Talk:The Johns Hopkins Medical Journal 8 (1897)

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[No. 79.

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.]

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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

JOHNS HOPKINS HOSPITAL BULLETIN.

[\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.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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).

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[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.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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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

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JOHNS HOPKINS HOSPITAL BULLETIN.

[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

JOHNS HOPKINS HOSPITAL BULLETIN.

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.'"

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JOHNS HOPKINS HOSPITAL BULLETIN.

[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

JOHNS HOPKINS HOSPITAL BULLETIN.

[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

JOHNS HOPKINS HOSPITAL BULLETIN.

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

JOHNS HOPKINS HOSPITAL BULLETIN.

[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.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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

JOHNS HOPKINS HOSPITAL BULLETIN.

[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.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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

JOHNS HOPKINS HOSPITAL BULLETIN.

[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.

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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.

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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

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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.

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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.

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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.

a.. HE

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

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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.

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[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.

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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.

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[No. 80.

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.

[Price, 15 Cents.

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 !

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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

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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) oppo

• 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.

nent so hard that " it went to the braynes and the Knyght felle downe dede."

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.'"

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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).

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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

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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,

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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

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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.

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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

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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

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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

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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.

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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

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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.

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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.

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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

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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.

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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

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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;

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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

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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.

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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,

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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.

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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.

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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,

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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

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[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

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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

JOHNS HOPKINS HOSPITAL BULLETIN.

[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.

December, 1897.]

JOHNS HOPKINS HOSPITAL BULLETIN.

269

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

JOHNS HOPKINS HOSPITAL BULLETIN.

[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.]

JOHNS HOPKINS HOSPITAL BULLETIN.

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.

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.

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

JOHNS HOPKINS HOSPITAL BULLETIN.

[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