved in an extensive necrosis which is at one time fibrillated, at another granular or hyaline.

The little refractive globules described iu thecellular tubercular tissue of the uterus as Russell's fuchsin bodies are present also in the tube iu considerable number. They lie by preference in the middle coat, in which the tubercle tissue is best preserved. They pi-esent the same general characteristics as the hyaline bodies of the uterus, but are somewhat smaller. Indeed, whereas in the uterus their average diameter is that of a red blood corjjuscle, in the tube their average size is that of a micrococcus ; and, where Weigert's fibrin stain is used, they could readily be mistaken for such, were it not that upon careful examination they show less uniformity in size, take a more solid stain, and because larger globules, both free aud in cells, are found in the same neighborhood. Extra-cellular spheres of large size grouped with smaller hyaline globules are sometimes found occupying open spaces iu the tissues.

The borders of the necrotic zones, both mucous and serous, iu all parts of the tube, are invaded to some depth by deeply staining micrococci, which in form, size, grouping and arrangement in the tissues, resemble the organisms found in the uterine coats. Similar organisms are found at times in the blood-vessels of the middle coat. Tlie streptococci predominate, and the average length of the chains is six members. Tubercular bacilli are likewise found.

Rigid Ovary. The right ovary is somewhat enlarged. Its surface presents a smooth, wavy outline and is covered by a thick, cedematous, vascular connective tissue which contains lymphoid and epithelioid cells, but no giant cells. There are also numerous dilated lymphatic vessels filled with lymphocytes. The edges of this connective tissue covering are ragged and represent the remains of old fibrous adhesions between the ovary and neighboring structures. Deep within the ovarian stroma are several isolated and conglomerate caseous tubercles. There are many advanced corpora fibrosa, aiul an unruptured Graafian follicle in the process of retrograde metamorphosis, liussell's fuchsin bodies are numerous in the tubercular tissue covering the ovary, and iu the ovarian tissue itself. They are present where the degeneration is least advanced, aud may be seen, not only in the tubercular areas, but in association with other degenerative changes — in the hyaline degeneration of corpora fibrosa and in the retrograde metamorphosis of unruptured Graafian follicles.

Streptococci, staphylococci and tubercle bacilli are present. Of these the streptococci are most abundant and occur iu long chains, at times reaching the length of fourteen members. They are located within the lumen of blood-vessels, in the blood-vessel walls, or in the perivascular lymphatics of the


May, 1897.]

97


coimective tissue covering the ovary, and are ofteuest free, but may be found enclosed in cells.

Left Fallopian Tule. The left Fallopian tube has the same general structure as the right, the only difference being that the tubercular lesion is more advanced. The middle portion of the tube is converted into a dense neci'otic cord, the transverse section of which shows a ragged longitudinal rift in the centre of an oval area of hyaline necrotic material. This is surrounded bv a fibro-cellular border, whose surface is roughened by fibrous shreds torn in the process of separation from adjacent structures. The fibro-cellular border corresponds with both middle and outer zones of the other tube. The fimbriated extremity, like its fellow, is extensively degenerated, and the lumen is also much enlarged. Its walls, however, are less uneven and are but half the thickness of those of the corresponding tube. Continuous with the middle portion of the tube the fimbriated extremity likewise has an outer border of fibro-cellular tissue and an inner hyaline necrotic coat. In this tube there are fewer giant cells than in the other, and the tubercle tissue in places shows fibroid change. Russell's fuchsin bodies are present in small number.

The micro-organisms found are similar to those in the other tube.

Thus, while both tubes show in the main the same tubercular lesions, they differ in that the left tube has somewhat thinner walls, contains a smaller number of giant cells, exhibits in places fibroid change, and the thickened necrotic serous coat is wanting.

Left Ovary. The left ovary is smaller than the right and is surrounded by diffuse tubercular tissue. In gland-like spaces near the surface are found great accumulations of nuclei, bound together by hyaline and fibrillated fibrin, and often presenting the appearance of the tubercle giant cell. In this ovary there is but one solitary caseous tubercle, about the size of a split pea, which projects slightly above the surface and dips down into the stroma. Fuchsia bodies and microorganisms are present, resembling in every respect those found in the right ovary.

The Vagina. The vagina shows no tubercular involvement. The elevated greyish white patches observed on macroscopic examination consist of swollen, distorted, stratified epithelial cells. Occasional polymorphonuclear and mononuclear cells have wandered up into the epithelium. There is slight proliferation of the cellular elements in the upper portion of the corium. Fuchsin bodies are found in these proliferating areas. More densely stained globules are seen in the swollen epithelium above. Upon the surface of the mucous membrane there are a few cocci and long bacilli. Within the blood-vessels of the vaginal wall, and especially in the larger ones, cocci occur in pairs and chains, both within cells and outside of them.

The bladder and urethra show nothing abnormal.

Pus Sac. The wall of the pus sac, portions of which remain adherent to the pelvic viscera, is from 4 to 6 mm. in thickness. It consists of three coats not sharply differentiated one from the other. In the inner necrotic coat, which represents about one-third of the thickness of the sac wall, the degeneration is extreme. Its surface is edged by dense aggregations of micrococci which in places extend deep into the


necrotic structure. The middle coat is fibro-cellular and con tains a few isolated clusters of fat cells. It is infiltrated with diffuse tubercular tissue. The outermost coat is not sharply separated from the middle, and differs from this in containing numerous closely packed caseous tubercles. Fuchsin bodies are present as intracellular and extracellular globules. They are of all sizes, and contrary to what occurs elsewhere, they are found in the most advanced necrosis. In such places theytake a less intense gentian-violet stain and merge gradually into the surrounding necrotic structure. Micrococci are found in all three coats arranged in pairs, clusters and chains. They are especially numerous upon the inner surface of the sac, where they form a continuous irregular layer. Tubercle bacilli are also present in small number.

General Viscera.

The lung shows very little that is abnormal. The visceral pleura is considerably thickened and presents an irregular wavy outline. Its surface is covered by a layer of fibrin formed by the coalescence of highly refractive clumps. These, in places, extend deep into the tissues, where they appear as densely hyaline whorls, or the fibrin remains limited to the surface, where it forms a meshwork enclosing polymorphonuclear cells. The more hyaline portions are at times invaded by organizing connective tissue. Beneath the fibrinous covering is a layer of highly vascular granulation tissue which contains closely-set flattened tubercles. These tubercles project here and there between the clumps of hyaline fibrin, extending at times to the surface, or dip down into the lung substance. They are more or less caseous and show the same general structure as the tubercles already described. Where less advanced they contain many giant cells. The deeper layers of the pleura contain dark brown and black granular pigment, both free and enclosed in cells.

The parietal pleura resembles the visceral in its general histological features. It is composed of a superficial laj'er of fibrin, beneath which are granulation tissue and caseous tubercles. Quite beneath is a third layer consisting of cedematous connective tissue, the meshes of which are widely separated by serum and the spaces of which are occupied by swollen mononuclear cells. In the parietal pleura there are small extravasations of blood. Both layers of the pleura contain the fuchsin bodies and basophilic cells. A few pairs and chains of cocci and tubercle bacilli are present.

Liver. The capsule is thickened by tubercular growth. The lobules show dilatation of the central veins and adjacent capillaries. The hepatic cells in the centre of the lobule contain a brownish yellow pigment. The peripheral cells are filled with fatty globules.

Distributed thickly through the liver substance, in close relation with the blood-vessels, are countless tubercles, most of which are of microscopic size. Large nodules evident to the naked eye are less abundant. The former consist for the most part of lymphoid cells or of lymphoid with a central accumulation of epithelioid cells. The larger tubercles are evidently older and exhibit the typical structure of miliary tubercles with advanced central necrosis. There are a few pairs and chains of cocci in the liver capillaries.


98



Spleen. The capsule is thickened by a new growth of cellular connective tissue containing caseous miliary tubercles. The spleen parenchyma shows an increase in its cellular elements. Much blood pigment and many red blood corpuscles are found. The arterial walls are considerably thickened, and an occasional hyaline thrombus in one of the smaller vessels is seen. There are numerous tubercles, both young and old, scattered through the splenic substance. Fuchsin bodies are present. Micrococci in pairs, masses and chains are found. They are sometimes arranged within cells, but are usually extra-cellular.

Kidney. The kidney shows parenchymatous and fatty degeneration of the epithelium lining the Malpighian tufts and the convoluted tubules. There is a slight increase of connective tissue, especially under the capsule. The tubules are here compressed, but elsewhere they are at times dilated. Hyaline and granular casts are found. The wedge-shaped area described among the macroscopic lesions is found to consist almost entirely of connective tissue in various stages of development. It compresses the tubules, many of which are completely obliterated ; while others persist with intact epithelium or with lumen distended by hyaline casts. The Malpighian tufts are small and fibrous, and in places are converted into hyaline balls. Indeed, the connective tissue invades all structures in the triangular area, and tubules, blood-vessels and glomeruli are alike involved. The central cyst is lined by cuboidal or flattened epithelium. Its walls appear to contain a large number of muscle fibres which have an irregular arrangement and include masses of lymphoid cells. It is continuous with several smaller tubular dilatations and is undoubtedly a retention cyst. At the apes of the triangle is a large dilated blood-vessel with irregular thickened walls and lumen containing remnants of a probable thrombus. The area resembles an infarct in the process of cicatrization, but for the presence of apparently functioning structures. A few cocci arranged in pairs are found within a blood-vessel of the kidney.

Pancreas. The capsule is considerably thickened by a new growth of connective tissue, alternately fibrous, cellular, vascular and cedematous. Numerous closely-set tubercles are embedded in the capsule. They are round and project beyond the surface, or they may be flattened and elongated. They show the typical structure of cellular, caseous and fibroid tubercles. The capsule contains the fuchsin bodies and masses of micrococci.

Lymph Glands. The bronchial lymph glands are invaded by lymphoid, epithelioid and giant cells and show a tendency to fibroid change. Some of the central arteries are sclerotic, others show tubercular lesions. Masses of basophiles are present in the centre of the glands, especially grouped around blood-vessels, and the fuchsin bodies are found at times occupying the interior of basophilic cells. Micrococci occur in pairs and chains within blood-vessels and in the perivascular connective tissue.

In the mesenteric lymph glands the tubercular process is more advanced. The centre is necrotic, with original structural outlines still preserved. The periphery of the gland retains its lymphoid nodules, but these are invaded by tubercle


tissue. The blood-vessels are thickened, and basophiles are found. The gland is covered by (Edematous tubercular tissue. Diplococci and stajihylococci are numerous in the surrounding connective tissue, and beaded tubercle bacilli are found in the interior of the gland.

The aortic valve, the aorta and the coronary arteries show irregular thickening of the intima due to increase of connective tissue which in places is swollen, and the interstices between the branching connective tissue cells are occupied by translucent, highly refractive masses. Or again, the tissue is non-cellular and diffusely hyaline. On the edge of the aortic valve where it appears necrotic a few diplococci are found.

Fibro-caseous bands. The fibro-caseous bands extending across the abdominal pus cavity, and those in the pleural sac, are made up of fibrillated connective tissue, everywhere invaded by diffuse tubercle tissue and circumscribed tubercles in all stages of gi'owth or of retrograde metamorphosis. The peripheries of the bands consist of necrotic zones edged by a closely packed layer of micrococci. The connective tissue stroma shows every stage of organization from young granulation tissue to dense hyaline bands ; the bloodvessel walls are thin and easily rupture"d, and extravasations of blood are sometimes found. The diffuse tubercle tissue consists for the most part of lymphoid and epithelioid cells grouped usually in the neighborhood of blood-vessels. Few giant cells and some basophiles are found. The tubercles exhibit every stage of growth and of retrogi'ade metamorphosis. At times they present a typical cellular structure with giant cells in the centre. Again, the centre is occupied by a blood-vessel, and the lumen of such vessel may contain well preserved fluid contents, fibrillated fibrin, or a hyaline or mixed thrombus. The caseous peripheral zone is from 2 to 6 mm. in thickness. It contains no cells nor nuclear fragments, but is made upof a structureless necrotic substance, alternately granular, fibrillated and hyaline. Fuchsin bodies are easily demonstrable. They are of all sizes, from that of a basophilic granule to a lymphoid cell, and are both intracellular and extracellular. They occur in the diffuse tubercle tissue where degeneration has just begun. The micrococci found on the surface of the band sometimes extend deep into its substance ; they occur in pairs, in masses and in chains. In the bands of the abdominal pus cavity compressed lobules of adipose tissue exist.

Bacteriological Examinatiox.

Cover-slip preparations made at autopsy from a tubercle upon the pleura demonstrated large numbers of long beaded tubercle bacilli and clusters of micrococci. Cultures made from this tubercle enable one to isolate white, lemon yellow and orange colored colonies Inoculations from these colonies into the various culture media exhibit the peculiar cultural characteristics of the staphylococcus pyogenes aureus, citreus and albus, and cover-slip preparations from the various cultures invariably show cocci arranged in clusters and in pairs. Unfortunately, no cultures could be made from the abdominal viscera, but hardened sections of the organs stained by Gram's, Weigert's and Gabbet's methods exhibit staphylococci, streptococci and tubercle bacilli in all.


JlAY, 1897.]

99


Summary of Histologhcal and Bacteriological examinatiok.

(1) The condition is a mixed infection due to the tubercle bacillus, the streptococcus pyogenes, and the staphylococcus pyogenes aureus, citreus and albus.

(3) Miliary tubercles, both grey and caseous, are found in all the viscera of the body except the heart and pancreas ; in the lymph glands, and in all serous membranes excefit the pericardium.

(3) Diffuse tubercle tissue is found only in the more chronic lesions — in the pelvic viscera, the lymph glands, the pleura, the peritoneum, in the wall of the newly formed abdominal sac, and fibro-caseous bands. In the viscera this is usually cellular, but may be caseous. In the serous membranes it is always caseous.

(4) Tubercle bacilli are numerous in the tubercular lesions throughout the body. They are especially numerous in the pelvic viscera, lymph glands and alidominal pus sac.

(5) The products of ordinary inflammation are often found associated with the tubercular lesions.

(6) Staphylococci are found in all the organs. They are most numerous in the lining of the abdominal pus sac and the tibro-caseous bands.

(7) Streptococci are likewise found throughout the body, but are especially abundant in the pelvic viscera, the pus sac and the fibro-caseous bands.

(8) Kussell's fuchsin bodies are found wherever the tubercular tissue is beginning to degenerate and occasionally where the degeneration is extreme.

(9) The viscera are congested and there is general arteriosclerosis.

Conclusions.

From the clinical history, gross anatomical lesions and histological appearances, we therefore conclude that the disease began as a tubercular inflammation of low grade in the pelvic viscera some time before pregnancy.

That the tubercular process spread by direct extension or by the lymph channels to the anterior part of the abdomen, which thus became shut off from the rest of the peritoneal cavity by chronic adhesions.

That the phenomena incident to pregnancy and the puerperium excited the process to increased activity, to which, either at this time or later, was probably superadded a pyogenic infection.

That this infection remained limited to the pelvic organs because of occlusion of the tubes by previous tubercular adhesions or by the more receutinflammatory process, until manual examination of the already much diseased organs caused unavoidable rupture into the anterior abdominal sac.

The pain, rise of temperature and abdominal distension were the result of the secondary pyogenic infection of this cavity, from which the general infection took place. I The general tubercular infection doubtless spread, partly

by direct extension, partly by the lymph channels, but principally through the blood-vessels. The first two modes of invasion are shown by the extensive diffuse infiltration of all structures continuous with and contiguous to the pelvic viscera


and the abdominal pus sac. Infection through the blood is evidenced by the general miliary tuberculosis of all the viscera of the body.

Tuberculosis of the tubes and peritoneum is usually a secondary condition. It may follow tubercular disease of any organ of the body, but is seen most commonly associated with tuberculosis of the lungs. In this case, however, the process must have originated either in the peritoneum or in the tubes. The lungs showed no old tubercular foci, but were involved only in the general miliary tuberculosis. The pleura was diseased, but to a much less extent than the peritoneum or the tubes. The intestines were not at all involved, and the lymph glands were enlarged and caseous, but not extensively diseased.

The question arises, what was the relation of the tubercular disease in the tubes to that in the peritoneum ? Which was primary, which secondary? Considerable difference of ojnnion exists as to the relation between tubercular peritonitis and tuberculosis of the tubes. In his monograph on "Tubercular Peritonitis" Osier" says: "The Fallopian tubes are often affected, but the proportion given by various writers differs much. It is safe to say, I think, that in .30 to 40 per cent, of the cases in women the tubes are found affected. The process is commonly confined to the distal ends and may be primary — which is usual — or is secondary to the peritoneal involvement."

In this opinion of primary tubal involvement the majority of observers agree.

On the other hand Williams" asserts that "Tuberculosis of the Fallopian tubes is far more frequently of secondary than of primary origin, and when it occurs in combination with tubercular peritonitis, it is far more often the result of than the cause of the latter. The fact that the fimbriated extremity of the tube is the portion most frequently affected is of itself evidence in favor of its secondary origin, and in several cases of tubercular peritonitis we have found tubercles on the exterior ofthe tube and its fimbriated end, but none in its interior,showing that the process was extending from above downward." Among others, Siinger and Borschike confirm his view.

In this case the only indication pointing to the peritoneum as the source of disease is the extensive caseous involvement of its anterior part. On the other hand, primary disease of the tubes is indicated by the still more extensive involvement of their walls, by the presence of numerous giant cells, considered by Baumgarten' as significant of jDrimary tubal disease, and by the clinical history which points to the pelvic organs as the first affected. As shown by the foregoing studies, the fimbriated extremity of the left Fallopian tube must be regarded as the probable starting point of the whole tubercular process.

If then the tubercular disease of the tube is of primary origin, the further question presents itself, how did the disease arise ? Primary tuberculosis of the tubes may originate in two possible ways: (1) By infection through the blood, and (2) by infection from without. Primary infection through the blood is a matter of pure speculation and is highly improbable. The more likely source of infection is through the vagina from without. Although no history of such invasion could


100

[No. 74,


be obtained in this case, yet it is regarded as tliemost probable portal of entry. The fact that the nterus was less involved than the tube, and that the vagina was not all diseased, does not negative this theory of infection, since the tubercle bacilli, failing to find conditions favorable for their growth until the left fimbriated extremity was reached, here set up their characteristic lesions. Thence they probably sjiread to the fundus of the uterus, to the uterine cavity and cervix, to the opposite tube, and to the peritoneal cavity, from which the general infection took place.

The associated involvement of pleura and peritoneum must be considered of diagnostic value, since coincident inflammation of both these membranes is so often of tubercular origin.

Besides the extensive character of the lesions, there are several unusual features in the case. In the first place, considerable interest attaches to the fuchsin bodies so numerous in this case. These bodies resemble the little globular masses described by Russell"' in 1890 as " a characteristic organisnx of carcinom.a," and correspond in every particular with the description of these bodies as given by Lubarsch' under the head of "Albuminous Degeneration."

There is scarcely a normal condition or pathological process in which they have not been found, but their relation to malignant tumors has been especially noted. They are not of constant occurrence in any pathological change.

With regard to their nature, the view of Eussell that they may be considered as yeast fungi is no longer held. Tliey have been variously interpreted as protozoa, hyaline thrombi, altered Altmann's granules, von Recklinghausen's hyaline, bodies resembling corpora amylacea, transformation of the cell protoplasm, and as a product of the tissue fluids in which a degenerative process is added to a beginning coagulation process.

Lubarsch himself inclines to the view that the Russell's fuchsin bodies ai'e the product of cell protoplasm, the granules of which have undergone certain chemical and physical changes. He believes that they may be due either to a secretion or to a degeneration of the cell, the former occurring in normal conditions, the latter in pathological processes. Lubarsch also refers to the relative increase of basophiles in areasin which the fuchsin bodies abound — a phenomenon noted by Niehus and Klien, and observed also in the present case. In explanation of their coincident occurrence he attributes the formation of the fuchsin bodies to a chemical change and confluence of the granules of the former and some of the wandering cells, and suggests that both are due to active tissue transformation. From the description given in the present case, this mode of origin seems probable.

A second point of interest is the rare combination of tuberculosis in both body and cervix of the uterus. Regarding this Williams" says: "The affection is almost always limited to the body of the uterus, rarely extending beyond the os to involve the cervix ; and of the few cases of tuberculosis of the cervix on record, a considerable portion occurred without any involvement of the rest of the uterus. Tuberculosis of the uterus which also involves the cervix is rarely met with, and as far as we can ascertain from a careful survey of the literature, has ouly been noted in seven cases."


In this connection may also be mentioned the tubercular invasion of the muscular coat of the tube, which, as a rule, escapes involvement even in advanced tuberculosis.

The large sacculated exudation occupying the anterior portion of the peritoneal cavity and simulating ovarian cyst is rare. Among the few recorded cases of tubercular peritonitis with encysted collection of fluid are those reported by Bernutz, Spencer Wells, Gardner, Howard, Erich, Ewing, Mears and Atlee.

A feature of special interest is the thick fibro-caseous band which extends across the pus sac in the median line of the abdomen, and is probably the remains of the rolled-up omentum. In structure it bears some resemblance to the thickened strands described by Klebs' as passing transversely across the abdominal cavity below the umbilicus, and which he attributed to retraction of the omentum. Such omental tumors are not uncommon and have frequently been described. In location, however, this fibro-caseous band does not correspond with the transverse omental tumors, since its direction is anteroposterior and from above downward, and its attachment is by its extremities. In explanation of this formation one can only assume some distortion of the original omentum, with displacement, thickening, caseation and complete transformation into the fibro-caseous band.

In conclusion, I wish to thank Dr. Flexner for valuable suggestions during the course of this work. Dr. B. B. Browne for kindly allowing the use of his clinical notes, and Mr. Max Briklel for the accurate drawing which accompanies the text.

Bibliography.

1. Baumgarten: Zeitschrift f. kliu. Med., Bd. IX and X, Wien, 1885.

2. Oullen, Thos. S. : Tuberculosis of Endometrium. Johns Hopkins Hospital Reports, Vol. IV, Nos. 7 and 8, 1895.

3. Flint: General Jliliary Tuberculosis, Tubercular Peritonitis, Pulmonary Phthisis. Principles and Practice of Medicine, 1886.

4. Gardner: Tuberculosis of Anterior Peritoneal Cavity. Canada Medical Journal, Vol. 13, 1885.

5. Hegar: Monograph, Genital-Tuberculose des AVeibes. Stuttgart, 1886.

6. IIektoen,Ludwig: Vascular Changes of Tubercular Meningitis, especially the Tubercular Endarteritis. The Journal of Experimental Medicine, V^ol. I, No. 1, January, 1896.

7. Howard, Wni. T. : The President's Address, Transactions American Gynaecological Society, Vol. X, 1885.

8. Klebs : Handbuch der path. Anatomie, Bd. I, p. 335.

9. Lubarsch, O., and Ostertag, 0.: Diealbuminosen Degenerationen, Ergebnisse der allgemeinen pathologischen Morphologic und I'hysiologie des Menschen und der Thiere, Vol. II, 1S95.

10. McFarland, Joseph : The (iiant Cell of Tubercle. International Medical Magazine, Vol. I, No. 10, 1892.

11. Osier, Wm. : Tubercular Peritonitis. Johns Hopkins Hospital Reports, Vol. II, 1890.

13. Russell, Wm. : An Address on the Characteristic Organism of Carcinoma. British Medical Journal, Vol. II, 1890.


May, 189r.]

101


13. Williams, J. Whitridge: Tuberculosis of the Female Generative Organs. Johns Hopkins Hospital Reports, Vol. Ill, 1893.

14. Williams, J. Whitridge: Tubercular Peritonitis. Maryland Medical Journal, Vol. 32, K^os. 3 and 4, 1894.

15. Lenhart, C. M. : Tubercular Peritonitis. Medical Record, Vol. XLVIII, October, 1895.

Description of Plate.

Pelvic viscera fixed in formalin and hardened in alcohol, viewed from above. Right tubo-ovariau mass seen in crosssection.


F. U., fundus of uterus.

Right tube, showing cross-sections of tubercular lumen.

r. F. E., fimbriated extremity of right tube.

r. Ov., right ovary.

if., myoma.

Rd. Lig., round ligament (left).

I. T., left tube.

I. F. E., fimbriated extremity of left tube.

I. Ov., left ovary.

From the left surface of the larger myoma projects a fibrocaseous band. To the right is attached a portion of the abdominal pus sac.


A VISIT TO BAD NAUHEIM, WITH THE PURPOSE OF INVESTIGATING THE "SCHOTT TREATMENT" FOR CHRONIC HEART DISEASE.

By C. N. B. Camac, M. D., First Assistant Resident Physician.


Last November, at Dr. Osier's suggestion, we undertook to introduce into the hospital the Schott treatment of exercises and medicated baths for cases of chronic heart disease. After consulting the bibliography of the subject, several cases were placed under treatment according to the instructions contained therein. At once, however, we were confronted by numerous questions, answers to which it seemed quite impossible to find in any of the references at hand. Although the literature dealt at length with changes in the cardiac outline, the position of the cardiac maximum impulse and the respiration, the theories upon which the beneficial effects were based, etc., no answers to such practical questions as the following were given :

(1) Is any massage to be employed during or after the bath ?

(2) What drugs are to be employed daring the treatment, and what drugs are contraindicated ?

(3) Should the baths and exercises be given together; or if separately, which should precede?

(4) Are stimulants to be administered before or after the bath ?

(5) What should be the diet of the patient?

(6) Are cases of hydrothorax or ascites to be tapped ? etc., through quite a list with which it is hardly necessary to weary you.

Finding many of these questions unanswered, it was with considerable interest that I received Dr. Osier's suggestion to visit Bad Nauheim, the home of the treatment and of Dr. Schott, its originator.

Nauheim is in the Grand Duchy of Hesse, three-quarters of an hour from Frankfurt a. M. and two hours from Homburg. Nearly in the centre of the northeastern half of what geologists have called the Mayence Basin (Mainzerbecken) Frankfurt is located, and at the eastern slope of the Johannesburg, the last spur of the Taunus mountains, is situated Bad Nauheim. As one approaches Nauheim he is struck by the great trestlework structures in the midst of the fields. On examining these more closely they are found to be frame structures about


200 to 300 feet long and about 50 feet high, supporting switches closely stacked one upon another. The salt waters are raised to the top of these trestles and allowed to filter through the interlacing switches, upon which, by the evaporation of the water, the salt is deposited. These switches are removed every few months or so, the salt broken from the branches, ground and refined, and serves as the commercial salt of the surrounding country. The most beautiful forms result from these deposits, and by the clever devices of the natives the most grotesque figures are produced. I have some of the figures thus produced.

An estimation of the commercial value of these works today may be made by the value put upon them in 1806, when they were considered by Napoleon an adequate reward to Marshal Louis Nicolas Davout (erroneously written Davoust) for his services in the French army ; and again in 1866, when they fell to Hesse Darmstadt in exchange for Homburg. Since 1834 the reputation of Nauheim for the efficacy of its springs has been steadily coming to the notice of Europeans. Frankfurt up to this time forming the centre and battlefield of many of the German disputes with France, rendered Nauheim scarcely a fit place for invalids.

It was therefore not until 1834 that we begin to hear of Nauheim as a resort for invalids. It was not until 18G0, however, that Dr. Beneke of Marburg considered scientifically the value of the medicated bath treatment. From 1859-1870 several articles by Beneke of Marburg, upon the waters of Nauheim, appeared in the Berlin. Klin. Woch. From 1870 to 1890 August and Theodore Schott and J. Groedel were frequent contributors on this subject to the Berlin. Klin. Woch., also to the Deutsch. Med. Zeitung. August Schott died, but his brother Theodore continued the work, and published in 1892 an article in the Lancet which caused little comment.

In 1894 W. Bezley Thorn became an ardent advocate of the bath treatment, and published an article in the Lancet and also a small book in which he described quite fully the baths and exercises. AVith the appearance of this systematic little book up to the present the treatment has been very popular in


102



England. Nauheim, its waters, and the resistance exercises, have been frequent topics in English and German medical journals. lu France and America the treatment has as yet received no very thorough trial. It is interesting to note here the increase in the number of visitors from 1871 to 1895. In 1871 the visitors numbered 5,249; in 1891, 9,244; 1892, 10,272; 1893, 10,-384; 1894, 11,0)81; 1895, 14,136.

Although the season was over when I visited Bad Nauheim, I had the opportunity of seeing the baths through the courtesy of Dr. Hirsch, Dr. Schott's assistant, who showed me over the grounds and described very fully the details of the treatment. It can best be described in Dr. Schott's own words : " The springs of Nauheim may be divided into two classes, those suitable for bathing and those suitable for drinking. Together with other ingredients the bath waters contain from two to three per cent of sodium chloride, from two to three per 1000 of calcium chloride, various salts of iron, above all, very large amounts of carbonic acid.

Coming from the dejiths of the earth, they have a temperature of 83-95° F. Springing from a depth of 180 metres, supercharged with carbonic acid gas by the pressure to which they are subjected, the waters gush far above the surface; for example, spring No. 12 rises to a height of 56 feet and falls again in white seething masses." This is a most sti-iking condition ; so richly charged with carbonic acid are these waters that the reservoir into which they fall has the appearance of a great mass of clouds. " Conveyed directly from the main by means of subterranean pipes, these waters charged with their natural gas are allowed to completely cover the body of the bather. Little bubbles of gas are seen to immediately cover the whole surface of the body; the waters of springs Nos. 7 and 12 escape from a pressui-e of from IJ to 2i atmospheres, and afford a surf bath which compares accurately with the strongest surf bath of sea water."

The first question which arose when this matter came to be scientifically investigated was, how do these baths and exercises act ? That they were vei'y efficacious in the relief of chronic cardiac disease had been demonstrated for some years back, but their action had never been investigated. There are several explanations given :

(1) That given by Dr. Schott in the following woi'ds: " Physiological research of recent years seems to show that the salts held in solution in water externally applied have uo direct action on the system; the light and mobile molecules of the gas, on the other hand, pass rapidly through the skin to the corium with its rich supply of blood. We must look upon the salts held in solution as passing by imbibition through the outermost layer of the epidermis, and so acting on the terminal nerves of the skin as to exert a reflex action on the internal organs. The warm baths act in their own peculiar manner on the organism as a whole ; increased tissue change seems to be induced by an increase of the oxygen absorbing power of the cells, and hence follows the sense of the need of rest and sleep as an immediate consequence of the bath, as well as influences speedily brought to bear on the nervous system as a whole. Excessive bathing induces an excitable state of the nervous system, sleeplessness, loss of appetite and consequent loss of strength. The principal changes which ensue


in the system and in the function of the special organs are that the heart beats more slowly and strongly, the jnilse becomes full and increases in force, and the blood pressure may rise to the extent of 20, 30 mm. of mercury; the breathing becomes regular and quiet, and the capacity of the lungs increased.

While the patient is in the bath he becomes flushed and a feeling of comfort and warmth ensues which may even rise to one of an agreeable intoxicating character. Almost invariably the excretion of urine is increased; exudates in the body cavities, especially from the peritoneum, pericardium and pleura, are absorbed. This latter action and that on the valves of the heart can only be exjjlained on the theory of reflex action produced by influences acting upon the terminal nerves."

Another explanation is that given by Dr. Bezley Thorn, that there is a dilatation of the muscular arteries and afterwards those of the skin, and thus there is a relief of the heart from backward pressure.

In Lauder-Brunton's massage experiments he demonstrates that more blood flows through the massaged part and that blood pressure at first rises and then falls, and that on the conclusion of massage more blood collects in the massaged part. These exjjeriments were confirmed by Dr. Oliver.* T. Grainger Stewartf concludes that the passive exercises (I) improve the circulation of lymph within the tissues, and (2) bring a larger volume of blood into the muscles. He quotes the conclusion of Ludwig to the effect that the capacity of muscles for blood is equal to the combined capacities of the internal organs and the skin. If therefore this be so and Dr. Lai^der-Brunton's experiments be correct, the increased amount of blood in the muscles must indicate a relief of the congestion in the internal organs.

In Dr. Schott's explanation there are two actions :

(1) A cutaneous excitation induced by the mineral and gaseous constituents, and

(2) a more prolonged stimulation of the sensory nerves excited by imbibition into the superficial layer of the corium. The salt producing this excitation is the calcium chloride.

Whatever the explanation of their action may be, two points seem established:

(1) That the apex beat alters its position ;

(2) the area of cardiac dulness is diminished. These two facts, esjDecially the first one, were most strikingly obvious in our first cases, and both facts were most forcibly demonstrated to me in the cases which I saw abroad. One can scarcely credit the results published until he has seen for himself these marked changes.

The case rej^orted by Dr. Bowles in the Practitioner for July, 1896, shows a change of 3 cm. in the apex beat before and after a bath of ten minutes duration, and he says after his visit to Nauheim, which was made for the purpose of seeing for himself, " that which I thought impossible is shown to be quite possible." This case reported by Dr. Bowles was one of chronic myocarditis, moderate pleural effusion, general aiuisarca and general enlargement of the heart. The age of


• Brit. Med. Jour., .Tune 13, 1896. 1 //'«/., September 19, 1896.


May, 1897.]

103


the patient was not given. I shall not at this time attempt to report cases, but merely mention this one of Bowles in order to contirm what has been our experience of the effect of the bath upon the j.osition of the apex beat, and many other reports confirmatory of this remarkable change are to be found in the literature on this subject.

The diagrams of the cardiac outline made by Dr. Bowles are not quite accurate, but there can be little difference in opinion as to the position of the maximum cardiac impulse.

To quote Hr. Schott again: "The methods of administering the baths are of the greatest importance. It is advisable to begin with a 1 per cent salt bath containing Yawn '^^ chloride of calcium, freed from gas and at temperatures varying from 93° to 95° F., the bath lasting from six to eight minutes. The course of treatment should be interrujited by frequent intervals of one day. The temperature of the bath should, if possible, be gradually lowered, while the proportion of solids in solution and the duration of the bath are gradually increased. At a later stage it is permissible to proceed to the baths containing carbonic acid. The temperature may then be rapidly lowered, especially if chloride of calcium be added in order to increase the mineral strength of the bath."

The course consists of six baths: the first and the second being simply with salts, calcium chloride and the sodium chloride; the third, fourth, fifth and sixth contain carbonic acid as well as these salts.

The preparation of the baths artificially was taken up especially by W. Bezley Thorn, in London, in 1895, since which time Ewart, Bowles and Broadbent have employed them in London, Moeller in Brussels, and Heiuemann in New York. Following the analysis of the Nauheim waters made by the chemist Fresenius of Wiesbaden, the artificial baths may be readily prepared. We have now packages made up at our pharmacy each containing the proportion of salts for the different strengths of the baths, each package corresponding to 40 gallons of water, which is just about enough to entirely immerse the body. The baths of different strengths are given to appropriate cases.

I have not attempted in this note in any way to speak for or against the treatment nor to report cases. I have thought it best for the present simply to give an outline of the trip to Bad Nauheim, the purpose of which was to see the effects of the treatment and to learn something about it with the object of trying it in the Hospital here. We have now five cases under treatment, and I trust by keeping careful records of the effects of these baths and exercises that we shall be able to pass judgment upon the weak points as well as the strong points of the method. Only by a careful trial can one place himself in a position either to recommend or to condemn the treatment. I take this opportunity of exjjressiug my apjireciation of the patience with which Dr. Schott heard and answered my many questions. I also wish to thank Dr. Ileineman for the instruction in the movements which he so carefully gave me.

In regard to the exercises, which are worthy of a lengthy description, something must be said. They consist of nineteen movements, each movement restrained by the very lightest resistance. This part of the treatment, under the supervision


of a physician, is entrusted to the nurses, to whom we have given careful instructions as to the method of carrying it out. The following are the instructions which we have laid down for the nurses in the administration of the bath, also the chart showing the observation which should be made.*

Rules fok Schott Bath.

(1) Always understand clearly from the doctor the following points: (V) Strength of the bath to be given; (3) temperature of the bath; (3) length of time patient is to remain in the bath. Note. — Give the bath in the morning unless otherwise ordered.

(3) Observe carefully the chart and note the points therein called for. (1) Give bath on an empty stomach. (2) Note the time from the moment patient is immersed to that when he is taken out. (3) Allow the patient to make as little exertion as possible; assist him in every way. (4) A sheet may be drawn over the tub, but not around the patient. (5) Be sure the entire body is immersed. (6) Keep the finger on the pulse during the entire time the patient is in the bath.

Danger Signals. — Cyanosis (bluing of the face), dyspnoea (diflicult breathing), apncea (gasping), inappreciable pulse. On the appearance of any of these, take the f)atient out of the bath immediately, put him to bed and keej) him as quiet as possible. Friction while in the bath is not necessary, but if the fingers and toes become bluish the extremities may be rubbed slightly towards the trunk. Friction should be cautiously employed ; when the patient is out of the tub rub hini to a glow; give him a glass of milk or cup of bouillon and allow him to rest for an hour.

Diet. — Small quantity q. 4 h. Meat — boiled chicken, mutton chops ; eggs, two a day ; oysters, raw or panned ; vegetables — peas, beans, lettuce; liquids — beef tea, bouillon, cocoa, lemonade, milk. Note. — Never give more than 4 ounces of fluid at a time. Should be sipped. Wine — Port, Ehine, sherry, brandy, dram to half ounce.

Note. — Something light (cocoa and toast) should be taken one-half hour before the bath ; something light and hot (bouillon, milk piuncb and toasted crackers) should be taken directly after the bath. If the heart's action is poor, sherry, brandy or port wine may be given after the bath. Last meal to be taken three hours before retiring.

Bath No. I. Sodium chloride, 4 pounds; cal. chlor., 6 ozs.

Bath No. IT. Sodium chloride, 5 pounds; cal. chlor., 8 ozs.

Bath No. HI. Sodium chloride, 6 pounds; cal. chlor., 10 ounces; sodium bicarb., 6 ounces; HCl, 7 ounces.

Bath No. IV. Sodium chloride, 7 pounds; cal. chlor., 10 ounces; sodium bicarb., 8 ounces; HCl, 13 ounces.

Batli No. V. Sodium chloride, 9 pounds; cal. chlor., 11 ounces; sodium bicarb., 1 pound; HCl, 1 pound.

Bath No. VI. Sodium chloride, 11 pounds; cal. chlor., 12 ounces; sodium bicarb., 1 pound; IICl, 2 pounds.

Each bath consists of 40 gallons of water.

Note. — By using a little more NallCOn than is required


  • These rules are made after perus.al of the literature, also from

instruction obtained from Dr. Schott personally.


104



to take up the HCl, the metal tubs may be employed without doing them auy harm.

NaHCOs + HCl = NaCl + H=0 +00^.


83.75


36.37 The Exercises.*


The exercises are called by Dr. Schott "Widerstandgymnastik," or resistance gymnastics, and consist in slow movements executed by the patient and resisted by the physician or operator. A short interval is allowed after each movement, during which the patient sits down. The exertion employed must be very small, and should cause no increase in resjjiratory movements, flushing or j)allor. The patient should be loosely and lightly clothed, and instructed to breathe quietly. The resistance made should be of such a kind that the patient may always feel himself easily the master. The operator must not grasp or in any way constrict the limb, but should oppose by the hand held flatly. The movements are nineteen in number:

Arm. (1) Arms extended in front of body on a level with shoulder, hands meeting; arms carried out until in line, and brought back to original position. (2) Arms hanging at sides, palms forwards; arms flexed at elbow until tips of fingers touch shoulder, back to original position ; one arm only moved at a time. (3) Arms down, palms forward, arms carried outwards and upwards until thumbs meet over head; back to original position ; one arm only moved at a time. Not always advisable. (4) Hands in front of abdomen, fingers flexed so that the second phalanges touch those of opposite hand; arms raised until hands rest on top of head ; back to original position. (5) Arms down, palms against thighs, arms raised in parallel planes as high as possible; back to original position.

Trunk. (6) Trunk flexed on hips ; return to original position. Resist tvith hoth hands. (7) Trunk rotated to left, to right; return to original position. Resist with both hands. (8) Trunk flexed laterally. Resist with both hands. (9) As No. 1, but fists clenched. Resist with both hands. (10) As No. 2, but fist clenched. Resist with both hands.

Large Arm Movements. (11) Arms down, palms against

  • The description of each movement is taken (with a few modifications) from "Chronic Disease of the Heart" by W. Bezley

Thome.


thighs, each in turn raised forwards and upwards until arm is alongside of ear, then turned outward, and arm descends backwards. Not always safe. (12) Arms down, palms to thighs, both together moved backwards in parallel planes as far as possible without bending the trunk forwards. Not always safe.

Legs. (13) Thighs in turn flexed on trunk, opposite hand resting on chair. (14) Lower extremities in turn extended fully, and bent on trunk forwards and backwards to extreme limits of movement, opposite hand resting on chair. (15) Legs in turn flexed on thigh, both hands on chair. (16) Feet together, lower extremities in turn abducted as far as possible and brought back to original position, opposite hand on chair.

Hands and Feet. (17) The arms, extended horizontally outwards, are rotated from the shoulder-joint to the extreme limits forwards and backwards. (18) The hands in turn are extended and flexed on the forearm to extreme limits, and brought back in line with arm. Resist tuith both hands. (19) The feet in turn are flexed and extended to extreme limits, and then brought back to their natural position. Resist with both hands.

We have arranged these in 5 groups, as in this way they may be more readily committed to memory.

Rules for Operators.

1. Each movement to be performed slowly and evenly at an uniform rate.

2. No movement to be repeated twice in succession in the same limb or group of muscles.

3. Each single or combined movement to be followed by interval of rest. Count five.

4. Patient's breathing should not be accelerated.

I. Avoid. 1. Dilatation of the ala? nasi (dilating of nostrils).

2. Drawing of corners of mouth.

3. Duskiness and pallor of cheeks and lips.

4. Yawning.

5. Sweating.

6. Palpitation.

If any of the above make a complete interval, or if excessive, stop the exercises for the day.

5. Direct patient to breathe regularly. If he holds his breath, make him count in a whisper.

(i. Do not constrict the part which is being moved.


SCHOTT METHOD OF BATHS AND RESISTED MOVEMEN" Diagnosis Name Hospital No.


Johns fi

rs.


0PKIN^


Hospital. Ward



• Balh !

l| ana


TIME


Respiration. Pulse and Heart [P,".|-Jr;?ile f SEE HISTORY '«-n?e\%e°e°jr']



It

as



Date


of samel aud Movements


In bod


Just before


1st halt


2nd halt


Immed. after


10 mtu. after


Pulse Pressure


Calibre of Radial


Point Maximum Impulse,


Remarks



Begin


End


R.


P.


R.


P.


R.


P.


B.


P.


R.


P.


K.


P.


Before


After


Before


After


Before


During


Afterl>Betore


During


Atter














May, 1897.]

105


Bibliography.

[Those references without the asterisk the writer was unable to consult. Arranged in chronological onler.]

Beueke, F. W.: Ueber Naiilieim's Soolthermen, etc. Marburg, 1859.

Weitere Mittheihmgen iiber die Wirkungen der Sool thermen Nauheims. Marburg, 1861.

  • Nauheim's Soolthermeu gegen Gelenkrheuiuatismus mit

oder ohne Herzaffection. Berlin, kliu. Wocheuschr., No. 33, 1870, p. 269.

Zur Therapie des Gelenkrheumatismus luid der damit

verbundenen Herzkraukheiten. Berlin, Hirschwald, 1872.

  • Neue Erfahruugen iiber die Wirkungen der kohlen

siiurehaltigeu 8oolthermen Nauheims, etc. Berlin, klin. Wochenschr., 1875, No. 9, p. 109 ; No. 10, p. 134.

  • Groedel, J. : Ein Beitrag zur Behandlung der Lilhniungeu

bei Apoplektikern mit Herzfehlern. Berlin, klin. Med. AVoeheuschr., No. 10, 1878, p. 137.

  • Pneumatometrische Beobachtuugen iiber den Eiufluss

verschiedener Biider auf die Kespiration. Berlin, klin. Wochenschr., No. 32, 1880, p. 314.

  • Die Wirkung der Biider auf das Herz. Berl. klin.

Wochenschrift, 1880, No. 20, p. 438.

  • Zur Behandlung Herzkranker. Berlin, kliu. Wochenschr., No. 35, 1883, p. 381.
  • Schott, T. : Beitrag zur tonisirenden Wirkung kohlensiiurehaltiger Theramalsoolbilder auf's Herz. Berl. klin. Wochenschrift, 1883, No. 28, p. 428.
  • Schott, A. und Theo. : Die Nauheimer Sprudel und Sprudelstrombiider. Berlin, klin. Wochensch., 1884, No. 19, p. 394.
  • Schott, A. : Zur Therapie der chronischen Herzkraukheiten.

Berl. klin. Wochenschrift, No. 33, p. 534. 1885.

Leichtenstern, 0. : General Balneotherapeutics. Ziemssen's Handbook of Therapeutics, Vol. IV, p. 395. London, 1885.

Schott, August: Die Bedeutuug der Gymnastik fiir Diagnose, Prognose und Therapie der Herzkraukheiten. Zeitsch. f. Therapie, 1885.

Schott, Th. : Die Hautresorption und ihre Bedeutuug fiir die Physiologie der Badewirkungen. Deut. Med. Zeitung, 1885.

Oertel, M. J. : Therapeutics of Circulatory Derangements. Ibid., Vol. 7, 1887.

Schott, Th. : Die Behandlung der chronischen Herzkraukheiten. Berlin, Grosser, 1887.

Zur Pathologie und Therapie der Angina Pectoris.

Deut. med. Zeitung, 1888, No. 35-38.

Wiborgh, Aug. : Bad Nauheim, etc. Stockholm, 1888.

Bode, W. : Bad Nauheim, seine Curmittel, Indicationen und Erfolge. Zweite Aufl., Wiesbaden, 1889.

  • Schott, Theodore: Herzkraukheiten. Separat-Abdruck aus

der Keal-Encyc. der gesammten Heilkunde. Wien und Leipzig, 1890. (Reprint.;

  • Zur acuten L^eberanstrengung des Herzens und dereu

Behandlung. 1890. Separ. Abdr. aus den Verhandlungen des IX. Congresses fiir innere Medicin zu Wien. (Eeprint.)

  • Herzkraukheiten. Keal-Encycl. der gesammten Heilkunde. Wien und Leipzig, 1890. (Reprint.)


  • Groedel, J. : Ueber abnorme Herzthiitigkeit in Folge von

lunervationsstoruugen. No. 21, 1890, p. 467.

  • Schott, Theodore: The Treatment of Chronic Diseases of

the Heart by means of Baths and Gymnastics. Lancet, 1891, Vol. I, p. 1143. Concluded on p. 1199. (Reprint.)

Israel, E. : Om Nauheimkur, etc. Copenhagen, 1891.

Schott, Th.: Balneo-therapeutic and Mechano-therapeutics applied to the Treatment of Chronic Heart Disease. Medical Record, No. 7, Vol. XXXIX, 1891.

  • Zur Differentialdiagnose des Pericardialexudats uud

der Herzdilatation. (Reprint.) Berlin, klin. Wocheuschrift, 1891, No. 18.

Ueber Herzneurosen. 1893. Separ. Abdr. aus der Real-Encycl. der gesammten Heilkunde.

  • Moeller: Traitement des maladies du coeur par la methode

des Drs. Schott. Bruxelles, 1893. (Repriut.)

  • Babcock : Schott Method of treating Chronic Diseases of the

Heart. Journal of American Medical Assoc, XXI, pp. 717-734, 1893.

Summers, Guillermo: Tratamiento de las enfermades cronicas del corazon por el metodo del Dr. Schott. Gaceta Medica de Cadiz, 1893.

Groedel: Bad Nauheim and the Treatment of Chronic Heart Disease. St. Petersburg Med. Woch., 1893.

  • Schott, T. : The Mineral Waters of Nauheim, their Action,

Uses and Effects. Eyre & Spottiswoode, London, 1894.

Smyly, P. C. : On the Treatment of Enlarged Heart by Certain Movements as taught by Dr. Schott, Nauheim. Dublin Jour, of Med. Scieu., 1894, Vol. 3, p. 185.

  • Thorne, W. Bezley : Treatment of Chronic Diseases of the

Heart by Baths and Exercises according to the Methods of Dr. Schott. 1894. Churchill, London.

  • Thorne, W. B. : The Treatment of Chronic Diseases of the

Heart by Baths and Exercises according to the Method of Dr. Schott. Lancet, 1894, Vol. I, p. 1117.

  • Wethered, F. J. : The Treatment of Chronic Diseases of the

Heart by Baths and Gymnastics as practised at Nauheim. Brit. Med. Jour., 1894, Vol. II, p. 1045.

  • Brunton, T. L. : The Harveian Oration, 1894. London.

♦Campbell, H. : The Mechanical Treatment of Heart Disease. British Med. Journal, 1894, Vol. 2, p. 1101.

  • Eccles, A. Symous: Mechanotherapy in Chronic Diseases of

the Heart. The Practitioner, 1894, Vol. I, p. 107.

  • Pagenstecher de Mexico, G. : Du traitement balneomechanique des maladies chroniques du coeur d'apres la m6thode des docteurs Schott de Nauheim. Bulletin General

de Therapeutique, Paris, 1894, Nos. 15-30, Juin. (Reprint.)

  • Babcock, Robert H. : Report of Cases of Chronic Heart

Disease treated by the Schott Method of Baths and Gymnastics. N. Y. M. J., LX, pp. 705-710, 1894.

  • Schott, Th. : Zur Behandlung des Fettherzens. Deut. Med.

Wochensch., XX, 561, 1894.

Armstrong: Nauheim Treatment of Chronic Cardiac and Allied Diseases. Liverpool Medico-Chirurgical Journal, July, 1895.

  • Sturge, W. A. : Note ou the Treatment of Dilated Heart as


106



practised at Naiiheim. Brit. Med. Jour., 1895, Vol. I,

p. 537.

  • Thorne, W. B. : Tlie Treatment of Chronic Affections of the

Heart by Baths and Esereises. Brit. Med. Jour., 1895,

Vol. I, p. 524.

  • The Schott Method of Treatment in Chronic Diseases

of the Heart. London, 1895.

  • Practitioner, May, 1895, p. 385. The Treatment of Chronic

Heart Disease by the Method of Dr. Schott, Nauheim. By

John F. H. Broadbeut. With some remarks on the mode

of action of the treatment and its indications. By Sir

William Broadbent, Sen. Physician to St. Mary's Hospital.

  • Thorne, W. B. : The Treatment of Chronic Affection of

the Heart. Brit. Med. Jour., 1895, I, p. 524. Kraus, W. C. : Some Advances in Cardiac Therapeutics. Med.

Press and Circ, Loudon, 1895.

  • CTroedel: The Mechanico-Gymuastic and Balneo-Tliera

peutic Treatment of Chronic Cardiac Disorders. Lancet,

London, pp. 802-804, 1895.

Baths in Cases of Arterio-sclerosis. Deut, Med. Zeitung,

1895.

Green, C. L. : The Treatment of Chronic Heart Disease by the Schott Method. N. W. Lancet, St. Paul, XV, 345-349, 1895.

Pospischil: Hydrotherapie bei organischen Herzkrankheiten. Deutsch. med. Ztg., Berlin, XVI, 581-586, 1895.

de Bosia, H. : Des indications des eaux minerales dans les traitemeut des maladies da coeur. Cong. Franc, de MC'd., Paris, 845-852, 1895.

  • Sauudby, Robert: Remarks on the Nauheim (Schott) Treatment of Heart Disease. B. M. J., Nov. 2, 1895, p. 1081.

Discussion, p. 1129.

Birmingham Medical Review, Vol. XXXVIII, 1895, No.

208.

Fisher, T. : The Treatment of Heart Disease. The Hospital, August 24, 1895.

  • Heinemauu, PI. N. : Experiences with the Physical and Schott

Treatment of Chronic Heart Disease. N. Y. Medical Record, 1896, L, 847-852.

  • Mason, A. L. : The Baths of Nauheim in Heart Disease. Boston M. and S. J., 1896, CXXXV, 302.
  • Morrison, A. : The " Schott Treatment " of Heart Disease.

Practitioner, London, 1896, LVII, 268-275.

♦Report of the Lancet Commission on Balneological and Gymnastic Treatment of Heart Disease at Nauheim. Lancet, London, 1896, II, 619-621.

  • McArthur, A. N. : Heart Disease treated by Saline Baths.

B. M. J., 1896, I, 1384.

♦Carter, A. H. : The Schott Treatment of Heart Disease. Practitioner, 1896, LVII, 166. [No direct bearing upon the treatment.]

  • Erebuske, C. J.: Gymnastics in Heart Disease. Bost. M. &

S. J., 1896, CXXXIV, 610-612. (Discussion) 618-620.

  • Graiipner. Die Balneotherapie der chronischeu Herzkrankheiten, ihrMechanismus und ihre Beziehung zur Dynamik

des Kreislaufs. Deutsche Med. Wochensch., 1896, XXII, 529-531.

Nauheimer Mineralbader und einfache Wasserbader:


ihr Einfluss auf Blutdruck und Herzthiltigkeit. Allg. Med. Centr. Ztg., Berl., 1896, LXV.

Cireene, C. L. : Extreme Dilatation of the Heart due to Valvular Disease, with Special Reference to Treatment by the Schott Method. luternat. Clin., Phila., 1896, 6 s., II, 63-73.

Yeo, F. B. : Rest, Exercise and Baths in the Treatment of Cardiac Affections. luternat. Clinic, Phila., 1896, 6 s., II, 31-42.

Bowles, R. L. : Nauheim and the Schott Treatment of Diseases of the Heart. Med. Press and Circ, London, 1896, N. S., LXI, 339. Discussion, 345.

  • Kingscote, E. : Fifteen Months' Practice of the Schott Methods for the Treatment of Chronic Affections of the Heart.

Lancet, London, 1896, I, 761-7C3.

  • Nebel, H. : The Treatment of Heart Diseases by Baths and

Gymnastics. N. Y. Med. Record, 1896, XLIX, 7)7. (Early literature.)

  • Broadbent, Sir W. N. : Note on Auscultatory Percussion and

the Schott Treatment of Heart Disease. Brit. M. J., 1896, I, 769.

  • Leith, R. F. C. : An Inquiry into the Physiology of the

Action of Thermal Saline Baths and Resistance Exercises in the Treatment of Chronic Heart Disease (the Nauheim and Schott System). Edinb. M. J., 1895-6, XLI, 804, 814. Also Lancet, 1896, I, 757, 841.

♦Campbell, H. : The Schott Treatment of Heart Disease. Lancet, 1896, I, 951. [Communication on Leith's paper.]

  • The Schott Treatment as carried out at Sidmouth. Brit. M.

J., 1896, I, 924.

Anderson, McO. : Dilatation of the Heart treated by Exercises on the Schott Principle. Glasgow M. J., 1896, XLV, 266, 268.

♦Poore, G. V.: Two Cases of Heart Disease treated by Saline Baths. B. M. J., London, 1896, I, 1139.

  • Rives, W. C. : The Baths of Nauheim in the Treatment of

Disease of the Heart and the Therapeutic Methods of the Doctors Schott. N. Y. M. J., 1896, LXIII, 471-479.

Steven, J. L. : On the Nauheim (Schott) Methods of Treatment as applied to Cases of Cardiac Valve Disease of Rheumatic Origin. Glasgow M. J., 1896, XLV, 339-361.

  • Thorne, W. B. : Self -Poisoning in Heart Disease ; its Relation to Schott Methods of Treatment. Lancet, Loudon,

1896, I, 755-757.

♦Schott, T.: Ueber gichtische Herzaffectiouen und dereu Behandlung. Berliner klin. Wochenschrift, XXXIII, 457-519, 1896.

♦Stewart, Grainger: Discussion on Treatment of Cardiac Failure. Brit. Med. Journal, September 19, 1896.

♦Bowles, R. L. : An Experimental Inquiry into the " Schott Treatment" of Certain Diseases of the Heart at Bad Nauheim. The Practitioner, July, 1896. (Reprint.)

♦Ileinenmu, H. Newton: Die physikalische Behandlung der chronischen Herzkrankheiten. Deut. Med. Woch., 1896, No. 33, Leipzig. (Reprint.)

♦Cohen, Solomon Solis : The Schott Method of Gymnastics in Chronic Heart Disease. JIaryland Jledical Journal, Feb. 20, 1897.


May, 1897.]

107


A CASE OF POROKERATOSIS WITH


(MIBELLI) OR HYPERKERATOSIS EXCENTRICA (RESPIGHD A REMARKABLE FAMILY HISTORY.*


PKELIMINAEY NOTICE.


By T. Caspar CtILCHRist, M. 11. C. S., L. S. A., Associate in Dermafologi/, Johns Hopki)is Unicersifi/.


In October, 1893, Mibelli, of Italy, described three (slight references were made to three others) cases of a new disease which, after a careful and detailed histological examination, he named Porokeratosis. The disease began at an early age, and was chiefly distributed on the backs of the hands, feet, other portions of the extremities, neck, face and scalp. The lesions commenced as minute, dirty brown, dry, cone-shaped elevations of different sizes and forms, which became much altered as they very slowly increased in size. The lesions extended centrifugally, and the central portion gradually sank in and still remained callous, but the margin was represented by a raised wavy ridge which presented the features of a raised seam. Some patches grew to a very large size and covered almost the whole forearm. Mibelli gave the name porokeratosis to this disease because the most important anatomical lesion was the hyperkeratosis of the sweat duct and sweat pore. In one instance a brother and sister had the disease, mainly on the face and neck. The disease was exceedingly chronic and was unaccompanied by any inflammation or any subjective symptoms.

On January 15, 189-1, Respighi, also of Italy, described seven cases of a disease which was recognized by Mibelli as belonging to the same group. Respighi gave the name of " Hyper


  • Exhibited before the Johns Hopkins Hospital Medical Society,

March 1, 1897.


keratosis excentrica" to this affection. In one of the cases the father of the patient also was affected with similar lesions. Two years later, three more cases were described by the same author. A single case has been recorded outside of Italy, by Dr. M. B. Hutchius, of Atlanta, Ga., in the Journal of Cutaneous and Genito- Urinary Diseases for October, 1890. In Hutchins' case the disease began at two years of age, on the 2)alni of the left hand. The patient is now a man, 33 years old, and has the disease on the left palm, the back of the hand and forearm, and on the face. No histological examination was made. Hutchins compares the boundary of the patches to the "outside of a seam with a thread-like line dividing its lateral halves, and consisting of horny epidermis." No other member of the family had it. In all the cases which have thus far been recorded, only two gave histories of other members of the same family having the disease. In the one case (Mibelli's) a brother had it, and in another (Respighi's), the father of the i^atient had it.

The patient whom I exhibit this evening is a young man, 21 years of age, who has had the disease since he was five years old, when it commenced on his ears, nose, chin, neck, back of hands and right forearm. The lesions were extremely slow in ap2)earing and in growing. The most remarkable feature about the whole case is the family history, which is here given in a tabular form, together with a very brief descrijitiou of the disease in each case.


Grandmother.

Disease on the face ; commeuced when she was a child iu 1813, now dead.


One Brother.

Lesions on the face, oommeucing at an early afie and lasting until death.


Father.


Disease began at about 8 years of age and is on the face, palms, back of hands, forearms, legs, feet, and sole of one foot.


One Brother.

Disease commenced at about 9 years of age, on face and leg; died


One Son. No eruption.


28 years old, married. Disease commenced at 7 years, on face.


Brother 0).

Aged 30 ; four lesions on left side of nose, commenced at 5 yrs.


Brother i2). Aged 17; disease just commencing (?), one lesion on neck.


Aged 15; number «)f lesions on face which began at about 9.


9 years old: disease commenced at 7 and quite extensive on face.


Aged 11; disease commenced at 9 years on face.


108



It will be seen that eleven persons in one family have had this disease. The patient gave me this history after careful inquiry, and I have since been able to verify his statements with reference to seven of the cases, viz. father, three brothers, a married sister and two of her children, by personal observation. The patient's description of the lesions in his father and brothers, whom I examined later, was so correct that I feel confident the other descriptions are also true, especially since the remaining family history was verified by his father and mother. The father of the patient also described to me the disease as it existed on his mother, an uncle and brother. I will not go any further into the history or description of the lesions occurring in other members of the family, but will reserve that for a more detailed histological description with photograph and drawings, which will appear later.

The patient first came under my care eighteen months ago, and my attention was then only directed to the lesions on the face. I did not diagnose the disease until I had made ten or more histological examinations of excised portions and had seen Mibelli's and llespighi's articles.

The eruption consists of lesions of various sizes and forms which appear to take on two characters according to their age. The smallest variety, which are distributed chiefly over the face, consist of minute (less than 1 mm. in diameter), dirty brown, semi-globular elevations of a horny nature. When they reach the size of a small pinhead the centre becomes depressed and the margin in some is slightly raised, round, oval or slightly irregular, and presents the appearance of a raised seam, along the centre of which runs a thin black line. As the patch becomes very slowly larger the base takes on a somewhat atrophic character. In a few of the lesions, especially those on the neck, a number of minute conical elevations are distributed along the ridge, giving it an irregular appearance, and sometimes one or two of these minute cones appear in the central portion of the plaque. The largest patches are about the size of a split pea.

After removing some of the diseased portions with a curette and applying very thoroughly the silver nitrate stick, I


have seen on four or five occasions the disease return within a month or two in the manner described, viz. a very minute, dirty brown papule, which within two or three weeks apparently began to clear up in the centre. Other lesions return in the form of a ring or oval ridge. If one of the patches is curetted it is fairly easily removed, but the operation is followed by almost as much bleeding as the removal of a small epithelioma. Examination of the scrapings, either fresh or after treatment with liquor potassaj, is negative. While watching the course of the disease week by week, I have seen new lesions arise which I had not detected the week previous.

One or two of the lesions appeared to have formed round a hair follicle, but others did not exhibit any such relationship.

A histological examination of a large number of sections from the most recent as well as from the oldest patches showed that the disease consisted of a marked hyperkeratosis of the sweat pore and duct and of the adjacent hair follicle. In some of the material excised from the face it was not clear tliat the hyperkeratosis had commenced in the mouth of a hair follicle, but in other sections, especially of the smallest variety of lesions, the disease had undoubtedly commenced about the sweat pore. The oldest lesion, especially from the ear, presented a picture almost identical with that of a mild psorospermosis foUicularis (Darier).

From the clinical and histological characters of the disease there was no doubt of the diagnosis of all the cases, but the special feature of this rare lesion was perhaps most marked in the case of the father of the patient, who presented on the hands lesions which showed the well-defined raised wavy edge with a thin blackish line along the centre.

The character of the disease on the hands agreed perfectly with the descriptions of Mibelli and Hutchins. JSfibelli has reported 6 cases, Eespighi 10 cases, and Hutchins 1. I am able to record a group of eleven in one family, which fact seems at first sight to point to a strong hereditary taint. The histological features will be discussed in detail and a fuller clinical description will be given in a later article.


A RAPID METHOD OF MAKING PERMANENT SPECIMENS FROM FROZEN SECTIONS BY

THE USE OF FORMALIN.

By Thomas S. Gdllen, M. B., Resident Gynecologist.


In April, 1895, I published two methods under the above title in the Bulletin.

Since then, numerous requests have been made for reprints or for copies of the Bulletin of that number, and as the supply is exhausted, it has been thought best to publish the article again with one or two minor alterations. The methods have been continuously employed in the Hospital, and especially in the gynecological department, and have proved uniformly satisfactory.

A complete freezing outfit has been placed in close proximity to the operating room, so that as little delay as possible may occur in examining a specimen. For example, if a carcinoma


of the uterus is suspected, the patient is brought to the operating room prepared for hysterectomy. The uterus is curetted and the scrapings are examined while the usual preparations for abdominal section are being made. By the time all prejsarations are completed the diagnosis is given; if negative, the patient is returned to the ward with the assurance that there is no cause for alarm ; if positive, the organ is immediately removed. The woman is thus saved from taking an anajsthetic twice, and avoids the period of anxious suspense of four or five days generally required by the ordinary methods to ascertain whether she has malignant trouble or not. Any one who has hardened tissues in formalin will be im


May, 1897.]

109


pressed with the rapidity of its action, with the firm consistence of the tissue, and with the absence of the contraction of the specimen so often seen when alcoliol is used as the hardening medium. Microscopical examination of a specimen hardened in formalin, as we all know, shows almost perfect preservation of the cellular structure. Recently it occurred to me that formalin might be used in the preparation of frozen sections.

One of the greatest difficulties experienced in rendering frozen sections permanent lies in the fact that when passed through alcohol the section frequently not only contracts but contracts irregularly, distorting the specimen ; further, such specimens will often stain imperfectly. The use of formalin will obviate these difficulties, allowing one to make an excellent permanent specimen from the frozen section. My method is as follows: The tissue to be examined is frozen with carbonic acid or ether aud then cut; the sections are then placed in 5 per cent, watery solution of formalin for 3 to 5 minutes, or longer if desired; in 50 per cent, alcohol 3 minutes, and in absolute alcohol 1 minute. The tissue is now thoroughly hardened aud can be treated as an ordinary celloidin section, being stained and mounted in the usual way. On examining this mounted section one might readily take it for a well preserved alcoholic specimen. Supposing we stain with hematoxylin and eosin, the entire process is as follows :

Method I. a. Place the frozen section in 5 per cent. aq. sol. formalin for 3 to 5 minutes.

b. Leave in 50 per cent, alcohol 3 minutes.*

c. In absolute alcohol 1 minute.

d. Wash out in water.

e. Stain in ha^matoxylin for 2 minutes. /. Decolorize in acid alcohol.

g. Rinse in water.

h. Stain with eosin.

i. Transfer to 95 j)er cent, alcohol.

j. Pass through absolute alcohol, then through either creasote or oil of cloves, and mount in Canada balsam.

The blood is lost in frozen sections. To overcome this Prof. Welch suggested that the sjiecimen be first fixed in formalin and then frozen. I tried this aud found that we were able to preserve the blood, but that it did not stain very distinctly. For convenience this second procedure will be called method II. The essential factor is the same in each case. The latter process, however, requires at least two hours. A small piece of the tissue is thrown into 10 per cent, solution formalin for two or three hours. It is then put on the freezing microtome and thin sections can be readily made. The sections are stained in the usual way. The detailed procedure of method II is as follows:


  • The sliglit modification of Method 1, recently suggested by L.

Pick, Centralblalt f. Gyn., Bd. XX, S. 1016, 1896, I cannot recomirieiul. When first experimenting with formalin, among other prolures I tried staining the sections after hardening in the formalin I before placing them in alcohol, as Pick now suggests. The ifsulls were fair, but the definition so obtained was not to be compared with that gained by first passing through 60 per cent, and absolute alcohol for the short period. I accordingly abandoned it and did not think it worthy of publication.


Metliod II. a. A piece of tissue lx.5x.2 cm. is placed in 10 per cent. aq. sol. formalin for 3 hours. Rinsed in water.

1). Frozen sections are made.

c. Left in 50 per cent, alcohol 3 minutes.*

(/. In absolute alcohol 1 minute.

e. The sections are now run through water and stained in hsematoxylin for 3 minutes.

/. Decolorized in acid alcohol.

g. Rinsed in water.

/;. Stained in eosin.

/. Transferred to 95 per cent, alcohol.

j. Passed through absolute alcohol, then either through creasote or oil of cloves, and mounted in Canada balsam.

For ordinary use method I is all that is required. Given a piece of tumor from the operating room, it is possible to give as definite a report in 15 minutes as one would be able to give after examining the alcoholic or Miiller's fl.uid sjjecinieus at the expiration of two weeks. Method II is of especial value in the examination of uterine scrapings. Instead of putting them in the 95 per cent, alcohol in the operating room, they may be immediately dropped into 10 per cent. aq. sol. formalin. By the time the pathologist receives them, which is at least two hours afterwards, they are firm enough to be frozen without difficulty, and permanent sections can be immediately made. The second method is to be recommended for all delicate tissues. In employing these methods one must remember, as for example in epithelioma, that some of the cell-nests will drop out, there not being anything to hold them in situ, as there is when celloidin is used. AYe have, however, hardened and stained epithelioma of the cervix by this method without the slightest difficulty.


NOTICE.

All inquiries concerning the admission of free, part pay, or private patients to the Johns Hopkins Hospital should be addressed to Dr. Henry M. Hurd, the Superintendent, at the Hospital.

Letters of inquiry can be sent, which will receive prompt answer, or personal interviews may be held.

Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indigent patients a uniform rate of $5.00 per week has been established. The Superintendent has authority to modify these terms to meet the necessity of urgent cases.

The Hospital is designed for cases of acute disease. Cases of chronic disease are not admitted except temporarily. Private patients can be received irrespective of residence. The rates in the private wards are governed by the locality of rooms and range from $20.00 to $35.00 per week. The extras are laundry expenses, massage, the services of an exclusive nurse, the services of a throat, eye, ear and skin or nervous specialist, and surgical fees. Wherever room exists in the private wards and the condition of the patient does not forbid it, companions can be accommodated at the rate of $15.00 per week.

One week's board is payable when a patient is admitted.

DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL

Bv John s. lin.i.iNos, M. D., LL. D. C.mtalulng 60 Urgo cjuartu pl.-iiofl, phototyDOS, and llth<.gi-apli», wli.h vIbwb lilaua and detail drawings ot all tUo bulldiugs, aud Uielr liuerl"!- arranguniouts— also wood-cuts of apparatus and flxtures; also U6 pages of letter-press describing the plans followed In the cnnstruoUou, and giving full details ot heatlug-apparatua, ventilation, sewerage and plumbing. Price, bound In cloth, $7.50.



PROCEEDINGS OF SOCIETIES THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of December 7, 1896.

Dr. Thayer in the Chair.

Typlioid Perforation treated by Surgical Operation.— Dr.

FiNNKY.

In 1762 Richter, in Vienna, first suggested the advisability of oiJeuiug and draining the peritoneal cavity in cases of general suppurative peritonitis. The operation did not come to general notice, however, until 1884, and was not applied to cases of suspected perforation of the intestine in typhoid fever until 1887. Since that date 46 cases have been reported, to which may be added 6 unpublished cases, including 3 of Dr. Finney's, making a total of 53.

According to statistics taken from various sources, perforation of the intestine occurs in from 1 per cent, to 2 per cent. of all typhoid fever cases. In 80 per cent, of the cases it occurs in a thickened and iutlamed Peyer's patch of the ileum, from 2 cm. to 1 m. above the ileo-cascal valve. In over 12 per cent, it occurs in the large intestine, and in 5 per cent, in the appendix vermiformis. There is usually but one perforation. In twelve cases, however, multiple inflamed Peyer's patches were observed. It occurs more often in men than in women ; more frequently between the ages of 20 and 30 years, and usually during the third week of the disease. The duration of life is usually short. In typhoid fever, perforation is always followed by suppurative peritonitis, either general or local ; howevei', peritonitis may arise during the fever without any discoverable perforation. It occurs much more frequently in mild than in severe forms, and the symptoms may be severe, mild, or wanting. The most constant and characteristic symptom is sudden, severe abdominal pain, persisting with increasing intensity ; there may be collapse, nausea and vomiting. A few of the cases have shown chill, hiccough, a marked fall of temperature, and absence of the liver dulness. Owing to the great difficulties of diagnosis it is impossible to get data as to the number of recoveries without operation.

A study of the reports of the operations brings out the following facts. The time between theonsetof the symptoms of perforation and the oj)eration varied between 2 and 12 hours. The condition of the patients at the time of operation was usually markedly unfavorable. Ether and chloroform were used about equally ; in one case both were used. The median incision was the most common. Thirty-three of the cases showed marked general septic peritonitis with foul pus and exudate. Faecal matter was usually present, and the mesenteric glands opposite the ulcerated Peyer's patches were, as a rule, enlarged and softened. In the treatment, irrigation of the peritoneal cavity was employed more often than simply wiping. As regards the perforation itself, in 8 cases the edges were incised before suturing; in 2 a wedge-shaped piece of the bowel was removed, and in 1 the edges of the bowel were stitched to tlie abdominal wound while an artificial anus was established. Including all of the 52 cases, there have been 17 recoveries; but if doubtful cases are excluded, the result is


13 recoveries from 47 cases,making a percentage of 27.65. In 19 of the fatal cases autopsies were obtained.

These data are hardly sufficient for general conclusions, but several points are brought out quite prominently in studying the group as a whole. The best time for operation is apparently as soon as possible after the patient has recovered from the shock attending the perforation. This is usually in a few hours. There is a remarkable uniformity in the condition of the peritoneum and viscera ; intense congestion, much feculent pus and exudate, with distension of the bowel. As the ileum is the usual place of perforation, it should be examined first ; a suture should be taken over any suspicious-looking patches, and the appendix should be removed if it be at all abnormal. If the inflammation does not involve the whole peritoneal surface, irrigation with the necessarily mild fluids might tend to spread the infection. In dealing with the perforation, to excise the edges takes too long, and healing usually takes place without. Should the wall be in such a condition as to make suture impossible, it would be better to pull out the loop of intestine and leave it until the patient had recovered from his fever. The line of suture must be determined by circumstances; the mattress suture of Halsted is to be preferred. Drainage should always be employed. The fact that in 8 cases a wrong diagnosis was made shows how little dependence can be placed on the so-called characteristic symptoms. However, the systematic examination of the blood promises to be of the greatest assistance. During typhoid fever there is no leucocytosis, but immediately after a perforation a marked increase in the number of white corpuscles occurs. Cabot mentions a case of 8,300 before and 24,000 after ; in Porter's case the figures are 6,500 and 10,600 ; in his (Dr. Finney's), 3,000 and 16,400.

Fitz has pointed out the striking similarity of the symptoms of typhoid perforation to those of inflammation of the appendix. Dieulafoy recognizes two forms of typhoid appendicitis capable of producing peritonitis ; one, "peritonitis by propagation," involving the lymphoid tissue of the appendix, the other, " para-appendicitis," which is of the usual variety.

The symptoms of peritonitis quickly follow perforation. Examination shows that pyogenic cocci, especially the streptococcus pyogenes, are rarely absent, indicating that they are common inhabitants of the intestine. The Johns Hopkins Hospital autopsy reports show in 4 cases a mixed infection of streptococcus pyogenes and bacillus coli communis, in one a pure culture of the streptococcus, and in one a pure culture of the colon bacillus. The absence of the bacillus of Eberth and Gaifky is probably due to its being destroyed by its more active companions, streptococcus pyogenes and bacillus coli communis. In Dr. Finney's third case pure colon bacillus was found; in other cases the typhoid bacilli were present in liver or spleen or in a peritoneal abscess.

As regards the incision, the median has obvious advantages in general, but if the abdominal muscles are too rigid, it is lielter made over the part most often affected. Its length should always be amply suflicient. On the other hand, the


May, 1897.]

Ill


time consumed in operation should be as short as possible. The autopsies showed that healing was always well under way. Death usually occurred from septic absorption, but the records show some other complications, obstruction of the intestine, a second perforation, defective drainage or an abscess. General peritonitis makes a case very serious, but with operation the chances are about 1 in 4. The treatment of a case of perforating typhoid ulcer involves three things: (1) Finding and closing the perforation ; (3) emptying and cleansing the peritoneal cavity; (3) the establishment and maintenance of effective drainage.

For these ends the following method, employed in his (Dr. Finney's) third case, has proved the most satisfactory. An oblique incision, about 6 inches, is made in the right iliac fossa. The Ciscum is found as a guide to the ileum (or appendix); the coils of small intestine, beginning with the ileum, are pulled out systematically. One assistant wipes vigorously and thoroughly the coils with a gauze sponge wrung out of hot salt solution as they are withdrawn, while another keeps them covered with warm sterile gauze. If necessary the entire small intestine is pulled out through the wound and laid to one side, covered with warm gauze. The peritoneal cavity is then wiped out thoroughly, and the coils uncovered and irrigated outside the abdomen with hot salt solution. They are then replaced in the abdomen. The worst or sutured coil is placed with its suture next the abdominal wound, and is packed about with strips of bismuth gauze to insure good drainage. The abdominal wound is closed tightly except a small opening for the gauze drain. In case of distension the bowels should be moved early and thoroughly by calomel in broken doses, followed by salts, and if necessary, a high turpentine and soapsuds enema. If stimulation is necessary, use hypodermics of strychnia, enemata of hot black coffee, or transfusion of a quart or more of the normal salt solution into the cellular tissues under the breast.

Finally, in summing up the experience of himself and others, he concludes that (1) of all the so-called diagnostic signs of perforating typhoid ulcer, most reliance is to be placed upon the development during the third or fourth week of an attack of typhoid fever, of severe, continued abdominal pain, coupled with nausea and vomiting, and at the same time a marked increase in the number of white blood corpuscles.

(2) The surgical is the only rational treatment of perforating typhoid ulcer. •

(3) There is no contraindication to the operation, surgically speaking, save a moribund condition of the patient.*

Case I. — Mr. M.,aged about fifty-five years, was taken sick about October 15, 1894, complaining of headaclie, general malaise, pains in limbs and joints, togettier with irritability of the bladder. Was


•Since the above was written one other case has been reported by Armstrong, of Montreal (Montreal Med. Journal, Vol. XXV, No. 8, 1897). This case recovered from an operation for the relief of first perforation. Twenty-four days later, however, a second, and four days later a third perforation occurred, from the effects of which the patient finally succumbed. Reference is also made to the fact that two other fatal cases had occurred in that vicinity.


seen on October 19 by his physician, Dr. Wesley C. Stick, of Glenville, Pa., to whom I am indebted for the notes of the case. " He gave an indefinite history of having felt badly for about ten days. He had at this time a temperature of 102° F., frequent micturition, bowels constipated, pulse 100. Patient up and dressed ; was put to bed and bowels opened by enemata. In a few days temperature came down to about 100° F., pulse to 90. Would not stay in bed. Irritation of bladder ceased. Was getting along very nicely until the night of October 2(ith, when he was suddenly seized witli a violent pain in his abdomen while lying in bed. Was seen the next morning. Pain in abdomen very severe, relieved somewhat by emptying the over-distended bladder through a catheter. He had been unable to void urine during the night, although having frequent and urgent desire to do so. Several hypodermics of morphine were necessary, however, before he became easy. An enema was given with little result. His abdomen was moderately distended, and not very tender to the touch. In the evening of the same day he was seen again and found to have considerable pain, which was relieved by a hypodermic. Had vomited some during the day. His pulse was about 90 ; temperature 99° to 100° F. The following day, October 28, he vomited frequently a coffee-ground-looking fluid. On the fourth day, October 29, his condition remained about the same ; he could get in and out of bed by himself (he was a largeframed, heavy man, weighing about 225 pounds) ; pulse regular and not above 90 ; cheerful ; the constant regurgitation of coffee-ground fluid being the most troublesome symptom. On the next day, October 30, he was able to sit up in bed, but his pulse had risen to 100 and his temperature to 100° F. Abdomen still not much distended nor very tender."

I saw him at eleven o'clock the night of October 30; his condition then was fairly good, temperature and pulse about 100. Abdomen not much distended, rather retracted ; muscles, especially the recti, very rigid ; tenderness general, but not marked ; frequent and copious vomiting of a dark brownish fluid ; countenance pallid and anxious. The diagnosis was general peritonitis, cause unknown, probably appendicitis, although Dr. Stick had from the first suspected typhoid fever with a subsequent perforation of the intestine. The patient had been exposed to typhoid contagion during a recent visit.

As his condition was evidently becoming worse, it was thought best to open the abdomen. The operation was accordingly performed, and under most disadvantageous conditions, about midnight, in a small log house, with very poor light. On opening the peritoneum it was found to be everywhere intensely congested, of a dark chocolate color ; the coils of intestine distended and covered here and there with flakes of exudate. There was a considerable quantity of turbid feculent fluid everywhere in the abdomen. A perforation was found in the ileum, about six inches from the cKcum, about one and a half centimetres in diameter, with sloughy edges. These were turned in and sutured with Halsted's mattress suture. The peritoneal cavity was cleansed as thoroughly as possible by sponging, the sutured coil irrigated with salt solution and replaced. The appendix was found normal, save the inflammation of its serous covering. The abdominal cavity was thoroughly drained with strips of iodoform gauze, the ends of which were brought out through the wound. The operation took about one hour. His condition at the end was somewhat collapsed, but he rallied under stimulation, administered hypodermically and by rectum. He began to fail, however, and died about seven hours after the operation. No autopsy.

Case II.— J. P. D., aged twenty-six years; single; American; tailor; entered the Medical Ward of Johns Hopkins Hospital, August 3, 1895. Family history is negative, except that his father died of some intestinal trouble, the nature of which was unknown, and one brother died, a year ago, of typhoid fever.

Has had diseases of childhood and several attacks of chills and


112

[No. 74.


fever at varying intervals. With these exceptions has been well. Smokes much, does not ilrink, denies venereal contagion. Present illness l)egan six days before entrance, with severe frontal lieadaches and a slight chill followed by fever. These symptoms have persisted, together with anorexia ; no nose-bleed. For past two days, diarrhoea ; has vomited twice ; slight abdominal pain, especially before micturition. Temperature on admission, 103.8° F.; pulse, 92. Blood examination negative as to malarial organism ; abdomen generally tender, slightly distended ; no rose spots ; spleen palpal)le. Leucocytes 3000 per cubic millimetre.

The patient's disease ran a more or less typical severe typhoid course, up to August 16, a. m., thirteen days after entering the hospital, when the following note appeared in the medical history: " Last night patient began to complain of a sharp pain at base of penis, notrelieved by catheterization. Temperature has been rather higher, reaching 105° F., pulse 108, regular, though soft and dicrotic. Very nervous ; abdomen very tense, though not greatly distended. Everywhere tympanitic ; complains of pain ; tenderness marked ; tongue coated ; sweating profusely, and frequently cries out with pain ; baths discontinued and cold sponging substituted." P. M. " Patient has been comparatively quiet since a. m., but at about 4 p. m. liegan to cry out and complain of intense pain in abdomen. Morphine administered hypodermically. Leucocytes, 16,400 per cubic millimetre."

The patient was seen by me with Dr. Thayer at 9.30 p. m., and operation decided upon.

Operatio7i. — Median incision. Peritoneal cavity filled with cloudy, sero-purulent fluid. Peritoneum dark red and much congested. Coils of intestine distended and covered here and there by flakes of lymph. A single perforation, about one centimetre in diameter, was found in the ileum, about sixteen centimetres from ileo-csecal valve. It was situated, apparently, in the centre of a thickened Peyer's patch, and had sharply punched-out edges. Numbers of raised, red areas could be seen here and there along the lower few feet of the ileum. The loop containing the perforation was drawn out of the abdomen, carefully cleaned of the exuded lymph and fiEcal matter, and the rent closed transversely with eight fine, black-silk mattress sutures (Halsted's). Owing to the rigidity of the abdominal walls and the distension of the bowels, puncture of the intestine in several places was necessary, in order to allow of the escape of gas. The loops of intestine were carefully cleansed by irrigation with hot salt solution, and the entire peritoneal cavity thoroughly wiped out with dry gauze. Iodoform gauze was used for drainage, and the abdominal wound closed except where the gauze drainage was brought out.

At end of operation, which lasted a little over an hour, the patient was somewhat collapsed ; temperature 103.3° F. ; pulse, 150 ; respiration, 56. He recovered from this somewhat, under vigorous stimulation, and in four hours his temperature was 101.6° F.; pulse, 130 ; and respiration, 28. His condition did not change materially, except that he became gradually weaker, and died twenty-six hours after the operation. I regret to say tliat no bacteriological examination was made, and no autopsy allowed.

C.\seIII. — Charles H., German, aged forty-seven years; married; laborer; admitted to Johns Hopkins Hospital, .\ugust 15, 1896. Family history good ; no cancer or tuberculosis. Has had the usual diseases of childhood, since which time has been strong and well, except an attack of malaria with chills and fevers eight years ago. I'his attack lasted four weeks. Denies venereal disease; smokes and drinks in moderation. One week before was taken ill with a lieadache, general malaise, and loss of appetite, and later in the day had a distinct chill, followed by fever. Next day felt somewhat better, but was weak and unable to work. He kept in bed until his admission to the hospital one week later. During this time had had several chills and more or less fever, appetite fairly good, but had eaten nothing but liquids and soft solids. He had no


epistaxis nor vomiting ; no pain, nod-arrhoea, bowels had been regular. At about 8 o'clock on the evening before admission (August 14), wliile at stool, he was seized with sharp, stabbing pains in right side of abdomen, with marked tenderness to the touch. Nauseaand vomiting were present. His physician was called in and gave him morphine hypodermically, which relieved thepain. He passedafairly comfortable night and was brought to the hospital early the next a. m., when the following condition was noted :

Face pallid and expression anxious ; tongue coated, margin and tip clean and red. Temperature, 101° F.; pulse, 116, regular and of good volume. Lungs and heart negative ; alidomen is uniformly distended, no undue prominence in any region noted ; skin normal; tympanitic throughout ; rigidity of abdominal muscles throughout, especially of the right rectus in its lower part. In iliac region indistinct tumefaction felt ; tenderness general, but more markeil over right lower quadrant. Rectal examination negative ; no eruption on skin ; urine showed nothing abnormal.

A diagnosis of beginning general peritonitis, jirobably due to appendicitis, was made. I confess, at the time, the possibility of perforating typhoid ulcer did not occur to me.

Immediate operation advised and agreed to. After the usual ])reliminary preparation the abdomen was opened through an incision along outer border of right rectus. Abdominal wall distinctly cedematous. The peritoneum was everywhere intensely congested, roughened and dull, with flakes of plastic lymph. In the pockets between coils of intestine and extending down into the pelvis there was an accumulation of thin, yellowish, turbid fluid, containing flakes of exudate. There was no marked fsecal odor to this fluid. The intestines were distended, congested, and dark colored. In passing towards the median line and hypogastric region the congestion and peritonitis became less marked, and in the upper left quadrant the peritoneum seemed fairly normal. At no place was there the slightest attempt apparent at walling off the inflammatory process. The appendix was found in its normal position, somewhat thickened and congested, and constricted at about its centre, due to old adhesions. It was ligated, excised, and stump covered with peritoneal cuflf. About fourteen inches from ileo-cascal valve, in the ileum on its free border, a small hole, about four millimetres in diameter, was found. It was sharply defined, edges bright red and thickened. It was in the middle of what appeared to be a swollen and enlarged Pej'er's patch. Soft yellow ftecal matter was exuding from the opening. Opposite the ulcer was a mesenteric gland enlarged to the size of an olive, soft and of a bright red color. The loop of ileum was brought out through the wound and packed about with gauze. The edges of the ulcer were turned in and sutured with eight mattress sutures of fine black silk. The edges of the ulcer were not excised. After suturing, the loop was thoroughly cleansed with salt solution and dry gauze and returned, the peritoneal cavity thoroughly and systematically wiped out with pledgets of dry gauze. Some distance below in the ileum a second swollen Peyer's patch could be made out. Bismuth gauze in strips was packed loosely about the sutured portion, and theends brought out through the lower end of the incision. Tiie rest of it was closed with buried sutures of silver wire. The wound was dressed with silver foil and sterile gauze. His condition at the end of the operation was good. Time of operation one and a half hours. Pulse, 120, and of good volume ; respiration. 20 to 25, regular ; color good ; no sweating or coldness of extremities. Shortly after operation an enema of several ounces of black coffee and peptonized milk given.

August 16. Patient passed a fairly comfortable night. Pain not so severe as before oi>eration ; very little ^listension ; says he feels better. Temperature and pulse still somewhat elevated, 102° F. and 110 respectively. liis general condition improved steadily forabout a week, when his temperature and pulse began to go up a little. His tongue became more coated, but abdomen not distended nor tender. Spleen not palpable ; no rose spots. An offensive discharge


May, 1897.]

113


of pus from the right ear indicated an otitis media. About this time a severe pain in the lower part of left thorax developed. Auscultation detected a slight friction rub beginning just below the nipple and running into axillary line.

Blood cultures aspirated from spleen were negative. His temperature and pulse almost reached the normal on August 28, and remained there for a week, when a sharp rise, accompanied by a chill, occurred. His second relapse was quite a severe and prolonged one, so much so that he was transferred to Dr. Osier's ward, where he could be given the cold-bath treatment more conveniently. On September 14 the following note was made by Dr. Osier: " Tongue a little dry ; temperature has been continuously elevated since Septembers. Between 6th and 9th not above 100° F. Since 9th above 101° F. On the 12th and 13th, 104°, and on 14th, 105° F.; pulse, 128. Complains of pain in abdomen, which is fiat and natural looking. Respiratory movements well marked ; no tension ; everywhere soft. Pain referred to hypogastric region and about navel. Edge of spleen not palpable." During the ten days, from September 17 to 27, his temperature ranged about 103° F., occasionally going above 104° F. He was given thirty-eight tubbaths during this period. It reached the normal on October 6, and remained there.

During this time he developed great tenderness in the toes of both feet, and extending up the front of right leg to the knee was some redness and stiffness. This gradually subsided. Several small furuncles on buttocks and sacrum appeared, which were opened. On October 23 he was well enough to be up for the first time. Improved steadily up to November 2, when a phlebitis of right femoral vein with pain and swelling of leg developed. This gradually subsided, and he eventually made a perfect recovery.

Cultures taken at the time of operation from the peritoneal cavity and edges of ulcer showed pure culture of bacillus coli communis.

Dr. OsLER. — It may interest you to know of the number of cases of perforation in our series. Since the hospital opened we have had about 530 cases (I have not the exact figures for this year) of typhoid fever, with 48 deaths, of which 16 occurred from perforation. The percentage of death from this cause is unusually high, for I think Dr. Finney mentioned it was the cause of death only in about six per cent, of the fatal cases.

That two of Dr. Finney's cases were supposed to be appendicitis is a point of great interest. It is not the first nor will it be the last time that this mistake has been made. There are instances in which patients with typhoid fever without perforation have been operated upon for appendicitis with a fever of five or six days' duration and a swelling in the right iliac fossa. Patient has been admitted to the hospital, operated upon for apjiendicitis, no perforation found, but an enlarged ileum and swollen mesenteric glands. It is to be borne in mind, however, how frequent is perforation of the appendix among cases of perforation in typhoid. We have had at least four or five in our cases. There have been two cases of recovery in which symptoms of appendicitis in typhoid seemed very clear.

One word as to the time of the operation. This case was unusually favorable inasmuch as it was seen early and the perforation occurred before the 8th day, which is, perhaps, as soon as ever it occurs in typhoid fever. I think the very early and the very late cases will probably be the most favorable for operation. The statistics that Dr. Finney gives are certainly most encouraging.


NOTES ON NEW BOOKS.

Transactions of the American Pediatric Society, held at Virginia

Hot Springs, May 27, 28, 29, 1895. Edited by Floyd M. Cran DALL. (Philadelphia, 1896. Reprinted from the Archives of

Pediatrics.)

The meetings of this society are characterized by the practical papers presented and the general discussion of them by the members present.

The present report of its seventh session contains a number of articles relative to the more important diseases of infancy and childhood, with discussion of many of the newer remedies. The list of contributors includes many of the best-known writers on the subjects mentioned.

The treatment of diphtheria with antitoxin as an immunizing agent, and its toxic effects, are especially dwelt upon. A resolution was finally adopted that in the opinion of the society the evidences thus far produced of the beneficial action of this remedy justify its further and extensive trial.

Several papers on anomalous forms of scarlet fever and eruptions simulating this disease, and one on the use of icthyol ointment for the local treatment of the eruption of scarlet fever, are worthy of special notice.

With regard to the use of the antitoxin of tetanus in tetanus of the newborn, the evidence seems to show that up to this time it is uncertain in its action, and that chloral hydrate with one of the bromides is to be preferred.

The antitoxin of erysipelas seems to have had no influence in treatment of sarcoma of the kidney, but the author of the paper is inclined to the view that any foreign substance injected into or near the substance of a sarcoma tends to effect a cure, by setting up degenerative changes in the neoplasm, hence the apparent favorable action of erysipelas antitoxin in sarcomata which are external and accessible, and its failure in visceral sarcomata.

There are also papers on purulent otitis media, " inanition " fever in the newly born, the frequency of typhoid fever in children under three or four years, hyperpyrexia, pygopagus, the neuroses of childhood, tetany, symmetrical gangrene following scarlet fever, angina resembling diphtheria with absence of the bacillus, cardiac anomaly, and the association of enormous heart hypertrophy, chronic proliferative peritonitis and recurring ascites with adherent pericardium, in which the view is expressed of the probable progress of the chronic proliferative process along the veins, through the diaphragm, until it involves the peritoneum.

The report is in good type, well edited and arranged.


BOOKS RECEIVED.


A Collection of the Published Writings of William Withey Oull, Bart., M. D., F. R. S. Edited by Theodore Dyke Acland, M. D. Memoir and Addresses. 1806. 8vo. 184 pages. The New Sydenham Society, London.

Proceedings of the American Medico-Psychological Association, at the Fifty-Second Annual Meeting, held in Boston, May 26-29, 1896. 8vo. 332 pages. Published by American Medico-Psychological Association.

Saint Thomas's Hospital Reports. New Series. Edited by Dr. T. D. Acland and Mr. Bernard Pitts. . Vol. XXIV. 1897. 8vo. 510 -i118 pages. J. and A. Churchill, London.

Archives of Clinical Skiagraphy. Edited by Sydney Rowland, B. A. Camb. Vol. I, No. 3, December, 1896. Fol. The Rebman Pub. Co., Limited, London.

Pathological Report Illinois Eastern Hospital for the Insane. 1896. 8vo. 236 pages. The Blakely Printing Co., Chicago.

Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America. Edited by T. L. Stedman, M. D. Vol. IX. Diseases of the Digestive Organs. 1897. 8vo. 820 pages. William Wood & Co., New York.


114

[No. 74.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report In Patliologry.

The VesselB and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

(Atrophy). By Heney J. Berkley, M. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By P. P.

Mall, M. D.

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

T. C. GlLCHKiST, M. D., and Emmet RliroRD, M. D. A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum

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

T. C. Gilchrist, M. D.

Report In PatliologTAn Experimental Study of the Thyroid Gland of Dogs, with especial consideration

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


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

Report In Medicine.

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

Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Laelecr, M. D. Cases of Post-febrile Insanity. By William Oslbk, M. D. Acute Tuberculosis in an Infant of Four Months. By Hahkt Todlmin, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

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

Report in Gynecolosry. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

A. Kelly, M. D., and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,

M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

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

March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one Gynecological Cases. By HowABD

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, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxosarcoma of the CHitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment

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

Howard A. Kelly, M. D.

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

in the Management of Dead Spaces. By W. S. Halbted, M. D. Report in Neurology, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By AoonsT HocH, M. D. A Case of Cerebrospinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report in Patlioloery* I. Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafledk, M. D.


Volume III. 766 pages, with G9 plates and figures.

Report in Patliology.

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

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

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

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

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

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

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

Report in Gynecology.

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

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

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


Gynecological Operations not involving Cceliotomy. By Howard A. Kelly, M. D.

Tabulated by A. L. Stavely, M. D. The Employment of an Artificial Retroposition of the Uterus in covering Extensive

Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdo minal Pelvic Operations. By Howard A. Kelly, M. D. Photography applied to Surgery. By A. S. Murray. Traumatic Atresia of the Vagina with Haematokolpos and Hxmatometra. By Howard

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

The Importance of employing Ansesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D. Resuscitation in Cihloroform Asphyxia. By Howard A. Kelly, M. D. One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.

By Howard A. Kelly, M. D., and Mary Sherwood, M. D. Abdominal Operations performed in the Gynecological Department, from March 5,

1890, to December 17, 1892. By Howard A. Kelly, JI. D. Record of Deaths occurring in the Gynecological Department from June 6, 1890, to

May 4, 1892.


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

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

Report in Neurology.

Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of J/«s mitsculus; The Intrinsic Nerves of the Thyroid Gland of the Dog: The Nerve Elements of the Pituitary Gland. By Henry J. Berkley, M. D.

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

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


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

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

Studies in Typhoid Fever. By William Osler, M. D., with additional papers by G. Bluueb, M. D., Simon Flexner, M. D., Walter Reed, M. D., and U. C. Pabscns, M. D.


Volume VI. About 500 pages, many illustrations.

Report In Neurology.

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

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

Report in Pathology.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.

CULLEN, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of

Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins, M. D. Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. C^ullen, M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By

William D. Booker, M. D. The Pathology of Toxalbumin Intoxications. By Simon Flexner, M. D. Tlie price of a set hound in cloth iJols. I-VI] oftlir Hospital Reports is

$30.00. Vols. I, Jl ami JII are not sold sejKiratcli/. The price of

Vols. IV, r and VI is $5.00 each.

MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID 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 Rufobd,

M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,

$3.00. THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.

Hewetson, II. D. And A STUDY OF SOME FAT.\L CASES OF MAI^ARIA.

My Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ^.76. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports, 1 volume of 481

pages. Price, bound in paper, $3.00. Subscriptions for the above publications may be sent to

The Johns HorKiNS Press, Baltihors, Ud.


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


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No. 75.]


BALTIMORE. JUNE. 1897.




COIsTTEIsTTS.


Report of a Case of Polybacterial Infection in Typhoid Fever, with especial Reference to certain Involutions exhibited by the Bacillus Typhosus. By Edward Perkins Carter, M. D., 115

A Case of Typhoid Fever in which the Typhoid Bacillus was obtained twice from the Blood during Life. By E. Bates Block, JI. D., 119

Successful Cultivation of Gonococcus in two Cases of Gonorrheal Arthritis and one of Tfenosynoviti4, with Remarks on a New Medium. By Francis R. Hagner, M. D., - - -121

A New ^sthesiometer. By Lewellys F. Barker, M. B., - 125

Edinger on " The Development of Brain Paths in the Animal Series." By C. R. Bardben, M. D.. 126


page. By Simon Flex-" - - - 128


Pseudo-Tuberculosis Hominis Streptotricha.

NER, M.D.,

Proceedings of Societies :

Hospital Medical Society, 129

Discussion of Dr. Friedenwald's paper on Congenital Motor Defects of the Eyeballs; — Congenital Facial Diplegia [Dr. Thomas]; — A Case of Acquired Paralysis of both External Recti Muscles, with Unilateral Facial Paralysis [ Dr. S. Theobald]; — Exhibition of Ophthalmological Cases: Bilateral Dacryo-adenitis, Operations for Cataract [Dr. Randolph]; — Demonstration of Florence's Iodine Test for Seminal Stains [Dr. Lewellys F. Barker].

Notes on New Books, - - 133

Books Received, 185


REPORT OF A CASE OF POLYBACTERIAL LNFECTIOX IN TYPHOID FEVER, WITH ESPECIAL REFERENCE TO CERTAIN INVOLUTIONS EXHIBITED BY THE BACILLUS TYPHOSUS.

By Edward Perkins Carter, M. D., FeUov) in Pathology. [From the Pnthologieal Laboratory of the Johns Hopkins University and Ilospital.]


The following case seems worthy of publication in view of the opportunity it afforded to study an unusual variation in morphology of the bacillus typhosus isolated from it, and because of the interesting poly-infection with bacteria which existed at autopsy.

The patient, G. C, was admitted to the Johns Hopkins Hospital on October 11, 1896, complaining of fever, weakness and loss of appetite. He had not been feeling well for three weeks, and had been unable to work for the past seven days.

Family history negative. Personal history negative. For the past four years he had led an active out-of-door life, and had up to the onset of present illness enjoyed "good health."

His illness began wnth a general feeling of weakness, which increased until on Monday, October .5th, 1896, he was unable to go to work, and complained of fever, loss of appetite and pains in the back and legs. He kept up until October 9th, and on October 11th, 1896, when admitted to the ward, he had a temperature of 102.5°, pulse 100 to the minute, and


respirations 20. E.xamination of the blood at this time and at all subsequent examinations was negative for malarial organisms. Examinations of the thorax and heart were negative. Abdomen was not distended. No tenderness and no gurgling in right iliac fossa. Several suggestive rose spots. Spleen was just palpable. Liver dulness normal. The diagnosis of typhoid fever was made and the patient put upon a strictly typhoid treatment.

I have abstracted the following notes from the history of the case, omitting the treatment as being foreign to our purpose.

October 12th, '96, at 7 a. m. The patient had a large semiliquid stool, containing some formed particles, and a considerable amount of blood fairly bright red in color. At 8.30 a. m. a second hemorrhage, rather brighter red than preceding. Both considerable in amount. Temperature 103.5°, pulse 102.

October 14th. Patient flushed, looks well. Tongue furred,


116

[No. 75.


not tremulous, pulse good. Two fresh rose spots. Abdomen flat, uo distension.

October 16th, 1.40 p. m. Hemorrhage, somewhat thick tarry consistence, with some blood clots. Amount of movement about 400-500 cc. 5.30-6.30 p. m., patient had two movements like preceding, quantity same, about 400-500 cc. Pulse very running and feeble. Temperature at 8 a. m. 101.5°, pulse 124.

October 17th. This a. m. condition is distinctly better. Pulse at visit 29 to the quarter. Abdomen not distended and nowhere tender. 11.30 p. m. the patient had a stool of about 250 cc. in amount, which contained blood dark in color.

October 18th, 10 p. m. A stool, about 200 cc, containing blood, no clots. The patient's condition did not show any material change. Temperature at a. m. 102.8°, pulse 120.

October 25th, 2 p. m. The patient had a large movement, 1000 cc. Total amount of blood estimated 500 cc. Temperature at 8 p. m. 101.5°, pulse 148.

From this time, though he had no subsequent hemorrhages, the patient's condition remained critical until his death.

On October 28th he developed well marked signs of consolidation in the lower left back over a small area, and on November 1st the same signs were found in the lower right back.

November 9th. Breath sounds at left base seem almost clear. Percussion at right base impaired, breath sounds distant. Temperature at 8 a. m. 103°, pulse 124.

November 11th. This a. m. pulse 32 to the quarter. The patient passed a restless night, complaining considerably of pain in the left side. Lying on left side, skin moist. Tongue dry and tremulous. Eespirations 13 to the quarter. Profuse sweating. Eespiration on left side is enfeebled. Back not examined.

The patient's general condition gradually grew weaker and he died at 12.30 a. m., November 12th, 1896. The temperature just before death touched 105°; the pulse was 160.

The autopsy was held 34 hours after death, and the body, apart from slight post-mortem gas development, showed no other distinctive signs of decomposition.

Anatomical Diagnosis. Typhoid fever. Small number of healing ulcers in the ileum ; little glandular enlargement. Subacute spleen tumor, parenchymatous degeneration of the viscera, abscess of prostate gland, necrosis of the cricoid cartilage, pneumonia, fibrino-serous pleurisy.

Body 170 cm. long, pale, no oedema. Moderate emaciation. Rigor mortis in both extremities. Abdomen greatly distended, tympanitic and greenish in color.

The spleen weighed 210 grams. It was free from adhesions. On section moderately firm, pale grayish red in color. Malpighian bodies not prominent. Several phleboliths of the size of bird-shot in cut surface.

The small intestine was moderately distended, the mucosa opaque, containing soft fa3ces. No ulceration until within 100 cm. of the valve, where a small, clear, punched-out ulcer 1 cm. in diameter existed. The surrounding mucosa was congested. No more ulcers found for the next 50 cm., where a large group of coalescent clean ulcers with united edges occurred, which were shallow and rapidly skinning over.


These measured 3x5 cm. in extent, and the individuals composing the group were hardly larger than the above single one. The most important group of ulcers was located a hand's breadth above the valve; these numbered nine (2.5 cm. in diameter), the largest not much exceeding a silver twentyfive cent piece in size. They were perfectly clean and rapidly healing, judging from the manner in which their bases were filled up; and they appeared to be skinning over at the same time from the edges. The caecum and appendix vermiformis were free from ulceration.

The larynx on the left side shows a small aperture measuring 1 cm. in diameter, which leads into a cavity in relation to the cricoid cartilage. On dissection a cavity the size of the little finger, lined by granulation tissue, is found, and into the cavity the upper and eroded end of the cricoid cartilage projects. The upper surface gives the impression of being calcified ; it is eroded and hard. The contents of the cavity are semi-fluid pus of rather dark color.

In the right lobe of the prostate gland there existed a small abscess the size of a hazel-nut, containing creamy pus. The walls of the cavity are thin and ill-formed. No communication existed with the bladder.

The mesenteric and retroperitoneal glands were little if at all enlarged.

Bacteriological Examixation.

Cover-slip preparations made at the time of the autopsy showed from the fj^ewra large numbers of streptococci, which occurred in threads of 6-8 segments, and a few long evenly staining straight bacilli.

From the abscess in jjwstafe gland great numbers of small thin straight bacilli, which looked not unlike the bacillus of typhoid fever; also numbers of cocci, appearing chiefly in pairs (diplococci).

From the heart's Hood a number of long straight bacilli resembling closely those seen in the cover-slips from the j)leura ; also a few single cocci were seen.

Cultures.

Pleura. The agar-agar plate was studded with minute pin-point, finely granular colonies.

Microscopically these proved to be streptococci, which were identified as the streptococcus pyogenes.

Lung. The plate on the same medium resembled identically that from the pleura and contained the same microorganism in pure culture.

Larynx. The agar-agar plate showed superficially many round grayish brown pin-bead colonies, limited to one-half of surface, the remaining area being overgrown with colonies which exhibited a bluish green color. In the substance of the medium were great numbers of small, finely granular pinpoint colonies and smaller numbers of large whetstone and irregularly round colonies. This plate being so crowded, a series of plates was made, and from the third dilution the following micro-organisms were isolated and identified : streptococcus pyogenes, bacillus lactis aerogenes and bacillus pyocyaneus.

Kidney. The agar-agar plate was studded with small


June, 1897.]

117


round dark granular colonies, much larger than the usual streptococcus colonies. In the substance of the medium there were also a number of whetstone and irregularly round colonies, and on the surface two grayish white spreading colonies and five slightly smaller grayish white more ti-anslucent ones. The small granular colonies were composed of the streptococcus pyogenes. From the other colonies two bacilli were isolated and identified as the bacillus coli communis and the bacillus typhosus. (See notes below.)

Liver. The agar-agar plate presented practically the same appearance as that from the kidney, and the same microorganisms were isolated from it.

Heart. The agar-agar plate showed two sets of colonies. The substance of the medium was studded with small finely granular colonies, and here and there a few scattered grayish white whetstone forms occurred, while on the surface there were a number of grayish white, small, fairly round and slightly elevated forms. From the small granular colonies the streptococcus pyogenes was isolated, and from the whetstone colonies in the depth and the round colonies on the surface of the medium a bacillus was isolated which was identified as the bacillus typhosus.

Mesenteric gland. The agar-agar plate showed two superficial, spreading, grayish white irregular colonies, and numbers of whetstone colonies in the substance of the medium. From the plate two bacilli were isolated and identified as the bacillus coli communis and the bacillus typhosus.

Abscess in the prostate gland. The agar-agar plate was studded with small finely granular colonies, and in addition showed a few scattered whetstone colonies in the substance, and several small, reddish brown, irregular, spreading forms on the surface of the medium. From the finely granular colonies the streptococcus pyogenes was isolated. From the superficial colonies a bacillus was isolated which was identified as the proteus vulgaris.

Spleen. The agar-agar plate from the spleen remained sterile after 48 hours in the thermostat.

The bacillus which is, however, of greatest interest in this case is that which was isolated from the heart, liver, kidney, mesenteric gland, and by Mr. Potter from the bile by means of Eisner's method, and which, though it shows great variation upon certain media, must, we think, be considered the true bacillus of Eberth.

Culturally and morphologically this bacillus was proven identical, from all of the above given sources, and our study of it has therefore been made with the cultures obtained from the kidney and bile. At the same time there was carried along with these for control a culture of an established typhoid bacillus. The bacillus isolated from the case under consideration, taken from a 24-hour growth upon agar-agar, is of medium size, straight and thin, with slightly rounded ends, taking the stain deeply and uniformly. It stains with all the ordinary aniline dyes, though most satisfactorily with gentian violet.

The Eisner plates made by Mr. Potter directly from the bile gave what has been and is considered the typical reaction for a mixture of typhoid and colon colonies. The colon colonies were larger, more coarsely granular and more numer


ous than the small, very pale, transparent and faintly granular colonies from which the typhoid bacillus was isolated in pure culture.

Upon agar-agar plates the colonies of the bacillus under study are small, grayish white in color, slightly elevated and irregularly round upon the surface of the medium, while in its substance they presented the common small whetstone or irregularly round outline. By transmitted light under low power they are of a reddish brown color and faintly granular structure. Upon gelatine plates the colonies are, after 34 hours, small, very finely granular, irregular in outline, and tend to increase in size very slightly during the second 48 hours, thus appearing as typical typhoid colonies.

