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

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BULLETIN  OF THE JOHNS HOPKINS HOSPITAL.
  
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Vol. VIII. - No. 70.  
 
 
 
 
 
 
JOHNS HOPKINS HOSPITAL
 
 
 
 
 
 
 
BULLETIN
 
 
 
 
 
 
 
VOLUME VIII
 
 
 
 
 
 
 
BALTIMORE
 
1897
 
 
 
 
 
BALTIMORE.
 
 
 
 
 
 
 
BULLETIN  OF
 
 
 
 
 
 
 
THE JOHNS HOPKINS HOSPITAL.
 
 
 
 
 
 
 
Vol. VIM.-No. 70.]
 
  
  
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Contents
  
 
Presentation of Thorwaldsen's Statue of Christ to the Hospital, 1  
 
Presentation of Thorwaldsen's Statue of Christ to the Hospital, 1  

Latest revision as of 12:28, 16 February 2020


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BULLETIN OF THE JOHNS HOPKINS HOSPITAL.

Vol. VIII. - No. 70.


BALTIMORE, JANUARY, 1897.


Contents

Presentation of Thorwaldsen's Statue of Christ to the Hospital, 1

The Bacilhis Proteus Zenker! in an Ovarian Abscess. By Hunter Robb, M. D., and Albert A. Ghriskey, M. D., - 4


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

M. B., - - - - - 7

Notes on New Books, ......... 14,

Books Received, 15


PRESENTATION OF THORWALDSEN'S STATUE OF CHRIST TO THE HOSPITAL


Oa Wednesday afternoon, October 14, 1896, at 3 o'clock, there was uuveiled in the rotunda of the Administration Building of the Jolms Hojjkins Hospital, in the presence of the trustees and officers and a large audience of invited guests. Stein's reproduction of Thorwaldsen's statue of Christ, a gift from William Wallace Spence, of Baltimore. Mr. Spence, in presenting the statue, spoke as follows:

"I have but a few words to say on this occasion; merely to state how it happens that this statue stands here.

" On a visit to Copenhagen I saw the great work of Thorwaldsen, his ideal conception in marble, of ' Christ, the Divine Healer.' It impressed me more than did any statue I had ever seen, and I think this is the general experience of those who have the good fortune to see it. It was stated that Thorwaldsen himself said, ' I never was satisfied with any work of my own until I executed the Christ; now I am satisfied.' He felt that his genius had reached the zenith of its powers and that he could go no higher. Well might he be satisfied, for the grace, dignity and majesty of this figure have never been surpassed.

" Later on the thought came into my heart how eminently appropriate it would be to have this ideal statue placed where it now stands, in the centre of this hall, under the lofty dome of this great hospital. To every weary sufferer entering these doors, the first object presented to him is this benign, gracious figure, looking down upon him with pitying eyes and outstretched arms, and as if it were saying to him, ' Come unto Me and I will give you rest' I thought it might help to comfort some sad and weai-y one, and lead his heart and thoughts up to the ever-living Divine Healer, who alone could give that


rest. With this feeling I asked permission of the trustees to present this statue to the hospital. It was cordially given, and at once I placed an order with Professor Stein, the eminent sculptor and Director of the Royal Academy of Art in Copenhagen, and there it stands. How well he has executed it you will judge.

"A few years ago, at the formal opening of the Hospital, President Gilman expressed the hope that some day it might stand there. To-day his hope is realized. And now, Mr. President, I beg to present this statue to the Johns Hopkins Hospital."

The statue was then unveiled by little Emily Riggs, an infant great-granddaughter of Mr. Spence.

Mr. W. T. Dixon, the President, in behalf of the Board of Trustees of the Hospital, accepted the gift in the following words :

" Mr. Spence — It gives me very great pleasure to accept, in behalf of the Board of Trustees of the Johns Hopkins Hospital, your generous gift, this beautiful and impressive statue, and to assure you of our appreciation of your motives and munificence.

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

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


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[No. 70.


held out to this company, this community and the people of this age, but they will remain extended to tens of thousands of the generations yet to come.

" There are grave responsibilities and many discouragements in maintaining and conducting a hospital, especially a hospital with the high aims and beneficent purposes of the one you are honoring to-day, and we cannot too earnestly assure you that such evidences of interest in our efforts to comfort the sick, relieve the suffering and advance knowledge, as come with your gift, are most encouraging and insj)iring to us all."

The following hymn by Whittier was sung by a male quartet :

" So stood of old the holy Christ Amidst the suffering throng ; With whom his lightest touch sufficed To make the weakest strong.

That healing gift he lends to them

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

Is evermore the same.

For lo ! in human hearts unseen

The Healer dwelleth still, And they who make his temples clean

The best subserve his will.

That Good Physician liveth yet

Thy friend and guide to be ; The Healer by Gennesaret

Shall walk tlie rounds with thee."

President Gilman of the Johns Hopkins University, upon a special invitation from the trustees of the Hospital, afterwards made the following address:

We are assembled in the presence of one of the best works of modern Christian sculpture, — a transcendent theme, treated by an illustrious artist, in his noblest manner; a work, too, that has stood the test of more than seventy-five years without a word of censorious criticism. Canova saw it in Rome, while it was modeling by the artist, and praised it. The people of Copenhagen determined to have it. It was reproduced at Potsdam (Berlin) in front of the Church of Peace, near which the Emperor Frederic lies buried. A copy, in plaster, surrounded by the twelve apostles, from the same artist, was brought to New Yoi-k at least forty years ago and exhibited in what was known as the Crystal Palace or the World's Fair.

But we have here, not the original cast in clay, nor a plaster reproduction, nor one in galvano-plastic ; but we have a marble like that which Thorwaldsen himself touched with his chisel. The pose, the drapery, the figure, the outstretched arms, the head, the face, are reproduced for us with exactness by a living artist of Copenhagen.

We are greatly indebted to that honored citizen of Baltimore who has brought here a work which from so many points of view delights and inspires us.

This is not the first time that a hospital has been decorated by a great work of art. If I remember rightly, Benjamin West painted the picture of " Christ Healing the Sick," for the Pennsylvania Hospital in Philadelphia; and, if I am not mistaken, in St. Luke's Hospital, New York, there is still a


famous picture by Daniel Huntington, "The Dream of Mercy," based upon an incident in Buuyan's Pilgrim's Progress.

Nor is this the first gift that this hospital has received. Its munificent endowment by Johns Hopkins has been strengthened by fuuds provided for the foundation of a school of medicine and surgery, which supplements the work of the Hospital. And minor gifts have come in. Not long ago we had a very small but noteworthy present, a likeness of Florence Nightingale. At another time a friend gave us models and pictures of various public institutions throughout the country. Again, one who loves medical biography and history has hung upon these walls a fine collection of the portraits of illustrious physicians and surgeons who in many countries and in many generations have adorned their profession. Eecently a large gift has enabled the trustees to provide better facilities for the instruction of those who are here engaged in preparing themselves for the profession of medicine or for nursing. And now we have this work of art which, perhaps, appeals to more of us than any of the other gifts, unless it be that touching memento of a departed child, the "White Eose Fund," which enables the Superintendent every year to distribute flowers to, and to provide for the entertainment of those who are convalescing in the Children's Ward.

Baltimore is fortunate in many ways in the gifts that are coming to it. We seem to have reached a period in the history of this city when its citizens are ready to adorn and decorate the place of their residence. Mr. Spence has presented a noble statue of William Wallace that stands in Druid Hill Park. Around the Washington Jlonument are the works of Barye, of Dubois, and of Story, and also the grand figure of Chief Justice Taney, perhaps the best portrait statue, with one or two exceptions, that has ever been produced in this country, the work of our own Rinehart. But pleasant as these tokens are, I must not dwell upon them, but must rather speak of the circumstances under which this work of Thorwaldsen was produced, and tell you some things regarding the sculptor.

The city of Copeijhagen, at the entrance to the " Sound," is not a very large place; I should say not more than one-half or two-thirds the size of Baltimore (if size is measured by population) ; but it has a port, a university, a citadel, a harbor, and an academy of fine arts, the latter holding high rank among the academies of Europe. The city suffered greatly by the bombardment of 1807 during the Napoleonic wars, and it was not till some twelve or thirteen years afterward that an historic edifice, which had thus been destroyed, was reconstructed. This was the old church which bears the name of the " Frue Kirke." The sound would be more familiar to us if I called it Notre Dame, or the Church of Our Lady. Denmark, as you know, is a Protestant country, and this is a Lutheran church. I have heard it called a Presbyterian church, and I do not know that Mr. Spence will object to that. While in the process of reconstruction, the commissioners had a conference with Thorwaldsen, a native of Copenhagen, and arrangements were made by which he should model a statue of Christ. It was also agreed that the approach to the altar from the main portal should be lined with statues of the apostles, beginning with Peter and Paul. This arrangement was carried


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


out by the artist, then liviug in Home; and such is the origin of the Christus Consolator upon which we are loolviug.

Not far away from this church stands the Thorwaldsen Museum, constructed by the people of Copenhagen for the reception of the casts of all or nearly all the works that Thorwaldsen made. This museum was subsequently endowed by him with a very considerable sum of money, and now constitutes his monument. In the interior court his body lies buried.

Now perhaps you would like me to tell you regarding the artist himself. Perhaps I may mention two or three things that will connect him with this country. Those of us who have watched the ships coming in and going out of a great harbor, as I did in my boyhood in New York, remember how common it was to see ships with carved beaks, often quite well wrought. Now Thorwaldsen commenced his sculpture by carving beaks for great ships. It is not unlikely that in some such place as the Naval Museum in Brooklyn some of those images which Thorwaldsen and his father carved are still preserved.

When Thorwaldsen was beginning to acquire a reputation, about the year 1807, the United States Consul at Leghorn negotiated with him to model a statue of Liberty to be placed in Washington. Whether it was for the summit of the capitol or to stand upon the ground, I do not know, but the life of Thorwaldsen records the fact that negotiations weut forward for the statue, and also that a proposal was made to him to make a monument t6 commemorate the American victories over the pirates of Tripoli and Tunis.

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

The enterprising secretary of the Rhode Island Historical Society took occasion to address a letter to Thorwaldsen congratulating him not only on his honors but on his origin, and Thorwaldsen replied, with a fine touch of courteous humor, "Let us admire those savants, for if it were uot for them, we should not know where we came from or whither we are going."

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


found other conveyances to carry him from Malta to Palermo, to Naples, and so on to Rome. There he went to work.

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

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

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

A great many illustrious people came to Rome. An amusing story is told of Sir Walter Scott. He was very desirous of meeting and talking with Thorwaldsen, and they were introduced to one another; but Thorwaldsen could not speak a word of English, and Sir AValter was not at his ease in French. All that any one could hear was "plaisir," "plaisir," "connaissance," and similar nouns, expressing gratification that they had met.

The sculptor soon came into church circles. He was a particular friend of Cardinal Consalvi, and made his monument. It was through his influence, undoubtedly, that Thorwaldsen was selected to make for the Church of St. Peter the famous monument of Pius the Seventh. Some one objected that a Protestant had been selected. The Pope inquired, " Is not he the


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[No. 70.


best artist in Eome?" "Undoubtedly," was the answer. "Then let him hold the place."

Thorwaldsen after a time went home, and, as I have said, received the commission for a statue of Christ. He returned to liome, and with his helpers, it took him eight or nine years to complete the group of Christ and the Apostles.

You must be familiar with many of the works which he produced meanwhile. The little medallions of Night and Day which hang in so many parlors were his. Almost every one who goes to Eurojie knows the Sleeping Lion of Lucerne and the statue of Lord Byron at Cambridge. He made many portrait busts. He worked long on mythological subjects, till finally " he turned from Jove and Mars to nobler themes."

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

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

Now, ladies and gentlemen, it is not for me to draw the lesson of the statue. I suppose (to use a phrase of Coleridge) that this statue "will find each one" of us in his own mood. To some it will be a reminiscence of travel, — of a delightful day in Copenhagen. To others it will be a work that is famous in the history of modern art. To many of the anxious and suffering it will be suggestive of hope and faith and love. To each, according to the inward eye that he brings to bear upon it, will the lesson be given. I do not propose to read a homily ; but I may remind you that throughout modern literature and art this figure appears. From the Divine Comedy of Dante to the Paradise Lost of Milton, in the Saul of Browning and Tennyson's Crossing the Bar, one name


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

In the presence of Mr. Spence it will not do for me to recount the many good deeds which he has done for the city, the many great services, political, financial, mercantile, philanthropic, educational and religious, which he has rendered to Baltimore ; but I must be allowed to say that twice when the finances of the Johns Hopkins University have been in a critical condition, he has been the one citizen to come forward and by his example to inspire the liberality of others. He was kind enough to tell you that I had on a " wishing cap," or words to that effect, seven years ago. I am going to put on my "wishing cap" now, and I am going "to wish" that as long as Baltimore lives and flourishes it may have the presence and influence and co-operation of such men as William Wallace Spence.


THE BACILLUS PROTEUS ZENKERl IN AN OVARIAN ABSCESS.

By Hunter Robb, M. D., Professor of Gynecology, Western Reserve University, Cleveland, 0., and Albekt A. Ghriskey, M. D.,

former Assistant Gytiecologist to the Johns Hopkins Hosjntal.


Mrs. T. G. was admitted to the gynecological ward of the Johns Hopkins Hospital, August 8, 1891, with the following history :

The patient was a Bohemian, 36 years of age, and had been married seven years. She had had three children, and said that she had never miscarried. The oldest child is six and the second four years old; the third child, born in Jan., 1890, died of " summer complaint " at the age of six months. Her labors had been easy ; she remained in bed for two days after each, being attended only by a midwife. PIcr menses first appeared at 16 years of age. They were irregular, lasting usu


ally seven days, and were often profuse and painful; since marriage her menses have been regular, lasting five or six days, being profuse but not painful. In May, 1890, she ceased to menstruate for two months, but in July her menses reappeared and lasted six days. At this time they were profuse and accompanied with a great deal of backache and pain in both ovarian regions. She had never had leucorrhiva; she suffered from constipation. There was no urinary difficulty. The patient remained well until April, 1891, when a hemorrhage from the vagina occurred suddenly and continued for six days. Two hours after the hemorrhage ceased she passed foul


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


smelling black clots of blood and experienced labor-like pains. During May, June and July she was free from these laborlike pains, but complained during these months of weakness, of occasional chills and fever, of pains in the lower zone of the abdomen, and backache. On admission to the hospital she was too weak to walk. The slightest touch over the region of the left ovary provoked intense pain. The temperature on admission was normal ; the jiatient weighed 123 pounds.

At the examination made August 8, 1891, under chloroform narcosis, the following note was made :

Vaginal outlet moderately relaxed; vagina bathed with bloody fluid ; cervix small, bilaterally lacerated, pointing upwards; uterus anteflexed, sagging in the pelvis, enlarged, soft and movable. Right broad ligament thickened. Fallopian tube and ovary not definitely palpated.

On the left side a fluctuating tumor is outlined, about the size of an orange, adherent to the uterus.

Diagnosis. Abscess of the left ovary. Treatment advised, coeliotomy.

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

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

Operation August 12, 1891, under chloroform narcosis.

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

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

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

The specimens removed consist of the tube and ovary of the


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

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

The cotton immediately over the drainage tube was slightly moistened with the same character of secretion as that seen upon the plug and upon the cotton pledgets.

Abdomen flat, no distension, general condition good, usual cultures taken.

VIII-14-91. Second dressing. Slight amount of fluid on cotton over the drainage tube ; plug in tube moistened by a clear fluid holding a clot of blood at the lower end. On the gauze plug there are white opaque points of lymph, corresponding in position to the perforation in the drainage tube. The fluid has the same odor of decomposition. Tube cleansed with twelve pledgets of cotton, which when withdrawn were stained with a serum-like fluid, the two last being hardly soiled at all. Drainage tube removed and a plug of iodoformized gauze inserted down the track of the tube. Abdomen flat, general condition good ; usual cultures taken.

VIII-15-91. Third dressing. Gauze removed from the tube track; moistened; not as much odor. Track of tube cleansed with peroxide of hydrogen. Abdomen flat, general condition good. Gauze reapplied to wound, but not down the track ; abdomen sensitive. Gauze impregnated with permanganate of potassium and oxalic acid applied over the protective dressing and track of the tube.

VIII-19-91. Fourth dressing. Stitches removed. Line of union good; some suppuration about the track of the tube. General condition good.

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

Analysis of temperature cliart. — The temperature was taken for ten days after the operation by the mouth, rectu m and vagina. The highest point registered was that on the fourth day, when it was 102° F. by the rectum, 101.8° F. by the vagina, and 101.2° F. by the mouth. After this it was never above 101° F. and on the 9th day registered 100.5° F.

Bacteriological examination. — The following cultures were made from the left Fallopian tube and abscess cavity: Two sets of Esmarch's roll plates on agar-agar, one smear and one stab culture in the same medium ; a blood-serum tube (bullock's blood) and a litmus milk tube. From the right Fallopian tube, which was distended by a muco-purulent, rather viscid looking fluid, we only made gelatine Esmarch's roll jilates.

Microscopical examination. — Cover-slips stained with gentian violet show numerous polynuclear leucocytes, with compound granular bodies, and a few cells with large round nuclei resembling epithelial cells. Many bacilli were observed; they were rather faintly stained, and were seen only occasionally within the leucocytes. These bacteria were stained best with carbolic gentian violet.

Numerous rod-shaped bacilli were found in the preparation


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[No. 70.


from the Fallopian tube on the right side. Though less intensely stained, they resemble tubercle bacilli somewhat morphologically. They are, however, completely decolorized when treated after the method of staining for the latter organisms. It is to be noted that the organisms were very numerous in the specimen from the point at which the cultures were made.

After 48 hours in the thermostat all tubes were sterile, except the blood serum slants, which showed an opaque, very faintly granular growth, apparently due to closely set colonies. Only the growths from the two inoculations from the abscess contents were considered reliable for study. Inoculations were made from these on the agar-agar, blood serum, potato and gelatine. Examined microscopically they proved to be pure cultures of a bacillus.

All these tubes showed growth after 24 hours on agar; very faintly after 48 hours on gelatine, on account of the lower temperature, but more distinctly on the latter on succeeding days. The appearance of the colonies in gelatine corresponded to that presented by the bacillus proteus, a fact suggested by Dr. Booker and confirmed by Dr. Welch. These colonies showed the typical twisted wandering offshoots (schwiirmende Colonien) characteristic of the proteus group. The gelatine was not liquefied.

Cultures from the Dramage Tube. — First dressing 24 hours after operation. Roll plate, agar-agar, Esmarch's tubes. The colonies on the tubes from the gauze plug were composed of the skin-coccus. Microscopical examination of stained coverglass preparations from the secretion showed a few diplococci, and numerous bacilli identical with those found in the abscess cavity. The coccus grew on potato and in bouillon with the characters of the streptococcus pyogenes albus, but liquefied gelatine, though less rapidly than this organism.

The inoculation of a guinea-pig subcutaneously in the flank with the serum-like secretion from the gauze plug was without result.

Further inoculations from the drainage tube on bullock serum were not made, as the supply of culture medium was exhausted.

The case is of unusual interest on account of the results of the bacteriological examination. The bacillus proteus vulgaris (variety Zenkeri ?) was found in cultures from the abscess cavity in the left ovary, and on cover-slips in the right Fallopian tube. In all our previous examinations of abscess cavities, cysts and Fallopian tubes, we have never met with another instance in which it was present.

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

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


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

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

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

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

There is also a marked endarteritis.

Sections through the wall of the ovarian abscess show that the jDortion adjacent to the cavity contains many newly formed blood-vessels; it is filled with leucocytes and most beautiful fibroblasts, which are rapidly proliferating, nuclear figures and cell division being well seen.

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

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

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

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


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

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

It seems fair to assume that our patient had a puerperal endometritis following the abortion which occurred last April, and that the infection subsequently involved the Fallopian tube and ovary.

The proteus Zenkeri, which he classifies among the anaerobes of putrefaction, is described by Hauser' as follows: The organisms 0.4 in bi'eadth, and of an average length of 1.65; in some instances the forms are rounder, at other times longer. After inoculation on gelatine, a layer which towards the periphery becomes thinner and has the appearance of the steps of stairs, is formed around the point of inoculation, and from the margin of this layer numerous threads and rods begin to pass out; after 24 hours we find large numbers of moving islands, composed of rods and threads presenting exactly the same appearance as in the case of proteus mirabilis. The deposit becomes gradually thicker and opaque, but no lique


faction of the gelatine occurs except sometimes quite at the surface. The formation of spirilla is seldom observed. Cultures in gelatine and blood serum do not show any marked odor; meat infusion, on the other hand, is decomposed by the organism with the production of a strong smell. In its other effects the proteus Zenkeri resembles the proteus mirabilis and the proteus vulgaris, and as Hauser' has pointed out, there is probably only one species of proteus, the vulgaris, of which the other forms are to be regarded as simple physiological variations.

Literature.

1. Hauser: Ueber das Vorkommen von Proteus vulgaris bei einem jauchig-phlegmonosen Eiterung. Munchener medicinische Wocheuschrift No. 7, 16 Februar, 1S92, p. 103.

2. Beck : Die Faulnisbachterieu der menschlichen Leiche. Baumgarten: Arbeiten auf dem Gebiete der pathologischen Anatomie und Bacteriologie aus dem pathologisch-anatomischen Institute zu Tiibingen, Bd. I, S. 155, 1889.

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

4. Fliigge: Die Microorganismen, 188G, p. 310.


THE PHRENOLOGY OF GALL AND FLECHSIG'S DOCTRINE OF ASSOCIATION CENTRES

IN THE CEREBRUM.

Br Lewellts F. Barker, JI. B., Associate Professor of Anatomy in the Johns ffopki7is University and Assistant Resident Pathologist to the Johns Hopkins Hospital.

[Remarks made before the Clinical Society of Maryland, November 20, 1896.]


In the history of medicine the 18th century stands out prominently as a period in which flourished a whole host of so-called medical systems and theories. The animismus of Stahl and the nerve-ether theory of Hoffman had been displaced by the system of Boerhaave ; the last, in turn, being gradually supplanted by the doctrine of irritability advanced by Albrecht von Haller, who had formulated a new theory based upon his experiments in physiology. William Cullen, again, combining Hoffman's system with the doctrine of irritability of Haller, sought the cause for all pathological processes in the nervous system. Each individual attempted to subordinate the most varied phenomena met with in disease to his own particular principle, and as yet the newer studies in anatomy and physiology were not wide-reaching enough in their influence to prevent the development of the most diverse and contradictory medical theories. The " excitation theory " introduced by John Brown met with an enthusiastic reception not only in England but also on the Continent, although it was gradually undermined by the vigorous opposition of Stieglitz and of Hufeland. It was only toward the end of the 18th century and the beginning of the 19th that the investigations in the field of natural science began to affect medical ideas to any very considerable degree. The natural philosophy of Schelling, which was accepted widely by physicians, especially in Germany, benefited medicine very little, if at all.


Indeed, the statement has been made that the general tendency of the time to favor Schelling's philosophy did more than anything else, except the curiosity of the public, to spread the three false doctrines, animal magnetism, phrenology, and homCEopathy. Animal magnetism, fathered by the shrewd Anton Mesmer, had a brilliant career until the French commission with Franklin at its head successfully demolished it. Homceopathy, founded by Christian Friedr. Samuel Hahnemann, which attempted to subordinate the whole of the healing art to an arbitrary dictum, Siinilia similibus curantur, still has many adherents, especially in America. Phrenology or cranioscopy, connected closely with the name of Franz Josef Gall, has now but few disciples, and an avowal of belief in phrenological doctrines is usually received, even by the layman, with a suppressed smile.

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


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the ecclesiastical authorities he was commanded by the Austrian government to discontinue "his public teaching. On leaving Vienna he went to Paris, where he gathered around him many supporters and continued to lecture, investigate and publish. He died at Montrouge, near Paris, in 1828.

It has been thought by many that Gall's statement concerning his early observations of his schoolfellows was made late in his life with the object of bolstering up his claims to originality. Macal lister, in his excellent and comprehensive article on Phrenology in the Encyclopedia Britannica, points out that Prochaska, of Vienna, who had published a work on the nervous system in 1784, is really to be looked upon as the father of phrenology, inasmuch as in his volume are to be found the germs of the views propounded by Gall in the same city a few years later. Prochaska in turn was preceded, at any rate as far as the idea of connecting the anatomical diversities of the brain with intellectual peculiarities is concerned, by Metzger, who 20 years before had proposed the inauguration of a series of observations bearing upon this point. Moreover, the doctrines of localization of function in the brain are of still older date, though it must be admitted that very little positive knowledge upon this point existed before the beginning of the 19th century.

After leaving Vienna, Gall attached to himself Spurzheim, who seems to have been for some time an enthusiastic pupil, and, along with his preceptor, to have made many investigations upon the structure of the brain and the shape of the skull. Spurzheim rendered great service to the phrenological doctrines in England and America, where he lectured to large audiences and attracted many pupils, the most important one in America being perhaps George Combe. Gall and Spurzheim did not, however, remain throughout life in harmony. They separated in 1813, in the subsequent years, each preaching his own doctrine and disparaging to a certain extent, at least, the philosophical views of the other.

The doctrines of the phrenologists maybe briefly summed up as follows : They believed that the brain, as a whole, is the organ of the mind, and that it is made up of multiple organs, each mental capacity displayed by an individual depending upon the development of its corresponding organ in the brain. The form of the skull was thought to depend upon its relations to the brain within it, though Gall in one of his publications vigorously opposes the appellation " cranioscopy " as descriptive of his doctrines, stating that he had always maintained that his work was directed toward the anatomy and physiology of the brain, the contributions concerning the relations of the form of the skull to the morphology of the brain being merely an appendage of the bulk of his studies.

It is not my purpose in this brief communication to describe the whole list of faculties and the portion of the brain assigned to each by Gall, Spurzheim and others; phrenological diagrams are familiar to all of us, and, moreover, 'an account of the views of the various adherents and modifiers of the system is to be found in almost any encyclopedia. A glance at the loose manner in which some of the so-called organs of the mind were localized in the brain by bumps upon the skull will suffice to show the


unscientific nature of the whole system. Whereas Gall believed that there were only some 26 or 27 organs of the brain, with some of his followers the number was increased considerably. Fowler, for example, describing as many as 43 different faculties. Spurzheim divided the different capacities of the human mind into (1) the feelings, including the propensities and sentiments, and (2) the intellechial families, including the perceptive and reflective activities. As examples of the propensities may be mentioned concentrativeness, amativeness, philoprogenitiveness, combativeness and acquisitiveness ; of the lower sentiments, self-esteem, vanity and cautiousness may be mentioned; and of the higher sentiments, benevolence, veneration and firmness. Among the perceptive faculties he included the appreciation of form, size, weight, color, locality, number, order, time and language; while the power to study causality and the ability to compare one thing with another were described as reflective faculties. Having gained an idea as to the localization of a certain faculty, Gall and his friends would examine the heads of their acquaintances and the casts of the skulls of persons who had possessed the particular mental characteristic under examination, and would seek for a distinctive feature corresponding to this particular trait. The following examples are excerpted from Macallister's article. Amfitiveness was located by Gall in the lower part of the posterior surface of the head because he found this area to be hot in an hysterical widow. He referred the faculty to the underlying cerebellum. It is amusing to learn that the adherents of phrenology explained the presence of a rudimentary cerebellum in the girl Labrosse, who had during life exhibited very marked amative tendencies, by assuming its obliteration from over-use. Destructiveness was located above the external auditory meatus, inasmuch as this is the widest part of the skulls in carnivorous animals. A marked prominence had been found in this situation on the head of a student, "so fond of torturing animals that he afterwards became a surgeon," and it was also well developed in the head of an apothecary who subsequently became an executioner. Acquixitivcness, located upon the upper edge of the anterior half of the squamous suture, was attributed to"this region because Gall had noticed it to be prominent among the pickpockets of his acquaintance. The bump of con.(riictireiiess was easily found, since it was large on the head of a milliner of very good taste and upon a skull said to have been that of Eaphael. iSi If -esteem was located over the obelion because Gall found this region prominent in a beggar who had excused his poverty on account of his pride. The lore of approbation was supposed to be situated outside the obelion, inasmuch as this part of the head was especially protuberant in a lunatic who thought herself the queen of France. Cau/ioumess was assigned its proper situation from the observation of the large size of the parietal eminences in an ecclesiastic of hesitating disposition. Veneration, located in the middle line at the bregma, was determined by Gall after visiting churches, where he found that those who prayed with the greatest fervor had distinct prominences in this region. The bump of ideality was found especially developed in the busts of poets, and was said to be the part touched by the hand when comjiosing poetry. Since the frontal eminence was prominent in llabe


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lais and Swift, it was believed to be the organ of the sense of the ludicrous. The capacity for recognizing faces was supposed to depend upon the width of the interval between the eyes, inasmuch as Gall found in a squinting girl a good memory for faces. The murderer Thurtell, who had a large organ of benevolence, is said by devotees to phrenology to have been in reality generous, since it was discovered that he once gave half a guinea to a friend. Many other laughable instances might be given of these crude methods of localization and of the futile attempts of the adherents of the doctrine to bolster up their tumbling edifices.

It is easy to understand how a shrewd man like Gall, — and any one who reads his books will be very ready to grant his shrewdness and intelligence, — developing with great rapidity a system full of interest for the public and stimulating their curiosity by providing them with an infallible clue to the determination of character and fitness for occupation in life, should have attained wide-spread and lucrative popularity. He soon made large amounts of money, lived in state, and numbered among his personal friends some of the first names in France. Nor was he a charlatan pure and simple; he undoubtedly had a brilliant mind, and made elaborate and careful studies of the brain and skull which resulted in discoveries of permanent value concerning the anatomy and physiology of the brain. No better proof of this statement can be obtained than by perusing the volumes which I place before you, kindly loaned by the Provost of the Peabody Library. This atlas, with its well-executed copper- plates, in particular, shows the care with which much of his work must have been done. The edition, including the atlas, sold in Paris at 1000 francs.

It is curious how nearly a man starting with false premises may often approach to actual conditions. 'I'he newer investigations bearing upon the architecture of the brain have thrown much unexpected light upon the origin of the phenomena of the mind; the significance of the brain for the psychic phenomena has been established upon the basis of exact scientific investigations, and we are now justified perhaps in speaking in a certain sense of a " new phrenology." It may be interesting to refer briefly to the series of investigations which have led up to our present knowledge upon this subject.

In so far as his doctrine maintained that the convolutions represented the most important substratum of the mental activity, and that the single convolutions of the cerebral cortex are not of equal significance for intellectual life, Gall most certainly approached the modern theory of cerebral localization. The investigations of Flourens led him to very different conclusions, and in 1812 he published his well-known " Examen de la Phrenologie," which was thought to have demolished the phrenological doctrines. It was Flourens' idea that every portion of the substance of the cerebral cortex had precisely the same significance. He believed that the removal of any given mass of the grey matter affected all the mental functions in exactly the same way, so that visual or olfactory perceptions would not be diminished in different proportions, no matter what area was extirpated. The facts which have been discovered by pathologists and clinicians concerning aphasia were, however, in entire opposition to these ideas of Flourens. Gall and Bouillaud had recognized that circumscribed lesions


in the cerebrum, especially in the frontal region, could give rise to definite disturbances in speech. Later, Marc Dax pointed out that aphasia occurred practically only when the left half of the cerebrum was diseased, and in 1863 Broca established the fact that in right-handed people the third left frontal convolution is the portion of the grey matter of the cerebral cortex which is important for articular speech. Subsequent studies upon aphasia have shown that there are several dift'erent kinds of the affection, only one variety of which depends upon disease of Broca's convolution, i. e. the one in which the capacity to speak out the word which the individual has in his consciousness is lost; the inability to understand spoken words, and the incapacity to call into consciousness the names of objects which are visible to the individual, being associated with disease of other parts. These facts alone prove that different regions of the brain are of different significance for the intellectual functions.

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

In 1870 Fritsch and Hitzig reported the results of their investigations concerning galvanic excitation of the surface of the brain of animals, in which it was shown that stimulation of definite regions calls forth movements of certain only of the parts of the body. Three years later Ferrier used faradic stimulation of the cortex and was able to elicit quite complicated movements of different parts of the body, movements which seemed to be purposeful, inasmuch as they correspond to those employed by the animal when utilizing its sense organs, that is to say, movements such as are employed in listening, touching, looking at, or smelling external objects. Munk proved fiirther that by the removal of certain convolutions it was possible to produce in animals disturbances of sensory activity quite analogous to those which had been observed in the clinical and pathological study of diseased human beings.

The studies of Goltz upon dogs supply an exceedingly interesting link in the chain of experimentation. This investigator demonstrated the possibility of keeping a dog alive for a considerable length of time in the entire absence of a cerebral cortex, and in this way was able to ascertain what faculties the animal possesses when only the lower parts of the brain are functioning uncontrolled by the cerebrum. He found that an animal without a cerebrum still possesses a very complex nerve life, a fact which is not so very surprising when one recollects the observations of comparative afiatomy. While the dog of Goltz's experiment appeared to be devoid of memory and judgment and incapable of finding out for himself among the objects outside of the body those necessary for the satisfaction of his needs, he showed himself to be by no


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[No. 70.


means an involuntary machine. Goltz states that he could stand upright, could run, could be set in motion by external stimuli of various kinds, that he could show evidences of emotion, becoming angry and biting and howling under provocation. When hungry the whole body entered into lively motion, and after food had been taken the animal again became restful and showed evident signs of satisfaction. As Flechsig points out, these experiments do not permit any conclusion regarding the condition of consciousness after the loss of the cerebrum, but they do show distinctly the power and the independence of the bodily instincts, and teach us that no small part of the acts concerned in these can be set free simply through bodily influences, entirely independent of the higher mental faculties.

The studies of His and Flechsig, which have done so much in recent years to give us an insight into the finer organization of the nervous system, have been especially devoted to the development of the nervous system. It is to the work of Flechsig to which I wish on this occasion to especially direct your attention.* His method of outlining tracts by the observation of successive periods of myelinization is not new. His larger work, published many yeai'S ago and entitled "Die Leitungsbahnen iniGehirn und Riickenmark," is based almost entirely upon studies made after this fashion. The tracts which function first, receive their myelin sheaths before the others, and a tolerably definite idea of the physiological capacities of a develojiing animal at a given moment, up to a certain period at least, can be gained by ascertaining the number of tracts which have already been medullated. Thus the spinal cord, medulla, pons and corpora quadrigemina are almost entirely medullated at a time when the parts higher up show very little or no myelin. Even in the new-born child, Flechsig has shown that the cerebrum is almost entirely unripe, inasmuch as extremely few of the myriads of nerve fibres which it contains are at this period medullated. Man, therefore, at the beginning of his earthly experience, resembles very closely the dog of Goltz's experiments; he is practically a being without a cerebrum, and yet, as in Goltz's dog, even with the drawing of the first breath, the bodily instincts in the child demand satisfaction. The new-born infant, with satisfied impulses and unaffected by external stimuli of a disagreeable nature, shows no evidence of consciousness. H it become hungry or be exposed to cold, or if painful stimuli be applied to it, active movements of the body result.

Flechsig has shown, in his study of the embryonal cerebrum, that it is the sensory paths which first become medullated.

  • I have thought it best at this time to present, in as clear and

brief a manner as possible and without discussion, the main tenets of Flechsig with regard to the structure and function of the brain. While in such a short communication it is impossible to do justice to so broad a subject, it is to be hoped that it may be possible to show at least the trend of his views. The anatomical basis for his studies is given at some length in the voluminous notes appended to his "Gehirn und S'eele " (Leipzig, Veit. Co., 189(>). An idea of some of the criticisms which may be made of his doctrines can be gained by a perusal of the discussion of the address delivered by Flechsig at the Versammlung deutscher Naturforscher und Aerzte, Frankfurt, September, lS9()(cf. Centralbl. f. Nervenheilkunde und Psychiatric, October, ISOO).


Gradually the individual fibres of one sensory path after another, beginning with that concerned in the sense of smell and ending with that by which are carried auditory impulses, passing from the sense organs of the body toward the cerebral cortex, gain their myelin sheaths. Each sensory path includes a very large number of nerve fibres containing the axones of neurones whose cell bodies are situated lower down. Following the different sensory paths to their cortical termination, it is easy to show in these early stages, in which very little of the brain is medullated, that the individual sensory paths terminate in tolerably sharply circumscribed cortical regions, for the most part widely removed from one another, being separated by masses of cortical sitbstauce which remain for a considerable period entirely unripe. Indeed, the cortical terminations of the individual sense paths correspond entirely to those regions of the surface of the brain which pathological observation has shown to stand in relation to the different qualities of sensation. It is the destruction of these internal sense organs which results in cortical blindness, cortical deafness, etc.

After these sensory paths in the child's brain have become medullated, new paths begin to develop from the points where the sense fibres terminate — paths which go in the opposite direction. These fibres as they become medullated can be traced passing downwards to the medulla and the spinal cord, to the nuclei of origin of the motor nerves, and connecting in this way the sensory regions on the surface of the cerebrum with the motor apparatus. The area of the cortex concerned in the sense of touch has an especially well developed bundle of these motor fibres, the fasciculus cerebro-spinalis or so-called pyramidal tract, which consists of more than 100,000 fibres on each side, an arrangement which permits the carrying out of very delicate movements, especially of the parts of the body concerned in the sense of touch. Connections between the cortical sensory areas and the lower centres which appear to be concerned more directly with the bodily instincts, have already been made out. It is clear, therefore, that bodily instincts and external sense impressions may reciprocally influence one another. According to Flechsig, the sense of smell is moat intimately connected, the sense of hearing least associated with the centres concerned in the exercise of the lower instincts, a fact which, if confirmed, might account for the more ideal character of auditory impressions.

In the diagram before you, the localization of these various sense areas in the brain, according to the newest investigations of Flechsig, has been pictured. It will be seen that they are very sharply circumscribed, although at the peripheries of the areas the fibres do not terminate so close together as in the central parts. The large region, the sonifesthetic area, occupying the whole domain between the fossa sylvii up to the corpus callosum, including the gyri centrales and the feet of the frontal convolutions, together with the lobulus paracentralis and the middle third of the gyrus fornicatus, represents the cortical field in which terminate on either side those of the 200,000 fibres of the medial lemniscus which do not stop at the basal ganglia. These fibres, together with those relaid in the thalamus, it is believed, carry to the cortex the impulses which are concerned in the projection


Gyru.cm,.r..l,{J»«;r;;p,S<,m»»>.l,.tlo.,„.


Corpus cAllonnn

Porulx louguti,

(Septum pellucW,



"^ti^^i^r^^^j^


^^^


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



Fig-. 6.


Soraae»tUetic



Gynm hippocampi.


Fig. +.




LEGENDS.

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

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

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

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

olfactory area and the gyrus hippocampi).

c. Corpus callosum corresponding to the somiesthetic area. D. Superior I

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

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

II. Tractus opticus.

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

Fio. 3. Horizontal section from the brain of a child a little over a week old. {After Flcchxig.)

C. Nucleus oaudatus. P. Putamen of the nucleus lenticularis. gp. Globus pallidus of the nucleus lenticularis. The optic radiation is well medullated ; the auditory path is not yet medullated as far as the cortex.

Fig. 4. Sagittal section through the brain of a child said to have died in the fifth month of life. (The child was probably some months older.) (After Fleclmii.) All parts of the white substance medullated, only in places still mixed with non-medullated fibres.

C, P. (IP, as in Fig. 3. T. Thalamus (lateral nucleus). II. External geniculate body.

X. Substantia iiinominata Rei! (gray substance between the n. lenticularis and the n. amygdalse). M. Nucleus amygdalir.

x—y. Projection fibres of the anterior upper and inner part of the somiEsthetic area (KOrperfiihlsphiire); these run from the internal capsule (between P and C) forwards and bend around at an acute angle at x to pass upwards and inwards. V. Lateral ventricle.

Fig. .5. External view of right cerebral hemisphere, showing sense-centres and association-centres. (After Fle.chxig.) The more closely dotted areas show the regions in which the majority of the sensory projection fibres terminate. The large areas between the dotted areas represent the association centres.

Fio. 6. Internal view of left cerebral hemisphere. (After FUchHg.)

1. Corpus mammillare.

2. Median section of optic chiasm.

3. Cross-section of anterior commissure.

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

6 Fornix.

7. Septum pellucidum. z. Pineal gland. H.S. Tegmentum. T. Basis pedunculi.


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JOHNS HOPKINS HOSPITAL BULLETIN.


11


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

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

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

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

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

When all these sense centres have become ripe, that is, when the fibres going to them and the motor fibres passing from them to become connected with the lower motor centres, are medullated, only about one-third of the whole area of the cortical surface has been concerned. This means that approximately only one-third of the human cerebral cortex is directly connected with the paths which bring sensory impressions from the periphery into consciousness, or carry motor impressions to the periphery causing muscular contractions. Twothirds of the whole cortex appears to have nothing directly to do with the periphery, but to be reserved for another and apparently a higher work. These other areas which are left


uncolored in the diagram are the so-called association centres of Flechsig. They make up the main portion of the frontal lobe, a large part of the temporal and occipital lobes, the island of Eeil, and occupy a large area in the posterior parietal region of the brain. For a whole month after birth these portions of the cortex remain uuripe and are entirely devoid of myelin. But after the development of the sense areas of the cortex, Flechsig has been able to follow baud after band of nerve fibres passing from the different sense areas into these other immature portions of the cerebral cortex, and ending there close beside one another, thus forming true centres of association between the different sense centres. And it is his belief that these association centres represent arrangements which unite the activities of the central internal sense organs and build them up to higher units. Sensory impressions of different qualities, visual, auditory, tactile, olfactory and gustatory, are united, or at any rate the anatomical mechanism is afforded for their union. The association centres have an entirely different microscopic structure from that to be made out in the sense centres, a topic into which, however, I cannot now enter.

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

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


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pfo. 70.


alterations in the cerebral substance. In cases of the disease in which the lesions are widely diffused over very many different areas of the cortex, no reliable conclusions can be drawn regarding the significance of the association centres ; but occasionally the disappearance of nerve fibres is limited almost entirely to the association centres, and in some instances especially favorable for the study of function, the frontal association centre alone or the large posterior parietal association centre alone is chiefly diseased.

The study of such lesions and of the symptoms manifested by the patients during life, has not yet gone far enough to justify many positive assertions regarding the specific function of the different association centres; but enough has been done to warrant the consideration of certain statements which possess some degree of probability. Thus, where there has been bilateral disease of the frontal lobes, that is, of the anterior association centre, there has been observed in the individual during life an alteration or loss of ideas regarding his own personality and his relations to what is taking place inside and outside his body — symptoms which are quite in accord with those observed in higher apes by Bianchi after extirpation of the frontal lobes. The phenomena vary of course according to the irritative or destructive nature of the lesion. The individual may in his mind connect his personality with mental pictures which have in reality nothing to do with himself; thus he may think himself of enormous dignity, or that he is possessed of great wealth or that he is a genius. In other cases he fails to connect his own person in any way by means of association with external perceptions, so that he may forget himself or may fail altogether to observe his surroundings. Still in possession of numerous ideas, he may speak in an orderly fashion, although he appears unable to distinguish the true from the false and the imagined from the experienced. Besides these logical defects he may show a diminution of his capacity for ethical and esthetic judgment, so that he will perform acts entirely irreconcilable with his character as manifested earlier in his life. Even in the absence of emotion he may appear to be devoid of his normal self-command; but when subjected to unaccustomed stimuli, especially to sexual excitement, anger or vexation, he may lose all control of his movements and acts, so that some simple influence may lead him to try to satisfy his desires without any regard to custom or good taste. In late stages of the disease imbecility may appear, with entire loss of the mental pictures regarding his personality.

The mental phenomena displayed in connection with disease of the posterior parietal association centres appear to stand in marked contrast to those just outlined. They have been studied in cases of general jjaresis, but better opportunities for the observation of such phenomena are often afforded where there has been focal softening of the cortex due to vascular disease. Here the individual may be incapable of naming correctly objects outside his body which he can touch and see ; and if this centre on both sides be widely diseased, he may not recognize at all the nature of these objects, so that he loses the power of forming intelligent conceptions of the external world. On the contrary, he may be entirely clear as regards his own personality; he may appear to possess his


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

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

Time will not permit me to discuss the so-called functional disturbances ascribable to conditions of exhaustion of different cortical areas dependent upon prolonged and violent emotion, various intoxications, impoverishment of the blood, and other causes. Suffice it to say that, on theoretical grounds at least, more or less sharp criteria can be mentioned for the participation in the process of the different centres, especially the somresthetic area, the frontal lobes and the posterior large association centres. In many instances, however, the phenomena presented show, what we a priori might expect, that several of the sense areas and association centres are diseased at once. The various permutations and combinations possible will doubtless account for the manifold symptomatology of the great group of nervous and mental diseases, a symptomatology which as yet is in almost hopeless confusion and which calls urgently for an ordering hand. It will be the task of psychology and neurology in the future to analyse the specific activities of the various regions of the cortex, and to correlate these with the mental phenomena of human beings in health and disease.

Flechsig's researches have established the fact that the human cerebral cortex is made up of at least seven anatomically more or less well separated areas. As the phrenologists


January, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


13


thought, the brain is the organ of the mind, and the whole is in reality made up of multiple organs. But instead of calling these, as did the old phrenology, after certain qualities, friendship, good-nature, wit, firmness, and the like, thanks to Flechsig's studies we can now adopt a more rational nomenclature. We can now speak of sense centres and of association centres in the cerebral cortex. The sense centres may be roughly grouped as the somssthetic area, the visual sense area, the olfactory sense area and the auditory sense area ; the association centres for the present have to be designated according to their position as frontal or anterior, insular or middle, and parieto-occipital or posterior. Thus a distinct advance has already been made, and it is hardly too much to expect that further study will permit of much more complete differentiation and more definite localization of both kinds of areas.

It is not stating too much to affirm that advances in true psychology are to be mainly hoped for from strictly scientific investigations into the structure and function of the nervous system. Pure philosophical psychology has advanced but little beyond the concepts of Aristotle and the other ancients, and as Flechsig says, " Medicine at all periods has been nearer the ideas believed in to-day mainly on account of the fact that the physician has had ever before him as the special object of his observations the human individual, presenting healthy or diseased conditions, in life and in death."

It would take too long to give even a brief resume at this time of the insight into psychological processes which are afforded by Flechsig's work. His recent publications speak for themselves, and his treatment of the subject cannot fail to prove interesting to the reader. Doubtless many of the theories which he has advanced as a result of his anatomical studies will not stand the test of time. But we owe to him a deep debt of gratitude for supplying us with a large mass of entirely new knowledge, from which further investigations may start.* The relative 2'ositions of the individual sense centres to the association centres are, as can be seen from the diagram, very peculiar. The posterior association centre is situated among the visual, auditory and somajsthetic areas of the cortex; while the anterior association centre is related, in gross at least, only to the somajsthetic area and to the olfactory sense area. The middle association centre has adjacent to it the auditory, olfactory and somaesthetic areas. When one remembers that the association centres receive bands of fibres which run into them from the adjacent sense areas, the remarks made before concerning the specific functions of the different association centres will perhaps be more easily appreciated.

Flechsig in his " Kectoratsrede," as well as in his later


  • We should be particularly grateful for the deflnitiveness of the

concepts of brain structure which Flechsig has afforded us. In this embryological self-analysis of the cerebral tracts, the bands of medullated libres, stained by the method of Weigert, stand out as clear-cut on the yellow background of non-medullated nervous tissue as the lines of a diagram. The illustrations of sections in Flechsig's book are by no means fanciful. In his regular lectures during the spring semester of 1895, Flechsig showed us a large number of his preparations which bear out fully his anatomical statements and illustrations.


address upon the " Border-lands of mental health and disease," has laid especial emphasis upon the significance of the somajsthetic area. Assuming it to be the portion of the cerebral cortex where impressions regarding the body enter into consciousness, the centre which appears to have to do with the bodily emotions and bodily needs, and upon the excitability of which the crudity or delicacy of the instincts which enter into consciousness depends, as well as the centre whence start nearly all motor impulses which are concerned in conduct, be they those leading to the closure of the fist, the pressure of the hand, or the most delicate embrace, Flechsig believes that this somsesthetic area is to be looked upon as the main organ of character. This cortical area, connected as it is on the one side directly with the peripheral sensory and motor apparatus of the body, and on the other with the higher association centres in the cortex, stands, as it were, like a buffer intercalated between the organs of the body and the organs of the intellect. The character of the activities manifested by these complex cortical centres of which the somfesthetic area is made up, may thus be influenced from either of the two sides. As Flechsig says, it represents a sort of arena in which, at least in the more nobly endowed natures, the lower inpnlses struggle for the mastery with the higher feelings and ideas. To follow this struggle between the reciprocal influences of the body and the intellect will form one of the most stimulating problems of brain investigation, especially when it is remembered that the subject is of eminently practical significance. In the investigation of the brain it will be necessary to study the conditions which lead to an ennobling of the sensual instincts, whether it come immediately through bodily influences or from the other side through the intellect. Since, further, in these studies the presumptive existence of an ennobling of the intellect through refinement of the sensual instincts must be kept in view, the new brain anatomy and physiology is brought into contact with the fundamental problems of all scientific pedagogy and the aims of all true culture. The old a priori ideas concerning the antitheses of sensuality and reason, and of the " heart " and the " brain," would seem to find some actual confirmation in recent anatomical discoveries.

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

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


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[No. 70.


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


NOTES ON NEW BOOKS.

Practical Points in Nursing, for Nurses in Private Practice, with an Appendix. By Emily A. M. Stoney, Superintendent of Training School for Nurses, Carney Hospital, Boston. Illustrated with 73 engravings and 9 colored and half-tone plates. {Philadelphia: W. B. Saunders, 1896.)

This little book is primarily designed for the instruction of private nurses, and as such it will undoubtedly serve a useful purpose. It is to be regretted, however, that it is also intended to be used for the instruction of classes, and for the home nurse, for which purposes it seems very inadequate. It may help those who are already instructed and who require a book of reference, but it presupposes a degree of previous knowledge on the part of the student which pupil nurses and home nurses do not possess.

The chapters on physiology and descriptive anatomy are of the most elementary character and are couched in such terms as to convey no adequate idea of the subjects treated. Witness the following: "The parotid gland is situated below and toward the front of the ear. It secretes saliva, and it is inflammation of this gland that causes mumps." — or " The skull is a box of bone containing the brain, which is a soft pulpy substance, and is the chief organ of the nervous system." Coulil tlie modicum of technical knowledge be made any smaller? The book ought to be very popular fur the instruction of nurses among those who are apprehensive of the over-education of nurses and are fearful that they will make thirdclass physicians.

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


thalmia neonatorum is inflammation of the conjunctiva, which is one of the coats of the eyeball. Its causes are numerous, but in the newborn it is generally caused by infection during birth from the urethral or vaginal discharges of the mother."

The chapter in which directions are given to nurses as to their conduct is clearly and judiciously written. Some nurses would doubtless take exceptions to the author's declaration that " it is not degrading to the nurse to assist in tlie kitchen when emergencies arise ; it shows the true spirit of a nurse, and the kindness is not lost." Tlie chapters also on the Sick Room, of the Patient, and Accidents and Emergencies, are to be commended. The book is well printed and illustrated, and has a good index.

Practical Notes on Urinary Analysis. By W. B. Caxfield, M. D.

{Published by Oeorge 8. Davis, Detroit, 1896.3

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

Diseases of the Eye. A [Hand-book of Ophthalmic Practice for Students and Practitioners. By G. E. deSchweinitz, A. M., M. D., Professor of Ophthalmology in Jefferson Medical College, etc. With 256 illustrations and 2 chromo-lithographic plates. Second edition, thoroughly revised. {Philadelphia : W. B. Saunders, 1896.)

This admirable textbook of ophthalmology is so well and so favorably known, and so short a time has elapsed since the appearance of the first edition (1892), that an extended notice seems scarcely called for at this time. In the preface to the present eilition the author states that the entire book has been thoroughly revised, and that in addition to this general revision, new paragraphs have been addeii upon Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies (Drusen) in the Papilla, Jlonocular Diplopia, Subconjunctival Injection of Germicides, InfiltrationAnaisthesia, and Sterilization of CoUyria.

For the bibliography of tlie first edition an appendix containing a description of the method of using the ophthalmometer of Javal & Schiotz and the tropometer of Stevens has been substituted. The


January, 1897.]


JOHNS HOPKINS HOSPITA.L BULLETIN.


15


chapter on operations has been enlarged and rewritten, and those on General Optical Principles and on Abnormal Refraction, which were contributed to the first edition by Dr. James Wallace, have been revised by Dr. Edward Jackson, who has also recast the section written by himself upon Eetinoscopy.

Dr. Jackson's revision of these chapters has evidently been carefully done, and we note a number of instances, as, for example, in the definition of emmetropia and of ametropia (p. 140), and in the description of the refraction of light by an astigmatic eye (p. 163), in which it has resulted in the elimination of errors, some of which had previously arrested our attention in the perusal of the first edition. It is perhaps not to be wondered at that he has not, in every instance, succeeded in noting and correcting these faults. The description of the "seat of astigmatism" on p. 161, which, in the new edition as in the old, seems to warrant the inference that lenticular astigmatism is due always to an oblique position of the lens, it would appear, might easily have been improved upon. So, too, as to the description given of the well-known illustration (p. 163) of the refraction of a pencil of light in regular astigmatism. It is certainly not correct to speak of the different sections of the pencil there shown, as representing the "retinal images of a point" in compound hypermetropic astigmatism, simple hypermetropic astigmatism, mixed astigmatism, etc., unless absence of accommodative power in the eye be presupposed.

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

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

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

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

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

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

Health to the Essex Co. Council, etc. (London : The Rebman

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

This excellent little book can be commended unreservedly as

probably the best short treatise on Water and Water Supplies in the

English language. The information contained in it is concise and

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

that the author shares the opinion of Koch that the best of all


water supplies for a city is that obtained from deep wells. The sourcesof water pollution are clearly described and well illustrated. We are pleased to see that careful directions are given for the filtration of water, and the dangers which lurk in improper filtration are distinctly stated. If the book could be in the hands of every householder, the preventable causes of water-borne disease would unquestionably be mucli better understood. The book is well printed and sensibly illustrated, and deserves a large sale.


BOOKS RECEIVED,


Transactions of the Association of American Physicians. Eleventh Session held at Washington, D. C, April 30 and May 1 and 2, 1896. Vol. XI. 8vo. 1896. 453 pages. Printed for the Association. Philadelphia.

Transactions of the Medical Society of the State of Pennsylvania. Forty-sixth Annual Session, held at Harrisburg, 1896. Vol. XXVII. 8vo, 499 pages. Published by the Society. The Edwards & Docker Co., printers, Philadelphia.

An American Text Book of Applied Therapeutics. For the use of practitioners and students. Edited by J. C. Wilson, M. D., assisted by Augustus A. Eshner, M. D. 1896. 4to, 1326 pages. W. B. Saunders, Philadelphia.

An American Text-book of Physiology . Edited by William H. Howell, Ph. D., M. D. 1896. 4to, 1052 pages. W. B. Saunders, Philadelphia.

A Te.vt-book of Histology, Descriptive and Practical. For the use of students. By Arthur Clarkson, M. B., C. M. Edin. 1896. 8vo, 554 pages. W. B. Saunders, Philadelphia.

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

Transactions of the Michigan State Medical Society, for the year 1896. Vol. XX. 8vo, 834 pages. Published by the Society. Grand Kapids.

A Text-Book of Materia Medica, Therapeutics and Pharmacology. By George Frank Butler, Ph. G., M.D. 1896. 8vo, 858 pages. W.

B. Saunders, Philadelphia.

Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America. Edited by Thomas L.Stedman, M. D. Vol. VII. Diseasesof the respiratory organs and blood, and functional sexual disorders. 1896. 8vo, 796 pages. William Wood & Co., New York.

A Treatise on Appendicitis. By John B. Deaver, M. D. Containing 32 full-page plates and other illustrations. 8vo. 1896. 168 pages. P. Blakiston, Son & Co., Philadelphia.

Index-Catalogue of the Library of the Surgeon-Oeneral's Office, U.S. A. Authors and subjects. Second series- Vol. I. A-Azzurri. 1896. 4to, 828 pages. Government Printing Office. Wathington.

Transactions of the Texas State Medical Association. 28th annual session held at Fort Worth, Texas, April 28th-30tli and May 1st, 1896. 8vo, 458 pages. Eugene von Boeckmann, printer, Austin, Texas.

The British Guiana Medical Annual. Ed. by J. S. Wallbridge and

C. W. Daniels. Eighth year of issue. 8vo, 1896. 95 -}- xxxix pages. Printed by Baldwin & Co., Demerara.

Twenty-seventh An7iual Report of tlie Slate Board of Health of Massachusetts, 1895. 8vo, 807 pages. Wright & Potter Printing Co., Boston. 1896.

Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A. M., M. D. 2d ed. 1896. 12mo, 199 pages. W. B. Saunders, Philadelphia.

Atlas of the Diseases of the Skin. By H. Radcliffe Crocker, M. D., F. R.C. P. Fol. n. d. 2 vols. Young J. Pentland, Edinburgh and London.


16


JOHNS HOPKINS HOSPITAL BULLETIN.


[No, 70.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL


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

Report in Putliology.

The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

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

Mall, if. D.

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

T. C. Gilchrist, M. D., and Emmet Rixford. M. D. A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

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

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

T. C. Gilchrist, M. D.

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

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


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

Report in Medicine.

On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with

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

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

Report in Gynecology. Tlie Gj-neeological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1S89, to March 3, 1890. By Howard

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

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

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

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

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

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

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

Report in Gynecology.

The Gynecological Operating Room; An Kxtornal Direct Method of Measurins: the Conjugata Vera; Prolapsus Uteri witliout Diverticulum and with Anterior Entorocele; Lipoma of the- Labium Majus; Deviations of the Rectum and Sigmoid Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofiexed Uterus. By Howard A. Kelly, M. D.

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

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


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

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

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

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

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

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

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

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BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No. 71.]


BALTIMORE. FEBRUARY, 1897.




GOiTTZEITTS.


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

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

Puerperal Sepsis due to Infection with the Bacillus Aerogenes Capsulatus. By George W. Dobbin, M. D., - . - .


Proceedings of Societies :

Hospital Medical Society, 29

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

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


A CASE OF DERMATITIS DUE TO THE x RAYS.

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


Since the discovery of the x rays by Rontgen, thousands of observations and experiments have been made with them both in Europe and in this country, and hundreds of investigators have exposed various portions of the body, particularly the hands, frequently, iind for long periods of time, yet, after searching the literature, records of only twenty-three cases (including the present one) have been given where injurious results have followed their use, and in these, lesions of the skin only have been described. Of these twenty-three cases, twelve occurred in this country, one in Canada, four in England and six in Germany.

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

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

After examining the other reports (the references are given at the end of the article) it was found that the eruptions of the skin presented many points of similarity, and differed chiefly in


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

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

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

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


18


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71.


Distribution.


Character of the Lesions.


Subjective Symptoms.


O. Leppin (person al experience). .


Used very frequently for many days.


Left hand and


Peculiar redness, swollen, vesicles on middle and ring fingers.


Dr. Marcuee.


Young man, 17, exposed 5-10 minutes once or twice a day for four weeks.


Dr. Feilchenfeld Dr. Conrad.


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

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


No mention. After five weeks hand still

looks "older" than the other.

No pain in face ;lThree months later, hair


back much tenderness, but no pain was felt until just previous to the eruption.


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


Dr. Paul Fuchs (personal expe rience).


Dr. Sehrwald.


S. J. R. (personal experience).


Dr. H. C. Dunn.


Dr. G. C. Skinner (personal expe rience).


J. Macintyre (personal experience).


Dr. Freund.


Aphotographerbad used the X rays very fre quently and for some time.


After prolonged use of the X rays.


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


Used the rays several hours daily and eruption appeared three weeks after.


Man aged 35 years. Ex posed first for one hour and afterwards for an hour and a half, the second with inter val of seven days. Two days later eruption appeared.


Exposed the wrist 10-15 minutes for 3 or4day8 in succession. Ten days later eruption followed.

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

10 days, child who had hypertrichosis.


1st and 2d fin gers, left hand.


Left hand and fingers.


Abdomen.


Right hand and fingers. Later left band.


Abdomen.


Wrist.


Neck, back, upper arm and scalp.


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

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

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

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

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

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

Appearance of a sunburn. Skin red and swollen, followed by exfoliation of the " epidermis" and loss of hair.

X rays used as a depilatory for 10 days, when the hair began to fall nut.


Berlin Medical Society.

Fingers extremely No mention, sensitive and pain was of a burning and scalding character.


None given.


Itching when the vesicles appeared.


After inflamma tion hand smarted very much Skin became insensible to the touch. After second exposure serious discom fort and pain followed.


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


Great pain and ex cessive tenderness.


Cured in 9 or 10 weeks.


Results similar to those of sunburn but much more acute.


None given.


Eruption healed after 28 days, but skin was like boiled fish skin. After cauterization of surface a slough separated and a tough yellow opaque membrane formed.


Process of repair was very slow.


Authorthinksconditiondue to heat and electricity ; the latter the chief cause of injury to the tissues.


February, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


19


Dr. E. E. King.


Dr. M. J. Stern.


Dr. F. Kolle.


Dr. J. C. White.


Prof. E. Thomson


Dr. H.R.Crocker


Prof. John Daniel


Dr. M. H. Rich ardson.


Dr. W. E. Parker.


University of Minnesota.

Dr. Banister, U S. Army.


Dr. T.C.Gilchrist.


Patient used the x rays for two and a half months from two to six hours daily before cutaneous lesion ap peared.


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

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

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

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

Boy aged 16. One exposure of one hour. Eruption appeared next day.


Distribution.


Hand, left.


Man ; exposure 1 hour Alopecia 21 days later.

Woman. Exposed three times to the rays, 20, 30 and 3.5 minutes. Eruption appeared two days later.

Man. Exposed five times, from 20 minutes to 80 minutes.

Man whose ear was exmined for several hours.

Man. Numerous expo

sures.


ray operator. Eruption began after frequent and continued exposures.


Extended from thesideof the face down to the umbilicus.

Right side of head.


Sternal region


Little finger of left hand.


Epigastrium.


One side of scalp.

Abdominal re gion, particu larly over liver area.


Jaw and neck.


Ear and surrounding scalp.

Abdomen, chest and beard.


Right hand, wrist, and lower portion of forearm dorsal sursurface.


Character of Lesions.


Hand felt stiff, then became swollen and large " blisters formed ; after five weeks rest he exposed the hand again 7-8 hours daily. In two weeks left hand became swollen, tender, discolored ; vesicles followed, and the fingernails began to fall off. The hairs disappeared. Left side of the face was also affected. The skin was swollen and erythematous, and the hair over the temple disappeared. Eyebrows were almost gone and left side of the mustache had almost disappeared.

Erythematous blush first appeared, which a few days later ap peared like a severe burn, followed by a large slough.

Large area of alopecia over the region exposed to the rays Hair fell out all at once the night previous. Skin slightly cedematous.

Skin was first reddened, then blistered. Three months later the patch showed angry-looking granulations which had refused to heal.

Finger became hypersensitive, then dark red, swollen, stiff, and soon after vesiculation occurred. Pus formed and the epidermis became detached, but pustules remained over 3 weeks

A Crookes tube placed five inches distant — flanelette shirt inter vened. Next day, skin deep red in color. Nine days later vesicles appeared. Palm-sized patch, well-defined, purplish red. Vesicles increased in number ; 9 days later the epidermis had separated. Healing very slow. Alopecia very slight.

Tube was 1^'4 inches distant from head. Bald spot was 2 inches in diameter ; skin healthy.

Bulb was 18 inches distant. First appearance was that of sunburn, gradually became brown, and ulcer, 8 inches in diameter, formed ; slough thrown off ; very slow in healing.

After two exposures face and neck became swollen and red. The later sittings were also followed by eruption.

The parts presented later a frozen appearance. All the hair from this side of scalp was lost.

At first a patch, red, inflamed, hypersesthetic, about half the size of a man's hand. The lesion increased in size until a denuded surface .SxlS inches was formed. Exudation profuse and uncontrollable. Beard turned white in places and growth stopped.

Hypersemia and swelling of back of hand ; afterwards inflammation of fingers and hand. Skin became dark brown in color and gradually exfoliated.


Subjective Symptoms.


Great pain follow ed the appear ance of the blis ters.

Second eruption followed by aching.

Face became tender and painful.


No symptoms.


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

Pain.


Stiffnessfeltatfirsl and soreness when the vesicles appeared.


None.


Pain accompanied the first appearance of the lesion.


No pain or sensation at the time.

Raw surface, very painful and hyperjesthetic. Pain agonizing even six weeks after.


No pain at first, but afterwards severe aching and shooting pains, which lasted about 2 weeks.*


The case has been carefully and continuously watched.


Examination of the chest after a gun-shot wound.


Later, lanugo hairs began to appear.


At the timeof writingthere were still two open spots.


Four months later, even after curetting, granulating surface 4 inches in diameter still remained.


16 days afterwards skin discolored and exfoliated.


Patient confined to bed for one month, and will probably be in bed another month.


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



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

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

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

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

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


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

The case which I will now report presents a suflBcient number of interesting points to make it worthy of record.

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

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

On comparing the two hands they were found to be practically of the same temperature. The fingers of both were of about the same calibre. A photograph, which is represented here (Fig. 1), was taken of the hand the first time I sawj him,


Febrdaet, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


21


and it shows very well the exfoliatiou of the epidermis. It also represents the position of the hand which was most restful and least painful to the patient. The palmar surface was dry and paler than that of the normal hand, but the palmar surface of the fingers appeared swollen.

I saw the patient ten days later, and the exfoliating epidermis had all been removed; the skin now presented a glossy appearance, and over the lingers it appeared to be tighter than on the corresponding fingers of the healthy hand. The palmar surface was still a little drier.

On careful examination the patient comjjlained of rather severe pain when the first phalanx of his right index finger was grasped, and it was then noticed that this bone was distinctly thickened, especially as compared with the corresponding phalanx of the other hand. The first and second phalanges of all the fingers were found to be thickened, but the increase in size was most marked in the first phalanges of the index and second fingers. Further careful examination of the other bones of the hand revealed a very painful spot over the wrist joint. The metacarpals were also tender on pressure, and the head of the second metacarpal was enlarged. The hairs were found to be less numerous on the affected hand, but they may have been removed in tearing off the exfoliating epidermis.

Mbvemeids of the hands. All movements were found to be quite difficult of accomplishment and very painful. When the patient first consulted me, voluntary movements of both fingers and hand were abolished, except of the little finger, which could be slightly flexed. Wrist movements were also very limited in extent and caused much pain. The thumb and fingers could scarcely be apposed. The patient could not pick up a lead pencil or penholder, and could grasj) with but slight force; if he could get his finger or thumb beneath an oVject he could pick it up. He complained of the joints being very stiff.

Sensation was very much impaired before exfoliation occurred, and even after that it was much diminished as compared with the normal hand. The sense of touch on the palmar surface was also markedly decreased.

When the distinct thickening of the phalanges was detected I requested him to obtain careful x ray photographs of both hands under similar conditions at the same distance from the bulb. The accom23anying photographs show the bones of the two hands clearly, and I am particularly indebted to Professor W. C. A. Hammel, of Baltimore, for such excellent pictures.

The hands were placed exactly twelve and a half inches from the x ray tube, the distance being carefully measured from a plane passing through the long diameter of the tube to the fixed support on which the hand rested. The time of exposure was exactly three minutes for each hand.

It will at once be noticed from the photographs how much thicker all the first phalanges of the right hand (Fig. 3) are than those of the left normal hand (Fig. 2). The increase in size is particularly marked in the first phalanges of the index and second finger; that of the little finger is less marked The second row of phalanges is also thicker than normal, but less thick than those of the first row. The heads of the second and third metacarpal bones are enlarged, and their shafts are also slightly thickened. It cannot be said, from the


photographs alone, that any of the carpal bones of the affected hand were at all increased in size.

A number of other points were discovered from these photographs. The spaces between the bones at the joints, particularly at the metacarpo-phalangeal and the interphalangeal joints, were much less marked and narrower than in those of the normal hand. The outline of the affected bone« was also more irregular and rougher than that of the left hand. On looking at the hand as a whole, it is also, I think, noticed that all the bones are denser in appearance in the affected hand.*

Two portions of skin were excised for histological purposes on the first day. One portion was taken from dorsal surface of the phalangeal region of the third finger, and the other from the lateral margin of the hand over tlie base of the metacarpal of the little finger. Neither stained nor unstained sections demonstrated the presence of any foreign particles, and only showed chronic inflammatory changes. The horny layer was thickened and half of it was partially detached. A large number of brown pigment granules were found in the exfoliating portion. The mucous layer was not thickened, but it was more pigmented than normal. In the corium the vessels were dilated, and the pigment cells of thepapillas were almost as numerous as are usually found in a section of negro skin. It was suggested that particles of platinum might have passed from the tube through the glass bulb deep into the tissues.

Portions of the exfoliating skin were accordingly submitted to Professor Abel for chemical analysis, and he has very kindly furnished me with the following brief report: "I could find no platinum in the pieces of epidermis that you left with me for analysis. These pieces weighed, just as you sent them, 6-iO milligrams, or about ten grains."

Summary. In reviewing this case, there is here an example of a disease of the skin which was brought about by frequent and prolonged exposure to the x rays. The lesions, as I have already described, were first those of byperajmia, then cedema, without the accompaniment of pain. Subjective symptoms were felt later, and continued to increase in severity (he was still using his hand for exhibition purposes) until, on account of the severe pain, he was compelled to stop his work. These subjective symptoms consisted of aching, tiirobbing and shooting pains. The color of the skin gradually changed to a deep brown, and the epidermis began to exfoliate. The bones of the hand were very tender on pressure, particularly the first phalanges of the index and second finger and the carpal bones. The movements of the hand became so limited that it was practically useless for some weeks. Sensation was also much impaired, but after exfoliation occurred it recovered again, but only gradually. Recovery of all the lesions has been very gradual indeed.

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


  • As .an interesting point the photographs show the outlines even

of the finger-nails and the interosaei muscles.


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[No. 71.


carpal bones of the same fingers, and judging from the symptoms, even of some of the carpal bones.

This then accounts for the severe symptoms, the aching, throbbing and shooting pain which prevented sleep. The density of these bones has also been increased, showing that even bone tissue has been affected.

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

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

As the result of these observations, it proves that the x rays are even more powerful than have been generally thought, that the deleterious effects can iu some cases be quite serious, and that the cutaneous manifestations are not the most severe of the lesions, but those of the deeper tissues, and particularly of periosteum and bones, being more severe.

The discovery of this deeper and more profound effect at once overthrows many of the explanations which have been advanced to account for the cutaneous lesions. Tesla's theory of the ozone generated in contact with the skin will not explain these deeper effects. Prof. Thomson has demonstrated that they are not due to the ultra-violet rays. They cannot be compared to sunburn, since no case, as far as is at present known, has been published wheresunburu has produced periostitis and even osteitis. Nor can such serious results be produced by brush discharges, and Thomson has also proved that these cannot be the causes. His further explanation that the effects (he was not aware of the deeper injuries to the soft tissues and bone) are due to the x rays themselves or something which accompanies them, is rather indefinite. It was suggested to me, as I have already mentioned, that it might be due to the platinum particles piercing the bulb and then attacking the tissues, but this almost appears impossible, since serious cutaneous effects have even followed only one exposure of half an hour {vide Thomson's case).

I consulted with Professor Ames, Associate Pi'ofessor of Physics in the Johns Hopkins University, who, after reviewing all the facts of the case, kindly wrote as follows concerning the present theory of the x rays :

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

It will thus be seen that the opinion expressed here does


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

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

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

When I viewed my own hand two or three times near a new Edison bulb, through a tungstate of calcium screen, after four or five minutes I distinctly felt a tingling sensation throughout the dorsum of the hand; this symptom lasted for ten or fifteen minutes and passed away without any further results. It occurred to me that x ray operators and experimenters should expose to the rays the palmar surface of the hand, which is protected by a much thicker horny layer, rather than the back of the hand, which is much less protected.

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

Bibliography.

John Daniel : Medical Record, April 25, 1896, vol. 49, No. 17.

0. Leppin: Deutsche medicin. Wochensch., No. 28 (July 9), 189G, p. 454-.

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

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

Conrad: Codex Medicus, August, 1896.

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

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

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

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

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

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

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



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


"^




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


FIG. 3.

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


February, -1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


23


M. J. Stern : The American Medico-Surgical Bulletin, Nov. 31, 1896.

F. Kolle: Brooklyn Medical Journal, December, 1896, vol. X, No. 12.

J. C. White: Boston Medical and Surgical Journal, Dec. 3, 1896, vol. CXXXV, No. 23.

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

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


M. H. Kichardson: The Medical News, Dec. 26, 1896, vol. LXIX, No. 1250.

The Medical Record : References to case at University of Minnesota, vol. 50, No. 25, Dec. 19, 1896.

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

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

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

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


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

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


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

Ceni's work was done on rabbits and horses, with an acute and a chronic series. The first, after the inoculations with diphtheria cultures, lived from three to four days, and showed, in exquisite form, the beginning of the moniliform swellings of the dendrites of the cortical and hippocampal cells common to the action of all the toxins of the infectious series. The chronic series lived from 36 to 41 days after the inoculation with the toxin, during which period they lost full half their weight. Ceni also utilized the cerebra of horses which had been used in the Milan Bacteriological Laboratory to produce diphtheria serum. In these, after three or four months of the treatment, he found the cortical cells far degenerated, and to a degree not seen with the rabbits, the stouter dendrites and corpora of the cells being extensively involved in the destructive process.

Interesting to note, he also finds distinct lesions of the vascular neuroglia, principally tumefaction of the bodies and branches, the one attached to the blood-vessels' walls showing the alterations most distinctly, all being identical with those described and recorded in the III. study of this series (Art. Ricin Poisoning).

Our present series consisted of five diphtheria guinea-pigs, whose brains had been sent me by Dr. Flexner for the purposes of the study. The first two brains, after hardening and examination of the sections, were rejected on account of the possible presence of post-mortem changes. The other three cerebra were carefully hardened in Miiller's fluid and treated afterwards by the silver phospho-molybdate formula.

Guinea-pig No. 3 received an injection of the toxin at 2.30 P. M. and died about 3 A. M. the following morning. No. 4 was inoculated at 2 P. M., was re-inoculated two days later at 10.30 A. M., and died two days afterwards at noon. No. 5


•Carlo Ceni : Riforma Medica, vol. I, 1896.


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

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

With Case 3 the dendrites only show beginning changes. There are numerous small moniliform swellings scattered over their branches, not focally but uniformly throughout the cortex, and over the sites of these tumefactions the gemmules are either lost or are very sparingly present, while on those that have normal dendrites they are undiminished in numbers. On the stretch of dendrite between the swellings, which either appears normal or slightly below the natural calibre, the lateral buds are beginning to disappear, as shown by the paucity of their numbers and lessened tendency to assume a deej) black tint. The bodies of the cells do not appear to be in any way changed in staining properties, or to have lost in any degree the angularity of their contours.

The vascular neuroglia cells are uniformly stained throughout the outer layers of the cortex, and have their tentacles, jiarticularly the vascular foot, somewhat swollen, the degree being considerably less than in some specimens we have noted after the injection of other toxins. The axis-cylinders are distinct, and show no alterations. The tei-minal apparatus of the cortical fibres were so infrequently stained that it is hardly possible to determine with certainty whether they were pathologically altered or no, but those found appeared to be normal.

The larger vessels showed neither thickenings nor ruptures of their coats.

With cases Nos. 4 and 5 the pathological alteration is similar to that in No. 3, only increased in intensity, from the longer duration of the poisoning, and, perhaps, also from the repetition of the inoculations. The moniliform nodules are well marked over long stretches of cells in the pyramidal region of the sections, and are uniformly larger than in the more acute case. Also the denudation of the gemmules is


24


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[No. n.


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

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

The vascular neuroglia also shows signs of more advanced swelling, the tentacles being thicker and the pseudopodia more prominent.

The axons and collaterals are well stained, but show no unusual varicosity or other departure from the normal. A few of the cells having upturned axons are well stained, but the morbid changes are of less intensity than with the pyramidal variety.


The cerebellar cells, as in the previous studies, showed less damage than those of the cerebrum. The Purkinje variety was the only one recognisably involved. The peculiar axons of the basket cells were natural, and the various nerve fibres throughout the outer lamina of the cortex retained their histological appearance.

From the studies conducted on the cerebra of hydrophobic and diphtheritic guinea-pigs it would appear that all severe infections were followed by brain-cell degeneration of an order not dissimilar to that found in the cells of the abdominal viscera under similar conditions, a degenerative process unaccompanied by inflammatory reaction and a tendency to atrophy and necrosis.


PUERPERAL SEPSIS DUE TO INFECTION WITH THE BACILLUS AEROGENES CAPSULATUS.

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


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

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

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

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

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

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

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


with the small fontanelle to the left. The impaction of the head was so great that the cranial bones overlapped one another to the extent of one centimeter.

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

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

Owing to the mother's condition, and as the child was already dead, immediate delivery was indicated. She was given chloroform, placed across the bed in the lithotomy position, and a Tarnier axis-traction forceps was applied by Dr. Williams. The head was brought down to the outlet with great difficulty, and as it became more and more crushed out of shape with each traction it allowed the forceps blades to slip several times. The lateral blades of the Tarnier basiotribe were then applied, screwed tightly together, and the crushed head delivered.

