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NOTES ON NEW BOOKS.
Anomalies and Curiosities of Medicine, being an encyclopedic collection of rare and extraordinary cases, and of the most striking
instances of abnormality in all branches of Medicine and Surgery,
derived from an exhaustive research of medical literature from
its origin to the present day, abstracted, classi fled and indexed.
By Georqe M. Gould, A. M., M. D.,and Walter L. Pyi.e, A. M.,
M. D. With 295 illustrations and 12 half-tone and colored plate.s.
908 pp. (Philadelphia : W. B. Saunders, 1897.)
Tliestatementof Gibbon that objects which are only singular without being pleasing may excite surprise but soon lead to satiety and
<iisgust, does not apply to this volume, which is thoroughly interesting from beginning to end. The attempt of the authors "to
briefly epitomize and to arrange in order the records of the most
curious, bizarre and abnormal cases thatare found in medical literature of all ages and all languages," has been most successful. The
book is thoroughly scientiflc in its treatment of the varied material
which has been gathered with an industry which calls forth admiration. The Urst six chapters will probably be read most generally
and relate to anomalies of conception, birth and development, and
are of special interest to the gynecologist, obstetrician and student
of legal medicine. Chapter seven relates to gigantism, dwarflshness, obesity and abnormal leanness, and the accompanying illustrations form a curious collection of anomalies suggestive of a dime
museum.
The chapter on longevity taxes one's faith rather more than any
other. Think of Henry Jenkins dying at the age of 169 years ;
Thomas Parr at 152 ; Jean Korinat 172 and his wife atl64, and ason
left an orphan by their untimely death at the tender age of 116 ;
Petretsh Zartan at 185 or 187 (authorities differing), who walked a
mile to the post ofiice a few days before his death to ask for alms ;
and many other well-authenticated instances of nearly equal age.
The chapter on anomalous mental and nervous diseases is so complete it is a matter of surprise that it does not include the history
of the young man in Ohio who became totally blind at the age of
seven months, and who, while receiving an education at the school
for the blind, in consequence of a fall, lost both hearing and speech.
After a time, his eyesight being restored by the fall, he was transferred to an establishment for the education of deaf mutes. Here
eventually his hearing was suddenly restored, but epileptic attacks
developed which required hospital treatment, this time in an institution for the insane. This well-authenticated tale was published
in considerable detail in one of the State repoits and deserves a
place in these annals. The chapter on Historic Epidemics is timely,
especially the full account of the bubonic plagues of the middle
ages.
An excellent feature of the book is the judicial spirit shown by
the authors. Facts are weighed and reasons are advanced for the
conclusions which are reached. The book is well printed and
finely illustrated and is worthy of a large success. Every chapter
is of interest to every physician.
Text-Book of Materia Medica, Therapeutics and Pharmacology.
By G. F. Butler, M. D. [Philadelphia: W. B. Saundem, 1896.)
This work is dedicated to the " Medical Students of the United
States," and we have no doubt that many of them who enjoy buying
the latest work on this branch of medicine will find it serviceable.
It cannot be said to replace the oliier works of Wood, Hare and
others. There is very little true original thought in it, which
should be the the real reason for the publication of any new book,
especially to-day, when there is altogether too much production of
simply transient works. As the author states in the preface :
" From the U. S. Pharmacopeia chiefly, and from the National Dispensatory, have been adopted almost verbatim, the ' origin ' and
'description and properties' of tlie various drugs under consideration," so it is more in his arrangement of his material that we must
look for originality. He classifies the drugs by their properties,
rather than alphabetically, as is done by Hare. Both methodshave
their advocates, and [lersonally, as it is much the most rapid way to
look up any given drug, we prefer the latter method. Butler still
further cljftsifies the drugs into so called " Disease-Medicines," a
very unscientific term, as he himself recognizes, and "SymptomMedicines." In such a classification no two persons willagree as to
the class to which certain medicines will belong most properly, and
thus it becomes confusing and time-consuming to search for the drug
wanted. The author says: "A genuine specific is tolerated only
by the system in which it antagonizes some disease. For instance,
A and B are put under a prolonged course of mercury ; A is salivated
beyond recognition, while B's health improves — simply for the
re.ison that B had syphilis, which A had not." Such general
remarks are often not true, and the example given is a very poor
one, for we all know that syphilitic patients may be salivated, and
sometimes as severely as those who are not syphilitic. Also many
]>atients who have not sypliilis may take mercury in large doses for
long periods of time without becoming salivated. We do not
understand the following sentence: "Quinine was formerly considered a specific in malaria, until the fact was recognized that the
drug is analogous to a normal constituent of healthy bile in its
action upon plasmodia malariae." W^e believe that by most
authorities quinine is still considered to be a specific in malaria,
whatever the action of bile may be. In a work which covers so
much ground as this text-book, the value depends on an equal balancing of the different parts, and especially, in the description of
the drugs, of careful omission of all unnecessary parts, and still
more exact and concise information on all important points. Each
author naturally finds special interest in certain parts of his work,
and so not knowing these it is hard to criticise the book justly. But
in the 650 pages given to drugs and their actions we feel that much
improvement could have been made with careful revision — some
parts omitted, and other information of more importance added.
We think it quite out of place to introduce in such a work declensions of simple Latin words and other rules of Latin grammar,
which should be known by every student before he begins the
studj- of medicine, and if he does not know them, he should not be
helped to the knowledge in this superficial manner.
Diseases of the Ear, Nose and Throat. By S. P. Bishop, M. D.
(Philadelphia : F. A. Davis Co., 1897.)
This book, we think, fulfills pretty satisfactorily the object of the
author, as expressed in the preface; he says: "This work was
designed, first to help students in preparing for their degree ; second, for those progressive practitioners who wish to acquire the
proficiency necessary to properly treat those patients who are unable to visit specialists ; and third, for those who are gradually
exchanging their general practice for special work in these
branches." The chapter on blood-serum therapy in diphtheria seems
out of place ; it is merely an abstract of a few of the articles which
liave appeared on this subject during the past two years, and we see no
good reason for introducing it here. The work on the whole is a
fair presentation of our knowledge in these diseases, without any
attempt to take up any of them at length. The treatment as given
is generally satisfactory and simple. We do not agree with the
author in considering hay-fever, or "nervous catarrh," as he prefers to call it, a result of uric acid diathesis. There are many
questions in the study of this disease which are as yet quite inexl)licable, and this theory of its causation is insufficient to explain
them all ; the neurotic character of the disease is well established,
and that uric acid may in some caees play an inijiortant role in this
nervous affection is undoubted, but it is also equally certain that
other important causes play their role too in determining this
malady.
This book is clieaply gotten up and the cuts are of poor quality ;
tlie colored illustrations also seem very unsatisfactory. Many of
July, 1897.]
JOHNS HOPKINS HOSPITAL BULLETIN.
159
the cuts are reproductions of instruments wliich by this time should
be l^nown to all practitioners and to every student graduating from
a medical college. These simply add to the expense of the book
without adding to its intrinsic value.
Essentials of Physical Diagnosis of the Thorax. Second Edition.
By Arthur M. Cokwin, M. D. (Philadelphia: W. B. Saunders,
189a.)
That there is a demand for such a quiz-compend or aid in cramming for an examination is shown by the fact that a second edition
of this small book has been called for. We cannot recommend it,
however, for like other similar works it fails in attempting to condense much knowledge in a very limited space and although tolerably well arranged, there are numerous statements of fact with
which we cannot agree. The varieties of tympany (p. 69) are confusing and not generally used and were better omitted in such a
work. In the discussion of heart murmurs there is much needless
repetition, and on p. 176 the mitral systolic murmur described
as occurring in aortic insufficiency, otherwise known as Flint's
murmur, is presystolic in time. The chapter on congenital lesions
of the heart is treated too briefly to be of service, as is also the one
on hydatid cyst of the lung, which, when jiriniary, is not a condition easy to diagnose, nor could the signs of it as given by the author
differentiate it from pleurisy. 8pasm of the columnar carnese is a
condition which may occur, but it is hardly one of which a diagnosis could be made. Acute endocarditis without valvular lesion
is not a condition which can be recognized clinically, and inorganic
aortic systolic murmurs should usually be doubted. The ratio of
the inspiratory sound to the expiratory is not as tiiree to one, nor
in asthma is the dyspnosa (orthopncea) chiefly expiratory. CheyneStokes respiration does not ordinarily accompany opium poisoning.
No worse instrument for clinical instruction could well be devised
than the multiplex stethoscope, of which there is an illustration
in the beginning of this work.
Pathological Report of the Illinois Eastern Hospital tor the I
(Chicago: Blakely rrinting Co., 1896.)
This is an excellent report, full of much valuable mateiial, and
Dr. Adolf Meyer deserves much credit for it, considering the difficulties under which the work was prosecuted, due to a lack of general facilities for carrying it on. We cannot criticise any shortcomings when we read his closing remarks. He says: "It may
justly be said that the publication of so much raw material is of
little use. To polish the report, away from the records and the
material, did not seem to he in the interest of the accuracy of a
picture of the working of the laboratory which had barely come
into existence at the end of the period covered. The work was
planned on a broader basis than it was feasible to carry out in the
short period. The idea was that the plan of publishing ' interesting' cases only was not in the interest of sober study of the daily
experience, that selecting cases might lead to illustration of preconceived ideas instead of the facts as they present themselves in
reality, and that at the present stage of psychiatry a consideration
of all the things seen wouM be less dangerous than arbitrary selection. The same jirinciple should be carried out in the clinical side
as well." Although much of the material is raw, yet many facts of
interest are to be found — perhaps the most interesting being that 32
per cent, out of 49 cases of terminal dementia, and 27 per cent, of
192 cases of mental diseases, including the first series, died of florid
tuberculosis. Of course without fuller statistics as to the class of
patients in the hospital, too much stress should not be laidon these
figures, but nevertheless the percentage is high. A case of acute
mania, dying presumably of sulphonal poisoning, shows the necessity of the utmost care being used in the administration of drug.ito
patients with mental diseases to avoid accidents of this sort. We
shall await with pleasure sui cessive reports from Dr. Meyer, who
has now transferred his work to the Worcester State Hospital and
nsane.
Clark University, and trust he will be able to describe some of the
finer microscopical findings in brain and cord lesions from the interesting material at his disposal.
St. Thomas's Hospital Reports. New Series. Vol. XXIV. i London,
1895.)
The first half only of this volume is taken up with detailed
papers, and the second half with statistics of the different departments of the hospital, and brief abstracts of cases, medical and
surgical. Among the papers here preseuted, two are worthy of
special note. The article on " Osteo-arthropathy and its Relationships," with report of a case of pulmonary hypertrophic osteoarthropathy, both by Dr. Walters, is a very valuable contribution
to our knowledge of this curious condition and its relationship to
akromegaly. It is an exhaustive study, with a brief abstract of all
the cases reported of this bone disease up to the time of the publication of this volume. The other paper is on "Enteric Fever and
Sewage Gas," in which 11 cases of typhoid fever are described as
resulting from poisoning with sewer gas in one hospital within a
short space of time. Here milk, water and food as possible sources
of the contagion could apparently be eliminated without doubt, and
the only other discoverable source was a water-closet into which
typhoid organisms had probably been discharged but a few weeks
before the outbreak of this small epidemic, which ceased as soon
as the sewage pipes were overhauled and modified. With the
modern belief that typhoid fever in nearly every case re>ult8 from
milk, water or food contaminated by the typhoid organism, this
epidemic raises the most interesting question as to whether or not
typhoid bacilli may enter the body through the lungs and thus
cause the fever. There are other articles on tuberculous disease in
the knee-joint, and relapse in the si)ecific fevers, which will repay
careful reading.
Feeding in Early Infancy. By Arthur V. Meigs, 51. D. (Vhiladelphia: W. B. Saunders, 1896.)
In this paper Dr. Meigs emphasizes the results of his milk
analyses as expressed in his earlier publication, and describes in
detail the preparation of his food, based on these results.
He finds that human milk never contains more than one percent,
casein, cow's milk three times this amount, other constituents
being present in about equal quantities. In his preparation cow's
milk is therefore diluted with lime water, and cream and sugar
added in definite proportions. The food, piepared after this
manner, has been used for a number of years by the author, with
satisfactory results.
He thinks thatsulijecting milktohightemperaturesdetracts from
its usefulness as an infant food ; therefore it is better to be assured
of its source and avoid sterilization.
This course seems hardly practicable, and the injurious effect
accredited to sterilization is not sustained by most writers on the
subject.
Proceedings of the American Medico-Psychological Af-sociation
at the 52d Annual Meeting, held in Boston, May 26-29, 1896.
{American Medico-Psychological Associaiion, 1896.)
The proceedings of this society occupy nearly 300 large papers,
pretty closely printed ; but all the papers are good, while some are
of especial value. There is an interesting address on psychological
education by Stanley Hall, a leading authority on such a subject;
and there are important contributions by Brush, Worcester, Hoch,
and Berkley. The paper by Hoch, on " General Paralysis in Two
Sisters," is perhaps, while one of the most thorough articles, the
one of most general interest. To students who have given much
time to the study of the blood, the paper on " Leucocytosis Associated with Convulsions," by Burrows, will open up a point of much
interest as to the cause of leucocytosis, whether or not it be due to a
form of auto-intoxication.
160
JOHNS HOPKINS HOSPITAL BULLETIN.
[So, 76.
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.
THE JOHNS HOPKINS HOSPITAL REPORTS.
Volume I. 423 i>ages, 99 plates.
Report in Pntliologry.
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D.
A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis
(Atrophy). By Henry J. Berkley, M. D.
Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.
Mall, M. D.
Report in Dermntologry.
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
T. C. Gilchrist, M. D., and Emmf.t Rixford, M. D.
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of
Protozoa, and the Blastomyces found in the preceding Cases, with the BO-called
Parasites found in Various Lesions of the Skin, etc.; Two Cases of MoUuscuni
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
T. C. Gilchrist, M. D.
Report In Patholog^y.
An Experimental Study of tin' Thyroid Gland of Dogs, with especial consideration
of Hypertrophy of this Gland. By W. S. Halsted, M. D.
Volume II. 570 pages, with 28 plates and figures.
Report in Meillcine.
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
Gallstones. By William Osler, M. D.
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D.
On Pyrodin. By H. A. Lafleur, M. D.
Cases of Post-febrile Insanity. By William Osler, M. D.
Acute Tuberculosis in an Infant of Four Months. By Harry Toulmin. M. D.
Rare Forms of Cardiac Thrombi. By WtLLiAM Osler, M. D.
Notes on Endocarditis in Phthisis. By William Osler, M. D.
Report in Medicine.
Tubercular Peritonitis. By William Osler, M. D.
A Case of Raynaud's Disease. By H. M. Thomas, M. D.
Acute Nephritis in Typhoid Fever. By William Osler. M. D.
Report in Gynecology.
The Gynecological Operating Room. By Howard A. Kelly, M. D.
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard
A. Kelly, M. D.. and Hunter Robh, M. D.
The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of
Abdominal Section. By Howard A. Kelly, M. D.
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,
M. D.
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;
Ovarian Tumor; General Gynecological Operations from October 15, 1889, to
March 4, 1890. By Howard A. Kelly, M. D.
Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howasd
A. Kelly, M. D., and Albert A. Ghrisket, M. D.
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D.
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
Howard A. Kelly, M. D.
Report in Snri;:ery, I.
The Treatment of Wounds with Especial Reference to the VaUu^ of the Blond Clol
in the Management of Dead Spaces. By W. S. Halsted, M. D.
Report in tVenrologT-, I.
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.
.\cute Angio-Ncurotic Oedema. By Charles E. Simon, M. D.
Haematomyelia. By August Hoch, M. D.
A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By
Henry M. Thomas, M. D.
Report in Patbolo^y, I.
Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.
Volume III. 706 pages, with 69 plates and figures.
Report in Patholosry*
Papillomatous Tumors of the Ovary. By J. Whitridge Williams, M. D.
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.
Report in Piitliologry*
Multiple Lympho-Sarcomata, with a report of Two Cases. By SiMON Flexner, M. D.
The Cerebellar Cortex of the Dog. By Hknry J. Berkley, M. D.
A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
Report in Gynecology,
The Gynecological Operating Room; An External Direct Method of Measuring the
Conjugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid
Flexure associated with Constipation a Sourrc of Error in Gynecological Diagnosis; Operation for the Suspension of the Retroflexed Uterus. By Howard A.
KiXLY, M. D.
Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci.
By Mary Sherwood, M. D.
Intestinal Worms as a Complication in Abdominal Surgery. Bj A. L. Stavklt, M, D.
Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. D.
Tabulated by A. L. Stavely, M. D.
The Employment of an Artificial Retroposition of the Uterus in covering Extensive
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.
Photography applied to Surgery. By A. S. Murray.
Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howard
A. Kelly, M. D.
Urinalysis in Gynecology. By W. W. Russell, M. D.
The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.
<)ne Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.
Abdominal Operations performed in the Gynecological Department, from March 5,
1890, to December 17, 1892. By Howard A. Kelly, M. D.
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
May 4, 1892.
Volume IV. 504 pages, 33 charts and illustrations.
Report on Typhoid Fever.
By William Osler. M. D., with additional papers by W. S. Thayer, M. D., and J.
Hewetson, M. D.
Report in Neurology.
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The
Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of Mu^ miisruln.^; The Intrinsic Nerves of the Thyroid Gland of
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley.
M. D.
Report in Surgery.
Tlie Results of Operations for the Cure of Cancer of the Breast, from June, 1889, to
January, 1894. By W. S. IIalstkd, M. D.
Report in Gynecolof^y.
Hydn)salpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis;
Tuberculosis of the Endometrium. By T. S. Ctllen, M. B.
Report in Patlioloe^y.
Deciduoma Malignum. By J. Whitridge Williams, M. D.
\\)LUME V. 480 pageSj with 32 charts and illustrations.
CONTENTS:
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.
Studies in Typlioid Fever.
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon
Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.
Volume VI. About 500 pages, many illustrations.
Report in Nenrolojsry.
studies on the Lesions produced by the Action of Certain Poisons on the Cortical
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.
Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the
Chromate of Silver Methods; Part I.— Alcohol Poisoning.— Experimental Lesions
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol); P»rt II. — Serum
Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on
the Cortical Nerve Cell; Part III.— Ricin Poisoning.— Experimental Lesions Induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical
Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of
Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic BulKir Paralysis. By Henry J. Berkley, M. D.
Report in Pntliologry.
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. Bv Thomas S.
<'l-LLEN. M. B.
fii^aiancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of
Ovum and Spermatozoa. By Thomas S. Cullen. M. B., and G. L. Wilkins. M. D.
Adciio-Myoma Uteri Diffusum Benignum. By Thomas S. Cttllen, M. B.
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infanta. By
William D. Booker, M. D.
The Pathology of Toxalburain Intoxications. By Simon Flexner, M. D.
The price of a set houiid in cloth [VoU. I-Vl] of the Hospital Reports m
$30.00. Vols. If II and III are not sold seimrateltj. The price o/
Vols. 11% r and ri is $5.00 each.
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TYPHOID FEVER.
The following papers are reprinted from Vols. I, IV and V of the Reports, for those
who desire to purchase in this form:
STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmkt Rixford,
M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,
$3.00.
THE MALARIAL FEVERS OF BALTIMORE. By W. S, Thayer, M. D., and J.
Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.
By Lewellvs F. Barker, M. B. 1 volume of 280 pages. Price, in paper, f3.75.
STUDIES IN TYPHOID FEVER. Bv William Osler. M. D., and othere. Extracted
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481
pages. Price, bound in paper, $3.00.
Subscriptions for the above publications may be sent to
The Johns Hopkins Press, Baltimore, Md.
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimwr, Single copies
nuiy he pronired from Messrs. GUSHING & CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a tityir, may tte
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sini/lv topics will be sent by mail for fifteen cents each.
BULLETIN
OF
THE JOHNS HOPKINS HOSPITAL.
Vol. Vm.-Nos. 77-78.]
BALTIMORE, AUGUST-SEPTEMBER, 1897.
[Price, 15 Cents.
GOnSTTEJaSTTS.
PAGE.
Influence of Louis on American Medicine. By Willia.m
O.SLEB, M. D., - - - 161
AVilliam Harvey as an Embryologist. By William K. Brooks,
LL. D., - - - - - - 167
Long, the Discoverer of Anaesthesia. A Presentation of lii.s
Original Documents. By Hugh H. Young, A. M., M. D., - 174
The Early History of Ophthalmology and Otology in Baltimore (1800-1850). By Harry Friedknwald, A. B , M. D., - 184
Joseph Friederich Piringer: His Methods and Investigations.
By Harry Friedenwald, A.B., M. D., 191
Proceedings of Societies :
Hospital Medical Society, " - 195
Hsematomyelia from Gunshot Wound of the Cervical
Spine [Dr. Gushing].
Notes on New Books, _ . - _ 197
Books Received, 197
INFLUENCE OF LOUIS ON AMERICAN MEDICINE.
By William Oslek, M. D.
Harvey and Sydenham, types of the scientific and the
practical physician, though contemporaries, were uninfluenced,
80 far as we know, by the other's work or method. Harvey
had little reputation us a practical physician, and Sydenham
cared little for theories or e.\periment. Modern scientific
medicine, in which these two great types meet, liad its rise in
France in the early days of this century. True, there had
lived and worked in England the greatest anatomist and medical thinker of modern times; but John Hunter, to whose
broad vision disease was but one of the processes of nature to
be studied, was as a voice crying in the wilderness to the speculative, theoretical physicians of his day.
Bichat's Anatomie Gaicrale laid the foundation of the positive or modern method of the study of medicine, in which
theory and reasoning were replaced by observation and analysis.
Laennec, with the stethoscope, and with an accurate study of
disease at the bedside and in the post-mortem room, almost
created clinical medicine as we know it to-day.
The study of fevers occupied the attention of all the great
physicians of the time. Fever — what it was, how it should
be treated. What a vast literature exists between Sydenham
and BroussaisI What a desolate sea of theory and speculation !
•Read before the Stille Society of the Medical Department of the
University of Pennsylvania.
No one had been more influenced by Bichat's brilliant
teachings than Broussais, who ruled supreme in the medical
world of Paris in the early decades of this century. A strong
believer in careful observations at the bedside and in the jiostniortem room, he was led into hoj)eless error in attributing
fevers and many other disorders to irritation in the stomach
and intestines — his gastro-enteritis.
Writing in the American Medical Recorder, July, 1831, an
American student, Dr. F. J. Didier, says of the Paris professors of that date, "They were always talking of Hippocrates,
Galen, Oelsns, etc., as if not a particle had been added to the
stock of knowledge since their time." And again, " The doctrines of John Brown, mixed up with the reninantsof humoral
pathology, form the basis of the present system."
The same mi.xture prevailed early in the fourth decade,
as you may see from Broussais' Pathology, the American
edition of which was issued in 1833, and from Jackson's
(Samuel) Principles of Medicine, published in the same year.
Upon this scene, when Broussais was at the height of his
fame, came Louis. He, with his friends Andral and Chomel,
were very important factors in substituting finally in the
study of medicine, for speculation and theory, observation and
method.
The chief facts in Louis' life may be thus briefly stated. He
was born in 1787 at Ai. He began the study of law, but
abandoned it for that of medicine. He seems not to have
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JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 77-78.
beeu of a very strong constitution, as he did not pass the inspection for military service. He began the study of medicine
at Eheinis, and completed his course in Paris, where he graduated in 1813, in the twenty-seventh year of his age. While
waiting at home, hesitating what he should do, M. le conite
de Saint-Priest, who occupied au official position in Russia,
hajipened to stay for a few hours in the town of Ai to see
Louis' family, and it was suggested that the young physician
should accompany him to Russia. He consented and in
St. Petersburg obtained a diploma to practice. For three
years he seems to have had no settled abode, but wandered
about with his friend, who was Governor of one of the provinces. He then settled in Odessa, where he remained for four
years and practiced with great success. In the last year of
his stay in Odessa he was very much disturbed by the high
rate of mortality in children with diphtheria, and this appears
to have determined him to abandon for a time the practice of
medicine and to devote himself to study. With this object
in view he returned to Paris and for six months attended the
practice at the Children's Hospital. Among the younger
physicians in Paris he found an old fellow-pupil, Chomel,
physician to La Oharite, who offered him opportunities for
work in his wards. Louis at this time was thirty-four years
of age. Here for six years uninterruptedly he set himself to
work to study disease in the wards and in the post-mortem
i"oom. At first he appears to have occupied the position simply
as a voluntary assistant and friend of Chomel, but subsequently
he became his chef-de-cliniqiie, and during this period he occupied a room in the entresol of the hospital. He was a voluminous note-taker and collected in this time au enormous number of important facts.
This remarkable feature in Louis' life has scarcely been
dwelt upon sufficiently. I know of no other parallel instance
in the history of medicine. It is worth while reading the brief
extract from Dr. Cowan's introduction to his translation of the
work on Phthisis. " He entered the hospital of La Oharite as
a clinical clerk, under his friend. Professor Chomel. For nearly
seven years, including the flower of his bodily and mental
powers (from the age of thirty-three to forty), he consecrated
the whole of his time and talents to rigorous, impartial observation. All private practice was relimiuished, and he allowed no
considerations of personal emolument to interfere with the
resolution he had formed. For some time his extreme minuteness of inquiry and accuracy of description wei'e the subjects
of sneering and ridicule, and cui bonof was not infrequently
and tauntingly asked. The absence of any immediate result
seemed for a time to justify their contempt of a method involving too much labor and personal sacrifice to be generally
popular or easily imitated ; and M. Louis himself, at moments,
almost yielded to the increasing difficulties of the task he had
undertaken. No sooner, however, were his facts sufficiently
numerous to admit of numerical analysis than all doubt and
hesitation were dissi2}ated, and the conviction that the path he
was pursuing could alone conduct him to the discovery of
truth became the animating motive for future perseverance.
Many of the results to which he arrived soon attracted general attention, and among those who had formerly derided his
method while they admired his zeal, he found many toapplaud
and a few to imitate. From this moment may be dated the
presence of that strong impression of the necessity of exact
observation by which the school of Paris has beeu since so
distinguished, and which is now gradually pervading the
medical institutions of the continent and our own country; it
is undoubtedly to the author of the present volume that we
ought to ascribe the practical revival of that system, which
had for ages been verbally recognized but never before rigorously exemplified."
The following works appeared as a direct result of his
studies during these six years:*
" In 1823, a memoir on perforation of the small intestines,
in acute diseases; a second, on croup in the adult; a third, on
the communications between the right and left cavities of the
heart (Archives de medecine).
" In 1824, two memoirs on the pathological anatomy of the
mucous membrane of the stomach ; another on pericarditis.
"In 1826, a memoir on abscess of the liver; another on the
condition of the spinal marrow in Pott's disease; a third on
sudden and unforeseen deaths; a fourth upon slow but anticipated deaths, but which anatomy will not explain; a fifth on
the treatment of tajuia by the Darbon potion (Archives de
medecine).
"In 1825, his Anatomical Researches, etc., on Phthisis (1
vol. 8vo) ; reprinted with many additions in 1843.
" In 1828, Researches on the Typhoid Affection or Fever
(2 vols. 8vo); reprinted with many additions in 1841."
Louis introduced what is known as the Numerical Jlethod,
a plan which we use every day, though the phrase is not now
very often on our lips. The guiding motto of his life was
"Ars medica tota in observation ibus," in carefully observing
facts, carefully collating them, carefully analyzing them. To
get an accurate knowledge of any disease it is necessary to
study a large series of cases and to go into all the particulars
— the conditions under which it is met, the subjects specially
liable, the various symptoms, the pathological changes, the
effects of drugs. This method, so simple, so self-evident, we
owe largely to Louis, in whose hands it proved an invaluable
instrument of research. He remarks in one place that the
edifice of medicine reposes entirely upon facts, and that truth
cannot be elicited but from those which have been well and
completely observed.
American medicine felt the influence of Louis through two
channels, his books and his pupils. Let us speak first of the
former. No French writer of the century has had such a
large audience in this country; all of his important works
were translated and widely read. The work on phthisis, the
first important outcome of five years' hard work at La Oharite
in Ohomel's wards, was published in 1825. Much had already
been done by physicians of the French school on this subject.
Bayle's important Recherchcs had been issued in 1810, and
Laennec had revolutionized the study of phthisis by the publication of his treatise on auscultation. I cannot enter into
any detailed analysis of the work, but it is one which I can
commend to your notice as still of great value, particularly as
* Brief Memories of Louis and some of his Contemporaries. H.
I. Bowditch, Boston, 1872.
Adgust-September, 1897.]
JOHNS HOPKINS HOSPITAL BULLETIN.
163
a model of careful observation. The work was based ujjou the
study of 133 cases observed in Chomel's clinic. The lesions
observed at autopsy are first described under the different
organs, with great accuracy and detail, and then summarized,
following which is an elaborate description of the symjitomatology. I do not know of any single work on pulmonary
tuberculosis which can be studied with greater profit to-day by
the young physician. The fifty years which have elapsed,
since its publication, and the changes which have taken place
in our ideas of tuberculosis, diminish naught from the value
of his careful anatomical and clinical presentation of the subject.
In 1829 appeared his second great work, Anatomical, Pathological and Therapeutical Researches upon the disease knoivn
under the name of yctstro-enterite, putrid, adynamic, ataxic,
typhoid fever, etc., com^mred with the most common acute diseases. It was based upon 138 observations made between 1822
and 1837. He analyzed and determined the lesions found in
fifty patients who had died of the typhus fever, and compared
these with alterations found in other acute diseases. Altogether for this work he states that he analyzed the changes in
the viscera of 133 subjects and the symptoms of nearly 900.
In his introduction to this work he quotes a sentence from
Rousseau which is always to be kept in mind : " I know that
truth lies in the facts, and not in the mind that judges of
them, and that the less I introduce what is merely my own
into the deductions I make from them, the more certain I
shall be of approaching the truth." This work was translated
by Dr. H. I. Bowditch in 1836. At the time of Louis' observations, although differences were recognized between the
various forms of continued fevers, the profession had no accurate knowledge of the subject. It so happened that at this
period the disease prevailing at Paris known as tyjihus was
almost entirely what we now call typhoid fever, so that the
anatomical lesions found by Louis in his fifty autopsies were
chiefly in the intestines ; in all the Peyer's glands were diseased.
His method was to analyze carefully the appearances found
in the different organs in the series of fever cases, and compare them with patients who had died of other acute diseases;
thus of course the contrast was striking in the very matter of
involvement of Peyer's glands, which were more or less seriously changed in structure in all of the patients with the fever,
while in the persons dead of other acute diseases the elliptical
patches had no special redness or softening.
The symptomatology was also given in great detail, and the
same painstaking comparisons were instituted between the
subjects of the typhoid affection and those of other acute diseases. Louis' work convinced a majority of the members of
the Paris school that the essential lesions in continued fevers
were in the intestines, and Louis himself apjiears not to have
had any idea whatever that the disease which he was studying
was in any way different from the disease jirevailing in other
parts of Europe and which we now know as tyjjlius fever.
The next important memoir, the essay on Blood-letting,
had a very potent influence on professional opinion in this
country. It appeared in Paris in 1835 and was translated by
G. C. Putnam, with an introduction and appendix by Dr.
James Jackson. As this learned physician remarks in his
preface, " If anything may be regarded as settled in the treatment of disease, it is that blood-letting is useful in the class
of diseases called inflammatory, and especially in inflammations of the thoracic viscera." When one i-eads the reports of
the treatment by bleeding up to about the year 1840, one is
almost forced to ask the question, are the diseases the same ?
or surely the patients must have possessed much more
powerful constitutions than those which we are called upon
to treat at the end of the century.
At the time of Louis' return to Paris, under the influence
of Broussais' doctrine of irritation, local and general bloodletting was practised more extensively than at any previous
period in the history of medicine. As an interesting illustration it may be mentioned that the trade in France and Spain
in leeches had developed to proportions which assumed really
those of a national industry, and even in this country I
believe one of the medical societies offered a prize for the
best demonstration of the practical method of cultivating
leeches for medicinal purposes.
It must have been a terrible shock to Broussais and his
adherents when Louis attacked the subject of blood-letting in
pneumonia with his numerical method. For this purpose he
analyzed 78 cases, 28 of which proved fatal, and in a second
series 39 cases with 4 deaths. Among his conclusions were
that pneumonitis is never arrested at once by blood-letting, and
that the supposed haj)py effect on the progress of the disease
was very much less than was commonly believed. Incidentally he remarks with reference to the practice of blistering which was in vogue at the time, that he had rejected the
practice .after the treatment of 140 cases of pleurisy without
losing a case. I would refer you particularly to Putnam's
translation of this article, which you can obtain in any of the
libraries, not only for Louis' work, but for the excellent
introduction by Dr. Jackson on the value of the numerical
method in medicine, and also for the appendices, analyzing
the pneumonia cases of the Massachusetts General Hospital
from 1834 to 1834 (inclusive).
To American students one of Louis' most valuable works is
his Research on the Yellow Fever in 1828. On the 1st of
November, 1838, Louis, with Ghervin and Trousseau, left for
Gibraltar, where the disease prevailed. They made a very
careful study of the symptoms and morbid anatomy, and on
their return to Paris made a report to the Academy of Medicine, but the work remained in manuscript until Dr. Geo. C.
Shattuck translated it into English and it was published by
the Massachusetts Medical Society as Vol. X of their Library
of Practical Medicine. The work did not ajjpear in French
until 1844. It is chiefly valuable as a very accurate and
careful record of a series of cases studied clinically and
anatomically.
Powerful as was the effect of Louis' writings on American
medicine, it cannot compare with the influence which he
exerted through his pupils, who " caught his clear accents,
learned his great language, made him their model." Of the
great triumvirate of the French school of the fourth decade,
Louis possessed a singular power of attracting hard-working,
capable men, and this in spite of the fact that his rivals and
friends, Chomel and Audral, possessed more brilliant gifts of
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JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 77-78.
a certain kind. As a writer in the Lancet said (1872, II),
" Year by year fresh bands of students came to imbibe from
his lips the instruction which their predecessors had abandoned
with reluctance, till his academic progeny knew no distinction of race or even color, but coalesced into a noble band of
enthusiasts in the cause of medicine, of science and of
humanity." In this academic progeny Louis' American
pupils take a very unusual position. Among the thousands
in the profession of this country who have during this
century sought light and learning in the older lands, the
group of young men who studied in Paris, between 1830 and
1840, had no predecessors and have had no successors.
Partly because the time was ripe and they were active agents
in bringing the new art and science to the New World, partly
owing to inherent capabilities, etc., but not a little because
the brightest minds among them fell under the influence of
Louis — they more than any others gave an impetus, which it
still feels, to the scientific study of medicine in the United
States.
There had been, of course, in Paris many students from this
country prior to 1830, but they do not form a school, recognizable to us at present. One name comes to my mind, that
of the Rhode Island philosopher, Eiisha Bartlett, a jjeripatetic
of the peripatetics, in the days when men moved from city to
city, like the Sophists of ancient Greece. I do not know
whether when in Paris in 1828 he came personally under
Louis' influence— probably not, as Louis spent part of that
year in Spain — but he brought back recent French methods,
with Gallic lucidity and a keen appreciation of the value of
the numerical method. His well known work on Typhus and
Typhoid Fever, issued in 1842, is in itself a lasting witness to
the intelligence and progressive character of the younger
teachers of that day. With a clear separation of Typhus,
Typhoid, the Periodic and Yellow Fevers, it had at the date
of its publication no counterpart in Eurojiean literature, and
is in remarkable contrast to the chaotic treatises of Armstrong, Fordyce, Tweedie, Southwood Smith and othei'S.
Without attempting to give a comjilete list, the following
were among the American students in Paris between 1830
and 1840:
From Boston, James Jackson, Jr., H. I. Bowditch, Oliver
Wendell Holmes, Geo. 0. Shattuck, Jr., John D. Fisher, J. C.
Warren (then past middle age), and J. Mason Warren.
From New York, John A. Swett, Abraham Dubois, Alonzo
Clark, Charles L. Mitchell, Charles D. Smith, Valentine
Mott, Sr., and John T. Metcalf.
From Philadelphia, Geo. W. Norris, W. W. Gerhard, Casper
W. Pennock, Thomas Stewardson, Alfred Stille, Thomas D.
Muter, J. Campbell Stewart, Charles Bell Gibson, John B.
Biddle, David H. Tucker, Meredith Clymer, Wm. P. Johnston,
W. S. W. Itusheuberger, Edward Peace, William Pep2)er, Sr.
Fi-om Baltimore, William Power.
From the South, Peter C. Gaillard, Gibbs, and Peyre Porcher of Charleston ; J. L. Cabell, L. S. Joyues, Selden and
Randolph of Virginia.
" And many more whose names on earth are dark " — men
of the stamp of Dr. Bassett of Alabama, who felt the strong
impulsion to know the best that the world offei'ed, every one
of whom has left a deep and enduring impression in his sphere
of work.
It would be impossible to tell in detail how Louis' students
brought back his spirit and his methods to their daily work,
and of the revolution which they gradually effected in the
study and in the treatment of disease. I can best, perhaps,
fulfill my object by referring somewhat fully to two of the
most distinguished among them, James Jackson, Jr., and W.
W. Gerhard.
James Jackson, Jr., is the young Marcellus among the physicians of this country, "the young Marcellus, young, but great
and good." I do not know in our profession of a man who
died so young who has left so touching a memory. He was
the son of Dr. James Jackson, of Harvard, one of the most
distinguished of New England's physicians, a man to whom
our generation owes a heavy debt, since he, with Jacob Bigelow,
was mainly instrumental in bringing about more rational
ideas on the treatment of disease. Of Louis' pupils from this
side of the water, young .lackson seems to have been his special
favorite. After taking the B. A. degree at Cambridge in 1828,
Jackson attended the medical lectures at Harvard, and in the
spring of 1831 went to Paris, where he remained until the
summer of 1832. Returning home in 1833, he graduated in
medicine at Harvard in 1834. In the two years and a half of
his studies in this country before going abroad he had had
exceptional opi)ortunities with his father at the Massachusetts General Hospital, and showed his early industry and
ability by taking one of the lioylston Prize Essays before the
completion of his second year of study.
In Paris he attended the practice of La Pitie and St. Louis.
He soon became devoted to Louis, and by him was utilized
to the full in the cholera epidemic in 1832. Two letters from
Louis to James Jackson, Sr., show how important he thought
a prolonged period of study was for a young man. He says:
" I pointed out to him (James Jackson, Jr.) the advantage
it would be for science and for himself if he would devote
several years exclusively to the observation of diseases. I now
retain the same opinion and am strengthened in it; for the
more T become acquainted with, and the more I notice him
applying himself to observation, the more I am persuaded
that he is fitted to render real service to science, to promote
its progress. I find that he would be well pleased to follow
for a certain period the vocation for which nature has fitted
him ; but he has stated to me that there are many difKculties
which would prevent his devoting himself exclusively to
observation for several years. But can these difKculties be
insurmountable?"
xVud again : " Let us sup2)ose that he should pass four
more years without engaging in the practice of medicine, what
amass of positive knowledge will he have acquired! How
many important results will he have been able to publisli to
the world during that period ! After that he must necessarily
become one of the bright lights of his country; others will
resort to him for instruction, and he will be able to impart it
with distinguished honor to himself. If all things be duly
weighed, it will appear that he will soon redeem the four
years, which men of superficial views will believe him to have
lost." In another letter, the following year, just before young
August-September, 1897.]
JOHNS HOPKINS HOSPITAL BULLETIN.
165
Jackson's departure from Paris, he refers again to this question and urges Dr. Jackson to allow his son to devote himself exclusively to observation for several years in Boston.
The extract from this letter is worth quoting. "Think
for a moment, sir, of the situation in which we physicians are placed. We have no legislative chambers to enact
laws for us. We are our own lawgivers ; or rather we must
discover the laws on which our profession rests. We must
discover them and not invent them ; for the laws of nature
are not to be invented. And who is to discover these laws?
Who should be a diligent observer of nature for this purpose, if not the son of a physician, who has himself experienced the difficulties of the observation of disease, who
knows how few minds are fitted for it, and how few have at
once the talents and inclination requisite for the task ? The
inclination especially, for this requires that the observer should
possess a thorough regard for truth, and a certain elevation of
mind, or rather of character, which we rarely meet with. All
this is united in your son. You ought — for in my opinion it
is a duty — you ought to consecrate him for a few years to science. This, sir, is my conviction, and I hope it will be yours
also. I know very well that every one will not be of the same
opinion ; but what matters it, if it be yours ? — if you look upon
a physician, as I do, as holding a sacred office, which demands
greater sacrifices than are to be made in any other profession."
Young Jackson's letter to his father, just as he was quitting
Paris, indicates on what affectionate terms he had lived with
Louis. " In two hours I am out of Paris. I will not attempt
to describe to you the agony it gives me to quit Louis. He is
my second father, and God knows that is a name I of all
men cannot use lightly. I may not persuade you to look upon
him with my eyes exactly as a scientific man ; but in your
heart he must have the share of a brother; for he almost
shares my affection with you. From one upon whom I had
no claims but those which my life and mind and habits gave
me, I have experienced a care, an affection which I never could
dare expect from any but my dear father, and which I shall
ever feel to be the most honorable and truly worthy prize of
my life."
He seems to have inspired the same tender feelings in all
his American students. In the Memoir of Dr. Bowditch, to
which I have already referred, he speaks of Louis' fatherly
kindness to him during a prolonged attack of rheumatic fever
lasting for many weeks.
Young Jackson was one of the founders, in 1833, of the
Society for Medical Observation, which consisted of the ablest
of the students of Louis, Chomel and Andral. During his stay
in Paris he made an important study of cholera, which was
published in this country in 1833. It was most timely, as it gave
the profession here a very clear and accurate description of the
disease, of which up to that time they had had no experience.
Jackson's name, too, will always be associated with the studies
upon emphysema, and he is the discoverer of the prolonged
expiration in early pulmonary tuberculosis.
Returning to Boston in the autumn of 1833, he spent the
winter preparing for his degree and elaborating the notes which
he had taken in Paris. In March he fell ill with a dysentery, which proved fatal on the 37th of the month, in the
twenty-fifth year of his age. I know of no young man in the
profession who had given pledges of such exceptional eminence. His influence in extending Louis' methods and views
throughout New England was chiefly through his father, who,
though a man approaching his sixtieth year, became an ardent
follower of Louis and the numerical method.
In Oliver Wendell Holmes' recently issued Biography you
will find a delightful description of life at the Medical School
of Paris at this period. He bears witness to the good effect
which Jackson's warm friendship with Louis had had in promoting the interests of American students. I may conclude
with a quotation from Dr. Jackson's, Sr., memoir: "At the suggestion and request of one of my most judicious brethren I shall
add that my sou's influence on the profession here, in the
short time he was with us, was of a very salutary description.
This gentleman states that my son not only caused others, who
had not yet read the works of M. Louis, to study them with
care, but that he induced among the rising members of the
profession in our own city the habits of thorough observation
of the phenomena of disease in the living and in the dead,
which he had learned from the same great pathologist. He
also taught us much in respect to the physical signs of disease
in the thorax, with which we were imperfectly acquainted
before; at least I may say this was true as to myself. Indeed
I ought to say more, for he aided me very much in regard to
the diagnosis of the more obscure diseases of that region,
derived from the combination of the physical and rational
signs. On emphysema of the lungs he threw, for me, quite a
new light."
Wm. W. Gerhard was the most distinguished of the American pupils in Paris between 1830 and 1840. When you call
to mind the men whom I have mentioned, this may seem a
strong statement, but I feel certain that could we take their
suffrages they would accord him the place of merit in consequence of the character of his work. Dr. Gerhard was born
in Philadelphia, in 1809, and was graduated from the University of Pennsylvania in 1831. Early in the year he went to
Paris and attached himself to Louis at La Pitie. In one of
his letters* to his brother, dated January 18, 1833, he says:
"Dr. Louis is delivering an interesting clinic at La Pitie ; he
is a remarkable man, very different from the physicians of
Eni^land or America, and remarkable even at Paris by the
strict mathematical accuracy with which he arrives at his
results ; he is not a brilliant man, not of the same grade of
intellect as his colleague at La Pitie, Andral." In another
letter he gives an account of his day's work. "The morning
from seven to ten is occupied with the visit and clinic at the
hospital ; there are several distinct clinics now in actual proo-ress; each of them has its advantages. I shall vary my attendance at the different hospitals and select those lecturers
who are of real merit. At this moment we are following
ing Piorry at the SalpetriOre, a very distant hospital, two or
three miles from our lodgings; his patients are all old women,
and not interesting. My object in following his course is to
obtain some interesting information on the best mode of
* I am indebted to members of Dr. Gerhard's family for the letters
from which these extracts are taken.
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JOHNS HOPKINS HOSPITAL BULLETIN.
[Nos. 77-78.
investigating the diseases of the chest. M. Piorry has devoted
special attention to this subject. From Salpetriere we hurry
to La Pitie; we hear a surgical lecture, reach home to breakfast, and then to the school of medicine. The lectures at the
school, with a private course of anatomy during the hour of
intermission, fill up the remainder of the day until four. Fortunately a private clinic at La Charite introduces me to a set
of very interesting cases, especially on pectoral cases. Dr.
Dagueau has a class who pay him ten francs a month and
enjoy the privilege of examining the patients much more conveniently than is practicable during the morning visit in the
midst of a crowd of students. We dine at five-thirty and then
lectures again until eight o'clock. Imagine the facilities, the
delightful advantage of acquiring positive information, and
what is at least as important, of learning the mode of obtaining these positive results. We see and hear the men who are
so well known to us in America, learn to form a correct estimate of their relative worth — in short, one of the most striking
advantages of a medical visit to Europe is to acquire the sort
of liberal professional feeling which is rarely secured by the
continued intercourse with the same men, and the unpleasant
medical politics which divide the profession in America."
Evidently Broussais made no special impression on Dr.
Gerhard. He says, " Broussais is the best known, his reputation is universal, and the benefits he has conferred on medicine are immense, but unfortunately he is a wretched lecturer.
His own opinions are given in the most awkward, clumsy
manner; the manner and style of lecturing are coarse and
vulgar."
In another letter of February 3, 1833, he tells how he
induced Louis to give them private instruction. To his
brother he writes : " I must write you at least a few days before
the excitement has passed off : can you imagine how fortunate
I am — devinez si vous pouvez— two or three days ago, Jackson,
Pennock and myself were talking of hospitals and morbid
anatomy, when the idea occurred of attempting the study
of pathology in a particular manner. It was this: to obtain
the specimens and study them, the authors in our hand,
exactly and carefully comparing authorities with the subject
before us. We addressed ourselves to two of the internes at La
Pitie attached to the salles of Louis and And-ral, and they agree
to procure all facilities in their power and communicate their
own information for the compensation of 60 francs from each
of us ; we accordingly visit La Pitie on three afternoons of the
week and examine the parts at the hospital, afterwards carrying home such portions as require minute investigation. Our
first success in this opening of new sources of instruction
emboldened tis to attempt something of higher importance.
We were all desirous of studying auscultation, of studying it
in such a manner as to be sure of our ground on our return,
and to be capable of appreciating the advantages of the art.
Louis' public instructions were valuable, but his private
lessons upon a subject demanding minute and patient inquiry
we knew would be infinitely moi'e so. I therefore in the name
of my friends addressed him a polite note, accomjianied by a
handsome pecuniary offer; we did this with little hopes of
success, but happily for us he accepted our proposition, and
next week we are his private pupils at La Pitie. We are, I
believe, the first who have made this arrangement with M.
Louis, and you may estimate its importance when I tell you
that he is considered in excellence of diagnosis the successor
of Laennec. Our advantages for the study of pathology and
the diagnosis of diseases of ttie chest are now superior ; they
are indeed the very best in the world, and our eagerness to
embrace them will, I hope, render them of real utility ; of
course they involve an additional expenditure of 400 or ."300
fr., but I should be happy to shorten my stay at Paris a mouth
to improve the remainder of my time in this manner, if such
were necessary for me. Pennock and myself are very happy
to have become intimate with .Jackson ; he has superior talents,
and his excellent education, conducted by his father, unquestionably the first physician in America, has cultivated his mind
and developed an ardent attachment to medicine."
Few American students have occupied their time abroad
to greater purpose than Dr. Gerhard. He appears to have
been an indefatigable worker, and the papers which he published based upon material collected in Paris are among the
most important which we have from his pen. Thus with
Pennock he described Asiatic cholera in 1832. Devoting
himself particularly to the study of diseases of children, he
issued a very interesting paper on small-pox, and two papers
of very special value, the first on tuberculous meningitis and
the other upon pneumonia in children. Both of these papers
mark a distinct point in our knowledge of these two diseases.
He is usually accorded the credit of the first accurate clinical
study of tuberculous meningitis.
Late in the year 1833 he returned to Philadelphia, and at
his suggestion his friends had secured him the appointment
as resident physician at the Pennsylvania Hospital, which he
took early in 1831. This step indicated how carefully he had
weighed the important influence in Louis' career of the years
of quiet work at La Charite. At the Pennsylvania Hospital
he had an opportunity to study the common continued fever
of the country, and determined that it was identical, clinically
and anatomically, with the typhoid fever of Louis, and characterized by a special lesion in the glands of Peyer. I do not
know exactly how long he remained resident physician at the
Pennsylvania Hospital, but he was soon after appointed one
of the physicians at Blockley, and here in 1836 he was able io
carry out his most important piece of work. The general
opinion prevailed that the fever which Louis described and
which had the lesions in the small bowel was only a modification of the ordinary typhus fever which at that time prevailed so extensively, particularly in Great Britain and
Ireland. In London, Edinburgh and Dublin the intestinal
lesions were regarded as only accidental, and not indicative of
a special affection. Dr. Gerhard knew the typhoid fever of
Louis well, and had had an opportunity of studying it again
at the Pennsylvania Hospital, so that when the epidemic of
typhus fever developed in 1836 he was in a very good position
to make an accurate study of the disease. Two hundred and
fourteen cases were observed, and as a result of his study he
declared positively that the typhus fever, which was similar
to the disease which he had also seen in Edinburgh, was a
different affection altogether from the typhoid fever with
intestinal lesions. These observations, vou must remember.
August-September, 1897.]
JOHNS HOPKINS HOSPITAL BULLETIN.
167
were made in 1836, at a time when the greatest confusion
existed as to the forms of fever. It took a great many years
in Great Britain before the duality of the prevalent fever was
recognized, but owing to the influence of Gerhard's paper,
and to the accurate knowledge of fever brought to this
country by Louis' pupils, the differentiation of the two
diseases was here quickly recognized, since, as already mentioned, Bartlett in 1812 considered them apart.
Gerhard's work influenced his Paris friends greatly, and
this was strengthened by the papers read before the Society
for Medical Observation by Geo. C. Sbattuck and Alfred
Stille, of whom the former had had opportunities of studying
typhus fever in Great Britain, while the latter had been one
of Gerhard's house physicians in the typhus epidemic at
Blockley. Shattuck's paper is published in the Medical
Examiner for 1840. I have always regretted that Dr. Stille's
paper has never appeared in print. He was kind enough to
let me see it, and, as I have mentioned elsewhere, the differential points between typhus and tyi^hoid fever are nowhei-e
more clearly laid down.
The University of Pennsylvania early took advantage of
Gerhard's training and utilized him as clinical lecturer at the
Philadelphia Hospital. He soon acquired a special reputation
in diseases of the heart and lungs. In 1842 appeared the first
edition of his work on Diseases of the Chest, which ran through
four editions, and is still a valuable work of reference. One of
his fellow-students in Paris, Stewardson, has given a very pleasing picture of him as a clinical teacher : " As a clinical teacher
he was remarkably successful and exerted a powerful and
commanding influence. Without any pretension to eloquence,
he nevertheless riveted the attention of his hearers and
stimulated their enthusiasm. Himself deeply interested in
bis subject, he communicated this interest to his audience by
the sheer force of truth. Students saw that truth was his
object, not display ; the advancement of science, and not the
gratification of personal feelings, whether of vanity or ambition; in short, that in his mind, a deep interest in his subject
and a thorough conscientiousness in the pursuit of it were
the overmastering motives. In an easy and conversational
style he presented to his hearers a graphic portraiture of the
case before them, bringing into relief its most important
symptoms; impressing upon their minds the most striking
features in its history; pointing out, by a few clear and
practical expressions, the bearing of any particular fact upon
interesting medical questions, but avoiding long and labored
arguments, or general disquisitions upon the nature of
diseased action. He neither stimulated the fancy by the
flowers of rhetoric, nor amused the intellect with episodes upon
theoretical questions, but confined himself to drawing such
practical conclusions as were clearly deducible from the facts
presented. No man of his day enjoyed so high a reputation
as a clinical teacher, and not only did he succeed in an eminent
degree in arousing the enthusiasm of students and putting
them in sympathy with himself, by infusing into them his
own ardor in his favorite study ; but he produced an influence
upon the profession here which is felt still, which has fostered
the establishment of clinical teaching among us, and done
much to give it that rank which it now occupies here as a
branch of medical instruction."
Of the work of Louis' other students in this country time
would fail me to tell — of the influence of Bowditch, Holmes
and Shattuck in Boston, of Swett, Clark and others in New
York, of Pennock, Stewardson, Stille in Philadelphia, and of
Power in Baltimore. To them all we owe a heavy debt of
gratitude. They brought from Paris enthusiasm, faith in the
future, faith in the profession of their choice, accurate
methods and a loyal love of truth. Endowed with the spirit
and zeal of their master, they carried his great message to the
New World ; and more than this, touched with those finer
qualities which made Louis so lovable, they have become
bright ideals for all future generations of American students.
There remain, so far as I know, three only of the Paris
students of whom I have spoken, John T. Metcalf, Meredith
. Clymer, and your honored patron, Alfred Stille. They, too,
must soon go the way of all the earth ; but among the consolations of old age what greater solace can they feel than that
the lives of the men whose fathers and grandfathers they
taught are still made better by their presence.
WILLIAM HARVEY AS AN EMBRYOLOGIST.*
By William K. Brooks, LL. D., Professor of Zoology, Johns Hoiikins JJniversUy.
The immortal discoverer of the circulation of the blood is
held to be also the discoverer of the law of embryology —
"that all animals are produced out of ova" (Encyc. Brit.,
9th ed., art. Embryology, p. 164); and he is also held to have
had some vague premonition, scarcely worth mentioning in
history, of the great law that the complex animal arises, from
a relatively homogeneous germ, by gradual differentiation or
epigenesis.
I hope to show, by quotations from his work on embryology
(Exercitationes de Generatione Animalium, Amstelodami,
■ Read before the Johns Hopkins Historical Club, February, 1897.
1651, translated into English by Robert Willis, M. D., London,
1848), that both these current impressions are erroneous. He
not only formulated but demonstrated epigenesis. liis statement of this law is clear, definite and thoroughly modern,
and it is based upon actual observations which are fully
described.
On the other hand the conception which he sought to
express by the dictum "omne vivum ex ovo" is totally foreign
to the principles of modern embryology. Harvey was a worker,
not a dreamer, and his dictum is no mere guess or happy inspiration. It sums up results reached by laborious research, and
as a generalization based on actual study it still has value,


although its meaning has nothing in common with tliat  
although its meaning has nothing in common with tliat  

Revision as of 12:06, 16 February 2020

NOTES ON NEW BOOKS.

Anomalies and Curiosities of Medicine, being an encyclopedic collection of rare and extraordinary cases, and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, classi fled and indexed. By Georqe M. Gould, A. M., M. D.,and Walter L. Pyi.e, A. M., M. D. With 295 illustrations and 12 half-tone and colored plate.s. 908 pp. (Philadelphia : W. B. Saunders, 1897.)

Tliestatementof Gibbon that objects which are only singular without being pleasing may excite surprise but soon lead to satiety and <iisgust, does not apply to this volume, which is thoroughly interesting from beginning to end. The attempt of the authors "to briefly epitomize and to arrange in order the records of the most curious, bizarre and abnormal cases thatare found in medical literature of all ages and all languages," has been most successful. The book is thoroughly scientiflc in its treatment of the varied material which has been gathered with an industry which calls forth admiration. The Urst six chapters will probably be read most generally and relate to anomalies of conception, birth and development, and are of special interest to the gynecologist, obstetrician and student of legal medicine. Chapter seven relates to gigantism, dwarflshness, obesity and abnormal leanness, and the accompanying illustrations form a curious collection of anomalies suggestive of a dime museum.

The chapter on longevity taxes one's faith rather more than any other. Think of Henry Jenkins dying at the age of 169 years ; Thomas Parr at 152 ; Jean Korinat 172 and his wife atl64, and ason left an orphan by their untimely death at the tender age of 116 ; Petretsh Zartan at 185 or 187 (authorities differing), who walked a mile to the post ofiice a few days before his death to ask for alms ; and many other well-authenticated instances of nearly equal age.

The chapter on anomalous mental and nervous diseases is so complete it is a matter of surprise that it does not include the history of the young man in Ohio who became totally blind at the age of seven months, and who, while receiving an education at the school for the blind, in consequence of a fall, lost both hearing and speech. After a time, his eyesight being restored by the fall, he was transferred to an establishment for the education of deaf mutes. Here eventually his hearing was suddenly restored, but epileptic attacks developed which required hospital treatment, this time in an institution for the insane. This well-authenticated tale was published in considerable detail in one of the State repoits and deserves a place in these annals. The chapter on Historic Epidemics is timely, especially the full account of the bubonic plagues of the middle ages.

An excellent feature of the book is the judicial spirit shown by the authors. Facts are weighed and reasons are advanced for the conclusions which are reached. The book is well printed and finely illustrated and is worthy of a large success. Every chapter is of interest to every physician.

Text-Book of Materia Medica, Therapeutics and Pharmacology. By G. F. Butler, M. D. [Philadelphia: W. B. Saundem, 1896.)

This work is dedicated to the " Medical Students of the United States," and we have no doubt that many of them who enjoy buying the latest work on this branch of medicine will find it serviceable. It cannot be said to replace the oliier works of Wood, Hare and others. There is very little true original thought in it, which should be the the real reason for the publication of any new book, especially to-day, when there is altogether too much production of simply transient works. As the author states in the preface : " From the U. S. Pharmacopeia chiefly, and from the National Dispensatory, have been adopted almost verbatim, the ' origin ' and 'description and properties' of tlie various drugs under consideration," so it is more in his arrangement of his material that we must


look for originality. He classifies the drugs by their properties, rather than alphabetically, as is done by Hare. Both methodshave their advocates, and [lersonally, as it is much the most rapid way to look up any given drug, we prefer the latter method. Butler still further cljftsifies the drugs into so called " Disease-Medicines," a very unscientific term, as he himself recognizes, and "SymptomMedicines." In such a classification no two persons willagree as to the class to which certain medicines will belong most properly, and thus it becomes confusing and time-consuming to search for the drug wanted. The author says: "A genuine specific is tolerated only by the system in which it antagonizes some disease. For instance, A and B are put under a prolonged course of mercury ; A is salivated beyond recognition, while B's health improves — simply for the re.ison that B had syphilis, which A had not." Such general remarks are often not true, and the example given is a very poor one, for we all know that syphilitic patients may be salivated, and sometimes as severely as those who are not syphilitic. Also many ]>atients who have not sypliilis may take mercury in large doses for long periods of time without becoming salivated. We do not understand the following sentence: "Quinine was formerly considered a specific in malaria, until the fact was recognized that the drug is analogous to a normal constituent of healthy bile in its action upon plasmodia malariae." W^e believe that by most authorities quinine is still considered to be a specific in malaria, whatever the action of bile may be. In a work which covers so much ground as this text-book, the value depends on an equal balancing of the different parts, and especially, in the description of the drugs, of careful omission of all unnecessary parts, and still more exact and concise information on all important points. Each author naturally finds special interest in certain parts of his work, and so not knowing these it is hard to criticise the book justly. But in the 650 pages given to drugs and their actions we feel that much improvement could have been made with careful revision — some parts omitted, and other information of more importance added. We think it quite out of place to introduce in such a work declensions of simple Latin words and other rules of Latin grammar, which should be known by every student before he begins the studj- of medicine, and if he does not know them, he should not be helped to the knowledge in this superficial manner.

Diseases of the Ear, Nose and Throat. By S. P. Bishop, M. D. (Philadelphia : F. A. Davis Co., 1897.)

This book, we think, fulfills pretty satisfactorily the object of the author, as expressed in the preface; he says: "This work was designed, first to help students in preparing for their degree ; second, for those progressive practitioners who wish to acquire the proficiency necessary to properly treat those patients who are unable to visit specialists ; and third, for those who are gradually exchanging their general practice for special work in these branches." The chapter on blood-serum therapy in diphtheria seems out of place ; it is merely an abstract of a few of the articles which liave appeared on this subject during the past two years, and we see no good reason for introducing it here. The work on the whole is a fair presentation of our knowledge in these diseases, without any attempt to take up any of them at length. The treatment as given is generally satisfactory and simple. We do not agree with the author in considering hay-fever, or "nervous catarrh," as he prefers to call it, a result of uric acid diathesis. There are many questions in the study of this disease which are as yet quite inexl)licable, and this theory of its causation is insufficient to explain them all ; the neurotic character of the disease is well established, and that uric acid may in some caees play an inijiortant role in this nervous affection is undoubted, but it is also equally certain that other important causes play their role too in determining this malady.

This book is clieaply gotten up and the cuts are of poor quality ; tlie colored illustrations also seem very unsatisfactory. Many of


July, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


159


the cuts are reproductions of instruments wliich by this time should be l^nown to all practitioners and to every student graduating from a medical college. These simply add to the expense of the book without adding to its intrinsic value.

Essentials of Physical Diagnosis of the Thorax. Second Edition.

By Arthur M. Cokwin, M. D. (Philadelphia: W. B. Saunders,

189a.)

That there is a demand for such a quiz-compend or aid in cramming for an examination is shown by the fact that a second edition of this small book has been called for. We cannot recommend it, however, for like other similar works it fails in attempting to condense much knowledge in a very limited space and although tolerably well arranged, there are numerous statements of fact with which we cannot agree. The varieties of tympany (p. 69) are confusing and not generally used and were better omitted in such a work. In the discussion of heart murmurs there is much needless repetition, and on p. 176 the mitral systolic murmur described as occurring in aortic insufficiency, otherwise known as Flint's murmur, is presystolic in time. The chapter on congenital lesions of the heart is treated too briefly to be of service, as is also the one on hydatid cyst of the lung, which, when jiriniary, is not a condition easy to diagnose, nor could the signs of it as given by the author differentiate it from pleurisy. 8pasm of the columnar carnese is a condition which may occur, but it is hardly one of which a diagnosis could be made. Acute endocarditis without valvular lesion is not a condition which can be recognized clinically, and inorganic aortic systolic murmurs should usually be doubted. The ratio of the inspiratory sound to the expiratory is not as tiiree to one, nor in asthma is the dyspnosa (orthopncea) chiefly expiratory. CheyneStokes respiration does not ordinarily accompany opium poisoning. No worse instrument for clinical instruction could well be devised than the multiplex stethoscope, of which there is an illustration in the beginning of this work.

Pathological Report of the Illinois Eastern Hospital tor the I (Chicago: Blakely rrinting Co., 1896.)

This is an excellent report, full of much valuable mateiial, and Dr. Adolf Meyer deserves much credit for it, considering the difficulties under which the work was prosecuted, due to a lack of general facilities for carrying it on. We cannot criticise any shortcomings when we read his closing remarks. He says: "It may justly be said that the publication of so much raw material is of little use. To polish the report, away from the records and the material, did not seem to he in the interest of the accuracy of a picture of the working of the laboratory which had barely come into existence at the end of the period covered. The work was planned on a broader basis than it was feasible to carry out in the short period. The idea was that the plan of publishing ' interesting' cases only was not in the interest of sober study of the daily experience, that selecting cases might lead to illustration of preconceived ideas instead of the facts as they present themselves in reality, and that at the present stage of psychiatry a consideration of all the things seen wouM be less dangerous than arbitrary selection. The same jirinciple should be carried out in the clinical side as well." Although much of the material is raw, yet many facts of interest are to be found — perhaps the most interesting being that 32 per cent, out of 49 cases of terminal dementia, and 27 per cent, of 192 cases of mental diseases, including the first series, died of florid tuberculosis. Of course without fuller statistics as to the class of patients in the hospital, too much stress should not be laidon these figures, but nevertheless the percentage is high. A case of acute mania, dying presumably of sulphonal poisoning, shows the necessity of the utmost care being used in the administration of drug.ito patients with mental diseases to avoid accidents of this sort. We shall await with pleasure sui cessive reports from Dr. Meyer, who has now transferred his work to the Worcester State Hospital and


nsane.


Clark University, and trust he will be able to describe some of the finer microscopical findings in brain and cord lesions from the interesting material at his disposal.

St. Thomas's Hospital Reports. New Series. Vol. XXIV. i London,

1895.)

The first half only of this volume is taken up with detailed papers, and the second half with statistics of the different departments of the hospital, and brief abstracts of cases, medical and surgical. Among the papers here preseuted, two are worthy of special note. The article on " Osteo-arthropathy and its Relationships," with report of a case of pulmonary hypertrophic osteoarthropathy, both by Dr. Walters, is a very valuable contribution to our knowledge of this curious condition and its relationship to akromegaly. It is an exhaustive study, with a brief abstract of all the cases reported of this bone disease up to the time of the publication of this volume. The other paper is on "Enteric Fever and Sewage Gas," in which 11 cases of typhoid fever are described as resulting from poisoning with sewer gas in one hospital within a short space of time. Here milk, water and food as possible sources of the contagion could apparently be eliminated without doubt, and the only other discoverable source was a water-closet into which typhoid organisms had probably been discharged but a few weeks before the outbreak of this small epidemic, which ceased as soon as the sewage pipes were overhauled and modified. With the modern belief that typhoid fever in nearly every case re>ult8 from milk, water or food contaminated by the typhoid organism, this epidemic raises the most interesting question as to whether or not typhoid bacilli may enter the body through the lungs and thus cause the fever. There are other articles on tuberculous disease in the knee-joint, and relapse in the si)ecific fevers, which will repay careful reading.

Feeding in Early Infancy. By Arthur V. Meigs, 51. D. (Vhiladelphia: W. B. Saunders, 1896.)

In this paper Dr. Meigs emphasizes the results of his milk analyses as expressed in his earlier publication, and describes in detail the preparation of his food, based on these results.

He finds that human milk never contains more than one percent, casein, cow's milk three times this amount, other constituents being present in about equal quantities. In his preparation cow's milk is therefore diluted with lime water, and cream and sugar added in definite proportions. The food, piepared after this manner, has been used for a number of years by the author, with satisfactory results.

He thinks thatsulijecting milktohightemperaturesdetracts from its usefulness as an infant food ; therefore it is better to be assured of its source and avoid sterilization.

This course seems hardly practicable, and the injurious effect accredited to sterilization is not sustained by most writers on the subject.

Proceedings of the American Medico-Psychological Af-sociation at the 52d Annual Meeting, held in Boston, May 26-29, 1896. {American Medico-Psychological Associaiion, 1896.)

The proceedings of this society occupy nearly 300 large papers, pretty closely printed ; but all the papers are good, while some are of especial value. There is an interesting address on psychological education by Stanley Hall, a leading authority on such a subject; and there are important contributions by Brush, Worcester, Hoch, and Berkley. The paper by Hoch, on " General Paralysis in Two Sisters," is perhaps, while one of the most thorough articles, the one of most general interest. To students who have given much time to the study of the blood, the paper on " Leucocytosis Associated with Convulsions," by Burrows, will open up a point of much interest as to the cause of leucocytosis, whether or not it be due to a form of auto-intoxication.


160


JOHNS HOPKINS HOSPITAL BULLETIN.


[So, 76.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


THE JOHNS HOPKINS HOSPITAL REPORTS. Volume I. 423 i>ages, 99 plates.

Report in Pntliologry.

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

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

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

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

Mall, M. D.

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

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

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

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

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

T. C. Gilchrist, M. D.

Report In Patholog^y. An Experimental Study of tin' Thyroid Gland of Dogs, with especial consideration

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


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

Report in Meillcine.

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

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

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

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

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

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

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

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

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

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

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

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

Howard A. Kelly, M. D.

Report in Snri;:ery, I. The Treatment of Wounds with Especial Reference to the VaUu^ of the Blond Clol

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

Henry M. Thomas, M. D.

Report in Patbolo^y, I. Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.


Volume III. 706 pages, with 69 plates and figures.

Report in Patholosry*

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

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

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

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

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

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

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

Report in Gynecology,

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

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

Intestinal Worms as a Complication in Abdominal Surgery. Bj A. L. Stavklt, M, D.


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

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

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

Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

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

Report in Neurology.

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BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vm.-Nos. 77-78.]


BALTIMORE, AUGUST-SEPTEMBER, 1897.


[Price, 15 Cents.


GOnSTTEJaSTTS.


PAGE.

Influence of Louis on American Medicine. By Willia.m O.SLEB, M. D., - - - 161

AVilliam Harvey as an Embryologist. By William K. Brooks, LL. D., - - - - - - 167

Long, the Discoverer of Anaesthesia. A Presentation of lii.s Original Documents. By Hugh H. Young, A. M., M. D., - 174

The Early History of Ophthalmology and Otology in Baltimore (1800-1850). By Harry Friedknwald, A. B , M. D., - 184


Joseph Friederich Piringer: His Methods and Investigations.

By Harry Friedenwald, A.B., M. D., 191

Proceedings of Societies :

Hospital Medical Society, " - 195

Hsematomyelia from Gunshot Wound of the Cervical Spine [Dr. Gushing].

Notes on New Books, _ . - _ 197

Books Received, 197


INFLUENCE OF LOUIS ON AMERICAN MEDICINE.

By William Oslek, M. D.


Harvey and Sydenham, types of the scientific and the practical physician, though contemporaries, were uninfluenced, 80 far as we know, by the other's work or method. Harvey had little reputation us a practical physician, and Sydenham cared little for theories or e.\periment. Modern scientific medicine, in which these two great types meet, liad its rise in France in the early days of this century. True, there had lived and worked in England the greatest anatomist and medical thinker of modern times; but John Hunter, to whose broad vision disease was but one of the processes of nature to be studied, was as a voice crying in the wilderness to the speculative, theoretical physicians of his day.

Bichat's Anatomie Gaicrale laid the foundation of the positive or modern method of the study of medicine, in which theory and reasoning were replaced by observation and analysis. Laennec, with the stethoscope, and with an accurate study of disease at the bedside and in the post-mortem room, almost created clinical medicine as we know it to-day.

The study of fevers occupied the attention of all the great physicians of the time. Fever — what it was, how it should be treated. What a vast literature exists between Sydenham and BroussaisI What a desolate sea of theory and speculation !


•Read before the Stille Society of the Medical Department of the University of Pennsylvania.


No one had been more influenced by Bichat's brilliant teachings than Broussais, who ruled supreme in the medical world of Paris in the early decades of this century. A strong believer in careful observations at the bedside and in the jiostniortem room, he was led into hoj)eless error in attributing fevers and many other disorders to irritation in the stomach and intestines — his gastro-enteritis.

Writing in the American Medical Recorder, July, 1831, an American student, Dr. F. J. Didier, says of the Paris professors of that date, "They were always talking of Hippocrates, Galen, Oelsns, etc., as if not a particle had been added to the stock of knowledge since their time." And again, " The doctrines of John Brown, mixed up with the reninantsof humoral pathology, form the basis of the present system."

The same mi.xture prevailed early in the fourth decade, as you may see from Broussais' Pathology, the American edition of which was issued in 1833, and from Jackson's (Samuel) Principles of Medicine, published in the same year.

Upon this scene, when Broussais was at the height of his fame, came Louis. He, with his friends Andral and Chomel, were very important factors in substituting finally in the study of medicine, for speculation and theory, observation and method.

The chief facts in Louis' life may be thus briefly stated. He was born in 1787 at Ai. He began the study of law, but abandoned it for that of medicine. He seems not to have


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beeu of a very strong constitution, as he did not pass the inspection for military service. He began the study of medicine at Eheinis, and completed his course in Paris, where he graduated in 1813, in the twenty-seventh year of his age. While waiting at home, hesitating what he should do, M. le conite de Saint-Priest, who occupied au official position in Russia, hajipened to stay for a few hours in the town of Ai to see Louis' family, and it was suggested that the young physician should accompany him to Russia. He consented and in St. Petersburg obtained a diploma to practice. For three years he seems to have had no settled abode, but wandered about with his friend, who was Governor of one of the provinces. He then settled in Odessa, where he remained for four years and practiced with great success. In the last year of his stay in Odessa he was very much disturbed by the high rate of mortality in children with diphtheria, and this appears to have determined him to abandon for a time the practice of medicine and to devote himself to study. With this object in view he returned to Paris and for six months attended the practice at the Children's Hospital. Among the younger physicians in Paris he found an old fellow-pupil, Chomel, physician to La Oharite, who offered him opportunities for work in his wards. Louis at this time was thirty-four years of age. Here for six years uninterruptedly he set himself to work to study disease in the wards and in the post-mortem i"oom. At first he appears to have occupied the position simply as a voluntary assistant and friend of Chomel, but subsequently he became his chef-de-cliniqiie, and during this period he occupied a room in the entresol of the hospital. He was a voluminous note-taker and collected in this time au enormous number of important facts.

This remarkable feature in Louis' life has scarcely been dwelt upon sufficiently. I know of no other parallel instance in the history of medicine. It is worth while reading the brief extract from Dr. Cowan's introduction to his translation of the work on Phthisis. " He entered the hospital of La Oharite as a clinical clerk, under his friend. Professor Chomel. For nearly seven years, including the flower of his bodily and mental powers (from the age of thirty-three to forty), he consecrated the whole of his time and talents to rigorous, impartial observation. All private practice was relimiuished, and he allowed no considerations of personal emolument to interfere with the resolution he had formed. For some time his extreme minuteness of inquiry and accuracy of description wei'e the subjects of sneering and ridicule, and cui bonof was not infrequently and tauntingly asked. The absence of any immediate result seemed for a time to justify their contempt of a method involving too much labor and personal sacrifice to be generally popular or easily imitated ; and M. Louis himself, at moments, almost yielded to the increasing difficulties of the task he had undertaken. No sooner, however, were his facts sufficiently numerous to admit of numerical analysis than all doubt and hesitation were dissi2}ated, and the conviction that the path he was pursuing could alone conduct him to the discovery of truth became the animating motive for future perseverance. Many of the results to which he arrived soon attracted general attention, and among those who had formerly derided his method while they admired his zeal, he found many toapplaud


and a few to imitate. From this moment may be dated the presence of that strong impression of the necessity of exact observation by which the school of Paris has beeu since so distinguished, and which is now gradually pervading the medical institutions of the continent and our own country; it is undoubtedly to the author of the present volume that we ought to ascribe the practical revival of that system, which had for ages been verbally recognized but never before rigorously exemplified."

The following works appeared as a direct result of his studies during these six years:*

" In 1823, a memoir on perforation of the small intestines, in acute diseases; a second, on croup in the adult; a third, on the communications between the right and left cavities of the heart (Archives de medecine).

" In 1824, two memoirs on the pathological anatomy of the mucous membrane of the stomach ; another on pericarditis.

"In 1826, a memoir on abscess of the liver; another on the condition of the spinal marrow in Pott's disease; a third on sudden and unforeseen deaths; a fourth upon slow but anticipated deaths, but which anatomy will not explain; a fifth on the treatment of tajuia by the Darbon potion (Archives de medecine).

"In 1825, his Anatomical Researches, etc., on Phthisis (1 vol. 8vo) ; reprinted with many additions in 1843.

" In 1828, Researches on the Typhoid Affection or Fever (2 vols. 8vo); reprinted with many additions in 1841."

Louis introduced what is known as the Numerical Jlethod, a plan which we use every day, though the phrase is not now very often on our lips. The guiding motto of his life was "Ars medica tota in observation ibus," in carefully observing facts, carefully collating them, carefully analyzing them. To get an accurate knowledge of any disease it is necessary to study a large series of cases and to go into all the particulars — the conditions under which it is met, the subjects specially liable, the various symptoms, the pathological changes, the effects of drugs. This method, so simple, so self-evident, we owe largely to Louis, in whose hands it proved an invaluable instrument of research. He remarks in one place that the edifice of medicine reposes entirely upon facts, and that truth cannot be elicited but from those which have been well and completely observed.

American medicine felt the influence of Louis through two channels, his books and his pupils. Let us speak first of the former. No French writer of the century has had such a large audience in this country; all of his important works were translated and widely read. The work on phthisis, the first important outcome of five years' hard work at La Oharite in Ohomel's wards, was published in 1825. Much had already been done by physicians of the French school on this subject. Bayle's important Recherchcs had been issued in 1810, and Laennec had revolutionized the study of phthisis by the publication of his treatise on auscultation. I cannot enter into any detailed analysis of the work, but it is one which I can commend to your notice as still of great value, particularly as


  • Brief Memories of Louis and some of his Contemporaries. H.