Agar slant. The growth upon a moderately dry agar tube was, after 24 hours, of a slight, narrow, rail-like character along the track of the needle, being slightly elevated and of a grayish white color. On the moist agar slant it grows somewhat more profusely, covering the surface of the medium more irregularly. This was equally true of the control typhoid culture.

Bouillon at the end of 24 hours is clouded and somewhat opaque. The reaction for indol was negative. In order to establish the certainty of the negative indol reaction beyond a doubt, a culture in bouillon, together with a culture of the control typhoid, and an uninoculated tube of bouillon were placed in the thermostat for three days and then tested for indol, adding at the same time the H2S0» and NaNO: to the uninoculated tube of bouillon and watching these three carefully for a few hours, and then replacing them in the thermostat over night. When examined the following day all three tubes presented the same appearance, and it could not be said that a true indol reaction was obtained. The test for indol was made again and again without obtaining a positive reaction.

Litmus milk after 24 hours was only faintly acidulated, and reached apparently its greatest degree of acidulation, which is very slight, on the third day. At the end of a month there was no increase of acidulation, as evidenced by the pale pink color which remained quite as noted on the third day following inoculation. Coagulation of the milk did not ensue.

Upon potato the growth bears an extremely close resemblance to the control typhoid. It shows at the same time under the microscope the most remarkable involution forms, which begin to appear upon the third day after inoculation.

If the potato is strongly acid the growth after 24 hours is just visible as a delicate white membrane over the surface of the potato extending from the track of the needle. The macroscopic appearance of the growth remains unaltered, being only Just visible after thirty days, while the potato remained undiscolored.

Upon a neutral potato, on the other hand, the growth after 24 hours appears as a slightly yellowish white line along the track of the needle, spreading out somewhat at the base of the potato, being plainly visible and much more luxuriant than is ordinarily true of the bacillus of typhoid fever. After five days the potato itself becomes a very little discolored, while the growth remains unaltered after the third day. At the end of three weeks no further change was noted.


118

[No. 7.5.


Under the microscope this bacillus shows the greatest variation in morphology, and apparently without relation to the reaction of the potato. After the third day involution forms appear, first as long rods with unstained bulbous ends, and these are quickly followed by the most extraordinary forms, such as long threads, irregular rods with unstained poles closely resembling spores, and shorter oval forms, a picture unlike anything one finds in cultures of the true bacillus typhosus.

Glucose agar. In a deep stab this organism again agrees well with the control typhoid. After 24 hours there is a delicate, small, nail-head growth upon the surface of the medium, while along the line of puncture the growth extends downwards for one-half the distance. This appearance remains in general the same, the growth increasing very gradually until at the end of thirty days there is only a more irregular nailhead appearance upon the surface with a slight growth along the line of the needle stab, thus bearing a striking similarity to the control culture. At no time was there gas formation. Here again under the microscope the cover-glasses made after the third day show the same remarkable involution forms seen in the growth upon the potato.

In a gelatine stab there is a slight nail-head growth on the surface of the medium after 24 hours, extending along the course of the needle for a short distance as a delicate linear growth, and giving identically the same picture as that seen in the control. Liquefaction of 5 per cent, or 10 per cent, gelatine does not occur, and the growth increases very slowly, showing after three weeks a surface growth of the size of the head of a small tack. Microscopically, after the fifth day, we find involution forms in the shape of straight and slightly curved threads, longer by at least twelve times than the bacillus as it appears after 24 hours. The very unusual forms seen in the growth upon potato and sugar agar are not present.

Motility. Hanging drops made from an agar-agar culture of any age always showed great numbers of the bacilli in the field in active motion, but the greatest motility was seen when examined from agar-agar slants of from eight to ten hours' growth; at this age all the bacilli in the field appeared to be in active motion.

It decolorizes by Gram's stain.

Fermentation tubes of glucose, lactose and saccharose bouillon failed to show any development of gas after eighteen days in the thermostat.

The thermal death-point of this bacillus as established by means of Sternberg's bulbs is between 53° and 55° C. at an exposure of ten minutes.

By means of Pittfield's stain the presence of flagella can be demonstrated extending around the entire organism.

Widal's test. Upon adding from i to Jj the volume of blood serum obtained from a case of typhoid fever to a 24hours-old bouillon culture of this organism, a control typhoid bacillus culture and a culture of the bacillus coli communis according to the method of Widal, the following results were obtained :

The control culture and the culture of the organism under study gave characteristic precipitates in the same time, while that of the bacillus coli communis remained unaffected.


A number of tests for agglutination were made by the Wyatt Johnston method, using blood of known activity. The control typhoid bacillus gave immediate clumping, and the organism under study showed a similar reaction in from twenty minutes to one hour.

It is interesting to note that cultures made from potato, sugar agar and gelatine, which showed the involution forms in great numbers, always grew upon re-transplantation as the normal-sized, straight bacilli which were originally met with.

Upon plain agar-agar in bouillon and in milk the growth varied but slightly from what seemed to be the normal.

Animal Experiments.

A mouse inoculated subcutaueously with two loops from a 34-hour agar growth died in less than 48 hours.

The autopsy showed no excess of fluid in the abdominal cavity and no focal visceral lesions. The lymphatic glands were nowhere enlarged. The spleen, liver and kidneys appeared normal. At the seat of inoculation the skin was bound down by quite firm fibrinous adhesions. In the cover-slips from the seat of inoculation great numbers of bacteria were seen. Cover-slips from heart and spleen were negative. Cultures from heart and spleen remained sterile after 48 hours.

A guinea-pig inoculated with 1 cc. of a 24-hours bouillon culture intraperitoneally died after thirty days. The autopsy showed the lymphatic glands somewhat swollen and injected. No excess of fluid in abdominal cavity. Peritoneum perhaps reddened and vessels somewhat congested, but no peritonitis present. Liver, spleen and kidneys appeared normal. Coverslips from peritoneum and from all the organs negative. Cultures from same sources remained sterile.

A rabbit inoculated with 1 cc. of a 24-hours bouillon culture intravenously was still alive after two months.

We have then a bacillus which agrees culturally with the typhoid organism, which reacts to all the known tests for the true bacillus of typhoid fever, and yet which, after the third day, upon certain media, potato, sugar agar, and gelatine, shows very unusual involution forms; forms so remarkable that were it not for the evidence given by the fulfilment of every test, it would seem impossible to consider this the true bacillus of Eberth.

During the past few years a number of bacilli, found under conditions which would seem to exclude the presence of the true bacillus of typhoid fever, have been isolated and studied by Losener,* Babes,! FiillesJ and Cassedebat.§ These bacilli resembled the true typhoid organism so closely in cultural and morphological properties, with the exception of a slight variation in the organisms reported by Cassedebat and by Babes, that it has thus far been very difficult, if not impossible, to distinguish between them and the bacillus typhosus.


  • Losener, Arbeiten aus ilem Kaiserl. Gesundheitsamte, XI.

t Babes, Variabilitat und Varietiiten des Typhus-bacillus. Zeitschrift fur Hygiene, IX, 1890, p. 323.

I Fulles, Bacteriologische Untersuchung des Bodens in der Uingebung von Freiburg i. B. Zeitschrift fur Hygiene, X, 1S90, p. 225.

§ Cassedebat, Sur un bacille pseudo-typhique trouve dans les eaux de riviere. Compt. rend, de I'Academie de Paris, CX, No. 15, 1S90, p. 798.


f 1

as*, B




- \

(




(


1


-- 5


June, 1897.]

119


These forms have therefore been designated pseudo-typhoid bacilli.

In addition to the irregular forms described by Babes as seen in growths upon agar-agar, and those in the bacillus studied by Oassedebat, Ohantemesse and Widal* have noted certain variations from the normal which appeared as longer thread-like forms upon gelatine, and as straight rods containing irregular vacuoles and unstained poles upon potato. Vilchurf further, in a study made of some 200 cultures from the organs of four tyj^hoid patients, describes variations in form, particularly on old gelatine cultures and upon potato. These occurred as vacuoles which after 73 hours took the stain and then more intensely than the rest of the organism. Aside from these irregular forms I have been unable to find in the literature any reference to such involution forms as are noted in this case.

The growth upon agar-agar in bouillon and in milk showed no variation from the normal, the irregular forms being seen only upon potato, sugar agar and gelatine, as noted above.


  • Chanteme8se et Widal, Recherches sur le bacille typhique et

I'etiologie de la fiSvre typhoide. Archives de Physiologie, I, 1887.

f Vilchur, Cultivation of Typhoid Bacillus from Organs and Evacuations of Typhoid Patients. Vrach, St. Petersburg, 1886, VII, pp. 456-458. Eef. Lancet, London, 1886, II, p. 137.


The control culture used in the study of this case did not at any time show such involution forms as the bacillus under consideration, while culturally the two organisms appeared identical.

It seems therefore unavoidable to consider that this bacillus, which was found in a patient dead of typhoid fever, being isolated from five different sources, and reacting to every test in the manner of the true bacillus of typhoid fever, is, in spite of the peculiar involutions it undergoes, no other than the bacillus typhosus.

In conclusion I wish to express my appreciation to Dr. Simon Flexner for his kindness and interest in the study of this case, and also to Dr. Gray of the Army Medical Museum, Washington, for his kindness in taking the photographs which illustrate this report.

Description of Plate.

Figs. I and II. Bacillus typhosus obtained from this case as it appears after a growth of 24 hours upon agar-agar. Zeiss II mm. apochromatic objective, No. IV projection ocular. Gentian violet staining.

Figs. Ill and IV. The same organism as it appears after a growth of two weeks upon glucose agar-agar. Same magnification. Gentian violet staining.


A CASE OF TYPHOID FEVER IN WHICH THE TYPHOID BACILLUS WAS OBTAINED TWICE

FROM THE BLOOD DURING LIFE.

By E. Bates Block, M. D., Assistant Resident Physician, The Johns Hopkins Hospital.


Evidence is strongly in favor of the fact that, at some period of the disease, the typhoid bacillus is present in the blood in nearly all patients suffering from typhoid fever, gaining entrance from time to time at the site of the intestinal lesions. It is the rule for the typhoid bacillus to be cultivated from the internal organs (spleen, mesenteric glands, etc.) after death, and sections of these organs usually show bacilli which resemble the bacillus typhosus, in clumps or masses in the capillary vessels. The early experiments of Wyssokowitsch* show that these organs are principally concerned in removing from the blood introduced bacteria. It was shown by Welch and Nuttallf in 1891 that human blood serum is capable of destroying many typhoid bacilli, and later by other observers that the blood serum from typhoid patients also possesses this power, so that the peculiar conditions which allow these organisms to live in the capillary vessels of the organs cannot, at least in the majority of cases, depend upon a simple loss of this power of the blood serum. That the invasion of the blood or organs by other micro-organisms, more particularly the streptococcus pyogenes, modifies the relation of the patient to the typhoid bacillus, has been clearly shown by VincentJ in experiments upon animals and by cultures made at autopsy

  • Zeit8chrifl fiir Hygiene, 1886.

f Verbal communication.

t Annales de I'lnst. Pasteur, 1883.


in human cases. In six out of 31 such autopsies he found the streptococcus associated with the typhoid bacillus. In one case a typhoid patient whose temperature had become normal developed a streptococcus angina, the temperature rose and on the fourth day the patient died. At autopsy the typhoid bacillus and streptococcus were obtained from the organs and the latter from the blood. The streptococcus pyogenes has also been found in association with typhoid bacillus post mortem by Flexner* in 5 out of 6 cases reported, by Wright and Stokesf in 2 out of 9 autopsies, by KleinJ in the blood, once in association with B. typhosus, by Netter, E. Fraeukel, and others. Karliuski§ has found streptoccoci in the pulmonary complications of typhoid fever in six out of nine cases, some of them being associated with the typhoid bacillus in the lungs. A similar case is reported by Flexner {op. cit.) In forty-one abscesses in typhoid cases examined by Vincent {op. cit.) the staph, pyogenes aureus was present thirty-two times, all of these patients recovering. In eight cases streptococcus alone or associated with the bacillus typhosus was met with, and of these, five died. Assuming that in these instances the typhoid bacillus was increased in virulence, it may be said that


  • Johns Hopkins Hospital Reports, Vol. V.

t Boston Med. and Surg. Jour., March-April, 1895.

tBaumgarten's Jahresb., 1894, Vol. 10.

§See Vincent, op. cit.


a similar modification of the physiological characters of the typhoid bacillus infection is produced (.Sanarelli*) by inoculating cultures together with the soluble products of the bacillus coli communis and the bacillus proteus.

The clinical history of this case presents points of interest in connection with the bacteriological investigations both before and after death.

M. Z., female, age 30, born in Poland, was admitted to Professor Osier's wards on Saturday the 4th of July, 1896. She could not speak English, so no history could be obtained. Upon admission she was restless, listless, weak, and gave evidence of shortness of breath and abdominal pain, frequently passing her hand over the abdomen. Soon after admission she became delirious. The examination of the thorax was negative. The abdomen was tender upon pressure, and resistant, especially in the splenic area. The pharynx was somewhat reddened and its vessels were injected.

On the 5th of July Dr. Thayer made the following note: Eespirations 44 to the minute, pulse 104; patient looks dull and a little confused ; the tongue has a thick pasty coat; the lungs are clear on auscultation and percussion; the heart sounds are feeble but clear; the abdomen is full, generally tympanitic, does not seem tender — it is held very tense so that palpation of the spleen is impossible. A number of small spots are seen on the abdomen, some of them apparently ecchymotic, others not unlike rose spots. There is slight cyanosis of the face and lips, which in connection with the rapidity of respiration suggests some pulmonary affection. The patient has had one liquid stool.

On the 8th of July Dr. Thayer noted further: The general condition of the patient is about the same; she is still dull, drowsy, delirious, and quite irresponsive when questioned. There is marked muscular resistance in the splenic region, and pressure here causes the patient to wince. There are no definite rose spots to-day.

The urine did not give the diazo reaction.

The temperature upon admission was 101.3°, respirations 44, and the pulse 120. Three hours later the temperature was 104.6°, and during the fourth, fifth and sixth of July ranged between 101° F. and 104.3° F., the low temperature being due to cold baths, to which she reacted well. From then on the temperature gradually declined and reached normal on the 8th of July. It remained practically normal for about 18 hours. On the following day it rose gradually, the highest point reached being 102.6°.

The respirations during her illness remained rapid and on the 9th of July became more labored, the pulse became more rapid and feeble, and the patient died at 12.45 a. m. on the 10th of July.

On the 5th of July a culture was taken from the stool of the patient, by Eisner's method, with a negative result.

On the 6th of July a hypodermic syringeful of blood was taken from a vein of the forearm with due antiseptic precautions. A few drops were allowed to fall on an agar slant, and the rest of the blood was mixed with melted gelatine and


•Ann. de I'lnst. Pasteur, 1892.


placed in a Buchner jar in the thermostat. The agar slant subsequently showed one colony, while the gelatine tube which contained a greater volume of blood showed about a dozen colonies identical in appearance. Several of these colonies were grown on the usual culture media. They did not coagulate milk, grew characteristically on Eisner's medium ; inconspicuous growth on potato with increase of moisture; did not form gas in glucose agar ; were actively motile ; did not liquefy gelatine, and morphologically resembled the typhoid bacillus.

On the 9th of July a second culture was taken by the same method. The volume of blood obtained was smaller than in the former culture and was allowed to fall on the surface of an agar slant, which 20 hours later showed one colony. Inoculations of other media from this showed the same reactions as in the previous instance. In addition these bacilli did not produce indol; grew anaerobically; did not change the color of Wurtz's medium; gave the agglutinative reaction with over 40 specimens of typhoid blood, and morphologically was identical with the bacillus obtained three days before.

A culture from the throat on the same day did not show diphtheria bacilli ; the chief organism found was the streptococcus.

I am indebted to Dr. Flexner for the privilege of making an abstract of the post-mortem examination.

The autopsy was held at 2 p. m. on the 11th of July, 37 hours after death.

Anatomical diagnosis : Typhoid fever; ulceration of small intestine; acute sjjleen tumor; swelling of the mesenteric glands; parenchymatous degeneration of the viscera; postmortem invasion of a gas-forming bacillus ; oedema of the lungs.

Body cold, has been on ice. No odor of decomposition.

The upper portion of the body shows dark spots and splotches. The face is discolored and swollen. The greatest discoloration is over the back.

Crepitation is present over the face, the neck, the upper portion of the thorax and over the back. The neck is much swollen, thick and discolored.

No oedema and no crepitation of lower extremities.

The abdomen is distended and contains gas which has a somewhat putrefactive odor. The intestines are distended, but not discolored.

The tissues about the kidneys, pancreas, caecum and the root of the mesentery are emphysematous. The mesenteric and cascal glands are enlarged, softened and reddened.

The spleen is enlarged and softened, and on section appears dark in color, almost diffluent.

The liver shows many gas bubbles under the capsule, and on section it is found to be penetrated throughout by small gas vesicles, and the blood which escapes from the cut ends of the portal veins is frothy. The organ is pale, homogeneous, and cloudy yellow in color.

Both kidneys are emphysematous, the capsules adherent, the cortex increased, and the stria? coarse.

The duodenum shows many gas cysts. The small intestine shows swollen patches of Peyer; lower down the patches exhibit small erosions. As the valve is approached the enlarge


y


June, 1897.]

121


ment of the patches increases, as does the extent of erosion. Occasionally these patches show hemorrhagic infiltration. At the valve nearly the whole of the intestine is involved in deep ulceration which presents a sloughy and necrotic appearance and is nearly black from imbibition of blood.

The lungs are deep in color, crepitate throughout, and almost sink in water. The cut surface is smooth and dark. The bronchi are dark in color from imbibed blood. The blood in the vessels is frothy. The right side of the heart is enormously distended. On incision there is escape of gas and collapse. The intima of the vessels, and endocardium, are deeply blood stained.

In the right upper angle of the cavity of the uterus is a portion of placenta the size of a walnut, apparently the remains of a recent abortion. It is oval in shape, firmly attached, dark in color, porous in consistence, and has a deep red color. The mucosa is congested.

Cover-slips from the heart's blood, liver, spleen and intestinal ulcer showed, along with other bacterial forms, a large capsulated bacillus resembling closely the bacillus aerogenes capsulatus. These were not seen upon cover-slips from the bile and placenta. Anaerobic cultures were taken from all of the organs, but the large bacillus failed to grow.

Cultures upon agar plates yielded the following results: Bacillus typhosus in placenta, spleen, liver and kidney. Bacillus coli communis in the kidney and heart's blood. Bacillus pyocyaueus in the heart's blood. Bacillus proteus in the bile.

Some of the appearances found at the autopsy must be regarded as due to post-mortem changes, so that the invasion of the bacillus coli communis and the bacillus proteus after death cannot be entirely excluded. It is not improbable, however, that they may have been present in the orgaiis or body fluids during life. The bacillus pyocyaneus is not a common post-mortem invader.

In reading over the available literature I find that the typhoid bacillus has been obtained during life from the blood of patients suffering from typhoid fever by three other writers. Thiemich* found it once in blood taken from a vein


' Baumgarten's Jahresbericht, Vol. 10, 1894, p. 266.


of the forearm. Ettlinger* obtained it twice by the same method, and Stern twice.f

Other writers report a negative result. NeuhausJ failed in twelve cases from blood taken from a vein of the forearm, and twenty-four cultures§ from blood obtained by pricking the skin of the forearm; Frilnkel and Simmonds|| in sis cases. Ettlinger** reports eight negative results with blood taken from the forearm, and Klein ten.|f Failvires are also reported by Gaffky, Riitimeyer, Chantemesse and Widal, v. Jaksch, and Vaquez.

In six other cases I failed to obtain the typhoid bacillus, although a syringeful (1.5 cc.) of blood was employed in each instance.

The typhoid bacillus has been obtained from the blood after death by several observers: Viucent,|| Friinkel and Simmonds,§§ Flexner,|||| Klein,*** and by Wright and Stokes.fft

Heretofore not much importance has been attached to the work of Letzerich,JII Almquist,m Maragliano,||| Riitimeyer,§§§ Pasquale,§§§ Guarnierl,§§§ and Karliuski,§§§ because their examinations were made at a time when the differentiation of the typhoid bacillus from other micro-organisms closely resembling it in morphological and biological characters, was not so clearly understood as it is at present. However, it is probable now, that since definite proofs exist of the not very infrequent occurrence of the bacillus typhosus in the blood, either before or after death, their work may come to have more significance.


  • Wirtz, Precis de Bacteriologie Clinique.

■fCentralb. f. innere Med. 1896, No. 49, p. 1249.

I See Wurtz.

§ Berliner klin. Wochenschr., No. 6, 1886.

II Sternberg, Text-book of Bacteriology, p. 352.

    • Loc. cit.

■H-Baumgarten, Vol. 10, 1894, p. 266.

XI Ann. d. I'lnst. Pastesr, 1893 ; Le Mercredi medical, 17 fev. 1892.

§§ Sternberg, Text-book of Bacteriology, 1896, p. 352.

ill Op. cit.

      • Baumgarten, 1894, Vol. 10.

tttOp. cit.

ttl Sternberg, op. cit. §§§See Flexner, op. cit.


SUCCESSFUL CULTIVATION OF GONOCOCCUS IN TWO CASES OF GONORRHEAL ARTHRITIS AND ONE OF TiENOSYNOVITIS, WITH REMARKS ON A NEW MEDIUM.

By Francis R. Hagner, M. D., Assistant Resident Surgeon, Johns Hopkins Hospital.


The more successful attempts to cultivate the gonococcus from pathological conditions other than urethritis and conjunctivitis, have widened our view concerning the part played by this organism in human pathology.

Even now it would take much space to enumerate all the different lesions and parts of the body in which this organism has been found. The gonococcus, as is well known, cannot be cultivated with the facility of the other pyogenic cocci, and it has for this reason not lent itself so readily as an aid to diagnosis in obscure cases, unless perchance it could be found in


cover-slips, where its peculiar form and definite staining reaction might suflBce for its identification.

Greater experience, on the other hand, has shown that, although this organism does not grow at all, or at least most feebly and unsatisfactorily, upon the ordinary culture media, its choice of substance is still not a small one.

Since Steinschneider's observation of the great value of urine in the composition of a culture medium for the gonococcus, no really easy practicable method of preparing a medium containing this fluid has been devised.


122

[No. 75.


We offer iu the accompanying paper a simple method which, in the limited number of cases at our disposal, has proven successful.

It is in part my object in presenting these cases to draw attention to the ease with which, by the use of this medium, the gonococcus may be cultivated.

I must state that the value of the medium was further tested and proven by cultivating this micro-organism from urethral piis. The cases themselves are of interest from their clinical aspects, and as illustrating the good results which surgical interference gives when undertaken in time.

The possibility of making a positive diagnosis before opening the infected joint enhances the likelihood of good which may be confidently expected from these measures.

No question is likely to arise as to the identity of the cocci isolated in these cases, even in view of the fact that in one case the organism did not completely decolorize when treated according to Gram's method.

The later writers on the subject, among whom I shall only mention Caplewski,* concede great difference in the behavior of cocci from different sources.

Most samples of gonococci are quickly and readily decolorized; some few are more refractory and may retain the stain in part. On the other hand, the ordinary pyogenic cocci which resist Gram's method sometimes become decolorized.

No small part in this procedure is played by the composition of the stain and decolorizing agents.

But when all the facts are gathered, namely, the source of the organisms, their morphological properties, their diflBculty of culture, and slight viability, together with their staining reaction, no doubt is likely to be entertained concerning their nature.

Case I.

B. B., set. 21, female, colored. Domestic. Admitted December 5, 1896.

Previous History. Patient has never been very healthy. One year ago she had an attack of rheumatism; at this time the right knee was swollen and painful. The jjatient was confined to bed for one month, and has never had any trouble with the joint since. There was no history of any vaginal discharge at this time.

Present Illness. Patient acknowledges exposure within the last month. Has had vaginal discharge for three weeks. Six days before entrance to the hospital she noticed pain and swelling of the left knee. Pain more marked at night and increased by motion.

Examination. The patient is a rather poorly nourished, unintelligent woman, with a slight blowing murmur over the apex of the heart, transmitted to axilla. The joint is quite tense, painful on palpation and motion. Patella floats. There is marked induration and thickening of the peri-articular tissues, which are boggy. Distinct fluctuation over the joint. A purulent discharge observed to be present in vagina and urethra. The examination of cover-slips was negative for typical gonococcus-like organisms.


  • Hygienische Rundschau, Vol. 6, No. 21, p. 1029.


December 5th. Knee aspirated with sterile syringe and a straw-colored fluid obtained; this showed under the microscope a great many polymorphonuclear leucocytes, and a few large diplococci which were not contained in the pus cells. Cultures made on agar-agar, gelatin, potato and bouillon were negative after forty-eight hours in the thermostat. Cultures made at the same time on albuminous urine agar in twentyfour hours showed no perceptible growth, but at the end of forty-eight hours in the thermostat about a dozen isolated colonies, a little larger than ordinary streptococcus colonies, elevated above the surface of the medium, presenting an opaque white color, but still translucent, were easily seen.

Cover-slips were made, staiued with Sterling's gentian violet, mounted in water. The examination showed diplococci morphologically identical with the gonococcus. The same specimens were then stained by Gram's method and almost completely decolorized, a faint outline still being visible here and there. The ordinary media (mentioned previously) were inoculated from the cultures with negative results; but another albuminous urine agar tube, inoculated, gave a similar growth to the first after forty-eight hours in the thermostat, and this showed the same morphological characteristics.

Another generation, third in succession, was obtained on the albuminous urine agar medium; this one was feebler than the preceding ones, and no further growth was obtainable.

December 8lh. Knee again aspirated, the fluid giving the same growth when inoculated on the albuminous urine agar tube.

The same negative results as described previously were obtained on the ordinary media. The growth mentioned was carried through three generations, but again would not grow on the fourth transplantation.

December 17th. The knee joint was opened and cultures taken, two tubes of the albuminous urine agar being inoculated. One of these became contaminated ; in the other the growth was very slight and did not survive for a second transplantation.

The following is a brief description of the mode of preparation of the albuminous urine agar, which was prepared by Dr. Hugh Young and myself.

Acid urine containing 0.05 albumen or more should be collected and allowed to stand for twenty-four hours, no effort being made to prevent decomposition. The urine is boiled until a large albuminous precipitate is formed ; it is filtered through paper, when the resulting fluid will be clear. The filtered urine is boiled, and agar-agar, peptone, beef extract and sodium chloride are added in the same proportion as making ordinary agar.

The other steps are the same as in making ordinary agar, except that filtered albuminous urine instead of water is used throughout the preparation of the medium. It is important to see that the medium before being placed in tubes has a neutral or slightly acid reaction.

The advantages of using albuminous urine are, first, that iu such urine albumens are always present, which are not coagulated by heat, and second, the albumen that is coagulated acts as a clarifying agent in the removal of the salts that usually cause the cloudiness of urine agar-agar as prepared by


June, 1897.]

123


mixing the urine agar separately and sterilizing by discontinuous heating below the point of coagulation. It is important to have the medium very moist when inoculated.

The operation consisted of opening and irrigating with bichloride of mercury 1 to 1000, followed by salt solution, an Esmarch bandage being applied above the joint to prevent absorption of the bichloride solution.

The wound was approximated with subcutaneous silver wire sutures, silver foil dressing applied, and the leg put up in plaster. Of course very strict cleanliness is necessary in these operations — in all cases the operator and assistants wearing rubber gloves. The wound healed perprimani.

At the time of operation the subcutaneous tissues were found very edematous and thickened, and minute hemorrhagic areas were seen in the tissues near the joint. The fluid within the joint was serous in character, although flakes of fibrin were contained in it. The synovial membrane was thickened and its surface covered with hemorrhagic material that in places had a plush-like appearance, having lost its gloss. At the junctions of the cartilages and synovial membrane there were a number of tessellated, very vascular fringes of fibrinous material 3 to 5 mm. in length.

The cartilages showed no change.

The patient is at present more comfortable, but has not entirely recovered.

Case II.

A. D., female, fet. 20 years, colored, domestic. Admitted August 25, 1895.

No history of rheumatism.

Has had vaginal discharge for two weeks. (Patient acknowledges exposure several days before the discharge was noted.)

Three days before entrance left knee joint became painful and swollen, pain being more marked at night; fever was present, the highest temperature recorded being 103° F.

Examination. Large, well nourished woman.

Left knee slightly flexed, and warmer than adjacent parts. Slight fluctuation on inner side of patella ; movement of the affected joint caused great pain.

The peri-articular tissues were indurated and boggy.

There was a purulent discharge from the vagina and urethra that contained diplococci. These were in a manner suggestive of the gonococcus and occurred within the pus cells; they completely decolorized when stained according to Gram's method.

The operation was done on the fifth day of the disease, and consisted in the application of an Esmarch bandage, incision of the joint, irrigation with 1 to 1000 bichloride of mercury followed by salt solution, and closure of wound with silver wire. Silver foil dressing and plaster cast applied.

Patient made good recovery.

The examination of joint at time of operation showed the peri-articular tissues to be in an cedematous and hemorrhagic condition.

The joint contained about 25 cc. of blood-stained fluid in which floated small pieces of a fibrinous material.

The synovial membrane was roughened, thickened and had the same appearance described in the preceding case.


Larger tessellated masses of fibrin adhered to synovial membrane wherever it came in contact with the cartilage.

Bacteriological Examination.

The fluid for culture was removed from the joint with a sterile Volkman spoon, and placed in sterile test tube. A small quantity of blood was obtained by allowing a stream from a small artery to spurt into a sterile test tube.

The tube containing the blood was allowed to stand for two hours, during which time the serum had separated from the clot and could be pipetted off. An ordinary agar tube was melted and cooled to 46° C, so as to prevent the blood serum from coagulating when added. About 5 cc. of the human blood serum was added, making the proportion one-third human blood serum and two-thirds nutrient agar-agar; the resulting medium was perfectly clear. The fluid medium was then mixed thoroughly, and inoculated with three loops of fluid obtained from the joint, great care being taken not to add the fluid until the medium was observed to be on the point of solidifying, so as to prevent all chances of destruction of the organism by heat.

The inoculated medium was poured into a Petri's dish and placed in thermostat at 37° C. No growth was visible at the end of the first twenty-four hours, but at the expiration of forty-eight hours five or six small colonies could be seen. These were isolated and about the size of the ordinary streptococcus colonies, but they were more elevated when they appeared on the surface of the medium, and of a more opaque white color; they were, however, slightly translucent.

Cover-slips prepared from such a colony and stained with Sterling's gentian violet, mounted in water, showed numerous diplococci somewhat larger than the ordinary pyogenic cocci, composed of two hemispheres separated by a narrow unstained interval ; a few tetrad forms were also seen. The same preparation treated by Gram's method was completely decolorized.

Agar-agar, bouillon, potato, gelatin, and glycerine-agar were then inoculated from one of the colonies.

At the same time another culture was made on the serum agar. No growth could be seen after forty-eight hours on any of the tubes except the one containing the human serum agar, and on this a growth similar in appearance to the ones described before, consisting of cocci with the same morphological properties, was found; further transplantation was not successful on this medium.

As no perceptible growth occurred on any of the ordinary cultural media, and cover-slips taken from their surfaces were negative, the conclusion that the organism was the gonococcus was considered justified.

It is interesting to note that although numerous coverslips were made from the fluid at the time of operation, and numbers of polymorphonuclear leucocytes were found, no micro-organisms could be discovered.

Case III. A. P., male, white, single, 39 years. Admitted May 20, 1896.

Denied any venereal disease. (Very questionable.) Patient felt, without any premonitory symptoms, great pain


124

[No. 75.


in the left aukle joint, and at the same time noticed that there was considerable swelling and redness of the skin over the joint.

The pain was more marked at night, and increased with movement.

The condition mentioned gradually grew worse until the twenty-fourth day after the beginning of the disease, when patient was transferred to the surgical ward.

Examination. Patient was a well nourished man. Temperature on entrance 100° F. There was a fluctuating swelling extending from the juncture of middle and lower third of tibia, following the sheaths of extensor muscles, to a point on the dorsum of foot 3 cm. below the ankle joint.

May '21st, Operation. Same operation as described previously.

Incision of abscess and excision of fibrinous material from tendon sheaths. Irrigation of bichloride of mercury 1 to 1000, wounds closed with silver wire and dressed with silver foil, and leg put up in plaster. Patieut made good recovery in three weeks, wound healing per prima?/!. On incision the subcutaneous tissues were oedematous and slightly hemorrhagic. The tendon sheaths were thickened and covered with hemorrhagic fibrinous material.

The pus was confined principally to the sheaths of tibialis anticus and extensor proprius poUicis, chiefly about the annular ligament, but followed the pollicis to a distance of 3 cm. below. The sheaths were opened and about 100 cc. of bloodstained fluid escaped, which was placed by means of a Volkman spoon in a sterile test tube.

The internal portions of the sheaths were covered with a hemorrhagic fibrinous material and some granulation tissue.

I am indebted to Dr. Flexner for the privilege of reporting his successful cultivation of the gonococcus in this case. The pus collected at operation in a sterile manner was sent to the Pathological Laboratory.

Cover-slips when stained with Sterling's gentian violet showed polymorphonuclear leucocytes filled with diplococci morphologically resembling the gonococcus; a few of the organisms seen were extra-cellular.

When stained according to Gram's method the organisms were completely decolorized. Inoculations of the pus were made on the mixture of Steinschneider,* on a mixture composed of human ascitic fluid and agar-agar,t on a mixture of human blood serum and uriue,J on an infusion of pig-fcetuses and nutrient agar,§ and also upon ordinary agar slants. The


  • Steinschneider'8 medium consists of a mixture of bullock's

serum, urine, and agar-agar.

tThe mixture of ascitic fluid i and agar-agar J, which after being placed in tubes is sterilized and slanted. An albuminous flaky precipitate collects at the bottom of the medium, leaving surface clear.

t Human blood serum and urine medium is composed of J urine, f human blood serum sterilized in autoclave at 220° F. (Human serum derived from placenta.)

§ Preparation of pig-failvt a<]ar : Fresh pig-foetuses not exceeding 5 cm. in length separated from placenta and membranes are minced in a sausage machine. An equal volume of distilled water is added to the finely divided foetuses, and after thoroughly stirring, the mixture is allowed to macerate in a cool place for from


cultures were placed in a thermostat at 37° C, and at end of twenty-four hours a scarcely perceptible growth was found on all the inoculated tubes except the agar slants, which last remained sterile, whereas the growth on the other tubes increased somewhat during the next twenty-four hours.

The appearance of the growth was the same as that described in previous cases.

Growth on pig-fcBtus agar was more abundant and apparently more vigorous than on the other media.

Cover-slips from the cultures showed the same diplococcus as was found in the pus, and it became decolorized completely by Gram's method.

Transplantations at intervals of forty-eight hours were made on pig-foetus medium mentioned and growth obtained for four generations, but from the fifth inoculation no growth resulted.

It is interesting to note that the condition of synovial membranes and peri-articular tissues in these cases was practically the same, namely subcutaneous oedema, thickening and induration of peri-articular tissues, with small hemorrhagic areas.

The synovial membrane was thickened, very hemorrhagic and had the appearance of plush, having lost the glossy condition.

The fringe-like pieces of fibrin were very hemorrhagic. In neither case was the cartilaginous portion of joint affected.


six to twelve hours. The fluid is then freed from contamination by filtration through a Chamberland filter under a pressure of 150 to 200 lbs.

Two per cent, sterilized nutrient agar is then melted and cooled to 40° C. and to it J of its volume of the infusion of foetuses is added. The tubes are then slanted.


NOTICE.

All inquiries concerning the admission of free, part pay, or private patients to the Johns Hopkins Hospital should be addressed to Dr. Henry M. Hurd, the Superintendent, at the Hospital.

Letters of inquiry can be sent, which will receive prompt answer, or personal interviews may be held.

Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indigent patients a uniform rate of $5.00 per week has been established. The Superintendent has authority to modify these terms to meet the necessity of urgent cases.

The Hospital is designed for cases of acute disease. Cases of chronic disease are not admitted except temporarily. Private patients can be received irrespective of residence. The rates in the private wards are governed by the locality of rooms and range from $20.00 to $35.00 per week. The extras are laundry expenses, massage, the services of an exclusive nurse, the services of a throat, eye, ear and skin or nervous specialist, and surgical fees. Wherever room exists in the private wards and the condition of the patient does not forbid it, companions can be accommodated at the rate of $15.00 per week.

One week's board is payable when a patient is admitted.


June, 1897.]

J^ NEW ^ESTHESIOMETER.

By Lewellts F. Barkee, M. B. {Exhibited to the Johns Hopkins Hospital Medical Society, January 18th, 1897.]


I exhibited at this Society some time ago the test hairs employed by Professor von Frey in studying pain and pressure sense. These consisted, it may be recalled, of short wooden handles of suitable length, to which finer and coarser hairs were fastened at one end at right angles with sealing wax. The most suitable form is perhaps a four-sided wooden handle measuring 4 mm. on each side and 80 mm. in length. Hairs of different strength are obtained from the scalp of men, women and children ; hairs from the beard, from the horse's tail and hog bristles are also of service where stronger stimuli are required. The advantage of these test hairs consisted, it will be remembei'ed, (1) in the very small surface of skin acted upon, and (2) in the possibility of grading accurately the intensity of the stimulus applied. In order to test the stimulus- value of the hair, its area in cross section must be determined, as well as the weight which can be lifted by the hair when it is pressed with its cross section against one of the scale pans of a delicate balance. I described on the former occasion the methods of determining these two constants and shall not now repeat the details. Suffice it to say that with time and patience a set of such test hairs can be prepared varying in stimulus-value from 0.1 gr./mm^ to 300 gr./nim', though, as Professor von Frey says, the jireparation of them is " nicht jedermanns Sache."

A


B



FlQ. 1.

The form of the hair and its mode of action are shown in Fig. 1. A represents the test hair when it is placed upon the skin at the point F, though as yet no pressure has been exerted. In B the handle is nearer the skin, through pressure made parallel to the surface of the skin, and the hair is bent into an S-shaped curve, the turning point of which is at W. If W is perpendicularly above the point F, then the hair exerts exclusively an influence of pressure upon the skin ; but if W be directed to one side, there arises along with the pressure a "shoving" component. The latter appears, as one finds on bending the hair, as soon as it begins to twist out of one plane; that is, a space-curve arises instead of the plane-curves.


The set of hairs which I pass around were prepared under Professor von Frey's direction in Leipzig in the spring of 1895. I have tested them at intervals since that time and find that they have undergone very little variation. For accurate testing of pressure and pain sense some such delicate testing mechanism is indispensable. Such hairs, however, are not in the market, and I fear if one wished a set of them he would have to prepare them for himself.

Kecently, however. Prof, von Frey, // with the aid of the mechanician Zimmermann, has prepared a simple instrument which, for purposes of clinical examination at least, will take the place of the set of test hairs. This Ksthesiometer, which depends upon the same principle as that involved in the construction of the test hairs, has the advantage that with a single hair one can obtain a large series of pressurevalues at will. It consists of a long hair pushed through a capillary tube of very narrow lumen, much like that of a thermometer tube; the hair can be shoved through the lumen easily, but on pressure only the part of the ' hair outside the capillary tube can bend, and the force exerted is always g greater the less the amount of hair outside the tube, and feebler the greater the length of hair not inside the capillary tube. In Fig. 2 the mechanism is shown, though the sample which I pass around has some improvements not illustrated in the figure. The capillary tube consists of a brass tube, S, of very narrow bore, over which a sheath H glides with slight friction. In the axis of the siieath, and of the same length as this, runs a wire, which fits in the bore of the tube S, and at the end of which the test hair is fastened. If the sheath be shoved entirely over the scale the hair projects in its greatest length, and has accordingly only very slight force. On the other hand, if the sheath be drawn back as far as possible the greatest part of thf iiair


K7


126

[No. 75.


disappears within the bore, and the short still projecting part is capable of exercising very considerable pressure force. By means of a screw the sheath can be held iirmly in any position corresponding to a test hair of any desired length. There is a millimetre scale on the tube, by the help of which a given length of test hair can always be found again, together with a protecting tube for the free end of the hair to complete the instrument.

The testing of the hair for its pressure values at different lengths can be carried out with the aid of a delicate balance, and if one makes determinations for every fifth or tenth line of the millimetre scale he can easily calculate the values for the intervening lines. With this instrument it is easy to pass from very low pressure values, even below the threshold for the most delicate pressure points, to pressure values above the pain threshold in parts of the body where the pain threshold is high.

The value of this instrument was demonsitrated with Dr.


Gushing in the ward the other day. In a case in which ordinary slight stimuli appeared to call forth pain constantly, the idea had arisen that pressure sense was absent, the pain sense being very much exaggerated. It was easy with this instrument to show that the pressure sense was not abolished, though the threshold for pain was almost at the same level as the threshold for touch. With care, however, the pressure points could easily be made out. The significance of careful examinations in such cases is obvious, for it would be easy for the clinician to make the statement that tactile sense was destroyed in a given case in which in reality it was unaffected or but little affected. If such a case should come to autopsy, one might be entirely misled in interpreting the lesions found.

The sesthesiometer is not expensive, costing I believe five marks, when purchased from E. Zimmermaun of Leipzig. I cannot recommend it too highly for use in clinical examinations.


EDINGER ON "THE DEVELOPMENT OF BRAIN PATHS IN THE ANIMAL SERIES."*

[Abstract of a Keport made by C. K. Bardeen, M. D., before the Journal Club of the Johns Hopkins Hospital.]


In this address Edinger speaks in a most interesting way of the value and possibilities of a comparative psychology based on careful biological and morphological study. He himself, he says, was led to undertake this line of research by the knowledge that the lowest vertebrates have no cerebral cortex. In man and in the higher vertebrates the finer conscious activities take place in this part of the brain, and in the ascending vertebrate series there is a gradual development of the cerebral cortex up to man. " Indeed, in man," says Edinger, " the evolution of the brain cortex is still under way." The interesting questions arose. What nervous activities are possible in animals without a cerebral cortex ? and What nervous and mental activities have been added as the cortex has been evolved in the animal series ? The solution of these questions involved the broader task of studying the finer structure of the nervous system of the lower vertebrates. It was found on investigation that those parts of the brain which, as opposed to the cortex, are designated as the " lower parts " are essentially similar in all vertebrates. The spinal cord and medulla of the fish and of man do not differ fundamentally.

"So far as we know to-day," says Edinger, "we may ascribe to similar structure similar function." If this be true we may hope by careful study of the morphology of the nervous system to have opened up new points of view for physiology and psychology. If to the spinal cord, for example, the functions


  • " Die Eatwickelung der Gehirnbahnen in der Thiereihe," delivered before the medical section of the " Gesellschatt deutschcr

Naturforscher und Aerzte," in Frankfurt a. M., Sept. 23, 1896, and reported in the Deutsche medicinische Woehenschrift, Sept. 24, 1896, Vol. XXII, No. 39. [Prof. L Edinger of FrankCort is well known in America as the author of a very lucid text-book on the structure of the brain, "Der Bau des Gehirne." He is perhaps the foremost worker in the line of research of which he speaks in his address.]


of which are well known, comparative anatomical study shows that other structures are added little by little, we may suppose corresponding additions in functional capacity.

Edinger lays special stress on the need of care in forming our conceptions of the operations of the nervous system of the simpler animals. We must carefully rid ourselves of all preconceived notions of perception and desire as the necessary accompaniments of complex reactions to stimuli. We have, he says, no grounds for belief that such states of consciousness arise outside the higher centres of the cerebrum. We have no right to assume that in the lower animals the simpler nervous system performs functions like those performed by the higher centres of the nervous system in the higher vertebrates. " I trust I may be able to prove," says Edinger, " that the latter assumption, so commonly made, cannot be maintained."

To show how easily one might falsely attribute a conscious origin to complex movements, two or three examples are given from the invertebrate kingdom. Loeb's interesting experiments with the actinia are quoted. If a bit of fish be placed on the tentacle ring of one of these animals the tentacles close in and force the food into the mouth between the tentacles. But a piece of white paper put in the same situation is left undisturbed. This at first sight might seem a voluntary choice between the food and the paper, involving a conscious perception of taste. But if the mouth be destroyed and the bit of fish be again put on the tentacle ring the actiniau will double itself up trying vainly to force the morsel into the closed mouth. The definite activity caused by the meat is, roughly speaking, a direct reaction of the tissues to a chemical stimulus. The actiniau has no very definite nervous .system, though certain of its cells are taken to represent nerve

rrlLs.

Hdiu^er also refers to the recent studies on the nervous


June, 1897.]

127


system of tlie earth-worm. Thanks to the work of Loeb aud Friedlaender on the living earth-worm, and that of Retzius aad von Lenhossek on the morphology of its nervous system, the task of comparing its structure with its psycho-physiological activity has been greatly lightened. If the earth-worm be cut into pieces not too short, and one of the pieces is stimulated to move, it will continue creeping. The movement is produced as follows: from large epithelial cells in the external skin the earth-worm's sensory fibres pass into the central ganglia situated in the ventral band ; here the process divides into at least two parts. These lie in contact with the dendrites of large ganglion cells lying in this ganglion and in those immediately adjoining. These large cells send processes to the muscles. Each ganglion sends motor fibres, not only to the muscles of the segment within which it lies, but also to those of the neighboring segments. Some of the fibres cross the median line. A third set of cells have processes which run up and down the veutral band connecting different ganglia. Thus a sensory impulse started in a large epithelial cell is carried to the neighboring ganglion. Here the motor and associative cells are called into activity, and the muscles in the vicinity of the segment whose surface has been stimulated contract. This throws increased tension on the surface of the neighboring segments and they in turn are stimulated to contraction. A contraction wave is thus started along the worm, called forth by simple reflex action. This scheme is not diagramatic; it is based on the actual observations of trained observers.

The mechanism which controls intestinal contraction in the higher animals is very similar.

The nervous mechanism found in the vertebrate spinal cord is fundamentally the same. Here again we find motor cells sending processes to the muscles; here again processes from sensory cells terminating in gray matter ; here ag.ain, but in a far more developed degree, association neurones. That the spinal cord is capable, unassisted by the higher centres, of carrying out very complex movements is shown by the complex activity of the frog deprived of a cerebrum, the jumping of the brainless rabbit and the swimming of the brainless


The morphological structure on which the functions of the spinal cord depend has now been fairly well determined. Beside the factors already mentioned there enter into its structure paths connecting it with the brain. In the fish paths connect mid-brain and cerebellum with the spinal cord. Connections between the cerebrum and the spinal cord first appear in mammals. " The direct influence of the cerebrum on the activities controlled by the spinal cord varies, therefore, according to the class of animal, and it does not even exist among the lower vertebrates." The pyramidal tract is not found in birds.

The medulla, while, like the cord, serving as a primary centre for the reception of sensory and the origin of motor fibres, has a much more highly developed associative mechanism than the cord. Yet the development of these paths of association varies greatly in different animals. In the carps and many other fishes it has a more complex development than in man. The complexity of development of the medulla depends chiefly


on the uses to which the cranial nerves are put. The terminal area of the fifth nerve, so well developed in the sensitive-faced mammals, is but slightly developed in the snakes, but the motor area of the fifth nerve in snakes is relatively more developed than in the mammals, owing to the snake's powerful jaw muscles.

The cerebellum varies greatly in development, even among the fishes. Those that swim actively have it more highly developed than the mud-seeking varieties. Birds being animals of delicate sense of balance have it well developed. In snakes it is very rudimentary. Whatever the functions of the cerebellum may be, this organ is well developed in all animals executing carefully poised movements. The hemispheres of the cerebellum first appear in the mammals.

The connections of the cerebellum with other parts of the central nervous system are interesting. The pons fibres first appear in the mammals, and it is probable that the olivary paths do not occur in the lower forms. On the other hand the connections with the spinal cord through the corpus restiforme and with the thalamus through the suj)erior cerebellar peduncle are primordially old. The latter are more highly developed in fishes than in man.

Next to the spinal cord the mid-brain is that part of the central nervous system most alike in all vertebrates. It is the primary terminus for the optic fibres, and in it end a large part of the secondary sensory fibres transmitting impulses from the other sense organs. It is the great centre for the association of sensory impulses in the animals without a well developed cerebrum.

The cerebrum in all vertebrates is composed of olfactory apparatus, basal ganglia and cortex.

The olfactory region varies greatly in development. In reptiles and in fishes it makes up half the brain mass. In birds it is scarcely to be traced.

The corpus striatum, which lies just behind the olfactory apparatus, appears developed throughout the vertebrates. It plays a chief part in connecting thalamus and fore-brain, but in large part its functions are ill understood. The optic thalamus is likewise complexly developed throughout the vertebrates. The cortex stands in marked contrast to the lower parts of the central nervous system which are so much alike among all the vertebrates. In fishes the cortex consists of a thin epithelial plate. In the amphibia it contains a simple nervous apparatus. In reptiles a true cortex appears for the first time.

Within the last twenty-five years it has been definitely shown that the cortex performs the highest functions of the nervous system. On the existence of a normal cortex depend all those functions which may be learned, almost all which are carried out by memory pictures, and, above all, those complex conscious processes designated "associative." The silver stain has shown into what a complexity of relations each nerve cell is brought by its processes. From the reptiles to man this associative complexity increases.

It seems probable that various sensory areas in the cortex have been added as the need has arisen for more highly developed associative processes connected with the special senses. The earliest cortical relations are with the sense of smell


128

[No. 75.


only. Reptiles, we may assume, differ from fishes in that they can "retain their smell impressions, associate them and choose." For the reptile the cortex is an olfactory centre and out little more.

" This first inheritance of the cortex, the olfactory centre, remains throughout the entire series ; in birds alone is it somewhat uncertain. There is no difficulty in following the cortex of the reptiles into the Amnion's horu and the uncinate gyrus of mammals and mau."

But in the course of evolutionary development other brain centres have been added to this ; the cortex has been built up piece by piece. Unfortunately most of the steps are still uncertain. Something is, however, known of the optic paths. In fishes the optic nerve ends in the mid-brain. And so too in man at birth the only functional fibres end there. The babe is not blind, but it has no association centres for sight impressions. During the second mouth of life paths are developed from mid-brain to occipital lobe, the cortical sightcentre is called into activity, and association paths are formed between it and the rest of the cortex. The child only then begins to perceive what it sees.

It is because the fish has no cortical centre for sight that it can be hooked. To a similar reason is due the fact that reptiles and amphibia often go hungry when they do not smell their prey and it does not move. Snakes which do not eat dead mice will seize and devour, without a trace of dislike, dead mice artificially made to move.

Birds have a well marked cortical area for sight, and hence they exhibit many phenomena which indicate reason and memory founded on sight impressions.

It is clear, however, that in the lower animals many functions are performed without the influence or control of a cortex, and the question naturally arises as to the real nature of


the functions of the lower centres. It is well known that man and the higher mammals are more injured in normal activity by loss of the cortex than are the lower vertebrates ; that the cortex becomes indispensable iu proportion as it becomes well developed and is brought into close association with the lower centres. This has been shown by the study of the diseased human brain and by experiments on animals. But nature offers us animals with no cortices and with cortices variously developed along special lines. We have here a beautiful opportunity to study the functions of the cortex in the animal economy. Most interesting points of view might be obtained by excitation of the olfactory nerves of fishes which have no cortical centres, and of snakes which have cortical centres for smell ; or by comparing the effects of visible objects on snakes which have no developed associative centre for sight, and on birds which have them well developed.

And this same sort of study carried to man will also prove productive. The great man need not necessarily have a heavier brain than the average man, but we should expect that part of his brain which he had occasion to use to be better developed than the average. The great painter should have a well developed occipital lobe ; the great musician a well developed temporal lobe. Gambetta's brain was not above the average in size and weight, but the speech area was very greatly developed. For the present, Edinger points out, we may willingly refrain from speculating about convolution anomalies and criminal types. More fruitful fields of investigation are offered the scientist. The field of comparative psycho-physiology and comparative morphology gives every promise of being most fertile. One thing seems sure, " there is no boundary to be established between the conscious activities of the lowest and those of the highest vertebrates."


PSEUDO-TUBERCULOSIS HOMINIS STREPTOTRICHA.

[A PRELIMINARY NOTE.]

Bt Simon Flexnee, M.D.

[From the Pathological Laboratory of the Johns Hopkins University and Hotpital.'\


At the meeting of the Johns Hopkins Hospital Medical Society held on October 19th, 1896, 1 presented specimens from the lungs and peritoneum of a man who had succumbed to a disease characterized by symptoms which resembled those of phthisis pulmonum, but in the lesions of which, instead of the bacillus tuberculosis, another and probably entirely distinct microorganism was discovered, for which I have proposed the name of streptothrix pseudo-tuberculosa. As the publication of the full report of the case and the complete description of the micro-organism has been somewhat delayed, a brief outline of the case may be of interest at the present time.

The patient was a male, colored, aged 70 years, in whom extensive consolidation was made out in both lungs. The symptoms were generally those of pulmonary tuberculosis. Sputum was carefully watched for during his stay in the


Hospital (Dr. Osier's clinic), but none was obtained. No microscopical examination could therefore be made.

Autojjsy. The body was that of a slightly built, somewhat emaciated man. The abdomen was moderately distended. The autopsy was made 19 hours after death, the body having iu the meantime been kept on ice. No evidences of post-mortem decomposition were noticeable. The description of the viscera is limited here to the organs especially affected.

The Lungs are voluminous and meet in the middle line anteriorly. They are not bound to the chest wall. Left. The entire lung, except the anterior edge of the upper lobe, which is insufflated, is consolidated more or less perfectly. Where the consolidation is frank the lung presents an opaque appearance, is gray in color, and beginning softening (disintegration with early cavity formation) is going on. The cavities often


June, 1897.]

129


still contain the products of disintegration, and all appearances of reactive encapsulation are wanting. Where the hepatization is less complete the lung tissue is cedematous and swollen, although perhaps not completely airless, and discrete tubercle-like nodules may be seen. The pleura over the hepatized areas is covered with a fibrinous exudate. Right. The consolidation is less extensive and more focal in character, but occupies in places areas as large in extent as 4x5 cm. The pleural cavity contains a small quantity of fluid, pink in color, in which flakes of fibrin occur.

The intestines are moderately distended. The omentum is rolled up ; it occupies a position beneath the transverse colon and extends across the abdominal cavity. The pelvis contains about 15 cc. of fluid of brownish color and mucilaginous consistence. Between the intestinal loops delicate shreds of fibrin exist. In addition smaller and larger nodules resembling tubercles, usually translucent, are scattered irregularly over all the exposed peritoneal surfaces, and occur more uniformly upon and within the thickened, rolled-up omentum. The liver and spleen on section show similar nodules.

The bacteriological examination consisted in the study of cover-slips from the fresh lungs, the inoculation of glycerineagar tubes, and the injection of a suspension from the consolidated lung subcutaneously into a guinea-pig. The histological study embraced all the organs of the body. Cover-slips from the lungs, stained by Gabbett's method, showed no micro-organisms which resembled the bacillus tuberculosis in their morphology. There remained faintly stained in carbolfuchsin upon the cover-slips numerous examples of a branching organism, occurring often in clumps or convoluted masses, among which no ordinary bacillary forms were discovered. From the history of the case, the character of the lesions and the known variation in morphology of the bacillus tuberculosis, it was, for the time, assumed that the organism was a streptothrix form of the former bacillus. Its subsequent study has rendered this assumption highly improbable.

The cultures from the left pleural cavity and the peritoneum remained sterile. Three separate sets of cultures were prepared from the lungs. In all these, at the end of 34 hours, a vigorous growth of a bacillus, identified as belonging to the


group of B. coli communis, had taken place. The streptothrix did not grow. The guinea-pig showed no reaction to speak of at the site of inoculation, the adjacent lymph glands could not at any time be felt; the animal, however, lost in weight and died at the end of the 7th week, at the autopsy showing great emaciation. None of the lymphatic glands were found enlarged ; there were no lesions resembling tubercles in these and other organs, and cultures upon glycerine agar, made from several sources, remained sterile. Cover-slips from the serous cavities, blood and viscera were negative for any kind of bacteria.

The further study of the staining proj^erties of this organism in cover-slips, made from the lungs at the time of the autopsy, shows that as stained by the ordinary methods employed for tubercle bacilli, and decolorized by means of acids, the dye is held very loosely and quite readily given up. The best method of staining is either Gram's or Weigert's modified fibrin stain. The same holds true for its demonstration in the tissues.

The lesions in the tissues are of two kinds, depending in part upon their situation. In the peritoneal cavity tuberclelike nodules are formed, consisting of epithelioid and lymphoid cells with an occasional giant cell. Necrosis by fragmentation is not unusual in the centers of the tubercles, and fibrin, either before or coincident with the necrosis, is commonly observed in the nodules. In the lungs tubercles also exist, but they are less striking than a diffuse exudation of leucocytes, plasma and fibrin which fills the air cells, infiltrates the stroma and tends to undergo necrosis, producing larger and smaller spreading caseous foci of degeneration. The number of masses of the streptothrix is very great indeed and they are in intimate relation to the pathological process.

From these and some other considerations which will appear in the full report, it is believed that the organism is probably a new species, for which the name streptothrix pseudotuberculosa is proposed, and, further, that it is capable of causing in human beings a rapidly spreading and destructive disease resembling phthisis florida, for which the appellation of pseudo- tuberculosis hominis streptotricha seems warranted.


PROCEEDINGS OF SOCIETIES


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of December 7, 1896.

Dr. Thayer in the Chair.

Discussion of Dr. Frledenwald's Paper on Consjenital Motor Defects of tlie Eyeballs. See p. 203, Nov.-Dec. Bulletin, 1896.

Dr. Paton. — This case is of very great interest, and so unique that I feel interested from an anatomical standpoint. Cases of unilateral paralysis are easily explained, but for cases of double paralysis of the 6th nerve there is no anatomical explanation. As yet there has been no demonstration of the crossing of the 6th nerve in man. It has been demonstrated in monkeys. The crossing of the 4th nerve has been demon


strated in man. The further interesting fact that this case brings forward is the relation of the 6th nerve to the oculomotor. There are two possible ways in which these nerves can be related. If you take a section of medulla at the level of the 6th nerve and look at the right side, the fibres are seen to pass across to the left side, and then upward in the posterior longitudinal bundle as far as the nucleus of the third nerve. The main function of that bundle is to connect the nuclei of the cranial nerves, and there you find the connection between the 6th and 3rd. Recently another path has been marked out. The 6th on the right side may pass up on the same side as the rio-ht nucleus, and join the fibres of the 3rd nerve from the other side ; so you have two possible connections. Either the


130

[No. 75.


6th nerve crosses or the third nerve crosses, and the probability is the latter, because the crossing higher up of the 3rd nerve fibres is the simplest physiological explanation.

Dr. Theobald. — Dr. Friedenwald has had an exceptional experience in meeting with so many of these very interesting cases. It would seem that in this case there is a marked want of power of the internal rectus of the left eye as well as of the extei'nal rectus. This suggests the related cases of congenital ptosis sometimes accompanied by inability to turn the eyes upwards, that one meets with. It is well known that in this case the defect is not central, but is due to absence of or faulty development of the levator muscle of the upper lid and of the rectus superior. Such cases are not so rare as the one shown. I have met with several of quite marked degree. Frequently they are associated with epicanthus. It seems to me that the most probable explanation of this case is that we have here a similar want of development of the external recti. Indeed all the eye muscles here appear to be more or less faulty or weak, for it is difficult to induce the patient to turn his eyes in any direction, all of the movements being defective. We not uufrequently meet with cases of pronounced weakness of the recti muscles, particularly of the external recti, but such cases as the one shown are rare and extremely interesting.

Congenital Facial Diplegia.— Dr. Thomas.

In connection with the case which Dr. Friedenwald has exhibited. Dr. Thayer thought it might be interesting to have this rather unusual case presented to the Society. He has asked me to bring it before you.

The patient, a youth of 19, came to the Hospital from a neighboring State, in the hope that something might be done to improve bis uiifortunate appearance. Dr. Halsted has admitted him to his wards, and it is through his kindness that I have had the opportunity of examining him.

The family history is important. Father and mother are healthy and there is no history of any hereditary taint in either of their families. Patient is the third child of a family of nine. Three children died young, one of these having a niisformed foot. The eldest child, a girl, is perfectly healthy; the second child, a boy, now twenty-one years old, was born in a condition similar to that of our patient. The patient's birth was not particularly difficult and was non-instrumental. It was noticed soon after he was born that he was unable to close his eyes and that his underlip dropped while nursing. In crying his face remained motionless and he was unable to smile. He learned to speak at the usual time but was never able to pronounce certain letters. His general development was good except that he had some glandular trouble. He played with other boys and was able to do everything they did.

You see what a remarkable appearance the patient has ; the face is mask-like and expressionless, the mouth open, the lower lip pendulous, and the lower jaw protruded. He is absolutely nnable to move the muscles of his forehead, and when told to close his eyes he simply rolls the eyeballs up and relaxes the upper lid. He is unable to elevate or pucker his lips, but can move the angles of the moxxth out and down ; in doing this, you see, he brings into play the platysmata. In speaking he cannot pronounce the sounds which require the


use of the lips, viz. b, f, m, p, v. His eyes are prominent; the pupils are equal and react normally to light and during accommodation ; all movements of eyeballs are normal. He complains of being somewhat near-sighted ; there is no disturbance of the visual field. Muscles of mastication unaffected. There is no disturbance of sensation and taste is normal. Tongue is well developed and freely movable, indeed he makes his tongue take the place of his lips as much as possible, drinks and smokes by its aid. I have been unable to discover any abnormality in the muscular development of his trunk or limbs. Stimulating the facial nerves by electricity causes contraction in the muscles back of the ear and of theplatysma. By direct stimulation the platysma can be made to contract.

Before leaving the patient I should like to call your attention to the congenital defect in the right lobe of his ear. You will see that it is notched.

This, then, is a case of congenital facial diplegia. Dr. Friedenwald has told you that certain of the cases of congenital defect of the ocular movements have been associated with a similar condition in the facial muscles, and it is on account of this association that I have brought the case before you at this time.

Dr. Chisolm, of this city, reported one of the very first examples of this condition. In his case there was bilateral paralysis of the sixth and seventh nerves, a combination of the symptoms seen in Dr. Friedenwald's case and of those in the boy whom I have just shown you.

Moebius had a somewhat similar case, which he described in 1888, after which he made a fairly complete collection of all like and analogous cases. These he published in 1892. In this article he expresses the view to which, as Dr. Friedenwald has said, Kiihn takes exception, that the disease depends upon an atrophy of the nuclei, and he proposes the name " Infantiler Kernschwund."

Moebius was unable to find the record of any case in which congenital facial paralysis was unassociated with any defect of the eye muscles. Since then, however, two or three such cases have been described, but these cases were all unilateral, and, as far as I have been able to discover, the case which I have shown you to-night is the first one of its kind to be reported, although I have no doubt that others have been observed.

As to the anatomical condition which underlies these cases not much is known, and it seems scarcely worth while, at this time, to examine the theories which have been advanced.

The aspect and condition of the face in the patient whom we have seen suggest strongly the myopathic face which occurs in certain forms of progressive muscular dystrophy. We have examined the patient thoroughly with this point in view and have been unable to discover any other muscular abnormality, either hypertrophy or atrophy.

It tlierefore seems to me that the case cannot be classed with the progressive muscular dystrophies, although it might be considered as an abortive form of this disease, an explanation which has been given of a somewhat similar condition. As we do not understand the pathology of the muscular dystrophies, such an explanation helps but little. In this connection the condition of the patient's brother is of


June, 1897.]

131


importance, for if, as we are told, his symptoms are quite similar to those of our patient, and no other muscles are involved, it will make the classing of the case with the muscular dystrophies still more far-fetched.*

Dr. OsLER. — I do not think there are any muscular dystrophies of this kind that have that extreme atrophy without any involvement of other muscles. None that I have seen presented that appearance. You will probably find the brother the same as this patient.

Dr. Halsted. — Is the jaw of the brother the same?

Dr. Thomas.— The patient tells me that it is not quite so much so.

Dr. Theobald. — Were there any cases in the family previous to this ?

Dr. Thomas. — Not as far as I can find out, not even an ocular palsy.

Dr. Barker. — The absence of ocular paralysis in Dr. Thomas's case is an interesting feature. In consideration of the anatomical relations of the sixth and seventh nuclei, the occurrence of paralysis of the abducens along with paralysis of the seventh nerve is rather to be expected, if the lesions be in the region of the nucleus and due to pressure or hemorrhage. One of the most curious facts with which the anatomist has to deal is the relation of the fibres of the seventh nerve to the sixth nucleus after they leave the facial nucleus. Why these fibres should run up toward the middle line, turn and run along the fioor of the fourth ventricle and then turn again ventrally and laterally has never been satisfactorily explained. Such an out-of-the-way coui'se seems unnecessary.

During the development of the motor nerves whose nuclei of origin are situated in the medulla and poQS, the motor fibres belonging to the N. accessorius, N. hypoglossus, N. vagus, N. glossopharyngeus, N. abducens, etc., pass directly toward the periphery of the medullary tube and pass through the marginal veil to form the peripheral cranial nerves. The fibres of the N. facialis alone show the well known remarkable discursion. Whatever be the factors which determine the course of these fibres, they are active at a very early period of development, for the relations mentioned are visible in very young embryos. In his lectures on vertebrate embryology last year, Professor His of Leipzig made the ingenious suggestion that the cause of the deviation of the fibi'es of the N. facialis from the course we would expect them to take may possibly depend upon mechanical factors associated with the development of the auditory vesicle, since the ear vesicle is laid down laterally exactly in the region of the sixth and seventh nuclei.

It would be easy to speculate further and to think of such cases as the one before us as instances of congenital nuclear destruction from disturbances of the relations which ordinarily exist between the auditory apparatus and the neural tube, due either to an unfortunate variation or to early intra-uterine pathological lesions. That the affection is bilateral and that more than one member of the same family is diseased would


•The elder brother was seen at his house and was found to be in an almost exactly similar condition to that described above in the case of his brother. Both cases will be reported more fully at a later date.


favor rather than oppose such an hypothesis. It is surprising, considering the extremely complex character of the developmental relations of the internal, middle and external ear, that vicious developments of these parts are not more common than they are. It is interesting to note that, as Dr. Thomas has pointed out in this individual, there is faulty development of a portion of the external ear. Should this man or his brother be the father of children it would be important to determine the presence or absence in them of similar lesions, since, as is well known, variations favorable or unfavorable show a marked tendency to become inherited. That instances of extremely unfavorable variation persisting through many generations are comparatively rare need not surprise us, inasmuch as in the progress of the race, in the course of a very few generations, individuals bearing such peculiarities, owing to their unattractiveness and unfitness, are, as a rule, gently killed out without offspring.

While modern embryology permits the formation of hypotheses such as those here hinted at, it is to be remembered that for any real explanation we must await the results of pathological findings in actual cases. In view, however, of what has recently been done, the problem might perhaps be advantageously approached from the side of teratological experiment.

Meeting ofiDecemher 31, 1896.

Dr. Thayer in the Chair.

A Case of Acquired Paralysis of both External Recti Muscles, with Unilateral Facial Paralysis.— Dr. S. Theobald.

I thought this case would be of interest to show as supplementary to the one exhibited by Dr. Friedenwald several weeks ago. His was a case of congenital paralysis, or perhaps defective development, of the external recti muscles. He pointed out, as one of the interesting features of that form of paralysis, that there was no squint, and explained that in cases of congenital paralysis secondary squint does not usually occur. In the case which I exhibit we have the usual secondary squint found in acquired paralysis of the ocular muscles, and as both external recti are involved, it is of high degree.

This patient is 33 years of age and until August last was employed as a laboring man. His history shows that ten years ago he had a facial paralysis of the left side, and at the same time a paralysis of the right external rectus. There has been little or no change in his condition, so far as we can judge, in all that time. During August last he first developed a paralysis of the left external rectus. As to the cause of these paralyses the history is rather indefinite. It is more than probable, I think, that they are of syphilitic origin. He admits having once had gonorrhcea, and I think there must have been specific trouble also, though the history as to this is not clear. The points of interest are that so many years ago he should have had paralysis of the facial nerve occurring at the same time as the ocular paralysis. If the two had been on the same side it would not be so difficult to explain their co-existence, for we know that the nuclei of the 4th and 6th nerves lie close together in the floor of the fourth ventricle, and it is not uncommon to find both these nerves involved in the same case. It is of great interest, too, that after so long a


132

[No. 75.


lapse of time the external rectus of the other eye should have become iuvolved. The paralyses are evidently nuclear, and it would seem that some central change, either inflammatory or degenerative, involved the nucleus of left 7th nerve and the nucleus, which is quite close to it but on the other side of the brain, of the right external rectus, and that after a long lapse of time the left external rectus also became involved.

Paralyses of the ocular muscles are not uncommon. Their origin may be cortical, fascicular, nuclear, basilar, or orbital. Probably the commonest cause of paralysis of the ocular muscles is syphilis. We also often have a paralysis of the ocular muscles in tabes which is quite marked and yet which may in time entirely disappear. Paralysis of the ocular muscles may also be caused by diphtheria, disseminated sclerosis, poisoning by alcohol, nicotine, etc., and a certain class of cases certainly are due to cold. I have seen recently four cases of paresis of the external rectus due to cold or exposure. Such cases frequently occur in rheumatic subjects and are usually due to inflammation in the orbital portion of the nerve, and the prognosis is good.

The most marked symptom in cases of acute paralysis of ths eye muscles is diplopia, which is very annoying. In squint due to hypermetropia there is no complaint of dijjlopia, possibly because it usually develops in childhood ; but in paralytic squint, which oftener occurs in ^ults, diplopia is the most common symptom complained of.

There is one point in regard to this case which I have neglected to mention : this patient has well advanced atrophy of both optic nerves. The discs are decidedly white and the vision greatly impaired, in one eye being only ^^, in the other ^^. The treatment has been the administration of large doses of potassium iodide, and I think there is some slight improvement, but an operation will probably be necessary. It will not be sufficient to perform a tenotomy of the internal recti, but it will be necessary to combine with this an advancement of the externi.

Dr. Thomas. — There is the history of a decided facial paralysis ten years ago, and at present there is contracture of the muscles of the right side of the face. We know that in cases of severe facial paralysis there is very generally developed a secondary contracture of the paralyzed muscles. After a hurried examination it seems to me that upon voluntary effort the patient does move the left side of his face more than the right. An electrical examination would determine the point, but even now I am strongly inclined to the belief that it was the right side that was paralyzed. If this is found to be the case we can easily understand how a single lesion could cause a paralysis of the right 6th and 7th nerves; in fact there are many such cases reported. But on the other hand it is difficult to imagine a lesion involving the right 6th and the left 7th nerves.

Dr. OsLER. — One other point is of interest in this case : whether this may not be a facial paralysis and external rectus paralysis occurring with the secondary symptoms of syphilis, and whether his present paralysis and atrophy may not be the signs of tabes. The fact that he has the knee jerk is somewhat against this, but the persistence of these ocular paralyses is occasionally seen as an initial symptom of tabes.


Dr. Theobald. — I would only say in closing that the knee jerk was examined and found to be up to the usual normal standard. The suggestion of Dr. Osier is well worth considering, whether we are dealing with a greatly different state of affairs now from what originally existed ; whether this present paralysis is a tertiary, while the other was a secondary symptom.

I will be glad to have the patient come to Dr. Thomas's clinic and have the electrical examination made. My diagnosis of left facial paralysis was made simply on the drawing of the face to the right side and the fact that there is a certain blank expression about the left side of the face.

Exhibition of Opiithalmological Cases.— Dr. R. L. Randolph. Bilateral Dacryo-adenitis.

Dr. Randolph reported a case of bilateral dacryo-adenitis (mumps of the lachrymal glands, Hirschberg) in a negro woman thirty-nine years old. He spoke of the case as being one of the few cases reported in this country, the disease being very rare. Both lachrymal glands were so swollen that the upper lids had been pressed down at the outer canthus to such an extent as to hide the outer half of the eyeball. In the case of the left eye the hypertrophied gland had pressed the eyeball inward and slightly downward. The tumors were exceedingly painful to pressure, but at other times she suffered no local pain, the pain then being refeiTed to the sides of the face. There was nothing in her history that would give one a clue as to the origin of her trouble. She was put on small doses of bichloride of mercury and ten grains of iodide of potash three times daily, and frequent hot applications were made to the tumors, and after a month there was a noticeable diminution in their size. Six months after the beginning of the trouble there remained only a slight enlargement of the left


The trouble having passed away it is no longer interesting to show the patient, so she is not here this evening. It is the first case reported in the city, and certainly less than a dozen have been reported in this country.

Dr. Thayer. — In connection with Dr. Randolph's case I should like to say a word with regard to a somewhat similar instance which has been under our observation in the hospital. In 1894 a little girl, 10 years of age, was admitted to the hospital with bilateral hard enlargement of the lachrymal, parotid and salivary glands, for which we were unable to find any cause. The lachrymal glands were to be felt on either side as two small hard shot-like bodies. The child stayed in the wards for many months, and while there developed an ozoena and caries of the nasal bones which was clearly syphilitic in nature. Under treatment with mercury and iodide of potassium the glandular swellings slowly but completely disappeared. While in the hospital, however, some of the cervical and lymphatic glands became enlarged and remained so after treatment with mercury and iodide of potassium, and the child has since showed evidences of a tuberculous peritonitis. The enlargement of the lachrymal glands was very striking, though never as marked as in Dr. Randolph's case; it has entirely disappeared.


June, 1897.]

133


Operations for Cataract.

The other cases which I have to exhibit are some of the cataract cases upon which I have operated in this Hospital during the last summer. There are 12 or 13 here to-night. Some of them have interesting histories. One, an old man, 88 years of age, was operated upon early in September, and on the night of the operation had an attack of acute mania. He tore the bandage off several times, and finally had to be tied in bed, but in spite of that has a good result. When we consider how slight a disturbance may sometimes cause the operation to go to the bad this is rather a remarkable recovery. The bandage was disarranged at least three times. After the atropia was withdrawn he regained his senses and was rational for three days. One night after that he had another attack, jumped from his window, scaled the fence and was making his way homeward when found. Strange to say it had no effect upon the ultimate result.

The next case is a rare one. I operated for cataract early in June and the anterior chamber remained open after the operation for 17 days. At the last meeting of the American Ophthalmological Society I asked several of the members what was the longest time they had ever seen the anterior chamber remain open, and the longest period given in reply was 11 days. Four weeks after the operation when this patient left the hospital he had i^ vision, which is very good practical vision.

Very frequently in cataracts there seems to be a stage where they make no progress toward maturity. That was the case with this woman, aged 63, who, while having sight enough to get about, was unable to do work. Here I performed the maturing operation. This consists in doing an iridectomy and practicing massage upon the lens through the cornea. The cataract was ripened, then exti'acted. With the exception of that case I have performed the simple extraction, and in several of them there is no objective evidence of an operation having been performed.

Demonstration of Florence's Iodine Test for Seminal Stains.

— Dr. Lewellys F. Barker.

Professor Florence of Lyon has recently published in the Archiv d'Anthropologie a very delicate test for human seminal stains. He uses a mixture of iodine, iodide of potash and water not unlike the ordinary Lugol's solution.

To apply the test, if the seminal stain be upon linen, a small piece of the stained fabric is moistened with water, placed upon a glass slide and a drop of the reagent added beneath the cover-glass. If the stain be due to semen a very distinct precipitate of crystals results. The form of crystals is not unlike that of ordinary haemin.

We have used the test in the course in normal histology and find it very easy to apply and extremely delicate. The reaction is not yielded by blood, saliva, nasal mucus, vaginal mucus, urethral mucus, nor by the semen of other animals. I have placed under the microscope one specimen in which the seminal reaction is apparent, and under the other microscopes a number of other fluids mentioned in which no reaction has taken place. Urine sometimes throws down yellow-brown globules, but as far as we have been able to make tests, defi


nite crystals, likely to be confused with those of the reaction, are never deposited. Whether or not urine containing semen would yield the reaction I have not yet had the opportunity of testing; but inasmuch as minute quantities of the seminal fluid on linen will afford the reaction, it is very probable that urine containing this substance would also yield it. Some alkaloids are capable of yielding similar precipitates, a fact which must be borne in mind in medico-legal cases. Just what portion of the semen is concerned in the reaction has not yet been made out; it would be easy to ascertain this by testing the individual constituents of the seminal fluid obtained, say from the vas deferens, vesiculiE seminales, prostate and Cowper's glands at autopsy. Urethral mucus, as will be seen under one of the microscopes, does not yield the reaction. In case no single one of these constituents afforded the reaction, the latter must be due to some substance produced on their admixture.


NOTES ON NEW BOOKS.


The Practice of Medicine. A Text-book for Practitioners and Students, with special reference to Diagnosis and Treatment. By Jambs Tyson, M. D., Professor of Clinical Medicine in the Unisity of Pennsylvania, etc. Illustrated. {Philadelphia: P. Blakision, Sondb Co., 1896.)

This is in every respect an admirable boolt. The author's statement that it tias taken several years of labor is borne out by the careful and thorouglily conscientious way in which the suliject has been treated. It is a work of nearly 1200 pages, larger than the recent text-books issued in this country, containing on the whole rather more mattereven than Flint's, which is a very closely printed book.

Ttie author's method of dealing with a subject is well illustrated in the consideration of the important subject of myxoedema. Following the definition — and by the way the text-book is quite strong in clear, practical paragraphs defining diseases— the history of our knowledge of the affection is considered in nearly threefourths of a page. Dr. Tyson has in nearly every section dealt in a most instructive way with the historical development of the knowledge of the different diseases, and in myxoedema it is of course particularly interesting. I do not think that the statement is altogether clear about the dispute between Reverdin and Kocher as to the discovery of operative myxcedema. Unquestionably Reverdin published the first note in October, 1882, but he did not at that time appreciate fully the remarkable character of the changes following thyroidectomy. Kocher distinctly states that in the autumn of 1882, in Geneva, he spoke to Professor Reverdin of the remarkable sequences of the operation, and that Reverdin six days later read a paper on the subject. In Kocher's paper, which appeared in the spring of 1883, the description of operative myxoedema as we know it now, and which he called cachexia strumipriva, was fully and clearly drawn, and he certainly appreciated at that time, as Reverdin did not, the serious effects which might follow total extirpation. In the succeeding paper by the brothers Reverdin they recognized the condition as identical with myxoedema and called it myxoedeme operatoire. Three forms of myxoedema are recognized : pure myxoedema, myxcedema associated with congenital or sporadic cretinism, and operative myxcedema. There is in addition a full description of cretinism. On the subject of exophthalmic goitre, though the disease is placed under diseases of the thyroid gland, Dr. Tyson states that the neurotic nature of the disease is now generally admitted. He holds that the sympathetic neurosis theory


explains the symptoms rather more satisfactorily than any other. His practice is better than his precept in this respect, since he places the disease where it probably belongs, among those of the tliyroid gland. We are glad to notice that he insists upon the priority of the description by Graves. Of this, of course, there can be no doubt, though Parry and others published individual cases. Graves' clinical lecture in 1835 gave the first good description of the affection.

Naturally in a new textbook one turns to certain of the diseases about which there is still a good deal of difference of opinion. Appendicitis receives a very thorough and satisfactory treatment. There is no work in English which gives so good an account of the history of the affection. We are glad to see that Dr. Tyson does not consider it necessary to speak of a typhlitis, stercoral or otherwise. It is satisfactory to see that the name even does not occur in the index. lie describes catarrhal, ulcerative and interstitial forms of appendicitis. The clinical description of the different varieties is admirable. On the all-important matter of treatment the author takes rather advanced ground, stating that "the diagnosis being established, operative treatment should be recommended, except in those cases where the disease is so far advanced as to make it unlikely that the patient will be saved by operation." He thinks that the operation after the first attack is safer than during the first attack. On the much debated point of purgatives he leaves the matter to the circumstances of the case and the good judgment of the attendant, as the results may be either very happy or very mischievous. He believes that if there is doubt it is best not to purge.

The article on typhoid fever, with which the book opens, is in every way worthy of the great importance of the subject. The author is a strong believer in the use of the cold bath, and on the question of treatment he everywhere displays sound judgment.

We have said enough to indicate the importance of the work, its thoroughness, and its reliability in all practical details. The publishers are to be congratulated on the appearance of the volume. It is one of the handsomest works issued of late years in this country, and the type and paper are very much above the average. Altogether Tyson's Practice forms a very welcome addition to our textbooks, and we predict for it a most successful career.

An American Text-book of Applied Therapeutics, for the use of Practitioners and Students. Edited by J. C. Wilson, M. D., assisted by Augustcs A. Eshnek, M. D. Pp. 1-1326. {Philadelphia: W. B. Saunders, 1896.)

Since the main object of medical studies must always be the formulation of methods for the prevention and cure or alleviation of disease, it necessarily results that laboratory researches and clinical observations must ultimately be valued in proportion as they have brought us nearer to the attainment of these aims — in other words, according to the advances which have been derived from them in the establishment of a rational system of therapeutics. The world at large is apt to look at results rather than methods, and the busy practitioner may justly demand that the previous studies and experience of others should be presented to him in aconcrete form. For these reasons the status of medicine at any particular period will, to a great extent, be gauged by the therapeutic measures which prevail at that time, and of which the textbooks dealing with the subject are the exponents.

Graduates of twenty years ago will probably remember a time in the first few years of their practice during which they were tempted to become adherents of the doctrines of therapeutic nihilism. They had gone forth armed, they had been taught and for a time had firmly believed, with agents with which they could infallibly combat each and every untoward symptom. Is it to be wondered at that many of them in a short time exchanged their early therapeutic optimism for a hopeless therapeutic pessimism? Could they not justly reproach for this the faulty teaching which had been accorded to them?


Medicine is still to a great extent an empirical art, but although we can hardly hope that it will ever be numbered among the exact sciences, there are signs which indicate that by slow degrees we are attaining to a therapeusis which may always be at least rational.

The book before us shows a decided advance, not only because it registers real progress made in our knowledge of disease processes and in our methods of treatment, but because it shows that the difficult subject of therapeutics is now being attacked in a frank and true scientific spirit. The writers have been chosen from among men who have brought to bear upon the subjects allotted to them not not only the results of a profound study of the existing literature, but also those which can be obtained only by a wide personal experience. They are not mere compilers; they know whereof they speak. If not all of them have added much that is new, they have at least accepted the dicta of others only after a painstaking proving of their statements. They have chosen the middle ground, and while confident that much can be accomplished by the use of the various therapeutic measures which they recommend, they do not by the employment of specious generalities attempt to conceal those points upon which our present knowledge is still defective. They hold a strong position midway between therapeutic optimism and therapeutic nihilism. Above all and first of all they preach the doctrine of prophylaxis.

In many of the articles a short account of the more prominent manifestations of the disease underdiscussion will be found, which, although adding considerably to the bulk of the book, will assist the reader materially in better appreciating the treatment recommended later. It is impossible to speak here in detail of all or of any of the various contributions. In his article on tuberculosis, Whittaker summarizes our present knowledge upon prophylaxis in general, hygiene and climatology, and has ably marshaled all the recent experience, upon which he formulates a treatment which, if it contains little that is really new, is perhaps the best at hand. If his conclusions as to the advantages to be obtained by the use of tuberculin are not in accordance with those of other authors, his results certainly deserve the most respectful consideration. Tyson's article upon the diseases of the kidney is brief but admirably comprehensive. In speaking of typhoid fever, Wilson, after a careful consideration of other methods, not only endorses the cold bath treatment but repudiates the notion that it is cruel. This latter view will certainly not be conceded by many even of the most enthusiastic supporters of the procedure. Serum therapy receives a full share of attention, and the subject has been treated, by the writers upon the conditions for which it has been advised, with a full appreciation of its importance. Whatever may be the opinion with respect to Laveran's vie w as to the identity of the parasite for the different forms of malarial fever, the careful and precise treatment which he lays down will not easily be improved upon.

Another point to be noted is the comparative simplicity of the prescriptions which are given ; we are grateful for further evidence of the decline of polypharmacy. It would seem that we are beginning to appreciate Huxham's advice, " The physician should select a few (drugs) of the most effectual forhis useof each sortand stick to them and not run into an immense farrago which some are so fond of." Many of the illustrations are good, but not a few are superfluous. As might be expected, the book lays no claim to perfection. The student who looks to it for infallible remedies for every disease will naturally be disappointed ; the man of more moderate demands will find in it much that will help him in his daily work, and much that will stimulate him to the observation of disease processes and of the way in which they may best be met.

Frank R. Smith.

Die Fiirbetechnik desNervensystems. By Dr. B. Poll.^ck. {Pub lishcd by 8. Karger, Berlin, 1897.) Pp. 1-130.

This little book will be welcomed by neuro-histologists everywhere. It gives briefly the important steps in all the more impor


June, 1897.]

135


tant methods used in microscopic examination of the nervous system, including those of recent date. In the first section the technique of cutting up the brain at autopsy is described, togetlier with the methods for preserving the brain whole and forreproduc. ing plastically the specimens found at autopsy. In section two the general technique of hardening, staining, emliedding and section. ing is discussed. The methods of making serial sections, including the recent method of Flatau for making serial longitudinal sections of the whole spinal cord, are considered. We are glad to find mention made in section three of the work of Donaldson and others concerning the alteration in weight of the brain and cord after pri-servation in different hardening fluids. Too little attention has been paid to such alterations in previous books on technique. Apparatus for drawing and photography are described in section four. In the next section the methods of staining and impregnation are taken up. The various ways of demonstrating nerve cells and their axones and myelin sheaths are outlined. Golgi's method, Ehrlich's metliod and the new stains for neuroglia have been carefully considered. Nissl's method is given, and also Held's modification of it. The differentiation with alum solution is simple, easy to manage, very inexpensive, and yields in the reviewer's experience results fully as satisfactory as those afforded by the method with anilin oil and alcohol. In the sixth section certain general points to be borne in mind in the examination of normal and pathological cases are emphasized. It is particularly gratifying to find epitomized at the end of this section the routine methods employed in Waldeyer's laboratory for the study of the central and peripheral nervous systems. A brief bibliography is appended as well as an index. The book costs only two marks, and will probably find its way into many laboratories, where it will prove a safe and convenient guide. L. F. B.

Arbeiten aus dem Institut fiir Anatomie und Physiologic des Centralnervensystems an der Wiener Universitiit. Herausgegeben von Professor Dr. Heinrich Obeesteiner. Y. Heft, mit 5 Tafeln und 46 Abbildungen im Texte. (Leipzig und Wien : Franz Deuticke, 1897.)

The most recent number of the fasciculi which are appearing at intervals from Obersteiner's laboratory is fully up to the general standard set by the preceding numbers. Itcontains seven articles, one of which, on the innervation of the blood-vessels of the brain, is by Obersteiner himself. In this article Obersteiner discusses the work of previous investigators and describes and pictures a small artery of the pia mater stained with gold, in which he brings the direct anatomical proof that the finer intra-cranial vessels, at least within the pia mater, possess their own nerves. He refers briefly to the physiological and pathological significance of such innervation.

Schlagenhaufer contributes an article on the course of the fibres in the optic paths, in which is discussed also the tabetic atrophy of the optic nerve. He believes that there exists sometimes, at any rate, a compact uncrossed optic bundle which, however, forms only a part of the uncrossed bundle, and probably corresponds to the inferior (external) fibres. The direction of the course of this bundle gives, he thinks, in all probability, the anatomical course of the uncrossed bundle. The question of the total or partial crossing of the optic nerves in man must, therefore, be regarded as decided in favor of the latter through anatomical investigation. He thinks that by means of a scheme constructed accordingly it is possible to explain all the hemianopsias. As regards Gudden's commissure, he makes out that a part of the fibres stream into the ansa lenticularis to become connected with both lenticular nuclei. Some of the fibres run in the peduncle of the hypophysis. In front of Meynert's commissure in the upper anterior part of the chiasm there is a small system of fibres which remains intact when the optic nerves and chiasm atrophy. He thinks it possible that the tabetic atrophy of the optic nerves may be due to pressure at the foramen opticum.


F. Rezek describes and pictures a primary polymorphous sarcoma of the brain.

Pfiegler and Pilcz contribute along article entitled "Beitriige zur Lehre von der Mikrocephalie." They describe twelve cases of their own, with consideration of no less than 365 bibliographic references.

An interesting study of the histology of the ganglion cells of the horse in normal conditions and after arsenic poisoning is given by H. Dexler. Two beautiful plates accompany his article. The same writer publishes also a short note on the course of the fibres in the optic chiasm of the horse.

Julius Zappert, in an article on degenerations in the spinal cord and medulla oblongata in the child, embodies the results of his studies on the spinal cord and medulla of children who have died during the first three years of life. He has used Marchi's method and describes his findings with especial reference to the changes in the various nerve roots. L. F. B.


BOOKS RECEIVED.


Tuberculosis. By William Osier, M. D. 8vo. 1897. Reprinted from " Loomis' System of the Practice of Medicine," New York and Philadelphia, I, pp. 731-848.

Diseases of the Ear, Nose and Throat and their Accessory Camties. A condensed text-book. By Seth Scott Bishop, M. D., LL. D. 1897. 8vo, -196 pp. The F. A. Davis Co., Philadelphia, New York, Chicago.

Annual Report of the Trustees of the State Hospital for the Insane, at Warren, Pennsylvania, for the year ending No-oember 30, 1896, to the Board of Commissioners of Public Charities. 1897. 120 pp. Herald Printing and Publishing Co., Erie, Pa.

Medical and Surgical Report of the Presbyterian Hospital in the City of New York. Edited by A. J. McCosh, M. D., and W. B. James, M. D. Vol. II, Jan., 1897. 8vo, 272 pp. Trow Directory Printing and Bookbinding Co., New York.

Ouy's Hospital Reports. Edited by E. C. Perry, M. A., M. D., and W. H. A. Jacobson, M. A., M. Ch. Vol. LI, being Vol. XXXVI of the third series. 1895. 8vo, 272 pp. J. & A. Churchill, London.

Guy's Hospital Reports. Edited by E. C. Perry, M. A., M.D. , and W. H. A. Jacobson, M. A., M.Ch. Vol. LII, being Vol. XXXVII of the .third series. 8vo. 1896. 230 pp. J. & A. Churchill, London.

Lectures on Pharmacology for Practitioners and Students. By Dr. C. Binz. Translated from the second German edition by Peter AV. Latham, M. A., M.D. Vol. II, 1897. 451 pp. 8vo. New Sydenham Society, London.

A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in Photolithochromes from Models in the Museum of the St. Louis Hospital, Paris. With explanatory woodcuts and text. By E. Besnier, A. Founier, et al. Edited and annotated by J. J. Pringle, M.B., F. R. C. P. Fol. 1897. Part IX. W. B. Saunders, Philadelphia.

Transactions of the Indiana State Medical Society, 1895. Forty-sixth annual session held in Indianapolis, Ind., June 6th and 7th, 1895. Svo, 534 pp. Carlon & Hollenbeck, Indianapolis.

Hysteria and Certain Allied Conditions. By George J. Preston, M. D. 1897. Svo, 298 pp. P. Blakiston, Son & Co., Philadelphia.

DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL

Bv JOHN s. Billings, m. D., ll. D.

Contaiulng 56 large quarto plates, phototypes, and litliographa, with views, plans and detail drawings of all the buildings , and their Interior arrangements— also wood-cuts of apparatus and fixtures; also 116 pages of letter-press describing the plans followed In the construction, and giving full details of heating-apparatus, ventilation, sewerage and plumbing. Price, bound in cloth, $7.60.


136

rXo. 75.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report In Pathology.

The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

(Atrophy). By Henry J. Berklet, M. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

Mall, M. D.

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

T. C. Gilchrist, M. D., and Emmet Rixford, M. D. 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

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

T. C. Gilchrist, M. D.

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

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


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

Report in Medicine.

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

Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By JoHX N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleor, M. D. Cases of Post-febrile Insanity. By William Obler, M. D. Acute Tuberculosis in an Infant of Four Months. By Hahrt Toclmin, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

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

Report in Gynecology. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March S, 1890. By Howard

A. Kelly, M. D., and Hunter Robb, M. D, The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By HnuTER Robb,

M. D. The GonococcuB in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Pentoneum;

Ovarian Tumor; General Gynecological Operations from October 15, 1889, to

March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one GjTiecological Cases. By Howabd

A. Kelly, M. D., and Albert A. Ghriskey, M. D. Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (3hecking

Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D. Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoma of the Oitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment

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

Howard A. Kelly, M. D.

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

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Neurology, 1. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By Adqdst Hoch, M. D. A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

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


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

Report in Pathology.

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

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

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

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

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

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

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

Report In Gynecology.

The Gynecological Operating Room; An External Direct Method of Measuring the Co'njugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofle.xed Uterus. By Howard A Kelly, M. D.

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

Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavelt, M. D.


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

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

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

Traumatic Atresia of the Vagina with Hsmatokolpos and Bxmatometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

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

Report in Neurology. Dementia Paralj-tica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of .Whs- musculu^; The Intrinsic Nerves of the ThjToid <31and of the Dog; The Nerve Elements of the Pituitarj' Gland. By Henry J. Berkley, M. D.

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

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


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

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

Studies in Typhoid Feyer. By William Osler, M. D., n-ith additional papers by G. Bluher, M. D., Simok Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.


Volume VI. About 500 pages, many illustrations.

Report in Neurology.

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

Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. E.xperimental 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 by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Pathology.

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

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

Adeno-Myoma Uteri Diffusum Benignmn. By Thomas S. CJullen, M. B.

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

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

TJie price of n set hound in cloth [Vols. I-1'I'\ of the Hospital JSepoi-ts is $30.00. Vols. I, II and III are not sold separately. The price of Vols. IV, V and VI is $5.00 each.


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER. The following papers are reprinted from Vols. I, IV and V of the Reports, for thoee who desire to purchase in this form: STUDIES IN DERMATOLOGY. By T. C. GiLCHRiST, M. D., and Emmet Koeord,

M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,

J3.00. THE MALARIAL FEVERS OF B.-ILTIMORE. By W. S. ThaTER, M. D., and J.

Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARH.

By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.75. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. Subscriptions for the above publications may be sent to

The Johns Hopkins Press, Baltimore, Md.


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


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. VIII -No. 76.]


BALTIMORE. JULY, 1897.


IPrice, (5 Cents.


coisrT:E]isrTS.


PAGE

Studies on the Lesions induced by the Action of certain Poisons on the Cortical Nerve Cell. Study VII : Poisoning with Preparations of the Thyroid Gland. By Henry J Berkley, M.D., Five Successful Cases of General Suppurative Peritonitis treat ed hy a New Method. By J. M. T. Finney, M. D.,

An Experimental Study of the Treatment of Perforative Peri'


137


141


PAGE.

By Arthur


tonitis in Dogs by a New Method of Operation

W. Elting and Wm. J. Calvert, ......

Squamous Epithelioma and Epithelial Hyperplasia in Sinuses and Bone following Osteomyelitis. By S. M. Cone, M. D., ■

On the Blood-Pressure-Raising Constituent of the Sui)rarenal Capsule. By John J. Abel, M. D., and Albert C. Crawford, M. D.,

Notes on New Books,


151

158


STUDIES ON THE LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE

CORTICAL NERVE CELL

STUDY vn.

POISONING WITH PREPARATIONS OF THE THYROID GLAND. By Henry J. Berkley, M. D., Associite in Neuro-Patholoyii, The Johns Hopkins Universily.


The favorable side of the administration of the thyroid extracts is shown in the very numerous articles in current medical literature published both in this country and in Europe. Comparatively few of these papers treat of other than the bare clinical results from the most auspicious standpoint, and it is quite safe to say, after a review of some of them, that the results would have been as brilliant had no medicament been administered.

It is nevertheless true that the extract, when administered to either man or the lower animals, will occasion very grave symptoms of a toxasmic nature, symptoms that involve the cerebral, the vaso-motor and digestive functions, and perhaps also the normal action of those ductless glands that throw into the circulation a potent though unknown substance ; and when this administration is pushed even to a moderate degree death is almost invariably the result, either through the advent of convulsions, or extensive loss of weight with indications of profound poisoning of the central nervous system, shown by the change in the heart's action and in the respiratory movements.

A medicament having these qualities cannot, therefore, be administered with impunity to every sane or insane patient,


and it was therefore directly for the purpose of ascertaining the toxicity of one of the best known varieties of the thyroid extract that the following series of experiments was undertaken.

The first portion of the investigation was made upon eight patients at the City Asylum, who, with one exception (No. 1), had either passed or were about to pass the limit of time in which recovery could be confidently expected. To these patients the thyroid tablets, each pill representing five grains of the fresh sheep's gland, were administered, the dosage beginning always with a single pill daily for a period of three days, then, after a certain tolerance had been established the dosage was increased to two tablets daily, and, unless the symptoms induced became grave, the number of pills was increased to three daily, the length of continuance depending upon the results.

Loss of weight always attended the administration of the tablets, as did disturbances of the circulation in the form of tachycardia and enfeeblement of the cardiac action. Digestive disturbances and slight pyrexia were present in more than half the cases. A peculiar odorous sweating was noticed with two patients, and increase of the cutaneous transpiration in


138

[No. 76.


all. Irritability and a greater or less degree of mental and motor excitement were remarked in all cases, no matter how depressed or demented they had been previous to the administrations. Two jjatients became frenzied, and of these one died before the excitement had subsided, the immediate cause of the exitus being an acute disseminated tuberculosis. A peculiar gelatinous feel to the integument of the forehead and cheeks, precisely similar to that in myxcedema, combined with puflBness of the skin about the malar prominences, was very noticeable in those cases in which the administration of the extract was continued for any length of time. Urinary examinations were made several times before the commencement of the administration of the thyroid, and several times during its administration, but only for the purpose of noting the presence or absence of albumen and sugar. In the abstracts this analysis is mentioned only when there is evidence of the presence of these abnormal constituents.

Abstracts of Histories of Insane Patients Treated WITH Thyroid Extract.

I. Adolescent insanity. Martha H., set. 17. Sister insane. Admitted with melancholic symptoms accompanied by considerable mental confusion. Occasionally had to be fed with stomach tube. Could not speak, and it was imjoossible to determine what delusions were present. After being several weeks in the Asylum she partly recovered, and then relapsed, and there appeared to be considerable mental reduction after the lapse of several months. Then began to brighten, and take more interest in her surroundings, also to gain flesh. The thyroid gland was, apparently, small on palpation. Weight at beginning of the thyroid administration 115 pounds. A single thyroid tablet was administered for ten consecutive days, at the end of which time there was slight febrile reaction, with a pulse ranging from 100 to 110 (normal 78). The mental change was very slight, patient exhibiting some irritability, but nothing more. The weight is now 109 pounds.

On the fourteenth day, the thyroid being continued, the first signs of improvement were noticed. Patient became brighter, ate food without compulsion, and on the twentieth day volunteered to do work about the ward and conversed rationally. The thyroid extract was discontinued on the twenty-second day, and patient was discharged one week later, six months after her admission, and did not relapse.

II. Melancholia folloioed hij deep dementia. Olivia P., ist. 37. Education fair. No heredity. Married. Nutrition poor. Thyroid fairly well developed. Weight 100 pounds. Oil admission refused to speak, and would not take food.

Patient was deeply demented, and quiet for several months before the thyroid treatment was begun. She lost flesh very rapidly, and on the eleventh day of the treatment showed pronounced mental and motor excitement. Slight febrile reaction, accompanied by a pulse rate of 120 beats. On the twelfth day she passed into a state of frenzy, the motor excitement being more pronounced than the mental symptoms. The thyroid extract was now discontinued, but the excitement kept up, despite numerous attempts, with narcotics, baths, and systematic exercise, to allay it, for seven weeks, at the end of which time she died with the clinical


evidences of acute miliary tuberculosis. An autopsy was not permitted.

III. Beginning dementia. Frank G., aet. 20, well educated, was admitted to the asylum suffering from an attack of acute mania. There he improved, but was taken out too soon, relapsed, was readmitted, and then gradually demented. Thyroid of normal size. Is good tempered. Weight at beginning of thyroid administration 125 pounds. On the seventh day of the treatment became quite irritable and impatient. By the fifteenth day he was so quarrelsome that it was necessary to restrain him. During these 15 days he lost five pounds, and there was considerable tachycardia and sweating. The myxoedematous symptoms were not so pronounced as in some of the other cases. The administration of the extract now being discontinued, he regained weight, became more quiet, and after the lapse of several weeks he was sent to his friends somewhat improved.

IV. Dementia. John B., fet. 31, admitted as a case of acute mania, and after a period of four months gradually demented, became quiet, and not at all irritable. Thyroid gland normal. Treatment was now begun, and within a week there was j^ronounced febrile reaction, with tachycardia and sweating. There is a marked difference in the asjject of the face, which now appears puffed and rounded, in contrast to the former rather emaciated appearance. The facial expression also became anxious, but there was no pronounced excitement. The treatment was continued thr»c weeks longer, without producing other change than an increase of the myxcedematons characteristics, and was then discontinued. From a mental standjwint, the course of the patient's disease was now rapidly downward, and he became absolutely demented and degraded.

V. Chronic vielancholia. Marcus Z., set. 30, Russian Jew, admitted to the asylum with alternating melancholia and mania. Thyroid normal. Much emaciated from chronic diarrhcea. Refused food at first. Has been quiet for some months, suffering from well marked delusions of persecution. Under enforced feeding became well nourished, but not less melancholic. Six months after admission treatment with thyroid extract begun. One tablet for ten days, two for four days, and three daily for two weeks longer. On the 11th day became much excited, complaining that his countrymen wished to kill him. There was slight febrile reaction and increase in the pulse rate to 120 (normal 75). The cheeks soon began to assume a marked puflBness, and on palpation had a jelly-like feel. No other phenomena were noticed, except that at the end of the month's treatment he had lost eight pounds, which he rapidly regained after it was discontinued. Then he also became quiet, and at the date of writing still remains an inmate of the institution, retaining his oldtime delusions.

VI. Dementia following puerperal melancholia. Katie S., ret, 35, was admitted in 1893, four weeks after confinement. Recovered in about six weeks, was taken home, and there relapsed and became permanently demented. Is untidy, mischievous, but never excited. Pulse rate normally 85 to 90. Thyroid normal. Was placed on thyroid extract, one pill, then two pills ilaily. lu second week marked febrile reaction.


July, 1897.]

139


pulse 120 to 1.30, very weak. There is considerable sweating. Facial puffiaess well marked. Has become very irritable, restless, aud difficalt to control. Thyroid extract discontinued after three weeks' administration, after which she gradually returned to her usual condition.

Vn. Deep dementia foIJoioing confimonal mclnnrlioliu. ilaggie E., set. 2.5, was admitted in December, 1893. Thyroid normal. When treatment with the thyroid extract was commenced was untidy and deeply demented. On the tenth day there was slight febrile reaction accompanied by slight motor excitement. These symptoms abated in the course of a few days, though the administration of the thyroid extract was continued, and, after three weeks, no improvement having been noticed, it was discontinued.

VIII. Imbecility with recurrent mania, followed by apparent dementia. C. B., aet. 21, admitted with second attack of excitement in December, 1895, and within a few weeks became apparently deeply demented. Thyroid gland very small. Administration of the extract was begun, and after a few days there was febrile reaction, considerable sweating, and a myxcedeniatous appearance of the integument of the face. The pulse rate altered from 72 to 110, and the patient lost weight rapidly. There were also considerable motor and mental excitement, with the febrile symptoms, all of which gi'adualiy abated, though the treatment was faithfully kept up for a considerably longer time. The patient has had several lucid intervals during the fall of 1896, but now seems completely demented.

The above experiment upon eight human subjects points out conclusively that the administration of even the very best and purest of the commercial desiccated thyroid tablets is not unattended by danger to the health and life of the patient, and that at times the administration of very limited amounts of the gland may be followed by symptoms not only difficult to control, but of very marked influence upon the future mental powers of the subject.*

These results obtained, we then decided to further pursue our experiments upon the lower animals, to determine the amount necessary per kilo of weight to cause death, the immediate cause of the dissolution, and the lesions, both macroscopic and microscopic, present at death, especially those pertaining to the cerebrum.

Through the kindness of Dr. Crawford of the Pharmacological Laboratory, who undertook the ordering of the administration to the animals, we obtained material from five mice and three guinea-pigs, to which the same desiccated sheep's thyroid tablets used in the first part of the investigation had been fed; also the cerebrum from one guinea-pig to which had been administered thyroid extract, and the cerebrum of a dog from which the thyroid had been extirpated about one year previous to its death, but in which, at the autopsy, supernumerary thyroids were discovered, though the animal during life had exhibited minor symptoms of a cachexia.

A portion of the material for microscopic examination was

  • I do not take into consideration the possible presence of putrefactive products in the tablets, as they were perfectly free from all

evidences of decomposition.


hardened in Muller's fluid for after-treatment according to the silver-phospho-molybdate formula, and another portion in alcohol, for staining with the anilines, hematoxylin, aud more particularly to examine into the lesions of the blood-vessels, both in the abdominal viscera and cerebrum.

The five mice were first fed with the tablets. All of them ate the pills readily to obtain the sugar coating them. For a few days there was no appreciable effect. Then they grew dull, the cheeks became puffy, there was trembling and increase of the frequency of the respiratory movements, and death rather suddenly.

Abstract of the Histories of the Thyroid Mice.

No. I. Administration of the tablets commenced Aug. 22, '96. One pill 32nd; three, 24th. Animal remains bright and eats other food ; 2.5th, two tablets. On 26th, it seems frightened and the face appears swollen ; on the 37th instant, it is still trembling very greatly, and no pill was given. On the 28th, it is very much brighter and the trembling has almost ceased. On the 29th, is bright, and feeding of the thyroid was again begun. Sept. 1st, three pills were fed, the animal eating nearly the whole quantity. The 2nd instant, the face is again swollen, and on the 3rd, refused to eat a portion of the tablets, and has become quite dull. On the 4th and .5th instant, the animal continued dull, trembling, aud looks weak and sick. On the 7th, the eyes are very bright, and there is slight emaciation. Five pills were given, but not all were eaten. On the 8th, only two pills were taken ; there is much trembling. Died during the night of the 9th instant, having eaten a portion of the tablets left in the cage.

The autopsy showed congestion of all the viscera, but without hemorrhage. The brain was soft.

No. II. On the 33nd August, cue pill administered, on the 23rd aud 24th, the same quantity, but little not being eaten. On the 35th, two pills were eaten, the animal still remaining bright. On the 36th, two tablets were eaten, and the face shows signs of swelling. On the 27th, the testes have become swollen, in addition to the face, but the appetite is still retained. On the 38th, the eyes are partly closed, and on the 29th, the animal is trembling, the legs are dragged, but it still takes care of its coat.

September 1st, the animal is dull, the face much swollen. Three pills were eaten. On the 3rd, is much brighter, sleeps well, but has not taken all the pills during the last two days. On the 5th instant, will hardly touch the sugar-coated tablet. On the 7th, the face is markedly swollen, the animal is dull, the hair less sleek, and the eyes almost closed. Kespi ration 134 per minute. Died in convulsions at 2.30 1*. M.

The autopsy was performed immediately. Besides some unimportant congestion of the abdominal viscera there were no ascertainable lesions.

No. III. Commenced feeding on 33ud August, but no symptoms were noticed uutil the 36th, when the face became slightly swollen and the animal declined to eat the pill. On the 28th, there is slight trembling. On the 30th, the trembling continues. On Sept. 3nd and 3rd, took daily three pills. On the 5th, is dull, tottering, very weak. On the 7th instant, the hair is rough, and it seems weak, hut eats the pills


140

[No. 76.


well. On the 8th, is trembling very much, but eats the pills. Died during night.

Autopsy showed congestion of the abdominal viscera. Brain rather soft.

No. IV. Feeding commenced on August 'Z2nd, but does not eat the tablet well, hardly averaging J of a pill daily. On the 26th, the animal is bright, but the face is slightly swollen. On the 29th, refused to eat pill, but remaiued dull until September 3nd, and thereafter refused to eat pill at all. On the 12th instant, had apparently fully recovered.

No. V. Administration commenced on the 22nd August, and the dried gland was all eaten. On the 26th instant, the face is swollen. On the 28th, there is much trembling, but three pills were eaten. On the 29th, would not eat pill, but on Sept. 1st ate four pills. On the 5th instant, is trembling considerably, but ate two pills. On 8th instant, was bright, though trembling. On morning of 9th instant, found dead in cage. The autopsy showed the usual congestion.

Abstract op the Histories of the Thyroid Ctuinea-Pigs.