Tractions now made on the delivered head showed that the sh'oulders were so firmly impacted in the pelvis that they could not be delivered without tearing the head from the body. The blunt hook was then put into the posterior axilla and that shoulder brought down; this manipulation caused the separation of the epiphysis from the shaft of the humerus, and in order to effect delivery of the trunk it was necessary to put the blunt hook between the ribs beneath the substernal notch and literally drag the child from the mother.

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

The third stage of labor also gave considerable difficulty, for


February, 1897.]


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

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

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

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

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

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

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

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

The husband unfortunately allowed no autopsy.

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

The child weighs 2900 grammes, without the brain ; its length is 55 cm. The head is entirely crushed, the right arm almost completely torn from the body, and there is a large jagged wound in the chest, all of which were caused by the craniotomy instruments and blunt hook.

The fcetus is very offensive, being much decomposed and macerated. The entire body is emphysematous, and everywhere, on making pressure, we obtain the characteristic "feel " of gas in the subcutaneous tissue. By making pressure on the chest, lai-ge bubbles of gas are seen to escape from the wound in the neck. The body was then put under water, and on puncturing the abdomen there was marked escape of gas, which when ignited shot up in a flame six inches high.

Cover-slips made from the blood and subcutaneous tissues show large numbers of bacilli morphologically similar to the "gas bacillus" of Welch and Nuttall. Cultures on sugar media gave the characteristic growth.


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

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

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

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

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

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


26


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71.


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

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

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

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

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

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

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

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

Doleris' reported a case of a woman dead aftei- labor, of a


bacillar infection, this was before the work of AVelch and Nuttall, but the clinical history is so characteristic of the form of infection we are discussing, a short quotation from his report will not be out of place.

" In 1883 I submitted to the Anatomical Society a case of delivery at term, complicated by a myoma, after which the patient died. The labor was exceedingly difficult and marked by successive intervention (forceps, cephalotripsy, etc.), and I was not able to deliver the foetus. The patient succumbed to a septicfemia having its origin in an intense putrefaction of the uterine tissue, physometra, and putrid emphysema of the cellular tissue of the hypogastric region. I have studied the case carefully from a bacteriological point of view, and can affirm that it was a typical septicfemia caused by a bacillar organism and not by the streptococcus or staphylococcus."

In 1893 we find reports of two cases, one by Graham Stewart and Baldwin' and the other by P. Ernst.' As these cases were both worked up very carefully from a pathological and bacteriological standpoint, we give rather full abstracts.

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

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

Bacteriological examination of a specimen of blood showed the presence of the bacillus aerogenes capsulatus in large numbers.

It is very interesting to note that in this case production of gas took place to a very marked extent before death.

Ernst,' in doing an autopsy on a woman dead after operation for removal of a macerated foetus, was struck by the appearance of foam on the cut surface of the liver, which on being allowed to stand increased so rapidly as to form a layer several centimeters thick.

Bacteriological examination proved this case to be one of infection with the bacillus aerogenes capsulatus. An abstract of his case is as follows.

Patient 26 years old, with anteflexion of the uterus in her first pregnancy. Entered the hospital suffering with pain in ilic right side of four weeks' duration. She had also lately


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noticed a tumor in the lower abdomen. Tiiere being no definite signs of pregnancy, and the microscopic examination of scrapings from the uterus showing decidua, the cervix was dilated to admit manual exploration of the uterine cavity. Digital examination, however, revealing nothing, a vaginal tampon of iodoform gauze was introduced.

After this the patient became so much worse that the tampon had to be removed. A macerated foetus was found and extracted, and the uterus repeatedly douched with antiseptic solutions ; the patient, however, became steadily worse and died.

The autopsy showed fibrinous adhesions between abdominal wall and intestines ; cloudy sanguiueolent fluid in the pelvis. The musculature of the left ventricle is thickly beset with little miliary abscesses (?), in the centre of each of which is a small punctiform lumen. Fresh fibrinous exudate on the under border of the lungs. Spleen tumor with fibrinous coating and many necrotic areas appearing beneath its capsule. Cloudy swelling of both kidneys. In the liver, which is of a yellowish icteroid color, there are countless yellowish and whitish-gray foci, the size of a millet seed, in the centre of each of which there is a small lumen.

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

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

Ernst was unfortunately prevented from making cultures at this time,-and later the organism had died out.

In Ernst's article he goes very thoroughly into the histological changes produced in the internal organs. These changes are similar to those described by Welch and Nuttall, so they will not be mentioned in this report.

The changes mentioned in connection with the uterus are especially interesting to us owing to the fact that we were unable to get an autopsy in our case. Ernst mentions three different organisms : a large bacillus similar to those found in the internal organs, viz. the bacillus aerogenes capsulatus; a short thick bacillus which he considers a saprophyte; and cocci having a tendency to chain arrangement, however, as he says, not the typical chains as seen in streptococci. The short thick bacilli he finds only in the necrotic uterine mucosa, and they show no tendency to invade the deeper structure, while the cocci are found deep down in the uterine muscularis. The larger bacilli, which are found all through the internal organs, are very numerous in the uterine wall; they have formed "gas cysts," which give to the uterus the ragged, mesh-like appearance mentioned above.

In comparing these " gas cysts " with those found in the liver, Ernst says the principal difference is, that while in the liver the bacilli line the cyst in an unbroken zone, in the


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

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

Ernst is in doubt as to whether the infection took place along the veins or lymphatics, for in his specimens both contained large numbers of bacilli.

In 1895, Kronig, at the Sixth Congress of the Deutsche Gesellschaft fiir Gyniikologie, reports two cases of puerperal endometritis probably due to the bacillus aerogenes capsulatus.

During the last year Schnell' reports a case which, although he does not consider it an infection, has a clinical history so similar to our case that a short abstract will not be out of place.

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

At the autopsy 18 hours after death, in winter, nothing abnormal was found but gas in the large veins of heart, pericardial vessels, lungs, aorta, liver and spleen.

There is no record of any bacteriological examination, and Schnell considers the death due to air having gained entrance into the uterine sinuses during the successive manipulations.

On looking over and comparing these cases with our own, the following points are of interest: In every case the infection was very rapid and fatal. In all of the cases except that of Graham Stewart and Baldwin, there was for some time a dead fostus in the uterus, and the organism found an excellent medium for development in its dead tissues and in the placenta, and probably did not gain entrance to the general circulation until after death of the patient. In the case of Graham Stewart and Baldwin, on the other hand, there was nothing in the uterine cavity ; it only " gave evidence of a recent abortion." Here it is probable that the infection was more in the nature of a true septiciBmia, and the bacilli gained direct entrance to the vessels and lymphatics at the abraded placental site. As this was the only case in which gas was detected in the subcutaneous tissues before death, the above theory is not out of the line of probability.

In Schnell's case we feel sure that had a bacteriological examination been made, the organism would have been found.


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[No. 71.


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

The first question, in the absence of an accurate subjective history, cannot be answered with certainty. Suffice it to say that as the patient had been in labor two days before we were called In, and during that time a midwife had been in constant attendance, it is more than probable that the organisms were introduced by her during her examinations.

In regard to the action of the organism after it entered the body, i. e. whether the case was one of saprajmla or septicemia, we can say as follows: Welch and Nuttall' have proved by inoculation into rabbits, that when the organism Is introduced into the general circulation, death of the animal does not follow, but if shortly after the Inoculation the rabbit be killed, the bacillus develops very rapidly, with abundant formation of gas in the various organs.

In their experiments on rabbits, in only one case did the inoculation prove fatal. This occurred in a pregnant rabbit in which two of the embryos were dead and macerated at the time of the experiment. Here the bacilli gained foothold and developed.

From the above we can then argue that the organisms were introduced by the midwife early in labor. She failed to recognize the obstruction offered by the deformed pelvis, and allowed the case to go on. The child, after becoming firmly impacted in the pelvis, died, and the bacilli, which had before undergone little development, now having the most favorable culture medium for their growth, i. e. dead tissue deficient in oxygen, increased to an enormous extent and partly filled the uterine cavity with gas.

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

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

One other point deserves consideration. Did the infection of the fcEtus and placenta take place before or after fa3tal death ?

Again referring to the experiments of Welch and Nuttall, the fact of our finding the bacilli and " gas cysts" only in the lumina of the placental vessels is a strong point in favor of the theory that, just as in the mother, the organisms entered the blood before death, but did not undergo rapid development until the fcEtus died.

From the above I think we can consider our case as one of septic intoxication rather than a septic infection.

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


Eefeeences.

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

2. Welch and Flexner: Observations concerning the bacillus aerogenes capsulatus. Journal of Experimental Medicine, Vol. I, No. 1.

3. Graham Stewart and Baldwin : Bacillus aerogenes capsulatus — Case. Columbus Medical Journal, August, 1803.

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

5. Leduc : Le diable au corps. Witkowski's Accoucheurs et Sage-femmes celebres, p. 184.

6. Kronig : Discussion on Endometritis. VI Congress Deutscher Gesellschaft fiir Gyniikologie.

7. Schnell : Ueber einem Fall von gasblasen im Blut einer uach tympania uteri gestorben Puerpera. Mouatsschrift fiir Geburtshulfe und Gyniikologie, IV, 199-203, 1896.

8. Doleris : Inflammation puerperal. Arch. d'Obst. et de Gyn., Vol. IX, pp. 97-122, and pp. 142-161.

Discussion.

Dr. Flexner. — I was enabled, through the courtesy of Dr. Dobbin, to see, during life, the patient whose case he reports. At my first visit, some 6 or 8 hours previous to her death, I endeavored to ascertain If there was any evidence whatever of au ante-mortem development of gas within the tissues or vessels In parts remote from the genitalia. No such development was discovered. The nest time I saw the case was several hours (6 or 7) after death. At this time the appearances presented were those of extensive gas formation everywhere iu the soft tissues and serous cavities. From the nose and mouth frothy bloody serum exuded, which on cover-slip preparations showed many characteristic bacilli. From the account given by the family it was clear that rapid multiplication of the organisms had begun almost at once after death, thus indicating a general distribution of the bacilli during life. I should prefer to consider that other causes than merely the presence of oxygen in the circulating blood are to be taken into account in explaining the absence of any appreciable development of gas, and thus presumably of bacilli, in the body during life. I apprehend that still other factors play a part, and these probably are of the same nature as are reckoned with in other and more usual forms of infection with bacteria. This case is, I believe, the first oue which has been encountered in the Hospital in which the invasion followed parturition. It is iu itself a confirmation of the prediction made originally by Welch and Nuttall, namely, that many of the cases of supposed entrance of air into the uterine sinuses would be found to be due to infection with a gas-producing micro-organism. The prediction had, however, been abundantly confirmed before by Ernst and Graham, as related in Dr. Dobbin's paper.


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PROCEEDINGS OF SOCIETIES.


THE JOHNS PIOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of October 19, 1896. Dr. Thayer in the chair. The Surgical Significance of Gall Stones.— Dr. F. Lange.

Every physician who has practised for a long time knows that there are cases in which through a number of years attacks of gall stones will recur and eventually the patient will be entirely cured. I have, for instance, for a number of years watched a colleague of mine, a physician, who beyond any doubt has had gall stones, and indeed I have felt the gall stones in his dilated gall bladder. He had all the symptoms of cholangioitis, with frequent chills and high fever, through months and years. He, however, did not like to undergo surgical treatment, and he is now in flourishing health.

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

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


hernia formed. She got an acute strangulation of a small omental hernia which necessitated incision. It was in the immediate vicinity of the .gall bladder, and the gall bladder on that occasion was opened also. I found, to my surprise, that the gall bladder had assumed an hour-glass shape, through the loss of substance which had occurred in the expulsion of necrotic tissue in the first attack, and there existed two compartments communicating with each other by means of a very narrow canal. In both of these compartments was a considerable amount of mucous material, but no stones. The patient had suffered at the time from a certain degree of catarrh of the gall duct.

I have here a stone of not much smaller size, made up of cholesterine with lime outside. The patient had an acute attack of cholecystitis, and this stone was found impacted in the cystic duct.

This third stone, of smaller size, is from a case in which the destruction of the gall bladder was quite extensive. Eventually the patient made a good recovery.

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

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


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[Ko. 71.


the sewing of the wound, and so it was in this case. The sewed-up gall bladder was put upon a tension and burst, and the patient died from sepsis.

I have here a small cholesterine stone which led to a bad condition of the patient. A lady, about forty years of age, the wife of a physician, who was very carefully observed, had had one attack of gall stones about four or five months previously to the time I saw her. She was taken with chills, high fever and deep jaundice. I found her, about nine or ten days after the beginning of this attack, in a very low condition, so bad that the only indication at that time was to open the gall bladder, drain it and do away with the stagnation of the bile. About three weeks later this stone was removed from the common duct, and although the patient for a number of months after this presented some febrile symptoms, with occasionally slight chills, she eventually has entirely recovered.

Here is another stone, which has been removed from the ductus choledochus, and one of exceptional size for a choledochus stone.

I have one specimen in which I was obliged, apart from opening the gall bladder, to incise the cystic duct at two different places, and also the common duct. That was a case in which the gall stones were very small, not larger than peas, and which were caught behind the protruding folds and diverticula of the cystic duct, so that they could not be shifted. I sewed up the common duct as well as the cystic duct, and drained the gall bladder. This patient made a good recovery.

The principal point of resistance for gall stones is the region of the papilla in the wall of the duodenum. In a good many instances it has been found that large stones there destroy the surrounding parts and form fistulous communications with the duodenum. I have had the opportunity of operating in one such case, in which I thought I had to do with a malignant affection of the duodenum. The patient was sent to me as a case of cancer of the pylorus. It could be made out easily that the pylorus must be free, because vomited matters contained a large amount of bile. By palpation nothing certain could be made out, and in operating, I cut down through a great many adhesions and a good deal of scar tissue and found the duodenum obstructed by a hard mass, apparently of scar formation. I separated that, but in going further I met with a hard firm body which was apparently adherent to the vertebral column. I stopped the operation. The patient was very much run down. Believing that the duodenum was not sufficiently patulous I made a gastroenterostomy. The patient rallied from the operation fairly well, but fell into a state of collapse five or six hours later and died. In making the autopsy I found, to my very great surprise, that this large mass behind the duodenum was not a malignant affection, but a large mass of gall stones, partly lodged behind the wall of the duodenum and partly within the wall of the duodenum, with a number of fistulous openings into the duodenum. The constrictions from scars were such that the contents of the duodenum could not easily pass beyond this point, and the symptoms of obstruction of the intestinal tract were the consequence.

I show you here a stone which has been excised from the small intestine. It is a very beautiful specimen of a pure


cholesterine stone. Why a stone of this size cannot pass, while a Murphy's button will pass easily, I cannot tell. The patient in this case was an old lady. The operation was done very smoothly and I had good hopes for recovery, but she died in eight hours after the operation, from collapse.

These are the regular ways of the gall stones; but we know that from the gall bladder or from any other point in the gall system, through destruction of the surrounding tissues, they may find an outlet into a neighboring viscus or through the abdominal wall. Gases of this kind have at all times been very interesting and full of medical interest. I show you here specimens from one of my first cases of this kind, which occurred about seventeen years ago. It was a case of abscess of the abdominal wall, at the bottom of which I found gall stones. They were still lodged in the gall bladder. The patient would not submit to further surgical treatment and still has a fistula which discharges bile.

I have here some specimens, some 300 in number, from a case of acute cholecystitis. And here are specimens from another case of cholecystitis, in which I might call your attention to a point of interest, namely, on the cross-cut you see three small gall stones matted together by a binding mass, so that a single stone is simulated. Gall stones in the first stages of their development are very soft masses, and, owing to the beautiful and careful researches of Naunyn, we know that there is an organic substructure for their development.

A very serious complication that has led to fatal issue in several of my cases of advanced cholemia is an inclination of the patients to bleeding. Three of my cases I have lost from secondary hemorrhages. Two of these cases were complicated with malignant disease of the pancreas; at least I think they were cases of cancer of the pancreas. Autopsies were not made, and I can only say that I felt in the region of the head of the pancreas a resistant hard mass which I took for a malignant affection. Lately, Professor Riedel, a surgeon who has perhaps worked more in gall surgery than any other living man, has published cases in which he is inclined to assume that occasionally these apparent malignant thickenings of the pancreas may be but inflammatory thickenings, and he mentions one case which seems to be beyond any doubt. In an elderly gentleman, in whom the operation was abandoned, assuming that this was a case of cancer of the pancreas, the stones merely were removed. A fatal issue was awaited, but the patient lived for years and years and became healthy and strong, and there could be no question about his not having malignant disease. He assumes that through the presence of stones an irritation is kept up in the pancreas, and that this irritation, after the removal of the stone, may cease and the condition improve.

I have lost one of these cases by the separation of the Murphy's button after establishing cholecystenterostomy. The patient had had up to that time small hemorrhages from the inside of the gall bladder. I had purposely kept the gall bladiler open, stitched to the abdominal wall, because I had the impression that this probably would be a case of bleeding, and in order to tanijion and make counter pressure I kept the gall bladder open, and was able up to the tenth or eleventh day to check the bleeding, but after the separation of Murphy's


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button the patient had a profuse hemorrhage into the large intestine and succumbed to anaemia.

In another case there was no proof of any malignant infection. It was a young person with impaction of gall stones in the common duct. The operation went off very well, but on the fifth or sixth day she had a secondary intra-peritoneal hemorrhage which was, I am sorry to say, detected too late. It is a fact that has been observed repeatedly, that in some cases there is an inclination to hemorrhage a certain number of days after operation. These patients who are apt to bleed from cholsmia, show a great tendency to bleed while one is incising the abdominal wall. They are, as a rule, much run down in health.

I will show you here an exceptionally beautiful specimen of gall stones from a case of sarcoma of the gall bladder, — a sarcoma which was not detected at the time of operation. I thought it was a case of stenosis from impaction of a stone in the apex of the cystic duct. To be sure, there was a suspiciously rough surface at the point of this stone. After a number of months a tumor mass sprung up from the gall bladder. Evidently this stone had been lodged with its point on the irregular surface of the tumor, and I think the roughness of the stone is somewhat indicative of its being in contact with an irregular surface and not with the smooth surface of the gall bladder.

As far as the surgical technique of this operation is concerned: To begin with the abdominal incision, I must say that I have entirely abandoned the longitudinal incision ; but, according to the i)roposition of Corvisart and the experience of other surgeons, I do exclusively the operation parallel to the border of the ribs. Correspondingly to the thickness of the abdominal wall, this incision occasionally must be a very large one. A very great difficulty must occasionally be met with through the smallness of the liver. It is an entirely mistaken idea that in consequence of stagnation of bile the liver must be enlarged. On the contrary, I have had the experience that in occlusion of the common duct of long duration, probably through the influence of j)ressure, an atrophic condition of the liver tissue will take place, and occasionally the liver will be concealed high up behind the ribs, and this may cause a great deal of difficulty in consequence of the high and deep position of the field of operation. I have taken, in eight of these cases, to excising the adjacent cartilages of the ribs, and I should like to commend that. It facilitates the operation very much. On the other hand, of course the enlargement of the liver may be a great hindrance, and, esjiecially in fat and plump persons of short build, it maybe quite difficult to get down to the common duct. In one of the cases I was unable, in spite of excision of the ribs, to get effectually down to the point of the trouble, and not until I had pulled the liver as far as I could out of the incision, almost one-third of the liver substance being brought outside of the abdominal wall, was I able to easily get to the cystic and common ducts. It was the case in which I was obliged to open the cystic duct at two different points and, besides that, the common duct at the usual place about the middle of its course. In the cases of acute inflammation it is of course necessary, wherever one has reason to presume that the neighborhood of the gall blad


der is infected, to keep everything as much as possible open and give entirely free outlet for the peritoneal secretions. At the same time I always drain the gall bladder with a long tube with the view of having a siphon action upon the secreted gall, and this will act very effectually. Of course occasionally a blockage will take place through mucus or blood clot, and then it will be necessary to change the tube or make a cautious washing through it. I should advise against the injection of any irritating antisef)tic solution into the gall bladder. I have observed that occasionally this fluid will cause distressing symptoms, attacks of colic, probably because it may get into the common duct and the hepatic duct and irritate. I only use saline solution or boiled water. I have always found that the bile itself was an antiseptic agent. After a short time the amount of purulent secretion is insignificant, and the healing of the abdominal wounds, although constantly in contact with the bile, is mostly uneventful and without any untoward symptoms.

About stones in the liver substance I have no practical experience. I have once found a stone in the liver after it had perforated the walls of the gall bladder, but I have not had any experience with stones in the liver that have formed in the gall system above the hepatic duct. It is a fact that these stones will occur, and that occasionally quite extensive casts of stone formation will take place in the gall system.

I will not mention comparatively frequent uncomplicated cases, where we have to deal with dilated gall bladders and stones and where the surgical treatment is comparatively simple.

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

Discussion.

Dr. Halsted. Dr. Lange's talk has been instructive to all of us. At one of our meetings, not very long ago, I described three consecutive choledochotomies or incisions into the common duct for the removal of gall stones, all of which were successful. Two of these cases I exhibited on that occasion. What Dr. Lange says about the enlargement of the head of the pancreas interests me, because on several occasions I too have noticed in gall-stone cases that the pancreas was hard. On the first occasion, some four or more years ago, I was misled and thought for a time that the patient might have cancer of the pancreas. Since then I have several times found an indurated pancreas in these cases and have spoken of it at the operating table. The induration of the head of the pancreas was especially noticeable in one case. This case was one of great interest irrespective of this hardening. A very large stone occupied and had almost ulcerated through the common duct. There was, however, no local peritonitis. A little scratch and a little pressure on the wall of the common duct were enough to extrude the stone. The stone being extracted, we found quite a large hole in the common duct and duodenum just where they came together. This made a plastic operation necessary ; and a very difficult one it proved to be


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[No. 71


because we had to do such delicate work at such a very great depth. Even if the parts to be stitched could have been brought to the surface it would have been no easy task to accomplish the repair of the hole. The patient made an excellent recovery. She has gained nearly one hundred pounds and has no symptoms of stricture of the ductus choledoctinus. Of the other cases of stone in the common duct, one is interesting because complete obstruction was caused by a very small stone in the diverticulum of Vater, or near it. This stone, not more than 3 mm. in diameter, could not be pushed in either direction. After considerable manipulation we cut down upon it and removed it. It will undoubtedly strike you as very strange that we could not manage to extrude so small a stone. We might possibly have succeeded with the exercise of some violence ; but the choledochotomy recommended itself to me as the safer procedure. We might, with a hypodermic syringe, inject oil into the duct and so perhaps make smooth the folds of mucous membrane and dislodge the stone by subsequent manipulation.

Eegarding deaths from hemorrhage: Dr. Lauge speaks of the so-called parenchymatous hemorrhage in these highly jaundiced patients. We have had one death from this cause. Our first common duct case died on the tenth day from hemorrhage. There were absolutely no symptoms of peritonitis. The patient made a very good recovery from the operation, notwithstanding the fact that he was so weak that we hesitated to operate upon him.

In 1880 or 1881 I performed my first gall-stone operation. At that time only one or two operations for gall-stones had been performed in this country. The case is one of considerable interest. Seven stones were removed from the bladder, which was distended with pus and adherent to the abdominal wall. The common duct could not with safety have been examined even if it had occurred tome to do so. The patient lived for about two years after the operation. At no time after the operation was she entirely free from jaundice, nor was she at any time either before or after the operation profoundly jaundiced. The stools were usually acholic, but occasionally showed unmistakable signs of bile. The sinus which led to the gall-bladder was not allowed to close until a few weeks before the death of the patient. Death was precipitated by a slight local peritonitis. At the autopsy all signs of the sinus which had led to the gall-bladder had disappeared. Nothing but a few connective tissue threads remained to indicate where the sinus had probably been. The gall-bladder was reduced to nothing but a little knob of connective tissue. The liver was perhaps less than one-half its original size. The common duct and one hepatic duct were dilated sufficiently to permit a calculus as large as a plover's egg to glide easily up and down from the duodenum to the interior of the liver. The calculus was somewhat egg-shaped, and could almost be pushed into the duodenum through the openii)g which partly by ulceration, partly by dilation, it had made for itself. It became engaged at this ring of cicatricial tissue a little beyond its middle when allowed to fall naturally, point downwards, in the common duct, from the liver to the duodenum. The wall of the common duct was very thick. The stone had evidently freely traversed the entire length of this dilated canal,


from the very centre of the liver to, and almost into the intestine. At the autopsy which was made by a very distinguished pathologist the calculus was not found until the liver had been literally cut to pieces, so deeply was the stone imbedded in this organ. The occasional presence of bile in the stools and the absence of profound jaundice were thus readily explained by the findings at the autopsy. When the calculus was in the dilated branch of the hepatic duct, bile could escape through its other branch and appear in the feces. When the calculus plugged tightly the orifice into the duodenum the jaundice increased. That it should never have been profound could be explained by the fact that the stone traveled freely everywhere in the duct; a little bile could probably escape except when the stone was engaged at the duodenal end of the duct.

Will Dr. Lange kindly tell us if he always employs drainage of some kind in suture of the ductus choledochus; and if so, how long does he permit his di-aiu to remain ? Does he not think that the drainage material, gauze, etc., should be left undisturbed until the rest of the peritoneal cavity is well walled off and protected from reinfection ? Quite recently one of Germany's best surgeons removed the gauze in one of these cases on the third day. Peritonitis supervened promptly and the patient died. I have noted that this surgeon and several well-known English surgeons state that no harm is done by leakage from the duct after suture of it, provided one drains down to the sutures. I think that one should, if possible, so suture the duct that its contents cannotescape. Fluid can convey solid and infected particles to places in the general peritoneal cavity which are not protected by the gauze. Furthermore, I have the idea that adhesions take place more firmly about dry gauze than about gauze which is constantly bathed in fluids.

For this reason, if we have sutured a gall-bladder to the parietal peritoneum, or if we have packed gauze anywhere about this gall-bladder which we have opened and propose to drain, we endeavor to prevent leakage for the next three or four days bypassing a purse-string suture all along the edge of our opening into the gall-bladder, and drawing it up when we have introduced our gauze or drainage tube into the gall-bladder.

We explore all the ducts and open and evacuate the gallbladder in one act. Kiedel's advice to perform the operation in two acts, opening and evacuating the gall-bladder at the second act, is bad. We have more than once, while removing biliary calculi, remarked that it would have been impossible to extract them without the aid of fingers in the abdomen. Bimanual manipulation is of course impracticable when the bladder is adherent, all around, to the abdominal wall, as it is at the time of the second act in the operation in two acts.

Dr. Lange's suggestion to cut through one or two ribs to facilitate matters where the liver is very small and the gallbladder so high as to be otherwise almost inaccessible, is undoubtedly an excellent one.*

  • Jan. 2nd, 1897. I have recently had occasion to resort to this

procedure while removing a tuberculous kidney which was adherent to the diaphragm. After dividing two ribs I could proceed quite easily with a dissection which otherwise might not have been feasible. When the liver is very large this method of gaining room is indicated quite as much a when the liver is small.


February, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


33


Dr. Laxqe. — I think that in some of my cases I had reason to assume that there was some valve action, especially in one case of stoue in the common duct of small size. The patient had had an attack of gall stone some three months before this attack, with jaundice lasting several weeks, most likely because of obstruction from this stoue, which was solitary, as judged by its very round, regular shape. Probably after a time this stone shifted back and later on again caused obstruction together with an infection. This we saw not uncommonly in cases of obstruction of the common duct. Even if the stones are ball-like or rounded, at intervals a certain amount of bile will get into the gut. It is almost characteristic that if, in prolonged jaundice, at intervals the condition of the fajces and the urine points to the passage of a certain amount of bile through the duct, we have probably to deal with obstruction from stone.

Eegardiug the drainage of the common duct, I have tried everything: I have left the duct entirely open, and I have sewed it up with the insertion of a small drainage tube into the lumen of the duct, and I have sewed it up entirely. In cases where the wall of the common duct is healthy, I think it is preferable, if it can be done, to sew up the duct entirely. If there is reason to assume that there is obstruction beyond the stone, I should prefer to drain, and I do this in such a way that I insert a small drainage tube from the wound in the common duct and pack gauze around it. This gauze (iodoform gauze boiled in glycerine) I leave in for five or six days. The tube I leave for a sufficiently long time to secure the proper outlet of any secretion as long as it exists. In draining the gall bladder I pack the gauze around the tube and leave the opening comparatively large, for the reason that, at least in inflammatory cases, the surface of the gall bladder is such that it will necessitate some thorough cleansing and local treatment for a limited time. There will be clots of blood or shreds of tissue or inspissated mucus which might easily obstruct. I mostly remove this tampon in two or three days and give the inside of the gall bladder an additional thorough washing and cleansing.

Besides this we have either sewed the peritoneum to the surface of the gall bladder where there is no infection outside of it, or we have packed around the circumference of the gall bladder in such a way that even if some of the contents of the bladder escape it is not likely to cause a spreading inflammation.

Dr. Halsted has spoken of the necessity of having a proper needle ; I have a proper needle.

In one case I dissected the peritoneum from the walls of the abdomen. The case was that of an old gentleman, a physician, who had been suffering for years from attacks which were supposed to be stomach attacks, and there was a suspicion of his having chronic ulcer of the stomach and malignant induration. I opened in the middle line and found nothing, but on palpating the gall bladder I found it full of small stones. The liver was small and the gall bladder very high up. I was obliged to loosen the peritoneum. This gentleman had for five or six days incessant vomiting and the gall bladder was torn away from the peritoneum. He still has his gall stones in his gall bladder, but for a number of


years he did not have any attacks. Lately, I understand, he has had them again.

I have also done the sewing of the omentum against the gall bladder in the way that Lauenstein proposes, and have been quite satisfied with it.

Finally, I should like to say that I have regarded the invitation to come here as a very flattering one. I have come with the greatest imaginable pleasure, and for the reason, apart from the friendly relations which I have hei'e, that I have the consciousness of being at a place where science is promoted and sought for in a devoted and unselfish manner. I regard this institution as the pride of this country, and I hope that it will not be the only one, — that others will follow, and that this country will be eager to base medicine on the sound basis of scientific conception.


CORRESPONDElSrCE.


A Case of Pnetjmo-Cardial Rupture. To the Editor of the Johns Hopkins Hospital Bulletin.

Dear Sir:— I send herewith a report of a case of pneumocardial rupture which has come under my observation, which you may deem of sufficient interest to publish.

On March 36, 1896, a negro man, age 23, was brought to our hospital in a condition of collapse, with the history that a bank of sand or earth had fallen on him and a fellow-workman, the latter dying in a few hours afterwards from internal injuries. The patient's breathing was shallow, jerky, rapid and very painful, and every few minutes he had a hard spasm of coughing, which distressed him greatly and during which he expectorated a good deal of bright red blood. Morphin to relieve his pain and coughing, and strychnin were given him freely. On the second day he complained of intense pain in the cardiac region, and the stethoscope revealed a very interesting, if not an entirely unique state of affairs. This was a loud double friction sound with a bubbling and splashing sound, which could be distinctly heard with the stethoscope two inches from the chest wall. The diagnosis was a rupture between the pericardium and the lung. On the third day (losing sight of the fact that air from the lung is usually sterile) I supposed that he had a septic pericarditis due to the effusion of blood and air from the lung. An examination of the blood, however, showed no leucocytosis, which proved conclusively that the pericarditis was not septic. This examination was repeated daily for three days, each time with the same result; and as at no time had he much fever, and as the pulse and respiration during this three days gradually improved, a favorable prognosis was given, which was justified later by his complete recovery. The loud splashing and bubbling disappeared by the fourth day. The rough friction sound persisted for three weeks, and after that the heart sounds were in every respect normal.

Georue S. Brown, M. D.

2220 First Avknce, Birminoham, Ala. Vec. 10, 1898.


3i


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 71.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


THE JOHNS HOPKINS HOSPITAL REPORTS.


Volume I.


423 pages, 99 plates.

Report in Patliolosry.


The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Suturos; Reversal of the Intestine; The Contraction of the

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

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

Mall, M. D.

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

T. C. Gilchrist, M. D., and Emmet Rixford, M. D. A Case of Blastomycetic Dermatitis in Man; (Comparisons of the Two Varieties of

Protozoa, and the Blastomyces found in the preceding Cases, with tlie so-called

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

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

T. C. Gilchrist, M. D.

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

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

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

Report in Medicine.

On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with

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

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

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

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

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

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

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

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

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

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

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

Howard A. Kelly, M. D.

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

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

Henry M. Thomas, M. D.

Report In Pntliology, I. Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleor, M. D.


Volume III. 766 pages, with 69 plates and figures.

Report in Patlio1og:y.

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

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

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

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

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

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

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

Report in GJ-neeolog-y.

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

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

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


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

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

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

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

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

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

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

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

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

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

Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever,

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

Report in Nenrolog-y.

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

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

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


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

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

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


Volume VI. About 500 pages, many illustrations.

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

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

Report In Patliologry.

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

Pregnancy in a Rudimentary Uterine Horn. Rupture, Death. Probable Migration of Ovum and Spermatozoa. Bv Thomas S. Cullen, M. B.. and G. L. Wilkins, M. D.

Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen. SL B.

A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By William D. Booker. M. D.

The Pathology of Toxalbumin Intoxications. By Simon Flexner, M. D.

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


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

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

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BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. VIII.- No. 72.]


BALTIMORE, MARCH, 1897.




GOisrTEisrTS.


Is Malaria a Water-Borne Disease ? By Rupert Norton, M. D. 35 Tlie Radical Cure of Hernia by Implanting a Section of Sterilized Sponge. By W. B. Platt, F. R. C. S. (Eng.), - - 44 Additional Cases of Dermatitis due to the x Rays. By T. C.

Gilchrist, M.R.C.S., L.S. A., 46

Proceedings of Societies :

Hospital Medical Society, 47

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


Woods] ; — A Simple Contrivance for Effecting Pneumatic Massage of the Tympanal Membrane and Ossicles [Dr. Theobald] ; — Excision of a Parovarian Cyst without Removal of its Ovary or Tube [Dr. Kelly] ;— On the Pathology of Hpematozoan Infections in Birds [W. G. MacCalu'm] ; — On the HiBmocytozoa of Birds [Eugene L. Opie] ; — Discussion of Dr. Bloch's Paper on "Agglutination of Typhoid Bacilli, etc." Notes on New Books,



IS MALARIA A WATER-BORNE DISEASE ?=

By Rupert Norton, M. D., Washinf/ton, D. C.


There are several points in the consideration of this question which make an exact answer e.xtremely difficult. First and foremost stands the fact that the malarial organisms, those forms producing malarial fever in mankind, have not been recognized outside the blood of human beings. Other similar types or species of organisms have been found in the blood of birds, frogs, etc., but these do not seem to be of the same species as that which fji'oduces the fever in human beings. Thus at the outset we are hindered in the investigation of this question by not being able to find and study the life-history of these organisms in any extra-corporeal form. Another difficulty, and not a minor one, is the occurrence of malarial fevers and typhoid fever in the same places at the same time of the year, oftentimes with very similar types of fever. And again it is generally supposed that the malarial organisms exist in the soil, in damp soils, and so possibly in actual water, whether stagnant or running, and as the germs of typhoid fever exist in water, and we know that typhoid fever may be communicated by drinking-water, the belief is a common one that malarial fevers may be induced in the same way.

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


•Read before the Johns Hopkins Hospital Medical Society, Nov. 16, 1896.


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


36


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


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

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

Deaths from Malaria. From Typhoid.

1876 22 327

1877 73 321

1878 143 260

1879 198 159

1880 265 242

1881 357 257

1882 264 324

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

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

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


" Malarial fever has also appeared at the house of Mr. Donald Reid, about one-third of a mile from Lake Cossayuna, up the Summit pond brook at a height of one hundred feet above the lake. No other cases of fever were reported in this direction. An examination of the premises of Mr. Reid showed that his house stands upon rock, covered with a comparatively thin layer of clay, and that while the roads and ground a short distance away from the house were dry and dusty, the clay around this dwelling was saturated with water. This water comes from a sjn-ing north of the house. The water is brought from the spring to the barnyard through a pipe, and empties into an open trough, the overflow of which saturated the surrounding ground. The surface of the ground here is twelve feet higher than that about the dwelling The upper stratum is a loose soil some two feet deep, through this the water percolates until it reaches the clay over the rock, along which it readily finds its way down the steep slope to the house and saturates the clay about the dwelling. Water is also brought directly from the spring to the house and empties into a trough on the east side of the dwelling. The overflow of this trough is allowed to saturate the ground within ten feet of the eastern wall of the house. From these facts it appears that saturation of the soil about this dwelling, for which the owner is entirely responsible, is a sufficient cause for malarial fever in a region bordering upon such extensive swamps."

There can be but little doubt that these cases were not malaria, but typhoid; certainly the conditions existing were just such as to produce typhoid. Such unreliable statements as those quoted have led many who have not had the opportunity to investigate the question for themselves to believe that malaria was a water-borne disease.

It is a curious fact that almost all observers who want to prove that malaria may be due to drinking water refer to the cases of illness which broke out on the now famous ship Argo. The pros and cons of the evidence that these cases were or were not malaria have frequently been discussed and there is no general agreement. It seems quite fair, however and more than probable, to conclude that these cases were nol malaria. At any rate the burden of proof lies with those who maintain that the cases were malaria, and the proof they offer is unsatisfactory. If these were malaria, then the watei"borne theory needs no further demonstration ; but for those who doubt, new proof must be furnished. The story related by Boudin" is as follows. I translate freely:

" In the mouth of July, 1834, the Sardinian ship Argo sailed from Bone (Algeria) with 120 soldiers in good health, and arrived at Marseilles. Thirteen men had died during this short voyage and had been buried at sea; 90 men were brought to the hospital in Marseilles, showing pronounced ('• les moins equivoques ") symptoms of paludal intoxication, iu all its forms and types ; in some cases the disease was most severe, or if one prefers to say so, showed the greatest degree of perniciousness. Whereas the soldiers were attacked by choleriform, epileptic, comatose, tetanic and other types of fever, which yielded as though by enchantment to large doses of quinine, the sailors showed a marked contrast in their perfect health. Now what could be the cause of such a difference in individuals who were apparently, at least, subjected to identical conditions?


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An official inquiry, of which I had the direction, gave me the most complete information. The investigation showed that if the sailors had kept their good health they owed it to the purity of the drinking water, of v/hich they had a special supply, while the soldiers were forced to drink water drawn from a well in a marshy spot near Bone, which water had been taken on board just on the eve of departure. The soldiers who escaped this poisoning were those who, having saved a little money, were able to buy water from the Sardinian sailors. This fact demonstrates in a peremptory manner how paludal matter absorbed in a liquid form from the gastrointestinal surface, as by the lungs in a gaseous form, causes intoxication."* In another place the author himself admits that his evidence is not conclusive. He says : " Le faitsuivant, dont nous avons ete temoiu au lazaret de Marseille, in 1834, pourra paraitre concluant au premier abord, et pourtant, en y regardant de pres, on est contrait de rester dans le doute."

It is strange that nothing is said in this story as to the length of the voyage, nor whether the sailors had been allowed to land at Bone. Algeria is a malarious country, and if the cases were malaria, the soldiers may have been infected on land, and the drinking water may have only aggravated the sickness. In fact there ai-e many points in the story which need elucidation and without which the story is scientifically unreliable.

Oswald Baker' relates some cases of a similar sort, but here, too, his proof is insufficient, not so convincing even as that of the Argo. He attributes the cases of illness, which are not described, to the drinking water on board a vessel. Kershner° relates the case of a ship in which malaria (?) broke out, and where all the evidence went to prove that it was not due to drinking water. The author does not believe in the waterborne theory. The evidence is not clear as to what the illness really was. These are all the cases that I have found to prove or not to prove the development of malaria on shipboard as due to drinking water. If one case could be definitely shown to have occurred in this way, far from land, where the possibility of an air infection would be reduced to a minimum, the case, even then, would not be proven, for we know that the case might be one of latent infection, developing long after a stay in a malarious country.

On the origin of malaria we find many articles by medical men in various countries, and it will be better to examine these systematically, and thus see what proof has been brought forward to confirm the water-borne theory. Let us first look at some of the Reports of the Surgeon-General of the United States Army. In the report for 1889, pp. 32-33, it is stated:

"Much of this improvement has been attributed, and I believe correctly so, to the introduction of wholesome water supplies. In a recent communication, Col. Charles Page, Assistant Surgeon-General, makes an exception of Fort Sill,


  • "I have said above that the patients showed signs of paludal

intoxication in all its types; actually and for the first time at Marseilles, I observed cases of continued fevers, although quinine was administered (" des fiovres continues a quinquina"). Now my investigation showed that the patients with continued fevers were precisely those who appeared to be the most saturated with the marshy water."


Indian Territory, in this connection, claiming that the diminished malarial sick list which followed the introduction of a good water supply cannot be referred to the water, because there was a diminution of malarial diseases at Fort Supply, which had no new water supply, as well as Fort Sill, for several years after the introduction of the water supply at the latter post. He attributes the improvement to some general condition which affected Fort Supply as well as Fort Sill, and considers, therefore, that the theory of a water propagation of malarial fever does not always hold good. He says :

'An examination of the consolidated reports of the medical department of Fort Sill for several years will convince one that the supply of spring water did not diminish the ratio of malarial disease materially. The diarrhoeas diminished and the general health of the command was improved, most probably by the beneficial effects of a full sujiply of good water for drinking and bathing.'

" Here is an example of a garrison suffering from malarial poisoning supposed to be contained in the drinking water, which continued to feel the effects of malaria although the supply of water was changed from that of a doubtful character to one absolutely pure, being filtered for miles through sand, gravel, and lime-stone rock. It is apparent that the poison producing malarial diseases must be sought for in another source than in the drinking water. It is there at Fort Sill in the heat, moisture and soil which produce malarial fevers anywhere, or furnish good culture material for the bacteria that cause it. In New Mexico, where the climate is dry, though hot, malarial fevers do not exist; but turn the waters from the rivers upon the soil by means of acequias, and malarial fevers soon abound, regardless of the source of the water used for drinking. It will be observed that for several years before the improvement of the water supply at Fort Sill the ratio of malarial diseases was smaller than after the development of the spring which gave the garrison a pure filtered water. ... In 1881 the ratio was remarkably small, being but 59 per 1000 of mean strength ; surely that could not be accounted for by any improved source of the drinking water. There may have been some meteorological cause ; we know that in different years there is a marked variation in the prevalence of malarial diseases. . . . The diminution of the cases of malarial diseases at Fort Sill after 1884, when it appears that the greatest number prevailed, must be considered a sequence and not a consequence of the development of the spring of excellent drinking water. The ratio of malarial diseases at Fort Supply for the years 1884, 1885 and 188(5 shows a decrease of sickness after 1884. Fort Supply, where the water supply was not improved, like Fort Sill, has a reputation of being malarious. The water supply of this post has recently been materially improved . . . but it remains to be seen if the ratio of malarial fevers will be diminished."

In the report for 1890 it is stated: "Relatively fewer of the colored troops were attacked, but the proportion of remittents to intermittents was greater among them, and the average duration of the remittent was longer— 34.8 days for the colored, and only 21.2 days for the white men— an illustration of a well established fact, that when the negro becomes seriously ill he does not rally so readily as the Caucasian."


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The duratiou of the sickness in these cases is much against any considerable number of them having been malaria, and the use of the words "remittents" and "intermittents" adds to our difficulty in determining the etiology.

In 1890, Fort Brown, Texas, was supplied with distilled water, and the improvement in the general condition of the post after that year is attributed entirely to this factor.

The following quotation is found in the report for 1894, p. 52: Capt. W. Fitzhugh Carter, the post surgeon at Fort Sill, Oklahoma, writing on malarial diseases, says: "There is almost conclusive evidence that the water of the streams in this section of the country is a concentrated malarial poison, and at certain times of the year will give rise to malarial fevers in a large percentage of those who drink it," and he looks to the use of distilled water for the same beneficial results that have already been obtained at Fort Brown, Texas. But in the report for 1895, p. 41, we find that Fort Brown was the fourth army post having highest admission rate for malarial diseases. Washington Barracks, D. C, and Fort Meyer, Va., just across the river from Washington, came first and second in this list; both these places are well-known hotbeds of malaria. The third in rank was Fort Hamilton, in New York liay, where it is more than probable that the percentage of cases attributed to malaria is too large. From this we do not see that there could have been anj' great imjjrovement in the condition of Fort Brown, as it never ranked first on the list. The purer water supply does not seem to have reduced the cases of malaria very greatly. On the same page of the report for 1895 we find that "nearly one-fourth of the malarial cases of the army were remittent, with an average duration of 21.5 days; the average of the intermittents was 5.75 days" — • a long period for remittent, if by that we are meant to understand malarial fevers, and closely corresponding to the length of time usually given to typhoid. A supply of water supposed to be quite pure has not modified to an appreciable extent the number of cases occurring at the two army posts in Washington. Dr. Charles Smart, of the U. S. A., is an ardent supporter of the water-borne theory, but he has brought forward no convincing evidence of the truth of this theory. He believes surface waters, when used for drinking purposes, to be more dangerous than water from deep wells.

The best, and a very interesting paper that has appeared on malarial fever in these reports is by Dr. Walter Keed in the number issued this year. He has paid special attention to the cases of fever at Washington Barracks and Fort Meyer, and has examined the blood of many patients. Dr. Heed does not believe in the water-borne theory. He tells me that "the water supply at Washington Barracks has not been changed ; it has always been the same as that of the city. The sujiply at Fort Meyer was changed in November, 1894, from well water to Potomac river water. The following year the men and officers drank, as a rule, filtered and boiled Potomac river water, with the result that there were more cases of malarial fever in 1895 at Fort Meyer than during any one of the previous 23 years. It was also higher at the Barracks in 1895 than during any of the previous 23 years." There is much malarial fever in the city of Washington, and it is really endemic along the river flats, but has no apparent connection with the


drinking water of the city, since otherwise the people in the upper part of the city should naturally suffer as much, which they do not. The reports from the army posts are hard to analyze, since the officers in charge are frequently changed, and their personal views as to malaria and typhoid fever vary materially. But, as yet, all the evidence coming from the army posts is rather against than for the water-borne theory.

Through the kindness of Dr. G. M. Sternberg, Surgeon-General of the U. S. Army, I have received to-day proof-sheets of an address lately delivered by him in New York. In this he says : The facts which have been developed with reference to the transmission of cholera and typhoid fever, considered in connection with numerous recorded observations relating to the supposed development of malarial fevers as a result of drinking surface waters, have led some authors to the conclusion that malarial infection, also, commonly results from the introduction of the malarial parasite in this way. Without denying that this may occur, I am disposed to believe that much of the evidence which has been advanced in favor of this view is unreliable. In many cases the so-called malarial fevers which have been traced to the use of surface water from wells, streams, etc., have been of a " continued type " and not controlled by quinine. In the absence of positive evidence of the presence of the malarial parasite in the blood, continued or remittent fevers which resist the specific action of quinine cannot, in our opinion, be properly classed with the malarial fevers. If not due to infection by the typhoid bacillus, they are, at least, more nearly allied to typhoid than to the typical malarial fevers."

A large number of general jiractitioners throughout the United States believe firmly in the water-borne theory, among them Zwisohn,' West,' Waggener," and Hylaud,'" but the evidence they show to support their view is most incomplete.

Daly" wrote a long article attempting to prove this theory, and thought that vegetables washed in marshy water might produce malaria, but his paper is unconvincing. This called forth other articles by Norbury,"" Jones," and Cadwallader;" the first two mentioned agree with Daly, but Norbury gives an account of an epidemic which might have been typhoid, and Jones' paper is still less satisfactory than Norbury's. Cadwallader does not believe in the water-borne theory, but thinks the home of the plasmodia is in the sap of vegetable life rich in sugar, and thinks there is danger of infection in eating maple sugar and sorghum molasses. This startling theory is balanced by an equally strange one put forth by Newton," who thinks "the consumption of water-melons seemed to be provocative of malarial fever." He believes both the air- and water-borne theories have been proven, but most of his evidence is taken from the works of other men, some of whom I have mentioned, and his paper adds nothing material to strengthen the water-borne theory. Hurley," like Daly, attributes malaria to drinking w.ater, " though fruits and vegetables eaten raw may carry it." He does not believe it enters through the lungs. His proof is based on some eases, where people using boiled water were not attacked by some vague symptoms, which those who did not purify their water in this way, suffered from.

Lewis'" believes "water to be one of the chief avenues, if not


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the most important, by which malaria gets into the human system." His ideas are based on inquiries as to the origin of malaria sent to various doctors and laymen in the South ; the replies of these gentlemen are almost all of them in favor of the water-borne theory ; but the cases given are not described with sufficient detail to rule out typhoid in many instances, nor can infection through the air be eliminated, nor the possibility that the disease was acquired in some other locality than that where the patient was living when found sick. Many of the reports are founded on the disappearance of illness and fewer deaths in families when the supj)ly of water was changed ; the source of the drinking water often stood below the level of the houses and could easily have been polluted ; many cases of illness were said to be the result of drinking cistern water. The health of the people was improved by a change in position of a well, or from driving deep wells, and not depending on surface water for drinking purposes. Such evidence cannot be accepted as satisfactory proof of malaria being the result of drinking impure water. Cowan" reports a number of cases which he believes support the water-borne theory, but his ideas on the subject of malaria are so opposed to the exact knowledge we have at present in regard to that disease that his evidence may be fairly thrown aside as valueless. He says : " We shall, however, assert as true that the malignant types of malarial fever, and in fact almost all forms of malarial fever, are indebted to the water we drink, and not to atmospheric conditions, for the etiological factor in the transmission or rece^ition of the pathogenic material which produces malarial fever. ... In contradistinction, allow me to say that water in globule never produces malaria, but becomes an absorber and retainer of this pathogenic material, and may become loaded with this poison almost to saturation. Trees, wells, springs, creeks and branches may become so loaded with this poison that a single glass of water may contiiin pathogenic material sufficient to produce a case of intermittent fever. Without entering further into the manner of its formation or the power of water in globule to absorb or retain this pathogenic factor and disease producer, we will endeavor to give proof that the water we drink is the great factor and principal source of malarial fever in all its forms, but especially in the malignant types."

If the cases reported by Quine"' could be accepted without hesitation, their evidence might be looked upon as strongly in favor of the water-borne theory, but many of the facts given are so entirely contradictory of what has been proved as regards the effect of quinine on the malarial parasite that we cannot accept them — we feel sure that some mistake was made in the diagnosis. We quote the following cases in behalf of the stand we take :

Case 4. "Miss H., aged 16; has lived in Chicago many years in a good house and neighborhood. No excavations near. . April, 1894, she began to be sick gradually with a continued type of fever marked by irregular fluctuations, which was labeled by the attending physician. Dr. Samuel Cole, 'typhoid fever with malarial features.' The fever continued about four weeks, and then, after an .interval of normal temperature, lasting a few days, there was a relapse. The patient had taken


quinine freely from the beginning. Upon the basis of two examinations made by myself during the month of May, 1894, the diagnosis of the family physician was sustained. Later the blood of the patient was examined by Dr. F. S. Johnson and the fact of malarial infection, previously assumed to exist, was demonstrated. Quinine was administered with great freedom by the mouth, rectum and hypodermic method, and arsenic and iron were also pressed systematically, but without affecting the course of the disease. The patient was seen at this time by Dr. N. S. Davis. Her illness continued over four months, uninfluenced by treatment to an important extent, and finally came to be attended with acute pulmonary tulierculosis. Death occurred five or six weeks later. The blood of the jiatient crowded with plisiiwdin to the last." [The italics are mine.— K. N.]

Such resistance on the part of the plasmodia is unknown, especially when persisting in this manner for weeks. It is contrary to all the best evidence we have. Equally doubtful are the following cases reported by him.

Case 5. A girl with an alveolar abscess was thought to have contracted malaria in New York, or on her way to Chicago; but evidently the case was one of acute septica3mia, although Dr. Cole examined the patient's blood and found it stocked with malarial organisms: for "notwithstanding the administration of 40 to 60 grains daily [of quinine], and the fact that the patient was kept profoundly cinchonized, the chills and fever increased in frequency and severity. Some abscesses occurred in the site of subcutaneous injections. Malarial infection of the blood continued till the death of the patient."

Case 10. March, 1895. Woman with rlieuuuitic symptoms and erythematous nodes. "Examination cff the blood discovered small endoglobular bodies, and large amoeboid endoglobnlar bodies containing pigmented particles in active motion." "Under anti-malarial treatment the rheumatoid pains disappeared; the erythematous nodes continued, but were lessened in number; iut the chills and fever irerc not benefited." [Italics mine. — R. N.]

Case 13. A child 3 months old was supposed to have contracted malaria from a nurse. "An examination of her blood [the nurse's] showed malarial infection. Examination of the infant's blood revealed large and a few small endoglobular bodies." "No fever." [Italics mine. — E. N.]

In Case 10 the fact that " the chills and fever " were not benefited by quinine, if they were due to malaria, is incredible; and in Case 13 the statement that the child had " no fever," and yet its blood showed numerous malarial parasites, is also questionable. But the following remarks, quoted from his article, show that he does not agree with the best authorities on malaria. He says : " The proofs of water infection are quite as strong as those of air infection, and there is not a doubt that impure water is responsible for the occurrence of paludal disease with immensely greater frequency than is generally known. . . . Nor is the therapeutic test a reliable guide to diagnosis. . . . The entire absence of fever is a characteristic of many cases. . . . Quinine causes some symptoms to disappear, while others persist; and those showing periodicity may be the ones to persist." Such observations


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[No. 72.


and the doubtful proof of malaria in the cases he relates, minimize the value of the article.

Such is the evidence coming from American physicians, and certainly it is not sufficient to prove the water-borne theory. Let us now look at that offered by certain doctors in India; three papers by Boss,'" Rogers,^" and Hehir"' may furnish some further proof one way or the other. Ross believes that " malaria must be originally a disease among mosquitoes" (a view brought into more prominence by Manson), and says: "We may conjecture that infection may arise from the bite, or from deposition of the parasite by the mosquito on the skin of the patient or in his drinking water." Rogers brings no proof, but states : " In addition to the undoubted effect of drinking water in causing malarial fever, it is also universally admitted that perhaps an even commoner mode of entrance of the organism is through being inhaled into the lungs and so reaching the blood of the capillaries." In Hehir's article we find the following :

" Malaria is mixible with water. It is capable of being carried by currents of water through distances and periods of time altogether undetermined, without losing either its toxic effects or faculty of reproduction. It is possible that this means of conveyance has affected its distributions to continents and islands too widely separated to justify a belief that it was wind-wafted. No observations need be adduced to establish the water-borne habit of the malarial {poison, or the positive liability to its toxic effects, when received into the stomach throiTgh this medium. These facts have been well understood from the time of Hippocrates. The inhabitants of tracts of marshy country are pretty generally agreed that these waters may produce fevers."

He also thinks that milk left outdoors through the night in open pans may catch sufficient quantities of swamp poison to produce sickness, if exposed where malaria is rife. Daly \loc. cit.^ also thinks that milk may carry malarial infection, through the cans in which the milk is stored being infected by dirty water in washing them. The ancients may have believed that water could cause malaria, but we cannot accept their statement as proof, nor this one of Hehir's. This evidence which comes from India, where as yet the exact differentiation between typhoid fever and malaria is evidently not generally well understood, or where the discoveries of Laveran are not accepted (ex: Surg.-Gen. Laurie), adds nothing convincing to the water-borne theory.

In Germany malaria is not common, but much has been written on this disease by Germans who have studied it in foreign countries. Shellong,'" who wrote on the malarial fevers in New Guinea, does not believe in the water-borne theory. His is a careful study and his ideas deserve consideration. Steudel," also writing on foreign fevers, believes in the water-borne theory, and refers, like so many other authors, to Hirsch for confirmation. Hirsch's work, " Handbuch d. Historisch-geographischen Pathologic," was published, however, in 1860 and, though valuable as a reference book, cannot be accepted as an authority on malaria. Leonhardt," in a long and careful study, comes to the conclusion that malaria is not water-borne. He says those who believe it taken in with drinking water cannot prove this, because patients are subject


to infection by the atmosphere also. Two out of three Germans, we see, do not believe in the water-borne theory. Let us now review the beliefs of the French and Italian observers on this point.

Taking up the papers first whicli have appeared in French, we find articles by Verdan," Nicolas," Pepper," and Kelsch and Kiener." These contributions, like the German, are on malarial diseases as seen outside of France. The malarial fevers in Algiers are ascribed by Verdau to the water supply, which is very foul, and to effluvia carried by the winds. The work by Nicolas is a long one, but there is no proper differentiation made between typhoid, malaria and other forms of fever, so that his conclusions are not much to be relied upon. He believes stagnant water to be one of the main sources of origin of malarial fevers (" mais nous en savons assez deja pour nous convaincre que la stagnation de I'eau est necessaire pour engendrer la malaria"), but says little about drinking water. However, it may be surmised that he believes also in the waterborne theory, since the supplies of drinking water in the countries of which he writes are often stagnant. He recommends good, pure drinking water, and says, "en ce qui concerne la malaria la preuve semble faite: I'eau d'alimentation n'y est pour rien." But as regards typhoid fever he makes the following statement: "en realite rien n'est moins prouve que ces relations de causalite eutre I'eau et la fievre typhoide en particulier si savamment defendues par des observatenrs tres recommandables." Such statements diminish the value of his observations.

Pep25er, who like Verdau wrote on the fevers in Algiers, concludes his paper, which is not a brief one, with certain aphorisms, from which I quote the following :

1. "Dans une region malarienne, la malaria doniiae presque toute la pathologic."

2. "La malaria est, selon nous, raerotellurisme proteiforme."

3. "L'intoxication se produit durant Facte de la respiration et atteint principalement le systeme nerveux."

The first statement is very true, not only in Algiers but in many other countries, practitioners commonly attributing many maladies to malaria as a cause where malaria has actually no causal relation to the diseases in question. His third aphorism shows that he lays no special stress on water as producing malaria.

The final paper by Kelsch and Kiener is also against the water-borne theory. They believe infection is through the lungs, that this at least is the most common method. They think the water-borne theory is not confirmed by facts, and that the cases on the Argo do not support the theory. They say, however, that malaria may arise at sea, and relate one instance which furnishes no stronger proof than that of the Argo. Soldiers in Algeria, they note, who while marching drink foul water, are no more affected with fevers than when in camp using pure water. Towns on heights around the Roman C'ampagna are free of malaria, although their inhabitants drink water coming from malarious regions. This they bring forward as proof against the water-borne theory and say that foul water simply acts as a force to reduce the resistance of the body to morbid Influences.


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" Professor Colin, of Val de Grace, who is so well known for his researches on intermittent fever, is inclined to question the production of paroxysmal fevers by marsh water. He cites numerous cases in Algiers and Italy where impure marsh water gave rise to indigestion, diarrhcea and dysentery, but in no case to intermittent fever, and in all his observations he had never met with an instance of such an origin of ague." (Sternberg: Malaria and Malarial Diseases, 1884.) According to these French observers, then, the weight of evidence is against the water-borne theory.

The observations made by Italian physicians are among the most interesting we have. Celli," one of the best students of malarial fever, has written a paper of great value on this subject. It is a short article going to prove that water does not transmit malaria. He gives a chart showing that introduction of new water supply into a certain city did not diminish the number of cases of malaria. He says popular ideas on this matter are fallacious, and notes that persons may live in a malarious place and drink pure water and yet have malaria, while others in the same place drinking foul or "paludal" water do not have malaria. He himself gave water from the Pontine Marshes, which are acknowledged to be very malarious, in large quantities to a certain number of patients who had never had malaria, without its giving birth to this disease in them. Similar evidence is furnished by Salomoue-Marino." He experimented in the' same manner as Celli, giving 5 to 24 litres daily of paludal water for from G to 24 days, and did not succeed in a single instance in producing malaria. He says that those cases of malaria which are suspected to have been caused by infection through the digestive tract are usually grave cases with short periods of incubation. He relates two such cases, which, as the blood was not examined iu either case, do not furnish proof of his statement. One patient was vei-y ill and took three weeks to recover (typhoid ?). Stagnant water is likely, he thinks, to contain poisonous or noxious bodies which could produce gastro-intestinal symptoms similar to those sometimes caused by malaria. Bonizzardi," without relating any cases, concludes one short article with a number of deductions, from which I take the two following: "Intermittent fever may be contracted as well by drinking water as by air," and "infection by air is far more fatal than by water." Moscato," who has also carefully studied the question of malarial fevers, states, without furnishing any proof, that drinking water as a source of infection has been noted daily by observers : " I'acqua potabile, come sorgente del velino palustre f u riconosciuta auche da Ippocrate ; quale verita e stata anche sanzionata dagli osservatori odierui." The statement has been made that malaria may be transported from one infected district to another healthy one by a new water supjjly, but the proof here is not sufficient, since the turning up of the soil for the pipes may have been the real cause. Most of the Italian observers, it is seen, are opposed to the water-borne theory.

Such is the evidence that exists for aud against this theory, and though we cannot say that malaria is never contracted from drinking water, yet the best proof is against this common belief. It is impossible to demonstrate that something never occurs, and we must be satisfied with showing that all the evidence that has been so far collected to confirm


the water-borne theory is not of sufficiently exact quality to carry much weight. To prove that malaria is water-borne in a given case demands conditions of a peculiar character: first the patient must never have had malaria, and must live and have lived in a district supposedly quite free of malaria; after drinking a certain supply of water and allowing for the proper period of incubation, the malarial parasite must be found in the patient's blood. In the meantime no soil should have been turned up in the patient's neighborhood, he should not have exposed himself to infection in any way, as by traveling into a malarious country, sleeping out at night, etc. Even if all these demands could be satisfactorily met, there would at the present time still be the proof lacking that the malarial parasite lived in the water. Outside of the human body, we know nothing of the life-history of this jiarasite. It may be discovered later and found to thrive in water, in which case the probability of frequent infection through drinking water would be strongly enhanced. But it may turn out that it does not live in water for any length of time, aud then the possibility of infection through this medium would be greatly diminished. All we can say is that no case among all those recorded as water-borne gives a positive finding of the malarial parasite in the blood, certainly one of the most necessary proofs to show that the patient really had malaria.

To confirm our view we have the definite knowledge that drinking water from malarial places does not produce the fever experimentally. And finally, it is probable that a large number of the cases attributed to malarial infection are not malaria, but rather typhoid, and if not the latter, then due to some auto-intoxication from the intestine. We know how many illnesses starting in with vomiting, headache, chills, diarrhcea, and even blood in the stools, sometimes rapidly ending in death, are due to poisonous articles of food ; why then should we not have similar attacks which do in a measure simulate malarial infection, where the most marked symptoms are intestinal, as a result of drinking foul waters, as one of the Italian physicians mentioned above suggests? This does not seem unlikely, and until we know more of the life-history of the malarial parasite outside of the human body it is fair to question the water-borne theory of malaria.

Much light may be thrown on this question iu the future by further study on the climatic and telluric conditions underlying the existence of malaria in different places; but as yet, though an enormous amount of study has beeu given to these very points, the results obtained by the observers do not agree altogether, and we are unable to form any definite conclusions which elucidate the life of this obscure parasite. Above all, in the study of this subject it is absolutely necessary that malaria and typhoid fever should not be confounded, as they have been so often in the past.

In conclusion I would simply add the two following paragraphs from Sternberg's Malaria and Malarial Diseases, which, though written in 1884, are as true to-day as then. He says : " It is well established that enteric fever and certain alvine fluxes may result from the use of contaminated drinking water. And in the case of the former disease, we know that even very great dilution does not destroy the infectious properties of the con


42


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


taminated water, e. g. in those cases where it has been used to wash vessels in which milk was placed, aud in which typhoid fever has resulted from drinking this.

"That fevers having an intermittent or remittent character may also be produced in the same way cannot be doubted. But we have already seen, in the introduction to the present volume, that enteric fever frequently presents these characters; that in this case the differential diagnosis from malarial fevers presents great difficulties, and that in many parts of the world fevers of this character are attributed, without question, to malaria. We therefore feel inclined to accept the evidence with a great deal of caution. Moreover, we think that considerable weight should be accorded to the negative evidence. It Avould seem that if this mode of infection occurs at all, it should occur frequently, and in that case that it would be more generally recognized. From what has been said in the introduction, it will be seen that we cannot accept evidence relating to the iiroductiou of ' nuilarial diarrhoea,' or ' malarial dysentery,' or ' mountain fever,' or ' continued remittent fever,' or ' typho-malarial fever' in any of its forms."

Bibliography.

1. Chapin, C. V. : " The Origin and Progress of the Malarial Fevers now prevalent in New England." 1884. Fiske Fund Prize Dissertation No. 32.

2. Griswold, R. W. : " On the Epidemic of Malarial Fevers at present prevalent in Southwestern New England. Historical and Etiological." Gaillard's M. J., New York, 1885.

3. Baker, 0. : " Malaria on Shipboard." Brit. M. J., 1893.

4. Greeuleaf, K. AV.: "The Charles River in its Relation to the Etiology of Intermittent Fever." Boston M. and S. J., Vol. CXXX, 1891.

5. Green, J. S. : "The Appearance of Intermittent Fever near the Neponset River." Boston M. and S. J., 1887.

6. Kershner, E.: " Is Malaria a Water-borne Disease?" N. Y. Med. Rec, 1895.

7. Zwisohn, L. W. : " Is Malaria a Water-borne Disease ?" N. Y. Med. Rec, 1895.

8. West, G. H.: "Good Drinking Water vs. Malaria." North Carolina M. J., Wilmington, 1895.

9. Waggener, R. : " Drinkiug Water — a Source of Malaria." New Orleans M. and S. J., 1891-92.

10. Hylaud, C. S. : "Water a Source of Malarial Fever." New Orleans M. and S. J., 1893-94.

11. Daly, W. H. : "Some Practical Observations on socalled Malaria being a Water-borne Disease." N. Y. Med. Rec, 1894.

12. Norbury, F. P. : " Is Malaria a Water-borne Disease ?" N. Y. Med. Rec, 1894.

13. Jones, .J. J.,: "Is Malaria a Water-borne Disease?" N. Y. Med. Rec, 1894.

14. Cadwallader, R. : " Malaria and Drinking Water." N. Y. Med. Rec, 1894.

15. Newton, R. C. : "Some Observations which appear to establish the Aerial Transportation of Malarial Germs." Internat. M. Mag., Phila., 1895-9G.

16. Lewis, R. II.: "Drinking Water in its Relation to Malarial Diseases." The Sanitarian, Brooklyn, 1894.


17. Cowan, .1. B. : "Water vs. Atmosphere — the Cause of Malignant Malarial Fevers." Nashville .J. of M. and S., 1896.

18. Quine, W. E. : "The Malarial Disorders of Large Cities with especial reference to Chicago." J. of the Amer. Med. Assoc, 1895.

19. Ross, R. : "Some Practical Points respecting the Malarial Parasite." Indian Med. Gaz., Calcutta, 189G.

20. Rogers, L. : " The Etiology of Malarial Fever, with Special Reference to the Ground-water Level and the Parasite." Indian Med. Gaz., Calcutta, L896.

21. Ilehir, P.: "An Inquiry regarding Drinking Water in Relation to Malaria." The Indian Med. Chirurg. Review, 1895.

22. Shcllong, 0. : " Die Malaria-Krankheiten, etc." Berlin, 1890.

23. Steudel, B. : "Die Perniciose Malaria in Deutsch Ost. Africa." Leipzig, 1894.

24. Leonhardt : " Entstehung und Wesen d. Malaria Erkrankungen, etc" Zeitschrift fiir kliu. Med., Berlin, 188586.

25. Verdan: "Considerations sur la fievre intermittente a Ouargla, etc." Archives de Medecine et de Pharmacia militaires, Paris, 1885.

26. Nicolas, Ad. : " Chantiers de terrassements en pays paludeen." Paris, 1889.

27. Pepper, E. : "De la malaria." Paris, 1891.

28. Kelsch and Kiener: "Le poison palustre." Ann. d'llyg., Paris, 1888.

29. Celli, A.: "Acqua potabile e uuilaria." Gior. d. Soc. Ital. d'Eg. Milano, 1886.

30. Salomone-Marino, S. : "L'acqua die luoghi malarice porta infezione ?" Sicilia Med. Palermo, 1891.

31. Bouizzardi, T.: " Sulle Risaie." Salute Pubb. Perugia, 189L

32. Moscato, P.: "Etiologia e cura della malaria." II Morgagni. Milano, 1893.

33. Hurley, J. M. : " Pacific M. J., San Francisco, 1895.

34. Boudin, J. C. M. : "Traite des fievres intermittentes, etc." Paris, 1842.

DlSCUSSIOIi^.

Dr. Welch. — It is clear from Dr. Norton's careful analysis of the existing evidence for and against the water-borne theory of malaria, that the weight of evidence aud of authority is decidedly opposed to this theory. It is curious how prevalent is the belief in this theory among both the general public and practitioners of medicine, especially in the southern part of this country. As a matter of fact, the only infectious diseases whose germs we have good reason to believe to be conveyed by drinking water, are typhoid fever, Asiatic cholera, and dysentery. To this meagre list may be added indefinite gastro-enteric disturbances resulting from infection or intoxication from drinking water. The numerous claims that various other infectious diseases, including malaria, may result from infection through the drinking water, do not rest at present upon any substantial basis of demonstrated facts, altliougli it must be ailmitted that some of these claims have not been positively disproved. The criticism of the drinkingwater theory of malaria by Celli and Leri, aud above all their


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


43


couvinciug experimeutal iuvestigatious of this riiiestion, iadicate decidedly that drinking water is not a carrier of the malarial organism in a condition capable of producing infection through the alimentary canal underany ordinary conditions. There seem to me to be at present only two theories of the mode of malarial infection which deserve serious consideration, viz. the theory that infection occurs through the air, and the theory that infection is the result of inoculation with the malarial jjarasite through the agency of mosquitoes and perhaps other suctorial

insects. The question whether or not the malarial parasite 

may live and jjerhaps multiply in water would of course not be decided by the exclusion of water as a vehicle of infection, for it is possible, even probable from experiments, that infection with the malarial parasite does not occur from the intact alimentary canal, and the mucous membranes of this canal would be the only natural portal of entry for infectious agents in drinking water. The majority of authoritative writers on malaria have advocated the theory of air-borne infection, but we shall probably, since Hanson's publication, hear more and more of the inoculation theory.

Dr. Reed. — Dr. Norton has kindly referred to a report which I made to the Surgeon-General during August last, upon the etiology of malarial fevers at Washington Barracks and Fort Myer, during a period extending over twenty-six years. Washington Barracks is situated in the midst of marshy lands at an elevation of not more than twenty feet above the Potomac river, and upon soil deposited from this rivei". The post has had but one supply of water, viz. Potomac river water. During this time malarial fevers have prevailed to a greater or less extent, certain years being exceedingly severe and others comparatively light. I compared the malarial curve of that station with that of Fort Myer, wlMch is 240 feet above the Potomac and on high ground. I was sui'prised to find such a close agreement between the two. Indeed, in the last eleven years of this investigation the lines ran accurately together. If the line at Washington Barracks fell below that of Fort Myer, it was accounted for by the fact that the garrison had been sent into summer camp during the malarial season. In investigating the water supply at Fort Myer, I ascertained that until 1886 pure spring water had been furnished. During the latter year certain wells were sunk in low marshy soil, from which the garrison was supplied until 1894. It was curious to note that the supply of " marshy water," which was so much condemned by the various medical officers, did not increase the malarial cases; but that, on the contrary, during the six years immediately following the introduction of this supply, the disease was less prevalent than at any other jjcriod in the history of the post. In 1894, wells were discontinued and Potomac


water introduced. Filters were placed in the men's quarters and, in addition, the filtered water which the officers drank was boiled. Notwithstanding these precautions, the sick-rate from malarial diseases was higher in 1895 than during the previous twenty-three years, and corresponded accurately with the rate at Washington Barracks. All of which proved to my miud that the water supply had nothing to do with the prevalence of malarial diseases, and that their etiology was to be found in the low marshy lands lying along the Potomac river.

Dr. Tn.iTER. — Certainly all experimeutal evidence points directly against the idea that malarial fever can be conveyed by drinking water, and more than that against the idea of an infection through the alimentary tract. Grassi and FeTetti fed patients upon the dew collected from malarious districts, and further upon fresh blood taken from patients suffering from malarial fever, blood which, as is well known, if introduced hypodermically or intravenously, always results in a transference of the infection, without any positive result. Despite the fact that the patients on whom these experiments were made were often debilitated individuals suffering from chronic nervous diseases, etc., yet as they were, in almost all instances, in hospitals or in situations where they were well fed and well cared for, it would be impossible to entirely refute the critic who might suggest that it was the good surroundings which saved the patients from a progressive infection which otherwise would have occurred. Such a critic might suggest that had these individuals been suffering from distinct gastro-iutestinal lesions, infection would readily have occurred. In connection with this possibility it is interesting that out of 4G cases of amosbic dysentery which we have had in the Johns Hopkins Hospital, 5, or nearly 11 per cent, have suffered at the same time from malarial infection. May it be possible that the amcebic ulcers were in these instances the portals of entry for the malarial parasite ? It must of course be said, upon the other hand, that most of these instances of amoebic dysentery occurred during the malarial season and came from districts where the malarial parasite is doubtless endemic.

Dr. Norton's quotation from the author who thought he had found a large number of endoglobular, hyaline parasites in infant's blood is interesting, inasmuch as any observer who is familiar with examinations of fresh blood will immediately see how the author quoted has deceived himself. The vacuoliclike figures found particularly in the blood of children or infants who are auffimic or suffering from fever of any sort, simulate often very closely the malarial parasite, and always deceive the uninitiated ; to the skilled observer, iiowever, they are readily recognizable.


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44


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


THE RADICAL CURE OF HERNIA BY IMPLANTING A SECTION OF STERILIZED SPONGE.

By W. B. Platt, F. K. C. S. (Eng.) [Ueud before the Johns Hopkins Medical Society, January 4, 1897.]


The radical cure of hernia has long enlisted the attention of surgeons, and a method which is efficient, safe, reasonably simple, sacrificing no important part or function, causing little inconvenience and demanding but a short confinement to bed, has been eagerly sought. To simplify matters, the older surgeons cut the Gordian knot by removing the testicle and cord of the affected side. The presence of the cord at the end of a shallow funnel seemed to be the obstacle to the complete closure of the inguinal canal and rings, the pressure of the intestines acting as a wedge to keep them open.

To remove the cord by transplanting it to another location was the next step of the modern surgeon, and an efficient means of cure. The hernia oftener failed to return than by other methods. Certain drawbacks in this procedure are often noted, such as prolonged confinement to bed and great swelling of the testicle, so great in fact as to throw some doubt upon the future function of that organ, while very large incisions in the abdominal wall, a long cicatrix, a multitude of buried sutures, made the opei'ation more complicated to the surgeon and less agreeable in the end to the patient.

The writer has endeavored to efficiently close the inguinal rings and canal by a more simple procedure, and this can be done. The cases are all too recent to prove the permanency of the cure. He can only say that two cases of intractable hernia have been up and about for several months, and have never worn any truss or support of any kind since getting out of bed.

The idea of implanting a section of sponge in the inguinal canal which should form a firm connective tissue barrier to the descent of the hernia, occurred to the writer while experimenting upon rabbits in the Physiological Laboratory of the Johns Hopkins University in the spring of 1882, and observing the normal retraction of the testicle into the abdominal cavity in these animals.

As inguinal hernias are not readily produced in animals of this kind, I endeavored to so implant a piece of sponge within the inguinal canal as to retain the testicle in the scrotal pouch. The aseptic technique of that day was so imperfect that suppuration ensued and the sponge came out.

Later, I operated on a number of patients at the Garrett Hospital for Children, by simply removing the sac, suturing the conjoined tendon to Poupart's ligament, and sewing up the inguinal canal.

This succeeded very well in most cases. I have one of these cases here to-night, done five years ago. He has had no return of the hernia and wears no support or truss. The return of the hernia, however, in a case where I had every reason to hope for a permanent cure, led me to try the implantation of a section of sterilized sponge. The result certainly proved one thing, viz. that a piece of sterilized sponge as large as half a dollar could be introduced beneath the internal ring and remain there without causing any irritation, the wound healing over it and remaining healed.


Before this healing took place there was in my first case a small sinus at the upper part of the incision and I feared it might be due to the sponge. It turned out to be due to sutures, and these being removed, the wound healed without further trouble, but after five months the hernia came down. I operated upon this patient a second time, intending to insert a second piece of sponge. To my surprise I found an opening less than one-fourth of an inch in diameter in the location of the external ring. I inserted two small sutures, the wound healing promptly over them. The sponge in this first case was simjily laid beneath the ring.

In the succeeding three cases the section of sponge was secured to the cord. One description of the operation will suffice for these cases.

An incision about two and one-half inches long is made directly over the inguinal canal, following its course, the lower end extending about half an inch uj)on the scrotum. If the hernia is down, the operation is so much the easier. The canal is laid freely open. The sac, whether congenital or acquired, is opened in its entire length, the hernial contents reduced, and the sac cut away close to the internal ring, if congenital, while if it is an acquired sac it is cut square oflf after being ligated as high up as possible, and dropped beneath the ring. In the case of the congenital sac it is often necessary to leave the thin inferior \ajev in siiu and adherent to the cord.