I. Bowditch, Boston, 1872.


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a model of careful observation. The work was based ujjou the study of 133 cases observed in Chomel's clinic. The lesions observed at autopsy are first described under the different organs, with great accuracy and detail, and then summarized, following which is an elaborate description of the symjitomatology. I do not know of any single work on pulmonary tuberculosis which can be studied with greater profit to-day by the young physician. The fifty years which have elapsed, since its publication, and the changes which have taken place in our ideas of tuberculosis, diminish naught from the value of his careful anatomical and clinical presentation of the subject.

In 1829 appeared his second great work, Anatomical, Pathological and Therapeutical Researches upon the disease knoivn under the name of yctstro-enterite, putrid, adynamic, ataxic, typhoid fever, etc., com^mred with the most common acute diseases. It was based upon 138 observations made between 1822 and 1837. He analyzed and determined the lesions found in fifty patients who had died of the typhus fever, and compared these with alterations found in other acute diseases. Altogether for this work he states that he analyzed the changes in the viscera of 133 subjects and the symptoms of nearly 900. In his introduction to this work he quotes a sentence from Rousseau which is always to be kept in mind : " I know that truth lies in the facts, and not in the mind that judges of them, and that the less I introduce what is merely my own into the deductions I make from them, the more certain I shall be of approaching the truth." This work was translated by Dr. H. I. Bowditch in 1836. At the time of Louis' observations, although differences were recognized between the various forms of continued fevers, the profession had no accurate knowledge of the subject. It so happened that at this period the disease prevailing at Paris known as tyjihus was almost entirely what we now call typhoid fever, so that the anatomical lesions found by Louis in his fifty autopsies were chiefly in the intestines ; in all the Peyer's glands were diseased. His method was to analyze carefully the appearances found in the different organs in the series of fever cases, and compare them with patients who had died of other acute diseases; thus of course the contrast was striking in the very matter of involvement of Peyer's glands, which were more or less seriously changed in structure in all of the patients with the fever, while in the persons dead of other acute diseases the elliptical patches had no special redness or softening.

The symptomatology was also given in great detail, and the same painstaking comparisons were instituted between the subjects of the typhoid affection and those of other acute diseases. Louis' work convinced a majority of the members of the Paris school that the essential lesions in continued fevers were in the intestines, and Louis himself apjiears not to have had any idea whatever that the disease which he was studying was in any way different from the disease jirevailing in other parts of Europe and which we now know as tyjjlius fever.

The next important memoir, the essay on Blood-letting, had a very potent influence on professional opinion in this country. It appeared in Paris in 1835 and was translated by G. C. Putnam, with an introduction and appendix by Dr. James Jackson. As this learned physician remarks in his


preface, " If anything may be regarded as settled in the treatment of disease, it is that blood-letting is useful in the class of diseases called inflammatory, and especially in inflammations of the thoracic viscera." When one i-eads the reports of the treatment by bleeding up to about the year 1840, one is almost forced to ask the question, are the diseases the same ? or surely the patients must have possessed much more powerful constitutions than those which we are called upon to treat at the end of the century.

At the time of Louis' return to Paris, under the influence of Broussais' doctrine of irritation, local and general bloodletting was practised more extensively than at any previous period in the history of medicine. As an interesting illustration it may be mentioned that the trade in France and Spain in leeches had developed to proportions which assumed really those of a national industry, and even in this country I believe one of the medical societies offered a prize for the best demonstration of the practical method of cultivating leeches for medicinal purposes.

It must have been a terrible shock to Broussais and his adherents when Louis attacked the subject of blood-letting in pneumonia with his numerical method. For this purpose he analyzed 78 cases, 28 of which proved fatal, and in a second series 39 cases with 4 deaths. Among his conclusions were that pneumonitis is never arrested at once by blood-letting, and that the supposed haj)py effect on the progress of the disease was very much less than was commonly believed. Incidentally he remarks with reference to the practice of blistering which was in vogue at the time, that he had rejected the practice .after the treatment of 140 cases of pleurisy without losing a case. I would refer you particularly to Putnam's translation of this article, which you can obtain in any of the libraries, not only for Louis' work, but for the excellent introduction by Dr. Jackson on the value of the numerical method in medicine, and also for the appendices, analyzing the pneumonia cases of the Massachusetts General Hospital from 1834 to 1834 (inclusive).

To American students one of Louis' most valuable works is his Research on the Yellow Fever in 1828. On the 1st of November, 1838, Louis, with Ghervin and Trousseau, left for Gibraltar, where the disease prevailed. They made a very careful study of the symptoms and morbid anatomy, and on their return to Paris made a report to the Academy of Medicine, but the work remained in manuscript until Dr. Geo. C. Shattuck translated it into English and it was published by the Massachusetts Medical Society as Vol. X of their Library of Practical Medicine. The work did not ajjpear in French until 1844. It is chiefly valuable as a very accurate and careful record of a series of cases studied clinically and anatomically.

Powerful as was the effect of Louis' writings on American medicine, it cannot compare with the influence which he exerted through his pupils, who " caught his clear accents, learned his great language, made him their model." Of the great triumvirate of the French school of the fourth decade, Louis possessed a singular power of attracting hard-working, capable men, and this in spite of the fact that his rivals and friends, Chomel and Audral, possessed more brilliant gifts of


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a certain kind. As a writer in the Lancet said (1872, II), " Year by year fresh bands of students came to imbibe from his lips the instruction which their predecessors had abandoned with reluctance, till his academic progeny knew no distinction of race or even color, but coalesced into a noble band of enthusiasts in the cause of medicine, of science and of humanity." In this academic progeny Louis' American pupils take a very unusual position. Among the thousands in the profession of this country who have during this century sought light and learning in the older lands, the group of young men who studied in Paris, between 1830 and 1840, had no predecessors and have had no successors. Partly because the time was ripe and they were active agents in bringing the new art and science to the New World, partly owing to inherent capabilities, etc., but not a little because the brightest minds among them fell under the influence of Louis — they more than any others gave an impetus, which it still feels, to the scientific study of medicine in the United States.

There had been, of course, in Paris many students from this country prior to 1830, but they do not form a school, recognizable to us at present. One name comes to my mind, that of the Rhode Island philosopher, Eiisha Bartlett, a jjeripatetic of the peripatetics, in the days when men moved from city to city, like the Sophists of ancient Greece. I do not know whether when in Paris in 1828 he came personally under Louis' influence— probably not, as Louis spent part of that year in Spain — but he brought back recent French methods, with Gallic lucidity and a keen appreciation of the value of the numerical method. His well known work on Typhus and Typhoid Fever, issued in 1842, is in itself a lasting witness to the intelligence and progressive character of the younger teachers of that day. With a clear separation of Typhus, Typhoid, the Periodic and Yellow Fevers, it had at the date of its publication no counterpart in Eurojiean literature, and is in remarkable contrast to the chaotic treatises of Armstrong, Fordyce, Tweedie, Southwood Smith and othei'S.

Without attempting to give a comjilete list, the following were among the American students in Paris between 1830 and 1840:

From Boston, James Jackson, Jr., H. I. Bowditch, Oliver Wendell Holmes, Geo. 0. Shattuck, Jr., John D. Fisher, J. C. Warren (then past middle age), and J. Mason Warren.

From New York, John A. Swett, Abraham Dubois, Alonzo Clark, Charles L. Mitchell, Charles D. Smith, Valentine Mott, Sr., and John T. Metcalf.

From Philadelphia, Geo. W. Norris, W. W. Gerhard, Casper W. Pennock, Thomas Stewardson, Alfred Stille, Thomas D. Muter, J. Campbell Stewart, Charles Bell Gibson, John B. Biddle, David H. Tucker, Meredith Clymer, Wm. P. Johnston, W. S. W. Itusheuberger, Edward Peace, William Pep2)er, Sr.

Fi-om Baltimore, William Power.

From the South, Peter C. Gaillard, Gibbs, and Peyre Porcher of Charleston ; J. L. Cabell, L. S. Joyues, Selden and Randolph of Virginia.

" And many more whose names on earth are dark " — men of the stamp of Dr. Bassett of Alabama, who felt the strong impulsion to know the best that the world offei'ed, every one


of whom has left a deep and enduring impression in his sphere of work.

It would be impossible to tell in detail how Louis' students brought back his spirit and his methods to their daily work, and of the revolution which they gradually effected in the study and in the treatment of disease. I can best, perhaps, fulfill my object by referring somewhat fully to two of the most distinguished among them, James Jackson, Jr., and W. W. Gerhard.

James Jackson, Jr., is the young Marcellus among the physicians of this country, "the young Marcellus, young, but great and good." I do not know in our profession of a man who died so young who has left so touching a memory. He was the son of Dr. James Jackson, of Harvard, one of the most distinguished of New England's physicians, a man to whom our generation owes a heavy debt, since he, with Jacob Bigelow, was mainly instrumental in bringing about more rational ideas on the treatment of disease. Of Louis' pupils from this side of the water, young .lackson seems to have been his special favorite. After taking the B. A. degree at Cambridge in 1828, Jackson attended the medical lectures at Harvard, and in the spring of 1831 went to Paris, where he remained until the summer of 1832. Returning home in 1833, he graduated in medicine at Harvard in 1834. In the two years and a half of his studies in this country before going abroad he had had exceptional opi)ortunities with his father at the Massachusetts General Hospital, and showed his early industry and ability by taking one of the lioylston Prize Essays before the completion of his second year of study.

In Paris he attended the practice of La Pitie and St. Louis. He soon became devoted to Louis, and by him was utilized to the full in the cholera epidemic in 1832. Two letters from Louis to James Jackson, Sr., show how important he thought a prolonged period of study was for a young man. He says: " I pointed out to him (James Jackson, Jr.) the advantage it would be for science and for himself if he would devote several years exclusively to the observation of diseases. I now retain the same opinion and am strengthened in it; for the more T become acquainted with, and the more I notice him applying himself to observation, the more I am persuaded that he is fitted to render real service to science, to promote its progress. I find that he would be well pleased to follow for a certain period the vocation for which nature has fitted him ; but he has stated to me that there are many difKculties which would prevent his devoting himself exclusively to observation for several years. But can these difKculties be insurmountable?"

xVud again : " Let us sup2)ose that he should pass four more years without engaging in the practice of medicine, what amass of positive knowledge will he have acquired! How many important results will he have been able to publisli to the world during that period ! After that he must necessarily become one of the bright lights of his country; others will resort to him for instruction, and he will be able to impart it with distinguished honor to himself. If all things be duly weighed, it will appear that he will soon redeem the four years, which men of superficial views will believe him to have lost." In another letter, the following year, just before young


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Jackson's departure from Paris, he refers again to this question and urges Dr. Jackson to allow his son to devote himself exclusively to observation for several years in Boston. The extract from this letter is worth quoting. "Think for a moment, sir, of the situation in which we physicians are placed. We have no legislative chambers to enact laws for us. We are our own lawgivers ; or rather we must discover the laws on which our profession rests. We must discover them and not invent them ; for the laws of nature are not to be invented. And who is to discover these laws? Who should be a diligent observer of nature for this purpose, if not the son of a physician, who has himself experienced the difficulties of the observation of disease, who knows how few minds are fitted for it, and how few have at once the talents and inclination requisite for the task ? The inclination especially, for this requires that the observer should possess a thorough regard for truth, and a certain elevation of mind, or rather of character, which we rarely meet with. All this is united in your son. You ought — for in my opinion it is a duty — you ought to consecrate him for a few years to science. This, sir, is my conviction, and I hope it will be yours also. I know very well that every one will not be of the same opinion ; but what matters it, if it be yours ? — if you look upon a physician, as I do, as holding a sacred office, which demands greater sacrifices than are to be made in any other profession."

Young Jackson's letter to his father, just as he was quitting Paris, indicates on what affectionate terms he had lived with Louis. " In two hours I am out of Paris. I will not attempt to describe to you the agony it gives me to quit Louis. He is my second father, and God knows that is a name I of all men cannot use lightly. I may not persuade you to look upon him with my eyes exactly as a scientific man ; but in your heart he must have the share of a brother; for he almost shares my affection with you. From one upon whom I had no claims but those which my life and mind and habits gave me, I have experienced a care, an affection which I never could dare expect from any but my dear father, and which I shall ever feel to be the most honorable and truly worthy prize of my life."

He seems to have inspired the same tender feelings in all his American students. In the Memoir of Dr. Bowditch, to which I have already referred, he speaks of Louis' fatherly kindness to him during a prolonged attack of rheumatic fever lasting for many weeks.

Young Jackson was one of the founders, in 1833, of the Society for Medical Observation, which consisted of the ablest of the students of Louis, Chomel and Andral. During his stay in Paris he made an important study of cholera, which was published in this country in 1833. It was most timely, as it gave the profession here a very clear and accurate description of the disease, of which up to that time they had had no experience. Jackson's name, too, will always be associated with the studies upon emphysema, and he is the discoverer of the prolonged expiration in early pulmonary tuberculosis.

Returning to Boston in the autumn of 1833, he spent the winter preparing for his degree and elaborating the notes which he had taken in Paris. In March he fell ill with a dysentery, which proved fatal on the 37th of the month, in the


twenty-fifth year of his age. I know of no young man in the profession who had given pledges of such exceptional eminence. His influence in extending Louis' methods and views throughout New England was chiefly through his father, who, though a man approaching his sixtieth year, became an ardent follower of Louis and the numerical method.

In Oliver Wendell Holmes' recently issued Biography you will find a delightful description of life at the Medical School of Paris at this period. He bears witness to the good effect which Jackson's warm friendship with Louis had had in promoting the interests of American students. I may conclude with a quotation from Dr. Jackson's, Sr., memoir: "At the suggestion and request of one of my most judicious brethren I shall add that my sou's influence on the profession here, in the short time he was with us, was of a very salutary description. This gentleman states that my son not only caused others, who had not yet read the works of M. Louis, to study them with care, but that he induced among the rising members of the profession in our own city the habits of thorough observation of the phenomena of disease in the living and in the dead, which he had learned from the same great pathologist. He also taught us much in respect to the physical signs of disease in the thorax, with which we were imperfectly acquainted before; at least I may say this was true as to myself. Indeed I ought to say more, for he aided me very much in regard to the diagnosis of the more obscure diseases of that region, derived from the combination of the physical and rational signs. On emphysema of the lungs he threw, for me, quite a new light."

Wm. W. Gerhard was the most distinguished of the American pupils in Paris between 1830 and 1840. When you call to mind the men whom I have mentioned, this may seem a strong statement, but I feel certain that could we take their suffrages they would accord him the place of merit in consequence of the character of his work. Dr. Gerhard was born in Philadelphia, in 1809, and was graduated from the University of Pennsylvania in 1831. Early in the year he went to Paris and attached himself to Louis at La Pitie. In one of his letters* to his brother, dated January 18, 1833, he says: "Dr. Louis is delivering an interesting clinic at La Pitie ; he is a remarkable man, very different from the physicians of Eni^land or America, and remarkable even at Paris by the strict mathematical accuracy with which he arrives at his results ; he is not a brilliant man, not of the same grade of intellect as his colleague at La Pitie, Andral." In another letter he gives an account of his day's work. "The morning from seven to ten is occupied with the visit and clinic at the hospital ; there are several distinct clinics now in actual proo-ress; each of them has its advantages. I shall vary my attendance at the different hospitals and select those lecturers who are of real merit. At this moment we are following ing Piorry at the SalpetriOre, a very distant hospital, two or three miles from our lodgings; his patients are all old women, and not interesting. My object in following his course is to obtain some interesting information on the best mode of


  • I am indebted to members of Dr. Gerhard's family for the letters

from which these extracts are taken.


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investigating the diseases of the chest. M. Piorry has devoted special attention to this subject. From Salpetriere we hurry to La Pitie; we hear a surgical lecture, reach home to breakfast, and then to the school of medicine. The lectures at the school, with a private course of anatomy during the hour of intermission, fill up the remainder of the day until four. Fortunately a private clinic at La Charite introduces me to a set of very interesting cases, especially on pectoral cases. Dr. Dagueau has a class who pay him ten francs a month and enjoy the privilege of examining the patients much more conveniently than is practicable during the morning visit in the midst of a crowd of students. We dine at five-thirty and then lectures again until eight o'clock. Imagine the facilities, the delightful advantage of acquiring positive information, and what is at least as important, of learning the mode of obtaining these positive results. We see and hear the men who are so well known to us in America, learn to form a correct estimate of their relative worth — in short, one of the most striking advantages of a medical visit to Europe is to acquire the sort of liberal professional feeling which is rarely secured by the continued intercourse with the same men, and the unpleasant medical politics which divide the profession in America."

Evidently Broussais made no special impression on Dr. Gerhard. He says, " Broussais is the best known, his reputation is universal, and the benefits he has conferred on medicine are immense, but unfortunately he is a wretched lecturer. His own opinions are given in the most awkward, clumsy manner; the manner and style of lecturing are coarse and vulgar."

In another letter of February 3, 1833, he tells how he induced Louis to give them private instruction. To his brother he writes : " I must write you at least a few days before the excitement has passed off : can you imagine how fortunate I am — devinez si vous pouvez— two or three days ago, Jackson, Pennock and myself were talking of hospitals and morbid anatomy, when the idea occurred of attempting the study of pathology in a particular manner. It was this: to obtain the specimens and study them, the authors in our hand, exactly and carefully comparing authorities with the subject before us. We addressed ourselves to two of the internes at La Pitie attached to the salles of Louis and And-ral, and they agree to procure all facilities in their power and communicate their own information for the compensation of 60 francs from each of us ; we accordingly visit La Pitie on three afternoons of the week and examine the parts at the hospital, afterwards carrying home such portions as require minute investigation. Our first success in this opening of new sources of instruction emboldened tis to attempt something of higher importance. We were all desirous of studying auscultation, of studying it in such a manner as to be sure of our ground on our return, and to be capable of appreciating the advantages of the art. Louis' public instructions were valuable, but his private lessons upon a subject demanding minute and patient inquiry we knew would be infinitely moi'e so. I therefore in the name of my friends addressed him a polite note, accomjianied by a handsome pecuniary offer; we did this with little hopes of success, but happily for us he accepted our proposition, and next week we are his private pupils at La Pitie. We are, I


believe, the first who have made this arrangement with M. Louis, and you may estimate its importance when I tell you that he is considered in excellence of diagnosis the successor of Laennec. Our advantages for the study of pathology and the diagnosis of diseases of ttie chest are now superior ; they are indeed the very best in the world, and our eagerness to embrace them will, I hope, render them of real utility ; of course they involve an additional expenditure of 400 or ."300 fr., but I should be happy to shorten my stay at Paris a mouth to improve the remainder of my time in this manner, if such were necessary for me. Pennock and myself are very happy to have become intimate with .Jackson ; he has superior talents, and his excellent education, conducted by his father, unquestionably the first physician in America, has cultivated his mind and developed an ardent attachment to medicine."

Few American students have occupied their time abroad to greater purpose than Dr. Gerhard. He appears to have been an indefatigable worker, and the papers which he published based upon material collected in Paris are among the most important which we have from his pen. Thus with Pennock he described Asiatic cholera in 1832. Devoting himself particularly to the study of diseases of children, he issued a very interesting paper on small-pox, and two papers of very special value, the first on tuberculous meningitis and the other upon pneumonia in children. Both of these papers mark a distinct point in our knowledge of these two diseases. He is usually accorded the credit of the first accurate clinical study of tuberculous meningitis.

Late in the year 1833 he returned to Philadelphia, and at his suggestion his friends had secured him the appointment as resident physician at the Pennsylvania Hospital, which he took early in 1831. This step indicated how carefully he had weighed the important influence in Louis' career of the years of quiet work at La Charite. At the Pennsylvania Hospital he had an opportunity to study the common continued fever of the country, and determined that it was identical, clinically and anatomically, with the typhoid fever of Louis, and characterized by a special lesion in the glands of Peyer. I do not know exactly how long he remained resident physician at the Pennsylvania Hospital, but he was soon after appointed one of the physicians at Blockley, and here in 1836 he was able io carry out his most important piece of work. The general opinion prevailed that the fever which Louis described and which had the lesions in the small bowel was only a modification of the ordinary typhus fever which at that time prevailed so extensively, particularly in Great Britain and Ireland. In London, Edinburgh and Dublin the intestinal lesions were regarded as only accidental, and not indicative of a special affection. Dr. Gerhard knew the typhoid fever of Louis well, and had had an opportunity of studying it again at the Pennsylvania Hospital, so that when the epidemic of typhus fever developed in 1836 he was in a very good position to make an accurate study of the disease. Two hundred and fourteen cases were observed, and as a result of his study he declared positively that the typhus fever, which was similar to the disease which he had also seen in Edinburgh, was a different affection altogether from the typhoid fever with intestinal lesions. These observations, vou must remember.


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were made in 1836, at a time when the greatest confusion existed as to the forms of fever. It took a great many years in Great Britain before the duality of the prevalent fever was recognized, but owing to the influence of Gerhard's paper, and to the accurate knowledge of fever brought to this country by Louis' pupils, the differentiation of the two diseases was here quickly recognized, since, as already mentioned, Bartlett in 1812 considered them apart.

Gerhard's work influenced his Paris friends greatly, and this was strengthened by the papers read before the Society for Medical Observation by Geo. C. Sbattuck and Alfred Stille, of whom the former had had opportunities of studying typhus fever in Great Britain, while the latter had been one of Gerhard's house physicians in the typhus epidemic at Blockley. Shattuck's paper is published in the Medical Examiner for 1840. I have always regretted that Dr. Stille's paper has never appeared in print. He was kind enough to let me see it, and, as I have mentioned elsewhere, the differential points between typhus and tyi^hoid fever are nowhei-e more clearly laid down.

The University of Pennsylvania early took advantage of Gerhard's training and utilized him as clinical lecturer at the Philadelphia Hospital. He soon acquired a special reputation in diseases of the heart and lungs. In 1842 appeared the first edition of his work on Diseases of the Chest, which ran through four editions, and is still a valuable work of reference. One of his fellow-students in Paris, Stewardson, has given a very pleasing picture of him as a clinical teacher : " As a clinical teacher he was remarkably successful and exerted a powerful and commanding influence. Without any pretension to eloquence, he nevertheless riveted the attention of his hearers and stimulated their enthusiasm. Himself deeply interested in bis subject, he communicated this interest to his audience by the sheer force of truth. Students saw that truth was his object, not display ; the advancement of science, and not the gratification of personal feelings, whether of vanity or ambition; in short, that in his mind, a deep interest in his subject and a thorough conscientiousness in the pursuit of it were the overmastering motives. In an easy and conversational


style he presented to his hearers a graphic portraiture of the case before them, bringing into relief its most important symptoms; impressing upon their minds the most striking features in its history; pointing out, by a few clear and practical expressions, the bearing of any particular fact upon interesting medical questions, but avoiding long and labored arguments, or general disquisitions upon the nature of diseased action. He neither stimulated the fancy by the flowers of rhetoric, nor amused the intellect with episodes upon theoretical questions, but confined himself to drawing such practical conclusions as were clearly deducible from the facts presented. No man of his day enjoyed so high a reputation as a clinical teacher, and not only did he succeed in an eminent degree in arousing the enthusiasm of students and putting them in sympathy with himself, by infusing into them his own ardor in his favorite study ; but he produced an influence upon the profession here which is felt still, which has fostered the establishment of clinical teaching among us, and done much to give it that rank which it now occupies here as a branch of medical instruction."

Of the work of Louis' other students in this country time would fail me to tell — of the influence of Bowditch, Holmes and Shattuck in Boston, of Swett, Clark and others in New York, of Pennock, Stewardson, Stille in Philadelphia, and of Power in Baltimore. To them all we owe a heavy debt of gratitude. They brought from Paris enthusiasm, faith in the future, faith in the profession of their choice, accurate methods and a loyal love of truth. Endowed with the spirit and zeal of their master, they carried his great message to the New World ; and more than this, touched with those finer qualities which made Louis so lovable, they have become bright ideals for all future generations of American students.

There remain, so far as I know, three only of the Paris students of whom I have spoken, John T. Metcalf, Meredith . Clymer, and your honored patron, Alfred Stille. They, too, must soon go the way of all the earth ; but among the consolations of old age what greater solace can they feel than that the lives of the men whose fathers and grandfathers they taught are still made better by their presence.


WILLIAM HARVEY AS AN EMBRYOLOGIST.*

By William K. Brooks, LL. D., Professor of Zoology, Johns Hoiikins JJniversUy.


The immortal discoverer of the circulation of the blood is held to be also the discoverer of the law of embryology — "that all animals are produced out of ova" (Encyc. Brit., 9th ed., art. Embryology, p. 164); and he is also held to have had some vague premonition, scarcely worth mentioning in history, of the great law that the complex animal arises, from a relatively homogeneous germ, by gradual differentiation or epigenesis.

I hope to show, by quotations from his work on embryology (Exercitationes de Generatione Animalium, Amstelodami,


■ Read before the Johns Hopkins Historical Club, February, 1897.


1651, translated into English by Robert Willis, M. D., London, 1848), that both these current impressions are erroneous. He not only formulated but demonstrated epigenesis. liis statement of this law is clear, definite and thoroughly modern, and it is based upon actual observations which are fully described.

On the other hand the conception which he sought to express by the dictum "omne vivum ex ovo" is totally foreign to the principles of modern embryology. Harvey was a worker, not a dreamer, and his dictum is no mere guess or happy inspiration. It sums up results reached by laborious research, and as a generalization based on actual study it still has value,


although its meaning has nothing in common with tliat which the words have as we now use them. He repudiates in most energetic language the opinions, current at his time, which come nearest to the modern discovery that the physical continuity of living matter is never broken. In fact the chief aim of his treatise is to show that his observations, as he interpreted them, prove that there is no physical or " corporeal " continuity between parent and child.

Embryologists who permit Germans to write the history of their science, and make no protest when the demonstration that the embryo arises from the egg by epigenesis is attributed to Wolff (1759), and to Von Baer (1839), are either ignorant of Harvey's researches (1651) or indifferent to the fame of this great Englishman, who studied the history of the chick as laboriously and faithfully as Von Baer, nearly two hundred years before. While his resources were more limited, his ability to reflect upon the meaning of his observations and to state in clear and energetic words the results of his " Beobachtung und Eeflexion," were inferior in no way to those of the justly famous author of the "Entwickeluugsgeschichte der Thiere."

Harvey means just what more modern writers mean by "epigenesis," but the strangeness of the views he opposed gives us difficulty. The form of words into which an account of a scientific discovery falls is fixed by the view of the matter which is current at the writer's day, and later generations of readers may be puzzled by inability to occupy his standpoint. Thus it is with Harvey, and we thus explain the prevalence of the opinion that he had no more than a dim adumbration of truths the demonstration of which is generally credited to Wolff and Von Baer.

The evolutionary teachings of Bonnet are quite intelligible to us; and as we easily put ourselves in Von Baer's place, his refutation of Bonnet appeals to us with all its native force; but it is much harder for us to stand where Harvey stood.

So far as I can discover, no notion at all equivalent to Bonnet's conception of germs ever entered Harvey's mind or the mind of any one before his time. He presents the evidence for epigenesis as opposed, not to "evolution," but to "metamorphosis," and his way of using the last word is so unfamiliar to us that we cannot grasp what he has in mind without effort.

They who studied embryology before him held one modification or another of the very ancient belief that embryos arise from "excrement"; that they are products of decomposition.

He gives the evidence for epigenesis as opposed to this opinion which finds no pigeon-hole in the modern mind. Fortunately he is a ready writer. Hlustrations and analogies overflow his brain and pen; and patient study enables us to pick out passages which give his views on epigenesis uncomplicated by reference to " metamorphosis." When we have done this we find his reasoning as modern and definite as that of Von Baer, although his resources did not qualify him to sum up the evidence with modern exhaustiveness.

While Harvey does not deny that some " imperfect " animals may be genei-ated "out of a putrescent material, the drying of a moist substance, or the moistening of a dry one," he tells us, clearly and definitely enough, that the generation of all "per


fect " animals, such as the lion and the cock, " is the result of epigenesis as the man proceeds from the boy; the edifice of the body, to wit, is raised on the punctum saliens as a foundation ; as a ship is made from the keel, and as a potter makes a vessel . . . For out of the same material from which the first part of the chick or its smallest particle springs, from the very same is the whole chick born ; whence the first little droji of blood, thence also proceeds its whole mass by means of generation in the egg ; nor is there any difference between the elements which constitute and form the limbs or organs of the body, and those out of which all their similar [i. e. homogeneous] parts, to wit, the skin, the flesh, veins, membranes, nerves, cartilages, and bones derive their origin. For the part that was at first soft and fleshy, afterwards, without any change in the matter of nutrition, becomes a nerve, a ligament, a tendon ; what was a simple membrane becomes an investing tunic ; what had been cartilage is afterwards found to be a spinous process of bone, all variously diversified out of the same similar [homogeneous] material." From what "appears to be homogeneous in the beginning and resembles the spermatic jelly" the structure of the body arises; its parts being "at first delineated by an obscure division, and afterwards become separate and distinct organs."

He says the result of the process of development is just as if the chick were created by a command to this effect: " Let there be a similar [homogeneous] colorless mass, and let it be divided into parts and made to increase, and in the meantime, while it is growing, let there be a separation and delineation of parts ; and let this part be harder and denser and more glistening, that be softer and more colored."

" Now it is in this very manner that the structure of the chick in the egg goes on from day to day; all its parts are formed, nourished and augmented out of the same material. . . . For there is a greater and more divine mystery in the generation of animals than the simple collecting together, alteration and composition of the whole out of parts would seem to imply; inasmuch as here the whole has a separate constitution and existence before its parts, the mixture before the elements."

These passages summarize conclusions from observations which have been more fully described in forty-four preceding chapters or "exercises," and it would be difficult, even at the present day, to state in more definite language the truth that the developing embryo passes " from indefinite, incoherent homogeneity to definite, coherent heterogeneity by successive integrations and differentiations."

While we have no desire to ignore the merits of Wolff or to belittle the greatness of Von Baer, we find it hard to understand how any one who knows Harvey's works can, without protest, read this assertion or similar ones in the German works from which it is derived:

" It was reserved for Caspar Frederick Wolff, a German by birth ... to bring forward observations which . . . established the theory of epigenesis upon the secure basis of ascertained facts" (Encyc. Brit., 9th ed.. Embryology, 1(35).

We now know that the germ itself is an organism of wonderful complexity ; that its homogeneity is relative, not absolute ; but there is great mystery to us as well as to Harvey in the


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manner in which " the whole has a separate constitution and existence before its parts," and while the doctrine of "metamorphosis " as held in Harvey's day has vanished from science, I venture to believe that we shall Knd in his discussion of this doctrine, clear statement of other difficulties which are still as grave as he found them.

It is hard to decide just what his opinion on spontaneous generation was. No less careful a student than Huxley tells us (Encyc. Brit., 9th ed., art. Evolution, p. 746) that "Harvey believed as implicitly as Aristotle did in the equivocal generation of the lower animals." "Harvey shared the belief of Aristotle — whose writings he often quotes, and of whom he speaks as his precursor and model, with the generous respect with which one genuine worker should regard another — that such germs may arise by a process of 'equivocal generation' out of non-living matter."

1 am by no means confident that this assertion does justice to Harvey, or that the quotations from Aristotle prove anything except that Harvey was not yet quite prepared to demonstrate their error. I believe there is ample evidence that he had made many observations which, while he never published them, led him to distrust most of the familiar examples of spontaneous generation, although he may not have been fully armed to attack the teachings of " my leader," Aristotle, "one of nature's most diligent inquirers," "whose authority has such weight with me that I never think of differing from him inconsiderately." It is true that he quotes without comment, and occasionally without credit, many passages in which Aristotle affirms sjjontaneous generation ; but as an offset to this he tells us explicitly (Exercise the forty-first) that he shall show in another place " that many animals, especially insects, arise and are propagated from elements and seeds so small as to be invisible (like atoms flying in the air), scattered and dispersed here and there by the winds ; and yet these animals are supposed to have arisen spontaneously, or from decomposition, because their ova are nowhere to be found." He was far too cautious to have ventured to criticise " the philosopher," even to this extent, without pretty good evidence; and in Exercise the sixty-ninth he tells us why this evidence was never published. "Let gentle minds forgive me," he asks, "if, recalling the irreparable injuries I have suffered, I here give vent to a sigh. This is the cause of my sorrow: — whilst in attendance on his majesty the king, during our late trouble and more than civil wars, not only with the permission but by the command of the Parliament, certain rapacious hands stripped not only my house of all its furniture, but, what is subject of far greater regret with me, my enemies abstracted from my museum the fruits of many years of toil. Whence it has come to pass that many observations, parlictilarly on the generation of insects, have perished, with detriment, I venture to say, to the republic of letters."

Is there not reason to believe that, if they are ever discovered, those lost observations will be found to cover some of the ground which was so successfully explored by Spalanzanni more than a hundred years later ?

Harvey's reference (Exercise the twenty-seventh) to " the animalculae which are engendered in our bodies . . . lumbrici,


ascarides, lice, nits, syrones and acari," and to " the worms which are produced from plants and their fruits, as from gallnuts, the dog-rose, and various others," might be held to imply belief in heterogenesis, if he did not tell us, almost immediately, that: "It certainly cannot be that the living principles of these animals which arise in the gall-nuts existed in the oak, although these animals live attached to the oak and derive their sustenance from its juices."

Notwithstanding Huxley's opinion, Harvey seems to have been nearer than any of his successors for a hundred years to the modern discovery that all living things come from germs, although I shall show soon that he did not intend to imply anything at all like the modern view by his statement that this is true.

In his discussion of epigenesis as contrasted with " metamorphosis," he assumes the reality of " equivocal " generation, as he does in many other places, although, in view of the passages I have quoted, I believe that this is admitted out of courtesy to Aristotle, and for the sake of the argument, as something which he is not yet fully prepared to disprove.

He tells us (Exercise the forty-fifth) that there are two ways in which one thing may be made out of another. When a workman cuts the material already prepared, divides it and rejects what is superfluous, till he leaves it in the desired shape, as in nuiking a statue from a block of stone, the whole material of the future piece of work has already been in existence before it is finished into form or any part of the work is yet begun. AVhen on the other hand a potter educes a form out of clay by the addition of parts, increasing its mass, and giving it a figure, at the same time that he provides the material, which he prepares, adapts and applies to his work, "the form may be said rather to have been made than educed." " So exactly it is with regard to the generation of animals. Some, out of a material previously concocted and that has already attained its bulk, receive their forms and transfigurations ; and all their parts are fashioned simultaneously, each with its distinctive characteristics, by the process called metamorphosis, and in this way a perfect animal is at once born; on the other hand, there are some iu which one part is made before another, and these from the same material afterwards receive at once nutrition, bulk and form ; that is to say, they have some parts made before, some after others, and these are at the same time increased in size and altered in form. The structure of these animals commences from some one part as its nucleus and origin, by the instrumentality of which the rest of the limbs are joined on, and this we say takes place by the method of epigenesis, namely by degrees, part after part; and this is, in preference to the other mode, generation properly so called. In the former of the ways mentioned, the generation of insects is effected when by metamorphosis a worm is born from an egg ; or out of a putrescent material, the drying of a moist substance or the moistening of a dry one, rudiments are created from which, as from a caterpillar grown to its full size, or from an aurelia, springs a butterfly or fly already of a proper size, which never attains to any larger growth after it is first born. But the more perfect animals with red blood are made by epigenesis or the superposition of parts. In the former, chance or hazard seems the principal promoter of gen


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eration, aud the form is due to the potency of a pre-existing material ; and the first cause of generation is 'matter ' rather than an ' external efficient,' while the more perfect animals owe their immortality to one constant source — the perpetuation of the same species . . . Bees, wasj^s, butterflies, and whatever is generated from caterpillars by metamorphosis, are said to have sprung from chance, aud therefore to be not preservative of their own race. . . . The lion and the cock owe their existence, as it were, to nature, or an operative faculty of a divine quality, and require for their propagation an identity of species, rather than any supply of fitting material." " In the generation by metamorphosis forms are created as if by the impression of a seal, or as if they were adjusted in a mould . . . but an animal which is created by epigenesis attracts, prepares, elaborates, and makes use of the material all at the same time. The processes of formation aud growth are simultaneous. In generation by metamorphosis the whole is distributed and separated into parts, but in that by epigeuesis the whole is put together out of parts, in a certain order, and constituted /ro?» them. In the one case the result is due to matter ; in the other the animal makes itself.

" Now it appears clear from my history that the generation of the chick from the egg is the result of ejjigenesis rather than of metamorphosis, and that all its parts are not fashioned simultaneously, but emerge in their due succession and order; it appears, too, that its form proceeds simultaueously with its growth, aud its growth with its form; also that the generation of some parts supervenes on others previously existing, from which they become distinct; lastly, that its origin, growth aud consummation are brought about by the method of nutrition.

" The formative faculty of the chick rather acquires and prepares its own material than only finds it when prepared, aud the chick seems to receive its growth from no other than itself. And as all things receive their growth from the same power by which they were created, so likewise should we believe that the chick is created by the same power by which it is preserved and caused to grow."

The meaning of this rather puzzling passage will be somewhat clearer after we have examined Harvey's views on generation, but when we omit the complications which come from the reference to "metamorphosis," its meaning as interpreted by the rest of the essay is about as follows :

The substance which composes the body of all "perfect" animals does not exist as such before the body itself is formed; but it consists of unorganized or "homogeneous " food which is changed by nutrition into all the diversified parts of the complicated body, so that nutrition, growth aud development go on together. As the organized body is constructed by the assimilation of unorganized food, its structure cannot be the outcome of the ordinary or physical properties of this food. There must be some organizing iufiuence at work making use of these properties to construct out of homogeneous matter a definite organism belonging to the same species with the parents. To the question what this organizing influence is, he answers that this is a " divine mystery," or, in plain English, that he does not know, although he finds clear evidence of its existence. He says in many places that the egg has a ■' vital principle," but the context shows that he means


by this no more than we mean when we say it is " alive," and nothing is farther from his thoughts than recourse to supernatural agencies, for he tells us clearly that while the cause of its development is a " divine mystery," " the egg is a natural body endowed with animal virtues ... it is moreover a body which under favorable circumstances has the capacity to pass into an animal form; heavy bodies, indeed, do not sink more naturally, nor light ones float, when they are unimpeded, than do seeds aud eggs in virtue of their inherent capacity become changed into vegetables aud animals." (Exercise the twenty-sixth, p. 373.)

It would be a gross error to infer, from this passage or from others like it, any further similarity between Harvey's opinions aud the results of moderu microscopic study of ova and male cells. In order to understand the meaning of his celebrated dictum " omne vivum ex ovo " we must undertake more extended analysis of his observations aud reflections on generation, aud of the opinions of his predecessors.

Aristotle saw nothing strange or exceptional in the generation of animals from decomposing organic matter, for he believed that all generation takes place in essentially the same way ; and he regarded the generation of insects from putrescent slime as a simple or typical example, what we should now call a primitive type, of generation in general, in comparison with which more complicated instances are to be interpreted.

As a bloody substance is discharged at intervals from the reproductive organs of woman, during the fertile period of her life, and as its apjiearance marks the beginning and its cessation the end of fertility, he believed that the mammalian embryo is formed out of this substance just as other animals are generated from decomposing matter of other kinds.

" Milk aud the menstrual discharge," he tells us (De Gen. II, i), " are of the same nature." " When the semen masculinum enters the female uterus it coagulates the purest part of the catamenia," aud when this has " set in the uterus " it forms a coagulum like curdled milk. As heat causes milk to curdle, so " the semeu or geniture of the male bears the same affinity to the nature of the catamenia " aud causes it to " set " without itself contributing any part of the substance of the coagulum. " The female always supplies the matter, the male the power of creation, and this it is which constitutes one male and another fenuile." "The male is the efficient agent, aud by the motion of his geniture creates what is intended from the matter contained in the female." " The body and the bulk therefore are necessarily supplied by the female; nothing of the kind is required from the male; for it is not even requisite that the instrument, nor the efficient agent itself, be present in the thing that is produced. The body then proceeds from the female ; the life (anima) from the male."

Harvey points out the inconsistency of Aristotle's admission that hybrids "partake of the species of both parents" (De Gen. Anim. II, 3), and his assertion that '• the conception or egg receives '" "from the feuuile its body solely and its dimensions," and that the mother has no part in the trausmissiou of "form, species and life"; for the studj" of jiybrids shows the error of his opinion that creative force or vital power is


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derived exclusively from the male, and proves that both parents must be efficient in determining form or species.

The medical men of Harvey's day held a different opinion, as he tells us iu Exercise the thirty-second. Like Aristotle, they held that the embryo arises from "excrement"; but they held, in opposition to his teaching, " that the prime matter of conception is not blood, but the mingled geuitures of both sexes." They also held, iu opposition to Aristotle, the opinion, which Harvey shares, that the male is no more " the efficient cause of generation " than the female.

"Conception, according to the opinion of medical men, takes place in the following way: during intercourse the male and female dissolve in one voluptuous sensation, and eject their seminal fluids (geniturae) into the cavity of the uterus, where that which each contributes is mingled with that which the other supplies, the mixture having both equally the faculty of action and the force of matter; and according to the predominance of this or that geniture does the progeny turn out male or female. It is further imagined that immediately after the intercourse something of the conception is formed iu the uterus."

If the uterus contains a " conception " immediately after a fertile union, in the form of a bloody coagulum, as Aristotle supposes, or iu the form of the mingled emissions or geuitures of both sexes, as the medical men taught, this ought to be discoverable, and Harvey, a true scientific investigator, set himself to hunt for it without a microscope.

His facilities for making the search, and its results, are best described in his own words. He was the attending physician of the King of England, and he tells us : " It was customary with his Serene Majesty, King Charles, after he had come to man's estate, to take the diversion of hunting almost every week, both for the sake of finding relaxation from grave cares and for his health; the chase was principally the buck and the doe, and no prince iu the world had greater herds of deer. This gave me an opportunity of dissecting these animals almost every day during the whole of the season when they were rutting, taking the male and falling with young. I had occasion so often as I desired it to examine and study all their parts, particularly those devoted to the offices of generation."

His studies upon the development of the embryo of the deer are fully described at length in the essay on generation, but only those which relate to the question of conception concern us at present. Here his researches had a very definite result, "llepeated dissections performed in the course of the month of October, both before the rutting season was over and after it had passed, never enabled me to discover any blood or semen or a trace of anything else, either in the body of the uterus or its cornua." Neither the bloody coagulum of Aristotle nor the geniture of the medical men has any existence. The "conception" which should be discoverable iu the uterus if their teachings are correct, cannot be found there when a search is made for it, and actual observation shows that their teachings are erroneous and fanciful.

The keepers and huntsmen said " that I was both deceiving myself and had misled the king, and that there must of necessity be something of the conception to be found in the uterus. These men, however, when I got them to bring their


own eyes to the inquiry, gave up the point." Harvey tells us that the king fully appreciated the value of the investigation, and in order " that this important question might be the more satisfactorily settled in all time to come," provided means for isolating the does and for proving that there was no error as to the fact of conception ; but the physicians were still unconvinced, and "held it among their impossibilities that any conception should ever be formed without the presence of the semeu masculinum, or some trace remaining of a fertile intercourse within the cavity of the womb." But the man who had proved the error of their teachings regarding the function of the heart and blood-vessels had little tolerance for their belief iu anything which they were unable to demonstrate.

If they had insisted that Harvey's resources were inadequate, that the "conception" for which he sought is too minute to be found by such rough means, we now know they would have been in the right, for even at the present day our knowledge of the essential facts of mammalian conception is, for the most part, a deduction from observations on the eggs of animals which were almost or quite uuknown to Harvey, the sea-urchin and ascaris, for example. But his proof of the non-existence, in the uterus of the doe, of anything corresponding to their teachings is conclusive. He did not stop here, however, for he tells us: " In the dog, rabbit and several other animals, I have found nothing iu the uterus for several days after intercourse ; I therefore regard it as demonstrated that after fertile intercourse among viviparous as well as oviparous animals there are no remains in the uterus either of the semen of the male or of the female emitted in the act; nothing produced by any mixture of these two fluids, as medical writers maintain, nothing of the menstrual blood present as 'matter' iu the way Aristotle will have it; in a word, that there is not necessarily even a trace of the conception to be seen immediately after fruitful union of the sexes. It is not true, consequently, that in a prolific connexion there must be any prepared matter in the uterus, which the semen masculinum, acting as a coagulating agent, should congeal, concoct and fashion or bring into a positive genei'ative act."

His study of the generation of birds leads him to the same result. "As the hen does not emit any seminal fluid, and as the seminal fluid of the cock does not reach the uterus of the heu, and as there is no trace of an egg to be found in the uterus immediately after intercourse, it is obvious that it is not engendered" by the mixture of seminal fluid in the way the medical men teach (Exercise the thirty-second). After quoting Aristotle's opinion that the chick is formed out of menstrual blood coagulated by the influence of the cock, he says (Exercise the twenty-first) : " The business in the generation of an egg is very different from this; for neither does the semen or rather the 'genitura' proceeding from the male in the act of intercourse, enter the uterus in any way, nor has the hen after she conceives any particle of excremeutitious matter, even of the purest kind, or any blood in her uterus which might be fashioned or perfected by the discharge of the male. Neither are the parts of the egg produced by any kind of coagulation ; neither is there anything like curdled milk to be discovered iu the uterus. The cock, I say, contributes neither form nor


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matter to the egg, but that only by which it becomes fertile and fit to engender a chick. And this faculty the cock confers by his semen (genitura) emitted in the act of intercourse, not only on the egg which is already begun, but on the uterus and ovary and even on the body of the fowl herself, in such wise that eggs which have yet to be produced, eggs, none of the matter of which yet exists either in the ovary or in any other part of the body, are thence produced possessed of fecundity." "Inflammable material is not set on fire by the contact of flame more quickly than is the hen made pregnant by intercourse with the cock" (315).

Careful observation on the fowl, the deer, the dog, the rabbit, and on many other animals, jiroves that none of them are generated out of excrement or decomposing matter. There is no basis in nature for Aristotle's opinion or that of the medical men, and all these teachings break down when brought to the test of actual observation. It is no small thing to prove the error of the belief, which had been current for two thousand years, and is even now embodied, through a quotation from St. Paul, in our burial service, that all forms of reproduction find their type in generation from dead putrescent matter. This Harvey accomplished by methods which are rigorously scientific ; and with this accurate but very imperfect knowledge he boldly faced and tried to answer the question, what is it which the cock contributes in virtue of which the egg "becomes fertile and fit to engender a chick '"?

He undertakes "to seek the truth regarding the following difficult questions : Which and what principle is it whence motion and generation proceed':' By what virtue does the semeuact":' What is it that renders the semen itself fruitful? Whether is that which in the egg is canse, artificer and principle of generation and of all the vital and vegetative operations — conservation, nutrition, growth — innate or superadded ? and whether does it inhere primarily, of itself, and as a kind of nature, or intervene by accident, as the physician in curing disease? Whether is that which transfers the egg into a jiullet inherent or acquii-ed, or is it already conceived in the ovary, and does it nourish, augment, and perfect the egg there ? What is it besides that pireserves the egg sweet after it is laid ? What is it that renders an egg fruitful ?" (374).

" In truth, there is no proposition more magnificent to investigate or more useful to ascertain than this : How are all things formed by an ' univocal agent ' ? How does the like ever generate the like? . . . Why may not the thoughts, opinions, and manners now prevalent, many years hence return again, after an intermediate period of neglect? " (583).

As we find the embryologists of the present day vexing themselves over the question, " AVhether is that which transfers the egg into a pullet inherent or acquired?" we need not wonder if Harvey's success in the investigation of this magnificent proposition seems small to us. At least we must follow him in order to understand his dictum.

As a starting-point this much seems to be certain. "The egg, even when contained in the ovary, does not live by the vitality of the mother, but is like the youth who comes of age, made independent even from its first apj)earauce; as the acorn taken from the oak, and the seeds of jjlants in general are no longer to be considered parts of the tree or herb that supported


them, but things made in their own right, and which already enjoy life in virtue of a proper and inherent vegetative power" (375).

Furthermore, "although some animals . . . are produced from females alone" (386); "it is manifest that a fruitful [hen's] egg cannot be jjroduced without the concurrence of a cock and a hen ; without the hen no egg can be formed ; without the cock it cannot become fruitful. But this view is opposed to the opinion of those who derive the origin of animals from the slime of the ground " (384).

" The egg is the terminus from which all fowls, male and female, have sprung, and to which all their lives tend — it is the result which nature has proposed to herself in their being" (371).

"And this is the round that makes the race of the common fowl eternal; now pullet, now egg, the series is continued in perpetuity; from frail and perishing individuals an immortal species is engendered" (385).

" We cannot conceive an egg without the concurrence of a male and female fowl any more than we can conceive fruit to be produced without a tree. We therefore see individuals, males as well as females, existingr for the sake of preparing eggs, that the species may be perennial though their authors pass away. And it is indeed obvious that the parents are no longer youthful or beautiful, or lusty, and fitted to enjoy life, than while they jDOSsess the power of jiroducing and fecundating eggs, and by the medium of these, of engendering their like. But when they have accomplished this grand purpose of nature, they have already attained to the height, the dxnrj of their being ; the final end of their existence has been accouij)lished ; after this, effete and useless, they begin to wither, and, as if cast off and forsaken of nature and the Deity, they grow old, aud, a-weary of their lives, they hasten to the end. How different the males when they make themselves up for intercourse, aud swelling with desire are excited by venereal impulse! It is surprising to see with what passion they are inflamed, and then how trimly they are feathered, how vainglorious they show themselves, how proud of their strength, aud how pugnacious they prove. But the grand business of life accomplished, how suddenly, and with failing strength and pristine fervor quenched, do they take iu their swelling sails, and from late pugnacity, grow timid and desponding. Even during the season of jocund masking in Yeuus's domains, male animals in general are dejiressed by intercourse, aud become submissive and pusillanimous, as if reminded that in imparting life to others they were contributing to their own destruction. The cock alone, replete with spirit and fecundity, still shows himself alert aud gay, clapping his wings and ci'owiug triumphantly he sings the nuptial song at each of his espousals; yet even he after some length of timeiu Veuus's service, begins to fail; like the veteran soldier, he by and by craves discharge from active duty, and the hen, too, like the tree that is past bearing, becomes effete, aud is finally exhausted."

Having come to the end of his means of observation, Harvey turns to reflection, the second resource of the man of science, to see how this may help him to discover how "from frail and perishing individuals an immortal species is engen


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dered." As liis studies seemed to prove that the contagion which remains in the female "after intercourse, as the efficient of the future offspring, is not of the nature of any corporeal substance," he was unable to escape the admission that it is "incorporeal." Thus driven to the wall, if he had taken refuge in "soul " or "spirit," no one could greatly blame him, for spiritual agents had been the resource of philosophers for many ages before his time. He was a true soldier of science, however, seeing as clearly as we do that this venerable formula can do notliing to help us, and preferring outspoken ignorance to this antiquated and threadbare cloak for intellectual poverty.

" If on further inquiry it should appear that it [the efficient] is neither spirit nor demon, nor soul, nor any part of a soul, as I believe can be proved by various arguments and experiments, what remains, since I am unable myself to conjecture anything beside . . . but to confess myself at a standstill ? "

What does the modern man of science in such a case? Does he not search through the whole province of knowledge to see if perchance he may find some other natural phenomenon which bears some resemblance to the subject of his studies ? Harvey says he knows well " that some censorious persons will laugh at this . . . Yet this that I do is the practice of philosophers, who when they cannot clearly comprehend how a thing really is brought to pass, devise some mode for it in accordance with the other works of nature, and as near as possible to what is true."

" Since, tlien, nothing can be apprehended by the senses in the uterus after coition, and since it is necessary that there be something to render the female fruitful, and as this is probably not material, it remains for us to take refuge in a mere conception."

Men of science in all ages, from Aristotle to Tyndall, have believed in the virtues of the provisional hypothesis; and, armed by eminent authority, Harvey undertakes, by comparing a "mere conception" with other things in nature, to frame a provisional hypothesis of generation; but natural science seems to be an uncongenial soil for the nurture of such attempts, and if time has shown that Harvey's hypothesis has little value, he errs in good company, and he also takes pains to say he does not wish it "to be taken as if I thought it a voice from an oracle," although he does hope it may "stir up the intellects of the studious to search more deeply into so obscure a subject."

Starting with the belief that "the semen of the male does not so much as reach the cavity of the uterus . . . and that it carries with it a fecundating power by a kind of contagious property " from which the female "seems to receive influence and to become fecundated without the co-operation of any sensible corporeal agent, in the same way as iron touched by the magnet is endowed with its powers and can attract other iron to itself," he holds that "when this virtue is once received the woman exercises a plastic power and produces a being after her own image."

" Yet it is a matter of wonder where this faculty abides after intercourse is completed. ... To what is the active power of the male committed ? . . . Does the woman conceive in the womb as we see by the eye and think by the brain?" " Since there are no manifest signs of conception before the


uterus begins to relax . . . and since the substance of the uterus, when ready to conceive, is very like the structure of the brain, why should we not suppose that the function of both is similar, and that there is excited by coitus within the uterus a something identical with or at least analogous to an imagination or a desire in the brain, whence comes the generation or procreation of the ovum ?" "For the functions of both are termed conceptions, and both, although the primary source of every action throughout the body, are immaterial, the one of natural or organic, the other of animal action . . . Just as a desire arises as a conception of the brain, and this conception springs from some external object of desire, so also from the male, as being the more perfect animal, and as it were the most natural object of desire, does the natural (organic) conception arise in the icterus, even as the animal concej)tiou does in the brain. From this desire, or conception, it results that the female produces au offspring like the father. For just as we, from the conception of the 'form' or 'idea' in the brain, fashion in our works a form resembling it, so in like manner the 'idea' or 'form ' of the father, existing in the uterus, generates au offspring like himself with the help of the formative faculty.

"Whoever has pondered with himself how the brain of the artist, or rather the artist by means of his brain, pictures to the life things which are not present in him, but which he has once seen ; also in what manner birds immured in cages recall to mind the spring, and chant exactly the songs they had learned the preceding summer, although meanwhile they had never practiced them; again, and this is more strange, how the bird artistically builds its nest, the copy of which it had never seen, and this not from memory or habit, but by means of an imaginative faculty, and how the spider weaves its web, without either copy or brain, solely by the help of this imaginative power ; whoever, I say, ponders these things, will not, I think, regard it as absurd or monstrous, that the woman should be impregnated by the conception of a general immaterial ' idea ' and become the artificer of generation."

"For my own part then, when I see nothing left in the uterus after intercourse, to which I can ascribe the principle of generation, any more than there is in the brain anything discoverable after sensation and experience, which are the prime sources of art, and when I find the structure of both alike, I have devised this fable."

Whatever the value of this hypothesis may be, it serves well to emphasize the fact that Harvey's opinions on generation have nothing in common with the modern discovery of the physical continuity of living matter, and it shows that his teaching that all animals come from eggs cannot possibly mean what the words now mean.

He believes the uterus conceives an animal in the same way that the brain conceives an idea; and he also tells us that he agrees with Fabricius that " the egg [of the hen] is in a certain sense an exposed uterus " (290).

Furthermore, "the hen is not the efficient cause of a perfect egg, but that she is made so in virtue of an authority, if I may use the word, or power required of the cock. For the egg, unless prolific, can with no kind of propriety be accounted perfect; it only obtains perfection from the male, or rather


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from the female, as it were upon precept from the male, as if the hen received the art and reason, the form and laws of the future embryo from his addresses" (290). Ho much for the generation of the fowl. In Exercise the sixty-ninth he describes the embryo of the doe at about seven weeks, and the human embryo about the second month after conception, but, following Aristotle, he regards these embryos in their membranes, not as embryos, but as eggs without shells. " In the way above indicated do the hind and doe, affected by a kind of contagion, finally conceive and produce primordia, of the nature of eggs, or the seeds of plants, or the fruit of trees, although for a whole month and more they had exhibited nothing in the uterus."

In this sense, then, he holds that viviparous animals are generated from eggs. He therefore maintains (as contrasted with Fabricius, who held that the greater number of animals are produced from ova) "that all animals, even the vivipara, and man himself not excepted, are produced from ova; that the first conception, from which the foetus proceeds in all, is an ovum of one description or another, as well as the seed of all kinds of plants. Empedocles therefore spoke not improperly of the ' egg-bearing race of trees.' The history of the egg is therefore of the widest scope, as it illustrates generation of every description. . . . Fabricius has these additional words: "The foetus of animals is engendered in one case from an ovum, in another from the seminal fluid, in a third from putrefaction ; whence some creatures are oviparous, some


viviparous, and yet others born of putrefaction or by the spontaneous act of nature, automatically."

" Such a division as this, however, does not satisfy me, inasmuch as all animals whatsoever may be said in a certain sense to spring from ova, and in another sense from seminal fluid, and they are entitled oviparous, viviparous or vermiparous rather in resjoect of their mode of bringing forth than of their first formation."

We see then that, unfamiliar as his words often seem, and while he holds that the organizing influence which produces the chick from the egg is a "divine mystery," we owe to Harvey the demonstration and clear formulation of the following truths :

There is no basis for the venerable doctrine that the higher animals are generated from excrement.

The hen's egg, even before it leaves the ovary, is an independent orgauism, which enjoys life by its own right, and perfects itself by nutrition.

The embryo assimilates homogeneous food, and by means of an inherent organizing power converts it into the structure of the living animal Nutrition, growth and development go on together, and the embryo arises by epigenesis or differentiation.

Many animals which have been held to arise from putrescent slime actually come from microscopic eggs.

"Animals are entitled viviparous or oviparous or vermiparous rather in respect of their mode of bringing forth than of their first formation."


LONG, THE DISCOVERER OF ANESTHESIA.

A PRESENTATION OF HIS ORIGINAL DOCUMENTS.

By Hugh II. Young, A. M., M. D., Assistant Besident Siirgeon, Johns Hopkins Hospital, Baltimore.

[Being in substance a paper read before the Johns Hopkins Hospital Historical Society, Xorember 8, 1890, with additions.]


It was my good fortune last summer to meet Mrs. Fanny Long Taylor, whose father, Dr. Crawford W. Long, is thought by many to be the original discoverer of anesthesia.

As she put me in possession of her father's papers, I thought they might prove sufficiently interesting to warrant their presentation to this Society.

During the famous ether controversy which was waged in the forties and fifties the work of Long received little attention. A modest, retiring man, who abhorred public strife and controversy, too honorable to wish pecuniary reward for his discovery, it is not strange that he made no effort to get the reward from Congress, but preferred to let the justice of his claim be judged by an unbiased posterity.

Crawford W. Long was born in Danielsville, Ga., on the first of November, 1815. His grandfather was Capt. Samuel Long of Pennsylvania, who made a brilliant record in the Revolutionary war and was one of Lafayette's captains at Yorktown. Soon after the close of that eventful struggle he left his native State and took his family to Georgia, where they settled along with a large colony of Peunsylvanians. His son, James Long, received every educational advantage


there obtainable, and inheriting his father's executive ability, became one of the prominent men of his State. Although engaged in mercantile pursuits he was a hard student of the law, and so well versed in the principles of jurisprudence that he was often consulted by judges in difficult cases.

He represented his people in the Senate for a number of years and was the intimate friend, adviser and confidant of Wm. H. Crawford, Georgia's greatest statesman, at different times Secretary of State, minister to France and candidate for the Vice-Presidency. As an evidence of attachment he gave his eldest son the name of Crawford. Coming from such ancestry it is not wonderful that young Crawford early showed promise of rare ability. As a boy he was studious and mature beyond his years, and entered Franklin College at so early an age that he was known as " baby." Notwithstanding this fact he graduated as Master of Arts second in his class at the age of nineteen. Alexander II. Stephens was his room-mate, and so much older that he was dubbed "daddy" by the college boys. Though pursuing different paths, Stephens and Long kept up an inti.nate friendship all their lives. After studying under a preceptor for one year


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Long graduated at the University of Pennsylvania in 1839. While there he was recognized as a man of marked ability and fond of experimental work.

After graduation he spent one year in a New York hospital, where, it is said, he made such a reputation for himself as a surgeon that he was urged to apply for the position of surgeon in the U. S. Navy. Obedient to his father's wishes, however, he returned to practice in his native State and located in Jefferson, .Jackson Uo., Georgia, in 1841, at that time a small country town, far removed from any railroad, in the midst of a farming community whose only factory was the cotton gin.

Here Dr. Long soon acquired an extensive and lucrative practice, and although young was noted for his quiet, dignified bearing, which endeared him to all. His office was a favorite meeting-place for the young men of the town, who would often gather there to pass a merry evening together.

About this time it became fashionable to inhale laughinggas for its exhilarating effects. Itinerant lecturers on chemistry would conclude an evening's entertainment with a nitrous-oxide party in which the participants would get gloriously drunk from its inspiration.

The practice spread throughout the country, and at -Jefferson during the early part of the winter of '41 a coterie of young friends begged Dr. Long to let them indulge in the far-famed luxury.

Dr. Long replied that he had uo means of preparing nitrousoxide gas, but that sulphuric ether would produce similar exhilaration. The company being anxious to try it, the ether was produced, all inhaled of it and soon became hilarious.

The young men were delighted and hastened to tell their friends of Dr. Long's wonderful drug, and thus the inhalation of ether for sport soon became very popular over that section of Georgia, and almost every party ended up with an " ether frolic," as it was called.

During January, 1842, the ether frolics at Dr. Ijong's office became very frequent and were well attended, and some of the young men probably became pretty thoroughly intoxicated, as Dr. Long discovered that he and others would afterward have considerable bruises about their persons of which they had no knowledge.

Being a thoughtful man, he at once remarked thai ether must have the poiver of rendering one insensibU to pain, and therefore available for prevent itig pain in stirgical operations.

This was January, 1842, and Dr. Long at once determined to prove his discovery on the tirst surgical case_ he should have. That opportunity came on March 30th, when Long administered ether to Mr. James M. Venable till completely anaesthetized, and then excised a small cystic tumor from the back of his neck. Imagine the surprise of the patient when on regaining consciousness he was told that the operation was over, and his amazement when he saw the tumor in the hands of the surgeon and he had not felt a scratch. This was four and one-half years before Morton's earliest claims.

An original paper read by Dr. Long before the Georgia State Medical Society in 1852, describing these events in his own words, is appended to this paper — see Appendix I.

It is worthy of note that two and a half years later Wells of Hartford discovered the ansesthetic powers of nitrous oxide


under very similar circumstances. He attended an entertainment given by a popular lecturer on chemistry, inhaled nitrous oxide for its exhilaration, and saw a man under its influence injure his ankle severely without being conscious of it. From this he concluded that nitrous oxide was capable of producing anesthesia and proved it in extracting a tooth.

Morton, on the other hand, got his suggestion as to the ansEsthetic power of ether from Jackson, who, after using ether to relieve the pain and dyspnoea following the accidental inhalation of chlorine gas — an antidote well known in chemistry then — inferred that it might be useful as an anajsthetic. Jackson did not test the correctness of this observation, which he claims to have made about the same time that Long etherized his first case, but left it for Morton to prove practically four and a half years later.

Dr. liOng reports the first five cases in which he used ether, being desirous only of establishing priority of use. An examination of the letters and certificates before me, however, shows that he must have operated on at least eight cases before ^Morton's "discovery." This number seems small, but is not so astonishing when we remember that the country was sparsely settled, that Jefferson was a mere village, and Long had just entered practice.

I will now read in substantiation of these statements a copy of the original account in Dr. Long's journal against Mr. Venable for medical services rendered, certified to by a clerk of the Superior Court.

"James Venable

To Dr. C. W. Long, Dr. 1842. cts.

January 28th, sulphuric ether, .25

March 30th, sulphuric ether and exsecting tumor, 2.00 May 13th, sul. ether, .25

June 6th, exsecting tumor, 2.00

Georgia, I

Jackson County. ' I, P. F. Hinton, clerk of the superior court of said county, do certify that the above account is a correct copy of an original entry made in his book for medical services for the year 1842. Given under my name and seal of office this 27th of March, 1854. [Seal] (Signed) V. ¥. Hitfms, Vlerl.- S."

The following paper relative to the fashion of inhaling ether for its exhilarating effects is interesting as showing how the custom in Georgia started with Dr. Long :

" I certify that on the first of January, 1842, I resided in .Jefferson, Jackson Co., Georgia, and that about that time myself with several other young men were in the habit of meeting at Doct. C. W. Long's shop, and other rooms in the village, and inhaling ether which he adminutered to us.

On the 20th of January of the same year I removed to Athens, where I introduced the inhalation of ether. I and several of my young associates frequently assembled ourselves together and took it for the excitement it produced. After that I know it became very common to inhale ether in Athens, and tbat it was frequently taken in the college campus and on the street.

(Signed) R. H. Goodman,

August 4th, 1849. Athens, Georgia."

When we see daily the dreadful distaste patients who have been etherized have for ether, it seems strange that any one could become fond of its use.


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I will now read an account of the first operation as given by Mr. James M. Venable:

"I, James M. Venable, of the county of Cobb and State of Georgia, on oath depose and say, that in the year 1842 I resided at my mother's in Jaclcson County, about two miles from the village of Jefferson, and attended the village academy that year.

In the early part of the year the young men of Jefferson and the country adjoining were in the habit of inhaling ether for its exhilarating powers, and I inhaled it frequently for that purpose, and was very fond of its use.

While attending the academy I was frequently in the office of Dr. C. W. Long, and having two tumors on the back of my neck, I several times spoke to him about the propriety of cutting them out, but postponed the operation from time to time. On one occasion we had some conversation about the probability that the tumors might be cut out while I was under the influence of s. ether, without my experiencing pain, and he proposed operating on me while under its influence.

I agreed to have one tumor cut out and had the operation performed that evening after school was dismissed. This was in the early part of the spring of 1842.

I commenced inhaling the ether before the operation was commenced and continued it until the operation was over. I did not feel the slightest pain from the operation and could not believe the tumor was removed until it was shown to me.

A month or two after this time Dr. C. W. Long cut out the other tumor, situated on the same side of my neck. In this operation I did not feel the least pain until the last cut was made, when I felt a little pain. In this operation I stopped inhaling the ether before the operation was finished.

I inhaled the ether, in both cases, from a towel, which was the common method of taking it. Georgia, -v (Signed) James M. Ven.\blk.

Cobb Co., > Sworn to before me.

July 23rd, 1849. J Alfred Manes, J. P."

This operation was clone in the presence of fonr witnesses, Jas. E. Hayes, A. T. Thurmond, W. H. Thurmond, principal of the academy, and Edmund S. Rawls, the last of whom testifies as follows :

"Georgia, -i I, Edmund S. Rawls, of Rome, Floyd Co., Ga., on Clarke Co. J oath depose and say that ... on one occasion during that year (1842) I was present with James M. Venable in the office of Dr. C. W. Long in Jefferson, Jackson Co., Ga., and witnessed Dr. C. W. Long cut out a tumor from the side of neck of J. M. Venable while said Venable was fully under the effects of the vapor of s. ether inhaled from a towel, and without his exhibiting the least symptoms of suffering pain from the operation. J. M. Venable was so unconscious of the operation having been performed that he would not believe the tumor was removed until it was shown him. (Signed) E. S. Rawls.

Sworn to and subscribed before me this 2nd November, 1853.

E. L. Newton, /. J. C."

The patient continued to inhale ether until the operation was over, was entirely unconscious of its performance, and felt no pain. Surely this was complete ansEsthesia. This fact has been denied by Dr. Wm. J. Morton, son of the Boston discoverer, who says it was no more than mere exhilaration.

It has been stated that Long kept his discovery secret and that he therefore deserved no credit for it. I present certificates from Drs. Laperriere and Carlton, which show that his work was well known to citizens of the town of Jefferson and neighboring cities, particularly Athens, which was then the


centre of learning and culture in Georgia; that it was considered a remarkable discovery by the populace, and that the prominent physicians knew of it and realized its importance. See Appendix II.

Dr. Carlton was then a student under Dr. Moore. One year later (1844) he used ether in extracting a tooth. This was probably the first use of ether in extracting teeth. Dr. James Camak, another student of Moore, was present and assisted in the same operation and corroborates Carlton's statements.

Can Dr. Long be blamed for not publishing at once a report of his first case or two when they were well known to the physicians of that part of the State ? He had no Massachusetts General Hospital at his back, and he knew that such startling claims coming from one so young (he had not been practicing one year) would be severely criticised. It is but natural that he should be satisfied for the time being with the local and State publicity which was given to his great discovery, and waited until he could make a comprehensive report embracing all kinds of cases, such as every careful investigator does to-day.

But he kept on with his work, ojierating on two more cases under ether in 1842, and about three more during the next year, for most of which I find sworn certificates.

I have a letter from his first student. Dr. J. F. Groves, which is of particular interest as giving an insight into the character of Dr. Long and his work at that time. It is quite lengthy and I omit portions of it. The letter is written to Mrs. Taylor, Dr. Long's eldest daughter. See Appendix TIL

This letter shows conclusively that Dr. Long was thoroughly convinced of the anesthetic powers of ether, but was anxious to put it to a severe test in capital surgery. He withheld his cases of minor surgery because he wished to determine accurately the limitations and possibilities of ether.

In his paper Dr. Long does not give the details of the etherization with the minuteness we should desire. For instance, he does not say who gave the ether, the patient or himself, and he does not explain whether the patient was entirely unconscious or not, but simply remarks that he suffered no pain and did not know the tumor had been removed.

These omissions of Dr. Long led Dr. Wm. J. Morton, of New York, to write a forty-eight-page article in the Virginia j\Iedical Monthly, March, 1880, in which by dexterously quibbling with Long's innocent statements he arrives at the conclusion by a skilful process of deduction, that Long never did anything. I will read parts of this article :

"The Invention of An.esthetic Inhalation.

  • * * But we will proceed slowly. We must know who is giving the ether. Of the first operation Venable deposes under oath,

'I commenced inhaling the vapor before the ojieration was commenced and continued it until the operation was over.'

Tlius Venable kept his eye on the whole affair, knew just what was going on, otherwise how could he knowand swear to it thatbe continued the inhalation until the operation was over. Surely Veiiahlc administered the ether to himself and remained conscious all the time."

This is erroneous, for according to good legal authority


August-September, 1897


JOHNS HOPKINS HOSPITAL BULLETIN.


177


such a statement as Veiiable's could be made fi-um a knowledge based on satisfactory hearsaj' evidence and would be accepted in law.

But he goe.s on : "But now comes the damnatory point of this second experiment. The patient felt pain. Tliis both Long and Venable confess. Here tlien is positive failure ; Dr. Long's ansesthetic state was nothing more nor less tiian the fleeting peripheral numbness often associated with the first or e.Khilaratmg stage of the complete anesthesia of to-day. But why did Dr. Long not take the towel into his own hand and force the ether? Why not make his patient insensible to pain if he knew tliis could be done?

" Knowing what medicine knows to-day, how wonderful this halting of Long — tliis pause at a most critical moment — on the very threshold of discovery! So nicely balanced is the situation thiit it almost seems as if he would topple over into discovery; but he falls the other way.

" It seems almost inexplicable that he did not seize the towel, force the anaesthesia to the stage of stupor, perform the operation, and proclaim the discovery to the worUi," —

and we might add, patent it at once I

It is a fact well known to all surgeons that a patient may be entirely unconscious and still retain sensibility to pain. This is evidenced by the flinching before the knife when in this state. He may give evidence of feeling pain, but have no recollection of it afterward. All witnesses agree that Tenable gave no evidence of feeling pain in the first operation. He must have been jjretty thocoughly anffisthetiiied. The second operation was merely a test case to determine the length of the anaesthetic state, aud although the ether was discontinued from the beginning of the operation (which Long says was tolerably difficult on account of adhesions), still the anajsthetic state lasted until the last cut was made. We would consider .such a patient pretty thoroughly anaesthetized in Baltimore.

I have recently tested a number of patients who were being anaesthetized and found invariably that consciousness was lost before sensibility to pain — as evinced by movement of a member when pricked with a pin.

It was therefore practically certain that no j)erson could administer ether to himself, an act requiring consciousness — aud become sufficiently anaesthetized for even very small operations; but in order to settle the question definitely I determined to administer ether to myself, using the same methods as were employed by Long in 1842.

Accordingly, under the direction of Dr. F. II. Hagner of Washington, I placed a folded towel over my face and poured



Dr. CRAWFORD W. LONG


ether upon it from time to time at his bidding, as long as 1 was conscious. During this time Dr. Hagner pricked me with pins up to the last application that I remember. Toward the last the pin pricks did not produce the usual sensation of pain, but a peculiar disagreeable clanging sound in the ear.

Dr. Hagner thus briefly describes the experiment: "Dr. Young jjoured ether on the towel when so instructed by me. After a number of such additions the movements of his arm became very unsteady and he would spill some of the ether on his neck. Soon after the last application, made at my request, I pricked him with a pin and he moved his leg. I then instructed him several times to add more, but he made no attempt to do so and seemed unconscious. I then pricked him with pins several times, but received no response for about a minute, when he again responded to a prick of pin and suddenly became conscious. Comjilete consciousness returned almost immediately.

" I feel certain that he lost consciousness before sensibility to pain, and that if I had attempted to do the smallest surgical operation he would have been conscious of pain before its completion."

It is therefore certain that Yenable would have been conscious long before the small tumor was removed and would have suffered considerable pain, if he had conducted his own etherization. Nor is it probable that Long intended to convey that idea. We might with propriety say to-day that our patients "inhale ether until anesthetized," if we did not care to specify the details of etherization. Hut in a document quoted above R. H. Goodman says, in speaking of the ether frolics, " We were in the habit of meeting at Dr. Long's shop and inhaling ether which he administered to vs." It seems probable therefore that some one administered ether to the persons on whom he operated, too.

Desirous of settling these trivial points on which Morton would have Long deprived of every honor, I addressed a letter a few days ago to Long's first student. Dr. J. F. Groves, w'hose document I have quoted above. I saw that he would now be about 75 years of age and waited for an answer with considerable au.xiety. To my surprise and delight I received a letter from him yesterday which supplies all of Dr. Long's omissions. Dr. Groves did not see the first operations, as he did not enter Dr. Long's office till 18W, but soon after his entrance he assisted in the operation on the negro boy in which two fingers were amputated, early in 18-t5, aud at my request he describes this etherization in detail.


178


JOHNS HOPKINS HOSPITAL BULLETIN.


[Nos. 77-78.


As this case occurred a year ami a half before Morton's discovery, it is equally good as the first for my purposes. It is as follows :

A Recent Letter fkom Long's First Student.

"CoHUTTA, Ga., Jan. 15th, 1897. Dr. Hugh H. Young,

Dear Sir ; * * * The patient was placed in a recumbent position, on a bed, with hand to be operated on to the front for convenience to tlie surgeon. Dr. Long poured etiier on a towel and held it to the patient's nose and mouth, too, to get the benefit of inhalation from both sources. Dr. Long determined when the patient was sufficiently etherized to begin the operation by pinching or pricking him with a pin. Believing that no liarm would come of its use for a reasonable length of time he profoundly anesthetized the patient, then gave me the towel and I kept up the influence by holding it still to the patient's nose. The patient was entirely unconscious — no struggling — patient passive in the hands of operator. After a lapse of lifty years you would hardly suppose that a man could remember every minute detail, but I have clearly in mind all the facts I have given you.

Your ob't servant,

(Signed J J. F. Groves, M. D."

Long then administered ether as it is done to-day. He did not pause at the threshold of discovery or topple the other way, but kept right ahead and by careful observation, experimentation and reflection discovered that ether was a safe, sure and complete anajsthetic.

Nor did his patients etherize themselves and at the same time superintend the operation, as Dr. Morton would have us believe.

As quoted above, Morton grasps eagerly at the acknowledgment of pain at the end of the second operation, where the ether had been discontinued, and from tnat isolated instance characterizes all of Dr. Long's cases as failures. But in his eagerness to annihilate Dr. Long he seems to have overlooked the fact that in the first report of anassthesia with Morton's " Letheou " at the Massachusetts General in 1846, Dr. Bigelow* says, in speaking of the first operation, "During the operation the patient muttered as in a semi-unconscious state, and afterwards stated that the pain was considerable," and in the second, " The operation lasted four or five minutes, during which time the patient betrayed occasional marks of uneasiness." But these certainly were not failures, although the ausesthesia was not as complete as in Dr. Long's previous cases.

Li his paper Long speaks of "those high in authority who were advocating the mesmeric state as adequate to prevent pain in surgical operations." Contemporary medical literature furnishes ample verification of these statements, according to Dr. Grandy,t who says :

" The journals were full of discussions upon the phenomena of mesmerism, animal magnetism, etc., and wonderful reports were coming from European hospitals of operations done without pain during the ' magnetic sleep.'

"Jules Gloquet had excised a cancerous breast with the axillary glands and the patient showed no sign of pain. Top


  • Boston Medical and Surgical Journal, Nov. 1846.

t Va. Med. Monthly, Oct. 1893.


ham of London, in 1843, had amputated a thigh, and Dr. Diigas of Augusta, Georgia, in 184.5, twice extirpated the mamma of a female under the mesmeric sleep.

"We can imagine what efEect these cases had on the mind of Long. Need we wonder therefore that he was the more particular in his experiments on etherization. Such were the reasons for his silence, and while the sequel was unfortunate, his course was cautious and commendable."