No. I. Fed with thyroid extract, 20 mg. daily, from Oct. 21st until Oct. 30th, on which day it died. Weight at beginning of experiment, 620 grammes. The animal became dull and gradually emaciated. Weight at autopsy, 380 grammes. All intei-nal organs very much congested. The animal received a total of 180 mg. of extract.

No. II. Pig fed on the same desiccated thyroid as in the former experiments. Weight, 810 grammes. On Oct. 21st, one and a half pills administered; on 22nd, four pills; on the 23rd, the same quantity. The respiration had now reached 144 per minute. On the 24th, 2.5th and 26th, four tablets were fed daily, and during the night of the 26th, the animal died. At the autopsy the abdominal organs were found to be much congested. Weight, 620 grammes (loss 190 grammes). This animal received about seven grammes of the dried thyroid gland, or less than one per cent. (.864j of its bodily weight to produce a lethal effect.

No. III. Fed on desiccated thyroid tablets. Weight, 580 grammes. Oct. 21st, one pill ; on 22ud, three tablets ; on the 23rd instant, four; on the 24th, 25th and 26th, the same; on the 27th instant, six pills; on the 28th, four tablets; on the 29th, five ; on the 30th, five. The animal had been for several days very dull and had rapidly emaciated. The exitus took place on the morning of the 30th instant. At the autopsy the viscera were found to be much congested. The weight was 320 grammes. Loss of weight during the nine days of the experiment, 260 grammes. The animal received more than 2 per cent, of its weight in the dried gland to produce dissolution.

No. I\". The same thyroid preparation fed. Weight at beginning of the administration, 610 grammes. On Oct. 22ud, two tablets were fed to the animal ; on the 23rd, three ; on the 4th, four pills; on the 26th, six pills; on the 27th, four pills ; on the 28th, five pills. The pig has become very dull and does not take care of its fur. Died Oct. 30th. At the autopsy the animal weighed 370 grammes (loss, 240 grammes) and the viscera were much congested. This animal received 1.30 per cent, of its bodily weight of the gland to cause death.


No. V. Thyroid dog (Dr. Abel). Thyroid gland extirpated i)i loto in Oct. 1895 ; died one year later, after showing profound emaciation and a dermatitis suggestive of myxoedema. At the autopsy several parathyroid bodies the size of a small pea were discovered. This animal was fed for several mouths on thyroids and thyroid extracts, seemingly without benefit. The autopsy showed no demonstrable lesions.

The guinea-pig series may be looked upon as an example of the acute type of poisoning by the administration of thyroid gland, while the mice are of a more chronic order. It is impossible to estimate the exact percentage necessary to produce lethal results with the mice, for the reason that these small animals always left some crumbs of the tablets on the floor of their cages which it was not practicable to collect. The guinea-pigs on the other hand were fed with the entire pill without loss, and but in one case was less than about one per cent, of desiccated gland found to produce lethal results, the administration being distributed over five days.

The microscopic examination of the cerebra of the eight mice and guinea pigs showed, both with the silver phospliomolybdate, and aniline and hematoxylin stains, an absolutely normal condition of the nerve elements and neuroglia ; none of the varicose and atrophied dendrites, with loss of the gemmulffi, of the former studies being discovered. The corpora retain their angularity and sharp outlines, and the axons with their appendages, the collaterals, retaining their natural appearances. The sections stained with anilines and hematoxylin showed the normal appearances of the nucleus and nucleolus, and not even in the tunics of the blood-vessels, where pathological changes were most carefully sought for, could any demonstrable lesion be discovered.

The nearest approach to any pathological condition found was in the cerebrum of the dog that had had its thyroid gland extirpated a number of months before death, though even here the lesions were confined to a very few tumefied dendrites, a condition that was most probably caused by the long continued state of mal-nutrition into which the animal had fallen.

More particular attention was paid to the examination of the liver than to the other organs of the abdominal cavity, but here again we failed to find more than a turgescence of the blood-vessels, the liver cells retaining their natural characteristics.

It is obvious from these results that the death of the various animals was induced by an entirely different kind of intoxication than that causing the lesions of the nerve elements in riciu and alcohol tox£emias, and it is therefore a poison that does not induce degenerative alterations in the sheaths of the arteries, and the consequent disturbance of the nutritive supply, followed by pronounced changes in the neurons, dependent to a certain degree upon the intensity of the vascular lesions; but acts upon the general system in an entirely different manner, and is essentially more subtle in its effects upon the nerve tissues, corresponding more to the action of a group of chemical poisons that leave no trace of their effect after death upon the nerve cell, but during life inducing symptoms directly referable to the central nervous system. The tissue metabolism induced by the action of these poisons upon the nerve cell we can only at present conjecture.


July, 1897.]

141


FIVE SUCCESSFUL CASES OF GENERAL SUPPURATIVE PERITONITIS TREATED

BY A NEW METHOD.*

By J. M. T. Finney, M. D., Associate Professor of Surgery, The Johns Hopkins University.


Recovery following laparotomy for piiruleut peritonitis is nufortunately of sufficient rarity to excite interest whenever it occurs. My object in making this report to the Society is two-fold ; first, to record five successful cases of laparotomy for general suppurative peritonitis, all treated by the same method; and second, to describe briefly the method itself. The principle involved is not a new one; only in the manner of carrying it out is there any originality claimed.

Since the appearance in 1877 of the classical work of Wegner, and later that of Grawitz and others, it has been known that the healthy peritoneum is capable of disposing of a considerable amount of infectious material. J. G. Clark, in a recent article,f reviews the literature of the subject and gives the conclusions reached by the experimenters in this direction. All agree that the peritoneum is able under favorable conditions to take up a relatively large amount of infectious material and disjjose of it effectually. These observers were dealing with a more or less healthy peritoneum. On opening the abdomen of a patient suffering from general suppurative peritonitis, however, we have very different conditions with which to deal. The observations of Pawlowsky would indicate that the lymph channels leading from the peritoneal cavity are choked with infectious bacteria and inflammatory products in purulent peritonitis, and that thus the efficiency of the peritoneum would be greatly impaired. Our observations clinically seemed hardly to bear this out.

The question that suggested itself to our mind was this, whether or not the peritoneum, even under these most unfavorable conditions, still retained its absorptive power. It seemed to us, from our experience in operating upon such cases by the methods heretofore employed, that they were inadequate and did not remove a sufficient quantity of the exudate, but left the peritoneum little better off than before. With this idea in mind we devised a plan of treatment which, so far as we know, has not been employed elsewhere.

The steps of the operation are as follows : Make a sufficiently long incision to admit of easy access to all parts of the peritoneal cavity. Quickly withdraw the coils of small intestine from the peritoneal cavity, beginning with the worst coils first. Remove all, or as much as is necessary of the small intestine and place it outside the abdomen, covered with warm gauze or towels, thus practically disemboweling the patient for the time being Then thoroughly and systematically wipe out the peritoneal cavity with large pledgets of gauze wrung out of hot salt solution, paying particular attention to the pelvic portion. In some cases it may be well in addition to flush out the cavity with warm salt solution, but this is rarely necessary.


  • Read before the Medical and Chiriirgical Faculty of the State

of Maryland at its Annual Meeting in Baltimore, April 27, 1897. tBuUetin of the Johns Hopkins Hospital, April, 1897.


Next the small intestine should be systematically examined loop by loop while still outside the abdomen, and rendered macroscopically clean by wiping with gauze comjiresses wrung out of hot salt solution. It is necessary to wipe with considerable force at times, in order to remove adherent flakes of partly organized lymph. It should be done thoroughly and conscientiously, however, as upon this depends, we believe, in great measure, the success of the operation. It facilitates the cleansing process, as well as lessens the shock of the operation, if the wiping of the intestinal coils is carried on under a constant irrigation of warm salt solution.

After being cleansed macroscopically of all foreign material, pus, feces, lymph, etc., the intestine should be replaced in the abdomen — the worst or sutured coil being the last, or most superficial, in order that it may be the better drained by being packed about with gauze, if necessary.

The abdominal wound is then tightly closed, leaving just room enough between two sutures for the gauze drain. If there are any evidences of distension or pain the abdomen should have the Paquelin cautery thoroughly applied, and the bowels moved early by calomel in broken doses, followed by salts and a turpentine enema.

It is not claimed for this method that it will cure every case of general suppurative peritonitis. We believe, however, that a larger percentage of cases will recover after this method than any other with which we are familiar.

To insure success with any method it is essential that the operation should be performed within a few hours after the perforation has taken place. This is well brought out in the very interesting series of experiments on dogs made for me by Messrs. Elting and Calvert of the Johns Ilojikins Medical School, a report of which is subjoined.

Five cases have been operated upon by this method up to date, all of which have recovered. The first case, a case of perforating typhoid ulcer, has already been published,* and hence only a very brief abstract of the history will be given here.

Case I. — Male, aged 47, on about eighth day of mild attack of typhoid developed symptoms of perforation. Entered hosijital 14 hours later and was operated upon immediately. Peritoneum everywhere intensely congested, roughened and dull, and covered with flakes of plastic lymph. Considerable amount of turbid purulent fluid in abdominal cavity. Perforation in ileum about 14 inches from ileo-c;ecal valve. Fecal matter exuding from opening. Peritoneum cleansed in the manner described, gauze drainage. Recovery.

Case II. — G. W., male, aged 20. Saw patient for the lirst time, November 24, 1896, in consultation with Dr. Barringer in Charlottesville, Va. Patient gave history of four previous mild attacks of appendicitis, from which he liad promptly


  • AnnalB of Surgery, March, 1897


142

[No. 76.


recovered. The night before he had eaten very heartily of apples. He was awakened about 3 a. m. with severe abdominal pain, cramp-like in character. At about 6 a. m. Dr. Barringer was called. He stated that at this time, three hours after the beginning of the attack, the patient presented the classical symptoms of peritonitis. When I saw him, 24 hours later, he had a temperature of 103° and a pulse of over 100, and from the first had suffered intense pain, which was controlled only by morphia hypodermically. He had had nausea and vomiting all day. Examination of the abdomen showed slight distension and great rigidity of the abdominal muscles. A slight tumefaction could be made out just to the inner side of the anterior superior spine of the ilium on the right side. Tenderness very marked. Immediate operation advised and agreed to. Incision 5 inches long in right linea semilunaris. On opening the peritoneal cavity the intestinal coils in the right lower quadrant of the abdomen were found to be congested and dull and covered with flakes of adherent lymph. Elsewhere the intestinal coils were found to be congested, but not otherwise much changed in appearance. The pus, of which there was perhaps 200 cc, was not walled off, but everywhere present in pockets between the adherent intestinal coils. The appendix was readily found. It was closely adherent to the pelvic brim on the one side and the csecum on the other. Its distal end was swollen and distended to the size of my thumb, perforated and gangrenous over an area about as large as a five-cent piece. Appendix was ligated and excised, and stump covered with peritoneal cuff and suture. The peritoneum was treated in the manner above described. Recovery.

Case III. — This patient was seen first on December 14, 1896. His history is in brief as follows : R. S., male, aged 33 years. Has had no previoiis similar attack. The night before he was taken sick he attended a banquet and ate heartily of solid indigestible food. He was attacked with severe abdominal pain about 3 o'clock the next afternoon. The pain at first was general and cramp-like ; nausea and light vomiting during the night. Morphia was necessary to relieve him. The next day he was unable to get up. Toward evening his physician gave him a cathartic, after which the bowels moved 8 or 10 times in quick succession. The next morning the pain had shifted to the right side and was severe. He received a hypodermic of morphia and got on fairly well until about 6 p. m., about 60 hours after the onset of the attack, when he was taken with a sudden severe pain in the lower right side of the abdomen. The pain for a time was excruciating at the base of the penis. Vesical and rectal tenesmus marked. When I saw him, about 4 hours later, in consultation with Dr. Reiche, he had a temperature of 105° and pulse of 150, profoundly collapsed. I have never seen such a hard and retracted abdomen as he presented. His condition appeared grave. Immediate operation advised and consented to.

Incision about 5 inches long, in right linea semilunaris. On opening abdomen the intestinal coils were fol^nd not to be distended but considerably congested. Beginning in the right lower quadrant there was found a considerable amount of thin pus containing flakes of lymph. This condition


extended over into the left side, down into the pelvis and up into the hypogastric region. The appendix was found to be gangrenous and perforated, and was removed. The toilet of the peritoneum was made in the manner already described, by disemboweling and vigorously scrubbing the parietal and visceral peritoneum until macroscopically clean. The intestinal coils were then replaced, a gauze drain inserted, and the abdominal wound closed except a small opening for the drain. He made an uninterrupted recovery.

Case IV. — M. B., boy, aged 10. Operation by Dr. J. C. Bloodgood, January 7, 1897. Five days before admission to the hospital was struck in the abdomen by the fist of a playmate. Next day felt severe pain in the right iliac region. This progressively increased for three days, when vomiting began and the pain became general. Two days later was brought to the hospital, when his condition was found to be in brief as follows: Temperature 101°, pulse 128 and fairly good. Slight abdominal distension. Muscular spasm marked on right side, present but less marked on the left. General abdominal tenderness. Under ether a definite tumefaction could be made out in the region of the right kidney. This proved to be an abscess behind the cjecum, extending from the iliac fossa below to the liver above, and in this cavity was the diseased appendix. There was foiind no walling off of this from the general peritoneal cavity. The entire pelvis was filled with yellow pus and all the intestinal coils were covered with flakes of fibrin. The stomach and spleen were not seen, but the surface of the liver looked exactly as if it had been covered with yellowish-white paint. The appendix was removed and the entire abdominal cavity thoroughly wiped out with gauze pledgets wrung out of salt solution. The exudate was scrubbed oS the livers surface, after which it looked simply congested. A gauze drain was inserted and the abdominal wound partly closed. He made an uninterrupted recovery. Cultures and cover-slips from the peritoneum showed colon bacillus and a coccus (not differentiated).

Case V. — R. S. P., aged 9, a schoolboy, entered the Johns Hopkins Hospital, Feb. 26, 1897. He had always been healthy except for measles, whooping cough and chicken-pox.

Family history good except remote cases of tuberculosis on both sides.

Just 48 hours before entering the hospital first complained of pain in abdomen. Three hours later had an attack of vomiting. Pain in abdomen was at first general, but in a few hours became localized in the right iliac and lumbar regions. After about 24 hours the pain lessened somewhat, and he sat up for a little while, but shortly after pain and vomiting returned with increased severity. A physician saw him after about 36 hours and gave him calomel in broken doses. His bowels moved twice. His condition did not improve, and by advice of his physician was brought to the hospital at 8 p. m., 48 hours after the onset of the attack. His condition then was as follows : Face flushed and anxious. Pulse 126 ; temp. 102.8°; resp. 56, and entirely thoracic; abdomen generally distended and tender, especially in right iliac fossa, where the tenderness is extreme and muscle spasm very marked. Pain is most marked here also. Liver and spleen not palpable. Liver dullness on right corresponds about to costal border.


July, 1897.]

143


Percussion over right iliac and lumbar regions shows dullness; tympanitic over left side. Heart normal. Fine moist rales over bases of both lungs. No history of any similar previous attack.

Diagnosis. — Perforating appendicitis with beginning general peritonitis. Immediate laparotomy advised and agreed to. Ether. When thoroughly auassthetized, a small, hard mass, somewhat movable, could be felt just over the middle of Poupart's ligament. An incision about 15 cm. long was made parallel to and over the right linea semilunaris. After exposing the peritoneum and before opening it several bubbles of gas could be seen free in the peritoneal cavity. On opening the peritoneum a considerable amount of thin, cloudy seropuruleut fluid escaped and some gas. The mass felt before was found to be the appendix with a roll of omentum adherent. The intestines, especially the CEecum, were distended and congested, and covered with flakes of fresh fibrinous exudate. The congestion was most marked in the immediate vicinity of the appendix.

The appendix itself was superficially placed and freely movable, not walled off, but had a portion of omentum adherent. It was rather long, and curled upon itself, with a constriction at about the junction of its proximal and middle thirds. It contained two concretions, the larger of which was engaged tightly in the constriction, and from this point to the tip the appendix was gangrenous and softened. A


small perforation was present at the distal end of the dateseed like concretion. 'I'here had been an apparent attempt of the omentum to surround the entire gangrenous end of the ajjpendix, but it had not quite succeeded. The appendix together with the adherent omentum was ligated and excised.

Pelvis was found to be full of pus, and the peritoneum treated as above. He made a rapid and complete recovery.

Bacteriological examination of the peritoneal exudate showed the presence of streptococcus, staphylococcus, and bacillus coli communis.

NoTK. — Since reading the above article, I have operated upon one additional case of general peritonitis. The patient, a young woman, was in extremis at the time of the operation, which was undertaken simply as a forlorn hope. This operation was secondary to one performed several days previously by another surgeon for appendicular abscess. There was found present a general peritonitis, with much jjlastic lymph covering the greatly distended and adherent coils of intestine. There was very little purulent fluid in the abdomen. Her pulse was very rapiil and thready, and her temperature had risen several degrees. After the operation she was placed in a continuous bath, which added greatly to her comfort. The operation seemed to prolong her life, as she lived about thirtysix hours following it.


AN EXPERIMENTAL STUDY OF THE TREATxMENT OF PERFORATIVE

A NEW METHOD OF OPERATION.

By Arthur W. Elting and William J. Calvert.


'ERITONITIS IN DO(iS BY


[From the Anatomical Laboratory of the John) Hopkins University.']


At the suggestion of Dr. Finney and with the permission of Prof. Mall, the writers have undertaken an experimental study of perforative peritonitis in dogs, with especial reference to the method of treatment of this disease in human beings, introduced by Dr. Finney. Inasmuch as this is a preliminary report, the literature upon the subject will not be considered. It may be mentioned, however, that so- far as we know no previous work of this nature has been done from a surgical standpoint. It was decided to divide the series of experiments into four groups :

1. To scrub the intestines of a series of normal dogs and study the condition of the abdominal cavity at varying lengths of time after the operation, in order to determine the results of the mechanical irritation.

2. To determine how long it takes a perforative peritonitis to destroy life.

3. To perforate the intestines of a series of dogs, and after varying lengths of time to operate upon them again, closing in the perforation and cleansing the abdominal cavity and the surface of the intestine and mesentery, and after variable periods of time to kill the dogs which recovered, and study the condition of the abdominal cavity.


1. To perforate the intestines of a series of dogs, and after varying lengths of time to close in these perforations without removing from the abdominal cavity any of the exudate or foreign matter present, and to study the results of this operaation.

The dogs used in these experiments varied in weight between 18 and 53 pounds, most of them weighing about 25 pounds.

For the first group of experiments four dogs were used. By a median incision the abdomiiuxl cavity was opened, the intestine and parietal peritoneum were vigorously scrubbed with gauze sponges wrung out in warm normal salt solution, and kept covered with warm towels. After this treatment numerous minute hemorrhages caused by the scrubbing were noticed over the peritoneal surfaces, and the intestine presented an extremely congested appearance. It was then thoroughly irrigated with warm normal salt solution, which had a marked effect in reducing the congestion. The intestine was then replaced in the abdominal cavity and the wound closed. The process of scrubbing as performed by the operator and an assistant required from 8 to 12 minutes. In every case the dog appeared ill for about 24 hours after the operation, after


144

[No. 76.


which a marked improvement in the condition was noticeable. Usually by the end of the second day the animal seemed quite well.

Of these four dogs one was killed by an accident one day after the operation. Autopsy showed a very small amount of blood-tinged serum in the abdominal cavity. The surface of the intestine and parietal peritoneum presented numerous hemorrhagic areas caused by the scrubbing at the time of operation. The surface of the intestine was roughened, though not adherent. Cultures from the abdominal cavity were sterile.

A second dog was killed at the end of three days. At autopsy no appreciable amount of fluid was found in the abdominal cavity. Numerous fibrinous adhesions of the coils of intestine to each other, to the inner surface of the abdominal wound and to the omentum were found. The surface of the intestine was slightly roughened and presented numerous hemorrhagic areas. Similar areas were also seen upon the mesentery near its attachment to the intestine and upon the parietal peritoneum. These were likewise caused by the scrubbing at the time of operation. Cultures from the abdominal cavity were sterile.

A third dog which was in excellent health and condition was autopsied at the end of five weeks. No appreciable amount of fluid was found in the abdominal cavity. The appearance of the organs was everywhere normal except for numerous adhesions of coils of the intestine to each other, to the omentum, to the inner surface of the abdominal wound and to the stomach. These adhesions were of a firm character, being apparently composed of fully developed connective tissue. Cultures from the abdominal cavity were sterile. The fourth dog is still alive and will be autopsied later. From this group of experiments we conclude that mere mechanical irritation may cause the formation of extensive adhesions in the abdominal cavity of the dog, but these seem in no way to seriously interfere with the animal's general health.

For the second group of experiments four dogs were used. Because of its accessibility and the comparative ease with which the perforation could be closed, it was decided to perforate the CEBCum. By the use of a stick of caustic potash a perforation IJ cm. in diameter was made in the end of the caBcum, after which it was replaced in the abdominal cavity and the abdominal wound closed. These dogs showed symptoms of a severe peritonitis and died in from 12 to 20 hours from the time the perforation was produced. Autopsy showed practically the same pathological condition in each case. From 150 to 250 cc. of a turbid bloody fluid were found in the abdominal cavity. The surface of the intestine presented a marked hemorrhagic condition, both diffuse and petechial in character. The omentum, mesentery and parietal peritoneum presented a similar appearance. Flakes of reddish yellow lymph were deposited over the surface of the viscera, particularly in the region of the liver, diaphragm and lesser omentum. Slight fibrinous adhesions between the coils of intestine were noted. The mucosa of the intestine presented more or less of a hemorrhagic appearance, and in some of the cases bloody contents were found in the lumen of the gut. In short, the pathological condition was one of an intense hemorrhagic


peritonitis associated with a more or less extensive hemorrhagic enteritis. The bacteriology of each of these cases was carefully worked out and will be referred to later.

For the third group of experiments twelve dogs were used. The method of operation was as follows: An incision was made on the right side just outside the rectus muscle, the cajcum brought out and perforated in the same manner as practiced in the experiments already described. The cajcum was then replaced in the abdominal cavity and the abdominal wound closed. From five to seven hours after the perforation was produced these dogs were again opened by an incision in the median abdominal line. The perforated end of the crecum was brought out and the perforation closed by means of a row of mattress sutures, after the necrotic tissue at the seat of the opening had been resected. The abdominal cavity was then opened, and the intestines being lifted out, were kejit carefully covered with towels wet in warm normal salt solution. With gauze sponges wrung out in this solution the surface of the intestine and mesentery was carefully wiped till it appeared macroscopically clean. The abdominal cavity was next wiped out and rendered macroscopically clean, the intestine in the meantime being frequently irrigated with warm salt solution and kept covered with warm towels. After another thorough irrigation of the intestine with the warm salt solution it was replaced in the abdominal cavity and the wound closed in the usual manner. We cannot emphasize too strongl}', in doing these experiments, the advisability of thorough and constant irrigation of the intestine while it is outside the abdominal cavity, for in every case it seemed to reduce the congestion and in some cases the distension. The cleansing process required from 10 to 20 minutes according to the amount of exudate and foreign matter present.

Of these 12 dogs one was operated on at 5 hours after the perforation was produced, one at 5J hours, one at 5J hours, one at 6 hours, two at 6J hours, three at 6J hours, one at Gi hours, one at 7 hours, and one at 7} hours.

In every case the dog showed marked symptoms of peritonitis and evidences of pain. When lying down the legs were drawn toward the abdomen, which was held very tense. Any attemjjt to straighten out the legs seemed to cause great pain. In some cases the dog vomited a somewhat bile-stained fluid. In every case the abdominal cavity at the time of the second operation contained from 100 to 250 cc. of a turbid bloody fluid. The intestine, mesentery and omentum in nine of these cases presented a generalized hemorrhagic condition. In the remaining three cases this condition seemed more confined to the coils of intestine in the region of the ctecum, though all the peritoneal surfaces seemed more injected than normally. In nine of the cases more or less numerous flakes of yellowish red lymjih were found adherent to the gut, mesentery, greater and lesser omentum and other abdominal viscera. In eight of the cases the intestines seemed more or less distended when replaced in the abdominal cavity. Immediately after the cleansing of the surface of the intestine and the abdominal cavity the animals seemed to be much more comfortable, and in the Ciise of every dog which recovered there was a jirogressive improvement in the condition.

In no instance did a dog which recovered show signs of


JvhY, 1897.]

145


pain after the cleansing operation was performed, and usually in from two to three days the dog seemed to have recovered completely from the peritonitis, so far as external symptoms would indicate. Of course the abdominal wound made at the second operation was infected, and this in nearly every case failed to heal by first intention, which delayed somewhat the complete recovery of the animal. Of the 12 dogs thus treated three died without any apparent beneficial effect of the operation, death ensuing within 20 hours from the time the perforation was produced. These three dogs were operated upon 64, 7 and 7} hours respectively after the perforation was produced. A fourth dog operated upon GJ hours after the perforation died 30 hours later; the operation apparently prolonged its life about 20 hours. In three of these cases the peritonitis was the most severe we met with in our experimentation, and the dogs in a weak condition at the time of operation, which was done comparatively late in the disease. In each of these four cases the intense hemorrhagic peritonitis described under the second group of experiments was found at autopsy.

The remaining eight dogs were apparently cured of the peritonitis. Of these eight, one died from the protrusion of the intestine, due to the breaking down of the abdominal wound on the fifth day after the operation. In a second case death resulted on the eighth day from a localized peritonitis due to the extension of the suppurative process from the abdominal wall. A third dog which appeared quite well 2i days after the operation died rather suddenly on the fourth day from a perforation in another portion of the intestine which had come into contact with the caustic potash upon the end of the perforated ca3cnm at the time the first perforation was produced. A fourth dog appeared quite well at the end of twelve days after the operation, having an excellent appetite and seeming very lively. On the 13th day the dog seemed sick, and gradually grew worse till its death, on the 17th day after the perforation was produced. At autopsy small abscesses were found extending along each stitch in the abdominal wall down to the inner surface of the wound, where the intestines and omentum were adherent. No distinct sinus leading into the abdominal cavity could be demonstrated. The abdominal cavity contained about 100 cc. of yellow pus, collected for the most part in the pelvis and also extending up toward the diaphragm. The coils of intestine and omentum were firmly adherent in a mass in the upper part of the abdominal cavity. The intestine was also adherent to the liver and gall bladder. The parietal and visceral peritoneum were intensely hemorrhagic in places. No apparent walling off of the pus existed. An extension of the suppurative process along the stitches was supposed to have been the source of the infectious material. A fifth dog also apparently made a complete recovery, both wounds healing with the exception of a small sinus in one of them. This dog seemed quite well for nearly three weeks, when it became ill and died three weeks and two days from the time it was operated upon. At autopsy the abdominal cavity presented a perfectly normal appearance, with the exception of numerous adhesions of coils of the intestine to each other, to the omentum, liver and parietal peritoneum. These adhesions were not very firm in character. The


sinus mentioned above was found to lead to an abscess cavity about the size of a hen's egg, situated in the pelvis to the right of the uterus. This abscess was completely shuf off from the rest of the abdominal cavity and was the undoubted cause of death.

All of these dogs which died as a result of the suppurative process following the operation would probably have recovered could they have been subjected to the same treatment human beings would receive in a similar condition, for it must be remembered that it is practically impossible to drain or treat suppurating wounds in dogs. A sixth dog, apparently in the best of health and condition, was killed and autopsied four weeks after operation. Both wounds had healed with the exception of a small sinus leading to a stitch abscess, which, however, did not penetrate the abdominal wall. On examining the abdominal cavity the only abnormalities noted were seven or eight slight, loose adhesions between coils of the intestine, three or four loose adhesions of the omentum to the intestine, and some rather firm adhesions of intestine to the inner surface of the abdominal wound over an area 3x6 cm. The condition of the viscera seemed everywhere normal. All of the adhesions, except perhaps those uniting the intestine to the inner surface of the abdominal wound, were of such a slender character that they would in all probability have disappeared entirely in a few months. The remaining two animals are apparently perfectly well, one of them being a bitch which was in a moderately advanced state of pregnancy when operated upon. Cultures and cover-slips were made from the exudate in each case of peritonitis. The bacteriology was carefully worked out and will be referred to later. From this group of experiments we conclude that up to 6 hours after perforation the generalized peritonitis in dogs can be cured by this operation in practically every case. The prognosis of operation upon these animals at 6i hours after perforation is exceedingly favorable, but from that time on rapidly becomes less favorable.

For the fourth group of experiments six dogs were used. The method of procedure in this group was to perforate the cfficum in the usual manner. From 6 to 6i hours later the abdominal cavity was again opened, the cfficum brought out and the perforation closed in the way before described. After the replacement of the ca3cuni the abdominal cavity was closed without in any way attempting to cleanse it. At the second operation four of these dogs presented a generalized peritonitis with the characteristics before described, though in no case did the condition seem as bad as in the cases of two dogs in Group 3 cured by the cleansing of the surface of the intestine and the abdominal cavity. Of these four dogs one died about 20 hours after the perforation was produced. The other three failed to rally after the second operation, as the dogs in Group 3 did, and appeared ill till their death two to three and one-half days from the time the intestine was perforated. Autopsy upon two of these animals showed an intense hemorrhagic peritonitis, while in the case of the third the intestine and omentum were closely adherent in a mass, which when pulled apart disclosed numerous pockets of pus, presenting the condition of multiple abscess formation. The remaining two dogs of this series presented only a localized


146

[No. 76.


peritonitis. Tliere was not more than half as much of the turbid bloody fluid in the abdominal cavity as found in the other four cases, and only those coils of intestine in the vicinity of the ca3cum presented a hemorrhagic appearance. These were the most favorable cases we met with in all our experimentation. These two dogs are still alive, though their recovery has been slow.

In connection with the last two cases it is interesting to note that in two of the cases of Group 3 some exudate had collected in the abdominal cavity between the time the intestine was replaced and the abdominal wound closed, thus making it evident that the abdominal cavity possessed the power of caring for a considerable amount of the exudate. The bacteriology of this group of experiments was also carefully worked out and will be referred to along with the reports of the other cases of peritonitis.

This group of experiments seems to demonstrate that the mere closure of the perforation, though it may in some cases prolong life slightly, is not sufficient to cure a case of generalized peritonitis in dogs, and makes it very evident that without a careful cleansing of the surface of the intestines and the abdominal cavity recovery in such cases will be exceedingly rare. It must be borne in mind that the length of time which had elapsed since the perforation was produced and the condition of the abdomiual cavity would have afforded a most favorable prognosis in these cases had the cleansing operation been performed.

Cultures were made from the 4 cases of Group 2, 13 cases of Group 3, and 6 cases of Group 4. In one case of Group 3 the cultures failed to grow, although cover-slips


showed a few cocci and bacilli. Also in one case of Group 4, in which the peritonitis was not yet generalized, the cultures were negative. In the twenty cases in which bacteria developed in the cultures, from one to three species of microorganisms were found in each case. Members of the colon group were found 18 times, 4 times alone and 14 times in association. Streptococcus pyogenes was found 8 times, once alone and 7 times in association. Staphylococcus albus was found 5 times, in each case in association. Staphylococcus aureus was found 4 times, once alone and 3 times in association, and staphylococcus citreus was found 4 times, in each case in association. Cultures were also made from the heart blood at several of the autopsies, but in each case were sterile. Coverslips from the exudate in the abdominal cavity were examined in each case and more or less numerous bacteria were seen. An abundance of leucocytes was found in nearly every coverslip. The bacteria in general were outside the cells.

From our experimental work we feel justified in stating the following conclusions :

1. That mere mechanical irritation of the peritoneal surfaces will lead to the formation of adhesions.

3. That peritonitis in dogs caused by a perforation of the intestine is of an intensely hemorrhagic character, and if left to itself rapidly proves fatal.

3. That generalized peritonitis of this character, in dogs, can be cured as late as 6* hours after the perforation, by the cleansing operation introduced by Dr. Finney.

4. That mere closure of the perforation without this cleansing operation will rarely, if ever, cure a case of generalized peritonitis in dogs.


SQUAMOUS EPITHELIOMA AND EPITHELIAL HYPERPLASIA IN SINUSES AND BONE

FOLLOWING OSTEOMYELITIS.


By S. M. Cone, M. D., Assisfcmt in Surgical Pathology, The Johns Hopkins University.


In view of the interest manifested in the pathology of bone, the two cases about to be reported seem to be of value. They are striking examples of malignant and benign epithelial growth into old sinuses and medulla of bone.

Case I. — John H., colored, set. 45, laborer, was admitted to Dr. Halsted's wards, January 2, 1897.

Patient gives a history of injury to bis left tibia 19 years ago, with subsequent formation of a sinus and discharge of sequestra. One month before entering the hospital the patient began to feel pain in the leg, and the odor of the discharge became foul. No sequestra have come away for eight months. There is pulsation of discharging material synchronous with the radial pulse.

Upon Jan. 4, Dr. Bloodgood excised the sinus aud chiseled and curetted the bone. The bone was fractured 10 cm. below the knee, where the cavity was largest. The operator's note estimates the cavity communicating with the sinus as 3 cm. deep, 2 to 3 cm. wide, aud 14 cm. long. The diagnosis, squamous epithelioma, being confirmed, and the growth


recurring withiu two weeks, the leg was amputated above the knee, and glands of the groin excised by Dr. Finney on Jan. 29th. On Feb. 25th patient was discharged, the wounds having healed per primam.

Pathological rejmrt of the first operation. — Tiie specimen consists of the skin, sinus, eburnated bone, and soft material filling the cavity in the bone. The edges of the sinus are dense and pearly in appearance. The skin within i cni. of the sinus edge has lost its dark pigmentation. The bone next to the soft central mass is soft and crumbly, but outside of this is eburnated. It appears directly continuous with the skin at the orifice of the sinus. The sinus is lined by the same papillary growth that fills the cavity in the bone, and this same growth projects between the periosteum and eburnated bone, indenting it, causiug a jagged appearance. The medullary cavity is filled with a soft, necrotic-looking material, made up of soft yellowish white masses, aud with white papillary granular projections from a rather dense translucent pink ground substance looking like granulation tissue. The papil


July, 1897.]

147


lary projectious average 2 mm. diameter, aud are of varying length up to 4 mm. The growth within the cavity erodes the bone, leaving small spicules and granules in the soft necrotic mass. In places the dense bone has become granular and crumbles readily. There is no sequestrum nor cancellous bone. The periosteum is very much thickened aud not to be well differentiated from the subcutaneous tissue; it is invaded by the epithelial growth. The microscopical description of the original sections is the same as of the recurrent growth, so they will be included together.

The leg and lower third of the thigh removed at the second operation present no abnormal appearance outside of the gajiing granulating wound in the tibia, the seat of an osteotomy performed January ith. The wound, measuring 16s 4x4 cm., is surrounded by edges of skin inverted over the bone, which for the most part is covered by apparently healthy granulations. Only at one place is the bone exposed ; this is at the upper angle of the wound, where an edge of eburnated bone is left uncovered. At the outer rim of the excavated tibia, 4 cm. from the upper angle of the wound, is a projecting mass of papillary excrescences 4 cm. in diameter, whose surface is covered by a dry blood-stained crust. Scraping the up[)er layer away leaves the deeper papillae, pearly in appearance, closely aggregated and more or less intimately connected with the velvety granulations about them. Some of these epithelial uests are so closely packed without any apparent stroma that at first glance they give the appearance, on section, of a cheesy mass. Careful observation shows this to be made up of individual uests. This mass is at the seat of fracture alluded to. Similar uests of cells are seen iu smaller discrete masses over the whole surface in the granulations.

One area on the inner wall of the excavated tibia, 5 cm. from the uf)per angle of the wound and 2 cm. from the fracture, can be made out as a mass sharply defined from the surrounding granulations. The bone here seems excavated to fit the growth which is eroding it. Spicules of bone project into the growth between the epithelial plugs at the jjeriphery. Between the ends of the fracture the new growth projects, invading muscle and adjacent tissues. The ends of the bone are rough, and the papillary masses are seen indenting the ivory-like bone to a depth of 1 to 3 mm., giving it a wormeaten appearance ou removing the growth. The granulations, 2 to 4 mm. thick, covering the surface of the bone also groove it and cause a rough and gnawed appearance.

The bone sawn through at several places is dense aud eburnated aud shows no evidence of tumor formation which is not directly connected with the surface growth. The heads of femur, tibia aud fibula aud the astragalus are normal. The tibia and fibula are anchylosed by bony union at the interosseous ligament. No tumor can be traced from the bone along the vessels. The muscles and soft parts, except at the seat of fracture and ulcer edge, appear normal. The cartilage of the patella is softened, that over the outer head of the femur is depressed and soft. The synovial membrane is hemorrhagic where it envelops the crucial ligaments at their insertion into the head of the tibia.

The popliteal aud inguinal glands are firm, eularged and harder than normal, but do not show any areas of metastasis.


Microscopical Description.

Tumor iiivading musde at the seat of fracture. The tumor mass is sharply circumscribed. At that part nearest the invaded tissue the tumor is made up of single cells and small masses of cells in a fine reticulum; this passes, further away, into small non-cornified, non-cystic masses of cells, theu larger alveoli with cornified epithelium in the centre of the stratum mucosum layers. Furthest away from the muscle and nearest the periphery of the tumor mass are seen cystic dilatations with anastomosing alveoli lined by a few layers of columnar cells and containing scales of cornified epithelium aud fatty detritus. The invaded fibrous tissue shows no change. The muscle fibres are granular and fragmented ; the fragments and individual fibres contain many nuclei, giving the appearance of elongated giant cells. The vessel walls show round cell infiltration. There are newly formed capillaries among the degenerating fibres. There is evidence of endothelial proliferation in the capillaries.

Tumor mass and ski7i, the mass projecting betiveen the fractured ends of the tiiia. Where skiu and tumor pass over into one another the regular papills of the skin cease, as does the deep pigmentation. The pigment is no longer seen between the stratum mucosum cells as in the skin, aud is much less developed in the stratum granulosum and deepest columnar epithelium of the Malpighean layer.

It looks as if the stratum mucosum aud granulosum were continuous with like layers of cells lining the stroma of the tumor, keeping on over the tortuous papillary bulgings and corresponding depressions of the tumor mass. Similarly can the stratum corneum be followed, but it changes its appearance over the tumor, becoming less compact and scattered in flakes on the surface, or loosely filling cystic cavities along with cellular detritus, or it may be lacking on some of the plugs.

In the cornified layers over the tumor are masses of brown granular pigment containing crystals of hsematoidin. The tumor growth is divided by deep grooves caused by keratinizing and fatty degeneration of epithelial down-growths. This causes the follicular appearance described macroscopically.

Papillse, or stroma strands, better named, push the epithelium up into bulging papillary masses. These stroma strands vary in size, as do the corresponding cyliuders and plugs of epithelium lining them. The plugs aud cylinders anastomose freely at the surface. One cyst thus caused measures 1 X ^ cm. aud is made up of numerous small plugs containing keratinized epithelium and detritus around the margin. The contents must have fallen out in great part. The surface is covered with epithelial cells, polymorpho-nuclear leucocytes, and keratinized epithelium iu a mass of coagulation necrosis.

The stroma varies in different parts, from edematous young granulation tissue with stellate, epithelioid aud giant cells at the surface under the coagulation necrosis, to a very cellular fibrous tissue, with numerous capillaries aud spindle-shaped long nuclei deeper down. In places the stroma is homogeneous aud stains pink with eosin, like hyaline. There are areas of round cell infiltration in the stronui. The included plugs


148

[No. 76.


and cylinders of epiLhelinm comprise all the epidermis layers arranged in the same order as in the skin — a cylindrical or cuboidal layer next to the stroma, then polyhedral cells of the stratuna mucosum showing prickles most distinctly with Van Gieseu's stain, then two or three layers of spindle cells with pigment which takes the hEematoxyliu stain — the stratum granulosum. The outermost layer lining or filling the Ciivity of the plugs or cylinders is of loose keratinized epithelium, sometimes arranged compactly,

Where the centres are cystic we find besides the keratinized epithelial flakes, fat cells, cells which have undergone fatty degeneration, leucocytes and salts, granular and deeply stained with bajmatosylin. Cell multiplication is very active, as evidenced by the many divided and dividing nuclei ; 2 to 5 nuclei are contained in some cells, connected as if budding.

Tnto the basal layer of these cylinders there may be ingrowths of papilla?, explaining an unusual appearance, namely, a mass of fibres and connective tissue cells cut across in the centre of one of the above described plugs of epithelial cells. In the deepest part of the invading tumor the cylinders become very small, even narrowed to single cells separated by the same cellular stroma. Anastomosis is very free, many branches spreading throughout a loose stroma. The arteries included in the section show marked endarteritis and round cell infiltration of the adventitia also.

In staining the sections the Van Giesen method was found valuable in staining the stroma and the prickle cells. The keratinized cells stain yellow, the young stroma stains dull red. Gram's stain used for keratohyalin by Ernst' shows it well, staining these cells deep blue.

Sections of the pink granulations over the surface of the bone show granulation tissue without evidence of tumor.

The lymph glands of the popliteal space and groin show fatty atrophy and connective tissue formation, thickened capsules and endothelial hyperplasia. There are no metastases.

The popliteal artery and vein with surrounding tissue show no evidence of tumor growth about them. They are united by dense fibrous tissue. There is evidence of endarteritis.

The synovial membrane described as hemorrhagic shows round cell infiltration and vessels filled with blood, which also suffuses the surrounding tissue.

The bone cut across near the knee shows no microscopic evidence of carcinoma; it appears normal.

Section of fragments of hone with tumor and granulations mixed in an irregular friable mass. The tumor alveoli and stroma are as described above. Adjoining whorls are seen to become conglomerate, mixing together their contents of keratinized epithelium and fatty necrotic substances and bounding this by their several epidermis layers. Secondary papilla; project into the primary alveoli, giving a complicated appearance on section. In the proximity of the bone the cellular stroma is strewn with giant cells with centrally massed large oval vesicular nuclei containing big nucleoli. These are osteoclasts, for wherever the bone is seen undergoing absorption it is lacunar in nature and the Howship's lacunae contain osteoclasts to fit them. The tumor cells do not come in direct contact with the bone, being separated by stroma and osteoclasts.


The bone is very dense, with narrow compact lamella; containing few corpuscles, and these are small and far apart. The Haversian canals are filled with cellular connective tissue, vessels, old bone fragments looking as if shelled off, and osteoclasts in lacunaj. Branching canaliculi are distinctly seen. There is new formation of bone going on. The new lamellse are arranged at an angle to the old ones, they take the eosin stain deejier and are lined by osteoblasts, cuboidal and spindle-shaped. There is a granular line stained with hsematoxylin between old and new bone.

Section of hone zvith invading tumor at the seat of fracture. The lamellae are narrow and closely packed and enclose bone corpuscles at rather wide intervals. Some of the corpuscles nearest the invading tumor are enlarged and the cells are deeply stained. The Haversian canals are irregular in contour, of various sizes, and filled with granular detritus and fragments of bone. About their rim there is lacunar absorption, the grooves being small. The bone, where invaded, is being absorbed by the osteoclasts, for in every Howship"s lacuna can be seen a giant cell such as Kolliker' describes, or large osteoblasts which here take on the function of osteoclasts and are such.

These osteoclasts vary in size and shape, each fitting exactly a groove in the bone hollowed out to fit the absorbing agent. Some of the cells are seen completely surrounded by bone, others have only one-third of their body enclosed by the lacuna. The shape varies from oval, round, oblong, large cells to elongated flat cells lining quite a large part of the bone surface, looking almost as if one of the outer lamellae had broken off abruptly and taken in many large nuclei. The size varies from an osteoblast to cells five or six times as big.

The nuclei are either massed in the centre or arranged around the perijihery ; they are large, round or oval, and vesicular. The protoplasm of these osteoclasts is granular and stains deeply with eosin, especially at the centre. The edge of the cell next the bone is rough ; the other borders of some cells seem of double contour and quite smooth.

No foreign bodies were detected in any of these bodies next the bone, yet some of the giant cells near by included epithelial debris.

The protoplasm of some osteoclasts is drawn out like a pseudopod and pushes in between the connective tissue cells. Where granulations seem to fill the lacuna? one finds osteoclasts between them and the bone wall.

There is evidence of new bone formation. To the characteristics of newly deposited bone already mentioned can be added the closer approxinuitiou of bone cells — there being more of them than in the older adjacent bone. The medullary spaces between the cancel li of bone are filled with newly formed fibrous tissue and granulation tissue containing giant cells and all the cells usually found in embryonal tissue. There are also numerous capilhmes and larger vessels in the spaces. The bone cells vary in size and appearance, as do the bone corpuscles, some being round and spindle-shaped, others stellate. They can be best studied in the newly deposited bone or in bone undergoing absorption. It would seem as if when about to be freed from their imprisonment they take ou active functions again and are stained more readily.


July, 1897.]

149


As in other sections of bone, no tumor cells come in direct contact with the bone. The tumor advances as described above. There are small fragments of bone in the granulations, which look as if they had been eaten off and left. There is a deposit of new bone in the vicinity of the tumor and evidence of absorption going on in the same microscopic field.

Case II.— W. J. R., white, a3t. 5i, admitted June 26, '95.

For 49 years the patient has had discharging sinuses in the thigh communicating with necrotic bone.

Operation, June 28th, by Dr. Bloodgood. Amputation of thigh at the upper third. Notes made at the operation refer to the great friability of the bone, the thickened periosteum, thin shaft and presence of a sequestrum.

Nov. '96. Patient reports himself well.

The pathological report is as follows : The diseased condition of the bone begins 26 cm. above the condyles and involves the shaft for 16 cm. The last jjiece of bone removed, 3 cm. below the trochanter, appetu'S healthy. The periosteum is thickened, the shaft, stripped of periosteum, is rough and presents minute spicules. The shaft varies in thickness from 3 to 6 mm., and there is very little cancellous bone. It is brittle, fracturing easily. The medulla above seat of disease contains much fat and oily material. At the seat of disease there is no involucrum. In the sinus leading from the diseased bone there is a sequestrum 6 cm. long and li cm. wide. The periosteum about the necrotic portion is 5 to 6 mm. thick, and on section is peai'ly white and appears striated at right angles to the long axis of the bone. On the surface nest to the shaft it is covered with a yellow necrotic friable tissue covering a leathery surface. Fine spicules of bone are imbedded in this. The odor is foul. The surface of the shaft is rough and hard. The medullary cavity is filled with hard bone mixed with thick leathery tissue, and is riddled with small cavities containing the same material as covers the shaft. The only attemjit at new bone formation is in the medullary cavity. No attempt at formation of healthy granulations is evident. About the area of disease the shaft exhibits exostoses 1 to 1^ cm. in length. The knee joint is normal in appearance.

Microscojiical examination of the tissue between the periosteum and bone described as striated and friable with necrotic border next to the shaft, shows it to be made up in the main of large swollen polygonal cells with oval vesicular nuclei. The arrangement is such as one sees in the stratum mucosum of the skin. There are papillas jirojecting into the mass from the periosteum, which is thickened and infiltrated with small round cells. The cells next the papilla} are prickle cells; those nearer the shaft do not show the prickles. The cells arc massed in varying density. According to the location of the papilla} we get lighter and darker stained masses, the darker being more comjiact and approaching the cancroid pearl in appearance, but there is no cornified nor degenerated centre. Toward the bone the cells are flat and the nuclei lose the ability to stain. A thin layer of cornification covers their surface. Many of the nuclei are vacuolated. The papilla are very cellular. There is an absence of the stratum granulosum and lucidum ; simply a uniform growth of the mucosum


and corneum. There is considerable endo- and periarteritis. The muscle and connective tissue show no tumor invasion. The leathery material described in the medulla is like that just described.

Examination of the cortical bone from the shaft shows no tumor growth into it. The dense bone presents a feathery appearance commonly seen in eburnated bone. The edges show lacunar absorption.

A number of cases of squamous epithelioma developing in sinuses antl old scars which would come under the grouping I have purj)osely omitted, since the pathological description of the tumor is in every case essentially the same as in Case I. Two of the cases might be considered carcinoma developing in osteomyelitic sinuses, but the history does not fully substantiate this. In these cases the sinuses were lined by the tubules and plugs of epithelial cells continuous with the tumor mass in the bone itself. The invasion of the bone resembled that described in Case I.

The cases reported bring to mind several most interesting subjects in pathological histology: the development of carcinoma in sinuses, scars and ulcers, its invasion of bone, the peculiar character of epithelial growth, and the bone formation and absorption due to the invading tumor. They are interesting especially because they show side by side the picture of a typical squamous epithelioma and a mere enormous hyperplasia of the epithelial elements of the stratum mucosum in bone. The one is evidently quite malignant; the other does not appear to be very destructive in its growth, but merely a filling in of the space made void by the osteomyelitic process. The two tumors have their homologues in the epithelial growths in sinuses, ulcers and scars, some being typical epitheliomata, others simply hyperplastic growths of epithelium lining the sinus walls.

There is this point to be noted in Case II differing from any yet described — the great development of the cells of the stratum mucosum to the exclusion of the granulosnm and lucidum. There is simply a single layer of cuboidal cells covering the papilte, then 10 to 15 layers of large swollen polygonal cells covered by a thin layer of cornified epithelium. This not only fills the sinus and medullary cavity, but pushes in between the periosteum and the shaft, nowhere penetrating the bone itself. It may be compared in a way with a case of great epithelial cell hyperplasia of the outermost layers of the epidermis described by Busch'" in a case of lupus. Here there was an epithelial papillary growth covered by thickened, horny epithelium spread over the surface, finally breaking into the connective tissue and forming carcinoma.

Typical squamous epitheliomata in scars, ulcers and sinuses are not uncommon. There are only twenty-eight cases reported in which the epithelioma developed in the sinus following osteomyelitis. From the histories of many cases of epithelioma in ulcers I infer that a few if more accurately described would come under the heading of carcinoma in sinuses following osteomyelitis. Some give a history of osteomyelitis. See Van Hook,' Schindler,' Boegchold." Borchers' iu 1891 collected all the cases up to his time, numbering twenty-five. He records cases of Konig, Dittrich,'" Nicoladoni," Esmarch, Fischer," Bartens, Coruil and Kanvier,'


150

[No. 76.


Winiwarter," Hauuover"^ and Volkmauu." Another case is recorded by Feigel.' One of Van Hook's' two cases was undoubtedly carcinoma developed in an old fistula communicating with necrotic bone. Von Friedlander's" three cases, reported in 1894:, are the last recorded. All of the cases described have many points in common with our first case.

Clinically, the development of the disease in those beyond 40 years of age, the common involvement of the lower extremities, the uncertainty of fixing the exact time of development, its slow growth, the foul odor, the long existence of the fistulaj, the absence of pain until the carcinoma begins to develop, the ease with which the bone is broken, the fixation of the neighboring joints and ankylosis of adjoining bones, the infrequent involvement of lymphatic glands or other organs, and its almost sure recurrence unless the limb be amputated, are all most noteworthy points.

Volkmann" says that recurrence occurs in a few weeks or months after the operation, if at all; if not Avithin 1 to Ih years, it seldom occurs.

The pathological picture is not to be confused with any known disease of bone or sinus. The crater-like ulcer or cauliflower excrescences made up of individual oval yellowish white masses, are enough to make the diagnosis. Finding the same papillary growths in the medullary cavity is not calculated to make one think of simple osteomyelitis. The bone next the tumor is either soft and spongy or denser than normal bone. It is increased in circumference and the medullary canal may be smaller than normal. Osteophytes may form on the surface and the bone may rarely present the appearance of spina ventosa. Fracture is common.

The microscopical picture is that of squamous epithelioma modified in appearance according to the amount of degeneration and bone absorption and the greater or less development of tubules, alveoli or cysts. The tumor cells nowhere come in direct contact with the bone, being separated by connective tissue and giant cells or osteoblasts. The thickness of the growth varies, but it is thickest in the cloaca, and in places looking like granulation tissue. The sequestra in Nicoladoni's" cases were not invaded by epithelial cells.

Borchers' refers to the advance of the tumor into the Haversian canals. Our cases do not substantiate this, the epithelial cells never being found separate from the main growth.

In none of the cases were metastases found in the internal organs and rarely even in the lymph glands. The swollen glands usually became of normal size after amputation of the limb. The reason of the infrequent metastases is found in the sclerosis and condensation of tissues about the tumor and its very slow growth.

Thinking of the etiology and histogenesis of the tumors, one would naturally class those described with tumors developing in ulcers, fistulas and old scars. Many theories have been advanced to explain them: Virchow's" idea of chronic irritation, mechanical and chemical, being most naturally first alluded to. The question whether the connective tissue growth or epithelial proliferation be the primary factor has been most actively debated since Ribbert" so strongly advocated the former view. Boegehold,* who reported several


cases like my first one, believes in their connective tissue origin, and says that the epithelium is lost over scars and ulcers. He says : " If the surface epithelium cannot cover over the granulation surface, one cannot see why it shall grow into the depths of the granulation tissue."

Langeubeck," in discussing the development of carcinoma in lupus, expresses the view that the cause of development is like that in traumatic scars, a continuoiis irritation and the carcinoma develops from remaining epithelial cells. It is distinct from the lupus growth. "It is difficult to reconcile the notion of lupus — a granulation tissue — passing directly into carcinoma, because of our view that epithelioma must come from pre-existing epithelial cells."

AVenk,"' who believes in this direct transition, concedes that the epidermis projections have not been entirely destroyed. Langenbeck"" attributes its formation to development of epithelium in the outlying scar. Schindler cites cases to prove the development from the scars — either from the covering epithelium or glandular organs of the skin left intact by the lupus process. He answers Boegehold's* argument cited above, by explaining that the surface epithelium is prevented from spreading superficially by continual irritation (pressure or secretion) and therefore it dips down deeply where not exposed to these influences. Hulke,'"' in describing two cases of carcinoma in old scars, ascribes them to purely local causes. Pedraglia^^ refers to old age and periodic irritation as predisposing causes. This view that old age influences the growth corresponds with that of Verneuil referred to by Marcuse:" "Ein locus minoris resistentiae" of the connective tissues, the epithelium retaining and increasing its activity. Marcuse uses this theory in explaining the growths in the granulations covering ulcers — the granulation tissue, when not going on to scar formation, being not so resistant to epithelial hyperplasia as normal tissues. Here the epithelium grows into the tissues as stated by Thiersch'"' in his most valuable contribution to the etiology of epithelioma of the skin.

It is not much disputed now that epithelium only forms from preformed epithelium and not from leucocytes or connective tissue cells. This materially aids the histogenetic study of these tumors. Whatever the cause, the practical lessons obtained from them are of much value to the surgeon, and one is not tempted to use tentative measures to stop a growth which he knows by experience and microscopical study to go steadily onward in its course until it is excised radically.

1. Van Hook, W. : Carcinomas arising in Inveterate Ulcers and in Ancient Sinuses. North Amer. Practit., Sept., 1890.

2. Schindler, J. : Beitrag zur Eutwicklung maligner Tunioren aus Narben. Inaugural Diss., Strassburg, 1885.

3. Borchers, F. : Ueber das Carciuom welches sich in alten Fistelgiingen der Haut entwickelt. Inaug. Diss., Giittiugeu, 1891.

4. Boegehold : Ueber die Eutstehung maligner Tumoreu aus Narben. Virchow's Arch., No. 88, p. 229.

5. Feigel, L.: Ein Fall von primiirem Ki-ebs der Tibia. I'rzeglad lekarski, Nos. 3G and 37, 1891.


July, 1897.]

151


6. Cornil andKauvier: Journal de rAiiatoiiiie, 1SGIJ-G7, p. 277.

7. Erust, P. : Sfcudien iiber normale Verhornniig mit Hilfe der Gramscher Methode. Arch. f. mik. Aiiat. und Eutwickluugsgeschichte, Bd. 47, p. 669, 1896.

8. KoUiker: Die normale Kesorptiou des Kuocheiigewebes. Leipzig, 1873.

9. Ribbert: Miinchuer Med. Wocheusch., 1894, No. 17; Vircbow's Arcb., Bd. 135.

10. Dittrich : Prager Vierteljahresschrift, 1847, II.

11. Nicoladoni: Arch. f. klin. Cbir., No. 26, 1881.

12. Esmarcb: Langeubeck's Arch., XXII.

13. Fischer, S.: Zeitschr. f. Chir., 1881.

14. Winiwarter: Beitriige ziir Statistik des Carcinoms. Stuttgart, 1878.

15. Volkmann, Rud. : ITeber das primilre Krebs der Extremitiiteu. Volkmann's Sammlung klin. Vortrage, 1889.

16. Hauuover : Das Epitheliom. Leipsic, 1855-56.


17. V. Friedlander: Beitrag zur Kenntnissder Carcinomentwickelung in Sequesterhohlen und Fisteln. Deutsche Zeitschr. f. Chir., 1894.

18. Busch: Langenbeck's Archiv, XV, p. 48.

19. Virchow : Die krankhafteu Gescbwiilste, Bd. II, p. 487.

20. Langenbeck: Berlin, klin. Wochenschr., 1879, p. 329.

21. Wenk, L. H. : De exemplis nonnullis carciuomatia epithelialis exorti in cicatrice post lupnm exedentem relicto. Kiel, 1867. Reference from Schindler, see above.

22. Hulke, J. W.: London Medical Times, Vol. 1, 1873, p. 135.

23. Pedraglia: Vier Fiille von Epithelialkrebs anf alten Narben. Giessen, 1853.

24. Marcuse, J.: Deutsche Zeitschr. f. Chirurgie, Bd. VII, p. 550.

25. Thiersch: Der Epithelialkrebs, uamentlich der Haut. Leipzig, 1865.


ON THE BLOOD-PRESSURE-RAISING CONSTITUENT OF THE SUPRARENAL CAPSULE.*

By John J. Abel, M. D., and Albert C. Crawford, M. D.

[From the Pharmacological Laboratory of the Johns Hopkins University .'[


Both clinical experience and laboratory research have shown that the suprarenal capsule is an organ of vital importance.

Physiologistst have proved that a very small quantity of an aqueous extract of the medullary substance raises the blood pressure to a great height above the normal. It has also uuequaled power in reviving a poisoned heart. Gottlieb,J for example, has shown that it will revive the heart of a rabbit which has practically stopped beating in consequence of an intravenous injection of chloral hydrate.

Bates§ applied an aqueous solution to the eye and found that it exerted a marked vaso-constricting action. In numerous cases of congestion a small quantity dropped into the conjunctival sac brought about an immediate pallor, lasting for some time. According to this writer the extract is very useful in prolonged operations, for, when repeatedly applied, hajniorrhage is prevented and cocaine anfesthesia is in consequence indefinitely prolonged. As the result of his two years' use of the extract Bates concludes " that within the limits of its sphere of activity there is absolutely no other substance which can take its place."

Other experiments|| go to show that the aqueous extract is


•Read before the Association of American Physicians, May 6, 1897.

tSehiifer and Oliver, Journal of Physiology, xvi (1894) and xvii (1895); Szymonowicz and Cybulski, Wien. med. WochenBchrift, 18'JG, No. 6.

JArch. f. exp. Pathol, u. Pharmakol., xxxviii, 106.

§New York Medical Journal, Ixiii (189G), iiil .

||Foa and Pellacani, cited in Maly's Jahresb. d. Thier-Chemie, xiii, 129; M.arino-Zuco, ibid., xviii, 231 ; Gourfein, Rev. Med. de la Suisse Romande, Oct. 20, 1895; Compt. rend., cxxi (1895), 311314.


a powerful poison when injected directly into the circulation and may lead to fatal results.

The various extracts that have been used in these experiments were mixtures of unknown substances, and it is as yet an unsolved question whether the various actions at present ascribed to the gland are due to one and the same substance.

We are at present interested in the isolation of the bloodpressure-raising constituent, for in a purified state, separated from all other constituents, it might become a therapeutic agent of great importance.

On the chemical side but little advance has been made over Vulpian's* striking original contribution more than forty years ago. Vulpian observed that the juice expressed from the suprarenal capsule of many different animals behaved in a striking manner toward ferric chloride and toward solutions of iodine, giving with the former reagent an emerald green color, and with the latter a beautiful rose carmine tint. No other tissue of the body, so far as investigated by Vulpian, gave these reactions.

Virchowt substantiated Vulpian's statements, but added nothing new. A year after Vulpian's first announcement his second paper appeared in conjunction with Cloez,J verifying and extending his first observations and stating his failure to isolate the chromogenic substance or substances to which the above reactions are due.

Equally unsuccessful were Arnold§ and Ilolm.ji Kruken


  • Note sur quelqiies reactions propres i la substance des capsules

surrenales, Compt. rend., xliii (1856), 063-665. ■)■ Virchow'a Archiv, xii (1857), 481-483. X Compt. rend., xlv (1857), 340-343. § Virchow's Archiv, xxxv (1866), 64-107. II Journ. f. prakt. ('hemie, c (1867), 150.


152

[No. 7ri.


berg,* years after, repeated the work of Arnold and came to the conclusion that the chromogeu of the suprarenal capsule is a nou-volatile, nitrogenous and ferruginous organic acid which is probably related to the tnracin of the musophagidai and to chlorophyll. He assumed that the substance giving the green color with ferric chloride is not the chromogenic substance of Vulpian, but more likely pyrocatechiu accompanying the chromogen. Attention being thus attracted to the possible occurrence of pyrocatechiu in the suprarenal capsule, others took up the subject.

Brunnerf found that an alcoholic extract cau be made to give nearly all of the reactions of pyrocatechiu ; thus, it gives the well-known green color with ferric chloride, passing into a fine red on the addition of ammonium tartrate and a few drops of an alkali; it reduces silver nitrate at room temperature, and Fehliug's solution on boiling. The addition of an alkali soon causes it to take on a dark brown color, lead acetate gives a precipitate, sodium nitroprusside and very dilute ammonia give a wine-red color. All of the above reactions being given also by pyrocatechiu, Brunuer concluded that Krukenberg was right in his belief that pyrocatechiu is present in the suprarenal gland.

After the discovery of the blood-pressure-raisiug property of the suprarenal gland, B. Moore,J working in Schilfer's laboratory, came to the conclusion that Vulpiau's chromogen and the blood-pressure-raising constituent are identical. He based his ojjinion on the fact that chemical operations which destroy the color reactions by oxidizing the reducing agent appear also to destroy the blood-pressure-raising constituent. That the solubilities of the active principle are the same as those of the reducing agent appears also to support this opinion.

Fraenkel§ worked with residues obtained with the help of alcohol and acetone as solvents. These residues raise the blood pressure and do not contain pyrocatechiu, and on the strength of the ferric chloride reaction and its reducing power he concludes that the essential principle of the residue is a nitrogenous derivative of the o?'</(odihydroxy-benzene series.

According to Fraeukel both Krukenberg and Brunuer are wrong in their opinion that the suprarenal glaud contains pyrocatechiu. Fraeukel concludes, like Moore, that the bloodpressure-raising constituent and Vulpiau's chromogen are one and the same substance.

More recently still, Muhlmann|| has attempted to prove that the blood-pressure-raisiug constituent is a pyrocatechiu derivative. He asserts that on boiling fresh suprarenal capsules with dilute hydrochloric acid the active principle is decomposed and the pyrocatechiu which is split off may be taken up with ether. Miihlmann has not, however, furnished conclusive chemical proofs for his assertion. Both Miihlmann and Brunner might have settled this point by precipitating the supposed pyrocatechiu with lead acetate and analyzing the lead salt thus obtained. Pyrocatechiu may be preseut in


  • Virchow's Archiv, ci (1885), 542-591.

fSchweizer. Wochensclir. f. Ph.armacie, xxx (1892), 121-123.

} Journal of Physiology, xvii (1895), Pron. Physiol. See, p. xiv.

'i Wiener med. Blatter, 1896, No. 14-16.

II Deutsche med. Wochenschr., 1896, No. 26, 409-411.


small amounts in the gland, but no proof of this has yet been furnished.

There is therefore at present great diversity of opinion as to the chemical character of the blood-pressure-raising constituent of the gland.

Whatever the probability may be of the correctness of this or that view, it is to be noted that all of the above-named investigators have based their conclusions on reactions made with aqueous, alcoholic or acetonic extracts ; none of them have even roughly isolated a definite chemical comjiound. The subject is one of great diflBculty, and our own work is at jjreseut merely preliminary, but we have arrived at the following conclusions which we believe to be borne out by our experiments.

First, we have found by isolating the blood-pressure-raising constituent in the form of a benzoyl compound and decomposing it, that the active principle is a substance with basic characteristics and that it must in all probability be classed with the pyrrol compounds or with the pyridine bases or alkaloids.

Second, that pyrocatechiu caunot be split off from the isolated active compound by boiling with acids, as has been asserted.

Third, we have found that a carmiue-red pigment can be separated from the sulphate of the active principle without destroying its jiower to raise the blood pressure.

Fourth, iu addition to this, we have isolated from the crude benzoyl product a volatile basic body which fumes iu the air and which emits an odor very much like that of coniiue.

Method of Isolating the Active Principle in the Form of a Benzoyl Compound.

We have used sheep's glands in large quantity. The medullary substance of the fresh glands was scraped out, dried on the water-bath at 60° 0., ground up finely, and extracted with ether for several days until the fats and the substance known as Manasse's jecorin were removed. In this way a fine dry powder of a grayish white appearance is obtained, the aqueous extract of which is very active in raising the blood pressure.

AVith 100 grammes or more of this powder, representing one kg. in weight or about 1000 fresh glands, we proceeded as follows:. The powder is repeatedly extracted with warm water acidulated with a few drops of dilute sulphuric acid until the gland has yielded up all of its chromogenic substances, as tested by Vulpian's reactions. This aqueous extract is evajiorated on the water-bath to a small bulk, a large excess of strong alcohol is then added and the whole allowed to stand 24 hours, by which time the proteids have all settled out. The alcoholic fluid is then filtered and the greater part of the alcohol removed by distillation ; the remainder is driven off on the water-bath. The entire removal of the alcohol is necessary, and in order to avoid too great concentration of the acid fluid, which seems to destroy some of the active principle, water has now and then to be added. The brownish fluid when filtered gives all the well-known reactions characteristic of Vulpian's chromogeu, and on neutralizing the sulplmric acid we found the filtrate to be physiologically very active.


July, 1897.]

153


This filtered fluid is next treated with the proper quantity of benzoyl chloride and sodium hydrate according to the Baumauu-Schotten method of forming a benzoyl compound. There results a tarry substance of a light yellow color which sticks to the sides of the separator funnel and which is collected and washed until the wash fluid no longer gives an alkaline reaction. It is next dissolved as far as possible in alcohol and the alcohol evaporated. The residue is then treated with ether, which takes up the greater part of it, the ethereal solution is filtered and the ether driven oft.

The residue, which is of tarry consistence and amber color, is taken up in strong alcohol from which all basic substances have been removed by distilling from tartaric acid. It is then boiled for two hours with animal charcoal previously well washed with purified alcohol. After filtration and the evaporation of the alcohol a considerable quantity of crystalline residue is obtained which is found to consist of the benzoyl compound of the active principle contaminated with other benzoyl derivatives and which we may call the crude benzoyl product. It is insoluble in water, alkalies or acids of ordinary strength, is soluble in alcohol, ether, glacial acetic acid and concentrated sulphuric acid.

It is of interest in this connection to note that benzoyl chloride effects the complete removal of the blood-pressureraisiug constituent from an aqueous solution. This is proved by the fact that the filtrate from the insoluble benzoate no longer gives the characteristic chemical reactions of the active principle, and that chemical manipulations no longer yield a blood-pressure-raising constituent. Indeed, an injection of a sufficient amount of the material left after the sodium benzoate and the excess of alkali have been removed, causes a sharp and sudden fall of pressure instead of a rise.

It was not until long after we had made use of benzoyl chloride as a precipitant of the active jjrinciple that we obtained access to Fraenkel's* pai)er. From it we learned that a syrupy substance is thrown out when benzoyl chloride is shaken uj) with a pyridine solution of an extract of the gland. Fraeukel did not succeed in crystallizing this benzoyl conijjound, nor did he attempt to decompose it in order to ascertain whether it was in reality a benzoate of the blood-pressure-raising principle.

Methods of Decomposing the Benzoyl Compound.

A quick method always used by us as a qualitative test is as follows : The compound is dissolved in as little concentrated sulphuric acid as possible, crushed ice is slowly added, and the benzoic acid which has been split off is shaken out with ether. On neutralizing the solution we found it to give the reactions characteristic of aqueous solutions of the medullary substance. We have not considered this method adapted to the decomposition of large quantities of the product.

Decomposition of this benzoyl product was effected by means of an alcoholic solution of sodium alcoholate, and also with strong hydrochloric acid and alcohol, but these methods were found to be less satisfactory in practice than the following, which is the method on which we now rely. The benzoyl compound is dissolved in glacial acetic acid, the solution


  • VVien. med. BliiUer, IS'Jti, No. 14-16.


heated to near the boiling point, and an equal volume of a 25 per cent, solution of sulphuric acid actively boiling is slowly poured into the hot acetic acid solution, the whole being shaken meanwhile. The flask is now attached to a back-flow condenser ami heated on a small flame for about ten minutes.

The solution is next diluted with water and allowed to cool, the benzoic acid, which has been thrown out, is filtered off and the rest is removed with the help of ether.

Mixed with the benzoic acid which has been removed by filtration is found a dark brittle substance which softens on the water-bath, and which we assume to be a benzoyl compound of unknown composition which was apparently unaffected by the dilute sulphuric acid. On dissolving it in concentrated suljjhuric acid and diluting with crushed ice, the resulting fluid gives none of the reactions characteristic of suprarenal extracts.

After decomposing the benzoyl product with hot dilute sulphuric acid and removing the benzoic acid thus split off, we next get rid of the acetic acid by repeated partial evaporations, taking care not to let the solution become too concentrated and thus perhaps injure the active principle. After the removal of the acetic acid the sulphuric acid is precipitated with the help of lead carbonate. The lead sulphate is removed and the filtrate is allowed to stand in vacuo over sulphuric acid until it has become of tarry consistency. It is then exhausted with ether, acetone and absolute alcohol in succession.

The residue is physiologically very active, and it gives all the reactions characteristic of an aqueous solution of the gland — a beautiful rose color on the addition of an alkali, a green color with ferric chloride, reducing silver nitrate, etc.

However, we are not yet dealing with a pure substance. If we neutralize an aqueous solution of the product thus obtained with a free alkali or with a carbonate of the alkalies, an overpowering odor much like that of coniiue is jierceived. As this odor passes that of pyridine seems to take its place. The basic substance thus liberated fumes in the air or when a glass rod moistened with hydrochloric acid is brought into its neighborhood. To remove this basic substance we made an aqueous solution of the active principle as above isolated, rendered it faintly alkaline with sodium carbonate and shook out with ether several times in succession. But this method does not remove all of the coniiue-like substance. To effect this we were obliged to make the active principle strongly alkaline with sodium hydrate before shaking out with ether. The aqueous solution, in consequence of the addition of the free alkali, takes on a deep red color, and carmine red flocks are thrown out. After the removal of the coniine-like substance with ether, the fluid containing the red flocks was acidulated with sulphuric acid and the carmine-red substance was filtered off". The clear filtrate, which was a pale straw color, was concentrated in vacuo, and the active priuciiile taken up in weak alcohol. On account of the insolubility of the sulphate of the active principle in absolute alcohol it is difficult to obtain this entirely free of sodium sulphate. We hope in future to remove both the coniine-like substance and the pigment with the help of ammonia. The presence of pyridine in our ammonia prevented our using it for this purpose.


154

[No. 76.


This volatile base of a coniine-like odor has not hitherto been described as a constituent of the suprarenal capsule. The beautiful carmine-red pigment we take to be identical with the red substance which many other observers have found to be thrown out as a precipitate when ammonia is added to a concentrated aqueous solution of the gland, or when a solution is evaporated in the presence of lead acetate.* Others have believed this red precipitate to be the oxidation product of the active principle of the gland, but we shall presently see that the active principle is still present in the filtrate from the carmine-red body. We have as yet made no experiments with this pigment except to note that it is but slightly soluble in dilute alkalies and insoluble in dilute acids, and that iodine destroys the color. Our method appears to make the further study of this substance possible.

The coniine-like substance we have secured in the form of its hydrochlorate, and with it we have made certain studies which will be published at a later date.

Chaeacteristics of the Blood-Pressure-Eaising Constituent AS obtained by decomposing its Benzoyl Compound.

We have now obtained the active principle in the form of a sulphate. As thus far isolated it is a hygroscopic, strawcolored residue which tends to crystallize on standing over sulphuric acid, agglomerates of small crystals forming on the edge of the bowl and the entire residue taking on a semicrystalline appearance. This sulphate does not contain the volatile coniine-like substance, nor do we find the carminered pigment which falls out on the addition of an alkali. Alkalies no longer liberate the coniine-like substance, nor do they throw out the red pigment, but they cause a brownish discoloration, and on heating, alkaline vapoi's, probably ammonia, are given off.

Our sulphate is very active physiologically. A small quantity suffices to raise the blood-jjressure as seen in Fig. 1, and it is therefore evident that we have isolated the active principle but slightly contaminated with other substances.

A final product even more active in small quantities is that whose action is shown in Fig. 2, where the mercury is driven out of the manometer. This more active compound still contains much of the coniine-like substance, and at once throws out the carmine-red pigment on the addition of alkalies. The sulphate of the coniine-like substance does not, as we have seen, raise the blood pressure; it therefore remains for us to consider whether the carmine-red substance which is precipitated on the addition of alkalies, either alone or in conjunction with small quantities of oxidizing agents, has any j)hysiological significance or stands in any chemical relation to the blood-pressure-raising constituent. We incline to the opinion that this substance, which in the original aqueous solution of the gland gives with iodine water the " teinte rose-carmin tout a fait remarquable" of Vulpiau, is in nowise connected with the blood-pressure-raisiug constituent. We have repeatedly removed or destroyed this substance by boiling solutions containing it with strong ammonia or with sodium

•Holm, Journ. f. prakt. Chemie, c (1867), 150.


hydrate, and have always been able to separate subsequently an active material. In proof of this we append Fig. 3, showing a great rise of blood pressure, although the material from which this active principle was obtained had been boiled for one hour with a 5 per cent, solution of sodium hydrate. After such treatment with alkalies, care must be taken in the subsequent evaporation of the alcohol with which the active principle is removed, to keep an acid reaction, as otherwise the greater part, if not all of it, will be destroyed by oxidation. And unless all evaporations are carried on under reduced pressure, much material will be lost, even with the above precaution.

Although somewhat contaminated with its own decomposition products, this final sulphate has all the characteristics of an active substance. As shown by repeated experiments, it promptly raises the blood pressure, it constricts the vessels of an inflamed eye, and when injected into the dorsal lymph sac of the frog it acts like a narcotic or cerebro-spinal poison.

As freed of the red substance the sulphate of the active principle behaves as follows: It is very soluble in water, fairly soluble in weak alcohol (50 per cent), almost insoluble in absolute alcohol, and quite insoluble in ether, acetone, ligroine and chloroform. Its aqueous solution, even when freed from adherent sulphuric acid, has a slightly acid reaction. The addition of iodine water to a neutral solution does not give a rose-red color. Alkalies added to a strong solution give a brown color which deepens on heating. Ferric chloride gives a purplish brown, almost black in concentrated solution, which ou the addition of tartaric acid and an alkali passes into a deep red color. Before the removal of the carmine-red substance the addition of ferric chloride gives the well-known emerald green color, which passes into red on the addition of an alkali.

It is evident that our sulphate gives V^ulpian's ferric chloride reaction, though somewhat changed by the removal of what we take to be the chromogenic substance which gave his iodine reaction. It also promptly reduces silver nitrate in alkaline solution, but does not reduce Fehling's solution even on boiling.

Probable Eelation to the Alkaloids.

More than a year ago, during our first studies with suprarenal extract, we were struck with the fact that every extract entirely free of proteids and physiologically active gave a fine pyrrol reaction when subjected to dry distillation. This is evidenced both by the odor and by the pine sliver reaction. A small quantity of the isolated sulphate also gives the pyrrol reaction when heated either alone or with zinc dust.

We attach considerable importance to this reaction. As is well known, alkaloids in general give pyrrol ou dry distillation ; morphine, for instance, on being heated with 10 parts of zinc dust gives off pyrrol, ammonia, trimethylamine, pyridine, phenanthrene, etc.* During the past winter we made


  • We are well aware that certain salts of glutaminic, pyromucic

and its related acids also yield pyrrol on dry distillation. These compouuds, however, like the proteids and their allies, appear to us to be excluded.


July, 1897.]

155


several attempts to prove the presence of pyridine among the products of dry distillation of the active principle as above isolated, as its detection would prove that our principle was to be classed among the alkaloids.

In attempting to show the presence of pyridine we heated the active principle with zinc dust in a current of dry hydrogen and passed the distillation products through a test tube and two small flasks, the tube being placed in a cooling mixture, the first flask being partly filled with dilute sodium hydrate, and the second with dilute hydrochloric acid.

At the close of the experiment the test tube gave off alkaline vapors that smelled strongly of trimethylamine and had in addition a peculiar sweetish odor. The contents of the test tube diluted with water gave a jDrecipitate with bromine water and with copjier sulphate, but with the latter reagent the fine blue color characteristic of pyridine did not appear. The presence of amines seems to render difficult the detection of small quantities of pyridine. The contents of the third flask on exposure to the air took on a rose-red color and after a time threw out a precipitate of the same tint. Both flasks gave off the odor of benzaldehyde.

The following experiment was also made with a little of the sulphate, which no longer gave the rose-red reaction with iodine but which still contained a little of the coniine-like substance. For two hours it was kept at 150° C. in a sealed tube with 35 per cent, hydrochloric acid. On shaking out with ether a considerable crystalline residue was obtained which, without much purification, melted sharply at 130° C. and had all the properties of benzoic acid.

In the above decomposition experiments the quantity of material at command was small, perhaps not more than onefifth of a gramme at a time, and not entirely pure. We do not, therefore, lay much stress on our failure to detect pyridine.

The fact that the nitrogen of our compound is given off in the form of amines and pyrrol gives strong ground to believe that our substance is to be classed with the pyridine bases, using this term in a broad way. Its basic character, its ability to take up acid radicles, as illustrated by the formation of a benzoyl product, its reducing power and its color reaction with ferric chloride are all points which can be urged in support of this view. Furthermore, cupric acetate, the serviceableness of which as a precipitant of carbo-pyridine bases has been shown by Gautier and Landi,* also precipitates our active principle; and iodine chloride, which Dittmarf found to give brown or yellow halogen addition-derivatives with a large number of the alkaloids, gives with a neutral or slightly acid solution of our active sulphate a brownish flocculeut precipitate.

Of less weight in this connection, but nevertheless of some value, is the fact that its physiological action and its power in small doses is again in accord with what is known of alkaloids. Strychnine, thebaine and other alkaloids are readily called to mind as able to raise the blood pressure, and recently TunnicliffeJ has placed piperidine in the same list. The


•Compt. rend., cxiv (1892), 1154-1159.

fBerichte d. deutscb. chem. Gesellsch., xviii, 1612.

tCentralbl. f. Physiol., x, No. 25, 777.


pyrrol* bases are also physiologically active, although less attention has been paid to them.

Pyrocatechin cannot be split off from the Blood-Pressuke-Raising Constituent.

As already said, Miihlmann has stated with great positiveness that the blood-pressure-raising constituent is pyrocatechin joined to some other substance, probably an acid. Miihlmann does not offer sufficient proof for his conclusion ; and even had he proved the presence of pyrocatechiu in the gland itself, this is a very different thing from showing that it enters into the chemical constitution of the blood-pressureraising constituent.

We have repeated Miihlmann's work and have found that after boiling the medullary substance with hydrochloric acid, the ether takes up a trace of Vulpian's substance, as well as a substance that reduces Fehliug's solution.

The ether residue also gives a precipitate with neutral lead acetate which, on decomposition with dilute sulphuric acid, sets free a compound that gives with ferric chloride the reaction so characteristic of pyrocatechiu. Our blood-pressureraising constituent is not precipitated by lead acetate and could not, therefore, have been responsible for this result.

Furthermore, on decomposing a fairly large quantity of the crude benzoyl product before referred to and shaking out the resulting benzoic acid with ether, we have twice found that the ether has taken up in addition to the benzoic acid a small quantity of a substance which reduces Fehling's solution and gives a precipitate with neutral lead acetate. On decomposing the resulting lead compound with dilute sulphuric acid and neutralizing the filtrate, we obtained a solution which behaved with ferric chloride in the way characteristic of pyrocatechiu. The quantity of this lead compound obtained has been too small for analytical purposes.

We consider it, therefore, still uncertain whether or not a little pyrocatechiu is present in the gland.

That the blood-pressure-i-aising constituent is, however, not a pyrocatechiu derivative seems to us certain. To prove this we used, not the entire gland nor the medullary substance, but the active principle itself, as isolated by us by decomposing the benzoyl compound.

We have used large quantities of material representing in each experiment the active principle of several thousand glands. We have boiled this with hydrochloric acid of varying strength and for varying lengths of time, and in no case have we been able to find in the ether used as a solvent any trace of a substance that would reduce Fehling's solution or give a precipitate with lead acetate. Inasmuch as some of the chromogenic substance always passes into the ether from acid solutions, these two reactions are both necessary to establish the presence of pyrocatechin. In other words, we have failed to split off pyrocatechin from the active principle as isolated by us. If present, it could hardly have eluded our search, for even a minute quantity may be made to give a precipitate with neutral lead acetate.


  • Jac. Ginzberg, Ueber das Verhalten des Pyrrols, etc., luaug.

Diss., Konigsberg, 1890.


15G

[No. 76.


We propose during the coming autumn to continue this work. Having made arrangements for the use of a large amount of material, we hope to secure both the benzoate and the sulphate in a form pure enough for analysis and for further chemical study.

(Summary.

We may sunnnarize the results of our work as follows :

The blood-pressure-raising constituent of the suprarenal capsule may be completely precipitated fi-om an aqueous extract by treatment with benzoyl chlorideand sodium hydrate, according to the Schotten-Baumann method.

On decomposing the resulting benzoyl products, a residue is obtained which possesses great physiological activity. It gives the color reactions of Vulpian, reduces silver nitrate and possesses the other specific qualities of suprarenal extracts.

AVith the help of alkalies a carmine-red pigment may also be separated from these decomposition products. We take this pigment to be that one of the chromogenic substances of Vulpian which gives the rose-carmine color when suprarenal extracts are treated with oxidizing agents or alkalies.

A volatile, basic substance of a coniiue-like odor is always found to accompany the crude benzoate. When these substances ai'e removed the active principle is left as a highly active sulphate or hydrochlorate, as the case may be. It is therefore a basic substance. Its salts give a color reaction with ferric chloride; they also reduce silver nitrate, but not Fehling's solution.

It is not j)ossible to split oft' pyj'ocatechin from this isolated active principle. The fact that dry distillation causes the appearance of amines and pyrrol in abundance, taken in connection with its ability to take up acid radicles, its reducing power, its precipitability by cupric acetate and iodine chloride, and its jihysiological action, lead us to conclude that our active principle is to be classed with the pyridine bases or alkaloids.

Addendum, June 15, 1897.

Since the foregoing paper was read before the Association of American Physicians on May 6, 1897, B. Moore has published a paper in the Jotcrnal of Physiology, vol. xxi, Nos. 4 and 5, May 12, 1897, entitled, "On the Chromogen and on the active Physiological Substance of the Suprarenal Gland." In this paper it is suggested that the active principle may be a pyridine derivative. Moore's conjecture is based, lirst, on a formula calculated by him from a combustion analysis of Krukenberg, made with an impure, hygroscopic, noncrystalline residue obtained by merely decomposing and drying a precipitate secured out of an alcoholic extract of the gland with the help of basic lead acetate. The calculated formula, the carbon content of which differs by 1.33 per cent, from that actually found by Krukenberg, is CsHuNO.!, and Moore points out that in it the ratio in which the elements carbon and nitrogen stand to each other is the same as in pyridine, CrHr.N. Now such a calculation, though suggestive to the investigator, furnishes no proof of the presence of pyridine, for Krukenberg could not possibly have had in hand a chemical individual uncontaminated with other constituents of the gland. Krukenberg himself admits that his


material was a mixture of unaltered pigment and its decomposition products. It is also certain that it was contaminated with other constituents of the gland. This is proved by the fact that basic lead acetate precipitates several of the constituents of the gland which pass into alcohol, and also by the fact that the analysed material contained 0.0(38 per cent, of sulphur and from 1.18 per cent, to 1.44 per cent, of ash.

A second reason given by Moore in supj)ort of his conjecture is that when "some suprarenal extract was cautiously fused with caustic potash so as to avoid charring, the peculiar odor of pyridine was at ouce obtained." He admits that proteids were present in this extract, and that jjyridine and its homologues arc formed in the destructive distillation of proteids, but states that the experiment was "conducted so as to avoid charring," and considers this a sufficient safeguard. This experiment has also no value, for the odor of pyridine can always be obtained when a mixture of dry, powdered proteid and powdered caustic potash are fused together so as to avoid charring. This experiment, therefore, must be made with material entirely free of proteids. Since reading Moore's paper we have fused a little of our active i)rinciple with caustic potash, but have failed to detect pyridine. If present in the molecule of the active principle, it is evident that larger quantities of the material must be used to prove it. Only indisputable chemical proofs can establish the presence of Jiyridine ; the odor is not enough. We have frequently in various manipulations with the active substance met with what we took to be the odor of pyridine, but on shaking out with ether and adding an ethereal solution of hydrochloric acid and evaporating the ether we have been unable to detect pyridine in the residue.

Description of the Tracings.

Fig. 1. Tracing. Dog aniesthetized with morj)hine ; curare and artilicial respiration, both vagi cut. Injection of the active sulphate, freed from the carmiuesubstanceaud coniinelike body, at X.

A =: running base line.

i?z::time record.

(7 z= curve of the blood pressure, canula in the right carotid artery.

Fig. 3. Tracing. C!onditions of the experiment as in Fig. I. Injection at X of a highly active sulphate which still gives the rose-carmine color with iodine water and still contains some of the coniine-like substance which does not raise the blood pressure. The blood pressure is so high that the mercury is driven out of the manometer.

Fig. 3. Tracing. Conditions as in 1. Injection at X of a material which is still highly active although it had been boiled with 5 per cent, sodium hydrate for one hour. In this experiment a number of injections had already been made; the pressure had fallen to the normal before the injection indicated at X was made.

DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL

IJy JOHN S. lili, LINOS, M. I)., LL. D.

Ctmtalnlng 56 largo quarto plates, phototypes, and lithographs, wlih views, plaiiH iiutl ilotatl drawlugaof all the butldlugs.aiul their Interior arraugemeuts— also wood-cula of apparatus aud Uxtures; also 116 pages of letter-press describing the plans followed lu thecoustruollou, and giving full details of heatlug-apparatut, veutUatlou, sewerage aud plumblug. Price, bound lu cloth, $7.oO.



NOTES ON NEW BOOKS.

Anomalies and Curiosities of Medicine, being an encyclopedic collection of rare and extraordinary cases, and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, classi fled and indexed. By Georqe M. Gould, A. M., M. D.,and Walter L. Pyi.e, A. M., M. D. With 295 illustrations and 12 half-tone and colored plate.s. 908 pp. (Philadelphia : W. B. Saunders, 1897.)

Tliestatementof Gibbon that objects which are only singular without being pleasing may excite surprise but soon lead to satiety and <iisgust, does not apply to this volume, which is thoroughly interesting from beginning to end. The attempt of the authors "to briefly epitomize and to arrange in order the records of the most curious, bizarre and abnormal cases thatare found in medical literature of all ages and all languages," has been most successful. The book is thoroughly scientiflc in its treatment of the varied material which has been gathered with an industry which calls forth admiration. The Urst six chapters will probably be read most generally and relate to anomalies of conception, birth and development, and are of special interest to the gynecologist, obstetrician and student of legal medicine. Chapter seven relates to gigantism, dwarflshness, obesity and abnormal leanness, and the accompanying illustrations form a curious collection of anomalies suggestive of a dime museum.

The chapter on longevity taxes one's faith rather more than any other. Think of Henry Jenkins dying at the age of 169 years ; Thomas Parr at 152 ; Jean Korinat 172 and his wife atl64, and ason left an orphan by their untimely death at the tender age of 116 ; Petretsh Zartan at 185 or 187 (authorities differing), who walked a mile to the post ofiice a few days before his death to ask for alms ; and many other well-authenticated instances of nearly equal age.

The chapter on anomalous mental and nervous diseases is so complete it is a matter of surprise that it does not include the history of the young man in Ohio who became totally blind at the age of seven months, and who, while receiving an education at the school for the blind, in consequence of a fall, lost both hearing and speech. After a time, his eyesight being restored by the fall, he was transferred to an establishment for the education of deaf mutes. Here eventually his hearing was suddenly restored, but epileptic attacks developed which required hospital treatment, this time in an institution for the insane. This well-authenticated tale was published in considerable detail in one of the State repoits and deserves a place in these annals. The chapter on Historic Epidemics is timely, especially the full account of the bubonic plagues of the middle ages.

An excellent feature of the book is the judicial spirit shown by the authors. Facts are weighed and reasons are advanced for the conclusions which are reached. The book is well printed and finely illustrated and is worthy of a large success. Every chapter is of interest to every physician.

Text-Book of Materia Medica, Therapeutics and Pharmacology. By G. F. Butler, M. D. [Philadelphia: W. B. Saundem, 1896.)

This work is dedicated to the " Medical Students of the United States," and we have no doubt that many of them who enjoy buying the latest work on this branch of medicine will find it serviceable. It cannot be said to replace the oliier works of Wood, Hare and others. There is very little true original thought in it, which should be the the real reason for the publication of any new book, especially to-day, when there is altogether too much production of simply transient works. As the author states in the preface : " From the U. S. Pharmacopeia chiefly, and from the National Dispensatory, have been adopted almost verbatim, the ' origin ' and 'description and properties' of tlie various drugs under consideration," so it is more in his arrangement of his material that we must


look for originality. He classifies the drugs by their properties, rather than alphabetically, as is done by Hare. Both methodshave their advocates, and [lersonally, as it is much the most rapid way to look up any given drug, we prefer the latter method. Butler still further cljftsifies the drugs into so called " Disease-Medicines," a very unscientific term, as he himself recognizes, and "SymptomMedicines." In such a classification no two persons willagree as to the class to which certain medicines will belong most properly, and thus it becomes confusing and time-consuming to search for the drug wanted. The author says: "A genuine specific is tolerated only by the system in which it antagonizes some disease. For instance, A and B are put under a prolonged course of mercury ; A is salivated beyond recognition, while B's health improves — simply for the re.ison that B had syphilis, which A had not." Such general remarks are often not true, and the example given is a very poor one, for we all know that syphilitic patients may be salivated, and sometimes as severely as those who are not syphilitic. Also many ]>atients who have not sypliilis may take mercury in large doses for long periods of time without becoming salivated. We do not understand the following sentence: "Quinine was formerly considered a specific in malaria, until the fact was recognized that the drug is analogous to a normal constituent of healthy bile in its action upon plasmodia malariae." W^e believe that by most authorities quinine is still considered to be a specific in malaria, whatever the action of bile may be. In a work which covers so much ground as this text-book, the value depends on an equal balancing of the different parts, and especially, in the description of the drugs, of careful omission of all unnecessary parts, and still more exact and concise information on all important points. Each author naturally finds special interest in certain parts of his work, and so not knowing these it is hard to criticise the book justly. But in the 650 pages given to drugs and their actions we feel that much improvement could have been made with careful revision — some parts omitted, and other information of more importance added. We think it quite out of place to introduce in such a work declensions of simple Latin words and other rules of Latin grammar, which should be known by every student before he begins the studj- of medicine, and if he does not know them, he should not be helped to the knowledge in this superficial manner.

Diseases of the Ear, Nose and Throat. By S. P. Bishop, M. D. (Philadelphia : F. A. Davis Co., 1897.)

This book, we think, fulfills pretty satisfactorily the object of the author, as expressed in the preface; he says: "This work was designed, first to help students in preparing for their degree ; second, for those progressive practitioners who wish to acquire the proficiency necessary to properly treat those patients who are unable to visit specialists ; and third, for those who are gradually exchanging their general practice for special work in these branches." The chapter on blood-serum therapy in diphtheria seems out of place ; it is merely an abstract of a few of the articles which liave appeared on this subject during the past two years, and we see no good reason for introducing it here. The work on the whole is a fair presentation of our knowledge in these diseases, without any attempt to take up any of them at length. The treatment as given is generally satisfactory and simple. We do not agree with the author in considering hay-fever, or "nervous catarrh," as he prefers to call it, a result of uric acid diathesis. There are many questions in the study of this disease which are as yet quite inexl)licable, and this theory of its causation is insufficient to explain them all ; the neurotic character of the disease is well established, and that uric acid may in some caees play an inijiortant role in this nervous affection is undoubted, but it is also equally certain that other important causes play their role too in determining this malady.

This book is clieaply gotten up and the cuts are of poor quality ; tlie colored illustrations also seem very unsatisfactory. Many of


July, 1897.]

159


the cuts are reproductions of instruments wliich by this time should be l^nown to all practitioners and to every student graduating from a medical college. These simply add to the expense of the book without adding to its intrinsic value.

Essentials of Physical Diagnosis of the Thorax. Second Edition.

By Arthur M. Cokwin, M. D. (Philadelphia: W. B. Saunders,

189a.)

That there is a demand for such a quiz-compend or aid in cramming for an examination is shown by the fact that a second edition of this small book has been called for. We cannot recommend it, however, for like other similar works it fails in attempting to condense much knowledge in a very limited space and although tolerably well arranged, there are numerous statements of fact with which we cannot agree. The varieties of tympany (p. 69) are confusing and not generally used and were better omitted in such a work. In the discussion of heart murmurs there is much needless repetition, and on p. 176 the mitral systolic murmur described as occurring in aortic insufficiency, otherwise known as Flint's murmur, is presystolic in time. The chapter on congenital lesions of the heart is treated too briefly to be of service, as is also the one on hydatid cyst of the lung, which, when jiriniary, is not a condition easy to diagnose, nor could the signs of it as given by the author differentiate it from pleurisy. 8pasm of the columnar carnese is a condition which may occur, but it is hardly one of which a diagnosis could be made. Acute endocarditis without valvular lesion is not a condition which can be recognized clinically, and inorganic aortic systolic murmurs should usually be doubted. The ratio of the inspiratory sound to the expiratory is not as tiiree to one, nor in asthma is the dyspnosa (orthopncea) chiefly expiratory. CheyneStokes respiration does not ordinarily accompany opium poisoning. No worse instrument for clinical instruction could well be devised than the multiplex stethoscope, of which there is an illustration in the beginning of this work.

Pathological Report of the Illinois Eastern Hospital tor the I (Chicago: Blakely rrinting Co., 1896.)

This is an excellent report, full of much valuable mateiial, and Dr. Adolf Meyer deserves much credit for it, considering the difficulties under which the work was prosecuted, due to a lack of general facilities for carrying it on. We cannot criticise any shortcomings when we read his closing remarks. He says: "It may justly be said that the publication of so much raw material is of little use. To polish the report, away from the records and the material, did not seem to he in the interest of the accuracy of a picture of the working of the laboratory which had barely come into existence at the end of the period covered. The work was planned on a broader basis than it was feasible to carry out in the short period. The idea was that the plan of publishing ' interesting' cases only was not in the interest of sober study of the daily experience, that selecting cases might lead to illustration of preconceived ideas instead of the facts as they present themselves in reality, and that at the present stage of psychiatry a consideration of all the things seen wouM be less dangerous than arbitrary selection. The same jirinciple should be carried out in the clinical side as well." Although much of the material is raw, yet many facts of interest are to be found — perhaps the most interesting being that 32 per cent, out of 49 cases of terminal dementia, and 27 per cent, of 192 cases of mental diseases, including the first series, died of florid tuberculosis. Of course without fuller statistics as to the class of patients in the hospital, too much stress should not be laidon these figures, but nevertheless the percentage is high. A case of acute mania, dying presumably of sulphonal poisoning, shows the necessity of the utmost care being used in the administration of drug.ito patients with mental diseases to avoid accidents of this sort. We shall await with pleasure sui cessive reports from Dr. Meyer, who has now transferred his work to the Worcester State Hospital and


nsane.


Clark University, and trust he will be able to describe some of the finer microscopical findings in brain and cord lesions from the interesting material at his disposal.

St. Thomas's Hospital Reports. New Series. Vol. XXIV. i London,

1895.)

The first half only of this volume is taken up with detailed papers, and the second half with statistics of the different departments of the hospital, and brief abstracts of cases, medical and surgical. Among the papers here preseuted, two are worthy of special note. The article on " Osteo-arthropathy and its Relationships," with report of a case of pulmonary hypertrophic osteoarthropathy, both by Dr. Walters, is a very valuable contribution to our knowledge of this curious condition and its relationship to akromegaly. It is an exhaustive study, with a brief abstract of all the cases reported of this bone disease up to the time of the publication of this volume. The other paper is on "Enteric Fever and Sewage Gas," in which 11 cases of typhoid fever are described as resulting from poisoning with sewer gas in one hospital within a short space of time. Here milk, water and food as possible sources of the contagion could apparently be eliminated without doubt, and the only other discoverable source was a water-closet into which typhoid organisms had probably been discharged but a few weeks before the outbreak of this small epidemic, which ceased as soon as the sewage pipes were overhauled and modified. With the modern belief that typhoid fever in nearly every case re>ult8 from milk, water or food contaminated by the typhoid organism, this epidemic raises the most interesting question as to whether or not typhoid bacilli may enter the body through the lungs and thus cause the fever. There are other articles on tuberculous disease in the knee-joint, and relapse in the si)ecific fevers, which will repay careful reading.

Feeding in Early Infancy. By Arthur V. Meigs, 51. D. (Vhiladelphia: W. B. Saunders, 1896.)

In this paper Dr. Meigs emphasizes the results of his milk analyses as expressed in his earlier publication, and describes in detail the preparation of his food, based on these results.

He finds that human milk never contains more than one percent, casein, cow's milk three times this amount, other constituents being present in about equal quantities. In his preparation cow's milk is therefore diluted with lime water, and cream and sugar added in definite proportions. The food, piepared after this manner, has been used for a number of years by the author, with satisfactory results.

He thinks thatsulijecting milktohightemperaturesdetracts from its usefulness as an infant food ; therefore it is better to be assured of its source and avoid sterilization.

This course seems hardly practicable, and the injurious effect accredited to sterilization is not sustained by most writers on the subject.

Proceedings of the American Medico-Psychological Af-sociation at the 52d Annual Meeting, held in Boston, May 26-29, 1896. {American Medico-Psychological Associaiion, 1896.)

The proceedings of this society occupy nearly 300 large papers, pretty closely printed ; but all the papers are good, while some are of especial value. There is an interesting address on psychological education by Stanley Hall, a leading authority on such a subject; and there are important contributions by Brush, Worcester, Hoch, and Berkley. The paper by Hoch, on " General Paralysis in Two Sisters," is perhaps, while one of the most thorough articles, the one of most general interest. To students who have given much time to the study of the blood, the paper on " Leucocytosis Associated with Convulsions," by Burrows, will open up a point of much interest as to the cause of leucocytosis, whether or not it be due to a form of auto-intoxication.


160

[So, 76.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


THE JOHNS HOPKINS HOSPITAL REPORTS. Volume I. 423 i>ages, 99 plates.

Report in Pntliologry.

The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

(Atrophy). By Henry J. Berkley, M. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

Mall, M. D.

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

T. C. Gilchrist, M. D., and Emmf.t 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 BO-called

Parasites found in Various Lesions of the Skin, etc.; Two Cases of MoUuscuni

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

T. C. Gilchrist, M. D.

Report In Patholog^y. An Experimental Study of tin' Thyroid Gland of Dogs, with especial consideration

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


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

Report in Meillcine.

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

Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleur, M. D. Cases of Post-febrile Insanity. By William Osler, M. D. Acute Tuberculosis in an Infant of Four Months. By Harry Toulmin. M. D. Rare Forms of Cardiac Thrombi. By WtLLiAM Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

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

Report in Gynecology. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

A. Kelly, M. D.. and Hunter Robh, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,

M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

Ovarian Tumor; General Gynecological Operations from October 15, 1889, to

March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howasd

A. Kelly, M. D., and Albert A. Ghrisket, 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, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment

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

Howard A. Kelly, M. D.

Report in Snri;:ery, I. The Treatment of Wounds with Especial Reference to the VaUu^ of the Blond Clol

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in tVenrologT-, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. .\cute Angio-Ncurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By August Hoch, M. D. A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report in Patbolo^y, I. Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.


Volume III. 706 pages, with 69 plates and figures.

Report in Patholosry*

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

Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D. Report in Piitliologry*

Multiple Lympho-Sarcomata, with a report of Two Cases. By SiMON Flexner, M. D.

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

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

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

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

Report in Gynecology,

The Gynecological Operating Room; An External Direct Method of Measuring the Conjugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid Flexure associated with Constipation a Sourrc of Error in Gynecological Diagnosis; Operation for the Suspension of the Retroflexed Uterus. By Howard A. KiXLY, M. D.

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

Intestinal Worms as a Complication in Abdominal Surgery. Bj A. L. Stavklt, M, D.


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

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

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

Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

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

Report in Neurology.

Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of Mu^ miisruln.^; The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley. M. D.

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

Report in Gynecolof^y. Hydn)salpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Ctllen, M. B. Report in Patlioloe^y. Deciduoma Malignum. By J. Whitridge Williams, M. D.


\\)LUME V. 480 pageSj with 32 charts and illustrations.

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

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


Volume VI. About 500 pages, many illustrations.

Report in Nenrolojsry.

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

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

Report in Pntliologry.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. Bv Thomas S.

<'l-LLEN. M. B.

fii^aiancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of

Ovum and Spermatozoa. By Thomas S. Cullen. M. B., and G. L. Wilkins. M. D. Adciio-Myoma Uteri Diffusum Benignum. By Thomas S. Cttllen, M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infanta. By

William D. Booker, M. D. The Pathology of Toxalburain Intoxications. By Simon Flexner, M. D. The price of a set houiid in cloth [VoU. I-Vl] of the Hospital Reports m

$30.00. Vols. If II and III are not sold seimrateltj. The price o/

Vols. 11% r and ri is $5.00 each.


MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID 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 Emmkt Rixford,

M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,

$3.00. THE MALARIAL FEVERS OF BALTIMORE. By W. S, Thayer, M. D., and J.

Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.

By Lewellvs F. Barker, M. B. 1 volume of 280 pages. Price, in paper, f3.75. STUDIES IN TYPHOID FEVER. Bv William Osler. M. D., and othere. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. Subscriptions for the above publications may be sent to

The Johns Hopkins Press, Baltimore, Md.


The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimwr, Single copies nuiy he pronired from Messrs. GUSHING & CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a tityir, may tte addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sini/lv topics will be sent by mail for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vm.-Nos. 77-78.]


BALTIMORE, AUGUST-SEPTEMBER, 1897.




GOnSTTEJaSTTS.


PAGE.

Influence of Louis on American Medicine. By Willia.m O.SLEB, M. D., - - - 161

AVilliam Harvey as an Embryologist. By William K. Brooks, LL. D., - - - - - - 167

Long, the Discoverer of Anaesthesia. A Presentation of lii.s Original Documents. By Hugh H. Young, A. M., M. D., - 174

The Early History of Ophthalmology and Otology in Baltimore (1800-1850). By Harry Friedknwald, A. B , M. D., - 184


Joseph Friederich Piringer: His Methods and Investigations.

By Harry Friedenwald, A.B., M. D., 191

Proceedings of Societies :

Hospital Medical Society, " - 195

Hsematomyelia from Gunshot Wound of the Cervical Spine [Dr. Gushing].

Notes on New Books, _ . - _ 197

Books Received, 197


INFLUENCE OF LOUIS ON AMERICAN MEDICINE.

By William Oslek, M. D.


Harvey and Sydenham, types of the scientific and the practical physician, though contemporaries, were uninfluenced, 80 far as we know, by the other's work or method. Harvey had little reputation us a practical physician, and Sydenham cared little for theories or e.\periment. Modern scientific medicine, in which these two great types meet, liad its rise in France in the early days of this century. True, there had lived and worked in England the greatest anatomist and medical thinker of modern times; but John Hunter, to whose broad vision disease was but one of the processes of nature to be studied, was as a voice crying in the wilderness to the speculative, theoretical physicians of his day.

Bichat's Anatomie Gaicrale laid the foundation of the positive or modern method of the study of medicine, in which theory and reasoning were replaced by observation and analysis. Laennec, with the stethoscope, and with an accurate study of disease at the bedside and in the post-mortem room, almost created clinical medicine as we know it to-day.

The study of fevers occupied the attention of all the great physicians of the time. Fever — what it was, how it should be treated. What a vast literature exists between Sydenham and BroussaisI What a desolate sea of theory and speculation !


•Read before the Stille Society of the Medical Department of the University of Pennsylvania.


No one had been more influenced by Bichat's brilliant teachings than Broussais, who ruled supreme in the medical world of Paris in the early decades of this century. A strong believer in careful observations at the bedside and in the jiostniortem room, he was led into hoj)eless error in attributing fevers and many other disorders to irritation in the stomach and intestines — his gastro-enteritis.

Writing in the American Medical Recorder, July, 1831, an American student, Dr. F. J. Didier, says of the Paris professors of that date, "They were always talking of Hippocrates, Galen, Oelsns, etc., as if not a particle had been added to the stock of knowledge since their time." And again, " The doctrines of John Brown, mixed up with the reninantsof humoral pathology, form the basis of the present system."

The same mi.xture prevailed early in the fourth decade, as you may see from Broussais' Pathology, the American edition of which was issued in 1833, and from Jackson's (Samuel) Principles of Medicine, published in the same year.

Upon this scene, when Broussais was at the height of his fame, came Louis. He, with his friends Andral and Chomel, were very important factors in substituting finally in the study of medicine, for speculation and theory, observation and method.

The chief facts in Louis' life may be thus briefly stated. He was born in 1787 at Ai. He began the study of law, but abandoned it for that of medicine. He seems not to have


162

[Nos. 77-78.


beeu of a very strong constitution, as he did not pass the inspection for military service. He began the study of medicine at Eheinis, and completed his course in Paris, where he graduated in 1813, in the twenty-seventh year of his age. While waiting at home, hesitating what he should do, M. le conite de Saint-Priest, who occupied au official position in Russia, hajipened to stay for a few hours in the town of Ai to see Louis' family, and it was suggested that the young physician should accompany him to Russia. He consented and in St. Petersburg obtained a diploma to practice. For three years he seems to have had no settled abode, but wandered about with his friend, who was Governor of one of the provinces. He then settled in Odessa, where he remained for four years and practiced with great success. In the last year of his stay in Odessa he was very much disturbed by the high rate of mortality in children with diphtheria, and this appears to have determined him to abandon for a time the practice of medicine and to devote himself to study. With this object in view he returned to Paris and for six months attended the practice at the Children's Hospital. Among the younger physicians in Paris he found an old fellow-pupil, Chomel, physician to La Oharite, who offered him opportunities for work in his wards. Louis at this time was thirty-four years of age. Here for six years uninterruptedly he set himself to work to study disease in the wards and in the post-mortem i"oom. At first he appears to have occupied the position simply as a voluntary assistant and friend of Chomel, but subsequently he became his chef-de-cliniqiie, and during this period he occupied a room in the entresol of the hospital. He was a voluminous note-taker and collected in this time au enormous number of important facts.

This remarkable feature in Louis' life has scarcely been dwelt upon sufficiently. I know of no other parallel instance in the history of medicine. It is worth while reading the brief extract from Dr. Cowan's introduction to his translation of the work on Phthisis. " He entered the hospital of La Oharite as a clinical clerk, under his friend. Professor Chomel. For nearly seven years, including the flower of his bodily and mental powers (from the age of thirty-three to forty), he consecrated the whole of his time and talents to rigorous, impartial observation. All private practice was relimiuished, and he allowed no considerations of personal emolument to interfere with the resolution he had formed. For some time his extreme minuteness of inquiry and accuracy of description wei'e the subjects of sneering and ridicule, and cui bonof was not infrequently and tauntingly asked. The absence of any immediate result seemed for a time to justify their contempt of a method involving too much labor and personal sacrifice to be generally popular or easily imitated ; and M. Louis himself, at moments, almost yielded to the increasing difficulties of the task he had undertaken. No sooner, however, were his facts sufficiently numerous to admit of numerical analysis than all doubt and hesitation were dissi2}ated, and the conviction that the path he was pursuing could alone conduct him to the discovery of truth became the animating motive for future perseverance. Many of the results to which he arrived soon attracted general attention, and among those who had formerly derided his method while they admired his zeal, he found many toapplaud


and a few to imitate. From this moment may be dated the presence of that strong impression of the necessity of exact observation by which the school of Paris has beeu since so distinguished, and which is now gradually pervading the medical institutions of the continent and our own country; it is undoubtedly to the author of the present volume that we ought to ascribe the practical revival of that system, which had for ages been verbally recognized but never before rigorously exemplified."