Next, a section of fine, firm, surgical sponge is cut about one and one-half inches in diameter and one-eighth of an inch in thickness. This is sterilized without boiling, by immersion in soda solution, washed in sterilized water, treated with permanganate of potash and oxalic acid, and thoroughly washed in sterile normal saline solution. A radial cut is made in the section. The constituents of the cord are gathered together as high up as possible and placed in the center of the section and at a right augle to it. The edges of the cut in the sponge are now slightly overlapped, and two sutures inserted in the sponge to keep it in place on the cord which now pierces its centei-. The sponge section is spread out beneath the internal ring, and the conjoined tendon sewed firmly by two or more qiiilted sutures to Poupart's ligament, using a needle in a handle.

The inguinal canal is now snugly sewed up with silk sutures, and over all the skin sewed with silk-worm gut. It is absolutely necessary to use some kind of drainage in the upper augle of the wound, as there is invariably some serous oozing and swelling. This may be removed after 2-J: hours.

The patient is confined to bed and on his back for three weeks. If the patient is a boy it is well to use the Bradford frame, to keep him from sitting up and twisting about in bed. The skin sutures are removed on the 9th or 10th day, the wouud being treated on ordinary aseptic principles.

After three weeks the patient is allowed to sit up in bed a day or two, then sits for two or three days in a chair, after


March, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


45


which he goes about as usual. It is unnecessary to use any support over tlie site of the operation beyond a light strip of gaxize to protect the fresh cicatrix from friction.

In two of these cases where I was obliged to remove the deep silk-worm gut sutures before the patient left the hospital in order to close an obstinate little sinus in the upper angle of the wound, the hernia returned, as might have been expected. The trouble with these sutures may have been due to too great tension, or to a defect in the sterilization of the sutures. In none of the four cases was there any trouble from the sponge. In the two cases mentioned the wound healed promptly on removing the offending sutures. In the two other cases there was no difficulty whatever in securing complete permanent first-intention union, and there has been thus far no return of the hernia.

It is of course premature to say that there may never be a return of the hernia, nor do I know the ultimate fate of the sponge, whether it remains as organized tissue or whether it is absorbed.

From its open structure and the ease with which it is retained in the tissues it is not improbable that blood-vessels pass into it, and that it makes a framework for connective tissue, a close imitation of that barrier which nature places beneath all normal, internal, inguinal rings and which prevents every male from being a subject of hernia.

It is hardly necessary to say that the greatest care must be exercised in the perfect preparation of the sponge section to insure perfect sterilization. I have the pleasure of showing three of the four sponge cases ; also one of the older cases, where the rings were simply sewed up and no sponge section used.

Abstract of Gases.

All the following cases were operated ujion at the Garrett Hospital for Children, Baltimore.

1) G. L., set. 4. Complete inguinal hernia, right side, developed at two years of age, and is not kept up by trusses. Operation August 21, 1895. One deep suture causing a small sinus was removed 55 days after operation. Patient was discharged from the hospital, October 23, 1895, with the wound entirely healed. It has never since reopened. Hernia reappeared 5 months after operation. The return of the hernia doubtless due to the early removal of the suture closing the internal ring.

2) S. J., set. 8 years. Complete inguinal hernia, right side. Hernia developed when 2 years old. No truss effectually keeps up hernia. Admitted June 9, 1896. Operation June 17, 1896. Congenital variety of sac. Patient was walking about July 20, 1896. Discharged with the wound entirely healed, August 7, 1896. There has been no return of the hernia at the date of this paper.

3) T. W., aet. 12 years. Acquired inguinal hernia, right side. Kuptured since 2 to 3 years of age, and has been kept up with difficulty. Admitted to hospital August 4, 1896. Operation August 19, 1896. Out of bed September 18th. Walking about September 23. Discharged well with wound healed September 25, 1896. Patient is a student at the McDonogh Institute. There has been no return of the hernia up to the date of this paper.


4) G. M., Eet. 5 years. Complete inguinal hernia, leftside. Hernia appeared at 3 years of age. Trusses do not retain the hernia. Admitted to hospital August 18, 1896. Operation August 26. The wound healed at first. After about a week a small sinus appeared at the upper angle of the incision. This persisted, until on December 10th two deep sutures were removed, after which the wound promptly healed, and patient was discharged well with wound healed, December 24, 1896. Patient was seen January 1, 1897, when the hernia had begun to return, as evidenced by an elastic bulging tumor at the seat of the internal ring.

Notes.

In Oases 1 and 4, where the hernia returned, it is clear that the soft tissues of the recent operation were subjected to undue strain by the early removal of the most important sutures concerned in the operation, viz. those binding the conjoined tendon to Poupart's ligament. In all four cases the sponge remained without causing any irritation, the incision healing in each case.

I have not had an opportunity in any case to discover the actual condition of the implanted sponge after the lapse of time.

If sponge will thus heal in the depth of a wound, there is no reason why mats of silk or of other animal tissue might not also be used, and sutured firmly in place to close the openings of exit for heruiaj.

It is not impossible that the addition of these animal tissue barriers may be the element necessary to make the former operation of suturing the rings and canal without transplanting the cord, a success in the very great majority of cases.

In no case was any supjiort worn after the patient got out of bed, and in all cases the hernia was operated on because of the intractable nature of the hernia, no truss or support keeping the hernial contents in the abdomen, with the exception of No. 3, where a truss proved so great an annoyance that his family desired operation.

Discussion.

Dr. Bloodgood. — I cannot say from observation whether the scar tissue formed with the sponge is any stronger than that formed without it. A study of the statistics of operations for hernia will show that sometimes very simple operations will cure hernia in children. In looking over the cases of different operations, such as MacKewen's, Banks' and others, we find very few recurrences in children. We have found it so here, even in the cases where the wound suppurated and healed by granulation. It is interesting to know tliat a foreign body can be implanted in the tissues without giving rise to any trouble. Our observations here have caused us to think that silk sutures are more apt to cause suppuration than silver wire, and that the ideal suture would be an absorbable one.

It is unfortunate that Dr. Piatt has not had an opportunity to operate upon a recurrence in order to see what becomes of the sponge. I would ask him if he thinks the sponge remains permanently and if he has any observations to show that the scar tissue about the sponge is any firmer than ordinary scar tissue.


46


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 72.


Dr. Platt. — I have not yet had a chance to learn the ultimate fate of the sponge, but I think I shall determine it in the case of this boy whose hernia has returned. I have been surprised that his hernia has not returned sooner, for when I was obliged to remove the deep sutures to close the sinus I expected that it would soon recur.

My belief is that the sponge becomes incorporated into the tissues by aid of leucocytes and the blood-vessels which enter its meshes from the adjacent structures, and that when their work is done these probably atrophy, leaving scar-connective


tissue. Whether it is stronger and thicker than other scar tissue I do not know, but will take the first opportunity to find out. After the ordinary Banks operation a funnel opening is left, and the cord acts as a guide to further the descent of hernia. I^Iy idea is that by putting in the sponge j-ou obviated perhaps the last fault in the stitching operation, and thus get on without trausplauting the cord. It is, of course, too soon to draw conclusions as to the final result from these four cases. I shall report again after operating upon this patient.


ADDITIONAL OASES OF DERMATITIS DUE TO THE x RAYS

By T. C. Gilchrist, M. R. C. S., L. S. A.


During the time which intervened between the correction of the proofs of my article on "A Case of Dermatitis due to x Rays " and its publication, there have appeared in the literature a number of quite recent cases which have come under my notice and which could not be incorporated in my paper {vide Johns Hopkins Bulletin, February, 1897). I therefore add five more cases which have been recorded in various journals. Dr. Reid's case is of particular interest because a cutaneous lesion was not only produced on the anterior surface of the chest which was exposed to the rays, but


also on the posterior aspect of the chest and on an area which he thinks corresponded to the exit of the rays.

Literature. W. Downe: Lancet. 1896. Vol.11, p. 1049. (Abstract.) Sewell : Lancet. 1896. Vol. II, p. 1049. (Abstract.) W. Reid: Brit. Med. Journal. 1896. Vol. II, p. 1744. A. B. Kibbe: New York Medical Journal. January 16,

1897. Vol. LXV. No. 3.

M. Rendu : New York Med. Journal. February 20, 1897.

(Abstract from Progres Medicale. January 30, 1897.)


Dr. W. Downe.


Eruption appeared 10 days after exposure.


Distribution.


Back of neck and scalp.


Character of Lesions.


Extensive vesication on the back of the neck. The hair fell out over occiput, but the skin remained normal.


Subjective Symptoms.


At first a sense of


pricking heat. given.


No further observations


Dr. Sewell exhibited a similar case at the same society meeting. (See references.)


Dr. W. Reid (personal).


Dr. A. B. Kibbe.


Dr. M. Rendu.


Eruption appeared in the evening of the same day. Two exposures, varying from 20-90 minutes.

20 exposures from l/i-b minutes of left hand, and 3 exposures of elhow. Eruption appeared in a day or two.


Rays applied daily for 55 minutes.


Chest and abdomen.


Both hands and elbow.


First an erythema, followed by papules, and later by exfoliation of the epidermis, which exposed a raw, painful, weeping surface 16 days after exposure.

First a slight tingling, then a sense of irritation and itching; 10 days later extensive discoloration round elbow. No vesicles appeared.


After first application of rays intense erythema appeared, followed by vesicles and later by an eschar which did not heal for several weeks.


Painful after trie weej)ing surface was formed.


At first tingling followed by itching ; but there wasnosensitiveness or pain.


10-inch coil was used 3 inches from the skin.


Arm was covered by the usual clothing, viz. heavy woolen clothin<.' and coat sleeve. Portion of the skin was excised from forearm for histological examination.


THE MALARIAL FEVERS OF BALTIMORE.

An Analysis of 6i6 cases of Malarial Fever, with Special Reference to the

Relations existing between different Types of Haematozoa

and different Types of Fever.

By William Sidney Thayer, M.D., and John Hewetson, M. D., ABSisUints in the Medical Clinic of The Johns I/opktns VoBpital.

218 pages, qiiarlo, with platen and charts. I'rice ItiS.OO, Postage paid.

[Forming part of Tlie Johns Hophliis Ilospltal ileports. Vol. V, 1895.] Orders should bo addressed to TnK Johns Hopkins Phkss, Hai.timohk, Mu.


THE JOHNS HOPKINS HOSPITAL BULLETIN,

Volume VIII.

The Bulletin ot the .Tolms HnpUlus Hospital entered upon Its eighth volume laiumryl, 1897. It contAlus original communications relating to medical, surgical and gyuocologlcal topics, reports of dispensary iiracltce, reports from the pathological, anatomical, physlologlco-chemlcal, pharmacological and clinical laboracorle.-i, abstracts of papers road before, and of discussions In the various societies connected with the Huspllal, reports of lectures and other matters of general Interest In the work ot the Johns Hopkins Hospital and the Johns Hopkins Medical School.

The subscription price la $1.00 por year. Volume VII. bound In cloth. $1.50.


March, 1897.]


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PROCEEDINGS OF SOCIETIES.


THE JOFINS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of October 19, 1896.

Dr. Thayer in the Chair.

Rarer Cases of and Observation on Strcptococcns Infection.

— Dr. Bloodgood.

Case I. — Tliefirskcase isof especial interest because the patient recovered, although on two occasions pure cultures of the streptococcus were obtained from the blood by aspiration of a vein in the arm. In the records of the liospital only one other such observation had been made— that of Dr. Blumer, in a case of broncho-pneumonia.

In all other cases of streptococcus infection which have recovered, from which blood cultures have been taken, negative results have been obtained.

This case also presents the rare condition of a streptococcus infection of the finger, with an abscess situated between thepectoral muscles, but no evidence of any enlargement of the glands in the axilla. The abscess was distinctly localized and no other abscesses developed.

The patient presented to you to-night was admitted into the hospital, January 28, 1896. A history could not be obtained, as the patient spoke only Polish. He appeared about 25 years of age, strong and well nourished. There were two healed wounds covered with a dry scab on the index and middle fingers of the left hand. The fingers and entire arm presented no evidence of inflammation. The axilla was soft and not tender. The skin over the upper part of the chest was slightly red and (Edematous. The greater pectoral muscle was more prominent, and beneath it there seemed to be a fluctuating swelling. The aspirating needle withdrew some thin purulent material. Examination of coverslips demonstrated polymorjAous leucocytes and cocci in short and long chains. Thei'ectal temperature registered 104°, pulse 80, respiration 24.

An incision was made through the skin and through the greater pectoral muscle in the direction of its fibres, opening a large localized abscess.

Cultures from this abscess and from the blood taken from a vein in the opposite forearm contained in 48 hours numerous colonies of streptococci. Two days later blood cultures also showed colonies of streptococcus ; three observations after the fifth day were negative.

The patient had fever for IG days, the rise of temperature being from 101° to 104° and frequently 105°. Recovery followed. The wound healed and there was no loss of function of the muscles.

The early diagnosis of fluctuation, due to fluid beneath a large muscle, is a very difficult one. The muscle itself, when relaxed, gives to the fingers a sensation of fluctuation. For this reason in this case the aspirating needle was used to confirm the diagnosis of a deep abscess.

Omo II. — The second case presented to-night is of interest becauseof the very high temperature — 106.5° rectal — which was associated with the beginning of an attack of erysipelas of the neck and face. The patient recovered. Five weeks before the attack of erysipelas a large mass of suppurating and adherent


glands had been removed from the neck. The wound had healed with the exception of the small granulating area. The patient had been walking about for two or three weeks, with no rise of temperature. There were no cases of erysipelas in the wards. The attack began with a chill, and a temperature of 106.5°, taken one hour after the chill. Coverslips made from the granulating area showed cocci in long chains. No erythema could be seen. The patient was a colored man and only very deep redness can be made out. He was immediately transferred to the isolating ward and given a bath for 30 minutes, the temperature of the water being 70° F. The fever was reduced to 103° and did not rise above 104.6° afterwards. Later the skin of the neck and face became very red and oedematous; no abscesses formed. Coverslip and ciilture demonstrated streptococcus. Two blood cultures were negative.

The only treatment followed was cold sponging and local application of cold cloths to the neck and face.

During the last two years we have made a great number of coverslip examinations from the surfaces of granulating wounds, and also from cases in which there has been an attack of erysipelas. In almost every case in which there has been an infection of tlie streptococcus of erysipelas we have demonstrated in the coverslips taken from the granulating wound cocci in short and long chains, and in every case cultures and the clinical course have demonstrated the infection to have been due to the streptococcus. In thercoverslips from healthy granulating wounds we have never found .' r "occi in chains. But only a few were studied also by cultun > i '•(> few, only

staphylococci grew. These observations \\^" \i-w\ \.t.\\' llic early diagnosis of erysipelas.

Death from streptococcus infection has Dei,n a verv rare event. These organisms do not seem to have with us uL. virulence which in former years they must have had. In reading Billroth's and others of the older surgeries one is impressed with the large death rate from erysipelas and streptococcus infection of wounds.

There have been two interesting observations, in both of which, although the skin over a large area, including the lines of incision, was the seat of a very intense erysipelas, yet the healing of the wound was not interfered with. Both patients recovered.

The first patient was an old man, from whom a V-shaped piece had been removed from the lower lip for epithelioma, and the entire chain of glands beneath both sides of the jaw excised. Both wounds were closed. An attack of erysipelas began on the second day, starting from the lip and extending over the entire face and neck. The lines of incision healed per primani, and there was no deep suppuration.

The second case was a boy, from whom a large mass of inflamed glands had been excised from the axilla. The mass was very large and very adherent to the vein. Both pectoral muscles were divided to aid in the. complete removal. During the dissection along the vein a small abscess cavity was opened, infecting the wound. The wound was irrigated with j-jViy bichloride, the pectoral muscles sutured and the skin closed. Cultures from the glands demonstrated strejitococcus. The


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[No. 72.


adenitis followed an infection of the' finger. 24 hours after the operation an attack of erysipelas set in, beginning in the line of the incision. The erythema covered part of the chest and neclv. Coverslips and cultures from a small opening in the line of the incision demonstrated streptococci. The patient recovered ; there was no suppuration of the closed wound ; there was no impairment of the use of the pectoral muscles.

These two cases demonstrate that the skin over a closed wound may be the seat of erysipelas and yet the healing of the deep wound may not be interfered with.

Dr. Flexner. — The case reported by Dr. Bloodgood is of much interest from a theoretical as tvell as a practical standpoint. Experiments upon animals have led us to consider that the invasion of the blood by pathogenic bacteria, capable of setting up actual septicaemias, takes place a short time only before death, and in the great majority of instances, if not in all, presages a fatal termination. Flugge pointed out that in anthrax infection in the rabbit the bactericidal effect of the blood-serum is lost before this micro-organism is found in the larger blood-vessels. In pueumococcus infection in the same animal the blood invasion occurs a short time only before death.

Now since cultures are so readily made from the circulating blood of human beings we may expect important contributions to our knowledge of the occurrence of pathogenic bacteria in this fluid, and also of the capacity of the human organism to resist and overcome these parasites when they have once entered the blood and perhaps even increased there.

The elimination of the primary focus of infection must be of the greatest importance in these cases, for it is certainly probable thut from this site where the parasites are rapidly increasing not a single infection occurs, but a succession of invasions of the blood takes place. Perhaps after all, where recovery occurs, the power of the body fluids and cells to dispose of considerable numbers of the pyogenic cocci is not actually lost, and those present in the blood have entered from without and temporarily, at least, have not increased in the circulating blood. Under these circumstances the removal of the primary focus of infection before the bactericidal effect is lost, would in all probability determine the issue of the case.

We are told by Baumgarteu and by Stern that one does not meet in human beings examples of septicremia comparable to those seen in some of the lower animals. I think there is reason to doubt these statements, for we have seen at autopsy cases of streptococcus and staphylococcus infection in which the blood was crowded with the organisms and wide-spread capillary thrombi of cocci existed in the internal organs.

Much discrepancy has been noted by writers upon the subject of the virulence of streptococci obtained from severe infectious processes in human beings. The results of the cultivation experiments of Marmorek seem to give the explanation of the variations observed. It is an old observation that a minute quantity of the fluid containing streptococci from the inflamed peritoneum might show great virulence and set up a severe and perhaps fatal infection, while the cultures from this source may be quite without pathogenic effects. Marmorek has made it probable that the difference depends upon


the unfitness of artificial culture media for preserving the virulence of the streptococcus pyogenes. Through the use of human blood serum as a medium of cultivation he succeeded not alone in retaining the virulence of these micro-organisms for a time, but actually of increasing it, by successive passages through the bodies of animals and recultivation, to a remarkable degree. Finally it is no criterion of the vitality of streptococcei to test them upon artificial media, for Marmorek has also shown that cultures apparently dead are still capable of growth when transplanted to his blood serum medium.

Ophtlialmoplefjia Externa.— Dr. H. Woods.

On taking charge of the Presbyterian Eye, Ear and Throat Hospital in September, 1895, I found in the ward, D. 0., 73 years of age, under treatment for corneal ulcer of the left eye. This, I was told by my friend and associate. Dr. F. M. Ghisolm, had followed an operation performed by him during his service in August, for complete left ptosis. A slight iritis developed after he came under my care, but from this as well as from the ulcer he made a good recovery. Corneal ojjacity is peripheral, and a few pigment pin-point stains are on the capsule. The right eye is centrally blind from choroidal atrophy, but has eccentric vision. It was discovered during this visit to the Hospital that the extrinsic eye muscles were paralyzed. The paralysis is not absolute, for both eyes can move perceptibly up, down and laterally. He left the Hospital before the corneal ulcer was completely healed, returning in March, 189G. He gives the following history:

Prior to 1801, when he enlisted in the Federal army, he had good sight. He claims to have undergone medical examination at Williamsport, Pa., before enlistment. This is important, for the " Surgeon's Certificate of Disability for Discharge," which I have obtained from Washington, is as follows: "The injury to the eyes of said soldier was caused by over-exertion in lifting heavy timber in the year 1857." Signed by Captain.

The Brigade Surgeon's certificate is : " This is a case of ptosis; but having a suspicion that the loss of vision is feigned, the subject is respectfully referred to the Medical Director for decision." The discharge was approved by the Board of Inspectors. This bears date of February 15, 1862. It appears, then, that the only testimony of trouble before enlistment comes from the captain of his company. Against this there are the patient's statement, the nature of the trouble as given by the Brigade Surgeon — -ptosis, and the somewhat weighty improbability of a man with double ptosis being enlisted.

To return to the history, as given by the patient. In November, 1861, while marching rapidly early in the morning, he fell, with a number of others, into a stream and was thoroughly drenched. Within an hour afterwards both eyes were closed. He was unable to raise his lids. He was sent to camp, and discharged the following year, as recorded. For several months he was blind, being able to see only by elevating the upper lid. Then some power slowly returned in the right lid. In 1867, Dr. Brown, of Addison, New York, removed a piece of skin from the riglit upper lid, adding


March, 1897.]


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greatly to liis comfort. From '67 to '95 he relied entirely iipou his right eye. Left ptosis remained complete. His occupation was gardeuiug. lu the early summer of '95 he noticed occasional floating specks before the right eye ; " frequently tried to brush away a fly."

One Monday morning in July he went to his gardening as usual, but soon found he could not see clearly, also that he "put his foot where he did not mean to, on, instead of between his cabbage rows." He held open the left eye to make his way back to the house, and early in August appeared at the Presbyterian Eye and Ear Hospital. A central choroiditis explained his right blindness. Dr. Chisolm operated as stated, to give him use of his left eye, upon which he now depends. The muscular condition, noted partially in (September, and more accurately in March, is as follows : Complete ptosis both sides. The operation on the left upjier lid has given a larger palpebral opening than that on the right. The right orbicularis is constantly twitching. Though he can close each eye and wink, that power in the orbiculares is diminished is shown by failure to close the lids tightly — as in blepharospasm, for instance — or to resist in the slightest degree forcible separation of the lids. He seems to retain control of the paljiebral and to have lost use of the orbital portion of the orbicularis. The eyes themselves are fixed, the right diverging slightly out and up. When told to look in different directions he turns his head. There is, however, such slight motion up, down and laterally as already mentioned. Convergence and, so far as can be ascertained, rotation by the obliques are lost. The intrinsic eye muscles are spared. Each pupil responds to light, possibly a little tardily in contraction to moderate light, dilates under cocaine and contracts to eserine. He reads ordinary print with a convex 3.5 D, and has with this a range of 2 or 3 inches. Distant vision in the left eye is y^^, owing, most probably, to pigment deposit on lens capsule. Each paj)illa is normal. In the right eye there is central choroidal atrophy. Form field, barring the right central scotoma, is normal. This scotoma extends 10 degrees in all directions, except downwards, where it is 20 degrees.

When C. returned to the Hospital in March he asked, "Why, when I want to put my foot on a place, do I put it where it ain't?" This question is at the bottom of some curious things for which an explanation is not easy. With both eyes open he will reach to the right of an object held in front of him, with his right hand, but grasp it correctly with his left. Similarly, he will put his right foot to the right of an object, a narrow ruler, for instance, upon which he is told to step, but place his left foot correctly. With the right eye closed he grasps correctly with either hand and places each foot correctly. If the left eye be closed he either feels for the object or, turning his head for eccentric fixation, reaches it. When he leans far over, getting close to the niler on the floor, he places his right foot at times correctly. He did not know his eye muscles were affected until told so at the Hospital last September. I asked my friend. Dr. Thomas, to examine the patient, and his report is appended:

"The frontalis muscles are in constant over-action and possess a normal amount of power. The corrugator supercillii


acts with a fair amount of power on both sides. The right orbicularis palpebrarum is the seat of frequent momentary contractions ; at intervals there can be seen in the left lower eyelid muscular contractions which are synchronous with these. The right orbiculai-is is able to close the eye completely, but it is much weaker than normal, as the patient is unable to resist even slight traction on either eyelid. The left orbicularis, weaker than the right, is just strong enongh to close the eye. The other facial muscles act well and with equal force on the two sides.

" The muscles of mastication and those of the tongue act normally. No disturbance of sensation can be discovered in the face.

" The electrical examination shows that the facial nerve on both sides can be stimulated with a faradic current of moderate strength, the orbicularis palpebrarum taking part in the muscular contraction.

"To direct stimulation the orbicularis on both sides responds to the faradic and galvanic currents, but stronger currents must be used than is usual. The response to the galvanic current is sharp and quick. The right orbicularis responds to currents of less intensity than the left. The other facial muscles act normally.

"The involvement of the orbicularis in association with ophthalmoplegia is of great interest, bearing out, as it does, Mendel's view that this muscle receives nerve-fibres from the nucleus of the third and fourth nerves. Birdsall and Hughlings-Jackson have reported similar cases.

[Signed] H. M. Thomas."

Dr. Theobald. — I do not know of a case tliat I have met with in which there was a paralysis of the orbicularis associated with general ophthalmoplegia. I have, however, met with several instances where all of the external muscles of both eyes were involved. I have also met with cases where all of the recti muscles were involved without implication of the oblique muscles. These cases were almost invariably of specific origin.

A Simple Contrivance for Effecting Pneumatic Massage of tlie Tympanal Membrane and Ossicles.— Dr. Theobald.

Any apparatus which proves of use in dealing with affections of the middle ear is likely to be of especial value, for the reason that middle ear troubles are very common. Probably more than 75 per cent, of all the cases of impaired hearing which we encounter are due to changes in the middle ear. Deafness from nerve lesions is comparatively rare, forming not more than 2 or 3 per cent, of the cases of deafness met with in hospital and dispensary practice. Middle ear deafness is commonly the result of a chronic catarrhal inflammation, or perhaps of an acute inflammation of a higher grade, with plastic exudation. The changes are of one or two characters; either we have a sclerosis of the articulation of the ossicles, especially of the stapes, where it articulates in the oval window ; or there is a formation of bands which attach one ossicle to another, or one ossicle to some part of the wall of the tympanic cavity, in such a way as to interfere with the movement of the ossicles in response to the sound waves. Various devices


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[No. 72.


have been made to overcome this rigidity or aukylosis of the delicate joints in the middle ear, and especially contrivances which have been described as effecting one form or another of massage. There have been several distinct kinds of massage of the ossicles and tynipaniini proposed. One is a direct form of massage, pressure massage. The original way in which this was accomplished was by pressure with a delicate probe upon some portion of the malleus, either upon the short or the long process. This produced a certain amount of motion throughout the ossicular chain and in the various joints. More recently electricity has been brought into jjlay in this direction, and one contrivance has been made by which the rapid motion obtainable from the electric current has been made use of to operate a delicate probe which has a spiral spring in it. This probe strikes repeated delicate blows upon the long or short process of the malleus. Another form of massage is designated as phonetic massage ; that is, sound is used to produce vibrations of the tympanic membrane and ossicles. Several contrivances have been used for this purpose. One form is the phonograph, in which the sound is carried by tubes to the ear. The phonograph cylinders are cut deeply, so that the sounds are especially sharp and distinct and produce greater mechanical effect.

Pneumatic massage obtained by means of variations in the pressure of the air in the auditory canal is a third method. As far back as 1771 this method of influencing the movement of the ossicles was suggested by Cleland. More recently, this early experiment having been lost sight of. Moos suggested it again. There are several ways in which this has been brought about. The use of the Politzer bag is one method. This forces out the tympanic membrane and moves the delicate joints of the ossicular chain. Another method is with Siegel's pneumatic speculum, by means of which the air in the auditory canal is alternately condensed and rarefied, and thus the tympanal membrane is moved back and forth. One objection to this and other similar contrivances is that the jiower exerted is too great, and unless they are used with much care, serious injury may be done. If the pressure either outward or inward is too great there is a possibility of rupture of the tympanic membrane, or hemorrhage may be jiroduced. I do not think that marked beneficial results can be claimed for any of these forms of massage, although undoubtedly in some instances they do good, and it is a method which every one should be able to employ in treating ear maladies. One or two things are essential in order that this method may be employed with the hope of doing good. In the first place, the nature of the contrivance should be such that harm is not likely to be done in its use, as is the case when large air bulbs are used. If one uses a large air bag like the Politzer bag, a very little pressure of the hand will produce a marked variation in the density of the air in the auditory canal. Such a contrivance as this it is out of the question to place in the hands of a patient. It is essential in these cases, which are almost always chronic, that the massage should be of such a character that the patient may be able himself to practice it, and this is what I had in mind in contriving this apparatus. The bulb should be so small that one can do no harm in using it. This instrument consists simply of the rubber bulb taken from an eye-dropjier,


placed upon a small hard rubber tube with a bulbous tip which fits tightly into the auditory canal, rendering it air tight. This can be used in two ways. In the first place, we can compress the bulb before inserting the tube in the ear, and then by letting go the small bulb we rarefy the air and draw the membrane out. On the other hand, we can place it in the ear tiglitly, and then by squeezing the little bulb we drive the drum membrane in. I direct my patients to reverse the action, at one time drawing the membrane out, at another pressing it in. Ilynson & Westcott have made these instruments for me of several different sizes, so that they will fit any ear.

Excision of a Parovarian Cyst witliont Removal of its Ovary or Tube.— Dr. Kblly.

I will speak this evening of a new step in the conservative treatment of the uterus and its appendages. Before speaking of the subject in hand, I will call attention to a few of the advances we have made in the past few years. We no longer think of taking out the ovaries for enlarged Graafian follicles. If such a follicle is found it is simply exsected and the ovaries sewed up; small follicles maybe punctured or treated by the cautery as recommended by Pozzi. Cysts of the corpus luteum may be treated in like manner.

These parovarian cysts (showing pictures) were all removed several years ago and treated radically by i-emoviug the tube and ovary as well. I would not treat them so now, as I shall shortly demonstrate. This conservatism extends also to the tubes. Prof. Martin of Berlin has succeeded in saving quite a number of diseased tubes without hurt to the patient and with full restoration to health. Last year I removed from a patient the tube' of one side and the ovary of the other, laid the ovary and the tube both down behind the uterus, and the lady, who is the wife of a physician, returned home and has since borne a child. Still graver affections also come under this conservative treatment. We have for some years past been treating accumulations of pus behind the uterus, by puncture, evacuation and simple drainage through the vaginal outlet, even when the pus is in both tubes and ovaries. This has been followed by a large number of perfect recoveries. Occasionally the patient will return and require another drainage operation ; the ovaries and tubes can be removed later with greater ease, if necessary. In cases of myomatous uteri I have removed as many as 9 myoma through 7 incisions and had perfect recovery and perfect relief follow. I demonstrated last week the possibility of exsecting as many as 16 myoma without opening the uterine cavity.

The particular new subject along these lines of which I wish to speak to-night is simpler than many of the steps already taken, from a surgical standpoint, and yet, so far as I know, it is novel and is one of the last to follow in the line of conservative effort: that is, the removal of certain parovarian cysts without sacrifice of the correlated ovary and tube. To show how simply this may be done, I pass around specimens of such cysts in which the tubes and ovaries were also removed. It is evident at a glance how simple a matter it would be to remove these parovarian tumors and then to sew up the incision area after the enucleation. The first case I operated upon conservatively was in November, '95. The


March, 1897.]


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patient was suffering a great deal with pelvic pain, and the doctor who had examined her felt two tumors in the pelvis and sent her to me with the statement that both ovaries would have to be removed. I found one cyst the size of a hen's egg before the uterus and another behind it. On opening the abdomen the cysts were both found to be parovarian; they were in the mesosalpinx, and the ovaries were displaced and separated from the tubes by them. I treated the tumors in two different ways, both giving the same result. In oue, after ligating the larger vessels a little distance from the tumor, I made an incision through the jjeritoueum where the vessels were fewest, and I easily shelled the tumor out of its bed and then sewed up the peritoneum with a continuous catgut suture. On the other side I excised a portion of the redundant peritoneum while the circulation was controlled by the finger of an assistant, turned the tumor out and stitched up the wound with catgut. The uterus which had lain in retroflexion was suspended by two silk sutures by my method. Both ovaries were thus left intact. The patient made a perfect recovery, has kept her functions, is normal and regular, and in good health. This, I think, with the other circumstances cited, is one of the last and not least important of our gynecological advances, of particular importance to young women and women in the prime of life.

Dr. Welch. — How large a proportion of these cases are eligible to this treatment? As one who sees the ordinary parovarian cysts after operation and at autopsy, it is not clear to me how they can be taken out without removing at least the tube. The cyst grows between the layers of the broad ligament (there is no mesosalpinx, the layers are all separated), and the cyst comes i;p against the Fallopian tube, and, in some cases at least, it would be impossible to dissect it from the tube. The ovary may be quite well preserved, but not unfrequently it is sj^read out over the surface of the cyst. I sup2)ose Dr. Kelly does not mean that the conservative operation can be done in tumors of that kind, but refers to tumors of only moderate size.

Dr. Kelly. — Yes, the operation is most easily applicable to tumors of medium size, but can also be applied to many of the larger ones. In all of those cases where the cyst is thin walled and more or less pellucid, by slitting the capsule and evacuating the tumor, it can then be drawn out from under the tube, even though the tube is flattened out as shown in this specimen which I pass around. I would exclude from such treatment all those cases in which papillary elements are visible.

Meeting of November 16, 1896.

Dr. TnAVEE in the Chair.

On the Pathology of Heematozoan Infections in Birds.— W.

G. MAcC'ALLUiV.

Peculiar advantages are offered by the tissues of birds for the study of hsematozoan infections, in that all stages and degrees of infection may be examined without any difficulty in obtaining the materials. The material for the following observations was furnished in the tissues of the birds whose blood has just been described, and often the extent of the


changes in the organs was surprising when contrasted with the apparently good health of the birds.

Kruse, Danilewsky and Labbe have noted in a general way pigmentation of the spleen, liver and bone-marrow, and have observed the enclosure of pigment masses in niakrophages in the capillaries of these organs. There is nowhere any mention of inequality in the distribution of the parasites as such in the organs of the body, such as has been described in malaria in the human body giving rise to corresponding symptoms ; in no communication on the subject have any symptoms been described occurring in infected birds such as to lead to the suspicion of a definitely localized invasion of organisms, nor have we been able to demonstrate in any of our birds such localization or such symptoms.

As to the effects of the products of the organisms on the tissues we cannot speak definitely. No mention is made in the literature of such effects, but we have observed various degenerated areas in liver and spleen, some of which are explained by concurrent bacterial infections, others apparently by the presence of peculiar ovoid bodies with central nuclear particle, which occur in the cells in groups resembling a segmenting organism, while a third variety is still unexplained.

The invasion of the parasite into the red corpuscle appears to be followed eventually by the breaking down of the corpuscle, from the altered hasmoglobin of which there results a straw-colored pigment. This is seen deposited in considerable masses together with the dark pigment formed directly by the parasite. The process of storing these pigments away from the blood stream is similar to that observed in man. The phagocytic cells of the blood are apparently the cells which we have named Kubinophilcs,* and in a lesser degree the eosiuophiles, although neither of these is very active in engulfing extruded organisms and pigment. Indeed we have never observed in a fresh slide of blood a single pigmented leucocyte, and, although they have been observed to engulf parasites, they have also been seen to attack the jiarasite, and after disintegrating it to a great extent, to leave the pigment and wander away. Labbe denies the existence of true phagocytosis, and considers the presence of infected corpuscles within leucocytes to a certain extent accidental.

Danilewsky and Sakharoff describe the occurrence of organisms within leucocytes where they undergo part of their development, but we have observed nothing analogous to this. The hemopoietic organs are of especial interest, and it is iu these that the pigmentation has been noted by European writers. The spleen at autopsy is generally somewhat blackened, and on section shows a network of black lines corresponding to the pulp bands where the bulk of the pigment is deposited. This pigment occurs either iu large, clear or palely staining niakrophages with single or double vesicular nucleus, or iu the swollen endothelial cells of the capillaries. In the spleen the large cndothelioid cells of the pulp take on the character of makrophages, but iu the liver the pigmented


  • Cells with whetstone-shaped granules wliicli take on an eosin

stain after long standing, but are colored nmcli more readily by acid fuchsin.


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cells are all intracapillary. These large cells are seen to contain masses of yellow pigment, masses of black pigment, scattered grains of black pigment, infected corpuscles, shrunken parasites which at first sight look like small masses of yellow pigment, and debris of broken-down red corpuscles and parasites. The liver shows a less marked pigmentation than the spleen, but the character of the deposit is similar. In the bone-marrow which European authors have found so deeply pigmented we have found almost no pigment and but few organisms. The brain, heart, lungs, kidneys, stomach, intestine, pancreas, thyroid and voluntary muscle show no changes and only the presence of organisms which would be expected from the rich blood supply of these organs.

On the Hscinocytozoa of Birds.— Eugene L. Opie.

The presence of parasites closely resembling the malarial organisms of man, within the red corpuscles of birds, is well known. These organisms have been found in varying abundance in the blood of birds of many parts of Europe, but up to the present time they have not apparently been studied in this country. At the suggestion of Dr. Thayer these intracorpuscular parasites have been studied in the Clinical Laboratory of the Hospital. During the mouths of June, July, August and September one hundred and twenty-five birds have been examined. Of these the greater number, one hundred, were from the neighborhood of Baltimore. Of eighty English sparrows (Passer domesticus) from this locality, nine were infected with intracorpuscular parasites; of twelve red wing blackbirds (Agelaius phceniceus) six were infected; two swamp sparrows (Melospiza georgiaua) and one song sparrow (Melospiza fasciata) contained organisms. Of twenty-five birds, including a variety of species from the neighborhood of Dunnville, near Toronto, Ontario, five were similarly infected, namely, one great horned owl (Bubo virginianus) and four crows (Corvus americanus).

Although the small number of the infected birds makes it impossible to arrive at any genera] conclusions as to the particular species prone to infection or the local conditions favoring infection, a fairly accurate idea of the character of the parasites present in these localities can be obtained. The organisms found resemble the malarial parasites in that they undergo their whole development within the red corpuscle at the expense of its substance, transforming its hemoglobin into chai'acteristic pigment granules. Like the malarial organism they reproduce by segmentation, and the young parasites come to occupy other red corpuscles. Unlike the malarial organisms the younger parasites do not exhibit active amoeboid movements. Unlike the tertian and (juartan malarial organisms they show no cyclic development in great groups of which every organism is in approximately the same phase of development, and hence the length of their cycle of growth cannot be readily determined.

Two types of organism, similar to those observed in European birds, are found. Characteristic of each type is the morphology of the full-grown organism. In the one group an irregularly shaped body, approximately round or polygonal, occupies one end of the nucleated red corpuscle; the nucleus has been displaced into a transverse position in the opposite


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

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

Dr. OsLER. — The subject which these gentlemen have presented so clearly has a very definite bearing upon the life history of the malarial parasite in man, as it is quite possible that we may get a clue to the outside history of the parasites by a study of the forms in birds. In 18S(!, I think, just as I was busily engaged for the first time in the study of the malarial l^arasite, Mr. MacCallura's father. Dr. MacCallum, of Dunnville, Ontario, sent to the Biological Laboratory in Toronto a goose which was supposed to have malaria. I was extremely skejjtical about it, as I knew nothing at that time about the parasites in birds, but to my astonishment there were in large numbers the pigmented intracellular organisms, just such as Mr. Opie has demonstrated to. us to-night. They were present in very large numbers, and the spleen of the bird was also large and deeply pigmented.

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


March, 1897.]

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

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

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

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

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


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

Dr. Thayer. — Let me also congratulate Mr. Opie and Mr. MacCallum upon their careful piece of work.

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

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

There are, of course, many more points to be studied with regard to the morphological and biological characteristics of these avian hasmatozoa. In these present observations, for instance, no idea has been formed with regard to the length of the cycle of existence of the parasites. Danilevsky believes that he has been able to distinguish an acute and a chronic form, while Oelli divided the parasites of birds into three forms with cycles of existence corresponding to the quartan, tertian, and sestivo-autumnal parasites. Here, however, there has as yet been nothing to point out the exact length of the cycle of existence of each generation of parasites.

Further, it would be advisable to make careful measurements and observations of the temperature in infected birds, observations which, to be sure, have been made by other authors, but with regard to which there is as yet a lack of agreement.

It is also, I think, very important that the intimate structure of the parasites of birds' blood should be carefully followed out; this can be done with much greater facility than in the human being, inasmuch as specimens of tissues can be instantly obtained at any time desired.

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

With regard to the remark of Prof. Osier concerning the possibility that a human being may harbor the malarial parasites in an active condition for a considerable time without showing distinct clinical symptoms, I must say that the more of the disease one sees, the more reasonable seems the possibility that this condition may exist with relative frequency. In many cases of tertian fever after insufficient doses of quinine, or during attempts at spontaneous recovery, a few parasites may be found in the blood for very con


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

Afeeting of December 7, 1896. Dr. Thayek in the Chair.

Discnssion of Dr. Rlocli's Paper on "Agglutination of Typhoid Bacilli, etc." [See Bulletin, Nos. 68-69.]

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

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


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

Dr. Reed. — I have had no experience with the serum test. I have made use, however, of Johnson's modification of Widal's method, and, so far, have examined the blood in thirty-four supposed cases of typhoid fever. AVhen I began with this method — that is, the use of the dried blood — Johnson's paper had not been published, so I had to feel my way, as it were. I began by examining a small quantity of the blood dissolved in distilled water, placing a drop on a cover-slip and then inoculating it with an agar culture. I found the method worked fairly well in certain drops, while in others I had introduced too many bacilli, and, while many clumped, there were highly motile organisms to be seen after the lapse of two or three hours. I had just fixed upon a bouillon culture as the proper medium when Johnson's paper ajjpeared, and being convinced then that I was on the right road, I reviewed my cases with this method. I then had distinct clumping with arrest of motility in cases in which I did not get it when using the solid culture. So far I have examined the blood of thirty-four cases, twenty-eight of which have given me a positive reaction, that is, loss of motility and agglutination of the bacilli. It will be seen that I have met with success in a greater percentage of my cases than Dr. Block has reported to-night. Six cases failed to give the reaction. In two of these I found the Kstivo-autumnal parasite. A third case that did not give the reaction was considered to be a severe case of typhoid fever in the Freedman's Hospital. The patient had tympanites and high temperature. I examined the blood with negative result. The patient died the following day, and it M'as found that there was general peritonitis, having its origin in the appendix. The fourth case was a child who manifested distinct brain symptoms, and the attending physician had not been certain that it was a case of typhoid. Two other cases, one in the third and one in the sixth week, failed to give the reaction. AVhether they were i-eal cases of tyj)hoid I do not know. The earliest case in which I have examined the blood was that of a soldier at Fort Myer. Soldiers are generally put to bed early, and the reaction here was quite distinct on the fifth day After I had obtained a positive reaction in twenty-two cases, the particular bouillon that I was using — an old glucose bouillon (because there was no other in the laboratory at the time) — became exhausted and I began to use ordinary bouillon. I tried this latter in two new cases from the Freedman's Hospital, and was surprised to find prompt arrest of motility, but no clumping. For the sake of comparison I took the blood of an undoubted typhoid case and tested it with plain bouillon, and had no clumping until more than au hour had passed. I then tried some of my old glucose bouillon cultures, and to my surprise all three cases gave me good agglutination within fifteen or twenty minutes. I then began to examine my hanging drops, in plain and glucose bouillon, at the end of twenty-four hours, to see if I could distinguish any difference between them, aud found that from the margins of the


March, 189^]

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

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

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


NOTES ON NEW BOOKS.

A Treatise on Surgery, by American Authors. Edited by Koswell Park, A. M., M. D., Professor of Surgery in the Medical Department of the University of Buffalo, etc., etc. Vol. I. General Surgery and Surgical Pathology. 799 pp., 356 engravings, 21 jilates in colors. Lea Brothers & Co., Philadelphia and New Tork, 1890.

It was not one of the lightest proofs of the true inspiration of the sacred writers that they have handed down to us such nuggets of truth for all ages as the familiar "Much study is a weariness of the flesh, and of making many books there is no end."

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


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

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

A somewhat novel feature is the introduction of a chapter upon the pathology of the blood, which, however, abundantly vindicates its right to appear in a surgical treatise, as some excellent diagnostic and prognostic tests are based upon it.

Another instance of the breadth of view which pervades the whole treatment of the subject is the careful discussion of the many factors which, by lowering the resistance of the tissues, may predispose to an attack of surgical infection. With a candor which is rare in the operating surgeon, full credit is given to the extraordinary power on thepartof both the leucocytes and fixed cells of tlie body to ward off infections and to rei>el invaders of every description ; and the story of the " battle of the cells " is given in the most graphic manner. This view of the matter is particularly well developed in what is, to our view, one of the most original and valuable chapters of the volume, that upon "Auto-Infection in Surgica. Patients." Here the author impresses with convincing clearness and abundant illustration the too-little recogni/.ed truth that any secretion of the body tissues may become a poi.son to the entire system if its elimination is in any way interfered with, notonly medi


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

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

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

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

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

The chapters upon Minor Surgery are clear, concise and well illustrated.

The discussion of Cysts and Tumors is comprehensive and thoroughly up to date, the classification (based largely upon that of Sutton) being particularly commendable for its scientific simplicity and ease of comprehension. Growths are regarded as aberrant or "rebellious" groups of living tissue-cells differing mainly from each other in the particular tissues which they reproduce or imitate and in the perfection of their imitation. We would prefer, however, to transfer epithelioma from the " Tumors of Epithelial Type" to those of " Glandular-tissue Type," as its deadly qualities seem to be solely due to its power of " dipping down" or burrowing into the tissues, in its attempts to imitate the sebaceous, sweat or mucous gland of the surface where it originates.

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


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

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

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

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

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

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

Our only general criticism takes the form of a regret that the editor, in some of his chapters, felt himself so much under the necessity of condensing and systematizing and could not give his thought fuller and freer play. But a chapter or volume which fails by being too short is not far from a decided success, and we have Ycl. II tc look forward to for consolation. W. H.

A Manual of Syphilis and the Venereal Diseases. By J.4.mes Nevi.vs Hyde, A.M., M.D., and Frank H. Montgomery, M. D. 1 vol., 618 pages. {Philadelphia: W. B. Saunders, 1895.)

For several years there has existed the need of a condensed and at the same time sufiiciently comprehensive book on venereal diseases, which would enable medical students and practitioners, at a moderate cost, to obtain the latest opinions as to syphilis, and also to keep up with the advancing bacteriological work which is being done in genitourinary diseases.

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

The chapters on Syphilis are written in a most attractive style,


March, 1897.

57


and condensed so skilfully as to make a thorough review of the whole subject in a comparatively few pages. In their discussion of the treatment of syphilis the authors express some views as regards the inadvisability of using opium- in combination with mercury which may not obtain the endorsement of the profession.

The chapter on Chancroid closely follows the articles on this subject in Morrow's System of Genito-Urinary Diseases, and in addition furnishes a valuable table, in parallel columns, for the differential diagnosis of chancre and chancroid.

Cystitis and pyelitis are not given the prominence or attention that these comparatively frequent diseases merit, and no mention is made of the value of the cystoscope as a means of diagnosis in vesical and renal diseases.

The articles on Urethritis Acute and Chronic (including Endoscopy) are especially well written, and give a thorough and scientific presentation of the aubject.

The aim of the authors has been a compilation of the most recent literature and thought on " Syphilis and the Venereal Diseases," rather than to put forward any original work or ideas of their own.

A. B. G.

Transactions of the American Gynecological Society. Vol. 21, for the year 1896. {Philadelphia : Wm. J. Bornan, Printer, 1896.)

The Society is to be congratulated upon the almost unanimous tendency to conservatism displayed in its papers and their discussion, which gives a tone of advance, not so prominent in past meetings.

It is not surprising that the paper by Segond, of Paris, on the radical treatment of uterine myomata and inflammatory disease of the tubes and ovaries by vaginal hysterectomy gave rise to a most vigorous discussion and met with many pertinent objections ; the consensus of opinion of the American gynecologists seeming strongly against its unqualified acceptance.

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

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

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

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


a simple extension of the disease into tissue which appears to the eye and touch unsuspicious. Not until these precautions are taken and the results put into statistical tables will one be able to judge fairly of the remote results of operative treatment of cancer of the uterus. The statistics of to-day are absolutely valueless. Winter, in his most excellent article on the question of recurrences (Zeitschiift fiir Gynec. und Geburt., Band XXVII, Heft 1), apparently depends entirely upon the macroscopic appearance to define the limitsof the disease. One who has studied these tumors microscopically can testify to the utter impossibility of fixing the outermost limits of the disease by the eye or touch. On this account one cannot accept Dr. Byrne's conclusion as to the value of his method of performing vaginal hysterectomy by the cautery. Df. Halsted has proved, by the astonishing results of his operation for the removal of the breast for cancer, that a wide dissection and removal of the glands are demanded ; and the same is true in cancer of the uterus, which can only be successfully removed by the abdominal operation. W. W. R.

Transactions of the Chicago Pathological Society from October,

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

Association Press, 1896.)

This little book contains the transactions of a society which is not wholly pathological, and many of the articles are of medical rather than of pathological interest. The pathological papers, however, are well done, as, for example, "The Contribution to the Study of Malignant Growths in the Lower Animals," by Dr. Field, upon which the paper of Dr. Livingood in a recent Bulletin is an interesting commentary ; the report of cases of Leukemia and of Pernicious Anemia, and the paper on Embolic Abscesses due to the Micrococcus Lanceolatus. The papers on Appendicitis, Nephrorrhaphj' for Movable Kidney and Tubal Pregnancy, although not strictly pathological, are of general interest to medical men.

It is to be regretted that the volume is not uniformly printed, which will not seem strange when it is stated that the matter appeared first in the current numbers of a medical journal. If such a system of printing is continued in future, it would add materially to the appearance of subsequent volumes to have successive reports set up in a uniform type. The book deserves a better mechanical appearance.

Medical and Surgical Reports of the Boston City Hospital. Seventh Series. By George B. Shattuck, M. D., W. T. Councilm.\n, M. D., and Herbert L. Brewell, M. D. (Boston: Puhlished by the Tmstees, 1896.)

It is pleasant to know that the issue of reports by the Boston City Hospital has been resumed, and the volume before us is a worthy successor of those which have preceded. A marked feature of the book is the thoroughness of its report on pathological work. This is notably shown in the valuable study of the Lesions in Selected Autopsies by Prof. Councilman and Dr. Mallory, also in Adeno-Carcinoma of the Pancreas, by Dr. Wright. The preliminary essay on Surgical Morals, by Prof. Cheever, is a new departure in hospital reports and one which can be commended. The paper also on Methods of Routine Treatment in the Surgical Outpatient Department is of great value. Altogether the seventh series is worthy of high praise.

Annual Report of the Supervising General of the Marine Hospital Service of the United States for 1894. [Washington: Oovernment Printing Office, 1895.)

In addition to routine reports concerning the oper.itions of the Marine Hospital Service, and full accounts of the various hospitals and quarantine stations under its control, this volume contains much that is interesting to the medical man. Among these may be mentioned detailed histories of the cholera and yellow fever epidemics of 1894, and Prof. Kitasato's Preliminary Notice of the Bubonic Plague in Hongkong, China.

[No. 72.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


THE JOHNS HOPKINS HOSPITAL REPORTS.

Volume L 423 pages, 99 plates.

Report in Pathology,

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

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

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

Mall, M. D.

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

T. C. Gilchrist, JI. D., and Emmet Rixford, M. D. A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

Parasites found in Various Lesions of the Skin, etc. ; Tvfo Cases of Molluscum

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

T. C. Gilchrist, M. D.

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

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


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

Report in Medicine,

On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with

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

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

Report in Gynecologry. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

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

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

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

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

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

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

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

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

Howard A. Kelly, M. D.

Report in Snrg-cry, I. The Treatment of Wounds with Especial Reference to tlie Value of the Bloud Clot

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

Henry M. Thomas, M. D.

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


Volume III. ^6Q pages, with 69 plates and figiires.

Report in Pntliology.

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

Tuberculosis of the Female Generative Organs. By J, Whitridqe Williams, M. D. Report in Pathology.

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

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

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

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

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

Report in Gynecolog-y,

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

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

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


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

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

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

Traumatic Atresia of the Vagina with Hcematokolpcs and Hsematometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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

Volume IV. 504 pages, 33 charts and illustrations.

Report on TypUoid Fever.

By William Osler, M. D., with additional papers by W. S. Thateb, M. D., and J. IIewetbon, M. D.

Report in Nenrology.

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

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

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


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

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

Stndiea In Typboid Fever. By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon Flexner, M. D., Walter Reed, M. D., and H. C. Parscns, M. D.


Volume VI. About 500 pages, many illustrations.

Report in Neurolosy*

Studies on the Lesions produced bv the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nos. I to V). By Hen-ry J. Berkley. M. D.

Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the Chroma'te of Silver Methods; Part I.— Alcohol Poisoning.— Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); Part 11. — Serum Poisoning. — Experimental Lesions induced by the Action of the Doff*s Serum on the Cortical Nerve Cell; Part III. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Clironic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the' Cortical Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Ner\'e Cells from tlic Effects of Alcohol and Ricin Intcxication; Ner\'e Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Patliolosr.

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

CULLEN, M. B.

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

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

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

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Vols, ir, V and TI is $5,00 each.


I


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

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

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

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

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


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. VIII -No. 73.]


BALTIMORE, APRIL, 1897.




COnSTTIElsrTS.


Postural Method of Draining the Peritoneal Cavity after Abdominal Operations. By J. G. Clark, M. D., ... 59

Report of Five Cases of Infection by the Bacillus Aerogenes Capsulatus (Welch). By Edward K. Dunham, M.D., - - 68

Observations to Determine the Motility of the Bacillus Aerogenes Capsulatus under Anaerobic Conditions. By Edward K. Dunham, M. D., - - - 74


Multiple Tuberculous Ulcers of the Stomach, with a Report of

Three Cases. By Alice Hamilton, M. D., - - - - 75 Studies on Trichinosis. By Mr. T. R. Brown, - - - - 79 Proceedings of Societies :

Hospital Medical Society, 81

On Certain Visceral Pathological Alterations, the Result of Superficial Burns [Mr. Bardeen].

Notes on New Books, 82

Books Received, --- 83


POSTURAL METHOD OF DRAINmG THE PERITONEAL CAVITY AFTER ABDOMINAL OPERATIONS.

By J. G. Clark, M. D.


The general trend of recent medical literature relating to iutraperitoueal drainage tliroiigh the abdominal incision has been towards the limitation or reduction of the number of conditions demanding its employment, and a few European gynecologists have even gone so far as to discard drainage entirely, leaving the peritoneum to protect itself.

In a forthcoming article* on drainage based upon the bacteriological study of a large number of cases and upon the clinical records of 1700 cases of abdominal section performed in the gynecological department of the Johns Hopkins Hospital, I have been forced, notwithstanding my preconceived ideas in favor of drainage, to draw conclusions against it and to coincide with those few writers who discard it altogether.

The benefits to be derived from any form of drainage when used for the purpose of removing infectious matter from the peritoneal cavity, are infinitesimal compared with the untoward or disastrous results which may follow its use.

The greatest safety lies in closing the abdomen without drainage, except in cases of purulent peritonitis or in operations when there has been extensive suturing of the intestines, and in a few other rare conditions which I shall consider in detail in my paper on drainage.

Escape of pus during an operation, oozing of blood or serum, extensile raw areas in the pelvis, are usually sui:)posed toindi


  • A Critical Review of 1700 Cases of Abdominal Section from the

Standpoint of Intraperitoneal Drainage. The Johns Hopkins Hospital Reports, Vol. VII.


cate the necessity of some form of drain ; on the contrary, these are the cases which should be left to the care of the peritoneum, as demonstrated by a comparative study in our series of 1700 cases of abdominal section of a hundred cases each of similar pelvic inflammatory affections, drained and undrained. The undrained cases presented by far the best results.

Every surgeon recognizes the dangers of dead spaces in the abdominal cavity and endeavors to prevent their formation, but frequently this is impossible. Mikulicz first called attention to this subject in a forcible paper, and devised a siJecial drain for the prevention of oozing and for the removal of fluids from dead spaces; but this method, like all others, is unsatisfactory because the principle upon which it is based is wrong.

In an article (1889) by Laude the statement is made that it is not the principle but the methods of drainage which are wrong. I would reverse this statement by saying that it is not the method but the principle which is wrong. Zweifel claims that the subject of drainage should no longer be considered in surgical treatises, but should be relegated to medical history.

The chief objections to drainage of dependent pockets in the pelvis or abdomen through an abdominal opening are, first, fluids are frequently not removed, but on the contrary are pent up by the gauze drain ; and second, instead of removing infection, the gauze or tube may be the means of introducing it from the outside into the degenerated fluids.


60

[No. 73.


To overcome the dangers of dependent pockets and dead spaces in the pelvis, I would suggest the elevation of the patient's body after operation to a sufficient height to start the flow of collecting fluids from the pelvis towards the diaphragm, and thus promote the rapid elimination by the normal channels of exit from the peritoneal cavity, of infectious matter and of vital fluids which may stagnate in these pockets and form a culture medium for pyogenic micro-organisms.

Although it would appear at first sight that this method of drainage is opposed to sound surgical principles, I hope to offer proof from a review of recent literature bearing upon the function of the peritoneum under normal and pathological conditions, sustained by the clinical report of three cases, that it is not only a safe but may be a life-saving measure.

Function of the Peritoneum under Normal and Pathological Conditions.

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

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

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

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

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

4. The introduction of pus-producing cocci into the normal peritoneal cavity produces a purulent peritonitis, first, if the culture fluid is difficult of absorption, and second, if irritating materials are present which destroy the tissues of the peritoneum, thus preparing a place for the lodgment of the organisms, and the production, of an exudate upon which they may grow.

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


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

tCharite Annalen Jahrg., XI, 1886.

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

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


particulars, but disagreed in others. The main point of difEerence, however, between Pawlowsky and Grawitz related to the ability of the normal peritoneum to deal with the staphylococcus aureus.

Pawlowsky found that the large quantities of staphylococci injected by Grawitz without harm into dogs produced death very rapidly in the animals upon which he experimented, and that only a minimum quantity was harmless.

Reichel* went over the same ground in an experimental research, and in the main agreed with Grawitz. The essential points of value in Reichel's paper are, that peritonitis usually arises, first, because more organisms gain entrance than can be handled by the peritoneum, and second, because the stagnation of degenerating fluids in dead spaces favors the growth of the organisms.

He also accounts for Grawitz's and Pawlowsky's conflicting results, on the ground that some animals are more susceptible to infection than others, and that there are marked differences in the virulence of cultures of the same organism under varying conditions.

A carefully conducted experimental research by Waterhouse,t carried out under the oversight of Orth, appears to me to satisfactorily settle the question of the ability of the normal peritoneum to take care of infection.

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

Waterhouse then endeavored to simulate the conditions occasionally met with after operations, by introducing 8 cc. of urine and small quantities of blood with the cultures, and again the results were negative. If, however, 15 to 20 cc. of fresh blood were introduced into the peritoneal cavity, followed in a few minutes by the staphylococcus aureus, severe peritonitis was produced.

In these experiments Waterhouse agreed with Pawlowsky and Grawitz that the dangers of peritonitis are increased by tardy absorption of fluids, which in effect leaves a culture medium for the growth of the organisms.

After the introduction of blood clots 3 cm. in size, followed by the staphylococcus aureus, death occurred from peritonitis in 24 hours.

Waterhouse also found that the purulent exudate from acute abscesses is extremely virulent, 2 cc. of the staphylococcus aureus and 1 cc. of the streptococcus from this source causing death in twenty-four hours. If a very small quantity of the pus, however, was introduced with water, the animals frequently survived.

After the introduction of turpentine with the organisms, as done in Grawitz's experiments, peritonitis did not follow, which is explained by Waterhouse on the ground that the organisms are rendered inactive or are killed by the turpentine. He proved this point by injecting the turpentine first


  • Beitrage zur Aetiologie u. chirurg. Therapie der Sup. Peritonitis. Deutsche Zeit. f. Chir., Vol. XXX, 1889.

t Virchow's Archiv, Vol. 119, p. 342, 1890.


April, 1897.]

61


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

Dogs with a strangulation of the intestines were easily infected.

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

Burginsky* in a series of experiments also came to the conclusion that the discrepancies in the results of Pawlowsky's and Grawitz's experiments were due to variations in the virulence of the cultures employed.

Halstedf confirmed and extended the views of previous observers concerning the resistance of the normal peritoneum to infection, and called attention to the dangers of introducing pyogenic organisms about a ligated or strangulated area, or in conjunction with insoluble bodies. Pieces of sterile potato introduced into the peritoneal cavity of control animals were soon encapsulated and produced no disturbance, but when infected with pyogenic cocci, invariably caused peritonitis.

A recent paper by Cobbett and Melsome,J on " Local and General Immunity," contains some valuable observations bearing upon the resistance of the peritoneum to infection.

Notwithstanding the injection of large quantities of virulent streptococci, a few of their animals survived. They state that " in those animals which succumbed quickest, free cocci were very numerous in the peritoneal exudation, and in those which survived longest they were either absent or contained within phagocytes."

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

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

From this review of the literature bearing upon infection of the peritoneum I make the following summary :

1. Under normal conditions the peritoneum can dispose of large numbers of pyogenic organisms without producing peritonitis.

2. The less the absorption from the peritoneal cavity the greater the danger of infection.

3. Solid sterile particles, such as fecal matter, potato, etc., are partly absorbed and the remainder are encapsulated without the production of peritonitis.


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

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

t Journal of Pathology and Bacteriology, 1895.


4. Death may be produced by general septicaemia, and not by peritonitis, where large quantities of organisms are taken up by the lymph streams.

5. Irritant chemical substances destroy the tissues of the peritoneum and prepare a place for the lodgment of organisms which becomes the starting-point for peritonitis.

6. Stagnation of fluids in dead spaces favors the production of peritonitis by furnishing a suitable culture medium for the growth of bacteria.

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

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

The accumulated evidence of all these investigators proves beyond question that the peritoneum, under normal conditions or even when greatly handicapped by disease or artificial conditions, is capable of overcoming the invasion of comparatively large quantities of pyogenic bacteria.

Mechanism of Absorption of Fluids and Solid Particles in the Peritoneal Cavity.

Recent investigations by Muscatello* on the histology of the diaphragmatic peritoneum and the mechanism of absorption of substances from the peritoneal cavity, when considered in conjunction with the above conclusions, give ample ground for my suggestion of the elevated posture as a prophylactic measure against post-operative peritonitis.

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

Beneath the peritoneal endothelium of the diaphragm and between the connective tissue fibres are open spaces 4 to 16 mm. in diameter, occurring in groups of 50 to 60, which communicate with the lymph vessels. A careful search for these spaces failed to reveal them in any other portion of the peritoneum.

G. Wegner first proved that the peritoneum was capable of absorbing the most remarkable quantities of fluids, equivalent to three to eight per cent of the bodily weight in one hour, or the animal's entire weight in twenty-four hours.

By the injection of foreign particles suspended in a fluid medium into the peritoneal cavities of dogs, Muscatello was able to demonstrate the existence of an intraperitoneal current which carried fluids and small particles towards the diaphragm, regardless of the animal's posture. The rate of transmission


Virchow'a Archiv, 1895.


62

[No. 73.


of the foreign particles from the peritoneal cavity to their ultimate repository, the lymph glands, could, however, be increased or retarded by the influence of gravity.

In those dogs which were suspended with head down, carmine bodies appeared in the retrosternal and thoracic lymph glands in from five to seven minutes, while in animals in which the posture was reversed it was five and a half hours before they could be recovered from these glands.

Muscatello proved that small particles were carried from the peritoneal cavity into the lymph spaces of the diajihragm through the opening made by the retraction of the endothelium, then into the mediastinal lymphatic vessels and glands, then into the blood current, by which they were transported to the various organs of the body, from which they were picked up by the lymph vessels and deposited in the collecting glands of each organ. For this reason the large vascular organs, such as the liver, stomach, spleen and pancreas, show the particles first and in the greatest numbers, while the lymph glands of the mesentery, which gather their vessels from a limited area of the intestine, contain but few of the granules.

The function of the leucocyte is of especial importance in the elimination of foreign particles from the peritoneal cavity.

Muscatello and other observers find, on examining the precipitate in the peritoneal cavity after injecting innocuous foreign particles or bacteria, wandering cells interspersed among the particles, some of which are lightly laden with granules, while others are apparently distended to the point of bursting, and still others which have not yet taken up their burdens.

In some instances where the granules are too large for one leucocyte to encompass it, two or more join forces to surround the invader. The leucocytes are found in greatest abundance beneath the omentum. Prom the peritoneal cavity Muscatello traces the course of the leucocyte through the channels above described and finally finds them deposited in the lymph glands in various parts of the body.

In Muscatello's experiments the leucocytes were able to dispose of the innocuous particles rapidly and without apparent ill effect to the auimals. In Pawlowsky's, Cobbett's and Melsome's experiments, on the other hand, the conditions were different, the leucocyte having to meet an antagonistic invader. In those animals which survived the injection the infectious organisms were quickly encompassed by the leucocytes and carried into the general circulation, while in the fatal cases the peritoneal exudate was found swarming with free organisms and only a comparatively few enclosed in leucocytes.

The points in Wegner's and Muscatello's articles which I wish to draw especial attention to are :

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

3. Minute foreign particles are carried from the peritoneal cavity through the diaphragm into the mediastinal lymph vessels and glands, and thence into the blood, by which they are transmitted to the organs of the body, especially those of the abdomen, and later appear in the collecting lymph glands of these organs. (Muscatello.)


3. The leucocytes are largely the bearers of foreign particles from the peritoneal cavity. (Muscatello.)

4. There is normally a current in the peritoneal cavity which carries fluids and foreign particles towards the diaphragm, regardless of the posture of the animal, although gravity can greatly favor or retard it. (Muscatello.)

Postural Method of Draining Dead Spaces in the Pelvis.

The many bacteriological studies in cases of experimental and post-operative peritonitis and in experimental infections of the peritoneum show conclusively that the infecting organisms are quickly distributed more or less generally in the peritoneal cavity, from whence they are carried into the system at large.

Where there is no persistent source of infection, virulent species of bacteria may be destroyed effectually in this way; but when a nidus of infection exists in which the microorganisms are propagated, the patient is either carried off by a rapidly fatal septicaemia or peritonitis, or the peritoneal exudate forms a barrier to the further distribution of the infectious matter, which then follows the clinical course of any localized collection of pus.

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

Oozing should be controlled as far as possible, injury and exposure of the peritoneum should be guarded against, raw areas should be covered with adjacent healthy peritoneum when practicable, and all debris and fluids should be removed as far as possible before the abdomen is closed.

Notwithstanding every precaution, dead spaces will be left after many operations, which may become collecting places for degenerating fluids. In addition to these artiflcial spaces, oozing serum and blood may collect in Douglas' cul-de-sac or in the ante-uterine space, and become the focus of a genei'al peritonitis or a localized pelvic abscess.

To offset these dangers all dependent spaces should be drained as rapidly as possible, thus preventing the collection and stagnation of vital fluids, which are active germicides when first secreted, but become excellent culture media when degenerated.

By elevating the pelvis after operation, the normal intraperitoneal current may be assisted greatly in at once draining dead spaces, and thus give the general peritoneal cavity and system at large the best opportunity to meet the invading organisms before they have had time to increase in numbers. To remind one of the incredible rate of multiplication of micro-organisms it is only necessary to quote Cohn's classical statement that "one germ under proper conditions may give rise to more than a half million of similar organisms within twenty-four hours."

Stagnating fluids in the dependent parts of the abdominal cavity or in dead spaces may furnish such a favorable culture bed that a few organisms may quickly generate myriads of others and overcome the most resistant germicidal forces ; if on the other hand these spaces can be prevented from filling with fluids the organisms may easily be overcome.


April, 1897.]

63


In additiou to tbe mere transportation of the organisms from an area of decreased resistance to one of normal resistance, the irritant chemical toxines elaborated by the bacteria are diluted and the infectious matter is divided into a fine granular state, thus giving the leucocytes the best opportunity to encompass the organisms.

Although fatal septicasmia may be produced in animals by the absorption of large quantities of organisms from the peritoneal cavity, it appears to me correct to assume that after a well-conducted abdominal operation no such quantities of organisms will be left behind as are necessary to jiroduce septicemia in the animal experimentally. If such a condition should exist the patient would certainly die from the rapid multiplication of the organisms in dependent cavities. Hence I conclude that the better chance for the patient's recovery lies in the direction I have indicated.

My arguments therefore in support of this postural method of drainage are, first, stagnating fluids are prevented from collecting in dead spaces in the pelvis; second, infectious organisms are quickly carried into normal areas of the body where they are destroyed before they can increase in numbers; and third, toxic substances elaborated by the organisms are diluted and prevented from expending their irritant effects on a wounded area.

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

When the irrigation fluid is all sponged out, 500 to 1000 cc. of salt solution should be poured into the peritoneal cavity, so that when the patient is elevated after she is returned to the ward the artificial current may be started at once towards the diaphragm, thus supplementing the normal current.

After the introduation of the salt solution the omentum and intestines should be replaced in an orderly way and the abdomen closed.

As soon as the patient is returned to her room, the foot of the bed should be elevated about 30 degrees, which gives sufficient inclination of the posterior pelvic wall to assist the flow towards the general peritoneal cavity. This posture should be maintained for twenty-four to thirty-six hours, after which the bed may be lowered.

Leaving the salt solution in the abdominal cavity is not a novel procedure, as it has been done in a large number of cases during the last two years in the gynecological department, and other abdominal surgeons have used it with good effect.

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

It should therefore not be employed when an operation is performed for the relief of purulent peritonitis or for inflammatory conditions associated with general peritonitis, as for instance some cases of appendicitis.

From the experiments of Waterhouse in which he proved the danger of infection in cats suffering with ascites on account of the defective absorptive mechanism, it would also appear unsafe to adopt the postural method in cases when


this complication is coincident with the surgical affection. Pawlovvsky has sliown in his excellent experimental investigations that the lymph channels leading from the peritoneal cavity are choked with the infectious bacteria and inflammatory products in purulent peritonitis, and therefore advises free drainage through an abdominal incision.

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

Only one of the cases which I report in this paper showed organisms on culture. The presence of pyogenic organisms is not a contraindication to the employment of the jiostural method, because all investigations have proved conclusively that the peritoneum can overcome the invasion of large numbers of the most virulent organisms. Cases of pelvic inflammatory diseases, howevei-, rarely come to operation while the organisms are yet active, as shown by Miller of the Johns Hopkins Hospital, Schauta, Menge and others.

In forty-four cases of hysterectomy, mostly for pelvic inflammatory disease, examined by Miller, the cultures made from the interior of the uterus were negative, and cultures from the pus obtained from 51 cases of pyosalpinx, ovarian abscess and pelvic abscess, were negative in all but one case which showed gonococci.

Report of Cases in which the Postural Method of Drainage was employed.

Case I.

In this case all of the conditions usually supposed to indicate imperatively the emjiloynient of some one of the established methods of abdominal drainage were present.

Among these the chief indications were a sejitic temperature with great prostration of the patient before operation, and during the operation the separation of wide-spread adhesions which produced extensive injury to the peritoneum and free oozing of blood, the escape of a large quantity of pus and degenerated blood clots into the abdominal cavity. In addition to these conditions portions of the cyst wall and degenerated matter, and, most dangerous of all, a large cupshaped dead space beneath the intestines and mesentery, were left at the close of the operation.

Gynecological No. 4946. E. B. L., admitted January 18, 1897. Married, age 47 years.

Complaint. Pain in the lower abdomen, more marked on the right side. Slight cough.

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

Menstruation. Began at 13 years, regular, normal. Last period terminated December 18, 1896.

Present Illness. November 15, 1896, she had a severe chill, lasting two hours, followed by fever. The next day she had great pain, which continued one week and was accompanied with diarrlia.'a. Since then she has grown steadily weaker.


64

[No. 73.


fever and chills occurring frequently, and for the last week she has been confined to bed.

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

Examination of heart and lungs negative.

Temperature on admission 103° F., pulse 110.

Diagnosis. Large suppurating ovarian cyst.

Operation by Dr. Kelly, January 20, 1897. Cystectomy; part of cyst wall could not be removed.

Complications. Extensive adhesions to mesentery, bowel and vermiform appendix. Adhesions to entire posterior pelvis, to omentum, to bladder, and to anterior abdominal wall. Patient greatly prostrated, pulse before operation 118, at close 144, during operation as high as 156.


Incision 14 cm. in length, exposing red mottled and whitish cyst wall, closely adherent to anterior abdominal wall over a surface 10 cm. above symphysis pubis. Omentum adherent to anterior face of cyst over an area 10x8 cm. Adhesions separated; free oozing from thickened omentum checked by catgut sutures, no omentum removed; just above this point there was a fringe of flat adhesions, binding cyst to intestines and skirting the whole upper border of tumor from left to right. Adhesions so dense that separation was impossible without great injury to intestines.

Tumor tapped, about 3000 cc. of thick, fetid, yellow pus evacuated; the puncture was then closed with sutures.

Ten minutes were spent in separating tumor from anterior abdominal wall, bladder and anterior pelvic wall.

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


Jan.


18


19 20


21


23


24


25


26


Temp.

103 102 101 100

99

98

Temp.

Pulse Resp.

Stools


Day of Operation


6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 12 6 le 6 12 6 l2 P^l'se



5(10


540


560


6()0


>» •




670


^'"


5ilO +


^'*..


190 +


,\


30 +


130 120 110 100 90


80

70

4 60

50


Case I. Plain line indicates temperature. Broken line indicates pulse.


where it was lost in the tumor. Adhesions to uterus, to pelvic floor on right side, and to part of left pelvic wall divided. On floor of pelvis a sac coutaining 300 cc. of thick brown pasty blood was evacuated. Ovarian vessels at left pelvic brim exposed by dissecting with knife, fingers and scissors, and ligated, the left cornu uteri was then tied off and cyst cut loose from top of left broad ligament.

In separating adhesions on pelvic floor a sac was ruptured, discharging a large quantity of fetid pus into the peritoneal cavity. This was quickly mopped out and the hole in the sac stuffed with gauze. Cyst cut loose, leaving a portion of abscess wall 5x8 cm. in dimensions on the pelvic floor. Gauze


packed over this to protect it during the rest of the operation. Sac was peeled up and out of a dense bed of adhesions in the pelvis ; it was then found that the adhesions, extending between the entire length of the mesentery and out onto the intestines, were too extensive for further separation. The outer layers of the cyst wall were slit 2 cm. from bowel on all sides and dissected out from beneath the mesentery, thus completing the enucleation and leaving behind a large cup-shaped dead space. Slight capillary oozing occurred from the portion of cyst wall remaining behind.

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


April, 1897.]

65


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

Adhesions of right ovary to sac bled freely, requiring two sutures to control hemorrhage.

At completion of operation the abdomen was freely irrigated with many litres of salt solution, after which 700 cc. of salt solution were left in the abdomen. Abdomen closed with buried silkworm gut and subcutaneous catgut sutures.

Day of Operation. Patient's cough very troublesome, pulse 116, temperature 101° F. before operation. Eeturned from operating, room at eleven o'clock, pulse 140, respiration -18, profuse perspiration over entire body. Twelve o'clock, pulse 132, respiration 46. One o'clock, pulse 129, respiration 44. Two o'clock, foot of bed elevated twenty inches. Five o'clock, pulse 116. Six o'clock, pulse 116, temperature 100.4° F. Twelve o'clock, temperature 100.3° F., pulse 128. Patient uncomfortable, but not suffering great pain.

Second Day. Six o'clock A. M., temperature 99.6° F., pulse 126. Patient slept in all about two hours, often rendered uncomfortable by cough and heavy perspiration. Bed lowered.

Twelve o'clock noon, temperature 98.8° F., pulse 126. Patient has been comfortable up to this time, cough more troublesome, she now feels nauseated. Six o'clock, patient has vomited four times during afternoon, but is now comfortable, temperature 99.4° F., pulse 120.

Twelve o'clock midnight, temperature 99.3° F., pulse 124. Cough troublesome.

Third Day. Patient slept most of the night, awakened at intervals by paroxysms of coughing. Bowels moved. Temperature 98.8° F., pulse 124.

Twelve o'clock noon, temjDerature 98.6° F., pulse 114. Six o'clock, temperature 98.8°, pulse 108. With exception of pain produced by coughing, patient has passed a comfortable day.

Twelve o'clock midnight, temperature 100.4° F., pulse 118.

Fourth Day. Six o'clock, temperature 99.6° F., pulse 118. Bowels well moved, patient comfortable. Twelve o'clock noon, temperature 99.4° F., pulse 116, patient very comfortable. Six o'clock, temperature 99° F., pulse 110.

From the fourth until the tenth day the patient made as perfect a recovery as the most uncomplicated cases of abdominal section. The abdominal dressings were removed on the tenth day; incision healed /;er primam, subcutaneous suture entirely absorbed. Cough ceased about this time. Patient sat up in bed on the sixteenth day, and was out of bed in a wheel chair on her nineteenth day, and was able to walk on her twenty-fifth day. She was discharged from the hospital on her thirty-fifth day, feeling perfectly well.

Case II.

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

Gynecological No. 4892. A. E. T., widow, aged 34 years.

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


Menstruation began at fourteen, flov scanty but regular, lasting two to three days; always painful before marriage, since then painless.

Marital History. Married 14 years ago ; husband has been dead eight years. Four children, oldest 14 years, youngest 8 years of age. First labor instrumental, the others were easy. No miscarriages.

Family History. Negative.

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

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

Operation. Enucleation of both ovaries and tubes.

Complications. Dense adhesions binding pus sacs to pelvic walls and rectum, close relation of abscess on right side with the iliac vessels, persistent oozing following operation, escape of pus during the operation into the abdominal cavity.

Incision 12 cm. through thin abdominal walls, intestines packed back into abdomen with gauze bolsters. Impossible to differentiate pelvic structures at first on account of the dense adhesions covering in and binding all of the organs together.

Sigmoid flexure released from mass to which it was bound by dense adhesions. Outer coat of the bowel torn for about 3 cm. during the separation, but was at once closed with interrupted catgut sutures.