While thus waiting, his opportunity was lost. A second discovery was made in Boston in 1846, was published immediately, and anesthesia became the property of the world.

Friends of the other " discoverers " have often stated that as Long made no publication of his work he deserved no credit for it. To this Dr. J. Marion Sims responds very forcibly as follows:*

" Now upon this point Long, Wells, Morton and Jackson stand individually upon the same level.

Long exhibited to medical men and to the community his operations under ether in 1842. Wells exhibited to medical men and to the community his operations of the extraction of teeth under nitrous oxide gas in 1844. Morton exhibited to medical men and the community the use of his secret remedy "Letheon," 1846, as an anesthetic. But Morton was fortunate in showing his patent remedy to the great surgeons of Boston, and it was not Morton, but it was Warren and Ilayward and Bigelow who performed the operations to which the world owes the immediate and universal use of anfesthesia in surgery. If Morton could have had his w,iy he would have deodorized the ether and kept it secret from the world. Neither Wells nor Morton nor Jackson ever published a word on the subject till it burst forth in a blaze from the labors of the hospital surgeons already named. When Warren and Hay ward and Bigelow proved the real greatness of the discovery [and published it broadcast], then it was that Wells, Morton and Jackson began the war of pamjihlets, and not till then did either of them publish in any scientific journal a line about ana'sthesia."

The Famous Ether Controversy.

In 1849 Morton petitioned Congress for a reward for his discovery. He was at once opposed by Jackson and the friends of Wells, who was then dead. The celebrated ether controversy, thus begun, occupied the attention of Congress for many years, and was characterized by the greatest animosity between these former bosom friends and companions.

For five years Long i-efused to take part in the conflict, but finally in 1854, persuaded by his friends that in that way alone could he obtain recognition of his claims, he wrote to Senator Dawson giving an account of his work. It seems that Dawson was a friend of Jackson, for he wrote to him of this new claimant and requested him to investigate his case. This .Jackson did, calling upon Long at his home in Athens on March 8th, 1854.

The Ixtekview betweej^ Loxa .vxd Jacksox. At this interview lion. C. W. Andrews, a prominent justice.


  • Va. Med. :\ronthly, :\Iay, 187


August-September, 1807.]


JOHNS HOPKINS HOSPITAL BULLETIN.


179


was present, and certifies that after satisfying himself of the genuineness of the claims, Jackson proposed to Long to lay their claims conjointly before Congress — he, Jackson, to claim the discovery, and Long to claim the first practical use, — his object evidently being to get ahead of Morton.

This proposition Dr. Long rejected, being satisfied that he was entitled to both. In a letter to Hon. D. L. Swain, ex-governor of North Carolina, which I have here, he says in regard to this transaction: "The only ground Dr. Jackson urged for his right to the discovery was that while suffering with pain and dyspncea, in February, 1842, from breathing chlorine gas, he inhaled ether and found that while under its influence he was free from pain. He does not claim that he suggested its use to jjrevent pain in surgical operations until more than one year after my first operation was performed. I cannot give the exact date when I was first led to believe that ether would prevent pain in surgical operations, but I know it was as early as February, 1S42."

Now in 1839 Pereira, in his "Elements of Materia Medica," states : " The vapor of ether is inhaled to relieve the effects caused by accidental inhalation of chlorine gas. If the air be too strongly impregnated with ether, stujjefactiou ensues."

So there was very little new in Dr. Jackson's " discovery," and a mere untried inference hardly deserves the title of discovery.

Dr. Jackson finally acknowledged the justice of Dr. Long's claims and wrote to Senator Dawson to that effect.

On April 15th, 185-t, the appropriation bill was up before the Senate for its final reading. The friends of Wells and Morton, relying on the volumes of manuscript they had presented, were confidently awaiting the result, when Senator Dawson arose and said that he had a letter from Dr. Jackson which acknowledged that a Dr. Long in Georgia had undoubtedly used ether before any of the claimants for the appropriation.

Coming as it did from so prominent a contestant, this announcement fell like a thunderbolt on the rival claimants, and from that time they seem to have lost all Iwpe of gaining the reward and passively allowed the bill to die.

Desirous only of preventing another from being recognized by Congress as the discoverer, and not wishing any pecuniary reward himself, Long never pushed the matter farther, and his documents of proof were never even brought uj) before Congress.

I have here an interesting memento of that conference between the two discoverers, in a card on which Jackson has written a note to Long. On one side it reads :

"For Dr. C. W.Long,

of Athens, (Ja. C. T. Jackson,

New York Hotel, (over) " and on the reverse :

"Telegraph from J. L. Hayes, Washington. 'Assignee struck out by request of Mr. Everett.' Bill probably will come up in House July next."

Edward Everett was then senator from Massachusetts. In


the transactions of the Senate, April 19th, 1854, I find the following explanation of the bill by Senator AValker:

" The bill as amen. led recites that a discovery of anaesthesia has Ijeen made — that it is believed the discovery was made by some one of the following persons, W. T. G. Morton, Chas. T. Jackson and Horace Wells, but it does not appear to the satisfaction of Congress which of those parties was the original, true and first discoverer thereof. It proposes to ap|>ropriato $100,0(0.00 as a recompense for the real discoverer. In order to determine this it shall bo the duty of the district attorney of the United States for the Northern District of New York, to file in the circuit court of the United States for that district a bill of interpleader wherein reciting the act or its substance, the Secretary of tlie Treasury shall be complainant, and AV. T. G. Jlorton, Chas. T. Jackson and the personal representatives of Horace Wells or any other person who may make application to thecourt for that purpose shall be defendants. The issue is to be which of the parties named was the original, true and first discoverer of anseathesia, and the court is to decide which one that is and direst that the sum of $100,000 he paid over to him."

At the instance of Senator Dawson Dr. Long's name was also inserted in the bill.

I have carefully searched the Congressional Eecords and find that this bill never came up before the House for final passage, and conseqixently never reached the district court of New York. It seems to have been abandoned.

Several years later Dr. Jackson wrote an article in the Boston Medical and Surgical Journal giving Long the credit for the first use of ether in surgery. I have here Dr. Long's copy of that journal. The communication is so imjiortant that I will read most of it :

" The Boston Medical and Surgical Journal.

Boston, Thursday, Apr. 11, ]8()1.

First Peactical Use of Ether in Surgical Operations.

Messrs. Editors: — At the request of the Hon. Mr. Dawson, U. S. Senator from Georgia, on March Sth, 1854, 1 called upon Dr. C. W. Long, of Athens, Georgia, while on my way to the Dahlonega gold mines, and examined Dr. Long's evidence, on which his claims to the first practical operations with ether in surgery were founded, and wrote, as requested, to Mr. Dawson, who was then in the U. S. Senate, all I learned on the subiect. From the documents shown me by Dr. Long, it appears that he employed sulphuric ether as an anaesthetic agent :

1st, March 30th, 1812, when he extirpated a small glandular tumor from the neck of James M. Venable, a boy in Jefferson, Georgia, now dead.

2nd, July 3rd, 1842, in the amputation of the toe of a negro boy lielonging to Jlrs. Hemphill, of Jackson, Ga.

3rd, Sep. 9th, 1843, in extirpation of a tumor from the head of Mary Vincent, of JacKson, Ga.

4th, Jan. Sth, 1845, in the amputation of a finger of a negro boy belonging to Ralph Bailey, of Jackson, Ga.

Copies of the letters and depositions proving these operations with ether were all shown me by Dr. Long. * * *

I then called on Profs. Joseph and John Le Conte, then of the University of Georgia, at Athens, and inquired if they knew Dr. Long, and what his character was for truth and veracity. They both assured me that they knew him well, and that no one who knew him in that town would doubt his word, and that he was an honorable man in all respects.

Subsequently, on revisiting Athens, Dr. Long showed me his folio journal, or accountbook, in which stand the following entries :


180


JOHNS HOPKINS HOSPITAL BULLETIN.


[Nos. 77-78.


' James Venable

March 30th, 1842, Ether and excising tumor, $2.00 May 13th, Sul. Ether, .25

June 6th, Excising tumor, 2.00'

On the upper half of the same page, several charges for ether sold to the teacher of the Jefferson Academy are recorded, which ether Dr. Long told me was used by the teacher in exhibiting its exhilarating effects, and he said the boys used it for the same purpose in the academy. I observed that all these records bore the appearance of old and original entries in the book.

On asking Dr. Long why he did not write to me or make known what he had done, he said, when he saw my dates he perceived that I made the discovery before him, and he did not suppose that anything done after that would be considered of much importance, and that he was awakened to the idea of asserting his claims to the first practical use of ether in operations, by learning that such claims were set up by others for this merit, and consequently he wrote to the Georgia delegation at Washington, stating the facts which Senator Dawson had requested me to inquire into.

I have waited expecting Dr. Long to publish his statements and evidence in full, and therefore have not before published what I learned from him. He is a very modest, retiring man and not disposed to bring his claims before any but a medical or scientific tribunal. * * *

Had he written to me in season I would have presented his claims to the Academy of Sciences of France, but he allowed his case to go by default, and the academy knew no more of his claims to the practical use of ether in surgical operations than I did.

Boston, >ipril 3, 1861. Charles T. Jackson, M. D."

The list of operations as given by Dr. Jackson is not complete, as he has omitted the second operation on Venable, and a number of the later operations. In a letter to Dr. Sims, which I have, Dr. Long denies absolutely that he ever acknowledged that Dr. .Jackson was the prior discoverer. He had been led to infer that ether had ana3sthetic powers several months before he got a chance to verify it, and before Jacksou claims to have made similar inferences, but he dated bis claims of discovery from the time of his first practical demonstration. Before that it was a mere supposition, as was Jackson's also.

But barring these inaccuracies, Dr. Jackson's paper, coming as it does from one who so zealously coveted the title of discoverer, is a remarkable admission.

The interview between Long and Jackson must have been most amicable, and Long evidently felt the greatest respect for Jackson, as shown in the following letter:

"Athkns, Ga., Nov. 15th, 1854. Dr. C. T. Jackson.

Dear Sir: — I design to prepare an article with the proofs of the priority of my claims of the discovery of the anresthetic powers of ether and of its applicability to surgical operations. I design having this published in pamphlet form for distribution among the members of the medical profession, and I expect to present such proof with the article as will satisfy all that I am entitled to all I claim.

Ours are rival claims, and permit me, sir, to say that although our claims are conflicting, I would not knowingly say anything in the article which would be displeasing to you. I entertain high respect for you as a gentleman and man of science and feel honored by your acquaintance.

Still it becomes each one of us to use all honorable means to advance his own claims, and I know you will not blame me for attending to this matter, which so much concerns my reputation.

Shall it meet with your approbation, I may refer to your admis


sions to Hon. W. C. Dawson and myself, of the belief of the correctness of my claims. I will, however, make no allusion to your letter to Mr. Dawson or to the conversation held with myself unless

it meets with your sanction

Your obedient servant, C. AV. Long."

Morton's Patent.

It has often been stated by the friends of ilorton that he never attempted to enforce his patent. This statement has lately been reiterated by his wife in McClure's Magazine. On this point the following letter from a prominent army surgeon to Long may be of interest:

" U. S. Marine Hospital,

Chelsea, Mass., April, 1859. Dr. Crawford W. Long, Athens, Ga.

Sir: — Hon. Judge Hyllier, Solicitor of Treasury Department, informed me about a year since, and recently repeated the same, that some years since you used sulph. ether as an anaesthetic and had a record of the same. If it is not asking too much of you, I would be greatly obliged if at your earliest convenience you would forward me a statement of the facts.

I take the liberty to ask this of you because Mr. W. T. G. Morton, to whom in conjunction with Dr. C. T. Jackson a patent was granted in Nov., 1846, for using ether, has brought a suit against me as a government officer for an infringement of his patent.

Judge Hyllier was confident that you could furnish me with proof sufficient to satisfy a jury that you used it way before he or Jackson claimed to have made the discovery. I should have asked for these proofs through my attorney and had them properly witnessed, etc., but the Secretary of the Treasury having decided that I used the article on my own responsibility and therefore the Govt, were not bound to defend me, I wish to save as much expense as possible. Very respectfully,

[Signed] Charles A. Davis, M. D.,

Physician and Superintendent."

In reply Long gives a detailed account of his work, and then adds : " I presume Dr. Jackson is not party to the prosecution, as I know he entertains no good feelings towards W. T. Morton. If you think proper you can see him and ascertain the character of proof I can make. From the little acquaintance formed with him I entertain a high opinion of him as a gentleman and think he will do me justice notwithstanding he himself claims to have made the discovery and has received several awards."

Dr. Davis's letter was written twelve years after Morton's " Letheon " was patented, and many years after ether was the common property of the world. It was probably Morton's last attempt to get money from the U. S. Government.

The ether controversy was never reopened and Long's work was unknown to the world until 1877, when J. Marion Sims learning of him through accident, investigated his claims, was fully convinced of their merit, and vigorously demanded their recognition by the medical profession. His paper appeared in the Virginia Medical Monthly, May, 1877.

The Wilhite Cl.\ims.

This article, which obtiviued for Long the first recognition of any consequence, was the outcome of a conversation which Sims had with a Dr. P. A. Wilhite, of Anderson, S. C. Wilhite told Sims that be had witnessed the first surgical o])eration ever done under ether, and recounted Dr. Long's


August-September, 1897.]


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181


first case, saying that lie was one of four students who were then in Dr. Long's office.

He also said that " he presumed that he was the first j)erson who ever profoundly etherized any one," and told how he was at a quilting party in which the boys and girls had concluded the evening by inhaling ether for sjiort; how they had caught a negro boy, and as he refused to inhale the ether, had firmly held a handkerchief soaked with ether over his face, when to their horror his breathing became stertorous and he could not be aroused. He then vividly pictured their alarm when they realized that they had murdered a fellow-being, and thdr determination to leave the country, which was prevented by the timely arrival of a physician who restored the boy to consciousness.

Wilhite iheu related how when the idea of using ether to prevent pain in surgical operations had occurred to Long, he had eiicoura<jed him hy relating the story of the negro boy.

Dr. Sims at once communicated with Dr. Long and soon convinced himself of the truth of his claims, but unfortunately he failed to investigate Wilhite's statements, but embodied them in full in his article, giving to Wilhite the credit of first intentionally producing profound ana;sthesia with ether.

Dr. Sims' paper was given great publicity and the Wilhite story has been accej^ted as true, and copied by many writers on the subject, most notably by Sir Jas. Paget.*

The negro boy story lacks probability, as Wilhite did not enter Long's office until 1844, two years after the first operation, as the following letter from Long to Wilhite shows :

"Athens, Ga., May 20th, 1S77. Dk. p. a. Wilhite.

Bear Sir : — I received Br. Sims' article on anaesthesia yesterday and find several mistakes. Dr. Sims states that yourself, Dr. Groves, and Drs. J. D. and H. E. J. Long were students of mine and witnessed the operation performed on Venable in 1842. Your recollection failed you at the time. As it was several years, at least two, before either entered my office, you will see that you were mistaken in giving Dr. Sims this information. You also make a mistake in saying that the first inhalation in Jefferson of ether for its exhilarating effects was before the same persons.

  • * * I wrote to Dr. Sims informing him of the errors and

asking him if he considered the mistakes of sufficient importance to be noticed, etc. (Signed) 0. W. Long."

Dr. Wilhite replied as follows :

"Anderson, S. C, June 27, '77. Dr. C W. Long.

Dear Doctor : — Yours of the 22nd inst. is at hand, and I have also just received a letter from Dr. J. M. Sims, which I will answer to-day. » » *

In my statement I did make a mistake in regard to my being present at the first or second operation, which mistake I will correct. But if you still prefer I will send a certificate. * * •

Let me know and I will give you any information or assistance in this great matter. Yours truly, etc.,

(Signed ) P. A. Wilhite."

Ill the letter to Wilhite, Long makes no comment on the negro-boy incident, but his daughter informs me that he


  • The Nineteenth Cenliiry, 1880.


repeatedly told her that he had never heard of it before it appeared in Sims' article.

It is to be regretted that the justification of Long's claims should have been linked so closely with such misstatements.

Sims sailed for Europe soon after the publication of his article, and Long died in a few months, and Wilhite's statements went unchallenged for many years.*

Among Dr. Long's papers are many more documents — affidavits of persons operated on and witnesses to them, and letters to different prominent men — but their recital would take up too much time, so I will close with a few words regarding his after life.

In 1842 Dr. Long was married to Miss Caroline Swain, a niece of Governor Swain of North Carolina, a very handsome and attractive woman, who proved a devoted wife. She survived her husband many years.

Long remained in Jefferson for ten years, when he removed to Athens and there spent the rest of his days. By inheritance and professional labors Dr. Long had amassed a fortune, which was largely swept away by the war of secession, and at its close he found himself reduced to poverty, with a large family to support.

Although he soon regained an extensive practice, the desolation of the country and the general poverty of the people made the remainder of his life a continual struggle against poverty. His life, which, up to the time of Dr. Sims' article, had been one of disappointments, after that suddenly became brighter, for from all parts of the world men prominent in the medical profession hastened to give him the credit which had so long been withheld.

His claims were never investigated by the American Medical Association, as he often desired, but many minor societies and the "Eclectic" Medical Association passed decrees in his favor, and a statue was erected in his honor in Paris, France.

But he was not long to enjoy the praise and long-delayed honors which were now heaped upon him. Within a few months, while laboring at the bedside of a delicate patient, he was stricken with apoplexy and died the next day, June 16th, 1878, at the age of sixty-two, poor in worldly goods but rich in the gratitude of his people. His oft-repeated wish to die in harness had been granted.

A strange fatality seemed to hang over the lives of all connected with the discovery of auajsthesia !

Wells, disappointed and disheartened by the rejection of his claims by the French Academy, became insane and committed suicide in 1848.

Morton gave up a very lucrative practice and vainly spent his life in trying to enforce his patent and get a reward from Congress. He died in 1868 from congestion of the brain, brought on by excitement occasioned by an article attempting to deprive him of the honor he so jealously coveted.

Long died in poverty, from apoplexy brought on by overwork in 1878.

Jackson, like Wells, became insane from the bitter contentions of his life and died in an asylum in 1880.


  • ln an article in the Virginia Medical Monthly, 1893, Dr. L. 15.

Grandy, of Atlanta, showed the error of Wilhite's statements.


182


JOHNS HOPKINS HOSPITAL BULLETIN.


[Nos. 77-78.


Henri L. Stuart, founder of the Woman's Hospital, aud a great New York philanthropist, became interested in Long's claims and presented a portrait of him to tlie University of Georgia. After seeing it unveiled with great ceremony in the capitol in Atlanta, one year after Long's death, he went to Athens as a guest of the Longs, to visit the grave of the discoverer of anaesthesia. Arriving at night, he waited till morning to fulfil his heart's desire. But this was never gratified. IJuring the night he had a paralytic stroke aud died at the home of the Longs after lingering several weeks. At his own request his remains were interred next to those of Crawford Long — two great benefactors side by side.

Appendix I. Dr. Long's Original Paper.*

In the month of Dec, 1841, or Jan., 1842, the subject of the inhalation of nitrous oxide gas was introduced in a company of young men assembled at night in the village of Jefferson, Ga., and the party requested me to prepare tliem some. I informed them I had not the requisite apparatus for preparing or preserving the gas, but that I had an article (sul. ether) which would produce equally exhilarating effects and was as safe. The company were anxious to witness its effects, the ether was introduced and all present in turn inhaled. They were so. much pleased with its effects that they afterwards frequently used it and induced others to do the same, and the practice soon became quite fashionable in the county and some of the contiguous counties.

On numerous occasions I inhaled ether for its exhilarating properties, and would frequently, at some short time subsequent to its inhalation, discover bruised or painful spots on my person which I had no recollection of causing and which I felt satisfied were received while under the influence of ether. I noticed my friends while etherized received falls and blows which I believed were sufiicientto produce pain on a person not in a state of anaesthesia, and on questioning them they uniformly assured me that they did not feel the least pain from these accidents. Observing these facts I was led to believe that anesthesia was produced by the inhalation of ether, and that its use would be applicable in surgical operations.

The first patient to whom I administered ether in a surgical operation was Mr. James M. Venable, who then resided within two miles of Jefferson, and at present lives in Cobb Co., Ga. Mr. Venable consulted me on several occasions in regard to the propriety of removing two small tumors situated on the back part of his neck, but would postpone from time to time having the operation performed, from dread of pain. At length I mentioned to him the fact of my receiving bruises while under the influence of the vapor of ether without suffering, and as I knew him to be fond of and accustomed to inhale ether, I suggested to him the probability that the operations might be performed without pain, and proposed operating on him while under its influence. He consented to have one tumor removed, and the operation was performed the same evening. The ether was given to Mr. Venable on a towel, and when fully under its influence I extirpated the tumor.

It was encysted and about half an inch in diameter. The patient continued to inhale ether during the time of the operation, and when informed it was over, seemed incredulous until the tumor was shown him.

He gave no evidence of suffering during the operation, and assured me, after it was over, that he did not experience the least degree of pain from its performance. This operation was performed on the 30th ]\rarch, lSt2.


' Read liefore Georgia State Medical .Society in 18.')3.


The second I performed on a patient etherized was on the 6th June, 1812, and was on the same person, for the removal of the other small tumor. This operation required more time than the first, from the cyst of the tumor having formed adhesions to the adjoining parts.

The patient was insensible to pain during the operation until the last attachment of the cyst was separated, when he exhibited signs of slight suffering, but asserted after the operation was over that the sensation of pain was so slight as scarcely to be perceived. In this operation the inhalation of ether ceasrd before the first incision was made. Since that time I have invariabh' desired patients, when practicable, to continue the inhalation during the time of the operation.

Having permitted such a length of time toelapse without making public my experiments in etherization, in order to show the correctness of my statements I procured the certificate of the patient on whom the first operation was performed, the certificate of two who were present at the time of the oper.ation, and also those of his mother, brothers and sisters and a number of his immediate friends who heard him speak of the operations soon after they were performed. The Southern ]Med. and Surg. Journal* contained but two of the certificates. I have a number of others which can be seen or read if desired by the Society. My third case was a negro boy who had a disease of a toe which rendered amputation necessary, and the operation was performed July 3rd, 18)2, without the boy evincing the slightest sign of pain.

These were all the surgical operations performed by me during the year 1842 upon patients etherized, no other case occurring in which I believed the inhalation of ether applicable. Since '42 I have performed one or more surgical operations annually, on patients in a state of etherization.

I procured some certificates in regard to these operations, but not with the same particularity as in regard to the first operations, from the fact of my sole object in the publication being to establish my claim to priority of discovery of power of ether to produce anasthesia. However, these certificates can be examined.

Tlie reasons which influenced me in not publishing earlier are .as follows:

I was anxious, before making my publication, to try etherization in a sufficient number of cases to fully satisfy my mind that an£Bstliesia was produced by the ether, and was not the effect of the imagination or owing to any peculiar insusceptibility to pain in the persons experimented on.

At the time I was experimenting with ether there were physicians high in authority and of justly distinguished character who were the advocates of mesmerism, and recommended the induction of the me.wierjcs/a?*' as adequate to prevent pain in surgical operations. Notwithstanding thus sanctioned I was an unbeliever in tlie science, and of the oiiinion that if the mesmeric state could be produced at all it was only on those of strong imaginations and weak minds, and was to be ascribed solely to the workings of the patient's imagination. Entertaining this opinion, I was the more particular in my experiments in etherization.

Surgical operations are not of frequent occurrence in a country practice, and especially in the practice of a young phj'sician, yet I was fortunate enough to meet with two cases in which I could satisfactorily test the anEesthetic power of ether. From one of these patients I removed three tumors the same day ; the inhalation of ether was used only in the second operation, and was effectual in preventing pain, while the patient suffered severely from the extirpation of the other tumors. In the other case I amputated two fingers of a negro boy ; the boy was etherized during one amputation and not during the other ; he suffered from one operation and was insensible during the other.

After fully satisfying myself of the power of ether to produce aniesthesia, I was desirous of administering it in a severer surgical


FAC-SIMILE OF LONG'S MANUSCRIPT. SEE PAGE 182.

operation than any I had performeii. In my practice, prior to the published account of the use of ether as an antesthetic, I had no opportunity of experimenting with it in a capital operation, my cases being confined, with one exception, to the extirpation of small tumors and the amputation of fingers and toes.

While cautiously experimenting with ether, as cases occurred, with the view of fully testing its antesthetic powers and its applicability to severe as well as minor surgical operations, others more favorably situated engaged in similar experiments, and consequently the publication of etherization did not " bide my time."

I know that I deferred the publication too long to receive any honor from the priority of discovery, but having by the persuasion of my friends presented my claim before the profession, I prefer that its correctness be fully investigated before the Med. Society. Should the society say that the claim, though well founded, is forfeited by not being presented earlier, I will cheerfully respond, so mote it be.

Not wishing to intrude upon the time of the Society, I have made this short compendium of all the material points stated in my article in the Journal, and if the Society wishes any fuller information on the subject I will cheerfully comply with their wishes.

Appendix II.

" Georgia, 1 I, Ange De Laperriere, M. D., do certify that I

Jackson County. > resided in Jefferson, Jackson County, Georgia, in the year 1842, and that some time in that year I heard James M. Venable, then of said county, speak of Dr. C. W. Long's cutting out two tumours from his neck while under the influence of the inhalation of sulphuric ether, without pain or being conscious of the performance of the operation.

I do further certify that the fact of Dr. C. W. Long using sulphuric ether by inhalation to prevent pain in surgical operations was frequently spoken of and notorious in the county of Jackson, Georgia, in the year of 1842. A. De Laperriere, M. D.

Sworn to and subscribed before me this 30th of March, 1854.

N. H. Pe.ndergrass, J. P."

"Athens, Clarke Co., Georgia. I, the undersigned, do certify that in May, 1843, 1 assisted Dr. R. D. Moore in amputating the leg of a colored boy Augustus, then the property of Mr. Wm. Stroud, who resided in this county ; and that I distinctly recollect hearing Dr. R. D. Moore say, If I had thought of it before leaving home I would have tried Dr. C. W. Long's great discovery, namely, the administration of sulphuric ether as an anaisthetic in performing the operation. Having neglected to bring the ether. Dr. Moore finally concluded to influence the


patient with morphia ; under which influence the operation was performed. Jos. B. Carlton, M. D."

Appendix III. From Dr. Long's First Student.

"CoHUTTA, Ga., Dec. 13th, 1894. Mrs. Frances Long Taylor,

Dea7' Madam :—* * * In 1844, soon after I attained my majority, I decided to adopt medicine as my profession, and began to think where and under whom I should begin the preparatory study. My father asked me to choose from among the number of physicians whom 1 knew the one I preferred to act as preceptor to me.

Knowing Dr. Long so well and believing him to be a man of no ordinary ability, I at once fixed upon him as my choice.

I entered Dr. Long's office in May, 1844, as the first student ever under his care. As I progressed with my studies he saw fit to make known to me his discovery, by the use of which he could perform surgical operations without giving any pain to his patient. [Here follows a description of the first cases.]

Notsatisfied, however, that there was not more to learn about this great disco very, he proposed that we test it further personally, which we did in his office, where with closed doors we administered it to each other to prove its perfect anaesthetic effect and also to discover any bad effect to the subject etherized. Owing to the prejudice and ignorance of the populace Dr. Long was prevented from using ether in as many cases as he might have.

Thus in the two years preceding my entering Dr. Long's office he had had only about six cases in which to try the anaesthetic effects of ether.

The first case thatcame under his care where its use was applicable after my going into his office was not till January 8th, 1845, which was the case of a negro boy having two fingers to amputate, caused by neglected burn. I, as the only student still with the doctor, he had me to accompany him to see the operation and assist ill the administration of the ether. The first finger was removed while under the influence of ether, the little fellow evincing no pain ; the second without ether, the child suffered extremely. This was done to prove that insensibility to pain was due to the agent used.

Soon after this, in January, Mr. J. D. Long came into the office as a fellow-student ; later, toward spring, came P. A. Wilhite, and in August came Dr. Long's brother, H. R. J. Long. We four remained there at Dr. Long's oflBce as students until the opening of the fall term of the medical colleges. » * *

[Signed] J. F. Groves, M. D.

Sworn and subscribed to before me, Dec. 15th, 1894.

\V.M. H. Wilson, N. P."


THE EARLY HISTORY OF OPHTHALMOLOGY AND OTOLOGY IN BALTIMORE (1800-1850).*

By Harhy Friedenwald, A. B., M. D., Associate Professor of Ophthilmologij and Otology, College of Fliysicians and Sii-rgcons,

Baltimore, Md.


An old book tells us that each generation may be looked upon as standing on the shoulders of its fathers. If its vision is clearer, its intellectual view less obstructed, its horizon broader, it is in great part due to the height to which others have raised it, to tlie support others have given. Unmindful of this, it is apt to exaggerate its greatness and the importance of its own work.


  • Read before the Johns Hopkius Hospital Historical Club,

April, 1897.


In the following narrative I have brought together all that I could find relating to tlie lives and labors of those who, in the earlier years of this century and in our own city, tilled the soil of ophthalmology and otology. Some have been forgotten, few have been accorded deserved recogniiion.

Are not many of us as ignorant of their names and works as an old physician from whose memories I liad hoped to obtain information, but whose response was, "No work was done in Baltimore in those departments of medicine before 1850"? I must confess tliat when iny attention was first drawn to this


August-September, 1897.]


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185


subject I knew of biit one work of importance which a Baltimore physician had rendered to ophthalmology.

There is no reference in literature to anything done in Baltimore in the two branches we are considering before the beginning of this century. We must remember that in 1800 the population of Baltimore City was 26,614 and that in 1802 there were but 44 physicians.

It is probable that there were here as elsewhere those who confined themselves to diseases of the eye. This is indicated by a resolution adopted at the convention of the Medical and Chirurgical Faculty of Maryland in 1805.* It was resolved that " the Board of Examiners be authorised to grant special licenses to dentists and occulists to practice in their respective branches, subjecting them to an examination only on the branches they possess; and that such licentiates shall pay ten dollars for each license so obtained; provided it shall be the opinion of the attorney-general that the law authorizes the examiners to grant such licenses. The secretary having submitted the preceding resolution to the then attorney-general, he gave it as his opinion that the law authorized the board to act according to the spirit of the resolution." These "occulists" did not, it appears, stand in very good repute.

In the review in 1825 of an American treatise on diseases of the eye, the writer, who was probably Dr. Isaac Hays, the distinguished editor of the American Journal of Medical Sciences and an ophthalmologist of note, describes the condition of ophthalmology in the early years of this century. He tells us that " the neglect to which disorders of the eye were too long consigned is truly astonishing. Prepossessed with an idea that there was something peculiar in the diseases attacking different parts, physicians entirely abandoned these affections to persons who were exclusively devoted to them and were totally ignorant of the laws which influence diseases of other organs. To this cause is to be attributed the slow progress which tlie science of ophthalmology made during many centuries. The history of this science shows that while it made most rapid advances in improvementby the investigations of medical men, it invariably, when abandoned to professed oculists, not only ceased to advance but actually retrograded ... In this country much apathy has existed, and we fear still exists, with regard to these affections. Some of our distinguished surgeons have not, it is true, entirely neglected them ; yet the mass of medical practitioners have paid little attention to them, and the science has advanced so rapidly during the few years that we believe few have kept pace with the improvements that have been made. The length of time that generally elapses before opinions of European writers are diffused in this country — the want of regular lectures — and above all, clinical instruction and the opportunities furnished of observing these diseases in institutions established for the reception of these cases, are the cause, no doubt, of the present state of the science among us."

He mentions that the New York Eye Infirmary was established in 1830, the Pennsylvania Infirmary for Diseases of the Eye and Ear in 1822, and "with respect to the institution at Baltimore he has but little information to communicate. It is


'Summary of Proceedings, &c., published in 1817


attached to the Baltimore Dispensary and is committed to the care of the author of this work." [Dr. Geo. Frick.]

Pierre Chatard.

The earliest Baltimore publication having reference to diseases of the eye is found in a paper written by Dr. Pierre Chatard in the Medical Repository, vol. VII, p. 28. Dr. Chatard was born and educated in France, and had settled in Baltimore in 1797. He was a prolific writer, the paper referred to being one of the earliest. It was entitled "An account of a case of Fistula Lachrymalis, with reflections on the diflerent modes of operating in that disease." The paper describes a case of lachrymal fistula relieved by introducing threads of silk after the manner of a seton through the lachrymal duct and gradually increasing their number. He discusses at length the various methods in vogue at that time of treating the disease. It is written in an interesting and elegant manner. None of the other writings of Chatard relate to diseases of the eye.

William Gibson.

During the second decade of this century the celebrated surgeon, Wm. Gibson, practiced in Baltimore. Win. Gibson was born in 1784 in Baltimore, and was graduated in medicine in Edinburgh in 1809. He was a physician to the Baltimore General Dispensary in 1818-19, and professor of surgery at the University of Maryland from 1812-19, resigning to occupy the same chair at the University of Pennsylvania from 1819-54. He died about 1858 (?)•

His numerous publications date mainly from the latter period of his activity, but there are two notable and very interesting references to ophthalmic surgery dating from the Baltimore period.

In Hirsch's History of Ophthalmology* we find the statement that Prof. Gibson of Baltimore had made the experiment of introducing a seton through the cataractous lens, witli the view of producing its absorption, so original an experiment that Hirsch cites the description given by Dr. John Revere untranslated. My friend. Dr. O'Connor of Boston, had the kindness of looking up the reference in the New England Journal of Medicine, vol. VIII, p. 119, of 1819, and I will give this account in full because of its intense interest.

Extract of a letter to one of the editors:

" lam desirous of communicating through the medium of the New England Journal a new mode of operating for cataract, which has been projected and jiracticed recently, in two cases, with the mot;t .satisfactory success, by my friend, Dr. Gibson, professor of surgery at the University of Maryland.

The operation was performed in the following manner : The iris was in the first place dilated by the application of atropa belladonna. A common sewing needle, slightly curved and armed with a single thread of silk, was then passed through the tunica sclerotica about two lines from the cornea, where the couching needle is usually introduced, through the opaque lens and out of the opposite side of the cornea, at a point corresponding to the one at which it was introduced. The silk being drawn through, and the ends cut off, a single thread was thus left passing through tlie ball of the eye, and acting on the diseased lens in the mauner of a seton. It


•Graefe and Saemisch's Handbuch, Vol. VII, p. 517.


186


JOHNS HOPKINS HOSPITAL BULLETIN.


[Nos. 77-78.


was feared that serious inconvenience might arise from the irritation produced upon the tunica conjunctiva, from the excessive sensibility of this membrane. Fortunately, however, neither this nor any other accident intervened, and at tlie end of ten days, in both cases tlie diseased lens had disap])eared, and, in its place, the silk was distinctly seen passing like a bar across the pupil of the eye. Tlie silk was withdrawn, and in a few days the vision was restored. In the third and last case in wliich this operation was performed it failed in consequence of the iris being wounded. This caused such an inflammation of the organ that it was deemed proper to withdraw the seton at a very early period. This accident was attributed to not using the belladonna. One would think that a common sewing nee<lle is not the most convenient instrument that could be devised for this purpose, on account of the dense structure of the part througli wliich it is to pass, and the difficulty of having the perfect command of any instrument without a handle. From the nature ot the disease, from the known eflects of this remedy when applied to other parts of tlie body, and from the success which has already been experienced, there seems to be good reason to hope that this will be found an important improvement on the established practice in many forms, if not in every variety of the disease. But the practical benefit to be derived from this operation can only be tested by a more enlarged observation than in this country ever falls to the lot of any individual. I remain yours, J. Eeverb.

Balto.. Mch. 2nd. 1819."

We learn from Hirsch that Loewenhardt in 1828 operated in a similar manner for secondary cataract with anterior and posterior synechia, likewise with good resnlt; it ajopears that others have not attempted the operation.

In the American Appendix to the second edition of Cooper's Dictionary of Practical Surgery, edited in America in 1844 by David Meredith Keese, who in 1843 and 1843 was professor in Washington University of Baltimore, we find a very curious reference to Professor Gibson under the head of strabismus: "It apjiears from the Institutes of Surgery that Professor Gibson attempted the cure of strabismus by dividing the recti muscles of the eye, precisely as now practiced, some twenty years since, in Baltimore. Soon after he repeated it unsuccessfully in Philadelphia in several cases, and was induced to abandon it by unfavorable opinions exjiressed on the operation by Dr. Physick. He, however, inculcated the propriety of the operation upon his class many years since, and Dr. A. E. Hosack, of New York, then one of his pupils, distinctly recollects Dr. Gibson's expressions of confidence that the operation would ultimately succeed."

I had no little difiiciilty in finding the reference to which Dr. Reese refers. The first five editions of Gibson's Institutes of Surgery (published between 1824 and 1838) contain no chapter devoted to strabismus, and in the seventh edition the long account of strabismus and its treatment consists almost entirely in a paper written by Charles Bell and sent by him to Gibson. In this chapter the above reference is likewise not to be found. It is only in the sixth edition, published in 1841, that we find the reference. It is of such importance that I shall give it in detail. On page 375 Gibson states that:

"In the year 181S, while practising my profession extensively in Baltimore, the late Mr. B. J. consulted me about his daughter, a child of eleven or twelve years of age, both of whose eyes were directed very much inwards, and were thereby greatly deformed by a squint. I advised a pair of goggles, so contrived, by having a


small opening in the centre of each, as to oblige the ckild to direct the cornea to these openings, and by i)erseverance for several weeks, succeeded in diminishing the deformity but not effecting a cure. In the course of my visits the child remarked at different times that her eyes felt as if tied by a string. Struck with this observation, and conceiving the disease might depend upon shortening of the internal rectus muscle, I determined, the first opportunity, to try the result of divison of that muscle ; and as the friends of my young patient were unwilling the experiment should be first tried upon lier, I selected a hospital patient, and after some difficulty in fixing the eyeball and in cutting the muscle across, succeeded in restoring the eye partially to its natural situation. Upontwoother patients I repeated the experiment, without mucli better success, but on dividing a muscle in a fourth patient, after my removal to Philadelphia, the eye was so completely turned to the opposite direction as to bury the cornea beneath the lids and create a much greater deformity tlian liad previously existed. Upon showing the patient to Dr. Physick, he advised the experiments to be abandoned, as likely to be followed by very unfavorable results. I mention these circumstances, not from a desire to receive credit as an inventor or to detract from the claims of the distinguisiied surgeon with whom the modern operationof strabismus originated, but merely as a curious fact, calculating to show the importance of not laying aside processes apparently founded upon correct principles, simply because we are at first foiled in our attempts to execute them. How much benefit would have resulted to the community if I had followed up my operations until I ascertained the proper mode of correcting them, or how much injury I might have inflicted upon individuals by perseverance in ihe attempt, I shall not stop to inquire. It is sufficient for me to announce the fact — wliich I have no doubt could be easily substantiated by many pupils who attended my early lectures, some of whom have indeed already proffered their testimony — without being over-solicitous, in setting up a claim as an inventor, of exposing my aw kwardness and perhaps want of knowledge of the principles that should have guided me in following out the practice I had attempted to institute."

It may not be out of place to mention that; Stromeyer's important monograph, in which he recommended division of the muscle for strabismus appeared in 1838!

The chapters devoted to diseases of the eye in Gibson's Institutes are important, but as the book appeared after the author had left Baltimore, it is not proper to discuss them here.

Another reference which shows Gibson's interest in the eye occurs in the American Medical Eecorder (vol. II, p. 383). It is a "Letter of Charles Bell to Professor Gibson, of Baltimore," and its subject is, " The New Coat of the Eye discovered by McCarthy's demonstrator, Jacobs."

George Fkick.*

We may next take up the most important name of this narrative, that of Dr. George Frick, the author of a valuable treatise on diseases of the eye, the first ^\■ork of the kind that appeared in America.

George Frick was born in Baltimore in 1703. After obtaining a broad classical education he entered the University of Pennsylvania, where he obtained the degree of doctor of medi


  • The accompanying portrait of Dr. Frick is copied from one

recently presented to the Medical andChirurgical Faculty, together with a case of instruments which belonged to the doctor, by his niece, Mrs. AVhite and her daughter. Miss Mary White.


August- September, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


187


cine in 1815, and in 1&17 he was admitted as licentiate of medicine into the Medical and C'hirurgical Faculty of Maryland. He then spent several years abroad, returning to Baltimore about 1819 to engage in the practice of ophthalmology. He was api)ointed surgeon to the Baltimore General Dispensary, where he established the first Eye Dispensary in Baltimore, in 1824. In 18^3 he delivered clinical lectures at the Maryland Hospital. His name is found on the list of vaccine physicians for 1821.

He was a member of various medical societies; was secretary of the Faculty in 1823, and joined the Maryland Medical Society in 1822. He was much interested in general science, and was one of four physicians to organize a society for promoting science, in 1819. He was likewise a member of the Maryland Academy of Sciences, its librarian in 1824 and curator in 1836.

He devoted himself to the practice of ophthalmology and to the cultivation of general scientific stvrdies, as well as to music for a number of years. He was unfortunate in growing very deaf before middle life, and it is probable that this interfered greatly with his practice of medicine ; for somewhere about 1840 he entirely relinquished it and left Baltimore to spend most of his time in Europe, paying occasional visits to this country. He died in Dresden, March 36th, 1870, aged 77 years. Dr. Frick had never married. He was a man of very retiring and modest character and of kind disposition. He was a careful scientific student and his work and writings deserve high praise.

His first writing was his thesis for the degree in medicine; its subject was "On the Meloe Vfsicatorium" (1815). In 1820-31 his article on " Observations on Cataract and the various modes of operating for its cure" appeared in the American Medical Kecorder of Philadelphia. These articles cover over 40 pages. In 1821 an article on "Observation of the various forms of Conjunctivitis" appeared in the same journal, and in 1823 his paper on " Observation on Artificial Pupil and the modes of operating for its cure."* His most important work, however, was "A Treatise on the Diseases of the Eye; including the doctrines and practice of the most eminent modern surgeons and particularly those of

  • This curious error is cited as it is found.



Professor Beer," which was published in Baltimore by Fielding Lucas, .Jr., in 1823. It was inscribed to his teachei-, Dr. Physick of Philadelphia. The articles above referred to, though somewhat more elaborate, were in the main identical with the corresponding chapters of the treatise and do not therefore require special consideration. The treatise is of considerable value.* It is well and clearly written, the system irpon which it is classified is excellent, and no greater praise could be given it than stating the fact that it was republished three years lateiin London by an English surgeon, Richard Welbank, a member of the Royal College of Surgeons and of the Medical and Chirurgical Society of London, and dedicated to the ophthalmologist William Lawrence. Numerous foot-notes were added, but the te-xt suffered no change.

The reviews which the book received were very complimentary. The Philadelphia Journal of Medical and Physical Sciences (probably Dr. Isaac Hays) contains a review covering 18 pages: "The author evidently possesses a cultivated and well disciplined mind; he appears to be intimately familiar with German writers, and we feel much indebted to him for making us acquainted with their writings."

In the American Medical Recorder of 1824 a still longer review is to be found, covering 32 pages. The writer describes the book in terms of high praise. He "offers the humble tribute of (his) thanks to the author for the benefits which he has conferred on the profession generally, by presenting them with a volume of great value and utility, and one which was much


  • It is interesting to find numerous pencil notes in the articles in

the copies of the American Medical Recorder at the library of tlie Medical and Chirurgical Faculty of Maryland, notes suggesting slight changes in the phraseology, paragrap'-ing, etc., every one of which has been adopted in the treatise. I have been able to trace this copy, which was bought with other books by Dr. ,Iohn Morris at a public sale of the library of Dr. John Buckler, who was related by marriage to Dr. Frick, and whose library thus passed into Dr. Buckler's. Numerous books at our library contain Dr. Frick's autograph, and one, a copy of Gibson's Institutes of Surgery, has an inscription of the author to his friend Dr. Frick. In Beer's work on ophthalmology there are interesting pencil notes and several pages of written matter which correspond so thoroughly with Dr. Frick's writing that I have no hesitation in stating that tbev are his.


188


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[Nos. 77-78.


wanted. As a manual of the diseases of the eye, we believe it to be the best which has been published. It contains all the improvements which have enriched ophthalmic surgery, in such a siirpi'ising degree within a few years past," etc.

In 1835 this work was placed on the list of those which the student was required to liave read before applying to the Medical and Chirurgical Faculty of Maryland for the examination for licentiate in medicine.

Hirsch in his history of ophthalmology says that " George Frick was the apostle of the ophthalmological school of Vienna in North America; his treatise was next to Saunders's, the first large treatise on ophthalmology in America, and was received by physicians with great praise." Saunders's book was an English work and was republished in Philadelphia in 1831, two years before Frick's. The only other book in the English language of a similar kind was that of Travers, which appeared in London in 1820-31-24.

We thus see that Frick's book was the first American treatise (and for a number of years it remained alone). The work is much quoted in Cooper's Dictionary of Surgery.

In Quinan's Medical Annals of Baltimore I find a reference to a paper of Dr. Frick's " On the Senses," which he tells us was read before the Medical Society of Maryland in 1821. I have been unable to find this paper.

In Cordell's History of the University of Maryland we learn that the foiindation of the Infirmary was laid in 1823 and that patients were received in the same year. Of the four wards, "one was reserved for eye cases, instruction in ophthalmic surgery forming a prominent feature in the course. This was during the time of Frick's greatest activity, and it is possible that the prominence given to ophthalmology was through him, and that he delivered the clinical lectures in this branch. I am unable to verify this.

In conclusion it is interesting to call attention to the fact that Dr. George Frick was the uncle of the distinguished clinician, Professor Charles Frick.

Horatio G. Jameson.

Horatio G. Jameson, born in Pennsylvania about 1793, graduated in medicine at the University of Maryland in 1813. He held a number of important public positions, having been consulting surgeon of the Baltimore City Hospital from 1819 to 1835, consulting physician of the board of healtli of Baltimore City in 1827-35 ; he was incorporator of the AVashington Medical University in 1827, and professor of surgery and surgical anatomy in the same from 1827-35, when he became professor of surgery in the Cincinnati Medical College. He was one of the most prominent surgeons of Baltimore for a number of years, and a very active contributor to medical journals, writing important papers in medicine and in surgery. He was the editor of the Maryland Medical Recorder during its existence of several years (Sept. 1829-Nov. 1832), and a large number of its articles are from his pen.

Jameson appears to have been much interested in diseases of the eye. AVe find frequent references to publications on these subjects throughout his journal, several of which have remarks added by the editor. In vol. 2 there is an article on the


"Pathological Sympathy between Eye and Larynx" (p. 117) This article is without any value, indeed it is difficult to understand the real significance of his report after careful reading. An article on "A case of Enlargement of the Eye following the entrance of steel into the eye" describes the panophthalmitis followed by bursting and shrinking of the eyeball (p. 601).

In another paper he described " two cases of ossification of the lens with luxation through the pupil." These cases are of some interest. He extracted the lenses and the patients did well (p. 608). An article on amaurosis associated with inordinate thirst was probably written by Jameson (p. 664).

In the American Medical Recorder of Philadelphia (vol. XII, p. 340) we find an interesting account of the successful removal of " An encysted tumor of tiie orbit."

In discussing a letter on "Ophthalmia in the Philadelphia Alms House," written to Dr. Rusii, Jameson considers the question of the endemic or .contagious character of the ophthalmia, excludes the latter view, and attributes the very severe disease to the vitiated state of the atmosphere. He states that " we do not as a general rule of practice bleed sufficiently in cases of ophthalmia."

John Mason Gibson.

John Mason Gibson in 1832 published in Baltimore (W. R. Lucas) a " Condensation of Matter ujwn the Anatomy, Surgical Oj)erations and Treatment of Diseases of the Eye, together with remarks. Embellished with twelve lithographic plates, illustrative of the anatomy, operations, and morbid appearance."

I am unable to give any details of this author's life. I find that he vvas admitted into the Faculty in 1825, and that his name appears as late as 1848 in the list of members with the title of L. M. In the next succeeding list published in ISoS Gibson's name is missing.

In the preface he tells us that his book is an " attempt at collecting the best matter on diseases of the eye." That " diseases casiral to vision are many and frequently met with in this country; the curative practice has not been sufficiently inculcated in our universities, by impressing upon the mind of the student where and when the importance and great nicety of judgment are requisite in the treatment of them, and that by inadvertent and mal-practice the victim may grope through his existence here in the valley of darkness."

The work is one of compilation, "being made up of exten- f

sive quotations from the classical writers of the day." He claims originality only in the construction of his plates, and so far he is certainly correct, for the drawings are quite unlike anything seen in nature.

The arrangement of the work is very curious. The chapters follow in this order: Anatomy of the eyeball, cataract, ophthalmia, corneitis, iritis, choroiditis, retinitis, inflammation of the lens and its capsule, ulcers of the cornea, ojiacities of the cornea, ptergium, prolapse of the iris, extirpation of the eyeball, extraneous bodies, diseases of the lachrymal apparatus, under which is included entropium, ectropiuni, epiphorn, encaiitlius, injury of lids, ophthalmia tarsi and fistula hiclirv


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malis, looking very much as tlioxigh the subjects had been drawn haphazard from a grab-bag.*

At the end of several chapters the author adds original remarks. When we consider the very excellent and systematic work which Frick had published, nine years previously, as well as such other works from which copious quotations are made, it is quite inexplicable why Gibson showed such disregard of systematic classification, or indeed what purpose he had in publishing the work at all.

Dr. John Hakper.

Dr. David Jleredith Reese, in his American edition of Cooper's Dictionary of Practical Surgery, first published in 1833, tells us, under the section of cataract, that "one of the most successful operators in this country is Dr. John Harper, of Baltimore, and he seldom adopts any other operation than this (laceration of the capsule and lens substance), which he repeats as often as necessary on the same eye." I have given myself great pains to obtain some information concerning this " successful operator," but his memories appear to have been completely effaced. One single reference is to be found, a short obituary notice. In the Maryland Medical Recorder (vol. II, 179) there is a notice of the death of four members of the Medical and Chirurgical Faculty of the State of Maryland. One of these reads as follows : " Died in the month of January, 1831, Doctor John Harper. Doctor Harper was a native of Ireland, and graduated at Ghisgow. He was wellknown as an oculist." The title of oculist appears to have been elevated to the dignity of a special practice of medicine within a few years. For Harper was a member of the Faculty, and not of the despised class of oculists mentioned in the beginning of this paper.

William Alexander Clendinen.

Wni. A. Clendinen graduated in the medical department of the University of Maryland in 1840, a classmate of Dr. G. W. Miltenberger. He died of cholera at New Orleans in 18-1:9, having been seized with the disease while dissecting a victim of the epidemic. After his graduation he traveled extensively, devoting his time to the study of medicine. In the Boston Medical and Surgical Journal in 1847 we find several papers which were translations from the work of Prof. Desmarres. In his letter to the editors he tells us that the extracts are part of a "translation upon which he is now engaged"; he expresses his gratitude to Prof. Desmarres, who " has entrusted to him an onerous but useful task, one which from (his) connection with him (he) may be able to perform advantageously to readers of the English language." In the second article, published in the same journal, we find after the name of the author, " Chef de la clinique oculaire." There were in all but three articles, and the promised book never made its appearance, perhaps on acco^^nt of the untimely death of the author.


  • Not a few important subjects are entirely ignored, viz. errors

of refraction, strabismus, etc.


OTOLOGY.

The early contributions to Otology in Baltimore were very few. Two names deserve recognition ; the first of these is that of the renowned surgeon,

Nathan Rhyno Sjiith.

It is beyond the province of this paper to give a biographical sketch of Dr. Smith. A very complete sketch can be found in Dr. Cordell's History of the University of Maryland. He was born in 1797 in New Hampshire, graduated as A. M. in 1817, and as M. D. in 18-^3 in Yale College. He was professor of anatomy and surgery in the University of Vermont in 1825, soon leaving to occupy the chair of anatomy in the newly organized Jefferson Medical College of Philadelphia. From 1827-39 he was professor of anatomy in the University of Maryland, and from 1829-38 he occupied the chair of surgery at the same university, leaving this for three years to occupy the chair of theory and practice in the Transylvania University. He resumed it again in 1841 and held it until 1869.

One of the earliest writings of this prolific worker was the translation of a treatise on the ear from the French of Saissy,* with additions by the translator on diseases of the external ear. This book was published in Baltimore in 1829, and was, so far as I can learn, the second book on diseases of the ear printed in America, the first having been an American edition of Saunders on the eye and ear in 1821.

Saissy's work was "highly esteemed in France," and was one of the important factors in the revival of modern otology. In his preface Dr. Smith tells us that " a concise manual on the diseases of the ear is an acknowledged desideratum in our medical literature. No sufficient work on the subject has ever been issued from the American press. With a view to supply this deficiency (he has) translated the following pages from the French of Saissy . . . corrected and enlarged by its author, and after his death published in 1827 by his friend Montaion, etc.

" It embodies the excellencies of Saunders, Cooper, Leschevin, Maunoir, Itard and Alard . . .

" The attention of the reader will be particularly occupied with Saissy's excellent method of injecting the ear through the eustachian tube. We very well know how frequently the external ear is obstructed by its own secretions, free as is their egress from this cavity. The internal ear is also lined with a membrane which furnishes an excrementitious fluid. It can escape only by the narrow channel of the eustachian tube. How frequently then must it be delayed in the cavity of the tympanum and mastoid cells, giving rise to any degree of mischief."

To render " the work more complete and useful to the medical pupil (he has) added a brief supplement on diseases of the external ear. On this score, however, (he) claims nothing, as (his) addition is made up of commonplace iirinciples and


  • An Essay on the Diseases of the Internal Ear, by J. A. Saissy,

M. D., translated from the French by Nathan Rhyno Smith, M. D., Professor of Surgery in the University of Maryland, with a supplement on Diseases of the External Ear, by the translator. Published by Hatch & Dunning, Baltimore, 1829.


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precepts subjoined merely for the purpose named above." He concludes: "I have, it is true, for perforating tlie tympanum devised a new instrument wliich I trust will be useful."

The part of the book most interesting to us is the supplement on diseases of the external ear, covering about twenty pages. These chapters are written in the most concise and simple manner and cover most of the inflammatory afiections of the auditory canal, congenital deformities, injuries as well as the treatment of foreign bodies, insects and indurated wax in the auditory canal.

He describes his method of inspecting the canal as being " best accomplished by placing the head in such an attitude as to suffer the sun's rays to enter the meatus and impinge upon the tympanum. To effect this, the operator must seize the external ear, and drawing it outward from the head, extend and straighten the cartilaginous part of the meatus. I have been able to inspect the ear more perfectly by introducing, at the same moment, a steel director, with its groove toward the meatus and its convex side pressed firmly against the anterior walls. The passage is thereby straightened and expanded. If there be no wax present the tympanum will be seen of a pearly white color and concave."

The little instrument which he devised for perforating the membrani tympaui is a minute trephine, by revolving which a circular piece of the drum was excised. His object in constructing this instrument was to obtain a larger opening, for he tells us that in two instances in which he had occasion to perforate the membrani tympani he found the beneficial effects of the operation soon to cease in consequence of the speedy closure of the artificial opening. The Maryland Medical Recorder of 1839 reviews the work extensively, the review covering twenty pages. The review is by no means flattering.

It is very apparent that Dr. Nathan R. Smith must have been deeply interested in the subject of the diseases of the ear. He had an extensive j^ractice in diseases of the ear, and also of the eye, though none of his publications deal with the latter organ. Dr. Theobald has recently found a drawing of a knife designed by Dr. Smith to slit the lachrymal canal.

Dr. Joshua I. Cohen.

Dr. Cohen, born in Maryland in 1800, graduated at the University of Maryland in 1833, having been a student in Dr. Nathaniel Potter's office, and soon after devoted himself to the study of diseases of the ear. He was an intimate friend of Dr. George Frick, the oculist, and, like his friend, had wide interest in science beyond the domain of medicine. He thus for a time became professor of mineralogy in the academic department of the University of Maryland. He was much interested in the Medical and Chirurgical Faculty of Maryland, was its treasurer from 1839 to 1856 and president from 57-58. He was also much interested in the Maryland Academy of Sciences.

He practiced until about 1851, devoting himself almost exclusively to otology. His reputation as an aurist must have been quite great, for we read in Reese's American edition of Cooper's Dictionary of Practical Surgery (2nd ed., vol. 2, p. 73, under the heading "Ear"): "In the United States there have been a few surgeons who have distinguished themselves by their success in the treatment of diseases of the ear.


" Dr. Cohen of Baltimore and Dr. Dix of Boston have for several years directed their particular attention to diseases of the internal ear, and to the investigation of the abnormal condition of the tympanum and eustachian tube in cases of deafness. These gentlemen have employed condensing apparatus for administering the air douche through the eustachian tube after the plan of Kramer and others. By the air and also by the water douche, these gentlemen have acquired great tact in the diagnosis and treatment of obstructions in the tube and upon the tympanum."

In 1840 he established, in connection with his friend, Dr. Samuel Chew, an eye and ear institute in Baltimore, in which Dr. Chew had charge of the eye department. Dr. S. C. Chew has had the kindness to inform me that this association between Dr. Cohen and bis father lasted for a short time, as his father's appointment to a chair in the University of Maryland compelled him to withdraw from it.

Dr. Cohen was one of the earliest, perhaps the first, aurist in this country. He has left us, however, but one publication which pertains to diseases of the ear. It is entitled " Postmortem Appearances in a Case of Deafness."* The paper is very short, but is written in the most scientific manner.

In a note written by the editor of the Journal we read that this "valuable communication was read before the American Philosophical Society, at a recent meeting, and is noticed in the proceedings of that body. It has rarely happened that opportunities have been embraced for examining into the condition of the organ of hearing in cases of deafness, or that they have fallen within the observation of an investigator so competent as the author of this paper." The case was that of a patient who died of phthisis. The brain and seventh pair of nerves were examined carefully, but no changes observed. The lower part of the skull was then removed and the ear examined in minute detail.

In the right ear he found the drum-head dull and dark in appearance, irregularly thickened and retracted as a whole, thus diminishing the cavity of the tympanum. The tympanum itself was filled with muco-fibrous membranes passing from the membrani tympani to the posterior walls, presenting a cellular structure. These were carefully divided, exposing the tensor tympani muscle, the tendon of which was found to be of unusual shortness and attached to the handle of the hammer throughout its whole length, thus drawing the bone and the membrani tympani to within a line of cochlear process. Interesting irregularities in the ossicula were noted. The malleus was normal. The incus was undeveloped, diminutive in size. The stapes was wanting with the exception of the base, which was held in place by the circular ligament. The depression of the oval window was filled with membranous tissue, which likewise covered the fenestra rotunda. The tensor tympani muscle was strongly developed, its tendon short and thick as mentioned above. The stapedius muscle existed, but there was no tendon.

In the left ear the membrana tympani was found to have been entirely destroyed, with the exception of a very thin slip at the anterior inferior edge. The tympanum contained a


•Amer. Med. Intelligencer, July 1841 to July 1S42, p. 220 (Vol.1).


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quantity of yellowish fetid matter, and its lining membrane was completely disorganized. The union between the ossicula was slight, owing to the general disorganization of the ligamentous and mnco-fibroiis connections. The incus was in place, but the handle of the malleus was depressed. The stapes was not bound down in the oval window, for the annular ligament was entirely destroyed. Tiie tendon of the tensor tympani was disorganized and that of the stapedius destroyed; the whole condition of tiie tympanum showed a recent active suppuration which did not confine itself to this part; the vestibule was penetrated as well as the mastoid cells; the latter were covered with pus. Tlie cochlea and one of the semicircular canals were examined a day or two subsequently, but there was nothing remarkable about them at this time worthy of note.

Inquiry about the patient led the author to conclude that the faculty of hearing in the right earhad been entirely wantingor was very much impaired for many years.

Though he seems to regard the condition of the right ear to have been congenital, his critical analysis is as acute as the observations tliemselves are accurate. He cites cases of Morgagni in which membranes filled the cavity of the tympanum.


and another in which there was immobility or contracture of the muscles. At the conclusion of his paper he says: "In the case described in this paper, does not the absence of every part of the stapes, with the exception of the base, liken it to the osseous operculum found in the bombinatores, land salamander, and cfBciliffi ; of the effect of wliich, in the communication of sonoro:is undulations, I have already spoken ? " I am unable to find any other reference to this paper on undulations and do not know whether it was ever published.

This sketch must be brouglit to a close. Is it necessary to remark what any careful reader must have observed, that there were physicians in Baltimore in the first half of this century who labored faithfully and well in Ophthalmology and Otology? Their contributions were among the earliest and most important in this country.

In conclusion I desire to express my thanks to Dr. G. W. Miltenberger, to Dr. John Morris and to Dr. Eugene F. Cordell, who furnished me with important notes, as well as my indebtedness to Dr. John R. Quinan's "Jledical Annalsof Baltimore," and Dr. Cordell's " History of the Universiiy of Maryland."


JOSEPH FRIEDERICH PIRINGER: HIS METHODS AND INVESTIGATIONS.*

By Harry Friedenwald, A. B., M. D., Baltimore.


"Joseph FreiJerich Piringer was born, March 31st, 1800, in Klein-Zell in Upper Austria. He studied medicine in Vienna ; he afterwards turned his attention to ophthalmology in 1824. He was at first an assistant of Jaeger, then for three years of Rosas (beginning in 1825). He next obtained the extraordinary professorship of ophlhalmology in the medical school at Gratz. Here he founded a much-needed eye hospital, an institution out of which the ophthalmic department of the AUgemeines Krankenhaus gradually developed through his energy. Here he held a high position and was active as a teacher until ISGO. His clinical and experimental stuilies on blennorrhcea were made at this hospital. He wrote a work on blennorrho;a which was awarded a prize by the German Society of Physicians in St. Petersburg. Piringer has the merit of having shown that intentional infection of blennorrhceic secretion in pannus leads to clearing of the cornea. He founded a reputation upon this which extended far beyond the boundaries of Germany. He was for many years attached, as visiting physician, to the Elizabeth Hospital and to the City Asylum for the Aged, and published several other articles up to the time of his death, Sept. 22nd, 1879, including: Ueber Veratrinbehandlung des acuten Gelenk-Rheumatismus ; Die Behandlung der Variola mittelst lodtiuctur; Die richtige Pflege der neugebornen und kleinen Kinder ; Studien ueber die MortalitatsStatietik in Graz."f — (From Hirsch's Biographisches Lexikon, 1886, vol. IV, p. 575.)

Piringer's work on blennorrbceaj was awarded a prize, and the earlier works in ophtiialmology refer to his studies, especially to his investigations in the treatment of pannus.§ Arlt


•Read before the Johns Hopkins Hospital Historical Club. 1 1 am indebted to Professor Wm. H. Welch for having called my attention to this account of Piringer's life.

t Die Blennorrhoe am ^Menschenauge. Graz, 1841. lOest. Med. Jahrb., 1838, and chapter 8 of the monograph.


devotes some space to a summary of the work on blenuorrhcea.* But more recent works in ophthalmology make no mention of these important studies and their no less important results; in works on bacteriology I do not find his name, nor even in works on gonorrhcEa, such as that of Finger. Piringer's work was of such importance that it does not deserve to be thus forgotten.

The absence of any other references in ophthalmic literature leads me to believe that Piringer's studies in ophthalmology were confined to the subject of inquiry contained in the work above mentioned. This is the more readily understood when we read in his preface " that his itntiring efibrts during fifteen years were given up to the solution of the natural laws governing blennorrhoeas of the eye, as far as this lay in the limited powers of a single individual." We may aptly apply to Piringer the words, "therefore by their fruits ye sliall know them." Judged by this standard, Piringer stands out boldly as one of the greater luminaries of medical science in tlie first half of this century.

In order to properly estimate the importance of his investigations it will be necessary to examine into the state of knowledge of the subject previous to 1840.

In 1780 a treatise on diseases of the eye appeared, written by George Chandler, surgeon, of London, in which he gives this account of "venereal ophthalmy." He divides it into two varieties, the translative and the symptomatic.

"The translative ophthalmy begins with a copious discharge of a sebaceous humor of a yellowish white color, and is known by the tumor, lividness, sharp and lancing pain of tlie sclerotica, the


  • Klin. Daratellung d. Krankheiten d. Auges. Vienna, 18S1, pp.

35-37.


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cornea at the same time being as it were depressed within a pit. It frequently follows soon after an injudicious stoppage of a gonorrhoea, the venereal virus being translated into the eye. It has also been observed that a gonorrhoea which before seemed incurable has, upon the coming on of this ophthalmy, suddenly vanished ; and in like manner the ophthalmy has gone off upon the return of the gonorrha?a . . . The symptomatic remits towards morning, never turns into a chemosis, the morbid matter does not change place, the pains are milder, it is removed when the hies is cured, and is also attended with less danger."

He admits that "sometimes a venereal ophthalmy has been produced by the immediate application of the virus to the eyes."

Concerning the treatment he tells us that —

"The venereal ophthalmy in general is subdued and its poison extinguished by mercury, but it should never be applied to the eyes. The patient should be bled and purged, and his eye washed continually with brandy and water, etc. It is necessary also to evacuate the virulent matter collected in the cellular texture of the sclerotica and eyelids by slight incisions of each membrane ; an ichor, very like that of gonorrhtea, will be discharged."

This was the older view.

About the beginning of this century a remarkable development occurred in ophthalmology. Beer and Schmidt in Vienna, and Himly, Langenbeck, Graefe the elder, and others gave a new impetus to the scientific study of this branch of medicine. This was followed by the publication of a number of important treatises and monographs in ophthalmology, principally in Austria and Germany, but also in France, England and our own country. I shall pass these by and take up the subject as we find it in the third edition of one of the most important and valuable treatises on " Diseases of the Eye " written in the first half of this century, that of William Mackenzie of Glasgow. I take the third edition as it appeared in 1840, one year before Piringer's work. Here we find under the section of ophthalmia in new-born children, that "there is reason to suspect that this disease is not unfrequently an inoculation of the conjunctiva," etc., and "that therefore it may often be prevented by carefully washing the eyes of the infant with tepid water," etc.; secondly, "that the purulent ophthalmia of infants in its worst form is the result of the application of gonorrhceal matter, is generally admitted."

Concerning gonorrha'al ophthalmia he tells us that —

" Different views have been entertained of the purulent inflammation of the conjunctiva which is frequently found to attend or succeed gonorrhtea. First, this ophthalmia has been ascribed to inoculation with matter from the urethra; secondly, it has been supposed to be metastatic ; and thirdly, it has been considered, at least in certain cases, as an effect owing to irritation merely, without either inoculation or metastasis. It is quite possible that there may be three such varieties of this ophthalmia. The existence of the first I consider beyond all doubt ; but the second and third are somewhat problematical."

His description of the first form is quite clear, and in several cases which he reports the infection is definitely proved. He did not succeed in separating gonorrhcEal from what was called Egyptian ophthalmia, excepting as differing in degree. This distinction was not definitely made until about ten years later (by Bendz). Mackenzie's criticism of the views entertained by


some eminent ophthalmologists is so interesting that I shall quote the entire paragraph:

" Dr. Vetch tells us that in a soldier in a very advanced stage of Egyptian oplithalmia he attempted to divert the disease from the eyes to the urethra, by applying some of the matter taken from the eyes to the orifice of the urethra. No effect followed this trial. It was repeated in some other patients, all laboring under the most virulent state of the Egyptian disease; and in all the application was perfectly innocuous. But in another case, where the matter was taken from the eye of one man laboring under i)urulent ophthalmia, and applied to the urethra of another, the purulent inflammation commenced in 36 hours afterwards and became a very severe attack of gonorrhrea. From the result of these experiments, Dr. Vetch, while he admits that gonorrhceal matter taken from one person and applied to the conjunctiva of another will excite a highly purulent ophthalmia, regards himself justified in no longer admitting the possibility of infection being conveyed to the eyes from the gonorrhceal discharge of the same person. He adds that the impossibility of this effect was rendered decisive by an hospital assistant who, with more faith than prudence, conveyed the matter of a gonorrhcea into his eyes without any affection of the conjunctiva being the consequence. It is remarkable that Dr. Guillie has fallen into the same error of reasoning as Dr. Vetch, onlythathis negative experiments have led him to the very opposite conclusion. He applied the matter taken from the conjunctiva of one patient to the urethra of another; no effect followed, and hence he concludes that the notion of some regarding the propagation of puro-mucous inflammation from one mucous membrane to another in different individuals, is unfounded."

Mackenzie, however, devotes considerable space to the discussion of gonorrhceal ophthalmia from metastasis, though nothing could be better than his statement that writers had adopted these views " with too little hesitation and appear not to have sufficiently investigated the probability of the ophthalmia arising rather from inoculation than from metastasis." He goes on to enumerate " the causes of the suppression of the gonorrhcea, to which the rise of metastatic gonorrhct-al ophthalmia is attributed," and cites an illustrative case from a French writer. It is evident that ilackenzie had little confidence in the existence of this form of gonorrhceal ophthalmia.

A third form of gonorrhceal ophthalmia without inoculation or metastasis is described : "an alternation has been observed between the two diseases; that is to say, when the gonorrhcea came, the ophthalmia went, and vice versa." Mackenzie says that the cases reported "show the diversity which exists in opinions entertained regarding the ophthalmiaj which in some individuals are found to attend gonorrha'a, or to alternate with this disease"; and that "it is quite evident that the ophthalmia? which have been observed to do so are far from being uniform," that some are probably ophthalmia tarsi, others catarrhal ophthalmia. What is most important is his statement that '■ it may fairly be doubted whether there is any connexion between diseases of urethra and that of the eye, farther than that they occurred in the same iudividtials, while the occurrence of both might be attributed to a susceptibility for disease arising from peculiar or debilitated constitutions." We are somewhat surprised to see this statement followed by such a one as this, that "Swediar's hint to employ the bougie in cases of ophthalmia alternating with gonorrhcva may probably be found of use; it is evident, however, that this remedy cannot be trusted alone, but that the ophthalmia must be treated according to


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the particular symptoms it presents, not according to tlie conjectural notions entertained regarding its origin." Concerning Egyptian ophthalmia jMackenzie says:

"I think it probable that the ophthalmia which attacked the British anil the French armies in Egj'pt was an atmospheric puro-mucous conjunctivitis [described at another place as "excited by exposure to atmospheric alternations "], but that it afterwards degenerated into a contagious, perhaps infectious disease; that is to say, that it was propagated by actual contact of the discharge, and perhaps by miasmata from the eyes floating through the air."

Mackenzie's views may fairly be taken as the most advanced of this period and will serve as the proper point from which to view the investigations of Piringer.

It should be mentioned here that many subsequent writers held on tenaciously to these and older views for many years after Piringer's discovery had been made.

We may first direct our attention to Piringer's experiments in curing pannns by producing acute purulent ophthalmia. This method, we are told, was first suggested by Friederich Jiiger* some time during the second decade of this century, but little or no attention had been given it before Piringer's experiments were made. He tried the metliod in more than sixty cases, using the pus of various kinds and stages of purulent ophthalmia of bo(h adult and new-born. All of his cases were improved and not one was injured by the treatment. In the great majority of cases the cure was complete, so that no sign of the former disease could be discovered, and permanent. He therefore recommends this method of curing paunus in these words: "After so many highly successful experiments and observations, the inoculation of tlie blennorrhoea for the cure of pannus is no longer a doubtful measure which requires great courage, but an excellent method (ein grossartiges llittel)." This method remained in use for many years and is still being applied in a modified manner. The modification consists in the use of jequirity to produce a purulent ophthalmia instead of blennorrhceic matter.

It was in the study of this method of treatment that Piringer made his investigations as to the nature of blennorrhceaand the contagious property of the secretion. For this purjjose his experiments were varied inevery conceivable manner. Most of the experiments were made upon eyes which were already diseased, but these were controlled by other experiments upon amaurotic eyes with perfectly healthy conjunctiva, or by the accidental infection of normal eyes.

After describing the various forms of purulent inflammation of the conjunctiva he takes up the causes. Under this head he discusses the question as to the production of gonorrhoeal ophthalmia by metastasis. In the course of fifteen years he had never seen a case of suppression of a gonorrhoea with an outbreak at another point, excepting in the neighboring tissues.


  • In Hirsch's History of Ophthalmology, p. 441, we read thatLudwig reported the successful use of this method at the hands of a

friend, probably Friederich Jiiger.

Wharton Jones (in a manual on Ophth. Med. and Surg, published in 1847) states that Dr. Henry Walker was the first to suggest the method (Edinburgh Medical and Surgical Recorder) in 1811. I am unable to verify this citation.


Many physicians of great practice had likewise never seen true metatastic gonorrhcsal ophthalmia. He denies the occurrence of such a form of disease, and characterizes it as a very pretty fable which one after the other has been telling in the best of faith. Gonorrhceal ophthalmia is always due to the transference of infectious material directly into the conjunctiva!

In a similar manner he disproves the existence of a consensual form of gonorrhceal ophthalmia, supposed to be due to a sympathetic connection between the affected parts.

Gonorrhceal ophthalmia is known to be more common toward the end of the primary affection than during the period of its greatest virulence. He explains this very properly on the ground that Avhen the discharge is great much care is used in cleansing the fingers. It is after the discharge has become scant that patients become careless. The right eye is usually the one first affected, because most patients are right-handed.

Ilis experiments proved that the generally accepted view that the transference to the eye of gonorrhceal pus results in a simple conjunctivitis or a mild purulent ophthalmia, and only rarely in a severe inflammation, is false. On the contrary, he asserts that the result is always a purulent ophthalmia of a severe degree. The only exception occurs in those cases in ■which early treatment is successfully applied.

The contagious character of the secretion of ophthalmia neonatorum had been looked upon as ridiculous ;* when .Tuengken stated that a ni;rse had developed severe i)urulent ophthalmia during the night of the same day when she had infected them with a sponge that had been used to cleanse the eyes of an infant with ophthalmia, it was laughed at. No one can deny the infection in his own cases, because the material was carried across the street into another house and yet the result was always the same.

His experiments on the production of purulent ophthalmia embrace almost one hundred eyes, and this does not include a number of accidental infections which were observed with the same care. The matter with which infection was produced was obtained from eyes afl'ected with different forms of purulent ophthalmia as well as from genital blennorrhcea. All ages and both sexes were found to be equally predisposed.

One of the most interesting chapters is the one on the character of the blennorrhceic contagion. Though the pus from the conjunctiva causes infection when applied to the eyes of human beings, he was unable to produce any result when he applied it to the eyes of such animals as dogs, cats, hogs, and various birds. Others had claimed that they had produced effects in such cases. Our jiresent knowledge of the immunity of animals to gonorrhcea shows that Piringer was not deceived.

The granulation from which the pus is secreted carries the contagious property with it, as was shown in 1833 by Werwick, who experimented upon two nurses. Piringer never made any experiments w'ith granulations because it lacked any practical bearing.


  • The faith with which this opinion has been held can be measured by the much-quoted citation of Dr. Vetch, referreil to above.

Piringer likewise ciuotes Adams, who rubbed his eyes with a finger smeared with purulent matter without producing ill results, as did Van Sevenoeck and Kriebel. Morburgo smeared the eyes of 300 soldiers without effect.


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[Nos. 77-78.


The pure lachrymal fluid of a blennorrhoeic eye was found not to possess conhigioiis properties. An experiment is related in which lachrymal fluid collected upon a canielliair brush did not produce infection, while the purulent secretion gathered a few days later did.

The question of contagion far distance (per miasma) was studied in his hospital, where numerous blennorrhceic patients were placed beside those unaffected, in small wards. He was able to prove definitely that such contagion does not occur and that the cases in which it is suspected can always be traced to direct infection.

The vapor of drying secretion has no power of infection. Even those secretions which are perfectly serous leave a residue when evaporated, and it is this which still retains the contagious {)roperties.

The fluid secretion when kept for three or four days, even without evaporation, is no longer contagious.

If a finger is covered with blennorrhceic secretion and washed immediately in clear fresh water and well dried, it will cause no infection if rubbed over the conjunctiva.

Blennorrhoeic matter may be smeared over the eyelids if the palpebral fissure is kept firmly closed by adhesive plaster, and no infection will occur. In order to produce infection the secretion must reach the conjunctiva.

The secretion of acute blennorrhoea of a moderate degree is just as contagious as that of the most severe. Such pus is capable of producing infection even when diluted with 50 or 100 parts of water. The pus of a very mild purulent ophthalmia and of chronic ophthalmia has much less power of infection.

As long as there is any secretion in any case of purulent ophthalmia, whether mild or severe, so long the case is contagious. Wiien the secretion ceases, tiiough there maybe considerable congestion and photophobia, the infectious properties are lost.

The properties of infection inherent in the secretion do not vary in different seasons of the year nor under changed atmospheric condition, whether exposed to the glare of the sun or to the cold of the winter. Experiments .to determine this may appear meaningless to us, but we must not forget the opinions prevalent in Piringer's time.

Numerous experiments were made to determine the effect upon the contagious properties of the pus when separated for varying intervals of time from the human body. Thus the secretion was collected upon a camel-hair brush and allowed to become as dry as possible (" dry as glass ") in from three to six hours. If then applied to the conjunctival sac, but not allowed to soften in the tears, no infection occurred ; if softened in the tears, or previously in water, infection was sure to occur.