The following works appeared as a direct result of his studies during these six years:*

" In 1823, a memoir on perforation of the small intestines, in acute diseases; a second, on croup in the adult; a third, on the communications between the right and left cavities of the heart (Archives de medecine).

" In 1824, two memoirs on the pathological anatomy of the mucous membrane of the stomach ; another on pericarditis.

"In 1826, a memoir on abscess of the liver; another on the condition of the spinal marrow in Pott's disease; a third on sudden and unforeseen deaths; a fourth upon slow but anticipated deaths, but which anatomy will not explain; a fifth on the treatment of tajuia by the Darbon potion (Archives de medecine).

"In 1825, his Anatomical Researches, etc., on Phthisis (1 vol. 8vo) ; reprinted with many additions in 1843.

" In 1828, Researches on the Typhoid Affection or Fever (2 vols. 8vo); reprinted with many additions in 1841."

Louis introduced what is known as the Numerical Jlethod, a plan which we use every day, though the phrase is not now very often on our lips. The guiding motto of his life was "Ars medica tota in observation ibus," in carefully observing facts, carefully collating them, carefully analyzing them. To get an accurate knowledge of any disease it is necessary to study a large series of cases and to go into all the particulars — the conditions under which it is met, the subjects specially liable, the various symptoms, the pathological changes, the effects of drugs. This method, so simple, so self-evident, we owe largely to Louis, in whose hands it proved an invaluable instrument of research. He remarks in one place that the edifice of medicine reposes entirely upon facts, and that truth cannot be elicited but from those which have been well and completely observed.

American medicine felt the influence of Louis through two channels, his books and his pupils. Let us speak first of the former. No French writer of the century has had such a large audience in this country; all of his important works were translated and widely read. The work on phthisis, the first important outcome of five years' hard work at La Oharite in Ohomel's wards, was published in 1825. Much had already been done by physicians of the French school on this subject. Bayle's important Recherchcs had been issued in 1810, and Laennec had revolutionized the study of phthisis by the publication of his treatise on auscultation. I cannot enter into any detailed analysis of the work, but it is one which I can commend to your notice as still of great value, particularly as


  • Brief Memories of Louis and some of his Contemporaries. H.

I. Bowditch, Boston, 1872.


Adgust-September, 1897.]

163


a model of careful observation. The work was based ujjou the study of 133 cases observed in Chomel's clinic. The lesions observed at autopsy are first described under the different organs, with great accuracy and detail, and then summarized, following which is an elaborate description of the symjitomatology. I do not know of any single work on pulmonary tuberculosis which can be studied with greater profit to-day by the young physician. The fifty years which have elapsed, since its publication, and the changes which have taken place in our ideas of tuberculosis, diminish naught from the value of his careful anatomical and clinical presentation of the subject.

In 1829 appeared his second great work, Anatomical, Pathological and Therapeutical Researches upon the disease knoivn under the name of yctstro-enterite, putrid, adynamic, ataxic, typhoid fever, etc., com^mred with the most common acute diseases. It was based upon 138 observations made between 1822 and 1837. He analyzed and determined the lesions found in fifty patients who had died of the typhus fever, and compared these with alterations found in other acute diseases. Altogether for this work he states that he analyzed the changes in the viscera of 133 subjects and the symptoms of nearly 900. In his introduction to this work he quotes a sentence from Rousseau which is always to be kept in mind : " I know that truth lies in the facts, and not in the mind that judges of them, and that the less I introduce what is merely my own into the deductions I make from them, the more certain I shall be of approaching the truth." This work was translated by Dr. H. I. Bowditch in 1836. At the time of Louis' observations, although differences were recognized between the various forms of continued fevers, the profession had no accurate knowledge of the subject. It so happened that at this period the disease prevailing at Paris known as tyjihus was almost entirely what we now call typhoid fever, so that the anatomical lesions found by Louis in his fifty autopsies were chiefly in the intestines ; in all the Peyer's glands were diseased. His method was to analyze carefully the appearances found in the different organs in the series of fever cases, and compare them with patients who had died of other acute diseases; thus of course the contrast was striking in the very matter of involvement of Peyer's glands, which were more or less seriously changed in structure in all of the patients with the fever, while in the persons dead of other acute diseases the elliptical patches had no special redness or softening.

The symptomatology was also given in great detail, and the same painstaking comparisons were instituted between the subjects of the typhoid affection and those of other acute diseases. Louis' work convinced a majority of the members of the Paris school that the essential lesions in continued fevers were in the intestines, and Louis himself apjiears not to have had any idea whatever that the disease which he was studying was in any way different from the disease jirevailing in other parts of Europe and which we now know as tyjjlius fever.

The next important memoir, the essay on Blood-letting, had a very potent influence on professional opinion in this country. It appeared in Paris in 1835 and was translated by G. C. Putnam, with an introduction and appendix by Dr. James Jackson. As this learned physician remarks in his


preface, " If anything may be regarded as settled in the treatment of disease, it is that blood-letting is useful in the class of diseases called inflammatory, and especially in inflammations of the thoracic viscera." When one i-eads the reports of the treatment by bleeding up to about the year 1840, one is almost forced to ask the question, are the diseases the same ? or surely the patients must have possessed much more powerful constitutions than those which we are called upon to treat at the end of the century.

At the time of Louis' return to Paris, under the influence of Broussais' doctrine of irritation, local and general bloodletting was practised more extensively than at any previous period in the history of medicine. As an interesting illustration it may be mentioned that the trade in France and Spain in leeches had developed to proportions which assumed really those of a national industry, and even in this country I believe one of the medical societies offered a prize for the best demonstration of the practical method of cultivating leeches for medicinal purposes.

It must have been a terrible shock to Broussais and his adherents when Louis attacked the subject of blood-letting in pneumonia with his numerical method. For this purpose he analyzed 78 cases, 28 of which proved fatal, and in a second series 39 cases with 4 deaths. Among his conclusions were that pneumonitis is never arrested at once by blood-letting, and that the supposed haj)py effect on the progress of the disease was very much less than was commonly believed. Incidentally he remarks with reference to the practice of blistering which was in vogue at the time, that he had rejected the practice .after the treatment of 140 cases of pleurisy without losing a case. I would refer you particularly to Putnam's translation of this article, which you can obtain in any of the libraries, not only for Louis' work, but for the excellent introduction by Dr. Jackson on the value of the numerical method in medicine, and also for the appendices, analyzing the pneumonia cases of the Massachusetts General Hospital from 1834 to 1834 (inclusive).

To American students one of Louis' most valuable works is his Research on the Yellow Fever in 1828. On the 1st of November, 1838, Louis, with Ghervin and Trousseau, left for Gibraltar, where the disease prevailed. They made a very careful study of the symptoms and morbid anatomy, and on their return to Paris made a report to the Academy of Medicine, but the work remained in manuscript until Dr. Geo. C. Shattuck translated it into English and it was published by the Massachusetts Medical Society as Vol. X of their Library of Practical Medicine. The work did not ajjpear in French until 1844. It is chiefly valuable as a very accurate and careful record of a series of cases studied clinically and anatomically.

Powerful as was the effect of Louis' writings on American medicine, it cannot compare with the influence which he exerted through his pupils, who " caught his clear accents, learned his great language, made him their model." Of the great triumvirate of the French school of the fourth decade, Louis possessed a singular power of attracting hard-working, capable men, and this in spite of the fact that his rivals and friends, Chomel and Audral, possessed more brilliant gifts of


164

[Nos. 77-78.


a certain kind. As a writer in the Lancet said (1872, II), " Year by year fresh bands of students came to imbibe from his lips the instruction which their predecessors had abandoned with reluctance, till his academic progeny knew no distinction of race or even color, but coalesced into a noble band of enthusiasts in the cause of medicine, of science and of humanity." In this academic progeny Louis' American pupils take a very unusual position. Among the thousands in the profession of this country who have during this century sought light and learning in the older lands, the group of young men who studied in Paris, between 1830 and 1840, had no predecessors and have had no successors. Partly because the time was ripe and they were active agents in bringing the new art and science to the New World, partly owing to inherent capabilities, etc., but not a little because the brightest minds among them fell under the influence of Louis — they more than any others gave an impetus, which it still feels, to the scientific study of medicine in the United States.

There had been, of course, in Paris many students from this country prior to 1830, but they do not form a school, recognizable to us at present. One name comes to my mind, that of the Rhode Island philosopher, Eiisha Bartlett, a jjeripatetic of the peripatetics, in the days when men moved from city to city, like the Sophists of ancient Greece. I do not know whether when in Paris in 1828 he came personally under Louis' influence— probably not, as Louis spent part of that year in Spain — but he brought back recent French methods, with Gallic lucidity and a keen appreciation of the value of the numerical method. His well known work on Typhus and Typhoid Fever, issued in 1842, is in itself a lasting witness to the intelligence and progressive character of the younger teachers of that day. With a clear separation of Typhus, Typhoid, the Periodic and Yellow Fevers, it had at the date of its publication no counterpart in Eurojiean literature, and is in remarkable contrast to the chaotic treatises of Armstrong, Fordyce, Tweedie, Southwood Smith and othei'S.

Without attempting to give a comjilete list, the following were among the American students in Paris between 1830 and 1840:

From Boston, James Jackson, Jr., H. I. Bowditch, Oliver Wendell Holmes, Geo. 0. Shattuck, Jr., John D. Fisher, J. C. Warren (then past middle age), and J. Mason Warren.

From New York, John A. Swett, Abraham Dubois, Alonzo Clark, Charles L. Mitchell, Charles D. Smith, Valentine Mott, Sr., and John T. Metcalf.

From Philadelphia, Geo. W. Norris, W. W. Gerhard, Casper W. Pennock, Thomas Stewardson, Alfred Stille, Thomas D. Muter, J. Campbell Stewart, Charles Bell Gibson, John B. Biddle, David H. Tucker, Meredith Clymer, Wm. P. Johnston, W. S. W. Itusheuberger, Edward Peace, William Pep2)er, Sr.

Fi-om Baltimore, William Power.

From the South, Peter C. Gaillard, Gibbs, and Peyre Porcher of Charleston ; J. L. Cabell, L. S. Joyues, Selden and Randolph of Virginia.

" And many more whose names on earth are dark " — men of the stamp of Dr. Bassett of Alabama, who felt the strong impulsion to know the best that the world offei'ed, every one


of whom has left a deep and enduring impression in his sphere of work.

It would be impossible to tell in detail how Louis' students brought back his spirit and his methods to their daily work, and of the revolution which they gradually effected in the study and in the treatment of disease. I can best, perhaps, fulfill my object by referring somewhat fully to two of the most distinguished among them, James Jackson, Jr., and W. W. Gerhard.

James Jackson, Jr., is the young Marcellus among the physicians of this country, "the young Marcellus, young, but great and good." I do not know in our profession of a man who died so young who has left so touching a memory. He was the son of Dr. James Jackson, of Harvard, one of the most distinguished of New England's physicians, a man to whom our generation owes a heavy debt, since he, with Jacob Bigelow, was mainly instrumental in bringing about more rational ideas on the treatment of disease. Of Louis' pupils from this side of the water, young .lackson seems to have been his special favorite. After taking the B. A. degree at Cambridge in 1828, Jackson attended the medical lectures at Harvard, and in the spring of 1831 went to Paris, where he remained until the summer of 1832. Returning home in 1833, he graduated in medicine at Harvard in 1834. In the two years and a half of his studies in this country before going abroad he had had exceptional opi)ortunities with his father at the Massachusetts General Hospital, and showed his early industry and ability by taking one of the lioylston Prize Essays before the completion of his second year of study.

In Paris he attended the practice of La Pitie and St. Louis. He soon became devoted to Louis, and by him was utilized to the full in the cholera epidemic in 1832. Two letters from Louis to James Jackson, Sr., show how important he thought a prolonged period of study was for a young man. He says: " I pointed out to him (James Jackson, Jr.) the advantage it would be for science and for himself if he would devote several years exclusively to the observation of diseases. I now retain the same opinion and am strengthened in it; for the more T become acquainted with, and the more I notice him applying himself to observation, the more I am persuaded that he is fitted to render real service to science, to promote its progress. I find that he would be well pleased to follow for a certain period the vocation for which nature has fitted him ; but he has stated to me that there are many difKculties which would prevent his devoting himself exclusively to observation for several years. But can these difKculties be insurmountable?"

xVud again : " Let us sup2)ose that he should pass four more years without engaging in the practice of medicine, what amass of positive knowledge will he have acquired! How many important results will he have been able to publisli to the world during that period ! After that he must necessarily become one of the bright lights of his country; others will resort to him for instruction, and he will be able to impart it with distinguished honor to himself. If all things be duly weighed, it will appear that he will soon redeem the four years, which men of superficial views will believe him to have lost." In another letter, the following year, just before young


August-September, 1897.]

165


Jackson's departure from Paris, he refers again to this question and urges Dr. Jackson to allow his son to devote himself exclusively to observation for several years in Boston. The extract from this letter is worth quoting. "Think for a moment, sir, of the situation in which we physicians are placed. We have no legislative chambers to enact laws for us. We are our own lawgivers ; or rather we must discover the laws on which our profession rests. We must discover them and not invent them ; for the laws of nature are not to be invented. And who is to discover these laws? Who should be a diligent observer of nature for this purpose, if not the son of a physician, who has himself experienced the difficulties of the observation of disease, who knows how few minds are fitted for it, and how few have at once the talents and inclination requisite for the task ? The inclination especially, for this requires that the observer should possess a thorough regard for truth, and a certain elevation of mind, or rather of character, which we rarely meet with. All this is united in your son. You ought — for in my opinion it is a duty — you ought to consecrate him for a few years to science. This, sir, is my conviction, and I hope it will be yours also. I know very well that every one will not be of the same opinion ; but what matters it, if it be yours ? — if you look upon a physician, as I do, as holding a sacred office, which demands greater sacrifices than are to be made in any other profession."

Young Jackson's letter to his father, just as he was quitting Paris, indicates on what affectionate terms he had lived with Louis. " In two hours I am out of Paris. I will not attempt to describe to you the agony it gives me to quit Louis. He is my second father, and God knows that is a name I of all men cannot use lightly. I may not persuade you to look upon him with my eyes exactly as a scientific man ; but in your heart he must have the share of a brother; for he almost shares my affection with you. From one upon whom I had no claims but those which my life and mind and habits gave me, I have experienced a care, an affection which I never could dare expect from any but my dear father, and which I shall ever feel to be the most honorable and truly worthy prize of my life."

He seems to have inspired the same tender feelings in all his American students. In the Memoir of Dr. Bowditch, to which I have already referred, he speaks of Louis' fatherly kindness to him during a prolonged attack of rheumatic fever lasting for many weeks.

Young Jackson was one of the founders, in 1833, of the Society for Medical Observation, which consisted of the ablest of the students of Louis, Chomel and Andral. During his stay in Paris he made an important study of cholera, which was published in this country in 1833. It was most timely, as it gave the profession here a very clear and accurate description of the disease, of which up to that time they had had no experience. Jackson's name, too, will always be associated with the studies upon emphysema, and he is the discoverer of the prolonged expiration in early pulmonary tuberculosis.

Returning to Boston in the autumn of 1833, he spent the winter preparing for his degree and elaborating the notes which he had taken in Paris. In March he fell ill with a dysentery, which proved fatal on the 37th of the month, in the


twenty-fifth year of his age. I know of no young man in the profession who had given pledges of such exceptional eminence. His influence in extending Louis' methods and views throughout New England was chiefly through his father, who, though a man approaching his sixtieth year, became an ardent follower of Louis and the numerical method.

In Oliver Wendell Holmes' recently issued Biography you will find a delightful description of life at the Medical School of Paris at this period. He bears witness to the good effect which Jackson's warm friendship with Louis had had in promoting the interests of American students. I may conclude with a quotation from Dr. Jackson's, Sr., memoir: "At the suggestion and request of one of my most judicious brethren I shall add that my sou's influence on the profession here, in the short time he was with us, was of a very salutary description. This gentleman states that my son not only caused others, who had not yet read the works of M. Louis, to study them with care, but that he induced among the rising members of the profession in our own city the habits of thorough observation of the phenomena of disease in the living and in the dead, which he had learned from the same great pathologist. He also taught us much in respect to the physical signs of disease in the thorax, with which we were imperfectly acquainted before; at least I may say this was true as to myself. Indeed I ought to say more, for he aided me very much in regard to the diagnosis of the more obscure diseases of that region, derived from the combination of the physical and rational signs. On emphysema of the lungs he threw, for me, quite a new light."

Wm. W. Gerhard was the most distinguished of the American pupils in Paris between 1830 and 1840. When you call to mind the men whom I have mentioned, this may seem a strong statement, but I feel certain that could we take their suffrages they would accord him the place of merit in consequence of the character of his work. Dr. Gerhard was born in Philadelphia, in 1809, and was graduated from the University of Pennsylvania in 1831. Early in the year he went to Paris and attached himself to Louis at La Pitie. In one of his letters* to his brother, dated January 18, 1833, he says: "Dr. Louis is delivering an interesting clinic at La Pitie ; he is a remarkable man, very different from the physicians of Eni^land or America, and remarkable even at Paris by the strict mathematical accuracy with which he arrives at his results ; he is not a brilliant man, not of the same grade of intellect as his colleague at La Pitie, Andral." In another letter he gives an account of his day's work. "The morning from seven to ten is occupied with the visit and clinic at the hospital ; there are several distinct clinics now in actual proo-ress; each of them has its advantages. I shall vary my attendance at the different hospitals and select those lecturers who are of real merit. At this moment we are following ing Piorry at the SalpetriOre, a very distant hospital, two or three miles from our lodgings; his patients are all old women, and not interesting. My object in following his course is to obtain some interesting information on the best mode of


  • I am indebted to members of Dr. Gerhard's family for the letters

from which these extracts are taken.


166

[Nos. 77-78.


investigating the diseases of the chest. M. Piorry has devoted special attention to this subject. From Salpetriere we hurry to La Pitie; we hear a surgical lecture, reach home to breakfast, and then to the school of medicine. The lectures at the school, with a private course of anatomy during the hour of intermission, fill up the remainder of the day until four. Fortunately a private clinic at La Charite introduces me to a set of very interesting cases, especially on pectoral cases. Dr. Dagueau has a class who pay him ten francs a month and enjoy the privilege of examining the patients much more conveniently than is practicable during the morning visit in the midst of a crowd of students. We dine at five-thirty and then lectures again until eight o'clock. Imagine the facilities, the delightful advantage of acquiring positive information, and what is at least as important, of learning the mode of obtaining these positive results. We see and hear the men who are so well known to us in America, learn to form a correct estimate of their relative worth — in short, one of the most striking advantages of a medical visit to Europe is to acquire the sort of liberal professional feeling which is rarely secured by the continued intercourse with the same men, and the unpleasant medical politics which divide the profession in America."

Evidently Broussais made no special impression on Dr. Gerhard. He says, " Broussais is the best known, his reputation is universal, and the benefits he has conferred on medicine are immense, but unfortunately he is a wretched lecturer. His own opinions are given in the most awkward, clumsy manner; the manner and style of lecturing are coarse and vulgar."

In another letter of February 3, 1833, he tells how he induced Louis to give them private instruction. To his brother he writes : " I must write you at least a few days before the excitement has passed off : can you imagine how fortunate I am — devinez si vous pouvez— two or three days ago, Jackson, Pennock and myself were talking of hospitals and morbid anatomy, when the idea occurred of attempting the study of pathology in a particular manner. It was this: to obtain the specimens and study them, the authors in our hand, exactly and carefully comparing authorities with the subject before us. We addressed ourselves to two of the internes at La Pitie attached to the salles of Louis and And-ral, and they agree to procure all facilities in their power and communicate their own information for the compensation of 60 francs from each of us ; we accordingly visit La Pitie on three afternoons of the week and examine the parts at the hospital, afterwards carrying home such portions as require minute investigation. Our first success in this opening of new sources of instruction emboldened tis to attempt something of higher importance. We were all desirous of studying auscultation, of studying it in such a manner as to be sure of our ground on our return, and to be capable of appreciating the advantages of the art. Louis' public instructions were valuable, but his private lessons upon a subject demanding minute and patient inquiry we knew would be infinitely moi'e so. I therefore in the name of my friends addressed him a polite note, accomjianied by a handsome pecuniary offer; we did this with little hopes of success, but happily for us he accepted our proposition, and next week we are his private pupils at La Pitie. We are, I


believe, the first who have made this arrangement with M. Louis, and you may estimate its importance when I tell you that he is considered in excellence of diagnosis the successor of Laennec. Our advantages for the study of pathology and the diagnosis of diseases of ttie chest are now superior ; they are indeed the very best in the world, and our eagerness to embrace them will, I hope, render them of real utility ; of course they involve an additional expenditure of 400 or ."300 fr., but I should be happy to shorten my stay at Paris a mouth to improve the remainder of my time in this manner, if such were necessary for me. Pennock and myself are very happy to have become intimate with .Jackson ; he has superior talents, and his excellent education, conducted by his father, unquestionably the first physician in America, has cultivated his mind and developed an ardent attachment to medicine."

Few American students have occupied their time abroad to greater purpose than Dr. Gerhard. He appears to have been an indefatigable worker, and the papers which he published based upon material collected in Paris are among the most important which we have from his pen. Thus with Pennock he described Asiatic cholera in 1832. Devoting himself particularly to the study of diseases of children, he issued a very interesting paper on small-pox, and two papers of very special value, the first on tuberculous meningitis and the other upon pneumonia in children. Both of these papers mark a distinct point in our knowledge of these two diseases. He is usually accorded the credit of the first accurate clinical study of tuberculous meningitis.

Late in the year 1833 he returned to Philadelphia, and at his suggestion his friends had secured him the appointment as resident physician at the Pennsylvania Hospital, which he took early in 1831. This step indicated how carefully he had weighed the important influence in Louis' career of the years of quiet work at La Charite. At the Pennsylvania Hospital he had an opportunity to study the common continued fever of the country, and determined that it was identical, clinically and anatomically, with the typhoid fever of Louis, and characterized by a special lesion in the glands of Peyer. I do not know exactly how long he remained resident physician at the Pennsylvania Hospital, but he was soon after appointed one of the physicians at Blockley, and here in 1836 he was able io carry out his most important piece of work. The general opinion prevailed that the fever which Louis described and which had the lesions in the small bowel was only a modification of the ordinary typhus fever which at that time prevailed so extensively, particularly in Great Britain and Ireland. In London, Edinburgh and Dublin the intestinal lesions were regarded as only accidental, and not indicative of a special affection. Dr. Gerhard knew the typhoid fever of Louis well, and had had an opportunity of studying it again at the Pennsylvania Hospital, so that when the epidemic of typhus fever developed in 1836 he was in a very good position to make an accurate study of the disease. Two hundred and fourteen cases were observed, and as a result of his study he declared positively that the typhus fever, which was similar to the disease which he had also seen in Edinburgh, was a different affection altogether from the typhoid fever with intestinal lesions. These observations, vou must remember.


August-September, 1897.]

167


were made in 1836, at a time when the greatest confusion existed as to the forms of fever. It took a great many years in Great Britain before the duality of the prevalent fever was recognized, but owing to the influence of Gerhard's paper, and to the accurate knowledge of fever brought to this country by Louis' pupils, the differentiation of the two diseases was here quickly recognized, since, as already mentioned, Bartlett in 1812 considered them apart.

Gerhard's work influenced his Paris friends greatly, and this was strengthened by the papers read before the Society for Medical Observation by Geo. C. Sbattuck and Alfred Stille, of whom the former had had opportunities of studying typhus fever in Great Britain, while the latter had been one of Gerhard's house physicians in the typhus epidemic at Blockley. Shattuck's paper is published in the Medical Examiner for 1840. I have always regretted that Dr. Stille's paper has never appeared in print. He was kind enough to let me see it, and, as I have mentioned elsewhere, the differential points between typhus and tyi^hoid fever are nowhei-e more clearly laid down.

The University of Pennsylvania early took advantage of Gerhard's training and utilized him as clinical lecturer at the Philadelphia Hospital. He soon acquired a special reputation in diseases of the heart and lungs. In 1842 appeared the first edition of his work on Diseases of the Chest, which ran through four editions, and is still a valuable work of reference. One of his fellow-students in Paris, Stewardson, has given a very pleasing picture of him as a clinical teacher : " As a clinical teacher he was remarkably successful and exerted a powerful and commanding influence. Without any pretension to eloquence, he nevertheless riveted the attention of his hearers and stimulated their enthusiasm. Himself deeply interested in bis subject, he communicated this interest to his audience by the sheer force of truth. Students saw that truth was his object, not display ; the advancement of science, and not the gratification of personal feelings, whether of vanity or ambition; in short, that in his mind, a deep interest in his subject and a thorough conscientiousness in the pursuit of it were the overmastering motives. In an easy and conversational


style he presented to his hearers a graphic portraiture of the case before them, bringing into relief its most important symptoms; impressing upon their minds the most striking features in its history; pointing out, by a few clear and practical expressions, the bearing of any particular fact upon interesting medical questions, but avoiding long and labored arguments, or general disquisitions upon the nature of diseased action. He neither stimulated the fancy by the flowers of rhetoric, nor amused the intellect with episodes upon theoretical questions, but confined himself to drawing such practical conclusions as were clearly deducible from the facts presented. No man of his day enjoyed so high a reputation as a clinical teacher, and not only did he succeed in an eminent degree in arousing the enthusiasm of students and putting them in sympathy with himself, by infusing into them his own ardor in his favorite study ; but he produced an influence upon the profession here which is felt still, which has fostered the establishment of clinical teaching among us, and done much to give it that rank which it now occupies here as a branch of medical instruction."

Of the work of Louis' other students in this country time would fail me to tell — of the influence of Bowditch, Holmes and Shattuck in Boston, of Swett, Clark and others in New York, of Pennock, Stewardson, Stille in Philadelphia, and of Power in Baltimore. To them all we owe a heavy debt of gratitude. They brought from Paris enthusiasm, faith in the future, faith in the profession of their choice, accurate methods and a loyal love of truth. Endowed with the spirit and zeal of their master, they carried his great message to the New World ; and more than this, touched with those finer qualities which made Louis so lovable, they have become bright ideals for all future generations of American students.

There remain, so far as I know, three only of the Paris students of whom I have spoken, John T. Metcalf, Meredith . Clymer, and your honored patron, Alfred Stille. They, too, must soon go the way of all the earth ; but among the consolations of old age what greater solace can they feel than that the lives of the men whose fathers and grandfathers they taught are still made better by their presence.


WILLIAM HARVEY AS AN EMBRYOLOGIST.*

By William K. Brooks, LL. D., Professor of Zoology, Johns Hoiikins JJniversUy.


The immortal discoverer of the circulation of the blood is held to be also the discoverer of the law of embryology — "that all animals are produced out of ova" (Encyc. Brit., 9th ed., art. Embryology, p. 164); and he is also held to have had some vague premonition, scarcely worth mentioning in history, of the great law that the complex animal arises, from a relatively homogeneous germ, by gradual differentiation or epigenesis.

I hope to show, by quotations from his work on embryology (Exercitationes de Generatione Animalium, Amstelodami,


■ Read before the Johns Hopkins Historical Club, February, 1897.


1651, translated into English by Robert Willis, M. D., London, 1848), that both these current impressions are erroneous. He not only formulated but demonstrated epigenesis. liis statement of this law is clear, definite and thoroughly modern, and it is based upon actual observations which are fully described.

On the other hand the conception which he sought to express by the dictum "omne vivum ex ovo" is totally foreign to the principles of modern embryology. Harvey was a worker, not a dreamer, and his dictum is no mere guess or happy inspiration. It sums up results reached by laborious research, and as a generalization based on actual study it still has value,


although its meaning has nothing in common with tliat which the words have as we now use them. He repudiates in most energetic language the opinions, current at his time, which come nearest to the modern discovery that the physical continuity of living matter is never broken. In fact the chief aim of his treatise is to show that his observations, as he interpreted them, prove that there is no physical or " corporeal " continuity between parent and child.

Embryologists who permit Germans to write the history of their science, and make no protest when the demonstration that the embryo arises from the egg by epigenesis is attributed to Wolff (1759), and to Von Baer (1839), are either ignorant of Harvey's researches (1651) or indifferent to the fame of this great Englishman, who studied the history of the chick as laboriously and faithfully as Von Baer, nearly two hundred years before. While his resources were more limited, his ability to reflect upon the meaning of his observations and to state in clear and energetic words the results of his " Beobachtung und Eeflexion," were inferior in no way to those of the justly famous author of the "Entwickeluugsgeschichte der Thiere."

Harvey means just what more modern writers mean by "epigenesis," but the strangeness of the views he opposed gives us difficulty. The form of words into which an account of a scientific discovery falls is fixed by the view of the matter which is current at the writer's day, and later generations of readers may be puzzled by inability to occupy his standpoint. Thus it is with Harvey, and we thus explain the prevalence of the opinion that he had no more than a dim adumbration of truths the demonstration of which is generally credited to Wolff and Von Baer.

The evolutionary teachings of Bonnet are quite intelligible to us; and as we easily put ourselves in Von Baer's place, his refutation of Bonnet appeals to us with all its native force; but it is much harder for us to stand where Harvey stood.

So far as I can discover, no notion at all equivalent to Bonnet's conception of germs ever entered Harvey's mind or the mind of any one before his time. He presents the evidence for epigenesis as opposed, not to "evolution," but to "metamorphosis," and his way of using the last word is so unfamiliar to us that we cannot grasp what he has in mind without effort.

They who studied embryology before him held one modification or another of the very ancient belief that embryos arise from "excrement"; that they are products of decomposition.

He gives the evidence for epigenesis as opposed to this opinion which finds no pigeon-hole in the modern mind. Fortunately he is a ready writer. Hlustrations and analogies overflow his brain and pen; and patient study enables us to pick out passages which give his views on epigenesis uncomplicated by reference to " metamorphosis." When we have done this we find his reasoning as modern and definite as that of Von Baer, although his resources did not qualify him to sum up the evidence with modern exhaustiveness.

While Harvey does not deny that some " imperfect " animals may be genei-ated "out of a putrescent material, the drying of a moist substance, or the moistening of a dry one," he tells us, clearly and definitely enough, that the generation of all "per


fect " animals, such as the lion and the cock, " is the result of epigenesis as the man proceeds from the boy; the edifice of the body, to wit, is raised on the punctum saliens as a foundation ; as a ship is made from the keel, and as a potter makes a vessel . . . For out of the same material from which the first part of the chick or its smallest particle springs, from the very same is the whole chick born ; whence the first little droji of blood, thence also proceeds its whole mass by means of generation in the egg ; nor is there any difference between the elements which constitute and form the limbs or organs of the body, and those out of which all their similar [i. e. homogeneous] parts, to wit, the skin, the flesh, veins, membranes, nerves, cartilages, and bones derive their origin. For the part that was at first soft and fleshy, afterwards, without any change in the matter of nutrition, becomes a nerve, a ligament, a tendon ; what was a simple membrane becomes an investing tunic ; what had been cartilage is afterwards found to be a spinous process of bone, all variously diversified out of the same similar [homogeneous] material." From what "appears to be homogeneous in the beginning and resembles the spermatic jelly" the structure of the body arises; its parts being "at first delineated by an obscure division, and afterwards become separate and distinct organs."

He says the result of the process of development is just as if the chick were created by a command to this effect: " Let there be a similar [homogeneous] colorless mass, and let it be divided into parts and made to increase, and in the meantime, while it is growing, let there be a separation and delineation of parts ; and let this part be harder and denser and more glistening, that be softer and more colored."

" Now it is in this very manner that the structure of the chick in the egg goes on from day to day; all its parts are formed, nourished and augmented out of the same material. . . . For there is a greater and more divine mystery in the generation of animals than the simple collecting together, alteration and composition of the whole out of parts would seem to imply; inasmuch as here the whole has a separate constitution and existence before its parts, the mixture before the elements."

These passages summarize conclusions from observations which have been more fully described in forty-four preceding chapters or "exercises," and it would be difficult, even at the present day, to state in more definite language the truth that the developing embryo passes " from indefinite, incoherent homogeneity to definite, coherent heterogeneity by successive integrations and differentiations."

While we have no desire to ignore the merits of Wolff or to belittle the greatness of Von Baer, we find it hard to understand how any one who knows Harvey's works can, without protest, read this assertion or similar ones in the German works from which it is derived:

" It was reserved for Caspar Frederick Wolff, a German by birth ... to bring forward observations which . . . established the theory of epigenesis upon the secure basis of ascertained facts" (Encyc. Brit., 9th ed.. Embryology, 1(35).

We now know that the germ itself is an organism of wonderful complexity ; that its homogeneity is relative, not absolute ; but there is great mystery to us as well as to Harvey in the


August-September, 1897.J

169


manner in which " the whole has a separate constitution and existence before its parts," and while the doctrine of "metamorphosis " as held in Harvey's day has vanished from science, I venture to believe that we shall Knd in his discussion of this doctrine, clear statement of other difficulties which are still as grave as he found them.

It is hard to decide just what his opinion on spontaneous generation was. No less careful a student than Huxley tells us (Encyc. Brit., 9th ed., art. Evolution, p. 746) that "Harvey believed as implicitly as Aristotle did in the equivocal generation of the lower animals." "Harvey shared the belief of Aristotle — whose writings he often quotes, and of whom he speaks as his precursor and model, with the generous respect with which one genuine worker should regard another — that such germs may arise by a process of 'equivocal generation' out of non-living matter."

1 am by no means confident that this assertion does justice to Harvey, or that the quotations from Aristotle prove anything except that Harvey was not yet quite prepared to demonstrate their error. I believe there is ample evidence that he had made many observations which, while he never published them, led him to distrust most of the familiar examples of spontaneous generation, although he may not have been fully armed to attack the teachings of " my leader," Aristotle, "one of nature's most diligent inquirers," "whose authority has such weight with me that I never think of differing from him inconsiderately." It is true that he quotes without comment, and occasionally without credit, many passages in which Aristotle affirms sjjontaneous generation ; but as an offset to this he tells us explicitly (Exercise the forty-first) that he shall show in another place " that many animals, especially insects, arise and are propagated from elements and seeds so small as to be invisible (like atoms flying in the air), scattered and dispersed here and there by the winds ; and yet these animals are supposed to have arisen spontaneously, or from decomposition, because their ova are nowhere to be found." He was far too cautious to have ventured to criticise " the philosopher," even to this extent, without pretty good evidence; and in Exercise the sixty-ninth he tells us why this evidence was never published. "Let gentle minds forgive me," he asks, "if, recalling the irreparable injuries I have suffered, I here give vent to a sigh. This is the cause of my sorrow: — whilst in attendance on his majesty the king, during our late trouble and more than civil wars, not only with the permission but by the command of the Parliament, certain rapacious hands stripped not only my house of all its furniture, but, what is subject of far greater regret with me, my enemies abstracted from my museum the fruits of many years of toil. Whence it has come to pass that many observations, parlictilarly on the generation of insects, have perished, with detriment, I venture to say, to the republic of letters."

Is there not reason to believe that, if they are ever discovered, those lost observations will be found to cover some of the ground which was so successfully explored by Spalanzanni more than a hundred years later ?

Harvey's reference (Exercise the twenty-seventh) to " the animalculae which are engendered in our bodies . . . lumbrici,


ascarides, lice, nits, syrones and acari," and to " the worms which are produced from plants and their fruits, as from gallnuts, the dog-rose, and various others," might be held to imply belief in heterogenesis, if he did not tell us, almost immediately, that: "It certainly cannot be that the living principles of these animals which arise in the gall-nuts existed in the oak, although these animals live attached to the oak and derive their sustenance from its juices."

Notwithstanding Huxley's opinion, Harvey seems to have been nearer than any of his successors for a hundred years to the modern discovery that all living things come from germs, although I shall show soon that he did not intend to imply anything at all like the modern view by his statement that this is true.

In his discussion of epigenesis as contrasted with " metamorphosis," he assumes the reality of " equivocal " generation, as he does in many other places, although, in view of the passages I have quoted, I believe that this is admitted out of courtesy to Aristotle, and for the sake of the argument, as something which he is not yet fully prepared to disprove.

He tells us (Exercise the forty-fifth) that there are two ways in which one thing may be made out of another. When a workman cuts the material already prepared, divides it and rejects what is superfluous, till he leaves it in the desired shape, as in nuiking a statue from a block of stone, the whole material of the future piece of work has already been in existence before it is finished into form or any part of the work is yet begun. AVhen on the other hand a potter educes a form out of clay by the addition of parts, increasing its mass, and giving it a figure, at the same time that he provides the material, which he prepares, adapts and applies to his work, "the form may be said rather to have been made than educed." " So exactly it is with regard to the generation of animals. Some, out of a material previously concocted and that has already attained its bulk, receive their forms and transfigurations ; and all their parts are fashioned simultaneously, each with its distinctive characteristics, by the process called metamorphosis, and in this way a perfect animal is at once born; on the other hand, there are some iu which one part is made before another, and these from the same material afterwards receive at once nutrition, bulk and form ; that is to say, they have some parts made before, some after others, and these are at the same time increased in size and altered in form. The structure of these animals commences from some one part as its nucleus and origin, by the instrumentality of which the rest of the limbs are joined on, and this we say takes place by the method of epigenesis, namely by degrees, part after part; and this is, in preference to the other mode, generation properly so called. In the former of the ways mentioned, the generation of insects is effected when by metamorphosis a worm is born from an egg ; or out of a putrescent material, the drying of a moist substance or the moistening of a dry one, rudiments are created from which, as from a caterpillar grown to its full size, or from an aurelia, springs a butterfly or fly already of a proper size, which never attains to any larger growth after it is first born. But the more perfect animals with red blood are made by epigenesis or the superposition of parts. In the former, chance or hazard seems the principal promoter of gen


170

[Nos. 77-78.


eration, aud the form is due to the potency of a pre-existing material ; and the first cause of generation is 'matter ' rather than an ' external efficient,' while the more perfect animals owe their immortality to one constant source — the perpetuation of the same species . . . Bees, wasj^s, butterflies, and whatever is generated from caterpillars by metamorphosis, are said to have sprung from chance, aud therefore to be not preservative of their own race. . . . The lion and the cock owe their existence, as it were, to nature, or an operative faculty of a divine quality, and require for their propagation an identity of species, rather than any supply of fitting material." " In the generation by metamorphosis forms are created as if by the impression of a seal, or as if they were adjusted in a mould . . . but an animal which is created by epigenesis attracts, prepares, elaborates, and makes use of the material all at the same time. The processes of formation aud growth are simultaneous. In generation by metamorphosis the whole is distributed and separated into parts, but in that by epigeuesis the whole is put together out of parts, in a certain order, and constituted /ro?» them. In the one case the result is due to matter ; in the other the animal makes itself.

" Now it appears clear from my history that the generation of the chick from the egg is the result of ejjigenesis rather than of metamorphosis, and that all its parts are not fashioned simultaneously, but emerge in their due succession and order; it appears, too, that its form proceeds simultaueously with its growth, aud its growth with its form; also that the generation of some parts supervenes on others previously existing, from which they become distinct; lastly, that its origin, growth aud consummation are brought about by the method of nutrition.

" The formative faculty of the chick rather acquires and prepares its own material than only finds it when prepared, aud the chick seems to receive its growth from no other than itself. And as all things receive their growth from the same power by which they were created, so likewise should we believe that the chick is created by the same power by which it is preserved and caused to grow."

The meaning of this rather puzzling passage will be somewhat clearer after we have examined Harvey's views on generation, but when we omit the complications which come from the reference to "metamorphosis," its meaning as interpreted by the rest of the essay is about as follows :

The substance which composes the body of all "perfect" animals does not exist as such before the body itself is formed; but it consists of unorganized or "homogeneous " food which is changed by nutrition into all the diversified parts of the complicated body, so that nutrition, growth aud development go on together. As the organized body is constructed by the assimilation of unorganized food, its structure cannot be the outcome of the ordinary or physical properties of this food. There must be some organizing iufiuence at work making use of these properties to construct out of homogeneous matter a definite organism belonging to the same species with the parents. To the question what this organizing influence is, he answers that this is a " divine mystery," or, in plain English, that he does not know, although he finds clear evidence of its existence. He says in many places that the egg has a ■' vital principle," but the context shows that he means


by this no more than we mean when we say it is " alive," and nothing is farther from his thoughts than recourse to supernatural agencies, for he tells us clearly that while the cause of its development is a " divine mystery," " the egg is a natural body endowed with animal virtues ... it is moreover a body which under favorable circumstances has the capacity to pass into an animal form; heavy bodies, indeed, do not sink more naturally, nor light ones float, when they are unimpeded, than do seeds aud eggs in virtue of their inherent capacity become changed into vegetables aud animals." (Exercise the twenty-sixth, p. 373.)

It would be a gross error to infer, from this passage or from others like it, any further similarity between Harvey's opinions aud the results of moderu microscopic study of ova and male cells. In order to understand the meaning of his celebrated dictum " omne vivum ex ovo " we must undertake more extended analysis of his observations aud reflections on generation, aud of the opinions of his predecessors.

Aristotle saw nothing strange or exceptional in the generation of animals from decomposing organic matter, for he believed that all generation takes place in essentially the same way ; and he regarded the generation of insects from putrescent slime as a simple or typical example, what we should now call a primitive type, of generation in general, in comparison with which more complicated instances are to be interpreted.

As a bloody substance is discharged at intervals from the reproductive organs of woman, during the fertile period of her life, and as its apjiearance marks the beginning and its cessation the end of fertility, he believed that the mammalian embryo is formed out of this substance just as other animals are generated from decomposing matter of other kinds.

" Milk aud the menstrual discharge," he tells us (De Gen. II, i), " are of the same nature." " When the semen masculinum enters the female uterus it coagulates the purest part of the catamenia," aud when this has " set in the uterus " it forms a coagulum like curdled milk. As heat causes milk to curdle, so " the semeu or geniture of the male bears the same affinity to the nature of the catamenia " aud causes it to " set " without itself contributing any part of the substance of the coagulum. " The female always supplies the matter, the male the power of creation, and this it is which constitutes one male and another fenuile." "The male is the efficient agent, aud by the motion of his geniture creates what is intended from the matter contained in the female." " The body and the bulk therefore are necessarily supplied by the female; nothing of the kind is required from the male; for it is not even requisite that the instrument, nor the efficient agent itself, be present in the thing that is produced. The body then proceeds from the female ; the life (anima) from the male."

Harvey points out the inconsistency of Aristotle's admission that hybrids "partake of the species of both parents" (De Gen. Anim. II, 3), and his assertion that '• the conception or egg receives '" "from the feuuile its body solely and its dimensions," and that the mother has no part in the trausmissiou of "form, species and life"; for the studj" of jiybrids shows the error of his opinion that creative force or vital power is


August-September, 1897,

171


derived exclusively from the male, and proves that both parents must be efficient in determining form or species.

The medical men of Harvey's day held a different opinion, as he tells us iu Exercise the thirty-second. Like Aristotle, they held that the embryo arises from "excrement"; but they held, in opposition to his teaching, " that the prime matter of conception is not blood, but the mingled geuitures of both sexes." They also held, iu opposition to Aristotle, the opinion, which Harvey shares, that the male is no more " the efficient cause of generation " than the female.

"Conception, according to the opinion of medical men, takes place in the following way: during intercourse the male and female dissolve in one voluptuous sensation, and eject their seminal fluids (geniturae) into the cavity of the uterus, where that which each contributes is mingled with that which the other supplies, the mixture having both equally the faculty of action and the force of matter; and according to the predominance of this or that geniture does the progeny turn out male or female. It is further imagined that immediately after the intercourse something of the conception is formed iu the uterus."

If the uterus contains a " conception " immediately after a fertile union, in the form of a bloody coagulum, as Aristotle supposes, or iu the form of the mingled emissions or geuitures of both sexes, as the medical men taught, this ought to be discoverable, and Harvey, a true scientific investigator, set himself to hunt for it without a microscope.

His facilities for making the search, and its results, are best described in his own words. He was the attending physician of the King of England, and he tells us : " It was customary with his Serene Majesty, King Charles, after he had come to man's estate, to take the diversion of hunting almost every week, both for the sake of finding relaxation from grave cares and for his health; the chase was principally the buck and the doe, and no prince iu the world had greater herds of deer. This gave me an opportunity of dissecting these animals almost every day during the whole of the season when they were rutting, taking the male and falling with young. I had occasion so often as I desired it to examine and study all their parts, particularly those devoted to the offices of generation."

His studies upon the development of the embryo of the deer are fully described at length in the essay on generation, but only those which relate to the question of conception concern us at present. Here his researches had a very definite result, "llepeated dissections performed in the course of the month of October, both before the rutting season was over and after it had passed, never enabled me to discover any blood or semen or a trace of anything else, either in the body of the uterus or its cornua." Neither the bloody coagulum of Aristotle nor the geniture of the medical men has any existence. The "conception" which should be discoverable iu the uterus if their teachings are correct, cannot be found there when a search is made for it, and actual observation shows that their teachings are erroneous and fanciful.

The keepers and huntsmen said " that I was both deceiving myself and had misled the king, and that there must of necessity be something of the conception to be found in the uterus. These men, however, when I got them to bring their


own eyes to the inquiry, gave up the point." Harvey tells us that the king fully appreciated the value of the investigation, and in order " that this important question might be the more satisfactorily settled in all time to come," provided means for isolating the does and for proving that there was no error as to the fact of conception ; but the physicians were still unconvinced, and "held it among their impossibilities that any conception should ever be formed without the presence of the semeu masculinum, or some trace remaining of a fertile intercourse within the cavity of the womb." But the man who had proved the error of their teachings regarding the function of the heart and blood-vessels had little tolerance for their belief iu anything which they were unable to demonstrate.

If they had insisted that Harvey's resources were inadequate, that the "conception" for which he sought is too minute to be found by such rough means, we now know they would have been in the right, for even at the present day our knowledge of the essential facts of mammalian conception is, for the most part, a deduction from observations on the eggs of animals which were almost or quite uuknown to Harvey, the sea-urchin and ascaris, for example. But his proof of the non-existence, in the uterus of the doe, of anything corresponding to their teachings is conclusive. He did not stop here, however, for he tells us: " In the dog, rabbit and several other animals, I have found nothing iu the uterus for several days after intercourse ; I therefore regard it as demonstrated that after fertile intercourse among viviparous as well as oviparous animals there are no remains in the uterus either of the semen of the male or of the female emitted in the act; nothing produced by any mixture of these two fluids, as medical writers maintain, nothing of the menstrual blood present as 'matter' iu the way Aristotle will have it; in a word, that there is not necessarily even a trace of the conception to be seen immediately after fruitful union of the sexes. It is not true, consequently, that in a prolific connexion there must be any prepared matter in the uterus, which the semen masculinum, acting as a coagulating agent, should congeal, concoct and fashion or bring into a positive genei'ative act."

His study of the generation of birds leads him to the same result. "As the hen does not emit any seminal fluid, and as the seminal fluid of the cock does not reach the uterus of the heu, and as there is no trace of an egg to be found in the uterus immediately after intercourse, it is obvious that it is not engendered" by the mixture of seminal fluid in the way the medical men teach (Exercise the thirty-second). After quoting Aristotle's opinion that the chick is formed out of menstrual blood coagulated by the influence of the cock, he says (Exercise the twenty-first) : " The business in the generation of an egg is very different from this; for neither does the semen or rather the 'genitura' proceeding from the male in the act of intercourse, enter the uterus in any way, nor has the hen after she conceives any particle of excremeutitious matter, even of the purest kind, or any blood in her uterus which might be fashioned or perfected by the discharge of the male. Neither are the parts of the egg produced by any kind of coagulation ; neither is there anything like curdled milk to be discovered iu the uterus. The cock, I say, contributes neither form nor


172

[Nos. 77-78.


matter to the egg, but that only by which it becomes fertile and fit to engender a chick. And this faculty the cock confers by his semen (genitura) emitted in the act of intercourse, not only on the egg which is already begun, but on the uterus and ovary and even on the body of the fowl herself, in such wise that eggs which have yet to be produced, eggs, none of the matter of which yet exists either in the ovary or in any other part of the body, are thence produced possessed of fecundity." "Inflammable material is not set on fire by the contact of flame more quickly than is the hen made pregnant by intercourse with the cock" (315).

Careful observation on the fowl, the deer, the dog, the rabbit, and on many other animals, jiroves that none of them are generated out of excrement or decomposing matter. There is no basis in nature for Aristotle's opinion or that of the medical men, and all these teachings break down when brought to the test of actual observation. It is no small thing to prove the error of the belief, which had been current for two thousand years, and is even now embodied, through a quotation from St. Paul, in our burial service, that all forms of reproduction find their type in generation from dead putrescent matter. This Harvey accomplished by methods which are rigorously scientific ; and with this accurate but very imperfect knowledge he boldly faced and tried to answer the question, what is it which the cock contributes in virtue of which the egg "becomes fertile and fit to engender a chick '"?

He undertakes "to seek the truth regarding the following difficult questions : Which and what principle is it whence motion and generation proceed':' By what virtue does the semeuact":' What is it that renders the semen itself fruitful? Whether is that which in the egg is canse, artificer and principle of generation and of all the vital and vegetative operations — conservation, nutrition, growth — innate or superadded ? and whether does it inhere primarily, of itself, and as a kind of nature, or intervene by accident, as the physician in curing disease? Whether is that which transfers the egg into a jiullet inherent or acquii-ed, or is it already conceived in the ovary, and does it nourish, augment, and perfect the egg there ? What is it besides that pireserves the egg sweet after it is laid ? What is it that renders an egg fruitful ?" (374).

" In truth, there is no proposition more magnificent to investigate or more useful to ascertain than this : How are all things formed by an ' univocal agent ' ? How does the like ever generate the like? . . . Why may not the thoughts, opinions, and manners now prevalent, many years hence return again, after an intermediate period of neglect? " (583).

As we find the embryologists of the present day vexing themselves over the question, " AVhether is that which transfers the egg into a pullet inherent or acquired?" we need not wonder if Harvey's success in the investigation of this magnificent proposition seems small to us. At least we must follow him in order to understand his dictum.

As a starting-point this much seems to be certain. "The egg, even when contained in the ovary, does not live by the vitality of the mother, but is like the youth who comes of age, made independent even from its first apj)earauce; as the acorn taken from the oak, and the seeds of jjlants in general are no longer to be considered parts of the tree or herb that supported


them, but things made in their own right, and which already enjoy life in virtue of a proper and inherent vegetative power" (375).

Furthermore, "although some animals . . . are produced from females alone" (386); "it is manifest that a fruitful [hen's] egg cannot be jjroduced without the concurrence of a cock and a hen ; without the hen no egg can be formed ; without the cock it cannot become fruitful. But this view is opposed to the opinion of those who derive the origin of animals from the slime of the ground " (384).

" The egg is the terminus from which all fowls, male and female, have sprung, and to which all their lives tend — it is the result which nature has proposed to herself in their being" (371).

"And this is the round that makes the race of the common fowl eternal; now pullet, now egg, the series is continued in perpetuity; from frail and perishing individuals an immortal species is engendered" (385).

" We cannot conceive an egg without the concurrence of a male and female fowl any more than we can conceive fruit to be produced without a tree. We therefore see individuals, males as well as females, existingr for the sake of preparing eggs, that the species may be perennial though their authors pass away. And it is indeed obvious that the parents are no longer youthful or beautiful, or lusty, and fitted to enjoy life, than while they jDOSsess the power of jiroducing and fecundating eggs, and by the medium of these, of engendering their like. But when they have accomplished this grand purpose of nature, they have already attained to the height, the dxnrj of their being ; the final end of their existence has been accouij)lished ; after this, effete and useless, they begin to wither, and, as if cast off and forsaken of nature and the Deity, they grow old, aud, a-weary of their lives, they hasten to the end. How different the males when they make themselves up for intercourse, aud swelling with desire are excited by venereal impulse! It is surprising to see with what passion they are inflamed, and then how trimly they are feathered, how vainglorious they show themselves, how proud of their strength, aud how pugnacious they prove. But the grand business of life accomplished, how suddenly, and with failing strength and pristine fervor quenched, do they take iu their swelling sails, and from late pugnacity, grow timid and desponding. Even during the season of jocund masking in Yeuus's domains, male animals in general are dejiressed by intercourse, aud become submissive and pusillanimous, as if reminded that in imparting life to others they were contributing to their own destruction. The cock alone, replete with spirit and fecundity, still shows himself alert aud gay, clapping his wings and ci'owiug triumphantly he sings the nuptial song at each of his espousals; yet even he after some length of timeiu Veuus's service, begins to fail; like the veteran soldier, he by and by craves discharge from active duty, and the hen, too, like the tree that is past bearing, becomes effete, aud is finally exhausted."

Having come to the end of his means of observation, Harvey turns to reflection, the second resource of the man of science, to see how this may help him to discover how "from frail and perishing individuals an immortal species is engen


August-September, 1897.]

173


dered." As liis studies seemed to prove that the contagion which remains in the female "after intercourse, as the efficient of the future offspring, is not of the nature of any corporeal substance," he was unable to escape the admission that it is "incorporeal." Thus driven to the wall, if he had taken refuge in "soul " or "spirit," no one could greatly blame him, for spiritual agents had been the resource of philosophers for many ages before his time. He was a true soldier of science, however, seeing as clearly as we do that this venerable formula can do notliing to help us, and preferring outspoken ignorance to this antiquated and threadbare cloak for intellectual poverty.

" If on further inquiry it should appear that it [the efficient] is neither spirit nor demon, nor soul, nor any part of a soul, as I believe can be proved by various arguments and experiments, what remains, since I am unable myself to conjecture anything beside . . . but to confess myself at a standstill ? "

What does the modern man of science in such a case? Does he not search through the whole province of knowledge to see if perchance he may find some other natural phenomenon which bears some resemblance to the subject of his studies ? Harvey says he knows well " that some censorious persons will laugh at this . . . Yet this that I do is the practice of philosophers, who when they cannot clearly comprehend how a thing really is brought to pass, devise some mode for it in accordance with the other works of nature, and as near as possible to what is true."

" Since, tlien, nothing can be apprehended by the senses in the uterus after coition, and since it is necessary that there be something to render the female fruitful, and as this is probably not material, it remains for us to take refuge in a mere conception."

Men of science in all ages, from Aristotle to Tyndall, have believed in the virtues of the provisional hypothesis; and, armed by eminent authority, Harvey undertakes, by comparing a "mere conception" with other things in nature, to frame a provisional hypothesis of generation; but natural science seems to be an uncongenial soil for the nurture of such attempts, and if time has shown that Harvey's hypothesis has little value, he errs in good company, and he also takes pains to say he does not wish it "to be taken as if I thought it a voice from an oracle," although he does hope it may "stir up the intellects of the studious to search more deeply into so obscure a subject."

Starting with the belief that "the semen of the male does not so much as reach the cavity of the uterus . . . and that it carries with it a fecundating power by a kind of contagious property " from which the female "seems to receive influence and to become fecundated without the co-operation of any sensible corporeal agent, in the same way as iron touched by the magnet is endowed with its powers and can attract other iron to itself," he holds that "when this virtue is once received the woman exercises a plastic power and produces a being after her own image."

" Yet it is a matter of wonder where this faculty abides after intercourse is completed. ... To what is the active power of the male committed ? . . . Does the woman conceive in the womb as we see by the eye and think by the brain?" " Since there are no manifest signs of conception before the


uterus begins to relax . . . and since the substance of the uterus, when ready to conceive, is very like the structure of the brain, why should we not suppose that the function of both is similar, and that there is excited by coitus within the uterus a something identical with or at least analogous to an imagination or a desire in the brain, whence comes the generation or procreation of the ovum ?" "For the functions of both are termed conceptions, and both, although the primary source of every action throughout the body, are immaterial, the one of natural or organic, the other of animal action . . . Just as a desire arises as a conception of the brain, and this conception springs from some external object of desire, so also from the male, as being the more perfect animal, and as it were the most natural object of desire, does the natural (organic) conception arise in the icterus, even as the animal concej)tiou does in the brain. From this desire, or conception, it results that the female produces au offspring like the father. For just as we, from the conception of the 'form' or 'idea' in the brain, fashion in our works a form resembling it, so in like manner the 'idea' or 'form ' of the father, existing in the uterus, generates au offspring like himself with the help of the formative faculty.

"Whoever has pondered with himself how the brain of the artist, or rather the artist by means of his brain, pictures to the life things which are not present in him, but which he has once seen ; also in what manner birds immured in cages recall to mind the spring, and chant exactly the songs they had learned the preceding summer, although meanwhile they had never practiced them; again, and this is more strange, how the bird artistically builds its nest, the copy of which it had never seen, and this not from memory or habit, but by means of an imaginative faculty, and how the spider weaves its web, without either copy or brain, solely by the help of this imaginative power ; whoever, I say, ponders these things, will not, I think, regard it as absurd or monstrous, that the woman should be impregnated by the conception of a general immaterial ' idea ' and become the artificer of generation."

"For my own part then, when I see nothing left in the uterus after intercourse, to which I can ascribe the principle of generation, any more than there is in the brain anything discoverable after sensation and experience, which are the prime sources of art, and when I find the structure of both alike, I have devised this fable."

Whatever the value of this hypothesis may be, it serves well to emphasize the fact that Harvey's opinions on generation have nothing in common with the modern discovery of the physical continuity of living matter, and it shows that his teaching that all animals come from eggs cannot possibly mean what the words now mean.

He believes the uterus conceives an animal in the same way that the brain conceives an idea; and he also tells us that he agrees with Fabricius that " the egg [of the hen] is in a certain sense an exposed uterus " (290).

Furthermore, "the hen is not the efficient cause of a perfect egg, but that she is made so in virtue of an authority, if I may use the word, or power required of the cock. For the egg, unless prolific, can with no kind of propriety be accounted perfect; it only obtains perfection from the male, or rather


174

[Nos. 77-78.


from the female, as it were upon precept from the male, as if the hen received the art and reason, the form and laws of the future embryo from his addresses" (290). Ho much for the generation of the fowl. In Exercise the sixty-ninth he describes the embryo of the doe at about seven weeks, and the human embryo about the second month after conception, but, following Aristotle, he regards these embryos in their membranes, not as embryos, but as eggs without shells. " In the way above indicated do the hind and doe, affected by a kind of contagion, finally conceive and produce primordia, of the nature of eggs, or the seeds of plants, or the fruit of trees, although for a whole month and more they had exhibited nothing in the uterus."

In this sense, then, he holds that viviparous animals are generated from eggs. He therefore maintains (as contrasted with Fabricius, who held that the greater number of animals are produced from ova) "that all animals, even the vivipara, and man himself not excepted, are produced from ova; that the first conception, from which the foetus proceeds in all, is an ovum of one description or another, as well as the seed of all kinds of plants. Empedocles therefore spoke not improperly of the ' egg-bearing race of trees.' The history of the egg is therefore of the widest scope, as it illustrates generation of every description. . . . Fabricius has these additional words: "The foetus of animals is engendered in one case from an ovum, in another from the seminal fluid, in a third from putrefaction ; whence some creatures are oviparous, some


viviparous, and yet others born of putrefaction or by the spontaneous act of nature, automatically."

" Such a division as this, however, does not satisfy me, inasmuch as all animals whatsoever may be said in a certain sense to spring from ova, and in another sense from seminal fluid, and they are entitled oviparous, viviparous or vermiparous rather in resjoect of their mode of bringing forth than of their first formation."

We see then that, unfamiliar as his words often seem, and while he holds that the organizing influence which produces the chick from the egg is a "divine mystery," we owe to Harvey the demonstration and clear formulation of the following truths :

There is no basis for the venerable doctrine that the higher animals are generated from excrement.

The hen's egg, even before it leaves the ovary, is an independent orgauism, which enjoys life by its own right, and perfects itself by nutrition.

The embryo assimilates homogeneous food, and by means of an inherent organizing power converts it into the structure of the living animal Nutrition, growth and development go on together, and the embryo arises by epigenesis or differentiation.

Many animals which have been held to arise from putrescent slime actually come from microscopic eggs.

"Animals are entitled viviparous or oviparous or vermiparous rather in respect of their mode of bringing forth than of their first formation."


LONG, THE DISCOVERER OF ANESTHESIA.

A PRESENTATION OF HIS ORIGINAL DOCUMENTS.

By Hugh II. Young, A. M., M. D., Assistant Besident Siirgeon, Johns Hopkins Hospital, Baltimore.

[Being in substance a paper read before the Johns Hopkins Hospital Historical Society, Xorember 8, 1890, with additions.]


It was my good fortune last summer to meet Mrs. Fanny Long Taylor, whose father, Dr. Crawford W. Long, is thought by many to be the original discoverer of anesthesia.

As she put me in possession of her father's papers, I thought they might prove sufficiently interesting to warrant their presentation to this Society.

During the famous ether controversy which was waged in the forties and fifties the work of Long received little attention. A modest, retiring man, who abhorred public strife and controversy, too honorable to wish pecuniary reward for his discovery, it is not strange that he made no effort to get the reward from Congress, but preferred to let the justice of his claim be judged by an unbiased posterity.

Crawford W. Long was born in Danielsville, Ga., on the first of November, 1815. His grandfather was Capt. Samuel Long of Pennsylvania, who made a brilliant record in the Revolutionary war and was one of Lafayette's captains at Yorktown. Soon after the close of that eventful struggle he left his native State and took his family to Georgia, where they settled along with a large colony of Peunsylvanians. His son, James Long, received every educational advantage


there obtainable, and inheriting his father's executive ability, became one of the prominent men of his State. Although engaged in mercantile pursuits he was a hard student of the law, and so well versed in the principles of jurisprudence that he was often consulted by judges in difficult cases.

He represented his people in the Senate for a number of years and was the intimate friend, adviser and confidant of Wm. H. Crawford, Georgia's greatest statesman, at different times Secretary of State, minister to France and candidate for the Vice-Presidency. As an evidence of attachment he gave his eldest son the name of Crawford. Coming from such ancestry it is not wonderful that young Crawford early showed promise of rare ability. As a boy he was studious and mature beyond his years, and entered Franklin College at so early an age that he was known as " baby." Notwithstanding this fact he graduated as Master of Arts second in his class at the age of nineteen. Alexander II. Stephens was his room-mate, and so much older that he was dubbed "daddy" by the college boys. Though pursuing different paths, Stephens and Long kept up an inti.nate friendship all their lives. After studying under a preceptor for one year


August-September, 1897.]

175


Long graduated at the University of Pennsylvania in 1839. While there he was recognized as a man of marked ability and fond of experimental work.

After graduation he spent one year in a New York hospital, where, it is said, he made such a reputation for himself as a surgeon that he was urged to apply for the position of surgeon in the U. S. Navy. Obedient to his father's wishes, however, he returned to practice in his native State and located in Jefferson, .Jackson Uo., Georgia, in 1841, at that time a small country town, far removed from any railroad, in the midst of a farming community whose only factory was the cotton gin.

Here Dr. Long soon acquired an extensive and lucrative practice, and although young was noted for his quiet, dignified bearing, which endeared him to all. His office was a favorite meeting-place for the young men of the town, who would often gather there to pass a merry evening together.

About this time it became fashionable to inhale laughinggas for its exhilarating effects. Itinerant lecturers on chemistry would conclude an evening's entertainment with a nitrous-oxide party in which the participants would get gloriously drunk from its inspiration.

The practice spread throughout the country, and at -Jefferson during the early part of the winter of '41 a coterie of young friends begged Dr. Long to let them indulge in the far-famed luxury.

Dr. Long replied that he had uo means of preparing nitrousoxide gas, but that sulphuric ether would produce similar exhilaration. The company being anxious to try it, the ether was produced, all inhaled of it and soon became hilarious.

The young men were delighted and hastened to tell their friends of Dr. Long's wonderful drug, and thus the inhalation of ether for sport soon became very popular over that section of Georgia, and almost every party ended up with an " ether frolic," as it was called.

During January, 1842, the ether frolics at Dr. Ijong's office became very frequent and were well attended, and some of the young men probably became pretty thoroughly intoxicated, as Dr. Long discovered that he and others would afterward have considerable bruises about their persons of which they had no knowledge.

Being a thoughtful man, he at once remarked thai ether must have the poiver of rendering one insensibU to pain, and therefore available for prevent itig pain in stirgical operations.

This was January, 1842, and Dr. Long at once determined to prove his discovery on the tirst surgical case_ he should have. That opportunity came on March 30th, when Long administered ether to Mr. James M. Venable till completely anaesthetized, and then excised a small cystic tumor from the back of his neck. Imagine the surprise of the patient when on regaining consciousness he was told that the operation was over, and his amazement when he saw the tumor in the hands of the surgeon and he had not felt a scratch. This was four and one-half years before Morton's earliest claims.

An original paper read by Dr. Long before the Georgia State Medical Society in 1852, describing these events in his own words, is appended to this paper — see Appendix I.

It is worthy of note that two and a half years later Wells of Hartford discovered the ansesthetic powers of nitrous oxide


under very similar circumstances. He attended an entertainment given by a popular lecturer on chemistry, inhaled nitrous oxide for its exhilaration, and saw a man under its influence injure his ankle severely without being conscious of it. From this he concluded that nitrous oxide was capable of producing anesthesia and proved it in extracting a tooth.

Morton, on the other hand, got his suggestion as to the ansEsthetic power of ether from Jackson, who, after using ether to relieve the pain and dyspnoea following the accidental inhalation of chlorine gas — an antidote well known in chemistry then — inferred that it might be useful as an anajsthetic. Jackson did not test the correctness of this observation, which he claims to have made about the same time that Long etherized his first case, but left it for Morton to prove practically four and a half years later.

Dr. liOng reports the first five cases in which he used ether, being desirous only of establishing priority of use. An examination of the letters and certificates before me, however, shows that he must have operated on at least eight cases before ^Morton's "discovery." This number seems small, but is not so astonishing when we remember that the country was sparsely settled, that Jefferson was a mere village, and Long had just entered practice.

I will now read in substantiation of these statements a copy of the original account in Dr. Long's journal against Mr. Venable for medical services rendered, certified to by a clerk of the Superior Court.

"James Venable

To Dr. C. W. Long, Dr. 1842. cts.

January 28th, sulphuric ether, .25

March 30th, sulphuric ether and exsecting tumor, 2.00 May 13th, sul. ether, .25

June 6th, exsecting tumor, 2.00

Georgia, I

Jackson County. ' I, P. F. Hinton, clerk of the superior court of said county, do certify that the above account is a correct copy of an original entry made in his book for medical services for the year 1842. Given under my name and seal of office this 27th of March, 1854. [Seal] (Signed) V. ¥. Hitfms, Vlerl.- S."

The following paper relative to the fashion of inhaling ether for its exhilarating effects is interesting as showing how the custom in Georgia started with Dr. Long :

" I certify that on the first of January, 1842, I resided in .Jefferson, Jackson Co., Georgia, and that about that time myself with several other young men were in the habit of meeting at Doct. C. W. Long's shop, and other rooms in the village, and inhaling ether which he adminutered to us.

On the 20th of January of the same year I removed to Athens, where I introduced the inhalation of ether. I and several of my young associates frequently assembled ourselves together and took it for the excitement it produced. After that I know it became very common to inhale ether in Athens, and tbat it was frequently taken in the college campus and on the street.

(Signed) R. H. Goodman,

August 4th, 1849. Athens, Georgia."

When we see daily the dreadful distaste patients who have been etherized have for ether, it seems strange that any one could become fond of its use.


176

[Nos. 77-78.


I will now read an account of the first operation as given by Mr. James M. Venable:

"I, James M. Venable, of the county of Cobb and State of Georgia, on oath depose and say, that in the year 1842 I resided at my mother's in Jaclcson County, about two miles from the village of Jefferson, and attended the village academy that year.

In the early part of the year the young men of Jefferson and the country adjoining were in the habit of inhaling ether for its exhilarating powers, and I inhaled it frequently for that purpose, and was very fond of its use.

While attending the academy I was frequently in the office of Dr. C. W. Long, and having two tumors on the back of my neck, I several times spoke to him about the propriety of cutting them out, but postponed the operation from time to time. On one occasion we had some conversation about the probability that the tumors might be cut out while I was under the influence of s. ether, without my experiencing pain, and he proposed operating on me while under its influence.

I agreed to have one tumor cut out and had the operation performed that evening after school was dismissed. This was in the early part of the spring of 1842.

I commenced inhaling the ether before the operation was commenced and continued it until the operation was over. I did not feel the slightest pain from the operation and could not believe the tumor was removed until it was shown to me.

A month or two after this time Dr. C. W. Long cut out the other tumor, situated on the same side of my neck. In this operation I did not feel the least pain until the last cut was made, when I felt a little pain. In this operation I stopped inhaling the ether before the operation was finished.

I inhaled the ether, in both cases, from a towel, which was the common method of taking it. Georgia, -v (Signed) James M. Ven.\blk.

Cobb Co., > Sworn to before me.

July 23rd, 1849. J Alfred Manes, J. P."

This operation was clone in the presence of fonr witnesses, Jas. E. Hayes, A. T. Thurmond, W. H. Thurmond, principal of the academy, and Edmund S. Rawls, the last of whom testifies as follows :

"Georgia, -i I, Edmund S. Rawls, of Rome, Floyd Co., Ga., on Clarke Co. J oath depose and say that ... on one occasion during that year (1842) I was present with James M. Venable in the office of Dr. C. W. Long in Jefferson, Jackson Co., Ga., and witnessed Dr. C. W. Long cut out a tumor from the side of neck of J. M. Venable while said Venable was fully under the effects of the vapor of s. ether inhaled from a towel, and without his exhibiting the least symptoms of suffering pain from the operation. J. M. Venable was so unconscious of the operation having been performed that he would not believe the tumor was removed until it was shown him. (Signed) E. S. Rawls.

Sworn to and subscribed before me this 2nd November, 1853.

E. L. Newton, /. J. C."

The patient continued to inhale ether until the operation was over, was entirely unconscious of its performance, and felt no pain. Surely this was complete ansEsthesia. This fact has been denied by Dr. Wm. J. Morton, son of the Boston discoverer, who says it was no more than mere exhilaration.

It has been stated that Long kept his discovery secret and that he therefore deserved no credit for it. I present certificates from Drs. Laperriere and Carlton, which show that his work was well known to citizens of the town of Jefferson and neighboring cities, particularly Athens, which was then the


centre of learning and culture in Georgia; that it was considered a remarkable discovery by the populace, and that the prominent physicians knew of it and realized its importance. See Appendix II.

Dr. Carlton was then a student under Dr. Moore. One year later (1844) he used ether in extracting a tooth. This was probably the first use of ether in extracting teeth. Dr. James Camak, another student of Moore, was present and assisted in the same operation and corroborates Carlton's statements.

Can Dr. Long be blamed for not publishing at once a report of his first case or two when they were well known to the physicians of that part of the State ? He had no Massachusetts General Hospital at his back, and he knew that such startling claims coming from one so young (he had not been practicing one year) would be severely criticised. It is but natural that he should be satisfied for the time being with the local and State publicity which was given to his great discovery, and waited until he could make a comprehensive report embracing all kinds of cases, such as every careful investigator does to-day.

But he kept on with his work, ojierating on two more cases under ether in 1842, and about three more during the next year, for most of which I find sworn certificates.

I have a letter from his first student. Dr. J. F. Groves, which is of particular interest as giving an insight into the character of Dr. Long and his work at that time. It is quite lengthy and I omit portions of it. The letter is written to Mrs. Taylor, Dr. Long's eldest daughter. See Appendix TIL

This letter shows conclusively that Dr. Long was thoroughly convinced of the anesthetic powers of ether, but was anxious to put it to a severe test in capital surgery. He withheld his cases of minor surgery because he wished to determine accurately the limitations and possibilities of ether.

In his paper Dr. Long does not give the details of the etherization with the minuteness we should desire. For instance, he does not say who gave the ether, the patient or himself, and he does not explain whether the patient was entirely unconscious or not, but simply remarks that he suffered no pain and did not know the tumor had been removed.

These omissions of Dr. Long led Dr. Wm. J. Morton, of New York, to write a forty-eight-page article in the Virginia j\Iedical Monthly, March, 1880, in which by dexterously quibbling with Long's innocent statements he arrives at the conclusion by a skilful process of deduction, that Long never did anything. I will read parts of this article :

"The Invention of An.esthetic Inhalation.

  • * * But we will proceed slowly. We must know who is giving the ether. Of the first operation Venable deposes under oath,

'I commenced inhaling the vapor before the ojieration was commenced and continued it until the operation was over.'

Tlius Venable kept his eye on the whole affair, knew just what was going on, otherwise how could he knowand swear to it thatbe continued the inhalation until the operation was over. Surely Veiiahlc administered the ether to himself and remained conscious all the time."

This is erroneous, for according to good legal authority


August-September, 1897

177


such a statement as Veiiable's could be made fi-um a knowledge based on satisfactory hearsaj' evidence and would be accepted in law.

But he goe.s on : "But now comes the damnatory point of this second experiment. The patient felt pain. Tliis both Long and Venable confess. Here tlien is positive failure ; Dr. Long's ansesthetic state was nothing more nor less tiian the fleeting peripheral numbness often associated with the first or e.Khilaratmg stage of the complete anesthesia of to-day. But why did Dr. Long not take the towel into his own hand and force the ether? Why not make his patient insensible to pain if he knew tliis could be done?

" Knowing what medicine knows to-day, how wonderful this halting of Long — tliis pause at a most critical moment — on the very threshold of discovery! So nicely balanced is the situation thiit it almost seems as if he would topple over into discovery; but he falls the other way.

" It seems almost inexplicable that he did not seize the towel, force the anaesthesia to the stage of stupor, perform the operation, and proclaim the discovery to the worUi," —

and we might add, patent it at once I

It is a fact well known to all surgeons that a patient may be entirely unconscious and still retain sensibility to pain. This is evidenced by the flinching before the knife when in this state. He may give evidence of feeling pain, but have no recollection of it afterward. All witnesses agree that Tenable gave no evidence of feeling pain in the first operation. He must have been jjretty thocoughly anffisthetiiied. The second operation was merely a test case to determine the length of the anaesthetic state, aud although the ether was discontinued from the beginning of the operation (which Long says was tolerably difficult on account of adhesions), still the anajsthetic state lasted until the last cut was made. We would consider .such a patient pretty thoroughly anaesthetized in Baltimore.

I have recently tested a number of patients who were being anaesthetized and found invariably that consciousness was lost before sensibility to pain — as evinced by movement of a member when pricked with a pin.

It was therefore practically certain that no j)erson could administer ether to himself, an act requiring consciousness — aud become sufficiently anaesthetized for even very small operations; but in order to settle the question definitely I determined to administer ether to myself, using the same methods as were employed by Long in 1842.

Accordingly, under the direction of Dr. F. II. Hagner of Washington, I placed a folded towel over my face and poured



Dr. CRAWFORD W. LONG


ether upon it from time to time at his bidding, as long as 1 was conscious. During this time Dr. Hagner pricked me with pins up to the last application that I remember. Toward the last the pin pricks did not produce the usual sensation of pain, but a peculiar disagreeable clanging sound in the ear.

Dr. Hagner thus briefly describes the experiment: "Dr. Young jjoured ether on the towel when so instructed by me. After a number of such additions the movements of his arm became very unsteady and he would spill some of the ether on his neck. Soon after the last application, made at my request, I pricked him with a pin and he moved his leg. I then instructed him several times to add more, but he made no attempt to do so and seemed unconscious. I then pricked him with pins several times, but received no response for about a minute, when he again responded to a prick of pin and suddenly became conscious. Comjilete consciousness returned almost immediately.

" I feel certain that he lost consciousness before sensibility to pain, and that if I had attempted to do the smallest surgical operation he would have been conscious of pain before its completion."

It is therefore certain that Yenable would have been conscious long before the small tumor was removed and would have suffered considerable pain, if he had conducted his own etherization. Nor is it probable that Long intended to convey that idea. We might with propriety say to-day that our patients "inhale ether until anesthetized," if we did not care to specify the details of etherization. Hut in a document quoted above R. H. Goodman says, in speaking of the ether frolics, " We were in the habit of meeting at Dr. Long's shop and inhaling ether which he administered to vs." It seems probable therefore that some one administered ether to the persons on whom he operated, too.

Desirous of settling these trivial points on which Morton would have Long deprived of every honor, I addressed a letter a few days ago to Long's first student. Dr. J. F. Groves, w'hose document I have quoted above. I saw that he would now be about 75 years of age and waited for an answer with considerable au.xiety. To my surprise and delight I received a letter from him yesterday which supplies all of Dr. Long's omissions. Dr. Groves did not see the first operations, as he did not enter Dr. Long's office till 18W, but soon after his entrance he assisted in the operation on the negro boy in which two fingers were amputated, early in 18-t5, aud at my request he describes this etherization in detail.


178

[Nos. 77-78.


As this case occurred a year ami a half before Morton's discovery, it is equally good as the first for my purposes. It is as follows :

A Recent Letter fkom Long's First Student.

"CoHUTTA, Ga., Jan. 15th, 1897. Dr. Hugh H. Young,

Dear Sir ; * * * The patient was placed in a recumbent position, on a bed, with hand to be operated on to the front for convenience to tlie surgeon. Dr. Long poured etiier on a towel and held it to the patient's nose and mouth, too, to get the benefit of inhalation from both sources. Dr. Long determined when the patient was sufficiently etherized to begin the operation by pinching or pricking him with a pin. Believing that no liarm would come of its use for a reasonable length of time he profoundly anesthetized the patient, then gave me the towel and I kept up the influence by holding it still to the patient's nose. The patient was entirely unconscious — no struggling — patient passive in the hands of operator. After a lapse of lifty years you would hardly suppose that a man could remember every minute detail, but I have clearly in mind all the facts I have given you.

Your ob't servant,

(Signed J J. F. Groves, M. D."

Long then administered ether as it is done to-day. He did not pause at the threshold of discovery or topple the other way, but kept right ahead and by careful observation, experimentation and reflection discovered that ether was a safe, sure and complete anajsthetic.

Nor did his patients etherize themselves and at the same time superintend the operation, as Dr. Morton would have us believe.

As quoted above, Morton grasps eagerly at the acknowledgment of pain at the end of the second operation, where the ether had been discontinued, and from tnat isolated instance characterizes all of Dr. Long's cases as failures. But in his eagerness to annihilate Dr. Long he seems to have overlooked the fact that in the first report of anassthesia with Morton's " Letheou " at the Massachusetts General in 1846, Dr. Bigelow* says, in speaking of the first operation, "During the operation the patient muttered as in a semi-unconscious state, and afterwards stated that the pain was considerable," and in the second, " The operation lasted four or five minutes, during which time the patient betrayed occasional marks of uneasiness." But these certainly were not failures, although the ausesthesia was not as complete as in Dr. Long's previous cases.

Li his paper Long speaks of "those high in authority who were advocating the mesmeric state as adequate to prevent pain in surgical operations." Contemporary medical literature furnishes ample verification of these statements, according to Dr. Grandy,t who says :

" The journals were full of discussions upon the phenomena of mesmerism, animal magnetism, etc., and wonderful reports were coming from European hospitals of operations done without pain during the ' magnetic sleep.'

"Jules Gloquet had excised a cancerous breast with the axillary glands and the patient showed no sign of pain. Top


  • Boston Medical and Surgical Journal, Nov. 1846.

t Va. Med. Monthly, Oct. 1893.


ham of London, in 1843, had amputated a thigh, and Dr. Diigas of Augusta, Georgia, in 184.5, twice extirpated the mamma of a female under the mesmeric sleep.

"We can imagine what efEect these cases had on the mind of Long. Need we wonder therefore that he was the more particular in his experiments on etherization. Such were the reasons for his silence, and while the sequel was unfortunate, his course was cautious and commendable."

While thus waiting, his opportunity was lost. A second discovery was made in Boston in 1846, was published immediately, and anesthesia became the property of the world.

Friends of the other " discoverers " have often stated that as Long made no publication of his work he deserved no credit for it. To this Dr. J. Marion Sims responds very forcibly as follows:*

" Now upon this point Long, Wells, Morton and Jackson stand individually upon the same level.

Long exhibited to medical men and to the community his operations under ether in 1842. Wells exhibited to medical men and to the community his operations of the extraction of teeth under nitrous oxide gas in 1844. Morton exhibited to medical men and the community the use of his secret remedy "Letheon," 1846, as an anesthetic. But Morton was fortunate in showing his patent remedy to the great surgeons of Boston, and it was not Morton, but it was Warren and Ilayward and Bigelow who performed the operations to which the world owes the immediate and universal use of anfesthesia in surgery. If Morton could have had his w,iy he would have deodorized the ether and kept it secret from the world. Neither Wells nor Morton nor Jackson ever published a word on the subject till it burst forth in a blaze from the labors of the hospital surgeons already named. When Warren and Hay ward and Bigelow proved the real greatness of the discovery [and published it broadcast], then it was that Wells, Morton and Jackson began the war of pamjihlets, and not till then did either of them publish in any scientific journal a line about ana'sthesia."

The Famous Ether Controversy.

In 1849 Morton petitioned Congress for a reward for his discovery. He was at once opposed by Jackson and the friends of Wells, who was then dead. The celebrated ether controversy, thus begun, occupied the attention of Congress for many years, and was characterized by the greatest animosity between these former bosom friends and companions.

For five years Long i-efused to take part in the conflict, but finally in 1854, persuaded by his friends that in that way alone could he obtain recognition of his claims, he wrote to Senator Dawson giving an account of his work. It seems that Dawson was a friend of Jackson, for he wrote to him of this new claimant and requested him to investigate his case. This .Jackson did, calling upon Long at his home in Athens on March 8th, 1854.

The Ixtekview betweej^ Loxa .vxd Jacksox. At this interview lion. C. W. Andrews, a prominent justice.


  • Va. Med. :\ronthly, :\Iay, 187


August-September, 1807.]

179


was present, and certifies that after satisfying himself of the genuineness of the claims, Jackson proposed to Long to lay their claims conjointly before Congress — he, Jackson, to claim the discovery, and Long to claim the first practical use, — his object evidently being to get ahead of Morton.

This proposition Dr. Long rejected, being satisfied that he was entitled to both. In a letter to Hon. D. L. Swain, ex-governor of North Carolina, which I have here, he says in regard to this transaction: "The only ground Dr. Jackson urged for his right to the discovery was that while suffering with pain and dyspncea, in February, 1842, from breathing chlorine gas, he inhaled ether and found that while under its influence he was free from pain. He does not claim that he suggested its use to jjrevent pain in surgical operations until more than one year after my first operation was performed. I cannot give the exact date when I was first led to believe that ether would prevent pain in surgical operations, but I know it was as early as February, 1S42."

Now in 1839 Pereira, in his "Elements of Materia Medica," states : " The vapor of ether is inhaled to relieve the effects caused by accidental inhalation of chlorine gas. If the air be too strongly impregnated with ether, stujjefactiou ensues."

So there was very little new in Dr. Jackson's " discovery," and a mere untried inference hardly deserves the title of discovery.

Dr. Jackson finally acknowledged the justice of Dr. Long's claims and wrote to Senator Dawson to that effect.

On April 15th, 185-t, the appropriation bill was up before the Senate for its final reading. The friends of Wells and Morton, relying on the volumes of manuscript they had presented, were confidently awaiting the result, when Senator Dawson arose and said that he had a letter from Dr. Jackson which acknowledged that a Dr. Long in Georgia had undoubtedly used ether before any of the claimants for the appropriation.

Coming as it did from so prominent a contestant, this announcement fell like a thunderbolt on the rival claimants, and from that time they seem to have lost all Iwpe of gaining the reward and passively allowed the bill to die.

Desirous only of preventing another from being recognized by Congress as the discoverer, and not wishing any pecuniary reward himself, Long never pushed the matter farther, and his documents of proof were never even brought uj) before Congress.

I have here an interesting memento of that conference between the two discoverers, in a card on which Jackson has written a note to Long. On one side it reads :

"For Dr. C. W.Long,

of Athens, (Ja. C. T. Jackson,

New York Hotel, (over) " and on the reverse :

"Telegraph from J. L. Hayes, Washington. 'Assignee struck out by request of Mr. Everett.' Bill probably will come up in House July next."

Edward Everett was then senator from Massachusetts. In


the transactions of the Senate, April 19th, 1854, I find the following explanation of the bill by Senator AValker:

" The bill as amen. led recites that a discovery of anaesthesia has Ijeen made — that it is believed the discovery was made by some one of the following persons, W. T. G. Morton, Chas. T. Jackson and Horace Wells, but it does not appear to the satisfaction of Congress which of those parties was the original, true and first discoverer thereof. It proposes to ap|>ropriato $100,0(0.00 as a recompense for the real discoverer. In order to determine this it shall bo the duty of the district attorney of the United States for the Northern District of New York, to file in the circuit court of the United States for that district a bill of interpleader wherein reciting the act or its substance, the Secretary of tlie Treasury shall be complainant, and AV. T. G. Jlorton, Chas. T. Jackson and the personal representatives of Horace Wells or any other person who may make application to thecourt for that purpose shall be defendants. The issue is to be which of the parties named was the original, true and first discoverer of anseathesia, and the court is to decide which one that is and direst that the sum of $100,000 he paid over to him."

At the instance of Senator Dawson Dr. Long's name was also inserted in the bill.

I have carefully searched the Congressional Eecords and find that this bill never came up before the House for final passage, and conseqixently never reached the district court of New York. It seems to have been abandoned.

Several years later Dr. Jackson wrote an article in the Boston Medical and Surgical Journal giving Long the credit for the first use of ether in surgery. I have here Dr. Long's copy of that journal. The communication is so imjiortant that I will read most of it :

" The Boston Medical and Surgical Journal.

Boston, Thursday, Apr. 11, ]8()1.

First Peactical Use of Ether in Surgical Operations.

Messrs. Editors: — At the request of the Hon. Mr. Dawson, U. S. Senator from Georgia, on March Sth, 1854, 1 called upon Dr. C. W. Long, of Athens, Georgia, while on my way to the Dahlonega gold mines, and examined Dr. Long's evidence, on which his claims to the first practical operations with ether in surgery were founded, and wrote, as requested, to Mr. Dawson, who was then in the U. S. Senate, all I learned on the subiect. From the documents shown me by Dr. Long, it appears that he employed sulphuric ether as an anaesthetic agent :

1st, March 30th, 1812, when he extirpated a small glandular tumor from the neck of James M. Venable, a boy in Jefferson, Georgia, now dead.

2nd, July 3rd, 1842, in the amputation of the toe of a negro boy lielonging to Jlrs. Hemphill, of Jackson, Ga.

3rd, Sep. 9th, 1843, in extirpation of a tumor from the head of Mary Vincent, of JacKson, Ga.

4th, Jan. Sth, 1845, in the amputation of a finger of a negro boy belonging to Ralph Bailey, of Jackson, Ga.

Copies of the letters and depositions proving these operations with ether were all shown me by Dr. Long. * * *

I then called on Profs. Joseph and John Le Conte, then of the University of Georgia, at Athens, and inquired if they knew Dr. Long, and what his character was for truth and veracity. They both assured me that they knew him well, and that no one who knew him in that town would doubt his word, and that he was an honorable man in all respects.

Subsequently, on revisiting Athens, Dr. Long showed me his folio journal, or accountbook, in which stand the following entries :


180

[Nos. 77-78.


' James Venable

March 30th, 1842, Ether and excising tumor, $2.00 May 13th, Sul. Ether, .25

June 6th, Excising tumor, 2.00'

On the upper half of the same page, several charges for ether sold to the teacher of the Jefferson Academy are recorded, which ether Dr. Long told me was used by the teacher in exhibiting its exhilarating effects, and he said the boys used it for the same purpose in the academy. I observed that all these records bore the appearance of old and original entries in the book.

On asking Dr. Long why he did not write to me or make known what he had done, he said, when he saw my dates he perceived that I made the discovery before him, and he did not suppose that anything done after that would be considered of much importance, and that he was awakened to the idea of asserting his claims to the first practical use of ether in operations, by learning that such claims were set up by others for this merit, and consequently he wrote to the Georgia delegation at Washington, stating the facts which Senator Dawson had requested me to inquire into.

I have waited expecting Dr. Long to publish his statements and evidence in full, and therefore have not before published what I learned from him. He is a very modest, retiring man and not disposed to bring his claims before any but a medical or scientific tribunal. * * *

Had he written to me in season I would have presented his claims to the Academy of Sciences of France, but he allowed his case to go by default, and the academy knew no more of his claims to the practical use of ether in surgical operations than I did.

Boston, >ipril 3, 1861. Charles T. Jackson, M. D."

The list of operations as given by Dr. Jackson is not complete, as he has omitted the second operation on Venable, and a number of the later operations. In a letter to Dr. Sims, which I have, Dr. Long denies absolutely that he ever acknowledged that Dr. .Jackson was the prior discoverer. He had been led to infer that ether had ana3sthetic powers several months before he got a chance to verify it, and before Jacksou claims to have made similar inferences, but he dated bis claims of discovery from the time of his first practical demonstration. Before that it was a mere supposition, as was Jackson's also.

But barring these inaccuracies, Dr. Jackson's paper, coming as it does from one who so zealously coveted the title of discoverer, is a remarkable admission.

The interview between Long and Jackson must have been most amicable, and Long evidently felt the greatest respect for Jackson, as shown in the following letter:

"Athkns, Ga., Nov. 15th, 1854. Dr. C. T. Jackson.

Dear Sir: — I design to prepare an article with the proofs of the priority of my claims of the discovery of the anresthetic powers of ether and of its applicability to surgical operations. I design having this published in pamphlet form for distribution among the members of the medical profession, and I expect to present such proof with the article as will satisfy all that I am entitled to all I claim.

Ours are rival claims, and permit me, sir, to say that although our claims are conflicting, I would not knowingly say anything in the article which would be displeasing to you. I entertain high respect for you as a gentleman and man of science and feel honored by your acquaintance.

Still it becomes each one of us to use all honorable means to advance his own claims, and I know you will not blame me for attending to this matter, which so much concerns my reputation.

Shall it meet with your approbation, I may refer to your admis


sions to Hon. W. C. Dawson and myself, of the belief of the correctness of my claims. I will, however, make no allusion to your letter to Mr. Dawson or to the conversation held with myself unless

it meets with your sanction

Your obedient servant, C. AV. Long."

Morton's Patent.

It has often been stated by the friends of ilorton that he never attempted to enforce his patent. This statement has lately been reiterated by his wife in McClure's Magazine. On this point the following letter from a prominent army surgeon to Long may be of interest:

" U. S. Marine Hospital,

Chelsea, Mass., April, 1859. Dr. Crawford W. Long, Athens, Ga.

Sir: — Hon. Judge Hyllier, Solicitor of Treasury Department, informed me about a year since, and recently repeated the same, that some years since you used sulph. ether as an anaesthetic and had a record of the same. If it is not asking too much of you, I would be greatly obliged if at your earliest convenience you would forward me a statement of the facts.

I take the liberty to ask this of you because Mr. W. T. G. Morton, to whom in conjunction with Dr. C. T. Jackson a patent was granted in Nov., 1846, for using ether, has brought a suit against me as a government officer for an infringement of his patent.

Judge Hyllier was confident that you could furnish me with proof sufficient to satisfy a jury that you used it way before he or Jackson claimed to have made the discovery. I should have asked for these proofs through my attorney and had them properly witnessed, etc., but the Secretary of the Treasury having decided that I used the article on my own responsibility and therefore the Govt, were not bound to defend me, I wish to save as much expense as possible. Very respectfully,

[Signed] Charles A. Davis, M. D.,

Physician and Superintendent."

In reply Long gives a detailed account of his work, and then adds : " I presume Dr. Jackson is not party to the prosecution, as I know he entertains no good feelings towards W. T. Morton. If you think proper you can see him and ascertain the character of proof I can make. From the little acquaintance formed with him I entertain a high opinion of him as a gentleman and think he will do me justice notwithstanding he himself claims to have made the discovery and has received several awards."

Dr. Davis's letter was written twelve years after Morton's " Letheon " was patented, and many years after ether was the common property of the world. It was probably Morton's last attempt to get money from the U. S. Government.

The ether controversy was never reopened and Long's work was unknown to the world until 1877, when J. Marion Sims learning of him through accident, investigated his claims, was fully convinced of their merit, and vigorously demanded their recognition by the medical profession. His paper appeared in the Virginia Medical Monthly, May, 1877.

The Wilhite Cl.\ims.

This article, which obtiviued for Long the first recognition of any consequence, was the outcome of a conversation which Sims had with a Dr. P. A. Wilhite, of Anderson, S. C. Wilhite told Sims that be had witnessed the first surgical o])eration ever done under ether, and recounted Dr. Long's


August-September, 1897.]

181


first case, saying that lie was one of four students who were then in Dr. Long's office.

He also said that " he presumed that he was the first j)erson who ever profoundly etherized any one," and told how he was at a quilting party in which the boys and girls had concluded the evening by inhaling ether for sjiort; how they had caught a negro boy, and as he refused to inhale the ether, had firmly held a handkerchief soaked with ether over his face, when to their horror his breathing became stertorous and he could not be aroused. He then vividly pictured their alarm when they realized that they had murdered a fellow-being, and thdr determination to leave the country, which was prevented by the timely arrival of a physician who restored the boy to consciousness.

Wilhite iheu related how when the idea of using ether to prevent pain in surgical operations had occurred to Long, he had eiicoura<jed him hy relating the story of the negro boy.

Dr. Sims at once communicated with Dr. Long and soon convinced himself of the truth of his claims, but unfortunately he failed to investigate Wilhite's statements, but embodied them in full in his article, giving to Wilhite the credit of first intentionally producing profound ana;sthesia with ether.

Dr. Sims' paper was given great publicity and the Wilhite story has been accej^ted as true, and copied by many writers on the subject, most notably by Sir Jas. Paget.*

The negro boy story lacks probability, as Wilhite did not enter Long's office until 1844, two years after the first operation, as the following letter from Long to Wilhite shows :

"Athens, Ga., May 20th, 1S77. Dk. p. a. Wilhite.

Bear Sir : — I received Br. Sims' article on anaesthesia yesterday and find several mistakes. Dr. Sims states that yourself, Dr. Groves, and Drs. J. D. and H. E. J. Long were students of mine and witnessed the operation performed on Venable in 1842. Your recollection failed you at the time. As it was several years, at least two, before either entered my office, you will see that you were mistaken in giving Dr. Sims this information. You also make a mistake in saying that the first inhalation in Jefferson of ether for its exhilarating effects was before the same persons.

  • * * I wrote to Dr. Sims informing him of the errors and

asking him if he considered the mistakes of sufficient importance to be noticed, etc. (Signed) 0. W. Long."

Dr. Wilhite replied as follows :

"Anderson, S. C, June 27, '77. Dr. C W. Long.

Dear Doctor : — Yours of the 22nd inst. is at hand, and I have also just received a letter from Dr. J. M. Sims, which I will answer to-day. » » *

In my statement I did make a mistake in regard to my being present at the first or second operation, which mistake I will correct. But if you still prefer I will send a certificate. * * •

Let me know and I will give you any information or assistance in this great matter. Yours truly, etc.,

(Signed ) P. A. Wilhite."

Ill the letter to Wilhite, Long makes no comment on the negro-boy incident, but his daughter informs me that he


  • The Nineteenth Cenliiry, 1880.


repeatedly told her that he had never heard of it before it appeared in Sims' article.

It is to be regretted that the justification of Long's claims should have been linked so closely with such misstatements.

Sims sailed for Europe soon after the publication of his article, and Long died in a few months, and Wilhite's statements went unchallenged for many years.*

Among Dr. Long's papers are many more documents — affidavits of persons operated on and witnesses to them, and letters to different prominent men — but their recital would take up too much time, so I will close with a few words regarding his after life.

In 1842 Dr. Long was married to Miss Caroline Swain, a niece of Governor Swain of North Carolina, a very handsome and attractive woman, who proved a devoted wife. She survived her husband many years.

Long remained in Jefferson for ten years, when he removed to Athens and there spent the rest of his days. By inheritance and professional labors Dr. Long had amassed a fortune, which was largely swept away by the war of secession, and at its close he found himself reduced to poverty, with a large family to support.

Although he soon regained an extensive practice, the desolation of the country and the general poverty of the people made the remainder of his life a continual struggle against poverty. His life, which, up to the time of Dr. Sims' article, had been one of disappointments, after that suddenly became brighter, for from all parts of the world men prominent in the medical profession hastened to give him the credit which had so long been withheld.

His claims were never investigated by the American Medical Association, as he often desired, but many minor societies and the "Eclectic" Medical Association passed decrees in his favor, and a statue was erected in his honor in Paris, France.

But he was not long to enjoy the praise and long-delayed honors which were now heaped upon him. Within a few months, while laboring at the bedside of a delicate patient, he was stricken with apoplexy and died the next day, June 16th, 1878, at the age of sixty-two, poor in worldly goods but rich in the gratitude of his people. His oft-repeated wish to die in harness had been granted.

A strange fatality seemed to hang over the lives of all connected with the discovery of auajsthesia !

Wells, disappointed and disheartened by the rejection of his claims by the French Academy, became insane and committed suicide in 1848.

Morton gave up a very lucrative practice and vainly spent his life in trying to enforce his patent and get a reward from Congress. He died in 1868 from congestion of the brain, brought on by excitement occasioned by an article attempting to deprive him of the honor he so jealously coveted.

Long died in poverty, from apoplexy brought on by overwork in 1878.

Jackson, like Wells, became insane from the bitter contentions of his life and died in an asylum in 1880.


  • ln an article in the Virginia Medical Monthly, 1893, Dr. L. 15.

Grandy, of Atlanta, showed the error of Wilhite's statements.


182

[Nos. 77-78.


Henri L. Stuart, founder of the Woman's Hospital, aud a great New York philanthropist, became interested in Long's claims and presented a portrait of him to tlie University of Georgia. After seeing it unveiled with great ceremony in the capitol in Atlanta, one year after Long's death, he went to Athens as a guest of the Longs, to visit the grave of the discoverer of anaesthesia. Arriving at night, he waited till morning to fulfil his heart's desire. But this was never gratified. IJuring the night he had a paralytic stroke aud died at the home of the Longs after lingering several weeks. At his own request his remains were interred next to those of Crawford Long — two great benefactors side by side.

Appendix I. Dr. Long's Original Paper.*

In the month of Dec, 1841, or Jan., 1842, the subject of the inhalation of nitrous oxide gas was introduced in a company of young men assembled at night in the village of Jefferson, Ga., and the party requested me to prepare tliem some. I informed them I had not the requisite apparatus for preparing or preserving the gas, but that I had an article (sul. ether) which would produce equally exhilarating effects and was as safe. The company were anxious to witness its effects, the ether was introduced and all present in turn inhaled. They were so. much pleased with its effects that they afterwards frequently used it and induced others to do the same, and the practice soon became quite fashionable in the county and some of the contiguous counties.

On numerous occasions I inhaled ether for its exhilarating properties, and would frequently, at some short time subsequent to its inhalation, discover bruised or painful spots on my person which I had no recollection of causing and which I felt satisfied were received while under the influence of ether. I noticed my friends while etherized received falls and blows which I believed were sufiicientto produce pain on a person not in a state of anaesthesia, and on questioning them they uniformly assured me that they did not feel the least pain from these accidents. Observing these facts I was led to believe that anesthesia was produced by the inhalation of ether, and that its use would be applicable in surgical operations.

The first patient to whom I administered ether in a surgical operation was Mr. James M. Venable, who then resided within two miles of Jefferson, and at present lives in Cobb Co., Ga. Mr. Venable consulted me on several occasions in regard to the propriety of removing two small tumors situated on the back part of his neck, but would postpone from time to time having the operation performed, from dread of pain. At length I mentioned to him the fact of my receiving bruises while under the influence of the vapor of ether without suffering, and as I knew him to be fond of and accustomed to inhale ether, I suggested to him the probability that the operations might be performed without pain, and proposed operating on him while under its influence. He consented to have one tumor removed, and the operation was performed the same evening. The ether was given to Mr. Venable on a towel, and when fully under its influence I extirpated the tumor.

It was encysted and about half an inch in diameter. The patient continued to inhale ether during the time of the operation, and when informed it was over, seemed incredulous until the tumor was shown him.

He gave no evidence of suffering during the operation, and assured me, after it was over, that he did not experience the least degree of pain from its performance. This operation was performed on the 30th ]\rarch, lSt2.


' Read liefore Georgia State Medical .Society in 18.')3.


The second I performed on a patient etherized was on the 6th June, 1812, and was on the same person, for the removal of the other small tumor. This operation required more time than the first, from the cyst of the tumor having formed adhesions to the adjoining parts.

The patient was insensible to pain during the operation until the last attachment of the cyst was separated, when he exhibited signs of slight suffering, but asserted after the operation was over that the sensation of pain was so slight as scarcely to be perceived. In this operation the inhalation of ether ceasrd before the first incision was made. Since that time I have invariabh' desired patients, when practicable, to continue the inhalation during the time of the operation.

Having permitted such a length of time toelapse without making public my experiments in etherization, in order to show the correctness of my statements I procured the certificate of the patient on whom the first operation was performed, the certificate of two who were present at the time of the oper.ation, and also those of his mother, brothers and sisters and a number of his immediate friends who heard him speak of the operations soon after they were performed. The Southern ]Med. and Surg. Journal* contained but two of the certificates. I have a number of others which can be seen or read if desired by the Society. My third case was a negro boy who had a disease of a toe which rendered amputation necessary, and the operation was performed July 3rd, 18)2, without the boy evincing the slightest sign of pain.

These were all the surgical operations performed by me during the year 1842 upon patients etherized, no other case occurring in which I believed the inhalation of ether applicable. Since '42 I have performed one or more surgical operations annually, on patients in a state of etherization.

I procured some certificates in regard to these operations, but not with the same particularity as in regard to the first operations, from the fact of my sole object in the publication being to establish my claim to priority of discovery of power of ether to produce anasthesia. However, these certificates can be examined.

Tlie reasons which influenced me in not publishing earlier are .as follows:

I was anxious, before making my publication, to try etherization in a sufficient number of cases to fully satisfy my mind that an£Bstliesia was produced by the ether, and was not the effect of the imagination or owing to any peculiar insusceptibility to pain in the persons experimented on.

At the time I was experimenting with ether there were physicians high in authority and of justly distinguished character who were the advocates of mesmerism, and recommended the induction of the me.wierjcs/a?*' as adequate to prevent pain in surgical operations. Notwithstanding thus sanctioned I was an unbeliever in tlie science, and of the oiiinion that if the mesmeric state could be produced at all it was only on those of strong imaginations and weak minds, and was to be ascribed solely to the workings of the patient's imagination. Entertaining this opinion, I was the more particular in my experiments in etherization.

Surgical operations are not of frequent occurrence in a country practice, and especially in the practice of a young phj'sician, yet I was fortunate enough to meet with two cases in which I could satisfactorily test the anEesthetic power of ether. From one of these patients I removed three tumors the same day ; the inhalation of ether was used only in the second operation, and was effectual in preventing pain, while the patient suffered severely from the extirpation of the other tumors. In the other case I amputated two fingers of a negro boy ; the boy was etherized during one amputation and not during the other ; he suffered from one operation and was insensible during the other.

After fully satisfying myself of the power of ether to produce aniesthesia, I was desirous of administering it in a severer surgical


FAC-SIMILE OF LONG'S MANUSCRIPT. SEE PAGE 182.

operation than any I had performeii. In my practice, prior to the published account of the use of ether as an antesthetic, I had no opportunity of experimenting with it in a capital operation, my cases being confined, with one exception, to the extirpation of small tumors and the amputation of fingers and toes.

While cautiously experimenting with ether, as cases occurred, with the view of fully testing its antesthetic powers and its applicability to severe as well as minor surgical operations, others more favorably situated engaged in similar experiments, and consequently the publication of etherization did not " bide my time."

I know that I deferred the publication too long to receive any honor from the priority of discovery, but having by the persuasion of my friends presented my claim before the profession, I prefer that its correctness be fully investigated before the Med. Society. Should the society say that the claim, though well founded, is forfeited by not being presented earlier, I will cheerfully respond, so mote it be.

Not wishing to intrude upon the time of the Society, I have made this short compendium of all the material points stated in my article in the Journal, and if the Society wishes any fuller information on the subject I will cheerfully comply with their wishes.

Appendix II.

" Georgia, 1 I, Ange De Laperriere, M. D., do certify that I

Jackson County. > resided in Jefferson, Jackson County, Georgia, in the year 1842, and that some time in that year I heard James M. Venable, then of said county, speak of Dr. C. W. Long's cutting out two tumours from his neck while under the influence of the inhalation of sulphuric ether, without pain or being conscious of the performance of the operation.

I do further certify that the fact of Dr. C. W. Long using sulphuric ether by inhalation to prevent pain in surgical operations was frequently spoken of and notorious in the county of Jackson, Georgia, in the year of 1842. A. De Laperriere, M. D.

Sworn to and subscribed before me this 30th of March, 1854.

N. H. Pe.ndergrass, J. P."

"Athens, Clarke Co., Georgia. I, the undersigned, do certify that in May, 1843, 1 assisted Dr. R. D. Moore in amputating the leg of a colored boy Augustus, then the property of Mr. Wm. Stroud, who resided in this county ; and that I distinctly recollect hearing Dr. R. D. Moore say, If I had thought of it before leaving home I would have tried Dr. C. W. Long's great discovery, namely, the administration of sulphuric ether as an anaisthetic in performing the operation. Having neglected to bring the ether. Dr. Moore finally concluded to influence the


patient with morphia ; under which influence the operation was performed. Jos. B. Carlton, M. D."

Appendix III. From Dr. Long's First Student.

"CoHUTTA, Ga., Dec. 13th, 1894. Mrs. Frances Long Taylor,

Dea7' Madam :—* * * In 1844, soon after I attained my majority, I decided to adopt medicine as my profession, and began to think where and under whom I should begin the preparatory study. My father asked me to choose from among the number of physicians whom 1 knew the one I preferred to act as preceptor to me.

Knowing Dr. Long so well and believing him to be a man of no ordinary ability, I at once fixed upon him as my choice.

I entered Dr. Long's office in May, 1844, as the first student ever under his care. As I progressed with my studies he saw fit to make known to me his discovery, by the use of which he could perform surgical operations without giving any pain to his patient. [Here follows a description of the first cases.]

Notsatisfied, however, that there was not more to learn about this great disco very, he proposed that we test it further personally, which we did in his office, where with closed doors we administered it to each other to prove its perfect anaesthetic effect and also to discover any bad effect to the subject etherized. Owing to the prejudice and ignorance of the populace Dr. Long was prevented from using ether in as many cases as he might have.

Thus in the two years preceding my entering Dr. Long's office he had had only about six cases in which to try the anaesthetic effects of ether.

The first case thatcame under his care where its use was applicable after my going into his office was not till January 8th, 1845, which was the case of a negro boy having two fingers to amputate, caused by neglected burn. I, as the only student still with the doctor, he had me to accompany him to see the operation and assist ill the administration of the ether. The first finger was removed while under the influence of ether, the little fellow evincing no pain ; the second without ether, the child suffered extremely. This was done to prove that insensibility to pain was due to the agent used.

Soon after this, in January, Mr. J. D. Long came into the office as a fellow-student ; later, toward spring, came P. A. Wilhite, and in August came Dr. Long's brother, H. R. J. Long. We four remained there at Dr. Long's oflBce as students until the opening of the fall term of the medical colleges. » * *

[Signed] J. F. Groves, M. D.

Sworn and subscribed to before me, Dec. 15th, 1894.

\V.M. H. Wilson, N. P."


THE EARLY HISTORY OF OPHTHALMOLOGY AND OTOLOGY IN BALTIMORE (1800-1850).*

By Harhy Friedenwald, A. B., M. D., Associate Professor of Ophthilmologij and Otology, College of Fliysicians and Sii-rgcons,

Baltimore, Md.


An old book tells us that each generation may be looked upon as standing on the shoulders of its fathers. If its vision is clearer, its intellectual view less obstructed, its horizon broader, it is in great part due to the height to which others have raised it, to tlie support others have given. Unmindful of this, it is apt to exaggerate its greatness and the importance of its own work.