The enucleation was then begun on the floor of the pelvis, working upward and freeing the ovary and tube which formed a sac containing 30 cc. of pus. These structures were then tied off and cut away from the pelvic wall.

The fundus of the uterus was then partially liberated from adhesions, but this was discontinued on account of the free bleeding and danger of tearing into the rectum.

A long fusiform mass on the right side extended along the iliac vessels, with which it was closely adherent, around in front of the bladder. The sac contained 60 cc. of thick white pus, which partly escaped during the operation.

After freeing all the adhesions, the round ligament and ovarian vessels were tied off and the mass excised.

Active oozing to the right of the fundus over the ureteral area, also posterior to the fundus. After controlling several of these points there was still free hemorrhage at a point on the pelvic floor to the left of the rectum and from another point on the under surface of the broad ligament. This oozing was sufficient to stain a sponge as fast as it could be applied. The abdomen was irrigated thoroughly with salt solution, after which the bladder and fundus and the fundus and parietal peritoneum were stitched together to control oozing and to cover the raw areas with peritoneum.


66

[No. 7.3.


500 cc. of salt solution left in abdomen. Pulse at beginning of operation 93, at end 150. Time of operation one hour and a half.

First Day. Patient returned to ward at four P. M., pulse 140. Bed elevated. Four thirty P. M., pulse 120, of good volume; six o'clock, pulse 104; seven o'clock, 100; nine o'clock, 96; twelve o'clock midnight, 88. Patient recovered quickly from ether without symptoms of shock.

Second Day. Six o'clock A. M., temperature 100° F., pulse 9G. Patient complains of much pain. Twelve o'clock, pulse 92, temperature 100.8° F., patient sleeping quietly. Six o'clock P. M., temperature 100° F., pulse 100. Twelve o'clock midnight, temperature 99.8° F., pulse 92. Patient sleeping quietly.


Tliird Day. Six o'clock A. M., pulse 84, temperature 99.3° F. Bowels slightly moved. Condition remained about the same during day. Patient complained of some nausea, but did not vomit.

Fourth Day. Six o'clock A. M., pulse 80, temperature 99.4° F. Patient rested well, still slightly nauseated.

Fifth Day. Six o'clock A. M., temperature 99.6°, pulse 72. Bowels effectually moved, well formed stool. Patient passed a very comfortable day. From this time on the patient made a good recovery. On the tenth day after her operation the temperature rose to 100° F., and continued about this point until her seventeenth day, when it dropped to normal. At the time of her discharge she was feeling well.



V)a.y a?

Operation


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


Case III. In this case there were dense adhesions binding a large suppurating ovarian cyst to the intestines and the abdominal wall. A suppurating fistulous track extended between the caput coli and one loculus of the cyst, requiring a number of silk sutures to repair the opening in the intestine left after the enucleation of the cyst. Pus escaped into the abdominal cavity, and large handfuls of clotted blood were ladled out of


a hirge cavity in the pelvis. Pieces of the cyst wall and much debris remained behind at the completion of the operation.

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

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

Notwithstanding all these complications the patient made a good recovery.


April, 1897.]

67


Gynecological No. 4928J. A. E. S., admitted January 9, 1897. Single, age 35 years.

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

Family History. Negative.

Present Illness. Patient was always strong and well until four years ago; at this time she suffered with indigestion, and was treated by her physician for displacement of the uterus. She had an attack of peritonitis in September, 1895, which confined her bo bed four weeks. In October, 1896, she suffered


9 10 II 12 13 14 15 16 17


with " chills and fever," which lasted eight weeks. During the attack she passed pus from the rectum, her abdomen was swollen and very tender to pressure. Enlargement of the abdomen persisted after this attack, and has lately been increasing rapidly.

She suffers from stricture of the rectum, which followed an operation for hemorrhoids performed in 1892.

Present Condition. Body emaciated, complexion pale, expression anxious. Appetite good. Micturition normal.

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

Diagnosis. Suppurating ovarian cyst.



Case III.

Plain line indicates temperature. Broken line indicates pulse.


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

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

Puncture and evacuation through the abdominal incision of 2800 cc. of fetid pus, part of which escaped into the abdominal cavity. During enucleation of cyst it tore, allowing 150 cc. of pus to escape. Large hematoma filling lower pelvis opened and handfuls of thick putty-like blood were ladled out, in all about 200 cc. ITydrosalpinx and adherent ovary on the right side released, but not removed.

Adhesions between caput coli and tumor released, exposing


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

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

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


68

[No. 73.


under breasts, 500 cc. of salt solution left in the abdominal cavity. Pulse before operation 132, after 150.

First Day. On returning from operating room the pulse was 136, having dropped 14 beats in twenty minutes. Foot of bed elevated. Five o'clock in the evening pulse 128. Nine o'clock, 120. Twelve o'clock, 108. Patient comfortable and complaining of little pain.

Second Day. Pulse 108, temperatui'e 99.4° F. Patient complained of pain during the night, but slept three hours. Twelve o'clock noon, pulse 104, temperature 99.4° F. Six o'clock, pulse 104, temperature 100.4° F. Comfortable day. Foot of bed lowered.

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

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


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

Fifth Day. Temperature 98°, pulse 90. Patient had a comfortable night.

Sixth Day. Pulse 80, temperature 98° F.

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

Patient sat up on her 20th day.

Bacteriological Examination. Cover-glass preparations showed many cocci and bacilli. Two cc. of pus injected into a guinea jjig produced death from septicaemia in twenty-four hours. Cultures from pus at the time of operation and from autopsy of guinea-pig became contaminated, consequently it is impossible to make a definite statement as to the species of organisms present. The fact, however, that the cyst communicated with the intestine makes it practically certain that all of the intestinal bacteria were present in the pus.


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

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


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

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

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

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

Three days before her admission to the hospital she had noticed a swelling beneath the lower jaw ou the left side of the neck. This swelling was the seat of throbbing pain.

From the time she first noticed this swelling she suffered increasing malaise, with chilliness, headache, loss of appetite, nausea, and pains in the back.

At the time of her admission she had diflBculty in swallowing, stiffness of the jaw, and pain, with a sense of constriction, in the throat. The left submaxillary triangle was swollen, pale and oedematous. There was no fluctuation in the swelling, though it appeared somewhat softer near the angle of the jaw. On the left side of the lower jaw some of the teeth were carious. The floor of the mouth bulged upwards and was tense. The left tonsil was enlarged, but showed no signs of inflammation. Temperature 101.2°, respiration 22, pulse 98.

Hot applications were made to the neck, and a mouth-wash of listerine prescribed. She also received morphine subcutaneously, and phenacetine and quinine by mouth.

The next day, March 8th, the swelling had increased considerably in size, swallowing was very difficult, and the patient suffered somewhat from dyspnoea. The neck was stiff and gave great pain on the slightest motion. Articulation was also interfered with. An exploratory puncture of the swelling failed to reveal the presence of pus.

On the day following, March 9th, the pain in the neck was


excruciating; swallowing was practically impossible; the voice was husky and the dyspncea marked. The swelling was hard and rapidly increasing in size, the pulse rapid and weak, the facies drawn and anxious. The urine was found to contain " 5 per cent." of albumen. On this day the patient began to show signs of delirium.

During the afternoon of the succeeding day, March 10th, cedenia of the glottis set in and at one time completely arrested respiration, but by means of an O'Dwyer tube and artificial respiration for a few minutes the patient was restored and the tube could be removed. The patient gradually lapsed into a comatose condition.

Ou this day an incision was made into the swelling and a small quantity of fetid, " very virulent-looking " pus obtained.

The next morning, March 11th, there was no discharge from the wound, but emphysematous crackling was felt at the angle of the jaw. At 6 A. M. the patient was dead.

The pus obtained on the 10th of March reached the Carnegie Laboratory on the 11th, accompanied by a message stating that it came from an acutely septic case in which infection with the anthrax bacillus was suspected.

Cover-glass preparations of the very fluid pus revealed the presence of cocci and of bacilli of large size.

Agar tubes iu four dilutions were prepared and placed in the incubator. Upon these two sorts of colonies developed, one of a yellow color and the other white. All of these colonies were made up of cocci, the bacilli in the pus having failed to grow. Subsequent cultures of the cocci served to identify them as the staphylococcus pyogenes aureus and albus.

On the same day that the pus was received bouillon tubes were inoculated from it and placed in a Novy jar, in an atmosphere of hydrogen, at 37° C. The next day the broth in these tubes was cloudy, and a hanging drop showed the presence of cocci and bacilli.

A guinea-pig was inoculated subcutaueously with 1 cc. of one


April, 1897.]

69


of these bouillon cultures and died during the following night. At the autopsy the subcutaneous tissue was oedematous and emphysematous, and the fluid contained both cocci and bacilli, the lattei" predominating.

An effort was now made to isolate the bacillus and obtain it in pure culture for the purpose of identifying it.

A minute quantity of the broth culture used to inoculate the guinea-pig was distributed over the surfaces of several oblique agar tubes, which were placed in hydrogen in the incubator. No colony entirely devoid of cocci was found in any of these tubes, but one in which the bacilli greatly predominated was used to inoculate four rather dry blood-serum tubes, and upon these pure colonies of the bacillus were obtained and utilized for further study.

The bacillus was a large straight rod, about 0.9,a in diameter, with rounded ends, usually occurring singly or in pairs, but occasionally forming threads made up of four or five individuals. It stained readily with methylene blue, gentian violet and carbol fuchsin, and was very retentive of the dye when stained by Gram's method, resisting the decolorizing solution of iodine for ten minutes or longer. No spores were observed in any of the cultures, except those upon blood serum, though occasionally old agar cultures contained involution forms with an intimation of beginning sporulation, but without spores demonstrable by differential staining. In the subcutaneous fluid of animals it possessed a capsule, but this was usually not observed in cultures on artificial media.

It formed a moderately thin, moist, gray growth upon agar, and sometimes produced bubbles of gas in the condensation water at the bottom of the tube or between the agar and the wall of the tube.

Bouillon was rendered cloudy, and usually a few bubbles formed at its surface, while a gray sediment appeared at the bottom. In hanging drops, to which air had access, no evidence of motility could be detected.

Milk was coagulated in 24 hours and rendered acid, with a production of gas.

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

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

In order to determine the nature of this gas, six fermentation tubes containing glucose bouillon (1 per cent of glucose) were inoculated with the bacillus, and, after 24 hours, the gas collected in a eudiometer over mercury. 28.6 cc. of gas were obtained. This was subjected to the action of caustic potash, and when no more shrinkage in volume took place, air was introduced and an electric spark passed through the mixture. This was repeated until no more shrinkage in the bulk of the mixture resulted after the passage of a spark.

In this way the following approximate composition of the gas was determined :

Hydrogen 64.3 per cent.

CO2 27.6

Nitrogen (?) 8.1*

100.00 per cent.


On the 22d of March, i. e. eleven days after the pus was received at the laboratory, a guinea-pig was inoculated, subcutaueously, with a pure 24 hour culture of the bacillus in bouillon, one cubic centimeter being injected. The animal was found dead the next morning. The hair over the body was loosened so that it could be readily plucked from the skin, leaving it smooth and clean. The subcutaneous tissue was (Edematous, and so friable and filled with gas that the skin could be reflected from the abdominal wall without dissection. The gas burnt with a pale blue flame. The organs were of a dull gray color and very friable. The subcutaneous fluid contained great numbers of the bacilli surrounded by capsules, and apparently no other micro-organisms.

On April 3d, 23 days after obtaining the material from the hospital, another guinea-pig was inoculated, by means of a platinum needle, with a very small amount of a three-day culture of the bacillus on agar. The animal became very ill on the second day after inoculation and it was thought at that time that he would surely die in the following night, but he recovered after two days and remained well.

When injected into the blood of a rabbit, which was then killed after the lapse of a few minutes, the bacillus caused enormous swelling of the body of the animal within 20 hours, and the liver, kidney and spleen, as well as the subcutaneous tissue, were the seat of a very marked emphysema. The skin was rendered so tense by the accumulation of gas that it seemed on the point of rupturing.

The foregoing characters of the bacillus under study appear to identify it with the bacillus aerogeues capsulatus of Welch, the only point of difference being the spore-formation which was observed in cultures on blood serum. As the authors mentioned do not describe cultures on this medium, this spore-formation cannot be regarded as evidence against the identity of the two bacteria.f

A number of observations were made upon the resistance of these spores, and it was found that when taken from the condensation water of a blood-serum tube they could endure a temperature of 94° C. for one minute, but that an exposure of 5 seconds to the temperature of boiling water (99.5° C. at the time the observations were made) killed them. After being dried upon threads for 5 months and then immersed in water, they survived a temperature of 99° C. when subjected to it for one miuute.J

The vegetative form of the bacillus appeared to be killed by a temperature of 55° C. within one minute.

Ten mouths of desiccation and exposure to the air failed to kill the spores, which, at the end of that time, grew readily


  • The composition of the residual gas in the eudiometer was not

determined, but it did not contain CO3, for no diminution occurred when a fresh piece of caustic potash was introduced. This fact proves the absence of marsh gas or of any other hydrocarbon.

+ In a letter to the writer, dated February 19th, 1897, Dr. Welch states that the bacillus aerogenes capsulatus in his possession produced spores when cultivated on LoefHer's blood serum. This observation tends to still further establish the identity of the bacillus isolated by the writer.

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


70

[No. 7.3.


when placed iu broth at the body temperature under anaerobic conditions, and those cultures caused the same extensive production of gas when injected into the blood of a rabbit which was soon thereafter killed, as did the earlier cultures obtained from the original material.

The spores stain readily in hot solutions of fuchsin in anilin water, and are not decolorized by a moderate exposure to the action of a 3 percent, solution of hydrochloric acid in absolute alcohol.

They have an oval shape and are usually situated near the middle of the bacilli in which they have been formed, their long axes coinciding with those of the bacilli. Their short diameter exceeds the diameter of the bacilli, so that the latter appear swollen at the points where the spores are situated.

The cultures containing the spores frequently contain involution forms of the bacilli and threads of the latter, which stain but faintly with methylene blue, and appear more attenuated than the individuals in fresh cultures on other media.

A partial antojDsy of this first case of infection was made on the day following the death of the patient by my assistant, Dr. Harlow Brooks, from whose notes I take the following data: General nutrition excellent. Rigor mortis present. There was extensive post-mortem discoloration about the neck on the left side, and the tissues in this region were the seat of marked emphysema.

The incisions in the neck made before the death of the patient were opened and a focus of suppuration was found, which apparently arose from the left tonsil. The walls of this abscess cavity were not well defined, but appeared necrotic, and this condition extended far into the fascise of the neck.

The liver, kidneys and spleen were examined, but did not appear emphysematous. Microscopical examination of bits of those organs failed to reveal the bacillus.

Sections from the organs of the rabbit into the veins of which the bacillus was injected, when stained by Gram's method, revealed the presence of the bacillus in great numbers in the blood-vessels. (See " I," temperature chart.)

The second case of infection occurred in a boy, seven years of age, who fell over a banister from the fourth to the ground floor of a house and sustained a compound comminuted fracture of the right humerus. This accident took jjlace at 3 j). m. on the 19th of September, 1896.

After being under the care of a physician not connected with the hospital for a couple of hours, the patient was admitted to the Gouverueur Hospital at 6 p. m., in a semi-conscious and delirious condition. He had a lacerated wound of the forehead as well as a fracture of the humerus. The arm was very dirty and its tissues much contused. The wounds were treated antiseptically and the patient sent to the ward iu a poor condition.

At 8 p. m. his temperature was 100°, respiration H, pulse 130 and very feeble.

On the 20th he was delirious throughout the day. On the 21st the dressings were removed and the arm and shoulder found to be much swollen, the skin over them tense and of a greenish bronze color, the discoloration extending over the pectoral region. There was no sign of emphysema noted at this time.


Free incisions were made and the subcutaneous tissues found in a necrotic condition. The wounds were washed with mercuric chloride and drained.

On September 22d the patient was still delirious, very weak, with a fluttering pulse. The dressings were again removed and fresh incisions made in the arm. The cedema had extended well into the pectoral region and down to the elbow, and at this time, I believe, some emphysema of the tissue was noticed. There was, however, no discharge from the wounds, owing to the prostration of the patient.

At 3 p. m. the patient died, just three days after the accident which resulted in the fracture of the humerus.

Some of the discharge from the incisions made on the 2l8t of September was collected in a sterilized test-tube and sent to the Carnegie Laboratory. It was delayed in transit and had an offensive odor when received. Cover-glass preparations showed it to contain cocci and a large bacillus, with I'ounded ends, positive to Gram's stain, and, in some fields, surrouuded by a capsule.

Slant tubes of agar were prepared and placed in the incubator; one-half in a Novy jar with pyrogallate of potassium, the other half with access of air.

After 48 hours the aerobic cultures showed only colonies of cocci, while the anaerobic cultures contained colonies in which both cocci and bacilli had developed. The latter tubes gave evidence of gas production, the agar being raised from the bottoms of the tubes. These colonies, though not pure, were used for the preparation of bouillon cultures grown under anaerobic conditions, aud, after 2-1 hours, they were cloudy and covered with a froth, due to the evolution of gas. Jn hanging drops both cocci and bacilli were found, the latter iu greater number. One cubic centimeter of one of these cultures was injected under the skin of a guinea-pig, and iu a few hours the animal showed signs of illness. Its fur was ruflled, the animal drew itself together and avoided the light. But it recovered, and after three days appeared to be quite well again.

A few drops of the same culture were introduced into an ear-vein of a rabbit and five minutes later the animal killed. The next morning its body was greatly distended by universal emphysema of the subcutaneous tissues. Puncture of the skin permitted the escape of a gas which burned with a pale blue flame.

On autopsy the abdominal cavity was found to contain much gas, aud the liver, kidneys, spleen, aud the mucous membranes of the digestive tract aud bladder were emphysematous.

Cover-glass preparations from the viscera and subcutaneous fluid demonstrated the presence of the bacillus, accompanied by a few cocci.

Agar cultures prepared from the organs of this rabbit formed the basis of future pure cultures, which served to identify this bacillus with that found in the first case. No spores were found in any of the cultures, but, unfortunately, the bacillus was not grown on blood serum.

No autopsy was performed on this second case of infection. (See " II," temperature chart.)

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

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

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

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

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

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

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

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

Intravenous injection of a bouillon culture in a rabbit which was killed five minutes later, resulted in the post-mortem changes already noted in the other cases just described.

The bacillus produced spores when cultivated on l)lood serum.

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

The general nutrition was good.

Subcutaneous emphysema was noted, extending over the whole body, with a greenish discoloration over the thorax, right thigh and posterior surface of the body; most marked over the penis, scrotum and anus Puncture of the emphysematous area permitted the escape of gas, which burned with a faint blue flame.

The connective tissue under the skin of the thorax and abdomen was soft, pulpy and emphysematous. There were emphysematous areas on the pleurte and pericardium. There was general emphysema of the lungs. The cavities of the heart were distended, their walls soft and oedematous, and the blood they contained dark and fluid.

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


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

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

The mucous membrane of the bladder was extremely emphysematous.

The brain showed submeningeal emphysema, its substance was soft, the ventricles normal.

Microscopical examination of smears from the organs revealed the presence of large encapsulated bacilli resembling those found in the cultures. (See " III," temperature chart.)

The fourth case was a man, 23 years of age, who was admitted to the J. Hood Wright Memorial Hospital on the 6th of .January, 1897.

Four years ago he had gonorrhrea, which persisted for eight months, and three years ago he had another attack of the same trouble which lasted three months. Neither of these attacks was accompanied by symptoms pointing to inflammation of the bladder or testes.

Two years ago, i. e. about one year after the beginning of the second attack of gonorrhcEa, he felt pain on urination and noticed that the stream of urine was diminished in size. Shortly after this he had retention of urine, and was catheterized with some difficulty, and the urethral stricture then gradually dilated with sounds, the treatment lasting for two months. Since that time he had omitted all treatment.

At the time of his admission to the hospital the patient complained of pain on micturition, but there was no discharge from the urethra or increased frequency of urination. The urine was acid ; sp. gr. 1029; no albumen or sugar.

A urethral examination gave the following results :

No. 23 (French) bougie a boulu passed the meatus, but was stopped just bej'ond the urethral orifice.

No. 30 entered the urethra for a distance of 24 inches.

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

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

No. 4 and No. 2 bougies also failed to pass that point, as did also a filiform bougie. Even a bunch of filiform bougies failed to demonstrate a passage, although, subsequently, after etherization in preparation for the operation, a filiform bougie was successfully passed.

External urethrotomy was pei'formed on January 9th, at 4.40 p. m., and a perineal drainage tube was left in the bladder, held in place by a silk ligature passing through the skin. The bladder and urethra were irrigated with saline solution and an aseptic dressing applied to the perineal wound. The urethra admitted a No. 34 (French) sound.

The patient was returned to the ward at 5.20 p. m., and a conducting tube, with its distal end immersed in a 2J per cent, solution of carbolic acid, was attached to the perineal drainage tube.

At 6.30 p. m. the patient vomited some blood. The dressings were found to be saturated with blood and were renewed. A slight oozing of blood from a wound in the bulb of the urethra was noticed. This had ceased at 9 p. m., and the patient then felt comfortable.


72

[No. 73.


At 10.30 the bladder was agaia irrigated.

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

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

On the 11th and 12th of January the patient was doing well and the bladder was simply washed out.

The patient complained of some pain in the penis on the 13th, and at 3.30 p. m. sounds were passed down to the stricture, and gradually increasing in size up to No. 33 (French). The perineal drainage tube was then removed and a No. 33 sound passed through the entire urethra into the bladder, without difficulty. The perineal wound appeared healthy, and there was no discharge from the urethra except a small amount of blood which followed the manipulations. The auterior urethra was irrigated with saline solution and the perineal wound dressed. The patient felt somewhat chilly and received half an ounce of whiskey.

At 9.30, seven hours after the sounds were passed, the patient had a severe chill, lasting half an hour.

At 3.30 a. m., January 14th, a slight bleeding took place from the urethra.

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

At 11 a. m. a catheter was introduced throiigh the perineal wound and about 3 ounces of bloody fluid having a foul odor evacuated from the bladder, which was then irrigated with saline solution. The bladder and anterior urethra were again washed out at 5 p. m., this time with a solution of permanganate of potash, jtW- '^^^ wound was dressed at this time and looked clean. The patient conn^lained of pain on pressure in the left buttock.

At 9 p. m. the pains in the shoulder and buttock had become severe, and at 11 p. m. these parts were found to crepitate on manipulation. The skin over these areas was not reddened and the parts were only slightly swollen. The area on the left buttock did not extend to the perineum, but was limited to the region about the trochanter and the external aspect of the ilium. The area at the shoulder was confined to the region overlying the left scapula.

On January 15th, at 4 a. m., the emphysematous areas had become somewhat larger and more swollen, firmer to the touch, and a little darkened in color. The patient, who was conscious, had an anxious expression and presented an extremely septic appearance.

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

At 8.15 a. m. an incision, two inches in length, was made into the emphysematous area on the left buttock. A considerable amount of gas escaped through the wound, and a slight oozing of sanguineous fluid took place, but there was no sign of pus. Material for culture and bits of tissue for microscopical examination were taken from the walls of the incision.

At 9.30 the patient was still conscious, but died at 10.10


a. m., forty-five hours after the sounds were passed on the 13th of January.

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

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

Rigor mortis was marked; the general nutrition good.

Post-mortem discoloration was extreme from the pelvis up, and there was emphysematous crepitation over the abdomen, especially in the suprapubic region ; over the back, the buttocks, and the thigh, leg, and dorsum of the foot on the left side ; also, though in less degree, on the right side.

Puncture of the emphysematous areas permitted the escape of a gas which burned with a blue flame.

The abdominal wall was greatly distended, and when an incision was made the inflated intestines protruded.

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

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

The kidneys were enlarged; their capsules adherent.

The lungs were somewhat (Edematous.

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

The autopsy was necessarily both hurried and incomplete, as the relatives of the patient refused to have any of the organs removed from the body.

During the autopsy agar tubes were inoculated by Dr. Brooks from the blood in the left auricle and from the tissues of the liver, spleen and kidney. A bouillon culture was also made from the blood. These cultures were then incubated in a Novy jar with pyrogallate of potassium, and after 14 hours developed pure cultures of a bacillus identical with those found in the preceding cases.

When grown upon blood serum these bacilli developed spores identical in character with those produced by the bacillus isolated from the pus from the first case.

Cover-glass preparations made at the autopsy from the same organs from which cultures were taken showed the presence of the bacillus.

One cubic centimeter of the bouillon culture from the blood was used to inoculate a guinea-pig subcutaneously. Within three hours the animal was manifestly ill, appearing to feel cold and to wish to avoid the light. It died within 30 hours, and at the autopsy presented marked emphysema of the areolar tissues and orsrans.

A rabbit was also inoculated, intravenously, with the bouillon culture, killed and put in a moderately warm place. The next day it showed the emphysematous condition of the subcutaneous tissues and internal organs which has already been described in connection with the other cases.

The material removed when the incisions were made into the emphysematous area on the buttock at 4 p. m. on the day of the death of the patient was used to inoculate agar tubes, part of which were cultivated with access of air, the rest under anaerobic conditions. Those exposed to the air showed no growth. Those grown with exclusion of oxygen contained


April, 1897.]

73


a growth of a non-motile bacillus, positive to Gram, and morphologically resembling the bacillus aerogenes capsulatus. These cultures were lost and no further observations could be made, but as considerable work on this bacillus was being done at the time, no doubt exists as to the identity of the bacillus.

About 2i honi's after the death of the patient a sterile cotton swab was introduced into the urethra, and the moisture thus obtained used for the preparation of cultures.

Two bacilli developed in these cultures, and as they were both at least facultative anaerobes, efforts to separate that which proved to be a strict anaerobe were unsuccessful. One was smaller than the other and grew when air was admitted to the cultures. The other was morphologically identical with the bacillus aerogenes and did not grow in cultures exposed to the air. The smaller bacillus was thought to be the bacillus coli communis. A mixed bouillon culture of the two bacilli was injected into one of the veins of a rabbit's ear, and 15 minutes later the animal was killed. The next day the body was bloated and the large bacillus was found in the subcutaneous fluids, which were both emphysematous and (Edematous.

As a check upon this experiment a second rabbit was inoculated with a pure culture of the colon bacillus in the same manner and at about the same time as the first rabbit. The next day there were no signs of emphysema in its body. (See " IV," temperature chart)

The fifth case occurred in the private practice of a New York physician, who has kindly furnished the writer with the following facts concerning the history of the case.

The patient was a man, 73 years of age. His general condition was good, there being no organic trouble except some hypertrophy of the prostate.

On January 17th, 1897, the patient complained of pain and uneasiness in the perineum. This was traced to enlargement and tenderness of the prostate and of the tissues near the rectum in the median line.

The next day the pain was more severe, and a diagnosis of prostatitis was made. The pain was alleviated by means of opium and belladonna suppositories, and by the 20th of January the patient felt able to be about again.

That night, because of difliculty in voiding his urine, the patient passed a hard rubber catheter and drew some blood.

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

On the 22nd the pain in the right buttock was more severe. The patient was in bed, felt prostrated, and had a dry tongue and some fever. Temijerature about 101°.

On the 23rd the general condition was about the same as on the day before. Temperature 102°. There was increased harduess of the tissues of the right buttock, and the pain there was very great.

On the 2-l:th there was evidence of a pointing abscess in the buttock, in which the pain was excessive.

At midnight a sudden rupturing of this abscess into the neighboring tissues was felt, and immediately the scrotum became enlarged and the pain in the buttock was relieved.

The next morning, January 25th, the attending physician


found the scrotum emphysematous, with spots of gangrene upou it. Temperature 103°.

Later in the day the perineum was tense and distended, red and tympanitic. The scrotum was the size of a child's head (8 to 10 inches in diameter), dark in color, in places almost black, and cold to the touch. The skin of the penis was ballooned with gas and dark.

Very extensive incisions were made to the right of the raphe, from the penis to the tuberosity of the ischium. No pus was found, except at one point near the anus, where there was a cavity containing a dirty grayish-yellow pus of offensive odor.

The areolar tissue of the scrotum and penis were of an inky blackness and emphysematous, but contained no pus. A slight ojdematous condition prevailed in the deeper structures.

The tissues were irrigated with mercuric chloride and an iodoform dressing applied.

On the following day, January 26th, the emphysema had extended over the pubes and the hypogastric region, the skin being raised about half an inch. The color of the skin over this area was either normal or had a pinkish blush.

Two free incision* were made to evacuate the gas, and it was discovered that the subcutaneous areolar tissues were blackened. No pus was present.

A portion of this black slough was removed with sterile instruments and put in a sterilized bottle for examination.

On the 27th the emphysema and necrotic area had extended upwards to the sternum, and laterally to the shoulder-blades, and fresh incisions were made. A single focus of pus found above the navel.

In all the places where prior incisions had been made the sloughing had extended so as to include the skin, but without the formation of pus.

The patient lapsed into a low typhoid condition, then into coma, and died on the 31st of January.

Cover -glass preparations of the material removed from this patient on January 26th were examined on that day at the Carnegie Laboratory, and showed the presence of three species of bacteria : 1, a large bacillus, resembling the bacillus aerogenes capsulatus ; 2, a more slender bacillus; 3, streptococci.

The slender bacillus was identified as the bacillus coli communis, and when obtained in pure culture, produced no emj)hysema in the body of a rabbit killed shortly after the injection of the culture into a vein of the ear.

Experience with the mixed cultures, obtained from the cotton swab used to collect material from the urethra in the fourth case, had shown the difliculty of separating the bacillus aerogenes capsulatus from the bacillus coli communis. Without waiting, therefore, to obtain pure cultures of the large bacillus found in this ca^e, a mixed bouillon culture of the two bacilli was injected, intravenously, into a rabbit, which was shortly afterwards killed. The usual post-mortem emphysema was produced within a few houri?, and from the subcutaneous fluids pure cultures of the bacillus aerogenes capsulatus were finally obtained. These, unfortunately, died out in future cultures, owing, it is thought, to the reaction of the agar which was employed as a culture medium and which was found to be strongly acid.


74

[No. 73.


No accurate temperature chart could be obtained in this case, and there was no autopsy.

The foregoing cases appear of interest as showing that the bacillus aerogenes capsulatus is sometimes capable of rapid development within the human body, during life, and of causing an acute and speedily fatal infection.

They serve also to show that the bacillus is of pretty wide distribution ; for within eleven months these five cases have come under the observation of a single individual and were, notwithstanding, wholly unconnected with each other, occurring as they did in various parts of the city of New York and coming under the care of different physicians.

The mode of infection was not the same in all of the cases. But it is a striking circumstance that in three of the cases the infection started near the perineum after injury to the urethra, and in two of these the bacillus aerogenes capsulatus was associated, as far as the wound was concerned, with the bacillus coli communis.

In the case in which the site of infection was the wound of


a compound fracture of the humerus, the history states that the wound was covered with dirt. This fact naturally leads to the suspicion that the bacillus aerogenes capsulatus, like so many of the anaerobic bacteria with which we are familiar, may occur in the soil ; and the occasional production of spores, noted in the account of the first case and also observed in similar cultures from the fourth case, might readily explain the persistent vitality of the species under conditions which would otherwise be fatal to it.

From the soil to the intestinal tract of man would be a simple route by which the bacillus might gain access to the human body and find conditions not unfavorable to its development and, perhaps, spore-formation.

If the bacillus once gained access to the intestinal tract its presence in the perineal region couldoccasion no surprise. And if, through the wounded urethra, or some other lesion, it once reached the subcutaneous tissues and possessed sufficient virulence, the gangrenous process illustrated by these cases would ensue as a matter of course.


OBSERVATIONS TO DETERMINE THE MOTILITY OF THE BACILLUS AEROGENES CAPSULATUS

UNDER ANAEROBIC CONDITIONS.

By E. K. Dunham, M. D.


Bouillon cultures of the bacillus were studied in flattened capillary tubes from which the oxygen of the air had been absorbed by means of pyrogallate of potassium. Although these cultures were examined at intervals varying from 15 minutes to 24 hours, at no time could any evidence of motility on the part of the bacilli be detected.

The details of the experiment were as follows :

The cultures were obtained by putting threads, containing spores of the bacillus, which had been kept in a dry state for 11 months, into tubes containing sterile bouillon. Three such tubes were prepared, and after incubation in a bottle containing pyrogallate of potassium, they all showed an abundant growth of the bacillus within 24 hours. These cultures proved to be pure. One cubic centimeter of one of these cultures was then mixed with about 3 cc. of fresh sterile bouillon, in order that the bacilli present might have a good supply of nourishment, and this mixture used for the observations on motility.

The capillary tubes were prepared by heating a piece of glass tubing, about 8 inches long and with a bore measuring about i of an inch, strongly in the middle, then bringing the two halves parallel to each other and separating them about two inches (Fig. 1). In this way a U-shaped tube with a flatted bend was obtained. The limbs of this tube were then bent at right angles, so that their axes were in the same straight line. The ends of the tube were plugged with cotton and the tube sterilized by dry heat (Fig. 2).

A few moments before use, the middle of the flattened portion of the tube was heated until quite soft, and then rapidly drawn out to form a capillary tube. This was then broken in the centre and the end immersed in the bouillon culture.


A portion of the culture quickly filled the capillary part of the tube for a distance of from 2 to 3 inches. The end of the capillary tube was then sealed in the edge of the flame of a Bunsen burner. Enough pyrogallic acid to closely fill about 1 inch of the tube was then introduced into its large end, this was moistened with a 50 per cent, solution of caustic potash in water, and then the end of the tube was closed by means of a piece of rubber tubing plugged at the other end with a bit of glass rod (Fig. 3).


Fto. I.


Fig. <3.


F,g.l.

When prepared in this way the capillary tube containing the culture was so flat that it was possible to examine the whole contents of the tube under a Jj oil immersion objective.

Eight such tubes were prepared, and four of them preserved at the room temperature, the other four being placed in the incubator where the temperature was maintained at 35° C. They were examined at intervals of 15 minutes, 1 hour, 3J hours, 21 hours and 34 hours. In no case could any locomotion of the bacilli be detected.

After two and a half hours the bacilli were present in


April, 1897.]

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greater numbers than when the cultures were first introduced into the tubes, showing that the conditions were favorable for their multiplication. At the end of 24 hours the number had increased enormously, and there were two small bubbles of gas in one of the tubes which had been kept in the incubator. It might, perhaps, be thought that the chilling, occasioned by removing the tube from the incubator for the purpose of examining its contents under the microscope, would be sufficient to check the locomotion of the bacilli, before a clear


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

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


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

By Alice Hamilton, M. D.

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


Tuberculous ulcer of the stomach is conceded by all writers on pathology to be of extremely rare occurrence, some indeed of the earlier ones considering that organ almost immune from tubercular infection. Again, some few of the earlier writers claim to have found it with comparative frequency in the autopsies of tubercular subjects ; but as their results vary so greatly from those of the large majority, one is forced to believe that they have included cases of simple ulcer among the number. Forster, Rokitansky, Cornil et Ranvier, Ziegler, Orth, Birch-Hirschfeld and Klebs are unanimous in declaring the extreme rarity of this lesion.

Single cases purporting to be of this disease are reported from time to time in the literature, but it is imjjossible to accept all of these as actually cases of tubercular ulcer. As the greater number were reported before the discovery of the bacillus tuberculosis, one does not expect to find the diagnosis resting on its presence; but in many of these cases no histological examination was made, and in others no details of such examination are given. All such cases must be dismissed as doubtful or merely probable. Only those can be classed as proven where the report shows by a detailed description of the results of the microscopic examination that the histological characteristics of tubercle were present and which were confirmed or not, as the case may be, by the demonstration of the bacillus tuberculosis.

The earliest of these is Litten's. It was a case of tuberculosis of lungs and peritoneum with no lesion in the intestines, but with a single ulcer in the anterior wall of the stomach, which on microscopic examination showed typical caseating tubercles with giant cells. Talamon also describes tubercles found in the walls of ulcers in the stomach of a child which had died of pulmonary tuberculosis. In this case the ulcers were seven in number, scattered over the surface from cardla to pylorus. Brechemin's case resembled Litten's in presenting no lesion in the intestines. There was a single ulcer— its location not mentioned — with thickened edges and a floor covered with nodular elevations consisting of " caseated masses surrounded by embryonic and lymphoid cells." Eppinger's two cases are described in great detail and are interesting in being the first cases of multiple ulcer which have been accurately reported. Here, too, the intestines in both cases


were intact. The first one was a case of general miliary tuberculosis, and the stomach contained many miliary tubercles as well as innumerable small losses of substance in the mucosa. These ulcers had hard, elevated, regular " rampart-like " walls, and their bases were covered with whitish granulations, which on section proved to be caseated. His description of the microscopic appearances leaves nothing to be desired in either of the cases, the second resembling the first very closely.

Barbacci's case showed tuberculosis of lungs, peritoneum and intestines, besides which the stomach contained five ulcei'S near the pylorus, two of them having a diameter of 6 cm. These showed nodules of embryonic cells with caseation in the centre. The case of Pozzi is not quite positive. He found an ulcer near the greater curvature in the stomach of a man who had succumbed to pulmonary and intestinal tuberculosis. The walls and base of this ulcer showed no nodules, only "diffuse tubercular tissue." As it was impossible that the diagnosis here should be confirmed by the discovery of the tubercular bacillus — the case was published in 1868 — it must be regarded as somewhat doubtful. Duguet's case of a single ulcer near the pylorus in a phthisical patient is so obscurely described that one can come to no definite conclusion about it. Marfan rejects it in his resume of tubercular lesions of the stomach.

Coats was the first to demonstrate the bacillus in a gastric ulcer. His case, a child with pulmonary tuberculosis, presented numerous losses of substance in the mucosa of the stomach, and the examination showed not only the histological elements of tubercle, but also the specific bacillus. Serafini, Musser and Mathieu et Remond also found the bacillus in their cases. Mathieu et Remoud's case goes to swell the list of those which showed no lesion in the intestine.

J. Kiihl reports four cases from the Pathological Institute at Kiel. He examined all for the tubercle bacillus, but failed to demonstrate it in the two older specimens which had been a long time in the museum. Nevertheless, the histological appearances in the first of these cases point quite positively to tuberculosis; in the second his description is too scanty and obscure to place it above question. The third and fourth instances, which were recent, are described as containing caseating nodules with tubercle bacilli. R. G. Hebb and G. Lava


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report each a case of single ulcer — at the lesser curvature and at the pylorus respectively — and describe the microscopic findings as tubercles with caseation and giant cells. It is to be regretted that these observers failed to make any search for the bacillus tuberculosis. This omission is still more striking in Letorey's otherwise exhaustive description of a case of diffuse ulceration near the pylorus. He states that tubercle bacilli were found in the lungs and in the diseased part of the femur, but seems not to have looked for them in the ulcers, where he, however, found typical caseating nodules.

In the following cases it is difficult to decide whether the lesions described are really tubercular or not, the authors having satisfied themselves of the correctness of their diagnoses, but having failed to establish them by giving the facts on which they were founded. So, for instance, Hattute merely states that his case showed "elements of tubercle in the granulations." Lorey, Anger, Matthieu, (Jazinaud Beadles give no details at all. Finally, a large number must be utterly rejected as, according to the explicit statement of the authors, no microscopic examiuation was ever made. Such are the cases of Bignon, Paulicky, Chvostek (four), Hebb (second case), Lauge, Barlow and Quenu, which last rests for its diagnosis on a mere statement of the author, no description of its macroscopic appearance being given. Several others which have been placed in the list of tubercular ulcer were really miliary tubercles in the walls of the stomach. Kiihl's fifth case is an example, also Earth's. Labadie-Lagrave's case showed a cicatrix near the lesser curvature, its tubercular origin being merely hypothetical. Oppolzer's is described as a perforating ulcer connecting stomach and colon, supj)osedlyof tubercular origin, but it was impossible to say in which organ it originated. This covers all of the authentic literature so far as I have been able to discover, and it will be seen that it contains fifteen undoubted cases and nine more which are probable but not proven.

The two cases which I wish to report are, I think, undoubtedly tubercular, although neither could be considered as strictly typical. Indeed, the histological findings in the second case were so little suggestive of tuberculosis that, had it not been for the discovery of the tubercle bacillus, I should not have ventured to class it as tubercular, but the large numbers of bacilli present leave no doubt that they were the prime factor in causing the ulcerative process. The first case, which contained very few bacilli, presented an appearance that was much more characteristic of tuberculosis. I will omit the histories of these cases, which offered nothing of special interest, merely stating that both patients were admitted to the Johns Hopkins Hospital, to the service of Ur. Osier, in the advanced stages of pulmonary phthisis. The autopsies were performed by Dr. Flexner, from whose reports I will give merely the essential points.

Case 1. Colored female, aged 30 years. The right lung contained near the apex a cavity about the size of a small walnut, with smooth walls; the lung tissue adjacent was densely infiltrated and converted into a caseous mass. In the lower portions of the upper lobe, beneath the anterior surface and near the middle line, a small cavity existed with smooth walls which communicated freely with the bronchi. Its walls were caseous, and


adjacent to it were large caseous masses surrounded by oedematous and congested tissue, which often presented a gelatinous appearance. The upper portion of the lower lobe was taken np by a series of cavities, more or less communicating, the deepest of which extended almost to the pleura, and was separated from this only by thin granulation tissue in which could be seen many opaque tubercles. Over this cavity the two layers of the pleura were adherent. The dependent portion of this lobe anteriorly was drawn out to a tongue-like aj)pendage in which were caseous masses, the intervening lung tissue presenting a gelatinous appearance. Firm, dry and caseous tissue surrounded the cavity in the upper lobe, and most of the remainder of this lobe was converted into similar tissue. The lower lobe contained scattered caseous foci, while the pleura covering all of the left lung was scattered over with gray and opaque tubercles. The bronchi, larynx and trachea showed numerous superficial losses of substance reaching only through the mucous membrane. This ulcerative process in the larynx extended to the mucous membrane of the mouth and tongue, but did not pass to the esophagus. The bronchial lymphatic glands were pigmented, enlarged and caseous. Tubercles were observed in the liver and kidneys.

The intestines were the seat of numerous ulcerations, which occurred at intervals, beginning 165 cm. below the duodenum and extending to within 10 cm. of the rectum. They were partly circular, partly elongated — " girdle-ulcers " — and penetrated to the muscular coat. In many, small tubercles were visible in the depth. On the peritoneal surface a few tubercles were seen. The appendix vermiformis was free from ulceration.

The stomach showed a large number of losses of substance, from 115 to 120, scattered over the entire organ, but most thickly on the anterior aspect near the greater curvature. These ulcers were round or oval, usually smaller than a penny, with rounded thickened edges, generally smooth and undermined for a variable distance.

The chief interest for our purpose centers in the ulcerations existing in the stomach. Our studies embraced the examination of many of these, often in serial sections, both with respect to their pathologic histology and to the presence of tubercle bacilli. Ulcers of various sizes were sectioned, stained and examined microscopically. The details are purposely omitted. The ulcers vary in their histological appeai-auces, depending somewhat upon the extent of their development. Even in the youngest and most superficial the glandular elements are much disturbed, and a considerable proliferation of cells has taken place in the mucosa. The cells are small, round and lymphoid in type, but among them are also some which have the character of epithelioid cells. The deeper ulcers show a greater number, even a preponderance, of cells of an epithelioid habitus, and an arrangement at times into nodules of the size and I'oughly of the appearance of miliary tubercles, whose centres are formed by epithelioid, and whose peripheries by lymphoid elements. Giant cells were not discovered. On the other hand, necrosis of cells existed with fragmentation of nuclei, and, within the new tissue, even larger areas suggesting definite caseation. The nodules with central necrosis were sometimes in the mucous membrane, perhaps in


April, 1897.]

77


the overhanging edges of the ulcers, and again upon the floor formed by the submucosa, which was always found when exposed to be infiltrated with new cells, partly lymphoid, partly epithelioid in character. The thickened, undermined edges showed an increase of spindle-S'haped cells, suggesting a new growth of connective tissue, forming at times a decided band. Tubercle bacilli (Ziehl-Neelsen method of staining) appeared in small numbers along the free surface of the ulcers, and singly, imbedded in the tissues, among the clusters of epithelioid cells.

Case 3. Male, colored, age fifty years. The right lung was bound by adhesions to the chest wall and the diaphragm, and the lobes were bound to each other. On section the whole lung was quite consolidated. Old fibrous processes extended in all dii-ections through the lung, but they were most abundant posteriorly and at the apex. Small foci of caseation partly calcified were found, and in addition actual cavities lined with thin pyogenic membranes, the largest of them not exceeding the size of a walnut. The bronchial glands were enlarged, caseous and partly calcified.

The left lung, on the other hand, was free from adhesions except at the apex, the upper lobe was retracted at the apex, slaty in color and contained caseous masses, but elsewhere this lobe was quite smoothly consolidated. The lower lobe was voluminous, congested, containing very little air. In some smaller branches of the pulmonary artery partly decolorized thrombi existed, without infarction. Both bronchial and mediastinal glands were enlarged and caseous.

The small intestines were free from ulceration, but in the patches of Peyer in the ileum near the valve there were several elevated gray nodules, about the size of bird-shot or a little larger, with central depression, doubtless small tubercles with loss of substance in the centre. The large intestines were free; the appendix vermiformis contained about its centre an elevated grayish nodule similar to those in the ileum.

The mucous membrane of the stomach was congested and covered with sticky mucus, and along the greater curvature, almost over its entire extent, small losses of substanceoccurred, 70 to 75 in number. They presented worm-eaten edges and uneven bases, which sometimes, but rarely, were covered with small granulations. They extended usually only partly through the mucosa. The follicles of the oesophagus were enlarged, but without ulceration.

The histological and bacteriological examinations of these ulcers were carried out in the same manner as in the preceding case, fourteen of the ulcers in all being subjected to study. For this purpose ulcers of various sizes were chosen. With the exception of two or three, those examined involved only the upper layers of the mucous membrane, and the deepest ones did not extend beyond the muscularis mucosae. The edges of these ulcers were never deeply undermined, and the infiltration of the mucous membrane passed a very little way only beyond the ulcerations. In general the appearances presented were those of superficial and small ulcerations, whose floor was formed by the infiltrated mucous membrane, still showing glands or vestiges of glands, but in which the proliferation of cells had so altered the latter that they were often with difficulty recognizable. The new cells consisted chiefly of


the lymphoid variety, and they were diffusely scattered, but epithelioid or larger cell elements were not entirely absent. Only once was a perfectly distinct nodule, the size of a miliary tubercle, discovered, and this consisted of epithelioid cells more centrally and lymphoid more peripherally placed. On the other hand, in the floor of the ulcer it was possible to distinguish more nodular formed masses of lymphoid and epithelioid cells, but definite and typical tubercles, in the usual sense, were entirely wanting. The free surface of the ulcers showed more or less necrosis ; the deeper layers, which were in an excellent state of preservation (the tissue having been perfectly fresh), were quite free from such indications. Tubercle bacilli were present in great numbers; in no section were they wanting, and often they occurred in great clumps. The main masses were on the free surface of the ulcers, but they were also found deejjer down among the glands or within their luniina.

The foregoing cases seem to possess sufficient interest to warrant recording them, even though it is now admitted generally that the stomach at one time or another becomes directly involved in tuberculosis of the alimentary tract. It is interesting to consider for a moment a fact alluded to by many writers, that there is a want of correspondence between the appearance of lesions of a tuberculous nature in the stomach on the one hand and in the intestine on the other. While in the great majority of cases the latter shows great disposition for the development of tuberculous ulcers, it is interesting and striking to see how often in the cases reported in the literature, where ulcers existed in the stomach, the intestines entirely or almost entirely escaped. Every pathologist must be imjjressed with the unexpected variations in the localizations of tuberculous lesions, and must have observed instances in which the alimentary tract entirely escaped infection when the conditions seemed most favorable for it. It is impossible at the present time to give any satisfactory explanation of such occurrences.

Concerning the multiple nature of the ulcers in the two cases discovered above, they are in this respect, compared with other cases (except Eppingei-'s), peculiar. It is questionable whether they may be considered as having shown any special predilections for situation, excej)t in the second case to avoid the pylorus, apparently the most common seat of single ulcers. Two points may be considered in this connection, one of which is borne out by the bacteriological examination of the second case. The size of some of the ulcers and their limitation to the mucous membrane agree not a little with the small erosions following ecchymoses into the mucosa, the socalled hemorrhagic erosions. The absence of a specific histological structure peculiar to tubercle, in many of the more superficial losses of substance, is not inconsistent with such an origin. That such erosions are very common in many diseases is of course well known, and it may therefore with projn'iety be asked whether a part of the ulcers in the second case do not owe their origin to this cause, and the tubercle bacillus is responsible only secondarily for a further destruction; the production of those lesions more nearly resembling histological tul)ercles. Eppinger long ago declared that the u'sophagus was invulnerable to the tuberculous virus, unless a


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previous lesion existed to enable it to get a foothold; and while this statement has perhaps been disproven, yet that such a previous injury may act as a predisposing cause is more firmly established now than when he wrote (see Cordua). And if for the oesophagus, it may be asked why not for the stomach? The facts in our second case point more towards such a view, namely, that many small erosions, probably of hemorrhagic origin, existed in the stomach, some or all of which became invaded by tubercle bacilli swallowed with the sputum, than that they owe their production to a direct invasion, in the absence of a previous lesion, of the mucous membrane of the stomach, by the bacillus tuberculosis.

In closing I wish to express my gratitude to Dr. Flexner for the advice and assistance most kindly given me in the course of this investigation.

Addendum.

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

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

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

The anterior mediastinal and the lower cervical glands wei-e enlarged and caseous. The visceral and parietal layers of the pleura on the right side were studded with caseous tubercles, some of which reached the size of a beau.


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

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

The stomach was adherent to the transverse colon, the pancreas, and to the mass of enlarged peripancreatic lymph glands. The serous coat was covered with small and large caseous tubercles. Midway between the pylorus and the cardia on the posterior aspect of the lesser curvature, was a large, irregularly oval, crater-like erosion, 3 cm. by 2 em. in size. The edges were raised and somewhat undermined and more deeply congested than the surrounding parts. The floor was irregular, the deepest part of the crater measuring 8 mm., while the remainder was formed by projecting caseous tubercles. Directly behind this ulcer was a caseous lymphatic gland, so closely adherent to the stomach wall at this point that it was impossible to tell whether or not it formed the floor of the ulcer. A second smaller erosion was found above this one, in the middle of the lesser curvature. Its edges were slightly elevated, and in one place deeply undermined, the floor being formed by the muscularis. Here and there scattered through the mucous membrane were minute grayish white and yellow points looking like, but not proven to be, miliary tubercles. In the duodenum, just beyond the pyloric orifice, was a large ulcer with caseous tubercles covering its base; a similar but still lai-ger one was found in the cajcum, and smaller ones scattered through the small intestines.

In the microscopic examination of the larger of the two gastric ulcers, the section passed also through the adherent lymph gland, which was found to be completely necrotic. It


Apbil, 1897.]

79


was intimately adherent to the stomach, separated only by the remains of the muscular wall from the caseous masses within the stomach wall proper. The mucous membrane for quite a distance around the ulcer was infiltrated, becoming more or less necrotic at the edges, which were elevated and undermined. The deepest part of the ulcer had for its floor the muscularis, but the walls were formed by large caseous tubercles, some of which were completely necrotic. In the overhanging edge, which was formed by mucosa, and throughout the mucosa generally, were found small tubercles which, for the most part, had originated in the submucosa or muscularis mucosse. They represented all stages of tubercle formation. Giant cells were present in great numbers. Sections stained by the Ziehl-Neelsen method showed numerous tubercle bacilli, both in the superficial and deep layers.

In this case the question naturally arose whether or not the ulcerative process in the stomach was merely secondary, having been caused by the adherent lymph gland which had ulcerated through to the free surface. The microscopic examination proved, however, that the process in the stomach was quite independent in its origin, as the still intact muscular wall could be traced along the whole extent of the ulcer between it and the caseous gland behind.

Bibliography. Litten : Virchow's Archiv, 1876. Talamon ; Progres Medical, 1879. Brechemin: Bull. d. 1. Soc. Anat., May 1879. Eppinger: Prager Med. Wochenschrift, 1881.


Barbacci : Lo Sperimentale, May 1890.

Coats : Glasgow Med. Journal, 1886.

Serafini : Annal. clin. del Osp. di Napoli, 1888.

Mathieu and Remond : In Letorey's Thesis, Paris, 1875.

Musser: Phila. Hosp. Reports, 1890, I.

Kiihl : Thesis, Kiel, 1889.

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

Lava: Gazz. Med. di Torino, 1893.

Letorey: These, Paris, 1895.

Hattute: Gaz. des Hop., 1874.

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

Anger : In Marfan's Thesis, Paris, 1887.

Marfan : These, Paris, 1887.

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

Cazin : In Fernet's article. Bull, et Mem. d. 1. Soc. Med. des

Hop., 1880, t6me XVII. Beadles : British Med. Journ., 1893, II. Duguet: In Spillman's These, Paris, 1878. Paulicky : Berlin Klin. Wochenschrift, 1867. Chvostek : Wieu. Med. Blatt., 1882, V. Lange: Memorabilien. Heilbroun, 1871, XVI. Barlow : Path. Soc. London, 1887. Pozzi : Bull. Soc. Anat., 1868. Labadie-Lagrave : Bull. Soc. Anat., 1870. Oppolzer: In Marfan's These, Paris, 1887. Quenu : In Marfan's These, Paris, 1887. Oordua: Arbeiten aus dem pathalog. Institut in Gofctingen.

Berlin, 1893.


STUDIES ON TRICHINOSIS.


By T. R. Brown.


[Abstract of remarks and discussion before i

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

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

During his stay in the hospital the blood was examined daily. The number of leucocytes per cm. was determined and a differential count was made of the various forms; frequent examinations of the urine were made with quantitative determinations of the uric acid, urea and total nitrogen. The two small pieces of muscle which were removed were subsequently subjected to careful microscopical examination. The results of the studies may be summarized as follows:

(rt) The blood. The study of the blood was carried on con


the Johns Hopkins Hospital Medical Society.]

tinnally during the course of the disease, a determination of the leucocytes and a differential count of the various forms of leucocytes being made daily. The result of these observations showed : (a) A gradual rise of the proportion of eosinophiles, reaching 68.2 per cent — 35 per cent, higher than any previous record — and from this point a gradual decline to 16.8 per cent, on the patient's discharge; (b) a coincident depression of the polymorphonuclear neutrophiles, reaching at one time 6.6 per cent., while for two weeks these forms showed an absolute decrease in the blood, notwithstanding (c) the marked leucocytosis, reaching on some occasions above 30,000 per cubic millimetre.

In fact, the neutrophiles and eosinophiles showed at all times an inversely proportional relation, and the eosinophilic rise could be seen to be distinctly at the cost of the neutrophiles, the other forms showing relatively little fluctuation.

The presence of such quantities of eosinophiles suggests their possible diagnostic value in trichinosis, and perhaps, if it be found on further studies to be characteristic of this disease, may help to clear up the cases which are regarded intra vitam as rheumatic in nature and which, years afterward, the autopsy table shows to have been cases of trichinosis.

As an association has for a long time been noted between


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

{b) The uruie. The quantitative determinations of the uric acid, urea and total nitrogen were carried on mainly in connection with the ideas of Horbaczewski, that the uric acid, derived from the destruction of nuclein -holding material, comes normally in large part from the leucocytes and is therefore increased in leucocytoses.

Although the uric acid per 34 hours was determined on 23 different days, and on four of these the urea and total nitrogen also, on no occasion did the total uric acid excretion, or the relation between the nitrogen of the uric acid to that of the urea or to the total nitrogen exceed the normal limits, showing that the views of Horbaczewski are not universally correct. In this case, however, the leucocytosis differed somewhat from the ordinary in that here the eosinophiles were the cells markedly increased ; in his cases the ordinary polymorphonuclear neutrophiles.

(c) The mus'ie. The changes in the muscle were extensive. There was a great proliferation of the muscle nuclei throughout the section ; about the fibres containing trichina? this proliferation was very marked, especially in the second specimen ; not so extensive in the earlier specimen. In fact, in a few places where the parasite had but just wandered into the primitive bundle no change in the muscle substance nor any proliferation of nuclei was visible. Most of the fibres containing the worm showed a conversion of the muscle substance into a finely granular faintly-staining material containing many large swollen nuclei, i. e. the proliferated muscle nuclei ; and about many of the proliferated nuclei, both in the more and in the less degenerated portions, distinct vacuoles could be made out.

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

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

In the second specimen there were decidedly fewer neutro


philes and many more eosinophiles tlian in the first. That in

both cases these were typical eosinophiles was shown by staining them in the different acid stains and in the Biondi-IIeideuhein triple stain.

At the same time with this greatly increased projiortiou of eosinophiles in the extra-vascular leucocytes in the muscle, Ihe Mood vessels in the inferfascicuhir connective tissue showul the same proportion of neutrophiles and eosinophiles as icas found in the blood count for that day.

In another specimen of muscle from a case of acute trichinosis which was obtained from the pathological museum, great (juantities of eosinophiles were also found.

The study of the blood, showing the steady increase of the eosinophiles at the expense of the neutrophiles, together with the identical character of the nuclei of the two forms, would tend to support the view held by some observers, that the former variety of cells is derived by some transitional change from the latter.

That such a change might take place in the muscle is suggested by the presence here of neutrophiles, eosinophiles, and what may be regarded as transitional forms, in large quantities. Particularly suggestive is the great disproportion between neutrophiles and eosinophiles seen in the second muscle specimen. Here the eosinophiles were much increased, the neutrophiles correspondingly decreased, while the blood-vessels in the interfascicular connective tissue showed but the same proportion of these forms as was to be made out in the specimens of the peripheral blood for the same days. It is further noteworthy that the eosinojihiles increased in number soon after the increase in severity of the muscle symptoms, and shortly after the decrease of those symptoms, diminished gradually, descending toward the normal point as the symptoms abated. Suggestive also is the presence of large numbers of eosinophiles in a specimen of muscle from another case of acute trichinosis.

Dr. OsLBR. — This is the only case of trichinosis which has been in the hospital, or it is safer to say the only case recognized, since we know that not infrequently the disease escapes recognition or is mistaken for some other disorder. This is the second case which I have seen clinically, while in the postmortem room I have found on eight or ten occasions the calcified cysts. Mr. Brown is to be congratulated on the very thorough way in which he has followed this case.

Dr. Thayer. — The evidence offered by Mr. Brown in favor of the origin of the eosinophilic cells by transition from the so-called neutrophiles is very suggestive. The total number of polymorphonuclear cells found in the circulating blood was practically what one would expect in a leucocytosis of that extent. And yet, examining this percentage which normally should consist almost absolutely of so-called neutrophilic leucocytes, we find the great majority represented by eosinophiles. The fact also that in the affected parts the bloodvessels contained the same relative proportion of eosinophiles and neutrophiles as did the peripheral vessels, while the tissues round about contained an enormously greater percentage of eosinophiles, is very interesting.

That the so-called neutrophilic granules stain often with acid coloring matters is well known. With good acid dyes


April, 1897.]

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these granules almost always take a slight stain, and by sonie obseryei'S botli eosiuophiles and neutropbiles are classed as acidophilic cells. They stain, however, much better in fluids consisting of a mixture of acid and basic coloring matters. As Mr. Brown has sharply pointed out, this acid staining of the smaller granules was uot to be made out at all in the specimens of blood and in the blood-vessels in the tissues, and the fact that outside of the vessels in the affected parts numerous apparent transitional forms between the non-granular polymorphonuclear wandering cells and the true eosinophiles existed is very suggestive. That these cells were true eosiuophiles in the sense of Ehrlich, Mr. Brown has proven by careful tests with a number of different acid coloring matters.

The idea that the eosiuophiles represent a further change in the cell which we know as the neutrophile is, as Mr. Brown has said, not a uew one, but I am not aware that any argument in favor of this view as forcible as that which he presents has yet been published.

With regard to the actual blood condition — the increase of the eosinophiles — no similar case exists in the literature; the percentage of eosiuophiles in this instance is moi"e than twice as large as has been reported in any other case.

Dr. Barker. — Mr. Brown has referred, in speaking of the degeneration of the muscle, to a splitting up' of the muscle fibre into transverse disks. I should like to ask him whether or not he has been able to make out just where the splitting


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

I gather from his paper that Mr. Browu favors the view that the eosinophile granules represent the cyto-mikrosomas of the cells in which they occui\ This view, recently si;pported by Lovell Gulland, was previously urged by Martin Heidenhain, who found that the eosinojjhile granules stain black with his iron-haamatoxylin staining method, and that it is often possible to make out an arrangement of the granules radial to the attraction sphere of the cell. Both these observations are in favor of the cyto-mikrosomal nature of the granules.

The occurrence of such an enormous number of eosinophiles in the circulating blood is truly remarkable and makes the case unique in the bibliography.


PROCEEDINGS OF SOCIETIES,


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of December 7, 1896.

Dr. Thayer in the Chair.

On Certain Visceral Pathological Alterations, the Result of Superficial Burns.— Mr. Bardebn.

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

It is clear from this latter class of cases, at least, that alterations in the internal organs may follow the burning of the skin which cannot be accounted for on the supposition that they are directly caused by the heat. Thus arises the question as to the nature of the physiological relations between the lesions produced in the skin and the resulting constitutional effects. Many hypotheses have been advanced to answer this question, some of which have been supported and others destroyed by experimental work on animals.

Many of these hypotheses have been based upon the con


ception of a loss of normal cutaneous activity. But experiment has shown quite conclusively that death after burns is to be ascribed neither to the retention in the blood of products normally excreted through the skin, nor to heat radiation due to paralyzed blood-vessels in the latter structure.

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

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

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


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the histological alterations found in the tissues of the body after burns. A careful autopsy was made in each case by Dr. Flexner, and parts of the various organs were preserved and prepared for microscopic examination.

The lesions in all five cases were strikingly similar. Of the gross lesions the most notable were cloudy swelling of the liver and kidney, acute swelling of the spleen, and swelling and congestion of the lymphatic glands and other lymphatic tissue.

Microscopically, the most interesting lesions noted were parenchymatous degeneration of the kidneys and liver, focal areas of necrosis in the liver, and pronounced focal necrosis in the lymphatic tissue.

The lymphatic tissue was affected throughout the body. The Malpighian corpuscles of the spleen, the tonsils, gastric lymphatic follicles, enteric solitary and agminated follicles and the lymphatic glands all showed essentially the same changes.

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

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

Calvert has shown that the terminal artery breaks up in the centre of the follicle into capillaries which radiate towards the periphery of the follicle. It seems possible that the lesions focalized just at this region may in some way hold special relation to the circulation of tlie blood. For if the blood in these cases contains toxic materials, it is conceivable that it is just at the centre of the follicle that the poisonous plasma acts with greatest intensity on the lymph cells.

In the lymphatic follicles of the tonsils and stomach and in the Malpighian bodies of the spleen focal degeneration essentially similar to that of the follicles of the lymphatic glands occurs. In the intestines the greatly swollen lymphatic follicles, solitary and agminated, showed extensive focal areas of degeneration.

In these areas of degeneration in the lymphatic tissue we find appearances essentially similar to those seen after the injection into the body of various bacterial and other toxalbuminous substances. Indeed, the lymphatic glands from our cases of skin-burn might readily be mistaken for the lymphatic glands of children dead of diphtheria. The


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


NOTES ON NEW BOOKS.

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

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

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

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

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

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

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

The section on gynecology, by Baldy and Borland, occupies upwards of 200 pages, and touches upon a variety of interesting


Apeil, 1897.]

83


matter. The objection presented to Clark's radical operation for the relief of uterine cancer, that but few patients can endure the shock of the prolonged etherization, seems hardly tenable in the light of actual practice. The chapter on nervous and mental diseases, by Church and Patrick, is thoroughly well worked out, and presents a good review of the work of the past year. The section on materia medica is an excellent feature of the book. All things considered, the book is well arranged, admirably edited and well printed. Every physician who does not have leisure to inform himself on the latest advances in medicine and surgery from original sources, should procure and carefully read the volume.

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

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

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

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

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


BOOKS RECEIVED.

Transactions of the American Gynecological Society. Vol. 21. 1890.

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

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

1184 pages. P. Blackiston, Son & Co., Philadelphia. Anomalies and Curiosities of Medicine. By George M. Gould, A. M., M. D., and Walter L. Pyle, A. M., M. D. 1897. 4to. 968 pages. W. B. Saunders, Phila. A Pictorial Atlas of Skin Diseases and Syphilitic Affections. In Photo-Lithochromes from Models in the Museum of the Saint Louis Hospital, Paris, with explanatory woodcuts and text. By E. Besnier et al. Edited by J. J. Pringle, M. B., F. R. C. P. Part VI. 1896. W. B Saunders, Philadelphia. A Treatise on Cholelithiasis. By B. Naunyn, M. D. Translated by Archibald E. Garrod, M. A., M. D., F. R. C. P. 8vo. 197 pages. 1896. The New Sydenham Society, London. Principles or Guides for a Better Selection or Classification of Consumptives Amenable to High Altitude Treatment and to the Selection of Patients who may be more Successfully Treated in the Environment to which they were Accustomed Previous to their Illness. By A. Edgar Tussey, M. D. 1896. 8vo, 144 pages. P. Blakiston, Son & Co., Philadelphia. Twentieth Century Practice. An international encyclopaedia of mod ern medical science, by leading authorities of Europe and America Edited by Thomas L. Stedman, M. D. Vol. X. 1897. 859 pages 8vo. Wm. Wood & Co., New York. Transactions of the College of Physicans of Philadelphia. Third SeriesVol. XVIII. 1896. 8vo. 263 pages. Printed for the College Philadelphia. Injuries and Diseases of the Ear. Being reprints of papers on otol ogy. By Macleod Yearsley, F. R. C. S. 12mo. 1897. 40 pages The Rebman Publishing Co., Ltd., London. The American Tear-Book of Medicine and Surgery. Being a yearly digest of scientific progress and authoritative opinion in all branches of medicine and surgery, drawn from journals, monographs and text-books of the leading American and foreign authors and investigators. Collected and arranged, with critical editorial comments, by J. M. Baldy, '^l.D.,ei al. Under the general editorial charge of George M. Gould, M. D. Profusely illustrated. 4to. 1897. 1257 pages. W. B. Saunders, Philadelphia. Inebriety. Its Source, Prevention and Cure. By Charles Follen Palmer. 12mo. 1897. 109 pages. Fleming H. Revell Co., New York. The Medical Annual and Practitioner's Index. A work of reference for medical practitioners. Fifteenth year. 1897. 12mo. 851 pages. John Wright & Co., Bristol. Lectures on Angina Pectoris and Allied Stales. By William Osier, M.D. 1897. 8vo. 160 pages. D. Appleton & Co., New York.


84

[No. 73.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report in Patliolopry The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

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

Mall, M. D.

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

T. C. Gilchrist, M. D., and Emmet Rixford, M. D. A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

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

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

T. C. Gilchrist, M. D.

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

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


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

Report in Medicine.

On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with

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

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

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

A. Kelly, M. D.. and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards mth out Operation ; Composite Temperature and Pulse Charts of Forty Cases of

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

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

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

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

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

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

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

HowARD A. Kellt, M. D.

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

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

Henry M. Thomas, M. D.

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


Volume III. 766 pages, with 69 plates and figures.

Report in Patliology.

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

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

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

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

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

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

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

Report in Gyneeolog-y.

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

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

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


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

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

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

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

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

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

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

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

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

Report in Neurolog-y*

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

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

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


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

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

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


Volume VI. About 500 pages, many illustrations.

Report in Nenrolofo**

Studies on the Lesions produced by the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nob. I to V). By He.vry J. Berkley. M. D.

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

Report in Patliologry.

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

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

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BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No. 74.]


BALTIMORE. MAY, 1897.




GO]srT:E3srTS.


PAGE.

The Association between the so-called Perinuclear Basophilic Granules and the Elimination of the Alloxuric Bodies in the Urine. By T. B. Fittcher, M. B., 85

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

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

A Case of Porokeratosis (Mibelli) or Hyperkeratosis Excen


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

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

A Rapid Method of making Permanent Specimens from Frozen

Sections by the Use of Formalin. By Thomas S. Cullen,

M.B., Proceedings of Societies :

Hospital Medical Society,

Typhoid Perforation treated by Surgical Operation [Dr. Finney].

Notes on New Books,

Books Received, - ..


107


108


113 113


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

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


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


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

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


86



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

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

With the exception of the above difference, Neusser and Kolisch agree that the occurrence of the perinuclear basophilic granules indicates an increase in the nuclein constituents of the blood. Direct analyses of the blood for the amount of nuclein contained in it were naturally not made; and pure color reactions, even from a qualitative standpoint, are unreliable, as shown by L. Heine. If one accept without further questioning Neusser's view that the perinuclear granulation is a morfihological criterium for an over-production of nuclein derivatives from the cell nuclei, it is not easily explainable why an increase in the quantity of the alloxuric bodies eliminated in the urine should follow. If one considers these granules identical with the pyrenogenic granules of Lowit found in the leucocytes of the river crab (in the arthropoda the uric acid is not formed from the nuclein materials) and in certain normal leucocytes of the bone-marrow, then they fall under the general heading of karyorhexis or breaking up of the nucleus, and would more likely indicate a chromatolytic degeneration of the leucocytes. Prof. Kraus was able to demonstrate similar granules in the liver cells when portions of the liver substance were removed from the body while still warm and kept in a moist chamber at 40° C. At a definite stage in the breaking down of the nuclei he found granules in the protoplasm of the liver cells resembling and staining similarly to those found in the leucocytes by Neusser. If such a condition takes place under any circumstances, either physiological or pathological, in the living person, an increase in the alloxuric bodies eliminated might be expected.

In studying the subject of Neusser's granules I have endeavored to determine whether there is any regular coincidence between the presence of these granules and the elimination of the alloxuric bodies, and further, whether the granules are found only in cases showing the symptoms of a uratic diathesis.

Doubt as to this intimate association arose in my own mind while examining the blood of patients for the basophilic


granules, at first without studying their effect on metabolism. In a very large number of cases examined, both in healthy and diseased persons, I have never failed to find the granules present. Four of these cases were cases of true gout with typical joint affections and well defined tophi in the ears. In two of these cases the granules were very abundant, but not more so in the mononuclear than in the polymorphonuclear leucocytes. In the remaining two cases they were on the whole not very abundant, and the polymorphonuclears showed the granules more numerous than did the mononuclears. Further, I was able to convince myself, both in Baltimore and in Graz, that the granules were not more marked in the blood of patients suffering from the so-called uratic diathesis than in other diseases, or even in certain apparently healthy individuals. The fact that the granules are found in other diseases than in uratic diathesis, and also in healthy persons, lessens their clinical interest. Neusser believed their presence in tuberculosis was a favorable sign. In this disease I have observed cases with abundant granules and others with few granules without noticing any difference in its subsequent course. The granules vary in richness in the leucocytes from day to day in the same individual, notwithstanding his living under the same conditions of nourishment, etc. This fact seems to diminish the significance of the granules. It seems more common for variations of this kind to occur than for the granules to remain constant from day to day. No method seemed practicable for making an accurate count of these granules, and in the following cases reported it seemed sufficient for all practical purjioses to stain the specimens of dried blood and to compare from day to day the amount of granulation present in the different forms of leucocytes.

The following cases, in which the basophilic granules and their effect on metabolism were studied, were undertaken especially to ascertain whether the amount of granulation present really influenced the quantity of the alloxuric bodies eliminated in the urine.

In all, 8 cases were carefully studied. Blood specimens were stained each day with Neusser's staining mixture, and the same technique followed from day to day. The patients were as nearly as possible brought under the conditions of nitrogenous equilibrium before the observations on the urine were concluded. Each case was followed for a period of 5 to 6 days, and during this time the same amount of food was taken each day, and the body weight from day to da\' remained practically constant. The total amount of nitrogen ingested in the food and eliminated in the urine and fteces was estimated daily. In all the cases the alloxuric bodies were estimated, and in two cases the uric acid as well. The nitrogen was detei-mined according to the method of Kjeldahl, the uric acid according to Ludwig's, and the alloxuric bodies according to the Kriiger-Wulf* methods.

In order to assist in the understanding of the following tables I give what is considered the normal amount of nitrogen in grams contained in the alloxuric bodies for the 24 hours, as found by various observers who have made determinations up to the present date.


•Zeit. flir physiol. Chemie, Bd. XX.


May, 1897.]

87


For the 24 hours :

Kolisch gives 0.260 gram.

Weiutraud (1) 0.344-0.360

(2) 0.433-0.534 Richter 0.380

Magnus-Levy 0.506

Richter 0.387

I myself found in healthy persons (1) 0.499

(2) 0.551

Judging from these analyses it may be considered that values above 0.4 gram are physiologically high, while those above 0.5 gram may be regarded as pathological.

Case 1. — Dr. K., aged 32 years, weight 79.5 kilograms, with a well-marked tendency to a gradually increasing corpulence. Not inclined to undertake great muscular exertion, but in every respect perfectly healthy. After nitrogenous equilibrium had been established, 1.5 liters of Carlsbad water (Miihlbrunn) were drank daily for a period of 8 days.

The daily diet was as follows: Ham, 150 grams; roast beef, 100 grams ; milk, 500 grams ; 6 breakfast rolls ; butter, 65 grams; rice, 60 grams; sugar, 3 pieces; black coffee (infusion), 100 grams ; sherry, 100 grams ; soda water, 2 bottles.

The above diet represented about 1968 calories (about 25 calories per kilogram body weight), which were made up as follows :


Albumin Pat

Carbohydrates Alcohol


Total


362.17 calories. 837.73 646.35 122.15

1968.40


Table 1. — The Urine.


Date.


Q



a

U ID


at

'"C in


if



July 6 " 7 " 8 " 9 " 10 " 11 " 12 " 13* " 14 " 15 " 16 " 17 " 18 " 19 " 20


1

3 4

5 () 7 8 (1

10 11 12 13 14 15


995 1240 1630 1200 1080 1160 1630 2270

2«no

2345 27C0 3120 3045 2920 2810


14.7638 12.8898 14.7759 14.0700 15.5547 15.0666 15.4947 15.7682 14.1159 15.3560 13.9482 15.5719 12.9062 14.9825 14.. 3732


0.6042 0.4.318 0.5262 0.4169 0.4430 0.5602 0.5058 0.4149 0.4459 0.4042 0.3780 0.3849 0.3810 0.3244 0.4025


0.2550 0.2613


4.16 3.35 3.56 2.97 2.84 3.71 3.26 2.63 3.16 2.63 2.71 2.47 2.95 2.16 2.80


From 13 to 20 Carlsbad water was drunk. 


Table II. — Nitrogen Balance (N in Grams).


Date.


0% P


41


£ Si


NITROGEN ELIMINATED.


i ,

a — "3 |a|


S


Brlue.


FcBoes.


a


July 10 " 11 " 12

" 19 " 20


5 6

7 14 15


79.300 79.800 79.900 79.050 79.050


16. 2347 15.9769

18.6598


15.5547 15.0666 15.4947 14.9825 14.3732


1.1832 1.1832

'3.3325


16!2498 16 6779

17! 7057


— o'.7oio

+b'.954i


Condition of the leucocytes with reference to Neusser's granules : During the jjeriod in which no Carlsbad water was taken the granules were present only in very moderate numbers. On the other hand, from July 16th to 20th, during which the water was drank, there was a very distinct increase in the number of granules present in all the forms, particularly in the mononuclear leucocytes. At the same time it will be seen that there was a marked diminution in the allo.xuric bodies as represented by the amount of nitrogen eliminated.

Observation II. — Dr. L., a perfectly healthy man, aged 25 and weighing 69.5 kilograms. Muscular, moderate panniculus adiposus, and of a quiet disposition. My colleague, after bringing himself to a point of equal daily nitrogen elimination, drank Carlsbad water for a period of 4 days (1.5 liter of Muhlbruun per day).

The daily diet was as follows : Ham, 250 grams ; veal, 250 grams; milk, 100 grams; wine, 500 grams; tea (black infusion), 250 grams; rum, 15 grams; butter, 50 grams; breakfast rolls, 3.

The above food represented about 1895 calories daily (27 calories per kilo body weight), which were made up as follows:


Albumin Fat

Carbohydrates Alcohol


511.73 calories. 785.49 341.69 256.88


Total


1895.79


Table III.— Urine.


Q


0^


Dally amount of urine In com.


S Ml if


- u a

|g|i


A,


Percentage of alloxurlc body— N of total nitrogen.


June 12


1


1430


25.2421


0.5710



2.27


" 13


9


1815


30.1310


0.5595



1.85


" 14


3


1800


28.1925


0.5237



1.85


" 15


4


1880


30.3996


0.5791



1.90


" 16


5


2000


30.0650


0.5217


0.4222


1.73


" 17*


6


1890


27.2868


0.6515



2.38


" 18


7


3110


29.4983


0.5421



1.83


" 19


8


2840


28.40


0.6908


0.4222


2 43


" 20


9


2730


27.30


0.6162



2.10


f From June 17 to 20 Carlsbad water was drunk.

Table IV.— Nitrogen Balance (N in Grams).



1^


38


t

S

NITBOGEN eliminated.



S



Urine.