In seven cases the secretion which had been allowed to dry for thirty-six or forty hours in the open air had lost all contagious property, but in two in which the secretion had been allowed to get dry thirty- three or thirty-four hours in the room and was then softened it produced very severe ophthalmia blennorrhcea. Piecesof linen smeared with fresh blennorrhceic matter and given to a pannus patient to wipe his eyes produced infection, but if the cloth had been dried in the air for several days, the patient could use it about the eyes witiiout harm, and the


secretion when scraped off" the cloth and inserted into the conjunctival sac produced infection only when it was less than thirty-six hours old. On the other hand, if the secretion was placed in a vaccine case and hermetically sealed it retained its contagious property for forty-eight hours, but lost it entirely when kept for three days. The pus fioma case of ophthalmia neonatorum produced infection when kept in this way for two and a half days. Piringer therefore concludes that "?/Ze««orrJiieic pus loses its contagious properties as it hecornes older, and (jraduaUy dies in from twenty-six to forty -eight hours, jjossessing no more organic life token three days have passed." It is upon the discovery of this fact that Piringer bases important rules of prophylaxis, and explains the relative infrccjnency of gonorrhoeal ojDhthalmia among the common people.

Piringer studied carefully the length of time intervening between the entrance of the infectious material and the first signs of the developing disease, the period of incubation. This he found to vary according to the manner and the amount of the infection, as well as according to the individual peculiarity of the patient. The higher the degree of inflammation, the more rapidly did its pus infect. Thus the pus from a very severe ophthalmia produced infection in from six to twelve hours, or at most in thirty-six hours ; while that of very mild blennorrhoea might rec|uire sixty to seventy hours, and that of a case of chronic blennorrhcea seventy-two to ninety-six hours.

The secretion of the second stage of acute ophthalmia acts more slowly than that of the first; thus the pus from a case of very acute blenuorrhrea in which the secretion was markedly diminishing may take sixty hours to produce the first symptoms.

If the secretion while still warm is immediately transferred from an acute blennorrhcea, but six or eight hours are required for the first signs to show themselves, and in twelve or eighteen hours the disease is fully developed. In this respect the conjunctiva responds more rapidly than the genital mucous membrane. The longer the secretion is kept before it is placed in the conjunctiva, the less rapidly does it act. The rapidity likewise varies with the amount of secretion brought into the eye.

Piringer gave the prophylaxis of gonorrheal ophthalmia his careful attention and the results were very important. Can tiie inflammation be aborted after the infectious material has once reached the conjunctiva? Several cases in which the very early and continued application of ice comitresses produces this effect are described. In order to determine whether the infectious material can be removed and the outbreak of the disease prevented, several series of experiments were made. The method which required the application of very strong solutions of bichloride of mercury, concentrated acetic acid, etc., appeared to him too severe, and in the few cases in which it was tried the desired result was not obtained.

On the otiier hand he found that washing out the eye with water after the contagious material had been inserted prevented the development of the disease, provided that it is done sufficiently early. These experiments were made on three patients. In the first case he touched the eye with a large quantity of matter from a newborn babe, cleaned it out after a minute with a sponge dipped in cold water, and had cold water apiilicatioMs made for ten hours. No inflammation resulted.


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Four days later he varied the experiment by allowing the matter to remain two minutes and again no inflammation occurred. After another interval of four days the experiment was again repeated, the pus remaining in the eye for three minutes and the result was again the same. After another interval of 6ve days pus was inserted and allowed to remain in the eye for live minutes; no cold applications were made; the result was a violent inflammation. This patient had pannus, which was cured by the treatment.

In order to try tiiese experiments upon a perfectly normal conjunctiva he selected the eyes of an amaurotic beggar whom he paid for these privileges. In this case he found that no disease resulted if the blennorrhoeic matter was washed out within three minutes after its entrance into the conjunctival sac and cold water applied. In three minutes any one who has accidentally infected his eyes can obtain fresh water with which to wash them !

In order to determine whether the washing out of the conjunctival sac would accomplish the same result without the use of ice applications, he infected the eye of a girl suffering with pannus with blennorrhoeic matter and washed out the conjunctiva in three minutes. Ninety hours later a severe ophthalmia developed. And in a second case the experiment again resulted in the development of a purulent ophthalmia, but not until the fifth day, and in this case the ophthalmia was of a milder character. For these reasons he considers the cold water application as essential to the prevention of conjunctival blennorrhci'a after infection has occurred. Many other questions are considered by Piringer, but this review embraces the essential points, and will, I trust, suffice to show its importance.

The care, the true scientific spirit, the accuracy of observation and experiment, the unbiased search for truth, form marked characteristics of I'iringer's work. And yet he is so modest as not to claim that his results are "the absolute truth," though they are his own firm convictions; experiments and observations, he tells us, by other physicians at other times and places, made with care and without prejudice.


are needed to confirm them as well as to clear away any errors. His experiments were arranged carefully and judiciously to determine the character and the attributes of the contagion, the time during which it acted, the gradual diminution of its powers to the point when they were entirely lost, the intensity of the contagion, and the degrees of dilution which could be borne without loss of all contagious properties. Many of these questions were given their final solution by Piringer. He separated the fluid portions of the pus which could be evaporated, from the more solid matter which contained the contagious quality. He proved that the unknown cause of contagion was a something which had to be transferred in substance from one mucous membrane to the other, and which never acted at a distance, thus disproving the old miasmatic principles which were still current in those days.

In what is our knowledge today greater than that of Piringer, excepting that the active agent, the living microorganism, the gonococcus, has been discovered, a discovery only made in 1879 ? That it was a living organism even Piringer surmised, for, as we read above, he speaks of it as "growing older," and "dying," and "possessing organic life." Let us not forget when it was that Piringer worked. Though micro-organisms had been discovered toward the end of the seventeenth century, and micro-organisms were assigned as the causes of numerous diseases during the eighteenth century, it was not until 1840 that Henle first established the germ theory of disease upon the solid foundation of logic and fact.

One aspect of Piringer's experiments still deserves mention. Others had likewise made experiments with a view of transferring the disease which we have been considering; but most of these were unsystematic, few in number, and led only to confusion. Piringer's work was such as to give a definite solution to important questions, results which have stood the tests of time. His work was not in vain. His hopes were fulfilled that "the medical world would read not entirely without pleasure a number of results, whose collection in the field of practice had been made at the cost of much strain, great pains and many a sleepless night."


PROCEEDINGS OF SOCIETIES


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of May 3, 1897.

Dr. Thayer in the Chair.

Haeniatoniyelia from (xunshot Wonnd of tlie Cervical Spine.— Dr. CiisniNG.

This patient, a young woman of 27 years, was brought into Prof. Ilalsted's service, November Gth, 1896, with the hiotory of having been shot twice in the neck a few hours before entrance. Our chief interest centres in the injury produced by the missile, whose wound of enti-ance is situated here on the right side of the neck at the level of the cricoid cartilage. These skiagraphs show the point of lodgment of the bullet in the centrum of the sixth cervical vertebra.

The case illustrates some unusual features of one type of


the so-called Brown-Seqnard paralysis; the value of the X-rays in locating the offending missile; a practical recovery without operative interference; a residuum of symptoms resembling those of syringomyelia.

At entrance she was suffering from agonizing " pains " of a " pins and needles " character, especially in the arms, so severe she would cry out when they were touched. No radiating pains, such as are described iu the meningeal form of hemorrhage, were present. There had been no loss of consciousness. Motor paralysis was complete on the right side below the level of Thorburn's "5th root group." On the left there was a brachial monoplegia up to this same segmental level, namely that for the deltoid biceps and supinator longus muscles whose ventral horn ganglion cells lie in the 5th cervical segment, as you may see by comparison with this


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[Nos. 77-78.


familiar table of Starr's. Respiration was purely diaphragmatic.

On the left side, uji to the second intercostal space and down the ulnar side of the arm over an area which corresponds, as these diagrams taken from Starr and Kocher demonstrate, to the cutaneous sensory fields of the eighth cervical and first dorsal segments, there existed anassthesia to pain and thermic stimuli, aud a slight dulling of tactile or pressure sensibility. A segmental zone of similar anaesthesia was present on the side of motor paralysis across the chest aud including most of the right arm.

There was a marked elevation of surface temperature, cousiderable hyperalgesia, and also a diminution of reflex activity on the paralyzed side. Loss of sphincteric control over the contents of the bladder aud rectum was also jjresent.

liestitution from these paralytic symptoms has taken place up to the excellent conditiou in which you see the patient at present. The motor paralysis disapjjeared gradually. On the tenth day, motion, as is usual, was first observed in a slight flexion of the thigh. Turner in his experimental work called attention to this. At the present time there remains evidence of the degeneration of the right j)yramidal tract iu Wernicke's residuary paralysis of the dorsal flexors of the foot, giving the late hemiplegic character to the jjatient's gait. Mann has recently called attention to this residuum of motor paralysis aud has shown that it selects a certain muscle unit (bewegung einheit), this unit being that which lifts and shortens the leg in the first stage of walking, as can be demonstrated in this patient. Paralysis remains alone complete in some of the small muscles of the right hand, representing destruction of ganglion cells at the site of the lesion. There is au exaggeration of all the deep reflexes of both extremities. Myotatic contractions, as you see, are elicited iu the muscles of the right arm by gentle blows on the tendons. Resolution of the sensory disturbances has been less complete. Slight anEesthesia to painful aud especially thermic stimuli persists on the left.

A month ago there was present a peculiar distribution of areas of hyperesthesia, over which cold produced paiu without thermic sense, and the threshold for pain was so low to touch or pressure stimuli that the latter could only be elicited with difficulty by v. Frey's assthesiometer. This is illustrated by these diagrams.

The lesion was presumably due, as in Mann's case, to an intramedullary hemorrhage, the occurrence of which, especially in the cervical enlargement, as emphasized by Thorburn, is not uncommon. It seems that not only is traumatic hajmatomyelia much more common here than elsewhere in the cord, but that there is a certain level iu this enlargement giving symptoms corresponding to the "typus inferior" of Krause, iu which intramedullary hemorrhage is most likely to occur. This list of cases, collected from the literature, tends to confirm this view of a site of predilection in the lower cervical enlargement for hajmatomyelia, and illustrates the fact that not only in cases attributable to acute flexions of the neck does it occur, as was believed by Thorburn, but also iu those due to a great variety of traumatic causes. The hemorrhage also is apt to occur most extensively on one side of the


cord, thus often producing the symptom complex of a Brown Sequard type of paralysis.

That the hemorrhage also in these cases selects by preference the gray matter of the cord, presumably from the greater vascularity aud less support given to the vessels there, is well recognized. Frequent note has also been made of cavity formation at the original nidus of hemorrhage, which is interesting iu consideration of the association of the syndrome of syringomyelia which Minor and others have pointed out to be a common sequence of traumatic ha'matomyelia and which persists in this patient.

The case which Maun has recently reported in full with post-mortem examination of the cord, in the Dent. Zeit. f. Nervenheil. for 1896, and which clinically bears such close similarity to this case, illustrates many of these points very completely.

Dr. Thomas. — This case seems to me to be one of particular interest, aud the Society is to be congratulated on having it so admirably presented. Those of you who have had the opportunity of examining a similar case will recognize the difficulty of making such au exhaustive examination. I know of no case in the hospital records that has been worked up so carefully as this. Dr. Gushing was kind enough to bring the patient to me ou several occasions for examination, and I confirmed the results which he had already obtained. The patient's condition, after she had been in the hospital for some time, was, as Dr. Gushing has described to you, briefly as follows : there was weakness of the right leg and right arm. The muscles of the right arm were atrophied, aud there were sensory disturbances, as shown in the charts. The wound in the right side of the neck was in such a position that the bullet might have injured the brachial plexus before entering the spinal columu, and thus have produced the condition found in the right arm. An electrical examination of tlie paralysed and atrophied muscles showed that they responded normally to the currents. This was believed to indicate that the brachial plexus was not injured, aud also that the paralysis was not due to destruction of the anterior horns from which the nerves forming this plexus arise. I do not believe that there can be extensive destruction of the anterior horns without the occurrence of degenerative atrophy of those muscles which receive their nerves from that segment of the cord. In the case of Maun, to which Dr. Gushing has referred, there was paralysis and atrophy of the muscles of the left arm. This was completely recovered from, but, at the autopsy, a lesion iu corresponding anterior horn was found. This case is, as far as I know, the only one bearing on this poiut, and it does not seem to me to be conclusive. The lesion was limited to the eighth cervical segment, as shown by the fact that the eighth root was degenerated, while the seventh was not, and the first thoracic root was only slightly so. We know that each muscle is represented in more than one spinal segment, and it can be understood how a limited lesion in one segment need not necessarily produce degenerative atrophy to such a degree that it could be discovered during life. The autopsy on Mann's case was incomplete, in that neither the muscles nor the peripheral nerves were examined.

Dr. Cushing's case is of interest from so many standpoints


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that it is impossible to discuss it fully. Unilateral lesions of the cord are not very common. In the dispensary we have the records of only two typical cases. I have at present under observation a very beautiful example of this form of paralysis. The patient is a woman whose right leg is paralysed and who shows the disturbances of sensation in the left leg which Mann has pointed out as characteristic, i. e. the sensory conduction for touch is undisturbed, whereas pain, heat and cold stimuli do not produce their normal effect. The paths of sensory conduction within the cord have been and are the subject of much discussion. Of late the anatomists and physiologists have been inclined to the view that the paths do not cross, but remain on the same side of the cord until they reach the medulla. Clinicians, on the other hand, from the study of the cases of unilateral lesion of the spinal cord, have held to the belief that the sensory jiaths decussate soon after entering the spinal cord. That there must be an anatomical basis for the constant occurrence of the classical symptoms of Brown-Sequard's paralysis seems to me to be self-evident. The burden of jiroof must rest ujiou the anatomists and physiologists.


NOTES ON NEW BOOKS.

Diseases of the Rectum, Anus and Contiguous Textures. By S. G. Gant, M. D. (Philadelphia : F. A. Davis, 1896.)

With the exception of two chapters on Cancer of the Rectum and Colotomy by Allingliam, a recognized authority on these subjects, the worls of Dr. Gant is not to be commended. The booli contains nothing new, and there are many superior works on this subject. The two cliapters in which the author seems to talce special pride, one on auto-infection, tlie other on effects of railroading on diseases of the rectum, are not remarkable, and the first is unsatisfactory. That employes of railroads suffer much from constipation and hemorrhoids as a result of their occupation may be true, but the figures he gives can be handled in many ways. If we eliminate from the author's statistics all cases suffering from these two very common conditions, we have less than 1 per cent, out of over 170,000 cases seen in various hospitals suffering from other diseases of the rectum and anus; and 5.7 per cent, in the same number of cases does not seem to us an excessive number to be suffering from the two conditions mentioned. We believe that among the poor laboring class constipation is the usual condition found, and that figures more striking than these could easily be collected to show that constipation was one of the commonest symptoms in all hospital cases. We question whether the jarring of a railroad train will continually rock a stomach from side to side, produce a "sea-sick stomach," or whether it is suiEcient to bring about by itself dilatation of the veins about the anus and rectum by causing a venous stasis, and we know that swelling of the feet in railroad travelers is not an ordinary condition, to say the least. The chapter on sodomy might better have been omitted or much abbreviated ; such a book does not call for a psychological explanation of this practice. In speaking of the relation of pulmonary tuberculosis to fistula, the author states : "So we meet with two kinds of tubercular fistula — one as a result of localized tubercular ulceration with or without any lung complication ; the other a fistula in persons who have lung trouble, due to the absorption of fat about the iscliia, general debility, and abscess. In the feces of the first variety can be found the tubercle bacilli of Koch, while in the second variety they cannot be found unless the sputum containing them has been swallowed, and gastric digestion has been impaired to such an e.Ntent as not to destroy them or their spores." In either form the fistula is tubercular and the bacilli


can be found without these coming from the sputum ; and gastric digestion, even when normal, does not ordinarily destroy them, as we know from the large number of cases of primary intestinal tuberculosis which occur. We do not think that the following statements as regards auto-infection are true. On p. 271 we read : " Our Creator, however, foresaw all dangers and provided us abundantly with safeguards with which we can destroy or neutralize the poisons on the one hand, or throw them off on the other, as soon as they are formed"; and on p. 272, "Just so long, however, as the emunctories are working in harmony and perform their individual functions, and there is no lesion of the intestinal mucosa, all is well, and all poisons, no matter whether theyare the products of decomposition or of bacterial action, will do noharm, forthe reason that they are thrown into a special reservoir (the liver) where they are destroyed or neutralized and afterward discharged from the body."

The colored illustrations in this work are hideous and unnatural, and the woodcuts are not models of artistic excellence. Would it not be well for authors to cease to reproduce cuts of the most common and onlinary instruments, and of well-known positions and procedures in operations, which are quite valueless (cf. cuts on pp. 20, 21, 22, 25, 218,219, 220). Wedislike extremely to see theauthor's autograph on the outside cover, and the long list of societies to which he belongs following his name on the title-page. If the book possesses merit of its own, this sort of cheap advertisement does it no good ; and it does not help the work in any case.


BOOKS RECEIVED.

Second CtUalogne of the Library of the Peabody Institute of the City of Baltimore. Including theadditions made sinceI882. Parts I-II. A— D. 1890-97. 4to. Baltimore.

The Semi-Centennial of Anmsthesia. October 16, 1846-October 16 1896. 4to, 95 pages. 1897. Massachusetts General Hospital, Boston.

Saint Bartholomeio' s Hospital Reports. Edited by S. West, M. D., and W. J. Walsham, F. R. C. S. 1896. Vol. XXXII. 8vo, 518 '+ 197 pages. 1897. Smith, Elder & C >., London.

Transactions of the American Pediatric Society. Eighth session held in Montreal, Canada, May 25, 26 and 27, 1896. Edited by Floyd M. Crandall, M. D. Vol. VIII. 1896. 8vo, 243 pages. Reprinted from the Archives of Pediatrics. New York.

Medical and Surpical Reports of the Boston City Hospital. Eighth Series. Edited by G. B. Shattuck, M. D , W. T. Councilman, M. D., and H. L. Burrell, M. D. 1897. 8vo, 391 pages. Published by the Trustees, Boston.

King's College Hospital Rejiorts. Being the annual report of King's College Hospital and the medical department of King's College. Edited by N. Tirard, M. D., F. R. C. P., et al. Vol. III. (Oct. 1st, 1895-Sept. 30th, 1896.) 8vo. 1897. 332 pp. Printed by Adlard & Son, London.

Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America. Edited by T. L. Stedman, M. D. In twenty volumes. Vol. XI: Diseases of the Nervous System. 8vo. 1897. 962 pp. William Wood &, Co., New York.

Burdett's Hospitals and Charities, 1897. Being the year-book of philanthropy. By Henry C. Burdett. 12mo. 1897. 1018 pages. The Scientific Press, London.

Archives of Skiagraphy. Edited by Sydney Rowland, B. A., Camb. Fol. Vol. I, No. 4. April, 1897. The Rebman PublishingCo., Limited, London.

A Pictorial Atlas of Skin Diseases and Syphilitic Affections in PhotoLithochromes from Models in the Museum of the Saint Louis Hospital, Paris. With explanatory woodcuts and text by E. Besnier, A. Fournier et al. Edited and annotated by J. J. Pringle, M.B., F. R. C. P. Part X, 1897. W. B. Saunders, Philadelphia.


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[Nos. 77-78.


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Reiiort in Patbologry.

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

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

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

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

MiLL, M. D.

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

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

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

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

Fihrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duliring). By

T. C. Gilchrist, M. D.

Report in Patliology. An E.xperiniental Study of the Thyroid Gland of Dogs, with especial consideration

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


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

Report in Medicine.

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

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

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

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

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

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

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

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

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

A. Kelly, M. D., and Albert A. Ghbiskey, M. D. Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of (decking

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

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

Howard A. Kelly, M. D.

Report in Snrgery, I. The Treatment of Wounds with Especial Reference to the V.-ilue of the Ulocid Clul

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

Henky M. Thomas, M. D.

Report in Fntliology, I. Amoebic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleue, M. D.


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

Report in PatUology.

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


Tuberculoais of the Female Generative Organs. By J. Whitridge Williams, M. D. Report in Pjitliology.

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

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

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

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

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

Report in Gynecology.

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

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

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


Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. D.

Tabulated by A. L. Stavely, M. D. The Employment of an Artificial Retroposition of the Uterus in covering Extensive

Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D. Photography applied to Surgery. By A. S. Murray. Traumatic Atresia of the Vagina with Hsematokolpos and Hxmatometra. By Howa&d

A. Kelly, M. D. Urinalysis in Gynecology. By W. W. Russell, M. D. The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gj-neco logical Conditions. By Hunter Robb, M. D. Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D, One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.

By Howard A. Kelly, M. D., and Mary Sherwood, M. D. .\bdominal Operations performed in the Gynecological Department, from March 6,

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Report on Typliold Fever.

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Report in Pfenrology, Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of J/us musculu^; The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley, M. D.

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


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Studies in Typhoid Fever. By William Osler, M. D., with additional papers by G. Blumer, SI. D., Simon Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, >I. D.


A'olume VI. 414 pajif.s, with 7') plates and figures.

Report in Neurology.

studies on the Lesions produced by the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nos. 1 to V). By Henry J. Berkley, M. D.

Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning (l^thyl Alcohol) ; Part II. — Serum Poisoning. — Experimental Lesions induced by the Action of the Dog's Scrum on the Cortical Nerve Cell; Part HI. — Ricin Poisoning.— Experimental Lesions Induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by CJhronic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical Nerve Cell produced by the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from tlie Effects of Alcohol and Ricin Intoxication; Ner\-e Fibre Terminal Apparatus; .^sthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Patliology.

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

(3lTLLEN, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of

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

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BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No. 79.]


BALTIMORE, OCTOBER, 1897.


[Price, 15 Cents.


COlsTTIElNrTS.


A Second Series of Cataract Operations (One Hundred and

Fifty-eight). By Robert L. Randolph, M. D., . . Parotitis following Visceral Inflammation. — A Report of Two

Cases. By A. Duval Atkinson, M. D.,

Palpation of the Foetal Heart Impulse in Pregnancy. By

Douglas F. Duval, M. D.,

Squamous Epithelioma in a Dermoid of the Jaw. By S. M.

Cone, M. D.,

The Infectiousness of Chronic Urethritis. By E. R. Owings,

M. D., . .


The Importance of employing Pure Salts in the Preparation of the Schott Bath. [Communication.] By C. N. B. Camac, M. D., 214

Proceedings of Societies :

Hospital Medical Society, 215

Demonstration of a Case. Probable Brain Tumor [Dr. Thomas] ; — Demonstration of Specimens [Dr. Cullen].

Notes on New Books, 218


A SECOND SERIES OF CATARACT OPERATIONS (ONE HUNDRED AND FIFTY-EIGHT).*

By Egbert L. Randolph, M. D.


Five years ago I reported in the Bulletin of the Johns Hopkins Hospital a series of fifty consecutive cataract operations. Of these fifty operations six were performed in a hospital. With the exception of eighteen, the remaining twentysix were among the poorer classes of a country population in Virginia and in a mining region in the western part of Maryland. This series then is chiefly interesting from the rather unusual conditions which surrounded most of the patients. For instance, the first case reported (Series I, Case 1) was operated on in a log cabin near Warrenton, Va., and the old man was nursed by his daughter, who saw him only at meal times and at night (she being in service), and as a consequence he was exposed not infrequently to risks during her absence. He went through the same experience a year later with his other eye and, as in the first instance, obtained excellent vision. Case 8 (in the same series) had been blind for three years and lived at a remote point on a plantation in Virginia, and he was nursed by his wife. His cabin was too dark for the operation and I put him on a cot and operated out in the yard. He was very timid and jumped when the iridectomy was performed, causing some loss of vitreous. He counted my fingers after the operation and I assisted him upstairs to a room next


  • Read at the annual meeting of the American Ophthalmological

Society, AVashington, D. C, May, 1897.


to the roof, as the only other room in the house opened out into the yard. He remained there for a week, and at the end of that time was allowed to come downstairs. He subsequently obtained perfect vision. Case 39 (Series I) was operated on in a cabin full of negro children, and he was looked after by his daughter. The result was most satisfactory. In this series of fifty, two failed to recover sight, and as the circumstances peculiar to these were rather unusual and as such might explain the failure, I shall relate the histories. Case 49, woman 78 years old, had been troubled many years with dacryocystitis, more marked in the left eye than in the right. She had been blind from cataract for three years. Refused treatment for the lachrymal trouble, saying she was too weak and old to stand the pain incident itpou the probing. She was made acquainted with the additional risk of a cataract operation performed on an eye where there was disease of the lachrymal sac. She was willing, however, to run the risk of infection from this source, so I operated on the least affected eye. The result was a perfect success. A year later she presented herself for operation upon the second eye. The operation was smooth and she counted fingers with ease immediately afterward. I left the city that evening, not expecting to see her again for two weeks. She was entrusted to the care of the physician who assisted me in the operation. It is well to state here that she belonged to a most ignorant class of white


200


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 79.


people, and though nearly eighty years of age, was accustomed to going barefooted in tvarm weather. The first time I operated she had shown herself unmanageable and walked around the house three days after the operation. That was in the winter time. The second operation was in June last, and when I saw the patient two weeks after the operation her physician told me that she got up out of bed the next day, tore the plaster off her good eye and came downstairs and sat in the yard and smoked her pipe. The second day after the operation she walked nearly a mile barefooted to see her daughter. Whatever were the causes which produced it, when I saw her the second time the eye was lost. It is impossible, then, to say whether to attribute the loss of the eye to infection from the mucocele or to carelessness and exposure after the operation. Before each operation the contents of the lachrymal sac were pressed out, and, as far as possible, the conjunctival sac was rendered aseptic by irrigating it with a solution of corrosive sublimate t^^jtj-.

The second case (Case No. 47) is that of a man sixty-one years old. He had been subject for many years to rheumatism, and had suffered also for a long time with varicose veins on both legs, and as a result of the latter condition his right leg was covered with an eczema. The blood-vessels at his wrists and temples were tortuous and hard. Left eye, total cataract and good field of vision for light. The operation was absolutely smooth, and after the delivery of the lens the patient could see my face and count fingers readily. I removed the speculum and closed the eye, putting on the usual bandage. Ten minutes later, and just before I was about to leave the house, he complained of violent pain in the eye. I suspected hemorrhage and immediately removed the bandage to investigate. I found the latter soaked with blood. The mass of blood and protruding vitreous were cleaned away and strong pressure applied. On returning six hours later it was found that the oozing had continued and he was still suffering pain. The lids were opened and a clot of vitreous was discovered between the edges of the wound. This was removed, and after first irrigating the conjunctival sac with a very weak sublimate solution, a pressure bandage was applied. At my visit the next day I found the bandage quite moist and there was every evidence that the oozing was persisting. I cleaned out the sac again and renewed the bandage. On the afternoon of the second day I saw him again and there were still signs of hemorrhage. The same course of treatment was pursued and on the third day I found the bandage clean. Of course he was told that vision was irrevocably gone from the onset of the hemorrhage. In nearly all cases of this class the cornea sloughs, but this termination I fortunately escaped. Hemorrhage after cataract extraction is rare. Dr. Knapp reports in a recent number of the Archives of Ophthalmology his only case. In my own case I can account for the hemorrhage only by the condition of the blood-vessels throughout his body. ,v, No doubt the vessels of the retina were tortuous and their walls atheromatous, and when the lens was removed and intraocular tension thereby lowered, the blood-vessel walls could not withstand the pressure from the increased volume of blood pouring into them; so they ruptured. The whole condition of


the patient pointed to a diseased state of the circulatory apparatus. It is impossible to guard against such a termination, though I should regard it as a contra-indication for operation upon the other eye, for no matter how smooth the operation might be, the chances are that hemorrhage would follow the delivery of the lens.

Out of this series, then, all obtained useful vision but Cases 47 and 49.

Since the publication of this series I have operated upon 158* cases and the tabular statement is herewith appended. Two of the cases are especially interesting as being instances of maniacal excitement, possibly due to the use of atropine after the operation. The first case was a colored man, operated upon in the poorhouse of Mineral Co., W. Va. He was seventy-five years old and had been practically helpless from cataract for a year. Atropine was instilled immediately after the operation. The next morning the physician. Dr. C. S. Hoifman of Keyser, W. Va., was sent for and he wrote me that the patient had gotten up during the night, torn the bandage off, secured a razor from one of the inmates of the room and had gashed his throat in several places and was bleeding profusely when found. In the excitement which followed the eye was forgotten and it was some time before the bandage was replaced. He was quieted, and seven days later, that is, on the eighth day after the operation, he disappeared from the jDOorhouse and two mouths afterward was seen by Dr. Hoffman, in Piedmont, W. Va., 20 miles distant, where he was chopping wood and apparently getting along with absolute comfort. It might be added that he was entirely bliud in the other eye.

The other case was also a very old colored man (88 years old). The operation was simple extraction, and atropine was instilled as usual at the operation. Before daybreak of the next day he was a raving maniac and had to be tied down to his bed. His bandage was torn off several times and he was incessantly tossing his head from side to side, until that too had to be secured so as to be as far as possible immovable. I did not dare look at the eye, as I supposed that it was lost. He did not recover his reason for a week, and all that was done was to apply hot moist compi-esses to the eye. When he became rational and I was enabled to get a satisfactory view of the eye I found a rather small pupil, a slight prolapse, but very little pericorneal congestion. On the tenth day he seemed to be completely himself again, and as the eye evidently needed a mydriatic, one drop of a solution of atropine (4 gr. — si) was instilled and the nurse was instructed to repeat the dose at bedtime. When I returned to the hospitiil the next day I found that during the night he had jumped out of the window — 20 feet from the ground — scaled a high iron-spiked fence and was making off when overtaken by an orderly. Notwithstanding all this exposure he obtained 4^ vision. Nothing was done for the prolapse, which flattened out entirely.

Another interesting case was where the auterior chamber


  • At the meeting of the Amer. Oph. Soc. only 147 cases were

reported in my second series. Since the meeting I have operated upon eleven cases.


October, 1897.J


JOHNS HOPKINS HOSPITAL BULLETIN.


201


remained open for seventeen days. I have seen explanations for tliis phenomenon, but none seem adequate. The opei'ation was the combined one, and the wound had united about half way ujj on one side and the rest of the incision remained open. More than once during these seventeen days a spatula was jmssed beneath, the corneal flap, and it was easily seen that no uuion had taken place. The operation so far as could be seen appealed to have been normal, that is to say there was not the slightest hitch in any of the steps. Atropine and compress bandage were employed, and two weeks after he left the hospital his vision was jW Eight months later he returned to the hospital with serious iritis, and since then vision has been lost, though he still has light perception.

Iridectomy was pei-formed in 102 cases and simple extraction in 42 cases. Soft cataract was operated upon by needling in three cases.

In thirty-one cases the vision was not tested. Three of these cases were in very young children and any subjective test would have been very unreliable. The remaining twenty-eight were ones which I had operated upon at a distance and most of whom I saw only once after the operation. A number of cataract glasses were sent to them from which to make a selection, and in this way I learned to what extent the operation had benefited the patient. It will be seen from the table that the operation and healing process were uncomplicated in all of these cases and all obtained useful vision.

Tlie failures were as follows: C«*e 54. The operation was smooth, and when the bandage was removed she could see large objects in the room. This was on the seventh day. Two days later iritis of a very sluggish character developed, and in spite of all treatment ended in closed pujjil and light perception. Dr. H. Harlan of this city operated on the other eye and obtained good vision, but he told me that the ojDeration was also followed by iritis.

Cage 72 had an exactly similar history. Case 95 was one which I had treated for several months for dacryocystitis. Her left eye had been operated upon by a New York oculist two years previously, and the cause of the failure in the case of that eye was no doubt the same as in the case of the eye upon which I operated, for both eyes were affected with dacryocystitis. When first seen she had a fistulous opening which had been discharging for several months. Before operation she was under treatment for at least five months, during which time the fistula had closed and the epiphora had almost disappeared. She understood the danger, but being totally blind in the other eye, wanted the operation performed. The cornea sloughed within a week after the operation.

Case 137 was that of a man 81 years old. On opening the eye on the third day there was a very offensive discharge on the bandage and between the lids, and beginning clouding at the edge of the corneal wound. Vigorous local and constitutional treatment, however, prevented the corneal trouble from extending and he was left with a clear cornea and closed pupil. I think that I could have converted this failure into a success (as in Case 190) by iridotomy, but a few days before the proposed operation he was attacked with pneumonia and died on the eighth day.


The last case was that of an old colored man (Case 128) and the history here was similar to Cases 54 and 72.

In one case (male, both eyes, 67 and 68), the patient had good light perception, but after the extraction of the cataracts it was observed that while he could move about somewhat better, his sight continued very poor, and this was explained by the existence of optic nerve atrophy in both eyes.

In Cases 53 and 307 a cataractous lens (congenital) had undergone calcification and presented a bright white mass in the pupil. The operation was simply for cosmetic purposes.

As to prolajjse of the iris. In the 42 cases of simple extraction there were five prolapses. In three of these cases nothing was done, though in Case 181 the prolapse looked as though it would extend throiigh the entire wound. Under a compress bandage, however, and atropine the hernia smoothed over and she has now vision f^. In Case 182 the prolapse got worse from day to day till it nearly filled the wound, and it continued bulging more and more. There was no hernia on the second day when the eye was inspected, but he bad a little gush of tears that night followed by pain, and a small hernia was visible the next day. On the eighth day, fearing that the eyeball would be permanently disfigured (to say nothing of loss of sight), the protruding iris was cut off. There is now not the slightest ectasia of the cornea so far as can be seen, and the patient has f^ vision.

In these last two cases lachrymation and photophobia were present to a marked extent and some little pain was felt at the time when the prolapse occurred, but after this pain was conspicuously absent. So far as could be seen there were no evidences of infection in any of the cases of prolapse. When I say evidences I mean cloudy media and exudates. I think that the absence of infection in these and similar cases is to be attributed to the fact that the wound is filled with the protruded iris and probably there is no way for the bacteria to make entrance into the anterior chamber. The profuse lachrymation which is usually present must be regarded as a more or less protection from a mechanical point of view, i. e. to some extent in washing away bacteria. And I think that an examination of the statistics of simple extraction will disclose the fact that the failures are as a rule not associated with prolapse.

In commenting upon the visual results it will probably strike many as singular that |J was obtained only four times, but this may be explained by the fact that discission was performed only ten times and that in quite a number of cases (31) I made no test of the vision.

In all of the operations the incision was made well within the liinbus of the cornea and still a little further in at the top of the incision. The latter includes usually something less than half the circumference of the cornea.

The instruments with the exception of the knife are boiled. The knife is allowed to remain in Squibb's absolute alcohol for 20 minutes. The eyebrows and that side of the face are covered with a cloth saturated with a solution of sublimate 1:1000. Both the cocaine and atropine solutions are boiled in test tubes and only used once. Small pledgets of cotton secured by sponge holders and boiled are used for removino- debris from the field of operation, such for instance as strings of mucus and small clots of blood. The uuoperated eye is closed till the second day and a small pad of sterilized absorbent cotton is placed over the operated eye and over this a four-tail bandage. The eye is inspected on the second day, and earlier if there be unusual pain. The room is darkened, but is not uncomfortably dark. The patient is allowed to get up on the second day, and the bandage is removed on the seventh day, though there was a time when I removed it earlier. The following is the arrangement of the visual results:

20 I 1

TS '^^

U 35


2 Qfi

717 ^°

20 Of?

20 R

2110 "

Vision not tested .31

Atrophy of the optic nerve 2

Cosmetic purposes 2

Failures 5

158

Successes in the first series 48

Failures iu the first series 2

Total number of cases operated upon 208


No.


Sex.


Age.


Health.


Cataract,


Operation.


Healii.g- process. Duration of treatment.


Primary Vision.


51


Male.


77.


Good.


Hard. R. E.


Iridectomy, smooth.


Uncomplicated.


2 weeks.


20/70


52


Male.


75.


Good.


" "


11 II


Mild iritis.


2 "


20/100


53


Male.


36.


Good.


Calcareous. R. E.


.1 11


Uncomplicated.


2 "


Light perception.


54


Female.


50.


Good.


Hard. L. E.


" "


Iritis.


6 "


" "


55


Male.


71.


Good.


" "


It 11


Uncomplicated.


2 "


20/.30


56


Female.


68.


Bad.


" "


Escape vitreous.


Iritis.


5 "


20/70


57


Female.


66.


Good.


" "


Iridectomy, smooth.


Uncomplicated.


2 "


Not tested.


58


Female.


72.


Good.


R. E.


11 II


"


2 "


20/26


59


Female.


65.


Bad.


L. E.


11 11


Iritis.


4 "


20/100


60


Male.


70.


Good.


R. E.


" "


Uncomplicated.


2 "


20/30


61


Male.


50.


Good.


" "


11 11


"


2 "


20/40


62


Male.


50.


Good.


L. E.


II II


"


2 "


20/40


63


Female.


55.


Good.


"i ^.•■■^■


11 11



2 "


211/100


64


Female.


60.


Bad.



11 11


"


2 "


24/40


65


Male.


55.


Good.


!! L.E.


11 11


Mild iritis.


5 "


20/70


66


Female.


62.


Good.



11 11


Uncomplicated.


2 "


Not tested.


67


Male.


75.


Bad.


" "


Simple Ext.


"


2 "


Atrophy.


68


Male.


75.


Bad.


R. E.


Iridectomy.


"


2 '•


0. Nerve.


69


Female.


60.


Good.


" "


"


"


2 "


20/40


70


Female.


60.


Good.


L. E.


"


"


2 "


20/70


71


Female.


66.


Good.


R. E.


"


Iritis.


3 "


20/100


72


Male.


80.


Good.


L. E.


"


Irido-cyclitis.


8 "


Light perception.


73


Male.


63.


Good.


" "


"


Uncomplicated.


2 "


20/30


74


Male.


66.


Good.


R. E.


"



2 "


20/20


75


Female.


71.


Good.


L. E.


"


"


2 "


20/70


76


Female.


50.


Good.


R, E.


"


"


2 "


Not tested.


77


Female.


61.


Good.


L. E.


"


Mild iritis.


3 "


20/40


78


Female.


66.


Good.


R. E.


"


Uncomplicated.


2 "


20/40


79


Female.


54.


Good.


L. E.


"


"


2 "


20/40


80


Male.


75.


Good.


R. E.


"


"


2 "


20/70


81


Male.


71.


Good.


" "


"


"


2 "


Not tested.


82


Female.


63.


Good.


',! L.^E.


•'


Vitreous lost. Iritis.


4 "


20/100


83


Female.


50.


Good.


(t


"


Uncomplicated.


2 "


20/70


84


Female.


51.


Good.


R. E.


"


"


2 **


20/40


85


Male.


80.


Bad.


" "


"


"


5 "


20/100


86


Male.


64.


Good.



"


"


2 "


20/70


87


Male.


54.


Good.


L. E.


"


"


2 "


20/40


88


Male.


66.


Good.


R. E.


"


"


2 "


Not tested.


89


Male.


60.


Good.


" L. E.


"


"


2 "


11 11


90


Male.


.57.


Good.


R. E.


"


1'


2 *'


20/40


91


Male.


51.


Good.


L. E.


"


"


2 "


20/100


92


Female.


47.


Good.


II .1


"


"


2 "


20/100


93


Male.


55.


Good.


R. E.


"


"


2 "


20/70


94


Male.


71,


Good.


" "


"


"


2 "


20/70


95


Female.


65.


Bad.


" "


Escape vitreous.


Irido-cyclitis,


2 "



96


Female.


52.


Good,


L. E.


Iridectomy.


Uncomplicated.


3 "


20/200


97


Female.


53.


Good.


R. E.


"


"


3 "


Not tested.


98


Female.


77.


Good.


L. E.


"


Iritis.


4 "


20/100


99


Male.


56.


Bad.


R. E,


■'


Uncomplicated.


2 "


20/30


100


Male.


58.


Good.


L. E.


"


"


2 "


Not tested.


101


Male.


54.


Good.


R. E.


"


"


2 "


20/40


102


Male.


46.


Good.


L. E.


"


••


2 "


20/70


103


Female.


76.


Bad.


R. E.


"


"


2 "


Not tested.


104


Female.


64.


Good.


11 11


1'


"


3 "


20/40


105


Male.


.50.


Good.


II 11


"


"


2 "


20/70


106


Male.


65.


Bad.


L. E.


"


"


2 *'


20/70


107


Female.


60.


Good.


" "


"


"


2 "


20/40


108


Male.


72.


Good.


R. E.


"


"


2 "


20/40


October, 1897.1


JOHNS HOPKINS HOSPITAL BULLETIN.


203


No.


Sex.


Age.


Health.


Cataract.


Operation.


Healing process. Duration of treatment.


Primary Vision.


109


Female.


61.


Good.


Hard. L. E.


Iridectomy.


Uncomplicated.


3 weeljs.


20/70


110


Male.


79.


Good.


" "




"


2 "


20/100


111


Male.


55.


Good.


R. E.




"


2 "


20/40


112


Male.


80.


Good.


L. E.




"


2 "


20/70


113


Female.


56.


Good.


" "




"


3 "


20/100


114


Female.


63.


Good.


" "




"


3 "


Not tested .


115


Male.


72.


Good.


" '•




"


2 "


20/100


116


Male.


81.'


Good.


" "




"


2 "


20/7(t


117


Female.


66.


Good.


R. E.




"


2 "


20/70


118


Female.


50.


Good.


" "




"


2 •'


20/40


119


Female.


49.


Good.


L. E.




"


2 "


20/100


120


Female.


48.


Good.


R. E.




"


3 "


20/70


121


Female.


53.


Good.


" "




"


2 "


20/30


122


Male.


68.


Good.


L. E.




"


2 "


20/40


123


Male.


64.


Good.


" "




"


2 "


Not tested.


124


Female.


62.


Good.


" "




"


2 "


II II


125


Male.


7.


Bad.


Soft. R E.


Needling.


"


2 operations.


" "


126


Male.


7


Bad.


L. E.


"


"



11 11


127


Male.


Si'.


Bad.


Hard. L. E.


Iridectomy.


"


3 weeks.


20/40


128


Male.


81.


Bad.


R. E.


"


Iridocyclitis.



Light perception.


129


Male.


22


Good.


Soft. R. E.


Simple.


Uncomplicated.


2 weeks.


Not tested.


130


Male.


30'.


Good.


" "


if


"


2 "


20/200


131


Male.


44.


Good.


Hard. L. E.


Iridectomy.


"


2 "


20/100


132


Male.


4.


Good.


Soft. L. E.


Needling.


"



Not tested.


133


Male.


77.


Good.


Hard. R. E.


Combined.


"


6 "


20/100


134


Male.


77.


Good.


L. E.




"


2 "


Not tested.


135


Female.


52.


Good.


R.E.




"


2 "


20/200


136


Male.


65.


Good.





"


2 "


20/70


137


Female.


57.


Good.


L. E.




"


2 "


20/40


138


Male.


69.


Good.






2 '■


20/40


139


Male.


82.


Bad.


(I (1


"


Escape vitreous.



No change but 3 weeks' vision. 20/70.


140


Male.


34.


Good.


Hard. R. E.


Simple Ext.


Uncomplicated.


2 weeks.


20/40


141


Female.


51.


Good.


" "




"


2 "


20/70


142


Female.


51.


Good.


L. E.




"


2 "


20/40


143


Female.


45.


Good.


R. E.




"


2 "


20/200


144


Male.


58.


Good.


II II




"


2 "


20/100


145


Male.


58.


Good.


L. E.




'<


2 "


20/70


146


Male.


61.


Good.


<i 11




Escape vitreous.


Iritis. 4 "


20/30,


147


Female.


47.


Good.


R. E.




Uncomplicated.


2 "


20/40


148


Female.


60.


Good.


II 1.




"


2 "


Not tested.


149


Female.


50.


Good.


w L.E.




"


2 "


11 11


150


Male.


60.


Good.





"


2 "


20/40


151


Male.


55.


Good.


II •!




"


2 "


20/70


152


Male.


44.


Good.


" "




"


2 "


20/70


153


Male.


48.


Good.


U II




"


2 "


20/40


154


Male.


51.


Good.


!'i ^;.^



"


2 "


20/70


1.55


Male.


62.


Good.





"


2 "


20/70


1.56


Female.


59.


Good.


II II




"


2 "


20/100


157


Female.


71.


Good.


L. E.




'•


2 "


20/70


1.58


Female.


73.


Good.


<" B;E.




"


2 "


20/40


159


Male.


47.


Good.





"


2 "


20/30


IGO


Female.


53.


Good.


11 11




"


2 "


Not tested.


161


Female.


62.


Good.


II <I




"


2 "


20/80


162


Female.


50.


Good.


II II




Iritis.


4 "


20/100


163


Female.


.58.


Good.


U tl




"


5 "


20/70


164


Female.


78.


Bad.


L. E.


Iridectomy.


"


7 "


Closed pupil.


165


Female.


66.


Good.


U II


"


Uncomplicated.


2 "


20/70


166


Female.


66.


Good.


R. E.


"


"


2 "


20/100


167


Male.


68.


Good.


11 <i


"


Ant. C, open


17 davs.


20/200


168


Male.


28.


Good.


Soft.


S. L. Extracture.


Uncomplicated.


10 "■


Not tested.


169


Female.


47.


Good.


Hard. L. E.


Simple Ext.


  • '


2 weeks.


20/10


170


Female.


80.


Bad.


R. E.


Iridectomy.


Iritis.


5 "


20/200


171


Female.


65.


Good.


II 11


"


Uncomplicated.


2 "


20/70


172


Male.


88.


Good.


L. E.


Simple Ext.


Prolapse iris.


3 "


20/100


173


Female.


70.


Bad.


R. E.


II II


Iritis.


4 "


20/70


174


Female.


70.


Bad.


L. E.


Iridectomy.


Uncomplicated.


2 "


20/70


175


Male.


44.


Good.


'<! ^;.^

Simple Ext.


"


3 "


20/40


176


Male.


48.


Good.



Prolapse.


5 "


20/30


177


Male.


71.


Good.


II 11


Iridectomy.


Uncomplicated.


2 "


Not tested.


178


Female.


70.


Good.


II II


"


"


2 "


20/100


179


Female.


61.


Good.


L. E.


"


"


2 "


20/40


180


Female.


67.


Good.


R. E.


"


Iritis.


4 "


20/40


181


Female.


66.


Good.


L. E.


Simple Ext.


Big prolapse.


5 "


20/40


182


Male.


47.


Good.


!' •^■i'^

"


II


4 "


20/30


183


Female.


58.


Good.



Iridectomy.


Uncomplicated.


2 "


20/40


184


Female.


70.


Good.


11 11


"


"


2 "


Not tested.


185


Female.


50.


Good.


11 11


Simple Ext.


"


2 "


20/100


186


Male.


67.


Good.


!'. ^u-^

Iridectomy.


"


2 "


20/20


187


Female.


77.


Bad.



Simple Ext.


"


2 "


20/100


188


Female.


77.


Bad.


R. E.


Irid


Bctomy.


Iritis.


4 "


20/100


204


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 79.


No.


Sex.


Age.


Health.


Cataract.


Operation.


Healing process. Duration of treatment.


Primary Vision.


189


Male.


83.


Good


Hard. L. E.


Simple Ext.


Uncomplicated.


2 "


Not tested.


190


Female.


80.


Good.


U It


Iridectomy.


Closed pupil, but


iridotomy pave.


20/2C0


191


Female.


70.


Good.


R. E.


"


Uncomplicated.


2 weeks.


20/30


192


Female.


62.


Good .


" "


"



2 "


20/70


193


Male.


50.


Good.


" "


Simple Ext.



2 "


20/70


194


Male.


55.


Good.


" "


" "


"


2 "


Not tested.


195


Male.


60.


Good.


" "


" "


"


2 "


20/100


196


Male.


72.


Good.


" "


" "


"


2 "


20/70


197


Male.


72.


Good.


L. E.


" "


"


2 "


20/70


198


Female.


70.


Good.


" "


Iridectomy.


"


2 "


2(1/20


199


Female.


70.


Good.


R. E.


"


Slight iritis.


3 "


2<i/100


200


Female.


68.


Good.


L. E.


Simple Ext.


Uncomplicated.


2 "


20/40


201


Female.


66.


Bad.


R. E.


" "


Iritis.


4 "


Not tested.


202


Female.


68.


Delicate.


" "


Iridectomy.


Uncomiilicated.


2 "


" "


203


Female.


65.


Good.


" "


"


"


2 "


20/40


204


Female.


66.


Good.


L. E.


"


"


2 "


Not te&ted.


2 '5


Female.


60.


Good.


R. E.


"


"


2 "



20(i


Male.


44.


Good.


L. E.


"


"


2 '■


" "


207


Male.


50.


Good .


R. E.


"


"



Cosmetic.


20S


Female.


55.


Good.


" "


"


"


2 "


Not tested.


PAROTITIS FOLLOWING VISCERAL INFLAMMATION.-A REPORT OF TWO CASES.


(Service of Dr. O.sler.) By a. Duval Atkinson, M. D.


It is well known that parotitis is a complication in pyaamia and many infections diseases. There seems also to be a relation between the parotid gland and the generative organs, and an apparent sympathy (as pointed out by Stephen Paget in 1886) between the parotid gland and the abdominal viscera. Cases illustrating it are, however, of sufficient rarity to warrant the rej)ort of the following histories.

Case J. Parotitis following a supposed gastric ulcer. — A female, aged 34, single, by occupation housemaid, was admitted December 16th, 1895, complaining of general weakness and vertigo. Her family history was good ; her mother died of "dropsy": there was no history of titberculosis. She had always enjoyed good health until one year ago. She had had none of the diseases of childhood. The catamenia began at fourteen and were always regular until a year ago. She had not menstruated for four months. She had been sick during the past year, but not confined to bed. At the beginning of the illness her chief complaint was of a continual dull pain in the epigastrium and "cramps" in the legs, a condition which lasted for about one month, when the pain left the abdomen, but not the extremities. In them it persisted with the utmost severity, being of a shooting, darting character, coming on often in paroxysms lasting several minutes. At the height of these pains a feeling of "pins and needles" would be felt in the hands and fingers. During the six months previous to her admission her arms and hands had been swollen to some extent, also her eyelids, the latter especially in the early morning ; her eyesight had been failing.

She took to bed December 9th, 1895 (eight days before entrance. Late in the afternoon of that day she began to feel weak and nervous, and had a gnawing sensation in the epigastric region. Nausea immediately followed, and she vomited a considerable ([uantity of bloody-looking material. Four hours later she again vomited a considerable quantity of material which the patient thought was pure blood. She remained in


bed on account of her extreme weakness until she came to the hospital.

Physical Examinatioii. Patient's skin and mucous membranes were j)ale ; sordes on lips ; tongue pale, moist, and somewhat cracked. Distinct pulsation in external jugulars; pulse 25 to the quarter, regular in force and rhythm, tension distinctly raised ; vessel wall a little thickened.

The thorax was long ; costal angle narrow ; expansion only fair, but apparently equal. Respiration over front of chest was negative; clear on percussion. Over the back the breath sounds were quite clear.

Heart. Point of maximum cardiac iinpulse diffuse over fifth and sixth spaces, in and a little outside the nipple line; relative dullness was at the upper border of the third rib, extending to the nipple line and a little beyond the left sternal margin. At the point of maximum cardiac impulse the first sound was loud and booming, accompanied by a blowing systolic murmur which was heard as far out as the anterior axillary line. The second sound was accentuated. A systolic murmur was also heard in the aortic region, where the second sound was sharp and loud. Over the sternum the murmur was increased and the second sound was more booming. At the costal angle the murmur was very distinct and the second sound was greatly increased in intensity.

Hepatic flatness began at the sixth intercostal space and extended to the costal margin in the mammillary line; the border was indistinctly felt. Spleen not palpable. No cedema. Eefiexes normal. Blood count showed 2,314,000 red corpuscles to the cubic millimetre; white corpuscles, 8000; hajnioglobin 30 per cent. The urine was pale yellow in color ; specific gravity varied from 1010 to 1006; there was a decided trace of albumen. Microscopically granular casts were seen. There were no rigors.

During the night of Dec. 16th, 1895, the patient began to complain of pain, and tliero was some swelling in the region


OCTOBEll, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


205


of the left parotid gland. The next morning (two days after entrance) the following condition was noted. The patient presents great swelling of the left parotid gland. The swelling extends nji above the zygoma, and behind far over the mastoid. Below there is a marked amount of infiltration in side of neck, extending to the angle of the mouth. The swelling lifts the lobe of the ear. It is rounded, tense, hot, and very painful. The tongue is a little swollen. Nothing exudes from Steno's duct when external pressure is made over the gland. The abdomen is negative. There is no general enlargement of the superficial glands of the body.

At 13 noon, although no fluctuation was obtained, the gland was incised. Numerous small foci of inflammation were discovered, from which exuded a little creamy pus. Cover-s]ij)s from these areas showed streptococci and a large bacillus ; the latter was supposed to have come from the mouth. Cultures showed a pure growth of streptococcus, the bacillus not growing.

The following day, December 20th, the pain in the region of the neck had in a measure subsided; the swelling, however, remained about the same ; there was marked oedema of left eyelid.

The patient did fairly well until the 34th, the swelling and tedema of eyelids remaining about the same. On that day she was extremely pale, pulse 100, dropping a beat occasionally. The swelling of the cheek was perhaps a trifle less; she breathed noisily ; no infiltration in the lower neck. The patient sank rapidly and died. Unfortunately no autopsy was allowed. The diagnosis of parotitis, gastric ulcer, and chronic interstitial nephritis was made.

Case II. Cholecystitis (post typhoidal) complicated by double parotitis. — J. L., single, age 34, German, butcher by occupation, was admitted to Ward F, November 25, 1895, complaining of continual headache, pains in his muscles and joints. His family history was good ; there was no history of tuberculosis. His only disease during childhood was scarlet fever, from which he made a complete recovery, with no sequelae, and excepting an attack of rheumatism, which confined him to bed nine months in 1893, had always been a strong, able-bodied man. He gave no history of syphilis or gouorrhoeal infection. Had been a moderate drinker. The history of his present illness was that about one week before his admission he began to have headache, chills and nausea, accompanied by vomiting. The diagnosis of typhoid fever was made, and the patient had a typically mild course of fever, which was treated by means of the ice-baths. His temperature reached normal on December 5th, ten days after entrance. The urine showed a distinct diazo reaction, and there was a trace of albumen. The spleen was easily palpable, and there were a few typical rose spots. The liver was never palpable. Blood negative for malarial organisms. No leucocytosis. His convalescence was uninterrupted, and he was discharged well, January 1, 1896.

The patient was readmitted November 30, 1896, eleven months afterwards, complaining of headache and general weakness, stating that he had been feeling badly for ten days. The chief symptoms seemed to have been headache, muscular and slight abdominal pain. Two days before


entrance he had had a slight chill followed by fever and sweating. On entrance his temperature registered 103.4°, pulse 27 to the quarter minute, full and strong. The physical examination was negative save for a slight enlargement of the spleen and some rigidity of the right rectus muscle. The liver was not palpable and the hepatic flatness was not increased. The blood was entirely negative for malarial organisms, and there was no leucocytosis. The conjuuctivEe were injected, but there was no jaundice. No bile was found in the urine. His temperature, which reached 103° on the evening of his entrance, quickly dropped to normal, and the man was discharged December 15th, quite well, with no definite conclusions being reached concerning the nature of his trouble.

He again applied for admission March 5, 1897, stating that for three days he had had chills, accompanied, he thought, by fever, headache and pains in his back and limbs. His bowels had been very costive for some time.

The physical examination was as follows : Well nourished, strong-looking man ; face flushed; eyes bloodshot ; lips a trifle cedematous ; tongue had a slight brown coat. Pulse, 33 to the quarter minute, dicrotic ; capillavy circulation rather sluggish. Thorax symmetrical, expansion equal; an occasional sonorous rale was to be heard over chest and axillae. Heart sounds clear. Spleen just palpable on deep inspiration. Hepatic flatness began at the sixth rib, extending one finger's breadth below the costal margin. The muscular resistance of the abdominal wall was such that it was utterly impossible to palpate it. In the mammillary line there were 13 cm. of hepatic flatness. (Pain was complained of whenever deep palpation was attempted in the hypocondriac region.) On the following day, March 6th, there was no essential change in his condition. The morning temperature registered 104.3°, and that of evening 103°. There was well-marked tenderness on pressure in the hypocondriac region, and pressure between the crest of the ilium and ribs on the right side caused pain. The most tender part appeared to be just at the region of the gall-bladder. The conjunctivae were a little muddy, but not distinctly jaundiced. There was- a leucocytosis amounting to 11.300 to the cubic mm. The urine was negative, but no test for bile was made. On March 9th the conjunctivae were slightly yellow, and the urine reacted for bile. There was still great tenderness in the region of the gall-bladder. His temperature, which had been gradually falling, reached normal at 2 a. ni., where it remained until the 12th, when it was again elevated. On that day both parotid glands were swollen, the right more than the left. They were hot and very tender to pressure. No fluctuation was obtained. On the loth both glands were greatly swollen, the tissue of the face and neck was infiltrated, and eyelids (Edematous. The skin over the parotid glands was red, the gland itself imparting a hard infiltrated sensation to the examining hand. Both papillae at orifice of duct were swollen, and pus could be forced out. Although the patient was in poor condition, his temperature registering 102.8°, he insisted upon leaving the hospital, and was therefore discharged.

Cultures from the Ijlood on agar-agar and bouillon proved neo-ative. Diagnosis: Cholecystitis (post-typhoidal), com


206


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 79.


plicated by double parotitis. Later both parotids were incised, the bacteriological esamiuation showing a pure growth of staphylococcus aureus. The patient is now quite well.

The cases in many ways correspond to some of those referred to by Stephen Paget in the London Lancet for 1886, and spoken of in more detail in the British Medical Journal in 1887. In his series parotitis followed injury and diseases of the peritoneum, generative organs, and abdominal viscera. Two followed a supposed gastric ulcer. Of the 101 cases cited, 10 were due to injury of the urinary tract; 18 to diseases of the alimentary tract; 33 to injury or disease of the abdominal wall and peritoneum, or to the pelvic cellular tissues, and 50 to temporary derangement of the generative tract. He states that parotitis after abdominal or pelvic injury or disease is not as a rule accompanied by signs of septiegemia or pya3mia. Of his 101 cases mention is only made in 15 of septic symptoms. 37 died; of these 3 were over eighty years of age ; 3 had internal cancer ; 3 had perforation of the bowel ; and 3 had strangulated hernia; 7 had undergone severe surgical operation involving abdominal section ; 13 had septicEemia or pyfemia; 1 had infantile syphilis ; 1 had marasmus; and 1 had heart trouble. He adds that death was not due to parotitis joer se, but to a primary lesion, and he is ujiable to state to what extent parotitis is a dangerous complication. Its period of incubation is unknown, but in his opinion it is from one to thirteen days. There is as a rule no marked disturbance to general health, no rigors, and no high fever. On the other hand symptoms may be more severe from the onset, and great disturbance in general health may be noted. Eigors were noted in only 4 cases. In regard to the termination of the parotitis, whether by resolution or by suppuration, the figures show that out of 73 cases which give information on the point, 45 suppurated and 33 were resolved, and out of 45 that suppurated 34 died; but out of the 33 that resolved without suppuration only one died (in all probability from cancer). In other words, he thinks that they did not die because the parotids went on to suppuration, but that the parotids suppurated because they were going to die. In cases of undoubted septicasmia or pyemia the parotids always went on to sujipuration.

'I'he only autopsy reported by Paget is that of a woman dying from the effects of the removal of a sarcomatous growth of the mesentery, having parotitis as a complication. On section the parotid was found to be evenly and in every part infiltrated, not with pus, but with a reddish, slightly turbid fluid, causing it to look like a section of the spleen. There were no abscesses anywhere. Just in the proximal end of the duct where it left the gland lay two or three drops of healthy pus and a tiny calculus. The acini were separated, compressed, and breaking up, and here and there were seen ducts filled with the same small round cells as were infiltrated among the acini. No bacteriological examination was made. Mr. Paget cites a case reported by Rosenbach of parotitis following operation for strangulated hernia, in which staphylococcus aureus was obtained. He further states that this form of parotitis is in many ways a peculiar lesion, so far as l)eingdue


to septicemia. It was in 93 cases an isolated lesion, unaccompanied by any other lesion like itself, having no fixed period of incubation, and running no common course. Its invasion is not as a rule marked by rigors or great rise of temperature. It may subside and swell up and subside again. These facts make it impossible to say that this form of parotitis is due to any ordinary form of septicaemia. It is not, he thinks, due to inflammation following a parched and sore mouth, as the mouths of pyaBmic or septicaemic patients are not, as a rule, more parched than those of other patients. Also, he does not think that it is merely due to inflammation of the lymphatic tissue which is in the gland substance. " Admitting that the general condition of the patient, especially in cases of septicemia and pyaemia, is considered in the production of this form of parotitis, must we not take into consideration the reflex action of the nervous system, as the influence, direct and reflex, of the nervous system upon the salivary glands is shown in countless ways; viz. gastritis may be followed by salivation or arrest of salivary secretion. Parotitis may follow gastric ulcer, gastrotomy, etc. Even operations on the rectum and again diseases of the thoracic viscera cause inequality of the pupils, differing not only in size, but in their susceptibility to light. Thus, with regard to pyjemia after abdominal or pelvic lesions, we may admit that the general condition of the patient may help to cause it, without denying the local influence of the nervous system."

A. J. Oribb (Lancet, 1886) reports two cases ; in one jiarotitis followed irritation of the genito-urinary tract, and in the other ovaritis occurred in connection with parotitis. And again, Harkin (Lancet, 1886) reports parotitis in a woman aged 43 as one of the first symptoms of three successive pregnancies, no suppuration being present. These cases seem to point undoubtedly to some latent sympathy between the parotid glands and the organs either covered by or closely adjacent to the peritoneum. It is, however, difficult for us, with our present bacteriological knowledge, to conceive of inflammation being established in organs far remote from the seat of irritation by reflex causes alone, without the presence of micro-organisms. An interesting case, and one bearing a close resemblance in some respects to those cited, is one reported by W. Legg in the Pathological Society Reports for 1869, in which parotitis was a complication in contracted kidney and atheroma in a lad aged 16, who was admitted to the University College Hosjiital for albuminuria. Nine days after admission he complained of pain on right side of face. The day after well-marked right parotitis was noted. The swelling continued for eight days, when the patient died suddenly. There was found to be no obstruction to Steno's duct; the gland tissue was pale grey in color, not at all reddened, rather harder than natural, and on section there flowed from the cut surface a large quantity of pale greyish white fluid, somewhat thin, showing under the microscope a large number of rounded cells, larger on the average than pus corpuscles, having rather granular contents, and single small bright nuclei. The gland was the seat of small abscesses varying in size from a pin head to a barley corn. Microscopically was seen a great increase in epitiielial elements, the acini being iilled with them. The arteries wore atheromatous


October, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


207


and the kidneys contracted. No mention is made of lesions in other organs.

W. B. Morrow, in the Montreal Medical Journal of March, '96, has related the histories of three cases of parotitis fol]pwing pelvic disease. And Herbert and Hawkins, in the British


Medical Journal of April 10, 1897, report two cases of operation for jjerforation of gastric ulcer, in one of which there was a double parotitis three days after operation, the patient eventually making a complete recovery, the glands subsiding without incision being necessary.


PALPATION OF THE FCETAL HEART IMPULSE IN PREGNANCY.

By Douglas F. Duval, M. D., Assistant Resident Ognecologist.


It is not generally known that the impulse of the fcetal heart may under certain conditions be actually felt beating through the abdominal walls of the pregnant woman.

In this country but two cases have been observed, those of Dr. Kelly, which I now report. The first was in 1884 and the second in 1895. They represented the right bregmatic-iliacanterior and left occipito-iliac-posterior presentations, the latter being observed in the eighth month of pregnancy, all previous cases having been during labor.

Of the other observers, Fischel, in 1881, was the first to publish a definite account describing accurately three cases in which this phenomenon occurred. These cases represented the left bregmatic-iliac-anterior, the right occipito-iliac-posterior and the left mento-iliac-auterior presentations. Valenta, however, in 1885, claimed priority of observation, stating that he had noted it in 1860 in a first face presentation, and had recorded it in his "Text-Book on Midwifery," and that since then he had repeatedly spoken of its importance as a diagnostic sign in anterior face presentations. Fleischman in 1885, stimulated by Fischel's communications, published an interesting case in which this phenomenon was observed in a right men to-iliac-anterior presentation.

The following is a brief account of the various cases :

Case I. Observed by Dr. Kelly, in Kensington, Philadelphia, in 1884. Multipara, of medium build, mother of four or five children, abdominal walls moderately thin. A right bregmatic-iliac-anterior presentation. Membranes ruptured, OS half dilated, brow just engaging. The impulse of the foetal heart was forcible and distinctly palpated over an area about 3 cm in diameter ; to the right and about half way between the umbilicus and Poupart's ligament, separate beats were easily counted, 130. The child was born living after a protracted labor and manual rectification of position.

Case II. Observed by Dr. Kelly. Patient short brunette, well nourished, abdominal walls not thin, eighth month of her first pregnancy. A left occipito-iliac-posterior presentation. Heart sounds heard loud over an area 10x10 cm., and easily counted 140. On moderate pressure a rapid fluttering sensation was clearly distinguished over an area about 2.5 cm. in diameter. The separate beats could not be distinguished; a few days later, on examination, the heart impulse could not be felt. The patient has since passed through a normal confinement.

Fischel's Cases.

Case I. Mi. 36, 1 para, well nourished, strong. Pains began on 30th at 1) p. m. Li(juor auinii discharged on 31st at


13.15 a. m. At 7.45 a. m. os 6 cm. in diameter. Foetus in left bregmatic-iliac-anterior presentation. Heart sounds to the left and below umbilicus. At 13.15 fcetal heart impulse palpated to left and beside umbilicus, synchronous with foetal heart sounds, frequency 156-160. This phenomenon was observed for several hours. Change of presentation being impossible, craniotomy was performed.

Case II. Mt. 31. Well built, large, strong. Pains began at midnight. At 3 a. m. liquor amnii discharged. Entered hospital at 4 a. m. Cervix obliterated, back to the right, feet to the left above the umbilicus, chin 8 cm. above left os pubis, heart sounds above the symphysis. From this description very probably a right occipito-iliac-posterior presentation. The fcetal heart impulse was palpated just above the chin, easily demonstrable, frequency 156, maternal pulse 113. In the further course of labor, which was rapid and favorable, the impulse was palpated in the pauses between the pains, descending toward the symphysis and finally disappearing entirely, though the sounds continued to be heard. Examination of the child's heart after labor showed clearly that the sounds were of normal strength and clearness.

Case III. Mi. 30. 1 para, small, strongly built, moderately fat, abdominal walls thin. Pains began at 10 a. m. Entered hospital in the afternoon. External examination : Occiput above right os pubis, extremities to the left, heart sounds to the left of the umbilicus, loud and slow.' The presentation in this case was then a left meuto-iliac anterior. At 6.30 p. m. the heart impulse was clearly palpated 5 cm. to left of umbilicus. At 7.30 p. m. was 5 cm. to left of umbilicus, but lower. At 8 p. m. frequency ranged between 80 and 150 ; maternal pulse 66-73. At 11.30 p. m. heart impulse to left of umbilicus, but lower. Labor terminated at 13 m., fcetal heart sounds ceased two minutes before delivery, child stillborn.

Fleischman's Case.

Case I. Mt. 35. Abdominal walls thin and flabby. Entered hospital at 11 p. m., three hours after discharge of liquor amnii. Occiput over left os pubis, back to the left, heart sounds clearest four fingers' breadth to right of midline, chin to right and forward, forehead to left and backward. Evidently a right mento-iliac-anterior presentation. On the following morning the foetal heart impulse was palpated in the right hypogastrium, at the junction of the middle and lower thirds of a line drawn between the umbilicus and middle of Poupart's liganit'nt. In frequency doubled that of the maternal. 'J"he sounds were loud and clear.


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Fleischmau says: "The conditious iu this case for the observation of the pheuomenon were most favorable, the abdominal walls were thin and flabby and the liquor amnii had previously discharged, thus permitting the uterine walls to clasp firmly the foetal thorax."

The following is a summary of all the cases :

Fischel, 1881, three cases: Left bregmatic-iliac-auterior, right occipito-iliac-posterior, left meuto-iliac-anterior.

Valenta, 1885, one case: First face presentation (K. m. i. ant.)

Fleischman, 1885, one case: Right meuto-iliac-anterior.

Kelly, two cases : First iu 1884, a right bregmatic iliacanterior presentation; second iu 1895, left occipito-iliac-posterior presentation.

From the above it will be seen that the observation has been made in face, brow and occipito-posterior presentations — two of each. One may therefore infer that these are the most favorable presentations for the observation of this phenome


non ; especially is this the case in face and brow presentations, the fcetal thorax being arched forward and therefore in closer proximity to the maternal abdominal walls. In occipito-posterior jjresentations the festal curve is directed backward and consequently less favorable.

The liquor amnii also plays an important part, as shown by the fact that in all cases, with the exception of the second case of Dr. Kelly, the observation was made during labor. In this case one must naturally suppose that a small amount of liquor amuii was present. As for the maternal abdominal walls, they should be thin and flabby in order that there may be little hindrance to the transmission of the im^iulse of the foetal heart.

References.

American Text-Book of Obstetrics, Hirst, 1888. Fischel, Prager medicinische Wochenschrift, Nos. 13, 13, 39, 30, 1881.

Fleischman, ibid.. No. 35, 1885. Valenta, ibid., No. 45, 1885.


SQUAMOUS EPITHELIOMA IN A DERMOID OF THE JAW.

By S. M. Cone, M. D., Assistant in Surgical Pathology, Tlie Johns Hopkins University.


Few cases of epithelioma arising in dermoid cysts have been described. Taufier, whose article on carcinoma arising in dermoids of the ovary is very complete, knows of none originating in dermoids elsewhere. In none of the dissertations on dermoids of the ovary with carcinoma in their walls do we find reference to like tumors in other regions of the body. I can find but three cases and they are not very fully described. That of Franke, on an epidermoid of the ball of the thumb with carcinoma originating in it, is most complete. Czerny in 1869 reported a case in the coccygeal region, the first to be noted anywhere, which is interesting moreover because of the expression of the opinion that the squamous epithelium developed from cylindrical epithelium snch as is found in the intestinal tract, and the idea is expressed of the possibility of epithelium arising from connective tissue and lymph cells. Briddon reported a case before the New York Surgical Society and Dr. Thacher made the pathological report. This tumor was also from the coccygeal region. The sections which were kindly given me have some resemblance to the one I shall describe. The descriptions of those found in the ovaries are so much better described that it is best to reach our conclusions regarding origin and development through the gynecological literature.

Yamagiwa and Thumim have both reported cases this year. Thumim gives the literature on the subject up to date. Yamagiwa reports two cases, one of which he puts down as a glandular carcinoma developing from remains of a mammary gland in the dermoid. Thumim objects to including this among the dermoids with "carcinomatous degeneration" and rather thinks it to be part of a misplaced mammary gland forming a part of a teratoma of the ovary. ' If it is a true carcinoma it is the only one of its kind described ; the remain


ing eight cases arising in the ovary ;ind three elsewhere are all of the squamous cell variety.

All authors are careful to exclude the possibility of the growth of the epithelioma "per contiguitatem," both Tauffer and Thumim giving a list of doubtful cases. The analogous origin of carcinoma iu atheromas and other cysts lined by epithelium is mentioned by Lubarsch in his review of the subject, and many others refer to the subject as something not long discovered. A very interesting point is alluded to by Yamagiwa when in writing of his first case he refers to its resemblance to alveolar sarcoma or endothelioma. Such cases have been reported, but are rare.

The case to be reported is that of Patrick D., age i'i, blacksmith, who entered the surgical ward of the Johns Hopkins Hospital, June 30, 1894, with a tumor of the left lower jaw. Family history good ; past history good.

Present Illness. — In September, 1893, the patient noticed a pea-sized growth under the horizontal ramus of his left lower jaw. It began to pain him in November and grew rapidly with incessant pain. He refers its quickened growth to a fall when he injured the jaw.

Physical Examination. — The tumor extends from 1 cm. in front of the angle to the junction of the middle and outer third of the horizontal ramus of the lower jaw. It extends to the hyoid bone and appears to be the size of a small orange. It is fixed firmly, is sharply circumscribed and has smooth, rounded borders. It is firm in consistency except at the most prominent portion, where slight fluctuation can be felt. The skin is cedematous and red. At one point there is a small opening from which serum exudes on pressure. Teeth are normal. Alveolar process is not involved.

On June 35th the patient was operated on by Dr. Halsted.


OCTOBEE, 1897.J


JOHNS HOPKINS HOSPITAL BULLETIN.


209


Tracheotomy was first performed, aud the pharynx being tamponed the tumor and left lower jaw were excised. The patient's recovery from the operation was uuinterrnptedly good. He was discharged on July 13th. He returned September 6, 1894, aud was treated for phthisis pulmonalis — tubercle bacilli beiug found in his sputum. He was discharged on September 14th unimproved and died at home of phthisis pulmoualis. No autopsy was performed.

Descrip/ioH of the tumor by Dr. Bloodf/ood. — The tumor is removed with an area of skin 8x6 cm. and a piece of the lower jaw 7 cm. long, including the angle of the jaw. This mass is surrounded by skin, periosteum and healthy muscle at every point except one, which is at the inner side of the jaw 3i cm. from the angle where the tumor tissue is exposed. A second piece of the jaw including the two molar teeth and alveolar processes includes the remainder of the tumor, which is well circumscribed by muscle and mucous membrane; so that, putting the two pieces together, the entire mass is circumscribed. The point at which it is most superficial is beneath the myo-hyo-glossus muscle at its attachment to the alveolar process of bone which was removed.

The tumor has not invaded mucous membrane nor bone. On section from the skin to bone it consists of an encapsulated mass, the capsule beiug firmly adhereut to periosteum on one hand and skin on the other. There are several points on the skin communicating with the cyst contents and through which the contents can be expressed. The capsule is 4-5 mm. in thickness. The inner surface is rough and granular. The fatty granular contents are easily removed; they resemble those of a dermoid cyst except at the outer third of the tumor near the symphysis of the jaw. Here the contents are firm in consistency, greyish iu color, with pin-point dots of hemorrhage. In this tissue masses of the same consistency as that of the cyst can be found. The tumor presents the characteristics of a dermoid cyst.

On section of the mass within the jaw the submaxillary gland is found to be adhereut to the capsule of the cyst. The contents of the cyst show fatty squamous epithelium and crystals of cholesterin.

Microscopical Examination. — Sections of the cyst wall with adjacent structures were made at many points. The cyst varies in thickness. The inner lining is of horny epithelium which is more or less loose and swollen and mixed with the cyst contents. The same cornified epithelium is found in whorls on the surface mixed with the cyst contents. These cells look like long flakes, some containing nuclei, others being free of them, which stain deeply with eosin aud carbol fuchsin. Beneath this loosely arranged epithelium we see a denser layer aud then the gradation of epithelium as in normal skin, only not so thick.

The stratum grauulosum is much better marked in some places than in others. The stratum mucosum comprises the main mass of epidermis; the deeper cells of the malpighian layer are not pigmented. The cells appear swollen and oedematous. Some of the nuclei are vacuolated and irregular while others are fragmented. In the epidermis are a few irregular areas, about the size of the cells, which are granular and take the hcematoxylon stain deeply — evidence of calca


reous degeneration in the cyst wall. The cell borders are not nearly so well defined as iu normal epidermis. The papillai are fairly well marked, but there is an entire absence of sweat glands and hairs. A few sebaceoiis glands are to be seen iu the corium, which is not well marked because of the invasion of its territory by profuse round cell infiltration about epithelial projections.

These epithelial downgrowths between the papillary stroma into the deepest parts of the cyst wall are made up of masses of cells such as are found in the stratum mucosum and enclose cells of the more superficial layers of epidermis. These cells of the outer epidermal layers are sometimes formed into whorls iu the deepest ingrowths of the squamous epithelium, aud form the " pearly bodies."

The epithelium of these downshoots has better staining nuclei than that on the surface. These inter-papillary growths seem to be kept in definite paths for the most part, but when the deepest portion of the cyst wall is reached one can see epithelial cells spread throughout the tissue, some being isolated without any demonstrable relation to the primary downgrowth. This sprouting of epithelium deeply and irregularly into the wall of the dermoid is seen throughout the entire tumor wall, but does not go any further, for it is always preceded by a zone of round cell infiltration made up of mononuclear cells. This zone is preceded by one of connective tissue of varying thickness which invariably intervenes between the epithelial cells and adjacent tissues and organs. There are papillary projections into the cyst of various lengths from 1 mm. to 2 cm. which all show a lining of epithelium already described, and have a supporting conuective tissue basis. Between the stratum corneumand malpighian layer are to be seen hemorrhagic foci in some sections.