  • Read before the Johns Hopkius Hospital Historical Club,

April, 1897.


In the following narrative I have brought together all that I could find relating to tlie lives and labors of those who, in the earlier years of this century and in our own city, tilled the soil of ophthalmology and otology. Some have been forgotten, few have been accorded deserved recogniiion.

Are not many of us as ignorant of their names and works as an old physician from whose memories I liad hoped to obtain information, but whose response was, "No work was done in Baltimore in those departments of medicine before 1850"? I must confess tliat when iny attention was first drawn to this


August-September, 1897.]

185


subject I knew of biit one work of importance which a Baltimore physician had rendered to ophthalmology.

There is no reference in literature to anything done in Baltimore in the two branches we are considering before the beginning of this century. We must remember that in 1800 the population of Baltimore City was 26,614 and that in 1802 there were but 44 physicians.

It is probable that there were here as elsewhere those who confined themselves to diseases of the eye. This is indicated by a resolution adopted at the convention of the Medical and Chirurgical Faculty of Maryland in 1805.* It was resolved that " the Board of Examiners be authorised to grant special licenses to dentists and occulists to practice in their respective branches, subjecting them to an examination only on the branches they possess; and that such licentiates shall pay ten dollars for each license so obtained; provided it shall be the opinion of the attorney-general that the law authorizes the examiners to grant such licenses. The secretary having submitted the preceding resolution to the then attorney-general, he gave it as his opinion that the law authorized the board to act according to the spirit of the resolution." These "occulists" did not, it appears, stand in very good repute.

In the review in 1825 of an American treatise on diseases of the eye, the writer, who was probably Dr. Isaac Hays, the distinguished editor of the American Journal of Medical Sciences and an ophthalmologist of note, describes the condition of ophthalmology in the early years of this century. He tells us that " the neglect to which disorders of the eye were too long consigned is truly astonishing. Prepossessed with an idea that there was something peculiar in the diseases attacking different parts, physicians entirely abandoned these affections to persons who were exclusively devoted to them and were totally ignorant of the laws which influence diseases of other organs. To this cause is to be attributed the slow progress which tlie science of ophthalmology made during many centuries. The history of this science shows that while it made most rapid advances in improvementby the investigations of medical men, it invariably, when abandoned to professed oculists, not only ceased to advance but actually retrograded ... In this country much apathy has existed, and we fear still exists, with regard to these affections. Some of our distinguished surgeons have not, it is true, entirely neglected them ; yet the mass of medical practitioners have paid little attention to them, and the science has advanced so rapidly during the few years that we believe few have kept pace with the improvements that have been made. The length of time that generally elapses before opinions of European writers are diffused in this country — the want of regular lectures — and above all, clinical instruction and the opportunities furnished of observing these diseases in institutions established for the reception of these cases, are the cause, no doubt, of the present state of the science among us."

He mentions that the New York Eye Infirmary was established in 1830, the Pennsylvania Infirmary for Diseases of the Eye and Ear in 1822, and "with respect to the institution at Baltimore he has but little information to communicate. It is


'Summary of Proceedings, &c., published in 1817


attached to the Baltimore Dispensary and is committed to the care of the author of this work." [Dr. Geo. Frick.]

Pierre Chatard.

The earliest Baltimore publication having reference to diseases of the eye is found in a paper written by Dr. Pierre Chatard in the Medical Repository, vol. VII, p. 28. Dr. Chatard was born and educated in France, and had settled in Baltimore in 1797. He was a prolific writer, the paper referred to being one of the earliest. It was entitled "An account of a case of Fistula Lachrymalis, with reflections on the diflerent modes of operating in that disease." The paper describes a case of lachrymal fistula relieved by introducing threads of silk after the manner of a seton through the lachrymal duct and gradually increasing their number. He discusses at length the various methods in vogue at that time of treating the disease. It is written in an interesting and elegant manner. None of the other writings of Chatard relate to diseases of the eye.

William Gibson.

During the second decade of this century the celebrated surgeon, Wm. Gibson, practiced in Baltimore. Win. Gibson was born in 1784 in Baltimore, and was graduated in medicine in Edinburgh in 1809. He was a physician to the Baltimore General Dispensary in 1818-19, and professor of surgery at the University of Maryland from 1812-19, resigning to occupy the same chair at the University of Pennsylvania from 1819-54. He died about 1858 (?)•

His numerous publications date mainly from the latter period of his activity, but there are two notable and very interesting references to ophthalmic surgery dating from the Baltimore period.

In Hirsch's History of Ophthalmology* we find the statement that Prof. Gibson of Baltimore had made the experiment of introducing a seton through the cataractous lens, witli the view of producing its absorption, so original an experiment that Hirsch cites the description given by Dr. John Revere untranslated. My friend. Dr. O'Connor of Boston, had the kindness of looking up the reference in the New England Journal of Medicine, vol. VIII, p. 119, of 1819, and I will give this account in full because of its intense interest.

Extract of a letter to one of the editors:

" lam desirous of communicating through the medium of the New England Journal a new mode of operating for cataract, which has been projected and jiracticed recently, in two cases, with the mot;t .satisfactory success, by my friend, Dr. Gibson, professor of surgery at the University of Maryland.

The operation was performed in the following manner : The iris was in the first place dilated by the application of atropa belladonna. A common sewing needle, slightly curved and armed with a single thread of silk, was then passed through the tunica sclerotica about two lines from the cornea, where the couching needle is usually introduced, through the opaque lens and out of the opposite side of the cornea, at a point corresponding to the one at which it was introduced. The silk being drawn through, and the ends cut off, a single thread was thus left passing through tlie ball of the eye, and acting on the diseased lens in the mauner of a seton. It


•Graefe and Saemisch's Handbuch, Vol. VII, p. 517.


186

[Nos. 77-78.


was feared that serious inconvenience might arise from the irritation produced upon the tunica conjunctiva, from the excessive sensibility of this membrane. Fortunately, however, neither this nor any other accident intervened, and at tlie end of ten days, in both cases tlie diseased lens had disap])eared, and, in its place, the silk was distinctly seen passing like a bar across the pupil of the eye. Tlie silk was withdrawn, and in a few days the vision was restored. In the third and last case in wliich this operation was performed it failed in consequence of the iris being wounded. This caused such an inflammation of the organ that it was deemed proper to withdraw the seton at a very early period. This accident was attributed to not using the belladonna. One would think that a common sewing nee<lle is not the most convenient instrument that could be devised for this purpose, on account of the dense structure of the part througli wliich it is to pass, and the difficulty of having the perfect command of any instrument without a handle. From the nature ot the disease, from the known eflects of this remedy when applied to other parts of tlie body, and from the success which has already been experienced, there seems to be good reason to hope that this will be found an important improvement on the established practice in many forms, if not in every variety of the disease. But the practical benefit to be derived from this operation can only be tested by a more enlarged observation than in this country ever falls to the lot of any individual. I remain yours, J. Eeverb.

Balto.. Mch. 2nd. 1819."

We learn from Hirsch that Loewenhardt in 1828 operated in a similar manner for secondary cataract with anterior and posterior synechia, likewise with good resnlt; it ajopears that others have not attempted the operation.

In the American Appendix to the second edition of Cooper's Dictionary of Practical Surgery, edited in America in 1844 by David Meredith Keese, who in 1843 and 1843 was professor in Washington University of Baltimore, we find a very curious reference to Professor Gibson under the head of strabismus: "It apjiears from the Institutes of Surgery that Professor Gibson attempted the cure of strabismus by dividing the recti muscles of the eye, precisely as now practiced, some twenty years since, in Baltimore. Soon after he repeated it unsuccessfully in Philadelphia in several cases, and was induced to abandon it by unfavorable opinions exjiressed on the operation by Dr. Physick. He, however, inculcated the propriety of the operation upon his class many years since, and Dr. A. E. Hosack, of New York, then one of his pupils, distinctly recollects Dr. Gibson's expressions of confidence that the operation would ultimately succeed."

I had no little difiiciilty in finding the reference to which Dr. Reese refers. The first five editions of Gibson's Institutes of Surgery (published between 1824 and 1838) contain no chapter devoted to strabismus, and in the seventh edition the long account of strabismus and its treatment consists almost entirely in a paper written by Charles Bell and sent by him to Gibson. In this chapter the above reference is likewise not to be found. It is only in the sixth edition, published in 1841, that we find the reference. It is of such importance that I shall give it in detail. On page 375 Gibson states that:

"In the year 181S, while practising my profession extensively in Baltimore, the late Mr. B. J. consulted me about his daughter, a child of eleven or twelve years of age, both of whose eyes were directed very much inwards, and were thereby greatly deformed by a squint. I advised a pair of goggles, so contrived, by having a


small opening in the centre of each, as to oblige the ckild to direct the cornea to these openings, and by i)erseverance for several weeks, succeeded in diminishing the deformity but not effecting a cure. In the course of my visits the child remarked at different times that her eyes felt as if tied by a string. Struck with this observation, and conceiving the disease might depend upon shortening of the internal rectus muscle, I determined, the first opportunity, to try the result of divison of that muscle ; and as the friends of my young patient were unwilling the experiment should be first tried upon lier, I selected a hospital patient, and after some difficulty in fixing the eyeball and in cutting the muscle across, succeeded in restoring the eye partially to its natural situation. Upontwoother patients I repeated the experiment, without mucli better success, but on dividing a muscle in a fourth patient, after my removal to Philadelphia, the eye was so completely turned to the opposite direction as to bury the cornea beneath the lids and create a much greater deformity tlian liad previously existed. Upon showing the patient to Dr. Physick, he advised the experiments to be abandoned, as likely to be followed by very unfavorable results. I mention these circumstances, not from a desire to receive credit as an inventor or to detract from the claims of the distinguisiied surgeon with whom the modern operationof strabismus originated, but merely as a curious fact, calculating to show the importance of not laying aside processes apparently founded upon correct principles, simply because we are at first foiled in our attempts to execute them. How much benefit would have resulted to the community if I had followed up my operations until I ascertained the proper mode of correcting them, or how much injury I might have inflicted upon individuals by perseverance in ihe attempt, I shall not stop to inquire. It is sufficient for me to announce the fact — wliich I have no doubt could be easily substantiated by many pupils who attended my early lectures, some of whom have indeed already proffered their testimony — without being over-solicitous, in setting up a claim as an inventor, of exposing my aw kwardness and perhaps want of knowledge of the principles that should have guided me in following out the practice I had attempted to institute."

It may not be out of place to mention that; Stromeyer's important monograph, in which he recommended division of the muscle for strabismus appeared in 1838!

The chapters devoted to diseases of the eye in Gibson's Institutes are important, but as the book appeared after the author had left Baltimore, it is not proper to discuss them here.

Another reference which shows Gibson's interest in the eye occurs in the American Medical Eecorder (vol. II, p. 383). It is a "Letter of Charles Bell to Professor Gibson, of Baltimore," and its subject is, " The New Coat of the Eye discovered by McCarthy's demonstrator, Jacobs."

George Fkick.*

We may next take up the most important name of this narrative, that of Dr. George Frick, the author of a valuable treatise on diseases of the eye, the first ^\■ork of the kind that appeared in America.

George Frick was born in Baltimore in 1703. After obtaining a broad classical education he entered the University of Pennsylvania, where he obtained the degree of doctor of medi


  • The accompanying portrait of Dr. Frick is copied from one

recently presented to the Medical andChirurgical Faculty, together with a case of instruments which belonged to the doctor, by his niece, Mrs. AVhite and her daughter. Miss Mary White.


August- September, 1897.]

187


cine in 1815, and in 1&17 he was admitted as licentiate of medicine into the Medical and C'hirurgical Faculty of Maryland. He then spent several years abroad, returning to Baltimore about 1819 to engage in the practice of ophthalmology. He was api)ointed surgeon to the Baltimore General Dispensary, where he established the first Eye Dispensary in Baltimore, in 1824. In 18^3 he delivered clinical lectures at the Maryland Hospital. His name is found on the list of vaccine physicians for 1821.

He was a member of various medical societies; was secretary of the Faculty in 1823, and joined the Maryland Medical Society in 1822. He was much interested in general science, and was one of four physicians to organize a society for promoting science, in 1819. He was likewise a member of the Maryland Academy of Sciences, its librarian in 1824 and curator in 1836.

He devoted himself to the practice of ophthalmology and to the cultivation of general scientific stvrdies, as well as to music for a number of years. He was unfortunate in growing very deaf before middle life, and it is probable that this interfered greatly with his practice of medicine ; for somewhere about 1840 he entirely relinquished it and left Baltimore to spend most of his time in Europe, paying occasional visits to this country. He died in Dresden, March 36th, 1870, aged 77 years. Dr. Frick had never married. He was a man of very retiring and modest character and of kind disposition. He was a careful scientific student and his work and writings deserve high praise.

His first writing was his thesis for the degree in medicine; its subject was "On the Meloe Vfsicatorium" (1815). In 1820-31 his article on " Observations on Cataract and the various modes of operating for its cure" appeared in the American Medical Kecorder of Philadelphia. These articles cover over 40 pages. In 1821 an article on "Observation of the various forms of Conjunctivitis" appeared in the same journal, and in 1823 his paper on " Observation on Artificial Pupil and the modes of operating for its cure."* His most important work, however, was "A Treatise on the Diseases of the Eye; including the doctrines and practice of the most eminent modern surgeons and particularly those of

  • This curious error is cited as it is found.



Professor Beer," which was published in Baltimore by Fielding Lucas, .Jr., in 1823. It was inscribed to his teachei-, Dr. Physick of Philadelphia. The articles above referred to, though somewhat more elaborate, were in the main identical with the corresponding chapters of the treatise and do not therefore require special consideration. The treatise is of considerable value.* It is well and clearly written, the system irpon which it is classified is excellent, and no greater praise could be given it than stating the fact that it was republished three years lateiin London by an English surgeon, Richard Welbank, a member of the Royal College of Surgeons and of the Medical and Chirurgical Society of London, and dedicated to the ophthalmologist William Lawrence. Numerous foot-notes were added, but the te-xt suffered no change.

The reviews which the book received were very complimentary. The Philadelphia Journal of Medical and Physical Sciences (probably Dr. Isaac Hays) contains a review covering 18 pages: "The author evidently possesses a cultivated and well disciplined mind; he appears to be intimately familiar with German writers, and we feel much indebted to him for making us acquainted with their writings."

In the American Medical Recorder of 1824 a still longer review is to be found, covering 32 pages. The writer describes the book in terms of high praise. He "offers the humble tribute of (his) thanks to the author for the benefits which he has conferred on the profession generally, by presenting them with a volume of great value and utility, and one which was much


  • It is interesting to find numerous pencil notes in the articles in

the copies of the American Medical Recorder at the library of tlie Medical and Chirurgical Faculty of Maryland, notes suggesting slight changes in the phraseology, paragrap'-ing, etc., every one of which has been adopted in the treatise. I have been able to trace this copy, which was bought with other books by Dr. ,Iohn Morris at a public sale of the library of Dr. John Buckler, who was related by marriage to Dr. Frick, and whose library thus passed into Dr. Buckler's. Numerous books at our library contain Dr. Frick's autograph, and one, a copy of Gibson's Institutes of Surgery, has an inscription of the author to his friend Dr. Frick. In Beer's work on ophthalmology there are interesting pencil notes and several pages of written matter which correspond so thoroughly with Dr. Frick's writing that I have no hesitation in stating that tbev are his.


188

[Nos. 77-78.


wanted. As a manual of the diseases of the eye, we believe it to be the best which has been published. It contains all the improvements which have enriched ophthalmic surgery, in such a siirpi'ising degree within a few years past," etc.

In 1835 this work was placed on the list of those which the student was required to liave read before applying to the Medical and Chirurgical Faculty of Maryland for the examination for licentiate in medicine.

Hirsch in his history of ophthalmology says that " George Frick was the apostle of the ophthalmological school of Vienna in North America; his treatise was next to Saunders's, the first large treatise on ophthalmology in America, and was received by physicians with great praise." Saunders's book was an English work and was republished in Philadelphia in 1831, two years before Frick's. The only other book in the English language of a similar kind was that of Travers, which appeared in London in 1820-31-24.

We thus see that Frick's book was the first American treatise (and for a number of years it remained alone). The work is much quoted in Cooper's Dictionary of Surgery.

In Quinan's Medical Annals of Baltimore I find a reference to a paper of Dr. Frick's " On the Senses," which he tells us was read before the Medical Society of Maryland in 1821. I have been unable to find this paper.

In Cordell's History of the University of Maryland we learn that the foiindation of the Infirmary was laid in 1823 and that patients were received in the same year. Of the four wards, "one was reserved for eye cases, instruction in ophthalmic surgery forming a prominent feature in the course. This was during the time of Frick's greatest activity, and it is possible that the prominence given to ophthalmology was through him, and that he delivered the clinical lectures in this branch. I am unable to verify this.

In conclusion it is interesting to call attention to the fact that Dr. George Frick was the uncle of the distinguished clinician, Professor Charles Frick.

Horatio G. Jameson.

Horatio G. Jameson, born in Pennsylvania about 1793, graduated in medicine at the University of Maryland in 1813. He held a number of important public positions, having been consulting surgeon of the Baltimore City Hospital from 1819 to 1835, consulting physician of the board of healtli of Baltimore City in 1827-35 ; he was incorporator of the AVashington Medical University in 1827, and professor of surgery and surgical anatomy in the same from 1827-35, when he became professor of surgery in the Cincinnati Medical College. He was one of the most prominent surgeons of Baltimore for a number of years, and a very active contributor to medical journals, writing important papers in medicine and in surgery. He was the editor of the Maryland Medical Recorder during its existence of several years (Sept. 1829-Nov. 1832), and a large number of its articles are from his pen.

Jameson appears to have been much interested in diseases of the eye. AVe find frequent references to publications on these subjects throughout his journal, several of which have remarks added by the editor. In vol. 2 there is an article on the


"Pathological Sympathy between Eye and Larynx" (p. 117) This article is without any value, indeed it is difficult to understand the real significance of his report after careful reading. An article on "A case of Enlargement of the Eye following the entrance of steel into the eye" describes the panophthalmitis followed by bursting and shrinking of the eyeball (p. 601).

In another paper he described " two cases of ossification of the lens with luxation through the pupil." These cases are of some interest. He extracted the lenses and the patients did well (p. 608). An article on amaurosis associated with inordinate thirst was probably written by Jameson (p. 664).

In the American Medical Recorder of Philadelphia (vol. XII, p. 340) we find an interesting account of the successful removal of " An encysted tumor of tiie orbit."

In discussing a letter on "Ophthalmia in the Philadelphia Alms House," written to Dr. Rusii, Jameson considers the question of the endemic or .contagious character of the ophthalmia, excludes the latter view, and attributes the very severe disease to the vitiated state of the atmosphere. He states that " we do not as a general rule of practice bleed sufficiently in cases of ophthalmia."

John Mason Gibson.

John Mason Gibson in 1832 published in Baltimore (W. R. Lucas) a " Condensation of Matter ujwn the Anatomy, Surgical Oj)erations and Treatment of Diseases of the Eye, together with remarks. Embellished with twelve lithographic plates, illustrative of the anatomy, operations, and morbid appearance."

I am unable to give any details of this author's life. I find that he vvas admitted into the Faculty in 1825, and that his name appears as late as 1848 in the list of members with the title of L. M. In the next succeeding list published in ISoS Gibson's name is missing.

In the preface he tells us that his book is an " attempt at collecting the best matter on diseases of the eye." That " diseases casiral to vision are many and frequently met with in this country; the curative practice has not been sufficiently inculcated in our universities, by impressing upon the mind of the student where and when the importance and great nicety of judgment are requisite in the treatment of them, and that by inadvertent and mal-practice the victim may grope through his existence here in the valley of darkness."

The work is one of compilation, "being made up of exten- f

sive quotations from the classical writers of the day." He claims originality only in the construction of his plates, and so far he is certainly correct, for the drawings are quite unlike anything seen in nature.

The arrangement of the work is very curious. The chapters follow in this order: Anatomy of the eyeball, cataract, ophthalmia, corneitis, iritis, choroiditis, retinitis, inflammation of the lens and its capsule, ulcers of the cornea, ojiacities of the cornea, ptergium, prolapse of the iris, extirpation of the eyeball, extraneous bodies, diseases of the lachrymal apparatus, under which is included entropium, ectropiuni, epiphorn, encaiitlius, injury of lids, ophthalmia tarsi and fistula hiclirv


August-Septembek, 1897.]

189


malis, looking very much as tlioxigh the subjects had been drawn haphazard from a grab-bag.*

At the end of several chapters the author adds original remarks. When we consider the very excellent and systematic work which Frick had published, nine years previously, as well as such other works from which copious quotations are made, it is quite inexplicable why Gibson showed such disregard of systematic classification, or indeed what purpose he had in publishing the work at all.

Dr. John Hakper.

Dr. David Jleredith Reese, in his American edition of Cooper's Dictionary of Practical Surgery, first published in 1833, tells us, under the section of cataract, that "one of the most successful operators in this country is Dr. John Harper, of Baltimore, and he seldom adopts any other operation than this (laceration of the capsule and lens substance), which he repeats as often as necessary on the same eye." I have given myself great pains to obtain some information concerning this " successful operator," but his memories appear to have been completely effaced. One single reference is to be found, a short obituary notice. In the Maryland Medical Recorder (vol. II, 179) there is a notice of the death of four members of the Medical and Chirurgical Faculty of the State of Maryland. One of these reads as follows : " Died in the month of January, 1831, Doctor John Harper. Doctor Harper was a native of Ireland, and graduated at Ghisgow. He was wellknown as an oculist." The title of oculist appears to have been elevated to the dignity of a special practice of medicine within a few years. For Harper was a member of the Faculty, and not of the despised class of oculists mentioned in the beginning of this paper.

William Alexander Clendinen.

Wni. A. Clendinen graduated in the medical department of the University of Maryland in 1840, a classmate of Dr. G. W. Miltenberger. He died of cholera at New Orleans in 18-1:9, having been seized with the disease while dissecting a victim of the epidemic. After his graduation he traveled extensively, devoting his time to the study of medicine. In the Boston Medical and Surgical Journal in 1847 we find several papers which were translations from the work of Prof. Desmarres. In his letter to the editors he tells us that the extracts are part of a "translation upon which he is now engaged"; he expresses his gratitude to Prof. Desmarres, who " has entrusted to him an onerous but useful task, one which from (his) connection with him (he) may be able to perform advantageously to readers of the English language." In the second article, published in the same journal, we find after the name of the author, " Chef de la clinique oculaire." There were in all but three articles, and the promised book never made its appearance, perhaps on acco^^nt of the untimely death of the author.


  • Not a few important subjects are entirely ignored, viz. errors

of refraction, strabismus, etc.


OTOLOGY.

The early contributions to Otology in Baltimore were very few. Two names deserve recognition ; the first of these is that of the renowned surgeon,

Nathan Rhyno Sjiith.

It is beyond the province of this paper to give a biographical sketch of Dr. Smith. A very complete sketch can be found in Dr. Cordell's History of the University of Maryland. He was born in 1797 in New Hampshire, graduated as A. M. in 1817, and as M. D. in 18-^3 in Yale College. He was professor of anatomy and surgery in the University of Vermont in 1825, soon leaving to occupy the chair of anatomy in the newly organized Jefferson Medical College of Philadelphia. From 1827-39 he was professor of anatomy in the University of Maryland, and from 1829-38 he occupied the chair of surgery at the same university, leaving this for three years to occupy the chair of theory and practice in the Transylvania University. He resumed it again in 1841 and held it until 1869.

One of the earliest writings of this prolific worker was the translation of a treatise on the ear from the French of Saissy,* with additions by the translator on diseases of the external ear. This book was published in Baltimore in 1829, and was, so far as I can learn, the second book on diseases of the ear printed in America, the first having been an American edition of Saunders on the eye and ear in 1821.

Saissy's work was "highly esteemed in France," and was one of the important factors in the revival of modern otology. In his preface Dr. Smith tells us that " a concise manual on the diseases of the ear is an acknowledged desideratum in our medical literature. No sufficient work on the subject has ever been issued from the American press. With a view to supply this deficiency (he has) translated the following pages from the French of Saissy . . . corrected and enlarged by its author, and after his death published in 1827 by his friend Montaion, etc.

" It embodies the excellencies of Saunders, Cooper, Leschevin, Maunoir, Itard and Alard . . .

" The attention of the reader will be particularly occupied with Saissy's excellent method of injecting the ear through the eustachian tube. We very well know how frequently the external ear is obstructed by its own secretions, free as is their egress from this cavity. The internal ear is also lined with a membrane which furnishes an excrementitious fluid. It can escape only by the narrow channel of the eustachian tube. How frequently then must it be delayed in the cavity of the tympanum and mastoid cells, giving rise to any degree of mischief."

To render " the work more complete and useful to the medical pupil (he has) added a brief supplement on diseases of the external ear. On this score, however, (he) claims nothing, as (his) addition is made up of commonplace iirinciples and


  • An Essay on the Diseases of the Internal Ear, by J. A. Saissy,

M. D., translated from the French by Nathan Rhyno Smith, M. D., Professor of Surgery in the University of Maryland, with a supplement on Diseases of the External Ear, by the translator. Published by Hatch & Dunning, Baltimore, 1829.


190

[Nos. 77-78.


precepts subjoined merely for the purpose named above." He concludes: "I have, it is true, for perforating tlie tympanum devised a new instrument wliich I trust will be useful."

The part of the book most interesting to us is the supplement on diseases of the external ear, covering about twenty pages. These chapters are written in the most concise and simple manner and cover most of the inflammatory afiections of the auditory canal, congenital deformities, injuries as well as the treatment of foreign bodies, insects and indurated wax in the auditory canal.

He describes his method of inspecting the canal as being " best accomplished by placing the head in such an attitude as to suffer the sun's rays to enter the meatus and impinge upon the tympanum. To effect this, the operator must seize the external ear, and drawing it outward from the head, extend and straighten the cartilaginous part of the meatus. I have been able to inspect the ear more perfectly by introducing, at the same moment, a steel director, with its groove toward the meatus and its convex side pressed firmly against the anterior walls. The passage is thereby straightened and expanded. If there be no wax present the tympanum will be seen of a pearly white color and concave."

The little instrument which he devised for perforating the membrani tympaui is a minute trephine, by revolving which a circular piece of the drum was excised. His object in constructing this instrument was to obtain a larger opening, for he tells us that in two instances in which he had occasion to perforate the membrani tympani he found the beneficial effects of the operation soon to cease in consequence of the speedy closure of the artificial opening. The Maryland Medical Recorder of 1839 reviews the work extensively, the review covering twenty pages. The review is by no means flattering.

It is very apparent that Dr. Nathan R. Smith must have been deeply interested in the subject of the diseases of the ear. He had an extensive j^ractice in diseases of the ear, and also of the eye, though none of his publications deal with the latter organ. Dr. Theobald has recently found a drawing of a knife designed by Dr. Smith to slit the lachrymal canal.

Dr. Joshua I. Cohen.

Dr. Cohen, born in Maryland in 1800, graduated at the University of Maryland in 1833, having been a student in Dr. Nathaniel Potter's office, and soon after devoted himself to the study of diseases of the ear. He was an intimate friend of Dr. George Frick, the oculist, and, like his friend, had wide interest in science beyond the domain of medicine. He thus for a time became professor of mineralogy in the academic department of the University of Maryland. He was much interested in the Medical and Chirurgical Faculty of Maryland, was its treasurer from 1839 to 1856 and president from 57-58. He was also much interested in the Maryland Academy of Sciences.

He practiced until about 1851, devoting himself almost exclusively to otology. His reputation as an aurist must have been quite great, for we read in Reese's American edition of Cooper's Dictionary of Practical Surgery (2nd ed., vol. 2, p. 73, under the heading "Ear"): "In the United States there have been a few surgeons who have distinguished themselves by their success in the treatment of diseases of the ear.


" Dr. Cohen of Baltimore and Dr. Dix of Boston have for several years directed their particular attention to diseases of the internal ear, and to the investigation of the abnormal condition of the tympanum and eustachian tube in cases of deafness. These gentlemen have employed condensing apparatus for administering the air douche through the eustachian tube after the plan of Kramer and others. By the air and also by the water douche, these gentlemen have acquired great tact in the diagnosis and treatment of obstructions in the tube and upon the tympanum."

In 1840 he established, in connection with his friend, Dr. Samuel Chew, an eye and ear institute in Baltimore, in which Dr. Chew had charge of the eye department. Dr. S. C. Chew has had the kindness to inform me that this association between Dr. Cohen and bis father lasted for a short time, as his father's appointment to a chair in the University of Maryland compelled him to withdraw from it.

Dr. Cohen was one of the earliest, perhaps the first, aurist in this country. He has left us, however, but one publication which pertains to diseases of the ear. It is entitled " Postmortem Appearances in a Case of Deafness."* The paper is very short, but is written in the most scientific manner.

In a note written by the editor of the Journal we read that this "valuable communication was read before the American Philosophical Society, at a recent meeting, and is noticed in the proceedings of that body. It has rarely happened that opportunities have been embraced for examining into the condition of the organ of hearing in cases of deafness, or that they have fallen within the observation of an investigator so competent as the author of this paper." The case was that of a patient who died of phthisis. The brain and seventh pair of nerves were examined carefully, but no changes observed. The lower part of the skull was then removed and the ear examined in minute detail.

In the right ear he found the drum-head dull and dark in appearance, irregularly thickened and retracted as a whole, thus diminishing the cavity of the tympanum. The tympanum itself was filled with muco-fibrous membranes passing from the membrani tympani to the posterior walls, presenting a cellular structure. These were carefully divided, exposing the tensor tympani muscle, the tendon of which was found to be of unusual shortness and attached to the handle of the hammer throughout its whole length, thus drawing the bone and the membrani tympani to within a line of cochlear process. Interesting irregularities in the ossicula were noted. The malleus was normal. The incus was undeveloped, diminutive in size. The stapes was wanting with the exception of the base, which was held in place by the circular ligament. The depression of the oval window was filled with membranous tissue, which likewise covered the fenestra rotunda. The tensor tympani muscle was strongly developed, its tendon short and thick as mentioned above. The stapedius muscle existed, but there was no tendon.

In the left ear the membrana tympani was found to have been entirely destroyed, with the exception of a very thin slip at the anterior inferior edge. The tympanum contained a


•Amer. Med. Intelligencer, July 1841 to July 1S42, p. 220 (Vol.1).


August-September, 1897.]

191


quantity of yellowish fetid matter, and its lining membrane was completely disorganized. The union between the ossicula was slight, owing to the general disorganization of the ligamentous and mnco-fibroiis connections. The incus was in place, but the handle of the malleus was depressed. The stapes was not bound down in the oval window, for the annular ligament was entirely destroyed. Tiie tendon of the tensor tympani was disorganized and that of the stapedius destroyed; the whole condition of tiie tympanum showed a recent active suppuration which did not confine itself to this part; the vestibule was penetrated as well as the mastoid cells; the latter were covered with pus. Tlie cochlea and one of the semicircular canals were examined a day or two subsequently, but there was nothing remarkable about them at this time worthy of note.

Inquiry about the patient led the author to conclude that the faculty of hearing in the right earhad been entirely wantingor was very much impaired for many years.

Though he seems to regard the condition of the right ear to have been congenital, his critical analysis is as acute as the observations tliemselves are accurate. He cites cases of Morgagni in which membranes filled the cavity of the tympanum.


and another in which there was immobility or contracture of the muscles. At the conclusion of his paper he says: "In the case described in this paper, does not the absence of every part of the stapes, with the exception of the base, liken it to the osseous operculum found in the bombinatores, land salamander, and cfBciliffi ; of the effect of wliich, in the communication of sonoro:is undulations, I have already spoken ? " I am unable to find any other reference to this paper on undulations and do not know whether it was ever published.

This sketch must be brouglit to a close. Is it necessary to remark what any careful reader must have observed, that there were physicians in Baltimore in the first half of this century who labored faithfully and well in Ophthalmology and Otology? Their contributions were among the earliest and most important in this country.

In conclusion I desire to express my thanks to Dr. G. W. Miltenberger, to Dr. John Morris and to Dr. Eugene F. Cordell, who furnished me with important notes, as well as my indebtedness to Dr. John R. Quinan's "Jledical Annalsof Baltimore," and Dr. Cordell's " History of the Universiiy of Maryland."


JOSEPH FRIEDERICH PIRINGER: HIS METHODS AND INVESTIGATIONS.*

By Harry Friedenwald, A. B., M. D., Baltimore.


"Joseph FreiJerich Piringer was born, March 31st, 1800, in Klein-Zell in Upper Austria. He studied medicine in Vienna ; he afterwards turned his attention to ophthalmology in 1824. He was at first an assistant of Jaeger, then for three years of Rosas (beginning in 1825). He next obtained the extraordinary professorship of ophlhalmology in the medical school at Gratz. Here he founded a much-needed eye hospital, an institution out of which the ophthalmic department of the AUgemeines Krankenhaus gradually developed through his energy. Here he held a high position and was active as a teacher until ISGO. His clinical and experimental stuilies on blennorrhcea were made at this hospital. He wrote a work on blennorrho;a which was awarded a prize by the German Society of Physicians in St. Petersburg. Piringer has the merit of having shown that intentional infection of blennorrhceic secretion in pannus leads to clearing of the cornea. He founded a reputation upon this which extended far beyond the boundaries of Germany. He was for many years attached, as visiting physician, to the Elizabeth Hospital and to the City Asylum for the Aged, and published several other articles up to the time of his death, Sept. 22nd, 1879, including: Ueber Veratrinbehandlung des acuten Gelenk-Rheumatismus ; Die Behandlung der Variola mittelst lodtiuctur; Die richtige Pflege der neugebornen und kleinen Kinder ; Studien ueber die MortalitatsStatietik in Graz."f — (From Hirsch's Biographisches Lexikon, 1886, vol. IV, p. 575.)

Piringer's work on blennorrbceaj was awarded a prize, and the earlier works in ophtiialmology refer to his studies, especially to his investigations in the treatment of pannus.§ Arlt


•Read before the Johns Hopkins Hospital Historical Club. 1 1 am indebted to Professor Wm. H. Welch for having called my attention to this account of Piringer's life.

t Die Blennorrhoe am ^Menschenauge. Graz, 1841. lOest. Med. Jahrb., 1838, and chapter 8 of the monograph.


devotes some space to a summary of the work on blenuorrhcea.* But more recent works in ophthalmology make no mention of these important studies and their no less important results; in works on bacteriology I do not find his name, nor even in works on gonorrhcEa, such as that of Finger. Piringer's work was of such importance that it does not deserve to be thus forgotten.

The absence of any other references in ophthalmic literature leads me to believe that Piringer's studies in ophthalmology were confined to the subject of inquiry contained in the work above mentioned. This is the more readily understood when we read in his preface " that his itntiring efibrts during fifteen years were given up to the solution of the natural laws governing blennorrhoeas of the eye, as far as this lay in the limited powers of a single individual." We may aptly apply to Piringer the words, "therefore by their fruits ye sliall know them." Judged by this standard, Piringer stands out boldly as one of the greater luminaries of medical science in tlie first half of this century.

In order to properly estimate the importance of his investigations it will be necessary to examine into the state of knowledge of the subject previous to 1840.

In 1780 a treatise on diseases of the eye appeared, written by George Chandler, surgeon, of London, in which he gives this account of "venereal ophthalmy." He divides it into two varieties, the translative and the symptomatic.

"The translative ophthalmy begins with a copious discharge of a sebaceous humor of a yellowish white color, and is known by the tumor, lividness, sharp and lancing pain of tlie sclerotica, the


  • Klin. Daratellung d. Krankheiten d. Auges. Vienna, 18S1, pp.

35-37.


192

[Nos. 77-78.


cornea at the same time being as it were depressed within a pit. It frequently follows soon after an injudicious stoppage of a gonorrhoea, the venereal virus being translated into the eye. It has also been observed that a gonorrhoea which before seemed incurable has, upon the coming on of this ophthalmy, suddenly vanished ; and in like manner the ophthalmy has gone off upon the return of the gonorrha?a . . . The symptomatic remits towards morning, never turns into a chemosis, the morbid matter does not change place, the pains are milder, it is removed when the hies is cured, and is also attended with less danger."

He admits that "sometimes a venereal ophthalmy has been produced by the immediate application of the virus to the eyes."

Concerning the treatment he tells us that —

"The venereal ophthalmy in general is subdued and its poison extinguished by mercury, but it should never be applied to the eyes. The patient should be bled and purged, and his eye washed continually with brandy and water, etc. It is necessary also to evacuate the virulent matter collected in the cellular texture of the sclerotica and eyelids by slight incisions of each membrane ; an ichor, very like that of gonorrhtea, will be discharged."

This was the older view.

About the beginning of this century a remarkable development occurred in ophthalmology. Beer and Schmidt in Vienna, and Himly, Langenbeck, Graefe the elder, and others gave a new impetus to the scientific study of this branch of medicine. This was followed by the publication of a number of important treatises and monographs in ophthalmology, principally in Austria and Germany, but also in France, England and our own country. I shall pass these by and take up the subject as we find it in the third edition of one of the most important and valuable treatises on " Diseases of the Eye " written in the first half of this century, that of William Mackenzie of Glasgow. I take the third edition as it appeared in 1840, one year before Piringer's work. Here we find under the section of ophthalmia in new-born children, that "there is reason to suspect that this disease is not unfrequently an inoculation of the conjunctiva," etc., and "that therefore it may often be prevented by carefully washing the eyes of the infant with tepid water," etc.; secondly, "that the purulent ophthalmia of infants in its worst form is the result of the application of gonorrhceal matter, is generally admitted."

Concerning gonorrha'al ophthalmia he tells us that —

" Different views have been entertained of the purulent inflammation of the conjunctiva which is frequently found to attend or succeed gonorrhtea. First, this ophthalmia has been ascribed to inoculation with matter from the urethra; secondly, it has been supposed to be metastatic ; and thirdly, it has been considered, at least in certain cases, as an effect owing to irritation merely, without either inoculation or metastasis. It is quite possible that there may be three such varieties of this ophthalmia. The existence of the first I consider beyond all doubt ; but the second and third are somewhat problematical."

His description of the first form is quite clear, and in several cases which he reports the infection is definitely proved. He did not succeed in separating gonorrhcEal from what was called Egyptian ophthalmia, excepting as differing in degree. This distinction was not definitely made until about ten years later (by Bendz). Mackenzie's criticism of the views entertained by


some eminent ophthalmologists is so interesting that I shall quote the entire paragraph:

" Dr. Vetch tells us that in a soldier in a very advanced stage of Egyptian oplithalmia he attempted to divert the disease from the eyes to the urethra, by applying some of the matter taken from the eyes to the orifice of the urethra. No effect followed this trial. It was repeated in some other patients, all laboring under the most virulent state of the Egyptian disease; and in all the application was perfectly innocuous. But in another case, where the matter was taken from the eye of one man laboring under i)urulent ophthalmia, and applied to the urethra of another, the purulent inflammation commenced in 36 hours afterwards and became a very severe attack of gonorrhrea. From the result of these experiments, Dr. Vetch, while he admits that gonorrhceal matter taken from one person and applied to the conjunctiva of another will excite a highly purulent ophthalmia, regards himself justified in no longer admitting the possibility of infection being conveyed to the eyes from the gonorrhceal discharge of the same person. He adds that the impossibility of this effect was rendered decisive by an hospital assistant who, with more faith than prudence, conveyed the matter of a gonorrhcea into his eyes without any affection of the conjunctiva being the consequence. It is remarkable that Dr. Guillie has fallen into the same error of reasoning as Dr. Vetch, onlythathis negative experiments have led him to the very opposite conclusion. He applied the matter taken from the conjunctiva of one patient to the urethra of another; no effect followed, and hence he concludes that the notion of some regarding the propagation of puro-mucous inflammation from one mucous membrane to another in different individuals, is unfounded."

Mackenzie, however, devotes considerable space to the discussion of gonorrhceal ophthalmia from metastasis, though nothing could be better than his statement that writers had adopted these views " with too little hesitation and appear not to have sufficiently investigated the probability of the ophthalmia arising rather from inoculation than from metastasis." He goes on to enumerate " the causes of the suppression of the gonorrhcea, to which the rise of metastatic gonorrhct-al ophthalmia is attributed," and cites an illustrative case from a French writer. It is evident that ilackenzie had little confidence in the existence of this form of gonorrhceal ophthalmia.

A third form of gonorrhceal ophthalmia without inoculation or metastasis is described : "an alternation has been observed between the two diseases; that is to say, when the gonorrhcea came, the ophthalmia went, and vice versa." Mackenzie says that the cases reported "show the diversity which exists in opinions entertained regarding the ophthalmiaj which in some individuals are found to attend gonorrha'a, or to alternate with this disease"; and that "it is quite evident that the ophthalmia? which have been observed to do so are far from being uniform," that some are probably ophthalmia tarsi, others catarrhal ophthalmia. What is most important is his statement that '■ it may fairly be doubted whether there is any connexion between diseases of urethra and that of the eye, farther than that they occurred in the same iudividtials, while the occurrence of both might be attributed to a susceptibility for disease arising from peculiar or debilitated constitutions." We are somewhat surprised to see this statement followed by such a one as this, that "Swediar's hint to employ the bougie in cases of ophthalmia alternating with gonorrhcva may probably be found of use; it is evident, however, that this remedy cannot be trusted alone, but that the ophthalmia must be treated according to


August-September, 1897.]

193


the particular symptoms it presents, not according to tlie conjectural notions entertained regarding its origin." Concerning Egyptian ophthalmia jMackenzie says:

"I think it probable that the ophthalmia which attacked the British anil the French armies in Egj'pt was an atmospheric puro-mucous conjunctivitis [described at another place as "excited by exposure to atmospheric alternations "], but that it afterwards degenerated into a contagious, perhaps infectious disease; that is to say, that it was propagated by actual contact of the discharge, and perhaps by miasmata from the eyes floating through the air."

Mackenzie's views may fairly be taken as the most advanced of this period and will serve as the proper point from which to view the investigations of Piringer.

It should be mentioned here that many subsequent writers held on tenaciously to these and older views for many years after Piringer's discovery had been made.

We may first direct our attention to Piringer's experiments in curing pannns by producing acute purulent ophthalmia. This method, we are told, was first suggested by Friederich Jiiger* some time during the second decade of this century, but little or no attention had been given it before Piringer's experiments were made. He tried the metliod in more than sixty cases, using the pus of various kinds and stages of purulent ophthalmia of bo(h adult and new-born. All of his cases were improved and not one was injured by the treatment. In the great majority of cases the cure was complete, so that no sign of the former disease could be discovered, and permanent. He therefore recommends this method of curing paunus in these words: "After so many highly successful experiments and observations, the inoculation of tlie blennorrhoea for the cure of pannus is no longer a doubtful measure which requires great courage, but an excellent method (ein grossartiges llittel)." This method remained in use for many years and is still being applied in a modified manner. The modification consists in the use of jequirity to produce a purulent ophthalmia instead of blennorrhceic matter.

It was in the study of this method of treatment that Piringer made his investigations as to the nature of blennorrhceaand the contagious property of the secretion. For this purjjose his experiments were varied inevery conceivable manner. Most of the experiments were made upon eyes which were already diseased, but these were controlled by other experiments upon amaurotic eyes with perfectly healthy conjunctiva, or by the accidental infection of normal eyes.

After describing the various forms of purulent inflammation of the conjunctiva he takes up the causes. Under this head he discusses the question as to the production of gonorrhoeal ophthalmia by metastasis. In the course of fifteen years he had never seen a case of suppression of a gonorrhoea with an outbreak at another point, excepting in the neighboring tissues.


  • In Hirsch's History of Ophthalmology, p. 441, we read thatLudwig reported the successful use of this method at the hands of a

friend, probably Friederich Jiiger.

Wharton Jones (in a manual on Ophth. Med. and Surg, published in 1847) states that Dr. Henry Walker was the first to suggest the method (Edinburgh Medical and Surgical Recorder) in 1811. I am unable to verify this citation.


Many physicians of great practice had likewise never seen true metatastic gonorrhcsal ophthalmia. He denies the occurrence of such a form of disease, and characterizes it as a very pretty fable which one after the other has been telling in the best of faith. Gonorrhceal ophthalmia is always due to the transference of infectious material directly into the conjunctiva!

In a similar manner he disproves the existence of a consensual form of gonorrhceal ophthalmia, supposed to be due to a sympathetic connection between the affected parts.

Gonorrhceal ophthalmia is known to be more common toward the end of the primary affection than during the period of its greatest virulence. He explains this very properly on the ground that Avhen the discharge is great much care is used in cleansing the fingers. It is after the discharge has become scant that patients become careless. The right eye is usually the one first affected, because most patients are right-handed.

Ilis experiments proved that the generally accepted view that the transference to the eye of gonorrhceal pus results in a simple conjunctivitis or a mild purulent ophthalmia, and only rarely in a severe inflammation, is false. On the contrary, he asserts that the result is always a purulent ophthalmia of a severe degree. The only exception occurs in those cases in ■which early treatment is successfully applied.

The contagious character of the secretion of ophthalmia neonatorum had been looked upon as ridiculous ;* when .Tuengken stated that a ni;rse had developed severe i)urulent ophthalmia during the night of the same day when she had infected them with a sponge that had been used to cleanse the eyes of an infant with ophthalmia, it was laughed at. No one can deny the infection in his own cases, because the material was carried across the street into another house and yet the result was always the same.

His experiments on the production of purulent ophthalmia embrace almost one hundred eyes, and this does not include a number of accidental infections which were observed with the same care. The matter with which infection was produced was obtained from eyes afl'ected with different forms of purulent ophthalmia as well as from genital blennorrhcea. All ages and both sexes were found to be equally predisposed.

One of the most interesting chapters is the one on the character of the blennorrhceic contagion. Though the pus from the conjunctiva causes infection when applied to the eyes of human beings, he was unable to produce any result when he applied it to the eyes of such animals as dogs, cats, hogs, and various birds. Others had claimed that they had produced effects in such cases. Our jiresent knowledge of the immunity of animals to gonorrhcea shows that Piringer was not deceived.

The granulation from which the pus is secreted carries the contagious property with it, as was shown in 1833 by Werwick, who experimented upon two nurses. Piringer never made any experiments w'ith granulations because it lacked any practical bearing.


  • The faith with which this opinion has been held can be measured by the much-quoted citation of Dr. Vetch, referreil to above.

Piringer likewise ciuotes Adams, who rubbed his eyes with a finger smeared with purulent matter without producing ill results, as did Van Sevenoeck and Kriebel. Morburgo smeared the eyes of 300 soldiers without effect.


194

[Nos. 77-78.


The pure lachrymal fluid of a blennorrhoeic eye was found not to possess conhigioiis properties. An experiment is related in which lachrymal fluid collected upon a canielliair brush did not produce infection, while the purulent secretion gathered a few days later did.

The question of contagion far distance (per miasma) was studied in his hospital, where numerous blennorrhceic patients were placed beside those unaffected, in small wards. He was able to prove definitely that such contagion does not occur and that the cases in which it is suspected can always be traced to direct infection.

The vapor of drying secretion has no power of infection. Even those secretions which are perfectly serous leave a residue when evaporated, and it is this which still retains the contagious {)roperties.

The fluid secretion when kept for three or four days, even without evaporation, is no longer contagious.

If a finger is covered with blennorrhceic secretion and washed immediately in clear fresh water and well dried, it will cause no infection if rubbed over the conjunctiva.

Blennorrhoeic matter may be smeared over the eyelids if the palpebral fissure is kept firmly closed by adhesive plaster, and no infection will occur. In order to produce infection the secretion must reach the conjunctiva.

The secretion of acute blennorrhoea of a moderate degree is just as contagious as that of the most severe. Such pus is capable of producing infection even when diluted with 50 or 100 parts of water. The pus of a very mild purulent ophthalmia and of chronic ophthalmia has much less power of infection.

As long as there is any secretion in any case of purulent ophthalmia, whether mild or severe, so long the case is contagious. Wiien the secretion ceases, tiiough there maybe considerable congestion and photophobia, the infectious properties are lost.

The properties of infection inherent in the secretion do not vary in different seasons of the year nor under changed atmospheric condition, whether exposed to the glare of the sun or to the cold of the winter. Experiments .to determine this may appear meaningless to us, but we must not forget the opinions prevalent in Piringer's time.

Numerous experiments were made to determine the effect upon the contagious properties of the pus when separated for varying intervals of time from the human body. Thus the secretion was collected upon a camel-hair brush and allowed to become as dry as possible (" dry as glass ") in from three to six hours. If then applied to the conjunctival sac, but not allowed to soften in the tears, no infection occurred ; if softened in the tears, or previously in water, infection was sure to occur.

In seven cases the secretion which had been allowed to dry for thirty-six or forty hours in the open air had lost all contagious property, but in two in which the secretion had been allowed to get dry thirty- three or thirty-four hours in the room and was then softened it produced very severe ophthalmia blennorrhcea. Piecesof linen smeared with fresh blennorrhceic matter and given to a pannus patient to wipe his eyes produced infection, but if the cloth had been dried in the air for several days, the patient could use it about the eyes witiiout harm, and the


secretion when scraped off" the cloth and inserted into the conjunctival sac produced infection only when it was less than thirty-six hours old. On the other hand, if the secretion was placed in a vaccine case and hermetically sealed it retained its contagious property for forty-eight hours, but lost it entirely when kept for three days. The pus fioma case of ophthalmia neonatorum produced infection when kept in this way for two and a half days. Piringer therefore concludes that "?/Ze««orrJiieic pus loses its contagious properties as it hecornes older, and (jraduaUy dies in from twenty-six to forty -eight hours, jjossessing no more organic life token three days have passed." It is upon the discovery of this fact that Piringer bases important rules of prophylaxis, and explains the relative infrccjnency of gonorrhoeal ojDhthalmia among the common people.

Piringer studied carefully the length of time intervening between the entrance of the infectious material and the first signs of the developing disease, the period of incubation. This he found to vary according to the manner and the amount of the infection, as well as according to the individual peculiarity of the patient. The higher the degree of inflammation, the more rapidly did its pus infect. Thus the pus from a very severe ophthalmia produced infection in from six to twelve hours, or at most in thirty-six hours ; while that of very mild blennorrhoea might rec|uire sixty to seventy hours, and that of a case of chronic blennorrhcea seventy-two to ninety-six hours.

The secretion of the second stage of acute ophthalmia acts more slowly than that of the first; thus the pus from a case of very acute blenuorrhrea in which the secretion was markedly diminishing may take sixty hours to produce the first symptoms.

If the secretion while still warm is immediately transferred from an acute blennorrhcea, but six or eight hours are required for the first signs to show themselves, and in twelve or eighteen hours the disease is fully developed. In this respect the conjunctiva responds more rapidly than the genital mucous membrane. The longer the secretion is kept before it is placed in the conjunctiva, the less rapidly does it act. The rapidity likewise varies with the amount of secretion brought into the eye.

Piringer gave the prophylaxis of gonorrheal ophthalmia his careful attention and the results were very important. Can tiie inflammation be aborted after the infectious material has once reached the conjunctiva? Several cases in which the very early and continued application of ice comitresses produces this effect are described. In order to determine whether the infectious material can be removed and the outbreak of the disease prevented, several series of experiments were made. The method which required the application of very strong solutions of bichloride of mercury, concentrated acetic acid, etc., appeared to him too severe, and in the few cases in which it was tried the desired result was not obtained.

On the otiier hand he found that washing out the eye with water after the contagious material had been inserted prevented the development of the disease, provided that it is done sufficiently early. These experiments were made on three patients. In the first case he touched the eye with a large quantity of matter from a newborn babe, cleaned it out after a minute with a sponge dipped in cold water, and had cold water apiilicatioMs made for ten hours. No inflammation resulted.


August-September, 1897.]

195


Four days later he varied the experiment by allowing the matter to remain two minutes and again no inflammation occurred. After another interval of four days the experiment was again repeated, the pus remaining in the eye for three minutes and the result was again the same. After another interval of 6ve days pus was inserted and allowed to remain in the eye for live minutes; no cold applications were made; the result was a violent inflammation. This patient had pannus, which was cured by the treatment.

In order to try tiiese experiments upon a perfectly normal conjunctiva he selected the eyes of an amaurotic beggar whom he paid for these privileges. In this case he found that no disease resulted if the blennorrhoeic matter was washed out within three minutes after its entrance into the conjunctival sac and cold water applied. In three minutes any one who has accidentally infected his eyes can obtain fresh water with which to wash them !

In order to determine whether the washing out of the conjunctival sac would accomplish the same result without the use of ice applications, he infected the eye of a girl suffering with pannus with blennorrhoeic matter and washed out the conjunctiva in three minutes. Ninety hours later a severe ophthalmia developed. And in a second case the experiment again resulted in the development of a purulent ophthalmia, but not until the fifth day, and in this case the ophthalmia was of a milder character. For these reasons he considers the cold water application as essential to the prevention of conjunctival blennorrhci'a after infection has occurred. Many other questions are considered by Piringer, but this review embraces the essential points, and will, I trust, suffice to show its importance.

The care, the true scientific spirit, the accuracy of observation and experiment, the unbiased search for truth, form marked characteristics of I'iringer's work. And yet he is so modest as not to claim that his results are "the absolute truth," though they are his own firm convictions; experiments and observations, he tells us, by other physicians at other times and places, made with care and without prejudice.


are needed to confirm them as well as to clear away any errors. His experiments were arranged carefully and judiciously to determine the character and the attributes of the contagion, the time during which it acted, the gradual diminution of its powers to the point when they were entirely lost, the intensity of the contagion, and the degrees of dilution which could be borne without loss of all contagious properties. Many of these questions were given their final solution by Piringer. He separated the fluid portions of the pus which could be evaporated, from the more solid matter which contained the contagious quality. He proved that the unknown cause of contagion was a something which had to be transferred in substance from one mucous membrane to the other, and which never acted at a distance, thus disproving the old miasmatic principles which were still current in those days.

In what is our knowledge today greater than that of Piringer, excepting that the active agent, the living microorganism, the gonococcus, has been discovered, a discovery only made in 1879 ? That it was a living organism even Piringer surmised, for, as we read above, he speaks of it as "growing older," and "dying," and "possessing organic life." Let us not forget when it was that Piringer worked. Though micro-organisms had been discovered toward the end of the seventeenth century, and micro-organisms were assigned as the causes of numerous diseases during the eighteenth century, it was not until 1840 that Henle first established the germ theory of disease upon the solid foundation of logic and fact.

One aspect of Piringer's experiments still deserves mention. Others had likewise made experiments with a view of transferring the disease which we have been considering; but most of these were unsystematic, few in number, and led only to confusion. Piringer's work was such as to give a definite solution to important questions, results which have stood the tests of time. His work was not in vain. His hopes were fulfilled that "the medical world would read not entirely without pleasure a number of results, whose collection in the field of practice had been made at the cost of much strain, great pains and many a sleepless night."


PROCEEDINGS OF SOCIETIES


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of May 3, 1897.

Dr. Thayer in the Chair.

Haeniatoniyelia from (xunshot Wonnd of tlie Cervical Spine.— Dr. CiisniNG.

This patient, a young woman of 27 years, was brought into Prof. Ilalsted's service, November Gth, 1896, with the hiotory of having been shot twice in the neck a few hours before entrance. Our chief interest centres in the injury produced by the missile, whose wound of enti-ance is situated here on the right side of the neck at the level of the cricoid cartilage. These skiagraphs show the point of lodgment of the bullet in the centrum of the sixth cervical vertebra.

The case illustrates some unusual features of one type of


the so-called Brown-Seqnard paralysis; the value of the X-rays in locating the offending missile; a practical recovery without operative interference; a residuum of symptoms resembling those of syringomyelia.

At entrance she was suffering from agonizing " pains " of a " pins and needles " character, especially in the arms, so severe she would cry out when they were touched. No radiating pains, such as are described iu the meningeal form of hemorrhage, were present. There had been no loss of consciousness. Motor paralysis was complete on the right side below the level of Thorburn's "5th root group." On the left there was a brachial monoplegia up to this same segmental level, namely that for the deltoid biceps and supinator longus muscles whose ventral horn ganglion cells lie in the 5th cervical segment, as you may see by comparison with this


196

[Nos. 77-78.


familiar table of Starr's. Respiration was purely diaphragmatic.

On the left side, uji to the second intercostal space and down the ulnar side of the arm over an area which corresponds, as these diagrams taken from Starr and Kocher demonstrate, to the cutaneous sensory fields of the eighth cervical and first dorsal segments, there existed anassthesia to pain and thermic stimuli, aud a slight dulling of tactile or pressure sensibility. A segmental zone of similar anaesthesia was present on the side of motor paralysis across the chest aud including most of the right arm.

There was a marked elevation of surface temperature, cousiderable hyperalgesia, and also a diminution of reflex activity on the paralyzed side. Loss of sphincteric control over the contents of the bladder aud rectum was also jjresent.

liestitution from these paralytic symptoms has taken place up to the excellent conditiou in which you see the patient at present. The motor paralysis disapjjeared gradually. On the tenth day, motion, as is usual, was first observed in a slight flexion of the thigh. Turner in his experimental work called attention to this. At the present time there remains evidence of the degeneration of the right j)yramidal tract iu Wernicke's residuary paralysis of the dorsal flexors of the foot, giving the late hemiplegic character to the jjatient's gait. Mann has recently called attention to this residuum of motor paralysis aud has shown that it selects a certain muscle unit (bewegung einheit), this unit being that which lifts and shortens the leg in the first stage of walking, as can be demonstrated in this patient. Paralysis remains alone complete in some of the small muscles of the right hand, representing destruction of ganglion cells at the site of the lesion. There is au exaggeration of all the deep reflexes of both extremities. Myotatic contractions, as you see, are elicited iu the muscles of the right arm by gentle blows on the tendons. Resolution of the sensory disturbances has been less complete. Slight anEesthesia to painful aud especially thermic stimuli persists on the left.

A month ago there was present a peculiar distribution of areas of hyperesthesia, over which cold produced paiu without thermic sense, and the threshold for pain was so low to touch or pressure stimuli that the latter could only be elicited with difficulty by v. Frey's assthesiometer. This is illustrated by these diagrams.

The lesion was presumably due, as in Mann's case, to an intramedullary hemorrhage, the occurrence of which, especially in the cervical enlargement, as emphasized by Thorburn, is not uncommon. It seems that not only is traumatic hajmatomyelia much more common here than elsewhere in the cord, but that there is a certain level iu this enlargement giving symptoms corresponding to the "typus inferior" of Krause, iu which intramedullary hemorrhage is most likely to occur. This list of cases, collected from the literature, tends to confirm this view of a site of predilection in the lower cervical enlargement for hajmatomyelia, and illustrates the fact that not only in cases attributable to acute flexions of the neck does it occur, as was believed by Thorburn, but also iu those due to a great variety of traumatic causes. The hemorrhage also is apt to occur most extensively on one side of the


cord, thus often producing the symptom complex of a Brown Sequard type of paralysis.

That the hemorrhage also in these cases selects by preference the gray matter of the cord, presumably from the greater vascularity aud less support given to the vessels there, is well recognized. Frequent note has also been made of cavity formation at the original nidus of hemorrhage, which is interesting iu consideration of the association of the syndrome of syringomyelia which Minor and others have pointed out to be a common sequence of traumatic ha'matomyelia and which persists in this patient.

The case which Maun has recently reported in full with post-mortem examination of the cord, in the Dent. Zeit. f. Nervenheil. for 1896, and which clinically bears such close similarity to this case, illustrates many of these points very completely.

Dr. Thomas. — This case seems to me to be one of particular interest, aud the Society is to be congratulated on having it so admirably presented. Those of you who have had the opportunity of examining a similar case will recognize the difficulty of making such au exhaustive examination. I know of no case in the hospital records that has been worked up so carefully as this. Dr. Gushing was kind enough to bring the patient to me ou several occasions for examination, and I confirmed the results which he had already obtained. The patient's condition, after she had been in the hospital for some time, was, as Dr. Gushing has described to you, briefly as follows : there was weakness of the right leg and right arm. The muscles of the right arm were atrophied, aud there were sensory disturbances, as shown in the charts. The wound in the right side of the neck was in such a position that the bullet might have injured the brachial plexus before entering the spinal columu, and thus have produced the condition found in the right arm. An electrical examination of tlie paralysed and atrophied muscles showed that they responded normally to the currents. This was believed to indicate that the brachial plexus was not injured, aud also that the paralysis was not due to destruction of the anterior horns from which the nerves forming this plexus arise. I do not believe that there can be extensive destruction of the anterior horns without the occurrence of degenerative atrophy of those muscles which receive their nerves from that segment of the cord. In the case of Maun, to which Dr. Gushing has referred, there was paralysis and atrophy of the muscles of the left arm. This was completely recovered from, but, at the autopsy, a lesion iu corresponding anterior horn was found. This case is, as far as I know, the only one bearing on this poiut, and it does not seem to me to be conclusive. The lesion was limited to the eighth cervical segment, as shown by the fact that the eighth root was degenerated, while the seventh was not, and the first thoracic root was only slightly so. We know that each muscle is represented in more than one spinal segment, and it can be understood how a limited lesion in one segment need not necessarily produce degenerative atrophy to such a degree that it could be discovered during life. The autopsy on Mann's case was incomplete, in that neither the muscles nor the peripheral nerves were examined.

Dr. Cushing's case is of interest from so many standpoints


August-September, 1897.]

197


that it is impossible to discuss it fully. Unilateral lesions of the cord are not very common. In the dispensary we have the records of only two typical cases. I have at present under observation a very beautiful example of this form of paralysis. The patient is a woman whose right leg is paralysed and who shows the disturbances of sensation in the left leg which Mann has pointed out as characteristic, i. e. the sensory conduction for touch is undisturbed, whereas pain, heat and cold stimuli do not produce their normal effect. The paths of sensory conduction within the cord have been and are the subject of much discussion. Of late the anatomists and physiologists have been inclined to the view that the paths do not cross, but remain on the same side of the cord until they reach the medulla. Clinicians, on the other hand, from the study of the cases of unilateral lesion of the spinal cord, have held to the belief that the sensory jiaths decussate soon after entering the spinal cord. That there must be an anatomical basis for the constant occurrence of the classical symptoms of Brown-Sequard's paralysis seems to me to be self-evident. The burden of jiroof must rest ujiou the anatomists and physiologists.


NOTES ON NEW BOOKS.

Diseases of the Rectum, Anus and Contiguous Textures. By S. G. Gant, M. D. (Philadelphia : F. A. Davis, 1896.)

With the exception of two chapters on Cancer of the Rectum and Colotomy by Allingliam, a recognized authority on these subjects, the worls of Dr. Gant is not to be commended. The booli contains nothing new, and there are many superior works on this subject. The two cliapters in which the author seems to talce special pride, one on auto-infection, tlie other on effects of railroading on diseases of the rectum, are not remarkable, and the first is unsatisfactory. That employes of railroads suffer much from constipation and hemorrhoids as a result of their occupation may be true, but the figures he gives can be handled in many ways. If we eliminate from the author's statistics all cases suffering from these two very common conditions, we have less than 1 per cent, out of over 170,000 cases seen in various hospitals suffering from other diseases of the rectum and anus; and 5.7 per cent, in the same number of cases does not seem to us an excessive number to be suffering from the two conditions mentioned. We believe that among the poor laboring class constipation is the usual condition found, and that figures more striking than these could easily be collected to show that constipation was one of the commonest symptoms in all hospital cases. We question whether the jarring of a railroad train will continually rock a stomach from side to side, produce a "sea-sick stomach," or whether it is suiEcient to bring about by itself dilatation of the veins about the anus and rectum by causing a venous stasis, and we know that swelling of the feet in railroad travelers is not an ordinary condition, to say the least. The chapter on sodomy might better have been omitted or much abbreviated ; such a book does not call for a psychological explanation of this practice. In speaking of the relation of pulmonary tuberculosis to fistula, the author states : "So we meet with two kinds of tubercular fistula — one as a result of localized tubercular ulceration with or without any lung complication ; the other a fistula in persons who have lung trouble, due to the absorption of fat about the iscliia, general debility, and abscess. In the feces of the first variety can be found the tubercle bacilli of Koch, while in the second variety they cannot be found unless the sputum containing them has been swallowed, and gastric digestion has been impaired to such an e.Ntent as not to destroy them or their spores." In either form the fistula is tubercular and the bacilli


can be found without these coming from the sputum ; and gastric digestion, even when normal, does not ordinarily destroy them, as we know from the large number of cases of primary intestinal tuberculosis which occur. We do not think that the following statements as regards auto-infection are true. On p. 271 we read : " Our Creator, however, foresaw all dangers and provided us abundantly with safeguards with which we can destroy or neutralize the poisons on the one hand, or throw them off on the other, as soon as they are formed"; and on p. 272, "Just so long, however, as the emunctories are working in harmony and perform their individual functions, and there is no lesion of the intestinal mucosa, all is well, and all poisons, no matter whether theyare the products of decomposition or of bacterial action, will do noharm, forthe reason that they are thrown into a special reservoir (the liver) where they are destroyed or neutralized and afterward discharged from the body."

The colored illustrations in this work are hideous and unnatural, and the woodcuts are not models of artistic excellence. Would it not be well for authors to cease to reproduce cuts of the most common and onlinary instruments, and of well-known positions and procedures in operations, which are quite valueless (cf. cuts on pp. 20, 21, 22, 25, 218,219, 220). Wedislike extremely to see theauthor's autograph on the outside cover, and the long list of societies to which he belongs following his name on the title-page. If the book possesses merit of its own, this sort of cheap advertisement does it no good ; and it does not help the work in any case.


BOOKS RECEIVED.

Second CtUalogne of the Library of the Peabody Institute of the City of Baltimore. Including theadditions made sinceI882. Parts I-II. A— D. 1890-97. 4to. Baltimore.

The Semi-Centennial of Anmsthesia. October 16, 1846-October 16 1896. 4to, 95 pages. 1897. Massachusetts General Hospital, Boston.

Saint Bartholomeio' s Hospital Reports. Edited by S. West, M. D., and W. J. Walsham, F. R. C. S. 1896. Vol. XXXII. 8vo, 518 '+ 197 pages. 1897. Smith, Elder & C >., London.

Transactions of the American Pediatric Society. Eighth session held in Montreal, Canada, May 25, 26 and 27, 1896. Edited by Floyd M. Crandall, M. D. Vol. VIII. 1896. 8vo, 243 pages. Reprinted from the Archives of Pediatrics. New York.

Medical and Surpical Reports of the Boston City Hospital. Eighth Series. Edited by G. B. Shattuck, M. D , W. T. Councilman, M. D., and H. L. Burrell, M. D. 1897. 8vo, 391 pages. Published by the Trustees, Boston.

King's College Hospital Rejiorts. Being the annual report of King's College Hospital and the medical department of King's College. Edited by N. Tirard, M. D., F. R. C. P., et al. Vol. III. (Oct. 1st, 1895-Sept. 30th, 1896.) 8vo. 1897. 332 pp. Printed by Adlard & Son, London.

Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America. Edited by T. L. Stedman, M. D. In twenty volumes. Vol. XI: Diseases of the Nervous System. 8vo. 1897. 962 pp. William Wood &, Co., New York.

Burdett's Hospitals and Charities, 1897. Being the year-book of philanthropy. By Henry C. Burdett. 12mo. 1897. 1018 pages. The Scientific Press, London.

Archives of Skiagraphy. Edited by Sydney Rowland, B. A., Camb. Fol. Vol. I, No. 4. April, 1897. The Rebman PublishingCo., Limited, London.

A Pictorial Atlas of Skin Diseases and Syphilitic Affections in PhotoLithochromes from Models in the Museum of the Saint Louis Hospital, Paris. With explanatory woodcuts and text by E. Besnier, A. Fournier et al. Edited and annotated by J. J. Pringle, M.B., F. R. C. P. Part X, 1897. W. B. Saunders, Philadelphia.


198

[Nos. 77-78.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Reiiort in Patbologry.

The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

(Atrophy). By Henry J. Berklev, M. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

MiLL, M. D.

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

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

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum

Fihrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duliring). By

T. C. Gilchrist, M. D.

Report in Patliology. An E.xperiniental Study of the Thyroid Gland of Dogs, with especial consideration

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


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

Report in Medicine.

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

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

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

Report in Gynecology. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

A. Kelly, M. D., and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,

M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

Ovarian Tumor; General Gynecological Operations from October 15, 1889, to

March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one Gj-nccological Cases. By Howaed

A. Kelly, M. D., and Albert A. Ghbiskey, M. D. Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (decking

Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D. Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoraa of the Clitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of tlie Ureter through the Vagina, for the treatment

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

Howard A. Kelly, M. D.

Report in Snrgery, I. The Treatment of Wounds with Especial Reference to the V.-ilue of the Ulocid Clul

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Neurology, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Ilaeniatomyelia. Bv August Hoch, M. D. A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henky M. Thomas, M. D.

Report in Fntliology, I. Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleue, M. D.


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

Report in PatUology.

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


Tuberculoais of the Female Generative Organs. By J. Whitridge Williams, M. D. Report in Pjitliology.

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

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

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

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

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

Report in Gynecology.

The Gynecological Operating Room; An External Direct Method of Measuring tlie Conjugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Knterocele; 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 Retroflexcd Uterus. By Howard A. Kelly, M. D.

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

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


Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. D.

Tabulated by A. L. Stavely, M. D. The Employment of an Artificial Retroposition of the Uterus in covering Extensive

Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D. Photography applied to Surgery. By A. S. Murray. Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howa&d

A. Kelly, M. D. Urinalysis in Gynecology. By W. W. Russell, M. D. The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gj-neco logical Conditions. By Hunter Robb, M. D. Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D, One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.

By Howard A. Kelly, M. D., and Mary Sherwood, M. D. .\bdominal Operations performed in the Gynecological Department, from March 6,

1890, to December 17, 1892. By Howard A. Kelly, M. D. Record of Deatlis occurring in the Gynecological Department from June 6, 1890, to

May 4, 1892.


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typliold Fever.

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

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

Report in Surgery. The Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to January, 1891. By W. S. Halsted, M. D.

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


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

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

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


A'olume VI. 414 pajif.s, with 7') plates and figures.

Report in Neurology.

studies on the Lesions produced by the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nos. 1 to V). By Henry J. Berkley, M. D.

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

Report in Patliology.

Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.

(3lTLLEN, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of

Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. WiLSlNS, M. D. Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, JI. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By

William D. Booker, M. D. Tlie Pathology of Toxalbumin Intoxications. By Simon Flexnkr, M. D. Thr price of a .sit liuiiiid in cliith [Vul.i. I-VI] of tlir Ilospilnl Brportx is

$30.00. Voi.t. I, 11 niirl III iivr not sold stpiiratcli/. The price of Vols, ir, r and VI is $S.OO nirli.


AIonogrnpliH.

The followini; papers arc reprinted from Vols. I, IV, V ami VI of the Keports. for thoee who desire to purcliase in this form ; STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixkord,

M. D. 1 volume of 104 pages and 41 full-page plates. Price, bound in paper,

?3.00. THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.

Hewetson, M. D. And A STUDY OF SOME F.\TAL CASES OF MALARIA.

By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, 12.7."). STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. THE PATHllLdliY Ol' TO.XALIUMIN INTOXR'.VTIONS. Hy «m»n Flexner, M. U. 1

volume of 150 pages with 4 fuU-page lithographs. 1 rice, bounil in paper, $','.0(<. Subscriptions for the above publications may be sent to

The Johns Hopkins Press, Baltihorx, Md.


The Johns Hopkins Hospital Bulletins are issued monthly. They arc printed by THE FRIEDENWALD CO., Baltimore. Single copies may be procured from Messrs. CVSBI^'O iC- CO. and the BALTIMORE TfEWS COMP.iNT, Baltimore. Subscriptions, $1.00 a year, may be addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; siiiylc copies will be sent by mail for fifteen caits each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No. 79.]


BALTIMORE, OCTOBER, 1897.




COlsTTIElNrTS.


A Second Series of Cataract Operations (One Hundred and

Fifty-eight). By Robert L. Randolph, M. D., . . Parotitis following Visceral Inflammation. — A Report of Two

Cases. By A. Duval Atkinson, M. D.,

Palpation of the Foetal Heart Impulse in Pregnancy. By

Douglas F. Duval, M. D.,

Squamous Epithelioma in a Dermoid of the Jaw. By S. M.

Cone, M. D.,

The Infectiousness of Chronic Urethritis. By E. R. Owings,

M. D., . .


The Importance of employing Pure Salts in the Preparation of the Schott Bath. [Communication.] By C. N. B. Camac, M. D., 214

Proceedings of Societies :

Hospital Medical Society, 215

Demonstration of a Case. Probable Brain Tumor [Dr. Thomas] ; — Demonstration of Specimens [Dr. Cullen].

Notes on New Books, 218


A SECOND SERIES OF CATARACT OPERATIONS (ONE HUNDRED AND FIFTY-EIGHT).*

By Egbert L. Randolph, M. D.


Five years ago I reported in the Bulletin of the Johns Hopkins Hospital a series of fifty consecutive cataract operations. Of these fifty operations six were performed in a hospital. With the exception of eighteen, the remaining twentysix were among the poorer classes of a country population in Virginia and in a mining region in the western part of Maryland. This series then is chiefly interesting from the rather unusual conditions which surrounded most of the patients. For instance, the first case reported (Series I, Case 1) was operated on in a log cabin near Warrenton, Va., and the old man was nursed by his daughter, who saw him only at meal times and at night (she being in service), and as a consequence he was exposed not infrequently to risks during her absence. He went through the same experience a year later with his other eye and, as in the first instance, obtained excellent vision. Case 8 (in the same series) had been blind for three years and lived at a remote point on a plantation in Virginia, and he was nursed by his wife. His cabin was too dark for the operation and I put him on a cot and operated out in the yard. He was very timid and jumped when the iridectomy was performed, causing some loss of vitreous. He counted my fingers after the operation and I assisted him upstairs to a room next


  • Read at the annual meeting of the American Ophthalmological

Society, AVashington, D. C, May, 1897.


to the roof, as the only other room in the house opened out into the yard. He remained there for a week, and at the end of that time was allowed to come downstairs. He subsequently obtained perfect vision. Case 39 (Series I) was operated on in a cabin full of negro children, and he was looked after by his daughter. The result was most satisfactory. In this series of fifty, two failed to recover sight, and as the circumstances peculiar to these were rather unusual and as such might explain the failure, I shall relate the histories. Case 49, woman 78 years old, had been troubled many years with dacryocystitis, more marked in the left eye than in the right. She had been blind from cataract for three years. Refused treatment for the lachrymal trouble, saying she was too weak and old to stand the pain incident itpou the probing. She was made acquainted with the additional risk of a cataract operation performed on an eye where there was disease of the lachrymal sac. She was willing, however, to run the risk of infection from this source, so I operated on the least affected eye. The result was a perfect success. A year later she presented herself for operation upon the second eye. The operation was smooth and she counted fingers with ease immediately afterward. I left the city that evening, not expecting to see her again for two weeks. She was entrusted to the care of the physician who assisted me in the operation. It is well to state here that she belonged to a most ignorant class of white


200

[No. 79.


people, and though nearly eighty years of age, was accustomed to going barefooted in tvarm weather. The first time I operated she had shown herself unmanageable and walked around the house three days after the operation. That was in the winter time. The second operation was in June last, and when I saw the patient two weeks after the operation her physician told me that she got up out of bed the next day, tore the plaster off her good eye and came downstairs and sat in the yard and smoked her pipe. The second day after the operation she walked nearly a mile barefooted to see her daughter. Whatever were the causes which produced it, when I saw her the second time the eye was lost. It is impossible, then, to say whether to attribute the loss of the eye to infection from the mucocele or to carelessness and exposure after the operation. Before each operation the contents of the lachrymal sac were pressed out, and, as far as possible, the conjunctival sac was rendered aseptic by irrigating it with a solution of corrosive sublimate t^^jtj-.

The second case (Case No. 47) is that of a man sixty-one years old. He had been subject for many years to rheumatism, and had suffered also for a long time with varicose veins on both legs, and as a result of the latter condition his right leg was covered with an eczema. The blood-vessels at his wrists and temples were tortuous and hard. Left eye, total cataract and good field of vision for light. The operation was absolutely smooth, and after the delivery of the lens the patient could see my face and count fingers readily. I removed the speculum and closed the eye, putting on the usual bandage. Ten minutes later, and just before I was about to leave the house, he complained of violent pain in the eye. I suspected hemorrhage and immediately removed the bandage to investigate. I found the latter soaked with blood. The mass of blood and protruding vitreous were cleaned away and strong pressure applied. On returning six hours later it was found that the oozing had continued and he was still suffering pain. The lids were opened and a clot of vitreous was discovered between the edges of the wound. This was removed, and after first irrigating the conjunctival sac with a very weak sublimate solution, a pressure bandage was applied. At my visit the next day I found the bandage quite moist and there was every evidence that the oozing was persisting. I cleaned out the sac again and renewed the bandage. On the afternoon of the second day I saw him again and there were still signs of hemorrhage. The same course of treatment was pursued and on the third day I found the bandage clean. Of course he was told that vision was irrevocably gone from the onset of the hemorrhage. In nearly all cases of this class the cornea sloughs, but this termination I fortunately escaped. Hemorrhage after cataract extraction is rare. Dr. Knapp reports in a recent number of the Archives of Ophthalmology his only case. In my own case I can account for the hemorrhage only by the condition of the blood-vessels throughout his body. ,v, No doubt the vessels of the retina were tortuous and their walls atheromatous, and when the lens was removed and intraocular tension thereby lowered, the blood-vessel walls could not withstand the pressure from the increased volume of blood pouring into them; so they ruptured. The whole condition of


the patient pointed to a diseased state of the circulatory apparatus. It is impossible to guard against such a termination, though I should regard it as a contra-indication for operation upon the other eye, for no matter how smooth the operation might be, the chances are that hemorrhage would follow the delivery of the lens.

Out of this series, then, all obtained useful vision but Cases 47 and 49.

Since the publication of this series I have operated upon 158* cases and the tabular statement is herewith appended. Two of the cases are especially interesting as being instances of maniacal excitement, possibly due to the use of atropine after the operation. The first case was a colored man, operated upon in the poorhouse of Mineral Co., W. Va. He was seventy-five years old and had been practically helpless from cataract for a year. Atropine was instilled immediately after the operation. The next morning the physician. Dr. C. S. Hoifman of Keyser, W. Va., was sent for and he wrote me that the patient had gotten up during the night, torn the bandage off, secured a razor from one of the inmates of the room and had gashed his throat in several places and was bleeding profusely when found. In the excitement which followed the eye was forgotten and it was some time before the bandage was replaced. He was quieted, and seven days later, that is, on the eighth day after the operation, he disappeared from the jDOorhouse and two mouths afterward was seen by Dr. Hoffman, in Piedmont, W. Va., 20 miles distant, where he was chopping wood and apparently getting along with absolute comfort. It might be added that he was entirely bliud in the other eye.

The other case was also a very old colored man (88 years old). The operation was simple extraction, and atropine was instilled as usual at the operation. Before daybreak of the next day he was a raving maniac and had to be tied down to his bed. His bandage was torn off several times and he was incessantly tossing his head from side to side, until that too had to be secured so as to be as far as possible immovable. I did not dare look at the eye, as I supposed that it was lost. He did not recover his reason for a week, and all that was done was to apply hot moist compi-esses to the eye. When he became rational and I was enabled to get a satisfactory view of the eye I found a rather small pupil, a slight prolapse, but very little pericorneal congestion. On the tenth day he seemed to be completely himself again, and as the eye evidently needed a mydriatic, one drop of a solution of atropine (4 gr. — si) was instilled and the nurse was instructed to repeat the dose at bedtime. When I returned to the hospitiil the next day I found that during the night he had jumped out of the window — 20 feet from the ground — scaled a high iron-spiked fence and was making off when overtaken by an orderly. Notwithstanding all this exposure he obtained 4^ vision. Nothing was done for the prolapse, which flattened out entirely.

Another interesting case was where the auterior chamber


  • At the meeting of the Amer. Oph. Soc. only 147 cases were

reported in my second series. Since the meeting I have operated upon eleven cases.


October, 1897.J

201


remained open for seventeen days. I have seen explanations for tliis phenomenon, but none seem adequate. The opei'ation was the combined one, and the wound had united about half way ujj on one side and the rest of the incision remained open. More than once during these seventeen days a spatula was jmssed beneath, the corneal flap, and it was easily seen that no uuion had taken place. The operation so far as could be seen appealed to have been normal, that is to say there was not the slightest hitch in any of the steps. Atropine and compress bandage were employed, and two weeks after he left the hospital his vision was jW Eight months later he returned to the hospital with serious iritis, and since then vision has been lost, though he still has light perception.

Iridectomy was pei-formed in 102 cases and simple extraction in 42 cases. Soft cataract was operated upon by needling in three cases.

In thirty-one cases the vision was not tested. Three of these cases were in very young children and any subjective test would have been very unreliable. The remaining twenty-eight were ones which I had operated upon at a distance and most of whom I saw only once after the operation. A number of cataract glasses were sent to them from which to make a selection, and in this way I learned to what extent the operation had benefited the patient. It will be seen from the table that the operation and healing process were uncomplicated in all of these cases and all obtained useful vision.

Tlie failures were as follows: C«*e 54. The operation was smooth, and when the bandage was removed she could see large objects in the room. This was on the seventh day. Two days later iritis of a very sluggish character developed, and in spite of all treatment ended in closed pujjil and light perception. Dr. H. Harlan of this city operated on the other eye and obtained good vision, but he told me that the ojDeration was also followed by iritis.

Cage 72 had an exactly similar history. Case 95 was one which I had treated for several months for dacryocystitis. Her left eye had been operated upon by a New York oculist two years previously, and the cause of the failure in the case of that eye was no doubt the same as in the case of the eye upon which I operated, for both eyes were affected with dacryocystitis. When first seen she had a fistulous opening which had been discharging for several months. Before operation she was under treatment for at least five months, during which time the fistula had closed and the epiphora had almost disappeared. She understood the danger, but being totally blind in the other eye, wanted the operation performed. The cornea sloughed within a week after the operation.

Case 137 was that of a man 81 years old. On opening the eye on the third day there was a very offensive discharge on the bandage and between the lids, and beginning clouding at the edge of the corneal wound. Vigorous local and constitutional treatment, however, prevented the corneal trouble from extending and he was left with a clear cornea and closed pupil. I think that I could have converted this failure into a success (as in Case 190) by iridotomy, but a few days before the proposed operation he was attacked with pneumonia and died on the eighth day.


The last case was that of an old colored man (Case 128) and the history here was similar to Cases 54 and 72.

In one case (male, both eyes, 67 and 68), the patient had good light perception, but after the extraction of the cataracts it was observed that while he could move about somewhat better, his sight continued very poor, and this was explained by the existence of optic nerve atrophy in both eyes.

In Cases 53 and 307 a cataractous lens (congenital) had undergone calcification and presented a bright white mass in the pupil. The operation was simply for cosmetic purposes.

As to prolajjse of the iris. In the 42 cases of simple extraction there were five prolapses. In three of these cases nothing was done, though in Case 181 the prolapse looked as though it would extend throiigh the entire wound. Under a compress bandage, however, and atropine the hernia smoothed over and she has now vision f^. In Case 182 the prolapse got worse from day to day till it nearly filled the wound, and it continued bulging more and more. There was no hernia on the second day when the eye was inspected, but he bad a little gush of tears that night followed by pain, and a small hernia was visible the next day. On the eighth day, fearing that the eyeball would be permanently disfigured (to say nothing of loss of sight), the protruding iris was cut off. There is now not the slightest ectasia of the cornea so far as can be seen, and the patient has f^ vision.

In these last two cases lachrymation and photophobia were present to a marked extent and some little pain was felt at the time when the prolapse occurred, but after this pain was conspicuously absent. So far as could be seen there were no evidences of infection in any of the cases of prolapse. When I say evidences I mean cloudy media and exudates. I think that the absence of infection in these and similar cases is to be attributed to the fact that the wound is filled with the protruded iris and probably there is no way for the bacteria to make entrance into the anterior chamber. The profuse lachrymation which is usually present must be regarded as a more or less protection from a mechanical point of view, i. e. to some extent in washing away bacteria. And I think that an examination of the statistics of simple extraction will disclose the fact that the failures are as a rule not associated with prolapse.

In commenting upon the visual results it will probably strike many as singular that |J was obtained only four times, but this may be explained by the fact that discission was performed only ten times and that in quite a number of cases (31) I made no test of the vision.

In all of the operations the incision was made well within the liinbus of the cornea and still a little further in at the top of the incision. The latter includes usually something less than half the circumference of the cornea.

The instruments with the exception of the knife are boiled. The knife is allowed to remain in Squibb's absolute alcohol for 20 minutes. The eyebrows and that side of the face are covered with a cloth saturated with a solution of sublimate 1:1000. Both the cocaine and atropine solutions are boiled in test tubes and only used once. Small pledgets of cotton secured by sponge holders and boiled are used for removino- debris from the field of operation, such for instance as strings of mucus and small clots of blood. The uuoperated eye is closed till the second day and a small pad of sterilized absorbent cotton is placed over the operated eye and over this a four-tail bandage. The eye is inspected on the second day, and earlier if there be unusual pain. The room is darkened, but is not uncomfortably dark. The patient is allowed to get up on the second day, and the bandage is removed on the seventh day, though there was a time when I removed it earlier. The following is the arrangement of the visual results:

20 I 1

TS '^^

U 35


2 Qfi

717 ^°

20 Of?

20 R

2110 "

Vision not tested .31

Atrophy of the optic nerve 2

Cosmetic purposes 2

Failures 5

158

Successes in the first series 48

Failures iu the first series 2

Total number of cases operated upon 208


No.


Sex.


Age.


Health.


Cataract,


Operation.


Healii.g- process. Duration of treatment.


Primary Vision.


51


Male.


77.


Good.


Hard. R. E.


Iridectomy, smooth.


Uncomplicated.


2 weeks.


20/70


52


Male.


75.


Good.


" "


11 II


Mild iritis.


2 "


20/100


53


Male.


36.


Good.


Calcareous. R. E.


.1 11


Uncomplicated.


2 "


Light perception.


54


Female.


50.


Good.


Hard. L. E.


" "


Iritis.


6 "


" "


55


Male.


71.


Good.


" "


It 11


Uncomplicated.


2 "


20/.30


56


Female.


68.


Bad.


" "


Escape vitreous.


Iritis.


5 "


20/70


57


Female.


66.


Good.


" "


Iridectomy, smooth.


Uncomplicated.


2 "


Not tested.


58


Female.


72.


Good.


R. E.


11 II


"


2 "


20/26


59


Female.


65.


Bad.


L. E.


11 11


Iritis.


4 "


20/100


60


Male.


70.


Good.


R. E.


" "


Uncomplicated.


2 "


20/30


61


Male.


50.


Good.


" "


11 11


"


2 "


20/40


62


Male.


50.


Good.


L. E.


II II


"


2 "


20/40


63


Female.


55.


Good.


"i ^.•■■^■


11 11



2 "


211/100


64


Female.


60.


Bad.



11 11


"


2 "


24/40


65


Male.


55.


Good.


!! L.E.


11 11


Mild iritis.


5 "


20/70


66


Female.


62.


Good.



11 11


Uncomplicated.


2 "


Not tested.


67


Male.


75.


Bad.


" "


Simple Ext.


"


2 "


Atrophy.


68


Male.


75.


Bad.


R. E.


Iridectomy.


"


2 '•


0. Nerve.


69


Female.


60.


Good.


" "


"


"


2 "


20/40


70


Female.


60.


Good.


L. E.


"


"


2 "


20/70


71


Female.


66.


Good.


R. E.


"


Iritis.


3 "


20/100


72


Male.


80.


Good.


L. E.


"


Irido-cyclitis.


8 "


Light perception.


73


Male.


63.


Good.


" "


"


Uncomplicated.


2 "


20/30


74


Male.


66.


Good.


R. E.


"



2 "


20/20


75


Female.


71.


Good.


L. E.


"


"


2 "


20/70


76


Female.


50.


Good.


R, E.


"


"


2 "


Not tested.


77


Female.


61.


Good.


L. E.


"


Mild iritis.


3 "


20/40


78


Female.


66.


Good.


R. E.


"


Uncomplicated.


2 "


20/40


79


Female.


54.


Good.


L. E.


"


"


2 "


20/40


80


Male.


75.


Good.


R. E.


"


"


2 "


20/70


81


Male.


71.


Good.


" "


"


"


2 "


Not tested.


82


Female.


63.


Good.


',! L.^E.


•'


Vitreous lost. Iritis.


4 "


20/100


83


Female.


50.


Good.


(t


"


Uncomplicated.


2 "


20/70


84


Female.


51.


Good.


R. E.


"


"


2 **


20/40


85


Male.


80.


Bad.


" "


"


"


5 "


20/100


86


Male.


64.


Good.



"


"


2 "


20/70


87


Male.


54.


Good.


L. E.


"


"


2 "


20/40


88


Male.


66.


Good.


R. E.


"


"


2 "


Not tested.


89


Male.


60.


Good.


" L. E.


"


"


2 "


11 11


90


Male.


.57.


Good.


R. E.


"


1'


2 *'


20/40


91


Male.


51.


Good.


L. E.


"


"


2 "


20/100


92


Female.


47.


Good.


II .1


"


"


2 "


20/100


93


Male.


55.


Good.


R. E.


"


"


2 "


20/70


94


Male.


71,


Good.


" "


"


"


2 "


20/70


95


Female.


65.


Bad.


" "


Escape vitreous.


Irido-cyclitis,


2 "



96


Female.


52.


Good,


L. E.


Iridectomy.


Uncomplicated.


3 "


20/200


97


Female.


53.


Good.


R. E.


"


"


3 "


Not tested.


98


Female.


77.


Good.


L. E.


"


Iritis.


4 "


20/100


99


Male.


56.


Bad.


R. E,


■'


Uncomplicated.


2 "


20/30


100


Male.


58.


Good.


L. E.


"


"


2 "


Not tested.


101


Male.


54.


Good.


R. E.


"


"


2 "


20/40


102


Male.


46.


Good.


L. E.


"


••


2 "


20/70


103


Female.


76.


Bad.


R. E.


"


"


2 "


Not tested.


104


Female.


64.


Good.


11 11


1'


"


3 "


20/40


105


Male.


.50.


Good.


II 11


"


"


2 "


20/70


106


Male.


65.


Bad.


L. E.


"


"


2 *'


20/70


107


Female.


60.


Good.


" "


"


"


2 "


20/40


108


Male.


72.


Good.


R. E.


"


"


2 "


20/40


October, 1897.1

203


No.


Sex.


Age.


Health.


Cataract.


Operation.


Healing process. Duration of treatment.


Primary Vision.


109


Female.


61.


Good.


Hard. L. E.


Iridectomy.


Uncomplicated.


3 weeljs.


20/70


110


Male.


79.


Good.


" "




"


2 "


20/100


111


Male.


55.


Good.


R. E.




"


2 "


20/40


112


Male.


80.


Good.


L. E.




"


2 "


20/70


113


Female.


56.


Good.


" "




"


3 "


20/100


114


Female.


63.


Good.


" "




"


3 "


Not tested .


115


Male.


72.


Good.


" '•




"


2 "


20/100


116


Male.


81.'


Good.


" "




"


2 "


20/7(t


117


Female.


66.


Good.


R. E.




"


2 "


20/70


118


Female.


50.


Good.


" "




"


2 •'


20/40


119


Female.


49.


Good.


L. E.




"


2 "


20/100


120


Female.


48.


Good.


R. E.




"


3 "


20/70


121


Female.


53.


Good.


" "




"


2 "


20/30


122


Male.


68.


Good.


L. E.




"


2 "


20/40


123


Male.


64.


Good.


" "




"


2 "


Not tested.


124


Female.


62.


Good.


" "




"


2 "


II II


125


Male.


7.


Bad.


Soft. R E.


Needling.


"


2 operations.


" "


126


Male.


7


Bad.


L. E.


"


"



11 11


127


Male.


Si'.


Bad.


Hard. L. E.


Iridectomy.


"


3 weeks.


20/40


128


Male.


81.


Bad.


R. E.


"


Iridocyclitis.



Light perception.


129


Male.


22


Good.


Soft. R. E.


Simple.


Uncomplicated.


2 weeks.


Not tested.


130


Male.


30'.


Good.


" "


if


"


2 "


20/200


131


Male.


44.


Good.


Hard. L. E.


Iridectomy.


"


2 "


20/100


132


Male.


4.


Good.


Soft. L. E.


Needling.


"



Not tested.


133


Male.


77.


Good.


Hard. R. E.


Combined.


"


6 "


20/100


134


Male.


77.


Good.


L. E.




"


2 "


Not tested.


135


Female.


52.


Good.


R.E.




"


2 "


20/200


136


Male.


65.


Good.





"


2 "


20/70


137


Female.


57.


Good.


L. E.




"


2 "


20/40


138


Male.


69.


Good.






2 '■


20/40


139


Male.


82.


Bad.


(I (1


"


Escape vitreous.



No change but 3 weeks' vision. 20/70.


140


Male.


34.


Good.


Hard. R. E.


Simple Ext.


Uncomplicated.


2 weeks.


20/40


141


Female.


51.


Good.


" "




"


2 "


20/70


142


Female.


51.


Good.


L. E.




"


2 "


20/40


143


Female.


45.


Good.


R. E.




"


2 "


20/200


144


Male.


58.


Good.


II II




"


2 "


20/100


145


Male.


58.


Good.


L. E.




'<


2 "


20/70


146


Male.


61.


Good.


<i 11




Escape vitreous.


Iritis. 4 "


20/30,


147


Female.


47.


Good.


R. E.




Uncomplicated.


2 "


20/40


148


Female.


60.


Good.


II 1.




"


2 "


Not tested.


149


Female.


50.


Good.


w L.E.




"


2 "


11 11


150


Male.


60.


Good.





"


2 "


20/40


151


Male.


55.


Good.


II •!




"


2 "


20/70


152


Male.


44.


Good.


" "




"


2 "


20/70


153


Male.


48.


Good.


U II




"


2 "


20/40


154


Male.


51.


Good.


!'i ^;.^



"


2 "


20/70


1.55


Male.


62.


Good.





"


2 "


20/70


1.56


Female.


59.


Good.


II II




"


2 "


20/100


157


Female.


71.


Good.


L. E.




'•


2 "


20/70


1.58


Female.


73.


Good.


<" B;E.




"


2 "


20/40


159


Male.


47.


Good.





"


2 "


20/30


IGO


Female.


53.


Good.


11 11




"


2 "


Not tested.


161


Female.


62.


Good.


II <I




"


2 "


20/80


162


Female.


50.


Good.


II II




Iritis.


4 "


20/100


163


Female.


.58.


Good.


U tl




"


5 "


20/70


164


Female.


78.


Bad.


L. E.


Iridectomy.


"


7 "


Closed pupil.


165


Female.


66.


Good.


U II


"


Uncomplicated.


2 "


20/70


166


Female.


66.


Good.


R. E.


"


"


2 "


20/100


167


Male.


68.


Good.


11 <i


"


Ant. C, open


17 davs.


20/200


168


Male.


28.


Good.


Soft.


S. L. Extracture.


Uncomplicated.


10 "■


Not tested.


169


Female.


47.


Good.


Hard. L. E.


Simple Ext.


  • '


2 weeks.


20/10


170


Female.


80.


Bad.


R. E.


Iridectomy.


Iritis.


5 "


20/200


171


Female.


65.


Good.


II 11


"


Uncomplicated.


2 "


20/70


172


Male.


88.


Good.


L. E.


Simple Ext.


Prolapse iris.


3 "


20/100


173


Female.


70.


Bad.


R. E.


II II


Iritis.


4 "


20/70


174


Female.


70.


Bad.


L. E.


Iridectomy.


Uncomplicated.


2 "


20/70


175


Male.


44.


Good.


'<! ^;.^

Simple Ext.


"


3 "


20/40


176


Male.


48.


Good.



Prolapse.


5 "


20/30


177


Male.


71.


Good.


II 11


Iridectomy.


Uncomplicated.


2 "


Not tested.


178


Female.


70.


Good.


II II


"


"


2 "


20/100


179


Female.


61.


Good.


L. E.


"


"


2 "


20/40


180


Female.


67.


Good.


R. E.


"


Iritis.


4 "


20/40


181


Female.


66.


Good.


L. E.


Simple Ext.


Big prolapse.


5 "


20/40


182


Male.


47.


Good.


!' •^■i'^

"


II


4 "


20/30


183


Female.


58.


Good.



Iridectomy.


Uncomplicated.


2 "


20/40


184


Female.


70.


Good.


11 11


"


"


2 "


Not tested.


185


Female.


50.


Good.


11 11


Simple Ext.


"


2 "


20/100


186


Male.


67.


Good.


!'. ^u-^

Iridectomy.


"


2 "


20/20


187


Female.


77.


Bad.



Simple Ext.


"


2 "


20/100


188


Female.


77.


Bad.


R. E.


Irid


Bctomy.


Iritis.


4 "


20/100


204

[No. 79.


No.


Sex.


Age.


Health.


Cataract.


Operation.


Healing process. Duration of treatment.


Primary Vision.


189


Male.


83.


Good


Hard. L. E.


Simple Ext.


Uncomplicated.


2 "


Not tested.


190


Female.


80.


Good.


U It


Iridectomy.


Closed pupil, but


iridotomy pave.


20/2C0


191


Female.


70.


Good.


R. E.


"


Uncomplicated.


2 weeks.


20/30


192


Female.


62.


Good .


" "


"



2 "


20/70


193


Male.


50.


Good.


" "


Simple Ext.



2 "


20/70


194


Male.


55.


Good.


" "


" "


"


2 "


Not tested.


195


Male.


60.


Good.


" "


" "


"


2 "


20/100


196


Male.


72.


Good.


" "


" "


"


2 "


20/70


197


Male.


72.


Good.


L. E.


" "


"


2 "


20/70


198


Female.


70.


Good.


" "


Iridectomy.


"


2 "


2(1/20


199


Female.


70.


Good.


R. E.


"


Slight iritis.


3 "


2<i/100


200


Female.


68.


Good.


L. E.


Simple Ext.


Uncomplicated.


2 "


20/40


201


Female.


66.


Bad.


R. E.


" "


Iritis.


4 "


Not tested.


202


Female.


68.


Delicate.


" "


Iridectomy.


Uncomiilicated.


2 "


" "


203


Female.


65.


Good.


" "


"


"


2 "


20/40


204


Female.


66.


Good.


L. E.


"


"


2 "


Not te&ted.


2 '5


Female.


60.


Good.


R. E.


"


"


2 "



20(i


Male.


44.


Good.


L. E.


"


"


2 '■


" "


207


Male.


50.


Good .


R. E.


"


"



Cosmetic.


20S


Female.


55.


Good.


" "


"


"


2 "


Not tested.


PAROTITIS FOLLOWING VISCERAL INFLAMMATION.-A REPORT OF TWO CASES.


(Service of Dr. O.sler.) By a. Duval Atkinson, M. D.


It is well known that parotitis is a complication in pyaamia and many infections diseases. There seems also to be a relation between the parotid gland and the generative organs, and an apparent sympathy (as pointed out by Stephen Paget in 1886) between the parotid gland and the abdominal viscera. Cases illustrating it are, however, of sufficient rarity to warrant the rej)ort of the following histories.

Case J. Parotitis following a supposed gastric ulcer. — A female, aged 34, single, by occupation housemaid, was admitted December 16th, 1895, complaining of general weakness and vertigo. Her family history was good ; her mother died of "dropsy": there was no history of titberculosis. She had always enjoyed good health until one year ago. She had had none of the diseases of childhood. The catamenia began at fourteen and were always regular until a year ago. She had not menstruated for four months. She had been sick during the past year, but not confined to bed. At the beginning of the illness her chief complaint was of a continual dull pain in the epigastrium and "cramps" in the legs, a condition which lasted for about one month, when the pain left the abdomen, but not the extremities. In them it persisted with the utmost severity, being of a shooting, darting character, coming on often in paroxysms lasting several minutes. At the height of these pains a feeling of "pins and needles" would be felt in the hands and fingers. During the six months previous to her admission her arms and hands had been swollen to some extent, also her eyelids, the latter especially in the early morning ; her eyesight had been failing.

She took to bed December 9th, 1895 (eight days before entrance. Late in the afternoon of that day she began to feel weak and nervous, and had a gnawing sensation in the epigastric region. Nausea immediately followed, and she vomited a considerable ([uantity of bloody-looking material. Four hours later she again vomited a considerable quantity of material which the patient thought was pure blood. She remained in


bed on account of her extreme weakness until she came to the hospital.

Physical Examinatioii. Patient's skin and mucous membranes were j)ale ; sordes on lips ; tongue pale, moist, and somewhat cracked. Distinct pulsation in external jugulars; pulse 25 to the quarter, regular in force and rhythm, tension distinctly raised ; vessel wall a little thickened.

The thorax was long ; costal angle narrow ; expansion only fair, but apparently equal. Respiration over front of chest was negative; clear on percussion. Over the back the breath sounds were quite clear.

Heart. Point of maximum cardiac iinpulse diffuse over fifth and sixth spaces, in and a little outside the nipple line; relative dullness was at the upper border of the third rib, extending to the nipple line and a little beyond the left sternal margin. At the point of maximum cardiac impulse the first sound was loud and booming, accompanied by a blowing systolic murmur which was heard as far out as the anterior axillary line. The second sound was accentuated. A systolic murmur was also heard in the aortic region, where the second sound was sharp and loud. Over the sternum the murmur was increased and the second sound was more booming. At the costal angle the murmur was very distinct and the second sound was greatly increased in intensity.

Hepatic flatness began at the sixth intercostal space and extended to the costal margin in the mammillary line; the border was indistinctly felt. Spleen not palpable. No cedema. Eefiexes normal. Blood count showed 2,314,000 red corpuscles to the cubic millimetre; white corpuscles, 8000; hajnioglobin 30 per cent. The urine was pale yellow in color ; specific gravity varied from 1010 to 1006; there was a decided trace of albumen. Microscopically granular casts were seen. There were no rigors.

During the night of Dec. 16th, 1895, the patient began to complain of pain, and tliero was some swelling in the region


OCTOBEll, 1897.]

205


of the left parotid gland. The next morning (two days after entrance) the following condition was noted. The patient presents great swelling of the left parotid gland. The swelling extends nji above the zygoma, and behind far over the mastoid. Below there is a marked amount of infiltration in side of neck, extending to the angle of the mouth. The swelling lifts the lobe of the ear. It is rounded, tense, hot, and very painful. The tongue is a little swollen. Nothing exudes from Steno's duct when external pressure is made over the gland. The abdomen is negative. There is no general enlargement of the superficial glands of the body.

At 13 noon, although no fluctuation was obtained, the gland was incised. Numerous small foci of inflammation were discovered, from which exuded a little creamy pus. Cover-s]ij)s from these areas showed streptococci and a large bacillus ; the latter was supposed to have come from the mouth. Cultures showed a pure growth of streptococcus, the bacillus not growing.

The following day, December 20th, the pain in the region of the neck had in a measure subsided; the swelling, however, remained about the same ; there was marked oedema of left eyelid.

The patient did fairly well until the 34th, the swelling and tedema of eyelids remaining about the same. On that day she was extremely pale, pulse 100, dropping a beat occasionally. The swelling of the cheek was perhaps a trifle less; she breathed noisily ; no infiltration in the lower neck. The patient sank rapidly and died. Unfortunately no autopsy was allowed. The diagnosis of parotitis, gastric ulcer, and chronic interstitial nephritis was made.

Case II. Cholecystitis (post typhoidal) complicated by double parotitis. — J. L., single, age 34, German, butcher by occupation, was admitted to Ward F, November 25, 1895, complaining of continual headache, pains in his muscles and joints. His family history was good ; there was no history of tuberculosis. His only disease during childhood was scarlet fever, from which he made a complete recovery, with no sequelae, and excepting an attack of rheumatism, which confined him to bed nine months in 1893, had always been a strong, able-bodied man. He gave no history of syphilis or gouorrhoeal infection. Had been a moderate drinker. The history of his present illness was that about one week before his admission he began to have headache, chills and nausea, accompanied by vomiting. The diagnosis of typhoid fever was made, and the patient had a typically mild course of fever, which was treated by means of the ice-baths. His temperature reached normal on December 5th, ten days after entrance. The urine showed a distinct diazo reaction, and there was a trace of albumen. The spleen was easily palpable, and there were a few typical rose spots. The liver was never palpable. Blood negative for malarial organisms. No leucocytosis. His convalescence was uninterrupted, and he was discharged well, January 1, 1896.

The patient was readmitted November 30, 1896, eleven months afterwards, complaining of headache and general weakness, stating that he had been feeling badly for ten days. The chief symptoms seemed to have been headache, muscular and slight abdominal pain. Two days before


entrance he had had a slight chill followed by fever and sweating. On entrance his temperature registered 103.4°, pulse 27 to the quarter minute, full and strong. The physical examination was negative save for a slight enlargement of the spleen and some rigidity of the right rectus muscle. The liver was not palpable and the hepatic flatness was not increased. The blood was entirely negative for malarial organisms, and there was no leucocytosis. The conjuuctivEe were injected, but there was no jaundice. No bile was found in the urine. His temperature, which reached 103° on the evening of his entrance, quickly dropped to normal, and the man was discharged December 15th, quite well, with no definite conclusions being reached concerning the nature of his trouble.

He again applied for admission March 5, 1897, stating that for three days he had had chills, accompanied, he thought, by fever, headache and pains in his back and limbs. His bowels had been very costive for some time.

The physical examination was as follows : Well nourished, strong-looking man ; face flushed; eyes bloodshot ; lips a trifle cedematous ; tongue had a slight brown coat. Pulse, 33 to the quarter minute, dicrotic ; capillavy circulation rather sluggish. Thorax symmetrical, expansion equal; an occasional sonorous rale was to be heard over chest and axillae. Heart sounds clear. Spleen just palpable on deep inspiration. Hepatic flatness began at the sixth rib, extending one finger's breadth below the costal margin. The muscular resistance of the abdominal wall was such that it was utterly impossible to palpate it. In the mammillary line there were 13 cm. of hepatic flatness. (Pain was complained of whenever deep palpation was attempted in the hypocondriac region.) On the following day, March 6th, there was no essential change in his condition. The morning temperature registered 104.3°, and that of evening 103°. There was well-marked tenderness on pressure in the hypocondriac region, and pressure between the crest of the ilium and ribs on the right side caused pain. The most tender part appeared to be just at the region of the gall-bladder. The conjunctivae were a little muddy, but not distinctly jaundiced. There was- a leucocytosis amounting to 11.300 to the cubic mm. The urine was negative, but no test for bile was made. On March 9th the conjunctivae were slightly yellow, and the urine reacted for bile. There was still great tenderness in the region of the gall-bladder. His temperature, which had been gradually falling, reached normal at 2 a. ni., where it remained until the 12th, when it was again elevated. On that day both parotid glands were swollen, the right more than the left. They were hot and very tender to pressure. No fluctuation was obtained. On the loth both glands were greatly swollen, the tissue of the face and neck was infiltrated, and eyelids (Edematous. The skin over the parotid glands was red, the gland itself imparting a hard infiltrated sensation to the examining hand. Both papillae at orifice of duct were swollen, and pus could be forced out. Although the patient was in poor condition, his temperature registering 102.8°, he insisted upon leaving the hospital, and was therefore discharged.

Cultures from the Ijlood on agar-agar and bouillon proved neo-ative. Diagnosis: Cholecystitis (post-typhoidal), com


206

[No. 79.


plicated by double parotitis. Later both parotids were incised, the bacteriological esamiuation showing a pure growth of staphylococcus aureus. The patient is now quite well.