FsBces.


a

n


June 14 " 15 " 16 " 19 '• 20


3

4 5 8 9


69.700 6".700 69.800 70.200 70.000


31.7345 31..=S645 31.6679 31.5979


36.3996 30 ('650 28.40 29.30


l.'3V42 1.2619


31.3792 36.5702


+0 8536 -|-'l'.5643


Relation of Neusser's granules in the leucocytes: In the period before Carlsbad water was taken, with the amount of the alloxurlc bodies above the normal (and with a large amount of uric acid), the granules were not particularly abundant. In the second half (June 17-20), when the water was taken, the amount of the alloxurlc bodies eliminated was still higher,


88



whereas the granules had become distinctly diminished in nnmber, particularly in the small mononuclears.

Observation III. — A. F., a young woman, 33 years old, and a cook by occupation. She bad a severe anasmia (red corpuscles 1,900,000 per ccm., leucocytes 6800, and hiemoglobin 35 per cent, according to Fleischl's ha^monieter). The temperature was normal during the observation. Pulse averaged 110 per min. Slight dyspnoea even when at rest. Patient was of rather large frame, and the panniculus adiposus was not particularly reduced. No oedema ; urine free from albumin. Had suffered previously from some gastric trouble, but the symptoms had disappeared. From June 35th to July 7th her weight had become reduced from 57 to 53.4 kilograms.

The daily diet was as follows : Ham, 100 grams ; white bread, 100 grams ; milk, 500 grams; wine (white), 350 grams; water, about 1000 grams.

The diet administered represented about 938 calories (17 per kilo body weight), which were made up as follows :


Albumin Fat

Carbohydrates Alcohol


307.46 calories. 319.30 379.49 133.50


Total


938.65


Table V. — Ukinb.


Date.


1


a

h


.a


2

a a 2


a-2


ntage of uric -Nof otal nl









t>


? a


1



g « o « 


Perc alio bod the trog


July 1


1


1300


1022





" 2


9


1400


1010


10.0940


0.4827


4.78


" 3


3


1100


1014


8.8358


4832


5.46


" 4


4


950


1018


8.0964


0.3608


4.44


" 5


ft


1100


1016


9.9715


0.3735


3.72


" 6


6


750


1028


7.7963


0.3793


4.86



Table VI. — Nitkoqen Ingested (in Grams).



Date.


Day of observation.


Ham.


White bread.


Milk.


wine.


Total nitrogen.


July 1

" 3 " 4 " 5 " 6


1 2 3 4 5 6


4.4480 4.4480 4.4480 4.4480 4.4480 4.4480


1.5236 1.5236 1.5236 1.5236 1.5236 1.5236


2.9925 2.9925 2.9225 2.9225 2.9575 2.9575


0.0568 0.0568 0.0.i68 0.0568 0.0568 0.0568


9.0209 9.0209 8.9.509 8.9509 8.9859 8.9859


Table VII. — Nitkogen Balance (N in Grams).



o g


>,SS

1^


ll


NITBOGEN ELIMINATED.


111


g



Drluo.


Fceces.


B


July 1 " 2 " 3 " 4 " 5 " 6


1 2 3 4 5 6


54.200 54.300 54 200 53 9011 53.600 53.200


9.0209 9 0209 8.9509 8.9509 8.9859 8.9859


lb'.6940 8.8358 8.0964 9.9715 7.7963


b;3879 0.3879 0.3879 0.3879 0.3879


10.4819 9.2237 9.4843

10.3.594 8.1842


— l'.46i6 —0.2728 -0.5333 —1.3735 +0.8017


Relation of Neusser's granules in the leucocytes : On the day before the analyses were begun the granules were present in very small numbers in the leucocytes. This was also the


case on July 1st and 3nd, when a relatively high amount of alloxuric bodies was being eliminated. On July 3rd there was an apparent and on the following days a very marked increase in the number of granules, whilst the nitrogen of the alloxuric 1)odies both absolutely and in percentage became diminished. Observation IV. — Patient was a woman 45 years of age. Fourteen years ago she had her first severe attack of articular rheumatism, although she has had milder attacks since 1881. Both hands at present show characteristic deformities. Since 1891 she has had symptoms of some cardiac lesion. In 1895, tricuspid and aortic insufficiency was diagnosed. During the period that the patient was under observation she was comparatively well ; good diuresis and no cedema. Average pulserate, 80 ; respirations, 23. Moderate body exertion was possible without dyspnoea. Cyanosis was quite marked.

The diet was as follows : Ham, 100 grams ; breakfast rolls (4), 308 grams; milk, 500 grams; wine (white), 350 grams; tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces), 30 grams ; Rohitsch water, 300 grams.

These food materials represented about 1386 calories (36 calories per kilo body weight), which were made up as follows:

Albumin 334.19 calories.

Fat 323.47

Carbohydrates 643.19

Alcohol 185.50


Total 1386.35

Table VIII.— Urine.



i


a ga



,


^


% oo


Date.


°


Eg .


i


d j


§ "^ ffl


¥^i'u










f^


fi°"


% g


|gi


§5?g


Perc

bod tho trof


July 19


1


2400


1012


8.2320


0.3276


3.97


" 20


2


2800


1007


9.6530


0.4459


4.61


" 21


3


2150


1012


9.9706


0.3517


3.52


" 22


4


1400


1014


9.6530


0.3463


3.58


" 23


5


700


1023


9.9356


0.4383


4.41


Table IX. — Nitrogen Ingested (in Grams).



Day of



Date.


observation.


Ham.


July 19


1


5.2052


" 20


2


5.2052


" 21


3


5.2052


" 22


4


5.2052


" 23


5


5.2052


3.3473 2.9837

3.3473 2.9837

3.3473 2.8787

3.3473 2.6950

3.3473 2.9312


0.0785 0.0785 0.0785 0.0785 0.0785


0.1312 0.1312 0.1312 0.1312 0.1312


11.7459 11.7459 11.6409 11.4572 11.6934


Table X. — Nitrogen Balance (N in Grams).


Date.



.1


2

NITBOGEN ELIMINATED.


i .


§


Urine.


Fffices.



July 19 " 20 " 21 " 22 " 23


1 2

3

4 5


47.700 47.400 46.800 45.700 46.000


11.7459 11.7459 11.6400 11.4572 11.6934


8.2320 9.6530 9.9706 9.6530 9.9356


0.9985 0.9985 0.9985 0.9985 0.9985


9.2305 10.6515 10.9691 10.6488 10.9341


+2.5158 +1.0944 +0.6718 +0.80S4 +0.7593


Relation of Neusser's granules in the leucocytes: On the first two days of the observation the granules were comparatively few. On Jiily 21 they were relatively increased, whilst the alloxuric bodies, which had been comparatively high on the 20th, were distinctly diminished in quantity.

Observation Y. — The patient was a brewer, 30 years old, with hypertrophic cirrhosis of the liver. Since 1895 he has had icterus, with tenderness in the region of the liver. The jaundice has had a tendency to disappear and reappear. The faeces at times would be distinctly bile-tinged, and at other times free from biliary coloring matter. Appetite good. At present there is a characteristic enlargement of the liver and spleen, no ascites, and no well marked evidence of collateral circulation. No elevation of temperature. Rather poorly nourished ; weight has varied between 62 and 59 kilograms since April 10. Has a retinitis. Urine is free from albumin.

The daily diet was as follows : Ham, 300 grams ; bread, 700 grams ; wine, 500 grams ; tea (infusion), 500 grams ; mm, 30 grams ; sugar (6 pieces), 30 grams ; soda water, 4 bottles.

These food materials represent about 2806 calories (47 calories per kilo body weight), which were arranged as follows:


Albumin Fat

Carbohydrates Alcohol


516.27 calories. 256.21 1726.10 308.00


Total 2806.58

Table XI. — Urine.








^


Date.


1


i



Is

a 5


s?3i2 i


HS^.^



P^


¥


aui


s 3i

o a




May 15


1


1630


1026


13.2511


0.4773


3.60


" 16


2


1830


10:i3


14.6564


0.4153


2.83


" 17


3


1550


1023


16.2778


0.5089


3.12


" 18


4


nno


1024


17.2238


0.4918


2.85


" 19


5


2040


1024


20.2051


0.4118


2.03


" 20


6


1690


1022


16.4352


0.4771


2.90


Table XII. — Nitrogen Ingested (in Grams).


Date.


Day of observation.


Ham.


Bread.


White wine.


Total nitrogen.


May 15-19 " 20


1-5 6


13.0454 11.3237


7.9398 7.9398


0.2625 0.2625


21.2477 19.5260


Table XIII. — Nitrogen Balance (N in Grams).






NITROGEN ELIMIN

o^





^


§2


ATED.


a — t3


<0


Date.








1^


1?


§1


Urine.


Faeces.


5gi


n


May 15


1


59.200


21.2477


13.2510


2.2526


15.5036


-1-5.7741


" 16


2


58.500


21.2477


14.6564


2.2526


16.9090


-1-4.3387


" 17


3


58.500


21.2477


16.2778


2.2526


18.5304


-f2.7173


" 18


4


58.9(10


21.2477


17.2238


2,2526


19.4764


-hi 7713


" 19


5


59.400


21.2477


20.2051


2.2526


22.4577


-0 7900


" 20


6


60.000


19.52G0


16.4352


2 2o26


18.6878


-t-0.3611


Relation of Neusser's granules in the leucocytes : Several days before the commencement of the chemical analyses the granules were much more numerous than they were during the period of examination. There was no variation observed


during the latter period. Altogether the granules were only moderately numerous, but not more so in the mononuclear than in the other varieties of leucocytes. Some of the mononuclears were without granules. It will be seen that the amount of the alloxuric bodies was relatively high.

Observation VI. — This patient was a man also with hypertrophic cirrhosis of the liver. Since 1893 he had complained of gastric and intestinal symptoms. In 1895 enlargement of the liver and spleen was noticed. Icterus has been persistent, with the exception of one interval when he was free. Weighed 49 kilo when he came to the clinic, but has gained slightly since. The blood examination showed 2,500,000 red corpuscles, 7900 leucocytes, and 55 per cent hajmoglobin (Fleischl).

The daily diet was as follows: Ham, 300 grams; white bread, 450 grams ; milk, 500 grams; wine (red), 300 grams; tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces), 30 grams : Kohitsch water, 2 bottles.

The above diet represented about 2370 calories (48 per kilo body weight), which were made up as follows :


Albumin Fat

Carbohydrates Alcohol


515.65 calories. 385.02 1161.38 308.00


Total 2370.05

Table XIV. — Urine.



C*


2



g



o


Date.


Q^


g^8


as


-2 2 a a

1 °

|a


Alloxuric

body— N 1 grams.


Percentage alloxurlo body— N the total n trogen.


June 7


1


2500


1015


14.4813


0.6650


4.59


" 8


2


2050


1017


16.3590


0.6188


3.78


" 9


3


3200


1013


15.5680


0.7056


4.53


" 10


4


4000


1011


16.2400


0.5425


3.34


" 11


5


2500


1014


15.8375


0.7131


4.50



Table XV. — Nitrogen Ingested (in Grams).*



Date.


Day ot observation.


5am.


Bread.


Milk.


Red wine.


Total nitrogen.


June7A8 " 9&lfi " 11


1 &2 3<s4 5


12.2257 12.2257 12.2257


6.3503 6.3503 6.3503


2.8525 2.8175 2.6162


0.1225 0.1225 0.1225


21.5510 21.5160 21.3147


^Tea, rum and sugar not analyzed.

Table XVI. — Nitrogen Balance (in Grams).




1^


S

NITBOQEN eliminated.



g



Drlne.


Faeces.



June 7 " 8 " 9 " 10 " 11


1

2 3 4 5


49.500 49.400 49.200 50.000 49.600


21.5510 21.5510 21.5160 21.5160 21.3147


14.4812 16.3590 15.5681) 16.2-100 15.8375


1.6595 1.6-95 1.6595 1.659.i 1.659.-,


16. 14071-1-5.4 103 IS !)l85l-f-3 5325 17 227^1-1-4.2885 17.8995-|-V61(i5 17.49704-3.8177


Relation of the Neusser's granules in the leucocytes: Altoo-ether the granules were very few in all the different forms. Most of the white corpuscles are entirely free from the granules, and many almost entirely free. During the period that


90



the patient was under observation there was no apparent variation in the richness of the grannies. On the other hand, the alloxuric body nitrogen was both absolutely and relatively high (0.67, 0.71 gram per day).

Observation VII.— A. man, 20 years old, with physical signs of a commencing left-sided pulmonary tuberculosis. No tubercle bacilli were found in the sputum, however, after repeated examinations. His weight on May 26th was 57 kilo ; he was fairly well nourished. During the period of observation he was free from fever. Leucocytes were 10,000 per cmm. ; hemoglobin 70 per cent (Fleischl).

The daily diet was as follows: Ham, 300 grams,; white bread, 450 grams; milk, 500 grams; wine, 500 grams; tea (infusion), 500 grams; rum, 30 grams; sugar (6 pieces), 30 grams; Eohitsch water, 2 bottles.

The above food represented about 2370 calories (41 per kilo body weight), which were made up as follows:


Albumin Fat

Carbohydrates Alcohol

Total


615.65 calories. 385.02 1161.38 308.00

2370.05




Table XVII.—


Urine.





i


I




a


» O


Date.



§H


uj?


a a « 


S 1 2


S S 1 1 a




>.H







a "


a"



g MM


S o 2

^O M


Perc alio bod

the troj


May 27


1


4200


1010


15.5820


0.6064


3.89


•' 28


2


3450


1012


19.6822


0.5796


2.89


" 29


3


2700


1013


21 3097


0.5953


2.79


" 30


4


3000


1012


18.7950


0.5853


3.11


" 31


5


3400


1014


20.3490


0.5533


2.72


June 1


6


3350


1012


20.2842


0.5803


2.86


Table XVIII.— Nitrogen Ingested (in Grams)


.*


Date.


Day of observatlou.


Ham.


Bread.


Hllk.


wine.


Total nitrogen.


May 27 & 28 " 29 " 30 Maj 31 & June 1


1 42 3 4 5


15.3515 15.3515 17.4240 17.4240


5.8262 5.8262 5.8262 5.8262


3.9094 2.7956 2.7956 2.9198


0.0350 0.0350 0.0350 0.0350


25.1220 24.0083 26.0808 26.2050


  • Tea, rum and sugar not analyzed.



Table


XIX.— Nitrogen Balance (in Grams).



ig




NITROGEN ELIMIN

itroIm







o« 


Ji,


win










Jat i



O "


S^


»i

TJrlne.


Faeces.


gss « 


May 27


I


57.700


25.1222


15.5820


1.2634


16.8454+8.2763


" 28


2


.'>6.20(i


25.1222


19.6822


1.2634


20.9456+4.1766


" 29


3


55 400


24.0083


21.3097


1.2634


22.5731+1.7352


" 30


4


56.2011


26.0808 1 18.79.50


1.2634


20.0584+5.9214


" 31


5


56.2(0


26.2050 j 21.1.3490


1.2634


21.6124+4.5826


June 1



50.200


26.2050 i 20.2842

1


1.2634


21.5476+4.5574


Eelation of Neusser's granules in the leucocytes : The granules are altogether extremely numerous, particularly in the small mononuclears. There was no appreciable variation in the granules from day to day. In this case, with the large


number of granules, there was found to be an elimination of a large quantity of alloxuric body nitrogen.

Observation VIII. — The patient was a woman 45 years of age, with cirrhosis of the liver. Since 1895 she had complained of gastric symptoms ; pain in the epigastrium. Had emaciated considerably. Had been jaundiced. Thegastric juice showed a very marked acidity ; free and combined HCl 0.35 to 0.41 per cent, and free HCl alone 0.22 to 0.28 per cent. The liver was enlarged, hard and nodular. Spleen was not much enlarged, but was hard and could be palpated at the costal margin. Body weight averaged about 60 kilos. Vomiting was frequent and patient was moderately ansemic.

The daily diet was as follows : Bread, 300 grams ; milk, 500 ; wine, 500 ; tea (infusion from 6 grams), 250 grams ; rum, 30 grams; sugar (6 pieces), 30 grams; Eohitsch water, i bottle.

These food stuffs yielded about 1752 calories (28 calories per kilo body weight), which were made up as follows:


Albumin Pat

Carbohydrates Alcohol


283.31 calories. 233.43 927.33 308.00


Total 1752.07

Table XX.— Urine.


Date.



3

a 2

.bo



a a o!

Sis


SoSS


Percentage of alloxuric body— N of the total nitrogen.


June 24


1


1350


1023


12.4504


0.4831


3.87


" 25


2


lOOO


1022


10.7800


0.4498


4.17


" 26


3


550


1027


8.1428


0.4591


5.63


" 27


4


850


1025


11.5133


0.5087


4.32


" 28


5


1050


1020


11.0618


5375


4.85


" 29


6


1500


1018


11.1938


0.4594


4.10



Table XXI. — Nitrogen Ingested (in


Grams).*



Date.


Day of observation.


Ham.


Bread.


Milk.


wine.


Total nitrogen.


June 24 " 25 " 26427 "28429


1

2 3&4 546


8.8242 6.3491 48425 4.8425


5.6056 5.6056 5.6056 5.6056


2.7037 2.70J7 2.6C95 2.8875


0.0350 0.0350 0.0350 0.0350


17.1685 14.6934 13.0926 13.3706


  • The variation in the nitrogen in the ham was due to the fact

that the patient could not continue to take the full quantity (220 grams) that she was first given.



Table XXII.—


Nitrogen Balance (in Grams).




Ǥ




NITKOGEN ELIMIN

i . US .





s


as


ATED.


8


' ®*




£ Si




is^


§



a"


S^


a

Urine.


FtBces.


oS2


a


June 24


1


60.700


17.1685


12.4503


1.3508


13.8011


+3.3674


" 25


2


60.400


14.6934


10.7810


1.3508


12.1308


+2.5626


" 26


3


59.600


13.0926


8.1427


1.3508


9 4935


+3.5991


" 27


4


59.900


13.0926


11.5132


1.3508


12.86401+0.2286


" 28


5


59.700


13.3706


11.0617


1.3508


12.41251+0.9580


" 29


6


59.500


13.3706


11.1937


1 .3-^08


12.5445|+0.8261


Eelation of Neusser's granules in the leucocytes: The granules were very numerous, especially in the mononuclears.


Mat, 1897.]

91


although there was considerable variation in the granules from day to day. As will be seen from the table there was a large amount of alloxuric body nitrogen eliminated.

These observations that have been made do not in any way confirm the theory that there is a regular coincidence between an abundance of the granules and an increased excretion of the alloxuric bodies, nor do they favor the view that Neusser's granules occur exclusively in patients with an alloxuric diathesis. Cases occur in which, with numerous grannies in the leucocytes, there is a relatively small amount of the alloxuric bodies eliminated in the urine, while on the other hand the granules may be almost entirely absent and the alloxuric bodies be excreted in increased amount. Such directly opposed conditions may occur in different individuals having the same


disease, as in the two cases of hypertrophic cirrhosis of the liver. Not infrequently the granules become increased or diminished in the same person without there being a corresponding increase or diminution in the excretion of the alloxuric bodies. In fact, increase in the number of granules may be accompanied by a diminution of the alloxuric bodies and vice versa.

From the information obtained by the study of the above cases one seems justified in concluding thattlie supposed relationship between the perinuclear basophilic granules and an alloxuric diathesis, as claimed by Kolisch, is purely empirical.

In conclusion, I must thank Professor Kraus and his assistants for many kindnesses and for valuable aid in carrying on the above analyses.


ENCYSTED DROPSY OF THE PERITONEUM SECONDARY TO UTERO-TUBAL TUBERCULOSIS AND

ASSOCIATED WITH TUBERCULAR PLEURISY, GENERALIZED TUBERCULOSIS

AND PYOCOCCAL INFECTION.

By Claribel Cone, M. D., Professor of Puthology, Woman's Medical College, Baltimore. [From the Pathological Laboratory of the Johns Hopkins University and Hospital]


The following case is of interest not so much because of lesions in themselves unique, as because of the rare combination of many lesions, the extensive character of these lesions, and the multiple nature of the infection.

The case has many features in common with that reported by Gardner,' of Montreal, in the year 1885, and is similar to those described by Wm. T. Howard,' of Baltimore, the same year.

Clinical History.

N. A., primipara, aged 30 years ; colored. Admitted to the Maternite of the Hospital of the Good Samaritan, in the service of Dr. B. B. Browne, November 19, 1894.

The patient had been married several years ; had no children, no miscarriages. Menstruation commenced at the age of 15 ; it had always been regular, painful and profuse, lasting from six to eight days, during which time she was compelled to remain in bed. Her last jieriod occurred about the middle of March, 1894.

Past History. No family history could be obtained. The patient had measles after reaching adult life. Five years ago she suffered with an attack of " malaria " which lasted three months ; at this time she claims to have been " very sick." The attack recurred in September, 1894.

History of Present Condition. The patient is in the eighth month of her pregnancy. Throughout this time she has been feeling ill ; she has had pain in the back and abdomen, increased on exertion. At present there are constant backache, and pain in the lower part of the abdomen. Appetite is good ; bowels constipated ; urine of low specific gravity, otherwise normal.

E.t'xmination. Fcetus occupies the left occipito-posterior position. In the right iliac region is a mass, partly soft, partly resistant, which seems to be connected with the uterus, and is not painful except on deep pressure.


On November 18 at 9.30 p. m. the woman was delivered of a healthy child, but owing to uterine inertia the placenta had to be removed. The labor was protracted, lasting 38 hours. The perineum was lacerated and repaired at once. Two days after delivery the patient was attacked with a chill followed by fever and sweating. The record of the puerperium shows an irregular temperature of septic character whose highest point was 104.3°, whose average was 103°. There was no fever after the second week and the patient's condition was recorded as good.

On January 19, 1895, she was discharged from the hospital apparently in fair health. The following April the patient visited the hospital clinic for treatment, considering herself again pregnant since February. In July, 1895, she returned with enlarged abdomen and general discomfort. At this time she claimed to have felt the foetal movements; in August she was seen at the clinic by Dr. B. B. Browne, who, after examination, did not think her pregnant.

Second Admission. In October, still believing herself pregnant, the woman was readmitted to the Maternite. After careful examination under an anaesthetic, pregnancy was definitely excluded from the diagnosis. At this time a large hard mass was found to the right of the uterus and apparently connected with it. The nature of the tumor could not be determined. Following the ether examination the woman became quite ill. There was great pain in the lower part of the abdomen and sudden rise of temperature. The patient was then transferred to the gynecological department of the Hospital of the Good Samaritan. After the second day the abdomen beo-an gradually to swell, and on December 1st it was much distended. The patient was losing flesh and strength. The temperature showed a typical hectic range, being normal or subnormal in the morning, with an afternoon rise fluctuating between 100° and 103°. The lowest point reached was 95.4°, the highest point 104°.


92



Repeated examinatious of the sijutum showed no tubercle bacilli.

Diagnosis. Encysted dropsy of the peritoneum, probably tubercular.

Operation. For removal of the dropsical fluid. On February 26 th a laparotomy was performed by Dr. Browne. Au incision 5 cm. long was made in the median line of the abdomen. From this opening about eight litres of transparent, pale greenish fluid escaped. The entire anterior portion of the peritoneal cavity was found to be converted into a suppurating cyst. An additional litre of semi-solid caseous material resembling masses of congealed fat was removed by the hand of the oj)erator from the lower part of the sac where it covered the pelvic viscera on the right side. After evacuation of the fluid the surface of the peritoneum was found thickened and converted into a necrotic membrane resembling the caseous masses which floated in the jius.

Examination of Fresh Abdominal Fluid. The macroscopic appearance was that of a turbid, pale greenish yellow fluid in which floated shreds and flakes of caseous material. On standing it separated into two layers, au upper transparent, greenish fluid and a lower dense, creamy mass. The microscopic examination of this fluid showed numerous pvis cells, some red blood corpuscles and shreds of necrotic tissue entangling pus cells. Staiued cover-sliji preparations of the fluid exhibited numerous cocci in jjairs, clusters and short chains, but no tubercle bacilli were found.

Immediately following the operation the patient's condition was much depressed. She rallied, however, resi^ondiug to stimulation. Her general condition improved and she became much more comfortable until the tenth day, when without pain or other distressing symptom she died suddenly, March 6, 1896. The autopsy was made three hours after death.

Anatomical Diagnosis. Tuberculosis of the Fallopian tubes, uterus, ovaries, peritoneum, pleura, and viscera generally. Acute flbrino-puruleut and caseous peritonitis; acute serofibrinous and hemorrhagic pleurisy ; mixed tubercular, staphylococcus and streptococcus infection ; congestion of viscera; general arterio-sclerosis.

The body is much emaciated. In the median line of the abdomen is a gaping incision. It begins 3.7 cm. below the umbilicus and extends 5 cm. downward, exposing a sloughing, puriform cavity from which bubbles of gas are evolved ou pressure. The subcutaneous fat is quite absent; the muscles are brownish red in color.

Abdomen. On opening the abdomen the entire anterior portion of the peritoneal cavity is found to be converted into a suppurating cyst. This extends from the liver above to the pelvis below, and traverses the lateral diameter of the abdomen from flank to flank, dipping deeply on both sides. The walls of the sac are made up of dense, opaqire, yellow necrotic material about 5 cm. in thickness. The cavity contains a small amount of the same puriform material found at operation. Extending across the cavity obliquely downward, and from before backward, as if to support its somewhat flaccid walls, are four or five dense fibrous bands covered by caseous material, continuous with that lining the general suppurating sac. Of these the largest is in the median line. It is long and almost


cylindrical, measuring 3.7x2.5 cm. in diameter. Its anterior and upper attachment is to the abdominal wall 2 cm. below the umbilicus. Its jjosterior attachment below is by a broad expansion upon the posterior wall of the sac where it dips down to cover the pelvic viscera. A second organized band, smaller, but similar in character to the one just described, is found on the left side. A few adhesions are also found in the posterior wall of the sac on the right side. On transverse section these bauds show an organized, pink, fibrous groundwork thickly inlaid with miliary tubercles and limited by a zone of caseous material. The j)osterior wall of the pus sac is found so densely adherent to the intestines and other adjacent viscera that separation is diflicult. No trace of the normal omentum can be found, and the probabilities are that it enters largely into the comjiosition of the suppurating cyst and the traversing fibro-caseous bands.

The coils of intestine are densely matted together by old tilirous bands and by more recent and lighter adhesions, studded everywhere with yellow miliary tubercles, and form a single compact mass filling the greater part of the abdominal cavity. Not only are the intestinal coils adherent to each other, but they are bound to all neighboring viscera. The mesentery is greatly thickened and contracted, and is thickly infiltrated with yellow miliai-y tubercles.

The mesenteric lymph glands are enlarged, indurated and caseous.

Upon separation of the more delicate adhesions between the ui)per coils of intestine, several smaller cysts about the size of a hen's egg are found. They contain clear straw-colored fluid. There is a slight excess of clear fluid in the posterior peritoneal cavity, which appears to have been more recently infected.

Liver. The liver measures 35x17.5x8.7 cm. in its various dimensions. The capsule is much thickened, and strong adhesions unite it firmly to the diaphragm. The left lobe is drawn out into a tongue-like process, which extends completely across the abdomen, covering the spleen on its anterior and left lateral stirfaces. So completely adherent are these two organs that only on section can a line of organized union be made out. The lower surface of the liver is also in contact with the upper wall of the pus sac, with the stomach and with the intestines, to which it is bound by firm adhesions. On breaking up these adhesions and freeing the surface of its caseous membrane, the capsule is found thickly beset with yellow miliary tubercles. The surface is mottled. Ou section the parenchyma shows the characteristic appearance of nutmeg liver. Scattered throughout its substance are numerous tubercles, both grey and caseous. They are mostly submiliary, but larger ones exist.

Spleen. The spleen is considerably enlarged. It is densely bound down by old fibrous adhesions to all neighboring structures. Its anterior and lateral surfaces are almost completely concealed from view by the tongue-like expansion of liver. The capsule is irregularly thickened and contains caseous miliary tubercles. The consistence is much diminished. It tears readily. Ou section it is congested and contains grey and yellow tubercles, miliary, submiliary and conglomerate in form.



Kidneys. The kidneys are slightly enlarged; the capsules are somewhat thickened, but strip off with moderate ease. The surface of the right kidney shows a shallow circular scarlike depression about 12 mm. in diameter,somewhat paler than the surrounding cortex. Under the capsule of this kidney is also seen a solitary caseous tubercle about the size of a split pea. Upon section the kidneys are congested, somewhat increased in consistence, and contain an occasional isolated tubercle of large size. The circular depression seen upon the surface of the right kidney is found to be the base of a dense, pale, pyramidal area which extends quite down through both cortical and boundary zones, and contains in its centre a small cyst.

Ureters. The ureters ai'e normal, except for a slight dilatation of the right ureter in its upper jiortion.

Pancreas. The pancreas is pink and firm. Its capsule is thickly studded with miliary and conglomerate tubercles; none, however, can be seen in its substance.

Stomach. The stomach is adherent to all adjacent structures. Its mucous membrane shows congestion, most marked along the rugas. Some ecchymoses are found at the cardiac end.

Intestines. In some places the felt-like adherent sac wall forms a partial covering to the intestines. Beneath it, as elsewhere, the peritoneal coat is tolerably §mootb, congested, and contains numerous miliary and conglomerate tubercles. The mucous membrane is more or less congested throughout the entire extent. The congestion is most intense upon the valvulas conniventes. There are no tubercular ulcers, but in places tubercles can be seen extending inward from the peritoneal coat. The walls of the large intestine are thin and very deejily congested. The abdominal lymj)h glands are enlarged and caseous.

TJiorax. The sternum aud costal cartilages cannot be readily lifted because of adhesions between the two layers of the pleura on the right side.

Left Pleural Cavity. The left pleural cavity contains about 2.5 litres of blood-stained lluid with flocculi of fibrin. There is one dense organized baud of tissue connecting the two layers of the pleura (about the region of the seventh rib). There are also a few delicate adhesions in the posterior and lower part of the cavity. The apex is firmly adherent to the chest wall. The lung is compressed by the excess of fluid in the pleural cavity. Both layers of the pleura present a coarse reticulated mottling, as though a loose-meshed network of fibrin had been laid upon a dark red hemorrhagic background. Tubercles are also seen.

Upon the parietal pleura, as it covers the sixth rib, are seen two softened caseous tubercles, each about the size of a split pea. Cover-slip preparations made from one of these immediately at autopsy show the presence of tubercle bacilli and micrococci in large numbers.

Left Ln7ig. The left lung is compressed and atelectatic, except the anterior margin of the upper lobe, which contains a little air. Scattered irregularly and sparsely through the lung substance are miliary and conglomerate grey and caseous tubercles. No cavities nor old tubercular foci can be made out.

Right Pleural Cavity. The right pleural cavity is dry.


The lung is bound down throughout its entire extent by easily detached adhesions. At the base and posteriorly the adhesions are pretty firm.

The pleura is covered with a layer of fibrin of irregular thickness, more or less organized at the base of the lung. It contains caseous tubercles.

Right Lung. The right lung is also considerably contracted by the upward pressure from the abdomen and the lateral pressure from the left thorax. The lower lobes are atelectatic and congested. The upper lobe contains a little air and exhibits along its anterior margin a few emphysematous patches. The distribution of tubercles in its substance corresponds with that of the left lung.

The bi'onchial aud mediastinal lymph glands are enlarged and caseous.

Heart. Owing to the excess of fluid in the left ])leural cavity, the heart occupies a position behind the sternum, almost in the median line. The pericardium, the pericardial fluid, the endocardium and heart valves are normal. The aorta contains thickened yellow atheromatous plaques.

Cranial Cavity. There is a slight increase of cerel)i'al fluid. The meninges of both cerebrum and cerebelliun are congested, particularly on the under surface. The pia arachnoid at the base of the cerebellum contains two or tliree yellowisli wliite bodies resembling miliary tubercles.

Cover-slip preparations made from these nodules show no tubercle bacilli.

The pelvic viscera were removed at autopsy aud jjlaced iu formalin, for detailed description later.

Pelvic Viscera. Uterus. The uterus is S.-"> cm. long, 5 cm. broad aud 3.5 cm. iu the antero-posterior diameter. Both the anterior and posterior surfaces are covered by an opaijue, yellowish white, felt-like membrane, varying from 2 to mm. in thickness. This membrane passes directly from the uterine walls to the other pelvic viscera, forming a complete blanket, and constituting the lower part of the large jiu.s sac which occupied the anterior portion of the peritone.il cavity. Projecting from the middle third of the posterior wall is a myomatous nodule about the size of a large walnut, attached to the uterus by a short and broad pedicle, Fig. 1, M. Springing from the fundus of the uterus about 2 cm. anterior to the right cornu is another pedunculated myoma, large, ovoid, and 9.5x7.5x5.5 cm. in diameter, Fig. 1, M. From the left surface of this tumor springs a cylindrical band about :j cm. long and 13 mm. iu diameter, attaching it loosely to the coiled-up mass of intestines behind. This band is of the same general nature as the fibro-caseous bauds which traverse the abdominal cyst. Another band, broad, flattened, and 6 mm. thick, is attached to the right surface of the tumor. This forms part of the general peritoneal sac. On stripping back the dense, felt-like membrane covering these tumors, their surfaces are found studded with tubercular nodules of a yellowish white color, and from one to three mm. in diameter. The snuiller tumor can be easily shelled out of its capsule, owing to a peculiar orange-yellow caseous material separating the two in the regio^n of the pedicle. The myomata, so far as can be seen, do not contain tubercles in their interior. The uterine wall measures 1 cm. in thickness at the fundus. Fig. 1, F. U., 2 cm.


94



anteriorly and 1 cm. posteriorly. It is pale pink in color and is studded with sparsely scattered, yellowish, miliary and con glomerate nodules.

The cervix is 2.5 cm. in length. The mucous membrane of the body presents a shaggy, moth-eaten appearance, of yellowish color and friable consistence. The mucous membrane of the cervix, which is much less rough and friable, still presents indications of the normal rugte. The mucosa varies from 2 to 5 mm. in thickness.

Right Appendages. Springing from the right uterine cornu and extending backward and downward, so as to be completely concealed from view by the large myomatous tumor which filled the right inguinal region, is a mass 8 cm.x5.5 cm.x2.5 cm. in size. It presents at first sight the appearance of an enlarged ovary, covered by the general pyogenic membrane, beneath which, as in the uterus and elsewhere, are miliary and conglomerate tubercles studding the surface. Upon section, however, it is seen to consist of the convoluted tube, thickened and necrosed, with its exaggerated coils held together in a stroma of dense organized connective tissue studded with miliary tubercles. Beneath the lower part of this convoluted mass is seen a portion of the ovary, so completely covered by and adherent to the tube as almost to have lost its own identity. Fig. 1, r. Ov. A longitudinal section through this tuboovarian tumor gives transverse, oblique and longitudinal sections of the much distorted tube. They lie like scattered caseous islands with ulcerated centres, in the tubercle-dotted stroma. The walls of the tube are from 3 to 8 mm. thick, and are for the most part uniformly caseous. Here and there is a nodular studding which gives the mucosa an uneven surface; or again a rich infiltration of the other coats with barely agglomerated caseous tubercles is observed. The fimbriated extremity, dilated, and curled outward in trumpet-like expansion, is directly continuous throughout its circumference with the anterior peritoneal sac. Fig. 1, r. F. E. The folds of the fimbriated end are everywhere visible and appear densely thickened and ragged; the extremity itself measures 2.5 cm. in diameter.

Left Appendages. The left tube is exceedingly tortuous, and from the uterine cornu outward gradually increases in size, terminating in a fimbriated extremity 4.5 cm. in diameter. It is 11 cm. long in its contracted state. Fig. 1, F. E. The folds of the fimbria are transformed into a greatly thickened, motheaten membrane, from whose surface project numerous papillary processes varying in size and shape and measuring from 10 to 14 mm. in length. The interior of the tube bears some general resemblance to the necrotic membrane which covers its surface and which represents the walls of the abdominal sac with which both tubes appear to be directly continuous. The convolutions of this tube, while excessive, as are those of the right side, are not embedded in a dense organized stroma, but are held together by tolerably firm adhesions. These, as well as the surface of the tube, exhibit caseous, miliary tubercles. Fig. 1, 1. T. Longitudinal and transverse sections through the tube show extreme necrosis of its walls. They are more extensively ulcerated toward the outer third, where the condition is most advanced. The lumen at this point is increased to 13 mm. iu diameter. The walls of the tube are here from


3 to 5 mm. thick and consist mainly of caseous material with a narrow outer border of organized tissue. This forms a capsule which can be readily stripped away from the central necrotic mass. The thickness of the tube about its middle portion is 2 cm. There is no lumen visible on cross section, but the entire tube seems made up of one dense, yellowish, homogeneous mass.

'J'he left ovary lies behind and beneath the tube, to which it is bound by adhesions similar to those connecting the convolutions of the tube. Fig. 1, 1. Ov. From this it may be detached with moderate ease. It is about normal in size and position. The surface is covered by the same necrotic membrane, and exhibits upon its removal sago-like bodies. On section the structure is smooth, firm, grey and glistening, showing several corpora fibrosa, and one flattened tubercle Just beneath the surface.

t'onnected with thepelvic viscera and binding them together are portions of the peritoneum which went to make up the original sac wall but which were torn away at autopsy. They are of the same general appearance bs, the necrotic membrane covering the viscera. A similar sac, collapsed and dipping down behind and to the left of the cervix uteri, is covered in by the small myoma above described. This represents the remains of an abscess about the size of an orange which ruptured at autopsy, discharging thick, greenish yellow pus.

The Vagina. There are several small, greyish, flattened elevations upon the surface of the mucous membrane, irregular iu size and shape, some round, measuring from 1 to 2 mm. in diameter ; others with irregular edges measuring about 6x3 mm. in diameter. There is also ^ small superficial ulcer in the posterior vaginal wall just below the cervix. It is about the size of a split pea, has sharp irregular edges, but contains no tubercles in its walls. The vagina is otherwise normal.

The bladder is contracted and is apparently normal.

The rediim is partly covered by necrotic membrane, but shows no abnormalities.

Histological ExAiiisATioif. Pelvic Viscera.

Uterus. The surface epithelium has entirely disappeared, and the uterine mucosa shows a granular necrosis throughout the inner fourth of its thickness. Beneath this the normal stroma is invaded by diffuse tubercle tissue with discrete caseating nodules. It is the union of these nodules near the surface of the mucosa which results in the granular necrosis. In the depth of the membrane the uterine glands are preserved, although the epithelium is swollen and invaded by mononuclear and polymorphonuclear cells. They are often dilated, and contain swollen desquamated epithelial cells, polymorphonuclear leucocytes and granular detritus. The diffuse tubercle tissue consists largely of lymphoid and epithelioid cells, with an occasional giant cell. The discrete caseating nodules present the typical structure of caseous tubercles. The giant cells of both stroma and nodule are round, oval or irregular in shape, with a mural or polar arrangement of the nuclei. The epithelioid cells of the diffuse tubercle tissue are usuallyj round or polyhedral, with small vesicular nuclei. Those ofi


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the caseating nodules are irregular and elongated, with oval, bizarre and wavy nuclei, the close packing of which in the periphery of the nodule gives the appearance of a radiating fringe.

The muscular coat is infiltrated throughout its entire thickness with diffuse tubercle tissue and discrete miliary nodules, most of which are caseous. The diffuse infiltration is represented by small cells with solid and vesicular nuclei, arranged in longitudinal strands between the muscle bundles. The caseous nodules lie next to the peritoneal surface, and are irregularly triangular in shape, with bases toward the serosa. Sometimes the bases coalesce and form a continuous scalloped caseous zone. The muscle cells are increased in number, and here and there are myomatous foci which consist of dense aggregations of cells containing elongated club-shaped nuclei.

The blood-vessels of the muscular coat present interesting features; some of them show the typical changes of endarteritis obliterans, with more or less encroachment upon the lumen. But the most characteristic lesion is the tubercular involvement of the vessel walls. This process sometimes begins in the intima and remains limited to this coat, or extends to the media or adventitia. Sometimes it takes origin in the adventitia and perivascular tissues, and spreads inward in like manner through the other coats. It may be diffuse or circumscribed, it may be a cellular proliferation simply, or show all stages of degeneration, from an early nuclear fragmentation and karyolysis, to advanced caseation in which all the coats and even the vessel contents are transformed into a dense hyaline mass. The corpuscular contents of the vessels are often preserved intact, notwithstanding advanced changes in the vessel walls. Again there are thrombi, hyaline or mixed, in various stages of transformation. Sometimes the vessels are the centre of a tubercular process, in which case their fibrinous contents are continuous with a fibrillated fibrin which extends out into the surrounding tissues. Where the tubercular change is early and begins in the intima, the endothelium is sometimes preserved intact; here there is subendothelial proliferation of the connective tissue cells, forming ejDithelioid cells of a round or jjolyhedral shape, with moderate or abundant protoplasm and small round nuclei. But in other cases there is evidence of endothelial proliferation, these cells enlarging, becoming at times cul)oidal, and forming a lining of two or more rows to the lumen, with occasional complete occlusion.

In the serous membrane the changes are most marked ; on the surface is a dense, opaque, necrotic coat, granular, fibrillated and hyaline. Beneath this is a narrow zone of nuclear fragmentation, while yet below and forming aline of demarcation between the necrotic portion of the serous coat and the scalloped caseous zone of the muscular coat is a narrow band of (Edematous, vascular connective tissue containing a few muscle fasciculi, and showing infiltration with lymphoid, epithelioid, polymorphonuclear and occasional giant cells.

The process is least advanced in the cervix, most advanced in the fundus. In the cervix there is no invasion of the muscular coat, and the vaginal portion contains no evidence of tubercular involvement other than a solitary cellular tubercle under the stratified epithelium in its upper part, and


a cellular proliferation of the corium, gradually disappearing as the outlet is approached.

Among the diffuse tubercular tissue are found numerous homogeneous, highly refractive globules of various sizes, occurring singly or in groups. They show especial affiuity for acid aniline dyes, and also stain intensely with gentian violet. In shape they are invariably round; in size they vary from that of a micrococcus or a basophilic granule to that of a lymphoid cell, some even exceeding this. Their average diameter is that of a red blood corpuscle ; in fact, when uniform in size, and occurring in masses, they are readily mistaken for such in specimens which have been stained with ha^matoxyliu and eosin. The little globules are, however, more homogeneous and solid and more highly refractive than red blood corpuscles. These appear of tenest more or less closely packed within cell bodies, the nuclei of which are still preserved. Sometimes they accompany a more advanced degeneration, in which case the nucleus stains poorly or not at all. Again, they are free from cellular inclusion, and lie in groups or scattered through the tissues. The groups are circular, elongated or irregular, and contain from two to thirty or more members. With Weigert's fibrin stain they stand out conspicuously as deep blue spheres, homogeneous and structureless. With Russell's fuchsin stain they strike a bright red hue; with eosin they stain pink. In many respects they correspond with the hyaline bodies considered by Lubarsch" as a form of albuminous degeneration, found by various observers in both normal and pathological conditions, and described by Russell" as " Fuchsin bodies." In the present case they contain neither nuclei nor spores such as Russell and others have described.

In all three coats of the uterus micrococci are found arranged in pairs, clusters, or chains of greater or less length, numbering from three to sixteen members. They are especially numerous along the superficial caseous zone of the peritoneal coat, where they form a thick, irregialar border and extend deep into all fissures of its necrotic structure. In the muscular coat they are less numerous, and are found for the most part within and about blood-vessels in the bands of the infiltrated tubercle. In the mucous membrane they are again present in considerable number, somewhat sparsely scattered at times or occurring on the surface as dense aggregations. Where scattered, their arrangement is usually in the form of pairs and chains.

Tubercle bacilli are also found in the uterine tissues. They occur in the interior of vessels, either free or enclosed within cells, in the vessel walls, and in the tubercle tissue outside.

The uterine myoma is covered by newly formed connective tissue, with rich infiltration of diffuse and circumscribed tubercles and many pus cells. The capsule is made up of strata of well preserved fibro-muscular bands. But the interior of the tumor is necrotic throughout. Near the surface of the necrotic myoma is a narrow zone of calcareous matter; the walls of all blood-vessels in its vicinity are likewise calcified. A still broader zoueof necrotic myomatous structure, including the calcareous baud, is dotted over with spiculated spherules of golden yellow pigment. No tubercles are seen. Russell's fuchsin bodies are numerous in the tissue covering the myoma, but none are found in its substance. Micro-organisms similar


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to those found iu the utei'us are likewise found in the tubercular coFcring of the tumor.

Uiyhl Fallopian Tube. The mucous membrane of the right Fallopian tube at its uterine end has an almost intact epithelium. In one place, however, the epithelium is wanting, and here the stroma is invaded by a mass of tubercle tissue, some of which has broken off and lies free and degenerating in the centre of the lumen, together with the desquamated epithelium. The middle coat of this part of the tube retains its muscular structure; bands of muscle, however, are separated from each other by serous infiltration or by alternating baiuls of diffuse tubercle tissue. The serous coat is composed of solitary caseous tubercles so blended as to form a continuous scalloped zone. On passing outward from the uterine end the tuliercular process becomes more marked, and when the middle portion of the tube is reached the walls are so intensely involved as to form a thickened necrotic mass, with no evidences of structure except a narrow fibro-cellular zone encircling the tube about 2 mm. from the periphery. The necrotic substance is hyaline in the centre, where it is pierced by a ragged slit- like lumen. It corresponds here with the remains of the mucous membrane. There is nuclear fragmentation within the fibro-cellular zone, and among the nuclear fragments isolated bands of muscle are preserved in scanty nnnil)c'r The surface necrosis corresponds essentially with tliat of the uterine serosa, while the middle fibro cellular zone is continuous with the thickened, cedematous, vascular connective tissue of the uterus, which there formed a line of demarcation between the necrotic portion of the serous coat and the scalloped caseous zone of the muscular coat. Here, as there, it contains a few isolated muscle bundles, the only normal elements of the original Fallojjian tubes. Here, as there, it is infiltrated with tubercular cellular tissue and polymorphonuclear cells, and here, as there, it shows many vascular changes, both sclerotic and tubercular, similar to those described in the uterine muscular coat.

There are numerous dilated lymph spaces and blood-vessels with subeudothelial proliferation or a lining of cuboidal cells. Occasionally a well-defined giant cell takes origin iu the endothelium of a vessel and projects into the lumen, filling it more or less completely. Sometimes such a cell is found free in the vessel. Indeed, the giant cells are numerous thi-oughout the middle coat, and are especially abundant near the necrotic mucosa. They are often situated in little caverns, which are sometimes surrounded by lymphoid cells. Where not so situated, they are more apt to be surrounded by an irregular zone of epithelioid cells. They are elongated or irregularly ovoid in shape, of various sizes, and contain nuclei at their poles or about the periphery, seldom in the centre. Sometimes they are invaded by polymorphonuclear and lymphoid cells.

In the fimbriated extremity the degeneration is extreme. The lumen is considerably dilated, the walls are convoluted and thick. The mucous membrane is composed of three strata representing gradations of tubercular change. Next to the lumen is a narrow necrotic border, which takes an intense eosin stain. It gives occasional evidence of original structure in the preserved outlines of old blood-vessels, of connective


tissue bands, of g^ant cells, and even of an occasional caseous tubercle which has not yet lost its identity by coalescence with the general necrotic border. Outside of this is nuclear fragmentation with structural outlines still better preserved ; while yet beyond is the normal stroma invaded by infiltrated tubercle. Tlie middle coat is a comparatively narrow band of fibrocellular tissue, not yet degenerated, forming less than a third of the whole tubal thickness, .and presenting the same interesting features as the corresponding coat of the middle portion of the tube. The thickest part of the wall is the peritoneal coat; it is entirely involved in an extensive necrosis which is at one time fibrillated, at another granular or hyaline.

The little refractive globules described iu thecellular tubercular tissue of the uterus as Russell's fuchsin bodies are present also in the tube iu considerable number. They lie by preference in the middle coat, in which the tubercle tissue is best preserved. They pi-esent the same general characteristics as the hyaline bodies of the uterus, but are somewhat smaller. Indeed, whereas in the uterus their average diameter is that of a red blood corjjuscle, in the tube their average size is that of a micrococcus ; and, where Weigert's fibrin stain is used, they could readily be mistaken for such, were it not that upon careful examination they show less uniformity in size, take a more solid stain, and because larger globules, both free aud in cells, are found in the same neighborhood. Extra-cellular spheres of large size grouped with smaller hyaline globules are sometimes found occupying open spaces iu the tissues.

The borders of the necrotic zones, both mucous and serous, iu all parts of the tube, are invaded to some depth by deeply staining micrococci, which in form, size, grouping and arrangement in the tissues, resemble the organisms found in the uterine coats. Similar organisms are found at times in the blood-vessels of the middle coat. Tlie streptococci predominate, and the average length of the chains is six members. Tubercular bacilli are likewise found.

Rigid Ovary. The right ovary is somewhat enlarged. Its surface presents a smooth, wavy outline and is covered by a thick, cedematous, vascular connective tissue which contains lymphoid and epithelioid cells, but no giant cells. There are also numerous dilated lymphatic vessels filled with lymphocytes. The edges of this connective tissue covering are ragged and represent the remains of old fibrous adhesions between the ovary and neighboring structures. Deep within the ovarian stroma are several isolated and conglomerate caseous tubercles. There are many advanced corpora fibrosa, aiul an unruptured Graafian follicle in the process of retrograde metamorphosis, liussell's fuchsin bodies are numerous in the tubercular tissue covering the ovary, and iu the ovarian tissue itself. They are present where the degeneration is least advanced, aud may be seen, not only in the tubercular areas, but in association with other degenerative changes — in the hyaline degeneration of corpora fibrosa and in the retrograde metamorphosis of unruptured Graafian follicles.

Streptococci, staphylococci and tubercle bacilli are present. Of these the streptococci are most abundant and occur iu long chains, at times reaching the length of fourteen members. They are located within the lumen of blood-vessels, in the blood-vessel walls, or in the perivascular lymphatics of the


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coimective tissue covering the ovary, and are ofteuest free, but may be found enclosed in cells.

Left Fallopian Tule. The left Fallopian tube has the same general structure as the right, the only difference being that the tubercular lesion is more advanced. The middle portion of the tube is converted into a dense neci'otic cord, the transverse section of which shows a ragged longitudinal rift in the centre of an oval area of hyaline necrotic material. This is surrounded bv a fibro-cellular border, whose surface is roughened by fibrous shreds torn in the process of separation from adjacent structures. The fibro-cellular border corresponds with both middle and outer zones of the other tube. The fimbriated extremity, like its fellow, is extensively degenerated, and the lumen is also much enlarged. Its walls, however, are less uneven and are but half the thickness of those of the corresponding tube. Continuous with the middle portion of the tube the fimbriated extremity likewise has an outer border of fibro-cellular tissue and an inner hyaline necrotic coat. In this tube there are fewer giant cells than in the other, and the tubercle tissue in places shows fibroid change. Russell's fuchsin bodies are present in small number.

The micro-organisms found are similar to those in the other tube.

Thus, while both tubes show in the main the same tubercular lesions, they differ in that the left tube has somewhat thinner walls, contains a smaller number of giant cells, exhibits in places fibroid change, and the thickened necrotic serous coat is wanting.

Left Ovary. The left ovary is smaller than the right and is surrounded by diffuse tubercular tissue. In gland-like spaces near the surface are found great accumulations of nuclei, bound together by hyaline and fibrillated fibrin, and often presenting the appearance of the tubercle giant cell. In this ovary there is but one solitary caseous tubercle, about the size of a split pea, which projects slightly above the surface and dips down into the stroma. Fuchsia bodies and microorganisms are present, resembling in every respect those found in the right ovary.

The Vagina. The vagina shows no tubercular involvement. The elevated greyish white patches observed on macroscopic examination consist of swollen, distorted, stratified epithelial cells. Occasional polymorphonuclear and mononuclear cells have wandered up into the epithelium. There is slight proliferation of the cellular elements in the upper portion of the corium. Fuchsin bodies are found in these proliferating areas. More densely stained globules are seen in the swollen epithelium above. Upon the surface of the mucous membrane there are a few cocci and long bacilli. Within the blood-vessels of the vaginal wall, and especially in the larger ones, cocci occur in pairs and chains, both within cells and outside of them.

The bladder and urethra show nothing abnormal.

Pus Sac. The wall of the pus sac, portions of which remain adherent to the pelvic viscera, is from 4 to 6 mm. in thickness. It consists of three coats not sharply differentiated one from the other. In the inner necrotic coat, which represents about one-third of the thickness of the sac wall, the degeneration is extreme. Its surface is edged by dense aggregations of micrococci which in places extend deep into the


necrotic structure. The middle coat is fibro-cellular and con tains a few isolated clusters of fat cells. It is infiltrated with diffuse tubercular tissue. The outermost coat is not sharply separated from the middle, and differs from this in containing numerous closely packed caseous tubercles. Fuchsin bodies are present as intracellular and extracellular globules. They are of all sizes, and contrary to what occurs elsewhere, they are found in the most advanced necrosis. In such places theytake a less intense gentian-violet stain and merge gradually into the surrounding necrotic structure. Micrococci are found in all three coats arranged in pairs, clusters and chains. They are especially numerous upon the inner surface of the sac, where they form a continuous irregular layer. Tubercle bacilli are also present in small number.

General Viscera.

The lung shows very little that is abnormal. The visceral pleura is considerably thickened and presents an irregular wavy outline. Its surface is covered by a layer of fibrin formed by the coalescence of highly refractive clumps. These, in places, extend deep into the tissues, where they appear as densely hyaline whorls, or the fibrin remains limited to the surface, where it forms a meshwork enclosing polymorphonuclear cells. The more hyaline portions are at times invaded by organizing connective tissue. Beneath the fibrinous covering is a layer of highly vascular granulation tissue which contains closely-set flattened tubercles. These tubercles project here and there between the clumps of hyaline fibrin, extending at times to the surface, or dip down into the lung substance. They are more or less caseous and show the same general structure as the tubercles already described. Where less advanced they contain many giant cells. The deeper layers of the pleura contain dark brown and black granular pigment, both free and enclosed in cells.

The parietal pleura resembles the visceral in its general histological features. It is composed of a superficial laj'er of fibrin, beneath which are granulation tissue and caseous tubercles. Quite beneath is a third layer consisting of cedematous connective tissue, the meshes of which are widely separated by serum and the spaces of which are occupied by swollen mononuclear cells. In the parietal pleura there are small extravasations of blood. Both layers of the pleura contain the fuchsin bodies and basophilic cells. A few pairs and chains of cocci and tubercle bacilli are present.

Liver. The capsule is thickened by tubercular growth. The lobules show dilatation of the central veins and adjacent capillaries. The hepatic cells in the centre of the lobule contain a brownish yellow pigment. The peripheral cells are filled with fatty globules.

Distributed thickly through the liver substance, in close relation with the blood-vessels, are countless tubercles, most of which are of microscopic size. Large nodules evident to the naked eye are less abundant. The former consist for the most part of lymphoid cells or of lymphoid with a central accumulation of epithelioid cells. The larger tubercles are evidently older and exhibit the typical structure of miliary tubercles with advanced central necrosis. There are a few pairs and chains of cocci in the liver capillaries.


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Spleen. The capsule is thickened by a new growth of cellular connective tissue containing caseous miliary tubercles. The spleen parenchyma shows an increase in its cellular elements. Much blood pigment and many red blood corpuscles are found. The arterial walls are considerably thickened, and an occasional hyaline thrombus in one of the smaller vessels is seen. There are numerous tubercles, both young and old, scattered through the splenic substance. Fuchsin bodies are present. Micrococci in pairs, masses and chains are found. They are sometimes arranged within cells, but are usually extra-cellular.

Kidney. The kidney shows parenchymatous and fatty degeneration of the epithelium lining the Malpighian tufts and the convoluted tubules. There is a slight increase of connective tissue, especially under the capsule. The tubules are here compressed, but elsewhere they are at times dilated. Hyaline and granular casts are found. The wedge-shaped area described among the macroscopic lesions is found to consist almost entirely of connective tissue in various stages of development. It compresses the tubules, many of which are completely obliterated ; while others persist with intact epithelium or with lumen distended by hyaline casts. The Malpighian tufts are small and fibrous, and in places are converted into hyaline balls. Indeed, the connective tissue invades all structures in the triangular area, and tubules, blood-vessels and glomeruli are alike involved. The central cyst is lined by cuboidal or flattened epithelium. Its walls appear to contain a large number of muscle fibres which have an irregular arrangement and include masses of lymphoid cells. It is continuous with several smaller tubular dilatations and is undoubtedly a retention cyst. At the apes of the triangle is a large dilated blood-vessel with irregular thickened walls and lumen containing remnants of a probable thrombus. The area resembles an infarct in the process of cicatrization, but for the presence of apparently functioning structures. A few cocci arranged in pairs are found within a blood-vessel of the kidney.

Pancreas. The capsule is considerably thickened by a new growth of connective tissue, alternately fibrous, cellular, vascular and cedematous. Numerous closely-set tubercles are embedded in the capsule. They are round and project beyond the surface, or they may be flattened and elongated. They show the typical structure of cellular, caseous and fibroid tubercles. The capsule contains the fuchsin bodies and masses of micrococci.

Lymph Glands. The bronchial lymph glands are invaded by lymphoid, epithelioid and giant cells and show a tendency to fibroid change. Some of the central arteries are sclerotic, others show tubercular lesions. Masses of basophiles are present in the centre of the glands, especially grouped around blood-vessels, and the fuchsin bodies are found at times occupying the interior of basophilic cells. Micrococci occur in pairs and chains within blood-vessels and in the perivascular connective tissue.

In the mesenteric lymph glands the tubercular process is more advanced. The centre is necrotic, with original structural outlines still preserved. The periphery of the gland retains its lymphoid nodules, but these are invaded by tubercle


tissue. The blood-vessels are thickened, and basophiles are found. The gland is covered by (Edematous tubercular tissue. Diplococci and stajihylococci are numerous in the surrounding connective tissue, and beaded tubercle bacilli are found in the interior of the gland.

The aortic valve, the aorta and the coronary arteries show irregular thickening of the intima due to increase of connective tissue which in places is swollen, and the interstices between the branching connective tissue cells are occupied by translucent, highly refractive masses. Or again, the tissue is non-cellular and diffusely hyaline. On the edge of the aortic valve where it appears necrotic a few diplococci are found.

Fibro-caseous bands. The fibro-caseous bands extending across the abdominal pus cavity, and those in the pleural sac, are made up of fibrillated connective tissue, everywhere invaded by diffuse tubercle tissue and circumscribed tubercles in all stages of gi'owth or of retrograde metamorphosis. The peripheries of the bands consist of necrotic zones edged by a closely packed layer of micrococci. The connective tissue stroma shows every stage of organization from young granulation tissue to dense hyaline bands ; the bloodvessel walls are thin and easily rupture"d, and extravasations of blood are sometimes found. The diffuse tubercle tissue consists for the most part of lymphoid and epithelioid cells grouped usually in the neighborhood of blood-vessels. Few giant cells and some basophiles are found. The tubercles exhibit every stage of growth and of retrogi'ade metamorphosis. At times they present a typical cellular structure with giant cells in the centre. Again, the centre is occupied by a blood-vessel, and the lumen of such vessel may contain well preserved fluid contents, fibrillated fibrin, or a hyaline or mixed thrombus. The caseous peripheral zone is from 2 to 6 mm. in thickness. It contains no cells nor nuclear fragments, but is made upof a structureless necrotic substance, alternately granular, fibrillated and hyaline. Fuchsin bodies are easily demonstrable. They are of all sizes, from that of a basophilic granule to a lymphoid cell, and are both intracellular and extracellular. They occur in the diffuse tubercle tissue where degeneration has just begun. The micrococci found on the surface of the band sometimes extend deep into its substance ; they occur in pairs, in masses and in chains. In the bands of the abdominal pus cavity compressed lobules of adipose tissue exist.

Bacteriological Examinatiox.

Cover-slip preparations made at autopsy from a tubercle upon the pleura demonstrated large numbers of long beaded tubercle bacilli and clusters of micrococci. Cultures made from this tubercle enable one to isolate white, lemon yellow and orange colored colonies Inoculations from these colonies into the various culture media exhibit the peculiar cultural characteristics of the staphylococcus pyogenes aureus, citreus and albus, and cover-slip preparations from the various cultures invariably show cocci arranged in clusters and in pairs. Unfortunately, no cultures could be made from the abdominal viscera, but hardened sections of the organs stained by Gram's, Weigert's and Gabbet's methods exhibit staphylococci, streptococci and tubercle bacilli in all.


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Summary of Histologhcal and Bacteriological examinatiok.

(1) The condition is a mixed infection due to the tubercle bacillus, the streptococcus pyogenes, and the staphylococcus pyogenes aureus, citreus and albus.

(3) Miliary tubercles, both grey and caseous, are found in all the viscera of the body except the heart and pancreas ; in the lymph glands, and in all serous membranes excefit the pericardium.

(3) Diffuse tubercle tissue is found only in the more chronic lesions — in the pelvic viscera, the lymph glands, the pleura, the peritoneum, in the wall of the newly formed abdominal sac, and fibro-caseous bands. In the viscera this is usually cellular, but may be caseous. In the serous membranes it is always caseous.

(4) Tubercle bacilli are numerous in the tubercular lesions throughout the body. They are especially numerous in the pelvic viscera, lymph glands and alidominal pus sac.

(5) The products of ordinary inflammation are often found associated with the tubercular lesions.

(6) Staphylococci are found in all the organs. They are most numerous in the lining of the abdominal pus sac and the tibro-caseous bands.

(7) Streptococci are likewise found throughout the body, but are especially abundant in the pelvic viscera, the pus sac and the fibro-caseous bands.

(8) Kussell's fuchsin bodies are found wherever the tubercular tissue is beginning to degenerate and occasionally where the degeneration is extreme.

(9) The viscera are congested and there is general arteriosclerosis.

Conclusions.

From the clinical history, gross anatomical lesions and histological appearances, we therefore conclude that the disease began as a tubercular inflammation of low grade in the pelvic viscera some time before pregnancy.

That the tubercular process spread by direct extension or by the lymph channels to the anterior part of the abdomen, which thus became shut off from the rest of the peritoneal cavity by chronic adhesions.

That the phenomena incident to pregnancy and the puerperium excited the process to increased activity, to which, either at this time or later, was probably superadded a pyogenic infection.

That this infection remained limited to the pelvic organs because of occlusion of the tubes by previous tubercular adhesions or by the more receutinflammatory process, until manual examination of the already much diseased organs caused unavoidable rupture into the anterior abdominal sac.

The pain, rise of temperature and abdominal distension were the result of the secondary pyogenic infection of this cavity, from which the general infection took place. I The general tubercular infection doubtless spread, partly

by direct extension, partly by the lymph channels, but principally through the blood-vessels. The first two modes of invasion are shown by the extensive diffuse infiltration of all structures continuous with and contiguous to the pelvic viscera


and the abdominal pus sac. Infection through the blood is evidenced by the general miliary tuberculosis of all the viscera of the body.

Tuberculosis of the tubes and peritoneum is usually a secondary condition. It may follow tubercular disease of any organ of the body, but is seen most commonly associated with tuberculosis of the lungs. In this case, however, the process must have originated either in the peritoneum or in the tubes. The lungs showed no old tubercular foci, but were involved only in the general miliary tuberculosis. The pleura was diseased, but to a much less extent than the peritoneum or the tubes. The intestines were not at all involved, and the lymph glands were enlarged and caseous, but not extensively diseased.

The question arises, what was the relation of the tubercular disease in the tubes to that in the peritoneum ? Which was primary, which secondary? Considerable difference of ojnnion exists as to the relation between tubercular peritonitis and tuberculosis of the tubes. In his monograph on "Tubercular Peritonitis" Osier" says: "The Fallopian tubes are often affected, but the proportion given by various writers differs much. It is safe to say, I think, that in .30 to 40 per cent, of the cases in women the tubes are found affected. The process is commonly confined to the distal ends and may be primary — which is usual — or is secondary to the peritoneal involvement."

In this opinion of primary tubal involvement the majority of observers agree.

On the other hand Williams" asserts that "Tuberculosis of the Fallopian tubes is far more frequently of secondary than of primary origin, and when it occurs in combination with tubercular peritonitis, it is far more often the result of than the cause of the latter. The fact that the fimbriated extremity of the tube is the portion most frequently affected is of itself evidence in favor of its secondary origin, and in several cases of tubercular peritonitis we have found tubercles on the exterior ofthe tube and its fimbriated end, but none in its interior,showing that the process was extending from above downward." Among others, Siinger and Borschike confirm his view.

In this case the only indication pointing to the peritoneum as the source of disease is the extensive caseous involvement of its anterior part. On the other hand, primary disease of the tubes is indicated by the still more extensive involvement of their walls, by the presence of numerous giant cells, considered by Baumgarten' as significant of jDrimary tubal disease, and by the clinical history which points to the pelvic organs as the first affected. As shown by the foregoing studies, the fimbriated extremity of the left Fallopian tube must be regarded as the probable starting point of the whole tubercular process.

If then the tubercular disease of the tube is of primary origin, the further question presents itself, how did the disease arise ? Primary tuberculosis of the tubes may originate in two possible ways: (1) By infection through the blood, and (2) by infection from without. Primary infection through the blood is a matter of pure speculation and is highly improbable. The more likely source of infection is through the vagina from without. Although no history of such invasion could


100

[No. 74,


be obtained in this case, yet it is regarded as tliemost probable portal of entry. The fact that the nterus was less involved than the tube, and that the vagina was not all diseased, does not negative this theory of infection, since the tubercle bacilli, failing to find conditions favorable for their growth until the left fimbriated extremity was reached, here set up their characteristic lesions. Thence they probably sjiread to the fundus of the uterus, to the uterine cavity and cervix, to the opposite tube, and to the peritoneal cavity, from which the general infection took place.

The associated involvement of pleura and peritoneum must be considered of diagnostic value, since coincident inflammation of both these membranes is so often of tubercular origin.

Besides the extensive character of the lesions, there are several unusual features in the case. In the first place, considerable interest attaches to the fuchsin bodies so numerous in this case. These bodies resemble the little globular masses described by Russell"' in 1890 as " a characteristic organisnx of carcinom.a," and correspond in every particular with the description of these bodies as given by Lubarsch' under the head of "Albuminous Degeneration."

There is scarcely a normal condition or pathological process in which they have not been found, but their relation to malignant tumors has been especially noted. They are not of constant occurrence in any pathological change.

With regard to their nature, the view of Eussell that they may be considered as yeast fungi is no longer held. Tliey have been variously interpreted as protozoa, hyaline thrombi, altered Altmann's granules, von Recklinghausen's hyaline, bodies resembling corpora amylacea, transformation of the cell protoplasm, and as a product of the tissue fluids in which a degenerative process is added to a beginning coagulation process.

Lubarsch himself inclines to the view that the Russell's fuchsin bodies ai'e the product of cell protoplasm, the granules of which have undergone certain chemical and physical changes. He believes that they may be due either to a secretion or to a degeneration of the cell, the former occurring in normal conditions, the latter in pathological processes. Lubarsch also refers to the relative increase of basophiles in areasin which the fuchsin bodies abound — a phenomenon noted by Niehus and Klien, and observed also in the present case. In explanation of their coincident occurrence he attributes the formation of the fuchsin bodies to a chemical change and confluence of the granules of the former and some of the wandering cells, and suggests that both are due to active tissue transformation. From the description given in the present case, this mode of origin seems probable.

A second point of interest is the rare combination of tuberculosis in both body and cervix of the uterus. Regarding this Williams" says: "The affection is almost always limited to the body of the uterus, rarely extending beyond the os to involve the cervix ; and of the few cases of tuberculosis of the cervix on record, a considerable portion occurred without any involvement of the rest of the uterus. Tuberculosis of the uterus which also involves the cervix is rarely met with, and as far as we can ascertain from a careful survey of the literature, has ouly been noted in seven cases."


In this connection may also be mentioned the tubercular invasion of the muscular coat of the tube, which, as a rule, escapes involvement even in advanced tuberculosis.

The large sacculated exudation occupying the anterior portion of the peritoneal cavity and simulating ovarian cyst is rare. Among the few recorded cases of tubercular peritonitis with encysted collection of fluid are those reported by Bernutz, Spencer Wells, Gardner, Howard, Erich, Ewing, Mears and Atlee.

A feature of special interest is the thick fibro-caseous band which extends across the pus sac in the median line of the abdomen, and is probably the remains of the rolled-up omentum. In structure it bears some resemblance to the thickened strands described by Klebs' as passing transversely across the abdominal cavity below the umbilicus, and which he attributed to retraction of the omentum. Such omental tumors are not uncommon and have frequently been described. In location, however, this fibro-caseous band does not correspond with the transverse omental tumors, since its direction is anteroposterior and from above downward, and its attachment is by its extremities. In explanation of this formation one can only assume some distortion of the original omentum, with displacement, thickening, caseation and complete transformation into the fibro-caseous band.

In conclusion, I wish to thank Dr. Flexner for valuable suggestions during the course of this work. Dr. B. B. Browne for kindly allowing the use of his clinical notes, and Mr. Max Briklel for the accurate drawing which accompanies the text.

Bibliography.

1. Baumgarten: Zeitschrift f. kliu. Med., Bd. IX and X, Wien, 1885.

2. Oullen, Thos. S. : Tuberculosis of Endometrium. Johns Hopkins Hospital Reports, Vol. IV, Nos. 7 and 8, 1895.

3. Flint: General Jliliary Tuberculosis, Tubercular Peritonitis, Pulmonary Phthisis. Principles and Practice of Medicine, 1886.

4. Gardner: Tuberculosis of Anterior Peritoneal Cavity. Canada Medical Journal, Vol. 13, 1885.

5. Hegar: Monograph, Genital-Tuberculose des AVeibes. Stuttgart, 1886.

6. IIektoen,Ludwig: Vascular Changes of Tubercular Meningitis, especially the Tubercular Endarteritis. The Journal of Experimental Medicine, V^ol. I, No. 1, January, 1896.

7. Howard, Wni. T. : The President's Address, Transactions American Gynaecological Society, Vol. X, 1885.

8. Klebs : Handbuch der path. Anatomie, Bd. I, p. 335.

9. Lubarsch, O., and Ostertag, 0.: Diealbuminosen Degenerationen, Ergebnisse der allgemeinen pathologischen Morphologic und I'hysiologie des Menschen und der Thiere, Vol. II, 1S95.

10. McFarland, Joseph : The (iiant Cell of Tubercle. International Medical Magazine, Vol. I, No. 10, 1892.

11. Osier, Wm. : Tubercular Peritonitis. Johns Hopkins Hospital Reports, Vol. II, 1890.

13. Russell, Wm. : An Address on the Characteristic Organism of Carcinoma. British Medical Journal, Vol. II, 1890.


May, 189r.]

101


13. Williams, J. Whitridge: Tuberculosis of the Female Generative Organs. Johns Hopkins Hospital Reports, Vol. Ill, 1893.

14. Williams, J. Whitridge: Tubercular Peritonitis. Maryland Medical Journal, Vol. 32, K^os. 3 and 4, 1894.

15. Lenhart, C. M. : Tubercular Peritonitis. Medical Record, Vol. XLVIII, October, 1895.

Description of Plate.

Pelvic viscera fixed in formalin and hardened in alcohol, viewed from above. Right tubo-ovariau mass seen in crosssection.


F. U., fundus of uterus.

Right tube, showing cross-sections of tubercular lumen.

r. F. E., fimbriated extremity of right tube.

r. Ov., right ovary.

if., myoma.

Rd. Lig., round ligament (left).

I. T., left tube.

I. F. E., fimbriated extremity of left tube.

I. Ov., left ovary.

From the left surface of the larger myoma projects a fibrocaseous band. To the right is attached a portion of the abdominal pus sac.


A VISIT TO BAD NAUHEIM, WITH THE PURPOSE OF INVESTIGATING THE "SCHOTT TREATMENT" FOR CHRONIC HEART DISEASE.

By C. N. B. Camac, M. D., First Assistant Resident Physician.


Last November, at Dr. Osier's suggestion, we undertook to introduce into the hospital the Schott treatment of exercises and medicated baths for cases of chronic heart disease. After consulting the bibliography of the subject, several cases were placed under treatment according to the instructions contained therein. At once, however, we were confronted by numerous questions, answers to which it seemed quite impossible to find in any of the references at hand. Although the literature dealt at length with changes in the cardiac outline, the position of the cardiac maximum impulse and the respiration, the theories upon which the beneficial effects were based, etc., no answers to such practical questions as the following were given :

(1) Is any massage to be employed during or after the bath ?

(2) What drugs are to be employed daring the treatment, and what drugs are contraindicated ?

(3) Should the baths and exercises be given together; or if separately, which should precede?

(4) Are stimulants to be administered before or after the bath ?

(5) What should be the diet of the patient?

(6) Are cases of hydrothorax or ascites to be tapped ? etc., through quite a list with which it is hardly necessary to weary you.

Finding many of these questions unanswered, it was with considerable interest that I received Dr. Osier's suggestion to visit Bad Nauheim, the home of the treatment and of Dr. Schott, its originator.

Nauheim is in the Grand Duchy of Hesse, three-quarters of an hour from Frankfurt a. M. and two hours from Homburg. Nearly in the centre of the northeastern half of what geologists have called the Mayence Basin (Mainzerbecken) Frankfurt is located, and at the eastern slope of the Johannesburg, the last spur of the Taunus mountains, is situated Bad Nauheim. As one approaches Nauheim he is struck by the great trestlework structures in the midst of the fields. On examining these more closely they are found to be frame structures about


200 to 300 feet long and about 50 feet high, supporting switches closely stacked one upon another. The salt waters are raised to the top of these trestles and allowed to filter through the interlacing switches, upon which, by the evaporation of the water, the salt is deposited. These switches are removed every few months or so, the salt broken from the branches, ground and refined, and serves as the commercial salt of the surrounding country. The most beautiful forms result from these deposits, and by the clever devices of the natives the most grotesque figures are produced. I have some of the figures thus produced.

An estimation of the commercial value of these works today may be made by the value put upon them in 1806, when they were considered by Napoleon an adequate reward to Marshal Louis Nicolas Davout (erroneously written Davoust) for his services in the French army ; and again in 1866, when they fell to Hesse Darmstadt in exchange for Homburg. Since 1834 the reputation of Nauheim for the efficacy of its springs has been steadily coming to the notice of Europeans. Frankfurt up to this time forming the centre and battlefield of many of the German disputes with France, rendered Nauheim scarcely a fit place for invalids.

It was therefore not until 1834 that we begin to hear of Nauheim as a resort for invalids. It was not until 18G0, however, that Dr. Beneke of Marburg considered scientifically the value of the medicated bath treatment. From 1859-1870 several articles by Beneke of Marburg, upon the waters of Nauheim, appeared in the Berlin. Klin. Woch. From 1870 to 1890 August and Theodore Schott and J. Groedel were frequent contributors on this subject to the Berlin. Klin. Woch., also to the Deutsch. Med. Zeitung. August Schott died, but his brother Theodore continued the work, and published in 1892 an article in the Lancet which caused little comment.

In 1894 W. Bezley Thorn became an ardent advocate of the bath treatment, and published an article in the Lancet and also a small book in which he described quite fully the baths and exercises. AVith the appearance of this systematic little book up to the present the treatment has been very popular in


102



England. Nauheim, its waters, and the resistance exercises, have been frequent topics in English and German medical journals. lu France and America the treatment has as yet received no very thorough trial. It is interesting to note here the increase in the number of visitors from 1871 to 1895. In 1871 the visitors numbered 5,249; in 1891, 9,244; 1892, 10,272; 1893, 10,-384; 1894, 11,0)81; 1895, 14,136.

Although the season was over when I visited Bad Nauheim, I had the opportunity of seeing the baths through the courtesy of Dr. Hirsch, Dr. Schott's assistant, who showed me over the grounds and described very fully the details of the treatment. It can best be described in Dr. Schott's own words : " The springs of Nauheim may be divided into two classes, those suitable for bathing and those suitable for drinking. Together with other ingredients the bath waters contain from two to three per cent of sodium chloride, from two to three per 1000 of calcium chloride, various salts of iron, above all, very large amounts of carbonic acid.

Coming from the dejiths of the earth, they have a temperature of 83-95° F. Springing from a depth of 180 metres, supercharged with carbonic acid gas by the pressure to which they are subjected, the waters gush far above the surface; for example, spring No. 12 rises to a height of 56 feet and falls again in white seething masses." This is a most sti-iking condition ; so richly charged with carbonic acid are these waters that the reservoir into which they fall has the appearance of a great mass of clouds. " Conveyed directly from the main by means of subterranean pipes, these waters charged with their natural gas are allowed to completely cover the body of the bather. Little bubbles of gas are seen to immediately cover the whole surface of the body; the waters of springs Nos. 7 and 12 escape from a pressui-e of from IJ to 2i atmospheres, and afford a surf bath which compares accurately with the strongest surf bath of sea water."

The first question which arose when this matter came to be scientifically investigated was, how do these baths and exercises act ? That they were vei'y efficacious in the relief of chronic cardiac disease had been demonstrated for some years back, but their action had never been investigated. There are several explanations given :

(1) That given by Dr. Schott in the following woi'ds: " Physiological research of recent years seems to show that the salts held in solution in water externally applied have uo direct action on the system; the light and mobile molecules of the gas, on the other hand, pass rapidly through the skin to the corium with its rich supply of blood. We must look upon the salts held in solution as passing by imbibition through the outermost layer of the epidermis, and so acting on the terminal nerves of the skin as to exert a reflex action on the internal organs. The warm baths act in their own peculiar manner on the organism as a whole ; increased tissue change seems to be induced by an increase of the oxygen absorbing power of the cells, and hence follows the sense of the need of rest and sleep as an immediate consequence of the bath, as well as influences speedily brought to bear on the nervous system as a whole. Excessive bathing induces an excitable state of the nervous system, sleeplessness, loss of appetite and consequent loss of strength. The principal changes which ensue


in the system and in the function of the special organs are that the heart beats more slowly and strongly, the jnilse becomes full and increases in force, and the blood pressure may rise to the extent of 20, 30 mm. of mercury; the breathing becomes regular and quiet, and the capacity of the lungs increased.