The round cell infitration is intensely marked throughout the cyst wall. The papillary stroma aud deep layers of the dermoid are full of mononuclear leucocytes which are aggregated in some places, resembling lymphoid nodules. These cells have also penetrated between the epithelial cells of the surface and ingrowths. The centres of the "pearly bodies" contain both mono- and polyuuclear leucocytes and fragments of nuclei. There are typical tubercles in several sections which are most distinct in the sections containing muscle, including the sinuses alluded to above. No tubercle bacilli can be found iu them, however.

The lining wall of the dermoid shows evidence of degeneration in areas; the epithelium is invaded by mono- and polymorpho-nuclear leucocytes. The nuclei stain poorly and are fragmented. The cells appear separated from one another and are swollen.

Sections including skin and dermoid wall made at different points have essentially the same appearance. The points iu which the histology differs from the foregoing description are the giant cell formation between subcutaneous tissue and the fibrous limiting line of the dermoid and the openings in the skin alluded to in the macroscopic description. The giant cells are like the customary foreign body giant cells and are seen singly aud in groups at the margin of the dermoid wall. They are especially numerous on the dermoid side of the dividing fibrous tissue. Where these are in


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[No. 79.


greatest number and collected in groups the fibrous separating line has been almost completely substituted by them and the accompanying mono- and polynuclear leucocytes. Here the definition between dermoid and skin is not so good as elsewhere.

The giant cells in the subcutaneous tissue are grouped about hair shafts ; in the dermoid walls they enclose horny particles (stained deeply with carbol fuchsin), polynuclear leucocytes, fragmented nuclei and granules (stained deeply with hffimatoxylon and probably calcareous). Some have no contents and are vacuolated. Most of them contain large vesicular nuclei, grouped in the centre of the cell ; in some the nuclei have a polar arrangement.

Beneath the epidermis of the skin there are masses of red blood corpuscles, polynuclear leucocytes and fragmented nuclei. Here no papillary arrangement of the skin exists and the epidermis is flattened and thinned. The epidermis, too, is infiltrated with leucocytes. Adjoining this area of hemorrhage and necrosis a discontinuity in the epithelial covering is detected. The edges of epidermis are turned in and are continuous with a sinus which can be traced deep into the subcutaneous tissue, but not so far as the fibrous demarcation between skin and dermoid. This sinus is lined by necrotic tissue containing blood and fragmented nuclei. In its depths the connective tissue of the part is denser, but there is no evidence of new formation of tissue. There is no epithelial lining. Vessels included between the dermoid walls and subcutaneous tissue are obliterated by endarteritis. Their walls are all thickened.

In one of the sections there is a variation from the usual structure of the dermoid wall. Instead of the interpapillary growths of epithelium dipping down at once into the depths of the wall, we see a network of epithelial rods one and two cells thick surrounded by small round cells. The epithelial lining is very thin at this point, being composed only of cornified epithelium. Beneath this interlacing network of cells we see the larger groups containing pearly bodies described in the other sections.

The submaxillary gland is included in several sections of the tumor and in none does the epithelioma invade the gland. The capsule of the submaxillary is greatly thickened and only at one point is there any suspicion of invasion. Here the round cell infiltration is most marked, the connective tissue formation not being evident. Into the round cells can be seen jutting epithelial sprouts, but they do not enter the interlobular connective tissue of the submaxillary. The changes in the


submaxillary are due to pressure and infiltration of its connective tissue framework with small round cells. The connective tissue is thickened and some of the cells in the alveoli do not take the stain well. The cyst-wall next the submaxillary varies from 1 to 3 mm. in thickness and consists of epithelial masses and single cells included in the stroma, which is deeply infiltrated with small ronnd cells. The epithelial cells are of the same kind as in the stratum mucosum, but Ijetter defined and with more regular nuclei.

The muscle next the tumor is densely infiltrated with small round cells and is atrophied. The nuclei of the muscle cells next to the dermoid wall are greatly increased in number and arranged in rows. The muscle substance stains but faintly and there is no striation in the first rows next to the fibrous line between tumor and muscle. It appears like a homogeneous mass containing rows and bunches of nuclei. There are no giant cells nor necrotic areas to be seen. A nerve is included in the section with muscle. It is surrounded by dense fibrous tissue. The epithelial cells crowd close up upon the epineurium, but do not penetrate it. The round cell infiltration and new formation of connective tissue are very prolific about the nerve.

The presence of tubercles in the cyst walls, the great and uniform round cell infiltration, the profusion of giant cells of both the foreign body and tuberculosis variety, and the uniform distribution of the epithelioma in the wall of the dermoid, are all striking points.

References.

TaufEer: Virch. Arch., No. 143. Ueber die primilr carcinomatose Degeneration von Dermoidcysteu.

Frauke : Virch. Arch., No. 131, p. 444. Carcinomatus entartetes Epidermoid des Daumenballes.

Briddon : Annals of Surgery, Aug., 1894. Not a complete description.

Y. Czerny: Arch. f. klin. Chir., No. 10, 1869, p. 894. Entwickelung einesEpithelialcarcinoma aus eiuer angeboreuen Sacralgeschwulst.

Yamagiwa: Virch. Ai-ch., No. 147, Heft i. Zwei Piille von Dermoidcysten des Ovariums mit carcinomatosen Degeneration und Metastasenbildung.

Thumim: Arch. f. Gynek., liii. Ueber carcinomatose Degeneration der Eierstocksdermoide.

Lubarsch: Ergeb. der allg. Path. Morph. und Phys., Vol. II, 1894.


THE INFECTIOUSNESS OF CHRONIC URETHRITIS.


By E. R. Owings, M. D., Assisianf in Genito- Urinary Surgery, The Johns Hopkins Hospital Dispensary.


The possibility of infection from old cases of gonorrhoea is an important and by no means infrequent problem, presenting itself not only to the gynecologist and genito-urinary specialist, but also to the general practitioner.

Many cases of gonorrhoea extend over mouths or even years, often in spite of persistent and systematic treatment, and in


response to the inquiries, " Could I infect another?" or " Is my condition such that I may safely marry ? " the physician must often give evasive or unsatisfactory replies.

There is no fact better established than that a gonorrheal urethritis is due to the entrance and development within the urethra of a specific organism, the gonococcus Neisser,


October, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


211


which is constantly present in the discharge of an acute gonorrhoea.

The gouococcus, first described by Neisser' in 1879, has been isolated; a pure culture made first by Bumm,^ since by Wertheim,* Steinschueider and other observers ; and a gonorrhoeal urethritis produced by the introduction of pure culture within healthy urethra proving conclusively its etiological relation.

The infectiousness (i. e. jrower to produce gonorrhcea) therefore of an urethral inflaniuiation depends upon the presence of the gonococcus; and upon the demonstration of the presence of this organism rests the determination of the infectiousness of an urethral inflammation.

The gonococcus is a diplococcus, J to 1 micromillimeter in diameter, not round, but of biscuit or coffee-bean shajie, with flattened or concave surfaces contiguous, found within the leucocyte, around, never within the nuclei, and as determined by Roux,' if a preparation containing gonococci after being stained with aniline stain, be placed in Gram's solution, then decolorized by alcohol, the stain is not fixed by Gram's method, and the gonococci may be differentiated from other organisms found within the urethra, in that they are alone decolorized.

In 1887, Lustgarten and Mannaberg" in a series of investigations on the healthy urethra found among other organisms a coccus which they declare cannot be distinguished from the gonococcus Neisser by its morphology or staining reaction.

Petit and Wasserman,' on the contrary, in a large number of examinations (over 1000) of the normal urethra, have never found the organism described by Lustgarten, and in a number of cases of chronic urethritis were unable to demonstrate its presence.

Steinschueider" recognized beside the gonococcus four diplococci in the urethra, two of which were decolorized by Gram's method as follows :

No.

Urethra healthy, never infected by

gonococcus, 13

Urethra healthy, no gonorrhoea for

years. Chronic gonorrhoea,

Acute " (uuti-eated),

" " (under treatment), 22


3





15


2


11


33


1


33


22



32


86


66


In 86 cases there was present in four a diplococcus decolorized by Gram's method, or about 4J per cent., making Roux's test certain in about 95 J per cent, of all cases. He believes, however, that Roux's test, together with the characteristic grouping of the gonococcus within the pus cell around the nuclei, gives a definite result.

M. von Zeissl" has in the secretion of an urethritis due to chemical or medicinal irritants, found a diplococcus within the pus cell, which is decolorized by Gram's method ; whether this is readily differentiated by grouping from the gonococcus he does not state.

Wendt" believes " Roux's color test never fails to gives correct interpretation."


Allen," who worked conjointly with Wendt, believes "Roux's test final."

Carpenter'" says : " Peculiar characteristics of the gonococcus almost positively diagnostic when confirmed by Roux's test practically leaves no room for doubt."

Heiman '" says : " Diplococci found in normal urethra can be positively differentiated by Gram's stain."

Koplik-' says: "In skilled and tutored hands a mistake of identity is not possible."

Finger" says : " There is no doubt that in addition to gonococci other organisms are present in blenorrhagic pus, but these never give rise to the slightest diagnostic doubt. The number of foreign organisms is so slight, and they are found to such a large exteut outside the pus cells, their shape and grouping are so different, that the differences in staining are unnecessary to make a positive differential diagnosis."

Lustgarten", 1893, says: "If in a chronic torpid urethritis with a scanty whitish or greyish discharge, diplococci with all the characteristics of the gonococcus are found ; it does not prove that the affection is contagious, especially if these diplococci are found in comparatively small number and are accompanied by a variety of organisms. As far as personal experience goes I believe that many of these cases are not contagious and that the wives of such men remain healthy and prolific."

In the absence of confirmatory proof by cultivation, which is not always practicable owing to the difficulty attending the growth of the gonococcus, ordinary media being unsuitable for its growth, and as in chronic urethritis where its demonstration is especially desirable the jiresence of other organisms by their rapid growth makes it impossible to secure discrete colonies of the organism, we are compelled in these cases to rely solely upon its morphology and Roux's test for identification. By these methods the gonococcus may be differentiated from micro-organisms found within the urethra, with the possible excejition of the diplococcus described by Lustgarten, which at most is present in but a small per cent, of cases. The presence, in the secretion of an urethral inflammation, of a diplococcus with the characteristics and color reaction of the gonococcus is sufficient clinical though not medico-legal evidence of the infectiousness of same.

The examinations recorded in the paper were confined to chronic cases entirely. In many there was no discharge visible at the meatus, and in no case was there more than the "goutte militaire." Their duration varied from three months to four years. The majority were under active treatment at the Johns Hopkins Hospital Dispensary, and so far as was possible examinations were made on date of first visit and subsequently at short intervals. Unfortunately, as in all dispensaries, many failed to return after one or two visits, making it impossible in these instances to secure repeated examinations. The examinations recorded are of the tripperfilden, as in many of the cases this was the only material available.

The method pursued was as follows : The urine, and where possible the morning urine, was secured, one or two trijjperfilden were drawn uj) with a pipette and after being gently teazed-out on a slide, were dried over a flame and then washed carefully in warm water to dissolve out as far as possible salts of urine which were precipitated by evaporation. Specimens thus obtained were stained two minutes in aniline gentian violet solution, prepared by adding 1 cc. filtered concentrated solution to 15 cc. water.

In decolorizing the slides were placed in Gram's solution for 2 minutes, then in alcohol until no more blue color was extracted, generally from two to three minutes. A watery solution of Bismarck brown was used as counter stain.

In 15 instances no micro-organisms were found; in these cases the fiiden consisted almost entirely of epithelial cells with here and there a few leucocytes.

In the 35 remaining micro-organisms were fou nd ; these were identical with varieties already described by Lustgarten and other observers, and consisted of 4 varieties of cocci and !<! bacilli, as follows :

I. Small coccus in zoogleae.

II. Small coccus in chains.

III. Diplococcus about size of gonococcus.

IV. Large coccus, li to 3 mm. in diameter, generally in pairs.

V. Long slender bacillus (smegma bacillus?).

VI. Short thick bacillus with rounded ends (suggestive of colon bacillus).

These were not all present in every specimen examined, nor did they occur in equal frequency. I, small coccus in zoogleffi, and IV, large coccus, IJ to 2 mm. in diameter, were almost constantly present, while the smegma bacillus ? was noted in comparatively few instances, and VI, bacillus, short, with rounded ends, in one case only.

In five specimens examined, in addition to one or more of the varieties already described, diplococci were seen lying within leucocyte, morphologically identical with the gonococcus and decolorized by Gram's method.

These were the only organisms seen within the leucocytes. Others were either free in the intercellular space, lying on epithelial cells or on, not within, leucocytes, as could be determined by careful focusing.

In 5 cases then we have an organism which could be positively identified as the gonococcus Neisser.

Three of these 5 cases were of from 4 to 6 months' duration, 1 was of 9 months' and 1 of 2 years' duration, or, tabulating cases as regards age of disease —


13


6 50


Duration. Gonococei.

Under 6 months. 3

6 to 9 " 1

1 year.

2 " 1

3 ■' over 3 years


other

mlcro org:anisms.


35


Negative

as to organisms.

4 3 2 3 2 1

15


Out of 38 cases of more than 6 months' duration, in 2 instances only were gonococei demonstrated, and in 30 of more than a year's duration, in one case only could they be fou-nd.


Goll" in 1891 made repeated examinations of cases of chronic urethritis with the following results :


Durati(jn.

6 months

1 year

2 "

3 "

Over 3 years


No. of cases.

55 83 135 80 59

412


Gonococei.


12

7


29


cocci. Percent.

47 14

71 14

128 5

78 25

59

383


Petit and Wasserman' in their examination of chronic urethritis found various organisms, and believe them to be accidental or saprophytic, and that they vary with the individual.

Janet'-' has studied cases of chronic urethritis with respect to various organisms present, and divides them into three classes :

I. Gonococei present alone.

II. Gonococei and other micro-organisms.

III. No gonococei, but varied micro-organisms.

He believes that these organisms invade the urethra, probably in coitus, and the catarrhal mucous membrane presenting a favorable medium, they are able to keep up the inflammatory process after the disappearance of the gonococcus, producing an obstinate pseudo-gonorrhoea.

Hasse," 1893, "in 625 cases of chronic urethritis found gonococei unattended by other organisms in 37 cases. In acute gonorrhoea he found gonococei alone and their presence constant; with their disappearance and an increase in the epithelial cells in the discharge, other bacteria, both bacilli and cocci, appeared in large numbers."

In the small percentage of cases where the gonococcus is definitely determined to be present, we can without hesitation declare their infectiousness. Unfortunately, however, in the large majority we are unable to say with certainty that we have to do with a non-infectious malady, that is. in those where the gonococei are uniformly absent or present in so few numbers as to elude detection. For while the detection of the gonococcus renders infectiousness certain, a failure to detect it does not guarantee its absence, as often after many negative examinations the gonococei may suddenly appear in considerable numbers.

In one of the above recorded cases, that of 2 years' duration, the examination of which extended over several months, after 3 or 4 negative examinations, following an injection of 3 to 5 per cent, of AgNOs, with Tommasoli syringe, the gonococei could readily be detected.

In these cases then where there is still doubt, the test first proposed and still insisted upon by Neisser" is an invaluable adjunct, viz. the injection within the urethra of a solution of argent, nitrat. or hydrarg. chlor. corrosive, sufficiently strong to produce an inflammation with free purulent discharge, when, if the gonococei have been present but have escaped detection, they will be found in the discharge in sufficient number to make1,heir identification positive, and at the same time with the desquamation of the epithelium the accidental micro-organisms are removed to a large extent.


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Finger" "only permits marital intercourse after frequent examinations of the secretion or tripperfiklen show an absence of pus cells; and the discharge following the application of Neisser's test contains no gonococci."

Morel Lavallee'" says:

I. " The gonococcus may rest latent for months or even years in the urethra.

II. It is impossible to permit marriage in a man that has the slightest discharge until by Neisser's test it has been proved free of organisms."

It is reasonably certain that the gonococci suffer enfeeblement during their stay in the urethra. This attenuation is due probably to alteration of medium, viz. the urethral mucous membrane, consequent upon growth of organism. In this way we can readily account for their presence without resultant inflammatory reaction. A localized chronic urethritis does not, however, confer any immunity from fresh infection. Finger" has produced in four instances an acute gonorrhoea on patients with chronic urethritis by inoculation with pure culture of gonococcus.

He believes that the gonococcus is attenuated by long residence in the urethra, and that women infected by their husbands who suffer from chronic gonorrhoea have a urethritis which runs a chronic course.

Jamain'" believes " that the gonococcus becomes attenuated, but that in contact with a healthy mucous membrane in another individual it is rejuvenated and produces an acute gonorrhoea."

The secretion in cases of chronic urethritis being small as compared to an acute one, so small in many cases that it appears in the urine only as tripperfiklen, it follows that after being washed off by the urine, it requires some time for regeneration. (Hence arises the importance of examining the first urine passed after an interval of several hours, 23referably the morning urine, for if the patient has urinated within an hour or two the urine may be free from shreds.) So that a single act of coitus with an individual suffering from chronic urethritis and with a secretion bearing gonococci does not always produce infection.

Since we can only demonstrate the presence of the gonococcus in a small percentage of cases of chronic urethritis (in 37 of 625 reported by Hasse, or 6 per cent.; in 21 of 357 reported by Goll, of a duration of a year or more, or 6 per cent.; in 2 of 38, of same duration, reported in this paper, or 5J per cent.), and since when present they are, as compared to an acute gonorrhoea, few in number, often only demonstrated after frequent, careful and repeated examination, and since they are from attenuation probably less virulent, we must conclude that:

I. In many cases of chronic urethritis we are unable to demonstrate the presence of the gonococcus ; these cases are probably non-infectious.

II. In any case the possibility of infection as compared to an acute urethritis is small.

III. An urethritis due to an attenuated organism, and consequently modified in intensity, may be contracted from a chronic urethritis. Conversely:


IV. Several negative examinations of the secretion from a chronic urethritis do not prove its non-infectiousness.

V. The infectiousness or non-infectiousness of a chronic urethritis can only be determined by frequent and careful examinatious of the secretion, and if these prove negative, by the non-appearance of the gonococcus after the application of Neisser's test.

Bibliography.

1. Neisser: Oentralblatt f. d. med. Wissenschaft, 1879.

2. Bumm : Gonococcus Neisser. Wiesbaden, 1887.

3. Wertheim: Archiv. f. Gynakol., 1892.

■1. Steinschneider : Berlin klin. Wochensch., 1893.

5. Koux : Archives gen. de Medecine, 1886.

6. Lustgarteu and Mannaberg: Vierteljahresschrift f. Derm, und Syph., 1887.

7. Petit and Wasserman : Annales des maladies des (frg. genito-urin., June, 1891.

8. Steinschneider: Berlin klin. Wochensch., June, 1890.

9. Wendt: Medical News, Phil., 1887.

10. Carpenter: University Med. Magazine, Dec, 1892.

11. Finger: Blenorrhoea v. d. Sex. Organ. Leipzig and Wien, 1893.

12. Lustgarten : Etiology of Gonorrhoea. (Morrow's System, Cutaneous and Genito-Urinary Diseases )

13. Goll: Internat. Centralblatt fiir die Phys. u. Path, der Ham i;nd Sex. Organe, 1891.

14. Hasse: Inaug. Dissertation, Strassburg, 1893.

15. Morel Laval lee : Annales des mal. des org. genito-urin , Dec, 1893.

16. Jamain : Annales des mal. des org. genito-urin., Nov., 1894.

17. Allen : Journal of Cutaneous and Genito-Urinary Dis., 1887.

18. M. vonZeissl: Die acuten Krankheiten der miinnlichen Hai-nrohre. Leipzig, 1894.

19. Neisser: Deut. Med. Wocheuschrift, 1893.

30. Heiman : ]\Iedical Kecord, June, 1895; Archiv fiir Dermatologie uiid Syphilis, 1896, Vol. 34.

21. Koplik : Journal of Cutaneous and Genito Urinary Dis., 1893.

22. Annales des mal. des org. genito-urin. Aout-Juin, 1892.

THE JOHNS HOPKINS HOSPITAL BULLETIN,

Volume VIII.

The Bulletin of the Johns Hopklus Hospital entered upon Its eighth volume January 1, 1897. It contains original communlcatJous relating to medical, surgical and gynecological topics, reports of dispensary practice, reports from the pathological, anatomical, physlologlco-chemicai, pharmacological and clinical laboratories, abstracts of papers read before, and of discussions in the various societies connected with the Hospital, reports of lectures and other matters of general Interest In the work of the Johns Hopkins Hospital and the Johns Hopkins Medical School.

The subscription price Is $1.00 per year. Volume VII, bound la cloth $1.50.


THE MALARIAL FEVERS OF BALTIMORE.

An Analysis of 6l6 cases of Malarial Fever, with Special Reference to the

Relations existing between different Types of Haematozoa

and different Types of Fever.

By William Sidney Thayee, M. D., and John Hewetson, M. D.,

A8»l8ta7its iti the Medical Clinic of The Johns Hopkins Eospital. SIR p.-i^es, (|iiHr«a. wild plate and charts, rrlre $3.' O. Pnslngr paid.

[KoriniriK- part of The Johns Hopltinx Hnxpital Hcparts, Vol, V, 18U.5.] Orders should Ije addressed to TiiK Johns Hopkins Press, Ualtimore, Md.


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[\o. 79.


THE IMPORTANCE OF EMPLOYING PURE SALTS IN THE PREPARATION OF THE SCHOTT BATH.

The reason the carbonic acid is given off when bicarbonate of soda and hydrochloric acid are combined is because the hydrochloric acid has a greater affinity for the sodium than has the carbonic acid; the latter is, therefore, displaced, appearing as carbonic acid gas and the salt sodium chloride resulting.

The following would be the formula for this reaction:


Editor of Johns Hopkins Hospital Bulletin.

Dear Sir: I am lately in receipt of the following letter from a physician in the West. I submit to you the letter and my reply in full for publication, if you see fit, as I trust by so doing a similar mistake maybe averted.

I am very truly,

G. N. B. Camac. [communication.] Dr. C. N. B. Camac, Johns Hopkins Hospital, Baltimore, Md.

Dear Doctor: — The instructions contained in your article in the May issue of the Johns Hopkins Hospital Bulletin on the Schott treatment of heart disease have recently been followed by me in a case of hypertrophy with organic lesions.

We nearly had a disastrous result owing to an evident error in those instructions.

Bath V calls for sodium bicarb. 1 lb., HCl 1 lb. Bath VI increases the HCl to 3 lbs., but leaves the sodium bicarb, still at 1 lb., thereby producing an excess of 1 lb. of HCl which is not provided for.

I gave the journal to the hospital druggist with instructions to prepare each bath in order in accordance with the directions, paying no thought to chemical results. When bath VI was given the patient was attended by only one nurse, while usually two or three had been present. She noticed the chlorine gas rising from the tub, but supposed it was all right and put the patient in. He had no sooner stepped in than he was nearly suffocated and was quickly assisted out without harm.

The nurse seemed seriously prostrated for a time with a very severe bronchitis and laryngitis and the hospital attendants had a lively time to relieve her.

I relate these circumstances in order to call your attention to a mistake that must have been made in the article in question.

The patient has been rather worse during the course of baths, but that may be due to the progress of the disease, which is serious. As it takes more than one swallow to make a summer, I cannot pass an opinion on the method of treatment. Very truly yours,

Baltimore, Md., Sept. 4, 1897.

Dear Doctor: — I am indebted to you for your communication in reference to the Schott treatment.

We have had no experience similar to yours in using bath No. VI, which I may say is seldom called for. Chemically, the results which you had seem an impossibility, no matter how excessive the amount of hydrochloric acid may be. Suppose, for exampje, we take a formula expressing an excess of hydrochloric acid as follows :

NaHCO=-f5HCl=NaCl-fH«0 + CO;-t-4HCl.

The other two salts, sodium-chloride and calcium-chloride, are already in solution, and being bases in combination with the acid hydrochloric, remain chemically unchanged.


NaHOCOi + HCl = NaCl -I- IhO + C0=.

I can only account for your unhappy accident by supposing that one of two mistakes was made :

1st. Your druggist may have given you sulphuric or nitric acid instead of hydrochloric, both of which acids have a greater affinity for the bases sodium and calcium than has liydrochloric acid, and which would have combined with these to form sulphates or nitrates, free HCl being formed. (Formula see below. Experiment No. 3.)

2d. The calcium chloride (which is the more likely to have occurred) may have been adulterated with chloride of lime, or indeed chloride of lime may have been given to you instead of calcium chloride. This hypochlorite of calcium being the ordinary bleaching powder and much cheaper than the pure salt calcium chloride, forms a ready salt for adulteration, which in the presence of only a small amount of hydrochloric acid yields chlorine gas and would be, I can readily understand, not only dangerous to a heart case but even seriously injurious to a healthy individual. (Formula see below. Experiments 4 and 5.)

Actuated by your letter I made the following experiments:

1st. Bath No. 6 with the amounts of constituents as directed in my pamphlet from which you quote. Eesult: Abundance of carbonic acid gas. No unj)leasant effects.

2d. The same amount of constituents with excess of hydrochloric acid. Result: Same as experiment No. 1. (Nos. 1 and 2 performed in bath tub.)

3d. Small amount of sodium chloride, calcium chloride, and bicarbonate of soda and sulphuric acid (experiment performed in beaker glass). Kesult: Stifling odor;- no fumes visible. This "stifling" odor was probably due to the HCl forming.

4th. Salts, sodium chloride, calcium hypochlorite (bleaching powder), bicarbonate of soda, dilute hydrochloric acid. Result: Chlorine given off; suffocating; beaker had to be placed under the hood.

5th. Sodium chloride, calcium hypochlorite bicarb, soda and sulphuric acid. Result : More pronounced than in experiment No. IV.

Allow me to thauk you for your communication, which I consider of sufficient importance to publish in order that a like so serious mistake may not again be made. Very truly yours,

C. N. B. Camac.

Formula:

Experiment No. 1. Same as formula given at beginning of

letter.


OCTOBEK, 1807.]


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215


Experiment No. 3. (Same as foruuihi given at beginning of letter.

Experiment No. 3. 2NaCl + CaCL + 2NaH003 + 3H.S04 = 3Na.S0. + CaSO^ + 3H=0 + 2C0= + 4HC1.

Experiment No. 4. Ca(CIO). ■t-4HCl = CaCl. + 2HvO + 20L.


Experiment No. 5. L'u(,C10> + CaCh + 2ll.:SOi=3CaS04 + 31LO + 20k

Note. — I have not included iu these hist two formulfe — tlie NaCl, as it would have no effect upon the reaction — neither is the NallCOjincluded, as 00= would be evolved as already noted.


PROCEEDINGS OF SOCIETIES


TIIE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of Monday, May 17, 1897. Dr. Flexner in the Chair.

Denionstratioii of a Case. Probable Brain Tumor. — Dr.

Thomas.

The patient whom I wish to present to the Society will he brought from the ward in a few moments. She is a young, unmarried woman of twenty-six, with a good family history, except that one brother is believed to have tuberculosis. She has been a fairly strong girl, and has had no serious illness of any kind. Her occupation is that of a sewing woman, and she has been learning stenography and type-writing.

About a year ago she had an attack of unconsciousness ; this began with a painful contraction of the right hand, which lasted for a minute or two, and passed up the arm, when she became unconscious. She was found about half an hour afterwards by her brother, who shook lier and brought her to herself. After this attack she was comparatively well, and went to her employment the next day as usual. In August of last year she was under a great deal of nervous strain on account of the death of a relative. About this time she had several nervous attacks, which she calls " nervous chills," and which seem to have been hysterical. Ou November 8, 1896, while sitting with her arm resting ou the table, she became conscious of a sensation of numbness in the elbow of her right arm. This arm and the leg on the same side became suddenly powerless, and she has been told that her face was drawn to the left, but of this she was not conscious. With the onset of this paralysis she became absolutely unable to speak. She was put to bed, and showed so much nervousness that the attending physician, a very competent man, made the diagnosis of hysteria, and it was impressed upon her that she could, if she would, get up and walk and talk. The description which she gives of the loss of speech is remarkably distinct and clear. She says that she understood everything that was said to her, and remembers much of it. She knew every one who came into the room, but was absolutely unable to say a word. She thinks that she knew what she wanted to say, but had forgotten how to say it. She I tried to write with the left hand, but could not foi-m the letters and had forgotten how to spell the words. Upon making the attempt to read, after she had been sick about four days, she was unable to make anything of it, and three weeks afterwards she could not read the paper easily. After a week of complete speechlessness, during which every one arouud her had endeavored to make her talk, she was able to


repeat the first four words of a text of scripture which had been said to her over and over again. By being taught day by day, her speech gradually improved; the first words that she said voluntarily were "go out." These she said to her sister, who had been sitting with her constantly for a good many days. She knew all the time just what she wanted to say, but it was only after a good deal of silent practice, and several attempts, that she was able to utter the two words. Her speech improved slowly, but steadily, until she regained the speech which she now has, which shows no defect.

The first of last December she had another attack, and another on the twelfth of February, and still another on the 3Gth of April. These attacks have all been of the same character, beginning with a painful contraction of the fingers of the right hand ; this passes up the arm, and she describes an intense pain iu her liead. At this time she says that she loses all knowledge that the arm belongs to herself, although she still exjieriences pain in it. This is a remarkable statement. Iu these three attacks, consciousness seems not to have been lost.

As the patient enters the room, you will notice that she walks with a slight limp, and that the right hand is held iu the manner so characteristic of hemiplegia. I have been unable to find the slightest disturbance of her speech. She now speaks voluntarily, without difficulty, writes long and short hand, understands everything that is said to her, and reads with ease. The ophthalmoscopic examination showed that the fundus was normal, although there is a slight degree of hypersemia. She has a congenital squint and a slight nystagmus, but other than this, no abnormality of the cranial nerves. Her chief disability is in regard to her right arm, which, as you see, is very tremulous and nearly useless. She is unable to oppose the thumb to the little finger, and the movements of the finger are very weak. The movements at the wrist are better retained, and those at the elbow and shoulder better still. The movement of outward rotation of the arm is very weak indeed, whereas the inward rotation is comparatively strong. The deep reflexes are markedly exago-erated, percussion on any of the tendons causing active muscular contraction, and there is a well-marked wrist clonus. Objectively, there is not much muscular weakness of the right leg. Sensation is everywhere perfectly normal. , I have tested particularly for any abnormality of the muscular sense of the right arm, and found that she appreciates even very slight movements of any of the joints. There is no muscular atrophy. The examination of the chest shows no abnormality, and we have been unable to discover anything that indicates a preceding specific infection (syphilitic).


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[No. 79.


I have been much interested in this patient, and it is surely an unusual case. That a young woman of her age should have been affected with a hemiplegia associated with a temporary loss of speech, and followed by recurring attacks simulating closely Jacksouian epilepsy. Is very remarkable. The diagnosis of hysteria seems at first sight the most probable one. Organic vascular lesions are very fare at her age, except when they are associated with syphilis. In this case there is nothing in the previous history or in the present condition that suggests such a cause. The patient was at the onset undoubtedly very hysterical, and you will remember that she gave the history of preceding hysterical attacks, all of which speak for the diagnosis of hysteria ; but the condition in which you have seen the patient suggests an organic paralysis more than an hysterical one. Maun and other observers have studied the distribution of the paralysis due to organic brain disease, and have determined that there are certain movements which are most apt to be paralysed. The movements which are most often jjaralysed are those of the thumb, and next in order of importance is the outward rotation of the arm. In the case before you, these are just the muscles which are paralysed. The excessive increase of the deep reflexes, which is ijresent in this case, is also unusual in association with hysterical paralysis, so I think we are justified in stating that the character of the pai'alysis is that due to an organic brain lesiou, rather than to hysteria. The character of the convulsive attacks also points to an organic lesion, as true Jacksonian attacks are, as far as my knowledge goes, extremely rare in hysteria. Although I am not very positive about it, still I believe that we have a definite disease of the brain in this ease, and I am inclined to think that this disease is a slow-growing tumor. I have been led to this belief from an experience which we have lately had. Some of you will remember that I reported to this Society last fall the clinical history of a case upon which we had advised operation. The case was that of a man who, for six years, had had recurring attacks of Jacksonian epilepsy, beginning in his right foot, and which had later involved the right arm and face, and in whom there had developed paralysis of the leg, and of the arm. There were none of the general symptoms of brain tumor, and the operation revealed nothing abnormal; but the microscopical examination of the brain showed a most interesting new growth of the motor region, about which I hope Dr. Flexner will have something to say. The case which I have presented to you to-night, although not quite similar, will suggest this case strongly, and we fear is of a like nature.

Note. — While in the Hospital, in the early part of June, the patient had another attack. She was in the dining-room, talking with some friends, when the fingers of her right hand became stiff and painful. This extended up the arm, the hand and arm drew up, her head was drawn to the right side, and there was intense pain in her head. She then lost consciousness. Those who were about her say that her eyes were turned to the right and that her right leg was stiffened out, and that she fell to the floor. When she became conscious, in about five minutes, she could not talk for a few moments, and felt weak and badly, but was not hysterical.


Demonstration of Specimens.— By De. Ccllen.

Several weeks ago at a meeting of this Society, Dr. Kelly spoke at length on the operative treatment of myomata and pointed out tiie ease with which these growths could be removed. Since that time I have operated upon two patients where the conditions present rendered the enucleation very diflicult. Both of these cases present so many clinical points of interest that we may proiitably discuss them for a few moments.

Case 1. Umbilical hernia; multinodular myomatous icterus; large ovarian abscess communicating with the small intestine; hysterectomy.

K. L., aet. 40. Admitted to Dr. Kelly's service March 23, 1897. Complaint, abdominal tumor, pains in the lower right abdomen and leg. She had been married 20 years, but gave no history of pregnancy. Menses began at 13 years, and were regular until August 15, 1896, when they ceased fori months, since which time they reappeared. Flow moderate, at times clotted; occasionally it is painful.

Family history negative.

Previous history unimportant.

Present condition. Ten years ago she noticed a tumor about the size of an Qgg in the right side of the pelvis. This has steadily increased in size and has been almost constantly associated with a gnawing pain over its most prominent part. The pain has been so severe that she has at times been confined to bed, on one occasion for 3 months. The last attack was 3 months ago. Locomotion very difficult on account of pain in the legs. These are at times swollen and pit on pressure. No chills. No fever. The patient is well nourished, has a good appetite, bowels constipated. For the last two years she has had night sweats regularly.

The abdomen is much distended and presents an irregular lobulated appearance. At the umbilicus is a hernial sac fully 9 cm. in diameter. The skin over this can be drawn out for a distance of 6 cm., while the hernial ring whose margins are very sharply defined is 3 cm. in diameter. The following are the abdominal measurements : Distance from symphysis to umbilicus 1-1 cm.; from umbilicus to xyphoid 29 cm.; circumference at most prominent part of tumor 126 cm.; midway between umbilicus and xyphoid process 96 cm. Examination occasioned little pain.

Operation March 24, 1897. On account of the irregular hernial protrusion the abdominal incision was commenced at a point midway between the xyphoid cartilage and the umbilicus and continued downward to within a short distance of the pubes, the hernial sac being encircled and removed. At the umbilicus the omentum which was firmly adherent was ligated and then freed. Presenting at the incision were several subperitoneal myomata ; to these the omentum was also firmly adherent. After loosening up these adhesions, the nodular myomatous uterus, 28x21 cm., was delivered. (See the accompanying figure.)

Occupying the posterior part of the pelvic cavity was an elastic tumor 17 cm. in diameter ; this looked like an ovarian cyst and was intinuitely adherent to two loops of snnill intestine. On attempting to shell off the outer layers of the cyst


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leaving them attached to the intestines, the cyst ruptured and was found to contain about 900 cc. of greyish foetid pus. A glass trocar was introduced and the pus evacuated. The uterus was then removed in the usual way from left to right, but the left tube and ovary were left in situ. After bringing the cervical stump together the ovarian abscess was freed and the vessels at its pedicle controlled by silk ligatures. It was necessary, however, to leave a small part of the sac attached to the intestines, and on careful examination an opening 1 cm. in diameter was found between the intestine and the abscess sac. The margins of the intestinal opening were almost as dense as cartilage and at the same time very friable. After a good deal of dissection it was possible to turn the edges in and the opening was closed by fine silk sutures. This now was supported by a second and a third row.



A longitudinal section of the abdomen, showing from above downward the large multinodular mj-omatoug uterus, to the upper and anterior surface of which the omentum is adherent, an umbilical hernia to whose ring the omentum has become adherent, a pus tube and an unusually large ovarian abscess which communicates with a loop of small intestine. The abscess wastoore on the right side of the body, but has been drawn on the same level to bring it out more clearly.

During the entire operation, which lasted 5 hours, the patient did not lose 3 oz. of blood. The abdomen was thoroughly cleansed with two litres of salt solution, the pelvic peritoneum drawn over the cervical stump and the abdomen closed without drainage.

On the eighth day the temperature rose to 100.8° and about the "^Oth day reached 101°. At that time there was consider


able pain in the left iliac fossa and an indefinite thickening could be made out, but from this time on she rapidly recovered and was discharged May 4th feeling comparatively well. From this case we may learn that where there is an umbilical hernia or adhesions are suspected it is well to begin the incision at a point above this; the finger can then be introduced into the abdomen to act as a guide. The presence of the ovarian abscess is very readily explained. There has evidently been an ovarian cyst. With the increase in size of the myoma the cyst has been firmly pressed against the intestines, adhesions have formed, and as continuous pressure promotes absorption, the walls have gradually atrophied until an opening has formed between the two. Attention may also be drawn to the fact that no drainage was emj^loyed.

Case 2. Large tnyomatous uterus extending out laterally betiveen folds of broad ligament; complete hysterectoiny necessary as no cervix was left; danger of injuring the ureters.

M. F., aet. 40, admitted to Dr. Kelly's service March 29, 1897. Complaint, an abdominal tumor. Menstrual history somewhat indefinite, but the periods were regular until two years ago, since which time the patient has had a continuous bitt not excessive bloody discharge.

Family History. Mother's family showed a decided tuberculous tendency.

Present Condition. She first noticed abdoaiinal enlargement during the summer of 1896. It has steadily increased since then and showed more advancement on the left than right side. During the last four years she has had on an average one profuse uterine hemorrhage each year; the last was one week before admission and continued three days. For one year there has been marked but not constant pain in the lower abdomen. Micturition frequent. No history of chills or fever.

Abdominal Examination. The abdomen is the size of a full term pregnancy, the greatest prominence is to the left of the umbilicus. Just below the umbilicus in the mid-line is a hard flattened area 8 cm. broad, to the right of which is a second nodule. From the character and consistence of the nodules one instantly suspects myomata.

Measurements. Distance from symphysis pubes to umbilicus 24 cm.; from umbilicus to xyphoid process 20 cm.; from right ant. sup. spine to umbilicus 25 cm.; from left aijt. sup. spine to umbilicus 24.5 cm., girth at umbilicus 88 cm., greatest girth which is 8 cm. below the umbilicus is 91 cm.

On vaginal examination the cervix was felt as a half-moonshaped slit directly behind the pubes, while the whole upper part of the pelvis was filled with a hard globular mass, forming a part of that occupying the abdomen.

Operation March 31, 1897. Hysteromyomectomy. The abdominal incision extended from a point 4 cm. above the umbilicus almost to the pubes. The myoma was delivered without difficulty, but found firmly fixed in the pelvis. Upward it reached a point midway between the umbilicus and xyphoid cartilage, was lobulated and laterally stretched out under the broad ligaments. The right round ligament was tied and cut, the vessels of the right tube and ovary were controlled and the appendages on this side were left in situ. On the left side the


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[No. 79.


tube aud ovary were fouud lying on the ujiper surface of the tumor and could not be saved. After ligating and cutting the left round ligament the folds of the broad ligament were separated, exposing an artery 2 mm. in diameter lying on the surface of the tumor — this was probably the ovarian artery ; it was tied off and the bladder peritoneum freed from the tumor. The myoma was then rolled upward and to the right, but on the left side the uterine vessels as such could not be isolated ; they were, however, controlled by passiug stout sutures at their usual site.

It was now my intention to amputate at the cervix, but as this was entirely involved by the tumor the vault of the vagina was opened into, its upper portion being removed. The right uterine vessels were caught by the forceps and the tumor was freed. lu both broad ligaments were many dilated lymph spaces. After controlling the large vessels with silk and checking all oozing along the vaginal cut surface with catgut the vaginal mucosa was turned down into the vagina and the i-aw surfaces were brought together, thus shutting off the pelvic cavity. The bladder peritoneum was then drawn backward over the stump aud united with that of Douglas' sac. Considerable anxiety was felt as to the safety of the ureters, as it was necessary on account of the vaginal vault being so widely opened to control the uterine 'vessels further out than usual. On the left side a rounded cord was seen included in the ligature, but on unraveling this it was found to be a fold of peritoneum. After washing out the pelvis with two litres of salt solution the abdominal cavity was closed. The patient made a perfect recovery and was discharged May 3, 1897.

In this case the chief anxiety was centred around the ureters. We were loath to close the abdomen without further examination as to their safety, but the patient's condition did not warrant any delay. Strict orders were given to have all the urine measured to determine if sufficient were secreted. The amount obtained satisfied us that both kidneys were doing their normal amount of work. Had a ureter been tied the abdomen would have been again opened and the ureter anastomosed into the bladder.


NOTKS OX NEW BOOKS.

Archives of Clinical Skiagraphy. Sydney Rowland, B. A. Camb., Editor. Volume I, Parts I-IV. 1890-7. (The Rebman Publishing Company, Limited, London.)

A publication whose ol)ject is "to put on record in permanent form some of the most striking ai)plicationsof the ' New Photography to the Needs of Medicine and Surgery,' is being edited by Mr. Sydney Rowland, the special commissioner appointed by the British Medical Journal to make inquiry into the above-mentioned applications. The Archives of Clinical Skiagraphy published its first number iu May, 1886. Since then three more numbers have appeared at irregular intervals. Each of them contains a series of six collotype plates, taken from some excellent X-ray negatives, to which a brief clinical and explanatory note is appended. Most of the plates are of simple skeletal lesions of the extremities, illustrative of fractures, malformations and neoplasms.

There are few reproductions of .the more difficult exposures through tlie pelvis or chest, and but cur.sory mention of attempts to


recognize lesions other than osseous ones, euch as intra-thoracic

aneurism, changes in the cardiac area, pulmonary affections, renal calculi and the like. There is an excellent skiagrai)li of tubercular arthritis of the hip in No. 3 and of congenital dislocation of the hip in No. 4, evidently in children.

In the last number (April, 1897) the scope of the publication has been enlarged somewhat, and reijroductions of subjects other than purely clinical ones are presented, such as of zoological specimens, and reference is made to the possibility of taking moving shadow pictures for cinematographic purposes.

The life of such a publication, if devoted purely to clinical subjects, seems to come to a natural termination when its mission of calling attention to the great usefulness of the X-rays for the diagnosis of many pathological conditions has been fulfilled.

To-day an X-ray apparatus has become an almost necessary adjunct to the hospital or private armamentarium, and skiagraphs are as much to be expected in a clinical report as ordinary photographs, and will occupy an equally important place in the forthcoming text-books on fractures, orthopsedic?, etc.

It seems, therefore, that the value of such a periodical would be enhanced if it aimed, as do some of the better photographic journals, towards the perfection of the ways and means of betteringthe art of skiagraphy rather than towards the mere reproduction of its quite familiar results.

The Archives are very handsomely published by the Rebman Publishing Company. The reproductions are good. Such type, paper and broad margins would be welcomed in many better known and more generally useful medical magazines. H. W. C.

Injuries and Diseases of the Ear, being Reprints of Papers on Otology. By Macleod Yearsley, F. R C. S., Fellow of the British Laryngological, Rhinologiial and Otological Association, etc. (1897, London: The Rebman Publishing Co., Limited, 11 Adams St., Strand.)

This little book is an interesting collection of monographs, and is not a systematic treatise on diseases of the ear. All of the articles are interesting and suggestive. We would especially commend " Foreign bodies in the ear and their treatment," " What not to do in diseases of the ear," and " On the care of the ear in children." The chapter on "Aural Reflexes" is too brief to be .satisfactory. It is to be hoped that the author will at some future time esjtand it into a book.

Inebriety. Its Source, Prevention and Cure. By C. F. Palmer.

(New York: F. H. Retell Co., IS97.)

This short tract or sermon is not in any way a scientific discussion of this subject, and so lacks all special value for a physician. It is only suitable for that body of the laity who have a small amount of scientific knowledge. The point on which the author lays most stress is that inebriety is due to a neuropsychopathic constitution, and that consequently it is a result of mental deformity rather than a moral infraction, and he believes that almost all inebriety may be traced back to a mentally or physically diseased ancestry. But his remarks might be applied with almost as much fitness to any other form of mental deformity as inebriety.

Medical and Surgical Report of the Presbyterian Hospital in the

City of New York. Vol. II, January, 1897.

This report compares very favorably with Volume I, and with more supervision in the editing would be still better. Many of the papers published in this volume have appeared before in the New York medical journals, which detracts from their vivid interest. For those who have not read the journals there are good papers on tj'phoid fever, tuberculosis, and a variety of other topics both surgical and medical, reported at greater or lesser length. The description of the operating pavilion as an aid in construction for other hospitals is most valuable.


October, 1897.J


JOHNS HOPKINS HOSPITAL BULLETIN.


219


Hysteria and Certain Allied Conditions. Their Nature and Treatment with Special Reference to the Application of the Best Cure, Massage, Electro-therapy, Hypnotism, etc. By Geokqe J. Prbston, M. D., Professor of the Diseases of the Nervous System, College of Physicians and Surgeons, Baltimore, etc. 8vo, pp. 298. (P. Bktckision, Son & Go., Philadelphia, 1897.)

Dr. Preston modestly prefaces his book with an explanatory apology. Two reasons, he says, may perhaps be deemed of sufficient weight to warrant its appearance ; first the great importance of hysteria, and secondly tlie lack of a recent book in English on the subject. The book is intended for the American general practitioner. Its "object is to present the symptomatology and differential diagnosis of hysteria in as concise a manner as possible, and to indicate the various therapeutic measures that have been found useful in the treatment of the disorder."

The author first gives a short sketch of the history of hysteria, in which special attention is given to tlie epidemics of hysteria so common in the Middle Ages and occasionally seen since then. An interesting account is given of the hysterical " orgies" enacted at the religious revivals of Kentucky and Tennessee in the early part of this century, and of the camp-meeting "trances " of the Southern negro.

The historical account is followed by a chapter on the " Nature of Hysteria." The etiology is considered in some detail. Sex, age, race, climate, heredity, diathesis, education and environment, and " reflex irritation" are discussed. In regard to " race," the author, who has had considerable experience with hysteria in the negro, thinks that the disorder is more frequent in that race to-day than it was during the slavery period. Indeed, it is at present by no means uncommon. Special stress is put upon the part that environment plays in the etiology of hysteria. The part played by " reflex irritation " is considered undetermined. It is rare that an abnormal condition of the organs of generation gives rise to the disease, though a morbid train of associated ideas often makes the hysterical woman refer her troubles to these parts.

The consideration of the etiology of the disease is followed by a brief review of the many theories that have been held as to its nature. The author concludes that hysteria is an affection of the hij;her brain centres, perhaps an actual though temporary loss of protoplasm. In bringing together his reason for this conclusion Dr. Preston shows an acquaintance with the more recent work on the fine anatomy of the cerebral cortex and an admirable hesitancy in making deductions from the suggestive results of the histologists.

There follows a chapter on "Symptomatology." Hysteria is considered as a single disease, though most protean in nature. The symptoms of the disease are divided into the following categories: 1. Disturbances of sensation: anaesthesia, paraesthesia, hyperaesthesia, affecting both the general sensibility and also tlie special senses. 2. Disturbances of motion : paralysis, contracture, tremor, convulsive seizures. 3. Vaso-motor, visceral, and nutritive disturbances. 4. Mental symptoms. 5. Miscellaneous symptoms.

The disturbances of sensation are treated with the fulness of detail which the subject warrants. Special attention is given to " hysterogenesis." The author feels convinced from cases of his own that the hysterogenic zones, first described by Charcot, have a real existence and are not the result of suggestion.

A good description is given of the various disturbances of the motor-system. The author draws an interesting comparison between the manifestations of liysteria in this country and those in France. " 1 have often been struck," he says, " with the similarity between the cases of hysteria in negroes, who, of course, have never been in any possible manner under the influence of suggestion, and the so-called ' show cases' at the Salpetriere."


Under "mental symptoms" are considered the general mental state of the hysterical patient,* hysterical insanity, lethargy, narcolepsy, catalepsy, ecstasy, somnambulism, and vigil ambulism. Somnambulism, while not necessarily hysterical in nature, is considered to be very closely allied to hysteria on the one hand and to hypnotism on the other.

The visceral disturbances include contracture of the oesophagus, vomiting, hematemesis, hysterical anorexia, intestinal disturbances; affections of the genito-urinary apparatus ; disturbances of the respiration and of the voice. Under cardiac and vaso-motor symptoms are considered tachycardia, flushing of the face and upper part of the body, autographism and cutaneous affections. Nutritional disturbances include muscular atrophy and hysterical fever. The latter, the author concludes, is a real though rare condition.

A third of the book is given up to a detailed consideration of the diagnosis and treatment of hysteria. There has been an evident and successful effort to make this clear, practical and helpful. Under differential diagnosis emphasis is put upon the fact that though hysteria is manifold in nature it is almost always characterized by certain stigmata, as for instance anaesthesia, which as a rule may be clearly distinguished from similar disturbances due to organic disease. "The central idea in the treatment of hysteria may be expressed in the word 'suggestion.' " The physician must have the confidence of his patient. In the general treatment of the disease the main reliance is to be placed upon a careful regulation of the diet, the meals, rest, exercise, occupation, and habits. Drugs are useful mainly because the patient is apt to have faith in medicine. The treatment of special symptoms likewise depends chiefly on suggestion. In case of severe attacks pressure on the hysterogenic zones, ice suppositories, apomorphia, chloroform, at times hypnotism, may help to terminate the attack.

Electricity, which has proved so valuable in the treatment of hysteria, owes its main effects to the power of suggestion. On the other hand, water as a therapeutic agent has a direct marked beneficial physiological effect in addition to its suggestive use. For the routine treatment of hysteria the alternate warm and cold douche is warmly recommended. Massage is chiefly applicable to those cases of hysteria, often complicated with neurasthenia, in which the patient cannot or will not take out-door exercise. The Weir Mitchell Rest Cure is considered in some detail. Hypnotism, of which the author gives a very interesting account, is considered very valuable in some cases, though on the whole it has proved disappointing as a therapeutic agent. Its great value is "that it has taught us how to make our treatment of the hysterical subject suggestive." Surgical interference is rarely necessary or of value. The author deplores the frequency with which ovariotomy has been done in this country merely for the relief of hysteria.

The book as a whole is admirably fitted for the purpose for which it was designed. The author makes no attempt at an original treatment of hysteria. He has drawn extensively from the literature on the subject, giving references to the more important articles. Yet he is far from being a mere compiler. He views the subject throughout from a modest yet independent standpoint, based on an experience with hysterical patients rendered the more valuable by an evident deep personal interest in the subject. The style is direct, clear, and interesting, though at times rough. The book is illustrated by diagrams taken from Charcot and Gilles de la Tourette, and by pictures from the drawings of Richer. It is well printed and well bound. It should prove not only most valuable to the general practitioner, but also of interest to the specialist in nervous diseases. C. R. B.


» "As has been aptly put, the hysterical patient says ' I cannot,' it loolis like 'I will not,' but it really is 'I cannot will.'"


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JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 79.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel C. Gilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.

WiLLiAJi OsLER, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice

of Medicine. Henry M. Hdrd, M. D., LL. D., Professor of Psychiatry. William S. IIalsted, M. D., Professor of Surgery. Howard A. Kelly, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.

William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. William D. Booker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. Thomas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flexner, M. D., Associate Professor of Pathology. J. Whitridge Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy.


William S. Thayer, M. D., Associate Professor of Medicine.

John M. T. Finney, M. D., Associate Professor of Surgery.

George P. Dreyer, Ph. D., Associate in Physiology.

William W. Russell, M. D., Associate in Gynecology.

Henry J. Berkley, M. D., Associate in N euro- Pathology.

J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology,

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. Bl-oodgood, M. D., Instructor in Surgery.

Thomas S. Cullen, M. B., Instructor in Gynecologj'.

Frank R. Smith, M. D., Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jones, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology.

Louis E. Livingood, M. D., Assistant in Pathology.

Ross G. Harrison, Ph. D., Instructor in Anatomy.

Henry Barton Jacobs, M. D., Instructor in Medicine.

Charles R. Bardeen, M. D., Assistant in Anatomy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from Its close affiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

The course of instruction is planned for the professional education of those who have received a liberal education, as indicated by a collegiate degree iu arts or science, including a reading knowledge of French and German and adequate training in those branches of science, such as physics, chemistry and biology, which underlie the medical sciences. Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and iu the Dispensary and Wards of the Hospital. While the aim 'of the School is primarily to train practitioners of medicine and surgery, It is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. The first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in tlie Laboratories of Anatomy, Physiology, Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. During the last two years the student is given "abundant opportunity for the personal study of cases of disease, his time being spent largely in the Hospital Wards and Dispensary and in the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage In practical work In the Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives :

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

3. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as Is Imparted by the regular minor courses given in these subjects in this university.

The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week In the laboratory in each subject.

3. Those who give evidence by examination that they possess the general education implied by a degree in arts or In science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree In this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not caudidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING. Applicants for admission to advanced standing must furnish evidence (1) that the foregoing terms of admission as regards preliminary training have been fulfilled, (3) that courses equivalent in kind and amount to those given here, preceding that year of the course for admission to which application is made, have been satisfactorily completed, aud (3) must pass examinations at the beginning of the session in October in all the subjects that have been already pursued by the class to which admission is sought. Certificates of standing elsewhere cannot be accepted in place of these examinations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afl'orded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one.

The special courses of instruction for graduates in medicine are now given annually during the months of May and June. During April there is a preliminary course in Normal Histology.

These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and Is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital.

These courses are open to those who have taken a medical degree aud who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here otTered. The number of students who can be accommodated In some of the practical courses Is necessarily limited. For these the places are assigned according to the date of application.

The Annual Announcement and Catalogue will be scut upon application. Inquiries should be addressed to the

HEGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.


The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copiea may be prncwed from Messrs. CVSHIXO d CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a year, may be addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies will be sent by mail for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. VIII.- No. 80.]


BALTIMORE, NOVEMBER, 1897.


[Price, (5 Cents.


coisrTEisrTS.


PACK.

A Rare Case of Lithopedion. By J. G. Clark, M. D., - - 221 On Tuberculosis of the (Esophagus, with the Report of a Case

of Unusual Infection. By Clahibel Coxe, M. D., - - 229

A Rare Anomaly of the Arch of the Aorta, with an Additional

Muscle in the Neck. By A. B. Herrick, . . - - 234


On the Hsematozoan Infections of Birds. By W. G. MacCalLUM, M.D., - - - - - - - - - - 235

A Case of Cavernous Angioma (Vascular Nkvus) of the Tunica

Conjunctiva. By Dr. H. O. Reik, - - - . - 236 Books Received, . - - 237


A RARE CASE OF LITHOPEDION.


By J. G. Clark, M. D.


During the month of August, 1896, a patient suffering with an abdominal tumor, dyspncea and pain in the lower abdomen, was admitted to the gynecological wards of the Johns Hopkins Hospital for treatment, and, through the kindness of Dr. Kelly, I was given charge of the case.

The patient's history was strongly suggestive of the rupture, four years previous to her admission, of an extra-uterine pregnancy sac, with the extrusion of the fcetus into the abdominal cavity, and the physical examination revealed a stony-like mass, resembling a foetus in form, which proved at operation to be a lithopedion.

As the formation of a true lithopedion is of rare occurrence, and as this was a typical case, I have thought it worthy of publication.

History of Case.

B. H., colored, married, age 45 years. Admitted August 8, 1896.

Chief Complaints. Pains in the lower abdomen, enlargement of the abdomen, and dyspnoea.

Marital History. Married 14 years, three children, oldest 12, youngest 7 years old.

First labor difficult, attended by a midwife, who had to call in a physician to remove an adherent placenta. Last two labors easy, slight chills and fever after birth of last child.

Menstrual History. Flow appeared first in her thirteenth year, always regular, but accompanied by much pain in the left side. For the last three years the flow has been regular, lasting 4 to 5 days.


Family History. Mother is insane, otherwise no history of hereditary disease.

Present Illness. Four years ago the menstrual flow ceased and the patient had all the symptoms of early pregnancy.

Towards the end of term her lower extremities swelled very much, and she felt so weak and miserable that she was compelled to go to bed, where she remained itntil long after the regular term. During the latter months of pregnancy foetal movements were distinctly felt. About the time for her confinement she had an attack of severe pain in the left side and felt something break. Much watery fluid was passed by the vagina.

At the end of a week her physician was called, who told her that she had an extra-uterine pregnancy and advised an operation, which she declined. During the time while her legs were oedematous she became almost blind. The size of the abdomen has decreased slightly, but the pains in the left side still persist, and of late have grown more severe.

General Condition. Tall, emaciated woman, tongue slightly coated, lips and mucous membranes pale, patient seems moody and of a despondent disposition.

Bowels constipated, at times she goes a week or ten days without a movement.

Micturition painless. Appetite poor.

Examination. Abdomen irregularly distended by a tumor which presents most prominently on the left side. It is quite hard,


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JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 80.


only slightly movable, and is apparently connected by adhesions with the anterior and lateral abdominal walls.

The tumor lies in an obliqne position within the abdomen, the upper extremity is felt beneath the left lower rib, the lower extremity being crowded down into the right inguinal regiou.

The general surface of the tumor is smooth, but numerous hard projections are felt over it, which are denser than the main body of the tumor.

Abdomen tympanitic over right half. Immediately below and one inch to the left of the umbilicus, where the most resistant part of the mass is felt, the percussion note is flat.

No percussion wave.

Examination under anmsthena. Outlet relaxed, cervix in axis of vagina. Uterus normal in size, in anteposition, pushed forward against pubes by a mass posterior and above uterus.

The left tube and ovary are enlarged; nothing detected on right side except general, ill-defined bogginess.

The main body of the tumor may be pushed away from the uterus, but seems to have a slender pedicle.

The ill-defined mass in the right side, by rectal examination, feels very boggy and is in close relationship with the hard tumor.

Urinary Exainination. Color clear amber, slight cloudy sediment, sp. gr. 1035, acid reaction, no sugar or albumen. A few pus cells.

Operation.

Operation by Dr. Clark, August 14, 1896.

Abdominal section for the removal of a lithopedion, double salpingo-oophorectomy for hydrosalpinx and cystic ovary on left side, and for the removal of the right tube and ovary, which were converted into an ectopic gestation sac.

Complications. Adhesions between the anterior abdominal wall and back of foetus. Dense adhesions binding the gestation sac to the intestines. Placenta necrotic.

Incision 10 cm. in length, revealing a mottled yellow tumor closely adherent to the abdominal wall.

On releasing these adhesions and passing the hand up beneath the left lower rib, the foetal head was felt lying in close contact with the spleen. The left arm and shoulder were closely adherent to the anterior abdominal wall near the umbilicus.

In order to facilitate the delivery of the fostus the abdominal incision was enlarged to a point midway between the ensiform cartilage and umbilicus.

Numerous bleeding tags of adhesions were ligated.

The foetus occupied an oblique position in the abdomen, its chest lying in close contact with the aorta, from which it derived a distinct pulsation impulse.

The fo?tal head was grasped and gently delivered from the abdominal incision, after which the umbilical cord was cut close to its placental attachment in the pelvis. On inspecting the pelvic structures the fimbriated end of the tube was found adherent to the ectopic sac, having been apparently torn from the body of the Fallopian tube at the time of the primary rupture.

The secondary or adventitious sac was situated between the folds of the broad ligament. On the floor of the pelvis a large


placenta was attached. The larger portion of the sac projected up into the abdominal cavity, and was densely adherent to the vermiform appendix, ceecum and intestine. Secondary rupture had occurred in the superior wall of the sac, the umbilical cord projecting through it into the abdominal cavity.

The placenta was very friable, and on attempting to detach it, broke up into small bits, requiring its removal piecemeal. The ectopic sac was dissected free from the intestine and its attachments in the pelvis, and enucleated with the right tube. The ovary could not be distinguished in the necrotic mass.

A large cystic ovary and hydrosalpinx were removed from the left side.

Abdominal cavity irrigated with .5 litres of salt solution. Abdomen closed with buried silver and subcutaneous cat-gut sutures.

Pulse at beginning of operation 120, at completion 90 beats a minute.

Patient made an uncomplicated recovery, temperature at no time after operation rising above 100° F.

Discharged 28 days after operation, well.

Db. Barnum's History of the Case. In a private letter. Dr. Barnum, of Lancaster, Va., has given the following account of the case :

I remember the case of Mrs. Harris very well, owing to the fact that it is the only one of the kind ever seen by me. I was called to see the case in October, 1S92. I found the patient weak, nervous, despondent, and at times wicha mind decidedly unbalanced. From her and her husband, who is a colored man of intelligence and good standing, I learned that she became pregnant the previous November. There was the usual suppression of the menses, morning sickness, quickening, filling out of the breasts, and all of the signs which she, as the mother of several children, recognized as indications of the pregnant condition.

In August she was taken with perfectly normal labor pains and the colored midwife was sent for. Neither the patient nor her colored attendant suspected that anything was wrong until forced to believe it by the delay in the delivery.

At my first visit to the patient, two months later, an external examination showed her pregnant condition.

Digital examination, however, revealed the uterus of a nonpregnant woman.

At a still later visit I was able to grasp a knee of the foetus through the abdominal walls of the mother.

A rigid questioning of both husband and wife failed to elicit any history of previous abnormal pregnancy or miscarriage.

As this pregnancy had not been interru))ted by any unusual sickness, I gave it as my opinion that this was a case of abdominal pregnancy ;.or if it at any time had been one of tubal pregnancy, the tube must have ruptured early in the pregnancy.

At my first and at all of my subsequent visits I urged the patient to go to the hospital for treatment. As she was not willing to do this, I gave her tonics and remedies to improve her mental condition. She gradually improved, and has employed no physician, I think, during the past year. Allow me to thank you for your letter announcing the operation which confirmed my diagnosis.

Pathological Report. Extra-uterine foetus removed from the abdominal cavity four years after the rupture of the gestation sac.


November, i897.J


JOHNS HOPKINS HOSPITAL BULLETIN.


223


Foetal measurements :

Occipito-mental diameter, 12.3 cm.

frontal " 9.3 " Siib-occipito bregmatic diameter, 9.2 "

Bitemporal diameter, 7.9 "

Biparietal " 7.9 "

Circumference of head, .30. "

" " shoulders, 32. "

Length of fcetus, 43. "

Weight of fcetus, 4J lbs.



The fcetus is entirely covered with a thin translucent membrane which is easily peeled off.

Only the general outlines of the face can be distinguished, the eyes, nose, mouth and ears being entirely covered in with


the membranous covering, through which the hair of the fa?tus can be seen as a black mat.

Scattered throughout the foetal envelope are numerous yellowish white spots composed of a fatty, saponaceous material.

The cheeks are quite prominent, the left being much more so than the right.

The skin covering the face and forehead is of a brownish red color resembling burut leather, slightly mottled, and is firm and resistant, having lost all of its pliability.

On cutting into the skin at this point the knife encounters numerous gritty particles, but the general body of the skin is composed of adipocere.

The occiput and a part of the parietal bones may be seen projecting immediately beneath the membranous covering.

The parietal bones overlap the occipital, and the jagged sutures feel like saw-teeth.

The skin covering the left side of the head is of a white, bleached appearance, similar to the washerwoman's skin.

The membranous envelope, which is probably the remains of the amnion, is closely attached to the foetus, but can be peeled off. It is ten millimetres in thickness and has no visible blood-vessels when held up to the light.

The arm on the right side is closely glued to the body, and the space between the axilla and elbow is entirely obliterated.

The right forearm is flexed on the arm, and the fingers on the hand.

The dorsal tendons of the hand are seen as glistening cords beneath the mummified fcetal skin.

The left forearm is half-way flexed upon the arm and presents the same general appearance as the right side

The feet are flexed upon the legs, the legs upon the thighs, and the thighs partially upon the abdomen.

There is a considerable accumulation of adipocere aud calcareous matter in slightly raised plaques over the lower extremities.

The genital organs are entirely hidden by the enveloping membrane, so that it is impossible to differentiate the sex of the foetus without further dissection. The entire posterior aspect of the fretus is covered with glistening white organized tags of adhesions which have connected the foetus with the maternal tissues. On floating these adhesions out in water thev are seen to form a thick wavy veil.

On dissecting this layer of adhesions, loose numerous fatty plaques are seen in the skin.

The dorsal vertebraj form a prominent ridge, aud at points where the spinous processes shimmer through the translucent skin are seen to be in a cartilaginous state.

The skin of the buttocks and the underlying fat and gluteal muscles have undergone saponaceous change, with here and there patches of calcareous matter sparingly interspersed through the external portions of the tissues

The umbilical cord is shrunken to about half its usual size and contains many calcareous nodules.

Median incision from the neck down to and through the symphysis pubis reveals the following condition : Superficially the body is covered with a membranous layer which can be peeled off easily, next comes the thick brawny bacon-like


224


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 80.


skin, and beneath it the brownish red muscle which contains multiple fatty areas about the size of millet seeds.

The jjeritoneum is of a dull slate color, like that seen in an old post-mortem subject.

The intestines are collapsed, soft, pliable, and, except for the shrinking of the tissues from absorption of the watery elements, appear to have undergone little or no change.

The liver is of a light brownish red tint interspersed with slate colored patches.

On section the liver is found to be much denser than normal, the stroma is of a greenish brown color, with many minute yellowish spots.

The lungs are atelectatic and have a dense fleshy feeling. The color is brownish red, resembling the color of the liver.

On section, gritty particles are encountered with the knife.

The heart is collapsed, wrinkled, and of a dark brown color.

The spleen is small and dense.

On freeing the genital organs of the enveloping membrane the fcetus is found to be of the male sex.

Microscojiical Examination. Lungs : the air spaces are small and the epithelial lining is not visible, bui appears to be changed into fatty detritus and star-shaped crystals.

The connective tissue between the air spaces is pale, opaque and of a uniform homogeneous appearance, the separate connective tissue fibres not being distinguishable.

Interspersed throughout the connective tissue septa are many star-shaj^ed crystals.

The muscular tissue of the heart still maintains its characteristic form, although undergoing marked fatty degeneration. No calcareous changes visible.

The general histological structure of theliveris unchanged, although the liver cells are undergoing fatty degeneration.

Diagnosis. Extra-uterine foetus undergoing saponaceous mummification and calcareous changes. (Lithopedion.) The calcareous change is limited to the enveloping membrane, skin and lungs, the remainder of the internal organs showing only those changes due to fatty degeneration and absorption of their watery constituents.

Kuchenmeister makes the following classification of the calcareous changes which may occur in an extra-uterine embryo after its death :

Lithokelyphos, a condition in which the fcetal envelopes alone undergo calcareous changes, the foetus shrinking to a mummified mass after the absorption of the amniotic fluid.

Lithokelyphopedion, a condition in which the foetal envelopes and those parts of the fcetus which come in contact with the membranes undergo calcareous changes.

Lithopedion, a condition in which the fcetus after its expulsion into the abdominal cavity undergoes calcareous change, beginning externally in the vernix caseosa.

Li ectopic pregnancy cases which survive the primary or secondary rupture of the gestation sac and are not subjected to operation, the embryo may be disposed of in various ways, depending upon its age and the maternal conditions surrounding it.

Complete absorption only occurs when the embryonic tissues are largely composed of watery elements and the bones are yet in a cartilaginous state; it is therefore highly improbable that


an embryo more than three months old ever completely disappears in this way.

In order to arrive at an approximate idea concerning the ability of the human peritoneum to dispose of a young extrauterine embryo when expelled into the abdominal cavity, Leopold* made an extremely interesting experimental study upon rabbits.

For this purpose he selected four series of pregnant animals at different stages of pregnancy, from which he removed the embryos by abdominal section and implanted them in the peritoneal cavity of other rabbits.

The embryos were of the following sizes : 2.-5 cm. long, 5 to 6 cm. long, 8 cm. long, and the fully matured fcetus with intact membranes.

Some of the animals became infected and died from ])uru]ent peritonitis.

In these cases the rate of absorption was much more rapid than in those where the peritoneum remained normal.

Although the many experimental studies upon the function of the peritoneum have demonstrated its phenomenal absorptive ability, we are hardly prepared for Leopold's statement that when there was an accompanying peritonitis an embryo 2.5 cm. long was so completely absorbed by the end of the second day that no further trace of it could be found ; that a 5-cm. long foetus at the end of 24 hours showed only a small mass of bones, the epidermis and all of the internal organs having been absorbed; that of an 8-cm. long foetus th«re remained only a small mass of tissue consisting of the skin, paws and nails and the shrunken internal organs and skeleton ; and finally that the fully matured fcetus with its enveloping membranes was little less rajiidly absorbed.

As the rupture of an ectopic pregnancy sac is in the majority of cases a sterile process, the results obtained in those experiments of Leopold in which there was no accompanying peritonitis probably more nearly indicate the approximate rate of absorption in the human being.

In those animals the absorption was quite as effective, although much slower.

After a few days embryos 2.5 cm. long were very much softened; in two instances, at the end of fourteen days they were only the size of a lentil, after thirty-four days they I were still smaller, and at the end of fifty-two days were either \ completely absorbed or only a small trace of them could be found.

From these experiments Leopold concludes that a small embryo may be absorbed completely.

The accumulated observations upon the clinical course of exti-a-uterine pregnancy tend to prove that the great majority of cases will rupture within the first two months of pregnancy, and also that probably many accidents of this kind occur without the patient dying from their effects or being subjected to operation.

The natural course, therefore, in these cases will be for the embryo to be absorbed completely. It is only when the primary rupture is delayed beyond the third month, or when the embryo survives the rupture and continues to develop in an


•Archiv f. Gyn., vol. XVIII, p. 53.


November, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


225


adventitious sac until a secondary rupture occurs, that a lithopedion is likely to be formed.

In these cases the extruded embryo may lie free in the abdominal cavity as a non-irritant foreign body, or as is more likely, a wall of adhesions will form about it and thus shut it oif from the peritoneal cavity. The close proximity of these encapsulated masses to the intestines and rectum renders them liable to infection at any time.

In the event of this complication extensive suppuration will occur and the fcetus quickly becomes skeletonized, and its bones may be discharged through a fistulous track into the rectum, vagina, bladder, or through the abdominal wall. It is only in the non-infected cases that mummification, saponaceous and calcareous changes take place.

The first cases of lithopediou recorded excited the liveliest curiosity and speculation among physicians as to their origin, and usually the conclusion was reached that no law governed their formation and that their origin was due to some mysterious or occult influence.

As an evidence of the views held by these earlier physicians, we find the case referred to by Spachius prefaced by the following lines: "Deucalion cast stones behind him and thus fashioned the human race, hence comes it that nowadays the tender flesh of babes is formed of stone."

In 1881 Kuchenmeister* reported a case in which a lithopedion had lain in the abdominal cavity of a woman 57 years. He carefully reviewed the literature bearing upon the subject of lithopediou, covering the period between the report of Albosius's case in 1582 and the time of the publication of his article in 1880.

From the fact that a lithopedion has always been considered such a unique production it is safe to assume that more of these cases in proportion to the number which have actually occurred, have been reported than of almost any other pathological anomaly, and yet from 1583 until 1880 Kuchenmeister was able to collect only 47 cases of mummified, skeletonized and calcified fcetuses, and of this number only a few can be accepted as true lithopedions.

Many of the earlier cases were dignified by special titles, such as the Lithopjedion Senoeuse, Das Ileidelberger Lithopiidion von Nebel (1767), Das Berliner Lithopildion von Walter (1775), Das Dresdener Lithopildion von Seller, Sen. (1819), etc.

Notwithstanding the great activity in the field of abdominal surgery since 1880, the year of Kuchenmeister's publication, comparatively few additional cases have been reported, a fact which still further proves that they are of very rare occurrence. If we select those cases from Kuchenmeister's review which represent a definite epoch or interesting fact in the history of this subject, we find that Albosius's case (1583) was the first reported. Varnier and Mangin's case (1785) was the first of double ectopic fcetation with the formation of a skeletonized foetus and a lithokelyphos. Von Weinhardt's case (1802) was the first successfully operated upon by abdominal section, Bonisch's case (1831) the first successfully removed through the vagina, Lee Heiskell's case (1828) the first reported

•Archiv f. Gyn., vol. XVII, p. 153.


in the United States, and Kuchenmeister's case (1880) the one of longest standing. The case which I now report is the largest lithopedion yet removed by abdominal operation followed by recovery of the patient.

The cases just referred to are of sufficient interest to merit a short resume of their histories.

In Varnier and Mangin's case (1785) there were two extrauterine foetuses of different ages found at autopsy.

A woman who had borne twelve children again became pregnant and went on to an apparently normal labor, March, 1753. The labor pains continued many days; water and considerable blood were expelled from the uterus, causing her to become weak and faint. After this false labor the patient gradually recovered, the abdomen, however, remaining enlarged. Eighteen mouths later she again had bleeding, from which she recovered, and continued well until the time of her death, 1785, in her 75th year.

At autopsy a white, moderately hard tumor of 5J pounds weight was found adherent to the abdominal wall, intestines and mesentery. The outer surface was partly calcified, and within the tumor a male fcetus with its placenta and umbilical cord was found. The joints were flexible, not friable; the extremities were hard, but still fleshy and not calcified. The muscles were hard and brown ; the skin dense and yellow.

Ovaries and tubes normal. Close to the left uterine wall and between it and the rectum, a hard, chalky tumor the size of a hen's egg was found, which contained a thick reddish slime and the bones of a two or three months foetus.

This sac communicated through perforations in the uterine wall with the uterine cavity.

Von Weinhardt's case, 1802, should occupy a prominent place in the history of abdominal surgery on account of the courage exhibited by this barber-surgeon in attempting such a hazardous operation.

In this case the patient gave a history so characteristic of

' the rupture of an extra-uterine pregnancy sac that V. Wein hardt, after making an examination, not only diagnosed her

true condition, but advised an operation, which he performed

Sept. 35, 1801.

After exposing through an abdominal incision the tumor mass, the surface of which was covered with veins, he delivered it with a " flesh hook." Within the mass the foetal bones could be felt distinctly. The foetus was removed, but no attempt was made to enucleate the placenta. The umbilical cord was brought out through the abdominal incision. The abdominal wound was dressed with cotton and a solution of balsam Peru and adhesive plaster. The patient recovered.

In this case the foetal envelope alone had undergone calcareous changes, the foetus having become skeletonized. Kuchenmeister therefore classified it as a lithokelyphos.

In the case of Bonisch (1815) the fcetus had lain in the abdomen for seven years before the operation.

The patient first noticed a large lump in her left side, accompanied by pain which she referred to the region of the umbilicus. This was her eighth pregnancy. The foetal movements had been quite vigorous, and at full term all of the usual symptoms of labor came on and continued for three days, after which they ceased and her breasts decreased in


226


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 80.


size. For five weeks she had a bloody vaginal discharge. At the end of nine months the menses returned. The patient did not wholly recover, but suffered from dysuria, constipation, occasional abdominal pains, and emaciation. In 1817 and in 1819 she again bore children, but the pain and emaciation which had previously existed continued, and in addition she had a foul-smelling vaginal discharge.

At the time of the operation a sharp bone (frontal bone) projected into the vagina ; this was first removed, accompanied by the escape of pus, after which the cranium was crushed with bone forceps and removed piecemeal. The left arm was then torn off with a hook, but remained attached by adhesions to the abdomjnal wall.

The bone was removed, leaving the soft parts behind. The hook was then fastened to the right arm, and all of the parts removed except the right thigh. This bone with the adherent parts was removed later.

The patient recovered, but had an occasional discharge of calcareous and cheesy masses, and the soft parts which were left behind formed a hard swelling over thepubes. Involuntary urination still continued.

Lee Heiskell's case is of interest merely because it was the first reported in the United States. The lithopedion was removed at autopsy and weighed four pounds and six ounces.

The clinical history of Kuclienmeister's case was reported by Hirt, an accoucheur in Zittau, in V. Siebold's Journal fiir Geburtshiilfe in 18.34.

The patient gave birth to a dead foetus in 1819, after which she again menstruated regularly until the end of the year 1823, when symptoms of another pregnancy appeared.

During the second half of her pregnancy she began to have much pain, which increased as the fcetal movements grew stronger, until she did not have an hour free from suffering. At the time of her expected confinement she experienced labor-like pains for a few days.

On Oct. 25th, after eating a light midday meal, she suddenly had a feeling of heart anguish, cramp and lancinating pain in the abdomen accompanied by vomiting.