The cases in many ways correspond to some of those referred to by Stephen Paget in the London Lancet for 1886, and spoken of in more detail in the British Medical Journal in 1887. In his series parotitis followed injury and diseases of the peritoneum, generative organs, and abdominal viscera. Two followed a supposed gastric ulcer. Of the 101 cases cited, 10 were due to injury of the urinary tract; 18 to diseases of the alimentary tract; 33 to injury or disease of the abdominal wall and peritoneum, or to the pelvic cellular tissues, and 50 to temporary derangement of the generative tract. He states that parotitis after abdominal or pelvic injury or disease is not as a rule accompanied by signs of septiegemia or pya3mia. Of his 101 cases mention is only made in 15 of septic symptoms. 37 died; of these 3 were over eighty years of age ; 3 had internal cancer ; 3 had perforation of the bowel ; and 3 had strangulated hernia; 7 had undergone severe surgical operation involving abdominal section ; 13 had septicEemia or pyfemia; 1 had infantile syphilis ; 1 had marasmus; and 1 had heart trouble. He adds that death was not due to parotitis joer se, but to a primary lesion, and he is ujiable to state to what extent parotitis is a dangerous complication. Its period of incubation is unknown, but in his opinion it is from one to thirteen days. There is as a rule no marked disturbance to general health, no rigors, and no high fever. On the other hand symptoms may be more severe from the onset, and great disturbance in general health may be noted. Eigors were noted in only 4 cases. In regard to the termination of the parotitis, whether by resolution or by suppuration, the figures show that out of 73 cases which give information on the point, 45 suppurated and 33 were resolved, and out of 45 that suppurated 34 died; but out of the 33 that resolved without suppuration only one died (in all probability from cancer). In other words, he thinks that they did not die because the parotids went on to suppuration, but that the parotids suppurated because they were going to die. In cases of undoubted septicasmia or pyemia the parotids always went on to sujipuration.

'I'he only autopsy reported by Paget is that of a woman dying from the effects of the removal of a sarcomatous growth of the mesentery, having parotitis as a complication. On section the parotid was found to be evenly and in every part infiltrated, not with pus, but with a reddish, slightly turbid fluid, causing it to look like a section of the spleen. There were no abscesses anywhere. Just in the proximal end of the duct where it left the gland lay two or three drops of healthy pus and a tiny calculus. The acini were separated, compressed, and breaking up, and here and there were seen ducts filled with the same small round cells as were infiltrated among the acini. No bacteriological examination was made. Mr. Paget cites a case reported by Rosenbach of parotitis following operation for strangulated hernia, in which staphylococcus aureus was obtained. He further states that this form of parotitis is in many ways a peculiar lesion, so far as l)eingdue


to septicemia. It was in 93 cases an isolated lesion, unaccompanied by any other lesion like itself, having no fixed period of incubation, and running no common course. Its invasion is not as a rule marked by rigors or great rise of temperature. It may subside and swell up and subside again. These facts make it impossible to say that this form of parotitis is due to any ordinary form of septicaemia. It is not, he thinks, due to inflammation following a parched and sore mouth, as the mouths of pyaBmic or septicaemic patients are not, as a rule, more parched than those of other patients. Also, he does not think that it is merely due to inflammation of the lymphatic tissue which is in the gland substance. " Admitting that the general condition of the patient, especially in cases of septicemia and pyaemia, is considered in the production of this form of parotitis, must we not take into consideration the reflex action of the nervous system, as the influence, direct and reflex, of the nervous system upon the salivary glands is shown in countless ways; viz. gastritis may be followed by salivation or arrest of salivary secretion. Parotitis may follow gastric ulcer, gastrotomy, etc. Even operations on the rectum and again diseases of the thoracic viscera cause inequality of the pupils, differing not only in size, but in their susceptibility to light. Thus, with regard to pyjemia after abdominal or pelvic lesions, we may admit that the general condition of the patient may help to cause it, without denying the local influence of the nervous system."

A. J. Oribb (Lancet, 1886) reports two cases ; in one jiarotitis followed irritation of the genito-urinary tract, and in the other ovaritis occurred in connection with parotitis. And again, Harkin (Lancet, 1886) reports parotitis in a woman aged 43 as one of the first symptoms of three successive pregnancies, no suppuration being present. These cases seem to point undoubtedly to some latent sympathy between the parotid glands and the organs either covered by or closely adjacent to the peritoneum. It is, however, difficult for us, with our present bacteriological knowledge, to conceive of inflammation being established in organs far remote from the seat of irritation by reflex causes alone, without the presence of micro-organisms. An interesting case, and one bearing a close resemblance in some respects to those cited, is one reported by W. Legg in the Pathological Society Reports for 1869, in which parotitis was a complication in contracted kidney and atheroma in a lad aged 16, who was admitted to the University College Hosjiital for albuminuria. Nine days after admission he complained of pain on right side of face. The day after well-marked right parotitis was noted. The swelling continued for eight days, when the patient died suddenly. There was found to be no obstruction to Steno's duct; the gland tissue was pale grey in color, not at all reddened, rather harder than natural, and on section there flowed from the cut surface a large quantity of pale greyish white fluid, somewhat thin, showing under the microscope a large number of rounded cells, larger on the average than pus corpuscles, having rather granular contents, and single small bright nuclei. The gland was the seat of small abscesses varying in size from a pin head to a barley corn. Microscopically was seen a great increase in epitiielial elements, the acini being iilled with them. The arteries wore atheromatous


October, 1897.]

207


and the kidneys contracted. No mention is made of lesions in other organs.

W. B. Morrow, in the Montreal Medical Journal of March, '96, has related the histories of three cases of parotitis fol]pwing pelvic disease. And Herbert and Hawkins, in the British


Medical Journal of April 10, 1897, report two cases of operation for jjerforation of gastric ulcer, in one of which there was a double parotitis three days after operation, the patient eventually making a complete recovery, the glands subsiding without incision being necessary.


PALPATION OF THE FCETAL HEART IMPULSE IN PREGNANCY.

By Douglas F. Duval, M. D., Assistant Resident Ognecologist.


It is not generally known that the impulse of the fcetal heart may under certain conditions be actually felt beating through the abdominal walls of the pregnant woman.

In this country but two cases have been observed, those of Dr. Kelly, which I now report. The first was in 1884 and the second in 1895. They represented the right bregmatic-iliacanterior and left occipito-iliac-posterior presentations, the latter being observed in the eighth month of pregnancy, all previous cases having been during labor.

Of the other observers, Fischel, in 1881, was the first to publish a definite account describing accurately three cases in which this phenomenon occurred. These cases represented the left bregmatic-iliac-anterior, the right occipito-iliac-posterior and the left mento-iliac-auterior presentations. Valenta, however, in 1885, claimed priority of observation, stating that he had noted it in 1860 in a first face presentation, and had recorded it in his "Text-Book on Midwifery," and that since then he had repeatedly spoken of its importance as a diagnostic sign in anterior face presentations. Fleischman in 1885, stimulated by Fischel's communications, published an interesting case in which this phenomenon was observed in a right men to-iliac-anterior presentation.

The following is a brief account of the various cases :

Case I. Observed by Dr. Kelly, in Kensington, Philadelphia, in 1884. Multipara, of medium build, mother of four or five children, abdominal walls moderately thin. A right bregmatic-iliac-anterior presentation. Membranes ruptured, OS half dilated, brow just engaging. The impulse of the foetal heart was forcible and distinctly palpated over an area about 3 cm in diameter ; to the right and about half way between the umbilicus and Poupart's ligament, separate beats were easily counted, 130. The child was born living after a protracted labor and manual rectification of position.

Case II. Observed by Dr. Kelly. Patient short brunette, well nourished, abdominal walls not thin, eighth month of her first pregnancy. A left occipito-iliac-posterior presentation. Heart sounds heard loud over an area 10x10 cm., and easily counted 140. On moderate pressure a rapid fluttering sensation was clearly distinguished over an area about 2.5 cm. in diameter. The separate beats could not be distinguished; a few days later, on examination, the heart impulse could not be felt. The patient has since passed through a normal confinement.

Fischel's Cases.

Case I. Mi. 36, 1 para, well nourished, strong. Pains began on 30th at 1) p. m. Li(juor auinii discharged on 31st at


13.15 a. m. At 7.45 a. m. os 6 cm. in diameter. Foetus in left bregmatic-iliac-anterior presentation. Heart sounds to the left and below umbilicus. At 13.15 fcetal heart impulse palpated to left and beside umbilicus, synchronous with foetal heart sounds, frequency 156-160. This phenomenon was observed for several hours. Change of presentation being impossible, craniotomy was performed.

Case II. Mt. 31. Well built, large, strong. Pains began at midnight. At 3 a. m. liquor amnii discharged. Entered hospital at 4 a. m. Cervix obliterated, back to the right, feet to the left above the umbilicus, chin 8 cm. above left os pubis, heart sounds above the symphysis. From this description very probably a right occipito-iliac-posterior presentation. The fcetal heart impulse was palpated just above the chin, easily demonstrable, frequency 156, maternal pulse 113. In the further course of labor, which was rapid and favorable, the impulse was palpated in the pauses between the pains, descending toward the symphysis and finally disappearing entirely, though the sounds continued to be heard. Examination of the child's heart after labor showed clearly that the sounds were of normal strength and clearness.

Case III. Mi. 30. 1 para, small, strongly built, moderately fat, abdominal walls thin. Pains began at 10 a. m. Entered hospital in the afternoon. External examination : Occiput above right os pubis, extremities to the left, heart sounds to the left of the umbilicus, loud and slow.' The presentation in this case was then a left meuto-iliac anterior. At 6.30 p. m. the heart impulse was clearly palpated 5 cm. to left of umbilicus. At 7.30 p. m. was 5 cm. to left of umbilicus, but lower. At 8 p. m. frequency ranged between 80 and 150 ; maternal pulse 66-73. At 11.30 p. m. heart impulse to left of umbilicus, but lower. Labor terminated at 13 m., fcetal heart sounds ceased two minutes before delivery, child stillborn.

Fleischman's Case.

Case I. Mt. 35. Abdominal walls thin and flabby. Entered hospital at 11 p. m., three hours after discharge of liquor amnii. Occiput over left os pubis, back to the left, heart sounds clearest four fingers' breadth to right of midline, chin to right and forward, forehead to left and backward. Evidently a right mento-iliac-anterior presentation. On the following morning the foetal heart impulse was palpated in the right hypogastrium, at the junction of the middle and lower thirds of a line drawn between the umbilicus and middle of Poupart's liganit'nt. In frequency doubled that of the maternal. 'J"he sounds were loud and clear.


208

[No. 79.


Fleischmau says: "The conditious iu this case for the observation of the pheuomenon were most favorable, the abdominal walls were thin and flabby and the liquor amnii had previously discharged, thus permitting the uterine walls to clasp firmly the foetal thorax."

The following is a summary of all the cases :

Fischel, 1881, three cases: Left bregmatic-iliac-auterior, right occipito-iliac-posterior, left meuto-iliac-anterior.

Valenta, 1885, one case: First face presentation (K. m. i. ant.)

Fleischman, 1885, one case: Right meuto-iliac-anterior.

Kelly, two cases : First iu 1884, a right bregmatic iliacanterior presentation; second iu 1895, left occipito-iliac-posterior presentation.

From the above it will be seen that the observation has been made in face, brow and occipito-posterior presentations — two of each. One may therefore infer that these are the most favorable presentations for the observation of this phenome


non ; especially is this the case in face and brow presentations, the fcetal thorax being arched forward and therefore in closer proximity to the maternal abdominal walls. In occipito-posterior jjresentations the festal curve is directed backward and consequently less favorable.

The liquor amnii also plays an important part, as shown by the fact that in all cases, with the exception of the second case of Dr. Kelly, the observation was made during labor. In this case one must naturally suppose that a small amount of liquor amuii was present. As for the maternal abdominal walls, they should be thin and flabby in order that there may be little hindrance to the transmission of the im^iulse of the foetal heart.

References.

American Text-Book of Obstetrics, Hirst, 1888. Fischel, Prager medicinische Wochenschrift, Nos. 13, 13, 39, 30, 1881.

Fleischman, ibid.. No. 35, 1885. Valenta, ibid., No. 45, 1885.


SQUAMOUS EPITHELIOMA IN A DERMOID OF THE JAW.

By S. M. Cone, M. D., Assistant in Surgical Pathology, Tlie Johns Hopkins University.


Few cases of epithelioma arising in dermoid cysts have been described. Taufier, whose article on carcinoma arising in dermoids of the ovary is very complete, knows of none originating in dermoids elsewhere. In none of the dissertations on dermoids of the ovary with carcinoma in their walls do we find reference to like tumors in other regions of the body. I can find but three cases and they are not very fully described. That of Franke, on an epidermoid of the ball of the thumb with carcinoma originating in it, is most complete. Czerny in 1869 reported a case in the coccygeal region, the first to be noted anywhere, which is interesting moreover because of the expression of the opinion that the squamous epithelium developed from cylindrical epithelium snch as is found in the intestinal tract, and the idea is expressed of the possibility of epithelium arising from connective tissue and lymph cells. Briddon reported a case before the New York Surgical Society and Dr. Thacher made the pathological report. This tumor was also from the coccygeal region. The sections which were kindly given me have some resemblance to the one I shall describe. The descriptions of those found in the ovaries are so much better described that it is best to reach our conclusions regarding origin and development through the gynecological literature.

Yamagiwa and Thumim have both reported cases this year. Thumim gives the literature on the subject up to date. Yamagiwa reports two cases, one of which he puts down as a glandular carcinoma developing from remains of a mammary gland in the dermoid. Thumim objects to including this among the dermoids with "carcinomatous degeneration" and rather thinks it to be part of a misplaced mammary gland forming a part of a teratoma of the ovary. ' If it is a true carcinoma it is the only one of its kind described ; the remain


ing eight cases arising in the ovary ;ind three elsewhere are all of the squamous cell variety.

All authors are careful to exclude the possibility of the growth of the epithelioma "per contiguitatem," both Tauffer and Thumim giving a list of doubtful cases. The analogous origin of carcinoma iu atheromas and other cysts lined by epithelium is mentioned by Lubarsch in his review of the subject, and many others refer to the subject as something not long discovered. A very interesting point is alluded to by Yamagiwa when in writing of his first case he refers to its resemblance to alveolar sarcoma or endothelioma. Such cases have been reported, but are rare.

The case to be reported is that of Patrick D., age i'i, blacksmith, who entered the surgical ward of the Johns Hopkins Hospital, June 30, 1894, with a tumor of the left lower jaw. Family history good ; past history good.

Present Illness. — In September, 1893, the patient noticed a pea-sized growth under the horizontal ramus of his left lower jaw. It began to pain him in November and grew rapidly with incessant pain. He refers its quickened growth to a fall when he injured the jaw.

Physical Examination. — The tumor extends from 1 cm. in front of the angle to the junction of the middle and outer third of the horizontal ramus of the lower jaw. It extends to the hyoid bone and appears to be the size of a small orange. It is fixed firmly, is sharply circumscribed and has smooth, rounded borders. It is firm in consistency except at the most prominent portion, where slight fluctuation can be felt. The skin is cedematous and red. At one point there is a small opening from which serum exudes on pressure. Teeth are normal. Alveolar process is not involved.

On June 35th the patient was operated on by Dr. Halsted.


OCTOBEE, 1897.J

209


Tracheotomy was first performed, aud the pharynx being tamponed the tumor and left lower jaw were excised. The patient's recovery from the operation was uuinterrnptedly good. He was discharged on July 13th. He returned September 6, 1894, aud was treated for phthisis pulmonalis — tubercle bacilli beiug found in his sputum. He was discharged on September 14th unimproved and died at home of phthisis pulmoualis. No autopsy was performed.

Descrip/ioH of the tumor by Dr. Bloodf/ood. — The tumor is removed with an area of skin 8x6 cm. and a piece of the lower jaw 7 cm. long, including the angle of the jaw. This mass is surrounded by skin, periosteum and healthy muscle at every point except one, which is at the inner side of the jaw 3i cm. from the angle where the tumor tissue is exposed. A second piece of the jaw including the two molar teeth and alveolar processes includes the remainder of the tumor, which is well circumscribed by muscle and mucous membrane; so that, putting the two pieces together, the entire mass is circumscribed. The point at which it is most superficial is beneath the myo-hyo-glossus muscle at its attachment to the alveolar process of bone which was removed.

The tumor has not invaded mucous membrane nor bone. On section from the skin to bone it consists of an encapsulated mass, the capsule beiug firmly adhereut to periosteum on one hand and skin on the other. There are several points on the skin communicating with the cyst contents and through which the contents can be expressed. The capsule is 4-5 mm. in thickness. The inner surface is rough and granular. The fatty granular contents are easily removed; they resemble those of a dermoid cyst except at the outer third of the tumor near the symphysis of the jaw. Here the contents are firm in consistency, greyish iu color, with pin-point dots of hemorrhage. In this tissue masses of the same consistency as that of the cyst can be found. The tumor presents the characteristics of a dermoid cyst.

On section of the mass within the jaw the submaxillary gland is found to be adhereut to the capsule of the cyst. The contents of the cyst show fatty squamous epithelium and crystals of cholesterin.

Microscopical Examination. — Sections of the cyst wall with adjacent structures were made at many points. The cyst varies in thickness. The inner lining is of horny epithelium which is more or less loose and swollen and mixed with the cyst contents. The same cornified epithelium is found in whorls on the surface mixed with the cyst contents. These cells look like long flakes, some containing nuclei, others being free of them, which stain deeply with eosin aud carbol fuchsin. Beneath this loosely arranged epithelium we see a denser layer aud then the gradation of epithelium as in normal skin, only not so thick.

The stratum grauulosum is much better marked in some places than in others. The stratum mucosum comprises the main mass of epidermis; the deeper cells of the malpighian layer are not pigmented. The cells appear swollen and oedematous. Some of the nuclei are vacuolated and irregular while others are fragmented. In the epidermis are a few irregular areas, about the size of the cells, which are granular and take the hcematoxylon stain deeply — evidence of calca


reous degeneration in the cyst wall. The cell borders are not nearly so well defined as iu normal epidermis. The papillai are fairly well marked, but there is an entire absence of sweat glands and hairs. A few sebaceoiis glands are to be seen iu the corium, which is not well marked because of the invasion of its territory by profuse round cell infiltration about epithelial projections.

These epithelial downgrowths between the papillary stroma into the deepest parts of the cyst wall are made up of masses of cells such as are found in the stratum mucosum and enclose cells of the more superficial layers of epidermis. These cells of the outer epidermal layers are sometimes formed into whorls iu the deepest ingrowths of the squamous epithelium, aud form the " pearly bodies."

The epithelium of these downshoots has better staining nuclei than that on the surface. These inter-papillary growths seem to be kept in definite paths for the most part, but when the deepest portion of the cyst wall is reached one can see epithelial cells spread throughout the tissue, some being isolated without any demonstrable relation to the primary downgrowth. This sprouting of epithelium deeply and irregularly into the wall of the dermoid is seen throughout the entire tumor wall, but does not go any further, for it is always preceded by a zone of round cell infiltration made up of mononuclear cells. This zone is preceded by one of connective tissue of varying thickness which invariably intervenes between the epithelial cells and adjacent tissues and organs. There are papillary projections into the cyst of various lengths from 1 mm. to 2 cm. which all show a lining of epithelium already described, and have a supporting conuective tissue basis. Between the stratum corneumand malpighian layer are to be seen hemorrhagic foci in some sections.

The round cell infitration is intensely marked throughout the cyst wall. The papillary stroma aud deep layers of the dermoid are full of mononuclear leucocytes which are aggregated in some places, resembling lymphoid nodules. These cells have also penetrated between the epithelial cells of the surface and ingrowths. The centres of the "pearly bodies" contain both mono- and polyuuclear leucocytes and fragments of nuclei. There are typical tubercles in several sections which are most distinct in the sections containing muscle, including the sinuses alluded to above. No tubercle bacilli can be found iu them, however.

The lining wall of the dermoid shows evidence of degeneration in areas; the epithelium is invaded by mono- and polymorpho-nuclear leucocytes. The nuclei stain poorly and are fragmented. The cells appear separated from one another and are swollen.

Sections including skin and dermoid wall made at different points have essentially the same appearance. The points iu which the histology differs from the foregoing description are the giant cell formation between subcutaneous tissue and the fibrous limiting line of the dermoid and the openings in the skin alluded to in the macroscopic description. The giant cells are like the customary foreign body giant cells and are seen singly aud in groups at the margin of the dermoid wall. They are especially numerous on the dermoid side of the dividing fibrous tissue. Where these are in


210

[No. 79.


greatest number and collected in groups the fibrous separating line has been almost completely substituted by them and the accompanying mono- and polynuclear leucocytes. Here the definition between dermoid and skin is not so good as elsewhere.

The giant cells in the subcutaneous tissue are grouped about hair shafts ; in the dermoid walls they enclose horny particles (stained deeply with carbol fuchsin), polynuclear leucocytes, fragmented nuclei and granules (stained deeply with hffimatoxylon and probably calcareous). Some have no contents and are vacuolated. Most of them contain large vesicular nuclei, grouped in the centre of the cell ; in some the nuclei have a polar arrangement.

Beneath the epidermis of the skin there are masses of red blood corpuscles, polynuclear leucocytes and fragmented nuclei. Here no papillary arrangement of the skin exists and the epidermis is flattened and thinned. The epidermis, too, is infiltrated with leucocytes. Adjoining this area of hemorrhage and necrosis a discontinuity in the epithelial covering is detected. The edges of epidermis are turned in and are continuous with a sinus which can be traced deep into the subcutaneous tissue, but not so far as the fibrous demarcation between skin and dermoid. This sinus is lined by necrotic tissue containing blood and fragmented nuclei. In its depths the connective tissue of the part is denser, but there is no evidence of new formation of tissue. There is no epithelial lining. Vessels included between the dermoid walls and subcutaneous tissue are obliterated by endarteritis. Their walls are all thickened.

In one of the sections there is a variation from the usual structure of the dermoid wall. Instead of the interpapillary growths of epithelium dipping down at once into the depths of the wall, we see a network of epithelial rods one and two cells thick surrounded by small round cells. The epithelial lining is very thin at this point, being composed only of cornified epithelium. Beneath this interlacing network of cells we see the larger groups containing pearly bodies described in the other sections.

The submaxillary gland is included in several sections of the tumor and in none does the epithelioma invade the gland. The capsule of the submaxillary is greatly thickened and only at one point is there any suspicion of invasion. Here the round cell infiltration is most marked, the connective tissue formation not being evident. Into the round cells can be seen jutting epithelial sprouts, but they do not enter the interlobular connective tissue of the submaxillary. The changes in the


submaxillary are due to pressure and infiltration of its connective tissue framework with small round cells. The connective tissue is thickened and some of the cells in the alveoli do not take the stain well. The cyst-wall next the submaxillary varies from 1 to 3 mm. in thickness and consists of epithelial masses and single cells included in the stroma, which is deeply infiltrated with small ronnd cells. The epithelial cells are of the same kind as in the stratum mucosum, but Ijetter defined and with more regular nuclei.

The muscle next the tumor is densely infiltrated with small round cells and is atrophied. The nuclei of the muscle cells next to the dermoid wall are greatly increased in number and arranged in rows. The muscle substance stains but faintly and there is no striation in the first rows next to the fibrous line between tumor and muscle. It appears like a homogeneous mass containing rows and bunches of nuclei. There are no giant cells nor necrotic areas to be seen. A nerve is included in the section with muscle. It is surrounded by dense fibrous tissue. The epithelial cells crowd close up upon the epineurium, but do not penetrate it. The round cell infiltration and new formation of connective tissue are very prolific about the nerve.

The presence of tubercles in the cyst walls, the great and uniform round cell infiltration, the profusion of giant cells of both the foreign body and tuberculosis variety, and the uniform distribution of the epithelioma in the wall of the dermoid, are all striking points.

References.

TaufEer: Virch. Arch., No. 143. Ueber die primilr carcinomatose Degeneration von Dermoidcysteu.

Frauke : Virch. Arch., No. 131, p. 444. Carcinomatus entartetes Epidermoid des Daumenballes.

Briddon : Annals of Surgery, Aug., 1894. Not a complete description.

Y. Czerny: Arch. f. klin. Chir., No. 10, 1869, p. 894. Entwickelung einesEpithelialcarcinoma aus eiuer angeboreuen Sacralgeschwulst.

Yamagiwa: Virch. Ai-ch., No. 147, Heft i. Zwei Piille von Dermoidcysten des Ovariums mit carcinomatosen Degeneration und Metastasenbildung.

Thumim: Arch. f. Gynek., liii. Ueber carcinomatose Degeneration der Eierstocksdermoide.

Lubarsch: Ergeb. der allg. Path. Morph. und Phys., Vol. II, 1894.


THE INFECTIOUSNESS OF CHRONIC URETHRITIS.


By E. R. Owings, M. D., Assisianf in Genito- Urinary Surgery, The Johns Hopkins Hospital Dispensary.


The possibility of infection from old cases of gonorrhoea is an important and by no means infrequent problem, presenting itself not only to the gynecologist and genito-urinary specialist, but also to the general practitioner.

Many cases of gonorrhoea extend over mouths or even years, often in spite of persistent and systematic treatment, and in


response to the inquiries, " Could I infect another?" or " Is my condition such that I may safely marry ? " the physician must often give evasive or unsatisfactory replies.

There is no fact better established than that a gonorrheal urethritis is due to the entrance and development within the urethra of a specific organism, the gonococcus Neisser,


October, 1897.]

211


which is constantly present in the discharge of an acute gonorrhoea.

The gouococcus, first described by Neisser' in 1879, has been isolated; a pure culture made first by Bumm,^ since by Wertheim,* Steinschueider and other observers ; and a gonorrhoeal urethritis produced by the introduction of pure culture within healthy urethra proving conclusively its etiological relation.

The infectiousness (i. e. jrower to produce gonorrhcea) therefore of an urethral inflaniuiation depends upon the presence of the gonococcus; and upon the demonstration of the presence of this organism rests the determination of the infectiousness of an urethral inflammation.

The gonococcus is a diplococcus, J to 1 micromillimeter in diameter, not round, but of biscuit or coffee-bean shajie, with flattened or concave surfaces contiguous, found within the leucocyte, around, never within the nuclei, and as determined by Roux,' if a preparation containing gonococci after being stained with aniline stain, be placed in Gram's solution, then decolorized by alcohol, the stain is not fixed by Gram's method, and the gonococci may be differentiated from other organisms found within the urethra, in that they are alone decolorized.

In 1887, Lustgarten and Mannaberg" in a series of investigations on the healthy urethra found among other organisms a coccus which they declare cannot be distinguished from the gonococcus Neisser by its morphology or staining reaction.

Petit and Wasserman,' on the contrary, in a large number of examinations (over 1000) of the normal urethra, have never found the organism described by Lustgarten, and in a number of cases of chronic urethritis were unable to demonstrate its presence.

Steinschueider" recognized beside the gonococcus four diplococci in the urethra, two of which were decolorized by Gram's method as follows :

No.

Urethra healthy, never infected by

gonococcus, 13

Urethra healthy, no gonorrhoea for

years. Chronic gonorrhoea,

Acute " (uuti-eated),

" " (under treatment), 22


3





15


2


11


33


1


33


22



32


86


66


In 86 cases there was present in four a diplococcus decolorized by Gram's method, or about 4J per cent., making Roux's test certain in about 95 J per cent, of all cases. He believes, however, that Roux's test, together with the characteristic grouping of the gonococcus within the pus cell around the nuclei, gives a definite result.

M. von Zeissl" has in the secretion of an urethritis due to chemical or medicinal irritants, found a diplococcus within the pus cell, which is decolorized by Gram's method ; whether this is readily differentiated by grouping from the gonococcus he does not state.

Wendt" believes " Roux's color test never fails to gives correct interpretation."


Allen," who worked conjointly with Wendt, believes "Roux's test final."

Carpenter'" says : " Peculiar characteristics of the gonococcus almost positively diagnostic when confirmed by Roux's test practically leaves no room for doubt."

Heiman '" says : " Diplococci found in normal urethra can be positively differentiated by Gram's stain."

Koplik-' says: "In skilled and tutored hands a mistake of identity is not possible."

Finger" says : " There is no doubt that in addition to gonococci other organisms are present in blenorrhagic pus, but these never give rise to the slightest diagnostic doubt. The number of foreign organisms is so slight, and they are found to such a large exteut outside the pus cells, their shape and grouping are so different, that the differences in staining are unnecessary to make a positive differential diagnosis."

Lustgarten", 1893, says: "If in a chronic torpid urethritis with a scanty whitish or greyish discharge, diplococci with all the characteristics of the gonococcus are found ; it does not prove that the affection is contagious, especially if these diplococci are found in comparatively small number and are accompanied by a variety of organisms. As far as personal experience goes I believe that many of these cases are not contagious and that the wives of such men remain healthy and prolific."

In the absence of confirmatory proof by cultivation, which is not always practicable owing to the difficulty attending the growth of the gonococcus, ordinary media being unsuitable for its growth, and as in chronic urethritis where its demonstration is especially desirable the jiresence of other organisms by their rapid growth makes it impossible to secure discrete colonies of the organism, we are compelled in these cases to rely solely upon its morphology and Roux's test for identification. By these methods the gonococcus may be differentiated from micro-organisms found within the urethra, with the possible excejition of the diplococcus described by Lustgarten, which at most is present in but a small per cent, of cases. The presence, in the secretion of an urethral inflammation, of a diplococcus with the characteristics and color reaction of the gonococcus is sufficient clinical though not medico-legal evidence of the infectiousness of same.

The examinations recorded in the paper were confined to chronic cases entirely. In many there was no discharge visible at the meatus, and in no case was there more than the "goutte militaire." Their duration varied from three months to four years. The majority were under active treatment at the Johns Hopkins Hospital Dispensary, and so far as was possible examinations were made on date of first visit and subsequently at short intervals. Unfortunately, as in all dispensaries, many failed to return after one or two visits, making it impossible in these instances to secure repeated examinations. The examinations recorded are of the tripperfilden, as in many of the cases this was the only material available.

The method pursued was as follows : The urine, and where possible the morning urine, was secured, one or two trijjperfilden were drawn uj) with a pipette and after being gently teazed-out on a slide, were dried over a flame and then washed carefully in warm water to dissolve out as far as possible salts of urine which were precipitated by evaporation. Specimens thus obtained were stained two minutes in aniline gentian violet solution, prepared by adding 1 cc. filtered concentrated solution to 15 cc. water.

In decolorizing the slides were placed in Gram's solution for 2 minutes, then in alcohol until no more blue color was extracted, generally from two to three minutes. A watery solution of Bismarck brown was used as counter stain.

In 15 instances no micro-organisms were found; in these cases the fiiden consisted almost entirely of epithelial cells with here and there a few leucocytes.

In the 35 remaining micro-organisms were fou nd ; these were identical with varieties already described by Lustgarten and other observers, and consisted of 4 varieties of cocci and !<! bacilli, as follows :

I. Small coccus in zoogleae.

II. Small coccus in chains.

III. Diplococcus about size of gonococcus.

IV. Large coccus, li to 3 mm. in diameter, generally in pairs.

V. Long slender bacillus (smegma bacillus?).

VI. Short thick bacillus with rounded ends (suggestive of colon bacillus).

These were not all present in every specimen examined, nor did they occur in equal frequency. I, small coccus in zoogleffi, and IV, large coccus, IJ to 2 mm. in diameter, were almost constantly present, while the smegma bacillus ? was noted in comparatively few instances, and VI, bacillus, short, with rounded ends, in one case only.

In five specimens examined, in addition to one or more of the varieties already described, diplococci were seen lying within leucocyte, morphologically identical with the gonococcus and decolorized by Gram's method.

These were the only organisms seen within the leucocytes. Others were either free in the intercellular space, lying on epithelial cells or on, not within, leucocytes, as could be determined by careful focusing.

In 5 cases then we have an organism which could be positively identified as the gonococcus Neisser.

Three of these 5 cases were of from 4 to 6 months' duration, 1 was of 9 months' and 1 of 2 years' duration, or, tabulating cases as regards age of disease —


13


6 50


Duration. Gonococei.

Under 6 months. 3

6 to 9 " 1

1 year.

2 " 1

3 ■' over 3 years


other

mlcro org:anisms.


35


Negative

as to organisms.

4 3 2 3 2 1

15


Out of 38 cases of more than 6 months' duration, in 2 instances only were gonococei demonstrated, and in 30 of more than a year's duration, in one case only could they be fou-nd.


Goll" in 1891 made repeated examinations of cases of chronic urethritis with the following results :


Durati(jn.

6 months

1 year

2 "

3 "

Over 3 years


No. of cases.

55 83 135 80 59

412


Gonococei.


12

7


29


cocci. Percent.

47 14

71 14

128 5

78 25

59

383


Petit and Wasserman' in their examination of chronic urethritis found various organisms, and believe them to be accidental or saprophytic, and that they vary with the individual.

Janet'-' has studied cases of chronic urethritis with respect to various organisms present, and divides them into three classes :

I. Gonococei present alone.

II. Gonococei and other micro-organisms.

III. No gonococei, but varied micro-organisms.

He believes that these organisms invade the urethra, probably in coitus, and the catarrhal mucous membrane presenting a favorable medium, they are able to keep up the inflammatory process after the disappearance of the gonococcus, producing an obstinate pseudo-gonorrhoea.

Hasse," 1893, "in 625 cases of chronic urethritis found gonococei unattended by other organisms in 37 cases. In acute gonorrhoea he found gonococei alone and their presence constant; with their disappearance and an increase in the epithelial cells in the discharge, other bacteria, both bacilli and cocci, appeared in large numbers."

In the small percentage of cases where the gonococcus is definitely determined to be present, we can without hesitation declare their infectiousness. Unfortunately, however, in the large majority we are unable to say with certainty that we have to do with a non-infectious malady, that is. in those where the gonococei are uniformly absent or present in so few numbers as to elude detection. For while the detection of the gonococcus renders infectiousness certain, a failure to detect it does not guarantee its absence, as often after many negative examinations the gonococei may suddenly appear in considerable numbers.

In one of the above recorded cases, that of 2 years' duration, the examination of which extended over several months, after 3 or 4 negative examinations, following an injection of 3 to 5 per cent, of AgNOs, with Tommasoli syringe, the gonococei could readily be detected.

In these cases then where there is still doubt, the test first proposed and still insisted upon by Neisser" is an invaluable adjunct, viz. the injection within the urethra of a solution of argent, nitrat. or hydrarg. chlor. corrosive, sufficiently strong to produce an inflammation with free purulent discharge, when, if the gonococei have been present but have escaped detection, they will be found in the discharge in sufficient number to make1,heir identification positive, and at the same time with the desquamation of the epithelium the accidental micro-organisms are removed to a large extent.


October, 1897.]

213


Finger" "only permits marital intercourse after frequent examinations of the secretion or tripperfiklen show an absence of pus cells; and the discharge following the application of Neisser's test contains no gonococci."

Morel Lavallee'" says:

I. " The gonococcus may rest latent for months or even years in the urethra.

II. It is impossible to permit marriage in a man that has the slightest discharge until by Neisser's test it has been proved free of organisms."

It is reasonably certain that the gonococci suffer enfeeblement during their stay in the urethra. This attenuation is due probably to alteration of medium, viz. the urethral mucous membrane, consequent upon growth of organism. In this way we can readily account for their presence without resultant inflammatory reaction. A localized chronic urethritis does not, however, confer any immunity from fresh infection. Finger" has produced in four instances an acute gonorrhoea on patients with chronic urethritis by inoculation with pure culture of gonococcus.

He believes that the gonococcus is attenuated by long residence in the urethra, and that women infected by their husbands who suffer from chronic gonorrhoea have a urethritis which runs a chronic course.

Jamain'" believes " that the gonococcus becomes attenuated, but that in contact with a healthy mucous membrane in another individual it is rejuvenated and produces an acute gonorrhoea."

The secretion in cases of chronic urethritis being small as compared to an acute one, so small in many cases that it appears in the urine only as tripperfiklen, it follows that after being washed off by the urine, it requires some time for regeneration. (Hence arises the importance of examining the first urine passed after an interval of several hours, 23referably the morning urine, for if the patient has urinated within an hour or two the urine may be free from shreds.) So that a single act of coitus with an individual suffering from chronic urethritis and with a secretion bearing gonococci does not always produce infection.

Since we can only demonstrate the presence of the gonococcus in a small percentage of cases of chronic urethritis (in 37 of 625 reported by Hasse, or 6 per cent.; in 21 of 357 reported by Goll, of a duration of a year or more, or 6 per cent.; in 2 of 38, of same duration, reported in this paper, or 5J per cent.), and since when present they are, as compared to an acute gonorrhoea, few in number, often only demonstrated after frequent, careful and repeated examination, and since they are from attenuation probably less virulent, we must conclude that:

I. In many cases of chronic urethritis we are unable to demonstrate the presence of the gonococcus ; these cases are probably non-infectious.

II. In any case the possibility of infection as compared to an acute urethritis is small.

III. An urethritis due to an attenuated organism, and consequently modified in intensity, may be contracted from a chronic urethritis. Conversely:


IV. Several negative examinations of the secretion from a chronic urethritis do not prove its non-infectiousness.

V. The infectiousness or non-infectiousness of a chronic urethritis can only be determined by frequent and careful examinatious of the secretion, and if these prove negative, by the non-appearance of the gonococcus after the application of Neisser's test.

Bibliography.

1. Neisser: Oentralblatt f. d. med. Wissenschaft, 1879.

2. Bumm : Gonococcus Neisser. Wiesbaden, 1887.

3. Wertheim: Archiv. f. Gynakol., 1892.

■1. Steinschneider : Berlin klin. Wochensch., 1893.

5. Koux : Archives gen. de Medecine, 1886.

6. Lustgarteu and Mannaberg: Vierteljahresschrift f. Derm, und Syph., 1887.

7. Petit and Wasserman : Annales des maladies des (frg. genito-urin., June, 1891.

8. Steinschneider: Berlin klin. Wochensch., June, 1890.

9. Wendt: Medical News, Phil., 1887.

10. Carpenter: University Med. Magazine, Dec, 1892.

11. Finger: Blenorrhoea v. d. Sex. Organ. Leipzig and Wien, 1893.

12. Lustgarten : Etiology of Gonorrhoea. (Morrow's System, Cutaneous and Genito-Urinary Diseases )

13. Goll: Internat. Centralblatt fiir die Phys. u. Path, der Ham i;nd Sex. Organe, 1891.

14. Hasse: Inaug. Dissertation, Strassburg, 1893.

15. Morel Laval lee : Annales des mal. des org. genito-urin , Dec, 1893.

16. Jamain : Annales des mal. des org. genito-urin., Nov., 1894.

17. Allen : Journal of Cutaneous and Genito-Urinary Dis., 1887.

18. M. vonZeissl: Die acuten Krankheiten der miinnlichen Hai-nrohre. Leipzig, 1894.

19. Neisser: Deut. Med. Wocheuschrift, 1893.

30. Heiman : ]\Iedical Kecord, June, 1895; Archiv fiir Dermatologie uiid Syphilis, 1896, Vol. 34.

21. Koplik : Journal of Cutaneous and Genito Urinary Dis., 1893.

22. Annales des mal. des org. genito-urin. Aout-Juin, 1892.

THE JOHNS HOPKINS HOSPITAL BULLETIN,

Volume VIII.

The Bulletin of the Johns Hopklus Hospital entered upon Its eighth volume January 1, 1897. It contains original communlcatJous relating to medical, surgical and gynecological topics, reports of dispensary practice, reports from the pathological, anatomical, physlologlco-chemicai, pharmacological and clinical laboratories, abstracts of papers read before, and of discussions in the various societies connected with the Hospital, reports of lectures and other matters of general Interest In the work of the Johns Hopkins Hospital and the Johns Hopkins Medical School.

The subscription price Is $1.00 per year. Volume VII, bound la cloth $1.50.


THE MALARIAL FEVERS OF BALTIMORE.

An Analysis of 6l6 cases of Malarial Fever, with Special Reference to the

Relations existing between different Types of Haematozoa

and different Types of Fever.

By William Sidney Thayee, M. D., and John Hewetson, M. D.,

A8»l8ta7its iti the Medical Clinic of The Johns Hopkins Eospital. SIR p.-i^es, (|iiHr«a. wild plate and charts, rrlre $3.' O. Pnslngr paid.

[KoriniriK- part of The Johns Hopltinx Hnxpital Hcparts, Vol, V, 18U.5.] Orders should Ije addressed to TiiK Johns Hopkins Press, Ualtimore, Md.


214

[\o. 79.


THE IMPORTANCE OF EMPLOYING PURE SALTS IN THE PREPARATION OF THE SCHOTT BATH.

The reason the carbonic acid is given off when bicarbonate of soda and hydrochloric acid are combined is because the hydrochloric acid has a greater affinity for the sodium than has the carbonic acid; the latter is, therefore, displaced, appearing as carbonic acid gas and the salt sodium chloride resulting.

The following would be the formula for this reaction:


Editor of Johns Hopkins Hospital Bulletin.

Dear Sir: I am lately in receipt of the following letter from a physician in the West. I submit to you the letter and my reply in full for publication, if you see fit, as I trust by so doing a similar mistake maybe averted.

I am very truly,

G. N. B. Camac. [communication.] Dr. C. N. B. Camac, Johns Hopkins Hospital, Baltimore, Md.

Dear Doctor: — The instructions contained in your article in the May issue of the Johns Hopkins Hospital Bulletin on the Schott treatment of heart disease have recently been followed by me in a case of hypertrophy with organic lesions.

We nearly had a disastrous result owing to an evident error in those instructions.

Bath V calls for sodium bicarb. 1 lb., HCl 1 lb. Bath VI increases the HCl to 3 lbs., but leaves the sodium bicarb, still at 1 lb., thereby producing an excess of 1 lb. of HCl which is not provided for.

I gave the journal to the hospital druggist with instructions to prepare each bath in order in accordance with the directions, paying no thought to chemical results. When bath VI was given the patient was attended by only one nurse, while usually two or three had been present. She noticed the chlorine gas rising from the tub, but supposed it was all right and put the patient in. He had no sooner stepped in than he was nearly suffocated and was quickly assisted out without harm.

The nurse seemed seriously prostrated for a time with a very severe bronchitis and laryngitis and the hospital attendants had a lively time to relieve her.

I relate these circumstances in order to call your attention to a mistake that must have been made in the article in question.

The patient has been rather worse during the course of baths, but that may be due to the progress of the disease, which is serious. As it takes more than one swallow to make a summer, I cannot pass an opinion on the method of treatment. Very truly yours,

Baltimore, Md., Sept. 4, 1897.

Dear Doctor: — I am indebted to you for your communication in reference to the Schott treatment.

We have had no experience similar to yours in using bath No. VI, which I may say is seldom called for. Chemically, the results which you had seem an impossibility, no matter how excessive the amount of hydrochloric acid may be. Suppose, for exampje, we take a formula expressing an excess of hydrochloric acid as follows :

NaHCO=-f5HCl=NaCl-fH«0 + CO;-t-4HCl.

The other two salts, sodium-chloride and calcium-chloride, are already in solution, and being bases in combination with the acid hydrochloric, remain chemically unchanged.


NaHOCOi + HCl = NaCl -I- IhO + C0=.

I can only account for your unhappy accident by supposing that one of two mistakes was made :

1st. Your druggist may have given you sulphuric or nitric acid instead of hydrochloric, both of which acids have a greater affinity for the bases sodium and calcium than has liydrochloric acid, and which would have combined with these to form sulphates or nitrates, free HCl being formed. (Formula see below. Experiment No. 3.)

2d. The calcium chloride (which is the more likely to have occurred) may have been adulterated with chloride of lime, or indeed chloride of lime may have been given to you instead of calcium chloride. This hypochlorite of calcium being the ordinary bleaching powder and much cheaper than the pure salt calcium chloride, forms a ready salt for adulteration, which in the presence of only a small amount of hydrochloric acid yields chlorine gas and would be, I can readily understand, not only dangerous to a heart case but even seriously injurious to a healthy individual. (Formula see below. Experiments 4 and 5.)

Actuated by your letter I made the following experiments:

1st. Bath No. 6 with the amounts of constituents as directed in my pamphlet from which you quote. Eesult: Abundance of carbonic acid gas. No unj)leasant effects.

2d. The same amount of constituents with excess of hydrochloric acid. Result: Same as experiment No. 1. (Nos. 1 and 2 performed in bath tub.)

3d. Small amount of sodium chloride, calcium chloride, and bicarbonate of soda and sulphuric acid (experiment performed in beaker glass). Kesult: Stifling odor;- no fumes visible. This "stifling" odor was probably due to the HCl forming.

4th. Salts, sodium chloride, calcium hypochlorite (bleaching powder), bicarbonate of soda, dilute hydrochloric acid. Result: Chlorine given off; suffocating; beaker had to be placed under the hood.

5th. Sodium chloride, calcium hypochlorite bicarb, soda and sulphuric acid. Result : More pronounced than in experiment No. IV.

Allow me to thauk you for your communication, which I consider of sufficient importance to publish in order that a like so serious mistake may not again be made. Very truly yours,

C. N. B. Camac.

Formula:

Experiment No. 1. Same as formula given at beginning of

letter.


OCTOBEK, 1807.]

215


Experiment No. 3. (Same as foruuihi given at beginning of letter.

Experiment No. 3. 2NaCl + CaCL + 2NaH003 + 3H.S04 = 3Na.S0. + CaSO^ + 3H=0 + 2C0= + 4HC1.

Experiment No. 4. Ca(CIO). ■t-4HCl = CaCl. + 2HvO + 20L.


Experiment No. 5. L'u(,C10> + CaCh + 2ll.:SOi=3CaS04 + 31LO + 20k

Note. — I have not included iu these hist two formulfe — tlie NaCl, as it would have no effect upon the reaction — neither is the NallCOjincluded, as 00= would be evolved as already noted.


PROCEEDINGS OF SOCIETIES


TIIE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of Monday, May 17, 1897. Dr. Flexner in the Chair.

Denionstratioii of a Case. Probable Brain Tumor. — Dr.

Thomas.

The patient whom I wish to present to the Society will he brought from the ward in a few moments. She is a young, unmarried woman of twenty-six, with a good family history, except that one brother is believed to have tuberculosis. She has been a fairly strong girl, and has had no serious illness of any kind. Her occupation is that of a sewing woman, and she has been learning stenography and type-writing.

About a year ago she had an attack of unconsciousness ; this began with a painful contraction of the right hand, which lasted for a minute or two, and passed up the arm, when she became unconscious. She was found about half an hour afterwards by her brother, who shook lier and brought her to herself. After this attack she was comparatively well, and went to her employment the next day as usual. In August of last year she was under a great deal of nervous strain on account of the death of a relative. About this time she had several nervous attacks, which she calls " nervous chills," and which seem to have been hysterical. Ou November 8, 1896, while sitting with her arm resting ou the table, she became conscious of a sensation of numbness in the elbow of her right arm. This arm and the leg on the same side became suddenly powerless, and she has been told that her face was drawn to the left, but of this she was not conscious. With the onset of this paralysis she became absolutely unable to speak. She was put to bed, and showed so much nervousness that the attending physician, a very competent man, made the diagnosis of hysteria, and it was impressed upon her that she could, if she would, get up and walk and talk. The description which she gives of the loss of speech is remarkably distinct and clear. She says that she understood everything that was said to her, and remembers much of it. She knew every one who came into the room, but was absolutely unable to say a word. She thinks that she knew what she wanted to say, but had forgotten how to say it. She I tried to write with the left hand, but could not foi-m the letters and had forgotten how to spell the words. Upon making the attempt to read, after she had been sick about four days, she was unable to make anything of it, and three weeks afterwards she could not read the paper easily. After a week of complete speechlessness, during which every one arouud her had endeavored to make her talk, she was able to


repeat the first four words of a text of scripture which had been said to her over and over again. By being taught day by day, her speech gradually improved; the first words that she said voluntarily were "go out." These she said to her sister, who had been sitting with her constantly for a good many days. She knew all the time just what she wanted to say, but it was only after a good deal of silent practice, and several attempts, that she was able to utter the two words. Her speech improved slowly, but steadily, until she regained the speech which she now has, which shows no defect.

The first of last December she had another attack, and another on the twelfth of February, and still another on the 3Gth of April. These attacks have all been of the same character, beginning with a painful contraction of the fingers of the right hand ; this passes up the arm, and she describes an intense pain iu her liead. At this time she says that she loses all knowledge that the arm belongs to herself, although she still exjieriences pain in it. This is a remarkable statement. Iu these three attacks, consciousness seems not to have been lost.

As the patient enters the room, you will notice that she walks with a slight limp, and that the right hand is held iu the manner so characteristic of hemiplegia. I have been unable to find the slightest disturbance of her speech. She now speaks voluntarily, without difficulty, writes long and short hand, understands everything that is said to her, and reads with ease. The ophthalmoscopic examination showed that the fundus was normal, although there is a slight degree of hypersemia. She has a congenital squint and a slight nystagmus, but other than this, no abnormality of the cranial nerves. Her chief disability is in regard to her right arm, which, as you see, is very tremulous and nearly useless. She is unable to oppose the thumb to the little finger, and the movements of the finger are very weak. The movements at the wrist are better retained, and those at the elbow and shoulder better still. The movement of outward rotation of the arm is very weak indeed, whereas the inward rotation is comparatively strong. The deep reflexes are markedly exago-erated, percussion on any of the tendons causing active muscular contraction, and there is a well-marked wrist clonus. Objectively, there is not much muscular weakness of the right leg. Sensation is everywhere perfectly normal. , I have tested particularly for any abnormality of the muscular sense of the right arm, and found that she appreciates even very slight movements of any of the joints. There is no muscular atrophy. The examination of the chest shows no abnormality, and we have been unable to discover anything that indicates a preceding specific infection (syphilitic).


216

[No. 79.


I have been much interested in this patient, and it is surely an unusual case. That a young woman of her age should have been affected with a hemiplegia associated with a temporary loss of speech, and followed by recurring attacks simulating closely Jacksouian epilepsy. Is very remarkable. The diagnosis of hysteria seems at first sight the most probable one. Organic vascular lesions are very fare at her age, except when they are associated with syphilis. In this case there is nothing in the previous history or in the present condition that suggests such a cause. The patient was at the onset undoubtedly very hysterical, and you will remember that she gave the history of preceding hysterical attacks, all of which speak for the diagnosis of hysteria ; but the condition in which you have seen the patient suggests an organic paralysis more than an hysterical one. Maun and other observers have studied the distribution of the paralysis due to organic brain disease, and have determined that there are certain movements which are most apt to be paralysed. The movements which are most often jjaralysed are those of the thumb, and next in order of importance is the outward rotation of the arm. In the case before you, these are just the muscles which are paralysed. The excessive increase of the deep reflexes, which is ijresent in this case, is also unusual in association with hysterical paralysis, so I think we are justified in stating that the character of the pai'alysis is that due to an organic brain lesiou, rather than to hysteria. The character of the convulsive attacks also points to an organic lesion, as true Jacksonian attacks are, as far as my knowledge goes, extremely rare in hysteria. Although I am not very positive about it, still I believe that we have a definite disease of the brain in this ease, and I am inclined to think that this disease is a slow-growing tumor. I have been led to this belief from an experience which we have lately had. Some of you will remember that I reported to this Society last fall the clinical history of a case upon which we had advised operation. The case was that of a man who, for six years, had had recurring attacks of Jacksonian epilepsy, beginning in his right foot, and which had later involved the right arm and face, and in whom there had developed paralysis of the leg, and of the arm. There were none of the general symptoms of brain tumor, and the operation revealed nothing abnormal; but the microscopical examination of the brain showed a most interesting new growth of the motor region, about which I hope Dr. Flexner will have something to say. The case which I have presented to you to-night, although not quite similar, will suggest this case strongly, and we fear is of a like nature.

Note. — While in the Hospital, in the early part of June, the patient had another attack. She was in the dining-room, talking with some friends, when the fingers of her right hand became stiff and painful. This extended up the arm, the hand and arm drew up, her head was drawn to the right side, and there was intense pain in her head. She then lost consciousness. Those who were about her say that her eyes were turned to the right and that her right leg was stiffened out, and that she fell to the floor. When she became conscious, in about five minutes, she could not talk for a few moments, and felt weak and badly, but was not hysterical.


Demonstration of Specimens.— By De. Ccllen.

Several weeks ago at a meeting of this Society, Dr. Kelly spoke at length on the operative treatment of myomata and pointed out tiie ease with which these growths could be removed. Since that time I have operated upon two patients where the conditions present rendered the enucleation very diflicult. Both of these cases present so many clinical points of interest that we may proiitably discuss them for a few moments.

Case 1. Umbilical hernia; multinodular myomatous icterus; large ovarian abscess communicating with the small intestine; hysterectomy.

K. L., aet. 40. Admitted to Dr. Kelly's service March 23, 1897. Complaint, abdominal tumor, pains in the lower right abdomen and leg. She had been married 20 years, but gave no history of pregnancy. Menses began at 13 years, and were regular until August 15, 1896, when they ceased fori months, since which time they reappeared. Flow moderate, at times clotted; occasionally it is painful.

Family history negative.

Previous history unimportant.

Present condition. Ten years ago she noticed a tumor about the size of an Qgg in the right side of the pelvis. This has steadily increased in size and has been almost constantly associated with a gnawing pain over its most prominent part. The pain has been so severe that she has at times been confined to bed, on one occasion for 3 months. The last attack was 3 months ago. Locomotion very difficult on account of pain in the legs. These are at times swollen and pit on pressure. No chills. No fever. The patient is well nourished, has a good appetite, bowels constipated. For the last two years she has had night sweats regularly.

The abdomen is much distended and presents an irregular lobulated appearance. At the umbilicus is a hernial sac fully 9 cm. in diameter. The skin over this can be drawn out for a distance of 6 cm., while the hernial ring whose margins are very sharply defined is 3 cm. in diameter. The following are the abdominal measurements : Distance from symphysis to umbilicus 1-1 cm.; from umbilicus to xyphoid 29 cm.; circumference at most prominent part of tumor 126 cm.; midway between umbilicus and xyphoid process 96 cm. Examination occasioned little pain.

Operation March 24, 1897. On account of the irregular hernial protrusion the abdominal incision was commenced at a point midway between the xyphoid cartilage and the umbilicus and continued downward to within a short distance of the pubes, the hernial sac being encircled and removed. At the umbilicus the omentum which was firmly adherent was ligated and then freed. Presenting at the incision were several subperitoneal myomata ; to these the omentum was also firmly adherent. After loosening up these adhesions, the nodular myomatous uterus, 28x21 cm., was delivered. (See the accompanying figure.)

Occupying the posterior part of the pelvic cavity was an elastic tumor 17 cm. in diameter ; this looked like an ovarian cyst and was intinuitely adherent to two loops of snnill intestine. On attempting to shell off the outer layers of the cyst


October, 1897.]

217


leaving them attached to the intestines, the cyst ruptured and was found to contain about 900 cc. of greyish foetid pus. A glass trocar was introduced and the pus evacuated. The uterus was then removed in the usual way from left to right, but the left tube and ovary were left in situ. After bringing the cervical stump together the ovarian abscess was freed and the vessels at its pedicle controlled by silk ligatures. It was necessary, however, to leave a small part of the sac attached to the intestines, and on careful examination an opening 1 cm. in diameter was found between the intestine and the abscess sac. The margins of the intestinal opening were almost as dense as cartilage and at the same time very friable. After a good deal of dissection it was possible to turn the edges in and the opening was closed by fine silk sutures. This now was supported by a second and a third row.



A longitudinal section of the abdomen, showing from above downward the large multinodular mj-omatoug uterus, to the upper and anterior surface of which the omentum is adherent, an umbilical hernia to whose ring the omentum has become adherent, a pus tube and an unusually large ovarian abscess which communicates with a loop of small intestine. The abscess wastoore on the right side of the body, but has been drawn on the same level to bring it out more clearly.

During the entire operation, which lasted 5 hours, the patient did not lose 3 oz. of blood. The abdomen was thoroughly cleansed with two litres of salt solution, the pelvic peritoneum drawn over the cervical stump and the abdomen closed without drainage.

On the eighth day the temperature rose to 100.8° and about the "^Oth day reached 101°. At that time there was consider


able pain in the left iliac fossa and an indefinite thickening could be made out, but from this time on she rapidly recovered and was discharged May 4th feeling comparatively well. From this case we may learn that where there is an umbilical hernia or adhesions are suspected it is well to begin the incision at a point above this; the finger can then be introduced into the abdomen to act as a guide. The presence of the ovarian abscess is very readily explained. There has evidently been an ovarian cyst. With the increase in size of the myoma the cyst has been firmly pressed against the intestines, adhesions have formed, and as continuous pressure promotes absorption, the walls have gradually atrophied until an opening has formed between the two. Attention may also be drawn to the fact that no drainage was emj^loyed.

Case 2. Large tnyomatous uterus extending out laterally betiveen folds of broad ligament; complete hysterectoiny necessary as no cervix was left; danger of injuring the ureters.

M. F., aet. 40, admitted to Dr. Kelly's service March 29, 1897. Complaint, an abdominal tumor. Menstrual history somewhat indefinite, but the periods were regular until two years ago, since which time the patient has had a continuous bitt not excessive bloody discharge.

Family History. Mother's family showed a decided tuberculous tendency.

Present Condition. She first noticed abdoaiinal enlargement during the summer of 1896. It has steadily increased since then and showed more advancement on the left than right side. During the last four years she has had on an average one profuse uterine hemorrhage each year; the last was one week before admission and continued three days. For one year there has been marked but not constant pain in the lower abdomen. Micturition frequent. No history of chills or fever.

Abdominal Examination. The abdomen is the size of a full term pregnancy, the greatest prominence is to the left of the umbilicus. Just below the umbilicus in the mid-line is a hard flattened area 8 cm. broad, to the right of which is a second nodule. From the character and consistence of the nodules one instantly suspects myomata.

Measurements. Distance from symphysis pubes to umbilicus 24 cm.; from umbilicus to xyphoid process 20 cm.; from right ant. sup. spine to umbilicus 25 cm.; from left aijt. sup. spine to umbilicus 24.5 cm., girth at umbilicus 88 cm., greatest girth which is 8 cm. below the umbilicus is 91 cm.

On vaginal examination the cervix was felt as a half-moonshaped slit directly behind the pubes, while the whole upper part of the pelvis was filled with a hard globular mass, forming a part of that occupying the abdomen.

Operation March 31, 1897. Hysteromyomectomy. The abdominal incision extended from a point 4 cm. above the umbilicus almost to the pubes. The myoma was delivered without difficulty, but found firmly fixed in the pelvis. Upward it reached a point midway between the umbilicus and xyphoid cartilage, was lobulated and laterally stretched out under the broad ligaments. The right round ligament was tied and cut, the vessels of the right tube and ovary were controlled and the appendages on this side were left in situ. On the left side the


218

[No. 79.


tube aud ovary were fouud lying on the ujiper surface of the tumor and could not be saved. After ligating and cutting the left round ligament the folds of the broad ligament were separated, exposing an artery 2 mm. in diameter lying on the surface of the tumor — this was probably the ovarian artery ; it was tied off and the bladder peritoneum freed from the tumor. The myoma was then rolled upward and to the right, but on the left side the uterine vessels as such could not be isolated ; they were, however, controlled by passiug stout sutures at their usual site.

It was now my intention to amputate at the cervix, but as this was entirely involved by the tumor the vault of the vagina was opened into, its upper portion being removed. The right uterine vessels were caught by the forceps and the tumor was freed. lu both broad ligaments were many dilated lymph spaces. After controlling the large vessels with silk and checking all oozing along the vaginal cut surface with catgut the vaginal mucosa was turned down into the vagina and the i-aw surfaces were brought together, thus shutting off the pelvic cavity. The bladder peritoneum was then drawn backward over the stump aud united with that of Douglas' sac. Considerable anxiety was felt as to the safety of the ureters, as it was necessary on account of the vaginal vault being so widely opened to control the uterine 'vessels further out than usual. On the left side a rounded cord was seen included in the ligature, but on unraveling this it was found to be a fold of peritoneum. After washing out the pelvis with two litres of salt solution the abdominal cavity was closed. The patient made a perfect recovery and was discharged May 3, 1897.

In this case the chief anxiety was centred around the ureters. We were loath to close the abdomen without further examination as to their safety, but the patient's condition did not warrant any delay. Strict orders were given to have all the urine measured to determine if sufficient were secreted. The amount obtained satisfied us that both kidneys were doing their normal amount of work. Had a ureter been tied the abdomen would have been again opened and the ureter anastomosed into the bladder.


NOTKS OX NEW BOOKS.

Archives of Clinical Skiagraphy. Sydney Rowland, B. A. Camb., Editor. Volume I, Parts I-IV. 1890-7. (The Rebman Publishing Company, Limited, London.)

A publication whose ol)ject is "to put on record in permanent form some of the most striking ai)plicationsof the ' New Photography to the Needs of Medicine and Surgery,' is being edited by Mr. Sydney Rowland, the special commissioner appointed by the British Medical Journal to make inquiry into the above-mentioned applications. The Archives of Clinical Skiagraphy published its first number iu May, 1886. Since then three more numbers have appeared at irregular intervals. Each of them contains a series of six collotype plates, taken from some excellent X-ray negatives, to which a brief clinical and explanatory note is appended. Most of the plates are of simple skeletal lesions of the extremities, illustrative of fractures, malformations and neoplasms.

There are few reproductions of .the more difficult exposures through tlie pelvis or chest, and but cur.sory mention of attempts to


recognize lesions other than osseous ones, euch as intra-thoracic

aneurism, changes in the cardiac area, pulmonary affections, renal calculi and the like. There is an excellent skiagrai)li of tubercular arthritis of the hip in No. 3 and of congenital dislocation of the hip in No. 4, evidently in children.

In the last number (April, 1897) the scope of the publication has been enlarged somewhat, and reijroductions of subjects other than purely clinical ones are presented, such as of zoological specimens, and reference is made to the possibility of taking moving shadow pictures for cinematographic purposes.

The life of such a publication, if devoted purely to clinical subjects, seems to come to a natural termination when its mission of calling attention to the great usefulness of the X-rays for the diagnosis of many pathological conditions has been fulfilled.

To-day an X-ray apparatus has become an almost necessary adjunct to the hospital or private armamentarium, and skiagraphs are as much to be expected in a clinical report as ordinary photographs, and will occupy an equally important place in the forthcoming text-books on fractures, orthopsedic?, etc.

It seems, therefore, that the value of such a periodical would be enhanced if it aimed, as do some of the better photographic journals, towards the perfection of the ways and means of betteringthe art of skiagraphy rather than towards the mere reproduction of its quite familiar results.

The Archives are very handsomely published by the Rebman Publishing Company. The reproductions are good. Such type, paper and broad margins would be welcomed in many better known and more generally useful medical magazines. H. W. C.

Injuries and Diseases of the Ear, being Reprints of Papers on Otology. By Macleod Yearsley, F. R C. S., Fellow of the British Laryngological, Rhinologiial and Otological Association, etc. (1897, London: The Rebman Publishing Co., Limited, 11 Adams St., Strand.)

This little book is an interesting collection of monographs, and is not a systematic treatise on diseases of the ear. All of the articles are interesting and suggestive. We would especially commend " Foreign bodies in the ear and their treatment," " What not to do in diseases of the ear," and " On the care of the ear in children." The chapter on "Aural Reflexes" is too brief to be .satisfactory. It is to be hoped that the author will at some future time esjtand it into a book.

Inebriety. Its Source, Prevention and Cure. By C. F. Palmer.

(New York: F. H. Retell Co., IS97.)

This short tract or sermon is not in any way a scientific discussion of this subject, and so lacks all special value for a physician. It is only suitable for that body of the laity who have a small amount of scientific knowledge. The point on which the author lays most stress is that inebriety is due to a neuropsychopathic constitution, and that consequently it is a result of mental deformity rather than a moral infraction, and he believes that almost all inebriety may be traced back to a mentally or physically diseased ancestry. But his remarks might be applied with almost as much fitness to any other form of mental deformity as inebriety.

Medical and Surgical Report of the Presbyterian Hospital in the

City of New York. Vol. II, January, 1897.

This report compares very favorably with Volume I, and with more supervision in the editing would be still better. Many of the papers published in this volume have appeared before in the New York medical journals, which detracts from their vivid interest. For those who have not read the journals there are good papers on tj'phoid fever, tuberculosis, and a variety of other topics both surgical and medical, reported at greater or lesser length. The description of the operating pavilion as an aid in construction for other hospitals is most valuable.


October, 1897.J

219


Hysteria and Certain Allied Conditions. Their Nature and Treatment with Special Reference to the Application of the Best Cure, Massage, Electro-therapy, Hypnotism, etc. By Geokqe J. Prbston, M. D., Professor of the Diseases of the Nervous System, College of Physicians and Surgeons, Baltimore, etc. 8vo, pp. 298. (P. Bktckision, Son & Go., Philadelphia, 1897.)

Dr. Preston modestly prefaces his book with an explanatory apology. Two reasons, he says, may perhaps be deemed of sufficient weight to warrant its appearance ; first the great importance of hysteria, and secondly tlie lack of a recent book in English on the subject. The book is intended for the American general practitioner. Its "object is to present the symptomatology and differential diagnosis of hysteria in as concise a manner as possible, and to indicate the various therapeutic measures that have been found useful in the treatment of the disorder."

The author first gives a short sketch of the history of hysteria, in which special attention is given to tlie epidemics of hysteria so common in the Middle Ages and occasionally seen since then. An interesting account is given of the hysterical " orgies" enacted at the religious revivals of Kentucky and Tennessee in the early part of this century, and of the camp-meeting "trances " of the Southern negro.

The historical account is followed by a chapter on the " Nature of Hysteria." The etiology is considered in some detail. Sex, age, race, climate, heredity, diathesis, education and environment, and " reflex irritation" are discussed. In regard to " race," the author, who has had considerable experience with hysteria in the negro, thinks that the disorder is more frequent in that race to-day than it was during the slavery period. Indeed, it is at present by no means uncommon. Special stress is put upon the part that environment plays in the etiology of hysteria. The part played by " reflex irritation " is considered undetermined. It is rare that an abnormal condition of the organs of generation gives rise to the disease, though a morbid train of associated ideas often makes the hysterical woman refer her troubles to these parts.

The consideration of the etiology of the disease is followed by a brief review of the many theories that have been held as to its nature. The author concludes that hysteria is an affection of the hij;her brain centres, perhaps an actual though temporary loss of protoplasm. In bringing together his reason for this conclusion Dr. Preston shows an acquaintance with the more recent work on the fine anatomy of the cerebral cortex and an admirable hesitancy in making deductions from the suggestive results of the histologists.

There follows a chapter on "Symptomatology." Hysteria is considered as a single disease, though most protean in nature. The symptoms of the disease are divided into the following categories: 1. Disturbances of sensation: anaesthesia, paraesthesia, hyperaesthesia, affecting both the general sensibility and also tlie special senses. 2. Disturbances of motion : paralysis, contracture, tremor, convulsive seizures. 3. Vaso-motor, visceral, and nutritive disturbances. 4. Mental symptoms. 5. Miscellaneous symptoms.

The disturbances of sensation are treated with the fulness of detail which the subject warrants. Special attention is given to " hysterogenesis." The author feels convinced from cases of his own that the hysterogenic zones, first described by Charcot, have a real existence and are not the result of suggestion.

A good description is given of the various disturbances of the motor-system. The author draws an interesting comparison between the manifestations of liysteria in this country and those in France. " 1 have often been struck," he says, " with the similarity between the cases of hysteria in negroes, who, of course, have never been in any possible manner under the influence of suggestion, and the so-called ' show cases' at the Salpetriere."


Under "mental symptoms" are considered the general mental state of the hysterical patient,* hysterical insanity, lethargy, narcolepsy, catalepsy, ecstasy, somnambulism, and vigil ambulism. Somnambulism, while not necessarily hysterical in nature, is considered to be very closely allied to hysteria on the one hand and to hypnotism on the other.

The visceral disturbances include contracture of the oesophagus, vomiting, hematemesis, hysterical anorexia, intestinal disturbances; affections of the genito-urinary apparatus ; disturbances of the respiration and of the voice. Under cardiac and vaso-motor symptoms are considered tachycardia, flushing of the face and upper part of the body, autographism and cutaneous affections. Nutritional disturbances include muscular atrophy and hysterical fever. The latter, the author concludes, is a real though rare condition.

A third of the book is given up to a detailed consideration of the diagnosis and treatment of hysteria. There has been an evident and successful effort to make this clear, practical and helpful. Under differential diagnosis emphasis is put upon the fact that though hysteria is manifold in nature it is almost always characterized by certain stigmata, as for instance anaesthesia, which as a rule may be clearly distinguished from similar disturbances due to organic disease. "The central idea in the treatment of hysteria may be expressed in the word 'suggestion.' " The physician must have the confidence of his patient. In the general treatment of the disease the main reliance is to be placed upon a careful regulation of the diet, the meals, rest, exercise, occupation, and habits. Drugs are useful mainly because the patient is apt to have faith in medicine. The treatment of special symptoms likewise depends chiefly on suggestion. In case of severe attacks pressure on the hysterogenic zones, ice suppositories, apomorphia, chloroform, at times hypnotism, may help to terminate the attack.

Electricity, which has proved so valuable in the treatment of hysteria, owes its main effects to the power of suggestion. On the other hand, water as a therapeutic agent has a direct marked beneficial physiological effect in addition to its suggestive use. For the routine treatment of hysteria the alternate warm and cold douche is warmly recommended. Massage is chiefly applicable to those cases of hysteria, often complicated with neurasthenia, in which the patient cannot or will not take out-door exercise. The Weir Mitchell Rest Cure is considered in some detail. Hypnotism, of which the author gives a very interesting account, is considered very valuable in some cases, though on the whole it has proved disappointing as a therapeutic agent. Its great value is "that it has taught us how to make our treatment of the hysterical subject suggestive." Surgical interference is rarely necessary or of value. The author deplores the frequency with which ovariotomy has been done in this country merely for the relief of hysteria.

The book as a whole is admirably fitted for the purpose for which it was designed. The author makes no attempt at an original treatment of hysteria. He has drawn extensively from the literature on the subject, giving references to the more important articles. Yet he is far from being a mere compiler. He views the subject throughout from a modest yet independent standpoint, based on an experience with hysterical patients rendered the more valuable by an evident deep personal interest in the subject. The style is direct, clear, and interesting, though at times rough. The book is illustrated by diagrams taken from Charcot and Gilles de la Tourette, and by pictures from the drawings of Richer. It is well printed and well bound. It should prove not only most valuable to the general practitioner, but also of interest to the specialist in nervous diseases. C. R. B.


» "As has been aptly put, the hysterical patient says ' I cannot,' it loolis like 'I will not,' but it really is 'I cannot will.'"


220

[No. 79.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel C. Gilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.

WiLLiAJi OsLER, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice

of Medicine. Henry M. Hdrd, M. D., LL. D., Professor of Psychiatry. William S. IIalsted, M. D., Professor of Surgery. Howard A. Kelly, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.

William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. William D. Booker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. Thomas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flexner, M. D., Associate Professor of Pathology. J. Whitridge Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy.


William S. Thayer, M. D., Associate Professor of Medicine.

John M. T. Finney, M. D., Associate Professor of Surgery.

George P. Dreyer, Ph. D., Associate in Physiology.

William W. Russell, M. D., Associate in Gynecology.

Henry J. Berkley, M. D., Associate in N euro- Pathology.

J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology,

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. Bl-oodgood, M. D., Instructor in Surgery.

Thomas S. Cullen, M. B., Instructor in Gynecologj'.

Frank R. Smith, M. D., Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jones, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology.

Louis E. Livingood, M. D., Assistant in Pathology.

Ross G. Harrison, Ph. D., Instructor in Anatomy.

Henry Barton Jacobs, M. D., Instructor in Medicine.

Charles R. Bardeen, M. D., Assistant in Anatomy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from Its close affiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

The course of instruction is planned for the professional education of those who have received a liberal education, as indicated by a collegiate degree iu arts or science, including a reading knowledge of French and German and adequate training in those branches of science, such as physics, chemistry and biology, which underlie the medical sciences. Men and women are admitted upon the same terms.

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

REQUIREMENTS FOR ADMISSION.

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

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

3. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as Is Imparted by the regular minor courses given in these subjects in this university.

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

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

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

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

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

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

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

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afl'orded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one.

The special courses of instruction for graduates in medicine are now given annually during the months of May and June. During April there is a preliminary course in Normal Histology.

These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and Is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital.

These courses are open to those who have taken a medical degree aud who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here otTered. The number of students who can be accommodated In some of the practical courses Is necessarily limited. For these the places are assigned according to the date of application.

The Annual Announcement and Catalogue will be scut upon application. Inquiries should be addressed to the

HEGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.


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


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. VIII.- No. 80.]


BALTIMORE, NOVEMBER, 1897.


[Price, (5 Cents.


coisrTEisrTS.


PACK.

A Rare Case of Lithopedion. By J. G. Clark, M. D., - - 221 On Tuberculosis of the (Esophagus, with the Report of a Case

of Unusual Infection. By Clahibel Coxe, M. D., - - 229

A Rare Anomaly of the Arch of the Aorta, with an Additional

Muscle in the Neck. By A. B. Herrick, . . - - 234


On the Hsematozoan Infections of Birds. By W. G. MacCalLUM, M.D., - - - - - - - - - - 235

A Case of Cavernous Angioma (Vascular Nkvus) of the Tunica

Conjunctiva. By Dr. H. O. Reik, - - - . - 236 Books Received, . - - 237


A RARE CASE OF LITHOPEDION.


By J. G. Clark, M. D.


During the month of August, 1896, a patient suffering with an abdominal tumor, dyspncea and pain in the lower abdomen, was admitted to the gynecological wards of the Johns Hopkins Hospital for treatment, and, through the kindness of Dr. Kelly, I was given charge of the case.

The patient's history was strongly suggestive of the rupture, four years previous to her admission, of an extra-uterine pregnancy sac, with the extrusion of the fcetus into the abdominal cavity, and the physical examination revealed a stony-like mass, resembling a foetus in form, which proved at operation to be a lithopedion.

As the formation of a true lithopedion is of rare occurrence, and as this was a typical case, I have thought it worthy of publication.

History of Case.

B. H., colored, married, age 45 years. Admitted August 8, 1896.

Chief Complaints. Pains in the lower abdomen, enlargement of the abdomen, and dyspnoea.

Marital History. Married 14 years, three children, oldest 12, youngest 7 years old.

First labor difficult, attended by a midwife, who had to call in a physician to remove an adherent placenta. Last two labors easy, slight chills and fever after birth of last child.

Menstrual History. Flow appeared first in her thirteenth year, always regular, but accompanied by much pain in the left side. For the last three years the flow has been regular, lasting 4 to 5 days.


Family History. Mother is insane, otherwise no history of hereditary disease.

Present Illness. Four years ago the menstrual flow ceased and the patient had all the symptoms of early pregnancy.

Towards the end of term her lower extremities swelled very much, and she felt so weak and miserable that she was compelled to go to bed, where she remained itntil long after the regular term. During the latter months of pregnancy foetal movements were distinctly felt. About the time for her confinement she had an attack of severe pain in the left side and felt something break. Much watery fluid was passed by the vagina.

At the end of a week her physician was called, who told her that she had an extra-uterine pregnancy and advised an operation, which she declined. During the time while her legs were oedematous she became almost blind. The size of the abdomen has decreased slightly, but the pains in the left side still persist, and of late have grown more severe.

General Condition. Tall, emaciated woman, tongue slightly coated, lips and mucous membranes pale, patient seems moody and of a despondent disposition.

Bowels constipated, at times she goes a week or ten days without a movement.

Micturition painless. Appetite poor.

Examination. Abdomen irregularly distended by a tumor which presents most prominently on the left side. It is quite hard,


222

[No. 80.


only slightly movable, and is apparently connected by adhesions with the anterior and lateral abdominal walls.

The tumor lies in an obliqne position within the abdomen, the upper extremity is felt beneath the left lower rib, the lower extremity being crowded down into the right inguinal regiou.

The general surface of the tumor is smooth, but numerous hard projections are felt over it, which are denser than the main body of the tumor.

Abdomen tympanitic over right half. Immediately below and one inch to the left of the umbilicus, where the most resistant part of the mass is felt, the percussion note is flat.

No percussion wave.

Examination under anmsthena. Outlet relaxed, cervix in axis of vagina. Uterus normal in size, in anteposition, pushed forward against pubes by a mass posterior and above uterus.

The left tube and ovary are enlarged; nothing detected on right side except general, ill-defined bogginess.

The main body of the tumor may be pushed away from the uterus, but seems to have a slender pedicle.

The ill-defined mass in the right side, by rectal examination, feels very boggy and is in close relationship with the hard tumor.

Urinary Exainination. Color clear amber, slight cloudy sediment, sp. gr. 1035, acid reaction, no sugar or albumen. A few pus cells.

Operation.

Operation by Dr. Clark, August 14, 1896.

Abdominal section for the removal of a lithopedion, double salpingo-oophorectomy for hydrosalpinx and cystic ovary on left side, and for the removal of the right tube and ovary, which were converted into an ectopic gestation sac.

Complications. Adhesions between the anterior abdominal wall and back of foetus. Dense adhesions binding the gestation sac to the intestines. Placenta necrotic.

Incision 10 cm. in length, revealing a mottled yellow tumor closely adherent to the abdominal wall.

On releasing these adhesions and passing the hand up beneath the left lower rib, the foetal head was felt lying in close contact with the spleen. The left arm and shoulder were closely adherent to the anterior abdominal wall near the umbilicus.

In order to facilitate the delivery of the fostus the abdominal incision was enlarged to a point midway between the ensiform cartilage and umbilicus.

Numerous bleeding tags of adhesions were ligated.

The foetus occupied an oblique position in the abdomen, its chest lying in close contact with the aorta, from which it derived a distinct pulsation impulse.

The fo?tal head was grasped and gently delivered from the abdominal incision, after which the umbilical cord was cut close to its placental attachment in the pelvis. On inspecting the pelvic structures the fimbriated end of the tube was found adherent to the ectopic sac, having been apparently torn from the body of the Fallopian tube at the time of the primary rupture.

The secondary or adventitious sac was situated between the folds of the broad ligament. On the floor of the pelvis a large


placenta was attached. The larger portion of the sac projected up into the abdominal cavity, and was densely adherent to the vermiform appendix, ceecum and intestine. Secondary rupture had occurred in the superior wall of the sac, the umbilical cord projecting through it into the abdominal cavity.

The placenta was very friable, and on attempting to detach it, broke up into small bits, requiring its removal piecemeal. The ectopic sac was dissected free from the intestine and its attachments in the pelvis, and enucleated with the right tube. The ovary could not be distinguished in the necrotic mass.

A large cystic ovary and hydrosalpinx were removed from the left side.

Abdominal cavity irrigated with .5 litres of salt solution. Abdomen closed with buried silver and subcutaneous cat-gut sutures.

Pulse at beginning of operation 120, at completion 90 beats a minute.

Patient made an uncomplicated recovery, temperature at no time after operation rising above 100° F.

Discharged 28 days after operation, well.

Db. Barnum's History of the Case. In a private letter. Dr. Barnum, of Lancaster, Va., has given the following account of the case :

I remember the case of Mrs. Harris very well, owing to the fact that it is the only one of the kind ever seen by me. I was called to see the case in October, 1S92. I found the patient weak, nervous, despondent, and at times wicha mind decidedly unbalanced. From her and her husband, who is a colored man of intelligence and good standing, I learned that she became pregnant the previous November. There was the usual suppression of the menses, morning sickness, quickening, filling out of the breasts, and all of the signs which she, as the mother of several children, recognized as indications of the pregnant condition.

In August she was taken with perfectly normal labor pains and the colored midwife was sent for. Neither the patient nor her colored attendant suspected that anything was wrong until forced to believe it by the delay in the delivery.

At my first visit to the patient, two months later, an external examination showed her pregnant condition.

Digital examination, however, revealed the uterus of a nonpregnant woman.

At a still later visit I was able to grasp a knee of the foetus through the abdominal walls of the mother.

A rigid questioning of both husband and wife failed to elicit any history of previous abnormal pregnancy or miscarriage.

As this pregnancy had not been interru))ted by any unusual sickness, I gave it as my opinion that this was a case of abdominal pregnancy ;.or if it at any time had been one of tubal pregnancy, the tube must have ruptured early in the pregnancy.

At my first and at all of my subsequent visits I urged the patient to go to the hospital for treatment. As she was not willing to do this, I gave her tonics and remedies to improve her mental condition. She gradually improved, and has employed no physician, I think, during the past year. Allow me to thank you for your letter announcing the operation which confirmed my diagnosis.

Pathological Report. Extra-uterine foetus removed from the abdominal cavity four years after the rupture of the gestation sac.


November, i897.J

223


Foetal measurements :

Occipito-mental diameter, 12.3 cm.

frontal " 9.3 " Siib-occipito bregmatic diameter, 9.2 "

Bitemporal diameter, 7.9 "

Biparietal " 7.9 "

Circumference of head, .30. "

" " shoulders, 32. "

Length of fcetus, 43. "

Weight of fcetus, 4J lbs.



The fcetus is entirely covered with a thin translucent membrane which is easily peeled off.

Only the general outlines of the face can be distinguished, the eyes, nose, mouth and ears being entirely covered in with


the membranous covering, through which the hair of the fa?tus can be seen as a black mat.

Scattered throughout the foetal envelope are numerous yellowish white spots composed of a fatty, saponaceous material.

The cheeks are quite prominent, the left being much more so than the right.

The skin covering the face and forehead is of a brownish red color resembling burut leather, slightly mottled, and is firm and resistant, having lost all of its pliability.

On cutting into the skin at this point the knife encounters numerous gritty particles, but the general body of the skin is composed of adipocere.

The occiput and a part of the parietal bones may be seen projecting immediately beneath the membranous covering.

The parietal bones overlap the occipital, and the jagged sutures feel like saw-teeth.

The skin covering the left side of the head is of a white, bleached appearance, similar to the washerwoman's skin.

The membranous envelope, which is probably the remains of the amnion, is closely attached to the foetus, but can be peeled off. It is ten millimetres in thickness and has no visible blood-vessels when held up to the light.

The arm on the right side is closely glued to the body, and the space between the axilla and elbow is entirely obliterated.

The right forearm is flexed on the arm, and the fingers on the hand.

The dorsal tendons of the hand are seen as glistening cords beneath the mummified fcetal skin.

The left forearm is half-way flexed upon the arm and presents the same general appearance as the right side

The feet are flexed upon the legs, the legs upon the thighs, and the thighs partially upon the abdomen.

There is a considerable accumulation of adipocere aud calcareous matter in slightly raised plaques over the lower extremities.

The genital organs are entirely hidden by the enveloping membrane, so that it is impossible to differentiate the sex of the foetus without further dissection. The entire posterior aspect of the fretus is covered with glistening white organized tags of adhesions which have connected the foetus with the maternal tissues. On floating these adhesions out in water thev are seen to form a thick wavy veil.

On dissecting this layer of adhesions, loose numerous fatty plaques are seen in the skin.

The dorsal vertebraj form a prominent ridge, aud at points where the spinous processes shimmer through the translucent skin are seen to be in a cartilaginous state.

The skin of the buttocks and the underlying fat and gluteal muscles have undergone saponaceous change, with here and there patches of calcareous matter sparingly interspersed through the external portions of the tissues

The umbilical cord is shrunken to about half its usual size and contains many calcareous nodules.

Median incision from the neck down to and through the symphysis pubis reveals the following condition : Superficially the body is covered with a membranous layer which can be peeled off easily, next comes the thick brawny bacon-like


224

[No. 80.


skin, and beneath it the brownish red muscle which contains multiple fatty areas about the size of millet seeds.

The jjeritoneum is of a dull slate color, like that seen in an old post-mortem subject.

The intestines are collapsed, soft, pliable, and, except for the shrinking of the tissues from absorption of the watery elements, appear to have undergone little or no change.

The liver is of a light brownish red tint interspersed with slate colored patches.

On section the liver is found to be much denser than normal, the stroma is of a greenish brown color, with many minute yellowish spots.

The lungs are atelectatic and have a dense fleshy feeling. The color is brownish red, resembling the color of the liver.

On section, gritty particles are encountered with the knife.

The heart is collapsed, wrinkled, and of a dark brown color.

The spleen is small and dense.

On freeing the genital organs of the enveloping membrane the fcetus is found to be of the male sex.

Microscojiical Examination. Lungs : the air spaces are small and the epithelial lining is not visible, bui appears to be changed into fatty detritus and star-shaped crystals.

The connective tissue between the air spaces is pale, opaque and of a uniform homogeneous appearance, the separate connective tissue fibres not being distinguishable.

Interspersed throughout the connective tissue septa are many star-shaj^ed crystals.

The muscular tissue of the heart still maintains its characteristic form, although undergoing marked fatty degeneration. No calcareous changes visible.

The general histological structure of theliveris unchanged, although the liver cells are undergoing fatty degeneration.

Diagnosis. Extra-uterine foetus undergoing saponaceous mummification and calcareous changes. (Lithopedion.) The calcareous change is limited to the enveloping membrane, skin and lungs, the remainder of the internal organs showing only those changes due to fatty degeneration and absorption of their watery constituents.

Kuchenmeister makes the following classification of the calcareous changes which may occur in an extra-uterine embryo after its death :

Lithokelyphos, a condition in which the fcetal envelopes alone undergo calcareous changes, the foetus shrinking to a mummified mass after the absorption of the amniotic fluid.

Lithokelyphopedion, a condition in which the foetal envelopes and those parts of the fcetus which come in contact with the membranes undergo calcareous changes.

Lithopedion, a condition in which the fcetus after its expulsion into the abdominal cavity undergoes calcareous change, beginning externally in the vernix caseosa.

Li ectopic pregnancy cases which survive the primary or secondary rupture of the gestation sac and are not subjected to operation, the embryo may be disposed of in various ways, depending upon its age and the maternal conditions surrounding it.

Complete absorption only occurs when the embryonic tissues are largely composed of watery elements and the bones are yet in a cartilaginous state; it is therefore highly improbable that


an embryo more than three months old ever completely disappears in this way.

In order to arrive at an approximate idea concerning the ability of the human peritoneum to dispose of a young extrauterine embryo when expelled into the abdominal cavity, Leopold* made an extremely interesting experimental study upon rabbits.

For this purpose he selected four series of pregnant animals at different stages of pregnancy, from which he removed the embryos by abdominal section and implanted them in the peritoneal cavity of other rabbits.

The embryos were of the following sizes : 2.-5 cm. long, 5 to 6 cm. long, 8 cm. long, and the fully matured fcetus with intact membranes.

Some of the animals became infected and died from ])uru]ent peritonitis.

In these cases the rate of absorption was much more rapid than in those where the peritoneum remained normal.

Although the many experimental studies upon the function of the peritoneum have demonstrated its phenomenal absorptive ability, we are hardly prepared for Leopold's statement that when there was an accompanying peritonitis an embryo 2.5 cm. long was so completely absorbed by the end of the second day that no further trace of it could be found ; that a 5-cm. long foetus at the end of 24 hours showed only a small mass of bones, the epidermis and all of the internal organs having been absorbed; that of an 8-cm. long foetus th«re remained only a small mass of tissue consisting of the skin, paws and nails and the shrunken internal organs and skeleton ; and finally that the fully matured fcetus with its enveloping membranes was little less rajiidly absorbed.

As the rupture of an ectopic pregnancy sac is in the majority of cases a sterile process, the results obtained in those experiments of Leopold in which there was no accompanying peritonitis probably more nearly indicate the approximate rate of absorption in the human being.

In those animals the absorption was quite as effective, although much slower.

After a few days embryos 2.5 cm. long were very much softened; in two instances, at the end of fourteen days they were only the size of a lentil, after thirty-four days they I were still smaller, and at the end of fifty-two days were either \ completely absorbed or only a small trace of them could be found.

From these experiments Leopold concludes that a small embryo may be absorbed completely.

The accumulated observations upon the clinical course of exti-a-uterine pregnancy tend to prove that the great majority of cases will rupture within the first two months of pregnancy, and also that probably many accidents of this kind occur without the patient dying from their effects or being subjected to operation.

The natural course, therefore, in these cases will be for the embryo to be absorbed completely. It is only when the primary rupture is delayed beyond the third month, or when the embryo survives the rupture and continues to develop in an


•Archiv f. Gyn., vol. XVIII, p. 53.


November, 1897.]

225


adventitious sac until a secondary rupture occurs, that a lithopedion is likely to be formed.

In these cases the extruded embryo may lie free in the abdominal cavity as a non-irritant foreign body, or as is more likely, a wall of adhesions will form about it and thus shut it oif from the peritoneal cavity. The close proximity of these encapsulated masses to the intestines and rectum renders them liable to infection at any time.

In the event of this complication extensive suppuration will occur and the fcetus quickly becomes skeletonized, and its bones may be discharged through a fistulous track into the rectum, vagina, bladder, or through the abdominal wall. It is only in the non-infected cases that mummification, saponaceous and calcareous changes take place.

The first cases of lithopediou recorded excited the liveliest curiosity and speculation among physicians as to their origin, and usually the conclusion was reached that no law governed their formation and that their origin was due to some mysterious or occult influence.

As an evidence of the views held by these earlier physicians, we find the case referred to by Spachius prefaced by the following lines: "Deucalion cast stones behind him and thus fashioned the human race, hence comes it that nowadays the tender flesh of babes is formed of stone."

In 1881 Kuchenmeister* reported a case in which a lithopedion had lain in the abdominal cavity of a woman 57 years. He carefully reviewed the literature bearing upon the subject of lithopediou, covering the period between the report of Albosius's case in 1582 and the time of the publication of his article in 1880.

From the fact that a lithopedion has always been considered such a unique production it is safe to assume that more of these cases in proportion to the number which have actually occurred, have been reported than of almost any other pathological anomaly, and yet from 1583 until 1880 Kuchenmeister was able to collect only 47 cases of mummified, skeletonized and calcified fcetuses, and of this number only a few can be accepted as true lithopedions.

Many of the earlier cases were dignified by special titles, such as the Lithopjedion Senoeuse, Das Ileidelberger Lithopiidion von Nebel (1767), Das Berliner Lithopildion von Walter (1775), Das Dresdener Lithopildion von Seller, Sen. (1819), etc.

Notwithstanding the great activity in the field of abdominal surgery since 1880, the year of Kuchenmeister's publication, comparatively few additional cases have been reported, a fact which still further proves that they are of very rare occurrence. If we select those cases from Kuchenmeister's review which represent a definite epoch or interesting fact in the history of this subject, we find that Albosius's case (1583) was the first reported. Varnier and Mangin's case (1785) was the first of double ectopic fcetation with the formation of a skeletonized foetus and a lithokelyphos. Von Weinhardt's case (1802) was the first successfully operated upon by abdominal section, Bonisch's case (1831) the first successfully removed through the vagina, Lee Heiskell's case (1828) the first reported

•Archiv f. Gyn., vol. XVII, p. 153.


in the United States, and Kuchenmeister's case (1880) the one of longest standing. The case which I now report is the largest lithopedion yet removed by abdominal operation followed by recovery of the patient.

The cases just referred to are of sufficient interest to merit a short resume of their histories.

In Varnier and Mangin's case (1785) there were two extrauterine foetuses of different ages found at autopsy.

A woman who had borne twelve children again became pregnant and went on to an apparently normal labor, March, 1753. The labor pains continued many days; water and considerable blood were expelled from the uterus, causing her to become weak and faint. After this false labor the patient gradually recovered, the abdomen, however, remaining enlarged. Eighteen mouths later she again had bleeding, from which she recovered, and continued well until the time of her death, 1785, in her 75th year.

At autopsy a white, moderately hard tumor of 5J pounds weight was found adherent to the abdominal wall, intestines and mesentery. The outer surface was partly calcified, and within the tumor a male fcetus with its placenta and umbilical cord was found. The joints were flexible, not friable; the extremities were hard, but still fleshy and not calcified. The muscles were hard and brown ; the skin dense and yellow.

Ovaries and tubes normal. Close to the left uterine wall and between it and the rectum, a hard, chalky tumor the size of a hen's egg was found, which contained a thick reddish slime and the bones of a two or three months foetus.

This sac communicated through perforations in the uterine wall with the uterine cavity.

Von Weinhardt's case, 1802, should occupy a prominent place in the history of abdominal surgery on account of the courage exhibited by this barber-surgeon in attempting such a hazardous operation.

In this case the patient gave a history so characteristic of

' the rupture of an extra-uterine pregnancy sac that V. Wein hardt, after making an examination, not only diagnosed her

true condition, but advised an operation, which he performed

Sept. 35, 1801.

After exposing through an abdominal incision the tumor mass, the surface of which was covered with veins, he delivered it with a " flesh hook." Within the mass the foetal bones could be felt distinctly. The foetus was removed, but no attempt was made to enucleate the placenta. The umbilical cord was brought out through the abdominal incision. The abdominal wound was dressed with cotton and a solution of balsam Peru and adhesive plaster. The patient recovered.

In this case the foetal envelope alone had undergone calcareous changes, the foetus having become skeletonized. Kuchenmeister therefore classified it as a lithokelyphos.

In the case of Bonisch (1815) the fcetus had lain in the abdomen for seven years before the operation.

The patient first noticed a large lump in her left side, accompanied by pain which she referred to the region of the umbilicus. This was her eighth pregnancy. The foetal movements had been quite vigorous, and at full term all of the usual symptoms of labor came on and continued for three days, after which they ceased and her breasts decreased in


226

[No. 80.


size. For five weeks she had a bloody vaginal discharge. At the end of nine months the menses returned. The patient did not wholly recover, but suffered from dysuria, constipation, occasional abdominal pains, and emaciation. In 1817 and in 1819 she again bore children, but the pain and emaciation which had previously existed continued, and in addition she had a foul-smelling vaginal discharge.

At the time of the operation a sharp bone (frontal bone) projected into the vagina ; this was first removed, accompanied by the escape of pus, after which the cranium was crushed with bone forceps and removed piecemeal. The left arm was then torn off with a hook, but remained attached by adhesions to the abdomjnal wall.

The bone was removed, leaving the soft parts behind. The hook was then fastened to the right arm, and all of the parts removed except the right thigh. This bone with the adherent parts was removed later.

The patient recovered, but had an occasional discharge of calcareous and cheesy masses, and the soft parts which were left behind formed a hard swelling over thepubes. Involuntary urination still continued.

Lee Heiskell's case is of interest merely because it was the first reported in the United States. The lithopedion was removed at autopsy and weighed four pounds and six ounces.

The clinical history of Kuclienmeister's case was reported by Hirt, an accoucheur in Zittau, in V. Siebold's Journal fiir Geburtshiilfe in 18.34.

The patient gave birth to a dead foetus in 1819, after which she again menstruated regularly until the end of the year 1823, when symptoms of another pregnancy appeared.

During the second half of her pregnancy she began to have much pain, which increased as the fcetal movements grew stronger, until she did not have an hour free from suffering. At the time of her expected confinement she experienced labor-like pains for a few days.

On Oct. 25th, after eating a light midday meal, she suddenly had a feeling of heart anguish, cramp and lancinating pain in the abdomen accompanied by vomiting.

After this time she became very sick and no longer felt the foetal movements or labor pains. Three days later Hirt was called and found the woman in an unconscious condition, with all the signs of a septic fever associated with an inflammatory attack in the abdomen. On account of the tympanitic condition of the abdomen Hirt was only able to make out rather indefinitely the transverse position of the foetus above the umbilicus.

After an examination of the uterus, which he found empty, he felt convinced that this was a case of "abdominal pregnancy." On account of the serious condition of the patient and the death of the foetus he did not consider the recovery of the patient possible without an operation, but under the administration of medicines "nature asserted herself," and Hirt says, "Truly I had the pleasure of seeing a slow recovery set in." After this time the patient had an ill-smelling diarrhoea which gradually disappeared. Milk appeared in the breasts on the 21st day and was present for 14 days. Nine weeks after the first day of her illness she had a bright red flow of blood mixed with pieces of skin and fibres.


From this time on the patient made a good recovery, and with the exception of pain which she noticed in certain movements of the body as in bending far forwards, and an occasional sharp, sticking pain in the right side, she suffered no inconvenience. Ten years after the attack Hirt examined the patient and found the foetus still in a transverse position, the head towards the right side of the mother. Through the posterior wall of the vagina a part of the foetus which he took for one of the upper extremities could be felt.

In 1846, 13 years after Hirt's last note, Kuchenmeister first saw the case and found a tumor one and a half times as large as a head adherent to the abdominal wall in a transverse direction, making a prominent conical tumor near the umbilicus. The tumor was closely adherent to the abdominal wall and was only movable in so far as the abdominal wall was movable. The foetal parts could not be recognized. The uterus was normal in size and form and at most slightly anteverted. By the vagina the tumor could not be felt.

The patient continued in good health until 1880, when she died in her 88th year. The autopsy was performed by Kuchenmeister, June 3d, 1880. The body was greatly emaciated, and the abdomen presented a prominent conical appearance, most marked near the umbilicus. The tumor was intimately adherent to the mesentery and anterior abdominal wall, requiring the knife to separate the adhesions. The tumor was in part directly adherent beneath and at the sides to the adjacent intestine, and in part connected by band-like adhesions with the more distant intestines and especially with the uterine appendages. The broadest adhesions resembled the bursted tubal sac. From one part of the tumor a foetal foot projected, the skin over which was dry and the tendons stood out prominently like those seen in dried anatomical preparations. The tumor was hard, inflexible and calcified. The placenta was soft and easily differentiated from the ectopic sac.

On opening the sac a full-term mummified foetus was found. It was very much shrunken, the face was distorted but not calcified and was covered by the right arm. The umbilical cord was wound ai'ound the thorax of the foetus and easily visible. All of the inner organs could be recognized without difficulty. The general appearance of the scalp, cranium, - brain, lungs, heart, pericardial sac, diaphragm, spleen and liver was preserved, but the intestines had shrunk into an unrecognizable mass.

A microscopical examination of this and another specimen was made by T. Wyder, who found only calcareous deposits in the skin and amniotic sac and not in the internal organs. The various tissues were mostly easily recognized and in part were wholly ))reserved. In the denser tissues the cell elements were most resistant and retained their normal appearance and arrangement. In all localities where fat had previously existed margarine and cholesterine crystals were found.

As Kuchenuieister's table possesses considerable historical interest I have rearranged it according to the chronological report of the cases and append it to this paper.

Since the publication of Kuclienmeister's paper cases have been reported by the following writers, but none of them


November, 1897.]

227


-possess any special poiuts of interest over the cases found in his report:

Dahlmann, Archiv f. Gyn., 1879, Vol. XV, p. 128.

Oettinger, Progrus Med., 1884, Vol. XII, p. 196.

Sarrante, Archiv de Tocol., 1885, Vol. XII, p. 237.

Oppel, A., Miinch. med. Wochen., 1888, Vol. XIII, p. 151.

Stonham, Tr. Path. Soc. Loudon, 1886-7, Vol. XXXVIII, p. 445.

Hammer, Prag. med. Wochen., 1888, Vol. XIII, p. 151.

Fales, W. H., Boston M. and S. J., 1887, Vol. CX VII, p. 131.

Tarnier, Bull. Acad, de M6d., 1889, Vol. XXII, p. 57.

Schotte, G., Miinch. med. Woch., 1890, Vol. XXXVII, pp. 471, 489, 503.


Wilson, E. H., Brooklyn M. J., 1891, p. 515.

Elbiug, R., St. Petersb. med. Woch., 1890, Vol. VII, p. 299.

Lusk, Med. Eec, N. Y., 1892, Vol. XLII, p. 405.

Hofmeier, Sitzungs. d. phys.-med. Gesellsch., Wiirzburg, 1892, p. 134.

Gottschalk, Canad. Pract., 1893.

Patellani, Ann. di Obstet, Milano, 1893, Vol. XV, p. 817.

Dean and Marnoch, J. Anat. and Physiol., London, 1893-94, p. 77.

Fabbrovich, Gazz. d. Osp. Milano, 1894, Vol. XV, p. 890.

Djemil-Bey, Ann. de Gynec. et d'Obstet., Paris, 1894, Vol. XLII, p. 333.




KUCHENMEISTER'S TABLE OF C.4.SES REPORTED BETWEEN THE YEARS 1582 AND


1880.



Case No.



Name of observer.


Number of births before the ectopic pregnancy.


Time wheu labor pains or symptoms of rupture occurred.


Length

of time

foetus

was

retained.


3^


he

11

Si


•sj

3"°


i|.g


M


Primary

site.


Age of the woman at death.



Escape of

decidua

from

uterus.


Return of menses.


Other births after the ectopic pregnancy.


Remarks.


1


1583


Albosius.


None.



28yrs.



1





Normal uterus.


66 years.


Yes.


Yes.





2


1659


Densius, Pont a Mousson.



6th month


?



1












3


1661


Schnorffs in Dole



9th month





1





53 years.




Yes.




4


1675


de Blegny (Toulouse).


10


Full term


28 yrs.




1




Tube.


25 years.



Prolonged purulent discbarge




Pregnancy in the uterine end of the Fallopian tube. Fcetal head in fundus uteri.


5


1719


Bompard.



7th month 2 days in labor.


15 yrs.





1



Uterus ?







Skeletonization and softening of the foetus with partial spontaneous extrusion.


6


1720


Orth, Steinkind,



Full term.


51 yrs.



1





Probably


91 years.





2




Von Leinzell.



Labor pains 3 to 4 weeks.








in one horn of uterus.








7


1728


Bianchi.


2


In the 9th month.


15 yrs.


1






Ovary.








8


1741


Bromfleld.



Fullterm.


9 yrs.


1






Uterus, perforation of the cervix uteri.








9


1747


Middleton.



Full term.


16 yrs.




1




Fimbriated extremity of tube.



Yes.




4



10


1748


Bourdon and Chamerau in Troyes.


1 miscarriage.


Fullterm.

Labor

pains 2

days. Fullterm.


30 yrs.


1






Right tube.


61 years.






Two incisor teeth in jaw.


U


1767


Heidelberg case


2


54 yrs.




1





91 years.


Yes.



Yes.


2 abor

Patient recovered




of Nebel.















tions.


after many weeks.


12


1775


Walter, of Berlin.


1


9th month.


22 yrs.




1




Right ovary.








13


1784




Fullterm.

Labor

pains for

3 days. Fullterm.


8 yrs.


1






Left tube.


45 years.



Yes.


Two years later.




14


1785


Varnier and


12


33 yrs.


1




1



One fcetus


75 years.


Escape of


Probably


18 months



One foetus fully




Mangin.



Labor pains tor many days.








in abdom. cavity, the other n sac communicating with uterus.



water

with

blood.


decidua.


later.



developed (9th month), the other 3 months old.


15


1786


MQhlbeck.


1


11th month.


U}i yrs.




1




Uterus.



Yes.





Foetus died in the 7th month.


16


1798


Cheston(ca8ell.


3


Fullterm. Labor pains 3 weeks.


50 yrs.


1






Uterus unicornis unicoUis (mit Nebenhorn).


80 years.







17


1798


Chcston (case 2).



Fullterm.


4 yrs.





1



Normal uterus.


Operated upon in 29th year.


Flow of fetid

water for 15 months



1 years after operation.




18


1800


Denmann.


Ifullterm. Many mis

9th month.


32 yrs.













History of case very imperfect.


19


1802


Von Weinhardt.


carriages.


Near the


7 yrs. to the time


1






Probably



Yes, one


Blood and




Recovery.






7th







extra


week.


fleshy









month.


of operation.







uterine.




matter.





20


1805


Cad well.


No.


Fullterm. Labor pains one


26 yrs.




1




Retained in uterus.




Yes.




Died from operation performed through the .cer

21


1806


Grivel.



day.








Abdomen.


8;) years.






vix.


228

[No. 80.


KUCHENMEISTER'S TABLE OF CASES REPORTED BETWEEN THE YEARS i582 AND 1880. -Continued.


1819


Seller.


1819


Prael.


1830


Bruns.


1831


nonisch.


1825


Cruveilhier.


1828


Lee Heiskell


1832


Stoltz.


Case reported from the city of Danzii?, author not cited.

Bondet.


Virchow.

Will.

SteiQ in Steinau


Playfair.


Chiari.

Galli.

Deschamps.


Kuchenmeister.


Number of births before the ectopic pregnancy.


I full

terms, 3 abortions.


Time when labor pains or symptoms of rupture occurred.


At the end of the 9th month


No symptoms of labor.


Full term, 3 days long.


End of the

9tb

month


Labor pains at full term

Labor pains at full term

Full term. Labor pains continued 3 days.


Full term. Labor pains 14 days.


8th month.


49yrs


75 months.


87 yrs


Pull term. Labor pains for 3 days.


7yrs.

yrs.


Full term.

Labor

pains 33

hours. Full term.

Few days.


11 yrs

67 yrs


Length

of time

fa'tus

was

retained


46 yrs. 28 yrs.


7 yrs. up to time of operation. 47yis.

40 yrs.

2 yrs.


26 yrs. 10 yrs. >iyr.


^yr.


Abdomen. Uterus.


3.. tube

and ovary Abdomi

oal cavity Posterior

wall of

uterus

and its

adductor.

Possibly

in one

corner of

uterus. Abdominal cavity.


L. ovary. L. ovary?


R. ovar. and parov.


Tube and ovary.


Fimbriated end of left tube and 1. ovary

Inonecornu uteri.


Tube and ovary.


Canalis intercanaliculi.


Age of the woman at death.


) years. ! years.




Escape of decidua

from uterus.


Small amount of blood.


Bloody discharge.


4 months after the death of the fcetus.


Nine days after the death of

foetus.


Nine days after the death of foetus.


2S'5.D


Spontaneous delivery through vagina and rectum.


History of case imperfect.

Recovery. Fcetus removed through the vagina.


Vienna paste applied to the sac per vag. Before it was eroded the patient died.


The foetuswas more than a half year over term before it was delivered.


4 times delivered artificially


The foetus was undergoing suppuration.


ON TUBERCULOSIS OF THE (ESOPHAGUS, WITH THE REPORT OF A CASE OF UNUSUAL INFECTION.

By Claribel Cone, M. D., Professor of Pathology, Woman's Medical Colli ge, Bait i more. [From the Pathological Laboratory of the Johns Hopkins University and Hospital.^


Keuewed attention to the subject of tuberculosis of the oesophagus has shown that this organ is not so often spared in tuberculous affections as was at one time believed. Thus, in a critical review of the subject published in 1893, Dr. Flexner,* who reported a new case, was able to collect from the literature up to that date only eighteen undoubted cases. Since his publication there have appeared, so far as has come to the writer's notice, twenty-eight additional cases. Of these twenty-eight cases it is worthy of remark that nine were described by one observer, Mazzotti.f

Another case from this pathological laboratory is to be added to the list, and now that the affection is no longer recognized as of great rarity, its report is suggested as much by the peculiar distribution of the tubercles as by the pathological condition itself. It seems worth while at the same time to re-collect all the cases and to consider the classification with reference to their ajtiology.

The classification suggested by Flexner is as follows:

I. Instances in which the tuberculous process arises through continuity or contiguity of structure.

(ji) Where a caseous bronchial gland or group of glands becomes adherent to the cesophagus and ulcerates into the latter.

{b) In consequence of perforation of abscesses associated with caries of the vertebraj.

(c) Where tuberculous ulcers of the pharynx pass down and invade the cesophugus.

II. Cases in which there exists in the CBSophageal mucous membrane a previous lesion to be regarded as predisposing to the tuberculous infection.

III. Instances in which («) the cesophagus is affected in the course of a general disseminated miliary tuberculosis, and (b) in which there is infection of the mucous membrane from tuberculous sputum where no previous lesion existed.

Of the nineteen cases collected by Flexner,^ eleven belong to the first class, two to the second, and six to the third. In the first group are included the cases of Weichselbaum (1), Beck (2), Penzoldt (.3), Orth (2), Pitt (1), and Zenker (2) ; in the second group those of Eppinger (1) and Breus (1); while the third class includes the cases of Mazzotti (3), Spillman (1), Freriehs (1), and Flexner (1).

Of the six cases comprising the last group, one only occurred in the course of a disseminated miliary tuberculosis giving rise to an eruption of miliary tubercles in the cesophagus. This case, which was reported by Mazzotti, § is the only published account of miliary tuberculosis affecting the cesophagus.


  • KlexQer: Tuberculosis of the (Esophagus. .Toluis Hopkins

Hospital Bulletin, IV, 1893-4.

t Mazzotti : Nuove osservazioni intorno alia tuberculosi dell' esofago. Dal Bulletino d. Scienze IMediche ili Bologna, VII, ser. VII, 1896, 553-579.

X Flexner : Op. cit.

gMazzotti: Revisla Clinica, .Jannar, 1885.


The additional twenty-eight cases which have been reported since 1893, including cases omitted from Flexner's original publication, can be divided so that thirteen fall in the first, three in the second, and twelve in the third class.