While the patient is in the bath he becomes flushed and a feeling of comfort and warmth ensues which may even rise to one of an agreeable intoxicating character. Almost invariably the excretion of urine is increased; exudates in the body cavities, especially from the peritoneum, pericardium and pleura, are absorbed. This latter action and that on the valves of the heart can only be exjjlained on the theory of reflex action produced by influences acting upon the terminal nerves."

Another explanation is that given by Dr. Bezley Thorn, that there is a dilatation of the muscular arteries and afterwards those of the skin, and thus there is a relief of the heart from backward pressure.

In Lauder-Brunton's massage experiments he demonstrates that more blood flows through the massaged part and that blood pressure at first rises and then falls, and that on the conclusion of massage more blood collects in the massaged part. These exjjeriments were confirmed by Dr. Oliver.* T. Grainger Stewartf concludes that the passive exercises (I) improve the circulation of lymph within the tissues, and (2) bring a larger volume of blood into the muscles. He quotes the conclusion of Ludwig to the effect that the capacity of muscles for blood is equal to the combined capacities of the internal organs and the skin. If therefore this be so and Dr. Lai^der-Brunton's experiments be correct, the increased amount of blood in the muscles must indicate a relief of the congestion in the internal organs.

In Dr. Schott's explanation there are two actions :

(1) A cutaneous excitation induced by the mineral and gaseous constituents, and

(2) a more prolonged stimulation of the sensory nerves excited by imbibition into the superficial layer of the corium. The salt producing this excitation is the calcium chloride.

Whatever the explanation of their action may be, two points seem established:

(1) That the apex beat alters its position ;

(2) the area of cardiac dulness is diminished. These two facts, esjDecially the first one, were most strikingly obvious in our first cases, and both facts were most forcibly demonstrated to me in the cases which I saw abroad. One can scarcely credit the results published until he has seen for himself these marked changes.

The case rej^orted by Dr. Bowles in the Practitioner for July, 1896, shows a change of 3 cm. in the apex beat before and after a bath of ten minutes duration, and he says after his visit to Nauheim, which was made for the purpose of seeing for himself, " that which I thought impossible is shown to be quite possible." This case reported by Dr. Bowles was one of chronic myocarditis, moderate pleural effusion, general aiuisarca and general enlargement of the heart. The age of


• Brit. Med. Jour., .Tune 13, 1896. 1 //'«/., September 19, 1896.


May, 1897.]

103


the patient was not given. I shall not at this time attempt to report cases, but merely mention this one of Bowles in order to contirm what has been our experience of the effect of the bath upon the j.osition of the apex beat, and many other reports confirmatory of this remarkable change are to be found in the literature on this subject.

The diagrams of the cardiac outline made by Dr. Bowles are not quite accurate, but there can be little difference in opinion as to the position of the maximum cardiac impulse.

To quote Hr. Schott again: "The methods of administering the baths are of the greatest importance. It is advisable to begin with a 1 per cent salt bath containing Yawn '^^ chloride of calcium, freed from gas and at temperatures varying from 93° to 95° F., the bath lasting from six to eight minutes. The course of treatment should be interrujited by frequent intervals of one day. The temperature of the bath should, if possible, be gradually lowered, while the proportion of solids in solution and the duration of the bath are gradually increased. At a later stage it is permissible to proceed to the baths containing carbonic acid. The temperature may then be rapidly lowered, especially if chloride of calcium be added in order to increase the mineral strength of the bath."

The course consists of six baths: the first and the second being simply with salts, calcium chloride and the sodium chloride; the third, fourth, fifth and sixth contain carbonic acid as well as these salts.

The preparation of the baths artificially was taken up especially by W. Bezley Thorn, in London, in 1895, since which time Ewart, Bowles and Broadbent have employed them in London, Moeller in Brussels, and Heiuemann in New York. Following the analysis of the Nauheim waters made by the chemist Fresenius of Wiesbaden, the artificial baths may be readily prepared. We have now packages made up at our pharmacy each containing the proportion of salts for the different strengths of the baths, each package corresponding to 40 gallons of water, which is just about enough to entirely immerse the body. The baths of different strengths are given to appropriate cases.

I have not attempted in this note in any way to speak for or against the treatment nor to report cases. I have thought it best for the present simply to give an outline of the trip to Bad Nauheim, the purpose of which was to see the effects of the treatment and to learn something about it with the object of trying it in the Hospital here. We have now five cases under treatment, and I trust by keeping careful records of the effects of these baths and exercises that we shall be able to pass judgment upon the weak points as well as the strong points of the method. Only by a careful trial can one place himself in a position either to recommend or to condemn the treatment. I take this opportunity of exjjressiug my apjireciation of the patience with which Dr. Schott heard and answered my many questions. I also wish to thank Dr. Ileineman for the instruction in the movements which he so carefully gave me.

In regard to the exercises, which are worthy of a lengthy description, something must be said. They consist of nineteen movements, each movement restrained by the very lightest resistance. This part of the treatment, under the supervision


of a physician, is entrusted to the nurses, to whom we have given careful instructions as to the method of carrying it out. The following are the instructions which we have laid down for the nurses in the administration of the bath, also the chart showing the observation which should be made.*

Rules fok Schott Bath.

(1) Always understand clearly from the doctor the following points: (V) Strength of the bath to be given; (3) temperature of the bath; (3) length of time patient is to remain in the bath. Note. — Give the bath in the morning unless otherwise ordered.

(3) Observe carefully the chart and note the points therein called for. (1) Give bath on an empty stomach. (2) Note the time from the moment patient is immersed to that when he is taken out. (3) Allow the patient to make as little exertion as possible; assist him in every way. (4) A sheet may be drawn over the tub, but not around the patient. (5) Be sure the entire body is immersed. (6) Keep the finger on the pulse during the entire time the patient is in the bath.

Danger Signals. — Cyanosis (bluing of the face), dyspnoea (diflicult breathing), apncea (gasping), inappreciable pulse. On the appearance of any of these, take the f)atient out of the bath immediately, put him to bed and keej) him as quiet as possible. Friction while in the bath is not necessary, but if the fingers and toes become bluish the extremities may be rubbed slightly towards the trunk. Friction should be cautiously employed ; when the patient is out of the tub rub hini to a glow; give him a glass of milk or cup of bouillon and allow him to rest for an hour.

Diet. — Small quantity q. 4 h. Meat — boiled chicken, mutton chops ; eggs, two a day ; oysters, raw or panned ; vegetables — peas, beans, lettuce; liquids — beef tea, bouillon, cocoa, lemonade, milk. Note. — Never give more than 4 ounces of fluid at a time. Should be sipped. Wine — Port, Ehine, sherry, brandy, dram to half ounce.

Note. — Something light (cocoa and toast) should be taken one-half hour before the bath ; something light and hot (bouillon, milk piuncb and toasted crackers) should be taken directly after the bath. If the heart's action is poor, sherry, brandy or port wine may be given after the bath. Last meal to be taken three hours before retiring.

Bath No. I. Sodium chloride, 4 pounds; cal. chlor., 6 ozs.

Bath No. IT. Sodium chloride, 5 pounds; cal. chlor., 8 ozs.

Bath No. HI. Sodium chloride, 6 pounds; cal. chlor., 10 ounces; sodium bicarb., 6 ounces; HCl, 7 ounces.

Bath No. IV. Sodium chloride, 7 pounds; cal. chlor., 10 ounces; sodium bicarb., 8 ounces; HCl, 13 ounces.

Batli No. V. Sodium chloride, 9 pounds; cal. chlor., 11 ounces; sodium bicarb., 1 pound; HCl, 1 pound.

Bath No. VI. Sodium chloride, 11 pounds; cal. chlor., 12 ounces; sodium bicarb., 1 pound; IICl, 2 pounds.

Each bath consists of 40 gallons of water.

Note. — By using a little more NallCOn than is required


  • These rules are made after perus.al of the literature, also from

instruction obtained from Dr. Schott personally.


104



to take up the HCl, the metal tubs may be employed without doing them auy harm.

NaHCOs + HCl = NaCl + H=0 +00^.


83.75


36.37 The Exercises.*


The exercises are called by Dr. Schott "Widerstandgymnastik," or resistance gymnastics, and consist in slow movements executed by the patient and resisted by the physician or operator. A short interval is allowed after each movement, during which the patient sits down. The exertion employed must be very small, and should cause no increase in resjjiratory movements, flushing or j)allor. The patient should be loosely and lightly clothed, and instructed to breathe quietly. The resistance made should be of such a kind that the patient may always feel himself easily the master. The operator must not grasp or in any way constrict the limb, but should oppose by the hand held flatly. The movements are nineteen in number:

Arm. (1) Arms extended in front of body on a level with shoulder, hands meeting; arms carried out until in line, and brought back to original position. (2) Arms hanging at sides, palms forwards; arms flexed at elbow until tips of fingers touch shoulder, back to original position ; one arm only moved at a time. (3) Arms down, palms forward, arms carried outwards and upwards until thumbs meet over head; back to original position ; one arm only moved at a time. Not always advisable. (4) Hands in front of abdomen, fingers flexed so that the second phalanges touch those of opposite hand; arms raised until hands rest on top of head ; back to original position. (5) Arms down, palms against thighs, arms raised in parallel planes as high as possible; back to original position.

Trunk. (6) Trunk flexed on hips ; return to original position. Resist tvith hoth hands. (7) Trunk rotated to left, to right; return to original position. Resist with both hands. (8) Trunk flexed laterally. Resist with both hands. (9) As No. 1, but fists clenched. Resist with both hands. (10) As No. 2, but fist clenched. Resist with both hands.

Large Arm Movements. (11) Arms down, palms against

  • The description of each movement is taken (with a few modifications) from "Chronic Disease of the Heart" by W. Bezley

Thome.


thighs, each in turn raised forwards and upwards until arm is alongside of ear, then turned outward, and arm descends backwards. Not always safe. (12) Arms down, palms to thighs, both together moved backwards in parallel planes as far as possible without bending the trunk forwards. Not always safe.

Legs. (13) Thighs in turn flexed on trunk, opposite hand resting on chair. (14) Lower extremities in turn extended fully, and bent on trunk forwards and backwards to extreme limits of movement, opposite hand resting on chair. (15) Legs in turn flexed on thigh, both hands on chair. (16) Feet together, lower extremities in turn abducted as far as possible and brought back to original position, opposite hand on chair.

Hands and Feet. (17) The arms, extended horizontally outwards, are rotated from the shoulder-joint to the extreme limits forwards and backwards. (18) The hands in turn are extended and flexed on the forearm to extreme limits, and brought back in line with arm. Resist tuith both hands. (19) The feet in turn are flexed and extended to extreme limits, and then brought back to their natural position. Resist with both hands.

We have arranged these in 5 groups, as in this way they may be more readily committed to memory.

Rules for Operators.

1. Each movement to be performed slowly and evenly at an uniform rate.

2. No movement to be repeated twice in succession in the same limb or group of muscles.

3. Each single or combined movement to be followed by interval of rest. Count five.

4. Patient's breathing should not be accelerated.

I. Avoid. 1. Dilatation of the ala? nasi (dilating of nostrils).

2. Drawing of corners of mouth.

3. Duskiness and pallor of cheeks and lips.

4. Yawning.

5. Sweating.

6. Palpitation.

If any of the above make a complete interval, or if excessive, stop the exercises for the day.

5. Direct patient to breathe regularly. If he holds his breath, make him count in a whisper.

(i. Do not constrict the part which is being moved.


SCHOTT METHOD OF BATHS AND RESISTED MOVEMEN" Diagnosis Name Hospital No.


Johns fi

rs.


0PKIN^


Hospital. Ward



• Balh !

l| ana


TIME


Respiration. Pulse and Heart [P,".|-Jr;?ile f SEE HISTORY '«-n?e\%e°e°jr']



It

as



Date


of samel aud Movements


In bod


Just before


1st halt


2nd halt


Immed. after


10 mtu. after


Pulse Pressure


Calibre of Radial


Point Maximum Impulse,


Remarks



Begin


End


R.


P.


R.


P.


R.


P.


B.


P.


R.


P.


K.


P.


Before


After


Before


After


Before


During


Afterl>Betore


During


Atter














May, 1897.]

105


Bibliography.

[Those references without the asterisk the writer was unable to consult. Arranged in chronological onler.]

Beueke, F. W.: Ueber Naiilieim's Soolthermen, etc. Marburg, 1859.

Weitere Mittheihmgen iiber die Wirkungen der Sool thermen Nauheims. Marburg, 1861.

  • Nauheim's Soolthermeu gegen Gelenkrheuiuatismus mit

oder ohne Herzaffection. Berlin, kliu. Wocheuschr., No. 33, 1870, p. 269.

Zur Therapie des Gelenkrheumatismus luid der damit

verbundenen Herzkraukheiten. Berlin, Hirschwald, 1872.

  • Neue Erfahruugen iiber die Wirkungen der kohlen

siiurehaltigeu 8oolthermen Nauheims, etc. Berlin, klin. Wochenschr., 1875, No. 9, p. 109 ; No. 10, p. 134.

  • Groedel, J. : Ein Beitrag zur Behandlung der Lilhniungeu

bei Apoplektikern mit Herzfehlern. Berlin, klin. Med. AVoeheuschr., No. 10, 1878, p. 137.

  • Pneumatometrische Beobachtuugen iiber den Eiufluss

verschiedener Biider auf die Kespiration. Berlin, klin. Wochenschr., No. 32, 1880, p. 314.

  • Die Wirkung der Biider auf das Herz. Berl. klin.

Wochenschrift, 1880, No. 20, p. 438.

  • Zur Behandlung Herzkranker. Berlin, kliu. Wochenschr., No. 35, 1883, p. 381.
  • Schott, T. : Beitrag zur tonisirenden Wirkung kohlensiiurehaltiger Theramalsoolbilder auf's Herz. Berl. klin. Wochenschrift, 1883, No. 28, p. 428.
  • Schott, A. und Theo. : Die Nauheimer Sprudel und Sprudelstrombiider. Berlin, klin. Wochensch., 1884, No. 19, p. 394.
  • Schott, A. : Zur Therapie der chronischen Herzkraukheiten.

Berl. klin. Wochenschrift, No. 33, p. 534. 1885.

Leichtenstern, 0. : General Balneotherapeutics. Ziemssen's Handbook of Therapeutics, Vol. IV, p. 395. London, 1885.

Schott, August: Die Bedeutuug der Gymnastik fiir Diagnose, Prognose und Therapie der Herzkraukheiten. Zeitsch. f. Therapie, 1885.

Schott, Th. : Die Hautresorption und ihre Bedeutuug fiir die Physiologie der Badewirkungen. Deut. Med. Zeitung, 1885.

Oertel, M. J. : Therapeutics of Circulatory Derangements. Ibid., Vol. 7, 1887.

Schott, Th. : Die Behandlung der chronischen Herzkraukheiten. Berlin, Grosser, 1887.

Zur Pathologie und Therapie der Angina Pectoris.

Deut. med. Zeitung, 1888, No. 35-38.

Wiborgh, Aug. : Bad Nauheim, etc. Stockholm, 1888.

Bode, W. : Bad Nauheim, seine Curmittel, Indicationen und Erfolge. Zweite Aufl., Wiesbaden, 1889.

  • Schott, Theodore: Herzkraukheiten. Separat-Abdruck aus

der Keal-Encyc. der gesammten Heilkunde. Wien und Leipzig, 1890. (Reprint.;

  • Zur acuten L^eberanstrengung des Herzens und dereu

Behandlung. 1890. Separ. Abdr. aus den Verhandlungen des IX. Congresses fiir innere Medicin zu Wien. (Eeprint.)

  • Herzkraukheiten. Keal-Encycl. der gesammten Heilkunde. Wien und Leipzig, 1890. (Reprint.)


  • Groedel, J. : Ueber abnorme Herzthiitigkeit in Folge von

lunervationsstoruugen. No. 21, 1890, p. 467.

  • Schott, Theodore: The Treatment of Chronic Diseases of

the Heart by means of Baths and Gymnastics. Lancet, 1891, Vol. I, p. 1143. Concluded on p. 1199. (Reprint.)

Israel, E. : Om Nauheimkur, etc. Copenhagen, 1891.

Schott, Th.: Balneo-therapeutic and Mechano-therapeutics applied to the Treatment of Chronic Heart Disease. Medical Record, No. 7, Vol. XXXIX, 1891.

  • Zur Differentialdiagnose des Pericardialexudats uud

der Herzdilatation. (Reprint.) Berlin, klin. Wocheuschrift, 1891, No. 18.

Ueber Herzneurosen. 1893. Separ. Abdr. aus der Real-Encycl. der gesammten Heilkunde.

  • Moeller: Traitement des maladies du coeur par la methode

des Drs. Schott. Bruxelles, 1893. (Repriut.)

  • Babcock : Schott Method of treating Chronic Diseases of the

Heart. Journal of American Medical Assoc, XXI, pp. 717-734, 1893.

Summers, Guillermo: Tratamiento de las enfermades cronicas del corazon por el metodo del Dr. Schott. Gaceta Medica de Cadiz, 1893.

Groedel: Bad Nauheim and the Treatment of Chronic Heart Disease. St. Petersburg Med. Woch., 1893.

  • Schott, T. : The Mineral Waters of Nauheim, their Action,

Uses and Effects. Eyre & Spottiswoode, London, 1894.

Smyly, P. C. : On the Treatment of Enlarged Heart by Certain Movements as taught by Dr. Schott, Nauheim. Dublin Jour, of Med. Scieu., 1894, Vol. 3, p. 185.

  • Thorne, W. Bezley : Treatment of Chronic Diseases of the

Heart by Baths and Exercises according to the Methods of Dr. Schott. 1894. Churchill, London.

  • Thorne, W. B. : The Treatment of Chronic Diseases of the

Heart by Baths and Exercises according to the Method of Dr. Schott. Lancet, 1894, Vol. I, p. 1117.

  • Wethered, F. J. : The Treatment of Chronic Diseases of the

Heart by Baths and Gymnastics as practised at Nauheim. Brit. Med. Jour., 1894, Vol. II, p. 1045.

  • Brunton, T. L. : The Harveian Oration, 1894. London.

♦Campbell, H. : The Mechanical Treatment of Heart Disease. British Med. Journal, 1894, Vol. 2, p. 1101.

  • Eccles, A. Symous: Mechanotherapy in Chronic Diseases of

the Heart. The Practitioner, 1894, Vol. I, p. 107.

  • Pagenstecher de Mexico, G. : Du traitement balneomechanique des maladies chroniques du coeur d'apres la m6thode des docteurs Schott de Nauheim. Bulletin General

de Therapeutique, Paris, 1894, Nos. 15-30, Juin. (Reprint.)

  • Babcock, Robert H. : Report of Cases of Chronic Heart

Disease treated by the Schott Method of Baths and Gymnastics. N. Y. M. J., LX, pp. 705-710, 1894.

  • Schott, Th. : Zur Behandlung des Fettherzens. Deut. Med.

Wochensch., XX, 561, 1894.

Armstrong: Nauheim Treatment of Chronic Cardiac and Allied Diseases. Liverpool Medico-Chirurgical Journal, July, 1895.

  • Sturge, W. A. : Note ou the Treatment of Dilated Heart as


106



practised at Naiiheim. Brit. Med. Jour., 1895, Vol. I,

p. 537.

  • Thorne, W. B. : Tlie Treatment of Chronic Affections of the

Heart by Baths and Esereises. Brit. Med. Jour., 1895,

Vol. I, p. 524.

  • The Schott Method of Treatment in Chronic Diseases

of the Heart. London, 1895.

  • Practitioner, May, 1895, p. 385. The Treatment of Chronic

Heart Disease by the Method of Dr. Schott, Nauheim. By

John F. H. Broadbeut. With some remarks on the mode

of action of the treatment and its indications. By Sir

William Broadbent, Sen. Physician to St. Mary's Hospital.

  • Thorne, W. B. : The Treatment of Chronic Affection of

the Heart. Brit. Med. Jour., 1895, I, p. 524. Kraus, W. C. : Some Advances in Cardiac Therapeutics. Med.

Press and Circ, Loudon, 1895.

  • CTroedel: The Mechanico-Gymuastic and Balneo-Tliera

peutic Treatment of Chronic Cardiac Disorders. Lancet,

London, pp. 802-804, 1895.

Baths in Cases of Arterio-sclerosis. Deut, Med. Zeitung,

1895.

Green, C. L. : The Treatment of Chronic Heart Disease by the Schott Method. N. W. Lancet, St. Paul, XV, 345-349, 1895.

Pospischil: Hydrotherapie bei organischen Herzkrankheiten. Deutsch. med. Ztg., Berlin, XVI, 581-586, 1895.

de Bosia, H. : Des indications des eaux minerales dans les traitemeut des maladies da coeur. Cong. Franc, de MC'd., Paris, 845-852, 1895.

  • Sauudby, Robert: Remarks on the Nauheim (Schott) Treatment of Heart Disease. B. M. J., Nov. 2, 1895, p. 1081.

Discussion, p. 1129.

Birmingham Medical Review, Vol. XXXVIII, 1895, No.

208.

Fisher, T. : The Treatment of Heart Disease. The Hospital, August 24, 1895.

  • Heinemauu, PI. N. : Experiences with the Physical and Schott

Treatment of Chronic Heart Disease. N. Y. Medical Record, 1896, L, 847-852.

  • Mason, A. L. : The Baths of Nauheim in Heart Disease. Boston M. and S. J., 1896, CXXXV, 302.
  • Morrison, A. : The " Schott Treatment " of Heart Disease.

Practitioner, London, 1896, LVII, 268-275.

♦Report of the Lancet Commission on Balneological and Gymnastic Treatment of Heart Disease at Nauheim. Lancet, London, 1896, II, 619-621.

  • McArthur, A. N. : Heart Disease treated by Saline Baths.

B. M. J., 1896, I, 1384.

♦Carter, A. H. : The Schott Treatment of Heart Disease. Practitioner, 1896, LVII, 166. [No direct bearing upon the treatment.]

  • Erebuske, C. J.: Gymnastics in Heart Disease. Bost. M. &

S. J., 1896, CXXXIV, 610-612. (Discussion) 618-620.

  • Graiipner. Die Balneotherapie der chronischeu Herzkrankheiten, ihrMechanismus und ihre Beziehung zur Dynamik

des Kreislaufs. Deutsche Med. Wochensch., 1896, XXII, 529-531.

Nauheimer Mineralbader und einfache Wasserbader:


ihr Einfluss auf Blutdruck und Herzthiltigkeit. Allg. Med. Centr. Ztg., Berl., 1896, LXV.

Cireene, C. L. : Extreme Dilatation of the Heart due to Valvular Disease, with Special Reference to Treatment by the Schott Method. luternat. Clin., Phila., 1896, 6 s., II, 63-73.

Yeo, F. B. : Rest, Exercise and Baths in the Treatment of Cardiac Affections. luternat. Clinic, Phila., 1896, 6 s., II, 31-42.

Bowles, R. L. : Nauheim and the Schott Treatment of Diseases of the Heart. Med. Press and Circ, London, 1896, N. S., LXI, 339. Discussion, 345.

  • Kingscote, E. : Fifteen Months' Practice of the Schott Methods for the Treatment of Chronic Affections of the Heart.

Lancet, London, 1896, I, 761-7C3.

  • Nebel, H. : The Treatment of Heart Diseases by Baths and

Gymnastics. N. Y. Med. Record, 1896, XLIX, 7)7. (Early literature.)

  • Broadbent, Sir W. N. : Note on Auscultatory Percussion and

the Schott Treatment of Heart Disease. Brit. M. J., 1896, I, 769.

  • Leith, R. F. C. : An Inquiry into the Physiology of the

Action of Thermal Saline Baths and Resistance Exercises in the Treatment of Chronic Heart Disease (the Nauheim and Schott System). Edinb. M. J., 1895-6, XLI, 804, 814. Also Lancet, 1896, I, 757, 841.

♦Campbell, H. : The Schott Treatment of Heart Disease. Lancet, 1896, I, 951. [Communication on Leith's paper.]

  • The Schott Treatment as carried out at Sidmouth. Brit. M.

J., 1896, I, 924.

Anderson, McO. : Dilatation of the Heart treated by Exercises on the Schott Principle. Glasgow M. J., 1896, XLV, 266, 268.

♦Poore, G. V.: Two Cases of Heart Disease treated by Saline Baths. B. M. J., London, 1896, I, 1139.

  • Rives, W. C. : The Baths of Nauheim in the Treatment of

Disease of the Heart and the Therapeutic Methods of the Doctors Schott. N. Y. M. J., 1896, LXIII, 471-479.

Steven, J. L. : On the Nauheim (Schott) Methods of Treatment as applied to Cases of Cardiac Valve Disease of Rheumatic Origin. Glasgow M. J., 1896, XLV, 339-361.

  • Thorne, W. B. : Self -Poisoning in Heart Disease ; its Relation to Schott Methods of Treatment. Lancet, Loudon,

1896, I, 755-757.

♦Schott, T.: Ueber gichtische Herzaffectiouen und dereu Behandlung. Berliner klin. Wochenschrift, XXXIII, 457-519, 1896.

♦Stewart, Grainger: Discussion on Treatment of Cardiac Failure. Brit. Med. Journal, September 19, 1896.

♦Bowles, R. L. : An Experimental Inquiry into the " Schott Treatment" of Certain Diseases of the Heart at Bad Nauheim. The Practitioner, July, 1896. (Reprint.)

♦Ileinenmu, H. Newton: Die physikalische Behandlung der chronischen Herzkrankheiten. Deut. Med. Woch., 1896, No. 33, Leipzig. (Reprint.)

♦Cohen, Solomon Solis : The Schott Method of Gymnastics in Chronic Heart Disease. JIaryland Jledical Journal, Feb. 20, 1897.


May, 1897.]

107


A CASE OF POROKERATOSIS WITH


(MIBELLI) OR HYPERKERATOSIS EXCENTRICA (RESPIGHD A REMARKABLE FAMILY HISTORY.*


PKELIMINAEY NOTICE.


By T. Caspar CtILCHRist, M. 11. C. S., L. S. A., Associate in Dermafologi/, Johns Hopki)is Unicersifi/.


In October, 1893, Mibelli, of Italy, described three (slight references were made to three others) cases of a new disease which, after a careful and detailed histological examination, he named Porokeratosis. The disease began at an early age, and was chiefly distributed on the backs of the hands, feet, other portions of the extremities, neck, face and scalp. The lesions commenced as minute, dirty brown, dry, cone-shaped elevations of different sizes and forms, which became much altered as they very slowly increased in size. The lesions extended centrifugally, and the central portion gradually sank in and still remained callous, but the margin was represented by a raised wavy ridge which presented the features of a raised seam. Some patches grew to a very large size and covered almost the whole forearm. Mibelli gave the name porokeratosis to this disease because the most important anatomical lesion was the hyperkeratosis of the sweat duct and sweat pore. In one instance a brother and sister had the disease, mainly on the face and neck. The disease was exceedingly chronic and was unaccompanied by any inflammation or any subjective symptoms.

On January 15, 189-1, Respighi, also of Italy, described seven cases of a disease which was recognized by Mibelli as belonging to the same group. Respighi gave the name of " Hyper


  • Exhibited before the Johns Hopkins Hospital Medical Society,

March 1, 1897.


keratosis excentrica" to this affection. In one of the cases the father of the patient also was affected with similar lesions. Two years later, three more cases were described by the same author. A single case has been recorded outside of Italy, by Dr. M. B. Hutchius, of Atlanta, Ga., in the Journal of Cutaneous and Genito- Urinary Diseases for October, 1890. In Hutchins' case the disease began at two years of age, on the 2)alni of the left hand. The patient is now a man, 33 years old, and has the disease on the left palm, the back of the hand and forearm, and on the face. No histological examination was made. Hutchins compares the boundary of the patches to the "outside of a seam with a thread-like line dividing its lateral halves, and consisting of horny epidermis." No other member of the family had it. In all the cases which have thus far been recorded, only two gave histories of other members of the same family having the disease. In the one case (Mibelli's) a brother had it, and in another (Respighi's), the father of the i^atient had it.

The patient whom I exhibit this evening is a young man, 21 years of age, who has had the disease since he was five years old, when it commenced on his ears, nose, chin, neck, back of hands and right forearm. The lesions were extremely slow in ap2)earing and in growing. The most remarkable feature about the whole case is the family history, which is here given in a tabular form, together with a very brief descrijitiou of the disease in each case.


Grandmother.

Disease on the face ; commeuced when she was a child iu 1813, now dead.


One Brother.

Lesions on the face, oommeucing at an early afie and lasting until death.


Father.


Disease began at about 8 years of age and is on the face, palms, back of hands, forearms, legs, feet, and sole of one foot.


One Brother.

Disease commenced at about 9 years of age, on face and leg; died


One Son. No eruption.


28 years old, married. Disease commenced at 7 years, on face.


Brother 0).

Aged 30 ; four lesions on left side of nose, commenced at 5 yrs.


Brother i2). Aged 17; disease just commencing (?), one lesion on neck.


Aged 15; number «)f lesions on face which began at about 9.


9 years old: disease commenced at 7 and quite extensive on face.


Aged 11; disease commenced at 9 years on face.


108



It will be seen that eleven persons in one family have had this disease. The patient gave me this history after careful inquiry, and I have since been able to verify his statements with reference to seven of the cases, viz. father, three brothers, a married sister and two of her children, by personal observation. The patient's description of the lesions in his father and brothers, whom I examined later, was so correct that I feel confident the other descriptions are also true, especially since the remaining family history was verified by his father and mother. The father of the patient also described to me the disease as it existed on his mother, an uncle and brother. I will not go any further into the history or description of the lesions occurring in other members of the family, but will reserve that for a more detailed histological description with photograph and drawings, which will appear later.

The patient first came under my care eighteen months ago, and my attention was then only directed to the lesions on the face. I did not diagnose the disease until I had made ten or more histological examinations of excised portions and had seen Mibelli's and llespighi's articles.

The eruption consists of lesions of various sizes and forms which appear to take on two characters according to their age. The smallest variety, which are distributed chiefly over the face, consist of minute (less than 1 mm. in diameter), dirty brown, semi-globular elevations of a horny nature. When they reach the size of a small pinhead the centre becomes depressed and the margin in some is slightly raised, round, oval or slightly irregular, and presents the appearance of a raised seam, along the centre of which runs a thin black line. As the patch becomes very slowly larger the base takes on a somewhat atrophic character. In a few of the lesions, especially those on the neck, a number of minute conical elevations are distributed along the ridge, giving it an irregular appearance, and sometimes one or two of these minute cones appear in the central portion of the plaque. The largest patches are about the size of a split pea.

After removing some of the diseased portions with a curette and applying very thoroughly the silver nitrate stick, I


have seen on four or five occasions the disease return within a month or two in the manner described, viz. a very minute, dirty brown papule, which within two or three weeks apparently began to clear up in the centre. Other lesions return in the form of a ring or oval ridge. If one of the patches is curetted it is fairly easily removed, but the operation is followed by almost as much bleeding as the removal of a small epithelioma. Examination of the scrapings, either fresh or after treatment with liquor potassaj, is negative. While watching the course of the disease week by week, I have seen new lesions arise which I had not detected the week previous.

One or two of the lesions appeared to have formed round a hair follicle, but others did not exhibit any such relationship.

A histological examination of a large number of sections from the most recent as well as from the oldest patches showed that the disease consisted of a marked hyperkeratosis of the sweat pore and duct and of the adjacent hair follicle. In some of the material excised from the face it was not clear tliat the hyperkeratosis had commenced in the mouth of a hair follicle, but in other sections, especially of the smallest variety of lesions, the disease had undoubtedly commenced about the sweat pore. The oldest lesion, especially from the ear, presented a picture almost identical with that of a mild psorospermosis foUicularis (Darier).

From the clinical and histological characters of the disease there was no doubt of the diagnosis of all the cases, but the special feature of this rare lesion was perhaps most marked in the case of the father of the patient, who presented on the hands lesions which showed the well-defined raised wavy edge with a thin blackish line along the centre.

The character of the disease on the hands agreed perfectly with the descriptions of Mibelli and Hutchins. JSfibelli has reported 6 cases, Eespighi 10 cases, and Hutchins 1. I am able to record a group of eleven in one family, which fact seems at first sight to point to a strong hereditary taint. The histological features will be discussed in detail and a fuller clinical description will be given in a later article.


A RAPID METHOD OF MAKING PERMANENT SPECIMENS FROM FROZEN SECTIONS BY

THE USE OF FORMALIN.

By Thomas S. Gdllen, M. B., Resident Gynecologist.


In April, 1895, I published two methods under the above title in the Bulletin.

Since then, numerous requests have been made for reprints or for copies of the Bulletin of that number, and as the supply is exhausted, it has been thought best to publish the article again with one or two minor alterations. The methods have been continuously employed in the Hospital, and especially in the gynecological department, and have proved uniformly satisfactory.

A complete freezing outfit has been placed in close proximity to the operating room, so that as little delay as possible may occur in examining a specimen. For example, if a carcinoma


of the uterus is suspected, the patient is brought to the operating room prepared for hysterectomy. The uterus is curetted and the scrapings are examined while the usual preparations for abdominal section are being made. By the time all prejsarations are completed the diagnosis is given; if negative, the patient is returned to the ward with the assurance that there is no cause for alarm ; if positive, the organ is immediately removed. The woman is thus saved from taking an anajsthetic twice, and avoids the period of anxious suspense of four or five days generally required by the ordinary methods to ascertain whether she has malignant trouble or not. Any one who has hardened tissues in formalin will be im


May, 1897.]

109


pressed with the rapidity of its action, with the firm consistence of the tissue, and with the absence of the contraction of the specimen so often seen when alcoliol is used as the hardening medium. Microscopical examination of a specimen hardened in formalin, as we all know, shows almost perfect preservation of the cellular structure. Recently it occurred to me that formalin might be used in the preparation of frozen sections.

One of the greatest difficulties experienced in rendering frozen sections permanent lies in the fact that when passed through alcohol the section frequently not only contracts but contracts irregularly, distorting the specimen ; further, such specimens will often stain imperfectly. The use of formalin will obviate these difficulties, allowing one to make an excellent permanent specimen from the frozen section. My method is as follows: The tissue to be examined is frozen with carbonic acid or ether aud then cut; the sections are then placed in 5 per cent, watery solution of formalin for 3 to 5 minutes, or longer if desired; in 50 per cent, alcohol 3 minutes, and in absolute alcohol 1 minute. The tissue is now thoroughly hardened aud can be treated as an ordinary celloidin section, being stained and mounted in the usual way. On examining this mounted section one might readily take it for a well preserved alcoholic specimen. Supposing we stain with hematoxylin and eosin, the entire process is as follows :

Method I. a. Place the frozen section in 5 per cent. aq. sol. formalin for 3 to 5 minutes.

b. Leave in 50 per cent, alcohol 3 minutes.*

c. In absolute alcohol 1 minute.

d. Wash out in water.

e. Stain in ha^matoxylin for 2 minutes. /. Decolorize in acid alcohol.

g. Rinse in water.

h. Stain with eosin.

i. Transfer to 95 j)er cent, alcohol.

j. Pass through absolute alcohol, then through either creasote or oil of cloves, and mount in Canada balsam.

The blood is lost in frozen sections. To overcome this Prof. Welch suggested that the sjiecimen be first fixed in formalin and then frozen. I tried this aud found that we were able to preserve the blood, but that it did not stain very distinctly. For convenience this second procedure will be called method II. The essential factor is the same in each case. The latter process, however, requires at least two hours. A small piece of the tissue is thrown into 10 per cent, solution formalin for two or three hours. It is then put on the freezing microtome and thin sections can be readily made. The sections are stained in the usual way. The detailed procedure of method II is as follows:


  • The sliglit modification of Method 1, recently suggested by L.

Pick, Centralblalt f. Gyn., Bd. XX, S. 1016, 1896, I cannot recomirieiul. When first experimenting with formalin, among other prolures I tried staining the sections after hardening in the formalin I before placing them in alcohol, as Pick now suggests. The ifsulls were fair, but the definition so obtained was not to be compared with that gained by first passing through 60 per cent, and absolute alcohol for the short period. I accordingly abandoned it and did not think it worthy of publication.


Metliod II. a. A piece of tissue lx.5x.2 cm. is placed in 10 per cent. aq. sol. formalin for 3 hours. Rinsed in water.

1). Frozen sections are made.

c. Left in 50 per cent, alcohol 3 minutes.*

(/. In absolute alcohol 1 minute.

e. The sections are now run through water and stained in hsematoxylin for 3 minutes.

/. Decolorized in acid alcohol.

g. Rinsed in water.

/;. Stained in eosin.

/. Transferred to 95 per cent, alcohol.

j. Passed through absolute alcohol, then either through creasote or oil of cloves, and mounted in Canada balsam.

For ordinary use method I is all that is required. Given a piece of tumor from the operating room, it is possible to give as definite a report in 15 minutes as one would be able to give after examining the alcoholic or Miiller's fl.uid sjjecinieus at the expiration of two weeks. Method II is of especial value in the examination of uterine scrapings. Instead of putting them in the 95 per cent, alcohol in the operating room, they may be immediately dropped into 10 per cent. aq. sol. formalin. By the time the pathologist receives them, which is at least two hours afterwards, they are firm enough to be frozen without difficulty, and permanent sections can be immediately made. The second method is to be recommended for all delicate tissues. In employing these methods one must remember, as for example in epithelioma, that some of the cell-nests will drop out, there not being anything to hold them in situ, as there is when celloidin is used. AYe have, however, hardened and stained epithelioma of the cervix by this method without the slightest difficulty.


NOTICE.

All inquiries concerning the admission of free, part pay, or private patients to the Johns Hopkins Hospital should be addressed to Dr. Henry M. Hurd, the Superintendent, at the Hospital.

Letters of inquiry can be sent, which will receive prompt answer, or personal interviews may be held.

Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indigent patients a uniform rate of $5.00 per week has been established. The Superintendent has authority to modify these terms to meet the necessity of urgent cases.

The Hospital is designed for cases of acute disease. Cases of chronic disease are not admitted except temporarily. Private patients can be received irrespective of residence. The rates in the private wards are governed by the locality of rooms and range from $20.00 to $35.00 per week. The extras are laundry expenses, massage, the services of an exclusive nurse, the services of a throat, eye, ear and skin or nervous specialist, and surgical fees. Wherever room exists in the private wards and the condition of the patient does not forbid it, companions can be accommodated at the rate of $15.00 per week.

One week's board is payable when a patient is admitted.

DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL

Bv John s. lin.i.iNos, M. D., LL. D. C.mtalulng 60 Urgo cjuartu pl.-iiofl, phototyDOS, and llth<.gi-apli», wli.h vIbwb lilaua and detail drawings ot all tUo bulldiugs, aud Uielr liuerl"!- arranguniouts— also wood-cuts of apparatus and flxtures; also U6 pages of letter-press describing the plans followed In the cnnstruoUou, and giving full details ot heatlug-apparatua, ventilation, sewerage and plumbing. Price, bound In cloth, $7.50.



PROCEEDINGS OF SOCIETIES THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of December 7, 1896.

Dr. Thayer in the Chair.

Typlioid Perforation treated by Surgical Operation.— Dr.

FiNNKY.

In 1762 Richter, in Vienna, first suggested the advisability of oiJeuiug and draining the peritoneal cavity in cases of general suppurative peritonitis. The operation did not come to general notice, however, until 1884, and was not applied to cases of suspected perforation of the intestine in typhoid fever until 1887. Since that date 46 cases have been reported, to which may be added 6 unpublished cases, including 3 of Dr. Finney's, making a total of 53.

According to statistics taken from various sources, perforation of the intestine occurs in from 1 per cent, to 2 per cent. of all typhoid fever cases. In 80 per cent, of the cases it occurs in a thickened and iutlamed Peyer's patch of the ileum, from 2 cm. to 1 m. above the ileo-cascal valve. In over 12 per cent, it occurs in the large intestine, and in 5 per cent, in the appendix vermiformis. There is usually but one perforation. In twelve cases, however, multiple inflamed Peyer's patches were observed. It occurs more often in men than in women ; more frequently between the ages of 20 and 30 years, and usually during the third week of the disease. The duration of life is usually short. In typhoid fever, perforation is always followed by suppurative peritonitis, either general or local ; howevei', peritonitis may arise during the fever without any discoverable perforation. It occurs much more frequently in mild than in severe forms, and the symptoms may be severe, mild, or wanting. The most constant and characteristic symptom is sudden, severe abdominal pain, persisting with increasing intensity ; there may be collapse, nausea and vomiting. A few of the cases have shown chill, hiccough, a marked fall of temperature, and absence of the liver dulness. Owing to the great difficulties of diagnosis it is impossible to get data as to the number of recoveries without operation.

A study of the reports of the operations brings out the following facts. The time between theonsetof the symptoms of perforation and the oj)eration varied between 2 and 12 hours. The condition of the patients at the time of operation was usually markedly unfavorable. Ether and chloroform were used about equally ; in one case both were used. The median incision was the most common. Thirty-three of the cases showed marked general septic peritonitis with foul pus and exudate. Faecal matter was usually present, and the mesenteric glands opposite the ulcerated Peyer's patches were, as a rule, enlarged and softened. In the treatment, irrigation of the peritoneal cavity was employed more often than simply wiping. As regards the perforation itself, in 8 cases the edges were incised before suturing; in 2 a wedge-shaped piece of the bowel was removed, and in 1 the edges of the bowel were stitched to tlie abdominal wound while an artificial anus was established. Including all of the 52 cases, there have been 17 recoveries; but if doubtful cases are excluded, the result is


13 recoveries from 47 cases,making a percentage of 27.65. In 19 of the fatal cases autopsies were obtained.

These data are hardly sufficient for general conclusions, but several points are brought out quite prominently in studying the group as a whole. The best time for operation is apparently as soon as possible after the patient has recovered from the shock attending the perforation. This is usually in a few hours. There is a remarkable uniformity in the condition of the peritoneum and viscera ; intense congestion, much feculent pus and exudate, with distension of the bowel. As the ileum is the usual place of perforation, it should be examined first ; a suture should be taken over any suspicious-looking patches, and the appendix should be removed if it be at all abnormal. If the inflammation does not involve the whole peritoneal surface, irrigation with the necessarily mild fluids might tend to spread the infection. In dealing with the perforation, to excise the edges takes too long, and healing usually takes place without. Should the wall be in such a condition as to make suture impossible, it would be better to pull out the loop of intestine and leave it until the patient had recovered from his fever. The line of suture must be determined by circumstances; the mattress suture of Halsted is to be preferred. Drainage should always be employed. The fact that in 8 cases a wrong diagnosis was made shows how little dependence can be placed on the so-called characteristic symptoms. However, the systematic examination of the blood promises to be of the greatest assistance. During typhoid fever there is no leucocytosis, but immediately after a perforation a marked increase in the number of white corpuscles occurs. Cabot mentions a case of 8,300 before and 24,000 after ; in Porter's case the figures are 6,500 and 10,600 ; in his (Dr. Finney's), 3,000 and 16,400.

Fitz has pointed out the striking similarity of the symptoms of typhoid perforation to those of inflammation of the appendix. Dieulafoy recognizes two forms of typhoid appendicitis capable of producing peritonitis ; one, "peritonitis by propagation," involving the lymphoid tissue of the appendix, the other, " para-appendicitis," which is of the usual variety.

The symptoms of peritonitis quickly follow perforation. Examination shows that pyogenic cocci, especially the streptococcus pyogenes, are rarely absent, indicating that they are common inhabitants of the intestine. The Johns Hopkins Hospital autopsy reports show in 4 cases a mixed infection of streptococcus pyogenes and bacillus coli communis, in one a pure culture of the streptococcus, and in one a pure culture of the colon bacillus. The absence of the bacillus of Eberth and Gaifky is probably due to its being destroyed by its more active companions, streptococcus pyogenes and bacillus coli communis. In Dr. Finney's third case pure colon bacillus was found; in other cases the typhoid bacilli were present in liver or spleen or in a peritoneal abscess.

As regards the incision, the median has obvious advantages in general, but if the abdominal muscles are too rigid, it is lielter made over the part most often affected. Its length should always be amply suflicient. On the other hand, the


May, 1897.]

Ill


time consumed in operation should be as short as possible. The autopsies showed that healing was always well under way. Death usually occurred from septic absorption, but the records show some other complications, obstruction of the intestine, a second perforation, defective drainage or an abscess. General peritonitis makes a case very serious, but with operation the chances are about 1 in 4. The treatment of a case of perforating typhoid ulcer involves three things: (1) Finding and closing the perforation ; (3) emptying and cleansing the peritoneal cavity; (3) the establishment and maintenance of effective drainage.

For these ends the following method, employed in his (Dr. Finney's) third case, has proved the most satisfactory. An oblique incision, about 6 inches, is made in the right iliac fossa. The Ciscum is found as a guide to the ileum (or appendix); the coils of small intestine, beginning with the ileum, are pulled out systematically. One assistant wipes vigorously and thoroughly the coils with a gauze sponge wrung out of hot salt solution as they are withdrawn, while another keeps them covered with warm sterile gauze. If necessary the entire small intestine is pulled out through the wound and laid to one side, covered with warm gauze. The peritoneal cavity is then wiped out thoroughly, and the coils uncovered and irrigated outside the abdomen with hot salt solution. They are then replaced in the abdomen. The worst or sutured coil is placed with its suture next the abdominal wound, and is packed about with strips of bismuth gauze to insure good drainage. The abdominal wound is closed tightly except a small opening for the gauze drain. In case of distension the bowels should be moved early and thoroughly by calomel in broken doses, followed by salts, and if necessary, a high turpentine and soapsuds enema. If stimulation is necessary, use hypodermics of strychnia, enemata of hot black coffee, or transfusion of a quart or more of the normal salt solution into the cellular tissues under the breast.

Finally, in summing up the experience of himself and others, he concludes that (1) of all the so-called diagnostic signs of perforating typhoid ulcer, most reliance is to be placed upon the development during the third or fourth week of an attack of typhoid fever, of severe, continued abdominal pain, coupled with nausea and vomiting, and at the same time a marked increase in the number of white blood corpuscles.

(2) The surgical is the only rational treatment of perforating typhoid ulcer. •

(3) There is no contraindication to the operation, surgically speaking, save a moribund condition of the patient.*

Case I. — Mr. M.,aged about fifty-five years, was taken sick about October 15, 1894, complaining of headaclie, general malaise, pains in limbs and joints, togettier with irritability of the bladder. Was


•Since the above was written one other case has been reported by Armstrong, of Montreal (Montreal Med. Journal, Vol. XXV, No. 8, 1897). This case recovered from an operation for the relief of first perforation. Twenty-four days later, however, a second, and four days later a third perforation occurred, from the effects of which the patient finally succumbed. Reference is also made to the fact that two other fatal cases had occurred in that vicinity.


seen on October 19 by his physician, Dr. Wesley C. Stick, of Glenville, Pa., to whom I am indebted for the notes of the case. " He gave an indefinite history of having felt badly for about ten days. He had at this time a temperature of 102° F., frequent micturition, bowels constipated, pulse 100. Patient up and dressed ; was put to bed and bowels opened by enemata. In a few days temperature came down to about 100° F., pulse to 90. Would not stay in bed. Irritation of bladder ceased. Was getting along very nicely until the night of October 2(ith, when he was suddenly seized witli a violent pain in his abdomen while lying in bed. Was seen the next morning. Pain in abdomen very severe, relieved somewhat by emptying the over-distended bladder through a catheter. He had been unable to void urine during the night, although having frequent and urgent desire to do so. Several hypodermics of morphine were necessary, however, before he became easy. An enema was given with little result. His abdomen was moderately distended, and not very tender to the touch. In the evening of the same day he was seen again and found to have considerable pain, which was relieved by a hypodermic. Had vomited some during the day. His pulse was about 90 ; temperature 99° to 100° F. The following day, October 28, he vomited frequently a coffee-ground-looking fluid. On the fourth day, October 29, his condition remained about the same ; he could get in and out of bed by himself (he was a largeframed, heavy man, weighing about 225 pounds) ; pulse regular and not above 90 ; cheerful ; the constant regurgitation of coffee-ground fluid being the most troublesome symptom. On the next day, October 30, he was able to sit up in bed, but his pulse had risen to 100 and his temperature to 100° F. Abdomen still not much distended nor very tender."

I saw him at eleven o'clock the night of October 30; his condition then was fairly good, temperature and pulse about 100. Abdomen not much distended, rather retracted ; muscles, especially the recti, very rigid ; tenderness general, but not marked ; frequent and copious vomiting of a dark brownish fluid ; countenance pallid and anxious. The diagnosis was general peritonitis, cause unknown, probably appendicitis, although Dr. Stick had from the first suspected typhoid fever with a subsequent perforation of the intestine. The patient had been exposed to typhoid contagion during a recent visit.

As his condition was evidently becoming worse, it was thought best to open the abdomen. The operation was accordingly performed, and under most disadvantageous conditions, about midnight, in a small log house, with very poor light. On opening the peritoneum it was found to be everywhere intensely congested, of a dark chocolate color ; the coils of intestine distended and covered here and there with flakes of exudate. There was a considerable quantity of turbid feculent fluid everywhere in the abdomen. A perforation was found in the ileum, about six inches from the cKcum, about one and a half centimetres in diameter, with sloughy edges. These were turned in and sutured with Halsted's mattress suture. The peritoneal cavity was cleansed as thoroughly as possible by sponging, the sutured coil irrigated with salt solution and replaced. The appendix was found normal, save the inflammation of its serous covering. The abdominal cavity was thoroughly drained with strips of iodoform gauze, the ends of which were brought out through the wound. The operation took about one hour. His condition at the end was somewhat collapsed, but he rallied under stimulation, administered hypodermically and by rectum. He began to fail, however, and died about seven hours after the operation. No autopsy.

Case II.— J. P. D., aged twenty-six years; single; American; tailor; entered the Medical Ward of Johns Hopkins Hospital, August 3, 1895. Family history is negative, except that his father died of some intestinal trouble, the nature of which was unknown, and one brother died, a year ago, of typhoid fever.

Has had diseases of childhood and several attacks of chills and


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fever at varying intervals. With these exceptions has been well. Smokes much, does not ilrink, denies venereal contagion. Present illness l)egan six days before entrance, with severe frontal lieadaches and a slight chill followed by fever. These symptoms have persisted, together with anorexia ; no nose-bleed. For past two days, diarrhoea ; has vomited twice ; slight abdominal pain, especially before micturition. Temperature on admission, 103.8° F.; pulse, 92. Blood examination negative as to malarial organism ; abdomen generally tender, slightly distended ; no rose spots ; spleen palpal)le. Leucocytes 3000 per cubic millimetre.

The patient's disease ran a more or less typical severe typhoid course, up to August 16, a. m., thirteen days after entering the hospital, when the following note appeared in the medical history: " Last night patient began to complain of a sharp pain at base of penis, notrelieved by catheterization. Temperature has been rather higher, reaching 105° F., pulse 108, regular, though soft and dicrotic. Very nervous ; abdomen very tense, though not greatly distended. Everywhere tympanitic ; complains of pain ; tenderness marked ; tongue coated ; sweating profusely, and frequently cries out with pain ; baths discontinued and cold sponging substituted." P. M. " Patient has been comparatively quiet since a. m., but at about 4 p. m. liegan to cry out and complain of intense pain in abdomen. Morphine administered hypodermically. Leucocytes, 16,400 per cubic millimetre."

The patient was seen by me with Dr. Thayer at 9.30 p. m., and operation decided upon.

Operatio7i. — Median incision. Peritoneal cavity filled with cloudy, sero-purulent fluid. Peritoneum dark red and much congested. Coils of intestine distended and covered here and there by flakes of lymph. A single perforation, about one centimetre in diameter, was found in the ileum, about sixteen centimetres from ileo-csecal valve. It was situated, apparently, in the centre of a thickened Peyer's patch, and had sharply punched-out edges. Numbers of raised, red areas could be seen here and there along the lower few feet of the ileum. The loop containing the perforation was drawn out of the abdomen, carefully cleaned of the exuded lymph and fiEcal matter, and the rent closed transversely with eight fine, black-silk mattress sutures (Halsted's). Owing to the rigidity of the abdominal walls and the distension of the bowels, puncture of the intestine in several places was necessary, in order to allow of the escape of gas. The loops of intestine were carefully cleansed by irrigation with hot salt solution, and the entire peritoneal cavity thoroughly wiped out with dry gauze. Iodoform gauze was used for drainage, and the abdominal wound closed except where the gauze drainage was brought out.

At end of operation, which lasted a little over an hour, the patient was somewhat collapsed ; temperature 103.3° F. ; pulse, 150 ; respiration, 56. He recovered from this somewhat, under vigorous stimulation, and in four hours his temperature was 101.6° F.; pulse, 130 ; and respiration, 28. His condition did not change materially, except that he became gradually weaker, and died twenty-six hours after the operation. I regret to say tliat no bacteriological examination was made, and no autopsy allowed.

C.\seIII. — Charles H., German, aged forty-seven years; married; laborer; admitted to Johns Hopkins Hospital, .\ugust 15, 1896. Family history good ; no cancer or tuberculosis. Has had the usual diseases of childhood, since which time has been strong and well, except an attack of malaria with chills and fevers eight years ago. I'his attack lasted four weeks. Denies venereal disease; smokes and drinks in moderation. One week before was taken ill with a lieadache, general malaise, and loss of appetite, and later in the day had a distinct chill, followed by fever. Next day felt somewhat better, but was weak and unable to work. He kept in bed until his admission to the hospital one week later. During this time had had several chills and more or less fever, appetite fairly good, but had eaten nothing but liquids and soft solids. He had no


epistaxis nor vomiting ; no pain, nod-arrhoea, bowels had been regular. At about 8 o'clock on the evening before admission (August 14), wliile at stool, he was seized with sharp, stabbing pains in right side of abdomen, with marked tenderness to the touch. Nauseaand vomiting were present. His physician was called in and gave him morphine hypodermically, which relieved thepain. He passedafairly comfortable night and was brought to the hospital early the next a. m., when the following condition was noted :

Face pallid and expression anxious ; tongue coated, margin and tip clean and red. Temperature, 101° F.; pulse, 116, regular and of good volume. Lungs and heart negative ; alidomen is uniformly distended, no undue prominence in any region noted ; skin normal; tympanitic throughout ; rigidity of abdominal muscles throughout, especially of the right rectus in its lower part. In iliac region indistinct tumefaction felt ; tenderness general, but more markeil over right lower quadrant. Rectal examination negative ; no eruption on skin ; urine showed nothing abnormal.

A diagnosis of beginning general peritonitis, jirobably due to appendicitis, was made. I confess, at the time, the possibility of perforating typhoid ulcer did not occur to me.

Immediate operation advised and agreed to. After the usual ])reliminary preparation the abdomen was opened through an incision along outer border of right rectus. Abdominal wall distinctly cedematous. The peritoneum was everywhere intensely congested, roughened and dull, with flakes of plastic lymph. In the pockets between coils of intestine and extending down into the pelvis there was an accumulation of thin, yellowish, turbid fluid, containing flakes of exudate. There was no marked fsecal odor to this fluid. The intestines were distended, congested, and dark colored. In passing towards the median line and hypogastric region the congestion and peritonitis became less marked, and in the upper left quadrant the peritoneum seemed fairly normal. At no place was there the slightest attempt apparent at walling off the inflammatory process. The appendix was found in its normal position, somewhat thickened and congested, and constricted at about its centre, due to old adhesions. It was ligated, excised, and stump covered with peritoneal cuflf. About fourteen inches from ileo-cascal valve, in the ileum on its free border, a small hole, about four millimetres in diameter, was found. It was sharply defined, edges bright red and thickened. It was in the middle of what appeared to be a swollen and enlarged Pej'er's patch. Soft yellow ftecal matter was exuding from the opening. Opposite the ulcer was a mesenteric gland enlarged to the size of an olive, soft and of a bright red color. The loop of ileum was brought out through the wound and packed about with gauze. The edges of the ulcer were turned in and sutured with eight mattress sutures of fine black silk. The edges of the ulcer were not excised. After suturing, the loop was thoroughly cleansed with salt solution and dry gauze and returned, the peritoneal cavity thoroughly and systematically wiped out with pledgets of dry gauze. Some distance below in the ileum a second swollen Peyer's patch could be made out. Bismuth gauze in strips was packed loosely about the sutured portion, and theends brought out through the lower end of the incision. Tiie rest of it was closed with buried sutures of silver wire. The wound was dressed with silver foil and sterile gauze. His condition at the end of the operation was good. Time of operation one and a half hours. Pulse, 120, and of good volume ; respiration. 20 to 25, regular ; color good ; no sweating or coldness of extremities. Shortly after operation an enema of several ounces of black coffee and peptonized milk given.

August 16. Patient passed a fairly comfortable night. Pain not so severe as before oi>eration ; very little ^listension ; says he feels better. Temperature and pulse still somewhat elevated, 102° F. and 110 respectively. liis general condition improved steadily forabout a week, when his temperature and pulse began to go up a little. His tongue became more coated, but abdomen not distended nor tender. Spleen not palpable ; no rose spots. An offensive discharge


May, 1897.]

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of pus from the right ear indicated an otitis media. About this time a severe pain in the lower part of left thorax developed. Auscultation detected a slight friction rub beginning just below the nipple and running into axillary line.

Blood cultures aspirated from spleen were negative. His temperature and pulse almost reached the normal on August 28, and remained there for a week, when a sharp rise, accompanied by a chill, occurred. His second relapse was quite a severe and prolonged one, so much so that he was transferred to Dr. Osier's ward, where he could be given the cold-bath treatment more conveniently. On September 14 the following note was made by Dr. Osier: " Tongue a little dry ; temperature has been continuously elevated since Septembers. Between 6th and 9th not above 100° F. Since 9th above 101° F. On the 12th and 13th, 104°, and on 14th, 105° F.; pulse, 128. Complains of pain in abdomen, which is fiat and natural looking. Respiratory movements well marked ; no tension ; everywhere soft. Pain referred to hypogastric region and about navel. Edge of spleen not palpable." During the ten days, from September 17 to 27, his temperature ranged about 103° F., occasionally going above 104° F. He was given thirty-eight tubbaths during this period. It reached the normal on October 6, and remained there.

During this time he developed great tenderness in the toes of both feet, and extending up the front of right leg to the knee was some redness and stiffness. This gradually subsided. Several small furuncles on buttocks and sacrum appeared, which were opened. On October 23 he was well enough to be up for the first time. Improved steadily up to November 2, when a phlebitis of right femoral vein with pain and swelling of leg developed. This gradually subsided, and he eventually made a perfect recovery.

Cultures taken at the time of operation from the peritoneal cavity and edges of ulcer showed pure culture of bacillus coli communis.

Dr. OsLER. — It may interest you to know of the number of cases of perforation in our series. Since the hospital opened we have had about 530 cases (I have not the exact figures for this year) of typhoid fever, with 48 deaths, of which 16 occurred from perforation. The percentage of death from this cause is unusually high, for I think Dr. Finney mentioned it was the cause of death only in about six per cent, of the fatal cases.

That two of Dr. Finney's cases were supposed to be appendicitis is a point of great interest. It is not the first nor will it be the last time that this mistake has been made. There are instances in which patients with typhoid fever without perforation have been operated upon for appendicitis with a fever of five or six days' duration and a swelling in the right iliac fossa. Patient has been admitted to the hospital, operated upon for apjiendicitis, no perforation found, but an enlarged ileum and swollen mesenteric glands. It is to be borne in mind, however, how frequent is perforation of the appendix among cases of perforation in typhoid. We have had at least four or five in our cases. There have been two cases of recovery in which symptoms of appendicitis in typhoid seemed very clear.

One word as to the time of the operation. This case was unusually favorable inasmuch as it was seen early and the perforation occurred before the 8th day, which is, perhaps, as soon as ever it occurs in typhoid fever. I think the very early and the very late cases will probably be the most favorable for operation. The statistics that Dr. Finney gives are certainly most encouraging.


NOTES ON NEW BOOKS.

Transactions of the American Pediatric Society, held at Virginia

Hot Springs, May 27, 28, 29, 1895. Edited by Floyd M. Cran DALL. (Philadelphia, 1896. Reprinted from the Archives of

Pediatrics.)

The meetings of this society are characterized by the practical papers presented and the general discussion of them by the members present.

The present report of its seventh session contains a number of articles relative to the more important diseases of infancy and childhood, with discussion of many of the newer remedies. The list of contributors includes many of the best-known writers on the subjects mentioned.

The treatment of diphtheria with antitoxin as an immunizing agent, and its toxic effects, are especially dwelt upon. A resolution was finally adopted that in the opinion of the society the evidences thus far produced of the beneficial action of this remedy justify its further and extensive trial.

Several papers on anomalous forms of scarlet fever and eruptions simulating this disease, and one on the use of icthyol ointment for the local treatment of the eruption of scarlet fever, are worthy of special notice.

With regard to the use of the antitoxin of tetanus in tetanus of the newborn, the evidence seems to show that up to this time it is uncertain in its action, and that chloral hydrate with one of the bromides is to be preferred.

The antitoxin of erysipelas seems to have had no influence in treatment of sarcoma of the kidney, but the author of the paper is inclined to the view that any foreign substance injected into or near the substance of a sarcoma tends to effect a cure, by setting up degenerative changes in the neoplasm, hence the apparent favorable action of erysipelas antitoxin in sarcomata which are external and accessible, and its failure in visceral sarcomata.

There are also papers on purulent otitis media, " inanition " fever in the newly born, the frequency of typhoid fever in children under three or four years, hyperpyrexia, pygopagus, the neuroses of childhood, tetany, symmetrical gangrene following scarlet fever, angina resembling diphtheria with absence of the bacillus, cardiac anomaly, and the association of enormous heart hypertrophy, chronic proliferative peritonitis and recurring ascites with adherent pericardium, in which the view is expressed of the probable progress of the chronic proliferative process along the veins, through the diaphragm, until it involves the peritoneum.

The report is in good type, well edited and arranged.


BOOKS RECEIVED.


A Collection of the Published Writings of William Withey Oull, Bart., M. D., F. R. S. Edited by Theodore Dyke Acland, M. D. Memoir and Addresses. 1806. 8vo. 184 pages. The New Sydenham Society, London.

Proceedings of the American Medico-Psychological Association, at the Fifty-Second Annual Meeting, held in Boston, May 26-29, 1896. 8vo. 332 pages. Published by American Medico-Psychological Association.

Saint Thomas's Hospital Reports. New Series. Edited by Dr. T. D. Acland and Mr. Bernard Pitts. . Vol. XXIV. 1897. 8vo. 510 -i118 pages. J. and A. Churchill, London.

Archives of Clinical Skiagraphy. Edited by Sydney Rowland, B. A. Camb. Vol. I, No. 3, December, 1896. Fol. The Rebman Pub. Co., Limited, London.

Pathological Report Illinois Eastern Hospital for the Insane. 1896. 8vo. 236 pages. The Blakely Printing Co., Chicago.

Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America. Edited by T. L. Stedman, M. D. Vol. IX. Diseases of the Digestive Organs. 1897. 8vo. 820 pages. William Wood & Co., New York.


114

[No. 74.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report In Patliologry.

The VesselB and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

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

Mall, M. D.

Report In Dermatology. Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By

T. C. GlLCHKiST, M. D., and Emmet RliroRD, M. D. A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

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

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

T. C. Gilchrist, M. D.

Report In PatliologTAn Experimental Study of the Thyroid Gland of Dogs, with especial consideration

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


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

Report In Medicine.

On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with

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

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

Report in Gynecolosry. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

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

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

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

Ovarian Tumor; General Gynecological Operations from October 16, 1889, to

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

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

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

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

Howard A. Kelly, M. D.

Report In Snrgery, I. The Treatment of Wounds with Especial Reference to the Value of the Blood Clot

in the Management of Dead Spaces. By W. S. Halbted, M. D. Report in Neurology, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By AoonsT HocH, M. D. A Case of Cerebrospinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report in Patlioloery* I. Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafledk, M. D.


Volume III. 766 pages, with G9 plates and figures.

Report in Patliology.

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

Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D. Report in Pathology.

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

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

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

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

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

Report in Gynecology.

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

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

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


Gynecological Operations not involving Cceliotomy. By Howard A. Kelly, M. D.

Tabulated by A. L. Stavely, M. D. The Employment of an Artificial Retroposition of the Uterus in covering Extensive

Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdo minal Pelvic Operations. By Howard A. Kelly, M. D. Photography applied to Surgery. By A. S. Murray. Traumatic Atresia of the Vagina with Haematokolpos and Hxmatometra. By Howard

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

The Importance of employing Ansesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D. Resuscitation in Cihloroform Asphyxia. By Howard A. Kelly, M. D. One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.

By Howard A. Kelly, M. D., and Mary Sherwood, M. D. Abdominal Operations performed in the Gynecological Department, from March 5,

1890, to December 17, 1892. By Howard A. Kelly, JI. D. Record of Deaths occurring in the Gynecological Department from June 6, 1890, to

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BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No. 75.]


BALTIMORE. JUNE. 1897.




COIsTTEIsTTS.


Report of a Case of Polybacterial Infection in Typhoid Fever, with especial Reference to certain Involutions exhibited by the Bacillus Typhosus. By Edward Perkins Carter, M. D., 115

A Case of Typhoid Fever in which the Typhoid Bacillus was obtained twice from the Blood during Life. By E. Bates Block, JI. D., 119

Successful Cultivation of Gonococcus in two Cases of Gonorrheal Arthritis and one of Tfenosynoviti4, with Remarks on a New Medium. By Francis R. Hagner, M. D., - - -121

A New ^sthesiometer. By Lewellys F. Barker, M. B., - 125

Edinger on " The Development of Brain Paths in the Animal Series." By C. R. Bardben, M. D.. 126


page. By Simon Flex-" - - - 128


Pseudo-Tuberculosis Hominis Streptotricha.

NER, M.D.,

Proceedings of Societies :

Hospital Medical Society, 129

Discussion of Dr. Friedenwald's paper on Congenital Motor Defects of the Eyeballs; — Congenital Facial Diplegia [Dr. Thomas]; — A Case of Acquired Paralysis of both External Recti Muscles, with Unilateral Facial Paralysis [ Dr. S. Theobald]; — Exhibition of Ophthalmological Cases: Bilateral Dacryo-adenitis, Operations for Cataract [Dr. Randolph]; — Demonstration of Florence's Iodine Test for Seminal Stains [Dr. Lewellys F. Barker].

Notes on New Books, - - 133

Books Received, 185


REPORT OF A CASE OF POLYBACTERIAL LNFECTIOX IN TYPHOID FEVER, WITH ESPECIAL REFERENCE TO CERTAIN INVOLUTIONS EXHIBITED BY THE BACILLUS TYPHOSUS.

By Edward Perkins Carter, M. D., FeUov) in Pathology. [From the Pnthologieal Laboratory of the Johns Hopkins University and Ilospital.]


The following case seems worthy of publication in view of the opportunity it afforded to study an unusual variation in morphology of the bacillus typhosus isolated from it, and because of the interesting poly-infection with bacteria which existed at autopsy.

The patient, G. C, was admitted to the Johns Hopkins Hospital on October 11, 1896, complaining of fever, weakness and loss of appetite. He had not been feeling well for three weeks, and had been unable to work for the past seven days.

Family history negative. Personal history negative. For the past four years he had led an active out-of-door life, and had up to the onset of present illness enjoyed "good health."

His illness began wnth a general feeling of weakness, which increased until on Monday, October .5th, 1896, he was unable to go to work, and complained of fever, loss of appetite and pains in the back and legs. He kept up until October 9th, and on October 11th, 1896, when admitted to the ward, he had a temperature of 102.5°, pulse 100 to the minute, and


respirations 20. E.xamination of the blood at this time and at all subsequent examinations was negative for malarial organisms. Examinations of the thorax and heart were negative. Abdomen was not distended. No tenderness and no gurgling in right iliac fossa. Several suggestive rose spots. Spleen was just palpable. Liver dulness normal. The diagnosis of typhoid fever was made and the patient put upon a strictly typhoid treatment.

I have abstracted the following notes from the history of the case, omitting the treatment as being foreign to our purpose.

October 12th, '96, at 7 a. m. The patient had a large semiliquid stool, containing some formed particles, and a considerable amount of blood fairly bright red in color. At 8.30 a. m. a second hemorrhage, rather brighter red than preceding. Both considerable in amount. Temperature 103.5°, pulse 102.

October 14th. Patient flushed, looks well. Tongue furred,


116

[No. 75.


not tremulous, pulse good. Two fresh rose spots. Abdomen flat, uo distension.

October 16th, 1.40 p. m. Hemorrhage, somewhat thick tarry consistence, with some blood clots. Amount of movement about 400-500 cc. 5.30-6.30 p. m., patient had two movements like preceding, quantity same, about 400-500 cc. Pulse very running and feeble. Temperature at 8 a. m. 101.5°, pulse 124.

October 17th. This a. m. condition is distinctly better. Pulse at visit 29 to the quarter. Abdomen not distended and nowhere tender. 11.30 p. m. the patient had a stool of about 250 cc. in amount, which contained blood dark in color.

October 18th, 10 p. m. A stool, about 200 cc, containing blood, no clots. The patient's condition did not show any material change. Temperature at a. m. 102.8°, pulse 120.

October 25th, 2 p. m. The patient had a large movement, 1000 cc. Total amount of blood estimated 500 cc. Temperature at 8 p. m. 101.5°, pulse 148.

From this time, though he had no subsequent hemorrhages, the patient's condition remained critical until his death.

On October 28th he developed well marked signs of consolidation in the lower left back over a small area, and on November 1st the same signs were found in the lower right back.

November 9th. Breath sounds at left base seem almost clear. Percussion at right base impaired, breath sounds distant. Temperature at 8 a. m. 103°, pulse 124.

November 11th. This a. m. pulse 32 to the quarter. The patient passed a restless night, complaining considerably of pain in the left side. Lying on left side, skin moist. Tongue dry and tremulous. Eespirations 13 to the quarter. Profuse sweating. Eespiration on left side is enfeebled. Back not examined.

The patient's general condition gradually grew weaker and he died at 12.30 a. m., November 12th, 1896. The temperature just before death touched 105°; the pulse was 160.

The autopsy was held 34 hours after death, and the body, apart from slight post-mortem gas development, showed no other distinctive signs of decomposition.

Anatomical Diagnosis. Typhoid fever. Small number of healing ulcers in the ileum ; little glandular enlargement. Subacute spleen tumor, parenchymatous degeneration of the viscera, abscess of prostate gland, necrosis of the cricoid cartilage, pneumonia, fibrino-serous pleurisy.

Body 170 cm. long, pale, no oedema. Moderate emaciation. Rigor mortis in both extremities. Abdomen greatly distended, tympanitic and greenish in color.

The spleen weighed 210 grams. It was free from adhesions. On section moderately firm, pale grayish red in color. Malpighian bodies not prominent. Several phleboliths of the size of bird-shot in cut surface.

The small intestine was moderately distended, the mucosa opaque, containing soft fa3ces. No ulceration until within 100 cm. of the valve, where a small, clear, punched-out ulcer 1 cm. in diameter existed. The surrounding mucosa was congested. No more ulcers found for the next 50 cm., where a large group of coalescent clean ulcers with united edges occurred, which were shallow and rapidly skinning over.


These measured 3x5 cm. in extent, and the individuals composing the group were hardly larger than the above single one. The most important group of ulcers was located a hand's breadth above the valve; these numbered nine (2.5 cm. in diameter), the largest not much exceeding a silver twentyfive cent piece in size. They were perfectly clean and rapidly healing, judging from the manner in which their bases were filled up; and they appeared to be skinning over at the same time from the edges. The caecum and appendix vermiformis were free from ulceration.

The larynx on the left side shows a small aperture measuring 1 cm. in diameter, which leads into a cavity in relation to the cricoid cartilage. On dissection a cavity the size of the little finger, lined by granulation tissue, is found, and into the cavity the upper and eroded end of the cricoid cartilage projects. The upper surface gives the impression of being calcified ; it is eroded and hard. The contents of the cavity are semi-fluid pus of rather dark color.

In the right lobe of the prostate gland there existed a small abscess the size of a hazel-nut, containing creamy pus. The walls of the cavity are thin and ill-formed. No communication existed with the bladder.

The mesenteric and retroperitoneal glands were little if at all enlarged.

Bacteriological Examixation.

Cover-slip preparations made at the time of the autopsy showed from the fj^ewra large numbers of streptococci, which occurred in threads of 6-8 segments, and a few long evenly staining straight bacilli.

From the abscess in jjwstafe gland great numbers of small thin straight bacilli, which looked not unlike the bacillus of typhoid fever; also numbers of cocci, appearing chiefly in pairs (diplococci).

From the heart's Hood a number of long straight bacilli resembling closely those seen in the cover-slips from the j)leura ; also a few single cocci were seen.

Cultures.

Pleura. The agar-agar plate was studded with minute pin-point, finely granular colonies.

Microscopically these proved to be streptococci, which were identified as the streptococcus pyogenes.

Lung. The plate on the same medium resembled identically that from the pleura and contained the same microorganism in pure culture.

Larynx. The agar-agar plate showed superficially many round grayish brown pin-bead colonies, limited to one-half of surface, the remaining area being overgrown with colonies which exhibited a bluish green color. In the substance of the medium were great numbers of small, finely granular pinpoint colonies and smaller numbers of large whetstone and irregularly round colonies. This plate being so crowded, a series of plates was made, and from the third dilution the following micro-organisms were isolated and identified : streptococcus pyogenes, bacillus lactis aerogenes and bacillus pyocyaneus.

Kidney. The agar-agar plate was studded with small


June, 1897.]

117


round dark granular colonies, much larger than the usual streptococcus colonies. In the substance of the medium there were also a number of whetstone and irregularly round colonies, and on the surface two grayish white spreading colonies and five slightly smaller grayish white more ti-anslucent ones. The small granular colonies were composed of the streptococcus pyogenes. From the other colonies two bacilli were isolated and identified as the bacillus coli communis and the bacillus typhosus. (See notes below.)

Liver. The agar-agar plate presented practically the same appearance as that from the kidney, and the same microorganisms were isolated from it.

Heart. The agar-agar plate showed two sets of colonies. The substance of the medium was studded with small finely granular colonies, and here and there a few scattered grayish white whetstone forms occurred, while on the surface there were a number of grayish white, small, fairly round and slightly elevated forms. From the small granular colonies the streptococcus pyogenes was isolated, and from the whetstone colonies in the depth and the round colonies on the surface of the medium a bacillus was isolated which was identified as the bacillus typhosus.

Mesenteric gland. The agar-agar plate showed two superficial, spreading, grayish white irregular colonies, and numbers of whetstone colonies in the substance of the medium. From the plate two bacilli were isolated and identified as the bacillus coli communis and the bacillus typhosus.

Abscess in the prostate gland. The agar-agar plate was studded with small finely granular colonies, and in addition showed a few scattered whetstone colonies in the substance, and several small, reddish brown, irregular, spreading forms on the surface of the medium. From the finely granular colonies the streptococcus pyogenes was isolated. From the superficial colonies a bacillus was isolated which was identified as the proteus vulgaris.

Spleen. The agar-agar plate from the spleen remained sterile after 48 hours in the thermostat.

The bacillus which is, however, of greatest interest in this case is that which was isolated from the heart, liver, kidney, mesenteric gland, and by Mr. Potter from the bile by means of Eisner's method, and which, though it shows great variation upon certain media, must, we think, be considered the true bacillus of Eberth.

Culturally and morphologically this bacillus was proven identical, from all of the above given sources, and our study of it has therefore been made with the cultures obtained from the kidney and bile. At the same time there was carried along with these for control a culture of an established typhoid bacillus. The bacillus isolated from the case under consideration, taken from a 24-hour growth upon agar-agar, is of medium size, straight and thin, with slightly rounded ends, taking the stain deeply and uniformly. It stains with all the ordinary aniline dyes, though most satisfactorily with gentian violet.

The Eisner plates made by Mr. Potter directly from the bile gave what has been and is considered the typical reaction for a mixture of typhoid and colon colonies. The colon colonies were larger, more coarsely granular and more numer


ous than the small, very pale, transparent and faintly granular colonies from which the typhoid bacillus was isolated in pure culture.

Upon agar-agar plates the colonies of the bacillus under study are small, grayish white in color, slightly elevated and irregularly round upon the surface of the medium, while in its substance they presented the common small whetstone or irregularly round outline. By transmitted light under low power they are of a reddish brown color and faintly granular structure. Upon gelatine plates the colonies are, after 34 hours, small, very finely granular, irregular in outline, and tend to increase in size very slightly during the second 48 hours, thus appearing as typical typhoid colonies.

Agar slant. The growth upon a moderately dry agar tube was, after 24 hours, of a slight, narrow, rail-like character along the track of the needle, being slightly elevated and of a grayish white color. On the moist agar slant it grows somewhat more profusely, covering the surface of the medium more irregularly. This was equally true of the control typhoid culture.