After this time she became very sick and no longer felt the foetal movements or labor pains. Three days later Hirt was called and found the woman in an unconscious condition, with all the signs of a septic fever associated with an inflammatory attack in the abdomen. On account of the tympanitic condition of the abdomen Hirt was only able to make out rather indefinitely the transverse position of the foetus above the umbilicus.

After an examination of the uterus, which he found empty, he felt convinced that this was a case of "abdominal pregnancy." On account of the serious condition of the patient and the death of the foetus he did not consider the recovery of the patient possible without an operation, but under the administration of medicines "nature asserted herself," and Hirt says, "Truly I had the pleasure of seeing a slow recovery set in." After this time the patient had an ill-smelling diarrhoea which gradually disappeared. Milk appeared in the breasts on the 21st day and was present for 14 days. Nine weeks after the first day of her illness she had a bright red flow of blood mixed with pieces of skin and fibres.


From this time on the patient made a good recovery, and with the exception of pain which she noticed in certain movements of the body as in bending far forwards, and an occasional sharp, sticking pain in the right side, she suffered no inconvenience. Ten years after the attack Hirt examined the patient and found the foetus still in a transverse position, the head towards the right side of the mother. Through the posterior wall of the vagina a part of the foetus which he took for one of the upper extremities could be felt.

In 1846, 13 years after Hirt's last note, Kuchenmeister first saw the case and found a tumor one and a half times as large as a head adherent to the abdominal wall in a transverse direction, making a prominent conical tumor near the umbilicus. The tumor was closely adherent to the abdominal wall and was only movable in so far as the abdominal wall was movable. The foetal parts could not be recognized. The uterus was normal in size and form and at most slightly anteverted. By the vagina the tumor could not be felt.

The patient continued in good health until 1880, when she died in her 88th year. The autopsy was performed by Kuchenmeister, June 3d, 1880. The body was greatly emaciated, and the abdomen presented a prominent conical appearance, most marked near the umbilicus. The tumor was intimately adherent to the mesentery and anterior abdominal wall, requiring the knife to separate the adhesions. The tumor was in part directly adherent beneath and at the sides to the adjacent intestine, and in part connected by band-like adhesions with the more distant intestines and especially with the uterine appendages. The broadest adhesions resembled the bursted tubal sac. From one part of the tumor a foetal foot projected, the skin over which was dry and the tendons stood out prominently like those seen in dried anatomical preparations. The tumor was hard, inflexible and calcified. The placenta was soft and easily differentiated from the ectopic sac.

On opening the sac a full-term mummified foetus was found. It was very much shrunken, the face was distorted but not calcified and was covered by the right arm. The umbilical cord was wound ai'ound the thorax of the foetus and easily visible. All of the inner organs could be recognized without difficulty. The general appearance of the scalp, cranium, - brain, lungs, heart, pericardial sac, diaphragm, spleen and liver was preserved, but the intestines had shrunk into an unrecognizable mass.

A microscopical examination of this and another specimen was made by T. Wyder, who found only calcareous deposits in the skin and amniotic sac and not in the internal organs. The various tissues were mostly easily recognized and in part were wholly ))reserved. In the denser tissues the cell elements were most resistant and retained their normal appearance and arrangement. In all localities where fat had previously existed margarine and cholesterine crystals were found.

As Kuchenuieister's table possesses considerable historical interest I have rearranged it according to the chronological report of the cases and append it to this paper.

Since the publication of Kuclienmeister's paper cases have been reported by the following writers, but none of them


November, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


227


-possess any special poiuts of interest over the cases found in his report:

Dahlmann, Archiv f. Gyn., 1879, Vol. XV, p. 128.

Oettinger, Progrus Med., 1884, Vol. XII, p. 196.

Sarrante, Archiv de Tocol., 1885, Vol. XII, p. 237.

Oppel, A., Miinch. med. Wochen., 1888, Vol. XIII, p. 151.

Stonham, Tr. Path. Soc. Loudon, 1886-7, Vol. XXXVIII, p. 445.

Hammer, Prag. med. Wochen., 1888, Vol. XIII, p. 151.

Fales, W. H., Boston M. and S. J., 1887, Vol. CX VII, p. 131.

Tarnier, Bull. Acad, de M6d., 1889, Vol. XXII, p. 57.

Schotte, G., Miinch. med. Woch., 1890, Vol. XXXVII, pp. 471, 489, 503.


Wilson, E. H., Brooklyn M. J., 1891, p. 515.

Elbiug, R., St. Petersb. med. Woch., 1890, Vol. VII, p. 299.

Lusk, Med. Eec, N. Y., 1892, Vol. XLII, p. 405.

Hofmeier, Sitzungs. d. phys.-med. Gesellsch., Wiirzburg, 1892, p. 134.

Gottschalk, Canad. Pract., 1893.

Patellani, Ann. di Obstet, Milano, 1893, Vol. XV, p. 817.

Dean and Marnoch, J. Anat. and Physiol., London, 1893-94, p. 77.

Fabbrovich, Gazz. d. Osp. Milano, 1894, Vol. XV, p. 890.

Djemil-Bey, Ann. de Gynec. et d'Obstet., Paris, 1894, Vol. XLII, p. 333.




KUCHENMEISTER'S TABLE OF C.4.SES REPORTED BETWEEN THE YEARS 1582 AND


1880.



Case No.



Name of observer.


Number of births before the ectopic pregnancy.


Time wheu labor pains or symptoms of rupture occurred.


Length

of time

foetus

was

retained.


3^


he

11

Si


•sj

3"°


i|.g


M


Primary

site.


Age of the woman at death.



Escape of

decidua

from

uterus.


Return of menses.


Other births after the ectopic pregnancy.


Remarks.


1


1583


Albosius.


None.



28yrs.



1





Normal uterus.


66 years.


Yes.


Yes.





2


1659


Densius, Pont a Mousson.



6th month


?



1












3


1661


Schnorffs in Dole



9th month





1





53 years.




Yes.




4


1675


de Blegny (Toulouse).


10


Full term


28 yrs.




1




Tube.


25 years.



Prolonged purulent discbarge




Pregnancy in the uterine end of the Fallopian tube. Fcetal head in fundus uteri.


5


1719


Bompard.



7th month 2 days in labor.


15 yrs.





1



Uterus ?







Skeletonization and softening of the foetus with partial spontaneous extrusion.


6


1720


Orth, Steinkind,



Full term.


51 yrs.



1





Probably


91 years.





2




Von Leinzell.



Labor pains 3 to 4 weeks.








in one horn of uterus.








7


1728


Bianchi.


2


In the 9th month.


15 yrs.


1






Ovary.








8


1741


Bromfleld.



Fullterm.


9 yrs.


1






Uterus, perforation of the cervix uteri.








9


1747


Middleton.



Full term.


16 yrs.




1




Fimbriated extremity of tube.



Yes.




4



10


1748


Bourdon and Chamerau in Troyes.


1 miscarriage.


Fullterm.

Labor

pains 2

days. Fullterm.


30 yrs.


1






Right tube.


61 years.






Two incisor teeth in jaw.


U


1767


Heidelberg case


2


54 yrs.




1





91 years.


Yes.



Yes.


2 abor

Patient recovered




of Nebel.















tions.


after many weeks.


12


1775


Walter, of Berlin.


1


9th month.


22 yrs.




1




Right ovary.








13


1784




Fullterm.

Labor

pains for

3 days. Fullterm.


8 yrs.


1






Left tube.


45 years.



Yes.


Two years later.




14


1785


Varnier and


12


33 yrs.


1




1



One fcetus


75 years.


Escape of


Probably


18 months



One foetus fully




Mangin.



Labor pains tor many days.








in abdom. cavity, the other n sac communicating with uterus.



water

with

blood.


decidua.


later.



developed (9th month), the other 3 months old.


15


1786


MQhlbeck.


1


11th month.


U}i yrs.




1




Uterus.



Yes.





Foetus died in the 7th month.


16


1798


Cheston(ca8ell.


3


Fullterm. Labor pains 3 weeks.


50 yrs.


1






Uterus unicornis unicoUis (mit Nebenhorn).


80 years.







17


1798


Chcston (case 2).



Fullterm.


4 yrs.





1



Normal uterus.


Operated upon in 29th year.


Flow of fetid

water for 15 months



1 years after operation.




18


1800


Denmann.


Ifullterm. Many mis

9th month.


32 yrs.













History of case very imperfect.


19


1802


Von Weinhardt.


carriages.


Near the


7 yrs. to the time


1






Probably



Yes, one


Blood and




Recovery.






7th







extra


week.


fleshy









month.


of operation.







uterine.




matter.





20


1805


Cad well.


No.


Fullterm. Labor pains one


26 yrs.




1




Retained in uterus.




Yes.




Died from operation performed through the .cer

21


1806


Grivel.



day.








Abdomen.


8;) years.






vix.


228


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 80.


KUCHENMEISTER'S TABLE OF CASES REPORTED BETWEEN THE YEARS i582 AND 1880. -Continued.


1819


Seller.


1819


Prael.


1830


Bruns.


1831


nonisch.


1825


Cruveilhier.


1828


Lee Heiskell


1832


Stoltz.


Case reported from the city of Danzii?, author not cited.

Bondet.


Virchow.

Will.

SteiQ in Steinau


Playfair.


Chiari.

Galli.

Deschamps.


Kuchenmeister.


Number of births before the ectopic pregnancy.


I full

terms, 3 abortions.


Time when labor pains or symptoms of rupture occurred.


At the end of the 9th month


No symptoms of labor.


Full term, 3 days long.


End of the

9tb

month


Labor pains at full term

Labor pains at full term

Full term. Labor pains continued 3 days.


Full term. Labor pains 14 days.


8th month.


49yrs


75 months.


87 yrs


Pull term. Labor pains for 3 days.


7yrs.

yrs.


Full term.

Labor

pains 33

hours. Full term.

Few days.


11 yrs

67 yrs


Length

of time

fa'tus

was

retained


46 yrs. 28 yrs.


7 yrs. up to time of operation. 47yis.

40 yrs.

2 yrs.


26 yrs. 10 yrs. >iyr.


^yr.


Abdomen. Uterus.


3.. tube

and ovary Abdomi

oal cavity Posterior

wall of

uterus

and its

adductor.

Possibly

in one

corner of

uterus. Abdominal cavity.


L. ovary. L. ovary?


R. ovar. and parov.


Tube and ovary.


Fimbriated end of left tube and 1. ovary

Inonecornu uteri.


Tube and ovary.


Canalis intercanaliculi.


Age of the woman at death.


) years. ! years.




Escape of decidua

from uterus.


Small amount of blood.


Bloody discharge.


4 months after the death of the fcetus.


Nine days after the death of

foetus.


Nine days after the death of foetus.


2S'5.D


Spontaneous delivery through vagina and rectum.


History of case imperfect.

Recovery. Fcetus removed through the vagina.


Vienna paste applied to the sac per vag. Before it was eroded the patient died.


The foetuswas more than a half year over term before it was delivered.


4 times delivered artificially


The foetus was undergoing suppuration.


ON TUBERCULOSIS OF THE (ESOPHAGUS, WITH THE REPORT OF A CASE OF UNUSUAL INFECTION.

By Claribel Cone, M. D., Professor of Pathology, Woman's Medical Colli ge, Bait i more. [From the Pathological Laboratory of the Johns Hopkins University and Hospital.^


Keuewed attention to the subject of tuberculosis of the oesophagus has shown that this organ is not so often spared in tuberculous affections as was at one time believed. Thus, in a critical review of the subject published in 1893, Dr. Flexner,* who reported a new case, was able to collect from the literature up to that date only eighteen undoubted cases. Since his publication there have appeared, so far as has come to the writer's notice, twenty-eight additional cases. Of these twenty-eight cases it is worthy of remark that nine were described by one observer, Mazzotti.f

Another case from this pathological laboratory is to be added to the list, and now that the affection is no longer recognized as of great rarity, its report is suggested as much by the peculiar distribution of the tubercles as by the pathological condition itself. It seems worth while at the same time to re-collect all the cases and to consider the classification with reference to their ajtiology.

The classification suggested by Flexner is as follows:

I. Instances in which the tuberculous process arises through continuity or contiguity of structure.

(ji) Where a caseous bronchial gland or group of glands becomes adherent to the cesophagus and ulcerates into the latter.

{b) In consequence of perforation of abscesses associated with caries of the vertebraj.

(c) Where tuberculous ulcers of the pharynx pass down and invade the cesophugus.

II. Cases in which there exists in the CBSophageal mucous membrane a previous lesion to be regarded as predisposing to the tuberculous infection.

III. Instances in which («) the cesophagus is affected in the course of a general disseminated miliary tuberculosis, and (b) in which there is infection of the mucous membrane from tuberculous sputum where no previous lesion existed.

Of the nineteen cases collected by Flexner,^ eleven belong to the first class, two to the second, and six to the third. In the first group are included the cases of Weichselbaum (1), Beck (2), Penzoldt (.3), Orth (2), Pitt (1), and Zenker (2) ; in the second group those of Eppinger (1) and Breus (1); while the third class includes the cases of Mazzotti (3), Spillman (1), Freriehs (1), and Flexner (1).

Of the six cases comprising the last group, one only occurred in the course of a disseminated miliary tuberculosis giving rise to an eruption of miliary tubercles in the cesophagus. This case, which was reported by Mazzotti, § is the only published account of miliary tuberculosis affecting the cesophagus.


  • KlexQer: Tuberculosis of the (Esophagus. .Toluis Hopkins

Hospital Bulletin, IV, 1893-4.

t Mazzotti : Nuove osservazioni intorno alia tuberculosi dell' esofago. Dal Bulletino d. Scienze IMediche ili Bologna, VII, ser. VII, 1896, 553-579.

X Flexner : Op. cit.

gMazzotti: Revisla Clinica, .Jannar, 1885.


The additional twenty-eight cases which have been reported since 1893, including cases omitted from Flexner's original publication, can be divided so that thirteen fall in the first, three in the second, and twelve in the third class.

A. — Infection by Continuity or Contiguity of Structure.

1. Selenkow* reported a case of partial destruction of the cesophagus by tuberculosis. Gastrostomy was followed by impaired nutrition and death. In the lungs were found old tuberculous lesions, which, approaching the root on the right side, invaded the lymph glands. The latter became adherent to one another, forming a diffuse caseous mass both anterior and posterior to the oesophagus, and finally ulcerated into the anterior wall of the tube below the bifurcation of the trachea. A cavity about the size of a hen's egg was produced in the enlarged and caseous lymph glands, which"" was filled with detritus and into which the lumen of the oesophagus opened freely. Two distinct perforations occupying an area 5 cm. long and separated by a narrow strip of tissue existed. The lumen of the cesophagus was constricted in the lower segment and was only about half the size of the upper part. Although no bacteriological or histological examination was made in this case, the tuberculous nature of the lesions can scarcely be doubted.

3. Voelckerf reports the case of a boy, aged 9 years, in whom the post-mortem examination showed a mass of cretaceous glands at the hilum of the right lung. On opening the cesophagus a perforation was found on the anterior wall, a little to the right of the middle line and a little below the level of the bifurcation of the trachea. The opening was about 5 mm. in diameter; the edges were puckered and led into a cavity in which caseous material could be seen.

Voelcker has also collected from 2504 autopsies in the postmortem records of the Hospital for Sick Children, four other cases of tuberculosis of the cesophagus associated with general tuberculosis, to which he briefiy refers.

3_4_5. lu three of these cases caseous glands ruptured into the cesophagus.J

Letulle§ reports three cases, one of Londe and two of his own.


  • Selenkow: Kasuistische Mittheilungen a. il. ausser-staJti.sclien

Hospital. St. Petershurger raed. Wochenschr., IX, 1884, 491.

fVoelcker, A. F. Caseous Gland opening into the (Esophagus. Tr. Path. So'c, Lond., XLII, 1890-91, 87.

|Tlie additional case was one in which an oval ulcer, threequarters of an inch long, existed at the level of the bifurcation of the trachea ; but in this case the note says: "The muscular coat remains, the floor is smooth as if healed up, although in the neighborhood of a caseatina gland. The ulceration, as far as could be seen, had not started froniorbeen in any way caused bythegland." The Ktiology in this case must certainly be regardid as doubtful.

§Letulle: Lesions tuberculeusesde I'oesophage. Bull. Soc. Anat. de Paris, LXVIII, 1893,246.


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6. Loude's case was that of a man 50 years old, who died suddenly of hfematemesis. The autopsy revealed a fistula in the anterior surface of the (esophagus immediately below the bifurcation of the trachea, still filled with blood aud leading into a small tuberculous cavity which had developed in a caseous bronchial lymph gland. The starting point of the tuberculous lesions was found in a miliary tuberculosis of the pleura which, invading the thoracic glands, produced caseation and calcification, and later adhesion between the affected bronchial glands and the oesophagus, with ultimate perforation of the latter.

7. Letulle states that his first case was very similar to that of Loude and omits in his publication all details.

8. His second case occurred in a young man, the subject of a tuberculous empyema which had ruptured into the oesophagus. On microscopic examination the cesophagus showed infiltration of the muscular and submucous coats with embryonic cells, little caseation and no giant cells. Tubercle bacilli were not found.*

K. Zenker! adds four cases, of which two belong to the present class.

9. In the first case the tuberculous lesion of the cesophagus occurring in a young consumptive was accidentally discovered at autopsy. The tuberculosis originated in the lungs, spread to the bronchial lymph glands, the peri-glandular tissue, and the cesophagus, infiltrating the walls of the latter from without inward until ulceration and perforation were produced. The mici-oscopic examination showed tubercles in the muscular and submucous coats chieily, and numerous tubercle bacilli.

10. Zenker's second case was a man 46 years old who had tuberculosis of the serous membranes. The bronchial glands were considerably enlarged and caseous, and had ulcerated into the cesophagus at its mid-portion in three places. The histological examination of theresophagus showed tuberculous infiltration of the muscularis and submucosa, while the epithelium was scarcely affected. In the neighborhood of the ulcers, tubercles were found in the submucosa. These contained tiibercle bacilli.

11. A case reported by DanelJ: also belongs to this group. There were tubercle nodules in both lungs, general glandular enlargement, and tubercles, some of which had ulcerated in the mucosa of the pharynx. The (Esophagus in its jiosterior portion showed an extensive ulceration of the mucosa. The ulcer was about 10 cm. long and extended longitudinally. Its edges were eroded and it contained granules resembling tubercles. Other nodules taken to be tubercles were found


  • The validity of this case may well be questioned. Mixed infections in empyema are by no means unknown, so that the possibility of the invasion of the oesophagus by other micro-organisms

(pyogenic cocci?) is well worth considering.

f K.Zenker: Carcinom und Tuberkel in selben Organe. Deut. Arch. f. klin. Med., XLVII, 1891, 191 ; Beitrag zur Aetiologie und Casuistik der Tuberculose der Speiserohre. Deut. Arch. f. klin. Med., LV, 1895, 405.

I Danel : CEsophagite tuberculeuse consecutive ii une ancienne tuberculose peribronchique generalisation ganglionnaire. J. d. Sc. med. de Lille, XIX, 1896, 1, 520.


on the anterior surface. The cause of the infection of the cesophagus was a softened bronchial lymphatic gland situated at about the bifurcation of the trachea, which, having become adherent to the oesojihagus, perforated into this organ. The opening between the gland and the cesophagus measured about 1 cm. Although no histological or bacteriological examination was made, there can be no doubt of the specific nature of this case.

Of the nine cases added by Mazzotti to the three previously reported by him only one belongs to the present group. He confirmed his diagnosis of tuberculosis in each case by the demonstration of tubercle bacilli. His experience is remarkable, not only because of the large collection of cases of a pathological condition, the rarity of which is generally acknowledged, but also because of the predominance among them of that form of lesion which is admitted to be most infrecjuent. In eight of his cases the process began within the cesophagus, while, as stated, in one only there was an extension inward from caseous bronchial glands.

12. This case was that of a man aged 21 years, who died of pulmonary and intestinal tuberculosis. The oesophagus at the union of the upper with the middle third showed two ulcers, one near the other, somewhat elongated and of the size of a nentedmo. The edges of the ulcers were smooth and of a greenish color ; the irregular bases were also green. The ulcers perforated all the coats of the cesophagus, and their bases were formed by a collection of detritus situated under the cesophagus itself, and found to proceed from softened caseous bronchial glands. Two similar ulcers, also close together, communicating with each other beneath the mucosa, were seen at the junction of the middle and lower thirds of the oesophagus ; while yet below, were small superficial elliptical ulcers in the longitudinal direction of the canal. The lymph glands had also ulcerated into the left bronchus just at its origin from the trachea.

13. A case arising through continuity of structure is reported briefly by Birch-Hirschfeld.* At the autopsy (sex and age not given) there were found tuberculosis of the lungs and numerous tuberculous ulcers in the larynx, pharynx and upper third of the oesophagus. Tubercle bacilli were demonstrated.

B. — Pkedisposition to Infection due to a Previous Lesion.

1. K. Zenker's third case was an example of coincident carcinoma and tuberculosis of the cesophagus. A stricture of the tube, produced by a girdle ulcer of rodent character, existed, which on microscopic examination showed the typical appearance of squamous epithelioma. This growth invaded the deeper strata of the mucosa and at times penetrated the muscularis. In the border of the cancerous portion, toward the normal tissue, typical tubercles existed, some of which were caseous. The neighboring lymph glands also were involved in the cancerous and tuberculous conditions. Tubercle bacilli were found in small number in the tubercles.

Zenker does not commit himself as to whether the carciiio


  • Birch-Hirschfeia: Lehrbuch der path. Anat., II, 1894, 620.


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matotis or tuberculous lesion was primary, but favors the former view because of the admitted resistance offered by the intact epithelium to tuberculous infection.

2. In this group of cases the one reported by Cordua* is to be placed.

A man 60 years of age came to autopsy, the clinical diagnosis of carcinoma of the oesophagus, incipient pulmonary tuberculosis, and adhesive pleuritis having been made. In the (esophagus, at about the bifurcation of the trachea, was found an ulcer 10 to 15 cm. long, which affected this structure in its entire circumference. The edges of the ulcer were somewhat elevated and firm; the base was very soft and pulpy. A sound could be passed from the middle of the ulcer far into the pericesophageal tissues, but not into the air passages. Upon sectioning the ulcer, the entire wall of the oesophagus was found to be almost destroyed, forming a small tumor mass. The microscopic examination showed, in addition to the carcinomatous, a tuberculous infection. Tubercles in process of caseation were found in the middle of the cancerous ulcer and about its periphery. Careful search failed to reveal tubercle bacilli.

Cordua favors the view that the tuberculous invasion of the cancerous ulcer took place through the lymphatics leading from tuberculous areas in the lungs ; and he assigns as reasons for his belief in this mode of infection, the absence of cancerous metastases and the presence of coal pigment in the lymph glands, the deep location of the older tubercles in the cancerous ulcer, and the more superficial situation of the younger ones. It would seem, however, more probable that the secondary tuberculous infection was due to sputum deglutition.

3. Pepper and Edsallf report the case of a man, 42 years of age, who had tuberculosis of the lungs, larynx, cervical glands and ojsophagus. The oesophagus was patulous and normal as high up as the level of the arch of the aorta. Above this point and to the junction with the pharynx, the lumen had entirely disappeared. The oesophageal walls and surrounding tissues had formed a band of dense fibrous tissue, about 1.35 cm. thick and 3.75 cm. broad, which was firmly bound to the vertebra. Sections of the growth examined microscopically showed cancerous tissue in a dense fibrous tissue basis, tubercle-like masses undergoing fibroid change, an occasional giant cell, and tubercle bacilli.

The central and deeper portions of the tumor were composed mainly of fibrous tissue, and this appearance led the authors to conclude that tuberculosis was evidently the original cause of the disease, while cancer subsequently infiltrated the occlusion. (?) That the cancer was primary they consider improbable, both from the microscopic appearance of "infiltration of a previously existing mass, and from the history of cancer being here as elsewhere one of inexorable growth and onward progress, ulceration, and sloughing."


  • Cordua: Ein Fall von krebsig-tuberculosem Geschwiir des

Oesophagus. Arbeiten a. d. pathologischen Institut in GiJttingen, 1893, 147.

f Pepper and Edsall : Tuberculous occlusion of the rosophagus with partial cancerous infiltration. Amer. Jour, of the Med. Sci., CXIV, 1897, 44.


C. — Infection of the Intact Membrane directly (by Sputa) or from the Circulating Blood.

This class embraces those lesions which heretofore were regarded as most unusual, but which from Mazzotti's experience must rank in frequency with those described in class I. The eight cases of Mazzotti belonging to this group would seem for the most part to have been caused by the deglutition of tuberculous sputum, though the coexistence of ulcers and nodules makes it difficult in some instances to differentiate certainly the inoculation of tuberculous sputum from infection through the blood.

1. The first case reported by Mazzotti was a woman, aged 33 years, who died of pulmonary and (Esophageal tuberculosis. At autopsy the mucosa of the ossophagus, normal in its upper part, was found reddened below. The redness increased in intensity from above downward, becoming scarlet near the cardiac orifice of the stomach. On this red base were scattered numerous tuberculous ulcers. These were small and superficial in the upper segment, measuring several millimetres in diameter, becoming larger lower down, until near the cardiac orifice of the stomach several of them coalesced, forming an extensive loss of substance. The large ulcer thus produced was more irregular and deeper than the others, extending indeed to the muscular tunic.

2. The second occurred in a man, aged 40 years, who died of pulmonary phthisis. The oesophagus presented above, and in the anterior wall at its junction with the larynx, several white, rounded prominences, slightly larger than the head of a pin, with ulcerated centres. A little lower down there was an elliptical longitudinal ulcer with smooth base and slightly elevated edge, 5 cm. in circumference. Lower still, and rather near the end of the oesophagus, a yellowish nodule projected from the mucosa. This had ulcerated, and in all respects resembled the elliptical ulcer described. The mucous membrane in general was pale, but near the stomach there was some injection without ulceration.

3. The third case was a woman, aged 35 years, who had died of pulmonary tuberculosis. The (esophagus was normal in its upper part. At about the middle third the mucosa was of a greyish black color and contained several superficial ulcers with smooth margins and regular white bases. They were elliptical in the longitudinal direction. In the lower third the mucosa was pale, but here, too, were elliptical ulcers, smaller than the former, which they resembled in every other particular. The deepest of these ulcers scarcely reached the muscular coat.

4. The fourth was a man, aged 60 years, who succumbed to pulmonary and intestinal tuberculosis. The mucosa of the oesophagus in its lower half contained about 30 elliptical ulcers with smooth, regular margins and bases. They were smaller and more superficial above, but on descending the canal approached each other more closely, became larger and deeper, extending finally to the submucosa.

5. The fifth example was furnished by a male, aged 18 years, who died of pulmonary phthisis. Throughout the oesophagus were scattered numerous ulcers. They were elliptical in form, the larger ones being relatively longer than the smaller. In


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some places several ulcers were united in such a way as to present an irregular shape. In other places the ulcers were separated by little tracts of healthy mucosa, giviug the appearance of a network. They were not very deep, touching at most the submucous tissue, aud had greyish bases and smooth, regular, slightly elevated edges.

6. The sixth was a man, aged 67 years, in whom pulmonary and iutestinal tuberculosis were also found. In the oesophagus, three inches from its origin, was an ulcer of the mucosa 5 cm. in length. Near this were two small ulcers, while a little below was one of intermediate size. The remainder of the mucosa contained only smooth white elevations about the size of a piu-head. At the junction of the middle and lower third of the ojsophagus, was a diverticulum as large as the end of the little finger.

7. The seventh was a woman, aged 48 years, who presented the lesions of pulmonary and intestinal tuberculosis. In the lower two-thirds of the oesophagus the mucosa attracted attention by an intense redness which extended over a wide area. In the midst of this were twelve or fifteen ulcers of various sizes. The smaller ones were round, measuring 0.5 cm. in diameter; the larger were elongated, the diameter of the largest reaching more than 3 cm. The rest were all regular, with smooth superficial margins, except a single deeper one situated at the union of the middle and lower thirds.

8. Mazzotti's final case was a man, aged 61 years, who succumbed to pulmonary phthisis. The oesophagus in its upper part presented four or five scars several millimetres in length, with ulcerated centres, in the vicinity of which the mucosa was pale, but otherwise of normal appearance.

9. Zenker's fourth case belongs to this class. It occurred in a man 38 years old, who suffered from tuberculosis of the lungs, nose and throat, enlarged lymjDhatic glands, and stenosis of the oesophagus. At the autopsy, the oesophagus in its uppermost part presented a large superficial scar-like ulcer which included almost the entire circumference of the canal, and formed a marked constriction. At about its middle portion the oesophagus showed an elevated nodule the size of a bean, from which thiu pus escajjed. The bronchial and peri-oesophageal lymph glands were enlarged and caseous. The microscopic examination of the lesions in the cBSophagus exhibited the histological characters of tuberculosis, which was limited to the mucosa aud submucosa. Numerous tubercle bacilli were demonstratetl in the tubercles and pus.

Zenker* believes that the infection in this case was due to sputum deglutition, and brings forward the fact of the superficial character of the ulcers in support of this view.

10. Hasselmannf describes the case of a boy sis months old, in whom, in addition to tuberculosis of the oesophagus, there existed tuberculosis of the lungs and lymph glands. In the lower part of the oesophagus three crater-like ulcers were found which had no connection with either the trachea or the caseous lymph glands. The microscopic examination proved


  • Zenker: Op. cit.

t Haaselmann : Ueber Tuberculose des Oesophagus. luaug. -Dissertation, Miinchen, 1895.


them to be tuberculous in nature. The infection is believed to have taken place from the swallowed sputum.

11. The case reported by E. Friinkel* occurred in a man 33 years of age, who died of pulmonary and intestinal tuberculosis. The oesophagus contained a large number of yellowish spherical nodules about the size of a hemp seed, some with sujierficial loss of substance, others still covered with the intact mucosa. Adjacent to these were found small masses with irregular edges and uneven bases, and several small round ulcers with abrupt edges and perfectly smooth bases, averaging 3 mm. in diameter. The larynx, trachea and peritracheal lymph glands were quite intact. The microscopic examination of the lesions showed besides epithelioid and giant cells, tubercle bacilli.

Regarding the mode of infection in this case, Friinkel does not consider it possible to conclude certainly between a htematogenous origin and the inoculation of tuberculous sputum, but he inclines to the latter view.

1 3. Glocknerf describes a case which he regards as of haematogeuous origin, and which is peculiar in the limitation of the tubercles to the muscular coat of the oesophagus.

It occurred in a man, 48 years of age, in whom the autopsy showed old tuberculous areas in the apices of both lungs, tuberculosis of the pleura, peribronchial and mesenteric lymph glands, oesophagus aud viscera generally. The oesophagus at its mid-portion contained an irregular thickened zone, encircling the wall of the tube, 5 cm. in width, and from 5 to 7 mm. in thickness. On section of this thickened area it was found to consist of numerous caseous tubercles, varying in size from a piu-head to a hemp seed, irregularly infiltrating the muscular coat, to which they were strictly limited. The mucosa and submucosa were perfectly intact and freely movable over the deeper lying structures. The peri-cesophageal tissue was likewise free from diffuse infiltration, but contained several small strands with interrupted nodular swellings the size of a millet seed. These strands were interpreted by Glockuer as tubercle-infiltrated afferent vessels of lymph glands. The lymph glands in the neighborhood of the thickening, as well as those about 3 cm. above, were somewhat enlarged and caseous, but not abnormally adherent to the peri-cesophageal tissue. Microscopic examination showed the typical structure of caseous tubercles, and tubercle bacilli in great numbers were found.

Glockner regards this case as certainly of ha?matogenous origin and believes that he excludes all other modes of infection. Infection through continuity he eliminates by the absence of lesions in the continuous structures; direct inoculation of the inner surface of the mucous membrane is rendered improbable by the intact condition of both mucosa and submucosa; invasion from the peribronchial lymphatic glands, through lymph transport of tubercle bacilli, he excludes by the freedom from tuberculous infiltration of the peri-oesophageal tissue. In favor of hi^matogenous infection


  • E. Friinkel: Ueber Beltene Localisation lier TuberculoFC.

Miinch. med. Wochenschr., XLIII, ISOli, 27.

f Glockner: Ueber eine neue Form von Oesopliagns-Tuberciilose. Piag. med. Woch XXI, 1890, 114, 127, 138.




section of the esophagus showing discrete tubercles .opposed of epitheUoid a^d ^-* -Jl;^;; V" ™" node extending into the mucosa, Ha.matoxylin staining. /e,ss objeot.vc DO. e>e-p.cce No. 1.


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is adduced not only tlie peculiar localization of tubercles in the nuiscnlar coat of the resophagus, but also the dissemination of miliary tubercles in the viscera generally.

To this last series of cases may be added the one from this laboratory. It occurred in a colored man, aged 33 years, admitted to the surgical wards of the Johns Hopkins Hospital, service of Dr. Halsted, to whom we are indebted for the clinical notes. The history, however, has but little bearing upon the lesions in the resophagus, and may therefore be briefly stated.

Clinical History. The first admission to the hosi^ital was on September 16th, 1895, for an enlarged right testicle. There was a tuberculous family history. The patient had previously suffered from typhoid fever, gonorrhoea and syphilis, and for the past four years had been short of breath. His general health, however, had been good until a few months before admission. The examination showed, besides tuberculosis of the right testicle, a slight involvement of the right lung at the apex, and a dark and mottled condition of the mucous membrane of the mouth. The right testicle was removed, the wound healed promptly, and the patient was discharged from the hospital, October 22nd, 1895.

On February 7th, 1897, he returned to the hospital suffering with tuberculosis of the left testicle and cough. He failed rapidly and died March 1st, 1897.

The autopsy was performed by Dr. Flexner four hours after death. I shall abstract the protocol and give only the anatomical diagnosis and such notes as bear upon the lesions in the cesophagus.

A natomical Diagnosis. Kemoval of testicle (for tuberculosis) eighteen months previously ; tubei'culosis of epididymis and remaining testicle, seminal vesicles and prostate gland; generalized tuberculosis; chronic tuberculosis of lungs; peculiar nodular form of tuberculosis of spleen and kidneys ; tuberculosis of adrenal glands; Addison's disease; jiigmentation of mucous membrane of mouth.

The cesophagus shows in its lower two-thirds elevated dots and larger nodules in great numbei-s. None of these are caseous, but the smaller points resemble the individual tubercles found in the spleen, liver and other glands.

The tubercles in these organs are minute granulomata, submiliary in size, of pale grayish-white color, opaque and noncaseating.

Histological Examination. The elevated dots and nodules found in the lower two-thirds of the cesophagus are seen to be enlarged lymphoid follicles, invaded by miliary tubercles which at times become conglomerated. A section of one of the larger oval nodules, measuring 1.25x1.50 mm., contains nine small, pale, Irregularly circular areas of different sizes, with more or less definite contours, arranged in horse-shoe fashion around the periphery of the nodule. These pale areas contrast sharply with the more deeply-stained normal lymphoid structure.

Under somewhat greater magnification the pale areas are seen to consist of epithelioid cells, at times distinctly separated one from the other by irregular spaces in which are found sparsely scattered lymphoid cells. A scant reticulum holds these elements loosely together. The epithelioid cells are


round or oval, with abundant protoplasm and vesicular nuclei. The nuclei are round, oval, elongated or kidney-shaped. Some of these cells contain two or more nuclei, and occasionally is seen a well-defined giant cell with a mural arrangement of its nuclei. The epithelioid clumps are surrounded by lymphoid cells, but these cannot be differentiated from the normal structure of the lymphoid nodule. At other levels the nodule shows partial coalescence of the discrete tubercles, thus giving an appearance of more diffuse infiltration.

Other nodules examined show an appearance similar to that just described ; while the smaller dots, at times of microscopic size, often contain a single cellular tubercle.

Tubercle bacilli are present in small number.

Nowhere are the tubercles found outside the lymphoid nodules, and in no instance do they extend beneath the mucosa The oesophagus is otherwise normal.

The mode of infection in this case offers no difficulties ; it is clearly of hematogenous origin, the original focus being the diseased testicle. The case forms, together with the one instance of miliary tuberculosis of Mazzotti, excluding for the time the less certain cases of E. Friinkel and Glockner, the instances of undoubted blood infection of the cesophagus.

No other instance of the localization of the tuberculous lesions in the lymphoid structures of the oesophagus has thus far been published. According to Diirck* the relative insusceptibility of the cesophagus to tuberculosis depends in part upon the slight development of its lymphatic apparatus. There is, however, no great dearth of small nodular accumulations of lymphoid cells in the snbmucosa and mucous membrane of this organ, which may after all be oftener the seat of tubercles than is generally considered. The insignificance of these structures, even when, as in this case, they are involved in a general tuberculosis, may easily lead to their being overlooked. Without the microscopical examination of many different segments in a given case, the disease could readily escape observation.

The relative immunity of the oesophagus from other forms of tuberculosis, especially from those varieties included under classes II and III, may be explained in part upon purely mechanical grounds; namely, the rapid passage of infectious material over the mucous membrane of the oesophagus, and the resistance to such infection offered by the stratified pavement epithelium.

A review of the entire subject tends, however, to modify considerably the opinion once held that tuberculosis of the oesophagus arises in a large majority of cases through continuity or contiguity of structure. Thus, of the total fortyeight cases collected, only twenty-four took origin in this way, five arose through the addition of the tuberculous process to a previous predisposing lesion, four by blood infection, while the remaining fifteen arose through the inoculation of the mucous membrane by tuberculous sputum, without the existence of a previous demonstrable legion.

The study of this subject was undertaken at the suggestion of Dr. Flexner, to wliom the writer is indebted for kind assistance in the preparation of these notes.


  • Durik: Ueber Tub('ii;ulu.se iles Oesopljagus. Ergebniste <ler

Palhologie, I, 1897.


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A RARE ANOMALY OF THE ARCH OF THE AORTA, WITH AN ADDITIONAL MUSCLE IN

THE NECK.


By a. B. Herrick.


The variation herewith reported is from the cadaver of a negro dissected in the Anatomical Laboratory of the Johns Hopkins University. With the exception of the snpernume rary muscle, the variation can easily be explained by an arrest of the development of the aortic arches, showing also that in these cases the inferior laryngeal nerve is no longer held down by the fifth aortic arch and drawn into the chest.



a.. HE


Fig. 1. The aortic arch and its branches, showing their relations to the trachea and oesophagus, and the position of the recurrent laryngeal nerves.

00, common trunk of the two carotids ; RS, right subclavian ; LS, left subclavian; KC, right carotid ; iC, left carotid ; iJF, right vagus; LV, left vagus; RRL, right recurrent laryngeal; LRL, left recurrent laryngeal.

The number of arteries arising from the arch was normal, but their arrangement was unusual ; the two carotids arising nearest the heart by a common trunlv, then the left subclavian, and lastly the right subclavian passing behind the trachea and oesophagus. The common trunk of the two carotids is about 10 mm. in length and arises from the beginning of the transverse arch. The left carotid passes vertically upward, while the right passes transversely in front of the trachea, and at its right border turns upward to take its usual position. The left subclavian takes its origin from the highest part of the arch and follows the usual course. The right subclavian, however, arises just behind and to the right of the left, and almost immediately passes transversely behind the oesophagus to the right side of the body. It


extends beyond the cesophagns for about 8 mm., then turns upward 25 mm., and passes outward behind the scalenus anticus, reaching a point a little higher than normal, after which it continues downward in its usual course. The accompanying figure gives the origin and relation of the blood-vessels to one another. 'I'he vertebral arteries arise as usual.

The inferior laryngeal nerve on the left side arises from the vagus in the usual way, while on the right side it is not hooked around the subclavian, but passes directly from the vagus to the larynx in the neighborhood of the lower border of the cricoid cartilage.



Fig. 3. Diagram showing the mode of development of the great arteries in this anomaly. (Modilied from Quain's Anatomy.)

A U, union of aortie ; RS, right subclavian ; LS, left subclavian ; CC, common carotid; 7C, internal carotid; £'C, external carotid; P, pulmonary trunk ; V, vagus ; RL, recurrent laryngeal ; 1, 2, 8, 4, 5, aortic arches.

The origin of this anomaly is easily understood when the development of the aortic arches is taken into consideration. The scheme of the development of the aortic arches is shown in Fig. 2. As the successive bronchial arches are developed they receive within them, passing from their ventral to their dorsal side, the aortic arches. These encircle the pharynx and are collected into two descending aorta\ wliich later on unite. The isoint of union is represented in the figure at A U. Hand in hand with the development of the aortic arches, the ganglia of the nerves arise from the neural crest and at first lie lateral to the arteries. A twig from the vagus passes over to the pharynx behind the fourth branchial arch, and crosses the fifth aortic arch at right angles. The descent of the vessels into the chest throws the vagus on the ventral side of the aortic arches, and the twig to the pharynx being caught by


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the arch, becomes elongated to form the inferior laryngeal nerve.

In the diagram that portion of the arches which is to remain to form an anomaly such as this is printed black, while the vessels which are to disappear are only outlined. Through some mishap the fourth arch on the right side degenerated, thus liberating the inferior laryngeal nerve, while the circulation with the right arm was continued through the descending aorta of that side. By the later enlargement of these vessels the origin of the right subclavian was next shifted over to the left side of the body, thus making it arise immediately below the left subclavian from the arch of the aorta.

This variation has already been described by a number of authors,* but in this specimen the presence of an additional muscle within the neck adds interest to it and may possibly be the cause of this rare anomaly.

The anomalous muscle. — This muscle was present on the right side of the neck, as a thin, narrow, ribbon-like body, five centimetres in length, and in appearance resembled the anterior belly of the omohyoid muscle, as Fig. 3 shows. It arises from the anterior tubercle of the transverse process of the fifth cervical vertebra, and is inserted by an expanded aponeurosis into the posterior border of the clavicle. This expansion greatly resembles a fibrous arch, being easily detached from the bone at its center, but is firmly adherent at each lateral margin, which corresponds with the junction of the middle with the outer and the inner thirds of the clavicle.

Henlef considers this muscle as a variation of the omohyoid, regarding those specimens where either the anterior or posterior belly of the muscle is inserted into the clavicle as a


  • Meckel, Pathologische Anatomie ; Henle, Handbuch der Anatotnie; and Quain, Commentaries on the Arteries.

\ Henle, Anatomie, III, S. 121.


transition stage between the normal, and this rarer anomaly. This muscle may take its origin from any or from all of the middle cervical vertebrae.



/"ON


a.H.t.-(A


Fig. 3. The positiou and relations of the supernumerary muscle in the neck.

AM, additional muscle ; SA, scalenus anticus ; <SJ/, sterno-mastoid ; ST, steruo-thyroid ; SH, sterno-hyoid ; AOH, anterior belly of the omohyoid ; POH, posterior belly of the omohyoid ; 7", trapezius ; V, vagus; P, phrenic; BP, brachial plexus; S, subclavian; C, carotid; AT, anterior tubercle of the fifth cervical vertebra.

If it is true that the muscles in their development shift their position so that their attachment in the adult is only secondary, then we can see in this muscle a summation of the additional attachments of the two ends of the omohyoid. In one instance the posterior belly arises altogether or by an additional slip from the clavicle; in the other instance the anterior belly is inserted, by an additional slip, to the transverse process of a cervical vertebra. In the specimen reported these two variations are blended into a new muscle, and the omohyoid remains normal.


ON THE H^MATOZOAN INFECTIONS OF BIRDS.

By W. G. MacCallum, M. D. (Johns Hopkins), Johns HojMns Hospilal, Baltimore.


In the adult examples of the Halteridium of Labbe, which occurs abundantly in crows in Ontario, Opie in 1896-7 pointed out a distinction between two forms — a hyaline, non-staining form, and a form which is granular and takes on a comparatively dark stain with methylene blue — and suggested that the hyaline form alone might become flagellated. This distinction is readily confirmed, and it is a fact that only the hyaline forms become flagellated, the granular forms being extruded, and lying quiet as spheres beside the free nuclei of the red corpuscles which lately contained them.

Motile fusiform bodies, identical with the "Vermicnlus" described by Danilewsky in his " Parasitologie comparc'e du Sang," in 1889, are seen after fifteen or twenty-five minutes to develop from these quiet spheres and wander away. By careful watching of the two adult forms on extrusion from the


corpuscle, it is seen that the flagella from the flagellated forms, tearing themselves free, constitute themselves fertilizing agents or spermatozoa, and proceeding directly to the granular sphere, wriggle about it. One only of these gains admission, and plunges itself into the sphere, which after some agitation of the pigment becomes quiet for a period of fifteen or twentyfive minutes, after which it puts out a conical process, which grows and draws the protoplasm into itself, until we finally have the fusiform body with a small pigmented appendage and refractive, nucleus-like body such as was described by Danilewsky as a " Vermiculus." The origin of the vermicnlus is in every case exactly the same.

In other words, we have a sexual process with a resulting motile form, occurring under unfavorable circumstances, and comparable with analogous processes observed in the lower plants and animals.


236


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 80.


It is thought that a simihir process may be expected in the case of the human malaria.

The vermiculus moves actively and has great powers of penetration by means of its pointed anterior end, with which it breaks up the red corpuscles in its jiath, and it is thought that possibly it may penetrate the intestinal wall and escape as the resistant form which gains the external world. This idea is supported by the finding of free organisms in the mucous contents of the intestine.

In the organs, the connective tissue skeleton is one great storehouse of pigment, the branching cells being often loaded with foreign material. The endothelial cells are also yery generally jjigmented, and there occur in some of the organs, as well as in their blood-vessels, large makrophuges loaded with pigment and other debris. Many large jjhagocytic cells occur in various organs which engulf whole corpuscles with their contained organisms.

The organs fouud jngmented are, in the order of intensity of pigmentation, the spleen, liver, bone-marrow, intestine, kidney, adrenals and thyroid. The leucocytes take but little part in phagocytosis in the organs, although phagocytosis goes on actively in a slide of blood.

During the last week I have examined the blood of a woman suffering from an infection with the oestivo-autumiuil type of organism, in which a great number of crescents were to be seen. These in a freshly made slide of blood, with very few exceptions, retained their crescentic shape for only a few minutes. They soon drew themselves up, thus straightening


out the curve of the crescent while shortening themselves into the well-known ovoid form. After the lapse of 10 to 12 minutes most of them were quite round and extra-corpuscular, the " bib " lying beside them as a delicate circle or " shadow " of the red corpuscle.

After 20 to 25 minutes certain ones of these spherical forms became flagellated ; others, and especially those in which the pigment formed a definite ring and was not diffused throughout the organism, remained quiet and did not become flagellated. In a field where an example of each form could be watched, the flagella broke from the flagellated form and struggled about among the corpuscles, finally approaching the quiet spherical form ; one of them entered, agitating the pigment greatly, sometimes spinning the ring about. The rest were refused admission, but swarmed about, beating their heads against the wall of the organism. This occurred after .35 to 45 minutes.

After the entrance of the flagellum the organism again became quiet and rather swollen, but although in the two instances in which this process was traced the fertilized form was watched for a long time, no form analogous to the "vermiculus " was seen.

This is evidently foi' the human being what was foreshadowed by the organisms of the bird.

(In part an abstract of a paper read before the British Association for the Advancement of Science, August 24, 1897, and shortly to appeal', in extenso, in the Journal of Experimental Medicine.)


A CASE OF CAVERNODS ANGIOMA (VASCULAR NilVUS) OF THE TUNICA CONJUNCTIVA.


By Dr. H. 0. Reik.


James Minor, colored, aged 16 years, came to the Baltimore Eye, Ear and Throat Hospital, March 1st, 1897, for treatment of a growth on his left eye. His mother states that very shortly after birth a small, red, raised spot, probably twice as large as a pin-head, was noticed on his left eye. This statement is confirmed by the midwife ; there was no physician in attendance. For some time no change was noticed in the eye, but by the end of his first year the spot had increased some in size, and for the next five years continued to grow steadily, though not rapidly. It never seemed to give any pain nor did the tissue immediately surrounding it become inflamed at any time, so it was not considered necessary to consult a physician. The growth assumed its present size by the time he was six years old, and since then, his mother thinks, it has undergone little or no change. He consulted me simply because he desired, if possible, to have his appearance improved.

The tumor was quite noticeable even at some distance, but on close inspection, with the eye turned outward so that the cornea almost reached the outer canthus, an appearance like that seen in the accomjianying reproduction was obtained. (Fig. 1.) To the nasal side and about 3 millimetres removed from cornea was a dark purplish-red tumor about 15 mm. long, 3 to 5 mm. wide and 5 mm. in thickness, narrowed somewhat toward its upper extremity, which was rounded, and extending


below under the lid into the conjunctiva fornicis inferioris. Its anterior surface was convex, smooth and shiny, covered by conjunctiva, and two narrow, light bands of connective tissue ap23ear to pass almost horizontally across the tumor, thus producing a slightly lobulated appearance. Its posterior surface was slightly concave and rested in its entire length upon the lidbus ociili. The tumor was situated entirely in the lunica conjunctivcB bulbi, and one or two good-sized vessels passed from it below into the conjunctiva fornicis after pursuing a somewhat tortuous course. By pressure the tumor could be moved very slightly from side to side, but suflBciently to indicate that it was not adherent to the sclera. The plica semilunaris conjunctivcB was hypertrophied, slightly congested, and, when the eye was rotated inward, presented several delicate folds.

An incision was made in the conjunctiva near the outer edge of the growth, blunt-pointed scissors were then passed beneath the tumor and it was easily lifted off its bed. No hemorrhage was encountered until the base was cut well down in the conjunctiva fornicis, and even then the bleeding was slight.

I saw the patient last on March 28th. The wound was perfectly healed and the eye looked normal, save that the vessels mentioned before as connected with the tumor were still present, though greatly reduced in size.



Anterior portinn of Cross-Section.


NOVEMBEE, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


237


The specimen was hardeued in formalin and embedded iu celloiden. .Sections were cut in different directions through the growth and stained in hsematoxylin and eosin, picro-carmine, methylene-blne and lithium-carmine.

Under the low power the tissue seemed to be composed of a loose connective tissue with many small areolar spaces and to contain very numerous blood-vessels. These vessels run in every direction, and within a small radius one sees various sections of them, taken in their long axis, obliquely or crosswise. In addition, in the most vascular parts of the tumor, large blood spaces are to be made out with tolerably thin walls of connective tissue, walls which in places appear to be lined by endothelium, though this is not easily made out everywhere. These cavernous spaces show thin connective tissue bands running across them, lined by endothelium, and one can think of there being partial or complete partitions separating adjacent thin-walled sinuses.

By the higher power the connective tissue is seen to consist mainly of the white iibrous variety, loosely constructed and not very rich in connective tissue corpuscles. The anterior surface of the periphery of the growth is covered by conjunctival ej^ithelium, below which is a narrow band-like area of round cell infiltration. The endothelial cells lining the numerous small vessels are easily distinguished and the lumina of the vessels are filled with blood. The relative proportions of the different varieties of leucocytes, so far as could be judged, were not abnormal. (Fig. 2.) The tumor is then, histologically, a cavernous angioma, or it may be called if preferred, a vascular nfevus.

A careful search of literature for any similar cases which might have been reported has served to show us how very rare they are. As the distinction between angioma and vascular nsBvus is not a very clear one, depending apparently upon the question as to whether the tumor is actively growing or is remaining stationary, it occurred to me that various writers might have made different classification, so I looked not only for reports of angioma, but of vascular nasvi and telangiectasia as well. I could not believe that these growths were so extremely rare as this search would make it appear. So far as I am aware only one case has heretofore been reported in this country, that of Lippincott, and I have been able to find only two others in the English language, both by Dr. Simeon Snell, of London. One of Snell's reports is accompanied by a colored plate, and the shape, size and position of the tumor give it a strong resemblance to my own. No microscopical examination of either of his cases is mentioned. Lippincott's* specimen was examined by Prof. Whitney, of Harvard, and is described as a cavernous angioma. Rampoldi and Stefanini,f Armaignac,J Dubois, § Talko,|| Van Amnion and BlessigT[ have each described or mentioned one or two cases. Bossalino and


•Trs. Am. Oph. Soc, vol. 7, p. 372.

fAnn. di Ottal., Pavia, 1884, vol. XIII, p. 75.

t Rev. Clin. d'Ocul., Paris, 18S6, vol. VI, p. 73.

SAnal. d'Ocul., Brux., 18.55, vol. XXXIV, p. 267.

1 Klin. Monats. f. Augenh., Erlangen, 1873, vol. XI, p. 335.

IGrsefe and Saemisch Handbuch, vol. IV.


Hallaner,* Reichfand KroschinskiJ have each reported a single case accompanied by histological reports, and their findings are essentially similar to those described in the present case.

Fuchs in his treatise on diseases of the eye says "Angiomata of the conjunctiva are of rare occurrence. They are as a rule congenital and increase iu size after birth."

Noyes says that "Angioma of the conjunctiva sometimes occurs. Its most frequent seat is the caruncle." Neither of these authors mentions na^vi of the tunica conjiiitctiim hilhi.

"Angioma of the conjunctiva," says Saemisch, "either spread there from a palpebral tumor or develop pi'imarily in that membrane. They are mostly congenital and occur as a rule in the neighborhood of the inner commissure, or, exactly, on the plica semi-hmaris conjunctivce." He advises their removal, "because after remaining unchanged for some years, they gradually increase in circumference, and through narrowing of the conjunctival sac, and later by jjrojection from the palpebral fissure, become quite troublesome."

These tumors developing primarily in the conjunctiva, according to Virchow, "are very rare and seldom progress beyond the nfevus stage, although an occasional observation of more extensive growth is known."


BOOKS RECEIVED.


Exercises in Practical Physiology. By Augustus D. Waller, M.D., F. R. S. Part III. Physiology of the Nervous System, ElectroPhysiology. 1897. 8vo, 91 pages. Longmans, Green & Co., London.

Transactions of the Association of American Physicians. Twel f th Session, held at Washington, D. C, May 4, 5 and 6, 1897. Vol. XII. 1897. 8vo, 510 pages. Printed for the Association, Philadelphia.

The Diseases of Women. A Handbook for Students and Practitioners. By J. Bland Sutton, F. R. C. S. Eng., and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. Edin. 1897. 8vo, 436 pages. W. B. Saunders, Philadelphia.

A Text-book of Diseases of Women. By Charles B. Penrose, M. D., Ph. D. 1897. Svo, 529 pages. W. B. Saunders, Philadelphia.

Tuberculosis of the Oenito- Urinary Organs, Male and Female. By N. Senn, M. D., Ph. D., LL. D. 1897. Svo, 317 pages. W. B. Saunders, Philadelphia.

Transactions of the American Gynecological Society. Vol. XXII. 1897. Svo, 321 pages. Wm. J. Dornan, Printer, Philadelphia.

Twentieth Century Practice. An International Encyclopedia of Modern Medical Science by Leading Authorities of Europe and America. Edited by Thomas L. Stedman, M. D. In twenty volumes. Volume XII: Mental Diseases, Childhood, and Old Age. Svo. 1897. 849 pages. W. Wood & Co., New York.

Lectures on th^ Malarial Fevers. By William Sydney Thayer, M. D. 1897. Svo. 326 pages. D. Appleton & Co., New York.

Fifteenth Annual Report of the Provincial Board of Health of Ontario, being for the Year 1896. Svo. 165-|-cliii pages. 1897. Printed by order of the Legislative Assembly of Ontario, Toronto.

Incompatibilities in Prescriptions. By Edsel A. Rnddiman, Ph.M., M. D. First Edition. 1897. Svo. 264 pages, .lohn Wiley & Sons, New York.


♦Archiv f. Ophthalmologie, Leipz., 1895, vol. XLI, p. 186. •f CentralUl. f. prakt. Aiigenheilk , Leij)/,., 1877, vol. I, p. 176. JBeitriige zur Augenheilkunde, June, 1894.


238


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 80.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel C. Oilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.

William Osler, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice

of Medicine. Henry M. Hurd, M. D., LL. D., Professor of Psychiatry. William S. IL\lsted, M. D., Professor of Surgery. Howard A. Kelly, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.

William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. Robert Fletcher, M. D., M. R. C. S., Lecturer on Forensic Medicine. William D. Uooker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. Thomas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flexner, M. D., Associate Professor of Pathology. J. Whitridoe Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy. William S, Thayer, M. D., Associate Professor of Medicine. John M. T. Finney, M. D., Associate Professor of Surgery.


George P. Dreyer, Ph. D., Associate in Physiology.

William W. Russell, M. D., Associate in Gynecology.

Henry J. Berkley, M. D., Associate in Neuro-Pathology.

J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. Bloodgood, M, D., Associate in Surgery.

Thomas S. Cullen, M. B., Associate in Gynecology.

Ross G. Harrison, Ph. D., Associate in Anatomy.

Frank R. Smifh, M. D,, Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jones, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology.

Louis E. Livingood, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D., Instructor in &Iedicine.

Charles R. Bardeen, M. D., Assistant in Anatomy.

Stewart Paton, M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology.

Harvey W. Cushing, M. D., Assistant in Surgery.

J. M. Lazear, M. D., Assistant in Clinical Microscopy.

J, L. Walz, Ph. G., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. Tlie first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physiology, Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. "During the last two years the student is given abundant opportunity for the personal study of cases of disease, his time being spent largely in the Hospital Wards and Dispensary and in the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives :

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree In this university.

2. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.

3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be tilled out relating to their previous courses of study.

They are required to furnish certificates from oflicers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING. Applicants for admission to advanced standing must furnish evidence (1) that the foregoing terms of admission as regards preliminary training have been (ulQlled, (2) that courses equivalent in kind and amount to tliose given here, preceding that year of the course for atimission to which application ia made, have been satisfactorily completed, and [3| must pass examinations at the beginning of the session in October in all the subjects that have been already pursued by the class to which admission is sought. Certificates of standing elsewhere cannot be accepted in place of these examinations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance upon these courses has steadily inci'eased with each succeeding year and indicates gratifying appreciation of the special advantages here afforded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine are now given annually during the mouths of May and June. During April there is a preliminary course in Normal Histology. These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here ottered. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application.

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIAIORE.


The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may he procured from Messrs. CUSHINO £ CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a year, may be addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sinnle copies will be sent by mail for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. Vlll.-No, 81.]


BALTIMORE. DECEMBER, 1897.


[Price, 15 Cents.


COlsTTEaSTTS.


PAGE.

King Arthur's Medicine. By Geokgb M. Gould, M. D., and Walter L. Pyle, M.D., 239

The Presence in the Blood of Free Granules derived from Leucocytes, and their Possible Relations to Immunity. By Wm. Royal Stokes, M. D., and Arthur Wegeparth, M. D., - - 246

On the Anatomical Relations of the Nuclei of Reception of the Cochlear and Vestibular Nerves. By Florence R. Sabin, - 253

Typhoid Infection without Intestinal Lesions. By Simon FlexNKR, M. D., and Norman McL. Harris, M. B., ... 259


Apparatus for Sterilizing Instruments with Formaldehyde ; Experimental Tests. By II. 0. Reik, M.D., and W. T. Watson, M. D., --------- Proceedings of Societies :

Hospital Medical Society,

Exhibition of Specimens. — Fibroid Lung-Bronchiectasis — Brain Abscess [Dr. Livingood]. Notes on New Books, -------- Books Received, --..

Index to Vol. VIII,


KING ARTHUR'S MEDICINE.*

By George M. Gould, M. D., and Walter L. Pyle, M. D., Philadelphia.


" The Kynge Arthur toke the Kynge Ban, and the Kynge Bohors, and Merlin, and saide, ' Lete us go se oure felowes tliat be seke.' "

We Englisli folk are most fortunate iu that we have a literature of our racial adolescence which, certainly not excepting that of the Greeks, is infinitely richer and truer than any other, and pictures a people of far greater purity and power, beauty and bravery, loyalty and love. Although not "meek "we are still fated to "inherit the earth," and that inheritance has been gained because the man had a youth such as the Arthurian legends picture. The child is proverbially the father to the man, and peace and justice are to-day the enjoyment of the Indian, of the Egyptian, and of the commoners of England themselves, because Arthur's knights aud ladies were Avhat they were. To these legends we must progressively direct our attention as the purest materials of our future poetry aud inspiration. As now^here else, we here find a sincerity, an honor, an unbiased and uncolored revelation of the noble human heart not as yet spoiled by sin or selfconsciousness. And now— as Gleunie has pointed out — that science has come to us with its all-absorbing, all-transforming interest, revolutionizing most all methods and data of thought, these primitive records of our English and Cymric Paradise must become still more priceless aud precious ; for science has


  • Read by Dr. Gould before the Historical Club, Nov. 8, 1897.


not explained, and never can explain, life and character, and back to the time when life and character was (or was recorded to be) the sweetest and noblest ever conceived by the fancy of man we must ever go to find the comfort and inspiriting we so sadly need in ages of meanness, doubt, and selfishness. Of this early age and of its records Tennyson says that they

are —

"Touched by the adulterous finger of a time That hovered between war and wantonness, And crownings and dethronings."

To which our answer must be — Contemptible cant! With all our "progress " and self-conceit we cannot claim that we have lessened the adultery and the wantonness. War and crownings and dethronings have not been unlearued, but where are the courage, the banter, irony and humor, the give-all-to-love, the loyalty, the inerrant sense of and obedience to right, that made these men and women greater than all their joys and sorrows? Had we but also inherited the " honor rooted in dishonor " ! With relief we turn from the emasculate " Idylls " to the innocent sins, the personal warmth, the splendid vices, the thrilling pathos of these our ancestors for better poetry and more untarnished ideals than the effeminate and selfconscious echoes of later-day rhymesters. Better adultery with bravery and honor unto death, than adultery without these things !


240


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.


Study of these legends must therefore remain the pleasure and duty of those who love our race-spirit, and any new aspect of truth that may be gleaned from them must be rated as not without value even if it help but a little toward a final true comprehension. It is indeed difficult to keep the mind down to its task in attempting a distinctly medical gleaning. So many alluring glimpses, such paramount witchery, such dominant healthfulness is everywhere so manifest, the soul is so present and lordly, the body so forgotten, or so gloriously proud to serve in silence, that morbidity and therapeusis are kept from emerging out of the subliminal "Unbewusst." And our difficulty is doubled by the fact that it was so with them, and consequently they chronicled but a few hints, hid only a stray pebble or two which the medical mind may pick out beneath the gorgeous heap of flashing precious stones showered in our lap.

Although the specifically medical and physiologic findings are thus comparatively few and unimportant, their gathering and lessons are not unimportant; even for the corroborative testimony they bear to general mental and emotional characteristics, they would be worth the collecting and systematization. These beings really had bodies as well as loves, consciences, desires, and wills, and they are brought closer to us, our vision of them made all the clearer, and our love the warmer, by a recognition of their corporeal wants, woes, and wounds. But in the comparison of their medical science, or unscience, with that of later days, the physician finds at least historic lessons of professional interest well worth his labor, if indeed he were not more than compensated in other ways.

We must add another prefatory word, because it is, it seems to us, too little considered by our critics. We allude to the great difficulty — in the present state of criticism and research doubtless an impossibility — of distinguishing between the true records of premedieval life and the later additions. Malory, we know, made free use, but also free additions and changes as regards his texts. He was not the best editor in the world. But how much those who compiled the records he used changed and colored the earlier story, how far they truly represent to us the original documents — these things of course must at present make our deductions matters of some doubt. Perhaps it was five hundred years after Round-Table times that those wrote who served Malory with documents, and Malory himself was a thousand years removed. Where are the records of " Blayse the Mayster of Merlin that he did do wryte " ? But where are the snows of yester-year ? Internal evidence, however, tells us much, and, in reading, the alert sympathy is constantly aroused by the feeling that this or that is surely not the voice of frank Cymric childhood, but is the sorry tarnishings of the Latin-French media, the corruption of a self-conscious "civilization," or of a mind far removed from pristine juvenility and resilient buoyancy. Some time we shall perhaps know just how much each later age has added to and changed the primitive revelation — every such a debasing, certainly— and then we shall have a body of pure and luminous texts for our infinite reheartening and delight.

Despite Tennyson, neither war nor wantonness was the essential spirit, the inner Trieb of this age. Its dominant


characteristic, the source of both the war and the wantonness (thb latter a belieing and a belittling word), was the abounding sense of exuberant life, the fulness and immediacy of health that filled the actors and made of the women eternal models of das ewig weihUche, and so spurred the men that they were forced to find outlets for their inexhaustible physical energy in jousting, adventures, and feats of strength and endurance beyond our knowledge and belief. We are not mindless of the exaggeration of the hero-singer and the mythology-maker, but after all allowances have been made that a sceptical science may demand, the central fact remains that, physiologically speaking, these men were marvels of energy and endurance. Every page of Merlin and of Le Morte dariJnir bears witness of the fact. What modern athlete could don the helmet and coat of mail these men wore, much less carry them, nay, fight with them on and wield the huge glayves they used so effectually? The weight of the helmets is attested by the blows they resisted ; the strength of the arms that handled the swords is proved by the fact that the blows frequently clave through helmet and skull to the teeth. When one thinks of men in hot August days covered with these ponderous steel casings, head and face solidly bound with iron, and fighting all day long with the fiercest activity, one can only stand aghast at such wonders of bodily organization. It is perhaps useless to ask if the human arms are capable of certain feats that are frequently reported, as the cleaving at one sti'oke of a body through, or to the navel, the cutting off at one blow of a head and with such force that it rolls into the field.

Skill and strength for their own sake, the aim of modern " athletics," seem unknown. There are no evidences of useless games and braggart power, leading to nothing. Muscle jyer se is not the su7nmum honum. The everlasting jousting ajjpears the only game, but this was almost too serious to satisfy any purely "sporting" instinct, and it was of course in every case the actual and necessary exercise preparatory to dealing in life and death in the great business of the morrow. And even in this business of death one sees that simple physical power is, however necessary, only a secondary thing. It is the courtesy and honor, the moral energy and power of will and emotion behind the man's muscles that give the victory and that make him the beloved and revered.

Giants there are (some ridiculously large, by the help of Continental imaginations we suspect), but they are as hideous and detestable as the modern children's books could suggest. Giants and those only pihysically sti'ong are cowards and are always defeated by those whose strength is pre-eminently of the soul.

In this connection it might be noted that drunkenness and gluttony are not even suspected. There is here no all-day or all-night sitting at meat or drinking out of skulls till intoxication stops further drinking. There is "feasting," but with ladies always present, always in moderation, always with witty or serious converse, always as a preparation for something better. Moreover, the manner of its doing is always iu view rather than the matter — after bathing, e. g., and the putting on of clean clothes.

It was a superstition that a man's physical strength some


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times varied according to the time of day or the intensity of the sun's rays. It is said that "Syr Gauwayn had siiche a grace and gyfte that an holy man had gyuen to him, that euery day in the yere from uuderue tyl hyhe none hys myght eucreaced tho thre houres as moche as thryse hys strengthe, and tliat caused Syr Gauwayn to wyune grete honour."* Another reference to this curious belief is in that narrative of Sir Beaumayn, who is warned not to challenge the Knyght of the reed laund until afternoon, as all the forenoon his strength increased and at high noon be had the strength of seven men.

The surgical interest in the results of encounters is that most frequently excited. In the competitive jousts the object was to overcome by superior strength, skill and horsemanship. In them the mortality did not probably exceed that of a modern game of football or cross-country riding. To intentionally maim or kill was the greatest shame of which a knight could be guilty. Sir Launcelot is said to have nnhorsed five hundred knights, winning the victory over them all, and yet none is killed.

Even though severely wounded the spirit is not conquered ; with a spear-head in his side Sir Launcelot fights all day, overcoming more than thirty knights. And he recovers in a few days. In the conflict between Balan and Balin they "hadde eyther symtem other seuen grete woundes so that the lest of them myght have ben the dethe of the myghtyest gyaunt in the world." Sir Percyval and a knight inflict upon each other fifteen wounds, and they " bledde soo moche that it was merueyl that they stoode on their feet." Alysander " had no foote ne myght to staude upon the ertbe, for he had syxtene grete wounds and in especyl one of them was lyke to be his dethe." Exhaustion from profuse hemorrhage with the signs of extreme collapse is a frequent ending of a genuine combat. In such accounts the romancer's imagination is doubtless frequently evident, but in all the stories are descriptions too peculiar and detailed not to be the result of direct observation.

We find that it was quite possible to kill a man with a single blow. It is related that Marhaus kills a knight "stark dede " at a single encounter. The most common injuries were about the chest or side, as these were the points at which the spears were most directed. After an opponent is unhorsed a hand-to-hand combat on foot usually ensued, in which the principals hacked and struck at one another with swords ; and it is in these latter battles that the most serious wounds were inflicted.

Cerebral concussion is, of course, frequent. The modern lay description of " seeing stars " has its analogue in several passages. It is even said that a maiden gives Alysander such a buffet " that he thought the fyre flewe oute of his eyen." In one of his combats Sir Launcelot is struck on the helm so hard that " fyre sprange out of his eyen." Cerebral concussion followed by death, possibly by contrecoup, is evident in the account that Sir Gawayne smote his (helmeted) oppo


  • To save space we omit the references. They are from Sommer's

edition of Malory, the Merlin of the Early English Text Society, and the various French works obtainable, from which Malory drew his stories.


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

The common sign of basal fracture — hemorrhage froiji the nose, mouth and ears — occurs several times. How graphic is the account of Sir Launcelot's smiting of Sir Galahantyne on the helmet so " that his nose braste oute on blood and eeyrs and mouthe bothe, and ther with his hede hange lowe." He strikes another opponent so hard that the stroke "troubled his braynes, the blood brastynge oute of his mouthe, the nose, and the eres," and the knight falling to the earth as if dead. Syr Gareth and Sir Gaherys are also smitten " upon the brayne pannes " and killed. Arthur gives Sir Accolon such a buffet that " blood came oute at his eres, his nose and his mouthe." We read later that Accolon lived four days, and his ultimate death is attributed to the loss of blood, in ignorance of the fatal fracture. These symptoms, however, are not always precursors of fatality, for Sir Blamore has such a fall " that the blood braste oute at nose, mouth and his eres, but at the laste he recouerd well by good surgyens."

A noteworthy case of foreign body in the brain is that of Sir Marhaus, who was struck such a " myghty stroke" by Sir Trystram " that hit went thorou his helme and thorou the cayse of stele and thorou the brayn pan, and the swerd stak soo fast in the helme and in his brayn pan that Sir Trystram pulled thryes at his swerd or ever he myght pulle it out from his hede." " The edge " of the sword was left in " the brayne pan," and Marhaus ran groaning away. The foreign body could not be extracted by the surgeons, and at last caused the death of Marhaus. His sister, la beale Isoud, got the bit of sword, and by it her lover Tristram was identified as the one who had killed her brother — a great story well known and sung by later poets.

So mighty were the blows delivered on the head that we read of King Pellenore giving his opponent such a stroke on the helm " that he clafe the hede douue to the chynne that he fylle to the earthe dede"; and once more this mighty swordsman " clafe another hede unto the pappys " (breasts). A similar blow is delivered by Sir Launcelot, who " clafe his opponent's hede and neck unto the throte." Again it is said that Pellenore strikes King Lot " thorow the helme and hede unto the browes."

An occasional result of combat was a broken neck. Sir Florence rode against Sir Feraunt of Spain and " smote hym in the forhede and brake his uecke bone." Syr Gryffet ran unto a king, the fourth of his opponents, "and gaf hym suche a fall that his neck brake." Launcelot smites a porter under the ear with his gauntlet and breaks his neck. A mighty blow was that of Marhaus who smote his opponent so hard that " he brake his neck and the hors back."

An example of an injury to the neck, and a splendid sample of English irony is, "And Segramor lete renne to a Knight that com shovinge after hym, and he smote hym thourgh the throte that he fill deed up-right ; and thein he seide, ' Sir Knyght, with soche morsels I can yow fede and myn other enymes. Now be stille ther and a-bide hem that come after, and telle hem that this way gon the messagiers of the Kynge Arthur, that is theire rightfull lorde.'"


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Protected by the visor the face is rarely injured. We note once that the teeth were " stryken in tweyne."

For a similar reason thoracic wounds are usually non-penetrating. However, Sir Kehydius is wounded "on hyghe above the pappys" [bi-easts], and Gawayn gives an opponent such a blow that one " niyghte see bothe lyver and long," and again he smote a Saracen and " slitte hym down right so that men myght se his longes." Syr Tor smites his opponent through the " coost [rib or side] but the stroke slew hym not." The ribs of Arthur and of others are broken by the crushing embrace of another's arms. The single reference to cardiac injury we have noted is that whereby King Mark strikes his brother to the heart with a dagger. The wound was immediately fatal.

A remarkable abdominal and pelvic injury from a single blow is that whereby Arthur in a duel with agiant"hytte hym ageyn that he carf his bely and cutte of his genytours [genitals] that his guttes and his entraylles fylle doune to the ground." Sir Launcelot smites another giant " on the shoulder, and clafe hym to the navel."

Examples of transfixion from a single blow are found. Arthur smites Gryflet and " brake the spere that the troncheon stack in his body." A knight is " smote thorou shelde and thurgh the body." Launcelot smites a knight " thorugh the brest and thorou oute the back more than an ell." Probably the most interesting of this class of injuries is recorded in the description of the last combat in which Arthur smites Mordred "under the shelde wyth a foyne of his spere thoroughoute the body more than a fadoni." And yet thus transfixed, and with this wound, Mordred is able to push himself onward up to the hand-guard of the spear so as to reach his father, and before dying deals him bis death-blow, his sword cutting through the helmet to the brain — a ghastly and powerful deed!

It was a common belief that if a weapon entered the trunk, either very deeply or in a vital part, it should not be immediately withdrawn for fear of instant death. Bors pulls out a spear from his opponent's side and the man swoons. As Gawayne draws out a truncheon from Vwayne's side his soul departed from the body. Lauayne says to a wounded knight, " and I pulle oute the truncheon ye shall be in perylle of dethe." Later, Lauayne pulls the truncheon from the wounded man's side and the resultant symptoms are thus graphically described : " He gaf a grete shryche and a merueillous grysely grone, and the blood braste oute nyghe a pint at ones that at the last he sanke doun upon his buttoks an so swouued pale and dedely." That this was not the invariable result is shown by the fact that Sir Melyas drew out of his own body a truncheon, and swooned, but recovered in seven weeks by the aid of the ancient monk who had previously been a knight.

Vertebral fractures are occasionally mentioned and invariably spoken of as broken back. Sir Tristram smites an opponent's " back in sender." Sir Launcelot breaks liis opponent's back, and in another combat he broke the backs of four knights.

A curious wound of the buttocks is reported as happening to Launcelot, who by misfortune was shot accidentally by a


lady " in the thyck of the buttok over the barbys." It is further related that"thenne with grete payne the heremyte got ovte the arowes hede oute of Syr launcelots buttok, and mocheof his blood he shedde," "and the wound was passynge sore, and unhappyly smyten, for it was in suche a place that he myght not sytte in noo sadyl."

Of the injuries to the thigh we read that on one occasion Sir Tristram showed an arrow-wound of the thigh six inches deep. Launcelot is wounded by a boar that " rafe hym on the brawne of the thygh up to the houghbone " [hip-bone]. Sir Vwayne smites Edward so hard that " his swerd kerved [cut, carved] unto his canel-bone" [tibia]. In remorse, Sir Percyual " rofe hym self thurgh the thygh." Another reference to possible self-mutilation is found in the passage which says that Alysander, when told of the amorous intentions of Morgan le Fay towards him, replies that " I had leuer cutte away my hangers [testicles] than I wold do her suche pleasyr." Happily he was spared the necessity.

Amputations at a single stroke are frequently reported. A knight has an arm stricken away in combat ; Galahad smites off the left arm of an opponent ; Marhaus smote off a giant's " ryght arme above the elbowe "; Arthur peremptorily disposes of another giant named Galapas, "he shorted hym and smote of both his legges by the knees "; making the combat more equal as regards discrepancy in size of the participants.

Dislocations are spoken of in the following passages : King Pellenore's lady's horse stumbles and her arm is put " oute of lythe" [out of joint], and she almost swoons from pain; Launcelot bears down an opponent " soo that his shoulder wente out of lyth."

Fractures were not uncommon results of combats. Syr Dynas smites an opponent " that with the fall he brake his legge and his arm "; Sir Launcelot smites downe the Kynge of Northgalys who " brake his tliye in the falle "; another time Launcelot turns on a reviling mob "aud of some he brake the legges and the amies."

It is plain that the frequency of wounds and accidents made necessary those who should play the part of surgeons. It is, we think, almost equally sure that there was no official and separate profession. There is no record in the characteristic texts of any who made exclusive practice of surgery or medicine. In the Mahinogion, a book of Unarthurian and ajjochryphal character, it is recorded that Arthur " caused Morgan Tut to be called to him. He was the chief physician." It is supposed that this person was probably the same as that Morgan the Wise who prepared the ointment which restored Owain (Gawayne) to a state of health and sanity, in the romance of Ywaine and Gawin.*

In La Mort nu Roi Artus, the " maistre chirurgian" is several times spoken of who attends Launcelot, but later it is said that Boors sends the knight who healed Launcelot to the king, etc. Allusion to "the harbours of Bretayne" is, of


  • His reputation appears to have extemieil to Brittany, where the

inhabitants still call by the name of Morgan Tut an herh to which they ascribe the most universal healing properties. The name Morgan has been given to the Anthemis cotula, Linn, (rauuuuile) and Maruta cotula (dog-fennel).