A. — Infection by Continuity or Contiguity of Structure.

1. Selenkow* reported a case of partial destruction of the cesophagus by tuberculosis. Gastrostomy was followed by impaired nutrition and death. In the lungs were found old tuberculous lesions, which, approaching the root on the right side, invaded the lymph glands. The latter became adherent to one another, forming a diffuse caseous mass both anterior and posterior to the oesophagus, and finally ulcerated into the anterior wall of the tube below the bifurcation of the trachea. A cavity about the size of a hen's egg was produced in the enlarged and caseous lymph glands, which"" was filled with detritus and into which the lumen of the oesophagus opened freely. Two distinct perforations occupying an area 5 cm. long and separated by a narrow strip of tissue existed. The lumen of the cesophagus was constricted in the lower segment and was only about half the size of the upper part. Although no bacteriological or histological examination was made in this case, the tuberculous nature of the lesions can scarcely be doubted.

3. Voelckerf reports the case of a boy, aged 9 years, in whom the post-mortem examination showed a mass of cretaceous glands at the hilum of the right lung. On opening the cesophagus a perforation was found on the anterior wall, a little to the right of the middle line and a little below the level of the bifurcation of the trachea. The opening was about 5 mm. in diameter; the edges were puckered and led into a cavity in which caseous material could be seen.

Voelcker has also collected from 2504 autopsies in the postmortem records of the Hospital for Sick Children, four other cases of tuberculosis of the cesophagus associated with general tuberculosis, to which he briefiy refers.

3_4_5. lu three of these cases caseous glands ruptured into the cesophagus.J

Letulle§ reports three cases, one of Londe and two of his own.


  • Selenkow: Kasuistische Mittheilungen a. il. ausser-staJti.sclien

Hospital. St. Petershurger raed. Wochenschr., IX, 1884, 491.

fVoelcker, A. F. Caseous Gland opening into the (Esophagus. Tr. Path. So'c, Lond., XLII, 1890-91, 87.

|Tlie additional case was one in which an oval ulcer, threequarters of an inch long, existed at the level of the bifurcation of the trachea ; but in this case the note says: "The muscular coat remains, the floor is smooth as if healed up, although in the neighborhood of a caseatina gland. The ulceration, as far as could be seen, had not started froniorbeen in any way caused bythegland." The Ktiology in this case must certainly be regardid as doubtful.

§Letulle: Lesions tuberculeusesde I'oesophage. Bull. Soc. Anat. de Paris, LXVIII, 1893,246.


230

[No. 80.


6. Loude's case was that of a man 50 years old, who died suddenly of hfematemesis. The autopsy revealed a fistula in the anterior surface of the (esophagus immediately below the bifurcation of the trachea, still filled with blood aud leading into a small tuberculous cavity which had developed in a caseous bronchial lymph gland. The starting point of the tuberculous lesions was found in a miliary tuberculosis of the pleura which, invading the thoracic glands, produced caseation and calcification, and later adhesion between the affected bronchial glands and the oesophagus, with ultimate perforation of the latter.

7. Letulle states that his first case was very similar to that of Loude and omits in his publication all details.

8. His second case occurred in a young man, the subject of a tuberculous empyema which had ruptured into the oesophagus. On microscopic examination the cesophagus showed infiltration of the muscular and submucous coats with embryonic cells, little caseation and no giant cells. Tubercle bacilli were not found.*

K. Zenker! adds four cases, of which two belong to the present class.

9. In the first case the tuberculous lesion of the cesophagus occurring in a young consumptive was accidentally discovered at autopsy. The tuberculosis originated in the lungs, spread to the bronchial lymph glands, the peri-glandular tissue, and the cesophagus, infiltrating the walls of the latter from without inward until ulceration and perforation were produced. The mici-oscopic examination showed tubercles in the muscular and submucous coats chieily, and numerous tubercle bacilli.

10. Zenker's second case was a man 46 years old who had tuberculosis of the serous membranes. The bronchial glands were considerably enlarged and caseous, and had ulcerated into the cesophagus at its mid-portion in three places. The histological examination of theresophagus showed tuberculous infiltration of the muscularis and submucosa, while the epithelium was scarcely affected. In the neighborhood of the ulcers, tubercles were found in the submucosa. These contained tiibercle bacilli.

11. A case reported by DanelJ: also belongs to this group. There were tubercle nodules in both lungs, general glandular enlargement, and tubercles, some of which had ulcerated in the mucosa of the pharynx. The (Esophagus in its jiosterior portion showed an extensive ulceration of the mucosa. The ulcer was about 10 cm. long and extended longitudinally. Its edges were eroded and it contained granules resembling tubercles. Other nodules taken to be tubercles were found


  • The validity of this case may well be questioned. Mixed infections in empyema are by no means unknown, so that the possibility of the invasion of the oesophagus by other micro-organisms

(pyogenic cocci?) is well worth considering.

f K.Zenker: Carcinom und Tuberkel in selben Organe. Deut. Arch. f. klin. Med., XLVII, 1891, 191 ; Beitrag zur Aetiologie und Casuistik der Tuberculose der Speiserohre. Deut. Arch. f. klin. Med., LV, 1895, 405.

I Danel : CEsophagite tuberculeuse consecutive ii une ancienne tuberculose peribronchique generalisation ganglionnaire. J. d. Sc. med. de Lille, XIX, 1896, 1, 520.


on the anterior surface. The cause of the infection of the cesophagus was a softened bronchial lymphatic gland situated at about the bifurcation of the trachea, which, having become adherent to the oesojihagus, perforated into this organ. The opening between the gland and the cesophagus measured about 1 cm. Although no histological or bacteriological examination was made, there can be no doubt of the specific nature of this case.

Of the nine cases added by Mazzotti to the three previously reported by him only one belongs to the present group. He confirmed his diagnosis of tuberculosis in each case by the demonstration of tubercle bacilli. His experience is remarkable, not only because of the large collection of cases of a pathological condition, the rarity of which is generally acknowledged, but also because of the predominance among them of that form of lesion which is admitted to be most infrecjuent. In eight of his cases the process began within the cesophagus, while, as stated, in one only there was an extension inward from caseous bronchial glands.

12. This case was that of a man aged 21 years, who died of pulmonary and intestinal tuberculosis. The oesophagus at the union of the upper with the middle third showed two ulcers, one near the other, somewhat elongated and of the size of a nentedmo. The edges of the ulcers were smooth and of a greenish color ; the irregular bases were also green. The ulcers perforated all the coats of the cesophagus, and their bases were formed by a collection of detritus situated under the cesophagus itself, and found to proceed from softened caseous bronchial glands. Two similar ulcers, also close together, communicating with each other beneath the mucosa, were seen at the junction of the middle and lower thirds of the oesophagus ; while yet below, were small superficial elliptical ulcers in the longitudinal direction of the canal. The lymph glands had also ulcerated into the left bronchus just at its origin from the trachea.

13. A case arising through continuity of structure is reported briefly by Birch-Hirschfeld.* At the autopsy (sex and age not given) there were found tuberculosis of the lungs and numerous tuberculous ulcers in the larynx, pharynx and upper third of the oesophagus. Tubercle bacilli were demonstrated.

B. — Pkedisposition to Infection due to a Previous Lesion.

1. K. Zenker's third case was an example of coincident carcinoma and tuberculosis of the cesophagus. A stricture of the tube, produced by a girdle ulcer of rodent character, existed, which on microscopic examination showed the typical appearance of squamous epithelioma. This growth invaded the deeper strata of the mucosa and at times penetrated the muscularis. In the border of the cancerous portion, toward the normal tissue, typical tubercles existed, some of which were caseous. The neighboring lymph glands also were involved in the cancerous and tuberculous conditions. Tubercle bacilli were found in small number in the tubercles.

Zenker does not commit himself as to whether the carciiio


  • Birch-Hirschfeia: Lehrbuch der path. Anat., II, 1894, 620.


November, 1897.]

231


matotis or tuberculous lesion was primary, but favors the former view because of the admitted resistance offered by the intact epithelium to tuberculous infection.

2. In this group of cases the one reported by Cordua* is to be placed.

A man 60 years of age came to autopsy, the clinical diagnosis of carcinoma of the oesophagus, incipient pulmonary tuberculosis, and adhesive pleuritis having been made. In the (esophagus, at about the bifurcation of the trachea, was found an ulcer 10 to 15 cm. long, which affected this structure in its entire circumference. The edges of the ulcer were somewhat elevated and firm; the base was very soft and pulpy. A sound could be passed from the middle of the ulcer far into the pericesophageal tissues, but not into the air passages. Upon sectioning the ulcer, the entire wall of the oesophagus was found to be almost destroyed, forming a small tumor mass. The microscopic examination showed, in addition to the carcinomatous, a tuberculous infection. Tubercles in process of caseation were found in the middle of the cancerous ulcer and about its periphery. Careful search failed to reveal tubercle bacilli.

Cordua favors the view that the tuberculous invasion of the cancerous ulcer took place through the lymphatics leading from tuberculous areas in the lungs ; and he assigns as reasons for his belief in this mode of infection, the absence of cancerous metastases and the presence of coal pigment in the lymph glands, the deep location of the older tubercles in the cancerous ulcer, and the more superficial situation of the younger ones. It would seem, however, more probable that the secondary tuberculous infection was due to sputum deglutition.

3. Pepper and Edsallf report the case of a man, 42 years of age, who had tuberculosis of the lungs, larynx, cervical glands and ojsophagus. The oesophagus was patulous and normal as high up as the level of the arch of the aorta. Above this point and to the junction with the pharynx, the lumen had entirely disappeared. The oesophageal walls and surrounding tissues had formed a band of dense fibrous tissue, about 1.35 cm. thick and 3.75 cm. broad, which was firmly bound to the vertebra. Sections of the growth examined microscopically showed cancerous tissue in a dense fibrous tissue basis, tubercle-like masses undergoing fibroid change, an occasional giant cell, and tubercle bacilli.

The central and deeper portions of the tumor were composed mainly of fibrous tissue, and this appearance led the authors to conclude that tuberculosis was evidently the original cause of the disease, while cancer subsequently infiltrated the occlusion. (?) That the cancer was primary they consider improbable, both from the microscopic appearance of "infiltration of a previously existing mass, and from the history of cancer being here as elsewhere one of inexorable growth and onward progress, ulceration, and sloughing."


  • Cordua: Ein Fall von krebsig-tuberculosem Geschwiir des

Oesophagus. Arbeiten a. d. pathologischen Institut in GiJttingen, 1893, 147.

f Pepper and Edsall : Tuberculous occlusion of the rosophagus with partial cancerous infiltration. Amer. Jour, of the Med. Sci., CXIV, 1897, 44.


C. — Infection of the Intact Membrane directly (by Sputa) or from the Circulating Blood.

This class embraces those lesions which heretofore were regarded as most unusual, but which from Mazzotti's experience must rank in frequency with those described in class I. The eight cases of Mazzotti belonging to this group would seem for the most part to have been caused by the deglutition of tuberculous sputum, though the coexistence of ulcers and nodules makes it difficult in some instances to differentiate certainly the inoculation of tuberculous sputum from infection through the blood.

1. The first case reported by Mazzotti was a woman, aged 33 years, who died of pulmonary and (Esophageal tuberculosis. At autopsy the mucosa of the ossophagus, normal in its upper part, was found reddened below. The redness increased in intensity from above downward, becoming scarlet near the cardiac orifice of the stomach. On this red base were scattered numerous tuberculous ulcers. These were small and superficial in the upper segment, measuring several millimetres in diameter, becoming larger lower down, until near the cardiac orifice of the stomach several of them coalesced, forming an extensive loss of substance. The large ulcer thus produced was more irregular and deeper than the others, extending indeed to the muscular tunic.

2. The second occurred in a man, aged 40 years, who died of pulmonary phthisis. The oesophagus presented above, and in the anterior wall at its junction with the larynx, several white, rounded prominences, slightly larger than the head of a pin, with ulcerated centres. A little lower down there was an elliptical longitudinal ulcer with smooth base and slightly elevated edge, 5 cm. in circumference. Lower still, and rather near the end of the oesophagus, a yellowish nodule projected from the mucosa. This had ulcerated, and in all respects resembled the elliptical ulcer described. The mucous membrane in general was pale, but near the stomach there was some injection without ulceration.

3. The third case was a woman, aged 35 years, who had died of pulmonary tuberculosis. The (esophagus was normal in its upper part. At about the middle third the mucosa was of a greyish black color and contained several superficial ulcers with smooth margins and regular white bases. They were elliptical in the longitudinal direction. In the lower third the mucosa was pale, but here, too, were elliptical ulcers, smaller than the former, which they resembled in every other particular. The deepest of these ulcers scarcely reached the muscular coat.

4. The fourth was a man, aged 60 years, who succumbed to pulmonary and intestinal tuberculosis. The mucosa of the oesophagus in its lower half contained about 30 elliptical ulcers with smooth, regular margins and bases. They were smaller and more superficial above, but on descending the canal approached each other more closely, became larger and deeper, extending finally to the submucosa.

5. The fifth example was furnished by a male, aged 18 years, who died of pulmonary phthisis. Throughout the oesophagus were scattered numerous ulcers. They were elliptical in form, the larger ones being relatively longer than the smaller. In


232

[No. 80.


some places several ulcers were united in such a way as to present an irregular shape. In other places the ulcers were separated by little tracts of healthy mucosa, giviug the appearance of a network. They were not very deep, touching at most the submucous tissue, aud had greyish bases and smooth, regular, slightly elevated edges.

6. The sixth was a man, aged 67 years, in whom pulmonary and iutestinal tuberculosis were also found. In the oesophagus, three inches from its origin, was an ulcer of the mucosa 5 cm. in length. Near this were two small ulcers, while a little below was one of intermediate size. The remainder of the mucosa contained only smooth white elevations about the size of a piu-head. At the junction of the middle and lower third of the ojsophagus, was a diverticulum as large as the end of the little finger.

7. The seventh was a woman, aged 48 years, who presented the lesions of pulmonary and intestinal tuberculosis. In the lower two-thirds of the oesophagus the mucosa attracted attention by an intense redness which extended over a wide area. In the midst of this were twelve or fifteen ulcers of various sizes. The smaller ones were round, measuring 0.5 cm. in diameter; the larger were elongated, the diameter of the largest reaching more than 3 cm. The rest were all regular, with smooth superficial margins, except a single deeper one situated at the union of the middle and lower thirds.

8. Mazzotti's final case was a man, aged 61 years, who succumbed to pulmonary phthisis. The oesophagus in its upper part presented four or five scars several millimetres in length, with ulcerated centres, in the vicinity of which the mucosa was pale, but otherwise of normal appearance.

9. Zenker's fourth case belongs to this class. It occurred in a man 38 years old, who suffered from tuberculosis of the lungs, nose and throat, enlarged lymjDhatic glands, and stenosis of the oesophagus. At the autopsy, the oesophagus in its uppermost part presented a large superficial scar-like ulcer which included almost the entire circumference of the canal, and formed a marked constriction. At about its middle portion the oesophagus showed an elevated nodule the size of a bean, from which thiu pus escajjed. The bronchial and peri-oesophageal lymph glands were enlarged and caseous. The microscopic examination of the lesions in the cBSophagus exhibited the histological characters of tuberculosis, which was limited to the mucosa aud submucosa. Numerous tubercle bacilli were demonstratetl in the tubercles and pus.

Zenker* believes that the infection in this case was due to sputum deglutition, and brings forward the fact of the superficial character of the ulcers in support of this view.

10. Hasselmannf describes the case of a boy sis months old, in whom, in addition to tuberculosis of the oesophagus, there existed tuberculosis of the lungs and lymph glands. In the lower part of the oesophagus three crater-like ulcers were found which had no connection with either the trachea or the caseous lymph glands. The microscopic examination proved


  • Zenker: Op. cit.

t Haaselmann : Ueber Tuberculose des Oesophagus. luaug. -Dissertation, Miinchen, 1895.


them to be tuberculous in nature. The infection is believed to have taken place from the swallowed sputum.

11. The case reported by E. Friinkel* occurred in a man 33 years of age, who died of pulmonary and intestinal tuberculosis. The oesophagus contained a large number of yellowish spherical nodules about the size of a hemp seed, some with sujierficial loss of substance, others still covered with the intact mucosa. Adjacent to these were found small masses with irregular edges and uneven bases, and several small round ulcers with abrupt edges and perfectly smooth bases, averaging 3 mm. in diameter. The larynx, trachea and peritracheal lymph glands were quite intact. The microscopic examination of the lesions showed besides epithelioid and giant cells, tubercle bacilli.

Regarding the mode of infection in this case, Friinkel does not consider it possible to conclude certainly between a htematogenous origin and the inoculation of tuberculous sputum, but he inclines to the latter view.

1 3. Glocknerf describes a case which he regards as of haematogeuous origin, and which is peculiar in the limitation of the tubercles to the muscular coat of the oesophagus.

It occurred in a man, 48 years of age, in whom the autopsy showed old tuberculous areas in the apices of both lungs, tuberculosis of the pleura, peribronchial and mesenteric lymph glands, oesophagus aud viscera generally. The oesophagus at its mid-portion contained an irregular thickened zone, encircling the wall of the tube, 5 cm. in width, and from 5 to 7 mm. in thickness. On section of this thickened area it was found to consist of numerous caseous tubercles, varying in size from a piu-head to a hemp seed, irregularly infiltrating the muscular coat, to which they were strictly limited. The mucosa and submucosa were perfectly intact and freely movable over the deeper lying structures. The peri-cesophageal tissue was likewise free from diffuse infiltration, but contained several small strands with interrupted nodular swellings the size of a millet seed. These strands were interpreted by Glockuer as tubercle-infiltrated afferent vessels of lymph glands. The lymph glands in the neighborhood of the thickening, as well as those about 3 cm. above, were somewhat enlarged and caseous, but not abnormally adherent to the peri-cesophageal tissue. Microscopic examination showed the typical structure of caseous tubercles, and tubercle bacilli in great numbers were found.

Glockner regards this case as certainly of ha?matogenous origin and believes that he excludes all other modes of infection. Infection through continuity he eliminates by the absence of lesions in the continuous structures; direct inoculation of the inner surface of the mucous membrane is rendered improbable by the intact condition of both mucosa and submucosa; invasion from the peribronchial lymphatic glands, through lymph transport of tubercle bacilli, he excludes by the freedom from tuberculous infiltration of the peri-oesophageal tissue. In favor of hi^matogenous infection


  • E. Friinkel: Ueber Beltene Localisation lier TuberculoFC.

Miinch. med. Wochenschr., XLIII, ISOli, 27.

f Glockner: Ueber eine neue Form von Oesopliagns-Tuberciilose. Piag. med. Woch XXI, 1890, 114, 127, 138.




section of the esophagus showing discrete tubercles .opposed of epitheUoid a^d ^-* -Jl;^;; V" ™" node extending into the mucosa, Ha.matoxylin staining. /e,ss objeot.vc DO. e>e-p.cce No. 1.


November, 1897.]

233


is adduced not only tlie peculiar localization of tubercles in the nuiscnlar coat of the resophagus, but also the dissemination of miliary tubercles in the viscera generally.

To this last series of cases may be added the one from this laboratory. It occurred in a colored man, aged 33 years, admitted to the surgical wards of the Johns Hopkins Hospital, service of Dr. Halsted, to whom we are indebted for the clinical notes. The history, however, has but little bearing upon the lesions in the resophagus, and may therefore be briefly stated.

Clinical History. The first admission to the hosi^ital was on September 16th, 1895, for an enlarged right testicle. There was a tuberculous family history. The patient had previously suffered from typhoid fever, gonorrhoea and syphilis, and for the past four years had been short of breath. His general health, however, had been good until a few months before admission. The examination showed, besides tuberculosis of the right testicle, a slight involvement of the right lung at the apex, and a dark and mottled condition of the mucous membrane of the mouth. The right testicle was removed, the wound healed promptly, and the patient was discharged from the hospital, October 22nd, 1895.

On February 7th, 1897, he returned to the hospital suffering with tuberculosis of the left testicle and cough. He failed rapidly and died March 1st, 1897.

The autopsy was performed by Dr. Flexner four hours after death. I shall abstract the protocol and give only the anatomical diagnosis and such notes as bear upon the lesions in the cesophagus.

A natomical Diagnosis. Kemoval of testicle (for tuberculosis) eighteen months previously ; tubei'culosis of epididymis and remaining testicle, seminal vesicles and prostate gland; generalized tuberculosis; chronic tuberculosis of lungs; peculiar nodular form of tuberculosis of spleen and kidneys ; tuberculosis of adrenal glands; Addison's disease; jiigmentation of mucous membrane of mouth.

The cesophagus shows in its lower two-thirds elevated dots and larger nodules in great numbei-s. None of these are caseous, but the smaller points resemble the individual tubercles found in the spleen, liver and other glands.

The tubercles in these organs are minute granulomata, submiliary in size, of pale grayish-white color, opaque and noncaseating.

Histological Examination. The elevated dots and nodules found in the lower two-thirds of the cesophagus are seen to be enlarged lymphoid follicles, invaded by miliary tubercles which at times become conglomerated. A section of one of the larger oval nodules, measuring 1.25x1.50 mm., contains nine small, pale, Irregularly circular areas of different sizes, with more or less definite contours, arranged in horse-shoe fashion around the periphery of the nodule. These pale areas contrast sharply with the more deeply-stained normal lymphoid structure.

Under somewhat greater magnification the pale areas are seen to consist of epithelioid cells, at times distinctly separated one from the other by irregular spaces in which are found sparsely scattered lymphoid cells. A scant reticulum holds these elements loosely together. The epithelioid cells are


round or oval, with abundant protoplasm and vesicular nuclei. The nuclei are round, oval, elongated or kidney-shaped. Some of these cells contain two or more nuclei, and occasionally is seen a well-defined giant cell with a mural arrangement of its nuclei. The epithelioid clumps are surrounded by lymphoid cells, but these cannot be differentiated from the normal structure of the lymphoid nodule. At other levels the nodule shows partial coalescence of the discrete tubercles, thus giving an appearance of more diffuse infiltration.

Other nodules examined show an appearance similar to that just described ; while the smaller dots, at times of microscopic size, often contain a single cellular tubercle.

Tubercle bacilli are present in small number.

Nowhere are the tubercles found outside the lymphoid nodules, and in no instance do they extend beneath the mucosa The oesophagus is otherwise normal.

The mode of infection in this case offers no difficulties ; it is clearly of hematogenous origin, the original focus being the diseased testicle. The case forms, together with the one instance of miliary tuberculosis of Mazzotti, excluding for the time the less certain cases of E. Friinkel and Glockner, the instances of undoubted blood infection of the cesophagus.

No other instance of the localization of the tuberculous lesions in the lymphoid structures of the oesophagus has thus far been published. According to Diirck* the relative insusceptibility of the cesophagus to tuberculosis depends in part upon the slight development of its lymphatic apparatus. There is, however, no great dearth of small nodular accumulations of lymphoid cells in the snbmucosa and mucous membrane of this organ, which may after all be oftener the seat of tubercles than is generally considered. The insignificance of these structures, even when, as in this case, they are involved in a general tuberculosis, may easily lead to their being overlooked. Without the microscopical examination of many different segments in a given case, the disease could readily escape observation.

The relative immunity of the oesophagus from other forms of tuberculosis, especially from those varieties included under classes II and III, may be explained in part upon purely mechanical grounds; namely, the rapid passage of infectious material over the mucous membrane of the oesophagus, and the resistance to such infection offered by the stratified pavement epithelium.

A review of the entire subject tends, however, to modify considerably the opinion once held that tuberculosis of the oesophagus arises in a large majority of cases through continuity or contiguity of structure. Thus, of the total fortyeight cases collected, only twenty-four took origin in this way, five arose through the addition of the tuberculous process to a previous predisposing lesion, four by blood infection, while the remaining fifteen arose through the inoculation of the mucous membrane by tuberculous sputum, without the existence of a previous demonstrable legion.

The study of this subject was undertaken at the suggestion of Dr. Flexner, to wliom the writer is indebted for kind assistance in the preparation of these notes.


  • Durik: Ueber Tub('ii;ulu.se iles Oesopljagus. Ergebniste <ler

Palhologie, I, 1897.


A RARE ANOMALY OF THE ARCH OF THE AORTA, WITH AN ADDITIONAL MUSCLE IN

THE NECK.


By a. B. Herrick.


The variation herewith reported is from the cadaver of a negro dissected in the Anatomical Laboratory of the Johns Hopkins University. With the exception of the snpernume rary muscle, the variation can easily be explained by an arrest of the development of the aortic arches, showing also that in these cases the inferior laryngeal nerve is no longer held down by the fifth aortic arch and drawn into the chest.



Fig. 1. The aortic arch and its branches, showing their relations to the trachea and oesophagus, and the position of the recurrent laryngeal nerves.

00, common trunk of the two carotids ; RS, right subclavian ; LS, left subclavian; KC, right carotid ; iC, left carotid ; iJF, right vagus; LV, left vagus; RRL, right recurrent laryngeal; LRL, left recurrent laryngeal.

The number of arteries arising from the arch was normal, but their arrangement was unusual ; the two carotids arising nearest the heart by a common trunlv, then the left subclavian, and lastly the right subclavian passing behind the trachea and oesophagus. The common trunk of the two carotids is about 10 mm. in length and arises from the beginning of the transverse arch. The left carotid passes vertically upward, while the right passes transversely in front of the trachea, and at its right border turns upward to take its usual position. The left subclavian takes its origin from the highest part of the arch and follows the usual course. The right subclavian, however, arises just behind and to the right of the left, and almost immediately passes transversely behind the oesophagus to the right side of the body. It


extends beyond the cesophagns for about 8 mm., then turns upward 25 mm., and passes outward behind the scalenus anticus, reaching a point a little higher than normal, after which it continues downward in its usual course. The accompanying figure gives the origin and relation of the blood-vessels to one another. 'I'he vertebral arteries arise as usual.

The inferior laryngeal nerve on the left side arises from the vagus in the usual way, while on the right side it is not hooked around the subclavian, but passes directly from the vagus to the larynx in the neighborhood of the lower border of the cricoid cartilage.



Fig. 3. Diagram showing the mode of development of the great arteries in this anomaly. (Modilied from Quain's Anatomy.)

A U, union of aortie ; RS, right subclavian ; LS, left subclavian ; CC, common carotid; 7C, internal carotid; £'C, external carotid; P, pulmonary trunk ; V, vagus ; RL, recurrent laryngeal ; 1, 2, 8, 4, 5, aortic arches.

The origin of this anomaly is easily understood when the development of the aortic arches is taken into consideration. The scheme of the development of the aortic arches is shown in Fig. 2. As the successive bronchial arches are developed they receive within them, passing from their ventral to their dorsal side, the aortic arches. These encircle the pharynx and are collected into two descending aorta\ wliich later on unite. The isoint of union is represented in the figure at A U. Hand in hand with the development of the aortic arches, the ganglia of the nerves arise from the neural crest and at first lie lateral to the arteries. A twig from the vagus passes over to the pharynx behind the fourth branchial arch, and crosses the fifth aortic arch at right angles. The descent of the vessels into the chest throws the vagus on the ventral side of the aortic arches, and the twig to the pharynx being caught by


November, 1897.]

235


the arch, becomes elongated to form the inferior laryngeal nerve.

In the diagram that portion of the arches which is to remain to form an anomaly such as this is printed black, while the vessels which are to disappear are only outlined. Through some mishap the fourth arch on the right side degenerated, thus liberating the inferior laryngeal nerve, while the circulation with the right arm was continued through the descending aorta of that side. By the later enlargement of these vessels the origin of the right subclavian was next shifted over to the left side of the body, thus making it arise immediately below the left subclavian from the arch of the aorta.

This variation has already been described by a number of authors,* but in this specimen the presence of an additional muscle within the neck adds interest to it and may possibly be the cause of this rare anomaly.

The anomalous muscle. — This muscle was present on the right side of the neck, as a thin, narrow, ribbon-like body, five centimetres in length, and in appearance resembled the anterior belly of the omohyoid muscle, as Fig. 3 shows. It arises from the anterior tubercle of the transverse process of the fifth cervical vertebra, and is inserted by an expanded aponeurosis into the posterior border of the clavicle. This expansion greatly resembles a fibrous arch, being easily detached from the bone at its center, but is firmly adherent at each lateral margin, which corresponds with the junction of the middle with the outer and the inner thirds of the clavicle.

Henlef considers this muscle as a variation of the omohyoid, regarding those specimens where either the anterior or posterior belly of the muscle is inserted into the clavicle as a


  • Meckel, Pathologische Anatomie ; Henle, Handbuch der Anatotnie; and Quain, Commentaries on the Arteries.

\ Henle, Anatomie, III, S. 121.


transition stage between the normal, and this rarer anomaly. This muscle may take its origin from any or from all of the middle cervical vertebrae.



/"ON


a.H.t.-(A


Fig. 3. The positiou and relations of the supernumerary muscle in the neck.

AM, additional muscle ; SA, scalenus anticus ; <SJ/, sterno-mastoid ; ST, steruo-thyroid ; SH, sterno-hyoid ; AOH, anterior belly of the omohyoid ; POH, posterior belly of the omohyoid ; 7", trapezius ; V, vagus; P, phrenic; BP, brachial plexus; S, subclavian; C, carotid; AT, anterior tubercle of the fifth cervical vertebra.

If it is true that the muscles in their development shift their position so that their attachment in the adult is only secondary, then we can see in this muscle a summation of the additional attachments of the two ends of the omohyoid. In one instance the posterior belly arises altogether or by an additional slip from the clavicle; in the other instance the anterior belly is inserted, by an additional slip, to the transverse process of a cervical vertebra. In the specimen reported these two variations are blended into a new muscle, and the omohyoid remains normal.


ON THE H^MATOZOAN INFECTIONS OF BIRDS.

By W. G. MacCallum, M. D. (Johns Hopkins), Johns HojMns Hospilal, Baltimore.


In the adult examples of the Halteridium of Labbe, which occurs abundantly in crows in Ontario, Opie in 1896-7 pointed out a distinction between two forms — a hyaline, non-staining form, and a form which is granular and takes on a comparatively dark stain with methylene blue — and suggested that the hyaline form alone might become flagellated. This distinction is readily confirmed, and it is a fact that only the hyaline forms become flagellated, the granular forms being extruded, and lying quiet as spheres beside the free nuclei of the red corpuscles which lately contained them.

Motile fusiform bodies, identical with the "Vermicnlus" described by Danilewsky in his " Parasitologie comparc'e du Sang," in 1889, are seen after fifteen or twenty-five minutes to develop from these quiet spheres and wander away. By careful watching of the two adult forms on extrusion from the


corpuscle, it is seen that the flagella from the flagellated forms, tearing themselves free, constitute themselves fertilizing agents or spermatozoa, and proceeding directly to the granular sphere, wriggle about it. One only of these gains admission, and plunges itself into the sphere, which after some agitation of the pigment becomes quiet for a period of fifteen or twentyfive minutes, after which it puts out a conical process, which grows and draws the protoplasm into itself, until we finally have the fusiform body with a small pigmented appendage and refractive, nucleus-like body such as was described by Danilewsky as a " Vermiculus." The origin of the vermicnlus is in every case exactly the same.

In other words, we have a sexual process with a resulting motile form, occurring under unfavorable circumstances, and comparable with analogous processes observed in the lower plants and animals.


236

[No. 80.


It is thought that a simihir process may be expected in the case of the human malaria.

The vermiculus moves actively and has great powers of penetration by means of its pointed anterior end, with which it breaks up the red corpuscles in its jiath, and it is thought that possibly it may penetrate the intestinal wall and escape as the resistant form which gains the external world. This idea is supported by the finding of free organisms in the mucous contents of the intestine.

In the organs, the connective tissue skeleton is one great storehouse of pigment, the branching cells being often loaded with foreign material. The endothelial cells are also yery generally jjigmented, and there occur in some of the organs, as well as in their blood-vessels, large makrophuges loaded with pigment and other debris. Many large jjhagocytic cells occur in various organs which engulf whole corpuscles with their contained organisms.

The organs fouud jngmented are, in the order of intensity of pigmentation, the spleen, liver, bone-marrow, intestine, kidney, adrenals and thyroid. The leucocytes take but little part in phagocytosis in the organs, although phagocytosis goes on actively in a slide of blood.

During the last week I have examined the blood of a woman suffering from an infection with the oestivo-autumiuil type of organism, in which a great number of crescents were to be seen. These in a freshly made slide of blood, with very few exceptions, retained their crescentic shape for only a few minutes. They soon drew themselves up, thus straightening


out the curve of the crescent while shortening themselves into the well-known ovoid form. After the lapse of 10 to 12 minutes most of them were quite round and extra-corpuscular, the " bib " lying beside them as a delicate circle or " shadow " of the red corpuscle.

After 20 to 25 minutes certain ones of these spherical forms became flagellated ; others, and especially those in which the pigment formed a definite ring and was not diffused throughout the organism, remained quiet and did not become flagellated. In a field where an example of each form could be watched, the flagella broke from the flagellated form and struggled about among the corpuscles, finally approaching the quiet spherical form ; one of them entered, agitating the pigment greatly, sometimes spinning the ring about. The rest were refused admission, but swarmed about, beating their heads against the wall of the organism. This occurred after .35 to 45 minutes.

After the entrance of the flagellum the organism again became quiet and rather swollen, but although in the two instances in which this process was traced the fertilized form was watched for a long time, no form analogous to the "vermiculus " was seen.

This is evidently foi' the human being what was foreshadowed by the organisms of the bird.

(In part an abstract of a paper read before the British Association for the Advancement of Science, August 24, 1897, and shortly to appeal', in extenso, in the Journal of Experimental Medicine.)


A CASE OF CAVERNODS ANGIOMA (VASCULAR NilVUS) OF THE TUNICA CONJUNCTIVA.


By Dr. H. 0. Reik.


James Minor, colored, aged 16 years, came to the Baltimore Eye, Ear and Throat Hospital, March 1st, 1897, for treatment of a growth on his left eye. His mother states that very shortly after birth a small, red, raised spot, probably twice as large as a pin-head, was noticed on his left eye. This statement is confirmed by the midwife ; there was no physician in attendance. For some time no change was noticed in the eye, but by the end of his first year the spot had increased some in size, and for the next five years continued to grow steadily, though not rapidly. It never seemed to give any pain nor did the tissue immediately surrounding it become inflamed at any time, so it was not considered necessary to consult a physician. The growth assumed its present size by the time he was six years old, and since then, his mother thinks, it has undergone little or no change. He consulted me simply because he desired, if possible, to have his appearance improved.

The tumor was quite noticeable even at some distance, but on close inspection, with the eye turned outward so that the cornea almost reached the outer canthus, an appearance like that seen in the accomjianying reproduction was obtained. (Fig. 1.) To the nasal side and about 3 millimetres removed from cornea was a dark purplish-red tumor about 15 mm. long, 3 to 5 mm. wide and 5 mm. in thickness, narrowed somewhat toward its upper extremity, which was rounded, and extending


below under the lid into the conjunctiva fornicis inferioris. Its anterior surface was convex, smooth and shiny, covered by conjunctiva, and two narrow, light bands of connective tissue ap23ear to pass almost horizontally across the tumor, thus producing a slightly lobulated appearance. Its posterior surface was slightly concave and rested in its entire length upon the lidbus ociili. The tumor was situated entirely in the lunica conjunctivcB bulbi, and one or two good-sized vessels passed from it below into the conjunctiva fornicis after pursuing a somewhat tortuous course. By pressure the tumor could be moved very slightly from side to side, but suflBciently to indicate that it was not adherent to the sclera. The plica semilunaris conjunctivcB was hypertrophied, slightly congested, and, when the eye was rotated inward, presented several delicate folds.

An incision was made in the conjunctiva near the outer edge of the growth, blunt-pointed scissors were then passed beneath the tumor and it was easily lifted off its bed. No hemorrhage was encountered until the base was cut well down in the conjunctiva fornicis, and even then the bleeding was slight.

I saw the patient last on March 28th. The wound was perfectly healed and the eye looked normal, save that the vessels mentioned before as connected with the tumor were still present, though greatly reduced in size.



Anterior portinn of Cross-Section.


NOVEMBEE, 1897.]

237


The specimen was hardeued in formalin and embedded iu celloiden. .Sections were cut in different directions through the growth and stained in hsematoxylin and eosin, picro-carmine, methylene-blne and lithium-carmine.

Under the low power the tissue seemed to be composed of a loose connective tissue with many small areolar spaces and to contain very numerous blood-vessels. These vessels run in every direction, and within a small radius one sees various sections of them, taken in their long axis, obliquely or crosswise. In addition, in the most vascular parts of the tumor, large blood spaces are to be made out with tolerably thin walls of connective tissue, walls which in places appear to be lined by endothelium, though this is not easily made out everywhere. These cavernous spaces show thin connective tissue bands running across them, lined by endothelium, and one can think of there being partial or complete partitions separating adjacent thin-walled sinuses.

By the higher power the connective tissue is seen to consist mainly of the white iibrous variety, loosely constructed and not very rich in connective tissue corpuscles. The anterior surface of the periphery of the growth is covered by conjunctival ej^ithelium, below which is a narrow band-like area of round cell infiltration. The endothelial cells lining the numerous small vessels are easily distinguished and the lumina of the vessels are filled with blood. The relative proportions of the different varieties of leucocytes, so far as could be judged, were not abnormal. (Fig. 2.) The tumor is then, histologically, a cavernous angioma, or it may be called if preferred, a vascular nfevus.

A careful search of literature for any similar cases which might have been reported has served to show us how very rare they are. As the distinction between angioma and vascular nsBvus is not a very clear one, depending apparently upon the question as to whether the tumor is actively growing or is remaining stationary, it occurred to me that various writers might have made different classification, so I looked not only for reports of angioma, but of vascular nasvi and telangiectasia as well. I could not believe that these growths were so extremely rare as this search would make it appear. So far as I am aware only one case has heretofore been reported in this country, that of Lippincott, and I have been able to find only two others in the English language, both by Dr. Simeon Snell, of London. One of Snell's reports is accompanied by a colored plate, and the shape, size and position of the tumor give it a strong resemblance to my own. No microscopical examination of either of his cases is mentioned. Lippincott's* specimen was examined by Prof. Whitney, of Harvard, and is described as a cavernous angioma. Rampoldi and Stefanini,f Armaignac,J Dubois, § Talko,|| Van Amnion and BlessigT[ have each described or mentioned one or two cases. Bossalino and


•Trs. Am. Oph. Soc, vol. 7, p. 372.

fAnn. di Ottal., Pavia, 1884, vol. XIII, p. 75.

t Rev. Clin. d'Ocul., Paris, 18S6, vol. VI, p. 73.

SAnal. d'Ocul., Brux., 18.55, vol. XXXIV, p. 267.

1 Klin. Monats. f. Augenh., Erlangen, 1873, vol. XI, p. 335.

IGrsefe and Saemisch Handbuch, vol. IV.


Hallaner,* Reichfand KroschinskiJ have each reported a single case accompanied by histological reports, and their findings are essentially similar to those described in the present case.

Fuchs in his treatise on diseases of the eye says "Angiomata of the conjunctiva are of rare occurrence. They are as a rule congenital and increase iu size after birth."

Noyes says that "Angioma of the conjunctiva sometimes occurs. Its most frequent seat is the caruncle." Neither of these authors mentions na^vi of the tunica conjiiitctiim hilhi.

"Angioma of the conjunctiva," says Saemisch, "either spread there from a palpebral tumor or develop pi'imarily in that membrane. They are mostly congenital and occur as a rule in the neighborhood of the inner commissure, or, exactly, on the plica semi-hmaris conjunctivce." He advises their removal, "because after remaining unchanged for some years, they gradually increase in circumference, and through narrowing of the conjunctival sac, and later by jjrojection from the palpebral fissure, become quite troublesome."

These tumors developing primarily in the conjunctiva, according to Virchow, "are very rare and seldom progress beyond the nfevus stage, although an occasional observation of more extensive growth is known."


BOOKS RECEIVED.


Exercises in Practical Physiology. By Augustus D. Waller, M.D., F. R. S. Part III. Physiology of the Nervous System, ElectroPhysiology. 1897. 8vo, 91 pages. Longmans, Green & Co., London.

Transactions of the Association of American Physicians. Twel f th Session, held at Washington, D. C, May 4, 5 and 6, 1897. Vol. XII. 1897. 8vo, 510 pages. Printed for the Association, Philadelphia.

The Diseases of Women. A Handbook for Students and Practitioners. By J. Bland Sutton, F. R. C. S. Eng., and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. Edin. 1897. 8vo, 436 pages. W. B. Saunders, Philadelphia.

A Text-book of Diseases of Women. By Charles B. Penrose, M. D., Ph. D. 1897. Svo, 529 pages. W. B. Saunders, Philadelphia.

Tuberculosis of the Oenito- Urinary Organs, Male and Female. By N. Senn, M. D., Ph. D., LL. D. 1897. Svo, 317 pages. W. B. Saunders, Philadelphia.

Transactions of the American Gynecological Society. Vol. XXII. 1897. Svo, 321 pages. Wm. J. Dornan, Printer, 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. In twenty volumes. Volume XII: Mental Diseases, Childhood, and Old Age. Svo. 1897. 849 pages. W. Wood & Co., New York.

Lectures on th^ Malarial Fevers. By William Sydney Thayer, M. D. 1897. Svo. 326 pages. D. Appleton & Co., New York.

Fifteenth Annual Report of the Provincial Board of Health of Ontario, being for the Year 1896. Svo. 165-|-cliii pages. 1897. Printed by order of the Legislative Assembly of Ontario, Toronto.

Incompatibilities in Prescriptions. By Edsel A. Rnddiman, Ph.M., M. D. First Edition. 1897. Svo. 264 pages, .lohn Wiley & Sons, New York.


♦Archiv f. Ophthalmologie, Leipz., 1895, vol. XLI, p. 186. •f CentralUl. f. prakt. Aiigenheilk , Leij)/,., 1877, vol. I, p. 176. JBeitriige zur Augenheilkunde, June, 1894.



THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel C. Oilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.

William Osler, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice

of Medicine. Henry M. Hurd, M. D., LL. D., Professor of Psychiatry. William S. IL\lsted, M. D., Professor of Surgery. Howard A. Kelly, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.

William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. Robert Fletcher, M. D., M. R. C. S., Lecturer on Forensic Medicine. William D. Uooker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. Thomas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flexner, M. D., Associate Professor of Pathology. J. Whitridoe Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy. William S, Thayer, M. D., Associate Professor of Medicine. John M. T. Finney, M. D., Associate Professor of Surgery.


George P. Dreyer, Ph. D., Associate in Physiology.

William W. Russell, M. D., Associate in Gynecology.

Henry J. Berkley, M. D., Associate in Neuro-Pathology.

J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. Bloodgood, M, D., Associate in Surgery.

Thomas S. Cullen, M. B., Associate in Gynecology.

Ross G. Harrison, Ph. D., Associate in Anatomy.

Frank R. Smifh, M. D,, Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jones, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology.

Louis E. Livingood, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D., Instructor in &Iedicine.

Charles R. Bardeen, M. D., Assistant in Anatomy.

Stewart Paton, M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology.

Harvey W. Cushing, M. D., Assistant in Surgery.

J. M. Lazear, M. D., Assistant in Clinical Microscopy.

J, L. Walz, Ph. G., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

Men and women are admitted upon the same terms.

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

REQUIREMENTS FOR ADMISSION.

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

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

2. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

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

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

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

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

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

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

ADMISSION TO ADVANCED STANDING. Applicants for admission to advanced standing must furnish evidence (1) that the foregoing terms of admission as regards preliminary training have been (ulQlled, (2) that courses equivalent in kind and amount to tliose given here, preceding that year of the course for atimission to which application ia made, have been satisfactorily completed, and [3| must pass examinations at the beginning of the session in October in all the subjects that have been already pursued by the class to which admission is sought. Certificates of standing elsewhere cannot be accepted in place of these examinations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance upon these courses has steadily inci'eased with each succeeding year and indicates gratifying appreciation of the special advantages here afforded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine are now given annually during the mouths of May and June. During April there is a preliminary course in Normal Histology. These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here ottered. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application.

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIAIORE.


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


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No, 81.]


BALTIMORE. DECEMBER, 1897.




COlsTTEaSTTS.


PAGE.

King Arthur's Medicine. By Geokgb M. Gould, M. D., and Walter L. Pyle, M.D., 239

The Presence in the Blood of Free Granules derived from Leucocytes, and their Possible Relations to Immunity. By Wm. Royal Stokes, M. D., and Arthur Wegeparth, M. D., - - 246

On the Anatomical Relations of the Nuclei of Reception of the Cochlear and Vestibular Nerves. By Florence R. Sabin, - 253

Typhoid Infection without Intestinal Lesions. By Simon FlexNKR, M. D., and Norman McL. Harris, M. B., ... 259


Apparatus for Sterilizing Instruments with Formaldehyde ; Experimental Tests. By II. 0. Reik, M.D., and W. T. Watson, M. D., --------- Proceedings of Societies :

Hospital Medical Society,

Exhibition of Specimens. — Fibroid Lung-Bronchiectasis — Brain Abscess [Dr. Livingood]. Notes on New Books, -------- Books Received, --..

Index to Vol. VIII,


KING ARTHUR'S MEDICINE.*

By George M. Gould, M. D., and Walter L. Pyle, M. D., Philadelphia.


" The Kynge Arthur toke the Kynge Ban, and the Kynge Bohors, and Merlin, and saide, ' Lete us go se oure felowes tliat be seke.' "

We Englisli folk are most fortunate iu that we have a literature of our racial adolescence which, certainly not excepting that of the Greeks, is infinitely richer and truer than any other, and pictures a people of far greater purity and power, beauty and bravery, loyalty and love. Although not "meek "we are still fated to "inherit the earth," and that inheritance has been gained because the man had a youth such as the Arthurian legends picture. The child is proverbially the father to the man, and peace and justice are to-day the enjoyment of the Indian, of the Egyptian, and of the commoners of England themselves, because Arthur's knights aud ladies were Avhat they were. To these legends we must progressively direct our attention as the purest materials of our future poetry aud inspiration. As now^here else, we here find a sincerity, an honor, an unbiased and uncolored revelation of the noble human heart not as yet spoiled by sin or selfconsciousness. And now— as Gleunie has pointed out — that science has come to us with its all-absorbing, all-transforming interest, revolutionizing most all methods and data of thought, these primitive records of our English and Cymric Paradise must become still more priceless aud precious ; for science has


  • Read by Dr. Gould before the Historical Club, Nov. 8, 1897.


not explained, and never can explain, life and character, and back to the time when life and character was (or was recorded to be) the sweetest and noblest ever conceived by the fancy of man we must ever go to find the comfort and inspiriting we so sadly need in ages of meanness, doubt, and selfishness. Of this early age and of its records Tennyson says that they

are —

"Touched by the adulterous finger of a time That hovered between war and wantonness, And crownings and dethronings."

To which our answer must be — Contemptible cant! With all our "progress " and self-conceit we cannot claim that we have lessened the adultery and the wantonness. War and crownings and dethronings have not been unlearued, but where are the courage, the banter, irony and humor, the give-all-to-love, the loyalty, the inerrant sense of and obedience to right, that made these men and women greater than all their joys and sorrows? Had we but also inherited the " honor rooted in dishonor " ! With relief we turn from the emasculate " Idylls " to the innocent sins, the personal warmth, the splendid vices, the thrilling pathos of these our ancestors for better poetry and more untarnished ideals than the effeminate and selfconscious echoes of later-day rhymesters. Better adultery with bravery and honor unto death, than adultery without these things


Study of these legends must therefore remain the pleasure and duty of those who love our race-spirit, and any new aspect of truth that may be gleaned from them must be rated as not without value even if it help but a little toward a final true comprehension. It is indeed difficult to keep the mind down to its task in attempting a distinctly medical gleaning. So many alluring glimpses, such paramount witchery, such dominant healthfulness is everywhere so manifest, the soul is so present and lordly, the body so forgotten, or so gloriously proud to serve in silence, that morbidity and therapeusis are kept from emerging out of the subliminal "Unbewusst." And our difficulty is doubled by the fact that it was so with them, and consequently they chronicled but a few hints, hid only a stray pebble or two which the medical mind may pick out beneath the gorgeous heap of flashing precious stones showered in our lap.

Although the specifically medical and physiologic findings are thus comparatively few and unimportant, their gathering and lessons are not unimportant; even for the corroborative testimony they bear to general mental and emotional characteristics, they would be worth the collecting and systematization. These beings really had bodies as well as loves, consciences, desires, and wills, and they are brought closer to us, our vision of them made all the clearer, and our love the warmer, by a recognition of their corporeal wants, woes, and wounds. But in the comparison of their medical science, or unscience, with that of later days, the physician finds at least historic lessons of professional interest well worth his labor, if indeed he were not more than compensated in other ways.

We must add another prefatory word, because it is, it seems to us, too little considered by our critics. We allude to the great difficulty — in the present state of criticism and research doubtless an impossibility — of distinguishing between the true records of premedieval life and the later additions. Malory, we know, made free use, but also free additions and changes as regards his texts. He was not the best editor in the world. But how much those who compiled the records he used changed and colored the earlier story, how far they truly represent to us the original documents — these things of course must at present make our deductions matters of some doubt. Perhaps it was five hundred years after Round-Table times that those wrote who served Malory with documents, and Malory himself was a thousand years removed. Where are the records of " Blayse the Mayster of Merlin that he did do wryte " ? But where are the snows of yester-year ? Internal evidence, however, tells us much, and, in reading, the alert sympathy is constantly aroused by the feeling that this or that is surely not the voice of frank Cymric childhood, but is the sorry tarnishings of the Latin-French media, the corruption of a self-conscious "civilization," or of a mind far removed from pristine juvenility and resilient buoyancy. Some time we shall perhaps know just how much each later age has added to and changed the primitive revelation — every such a debasing, certainly— and then we shall have a body of pure and luminous texts for our infinite reheartening and delight.

Despite Tennyson, neither war nor wantonness was the essential spirit, the inner Trieb of this age. Its dominant characteristic, the source of both the war and the wantonness (thb latter a belieing and a belittling word), was the abounding sense of exuberant life, the fulness and immediacy of health that filled the actors and made of the women eternal models of das ewig weihUche, and so spurred the men that they were forced to find outlets for their inexhaustible physical energy in jousting, adventures, and feats of strength and endurance beyond our knowledge and belief. We are not mindless of the exaggeration of the hero-singer and the mythology-maker, but after all allowances have been made that a sceptical science may demand, the central fact remains that, physiologically speaking, these men were marvels of energy and endurance. Every page of Merlin and of Le Morte dariJnir bears witness of the fact. What modern athlete could don the helmet and coat of mail these men wore, much less carry them, nay, fight with them on and wield the huge glayves they used so effectually? The weight of the helmets is attested by the blows they resisted ; the strength of the arms that handled the swords is proved by the fact that the blows frequently clave through helmet and skull to the teeth. When one thinks of men in hot August days covered with these ponderous steel casings, head and face solidly bound with iron, and fighting all day long with the fiercest activity, one can only stand aghast at such wonders of bodily organization. It is perhaps useless to ask if the human arms are capable of certain feats that are frequently reported, as the cleaving at one sti'oke of a body through, or to the navel, the cutting off at one blow of a head and with such force that it rolls into the field.

Skill and strength for their own sake, the aim of modern " athletics," seem unknown. There are no evidences of useless games and braggart power, leading to nothing. Muscle jyer se is not the su7nmum honum. The everlasting jousting ajjpears the only game, but this was almost too serious to satisfy any purely "sporting" instinct, and it was of course in every case the actual and necessary exercise preparatory to dealing in life and death in the great business of the morrow. And even in this business of death one sees that simple physical power is, however necessary, only a secondary thing. It is the courtesy and honor, the moral energy and power of will and emotion behind the man's muscles that give the victory and that make him the beloved and revered.

Giants there are (some ridiculously large, by the help of Continental imaginations we suspect), but they are as hideous and detestable as the modern children's books could suggest. Giants and those only pihysically sti'ong are cowards and are always defeated by those whose strength is pre-eminently of the soul.

In this connection it might be noted that drunkenness and gluttony are not even suspected. There is here no all-day or all-night sitting at meat or drinking out of skulls till intoxication stops further drinking. There is "feasting," but with ladies always present, always in moderation, always with witty or serious converse, always as a preparation for something better. Moreover, the manner of its doing is always iu view rather than the matter — after bathing, e. g., and the putting on of clean clothes.

It was a superstition that a man's physical strength some


December, 1897.]

241


times varied according to the time of day or the intensity of the sun's rays. It is said that "Syr Gauwayn had siiche a grace and gyfte that an holy man had gyuen to him, that euery day in the yere from uuderue tyl hyhe none hys myght eucreaced tho thre houres as moche as thryse hys strengthe, and tliat caused Syr Gauwayn to wyune grete honour."* Another reference to this curious belief is in that narrative of Sir Beaumayn, who is warned not to challenge the Knyght of the reed laund until afternoon, as all the forenoon his strength increased and at high noon be had the strength of seven men.

The surgical interest in the results of encounters is that most frequently excited. In the competitive jousts the object was to overcome by superior strength, skill and horsemanship. In them the mortality did not probably exceed that of a modern game of football or cross-country riding. To intentionally maim or kill was the greatest shame of which a knight could be guilty. Sir Launcelot is said to have nnhorsed five hundred knights, winning the victory over them all, and yet none is killed.

Even though severely wounded the spirit is not conquered ; with a spear-head in his side Sir Launcelot fights all day, overcoming more than thirty knights. And he recovers in a few days. In the conflict between Balan and Balin they "hadde eyther symtem other seuen grete woundes so that the lest of them myght have ben the dethe of the myghtyest gyaunt in the world." Sir Percyval and a knight inflict upon each other fifteen wounds, and they " bledde soo moche that it was merueyl that they stoode on their feet." Alysander " had no foote ne myght to staude upon the ertbe, for he had syxtene grete wounds and in especyl one of them was lyke to be his dethe." Exhaustion from profuse hemorrhage with the signs of extreme collapse is a frequent ending of a genuine combat. In such accounts the romancer's imagination is doubtless frequently evident, but in all the stories are descriptions too peculiar and detailed not to be the result of direct observation.

We find that it was quite possible to kill a man with a single blow. It is related that Marhaus kills a knight "stark dede " at a single encounter. The most common injuries were about the chest or side, as these were the points at which the spears were most directed. After an opponent is unhorsed a hand-to-hand combat on foot usually ensued, in which the principals hacked and struck at one another with swords ; and it is in these latter battles that the most serious wounds were inflicted.

Cerebral concussion is, of course, frequent. The modern lay description of " seeing stars " has its analogue in several passages. It is even said that a maiden gives Alysander such a buffet " that he thought the fyre flewe oute of his eyen." In one of his combats Sir Launcelot is struck on the helm so hard that " fyre sprange out of his eyen." Cerebral concussion followed by death, possibly by contrecoup, is evident in the account that Sir Gawayne smote his (helmeted) opponent so hard that " it went to the braynes and the Knyght felle downe dede."


  • To save space we omit the references. They are from Sommer's

edition of Malory, the Merlin of the Early English Text Society, and the various French works obtainable, from which Malory drew his stories.



The common sign of basal fracture — hemorrhage froiji the nose, mouth and ears — occurs several times. How graphic is the account of Sir Launcelot's smiting of Sir Galahantyne on the helmet so " that his nose braste oute on blood and eeyrs and mouthe bothe, and ther with his hede hange lowe." He strikes another opponent so hard that the stroke "troubled his braynes, the blood brastynge oute of his mouthe, the nose, and the eres," and the knight falling to the earth as if dead. Syr Gareth and Sir Gaherys are also smitten " upon the brayne pannes " and killed. Arthur gives Sir Accolon such a buffet that " blood came oute at his eres, his nose and his mouthe." We read later that Accolon lived four days, and his ultimate death is attributed to the loss of blood, in ignorance of the fatal fracture. These symptoms, however, are not always precursors of fatality, for Sir Blamore has such a fall " that the blood braste oute at nose, mouth and his eres, but at the laste he recouerd well by good surgyens."

A noteworthy case of foreign body in the brain is that of Sir Marhaus, who was struck such a " myghty stroke" by Sir Trystram " that hit went thorou his helme and thorou the cayse of stele and thorou the brayn pan, and the swerd stak soo fast in the helme and in his brayn pan that Sir Trystram pulled thryes at his swerd or ever he myght pulle it out from his hede." " The edge " of the sword was left in " the brayne pan," and Marhaus ran groaning away. The foreign body could not be extracted by the surgeons, and at last caused the death of Marhaus. His sister, la beale Isoud, got the bit of sword, and by it her lover Tristram was identified as the one who had killed her brother — a great story well known and sung by later poets.

So mighty were the blows delivered on the head that we read of King Pellenore giving his opponent such a stroke on the helm " that he clafe the hede douue to the chynne that he fylle to the earthe dede"; and once more this mighty swordsman " clafe another hede unto the pappys " (breasts). A similar blow is delivered by Sir Launcelot, who " clafe his opponent's hede and neck unto the throte." Again it is said that Pellenore strikes King Lot " thorow the helme and hede unto the browes."

An occasional result of combat was a broken neck. Sir Florence rode against Sir Feraunt of Spain and " smote hym in the forhede and brake his uecke bone." Syr Gryffet ran unto a king, the fourth of his opponents, "and gaf hym suche a fall that his neck brake." Launcelot smites a porter under the ear with his gauntlet and breaks his neck. A mighty blow was that of Marhaus who smote his opponent so hard that " he brake his neck and the hors back."

An example of an injury to the neck, and a splendid sample of English irony is, "And Segramor lete renne to a Knight that com shovinge after hym, and he smote hym thourgh the throte that he fill deed up-right ; and thein he seide, ' Sir Knyght, with soche morsels I can yow fede and myn other enymes. Now be stille ther and a-bide hem that come after, and telle hem that this way gon the messagiers of the Kynge Arthur, that is theire rightfull lorde.'"


242

[No. 81.


Protected by the visor the face is rarely injured. We note once that the teeth were " stryken in tweyne."

For a similar reason thoracic wounds are usually non-penetrating. However, Sir Kehydius is wounded "on hyghe above the pappys" [bi-easts], and Gawayn gives an opponent such a blow that one " niyghte see bothe lyver and long," and again he smote a Saracen and " slitte hym down right so that men myght se his longes." Syr Tor smites his opponent through the " coost [rib or side] but the stroke slew hym not." The ribs of Arthur and of others are broken by the crushing embrace of another's arms. The single reference to cardiac injury we have noted is that whereby King Mark strikes his brother to the heart with a dagger. The wound was immediately fatal.

A remarkable abdominal and pelvic injury from a single blow is that whereby Arthur in a duel with agiant"hytte hym ageyn that he carf his bely and cutte of his genytours [genitals] that his guttes and his entraylles fylle doune to the ground." Sir Launcelot smites another giant " on the shoulder, and clafe hym to the navel."

Examples of transfixion from a single blow are found. Arthur smites Gryflet and " brake the spere that the troncheon stack in his body." A knight is " smote thorou shelde and thurgh the body." Launcelot smites a knight " thorugh the brest and thorou oute the back more than an ell." Probably the most interesting of this class of injuries is recorded in the description of the last combat in which Arthur smites Mordred "under the shelde wyth a foyne of his spere thoroughoute the body more than a fadoni." And yet thus transfixed, and with this wound, Mordred is able to push himself onward up to the hand-guard of the spear so as to reach his father, and before dying deals him bis death-blow, his sword cutting through the helmet to the brain — a ghastly and powerful deed!

It was a common belief that if a weapon entered the trunk, either very deeply or in a vital part, it should not be immediately withdrawn for fear of instant death. Bors pulls out a spear from his opponent's side and the man swoons. As Gawayne draws out a truncheon from Vwayne's side his soul departed from the body. Lauayne says to a wounded knight, " and I pulle oute the truncheon ye shall be in perylle of dethe." Later, Lauayne pulls the truncheon from the wounded man's side and the resultant symptoms are thus graphically described : " He gaf a grete shryche and a merueillous grysely grone, and the blood braste oute nyghe a pint at ones that at the last he sanke doun upon his buttoks an so swouued pale and dedely." That this was not the invariable result is shown by the fact that Sir Melyas drew out of his own body a truncheon, and swooned, but recovered in seven weeks by the aid of the ancient monk who had previously been a knight.

Vertebral fractures are occasionally mentioned and invariably spoken of as broken back. Sir Tristram smites an opponent's " back in sender." Sir Launcelot breaks liis opponent's back, and in another combat he broke the backs of four knights.

A curious wound of the buttocks is reported as happening to Launcelot, who by misfortune was shot accidentally by a


lady " in the thyck of the buttok over the barbys." It is further related that"thenne with grete payne the heremyte got ovte the arowes hede oute of Syr launcelots buttok, and mocheof his blood he shedde," "and the wound was passynge sore, and unhappyly smyten, for it was in suche a place that he myght not sytte in noo sadyl."

Of the injuries to the thigh we read that on one occasion Sir Tristram showed an arrow-wound of the thigh six inches deep. Launcelot is wounded by a boar that " rafe hym on the brawne of the thygh up to the houghbone " [hip-bone]. Sir Vwayne smites Edward so hard that " his swerd kerved [cut, carved] unto his canel-bone" [tibia]. In remorse, Sir Percyual " rofe hym self thurgh the thygh." Another reference to possible self-mutilation is found in the passage which says that Alysander, when told of the amorous intentions of Morgan le Fay towards him, replies that " I had leuer cutte away my hangers [testicles] than I wold do her suche pleasyr." Happily he was spared the necessity.

Amputations at a single stroke are frequently reported. A knight has an arm stricken away in combat ; Galahad smites off the left arm of an opponent ; Marhaus smote off a giant's " ryght arme above the elbowe "; Arthur peremptorily disposes of another giant named Galapas, "he shorted hym and smote of both his legges by the knees "; making the combat more equal as regards discrepancy in size of the participants.

Dislocations are spoken of in the following passages : King Pellenore's lady's horse stumbles and her arm is put " oute of lythe" [out of joint], and she almost swoons from pain; Launcelot bears down an opponent " soo that his shoulder wente out of lyth."

Fractures were not uncommon results of combats. Syr Dynas smites an opponent " that with the fall he brake his legge and his arm "; Sir Launcelot smites downe the Kynge of Northgalys who " brake his tliye in the falle "; another time Launcelot turns on a reviling mob "aud of some he brake the legges and the amies."

It is plain that the frequency of wounds and accidents made necessary those who should play the part of surgeons. It is, we think, almost equally sure that there was no official and separate profession. There is no record in the characteristic texts of any who made exclusive practice of surgery or medicine. In the Mahinogion, a book of Unarthurian and ajjochryphal character, it is recorded that Arthur " caused Morgan Tut to be called to him. He was the chief physician." It is supposed that this person was probably the same as that Morgan the Wise who prepared the ointment which restored Owain (Gawayne) to a state of health and sanity, in the romance of Ywaine and Gawin.*

In La Mort nu Roi Artus, the " maistre chirurgian" is several times spoken of who attends Launcelot, but later it is said that Boors sends the knight who healed Launcelot to the king, etc. Allusion to "the harbours of Bretayne" is, of


  • His reputation appears to have extemieil to Brittany, where the

inhabitants still call by the name of Morgan Tut an herh to which they ascribe the most universal healing properties. The name Morgan has been given to the Anthemis cotula, Linn, (rauuuuile) and Maruta cotula (dog-fennel).


December, 1897.]

243


course, not Arthurian. There is no mention of a court physician in Le Morte darfhur, or Merlin. It is quite likely that had there been one, some mention of the fact would have been made, and the people would have deserted the hermits for this official physician, as it is said in Le Mort darthur, in speaking of the speedy popularity of Modred, " the people were soo newe fangle."

We have much evidence as to the disposition of the wounded. The sick and wounded were frequently sent to the monasteries and nunneries. Malory says that the hermits of those days were not like those of his time, but "held grete householde, and refresshyed people that were in distresse." It is a hermit who heals Sir Launcelot after one of his many accidents. After combat with Pellinore, Arthur "departed and wente untyl an ermyte that was a good man and grete leche "; Sir Palamydes goes to a nunnery to be cured. At the "lytel pryory " of Marhaus " laydes and damosels looked to their hurtes." In fact, not only the female inmates of religious asylums were skilled in dressing wounds, but many of the noble-women were experts in this art. Mayden Lynet comes to Sir Beaumayns and "serched his wounds, and stynted his blood." This damoiselle also stanches Sir Gareth's and Sir Gawayn's wounds. Tristram's wounds are "serched" by la beale Isoud, who was a " noble surgeon." She found in the bottom of this wound " poysou and heled him." It is said that after his fight with Marhaus, Tristram is searched by "alle manere of leches and surgeons both unto men and wymmen." Here there may possibly be indicated some distinction between a leche and a surgeon, such as arose later. The knights themselves were often skilled in surgery. Sir Baudewyn of Bretayn is called a"ful noble surgeon and a good leche." King Arthur attends on Syr Gawayn and " dyd so ransake his woundes and comforted hym." " Sir Mador was had to leche craft, and Sir Launcelot was helyd of his wound."

It is related of Sir Fercyual that he " stopped his bledyng wounde with a pyce of sherte" — an excellent bit of emergency-surgery.

Of the limitations of the power of the leeches we have ample proof. " Sir Gawayn laye seek thre wekes in his tentes with al maner of leche crafte that myght be had." Even malpractice was recognized, for, according to Tristram, Sir Marhaus "dyed through fals leches."

From these quotations it is made certain that what represented the practice of medicine was carried on by women and men without any official status or special training other than that picked up by aptitude, circumstances, and experience. The application of the terms surgeon and leche to women is indicative of the same fact and of the primitive simplicity of all the arrangements. There is little record of much more extended or varied treatment of the wounded than that of ransaklng and serchivg the wounds, stopping the flow of blood, applying salves, etc. The broken, dislocated, or amputated limbs and the thousand surgical diseases we know were left to the care of the vis medicatrix nnturm. The business of life was to give the enemy the wounds. Vae Vidis! These heroic children of our race stood before disease much as does a child of to-day, without discrimination, diagnosis, or sug


gestion of treatment. All diseases to them were alike mysterious. Where our nosologies register thousands, theirs saw but one — " sekenesse."

The pulse was a factor in diagnosis. Launcelot was found lying by a chamber door, and " they looked upon hym and felte his pouse to wyte whether there were any lyf iu hym." Malory shows knowledge of the blood-vessels iu narrating that Gawayn received a blow that caused a "grete wound and kytte a vayne, and he bledde sore." Sir Gareth is given a wound " a shaf tmon brode, and had cutte atwo many vaynes and senewes." Recent wounds were called " grene wounds." Trystram was so stirred by his desire for his fair bedfellow that "in his ragyne he took no kepe of his grene wound" and breaks it open. Disastrous results are attributed to the breaking open of wounds. Launcelot suffers this accident by getting on a horse too soon after convalescence. Gauwayn is stricken by Launcelot, and an old wound is broken open by the blow, which ultimately causes his death.

Just as infection of wounds is called by the laity of to-day " taking cold," so we read that Arthur tells Syr Bedwere he has taken cold and will soon die. After being sore wounded by Marhaus, Tristram "ful sore bled that he myght not within a lytel while when he had take cold unuethe stere hym of his lymmes" — a fact that may refer to inability to walk due to rheumatism contracted from exposure.

All wounds are treated by salves and ointments. Gawayn is healed of a wound by salve, and after the battle between Launcelot and Arthur, " to the wounded men they leid softe salues." Sir Gauwayn was borne " in to Kyng Arthur's pauyllon, and leches were brought to him and serched and salued with softe oynementes." After a battle " they putte salf unto the wounded men." It is evident when infection was expected, as after animal bites, which of course were supposed to be venomous, the wounds were carefully cleansed. After killing the great cat Arthur was led to his tent and unarmed, " and loked on the cracchinge and the bitiuge of the catte ; and the leches waisshed softly his wounds, and laide thereto salue and onyementes to cleanse the venym." There is a belief in the almost magical effects of some of the salves. Lynet undertakes to heal Gareth in fifteen days, "and thenne she leid an oynement and a salue to him." After his battle with Pellinore, a " hermyte serched all his woundys and gaf hym good salues," healing him in three days. Sir Pryamus heals his own and Gawayne's wounds by " a vyolle ful of the four waters that came oute of paradys, and with certain baume," in an hour they were "as hole as euer they were." This is plainly an oriental echo. Some of the styptic ointments were very severe, as Morgan le Fay searched Alexander's wounds and "gaf suche an oynement unto hym that he shold have dyed, and on the morne whanne she came to hym he complayned hym sore, and thenne she put other oynements upon hym and thenne he was out of his payne."

But there is occasionally slow convalescence from wpunds. Trvstram lies at a nunnery a half year to recover from a wound. Sir Vwayn stops with a layde a half year that " he myghte be hole of his grete hurtes " !

Potions and alcoholics are frequently administered. Gareth is given a " dryuke that relieved him wouderly wel." Besides


244

[No. 81.


being attended to surgically by his magnanimous opponent " Sir la Cote male tayle is given wyn," and a hermit stanches Sir Launcelot's blood and gives him wine to strengthen him. Healing by enchantment, miracle, and divine influence is a natural belief of the time, and tliere is a curious faith in virtue, moral qualities, virginity, etc., to heal wounds. This is doubtless due either to the desire of vengeance, or to that secret conscience of sin and lapse from virtue which brought about the injury or illness. The murderer of Syr Gylbert can never be "hole" until some knight goes to the "chappel peryllous" and finds a sword and a bloody cloth that the knight is wrapped in and " serches" the wounds with them. Launcelot achieves this and heals the sick knight with Sir Gylbert's sword and by wiping his wound with the bloody cloth. Balyn's host tells of his son's wounds " that can not be hole tyll I haue of that kuighte's blood." Balyu procures the blood by killing this knight, obeying the old injunction of an eye for an eye, a tooth for a tooth. Sir Vrre has seven great wounds, three on the head and four on the body, which at one time festered, at another bled, and which could only be healed by being searched by the best knight in the world. At the command of Arthur, Vrre is searched by one hundred and ten knights, but Launcelot being the best knight, alone is able to heal the wounds. The Sangrail is of course effective in curing and healing. The damsel from the castle comes out with a dish " asses grant par raison," and tells Balaain's companion (another lady) that the lady of the castle has been long suffering from a terrible disease " comme est de liepre." All remedies hitherto have been proved useless, but " un seul homme viel et anchiien" had told her she could get well again through the blood of " une pucielle vierge en volonte et en oevre, fille de roi et de roiue." The lady is bled at both arms. " This custom," says the pseudo Robert de Boron, " will be continued unto the day when the lady of the castle is healed by the blood of la serour de Percheval le Galois." By a logical reversal is it not possible that later the belief gave rise to the custom of bleeding ? If good blood could cure, bleeding the patient would appear to lessen the quantity, so to speak, of disease contained in him. The damosel with Balyn is voluntarily bled to help the victim, but to no avail. The blood of Sir Percyval's sister finally cures the lady, but the benefactress loses her own life. It is an old superstition, perpetuated in remote parts of Ireland to this day, that venereal disease can only be cured by coitus or genital contact with a virgin. Modern instances of infection have been traced to this superstition.

There is, of course, doubt as to the correct interpretation of the term mesel. It may have been used to designate leprosy, as the learned think (somewhat doubtfully), but it may also have been applied to another disease. Our indecision becomes clearer by what is the most interesting quotation as to disease we have met in the stories. In Merlin (p. 537, Early English Test Society) we find that King Looth, after censuring his son Agravain for his disrespectful treatment of women, says : "Yef ye yow thus demene as ye say, wite ye well ye shull myscheve, and that shull ye well se." The paragraph ends by saying, "and euen as the kynge seide so hym be-flll, after that he langwissid longe a-boue the erthe for the vilonye that


he dide to a mayden, that rode with her frende with whom he faught till that he hadde dicounfitted and maymed of oon of his armes, and after wolde haue leyen by his love and fonde liir roynouse of oon of hir thighes, and seid her soche vilonye that she after hurte his oo thigh and his arme, so that it sholde neuer be made hooll ; but yef it were be tweyne of the beste knyghtes of the worlde to whom she sette terme of garison, as the booke shall yow devyse here-after, how that it was warrisshed by Gawein his brother and by launcelot de lak that was so noble a knyght." However we may doubt of the cure, it appears from all the evidence that we have here proof of the existence of syphilis at this time. Roynouse means itchy, scaly, etc., and the French rogyie to-day means the itch. But for patent reasons such a meaning cannot be applied in this case, and the context makes more clear the virulent nature of the disease. The location of the lesion, the duration of the disease, and the girl's plain knowledge of its infectious nature are evident. In the Quest of the Holy Grail Launcelot laments that through his sinful life he has lost his eyesight and his strength — an addition to the original record, doubtless, by a later hand.

There are allusions to violent epistaxis. It is said that the venerable Joseph " bled sore at nose, so that he niyght not by no meane be staunched"; and of Garynsch we read that on beholding his faithless lady sleeping with her paramoixr, " for pure sorou his mouth and nose braste oute on bledynge." In Le Conte de la Charrette Keux is declared not guilty by the queen, because " her nose bled during the night, as it often does."

Swooning is most commonly due to physical exhaustion and extreme hemorrhage, but we read of instances due to fright and violent emotion. When told Tristram was near, " for very jnire Joye la beale Isoud swooned." Quite natural is the act of Bois, who "dawes" (sprinkles the face) of the swooning Queen Gueneuer. It is said that the hermit knight, seeing Sir Launcelot helpless and bleeding, "put a thynge in his nose and a lytel dele of water in his mouthe, and thenne Sir Launcelot waked of his swoune." The " thynge " was probably some pungent substance, not unlike the custom of to-day.

The obstetrician finds an occasional line of interest. The babe Arthur was placed in charge of Sir Ector, whose "wyf nourysshed hym with her owue pappe." The significance of the last words arises from the belief that the child's characteristics are derived from the mother or the one who nurses him, through the milk. In this way is explained the baddish character of Arthur's foster-brother Sir Kay, who, as a babe, was given to another woman to nurse. Explaining the bad chai-acter of Keux " et se il est fel es fans et vilains, voiis le deves bien sousfrir," says Auctor to Artus, "que toutes les mauvaises choses qu'il a n'a il prises se par le norriche non qui I'alaita, et pour vous norrir est il si desnatures." An instance of premature labor is recorded in the case of Elisabeth, the wife of King Melyodas, who ran into a forest to seek her spouse and by reason of her violent exercise " began to travaille fast of her child and had many grymly throwes and was delivered "with grete paynes " by a gentlewoman. A distressing case of rape is that of the Duchess of Bretayne,


I


December, 1897.]

246


who Wcas murderously assaulted by a giaut who " in forcyne her slytte her unto the iiauyl." The body of the babe Merliu is covered with hair, a fact that frightens the mother and women. In the State de Merlin an interesting medico-legal question is solved by Arthur and Merliu as to the illegitimacy of Tor, begotten as a result of rape by Pellinor upon " uue pastorelle," who kept the fact a secret and was married to a " vakier " the same week. The conte is finely told, with true English hiimor. To the fact that Tor is a king's son is ascribed his longing to be a knight, all his other numerous brothers, according to the then concei)tion of the laws of heredity, being content with their plebeian lot, because they were the legitimate sons of the cowherd.

The neurologist and alienist will note what may be called a case of aphasia, that of King Uther, the father of Arthur, who " fyll passynge sore seke, so that thre dayes and thre nights he was specheles." Frequent references to insanity are couched in the terms " madde man," " out of wytte," " wood man," etc. Loss of mind through unrequited or unsatisfied love is quite common. Launcelot becomes insane through his love for Queen Gueneviere, runs about almost nude, and is compared to a " wood man in his sherte." He " empayred and waxed feble bothe of his body and of his wit for defaute of sustenauuce" and became "more wooder." Tristram is another victim of love, and his paramour, Queen Isoud, "maade suche sorowe, that she was nyghe oute of her mynde." Merliu makes a bed that " never a man lye therein but he wente oute of his wytte." Sir Kehydius died for love of this same fair Queen. Sir Matto le breune " felle oute of his wytte by cause he lost his lady." That Launcelot was, in modern lingo, of a neurotic temperament appears from a number of hints ; e. g., " he woulde clater in his sleep," and a peculiar effect of his great attack of sleeplessness was anorexia and adipsia ; " he drys and dwindles away until he was a kybbet (cubit) shorter." On another occasion he lay unconscious for twenty-four days and nights.

The criminal use of narcotics and poisonous potions is noticed. Queen Morgan le fay gives " Alysander such a drynke that in three dayes and three nyghtes he waken neuer but slepte." King Mark gives Trystram a drink causing him to fall asleep. There is mention of a " remedy that is the grettest poyson that euer ye herd speke of," to poison Arthur while he is at Camelot. Pyonel poisons the apple at the Queen's feast, hoping to make way with Gawayn, who was particularly fond of apples, but happily the victim escapes, the unfortunate Sir Patryse eating the fatal fruit, which causes him to swell and burst and fall dead. We cannot imagine what was the nature of such a poison. Unless mistaken for the fatal infection from an ordinary wound, we must believe poisoned weapons were used. Tristram is shot through the shoulder with a poisoned arrow. In medieval times it was commonly believed that certain persons possessed poisons, the antidote of which they alone knew. Tristram is struck in the side by Marhaus with an "enueymed" spear, and had to go to Ireland, the source of the poison, in order to be relieved. Wounded in the arm by a saiete envenimee by an archer, Gavain is weakened by the shot, and the next morning he finds that his arm is swollen, and " cstoit asses phis gras que la


cuisse d'un homme,'" and believes without help he must die. Merlin later prophesies Gavain will soon recover, which comes to pass.

Reference is made to the use of what our balneologists would call a medicated bath. Sir Launcelot "made fayre Elayne to gadre herbes for hym to make hym a bayne." There is one reference to gout. Uterpendragon " fell into a grete sekeness of the gowte in the handes and feet." (This is hardly sixth century wisdom.) Besides the one quoted there is a possible allusion to leprosy in the passages relating to la beale Isoud's confinement in a " lazar cote," and to the lady who " felle unto a mesel." Lamorek desires a I'emedy to make him whole of the disease which he had " taken in the see," which may have been one of the numerous complications resulting from exposure in cold water.

The use of horse-litters to convey the wounded was well known.

The embalming of sixty fallen Roman Senators, etc., is surely not of Cymric or English origin.

Is it possible that Gueneviere had some chronic bronchial or pulmonary disease ? It is recorded that she " coughed soo loude that Syre Launcelot awaked and he knewe her hemynge." Of course a beautiful woman never snores ! In one text also she seeks to avert suspicion as regards the blood on the bed-clothing by saying that her nose bled in the night " as it often does."

We thus learn that in the hei'oic youth-time of our race the indications gleaned from these early records of the practice and condition of medicine were singularly in harmony with the character of the people. We are well aware that in such matters omission of descriptions and details does not imply their non-existence, and yet in general the picture is fairly and essentially accurate and complete. The thousand unconscious hints and touches conveyed in other matters as to things just beyond the definite and intended purpose would have been also given in regard to matters medical if they had been actualities. Had there been more competent physicians than la belle Isoud, she would not have been called " the noble surgeon," and the lives of the heroes would not have been entrusted to her cure. Professional practice did not exist, except as by-play, in the hands of the more intelligent and expert of those a little less busy than the heroes. It engrossed no one's sole attention.

It is also to be noted, as we have seen, that the method of treatment was extremely simple and unlearned except as a result of common sense and self-gained exj)erience. It consisted almost entirely of the highly sound practice of removing foreign bodies from wounds and cleansing them, then in applying some simple herbal ointment with a bandage. The rest was left to God and a little quiet. As to the treatment of diseases other than surgical, it consisted in perhaps the exhibition of some simple herbal decoction, and a little wine and food. So far the patient was only cursed with the disease, and not, as later, with both disease and physician. Through all was the belief in the identity of disease and virtue, and when possible of the substitution or imputation of the moral health of another for the physical disease. This latter belief was, we must confess, a truthful error, the


246

[No. 81.


adumbration of a profound verity which our materialistic age in ignoring falls into an opposite and equally grave blunder. Almost all disease, if we but knew it, has a moral or metaphysical cause and result. For the rest, most remarkable is the entire absence of medical superstition of the distinctively primitive or medieval type. Where else do we fiud in the adolescence or childhood of a race such an utter absence of medical barbarism and savagery ? There is not here any faintest glimpse of delight in the nasty, the obscene, the ugly and the outrageous. There is no pouring into the sufferer recipes outdoing in hideousness the mess of the witches' cauldron. Now all this, and especially the last-mentioned fact, has most emphatic, exceptional and manifold significance: —

1. It is an added proof of the remarkable psychologic sanity and natural elevation of character, of splendid nobility of soul, on the part of our young racial ancestors. It may not show any medical "science" (that began gestation only a thousand or more years later), but it shows freedom from pseudo-science, medical filth, and egregious superstition. Great must be the purity of a people in mind and body that needs no medicineman caste, that makes the most beautiful and revered women its best surgeons, and that keeps the disgusting out of its materia medica.

2. It throws a strong side-light for the benefit of literary


and historic criticism on the genuineness of documents by which we have come into possession of the pricelessly precious Arthurian legends. Ho little has this aid and value been recognized that Sommer has failed to include in the Glossary of his superb edition of Malory all medical and anatomic terms. We have little doubt that it will be found that future critical exegetists will learn that all the allusions, e. g. to embalming, to what pertains to the medically nasty and superstitious, the recondite, civilized, scientific, or miraculous, are interpolations, ill weeds, mostly of Continental and Oriental sowing, and may serve as clues to be dropped in our voyage of discovery backward to the originally pure, natural and healthy fountain of eternal youth.

3. As a profession the fact may teach us to hark back to the Cymric springs of our English tributary stream and properly to reverence and value its earlier purity. A further study of medieval medicine will yield us little to honor more, and much to be heartily ashamed of. Slowly we shall see flowing into the limpid English mountain brook the polluting streams of therapeutic filth and nonsense that have rendered the river so nauseous, and that still prevent a newly-arisen and genuine science from ridding ourselves of the loathsome quackeries and sectarianisms that infect its waters and prevent the " healing of the nations."



THE PRESENCE IN THE BLOOD OF FREE GRANULES DERIVED FROM LEUCOCYTES, AND THEIR

POSSIBLE RELATIONS TO IMMUNITY.*

By Wm. Royal Stokes, M. D., and Arthur Wegefarth, M. D.


[From the Bacteriological Laboratory of the Health Department of Baltimore.]


I. — Free Granular Bodies in the Blood.

H. F. Miiller,' an assistant in Nothnagel's clinic in Vienna, has recently described certain "small, generally round, colorless granules," which he finds constantly present in the freshly-drawn blood from healthy and diseased persons. These granules are readily distinguishable from blood plates.

We have been able to confirm Mtiller's observation by the examination of numerous specimens of blood taken from human beings and certain of the lower animals. Since some of our conclusions are different from those drawn by Miiller, we shall first present an abstract of his work and then the results of our own experiments.

Miiller always found the above-mentioned granules in fresh human blood, and by means of their small size he was able to differentiate them from red blood corpuscles, leucocytes and blood plates. He describes them as small, round, colorless bodies, about the size of the finest fat particles, and is quite sure that they are normal constituents of the blood and not foreign matter introduced through accident. His attention was first called to these granules by observing many small bodies resembling mici'ococci free in the plasma of a case of


  • Read before the Johns Hopkins Hospital Medical Society,

October 18th, 1897.


Addison's disease. Upon examining healthy blood as a control, the presence of similar granules was demonstrated, and, as mentioned above, after many observations upon the blood of healthy and diseased individuals, Miiller came to the conclusion that these refractive bodies are regularly present in the blood. Their diameter is 1 ii or under, their size being somewhat variable. They are further described as highly refractive, round or dumb-bell shaped bodies, which show a dancing, molecular movement, but no independent motion. When the fresh blood is prevented from drying by surrounding the cover-slip with oil, these granules can still be seen after 24 hours, and the same may be said when the blood is mounted in 1 per cent, osmic acid. The reaction for fat does not occur with this acid, nor can they be dissolved by acetic acid or ether. They are not concerned in the formation of fibrin, since they remain outside of the fibrinous network or are only accidentally attached to it.

From these observations the author concludes that these granules are a normal constituent of the blood. His technique guarded against the introduction of foreign particles from the skin, etc. He does not consider them as Ehrlich's neutrophilic granules escaped from leucocytes. He states that the neutrophilic granules are dissolved by dilute acetic acid, while the bodies which he has studied are not dissolved by this acid.


December, 1897.]

247


He does not believe that they are true particles of fat, since they do not give a reaction with osniic acid, but advances the opinion that they may be bodies resembling fat, but which fail to show the osmic acid stain. He leaves the question open as to their fatty or albuminous nature, and ends by calling them " Haemokonien," or "Blutstiiubcheu" (blood dust). No mention is made of any attempts at staining.

Briefly stated, therefore, Mtiller has observed a varying number of small refractive, spherical bodies, of undetermined origin and composition, in all of the specimens of human blood which he examined.

Other authors have also observed bodies resembling fat granules in the blood of normal human beings, Kolliker,^ Kanvier,^ Bizzozero,* and von Limbeck' all mention such bodies in the blood. Mtiller was unable to reconcile their description by these authors with the bodies which he observed, but he thinks that certain fat drops or granules described by Schiefferdecker and Kossel" are probably identical with his bodies. Hayem' also speaks of spherical granulations resembling fatty particles, which Miiller considers as identical with the granules described by himself.

The bodies which we have observed correspond in their general appearance to those described by Miiller. We especially wish to emphasize the fact already mentioned that the granules vary in size. Occasionally one meets with the larger round body about 1 //. in diameter, but by far the more frequent variety are the fine granules, almost diist-like in appearance. They exhibit molecular movement, but no independent motility.

We first began the study of the bodies by ordinary daylight, but we soon found that they can be brought out much more clearly by means of the artificial light of the Welsbach gasburner. We have been able to demonstrate the presence of these granules in the fresh specimens of blood taken from the lobes of the ears of about 500 persons. Most of the specimens were from dispensary patients, but about 100 were taken from normal individuals. Care was always taken to thoroughly cleanse the ear, and the first drop of blood was always wiped away with a clean towel. In perfectly fresh specimens the granules were not numerous, but they seemed somewhat increased in patients who had been taking tonics or the various alcoholic drinks. No attempt was made to determine their relative frequency in different diseases.

After having observed these granules in all of the specimens of human blood which we had examined, the question naturally arose as to their origin. It was first noted that these granules, when examined by artificial light, resembled those of the eosinophilic and neutrophilic leucocyte. These leucocytes, when observed at once in a perfectly fresh drop of blood, kept at the room temperature, are usually motionless, and the granulations show no activity. AVhen the blood specimen is surrounded by vaseline and is then exposed to a temperature of 35° C. for an hour or more, the picture becomes somewhat different. At times the granular leucocytes become actively amoeboid, and the granules within the ueutrophile exhibit a characteristic activity, which might be compared to the swarming of bees around a hive. The number of fine granules free in the plasma is perceptibly increased. The


eosinophilic granulations also show a less vigorous tremulous motion, and both varieties follow the changes in the direction of the pseudopodia, the protoplasm being thrown out first, and the granules slowly following. The characteristic dancing motion of the granules in the neutrophilic leucocyte can be brought out very plainly by simply mixing the drop of blood with an equal amount of distilled water containing 1 per cent, of alcohol. The granules soon become very active and present a characteristic picture.

And now a difficult question presents itself. Can these granules be actually seen to leave the leucocyte ? It is certainly not easy to be sure, even after continuous observation for an hour or more, that one has actually seen one of these granules leave an amceboid leucocyte. We think, however, that we have observed this phenomenon upon several occasions, both in fresh specimens of blood exposed to 35° C. and in blood to which 1 per cent, of alcohol had been added.

As already mentioned, Miiller does not think that his granular bodies can be derived from the neutrophilic leucocytes, since Ehrlich's granules are dissolved by dilute acetic acid, while the bodies which he describes are not dissolved by this fluid. According to our observation, dilute solutions of glacial acetic acid (c. p. 99.5 per cent.) cause a great increase in the number of granules free in the plasma when added in equal parts to fresh blood. Many granules can still be seen in the protoplasm of both varieties of granular leucocytes, however, and we cannot convince ourselves that any destruction of the granules has taken place. If a 0.5 per cent, solution of this acid be added to a drop of blood, the eosinophilic and neutrophilic leucocytes often become amceboid, and the granules of the eosinophile often show a slight tremulous motion. The neutrophilic granules exhibit a most characteristic movement, and soon flow into and fill the clear spaces present in the fresh pseudopodia of amoeboid leucocytes. Many fine granules can be seen in the clear plasma and around the neutrophile, and it would seem that occasionallv a granule leaves the active leucocyte and becomes free in the surrounding fluid. When 1 per cent, glacial acetic acid is employed the leucocytes are no longer amoeboid, nor the intracellular granules active. Many granules can still be made out, however, within the protoplasm of the leucocyte, and there are more granules present in the plasma than in the fluid portion of untreated blood. When 5 per cent., 10 per cent., and even stronger solutions are used, the protoplasm of the leucocyte becomes clear and practically free from granules.

Similar free granules can also be made out in the clear blood serum, and they are fairly numerous if the separation has taken place at 35° C. In specimens of blood heated in the usual way for microscopical study, extracellular granules can be stained by a deep red solution of aqueous eosin. This stains the eosinophilic and neutrophilic granulations, and at times a granule of both kinds can be seen immediately adjacent to the leucocyte. Of course such pictures may be due to the manipulation of spreading, and the most convincing phenomena are certainly to be obtained by studying specimens of fresh blood.

Our next series of investigations consisted in the observation of the blood of various animals. In the blood of the


248

[No. 81.


horse the eosinophile presents a remarkable appearance, the individual granules being often from five to ten times the size of the human variety. Even in perfectly fresh horse's blood a few large, round, refractive bodies can be seen free in the plasma, which entirely resemble the intracellular bodies in size and appearance. Another variety of leucocyte containing granules about the size of the human eosinophilic granules is also present, and a few granules of the same size can be made out in the surrounding fluid. When the specimens of horse's blood are exposed to 35° C. for an hour or more, both varieties become amoeboid, and the intracellular granules show a slow flowing motion. The number of the granules free in the plasma, resembling both varieties, is also perceptibly increased, and the conclusion seems almost irresistible that they have been extruded from the leucocytes. The serum which has separated from the clot also contains many granules I'esembling those described above, especially if the separation has taken place at 35° C.

The eosinophile is the only granular leucocyte present in rabbit's blood, and the granules are about the size of those of the human eosinophile. When the blood has been exposed to a temperature of 35° for an hour, a few round bodies can be seen free in the plasma which resemble the granules of the eosinophile in size and appearance. No smaller dust-like particles can be seen, and this can probably be explained by the fact that the rabbit possesses no finely granular leucocytes. In hardened specimens stained by aqueous eosin the intracellular granules can be easily seen, and at times similar bodies can be observed outside of the leucocyte.

The cat's blood contains about an equal number of eosinophiles and finely granular leucocytes, and the granules are about the size of those present in these respective leucocytes of the human being. Even in perfectly fresh specimens a few granules can be found corresponding exactly to both varieties mentioned above, and when the blood is exposed in the thermostat for an hour there is a great increase in the number of granules of both kinds.

In the guinea-pig the blood contains a few eosinophiles, and many more finely granular polymorphonuclear cells, and the granules of both varieties can be plainly made out in the leucocyte ; while if the blood is placed at an artificial temperature, similar granules can be seen dancing round the leucocytes, or free in the plasma. When stained by aqueous eosin the smaller granules are slightly smaller than the human neutrophile, while the larger granules about equal the human variety in size.

In the blood of the rat both eosinophilic and finely granular leucoytes are present. Many large and small granules, entirely resembling those inclosed in the protoplasm of both varieties, can be made out free in the plasma, especially after an hour at 35° C. In stained specimens the fine granules are as small as the human variety, and the rarer eosinophilic leucocytes contain perceptibly larger granules.

After exposure to a temperature of 35° 0. for an hour there are more free granules present in the blood of the cat and white rat than in the blood of the other animals which we have studied. There are also granules present in the blood of such animals as mice, frogs, fishes, land-terrapins, tadpoles.


and even oysters and clams. They are also present in hydrocele fluid, and the serum of such animals as the horse, hog, steer, rabbit, and dog. They present a striking appearance in the usual varieties of pus, and the intracellular granules are often active.

These observations simply strengthen the conclusion that the granules of the eosinophile and the neutrophile are present as free bodies in the plasma and serum.

II. — Bearing of the Foregoing Observations upon Immunity and Natural Kesistance.

Our observations indicate that granules derived from leucocytes appear free in the blood. It occurred to us that these granules may be concerned in the protective properties of the blood in immunity. A brief review of the two principal theories in regard to immunity, and the later work concerning this matter, will here be in place.

Metchnikoff, as is well known, believes that bacteria are destroyed in the body chiefly by means of the leucocytes. These amoeboid cells or phagocytes engulf the invading organisms and gradually destroy them, being attracted to certain bacteria by means of positive chemotaxis. If this attraction exists between the phagocytes and the bacteria, and the former are able to include and destroy the latter, the animal is saved. If, on the other hand, the bacteria repel the phagocytes by means of negative chemotaxis, or the phagocytes are incapable of completely destroying or preventing the development of the infectious organisms, the bacteria gain the upper hand and the animal suffers a fatal infection. This well known theory of phagocytosis is summarized by Metchnikoff as follows :

" We have the right to maintain that in the property of its amreboid cells to include and to destroy micro-organisms the animal body possesses a formidable means of resistance and defense against infectious agents."

The work of Buchner has certainly imposed some restrictions upon the unqualified acceptance of this theory, although his later investigations point towards the leucocyte as* the origin of the germicidal material. Buchner demonstrated that the bactericidal property of blood is not dependent upon the presence of leucocytes, inasmuch as the serum of the dog and rabbit, which had been freed from cellular elements by separation and centrifugalization, is still capable of destroying such bacteria as the typhoid and anthrax bacilli, and the spirillum of Asiatic cholera.

After freezing and thawing the blood serum he found that it still remained bactericidal while this treatment destroyed the leucocytes, and he excluded the action of these cells by filtration of the serum through double filter paper. From these results he concluded that the actual presence of the leucocyte is not necessary for the bactericidal power of the serum. He later modified his earlier views by admitting that the leucocytes probably furnish a bactericidal substance, although he does not believe that they actually as a rule consume and destroy the agents of infection.

He demonstrated this property of the leucocytes to furnish a germicidal substance in the following manner. He first injected a sterilized emulsion of wheat-flour paste into the


December, 1897.]

249


pleural cavity of dogs and rabbits, thereby obtaining an exudate which had much more germicidal strength than the blood or serum of the injected auimals. Although this was referred to the greatly increased number of leucocytes present, he argued that it was not due to their phagocytic action, since by freezing the exudate the leucocytes were destroyed, and yet upon thawing out this material the bactericidal proijerties of this fluid were even slightly increased.

Other observers have also recently pointed out that the leucocytes seem to contain germicidal substances in a concentrated form. Hahn° has confirmed the work of Buchner in regard to the heightened bactericidal effect of pleural exudates containing a large number of leucocytes, and' he has also succeeded in partially extracting this material and imparting the power of destroying bacteria to other fluids than serum. He first introduced wads moistened with sterile chemotactic substances into the peritoneal cavity of rabbits. After 24 hours these wads were I'emoved and were found to contain countless leucocytes. The fluid from the sponges was then frozen and the leucocytes thereby destroyed. After thawing, this fluid was found to possess decided bactericidal effects. From his experiments he concludes that the germicidal material is not a j)roduct of the destruction of the leucocyte by the system, but that it is a secretion formed during the active existence of this cell.

Bordet" has also made a number of important communications bearing upon this subject. This investigator produced an cedematous fluid free from leucotypes in guinea-pigs immune from the cholera spirillum, by means of compression exerted by rubber bauds around the extremities. He then compared the bactericidal power of this cell-free fluid to that of the animal's serum containing leucocytes, by introducing into each equal numbers of cholera spirilla. He found that cultures made from the serum were always sterile in from one to one and a half hours, while similar cultures taken from the cedematous fluid showed a perceptible increase in the number of bacteria. Later cultures from the (Edematous fluid showed even greater increase. He also produced a hypoleucocytosis by means of carmine injections, and found that the power of such blood to destroy bacteria was greatly decreased when compared with its bactericidal properties before the artificial diminution of the leucocytes. Bordet concludes that the leucocyte is the seat of the bactericidal material, which under abnormal circumstances it gives up to the surrounding fluid.

Schattenfroh'" has made some exceedingly interesting observations in regard to the bactericidal properties of the leucocyte. He has found that the diluted inflammatory exudates from rabbits were much more bactericidal when he added many leucocytes than when the fluid was free from cellular elements. He also secured leucocytes by centrifugalizing these fluids, and by adding the sediment to salt solution he found that this fluid became capable of destroying bacteria. By drying this sediment of leucocytes in a vacuum over phosphorus pentoxide he secured a fine powder which rendered salt solution very destructive to bacteria. He thinks that the leucocytes furnish the bactericidal substance by a process of destruction. His promised detailed account should be a communication of great interest.


Bail" has made some tests which in his opinion prove that the leucocytes contain a bactericidal material. After injecting virulent stajjhylococci into the pleural cavity of rabbits he found that the leucocytes underwent a characteristic change. They formed round, empty bodies, containing several vacuoles in the nucleus. The granules generally disappeared. Upon destroying the staphylococci by adding ether, and diluting the centrifugalized sediment, the granules showed a dancing motion, and were seen to leave the periphery of the cell and enter the surrounding medium.

He also secured leucocytes by Buchuer's method, added sterile salt solution, and obtained a sediment of leucocytes by centrifugalization. By adding a diluted product of the staphylococcus pyogenes aureus called leukocidin to this sediment, he found that the leucocytes were destroyed, and that they then gave up their bactericidal material to the surrounding fluid. If the leukocidin was heated to 60° 0. it lost its property of destroying leucocytes. He found that nutrient fluids to which untreated leukocidin and leucocytes were added, became very destructive to bacteria. This he explained by the fact that the leukocidin destroyed the leucocytes, thus freeing the alexin. When the leukocidin was heated to 60° 0. its destructive powers were destroyed, and when this altered material was added to the fluid containing the sediment of leucocytes the fluid was not destructive to bacteria. This was because the inactive leukocidin could not free the bactericidal substance from the leucocytes. Such bacteria as the typhoid and colon bacillus, the spirillum of Asiatic cholera, and the staphylococcus pyogenes aureus were practically destroyed in 6 hours.

Bail concluded from these and other experiments that the white blood corpuscles of the rabbit contain a bactericidal material, which at times becomes free and appears in the surrounding medium.

We have also performed a series of experiments which seem to show that the leucocytes are directly concerned in furnishing a definite amount of bactericidal material, but the methods need a preliminary explanation.

Certain investigations were made for the purpose of determining whether there existed any difference in the bactericidal power of fresh blood serum before and after it had been filtered through new sterile Miincke filter-cylinders.

Dziergowski" has shown that such fluids as abrin solution, diphtheria toxin and tetanus toxin suffer a slight diminution in their toxic properties when filtered through porcelain cylinders, and Martini" has shown that the antitoxin of diphtheria is also weakened by this process.

Denys and Havet" consider that the leucocytes of the dog play the principal part in the destruction of bacteria, and they base their conclusions upon the results obtained from the following experiments.

They first proved that the blood of the dog was capable of destroying many more colon bacilli than the serum of this animal in a given space of time. Thinking that this increase in the bactericidal power of the blood, as compared to that of the serum, might be due to the greater number of leucocytes present in the former fluid, they next compared ihe relative destructive powers of filtered and unfiltered blood. The fluid


250

[No. 81.


was filtered through double filter paper, as this method was found to deprive the blood of its white blood corpuscles. They found an enormous difference between the bactericidal power of the blood possessing its leucocytes, and that which had been deprived of the same by filtration.

These observers were also able to greatly increase the bactericidal power of the serum by the addition of the sediment of leucocytes obtained from a sero-puruleut exudate in the pleural cavity of a dog. This was produced by the injection of dead fluid cultures of the staphylococcus pyogenes aureus. By the addition to filtered blood of the leucocytes obtained from the pleural fluid of a dog injected with dead spirilla of Asiatic cholera they were able to restore the lost bactericidal properties of the blood.

They conclude from the observations above mentioned that the blood of the dog when filtered loses its bactericidal power, but that this property can be restored by the addition of living leucocytes.

The blood from which we obtained our serum was secured from rabbits and dogs by means of a sterile cannula introduced into the carotid artery under aseptic precautions. The first few drops were allowed to escape and the rest of the blood was caught in sterile jars. These were stoppered with cotton and allowed to stand at 33° C. for from 13 to 34 hours, when one-half of the serum was filtered through porcelain, while the other half was siphoned off into sterile flasks, care being taken to prevent any admixture of red blood corpuscles. We never worked with serum over 48 hours old.

Our first series of experiments demonstrated a decided difference between the undiluted serum of dogs and rabbits before and after filtration through the unglazed porcelain filter.

When such motile bacteria as the spirillum of Asiatic cholera, the Finkler-Prior spirillum, and the typhoid bacillus were introduced into unfiltered dog serum, complete agglutination took place in from 15 to 30 minutes, together with cessation of motility; but when filtered serum was used no cessation of motility or agglutination took place, even after 3 hours. The rabbit's unfiltered serum caused agglutination and cessation of motility of the typhoid and cholera organism in 15 minutes, and affected the Pinkler-Prior spirillum and bacillus pyocyaneus similarly in about 30 minutes. This condition did not change during 34 hours. The specimens in filtered serum remained active and showed no signs of agglutination, even after 34 hours.

The specimens were all examined in hanging drop-slides, and allowed to remain at the room temperature. From the foregoing experiments we concluded that filtration of the undiluted serum of rabbits and dogs removes their normal property of causing the agglutination and cessation of motility of the organisms above mentioned.

Our next endeavor was to ascertain whether we could demonstrate any difference in the capacity of the filtered and unfiltered serum actually to destroy these bacteria, and for this purpose we adopted the following method :

Twenty-four hour cultures on slanted glycerine-agar of the various organisms to be mentioned below were prepared, and one loopfnl of the surface growth was transferred into 2


cubic centimeters of sterile salt solution. Two loopfuls of this fluid were then introduced into 1 cubic centimeter of the unfiltered serum of the rabbit, and a similar amount was used in 1 cubic centimeter of the filtered serum. The same loop was always used, and an agar plate culture was made from the filtered and unfiltered serum at once, in order to compare the number of germs originally introduced with those present in the serum at varying intervals of time. In all our experiments control plates made from the serum before using remained sterile.

Five loojifuls were planted at the end of 3 hours from both varieties of serum, and at the end of 17 hours 1 loop was planted from the different filtered serums, and 5 loops were planted from the unfiltered serums. With anthrax 1 loopful of the culture was directly introduced into the serums. All of the specimens were kept at a temperature of 35° C. during the experiments.

Table I. — Results with Rabbit's Serum.* Bacillus typhosus. Colonies.

At once. 2 hrs, 17 hrs.

Filtered serum. 1960 730 Great increase.

Unfiltered serun. 936 Sterile. Sterile.


Spirillum of Finkler-Prior. Filtered serum. Unfiltered serum.

Cholera spirillum. Filtered serum. Unfiltered serum.

Proteus mirabilis. Filtered serum. Unfiltered serum.

Anthrax bacillus. Filtered serum. Unfiltered serum.

Staph, pyog. aur. Filtered serum. Unfiltered serum.


1330 1010 Great increase.

959 Sterile. Sterile.

201 960 Great increase.

3 Sterile.

1740 1650 Great increase.

1934 1806 "

804 1530 Great increase.

643 163

743 383 Great increase.

1050 348 "


The foregoing table shows that while unfiltered serum will completely destroy such organisms as the typhoid bacillus and the spirilla of cholera and Finkler-Prior, these same bacteria will increase enormously in filtered serum. The growth of the anthrax bacillus was only temporarily restrained, while the remaining bacteria were not affected.

A similar series of experiments was carried on with the serum of a dog.


  • AI1 serums from the same species of animal are not equally

bactericidal, and the results are affected by the amount of serum used and the number of bacteria introduced. Buchner says 1 cubic centimeter of serum will destroy 1000 typhoid bacilli. With a certain rabbit's unfiltered serum we obtained the following results : One cc. of serum. Typhoid bacillus ; at once, 734 ; 2 hrs., 4 colonies; 5 hrs., sterile; 20 hrs., great increase. — Anthrax ; at once, 9144 ; 2 hrs., 2394 ; 5 hrs., 354 ; 20 hrs., 28,800.


December, 1897.]

251


Table II. — Results with Doq Serum Spirillum of cholera.


At once. 2 hrs. 20 hrs.

941 1334 Great increase. 876 Sterile. Sterile.


535


455


Great increase.


638


38


Sterile.


1308


1494


Great increase.



Sterile.


Sterile.


1800


1140 240


Great increase.


Filtered serum. Unfiltered serum.

Bacillus typhosus. Filtered serum. Unliltered serum.

Spirillum of Fiukler-Prior. Filtered serum. Uutiltered serum.

Bacillus pyocyaneus. Filtered serum. Unfiltered serum.

These tables show that the filtered serum cannot destroy the typhoid bacillus or the spirilla of cholera and of FinklerPrior, while the unfiltered serum can practically bring about this result in about two hours.

Having demonstrated that the filtered serum had lost its bactericidal property, our next endeavor was to ascertain whether we could restore this lost property by adding the leucocytes to the filtered serum. We found that the centrifugalization of clear serum will cause the precipitation of many leucocytes and red blood corpuscles. Many granules similar to those described before were also present in the sediment.

Our method of restoring the leucocytes to the serum was as follows :

Ten cubic centimeters of clear unfiltered dog serum were thoroughly centrifugalized in sterile tubes, and the supernatant fluid was then poured off, care being taken not to contaminate the sediment. The few remaining drops were removed from the sediment by means of sterilized swabs of absorbent paper, and a semi-fluid deposit was allowed to remain in the bottom of the tube. Under the microscope this consisted of leucocytes, free granules and red blood corpuscles. This we designated as the small sediment. In another instance 10 more cubic centimeters of serum were added to a tube already containing a sediment, and a second deposit was obtained from this fluid by means of centrifugalization, making the accumulated deposit from 30 cubic centimeters of unfiltered serum. This we called the large sediment.

Two cubic centimeters of filtered (non-bactericidal) serum were then added to tubes containing the large and small sediment, and as a control, filtered aud unfiltered serum was used. All of the serum tubes were then inoculated by means of the following method.

One loop of a 24-hour culture of the typhoid bacillus was added to 3 cubic centimeters of sterile bouillon, and 1 loop of this fluid was then added to the filtered serum, the filtered serums plus the sediments, and the unfiltered serum. Three loops from the inoculated serums were always used for the plates made for numerical comparison, and the serum was kept at 35° C. during the experiments. The plates were allowed to remain in the thermostat for 48 hours before counting. The typhoid bacillus was used for the experiments.


Table III. — Results with Bacillus Typhosus.

Colonies present. At once. 3 hrs. 6 hrs. 20 hrs.

Filtered serum plus

Small sediment. 383 367 690 Great increase.

Filtered serum plus

Large sediment. 463 318 596

Filtered serum. 334 900 29445

Unfiltered serum. 346 Sterile. Sterile. Sterile.

These figures show conclusively that the presence of the sediment consisting of granules, leucocytes and red blood corpuscles in the filtered serum rendered this fluid capable of inhibiting the growth of large numbers of bacteria, although it was incapable of preventing the subsequent development of bacteria in this fluid. This later development was probably due to the presence of the nutritive material in the red blood corpuscle, which property gradually neutralized the germicidal qualities of the serum. The abstraction of the red blood corpuscles by water robbed the sediment of its bactericidal qualities, so that so far we have been unable to eliminate its nutritive effect. This has been accomplished by the work of Schattenfroh and others, and the results, therefore, accord with our experiments. We have not been able to render the bactericidal power of filtered serum equal to that of the unfiltered fluid, but we mention our method at this time in order to propose a simple method of obtaining large quantities of fluid for further experimentation, and as a slight addition to the mass of evidence in favor of considering the leucocyte as the dispenser of the bactericidal material.

Conclusions.

In the blood plasma and serum of man and many of the lower animals there are present varying numbers of granules, which resemble the granules of the eosinophilic and neutrophilic leucocytes in size aud appearance.

After addition of dilute acids, dilute alcohol, etc., and subjection to body temperature, the granules of the leucocyte assume marked activity, and such treatment increases the number of granules present in these fluids. These free granules are almost certainly derived from the granular leucocytes.

The filtration of the serum of the dog and rabbit through new Miincke porcelain cylinders removes its normal property of causing the agglutination and cessation of motility of many motile pathogenic bacteria, and of destroying large numbers of these organisms. This property can be partially restored by adding a sediment consisting of leucocytes, free granules and red blood corpuscles. Siuce the red blood corpuscles are not germicidal (Buchner), it follows that the restoration of the bactericidal property is due to the addition of the leucocytes and free granules, aud that these cells can furnish a germicidal material.