Bouillon at the end of 24 hours is clouded and somewhat opaque. The reaction for indol was negative. In order to establish the certainty of the negative indol reaction beyond a doubt, a culture in bouillon, together with a culture of the control typhoid, and an uninoculated tube of bouillon were placed in the thermostat for three days and then tested for indol, adding at the same time the H2S0» and NaNO: to the uninoculated tube of bouillon and watching these three carefully for a few hours, and then replacing them in the thermostat over night. When examined the following day all three tubes presented the same appearance, and it could not be said that a true indol reaction was obtained. The test for indol was made again and again without obtaining a positive reaction.

Litmus milk after 24 hours was only faintly acidulated, and reached apparently its greatest degree of acidulation, which is very slight, on the third day. At the end of a month there was no increase of acidulation, as evidenced by the pale pink color which remained quite as noted on the third day following inoculation. Coagulation of the milk did not ensue.

Upon potato the growth bears an extremely close resemblance to the control typhoid. It shows at the same time under the microscope the most remarkable involution forms, which begin to appear upon the third day after inoculation.

If the potato is strongly acid the growth after 24 hours is just visible as a delicate white membrane over the surface of the potato extending from the track of the needle. The macroscopic appearance of the growth remains unaltered, being only Just visible after thirty days, while the potato remained undiscolored.

Upon a neutral potato, on the other hand, the growth after 24 hours appears as a slightly yellowish white line along the track of the needle, spreading out somewhat at the base of the potato, being plainly visible and much more luxuriant than is ordinarily true of the bacillus of typhoid fever. After five days the potato itself becomes a very little discolored, while the growth remains unaltered after the third day. At the end of three weeks no further change was noted.


118

[No. 7.5.


Under the microscope this bacillus shows the greatest variation in morphology, and apparently without relation to the reaction of the potato. After the third day involution forms appear, first as long rods with unstained bulbous ends, and these are quickly followed by the most extraordinary forms, such as long threads, irregular rods with unstained poles closely resembling spores, and shorter oval forms, a picture unlike anything one finds in cultures of the true bacillus typhosus.

Glucose agar. In a deep stab this organism again agrees well with the control typhoid. After 24 hours there is a delicate, small, nail-head growth upon the surface of the medium, while along the line of puncture the growth extends downwards for one-half the distance. This appearance remains in general the same, the growth increasing very gradually until at the end of thirty days there is only a more irregular nailhead appearance upon the surface with a slight growth along the line of the needle stab, thus bearing a striking similarity to the control culture. At no time was there gas formation. Here again under the microscope the cover-glasses made after the third day show the same remarkable involution forms seen in the growth upon the potato.

In a gelatine stab there is a slight nail-head growth on the surface of the medium after 24 hours, extending along the course of the needle for a short distance as a delicate linear growth, and giving identically the same picture as that seen in the control. Liquefaction of 5 per cent, or 10 per cent, gelatine does not occur, and the growth increases very slowly, showing after three weeks a surface growth of the size of the head of a small tack. Microscopically, after the fifth day, we find involution forms in the shape of straight and slightly curved threads, longer by at least twelve times than the bacillus as it appears after 24 hours. The very unusual forms seen in the growth upon potato and sugar agar are not present.

Motility. Hanging drops made from an agar-agar culture of any age always showed great numbers of the bacilli in the field in active motion, but the greatest motility was seen when examined from agar-agar slants of from eight to ten hours' growth; at this age all the bacilli in the field appeared to be in active motion.

It decolorizes by Gram's stain.

Fermentation tubes of glucose, lactose and saccharose bouillon failed to show any development of gas after eighteen days in the thermostat.

The thermal death-point of this bacillus as established by means of Sternberg's bulbs is between 53° and 55° C. at an exposure of ten minutes.

By means of Pittfield's stain the presence of flagella can be demonstrated extending around the entire organism.

Widal's test. Upon adding from i to Jj the volume of blood serum obtained from a case of typhoid fever to a 24hours-old bouillon culture of this organism, a control typhoid bacillus culture and a culture of the bacillus coli communis according to the method of Widal, the following results were obtained :

The control culture and the culture of the organism under study gave characteristic precipitates in the same time, while that of the bacillus coli communis remained unaffected.


A number of tests for agglutination were made by the Wyatt Johnston method, using blood of known activity. The control typhoid bacillus gave immediate clumping, and the organism under study showed a similar reaction in from twenty minutes to one hour.

It is interesting to note that cultures made from potato, sugar agar and gelatine, which showed the involution forms in great numbers, always grew upon re-transplantation as the normal-sized, straight bacilli which were originally met with.

Upon plain agar-agar in bouillon and in milk the growth varied but slightly from what seemed to be the normal.

Animal Experiments.

A mouse inoculated subcutaueously with two loops from a 34-hour agar growth died in less than 48 hours.

The autopsy showed no excess of fluid in the abdominal cavity and no focal visceral lesions. The lymphatic glands were nowhere enlarged. The spleen, liver and kidneys appeared normal. At the seat of inoculation the skin was bound down by quite firm fibrinous adhesions. In the cover-slips from the seat of inoculation great numbers of bacteria were seen. Cover-slips from heart and spleen were negative. Cultures from heart and spleen remained sterile after 48 hours.

A guinea-pig inoculated with 1 cc. of a 24-hours bouillon culture intraperitoneally died after thirty days. The autopsy showed the lymphatic glands somewhat swollen and injected. No excess of fluid in abdominal cavity. Peritoneum perhaps reddened and vessels somewhat congested, but no peritonitis present. Liver, spleen and kidneys appeared normal. Coverslips from peritoneum and from all the organs negative. Cultures from same sources remained sterile.

A rabbit inoculated with 1 cc. of a 24-hours bouillon culture intravenously was still alive after two months.

We have then a bacillus which agrees culturally with the typhoid organism, which reacts to all the known tests for the true bacillus of typhoid fever, and yet which, after the third day, upon certain media, potato, sugar agar, and gelatine, shows very unusual involution forms; forms so remarkable that were it not for the evidence given by the fulfilment of every test, it would seem impossible to consider this the true bacillus of Eberth.

During the past few years a number of bacilli, found under conditions which would seem to exclude the presence of the true bacillus of typhoid fever, have been isolated and studied by Losener,* Babes,! FiillesJ and Cassedebat.§ These bacilli resembled the true typhoid organism so closely in cultural and morphological properties, with the exception of a slight variation in the organisms reported by Cassedebat and by Babes, that it has thus far been very difficult, if not impossible, to distinguish between them and the bacillus typhosus.


  • Losener, Arbeiten aus ilem Kaiserl. Gesundheitsamte, XI.

t Babes, Variabilitat und Varietiiten des Typhus-bacillus. Zeitschrift fur Hygiene, IX, 1890, p. 323.

I Fulles, Bacteriologische Untersuchung des Bodens in der Uingebung von Freiburg i. B. Zeitschrift fur Hygiene, X, 1S90, p. 225.

§ Cassedebat, Sur un bacille pseudo-typhique trouve dans les eaux de riviere. Compt. rend, de I'Academie de Paris, CX, No. 15, 1S90, p. 798.


f 1

as*, B




- \

(




(


1


-- 5


June, 1897.]

119


These forms have therefore been designated pseudo-typhoid bacilli.

In addition to the irregular forms described by Babes as seen in growths upon agar-agar, and those in the bacillus studied by Oassedebat, Ohantemesse and Widal* have noted certain variations from the normal which appeared as longer thread-like forms upon gelatine, and as straight rods containing irregular vacuoles and unstained poles upon potato. Vilchurf further, in a study made of some 200 cultures from the organs of four tyj^hoid patients, describes variations in form, particularly on old gelatine cultures and upon potato. These occurred as vacuoles which after 73 hours took the stain and then more intensely than the rest of the organism. Aside from these irregular forms I have been unable to find in the literature any reference to such involution forms as are noted in this case.

The growth upon agar-agar in bouillon and in milk showed no variation from the normal, the irregular forms being seen only upon potato, sugar agar and gelatine, as noted above.


  • Chanteme8se et Widal, Recherches sur le bacille typhique et

I'etiologie de la fiSvre typhoide. Archives de Physiologie, I, 1887.

f Vilchur, Cultivation of Typhoid Bacillus from Organs and Evacuations of Typhoid Patients. Vrach, St. Petersburg, 1886, VII, pp. 456-458. Eef. Lancet, London, 1886, II, p. 137.


The control culture used in the study of this case did not at any time show such involution forms as the bacillus under consideration, while culturally the two organisms appeared identical.

It seems therefore unavoidable to consider that this bacillus, which was found in a patient dead of typhoid fever, being isolated from five different sources, and reacting to every test in the manner of the true bacillus of typhoid fever, is, in spite of the peculiar involutions it undergoes, no other than the bacillus typhosus.

In conclusion I wish to express my appreciation to Dr. Simon Flexner for his kindness and interest in the study of this case, and also to Dr. Gray of the Army Medical Museum, Washington, for his kindness in taking the photographs which illustrate this report.

Description of Plate.

Figs. I and II. Bacillus typhosus obtained from this case as it appears after a growth of 24 hours upon agar-agar. Zeiss II mm. apochromatic objective, No. IV projection ocular. Gentian violet staining.

Figs. Ill and IV. The same organism as it appears after a growth of two weeks upon glucose agar-agar. Same magnification. Gentian violet staining.


A CASE OF TYPHOID FEVER IN WHICH THE TYPHOID BACILLUS WAS OBTAINED TWICE

FROM THE BLOOD DURING LIFE.

By E. Bates Block, M. D., Assistant Resident Physician, The Johns Hopkins Hospital.


Evidence is strongly in favor of the fact that, at some period of the disease, the typhoid bacillus is present in the blood in nearly all patients suffering from typhoid fever, gaining entrance from time to time at the site of the intestinal lesions. It is the rule for the typhoid bacillus to be cultivated from the internal organs (spleen, mesenteric glands, etc.) after death, and sections of these organs usually show bacilli which resemble the bacillus typhosus, in clumps or masses in the capillary vessels. The early experiments of Wyssokowitsch* show that these organs are principally concerned in removing from the blood introduced bacteria. It was shown by Welch and Nuttallf in 1891 that human blood serum is capable of destroying many typhoid bacilli, and later by other observers that the blood serum from typhoid patients also possesses this power, so that the peculiar conditions which allow these organisms to live in the capillary vessels of the organs cannot, at least in the majority of cases, depend upon a simple loss of this power of the blood serum. That the invasion of the blood or organs by other micro-organisms, more particularly the streptococcus pyogenes, modifies the relation of the patient to the typhoid bacillus, has been clearly shown by VincentJ in experiments upon animals and by cultures made at autopsy

  • Zeit8chrifl fiir Hygiene, 1886.

f Verbal communication.

t Annales de I'lnst. Pasteur, 1883.


in human cases. In six out of 31 such autopsies he found the streptococcus associated with the typhoid bacillus. In one case a typhoid patient whose temperature had become normal developed a streptococcus angina, the temperature rose and on the fourth day the patient died. At autopsy the typhoid bacillus and streptococcus were obtained from the organs and the latter from the blood. The streptococcus pyogenes has also been found in association with typhoid bacillus post mortem by Flexner* in 5 out of 6 cases reported, by Wright and Stokesf in 2 out of 9 autopsies, by KleinJ in the blood, once in association with B. typhosus, by Netter, E. Fraeukel, and others. Karliuski§ has found streptoccoci in the pulmonary complications of typhoid fever in six out of nine cases, some of them being associated with the typhoid bacillus in the lungs. A similar case is reported by Flexner {op. cit.) In forty-one abscesses in typhoid cases examined by Vincent {op. cit.) the staph, pyogenes aureus was present thirty-two times, all of these patients recovering. In eight cases streptococcus alone or associated with the bacillus typhosus was met with, and of these, five died. Assuming that in these instances the typhoid bacillus was increased in virulence, it may be said that


  • Johns Hopkins Hospital Reports, Vol. V.

t Boston Med. and Surg. Jour., March-April, 1895.

tBaumgarten's Jahresb., 1894, Vol. 10.

§See Vincent, op. cit.


a similar modification of the physiological characters of the typhoid bacillus infection is produced (.Sanarelli*) by inoculating cultures together with the soluble products of the bacillus coli communis and the bacillus proteus.

The clinical history of this case presents points of interest in connection with the bacteriological investigations both before and after death.

M. Z., female, age 30, born in Poland, was admitted to Professor Osier's wards on Saturday the 4th of July, 1896. She could not speak English, so no history could be obtained. Upon admission she was restless, listless, weak, and gave evidence of shortness of breath and abdominal pain, frequently passing her hand over the abdomen. Soon after admission she became delirious. The examination of the thorax was negative. The abdomen was tender upon pressure, and resistant, especially in the splenic area. The pharynx was somewhat reddened and its vessels were injected.

On the 5th of July Dr. Thayer made the following note: Eespirations 44 to the minute, pulse 104; patient looks dull and a little confused ; the tongue has a thick pasty coat; the lungs are clear on auscultation and percussion; the heart sounds are feeble but clear; the abdomen is full, generally tympanitic, does not seem tender — it is held very tense so that palpation of the spleen is impossible. A number of small spots are seen on the abdomen, some of them apparently ecchymotic, others not unlike rose spots. There is slight cyanosis of the face and lips, which in connection with the rapidity of respiration suggests some pulmonary affection. The patient has had one liquid stool.

On the 8th of July Dr. Thayer noted further: The general condition of the patient is about the same; she is still dull, drowsy, delirious, and quite irresponsive when questioned. There is marked muscular resistance in the splenic region, and pressure here causes the patient to wince. There are no definite rose spots to-day.

The urine did not give the diazo reaction.

The temperature upon admission was 101.3°, respirations 44, and the pulse 120. Three hours later the temperature was 104.6°, and during the fourth, fifth and sixth of July ranged between 101° F. and 104.3° F., the low temperature being due to cold baths, to which she reacted well. From then on the temperature gradually declined and reached normal on the 8th of July. It remained practically normal for about 18 hours. On the following day it rose gradually, the highest point reached being 102.6°.

The respirations during her illness remained rapid and on the 9th of July became more labored, the pulse became more rapid and feeble, and the patient died at 12.45 a. m. on the 10th of July.

On the 5th of July a culture was taken from the stool of the patient, by Eisner's method, with a negative result.

On the 6th of July a hypodermic syringeful of blood was taken from a vein of the forearm with due antiseptic precautions. A few drops were allowed to fall on an agar slant, and the rest of the blood was mixed with melted gelatine and


•Ann. de I'lnst. Pasteur, 1892.


placed in a Buchner jar in the thermostat. The agar slant subsequently showed one colony, while the gelatine tube which contained a greater volume of blood showed about a dozen colonies identical in appearance. Several of these colonies were grown on the usual culture media. They did not coagulate milk, grew characteristically on Eisner's medium ; inconspicuous growth on potato with increase of moisture; did not form gas in glucose agar ; were actively motile ; did not liquefy gelatine, and morphologically resembled the typhoid bacillus.

On the 9th of July a second culture was taken by the same method. The volume of blood obtained was smaller than in the former culture and was allowed to fall on the surface of an agar slant, which 20 hours later showed one colony. Inoculations of other media from this showed the same reactions as in the previous instance. In addition these bacilli did not produce indol; grew anaerobically; did not change the color of Wurtz's medium; gave the agglutinative reaction with over 40 specimens of typhoid blood, and morphologically was identical with the bacillus obtained three days before.

A culture from the throat on the same day did not show diphtheria bacilli ; the chief organism found was the streptococcus.

I am indebted to Dr. Flexner for the privilege of making an abstract of the post-mortem examination.

The autopsy was held at 2 p. m. on the 11th of July, 37 hours after death.

Anatomical diagnosis : Typhoid fever; ulceration of small intestine; acute sjjleen tumor; swelling of the mesenteric glands; parenchymatous degeneration of the viscera; postmortem invasion of a gas-forming bacillus ; oedema of the lungs.

Body cold, has been on ice. No odor of decomposition.

The upper portion of the body shows dark spots and splotches. The face is discolored and swollen. The greatest discoloration is over the back.

Crepitation is present over the face, the neck, the upper portion of the thorax and over the back. The neck is much swollen, thick and discolored.

No oedema and no crepitation of lower extremities.

The abdomen is distended and contains gas which has a somewhat putrefactive odor. The intestines are distended, but not discolored.

The tissues about the kidneys, pancreas, caecum and the root of the mesentery are emphysematous. The mesenteric and cascal glands are enlarged, softened and reddened.

The spleen is enlarged and softened, and on section appears dark in color, almost diffluent.

The liver shows many gas bubbles under the capsule, and on section it is found to be penetrated throughout by small gas vesicles, and the blood which escapes from the cut ends of the portal veins is frothy. The organ is pale, homogeneous, and cloudy yellow in color.

Both kidneys are emphysematous, the capsules adherent, the cortex increased, and the stria? coarse.

The duodenum shows many gas cysts. The small intestine shows swollen patches of Peyer; lower down the patches exhibit small erosions. As the valve is approached the enlarge


y


June, 1897.]

121


ment of the patches increases, as does the extent of erosion. Occasionally these patches show hemorrhagic infiltration. At the valve nearly the whole of the intestine is involved in deep ulceration which presents a sloughy and necrotic appearance and is nearly black from imbibition of blood.

The lungs are deep in color, crepitate throughout, and almost sink in water. The cut surface is smooth and dark. The bronchi are dark in color from imbibed blood. The blood in the vessels is frothy. The right side of the heart is enormously distended. On incision there is escape of gas and collapse. The intima of the vessels, and endocardium, are deeply blood stained.

In the right upper angle of the cavity of the uterus is a portion of placenta the size of a walnut, apparently the remains of a recent abortion. It is oval in shape, firmly attached, dark in color, porous in consistence, and has a deep red color. The mucosa is congested.

Cover-slips from the heart's blood, liver, spleen and intestinal ulcer showed, along with other bacterial forms, a large capsulated bacillus resembling closely the bacillus aerogenes capsulatus. These were not seen upon cover-slips from the bile and placenta. Anaerobic cultures were taken from all of the organs, but the large bacillus failed to grow.

Cultures upon agar plates yielded the following results: Bacillus typhosus in placenta, spleen, liver and kidney. Bacillus coli communis in the kidney and heart's blood. Bacillus pyocyaueus in the heart's blood. Bacillus proteus in the bile.

Some of the appearances found at the autopsy must be regarded as due to post-mortem changes, so that the invasion of the bacillus coli communis and the bacillus proteus after death cannot be entirely excluded. It is not improbable, however, that they may have been present in the orgaiis or body fluids during life. The bacillus pyocyaneus is not a common post-mortem invader.

In reading over the available literature I find that the typhoid bacillus has been obtained during life from the blood of patients suffering from typhoid fever by three other writers. Thiemich* found it once in blood taken from a vein


' Baumgarten's Jahresbericht, Vol. 10, 1894, p. 266.


of the forearm. Ettlinger* obtained it twice by the same method, and Stern twice.f

Other writers report a negative result. NeuhausJ failed in twelve cases from blood taken from a vein of the forearm, and twenty-four cultures§ from blood obtained by pricking the skin of the forearm; Frilnkel and Simmonds|| in sis cases. Ettlinger** reports eight negative results with blood taken from the forearm, and Klein ten.|f Failvires are also reported by Gaffky, Riitimeyer, Chantemesse and Widal, v. Jaksch, and Vaquez.

In six other cases I failed to obtain the typhoid bacillus, although a syringeful (1.5 cc.) of blood was employed in each instance.

The typhoid bacillus has been obtained from the blood after death by several observers: Viucent,|| Friinkel and Simmonds,§§ Flexner,|||| Klein,*** and by Wright and Stokes.fft

Heretofore not much importance has been attached to the work of Letzerich,JII Almquist,m Maragliano,||| Riitimeyer,§§§ Pasquale,§§§ Guarnierl,§§§ and Karliuski,§§§ because their examinations were made at a time when the differentiation of the typhoid bacillus from other micro-organisms closely resembling it in morphological and biological characters, was not so clearly understood as it is at present. However, it is probable now, that since definite proofs exist of the not very infrequent occurrence of the bacillus typhosus in the blood, either before or after death, their work may come to have more significance.


  • Wirtz, Precis de Bacteriologie Clinique.

■fCentralb. f. innere Med. 1896, No. 49, p. 1249.

I See Wurtz.

§ Berliner klin. Wochenschr., No. 6, 1886.

II Sternberg, Text-book of Bacteriology, p. 352.

    • Loc. cit.

■H-Baumgarten, Vol. 10, 1894, p. 266.

XI Ann. d. I'lnst. Pastesr, 1893 ; Le Mercredi medical, 17 fev. 1892.

§§ Sternberg, Text-book of Bacteriology, 1896, p. 352.

ill Op. cit.

      • Baumgarten, 1894, Vol. 10.

tttOp. cit.

ttl Sternberg, op. cit. §§§See Flexner, op. cit.


SUCCESSFUL CULTIVATION OF GONOCOCCUS IN TWO CASES OF GONORRHEAL ARTHRITIS AND ONE OF TiENOSYNOVITIS, WITH REMARKS ON A NEW MEDIUM.

By Francis R. Hagner, M. D., Assistant Resident Surgeon, Johns Hopkins Hospital.


The more successful attempts to cultivate the gonococcus from pathological conditions other than urethritis and conjunctivitis, have widened our view concerning the part played by this organism in human pathology.

Even now it would take much space to enumerate all the different lesions and parts of the body in which this organism has been found. The gonococcus, as is well known, cannot be cultivated with the facility of the other pyogenic cocci, and it has for this reason not lent itself so readily as an aid to diagnosis in obscure cases, unless perchance it could be found in


cover-slips, where its peculiar form and definite staining reaction might suflBce for its identification.

Greater experience, on the other hand, has shown that, although this organism does not grow at all, or at least most feebly and unsatisfactorily, upon the ordinary culture media, its choice of substance is still not a small one.

Since Steinschneider's observation of the great value of urine in the composition of a culture medium for the gonococcus, no really easy practicable method of preparing a medium containing this fluid has been devised.


122

[No. 75.


We offer iu the accompanying paper a simple method which, in the limited number of cases at our disposal, has proven successful.

It is in part my object in presenting these cases to draw attention to the ease with which, by the use of this medium, the gonococcus may be cultivated.

I must state that the value of the medium was further tested and proven by cultivating this micro-organism from urethral piis. The cases themselves are of interest from their clinical aspects, and as illustrating the good results which surgical interference gives when undertaken in time.

The possibility of making a positive diagnosis before opening the infected joint enhances the likelihood of good which may be confidently expected from these measures.

No question is likely to arise as to the identity of the cocci isolated in these cases, even in view of the fact that in one case the organism did not completely decolorize when treated according to Gram's method.

The later writers on the subject, among whom I shall only mention Caplewski,* concede great difference in the behavior of cocci from different sources.

Most samples of gonococci are quickly and readily decolorized; some few are more refractory and may retain the stain in part. On the other hand, the ordinary pyogenic cocci which resist Gram's method sometimes become decolorized.

No small part in this procedure is played by the composition of the stain and decolorizing agents.

But when all the facts are gathered, namely, the source of the organisms, their morphological properties, their diflBculty of culture, and slight viability, together with their staining reaction, no doubt is likely to be entertained concerning their nature.

Case I.

B. B., set. 21, female, colored. Domestic. Admitted December 5, 1896.

Previous History. Patient has never been very healthy. One year ago she had an attack of rheumatism; at this time the right knee was swollen and painful. The jjatient was confined to bed for one month, and has never had any trouble with the joint since. There was no history of any vaginal discharge at this time.

Present Illness. Patient acknowledges exposure within the last month. Has had vaginal discharge for three weeks. Six days before entrance to the hospital she noticed pain and swelling of the left knee. Pain more marked at night and increased by motion.

Examination. The patient is a rather poorly nourished, unintelligent woman, with a slight blowing murmur over the apex of the heart, transmitted to axilla. The joint is quite tense, painful on palpation and motion. Patella floats. There is marked induration and thickening of the peri-articular tissues, which are boggy. Distinct fluctuation over the joint. A purulent discharge observed to be present in vagina and urethra. The examination of cover-slips was negative for typical gonococcus-like organisms.


  • Hygienische Rundschau, Vol. 6, No. 21, p. 1029.


December 5th. Knee aspirated with sterile syringe and a straw-colored fluid obtained; this showed under the microscope a great many polymorphonuclear leucocytes, and a few large diplococci which were not contained in the pus cells. Cultures made on agar-agar, gelatin, potato and bouillon were negative after forty-eight hours in the thermostat. Cultures made at the same time on albuminous urine agar in twentyfour hours showed no perceptible growth, but at the end of forty-eight hours in the thermostat about a dozen isolated colonies, a little larger than ordinary streptococcus colonies, elevated above the surface of the medium, presenting an opaque white color, but still translucent, were easily seen.

Cover-slips were made, staiued with Sterling's gentian violet, mounted in water. The examination showed diplococci morphologically identical with the gonococcus. The same specimens were then stained by Gram's method and almost completely decolorized, a faint outline still being visible here and there. The ordinary media (mentioned previously) were inoculated from the cultures with negative results; but another albuminous urine agar tube, inoculated, gave a similar growth to the first after forty-eight hours in the thermostat, and this showed the same morphological characteristics.

Another generation, third in succession, was obtained on the albuminous urine agar medium; this one was feebler than the preceding ones, and no further growth was obtainable.

December 8lh. Knee again aspirated, the fluid giving the same growth when inoculated on the albuminous urine agar tube.

The same negative results as described previously were obtained on the ordinary media. The growth mentioned was carried through three generations, but again would not grow on the fourth transplantation.

December 17th. The knee joint was opened and cultures taken, two tubes of the albuminous urine agar being inoculated. One of these became contaminated ; in the other the growth was very slight and did not survive for a second transplantation.

The following is a brief description of the mode of preparation of the albuminous urine agar, which was prepared by Dr. Hugh Young and myself.

Acid urine containing 0.05 albumen or more should be collected and allowed to stand for twenty-four hours, no effort being made to prevent decomposition. The urine is boiled until a large albuminous precipitate is formed ; it is filtered through paper, when the resulting fluid will be clear. The filtered urine is boiled, and agar-agar, peptone, beef extract and sodium chloride are added in the same proportion as making ordinary agar.

The other steps are the same as in making ordinary agar, except that filtered albuminous urine instead of water is used throughout the preparation of the medium. It is important to see that the medium before being placed in tubes has a neutral or slightly acid reaction.

The advantages of using albuminous urine are, first, that iu such urine albumens are always present, which are not coagulated by heat, and second, the albumen that is coagulated acts as a clarifying agent in the removal of the salts that usually cause the cloudiness of urine agar-agar as prepared by


June, 1897.]

123


mixing the urine agar separately and sterilizing by discontinuous heating below the point of coagulation. It is important to have the medium very moist when inoculated.

The operation consisted of opening and irrigating with bichloride of mercury 1 to 1000, followed by salt solution, an Esmarch bandage being applied above the joint to prevent absorption of the bichloride solution.

The wound was approximated with subcutaneous silver wire sutures, silver foil dressing applied, and the leg put up in plaster. Of course very strict cleanliness is necessary in these operations — in all cases the operator and assistants wearing rubber gloves. The wound healed perprimani.

At the time of operation the subcutaneous tissues were found very edematous and thickened, and minute hemorrhagic areas were seen in the tissues near the joint. The fluid within the joint was serous in character, although flakes of fibrin were contained in it. The synovial membrane was thickened and its surface covered with hemorrhagic material that in places had a plush-like appearance, having lost its gloss. At the junctions of the cartilages and synovial membrane there were a number of tessellated, very vascular fringes of fibrinous material 3 to 5 mm. in length.

The cartilages showed no change.

The patient is at present more comfortable, but has not entirely recovered.

Case II.

A. D., female, fet. 20 years, colored, domestic. Admitted August 25, 1895.

No history of rheumatism.

Has had vaginal discharge for two weeks. (Patient acknowledges exposure several days before the discharge was noted.)

Three days before entrance left knee joint became painful and swollen, pain being more marked at night; fever was present, the highest temperature recorded being 103° F.

Examination. Large, well nourished woman.

Left knee slightly flexed, and warmer than adjacent parts. Slight fluctuation on inner side of patella ; movement of the affected joint caused great pain.

The peri-articular tissues were indurated and boggy.

There was a purulent discharge from the vagina and urethra that contained diplococci. These were in a manner suggestive of the gonococcus and occurred within the pus cells; they completely decolorized when stained according to Gram's method.

The operation was done on the fifth day of the disease, and consisted in the application of an Esmarch bandage, incision of the joint, irrigation with 1 to 1000 bichloride of mercury followed by salt solution, and closure of wound with silver wire. Silver foil dressing and plaster cast applied.

Patient made good recovery.

The examination of joint at time of operation showed the peri-articular tissues to be in an cedematous and hemorrhagic condition.

The joint contained about 25 cc. of blood-stained fluid in which floated small pieces of a fibrinous material.

The synovial membrane was roughened, thickened and had the same appearance described in the preceding case.


Larger tessellated masses of fibrin adhered to synovial membrane wherever it came in contact with the cartilage.

Bacteriological Examination.

The fluid for culture was removed from the joint with a sterile Volkman spoon, and placed in sterile test tube. A small quantity of blood was obtained by allowing a stream from a small artery to spurt into a sterile test tube.

The tube containing the blood was allowed to stand for two hours, during which time the serum had separated from the clot and could be pipetted off. An ordinary agar tube was melted and cooled to 46° C, so as to prevent the blood serum from coagulating when added. About 5 cc. of the human blood serum was added, making the proportion one-third human blood serum and two-thirds nutrient agar-agar; the resulting medium was perfectly clear. The fluid medium was then mixed thoroughly, and inoculated with three loops of fluid obtained from the joint, great care being taken not to add the fluid until the medium was observed to be on the point of solidifying, so as to prevent all chances of destruction of the organism by heat.

The inoculated medium was poured into a Petri's dish and placed in thermostat at 37° C. No growth was visible at the end of the first twenty-four hours, but at the expiration of forty-eight hours five or six small colonies could be seen. These were isolated and about the size of the ordinary streptococcus colonies, but they were more elevated when they appeared on the surface of the medium, and of a more opaque white color; they were, however, slightly translucent.

Cover-slips prepared from such a colony and stained with Sterling's gentian violet, mounted in water, showed numerous diplococci somewhat larger than the ordinary pyogenic cocci, composed of two hemispheres separated by a narrow unstained interval ; a few tetrad forms were also seen. The same preparation treated by Gram's method was completely decolorized.

Agar-agar, bouillon, potato, gelatin, and glycerine-agar were then inoculated from one of the colonies.

At the same time another culture was made on the serum agar. No growth could be seen after forty-eight hours on any of the tubes except the one containing the human serum agar, and on this a growth similar in appearance to the ones described before, consisting of cocci with the same morphological properties, was found; further transplantation was not successful on this medium.

As no perceptible growth occurred on any of the ordinary cultural media, and cover-slips taken from their surfaces were negative, the conclusion that the organism was the gonococcus was considered justified.

It is interesting to note that although numerous coverslips were made from the fluid at the time of operation, and numbers of polymorphonuclear leucocytes were found, no micro-organisms could be discovered.

Case III. A. P., male, white, single, 39 years. Admitted May 20, 1896.

Denied any venereal disease. (Very questionable.) Patient felt, without any premonitory symptoms, great pain


124

[No. 75.


in the left aukle joint, and at the same time noticed that there was considerable swelling and redness of the skin over the joint.

The pain was more marked at night, and increased with movement.

The condition mentioned gradually grew worse until the twenty-fourth day after the beginning of the disease, when patient was transferred to the surgical ward.

Examination. Patient was a well nourished man. Temperature on entrance 100° F. There was a fluctuating swelling extending from the juncture of middle and lower third of tibia, following the sheaths of extensor muscles, to a point on the dorsum of foot 3 cm. below the ankle joint.

May '21st, Operation. Same operation as described previously.

Incision of abscess and excision of fibrinous material from tendon sheaths. Irrigation of bichloride of mercury 1 to 1000, wounds closed with silver wire and dressed with silver foil, and leg put up in plaster. Patieut made good recovery in three weeks, wound healing per prima?/!. On incision the subcutaneous tissues were oedematous and slightly hemorrhagic. The tendon sheaths were thickened and covered with hemorrhagic fibrinous material.

The pus was confined principally to the sheaths of tibialis anticus and extensor proprius poUicis, chiefly about the annular ligament, but followed the pollicis to a distance of 3 cm. below. The sheaths were opened and about 100 cc. of bloodstained fluid escaped, which was placed by means of a Volkman spoon in a sterile test tube.

The internal portions of the sheaths were covered with a hemorrhagic fibrinous material and some granulation tissue.

I am indebted to Dr. Flexner for the privilege of reporting his successful cultivation of the gonococcus in this case. The pus collected at operation in a sterile manner was sent to the Pathological Laboratory.

Cover-slips when stained with Sterling's gentian violet showed polymorphonuclear leucocytes filled with diplococci morphologically resembling the gonococcus; a few of the organisms seen were extra-cellular.

When stained according to Gram's method the organisms were completely decolorized. Inoculations of the pus were made on the mixture of Steinschneider,* on a mixture composed of human ascitic fluid and agar-agar,t on a mixture of human blood serum and uriue,J on an infusion of pig-fcetuses and nutrient agar,§ and also upon ordinary agar slants. The


  • Steinschneider'8 medium consists of a mixture of bullock's

serum, urine, and agar-agar.

tThe mixture of ascitic fluid i and agar-agar J, which after being placed in tubes is sterilized and slanted. An albuminous flaky precipitate collects at the bottom of the medium, leaving surface clear.

t Human blood serum and urine medium is composed of J urine, f human blood serum sterilized in autoclave at 220° F. (Human serum derived from placenta.)

§ Preparation of pig-failvt a<]ar : Fresh pig-foetuses not exceeding 5 cm. in length separated from placenta and membranes are minced in a sausage machine. An equal volume of distilled water is added to the finely divided foetuses, and after thoroughly stirring, the mixture is allowed to macerate in a cool place for from


cultures were placed in a thermostat at 37° C, and at end of twenty-four hours a scarcely perceptible growth was found on all the inoculated tubes except the agar slants, which last remained sterile, whereas the growth on the other tubes increased somewhat during the next twenty-four hours.

The appearance of the growth was the same as that described in previous cases.

Growth on pig-fcBtus agar was more abundant and apparently more vigorous than on the other media.

Cover-slips from the cultures showed the same diplococcus as was found in the pus, and it became decolorized completely by Gram's method.

Transplantations at intervals of forty-eight hours were made on pig-foetus medium mentioned and growth obtained for four generations, but from the fifth inoculation no growth resulted.

It is interesting to note that the condition of synovial membranes and peri-articular tissues in these cases was practically the same, namely subcutaneous oedema, thickening and induration of peri-articular tissues, with small hemorrhagic areas.

The synovial membrane was thickened, very hemorrhagic and had the appearance of plush, having lost the glossy condition.

The fringe-like pieces of fibrin were very hemorrhagic. In neither case was the cartilaginous portion of joint affected.


six to twelve hours. The fluid is then freed from contamination by filtration through a Chamberland filter under a pressure of 150 to 200 lbs.

Two per cent, sterilized nutrient agar is then melted and cooled to 40° C. and to it J of its volume of the infusion of foetuses is added. The tubes are then slanted.


NOTICE.

All inquiries concerning the admission of free, part pay, or private patients to the Johns Hopkins Hospital should be addressed to Dr. Henry M. Hurd, the Superintendent, at the Hospital.

Letters of inquiry can be sent, which will receive prompt answer, or personal interviews may be held.

Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indigent patients a uniform rate of $5.00 per week has been established. The Superintendent has authority to modify these terms to meet the necessity of urgent cases.

The Hospital is designed for cases of acute disease. Cases of chronic disease are not admitted except temporarily. Private patients can be received irrespective of residence. The rates in the private wards are governed by the locality of rooms and range from $20.00 to $35.00 per week. The extras are laundry expenses, massage, the services of an exclusive nurse, the services of a throat, eye, ear and skin or nervous specialist, and surgical fees. Wherever room exists in the private wards and the condition of the patient does not forbid it, companions can be accommodated at the rate of $15.00 per week.

One week's board is payable when a patient is admitted.


June, 1897.]

J^ NEW ^ESTHESIOMETER.

By Lewellts F. Barkee, M. B. {Exhibited to the Johns Hopkins Hospital Medical Society, January 18th, 1897.]


I exhibited at this Society some time ago the test hairs employed by Professor von Frey in studying pain and pressure sense. These consisted, it may be recalled, of short wooden handles of suitable length, to which finer and coarser hairs were fastened at one end at right angles with sealing wax. The most suitable form is perhaps a four-sided wooden handle measuring 4 mm. on each side and 80 mm. in length. Hairs of different strength are obtained from the scalp of men, women and children ; hairs from the beard, from the horse's tail and hog bristles are also of service where stronger stimuli are required. The advantage of these test hairs consisted, it will be remembei'ed, (1) in the very small surface of skin acted upon, and (2) in the possibility of grading accurately the intensity of the stimulus applied. In order to test the stimulus- value of the hair, its area in cross section must be determined, as well as the weight which can be lifted by the hair when it is pressed with its cross section against one of the scale pans of a delicate balance. I described on the former occasion the methods of determining these two constants and shall not now repeat the details. Suffice it to say that with time and patience a set of such test hairs can be prepared varying in stimulus-value from 0.1 gr./mm^ to 300 gr./nim', though, as Professor von Frey says, the jireparation of them is " nicht jedermanns Sache."

A


B



FlQ. 1.

The form of the hair and its mode of action are shown in Fig. 1. A represents the test hair when it is placed upon the skin at the point F, though as yet no pressure has been exerted. In B the handle is nearer the skin, through pressure made parallel to the surface of the skin, and the hair is bent into an S-shaped curve, the turning point of which is at W. If W is perpendicularly above the point F, then the hair exerts exclusively an influence of pressure upon the skin ; but if W be directed to one side, there arises along with the pressure a "shoving" component. The latter appears, as one finds on bending the hair, as soon as it begins to twist out of one plane; that is, a space-curve arises instead of the plane-curves.


The set of hairs which I pass around were prepared under Professor von Frey's direction in Leipzig in the spring of 1895. I have tested them at intervals since that time and find that they have undergone very little variation. For accurate testing of pressure and pain sense some such delicate testing mechanism is indispensable. Such hairs, however, are not in the market, and I fear if one wished a set of them he would have to prepare them for himself.

Kecently, however. Prof, von Frey, // with the aid of the mechanician Zimmermann, has prepared a simple instrument which, for purposes of clinical examination at least, will take the place of the set of test hairs. This Ksthesiometer, which depends upon the same principle as that involved in the construction of the test hairs, has the advantage that with a single hair one can obtain a large series of pressurevalues at will. It consists of a long hair pushed through a capillary tube of very narrow lumen, much like that of a thermometer tube; the hair can be shoved through the lumen easily, but on pressure only the part of the ' hair outside the capillary tube can bend, and the force exerted is always g greater the less the amount of hair outside the tube, and feebler the greater the length of hair not inside the capillary tube. In Fig. 2 the mechanism is shown, though the sample which I pass around has some improvements not illustrated in the figure. The capillary tube consists of a brass tube, S, of very narrow bore, over which a sheath H glides with slight friction. In the axis of the siieath, and of the same length as this, runs a wire, which fits in the bore of the tube S, and at the end of which the test hair is fastened. If the sheath be shoved entirely over the scale the hair projects in its greatest length, and has accordingly only very slight force. On the other hand, if the sheath be drawn back as far as possible the greatest part of thf iiair


K7


126

[No. 75.


disappears within the bore, and the short still projecting part is capable of exercising very considerable pressure force. By means of a screw the sheath can be held iirmly in any position corresponding to a test hair of any desired length. There is a millimetre scale on the tube, by the help of which a given length of test hair can always be found again, together with a protecting tube for the free end of the hair to complete the instrument.

The testing of the hair for its pressure values at different lengths can be carried out with the aid of a delicate balance, and if one makes determinations for every fifth or tenth line of the millimetre scale he can easily calculate the values for the intervening lines. With this instrument it is easy to pass from very low pressure values, even below the threshold for the most delicate pressure points, to pressure values above the pain threshold in parts of the body where the pain threshold is high.

The value of this instrument was demonsitrated with Dr.


Gushing in the ward the other day. In a case in which ordinary slight stimuli appeared to call forth pain constantly, the idea had arisen that pressure sense was absent, the pain sense being very much exaggerated. It was easy with this instrument to show that the pressure sense was not abolished, though the threshold for pain was almost at the same level as the threshold for touch. With care, however, the pressure points could easily be made out. The significance of careful examinations in such cases is obvious, for it would be easy for the clinician to make the statement that tactile sense was destroyed in a given case in which in reality it was unaffected or but little affected. If such a case should come to autopsy, one might be entirely misled in interpreting the lesions found.

The sesthesiometer is not expensive, costing I believe five marks, when purchased from E. Zimmermaun of Leipzig. I cannot recommend it too highly for use in clinical examinations.


EDINGER ON "THE DEVELOPMENT OF BRAIN PATHS IN THE ANIMAL SERIES."*

[Abstract of a Keport made by C. K. Bardeen, M. D., before the Journal Club of the Johns Hopkins Hospital.]


In this address Edinger speaks in a most interesting way of the value and possibilities of a comparative psychology based on careful biological and morphological study. He himself, he says, was led to undertake this line of research by the knowledge that the lowest vertebrates have no cerebral cortex. In man and in the higher vertebrates the finer conscious activities take place in this part of the brain, and in the ascending vertebrate series there is a gradual development of the cerebral cortex up to man. " Indeed, in man," says Edinger, " the evolution of the brain cortex is still under way." The interesting questions arose. What nervous activities are possible in animals without a cerebral cortex ? and What nervous and mental activities have been added as the cortex has been evolved in the animal series ? The solution of these questions involved the broader task of studying the finer structure of the nervous system of the lower vertebrates. It was found on investigation that those parts of the brain which, as opposed to the cortex, are designated as the " lower parts " are essentially similar in all vertebrates. The spinal cord and medulla of the fish and of man do not differ fundamentally.

"So far as we know to-day," says Edinger, "we may ascribe to similar structure similar function." If this be true we may hope by careful study of the morphology of the nervous system to have opened up new points of view for physiology and psychology. If to the spinal cord, for example, the functions


  • " Die Eatwickelung der Gehirnbahnen in der Thiereihe," delivered before the medical section of the " Gesellschatt deutschcr

Naturforscher und Aerzte," in Frankfurt a. M., Sept. 23, 1896, and reported in the Deutsche medicinische Woehenschrift, Sept. 24, 1896, Vol. XXII, No. 39. [Prof. L Edinger of FrankCort is well known in America as the author of a very lucid text-book on the structure of the brain, "Der Bau des Gehirne." He is perhaps the foremost worker in the line of research of which he speaks in his address.]


of which are well known, comparative anatomical study shows that other structures are added little by little, we may suppose corresponding additions in functional capacity.

Edinger lays special stress on the need of care in forming our conceptions of the operations of the nervous system of the simpler animals. We must carefully rid ourselves of all preconceived notions of perception and desire as the necessary accompaniments of complex reactions to stimuli. We have, he says, no grounds for belief that such states of consciousness arise outside the higher centres of the cerebrum. We have no right to assume that in the lower animals the simpler nervous system performs functions like those performed by the higher centres of the nervous system in the higher vertebrates. " I trust I may be able to prove," says Edinger, " that the latter assumption, so commonly made, cannot be maintained."

To show how easily one might falsely attribute a conscious origin to complex movements, two or three examples are given from the invertebrate kingdom. Loeb's interesting experiments with the actinia are quoted. If a bit of fish be placed on the tentacle ring of one of these animals the tentacles close in and force the food into the mouth between the tentacles. But a piece of white paper put in the same situation is left undisturbed. This at first sight might seem a voluntary choice between the food and the paper, involving a conscious perception of taste. But if the mouth be destroyed and the bit of fish be again put on the tentacle ring the actiniau will double itself up trying vainly to force the morsel into the closed mouth. The definite activity caused by the meat is, roughly speaking, a direct reaction of the tissues to a chemical stimulus. The actiniau has no very definite nervous .system, though certain of its cells are taken to represent nerve

rrlLs.

Hdiu^er also refers to the recent studies on the nervous


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system of tlie earth-worm. Thanks to the work of Loeb aud Friedlaender on the living earth-worm, and that of Retzius aad von Lenhossek on the morphology of its nervous system, the task of comparing its structure with its psycho-physiological activity has been greatly lightened. If the earth-worm be cut into pieces not too short, and one of the pieces is stimulated to move, it will continue creeping. The movement is produced as follows: from large epithelial cells in the external skin the earth-worm's sensory fibres pass into the central ganglia situated in the ventral band ; here the process divides into at least two parts. These lie in contact with the dendrites of large ganglion cells lying in this ganglion and in those immediately adjoining. These large cells send processes to the muscles. Each ganglion sends motor fibres, not only to the muscles of the segment within which it lies, but also to those of the neighboring segments. Some of the fibres cross the median line. A third set of cells have processes which run up and down the veutral band connecting different ganglia. Thus a sensory impulse started in a large epithelial cell is carried to the neighboring ganglion. Here the motor and associative cells are called into activity, and the muscles in the vicinity of the segment whose surface has been stimulated contract. This throws increased tension on the surface of the neighboring segments and they in turn are stimulated to contraction. A contraction wave is thus started along the worm, called forth by simple reflex action. This scheme is not diagramatic; it is based on the actual observations of trained observers.

The mechanism which controls intestinal contraction in the higher animals is very similar.

The nervous mechanism found in the vertebrate spinal cord is fundamentally the same. Here again we find motor cells sending processes to the muscles; here again processes from sensory cells terminating in gray matter ; here ag.ain, but in a far more developed degree, association neurones. That the spinal cord is capable, unassisted by the higher centres, of carrying out very complex movements is shown by the complex activity of the frog deprived of a cerebrum, the jumping of the brainless rabbit and the swimming of the brainless


The morphological structure on which the functions of the spinal cord depend has now been fairly well determined. Beside the factors already mentioned there enter into its structure paths connecting it with the brain. In the fish paths connect mid-brain and cerebellum with the spinal cord. Connections between the cerebrum and the spinal cord first appear in mammals. " The direct influence of the cerebrum on the activities controlled by the spinal cord varies, therefore, according to the class of animal, and it does not even exist among the lower vertebrates." The pyramidal tract is not found in birds.

The medulla, while, like the cord, serving as a primary centre for the reception of sensory and the origin of motor fibres, has a much more highly developed associative mechanism than the cord. Yet the development of these paths of association varies greatly in different animals. In the carps and many other fishes it has a more complex development than in man. The complexity of development of the medulla depends chiefly


on the uses to which the cranial nerves are put. The terminal area of the fifth nerve, so well developed in the sensitive-faced mammals, is but slightly developed in the snakes, but the motor area of the fifth nerve in snakes is relatively more developed than in the mammals, owing to the snake's powerful jaw muscles.

The cerebellum varies greatly in development, even among the fishes. Those that swim actively have it more highly developed than the mud-seeking varieties. Birds being animals of delicate sense of balance have it well developed. In snakes it is very rudimentary. Whatever the functions of the cerebellum may be, this organ is well developed in all animals executing carefully poised movements. The hemispheres of the cerebellum first appear in the mammals.

The connections of the cerebellum with other parts of the central nervous system are interesting. The pons fibres first appear in the mammals, and it is probable that the olivary paths do not occur in the lower forms. On the other hand the connections with the spinal cord through the corpus restiforme and with the thalamus through the suj)erior cerebellar peduncle are primordially old. The latter are more highly developed in fishes than in man.

Next to the spinal cord the mid-brain is that part of the central nervous system most alike in all vertebrates. It is the primary terminus for the optic fibres, and in it end a large part of the secondary sensory fibres transmitting impulses from the other sense organs. It is the great centre for the association of sensory impulses in the animals without a well developed cerebrum.

The cerebrum in all vertebrates is composed of olfactory apparatus, basal ganglia and cortex.

The olfactory region varies greatly in development. In reptiles and in fishes it makes up half the brain mass. In birds it is scarcely to be traced.

The corpus striatum, which lies just behind the olfactory apparatus, appears developed throughout the vertebrates. It plays a chief part in connecting thalamus and fore-brain, but in large part its functions are ill understood. The optic thalamus is likewise complexly developed throughout the vertebrates. The cortex stands in marked contrast to the lower parts of the central nervous system which are so much alike among all the vertebrates. In fishes the cortex consists of a thin epithelial plate. In the amphibia it contains a simple nervous apparatus. In reptiles a true cortex appears for the first time.

Within the last twenty-five years it has been definitely shown that the cortex performs the highest functions of the nervous system. On the existence of a normal cortex depend all those functions which may be learned, almost all which are carried out by memory pictures, and, above all, those complex conscious processes designated "associative." The silver stain has shown into what a complexity of relations each nerve cell is brought by its processes. From the reptiles to man this associative complexity increases.

It seems probable that various sensory areas in the cortex have been added as the need has arisen for more highly developed associative processes connected with the special senses. The earliest cortical relations are with the sense of smell


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only. Reptiles, we may assume, differ from fishes in that they can "retain their smell impressions, associate them and choose." For the reptile the cortex is an olfactory centre and out little more.

" This first inheritance of the cortex, the olfactory centre, remains throughout the entire series ; in birds alone is it somewhat uncertain. There is no difficulty in following the cortex of the reptiles into the Amnion's horu and the uncinate gyrus of mammals and mau."

But in the course of evolutionary development other brain centres have been added to this ; the cortex has been built up piece by piece. Unfortunately most of the steps are still uncertain. Something is, however, known of the optic paths. In fishes the optic nerve ends in the mid-brain. And so too in man at birth the only functional fibres end there. The babe is not blind, but it has no association centres for sight impressions. During the second mouth of life paths are developed from mid-brain to occipital lobe, the cortical sightcentre is called into activity, and association paths are formed between it and the rest of the cortex. The child only then begins to perceive what it sees.

It is because the fish has no cortical centre for sight that it can be hooked. To a similar reason is due the fact that reptiles and amphibia often go hungry when they do not smell their prey and it does not move. Snakes which do not eat dead mice will seize and devour, without a trace of dislike, dead mice artificially made to move.

Birds have a well marked cortical area for sight, and hence they exhibit many phenomena which indicate reason and memory founded on sight impressions.

It is clear, however, that in the lower animals many functions are performed without the influence or control of a cortex, and the question naturally arises as to the real nature of


the functions of the lower centres. It is well known that man and the higher mammals are more injured in normal activity by loss of the cortex than are the lower vertebrates ; that the cortex becomes indispensable iu proportion as it becomes well developed and is brought into close association with the lower centres. This has been shown by the study of the diseased human brain and by experiments on animals. But nature offers us animals with no cortices and with cortices variously developed along special lines. We have here a beautiful opportunity to study the functions of the cortex in the animal economy. Most interesting points of view might be obtained by excitation of the olfactory nerves of fishes which have no cortical centres, and of snakes which have cortical centres for smell ; or by comparing the effects of visible objects on snakes which have no developed associative centre for sight, and on birds which have them well developed.

And this same sort of study carried to man will also prove productive. The great man need not necessarily have a heavier brain than the average man, but we should expect that part of his brain which he had occasion to use to be better developed than the average. The great painter should have a well developed occipital lobe ; the great musician a well developed temporal lobe. Gambetta's brain was not above the average in size and weight, but the speech area was very greatly developed. For the present, Edinger points out, we may willingly refrain from speculating about convolution anomalies and criminal types. More fruitful fields of investigation are offered the scientist. The field of comparative psycho-physiology and comparative morphology gives every promise of being most fertile. One thing seems sure, " there is no boundary to be established between the conscious activities of the lowest and those of the highest vertebrates."


PSEUDO-TUBERCULOSIS HOMINIS STREPTOTRICHA.

[A PRELIMINARY NOTE.]

Bt Simon Flexnee, M.D.

[From the Pathological Laboratory of the Johns Hopkins University and Hotpital.'\


At the meeting of the Johns Hopkins Hospital Medical Society held on October 19th, 1896, 1 presented specimens from the lungs and peritoneum of a man who had succumbed to a disease characterized by symptoms which resembled those of phthisis pulmonum, but in the lesions of which, instead of the bacillus tuberculosis, another and probably entirely distinct microorganism was discovered, for which I have proposed the name of streptothrix pseudo-tuberculosa. As the publication of the full report of the case and the complete description of the micro-organism has been somewhat delayed, a brief outline of the case may be of interest at the present time.

The patient was a male, colored, aged 70 years, in whom extensive consolidation was made out in both lungs. The symptoms were generally those of pulmonary tuberculosis. Sputum was carefully watched for during his stay in the


Hospital (Dr. Osier's clinic), but none was obtained. No microscopical examination could therefore be made.

Autojjsy. The body was that of a slightly built, somewhat emaciated man. The abdomen was moderately distended. The autopsy was made 19 hours after death, the body having iu the meantime been kept on ice. No evidences of post-mortem decomposition were noticeable. The description of the viscera is limited here to the organs especially affected.

The Lungs are voluminous and meet in the middle line anteriorly. They are not bound to the chest wall. Left. The entire lung, except the anterior edge of the upper lobe, which is insufflated, is consolidated more or less perfectly. Where the consolidation is frank the lung presents an opaque appearance, is gray in color, and beginning softening (disintegration with early cavity formation) is going on. The cavities often


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still contain the products of disintegration, and all appearances of reactive encapsulation are wanting. Where the hepatization is less complete the lung tissue is cedematous and swollen, although perhaps not completely airless, and discrete tubercle-like nodules may be seen. The pleura over the hepatized areas is covered with a fibrinous exudate. Right. The consolidation is less extensive and more focal in character, but occupies in places areas as large in extent as 4x5 cm. The pleural cavity contains a small quantity of fluid, pink in color, in which flakes of fibrin occur.

The intestines are moderately distended. The omentum is rolled up ; it occupies a position beneath the transverse colon and extends across the abdominal cavity. The pelvis contains about 15 cc. of fluid of brownish color and mucilaginous consistence. Between the intestinal loops delicate shreds of fibrin exist. In addition smaller and larger nodules resembling tubercles, usually translucent, are scattered irregularly over all the exposed peritoneal surfaces, and occur more uniformly upon and within the thickened, rolled-up omentum. The liver and spleen on section show similar nodules.

The bacteriological examination consisted in the study of cover-slips from the fresh lungs, the inoculation of glycerineagar tubes, and the injection of a suspension from the consolidated lung subcutaneously into a guinea-pig. The histological study embraced all the organs of the body. Cover-slips from the lungs, stained by Gabbett's method, showed no micro-organisms which resembled the bacillus tuberculosis in their morphology. There remained faintly stained in carbolfuchsin upon the cover-slips numerous examples of a branching organism, occurring often in clumps or convoluted masses, among which no ordinary bacillary forms were discovered. From the history of the case, the character of the lesions and the known variation in morphology of the bacillus tuberculosis, it was, for the time, assumed that the organism was a streptothrix form of the former bacillus. Its subsequent study has rendered this assumption highly improbable.

The cultures from the left pleural cavity and the peritoneum remained sterile. Three separate sets of cultures were prepared from the lungs. In all these, at the end of 34 hours, a vigorous growth of a bacillus, identified as belonging to the


group of B. coli communis, had taken place. The streptothrix did not grow. The guinea-pig showed no reaction to speak of at the site of inoculation, the adjacent lymph glands could not at any time be felt; the animal, however, lost in weight and died at the end of the 7th week, at the autopsy showing great emaciation. None of the lymphatic glands were found enlarged ; there were no lesions resembling tubercles in these and other organs, and cultures upon glycerine agar, made from several sources, remained sterile. Cover-slips from the serous cavities, blood and viscera were negative for any kind of bacteria.

The further study of the staining proj^erties of this organism in cover-slips, made from the lungs at the time of the autopsy, shows that as stained by the ordinary methods employed for tubercle bacilli, and decolorized by means of acids, the dye is held very loosely and quite readily given up. The best method of staining is either Gram's or Weigert's modified fibrin stain. The same holds true for its demonstration in the tissues.

The lesions in the tissues are of two kinds, depending in part upon their situation. In the peritoneal cavity tuberclelike nodules are formed, consisting of epithelioid and lymphoid cells with an occasional giant cell. Necrosis by fragmentation is not unusual in the centers of the tubercles, and fibrin, either before or coincident with the necrosis, is commonly observed in the nodules. In the lungs tubercles also exist, but they are less striking than a diffuse exudation of leucocytes, plasma and fibrin which fills the air cells, infiltrates the stroma and tends to undergo necrosis, producing larger and smaller spreading caseous foci of degeneration. The number of masses of the streptothrix is very great indeed and they are in intimate relation to the pathological process.

From these and some other considerations which will appear in the full report, it is believed that the organism is probably a new species, for which the name streptothrix pseudotuberculosa is proposed, and, further, that it is capable of causing in human beings a rapidly spreading and destructive disease resembling phthisis florida, for which the appellation of pseudo- tuberculosis hominis streptotricha seems warranted.


PROCEEDINGS OF SOCIETIES


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of December 7, 1896.

Dr. Thayer in the Chair.

Discussion of Dr. Frledenwald's Paper on Consjenital Motor Defects of tlie Eyeballs. See p. 203, Nov.-Dec. Bulletin, 1896.

Dr. Paton. — This case is of very great interest, and so unique that I feel interested from an anatomical standpoint. Cases of unilateral paralysis are easily explained, but for cases of double paralysis of the 6th nerve there is no anatomical explanation. As yet there has been no demonstration of the crossing of the 6th nerve in man. It has been demonstrated in monkeys. The crossing of the 4th nerve has been demon


strated in man. The further interesting fact that this case brings forward is the relation of the 6th nerve to the oculomotor. There are two possible ways in which these nerves can be related. If you take a section of medulla at the level of the 6th nerve and look at the right side, the fibres are seen to pass across to the left side, and then upward in the posterior longitudinal bundle as far as the nucleus of the third nerve. The main function of that bundle is to connect the nuclei of the cranial nerves, and there you find the connection between the 6th and 3rd. Recently another path has been marked out. The 6th on the right side may pass up on the same side as the rio-ht nucleus, and join the fibres of the 3rd nerve from the other side ; so you have two possible connections. Either the


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6th nerve crosses or the third nerve crosses, and the probability is the latter, because the crossing higher up of the 3rd nerve fibres is the simplest physiological explanation.

Dr. Theobald. — Dr. Friedenwald has had an exceptional experience in meeting with so many of these very interesting cases. It would seem that in this case there is a marked want of power of the internal rectus of the left eye as well as of the extei'nal rectus. This suggests the related cases of congenital ptosis sometimes accompanied by inability to turn the eyes upwards, that one meets with. It is well known that in this case the defect is not central, but is due to absence of or faulty development of the levator muscle of the upper lid and of the rectus superior. Such cases are not so rare as the one shown. I have met with several of quite marked degree. Frequently they are associated with epicanthus. It seems to me that the most probable explanation of this case is that we have here a similar want of development of the external recti. Indeed all the eye muscles here appear to be more or less faulty or weak, for it is difficult to induce the patient to turn his eyes in any direction, all of the movements being defective. We not uufrequently meet with cases of pronounced weakness of the recti muscles, particularly of the external recti, but such cases as the one shown are rare and extremely interesting.

Congenital Facial Diplegia.— Dr. Thomas.

In connection with the case which Dr. Friedenwald has exhibited. Dr. Thayer thought it might be interesting to have this rather unusual case presented to the Society. He has asked me to bring it before you.

The patient, a youth of 19, came to the Hospital from a neighboring State, in the hope that something might be done to improve bis uiifortunate appearance. Dr. Halsted has admitted him to his wards, and it is through his kindness that I have had the opportunity of examining him.

The family history is important. Father and mother are healthy and there is no history of any hereditary taint in either of their families. Patient is the third child of a family of nine. Three children died young, one of these having a niisformed foot. The eldest child, a girl, is perfectly healthy; the second child, a boy, now twenty-one years old, was born in a condition similar to that of our patient. The patient's birth was not particularly difficult and was non-instrumental. It was noticed soon after he was born that he was unable to close his eyes and that his underlip dropped while nursing. In crying his face remained motionless and he was unable to smile. He learned to speak at the usual time but was never able to pronounce certain letters. His general development was good except that he had some glandular trouble. He played with other boys and was able to do everything they did.

You see what a remarkable appearance the patient has ; the face is mask-like and expressionless, the mouth open, the lower lip pendulous, and the lower jaw protruded. He is absolutely nnable to move the muscles of his forehead, and when told to close his eyes he simply rolls the eyeballs up and relaxes the upper lid. He is unable to elevate or pucker his lips, but can move the angles of the moxxth out and down ; in doing this, you see, he brings into play the platysmata. In speaking he cannot pronounce the sounds which require the


use of the lips, viz. b, f, m, p, v. His eyes are prominent; the pupils are equal and react normally to light and during accommodation ; all movements of eyeballs are normal. He complains of being somewhat near-sighted ; there is no disturbance of the visual field. Muscles of mastication unaffected. There is no disturbance of sensation and taste is normal. Tongue is well developed and freely movable, indeed he makes his tongue take the place of his lips as much as possible, drinks and smokes by its aid. I have been unable to discover any abnormality in the muscular development of his trunk or limbs. Stimulating the facial nerves by electricity causes contraction in the muscles back of the ear and of theplatysma. By direct stimulation the platysma can be made to contract.

Before leaving the patient I should like to call your attention to the congenital defect in the right lobe of his ear. You will see that it is notched.

This, then, is a case of congenital facial diplegia. Dr. Friedenwald has told you that certain of the cases of congenital defect of the ocular movements have been associated with a similar condition in the facial muscles, and it is on account of this association that I have brought the case before you at this time.

Dr. Chisolm, of this city, reported one of the very first examples of this condition. In his case there was bilateral paralysis of the sixth and seventh nerves, a combination of the symptoms seen in Dr. Friedenwald's case and of those in the boy whom I have just shown you.

Moebius had a somewhat similar case, which he described in 1888, after which he made a fairly complete collection of all like and analogous cases. These he published in 1892. In this article he expresses the view to which, as Dr. Friedenwald has said, Kiihn takes exception, that the disease depends upon an atrophy of the nuclei, and he proposes the name " Infantiler Kernschwund."

Moebius was unable to find the record of any case in which congenital facial paralysis was unassociated with any defect of the eye muscles. Since then, however, two or three such cases have been described, but these cases were all unilateral, and, as far as I have been able to discover, the case which I have shown you to-night is the first one of its kind to be reported, although I have no doubt that others have been observed.

As to the anatomical condition which underlies these cases not much is known, and it seems scarcely worth while, at this time, to examine the theories which have been advanced.

The aspect and condition of the face in the patient whom we have seen suggest strongly the myopathic face which occurs in certain forms of progressive muscular dystrophy. We have examined the patient thoroughly with this point in view and have been unable to discover any other muscular abnormality, either hypertrophy or atrophy.

It tlierefore seems to me that the case cannot be classed with the progressive muscular dystrophies, although it might be considered as an abortive form of this disease, an explanation which has been given of a somewhat similar condition. As we do not understand the pathology of the muscular dystrophies, such an explanation helps but little. In this connection the condition of the patient's brother is of


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importance, for if, as we are told, his symptoms are quite similar to those of our patient, and no other muscles are involved, it will make the classing of the case with the muscular dystrophies still more far-fetched.*

Dr. OsLER. — I do not think there are any muscular dystrophies of this kind that have that extreme atrophy without any involvement of other muscles. None that I have seen presented that appearance. You will probably find the brother the same as this patient.

Dr. Halsted. — Is the jaw of the brother the same?

Dr. Thomas.— The patient tells me that it is not quite so much so.

Dr. Theobald. — Were there any cases in the family previous to this ?

Dr. Thomas. — Not as far as I can find out, not even an ocular palsy.

Dr. Barker. — The absence of ocular paralysis in Dr. Thomas's case is an interesting feature. In consideration of the anatomical relations of the sixth and seventh nuclei, the occurrence of paralysis of the abducens along with paralysis of the seventh nerve is rather to be expected, if the lesions be in the region of the nucleus and due to pressure or hemorrhage. One of the most curious facts with which the anatomist has to deal is the relation of the fibres of the seventh nerve to the sixth nucleus after they leave the facial nucleus. Why these fibres should run up toward the middle line, turn and run along the fioor of the fourth ventricle and then turn again ventrally and laterally has never been satisfactorily explained. Such an out-of-the-way coui'se seems unnecessary.

During the development of the motor nerves whose nuclei of origin are situated in the medulla and poQS, the motor fibres belonging to the N. accessorius, N. hypoglossus, N. vagus, N. glossopharyngeus, N. abducens, etc., pass directly toward the periphery of the medullary tube and pass through the marginal veil to form the peripheral cranial nerves. The fibres of the N. facialis alone show the well known remarkable discursion. Whatever be the factors which determine the course of these fibres, they are active at a very early period of development, for the relations mentioned are visible in very young embryos. In his lectures on vertebrate embryology last year, Professor His of Leipzig made the ingenious suggestion that the cause of the deviation of the fibi'es of the N. facialis from the course we would expect them to take may possibly depend upon mechanical factors associated with the development of the auditory vesicle, since the ear vesicle is laid down laterally exactly in the region of the sixth and seventh nuclei.

It would be easy to speculate further and to think of such cases as the one before us as instances of congenital nuclear destruction from disturbances of the relations which ordinarily exist between the auditory apparatus and the neural tube, due either to an unfortunate variation or to early intra-uterine pathological lesions. That the affection is bilateral and that more than one member of the same family is diseased would


•The elder brother was seen at his house and was found to be in an almost exactly similar condition to that described above in the case of his brother. Both cases will be reported more fully at a later date.


favor rather than oppose such an hypothesis. It is surprising, considering the extremely complex character of the developmental relations of the internal, middle and external ear, that vicious developments of these parts are not more common than they are. It is interesting to note that, as Dr. Thomas has pointed out in this individual, there is faulty development of a portion of the external ear. Should this man or his brother be the father of children it would be important to determine the presence or absence in them of similar lesions, since, as is well known, variations favorable or unfavorable show a marked tendency to become inherited. That instances of extremely unfavorable variation persisting through many generations are comparatively rare need not surprise us, inasmuch as in the progress of the race, in the course of a very few generations, individuals bearing such peculiarities, owing to their unattractiveness and unfitness, are, as a rule, gently killed out without offspring.

While modern embryology permits the formation of hypotheses such as those here hinted at, it is to be remembered that for any real explanation we must await the results of pathological findings in actual cases. In view, however, of what has recently been done, the problem might perhaps be advantageously approached from the side of teratological experiment.

Meeting ofiDecemher 31, 1896.

Dr. Thayer in the Chair.

A Case of Acquired Paralysis of both External Recti Muscles, with Unilateral Facial Paralysis.— Dr. S. Theobald.

I thought this case would be of interest to show as supplementary to the one exhibited by Dr. Friedenwald several weeks ago. His was a case of congenital paralysis, or perhaps defective development, of the external recti muscles. He pointed out, as one of the interesting features of that form of paralysis, that there was no squint, and explained that in cases of congenital paralysis secondary squint does not usually occur. In the case which I exhibit we have the usual secondary squint found in acquired paralysis of the ocular muscles, and as both external recti are involved, it is of high degree.

This patient is 33 years of age and until August last was employed as a laboring man. His history shows that ten years ago he had a facial paralysis of the left side, and at the same time a paralysis of the right external rectus. There has been little or no change in his condition, so far as we can judge, in all that time. During August last he first developed a paralysis of the left external rectus. As to the cause of these paralyses the history is rather indefinite. It is more than probable, I think, that they are of syphilitic origin. He admits having once had gonorrhcea, and I think there must have been specific trouble also, though the history as to this is not clear. The points of interest are that so many years ago he should have had paralysis of the facial nerve occurring at the same time as the ocular paralysis. If the two had been on the same side it would not be so difficult to explain their co-existence, for we know that the nuclei of the 4th and 6th nerves lie close together in the floor of the fourth ventricle, and it is not uncommon to find both these nerves involved in the same case. It is of great interest, too, that after so long a


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lapse of time the external rectus of the other eye should have become iuvolved. The paralyses are evidently nuclear, and it would seem that some central change, either inflammatory or degenerative, involved the nucleus of left 7th nerve and the nucleus, which is quite close to it but on the other side of the brain, of the right external rectus, and that after a long lapse of time the left external rectus also became involved.

Paralyses of the ocular muscles are not uncommon. Their origin may be cortical, fascicular, nuclear, basilar, or orbital. Probably the commonest cause of paralysis of the ocular muscles is syphilis. We also often have a paralysis of the ocular muscles in tabes which is quite marked and yet which may in time entirely disappear. Paralysis of the ocular muscles may also be caused by diphtheria, disseminated sclerosis, poisoning by alcohol, nicotine, etc., and a certain class of cases certainly are due to cold. I have seen recently four cases of paresis of the external rectus due to cold or exposure. Such cases frequently occur in rheumatic subjects and are usually due to inflammation in the orbital portion of the nerve, and the prognosis is good.

The most marked symptom in cases of acute paralysis of ths eye muscles is diplopia, which is very annoying. In squint due to hypermetropia there is no complaint of dijjlopia, possibly because it usually develops in childhood ; but in paralytic squint, which oftener occurs in ^ults, diplopia is the most common symptom complained of.

There is one point in regard to this case which I have neglected to mention : this patient has well advanced atrophy of both optic nerves. The discs are decidedly white and the vision greatly impaired, in one eye being only ^^, in the other ^^. The treatment has been the administration of large doses of potassium iodide, and I think there is some slight improvement, but an operation will probably be necessary. It will not be sufficient to perform a tenotomy of the internal recti, but it will be necessary to combine with this an advancement of the externi.

Dr. Thomas. — There is the history of a decided facial paralysis ten years ago, and at present there is contracture of the muscles of the right side of the face. We know that in cases of severe facial paralysis there is very generally developed a secondary contracture of the paralyzed muscles. After a hurried examination it seems to me that upon voluntary effort the patient does move the left side of his face more than the right. An electrical examination would determine the point, but even now I am strongly inclined to the belief that it was the right side that was paralyzed. If this is found to be the case we can easily understand how a single lesion could cause a paralysis of the right 6th and 7th nerves; in fact there are many such cases reported. But on the other hand it is difficult to imagine a lesion involving the right 6th and the left 7th nerves.

Dr. OsLER. — One other point is of interest in this case : whether this may not be a facial paralysis and external rectus paralysis occurring with the secondary symptoms of syphilis, and whether his present paralysis and atrophy may not be the signs of tabes. The fact that he has the knee jerk is somewhat against this, but the persistence of these ocular paralyses is occasionally seen as an initial symptom of tabes.


Dr. Theobald. — I would only say in closing that the knee jerk was examined and found to be up to the usual normal standard. The suggestion of Dr. Osier is well worth considering, whether we are dealing with a greatly different state of affairs now from what originally existed ; whether this present paralysis is a tertiary, while the other was a secondary symptom.

I will be glad to have the patient come to Dr. Thomas's clinic and have the electrical examination made. My diagnosis of left facial paralysis was made simply on the drawing of the face to the right side and the fact that there is a certain blank expression about the left side of the face.

Exhibition of Opiithalmological Cases.— Dr. R. L. Randolph. Bilateral Dacryo-adenitis.

Dr. Randolph reported a case of bilateral dacryo-adenitis (mumps of the lachrymal glands, Hirschberg) in a negro woman thirty-nine years old. He spoke of the case as being one of the few cases reported in this country, the disease being very rare. Both lachrymal glands were so swollen that the upper lids had been pressed down at the outer canthus to such an extent as to hide the outer half of the eyeball. In the case of the left eye the hypertrophied gland had pressed the eyeball inward and slightly downward. The tumors were exceedingly painful to pressure, but at other times she suffered no local pain, the pain then being refeiTed to the sides of the face. There was nothing in her history that would give one a clue as to the origin of her trouble. She was put on small doses of bichloride of mercury and ten grains of iodide of potash three times daily, and frequent hot applications were made to the tumors, and after a month there was a noticeable diminution in their size. Six months after the beginning of the trouble there remained only a slight enlargement of the left


The trouble having passed away it is no longer interesting to show the patient, so she is not here this evening. It is the first case reported in the city, and certainly less than a dozen have been reported in this country.

Dr. Thayer. — In connection with Dr. Randolph's case I should like to say a word with regard to a somewhat similar instance which has been under our observation in the hospital. In 1894 a little girl, 10 years of age, was admitted to the hospital with bilateral hard enlargement of the lachrymal, parotid and salivary glands, for which we were unable to find any cause. The lachrymal glands were to be felt on either side as two small hard shot-like bodies. The child stayed in the wards for many months, and while there developed an ozoena and caries of the nasal bones which was clearly syphilitic in nature. Under treatment with mercury and iodide of potassium the glandular swellings slowly but completely disappeared. While in the hospital, however, some of the cervical and lymphatic glands became enlarged and remained so after treatment with mercury and iodide of potassium, and the child has since showed evidences of a tuberculous peritonitis. The enlargement of the lachrymal glands was very striking, though never as marked as in Dr. Randolph's case; it has entirely disappeared.


June, 1897.]

133


Operations for Cataract.

The other cases which I have to exhibit are some of the cataract cases upon which I have operated in this Hospital during the last summer. There are 12 or 13 here to-night. Some of them have interesting histories. One, an old man, 88 years of age, was operated upon early in September, and on the night of the operation had an attack of acute mania. He tore the bandage off several times, and finally had to be tied in bed, but in spite of that has a good result. When we consider how slight a disturbance may sometimes cause the operation to go to the bad this is rather a remarkable recovery. The bandage was disarranged at least three times. After the atropia was withdrawn he regained his senses and was rational for three days. One night after that he had another attack, jumped from his window, scaled the fence and was making his way homeward when found. Strange to say it had no effect upon the ultimate result.

The next case is a rare one. I operated for cataract early in June and the anterior chamber remained open after the operation for 17 days. At the last meeting of the American Ophthalmological Society I asked several of the members what was the longest time they had ever seen the anterior chamber remain open, and the longest period given in reply was 11 days. Four weeks after the operation when this patient left the hospital he had i^ vision, which is very good practical vision.

Very frequently in cataracts there seems to be a stage where they make no progress toward maturity. That was the case with this woman, aged 63, who, while having sight enough to get about, was unable to do work. Here I performed the maturing operation. This consists in doing an iridectomy and practicing massage upon the lens through the cornea. The cataract was ripened, then exti'acted. With the exception of that case I have performed the simple extraction, and in several of them there is no objective evidence of an operation having been performed.

Demonstration of Florence's Iodine Test for Seminal Stains.

— Dr. Lewellys F. Barker.

Professor Florence of Lyon has recently published in the Archiv d'Anthropologie a very delicate test for human seminal stains. He uses a mixture of iodine, iodide of potash and water not unlike the ordinary Lugol's solution.

To apply the test, if the seminal stain be upon linen, a small piece of the stained fabric is moistened with water, placed upon a glass slide and a drop of the reagent added beneath the cover-glass. If the stain be due to semen a very distinct precipitate of crystals results. The form of crystals is not unlike that of ordinary haemin.

We have used the test in the course in normal histology and find it very easy to apply and extremely delicate. The reaction is not yielded by blood, saliva, nasal mucus, vaginal mucus, urethral mucus, nor by the semen of other animals. I have placed under the microscope one specimen in which the seminal reaction is apparent, and under the other microscopes a number of other fluids mentioned in which no reaction has taken place. Urine sometimes throws down yellow-brown globules, but as far as we have been able to make tests, defi


nite crystals, likely to be confused with those of the reaction, are never deposited. Whether or not urine containing semen would yield the reaction I have not yet had the opportunity of testing; but inasmuch as minute quantities of the seminal fluid on linen will afford the reaction, it is very probable that urine containing this substance would also yield it. Some alkaloids are capable of yielding similar precipitates, a fact which must be borne in mind in medico-legal cases. Just what portion of the semen is concerned in the reaction has not yet been made out; it would be easy to ascertain this by testing the individual constituents of the seminal fluid obtained, say from the vas deferens, vesiculiE seminales, prostate and Cowper's glands at autopsy. Urethral mucus, as will be seen under one of the microscopes, does not yield the reaction. In case no single one of these constituents afforded the reaction, the latter must be due to some substance produced on their admixture.


NOTES ON NEW BOOKS.


The Practice of Medicine. A Text-book for Practitioners and Students, with special reference to Diagnosis and Treatment. By Jambs Tyson, M. D., Professor of Clinical Medicine in the Unisity of Pennsylvania, etc. Illustrated. {Philadelphia: P. Blakision, Sondb Co., 1896.)

This is in every respect an admirable boolt. The author's statement that it tias taken several years of labor is borne out by the careful and thorouglily conscientious way in which the suliject has been treated. It is a work of nearly 1200 pages, larger than the recent text-books issued in this country, containing on the whole rather more mattereven than Flint's, which is a very closely printed book.

Ttie author's method of dealing with a subject is well illustrated in the consideration of the important subject of myxoedema. Following the definition — and by the way the text-book is quite strong in clear, practical paragraphs defining diseases— the history of our knowledge of the affection is considered in nearly threefourths of a page. Dr. Tyson has in nearly every section dealt in a most instructive way with the historical development of the knowledge of the different diseases, and in myxoedema it is of course particularly interesting. I do not think that the statement is altogether clear about the dispute between Reverdin and Kocher as to the discovery of operative myxcedema. Unquestionably Reverdin published the first note in October, 1882, but he did not at that time appreciate fully the remarkable character of the changes following thyroidectomy. Kocher distinctly states that in the autumn of 1882, in Geneva, he spoke to Professor Reverdin of the remarkable sequences of the operation, and that Reverdin six days later read a paper on the subject. In Kocher's paper, which appeared in the spring of 1883, the description of operative myxoedema as we know it now, and which he called cachexia strumipriva, was fully and clearly drawn, and he certainly appreciated at that time, as Reverdin did not, the serious effects which might follow total extirpation. In the succeeding paper by the brothers Reverdin they recognized the condition as identical with myxoedema and called it myxoedeme operatoire. Three forms of myxoedema are recognized : pure myxoedema, myxcedema associated with congenital or sporadic cretinism, and operative myxcedema. There is in addition a full description of cretinism. On the subject of exophthalmic goitre, though the disease is placed under diseases of the thyroid gland, Dr. Tyson states that the neurotic nature of the disease is now generally admitted. He holds that the sympathetic neurosis theory


explains the symptoms rather more satisfactorily than any other. His practice is better than his precept in this respect, since he places the disease where it probably belongs, among those of the tliyroid gland. We are glad to notice that he insists upon the priority of the description by Graves. Of this, of course, there can be no doubt, though Parry and others published individual cases. Graves' clinical lecture in 1835 gave the first good description of the affection.