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course, not Arthurian. There is no mention of a court physician in Le Morte darfhur, or Merlin. It is quite likely that had there been one, some mention of the fact would have been made, and the people would have deserted the hermits for this official physician, as it is said in Le Mort darthur, in speaking of the speedy popularity of Modred, " the people were soo newe fangle."

We have much evidence as to the disposition of the wounded. The sick and wounded were frequently sent to the monasteries and nunneries. Malory says that the hermits of those days were not like those of his time, but "held grete householde, and refresshyed people that were in distresse." It is a hermit who heals Sir Launcelot after one of his many accidents. After combat with Pellinore, Arthur "departed and wente untyl an ermyte that was a good man and grete leche "; Sir Palamydes goes to a nunnery to be cured. At the "lytel pryory " of Marhaus " laydes and damosels looked to their hurtes." In fact, not only the female inmates of religious asylums were skilled in dressing wounds, but many of the noble-women were experts in this art. Mayden Lynet comes to Sir Beaumayns and "serched his wounds, and stynted his blood." This damoiselle also stanches Sir Gareth's and Sir Gawayn's wounds. Tristram's wounds are "serched" by la beale Isoud, who was a " noble surgeon." She found in the bottom of this wound " poysou and heled him." It is said that after his fight with Marhaus, Tristram is searched by "alle manere of leches and surgeons both unto men and wymmen." Here there may possibly be indicated some distinction between a leche and a surgeon, such as arose later. The knights themselves were often skilled in surgery. Sir Baudewyn of Bretayn is called a"ful noble surgeon and a good leche." King Arthur attends on Syr Gawayn and " dyd so ransake his woundes and comforted hym." " Sir Mador was had to leche craft, and Sir Launcelot was helyd of his wound."

It is related of Sir Fercyual that he " stopped his bledyng wounde with a pyce of sherte" — an excellent bit of emergency-surgery.

Of the limitations of the power of the leeches we have ample proof. " Sir Gawayn laye seek thre wekes in his tentes with al maner of leche crafte that myght be had." Even malpractice was recognized, for, according to Tristram, Sir Marhaus "dyed through fals leches."

From these quotations it is made certain that what represented the practice of medicine was carried on by women and men without any official status or special training other than that picked up by aptitude, circumstances, and experience. The application of the terms surgeon and leche to women is indicative of the same fact and of the primitive simplicity of all the arrangements. There is little record of much more extended or varied treatment of the wounded than that of ransaklng and serchivg the wounds, stopping the flow of blood, applying salves, etc. The broken, dislocated, or amputated limbs and the thousand surgical diseases we know were left to the care of the vis medicatrix nnturm. The business of life was to give the enemy the wounds. Vae Vidis! These heroic children of our race stood before disease much as does a child of to-day, without discrimination, diagnosis, or sug


gestion of treatment. All diseases to them were alike mysterious. Where our nosologies register thousands, theirs saw but one — " sekenesse."

The pulse was a factor in diagnosis. Launcelot was found lying by a chamber door, and " they looked upon hym and felte his pouse to wyte whether there were any lyf iu hym." Malory shows knowledge of the blood-vessels iu narrating that Gawayn received a blow that caused a "grete wound and kytte a vayne, and he bledde sore." Sir Gareth is given a wound " a shaf tmon brode, and had cutte atwo many vaynes and senewes." Recent wounds were called " grene wounds." Trystram was so stirred by his desire for his fair bedfellow that "in his ragyne he took no kepe of his grene wound" and breaks it open. Disastrous results are attributed to the breaking open of wounds. Launcelot suffers this accident by getting on a horse too soon after convalescence. Gauwayn is stricken by Launcelot, and an old wound is broken open by the blow, which ultimately causes his death.

Just as infection of wounds is called by the laity of to-day " taking cold," so we read that Arthur tells Syr Bedwere he has taken cold and will soon die. After being sore wounded by Marhaus, Tristram "ful sore bled that he myght not within a lytel while when he had take cold unuethe stere hym of his lymmes" — a fact that may refer to inability to walk due to rheumatism contracted from exposure.

All wounds are treated by salves and ointments. Gawayn is healed of a wound by salve, and after the battle between Launcelot and Arthur, " to the wounded men they leid softe salues." Sir Gauwayn was borne " in to Kyng Arthur's pauyllon, and leches were brought to him and serched and salued with softe oynementes." After a battle " they putte salf unto the wounded men." It is evident when infection was expected, as after animal bites, which of course were supposed to be venomous, the wounds were carefully cleansed. After killing the great cat Arthur was led to his tent and unarmed, " and loked on the cracchinge and the bitiuge of the catte ; and the leches waisshed softly his wounds, and laide thereto salue and onyementes to cleanse the venym." There is a belief in the almost magical effects of some of the salves. Lynet undertakes to heal Gareth in fifteen days, "and thenne she leid an oynement and a salue to him." After his battle with Pellinore, a " hermyte serched all his woundys and gaf hym good salues," healing him in three days. Sir Pryamus heals his own and Gawayne's wounds by " a vyolle ful of the four waters that came oute of paradys, and with certain baume," in an hour they were "as hole as euer they were." This is plainly an oriental echo. Some of the styptic ointments were very severe, as Morgan le Fay searched Alexander's wounds and "gaf suche an oynement unto hym that he shold have dyed, and on the morne whanne she came to hym he complayned hym sore, and thenne she put other oynements upon hym and thenne he was out of his payne."

But there is occasionally slow convalescence from wpunds. Trvstram lies at a nunnery a half year to recover from a wound. Sir Vwayn stops with a layde a half year that " he myghte be hole of his grete hurtes " !

Potions and alcoholics are frequently administered. Gareth is given a " dryuke that relieved him wouderly wel." Besides


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being attended to surgically by his magnanimous opponent " Sir la Cote male tayle is given wyn," and a hermit stanches Sir Launcelot's blood and gives him wine to strengthen him. Healing by enchantment, miracle, and divine influence is a natural belief of the time, and tliere is a curious faith in virtue, moral qualities, virginity, etc., to heal wounds. This is doubtless due either to the desire of vengeance, or to that secret conscience of sin and lapse from virtue which brought about the injury or illness. The murderer of Syr Gylbert can never be "hole" until some knight goes to the "chappel peryllous" and finds a sword and a bloody cloth that the knight is wrapped in and " serches" the wounds with them. Launcelot achieves this and heals the sick knight with Sir Gylbert's sword and by wiping his wound with the bloody cloth. Balyn's host tells of his son's wounds " that can not be hole tyll I haue of that kuighte's blood." Balyu procures the blood by killing this knight, obeying the old injunction of an eye for an eye, a tooth for a tooth. Sir Vrre has seven great wounds, three on the head and four on the body, which at one time festered, at another bled, and which could only be healed by being searched by the best knight in the world. At the command of Arthur, Vrre is searched by one hundred and ten knights, but Launcelot being the best knight, alone is able to heal the wounds. The Sangrail is of course effective in curing and healing. The damsel from the castle comes out with a dish " asses grant par raison," and tells Balaain's companion (another lady) that the lady of the castle has been long suffering from a terrible disease " comme est de liepre." All remedies hitherto have been proved useless, but " un seul homme viel et anchiien" had told her she could get well again through the blood of " une pucielle vierge en volonte et en oevre, fille de roi et de roiue." The lady is bled at both arms. " This custom," says the pseudo Robert de Boron, " will be continued unto the day when the lady of the castle is healed by the blood of la serour de Percheval le Galois." By a logical reversal is it not possible that later the belief gave rise to the custom of bleeding ? If good blood could cure, bleeding the patient would appear to lessen the quantity, so to speak, of disease contained in him. The damosel with Balyn is voluntarily bled to help the victim, but to no avail. The blood of Sir Percyval's sister finally cures the lady, but the benefactress loses her own life. It is an old superstition, perpetuated in remote parts of Ireland to this day, that venereal disease can only be cured by coitus or genital contact with a virgin. Modern instances of infection have been traced to this superstition.

There is, of course, doubt as to the correct interpretation of the term mesel. It may have been used to designate leprosy, as the learned think (somewhat doubtfully), but it may also have been applied to another disease. Our indecision becomes clearer by what is the most interesting quotation as to disease we have met in the stories. In Merlin (p. 537, Early English Test Society) we find that King Looth, after censuring his son Agravain for his disrespectful treatment of women, says : "Yef ye yow thus demene as ye say, wite ye well ye shull myscheve, and that shull ye well se." The paragraph ends by saying, "and euen as the kynge seide so hym be-flll, after that he langwissid longe a-boue the erthe for the vilonye that


he dide to a mayden, that rode with her frende with whom he faught till that he hadde dicounfitted and maymed of oon of his armes, and after wolde haue leyen by his love and fonde liir roynouse of oon of hir thighes, and seid her soche vilonye that she after hurte his oo thigh and his arme, so that it sholde neuer be made hooll ; but yef it were be tweyne of the beste knyghtes of the worlde to whom she sette terme of garison, as the booke shall yow devyse here-after, how that it was warrisshed by Gawein his brother and by launcelot de lak that was so noble a knyght." However we may doubt of the cure, it appears from all the evidence that we have here proof of the existence of syphilis at this time. Roynouse means itchy, scaly, etc., and the French rogyie to-day means the itch. But for patent reasons such a meaning cannot be applied in this case, and the context makes more clear the virulent nature of the disease. The location of the lesion, the duration of the disease, and the girl's plain knowledge of its infectious nature are evident. In the Quest of the Holy Grail Launcelot laments that through his sinful life he has lost his eyesight and his strength — an addition to the original record, doubtless, by a later hand.

There are allusions to violent epistaxis. It is said that the venerable Joseph " bled sore at nose, so that he niyght not by no meane be staunched"; and of Garynsch we read that on beholding his faithless lady sleeping with her paramoixr, " for pure sorou his mouth and nose braste oute on bledynge." In Le Conte de la Charrette Keux is declared not guilty by the queen, because " her nose bled during the night, as it often does."

Swooning is most commonly due to physical exhaustion and extreme hemorrhage, but we read of instances due to fright and violent emotion. When told Tristram was near, " for very jnire Joye la beale Isoud swooned." Quite natural is the act of Bois, who "dawes" (sprinkles the face) of the swooning Queen Gueneuer. It is said that the hermit knight, seeing Sir Launcelot helpless and bleeding, "put a thynge in his nose and a lytel dele of water in his mouthe, and thenne Sir Launcelot waked of his swoune." The " thynge " was probably some pungent substance, not unlike the custom of to-day.

The obstetrician finds an occasional line of interest. The babe Arthur was placed in charge of Sir Ector, whose "wyf nourysshed hym with her owue pappe." The significance of the last words arises from the belief that the child's characteristics are derived from the mother or the one who nurses him, through the milk. In this way is explained the baddish character of Arthur's foster-brother Sir Kay, who, as a babe, was given to another woman to nurse. Explaining the bad chai-acter of Keux " et se il est fel es fans et vilains, voiis le deves bien sousfrir," says Auctor to Artus, "que toutes les mauvaises choses qu'il a n'a il prises se par le norriche non qui I'alaita, et pour vous norrir est il si desnatures." An instance of premature labor is recorded in the case of Elisabeth, the wife of King Melyodas, who ran into a forest to seek her spouse and by reason of her violent exercise " began to travaille fast of her child and had many grymly throwes and was delivered "with grete paynes " by a gentlewoman. A distressing case of rape is that of the Duchess of Bretayne,


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who Wcas murderously assaulted by a giaut who " in forcyne her slytte her unto the iiauyl." The body of the babe Merliu is covered with hair, a fact that frightens the mother and women. In the State de Merlin an interesting medico-legal question is solved by Arthur and Merliu as to the illegitimacy of Tor, begotten as a result of rape by Pellinor upon " uue pastorelle," who kept the fact a secret and was married to a " vakier " the same week. The conte is finely told, with true English hiimor. To the fact that Tor is a king's son is ascribed his longing to be a knight, all his other numerous brothers, according to the then concei)tion of the laws of heredity, being content with their plebeian lot, because they were the legitimate sons of the cowherd.

The neurologist and alienist will note what may be called a case of aphasia, that of King Uther, the father of Arthur, who " fyll passynge sore seke, so that thre dayes and thre nights he was specheles." Frequent references to insanity are couched in the terms " madde man," " out of wytte," " wood man," etc. Loss of mind through unrequited or unsatisfied love is quite common. Launcelot becomes insane through his love for Queen Gueneviere, runs about almost nude, and is compared to a " wood man in his sherte." He " empayred and waxed feble bothe of his body and of his wit for defaute of sustenauuce" and became "more wooder." Tristram is another victim of love, and his paramour, Queen Isoud, "maade suche sorowe, that she was nyghe oute of her mynde." Merliu makes a bed that " never a man lye therein but he wente oute of his wytte." Sir Kehydius died for love of this same fair Queen. Sir Matto le breune " felle oute of his wytte by cause he lost his lady." That Launcelot was, in modern lingo, of a neurotic temperament appears from a number of hints ; e. g., " he woulde clater in his sleep," and a peculiar effect of his great attack of sleeplessness was anorexia and adipsia ; " he drys and dwindles away until he was a kybbet (cubit) shorter." On another occasion he lay unconscious for twenty-four days and nights.

The criminal use of narcotics and poisonous potions is noticed. Queen Morgan le fay gives " Alysander such a drynke that in three dayes and three nyghtes he waken neuer but slepte." King Mark gives Trystram a drink causing him to fall asleep. There is mention of a " remedy that is the grettest poyson that euer ye herd speke of," to poison Arthur while he is at Camelot. Pyonel poisons the apple at the Queen's feast, hoping to make way with Gawayn, who was particularly fond of apples, but happily the victim escapes, the unfortunate Sir Patryse eating the fatal fruit, which causes him to swell and burst and fall dead. We cannot imagine what was the nature of such a poison. Unless mistaken for the fatal infection from an ordinary wound, we must believe poisoned weapons were used. Tristram is shot through the shoulder with a poisoned arrow. In medieval times it was commonly believed that certain persons possessed poisons, the antidote of which they alone knew. Tristram is struck in the side by Marhaus with an "enueymed" spear, and had to go to Ireland, the source of the poison, in order to be relieved. Wounded in the arm by a saiete envenimee by an archer, Gavain is weakened by the shot, and the next morning he finds that his arm is swollen, and " cstoit asses phis gras que la


cuisse d'un homme,'" and believes without help he must die. Merlin later prophesies Gavain will soon recover, which comes to pass.

Reference is made to the use of what our balneologists would call a medicated bath. Sir Launcelot "made fayre Elayne to gadre herbes for hym to make hym a bayne." There is one reference to gout. Uterpendragon " fell into a grete sekeness of the gowte in the handes and feet." (This is hardly sixth century wisdom.) Besides the one quoted there is a possible allusion to leprosy in the passages relating to la beale Isoud's confinement in a " lazar cote," and to the lady who " felle unto a mesel." Lamorek desires a I'emedy to make him whole of the disease which he had " taken in the see," which may have been one of the numerous complications resulting from exposure in cold water.

The use of horse-litters to convey the wounded was well known.

The embalming of sixty fallen Roman Senators, etc., is surely not of Cymric or English origin.

Is it possible that Gueneviere had some chronic bronchial or pulmonary disease ? It is recorded that she " coughed soo loude that Syre Launcelot awaked and he knewe her hemynge." Of course a beautiful woman never snores ! In one text also she seeks to avert suspicion as regards the blood on the bed-clothing by saying that her nose bled in the night " as it often does."

We thus learn that in the hei'oic youth-time of our race the indications gleaned from these early records of the practice and condition of medicine were singularly in harmony with the character of the people. We are well aware that in such matters omission of descriptions and details does not imply their non-existence, and yet in general the picture is fairly and essentially accurate and complete. The thousand unconscious hints and touches conveyed in other matters as to things just beyond the definite and intended purpose would have been also given in regard to matters medical if they had been actualities. Had there been more competent physicians than la belle Isoud, she would not have been called " the noble surgeon," and the lives of the heroes would not have been entrusted to her cure. Professional practice did not exist, except as by-play, in the hands of the more intelligent and expert of those a little less busy than the heroes. It engrossed no one's sole attention.

It is also to be noted, as we have seen, that the method of treatment was extremely simple and unlearned except as a result of common sense and self-gained exj)erience. It consisted almost entirely of the highly sound practice of removing foreign bodies from wounds and cleansing them, then in applying some simple herbal ointment with a bandage. The rest was left to God and a little quiet. As to the treatment of diseases other than surgical, it consisted in perhaps the exhibition of some simple herbal decoction, and a little wine and food. So far the patient was only cursed with the disease, and not, as later, with both disease and physician. Through all was the belief in the identity of disease and virtue, and when possible of the substitution or imputation of the moral health of another for the physical disease. This latter belief was, we must confess, a truthful error, the


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adumbration of a profound verity which our materialistic age in ignoring falls into an opposite and equally grave blunder. Almost all disease, if we but knew it, has a moral or metaphysical cause and result. For the rest, most remarkable is the entire absence of medical superstition of the distinctively primitive or medieval type. Where else do we fiud in the adolescence or childhood of a race such an utter absence of medical barbarism and savagery ? There is not here any faintest glimpse of delight in the nasty, the obscene, the ugly and the outrageous. There is no pouring into the sufferer recipes outdoing in hideousness the mess of the witches' cauldron. Now all this, and especially the last-mentioned fact, has most emphatic, exceptional and manifold significance: —

1. It is an added proof of the remarkable psychologic sanity and natural elevation of character, of splendid nobility of soul, on the part of our young racial ancestors. It may not show any medical "science" (that began gestation only a thousand or more years later), but it shows freedom from pseudo-science, medical filth, and egregious superstition. Great must be the purity of a people in mind and body that needs no medicineman caste, that makes the most beautiful and revered women its best surgeons, and that keeps the disgusting out of its materia medica.

2. It throws a strong side-light for the benefit of literary


and historic criticism on the genuineness of documents by which we have come into possession of the pricelessly precious Arthurian legends. Ho little has this aid and value been recognized that Sommer has failed to include in the Glossary of his superb edition of Malory all medical and anatomic terms. We have little doubt that it will be found that future critical exegetists will learn that all the allusions, e. g. to embalming, to what pertains to the medically nasty and superstitious, the recondite, civilized, scientific, or miraculous, are interpolations, ill weeds, mostly of Continental and Oriental sowing, and may serve as clues to be dropped in our voyage of discovery backward to the originally pure, natural and healthy fountain of eternal youth.

3. As a profession the fact may teach us to hark back to the Cymric springs of our English tributary stream and properly to reverence and value its earlier purity. A further study of medieval medicine will yield us little to honor more, and much to be heartily ashamed of. Slowly we shall see flowing into the limpid English mountain brook the polluting streams of therapeutic filth and nonsense that have rendered the river so nauseous, and that still prevent a newly-arisen and genuine science from ridding ourselves of the loathsome quackeries and sectarianisms that infect its waters and prevent the " healing of the nations."



THE PRESENCE IN THE BLOOD OF FREE GRANULES DERIVED FROM LEUCOCYTES, AND THEIR

POSSIBLE RELATIONS TO IMMUNITY.*

By Wm. Royal Stokes, M. D., and Arthur Wegefarth, M. D.


[From the Bacteriological Laboratory of the Health Department of Baltimore.]


I. — Free Granular Bodies in the Blood.

H. F. Miiller,' an assistant in Nothnagel's clinic in Vienna, has recently described certain "small, generally round, colorless granules," which he finds constantly present in the freshly-drawn blood from healthy and diseased persons. These granules are readily distinguishable from blood plates.

We have been able to confirm Mtiller's observation by the examination of numerous specimens of blood taken from human beings and certain of the lower animals. Since some of our conclusions are different from those drawn by Miiller, we shall first present an abstract of his work and then the results of our own experiments.

Miiller always found the above-mentioned granules in fresh human blood, and by means of their small size he was able to differentiate them from red blood corpuscles, leucocytes and blood plates. He describes them as small, round, colorless bodies, about the size of the finest fat particles, and is quite sure that they are normal constituents of the blood and not foreign matter introduced through accident. His attention was first called to these granules by observing many small bodies resembling mici'ococci free in the plasma of a case of


  • Read before the Johns Hopkins Hospital Medical Society,

October 18th, 1897.


Addison's disease. Upon examining healthy blood as a control, the presence of similar granules was demonstrated, and, as mentioned above, after many observations upon the blood of healthy and diseased individuals, Miiller came to the conclusion that these refractive bodies are regularly present in the blood. Their diameter is 1 ii or under, their size being somewhat variable. They are further described as highly refractive, round or dumb-bell shaped bodies, which show a dancing, molecular movement, but no independent motion. When the fresh blood is prevented from drying by surrounding the cover-slip with oil, these granules can still be seen after 24 hours, and the same may be said when the blood is mounted in 1 per cent, osmic acid. The reaction for fat does not occur with this acid, nor can they be dissolved by acetic acid or ether. They are not concerned in the formation of fibrin, since they remain outside of the fibrinous network or are only accidentally attached to it.

From these observations the author concludes that these granules are a normal constituent of the blood. His technique guarded against the introduction of foreign particles from the skin, etc. He does not consider them as Ehrlich's neutrophilic granules escaped from leucocytes. He states that the neutrophilic granules are dissolved by dilute acetic acid, while the bodies which he has studied are not dissolved by this acid.


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He does not believe that they are true particles of fat, since they do not give a reaction with osniic acid, but advances the opinion that they may be bodies resembling fat, but which fail to show the osmic acid stain. He leaves the question open as to their fatty or albuminous nature, and ends by calling them " Haemokonien," or "Blutstiiubcheu" (blood dust). No mention is made of any attempts at staining.

Briefly stated, therefore, Mtiller has observed a varying number of small refractive, spherical bodies, of undetermined origin and composition, in all of the specimens of human blood which he examined.

Other authors have also observed bodies resembling fat granules in the blood of normal human beings, Kolliker,^ Kanvier,^ Bizzozero,* and von Limbeck' all mention such bodies in the blood. Mtiller was unable to reconcile their description by these authors with the bodies which he observed, but he thinks that certain fat drops or granules described by Schiefferdecker and Kossel" are probably identical with his bodies. Hayem' also speaks of spherical granulations resembling fatty particles, which Miiller considers as identical with the granules described by himself.

The bodies which we have observed correspond in their general appearance to those described by Miiller. We especially wish to emphasize the fact already mentioned that the granules vary in size. Occasionally one meets with the larger round body about 1 //. in diameter, but by far the more frequent variety are the fine granules, almost diist-like in appearance. They exhibit molecular movement, but no independent motility.

We first began the study of the bodies by ordinary daylight, but we soon found that they can be brought out much more clearly by means of the artificial light of the Welsbach gasburner. We have been able to demonstrate the presence of these granules in the fresh specimens of blood taken from the lobes of the ears of about 500 persons. Most of the specimens were from dispensary patients, but about 100 were taken from normal individuals. Care was always taken to thoroughly cleanse the ear, and the first drop of blood was always wiped away with a clean towel. In perfectly fresh specimens the granules were not numerous, but they seemed somewhat increased in patients who had been taking tonics or the various alcoholic drinks. No attempt was made to determine their relative frequency in different diseases.

After having observed these granules in all of the specimens of human blood which we had examined, the question naturally arose as to their origin. It was first noted that these granules, when examined by artificial light, resembled those of the eosinophilic and neutrophilic leucocyte. These leucocytes, when observed at once in a perfectly fresh drop of blood, kept at the room temperature, are usually motionless, and the granulations show no activity. AVhen the blood specimen is surrounded by vaseline and is then exposed to a temperature of 35° C. for an hour or more, the picture becomes somewhat different. At times the granular leucocytes become actively amoeboid, and the granules within the ueutrophile exhibit a characteristic activity, which might be compared to the swarming of bees around a hive. The number of fine granules free in the plasma is perceptibly increased. The


eosinophilic granulations also show a less vigorous tremulous motion, and both varieties follow the changes in the direction of the pseudopodia, the protoplasm being thrown out first, and the granules slowly following. The characteristic dancing motion of the granules in the neutrophilic leucocyte can be brought out very plainly by simply mixing the drop of blood with an equal amount of distilled water containing 1 per cent, of alcohol. The granules soon become very active and present a characteristic picture.

And now a difficult question presents itself. Can these granules be actually seen to leave the leucocyte ? It is certainly not easy to be sure, even after continuous observation for an hour or more, that one has actually seen one of these granules leave an amceboid leucocyte. We think, however, that we have observed this phenomenon upon several occasions, both in fresh specimens of blood exposed to 35° C. and in blood to which 1 per cent, of alcohol had been added.

As already mentioned, Miiller does not think that his granular bodies can be derived from the neutrophilic leucocytes, since Ehrlich's granules are dissolved by dilute acetic acid, while the bodies which he describes are not dissolved by this fluid. According to our observation, dilute solutions of glacial acetic acid (c. p. 99.5 per cent.) cause a great increase in the number of granules free in the plasma when added in equal parts to fresh blood. Many granules can still be seen in the protoplasm of both varieties of granular leucocytes, however, and we cannot convince ourselves that any destruction of the granules has taken place. If a 0.5 per cent, solution of this acid be added to a drop of blood, the eosinophilic and neutrophilic leucocytes often become amceboid, and the granules of the eosinophile often show a slight tremulous motion. The neutrophilic granules exhibit a most characteristic movement, and soon flow into and fill the clear spaces present in the fresh pseudopodia of amoeboid leucocytes. Many fine granules can be seen in the clear plasma and around the neutrophile, and it would seem that occasionallv a granule leaves the active leucocyte and becomes free in the surrounding fluid. When 1 per cent, glacial acetic acid is employed the leucocytes are no longer amoeboid, nor the intracellular granules active. Many granules can still be made out, however, within the protoplasm of the leucocyte, and there are more granules present in the plasma than in the fluid portion of untreated blood. When 5 per cent., 10 per cent., and even stronger solutions are used, the protoplasm of the leucocyte becomes clear and practically free from granules.

Similar free granules can also be made out in the clear blood serum, and they are fairly numerous if the separation has taken place at 35° C. In specimens of blood heated in the usual way for microscopical study, extracellular granules can be stained by a deep red solution of aqueous eosin. This stains the eosinophilic and neutrophilic granulations, and at times a granule of both kinds can be seen immediately adjacent to the leucocyte. Of course such pictures may be due to the manipulation of spreading, and the most convincing phenomena are certainly to be obtained by studying specimens of fresh blood.

Our next series of investigations consisted in the observation of the blood of various animals. In the blood of the


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horse the eosinophile presents a remarkable appearance, the individual granules being often from five to ten times the size of the human variety. Even in perfectly fresh horse's blood a few large, round, refractive bodies can be seen free in the plasma, which entirely resemble the intracellular bodies in size and appearance. Another variety of leucocyte containing granules about the size of the human eosinophilic granules is also present, and a few granules of the same size can be made out in the surrounding fluid. When the specimens of horse's blood are exposed to 35° C. for an hour or more, both varieties become amoeboid, and the intracellular granules show a slow flowing motion. The number of the granules free in the plasma, resembling both varieties, is also perceptibly increased, and the conclusion seems almost irresistible that they have been extruded from the leucocytes. The serum which has separated from the clot also contains many granules I'esembling those described above, especially if the separation has taken place at 35° C.

The eosinophile is the only granular leucocyte present in rabbit's blood, and the granules are about the size of those of the human eosinophile. When the blood has been exposed to a temperature of 35° for an hour, a few round bodies can be seen free in the plasma which resemble the granules of the eosinophile in size and appearance. No smaller dust-like particles can be seen, and this can probably be explained by the fact that the rabbit possesses no finely granular leucocytes. In hardened specimens stained by aqueous eosin the intracellular granules can be easily seen, and at times similar bodies can be observed outside of the leucocyte.

The cat's blood contains about an equal number of eosinophiles and finely granular leucocytes, and the granules are about the size of those present in these respective leucocytes of the human being. Even in perfectly fresh specimens a few granules can be found corresponding exactly to both varieties mentioned above, and when the blood is exposed in the thermostat for an hour there is a great increase in the number of granules of both kinds.

In the guinea-pig the blood contains a few eosinophiles, and many more finely granular polymorphonuclear cells, and the granules of both varieties can be plainly made out in the leucocyte ; while if the blood is placed at an artificial temperature, similar granules can be seen dancing round the leucocytes, or free in the plasma. When stained by aqueous eosin the smaller granules are slightly smaller than the human neutrophile, while the larger granules about equal the human variety in size.

In the blood of the rat both eosinophilic and finely granular leucoytes are present. Many large and small granules, entirely resembling those inclosed in the protoplasm of both varieties, can be made out free in the plasma, especially after an hour at 35° C. In stained specimens the fine granules are as small as the human variety, and the rarer eosinophilic leucocytes contain perceptibly larger granules.

After exposure to a temperature of 35° 0. for an hour there are more free granules present in the blood of the cat and white rat than in the blood of the other animals which we have studied. There are also granules present in the blood of such animals as mice, frogs, fishes, land-terrapins, tadpoles.


and even oysters and clams. They are also present in hydrocele fluid, and the serum of such animals as the horse, hog, steer, rabbit, and dog. They present a striking appearance in the usual varieties of pus, and the intracellular granules are often active.

These observations simply strengthen the conclusion that the granules of the eosinophile and the neutrophile are present as free bodies in the plasma and serum.

II. — Bearing of the Foregoing Observations upon Immunity and Natural Kesistance.

Our observations indicate that granules derived from leucocytes appear free in the blood. It occurred to us that these granules may be concerned in the protective properties of the blood in immunity. A brief review of the two principal theories in regard to immunity, and the later work concerning this matter, will here be in place.

Metchnikoff, as is well known, believes that bacteria are destroyed in the body chiefly by means of the leucocytes. These amoeboid cells or phagocytes engulf the invading organisms and gradually destroy them, being attracted to certain bacteria by means of positive chemotaxis. If this attraction exists between the phagocytes and the bacteria, and the former are able to include and destroy the latter, the animal is saved. If, on the other hand, the bacteria repel the phagocytes by means of negative chemotaxis, or the phagocytes are incapable of completely destroying or preventing the development of the infectious organisms, the bacteria gain the upper hand and the animal suffers a fatal infection. This well known theory of phagocytosis is summarized by Metchnikoff as follows :

" We have the right to maintain that in the property of its amreboid cells to include and to destroy micro-organisms the animal body possesses a formidable means of resistance and defense against infectious agents."

The work of Buchner has certainly imposed some restrictions upon the unqualified acceptance of this theory, although his later investigations point towards the leucocyte as* the origin of the germicidal material. Buchner demonstrated that the bactericidal property of blood is not dependent upon the presence of leucocytes, inasmuch as the serum of the dog and rabbit, which had been freed from cellular elements by separation and centrifugalization, is still capable of destroying such bacteria as the typhoid and anthrax bacilli, and the spirillum of Asiatic cholera.

After freezing and thawing the blood serum he found that it still remained bactericidal while this treatment destroyed the leucocytes, and he excluded the action of these cells by filtration of the serum through double filter paper. From these results he concluded that the actual presence of the leucocyte is not necessary for the bactericidal power of the serum. He later modified his earlier views by admitting that the leucocytes probably furnish a bactericidal substance, although he does not believe that they actually as a rule consume and destroy the agents of infection.

He demonstrated this property of the leucocytes to furnish a germicidal substance in the following manner. He first injected a sterilized emulsion of wheat-flour paste into the


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pleural cavity of dogs and rabbits, thereby obtaining an exudate which had much more germicidal strength than the blood or serum of the injected auimals. Although this was referred to the greatly increased number of leucocytes present, he argued that it was not due to their phagocytic action, since by freezing the exudate the leucocytes were destroyed, and yet upon thawing out this material the bactericidal proijerties of this fluid were even slightly increased.

Other observers have also recently pointed out that the leucocytes seem to contain germicidal substances in a concentrated form. Hahn° has confirmed the work of Buchner in regard to the heightened bactericidal effect of pleural exudates containing a large number of leucocytes, and' he has also succeeded in partially extracting this material and imparting the power of destroying bacteria to other fluids than serum. He first introduced wads moistened with sterile chemotactic substances into the peritoneal cavity of rabbits. After 24 hours these wads were I'emoved and were found to contain countless leucocytes. The fluid from the sponges was then frozen and the leucocytes thereby destroyed. After thawing, this fluid was found to possess decided bactericidal effects. From his experiments he concludes that the germicidal material is not a j)roduct of the destruction of the leucocyte by the system, but that it is a secretion formed during the active existence of this cell.

Bordet" has also made a number of important communications bearing upon this subject. This investigator produced an cedematous fluid free from leucotypes in guinea-pigs immune from the cholera spirillum, by means of compression exerted by rubber bauds around the extremities. He then compared the bactericidal power of this cell-free fluid to that of the animal's serum containing leucocytes, by introducing into each equal numbers of cholera spirilla. He found that cultures made from the serum were always sterile in from one to one and a half hours, while similar cultures taken from the cedematous fluid showed a perceptible increase in the number of bacteria. Later cultures from the (Edematous fluid showed even greater increase. He also produced a hypoleucocytosis by means of carmine injections, and found that the power of such blood to destroy bacteria was greatly decreased when compared with its bactericidal properties before the artificial diminution of the leucocytes. Bordet concludes that the leucocyte is the seat of the bactericidal material, which under abnormal circumstances it gives up to the surrounding fluid.

Schattenfroh'" has made some exceedingly interesting observations in regard to the bactericidal properties of the leucocyte. He has found that the diluted inflammatory exudates from rabbits were much more bactericidal when he added many leucocytes than when the fluid was free from cellular elements. He also secured leucocytes by centrifugalizing these fluids, and by adding the sediment to salt solution he found that this fluid became capable of destroying bacteria. By drying this sediment of leucocytes in a vacuum over phosphorus pentoxide he secured a fine powder which rendered salt solution very destructive to bacteria. He thinks that the leucocytes furnish the bactericidal substance by a process of destruction. His promised detailed account should be a communication of great interest.


Bail" has made some tests which in his opinion prove that the leucocytes contain a bactericidal material. After injecting virulent stajjhylococci into the pleural cavity of rabbits he found that the leucocytes underwent a characteristic change. They formed round, empty bodies, containing several vacuoles in the nucleus. The granules generally disappeared. Upon destroying the staphylococci by adding ether, and diluting the centrifugalized sediment, the granules showed a dancing motion, and were seen to leave the periphery of the cell and enter the surrounding medium.

He also secured leucocytes by Buchuer's method, added sterile salt solution, and obtained a sediment of leucocytes by centrifugalization. By adding a diluted product of the staphylococcus pyogenes aureus called leukocidin to this sediment, he found that the leucocytes were destroyed, and that they then gave up their bactericidal material to the surrounding fluid. If the leukocidin was heated to 60° 0. it lost its property of destroying leucocytes. He found that nutrient fluids to which untreated leukocidin and leucocytes were added, became very destructive to bacteria. This he explained by the fact that the leukocidin destroyed the leucocytes, thus freeing the alexin. When the leukocidin was heated to 60° 0. its destructive powers were destroyed, and when this altered material was added to the fluid containing the sediment of leucocytes the fluid was not destructive to bacteria. This was because the inactive leukocidin could not free the bactericidal substance from the leucocytes. Such bacteria as the typhoid and colon bacillus, the spirillum of Asiatic cholera, and the staphylococcus pyogenes aureus were practically destroyed in 6 hours.

Bail concluded from these and other experiments that the white blood corpuscles of the rabbit contain a bactericidal material, which at times becomes free and appears in the surrounding medium.

We have also performed a series of experiments which seem to show that the leucocytes are directly concerned in furnishing a definite amount of bactericidal material, but the methods need a preliminary explanation.

Certain investigations were made for the purpose of determining whether there existed any difference in the bactericidal power of fresh blood serum before and after it had been filtered through new sterile Miincke filter-cylinders.

Dziergowski" has shown that such fluids as abrin solution, diphtheria toxin and tetanus toxin suffer a slight diminution in their toxic properties when filtered through porcelain cylinders, and Martini" has shown that the antitoxin of diphtheria is also weakened by this process.

Denys and Havet" consider that the leucocytes of the dog play the principal part in the destruction of bacteria, and they base their conclusions upon the results obtained from the following experiments.

They first proved that the blood of the dog was capable of destroying many more colon bacilli than the serum of this animal in a given space of time. Thinking that this increase in the bactericidal power of the blood, as compared to that of the serum, might be due to the greater number of leucocytes present in the former fluid, they next compared ihe relative destructive powers of filtered and unfiltered blood. The fluid


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was filtered through double filter paper, as this method was found to deprive the blood of its white blood corpuscles. They found an enormous difference between the bactericidal power of the blood possessing its leucocytes, and that which had been deprived of the same by filtration.

These observers were also able to greatly increase the bactericidal power of the serum by the addition of the sediment of leucocytes obtained from a sero-puruleut exudate in the pleural cavity of a dog. This was produced by the injection of dead fluid cultures of the staphylococcus pyogenes aureus. By the addition to filtered blood of the leucocytes obtained from the pleural fluid of a dog injected with dead spirilla of Asiatic cholera they were able to restore the lost bactericidal properties of the blood.

They conclude from the observations above mentioned that the blood of the dog when filtered loses its bactericidal power, but that this property can be restored by the addition of living leucocytes.

The blood from which we obtained our serum was secured from rabbits and dogs by means of a sterile cannula introduced into the carotid artery under aseptic precautions. The first few drops were allowed to escape and the rest of the blood was caught in sterile jars. These were stoppered with cotton and allowed to stand at 33° C. for from 13 to 34 hours, when one-half of the serum was filtered through porcelain, while the other half was siphoned off into sterile flasks, care being taken to prevent any admixture of red blood corpuscles. We never worked with serum over 48 hours old.

Our first series of experiments demonstrated a decided difference between the undiluted serum of dogs and rabbits before and after filtration through the unglazed porcelain filter.

When such motile bacteria as the spirillum of Asiatic cholera, the Finkler-Prior spirillum, and the typhoid bacillus were introduced into unfiltered dog serum, complete agglutination took place in from 15 to 30 minutes, together with cessation of motility; but when filtered serum was used no cessation of motility or agglutination took place, even after 3 hours. The rabbit's unfiltered serum caused agglutination and cessation of motility of the typhoid and cholera organism in 15 minutes, and affected the Pinkler-Prior spirillum and bacillus pyocyaneus similarly in about 30 minutes. This condition did not change during 34 hours. The specimens in filtered serum remained active and showed no signs of agglutination, even after 34 hours.

The specimens were all examined in hanging drop-slides, and allowed to remain at the room temperature. From the foregoing experiments we concluded that filtration of the undiluted serum of rabbits and dogs removes their normal property of causing the agglutination and cessation of motility of the organisms above mentioned.

Our next endeavor was to ascertain whether we could demonstrate any difference in the capacity of the filtered and unfiltered serum actually to destroy these bacteria, and for this purpose we adopted the following method :

Twenty-four hour cultures on slanted glycerine-agar of the various organisms to be mentioned below were prepared, and one loopfnl of the surface growth was transferred into 2


cubic centimeters of sterile salt solution. Two loopfuls of this fluid were then introduced into 1 cubic centimeter of the unfiltered serum of the rabbit, and a similar amount was used in 1 cubic centimeter of the filtered serum. The same loop was always used, and an agar plate culture was made from the filtered and unfiltered serum at once, in order to compare the number of germs originally introduced with those present in the serum at varying intervals of time. In all our experiments control plates made from the serum before using remained sterile.

Five loojifuls were planted at the end of 3 hours from both varieties of serum, and at the end of 17 hours 1 loop was planted from the different filtered serums, and 5 loops were planted from the unfiltered serums. With anthrax 1 loopful of the culture was directly introduced into the serums. All of the specimens were kept at a temperature of 35° C. during the experiments.

Table I. — Results with Rabbit's Serum.* Bacillus typhosus. Colonies.

At once. 2 hrs, 17 hrs.

Filtered serum. 1960 730 Great increase.

Unfiltered serun. 936 Sterile. Sterile.


Spirillum of Finkler-Prior. Filtered serum. Unfiltered serum.

Cholera spirillum. Filtered serum. Unfiltered serum.

Proteus mirabilis. Filtered serum. Unfiltered serum.

Anthrax bacillus. Filtered serum. Unfiltered serum.

Staph, pyog. aur. Filtered serum. Unfiltered serum.


1330 1010 Great increase.

959 Sterile. Sterile.

201 960 Great increase.

3 Sterile.

1740 1650 Great increase.

1934 1806 "

804 1530 Great increase.

643 163

743 383 Great increase.

1050 348 "


The foregoing table shows that while unfiltered serum will completely destroy such organisms as the typhoid bacillus and the spirilla of cholera and Finkler-Prior, these same bacteria will increase enormously in filtered serum. The growth of the anthrax bacillus was only temporarily restrained, while the remaining bacteria were not affected.

A similar series of experiments was carried on with the serum of a dog.


  • AI1 serums from the same species of animal are not equally

bactericidal, and the results are affected by the amount of serum used and the number of bacteria introduced. Buchner says 1 cubic centimeter of serum will destroy 1000 typhoid bacilli. With a certain rabbit's unfiltered serum we obtained the following results : One cc. of serum. Typhoid bacillus ; at once, 734 ; 2 hrs., 4 colonies; 5 hrs., sterile; 20 hrs., great increase. — Anthrax ; at once, 9144 ; 2 hrs., 2394 ; 5 hrs., 354 ; 20 hrs., 28,800.


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Table II. — Results with Doq Serum Spirillum of cholera.


At once. 2 hrs. 20 hrs.

941 1334 Great increase. 876 Sterile. Sterile.


535


455


Great increase.


638


38


Sterile.


1308


1494


Great increase.



Sterile.


Sterile.


1800


1140 240


Great increase.


Filtered serum. Unfiltered serum.

Bacillus typhosus. Filtered serum. Unliltered serum.

Spirillum of Fiukler-Prior. Filtered serum. Uutiltered serum.

Bacillus pyocyaneus. Filtered serum. Unfiltered serum.

These tables show that the filtered serum cannot destroy the typhoid bacillus or the spirilla of cholera and of FinklerPrior, while the unfiltered serum can practically bring about this result in about two hours.

Having demonstrated that the filtered serum had lost its bactericidal property, our next endeavor was to ascertain whether we could restore this lost property by adding the leucocytes to the filtered serum. We found that the centrifugalization of clear serum will cause the precipitation of many leucocytes and red blood corpuscles. Many granules similar to those described before were also present in the sediment.

Our method of restoring the leucocytes to the serum was as follows :

Ten cubic centimeters of clear unfiltered dog serum were thoroughly centrifugalized in sterile tubes, and the supernatant fluid was then poured off, care being taken not to contaminate the sediment. The few remaining drops were removed from the sediment by means of sterilized swabs of absorbent paper, and a semi-fluid deposit was allowed to remain in the bottom of the tube. Under the microscope this consisted of leucocytes, free granules and red blood corpuscles. This we designated as the small sediment. In another instance 10 more cubic centimeters of serum were added to a tube already containing a sediment, and a second deposit was obtained from this fluid by means of centrifugalization, making the accumulated deposit from 30 cubic centimeters of unfiltered serum. This we called the large sediment.

Two cubic centimeters of filtered (non-bactericidal) serum were then added to tubes containing the large and small sediment, and as a control, filtered aud unfiltered serum was used. All of the serum tubes were then inoculated by means of the following method.

One loop of a 24-hour culture of the typhoid bacillus was added to 3 cubic centimeters of sterile bouillon, and 1 loop of this fluid was then added to the filtered serum, the filtered serums plus the sediments, and the unfiltered serum. Three loops from the inoculated serums were always used for the plates made for numerical comparison, and the serum was kept at 35° C. during the experiments. The plates were allowed to remain in the thermostat for 48 hours before counting. The typhoid bacillus was used for the experiments.


Table III. — Results with Bacillus Typhosus.

Colonies present. At once. 3 hrs. 6 hrs. 20 hrs.

Filtered serum plus

Small sediment. 383 367 690 Great increase.

Filtered serum plus

Large sediment. 463 318 596

Filtered serum. 334 900 29445

Unfiltered serum. 346 Sterile. Sterile. Sterile.

These figures show conclusively that the presence of the sediment consisting of granules, leucocytes and red blood corpuscles in the filtered serum rendered this fluid capable of inhibiting the growth of large numbers of bacteria, although it was incapable of preventing the subsequent development of bacteria in this fluid. This later development was probably due to the presence of the nutritive material in the red blood corpuscle, which property gradually neutralized the germicidal qualities of the serum. The abstraction of the red blood corpuscles by water robbed the sediment of its bactericidal qualities, so that so far we have been unable to eliminate its nutritive effect. This has been accomplished by the work of Schattenfroh and others, and the results, therefore, accord with our experiments. We have not been able to render the bactericidal power of filtered serum equal to that of the unfiltered fluid, but we mention our method at this time in order to propose a simple method of obtaining large quantities of fluid for further experimentation, and as a slight addition to the mass of evidence in favor of considering the leucocyte as the dispenser of the bactericidal material.

Conclusions.

In the blood plasma and serum of man and many of the lower animals there are present varying numbers of granules, which resemble the granules of the eosinophilic and neutrophilic leucocytes in size aud appearance.

After addition of dilute acids, dilute alcohol, etc., and subjection to body temperature, the granules of the leucocyte assume marked activity, and such treatment increases the number of granules present in these fluids. These free granules are almost certainly derived from the granular leucocytes.

The filtration of the serum of the dog and rabbit through new Miincke porcelain cylinders removes its normal property of causing the agglutination and cessation of motility of many motile pathogenic bacteria, and of destroying large numbers of these organisms. This property can be partially restored by adding a sediment consisting of leucocytes, free granules and red blood corpuscles. Siuce the red blood corpuscles are not germicidal (Buchner), it follows that the restoration of the bactericidal property is due to the addition of the leucocytes and free granules, aud that these cells can furnish a germicidal material.

The larger extracellular granules of man, and of the frog, horse and rabbit can be stained by eosin, or by means of Ehrlich's triple blood stain.

Theory of Immunity based upon these Observations. And now it being demonstrated that the leucocytes not only contain a bactericidal substance, but also under certain conditions can give up a portion of their protoplasm to the sur


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rounding medium, one naturally looks for some experimental proof showing that the germicidal substance and the material that leaves the leucocyte are identical. This jiroof, however, is extremely difficult to furnish, since filtration of a sediment even through double filter paj^er will allow leucocytes as well as granules to pass.

We have added the typhoid bacillus to various normal bloods and serums, but without demonstrating any distinct attraction of the bacilli for the free granules. We have succeeded in immunizing a guinea-pig from the typhoid bacillus by means of Pfeiffer's method, and upon adding 24-hour motile bacilli to the fresh blood of such an animal the results are slightly more suggestive.

The bacilli become immediately motionless and clumped, and after 15 minutes at 35° 0. fine granules can be seen around the periphery of the clumps, or even dancing about in the meshes of the massed organisms. This condition can be noticed even after several hours, but the granules are never vei'y uumerous. Often several can be seen about a single typhoid bacillus.

Novy and Vaughn" have extracted a germicidal nuclein from blood serum, and they think that it is derived from the leucocyte. Hankin" believes that the granules of the eosiuophile gradually dissolve in the serum, thereby furnishing the alexin.

The suggestive work of Kauthack and Hardy" should also be mentioned in this connection. These investigators made a number of painstaking observations concerning the effect of the introduction of a few anthrax bacilli into the lymph of the frog. They either injected the bacilli into the various lymph sacs and then withdrew the mixture of lymph and bacilli at varying intervals of time, or they mixed the lymph and bacteria, and then observed the specimen in the hanging drop for several hours.

They found that the destruction of the bacteria could be divided into two distinct stages. The first stage consisted in the approach of the oxyphilic or eosinophilic leucocyte to the chains of anthrax bacilli. These leucocytes were said to apply themselves to the surfaces of the chains of bacilli, and then discharge their granules by a quick streaming motion, when the bacilli would begin to show signs of degeneration.

The next stage in the phenomenon of destruction was the approach of a cell described by the writers as the hyaline cell, which was said to contain a round or kidney-shaped nucleus, but no granules. These cells were seen to approach the masses of eosinophiles and bacilli and gradually replace the eosinojihiles.

The hyaline cells would then include the bacteria within their protoplasm, and many cells could be found possessing vacuoles containing fragmented bacilli. The eosinophiles were thought to prepare the bacteria for ingestion by the hyaline cells, but they never were seen to include the bacteria themselves.

Although in a more limited series of observations on five frogs we have failed to observe any distinct clinging of the eosinophile to the chains of anthrax bacilli, we have noticed the fact that after an hour or more the eosinophile will frequently only contain a few granules. Many large eosino


philic granules can be made out free in the plasma, but these are accompanied by smaller dust-like granules. We believe that these smaller granules are derived from the leucocyte of the frog possessing fine granules and a nucleus of the polymorphous variety. These fine granules are at times active within the protoplasm of the cell, and upon one occasion we observed such a leucocyte with active granules which contained an anthrax bacillus in its protoplasm. When specimens taken from the subcutaneous sacs of the frog into which a few anthrax bacilli had been introduced, were stained with methylene blue, typical phagocytosis could be observed in cover-slij)S prepared half an hour after the injection of the bacilli. Often from one to three bacilli could be made out within the protoplasm of a cell containing a typical polymorphous nucleus, and resembling the ordinary pus cell.

In hardened specimens stained by Ehrlich's triple blood stain, or simple eosin and methylene blue, many large granules exactly resembling the large intracellular granules of the eosinophilic leucocyte could be made out as extracellular bodies, but bacilli were never found within the protoplasm of the eosinophile. The eosinophile seems to form the majority of the white blood corpuscles of the frog, the finely granular cell being more rarely seen.

It would seem, therefore, that the free granules, both from the eosinophilic and finely granular leucocyte, may weaken and destroy the anthrax bacilli by their presence in the plasma, and that then the finely granular leucocyte with the nucleus of the polymorphous variety, together with the hyaline cell of Kanthack and Hardy, complete the process of destruction by inchiding the bacteria within their protoplasm.

The many suggestive facts which we have just mentioned have induced us to advance the following theory :

The bactericidal power of the leucocyte of the blood, and of the serum of man and many animals, is due to the presence of specific granules, especially the eosinophilic and neutrophilic.

When called upon to resist the action of invading bacteria, the granular leucocytes can give up their granules to the surrounding fluids or tissues.

Not only does this enable us to understand how apparently cell-free fluids can destroy bacteria, but the production of the alexin by the leucocytes also affords a better explanation of the hyperleucocytosis of infection so strongly urged by Metchnikoff, and by no means disproves the supposition that the leucocytes can take up bacteria either while alive or after being destroyed by means of the germicidal granules.

References.

1. Miiller: Ceutralbl. f. allg. Path, und path. Anat., VIII, (1S9G).

2. Kolliker: Handbuch der Gewebelehre des Menschen. 5 Aufl., Leipzig, 1867, S. 630.

3. Kanvier: Traite technique d'histologie. Paris, Savy, 1875, p. 214.

4. Bizzozero: Handbuch der klin. Mik. 2 Aufl., Erlangen, Besold, 1887, S. 43 u. 74.

5. von Limbeck : Grundriss einer klinischen I'athologie des Blutes. 2 Aufl., Jena, G. Fischer, 1896, y. 131.


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6. SchiefferdeckerandKossel: Gewebelehre. Braunschweig, Brun, 1891, Bd. II, 1 Abth., S. 356.

7. Hayem : Du sang et de ses alterations anatomiques. Paris, Masson, 1889, p. 113.

8. Hahn: Archiv f. Hygiene, Bd. XXV, S. 105.

9. Bordet: Annales de I'lnstitui Pasteur, T. IX, No. 6.

10. Scliatteufroh : Miiuch. med. Woclienschr., April 20th, 1897, No. 16.


11. Dziergowski: Archiv d. sciences biologiques, IV, 43.

12. Martini : Centralbl. f. Bakt., XX, Nos. 23, 21.

13. Novyand Vaughn : Ptomaines and Leucomaines. 1896.

14. Hankin : Centralbl. f. Bakt., Bd. XII, Nos. 22, 23, 1892.

15. Deuys and Havet : La Cellule, T. X, 1894.

16. Kauthack and Hardy: Phil. Trans., Vol. CLXXXV, 1894, p. 279.

17. Bail: Berliner klin. Woehenschrift, Oct. 11th, 1897.


ON THE ANATOMICAL RELATIONS OF THE NUCLEI OF RECEPTION OF THE COCHLEAR

AND VESTIBULAR NERVES.

By Florence R. Sabin. [From the Anatomical Laboratory of the Johns Hopkins Unieersity.]


Since the investigations of Babiuski,' v. Bechterew,' Bumm,' Cramer,' Flechsig, Forel,' Kirilzew," v. Monakow,'" Ouufrowicz," and Roller,'* much light has been thrown on the central connections of the cochlear and vestibular nerves by Ramon y Cajal,' Held,' v. Kolliker,'" Martin" and Sala." The exact topographical relations of these nuclei have, however, so far been only imperfectly described.

The material used in the present study was human tissue and consisted of two superb sets of serial sections, transverse and horizontal, through the medulla of the new-born babe, prepared by Dr. John Hewetson at the Anatomical Laboratory of the University of Leipzig. Through the courtesy of Dr. Hewetson these preparations have been made accessible for study to research-workers in the Anatomical Laboratory of the Johns Hopkins University.

A flat reconstruction on millimetre paper has been made from the right-hand side of the sections of the transverse series which show the nuclei in question. Reference to the diagram (Fig. 1) will show the following points : At the lower end of the diagram the zero point on the scale represents the superior (anterior) limit of the decussation of the pyramids, and at the npper end the diagram extends nearly to the lower border of the inferior colliculus of the corpora quadrigemina. The lines drawn across the diagram represent approximately the planes of the sections having the corresponding numbers.* The areas occupied by the nuclei of the nervus hypoglossus and nervus abducens are given to help in orientation. The lines rt-re represent the lateral boundary of the fourth ventricle, which has been traced from the point at which the canalis centralis opens out into the floor of the ventricle, through the area of the recessus lateralis and forwards to the aqueductus cerebri. The line b-b represents the lateral boundary of the corpus restiforme. The entrance of the corpus restiforme into the cerebellum is not shown, but the line runs to its upper


  • Tbe planes of the sections are in reality slightly different from

those represented by the lines on the diagram, which are drawn at right angles to the median line. The sections have been cut slightly obliquely, the right side being struck at a higher plane than the left. Theslightdiscrepanciesbetween the drawings of the sections and the diagrams are thus explained.


limit. The motor and sensory nuclei of the nervus trigeminus are shown with the exception of the nuclei minores (radicis descendentis). The tractus spinalis uervi trigemiui, together with the adjacent substantia gelatiuosa, is represented in outline from its beginning, at the entry zone of the nerve, downward as far as the decussation of the pyramids. Its course further spinalwards is not given. The entering root bundle of the nervus trigeminus is also not illustrated, but the lowest section which shows it corresponds to number 45 on the scale, and as the nuclei of the nerve are inferior to the point where it enters, the fibres can be traced farther upwards than the diagram goes. The lines dz and di represent the surface markings on the floor of the fourth ventricle corresponding to the ala cinerea. The complete length of the nucleus alffi cinerea3 is not shown, but it can be traced from the inferior end of the nucleus nervi hypoglossi to the point marked d\ on the diagram. The line rfi-rfs, in which the two sulci meet, corresponds to the portion of the ala cinerea which has been pushed into the depth by the spreading of the nucleus nervi vestibularis medialis dorsal to it over the floor of the ventricle.

The line e represents the continuation of the lateral sulcus over the area occujiied by the nucleus nervi abducentis. The sulcus is here further lateral, corresponding to the position of the nucleus nervi abducentis, which is further from the median line than the nucleus nervi hypoglossi.

Nervus vestibuU. The area of entrance of the root bundle of the vestibular nerve is shown in the diagram. The well known fact that the vestibular root bundle is farther forwards (cerebralwards) than the cochlear root bundle is well illustrated. The reconstruction shows clearly the generally recognized fact that the four principal vestibular nuclei are continuous with one another. (See J/., L., S., and R. d. n. ve. in the diagram.) These nuclei can be distinguished in part by position and in part by the character of the cells within them. The relation of the nucleus nervi vestibularis medialis to the nucleus of the descending tract of the vestibular nerve is very striking. Ramon y Cajal has already pointed out their close connection. The lowest sections in which descending vestibular fibres can be distinctly made out show cells between the fibres (sections between 15 and 17 on the scale). These cells higher up make an oval mass which lies.


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lateral to the ala cinerea and extends dorsal aud medial to the descending vestibular fibres. As the ala cinerea recedes into the depth, and the nucleus nervi hypoglossi disappears, these cells spread to very near the middle line. The large area M, together \vith the dark area Y, represents the nucleus nervi vestibularis medialis ; it can easily be seen that any division between this nucleus and the nucleus of the descending vestibular tract, throughout their whole extent, must be merely an arbitrary one. It is extremely difficult, too, to determine exactly the medial border of the nucleus nervi vestibuli medialis ; it goes over insensibly into the central gray matter surrounding the ventricle. In general the nucleus nervi vestibularis medialis begins from 2 J to 3 mm. below the superior end of the nucleus nervi hypoglossi and extends in the floor of the fourth ventricle as far forward as the nucleus nervi abducentis. Its anterior extremity (J' in the diagram) passes forward some distance further lateral to the nucleus of the sixth nerve. The descending tract of the nervus vestibuli begins at the entry zone of the vestibular root fibres in the region of the nucleus nervi vestibularis snperior (Bechterew), and of the nucleus nervi vestibularis lateralis (Deiters). It is made up of the descending branches of the root fibres and lies dorsal to the tnictus spinalis nervi trigemiui, at first at a distance of 1.3 mm. from the floor of the ventricle (Fig. 3). Farther posterior it approaches the floor, and the isolated bundles of fibres of which it is made up occupy a very characteristic oval area, the long diameter of which lies in the dorso-ventral direction (Fig. 3). A reference to the diagram will show that it extends downward from its origin in a straight line as far as the level of the superior (anterior) end of the nucleus nervi hypoglossi. From this point it curves medialwards, giving place to the nucleus funiculi cuueati. It can be traced downwards to a plane a little superior to the middle of the nucleus nervi hypoglossi. The ascending branches of the vestibular fibres are not represented in the diagram, but they are shown in figs. 3 and 4.*

At the extreme superior and lateral angle of the nucleus nervi vestibularis medialis is situated a.large group of cells, in part capping the descending tract of the vestibular nerve (Fig. 3, Nil. ij). It is oval in shape aud is distinctly visible in section just below the floor of the fourth ventricle. As will be seen in the diagram (Fig. 1, P), it lies adjacent to the nucleus nervi vestibularis lateralis, to the nucleus nervi vestibularis medialis, and to the nucleus nervi vestibularis spinalis (Kadix descendens). This nucleus, however, is worthy of a special description in that it is peculiar: (1) in the size of the cells, they being much larger than those of that part of the nucleus nervi vestibularis medialis marked M in the diagram, but smaller than those of the nucleus nervi vestibularis lateralis; (2) by the staining capacity of the mass, which on the whole stains in Weigert-Pal preparations of the new-born babe much darker than Deiters' nucleus of the


  • The so-called cerebellar acoustic nucleus of Ramon y Cajal, the

cells of which accompany these fibres, is not representeil. No attempt was made to locate in the diagram the gray masses in the roof of the cerebellum, with which tlie ascending branches of the vestibular nerve undoubtedly come into relation.


same section ; (3) by the fact that the cells are closely packed together, which brings it into marked contrast with the more scattered cells of the nucleus nervi vestibularis lateralis ; (4) by its distinct outline in ruell stained preparations, which makes this group of cells easier to differentiate than any of the other vestibular nuclei. A reference to Figs. 3 and 4, and to the diagram, Fig. 1, will show the position of the nucleus. This nucleus evidently corresponds to a part of the ganglion dorsale acusHci of v. Kolliker (Hattptkern of Sch walbe.) It is continuous posteriorly with the nucleus of the descending root, and laterally (in its posterior part) with the rest of the nucleus nervi vestibuli medialis. It is not so easy t.o locate it definitely in series in which the gray masses are not particularly well differentiated, but even in such a series, after having defined it easily in Dr. Hewetsou's sections, its limits have been recognized without much difficulty. Until attention can be paid to the course of the axones of these cells and a comparison can be instituted between its constituent neurones and those of the other vestibular nuclei, I prefer to give the group a distinct place in the diagram and to refer to it as nucleus y.

It may further be seen in the diagram that the nucleus nervi vestibularis lateralis and the nucleus nervi vestibularis superior are in the region of the entry zone of the vestibular nerve. The lateral nucleus appears to be separated into two portions by the root fibres of the nerve. One part {Lt in Fig. 1, and Nu. n. v. I, in Fig. 3) is further inferior (posterior) and lateral, and it lies also further ventral than the other part (Z/ in Fig. 1, and Nu. n. v. I in Fig. 4). L\ lies between the entry zone of the vestibular root fibres and the corpus restiforme. Its cells are rather smaller than those of L. The part of Deiters' nucleus marked L lies in its upper part almost in the floor of the fourth ventricle and is continuous laterally with Bechterew's nucleus, from which it can be easily distinguished, however, by the size of the cells. In the longitudinal series these two parts of Deiters' nuclei Zand L\ are seen to be in reality continuous; a few scattered cells joining them can be seen between the fibres of the nerve. They are seen with the high power not to be such separate entities as the diagram would make them appear. In his articles on the medulla oblongata Ramon y Cajal describes the nucleus nervi vestibularis lateralis in the white mouse as a crescent-shaped mass, convex on its dorsal border, and showing two sorts of cells, the larger being further ventral, the smaller more dorsal and lateral. In human tissue I find that the nucleus is convex on the ventral border, and to be so inclined that on the whole the smaller cells are further ventral as well as lateral. Fig. 3 shows the lateral portion (Zi)ofthe nucleus nervi vestibularis lateralis, while Fig. 4, which represents a section .6 mm. further forward, shows the medial portion (Z).

The nucleus nervi vestibularis superior (Bechterew) lies in the floor and lateral wall of the fourth ventricle, occupying its lateral angle. In the diagram. Fig. 1, it is marked .5 and is given a heavy outline. It lies in a plane dorsal to that of the nucleus nervi vestibularis medialis, and its inferior (posterior) extremity corresponds about to the inferior (posterior) end of Deiters' nucleus. As seen in the diagram


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it extends even further laterally than does the nucleus nervi vestibularis lateralis of Deiters. A reference to Figs. 3 and 4 will show that it is bounded laterally in a part of its course by the corpus restiforme. As the nucleus extends upwards (cerebral wards) it lies more and more dorsally, so that it comes to lie between the lateral wall of the ventricle and the brachium conjunctivum. It is interesting to note how far it can be traced at its cephalic extremity into the region of the nuclei of the nervus trigeminus. It is traversed by the ascending branches of the root fibres of the vestibular nerve.

Thtre seems to be a general agreement that the root fibres of the vestibular nerve bifurcate. The descending limbs pass into the descending root, many of the ascending go up into the cerebellum. Keceut investigations make it probable that axones also run in the opposite direction from the cerebellum to the nucleus nervi vestibularis lateralis. Fig. 4 shows two distinct sets of fibres extending between the cerebellum and Deiters' nucleus; one running between the brachium conjunctivum and the corpus restiforme and lying in the plane of the transverse section for a considerable distance, the other being more medial and going actually through the nucleus nervi vestibularis superior and the brachium conjunctivum. The latter fibres are so inclined that they do not run far in the plane of any one section, but by following the series downward (caudalwards) from the region of Deiters' nucleus, scattered fibres show in the brachium conjunctivum, lying in a plane perpendicular to the fibres of the latter, and so contrasting strongly with them. These fibres are farther dorsal in each succeeding section downward as far as the nucleus fastigii, dorsal to which a well marked decussation is visible (Figs. 3 and 2).

Fig. 5 repi'esents a longitudinal section taken through the area of the vestibular nuclei. The lines 66 on the transverse sections represent approximately the plane of this section. All of the vestibular nuclei, the nucleus nervi vestibularis medialis (with the part of it which I have designated nucleus F), the nucleus of the descending vestibular root, the nucleus nervi vestibularis lateralis and nucleus nervi vestibularis superior, are shown.

Very little of the nucleus nervi vestibularis superior shows, however, inasmuch as this nucleus lies for the most part dorsal to the plane of this section. It will be seen that there is a well marked group of fibres /? running obliquely forwards from the region of the nucleus nervi vestibularis superior. These fibres have been traced on both series, and the area they occupy is represented in the general diagram (Fig. 1, z). They extend between the nuclei of the nervus trigeminus and the raphe. Toward the floor of the ventricle they pass through the nucleus nervi vestibularis superior, as is shown in the diagram. They decussate in the raphe dorsal to the fasciculus longitudinalis medialis. As to their further course it is impossible to say from these sections.

Nervus Cochlea. The areas corresponding to the nuclei of the nervus cochleae are illustrated in Fig. 1. It is interesting to note that the nucleus nervi cochlearis dorsalis is continuous with the nucleus nervi cochlearis ven trails and that the transition from the one to the other is very rapid. Figure 6 represents a reconstruction to show the relations of the


cochlear nuclei to the corpus trapezoideum and the complex of the nucleus olivaris superior. The nucleus nervi cochlearis dorsalis begins just above (anterior to) the nucleus nervi hypoglossi. It is in the dorso-ventral direction a long, narrow nucleus, the apparent breadth of the area represeniing it in the diagram being due to the fact that it curves somewhat around the corpus restifoi-me. Its size and general character are illustrated in Fig. 2. Both the section and the diagram show how far lateral it lies, though it by no means extends so far lateral as the nucleus nervi cochlearis ventralis, a point which is in disagreement with many of the figures in the textbooks. It has comparatively few medullated axones in it, and these run parallel to the long axis of the nucleus as seen in transverse section. The division into three zones, a mesial, middle and lateral, is clearly shown in Fig. 2. This division has already been described by von Kolliker and by Sala. The mesial and lateral zones are rich in medullated fibres.*

In Fig. 6 is represented a flat reconstruction of the mesial and lateral bundles of medullated fibres of the nucleus nervi cochlearis dorsalis. The mesial bundle is marked m, and the lateral I. It may be seen that the areas corresponding to both bundles run toward the middle line.

The fact that the root bundle of the cochlear nerve enters the nucleus nervi cochlearis ventralis has been observed by Held and Sala. It is interesting to note in Fig. 6 that the area of the entering root bundle of the nervus cochlese is considerably superior (anterior) to that of the nucleus nervi cochlene dorsalis. Both Held and von Kolliker have described the bifurcation of the cochlear root fibres. Eamon y Cajal has observed the bifurcation both in the new-born mouse and in the rabbit and says that it takes place in the nucleus nervi cochlearis ventralis.

The two branches are, he states, usually equal in calibre, but the ascending branches are short and end in the nucleus nervi cochlearis ventralis. On the other hand the descending branches are longer and can be traced in a definite bundle to the inferior part of the nucleus nervi cochlearis ventralis and the nucleus nervi cochlearis dorsalis. He says that jn the mouse these fibres, at first scattered, soon form a definite bundle, which can be traced to the inferior part of the nucleus nervi cochlearis dorsalis. A bundle of medullated fibres, apparently corresponding to the bundle of axones described by Ramon y Cajal, has been easily traced in the sections I have studied, and is shown in the figure (Fig. 6, /*). Near the entry zone of the cochlear nerve it consists of scattered fibres, but it soon forms a compact bundle on the mesial border of the ventral nucleus. The bundle runs spinalwards and at the same time so rapidly dorsalwards that in cross section its fibres are cut almost longitudinally. The reconstruction brings out the fact that it is connected with the mesial zone of the nucleus nervi cochlearis dorsalis corresponding to the area of medullated fibres m (Fig. 6).

The arrangement of the fibres of the nucleus nervi cochlearis dorsalis in parallel lines has already been mentioned (Fig. 2). In strong contrast to this is the appearance of the nucleus


  • According to Sala the cells of the mesial layer and the middle

zone give rise to the striie acusticte.


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nervi cochlearia ventralis (Fig. 3). The arrangement of the cells and fibres of the ventral nucleus in the form of a basketwork has already been described by Held, von Kolliker and Ramon y Cajal. The latter divides the nucleus nervi cochlearis ventralis into two regions, an inferior (tail) and a superior (head). In the human tissue which I have studied it is the inferior part that is characterized by the basketwork. In the superior portion the cells are fewer and more scattered. Indeed, the cells are so scattered and there are so many fibres running to the corpus trapezoideum in this I'egion that it is very difficult to determine exactly in Weigert-Pal preparations the superior limit of the nucleus. The area C i. (Fig. 6) represents the corpus trapezoideum. It may be noticed that the lateral boundary of the corpus traiiezoideum is continuous with that of the lemniscus lateralis. In both series of sections a continuous line of cells can be traced from the nucleus olivaris superior to the nucleus of the lemniscus lateralis, so that it is impossible to say where the nucleus of the lemniscus lateralis begins. A description of the auditory neurones of the second order cannot be entered into at this time. The diagram shows vei-y clearly, however, the intimate connection of the nucleus nervi cochlearis ventralis with the corpus trapezoideum and superior olivary complex. An examination of Fig. 2 shows how few fibres are medullated at this period in the nucleus nervi cochlearis dorsalis. They are so scattered after leaving the nucleus that it is very difficult to follow them far. The long distance between the nucleus olivaris superior and the anterior extremity of the dorsal cochlear nucleus is another striking feature of the diagram.

This study was undertaken at the suggestion of Dr. Mall and Dr. Barker. I wish to thank them for constant advice and suggestion.

Bibliography.

1. Baginski : Ueber den Ursprung und den centraleu Verlauf des Nervus acusticus des Kaninchens. Virchow's Archiv, Bd. 105, H. 1, S. 28. — Ueber den Ursprung und den centraleu Verlauf des Nervus acusticus des Kaninchens und der Katze. Virchow's Archiv, Bd. 119, H. 1, S. 81.

2. Von Bechterew, W. : Ueber die inuere Abtheiluug des Strickkorpers und den achten Hirnnerven. Neurol. Centralbl., Bd. IV (1885), S. 145.— Zur Frage liber den Ursprung der Hornerven. Neurol. Centralbl., Bd. VI (1887), S. 193.— Zur Frage fiber die Striae medullares desverliingerten Markes. Neurol. Centralbl., Bd. XI, 1892, S. 297.— Der hintere Zweihiigel als Centrum fiir das Gehor, die Stimme und die Eeflexbewegungen. Neurol. Centralbl., Bd. XIV (1895), S. 706.

3. Bumm: Experimenteller Beitrag zur Kenutnissdes Hornerveuursprungs beim Kaninchen. Allgem. Zeitschrift f. Psych , Bd. 45, S. 568. — Experimentelle Untersuchungen fiber das Corpus trapezoides und den Hornerven der Katze. Festschr. zur 150 jithr. Stiftungsfeier der Univ. Erlangen, Wiesbaden, 1893 ; Abstract Neur. Centralbl., Bd. XIII (1894), S. 448.

4. Cajal, Eamon y S. : Beitrag zum Studium der Medulla oblongata des Kleinhirns und des Ursprungs der Gehirnnerven. Deut. Uebersetz. von Bresler. Leipzig, 1896.

5. Cramer, A.: Beitriige zur feineren Anatomic der Medulla oblongata und der Briicke mit besonderer Beriicksichtigung des 3.-12. Hirnnerven. Jena, 1894.


6. Flechsig, P. : Zur Lehre vom centraleu Verlauf der Sinuesnerven. Neurol. Centralbl., Bd. V (18S6), No. 23.— Weitere Mittheilungen fiber die Beziehungen des unteren Vierhfigels zum Hornerven. Neurol. Centralbl., Bd. IX, 1890, S. 98.

7. Forel: Vorlitufige Mittheilung iiber den Ursprung des Nervus acusticus. Neurol. Centralbl., Bd. IV, 1885, S. 101.

8. Held, H.: Die centraleu Bahnendes Nervus acusticus bei der Katze. Arch. f. Anat. und Phys., Anat. Abth., 1891. — Die Endigungsweise der sensiblen Nerven im Gehirn. Arch, f. Anat. u. Phys., Anat. Abth., 1892. — Die centrale Gehorleitung. Arch. f. Anat. u. Phys., Anat. Abth., 1893.— Ueber eine directe acustische Eindenbahu und den Ursprung des Vorderstrangrestes beim Menschen. Arch. f. Anat. u. Physiol., Anat. Abth., 1892.

9. Kirilzew: Zur Lehre vom Ursprung und centralen Verlauf der Gehornerven. Vorliiufige Mitth., Neurol. Centralbl., Bd. XI (1892), S. 669.

10. Von Kolliker : Der feinere Bau des verliingerten Markes. Anat. Anzeiger, Bd. VI (1891), S. 427-431 ; Handbuch der Gewebelehre des Menschen, 6 Aufl., II. Bd. 1893.

11. Martin, P. : Zur Endigung des Nervus acusticus im Gehirn der Katze. Anat. Anzeiger, Bd. IX (1894), S. 181.

12. Von Monakow: Ueber den Ursprung und den centralen Verlauf des Nervus acusticus. Correspondeuzblattf. Schweizer Aerzte, 1887, No. 5 ; Abstract in Neurolog. Centralblatt, Bd. VI, 1887, S. 201.— Striae acusticae und untere Schleife. Arch. f. Psych, u. Nervenkr., Bd. XXII, S. 1.

13. Onufrowicz, B. : Experimenteller Beitrag zur Kenntniss des Ursprungs des Nervus acusticus des Kaninchens. Arch, f. Psych, und Nervenkr., Bd. XVI, S. 711.

14. Eoller : Die cerebralen und cerebellaren Verbindungeu des 3.-12. Hirnnervenpaares. Die spinaleu Wurzeln der cerebralen Sinnesnerven. Allgem. Zeitsch. f. Psych., Bd. XXXVIII (1882), S. 228.

15. Sala, L. : Sur I'origine du nerf acoustique. Arch. ital. de biol., t. XVI, 1891, p. 196 ; also in Monitore zoologico italiano, Florence, Ann. II (1891), and in Neurol. Centralbl., Bd. XI, 1892, S. 200.

Legends for Figures. Fig. 1. Diagram representing flat reconstruction of the nuclei of reception of the cochlear and vestibular nerves. The line a, a represents the lateral wall of the ventricle; the line b corres2ionds to the lateral outline of the corpus restiforme ; the line d\ to (U, (h to rfa, and the line e, e, e correspond to sulci in the floor of the fourth ventricle ; C. d., nucleus nervi cochlearis dorsalis ; G. v., nucleus nervi cochlearis ventralis ; the graduated line corresponds to the middle line of the floor of the ventricle. Flor., flocculus ; K. VII, knee of nervus facialis; L., medial portion of nucleus nervi vestibuli lateralis (Deiters); L\, lateral portion of nucleus nervi vestibuli lateralis (Deiters) ; M together with y, nucleus uervi vestibuli medialis (Schwalbe); Nuc. XII, nucleus nervi hypoglossi; Nuc. VI, nucleus nervi abducentis ; F.f., pedunculus flocculi ; N.m.p. F., nucleus motorius princeps nervi trigemini ; N.o. s., nucleus olivaris superior ; A', s. V., nucleus uervi trigemini (sensory); TV. c, root bundle of nervus cochleie; N.vesi., root bundle of nervus vestibuli; Ii. d. n. re, radix descendens nervi


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vestibuli ; iS., nucleus uervi vestibuli sujjerior (Bechterew) (area enclosed iu the broad black Hue) ; Ti: s. n. t., tractus spinalis nervi tvigemini; F, nucleus ?/, antero-lateral portion of nucleus nervi vestibuli medialis ; z, decussatio nervi trigeniini.

JrConj, Cr



Fig. 3 (corresponds approximately to line 3 on the diagram, Fig. 1). G.r., corpus restifornie; F. (f., fasciculus ventro-lat


eralis (Gowersi); i^. ?.?»., fasciculus longitudinalis medialis; N. XII, root bundles of the nervus hypoglossus; Nu. d., nucleus dentatus cerebelli ; N^(. n. c. d., nucleus nervi cochlearis dorsalis ; N. o. i., nucleus olivaris inferior ; Nu. n. v. m., nucleus nervi vestibularis medialis ; Nu. t.s., nucleus tractus solitarius ; Py., pyramis ; R.d.n.i'esf.,Ym\\\ descendeus nervi vestibuli.



Fig. 3 (corresponds approximately to line 4 on the diag. Fig. 1). Br.Conj., brachium coujunctivum ; C. r., corpus restiforme; i. G'., fasciculus veutro-lateralis (Gowersi); F.J.m., fasciculus longitudinalis medialis; i\. c, nervus cochlese; N. IX and X, nervus glossopharyugeus et vagus ; JVJt. n. c. v., nucleus nervi cochlearis ventralis ; Nu. «. v. I., nucleus nervi vestibularis lateralis (Deiters) ; Nu. n. v. m., nucleus nervi vestibularis medialis (Schwalbe) ; N^i. n. v. s., nucleus nervi vestibularis superior (Bechterew) ; A^«. o. /., nucleus olivaris inferior ; Nu. y., nucleus y (anterior-lateral portion of nucleus nervi vestibularis medialis); P. /., peduneulus fiocculi ; Py., pyramis ; R. d. n. vest., radix descendeus nervi vestibuli ; (SV. )'. l, stratum interolivare lemnisci.