The larger extracellular granules of man, and of the frog, horse and rabbit can be stained by eosin, or by means of Ehrlich's triple blood stain.

Theory of Immunity based upon these Observations. And now it being demonstrated that the leucocytes not only contain a bactericidal substance, but also under certain conditions can give up a portion of their protoplasm to the sur


252

[No. 81.


rounding medium, one naturally looks for some experimental proof showing that the germicidal substance and the material that leaves the leucocyte are identical. This jiroof, however, is extremely difficult to furnish, since filtration of a sediment even through double filter paj^er will allow leucocytes as well as granules to pass.

We have added the typhoid bacillus to various normal bloods and serums, but without demonstrating any distinct attraction of the bacilli for the free granules. We have succeeded in immunizing a guinea-pig from the typhoid bacillus by means of Pfeiffer's method, and upon adding 24-hour motile bacilli to the fresh blood of such an animal the results are slightly more suggestive.

The bacilli become immediately motionless and clumped, and after 15 minutes at 35° 0. fine granules can be seen around the periphery of the clumps, or even dancing about in the meshes of the massed organisms. This condition can be noticed even after several hours, but the granules are never vei'y uumerous. Often several can be seen about a single typhoid bacillus.

Novy and Vaughn" have extracted a germicidal nuclein from blood serum, and they think that it is derived from the leucocyte. Hankin" believes that the granules of the eosiuophile gradually dissolve in the serum, thereby furnishing the alexin.

The suggestive work of Kauthack and Hardy" should also be mentioned in this connection. These investigators made a number of painstaking observations concerning the effect of the introduction of a few anthrax bacilli into the lymph of the frog. They either injected the bacilli into the various lymph sacs and then withdrew the mixture of lymph and bacilli at varying intervals of time, or they mixed the lymph and bacteria, and then observed the specimen in the hanging drop for several hours.

They found that the destruction of the bacteria could be divided into two distinct stages. The first stage consisted in the approach of the oxyphilic or eosinophilic leucocyte to the chains of anthrax bacilli. These leucocytes were said to apply themselves to the surfaces of the chains of bacilli, and then discharge their granules by a quick streaming motion, when the bacilli would begin to show signs of degeneration.

The next stage in the phenomenon of destruction was the approach of a cell described by the writers as the hyaline cell, which was said to contain a round or kidney-shaped nucleus, but no granules. These cells were seen to approach the masses of eosinophiles and bacilli and gradually replace the eosinojihiles.

The hyaline cells would then include the bacteria within their protoplasm, and many cells could be found possessing vacuoles containing fragmented bacilli. The eosinophiles were thought to prepare the bacteria for ingestion by the hyaline cells, but they never were seen to include the bacteria themselves.

Although in a more limited series of observations on five frogs we have failed to observe any distinct clinging of the eosinophile to the chains of anthrax bacilli, we have noticed the fact that after an hour or more the eosinophile will frequently only contain a few granules. Many large eosino


philic granules can be made out free in the plasma, but these are accompanied by smaller dust-like granules. We believe that these smaller granules are derived from the leucocyte of the frog possessing fine granules and a nucleus of the polymorphous variety. These fine granules are at times active within the protoplasm of the cell, and upon one occasion we observed such a leucocyte with active granules which contained an anthrax bacillus in its protoplasm. When specimens taken from the subcutaneous sacs of the frog into which a few anthrax bacilli had been introduced, were stained with methylene blue, typical phagocytosis could be observed in cover-slij)S prepared half an hour after the injection of the bacilli. Often from one to three bacilli could be made out within the protoplasm of a cell containing a typical polymorphous nucleus, and resembling the ordinary pus cell.

In hardened specimens stained by Ehrlich's triple blood stain, or simple eosin and methylene blue, many large granules exactly resembling the large intracellular granules of the eosinophilic leucocyte could be made out as extracellular bodies, but bacilli were never found within the protoplasm of the eosinophile. The eosinophile seems to form the majority of the white blood corpuscles of the frog, the finely granular cell being more rarely seen.

It would seem, therefore, that the free granules, both from the eosinophilic and finely granular leucocyte, may weaken and destroy the anthrax bacilli by their presence in the plasma, and that then the finely granular leucocyte with the nucleus of the polymorphous variety, together with the hyaline cell of Kanthack and Hardy, complete the process of destruction by inchiding the bacteria within their protoplasm.

The many suggestive facts which we have just mentioned have induced us to advance the following theory :

The bactericidal power of the leucocyte of the blood, and of the serum of man and many animals, is due to the presence of specific granules, especially the eosinophilic and neutrophilic.

When called upon to resist the action of invading bacteria, the granular leucocytes can give up their granules to the surrounding fluids or tissues.

Not only does this enable us to understand how apparently cell-free fluids can destroy bacteria, but the production of the alexin by the leucocytes also affords a better explanation of the hyperleucocytosis of infection so strongly urged by Metchnikoff, and by no means disproves the supposition that the leucocytes can take up bacteria either while alive or after being destroyed by means of the germicidal granules.

References.

1. Miiller: Ceutralbl. f. allg. Path, und path. Anat., VIII, (1S9G).

2. Kolliker: Handbuch der Gewebelehre des Menschen. 5 Aufl., Leipzig, 1867, S. 630.

3. Kanvier: Traite technique d'histologie. Paris, Savy, 1875, p. 214.

4. Bizzozero: Handbuch der klin. Mik. 2 Aufl., Erlangen, Besold, 1887, S. 43 u. 74.

5. von Limbeck : Grundriss einer klinischen I'athologie des Blutes. 2 Aufl., Jena, G. Fischer, 1896, y. 131.


ll


December, 1897.]

25S


6. SchiefferdeckerandKossel: Gewebelehre. Braunschweig, Brun, 1891, Bd. II, 1 Abth., S. 356.

7. Hayem : Du sang et de ses alterations anatomiques. Paris, Masson, 1889, p. 113.

8. Hahn: Archiv f. Hygiene, Bd. XXV, S. 105.

9. Bordet: Annales de I'lnstitui Pasteur, T. IX, No. 6.

10. Scliatteufroh : Miiuch. med. Woclienschr., April 20th, 1897, No. 16.


11. Dziergowski: Archiv d. sciences biologiques, IV, 43.

12. Martini : Centralbl. f. Bakt., XX, Nos. 23, 21.

13. Novyand Vaughn : Ptomaines and Leucomaines. 1896.

14. Hankin : Centralbl. f. Bakt., Bd. XII, Nos. 22, 23, 1892.

15. Deuys and Havet : La Cellule, T. X, 1894.

16. Kauthack and Hardy: Phil. Trans., Vol. CLXXXV, 1894, p. 279.

17. Bail: Berliner klin. Woehenschrift, Oct. 11th, 1897.


ON THE ANATOMICAL RELATIONS OF THE NUCLEI OF RECEPTION OF THE COCHLEAR

AND VESTIBULAR NERVES.

By Florence R. Sabin. [From the Anatomical Laboratory of the Johns Hopkins Unieersity.]


Since the investigations of Babiuski,' v. Bechterew,' Bumm,' Cramer,' Flechsig, Forel,' Kirilzew," v. Monakow,'" Ouufrowicz," and Roller,'* much light has been thrown on the central connections of the cochlear and vestibular nerves by Ramon y Cajal,' Held,' v. Kolliker,'" Martin" and Sala." The exact topographical relations of these nuclei have, however, so far been only imperfectly described.

The material used in the present study was human tissue and consisted of two superb sets of serial sections, transverse and horizontal, through the medulla of the new-born babe, prepared by Dr. John Hewetson at the Anatomical Laboratory of the University of Leipzig. Through the courtesy of Dr. Hewetson these preparations have been made accessible for study to research-workers in the Anatomical Laboratory of the Johns Hopkins University.

A flat reconstruction on millimetre paper has been made from the right-hand side of the sections of the transverse series which show the nuclei in question. Reference to the diagram (Fig. 1) will show the following points : At the lower end of the diagram the zero point on the scale represents the superior (anterior) limit of the decussation of the pyramids, and at the npper end the diagram extends nearly to the lower border of the inferior colliculus of the corpora quadrigemina. The lines drawn across the diagram represent approximately the planes of the sections having the corresponding numbers.* The areas occupied by the nuclei of the nervus hypoglossus and nervus abducens are given to help in orientation. The lines rt-re represent the lateral boundary of the fourth ventricle, which has been traced from the point at which the canalis centralis opens out into the floor of the ventricle, through the area of the recessus lateralis and forwards to the aqueductus cerebri. The line b-b represents the lateral boundary of the corpus restiforme. The entrance of the corpus restiforme into the cerebellum is not shown, but the line runs to its upper


  • Tbe planes of the sections are in reality slightly different from

those represented by the lines on the diagram, which are drawn at right angles to the median line. The sections have been cut slightly obliquely, the right side being struck at a higher plane than the left. Theslightdiscrepanciesbetween the drawings of the sections and the diagrams are thus explained.


limit. The motor and sensory nuclei of the nervus trigeminus are shown with the exception of the nuclei minores (radicis descendentis). The tractus spinalis uervi trigemiui, together with the adjacent substantia gelatiuosa, is represented in outline from its beginning, at the entry zone of the nerve, downward as far as the decussation of the pyramids. Its course further spinalwards is not given. The entering root bundle of the nervus trigeminus is also not illustrated, but the lowest section which shows it corresponds to number 45 on the scale, and as the nuclei of the nerve are inferior to the point where it enters, the fibres can be traced farther upwards than the diagram goes. The lines dz and di represent the surface markings on the floor of the fourth ventricle corresponding to the ala cinerea. The complete length of the nucleus alffi cinerea3 is not shown, but it can be traced from the inferior end of the nucleus nervi hypoglossi to the point marked d\ on the diagram. The line rfi-rfs, in which the two sulci meet, corresponds to the portion of the ala cinerea which has been pushed into the depth by the spreading of the nucleus nervi vestibularis medialis dorsal to it over the floor of the ventricle.

The line e represents the continuation of the lateral sulcus over the area occujiied by the nucleus nervi abducentis. The sulcus is here further lateral, corresponding to the position of the nucleus nervi abducentis, which is further from the median line than the nucleus nervi hypoglossi.

Nervus vestibuU. The area of entrance of the root bundle of the vestibular nerve is shown in the diagram. The well known fact that the vestibular root bundle is farther forwards (cerebralwards) than the cochlear root bundle is well illustrated. The reconstruction shows clearly the generally recognized fact that the four principal vestibular nuclei are continuous with one another. (See J/., L., S., and R. d. n. ve. in the diagram.) These nuclei can be distinguished in part by position and in part by the character of the cells within them. The relation of the nucleus nervi vestibularis medialis to the nucleus of the descending tract of the vestibular nerve is very striking. Ramon y Cajal has already pointed out their close connection. The lowest sections in which descending vestibular fibres can be distinctly made out show cells between the fibres (sections between 15 and 17 on the scale). These cells higher up make an oval mass which lies.


264

[No. 81.


lateral to the ala cinerea and extends dorsal aud medial to the descending vestibular fibres. As the ala cinerea recedes into the depth, and the nucleus nervi hypoglossi disappears, these cells spread to very near the middle line. The large area M, together \vith the dark area Y, represents the nucleus nervi vestibularis medialis ; it can easily be seen that any division between this nucleus and the nucleus of the descending vestibular tract, throughout their whole extent, must be merely an arbitrary one. It is extremely difficult, too, to determine exactly the medial border of the nucleus nervi vestibuli medialis ; it goes over insensibly into the central gray matter surrounding the ventricle. In general the nucleus nervi vestibularis medialis begins from 2 J to 3 mm. below the superior end of the nucleus nervi hypoglossi and extends in the floor of the fourth ventricle as far forward as the nucleus nervi abducentis. Its anterior extremity (J' in the diagram) passes forward some distance further lateral to the nucleus of the sixth nerve. The descending tract of the nervus vestibuli begins at the entry zone of the vestibular root fibres in the region of the nucleus nervi vestibularis snperior (Bechterew), and of the nucleus nervi vestibularis lateralis (Deiters). It is made up of the descending branches of the root fibres and lies dorsal to the tnictus spinalis nervi trigemiui, at first at a distance of 1.3 mm. from the floor of the ventricle (Fig. 3). Farther posterior it approaches the floor, and the isolated bundles of fibres of which it is made up occupy a very characteristic oval area, the long diameter of which lies in the dorso-ventral direction (Fig. 3). A reference to the diagram will show that it extends downward from its origin in a straight line as far as the level of the superior (anterior) end of the nucleus nervi hypoglossi. From this point it curves medialwards, giving place to the nucleus funiculi cuueati. It can be traced downwards to a plane a little superior to the middle of the nucleus nervi hypoglossi. The ascending branches of the vestibular fibres are not represented in the diagram, but they are shown in figs. 3 and 4.*

At the extreme superior and lateral angle of the nucleus nervi vestibularis medialis is situated a.large group of cells, in part capping the descending tract of the vestibular nerve (Fig. 3, Nil. ij). It is oval in shape aud is distinctly visible in section just below the floor of the fourth ventricle. As will be seen in the diagram (Fig. 1, P), it lies adjacent to the nucleus nervi vestibularis lateralis, to the nucleus nervi vestibularis medialis, and to the nucleus nervi vestibularis spinalis (Kadix descendens). This nucleus, however, is worthy of a special description in that it is peculiar: (1) in the size of the cells, they being much larger than those of that part of the nucleus nervi vestibularis medialis marked M in the diagram, but smaller than those of the nucleus nervi vestibularis lateralis; (2) by the staining capacity of the mass, which on the whole stains in Weigert-Pal preparations of the new-born babe much darker than Deiters' nucleus of the


  • The so-called cerebellar acoustic nucleus of Ramon y Cajal, the

cells of which accompany these fibres, is not representeil. No attempt was made to locate in the diagram the gray masses in the roof of the cerebellum, with which tlie ascending branches of the vestibular nerve undoubtedly come into relation.


same section ; (3) by the fact that the cells are closely packed together, which brings it into marked contrast with the more scattered cells of the nucleus nervi vestibularis lateralis ; (4) by its distinct outline in ruell stained preparations, which makes this group of cells easier to differentiate than any of the other vestibular nuclei. A reference to Figs. 3 and 4, and to the diagram, Fig. 1, will show the position of the nucleus. This nucleus evidently corresponds to a part of the ganglion dorsale acusHci of v. Kolliker (Hattptkern of Sch walbe.) It is continuous posteriorly with the nucleus of the descending root, and laterally (in its posterior part) with the rest of the nucleus nervi vestibuli medialis. It is not so easy t.o locate it definitely in series in which the gray masses are not particularly well differentiated, but even in such a series, after having defined it easily in Dr. Hewetsou's sections, its limits have been recognized without much difficulty. Until attention can be paid to the course of the axones of these cells and a comparison can be instituted between its constituent neurones and those of the other vestibular nuclei, I prefer to give the group a distinct place in the diagram and to refer to it as nucleus y.

It may further be seen in the diagram that the nucleus nervi vestibularis lateralis and the nucleus nervi vestibularis superior are in the region of the entry zone of the vestibular nerve. The lateral nucleus appears to be separated into two portions by the root fibres of the nerve. One part {Lt in Fig. 1, and Nu. n. v. I, in Fig. 3) is further inferior (posterior) and lateral, and it lies also further ventral than the other part (Z/ in Fig. 1, and Nu. n. v. I in Fig. 4). L\ lies between the entry zone of the vestibular root fibres and the corpus restiforme. Its cells are rather smaller than those of L. The part of Deiters' nucleus marked L lies in its upper part almost in the floor of the fourth ventricle and is continuous laterally with Bechterew's nucleus, from which it can be easily distinguished, however, by the size of the cells. In the longitudinal series these two parts of Deiters' nuclei Zand L\ are seen to be in reality continuous; a few scattered cells joining them can be seen between the fibres of the nerve. They are seen with the high power not to be such separate entities as the diagram would make them appear. In his articles on the medulla oblongata Ramon y Cajal describes the nucleus nervi vestibularis lateralis in the white mouse as a crescent-shaped mass, convex on its dorsal border, and showing two sorts of cells, the larger being further ventral, the smaller more dorsal and lateral. In human tissue I find that the nucleus is convex on the ventral border, and to be so inclined that on the whole the smaller cells are further ventral as well as lateral. Fig. 3 shows the lateral portion (Zi)ofthe nucleus nervi vestibularis lateralis, while Fig. 4, which represents a section .6 mm. further forward, shows the medial portion (Z).

The nucleus nervi vestibularis superior (Bechterew) lies in the floor and lateral wall of the fourth ventricle, occupying its lateral angle. In the diagram. Fig. 1, it is marked .5 and is given a heavy outline. It lies in a plane dorsal to that of the nucleus nervi vestibularis medialis, and its inferior (posterior) extremity corresponds about to the inferior (posterior) end of Deiters' nucleus. As seen in the diagram


December, 1897.]


JOHNS HOPKINS HOSPITA.L BULLETIN.


255


it extends even further laterally than does the nucleus nervi vestibularis lateralis of Deiters. A reference to Figs. 3 and 4 will show that it is bounded laterally in a part of its course by the corpus restiforme. As the nucleus extends upwards (cerebral wards) it lies more and more dorsally, so that it comes to lie between the lateral wall of the ventricle and the brachium conjunctivum. It is interesting to note how far it can be traced at its cephalic extremity into the region of the nuclei of the nervus trigeminus. It is traversed by the ascending branches of the root fibres of the vestibular nerve.

Thtre seems to be a general agreement that the root fibres of the vestibular nerve bifurcate. The descending limbs pass into the descending root, many of the ascending go up into the cerebellum. Keceut investigations make it probable that axones also run in the opposite direction from the cerebellum to the nucleus nervi vestibularis lateralis. Fig. 4 shows two distinct sets of fibres extending between the cerebellum and Deiters' nucleus; one running between the brachium conjunctivum and the corpus restiforme and lying in the plane of the transverse section for a considerable distance, the other being more medial and going actually through the nucleus nervi vestibularis superior and the brachium conjunctivum. The latter fibres are so inclined that they do not run far in the plane of any one section, but by following the series downward (caudalwards) from the region of Deiters' nucleus, scattered fibres show in the brachium conjunctivum, lying in a plane perpendicular to the fibres of the latter, and so contrasting strongly with them. These fibres are farther dorsal in each succeeding section downward as far as the nucleus fastigii, dorsal to which a well marked decussation is visible (Figs. 3 and 2).

Fig. 5 repi'esents a longitudinal section taken through the area of the vestibular nuclei. The lines 66 on the transverse sections represent approximately the plane of this section. All of the vestibular nuclei, the nucleus nervi vestibularis medialis (with the part of it which I have designated nucleus F), the nucleus of the descending vestibular root, the nucleus nervi vestibularis lateralis and nucleus nervi vestibularis superior, are shown.

Very little of the nucleus nervi vestibularis superior shows, however, inasmuch as this nucleus lies for the most part dorsal to the plane of this section. It will be seen that there is a well marked group of fibres /? running obliquely forwards from the region of the nucleus nervi vestibularis superior. These fibres have been traced on both series, and the area they occupy is represented in the general diagram (Fig. 1, z). They extend between the nuclei of the nervus trigeminus and the raphe. Toward the floor of the ventricle they pass through the nucleus nervi vestibularis superior, as is shown in the diagram. They decussate in the raphe dorsal to the fasciculus longitudinalis medialis. As to their further course it is impossible to say from these sections.

Nervus Cochlea. The areas corresponding to the nuclei of the nervus cochleae are illustrated in Fig. 1. It is interesting to note that the nucleus nervi cochlearis dorsalis is continuous with the nucleus nervi cochlearis ven trails and that the transition from the one to the other is very rapid. Figure 6 represents a reconstruction to show the relations of the


cochlear nuclei to the corpus trapezoideum and the complex of the nucleus olivaris superior. The nucleus nervi cochlearis dorsalis begins just above (anterior to) the nucleus nervi hypoglossi. It is in the dorso-ventral direction a long, narrow nucleus, the apparent breadth of the area represeniing it in the diagram being due to the fact that it curves somewhat around the corpus restifoi-me. Its size and general character are illustrated in Fig. 2. Both the section and the diagram show how far lateral it lies, though it by no means extends so far lateral as the nucleus nervi cochlearis ventralis, a point which is in disagreement with many of the figures in the textbooks. It has comparatively few medullated axones in it, and these run parallel to the long axis of the nucleus as seen in transverse section. The division into three zones, a mesial, middle and lateral, is clearly shown in Fig. 2. This division has already been described by von Kolliker and by Sala. The mesial and lateral zones are rich in medullated fibres.*

In Fig. 6 is represented a flat reconstruction of the mesial and lateral bundles of medullated fibres of the nucleus nervi cochlearis dorsalis. The mesial bundle is marked m, and the lateral I. It may be seen that the areas corresponding to both bundles run toward the middle line.

The fact that the root bundle of the cochlear nerve enters the nucleus nervi cochlearis ventralis has been observed by Held and Sala. It is interesting to note in Fig. 6 that the area of the entering root bundle of the nervus cochlese is considerably superior (anterior) to that of the nucleus nervi cochlene dorsalis. Both Held and von Kolliker have described the bifurcation of the cochlear root fibres. Eamon y Cajal has observed the bifurcation both in the new-born mouse and in the rabbit and says that it takes place in the nucleus nervi cochlearis ventralis.

The two branches are, he states, usually equal in calibre, but the ascending branches are short and end in the nucleus nervi cochlearis ventralis. On the other hand the descending branches are longer and can be traced in a definite bundle to the inferior part of the nucleus nervi cochlearis ventralis and the nucleus nervi cochlearis dorsalis. He says that jn the mouse these fibres, at first scattered, soon form a definite bundle, which can be traced to the inferior part of the nucleus nervi cochlearis dorsalis. A bundle of medullated fibres, apparently corresponding to the bundle of axones described by Ramon y Cajal, has been easily traced in the sections I have studied, and is shown in the figure (Fig. 6, /*). Near the entry zone of the cochlear nerve it consists of scattered fibres, but it soon forms a compact bundle on the mesial border of the ventral nucleus. The bundle runs spinalwards and at the same time so rapidly dorsalwards that in cross section its fibres are cut almost longitudinally. The reconstruction brings out the fact that it is connected with the mesial zone of the nucleus nervi cochlearis dorsalis corresponding to the area of medullated fibres m (Fig. 6).

The arrangement of the fibres of the nucleus nervi cochlearis dorsalis in parallel lines has already been mentioned (Fig. 2). In strong contrast to this is the appearance of the nucleus


  • According to Sala the cells of the mesial layer and the middle

zone give rise to the striie acusticte.


256

[No. 81.


nervi cochlearia ventralis (Fig. 3). The arrangement of the cells and fibres of the ventral nucleus in the form of a basketwork has already been described by Held, von Kolliker and Ramon y Cajal. The latter divides the nucleus nervi cochlearis ventralis into two regions, an inferior (tail) and a superior (head). In the human tissue which I have studied it is the inferior part that is characterized by the basketwork. In the superior portion the cells are fewer and more scattered. Indeed, the cells are so scattered and there are so many fibres running to the corpus trapezoideum in this I'egion that it is very difficult to determine exactly in Weigert-Pal preparations the superior limit of the nucleus. The area C i. (Fig. 6) represents the corpus trapezoideum. It may be noticed that the lateral boundary of the corpus traiiezoideum is continuous with that of the lemniscus lateralis. In both series of sections a continuous line of cells can be traced from the nucleus olivaris superior to the nucleus of the lemniscus lateralis, so that it is impossible to say where the nucleus of the lemniscus lateralis begins. A description of the auditory neurones of the second order cannot be entered into at this time. The diagram shows vei-y clearly, however, the intimate connection of the nucleus nervi cochlearis ventralis with the corpus trapezoideum and superior olivary complex. An examination of Fig. 2 shows how few fibres are medullated at this period in the nucleus nervi cochlearis dorsalis. They are so scattered after leaving the nucleus that it is very difficult to follow them far. The long distance between the nucleus olivaris superior and the anterior extremity of the dorsal cochlear nucleus is another striking feature of the diagram.

This study was undertaken at the suggestion of Dr. Mall and Dr. Barker. I wish to thank them for constant advice and suggestion.

Bibliography.

1. Baginski : Ueber den Ursprung und den centraleu Verlauf des Nervus acusticus des Kaninchens. Virchow's Archiv, Bd. 105, H. 1, S. 28. — Ueber den Ursprung und den centraleu Verlauf des Nervus acusticus des Kaninchens und der Katze. Virchow's Archiv, Bd. 119, H. 1, S. 81.

2. Von Bechterew, W. : Ueber die inuere Abtheiluug des Strickkorpers und den achten Hirnnerven. Neurol. Centralbl., Bd. IV (1885), S. 145.— Zur Frage liber den Ursprung der Hornerven. Neurol. Centralbl., Bd. VI (1887), S. 193.— Zur Frage fiber die Striae medullares desverliingerten Markes. Neurol. Centralbl., Bd. XI, 1892, S. 297.— Der hintere Zweihiigel als Centrum fiir das Gehor, die Stimme und die Eeflexbewegungen. Neurol. Centralbl., Bd. XIV (1895), S. 706.

3. Bumm: Experimenteller Beitrag zur Kenutnissdes Hornerveuursprungs beim Kaninchen. Allgem. Zeitschrift f. Psych , Bd. 45, S. 568. — Experimentelle Untersuchungen fiber das Corpus trapezoides und den Hornerven der Katze. Festschr. zur 150 jithr. Stiftungsfeier der Univ. Erlangen, Wiesbaden, 1893 ; Abstract Neur. Centralbl., Bd. XIII (1894), S. 448.

4. Cajal, Eamon y S. : Beitrag zum Studium der Medulla oblongata des Kleinhirns und des Ursprungs der Gehirnnerven. Deut. Uebersetz. von Bresler. Leipzig, 1896.

5. Cramer, A.: Beitriige zur feineren Anatomic der Medulla oblongata und der Briicke mit besonderer Beriicksichtigung des 3.-12. Hirnnerven. Jena, 1894.


6. Flechsig, P. : Zur Lehre vom centraleu Verlauf der Sinuesnerven. Neurol. Centralbl., Bd. V (18S6), No. 23.— Weitere Mittheilungen fiber die Beziehungen des unteren Vierhfigels zum Hornerven. Neurol. Centralbl., Bd. IX, 1890, S. 98.

7. Forel: Vorlitufige Mittheilung iiber den Ursprung des Nervus acusticus. Neurol. Centralbl., Bd. IV, 1885, S. 101.

8. Held, H.: Die centraleu Bahnendes Nervus acusticus bei der Katze. Arch. f. Anat. und Phys., Anat. Abth., 1891. — Die Endigungsweise der sensiblen Nerven im Gehirn. Arch, f. Anat. u. Phys., Anat. Abth., 1892. — Die centrale Gehorleitung. Arch. f. Anat. u. Phys., Anat. Abth., 1893.— Ueber eine directe acustische Eindenbahu und den Ursprung des Vorderstrangrestes beim Menschen. Arch. f. Anat. u. Physiol., Anat. Abth., 1892.

9. Kirilzew: Zur Lehre vom Ursprung und centralen Verlauf der Gehornerven. Vorliiufige Mitth., Neurol. Centralbl., Bd. XI (1892), S. 669.

10. Von Kolliker : Der feinere Bau des verliingerten Markes. Anat. Anzeiger, Bd. VI (1891), S. 427-431 ; Handbuch der Gewebelehre des Menschen, 6 Aufl., II. Bd. 1893.

11. Martin, P. : Zur Endigung des Nervus acusticus im Gehirn der Katze. Anat. Anzeiger, Bd. IX (1894), S. 181.

12. Von Monakow: Ueber den Ursprung und den centralen Verlauf des Nervus acusticus. Correspondeuzblattf. Schweizer Aerzte, 1887, No. 5 ; Abstract in Neurolog. Centralblatt, Bd. VI, 1887, S. 201.— Striae acusticae und untere Schleife. Arch. f. Psych, u. Nervenkr., Bd. XXII, S. 1.

13. Onufrowicz, B. : Experimenteller Beitrag zur Kenntniss des Ursprungs des Nervus acusticus des Kaninchens. Arch, f. Psych, und Nervenkr., Bd. XVI, S. 711.

14. Eoller : Die cerebralen und cerebellaren Verbindungeu des 3.-12. Hirnnervenpaares. Die spinaleu Wurzeln der cerebralen Sinnesnerven. Allgem. Zeitsch. f. Psych., Bd. XXXVIII (1882), S. 228.

15. Sala, L. : Sur I'origine du nerf acoustique. Arch. ital. de biol., t. XVI, 1891, p. 196 ; also in Monitore zoologico italiano, Florence, Ann. II (1891), and in Neurol. Centralbl., Bd. XI, 1892, S. 200.

Legends for Figures. Fig. 1. Diagram representing flat reconstruction of the nuclei of reception of the cochlear and vestibular nerves. The line a, a represents the lateral wall of the ventricle; the line b corres2ionds to the lateral outline of the corpus restiforme ; the line d\ to (U, (h to rfa, and the line e, e, e correspond to sulci in the floor of the fourth ventricle ; C. d., nucleus nervi cochlearis dorsalis ; G. v., nucleus nervi cochlearis ventralis ; the graduated line corresponds to the middle line of the floor of the ventricle. Flor., flocculus ; K. VII, knee of nervus facialis; L., medial portion of nucleus nervi vestibuli lateralis (Deiters); L\, lateral portion of nucleus nervi vestibuli lateralis (Deiters) ; M together with y, nucleus uervi vestibuli medialis (Schwalbe); Nuc. XII, nucleus nervi hypoglossi; Nuc. VI, nucleus nervi abducentis ; F.f., pedunculus flocculi ; N.m.p. F., nucleus motorius princeps nervi trigemini ; N.o. s., nucleus olivaris superior ; A', s. V., nucleus uervi trigemini (sensory); TV. c, root bundle of nervus cochleie; N.vesi., root bundle of nervus vestibuli; Ii. d. n. re, radix descendens nervi


258

[No. 81.


vestibuli ; iS., nucleus uervi vestibuli sujjerior (Bechterew) (area enclosed iu the broad black Hue) ; Ti: s. n. t., tractus spinalis nervi tvigemini; F, nucleus ?/, antero-lateral portion of nucleus nervi vestibuli medialis ; z, decussatio nervi trigeniini.

JrConj, Cr



Fig. 3 (corresponds approximately to line 3 on the diagram, Fig. 1). G.r., corpus restifornie; F. (f., fasciculus ventro-lat


eralis (Gowersi); i^. ?.?»., fasciculus longitudinalis medialis; N. XII, root bundles of the nervus hypoglossus; Nu. d., nucleus dentatus cerebelli ; N^(. n. c. d., nucleus nervi cochlearis dorsalis ; N. o. i., nucleus olivaris inferior ; Nu. n. v. m., nucleus nervi vestibularis medialis ; Nu. t.s., nucleus tractus solitarius ; Py., pyramis ; R.d.n.i'esf.,Ym\\\ descendeus nervi vestibuli.



Fig. 3 (corresponds approximately to line 4 on the diag. Fig. 1). Br.Conj., brachium coujunctivum ; C. r., corpus restiforme; i. G'., fasciculus veutro-lateralis (Gowersi); F.J.m., fasciculus longitudinalis medialis; i\. c, nervus cochlese; N. IX and X, nervus glossopharyugeus et vagus ; JVJt. n. c. v., nucleus nervi cochlearis ventralis ; Nu. «. v. I., nucleus nervi vestibularis lateralis (Deiters) ; Nu. n. v. m., nucleus nervi vestibularis medialis (Schwalbe) ; N^i. n. v. s., nucleus nervi vestibularis superior (Bechterew) ; A^«. o. /., nucleus olivaris inferior ; Nu. y., nucleus y (anterior-lateral portion of nucleus nervi vestibularis medialis); P. /., peduneulus fiocculi ; Py., pyramis ; R. d. n. vest., radix descendeus nervi vestibuli ; (SV. )'. l, stratum interolivare lemnisci.

Fig. 4 (corresponds approximately to line 5 on the diagram, Fig. 1). jBr. Conj., brachium coujunctivum ; 0. r., corpus restifornie; F. I. in., fasciculus longitudinalis medialis; F. p., libra? pontis; iV.c, nervus cochlere; N. VI f, nervus facialis;


December, 1897.]

259


JV.vesL, nervus vestibuli; Nu.n. VI, nucleus iiervi abduceutis ; JVu. n. VII, nucleus nervi facialis ; JVu. n. c. v., nucleus ner?i cochlearis ventralis; Nu.o.i., nucleus olivaris inferior; Pif., pyramis; S.g., substantia gelatinosa; St.i.l., stratum iuterolivare lemnisci; Tr.s.n.t., tractus spinalis nervi trigemini.

Fig. 5 (section 66, horizontal sei-ies). a, fibres extending between lateral lemniscus and brachium conjunctivum; Aq.c, aqueductus cerebri; /J, decussating fibres of nervus trigeminus; C. I., colliculus inferior; C r, corpus restiforme; C. s., colliculus superior; F. c, fasciculus cuneatus ; F. g., fasciculus gracilis ; L. I., lemniscus lateralis ; N. IV, root fibres of nervus trochlearis; iVJ«. «. c, nucleus alse cinerets; Nu.n.c.d., nucleus nervi cochlearis dorsalis ; Nu.f. c, nucleus funiculi cuneati; Nu.f.g., nucleus funiculi gracilis; Nu.n. v. I., nucleus nervi vestibularis lateralis (pars medialis) ; Nu. n. v. h, nucleus nervi vestibularis latei'alis (pars lateralis); Nu. n. v. m., nuc


leus nervi vestibularis medialis ; Nu. n. v. s., nucleus nervi vestibularis superior (Bechterew); Mi. n. XII, nucleus nervi hypoglossi; Nu.Vl, nucleus nervi abducentis ; Nu. Y, nucleus y (antero-lateral portion of nucleus nervi vestibularis medialis) ; R. d. n. t., radix descendens nervi trigemini ; R. d. n. vest., radix descendens nervi vestibuli ; TV. s., tractus solitarius. Fig. 6. Diagram representing flat reconstruction of nuclei nervi cochlearis and corpus trapezoideum. C. d , nucleus nervi cochlearis dorsalis ; C. f., corpus trapezoideum ; C. v., nucleus nervi cochlearis ventralis; h., portion of root bundle of cochlear nerve running past the ventral cochlear nucleus to the region of the dorsal cochlear nucleus ; I., area occupied by medullated fibres of lateral portion of dorsal cochlear nucleus ; ?«., area occupied by medullated fibres in the medial portion of the dorsal cochlear nucleus; L.I., region of lemniscus lateralis; N.c, nervus cochlea; Mo.s., complex of nucleus olivaris superior.


TYPHOID INFECTION WITHOUT INTESTINAL LESIONS.

By Simon Flexner, M. D., and Norman McL. Harris, M. B.

[From the Patliological Laboratory of the Johns Hopkins University and Hospital.']


The observation that the clinical symptoms of typhoid fever may co-exist with relatively very slight intestinal lesions indi_cative of the disease is not a new one, but it was not jiossible before the present era in bacteriological study, and especially before the isolation of the bacillus typhosus by Gaffky, to bring forward conclusive evidence of the occurrence of typhoid fever without any demonstrable intestinal lesions whatever. The studies of the last few years have shown the typhoid bacillus to be much more widely disseminated than would have been predicted, and to be associated with a considerable number of different pathological conditions. But thus far the number of instances in which the typhoid bacillus has been found in human cases which presented during life the symptoms of typhoid fever and in which there was an entire absence of intestinal lesions at autopsy, is limited to a very few authentic reports. Accepting the cases reported by Banti,f Karlinski,J and Guaruieri,!! which date from a period in which the difficulty in separating the bacillus typhosus from the colon group of organisms was less appreciated than now, there exist, in addition, in the literature available to us, the cases of Du Cazal,§ Kiihnau,^] Guinon andMeunier,** Pick,tfand especially those of Chiari and Kraus.|J

  • A more complete report on this subject is reserved for the

Report on Typhoid Fever, No. 3, to be issued in the Johns Hopkins Hospital Reports, Vol. VII.

t Riforma medica, Ottobre 1887 ; Ref. Baumgarten's Jahresbericht, 1888, p. 148.

t Wiener med. Wochenachrift, 1891, No. 11 u. 12.

||Riv. gen. ital. di clin. med. 1892; Ref. Baumgarten's Jahresbericht, 1892, p. 234.

§Bull. et m^m. Soc. med. d. h6p. de Paris, 189,3, p. 243.

Tl Berliner klin. Wochenschrift, 1896, No. 30.

••Le Bull, med., 1897, p. 313.

ttWiener klin. Wochenschrift, 1897, No. 4.

XX Zeitschrift f . Heilkunde, 1897, Heft. V u. VI, p. 471.


Guarnieri as early as 1892 described a case of primary typhoid infection of the bile passages (angio-cholitis). Lesions of the intestine were absent; but cultures from the liver and spleen, as well as a culture made from the blood 12 days before death, gave growths of bacilli having the character of the bacillus typhosus. In the case reported by Du Cazal the symptoms during life were those of typhoid fever, but at the autopsy there could not be discovered, even upon the closest inspection, any lesion of the intestinal mucosa. However, the mesenteric glands, spleen and kidneys were in a swollen and congested condition, and cultures from the much enlarged spleen yielded a growth of bacilli morphologically and culturally agreeing with the bacillus typhosus.

The very recent case of Kiihnau occurred in a puerperal woman 32 years of age, who died in the eighth week of the disease. There was an absence of intestinal lesions at the autopsy. The mesenteric glands were swollen and showed areas of necroses or abscesses, the kidneys also contained abscesses, and the left internal spermatic vein contained a partially softened thrombus. Typhoid bacilli were isolated from the abscesses and from the spleen. The case of Guinon and Meunier is of much interest, as it indicates an unusual portal of entry of the typhoid bacillus. The patient, a boy 8 years of age, presented the symptoms of recent lung tuberculosis. Some days after his entrance to the hospital rose spots appeared and the temperature curve became typhoidal. The Widal reaction was positive. At the autopsy the lesions appeared to be those of acute miliary tuberculosis, small ulcers in the intestine being typically tubercular in character. Typhoid bacilli, however, wei'e cultivated from the spleen, pleural fluid and lungs. The peculiar lesions of typhoid fever were not present. Pick's case gave a marked positive serum reaction, but at autopsy no typhoid intestinal lesions and no swelling of the spleen were found; the bacteri


260

[No. 81.


ological examination gave typhoid bacilli, not, however, in the spleen.

The most important contribution to this subject has just been made by Chiari and Kraus. They had the remarkable experience of finding in 19 cases (autopsies from January to May, 1897) of typhoid fever, 7 in which the anatomical lesions of the disease were wanting. The negative eases from thepost mortem point of view had, however, given positive serum reactions. Chiari and Kraus divide the cases of typhoid fever into four anatomical groups. The first is the group of anatomically typhoid cases; the second, anatomically atypical cases in which, however, at the autopsy a diagnosis can still be made ; the third comprises cases in which an anatomical diagnosis of typhoid fever is not possible, but in which the bacteriological examination discloses infection with typhoid bacilli. Among these cases examples of typhoid septicaamia are met with. His fourth group contains instauces in which no anatomical typhoid lesions exist, the serum test during life being positive, but in which at autopsy the bacteriological examination is negative while the serum test may still be positive.

Of interest to us, in this connection, are groups II and III, especially the latter. In the three cases reported by Chiari and Kraus belonging to the second group the intestinal lesions consisted of slight swelling of follicles in the ileum or large intestine ; no necrosis. Mesenteric glands and spleen usually enlarged. The cultures from the mesenteric glands, spleen and bile were positive in one case only, so that the diagnosis of typhoid fever rests largely upon the serum reaction.

Chiari and Kraus describe in their third group five cases. These are regarded as anatomically non-diagnoscible. They represent, in their opinion, examples of typhoid septicajmia. We purposely refrain from discussing their views at this time, but will call attention only to the fact that iu three of the cases only were bacilli demonstrated in cultures. In their Case XIII, from the gall-bladder and mesenteric glands; spleen negative; Case XIV, bile immediately at autopsy negative, but from the bile after several days iu the thermostat pure culture of bacillus typhosus ; mesenteric glands and spleen negative ; Case XVII, gall-bladder, b. coli com.; spleen, staphylococcus aureus; urine, staphylococcus aureus and b. typhi; abscesses kidney, s. aureus; pneumonic lung, micrococcus lanceolatus. The remaining two cases (XV and XVI) showed upon histological examination clumps of bacilli in mesenteric glands, and in Case XV in the spleen as well; cultures negative.

• The case which we have encountered will be found to belong to the third group of the above classification. It, however, fulfills the conditions there laid down much more perfectly than any of the cases given. We are indebted to Dr. Osier for the privilege of abstracting the clinical notes.

Clinical Summary. W. G., male, aged 68, native of U. S., admitted to hospital, October 38th. On entrance complains of shortness of breath. Past history unimportant. Present illness dates back two months, since which time he has been losing weight and strength. Appetite poor. No chills or fever; no night sweats. Two weeks ago suffered from


severe pain in the back ; shortness of breath began at this time, as well as painful sensations in the abdomen. October 2Cth, while undressing, fell to the floor; very quiet next day, not having moved from the position in which he had been placed on the bed.

On admission (Oct. 38th) very dull and listless; seems in much pain ; groaning with each expiration. Kespirations -14 to minute. Thorax : somewhat barrel-shaped ; right side more prominent than left; jjercussion note in front hyper-resonant; in back more resonant than normal. Eespiration harsh; expiration prolonged; loud friction rub iu axilla. Heart: relative dullness at sternal margin 3d rib ; absolute dullness at 4th rib. Point of maximum impulse visible and palpable in 5th space 10 cm. from median line. Spleen : not palpable. Examination of blood negative for malarial organisms ; leucocytosis of 18,000. Patient gradually sank and died at 10 o'clock, October 30th.

Abstract of Protocol. — Anatomical Diagnosis. Typhoid fever without intestinal lesions ; typhoid septictemia. Thrombosis of main branch of pulmonary artery supplying lower lobe of right lung ; gangreue of lung ; perforation of pleura ; pyo-pneumo-thorax. Acute splenic tumor. Parenchymatous degeneration of liver and kidneys ; obliteration of lumen of appendix vermiformis.

Autopsy, one hour post mortem. Body of a large, stronglybuilt and moderately well-nourished man. Surface of the body presents a sallow hue. Patchy li vor mortis over posterior aspects of the trunk.

The right half of the thorax is more prominent than the left; on percussion hyper-resonant. Diaphragm at right side 7th rib ; left side 6th space. On puncturing the right pleural cavity under water free escape of gas.

The right lung is compressed, the upper and middle lobes are quite airless ; the lower lobe more voluminous ; this lobe is bound to the diaphragm by old adhesions. The parietal pleura is generally thickened and covered by a layer of shaggy fibrin. The fibrinous membrane is thickest over the visceral pleural membrane. The lower lobe is not only voluminous, but of very dark color and quite solid consistence. The pseudo-membrane covering this portion of the lung is also dark in color. On the removal of this membrane several defects in the pleura become evident ; but the whole pleural membrane is so friable that it easily breaks on handling the specimen. The main branch of the pulmonary artery supplying this lobe is occluded by a moderately firm, partially decolorized thrombus, from which more recent, usually red, thrombi extend into the communicating branches iu several directions. The section of this lobe of the lung presents a dark greyish appearance. The odor is moderately offensive.

Spleen weighs 160 grams; consistence diminished; cut surface dark iu color.

The gall-bladder moderately distended with thick, darkcolored bile. Contains a large number of small concretions (gall-stones).

The 03Sophagus, stomach and intestines, except the appendix vermiformis, which is converted into a fibrous cord, show nothing abnormal.

The mesenteric glands are not swollen.


December, 1897.]

261


Bdderiological examination. Plate cultures upou agar-agar were made from the heart's blood, right lung (gangrenous portion), left lung, liver, kidneys and spleen, and a blood serum tube was inoculated from the cerebro-spinal fluid. After 48 hours in the thermostat at 37° C. the plate from the heart and the serum tube only remained sterile.

The results of the plate method were as follows : Plate from the consolidated right lung crowded with colonies, necessitating replating ; plate from left lung about 65 separate colonies ; from the spleen eleven colonies ; liver 80 to 90 colonies ; kidney a single colony only. With the exception of the single colony in the kidney, which proved to be a diplococcus forming at times short chains, a single bacillary form only was found in all the plates.

In morphology the organism isolated from the plates agreed with the bacillus typhosus. The tests employed to distinguish the colonies from each plate consisted of growths on agar-agar, potato, litmus-milk and 1 per cent, glucoseagar ; the absence of indol in Dunham's solution,* the demonstration of flagella with the arrangement seen in typhoid bacilli (peri-tricha), and finally the reaction with blood serum from a case of undoubted typhoid fever.

The bacilli isolated from the various sources were actively motile, grew characteristically upon agar-agar, slightly reddened but did not coagulate the litmus-milk, failed to ferment glucose-agar, but upou the potatoes gave vise to a slightly visible growth. Parallel cultures upon potato made with typhoid bacilli of known origin showed a similar growth in each. The agglutinating reaction was obtained in 30 minutes


with a serum dilution of 1 to 35, and in one hour with a dilution of 1 to 50.

The cover-slip preparations from the gangrenous lung and pleural exudate showed bacillary forms of several kinds, including large, coarse individuals not unlike certain putrefactive bacteria. It is interesting to note that upon the aerobic plates only the bacillus typhosus developed.

Histological examination. Study of sections of the liver, spleen and kidneys from the case stained by the ordinary histological methods, and especially for bacteria (carbolthionin, polychrome methylene-blue, alkaline niethyleneblue), failed to develop anything which especially supports the diagnosis of typhoid infection. The " lymphomata " so often found in the liver of ordinary cases of typhoid fever were absent, a single area of necrotic liver cells the size of a miliary tubercle alone being found in many sections; and the typical appearance of clumping of the bacilli in the spleen and liver was wanting, while, however, single bacilli were discovered in several sections. The spleen showed a moderate hyperplasia of lymph cells and considerable congestion; the liver cells were swollen and granular.

The tests employed for the identification of the organisms isolated from the several viscera leave no doubt as to their nature, and the case therefore is properly to be regarded as one of typhoid infection without intestinal lesions or glandular enlargement. Indeed it would have been impossible to diagnose the case as typhoid fever in the absence of the bacteriological examination.


APPARATUS FOR STERILIZINCx INSTRUMENTS WITH FORMALDEHYDE; EXPERIMENTAL TESTS.

By H. 0. Eeik, M. D., and AV. T. Watson, M. D.


At the recent meeting of the American Medical Association in Philadelphia, Dr. E. A. de Schweinitz, bacteriologist to the Bureau of Animal Industry, United States Department of Agriculture, presented to the Ophthalmological Section a paper treating of the sterilization of instruments by formaldehyde, both in solution and in the gaseous form.

Knives which had been used in dissecting were washed in water and placed in a 1 to 2000 formaldehyde solution. It was found that in thirty-five minutes they were completely sterilized.

In testing the effect of the gas, a small copper drying oven was used, and 25 cc. of 40 per cent, formaldehyde solution (the preparation known as formalin) was placed in a small dish in the bottom of the oven. The instruments used were proven sterile, then infected with staphylococcus pyogenes aureus, wiped with dry cotton, placed in the oven, and when tested after ten minutes showed growth on culture media. If knives infected in a similar manner were rinsed in hot water, wiped dry and placed in the oven, no growth was


•Planted in Peckham's alkali-peptone bouillon and incubated for 3 days, a faint but unmistakable indol reaction could be obtained. See Journal Experimental Medicine, No. 5, 1897.


noted after a teii minutes' exposure. Forceps treated in the same way required from fifteen to twenty minutes. The gas used was obtained by spontaneous evaporation of formalin, but it is important to note that "the solution of the gas was placed in the oven some hours before the instruments which were to be disinfected, in order that a sufficient volume of the gas might be present to act immediately upon the organisms adhering to the knives."

The length of time required to disinfect the knives by the formalin solution and the length of time required to generate the gas in the chamber previous to disinfection would materially interfere with the practicability of these methods, for if so much time is necessary to put them into operation they offer but little advantage over other methods.

Again, we would respectfully suggest that the tests were scarcely conclusive as to the value of the gas, for, may not some portion, at least, of the disinfection have been produced by the rinsing of the infected instruments in hot water and their subsequent wiping with dry cotton ?

We have seen no other report of work in the direction of disinfecting instruments with formaldehyde, although Dr. Valude, in the Revue Generale d'Ophthalmologie for July, 1893, recommended that, " as formalin does not attack metals,


262

[No. 81.


it is well adapted for antiseptic solutions in which to keep instruments before and during operations."

The report by Dr. de Schweinitz, however, in connection with the experiments of others to disinfect various objects and large areas, led us to expect that instruments could be more quickly sterilized by the gas if it could be conveniently and rapidly prepared in a small apparatus. We used in our experiments the box exhibited here, simply an air-tight tin oven with a capacity of 1} cubic feet. By the introduction of wooden blocks the capacity was reduced to 1 cubic foot. Two racks or trays for holding instruments are suspended in the upper half of the box and the gas is manufactured below. We first attempted to secure the gas by spontaneous evaporation. One hundred cc. of the 40 per cent, solution, formalin, was placed in an evaporating dish in the bottom of the box and presented a surface of about 16 sq. inches. The knives and probes here presented, and which were used in all our tests, were infected with a fresh culture of staphylococcus pyogenes aureus and placed on the racks over the formalin dish. The cover was then removed from this dish, the door of the apparatus quickly closed and evaporation allowed to proceed. At the end of 1 minute the door was opened, the knife removed, and the formalin dish re-covered. A culture was made from this knife upon agar and placed in the thermostat. Control cultures were also made from the aureus used, in order to be sure of its vitality.

This experiment was repeated with the exception that the time of exposure was lengthened to 2, 3, 4, 5, 10 and 15 minutes. Then a jump of large intervals was made, the tests being at half-hour intervals up to four hours. In every interval between the tests the door of the box was left open to permit escape of the gas, so that there might be no accumulation of it and we might thus be able to determine just how long au exposure to the spontaneous evaporation of the gas would be necessary. The time proved much longer than we had expected, and it was only after a 2i hour exposure that we could feel sure of sterilization. This would evidently not do for practical work and we were compelled to look for some more rapid means.

We did not use formalin for the generation of the formaldehyde gas by heat, for two reasons : 1st, we feared that the heat which would drive off the gas would at the same time vaporize the water which contained it and thus possibly cause a rusting of the instruments; 3nd, we found in paraform a much more convenient substance for the purpose.

Paraform is polymerized formaldehyde and occurs as a light white jjowder, which can by means of heat be entirely converted into formaldehyde. Commercially it can be obtained in the form of j)astilles weighing 1 gram each.

The next problem was how to get the gas in the chamber. Should it be generated outside and then introduced, or could we generate it inside the apparatus ? To generate it outside has many objections. Our next experiments were made to discover if it were possible to vaporize the tablets by means of a lamp inside the closed chamber. We feared that the oxygen contained in the chamber would not support combustion long enough to develop suflBcient heat to generate the amount of formaldehyde needed. Our fears in this regard


proved to be quite unfounded, but we found that the kind of alcohol lamp used was a very important factor. After using two ordinary alcohol lamps in our possession we abandoned them for the Sobering formalin lamp, which we found more efficacious, generating far more gas with the amount of oxygen at our disposal and beins: much more economical in the use of alcohol.

This lamp we find will burn in a closed chamber containing 1 cubic foot of air for about 14 minutes. In that time it will vaporize 35 grains of paraform. The temperature of the apparatus will be raised in this time to less than 30 degrees Centigrade, so that the element of heat does not affect our results.

This amount (35 grains) of paraform was found to be far in excess of the quantity necessary to disinfect this chamber. We then proceeded to find the minimum amount of paraform required to disinfect the chamber in a reasonable length of time. We vaporized quantities ranging from 3 grains up to 10 grains for different intervals of time. Even 2 grains will sterilize the chamber if given sufficient time. Three grains will do it in 15 minutes, 5 grains in 10 minutes, and 10 grains in 7 minutes. We could not proceed in this way indefinitely to use larger quantities and diminish the time because 10 grains in 7 minutes is the full vaporizing capacity of the lamp. Nor is it desirable to increase the amount of jiaraform, for when the chamber is opened there is an escape of gas into the room which, while not injurious or particularly objectionable, yet is not to be desired. For practical purposes 10 or 15 miniites is a short enough time for the sterilization of instruments, and this can be done with 5 or 3 grains of paraform.

The micro-organisms used in these experiments were the staphylococcus pyogenes aureus and the anthrax bacillus. The knives were sterilized by boiling and then infected from slant agar cultures. The germs could in every instance be seen en masse upon the instruments when put into the chamber. After exposure to the gas, cultures were made upon slant agar.

One feature of this disinfection by evaporation of the paraform needs a little further investigation. After performing numerous experiments during which large quantities of paraform were vaporized, there appeared upon the sides of the chamber a thin greasy deposit which afterwards became converted into a dry white powder. This, we are informed from the literature on the subject, is paraform which has become deposited again from the gaseous state. We did not in any instance find this deposit visible upon our instruments, still the possibility of its adhering we have in mind, and later will experiment to determine whether or not it is present, and if so, whether or not it would have a deleterious influence upon wounds. From the literature at our command we believe that there is but little danger from this source.

Another important matter to be considered is whether or not the cutting edge of the instruments is dulled by this method of disinfection. Upon this point we have the opinions of Drs. E. A. de Schweinitz and Swan M. Burnett of Washington, who state that from the use both of the gas and of the liquid formalin there has been no influence whatever upon the sharpness of the instruments.


December, 1897.]

263


From these experiments we conclude that :

1st. A lamp will hum in any absolutely closed chamber long enough to generate more than sufficient formaldehyde for its disinfection.

2nd. In a chamber of 1 cubic foot space 3 grains of paraform in 15 minutes, or 5 grains in 10 minutes, will accomj)lish disinfection.

3rd. The expense of such disinfection, including the cost of paraform and alcohol, will not exceed 1 cent, and the labor involved is almost nil.

4th. For the disinfection of small instruments, such as those used by ophthalmologists, otologists, laryngologists and dentists, it is by far the most convenient and speedy method.

5th. This method, probably better than any other, for the work designed, carries out the principles of disinfection laid down by Koch, viz. " the absolutely certain destruction of all pathogenic organisms, in the shortest possible time, at the least expense and with a minimum of injury to the object of disinfection."

E. B. Meyrowitz, of New York, has in preparation an apparatus specially designed by us for the use of this method, and Sobering and Glatz will manufacture pastilles of 5 grains each for use in the apparatus.

In concluding we wish to thank Dr. McShane for permission to conduct these experiments in the City's Bacteriological Laboratory, and Dr. Stokes for advice and guidance in our work.

Discussion.

Dr. OuLLEN. — Dr. Hurdon is, at the suggestion of Dr. Kelly, now carrying on experiments in this line. The apparatus used contains about 6 cubic feet, and particular attention has been paid to the sterilization of dressings. Using four pastilles of paraform it was possible to render a piece of gauze that had been dipped in a jnire culture of anthrax, sterile in ten minutes, but if the piece of gauze was wrapped in seven or eight layers of gauze and this bundle enveloped in three thicknesses of foolscap paper, twenty minutes were required for sterilization. The only disadvantage noted was that on opening the box the escaping gas caused considerable irritation of the eyes of those in the room. With regard to the effect on instruments I was glad to hear what Dr. Keik said, because the ophthalmologist's instruments are so delicate, and, as Dr. Kinyoun, in a recent report on experiments with formaldehyde, states that gold and


silver are not affected, but that the effect on the iron is to cause oxidation.

Dr. Theobald. — I was very much interested in the report by Dr. Reik, and I think it would be a distinct advantage if we could have such a sure and easy method of disinfection of our instruments. It is very diflBcult to submit our instruments to boiling or even to dry heat without dulling the knives, and they also become tarnished when immersed only for a few moments. To sterilize them by this method would certainly seem to be a distinct gain.

Dr. Watson.— I would like to ask Dr. Cullen whether Dr. Hurdon found much deposit on the bandages. I read in a circular issued by the manufacturers of the pastilles that after vaporizing the paraform it was readily deposited upon woolen goods. We did not find it on the knives at all, and thought possibly this might be due to their smooth surfaces or to the nature of the metal.

Dr. Cullen. — The box used was six cubic feet, very large, and Dr. Hurdon has not noticed any deposit.

Dr. Stokes. — These experiments are of value when viewed from several different standpoints. It is a good thing to have proved that the spontaneous evaporation of the gas is not a very practical method for the sterilization of instruments, and again it is of value to have shown that the evaporation of such small quantities of the gas from the solid pastilles will cause the thorough surfiice disinfection of such a chamber.

This work seems to show that it is possible to render not only the instruments of the ophthalmologists sterile, but to destroy bacteria on the surfaces of even larger instruments, and so this method may be applied in general surgery.

I am also glad to learn from Dr. Cullen that several layers of gauze can be disinfected even when wrapped in paper, for that seems to show that the ordinary dressings used by the ophthalmologists, for instance, may be rendered sterile. I think the general experience with formaldehyde has shown that with finely woven textures, like cotton, penetration is a difficult thing to attain.

In regard to Kinyoun's experiments, they were performed in a large room and the gas was allowed to remain in contact with the iron lor some time. I hardly think that any harm could be done the instruments in just the few minutes they are exposed in this chamber, but this can be determined by further experimentation.


PROCEEDINGS OF SOCIETIES.


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of October 4, 1897. Dr. Barker in the Chair.

Exhibition of Specimens.— Fibroid Lnng-Bronchiectasis—

Brain Abscess. — Dr. Livingood.

The first is a section of lung showing fibroid induration. The upper lobe is uniformly solid, grey and very firm. The middle lobe is not so firm. The lower lobe is congested and shows an area of fibrous induration in the lower part. Extend


ing through these solidified portions are tubular bronchiectatic cavities with blood-stained walls.

The other specimen is a section through the right hemisphere of the brain about the paracentral convolution, in the upper part of which is an abscess cavity the walls of which are irregular.

Both these specimens came from the same case and demonstrate an interesting association. Their color is partially preserved by the Kaiserling method, but is no longer as intense as at the time of autopsy.


264

[No. 81.


The case was that of a young colored man (F. C), 21 years old, who was brought here by strangers in a half-conscious condition, so that at the time of admission no history at all could be obtained, except that he had been working but half a day at North Point, when he was " taken with a fit," his condition later being the same as at the time of admission. It was learned later that he had been living a rough life, wandering about the country in search of work ; that he had had a cough for two years and was said by his friends to have had "consumption."

On admission he did not present the appearance of one who was suffering from chronic disease ; his frame was well formed and there was no evidence of emaciation. He died four days after admission. During this time his condition remained about the same, except that he became progressively weaker, and during the last two days had an apparent right-sided hemiplegia and athetoid movements of left arm. His greatest distress seemed to be a violent pain in the head. He was in profound stupor during this whole time ; was seized with paroxysms of coughing of a sharp, moist character, accompanied by very little expectoration owing to his weakness and stupor. The sputum which was obtained was of a dark reddish-brown color, containing necrotic material and of extremely foetid odor. Examination showed it to contain pus and epithelial cells and a great number of organisms, both cocci and bacilli, none of which showed the typical staining reaction of tubercle bacilli. He was extremely restless at times, and in the last two days showed athetoid movements of the left side. I will have to omit the other interesting nervous phenomena which were noted by Dr. Camac and Dr. Bardeen at different times. His temperature curve was very irregular, running up each evening ; once to 104.5° F.

Physical examination of his chest indicated complete consolidation of the upper lobe of the right lung, which was noted to be very intense ; signs of partial consolidation in the lower lobe. Associated with these signs were coarse, moist rdles. The left lung was apparently normal during the first three days, on the fourth day there developed signs of broncho-pneumonia.

At autopsy the right pleural cavity was found obliterated in the upper part. The middle lobe of the lung was slightly adherent. The lower lobe was very firmly attached to the diaphragm about the middle of its posterior margin. The fibrous adhesions about the upper lobe were very dense, and at two points the sub-pleural tissue seemed to be involved, so tliat on freeing the lung some of its substance remained adherent to the ribs at these points. In this way two cavities were exposed extending into the lung tissue.

The pleura covering the upper lobe was oedematous. The lobe was strikingly firm, voluminous, with little puckering and of grey color. The middle lobe was more resistant than normal, likewise grey, but more translucent than the upper lobe. The lower lobe was for the most part congested, but through its substance ran an area of fibrous consolidation, broadest in the lower part where the lung was adherent to the diaphragm.

On section through the lung, the upper lobe had a firm, glistening, almost cartilaginous appearance, with broad


strands of fibrous tissue radiating out from the thickened bronchi. Scattered over the surface were small translucent and opaque yellow points resembling miliary tubercles. The middle lobe was not so completely solidified, it appeared more translucent and elastic. The lower lobe had a salmon pink color; its density was generally increased, and through its centre extended downwards an area presenting the same condition as upper lobe.

Through the upper, middle and dense portion of lower lobe ran tubular cavities, the lumen about a centimeter in diameter. The walls were much thickened and the inner surface hsemorrhagic. These cavities communicated freely with the bronchi, and sections showed that they were directly continuous with them. They contained a fcetid, blood-stained muco-pus. The peribronchial glands were enlarged, but showed no tubercles. The left lung was congested and in the lower lobe showed patches of broncho-pneumonia.

Examination of the brain showed that the dura was adherent and thickened, especially on the right side. There was slight oedema of the pia at a point where the brain surface was discolored and depressed. This corresponded to a point at the upper end of the fissure of Eolando in the right hemisphere. On lifting up the pia an underlying cavity discharged a small amount of a greenish foetid pus. This cavity, measuring about 3 cm. in all diameters, was seen to occupy the paracentral convolution and to cause a bulging of this area into the longitudinal fissure. The ascending frontal convolution showed no involvement, but the area of softening extended down the ascending parietal convolution for a distance of 5 cm.

Microscopically the induration of the lung is seen to consist of broad strands of fibrous tissue which represent thickened inter- and intra-lobular connective tissue. These main strands have the appearance of old fibrous tissue, poor in cells. Encroaching still more upon the bronchioles and individual alveoli is a younger, much more cellular, fibrous tissue, which surrounds them and which has compressed the alveoli into the form of small racemose gland acini, the epithelium having reverted to its embryonic cubical form. Often the alveoli are filled with fatty epithelial ceils which, in the gross specimen, gave the appearance of caseous tubercles. The walls of the bronchi are very thick and are surrounded by cellular fibrous tissue, and are infiltrated withpolymorpho-nuclear leucocytes. The bronchi are filled with pus cells and desquamated epithelial cells. The induration in the middle lobe is of the same character but is not so complete. There is a slight deposit of coal pigment in the peribronchial tissue.

The type of fibroid lung here seen is not that which has been described by Ziegler, Von Kahlden and others, in which there is an organization of an alveolar exudate by an outgrowth from the connective tissue of the alveoli, nor of the type secondary to atelectasis described by Orth. It is rather a more common form due to a thickening of the interlobular connective tissue, but is of interest in its extensiveuess and in the distribution which seems to indicate its etiology. Structurally it has the appearance, described by Charcot, which follows subacute broncho-pneumonia.

By far the commonest cause of fibroid lung is tuberculosis,


December, 1897.]

265


but I think that we have grounds to exclude this in the present case. There is no evidence of tuberculosis elsewhere, no appearance of tubercle or of tuberculous tissue in the lung itself, no areas of caseation, sections stained for tubercle bacilli after careful search failed to reveal the organism. There are a few giant cells, but they have the character found about foreign bodies, with centrally located nuclei and distinct, rounded peripheries.

Inhalation of dust and of irritating vapors is a frequent cause of induration. As in this case there is a distribution along the bronchi, but our specimen shows but little foreign substance, coal pigment, — not enough to give rise to the marked changes.

Syphilis, which has its distribution along the bronchi, is difficult to exclude, although its involvement is usually at the root of the lung and is sometimes associated with gummata. The distribution and histological picture in this case seem to indicate that it is one of those cases of induration subsequent to the absorption of toxic substances, bacterial in origin, by way of the bronchi : a subacute bronchitis and peri-bronchitis. The irritation is not intense enough at any time to produce an acute reaction throughout the lung, but sets up a slow formation of connective tissue. Subsequently, as frequently happens, there is the formation of bronchiectatic cavities at the points where the bronchial walls are weakened by the more intense effects of the toxic substances, and these cavities in turn offer opportunity for lodgment and activity of various kinds of bacteria. In this way a fresh inflammatory process is lit up and a vicious circle is established which in time causes complete induration of the lung tissue.

The association of brain abscess with bronchiectatic cavities has frequently been noted. Williamson has recently reported that out of 39 cases of brain abscess, 17 were associated with putrid bronchiectasis.

On cover-slips from the cavities there appeared a great variety of organisms, from which I succeeded in isolating but one, the pyogenic streptococcus. Cover-slips from the brain abscess showed likewise a great number of organisms, some of which I had recognized on cover-slips from the lung. None, however, grew out on my culture plates. If the streptococcus pyogenes was present, it failed to grow.


NOTES ON NEW BOOKS.


Burdett's Hospital and Charities, 1897, being the Year-Book of Philanthropy, containing a Review of the Position and Requirements, and Chapters on the Management, Revenue and Cost of the Charities, etc. By Henry C. Burdett, Editor of "The Hospital." [London: The Scientific Press, Limited, 1897.) We have had occasion in previous years to speak in the highest terms of this Year-Book which is now in the eighth year of publication. It presents a volume of statistics of the greatest utility to all who are engaged in any form of philanthropic work. It would be fortunate for all charitable boards, not only of hospitals, but of missionary societies, orphanages, nursing and convalescent homes, if copies could be placed in the hands of each member.

As might be anticipated in view of the fact that the Queen of England and the Prince of Wales have shown great interest in hospitals and nurses' training schools, two chapters of the present


volume are given up to the Queen's commemoration and the Prince of Wales' fund for the relief of distressed London hospitals.

The chapter on "Hospital Construction during 1896" is a new feature and one which is destined to become increasingly valuable. Il gives sensible and brief criticisms on the plans of infirmaries, general hospitals, nurses' homes, cottage hospitals and convalescent homes which have been erected in Great Britain during the year. If a similar chapter can become an annual affair it is altogether probable that many mistakes in future hospitals will be corrected. The editor in a previous volume recommended that all hospital plans be revised by competent experts prior to letting any contracts or commencing any building. It is to be hoped that the present attempt to criticise hospital plans may eventually lead to this.

We are much gratified to know that the editor still insists upon his former dictum in hospital expenditures, viz. that lavish expenditures do not necessarily imply efficient administration. The list of institutions for the insane in the United States is far from complete and should he revised before another edition of the book.

Lectures on the Malarial Fevers. By Wm. Sydney Thay'er, Associate Professor of Medicine in the Johns Hopkins University, pp. 1-326, with 19 illustrative charts and 3 lithographic plates. (New York: D. Appleton & Co., 1897.)

The publication of this book has occurred opportunely. The exhaustive studies which have been made during the past seventeen years have led to marked changes in the ideas of the medical profession concerning the nature of the malarial diseases. These researches, especially those dealing with the parasitology, have now attained to a degree of completeness which permits of a satisfactory collective treatment of the subject.

When Laveran in 1880, while studying the blood of fever patients in Algiers, discovered the malarial parasite, he could have had but little idea of the richness of the mine in which he was doing such successful prospecting. He knew he had made a valuable finding, for within a month after his first positive observation a preliminary paper concerning it was presented to the Academy of Paris. This was soon followed by other communications from the same investigator, who appeared to be well aware that where so valuable a nugget had been easily extracted, richer treasures might reasonably be supposed to exist.

Laveran was at once convinced, on seeing the organism, that he was dealing with a living parasite. He studied the various forms which it assumed, and the descriptions which he has given us of his early observations are interesting and accurate. His contributions, however, remained for some time without marked influence, a fact attributable largely to the wide acceptance met with by the ideas concerning the aetiology of malaria which had been advanced by Klebs and Tomassi Crudelli in 1879. The doctrine of the bacillary origin of malaria, fathered by these investigators, was advanced in the blooming period of the science of bacteriology at a time when protozoan diseases had scarcely been heard of. Notwithstanding its falsity it is perhaps but little wonder that it attained to such sudden general credence.

Although Richard, as a result of his own research, confirmed Laveran's statements, and the latter made personal demonstrations of the parasite to others, it was not until some five years later that general interest became aroused in the subject and investigators in different countries recognized the truth and significance of his reports. About this time a number of clinicians began investigating for themselves, and since 1885 a host of men have been at work at the subject in the most different parts of the world, perhaps most actively in Italy and America.

Three distinct varieties of the malarial parasite have been identified: (1) that of quartan fever; (2) that of tertian fever ; (3) that of the sestivo-autumnal fevers. Each of these varieties of the parasite undergoes a peculiar and characteristic developmental


266

[Ko. 81.


cycle, culminating in its multiplication by the process of segmentation. Coincident with the segmentation simultaneously of a large group of parasites a malarial paroxysm occurs.

The cycle of development of the parasite in quartan and tertian infections was first made out by Golgi ; that of the restivo-autumnal fevers was independently established by I\Iarcbiafava and Celli and Canalis.

The clinician has now at his ilisposal a mass of diagnostic and prognostic data with reference to the malarial diseases. Not only have the various stages in the developmental cycle of each variety of the parasite been accurately studied and described, but the time relations in the different cycles have been ascertained with astonishing exactness. The skilled hamatologist can now decide, from his study of the blood alone, not only that he is dealing with a case of malaria, but also as to the particular nature of the attack. He can tell the patient the periods of past paroxysms, and if the case be left untreated, can prophesy within tolerably narrow limits the time of occurrence of those to come. He is afforded many clues as to the gravity or benignancy of a given infection, and is able to draw valuable conclusions concerning the probable efficacy of quinine in a given case. He is further able to pass judgment as to whether urgency in the treatment is essential, and thus is ready to suggest the method of administration of the specific drug most suitable to the case.

The bibliography of the malarial fevers has by now assumed enormous proportions, for although many important veins remain to be followed up, the malarial mine has already been very thoroughly worked. In the process much pure metal has been extracted. A great deal of valuable material is still mixed, however, with baser mineral, and unfortunately the literature also is encumbered with quantities of spurious ore, consequent mainly upon investigation guided by the "divining rod" of preconceived idea.

To write a comprehensive and discriminative book on the malarial fevers correspondent to the needs of students and practitioners at the present time, one not only must be widely read in the bibliography of his subject, but he must also have had an extensive practical acquaintance with the microscopic characters of the blood of a large number of patients at various seasons of the year. To read and assimilate all the articles — and there are now many hundreds of them — dealing with malaria since 1880 is of itself no small task. To painstakingly analyze more than 1600 cases of malarial infection in which the type-diagnosis has been established by actually demonstrating the variety or varieties of the parasite present in the blood or in the juice removed from the spleen is a laborious undertaking. "It's dogged as does it," but it is thus that the author of the lectures before us has qualified himself for his work.

Dr. Thayer's book, which, very appropriately we think, he has dedicated to Dr. Osier, contains nine lectures. In these the essential facts concerning the parasitology of the disease, the clinical phenomena, the morbid anatomy, the pathogenesis, diagnosis, prognosis, treatment and prophylaxis are dealt with.

In the first lecture a brief history of the development of knowledge concerning the pathogenic agent of the malarial fevers is given. Copious references in the form of footnotes make it possible for the reader to consult the original articles in all languages. The different views which have been advanced concerning the classification of the parasites, their finer structure and manner of reproduction, are here briefly but clearly discussed. The author believes in the specificity of the three main types of malarial parasites —tertian, quartan, and restivoautumnal, and combats the idea still held by some that the organisms are all varieties of one parasite, and that the morphology varies simply according to the season of the year and the conditions to which it is subjected. To the viewformerly expressed in his monograph (in conjunction with Hewetson) entitled "The Malarial Fevers of Baltimore," concerning the parasites of the sestivo-autumnal fevers, namely, that they all rep


resent varieties of one specific type, and are not divisible into a quotidian and tertian variety as Marchiafava and Bignami assert, in the absence of inoculation experiments bearing on the question, the author still adheres.

The methods of examination of the blood and the appearances of the different varieties of the parasite in all stages of development in fresh blood and in dried and stained specimens, are described at length in the second and third lectures. We are glad to see italicized as the opening paragraph of this section of the book the following statement : — "It is impossible to make reliable examinations of the blood for malarial parasites without first being familiar with the ordinary appearances of normal blood and the more common pathological changes." How many unfortunate mistakes and lamentable exhibitions of ignorance would have been avoided had the appreciation of this fact been more general ! Non-acquaintance with thevacuolelike appearances so often met with in the red corpuscles, certain puzzling forms encountered in poikilocytic conditions, the blood platelets, the various kinds of white blood corpuscles which exist, or the artefacts which can arise from faulty preparation of the specimen and the like, has led many an observer into error, and has been responsible for more than one publication which should have, if it has not, made its author long for an obscurity in which, as Johnson put it, he could be " glad to be hid, and proud to be forgot." However excusable some of those may have been who have fallen into such traps in the past, there is no longer any justification for the repetition of these foolish and unnecessary errors, and it is a pity that articles containing them still occasionally creep into respectable medical journals.

All who have had practical experience will agree with the statement on page 35 that "the best method of studying the malarial parasite is in the fresh untreated blood at the bedside or in the consulting room." Dried and stained specimens are at best an unsatisfactory substitute for the fresh blood-slide. The directiors given in this section are detailed and might at first thought seem unnecessarily minute, but any one who has observed students fail over and over again simply from the non-observance of some trifling technical point will approve of the explicit directions. It would seem scarcely possible, with the clean-cut morphological description of tertian, quartan andrestivo-autumnal parasites given in these pages, that the careful student should fail to identify them, especially as the descriptions are accompanied by three admirable lithographic plates reproducing Max Broedel's drawings made directly from the parasites in the fresh blood. These plates include some 35 illustrations of the parasite of tertian fever, 17 of those of quartan, and 49 of those of £estivo-autumnal fever. In fact, all the forms likely to be met with in ordinary clinical examinations are faithfully delineated.

The various views which have been advanced concerning the nature of the flagellate bodies are outlined on page 78 and the following three pages. Since the writing of Dr. Thayer's book, much new light has been thrown upon these curious structures by the researches of Dr. W. G. MacCallum. When another edition of the book is called for, it will be the author's pleasant task to supplement the unsatisfactory hypotheses concerning the flagella referred to in the present volume with a description of the process of fertilization in the malarial parasite, as observed by the investigator referred to.

The general conditions under which the malarial fevers prevail are dealt with on pages 82 to 96. The geographical distribution ; the effect of climate, seasons, time of day ; the influence of moisture, soil, altitude, and winds; the effects of cultivation and drainage of malarious districts ; the relation of malaria to the drinking water, are among the topics which here receive atten^tion. There are short paragraphs also on the significance of race, sex, age and occupation in connection with malaria. The various modes of infection which have been suggested are discussed ; it is to be regretted that the author, concluding this section, is compelled to make the statement, " We are absolutely ignorant of the form in


December, 1897.]

267


which the malarial parasite exists outside of the human body, and equally ignorant of the manner in which it enters."

The clinical description of the malarial fevers is given in Lectures IV and V. Each type of the fever is analyzed, and the various modifications met with fully illustrated. This portion of the book is liberally interleaved with charts showing the temperature-range in typical cases personally observed by the author. The description given of the pernicious fevers is worthy of especial mention, as are the paragraphs dealing with masked malarial infections, and the cases in which combined infections with dilferent varieties of the malarial parasite have been encountered.

The sequelaj and complications of the malarial fevers are next taken up. The eases in which simple insolation has been confused with pernicious malaria are among those referred to under this heading.

In his lectures on the morbid anatomy of the malarial diseases, Dr. Thayer follows closely the accurate ilescriptions of Bignami, the investigator who certainly has made more important contrilmtions in this field than any other single individual. The anatomical changes in both acute and chronic infections are clearly set forth, though not at greater length than is consonant with the nature of a clinical manual.

The only part of the book in which the writer has indulged in speculation is in Lecture YIII, the section on General Pathology. The hypotheses brought forward are, however, unmistakably designated as such, and nowhere are they confused with a statement of facts. Considering the extended first-hand knowledge which the author possesses, there will be scarcely any one, we believe, deeply interested in the problems discussed, who will not seek his opinion respectfully regarding disputed points, or who will not weigh carefully the conclusions to which he has arrived. Dr. Thayer thinks it highly probable that the febrile manifestations in malaria are excited by the presence of circulating toxic substances, and proceeds to enquire as to the nature and origin of the toxines. Considering the data at hand he says (p. 254) : " Despite the lack of absolute proof, we are inevitably led to the conclusion that the most important exciting cause of the malarial paroxysm is the liberation of some toxic substance by the specific parasites at the time of their sporulation. While, very possibly, toxic substances may arise as a result of the disintegration and destruction of red blood corpuscles which occur at this period, it is improbable that these play the primary part in exciting the paroxysm."

After brief paragraphs upon the pathogeny of the antcmia, the pain in the bones, the jaundice, the cerebral symptoms, and the phenomena referable to disturbance of the alimentary tract, two important topics are considered : (1) The Origin of Infections with Multiple Groups of Parasites, and (2) The Mechanisms of Defence in Malarial Infections. With regard to the former subject, the author thinks that the main difficulty lies in the explanation, not of the multiple seativo-autumnaH but rather of the double tertian, and of the double and triple quartan infections. The occurrence of the paroxysms so nearly at intervals of 24 hours, and the tendency to segmentation in the morning hours, are especially difficult things to explain, and it is admitted that the whole question still remains unsolved. The author believes that a number of the cases represent instances of multiple infection from the beginning, but thinks that there are examples in which a second group may be derived from one original generation, through anticipation or retardation of the ripening of certain of the parasites. Some ingenious suggestions are offered to explain this process, and especially to account for the fact that the anticipation or retardation usually amounts to almost exactly twenty-four hours.

As regards the mechanisms of defence involved in malarial infections, the author is of the opinion that too much stress has been laid by many upon the riMe played by phagocytes. He would rather assume that the more important factor in spontaneous cure is some parasiticidal substance or substances circulating in the


blood serum, admitting, however, that the latter may be of cellular origin. The dispute is an old one, and is not limited to malaria alone, but pertains to the whole group of infectious diseases, and is, moreover, one not likely to be settled to the entire satisfaction of all, at least in the very near future.

The last chapter of the book deals with diagnosis, prognosis, treatment, and prophylaxis. This chapter is eminently satisfactory. The disease is sharply differentiated from conditions likely to be confounded with it, and the diagnosis is helped out to a certain extent by the introduction of comparative tables in the text. Concerning the treatment, the writer seems to have rejoiced at the opportunity of dealing with a disease in which there can be no talk of therapeutic nihilism. The modes of administration of the specific drug best suited to the different kinds of malarial infection are treated of at some length. Sensible advice is also given as to the application of general measures, such as rest in bed, change of surroundings and diet.

The work of the publishers is, on the whole, excellent ; the type and paper are agreeable, and the binding neat. One finds rather more imperfect letters, however, than should appear in a first edition. We prefer the spelling defence rather than defense as employed throughout the book. The index is full, and as far as we have tested it, accurate. The introduction of an in<lex of authors' names is a pleasing feature. The book will not only be valuable to clinicians in the districts in which malaria prevails, but doubtless will, from the especial interest which the subject has excited, also appeal to many who practice in regions in which the disease is but rarely met with. L. F. B.

A Manual of the Practice of Medicine. By Geoege Roe LocKwoon, M. D., Professor of Practice in the Woman's College of the New York Infirmary, etc. With 75 illustrations in the text and 22 full-page colored plates. (Philadelphia: W. B. Saunders, 1890.) This admirable little book is a useful manual for students and medical men who desire to get terse and clear accounts of diseases and their treatment. Some of the sections are models of concise, orderly and systematic statements. Take for example the opening section on typhoid fever, the sections on nervous diseases and the section on malarial fever. Some of the remarks on treatment are less satisfactory, as for example, in the treatment of cholera infantum no mention is made of the desirability of withdrawing milk, which in the majority of cases is the essential thing to do. In delirium also bleeding and purging are recommended. The letterpress and illustrations are good, and the book is almost wholly free from annoying typographical errors. We notice, however, that cholera nostras appears as cholera nostra.


BOOKS RECEIVED.

A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in Photolithochromes from Models in the Museum of the Saint Louis Hospital, Paris. By E. Besnier, A. Fournier et al. Edited and annotated by .T. J. Pringle, 1\LB., F. R. C. P. Fol. 1897. Part XII. AV. B. Saunders, Phila., Pa.

Constipation in Adults and Children. With especial reference to habitual constipation and its most successful treatment by the mechanical methods. By H. lUoway, M. D. Svo. 1897. 495 pages. The Macmillan Co., New York.

Twenty-eighth Annual Report of the State Board of Health of Massachusetts, 1896. Svo. 920 pages. 1897. Wright & Potter Printing Co., Boston.

Fiftieth Anniversary of the Hartford Medical Society. Founded September 15, 1846. Proceedings at the Celebration, October £G, 1896. 4to. 124 pages. Hartford, Connecticut.

Essentials of Bacteriology : being a Concise and Systematic Introduction to the Study of Micro-organisms. M. N. Ball, M. D. Third edition. 1897. 12mo. 218 pages. W. B. Saunders, Phila.


268

[No. 81.


Archives of the Roentgen Uai/. (Formerly Archives of Skiagraphy.

Edited by W. S. Hedley, M. D., and S. Rowland, M. A. Fol.

Vol. II, No. 1. July, 1897. The Rebman Publishing Co.,

Limited, London. W. B. Saunders, Philadelphia. Pathological Technique. A Practical Manual for the Pathological

Laboratory. By Frank Burr Mallory, A. M., M. D., and James

Homer Wright, A. M., M. D. 1897. 8vo. 397 pages. W. B.

Saunders, Phila. Transactions of the Chicago P.ithological Society from December, 1895,

to April, 1897. Vol. II. 1897. 12mo. 328 pages. American

Medical Association Press, Chicago.


Report of the Sewerage Commission of the City of Baltimore ; consisting of Mendes Cohen, F. H. Hambleton and E. L. Bartlett, appointed by joint resolution of the City Council, approved May 25th, 1893. 8vo. 1897. 231 pages. (Plates.) Baltimore, 1897.

An Epitome of the History of Medicine. By Roswell Park, A. M., M. D. Based upon a Course of Lectures delivered in the University of Buffalo. 1897. 8vo. 348 pages. The F. A. Davis Co., Phila.

A Te.vt-Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D.,LL.D. 1898. 8vo. 1287 pages. W. B. Saunders, Phila.


INDEX TO VOLUME VIII. OF THE JOHNS HOPKINS HOSPITAL BULLETIN.


Abel, John J. On the blood-pressure-raising constituent of the suprarenal capsule, 151.

iEsthesiometer, 125.

Anatomical relations of the nuclei of reception of the cochlear and vestibular nerves, 253.

Apparatus tor sterilizing instruments with formaldehyde; experimental tests, 201.

Arch of aorta, anomaly of, with additional muscle in neck, 234.

Atkinson, A. Duval. Parotitis following visceral inflammation, 204.

Bacillus aerogenes capsulatus (Welch), cases of infection by, 68.

Bacillus aerogenes capsulatus, observations to determine motility of, under anaerobic conditions, 74.

Bacillus proteus Zenkeri in an ovarian abscess, 4.

Bad Nauheim, visit to, 101.

Bardeen, C. R. Certain visceral pathological alterations, the result of superficial burns, 81; — Edingeron "The Development of Brain Paths in the Animal Series," 120.

Barker, Lewellys F. A new sesthesiometer, 125 ; — Congenital facial diplegia, 131 ; — Demonstration of Florence's iodine test for seminal stains, 133 ; — Hsemocytozoa of birds, 52 ; — Phrenology of Gall and Flechsig's doctrine of association centres in the cerebrum, 7 ; — Trichinosis, remarks on, 81.

Berkley, Henry J. Lesions induced by action of certain poisons on nerve cell. Study VI. Diphtheria, 23; — Studies on the lesions induced by the action of certain poisons on the cortical nerve cell. Study VII. Poisoning with preparations of the thyroid gland, 137.

Block, E. Bates. Case of typhoid fever in which the typhoid bacillus was obtained twice from the blood during life, 119.

Bloodgood, Jos. C. Rarer cases of, and observation on streptococcus infection, 47 ; — Cure of hernia by implanting section of sterilized sponge, discussion of, 45.

Books received, 15, 83, 113, 135, 197, 287, 207.

Brain paths in the animal series, Edinger on development of, 120.

Brain tumor, demonstration of probable case of, 215.

Brooks, Wm. K. William Harvey as an embryologist, 167.

Brown, George S. Case of pneumo-cardial rupture, 33.

Brown, T. R. Studies on trichinosis, 79.

Calvert, Wm. J., and Elting, Arthur W. Experimental study of the treatment of perforative peritonitis in dogs by a new method of operation, 143.

Camac, C. N. B. Visit to Bad Nauheim, 101 ;— Importance of employing pure salts in Schott bath, 214.

Carter, Edward Perkins. Report of a case of polybacterial infection in typhoid fever, 115.

Cataract, second series of operations (one hundred and fifty-eight), 199.

Cavernous angioma of the tunica conjunctiva, case of, 236.

Chatard, Pierre, 185.

Clark, J. G. Function of the peritoneum under normal and pathological conditions, 60 ;— Postural method of draining dead spaces in the pelvis, 62 ; — Mechanism of absorption of fluids and solid


particles in the peritoneal cavity, 01 ; — Postural method of draining the peritoneal cavity after abdominal operations, .59 ; — Rare case of lithopedion, 221 ; — Report of cases where postural method of drainage was employed, 03.

Clendinen, William Alexander, 189.

Cohen, Joshua I., 190.

Cone, Claribel. Encysted dropsy of the peritoneum secondary to utero-tubal tuberculosis and associated with tubercular pleurisy, generalized tuberculosis and pyococcal infection, 91 ; — Tuberculosis of the cesophagus, 229.

Cone, S. M. Squamous epithelioma and epithelial hyperplasia in sinuses and bone following osteomyelitis, 140 ; — Squamous epithelioma in a dermoid of the jaw, 208.

Correspondence, 33.

Cullen, Thomas S. Rapid method of making permanent specimens from frozen sections by the use of formalin, 108 ; — Demonstration of specimens, 216.

Cushing, H. W. Hrematomyelia from gunshot wound of the cervical spine, 195.

Dermatitis, a case of, due to the X rays, 17.

Dermatitis, due to the X rays, additional cases of, 46.

Diphtheria, lesions induced by the action of certain poisons on the nerve cell, 23.

Discussion : Dr. Barker, Trichinosis, 81 ;— Dr. Bloodgood, Cure of hernia by implanting section of sterilized sponge, 45 ; — Dr. Flexner, Puerperal sepsis due to infection with bacillus aerogenes capsulatus, 28 ;— Dr. Halsted, Gall stones, 31 ; — Dr. Osier, Trichinosis, 80 ; Congenital facial diplegia, 131 ; — Dr. Piatt, Cure of hernia by implanting section of sterilized sponge, 46 ;^Dr.Reed, Malaria as a water-borne disease, 43 ;— Dr. Thayer, Malaria as a water-borne disease, 43 ; Trichinosis, 80 ;— Dr. Thomas, Congenital facial diplegia, 130 ; — Dr. Welch, Malaria as a water-borne disease, 42.

Dixon, W. T. Address at presentation of Thorwaldsen's statue of Christ, 1.

Dobbin, George W. Puerperal sepsis due to infection with bacillus aerogenes capsulatus, 24.

Dunham, Edward K. Cases of infection by the bacillus aerogenes capsulatus (Welch), 08 ; — Observations to determine mobility of bacillus aerogenes capsulatus under anaerobic conditions, 74.

Duval, Douglas F. Palpation of the foetal heart impulse in pregnancy, 207.

Elting, Arthur W., and Calvert, Wm. J. Experimental study of the treatment of perforative peritonitis in dogs by a new method of operation, 143.

Epithelioma, squamous, and epithelial hyperplasia in sinuses and bone following osteomyelitis, 146.

Epithelioma, squamous, in a dermoid of the jaw, 208.

Eyeballs, congenital motor defects of, discussion on, 129.

Finney, J. M. T. Five successful cases of general suppurative peritonitis treated by a new method, 141 ;— Typhoid perforation treated by surgical operation, 110.


Flexner, Simon. Discussion of puerperal sepsis, 28 ;— of agglutination of typhoid bacilli, etc., 54;— of pseudo-tuberculosis hominis streptotricha, preliminary note, 128.

Fle.xner, Simon, and Harris, Norman McL. Typhoid infection without intestinal lesions, 259.

Friedenwald, Harry. Early history of ophthalmology and otology in Baltimore, 184 ; — Joseph Friederich Piringer, his methods and investigations, 191.

Frick, George, 186.

Futcher, T. B. Association between so-called perinuclear basophilic granules and the elimination of the alloxuric bodies in the urine, 85.

Gall stones, surgical significance of, 31.

Ghriskey, Albert A., and Kobb, Hunter. Bacillus proteus Zenkeri in an ovarian abscess, 4.

Gibson, John Mason, 188.

Gibson, William, 185.

Gilchrist, T. Caspar. Additional cases of dermatitis due to the X rays, 46 ; — Case of dermatis due to the X rays, 17 ; — Case of porokeratosis, preliminary notice of, 107.

Gilman, D. C. Address at presentation of Thorwaldsen's statue of Christ, 2.

Gonococcus, cultivation of, in two cases of gonorrheal arthritis and one of tsenosynovitis, 121.

Gould, George M., and Pyle, Walter L. King Arthur's medicine, 239.

Hsematomyelia from gunshot wound of cervical spine, 195.

Hsematozoan infections of birds, 235.

Hjematozoan infections of birds, pathology of, 51.

Hsemocytozoa of birds, 52.

Hagner, Francis R. Successful cultivation of gonococcus in two cases of gonorrheal arthritis and one of tsenosynovitis, 121.

Hamilton, Alice. Multiple tuberculous ulcers of the stomach, with report of three cases, 75.

Harper, John, 189.

Harvey, William, as an embryologist, 167.

Hernia, radical cure of, by implanting section of sterilized sponge, 44.

Herrick, A. B. Rare anomaly of arch of aorta, with additional muscle in neck, 234.

Influence of Louis on American medicine, 161.

Is malaria a water borne disease? 35; — Discussion, 42.

Jameson, Horatio G., 188.

Johns Hopkins Hospital Medical Society Proceedings: Bilateral dacryo-adenitis. Dr. Randolph, Dr. Thayer, 132;— Case of acquired paralysis of both external recti muscles with unilateral facial paralysis, Dr. Theobald, Dr. Thomas, 131, 132 ;— Certain visceral pathological alterations, the result of superficial burns, C. R. Bardeen, 81 ; — Congenital facial diplegia. Dr. Barker, Dr. Osier, Dr. Thomas, 130, 131 ;— Discussion of "agglutination of typhoid bacilli," etc., Dr. Flexner, Dr. Reed, 54 ; Dr. Thayer, 55 ; —Discussion of congenital motor defects of the eyeballs, Dr. Baton, Dr. Theobald, 129, 130 ;— Discussion of surgical significance of gall stones, Dr. Halsted, 31 ;— Demonstration of a case of probable brain tumor. Dr. Thomas, 215 ;— Demonstration of Florence's iodine test for seminal stains, Dr. Barker, 133 ;— Demonstration of specimens. Dr. Cullen, 216; — Excision of a parovarian cyst without removal of its ovary or tube. Dr. Kelly, 50,51 ; Discussionof, Dr. Welch,51 ;— Fibroid lung-bronchiectasis — brain abscess. Dr. Livingood, 263 ; — Hsemocytozoa of birds. Dr. L. F. Barker, 52; E. L. Opie, 52, 53; Dr. Osier, 52, 53; Dr. Thayer, 53; Dr. Welch, 53 ;— Hsematomyelia from gunshot wound of cervical spine, Dr. Cushing, 195 ;— Operations for cataract, Dr. Randolph, 133 ;— Ophthalmoplegia externa. Dr. Woods, 48 ; — Pathology of hsematozoan infections in birds, W. G. MacCallum, 51 ; — Rarer cases of and observation on streptococcus infection, Dr. Bloodgood, 47 ;— Simple contrivance for effecting pneumatic massage of the tympanal membrane and ossicles. Dr.


Theobald, 49 ; — Surgical significance of gall stones, Dr. Lange, 29 ;— Typhoid perforation treated by surgical operation. Dr. Finney, 110 ; Discussion of. Dr. Osier, 113.

Johns Hopkins Medical Society, 29, 47, 81, 110, 129, 195, 215, 263.

Kelly, Howard A. Excision of a parovarian cyst without removal of ovary or tube, 50, 51.

King Arthur's medicine, 239.

Lange, F. Surgical significance of gall stones, 29.

Lesions induced by action of certain poisons on cortical nerve cell. Study VII : Poisoning with preparations of the thyroid gland, 137.

Lesions induced by action of certain poisons on the nerve cell — diphtheria, 23.

Lithopedion, rare case of, 221.

Livingood, Louis E. Fibroid lung-bronchiectasis — brain abscess, 263.

Long, the discoverer of ansesthesia ; presentation of his original documents, 174.

Norton, Rupert. Is malaria a water-borne disease? 35.

MacCallum, W. G. Hsematozoan infections of bird.s, 235 ;— Pathology of hsematozoan infections in birds, 51.

Notes on new books:— Annual report of the Supervising General of the Marine Hospital Service, 57, 83 ;— Baldy, J. M., and Gould, George M., American year-book of medicine and surgery, 82 ; — Bishop, S. F., Diseases of the ear, nose and throat, 158 ; — Burdett's Hospital and Charities, 1897, 265;— Butler, G. F., Textbook of materia medica, therapeutics and pharmacology, 158 ; — Canfield, W. B., Practical notes on urinary analysis, 14 ; — Corwin, Arthur M., Essentials of physical diagnosis of the thorax, 159 ;— Crandall, Floyd M., Transactions of the American Pediatric Society, 113 ;— De Schweinitz, G. E., Diseases of the eye, 14 ; — Dorland, W. A. Newman, Manual of obstetrics, 15 ;-Fuller, Wm., Architecture of the brain, 83; — Gant, S. G., Diseases of the rectum, anus and contiguous textures, 197 ;— Gould, George M., and Pyle, Walter L., Anomalies and curiosities of medicine, 158 ; — Hyde, James Nevins, Manual of syphilis and the venereal diseases, 56; — Lockwood, G. R., Manual of the practice of medicine, 267 ;— McCosh, Andrew J., and James, Walter B., Medical and surgical report of the Presbyterian Hospital, S3; — Meigs, Arthur v., Feeding in early infancy, 159 ;—Obersteiner, Heinrich, Arbeiten aus dem Institut fiir Anatomic und Physiologie desCentralnervensystems an der Wiener Universitiit, 135 ; — Palmer, C. F., Inebriety, 218 ; — Park, Roswell, Treatise on surgery, by American authors, 55 ; — Pathological Report of the Illinois Eastern Hospital for the Insane, 159;^ — Pollack, Dr. B., Die Fiirbetechnic des Nervensystems, 134;— Preston, George J., Hysteria and certain allied conditions, 219 ;— Proceedings of the American Medico-Psychological Association at the 52d Annual Meeting, 159; — Rowland, Sydney, Archives of clinical skiagraphy, 218;— Shattuck, George B., Councilman, W. T., and Burrell, Herbert L., Medical and surgical reports of the Boston City Hospital, 57 ; — Stoney, Emily A. M., Practical points in nursing, 14;— St. Thomas's Hospital Reports, 159 ;— Thayer, W. S., Lectures on the malarial fevers, 265; — Thrush, John C, Water and water supplies, 15 ; — Transactions of the American Gynecological Society, 57 ;— Transactions of the Chicago Pathological Society, 57j_Xyson, James, The practice of medicine, 133 ;— Wilson, J. C, and Eshner, Augustus A., An American text-book of applied therapeutics, 134 ;— Yearsley, Macleod, Injuries and diseases of the ear, 218.

Ophthalmology and otology in Baltimore, early history of, 181.

Ophthalmoplegia externa, 48.

Opie, Eugene L. Hsemocytozoa of birds, 52, 53.

Osier, William. Congenital facial diplegia, 131 ; — Hsemocytozoa of birds, 52, 53 ; — Influence of Louis on American medicine, 161 ; — Trichinosis, remarks on, 80; — Typhoid perforation treated by surgical operation, 113.

Otology, early history of, in Baltimore, 189.


270

[Xo. 81.


Owings, E. B. Infectiousness of chronic urethritis, 210.

Parotitis following visceral inflammation, 204.

Parovarian cyst, excision of, without removal of its ovary or tube, 50.

Pelvis, postural method of draining dead spaces in, G2.

Perinuclear bisopliilic granules, association between, and elimination of alloxuric bodies in the urine, 85.

Peritoneal cavity, mechanism of absorption of fluids and solid particles in, 61.

Peritoneum, encysted dropsy of, secondary to utero-tubal tuberculosis and associated with tubercular pleurisy, generalized tuberculosis and pyococcal infection, 91.

Peritoneum, function of under normal and pathological conditions, 60.

Peritonitis, general suppurative, cases of treated by new method, 141.

Peritonitis, perforative, in dogs, treated by new method of operation, 143.

Permanent specimens from frozen sections, rapid method of raaliing by formalin, 108.

Phrenology of Gall and Flechsig's doctrine of association centres in the cerebrum, 7.

Piringer, Joseph Friederich, his methods and investigations, 191.

Piatt, W. B. Cure of hernia by implanting section of sterilized sponge, 44.

Pneumo-cardial rupture, case of, 33.

Porokeratosis, case of, 107.

Pregnancy, palpation of fojtal heart impulse in, 207.

Presence in the blood of free granules derived from leucocytes, and their possible relations to immunity, 246.

Proceedings of societies, 29, 47, 81, 110, 129, 195, 215, 203.

Pseudo-tuberculosis bominis streptotricha, preliminary note, 128.

Puerperal sepsis due to infection with bacillus aerogenes capsulatus, 24.

Randolph, Robert L. Bilateral dacryo-adenitis, 132 ;— Operations for cataract, 133 ;— Second series of cataract operations (one hundred and fifty-eight), 199.

Recti muscles, case of acquired paralysis of, with unilateral facial paralysis, 131.

Reed, Walter. Discussion of malaria as a water-borne disease, 43 ;— Of agglutination of typhoid bacilli, etc., 54.

Reik, H. 0. Case of cavernous angioma of the tunica conjunctiva, 236.

Reik, H. O., and Watson, W. T. Apparatus for sterilizing instruments with formaldehyde; experimental tests, 261.

Robb, Hunter, and Ghriskey, Albert A. Bacillus proteus Zenkeri in an ovarian abscess, 4.

Sabin, Florence R. On the anatomical relations of the nuclei of reception of the cochlear and vestibular nerves, 253.

Schott bath, importance of employing pure salts in, 214.

Schott bath, rules for, 103.

Schott exercises, 104.

Schott treatment, bibliography of, 105.

Schott treatment, rules for operators, 104.

Seminal stains, Florence's iodine test for, demonstration of, 133.

Smith, Nathan Rhyno, 189.

Specimens, demonstration of, 216.

Spence, W. W. Address at presentation of Thorwaldsen's statue of Christ, 1.

Stokes, Wm. Royal, and Wegefarth, Arthur. The presence in the blood of free granules derived from leucocytes, and their possible relations to immunity, 246.

Stomach, tuberculous ulcers of, 75.

Streptococcus infection, rarer cases of and observation on, 47.

Suprarenal capsule: alkaloids, 154.

Suprarenal capsule, blood-pressure-raising constituent of, 151.

Thayer, William Sydney. Discussion of case of bilateral dacryoadenitis, 132 ;— Of agglutination of typhoid bacilli, etc., 55 ; — Of


hsemocytozoa of birds, 53;— Of malaria, a water-borne disease,

43 ;— Of trichinosis, 80.

Theobald, Samuel. Case of acquired paralysis of both external recti muscles with unilateral facial paralysis, 131, 132; — Contrivance for effecting pneumatic massage of the tympanal membrane and ossicles, 49; — Discussion of congenital motor defects of the eyeballs, 130.

Thomas, H. M. Discussion of case of acquired paralysis of both external recti muscles with unilateral facial paralysis, 132 ;— Of congenital facial diplegia, 130 ;— Demonstration of a case. Probable brain tumor, 215.

Thorwaldsen's statue of Christ, presentation of, 1.

Thyroid extract, insane patients treated with, histories of, 138.

Thyroid guinea-pigs, histories of, 140.

Thyroid mice, liistories of, 139.

Trichinosis, studies on, 79.

Tuberculosis of the oesophagus, 229.

Tympanal membrane and ossicles, pneumatic massage of, 49.

Typhoid fever, case of, in which typhoid bacillus was obtained twice from blood during life, 119; — Case of polybacterial infection in, 115.

Typhoid infection without intestinal lesions, 259.

Typhoid perforation treated by surgical operation, 110.

Urethritis, chronic, infectiousness of, 210.

Visceral pathological alterations, the result of superficial burns, 81.

Welch, William H. Discussion of excision of parovarian cyst without removal of ovary or tube, 51 ;— Of haemocytozoa of birds, 53 ; — Of malaria as a water-borne disease, 42.

Woods, H. Ophthalmoplegia externa, 48.

Young, Hugh H. Long, the discoverer of anaesthesia, presentation of his original documents, 174.


ILLUSTRATIONS.


Thorwaldsen's statue of Christ, 2.

Sagittal section through brain (Fig. 1), 11.

Horizontal section through brain (Fig. 2), 11.

Horizontal section of brain (Fig. 3), 11.

Sagittal section through brain (Fig. 4), 11.

External view of right cerebral hemisphere (Fig. 5), 11.

Internal view of left cerebral hemisphere (Fig. 6), 11.

Case of X-ray dermatitis (Figs. 1, 2, 3), 22.

Temperature charts of infection by bacillus aerogenes capsulatus (Cases 1, 2, 3, 4), 70.

Encysted dropsy of the peritoneum (Fig. 1), 94.

Bacillus typhosus (Figs. 1, 2, 3, 4), 119.

A new KSthesiometer (Figs. 1, 2), 125.

Tracings of blood-pressure-raising constituent of suprarenal capsule (Figs. 1, 2, 3), 156.

Portrait of Dr. Crawford W. Long, 177.

Portrait of Dr. George Frick, 187.

Longitudinal section of abdomen, 217.

A lithopedion, 223.

Section of oesophagus, 232.

Aortic arch and its branches (Figs. 1, 2), 234.

Supernumerary muscle in the neck (Fig. 3), 235.

Cavernous angioma (Figs. 1, 2), 236.

Diagram of reception nuclei of cochlear and vestibular nerves (Fig. 1), 257.

Section of nuclei of cochlear and vestibular nerves (Fig. 2), 257.

Section of nuclei of cochlear and vestibular nerves (Fig. 3), 257.

Section of nuclei of cochlear and vestibular nerves (Fig. 41, 268.

Section 66 horizontal series (Fig. 5), 258.

Diagram of nuclei of nervi cochlearis and corpus trapeioides (Fig. 6), 258.


December, 1897.]

271


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report in Pntbolosy.

The Vessels and Walls of the Dog's Stomach; A Study o( the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

(Atrophy). By Henry J. Berkley, M. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

Mall, 51. D.

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

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

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

Parasites found in Various Lesions of the Skin, etc. ; Two Cases of MoUuscum

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

T. C. Gilchrist, M. D.

Report in Patliology. An Experimental Study of the Thyroid Gland of Dogs, with especial consideration

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


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

Report in Medicine.

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

Gallstonea. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By J0H» N. Maceenzie, M. D. On Pyrodin. By H. A. Lafleor, M. D. Cases of Post-febrile Insanity. By William Osler, M. D. Acute Tuberculosis in an Infant of Four Months. By Harry Toulmih, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

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

Report in Gynecology. The Gynecological Operating Room. By Howard A. Eellt, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

A. Kelly, if. D., and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of

Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,

M. D. Tlie Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;

Ovarian Tumor; General Gynecological Operations from October 15, 1889, to

March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one GjTiecological Cases. By Howard

A. Kelly, M. D., and Albert A. Ghriskey, M. D. Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of CHiecking

Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D. Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoma of the Clitoris. By Hunter Robb. M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment

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

Howard A. Kelly, M. D.

Report in Snrgery, 1. The Treatment of Wounds with Especial Reference to the Value of the Blood Clot

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in >enrology, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By August Hoch, M. D. A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report in Fatliologry, I. AmtBbic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleub, M. D.


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

Report in Patliologry.

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

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

Multiple Lympho-Sarcomata, with a report of Two Cases. By SIUON Flexner, M. D.

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

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

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

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

Report in Gynecology.

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

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

Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stayelt, M. D.


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

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

Photography applied to Surgerj*. By A. S. Murray.

Traumatic Atresia of the Vagina with Hsmatokolpos and Hxmatometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever,

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

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

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

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

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

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

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

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

Report in Nenrology.

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

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

Report in Patliology.

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

Pregnancy in a Rudimentary LTterine Horn. Rupture, Death, Probable Migration of 0\'um and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins, M. D.

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

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

The Pathology of Toxalbumin Intoxications. By Simon Flexn'ER, M. D.


Monographs.

The following papers are reprinted from Vols. I, IV, V and VI of the Ilcports, for those who desire to purchase in this form: STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixford,

M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,

$3.00. THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.

Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.

By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.76. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. THE PATHOLDGY OF TOXALTIUMIN INTOXICATIONS. By Simon Flexner. M. D. 1

volume of 150 pages with 4 full-page lithographs. 1 rice, bound in paper, $.\nO. Subscriptions for the above publications may be sent to

The Johns Hopkins Press, Baltimore, Md.


272

[No. 81.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel 0. Oilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.

William Osler, M. D., LL. D., F, R. C. P., Professor of the Principles and Practice

of Medicine. Henry M. Hord, M. D., LL. D., Professor of Psychiatry. William S. Halsted, M. D., Professor of Surgery. Howard A. Kei.lt, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.

William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. Robert Fletcher, M. D., M. R. 0. S., Lect\u-er on Forensic Medicine. William D. Booker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. 1'homas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flesner, M. D., Associate Professor of Pathology. J. Whitridge Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy. William S. Thayer, M. D., Associate Professor of Medicine. John M. T. Finney, M. D., Associate Professor of Surgery.


Georqe P. Deeyer, Ph. D., Associate in Physiology.

William W. Rdssell, M. D., Associate in Gynecology.

Henry J. Berkley, M. D., Associate in Neuro-Pathology.

J. Williams Lord, M. D,, Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph O. Bloodqood, M. D., Associate in Surgery.

Thomas S. Cullen, M. B., Associate in Gj-necology.

Ross G. Harrison, Ph. D., Associate in Anatomy.

Frank R. Smith, M. D., Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jo.ves, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Patholc^y.

Louis E. Livinqood, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D., Instructor in Medicine,

Charles R. Bardeen, M. D., Assistant in Anatomy.

Stewart Patos". M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology.

Haevey W. Gushing, M. D., Assistant in Surgery.

J. M. Lazear, M. D., Assistant in Clinical Microscopy.

J. L. Walz, Ph. G., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from Its close afiiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

Men and women are admitted upon the same terms.

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

REQUIREMENTS FOR ADMISSION.

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

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

3. Graduates of approved colleges or scientific schools who can furnish evidence: (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

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

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

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

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

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

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

ADMISSION TO ADVANCED STANDING. Applicants for admission to advanced standlug must furnish evidence (1) that the foregoing terms of admission as regards prellmluary training have been fulflUed, (2) tliat courses equivalent iu kind aud amount to those giveu here, preceding that ye.ir of tho course for adtnisslon to which application is made, have been satisfactorily completed, and (3| must pass examiuatlons nt the beginning of the sosslon iu October in all tho subjects that have been already pursued by the class to which admission is sought. Certiflcates of standing elsewhere cannot be accepted iu place of these examiuations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been ofl"ered to graduates in medicine. The attendance upon these courses has steadily increased with each sticceeding year and indicates gratifying appreciation of the special advantages here afforded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine ai'e now given annually during the months of May and June. During April there is a preliminary course in Normal Histology. These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here offered. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application.

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

Retrieved from ‘https://embryology.med.unsw.edu.au/embryology/index.php?title=Talk:The_Johns_Hopkins_Medical_Journal_8_(1897)&oldid=401923’
Powered by MediaWiki