Naturally in a new textbook one turns to certain of the diseases about which there is still a good deal of difference of opinion. Appendicitis receives a very thorough and satisfactory treatment. There is no work in English which gives so good an account of the history of the affection. We are glad to see that Dr. Tyson does not consider it necessary to speak of a typhlitis, stercoral or otherwise. It is satisfactory to see that the name even does not occur in the index. lie describes catarrhal, ulcerative and interstitial forms of appendicitis. The clinical description of the different varieties is admirable. On the all-important matter of treatment the author takes rather advanced ground, stating that "the diagnosis being established, operative treatment should be recommended, except in those cases where the disease is so far advanced as to make it unlikely that the patient will be saved by operation." He thinks that the operation after the first attack is safer than during the first attack. On the much debated point of purgatives he leaves the matter to the circumstances of the case and the good judgment of the attendant, as the results may be either very happy or very mischievous. He believes that if there is doubt it is best not to purge.

The article on typhoid fever, with which the book opens, is in every way worthy of the great importance of the subject. The author is a strong believer in the use of the cold bath, and on the question of treatment he everywhere displays sound judgment.

We have said enough to indicate the importance of the work, its thoroughness, and its reliability in all practical details. The publishers are to be congratulated on the appearance of the volume. It is one of the handsomest works issued of late years in this country, and the type and paper are very much above the average. Altogether Tyson's Practice forms a very welcome addition to our textbooks, and we predict for it a most successful career.

An American Text-book of Applied Therapeutics, for the use of Practitioners and Students. Edited by J. C. Wilson, M. D., assisted by Augustcs A. Eshnek, M. D. Pp. 1-1326. {Philadelphia: W. B. Saunders, 1896.)

Since the main object of medical studies must always be the formulation of methods for the prevention and cure or alleviation of disease, it necessarily results that laboratory researches and clinical observations must ultimately be valued in proportion as they have brought us nearer to the attainment of these aims — in other words, according to the advances which have been derived from them in the establishment of a rational system of therapeutics. The world at large is apt to look at results rather than methods, and the busy practitioner may justly demand that the previous studies and experience of others should be presented to him in aconcrete form. For these reasons the status of medicine at any particular period will, to a great extent, be gauged by the therapeutic measures which prevail at that time, and of which the textbooks dealing with the subject are the exponents.

Graduates of twenty years ago will probably remember a time in the first few years of their practice during which they were tempted to become adherents of the doctrines of therapeutic nihilism. They had gone forth armed, they had been taught and for a time had firmly believed, with agents with which they could infallibly combat each and every untoward symptom. Is it to be wondered at that many of them in a short time exchanged their early therapeutic optimism for a hopeless therapeutic pessimism? Could they not justly reproach for this the faulty teaching which had been accorded to them?


Medicine is still to a great extent an empirical art, but although we can hardly hope that it will ever be numbered among the exact sciences, there are signs which indicate that by slow degrees we are attaining to a therapeusis which may always be at least rational.

The book before us shows a decided advance, not only because it registers real progress made in our knowledge of disease processes and in our methods of treatment, but because it shows that the difficult subject of therapeutics is now being attacked in a frank and true scientific spirit. The writers have been chosen from among men who have brought to bear upon the subjects allotted to them not not only the results of a profound study of the existing literature, but also those which can be obtained only by a wide personal experience. They are not mere compilers; they know whereof they speak. If not all of them have added much that is new, they have at least accepted the dicta of others only after a painstaking proving of their statements. They have chosen the middle ground, and while confident that much can be accomplished by the use of the various therapeutic measures which they recommend, they do not by the employment of specious generalities attempt to conceal those points upon which our present knowledge is still defective. They hold a strong position midway between therapeutic optimism and therapeutic nihilism. Above all and first of all they preach the doctrine of prophylaxis.

In many of the articles a short account of the more prominent manifestations of the disease underdiscussion will be found, which, although adding considerably to the bulk of the book, will assist the reader materially in better appreciating the treatment recommended later. It is impossible to speak here in detail of all or of any of the various contributions. In his article on tuberculosis, Whittaker summarizes our present knowledge upon prophylaxis in general, hygiene and climatology, and has ably marshaled all the recent experience, upon which he formulates a treatment which, if it contains little that is really new, is perhaps the best at hand. If his conclusions as to the advantages to be obtained by the use of tuberculin are not in accordance with those of other authors, his results certainly deserve the most respectful consideration. Tyson's article upon the diseases of the kidney is brief but admirably comprehensive. In speaking of typhoid fever, Wilson, after a careful consideration of other methods, not only endorses the cold bath treatment but repudiates the notion that it is cruel. This latter view will certainly not be conceded by many even of the most enthusiastic supporters of the procedure. Serum therapy receives a full share of attention, and the subject has been treated, by the writers upon the conditions for which it has been advised, with a full appreciation of its importance. Whatever may be the opinion with respect to Laveran's vie w as to the identity of the parasite for the different forms of malarial fever, the careful and precise treatment which he lays down will not easily be improved upon.

Another point to be noted is the comparative simplicity of the prescriptions which are given ; we are grateful for further evidence of the decline of polypharmacy. It would seem that we are beginning to appreciate Huxham's advice, " The physician should select a few (drugs) of the most effectual forhis useof each sortand stick to them and not run into an immense farrago which some are so fond of." Many of the illustrations are good, but not a few are superfluous. As might be expected, the book lays no claim to perfection. The student who looks to it for infallible remedies for every disease will naturally be disappointed ; the man of more moderate demands will find in it much that will help him in his daily work, and much that will stimulate him to the observation of disease processes and of the way in which they may best be met.

Frank R. Smith.

Die Fiirbetechnik desNervensystems. By Dr. B. Poll.^ck. {Pub lishcd by 8. Karger, Berlin, 1897.) Pp. 1-130.

This little book will be welcomed by neuro-histologists everywhere. It gives briefly the important steps in all the more impor


June, 1897.]

135


tant methods used in microscopic examination of the nervous system, including those of recent date. In the first section the technique of cutting up the brain at autopsy is described, togetlier with the methods for preserving the brain whole and forreproduc. ing plastically the specimens found at autopsy. In section two the general technique of hardening, staining, emliedding and section. ing is discussed. The methods of making serial sections, including the recent method of Flatau for making serial longitudinal sections of the whole spinal cord, are considered. We are glad to find mention made in section three of the work of Donaldson and others concerning the alteration in weight of the brain and cord after pri-servation in different hardening fluids. Too little attention has been paid to such alterations in previous books on technique. Apparatus for drawing and photography are described in section four. In the next section the methods of staining and impregnation are taken up. The various ways of demonstrating nerve cells and their axones and myelin sheaths are outlined. Golgi's method, Ehrlich's metliod and the new stains for neuroglia have been carefully considered. Nissl's method is given, and also Held's modification of it. The differentiation with alum solution is simple, easy to manage, very inexpensive, and yields in the reviewer's experience results fully as satisfactory as those afforded by the method with anilin oil and alcohol. In the sixth section certain general points to be borne in mind in the examination of normal and pathological cases are emphasized. It is particularly gratifying to find epitomized at the end of this section the routine methods employed in Waldeyer's laboratory for the study of the central and peripheral nervous systems. A brief bibliography is appended as well as an index. The book costs only two marks, and will probably find its way into many laboratories, where it will prove a safe and convenient guide. L. F. B.

Arbeiten aus dem Institut fiir Anatomie und Physiologic des Centralnervensystems an der Wiener Universitiit. Herausgegeben von Professor Dr. Heinrich Obeesteiner. Y. Heft, mit 5 Tafeln und 46 Abbildungen im Texte. (Leipzig und Wien : Franz Deuticke, 1897.)

The most recent number of the fasciculi which are appearing at intervals from Obersteiner's laboratory is fully up to the general standard set by the preceding numbers. Itcontains seven articles, one of which, on the innervation of the blood-vessels of the brain, is by Obersteiner himself. In this article Obersteiner discusses the work of previous investigators and describes and pictures a small artery of the pia mater stained with gold, in which he brings the direct anatomical proof that the finer intra-cranial vessels, at least within the pia mater, possess their own nerves. He refers briefly to the physiological and pathological significance of such innervation.

Schlagenhaufer contributes an article on the course of the fibres in the optic paths, in which is discussed also the tabetic atrophy of the optic nerve. He believes that there exists sometimes, at any rate, a compact uncrossed optic bundle which, however, forms only a part of the uncrossed bundle, and probably corresponds to the inferior (external) fibres. The direction of the course of this bundle gives, he thinks, in all probability, the anatomical course of the uncrossed bundle. The question of the total or partial crossing of the optic nerves in man must, therefore, be regarded as decided in favor of the latter through anatomical investigation. He thinks that by means of a scheme constructed accordingly it is possible to explain all the hemianopsias. As regards Gudden's commissure, he makes out that a part of the fibres stream into the ansa lenticularis to become connected with both lenticular nuclei. Some of the fibres run in the peduncle of the hypophysis. In front of Meynert's commissure in the upper anterior part of the chiasm there is a small system of fibres which remains intact when the optic nerves and chiasm atrophy. He thinks it possible that the tabetic atrophy of the optic nerves may be due to pressure at the foramen opticum.


F. Rezek describes and pictures a primary polymorphous sarcoma of the brain.

Pfiegler and Pilcz contribute along article entitled "Beitriige zur Lehre von der Mikrocephalie." They describe twelve cases of their own, with consideration of no less than 365 bibliographic references.

An interesting study of the histology of the ganglion cells of the horse in normal conditions and after arsenic poisoning is given by H. Dexler. Two beautiful plates accompany his article. The same writer publishes also a short note on the course of the fibres in the optic chiasm of the horse.

Julius Zappert, in an article on degenerations in the spinal cord and medulla oblongata in the child, embodies the results of his studies on the spinal cord and medulla of children who have died during the first three years of life. He has used Marchi's method and describes his findings with especial reference to the changes in the various nerve roots. L. F. B.


BOOKS RECEIVED.


Tuberculosis. By William Osier, M. D. 8vo. 1897. Reprinted from " Loomis' System of the Practice of Medicine," New York and Philadelphia, I, pp. 731-848.

Diseases of the Ear, Nose and Throat and their Accessory Camties. A condensed text-book. By Seth Scott Bishop, M. D., LL. D. 1897. 8vo, -196 pp. The F. A. Davis Co., Philadelphia, New York, Chicago.

Annual Report of the Trustees of the State Hospital for the Insane, at Warren, Pennsylvania, for the year ending No-oember 30, 1896, to the Board of Commissioners of Public Charities. 1897. 120 pp. Herald Printing and Publishing Co., Erie, Pa.

Medical and Surgical Report of the Presbyterian Hospital in the City of New York. Edited by A. J. McCosh, M. D., and W. B. James, M. D. Vol. II, Jan., 1897. 8vo, 272 pp. Trow Directory Printing and Bookbinding Co., New York.

Ouy's Hospital Reports. Edited by E. C. Perry, M. A., M. D., and W. H. A. Jacobson, M. A., M. Ch. Vol. LI, being Vol. XXXVI of the third series. 1895. 8vo, 272 pp. J. & A. Churchill, London.

Guy's Hospital Reports. Edited by E. C. Perry, M. A., M.D. , and W. H. A. Jacobson, M. A., M.Ch. Vol. LII, being Vol. XXXVII of the .third series. 8vo. 1896. 230 pp. J. & A. Churchill, London.

Lectures on Pharmacology for Practitioners and Students. By Dr. C. Binz. Translated from the second German edition by Peter AV. Latham, M. A., M.D. Vol. II, 1897. 451 pp. 8vo. New Sydenham Society, London.

A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in Photolithochromes from Models in the Museum of the St. Louis Hospital, Paris. With explanatory woodcuts and text. By E. Besnier, A. Founier, et al. Edited and annotated by J. J. Pringle, M.B., F. R. C. P. Fol. 1897. Part IX. W. B. Saunders, Philadelphia.

Transactions of the Indiana State Medical Society, 1895. Forty-sixth annual session held in Indianapolis, Ind., June 6th and 7th, 1895. Svo, 534 pp. Carlon & Hollenbeck, Indianapolis.

Hysteria and Certain Allied Conditions. By George J. Preston, M. D. 1897. Svo, 298 pp. P. Blakiston, Son & Co., Philadelphia.

DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL

Bv JOHN s. Billings, m. D., ll. D.

Contaiulng 56 large quarto plates, phototypes, and litliographa, with views, plans and detail drawings of all the buildings , and their Interior arrangements— also wood-cuts of apparatus and fixtures; also 116 pages of letter-press describing the plans followed In the construction, and giving full details of heating-apparatus, ventilation, sewerage and plumbing. Price, bound in cloth, $7.60.


136

rXo. 75.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report In Pathology.

The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;

Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the

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

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

Mall, M. D.

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

T. C. Gilchrist, M. D., and Emmet Rixford, M. D. A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of

Protozoa, and the Blastomyces found in the preceding Cases, with the so-called

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

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

T. C. Gilchrist, M. D.

Report In Pathology. An Experimental Study of the Thyroid Gland of Dogs, with especial consideration

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


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

Report in Medicine.

On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with

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

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

Report in Gynecology. The Gynecological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1889, to March S, 1890. By Howard

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

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

M. D. The GonococcuB in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Pentoneum;

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

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

A. Kelly, M. D., and Albert A. Ghriskey, M. D. Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (3hecking

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

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

Howard A. Kelly, M. D.

Report in Surgery, I. The Treatment of Wounds with Especial Reference to the Value of the Blood Clot

in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Neurology, 1. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By Adqdst Hoch, M. D. A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By

Henry M. Thomas, M. D.

Report in Pathology, I. Amffibic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleub, M. D.


Volume III. 766 pages, with 69 plates and figures.

Report in Pathology.

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

Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D. Report in Pathology.

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

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

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

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

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

Report In Gynecology.

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

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

Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavelt, M. D.


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

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

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

Traumatic Atresia of the Vagina with Hsmatokolpos and Bxmatometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

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

Report in Neurology. Dementia Paralj-tica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of .Whs- musculu^; The Intrinsic Nerves of the ThjToid <31and of the Dog; The Nerve Elements of the Pituitarj' Gland. By Henry J. Berkley, M. D.

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

Report in Gynecology. Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Cullen, M. B. Report in Pathology. Deciduoma Malignura. By J. Whitridqe Williams, M. D.


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

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

Studies in Typhoid Feyer. By William Osler, M. D., n-ith additional papers by G. Bluher, M. D., Simok Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.


Volume VI. About 500 pages, many illustrations.

Report in Neurology.

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

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

Report in Pathology.

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

Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of Ovum and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. WiLKlNS, M. D.

Adeno-Myoma Uteri Diffusum Benignmn. By Thomas S. CJullen, M. B.

A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. Bj William D. Booker, M. D.

The Pathology of Toxalbumin Intoxications. By Simon Flbxnieb, M. D.

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Vol. VIII -No. 76.]


BALTIMORE. JULY, 1897.


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PAGE

Studies on the Lesions induced by the Action of certain Poisons on the Cortical Nerve Cell. Study VII : Poisoning with Preparations of the Thyroid Gland. By Henry J Berkley, M.D., Five Successful Cases of General Suppurative Peritonitis treat ed hy a New Method. By J. M. T. Finney, M. D.,

An Experimental Study of the Treatment of Perforative Peri'


137


141


PAGE.

By Arthur


tonitis in Dogs by a New Method of Operation

W. Elting and Wm. J. Calvert, ......

Squamous Epithelioma and Epithelial Hyperplasia in Sinuses and Bone following Osteomyelitis. By S. M. Cone, M. D., ■

On the Blood-Pressure-Raising Constituent of the Sui)rarenal Capsule. By John J. Abel, M. D., and Albert C. Crawford, M. D.,

Notes on New Books,


151

158


STUDIES ON THE LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE

CORTICAL NERVE CELL

STUDY vn.

POISONING WITH PREPARATIONS OF THE THYROID GLAND. By Henry J. Berkley, M. D., Associite in Neuro-Patholoyii, The Johns Hopkins Universily.


The favorable side of the administration of the thyroid extracts is shown in the very numerous articles in current medical literature published both in this country and in Europe. Comparatively few of these papers treat of other than the bare clinical results from the most auspicious standpoint, and it is quite safe to say, after a review of some of them, that the results would have been as brilliant had no medicament been administered.

It is nevertheless true that the extract, when administered to either man or the lower animals, will occasion very grave symptoms of a toxasmic nature, symptoms that involve the cerebral, the vaso-motor and digestive functions, and perhaps also the normal action of those ductless glands that throw into the circulation a potent though unknown substance ; and when this administration is pushed even to a moderate degree death is almost invariably the result, either through the advent of convulsions, or extensive loss of weight with indications of profound poisoning of the central nervous system, shown by the change in the heart's action and in the respiratory movements.

A medicament having these qualities cannot, therefore, be administered with impunity to every sane or insane patient,


and it was therefore directly for the purpose of ascertaining the toxicity of one of the best known varieties of the thyroid extract that the following series of experiments was undertaken.

The first portion of the investigation was made upon eight patients at the City Asylum, who, with one exception (No. 1), had either passed or were about to pass the limit of time in which recovery could be confidently expected. To these patients the thyroid tablets, each pill representing five grains of the fresh sheep's gland, were administered, the dosage beginning always with a single pill daily for a period of three days, then, after a certain tolerance had been established the dosage was increased to two tablets daily, and, unless the symptoms induced became grave, the number of pills was increased to three daily, the length of continuance depending upon the results.

Loss of weight always attended the administration of the tablets, as did disturbances of the circulation in the form of tachycardia and enfeeblement of the cardiac action. Digestive disturbances and slight pyrexia were present in more than half the cases. A peculiar odorous sweating was noticed with two patients, and increase of the cutaneous transpiration in


138

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all. Irritability and a greater or less degree of mental and motor excitement were remarked in all cases, no matter how depressed or demented they had been previous to the administrations. Two jjatients became frenzied, and of these one died before the excitement had subsided, the immediate cause of the exitus being an acute disseminated tuberculosis. A peculiar gelatinous feel to the integument of the forehead and cheeks, precisely similar to that in myxcedema, combined with puflBness of the skin about the malar prominences, was very noticeable in those cases in which the administration of the extract was continued for any length of time. Urinary examinations were made several times before the commencement of the administration of the thyroid, and several times during its administration, but only for the purpose of noting the presence or absence of albumen and sugar. In the abstracts this analysis is mentioned only when there is evidence of the presence of these abnormal constituents.

Abstracts of Histories of Insane Patients Treated WITH Thyroid Extract.

I. Adolescent insanity. Martha H., set. 17. Sister insane. Admitted with melancholic symptoms accompanied by considerable mental confusion. Occasionally had to be fed with stomach tube. Could not speak, and it was imjoossible to determine what delusions were present. After being several weeks in the Asylum she partly recovered, and then relapsed, and there appeared to be considerable mental reduction after the lapse of several months. Then began to brighten, and take more interest in her surroundings, also to gain flesh. The thyroid gland was, apparently, small on palpation. Weight at beginning of the thyroid administration 115 pounds. A single thyroid tablet was administered for ten consecutive days, at the end of which time there was slight febrile reaction, with a pulse ranging from 100 to 110 (normal 78). The mental change was very slight, patient exhibiting some irritability, but nothing more. The weight is now 109 pounds.

On the fourteenth day, the thyroid being continued, the first signs of improvement were noticed. Patient became brighter, ate food without compulsion, and on the twentieth day volunteered to do work about the ward and conversed rationally. The thyroid extract was discontinued on the twenty-second day, and patient was discharged one week later, six months after her admission, and did not relapse.

II. Melancholia folloioed hij deep dementia. Olivia P., ist. 37. Education fair. No heredity. Married. Nutrition poor. Thyroid fairly well developed. Weight 100 pounds. Oil admission refused to speak, and would not take food.

Patient was deeply demented, and quiet for several months before the thyroid treatment was begun. She lost flesh very rapidly, and on the eleventh day of the treatment showed pronounced mental and motor excitement. Slight febrile reaction, accompanied by a pulse rate of 120 beats. On the twelfth day she passed into a state of frenzy, the motor excitement being more pronounced than the mental symptoms. The thyroid extract was now discontinued, but the excitement kept up, despite numerous attempts, with narcotics, baths, and systematic exercise, to allay it, for seven weeks, at the end of which time she died with the clinical


evidences of acute miliary tuberculosis. An autopsy was not permitted.

III. Beginning dementia. Frank G., aet. 20, well educated, was admitted to the asylum suffering from an attack of acute mania. There he improved, but was taken out too soon, relapsed, was readmitted, and then gradually demented. Thyroid of normal size. Is good tempered. Weight at beginning of thyroid administration 125 pounds. On the seventh day of the treatment became quite irritable and impatient. By the fifteenth day he was so quarrelsome that it was necessary to restrain him. During these 15 days he lost five pounds, and there was considerable tachycardia and sweating. The myxoedematous symptoms were not so pronounced as in some of the other cases. The administration of the extract now being discontinued, he regained weight, became more quiet, and after the lapse of several weeks he was sent to his friends somewhat improved.

IV. Dementia. John B., fet. 31, admitted as a case of acute mania, and after a period of four months gradually demented, became quiet, and not at all irritable. Thyroid gland normal. Treatment was now begun, and within a week there was j^ronounced febrile reaction, with tachycardia and sweating. There is a marked difference in the asjject of the face, which now appears puffed and rounded, in contrast to the former rather emaciated appearance. The facial expression also became anxious, but there was no pronounced excitement. The treatment was continued thr»c weeks longer, without producing other change than an increase of the myxcedematons characteristics, and was then discontinued. From a mental standjwint, the course of the patient's disease was now rapidly downward, and he became absolutely demented and degraded.

V. Chronic vielancholia. Marcus Z., set. 30, Russian Jew, admitted to the asylum with alternating melancholia and mania. Thyroid normal. Much emaciated from chronic diarrhcea. Refused food at first. Has been quiet for some months, suffering from well marked delusions of persecution. Under enforced feeding became well nourished, but not less melancholic. Six months after admission treatment with thyroid extract begun. One tablet for ten days, two for four days, and three daily for two weeks longer. On the 11th day became much excited, complaining that his countrymen wished to kill him. There was slight febrile reaction and increase in the pulse rate to 120 (normal 75). The cheeks soon began to assume a marked puflBness, and on palpation had a jelly-like feel. No other phenomena were noticed, except that at the end of the month's treatment he had lost eight pounds, which he rapidly regained after it was discontinued. Then he also became quiet, and at the date of writing still remains an inmate of the institution, retaining his oldtime delusions.

VI. Dementia following puerperal melancholia. Katie S., ret, 35, was admitted in 1893, four weeks after confinement. Recovered in about six weeks, was taken home, and there relapsed and became permanently demented. Is untidy, mischievous, but never excited. Pulse rate normally 85 to 90. Thyroid normal. Was placed on thyroid extract, one pill, then two pills ilaily. lu second week marked febrile reaction.


July, 1897.]

139


pulse 120 to 1.30, very weak. There is considerable sweating. Facial puffiaess well marked. Has become very irritable, restless, aud difficalt to control. Thyroid extract discontinued after three weeks' administration, after which she gradually returned to her usual condition.

Vn. Deep dementia foIJoioing confimonal mclnnrlioliu. ilaggie E., set. 2.5, was admitted in December, 1893. Thyroid normal. When treatment with the thyroid extract was commenced was untidy and deeply demented. On the tenth day there was slight febrile reaction accompanied by slight motor excitement. These symptoms abated in the course of a few days, though the administration of the thyroid extract was continued, and, after three weeks, no improvement having been noticed, it was discontinued.

VIII. Imbecility with recurrent mania, followed by apparent dementia. C. B., aet. 21, admitted with second attack of excitement in December, 1895, and within a few weeks became apparently deeply demented. Thyroid gland very small. Administration of the extract was begun, and after a few days there was febrile reaction, considerable sweating, and a myxcedeniatous appearance of the integument of the face. The pulse rate altered from 72 to 110, and the patient lost weight rapidly. There were also considerable motor and mental excitement, with the febrile symptoms, all of which gi'adualiy abated, though the treatment was faithfully kept up for a considerably longer time. The patient has had several lucid intervals during the fall of 1896, but now seems completely demented.

The above experiment upon eight human subjects points out conclusively that the administration of even the very best and purest of the commercial desiccated thyroid tablets is not unattended by danger to the health and life of the patient, and that at times the administration of very limited amounts of the gland may be followed by symptoms not only difficult to control, but of very marked influence upon the future mental powers of the subject.*

These results obtained, we then decided to further pursue our experiments upon the lower animals, to determine the amount necessary per kilo of weight to cause death, the immediate cause of the dissolution, and the lesions, both macroscopic and microscopic, present at death, especially those pertaining to the cerebrum.

Through the kindness of Dr. Crawford of the Pharmacological Laboratory, who undertook the ordering of the administration to the animals, we obtained material from five mice and three guinea-pigs, to which the same desiccated sheep's thyroid tablets used in the first part of the investigation had been fed; also the cerebrum from one guinea-pig to which had been administered thyroid extract, and the cerebrum of a dog from which the thyroid had been extirpated about one year previous to its death, but in which, at the autopsy, supernumerary thyroids were discovered, though the animal during life had exhibited minor symptoms of a cachexia.

A portion of the material for microscopic examination was

  • I do not take into consideration the possible presence of putrefactive products in the tablets, as they were perfectly free from all

evidences of decomposition.


hardened in Muller's fluid for after-treatment according to the silver-phospho-molybdate formula, and another portion in alcohol, for staining with the anilines, hematoxylin, aud more particularly to examine into the lesions of the blood-vessels, both in the abdominal viscera and cerebrum.

The five mice were first fed with the tablets. All of them ate the pills readily to obtain the sugar coating them. For a few days there was no appreciable effect. Then they grew dull, the cheeks became puffy, there was trembling and increase of the frequency of the respiratory movements, and death rather suddenly.

Abstract of the Histories of the Thyroid Mice.

No. I. Administration of the tablets commenced Aug. 22, '96. One pill 32nd; three, 24th. Animal remains bright and eats other food ; 2.5th, two tablets. On 26th, it seems frightened and the face appears swollen ; on the 37th instant, it is still trembling very greatly, and no pill was given. On the 28th, it is very much brighter and the trembling has almost ceased. On the 29th, is bright, and feeding of the thyroid was again begun. Sept. 1st, three pills were fed, the animal eating nearly the whole quantity. The 2nd instant, the face is again swollen, and on the 3rd, refused to eat a portion of the tablets, and has become quite dull. On the 4th and .5th instant, the animal continued dull, trembling, aud looks weak and sick. On the 7th, the eyes are very bright, and there is slight emaciation. Five pills were given, but not all were eaten. On the 8th, only two pills were taken ; there is much trembling. Died during the night of the 9th instant, having eaten a portion of the tablets left in the cage.

The autopsy showed congestion of all the viscera, but without hemorrhage. The brain was soft.

No. II. On the 33nd August, cue pill administered, on the 23rd aud 24th, the same quantity, but little not being eaten. On the 35th, two pills were eaten, the animal still remaining bright. On the 36th, two tablets were eaten, and the face shows signs of swelling. On the 27th, the testes have become swollen, in addition to the face, but the appetite is still retained. On the 38th, the eyes are partly closed, and on the 29th, the animal is trembling, the legs are dragged, but it still takes care of its coat.

September 1st, the animal is dull, the face much swollen. Three pills were eaten. On the 3rd, is much brighter, sleeps well, but has not taken all the pills during the last two days. On the 5th instant, will hardly touch the sugar-coated tablet. On the 7th, the face is markedly swollen, the animal is dull, the hair less sleek, and the eyes almost closed. Kespi ration 134 per minute. Died in convulsions at 2.30 1*. M.

The autopsy was performed immediately. Besides some unimportant congestion of the abdominal viscera there were no ascertainable lesions.

No. III. Commenced feeding on 33ud August, but no symptoms were noticed uutil the 36th, when the face became slightly swollen and the animal declined to eat the pill. On the 28th, there is slight trembling. On the 30th, the trembling continues. On Sept. 3nd and 3rd, took daily three pills. On the 5th, is dull, tottering, very weak. On the 7th instant, the hair is rough, and it seems weak, hut eats the pills


140

[No. 76.


well. On the 8th, is trembling very much, but eats the pills. Died during night.

Autopsy showed congestion of the abdominal viscera. Brain rather soft.

No. IV. Feeding commenced on August 'Z2nd, but does not eat the tablet well, hardly averaging J of a pill daily. On the 26th, the animal is bright, but the face is slightly swollen. On the 29th, refused to eat pill, but remaiued dull until September 3nd, and thereafter refused to eat pill at all. On the 12th instant, had apparently fully recovered.

No. V. Administration commenced on the 22nd August, and the dried gland was all eaten. On the 26th instant, the face is swollen. On the 28th, there is much trembling, but three pills were eaten. On the 29th, would not eat pill, but on Sept. 1st ate four pills. On the 5th instant, is trembling considerably, but ate two pills. On 8th instant, was bright, though trembling. On morning of 9th instant, found dead in cage. The autopsy showed the usual congestion.

Abstract op the Histories of the Thyroid Ctuinea-Pigs.

No. I. Fed with thyroid extract, 20 mg. daily, from Oct. 21st until Oct. 30th, on which day it died. Weight at beginning of experiment, 620 grammes. The animal became dull and gradually emaciated. Weight at autopsy, 380 grammes. All intei-nal organs very much congested. The animal received a total of 180 mg. of extract.

No. II. Pig fed on the same desiccated thyroid as in the former experiments. Weight, 810 grammes. On Oct. 21st, one and a half pills administered; on 22nd, four pills; on the 23rd, the same quantity. The respiration had now reached 144 per minute. On the 24th, 2.5th and 26th, four tablets were fed daily, and during the night of the 26th, the animal died. At the autopsy the abdominal organs were found to be much congested. Weight, 620 grammes (loss 190 grammes). This animal received about seven grammes of the dried thyroid gland, or less than one per cent. (.864j of its bodily weight to produce a lethal effect.

No. III. Fed on desiccated thyroid tablets. Weight, 580 grammes. Oct. 21st, one pill ; on 22ud, three tablets ; on the 23rd instant, four; on the 24th, 25th and 26th, the same; on the 27th instant, six pills; on the 28th, four tablets; on the 29th, five ; on the 30th, five. The animal had been for several days very dull and had rapidly emaciated. The exitus took place on the morning of the 30th instant. At the autopsy the viscera were found to be much congested. The weight was 320 grammes. Loss of weight during the nine days of the experiment, 260 grammes. The animal received more than 2 per cent, of its weight in the dried gland to produce dissolution.

No. I\". The same thyroid preparation fed. Weight at beginning of the administration, 610 grammes. On Oct. 22ud, two tablets were fed to the animal ; on the 23rd, three ; on the 4th, four pills; on the 26th, six pills; on the 27th, four pills ; on the 28th, five pills. The pig has become very dull and does not take care of its fur. Died Oct. 30th. At the autopsy the animal weighed 370 grammes (loss, 240 grammes) and the viscera were much congested. This animal received 1.30 per cent, of its bodily weight of the gland to cause death.


No. V. Thyroid dog (Dr. Abel). Thyroid gland extirpated i)i loto in Oct. 1895 ; died one year later, after showing profound emaciation and a dermatitis suggestive of myxoedema. At the autopsy several parathyroid bodies the size of a small pea were discovered. This animal was fed for several mouths on thyroids and thyroid extracts, seemingly without benefit. The autopsy showed no demonstrable lesions.

The guinea-pig series may be looked upon as an example of the acute type of poisoning by the administration of thyroid gland, while the mice are of a more chronic order. It is impossible to estimate the exact percentage necessary to produce lethal results with the mice, for the reason that these small animals always left some crumbs of the tablets on the floor of their cages which it was not practicable to collect. The guinea-pigs on the other hand were fed with the entire pill without loss, and but in one case was less than about one per cent, of desiccated gland found to produce lethal results, the administration being distributed over five days.

The microscopic examination of the cerebra of the eight mice and guinea pigs showed, both with the silver phospliomolybdate, and aniline and hematoxylin stains, an absolutely normal condition of the nerve elements and neuroglia ; none of the varicose and atrophied dendrites, with loss of the gemmulffi, of the former studies being discovered. The corpora retain their angularity and sharp outlines, and the axons with their appendages, the collaterals, retaining their natural appearances. The sections stained with anilines and hematoxylin showed the normal appearances of the nucleus and nucleolus, and not even in the tunics of the blood-vessels, where pathological changes were most carefully sought for, could any demonstrable lesion be discovered.

The nearest approach to any pathological condition found was in the cerebrum of the dog that had had its thyroid gland extirpated a number of months before death, though even here the lesions were confined to a very few tumefied dendrites, a condition that was most probably caused by the long continued state of mal-nutrition into which the animal had fallen.

More particular attention was paid to the examination of the liver than to the other organs of the abdominal cavity, but here again we failed to find more than a turgescence of the blood-vessels, the liver cells retaining their natural characteristics.

It is obvious from these results that the death of the various animals was induced by an entirely different kind of intoxication than that causing the lesions of the nerve elements in riciu and alcohol tox£emias, and it is therefore a poison that does not induce degenerative alterations in the sheaths of the arteries, and the consequent disturbance of the nutritive supply, followed by pronounced changes in the neurons, dependent to a certain degree upon the intensity of the vascular lesions; but acts upon the general system in an entirely different manner, and is essentially more subtle in its effects upon the nerve tissues, corresponding more to the action of a group of chemical poisons that leave no trace of their effect after death upon the nerve cell, but during life inducing symptoms directly referable to the central nervous system. The tissue metabolism induced by the action of these poisons upon the nerve cell we can only at present conjecture.


July, 1897.]

141


FIVE SUCCESSFUL CASES OF GENERAL SUPPURATIVE PERITONITIS TREATED

BY A NEW METHOD.*

By J. M. T. Finney, M. D., Associate Professor of Surgery, The Johns Hopkins University.


Recovery following laparotomy for piiruleut peritonitis is nufortunately of sufficient rarity to excite interest whenever it occurs. My object in making this report to the Society is two-fold ; first, to record five successful cases of laparotomy for general suppurative peritonitis, all treated by the same method; and second, to describe briefly the method itself. The principle involved is not a new one; only in the manner of carrying it out is there any originality claimed.

Since the appearance in 1877 of the classical work of Wegner, and later that of Grawitz and others, it has been known that the healthy peritoneum is capable of disposing of a considerable amount of infectious material. J. G. Clark, in a recent article,f reviews the literature of the subject and gives the conclusions reached by the experimenters in this direction. All agree that the peritoneum is able under favorable conditions to take up a relatively large amount of infectious material and disjjose of it effectually. These observers were dealing with a more or less healthy peritoneum. On opening the abdomen of a patient suffering from general suppurative peritonitis, however, we have very different conditions with which to deal. The observations of Pawlowsky would indicate that the lymph channels leading from the peritoneal cavity are choked with infectious bacteria and inflammatory products in purulent peritonitis, and that thus the efficiency of the peritoneum would be greatly impaired. Our observations clinically seemed hardly to bear this out.

The question that suggested itself to our mind was this, whether or not the peritoneum, even under these most unfavorable conditions, still retained its absorptive power. It seemed to us, from our experience in operating upon such cases by the methods heretofore employed, that they were inadequate and did not remove a sufficient quantity of the exudate, but left the peritoneum little better off than before. With this idea in mind we devised a plan of treatment which, so far as we know, has not been employed elsewhere.

The steps of the operation are as follows : Make a sufficiently long incision to admit of easy access to all parts of the peritoneal cavity. Quickly withdraw the coils of small intestine from the peritoneal cavity, beginning with the worst coils first. Remove all, or as much as is necessary of the small intestine and place it outside the abdomen, covered with warm gauze or towels, thus practically disemboweling the patient for the time being Then thoroughly and systematically wipe out the peritoneal cavity with large pledgets of gauze wrung out of hot salt solution, paying particular attention to the pelvic portion. In some cases it may be well in addition to flush out the cavity with warm salt solution, but this is rarely necessary.


  • Read before the Medical and Chiriirgical Faculty of the State

of Maryland at its Annual Meeting in Baltimore, April 27, 1897. tBuUetin of the Johns Hopkins Hospital, April, 1897.


Next the small intestine should be systematically examined loop by loop while still outside the abdomen, and rendered macroscopically clean by wiping with gauze comjiresses wrung out of hot salt solution. It is necessary to wipe with considerable force at times, in order to remove adherent flakes of partly organized lymph. It should be done thoroughly and conscientiously, however, as upon this depends, we believe, in great measure, the success of the operation. It facilitates the cleansing process, as well as lessens the shock of the operation, if the wiping of the intestinal coils is carried on under a constant irrigation of warm salt solution.

After being cleansed macroscopically of all foreign material, pus, feces, lymph, etc., the intestine should be replaced in the abdomen — the worst or sutured coil being the last, or most superficial, in order that it may be the better drained by being packed about with gauze, if necessary.

The abdominal wound is then tightly closed, leaving just room enough between two sutures for the gauze drain. If there are any evidences of distension or pain the abdomen should have the Paquelin cautery thoroughly applied, and the bowels moved early by calomel in broken doses, followed by salts and a turpentine enema.

It is not claimed for this method that it will cure every case of general suppurative peritonitis. We believe, however, that a larger percentage of cases will recover after this method than any other with which we are familiar.

To insure success with any method it is essential that the operation should be performed within a few hours after the perforation has taken place. This is well brought out in the very interesting series of experiments on dogs made for me by Messrs. Elting and Calvert of the Johns Ilojikins Medical School, a report of which is subjoined.

Five cases have been operated upon by this method up to date, all of which have recovered. The first case, a case of perforating typhoid ulcer, has already been published,* and hence only a very brief abstract of the history will be given here.

Case I. — Male, aged 47, on about eighth day of mild attack of typhoid developed symptoms of perforation. Entered hosijital 14 hours later and was operated upon immediately. Peritoneum everywhere intensely congested, roughened and dull, and covered with flakes of plastic lymph. Considerable amount of turbid purulent fluid in abdominal cavity. Perforation in ileum about 14 inches from ileo-c;ecal valve. Fecal matter exuding from opening. Peritoneum cleansed in the manner described, gauze drainage. Recovery.

Case II. — G. W., male, aged 20. Saw patient for the lirst time, November 24, 1896, in consultation with Dr. Barringer in Charlottesville, Va. Patient gave history of four previous mild attacks of appendicitis, from which he liad promptly


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recovered. The night before he had eaten very heartily of apples. He was awakened about 3 a. m. with severe abdominal pain, cramp-like in character. At about 6 a. m. Dr. Barringer was called. He stated that at this time, three hours after the beginning of the attack, the patient presented the classical symptoms of peritonitis. When I saw him, 24 hours later, he had a temperature of 103° and a pulse of over 100, and from the first had suffered intense pain, which was controlled only by morphia hypodermically. He had had nausea and vomiting all day. Examination of the abdomen showed slight distension and great rigidity of the abdominal muscles. A slight tumefaction could be made out just to the inner side of the anterior superior spine of the ilium on the right side. Tenderness very marked. Immediate operation advised and agreed to. Incision 5 inches long in right linea semilunaris. On opening the peritoneal cavity the intestinal coils in the right lower quadrant of the abdomen were found to be congested and dull and covered with flakes of adherent lymph. Elsewhere the intestinal coils were found to be congested, but not otherwise much changed in appearance. The pus, of which there was perhaps 200 cc, was not walled off, but everywhere present in pockets between the adherent intestinal coils. The appendix was readily found. It was closely adherent to the pelvic brim on the one side and the csecum on the other. Its distal end was swollen and distended to the size of my thumb, perforated and gangrenous over an area about as large as a five-cent piece. Appendix was ligated and excised, and stump covered with peritoneal cuff and suture. The peritoneum was treated in the manner above described. Recovery.

Case III. — This patient was seen first on December 14, 1896. His history is in brief as follows : R. S., male, aged 33 years. Has had no previoiis similar attack. The night before he was taken sick he attended a banquet and ate heartily of solid indigestible food. He was attacked with severe abdominal pain about 3 o'clock the next afternoon. The pain at first was general and cramp-like ; nausea and light vomiting during the night. Morphia was necessary to relieve him. The next day he was unable to get up. Toward evening his physician gave him a cathartic, after which the bowels moved 8 or 10 times in quick succession. The next morning the pain had shifted to the right side and was severe. He received a hypodermic of morphia and got on fairly well until about 6 p. m., about 60 hours after the onset of the attack, when he was taken with a sudden severe pain in the lower right side of the abdomen. The pain for a time was excruciating at the base of the penis. Vesical and rectal tenesmus marked. When I saw him, about 4 hours later, in consultation with Dr. Reiche, he had a temperature of 105° and pulse of 150, profoundly collapsed. I have never seen such a hard and retracted abdomen as he presented. His condition appeared grave. Immediate operation advised and consented to.

Incision about 5 inches long, in right linea semilunaris. On opening abdomen the intestinal coils were fol^nd not to be distended but considerably congested. Beginning in the right lower quadrant there was found a considerable amount of thin pus containing flakes of lymph. This condition


extended over into the left side, down into the pelvis and up into the hypogastric region. The appendix was found to be gangrenous and perforated, and was removed. The toilet of the peritoneum was made in the manner already described, by disemboweling and vigorously scrubbing the parietal and visceral peritoneum until macroscopically clean. The intestinal coils were then replaced, a gauze drain inserted, and the abdominal wound closed except a small opening for the drain. He made an uninterrupted recovery.

Case IV. — M. B., boy, aged 10. Operation by Dr. J. C. Bloodgood, January 7, 1897. Five days before admission to the hospital was struck in the abdomen by the fist of a playmate. Next day felt severe pain in the right iliac region. This progressively increased for three days, when vomiting began and the pain became general. Two days later was brought to the hospital, when his condition was found to be in brief as follows: Temperature 101°, pulse 128 and fairly good. Slight abdominal distension. Muscular spasm marked on right side, present but less marked on the left. General abdominal tenderness. Under ether a definite tumefaction could be made out in the region of the right kidney. This proved to be an abscess behind the cjecum, extending from the iliac fossa below to the liver above, and in this cavity was the diseased appendix. There was foiind no walling off of this from the general peritoneal cavity. The entire pelvis was filled with yellow pus and all the intestinal coils were covered with flakes of fibrin. The stomach and spleen were not seen, but the surface of the liver looked exactly as if it had been covered with yellowish-white paint. The appendix was removed and the entire abdominal cavity thoroughly wiped out with gauze pledgets wrung out of salt solution. The exudate was scrubbed oS the livers surface, after which it looked simply congested. A gauze drain was inserted and the abdominal wound partly closed. He made an uninterrupted recovery. Cultures and cover-slips from the peritoneum showed colon bacillus and a coccus (not differentiated).

Case V. — R. S. P., aged 9, a schoolboy, entered the Johns Hopkins Hospital, Feb. 26, 1897. He had always been healthy except for measles, whooping cough and chicken-pox.

Family history good except remote cases of tuberculosis on both sides.

Just 48 hours before entering the hospital first complained of pain in abdomen. Three hours later had an attack of vomiting. Pain in abdomen was at first general, but in a few hours became localized in the right iliac and lumbar regions. After about 24 hours the pain lessened somewhat, and he sat up for a little while, but shortly after pain and vomiting returned with increased severity. A physician saw him after about 36 hours and gave him calomel in broken doses. His bowels moved twice. His condition did not improve, and by advice of his physician was brought to the hospital at 8 p. m., 48 hours after the onset of the attack. His condition then was as follows : Face flushed and anxious. Pulse 126 ; temp. 102.8°; resp. 56, and entirely thoracic; abdomen generally distended and tender, especially in right iliac fossa, where the tenderness is extreme and muscle spasm very marked. Pain is most marked here also. Liver and spleen not palpable. Liver dullness on right corresponds about to costal border.


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Percussion over right iliac and lumbar regions shows dullness; tympanitic over left side. Heart normal. Fine moist rales over bases of both lungs. No history of any similar previous attack.

Diagnosis. — Perforating appendicitis with beginning general peritonitis. Immediate laparotomy advised and agreed to. Ether. When thoroughly auassthetized, a small, hard mass, somewhat movable, could be felt just over the middle of Poupart's ligament. An incision about 15 cm. long was made parallel to and over the right linea semilunaris. After exposing the peritoneum and before opening it several bubbles of gas could be seen free in the peritoneal cavity. On opening the peritoneum a considerable amount of thin, cloudy seropuruleut fluid escaped and some gas. The mass felt before was found to be the appendix with a roll of omentum adherent. The intestines, especially the CEecum, were distended and congested, and covered with flakes of fresh fibrinous exudate. The congestion was most marked in the immediate vicinity of the appendix.

The appendix itself was superficially placed and freely movable, not walled off, but had a portion of omentum adherent. It was rather long, and curled upon itself, with a constriction at about the junction of its proximal and middle thirds. It contained two concretions, the larger of which was engaged tightly in the constriction, and from this point to the tip the appendix was gangrenous and softened. A


small perforation was present at the distal end of the dateseed like concretion. 'I'here had been an apparent attempt of the omentum to surround the entire gangrenous end of the ajjpendix, but it had not quite succeeded. The appendix together with the adherent omentum was ligated and excised.

Pelvis was found to be full of pus, and the peritoneum treated as above. He made a rapid and complete recovery.

Bacteriological examination of the peritoneal exudate showed the presence of streptococcus, staphylococcus, and bacillus coli communis.

NoTK. — Since reading the above article, I have operated upon one additional case of general peritonitis. The patient, a young woman, was in extremis at the time of the operation, which was undertaken simply as a forlorn hope. This operation was secondary to one performed several days previously by another surgeon for appendicular abscess. There was found present a general peritonitis, with much jjlastic lymph covering the greatly distended and adherent coils of intestine. There was very little purulent fluid in the abdomen. Her pulse was very rapiil and thready, and her temperature had risen several degrees. After the operation she was placed in a continuous bath, which added greatly to her comfort. The operation seemed to prolong her life, as she lived about thirtysix hours following it.


AN EXPERIMENTAL STUDY OF THE TREATxMENT OF PERFORATIVE

A NEW METHOD OF OPERATION.

By Arthur W. Elting and William J. Calvert.


'ERITONITIS IN DO(iS BY


[From the Anatomical Laboratory of the John) Hopkins University.']


At the suggestion of Dr. Finney and with the permission of Prof. Mall, the writers have undertaken an experimental study of perforative peritonitis in dogs, with especial reference to the method of treatment of this disease in human beings, introduced by Dr. Finney. Inasmuch as this is a preliminary report, the literature upon the subject will not be considered. It may be mentioned, however, that so- far as we know no previous work of this nature has been done from a surgical standpoint. It was decided to divide the series of experiments into four groups :

1. To scrub the intestines of a series of normal dogs and study the condition of the abdominal cavity at varying lengths of time after the operation, in order to determine the results of the mechanical irritation.

2. To determine how long it takes a perforative peritonitis to destroy life.

3. To perforate the intestines of a series of dogs, and after varying lengths of time to operate upon them again, closing in the perforation and cleansing the abdominal cavity and the surface of the intestine and mesentery, and after variable periods of time to kill the dogs which recovered, and study the condition of the abdominal cavity.


1. To perforate the intestines of a series of dogs, and after varying lengths of time to close in these perforations without removing from the abdominal cavity any of the exudate or foreign matter present, and to study the results of this operaation.

The dogs used in these experiments varied in weight between 18 and 53 pounds, most of them weighing about 25 pounds.

For the first group of experiments four dogs were used. By a median incision the abdomiiuxl cavity was opened, the intestine and parietal peritoneum were vigorously scrubbed with gauze sponges wrung out in warm normal salt solution, and kept covered with warm towels. After this treatment numerous minute hemorrhages caused by the scrubbing were noticed over the peritoneal surfaces, and the intestine presented an extremely congested appearance. It was then thoroughly irrigated with warm normal salt solution, which had a marked effect in reducing the congestion. The intestine was then replaced in the abdominal cavity and the wound closed. The process of scrubbing as performed by the operator and an assistant required from 8 to 12 minutes. In every case the dog appeared ill for about 24 hours after the operation, after


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which a marked improvement in the condition was noticeable. Usually by the end of the second day the animal seemed quite well.

Of these four dogs one was killed by an accident one day after the operation. Autopsy showed a very small amount of blood-tinged serum in the abdominal cavity. The surface of the intestine and parietal peritoneum presented numerous hemorrhagic areas caused by the scrubbing at the time of operation. The surface of the intestine was roughened, though not adherent. Cultures from the abdominal cavity were sterile.

A second dog was killed at the end of three days. At autopsy no appreciable amount of fluid was found in the abdominal cavity. Numerous fibrinous adhesions of the coils of intestine to each other, to the inner surface of the abdominal wound and to the omentum were found. The surface of the intestine was slightly roughened and presented numerous hemorrhagic areas. Similar areas were also seen upon the mesentery near its attachment to the intestine and upon the parietal peritoneum. These were likewise caused by the scrubbing at the time of operation. Cultures from the abdominal cavity were sterile.

A third dog which was in excellent health and condition was autopsied at the end of five weeks. No appreciable amount of fluid was found in the abdominal cavity. The appearance of the organs was everywhere normal except for numerous adhesions of coils of the intestine to each other, to the omentum, to the inner surface of the abdominal wound and to the stomach. These adhesions were of a firm character, being apparently composed of fully developed connective tissue. Cultures from the abdominal cavity were sterile. The fourth dog is still alive and will be autopsied later. From this group of experiments we conclude that mere mechanical irritation may cause the formation of extensive adhesions in the abdominal cavity of the dog, but these seem in no way to seriously interfere with the animal's general health.

For the second group of experiments four dogs were used. Because of its accessibility and the comparative ease with which the perforation could be closed, it was decided to perforate the CEBCum. By the use of a stick of caustic potash a perforation IJ cm. in diameter was made in the end of the caBcum, after which it was replaced in the abdominal cavity and the abdominal wound closed. These dogs showed symptoms of a severe peritonitis and died in from 12 to 20 hours from the time the perforation was produced. Autopsy showed practically the same pathological condition in each case. From 150 to 250 cc. of a turbid bloody fluid were found in the abdominal cavity. The surface of the intestine presented a marked hemorrhagic condition, both diffuse and petechial in character. The omentum, mesentery and parietal peritoneum presented a similar appearance. Flakes of reddish yellow lymph were deposited over the surface of the viscera, particularly in the region of the liver, diaphragm and lesser omentum. Slight fibrinous adhesions between the coils of intestine were noted. The mucosa of the intestine presented more or less of a hemorrhagic appearance, and in some of the cases bloody contents were found in the lumen of the gut. In short, the pathological condition was one of an intense hemorrhagic


peritonitis associated with a more or less extensive hemorrhagic enteritis. The bacteriology of each of these cases was carefully worked out and will be referred to later.

For the third group of experiments twelve dogs were used. The method of operation was as follows: An incision was made on the right side just outside the rectus muscle, the cajcum brought out and perforated in the same manner as practiced in the experiments already described. The cajcum was then replaced in the abdominal cavity and the abdominal wound closed. From five to seven hours after the perforation was produced these dogs were again opened by an incision in the median abdominal line. The perforated end of the crecum was brought out and the perforation closed by means of a row of mattress sutures, after the necrotic tissue at the seat of the opening had been resected. The abdominal cavity was then opened, and the intestines being lifted out, were kejit carefully covered with towels wet in warm normal salt solution. With gauze sponges wrung out in this solution the surface of the intestine and mesentery was carefully wiped till it appeared macroscopically clean. The abdominal cavity was next wiped out and rendered macroscopically clean, the intestine in the meantime being frequently irrigated with warm salt solution and kept covered with warm towels. After another thorough irrigation of the intestine with the warm salt solution it was replaced in the abdominal cavity and the wound closed in the usual manner. We cannot emphasize too strongl}', in doing these experiments, the advisability of thorough and constant irrigation of the intestine while it is outside the abdominal cavity, for in every case it seemed to reduce the congestion and in some cases the distension. The cleansing process required from 10 to 20 minutes according to the amount of exudate and foreign matter present.

Of these 12 dogs one was operated on at 5 hours after the perforation was produced, one at 5J hours, one at 5J hours, one at 6 hours, two at 6J hours, three at 6J hours, one at Gi hours, one at 7 hours, and one at 7} hours.

In every case the dog showed marked symptoms of peritonitis and evidences of pain. When lying down the legs were drawn toward the abdomen, which was held very tense. Any attemjjt to straighten out the legs seemed to cause great pain. In some cases the dog vomited a somewhat bile-stained fluid. In every case the abdominal cavity at the time of the second operation contained from 100 to 250 cc. of a turbid bloody fluid. The intestine, mesentery and omentum in nine of these cases presented a generalized hemorrhagic condition. In the remaining three cases this condition seemed more confined to the coils of intestine in the region of the ctecum, though all the peritoneal surfaces seemed more injected than normally. In nine of the cases more or less numerous flakes of yellowish red lymjih were found adherent to the gut, mesentery, greater and lesser omentum and other abdominal viscera. In eight of the cases the intestines seemed more or less distended when replaced in the abdominal cavity. Immediately after the cleansing of the surface of the intestine and the abdominal cavity the animals seemed to be much more comfortable, and in the Ciise of every dog which recovered there was a jirogressive improvement in the condition.

In no instance did a dog which recovered show signs of


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pain after the cleansing operation was performed, and usually in from two to three days the dog seemed to have recovered completely from the peritonitis, so far as external symptoms would indicate. Of course the abdominal wound made at the second operation was infected, and this in nearly every case failed to heal by first intention, which delayed somewhat the complete recovery of the animal. Of the 12 dogs thus treated three died without any apparent beneficial effect of the operation, death ensuing within 20 hours from the time the perforation was produced. These three dogs were operated upon 64, 7 and 7} hours respectively after the perforation was produced. A fourth dog operated upon GJ hours after the perforation died 30 hours later; the operation apparently prolonged its life about 20 hours. In three of these cases the peritonitis was the most severe we met with in our experimentation, and the dogs in a weak condition at the time of operation, which was done comparatively late in the disease. In each of these four cases the intense hemorrhagic peritonitis described under the second group of experiments was found at autopsy.

The remaining eight dogs were apparently cured of the peritonitis. Of these eight, one died from the protrusion of the intestine, due to the breaking down of the abdominal wound on the fifth day after the operation. In a second case death resulted on the eighth day from a localized peritonitis due to the extension of the suppurative process from the abdominal wall. A third dog which appeared quite well 2i days after the operation died rather suddenly on the fourth day from a perforation in another portion of the intestine which had come into contact with the caustic potash upon the end of the perforated ca3cnm at the time the first perforation was produced. A fourth dog appeared quite well at the end of twelve days after the operation, having an excellent appetite and seeming very lively. On the 13th day the dog seemed sick, and gradually grew worse till its death, on the 17th day after the perforation was produced. At autopsy small abscesses were found extending along each stitch in the abdominal wall down to the inner surface of the wound, where the intestines and omentum were adherent. No distinct sinus leading into the abdominal cavity could be demonstrated. The abdominal cavity contained about 100 cc. of yellow pus, collected for the most part in the pelvis and also extending up toward the diaphragm. The coils of intestine and omentum were firmly adherent in a mass in the upper part of the abdominal cavity. The intestine was also adherent to the liver and gall bladder. The parietal and visceral peritoneum were intensely hemorrhagic in places. No apparent walling off of the pus existed. An extension of the suppurative process along the stitches was supposed to have been the source of the infectious material. A fifth dog also apparently made a complete recovery, both wounds healing with the exception of a small sinus in one of them. This dog seemed quite well for nearly three weeks, when it became ill and died three weeks and two days from the time it was operated upon. At autopsy the abdominal cavity presented a perfectly normal appearance, with the exception of numerous adhesions of coils of the intestine to each other, to the omentum, liver and parietal peritoneum. These adhesions were not very firm in character. The


sinus mentioned above was found to lead to an abscess cavity about the size of a hen's egg, situated in the pelvis to the right of the uterus. This abscess was completely shuf off from the rest of the abdominal cavity and was the undoubted cause of death.

All of these dogs which died as a result of the suppurative process following the operation would probably have recovered could they have been subjected to the same treatment human beings would receive in a similar condition, for it must be remembered that it is practically impossible to drain or treat suppurating wounds in dogs. A sixth dog, apparently in the best of health and condition, was killed and autopsied four weeks after operation. Both wounds had healed with the exception of a small sinus leading to a stitch abscess, which, however, did not penetrate the abdominal wall. On examining the abdominal cavity the only abnormalities noted were seven or eight slight, loose adhesions between coils of the intestine, three or four loose adhesions of the omentum to the intestine, and some rather firm adhesions of intestine to the inner surface of the abdominal wound over an area 3x6 cm. The condition of the viscera seemed everywhere normal. All of the adhesions, except perhaps those uniting the intestine to the inner surface of the abdominal wound, were of such a slender character that they would in all probability have disappeared entirely in a few months. The remaining two animals are apparently perfectly well, one of them being a bitch which was in a moderately advanced state of pregnancy when operated upon. Cultures and cover-slips were made from the exudate in each case of peritonitis. The bacteriology was carefully worked out and will be referred to later. From this group of experiments we conclude that up to 6 hours after perforation the generalized peritonitis in dogs can be cured by this operation in practically every case. The prognosis of operation upon these animals at 6i hours after perforation is exceedingly favorable, but from that time on rapidly becomes less favorable.

For the fourth group of experiments six dogs were used. The method of procedure in this group was to perforate the cfficum in the usual manner. From 6 to 6i hours later the abdominal cavity was again opened, the cfficum brought out and the perforation closed in the way before described. After the replacement of the ca3cuni the abdominal cavity was closed without in any way attempting to cleanse it. At the second operation four of these dogs presented a generalized peritonitis with the characteristics before described, though in no case did the condition seem as bad as in the cases of two dogs in Group 3 cured by the cleansing of the surface of the intestine and the abdominal cavity. Of these four dogs one died about 20 hours after the perforation was produced. The other three failed to rally after the second operation, as the dogs in Group 3 did, and appeared ill till their death two to three and one-half days from the time the intestine was perforated. Autopsy upon two of these animals showed an intense hemorrhagic peritonitis, while in the case of the third the intestine and omentum were closely adherent in a mass, which when pulled apart disclosed numerous pockets of pus, presenting the condition of multiple abscess formation. The remaining two dogs of this series presented only a localized


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peritonitis. Tliere was not more than half as much of the turbid bloody fluid in the abdominal cavity as found in the other four cases, and only those coils of intestine in the vicinity of the ca3cum presented a hemorrhagic appearance. These were the most favorable cases we met with in all our experimentation. These two dogs are still alive, though their recovery has been slow.

In connection with the last two cases it is interesting to note that in two of the cases of Group 3 some exudate had collected in the abdominal cavity between the time the intestine was replaced and the abdominal wound closed, thus making it evident that the abdominal cavity possessed the power of caring for a considerable amount of the exudate. The bacteriology of this group of experiments was also carefully worked out and will be referred to along with the reports of the other cases of peritonitis.

This group of experiments seems to demonstrate that the mere closure of the perforation, though it may in some cases prolong life slightly, is not sufficient to cure a case of generalized peritonitis in dogs, and makes it very evident that without a careful cleansing of the surface of the intestines and the abdominal cavity recovery in such cases will be exceedingly rare. It must be borne in mind that the length of time which had elapsed since the perforation was produced and the condition of the abdomiual cavity would have afforded a most favorable prognosis in these cases had the cleansing operation been performed.

Cultures were made from the 4 cases of Group 2, 13 cases of Group 3, and 6 cases of Group 4. In one case of Group 3 the cultures failed to grow, although cover-slips


showed a few cocci and bacilli. Also in one case of Group 4, in which the peritonitis was not yet generalized, the cultures were negative. In the twenty cases in which bacteria developed in the cultures, from one to three species of microorganisms were found in each case. Members of the colon group were found 18 times, 4 times alone and 14 times in association. Streptococcus pyogenes was found 8 times, once alone and 7 times in association. Staphylococcus albus was found 5 times, in each case in association. Staphylococcus aureus was found 4 times, once alone and 3 times in association, and staphylococcus citreus was found 4 times, in each case in association. Cultures were also made from the heart blood at several of the autopsies, but in each case were sterile. Coverslips from the exudate in the abdominal cavity were examined in each case and more or less numerous bacteria were seen. An abundance of leucocytes was found in nearly every coverslip. The bacteria in general were outside the cells.

From our experimental work we feel justified in stating the following conclusions :

1. That mere mechanical irritation of the peritoneal surfaces will lead to the formation of adhesions.

3. That peritonitis in dogs caused by a perforation of the intestine is of an intensely hemorrhagic character, and if left to itself rapidly proves fatal.

3. That generalized peritonitis of this character, in dogs, can be cured as late as 6* hours after the perforation, by the cleansing operation introduced by Dr. Finney.

4. That mere closure of the perforation without this cleansing operation will rarely, if ever, cure a case of generalized peritonitis in dogs.


SQUAMOUS EPITHELIOMA AND EPITHELIAL HYPERPLASIA IN SINUSES AND BONE

FOLLOWING OSTEOMYELITIS.


By S. M. Cone, M. D., Assisfcmt in Surgical Pathology, The Johns Hopkins University.


In view of the interest manifested in the pathology of bone, the two cases about to be reported seem to be of value. They are striking examples of malignant and benign epithelial growth into old sinuses and medulla of bone.

Case I. — John H., colored, set. 45, laborer, was admitted to Dr. Halsted's wards, January 2, 1897.

Patient gives a history of injury to bis left tibia 19 years ago, with subsequent formation of a sinus and discharge of sequestra. One month before entering the hospital the patient began to feel pain in the leg, and the odor of the discharge became foul. No sequestra have come away for eight months. There is pulsation of discharging material synchronous with the radial pulse.

Upon Jan. 4, Dr. Bloodgood excised the sinus aud chiseled and curetted the bone. The bone was fractured 10 cm. below the knee, where the cavity was largest. The operator's note estimates the cavity communicating with the sinus as 3 cm. deep, 2 to 3 cm. wide, aud 14 cm. long. The diagnosis, squamous epithelioma, being confirmed, and the growth


recurring withiu two weeks, the leg was amputated above the knee, and glands of the groin excised by Dr. Finney on Jan. 29th. On Feb. 25th patient was discharged, the wounds having healed per primam.

Pathological rejmrt of the first operation. — Tiie specimen consists of the skin, sinus, eburnated bone, and soft material filling the cavity in the bone. The edges of the sinus are dense and pearly in appearance. The skin within i cni. of the sinus edge has lost its dark pigmentation. The bone next to the soft central mass is soft and crumbly, but outside of this is eburnated. It appears directly continuous with the skin at the orifice of the sinus. The sinus is lined by the same papillary growth that fills the cavity in the bone, and this same growth projects between the periosteum and eburnated bone, indenting it, causiug a jagged appearance. The medullary cavity is filled with a soft, necrotic-looking material, made up of soft yellowish white masses, aud with white papillary granular projections from a rather dense translucent pink ground substance looking like granulation tissue. The papil


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lary projectious average 2 mm. diameter, aud are of varying length up to 4 mm. The growth within the cavity erodes the bone, leaving small spicules and granules in the soft necrotic mass. In places the dense bone has become granular and crumbles readily. There is no sequestrum nor cancellous bone. The periosteum is very much thickened aud not to be well differentiated from the subcutaneous tissue; it is invaded by the epithelial growth. The microscopical description of the original sections is the same as of the recurrent growth, so they will be included together.

The leg and lower third of the thigh removed at the second operation present no abnormal appearance outside of the gajiing granulating wound in the tibia, the seat of an osteotomy performed January ith. The wound, measuring 16s 4x4 cm., is surrounded by edges of skin inverted over the bone, which for the most part is covered by apparently healthy granulations. Only at one place is the bone exposed ; this is at the upper angle of the wound, where an edge of eburnated bone is left uncovered. At the outer rim of the excavated tibia, 4 cm. from the upper angle of the wound, is a projecting mass of papillary excrescences 4 cm. in diameter, whose surface is covered by a dry blood-stained crust. Scraping the up[)er layer away leaves the deeper papillae, pearly in appearance, closely aggregated and more or less intimately connected with the velvety granulations about them. Some of these epithelial uests are so closely packed without any apparent stroma that at first glance they give the appearance, on section, of a cheesy mass. Careful observation shows this to be made up of individual uests. This mass is at the seat of fracture alluded to. Similar uests of cells are seen iu smaller discrete masses over the whole surface in the granulations.

One area on the inner wall of the excavated tibia, 5 cm. from the uf)per angle of the wound and 2 cm. from the fracture, can be made out as a mass sharply defined from the surrounding granulations. The bone here seems excavated to fit the growth which is eroding it. Spicules of bone project into the growth between the epithelial plugs at the jjeriphery. Between the ends of the fracture the new growth projects, invading muscle and adjacent tissues. The ends of the bone are rough, and the papillary masses are seen indenting the ivory-like bone to a depth of 1 to 3 mm., giving it a wormeaten appearance ou removing the growth. The granulations, 2 to 4 mm. thick, covering the surface of the bone also groove it and cause a rough and gnawed appearance.

The bone sawn through at several places is dense aud eburnated aud shows no evidence of tumor formation which is not directly connected with the surface growth. The heads of femur, tibia aud fibula aud the astragalus are normal. The tibia and fibula are anchylosed by bony union at the interosseous ligament. No tumor can be traced from the bone along the vessels. The muscles and soft parts, except at the seat of fracture and ulcer edge, appear normal. The cartilage of the patella is softened, that over the outer head of the femur is depressed and soft. The synovial membrane is hemorrhagic where it envelops the crucial ligaments at their insertion into the head of the tibia.

The popliteal aud inguinal glands are firm, eularged and harder than normal, but do not show any areas of metastasis.


Microscopical Description.

Tumor iiivading musde at the seat of fracture. The tumor mass is sharply circumscribed. At that part nearest the invaded tissue the tumor is made up of single cells and small masses of cells in a fine reticulum; this passes, further away, into small non-cornified, non-cystic masses of cells, theu larger alveoli with cornified epithelium in the centre of the stratum mucosum layers. Furthest away from the muscle and nearest the periphery of the tumor mass are seen cystic dilatations with anastomosing alveoli lined by a few layers of columnar cells and containing scales of cornified epithelium aud fatty detritus. The invaded fibrous tissue shows no change. The muscle fibres are granular and fragmented ; the fragments and individual fibres contain many nuclei, giving the appearance of elongated giant cells. The vessel walls show round cell infiltration. There are newly formed capillaries among the degenerating fibres. There is evidence of endothelial proliferation in the capillaries.

Tumor mass and ski7i, the mass projecting betiveen the fractured ends of the tiiia. Where skiu and tumor pass over into one another the regular papills of the skin cease, as does the deep pigmentation. The pigment is no longer seen between the stratum mucosum cells as in the skin, aud is much less developed in the stratum granulosum and deepest columnar epithelium of the Malpighean layer.

It looks as if the stratum mucosum aud granulosum were continuous with like layers of cells lining the stroma of the tumor, keeping on over the tortuous papillary bulgings and corresponding depressions of the tumor mass. Similarly can the stratum corneum be followed, but it changes its appearance over the tumor, becoming less compact and scattered in flakes on the surface, or loosely filling cystic cavities along with cellular detritus, or it may be lacking on some of the plugs.

In the cornified layers over the tumor are masses of brown granular pigment containing crystals of hsematoidin. The tumor growth is divided by deep grooves caused by keratinizing and fatty degeneration of epithelial down-growths. This causes the follicular appearance described macroscopically.

Papillse, or stroma strands, better named, push the epithelium up into bulging papillary masses. These stroma strands vary in size, as do the corresponding cyliuders and plugs of epithelium lining them. The plugs aud cylinders anastomose freely at the surface. One cyst thus caused measures 1 X ^ cm. aud is made up of numerous small plugs containing keratinized epithelium and detritus around the margin. The contents must have fallen out in great part. The surface is covered with epithelial cells, polymorpho-nuclear leucocytes, and keratinized epithelium iu a mass of coagulation necrosis.

The stroma varies in different parts, from edematous young granulation tissue with stellate, epithelioid aud giant cells at the surface under the coagulation necrosis, to a very cellular fibrous tissue, with numerous capillaries aud spindle-shaped long nuclei deeper down. In places the stroma is homogeneous aud stains pink with eosin, like hyaline. There are areas of round cell infiltration in the stronui. The included plugs


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and cylinders of epiLhelinm comprise all the epidermis layers arranged in the same order as in the skin — a cylindrical or cuboidal layer next to the stroma, then polyhedral cells of the stratuna mucosum showing prickles most distinctly with Van Gieseu's stain, then two or three layers of spindle cells with pigment which takes the hEematoxyliu stain — the stratum granulosum. The outermost layer lining or filling the Ciivity of the plugs or cylinders is of loose keratinized epithelium, sometimes arranged compactly,

Where the centres are cystic we find besides the keratinized epithelial flakes, fat cells, cells which have undergone fatty degeneration, leucocytes and salts, granular and deeply stained with bajmatosylin. Cell multiplication is very active, as evidenced by the many divided and dividing nuclei ; 2 to 5 nuclei are contained in some cells, connected as if budding.

Tnto the basal layer of these cylinders there may be ingrowths of papilla?, explaining an unusual appearance, namely, a mass of fibres and connective tissue cells cut across in the centre of one of the above described plugs of epithelial cells. In the deepest part of the invading tumor the cylinders become very small, even narrowed to single cells separated by the same cellular stroma. Anastomosis is very free, many branches spreading throughout a loose stroma. The arteries included in the section show marked endarteritis and round cell infiltration of the adventitia also.

In staining the sections the Van Giesen method was found valuable in staining the stroma and the prickle cells. The keratinized cells stain yellow, the young stroma stains dull red. Gram's stain used for keratohyalin by Ernst' shows it well, staining these cells deep blue.

Sections of the pink granulations over the surface of the bone show granulation tissue without evidence of tumor.

The lymph glands of the popliteal space and groin show fatty atrophy and connective tissue formation, thickened capsules and endothelial hyperplasia. There are no metastases.

The popliteal artery and vein with surrounding tissue show no evidence of tumor growth about them. They are united by dense fibrous tissue. There is evidence of endarteritis.

The synovial membrane described as hemorrhagic shows round cell infiltration and vessels filled with blood, which also suffuses the surrounding tissue.

The bone cut across near the knee shows no microscopic evidence of carcinoma; it appears normal.

Section of fragments of hone with tumor and granulations mixed in an irregular friable mass. The tumor alveoli and stroma are as described above. Adjoining whorls are seen to become conglomerate, mixing together their contents of keratinized epithelium and fatty necrotic substances and bounding this by their several epidermis layers. Secondary papilla; project into the primary alveoli, giving a complicated appearance on section. In the proximity of the bone the cellular stroma is strewn with giant cells with centrally massed large oval vesicular nuclei containing big nucleoli. These are osteoclasts, for wherever the bone is seen undergoing absorption it is lacunar in nature and the Howship's lacunae contain osteoclasts to fit them. The tumor cells do not come in direct contact with the bone, being separated by stroma and osteoclasts.


The bone is very dense, with narrow compact lamella; containing few corpuscles, and these are small and far apart. The Haversian canals are filled with cellular connective tissue, vessels, old bone fragments looking as if shelled off, and osteoclasts in lacunaj. Branching canaliculi are distinctly seen. There is new formation of bone going on. The new lamellse are arranged at an angle to the old ones, they take the eosin stain deejier and are lined by osteoblasts, cuboidal and spindle-shaped. There is a granular line stained with hsematoxylin between old and new bone.

Section of hone zvith invading tumor at the seat of fracture. The lamellae are narrow and closely packed and enclose bone corpuscles at rather wide intervals. Some of the corpuscles nearest the invading tumor are enlarged and the cells are deeply stained. The Haversian canals are irregular in contour, of various sizes, and filled with granular detritus and fragments of bone. About their rim there is lacunar absorption, the grooves being small. The bone, where invaded, is being absorbed by the osteoclasts, for in every Howship"s lacuna can be seen a giant cell such as Kolliker' describes, or large osteoblasts which here take on the function of osteoclasts and are such.

These osteoclasts vary in size and shape, each fitting exactly a groove in the bone hollowed out to fit the absorbing agent. Some of the cells are seen completely surrounded by bone, others have only one-third of their body enclosed by the lacuna. The shape varies from oval, round, oblong, large cells to elongated flat cells lining quite a large part of the bone surface, looking almost as if one of the outer lamellae had broken off abruptly and taken in many large nuclei. The size varies from an osteoblast to cells five or six times as big.

The nuclei are either massed in the centre or arranged around the perijihery ; they are large, round or oval, and vesicular. The protoplasm of these osteoclasts is granular and stains deeply with eosin, especially at the centre. The edge of the cell next the bone is rough ; the other borders of some cells seem of double contour and quite smooth.

No foreign bodies were detected in any of these bodies next the bone, yet some of the giant cells near by included epithelial debris.

The protoplasm of some osteoclasts is drawn out like a pseudopod and pushes in between the connective tissue cells. Where granulations seem to fill the lacuna? one finds osteoclasts between them and the bone wall.

There is evidence of new bone formation. To the characteristics of newly deposited bone already mentioned can be added the closer approxinuitiou of bone cells — there being more of them than in the older adjacent bone. The medullary spaces between the cancel li of bone are filled with newly formed fibrous tissue and granulation tissue containing giant cells and all the cells usually found in embryonal tissue. There are also numerous capilhmes and larger vessels in the spaces. The bone cells vary in size and appearance, as do the bone corpuscles, some being round and spindle-shaped, others stellate. They can be best studied in the newly deposited bone or in bone undergoing absorption. It would seem as if when about to be freed from their imprisonment they take ou active functions again and are stained more readily.


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As in other sections of bone, no tumor cells come in direct contact with the bone. The tumor advances as described above. There are small fragments of bone in the granulations, which look as if they had been eaten off and left. There is a deposit of new bone in the vicinity of the tumor and evidence of absorption going on in the same microscopic field.

Case II.— W. J. R., white, a3t. 5i, admitted June 26, '95.

For 49 years the patient has had discharging sinuses in the thigh communicating with necrotic bone.

Operation, June 28th, by Dr. Bloodgood. Amputation of thigh at the upper third. Notes made at the operation refer to the great friability of the bone, the thickened periosteum, thin shaft and presence of a sequestrum.

Nov. '96. Patient reports himself well.

The pathological report is as follows : The diseased condition of the bone begins 26 cm. above the condyles and involves the shaft for 16 cm. The last jjiece of bone removed, 3 cm. below the trochanter, appetu'S healthy. The periosteum is thickened, the shaft, stripped of periosteum, is rough and presents minute spicules. The shaft varies in thickness from 3 to 6 mm., and there is very little cancellous bone. It is brittle, fracturing easily. The medulla above seat of disease contains much fat and oily material. At the seat of disease there is no involucrum. In the sinus leading from the diseased bone there is a sequestrum 6 cm. long and li cm. wide. The periosteum about the necrotic portion is 5 to 6 mm. thick, and on section is peai'ly white and appears striated at right angles to the long axis of the bone. On the surface nest to the shaft it is covered with a yellow necrotic friable tissue covering a leathery surface. Fine spicules of bone are imbedded in this. The odor is foul. The surface of the shaft is rough and hard. The medullary cavity is filled with hard bone mixed with thick leathery tissue, and is riddled with small cavities containing the same material as covers the shaft. The only attemjit at new bone formation is in the medullary cavity. No attempt at formation of healthy granulations is evident. About the area of disease the shaft exhibits exostoses 1 to 1^ cm. in length. The knee joint is normal in appearance.

Microscojiical examination of the tissue between the periosteum and bone described as striated and friable with necrotic border next to the shaft, shows it to be made up in the main of large swollen polygonal cells with oval vesicular nuclei. The arrangement is such as one sees in the stratum mucosum of the skin. There are papillas jirojecting into the mass from the periosteum, which is thickened and infiltrated with small round cells. The cells next the papilla} are prickle cells; those nearer the shaft do not show the prickles. The cells arc massed in varying density. According to the location of the papilla} we get lighter and darker stained masses, the darker being more comjiact and approaching the cancroid pearl in appearance, but there is no cornified nor degenerated centre. Toward the bone the cells are flat and the nuclei lose the ability to stain. A thin layer of cornification covers their surface. Many of the nuclei are vacuolated. The papilla are very cellular. There is an absence of the stratum granulosum and lucidum ; simply a uniform growth of the mucosum


and corneum. There is considerable endo- and periarteritis. The muscle and connective tissue show no tumor invasion. The leathery material described in the medulla is like that just described.

Examination of the cortical bone from the shaft shows no tumor growth into it. The dense bone presents a feathery appearance commonly seen in eburnated bone. The edges show lacunar absorption.

A number of cases of squamous epithelioma developing in sinuses antl old scars which would come under the grouping I have purj)osely omitted, since the pathological description of the tumor is in every case essentially the same as in Case I. Two of the cases might be considered carcinoma developing in oste