Fig. 4 (corresponds approximately to line 5 on the diagram, Fig. 1). jBr. Conj., brachium coujunctivum ; 0. r., corpus restifornie; F. I. in., fasciculus longitudinalis medialis; F. p., libra? pontis; iV.c, nervus cochlere; N. VI f, nervus facialis;


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JV.vesL, nervus vestibuli; Nu.n. VI, nucleus iiervi abduceutis ; JVu. n. VII, nucleus nervi facialis ; JVu. n. c. v., nucleus ner?i cochlearis ventralis; Nu.o.i., nucleus olivaris inferior; Pif., pyramis; S.g., substantia gelatinosa; St.i.l., stratum iuterolivare lemnisci; Tr.s.n.t., tractus spinalis nervi trigemini.

Fig. 5 (section 66, horizontal sei-ies). a, fibres extending between lateral lemniscus and brachium conjunctivum; Aq.c, aqueductus cerebri; /J, decussating fibres of nervus trigeminus; C. I., colliculus inferior; C r, corpus restiforme; C. s., colliculus superior; F. c, fasciculus cuneatus ; F. g., fasciculus gracilis ; L. I., lemniscus lateralis ; N. IV, root fibres of nervus trochlearis; iVJ«. «. c, nucleus alse cinerets; Nu.n.c.d., nucleus nervi cochlearis dorsalis ; Nu.f. c, nucleus funiculi cuneati; Nu.f.g., nucleus funiculi gracilis; Nu.n. v. I., nucleus nervi vestibularis lateralis (pars medialis) ; Nu. n. v. h, nucleus nervi vestibularis latei'alis (pars lateralis); Nu. n. v. m., nuc


leus nervi vestibularis medialis ; Nu. n. v. s., nucleus nervi vestibularis superior (Bechterew); Mi. n. XII, nucleus nervi hypoglossi; Nu.Vl, nucleus nervi abducentis ; Nu. Y, nucleus y (antero-lateral portion of nucleus nervi vestibularis medialis) ; R. d. n. t., radix descendens nervi trigemini ; R. d. n. vest., radix descendens nervi vestibuli ; TV. s., tractus solitarius. Fig. 6. Diagram representing flat reconstruction of nuclei nervi cochlearis and corpus trapezoideum. C. d , nucleus nervi cochlearis dorsalis ; C. f., corpus trapezoideum ; C. v., nucleus nervi cochlearis ventralis; h., portion of root bundle of cochlear nerve running past the ventral cochlear nucleus to the region of the dorsal cochlear nucleus ; I., area occupied by medullated fibres of lateral portion of dorsal cochlear nucleus ; ?«., area occupied by medullated fibres in the medial portion of the dorsal cochlear nucleus; L.I., region of lemniscus lateralis; N.c, nervus cochlea; Mo.s., complex of nucleus olivaris superior.


TYPHOID INFECTION WITHOUT INTESTINAL LESIONS.

By Simon Flexner, M. D., and Norman McL. Harris, M. B.

[From the Patliological Laboratory of the Johns Hopkins University and Hospital.']


The observation that the clinical symptoms of typhoid fever may co-exist with relatively very slight intestinal lesions indi_cative of the disease is not a new one, but it was not jiossible before the present era in bacteriological study, and especially before the isolation of the bacillus typhosus by Gaffky, to bring forward conclusive evidence of the occurrence of typhoid fever without any demonstrable intestinal lesions whatever. The studies of the last few years have shown the typhoid bacillus to be much more widely disseminated than would have been predicted, and to be associated with a considerable number of different pathological conditions. But thus far the number of instances in which the typhoid bacillus has been found in human cases which presented during life the symptoms of typhoid fever and in which there was an entire absence of intestinal lesions at autopsy, is limited to a very few authentic reports. Accepting the cases reported by Banti,f Karlinski,J and Guaruieri,!! which date from a period in which the difficulty in separating the bacillus typhosus from the colon group of organisms was less appreciated than now, there exist, in addition, in the literature available to us, the cases of Du Cazal,§ Kiihnau,^] Guinon andMeunier,** Pick,tfand especially those of Chiari and Kraus.|J

  • A more complete report on this subject is reserved for the

Report on Typhoid Fever, No. 3, to be issued in the Johns Hopkins Hospital Reports, Vol. VII.

t Riforma medica, Ottobre 1887 ; Ref. Baumgarten's Jahresbericht, 1888, p. 148.

t Wiener med. Wochenachrift, 1891, No. 11 u. 12.

||Riv. gen. ital. di clin. med. 1892; Ref. Baumgarten's Jahresbericht, 1892, p. 234.

§Bull. et m^m. Soc. med. d. h6p. de Paris, 189,3, p. 243.

Tl Berliner klin. Wochenschrift, 1896, No. 30.

••Le Bull, med., 1897, p. 313.

ttWiener klin. Wochenschrift, 1897, No. 4.

XX Zeitschrift f . Heilkunde, 1897, Heft. V u. VI, p. 471.


Guarnieri as early as 1892 described a case of primary typhoid infection of the bile passages (angio-cholitis). Lesions of the intestine were absent; but cultures from the liver and spleen, as well as a culture made from the blood 12 days before death, gave growths of bacilli having the character of the bacillus typhosus. In the case reported by Du Cazal the symptoms during life were those of typhoid fever, but at the autopsy there could not be discovered, even upon the closest inspection, any lesion of the intestinal mucosa. However, the mesenteric glands, spleen and kidneys were in a swollen and congested condition, and cultures from the much enlarged spleen yielded a growth of bacilli morphologically and culturally agreeing with the bacillus typhosus.

The very recent case of Kiihnau occurred in a puerperal woman 32 years of age, who died in the eighth week of the disease. There was an absence of intestinal lesions at the autopsy. The mesenteric glands were swollen and showed areas of necroses or abscesses, the kidneys also contained abscesses, and the left internal spermatic vein contained a partially softened thrombus. Typhoid bacilli were isolated from the abscesses and from the spleen. The case of Guinon and Meunier is of much interest, as it indicates an unusual portal of entry of the typhoid bacillus. The patient, a boy 8 years of age, presented the symptoms of recent lung tuberculosis. Some days after his entrance to the hospital rose spots appeared and the temperature curve became typhoidal. The Widal reaction was positive. At the autopsy the lesions appeared to be those of acute miliary tuberculosis, small ulcers in the intestine being typically tubercular in character. Typhoid bacilli, however, wei'e cultivated from the spleen, pleural fluid and lungs. The peculiar lesions of typhoid fever were not present. Pick's case gave a marked positive serum reaction, but at autopsy no typhoid intestinal lesions and no swelling of the spleen were found; the bacteri


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ological examination gave typhoid bacilli, not, however, in the spleen.

The most important contribution to this subject has just been made by Chiari and Kraus. They had the remarkable experience of finding in 19 cases (autopsies from January to May, 1897) of typhoid fever, 7 in which the anatomical lesions of the disease were wanting. The negative eases from thepost mortem point of view had, however, given positive serum reactions. Chiari and Kraus divide the cases of typhoid fever into four anatomical groups. The first is the group of anatomically typhoid cases; the second, anatomically atypical cases in which, however, at the autopsy a diagnosis can still be made ; the third comprises cases in which an anatomical diagnosis of typhoid fever is not possible, but in which the bacteriological examination discloses infection with typhoid bacilli. Among these cases examples of typhoid septicaamia are met with. His fourth group contains instauces in which no anatomical typhoid lesions exist, the serum test during life being positive, but in which at autopsy the bacteriological examination is negative while the serum test may still be positive.

Of interest to us, in this connection, are groups II and III, especially the latter. In the three cases reported by Chiari and Kraus belonging to the second group the intestinal lesions consisted of slight swelling of follicles in the ileum or large intestine ; no necrosis. Mesenteric glands and spleen usually enlarged. The cultures from the mesenteric glands, spleen and bile were positive in one case only, so that the diagnosis of typhoid fever rests largely upon the serum reaction.

Chiari and Kraus describe in their third group five cases. These are regarded as anatomically non-diagnoscible. They represent, in their opinion, examples of typhoid septicajmia. We purposely refrain from discussing their views at this time, but will call attention only to the fact that iu three of the cases only were bacilli demonstrated in cultures. In their Case XIII, from the gall-bladder and mesenteric glands; spleen negative; Case XIV, bile immediately at autopsy negative, but from the bile after several days iu the thermostat pure culture of bacillus typhosus ; mesenteric glands and spleen negative ; Case XVII, gall-bladder, b. coli com.; spleen, staphylococcus aureus; urine, staphylococcus aureus and b. typhi; abscesses kidney, s. aureus; pneumonic lung, micrococcus lanceolatus. The remaining two cases (XV and XVI) showed upon histological examination clumps of bacilli in mesenteric glands, and in Case XV in the spleen as well; cultures negative.

• The case which we have encountered will be found to belong to the third group of the above classification. It, however, fulfills the conditions there laid down much more perfectly than any of the cases given. We are indebted to Dr. Osier for the privilege of abstracting the clinical notes.

Clinical Summary. W. G., male, aged 68, native of U. S., admitted to hospital, October 38th. On entrance complains of shortness of breath. Past history unimportant. Present illness dates back two months, since which time he has been losing weight and strength. Appetite poor. No chills or fever; no night sweats. Two weeks ago suffered from


severe pain in the back ; shortness of breath began at this time, as well as painful sensations in the abdomen. October 2Cth, while undressing, fell to the floor; very quiet next day, not having moved from the position in which he had been placed on the bed.

On admission (Oct. 38th) very dull and listless; seems in much pain ; groaning with each expiration. Kespirations -14 to minute. Thorax : somewhat barrel-shaped ; right side more prominent than left; jjercussion note in front hyper-resonant; in back more resonant than normal. Eespiration harsh; expiration prolonged; loud friction rub iu axilla. Heart: relative dullness at sternal margin 3d rib ; absolute dullness at 4th rib. Point of maximum impulse visible and palpable in 5th space 10 cm. from median line. Spleen : not palpable. Examination of blood negative for malarial organisms ; leucocytosis of 18,000. Patient gradually sank and died at 10 o'clock, October 30th.

Abstract of Protocol. — Anatomical Diagnosis. Typhoid fever without intestinal lesions ; typhoid septictemia. Thrombosis of main branch of pulmonary artery supplying lower lobe of right lung ; gangreue of lung ; perforation of pleura ; pyo-pneumo-thorax. Acute splenic tumor. Parenchymatous degeneration of liver and kidneys ; obliteration of lumen of appendix vermiformis.

Autopsy, one hour post mortem. Body of a large, stronglybuilt and moderately well-nourished man. Surface of the body presents a sallow hue. Patchy li vor mortis over posterior aspects of the trunk.

The right half of the thorax is more prominent than the left; on percussion hyper-resonant. Diaphragm at right side 7th rib ; left side 6th space. On puncturing the right pleural cavity under water free escape of gas.

The right lung is compressed, the upper and middle lobes are quite airless ; the lower lobe more voluminous ; this lobe is bound to the diaphragm by old adhesions. The parietal pleura is generally thickened and covered by a layer of shaggy fibrin. The fibrinous membrane is thickest over the visceral pleural membrane. The lower lobe is not only voluminous, but of very dark color and quite solid consistence. The pseudo-membrane covering this portion of the lung is also dark in color. On the removal of this membrane several defects in the pleura become evident ; but the whole pleural membrane is so friable that it easily breaks on handling the specimen. The main branch of the pulmonary artery supplying this lobe is occluded by a moderately firm, partially decolorized thrombus, from which more recent, usually red, thrombi extend into the communicating branches iu several directions. The section of this lobe of the lung presents a dark greyish appearance. The odor is moderately offensive.

Spleen weighs 160 grams; consistence diminished; cut surface dark iu color.

The gall-bladder moderately distended with thick, darkcolored bile. Contains a large number of small concretions (gall-stones).

The 03Sophagus, stomach and intestines, except the appendix vermiformis, which is converted into a fibrous cord, show nothing abnormal.

The mesenteric glands are not swollen.


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Bdderiological examination. Plate cultures upou agar-agar were made from the heart's blood, right lung (gangrenous portion), left lung, liver, kidneys and spleen, and a blood serum tube was inoculated from the cerebro-spinal fluid. After 48 hours in the thermostat at 37° C. the plate from the heart and the serum tube only remained sterile.

The results of the plate method were as follows : Plate from the consolidated right lung crowded with colonies, necessitating replating ; plate from left lung about 65 separate colonies ; from the spleen eleven colonies ; liver 80 to 90 colonies ; kidney a single colony only. With the exception of the single colony in the kidney, which proved to be a diplococcus forming at times short chains, a single bacillary form only was found in all the plates.

In morphology the organism isolated from the plates agreed with the bacillus typhosus. The tests employed to distinguish the colonies from each plate consisted of growths on agar-agar, potato, litmus-milk and 1 per cent, glucoseagar ; the absence of indol in Dunham's solution,* the demonstration of flagella with the arrangement seen in typhoid bacilli (peri-tricha), and finally the reaction with blood serum from a case of undoubted typhoid fever.

The bacilli isolated from the various sources were actively motile, grew characteristically upon agar-agar, slightly reddened but did not coagulate the litmus-milk, failed to ferment glucose-agar, but upou the potatoes gave vise to a slightly visible growth. Parallel cultures upon potato made with typhoid bacilli of known origin showed a similar growth in each. The agglutinating reaction was obtained in 30 minutes


with a serum dilution of 1 to 35, and in one hour with a dilution of 1 to 50.

The cover-slip preparations from the gangrenous lung and pleural exudate showed bacillary forms of several kinds, including large, coarse individuals not unlike certain putrefactive bacteria. It is interesting to note that upon the aerobic plates only the bacillus typhosus developed.

Histological examination. Study of sections of the liver, spleen and kidneys from the case stained by the ordinary histological methods, and especially for bacteria (carbolthionin, polychrome methylene-blue, alkaline niethyleneblue), failed to develop anything which especially supports the diagnosis of typhoid infection. The " lymphomata " so often found in the liver of ordinary cases of typhoid fever were absent, a single area of necrotic liver cells the size of a miliary tubercle alone being found in many sections; and the typical appearance of clumping of the bacilli in the spleen and liver was wanting, while, however, single bacilli were discovered in several sections. The spleen showed a moderate hyperplasia of lymph cells and considerable congestion; the liver cells were swollen and granular.

The tests employed for the identification of the organisms isolated from the several viscera leave no doubt as to their nature, and the case therefore is properly to be regarded as one of typhoid infection without intestinal lesions or glandular enlargement. Indeed it would have been impossible to diagnose the case as typhoid fever in the absence of the bacteriological examination.


APPARATUS FOR STERILIZINCx INSTRUMENTS WITH FORMALDEHYDE; EXPERIMENTAL TESTS.

By H. 0. Eeik, M. D., and AV. T. Watson, M. D.


At the recent meeting of the American Medical Association in Philadelphia, Dr. E. A. de Schweinitz, bacteriologist to the Bureau of Animal Industry, United States Department of Agriculture, presented to the Ophthalmological Section a paper treating of the sterilization of instruments by formaldehyde, both in solution and in the gaseous form.

Knives which had been used in dissecting were washed in water and placed in a 1 to 2000 formaldehyde solution. It was found that in thirty-five minutes they were completely sterilized.

In testing the effect of the gas, a small copper drying oven was used, and 25 cc. of 40 per cent, formaldehyde solution (the preparation known as formalin) was placed in a small dish in the bottom of the oven. The instruments used were proven sterile, then infected with staphylococcus pyogenes aureus, wiped with dry cotton, placed in the oven, and when tested after ten minutes showed growth on culture media. If knives infected in a similar manner were rinsed in hot water, wiped dry and placed in the oven, no growth was


•Planted in Peckham's alkali-peptone bouillon and incubated for 3 days, a faint but unmistakable indol reaction could be obtained. See Journal Experimental Medicine, No. 5, 1897.


noted after a teii minutes' exposure. Forceps treated in the same way required from fifteen to twenty minutes. The gas used was obtained by spontaneous evaporation of formalin, but it is important to note that "the solution of the gas was placed in the oven some hours before the instruments which were to be disinfected, in order that a sufficient volume of the gas might be present to act immediately upon the organisms adhering to the knives."

The length of time required to disinfect the knives by the formalin solution and the length of time required to generate the gas in the chamber previous to disinfection would materially interfere with the practicability of these methods, for if so much time is necessary to put them into operation they offer but little advantage over other methods.

Again, we would respectfully suggest that the tests were scarcely conclusive as to the value of the gas, for, may not some portion, at least, of the disinfection have been produced by the rinsing of the infected instruments in hot water and their subsequent wiping with dry cotton ?

We have seen no other report of work in the direction of disinfecting instruments with formaldehyde, although Dr. Valude, in the Revue Generale d'Ophthalmologie for July, 1893, recommended that, " as formalin does not attack metals,


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it is well adapted for antiseptic solutions in which to keep instruments before and during operations."

The report by Dr. de Schweinitz, however, in connection with the experiments of others to disinfect various objects and large areas, led us to expect that instruments could be more quickly sterilized by the gas if it could be conveniently and rapidly prepared in a small apparatus. We used in our experiments the box exhibited here, simply an air-tight tin oven with a capacity of 1} cubic feet. By the introduction of wooden blocks the capacity was reduced to 1 cubic foot. Two racks or trays for holding instruments are suspended in the upper half of the box and the gas is manufactured below. We first attempted to secure the gas by spontaneous evaporation. One hundred cc. of the 40 per cent, solution, formalin, was placed in an evaporating dish in the bottom of the box and presented a surface of about 16 sq. inches. The knives and probes here presented, and which were used in all our tests, were infected with a fresh culture of staphylococcus pyogenes aureus and placed on the racks over the formalin dish. The cover was then removed from this dish, the door of the apparatus quickly closed and evaporation allowed to proceed. At the end of 1 minute the door was opened, the knife removed, and the formalin dish re-covered. A culture was made from this knife upon agar and placed in the thermostat. Control cultures were also made from the aureus used, in order to be sure of its vitality.

This experiment was repeated with the exception that the time of exposure was lengthened to 2, 3, 4, 5, 10 and 15 minutes. Then a jump of large intervals was made, the tests being at half-hour intervals up to four hours. In every interval between the tests the door of the box was left open to permit escape of the gas, so that there might be no accumulation of it and we might thus be able to determine just how long au exposure to the spontaneous evaporation of the gas would be necessary. The time proved much longer than we had expected, and it was only after a 2i hour exposure that we could feel sure of sterilization. This would evidently not do for practical work and we were compelled to look for some more rapid means.

We did not use formalin for the generation of the formaldehyde gas by heat, for two reasons : 1st, we feared that the heat which would drive off the gas would at the same time vaporize the water which contained it and thus possibly cause a rusting of the instruments; 3nd, we found in paraform a much more convenient substance for the purpose.

Paraform is polymerized formaldehyde and occurs as a light white jjowder, which can by means of heat be entirely converted into formaldehyde. Commercially it can be obtained in the form of j)astilles weighing 1 gram each.

The next problem was how to get the gas in the chamber. Should it be generated outside and then introduced, or could we generate it inside the apparatus ? To generate it outside has many objections. Our next experiments were made to discover if it were possible to vaporize the tablets by means of a lamp inside the closed chamber. We feared that the oxygen contained in the chamber would not support combustion long enough to develop suflBcient heat to generate the amount of formaldehyde needed. Our fears in this regard


proved to be quite unfounded, but we found that the kind of alcohol lamp used was a very important factor. After using two ordinary alcohol lamps in our possession we abandoned them for the Sobering formalin lamp, which we found more efficacious, generating far more gas with the amount of oxygen at our disposal and beins: much more economical in the use of alcohol.

This lamp we find will burn in a closed chamber containing 1 cubic foot of air for about 14 minutes. In that time it will vaporize 35 grains of paraform. The temperature of the apparatus will be raised in this time to less than 30 degrees Centigrade, so that the element of heat does not affect our results.

This amount (35 grains) of paraform was found to be far in excess of the quantity necessary to disinfect this chamber. We then proceeded to find the minimum amount of paraform required to disinfect the chamber in a reasonable length of time. We vaporized quantities ranging from 3 grains up to 10 grains for different intervals of time. Even 2 grains will sterilize the chamber if given sufficient time. Three grains will do it in 15 minutes, 5 grains in 10 minutes, and 10 grains in 7 minutes. We could not proceed in this way indefinitely to use larger quantities and diminish the time because 10 grains in 7 minutes is the full vaporizing capacity of the lamp. Nor is it desirable to increase the amount of jiaraform, for when the chamber is opened there is an escape of gas into the room which, while not injurious or particularly objectionable, yet is not to be desired. For practical purposes 10 or 15 miniites is a short enough time for the sterilization of instruments, and this can be done with 5 or 3 grains of paraform.

The micro-organisms used in these experiments were the staphylococcus pyogenes aureus and the anthrax bacillus. The knives were sterilized by boiling and then infected from slant agar cultures. The germs could in every instance be seen en masse upon the instruments when put into the chamber. After exposure to the gas, cultures were made upon slant agar.

One feature of this disinfection by evaporation of the paraform needs a little further investigation. After performing numerous experiments during which large quantities of paraform were vaporized, there appeared upon the sides of the chamber a thin greasy deposit which afterwards became converted into a dry white powder. This, we are informed from the literature on the subject, is paraform which has become deposited again from the gaseous state. We did not in any instance find this deposit visible upon our instruments, still the possibility of its adhering we have in mind, and later will experiment to determine whether or not it is present, and if so, whether or not it would have a deleterious influence upon wounds. From the literature at our command we believe that there is but little danger from this source.

Another important matter to be considered is whether or not the cutting edge of the instruments is dulled by this method of disinfection. Upon this point we have the opinions of Drs. E. A. de Schweinitz and Swan M. Burnett of Washington, who state that from the use both of the gas and of the liquid formalin there has been no influence whatever upon the sharpness of the instruments.


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From these experiments we conclude that :

1st. A lamp will hum in any absolutely closed chamber long enough to generate more than sufficient formaldehyde for its disinfection.

2nd. In a chamber of 1 cubic foot space 3 grains of paraform in 15 minutes, or 5 grains in 10 minutes, will accomj)lish disinfection.

3rd. The expense of such disinfection, including the cost of paraform and alcohol, will not exceed 1 cent, and the labor involved is almost nil.

4th. For the disinfection of small instruments, such as those used by ophthalmologists, otologists, laryngologists and dentists, it is by far the most convenient and speedy method.

5th. This method, probably better than any other, for the work designed, carries out the principles of disinfection laid down by Koch, viz. " the absolutely certain destruction of all pathogenic organisms, in the shortest possible time, at the least expense and with a minimum of injury to the object of disinfection."

E. B. Meyrowitz, of New York, has in preparation an apparatus specially designed by us for the use of this method, and Sobering and Glatz will manufacture pastilles of 5 grains each for use in the apparatus.

In concluding we wish to thank Dr. McShane for permission to conduct these experiments in the City's Bacteriological Laboratory, and Dr. Stokes for advice and guidance in our work.

Discussion.

Dr. OuLLEN. — Dr. Hurdon is, at the suggestion of Dr. Kelly, now carrying on experiments in this line. The apparatus used contains about 6 cubic feet, and particular attention has been paid to the sterilization of dressings. Using four pastilles of paraform it was possible to render a piece of gauze that had been dipped in a jnire culture of anthrax, sterile in ten minutes, but if the piece of gauze was wrapped in seven or eight layers of gauze and this bundle enveloped in three thicknesses of foolscap paper, twenty minutes were required for sterilization. The only disadvantage noted was that on opening the box the escaping gas caused considerable irritation of the eyes of those in the room. With regard to the effect on instruments I was glad to hear what Dr. Keik said, because the ophthalmologist's instruments are so delicate, and, as Dr. Kinyoun, in a recent report on experiments with formaldehyde, states that gold and


silver are not affected, but that the effect on the iron is to cause oxidation.

Dr. Theobald. — I was very much interested in the report by Dr. Reik, and I think it would be a distinct advantage if we could have such a sure and easy method of disinfection of our instruments. It is very diflBcult to submit our instruments to boiling or even to dry heat without dulling the knives, and they also become tarnished when immersed only for a few moments. To sterilize them by this method would certainly seem to be a distinct gain.

Dr. Watson.— I would like to ask Dr. Cullen whether Dr. Hurdon found much deposit on the bandages. I read in a circular issued by the manufacturers of the pastilles that after vaporizing the paraform it was readily deposited upon woolen goods. We did not find it on the knives at all, and thought possibly this might be due to their smooth surfaces or to the nature of the metal.

Dr. Cullen. — The box used was six cubic feet, very large, and Dr. Hurdon has not noticed any deposit.

Dr. Stokes. — These experiments are of value when viewed from several different standpoints. It is a good thing to have proved that the spontaneous evaporation of the gas is not a very practical method for the sterilization of instruments, and again it is of value to have shown that the evaporation of such small quantities of the gas from the solid pastilles will cause the thorough surfiice disinfection of such a chamber.

This work seems to show that it is possible to render not only the instruments of the ophthalmologists sterile, but to destroy bacteria on the surfaces of even larger instruments, and so this method may be applied in general surgery.

I am also glad to learn from Dr. Cullen that several layers of gauze can be disinfected even when wrapped in paper, for that seems to show that the ordinary dressings used by the ophthalmologists, for instance, may be rendered sterile. I think the general experience with formaldehyde has shown that with finely woven textures, like cotton, penetration is a difficult thing to attain.

In regard to Kinyoun's experiments, they were performed in a large room and the gas was allowed to remain in contact with the iron lor some time. I hardly think that any harm could be done the instruments in just the few minutes they are exposed in this chamber, but this can be determined by further experimentation.


PROCEEDINGS OF SOCIETIES.


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of October 4, 1897. Dr. Barker in the Chair.

Exhibition of Specimens.— Fibroid Lnng-Bronchiectasis—

Brain Abscess. — Dr. Livingood.

The first is a section of lung showing fibroid induration. The upper lobe is uniformly solid, grey and very firm. The middle lobe is not so firm. The lower lobe is congested and shows an area of fibrous induration in the lower part. Extend


ing through these solidified portions are tubular bronchiectatic cavities with blood-stained walls.

The other specimen is a section through the right hemisphere of the brain about the paracentral convolution, in the upper part of which is an abscess cavity the walls of which are irregular.

Both these specimens came from the same case and demonstrate an interesting association. Their color is partially preserved by the Kaiserling method, but is no longer as intense as at the time of autopsy.


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[No. 81.


The case was that of a young colored man (F. C), 21 years old, who was brought here by strangers in a half-conscious condition, so that at the time of admission no history at all could be obtained, except that he had been working but half a day at North Point, when he was " taken with a fit," his condition later being the same as at the time of admission. It was learned later that he had been living a rough life, wandering about the country in search of work ; that he had had a cough for two years and was said by his friends to have had "consumption."

On admission he did not present the appearance of one who was suffering from chronic disease ; his frame was well formed and there was no evidence of emaciation. He died four days after admission. During this time his condition remained about the same, except that he became progressively weaker, and during the last two days had an apparent right-sided hemiplegia and athetoid movements of left arm. His greatest distress seemed to be a violent pain in the head. He was in profound stupor during this whole time ; was seized with paroxysms of coughing of a sharp, moist character, accompanied by very little expectoration owing to his weakness and stupor. The sputum which was obtained was of a dark reddish-brown color, containing necrotic material and of extremely foetid odor. Examination showed it to contain pus and epithelial cells and a great number of organisms, both cocci and bacilli, none of which showed the typical staining reaction of tubercle bacilli. He was extremely restless at times, and in the last two days showed athetoid movements of the left side. I will have to omit the other interesting nervous phenomena which were noted by Dr. Camac and Dr. Bardeen at different times. His temperature curve was very irregular, running up each evening ; once to 104.5° F.

Physical examination of his chest indicated complete consolidation of the upper lobe of the right lung, which was noted to be very intense ; signs of partial consolidation in the lower lobe. Associated with these signs were coarse, moist rdles. The left lung was apparently normal during the first three days, on the fourth day there developed signs of broncho-pneumonia.

At autopsy the right pleural cavity was found obliterated in the upper part. The middle lobe of the lung was slightly adherent. The lower lobe was very firmly attached to the diaphragm about the middle of its posterior margin. The fibrous adhesions about the upper lobe were very dense, and at two points the sub-pleural tissue seemed to be involved, so tliat on freeing the lung some of its substance remained adherent to the ribs at these points. In this way two cavities were exposed extending into the lung tissue.

The pleura covering the upper lobe was oedematous. The lobe was strikingly firm, voluminous, with little puckering and of grey color. The middle lobe was more resistant than normal, likewise grey, but more translucent than the upper lobe. The lower lobe was for the most part congested, but through its substance ran an area of fibrous consolidation, broadest in the lower part where the lung was adherent to the diaphragm.

On section through the lung, the upper lobe had a firm, glistening, almost cartilaginous appearance, with broad


strands of fibrous tissue radiating out from the thickened bronchi. Scattered over the surface were small translucent and opaque yellow points resembling miliary tubercles. The middle lobe was not so completely solidified, it appeared more translucent and elastic. The lower lobe had a salmon pink color; its density was generally increased, and through its centre extended downwards an area presenting the same condition as upper lobe.

Through the upper, middle and dense portion of lower lobe ran tubular cavities, the lumen about a centimeter in diameter. The walls were much thickened and the inner surface hsemorrhagic. These cavities communicated freely with the bronchi, and sections showed that they were directly continuous with them. They contained a fcetid, blood-stained muco-pus. The peribronchial glands were enlarged, but showed no tubercles. The left lung was congested and in the lower lobe showed patches of broncho-pneumonia.

Examination of the brain showed that the dura was adherent and thickened, especially on the right side. There was slight oedema of the pia at a point where the brain surface was discolored and depressed. This corresponded to a point at the upper end of the fissure of Eolando in the right hemisphere. On lifting up the pia an underlying cavity discharged a small amount of a greenish foetid pus. This cavity, measuring about 3 cm. in all diameters, was seen to occupy the paracentral convolution and to cause a bulging of this area into the longitudinal fissure. The ascending frontal convolution showed no involvement, but the area of softening extended down the ascending parietal convolution for a distance of 5 cm.

Microscopically the induration of the lung is seen to consist of broad strands of fibrous tissue which represent thickened inter- and intra-lobular connective tissue. These main strands have the appearance of old fibrous tissue, poor in cells. Encroaching still more upon the bronchioles and individual alveoli is a younger, much more cellular, fibrous tissue, which surrounds them and which has compressed the alveoli into the form of small racemose gland acini, the epithelium having reverted to its embryonic cubical form. Often the alveoli are filled with fatty epithelial ceils which, in the gross specimen, gave the appearance of caseous tubercles. The walls of the bronchi are very thick and are surrounded by cellular fibrous tissue, and are infiltrated withpolymorpho-nuclear leucocytes. The bronchi are filled with pus cells and desquamated epithelial cells. The induration in the middle lobe is of the same character but is not so complete. There is a slight deposit of coal pigment in the peribronchial tissue.

The type of fibroid lung here seen is not that which has been described by Ziegler, Von Kahlden and others, in which there is an organization of an alveolar exudate by an outgrowth from the connective tissue of the alveoli, nor of the type secondary to atelectasis described by Orth. It is rather a more common form due to a thickening of the interlobular connective tissue, but is of interest in its extensiveuess and in the distribution which seems to indicate its etiology. Structurally it has the appearance, described by Charcot, which follows subacute broncho-pneumonia.

By far the commonest cause of fibroid lung is tuberculosis,


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but I think that we have grounds to exclude this in the present case. There is no evidence of tuberculosis elsewhere, no appearance of tubercle or of tuberculous tissue in the lung itself, no areas of caseation, sections stained for tubercle bacilli after careful search failed to reveal the organism. There are a few giant cells, but they have the character found about foreign bodies, with centrally located nuclei and distinct, rounded peripheries.

Inhalation of dust and of irritating vapors is a frequent cause of induration. As in this case there is a distribution along the bronchi, but our specimen shows but little foreign substance, coal pigment, — not enough to give rise to the marked changes.

Syphilis, which has its distribution along the bronchi, is difficult to exclude, although its involvement is usually at the root of the lung and is sometimes associated with gummata. The distribution and histological picture in this case seem to indicate that it is one of those cases of induration subsequent to the absorption of toxic substances, bacterial in origin, by way of the bronchi : a subacute bronchitis and peri-bronchitis. The irritation is not intense enough at any time to produce an acute reaction throughout the lung, but sets up a slow formation of connective tissue. Subsequently, as frequently happens, there is the formation of bronchiectatic cavities at the points where the bronchial walls are weakened by the more intense effects of the toxic substances, and these cavities in turn offer opportunity for lodgment and activity of various kinds of bacteria. In this way a fresh inflammatory process is lit up and a vicious circle is established which in time causes complete induration of the lung tissue.

The association of brain abscess with bronchiectatic cavities has frequently been noted. Williamson has recently reported that out of 39 cases of brain abscess, 17 were associated with putrid bronchiectasis.

On cover-slips from the cavities there appeared a great variety of organisms, from which I succeeded in isolating but one, the pyogenic streptococcus. Cover-slips from the brain abscess showed likewise a great number of organisms, some of which I had recognized on cover-slips from the lung. None, however, grew out on my culture plates. If the streptococcus pyogenes was present, it failed to grow.


NOTES ON NEW BOOKS.


Burdett's Hospital and Charities, 1897, being the Year-Book of Philanthropy, containing a Review of the Position and Requirements, and Chapters on the Management, Revenue and Cost of the Charities, etc. By Henry C. Burdett, Editor of "The Hospital." [London: The Scientific Press, Limited, 1897.) We have had occasion in previous years to speak in the highest terms of this Year-Book which is now in the eighth year of publication. It presents a volume of statistics of the greatest utility to all who are engaged in any form of philanthropic work. It would be fortunate for all charitable boards, not only of hospitals, but of missionary societies, orphanages, nursing and convalescent homes, if copies could be placed in the hands of each member.

As might be anticipated in view of the fact that the Queen of England and the Prince of Wales have shown great interest in hospitals and nurses' training schools, two chapters of the present


volume are given up to the Queen's commemoration and the Prince of Wales' fund for the relief of distressed London hospitals.

The chapter on "Hospital Construction during 1896" is a new feature and one which is destined to become increasingly valuable. Il gives sensible and brief criticisms on the plans of infirmaries, general hospitals, nurses' homes, cottage hospitals and convalescent homes which have been erected in Great Britain during the year. If a similar chapter can become an annual affair it is altogether probable that many mistakes in future hospitals will be corrected. The editor in a previous volume recommended that all hospital plans be revised by competent experts prior to letting any contracts or commencing any building. It is to be hoped that the present attempt to criticise hospital plans may eventually lead to this.

We are much gratified to know that the editor still insists upon his former dictum in hospital expenditures, viz. that lavish expenditures do not necessarily imply efficient administration. The list of institutions for the insane in the United States is far from complete and should he revised before another edition of the book.

Lectures on the Malarial Fevers. By Wm. Sydney Thay'er, Associate Professor of Medicine in the Johns Hopkins University, pp. 1-326, with 19 illustrative charts and 3 lithographic plates. (New York: D. Appleton & Co., 1897.)

The publication of this book has occurred opportunely. The exhaustive studies which have been made during the past seventeen years have led to marked changes in the ideas of the medical profession concerning the nature of the malarial diseases. These researches, especially those dealing with the parasitology, have now attained to a degree of completeness which permits of a satisfactory collective treatment of the subject.

When Laveran in 1880, while studying the blood of fever patients in Algiers, discovered the malarial parasite, he could have had but little idea of the richness of the mine in which he was doing such successful prospecting. He knew he had made a valuable finding, for within a month after his first positive observation a preliminary paper concerning it was presented to the Academy of Paris. This was soon followed by other communications from the same investigator, who appeared to be well aware that where so valuable a nugget had been easily extracted, richer treasures might reasonably be supposed to exist.

Laveran was at once convinced, on seeing the organism, that he was dealing with a living parasite. He studied the various forms which it assumed, and the descriptions which he has given us of his early observations are interesting and accurate. His contributions, however, remained for some time without marked influence, a fact attributable largely to the wide acceptance met with by the ideas concerning the aetiology of malaria which had been advanced by Klebs and Tomassi Crudelli in 1879. The doctrine of the bacillary origin of malaria, fathered by these investigators, was advanced in the blooming period of the science of bacteriology at a time when protozoan diseases had scarcely been heard of. Notwithstanding its falsity it is perhaps but little wonder that it attained to such sudden general credence.

Although Richard, as a result of his own research, confirmed Laveran's statements, and the latter made personal demonstrations of the parasite to others, it was not until some five years later that general interest became aroused in the subject and investigators in different countries recognized the truth and significance of his reports. About this time a number of clinicians began investigating for themselves, and since 1885 a host of men have been at work at the subject in the most different parts of the world, perhaps most actively in Italy and America.

Three distinct varieties of the malarial parasite have been identified: (1) that of quartan fever; (2) that of tertian fever ; (3) that of the sestivo-autumnal fevers. Each of these varieties of the parasite undergoes a peculiar and characteristic developmental


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[Ko. 81.


cycle, culminating in its multiplication by the process of segmentation. Coincident with the segmentation simultaneously of a large group of parasites a malarial paroxysm occurs.

The cycle of development of the parasite in quartan and tertian infections was first made out by Golgi ; that of the restivo-autumnal fevers was independently established by I\Iarcbiafava and Celli and Canalis.

The clinician has now at his ilisposal a mass of diagnostic and prognostic data with reference to the malarial diseases. Not only have the various stages in the developmental cycle of each variety of the parasite been accurately studied and described, but the time relations in the different cycles have been ascertained with astonishing exactness. The skilled hamatologist can now decide, from his study of the blood alone, not only that he is dealing with a case of malaria, but also as to the particular nature of the attack. He can tell the patient the periods of past paroxysms, and if the case be left untreated, can prophesy within tolerably narrow limits the time of occurrence of those to come. He is afforded many clues as to the gravity or benignancy of a given infection, and is able to draw valuable conclusions concerning the probable efficacy of quinine in a given case. He is further able to pass judgment as to whether urgency in the treatment is essential, and thus is ready to suggest the method of administration of the specific drug most suitable to the case.

The bibliography of the malarial fevers has by now assumed enormous proportions, for although many important veins remain to be followed up, the malarial mine has already been very thoroughly worked. In the process much pure metal has been extracted. A great deal of valuable material is still mixed, however, with baser mineral, and unfortunately the literature also is encumbered with quantities of spurious ore, consequent mainly upon investigation guided by the "divining rod" of preconceived idea.

To write a comprehensive and discriminative book on the malarial fevers correspondent to the needs of students and practitioners at the present time, one not only must be widely read in the bibliography of his subject, but he must also have had an extensive practical acquaintance with the microscopic characters of the blood of a large number of patients at various seasons of the year. To read and assimilate all the articles — and there are now many hundreds of them — dealing with malaria since 1880 is of itself no small task. To painstakingly analyze more than 1600 cases of malarial infection in which the type-diagnosis has been established by actually demonstrating the variety or varieties of the parasite present in the blood or in the juice removed from the spleen is a laborious undertaking. "It's dogged as does it," but it is thus that the author of the lectures before us has qualified himself for his work.

Dr. Thayer's book, which, very appropriately we think, he has dedicated to Dr. Osier, contains nine lectures. In these the essential facts concerning the parasitology of the disease, the clinical phenomena, the morbid anatomy, the pathogenesis, diagnosis, prognosis, treatment and prophylaxis are dealt with.

In the first lecture a brief history of the development of knowledge concerning the pathogenic agent of the malarial fevers is given. Copious references in the form of footnotes make it possible for the reader to consult the original articles in all languages. The different views which have been advanced concerning the classification of the parasites, their finer structure and manner of reproduction, are here briefly but clearly discussed. The author believes in the specificity of the three main types of malarial parasites —tertian, quartan, and restivoautumnal, and combats the idea still held by some that the organisms are all varieties of one parasite, and that the morphology varies simply according to the season of the year and the conditions to which it is subjected. To the viewformerly expressed in his monograph (in conjunction with Hewetson) entitled "The Malarial Fevers of Baltimore," concerning the parasites of the sestivo-autumnal fevers, namely, that they all rep


resent varieties of one specific type, and are not divisible into a quotidian and tertian variety as Marchiafava and Bignami assert, in the absence of inoculation experiments bearing on the question, the author still adheres.

The methods of examination of the blood and the appearances of the different varieties of the parasite in all stages of development in fresh blood and in dried and stained specimens, are described at length in the second and third lectures. We are glad to see italicized as the opening paragraph of this section of the book the following statement : — "It is impossible to make reliable examinations of the blood for malarial parasites without first being familiar with the ordinary appearances of normal blood and the more common pathological changes." How many unfortunate mistakes and lamentable exhibitions of ignorance would have been avoided had the appreciation of this fact been more general ! Non-acquaintance with thevacuolelike appearances so often met with in the red corpuscles, certain puzzling forms encountered in poikilocytic conditions, the blood platelets, the various kinds of white blood corpuscles which exist, or the artefacts which can arise from faulty preparation of the specimen and the like, has led many an observer into error, and has been responsible for more than one publication which should have, if it has not, made its author long for an obscurity in which, as Johnson put it, he could be " glad to be hid, and proud to be forgot." However excusable some of those may have been who have fallen into such traps in the past, there is no longer any justification for the repetition of these foolish and unnecessary errors, and it is a pity that articles containing them still occasionally creep into respectable medical journals.

All who have had practical experience will agree with the statement on page 35 that "the best method of studying the malarial parasite is in the fresh untreated blood at the bedside or in the consulting room." Dried and stained specimens are at best an unsatisfactory substitute for the fresh blood-slide. The directiors given in this section are detailed and might at first thought seem unnecessarily minute, but any one who has observed students fail over and over again simply from the non-observance of some trifling technical point will approve of the explicit directions. It would seem scarcely possible, with the clean-cut morphological description of tertian, quartan andrestivo-autumnal parasites given in these pages, that the careful student should fail to identify them, especially as the descriptions are accompanied by three admirable lithographic plates reproducing Max Broedel's drawings made directly from the parasites in the fresh blood. These plates include some 35 illustrations of the parasite of tertian fever, 17 of those of quartan, and 49 of those of £estivo-autumnal fever. In fact, all the forms likely to be met with in ordinary clinical examinations are faithfully delineated.

The various views which have been advanced concerning the nature of the flagellate bodies are outlined on page 78 and the following three pages. Since the writing of Dr. Thayer's book, much new light has been thrown upon these curious structures by the researches of Dr. W. G. MacCallum. When another edition of the book is called for, it will be the author's pleasant task to supplement the unsatisfactory hypotheses concerning the flagella referred to in the present volume with a description of the process of fertilization in the malarial parasite, as observed by the investigator referred to.

The general conditions under which the malarial fevers prevail are dealt with on pages 82 to 96. The geographical distribution ; the effect of climate, seasons, time of day ; the influence of moisture, soil, altitude, and winds; the effects of cultivation and drainage of malarious districts ; the relation of malaria to the drinking water, are among the topics which here receive atten^tion. There are short paragraphs also on the significance of race, sex, age and occupation in connection with malaria. The various modes of infection which have been suggested are discussed ; it is to be regretted that the author, concluding this section, is compelled to make the statement, " We are absolutely ignorant of the form in


December, 1897.]


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which the malarial parasite exists outside of the human body, and equally ignorant of the manner in which it enters."

The clinical description of the malarial fevers is given in Lectures IV and V. Each type of the fever is analyzed, and the various modifications met with fully illustrated. This portion of the book is liberally interleaved with charts showing the temperature-range in typical cases personally observed by the author. The description given of the pernicious fevers is worthy of especial mention, as are the paragraphs dealing with masked malarial infections, and the cases in which combined infections with dilferent varieties of the malarial parasite have been encountered.

The sequelaj and complications of the malarial fevers are next taken up. The eases in which simple insolation has been confused with pernicious malaria are among those referred to under this heading.

In his lectures on the morbid anatomy of the malarial diseases, Dr. Thayer follows closely the accurate ilescriptions of Bignami, the investigator who certainly has made more important contrilmtions in this field than any other single individual. The anatomical changes in both acute and chronic infections are clearly set forth, though not at greater length than is consonant with the nature of a clinical manual.

The only part of the book in which the writer has indulged in speculation is in Lecture YIII, the section on General Pathology. The hypotheses brought forward are, however, unmistakably designated as such, and nowhere are they confused with a statement of facts. Considering the extended first-hand knowledge which the author possesses, there will be scarcely any one, we believe, deeply interested in the problems discussed, who will not seek his opinion respectfully regarding disputed points, or who will not weigh carefully the conclusions to which he has arrived. Dr. Thayer thinks it highly probable that the febrile manifestations in malaria are excited by the presence of circulating toxic substances, and proceeds to enquire as to the nature and origin of the toxines. Considering the data at hand he says (p. 254) : " Despite the lack of absolute proof, we are inevitably led to the conclusion that the most important exciting cause of the malarial paroxysm is the liberation of some toxic substance by the specific parasites at the time of their sporulation. While, very possibly, toxic substances may arise as a result of the disintegration and destruction of red blood corpuscles which occur at this period, it is improbable that these play the primary part in exciting the paroxysm."

After brief paragraphs upon the pathogeny of the antcmia, the pain in the bones, the jaundice, the cerebral symptoms, and the phenomena referable to disturbance of the alimentary tract, two important topics are considered : (1) The Origin of Infections with Multiple Groups of Parasites, and (2) The Mechanisms of Defence in Malarial Infections. With regard to the former subject, the author thinks that the main difficulty lies in the explanation, not of the multiple seativo-autumnaH but rather of the double tertian, and of the double and triple quartan infections. The occurrence of the paroxysms so nearly at intervals of 24 hours, and the tendency to segmentation in the morning hours, are especially difficult things to explain, and it is admitted that the whole question still remains unsolved. The author believes that a number of the cases represent instances of multiple infection from the beginning, but thinks that there are examples in which a second group may be derived from one original generation, through anticipation or retardation of the ripening of certain of the parasites. Some ingenious suggestions are offered to explain this process, and especially to account for the fact that the anticipation or retardation usually amounts to almost exactly twenty-four hours.

As regards the mechanisms of defence involved in malarial infections, the author is of the opinion that too much stress has been laid by many upon the riMe played by phagocytes. He would rather assume that the more important factor in spontaneous cure is some parasiticidal substance or substances circulating in the


blood serum, admitting, however, that the latter may be of cellular origin. The dispute is an old one, and is not limited to malaria alone, but pertains to the whole group of infectious diseases, and is, moreover, one not likely to be settled to the entire satisfaction of all, at least in the very near future.

The last chapter of the book deals with diagnosis, prognosis, treatment, and prophylaxis. This chapter is eminently satisfactory. The disease is sharply differentiated from conditions likely to be confounded with it, and the diagnosis is helped out to a certain extent by the introduction of comparative tables in the text. Concerning the treatment, the writer seems to have rejoiced at the opportunity of dealing with a disease in which there can be no talk of therapeutic nihilism. The modes of administration of the specific drug best suited to the different kinds of malarial infection are treated of at some length. Sensible advice is also given as to the application of general measures, such as rest in bed, change of surroundings and diet.

The work of the publishers is, on the whole, excellent ; the type and paper are agreeable, and the binding neat. One finds rather more imperfect letters, however, than should appear in a first edition. We prefer the spelling defence rather than defense as employed throughout the book. The index is full, and as far as we have tested it, accurate. The introduction of an in<lex of authors' names is a pleasing feature. The book will not only be valuable to clinicians in the districts in which malaria prevails, but doubtless will, from the especial interest which the subject has excited, also appeal to many who practice in regions in which the disease is but rarely met with. L. F. B.

A Manual of the Practice of Medicine. By Geoege Roe LocKwoon, M. D., Professor of Practice in the Woman's College of the New York Infirmary, etc. With 75 illustrations in the text and 22 full-page colored plates. (Philadelphia: W. B. Saunders, 1890.) This admirable little book is a useful manual for students and medical men who desire to get terse and clear accounts of diseases and their treatment. Some of the sections are models of concise, orderly and systematic statements. Take for example the opening section on typhoid fever, the sections on nervous diseases and the section on malarial fever. Some of the remarks on treatment are less satisfactory, as for example, in the treatment of cholera infantum no mention is made of the desirability of withdrawing milk, which in the majority of cases is the essential thing to do. In delirium also bleeding and purging are recommended. The letterpress and illustrations are good, and the book is almost wholly free from annoying typographical errors. We notice, however, that cholera nostras appears as cholera nostra.


BOOKS RECEIVED.

A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in Photolithochromes from Models in the Museum of the Saint Louis Hospital, Paris. By E. Besnier, A. Fournier et al. Edited and annotated by .T. J. Pringle, 1\LB., F. R. C. P. Fol. 1897. Part XII. AV. B. Saunders, Phila., Pa.

Constipation in Adults and Children. With especial reference to habitual constipation and its most successful treatment by the mechanical methods. By H. lUoway, M. D. Svo. 1897. 495 pages. The Macmillan Co., New York.

Twenty-eighth Annual Report of the State Board of Health of Massachusetts, 1896. Svo. 920 pages. 1897. Wright & Potter Printing Co., Boston.

Fiftieth Anniversary of the Hartford Medical Society. Founded September 15, 1846. Proceedings at the Celebration, October £G, 1896. 4to. 124 pages. Hartford, Connecticut.

Essentials of Bacteriology : being a Concise and Systematic Introduction to the Study of Micro-organisms. M. N. Ball, M. D. Third edition. 1897. 12mo. 218 pages. W. B. Saunders, Phila.


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[No. 81.


Archives of the Roentgen Uai/. (Formerly Archives of Skiagraphy.

Edited by W. S. Hedley, M. D., and S. Rowland, M. A. Fol.

Vol. II, No. 1. July, 1897. The Rebman Publishing Co.,

Limited, London. W. B. Saunders, Philadelphia. Pathological Technique. A Practical Manual for the Pathological

Laboratory. By Frank Burr Mallory, A. M., M. D., and James

Homer Wright, A. M., M. D. 1897. 8vo. 397 pages. W. B.

Saunders, Phila. Transactions of the Chicago P.ithological Society from December, 1895,

to April, 1897. Vol. II. 1897. 12mo. 328 pages. American

Medical Association Press, Chicago.


Report of the Sewerage Commission of the City of Baltimore ; consisting of Mendes Cohen, F. H. Hambleton and E. L. Bartlett, appointed by joint resolution of the City Council, approved May 25th, 1893. 8vo. 1897. 231 pages. (Plates.) Baltimore, 1897.

An Epitome of the History of Medicine. By Roswell Park, A. M., M. D. Based upon a Course of Lectures delivered in the University of Buffalo. 1897. 8vo. 348 pages. The F. A. Davis Co., Phila.

A Te.vt-Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D.,LL.D. 1898. 8vo. 1287 pages. W. B. Saunders, Phila.


INDEX TO VOLUME VIII. OF THE JOHNS HOPKINS HOSPITAL BULLETIN.


Abel, John J. On the blood-pressure-raising constituent of the suprarenal capsule, 151.

iEsthesiometer, 125.

Anatomical relations of the nuclei of reception of the cochlear and vestibular nerves, 253.

Apparatus tor sterilizing instruments with formaldehyde; experimental tests, 201.

Arch of aorta, anomaly of, with additional muscle in neck, 234.

Atkinson, A. Duval. Parotitis following visceral inflammation, 204.

Bacillus aerogenes capsulatus (Welch), cases of infection by, 68.

Bacillus aerogenes capsulatus, observations to determine motility of, under anaerobic conditions, 74.

Bacillus proteus Zenkeri in an ovarian abscess, 4.

Bad Nauheim, visit to, 101.

Bardeen, C. R. Certain visceral pathological alterations, the result of superficial burns, 81; — Edingeron "The Development of Brain Paths in the Animal Series," 120.

Barker, Lewellys F. A new sesthesiometer, 125 ; — Congenital facial diplegia, 131 ; — Demonstration of Florence's iodine test for seminal stains, 133 ; — Hsemocytozoa of birds, 52 ; — Phrenology of Gall and Flechsig's doctrine of association centres in the cerebrum, 7 ; — Trichinosis, remarks on, 81.

Berkley, Henry J. Lesions induced by action of certain poisons on nerve cell. Study VI. Diphtheria, 23; — Studies on the lesions induced by the action of certain poisons on the cortical nerve cell. Study VII. Poisoning with preparations of the thyroid gland, 137.

Block, E. Bates. Case of typhoid fever in which the typhoid bacillus was obtained twice from the blood during life, 119.

Bloodgood, Jos. C. Rarer cases of, and observation on streptococcus infection, 47 ; — Cure of hernia by implanting section of sterilized sponge, discussion of, 45.

Books received, 15, 83, 113, 135, 197, 287, 207.

Brain paths in the animal series, Edinger on development of, 120.

Brain tumor, demonstration of probable case of, 215.

Brooks, Wm. K. William Harvey as an embryologist, 167.

Brown, George S. Case of pneumo-cardial rupture, 33.

Brown, T. R. Studies on trichinosis, 79.

Calvert, Wm. J., and Elting, Arthur W. Experimental study of the treatment of perforative peritonitis in dogs by a new method of operation, 143.

Camac, C. N. B. Visit to Bad Nauheim, 101 ;— Importance of employing pure salts in Schott bath, 214.

Carter, Edward Perkins. Report of a case of polybacterial infection in typhoid fever, 115.

Cataract, second series of operations (one hundred and fifty-eight), 199.

Cavernous angioma of the tunica conjunctiva, case of, 236.

Chatard, Pierre, 185.

Clark, J. G. Function of the peritoneum under normal and pathological conditions, 60 ;— Postural method of draining dead spaces in the pelvis, 62 ; — Mechanism of absorption of fluids and solid


particles in the peritoneal cavity, 01 ; — Postural method of draining the peritoneal cavity after abdominal operations, .59 ; — Rare case of lithopedion, 221 ; — Report of cases where postural method of drainage was employed, 03.

Clendinen, William Alexander, 189.

Cohen, Joshua I., 190.

Cone, Claribel. Encysted dropsy of the peritoneum secondary to utero-tubal tuberculosis and associated with tubercular pleurisy, generalized tuberculosis and pyococcal infection, 91 ; — Tuberculosis of the cesophagus, 229.

Cone, S. M. Squamous epithelioma and epithelial hyperplasia in sinuses and bone following osteomyelitis, 140 ; — Squamous epithelioma in a dermoid of the jaw, 208.

Correspondence, 33.

Cullen, Thomas S. Rapid method of making permanent specimens from frozen sections by the use of formalin, 108 ; — Demonstration of specimens, 216.

Cushing, H. W. Hrematomyelia from gunshot wound of the cervical spine, 195.

Dermatitis, a case of, due to the X rays, 17.

Dermatitis, due to the X rays, additional cases of, 46.

Diphtheria, lesions induced by the action of certain poisons on the nerve cell, 23.

Discussion : Dr. Barker, Trichinosis, 81 ;— Dr. Bloodgood, Cure of hernia by implanting section of sterilized sponge, 45 ; — Dr. Flexner, Puerperal sepsis due to infection with bacillus aerogenes capsulatus, 28 ;— Dr. Halsted, Gall stones, 31 ; — Dr. Osier, Trichinosis, 80 ; Congenital facial diplegia, 131 ; — Dr. Piatt, Cure of hernia by implanting section of sterilized sponge, 46 ;^Dr.Reed, Malaria as a water-borne disease, 43 ;— Dr. Thayer, Malaria as a water-borne disease, 43 ; Trichinosis, 80 ;— Dr. Thomas, Congenital facial diplegia, 130 ; — Dr. Welch, Malaria as a water-borne disease, 42.

Dixon, W. T. Address at presentation of Thorwaldsen's statue of Christ, 1.

Dobbin, George W. Puerperal sepsis due to infection with bacillus aerogenes capsulatus, 24.

Dunham, Edward K. Cases of infection by the bacillus aerogenes capsulatus (Welch), 08 ; — Observations to determine mobility of bacillus aerogenes capsulatus under anaerobic conditions, 74.

Duval, Douglas F. Palpation of the foetal heart impulse in pregnancy, 207.

Elting, Arthur W., and Calvert, Wm. J. Experimental study of the treatment of perforative peritonitis in dogs by a new method of operation, 143.

Epithelioma, squamous, and epithelial hyperplasia in sinuses and bone following osteomyelitis, 146.

Epithelioma, squamous, in a dermoid of the jaw, 208.

Eyeballs, congenital motor defects of, discussion on, 129.

Finney, J. M. T. Five successful cases of general suppurative peritonitis treated by a new method, 141 ;— Typhoid perforation treated by surgical operation, 110.


December, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


269


Flexner, Simon. Discussion of puerperal sepsis, 28 ;— of agglutination of typhoid bacilli, etc., 54;— of pseudo-tuberculosis hominis streptotricha, preliminary note, 128.

Fle.xner, Simon, and Harris, Norman McL. Typhoid infection without intestinal lesions, 259.

Friedenwald, Harry. Early history of ophthalmology and otology in Baltimore, 184 ; — Joseph Friederich Piringer, his methods and investigations, 191.

Frick, George, 186.

Futcher, T. B. Association between so-called perinuclear basophilic granules and the elimination of the alloxuric bodies in the urine, 85.

Gall stones, surgical significance of, 31.

Ghriskey, Albert A., and Kobb, Hunter. Bacillus proteus Zenkeri in an ovarian abscess, 4.

Gibson, John Mason, 188.

Gibson, William, 185.

Gilchrist, T. Caspar. Additional cases of dermatitis due to the X rays, 46 ; — Case of dermatis due to the X rays, 17 ; — Case of porokeratosis, preliminary notice of, 107.

Gilman, D. C. Address at presentation of Thorwaldsen's statue of Christ, 2.

Gonococcus, cultivation of, in two cases of gonorrheal arthritis and one of tsenosynovitis, 121.

Gould, George M., and Pyle, Walter L. King Arthur's medicine, 239.

Hsematomyelia from gunshot wound of cervical spine, 195.

Hsematozoan infections of birds, 235.

Hjematozoan infections of birds, pathology of, 51.

Hsemocytozoa of birds, 52.

Hagner, Francis R. Successful cultivation of gonococcus in two cases of gonorrheal arthritis and one of tsenosynovitis, 121.

Hamilton, Alice. Multiple tuberculous ulcers of the stomach, with report of three cases, 75.

Harper, John, 189.

Harvey, William, as an embryologist, 167.

Hernia, radical cure of, by implanting section of sterilized sponge, 44.

Herrick, A. B. Rare anomaly of arch of aorta, with additional muscle in neck, 234.

Influence of Louis on American medicine, 161.

Is malaria a water borne disease? 35; — Discussion, 42.

Jameson, Horatio G., 188.

Johns Hopkins Hospital Medical Society Proceedings: Bilateral dacryo-adenitis. Dr. Randolph, Dr. Thayer, 132;— Case of acquired paralysis of both external recti muscles with unilateral facial paralysis, Dr. Theobald, Dr. Thomas, 131, 132 ;— Certain visceral pathological alterations, the result of superficial burns, C. R. Bardeen, 81 ; — Congenital facial diplegia. Dr. Barker, Dr. Osier, Dr. Thomas, 130, 131 ;— Discussion of "agglutination of typhoid bacilli," etc., Dr. Flexner, Dr. Reed, 54 ; Dr. Thayer, 55 ; —Discussion of congenital motor defects of the eyeballs, Dr. Baton, Dr. Theobald, 129, 130 ;— Discussion of surgical significance of gall stones, Dr. Halsted, 31 ;— Demonstration of a case of probable brain tumor. Dr. Thomas, 215 ;— Demonstration of Florence's iodine test for seminal stains, Dr. Barker, 133 ;— Demonstration of specimens. Dr. Cullen, 216; — Excision of a parovarian cyst without removal of its ovary or tube. Dr. Kelly, 50,51 ; Discussionof, Dr. Welch,51 ;— Fibroid lung-bronchiectasis — brain abscess. Dr. Livingood, 263 ; — Hsemocytozoa of birds. Dr. L. F. Barker, 52; E. L. Opie, 52, 53; Dr. Osier, 52, 53; Dr. Thayer, 53; Dr. Welch, 53 ;— Hsematomyelia from gunshot wound of cervical spine, Dr. Cushing, 195 ;— Operations for cataract, Dr. Randolph, 133 ;— Ophthalmoplegia externa. Dr. Woods, 48 ; — Pathology of hsematozoan infections in birds, W. G. MacCallum, 51 ; — Rarer cases of and observation on streptococcus infection, Dr. Bloodgood, 47 ;— Simple contrivance for effecting pneumatic massage of the tympanal membrane and ossicles. Dr.


Theobald, 49 ; — Surgical significance of gall stones, Dr. Lange, 29 ;— Typhoid perforation treated by surgical operation. Dr. Finney, 110 ; Discussion of. Dr. Osier, 113.

Johns Hopkins Medical Society, 29, 47, 81, 110, 129, 195, 215, 263.

Kelly, Howard A. Excision of a parovarian cyst without removal of ovary or tube, 50, 51.

King Arthur's medicine, 239.

Lange, F. Surgical significance of gall stones, 29.

Lesions induced by action of certain poisons on cortical nerve cell. Study VII : Poisoning with preparations of the thyroid gland, 137.

Lesions induced by action of certain poisons on the nerve cell — diphtheria, 23.

Lithopedion, rare case of, 221.

Livingood, Louis E. Fibroid lung-bronchiectasis — brain abscess, 263.

Long, the discoverer of ansesthesia ; presentation of his original documents, 174.

Norton, Rupert. Is malaria a water-borne disease? 35.

MacCallum, W. G. Hsematozoan infections of bird.s, 235 ;— Pathology of hsematozoan infections in birds, 51.

Notes on new books:— Annual report of the Supervising General of the Marine Hospital Service, 57, 83 ;— Baldy, J. M., and Gould, George M., American year-book of medicine and surgery, 82 ; — Bishop, S. F., Diseases of the ear, nose and throat, 158 ; — Burdett's Hospital and Charities, 1897, 265;— Butler, G. F., Textbook of materia medica, therapeutics and pharmacology, 158 ; — Canfield, W. B., Practical notes on urinary analysis, 14 ; — Corwin, Arthur M., Essentials of physical diagnosis of the thorax, 159 ;— Crandall, Floyd M., Transactions of the American Pediatric Society, 113 ;— De Schweinitz, G. E., Diseases of the eye, 14 ; — Dorland, W. A. Newman, Manual of obstetrics, 15 ;-Fuller, Wm., Architecture of the brain, 83; — Gant, S. G., Diseases of the rectum, anus and contiguous textures, 197 ;— Gould, George M., and Pyle, Walter L., Anomalies and curiosities of medicine, 158 ; — Hyde, James Nevins, Manual of syphilis and the venereal diseases, 56; — Lockwood, G. R., Manual of the practice of medicine, 267 ;— McCosh, Andrew J., and James, Walter B., Medical and surgical report of the Presbyterian Hospital, S3; — Meigs, Arthur v., Feeding in early infancy, 159 ;—Obersteiner, Heinrich, Arbeiten aus dem Institut fiir Anatomic und Physiologie desCentralnervensystems an der Wiener Universitiit, 135 ; — Palmer, C. F., Inebriety, 218 ; — Park, Roswell, Treatise on surgery, by American authors, 55 ; — Pathological Report of the Illinois Eastern Hospital for the Insane, 159;^ — Pollack, Dr. B., Die Fiirbetechnic des Nervensystems, 134;— Preston, George J., Hysteria and certain allied conditions, 219 ;— Proceedings of the American Medico-Psychological Association at the 52d Annual Meeting, 159; — Rowland, Sydney, Archives of clinical skiagraphy, 218;— Shattuck, George B., Councilman, W. T., and Burrell, Herbert L., Medical and surgical reports of the Boston City Hospital, 57 ; — Stoney, Emily A. M., Practical points in nursing, 14;— St. Thomas's Hospital Reports, 159 ;— Thayer, W. S., Lectures on the malarial fevers, 265; — Thrush, John C, Water and water supplies, 15 ; — Transactions of the American Gynecological Society, 57 ;— Transactions of the Chicago Pathological Society, 57j_Xyson, James, The practice of medicine, 133 ;— Wilson, J. C, and Eshner, Augustus A., An American text-book of applied therapeutics, 134 ;— Yearsley, Macleod, Injuries and diseases of the ear, 218.

Ophthalmology and otology in Baltimore, early history of, 181.

Ophthalmoplegia externa, 48.

Opie, Eugene L. Hsemocytozoa of birds, 52, 53.

Osier, William. Congenital facial diplegia, 131 ; — Hsemocytozoa of birds, 52, 53 ; — Influence of Louis on American medicine, 161 ; — Trichinosis, remarks on, 80; — Typhoid perforation treated by surgical operation, 113.

Otology, early history of, in Baltimore, 189.


270


JOHNS HOPKINS HOSPITAL BULLETIN.


[Xo. 81.


Owings, E. B. Infectiousness of chronic urethritis, 210.

Parotitis following visceral inflammation, 204.

Parovarian cyst, excision of, without removal of its ovary or tube, 50.

Pelvis, postural method of draining dead spaces in, G2.

Perinuclear bisopliilic granules, association between, and elimination of alloxuric bodies in the urine, 85.

Peritoneal cavity, mechanism of absorption of fluids and solid particles in, 61.

Peritoneum, encysted dropsy of, secondary to utero-tubal tuberculosis and associated with tubercular pleurisy, generalized tuberculosis and pyococcal infection, 91.

Peritoneum, function of under normal and pathological conditions, 60.

Peritonitis, general suppurative, cases of treated by new method, 141.

Peritonitis, perforative, in dogs, treated by new method of operation, 143.

Permanent specimens from frozen sections, rapid method of raaliing by formalin, 108.

Phrenology of Gall and Flechsig's doctrine of association centres in the cerebrum, 7.

Piringer, Joseph Friederich, his methods and investigations, 191.

Piatt, W. B. Cure of hernia by implanting section of sterilized sponge, 44.

Pneumo-cardial rupture, case of, 33.

Porokeratosis, case of, 107.

Pregnancy, palpation of fojtal heart impulse in, 207.

Presence in the blood of free granules derived from leucocytes, and their possible relations to immunity, 246.

Proceedings of societies, 29, 47, 81, 110, 129, 195, 215, 203.

Pseudo-tuberculosis bominis streptotricha, preliminary note, 128.

Puerperal sepsis due to infection with bacillus aerogenes capsulatus, 24.

Randolph, Robert L. Bilateral dacryo-adenitis, 132 ;— Operations for cataract, 133 ;— Second series of cataract operations (one hundred and fifty-eight), 199.

Recti muscles, case of acquired paralysis of, with unilateral facial paralysis, 131.

Reed, Walter. Discussion of malaria as a water-borne disease, 43 ;— Of agglutination of typhoid bacilli, etc., 54.

Reik, H. 0. Case of cavernous angioma of the tunica conjunctiva, 236.

Reik, H. O., and Watson, W. T. Apparatus for sterilizing instruments with formaldehyde; experimental tests, 261.

Robb, Hunter, and Ghriskey, Albert A. Bacillus proteus Zenkeri in an ovarian abscess, 4.

Sabin, Florence R. On the anatomical relations of the nuclei of reception of the cochlear and vestibular nerves, 253.

Schott bath, importance of employing pure salts in, 214.

Schott bath, rules for, 103.

Schott exercises, 104.

Schott treatment, bibliography of, 105.

Schott treatment, rules for operators, 104.

Seminal stains, Florence's iodine test for, demonstration of, 133.

Smith, Nathan Rhyno, 189.

Specimens, demonstration of, 216.

Spence, W. W. Address at presentation of Thorwaldsen's statue of Christ, 1.

Stokes, Wm. Royal, and Wegefarth, Arthur. The presence in the blood of free granules derived from leucocytes, and their possible relations to immunity, 246.

Stomach, tuberculous ulcers of, 75.

Streptococcus infection, rarer cases of and observation on, 47.

Suprarenal capsule: alkaloids, 154.

Suprarenal capsule, blood-pressure-raising constituent of, 151.

Thayer, William Sydney. Discussion of case of bilateral dacryoadenitis, 132 ;— Of agglutination of typhoid bacilli, etc., 55 ; — Of


hsemocytozoa of birds, 53;— Of malaria, a water-borne disease,

43 ;— Of trichinosis, 80.

Theobald, Samuel. Case of acquired paralysis of both external recti muscles with unilateral facial paralysis, 131, 132; — Contrivance for effecting pneumatic massage of the tympanal membrane and ossicles, 49; — Discussion of congenital motor defects of the eyeballs, 130.

Thomas, H. M. Discussion of case of acquired paralysis of both external recti muscles with unilateral facial paralysis, 132 ;— Of congenital facial diplegia, 130 ;— Demonstration of a case. Probable brain tumor, 215.

Thorwaldsen's statue of Christ, presentation of, 1.

Thyroid extract, insane patients treated with, histories of, 138.

Thyroid guinea-pigs, histories of, 140.

Thyroid mice, liistories of, 139.

Trichinosis, studies on, 79.

Tuberculosis of the oesophagus, 229.

Tympanal membrane and ossicles, pneumatic massage of, 49.

Typhoid fever, case of, in which typhoid bacillus was obtained twice from blood during life, 119; — Case of polybacterial infection in, 115.

Typhoid infection without intestinal lesions, 259.

Typhoid perforation treated by surgical operation, 110.

Urethritis, chronic, infectiousness of, 210.

Visceral pathological alterations, the result of superficial burns, 81.

Welch, William H. Discussion of excision of parovarian cyst without removal of ovary or tube, 51 ;— Of haemocytozoa of birds, 53 ; — Of malaria as a water-borne disease, 42.

Woods, H. Ophthalmoplegia externa, 48.

Young, Hugh H. Long, the discoverer of anaesthesia, presentation of his original documents, 174.


ILLUSTRATIONS.


Thorwaldsen's statue of Christ, 2.

Sagittal section through brain (Fig. 1), 11.

Horizontal section through brain (Fig. 2), 11.

Horizontal section of brain (Fig. 3), 11.

Sagittal section through brain (Fig. 4), 11.

External view of right cerebral hemisphere (Fig. 5), 11.

Internal view of left cerebral hemisphere (Fig. 6), 11.

Case of X-ray dermatitis (Figs. 1, 2, 3), 22.

Temperature charts of infection by bacillus aerogenes capsulatus (Cases 1, 2, 3, 4), 70.

Encysted dropsy of the peritoneum (Fig. 1), 94.

Bacillus typhosus (Figs. 1, 2, 3, 4), 119.

A new KSthesiometer (Figs. 1, 2), 125.

Tracings of blood-pressure-raising constituent of suprarenal capsule (Figs. 1, 2, 3), 156.

Portrait of Dr. Crawford W. Long, 177.

Portrait of Dr. George Frick, 187.

Longitudinal section of abdomen, 217.

A lithopedion, 223.

Section of oesophagus, 232.

Aortic arch and its branches (Figs. 1, 2), 234.

Supernumerary muscle in the neck (Fig. 3), 235.

Cavernous angioma (Figs. 1, 2), 236.

Diagram of reception nuclei of cochlear and vestibular nerves (Fig. 1), 257.

Section of nuclei of cochlear and vestibular nerves (Fig. 2), 257.

Section of nuclei of cochlear and vestibular nerves (Fig. 3), 257.

Section of nuclei of cochlear and vestibular nerves (Fig. 41, 268.

Section 66 horizontal series (Fig. 5), 258.

Diagram of nuclei of nervi cochlearis and corpus trapeioides (Fig. 6), 258.


December, 1897.]


JOHNS HOPKINS HOSPITAL BULLETIN.


271


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report in Pntbolosy.

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

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

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

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

Mall, 51. D.

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

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

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

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

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

T. C. Gilchrist, M. D.

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

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


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

Report in Medicine.

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

Gallstonea. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By J0H» N. Maceenzie, M. D. On Pyrodin. By H. A. Lafleor, M. D. Cases of Post-febrile Insanity. By William Osler, M. D. Acute Tuberculosis in an Infant of Four Months. By Harry Toulmih, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.

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

Report in Gynecology. The Gynecological Operating Room. By Howard A. Eellt, M. D. The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

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

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

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

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

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

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

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

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

Howard A. Kelly, M. D.

Report in Snrgery, 1. The Treatment of Wounds with Especial Reference to the Value of the Blood Clot

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

Henry M. Thomas, M. D.

Report in Fatliologry, I. AmtBbic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleub, M. D.


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

Report in Patliologry.

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

Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D. Report in Pathology.

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

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

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

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

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

Report in Gynecology.

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

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

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


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

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

Photography applied to Surgerj*. By A. S. Murray.

Traumatic Atresia of the Vagina with Hsmatokolpos and Hxmatometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever,

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

Report in Nenrology. Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of Mus musculus; The Intrinsic Nerves of the Thvroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley, M. D.

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

Report in Gynecology, Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitts; Tuberculosis of the Endometrium. By T. S. Cullen, M. B. Report in Pathology. Deciduoma Malignum. By J. Whitridqe Williams, il. D.

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

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

Studies in Typhoid Fever. By William Osler, M. D., with additional papers by G. Blumer, M. D., Simo.v Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.

Volume VI. 414 pages, with 79 plates and figures.

Report in Nenrology.

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

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

Report in Patliology.

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

Pregnancy in a Rudimentary LTterine Horn. Rupture, Death, Probable Migration of 0\'um and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins, M. D.

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

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

The Pathology of Toxalbumin Intoxications. By Simon Flexn'ER, M. D.

Tlie price of a srt hound In cloth [Vols. I-T'I} of the Hosjiital licparts is $30.00. Vols. I, 11 and III ni-e not sold sejMimtel!/. The price 0/ Vols. IV, V and VI is $S.OO each.


Monographs.

The following papers are reprinted from Vols. I, IV, V and VI of the Ilcports, for those who desire to purchase in this form: STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixford,

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

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

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

By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.76. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted

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

pages. Price, bound in paper, $3.00. THE PATHOLDGY OF TOXALTIUMIN INTOXICATIONS. By Simon Flexner. M. D. 1

volume of 150 pages with 4 full-page lithographs. 1 rice, bound in paper, $.\nO. Subscriptions for the above publications may be sent to

The Johns Hopkins Press, Baltimore, Md.


272


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 81.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel 0. Oilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.

William Osler, M. D., LL. D., F, R. C. P., Professor of the Principles and Practice

of Medicine. Henry M. Hord, M. D., LL. D., Professor of Psychiatry. William S. Halsted, M. D., Professor of Surgery. Howard A. Kei.lt, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.

William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. Robert Fletcher, M. D., M. R. 0. S., Lect\u-er on Forensic Medicine. William D. Booker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. 1'homas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flesner, M. D., Associate Professor of Pathology. J. Whitridge Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy. William S. Thayer, M. D., Associate Professor of Medicine. John M. T. Finney, M. D., Associate Professor of Surgery.


Georqe P. Deeyer, Ph. D., Associate in Physiology.

William W. Rdssell, M. D., Associate in Gynecology.

Henry J. Berkley, M. D., Associate in Neuro-Pathology.

J. Williams Lord, M. D,, Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph O. Bloodqood, M. D., Associate in Surgery.

Thomas S. Cullen, M. B., Associate in Gj-necology.

Ross G. Harrison, Ph. D., Associate in Anatomy.

Frank R. Smith, M. D., Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jo.ves, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Patholc^y.

Louis E. Livinqood, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D., Instructor in Medicine,

Charles R. Bardeen, M. D., Assistant in Anatomy.

Stewart Patos". M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology.

Haevey W. Gushing, M. D., Assistant in Surgery.

J. M. Lazear, M. D., Assistant in Clinical Microscopy.

J. L. Walz, Ph. G., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from Its close afiiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and iu the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. The first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physiology, Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. During the last two years the student is given abundant opportunity for the personal study of cases of disease, his time being spent largely in the Hospital Wards and Dispensary and iu the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives ;

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

3. Graduates of approved colleges or scientific schools who can furnish evidence: (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

The phrase "a minor course," as here employed^ means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room eierclses and five hours a week In the laboratory in each subject.

3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above iAdicatcd.

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING. Applicants for admission to advanced standlug must furnish evidence (1) that the foregoing terms of admission as regards prellmluary training have been fulflUed, (2) tliat courses equivalent iu kind aud amount to those giveu here, preceding that ye.ir of tho course for adtnisslon to which application is made, have been satisfactorily completed, and (3| must pass examiuatlons nt the beginning of the sosslon iu October in all tho subjects that have been already pursued by the class to which admission is sought. Certiflcates of standing elsewhere cannot be accepted iu place of these examiuations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been ofl"ered to graduates in medicine. The attendance upon these courses has steadily increased with each sticceeding year and indicates gratifying appreciation of the special advantages here afforded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine ai'e now given annually during the months of May and June. During April there is a preliminary course in Normal Histology. These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here offered. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application.

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the